delirious. There was no paralysis, and the cranial nerves were apparently uninvolved. No bleeding from ears, nose, mouth. No pressure; pulse 96. Respiration not accelerated. Complaint of pain at nape of neck; possibly slight rigidity at nape of neck. Contused wound, about 6 cm. in length, on forehead; deep compression of root of nose, glabella and all portions of forehead surrounding the injury. Slight bulging of the eyeballs; slight hæmatoma of the lids. Bony fragment visible in the gaping frontal wound. Trephining and removal of the bone fragments directly after admission to the clinic. Tamponing. Gradual subsidence of the meningitic symptoms. The wound healed by granulation.

Operation: Plastic bone covering (Garré). Curretting of the thin epithelial covering of the cicatrix. Mobilization of the skin at the margins of the bony defect, with slight undermining toward the periphery in all directions. Sagittal longitudinal incision through the scalp from the middle of the posterior bone margin backwards, about 5 cm. in length; formation of two skin flaps from this point in both directions. Next, two symmetrical thin periosteum bone flaps were cut around, with a broad pedicle on the side and in front. These were mobilized from their base, rotated about 90 degrees, fitted into the defect, and the periosteal margins were then fixed to each other and to the periosteum of the anterior edge of the defect by means of a few fine silk sutures. Some bits of lamella which were splintered off were utilized peripherally for covering purposes. The skin flaps were then sutured to the mobilized skin at the root of the forehead and the nose.

Course: Afebrile and without complications. Large post-operative hæmatoma

of both upper lids and nasal root area. Wound healed by first intention. At the end of a month the plastics had healed, all but a slightly secreting fistula over the root of the nose, in the center of the original suture. Loose roughened bone splinters could be felt (presumably the bony lamella without periosteum of the plastics). Otherwise, the plastic closure was perfect. The transplanted lamellæ had grown fast solidly and without yielding. The fistula was enlarged and the bony fragments were extracted. At the end of a week the wound had closed all but the small orifice of the fistula, and two more small bony fragments were removed. A protective bandage was applied and the patient was discharged in excellent condition. Nervous system without findings.

E. F. Sauerbruch, Surgery of the Thorax. Marburg, Germany, (Journal A. M. A., September 5), describes his device of a pneumatic cabinet. to avoid the danger of pneumothorax in operations on the thoracic organs and the rules to be followed in its use. It is remarkable, he says, how little of the anæsthetic is required and then only at the times of opening and closing the thoracic cavity. Between these very little is needed. It has been found unwise to reduce the pressure more than from 7 to 8 mm. Hg, and Friedrich has had excellent results with a negative pressure of from 3 to 5 mm. ; in fact, such a minimum pressure should always be employed during intrathoracic operations, as on the esophagus or lungs, or when it becomes necessary to expose the mediastinum. Before concluding the operation, however, it is essential to raise the pressure to 7 or 8 mm., so that the lung will be fully expanded and completely fill the chest cav

ity. The strictest asepsis is as important as in abdominal operations, and complete hæmostasis is of the utmost importance, so that as little blood as possible enters the thoracic cavity. As regards the indications for this method, he says that it is particularly applicable for the removal of large tumors of the chest wall, lessening the dangers and rendering it possible to operate more extensively, and the contraindications are fewer. If, in spite of care, the pleura is injured, the apparatus will prevent the occurrence of pneumothorax. Its possibilities in the treatment of pulmonary tuberculosis will increase, but too much must not be expected; in fact, he believes that in such cases thoracoplastic operations will give better results. Excellent results have been obtained with the method in empyema, and it has great advantages in the surgery of deep abscess and gangrene of the lung. Changes of dressings, it has been shown by experience, should be made in these cases, at least in the beginning of the after-treat

ment, under negative pressure, not because of pneumothorax, but solely because it tends to remove blood and pus from the bronchi. In bronchiectasis it is applicable only when the lesion is isolated in one lobe of the lung. The method is useful in operating for intrapleural injuries, and it is especially indicated in operations on the intrathoracic portion of the œsophagus, and Sauerbruch has developed a technique which makes it possible, at least in animals, to resect large portions of the œsophagus. The essential feature is the avoidance of sutures and the use of the

Murphy button for the anastomosis. Gastrocesophageal anastomoses and resection of the cardia have been performed on man. The operation is described. The surgery of the heart is the least advanced by this new method of using negative pressure, as heart injuries are always emergency cases. In closing, Sauerbruch speaks of the value of exploratory thoracotomy in clearing up doubtful diagnoses. which he considers more often justifiable than has been thought to be the case.

blue, followed by a short rinsing with tannin orange). Among the 158 cases the influenza bacillus was found in 29 instances, including 22 per cent. of the cases of pulmonary tuberculosis; it was often met with in pure culture. These influ

enza bacilli in the bronchial contents do

not possess any particular pathogenetic importance. Besides in pulmonary tuberculosis, influenza bacilli are frequently encountered in the acute infectious dis

eases of children, especially whoopingcough, but also in measles. The entrance of the influenza bacilli into the blood could not be demonstrated in any instance (examination of the heart blood). F. R.

in the Urine.

Ammonia Coefficient Hopkins describes a method of determining the ammonia coefficient by direct nesslerization. The ammonia is determined by diluting the urine volumetrically until the ammonia nitrogen in the dilution is between .001 and .02 millegrams per cc. A definite portion of the dilution is nesslerized, and the ammonia nitrogen in I cc. of urine computed. The total nitrogen is estimated in the same manner, first reducing the organic nitrogen to ammonium. sulphate by the Kjeldahl process. The ratio between the amount of ammonia nitrogen and total nitrogen thus determined is taken as the ammonia coefficient; as there is a possible error of 10 per cent. in the method, he concludes that it is applicable to the determination of pathological variations only. For this purpose it answers the requirements. It is sufficiently accurate to determine variations of clinical importance, and has great advantages in its rapidity and in the simplicity of technique and apparatus used.

Negri Cell Inclusions After describing the in the Salivary Glands. gross autopsy technique and the technique applied in the

Pasteur Laboratories of the University College of Medicine for the preparation of microscopic slides for the rapid diagnosis of rabies, as well as for permanent and durable specimens, Dr. Hoen calls attention to the demonstration of the Negri cell inclusions in the secreting cells of the salivary glands (parotid) by a special

combination stain of HæmatoxylinFuchs-in-Ammonium Picrate and Gram.

of interest, as indicating the investigative Whilst priority of discovery is always trend of any laboratory, it is of minor importance when compared to the significance of the finding of structures, in the organs furnishing the infectious fluid. which are identical morphologically with those found in the brains of rabid animals. and practically validates Dr. Negri in his assumption that these bodies, named after him, are the aetiological factor of rabies.Bulletin Univ. College of Med., Richmond, l'a.

Diagnosis of Rabies.

J. B. Rucker, Philadelphia (Journal A. M. A., July 25), has used the smear method of Williams and Lowden in the examination of 13 cases for the Negri bodies, and described it as follows: A small piece of the gray matter of the brain is excised and placed on a clean slide near one end. The cut should be at right angles to the surface, only a thin piece being taken in order to avoid the white matter as much as possible. A clean cover-glass is placed over the tissue and pressed down with the thumb until it is thinly spread out, and with even pressure. the cover-glass is drawn almost to the other end of the slide. A little practice will enable one to thus produce a thin, even film of tissue. He used both the modified Giesma stain and also the modified Van Gieson stain as used by Williams

and Lowden. The details of his 13 examinations are briefly given, and he concludes from his experience that the smear method is preferable to all other methods, because: 1. It is much simpler than any other, on account of the extreme facility with which the smears may be made and

stained. 2. It is much shorter than any other, requiring only from 15 minutes to three hours. 3. In the smear method the Negri bodies appear very distinctly, and their minute structure is brought out very clearly. 4. The smear method is absolutely reliable.

Renal Decapsulation in W. Falgowski (CenPuerperal Eclampsia. tralbl. f. Geb. 1. Gyn., No. 2, 1908; Ref., Fort. d. Med., February 20, 1908, p. 136).

Renal decapsulation, first employed by Edebohls and warmly advocated by Sippel, is gradually finding more adherents in Germany in cases of eclampsia. Aside from pure puerperal convulsions, i. e., eclampsia occurring in childbed, the procedure is indicated also in eclampsia during gravidity and sub partu in case artificial emptying of the uterus is not at once followed by improvement. The author reports a case of pure puerperal eclampsia of the severest type in which double decapsulation was very rapidly followed by cure.

A IV-para, 28 years of age, was suddenly seized 13 hours after normal labor with quite violent and rapidly recurring typical eclamptic convulsions, accompanied by all the well-known symptoms. Uninterrupted coma in the intervals; finally cardiac failure and pulmonary oedema. Immediately with the onset of the affection there was very severe hæmorrhagic nephritis, with 12 per cent. albumin and threatening oliguria. After about 30 severe paroxysms and 21 hours' uninterrupted coma, other therapeutic

measures failing, bilateral renal decapsulation was performed. Both kidneys were found to be distinctly venous hyperæmic and swollen (renal glaucoma). The capsule was stripped off on both sides and pushed toward the hilus.

After the operation the paroxysms immediately ceased; the coma disappeared after six and a half hours. On the succeeding days abundant urine was voided spontaneously, and on the fourth day the albumin content fell to 2 per cent. Respiration and pulse soon became normal, and on the twentieth day the patient was "as good as cured."

The rapid subsidence of the acute nephritis was remarkable. Apparently the kidneys at the time of operation were severely inflamed and insufficient, but the epithelial apparatus had not yet been destroyed. In the latter case the operation would have been useless. It is important also to operate at the right moment. If arrest of urinary secretion, cardiac weakness and pulmonary œdema also are present, there should not be a moment's delay.

The favorable effects of decapsulation are explained by overcoming of the excessive intracapsular pressure under which the kidney suffers in the course of the affection and which is so injurious.

to the epithelium. This excessive pressure inhibits the circulation of the blood as well as the exchange of materials, and resembles in cause and effect a continued venous stasis. Operative relief of pressure is followed by arterial hyperæmia, which acts by absorption of any accumulated inflammatory materials.

The technique of the operation is simple and can be carried out in any house.

Inequality of the M. Variot and M. Two Breasts. Lassablière have been investigating an anomaly which, so far as we know, has not often, if at all, engaged the attention of physicians, that of a difference in the size of the two breasts. They reported, at a recent meeting of the French Academy of Sciences (Semaine médicale, August 5), that they had examined the breasts of 550 women from the country who sought employment as wet nurses in a Paris hospital for children. They found inequality of the two breasts in size to be by no means exceptional, but rather the rule, during lactation; in fact, in only 24 per cent. of the women examined did they find the two breasts of the same size. Generally it was the left breast that was the larger, 281 times, while in only 138 instances did the right breast exceed its fellow in size.

As the efficiency of a secreting organ is proportionate to its size, other things being equal, it is not astonishing that they found that more milk was secreted by the larger breast than by the other one. They milked 40 women dry, and the difference in the amounts of milk obtained from the large and from the small breasts ranged from 40 to 335 cubic centimeters (approximately 10 fluid drachms to 101⁄2 fluid ounces.) But it does not seem so easy to account for differences in the quality of the milk from the two breasts. The

smaller gland, they find, yields milk richer in fat and casein, but somewhat defective in sugar. As a consequence, the baby is inclined to avoid the little breast, and that leads to a still greater reduction of its size, so that sometimes it undergoes such a degree of atrophy that the nurse is left with only one available breast.

Our authors state that this inequality of the breasts as regards size exists in young girls as well as in nursing women. This fact they set down as probably due to heredity, but they add that in the nurses examined by them the difference in the size of the breasts was manifestly due to the greater frequency with which, for reasons of convenience, the women gave the left breast to the child. Now, if the anomaly which they have investigated is really hereditary, why should they endeavor to account for it as something acquired? At all events, it ought to be corrected, they remark, and they think that the best way to secure that result is to insist on giving the infant the lesser breast. -Editorial New York Medical Journal, August 22, 1908.

in

The Time to Operate Dr. W. P. Manton
Intra-abdominal has
has an interesting
Hæmorrhage Due to
Tubal Pregnancy.

article on this subject in American Journal of Obstetrics (July, 1908). He considers five conditions of this accident: 1. The fulminating cases, with excessive hæmorrhage from rupture of the tube or expulsion of the ovum from the ostium abdominale, with profound shock and collapse. 2. Those in which there are repeated attacks of pain, with faintness, vomiting and shock, but without excessive bleeding, as in tubal abortion. 3 Those in which rupture has occurred and a hæmatocele has been walled off from