DaCosta believes that these are merely different expressions of the same pathological condition, a hyperemia of the skin, with here and there, in the measly form, an exudation in its layers, most like a swelling and thickening of the corium and rete malpighii, much as exists in measles.

SURGERY.

UNDER CHARGE OF W. B. ROGERS, M.D.

Professor of the Principles and Practice of Surgery and Clinical Surgery,
Memphis Hospital Medical College.

Surgical Appendicitis.

Ricketts (Amer. Jour. Surg. & Gyne., vol. 12, no. 11) writes interestingly of this subject, and summarizes his article in the following pertinent conclusions: 1. Recovery is more certain when operation is made early in the first attack. 2. Diagnosis is more difficult in the female, especially when pregnant. 3. It is often impossible to determine character of trouble without explo

5. Incision through the belly wall should not be closed in cases where pus is present, or where there is doubt as to continued slight bleeding.

6. Removal of the appendix is not necessary or advisable in all cases, especially when not easily discovered upon opening a pus cavity.

7. It is safer to allow a perforated appendix to remain than to lacerate a pyogenic wall in searching for it.

8. The ability of a remaining perforated appendix to cause subsequent trouble is in doubt, as the process which is active enough to perforate the muscular walls of an appendix would seem active enough to destroy its mucous membrane.

9. There is but a very small per cent. of gut perforations under these circumstances which should be closed by suture, or otherwise, at time of primary operation, and still fewer which will require such thereafter.

10. All abscess cavities should be packed from the bottom with gauze, which will absorb serum, blood and pus.

11. Appendicular pain may be inflammatory or mechanical, either one being acute or chronic.

12. The presence or absence of abnormal temperature should not be considered if severe pain or tenderness are present.

13. Foreign bodies may be evacuated from the appendix into the gut without having caused any trouble, leaving the appendix undisturbed.

14. It is safer to operate upon acute cases of appendicitis in their homes than to do so in the finest operating room if ambulances or trains must be brought into requisition to take them to that room.

15. A secondary operation for the removal of an appendix which has been left undisturbed at time of opening the abscess is one of the most difficult in abdominal surgery.

16. Diseased ovary or tube may produce a pathologic appendix, and vice versa. 17. Appendicitis may terminate in spontaneous recovery, which is, however,

rare.

18. The appendix is subject to the diseases of other parts of the alimentary tract.

Porencephaly.

At the recent German Surgical Congress, Von Bergmann (Med. Press & Cir., vol. 67, no. 3130) read a paper on porencephaly, the patient being shown, and which the speaker said bore out Kocher's theory as to epilepsy. There was a cyst formation in the head which often led to epilepsy. This was the traumatic form of the disease, but not all cases were of that nature. The clinical features of the disease were quite typical; there were localized paralyses with contractions, and arrest of growth in the paralyzed extremities in childhood, and there were epileptiform attacks. The patients were imbecile, or at least their intelligence was defective. The case shown was one of traumatic porencephaly, from a fracture of the skull caused by pressure of the forceps at birth. There was a cyst in the skull, but apparently no meningocele. During the epileptic attacks, and when the head was sharply flexed, however, the open space became tense and the skin thrust forward. According to Köning, when such defects were covered with bone, a cure was effected. This had been attempted after extirpation of the cyst, and as the margins of the defect were very thin, like the skull bone of a child, a bone flap had been taken from the tabula vitreca and pushed over the defective spot. The covering-in was not successful, however, until after several operations, as the space had a length of 14 c. m. and a maximum width of 8 c. m. The first operation was at the beginning of April, 1898, and the last on July 11th. A small part still remained uncovered; the requirements of Kocher as regarded "ventilation" were therefore fulfilled. The epilepsy had ceased. The child (shown) displayed shortening of the left upper and lower extremities, left-sided club foot, and spastic position of the fingers. As the cyst communicated with a lateral ventrical drainage had been 'kept up for a long time. The anatomical features of this porencephaly were

constant.

The speaker showed a preparation from a child of 7 who had died of collapse after operation, but had not suffered either from fits or paralysis, though there was a very large tumor. When operation should be undertaken he urged that Kocher's procedure should be followed, although it could not be diagnosed with certainty whether intracranial pressure was always increased or not. The most important indication was always casual, and the treatment should always be carried out before an epileptic condition of the brain had become established. Treatment of Fractures of the Patella.

Means (Columbus Med. Jour., vol. 23, no. 1), from his experience in treating six cases of fracture of the patella, draws these conclusions:

1. The results of the non-operative treatment are unsatisfactory, both as to long confinement and functional disability. 2. The methods of maintaining apposition of the fragments by external appliances are unsatisfactory and unsci. entific. 3. In open arthrotomy the fragments can be carefully approximated and sutured in such manner as will maintain apposition and, ultimately, bony union. 4. The operative method saves months of confinement, and gives permanent results. 5. The buried suture material should be absorbable, such as catgut or kangaroo tendon. 6. The field of operation should be continuously irrigated with a hot salt solution during the manipulation, and the incision closed without drainage. 7. The massage treatment begun at an early date is an important factor in restoring the functional activity of the joint.

OPHTHALMOLOGY.

UNDER CHARGE OF A. G. SINCLAIR, M.D.

Professor of Ophthalmology, Otology and Laryngology, Memphis Hospital Medical College; Ophthalmic, Aural and Laryngeal Surgeon to St. Joseph's Hospital; Ophthalmic and Aural Surgeon to the City Hospital.

Ocular Accidents Dependent on Epidemic Influences.

Galezowski (Recueil. d'Ophthalmologie) states that five different and distinct types of ocular disease are caused by la grippe. The conjunctivitis noticed is rarely purulent in character, being usually of catarrhal nature. Generally speaking, the epithelium of the conjunctiva and at times that of the cornea are the parts that are involved, the trouble in the latter type appearing in the form of small herpetic ulcers. The cornea becomes covered with vessels, and the whole eye is vascularized and irritated. The author believes that the bacillus of Pfeiffer gives rise to this form of disturbance. Usually, both eyes are attacked, and frequently the iris, the lachrymal ducts, and the edges of the lids are involved. The author has found that the lachrymal types of conjunctivitis are sometimes quite marked, the diseased areas being clearly limited. These cases produce peripheral, functional troubles which, in their turn, through their toxins act as causative agents. These forms present symptoms that resemble the changes seen in diptheritic and granular conjunctivitis. In this type general therapy is much more useful than local treatment.

The cornea may be attacked in two ways: either as the influenza, acting as a predisposing cause, renders the tissues less resistant, or else the disease produces trophic changes that give rise to loss of transparency, ulcers and abscesses. Central lesions may follow attacks of la grippe. These may be of the nature of softening of the nervous structures or dependent on changes that are due to thrombosis or embolism. Serous retinitis is to be regarded as being a fairly frequent sequel of the affection. This is due, the author says, to an inoculation of malarial germs into a system that is already weakened by the primary infection. It readily yields to quinine. Conditions such as glaucoma, plastic iridochoroiditis, etc., are also precipitated by attacks of the influenza in patients having a predisposition to such diseases.

Galezowski attributes the epidemics that we have had to the nuteorological conditions which exist during those seasons of the year in which the disease is particularly prevalent. During those years in which the average readings of the barometer have been high the disease has been of a less virulent type than when the readings have been low.

Treatment varies with the parts that are affected, and with the severity of the attacks. In conjunctivitis, nitrate of silver and sulphate of zinc are given the first place. In herpes of the cornea, ointments containing iodoform and cocaine have rendered the best results. A general tonic treatment, with continuous use of quinine is to be maintained.—Annals of Oph.

On the Treatment of Trachomatous Conjunctivitis by Incision of the Conjunctival Cul-de-Sac.

Galezowski (Recueil. d'Ophthalmologie). The best medicinal measure for trachoma in Galezowski's hands has been the "mitigated stick of nitrate of

silver," which consists of silver mixed with nitrate of potassium. This failing, he resects the affected portion of the conjunctiva. He has found that three things are essential to the success of the operation, viz.:

1. To excise nothing but the conjunctiva.

2.

The excision should reach from angle to angle.

3. The tarsus should not be touched.-Annals of Oph.

Follicular Conjunctivitis and Adenoid Vegetations of Naso-Pharynx. Coppez (Archives d'Ophthalmologie) insists upon the facts already noticed by Snellen and others, that follicular conjunctivitis is frequently associated with adenoids of the naso-pharynx, and that the removal of these growths facilitates a cure of the conjunctival inflammation, and at times is absolutely essential for the cure of the condition.

NOSE, THROAT AND EAR.

UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS.
Laryngologist to the East End Dispensary.

The Results of the Removal of Adenoid Vegetations.

Brindel, at a recent meeting of the French Society of Otology and Laryngology (Revue Hebdomadaire de Laryngologie, etc., vol. 20, no. 23), contributed a study of the results following the removal of adenoid growths, which is remarkable for its thoroughness. The author, in his essay, considered solely the influences of adenoidectomy:

1. On the ear.

2. On the nasal mucosa.

3. On the hypertrophy of the palatine tonsils.

4. The recurrence of the vegetations.

The paper is based on 705 observations compiled at the clinic of Dr. Moure, in Bordeaux, where the patients have been operated during the last two years. 1. With regard to the ears:

(a) If they were sound before the operation, they remained in the same condition afterward.

(b) If there existed an exudative catarrhal otitis, no matter at what age operated, the ear returned to a normal condition.

(c) If the adenoid sufferer has a chronic catarrhal otitis, with the membrana tympani very depressed and synechias, without an exudate in the tympanum, the audition became strongly better, but did not return to the normal.

(d) If there was discovered a dry otitis, without depression of the tympanic membranes or liquid in the tympanum, the removal of the adenoids ameliorated to a degree the deafness and impeded the evolution of this latter.

(e) In a sclerosis with a normal tympanic membrane the operation retarded the progress of the deafness and suppressed the catarrhal otitis.

(f) Deaf mutes are benefited frequently from adenoidectomy. In at least half of Brindel's cases they acquired sufficient audition to understand words and to learn to talk.

(g) Finally, in removing the vegetations, we secure the drying up ipso facto of a number of old chronic otorrheas. Those which do not heal after removal of the adenoids are susceptible to surgical treatment.

2. We see very often the passage of air to the nasal mucous membrane, after an adenoid operation, provoke an inflammation, and afterward a polypoidal degeneration of this mucosa. The irritation provoked by the air suffices now and then to cure an atrophic rhinitis preëxistent to the operation.

3. The removal of adenoids causes in the long run a retrogression of the faucial tonsils in a good half of the operated cases.

4-(a). With regard to the recurrence of adenoids, this is favored by lack of thorough removal of the debris, for these latter never atrophy.

(b) There may be found before the operation, or may be observed afterward, those contractions of the nasal fossæ which favor a recurrence; of this class are congenital narrowness of the choane, a hypertrophic coryza of a turbinated body, or a deviation or a spur of the septum.

(c) There certainly may be a recurrence of adenoids after removal, but this rarely transpires.

Stenosis of the Trachea.

At the Vienna Gesellschaft der Aertze (Med. Press & Cir., vol. 68, no. 3139) Harmer exhibited a male patient, æt. 24, on whom he had successfully operated for stenosis of the trachea. It appears from the history that this young man had croup when he was five years of age, for which tracheotomy was performed, but for some reason not yet explained the cannula was never removed, which gave rise to a large cicatrix, so that at the age of 16 the whole pharynx and vocal cords were involved in a thick, hard belt of fibrous tissue.

According to our plastic dicta two operations are given for the correction of this distortion on the aerial tract, viz.: (1) That long, wearisome endo-laryngeal process of distending the passage by means of a tube; (2) extra-laryngeal operation by means of reopening the cicatrix and guiding the union, or what is more recently performed, cutting out the cicatrix altogether and so promote union of the healthy edges of the tracheal wall.

Harmer selected a modification of the latter method by making an opening into the larynx in which he left thick threads of silk as drains. Latter he applied a Schornstein cannula and dismissed the patient from hospital with it in, and it was removed a few months later. The edges of the wound were finally pared and freshened for reunion, which took place soon after with excellent results. Before the operation the man was unable to converse with his fellow inmates unless by signals or movement of the lips, whereas now he can speak with a loud voice, though a little rough, which may yet improve. With the assistance of the laryngoscope the vocal cords are shown to be quite normal with a good wide larynx.

The Importance of Operation in the First Stage of Thrombosis of the Sigmoid Sinus.

Bacon (N. Y. Med. Jour., vol. 70, no. 1) reports three cases of thrombosis of the sigmoid sinus following acute purulent otitis media. The course of these cases emphasized most forcefully the following deductions which he draws: