These last four are regarded by this authority as the only certain and conclusive diagnostic signs of pus in the antrum.

Of these, the demonstration of pus through the natural opening is not at all generally recommended, because of the tediousness of the process (McBride2).

Puncture through an alveolus (of the first molar or second bicuspid tooth) is usually easy, but requires a general anesthetic. If this plan were adopted, a larger trocar or a drill would be used, so that, were pus found, a silver drainage tube could be at once inserted.

Puncture through the outer wall of the middle meatus is easy, as the bone here is paper thin, but is not recommended because of the proximity of the orbital cavity (Watson Williams).

The puncture of the antrum through the outer wall of the inferior meatus is the method in greatest favour (Grünwald, Tilley, Bond, St. Clair Thomson), being in most cases surprisingly easy, and, under cocaine, almost entirely painless.

A Lichtwitz's trocar and canula (or any straight-slender trocar about 11cm. long and 24mm. thick) is passed under the anterior end of the inferior turbinal bone. When the point of the trocar is half an inch past the anterior end of this bone, it is fixed on the outer wall of the meatus by simply pressing the handle of the trocar inwards against the septum. Very moderate pressure now, direction back

in

wards, outwards and slightly upwards, on the handle of the instrument will easily send the point into the antrum. The instrument designed by Dr. Hankins, and which is illustrated in the March number of the Gazette of last year, has a slight curve, and is, I think, an improvement on the Lichtwitz

Grünwald has had at times to use a thick

trocar, a drill, or a common shoemaker's awl,

because of the thickness of the bone.

St. Clair Thomson says if moderate pressure fail to pierce the wall in this situation, gently move the point of the trocar on to various contiguous spots, making pressure till the lessened sense of resistance indicates a thinner

area has been found, when the point may be readily pushed in.

2. "Diseases of the Throat, Nose, and Ear." 3. "Diseases of the Upper Respiratory Tract." 4. "Nasal Suppuration."

The trocar is withdrawn, leaving the canula in position, through which some tepid antiseptic solution may be injected. It is a good plan to receive the fluid which escapes from the nostril in a black tray, as small quantities of pus are more easily noticed against a dark background.

Small quantities of pus may be also easily demonstrated by injecting a few drops of hydrogen peroxide, when the characteristic white foam will appear in the nose.

It is most important that, before puncturing the antrum, the nasal cavity be inspected, especially in the inferior and also in the middle meatus, and any pus there carefully wiped

of the third occipital nerve and under cover of the trapezius. Deeper down under cover of the complexus were found a series of larger blended fusiform swellings on the fibres of the so-called posterior cervical plexus. At the same level, but extending forward into the side of the neck, was a similar but larger tumour on the external branch of the posterior primary division of the fourth nerve.

The neuromata were comparatively easily shelled out of a distinct but thin and loosely adhering capsule, and were cut away from the entering and issuing nerve fibres.

After the operation I discovered an area of diminished sensibility on the right side of the head close to the middle line, extending from the occiput upwards.

In Fasciculus xi. of the new Sydenham Society's Atlas of Illustrations of Pathology is a series of plates of similar conditions of various nerves.

These tumours consist of fibrous tissue contained in the neurilemma, and their growth chiefly along the direction of the nerve fibres gives to them their usual fusiform shape.

FRED. J. T. SAWKINS, M.B., Ch. M., Syd. College St., Sydney.

Perforative Appendicitis.

AT 6 p.m. I was called to see a woman who was said to be dying in agony. She was lying in bed on the right side, with the knees drawn up, groaning in pain, the face and lips were bluish and cold, the hands and feet were cold, and the whole body bathed in perspiration. Vomiting and retching were continual; it was very evident she could not live very long.

The patient at the time was too ill to give her own history; all that could be drawn from her was, that she had suffered previously from attacks of inflammation of the stomach, while her friends stated that she had had gastric ulcer.

There was a tender area over the region of the stomach, and a well marked transverse crease across the abdomen, which seemed to mark its lower border. There was also a tender area over the appendix, and the abdominal wall at that spot was slightly more rigid. Although a perforation into the abdominal cavity had certainly taken place, it was impossible to locate it. The available history, and the local conditions, pointed to the stomach first, and then to the appendix.

Although the woman was in a condition which would formerly have been called dying, she was immediately operated upon. The loca

tion of the lesion being doubtful, the usual incision in the middle line was made. The small intestine, where seen, was very red and dull, there was no lymph to be seen, but this condition of redness decreased upwards and increased downwards until the region of the appendix was reached, when some flakes of lymph appeared, and a fæcal smell was noticed. The cæcum was firmly bound down, and out of reach. An incision was therefore made at right angles to the original one into the iliac fossa. The appendix was then easily found, separated, and removed. At the junction with the cæcum was a small perforation, through which fæcal matter was escaping. During the operation the abdominal cavity was continually flushed with hot saline solution. This treatment entirely altered the condition of the patient. The collapse was much lessened, and her condition during the course of the operation was far better than before it was begun. The wound was drained; at the end of three days some fæces appeared in the wound. This soon disappeared, and the sinus closed without further trouble. She is now quite well.

My opinion is daily confirmed that these cases should never be abandoned, and are never to be despaired of.

FRANK TRATMAN, M.D. LOND.,
Senior Surgeon, Perth Public Hospital.

Perth, W.A.

The Undulatory Impulse of Pericardial Effusion.

IN the article by Dr. Roberts on "Pericarditis in Allbutt's "System of Medicine," the following paragraph occurs (Vol. V., p. 762):-"It is a disputed question whether pericardial effusion can produce any definite change in the character of the cardiac movements, tactile or visible. Certainly the impulse observed over the upper part of the chest may be more or less undulatory; and a wave-like motion has been described, which can be seen, but not felt, and is supposed to be communicated to the fluid by the action of the heart. I must say that I have never been able to recognise this phenomenon positively. Some authorities regard an undulatory impulse as a sign, not in favour of pericardial effusion, but against it." Recently a case presented itself at the Prince Alfred Hospital, which throws considerable light on this point. The patient was a boy, about fourteen years old. suffering severe cardiac embarrassment. The area of pericardial dulness much increased, and towards the lower part,

was

with each heart beat could be both seen and felt a diffuse impulse, which at once conveyed, by its undulatory character to the sight and touch the idea of an organ vigorously moving and displacing fluid, much in the same way as the walls of a tank and the surface of the water in an aquarium are disturbed by the submerged gambols of some large marine animal, such as a seal. A needle was inserted, but failed to

withdraw fluid. Sudden death terminated the case. At the post-mortem, the pericardial sac was found quite lax, so that it could be easily seized with the fingers, and yet it contained 22oz. of straw-coloured fluid, and surrounded a greatly hypertrophied heart. There was some old peri- and endocarditis, and the usual results of backward pressure. Now, in an ordinary case of pericardial effusion, the sac is tensely filled with fluid, and stretched to nearly its utmost capacity, its shape being such as will yield the greater cubic contents. The contraction of the heart can thus alter but little the position of the fluid, merely increasing the already high pressure by altering the cubic capacity without changing to any extent the position of the particles. Now if, as in the the case cited, part of the fluid has been reabsorbed, but owing to stretching, the elasticity of the sac has been lost, and it does not accompany the absorption by contraction, then the remaining fluid tends to collect in the various pouches and dependent positions, and with the different movements is hurried from to another with a consequent undulatory motion. In just the same way, an extremely tense cyst feels to palpation like a solid tumour, while in a laxer one fluctuation is easily detected. Probably in most cases of effusion, as the fluid is absorbed or removed by aspiration, the stretched pericardium is still resilient enough to contract pari passu, and it is only in occasional cases, such as the above that this very marked phenomenon appears. The failure of the exploratory needle to reveal fluid is easily explained by supposing it to have entered the collapsed portion of the partially distended sac.

one corner

J. BURTON CLELAND, M.B., CH.M. SYD., Resident Pathologist, Prince Alfred Hospital.

At a recent meeting of the Vienna Society of Surgeons a demonstration was given of a new apparatus for sewing up a wound after an operation. The verdict on it was that it was swift, easy to handle and reliable. The aseptic state of the wounds after its use is better maintained than heretofore. The essential feature of the apparatus is that the wound is not actually sewn up, but is held together by means of minute clamps.

MIRROR OF HOSPITAL PRACTICE IN AUSTRALASIA.

ADELAIDE HOSPITAL, S.A. COMPOUND FRACTURE OF SKULL-No Loss OF CONSCIOUSNESS-PARALYSIS OF LEFT SIDE -TREPHINING-RECOVERY.

(Under the Care of LEONARD W. BICKLE, F.R.C.S. E., Hon. Surgeon.)

was

ON August 8th, 1901, the patient, a man, aged 21 years, was larking with a brother, and in a dispute which arose the brother picked up a piece of road metal and threw it at the patient, The wound bled striking him on the head. freely, and a doctor was sent for. It was late in the evening, and as the room was badly lighted examination very difficult and unsatisfactory. There were no symptoms of concussion or compression, and the case was treated as a scalp wound. On the 9th and 10th, patient was very well. On the 11th, in the afternoon, about 4 p.m., he felt giddy, and his left leg was weak On the 12th, Dr. H. Russell was sent for, as the man seemed worse, being drowsy, and the left arm as well as the left leg paralysed. Immediate removal to the hospital was advised. The patient remembers distinctly all details, and that the jolting of the ambulance made his headache. He was admitted into the Victoria ward of the Adelaide Hospital under my care.

State on Admission.-On seeing the patient shortly after admission he was found to be in a very drowsy condition from which he could be roused with considerable difficulty. His answers were, however, rational. The breathing was slow and laboured; the pulse about 46, full; the pupils unequal; the left being widely dilated. There was complete paralysis of the left arm and left leg. On examining the head a small scalp wound about 1 inches long was found on the right side, the edges glued together, a little sero purulent fluid coming from anterior end on pressure. On separating the edges the finger came upon a well-marked about half-an-inch in length and a quarter-inch fracture with a portion of the outer table, at widest part missing. Immediate trephining was decided on.

Operation. A curved flap with its convexity downwards was raised, having the wound about its centre. On exposing the skull it was found to be extensively fractured, with brain matter exuding. A large trephine was used and a crown of bone removed. The inner table was

fractured, and the splinters driven into the brain substance. There was a small clot of blood between skull and brain. The dura mater was torn. The portion of the missing outer table was found deeper in the brain, having been driven past the inner table. The brain was extensively lacerated and softened, the fore-finger passing in to its full length without least resistance. The softening extended to the ventricle, as there was a free escape of cerebro-spinal fluid when finger was withdrawn. Douching with boracic acid solution was carried out, the flap sutured, the edges of scalp wound cleaned, and a gauze drain inserted through it.

August 13th.-Patient very quiet and comfortable, no pain, quite intelligent.

August 16th.-Progress satisfactory, temperature normal, some movement in leg.

August 19th-Doing well, wound clean, flap united by first intention, drain left out.

August 23rd.-Good deal of pain, some bagging, and pus escaped from wound when opened by probe, small tube inserted.

Angust 26th.-Some indications of hernia cerebri. Graduated pressure by compresses boracic acid, formalin, and itrol (1-1000) was tried, and also free use of nitrate of silver stick.

September 10th.-Despite all treatment hernia has increased rapidly. Under chloroform the hernia was shaved off, and a silver plate, with perforations in centre, was placed over trephine wound.

September 18th-Patient doing well, except that plate was showing at one place where edge (although carefully bevelled) had ulcerated through. Edge trimmed under chloroform.

October 5th-Plate still troublesome. The trephine wound has cicatrised, so plate was removed under chloroform. There has been no post anæsthetic sickness on any occasion.

By this time the leg had so far recovered that he could get about with a stick; but the arm

remained helpless. A few days later he found he could move the arm from the shoulder. Ten days later he found that if he tried to close the fingers of left hand he could not do so, but if he shut the right hand at same time the left I would close too. It was interesting to watch the progress of recovery of the movements of fingers. They can now be moved by themselves.

When seen on January 3rd, 1902, he could walk freely without a stick, with just a slight drag of the leg; the left arm can be moved in all directions from the shoulder and elbow; the finger can be closed at will, but the full grasp of the hand has not yet returned. He looks well, has no headache, and his intellect is as good as ever.

Remarks.-The position of the hernia as seen in the illustration (from photo by author) will serve better than any description to locate the injury. The case is of marked interest in location of brain centres, and it is not a little remarkable that so serious an injury should have been unaccompanied by loss of consciousness, and that the onset of symptoms should have been so gradual.

HOSPITAL FOR SICK CHILDREN,
SYDNEY.

A PECULIAR CASE OF PERITONITIS.
(Under the care of Mr. C. P. B. CLUBBE).
Reported by REGINALD DAVIES, M.B., CH. M,
House Surgeon.

H.G.. 7 years of age, was admitted to the Children's Hospital under Mr. Clubbe on January 4th, 1902.

History of illness. The patient was suddenly attacked about six days ago with vomiting and diarrhoea which continued almost incossantly for three days. The attack was supposed to have been due to the eating of a "shop-made meat pie. Three days after the onset of the illness the diarrhoea suddenly stopped and since then the child has passed no motion, but the vomiting has continued, and all food is rejected. Child is complaining of pain in stomach, most marked in region of the umbilicus

On examination.-Child lying with both legs flexed on abdomen. Face very drawn. Temperature 101-8°, pulse 128, respiration 36.

Abdomen.-Distended and tympanitic in upper part. In left iliac fossa there is dulness. No marked tenderness over McBurney's point, nor any dulness in that region. Per rectum no mass to be felt.

Operation. The abdomen was opened in middle line almost immediately. The appendix was searched for and found healthy. The intestines were found to be matted together by thick purulent lymph, but there was no smell from abdomen. In the left iliac fossa were found numerous coils of small intestine-collapsedwhich had evidently given the dull note on percussion over that region. The coils of intestine were brought to the surface, examined carefully, and the purulent lymph removed. In this manner the whole length of the intestine was examined, and found to contain no lesion until the upper portion of the jejunum was reached. It was then seen that, corresponding with the length of collapsed bowel, the mesenteric veins were thrombosed in several places. There were about four thrombosed veins to be seen; the area of thrombosis being about an inch and a half long and about half an inch wide. The thrombosis of the mesenteric veins was apparently the cause of the collapse of the bowel. The abdominal wound was closed after insertion of a glass drainage tubo. The child gradually sank, and died in 36 hours' time.

No post-mortem was allowed, but was hardly necessary, as such a thorough examination was made during the operation.

REVIEWS AND NOTICES OF BOOKS,

to

STUDIES IN HETEROGENESIS. By H. Charlton Bastian, M.A., M.D., F.R.S. Lond. Emeritus Professor of the Principles and Practice of Medicine and of Clinical Medicine in University College, London; Consulting Physician University College Hospital; and Senior Physician to the National Hospital for the Paralysed and Epileptic. Part First. With 210 illustrations from photomicrographs. Williams and Norgate, London, 1901.

In this memoir, Dr. Bastian returns to a subject upon which, as he tells us, he has been silent for twenty-nine years. He again enters vigorously upon a defence of the position he took up in his work on the "Beginnings of Life," published in 1872, and we cannot but admire the keen scientific spirit in which the veteran physician again tackles the problem of heterogenesis. In his leisure hours he has been making observations upon the life history of some of the low forms of vegetable life, such as the confervæ, euglenæ, spirogyra, etc., and tells how from these vegetable forms he has seen emerge ambæ and other low forms of animal life. He has studied photomicrography specially that he might be able to present a clear and unbiassed account of what has happened under his own observations, and what, as he says, anyone who takes the trouble can verify for himself. At the end of the work are appended over 200 reproductions from photomicrographs taken by the author himself, and which well illustrate the text. In conclusion, Dr.

Bastian points out how the doctrine of heterogenesis will explain many of the difficulties which have long been apparent in the doctrine of evolution, and which were well known and recognised by Darwin himself; and how this will explain the persistence of the low forms of animal life, without assuming that they have persisted undeveloped through countless ages, and in all parts of the world. While the appearances described and figured by Dr. Bastian may possibly admit of another interpretation, one cannot but respect the opinion of so able and scientific a worker, and all who appreciate the motto "audi alteram partem," will much enjoy the perusal of this contribution to a most interesting subject.

G.E.R.

MATIERE MEDICALE ZOOLOGIQUE, HISTORIE DES DROGUES D'ORIGINE ANIMALE, par H. Beauregard, Professeur à l'Ecole Supérieure de Pharmacie de Paris, etc, Revisé par M. Coutière, Professeur agrégé chargé de Cours à l'Ecole de Pharmacie. Avec préface de M. D'Arsonval, Professeur au College de France. Paris: C. Naud, Editeur, 3 Rue Racine, 1901.

In order to understand the nature of this work, we may premise that the author was by profession a zoologist, and, becoming attached as professor to the Superior School of Pharmacy at Paris, naturally was led to survey the natural history of animals from the stand-point of the pharmacist.

Hence, while his object in this treatise is "to give the history of the animals, and drugs of animal origin used in therapeutics," there are certain points in which the result greatly differs from most of its predecessors. The latter usually have been simple collations, or have contained zoological descriptions of so very compre hensive and detailed a nature, as to consist of material of no use to the pharmaceutist who might be seeking information about objects of special interest to himself.

The author, in well-chosen, clear language, gives only such general information as regards classification, anatomy and physiology as will enable any one with very moderate preliminary knowledge to follow him in subsequently are referred to. the detailed descriptions of the special objects which

By avoiding over-elaboration in general matters, he has been able to give very full and interesting information upon many points hitherto misunderstood, or not known. Much of the work, indeed, is composed of the results of years of original investigation, which have been published in comparatively inaccessible forms.

Particu

This leads to a certain lack of proportion, which in the case of a mere text-book would be undesirable, but in a treatise of this nature is more than pardonable, being counterbalanced by the valuable information thus for the first time made easy of access. larly interesting are the articles treating of the cachalot, vesicating insects, and the genito-urinary glands of the mammifers. It is not likely that medical practitioners will be extensive patrons of such a work, but to the pharmacist it must prove of the greatest interest.

The large number of illustrations, many of which are in colours, enable the reader to follow the text with great ease. The price of the work is very moderate in view of its contents, and the satisfactory form in which it has been issued.

A melancholy interest attaches to this publication, for the author died before its issue, and it was therefore left to others to take his place, their kindly expressions of love and respect being incorporated in the form of a graceful prelude. T.S.D.