entrance of foreign bodies and the common result is suppurative choroiditis and subsequent panophthalmitis. Non-penetrating wounds are usually the result of indirect violence and are followed in most cases by detachment, hæmorrhage, or rupture with marked irreparable loss of vision.

INJURIES OF THE RETINA

Include those due to exposure to extreme degrees of light and those due to direct or indirect violence. In the first group may be placed blindness due to direct sunlight, electric light, ophthalmia, and snow-blindness. In blindness due to exposure to direct sunlight (as in observing solar eclipse without protective lenses) the outlook is always unfavorable, as the resulting scotoma may become permanent. Complete recovery is very exceptional, but in mild cases a decided improvement may be expected if appropriate treatment is promptly instituted. The same may be said of the prognosis in electric light ophthalmia and snowblindness. As regards injuries due to violence, the common results are hæmorrhage and detachment, both of which impair vision permanently, but in varying degrees, according to their situation.

INJURIES OF THE OPTIC NERVE

Are rather uncommon. The entrance of foreign bodies into the orbit may involve the optic nerve. In such cases atrophy follows but does not manifest itself at once. Rupture of the nerve, which occasionally happens, is attended by immediate and complete blindness. Concussion of the nerve or hæmorrhages into its sheath may occur with suspension of vision more or less permanent. A great variety of injuries of the optic nerve may follow traumatism to the skull, particularly fracture of the base and the orbit. Vision is lost and atrophy follows in such cases.

INJURIES OF THE LENS

Include traumatic cataract and displacement, both of which interfere greatly with

the existing inflammation. Hence, some surgeons prefer non-interference during an attack.

The question of interference or non-interference during an attack is not yet settled; although the vast majority of operators agree that the dangers of removal of the appendix-even during the attack-are not so great as the risk incurred by the patient leaving the operation undone. However, fortunate indeed is the patient who has recovered without special harm from a first attack of appendicitis.

The question for decision now is, which is the wisest course to pursue the removal of the appendix when the inflammation has entirely subsided, during the socalled period of election, or waiting for the symptoms of a new attack before proceeding to surgical interference?

This is now, I believe, absolutely settled in the minds of surgeons. The indication. for safety and efficiency, for rapidity of operative result and an uneventful recovery, point to the removal of the appendix during this period of quiescence, or period of election.

The patient brought before you to-day, aged 35 years, has had her fourth attack of appendicitis, having persistently refused operation previous to her last attack from which she has just recovered a few days ago. She is now convinced of the probable recurrence of other attacks, and of their increased gravity. She has heard, and is now convinced, of the disastrous results which may follow such persistent and obstinate delay; and though tardy, has consented to the removal of her appendix during this fourth period of quiescence.

While she has been fortunate enough to have escaped serious harm up to this time, her delay should not be taken as an example by any one, that the fourth attack could safely be stood before finally consenting to an operation. The fact that this woman recovered from past attacks must be attributed entirely to her good fortune, for we all

know that many never recover from even the first attack.

Should we attempt to foretell the pathological conditions we are about to discover in the region of this patient's appendix, we would say, that each attack-attended as it must have been by violent congestion and some diapedesis, and by consequent fibrinous effusion-has resulted in the formation of fibro-connective tisue, binding the appendix variously about the ileo-cæcal region. Each attack brings its additional quota of such adhesions. These adhesions only tend to contract, bending the appendix in so many ways that Lucas-Championniere has called this a twist, and reckons the number of past attacks by the number of twists which he discovers in the appendix to be removed; these bends or twists correspond to the succeeding formations of adhesions and fibers resulting from each attack.

It is a problem still unknown, why one may recover from an acute attack of appendicitis, remain apparently well, and still be predisposed to future more serious attacks. It would seem that with each attack the appendix on the one hand would lose its power of resistance to future invading germs. This explanation of gradual debility would only be acceptable when the caliber of the appendix furthering an attack still remained open.

There are cases, however, where the patient having recovered from several attacks, operation reveals that recovery had taken place in spite of the fact that the isolated appendix was practically a purulent or gangrenous sac. How, under such conditions, Nature could so have reacted about the spot as to dissipate all symptoms of active inflammatory disease, is to me still an open question, and offers food for much thought along the lines of recovery by local immunity to inflammatory conditions. When, however, such a curious phenomenon has taken place as revealed by operation, we can safely conclude that some future attack would have caused the death of the patient.

In the present case, the temperature and the pulse have been normal for two weeks. There is no pain in the region of the appendix, but a slight soreness on deep pressure. There is no discernible rigidity of the abdominal wall. The conditions therefore seem ideal for a successful result.

Operation. I have adopted the straight incision through the rectus muscle separating the fibers and the rectus, and have opened the peritoneum cautiously in the direction parallel with the incision. This opening in the peritoneum is enlarged according to the necessities of the case. If a free appendix is found, and if there are no complicating conditions, it is possible to bring the appendix out through a small peritoneal opening, though the separation in the rectus muscle be very much longer. This point I consider important.

Should we find that the appendix is adherent, we should remember the great surgical principle: to see absolutely what we are doing when it is possible. The peritoneum should be then cut to the extent necessary to dissect the appendix from its adhesions.

As I introduce my finger in the ileocæcal region, I detect a mass which does not convey to me the knowledge of the present condition of things in this region. Evidently, the omentum, cæcum, ileum, and appendix share in a conglomerate mass. I must therefore see absolutely the parts if I wish to cut intelligently without running a risk of tearing the gut, or producing unnecessary hæmorrhage. I now cut the peritoneum to the full length of my incision in the abdominal wall, and by introducing these broad gauze pads, I isolate the intestines on all sides from this mass which I intend to separate so as to isolate the appendix.

These two pads are used for two distinct reasons: first, to prevent undue manipulation of the intestines, thus reducing the risk of infection from without, and to keep the intestines away from the operative field;

and secondly, by way of precaution, for, as I have hinted above, we have no assurance that in this mass of adhesions we may not find about the appendix a few drops of pus remaining there from a previous attack, which, if not controlled, would accidentally spread.

I now proceed to separate this mass, dissecting it with my forefinger. These adhesions yield much more easily to digital pressure, which proves to be safest in this form of dissection; the knife, or even the scissors, would produce too much traumatism and unnecessary hæmorrhage. Of course, there is constant danger-should the adhesions be dense of rupturing the gut. Here is where one's delicacy of touch will restrain him within the bounds of safety.

This first structure which I have separated is the omentum; its edges are thickened and inflamed; it will be ligated and removed. I now discover the top of the appendix; it is swollen and adherent to the cæcum and ileum, as well as to the parietal peritoneum, and pointing downward. Separating the adhesions causes considerable oozing. The mesappendix is very much thickened and shortened; probably contracted from long-continued irritation. Gentle compression by means of gauze bandages will stop the oozing.

Near its base the appendix is not so inflamed. I now ligate the mesappendix in two places, and having clamped the appendix near its top, I separate it from the mesappendix by dissecting away its serous membrane. The appendix is now clamped with an angiotribe at its base. This transforms that spot into a tissue of ribbon-like appearance and consistency entirely preventing any matter from exuding either from the appendix or from the cæcum, and allowing me to cut the appendix away in the most efficient manner.

The stump of the appendix is now inverted within the cæcum by sutures, and is reinforced by another row of continuous sutures.

Removing the compressing pads over the hæmorrhagic spots, I find the parts quite clean and dry. There seems to be no evidence of present active inflammation, and therefore it will be quite safe to close the abdominal wall without drainage. In order to effect this, with a view toward building a strong abdominal wall, I introduce light chromicized catgut sutures through half the thickness of the rectus muscle and the peritoneum on one side, and include the corresponding structures on the other sides. These stitches are put at a distance of half an inch away from the other. Similar stitches are made to include the upper layers of the rectus fibers, and the sheath of the rectus on both sides; thus the strong protecting structure of the abdominal wall is absolutely restored. The skin is now closed as usual with silk-worm gut.

The

The examination of this appendix reveals a very much thickened and inflamed mucous membrane, with two manifestly gangrenous spots, which, however, had not gone beyond the muscular layer of the appendix. Considerable foul mucus is present. evidence here is that the progress of this case was toward a worse and worse condition, rather than toward an atrophic condition of the appendix; and therefore is a fair witness of the gravity which some future attack would have attained, and which would have jeopardized the life of the pa

tient.

In the after-treatment, I believe strongly in the principle of rest generally applied. Rest, especially of the intestinal tract, and stimulation of the circulation. Strychnia in doses of 1/30 grain every four hours is

administered during the first three days.

Nothing is given by the mouth; but should the patient complain of much thirst, the

mouth and throat are washed out with cold

glycerinized solution. During four days. nutrition is kept up by an enema, which is administered every four hours, and consists of 1 ounce of beef tea, and 1 egg to 1 ounce of whisky and 4 ounces of milk.

6

Evacuations are produced after twentyfour hours, consisting of 1/ grain of calomel every half-hour until six doses are taken. This is followed by the injection of 1 ounce of magnesia sulphate in a glassful of water.

It is my practice never to administer opium in any shape except when abdominal pain for some reason becomes so acute as to be unbearable; then 1% grain of morphia is administered hypodermically merely to cut the pain; but not sufficient to cause sleep or to produce constipation. Should either of these effects follow the administration of a slight dose of morphia, they are counteracted by administering strychnia, and by increasing the purgation.

Such a case as this is expected to be well enough to return home in ten days. For protection, an abdominal supporter is advised to be worn for a month. Otherwise, no special precaution is resorted to.

Abstracts.

A Little-known Affection of Nasal Origin.

Dr. Stevani resumes the study of a littleknown malady, which prevails in countries where the bean is largely cultivated. This affection is marked by an extensive jaunheadache, accompanied by epigastric pain, dice of the entire surface, with intense vomiting, and sometimes diarrhoea. The author distinguishes trivial gastro-enteritis due to the ingestion of beans and favism, a disease produced only when the pollen of the legumen is breathed after having been

deposited upon flowers and fresh fruits.

The author classes the affection in the

group of reflex maladies of nasal origin.Hebdomadaire de Laryngologie, etc.

Biliary Cirrhosis of Typhoid Origin.

At a meeting of the Biological Society MM. Gilbert and Lereboullet said that among the consequences of typhoid infec

tion of the biliary passages, in addition to biliary lithiasis and catarrhal angiocholitis, biliary cirrhosis must be recognized. In several cases an anterior typhoid fever has seemed to be the point of departure of cirrhosis.

The interval, sometimes considerable, which separates the beginning of the hepatic affection from the typhoid fever, does not suppress the etiological connection any more than it does the tardy occurrence of osteomyelitis or biliary lithiasis in consequence of typhoid fever.

In one of the patients observed the biliary complications almost immediately followed typhoid fever, but nevertheless the cirrhosis. was not established until after nine years had passed. The sero-diagnosis practiced at the end of the nine years was clearly positive and the typhoid fever was the only pathological antecedent.-Le Progrès Médical.

Examination of the Blood in Acromegaly.

At a meeting of the Biological Society MM. Sabrazes and Bonnes, of Bordeaux, stated that they had examined the blood in two cases, representing two types, of acromegaly, one juvenile in the beginning with gigantism, the other of tardy development without increase of the stature. The blood differed from the normal in the first case by a diminution in the proportion of hæmoglobin, by a feeble leucocytosis, and by a comparative and absolute very marked lymphocytosis.

In the second case the proportion of hæmoglobin and the number of red globules were above the normal, but the lymphocytosis was very marked and the number of polynucleated neutrophile leucocytes was reduced.-Le Progrès Médical.

Gangrenous Phlegmon in the Course of Varicella.

At a meeting of the Society of Pediatrics M. Hallé communicated the particulars of a case of gangrenous phlegmon occur

ring in a little girl during the course of varicella and originating in a pustule situated upon the labium majus. Thence the phlegmonous inflammation extended rapidly to Scarpa's triangle and the lumbar region. Incisions gave issue to an almost clear, extremely fœtid serosity, but no pus. The phlegmonous swelling with gaseous crepitation soon ascended as far as the shoulder blade. At the same time the general condition became very serious and caused the fear of a fatal termination. New incisions were made and gave exit, like the first, to serum of excessive fœtor and finally to sphacelated débris. Nevertheless, the child made a remarkable recovery. · Le Progrès Médical.

Pemphigus with Epidermic Cysts.

At a meeting of the French Society of Dermatology and Syphilography M. Gaucher presented a young boy attacked by this congenital affection described by Vidal and Brocq. It is characterized by the appearance upon the skin of bullæ which, when they cicatrize, leave behind them small groups of miliary cysts. These cysts, in the actual case, occurred even upon the hairy scalp, which is exceptional. -Le Bulletin Médical.

Nodular Syphilitic Phlebitis.

At a meeting of the French Society of Dermatology and Syphilography MM. Darier and Civatte spoke of a case of eruption of indolent subcutaneous nodules roll

ing under the finger, coinciding with a These secondary papular syphilide. nodules corresponded to small neoplasms developed in the wall of the cavity of small veins. They were formed of plasma cells and giant cells. There was no phlebitis above or below these nodules. Clinically, there was neither oedema nor the sense of constriction. The lesions disappeared by treatment without leaving any traces.-Le Bulletin Médical.