The result of operation in the milder cases of non-calculous cases are as good as in uncomplicated calculous cholecystitis, while in the more severe the mortality is

EPIDERMIS GRAFTS IN THE OPERATION

FOR SYMBLEPHARON.

F. C. Holtz, M. D., Chicago, (Annals of Ophthalmology, July, 1905). The author probably has done more to advance plastic surgery of the eyes than any other man. He now gives us his operation for symblepharon, as he performs it, after many modifications. It sounds good, and I have no doubt it will do all he claims for it.

If we have to deal with a symblepharon of the lower lid, the lid and globe are separated, and cicatricial bands excised. A half-moon-shaped disc is made just large enough to fit into the lid pocket. Its upper straight edge is perforated at intervals of 1⁄2 cm., and this edge conforms to the lid border. This disc is cut from a plate of lead or tin 1⁄2 mm. in thickness. The ends of the plate are rounded to conform to the ends of the pocket at the internal and external canthi. After being satisfied of the accurate fitting of the plate, the next step is the cutting of the epidermis flap from the outer surface of the patient's arm, the part having been previously prepared. The arm is extended from the shoulder, and while supported by an assistant the arm is grasped by the operator between the fingers and thumb of his left hand so as to keep the skin from which the flap is to be shaved evenly stretched. A flat razor is used, and its side, which is laid upon the skin, is lubricated with sterile vaseline. If this is done it is not difficult to cut a flap wide enough

wound and to get it so thin that it contains merely epidermis and the tops of the papillæ. The cut flap is transported directly from the blade to the wound, over which it is spread while the assistant holds the lid everted. The bulbar portion of the flap is then fastened by a few fine silk sutures to the wound edges of the ocular conjunctiva at the nasal and temporal side. Then the flap is tucked down into the angle between the eyeball and lid and finely spread out over the lid mound to the free margin. The convex edge of the lead plate is now placed upon the flap at the junction of the lid and eyeball and held there by moderate pressure, while the assistant allows the lid to slowly return to its normal position. After being satisfied that the flap is smooth and not rolled in at any point, and while still holding the plate in place, insert a needle armed with fine black silk into the hole in the edge of the plate which is nearest the center and pass it through the lid and let the assistant tie the thread. A similar suture is placed near the outer and inner margins. This plate assures even pressure of the flap as well as immobilizes the lid, thus rendering it unnecessary to sew the lid margins together. The eye should be kept bandaged for three days. The plate is taken out at the end of a week.

PTOSIS AND THE OPERATION OF MOTAIS.

Henry Dickson Burns, M. D., New Orleans (Annals of Ophthalmology, July, 1905). After reviewing the causes of

ptosis and its treatment the author describes Motais' operation for ptosis and reports five cases he has operated upon by that method. The operation consists in exposing the tendon of the superior rectus muscle from its attachment in the sclera to a point as high as possible in the fornix. With the tendon held up by a tenotomyhook a suture is passed through the central fibers of the tendon and tied. The fibers included in the suture are severed from their scleral attachment and stripped up by two incisions carried backward through the muscle as far as possible. The sutures are then carried through a dissection of the skin from the tarsus and emerge through the skin close to the lid border. The tendon is now pulled close up under this point and the suture tied

over a little roll of gauze. The ocular and fornix conjunctiva are brought together with sutures and the eye closed. The conjunctival sutures are removed on the third day and the tendon suture on the fifth or seventh day. The immediate effect of the operation is to cause a decided pulling up of the upper lid, so much so that the eyelids cannot be closed. The ultimate result, however, is that the upper lid is pulled up just enough to expose the pupil. There is no deformity to the upper lid and brow such as obtains in ptosis operations uniting these two structures together by cicatricial tissue. This, certainly, is a step forward in the operative management of ptosis, and is well worthy of consideration. MELVILLE BLACK, M. D.

Editor.

VEGETARIANISM MILITANT.

Vegetarians held an international conference at London June 21 and 22. The following resolution was adopted by the women's section of the conference: "As the practice of flesh-eating is associated. with cruelty and suffering, and as flesh food is unnecessary for physical and intellectual development, and as the use of a properly selected vegetarian diet will promote health, diminish drunkenness, help to solve the problem of uncultivated land and unemployed people, and prevent much of the physical degeneration which is causing such widespread alarm, the members of the First International Conference of Vegetarian Women appeal to all women who have at heart the welfare of the world to give the important subject of vegetarianism their most serious and careful consideration." A vegetarian school of cookery is to be established in London with branch schools in various other cities. A. D.

HENRY SEWALL, Ph. D., M. D., Consulting Editor.

SANITARY AND MORAL PROPHYLAXIS.

In an inaugural address read before the Society of Sanitary and Moral Prophylaxis, Feb. 9, 1905, and published in American Medicine, Feb. 25, 1905, Dr. Prince A. Morrow discusses the object and aims of the society. With his usual frankness and "practical prudence" he grapples with the most difficult of all the problems of social hygiene, that of defending society against a class of diseases that is most injurious to its highest interests, those comprehended under the general term "venereal."

Immorality and its consequent diseases ate the heart out of the greatest empire this old world has ever seen, and many modern nations are beginning to appreciate their dangers. Increased interest along these lines is attributed to "more accurate knowledge of the enormous extent and prevalence of these diseases, to a more thorough comprehension of the wide range and far-reaching char

acter of the pathologic effects, and especially to a clearer recognition of their important relations to the health and productive energy of the family, the vitality and the vigor of the descendants, and the physical progress of the race." Moral, legislative, and social as well as medical means were urged in the prophylaxis of these diseases.

One phase of venereal morbidity receives special attention, the "criminal" infection within the marriage bonds, and, quoting from Osler, the writer says: "These are in one respect the worst of all (infectious diseases) we have to mention, for they are the only ones transmitted in full virulence to innocent children to fill their lives with suffering, and which involves equally innocent wives in the misery and shame." The frequency and The frequency and gravity of marital infection are not appreciated and cannot be computed.

Ignorance is responsible for this state of affairs and education is urged as one of the most effective weapons for the fighting of this peril.

All other infectious diseases are contracted involuntarily and unconsciously; but in this class of diseases any man must voluntarily expose himself to the infection-ignorantly no doubt, but by individual free will.

The author advises that the education should be addressed first of all to the rising generation. Let the young men learn that sexual indulgence is not a ne

cessity and that continence is compatible with the highest physical and mental vigor, and let them not minimize the danger of venereal infections. The educated class of young men is very limited, and this information must reach all. It is urged that lectures, conferences and printed material of all kinds be used for this purpose and that the sympathy of legislators and public-spirited men be enlisted to aid in the carrying out of this colossal propaganda.

Prophylaxis by treatment is most important to limit as much as possible the spread of these diseases and so protect the community from the extension of this.

curse.

Moral prophylaxis is vital, for the diseases cannot exist except on account of the immorality which is their cause. Let it not be said that debauchery is a necessity for men.

Most efforts are directed toward the making of prostitution safe. The moral side of the question is left untouched. To prevent the making of prostitutes will do vastly more in the control of venereal dis

eases.

When the ignorance which has so often resulted in the bringing of venereal diseases into the homes of our land is dispelled, much of this criminal infection will be avoided, and the bulwark of our nation shall stand, and we shall prevent a great curse from falling on generations yet unborn. H. P. PACKARD, M. D.

INDICANURIA.

The most frequent abnormality of human urine is excess of indoxyl-potassium sulphate, or "indican," along with other ethereal sulphates. The examination of the urine for indican is of considerable therapeutic importance, since indicanuria

is an index of gastrointestinal autointoxication (putrefaction of proteins), which is the most common cause of feeling ill (headache, depression, waking tired, etc.). Indicanuria is noted in hypochlorhydria, achlorhydria and sometimes in diarrhea, appendicitis, peritonitis and gastric or

hepatic carcinoma. The greatest excess of indican is observed in cholera and intestinal obstruction or tuberculosis. Indican is increased by a meat diet; diminished on milk or buttermilk. It is increased in the urine by castor oil and salines; markedly diminished by calomel or lactic acid.

A simple and sufficient test for indican is to add to a little urine one-fourth as much hydrochloric acid and a few crystals of saltpeter. Boil the mixture, let cool, shake with one-sixth as much chloroform, and let settle. If indican is norIf indican is normal in amount, the layer of chloroform is colorless. When there is excess of indican, this layer is colored light blue to a deep purple, according to the amount of indican. Slow oxidation produces indigo red (indoxyl plus isatin); by further oxidation indigo blue is changed to colorless isatin. Iodids taken internally color the chloroform blue, but the color disappears on shaking with sodium thiosulphate. In Robin's quantitative test for indican, three reagents are required: (1) HCl containing 2 p. m. Fe Cl; (2) a 25 per cent. solution of Pb (C2H3O2)2; (3) KCIO, 34.6 gm. per liter of water-contains I per cent. available chlorin. To 10 c. c. of

urine add I c. c. of lead acetate solution, and filter through a double filter. Put 5 c. c. of filtrate in a test-tube, add 5 c. c. of reagent (1) and 2 c. c. of chloroform, and invert tube about ten times. Now add from a dropper the KCIO solution until the blue color in the chloroform disappears. One to two drops normally cause decoloration.

Indigo red in the urine has the same significance as indican. It is recognized (Rosenbach) by adding nitric acid drop by drop to the boiling urine, getting a deep red color, with a violet foam on shaking. Skatoxyl-sulphuric and skatoxylcarbonic acids also give a red or a violet color on treating the urine with hydrochloric acid containing a little ferric chlorid, after filtering off the sediment produced by lead acetate.

To discover phenol-potassium sulphate, distill 25 c. c. of the urine with 5 per cent. of sulphuric acid, and add bromin water to the distillate, getting a yellowish ppt. of tribromphenol. Millon's reagent gives a beautiful red color with the distillate. An intense phenol reaction has been noted in liver disease, chronic alcoholism and infectious fevers.

EDWARD C. HILL.

PATHOLOGIC ANATOMY AND METHOD OF

INFECTION IN CEREBRO-SPINAL

MENINGITIS.

Westenhoeffer (Berlin. klin. Woch., No. 24, 1905) sums up as follows:

I. The entrance of the germs causing cerebro-spinal meningitis is from the nasopharynx, particularly the pharyngeal tonsil.

2. The meningeal inflammation is always primarily a basilar one and in the region of the hypophysis, infection occurring through the lymph channels.

3. The meningeal inflammation as a

sign of disease of the cranum cavii is analogous to the disease of the mucous membrane of the retro-pharyngeal spaces.

4. Never, or certainly only rarely, is the meningitis an extension of the disease by way of the ethmoid cells.

5. The disease is pre-eminently one of childhood.

6. Children and adults attacked show marked signs of a so-called lymphatic constitution.

7. Cerebro-spinal meningitis is an "inhalation disease."

8. Stamping out the disease is essen

9. The meningo-coccus WeichselbaumJaeger is present in the large majority of the cases, but that it is the only cause of the disease is not fully proved. The fact that other cocci are found present with the meningo-coccus, or even alone, does not prove that they all do not play a secondary role and that the true cause of the disease is not yet known.

PREMENSTRUAL ELEVATION OF TEMPERA

TURE IN TUBERCULOSIS.

Kraus (Wien, med. Woch., No. 13, 1905) believes that two-thirds of all tuberculous women will show elevation in temperature of .5 to 1° C. one to two days before the beginning of the menstrual turn, and that, in case the diagnosis is in doubt, this premenstrual rise in temperature may be a valuable help in determining the existence of tuberculosis. He has noticed, too, that the physical signs are more marked at or immediately before the menstrual period.

[NOTE-In my own work with Koch's tuberculin I have noticed so often a premenstrual rise of temperature that I have come to expect it in all cases and to be able to rapidly increase the dosage at this time. Only a few days ago a patient reacted to 0.6 old tuberculin with a temperature of 37.7° and marked local reaction. Twenty-four hours later menstruation set in and forty-eight hours later 0.7 old tuberculin gave no reaction either local or general, the temperature being 37.1°.-EDITOR.]

TUBERCULOUS DISEASE OF THE EAR IN INFANCY.

Haike (Berlin. klin. Woch., No. 24, 1905) reports and discusses five cases.

Case 1. A female, age four months, whose mother and two sisters died of phthisis, had a stinking discharge from

discharge from the ear, stools, and sputum 'pumped from the stomach, tubercle bacilli were found. Death occurred at 5 months.

At the autopsy cheesy masses and submiliary tubercles were found in the lungs, tuberculous glands in the neck, axilla and inguinal region, submiliary tubercles in the liver and spleen, tuberculous ulcers in the small intestine, cheesy degeneration of mesentaric glands, caries and sequestrum formation in the temporal bone, microscopic tuberculous ulcers of the mucous membrane of the tube and tympanum, and beginning disease of the labyrinth, vestibular portion.

She died

Case 2. A female, 12 years of age, whose mother died of tuberculosis, had a discharge from the right ear. of caseous pneumonia at six months. An autopsy revealed cheesy masses in each. lung, spleen, and mesenteric and bronchial glands. On the mastoid and posterior wall of the pharynx were glands in cheesy degeneration. The probable infection of the ear was from the pharynx or glands. of the mastoid region.

Case 3. A female, seven months old, whose mother was tubercular, had a discharge from the ear which was very of

fensive. Membrane from the middle ear of the auditory canal showed diphtheria bacilli, but there was no pharyngeal diphtheria. Facial paralysis appeared three week before death, which occurred at 81⁄2 months. An autopsy showed edema of the brain, tuberculous bronchial glands at the bifurcation, caries of the temporal bone, pachymeningitis externa, tuberculous ulceration of the auditory canal, tympanum, and mucous membrane of the tube. Infection was likely primary in the ear, the diphtheria being secondary.

Case 4. A 22 weeks old child when received was seemingly healthy. At five weeks, following swelling of the mastoid glands, there was purulent discharge