symptoms, or attacks of mania may alternate with symptoms of phthisis. In by far the majority of such cases, however, the phthisical symptoms are merely marked, when the deposition and tubercle goes on."

X. Summary.

For the analysis of the following papers we have not space:

Annalen des Charité-Krankenhauses, &c., zu Berlin, xi. 1. 1863.-The entire number, 334 pages, is taken up with a critical inquiry by Dr. Joseph Mayer into the therapeutics of pleurisy, based on thirty-five cases, which are all given in detail.

On the Doctrine of Thrombosis and Emboli, especially in the Cerebral Vessels. Dr. H. Meissner, Leipsic. (Schmidt's Jahrb., ii. p. 209. 1863.) Cases of Gastric Fistula. Dr. Müller, and Dr. Witt. (Schmidt's Jahrb., N. 2, p. 171. 1863.)

On the Changes in the Note of Metallic Tinkling in Pyo-pneumothorax. By Professor Merbach. (Schmidt's Jahrb., No. 10, 1863, p. 47. Quoted from Varges, Ztschrs. N. F. II. 1863. p. 16.)

A Case of Acute Atrophy of the Liver. Von Dr. Mann, Privat-docent in Halle. (Annalen des Charité-Krankenhauses, zu Berlin, x. 2, 1863, p. 109.) General Considerations, Theoretical and Practical, on the Nature and Treatment of Yellow Fever. By M. Cazalas. Read before the Société Médicale d'Emulation. (L'Union Médicale for May 31, p. 408; June 2, p. 427.)

Report on Canine Madness. By M. Bouley. Read before the French Academy of Medicine. (L'Union Médicale for June 9, p. 469; June 11, p. 486; June 13, p. 504; June 16, p. 517.)

On Pellagra and Mental Alienation. By Dr. Pain. (L'Union Médicale, June 18, p. 534.)

On Amenorrhoea and Menorrhagic Fever. By M. Trousseau. (L'Union Médicale, June 23, p. 572; June 27, p. 600.)

On the Disease of the Respiratory Organs in Children. By M. Henri Roger. (L'Union Médicale, July 28, p. 177; Aug. 25, p. 374; Aug. 29, p. 404; Oct. 29, p. 193.)

On a Species of Epidemic Otitis and Otorrhoea which has prevailed for some months in París. By M. Bonnafont. (L'Union Médicale, August 1, p. 212.)

On the Diagnostic Value of an Accentuated Cardiac Second Sound. By J. Warburton Begbie, M.D. (Edinburgh Medical Journal, June, 1863.)

Discussion on Yellow Fever in the French Academy of Medicine. (L'Union Médicale, August 13, p. 298; August 15, p. 313; August 18, p. 327; Aug. 20, p. 350.)

Clinical Remarks on the Diseases of the Skin, called Parasitic. By Dr. Maurice Chausil. (L'Union Médicale, August 22, and following numbers, to September 15.)

Discussion on Hydrophobia in the Academy of Medicine. (L'Union Médicale, Sept. 17, and following numbers.)

On Pellagra. By M. Landouzy. (L'Union Médicale, Oct. 8, 13, and 17.)

Ón Glosso-Pharyngeal Paralysis. By M. Trousseau. (L'Union Médicale, Oct. 6, 10, 17, and 22.)

On the Etiology and Treatment of Asiatic Cholera. By Dr. Chabasse. (L'Union Médicale, August 11, p. 281.)

On the Mensuration of the Heart. By Professor Piorry. (L'Union Médicale, August 6, p. 243; August 8, p. 260.)

Case of Subacute Pleurisy following on a Perforation of the Diaphragm, produced by the Rupture of a Suppurated Hydatid Cyst. By Dr. Peter. (L'Union Médicale, October 24, p. 172.)

On the Present Aspect of the Doctrine of Cellular Pathology. By W. Turner, M.B. (Edinburgh Medical Journal, April, p. 873.)

On Diphtherial Nerve Affections. By Dr. E. H. Greenhow. (Edinburgh Medical Journal, August, 1863, p. 97.)

Cases of Diphtheria; with Remarks on the Treatment of Croup and the Throat Affection in Scarlatina. By Dr. G. Hamilton. (Edinburgh Medical Journal, August, p. 132; October, p. 315.)

Medical Notes on New Zealand. By Dr. J. B. Tuke. (Edinburgh Medical Journal, September, p. 220.)

Cases of Cancer of the Heart and Lungs. By Robert Law, M.D. (Dublin Quarterly Journal of Medical Science, May, 1863, p. 304.)

Cases of Pleuritic Effusion. By Samuel Gordon, M.B. (Dublin Quarterly Journal of Medical Science, May, p. 373.)

On Patency of the Foramen Ovale with Cyanosis. By B. W. Foster, M.D. (Dublin Quarterly Journal of Medical Science, August, p. 112.)

On the Natural History of Articular Rheumatism. By Austin Flint, M.D. (American Journal of Medical Science, July, 1863, p. 17.)

On Melancholia. By W. H. O. Sankey, M.D. (Journal of Mental Science, No. 46, July, 1863, p. 173.)

QUARTERLY REPORT ON SURGERY.

By JOHN CHATTO, Esq., M.R.C.S.E.

I. On Foreign Bodies in the Ear. By Dr. VOLTOLINI. (Preuss. Méd. Zeitung, No. 10.)

THE first thing we have to do is to assure ourselves that a foreign body really is within the ear, for it by no means rarely happens that persons apply under the belief that an insect or other body is within the ear, which the most exact inspection fails to discover. In some cases, inflammation of the membrana tympani is the cause of the deceptive sensation, and this becomes aggravated by the unsuccessful searching for the foreign body. On the other hand, persons sometimes have foreign bodies in the ear without being the least aware of it. The author removed a rolled-up, hairy leaf from the bottom of the meatus, in the case of a lady, who had not the slightest idea how it came there, and who consulted him for deafness of the other ear. In another case, a hexangular glass bead was removed, the patient being entirely ignorant that she had any foreign body in the ear. We should always make a very careful examination, and, when possible, by aid of the direct rays of the sun. No artificial or reflected light is a substitute for this; but where it is not attainable, Dr. Voltolini employs an apparatus of his own invention, which is also serviceable in laryngoscopy. The simplest means of all, however, is to fasten a waxtaper to the handle of a bright spoon in such a manner that the flame exactly reaches to the bowl of the spoon. Taking the spoon by its handle, and holding the light against the ear, by looking over it we are not dazzled, and can explore at our leisure. While in some cases the symptoms caused by foreign bodies in the ear are of a frightful intensity, in others they are wholly insignificant, and do not attract attention to the seat of mischief. For want of due examination of the ear, many patients complaining of giddiness, stupor, singing in the ears, &c., are sent to Carlsbad, Kissingen, or the sea-side, when all the mischief is due to a foreign body in the ear. Distant organs of the body may

exhibit more or less considerable symptoms without, in some instances, the foreign body in the ear giving rise to any peculiar sensation, so that its presence remains unsuspected.

eye.

For the removal of foreign bodies we should first employ only the gentlest means, such as syringing the ear with warm water; and by this substances of the most different form and composition-even lead-pencil-may be removed. Beyond a bent forceps, an ear-scoop with a long handle, and a small corkscrew, almost all the instruments recommended for this purpose are more or less toys, or dangerous. By means of the corkscrew, wadding and similar soft substances may be easily drawn out; and in many cases we can remove bodies by passing the ear-scoop behind them. We should never employ force, and never should pass any instrument a line farther into the meatus than we can follow it with the For want of such precaution, many a patient has lost his life or his hearing. The first effect of rough procedures is to make matters more obscure, the bleeding and swelling which ensue rendering complete inspection impossible. If the gentlest endeavours (or syringing), during which the eye guides the hand, do not succeed, the body should be left at rest in the ear-ay, even were it a dagger's point; and strong as the expression seems, the author justifies it by reference to cases on record in which pointed bodies have remained for years in the ear with impunity. It is not meant to be said that bodies should in general be left in the ear, but that matters should not be made worse than they are by violent manipulations. Leaving the body in the ear, then, warm-water syringing, and soft poultices, are to be daily resorted to, until the ensuing suppuration loosens it and gives it a new direction.

II. On the Reduction of Dislocation of the Shoulder by Slow Manœuvres. By M. ALPHONSE SALMON. (Gazette des Hôpitaux, 137.)

ment.

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M. Salmon's plan consists in eluding muscular resistance by the employment of slow and gentle procedures, leading the patient to believe that he is rather engaged in examining the nature of the accident than rectifying the displaceHe is laid flat on the back, and so much on the edge of the bed that the half of the body corresponding to the injured side projects beyond, and is, so to say, suspended outside the bed. Even in health, such a position prevents persons exercising extensive movements with the arm without making great effort. An assistant stands beside the bed, to give the patient the idea of venting his falling, but whose principal object it is really to leave him to make every effort with his sound side, for the purpose of securing for himself a solid position on the bed. The limb having been in the meantime carefully supported, so as to avoid all pain, the surgeon, standing by its side, gently grasps the hand and forearm, and draws the extremity from the trunk with extreme slowness, stopping whenever the patient manifests the slightest suffering, gently kneading the muscles situated around the point of the shoulder, frequently asking the patient whether he is giving him pain, and leading him to believe that the examination will be the more easily made in proportion as the pain is slight. All this may occupy some ten or fifteen minutes, during which the arm becomes, little by little, separated from the trunk, and gradually raised until it is parallel with the axis of the body. In order to effect the reduction, the surgeon gently transfers the limb to the care of an assistant, enjoining him to retain it without any effort in the position given to it, and places himself on the inner side of the limb, opposite to the axilla, as if he wished to explore the cavity of the joint. He now grasps the shoulder with the four fingers of each hand, joining them above the acromion, so as to render the scapula immovable. He next carries the two thumbs gently on to the head of the humerus, situated in

the axilla, and, by exerting some pressure upon it-aided if necessary by slight extension made by the assistant who supports the limb-easily causes it to slip into the glenoid cavity. The arm is then brought to the side, and, to the great astonishment of the patient, who generally has not experienced the slightest pain, the operation is at an end.

M. Salmon adduces six cases in proof of the simplicity and efficacy of the procedure, and exhibiting its superiority to those more forcible means commonly used, which cause much suffering, and often defeat their own object.

III. On Syphilitic Epididymis. By M. DRON. (Archives Générales,
Nov. and Dec.)

In a brief historical survey, M. Dron shows that, among writers on syphilis, most have denied the existence of any syphilitic affection of the epididymis (apart from that due to gonorrhoea), while some have admitted that this organ may become affected by propagation of syphilitic disease of the testicle. None, however, have recognised a lesion of the epididymis existing independently of any affection of the testis itself. It is the object of this paper to prove that such a form of syphilis does really exist; and to this end the author furnishes accounts of sixteen cases he has met with at the Venereal Hospital at Lyons in the course of less than six months of the present year. Out of this number, it is true that in two there existed at the same time syphilitic orchitis; and the number of this class of cases might easily have been increased, had not the object been chiefly to demonstrate that the affection of the epididymis may occur in an isolated manner. Care has been taken to prove that the occurrence of this affection in the sixteen cases cannot be explained by the existence of gonorrhoea, contusion, or other causes; and there can be no reason to doubt that the tumour of the epididymis really constituted one of the manifestations of syphilis of which these patients were the subjects. The prompt efficacy of the anti-syphilitic treatment adopted strongly confirms this view.

When the head of the epididymis is not exclusively the seat of the syphilitic tumour, it is always the part in which it becomes most developed and persists the longest. Generally, the tumour does not exceed a nut or an olive in size, the largest being equal to a small walnut. Its surface is irregular and knobby, and its consistence increases in solidity with its duration. It is always easily distinguishable from the testis, and it is usually very indolent, so that the patients may not be themselves aware of its existence. In some cases, however, it is somewhat painful. The functions of the organ do not seem to be influenced by the presence of the tumour, which is also usually unaccompanied by lesions of any other portions of the spermatic apparatus. The period of its appearance cannot always be determined, so little has it excited the attention of the pa tient; but in some cases this has been between three and four months after the occurrence of the chancre, while in others it has been much later. Left to itself, its duration seems to be almost indefinite, as it is met with persisting years after the attack of syphilis. Under treatment, it has always terminated by resolution, about two months being the mean time required for this to take place. Acute or chronic epididymitis, from gonorrhoea or violence, may usually be distinguished easily from this affection; and although tuberculosis of the epididymis may at first resemble it, its very different mode of progress and resistance to specific treatment will establish the diagnosis. When syphilitic testis and syphilitic tumour of the epididymis co-exist, the respective lesions are easily distinguishable; while syphilitic testis, when existing alone, can scarcely be confounded with the affection of the epididymis. This integrity of the latter organ with a syphilitic condition of the testis is by no means a rare

occurrence, however prolonged or considerable the testicular affection may be an additional proof that syphilitic disease of the epididymis, when it exists, is not a mere extension of that of the testis, but an independent venereal accident. Although a lesion not of any great severity, it is usually coexistent with other symptoms indicative of a deep-seated affection of the economy; and it has been in several cases characterized by a disposition to relapse. Nevertheless it has, in all cases that have been watched, yielded to the means employed. Accordingly, as these tumours seemed to have belonged to the secondary or tertiary periods of syphilis, mercury or hydriodate of potass has been resorted to-these remedies having been employed in some cases also simultaneously or in succession. As, however, the lesion of the epididymis is usually only one among various symptoms of confirmed syphilis, it falls in with the treatment applicable to these in general. Local treatment is unnecessary.

IV. On the Employment of Hypodermic Injections in Ophthalmic Practice. By Dr. A. VON GRAEFE. (Archiv für Ophthalmologie, vol. ix. part 2.) This method of treatment, Dr. von Graefe observes, is especially remarkable for the rapidity of its operation, and for the completeness and precision with which it may be applied. In the present paper he communicates the results of the extensive trials with the acetate of morphia which he has made during the last four years. As an instrument he prefers Luer's modification of Pravaz' syringe, which admits of the injection being made with great rapidity. The middle of the temple is the best locality, as neither considerable ecchymosis nor irritation of the skin is to be feared in consequence of the repetition of the injections. Allowing a day or two intervals, these may be performed a hundred times without any ill effect resulting. The sensibility of the skin is less here than in any other suitable part, while the loose condition of the subjacent connective tissue allows of a sufficient fold of skin to be raised and a sufficient quantity of fluid to be at once thrown in without inducing distension. It is essential that the fold of the skin should be well raised up, so that the point of the canula may be freely moved in the connective tissue prior to the injection being made. Before compressing the piston this fold should be let fall again, or the pressure exerted on the connective tissue may, on the withdrawal of the syringe, give rise to a partial return of the injected fluid. The quantity of morphia employed may vary from one-tenth to half a grain; on an average, one-sixth or one-fifth of a grain-the dose being, in fact, somewhat less than when given internally, as the effect produced is greater.

The following are the circumstances under which Dr. Von Graefe recommends the injections to be employed:-1. After injuries of the eye attended with severe pain, especially when these are accompanied with loss of the epithelium of the cornea, inducing exposure of the nerve and insupportable suffer ing. If unrelieved, this may give rise to a neuralgia of the cornea, preventing the use of the eye for a long period. In pain arising from contusions or penetrating wounds, the injections are of infinite more service and of less danger than local bleeding and the application of ice. 2. After operations upon the eye, when severe pain arises. They are often of surprising utility where this even depends upon mechanical causes of irritation, as in prolapse of fragments of membrane into the anterior chanıber, or pressure of a portion of the lens against the iris. They must, however, be employed with caution after extraction, as they may give rise to vomiting. 3. In ophthalmia accompanying ciliary neurosis, in iritis, glaucomatous choroïditis, several forms of keratitis, &c. A strong morphia injection is an excellent means for reducing a glaucomatous attack prior to operation; and in those cases of glaucoma in which