The statistics of Sir Spencer Wells, 1876-77, of 150 cases there were 29 deaths, over 19 per cent., and 23 were due to septic peritonitis. One cause was a defective method in dealing with the pedicle, and imperfect understanding of the power of the peritonæum, as a medium for absorption. The risk was largely in the clamp, which for obvious reasons was long since abandoned.

Another improvement he attributes to Lister's teachings, which established indirectly, the necessity of surgical cleanliness, which with drainage and flushing of the abdominal cavity, had revolutionized the practice of abdominal surgery. The addition of antiseptics to water used in the peritoneal cavity was dangerous and without value, and using water previously boiled was not essential to success. If no decomposing material was left in the abdominal cavity, the peritoneum was capable of getting rid of a small amount of fluid remaining, and a few stray organisms thus deprived of the moisture needful for their development, were probably absorbed and excreted.

He looked with disfavor upon the administration of opium, as it restrained both absorption and excretion; and the value of the administration of saline cathartics in the early stage of peritonitis was due to their promoting absorption and excretion. As a result of improved methods in 1888-89, he quotes the records of the Samaritan Hospital, in which 130 ovariotomies with only 6 deaths, a percentage of 4.3.

During the discussion on this paper, Mr. Mayo Robsen (Leeds) gave the results of his ovariotomies, numbering 69, with 2 deaths, both of which were apparently very unfavorable cases.

CODEIA IN PELVIC PAIN.

Freund, in "Medical Chronicle," May, 1890, confirms Lauder Brunton's recommendation as to value of codeia in disease of women. In pains which proceed from the uterus it gives relief, and in ovarian troubles it is of great value, while in exudations of pelvic peritoneum and connective tissues and affections of tubes, it is inert.

He gives half a grain three times a day, which promptly relieves ovarian pain, whether functional or inflammatory. He claims its action is local, and does not impair the appetite, stupefy, or constipate.

MENSTRUATION AND REMOVAL OF BOTH OVARIES.

Englemann (Annals of Gynecology and Pædiatry, April, 1890). His conclusions and deductions are as follows:

"From the history and microscopical examination in my own cases and in that of Prof. Schatz, we may safely draw the following physiological conclusions, which are corroborated by numerous cases of oöphorectomy and of double ovariotomy, now observed, the histories. of which have been recorded for a sufficient length of time after recovery from the operation:

"I. That the continuance of menstruation after removal of both ovaries is due to remnants of ovarian stroma left in situ.

"2. That particles of ovarian tissue, however small, which remain after the removal of the greater portion of the organ, whether or not the Fallopian tube be preserved, may retain their activity and continue the functions of the entire organ, and from this we infer that menstruation is more or less intimately associated with ovulation, and that the menstrual condition indicates the ovarian status, provided the uterine tissues be normal in character.

"3. That even elongated pedicles may contain ovarian stroma in which the functional activity of the organ may be continued.

"4. That remnants of ovarian stroma do not necessarily preserve their vitality and functional activity.

"5. That the ovary is an essential factor in the functional life of woman, and that menstruation is inseparable from ovarian activity, if not ovulation.

"The deductions of practical value to the operator are as follows: "Ist. If menstruation is to be checked and the change of life produced, it is requisite that every particle of ovarian stroma shall be removed, if the result desired is to be expected with certainty.

"2d. If shrinkage of fibroids, limitation of hæmorrhage, or cessation of annoying symptoms is to be accomplished with the greatest possible certainty, both ovaries must be completely removed.

"3d. In the performance of double ovariotomy in women not yet beyond the climacteric, and not suffering from uterine reflexes, such healthy ovarian tissue as may exist should be spared in order that functional activity may not be impaired."

THE SHARP CURETTE.

In a clinical lecture (Sims, Annals Gynecology and Pædiatry, April, 1890) he incidentlly refers to the sharp curette and his preference for it. He says:

"I wish, in this connection, to emphatically state my preference for the Sims, or sharp curette, as compared with the Thomas, or dull curette. I have used both of these instruments, and it has been my experience that I can certainly remove more effectually and more thoroughly any growth or fungoid degeneration of the utricular glands with the sharp curette, and I have seen the dull curette fail completely to give relief in a number of cases. I have even had cases like the one now before you, in which the operation had to be done finally with the sharp curette in order to remove all the pathological conditions that existed within the uterus.

"It has been stated by many operators that the sharp curette is a dangerous instrument. That I do not believe, for I have used the

instrument now continually for nearly twenty years, and I have yet to see the first case of accident follow its use. Like any sharp instru ment, it is a valuable one in the hands of those who understand its use, and, probably for the same reason, it may be called a dangerous instrument in reckless hands.

"In using the sharp curette, you will always find that when you are curetting over a diseased area, the instrument will emit no sound whatever; it will, in fact, be perfectly noiseless; but as soon as your instrument has touched healthy tissue you will get that peculiar rasping sound similar to the sound produced if the curette be drawn over the palm of the hand."

DISEASES OF THE SKIN.

BY SAMUEL SHERWELL, M. D.,

Clinical Professor of Dermatology, Long Island College Hospital; Attending Physician, Brooklyn Hospital; Surgeon to Skin and Throat Department, Brooklyn Eye and Ear Hospital.

"SHOULD DOCTORS WHO HAVE BECOME SYPHILITIC CONTINUE THEIR MEDICAL DUTIES?"

Or, as Neisser's title in the original stands: "Dürfen syphilitisch infizierte Arzte ihre ärztliche Thätigkeit fortsetzen." A. Neisser, Breslau (Centralblatt. f. Chirurgie, 1889, No. 39.

This instructive, or at any rate interesting, treatise on this subject had for its origin a reply to a direct question on the subject by a medical colleague.

In this answer he lays stress on the following points: 1st. On the stage of the disease. 2d. As to whether it has been treated thoroughly up to the time. 3d. As to whether the hands of the actively-operating medical man are free from efflorescences. 4th. If any other, though perhaps non-syphilitic skin affection is present.

Points one and two do not deserve any lengthy mention. It stands to reason that the older the date of infection and the more pronounced and continuous the specific treatment, the slimmer the chances of conveying contagion to another; but even in cases of relatively recent, etc., small ulcera, and papula, Neisser thinks there is no real reason why danger should exist with care on the part of the medical man, the surfaces being protected as they should be with rubber cots, or impermeable and solid dressings. In regard to poiut No. 4, he thinks the danger here also infinitesimal with any degree of care; the eruptions

themselves cannot be dangerous, the only chance being from hæmorrhages from their surfaces conveyed to raw surfaces on the patient. He thinks this possibility of infection still a moot or open question.

He finally and in conclusion leaves the question pretty open, by saying that in every case the propriety of the operation, by surgeon or accoucheur attending right along to their proper and continuous duties, should be judged by its own merits, and no Draconian law at least can be instituted.

ON

KELOIDS: THEIR SYMPTOMATOLOGY AND PATHOLOGICAL ANATOMY, BY H. LELOIR, OF LILLE, AND E. VIDAL, PARIS. TREATMENT OF KELOID AND HYPERTROPHIC SCAR, BY E. VIDAL.

(Annales de Derm. et de Syphilographie, March 25, 1890, p. 193.) The author gives first the history of the name in the usual style, and the original credit of the nomenclature, beyond all doubt, to Alibert, 1817. They insist that it should be spelled cheloid, instead of as above; also giving credit to Alibert for his distinction of the idiopathic or true keloid, from the false or hypertrophic cicatricial tissue so resembling it. The authors make the following suggestions in the study of this affection, or, more properly, these affections, as helping to show their non-identity.

(1) Spontaneous, or idiopathic, true keloid.

(2) True keloid, but still springing from and not exceeding limit of cicatrix, or

(3) Simple hypertrophic scar.

Vidal says that the true spontaneous keloid can always be differentially diagnosticated from cicatricial hypertrophy by the fact of its having more or less of the glandular elements, as, for instance, the sweat or sebaceous ducts manifest on the surface, or at any rate demononstrable by the microscope, there may be also some downy hairs. Kaposi appears to agree with him in this; he at any rate quotes that author in his support; and Dr. L. also adds that it can be often witnessed on a keloidal tumor that there is a slight moisture when the rest of the body is perspiring; thus showing that the perspiratory function still has some action. This, he states, can be more readily proved by the administration of pilocarpine.

Another and distinguishing diagnostic proof of idiopathic keloid as contradistinguished from hypertrophic scar is the fact that it, the true keloid, never goes below the true skin-tissue, and is always movable over the subjacent tissues.

A true keloid, to tactile sense, should give more the impression of a tendon than a cartilage.

It may be insensitive, but is usually sensitive, or quite painful. The tumors of true keloid are not likely to extend over so large an area as the secondary keloid occurring in scar-tissue; they are not usually so numerous either.

Spontaneous resolution, or absorption of primitive keloids, has been observed, but that rarely; among others by Alibert twice, by F. Hebra, Sedgwick, Neumann, Hutchinson, and De Amicis, each, once.

They are inclined to occur in neurotic people, a fact which has some bearing on the disease, as perhaps being a tropho-neurosis.

Among other anatomo-pathological facts, he states that when a vertical section is made of a true keloid, the fibrous tissue will all be found to run parallel with the long axis of the tumor. The epiderm and its interpapillary prolongations are normal in the true keloid, therein differing from the cicatricial and hypertrophic form.

Giant cells may be found, but only in young keloids. In recent keloids, he says, that often round cells may be found around the broken-down vestiges of the hair and sebaceous follicles and glands, whtch goes to show that even what we term spontaneous keloid may after all have for its point of departure an acne, and perhaps should be considered secondary, as some (MOST AMERICAN) dermatologists believe. There is certainly, he says, no microbe present.

Treatment. The author's (Dr. Vidal) treatment for this affection, whether of primitive or secondary keloid, or hypertrophic scar, is identical. He makes mention of the various medicaments, both internal and external, that have been employed, and is, as every one is, convinced of their inutility; believes, however, he has seen good results follow emplastrum vigo, applied on cloth, and that continually. He also condemns, as do all other authorities, all radical surgical operative treatment, as of excision, and has no good word for actual or potential caustics; mentions, however, two reported cases-one of Warren, Boston, 1837; another of "Michon," Paris, 1848-where the operators claim by removing the tumor with a very large border of normal skin they had effected cure; he says this is not to be recommended, as the deformity, etc., would be great.

To be brief, the treatment Dr. V. recommends is scarification repeated and deep, not carried beyond the limits of tumor itself; these scarifications may be at right angles to each other (cross-hatching), or lozenged. He believes he has seen great relief to the subjective symptoms, pain, etc., afforded by this method; and says he believes by cutting the network of nerve-tissue in this manner relief is absolute after the third operation.