ventricles may be opened even at a level with the skull so great is the eversion of brain. If the hernia be small excision of the mass and covering in with a flap of scalp freely cut may cure. If not, good drainage must be secured by enlarging the opening, and the wounded, inflamed brain treated in the same manner as any other inflamed part. Spontaneous revovery may result even after large quantities of brain tissue have sloughed away, the space within being filled with serous fluid. Washing with hydrogen dioxide, dusting with iodoform and application of antiseptic gauze with free drainage is the only treatment for cases too large for excision.

or of pus between the bone and dura, the trephine should be used.

5. In every case of localized injury to the head where unconsciousness persists for more than two hours, exploratory operation, including opening the skull if necessary, should be done.

6. The appearance of stupor some hours after a head injury indicates meningeal hemorrhage and requires trephining at the point of injury if known; or at the point indicated by cerebral localization: the middle meningeal lining the usual source of trouble.

7. Even in very extensive injury to the head operation should be made, since removal of debris, restoration of normal contour and cleaning of injured tissues can add but little to the danger and may save life.. 8. In every case of doubt exploratory operation is justifiable.

9. Compound fractures, with or without apparent depression, demand enlargement of the wound and careful exploration.

Celiotomy vs. Laparotomy.-The above is the caption of an editorial in a recent number of the Medical Record.

Fragments of bone having been removed, depressed areas raised to their normal position and the whole cleaned sufficiently well the question of closure confronts the surgeon. As a result of my own experience, I give the following: All oozing having been arrested by the application of very hot water, the hole in the dura is closed with finest catgut, introduced as a continuous suture with a fine, curved needle, with fine strands of catgut placed in the lower angle of the wound for drainage (if necessary). If for any reason the buttons are to be replaced they are now removed from the hot solution and put in their places just as removed; or in small pieces they may be put back upon the dura in a kind of mosaic; or the cavity may be filled with decal"We commented some time ago on the sudden cified bone chips. The flap is then cleaned, the encir cling ligature removed and all bleeding from the scalp of the surgeons of this city. While not denying a adoption of celiotomy in place of laparotomy by some checked. After a final washing the surface is dried certain etymological justification to the former term, it with bichloride gauze, iodoform dusted freely over the seemed to us not altogether unobjectionable for various dura and the scalp closed with a few interrupted or conreasons. Dr. R. P. Harris has been kind enough to tinuous catgut stitches. No silk should be used in the send us his original pamphlet, published in 1890, in scalp; if catgut is contraindicated because of imminent which he presents with much learning the argument for suppuration silk-worm gut should be used instead. In the change of nomenclature. The argument amounts the posterior angle a few strands of catgut may be laid -for drainage.

The scalp is again wiped dry and powdered with iodoform, dry bichloride gauze applied in great quantities, the head enveloped in cotton and a bandage applied over all. This is not removed until the tenth day unless some special symptom demand it. Such are some of the rules of practice I have been following in my treatment of injuries of the cranium. In conclusion I wish to offer my

RULES FOR TREPHINING IN INJURIES OF THE SKULL. 1. All cases of depressed fracture, either simple or compound, require trephining and elevation, whether there be pressure symptoms or not.

2. All punctured fractures and gunshot wounds (if not too severe) imperatively demand the use of the trephine.

3. In simple fracture of the skull where any symp. toms of brain trouble persist exploratory operation should be done.

The editor discusses it as follows:

essentially to this: that celia means 'belly,' while To this it must be said, however, that celia, according lapara means 'flanks,' hence celia is the proper word. to Foster, has had in the past four different meanings, viz., the abdomen, the intestines, the feces, and 'any cavity of the body such as the socket of a bone' (Hippocrates)..

"As we stated before, the word has already been adopted by neuro-anatomists to indicate the cavities of the nervous system. Celiolymph (Wilder) is the cere bro-spinal fluid, while the root 'cele' is in common use in medicine to indicate a cavity.

"While laparotomy may not be strictly accurate, therefore, celiotomy is not inherently much better."

After all why not use the term Abdominal Section? It seems that this expresses the meaning more distinctly than either of the other two, and cannot under any circumstances be mistaken for any other surgical procedure. W. B. D.

Now is the time to subscribe for the MEDICAL

4. In all cases of local injury to the skull, whether fracture or bruise, followed by evidence of inflamma. tion of bone, or persistant symptoms of brain irritation, REVIEW.

1

not.

If these dogs were instead placed into an asylum or hospital for dogs where they could be watched for a sufficient length of time, all fear might be removed. from all concerned in case the dog turned out to be healthy. An institution for this purpose would do away also with a great deal of charlatanism and superstition, since charlatans could no longer claim to cure hydrophobia where none existed and the madstone would lose its wonderful effect. We have no doubt that if the boards of health of our large cities would take the founding of a hospital for the purpose stated under advisement, they would meet with the moral support of all reputable physicians.

The Grippe Epidemic in St. Louis Abating.

est.

There has been a decided decrease in the number of cases of influenza within the last two weeks and the medical societies are now discussing the cases of interTwo rather unusual cases were reported by Dr. Edw. Evers at the Society of German Physicians, St. Louis, at its last meeting, which presented indubitable symptoms of Grippe. In both one leg began to become painful and much swollen and in the one case red streaks due to lymphangitis, extending from the foot The directions of absolute rest upwards, were noticed.

were disobeyed and both patients died suddenly under the symptoms of rapid and labored respiration and cyanosis. A thrombus no doubt was carried from an inflamed vein to the right side of the heart and thence into the pulmonary artery, obstructing the latter and thereby causing death. That influenza may cause inflammations is well known and has often been demonstrated by the fact that in operations done under careful aseptic precautions suppuration frequently occurs and sometimes fatal inflammations. Surgeons should therefore, if possible, postpone operations until patients are completely well from an attack of influenza and in times of an epidemic they should carefully inquire whether the patient had recently an attack of this disease.

The Effect of Castration on Woman.

of Dogs Suspected of Hydrophobia. Whenever an individual is bitten by a dog which is supposed to have rabies there is great anxiety on the part of friends and relatives and it is expected from the attending physician to give a prognosis as to the possibility of development of rabies. In the vast majority of cases the fear and anxiety has no foundation as there are not many mad dogs at large at any time, which fact accounts for the frequent wonderful cures of the madstone, in whose curative properties so many-even educated people-believe; yet, a conscientious physician must give his prognosis with some little reserve since he has no positive proof that the wound is not due to the bite of a mad dog. Some patients or their friends, particularly neurasthenics, are in constant dread for a long period after the accident that rabies might some day develop, and by neurasthenics every little symptom is frequently referred to the beginning of the dreaded In my "Lessons in Gynecology" and in my early disease. How much satisfaction would it therefore be teachings I maintained that the removal after puberty for the physician as well as the patients and their of the ovaries and the tubes does not unsex the woman friends to have a certain guarantee that the dog in at least not to a greater extent than castration after question was not mad. At present many dogs after puberty unsexes the man. In the one the ability to inthey have bitten a person are killed and there is no seminate is lost; in the other the capability of being chance of finding out whether they were diseased or inseminated; but in both the sexual feelings remain

William Goodell, M.D., writes in the Medical News: Does the removal of the uterine appendages affect the sexual sense of the woman, or in any way unsex her? Here we have an embarassing diversity of opinion. Some operators contend that in these respects castration does not affect her at all; others that it does so, and often very decidedly. The truth in such cases usually lies in the mean, as I shall try to show.

pretty much the same. Males who have lost their who may be considered as having abruptly reached the testes after the age of puberty are said to retain the climacteric. Their instincts and affections remain the power of erection, and even of ejaculation, the fluid same, their sexual organs continue excitable, and their being of course merely a lubricating one. The amorous breasts do not wither up." (Nouveau Dictionnaire de proclivities of the ox or of the steer are the scandal of Medicine et de Chirurgie,"). our highways. Alive to these facts, Oriental jealousy A riper experience, of which time was the main eledemands in a eunuch the complete ablation of the ment, has led me still further to modify my views on genital organs. Not only are the testes, therefore, re- this subject. Unquestionably the natural change of moved, but also the scrotum and the penis flush with life when fully established, but not until it is fully esthe pubes. Hence, to avoid the soiling of his clothes, tablished, does very sensibly dull and deaden the sexual every eunuch carries in his pocket a short silver tube, sense of woman, which ultimately disappears in her which he inserts merely in the pubic meatus whenever long before virility is effaced in man. Nor is the surhe passes his water. I contended, further, that, apart vival of this sense after the menopause so essential to from cessation of menstruation and from inevitable woman, because after the cessation of menstruation she sterility, the woman after castration remains unchanged, loses the power of procreation, which is retained to an having the same natural instincts and affections; that advanced age by man. This is a wise provision of the sexual organs continue excitable, and that she is Nature, for, did the sexual sense of the wife outlast just as womanly and as womanish as ever. I held that that of the husband it could not be gratified. Sensible the seat of sexuality in woman had long been sought of these changes, a gifted French authoress makes one for, but in vain. The clitoris had been amputated, the of her heroines say, with italicized emphasis: "Men nymphæ had been excised, and the ovaries and tubes may forget the course of years; they may love and extirpated; yet the sexual desire had survived these mu become parents at a more advanced period than we can tilations. The seat had not been found, because sex for Nature prescribes a term after which there seems to uality is not a member or an organ, but a sense-a be something monstrous and impious in the idea of (our) sense dependent on the sexual apparatus, not for its seeking to awaken love. Yes; age closes our being, but merely for its fruition. My inference was mission as women and deprives us of our sex." Now that the physical and psychic influence of the ovaries what happens in the natural menopause holds good in upon woman had been greatly overrated. In the popu that artificially and abruptly produced, with this imlar mind a woman without ovaries is not a woman. portant difference, that in the latter the sexual feeling is Even Virchaw contends that "on these two organs (the sooner lost. I am willing to concede that in some ovaries) depend all the specific properties of her body women, by no means in all, whose health had been so and her mind, all her nutrition and her nervous sensibi crippled by diseased appendages as to extinguish all lity, the delicacy and roundness of her figure, and, in sexual feelings, there is, after castration, a partial refact, all other womanly characteristics." This statement covery of the lost sense whenever health has been reI held to be true only in so far as the ovaries are need gained. Yet even in these cases, as far as I can ascerful for the primary or rudimental development of tain-for women are loath to talk about these matterswoman, but not true when once she is developed; for the flame merely flares up, flickers, and soon goes out. then they are not essential to her perpetuation as

woman.

*

*

My own experience would lead me to the conclusion that in the majority of women who have been castrated the sexual impulse soon abates in intensity, much sooner than after a natural menopause, and that in many cases it wholly disappears. This tallies with Glavaecke's conclusion that "in most of the cases the sexual desire is notably diminished and in many cases is extinguished." In corroboration of this statement let me cite, out of many cases in point, a few of the more salient ones. The wife, aged thirty-four, of a farmer, so exhausted him by her sexual exactions that his health suffered very seriously: The appendages were diseased and fixed by adhesions. After their removal menstruation and the sexual impulse continued unabated for

In time, however, I slowly found out that the removal of the ovaries does blunt and often does extinguish ultimately the sexual feeling in woman; although the re moval of the testes after puberty is said not to impair the virile sense of the male. This random opinion, however, I very much doubt, despite the maudlin sentiment expressed even about enunuchs by De Amicis and by other travellers in the Orient. For the secretion of the seminal fluid is in itself the great aphrodisiac, and how otherwise can we explain the changed behavior of Abelard toward Heloise after his forcible castration? Giving up this analogy, therefore, in my more recent teachings I adopted that of the menopause as suggested a little over a year, when the former wholly ceased, and by Keberle. I accepted his analogy, although I could not wholly accept his inference that woman is not affected sexually by the natural cessation of her menses. Keberle sums up his opinion in the following words: "In my own experience the extirpation of both ova ries causes no marked change in the general condition of those who have been operated on. They are women

the latter not long after disappeared. Another case was the very ardent wife, aged thirty, of a man who was not so well-mated to her. She was sterile and had excessive menorrhagia from a uterine fibroid, for which her ovaries were removed. Menstruation did not reappear, and in less than two years all sexual feeling was lost. In a third case, a young lady of high intelli

gence was reduced to a pitiable condition of ill health of active, routine work. The by-laws and rules were by menorrhagia and by frequent acts of self-abuse. She revised and amended, while the name was modified in was not insane, yet, incredible as it may seem, she accordance with a demand from medical publishers of sometimes masturbated no fewer than eight times in a general nature who desired to become members of the four and twenty hours. For several months after the Association. The active co-operation of every the removal of the ovaries, which were apparently medical publisher is earnestly solicited. Next meeting healthy in every respect, she kept up her bad habits, in Washington, D. C., September, 1894. Officers: although the monthly flow never returned. Then the President, Dr. Landon B. Edwards, Richmond, Virsexual feeling gradually vanished, and she gave up her ginia; Vice-President, Dr. J. C. Culbertson, Cinsolitary vice. In a fourth case I removed the healthy cinnati, Ohio; Treasurer, S. MacDonald, Jr., New York ovaries of an unmarried lady of middle age who was City. For application blanks and copies of the Articles queer, but not insane enough to be confined. Toward of Association, address, her monthly periods she was goaded by so irresistible a desire for sexual intercourse that she herself feared her going astray. Not long after her castration, which was done more to save her from reproach than to cure her insanity, she lost the desire wholly and absolutely. She did not, however, regain her reason, and ultimately had to be placed in an insane asylum.

CHARLES WOOD FASSETT, Secretary, Corner Sixth and Charles, St. Joseph, Mo.

A New and Safe Method of Cutting Imlach's case is a celebrated one in medico-legal Eosphageal Strictures.-This is described by Dr. jurisprudence. This skillful surgeon, after removing Robert Abbe, (N. Y. Med. Rec) and is claimed by him the appendages of a woman, was prosecuted by her for unsexing her, and by her husband for spoiling thereby te have been successfully used, and to be superior to the his marital pleasures. The special committee ap "Billroth" method (external esophagotomy and division pointed to investigate Imlach's numerous cases of cas of stricture by incision, for high strictures only), or tration at the Woman's Hospital, in Liverpool, re- internal esophagotomy, an operation always "in the ported that they found "a distinct loss of sexual feeling dark" and at times very dangerous. It is especially into such an extent as to cause serious domestic unhappi- dicated in cases of dense fibrous strictures such as result ness in not a few instances." The correctness of this from lesions due to caustics. For "impermeable" or report is corroborated from cases in my own practice, of very tight strictures, gastrostomy through the oblique engagements, broken off, of conjugal estrangements, incision, parallel to the costal arch is first performed. and of marital infidelity. The esophageal orifice is explored with the finger and a small-conical (gum elastis) bougie guided into it with the finger. Dilate, if it can be done without force, by the gradual method. If unyielding, carry a heavy braided silk ligature by a small bougie up the esophagus until it can be drawn out through the mouth. The largest bougie which the stricture will admit is now introduced so as to put it on the stretch. The string is now drawn upward by the fingers introduced well back in the mouth, and the bougie is felt to advance as the tense string wears away the tense stricture. The oper ator see saws the string up and down, while his assistant presses the bougie gently through the stricture. Larger bougies are passed in the same way as the stricture yields. When the desired dilatation is attained, a rubber tube of corresponding diameter is drawn up into the esophagus till one end is above the seat of the stricture and the other remains outside the abdominal wound. A smaller tube is also introduced into the stomach for nourishment. The patient can thus swallow water to clean the mouth, or saliva, without injury to the wounded surface. The tube also keeps up dilata. tion. It is removed on the second or third day and

Let me here remark that I was once consulted by the late Dr. Kerlin about the propriety of removing the ovaries from a feeble minded inmate of his institution, whose shameless intercourse with the other sex was the only bar to her being at large. Being very sanguine that the operation would succeed in its object I urged its performance. He, however, could not get the official sanction which we both wished for our own legal pro tection, and nothing further was done than to keep the girl under lock and key.

In other sexual characteristics I have not found in these women any marked changes, either physical or psychic. Their affections seem to remain the same; their breasts do not flatten or wither up; they do not become obese; abnormal growths of hair do not appear on the face or on the body, and the tone of their voice and its quality are not changed. In one word there has not been in a single one of my cases a tendency toward any characteristic of the male type. If any change has taken place, it has been in the direction of old-maidhood.

Americrn Medical Publishers' Association. the subsequent dilatation accomplished through the

The first annual meeting of this Association was held in the Grand Hotel, Cincinnati, on Monday, December 4, 1893, and steps were taken in the direction

mouth by bougies. The gastric fistula is subsequently closed as soon as the condition of patient will permit the operation, in one case eight weeks after the primary dilatation.-Boston Med. and Surg. Journ.

BOOK REVIEWS

ABSTRACTS

MEDICINE.

Clinical Gynecology. Being a Hand Book of Diseases Peculiar to Women. By Thomas Moore Madden, M.D., F.R.C.S., Editor. [Philadelphia: J. B. Lippincott Company. St. Louis: J. H. Chambers & Co., 914 Locust Street. The Predisposing Causes of Retention of Bile in the Gall Bladder.-In the concluding por. This work, profusely embelished with 259 illustration of an article, "Some Observations on the Pathology, tione, some of which are original, is well worth reading. Etiology, and Treatment of Gallstones," by Dr. E. M. Many things new can be gleaned from its pages. Due Brockbank, of Manchester England, published in the credit is given to the work of American gynecologists November number of the Medical Chronicle, attention for their efforts in this branch of medicine. Conserva is given to the causes which predispose to the retention tion is stamped upon the consideration of vital diseases, of bile in the gall bladder (New York Med. Journ.). particularly is this true in Part IV, Diseases of the The first one considered is the dependent position of the Uterine Appendages. fundus of the gall bladder. If, says the author, a norm He says: "The first duty of the surgeon is to save al gall bladder and liver are examined—and this is best his patient's life and therefore, if in a case of Fallopian done on a model taken from a frozen normal liver, such tube or other disease this can be done only by immedi as is used for teaching purposes in the anatomical lecture ate removal of the uterine appendages it is obvious that room-it will be found that the fundus is distinctly this operation should at once be resorted to. But un at a lower level than the termination of the cystic der any other circumstances it should never be lost sight duct at it junction with the hepatic duct. As the gall of that the uterine appendages are as essential to repro- bladder is directly apposed to the lower surface of the ductive capacity in women as the testes are in men, and right lobe of the liver, it follows the direction taken by that by their complete removal the patient is practically the anterior margin of the lobe as it curves down to the unsexed or incapacited for the chief function and pri- costal arch. The fundus is movable, and is always the mary object of woman's married life. Nor can it ever most dependent part, while the cystic duct remains be justifiable to perform such operations without the fixed at the hilum of the liver. The line drawn through patient's full conservance and knowledge of the conse the long axis of the gall bladder, passing through the queuces, a rule the propriety of which is now generally cystic duct as its junction with the hepatic duct and (but fortunately not invariably), recognized and acted through the fundus, will be found to be oblique, running forward and downward, and the difference of level at the To the careful reader who is interested in this sub- two extremities, when the normal gall bladder is in a ject the above parenthetical remark, "but unfortunately state of medium distention, will be about an inch. not invaliably" means much. For we are aware that This difference in level can easily be seen in the posttoo much of this "spaying of women" is carried on mortem room, where it will very often be found to when the life of the patient is not in the balance and be much increased, especially if the gall bladder is dis when less beroic treatment will effect a cure, and while the sin of omission should not be regarded as less heinous than that of commission. Still we must admit that it is certainly less frequently committed.

on."

The entire work is in the form of lectures and the writer seems to appear before the reader (listeners) in his individuality and what he says carries the weight not easily obtained by any other style.

It is a work equally suited to the student and practi-
W. B. D.

tioner.

Black Urine.-Derivates of biliary pigment in the urine may simulate melanin. It cannot, therefore, be concluded that a melanotic tumor exists if the urine reacts to chromic acid. All melanotic tumors are not at tended with elimination of melanin in the urine. It should be borne in mind that the urine of patients with melanotic tumors may contain melanin, and yet not re

act to chromic acid.-Senator.

tended.

of

Any causes that depress the anterior portion of the right lobe of the liver will tend to increase the obliquity of the longitudinal axis. The wearing of a tight corset is an example of such a cause, as it produces a marked groove in the right lobe and depresses it greatly at the same time. The German pathologists term this altered liver Schnurleber, and mention it as probably the exciting cause of gallstones. The consequence all this is that even under normal conditions the gall bladder has to be emptied against the action of gravity, so that there is a tendency for it to be emptied only incompletely, and this would be more decided where the bile was thickened or contained a sediment. This dependent position of the fundus of the gall bladder, the author says, is much more marked in quadrupeds than in man, and the long axis is almost vertical. When the animal lies on its side the gall bladder is in a much better position to discharge its contents. Can this, the author asks, be a reason why animals, especially dogs,