and desquamated, and the feet, the head, and the body were successively affected in a similar manner. On examination there was cedema of the forearms and hands, also of the legs and feet, and the skin was red and scaling freely. The thighs and the lower part of the trunk presented red scaly patches at the periphery of which minute discrete red papules could be seen. The scalp was red and scaly and bald on the crown and the hair which remained was very thin. There were a few scaly patches and pustules on the face. Several boils were found on the thighs, the genitals, and the shoulders. There was no history of any form of skin disease before taking the boric acid and borax. elimination of boric acid by healthy kidneys may perhaps During the past year I have administered boric acid to nearly 40 patients who were likely to derive benefit from the drug and I have carefully watched the cases. In no case has any bad effect followed, though one patient has taken the drug continuously for four months. In one case, that of a man, seventy years of age, who took 80 grains of boric acid per day in divided doses for four weeks, there was a distinct flushing and redness of the skin with the appearance of slight albuminuria. The urine was normal before taking the boric acid and the albumin disappeared about two weeks after it was discontinued. I have taken boric acid myself in 15 grain doses without any inconvenience. On one occasion I took 120 grains within four hours. The result was nausea but no vomiting, and colicky pains in the abdomen, followed by diarrhoea seven hours after the first dose, which continued during the night and the following morning. On the next day I suffered from slight headache, a feeling of depression, a want of appetite, and a marked flushing of the skin. The urine was increased and 60 oz. were passed in the twenty-four hours following the first dose. It contained free boric acid which was present in that which was first passed four hours after taking the drug and could still be found twentysix hours after, but it could not be detected forty-four hours after the administration. A portion of the urine was evaporated to dryness and incinerated, the ash being repeatedly extracted by 90 per cent. alcohol until there was no green tinge in the flame when the alcohol was ignited. The residue was again ignited, acidified by sulphuric acid, and mixed with alcohol, and on igniting the alcohol a green MEDICAL, SURGICAL, OBSTETRICAL, AND flame was at once produced. From these experiments I conclude that while a great part of the boric acid is excreted unchanged a certain portion is converted into borates (probably sodium) and excreted in that form. I was unable to make a quantitative determination owing to the fact that as boric acid volatilises in the presence of steam a large part was lost in the process of evaporating the urine. Neumann states that from 1 part of boric acid in 1000 to 1 in 500 is sufficient to preserve milk. These amounts are not infrequently exceeded. It may be noted that even 1 in 500 corresponds to 17.5 grains per pint and constitutes a very large | dose for an infant on milk diet and is likely in some cases to produce disturbance of the alimentary canal. In ordering milk diet for cases of kidney disease it ought also to be ascertained that the milk supplied is free from excess of boric acid or borax. The use of boric acid or the borates in surgery and their internal administration, though usually free from danger, ought to be carefully guarded in patients whose kidneys are diseased, and immediately discontinued should dermatitis or other toxic symptoms appear. suspected cases the examination of the urine for boric acid and borax may afford valuable evidence of the absorption of the drug. Manchester Experiments upon animals have been performed by J. Neumann, 15 who found that dogs weighing 15 kilos. could tolerate from 5 to 6 grammes of boric acid without other injury than fall of temperature, but larger doses caused in addition vomiting and diarrhoea. Quantities up to four grammes were injected into the pleural and peritoneal cavities in a three per cent. solution without causing inflammation; a five per cent. solution, however, excited peritonitis. Large doses (10 grammes or more) caused death through nerve and muscle paralysis. Rabbits, pigs, horses and fowls gave similar results. From a review of the recorded cases of intoxication from the use of boric acid and borax it seems clear that two forms must be distinguished-one in which a large quantity of the drug is rapidly absorbed from the alimentary canal, from a serous or other cavity, or from an extensive raw surface; in these cases vomiting and diarrhoea, general depression, and partial paralysis of the nervous and muscular systems occur and may cause death. A rash is noted in many of the cases, especially where the patient recovered or lived some days after the absorption of the drug. The other class of cases results from the administration of boric acid or borax in comparatively small doses for long periods, and the symptoms appear at a variable time after the commencement of the drug. In some of these cases it is mentioned that the kidneys were diseased, in other cases albumin appeared in the urine, and in several cases ending fatally uræmic symptoms are described. Whether the condition of the kidneys or an individual idiosyncracy in regard to the drug is the determining factor in causing toxic symptoms requires further investigation, but it is an important fact that the great majority of persons taking boric acid or borax do so without any injurious consequences. The very rapid 25 Archiv für Experimentelle Pathologie und Pharmacologie, 1881. Clinical Notes: THERAPEUTICAL. HYDATID CYST OF THE AXILLA IN A CHILD. BY P. J. THOMSON, M.R.C.S. ENG., L.R.C.P. LOND. In On Nov. 14th, 1898, a strong, healthy-looking little Flemish girl was brought to my clinique by her mother who was very anxious to have the child relieved of a swelling in the right axilla. The mother stated in answer to questions that the child was just two years old and but for the swelling had always been perfectly healthy. She also said that the child had had nothing but the breast until she was six months old when she was fed like all the other members of the family. The swelling was first noticed when the child was six weeks old; it was then of about the size of a pea. It appeared to remain stationary for about a year and began to increase in size and gradually attained its present volume. The child had never appeared to suffer any inconvenience or pain of any kind in the tumour. On examination a hard, globular, freely moveable mass of about the size of a large marble was found close to the lower edge of the right pectoralis major. The mass was not tender to the touch and examination appeared to cause the child no inconvenience whatever. The little girl was florid and healthy-looking without a trace of any constitutional affection. Both my friend and colleague Dr. Nisot and myself were rather at a loss as to the nature of the tumour. We put aside at once the idea that it might be a glandular swelling. The hardness of the mass reminded one of tumours of a fibrous nature, but neither of us could romember having met with or read of cases of fibrous tumours in so young a child. Finally, we came to the conclusion that we had to deal with a cyst with very thick walls, possibly a dermoid cyst. The mass was removed a few days afterwards by a simple incision through the skin and subcutaneous fatty tissue. I found it less easy to enucleate than I had expected, as it had rather firm adhesions to the pectoralis major muscle. The wound healed by first intention. On cutting through the tumour we found it was a rows. cyst with very thick walls. The cavity was of about the size of a pea and contained clear watery-looking fluid in which floated a thin, very delicate membrane. Under the microscope this membrane showed no traces of organised tissue or epithelium, but appeared as a transparent membrane covered with calcareous particles. Attached to the end was a small vesicle apparently of the same structure through the wall of which could be seen a circle of hooklets. By careful manipulation I succeeded in making the head of the echinococcus to protrude. It had four large suckers and a corona of twenty hooklets placed in two more or less distinct Hydatid cysts do not appear to have been frequently met with in this position. Davain in his "Traité des Entozoaires" (second edition) mentions two cases of hydatids in the axillary region and one in the pectoralis major muscle. In THE LANCET of August 17th, 1895, Dr. W. J. Collins reported a case of hydatid cyst of the right axilla which was operated on by him and in which "the diagnosis remained uncertain until the operation, although fatty tumour and chronic abscess had been suggested. With regard to the origin of the hydatid cyst in my case, the mother of the child informed me that the water-supply of their farm was derived from a well and that she had often noticed it to be full of insects and living organisms. She also stated that the child had from an early age shown a great liking for raw meat and uncooked vegetables. Personal hygiene did not appear to be one of the mother's strong points. Brussels. VIABILITY IN CHILDREN. BY O. H. L. JOHNSTON, M.D., L.R.O.S, EDIN. THE following case is worth recording. A married woman, the mother of two children, who had been a patient under my care for about ten years, was visited by me and delivered of a living male infant at 4 A.M. on Dec. 2nd, 1898. She stated that she had last menstruated on June 6th, 1898, that she felt the movements of the child about the middle of October, and considered herself six months pregnant. The infant was very small; his skin was of an intense red colour, much wrinkled, and covered with a down, and there was an absence of sebaceous matter. Not deeming it advisable to use water I directed the nurse to wipe the child and after enveloping him in flannel placed him in bed beside the mother. At first some diluted sweetened milk was given which the stomach rejected. The day after his birth he weighed 11b. 13oz. avoirdupois and his length was 124 in. More diluted milk was given which was retained and also a few drops of port wine. Although he was kept in a room at a uniform temperature, was covered with flannel, and took a small quantity of nourishment, he did not possess sufficient vital energy to keep the body warm, and he died on the evening of Dec. 4th, having survived his birth two and a half days. Assuming conception to have taken place after the last menstruation the duration of gestation would be 178 days or under six months. St. John, New Brunswick. THE TOPICAL USE OF QUININE IN LEUCORRHŒA. BY W. WRIGHT HARDWICKE, M.D. ST. AND., M.R.C.P., L.R.C.S. EDIN. QUININE topically applied to the mucous surfaces of the cervix uteri and vagina was suggested by the good effects accidentally manifested by this drug when used in the form of pessaries though for quite a different purpose. A patient, the mother of six children, who had been a sufferer from the above complaint for some years, having used the various remedies usually prescribed in such cases but with only temporary benefit, her trouble sooner or later recurring, adopted the use, from prudential motives, of what I found to be quinine pessaries. I learned from her that since using them not only had her leucorrhoea disappeared but her general health had improved also. Though she had been in the habit of using from two to four of these pessaries a week for a period of over two years she had never suffered any ill-effects such as quinism. I have since used quinine topically in several cases of simple leucorrhoea and in every case with great success-in fact, I do not know of a single instance in which it has failed or in which quinism has been produced. It may be used in the form of douche or pessary. I adopt the latter form as being obviously the better one, the drug having a better chance of closer and more continuous contact with the congested membrane. I prescribe three grains of the hydrobromate in a half-drachm pessary in com-. bination with oleum theobromatis, but the pessus quinine of the "Extra Pharmacopoeia" containing the hydrochloride answers just as well. One insertion a day is generally sufficient, a good result being very soon manifest. It is a matter of astonishment that quinine in the form of pessary has never been used before in the treatment of leucorrhoea and ulceration, for its valuable properties-tonic, astringent, and antipyretic-suggest it as a useful remedy in such cases, but I can find no record of such in any of the well-known works on the subject. Fast Molesey, In the IN the Mirror of Hospital Practice we published recently" an account of an interesting case at St. Thomas's Hospital, under the care of Mr. W. H. Battle, in which the intestine ruptured without external wound was sutured and the patient survived the operation nearly a month, dying finally from an abscess behind the liver. following case also the intestine was torn without any wound of the abdominal wall and the very successful result may be in great part attributed to the short interval (less than two and a half hours) which elapsed between the accident and the operation. In some introductory remarks to the case already mentioned we pointed out that disappearance of liver dulness was by no means invariably found in rupture of the stomach or intestine and Mr. Walsham's. case illustrates this point very clearly. With regard to the use of morphia in abdominal operations we think it impossible to lay down hard and fast rules. There is at present. a disinclination to employ it, but a reaction in the opposite: direction is by no means unlikely. If only sufficient morphia is administered to allay the irritation and to calm the patient and not enough to produce troublesome constipation or to hide dangerous complications then in our opinion the morphia will do nothing but good. For the notes of the casewe are indebted to Dr. Gilbert Smith, house surgeon, and Mr. Hulton, dresser. A boy, thirteen years of age, was admitted into the surgery ward of St. Bartholomew's Hospital under the carc of Mr. Walsham on June 16th, 1898, at 8.40 P.M. He had just been knocked down by an empty four-wheeled postthe upper part of the abdomen. On admission the patient. office van, a wheel of which had apparently passed across was pale and collapsed; the pulse was 78, small, and feeble... and the temperature was normal. The abdomen was slightly retracted but moved feebly on respiration and was not hard or very tender on palpation. There was a mark across the abdomen just above the umbilicus such as might have been produced by the passage of a wheel. The liver dulness was not lost and it was thought that there was some slight. dulness in the left flank. The lad complained of severe pain in the back and there was some bruising over the spine at a 1 THE LANCET, Dec. 10th, 1898, p. 1548. spot corresponding to the mark of the wheel in front. At a rupture of the intestine, but I was determined to remain at the hospital and see him from time to time till a more definite diagnosis could be arrived at. I had not long to wait. He soon began to vomit and immediately afterwards the abdomen, which had hitherto moved, though feebly, and was not hard or particularly tender on palpation, became rigid and board-like, markedly retracted, and ceased to move on respiration. The pain became intense and the pulse rose to 100. I now ventured to diagnose ruptured intestine and at once proceeded to explore. The successful issue, I think, is to be attributed in great part to the early surgical interference, for practically no fæcal extravasation had yet occurred. After completion of the suture of the intestine, therefore, no general flushing out of the peritoneal cavity was required, and consequently there was little handling of the coils of intestine and absolutely no shock. For the first forty-eight hours the patient was fed entirely by the rectum but had teaspoonfuls of warm water by the mouth from time to time. Until June 21st he was kept under the influence of morphia; on this day the bowels were opened by a dose of castor oil which was never repeated. When he retched or felt sick, as he always seemed to do in coming out of the influence of the drug, another subcutaneous injection was given; the pulse-rate was always markedly decreased after each injection. I cannot help thinking, contrary to the fashionable doctrine of the day as regards the administration of opium in abdominal cases, that cautiously and judiciously used it is of great value. ROYAL INFIRMARY, NEWCASTLE-UPON TYNE. A CASE OF EXCISION OF THE SPLEEN FOR INJURY ; a (Under the care of Mr. RUTHERFORD MORISON.) THE operation of removal of the spleen is remarkable for the great diversity in the results obtained according to the cause for which the operation is performed. In most cases so far as the operation itself is concerned the difficulties are by no means great, and the differences in the mortalities must be wholly attributable to the cause requiring the operation. In leucocythæmia removal of the spleen has been recorded 25 times,' and of these cases only 1 recovered; doubtless many other instances of fatal result after the operation for this condition have never been published. With such a result splenectomy for leucocythemia is practically unjustifiable. A very different death-rate exists after excision of the spleen for trauma. Even in pre-antiseptic days it happened several times that an abdominal wound permitted the extrusion of the spleen and a ligature having been tied round its pedicle the spleen was removed; and these cases recovered. Since surgeons have been able to open the abdomen without fear of sepsis it has been found that removal of a ruptured spleen can be effected with a surprisingly low mortality and no better example of this operation could be given than that reported below. The evidence of fluid in the peritoneal cavity was very distinct and the diagnosis was practically certain before the abdomen was opened. For conditions other than leucocythæmia and trauma the statistics of splenectomy vary greatly, but a steady diminution in the No shock followed the operation which was rapidly completed without any difficulty, the pulse being 96 and of good volume and the temperature normal. There was no vomiting. At 2 A.M. a subcutaneous injection of morphia (1 minim) was administered as the patient was very restless, after which he slept for four hours. At 9.30 A.M. on June 17th the pulse was 130 and the temperature was 101 2° F. There was neither abdominal pain nor distension. During the course of the day the patient vomited and complained of slight pain in both | iliac regions. His urine had to be drawn off. On the 18th there was some pain as well as distension; he vomited twice and passed flatus. The pulse ranged from 100 to 120, and the temperature varied from 99.4° to 100°. On the 19th he complained of a good deal of pain. The distension had rather increased. The pulse ranged from 96 to 100 and the temperature from 98.8° to 99°. He retched a little early in the morning. The administration of a soap enema brought about a slight result. On the 20th the patient was fairly comfortable; the pulse was 96 and the temperature was 99°. There was some abdominal pain; he vomited once during the day. The rectum was cleared out. On the 21st he vomited frequently until noon; he was given half an ounce of castor oil with 12 minims of tincture of opium, after which the bowels were opened four times and the abdominal pain ceased. On the 22nd the patient was removed to Harley Ward and from this time he improved steadily, pre-death-rate is very noticeable. Spanton gives the mortality senting nothing noteworthy. On the 28th the wound was dressed. The scar was found to be dry and quite healthy. All the sutures were removed. In July the patient was discharged from the hospital in the best of health. His bowels acted regularly, his appetite was good, and he had no pain or abdominal discomfort of any kind. from 1865 to 1875 at 80 per cent.; from 1876 to 1885 it was For the notes of the case we are indebted to Dr. Grant The patient, a youth, aged sixteen years, was admitted to the Royal Infirmary, Newcastle-upon-Tyne, on August 7th, Remarks by Mr. WALSHAM.-Abdominal injuries, espe- 1898. Whilst riding down a steep hill on the front seat of a cially when there is no external wound, are always of much tandem bicycle he ran against the wall of a cottage. He interest since few cases present more difficulty in arriving at was thrown off the bicycle, crushing his abdomen against a correct diagnosis and in no case is à correct and early the handlebar. When he was picked up he was quite diagnosis of more paramount importance. The present case unconscious and blood was streaming from his nose. well illustrates the axiom laid down by the late Mr. Greig The accident occurred at 11 A.M. on the day of adSmith of the value of watching an abdominal case till an mission. The patient when he was admitted to the approximate guess, at any rate, can be made as to the nature infirmary at 10 P.M. was collapsed, pale, and unconscious, of the affection. When I was first called to the patient-the but appeared to be in pain. There was a subconjunctival fear of injury to the bladder, liver, or spleen being absent hæmorrhage of the left eye over the external rectus and also from my mind I came to the conclusion that he was pro-a contusion over the left temple. There was no bruise on the bably merely suffering from abdominal shock, a condition so frequently met with in hospital practice, or possibly from 1 Brit. Med. Jour., Nov. 2nd, 1895. 2 Loc. cit. liver cells themselves. The glands in the portal fissure were affected, but no other growths were found.-Dr. PARKES WEBER asked if the infiltration in the portal fissure might not have been inflammatory as in most cases of chronic biliary obstruction and after ligature of the bile-ducts in dogs.-Dr. GREEN, in reply, said he thought the infiltration was malignant. Obstruction to the flow of bile was not a marked feature in his case. Dr. F. PARKES WEBER read a paper on an Apparent Thickening of the Subcutaneous Veins. He said that if the superficial veins, especially the internal saphenous veins, were examined in a number of rather cachetic men the vessel walls in some cases felt as if they were thickened, and occasionally the veins could be rolled about under the finger like thin solid cords. This apparent thickening, as far as could be judged from post-mortem examinations, seemed to be due to a contracted condition in the veins especially if the longitudinal bundles of unstriped muscle fibres, which constituted the inner portion of the tunica media, happened to be well developed. The relative amount of this longitudinal muscle probably differed much in different individuals. In transverse sections this inner portion of the vesselwall was seen collected into ridges and projecting into the lumen, as if squeezed together by the circular muscle fibres which formed the main portion of the tunica media. When the vein had been kept artificially distended during the hardening process this appearance of the sections was not found. The reasons why an apparent thickening of veins was clinically noticeable in men about thirty years of age suffering from some wasting disease were probably the following: (1) the active muscular employment of a working man gave rise before the age of thirty years to full development of the unstriped muscle in the walls of the superficial veins of the limbs; (2) the compulsory rest in hospital, diminishing the circulation of blood through the limbs, caused some of the superficial veins to be comparatively empty and contracted; and (3) the wasting of subcutaneous fat consequent on disease allowed the superficial veins to be more easily felt and rolled about under the finger.— Mr. W. H. BENNETT said that he had been familiar with this apparent thickening of superficial veins for some years without being able to explain it. He had regarded it as physiological and in some way due to excessive function. He mentioned that he had seen it frequently in young women in whom there was some menstrual trouble, the thickening disappearing after the period was over. There appeared to be two varieties-one transitory, in which the vein was tender and felt like the vas deferens but relaxed and became softer on the application of a hot sponge; and the other more permanent, the veins afterwards becoming dilated and varicose. The veins about the ankle were also sometimes affected in some cases of hæmorrhoids, pain in the foot alternating with the hæmorrhoidal trouble. He mentioned He mentioned one case in which after successful operation for hæmorrhoids there was permanent tenderness and thickening along the lower part of the internal saphena. Mr. D'ARCY POWER brought forward two cases of Intussusception to show how death might result from the two opposite conditions of absolute irreducibility and of too easy reducibility. He had operated upon the patients on two successive evenings. The first case occurred in a girl, aged five months, who had been seized with sudden pain in her abdomen two days before the operation. Laparotomy was performed after unsuccessful irrigation of the bowel with hot saline solution, but though the intussusception was exposed it was found to be quite irreducible and the child died on the following day, an enterostomy having relieved the more urgent symptoms. Subsequent examination of the tumour showed that the intussusception was extremely complex. The primary invagination was ileo-cæcal and of the ordinary descending type, the apex of the invagination consisting of the congested and thickened ileo-cæcal valve with the openings of the ileum and vermiform appendix. This primary invagination was enveloped in a second intussusception passing in the reverse direction-that is to say, it was of the retrograde variety, whilst the retrograde intussusception was itself complicated by a third intussusception | also retrograde. The primary intussusception and the first retrograde intussusception had occurred during life, for their apposed surfaces were glued together by inflammatory | exudation. The third invagination which was much smaller was post mortem in origin. Two lymphatic glands were carried down in the first intussusception and both were inflamed. Mr. Power maintained that the one recognition of such a form of intussusception was of practical importance, first because it was not very uncommon, and secondly because it was very fatal. Distension of the colon by irrigation had no tendency to relieve such an invagination, indeed it rather made it worse, whilst after the abdomen had been opened the quantity of intestine involved made it impossible in a young child to bring the tumour to the surface. Any attempt to reduce the intussusception by pressing upon the apex defeated its object by increasing the size of the retrograde invagination. The second specimen was as simple as the previous was complex. The patient was a boy, aged six months, who was said to have fainted two days before he was admitted to the hospital. He presented many of the symptoms of intussusception, but no tumour could be felt until the patient was anesthetised. The abdomen was opened after an unsuccessful attempt to reduce the invagination by irrigation. The intussusception reduced itself spontaneously as soon as the apex of the tumour was touched and the wound being sewn up and dressed the patient was put to bed. Twenty-four hours later the child died and an ordinary ileo-colic intussusception was found at the postmortem examination. The invagination had therefore recurred as easily as it had been reduced. Mr. D'ARCY POWER also showed, for Dr. R. H. LUCY of Plymouth, a very interesting specimen of Enteric Intussusception similar in some respects to his first specimen. It was taken from a girl, aged thirteen years, who was seized four days before her death with a violent pain in the right iliac region. Dr. Lucy performed an abdominal section and opened the bowel above the seat of obstruction. The patient died six hours later and at the post-mortem examination a distended coil of intestine was found situated 4 ft. from the ileo-cæcal valve. The distended coil contained an intussusception and on slitting open the intussusception 3 ft. of collapsed and slaty-blue ileum were found packed away and adherent between the entering and returning layers. The ileum ended in the intussusceptum proper. Mr. RICHARD BARWELL exhibited photographs and skiagrams from a case of Congenital Limb Deficiency and Redundancy. The skiagrams were made by Mr. Mackenzie Davidson by his stereoscopic method and showed in great relief the bony defects. Mr. Davidson exhibited these with his mirror - stereoscope and gave demonstrations of his method and its value. The patient was a girl, sixteen years of age; she was not mentally deficient and with her deformed hands sewed remarkably well. The right forearm and hand were absent, being merely represented at the end of the humerus by a somewhat square fleshy cushion bearing at each of the distal corners a minute fingertip with a nail bed. By x rays this cushion was found to contain only a small misshapen piece of the ulna and a nondescript curved strip of bone. The right lower limb possessed no thigh, the buttock seemed slightly elongated forwards rather than downwards, merging into a very slightly narrower part in which the upper end of the tibia could be felt. The limb, therefore, was short by nearly the length of the thigh. In standing her right foot was very little below the level of the other knee. Stereo-skiagraphy showed the pelvis to be perfect, or nearly so; the acetabulum contained probably a femoral head and about an inch of the neck. Also lying on the upper end of the tibia was a small part of the condyloid end of the thighbone. Mr. Barwell reminded the society that many years ago he had controverted the then prevalent opinion that these truncations were mostly due to intra-uterine amputation, but he held that they resulted from a defect in development. During foetal life the foundation of every limb bone was laid down as a cell or a cluster of cells before each particular area of the limb bud had quitted the Wolffian ridge. In any part that had so sprouted forth no further foundations of bone were deposited. cases of truncation a cause hercafter alluded to produced just at the first appearance of the upper right limb bud a cessation of formative activity which continued until that period of gestation when the humerus would begin to appear. Then in growing it pressed the more distal limb segments out of the ridge and away from the area of depositary work. Meanwhile in the right lower limb development had taken the normal course until formative action re-commenced in the upper, that is until the foot and tibia had budded out of the ridge; it then ccased, hence the shaft of the femur was absent. Mr. Barwell thought that there was between the third and fourth week of In |