SUliUIUAL EXT It A UTS.

Trkphining foii Tubercular Meningitis

(Lnicet.) The case <>t' Ord and W'aterhouse re-

cently report,ed is <>f tli' greatest interest. It is that of ;i Ii i tie <nrl 5 years old, who was admitted into the Victoria Hospiial, ('heltsea, suffering t'roni all tin* symptoms of tubercular meningitis?the symptoms became more marked, and at last the child was becoming eoinat.ose, and seemed likely to <lie in a tew hours from compression. The

surgeon attending and the entire medical staff

diagnosed the case as one of tubercular meningitis, and agreed that an operation wa.s both justifiable and advisable, and accordingly they decided to open and drain the subarachnoid space.

" A

curved incision about '1\ inches in length was made over the left cerebellar fo.-sa of the occipital bone, commencing below and behind the mastoid process, passing with its convexity upwards and ending externally to the external occipital crest. The pericranium was raised in a flap correspond- ing to the scalp flap. A trephine f inch in diameter was then applied midwa}' between the external occipital crest and the mastoid process; the disc of bone removed was placed in warm boric solution. The dura mater, which bulged into the trephine opening was then incised, and some thirty drops of a slightly greenish serous fluid escaped. The cerebellum then bulgedlintOj the foramen in the skull, fit-ting: it tightly like a; cork in a bottle. A silver probe, the terminal ? ,

inch of which was bent to a right angle, was theu-j i nserted!between the cei ebeli u uis and-the. .aracUij noid"i ft wards -towards; i ithei fali ?icerebel.Hvr.i.AiSl

30 INDIAN MEDICAL GAZETTE. [Jan. 1896.

soon as the latter was felt the probe was rotated, so that the end projected forward into the laige subarachnoid space between the cerebellum and the medulla. Some drachms of serous fluid at

once escaped. A drainage tube was then passed along the probe and left in position; it was found that the fluid passed slowly along it. The dura mater was then sutured, and the disc of bone having been cut up into small pieces, these were packed carefully in a mosaic after the manner of MacEwen so as to fill the foramen, leaving only room for the drainage tube in the centre ; the latter was then brought out

through a hole made in the centre of the flap; the flap was readjusted with horse-hair sutures, and the wound dressed with cyanide dressings." The sequel of this operation was favourable in

every respect; many of the symptoms were at once relieved. The drainage tube was taken out 18 days later, and the child made a complete recovery. The reporters of this case believe that it belongs to the well-known type in which the tubercles are few and the fluid effusion large in quantity. To those that may be sceptical of the diagnosis in this case, they refer to the pro- minent symptoms present; the hectic tempera- ture, the occasional vomiting, and the persistence of the double optic neurites. Trephining ac- cording to Hirschberg, apart from relieving pressure, does good otherwise. We may to a

certain extent liken tuberculous meningitis to

tubercular peritonitis. Now we know that the

simple opening of the peritoneal cavity with drainage of the fluid sometimes brings about

the cure of peritonitis. Why may not drainage of the arachnoid spaces produce the same good result in tuberculous meningitis ?

A Variation in the Technique of Major Amputations. (.Medical and Surgical Report- er).?Crede's experience in 22 major amputations are given in an article in which lie states he obtained excellent results. Contrary to general custom, this surgeon makes flaps composed of both skin and muscular tissues and uses neither drains nor sutures.

After making the flaps and tying the arteries he places the flaps in apposition, and holds them there by means of a moist gauze bandage, 3 inches wide applied so as to exert a uniform pressure, and using neither drainage tubes nor sutures. The difficulty in the method is the application of direct pressure to the surface of the stump, which he does sufficiently to hinder serous exu- dation and to prevent bleeding. If there chance to be points in which the skin surfaces are not in exact apposition, they heal more quickly than the tracks left by drainage tubes. The bandage begins on the under-side of the stump, passes over the end, and is repeated till the stump is covered over; during this time the apposition of the skin edges can be observed through the thin bandage. These longitudinal turns are followed

by circular ones, covering in the stump; then turns, starting on the sides and passing over, the end of the stump are used, followed again by spiral turns. The bandage remains in place from eight to ten days, when all the deeper por- tions will have healed. If pain or high fever come on, Crede splits up the bandage but does not remove it, covering it in with another bandage.

Pseudo-chancre (New York Medical Jour- nal).?Dr. Gottheil, after remarking that few sy- philographers, doubt the occurrence of syphilitic re-infection, but believe that this occurrence is one of extreme rarity goes on to say that there are numerous records of cases professing to

prove a reinfectio syphilitica but few survive the test of critical examination. There are so many lesions which at times simulate a true chancre, and deceive even good men. As even the latest edition of Erichsen does not condescend to go into these numerous sources of confusion, a resumd of the lesions that may simulate true chancre, as taken from this paper, may profitably serve to

remind Us of the pitfalls that, at times, beset us in diagnosing such cases.

1. An artificial induration.?Such as may be produced under a herpetic or chancroidal ulceration by the use of nitrate of silver, car-

bolic, nitric or acetic acids, the acid nitrate of

mercury, or even alcohol. This is undoubtedly a frequent source of error, and it requires the

strongest corroborative evidence, in the shape of other early syphilitic lesions to diagnose as a chancre any ulceration that has been so treated.

2. A nodular lymphangitis in gonorrhcea. ?If phimosis is also present, the nodule can be felt but not seen; and until the glans can be ex- posed, we must remain in the dark. Even if there is no phimosis, the nodule may be ulcera-

ted, and we must suspend judgment. 3. Scabies.?These lesions on the penis are

frequent; if now such a lesion has been scratched or irritated in any way, it is quite liable to be mistaken for an initial lesion.

4. A secondary induration?Occurring late in the disease at the site of the initial lesion. This is the pseudo-chancre of Fournier; and while it is of rare occurrence, it exactly simu- lates the original tumour.

5. A papule or tubercle?Situated on the

penis as part of a more or less general specific eruption. This has to a certain degree the same characters as a chancre, being a small celled accumulation of similar morphological charac- ters.

6. An ulcerating gumma.? This is specially likely to deceive when situated on the corona, where induration is, with difficulty determined, of not unfrequent appearance in late syphilis, its beginning as a submucous induration, and its hard base and border when ulcerated, cause it to simulate an initial lesion very exactly.

Jan. 1896.] CURRENT MEDICAL LITERATURE. 31

7. An epithelioma.?In certain cases the

ulcerated tumour with glandular involvement

may render the diagnosis difficult. All of these pseudo-chancres are fertile sources

of error in diagnosis. All of them may look so like a true chancre as to deceive even an ex-

pert. Some necessarily occur in patients al-

ready syphilitic; in others the patient mayor may not have had the disease.

A Deodoriser for Iodoform (ibid).?The oil of turpentine will cause this offensive odour to disappear immediately from anything with which this antiseptic has come in contact. The hands

may be first washed in water to which some tur-

pentine has been added, and afterward with soap and water, and it will be found that the odour has entirely disappeared.

H. W. Pilgrim, m.b., Lond.