November 26.-Much the same, but shows some irritability when interfered with, and the comatose condition is disappearing. November 27.-Cerebral irritability increased; patient lying upon one or other side with limbs flexed, and he is constantly pulling at his penis; urine still flows into the bed, pupils normal and responsive, and swelling of eye-lid is decreasing. Since admission the pulse has averaged 60 beats to the minute, full; for first time opens eyes voluntarily; bed-sores have appeared over sacrum; seems to recognize friends; no stool since admission; a calomel purge acted freely.

December 3.-From day after admission the wound had been allowed to gape and had suppurated freely; at bottom of wound pulsation of dura-mater was plainly to be seen; patient, on this date, steadily improving, his appetite for food was good, the cerebral irritability had passed away, but he still passed water in bed ; is conscious, but slow to answer when addressed, then answers rationally.

December 6.-Now asks regularly for urinal and is fully aware of his surroundings; wound over left parietal still gaping and suppurating freely; wound over right parietal has long since healed. Nothing to note of consequence until

December 14.-On this day, at his request, he was discharged. His condition then was as follows: He still speaks slowly (this may be a peculiarity of the patient); his gate is somewhat tottering, but shows no tendency to ataxia or paralysis of either side; is perfectly sensible, and has lately gained in weight.

April 14, 1886.-Patient presented himself to-day; mental condition good. He still speaks slowly, but distinctly. There is no strabismus, vision and pupil contraction are good, and handgrip is seemingly as strong upon one side as upon the other. There was a depression upon left side of skull, in parieto temporal region, of fully one-half inch in depth; at bottom of depression a granulating wound one-half by one-eighth of an inch. in size. This wound did not pulsate. The patient has wonderfully increased in weight and strength.

April 30, 1886.-Wound has now entirely healed, no pulsation, and patient is going on a trip of pleasure to last some weeks.

CASE III.-Henry L., German painter, aged 54, 5 feet 9 inches in height, weighs 160 pounds. At 3:30 P. M., April 16, 1886, fell 22 feet, striking fairly upon his head. Was admitted into

City Hospital half an hour afterward.

since fall.

Had been unconscious

Condition on admission, 4 P. M.: Greatly shocked, but could be aroused. In answer to questions, nothing but his name could be recognized; a very large hematoma under the scalp on both sides, rapidly increasing; a very small lacerated wound of scalp over left parietal bone, near boss; a considerable depression of the skull to be recognized in the neighborhood; pupils normal; no bleeding from the nose, ear or mouth; left arm motionless; left leg drawn up and extended constantly; apparently some voluntary movement of limbs of right side; two lower true ribs, left side, fractured near axillary line; pulse 84, weak; respirations stertorous and slow. 5 P. M., patient cannot be roused; right pupil dilated, left normal; movements of left leg continue; right arm is now in continuous motion; pulse 88; diagnosis was made of depressed fracture of left parietal bone, extending by a linear separation of bone into the base of the skull, with laceration of brain; too much shocked to admit of operation. At 6:20, pulse 120, slightly stronger. An incision, an inch and a half in length, was made through the scalp down to the bone, commencing at the small wound. Another of same length at an obtuse angle, to first enable me to raise a flap and get upon the bone, which I denuded of periosteum over a space one inch in every diameter. Skull was here smooth, and no fracture was anywhere discovered by the finger-nail or probe. Hemorrhage considerable, and pulse again became imperceptible. Whiskey, hypodermically, rallied pulse somewhat. At 11 P. M., pulse still stronger, the only sign of improvement.

April 17, 7 A. M.-Pulse stronger; breathing stertorous at intervals; right pupil still dilated, but left contracted. 3 P. M., temperature 99°; general condition otherwise the same; hematoma increased, though wound in scalp gaped widely; emphysema over fractured ribs; takes small quantities of milk. 6 P. M., temperature 100; priapism; tickling sole of foot produces strong contraction of lower extremity on either side; arms have been kept still all day, but any attempt to straighten them reveals presence of the state of "irritative paralysis."

April 18.-No change for better. Gradual rise of temperature to 102.5°, and death at 3.45 P. M. Patient never having regained consciousness.

*Post-mortem Appearances.

Extensive bruise of right upper extremity; a large collection of blood over the skull, one-quarter of an inch in thickness; a depressed fracture of skull, saucer-shaped, three by four inches in diameter, involving parietal bone of left side and crushing bone into many pieces. From one part of this crush a linear fracture ran downward through external angle of frontal bone, lesser wing of sphenoid, greater wing of same bone, and ended at foramen rotundum.

On right side of skull the parietal was separated from the temporal, except at lower part, where a line of fracture ran downward through a small part of parietal, then temporal and towards median line to end at foramen spinosum. There was found an extra meningeal hemorrhage, to extent of about four ounces, covering an area two by three inches, and half an inch thick, and situated over fissure of Rolando on right side. Under this clot a rent in the dura-mater two inches in length and corresponding to the separation of the bones in coronal suture.

There was also an intra-meningeal clot to the extent of about three ounces, covering two-thirds of right hemisphere and directly connected with the extra-meningeal clot. The sources of hemorrhage were found to be the superior longitudinal sinus (which was torn up), as well as the brain substance itself at sight of laceration (in superior frontal convolutions of right side). The extent of the brain laceration was one inch in length by half an inch in depth.

* Made by Dr. Friedenwald, Assistant House Surgeon.

CLINICAL NOTES IN GENITO-URINARY SURGERY, AT

BAY VIEW HOSPITAL.

BY J. H. BRANHAM, M. D.

CASE I.-James Duffy, white, male, aged 29; last connection November 5, 1884; admitted to hospital December 28, suffering with a soft, round sore on dorsum penis near the root, which was discharging profusely; treated by iodoform, but it spread rapidly, until on January 7 it extended almost around the organ. At this time it was cauterized with strong nitric acid, after which it slowly healed.

January 20.-Was surprised to find the patient covered with papular syphilide. He did badly on mercury internally, becoming salivated and loosing strength rapidly, while the eruption changed to a pustulo-crustaceous. The treatment was then changed to iodide of potassium, beginning with 30 grains, and gradually increased to 170 grains, three times a day. No improvement noted at first, but after very large doses were given he recovered rapidly.

CASE II.-Harry C. Blair, white, male, aged 24. On Nov. 1, 1885, about ten days after connection, noticed a small sore on lower part of the mucus surface of prepuce; admitted Nov. 19, suffering with phimosis; dorsal incision on Nov. 26; January 1, 1886, prepuce so indurated and oedematous that sore cannot be seen or treated locally; glands in both inguinal regions enlarged and matted, and scrotum enlarged to the size of a child's head; he is suffering with well-marked secondary syphilis. Patient kept in bed; scrotum supported by a suspensory apparatus; black wash used locally and iodide of potassium internally. Under this treatment he improved slowly, but on April 1, when he passed out of my charge, the induration of prepuce and scrotum was still present, though much improved. The sore ceased discharging about the middle of February.

CASE III.-Lewis E., white, male, aged 27. Last connection November 28, 1885; about the 10th or 12th of January 1886, noticed that the foreskin was sore and that he could not draw it over the glans. Admitted to hospital February 12, when an extensive induration could be felt under, upon and on back part of prepuce. Treatment: dorsal incision. This was followed by great oedema and inflammation of part, which was only partially controlled by cold water dressings. It was necessary to continue these at intervals until February 24; after this iodoform was used and the sore gradually healed.

CASE IV.-John Dumphy, white, male, age 40, laborer; admitted February 11, 1886. On examination, large chancroid found on outer side of prepuce. As he was suffering from phimosis and a profuse fetid discharge was coming from beneath the prepuce, circular circumcision was done on February 13, when a large, irregular sore was found at the base of the glans. The parts were washed thoroughly with bichloride solution (1 to 2000), and afterward dressed with iodoform; patient had no bad symptoms and was entirely well on March 11. About March 1, a slight pustular eruption appeared on the lower part of abdomen; as he had no other symptoms of syphilis, this was probably not specific.

CASE V.-George W. White, male, aged 35 years. Seven years ago he had gonorrhea, which continued for a long time, and was followed by gleet and symptoms of stricture. Three, and again two and a-half years ago, he had to be catherized.

Feb

Admitted February 20, suffering with the ordinary symptoms of stricture. Examined on February 23, when an instrument could not be gotten further than the membranous urethra. ruary 27, patient given chloroform; when a slight contraction was noted at the meatus, and another, which would admit with difficulty No. 10 (English) sound, was found in the membranous urethra. Internal urethrotomy was done, and after enlarging the meatus sound No. 18 was introduced. He had a chill after passing his water next morning. This was treated by quinine, gr. X, and morphia, gr. 4. No other bad symptom followed. He was taught to use the sound, which he did without difficulty. He was discharged April 1, but ordered to continue using sound every two weeks, to prevent the possibility of recontraction.

I have selected these cases from a large number, because they presented special points to which I wished to draw the attention. of the Association.