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of the duodenum enables the operator to deal with the duct extraperitoneally. If the stone occupies the sinus of Vater and it cannot be dealt with by the latter route, the incision in the posterior parietal peritoneum should be closed and the descending portion of the duodenum opened, a procedure which is familiar to all.
7. Where, as in many of these cases, a temporary biliary fistula is indicated, suture the wall of the divided gall bladder to the belly wall, exclusive of the skin and superficial fascia. The fistulous orifice will become occluded shortly after the removal of the drainage, by observance of the latter method.
Some Points in the Treatment of Appendicitis when Pus is Present. Woolsey (Med. Record, vol. 55, no. 13) arrives at these conclusions:
1. In operations for appendicitis, when pus is present, the first consideration is the life of the patient, the second the avoidance of disagreeable sequela, of which ventral hernia is the most common and hence the most serious.
2. Post-operative ventral hernia may be largely avoided in spite of the necessary use of drainage, (1) by the use of the McBurney muscle-splitting incision; (2) by suturing most of the wound, and (a) the use of provisional or secondary sutures in the part left open for drainage, or (b) the early removal of the gauze drain, facilitated by the use of a rubber tissue collar where it passes through the wound, allowing the walls of the cavity and the sinus to become approximated, thus avoiding the necessity of filling up by granulations.
3. By the latter method complete and firm wound union has been obtained in fifteen and one-half days on the average, and in all ordinary ones inside of three weeks. To this end the appendix should be removed if possible.
4. The relative frequency of hernia following pus cases with drainage is another argument for early operation in appendicitis. It is also an answer to the charge that surgeons are too eager to operate for appendicitis, not infrequently expressed by physicians who would defer operation until the chance of success is diminished and the danger of post-operative hernia is increased.
Hypertrophy of the Prostate.
At the meeting of the Paris Surgical Society, M. Monod (Med. Press & Circ., vol. 67, no. 3126) spoke on the ligature of the vessels of the spermatic cord for hypertrophy of the prostate. A patient suffering from that affection entered his ward for acute retention of urine. During three days, it being impossible to pass a catheter, the bladder was tapped, but finally a fine instrument was passed and left in situ. At the end of a week M. Monod placed a ligature on the vascular pedicle of the testicle, and in a short time the patient was able to micturate freely. As to the spermatic gland, it diminished slightly in volume, without, however, presenting any tendency to sphacelus. Monod considered that the benignity of ligature of the spermatic vessels toward the nutrition of the organ could be explained by the fact that when the vas deferens was separated from the vessels about to be ligatured, the artery of that canal is so intimately associated with it that it escaped being tied, and although of exceeding small caliber, is sufficient to maintain the nutrition of the gland.
M. Regnier thought that his colleague was particularly fortunate in the above case, for ligature of the spermatic vessels provoked frequently lesions of the
testicles, especially if the operation was not completely aseptic. Resection of the vas deferens exercised the favorable influence on the micturition trouble caused by hypertrophy of the prostate without having any evil effect on the nutrition of this gland. He could cite several cases of his own to confirm this fact. In one case the resection of the deferens canal was done on both sides, and not only did all retention disappear, but the genital function persisted.
M. Bazy said that it was a fact that resection of the deferens canal, as Sir Astley Cooper pointed out long ago, in no way interfered with the nutrition of the testicle, but, on the other hand, the operation had no effect on the hypertrophied prostate.
UNDER CHARGE OF A. G. SINCLAIR, M.D.
Professor of Ophthalmology, Otology and Laryngology, Memphis Hospital Medical College; Ophthalmic, Aural and Laryngeal Surgeon to St. Joseph's Hospital; Ophthalmic and Aural Surgeon to the City Hospital.
Double Chancre of the Lids.
Helborn, of v. Michel's clinic (Münch. Med. Wochenschr.), reports a case in a boy aged 11. On the upper and lower lids there was a semicircular, raised ulcer, with a yellowish gray slough. When the eyelids were closed the two halves made almost a complete circle. On the lower lid, in addition, there was a hard swelling in connection with the tarsal cartilage, but separated from the ulcer. The gland in front of the ear, and also one beneath the jaw, were enlarged. The ulcers healed in about four weeks. Six months later there was an iritis in the left eye; there were also two masses of granulation tissue in the neighborhood of the ligamentum pectinatum. A week later an opacity appeared on the posterior wall of the cornea, and an indurated nodule in the tissue of the left upper eyelid. A slight opacity was then noticed in the vitreous, and there was then also commencing optic neuritis. Inunction treatment was commenced a month later. The patient ultimately made a good recovery.
A double chancre of the lids is very rare. The origin of the disease was traced in this case to the boy sleeping with an elder sister who had mucous tubercles in the mouth and other evidence of syphilis. The disease was, in all probability, conveyed by kissing.
The granulation swellings in the iris should be looked upon as papules of the second stage. The vitreous did not present the characteristic opacity usually seen in syphilis. An acute syphilitic neuritis occurs usually only within one to five years. The earlier it appears the better the prognosis, as in this case. The syphilitic manifestations remained here confined to the eyes, showing thus a local, lessened resistance.—[Annals of Ophth.
A Case of Bilateral Ulcerating Gumma of the Eyelid.
Gruder, Leon (Wien. Klin. Wochenschr.), reports a case of a girl 17 years of age, who presented on the right lower eyelid, near the inner canthus, and on both lids of the left eye, reddened, painless swellings, each surrounded by an infiltrated area, and with an ulcerated surface. The patient had passed through an attack of bilateral ophthalmia, but nothing definite could be determined with
regard to it. The condition under consideration had begun three weeks previously, and had been treated with compresses saturated with some fluid furnished by a druggist. No cause could be discovered for the disease. Syphilitic infection was denied, and there were no signs of syphilis on the entire body. From the indolent, painless course of the process, with the presence of adenitis, and from the fact that it improved in a comparatively short time under treatment with compresses saturated with mercuric chlorid, a diagnosis of ulcerated gumma of the eyelid was made.—[Annals of Ophth.
A Case of Initial and Post-Initial Sclerosis of the Eyelid.
Gruder (Wien. Klin. Wochenschr.) As to relative frequency of syphilitic disease of the eye, statistics differ widely; so, too, is the exact proportion of chancres of the eye to other extra-genital chancres undetermined. It may be stated that, next to the lips and fingers, the eye is the most common site for extra-genital lesion. As the habits and social conditions of one country differ from those of another, and those of large cities from those of country districts, great variation is to be expected in the statistics on the subject frequency of primary chancre of the lid among the Russian peasantry is explained by the custom of licking the inflamed eye, or bathing it with urine. The most common site is the lower lid; occasionally the upper lid is invaded, and more rarely the conjunctiva. The lesion itself does not differ from that seen elsewhere in the body; it is usually solitary, although a limited number of cases (seven) are recorded in which there were two initial lesions. The contagion is transmitted indirectly by sponges, handkerchiefs and towels, and directly by kissing, licking, and the like. The prognosis is generally not grave. Small cicatrices will follow resolution, but no gross lesions are to be anticipated. Enlargement of the preauricular glands has no special significance, as this is a complication met with in connection with numerous other ocular affections. Gruder reports a case of double chancre of the lid, in which the manner of transmission was believed to be through the kisses of a syphilitic child.-[Annals of Ophth.
Glaucoma in Aphakia.
Hirsch, Camile (Wien. Klin. Wochenschr.), has observed glaucoma following cataract extraction in four cases, which he describes in detail. The relationship between extraction of the lens and glaucoma is not yet determined. Hirsch thinks that such eyes are predisposed to glaucoma. It is well to make a broad (so-called glaucoma) iridectomy in all hyperopic, cataractous eyes of old people, where the anterior chamber is shallow, instead of the usual small iridectomy. He is skeptical regarding the prognosis.-[Annals of Ophth.
NOSE, THROAT AND EAR.
UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS.
Laryngologist to the East End Dispensary.
Pneumatic Massage in the Treatment of Deafness and Tinnitus. Webster (Laryngoscope, vol. 7, no. 4) reports six cases of deafness and tinnitus resulting from chronic suppuration of the middle ear treated by massage alone, given through a Siegle's speculum by means of an air pump controlled by an electric motor. In the hearing these changes were noted:
Case B. Slight gain at first, followed by slight loss. The loss came after increase in force of massage over that usually given.
Case C. Gain right 9 feet, left 5 feet. In this case the right was treated by catheter also.
Case D. Whisper heard after, not before treatment.
Watch heard in each ear after, not before treatment; right increased
from loud to low voice, left from loud voice to loud whisper.
Gain right 10 feet; left, medium voice to loud whisper.
Of the tinnitus this was noted:
The cases showing greatest gain in hearing were cases where suppuration had recently ceased. One case, D, showing relief of tinnitus permanently, was not a recent case. Author thinks in class of cases detailed pneumatic massage may be of considerable value in addition to other means of treatment. Slow vibrations are as good as rapid. Siegle's speculum with a hand bulb or Delstanche's masseur, would do equally as well as a motor, in which author sees no advantage. Chronic Post-Nasal Catarrh.
Hawley (Medicine, vol. 5, no. 4) says this condition is found at all periods of life, from the nursing infant to the nonagenarian. It is particularly noticeable in the torpid and erethistic types of the tuberculous diathesis, characterized by very light or very dark hair, light or dark eyes, a dark, pallid, or light complexion, much perspiration, small blood vessels, slow, feeble or rapid pulse, and want or excess of energy in mental and physical functions.
The causes are predisposing and exciting. The predisposing causes are inherited or congenital from maternal leucorrhea, etc. The exciting causes are sudden changes of temperature and diseases affecting the upper air passages, such as measles, scarlet fever, diphtheria, etc. The author does not consider the symptoms, since they are so well known.
The clinical aspect of the disease varies according to the age of the patient and the duration of the trouble. In the early stage, particularly in the young, the post-nasal space is frequently found more or less filled with masses of tissue giving to the touch a sensation similar to that of angleworms (adenoid growths of Meyer). This mass is easily broken down and exceedingly vascular. Later
on, instead of masses of tissue, isolated growths or nodules occur, more or less evenly distributed over the vault, distinct and independent of each other. These also in the early stage of the disease are exceedingly friable. Later these growths become fibrous in character and are difficult to remove. This form of the disease is usually associated with granular pharyngitis. Often, as in cases of old chronic suppurative inflammation of the middle ear, the mucous membrane appears swollen and soggy. Again, the mucous membrane, though generally healthy in appearance, presents in the median line folds of hypertrophied tissues. These are parallel to each other, and run upward from behind the soft palate to the vault. In all of these conditions the mucous membrane is highly congested, causing that sense of fullness so distressing to the sufferers from this disorder.
The prognosis is good if seen in time and treated properly. If not, the condition gradually grows worse, affecting the neighboring parts and producing ear complications, and finally inflammation of the pharynx, larynx, and bronchial tubes. Disturbance of circulation caused by these conditions frequently leads to a gradual occlusion of the nose by thickened mucous membrane. Thus its natural function is almost entirely destroyed, causing mouth-breathing with all its ill effects. Treatment should be constitutional, cleansing, and by local applications. Author describes an ingenious spray device by which a medicament can be applied directly and forcibly against entire diseased mucosa.
Etiology of Nasal Polypi.
Wright (Laryngoscope, vol. 6, no. 4) has, with his usual thoroughness, made an exhaustive study of the etiology of nasal polypi. He carefully considers the theories of others, and from their observations and his own sums up these deductions :
Edematous infiltration of the nasal mucosa, either sessile or in the form of polypi, may result, first, from mechanical obstruction to venous return by the products of inflammation in the mucosa or in the underlying bone; or, second, from the vaso-motor phenomena accompanying chronic inflammation; or, third, from the vaso-motor phenomena present in neuroses, which may give rise to hay fever and bronchial asthma.
UNDER CHARGE OF T. J. CROFFORD, M.D.
Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.
Local Treatment in Gynecology.
Findley (Amer. Jour. of Surg. & Gyne., vol. 11, no. .9) arrives at the following conclusions in regard to some common measures employed in gynecological practice: >>:
1. The vast majority of pelvic lesions commonly treated by local applications belong either to the domain of surgery or to internal medicine.
2. Disorders of the pelvic viscera as the result of obstruction to the general circulation, primary and secondary anemias, chronic constipation; the uric acid diathesis; gout, rheumatism, syphilis and other constitutional diseases; passive