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1. The impropriety of giving antipyretics in all cases of suppurative otitis media.

2. The value of a bacteriological examination of the secretion from the external auditory canal in all cases of suppurative otitis media.

3. The importance of operating at the earliest possible stage after a diagnosis of thrombosis has been made.

4. The use of the normal saline solution during the operation for sinus thrombosis or immediately following it.



Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.

Surgical Gynecology Among the Insane.

Hobbs (Canadian Practitioner, vol. 24, no. 7) says that some years ago the medical staff of the Asylum for the Insane, at London, Ontario, were impressed with the idea that among the women congregated in that institution there must exist many cases of hitherto unsuspected pelvic disease. The only reliable method to ascertain the correctness of this impression was by actual examination of the most likely cases. After close scrutiny of the history of many of the women a number were selected and underwent a thorough examination while under the influence of an anesthetic.

At the time of his report Hobbs had examined 187 selected insane women to ascertain the existence or otherwise of disease of the pelvic organs. In 163 women there were diagnosed distinct pathological lesions and abnormalities. Furthermore, it was necessary, in his opinion, on physical grounds alone, to remedy or remove such disease by appropriate surgical treatment in 155 of these patients.

Tumors, malignant or benign, and other serious lesions involving the pelvic organs, necessitated the performance of 22 hysterectomies, 12 of which were abdominal and 10 vaginal. Three deaths followed these operations, one from exhaustion on the third day, the second from accidental hemorrhage (brought about by patient) on the seventeenth day, and the third from septic pneumonia on the seventh day succeeding the operation. The latter case was in extremis at time of operation, there being pus invasion of every organ of the pelvic cavity. Ovarian diseases, including tubal, dermoid cysts and hematoma, were the lesions removed in 21 cases, one of which died of pneumonia on the twelfth day.

In two cases of tubercular peritonitis the abdominal cavity was opened and flushed with warm salt solutions.

Dislocated and retro-displaced uteri were corrected and replaced by 42 Alexander operations and ventro-suspensions.

Injured and diseased uterine cervices received appropriate surgical treatment in 48 women so affected.

In 31 cases chronic endometritis, metritis, and subinvolutions of the uterus were attended to.

Lesions of the vagina and perineum, including fistulæ, existed in 22 cases. These lacerations were repaired and the fistulæ closed. It may be stated that


many of these patients had two or more lesions needing two or more operations to complete the treatment.

. Mental recovery followed the physical restoration to health in 60, or 38 per cent.; mental improvement in 40, or 26 per cent.; no mental improvement was observed in 51, or 33 per cent.; and 4, or 24 per cent., died. It may be said that 49 of the 100 women who either recovered or improved mentally had been insane two years or over prior to surgical treatment. The majority of these patients (many of them were apparently hopeless wrecks in body and mind) have returned to their homes and are enjoying good mental and bodily health, while it is as certain as anything can be that were it not for this surgical treatment many of them would have remained incarcerated for life as helpless, hopeless lunatics.

Appendicitis as a Cause of Inflammatory Disease of Right Ovary and Tube.

Ochsner (Amer. Med. Assn., June 6, 1899), from an experience of 103 cases in which the appendix was removed by him for inflammatory disease, draws the following conclusions:

1. Appendicitis frequently causes inflammatory disease of the right ovary and tube, and occasionally the left side is also involved.

2. This condition is especially likely to give rise to chronic invalidism because of the periodic exacerbation, resulting from the congestion due to menstruation. 3. In operating for the relief of pyosalpinx, the condition of the appendix should always be determined.

4. In operating for chronic or recurrent appendicitis in patients suffering also from dysmenorrhea, the right ovary and tube should be examined.

5. If the pain is limited to the right side in severe dysmenorrhea, the appendix is frequently primarily involved.

6. In catarrhal appendicitis, in which there is a fecal concretion in the appendix, or in appendicitis obliterans, the pain is frequently most severe during menstruation.

7. In patients who have recovered from gangrenous appendicitis, there is frequently no further disturbance from the condition of the appendix, except the digestive disturbance due to adhesions, while the secondary disturbance in the ovary and Fallopian tube may continue to be very great.

8. In young girls suffering from dysmenorrhea, the history should be followed very carefully, in order to determine the presence of a previous attack of appendicitis.

9. The fact that many of these cases are mistaken for salpingitis accounts for the theory that appendicitis is more common in men than in women.

Operations for Myoma Uteri.

At a recent meeting of the Vienna Gesellschaft der Aertze, Wertheim (Med. Press & Cir., vol. 67, no. 3134) read a paper on 53 operations for myoma which he has performed during the last year and a half. Since Chrobak promulgated his methods of vaginal "morcellement," five years ago for the removal of myoma, Grunfeld tells us that he has devoted most of his time to testing the different forms, and within the last year and a half has had 53 of this nature. He claims several modifications which are of considerable advantage.

His conclusions are that no tumor should be removed by this method if it rise above the umbilicus, as the loss of blood is too great to justify the operation. The length of time the patient has to be under chloroform is another danger to be feared. If the tumor be pediculated it should be ligatured and the stump returned to the uterus. In the case of multiple myoma the uterus must be removed with the tumor. The vaginal operation is limited to another class of cases. If these be anemic or affected with myo-degeneration, even when the tumor is small, this method should not be practiced, as the hemorrhage is apt to be so great as to precipitate a fatal result. Intra-ligamentary myoma, as well as the adhesive inflammatory form, should be removed by laparotomy. He has operated 36 times by the vagina, but in 2 intra-ligamentary cases had to abandon this method and complete the removal by laparotomy, 25 times "morcellement," 6 times dismembering, and 3 times enucleation. Of the 36 operations, 1 died of myo-degeneratio cordis.

The radical cure he favored was by total extirpation and supra-vaginal amputation, where there was less danger of wounding the ureters, and by removing the organ of the menstruating membrane danger was also removed, as well as fear of carcinoma in stump.

The indications for total extirpation were:

1. Colloid myoma, which developed in the pouch of Douglas.

2. Very large, or multiple myomata, though small.

3. Infection or complication with pus discharges.

Of 17 radical operations he performed, 3 were supra-vaginal and 14 total extirpation, with only 1 death.


Obstetrician to the City Hospital.

Three Steps in the Tuberculous Process in Children.

Bovaird (N. Y. Med. Jour., vol. 70, no. 1) makes a most interesting study of tuberculosis in children. This study is divided into three steps, and the author closes his valuable contribution with the following brief summary of the points made in his article:

1. The primary lesion of tuberculosis in children is regularly in the bronchial lymph nodes or lungs.

2. As to early manifestations of tuberculosis in children, these are extremely indefinite and uncertain.

(a) Tuberculosis infection of the bronchial lymph nodes, as a rule, cannot be diagnosticated.

(6) Latent tuberculosis is often roused and disseminated by the invasion of another disease (infection), such as measles, diphtheria, etc., the presence of tuberculosis not being suspected.

(c) losis.

(d) pneu

The common type of tuberculosis in children is acute miliary tubercu-
It may occur in well-nourished infants.

The course of tuberculosis is most often confused with chronic broncho-
onia or enterocolitis.

(e) The early manifestations are progressive emaciation, fever, and the pres ence of rales over the lungs. These are insufficient for puposes of distinction. 3. The terminal lesions include:

(a) Extension of the tuberculous process in the bronchial lymph nodes and lungs, resulting in the formation of abscesses, cavities, etc.

(b) Diffusion of the tuberculous infection, constituting acute miliary tuberculosis, the principal viscera being affected in the following order: spleen, liver, brain, kidney, heart. The involvement of the brain is most important, the meningitis being regularly fatal.

(c) When bone is involved and there is prolonged suppuration, waxy degeneration of the viscera may occur.

Vaginal Douches, Ante-Partum and Post-Partum.

Boston (N. Y. Med. Jour., vol. 69, no. 23) considers this important subject in a thorough manner. His article is thus summarized:

1. A profuse leucorrhea during the latter months of pregnancy is no indication for vaginal douching.

2. The chemical reaction of a discharge has but slight effect upon its antiseptic powers.

3. The vaginal secretions of pregnant women rarely, if ever, contain pathogenic germs except gonococci.

4. Vaginal douches favor the development of cervical gonorrhea and puerperal sepsis.

5. The vaginal secretions may contain streptococci, staphylococci, diplococci, and bacilli, all of which may be non-pathogenic.

6. A discharge from the cervix may show the presence of pathogenic bacteria after all other symptoms of sepsis have disappeared.

The Treatment of Labor in Abnormal Pelves.

Davis (Amer. Jour. Obstet., vol. 39, no. 6) summarizes an excellent paper thusly:


In 466 women examined by pelvimetry, 32 per cent. had abnormal pelves. 2. Among these, 20 per cent. required obstetric operations for safe delivery. 3. The mortality of these operations, which include the range of modern obstetric surgery, was nil from septic infection and hemorrhage. One patient died from nephritis. The fetal mortality of these cases, from birth pressure or injury to the fetus during delivery, was one.

4. The experience of the writer in Cæsarean section and symphyseotomy includes 14 Cæsarean sections and 8 symphyseotomies. The mortality rate of these operations for the mother was nil in cases where the patient was uninfected and sound before delivery. When death occurred in the mother it was from previously-existing streptococcus or pneumococcus infection, or from infection with the bacillus coli communis before labor or from eclampsia. In the 14 Cæsarean operations and 8 symphyseotomies, one child perished from inspiration pneumonia, its mother being infected before admission to the hospital.

5. In the writer's experience, celiohysterectomy with intrapelvic treatment of the stump, celiohysterotomy, symphyseotomy, forceps extraction in Walcher's position, version and embryotomy, in patients not infected before these operations were performed, have given excellent results.



Report of a Case of Alcoholic Multiple Neuritis, with Autopsy.

Larkin and Jelliffe (Med. Record, vol. 56, no. 2) thoroughly study a case of this character, prior to and after death, with the result that they arrive at the following general conclusions:

1. In fatal alcoholic multiple neuritis grave variations from the normal structure (equivalent picture of Nissl) of the ganglion cells of the anterior and posterior horns, the columns of Clarke, the nucleus of Stilling, and the nuclei of the medulla are always to be found when studied by appropriate methods.

2. These cytological variations are characterized by their extreme polymorphism. They may consist of simple swelling of the ganglion cell or of its chromatin particles; fine granular disintegration of the chromatin; destruction of the chromatin; central, peripheral, perinuclear, and general chromatolysis; wandering of the nucleus to an eccentric position, and destruction of the achromatic structures to complete disintegration of the cell.

3. To what extent these lesions are due to the direct action of the alcoholic poison on the molecular structure of the ganglion cell (primary), or the degeneration of the peripheral extensions of both sensory and motor neurons (secondary), cannot, we believe, be accurately determined. The conclusion drawn is, that the peripheral degeneration is the much more important one of the two. 4. The best hypothesis yet offered to account for the degeneration of the cells of the column of Clarke is that of Van Gehuchten, by the assumption that the ganglion cells of a nervous chain exercise the one upon the other a trophic action, the suspension of which produces a chromatolysis and disappearance of the corresponding cells.

Injection of Cocaine into the Medulla.

Professor Bier (Med., Press & Cir., vol. 67, no. 3130) has made some interesting experiments on the anesthetic effects of cocaine injected into the spinal cord. Up to the present two methods only were known of producing anesthesia, that of inhalation of chloroform, ether, etc., producing general insensibility, and local anesthesia obtained by the action of cocaine or cold on the sensitive nerves of a limited region. Prof. Bier has discovered a third or middle method by which two-thirds of the body can be rendered insensible, and leaving psychic faculties untouched. Convinced that the injection of a small quantity of cocaine into the rachidian canal would produce insensibility of the regions tributary to the nerves contained in that cavity, he injected hydrochlorate of cocaine into the rachidian canal of six patients with ages ranging from 11 to 34 years, and was able after this operation to perform, without the slightest pain, osseous resections and the opening of tuberculous abscesses. He proceeded as follows:

By means of subcutaneous injections of cocaine he rendered insensible the lumbar region, and then practiced the tapping of the canal according to the method of Quincke with the aid of a very fine canula. To this he adapted an ordinary Pravaz syringe, containing from to 1 per cent. solution of cocaine, and of which he injected from 10 to 60 drops, representing from to 1⁄2 of a grain. In five or eight minutes after the injection the lower limbs were rendered

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