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He is a most careful, thorough and conscientious operator. He uses rubber gloves in his operations, and attributes no little of his success to the perfect asepsis obtained by their use.

Deaver amputates the appendix close to the cecum, bringing the peritoneal services together by means of a continued fine silk suture passed through peritoneal and muscular coats. His abdominal incision is made through the rectus muscle preferably, because he contends that the union is stronger and consequently there is less liability to hernia.

With the opportunities now open to the recent graduate as well as the more ancient practitioner, I should welcome with much delight a law making it obligatory upon each doctor who holds himself in readiness to do gynecology and surgery to spend three months at least every five years with just such experienced men and operators as Drs. Price and Deaver. Then might we expect better operators throughout the land.

The man whose pride and ambition are not sufficiently developed to make him anxious to visit the centers of medical and surgical lore and see the ablest operators at their work, should be forced to retire. He it is who gives surgery in the small town the "black eye." He it is who is responsible for the suffering of the patient until it is a case of life and death before she will consent to submit to an operation. He it is who, when a patient has suffered the tortures of the damned, and finally in despair seeks the advice of a good man who, thinking to give her one chance in a hundred, operates and loses the patient, says "I told you so."

If such a man were not ignorant he would have my profoundest contempt. As it is he has my pity. But does he deserve pity? There are two avenues open to him. He may go and rub up against brilliant and skillful men until he is comparatively bright and absorbs enough to do intelligent work, or he should acknowledge his inferiority and for the welfare of his patients direct them to men under whose care they may have the most skillful attention. I consider it no disgrace to my surgical ability to refer a patient to an oculist to have an iridectomy performed; on the contrary, I consider it my duty to send my patient to one who is best qualified to give him the most satisfactory results.

Little Rock, Ark., Nov. 25, 1899.





Visiting Physician to St. Joseph's Hospital, Memphis.

Essential Hematuria.

At the Fourth Session of the French Association of Urology, MM. Malherte and Leguen read a very interesting report on essential hematuria (French Cor. Med. Press & Circ., vol. 68, no. 3155).

Up to late years the papers read on hematuria were divided into two classes, essential and symptomatic. The latter, the more frequent and the better known, depended on some well-defined cause; while the former seemed independent of any lesion of the urinary apparatus, and appears to constitute simultaneously symptom and malady. To distinguish that affection from the other, the term "essential hematuria" was invented. But could hematuria really exist independently of a lesion of the renal organ or of a more or less established disease? Such was the question the authors proposed to treat, after passing in review the different causes of symptomatic hematuria, which were of two orders—general and local.

INFECTIOUS MALADIES.—Hematuria was frequently observed in the course of infectious maladies, and more especially in those cases where the fever ran high; it constituted, generally, the ultimate period of the affection and rendered the prognosis very grave. The blood could come from any position of the urinary tract, but it was probable that the seat of the hemorrhage was the kidney. Where the cause was local the hematuria could arise from the urethra, the prostate, the bladder, the ureter, or the kidney. Abundant hematuria had its cause exclusively in the bladder or the kidney, and was provoked habitually by calculi, tuberculosis, neoplasms, or retention, more rarely by traumatism, inflammation (nephritis) or parasites (hot climates). Such were the principal causes of hematuria resulting from a manifest lesion of urinary apparatus and notably of the renal organ. Whether it was a case of traumatism (calculus), of inflammation (nephritis), or of a neoplasm, there was a factor which in the pathologic physi ology of hematuria intervened at each stage; it was congestion. Congestion played in urinary pathology a very effective role. M. Guyon had frequently insisted on that point. It was it which determined frequently the hematuria, modifying the clinical aspect of the symptom, and troubling the practitioner by a disconcerting paradox.

ESSENTIAL HEMATURIA.-After passing in review the great causes of symp tomatic hematuria, the authors treated of essential hematuria, which, in its clinical characters they said did not present any particular sign. It was frequently very abundant, so as to produce anemia, and was rebellious to all treatment. What was in reality essential hematuria? In pathology every phenomenon had a cause, and although the cause could not be determined, it did not follow that it did not exist. When hematuria occurred it should in some way have its

raison d'etre. If it was not found it was because the insignificant lesion had passed unperceived, and that lesion was almost in every case to be found in the kidney, consequently essential hematuria did not exist in fact.

The predominating character of pseudo-essential hematuria was that it did not resemble any of the forms habitual to that of calculus, neoplasm or tubercles. Abundant and continual, it was not influenced by rest or motion, and appeared at first as renal hematuria, but other symptoms were sought for in vain. The treatment of that kind of hematuria depended on the cause, but the cause was unknown; therefore an exploratory incision became necessary to complete an imperfect diagnosis. It was only in the course.of that incision that nephrotomy or nephrectomy could be best decided upon.



Professor of the Principles and Practice of Surgery and Clinical Surgery,
Memphis Hospital Medical College.

Operations in Gastric Ulcer.

Bidwell (Amer. Jour. Med. Sci., vol. 118, no. 3) contributes a study of the operative treatment of gastric ulcer, and concludes his interesting article with the following brief recapitulation of the class of cases of gastric ulcer in which an operation should be done :

1. In all cases of perforation at the very earliest possible moment; also in subphrenic abscess.

2. In cases of hemorrhage (a) when there is continued oozing of blood, especially if the stomach be dilated, and (b) in cases of repeated severe hemorrhage.

3. In cases where there is severe pain and vomiting unaffected by treatment, and which is producing progressive emaciation.

4. In cases of dilatation of the stomach from contraction within or from adhesions outside the stomach.

The operations to be performed are: In class 1, laparotomy and suture of the ulcer; in class 2, gastrotomy and suture of the ulcer, with a purse-string suture, combined with gastro-enterostomy; in class 3, gastro-enterostomy, in order to give physiologic rest to the ulcer; and in class 4, either gastro-enterostomy or, if the pylorus be affected, pyloroplasty or pylorectomy.

The author endeavors to show that no patient ought to be allowed to die, either from perforation or from hemorrhage from a gastric ulcer, without a surgical effort being made to save him; that the earlier such effort is made the better the chance for success, and, finally, that surgery offers much hope of success in other cases which resist the art of the physician.

The Treatment of Goitre.



Bouffleur (Medicine, vol. 5, no. 11) thinks that from our present knowledge goitre the following general conclusions seem justifiable:

1. Successful treatment depends upon accurate and early diagnosis of the ture of the goitre.

2. Struma should be treated by internal use of iodine or thyroid extract and intraparenchymatous injection of iodoform or carbolic acid.

3. If these fail, either enucleation or partial thyroidectomy is indicated.

4. Adenoma should be treated by enucleation if the tumor is small, and by partial thyroidectomy if of large size.

5. Cysts should be treated by evacuation and injection of carbolic acid solution or iodoform emulsion.

6. If this fails, they should be enucleated.

7. Sarcoma and carcinoma should be treated by complete removal of the thyroid gland, with subsequent administration of thyroid extract.

8. The treatment of exophthalmic goitre is generally unsatisfactory, and at the present time surgical measures promise the best results.

9. Undifferentiated goitre may be treated by thyroid extract and iodine, but intraparenchymatous injections, and if necessary operative treatment, should be employed early.

10. The surgical treatment of all varieties of chronic goitre is, generally speaking, the most successful and the most satisfactory.



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.

On the Normal Pupillary Conditions in Infancy and Early Childhood. Pfister, Herman (Archiv für Kinderheilkunde). Impelled by the utter lack of statistics as to the true status of the pupil in healthy babes, Pfister has devoted himself to a study of the pupillary phenomena in 293 children, of which 148 were males and 145 females. Of this number 249 (over 85 per cent.) were under six years of age, and all of them came under observation as clinical or hospital patients. Out of his study he formulates the following conclusions: 1. The average pupillary width increases steadily after the first month of life, at first rapidly, later on more gradually. By the third to the sixth year, the pupillary width is about double that at the end of the first month. The average adult pupil differs very little in size from that of a three to six year old child. Sex seems to make no special difference, nor do diseases of the respiratory or gastro-intestinal tract particularly influence the size of the pupil.

2. The average amplitude of pupillary reaction increases also from the first month of life on (although more gradually than the increase in pupillary area), and by the sixth year is fully double that at the end of the first month. In this observation girls showed at all stages of infancy a greater amplitude of reaction than boys, but said reaction was in no wise influenced by the above mentioned diseases.

3. Hippus was observed in barely 1 per cent. of the 293 cases. Of the three children presenting this phenomenon, two showed absolutely no disease of the central nervous system.

4. (a) Next to the light reflex, the corneal reflex was the earliest to develop, and the most nearly constant in presence.

(b) Next to this in development and order of frequency was the nictitation reflex, which appeared between the sixth and eighth week, and seemed pretty constant after the fourth month.

(c) Following this reflex comes in order of development the sensory skin reflex, which appeared about the end of the second month, became most frequent about the seventh month, reaching 87 per cent., and then fell off to a steady average of about 40 per cent.

5. Lastly, is to be mentioned the reflex to stimulus of the acoustic or auditory nerve, which was first noticed in the tenth week of life, and remained in about 50 per cent. of all cases.-[Annals of Ophthal.

Do Gross Pathological Changes Occur in the Eye after Injuries to the Spinal Cord ?

Roy (Phil. Med. Jour.) discusses this question and refers to numerous authorities and reported cases. His conclusions are:

1. That there is no anatomic connection between the eye and spinal cord, with the exception of the sympathetic system, which in itself is reflex.

2. That injury to the spinal cord causes no pathologic change in the eye, except in the size of the pupil.

3. That spinal injury might affect the vasomotor system, as evidenced in the eye by increased tension from dilatation of the blood vessels, but even this would be transitory.

4. When gross lesions do occur in both the spine and the eye, it is always the optic nerve that is affected, and even this association must be considered accidental and nowise in the light of cause and effect.

5. Observation teaches that such symptoms as do appear in the eye after injury to the spine are purely subjective and also very transitory.—[Ann. Oph.



Laryngologist to the East End Dispensary.

Pemphigus Chronicus Vulgaris of the Larynx and Mouth.

Bryan (N. Y. Med. Journal, vol. 70, no. 22) adds to the literature of this condition a report of one case. In this country the disease, as affecting the mucous membrane of the mouth and larynx, must be very uncommon, since the author is familiar with only one or two reports of cases by American authors. Foreign literature, however, is more replete.

Bryan's case occurred in a woman, in whom examination showed the nose, naso-pharynx and pharynx in good condition, but with the mirror a small white membranous deposit, about a quarter of an inch in diameter, was observed on the laryngeal surface of the right half of the epiglottis. This membrane came away while author was making a local application, and was pronounced by Dr.

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