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fed by small ascending branches from the ovarian artery, which enter the structure from the lower surface; consequently, when an incision is made it should be on the opposite side. Care should be taken to keep the intestines out of the way by means of pads, the tubes being incised along the outer two-thirds of the upper border. The contents should then be evacuated and the entire surface thoroughly swabbed with five-per-cent iodoform gauze. At first there will be considerable oozing of blood, which gradually subsides, no main vessel having been A small strip of iodoform gauze should then be placed over the raw surface, an end protruding into the vagina. The first effect of this treatment is to reduce the interstitial cellular infiltration, as it is a well-known fact that the gonococcus does not thrive well on exposed surfaces, its natural abode being in the deep recesses of compound racemose glands. The gauze may be removed from the culdesac in from five to six days. This may be done with safety after such a period, as the life of the gonococcus at best very short, except in racemose glands and closed sacs.
REPORTS OF CASES.
FRACTURE OF THE ULNA DURING MASSAGE FOLLOWING OPERATION FOR COLLES' FRACTURE.
DOCTOR FREDERICK C. KELLER: I wish to show this patient. After the removal of the splint her arm was being massaged when the ulna snapped at a point several inches above the original site of fracture. This occurred six or eight weeks after the operation, and could be attributed only to some inherent disease of the bone.
DOCTOR JOSEPH C. ROBERTSON: I have put up from two hundred to three hundred cases of Colles' fractures during the past eight years, and until two years ago have applied a posterior splint, the arm being semiflexed in a stiff position. This gave far from perfect results in eight out of ten cases. A careful study of these cases has convinced me that the best results are obtained by applying a posterior splint from the hand to the elbow, keeping the arm perfectly straight, and putting a pad of cotton under the wrist. As a result there is no sharp protrusion of the ulna at the elbow, as often occurs when the hand is put up anteflexed.
DOCTOR JOHN A. BODINE: Something was wrong with the composition of the bones of this patient, as ulnas do not snap from massage. The bones were probably chalky. As to Doctor Robertson's experience with Colles' fractures, I think that each surgeon favors the line of treatment with which he, personally, has obtained the best results. I think a posterior splint more practical, for the reason that the posterior surface of the arm is a straight surface, and has no cutaneous nerves and no return blood supply. If a rigid anterior splint is applied to the front of the arm, edema is caused by obstruction of the circulation.
DOCTOR ALEXANDER LYLE: I desire to report a case of intussusception occurring in a child seven and one-half months old. The patient, well-nourished, healthy, active and breast-fed, had enjoyed perfect health, with the exception of constipation, until the evening of December 18, 1905, when he was suddenly seized with severe abdominal pain, as evidenced by crying and flexion of the thighs upon the abdomen. He was given a hot mustard footbath, and, internally, hot water with gin and paregoric. His bowels had moved normally on the preceding day, but not on the day of the attack. At I A. M. the child passed about half an ounce of bloody mucus but no fecal matter. Pain was severe and recurrent in character and at 6 A. M. on the 19th a physician was summoned. He ordered half an ounce of castor oil. This failed to produce an evacuation of the bowels. On the evening of the 19th he ordered an enema (rectal) of glycerine and hot water. During the night the mother noticed a sudden change in the child's condition and thought it to be dying. She could not reach the physician, and in the morning I was summoned. On reaching the house I found that the physician had arrived and had given an enema of an ounce of castor oil and one pint of warm water, the water returning with bloody mucus.
Hasty examination showed a state of collapse, a weak pulse that could not be counted, a tense, rigid abdomen, and a rectal temperature of 103° Fahrenheit. A diagnosis of intussusception was made and immediate operation advised as offering the only hope (and that a poor one.)
The child was immediately brought to the Polyclinic Hospital and operated upon. No tumor could be mapped out, even after he had been anesthetized. An incision was made in the right rectus muscle, just below the umbilicus, the abdominal contents examined and intussusception located in the ileocecal region. A firm, dense band of adhesion anchored this portion of the intestine, necessitating a considerable amount of work before it could be brought into the wound. This was finally accomplished and the intussusception reduced. The gut was not gangrenous and therefore was returned to the abdominal cavity. A loop of small intestine was picked up and two drams of saturated solution of magnesium sulphate was thrown into it by means of a syringe, the needle of which was carried obliquely into the lumen, the object being to evacuate the bowels as soon as possible. The abdominal wound was then closed.
Following the operation the child's temperature rose to 103.5° Fahrenheit, and remained so until I A. M. of the next day, when it dropped gradually to 99.5° Fahrenheit, and did not rise above 100.8° Fahrenheit at any time afterward. The pulse could not be counted. until the temperature had fallen to 101.8° Fahrenheit, when it was 160, later falling to 118 or 120. The bowels moved five times during the first twenty-four hours after the operation.
I would emphasize the point that valuable time must not be lost by useless, or, more properly speaking, positively injurious and dangerous medication. The sudden abdominal pain, followed by a discharge of bloody mucus from the rectum, the recurrent attacks of pain and absence of fecal exacuations indicate immediate operation. Gangrene or extensive adhesions, or both, are produced by delay, and an intestinal resection and circular enterorrhaphy will be necessary. An early operation, on the contrary, enables the surgeon to early effect reduction.
DOCTOR BODINE: One point should be emphasized in the diagnosis of an inflammatory abdominal condition in a child, and that is the expression of the face, which is always typical. Another aid is the abdominal pain. I think it would have been impossible to have made a differential diagnosis between this condition and appendicitis if it had not been for the presence of the bloody mucus.
DOCTOR MAURICE PACKARD: In cases of abdominal lesions in children up to three years of age, the differential diagnosis between intussusception and strangulated hernia usually has to be made. The only point in diagnosis especially pointing to intussusception is the bloody mucus. A body temperature of 103° Fahrenheit, and a rapid pulse are also significant, as the statement is made in many text-books that, except in appendicitis and general peritonitis, the temperature and pulse are normal and the abdomen relaxed. It has been my experience that in intussusception children always have a high temperature and have a pulse so rapid that it is almost impossible to count it. In cases of intestinal obstruction the absence of stools and gas assists one in making a differential diagnosis, as in intussusception only mucous and blood pass from the bowels.
LARGE OVARIAN CYST.
DOCTOR CHARLES G. CHILD, JR.: I removed this cyst from a patient thirty-eight years of age. She has complained of pain for four or five years, during which time she noticed the presence of a tumor, which grew progressively larger. Examination revealed an enlargement reaching to the umbilicus. It was impossible to palpate the appendages on either side, and it was also impossible to determine on which side the tumor originated. On account of the pain being on the right side it was concluded that the tumor was of the right ovary, but at the time of operation it was found to involve the ovary on the left side and to have rotated the uterus. It firmly compressed the appendages on the right side, which accounted for the pain on that side. A transverse incision showed the cyst to be inherent in all directions to the omentum and posterior peritoneum. A portion of it was free from adhesions, and at this point the fluid contents were aspirated. The
sac was then pulled out, with the intestines and omentum, and the adhesions separated. The sac contained a dark, water-like fluid, which is rather unusual, the contents of such a tumor usually being of a yellow straw color.
BY GEORGE DOCK, A. M., M. D., D. SC., ANN ARBOR, MICHIGAN.
PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.
DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.
FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.
THE RHYTHMIC SOUNDS OF THE ALIMENTARY CANAL.
In a decidedly interesting description of a series of investigations into the causes of the various sounds produced in the gastroenteric canal, Cannon (Jama, January 20, 1906) concludes that stomach sounds are best heard over the pyloric ring at the tip of the eighth rib. These sounds are explosive in their character, loud, and correspond with the rhythmical contraction of the pylorus, they occur about once in every twenty seconds and are distinguished by auscultation with a stethoscope. Small intestine sounds can be differentiated from those of the stomach and large intestine sounds by auscultation over the lower portion of the abdomen. These sounds are best heard when the stomach is empty, in the early morning, and particularly over the lower left quadrant; the object of this position is to get as far away from the active portion of the colon as possible. The sounds are soft, confused, rolling, rising and falling in intensity, not rattling and explosive like those of the stomach. They continue for four or five seconds, disappear, and return again at intervals of seven or eight seconds, and persist in the same location for indefinite periods of time.
The sounds of the large intestine present no periodicity, are easily distinguished from the other sounds, and are heard over any portion of the active colon, the ascending and transverse portions. The sounds are very coarse and rumbling, with heavy gushes of gas from one segment to another. The intervals are longer, from fifteen to forty-five seconds.
The author used, as a method of eliminating the personal equation, a recording telephonic transmitter. The article should be read with care, as it is impossible to do justice to it in a brief review. The sounds are somewhat dependent upon the character of the food eaten, that is, certain sounds can be better differentiated if certain substances are
D. M. C.
BY FRANK BANGHART WALKER, PH. B., M. D., DETROIT, MICHIGAN.
PROFESSOR OF SURGERY AND OPERATIVE SURGERY IN THE DETROIT POSTGRADUATE SCHOOL OF MEDICINE; ADJUNCT Professor of operative SURGERY IN THE DETROIT COLLEGE OF MEDICINE.
CYRENUS GARRITT DARLING, M. D., ANN ARBOR, MICHIGAN.
CLINICAL professor of surgerY IN THE UNIVERSITY OF MICHIGAN.
THE MODERN TREATMENT OF FRACTURE.
CARL BECK, M. D., of New York (Medical Record, Volume LXIX, Number XII). It is quite refreshing to read an article with the above title, in which the writer dares to advance new ideas and cut away from some of the traditions which have long interfered with the scientific treatment of fractures.
The Roentgen ray has not only become a valuable aid in diagnosis, but compels much better results in treatment. Injuries that were formerly treated as dislocations, sprains, contusions or distortions are now. known to be fractures, a glance through the fluoroscope revealing the true condition.
Fractures without displacement, entering an articulation, may have considerable effusion. Without knowing the condition the surgeon would be strongly tempted to manipulate. A skiagraph would at once show the condition and suggest the line of treatment. The writer prefers a plaster-of-Paris dressing because it adapts itself to any part of the body and offers no obstacle to the Roentgen rays.
The rules, that fragments must be reduced, and that, after proper position has been attained fixation is in order, while simple, are frequently violated.
The dogma that the soft tissues are the most important part of the treatment of fractures, is dangerous. Repair must take place in the bone, while the soft parts may be injured by imperfect reduction. With perfect reduction joints and tendon-sheaths are at once set free and remain so, unless immobilized for a long time.
A fracture is a wound in which union by first intention is desired; accurate coaptation of parts is therefore necessary. What was formerly regarded by many as bone callus was nothing but a displaced bone fragment. The only way to insure the exact reposition is by using the Roentgen ray. The practitioner must resort to this not only for the good of his patient but for his own protection.
In old displacements of not more than two weeks standing refracture may be successfully performed under anesthesia. Old fractures. are to be opened and refractured with a thin broad chisel; in such. cases when there is great tendency to displacement suturing with bronze wire is indicated. Periosteal shreds may become ossified and lead to deformity. When the bone is treated by open operation these should. be carefully removed.
The patella offers a good example for technique of operation. It