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hook penetrated the forearm at the base of the thum, picking up the three tendons on the radial side-the two tendons forming the anatomical snuff-box and that of the supinator longus. He swung from this hook with his entire weight of one hundred seventy pounds. The tendons did not break, but pulled loose from their attachments to the muscles in the forearm, one of them hanging down for twelve inches. He wrapped his butcher apron around the forearm and tendons and in a few hours was on the operating table. The tendons were identified and two of them passed through the canal in the anterior ligament of the wrist and sutured in their proper positions. The loose tendon of the supinator longus, however, was so long that opening of the muscular planes of the forearm, near the elbow, would have been necessary in order to stitch it in place. It was therefore thought best to transplant it into the tendons of the extensor primi internodii pollicis. The wound healed kindly and the patient can now do with this thumb all that he can do with the other one.
VARICOSE VEINS OF THE LOWER LIMB.
DOCTOR BODINE: I also wish to present this patient. Of middle life, she presented for operation the worst type of this condition. Great masses of infected thrombi were present on the inner side of the leg. Three weeks' rest in bed, with ice-bags, et cetera, was insisted upon, until all inflammation and sepsis had disappeared. She was then operated upon. It is my belief that when the Trendelenberg operation cannot be utilized the only other to be recommended is that of excision of the entire internal saphenous vein, because if the blood current in the vein is cut off by any other operation, the walls of the useless vein may become a foreign body and require removal. The operation recommended by me is that of Caseta, in which the entire vein is removed through three or four small cuts in the overlying skin, the vein being pulled out subcutaneously, the numerous tributary vessels being torn across, but not litigated. At the junction of the middle with the lower third of the leg, the skin and subcutaneous fascia are then cut through to the muscles, the cut encircling the entire limb. After this operation the patient is usually in the hospital for two weeks. In every one of the twenty cases in which the speaker had operated according to this method the cure had been perfect.
ACUTE INFECTIOUS CHOLECYSTITIS.
DOCTOR BODINE: Here is a girl, seven years of age, who entered the hospital four weeks ago. The question of diagnosis is interesting in this case, because, judging from the symptoms, the condition might have been intestinal obstruction, pneumonia, diaphragmatic abscess, appendicitis, or acute infectious cholecystitis. As is well known, at times it is very difficult to differentiate in these acute abdominal lesions. Her vomiting was not progressive and her fever was too high for intestinal obstruction. The principal point of tenderness was too high. for appendicitis, unless it were of the type in which the pain is reflected. to the liver. Her entire right abdomen was rigid, and respiration,
while rapid, was not the dominant feature of the situation, although a cough was present from bronchitis. Diagnosis of acute infection of the gall-bladder was therefore tentatively made, and proved correct on operation. The liver was two and one-half inches below the costal border, and projecting below the liver was the tense, swollen gallbladder. This was quickly stitched to the abdominal wall, drained, but not removed. The child's condition was so critical that speed was an essential feature of the case. Four months previous to this illness she had an unusually severe attack of measles, followed by a persistent bronchitis and cough. From that time to the present illness she has complained frequently of pain in the pit of her stomach, so it seems quite probable that the measles were the cause of the infected gall-bladder by metastasis.
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 CAUSE AND IMPORTANCE OF THE HEART DISEASE OF NEPHRITIS.
PASSLER (Sammlung Klin. Vorträge, Inn. Med. Number CXXIII) has made a study of this subject, so often discussed in the past, and has brought to it the most advanced knowledge of cardiac physiology and pathology, since he has been an active coworker with Krehl, Romberg and others of the Leipzig school. Only the most important conclusions can be given here.
(1) The cardiac hypertrophy in nephritis is the result of the kidney disease.
(2) There is probably at first an increased irritability of the vaso'constrictor apparatus in consequence of the renal lesion, subsequently arterial spasm and increased resistance of the greater circulation. In cases where there is extensive arteriosclerosis, especially in the thoracic aorta or the small arteries of numerous organs in the splanchnic area, part of the hypertrophy of the left ventricle must be attributed to this complication.
(3) The hypertrophy of the left auricle and the right heart in nephritis is a result of insufficiency of the left ventricle.
(4) The polyuria of many renal diseases, especially of contracted kidney, does not depend upon an increased "filter pressure" of the glomerular capillaries; it is much more probable that the blood pressure
in the renal capillaries is not elevated above normal even in cases of the highest arterial pressure, as the excess must be used in overcoming the resistance in the small arteries.
(5) Therapeutic measures for preservation of compensation, and in disturbed compensation of the heart in interstitial nephritis, must regard not only the increase of cardiac power, but more especially the lowering of arterial resistance. (For the latter purpose the author recommends nitroglycerin).
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.
TUBERCULOSIS OF THE CERVICAL LYMPH NODES.
DANIEL EISENDRATH, M. D., of Chicago, in Surgery, Gynecology and Obstetrics, Volume II, Number I.
This old, familiar subject has made some advances of late, so that the cause, diagnosis and treatment at the present time will be considered. It has long been known that the tonsils are the common portals of entry of infection in the cervical lymph nodes. This has been confirmed beyond doubt by examination of the tonsils and adenoids removed from children. When the children crawl on the floor their tonsils probably become infected by the dust which lodges in them.
Infection may also come from the temporal bone or through carious teeth, by tubucular lesions of the buccal and mucous membranes. These latter represent a very small proportion of the cases. The tubercular organisms may remain latent in the cervical lymph nodes for many years, and then suddenly become active. Every case should be carefully examined before operation to see if it is complicated by disease of the tonsils, or by the presence of adenoids. The diagnosis of the chronic forms, such as have extended over a period of months or years, will be easy, and other cases, also, where the disease runs a very acute course so that caseation may occur, within two or three weeks after the onset of the disease.
Another class should be considered which Fischer has termed a pseudoleukemic form of tubercular lymph nodes, where the axillary and inguinal node are enlarged as well as the cervical. There is a gradual enlargement; with no tendency to softening, or the formation of adhesions between adjacent nodes.
Without a reliable history it is impossible to make a diagnosis. Besides these may be mentioned syphilitic lymphatic leukemia, chronic nontubercular hyperplastic nodes, lymposarcoma, and secondary car
cinomata. The treatment is divided into prophylactic, nonoperative, and operative. Prophylaxis is the same as may be applied in all instances for avoiding tuberculosis. To this may be added the removal of diseased tonsils and adenoids whenever found.
When, for any reason, an operation is deemed inadvisable or objected to, the patient should be sent to the mountains or seashore. When this is impossible tonics of cod-liver oil, guaiacol, or iodide of iron will be beneficial. If the condition is active medical treatment is of little avail.
The operative treatment consists in removing every tuberculous node, and, at the same time, the tonsil and diseased adenoids. The incision is made over the middle of the sterno-cleido-mastoid end to the other if necessary, and all the sinuses if they exist, are dissected out. The muscle is pulled backwards and the nodes exposed. Care is taken to catch every bleeding point at once. Few of the vessels require ligature except the external jugular vein, which is nearly always severed. The dissection is made with blunt-pointed, short-bladed, curved scissors. The writer states that in this way he has exposed the internal jugular vein from the chin to the clavicle without injury. By this method nodes can easily be stripped from the wall of the vein without injury. Occasionally a short vessel will be found extending directly from the internal jugular vein to the overlying node which will give troublesome bleeding if it is cut. This may be seized with a stitch and a parietal ligature applied. Care must be taken not to injure the spinal accessory nerve which emerges from the sterno-mastoid about the middle, and passes almost transversely across the triangle to enter the trapezius. A number of enlarged nodes are sometimes encountered at this point. The thoracic duct must not be forgotten when operating on the left side. A thorough removal of all fat will greatly aid in securing a perfect cure.
C. G. D.
BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
CHRISTOPHER GREGG PARNALL, A. B., M. D., ANN ARBOR, MICHIGAN.
FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
HAS EXPERIENCE SUSTAINED THE MORE RADICAL OPERATION FOR CANCER OF THE UTERUS?
CLARK (Surgery, Gynecology, and Obstetrics, Volume II, Number II) reviews his experience in the operative treatment of cancer of the uterus. Clark, Rumpf, and Ries, were among the first to advocate the extensive operation of removal of the iliac glands along with the uterus and appendages. The results of this method have, however, been disappointing. The immediate mortality is very great and recurrence is just about as frequent as in other less radical procedures. There is a
great difference of opinion between various operators regarding the time of metastasis in cancer of the cervix. The writer evidently now adopts the view advanced by Cullen and Winter that metastasis occurs comparatively late in the disease. When the operable glands are involved according to the studies of Schauta, only thirteen per cent show no involvement of the upper or nonoperable glands. Consequently, when there is extension of the cancerous process to the glands, the outlook is not at all hopeful even with a so-called radical operation.
In view of these findings, the author now limits his operative interference to a thorough local extirpation of the uterus and adnexa, including the upper portion of the vagina and the greater part of the broad ligaments and parametrium. The abdominal route is preferred to the vaginal, on account of the better opportunity to get well out on the broad ligaments.
C. G. P.
BY WILLIAM HORACE MORLEY, PH. B., M. D., ANN ARBOR, MICHIGAN.
DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.
WALES MELVIN SIGNOR, M. D., ANN ARBOR, MICHIGAN.
ASSISTANT IN OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.
OLSHAUSEN (Zentralblatt für Gynäkologie, 1906, Number I) reports his results in one hundred eighteen cases. This report is supplemental to one made by him in 1902 (Deutsche Klinik, Band IX), an abstract of which appeared in The Physician and Surgeon for February, 1904, page 81. In his one hundred eighteen cases Olshausen summarizes the indications as follows:
Among the cases of contracted pelves were those of the rachitic type most often seen. Seventy-one of the ninety-one cases were due to rachitis. The remaining twenty cases were distributed as follows: Five generally contracted, five obliquely contracted, two transversely contracted, two pseudoosteomalacic, three skoliotic, one kyphoskoliotic and two contracted or narrowed from exostoses. In eclampsia the author prefers Caesarean section to forceps or to version and extraction. He further states that the use of morphia in eclamptic cases is dangerous to the fetus.