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His technique has not been radically changed since his last report. He does not put as much faith in the course of the round ligaments in the determination of the placental site, as he did formerly. It can usually be located from the injection of the uterine wall and from the outpouching of either the anterior or posterior wall. Hemorrhage is not to be feared as it is easily controlled after the cut edges of the uterine wall have been brought together. In seven patients this operation was performed twice. In two three times and in three four times. All these cases recovered. In his ninety-one cases of contracted pelves Olshausen has only lost nine cases.
W. H. M.
BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN.
THE UNCERTAINTIES OF EARLY DIAGNOSIS AND THE NECESSITY OF EARLY AND VIGOROUS TREATMENT OF DIPHTHERIA.
MCMAHON (Pediatrics, Number IV, 1905) says the death-rate in Ontario as elsewhere is too high, and attaches much blame to faulty or tardy diagnosis and late and half-hearted treatment. He gives as causes of failure:
(1) The physician's attention is not especially directed to the throat and he fails to look at it and diagnoses something else; by the time he recognizes his error, the case is hopeless. The golden rule is "always examine the throat of a sick child, no matter what its symptoms are."
(2) He examines the throat and thinks he has a case of tonsillitis or coryza or croup to deal with, or that even if it is diphtheria it is so mild that the old-fashioned remedies are sufficient for its cure.
(3) He fails to follow up a suspicious case and finds, when too late, that the patient is in a desperate condition.
(4) He treats one amongst many children and fails to protect the others exposed to contagion, by a preventive injection.
(5) He uses antitoxin, but is half-hearted and does not use enough. (6) In cases of laryngeal diphtheria he uses antitoxin-perhaps in large doses but fails to make an early resort to accessory remedies, such as calomel fumigation and intubation.
(7) He makes an early diagnosis, but puts off the injection of antitoxin until tomorrow or the day after.
The author says the diagnosis of diphtheria should be made at the first visit if possible. He does not believe we should depend or wait for a bacteriological examination. In every case in which there is even a suspicion of diphtheria, give antitoxin at once and give it freely. If bacteriological examination shows the presence of the diphtheria bacillus, give an injection to each of the children of the household to prevent the spread of infection. In laryngeal diphtheria the author
treats his cases as follows: (1) Inject antitoxin (full doses) and fume calomel under a tent (thirty grams an hour) until stenosis is relieved. (3) Intubate early if symptoms demand. To have a low death-rate one must be prompt, bold and fearless in his treatment. In specially malignant cases he recommends twenty thousand to thirty thousand units as an initial dose injected into the median basilic vein.
BY IRA DEAN LOREE, M. D., ANN ARBOR, MICHIGAN.
FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN.
A CASE OF EXCISION OF THE HEAD OF THE HUMERUS FOR CONGENITAL SUBACROMIAL DISLOCA
TION OF THE HUMERUS.
JOHN B. ROBERTS, M. D., of Philadelphia (American Journal of the Medical Sciences, December, 1905). His patient was a boy age three years who came to operation December 5, 1903. The condition present was as follows: The head of the left humerus could be felt under the acromial process. The humerus was firmly abducted with the external condyle pointing forward. The elevation of the arm, so far as voluntary movement was concerned, was impossible and other movements restricted. He therefore decided to replace the head by operation, resecting the head for false joint providing the former method failed.
A vertical incision was made over the prominence of the head below the acromion and the capsule opened. As the attempt failed, a second incision on the front of the shoulder was made and carried down to the deep layer of muscles. Combined efforts from the two points gave no results.
He concluded that only a bloody and prolonged dissection would expose the glenoid fossa; even if reduction resulted he might obtain only a stiff joint, which was no better than the original deformity; that excision of the head would give as good, if not a better joint, with less risk.
The bone was sawed close to the head but in its removal the long head of the biceps was severed. Both cuts were closed without drainage and the forearm supported by a sling.
Examination June 1, 1905. The left arm was three-quarters inch shorter than the right arm. Grating at the false joint with passive motion. Rotation not so complete as on right side. Elevation of the humerus restricted and scapula moves with it, if passive movement is extensive. Humerus still rotates slightly forward. The patient can touch the back of his ear and neck on the left side, put his hand to his mouth, and can clasp his hands behind his back in the lumbar region. The belly of the biceps stands out prominently in the middle of the arm due, no doubt, to the division of its long head. He cannot
lift the left hand over his head but could merely touch the occipital region. He could put the left hand on the opposite shoulder and bring he elbow nearly in contact with the ribs.
Doctor Roberts thinks a large proportion of these cases result from intrauterine causes as many times they occur on both sides in the same patient and in more than one child of the same family.
BY WALTER ROBERT PARKER, B. S., M. D., DETROIT, MICHIGAN.
PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.
PROTARGOL AND ARGYROL AS SUBSTITUTES FOR NITRATE OF SIVER.
DOCTOR G. E. DE SCHWEINITZ (Ophthalmic Record, January, 1906) expresses his views concerning the use of the newer salts of silver.
At one time this writer had employed protargol very freely as a substitute for nitrate of silver but had found it comparatively unsatisfactory and had abandoned its use. He had employed argyrol first as a substitute for nitrate of silver in all forms of conjunctivitis, except diplobacillus conjunctivitis, in the treatment of purulent conditions of the lachrymonasal passages, in the management of infected cervical ulcerations, and in the preparation of the conjunctival sac prior to operations. In his earlier experiences he had been inclined to think argyrol was a satisfactory substitute for nitrate of silver in various. conjunctival inflammations, and particularly in ophthalmia neonatorum, but within the last year he had met with so many cases wherein it had been necessary to abandon this agent and substitute nitrate of silver, that his faith in the remedy had been seriously shaken.
The doctor was satisfied that nitrate of silver properly applied in gonorrheal conjunctivitis of newborn babies and in gonorrheal conjunctivitis of adults frequently was a more satisfactory remedy, although he recognized its many disadvantages. He had been accustomed to employ argyrol by the so-called immersion method, and continued so to use it in certain cases, but not to the exclusion of nitrate of silver. He thought the plan advocated by Bruns, that after its use for a few days nitrate of silver should be applied once a day by the surgeon, and in the meantime the conjunctiva should be kept flushed with argyrol, a good one. In many cases of gonorrheal conjunctivitis he did not believe that of itself it was as safe a remedy as nitrate of silver, and in a certain number of cases it failed completely and nitrate of silver had to be substituted. He continued to find argyrol useful as an adjunct in many forms of conjunctivitis, particularly of mild type, and thought it a satisfactory remedy for irrigating the lachrymonasal passages if purulent discharge was present. He also continued to use it in cleaning the conjunctiva, if there was hyperemia or slight discharge, preparatory to operations on the globe. Taking his experience as a whole, he was
satisfied that neither protargol nor argyrol represents in any sense a satisfactory substitute for nitrate of silver in gonorrheal affections of the conjunctiva.
NOTE. To use nitrate of silver to its best advantage requires perhaps more skill and careful observation than the use of any single drug in the armamentarium of the opththalmic surgeon; while nothing is more simple than the directions for use of its substitutes. When properly used, nitrate of silver still holds its supremacy. Our experience in the University clinic is in exact accord with that of Doctor de Schweinitz.
BY R. BISHOP CANFIELD, A. B., M. D., ANN ARBOR, MICHIGAN.
PROFESSOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN,
WILLIAM ROBINSON LYMAN, A. B., M. D., ANN ARBOR, MICHIGAN.
DEMONSTRATOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.
A REPORT OF TWO CASES OF MASTOIDECTOMY SINUS
MCKERNON (Archives of Otology, Volume XXXIV, Number IV). The first case was a male twenty-six months old, always healthy save for an attack of acute otitis one year before. When first examined there was a mucopurulent discharge in the external auditory canal, examination of which showed staphylococcus infection. The tympanic membrane was bulging and there was a small perforation in the posterior quadrant. The temperature was 102° and the child was rather drowsy. The tympanic membrane was incised and in twelve hours the temperature was 100°. On the fifth day temperature rose to 103.2° and there were signs of mastoid involvement. The mastoid was opened and a small amount of pus found in the antrum. For several days the patient did well and the wound looked healthy except in a small spot over the sigmoid groove in the region of the knee. The temperature was 103°, the child restless and refusing nourishment. The temperature the following day was 104.8° and the wound was bathed in pus. A diagnosis of sinus involvement was made, the sinus was opened and a clot removed, free hemorrhage obtained and the child apeared stronger. For four days the temperature ranged between 103° and 100°. On the fifth day the temperature went to 104.2°. The child was very restless and looked septic. A few hours later the hands and feet became cold, the temperature reached 105°; pulse 160. The vein was ligated below the clavicle and resected to its exit from the skull. It was found to contain a clot for nearly an inch below the skull. The facial vein was also involved and nearly an inch was resected. The wound closed and patient made an uninterrupted recovery.
The second case was a female, age thirty, who developed an acute otitis twenty-four hours after a partial turbinectomy with symptoms of a profound systemic infection. The tympanic membrane which was bulging was incised. The discharge showed many streptococci and a few pneumococci. The temperature was 102.2° and the mastoid tender. The temperature remained about the same and on the third day the mastoid was opened and found to be involved throughout. Within a few hours there was a sudden rise of temperature to 103.8° and a sudden fall to 98.4°. For six days the patient did well save for a slight fluctuation of temperature. On the tenth day there was a sudden rise to 103.8° with intense headache and marked variations of temperature during the next twenty-four hours. Sinus involvement was diagnosed but owing to the extreme weakness of the patient operation was delayed and stimulating treatment given for five days. On the sixth day the sinus was opened, and a large clot found extending backwards from the knee about two inches. In the lower part of the vein there was disintegrated clot and pus. There the internal jugular was exposed, ligated and resected. At the same time many suppurating glands were removed, the wound was sutured and the patient made a good recovery. All specimens removed contained numerous streptococci. It is worthy of note that in this case there were no chills, nausea, or vomiting.
From the subsequent history of the first case it is seen that it would have been wiser to have resected the vein at the time the sinus was opened, as there may be free hemorrhage at the bulb while the vein in the neck still contains a thrombus. Doctor McKernon feels like ligating the vein in all cases at the time of operation when the condition of the patient will allow.
R. B. C.
BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN.
ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.
THE LYMPHATIC DRAINAGE OF THE FAUCIAL
GEORGE BACON WOOD (American Journal of the Medical Sciences, August, 1905) has made a number of dissections of injected specimens to show the lymphatic drainage of the faucial tonsils. The fate of microorganisms which have entered the parenchyma of the tonsils is dependent upon two factors: First, the pathogenic potency of the germ itself, and second, the vital resistance offered by the tissues to its invasion. It has been proven that foreign bodies in the crypts can pass through the epithelium into the interfollicular tissue. The absorption is probably due to the action of the muscles and the presence of the lymph current.
The author describes the different lymphatic chain of glands and gives the regions they drain. The direction of the drainage from the