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The woman has done very well since the operation. The gallbladder was filled with calculi-there must have been twenty or more. I decided that inasmuch as the patient had never given any symptoms, we would leave them alone, as her condition at the completion of the rather long operation was none of the best.
DOCTOR CYRENUS DARLING: I think that everyone who removes a kidney and the patient recovers, thinks that is the easiest way.
DOCTOR CHARLES B. G. DE NANCREDE: I think when the absence of pus can be determined, the transperitoneal route is preferable. If one has to deal with a large tumor, by making a straight transverse incision, going, if necessary, past the median line, gives greater ease in reaching the pedicle. One can see what he has, and can control the hemorrhage more easily. Still, experience has shown that through the posterior route we can take out the large adherent tumors piecemeal without having much additional hemorrhage.
READING OF PAPERS.
"SOME CARDIAC ARHYTHMIAS."
DOCTOR LAWRENCE C. GROSH, of Toledo, Ohio, read a paper on this subject. (See next issue of The Physician and Surgeon.)
FRANK BANGHART WALKER, PH. B., M. D.
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.
CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.
THERE were three papers read before the Section on Surgery and Anatomy of the American Medical Association, at its last meeting, on "Exophthalmic Goitre," that clearly express (Journal of the American Medical Association, September 1, 1906) the present idea of the profession concerning this disease and the newer methods of its treatment.
The first article, by John Rogers, M. D., of New York, is on the treatment of thyroidism by a specific serum. He would discard the term exophthalmic goitre and designate the condition by the word thyroidism, modifying it by such variations as hyper, atypical, chronic toxic, acute toxic, and psychopathic or neuropathic. The symptoms which characterize each classification are carefully noted, an arrangement necessary
in order that individual cases may receive treatment indicated for the particular case. In certain cases he has employed a serum of his own with favorable results. It is obtained from the blood of animals (rabbits, dogs, and sheep) inoculated with nucleoproteids and thyroglobulin from the human thyroid gland. When injected into the patient this is supposed to have a specific effect on thyroidal epithelium. The best results are obtained where one cubic centimeter of the serum is injected every third or fourth day until from four to eight injections have been administered. Reaction is noticed by a burning sensation at the point of injection, followed in a few hours by swelling and redness, later by fever, with rapid pulse. He reports ninety cases treated; twentythree cured, fifty-two improvements, eleven failures, and four deaths.
Improvement is indicated by changes in the size and character of the thyroid. Large soft glands become smaller and harder, while a hard gland will become softer. Chronic cases past middle life, with hard glands, when not benefited by a month's treatment may consult a surgeon.
The second article, by S. P. Beebe, M. D., Ph. D., of New York, deals with the preparation of the serum mentioned in the previous paper. The first products were made from normal human thyroid glands obtained at autopsy. These contain a very small amount of nuclear material and a relatively large amount of colloid. The method of preparation is given in detail but is too extensive to be repeated here. The material thus prepared from the glands is injected into the peritoneal cavity of dogs, sheep, and Belgian hares. Rabbits are given five injections six to eight days apart and eight days after the last injection the animal is exsanguinated.
Other preparations were made with pathologic human glands removed at operation and from these he obtained the most active serum. No marked clinical difference was found in the results whichever serum was employed, except, that where the normal ceased to do good the serum prepared from pathologic glands would show marked results when employed in its stead. The degree of actvity differs according to the animal used in producing the serum.
The title of the third paper is "The Surgical Treatment of Exophthalmic Goitre," by Francis J. Shephard, M. D., of Montreal. Operative treatment, while comparatively new, is not yet conceded by all as the best means for relief though many cases of complete cure have been recorded. Operation is based on the opinion that the disease is due to increase of thyroid tissue, hyperactivity or hypersecretion. Early cperation is advised when the condition is not too severe, also in cases where the enlargement is greater on one side, not excessively vascular, and where symptoms of Graves' disease have preceded by months the tumor formation.
Operation should be avoided in large vascular thyroids with definite febrile exacerbations and excessive tachycardia, with acute dilatation of
the heart, precordial distress, gastric and abdominal pain, vomiting and diarrhea, sleeplessness, perspiration, sense of suffocation, great restlessness, edema of the feet-in fact all the symtoms of toxemia due to thyroidism. Most physicians are opposed to operative measures and nearly all recent medical writers on exophthalmic goitre condemn surgical procedures as being too dangerous and not always successful.
Statistics are of little value in estimating the mortality from operations as much depends upon the case in question. General anesthesia is looked upon by some as greatly increasing the danger. Collected cases by most experienced operators give a mortality of six to eight per cent.
In discussing these papers Doctor Ochsner, of Chicago, said that there were four distinct dangers connected with anesthesia for the operation. Unless anesthetized with great care patients may be so thoroughly asleep that it will be difficult or impossible to arouse them. There is danger of producing a toxemia by violently handling the gland while the patient is asleep, as well as of injuring the recurrent laryngeal nerve. There is also danger of infecting the wound through the patient's breath. Doctor Bacon believes that the line of progress in the surgical treatment of exophthalmic goitre will lie in a more careful analysis of the cases. Doctor Dawbarn advocated the ligation of the superior and inferior thyroid arteries on both sides as a safe operation, devoid of mortality, with no resulting deformity or mutilation. They all spoke favorably of the serum although they believed it to be in the. experimental stage and advised operation in selected cases where the serum failed.
C. G. D.
REUBEN PETERSON, A. B., M. D.
PROFESSOR of GYNECOLOGY ANd obstetRICS IN THE UNIVERSITY OF MICHIGAN.
CHRISTOPHER GREGG PARNALL, A. B., M. D.
FORMERLY FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
ARTIFICIAL RENAL COLIC AS A VALUABLE MEANS OF DIAGNOSIS.
HUTCHINGS (American Journal of Obstetrics, Volume LIV, Number III) continues Kelly's observations on the production of artificial renal colic, published first in May, 1899. One hundred cases in all were studied, being selected from one hundred fifty examinations made in Kelly's clinic. These examinations were made with a view to locate the cause of various pains in the abdomen and back when they could not be explained by ordinary methods of diagnosis. Aside from pains with definite locations are those of an indefinite character located in various regions of the body and not diagnostic of any one lesion. These pains may be met with under a variety of pathologic conditions
such as disease of the appendix, of the gall-bladder, the Fallopian tube, the kidney, the pleuræ, et cetera. The method employed to produce an artificial renal colic, to compare with the pain complained of, after a careful history is taken and a thorough examination is made, is to explain to the patient that a cystoscopic examination is to be made, but she is not warned that her original pain may be reproduced. With the patient in the knee-chest position the ureter of the affected side is catheterized. The catheter should reach the kidney pelvis and should never be forcibly inserted. The patient now assumes the dorsal recumbent position. The bladder is catheterized, and the urine from the ureteral catheter collected and examined. Warm methylene blue water is now injected slowly, by means of a glass syringe, into the ureteral catheter until the patient begins to feel pain. As soon as the pain is definite the desired information is obtained and relief immediately follows the release of the fluid.
The repeated injection of normal renal pelves has shown that pain in the back, just below the twelfth rib, is first experienced. The pain then extends anteriorly over the abdomen and then down the iliac crest and in the direction of the ureter, becoming more and more severe, as the injection proceeds, until a typical renal crisis is produced. If the pain caused by the injection is the same as that of which the patient originally complains, a diagnosis of renal disease is made.
The writer groups the one hundred cases under the following heads:
I. Normal kidney pain produced. Not that pain of which the patient complained. Disease of the kidney ruled out.
II. Kidney pain reproduced. Same pain as that of which patient complained. Diagnosis of renal or ureteral disease confirmed. Stricture of ureter.
III. Dilated pelvis of kidney.
Group I, twenty-three cases.-Typical kidney pain in all from injection. Located in "superior lumbar triangle." In none corresponding to the original pain. In seven cases the pain was found to be due to pelvic disease, in six to disease of the appendix, in six no diagnosis was made, and in two, operations showed nothing to account for pain.
Group II, fifty cases. In all, the typical renal pain was reproduced and recognized as the one originally complained of. In thirty-five cases movable kidney was diagnosed and suspension done. In eight cases operation for movable kidney was refused. In two, treatment by bandage was advised. There were three cases in which nephrotomy was done with relief of symptoms. Suspension of the uterus in one instance and removal of the appendix in another failed to obtain relief for pain.
Group III, seventeen cases.-For various reasons in ten cases no operation on the kidneys was performed. Of the remaining seven
cases, the kidneys were suspended and the renal pelves folded in one; the stomach, kidneys, and liver suspended in another; ureteral calculi removed in two; transplantation of the ureter in one; stricture of ureter relieved in one; and the kidney removed in one case. Thirteen of this group of patients complained of pain which was reproduced by injection.
Group IV, ten cases.-In six the answers of the patients were so unsatisfactory, and the location of the pain so vague that no positive diagnosis could be made. In three cases the same pain was reproduced; in one omental adhesions were found, in another gall-stones, and in the third no explanation for the pain could be conjectured.
To sum up, the author arrives at the following conclusions:
(1) The ability to reproduce, mechanically or otherwise, the pain of which the patient complains is always a most valuable aid in diagnosis.
(2) A definite and typical "kidney pain" (renal colic) can be produced in every instance by forcibly distending the pelvis of the kidney with a bland fluid.
(3) In a large majority of cases (ninety-eight per cent in our series), patients are able to accurately differentiate renal pain, caused by the method described above, from pains from other causes.
(4) By this method a diagnosis can frequently be made in a class of cases, as yet undifferentiated by the medical profession, whose symptoms are vague and indefinite.
(5) Accurate measurements of the amount of dilatation of the pelvis of the kidney may be made with the instrument used, and by this means valuable data are obtained.
C. G. P.
ARTHUR DAVID HOLMES, C. M., M. D.
TYPHOID IN CHILDREN.
BUTLER (Jama, November 11, 1905). The author reviews the literature thoroughly with reference to the frequency, causation, et cetera, and gives an analysis of two hundred ten cases of typhoid fever in children-one hundred six boys and one hundred four girls. The average duration of symptoms, such as restlessness, headache, vomiting, anorexia, fever, et cetera, before coming under observation was seven days. In one hundred seven of the cases the bowels were regular in seven, constipated in thirty-one, and sixty-nine had diarrhea. Nosebleed occurred in twenty-nine of the two hundred ten. Tympany of varying degrees was usually present after the first week, and in some cases was an annoying symptom, extending