cyst, showing the long Scandinavian hair. DR. CARSTENS also made the following report of abdominal operations made since last June: Abdominal hysterectomy, four; dermoid cyst, two; cirrhotic ovaries, two; chronic ovaritis, three; vaginal hysterectomy, one; extra-uterine pregnancy, one; appendicitis, one; ovarian cyst, three; cyst of broad ligament, two; Porro operation, one; malignant disease, two; tubercular peritonitis, one; pyosalpinx, four: total, twentyseven. One death from shock, and one from purulent peritonitis. DR. E. B. SMITH exhibited a leg amputated below the knee for indolent ulcer of many years standing, together with extensive caries. DR. VOORHEES: What was the age of the patient? DR. SMITH: Fifty-three years. The leg had been in this condition four years. DR. VOORHEES: I have been able to cure a good many cases by strapping oakum and bandages. I think that is the only way to treat these cases. remember one case thus cured which had existed twenty-five years. I DR. STONER: Inasmuch as there is also bone disease here as well as an ulceration of the soft parts, I think the amputation justifiable. The only criticism I could make is that the amputation might have been made a little lower. DR. FLINTERMANN: What treatment has she had? DR. SMITH: Recumbent posture, bandages, strapping applications, tonics, etc. The features of the case which to my mind necessitated the amputation were, first, extensive bone disease; second, the complete circling of the limb by the ulceration; and third, that the patient was a Polish woman and was, therefore, uncontrollable.. DR. VOORHEES: I have observed that in large and indolent ulcers of the leg, it is rather more advantageous to have the patient up and on his feet rather than lying down. DON M. CAMPBELL, M. D., Secretary. STATED MEETING, OCTOBER 24, 1892. THE PRESIDENT, FREDERICK W. MANN, M. D., IN THE CHAIR. DR. CARL BONNING presented a fœtal monstrosity. The mother gave birth to the child at full term last June, since which time she has been very excitable and nervous. She menstruated last on July 10, since which time she has been in poor health, being confined to her bed two or three weeks. She came under my observation two weeks ago having a slight show. Last Friday she was delivered of this two and one-half months fœtus. On examination it will be found to consist of one large head, two eyes, is joined at the sternum and presents four arms and four legs. The abdominal cavity is not closed and the sex is undetermined. It has been my experience to observe that twin pregnancies frequently abort. DR. N. W. WEBBER presented the ovaries from a woman, a subject of epilepsy beginning at the time of puberty. The convulsions became more and more frequent until finally she was having three or four attacks a day. Various modes of treatment had been employed without success. The ovaries were removed last May, since which time she has had but one epileptic seizure. He also presented ovaries removed from a young girl giving a history of long continued ovarian pain and discomfort, together with a recent rapidly developing swelling in the left ovarian region. Third, an enormous enlargement of the left ovary. The patient has been running down for two or three months. Six weeks ago she noticed a swelling in her left side and this enormous growth which looks like a sarcomatous growth of the ovary was removed at Harper hospital on Saturday. The right ovary which showed signs of degeneration was also removed. DR. E. B. SMITH exhibited a testicle showing chronic orchitis for four or five years. Hæmorrhage occurred four or five weeks ago. The testicle was then removed. DR. W. P. MANTON: I wish to compliment DR. BONNING on the rarity and beauty of his specimen. It is not often that we see such a monstrosity in so early a stage of development. DR. WEBBER'S case of epilepsy is a very interesting one. It is very questionable, however, if we can permanently cure epilepsy by these operations; still, I believe the operation to be justifiable if it hold out even a remote chance of modifying the severity of the disease. I saw to-day a case which I reported in the Detroit gynecological society as a case of hystero-mania treated by ovariotomy. At her last menstrual period she was slightly flighty, and at this period she lost consciousness for two hours. DISCUSSION OF PAPERS. DR. E. B. SMITH read a paper entitled "Lesions Above and Below the Cæcum." DR. E. T. TAPPEY presented an appendix vermiformis, removed from a child seven years old. DR. TAPPEY also read a translation of an article by DR. MAT SCHEDE, of Hamburgh, bearing upon the subject of perityphlitis. He says:. Perityphlitis belongs to that class of disease which has to thank the progress of surgery for our knowledge of its pathological anatomy as well as that of its treatment. Just as in diseases of the joints, we first attained to our accurate knowledge of the pathological anatomy when we obtained an insight into their progress by early resections, of which our knowledge had before been obtained only from amputated limbs and on the post-mortem table. But it is now only a short time since diseases of the cæcum and of the appendix have been brought into the domain of surgical treatment, and when the well-known German surgeon, FRIEDRICH LANGE, of New York, says, "In all of my student years and in my experience as assistant to two large university clinics I do not remember a single case of perityphlitis which was treated by surgical interference--" I can only subscribe to his personal experience. It describes the state of the case as it has been until within a very short time. Perityphlitis was assigned to the department of internal medicine of the hospitals, and, as a rule, only when the abscess involved the abdominal walls, was it opened by a single incision. We shall see that we must find other indications for operation, and that an active interference promises much benefit. In order to obtain a just appreciation of the question we must in the first place give up the generally accepted opinion that perityphlitis has to deal only with extra-peritoneal inflammation. BARDELABEN and LUSCHKA even in their time opposed the erroneous belief that the cæcum as well as the colon had only a partial covering of peritoneum. Lately SCHULLER, TREVIS, KOOTE, and LANGE have affirmed that the inflammatory processes in perityphlitis are almost without exception inside the peritoneum. Parityphlitic inflammation, if I include that which attacks the retro-peritoneal connective tissue, does occur, but much more seldom. The way in which it happens KOOTE has shown by means of a beautiful experiment, namely, that fluid injected between the folds of the mesentery of the appendix finds its way into the retroperitoneal tissue. That pus may be found in retro-peritoneal tissue after the cæcum has become adherent and an abscess has then broken through the parietal peritoneum is obvious. Furthermore, all recent investigations and statistics show that what is known as perityphlitis, in by far the great majority of cases does not begin in the cæcum but in the appendix. The arduous labors of LANG held in the post-mortem room of the Charité, those of EINHORN in the pathological institute of Munich, the labors of KRAFFE, LANGE, KÜMMELL, KÖOTE, and others, establish this fact so clearly that we may accept it as final. If now I should attempt to classify the different pathological conditions of which we are speaking, and to answer the question, If we shall interfere by surgical procedures and when shall we interfere? there would appear as the most usual and mild form the recurring inflammations of the appendix which finally close the lumen of the organ. This is accomplished in the greatest number of cases by small particles of fæces and (fæcal calculi) by enteroliths, much less often by foreign bodies, not unfrequent by cicatricial stricture, sometimes, no doubt, by ordinary catarrhal swelling. The integrity of the abdominal walls remains intact, and there is also no exudate upon the peritoneal surface; often, however, there is retention of the secretions and as a consequence there is a small circumscribed tumor which can often be plainly felt. Its position is that of the appendix. In the otherwise normal conditions of the appendix the cæcum in adults is at a point one and five-tenths inches to two inches from anterior superior spinous process in a line connecting this with the umbilicus. In America this point is named after the author who first described it-" McBurney's point." Clinically, the above mentioned conditions are characterized by severe attacks of pain of moderate duration, with only a small amount of exudation or without any at all. At the same time appear the so-called peritoneal cramps, vomiting and meteorisms, usually the lumen will become again open, the mucus or muco-purulent secretion of the appendix which has been confined is emptied into the cæcum and the attack is over. But returns are frequent and after a shorter or longer time it develops into a grave process. These forms appear to be much more common in America, where, on account of a poorly arranged diet and ways of living, chronic constipation is much more general than with us. LANGE remarks it as being very usual. I cannot speak personally in regard to the prevalence of constipation among us, for it is not often brought to the attention of a surgeon. Now, gentlemen, when a patient, in the course of seven months, has had four severe attacks, as happened in the first case reported, which in spite of his maintaining the greatest quiet, the severest diet, etc., rendered him for the greater part of the time incapacitated for labor, or when, indeed, as in the second case, the increased severity of the attack rendered the danger correspondingly greater, then it is not difficult to reach the determination to operate. But I imagine it would be going too far to operate in each such case before the tendency to recurrence is established by the progress of the case. SCHEDE NOW speaks of opening abscesses where we have diagnosticated pus. This is always to be done, and he discusses the question whether in case of such abscess we are to search long for the appendix. He * * * thinks not, for in many cases it is not to be found; then, too, we should not break up the adhesions of the peritoneum and thus endanger our patient with septic poisoning. SCHEDE finally ends his paper by saying that this disease is a most varied one, that of the eighteen cases he reports scarcely two are alike in all respects and no two cases can be handled in the same manner, and that the progress of each case is different from each other. DR. CHAS. DOUGLAS: This subject is coming very prominently forward as a surgical question. The question which confronts us clinically is, Shall we operate now or shall we treat the case conservatively, that is to say, when shall we and when shall we not operate? This question is still unsettled. I call to mind one instance in which the child was almost dead, but upon the earnest solicitation of the father and against my own judgment and expressed wish, I operated. The appendix was found almost ulcerated across, and imbedded in some hardened fæces, with their ends sticking through the ulceration, were found three bristles, such as might come from a blacking brush. There are also many cases over which we worry a good deal but do not operate upon, that recover spontaneously. When we have a steadily progressing disease in this locality, which at intervals is subject to exaggeration, then we know it is in the fit state for operation. There are many cases also which simulate perityphlitis, but which are due to impacted fæces. These cases clear up as soon as the impaction is relieved. Another case which I call to mind was that of a large accumulation of pus in a man who had long been under homœopathic treatment. I got on well with him until I proposed doing something for him, and although what I proposed was a simple aspiration, he became alarmed and dismissed me. I learned afterward that this large abscess discharged spontaneously through the bowels. He made a good recovery, but the disease returning at a latter date, he finally had to consent to an operation. The question of greatest importance and the one hardest to decide is, When to operate? DR. STONER: I am not acquainted with any fever except typhoid fever in which ulceration of Peyer's patches and the solitary glands occur. I do not think it possible to operate successfully in cases of perforating ulcer in typhoid fever. DR. J. B. NEWMAN: DR. SMITH'S assertions and DR. TAPPEY's translations seem to clash as to the causation of these cases. DR. TAPPEY: SCHEDE says that in almost all cases the cause is appendicitis. DR. NEWMAN: What was the cause of the abscess in DR. SMITH'S first case. DR. SMITH: It was the extreme muscular exertion during the prolonged skipping which did the damage. DON M. CAMPBELL, M. D., Secretary. STATED MEETING, OCTOBER 31, 1892. THE PRESIDENT, FREDERICK W. MANN, M. D., IN THE CHAIR. DR. GEORGE W. STONER read a paper entitled "A Case of General Dropsy." DR. C. W. HITCHCOCK: This is always an interesting subject because these cases invariably tax the ingenuity of the practitioner to the utmost, especially if the disease has a renal or cardiac origin. One case of general dropsy I now recall, had a history dating back many years, and as a cause of the dropsy presented a mitral regurgitation. She had a constant mitral murmur and was at intervals subject to attacks of general dropsy. This was especially the case after several attacks of the grippe from which she suffered. She recovered from many such attaks under the ordinary course of treatment, embracing diaphoretics and heart stimulants. Digitalis was always the heart stimulant to which she responded best. I would here say that in my experience infusion of digitalis has always proved to be by far the best remedy. She, however, finally had an attack from which she did not recover under any plan of treatment which I was able to suggest. Among other things which I tried was diuretine, which at first seemed to have the desired effect, but finally the taste of this drug became so unbearable, even when given in capsules, that it had to be discontinued. I also tried the sulphate of spartein with but indifferent results. She finally passed from my hands under the care of homoeopathic physicians. I saw her again to-day, and she is indeed in a pitiable condition. In the temporary case which DR. STONER has reported, the line of treatment which he has laid down is undoubtedly very good, but there are cases which will respond to no plan of treatment. DR. J. B. NEWMAN: There are a great many causes for general dropsy, such as anæmia and lesions of the heart, liver, kidneys and spleen. Heart, kidney. and liver diseases are the most usual causes. I have now a case under observation in which the dropsy is due to a tricuspid regurgitation. It is getting well under the tincture of digitalis, which I think is the best remedy we have, not excepting strophanthus. Digitalis can be used in all cardiac diseases except when the blood pressure is very high. In anæmic cases, strychnine is indicated together with the tincture of the chloride of iron, which is the best preparation of iron we have, probably because the hydrochloric acid which it contains, helps digestion. In dropsy due to kidney disease, the hot, wet sheet pack is a good remedy as are also hot baths, especially in children. Cathartics are indicated to relieve the kidneys and the best remedy for this purpose is the sulphate of magnesia in concentrated solution. DR. G. W. STONER: I purposely omitted any detailed treatment of dropsy due to chronic renal or cardiac disease because cures are unusual. Castor oil or sulphate of magnesia are efficient, but very unpalatable remedies. Podophylin and cream of tartar lemonade are in my experience the best remedies that can be administered. DR. E. W. JENKS: In the dropsy following acute desquamative nephritis, the hot air bath is the best remedy I know of. DR. C. G. JENNINGS: There is a peculiar form of ascites in children due to the enlargement of the lymphatic glands at the point where the portal vein enters the liver. This occurs chiefly in scrofulous children, and none of the usual causes of dropsy can be detected. They best respond to that treatment which is found most serviceable in the enlargement of other glands and which includes a careful regulation of the diet and the administration of cod-liver oil. DR. G. W. STONER: DR. JENNINGS' report of the exact point where the obstruction occurs is interesting. A case of general dropsy of the foetus has been reported. DON M. CAMPBELL, Secretary. |