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second foci. Both foci were removed and the patient recovered. As a matter of precaution, she is wearing a metal splint while performing her household duties. The ankylosis of the fingers is the result of the operation performed four years ago, and nothing seems ot correct it.

GUMMA OF THE FRONTAL BONE. Doctor PEDERSEN: I also wish to present this patient. I first saw this man last summer, eight weeks after he had received a violent blow on the head. At that time there was a tumor, which was supposed to be an adenoma, partly chancroidal, partly syphilitic. It traveled down under the skin, down into the fatty tissue, eating out large masses of the tissue, and finally was stopped by bromidia water. Soon after the lesion on the head broke and took on the characteristics of a specific lesion and was dressed surgically. There seemed to be a fissure the skull, which had been previously treated, and exfoliation of the bone took place. There was no temperature except that which would naturally accompany anemia. At one time the lesion was thought to be tubercular, but recovery under specific treatment seemed to confirm the diagnosis of gumma with profound anemia.

DESTRUCTION OF TISSUE AND NAILS OF FOOT. Doctor PEDERSEN: I will also present another patient, who came to the House of Relief two weeks ago, having been discharged from one of the city hospitals. The nails of the left foot and the tissue surrounding them showed evidence of great destruction, and there was a great deal of pus. The interesting question was whether to apply blue ointment or a wet dressing. The patient's conditions of life made it impossible for him to obtain any benefit from a wet dressing, so blue ointment was used, with beneficial results. The foot presented an appearance very similar to nephritis, but the other foot is not at all swollen.

VARICOSE VEINS. DOCTOR ALEXANDER LYLE: I desire to present this patient, a man, forty-eight years of age, who suffered from scarlet fever and whoopingcough as a child, and from typhoid fever when twenty-eight years of age. He is a heavy smoker and beer drinker. His present trouble dates back twenty years to swelling of the ankles. The veins of the right leg ulcerated several years ago, and a diagnosis of varicose veins was made. The ulcers are very large in both legs, but cause the patient no discomfort. I am of the opinion that at the time of the typhoid a thrombus had formed in the injured vena cava, and the superficial veins had taken up the circulation. No abdominal tumor can be located, and the veins all originate above the brim of the pelvis.

NEPHRECTOMY. DOCTOR F. C. YEOMAN: I wish to report the case of a man, aged fifty-six, who has been a heavy consumer of alcohol. About seven months previous to operation he was seized with a severe pain in the right groin, shooting downward to the groin and corona glandis, and the next day passed blood clots in his urine, but never passed any gravel to his knowledge. During the next three months he had attacks resembling renal colic at intervals of from two to five weeks, passing clots but no stones. During the past two months he had suffered severe intermittent pain during the night, beginning in the hypochondrium and extending over to the midline; also intermittent pain referred to the knees, more marked on the right side. The urine of late has been free from albumin and never showed any crystals. The patient's strength gradually diminished and he lost about forty-five pounds in weight. No tumor could be felt seven months ago, but during the past three months a mass gradually increasing in size has occupied the right hypochondrium. Patient would not permit cystoscopy. He was admitted to the Polyclinic Hospital February 15, demanding operation for the relief of intolerable pain, although he had refused all previous suggestions of surgical interference. His lungs, on physical examination, were found to be normal; heart-sounds soft, no murmur; radials moderately thickened. The abdomen was relaxed and the upper limit of liver dullness diminished one intercostal space. The right hypochondrium showed a tumor ovoid below, descending on deep inspiration to a position opposite the umbilicus. On pressure it took the position occupied by the normal kidney. Blood examination showed a white count of eight thousand, hemoglobin, one hundred per cent.

A right nephrectomy was done on February 20. The operation was difficult, as the kidney was about three times the normal size, covered with a network of veins, and adherent on all sides. The wound was closed, except for cigarette drains at angles. The time of operation was one and one-half hours, and the patient rallied fairly well; but the following two days there was almost total suppression of urine, only two ounces being secreted. Thereafter his condition improved, and he secreted about the same amount and character of urine as before the operation; but at the end of a week he began to fail, and died on the eighth day. Autopsy was refused, and thus the opportunity of discovering if metastases had occurred was lost.

A cursory review of the reported cases of hypernephroma warrants the following tentative conclusions: Metastases is the rule, especially to the liver, lungs and bones. These tumors have a tendency to spread and involve veins, but no lymphatics. The renal brim is usually involved, and sometimes the cava, but does not obstruct sufficiently to cause edema of the extremities. In a few cases the growth long remains local and can be successfully removed. Clinically, the symptom that may be of diagnostic value is bleeding and its results. Tumor and pain are present as in several other renal affections. Periodic attacks of hemorrhage, with frequency of micturition, often with passage of clots, seem characteristic. These clots sometimes block the ureter, cause diminished urine, and the pain is referred to the corona glandis. Between the attacks of bleeding there is fairly constant pain in the back. A fresh hemorrhage relieves the pain, thus contrasting with pain and bleeding connected with the passage of stone.

PATHOLOGIC SPECIMENS. PROFESSOR J. H. LARKIN, of Columbia University: I shall present some pathologic specimens of great interest and give the history of each, insofar as I have been able to obtain it. The first are of diseased appendages, a field of surgical research which is becoming more and more important. Until a few years ago it was supposed that lesions of the pancreas, as found at postmortem examinations, were fairly well understood, although little was known of the etiologic significance; but now pathologists are able to show the causative factor. Its close relationship to cholelithiasis and other diseases of the intestinal tract has been understood for some time. The clinical histories in these cases are very similar. There is usually a severe onset of gastric pain that at times is almost diagnostic to the surgeon of appendicitis or intestinal obstruction, and many patients have been operated on for one or the other of these conditions. In the majority of cases, stone in the ampulla duct has been a very common factor. The specimen which I present is mounted so as to preserve its normal color. On the right side is a portion of the duct and on the left a portion of the pancreas. It is presumed that one or more stones had been passed in this case, because of the immense dilatation of the common duct. The lesion is easily explained, and experiments have reproduced exactly the same condition. The stone passes down into the common duct and is impacted at Bardes' ampulla, and this leaves a continuous passage from the common duct to the ampulla, and the bile, instead of going down, is sidetracked and goes directly into the pancreas, and this produces hemorrhagic pancreatitis. This can be reproduced by putting bile into the pancreatic duct, or a solution of hydrochloric acid will produce the same result.

The next specimen shows the connection of the pancreas with the duct, and also shows the gall-bladder with an immense amount of stone. Of the several interesting brain specimens which I present, no clinical histories could be obtained. One specimen is from a patient who had been under observation for some time, and whose condition had been diagnosed as cerebral abscess. The specimen shows one side of the brain, with the cerebellum and one cubic centimeter of hemorrhagic blood which was removed at time of operation.

EXHIBITION OF INSTRUMENTS. DOCTOR J. E. FULD: I wish to present this intestinal depressor. I devised it for the purpose of depressing the intestines to prevent them from extruding into the abdominal wound and interfering with the operator. Gauze pads are usually inserted to overcome this difficulty. The instrument has proved of value in pushing aside not only the intestines, but the other abdominal contents as well, thus affording the operator a full view of the area to be inspected. The instrument is of polished steel, and shaped something like the ordinary glass tongue depressor, being eight inches long, one and one-half inches wide at one end and three-quarters of an inch wide at the other.






TIAL DIAGNOSIS OF OBSTRUCTIVE JAUNDICE. MOYNIHAN, in the lay issue of the Edinburgh Medical Journal, contributes an article "On the Violation of Courvoisier's Law," from which I abstract and rearrange what seem to be the most important points.

The Law.—“In cases of chronic jaundice due to obstruction of the common bile duct, a contraction of the gall-bladder signifies that the obstruction is due to stone; a dilatation of the gall-bladder, that the obstruction is due to causes other than stone."

Courvoisier's explanation of the contraction or sclerosis of the gallbladder is that stones had been present in the gall-bladder for long periods; that their presence had caused recurring attacks of cholecystitis, and that, as a result, the gall-bladder walls had become thickened and fibrous. The gall-bladder so affected, became by degrees more and more shrunken, and at last was represented by a shrivelled mass of fibrous tissue, its cavity was greatly reduced in size, or almost obliterated, and the shrunken dense adhesions hid it from sight. Oft repeated attacks of cholecystitis and peritonitis resulted in cicatricial compression and cramping of the gall-bladder.

Confirmation of the law has been made by Ferrier of France, Mayo Robson of England, and A. Cabot in this country. Moynihan cites a few cases which are directly in violation of Courvoisier's law, but calls attention to the fact that Courvoisier himself recognized that the law may sometimes be flagrantly infringed, and agrees with those just mentioned that in the great majority of cases that came under his own observation, the law has proved to be correct, but like all other laws is capable of infraction.

Moynihan sums up his short but very comprehensive paper by giving the following chief circumstances in which the law may be violated :

(1) Where there is a stone or a stricture in the cystic duct causing hydrops or empyema, together with the acute impaction of a stone in the common duct.

(2) Where there is a stone in the cystic duct pressing upon the common duct.

(3) Where there is distension of the gall-bladder by an acute inflammatory process, with obstruction of the common duct by stone.

(4) Where there is chronic induration of the head of the pancreas, with a stone in the common duct.

(5) Where there is malignant disease of the common duct at any part of its course, or cancer of the head of the pancreas, and a chronic sclerosing cholecystitis.

The validity of the law is established in at least ninety per cent of the cases in practice.

The value of the paper is in its suggestion for more careful differentiation of cases presenting the symptom of obstructive jaundice.

D. M. C.





CHARLES H. MAYO, M. D., of Rochester, Minnesota, in Surgery, Gynecology and Obstetrics, April, 1906. Of the many operations advised for the relief of varicose veins no one is suited to all cases. Not only the superficial veins produce the symptoms but the deeper veins are probably enlarged. The long or internal and the short or external sapheni veins are the ones usually affected. These connect at the knee and the internal also connects with the deeper veins at this point. The internal extends from the saphenous opening to the ankle and joins the external saphenous through the dorsal vein of the foot. These veins contain a number of valves which aid in separating the blood column. The internal vein is accompanied by the internal saphenous nerve, and the external vein by the external saphenous nerve.

The cause of varicose veins is difficult, in many cases, to understand. In some it may mean congenital defect in the vein walls, valves, or enervation. In some cases pregnancy is given as a cause and in others pressure of tumors or injury. Vocation oftentimes increases the condition and symptoms. The condition may begin as early as twenty years, but many years may elapse before disabling symptoms

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