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gave no history of difficulty in lower abdomen. Fetal movements were felt, the beginning of April, 1905. She continued her customary house and field work until the end of August, when she had labor-like pains which continued a few days. Along with these labor-like pains she passed bloody clots from the vagina. Toward the beginning of September fetal movements ceased. At the end of September, and November she had vaginal bleeding similar to her regular periods. The circumference of the abdomen remained unchanged during these months.
Patient came under Rödiger's care early in December, 1905. His examination revealed uterus empty, a cyst-like tumor pressing it to the right and upward. The lowest portion of the tumor was on a level with the cervix and the highest point reached four finger breadths above the umbilicus, being quite immovable. In the left vaginal wall a hard round body could be felt. This was taken to be the head of a fetus. From the breasts came milk in goodly quantity.
A diagnosis of extrauterine pregnancy was made upon the foregoing findings:
An operation was performed December II, 1905. A median incision was elected. A tense and fluctuating tumor covered with peritoneum presented, apparently arising from the pelvis. Toward the left it was intimately adherent to the parietal peritoneum. The adhesions on the posterior surface were very easily separated. The culdesac of Douglas was entirely free. The abdominal wall was sutured to the tumor, shutting off the abdominal cavity in such a manner as to leave segment of 10 x 5 centimeters of the tumor free. The tumor was opened through this free space, and contained one and one-half liters of dark green fluid, and the lining wall was also colored a dark green. The child was extracted by a foot and weighed eight pounds. Umbilical cord led to placenta adherent in bottom of cavity. The placenta was left in the sac, its cavity being first cleansed out and then packed with iodoform gauze.
The case went to recovery without a rise of temperature (so the author says). Upon the twentieth day the placenta was easily removed, without bleeding, and in three week's more the abdomen closed by granulation, no fistula remaining.
Patient was examined three months later when her usual health was found fully restored, she being able to do her customary work. The vaginal examination revealed scarcely a trace of thickening in the left ligamentum lata. The uterus was free and in the middle line. In neither adnexa nor culdesac could any pathological condition be determined.
The author, quoting Desguin, of Antwerp, says that the adhesions of extrauterine pregnancy are mostly of a mechanical nature and after their separation seem to entirely disappear, while adhesions due to infectious causes last much longer and possibly never disappear.
Schauta says the diagnosis of extrauterine intraligamentary pregnancy, with the abdomen open, is only positive when the "tumor" extends well up and out of the pelvis with separation of the layers of the ligamentum lata and the culdesac is entirely free.
The complete extraperitoneal position of the intraligamentarydeveloped sac made the prognosis in this form of ectopic pregnancy comparatively favorable. The fetus could develop to a normal fullterm, and in this case quite likely, if it had come under observation and in competent hands three months earlier, a living child would have been the result.
Möbius called attention in 1903 to the comparative painlessness of a developing intraligamentary extrauterine pregnancy in contradistinction to that of an ectopic developing in the free abdominal cavity.
The operation in this case was comparatively simple. The extirpation of the fruit-sac was not done. The expulsion of the placenta was safely left to nature. After removal of the afterbirth the two layers of the ligamentum lata quickly united themselves. The most important act in the whole operation would be absolute closing off of the abdominal cavity before opening the membranes, thus preventing the entrance of septic material from the fruit-sac into the peritoneal cavity. (The reviewer feels justified in casting doubt upon the propriety of procedure in this case. Would not an entire shelling out of the fruit-sac from between the layers of the ligamentum lata—and this is comparatively easy,-removal of redundant tissue, suture of the parts and a proper closure of the abdominal wall, thus avoiding future dangers of hernia, been the better procedure?) Ref.
The case is of further interest inasmuch as the patient was a farmer's wife, never having complained of difficulty in the lower abdomen. Any previous infection with gonorrhea could be almost with certainty excluded, and there is no ground to assume the presence of an acute or chronic condition in the region of the tube at time of impregnation. The history and subsequent findings favors the view and suggests that possibly the cause of ectopic pregnacy may be looked for in the ovum itself.
R. P. Detroit, Michigan,
ARTHUR DAVID HOLMES, C. M., M. D.
COLD-AIR TREATMENT OF INFANTILE PNEUMONIA.
This paper is discussed in a vigorous manner by Doctor W. P. Northrup, Professor of Pediatrics in Bellevue Hospital Medical College (New York Medical Record, February 18, 1905). The method is such a startling change from the orthodox treatment of past generations, and yet so in line with recently acquired knowledge in other directions, that it is time for the profession of medicine to call a halt and overhaul its stock opinions. If the child's temperature is 105° Fahrenheit it is certainly illogical to make it higher by hot chest poultices, heavy coverings, crib in a corner of the room, steam kettle boiling, gas leaking into room, and every breath of fresh air carefully excluded. Yet this is just the course instinctively followed by every mother, who always associates pneumonia with cold and its cure with heat. Northrup details two desperate cases treated upon the opposite plan, and though he leaves but little doubt as to the perfect reasonableness of it all, it is to be confessed that it will be difficult to make the average mother carry out the treatment. A room temperature which compels the attendants to wear overcoats and furs does seem harsh, but if the results are explained there should be no complaint. Cyanosis disappears, the blood reddens, restlessness diminishes, sleep comes on, the heart is stronger, the respiration is less labored, indigestion is improved—and all from the cold air which bathes the little sufferer's face and enters its lungs. If such great good can be accomplished by this simple means, surely an effort should be made to induce mothers to carry out the method in all such cases.
FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN,
THE CONSERVATIVE TREATMENT OF HIP DISEASE.
S. J. HUNKLIN, M. D., of San Francisco, in the American Journal of Orthopedic Surgery, July, 1906.
Without attempting a definite diagnosis, in many cases, he includes under this heading those diseases which present the symptoms of lamed function, limp, spasm and interference with the extremes of motion, especially rotation. His paper deals principally with the treatment of the condition which in his judgment is conservative, even in the class that goes on to suppuration and abscess formation. He regards rest as the essential principle, and, as the work performed by a joint is of two kinds, namely, motion and weight-carrying or friction and pressure, it is best obtained by immobilization and traction. By these methods absolute rest is obtained during the acute stage of the disease, after which time work within the limits of pain and spasm is more desirable. Outdoor life is strongly advised and these patients should never be confined to the house when the treatment can be applied with them up.
When complicated by abscess no change in treatment is necessary more than aspiration of its contents. If the latter condition exists and goes on to ulceration, confinement to bed may be advisable for reasons of cleanliness, the wound being dressed with sterile gauze and any meddling with it prohibited. This plan of treatment is preferable to operation even in those joints which show the whole epiphysis to be disorganized, when no joint line can be distinguished and clinically the head of the femur is on the dorsum of the ilium. When the latter condition prevails he relocates the head of the bone at once under an anesthetic.
R. BISHOP CANFIELD, A. B., M. D.
WHAT CASES OF CHRONIC PURULENT OTITIS REQUIRE
THE RADICAL OPERATION. KNAPP, of New York City, in Volume XXXV, Number II, of the Archives of Otology, considers that the present tendency is toward greater conservatism in the treatment of chronic purulent otitis media and notes Ballance as the only one who still insists that all these cases be treated by the radical operation.
Leaving out cases complicated by intracranial extensions, stenosis of the canal, or acute mastoiditis, the author arranges the remaining cases, according to the classification of the Berlin Ear Clinic, as dangerous and as not dangerous, the former series comprising those in which the bone is affected, especially in the attic and antrum, and the latter in which the inflammation is localized to the mucous membrane of the tympanum.
Bone involvement may be recognized by the characteristics of the discharge, its odor, and by the otoscopic picture which shows a total defect or a posterior and superior marginal perforation of the drum. The presence of cholesteatoma is important and if there is retention it is an urgent indication for operation. Cases showing simply chronic osseous involvement may often be benefited by conservative treatment but this procedure failing, operation should be considered. Headache, nausea, and vertigo are important symptoms and usually indicate operative measures though the first may be but a manifestation of hysteria. In the second group of cases one finds anterior or central perforations and usually involvement of the tube. Even in some of the dangerous cases minor operations will suffice and the patient is safe while under occasional observation. It is also important to consider the hearing in the other ear for one cannot guarantee but that the hearing will be diminished after operation. His conclusions are as follows:
The operation is not indicated when the tympanum and especially its mucous lining are involved, because intracranial complications are not likely to ensue and the operation usually accomplishes nothing.
The operation is urgent when the symptoms of headache, nausea, and vertigo are associated with, and in relation to, chronic purulent
otitis; when the bone is found affected or cholesteatoma is present, and these symptoms are not promptly refieved by a minor operation.
The operation is indicated when signs of bone involvement continue after conservative treatment has been followed for a certain length of time and the odor in the discharge persists. The operation is not necessarily urgent in these cases, as good drainage is present. The question of operation then depends on the patient's wishes and the condition of hearing in the other ear.
WILLIS SIDNEY ANDERSON, M. D.
M. L. C.
CLINICAL PROFESSOR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.
PALLIATIVES FOR HAY FEVER.
SOLOMON SOLIS-COHEN (Jama, July 28, 1906) first considers the suprarenal preparations. He advises the use of the active principle of the suprarenal gland made into tablets, with a little sugar of milk, in doses of one-fortieth to one-tenth grain. The tablet should be dissolved on the tongue and not swallowed. The dose may be repeated in from ten minutes to two hours, according to the effect. If the patient remains quietly at home, in a cool, semidark room, one or two doses will suffice. If out in the air and dust then a tablet every hour or two may be necessary. The drug taken by the stomach has little or no effect. Local application to the nose and eyes are advised. The author suggests that the active principle be made into an ointment, or diluted with compound stearate of zinc for use in the nose.
In regard to pollatin the author states that its effects are positive in from thirty to fifty per cent of the cases met with, but in these it is only palliative, and where the suprarenal preparations are effective pollatin offers no advantage over them. The nose should be carefully cleansed before any local medication is employed. Internal medication is considered and the judicious use of belladonna, or its active principle is advised in certain cases. The antilithic remedies and mild alkaline carbonated mineral waters are helpful in some cases. General precautions, such as change of residence, avoidance of dust, and regulation of diet are considered. The diet should be a simple one with avoidance of pastry and sweets.
One very practical point, not mentioned in the paper, in regard to the irritation of the eyes is the use of a separate handkerchief for wiping the eyes. Patients find that the nasal secretion is very irritating, and that the only way to avoid such irritation is to use a separate handkerchief.
DOCTOR BERTRAND DE GORSSE (Revue Hebdomadaire de Laryngologie, D'Otologie et de Rhinologie, July 28, 1906) calls attention to the importance of moderate degrees of nasal obstruction and its effects on the general health.