Surgery. FISCHL (LEOPOLD). Typhlitis after Appendicectomy. Prager med. Wochenschr., 1904. No. 7, p. 82. THE writer of this paper wishes to emphasise the fact that there is undoubtedly such a disease as typhlitis, quite apart from any inflammation of the appendix. He gives an account of five cases, in all of which at some previous time the appendix had been removed. These patients all had symptoms which would have assuredly been diagnosed as appendicitis, if their previous history had not been known. These cases all cleared up without operation under simple treatment, and the author thinks that the symptoms are referable to an inflammation of the cæcum. G. E. GASK. SPITZMÜLLER (WALTER). A Case of Neural Fibroma. Wochenschr., 1904, Nos. 9 and 10. A FULL account of a case of multiple neural fibromata. references to the literature are quoted. Wiener med. Copious G. E. GASK. HELLING (W.). On Serum Treatment of Tetanus. Deutsch. med. Wochenschr., 1904, No. 7. Two cases of tetanus treated with antitetano serum, with successful results. The author wishes such cases recorded in order that in time valuable statistics as to the usefulness of the antitoxin may be compiled. He suggests that the use of the antitoxin may be to neutralise any unfixed toxin circulating in the body produced at the seat of infection when that is incapable, owing to its position, of being excised. G. E. GASK. GOLDBERG (BERTHOLD). Deutsch, med. Wochenschr., 1904, No. 7. A DESCRIPTION of an aseptic method of carrying soft catheters. G. E. GASK. LUND (B. F.). Treatment of Diffuse Peritonitis. Boston Med, and Surg. Journ., 1903. Vol. cxlix., p. 583. THE author thinks that with a short anæsthesia and quick operation the danger of interference is much less than that of procrastination. A. J. Achsner, of Chicago, the most eminent advocate of the waiting policy, states that at no matter what stage a case of diffuse peritonitis comes into the hands of the surgeon, if the stomach simply be washed out and nothing given by the mouth, nourishment being given by the rectum, the process, in the vast majority of instances, will become walled off, the acute symptoms subside and the patient can safely be operated on at a later date. The author, from his experience, believes in early operation and removal of the infecting focus. In appendicitis and suppurative salpingitis removal of all diseased tissue wherever possible is the best policy; any infected diseased tissue which is left may be the cause of later mischief. The first object is the thorough removal of the infective focus; the second is thorough cleansing of the peritoneal cavity. To attain this latter object the author has irrigated the peritoneal cavity with decinormal salt solution at a temperature of 110°. Through a long glass nozzle of large calibre, pushed into all the recesses of the cavity, several quarts or gallons of salt solution are introduced. He does not wipe out, as he thinks it leaves raw bleeding surfaces with lymphatics open for further infection. The next thing is drainage; the author advocates gauze drainage because the irritating effect of the gauze causes adhesions which wall off the infected area, and before these are formed it drains away by capillarity a large quantity of fluid, some of it presumably septic. A glass tube surrounded with gauze drains the pelvis, the tube being removed in 24 hours and the gauze in four or five days; gauze is used alone for the stump of the appendix. He has seen no reason to think it has ever been the cause of intestinal obstruction. The head of the bed is elevated about one foot above the level of the floor and one or two pillows are placed under the shoulders; this position allows the fluid to drain into the pelvis. In cases of septic peritonitis accompanied by distension of the intestines, in addition to the above measures an incision about an inch long is made in the small intestine, the distended coils drawn outside the abdomen as far as possible, emptied of their contents and two ounces of a saturated solution of Epsom salts injected into the lumen; the opening is then closed with a continuous suture of silk or linen thread. After operation attempts to move the bowels with turpentine enemata, etc., are made; if these prove ineffective and the distension increasing and the patient becoming worse, a second enterostomy is done. The abdomen is opened in the middle line, the first distended coil of small intestine which presents is fastened to the transversalis fascia, opened, a glass tube put in and the fæces conducted away by a rubber tube. PRIESTLEY LEECH. PAINTER and ERVING. Chronic Villous Arthritis. Medical News, 1903. Vol. lxxxiii., p. 973 et seq. THE authors give notes of some 33 cases of this condition. Their conclusions are as follows:-Etiology: I. Traumata; II. Infections; III. Diathetic conditions. I. Traumata may include direct blows and injuries; indirect injuries, e.g., a strain or sprain; from within the joint as from a detached semi-lunar cartilage, etc.; loose bodies in the joint; forcible lacerations or wrenches of the ligaments of the joints; flat and pronated feet; fibrinous clots cause sufficient trauma to irritate the synovia. II. Infections. Tuberculosis; Tuberculosis; gonorrhoea, and probably other infective processes; syphilis. The extensive hypertrophy of the synovial membrane due to syphilis has been mistaken both before and after exploration of the joint for rheumatoid arthritis. III. Diathetic. Under this heading are rheumatoid arthritis and osteo-arthritis. Clinical History. The joints most frequently affected with these forms of arthritis are the knee, shoulder, ankle and hip. The knee is most frequently involved, probably from its exposed position, its function in bearing the weight of the body and the nature of its internal anatomy. If due to trauma the lesion is usually monoarticular; if to infections or diathesis usually poly-articular. The symptoms usually come on insidiously, and vary somewhat; a frequently recurring synovitis is often the main symptom. Treatment varies according to the cause of the arthritis. If due to pronated or flat foot treat thus: Adhesive strapping over the joint where the ligaments are relaxed. In diathetic cases treat the individual, but if no improvement takes place, the presence of the fringes being a source of irritation, operative measures should be taken. Failing other treatment, operation may be done. The authors have seen no bad result except one case, where too hot water was used to check the hemorrhage from the divided synovial fringes and scalding with subsequent sloughing of the fringe occurred. In the knee an incision of 5cm. or 6cm. long is made on the inner side of the joint and any fringes that may be felt are removed; if the fringes appear to be more numerous on the outer side a similar incision may be made there, and in bad cases an incision across the joint uniting the two lateral incisions and dividing the patellar tendon may be used, but in this case the knee requires to be kept immobile for some six weeks. Post-operative Treatment. The dressings are not disturbed for a week; the stitches are then removed and passive manipulation begun at At the end of a fortnight the patient begins to bear weight on the leg, using a crutch or cane. Daily hot and cold douches stimulate the joints. once. Pathology. The joint fringes vary within wide limits. The smaller are of a reddish-gray to purplish colour, of delicate dendritic appearance, attached to the joint surfaces by an extremely slender and delicate pedicle. At the other extreme are the large irregular and coarsely lobulated yellowish fatty masses of 4cm. to 5cm. in diameter, often glued by constant inflammation to the synovial lining over a wide area. The authors give a long list of the various surgeons in literature who D have written on this subject. Conservative treatment in suitable cases gives very good results; and in properly selected cases operation also gives good results. The difficulty is to discriminate between the two cases. PRIESTLEY LEECH. LAMBERT (0.). Interscapulo-Thoracic Amputation. L'Echo Medical du Nord, 1904, No. 1. THE author reports a case of this amputation for recurrence of an epithelioma in the stump of a previous amputation for epithelioma following lupus of the elbow. Removal at the shoulder joint was impossible; the patient suffered very little from shock, nor was much blood lost. Recurrence unfortunately took place locally and metastasis in the lungs, leading to death eight months afterwards. PRIESTLEY LEECH. SCHULTZE. Syphon Drainage in Empyemata. Die Therapie der Gegenwart, Jan., 1904, p. 20. THE writer recommends the treatment of recent empyemata, especially in children, by aspiration and syphon drainage. It is less dangerous, does not require an anesthetic and in weak patients is preferable to rib resection. In old-standing cases, of course, rib resection is necessary. PRIESTLEY LEECH. NORRIS (HENRY). Rupture of the Quadriceps Extensor Tendon. Univ. of Pennsylvania Med. Bulletin, Dec., 1903. IN 1896 Walker published an article on this subject, in which he added 141 cases tabulated by Maydl, making a total of 265. To these cases Norris adds 38 cases, making a total of 303 cases. Of 27 cases collected by Norris, in which the tendon was sutured, there were 27 complete cures. From a study of the above cases the following conclusions are apparent: 1. Cause. Direct cause in majority of cases is muscular violence, a sudden strong contraction of the quadriceps muscle taking place while the leg is slightly flexed. 2. Site of Rupture. Most commonly at or near the patella, either above or below, the injury being rarer if it takes place in the belly of the muscle. 3. Symptoms. The patient may hear a snapping sound; if rupture is incomplete the power of extension may be retained, but usually loss of extension is the most prominent symptom. Effusion into the knee joint and accompanying signs of inflammation and a depression may be felt. 4. Diagnosis. May be confounded with fracture of the patella or a severe contusion of the knee joint; the correct diagnosis is easily made after subsidence of the effusion. 5. Treatment, operative and non-operative. Operation consists in exposure of ends of ruptured tendon, suturing them and fixation of leg on splint in extended position. Massage and passive motion about two or three weeks after operation. The objections to non-operative treatment are the length of time required and possibility of failure of union. PRIESTLEY LEECH. WOOD (GEORGE B.). Tuberculosis of Parotid Gland. Univ. of THE writer reports a case of this rare disease in a man; the patient's tonsils were small, but contained some cheesy material, and the posterior sub-maxillary gland on the left side was enlarged, and in removing it a portion of the parotid was removed, which on examination was found to have a tuberculous nodule in it. The parotid gland may be infected through Steno's duct, through the lymph channels or through the bloodvessels. Of the nine cases reported by other observers, in three there was evidence of extension from the duct, in four the infection was obscure, in one from the blood and in one from a neighbouring lymph gland. In the author's case the extension was from the diseased submaxillary gland against the lymph current. He suggests that the infection of the posterior sub-maxillary gland was probably from the tonsils and from thence to the parotid. PRIESTLEY LEECH. NOBEL (G.). Gonorrheal Metastatic Synovitis. Wien. Klinik, Mai, 1903. (Quoted in Deutsch. Med. Zeitung, Nov. 16, 1903, p. 1025.) THE author bases his conclusions on 23 severe cases of this disease, 18 in males and five in females. In 14 cases the knee was affected, 12 the ankle, seven the hand, three the toe and finger joints, three the sterno clavicular joint. The tendon sheaths and bursæ were also affected. From the commencement of the local infection and the appearance of the joint metastases there was an interval varying from a few weeks to some months. In men the seat of the gonorrhoea was in the posterior urethitis in 16 cases out of 18. The route by which the poison is conveyed is the blood stream. Traumatism seems to be of some importance in localising the metastases. The polyarticular form of gonorrhæal synovitis is just as frequent as the monoarticular form. In some cases the metastatic complications are due to a secondary infection and not to the gonococcus itself; the theory that it is due to absorption of a toxin is not tenable. The treatment consists |