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“The mass or section from the peritoneum to the mucous membrane was an inch in depth, the inflammatory thickening being most marked opposite the mesentery.
"The appendix seemed to be pretty uniformly infiltrated and the only secondary deposits in the intestinal wall were those described as occurring some nine inches from the valve.
“The lymph glands were caseous in the centres."
The reporter does not state whether tubercle bacilli were present or not in the growths.
D. M. C.
By HENRY O. WALKER, M, D., DETROIT, MICHIGAN.
PROFESSOR OF SURGERY AND CLINICAL SURGERY IN THE DETROIT COLLEGE OF MEDICINE
CYRENUS GAVITT DARLING, M. D., ANN ARBOR, MICHIGAN.
THE PRESENT STATUS OF SURGERY OF THE GALL
BLADDER AND BILE DUCTS.
This is the title of a paper (Medical Record, February 21, 1903) read by William J. Mavo, A. M., M. D., before the New York Academy of Medicine.
The author believes that the medical profession has not accepted the modern view of gall-stone disease as readily as that of appendicitis because the conditions surrounding these diseases are so widely different. Gall-stones occur in persons of advanced age with degenerative lesions or adipose tissue. The relative danger of slumbering stones is not well understood. While statistics are not reliable as to the prevalence of the disorder, five to ten per cent of all adults would be a fair proportion. The removal of stones in quiet cases may be classed with removal of the normal appendix, except that the latent stone may become active. The quiet stone may become active because of infection, or mechanical interference with the drainage of the gall-bladder. Both of these conditions may be present at the same time.
Infection in the gall-bladder may not be as bad as pictured, normal bile being free from organisms, or infection once present may die out. The presence of infection may induce contraction of the canal and prevent the passage of stone. These cases under proper treatment may obtain a period of rest, but may be again made active by infection. His advice about the early removal of the active gall-stone is as follows: The death rate following operation is less than one per cent. Thie investigation of 2,000 operations does not disclose the reformation of gall-stones in a single instance. Delayed operation is a misfortune because of complications, any or all of which may arise, the stones becoming a mere incident in the process. There may be adhesions and rupture either into the abdominal cavity or a neighboring viscus. Adhesions or imperfect drainage may give rise to colics or pains. In some cases cancer may follow. Gall-stones in the feces give hope to the physician and the patient that a cure may be expected. This is a mistake, as we have always found others in the gall-bladder when these patients came to operation. Complications greatly increase the danger of operation. Infection according to kind and extent may go on to the formation of abscess or induce acute degeneration of the liver.
The principles underlying the operation are infection, whether it be acute or chronic, and involvement or noninvolvement of the liver ducts. The ideal operation (that is, closure of the gall-bladder and abdominal wound) may be undertaken when the stones are latent or discovered while performing some other operation. The presence of infection calls for drainage, which should be continued until the bile is normal. When the gall-bladder wall is thickened or the cystic duct has been obstructed the gall-bladder should be removed. When the liver ducts are free the cystic duct may be tied and the gall-bladder removed, but when the ducts are involved drainage must be provided. In such cases the serous and mucous coats may be removed, leaving the muscular tissue. The cystic duct is severed and left open at the bottom of the pouch, which is sutured to the abdominal wall to provide drainage.
C. G. D.
BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.
ELECTRIC CAUTERY CLAMP IN THE TREATMENT OF
CANCER OF THE UTERUS. CHARLES P. Noble (American Gynecology, December, 1902) calls attention to the advantages of the electric cautery clamp in the treatment of cancer of the uterus. Among these advantages may be mentioned: (1) More tissue outside of the uterus is removed (or cooked) than by the classical methods. (2) All the connections of the uterus are severed either through tissue which has been cooked in the bite of the cautery clamp or these connections have been severed with the electric cautery knife. In this way the lymphatic vessels are sealed either by the burning or the roasting process. Whatever the risk of implantation of cancer upon the field of operation may be, by this means it is greatly lessened or done away with. An exception to the above statement must be noted in that the attachments of the bladder to the uterus are severed in the usual way. (3) Much less blood is lost than is usual with the classical technique, and a dry, bloodless field is left after operation.
Byrne, of Brooklyn, obtained good results in cancer of the uterus by amputation of the cervix with the electric cautery knife. Skene's instrument for the same purpose proved a failure. Downs, however,
has invented a practical electric cautery clamp, and Noble has found this instrument useful in five vaginal hysterectomies, and mentions among the advantages of the method of its application: (1) By its use less blood is lost during operation; (2) the lymphatics are sealed up, thus lessening the risk of septic absorption and implantation of cancer; (3) more of the broad ligament is used than by other operations. Noble is of the opinion that although some years must elapse before the actual value of the electric cautery clamp in the treatment of cancer of the uterus can be determined, it is reasonable to expect, in view of the favorable results secured by Byrne, that it will give a larger percentage of cures than the older methods, especially when the disease has attacked the cervix.
As there is a general concord among writers that ten per cent is a fair average of cures, it is encumbent upon the profession to give a fair trial to any method which does not increase the primary mortality from operation and which gives promise of improving the ultimate results.
DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.
OBSTETRICS AND THE GENERAL PRACTICIAN.Er. FUSSELL (Journal of the American Medical Association, Volume XXIX, Number XXVI) discusses questions of great practical value to the accoucheur engaged in general practice. The vast majority of maternity cases are cared for by the general practician. This fact is made the raison d'être of the paper.
Education of the Public.-Every physician should impress upon his clients the necessity of seeking medical advice as soon as pregnancy occurs. Waiting until the onset of labor or a day or two before that event places a handicap upon the physician, and may endanger the life of mother and child.
Examination of the Urine.—The importance of periodic examinations of the urine (monthly for eight months, and weekly thereafter) is strongly urged. The writer states that the physician is morally responsible for the occurrence of convulsions in a patient who has previously engaged his services, and whose urine has not been thus examined. The practice of nct examining the urine unless the patient exhibits renal symptoms is condemned. Cases bearing upon this point are cited. (In addition to the tests for albumin and sugar, the amount of urea should be estimated as a routine if possible, and in suspicious cases in any event. Eye symptoms, severe headache or edema call for redoubled vigilance).
Abdominal Examination and Pelvimetry:—The writer urges the importance of repeated abdominal examination during the later months for determining the presentation. (This practice may save the patient great suffering, and the physician great anxiety. It takes but a moment to determine a normal position, and the diagnosis of an abnormal condition is worth the expenditure of whatever time and skill may be requisite. A malposition easily correctable before the onset of pains may offer the greatest difficulties after labor has proceeded for some time. Pelvimetry deserves more mention than the author gives it. I believe the pelvimeter should be to the obstetrician what the stethoscope is to the interinst. Its use is simple and its findings of value, especially when it reveals a condition rendering normal labor impossible. The patient will appreciate any conscientious effort to secure light as to her fitness for maternity).
Preparation for Confinement.— The patient should be instructed concerning the preparation of the bed. She should be told to have water boiled and cooled, and to have at hand towels, bașins, soap, et cetera. (The physician may properly suggest the selection of a room, with reference to accessibility, ventilation, light, heating arrangements, et cetera. These matters may be discussed with the nurse if one is in attendance prior to the beginning of labor. The patient's bowels should be regulated and thoroughly emptied by enema at the beginning of labor.)
Alanagement of Labor.–Vaginal examination must now supplement abdominal findings, to determine the progress of labor, and whether or not the physician may safely leave the patient for a time. Vaginal examinations should be as infrequent as possible. Cleanliness is here the sine qua non. The patient should have been bathed and the bladder emptied. The pubic hair should be clipped and the vulva and adjacent parts thoroughly scrubbed with soap and water, followed by one to one thousand bichlorid solution, and covered with a bichlorid towel. The physician should bare his arms to the elbows, and after cleaning the nails should scrub his hands and arms thoroughly for five minutes with brush, soap and water.
The hands and arms are then rinsed or preferably scrubbed with one to one thousand bichlorid solution. The hands must not be wiped nor brought in contact with anything whatever except the part to be examined. The same care should be taken to secure asepsis with each examination. A bichlorid towel over the vulva will keep the patient aseptic. (Examining the patient under the bed clothing is a most fruitful cause of sepsis. Examination should be made with the hands unimpeded. Fussell carries in his outfit a duck suit and Kelly pad. For the former an apron or a gown improvised from a clean sheet may be substituted. The latter is convenient and not bulky. It should be sterilized thoroughly before using. If not at hand it is only necessary to remember that whatever underlies the patient's hips must be at least clean. Fussell does not mention the use of rubber gloves. Nothing conduces so much to an aseptic confinement, especially if the physician has recently been handling infectious matter. The gloves can be boiled, put on in bichlorid solution, and offer no impediment whatever to the conduct of the case. A moderately heavy glove is preferable.) The author urges the same
strict asepsis in the use of whatever instruments, suture materials, et cetera, may be needed.
Management of the Puerperium.-The physician should personally see that the patient is thoroughly cleansed. A douche should not be given after an ordinary clean case. If given at all it should be by the physician. Careful examination for lacerations should be practiced. Lacerations, however slight, should be repaired at once. especially the untrained nurse, should be positively instructed not to give douches or otherwise handle the vulva. Misdirected zeal on the part of a well-meaning but ignorant nurse may have direful results. Catheterization should be practiced only by the physician or the trained nurse. (Fussell does not mention the necessity for attention to the uterus immediately after labor. The uterus should be followed down by the hand after the expulsion of the placenta, and should be palpated at short intervals for at least an hour after the patient has been made comfortable. It is good practice to instruct the attendant as to the feel of the contracted uterus, and in the method of massage to secure its firm contraction).
THE TREATMENT OF DIPHTHERIA BY THE INTRAVEXOUS ADIMINISTRATION OF ANTIDIPHTHERITIC
SERUM. CAIRNS (Lancet, December 20, 1902). The author reports several cases of malignant diphtheria in which antitoxin was given by the intravenous method, and says that the results of antitoxin injections in diphtheria may be improved by the use of larger doses than those commonly recommended and by the intravenous use of the remedy in certain cases. Serum given subcutaneously loses much of its power of neutralizing toxin in its passage through the lymphatic vessels and glands. The intravenous administration of antitoxin was first tried in cases of diphtheritic bronchopneumonia, where the diphtheritic process had extended from the throat to the pulmonary bronchials. This bronchopneumonia is the most frequent cause of death after tracheotomy. Tracheotomy fails to relieve the dyspnea which is pulmonary and not laryngeal. The author reports five cases of diphtheritic bronchopneumonia treated by the intravenous method and five recoveries. Cases of the so-called malignant type also call for the same mode of treatment. Some of the most marked results of the intravenous method of treament are the strikingly rapid disappearance of the signs of toxemia, the rapid disappearance of the great glandular enlargement in malignant cases and in the pneumonic cases, and the marked diminution of the restlessness. A serum rash was present in seventy per cent. of the cases. The dose employed subcutaneously varied from four thou