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immunity that babies who are fed on mother's milk are better protected against contagious diseases than are those artificially fed. The principal reason for this is that most mothers have had the ordinary diseases of childhood and enjoy immunity from them. Immunizing substances occur in their milk and are transferred to the child during the nursing. This constitutes another reason why mothers should be encouraged to nurse their offspring and not allowed to neglect this sacred duty unless there is some absolutely necessary reason.

REPORTS OF CASES.

AMPUTATION OF BREAST DEMONSTRATING TRIANGULAR DRESSING OF ARM.

DOCTOR JOHN A. BODINE: I desire to exhibit three patients who have undergone amputation of the breast for carcinoma, and in whom the arm had been dressed during the healing period on a triangle holding the upper arm at right angles to the body. Attention is called to the consequent freedom with which the patients can use their arms. I have been using this dressing in all such cases for the past three years. An isosceles triangle, made of light splint-wood held in position by rubber adhesive strips, is so placed against the side of the chest that the upper arm is at right angles to the body, while the forearm in supination rests along one side of the triangle with the hand resting upon the hip. The triangle presses along the body between the line of incision for removal of the breast and the posterior puncture made for the drainage tube. The arm being in this position the patient is perfectly comfortable while in bed and also while walking about. Adherence of the skin flap and scar to the under surface of the arm after enucleation of the axillary contents is an inch and a half to two inches nearer the shoulder end of the arm when dressed in this position than it is when bound aganst the chest. It is this difference in position of attachment of the scar and skin flap to the arm that gives such freedom from cicatricial contraction following amputation of the breast.

DISCUSSION.

DOCTOR ROBERT H. M. DAWBARN: I have employed the method demonstrated by Doctor Bodine several times. It is more comfortable because the abduction of the arm slides the scar so that it does not adhere to the region of the vein nor the main lymphatics. Patients at times have been made very miserable after amputation of the breast by swelling of the arm, due to adhesion of the scar, the forearm and arm becoming large and edematous and annoying the patient for a long time. I avoid it, partly by carrying the incision up the middle or even posterior part of the axilla, although the main dissection is sharply forward in the anterior portion of the axilla where the main vessels lie. There is only one muscle which can take the place of the pectoralis major and minor, both of which must be entirely removed in the modern operation, and that is the deltoid. It is wonderful how this muscle hypertrophied, and being inserted into the outer third of the collarbone, with a very poor leverage, how it accomplishes its mission. In the

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case of women who have very weak deltoids (the reverse of those shown by Doctor Bodine), it has been part of my regular operation of late years to dissect free from the clavicle one inch of the anterior edge of the deltoid, and to carry it inward as far as it will easily go, and then to sew it to the stump of the pectoralis major. That muscle, in course of time, becomes hypertrophied, and it helps a great deal; but in cases in which this operation is performed, it obviously would not do to use the isosceles triangle, with its necessary abduction of the arm. In the technique just described, as to the deltoid, the cephalic vein is liable to cause trouble, and I generally tie it off, but this may not be necessary if great care is taken. It is only when the axillary vein is involved in the cancerous growth that saving the little cephalic vein becomes a matter of importance.

EXTIRPATION OF THE JAW.

DOCTOR BODINE: I also wish to present two cases of fact surgery to illustrate two practical points which I consider important in the treatment of these cases. Control of hemorrhage in all surgery above the level of the cricoid cartilage is accomplished by rapidly making an incision down to the carotid artery supplying the area to be invaded, passing an ordinary rubber band that has been boiled around the vessel, and having it pulled taut by an assistant, thus as effectually controlling the blood-current as in the case of an Esmarch bandage around a limb. The rubber is withdrawn after the operation is completed without having done any damage to the walls of the blood-vessel. I have followed this plan many years in excisions of the tongue or jaw and in other bloody work about the head or face. The second point that I wish to emphasize is that wounds of the face made by the surgeon should never be dressed with gauze. If no dressing whatever is applied and the wound is exposed to the atmosphere, it heals per primam. Dressings applied to the wound usually becomes saturated, either with tear or with saliva, thus certainly infecting the line of incision. One patient had carcinoma of the superior maxilla. A wide removal was practiced, the hemorrhage being controlled as stated above. He did not lose more than a teaspoonful of blood during the operation, suffered no shock. whatever, and on the third day after operation was permitted to walk about the ward. The second case was one of removal of the left half of the upper lip, the gap being filled in by a plastic maneuvre. The wound healed per primam, no dressing having been applied.

FRACTURE OF THE PATELLA.

DOCTOR BODINE: I desire to show a third patient, who suffered fracture of the patella in which primary suture of the capsule had been practiced. In fracture of this bone the open operation of suture of the capsule is always to be preferred to treatment by splints. It is impcssible to obtain bony union with perfect joint function in any other way. than by open incision. The fringe of the fibroperiosteal capsule invariably drops between the broken margins of the patella, effectually preventing bony union. In addition, a blood clot forms, which becomes

organized and fixed. The only objection one can bring against the open operation is the possibility of sepsis. This can be avoided with almost absolute certainty, as illustrated by the patient shown, who was operated on without the fingers of the operator touching the wound, only four instruments being used. The entire operation can be performed in fifteen minutes, without any pain whatever, and with the use of onefourth of a grain of cocain. After incising the skin the blood clot is washed away by a stream of warm salt solution, the ruptured capsule is picked up and sutured with kangaroo tendon, and the skin incision closed by a subcuticular suture. A posterior splint is then applied and the patient returned to bed. It is not always necessary to enter the general articular cavity of the joint. The posterior reflection of the general synovial membrane is sometimes so high up on the posterior surface of the patella that the line of fracture is below it and the general articular cavity escapes. The patient was operated on four weeks previous to this meeting, and is now able to flex his knee-joint nearly to its full limit. In two weeks more it may be expected that the motion of the joint will be perfect.

DISCUSSION.

DOCTOR DAWBARN: In opening the discussion of Doctor Bodinc's cases I desire to say, in regard to extirpation of the jaw, that I differ with Doctor Bodine as to the wisdom of never dressing a face wound, as I think that an occasional stitch abscess, due to exposure to dust, might be prevented by the use, for instance, of sterile gold-beater's skin court plaster, one of the best dressings. Lately I have modified the Ferguson incision in these cases, carrying it distinctly below the orbital plate, as, if carried into or closely below the lid, a certain degree of ectropion will result. The lower the scar, the safer the operation in this respect. I believe in a preliminary operation for control of the external carotid in every severe operation about the face, such as excision of the jaw, and am convinced that many deaths from shock would not occur if this procedure were carried out. Regarding the fracture of the patella, I will say that if it were my own patelia, I would not submit to primary suture, but would have it treated by splints. I think a close fibrous union as satisfactory for practical purposes as bony union, and the element of risk much less, for some slight risk exists, even at the hands of the most rigid asceptician. I differ with Doctor Bodine in regard to the falling downward of the capsule between the bones being the chief cause of nonunion. I think the main obstacle is a bulging forward of the loose synovial membrane between the two fragments. The bones could not unite, of course, through this membrane.

DOCTOR JAMES H. BURTENSHAW: I well remember the first case of fractured patella that came under my care. I brought the two pieces of bone together by means of adhesive plaster applied to the anterior aspect of leg and thigh, bound the limb to a splint, and required the patient to remain in bed for about three months. The result was perfectly satisfactory. I think the danger of infection of the knee-joint by the

open method very pronounced, but no greater, in the hands of a competent surgeon, than in many other wounds.

DOCTOR WILLIAM H. LUCKETT: I do not think it best to omit the application of dressings to face wounds. I am in the habit of applying a wet dressing to all primary wounds of this character, not so much for its antiseptic effect as for its mechanical action in preventing too early sealing of the edges, with consequent accumulation of serum and blood in small pockets, which are favorable points for the growth of bacteria. With regard to the quadriceps muscle, I think it helps to keep pieces of fractured patella apart, as well as certain tissues both in front of and behind the bone. I have never seen a synoval membrane come between the fragments from behind; in fact, the normal position of the membrane would prohibit this action. An absolutely bloodless field is necessary for a successful outcome of the operation, as one reason for adoption of the open method is to remove the fluid and blood from the sac and from between the two pieces of bone.

DOCTOR VICTOR PEDERSEN: It is a well established fact that there is no synovial membrane behind the patella in the human being. It stops at the margin of the patella, and behind it extends only as a modified membrane. Probably the structure which would interfere most frequently with union of the fragments would be the capsule.

DOCTOR BODINE: In closing the discussion I wish to say that the suggestion of interference with union by the general synovial membrane was entirely new to me, and from my knowledge of the anatomy. involved, I do not see how it is possible. I did not think it wise to irrigate the general articular cavity of the joint at time of operation. The irrigation fluid would produce more damage than a moderate amount of blood effusion. It is only necessary to wash out the blood clot from between the two broken pieces and to suture the capsule. Operations should not be undertaken before the third day following the accident, during which time all oozing of blood from the broken surfaces has stopped, and the application of the tourniquet is unnecessary; in fact it is in the way.

ENCEPHLOCELE.

DOCTOR ALEXANDER LYLE: This child was born April 14, 1903, of healthy parents, and at birth had a tumor measuring one inch in diameter by one-half inch in depth above the nose and between the eyes. Through the courtesy of Doctor White I was asked to see the child, and I advised immediate operation. On April 17, three days after birth, the baby was placed under chloroform narcosis and a longitudinal incision was made over the tumor and the frontal bone The flaps were retracted, the sac dissected free and the contents easily withdrawn. Two small horns of the sac extended down into the nares. After the dissection was completed, it was found that the absence of bone corresponded in size and shape exactly to that of a silver quarter of a dollar. To cover this opening and to prevent a recurrence of the protrusion a corresponding amount of periosteum was raised from the frontal bone, turned on its pedicle and united with catgut to the margin of the ring. The skin was likewise.

sutured, a firm compress of gauze applied, and the head bandaged. The result was only fairly gratifying, and after a month a truss with double water-pads shaped like the finger tips was made and worn constantly. The present condition of the child is satisfactory.

APPENDICITIS WITH COMPLICATIONS.

DOCTOR LOUIS J. LADINSKI: I desire to show a girl, eighteen years old, on whom I operated for appendicitis. When I first saw the patient, it was impossible to make a diagnosis. A second examination a few days later revealed the presence of a large fluctuating tumor in the pelvis, posterior and adherent to the uterus, but nothing abnormal was found in the iliac fossa. An incision was made in the median line. The tumor was found to consist of a mass of hypertrophied omentum to which a coil of intestine and the inflamed appendix were intimately adherent. In the center of the mass was a large collection of pus. The tip of the appendix and the coil of the intestine were adherent to the walls of the posterior culdesac, and because of the gangrenous condition of this portion of the gut, about six inches of it were incised and a Murphy button inserted. The appendix was removed and the adherent omentum excised, and the pelvis and abdominal cavity drained from above. The patient made a good recovery after a protracted convalescence. Four weeks after the operation she developed a mastoiditis on the right side and the bone was incised and scraped. I also wish to present a patient with a large anterior labial hernia. There are two varieties of labial hernia, the anterior, which is similar to the scrotal hernia in the male, and the posterior, in which the hernia descends either in front of or behind the uterus into the vagina and labia. Labial hernia must be differentiated from fibromata, sarcomata, or cysts of the labia.

ORIGINAL ABSTRACTS.

MEDICINE.

BY GEORGE DOCK, A. M., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.

THE TREATMENT OF ACUTE RHEUMATIC CARDITIS AND PERICARDITIS.

LEES (British Medical Journal, November 21, 1903) begins his remarks with the statement that the treatment of acute cardiac inflammation is, in the great majoriy of cases, the treatment of an infection with the organism of acute rheumatism (micrococcus rheumaticus). He considers that sodium salicylate is as truly antirheumatic as is

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