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Case II.-M. C., aged thirty-eight years, gives a history that his father died at fifty with diabetes and that his mother is still living, aged sixty-five years, and in good health. The other member of his family, a brother, is living and enjoys good health. The patient has always been well until April, 1903, when he had an attack which undoubtedly was appendicitis, confining him to his bed for ten weeks, and although he was able to be about afterwards, gaining considerable in flesh and strength, he was unable to attend to his usual occupation, that of a farmer. In the latter part of July he noticed a swelling in the left iliac region just within and above the anterior superior spinous process. The swelling increased in size, and several physicians examined him, all agreeing that he had an intraabdominal tumor, and he was advised to undergo an immediate operation, which he refused, hoping that he might recover without one. From this time he lost flesh rapidly, falling in weight from one hundred forty-five to one hundred ten pounds, and now has obstinate constipation. As he lies upon the table you observe that though a man of large frame he is emaciated and presents a cachexia indicative of malignancy. It requires no other sense than that of sight to discern a large swelling in the left iliac region, which on manipulation is nodular in feel and firmly immovable. To aid us still further in our diagnosis, a blood count has been maile, showing that the red cells number only 3,150,000, with forty per cent of hemoglobin, while the white blood cells number 17,640. The moderate leukocytosis is probably due to an autoinfection rather than to inflammatory reaction.

It is pretty evident from the history and examination that this man has a malignant growth in the left iliac fossa. He has been under observation in the hospital for several days and I am satisfied that an operation will be useless and at first refused to perform one, but at the earnest solicitation of himself and friends I have consented to make an exploratory laparotomy. Incision through the median line reveals a mass involving the sigmoid and filling up the upper part of the iliac fossa, with metastatic involvement of the mesenteric glands, mahing any attempt at its removal useless. The occlusion of the colon is not sufficient to warrant performing a colostomy, as free evacuation of the Lowels occurs after the administration of a mild cathartic. While he remains in the hospital he will be given whatever benefit is possible from the Roentgen rays.

The pathologist, after examination of a portion of the growth removed, states that it is carcinomatous, which by the way, is the most common form of malignancy of the large intestine.


BOTH OVARIES. Case III.- Mrs. H., aged twenty-six years. Patient's father and mother are botii living at the ages of, respectively, forty-four and fortythree years, and are in poor health. This woman is the mother of three children, the youngest being two years, the oldest six. She has also had two abortions, the last in July of the present year. She began menstruating at the age of thirteen years, the function being painful and irregular. Since her children were born, however, she has menstruated regularly and the dysmenorrhea has been much less. Since the abortion in July she has had a profuse leucorrhea and has suffered from cystitis accompanied with dysuria. For the past four years the patient has suffered with severe pain over the region of the left ovary, a dull, aching pain in lower portion of back, and frequent attacks of pain in back of head. Aside from this she has suffered greatly from nervous exhaustion.

Combined vaginal and abdominal examination reveals the left ovary enlarged and prolapsed in Douglas's culdesac, and painful on pressure. There is a yellowish-white discharge from the uterus, and a bilateral laceration of the cervix. The perineum is practically normal.

It would be fair to judge from the ovarian pain and tenderness that we have to deal with a cystic condition of the ovary, and from the uterine discharge, a chronic endometritis. Our first step, then, in the way of treatment will be a thorough curetment of the uterus and repair of the lacerated cervix. Curettage, though seemingly one of the simplest operations in the whole domain of surgery, is in fact one of the most dangerous in the hands of the careless and inexperienced. There is probably no manipulation in surgery which requires more care and judgment than curettage. Among the contraindications to the procedure are ignorance of the operator as to the exact limits of the uterine cavity; the presence of the menstrual flow; extreme displacement of the uterus; and acute inflammations of the appendages. Among the indications are patients suffering from hemorrhage, acute or chronic infection of the endometrium, fungoid growths, et cetera. It is also performed to remove adventitious tissue for purposes of pathological examination. No matter for what purpose undertaken, rigorous antisepsis should both precede and follow the operation. In treating cases of this kind the sharp curet should be employed. Objection has been urged upon the ground that it destroys the epithelium, which is replaced by cicatricial tissue. This objection is not tenable unless the operation amounts to a practical endometrectomy, and it is here that the judgment which depends upon the tactus eruditus enables the operator to say when the diseased epithelium is removed to the normal tissue beneath. After the removal of the diseased mucous membrane the interior of the uterus should be thoroughly treated with a mixture of equal parts of tincture of iodin and carbolic acid and a small drain of iodoform gauze inserted which should be removed at the end of thirty-six or fortyeight hours. The repair of the cervix is accomplished by drawing it well down with a vulsella forceps. If not already done, the mucous membrane at the seat of the laceration should be vigorously curetted, and the mucus, blood and debris washed away, after which the surfaces to be approximated are denuded. This is accomplished either by knife, scissors or both, great care being exercised to remove all the cicatrical tissue, especialiy that at the upper angle of the wound. The two denuded surfaces are now approximated and sutured, preferably with silkwormgut. The sutures may be introduced with a short curved needle inserted in a needle holder or by means of the obliquely-curved needle after the Carstens pattern. Lastly a sound is inserted to determine the patency of the cervical canal.

We will now turn our attention to the intrapelvic condition by making a short incision in the median line, low down, but high enough to escape the bladder, incising the skin, fascia, and muscles to the peritoneum, which we will elevate with forceps and incise. With the first and second fingers the ovary is delivered through the wound. As we predicted it is prolapsed, enlarged, and has undergone degeneration. But a short time ago, operators would have removed both ovary and tube. Better knowledge and conservatism, however, has taught us that this is not necessary or warrantable in many cases, but that a proper resection of the diseased portion results in a cure, and leaves sufficient healthy ovarian stroma for procreation. Therefore we will simply resect the diseased portion of this ovary, close the wound with catgut suture and replace it in the pelvic cavity. We will now deliver the right ovary in precisely the same way for inspection. As is ferquently the case, we find this ovary in the same condition as the left, and conset quently we will subject it to the same operative treatment, replacing it as I did the other, in its former position. The abdomen is closed by absorbable suture, approximating the wound layer by layer.


Case IV.-R. R., aged seventeen years. Patient's father and mother are both living and in good health. Eleven years ago he suffered from some disease of the bone of one leg necessitating surgical interference. What this condition was is not clear from the patient's statement. It probably has no bearing upon the present, except perhaps showing a predisposition to bone lesion. Aside from this and barring the ailments of children, the patient has always enjoyed ordinarily good health. The present illness dates from four weeks ago. Patient first suffered exhaustion, speedily followed by pain in right arm, at first vague and transitory as to location, but quickly becoming localized at a point outside the arm and just below the shoulder. It speedily grew worse-agonizing and boring in character. With the increase in pain there was more and more general tenderness, which became exquisite, followed by redness and general swelling of the affected parts. A physician who was called incorrectly construed the condition as rheumatism and prescribed accordingly. This treatment was continued until patient entered the hospital four days ago.

At the time of admission, his temperature registered 100.8°, pulse I 20. While the acute pain had somewhat subsided, he still suffered acutely. There was a well-marked hard swelling,-just beneath the shoulder.—which extremely tender to the touch. Besides this condition there was characteristic muscle spasm, requiring the patient to assume certain postures, thereby relieving tension, any disturbance of these postures causing severe pain. Added to this were the signs of autointoxicatior. coincident with the general constitutional disturbance. In fact all the signs denoted an acute inflammatory condition. A diagnosis of acute osteomyelitis was made and an operation advised. You will observe as the patient is prepared for operation that the arm is fusiform in shape at the point of swelling, with a feel of bogginess, indicating that there has been an escape of pus from the bone canal, which is corroborated by the subsidence of the violent boring, aching pain.

By making a free incision down through the periosteum to the bone, the presence of pus is manifest. Further examination reveals separation of the periosteum from the bone and no difficulty is experienced in introducing a groove director through into the necrosed cavity of the bone. By means of a chisel we have made a gutter that permits of free curetting of the medullary canal. The after treatment will consist in drainage and daily cleansing. This case is fortunate in that the disease is localized and does not involve other medullary canals as is too often revealed, especialiy in young children. As we have no history that this young fellow received an injury or had been exposed to sudden heat or cold, the causative pyogenic organisms must have entered the circulation through the lymphatics from a source of suppuration either in the skin, mucous membrane, or deeper tissue. It is difficult to say just whence these organisms come that infect the marrow of the bone. Early recognition of this difficulty is important that we may prevent extensive destructiveness. Had this patient been treated early by a free opening, the conditions that are present would have been obviated. Pus cavities either in bone or other tissues (excepting possibly in the abdomen) are best treated by filling them with pure carbolic acid, allowing it to remain for a minute or two when it is gently mopped out and the cavity filled with pure alcohol. The alcohol destroys both escharotic and poisonous effect of the acid. REMOVAL OF BOTH LONG SAPHENOUS VEINS FOR THE RELIEF OF

RECURRING ULCERS OF THE LEG. Case V.-Mrs. H., washerwoman, aged forty-four years, has had recurring ulcers of both legs due to varix, for the last twenty years. Previous to each recurrence there would be an eczema. This wonian has been in the hospital for some time and confined in bed with the legs elevated, alternately treated by strapping, the application of an elastic bandage, nitrate of silver and other medications, and still you observe the ulcers, which are gradually healing, however, and in all probability would heal if given time, yet as soon as she gets upon her feet again to pursue her vocation the return of the ulcers would be certain. Varicose veins are due to their valvular insufficiency, growing more prominent with advancing age. Many people who have varicose veins have no discomfort, while others have untold agony from them. Martin's elastic bandage is a temporary expedient, that is, it compresses the superficial veins so that return circulation is carried on by the deeper


plexus. If the bandage gives relief while applied, why not do something more radical and give permanent relief, that is, make an entire resection of both the external saphenous veins.

Many methods of obliterating the vein have been suggested and performed, namely, interval ligation, interval resection and a circular cut as devised by Schede. Our patient has had the most rigid antiseptic preparation as it is extremely important that no infection should occur. Commencing on the right leg an oblique incision approximating iwo inches in length is made about three inches below the saphenous opening, giving a fine oportunity to secure the vein, which is tied well upwards. Another incision is made in the same manner as the first, from four to six inches below, and by blunt dissection with the fingers and a Kocher's dissector the vein is lifted from its bed beneath the integument. The same procedure is continued to the ankle if necessary, when the vein can be removed in its entirety. Finally, a circular incision is made through all the superficial veins over the greatest prominence of the calf of the leg, not exceeding two-thirds of the circumference, when the incisions are closed with a continuous silkwormgut suture. The other leg is treated in a like manner, and both legs are

a covered with a liberal dressing of gauze and absorbent cotton well above the groin on each side. The after treatment consists in keeping the legs on an inclined plane for several days. You will observe that we cut out the ulcers of both legs as a part of the operation, dissecting up the edges so as to approximate them as near as possible without having to resort to future skin-grafting.

TENDOPLASTY. Case VI.-Mrs. F., aged thirty-six years, received, several weeks ago, a severe cut across the palmar surface of the fingers of the left hand. The wound healed kindly, but she is unable to flex the first joint of the third finger, showing that the flexor tendons were severed and did not unite. An attempt will be made to dissect out the severed ends and approximate them with suture.

After considerable effort the ends, ragged in character, have been iiberated, yet not sufficiently to approximate accurately, and therefore it will be necessary to use several strands of small catgut that they may act as a lattice work for the building up of interval connective tissue material, and cover them with approximated fascia and integument. The finger is now dressed and placed upon a splint to keep it in the position until union and new tissue-formation occurs.


In looking over the hospital charts of the above cases we find that

Case I (Recurrent Appendicitis) left the hospital December 30. At no time did the temparature rise above 100°, and for but three days was there any fecal discharge. When patient left there was only a small superficial granulation.

Case II (Carcinoma of the Sigmoid Flexure) left the hospital

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