scribed, with the exception of the pouch at the upper the operation was not undertaken until many years had wall of the fossa navicularis, together with the lacuna of Morgagni and the mucosa boder of Morgagni's crypts of the cavernous portion. The former is often of considerable depth, but the latter can interfere with the passage of nothing but thin elastic instruments. The same holds good in case of the excretory ducts of the acinous mucous glands which, in health, are small microscopic fossæ, but under the influence of a gonor rhea may enlarge, but never to sufficient size to arrest a large instrument. K. claims for urethroscopy that it allows of an exact study of the urethral mucous membrane with all its glands, pouches, and fossæ, and that Oberlander, Neel sen, and Finger cleared up by its means those conditions which were matters of conjecture even to recent anatomists. Folds, pouches, and fosse, others than those men tioned above, are, in the author's experience excep tional. A case of Grunfeld's is mentioned in which there was found an opening three centimeters deep and eight centimeters from the external orifice, on the posterior urethral wall, leading down to a cavity lined with mucous membrane. Into this cavity instruments as large as fifteen Charriere could be passed. Author has seen a similar case; in the lower urethral wall, just anterior to the bulb, was a blind sac, one and one half centimeters deep, lined with urethral mucosa, and lying parallel to the long axis of the urethral canal. This allowed of the easy introduction of a No. 23. Such diverticula are to be regarded as congenital, and not as acquired. passed after the initial trauma, and after the beginning of the epilepsy. They conclude that if a long period of time has elapsed, all operative procedures will prove equally unavailing. As a result of their study of these cases, the paper closes with the following conclusions. 1. Surgical interference is advisable in those cases of partial epilepsy in which not more than one or, at the utmost, two years have elapsed since traumatic injury or the beginning of the disease which has given rise to the conclusive seizures. 2. In cases of depression or other injury of the skull surgical interference is warranted, even though a number of years have elapsed; but the prospect of recovery is brighter the shorter the period of time since the injury. 3. Simple trephining may prove sufficient in a number of cases, and particularly in those in which there is an injury to the skull or in which a cystic condition is the main cause of the epilepsy. 4. Excision of cortical tissue is advisable if the epilepsy has lasted but a short time, and if the symptoms point to a strictly circumscribed focus of disease. 5. Since such cortical lesions are often of a microscopical character, excision should be practiced even if the tissue appears to be perfectly normal at the time of operation; but the greatest caution should be exercised in order to make sure that the proper area is removed. 6. Surgical interference for the cure of epilepsy associated with infantile cerebral palsies may be attempted, particularly if too long an interval has not elapsed since the beginning of the palsy. K. has had the opportunity of observing rudimentary 7. In cases of epilepsy of long standing, in which pouch formations which interfered with catheterization, there is in all probability a wide spread degeneration of and which were not found described in endoscopic pub- the association fibres, every surgical procedure is useless. lications. He regards them of congenital origin, and on-American Journal of the Medical Sciences; Annals of account of their situation considers them to be places of Surgery. exit of Cowper's ducts. Henle observed in cadavers that the ducts of these glands were to be recognized by the accompanying small folds of mucous membrane, and pits or fossa. In the conclusion of his most interesting paper the author suggests that an urethroscopic examination should be made from the gland to the bulb, and not in the reverse order, as is usually the case This is im portant in order to make a complete examination of the urethral membrane, as otherwise the folds mentioned above may be so smoothed over the orifices of the ducts as to conceal them. The Surgical Treatment of Focal Epilepsy. -By B. Sachs, M.D., and A. G. Gerster, M.D. (New York.) This paper presents a critical analysis of nine teen cases operated upon by the authors. Of these three are reported as cured, five as improved, and eleven as unimproved. Of this last group three died as the result of the operation. The authors concede that surgical procedures will avail but little in the majority of cases. In all of the cases in which no improvement resulted, Breast Excision for Malignant Disease.— By Herbert Snow, M D. (London). From an experience of 300 cases of breast excision for malignant disease, during a period of twenty years, the author concludes that infection of the bone marrow is the great obstacle to radical cure by operation in mammary carcinoma. This takes place in all ordinary cases, within six months of inception, frequently earlier; its symptoms do not appear until within the second year; they may not be accompanied by nodular deposit or other palpable evidence of cancer for five or six years more. In the class of cases known as "atrophic," the condition may be delayed for several years. Hence, these latter excepted, apparent immunity from "recurrenc" for three years is a wholly indequate basis on which to pronounce the disease radically ex tirpated, unless insidious marrow symptoms are also excluded by examination, and unless there is a good reason to believe that excision has been performed before the marrow has become implicated. The most important practical point in excision of the female breast is a wide dissection of the subcutaneous connective tissue around the diseased organ from sternum to axilla, from the sub clavian fossa to the cartilage of the seventh rib. This tissue is the really dangerous tract to be feared as nidus for recurrence, not prolongations of the mammary parenchyma. But it can always be adequately extirpa ted by dissecting off a flap of healthy skin, and so bringing the edges to immediate union without undue tension. mic goitre depended in anyway upon a lesion of the sympathetic cervical, but rather maintained that it was due to the exaggerated action of the thyreoid gland. He reported cases in which removal of a portion of the enlarged gland had been followed by complete recovery. M. Souligoux reverts to the subject of his method of enter-oanastomosis by cauterization, which has already been described. M. Doyen protests, in the name of the modern prin. ciples of abdominal surgery, against this procedure. M. Picque, who has seen M. Souligoux operate upon the patients of his service, has found the procedure quite to be recommended. M. Chaput, who improved the procedure of M. Souligoux, declares that the procedure will give marvellous results. Kocher states that up to the present time he has per anastomosis, according to his own method. Of this number only four died. The results among those who lived were in the main satisfactory. No advantage whatever is gained by the destruction of an extensive skin tract. In every single instance seen by the author the utmost benefit that surgery could confer was perfectly compatible with the union of the greater part of the wound by first intention. Should the skin be infiltrated, no amount of ablation will avail to prevent reappearance, previously insured by the marrow condition. If we encounter instances of scirrhus, or even of encephaloid (acute) carcinoma, of but two or formed twenty-four laparotomies with gastro entero. three months' duration, no pains should be spared to eradicate permanently the disease by dissecting out the entire mamma, a wide area of subcutaneous tissue around. and the contents of the axilla; and at least one and a half hours should be devoted to that purpose. On the other hand, in advanced cases of long standing, it is futile to risk life by prolonged and heroic measures, when we know there is a deep-seated nidus which we can not touch. The utmost advantage we can attain is Plastic Substitution of the Mammary removal of the gross lesions without risk; prompt union Gland by a Lipoma.-By Professor Czerny (Heidof the wound; and then by after treatment with opium berg.) A woman with interstitial mastitis, with adenoand cocaine, to procure a state in which the disease re- fibromatous formation submitted to amputation of the mains stationary for years or advances with almost im-left breast. She had largely developed breasts, and perceptible slowness.-British Medical Journal; Annals of Surgery. Surgery in France.-From the transactions of the French Congress of Surgery, held in Paris, October, 1896, reported in Le Progres Medical, we learn that M. Schwartz of Paris recently sutured a lateral sinus which hed been injured by the kick of a horse, driving a frag. ment of bone into its side. (Medicine) Recovery en sued. M. Abadie reports cases of section of the cervical sympathetic nerve in grave forms of exophthalmic goitre. He bases his operation upon the theory that the disease depends upon derangement of the sympathetic nerve. M. Jonnesco reports cases of total resection of both cervical sympathetics. Hs describes his method of pro cedure, and closes his report with the following conclu sions: M. Demons, reporting cases of contusion of the abdomen, recommends that in the more severe cases of ab dominal injury without penetration, laparotomy be resorted to. possessed also a lipoma, somewhat larger than a fist, situated in the right lumbar region. In order to remedy the asymmetry consequent upon the removal of the breast, she desired to have the lipoma transplanted in its place. Two finger breadths below the nipple the skin was divided by an incision with its convexity downward. The overlying skin was thus preserved and the whole gland removed through this curved incision. After thoroughly checking the hemorrhage, the lipoma was rapidly enucleated and transplanted into the place of the breast under strict aseptic precautions, and the skin sutured with the exception of places for small drainage openings. At the end of eight days the skinwound had entirely healed. There was no inflammatory reaction. The wound remained rather sensitive for six months. After the lapse of a year's time the tumor had neither enlarged nor contracted, and formed a very shapely breast.- Verhand. der Deut. Gesell. . 1. That we may resect the sympathetic with im Chir.; Annals of Surgery. punity, having no fear of ulterior consequences. 2. This operation may always be tried in exophthalmic goitre, and indeed in all the troubles in which the sympathetic is involved. 3. The indications for this operation may be extended to the different neuroses and circulatory disturbances in which a modification of the encephalic blood-supply may seem to be of value. An Improved Surgical Needle. - Dr. John V. Roberts in the Philadelphia Polyclinic, describes what he is pleased to term the perfect surgical needle. He says: "The perfect surgical needle is only a carefully made and slightly modified glover's needle; that is to say, the needle that has, for many years, been found most satis Kocher, of Berne, contested the view that exophthal- factory to those who are continually sewing animal skins in the manufacture of gloves and leather articles. The requirements are practscally those pertaining to suturing ordinary cutaneous wounds. "The trocar-like point should occupy above one-third of the needle's length. The greatest diameter of the point should be near its middle. Although the end of the point should be very sharp, its three edges should not be keen, lest they cut the fingers when the operator pulls the needle through the skin. "The three-sided point gradually fades into the shaft, which must be cylindrical, not flat, and have a diameter a little less than that of the point where it is largest. The shaft then gradually tapers down towards the head, which must have a little less diameter than the thickest part of the shaft. The eye must be large, and oval or rectangular, not circular. The head at the sides of the eye must not be caused to bulge outwards by the drill or punch which makes the eye. Behind the eye, the head must be grooved on both sides; in this lies the thread, which consequently presents no shoulder to catch as the needle passes through the skin. There is a groove in front of the eye, on each side, to render cleansing easier, and to keep it free from dried blood and dirt." The Treatment of Peritonitis Due to Per forating Gastric Ulcer.-By K. Schuchardt. The author reports two cases operated upon within the space of fourteen days; and in one of these cases, notwithstanding that there was a pretty far reaching suppura tive peritonitis, the patient recovered. In both cases the ratients were young women, who gave no previous history of gastric ulcer, so that the operation was done only upon the ground of the diag nosis of peritonitis of the upper part of the abdomen. ness. tween the spleen and the stomach and in the left concavity of the diaphragm. CASE 2.-W. G., aged 16 years; serving maid; previously healthy. She was suddenly seized with severe pain in the abdomen, constipation, fever, but no vomiting. The abdomen was symmetrically dilated, very tender to pressure. Liver dulness was normal. Opium was administered. Four days later the abdomen was softer. Laparotomy was performed. In the upper part of the abdomen was found air and feculent pus. On account of the feculent character of the pus the stomach was not supposed to be the place of origin of the infec tion, and the large and small intestines were examined with the hope of finding in them the cause of the peritonitis. This necessitated extending the incision down. ward below the umbilicus. When no lesion was found in the intestine the stomach was examined, and a perfora. tion found in its anterior wall. This was closed with twenty fine silk sutures. The spaces between the stomach and liver and beneath the diaphragm were cleansed with dry sponges. Masses of fibrin as thick as one's finger were removed from between the liver and diaphragm. Counter openings were made on the right and left sides, and gauze drains passed into the peritoneal spaces. Fever continued for some time, but gradually subsided. At the end of two months, no complications having developed, she was discharged entirely well. From these cases the author concludes that the history may be of comparatively little value in arriving at a diagnosis. The symptoms of perforation may easily be the first symptoms of a marked ulcerative disease of the stomach. Often the first thing is a sudden pain in the abdomen, followed by symptoms of peritontis of the upper part of the belly. The peritonitis remains for a long time isolated between the diaphragm and the CASE 1.-H. M., aged 21 years; serving maid; always transverse colon: Usually the odor of the exudate is healthy. Fourteen days before she had suddenly ex- sour, though it is possible for it to be feculent. The perienced an attack of great weakness. Seven days preferable incision is from the sternum to the navel, and later she had again had an attack of sudden abdominal an incision at right angle to this as far as the border of pain, prostration and fever, followed by mental lassi- the ribs on the left side. When the hole in the stomach tude, herpes labialis, high fever, constipation, slight is found it is at once sutured. An excision of the ulcer nausea, moderate tympanites, and abdominal tender is not to be advised, as it complicates the operation After the administration of opium the tender- very much. The products of the peritonitis should be ness subsided, and remained only in the upper part of removed as much as possible with dry sponges. The the abdomen. A flat protrusion of the epigastrium de space between the stomach and liver should be drained veloped. This was punctured, and clear fluid evacuated. with gauze. The concavities of the diaphragm on both Laparotomy was done theough a small incision. An sides should be treated in the same way. exudate from in front of the liver was removed. The liver was found much enlarged. On incising the liver an abscess was found. Two days later the incision was enlarged. A sour-smelling exudate was found in the space between the liver and the stomach, and the upper part of the abdomen contained pus. A perforation the size of a pea was found in the anterior wall of the stomach near the lesser curvature. This was sutured, the abdominal cavity cleansed, and gauze drains introduced. Death occurred at the end of eighteen hours. The autopsy showed a circular ulcer six centimetres from the cardia. There was a large collection of pus be Nourishment can be given by the stomach at once. Thin, salted meat broth and wine in small doses may be allowed. Verhandl. der Deut Gesell, f. Chir.; Annals of Surgery. The Isolation of Non-Operable Carcinomata of the Pylorus.-Baron von Eiselsberg. The author reports twenty-five cases operated upon by him. self in Vienna and Utrecht by gastro enterostomy with six deaths. The indication for these operations was inoperable tumor of the pylorus-carcinoma in most cases. In the cases in which the stomach was not too much in filtrated, so that it could be easily rotated, he preferred that another child remained. Five days later she was the operation of von Hacker or the von Braham-Brenner admitted into Chrobak's clinic. On examination, a method, for the more difficult cases the method of Wolfler recommends itself. The operation of gastro enterostomy always relieves the symptoms of stenosis. Much less of the gastric contents comes in contact with the tumor, and it is thus spared this source of irritation. In two of his cases the pain persisted after the operation; and he explained it in that way. living child could be mapped out in the abdomen. The puerperal uterus was about the size of a man's fist, and the appendages on the right side were normal. On the left side a short, thick cord could be felt extending into a tumor which filled the left iliac fossa. Per vaginam this tumor was felt pressing down into Douglas' pouch, and the child's head could be made out in the pelvic excavation. The lochia were normal. Laparotomy was For this reason von Eiselsberg has practiced shutting performed. The ovum was found attached to the left off the pylorus from its stomach connection, as Salzer side of the uterus, from which the placenta appeared to recommended doing with the intestine. Of course, this grow. The vascular relations were so intimate that reisolation can not be complete, because provision must be moval of the sac without the uterus was impracticble. made for the bile which empties into the duodenum from The sac was opened and a healthy, well-developed the gall bladder. The operation of Billroth and later male child extracted, who cried lustily. An elastic that of Kocher showed the way, by resection of the stomach combined with gastro-enterostomy, how this isolation of the pylorus might be accomplished. It consists in a division of the stomach on the proximal side of an inoperable pylorus tumor, blind suturing of the cut edges of the stomach, and then the making of gastro enterostomy. This operation he performed in July, 1894, on two men of 56 and 62 years of age. Both were successful cases. In the course of three months one had gained in weight eight kilograms, and the other forty kilograms. Both of them had previously suffered from lancinating gastric pains until the tumor had been discovered and operated upon. The operation relieved the pain in both cases. In one case the healing was entirely without reaction; in the other case a tedious suppuration occurred. That this operation can bring about a quietus in the development of the tumor is demonstrated in a case of jejunostomy, which, in many respects, is very interesting. In a sixty-year old woman a carcinoma was present both in the cardia and the pylorus; and for this reason a jejunostomy was done after the method of Witzel. The fistula worked very well, the pain disappeared, and as the patient had gained eight kilograms at the end of four months, she was fed by the mouth, and it was found she could swallow well and retain the ingesta. Verhandl. der Deut. Gesell. f. Chir.; Annals of Surgery. OBSTETRICS AND GYNECOLOGY. ligature was placed on the uterus at the level of the internal os, and uterus and appendages were removed. The cervical canal was cauterized, and the stump treated extraperitoneally. Recovery was delayed by a rightsided pneumonia, but the mother and child left the hospital well at the end of a month. The right tube and Ovary were perfectly normal. The left tube could be distinctly traced into a tubo-ovarian ligament about half an inch wide. The ovarian ligament proper lost itself in the upper part of the sac: from the free end of the tube an ovarian fimbria led into the sac, of which the outer layers appeared to be formed by the remains of the ovary. The sac consisted of two parts, one of which closely attached to the left side of the uterus, was solid, while the other, situated externally, was membranous, and had contained the ovum. The former consisted mainly of a normal placenta, which received from the uterus two large vessels-artery and vein; the latter corresponded in its relations to a greatly enlarged ovary, and showed on its surface a number of cystic protrusions, ovarian follicles. Microscopic examination showed the presence of ovarian tissue covering the whole of the membranous portion of the sac; it con tained true ovarian tissue, a large number of follicies, and two corpora fibrosa. The placental tissue was normal in structure. The essential points in the diagnosis of ovarian pregnancy has been stated by Veit as complete presence of both tubes and one ovary, the other either being absent or forming part of the sac wall, while at the same time one ovarian ligament must run into the sac. All these requirements were satisfied in this case, and the diagnosis is clinched by the histological findings. Three Normal Pregnancies After NephSimultaneous Ovarian and Uterine Preg-rectomy.-E. Tridondani (Ann. de Obstet. e Ginecol.; nancy.-H. Ludwig of Chrobak's clinic ( Wien. klin. Woch.; Brooklyn Med. Jour.) The patient had previously been delivered at term of five healthy children, three of whom were still living. She became pregnant for the sixth time. On February 20, 1896, labor-pains In six hours she was delivered of a healthy girl, which presented by the vertex. It was evident came on. Br. Med. Jour.) Cases have been reportod by Schramm, Fritsch and Israel of pregnancy in women who had suf. fered the loss of one kidney. The author reports another of more than usual interest: A patient, aged 29, came into the Maternity at Pavia, suffering from symptoms resembling those of intestinal obstruction, accompanied with pain on micturition and position, and has explained to the patients the import ance of having all their clothing suspended from the shoulder, etc. With three exceptions, who did not complete the cure, the patients have all been able to eat solid food since without pain, and have increased in weight. His report includes fifty-five cases. scanty urine. She was in the eighth month of preg. eating and are relieved by acid vomiting. 4. The nancy; and to the left side of the uterus was a fluctuat hemorrhages. The diagnosis can never be absolutely ing tumor. Under treatment the symptoms improved, certain at the best, but this exclusive rectal alimentaand the woman was spontaneously delivered of a male tion benefits other gastric troubles and also serves to infant. Three months later the abdomen was opened differentiate ulcus from carcinoma ventriculi. It has and a cystic kidney (the left) was removed. Recovery also been successful in one case of nervous vomiting from was complete. Since then the patient has had three hyperesthesia of the stomach. He has found in each pregnancies. In none of the three were there any case that the stomach was not entirely normal in its abnormal symptoms. There was no edema, and the urine was normal in quantity and quality. The labors were at term and non-instrumantel. The placenta and membranes in each case were healthy, and the puer perium was normal. The infants were born alive, were healthy, and had a weight and size above the average. The author concludes, from a study of this and the three other reported cases, that pregnancy occurring in a woman with one kidney does not interfere with her health; that the absence of a kidney does not disturb the progress of gestation, labor and puerperium, and that the product of conception does not suffer. He does not, therefore, agree with Schramm, who advises that a woman with a single kidney should not marry, or if married already, should not become pregnant. It is noteworthy that in the above case the liquor amnii was increased in amount; but it is doubtful whether this was a consequence of the absence of one of the mother's kidneys. Ulcus Ventriculi Treated by Rectal Ali mentation Alone.-Boas and others have recommended this method of treating ulcus ventriculi when all others have failed, but E. Ratjen writes to the Deutsche Med. Woch., describing the brilliant results he has obtained with it, used exclusively. (Jour. Amr. Med. Ass'n.) Treatment commenced at once as soon as the diagnosis is established. He combines it with the strictest repose in bed and absolutely nothing taken into the stomach except clear water, peppermint tea, or pieces of ice dipped in brandy and water if there is heart weakness. The absolute rest for the stomach thus induced (even the secretion of hydrochloric acid ceases comparatively) allows the healing process to con tinue undisturbed, and the relief from pain reconciles the patient to the treatment. He uses Boas' clysma (250 grams milk, two yolks of eggs, a pinch of salt, one tablespoon red wine, one tablespoon starch flour) three times a day for ten days, after a natural or artificial evacuation of the bowels each morning. A special apart ment is set apart for the use of these patients in his hos pital or at their homes, where they never see or smell the food of others. Local hot compresses are used to relieve pain. As aids to diagnosis he mentions the following symptoms: 1 The subjective symptoms make their appearance soon after eating and depend upon the variety of food. 2. The freedom from pain after vomit ing and when the stomach is entirely empty. 3 The points painful to pressure in the epigastrium and in the back near the vertebra. The pains are worse during the ectasia of the organ from stenosis of the pylorus after Sulphate of Quinine in Labor. Schwab (Revue Obstetricale et Gynecologique; Brit. Med. Jour.) vaunts the efficiency of quinine as an oxytocic. Whenever he has given it in the course of a simple lingering labor it has awaked or accelerated uterine contractions. Quinine, he maintains, stimulates uterine fibres when once they have begun to contract of their own accord. Like ergot, it does not set contractions going; hence it is not an abortifacient. Quinine has one distinct advantage over ergot; the contractions which it sets going retain their normal intermittent character. It acts rapidly -within twenty five minutes as a rule. Large doses are needed; Schwab gives a gramme, that is, .4 gr. in two "cachets" taken at an interval of ten minutes. He prescribes these two doses of sulphate of quinine particulary when the membranes are ruptured and it is advisable that the labor should be ended as soon as possible. It is harmless to mother and child alike, since, should it fail, dilators or forceps may be used, and there is no difficulty from the tonic contractions caused by ergot. Shwab warns obstetricians that, as the placenta comes away, when quinine has been used there is a slight tendency to internal hemorrhage. Coules, as long ago as 1888, advocated quinine in abortion with retention of fetal relics. Schwab has given the drug in three such cases with good results, he relics being quickly expelled, but he can not feel sure how far the quinine contributed to the good result until further experience. Of its direct value in labor he has no doubt. Disinfection of the Urethra by the Interternal Administration of Enterol.-Enterol is a watery, colorless, sometimes slightly brown liquid, with a specific gravity of 1,036, and with the taste and smell of of kresol. It is slightly soluble in one hundred parts of water, and has about six times the antiseptic strength of carbolic acid, Properly diluted-that is, one part of the enterol to five hundred of water, it can be given in the dose of from half a dram to a dram daily for months at a time without producing any un toward symptoms. 3 The toward symptoms. It is given in pill, capsule, and mixture with equal parts of olive oil. Fass, in Centralblatt f. die Krankheit der Harn, etc., states that thirty of the capsules can be taken at a dose without harm. |