Le-Coq made a careful microscopical examination, which revealed that muscular structure of the heart was in a state of advanced fatty degeneration.-Am. Pract, and News, Dec. 11, 1886. Circulation in Ganglion Cells. Professor Adamkiewicz, of Cracow, has recently published some observations on the circulation in ganglion cells, which, if confirmed, certainly adds to our knowledge of the physiology of nervous tissue. The ganglia chosen for observation were the intervertebral ganglia connected with the cords forming the brachial plexus. Carmine injections were made by means of the spinal arteries, and examination showed that each cell has a special arterial twig, which is distended so that its walls surround the ganglion cell, which consequently is situated in the lumen of the vessel, and is bathed completely by the arterial stream somewhat in the same way as the placental tufts are bathed by the blood in the maternal sinuses. This, however, is not all; for the cell itself contains a number of exceedingly minute vessels or passages from the circumference to the centre, which, of course, admit serum only; and this, which enters the cell in an arterial condition through numberless peripheral orifices, is collected at its centre as venous serumforming, indeed, what has hitherto been looked upon as the cell nucleus,-which, therefore, instead of solid, is liquid, or rather a cell containing liquid, the only solid part being the nucleolus. This venous serum is conveyed away by a single vessel or vein which runs into the general venous circulation. Besides all this, it appears that the whole blood-vessel apparatus of the ganglion cell is surrounded by special lymph-vessels, so that the arrangement is highly complicated, and offers an interesting field for further research.-Lancet, Dec. 18, 1886. Rotter and Virchow on Charcot's Joint Disease. At the meeting of the Berlin Medical Society on the 17th ult. a discussion took place upon tabetic arthropathy, which, it may be remembered, excited so much attention at our clinical society two years ago. Dr. Rotter, who opened the debate, described succinctly the clinical and anatomical features of the disease, with a view of proving its distinct identity, and the dependence of the articular changes upon nerve disorder. Professor Virchow followed in a long and careful speech, in which he acknowledged the similarity of the affection to rheumatoid arthritis, and traced the development of the pathological changes in the joints from hyperplasia of the cartilaginous investment, followed by regressive change and atrophy, ossification of the medulla leading to eburnation, hyperplasia, and ossification of synovial fringes, and ultimately of ligamentous tissues. These changes, he declared, were hardly to be regarded as inflammatory; but, although he admitted their dependence upon disordered nerve influence, he maintained that in each case there must be a local determining cause also at work. Other members also spoke, but we must postpone a full analysis of the debate to a subsequent occasion. Neurologists will note that Professor Virchow objects to the phrase "tabetic," and prefers that of "arthropathia tabidorum."—Lancet, Dec. 11, 1886. The Differential Diagnosis between Chronic Rheumatic Arthritis and the Arthropathy of Locomotor Ataxia.-William Adams, in an article on "Chronic Rheumatic Arthritis, Especially as Affecting the Hip-Foint," adduces the following instructive points in differential diagnosis: In chronic rheumatic arthritis, the structural changes are essentially those of hypertrophy. In Charcot's disease, the structural changes are essentially those of atrophy. In chronic rheumatic arthritis, the affection commences in subacute or chronic inflammation of the synovial membrane, and fibrous tissues in the neighborhood of the joint, gradually extending to the articular ligaments, the periosteum, and the bone. In Charcot's disease, the affection commences in the bones, the osseous structure being the seat of the primary and essential changes all through. This affection may, therefore, properly be called osteo-arthritis. With regard to the clinical history, chronic rheumatic arthritis is a painful affection all through its course, from its commencement to its termination. Charcot's disease is a painless affection throughout its course. In chronic rheumatic arthritis, the pain complained of is always limited to the joint or joints involved, or to their immediate neighborhood. In Charcot's disease, shooting pains are complained of throughout the limb, and also in the opposite limb. In chronic rheumatic arthritis, there are no symptoms of febrile-disturbance, or any some cases of hæmatemesis from pressure gastric symptoms; nor are there any pupil-over the stomach. As a class, shoemakers lary symptoms, known by the name of their first observer, Argyll-Robertson. In Charcot's disease, all these symptoms are present, and diagnostic. In chronic rheumatic arthritis, the reflex phenomena are present; and, when the knee-joint is affected in one limb, the patellar reflex is always present in the opposite limb. In Charcot's disease, the absence of the patellar reflex is one of its earliest and diagnostic symptoms. Chronic rheumatic arthritis is characterized by very limited mobility of the joint affected, any attempt to increase motion being painful. Charcot's disease is characterized by increased mobility and a flaillike condition of the knee, hip, and other joints affected. In chronic rheumatic arthritis, the progress of the affection is remarkably slow and chronic in its character, the articular changes being slowly developed in the course of some years. In Charcot's disease, the progress of the joint-affection is remarkable for its rapidity, extensive destruction frequently occurring within a few months. In chronic rheumatic arthritis, the sufferers from this affection frequently live to an advanced period of life, not uncommonly reaching eighty years of age, or more. Charcot's disease, as far as I can learn, old age is seldom reached, the patients either dying as paralytic cripples, from some disease connected with nerve-lesions, or from some intercurrent disease, the progress of which they are unable to resist.-Brit. Med. Four., Nov. 13, 1886. Thomas (D.) on Shoemakers' Ulcer. While holding an inquest recently on the body of a shoemaker who had died suddenly from the bursting of an ulcer in the stomach, Dr. Thomas said it was a pity that shoemakers persisted in pressing the boot to the stomach when engaged on their work, for the pressure was apt to produce an ulcer. We are informed by Dr. Lomas, an excellent authority on the subject, that a very large number of shoemakers suffer from stomach-diseases. Some years ago an upright bench for shoemakers was exhibited which, it is believed, is now used in many boot-factories. The repairers of boots and shoes are the people who still carry on their work in the old way. In hospitals and dispensaries, he has met with are not healthy; many of them become very feeble at the age of forty to fifty.Brit. Med. Four., Oct. 30, 1886. Hall (de H.) on Hepatico-Bronchial Fistula. This lesion occurred in a meat salesman, who suffered much pain in the hepatic region, followed by jaundice three weeks before he was seen. Vomiting of bright bile also occurred. An enormous quantity of bilious fluid was brought up at one time. The liver was enlarged, not tender; the urine was loaded with bile, the motions pale, and the patient jaundiced. The discharge of bilious fluid was continued, and it was evident that the bile came from the lung, as it was expelled by coughing and was frothy. The patient eventually recovered. In the majority of cases hitherto recorded hepatico-bronchial fistulæ had been caused either by the rupture of an abscess or of a hydatid cyst in the liver, and the discharge of their contents into the lung; but from the result of his investigations he would add the impaction of a gall-stone and consequent dilatation of the bile ducts as another cause of these fistula. Two of four cases ultimately died. The treatment must necessarily be of an expectant kind. If there were complete obstruction to the entrance of bile into the intestine, purified ox bile might be given with advantage. Should there be any difficulty in clearing the lung of the bilious fluid, a stimulating emetic, such as ten grains of carbonate of ammonium and twenty grains of ipecacuanha, might be required. The question of surgical interference might come into question if bile accumulated in the pleural cavity.-Lancet, Nov. 13, 1886. White (H.) on Statistics of Cerebral Tumors.-An instructive piece of statistical work has been contributed to the current number of Guy's Hospital Reports by Dr. Hale White, on the cause, operative treatment, mode of death, and general symptoms of 100 cases of cerebral tumor collected from the post-mortem records of Guy's Hospital. Ninety-nine of the cases occurred during the years 1872-84, both inclusive; the total number of necropsies was 5,850, or about 450 a year, which gives 1 tumor of the brain for every 59 that come into the post-mortem theatre. Of the 100 cases, the growth wa tubercular in 45, gliomatous in 24, sar comatous in 10, carcinomatous in 5, glio- œsophageal ulcers were probably due to an sarcomatous in 2, cystic in 4, gummatous abscess which had existed at the upper part in 5, lymphomatous in 1, myxomatous in 1, of the oesophagus at its junction with the and of doubful nature in 3; 34 of the pharynx, and this bursting had caused the tubercular cases occurred in the male sex. discharge of pus noticed during life. It There is much useful information in the appeared that the cause of the abscess was paper, but the chief drift of the investiga- the extreme retraction of the head throwing tion was to ascertain, as far as possible, the larynx backwards and the spine forhow many cases could have been treated wards, so that the friction of the cricoid surgically after the fashion of recent cartilage against the spine during respiratimes. The conclusion was arrived at that tion set up the abscess. The case was also only 3 of the tuberculous cases could have of interest because it was possibly an exbeen benefited by operation, that at the ample of a rheumatic meningitis, for the outside 6, and probably only 4, of the patient had had rheumatic fever twice, and gliomata, 1 only of the sarcomata, none there was no cause obvious at the posteither of the carcinomata or of the gliosar-mortem examination to account for the incomata, perhaps 2 of the cysts, the myx- flammation of the meninges.-Brit. Med. oma but not the lymphoma, and 2 of the Four., Nov. 20, 1886. doubtful cases. Therefore, of the whole number of cases 10 might certainly have been operated upon, and probably 14. will not be forgotten that before this number could have been treated surgically it would have been necessary to diagnose the seat of the tumor, even so late in the case as shortly before the death of the patient would suffice, whilst, of course, earlier in their histories many others might have been operated on with good prospect of success.-Lancet, Sept. 25, 1886. It SURGERY. Richardson on Gastrotomy for Removal of a Plate of Teeth from the Esophagus; Recovery. The patient was a powerful teamster, thirtyseven years of age, who applied for treatment at the Out-Patient Department of the Massachusetts General Hospital, on September 26, 1885. Three days before, while eating, he had swallowed his false teeth, which he described as "about the size of a silver half-dollar, carrying the four anterior teeth of the left upper jaw, and as leaving two small hooks by which it was fastened to the teeth still in that bone." The plate was felt with a probang to be near the stomach. He was admitted to the hospital, where an unsuccessful attempt was made to remove the plate by means of a coin-catcher, but the end broke off and ten days later it was passed per rectum. White (H.) on Cerebro - Spinal Meningitis Causing Esophageal Abscess. The specimen, which was taken from the body of a girl, who was in Guy's Hospital for a month with retracted head, arching of the spine, cephalic and spinal pain, and other symptoms showing the existence of cerebro-spinal meningitis. About eighteen hours before death a quantity of pus began to pour from the mouth, but no cause for this could be discovered; the pus trickled down into the lungs, and the patient died. At the post-mortem examination, it was found that the spinal and cranial bones, dura mater, and cerebral vessels were all normal, without any trace of tubercle; there was abundant purulent meningitis of the base of the brain and the posterior surface of the spinal cord. Op- July 23, 1886, re-entered the hospital posite the cricoid cartilage on its posterior and came under Dr. Richardson's care. surface, was an oval ulcer, with its long The foreign body was in the same position vertical diameter measuring 1 inch. At At as before, fourteen inches from incisor the bottom of it the cricoid cartilage was teeth. Patient had lost sixty-five pounds exposed, but was not necrosed. Opposite in weight, and could with difficulty swallow this ulcer was another on the posterior wall enough liquid food to keep alive. The of the pharynx. There was some bron- operation is described as follows: chitis, and the mitral valve was thickened. The rest of the body was healthy. The 66 Two weeks later was given charpie cut fine, mixed with eggs. On November 10th, was improving in health and strength, had good appetite and less pain," and was discharged from the hospital with the teeth still in the oesophagus. August 5, 1886. Patient was carefully etherized. An unsuccessful attempt was first made to demonstrate beyond possibility of a doubt the presence of the foreign body. Some difficulty presented itself in doing this, and the attempt was abandoned to save time. Moreover, it was not essential, as the probang had been used the day before in studying the location of the plate. mass of soft granulations. The hand was withdrawn, and long-bladed forceps introduced into the oesophagus, guided by the index finger, but attempts to grasp the plate were unsuccessful. I then reintroduced my hand, and by careful manipulation with the index finger succeeded in detaching the left extremity of the plate from its bed in the left side of the canal. The other extremity was then loosened from the right side, and the plate passed easily into my fingers, and was withdrawn from the stomach. "The mucous membrane was united with a continuous silk suture, to control the hæmorrhage which followed the removal of the hæmostatic forceps. The peritoneal surface was closed with thirty-six fine silk sutures, after the method of Lembert, placed three-sixteenths of an inch apart, the line of union being most perfect and beautiful. The stomach was then dropped back into the abdominal cavity, and the external wound closed in the usual manner with interrupted deep and superficial silk sutures. Iodoform and gauze dressings were applied, with compression. Time of operation, one hour and a quarter." On the third day patient coughed up about 3 viii. of pus, and afterward smaller amounts. This is supposed to have come from an abscess about the œsophagus, which had ruptured during the manipulation into the lung. "An incision about six inches long was made one and one half inches below and parallel to the margin of the ribs in the left hypochondrium. It began at the other border of the rectus abdominis, three inches from tip of ensiform cartilage, and extended outwards and downwards. The abdominal wall was rapidly cut, layer by layer, until, all bleeding having been stopped, the peritoneal cavity was opened. The abdominal opening was held up by means of a T-hook at each extremity. The stomach was found lying empty in its usual position. An external examination was made of the cardiac orifice and of the whole stomach, to see if the foreign body might not be found and dislodged by manipulations. Nothing could be detected either in the stomach or the diaphragmatic opening. The stomach was now drawn out of the abdominal wound as far as possible, and placed upon a carbolized towel, and in this position all the subsequent manipulations were done. A small incision about one and one half inches long was first made through the anterior wall of the stomach, beginning near the pylorus, and extending upwards and backwards midway between the greater and lesser curvatures. The After the operation, Dr. Richardson walls were very thick and vascular. After made a number of measurements on the cutting through the peritoneal and muscu- cadaver, and found the distance from the lar layer, a dense network of large and upper incisors, when the head is fully extortuous vessels came into view, which, on tended, to the opening in the diaphragm to. being divided, bled very profusely. This be about fifteen inches in fourteen subwas controlled by smooth-bladed, hæmo-jects taken at random." He also found static forceps. the distance in a straight line from the "After two unsuccessful attempts to intro- centre of an incision five inches long, one duce grasping instruments into the oesopha-inch below and parallel to the margin of gus through this small opening, I enlarged the ribs on the left side, beginning at the the incision sufficiently to admit my hand outer border of the rectus abdominis to the and forearm. The stomach was first wiped oesophageal opening in the diaphragm, to out with sponges and held with T-hooks. be 7.55 inches." The walls of the diaphragmatic opening were found with some difficulty after passing the hand seemingly a very great distance. The middle and index fingers were then pushed up the esophagus between the heart in front and aorta behind until the plate was felt, with the teeth pointing downwards, apparently embedded in a Patient made a good recovery, and on October 25th resumed work as a teamster. In some subjects left oesophagotomy was done as well as gastrotomy, and the index finger of one hand passed through the opening in the neck could be made to touch the index finger of the other hand introduced through the stomach. The article includes brief histories of all the cases that the author could collect, and references to a number of other cases which may be summed up as follows, changing the cases of Polaillon and Bernays, now reported in full, from the incomplete to the complete list: (1) 14 authentic cases where the stomach, uninjured and non-adherent, has been opened; of these 3 died. (2) 11 cases where the stomach was injured and adherent; with 10 recoveries and I death. (3) 8, the authenticity of which is doubtful, with 6 recoveries, I death, and I unknown.Bost. Med. and Surg. Four., Dec. 16, 1886. G. B. P., JR. "A normal tendon, whose strength is in proper proportion with the parts connected with it, is very rarely ruptured. Cases are occasionally met with in the young and robust where this accident has occurred. A rupture occurring in those advanced in years, however, is different matter. Here the tendon is presumably weakened by senile atrophy or shoulder disease, so as to require only a slight force to tear it through. 66 a All cases of ruptured long tendon of the biceps, no matter what the cause be, show Bernays on a Successful Case of Gastrotomy, with Critical Remarks. -The patient was a healthy man, thirty-essentially the same deformity. The belly eight years of age, who, to amuse some friends, used an ordinary table-knife a little more than nine inches long, to do the sword-swallower's trick. The knife was introduced with the handle foremost, and when he released the blade for a moment, the knife was "pulled down" into the stomach. Vomiting soon followed, and the operation was done about an hour after the accident occurred. An incision five inches long was made in the linea alba between ensiform cartilage and umbilicus. No perforation was found in the stomach wall. The handle was near the pylorus, and it was grasped and carried out of the abdominal incision, where an incision five eighths of an inch long was made in the stomach, and the knife removed. The stomach wound was closed by five gut sutures intended to produce a direct union of the cut edges, which were buried by eight silk Lembert sutures; abdominal wall sutured; bichloride gauze dressing. Patient did perfectly. well, and took his regular food on the tenth day. Medical News, Jan. 1, 1887. of the affected muscle is unnaturally full, so much so at times as to suggest the idea of a tumor. Above the swelling is an abnormal depression, in which the tendon can be felt. The muscle, though apparently firmly contracted, is soft and flabby, and the patient is unable to make it as hard as the muscle of the other arm. One should, in all cases, be able to feel the tendon running upwards from the collapsed muscle in the direction of the bicipital groove. I mean in all cases except where that very rare injury, namely, rupture through the junction between the tendon and the muscle, has taken place. If we examine the outer head of the biceps muscle just as it issues from under cover of the deltoid, we find it is muscular, not tendinous. The tendon is entirely covered by the deltoid. If this tendon ruptures high up, the lower fragment slips down the groove, and can be felt below the margin of that muscle. "The diagnosis of a rupture of the tendon during life, when the deformity is marked, is a simple matter. Where, however, a parG. B. P., JR. tial rupture or only a laceration of the On the Rupture of the Tendon of sheath has occurred, the diagnosis is beset the Long Head of the Biceps Brachii with difficulties, for the sign of most imMuscle.-Dr. George H. Monks, in the portance is entirely wanting, namely, the Boston Medical and Surgical Journal, Nov. deformity. In such cases reliance must 25, 1886, reports four cases of this uncom- be placed on localized pain and tenderness, mon accident. All four cases occurred in and altered function of the muscle followmen over fifty years of age. Two had had ing an injury, which would in favorable for several years rheumatism in the shoul-cases be likely to cause a rupture. Gerster der of the arm injured. One case was has reported a case in which he considers caused by a fall on "face and left shoul- that a partial rupture occurred.' der"; one from 'shovelling snow into a city cart"; one from lifting a stove; one from an effort to prevent a heavy chest from falling. With this case there "The treatment of ruptured biceps is rest. A circular bandage around the arm, below 'New York Medical Journal, vol. 27, 1878, p. 487. |