Selected Articles.

The Treatment of Exophthalmic Goiter.

Although more than half a century has elapsed since the first descriptions of this disease by Graves and Basedow, our knowledge of its etiology and pathology is still involved in much obscurity, and hence the treatment is not yet established upon a satisfactory basis. Up to within the last few years cases of exophthalmic goiter have been treated exclusively by internal medication and galvanism; but observations since then have shown that in cases in which these measures fail, much may be accomplished by surgical therapeutics. It would seem that any operation which is capable of diminishing the size of the goiter will exert a marked beneficial influence, no matter whether it consist in thyroidectomy, ligation of the arteries, enucleation of nodules and cysts, or incision or puncture of the latter. The entire question of the surgical treatment was ably and impartially discussed by Prof. Mikulicz at the last meeting of the German Surgical Congress on the ground of his personal experience in eleven typical cases. In three of these the thyroid arteries were ligated, in three others nodules or cysts enucleated, and in the remaining two the goiter was resected. All the patients recovered from the operation; six being completely cured, four considerably, and one markedly improved. The permanency of the cure was confirmed by a period of observation varying from one to nine years. In regard to the choice of the operative procedures, Mikulicz advises enucleation where nodules or cysts are present, but under other circumstances ligation of the entire four arteries, and reserves thyroidectomy only for cases in which these procedures are inadequate. As to the rapidity with which the symptoms disappear after the operation, he found that their complete subsidence occupied from two weeks to one and one-half years. Much to the gratification of the patients, the psychoneurotic pneumonia were usually the first to disappear; the circulatory disturbances, the tachycardia and cardiac murmurs receding more slowly. Although the eye symptoms, especially the exophthalmos, may persist for a considerable

time, the patient may be regarded as cured, in the absence of other signs of the disease, as is evinced by the rapid increase in weight and marked improvement in the general health. Notwithstanding the brilliancy of his results, however, he makes the conservative statement that exophthalmic goiteris not a surgical affection, and that operative intervention is indicated only in the minority of cases.-Int. Jour. Surg.

Preliminary Report of 1000 Abdominal Operations by Prof. Schauta. During the ten years (Nov. 23, 1884, to Feb. 10, 1894,) the total mortality in these cases was 10.7 per cent. (104 deaths); 46 deaths were traced to the operations. In 54 cases septic processes caused death. Of the 46 deaths directly due to the operations, in 35 there were septic processes, in 8 secondary hemorrhage, in 2 intestinal perforation, in 1 acute anemia. Of the remaining 58 deaths, 12 were due to cardiac weakness, fatty heart and the anesthetics; of 11 exploratory operations, 7 were fatal. The operations are next arranged in groups: 1. Ovariotomies, 198 cases, 182 recoveries, mortality 8.1 per cent., 2 deaths from operative sepsis and 2 from secondary hemorrhage, together 2.2 per cent.; in 12 deaths indirectly the result of operation, were 2 cases of infection with streptococci from the contents of tumors. 2. Adnexa operations, 313 for chronic inflammatory affections; of these 290 were pyosalpinx, ovarian abscess, salpingitis, oophoritis; 259 times the adnexa were removed on both sides; in 75 times there was discharge of pus, in 27 cases gonococci were found in the pus, in 13 streptococci, in 4 staphylococci, in 5 diplococci whose nature could not be immediately decided, in 1 the bacterium coli commune; in the 25 remaining cases either no bacteriological examination was made or the pus was found. sterile; of the 290 cases 273 recovered, mortality 5.5 per cent. ;. 5 laparotomies for hydrosalpinx with 2 deaths (1 pneumonia, 1 peritonitis), 5 for hematosalpinx, 5 for tubercle of the tube with 1 death from intestinal perforation; from these 313 operations, 20 deaths, 14 due to the operation. 3. Castration, 56 cases, 2 deaths from secondary hemorrhage. 4. Porro's Cæsarian section, 7 cases, 2 for stenosis of soft parts, 1 for osteomalacia, 2 for existing infection of uterus, 2 for rupture of

uterus; 5 survived, 2 children lost (dead before removal); conservative Cæsarian section with suture, 37 cases, 16 times for absolute narrowing of pelvis, 15 for relative, 4 for eclampsia, and 1 for tumor causing stenosis of vagina; all the children survived; 4 mothers died, 1 from sepsis. 5. Supravaginal amputation of uterus, 74 cases, 13 deaths. 6. Supravaginal amputation with retroperitoneal provision for pedicle, 2 cases, 1 death. 7. Myomectomy (Schroder) with intraperitoneal provision for pedicle, once, with unfavorable result (sepsis). 8. Supravaginal amputation with interperitoneal suspension of stump (Maydl), 4 successful cases. 9. Enucleation of nodular myomata by laparotomy, 18 cases, 14 recoveries. 10. By ventrofixation, 77 cases, all recovered. 11. Total extirpation of uterus by laparotomy, 8 cases, 4 for myoma (1 death), 4 for carcinoma (3 deaths). 12. Total extirpation by vagina, 181 cases, 14 deaths. 13. Ventro - vaginal total extirpation, 8 cases, with 5 deaths from sepsis. 14. Sacral total extirpation for carcinoma of the uterus, 15 cases, with 5 deaths. 15. Laparotomy for extra-uterine pregnancy, 49 cases, with 4 deaths. 16. In this group are included laparotomies for various other indications; the most interesting is one for purulent peritonitis following abortion.- Centralblatt fur Gynakologie from Jour. Amer. Med. Asso.

Appendicitis.

M. Monod gave the result of his treatment of appendicitis before the Societe Chirurgicale. Although, he said, that the affection is much more frequent in man (eighty per cent.) than in woman, his cases comprised twenty-three men (sixty-two per cent.) and fourteen women (thirty-eight per cent.) Eight of the patients were under fifteen, while the youngest was four and a half and the oldest fifty-five. The debut was brusque in seventeen cases, insidious in the remaining twenty The fever in some cases was so slight that without the thermometer it would have passed unnoticed. Quite recently a patient was sent to him by a confrere, who had suspected that it was a case of appendicitis, but said that no fever could be detected. However, when the rectal temperature was taken, it was found to have reached 102 degrees, and the region of

the appendix was discovered to be the site of a large purulent collection. In another case there was fever which lasted four days, accompanied by a tumefaction in the iliac fossa; on the fifth day the temperature fell to the normal, and the swelling had almost disappeared, but pain was felt in the left iliac fossa. A few days subsequently the temperature rose again, and the patient had the facies of peritonitis. M. Monod operated and found pus in both sides; the patient died. From these and one or two other similar cases the speaker said that he made it a rule to operate when fever coincided with the existence of a tumor in the iliac fossa. The most difficult cases are those where no tumefaction could be felt, but the diagnosis can be based on the exquisite pain over the site of the organ.

M. Monod operated nineteen times on the thirteenth day, and six times after one month had elapsed. In three cases he operated on the third day, and found that pus was already formed. Out of thirty-two operations, he found it impossible to discover the appendix twenty-four times; five times he resected the organ, and in the remaining three the appendix was visible, but he did not remove it. Of the total number of operations twenty-three were successful, and of the nine patients who died one succumbed to tuberculous meningitis, and four others were operated on in extremis.-Correspondent in Medical Press.

First Aid in Accidents by Electricity.

The Pharmaz. Centralblatt, 1895, gives the following as the lines to be followed in giving first aid to a person injured by an electrical current:

1. The current should be shut off at once if the means are at hand, and the person called upon understands how to do it.

2. If this cannot be done, be careful not to touch the injured person's body with the hand. If no india-rubber gloves are at hand, the body should be dragged away from the wires by the coat tails, or the coat should be taken off and folded (a dry cloth may be used for the purpose), when the injured person may be grasped through it and dragged away.

3. When it is not possible to remove the injured person from the wires, raise that part of the body that is in contact

with the earth or the wire from it, using the covered hand. This will break the current, and it will generally be possible then to get the body away.

4. If this cannot be done, take a dry cloth and place it between the body and the ground, and then disentangle the body from the wires.

5. If the body is freed from the wires, remove all the clothing from the neck and treat the injured person as one drowned. Open the mouth and grasp the tongue, which should be covered with a cloth; then pull the tongue forward and gradually allow it to fall back; this movement should be repeated sixteen times a minute. Take care that the root of the tongue is thoroughly moved.

6. The bystanders should not be allowed to give the injured person spirits or wine.-Med. Press.

Collective Investigation on Anesthetics.

Gurlt of Berlin states that the collective investigation has now been going on for five years. This year 52,677 new cases were reported, of which 31,803 were chloroform narcosis, with 23 deaths, and 15,712 were ether narcosis, with 5 deaths. In 2148 cases narcosis was produced by a mixture of chloroform and ether, in 1554 by the so-called Billroth mixture, in 1425 by ethyl-bromide, and in 34 by pental. The use of ether has much increased. The mortality from chloroform seems to be much greater than that from ether; but very often grave disorders of the respiratory organs-such as pneumonia and bronchitis result from the inhalation of ether, and death from those complications ought to be regarded as equivalent to death under anesthetics. Ether was especially harmful after laparotomy.

Dr. Schleich of Berlin explained his theory of the action of anesthetics. According to him, they are more dangerous the more their boiling-points differ from the temperature of the body.

Dr. Rosenberg of Berlin recommended that the mucous membrane of the nose be brushed with a solution of cocaine before the commencement of narcosis.-Lancet.