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SURGERY

Edited by A. Vander Veer, M. D. The Radical Operation for Varicocele.- ALBERT NARATH (Wiener klinische Wochenscrift, 25 January, 1900) has performed the operation in several cases in the following manner: An incision through the skin, about ten centimetres in length, is made in the direction of the inguinal canal, about a finger breadth above Poupart's ligament. This incision, which is not carried as far down as the tuberculum pubis, is carried through the skin and superficial fascia. The external oblique muscle is then split in the same direction and the inguinal canal laid open in its whole extent, just as in Bassini's operation for inguinal hernia. The spermatic cord with the cremaster ani the tunica vaginalis is then lifted out of the inguinal caral, this being very easily accomplished. With a short longitudinal cut, or finger dissection, to separate the cremaster and the tunic, the whole outline of the spermatic cord is brought into clear view. The distended veins are exposed even when only slightly filled in the inguinal canal access is given either to the main trunk of the internal spermatic vein or its principal branches. The veins are dissected out as far as possible, tied with double ligatures and separated between the ligatures. The proxin:al stump of the incised vessels immediately retracts and disappears, as they lie higher than the internal ring. The distal veins are then traced as far as the externa! ring, and likewise separated between two ligatures. In this way a section of several centimetres in length is removed from the venous trunks and their branches, or, in high origin of the latter, from them alone. The veins are very easily separated from their relations with the spermatic cord. Following the operation care must be taken to prevent a peritoneal hernia. If this be present it must be isolated, twisted, ligated and amputated. Finally the external spermatic veins may be investigated, and if dilated, should be also resected. As the last act of the operation the inguinal canal should be closed after the manner practiced by Bassini.

The aavartages of this operation may be summarized as follows:

(1) The initial incision is made in a region which may be much more easily cleansed and sterilized than the scrotum; (2) the circulation in the internal spermatic vein is completely interrupted and the high pressure relieved; (3) the chance of wounding the internal spermatic artery is much more reduced than in any other operation; (4) if the external spermatic veins are in perceptible degree distended they may also be resected; (5) an inguinal hernia, when it exists, may be treated at the same time. Small peritoneal herniæ may also be found for the first time by the opening of the inguinal canal; their recovery is easy; (6) lipomata presenting onay also be removed at once; (7) the inguinal canal may be firmly closed; (8) the spermatic cord may be drawn forward and embedded in a narrow canal; (9) the testicles are made to lie higher, and the absolule length of the extra-abdominal scrotum is reduced, so that the column of the pendent blood vessels is reduced; (10) the influence of the abdominal pressure upon the circulation in the testicle is reduced or entirely relieved; (11) the collateral circulation in the scrotum remains, inasmuch as the scrotum itself has not been oper:sted us:on; (12) the operation is very neat and aseptic, the venous plexus remains intact, and the loss of blood is very slight.

Surgical Treatment of Carcinoma of the Stomach.-By Dr. H. L-INDNER Berl. klin. Woch., January 29, 1900. Billroth was the first to demonstrate that large pieces of a carcinomatous stomach could be removed with success. There appeared, however, to be comparatively few cases in which such an operation was practicable, and its place was largely taken by gastro-enterostomy which was first recommended by Wolfler. During the past two years the surgery of the stomach has come into special notice. and particularly the surgery of carcinoma of the stomach. At present there appear to be three important questions with regard to this matter: (1st.) Is it possible to remove a carcinoma of the stomach in a more radical fashion than formerly? (2d) Is it better in cases in which a radical operation is impossible to perform a total resection of the stomach, or to perform a gastro-enterostomy? (3d.) In cases in which only a palliative operation is possible is gastro-enterostomy to be preferred to jejunostomy?

In regard to the first question the necessity of removing lymphatic glands and vessels connected with the stomach must be borne in mind There are four groups of glands which are of special importance in carcinoma of the stomach; (ist.) the group in the ligamentum gastrocolicum; (2d.) the group in the ligamentum gastro-hepaticum; (3d.) the group in the bend of the duodenum; (4th.) the group about the choledochus and the portal vein.

The results of operation would appear to show that recurrences are more apt to occur in the stomach or duodenum than in the glan is. In twentyeight cases of resection of a portion of the stomach with autopsy there was local recurrence in fifteen, distinct recurrence in twelve, and gland recurrence in one. The writer especially emphasizes the necessity of the appreciation on the part of the internists of the value of an early diagnosis if operation is to be successfully performed.

In regard to the question as to whether a total resection is to be preferred to gastro-enterostomy in cases in which it is impossible to remove all of the carcinomatous growth, the writer is inclined to consider gastroenterostomy the operation to be preferred, and in general it appears to give more relief from the distressing symptoms. The writer usually prefers ante-colic gastro-enterostomy, associated with entero-anastomosis between the duodenum and jejunum, thus preventing the bile and pancreatic fluid from gaining access to the stomach. Maydl has been the chief advocate of the jejunostomy and Maydl's statistics are very satisfactory, but both theoretically and practically the writer feels that this operation is not so satisfactory as is gastro-enterostomy, for it does not provide for the relief of an obstructed yylorus if such should exist.

Operative Treatment of a Fibroma of the Mesentery with Extensive Resection of the Intestine.-By Dr. E. LEXER. Berl. klin. Woch., January 1, 1900. The mortality following operations for the removal of large tumors of the mesentery is necessarily high. Shock and peritonitis seem to be the chief cause; of death. Peritonitis usually comes from gangrene of the anastomoseri ends of the intestine, due to an insufficient blood supply.

The writer reports a case of a man of forty-one years, in whose abdomen there existed a large movable tumor situated below the umbilicus, and occupying the mid region of the abdomen. It did not cause the patient a great deal of discomfort aside from a colicky pain and a dragging sensation. At operation the tumor was found to be situated between the two layers of the mesentery, and along the convexity of the tumor ran a coil of ileum between which and the tumor there were two or three centimetres of mesentery. At the base of attachment of the tumor there were situated some large branches of the mesenteric artery and vein, which it was necessary to ligate. This necessitated the removal of all the intestine supplied by these branches, and accordingly two metres of the ileum were removed along with the tumor. There was no involvement of the lymphatic glands. The writer performed a lateral anastomosis of the resected ends of the intestine and the abdomen was closed The patient made an uninterrupted recovery. Microscopic examination of the tumor, which weighed five pounds, showed it to be a fibroma with small areas of myxomatous tissue. The writer refers to several cases of successful resections of large portions of the intestine, and says that the longest piece ever successfully removed was three metres and thirty centimetres, done by Ruggi in 1894. Montprofit has recently successfully removed a piece of intestine three metres and ten centimetres in length.

MEDICINE

Edited by Samuel B. Ward, M. D. Heredity in Chronic Nephritis.-By Dr. P. K. Pel (Zeit. für klin. Med., Bd 38, Hft. 1, 2, 3.) In studying the hereditary character of a disease, one should not only consider the frequency with which it occurs but should also pay especial attention to the conditions under which the hereditary tendency seems to manifest itself. The writer calls attention to the generally accepted hereditary tendencies in certain diseases, as hæmophilia, optic atrophy, and the so called diseases of metabolism, as gout, diabetes and obesity. In tuberculosis, nervous diseases, migraine, heart diseases, arteriosclerosis and lithiasis, hereditary tendencies are clearly proved to exist. The writer also states that in from ten to fifteen per cent. of cases of cancer there is an hereditary element.

With regard to chronic nephritis, there does not appear to exist any very strong sentiment that heredity plays a roll of any special importance. The writer has carefully gone over the literature and quotes from most of the more prominent writers on diseases of the kidney. With considerable accord they recognize the possibility of an hereditary tendency, but say that it is not clearly proved. A few writers are more positive in the statement that an hereditary tendency does exist. Dickinson has reported a most remarkable example in which eighteen cases of nephritis occurred in the same family in three generations. Tyson has also reported a series of sixteen cases of nephritis occuring in the same family in two generations. Kidd saw eleven cases in two generations of the same family.

The writer reports a series of eighteen cases occuring in the same family in three generations. These cases were all of chronic nephritis and the diagnosis in all of the cases was positive. All the cases reached rather an advanced age and they all died of uremia. Of the eighteen cases, nine were men and nine were women. It would appear that the sons inherited the tendency to the disease from their father and the daughters from their mother. The writer is inclined to assume in these cases the existence of an inherited predisposition of the kidneys to disease, as a result of which the kidney parenchyma becomes a locus minoris resistentiæ.

The recognition of an hereditary tendency in certain families is of much importance, for, as a result of its recognition, many undesirable sources of irritation of the kidney can be avoided.

The Prompt and Radical Cure of Syphilis. Syphilis and Mercury.-In the issue for the 15th of October, 1899, of the Belgian Presse Médicale, is a review, by BOULENGIER, of the third edition of Doctor Larrieu's work bearing the above title. The reviewer pronounces the book a scientific and critical study of the mercurial treatment of syphilis; that its author is neither a mercurialist nor anti-mercurialist, but that he seeks only to determine the mode of action of mercury, what doses of it to use and in what way to administer it. Inunction acts solely by means of the mercurial vapors absorbed by the respiratory tract; when these vapors are condensed into minute, metallic drops, they may even yet be absorbed through the respiratory mucous membrane and pass into the circulation; but then, as in the case of injections of liquid mercury under the skin or even in the blood, they may exert no dynamogenic nor therapeutic action, but may form little emboli or accumulate as larger or smaller drops in the organs, remain inert, encysted or act only as foreign bodies.

The curative effect of inunction is due solely, then, to the inspired vapor; how does it act? It is when, continuing to be absorbed and ceasing to be correspondingly eliminated, it passes into a liquid condition. This physical phenomenon gives rise to a considerable liberation of heat. This phenomenon, conjoined with the proved stimulation of murcurial vapor on the nervous system, is the whole secret of the incontestable effect of inunction on syphilis.

The author does not commend the gastric or hypodermatic exhibition of mercury or its compounds.

The smallest doses of mercury do not act as specifics nor anti-microbically but as bringing about the activity of the correlative exchanges of the organs. This salutary influence is not exerted solely in the syphilitic diathesis, but has given good results in chloro-anemia, in certain cases of Bright's disease, rebellious glycosuria, diabetes, etc. The author proves that other remedies besides mercury, especially iodin, can produce salutary. effects. So, without prescribing murcurials, ho formulates a treatment which he claims has assured lasting cures in from six to ten months. 1. Locally: (a) on papules, psoriasis or condylomata: Glycerole of starch

30 grams. White precipitate......

3 (0) On mucous patches in the mouth, gargles of sublimate solution, light penciling with nitric acid, mercury and the usual caustics.

2. General treatment:

(a) Early, every morning, three drops of the tincture of iodino, newly prepared with pure or sweetened water; (6) A teaspoonful of the following potion : Crystallized iodide of sodium...

20 grams. Distilled water ...

300 This treatment should be continued from five to eight months, fifteen to twenty days each month; after the fourth month reducing the number of days, per month, to fifteen.

The author ascribes the rapid action of the glycerole, used topically, to the combination of the iodin with the mercurial salt. It was long ago pointed out that serious accidents occurred, sometimes, when the iodin was used in internal treatment and calomel as a dry collyrium.

PATHOLOGY

Edited by George Blumer, M. D. The Central Nervous System in Leukæmia.- By Dr. Bloch and Dr. HERSCHFELD. (Zeit. für klin. Med., Bd. 39, Hft. 1 and 2.) The changes in the central nervous system associated with pernicious anæmia have received a great deal of attention. Those associated with leukæmia on the other hand have been studied in comparatively few instances. Changes have been found in the peripheral nerves, in the brain, in the cord, and in the meninges, associated with leukæmia. F. Schulze in 1884 first described degenerative changes in the cord associated with leukæmia. Eisenlohr, May and Muller have each described changes in the peripheral nerves associated with leukæmia. Most of these changes appear to have been due either to capillary hæmorrhage in the nerves or to the infiltration of the nerves with lymphoid cells. Changes in the brain in the nature of leukæmic hæmorrhages have long been recognized. Bramwell and Kretschy have reported marked cases of this character. Lymphomatous growths have been found in the meninges in association with leukæmia. Eichhorst has reported an exceedingly interesting case of this character, in which paralysis of the lower portion of the body was produced by pressure of the lymphomatous tumor situated in the meninges, upon the cord. W. Muller, Nonne and Kast have each reported cases of degenerative changes in ihe cord and medulla, associated with leukæmia. All of the cases hitherto reported of degenerative changes in the cord appear to have been of a rather scute character; that is, a parenchymatous degeneration.

The writers report a case of spleno-myelogenous leukæmia in a male child of eight months. At autopsy there was found to be in places a wel! marked leukæmic infiltration of the cord confined almost entirely to the gray matter and not especially associated with blood vessels. There

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