THE SURGICAL TREATMENT OF TUBERCU LAR CERVICAL LYMPH-NODES. Chas. N. Dowd, M. D., in the Annals of Surgery, July, 1905, in an article on the above subject, which is a study of 100 cases submitted to operation, states that there is a wide-spread feeling of uncertainty about the late results of operation, and there are many differences of opinion as to just what patients should be operated upon and just what kinds of operations should be done. After a study of published statistics concerning the course of the disease and the result of treatment, he has been impressed by three deductions, namely: I. The disease is a serious one, and often leads to tuberculosis of the lungs or other parts of the body. 2. The records after thorough removal of the nodes are better than those from their partial removal, or from palliative measures. LEONARD FREEMAN, M. D., continues downward along the internal jugular vein, also downward and backward toward the trapezius. The submaxillary and the submental groups may become involved later. The existence of a single enlarged gland in this central chain is evidence that others exist, and whenever one is removed, the region under the sterno-cleidomastoid muscle should be explored as a routine procedure. Dowd places great importance on the cosmetic result, and aptly says that the fear of unsightly scars may lead many to postpone the operation until the most favorable time has passed. For the reason that longitudinal scars stretch and thicken, and that transverse scars that follow the neck creases do not, and soon become practically unnoticeable, he advocates one or more transverse incisions, supplemented, when necessary, by a longitudinal incision posteriorly at, or near, the hair 3. The prognosis is better in children line. The only objection presented against than in adults. As an etiological factor, heredity seemed less important than environment. In 86 per cent. of the cases the infection atrium was in the throat or the naso-pharynx. The bacilli may pass through the mucous membrane and infect the lymphatics without leaving visible evidence of their transit. In cases of difficult diagnosis, Dowd recommends a removal of one of the glands for microscopic examination, saying the scar need hardly be seen, and the method is surely more satisfactory than is the injection of tuberculin. The upper nodes of the deep cervical chain of lymphatics are usually the first to be affected, and from here the infection the usual anterior, longitudinal incision, is that the cosmetic result is not good. The author does not approve of the removal of the nodes en masse together with the surrounding tissue, as though they were cancerous. Important structures are injured in this manner. Only so much of the adjacent tissue as has been infiltrated with tubercular inflammation should be removed. There are three structures which are liable to be damaged in the operation which must be studiously avoided, the internal jugular vein, the spinal accessory nerve, and the lower fibres of the facial cision and isolation of the vessel early in believe that the operation would not be the operation. endured. The spinal accessory nerve may be mistaken for gland capsule or a branch of the cervical plexus. The nerve should always be saved. (When assisting the late Christian Fenger in these operations, the editor learned to identify this nerve by pinching the suspected tissue with a pair of forceps; if it was the nerve there would be a twitching of the trapezius.) An unsightly paralysis of the lower lip sometimes follows incision in the neck below the border of the jaw, due to a division of the lower fibres of the facial nerve. The sterno-cleido-mastoid muscle need not often be divided. In this series of cases it was divided sixteen times, much less frequently in the later than in the earlier cases. Dowd has never seen disability or torticollis follow its division. Drainage as a routine measure will be advisable, small; a few strands of silkworm gut makes a good drain. Subcuticular catgut stitch is recommended. The records of operations justify the following assurances : In favorable cases—Safety of the operation, many operators report more than 100 cases without mortality; a scar that is hardly to be seen; probable confinement to bed of two or three days; the wearing of a bandage or dressing from 11⁄2 to 3 weeks; freedom from recurrence in about 75 per cent.; and ultimate recovery in about 90 per cent. of the cases. In less favorable cases-Less disfigurement from scars than a discharging sinus will cause; freedom from recurrence in 50 to 55 per cent.; and ultimate cure in 70 to 75 per cent. of the cases. It is not feasible to divide the cases into groups, some suitable, others unsuitable, for operation. Every case with tubercular cervical nodes should be operated upon unless there is a particular reason to The article is splendidly illustrated. THE CHRONIC COMPLICATIONS OF CHOLECYSTITIS. In the Medical Review of Reviews for July, Robert T. Morris contributes some concise comments upon this subject. He says that so many have webs of adhesion in the bile tract region, that post-mortem examiners get to consider the condition as almost normal. He likens these adhesions to those of the pelvis in the female, and to those occurring in the region of the cecum. The presence of these "cobwebs in the attic of the abdomen" is explained as follows: In a case of so-called acute indigestion, the rapidly increasing bacteria of the bowel are carried to the liver by the portal vein, and there cause an attack of acute cholecystitis. This infective invasion of the mucosa, of the subperitoneal structures of the biliary passages results in a desquamation of the endothelial cells of the peritoneal surface, and is replaced by connective tissue adhesions. These by connective tissue adhesions. adhesions spread in all directions and are responsible for a multitude of symptoms. In other cases, however, they present no symptoms. Morris dwells upon the importance of tenderness, over the lumbar ganglia, about an inch on each side of the navel near the spinal column. In eye strain cases neither one of the lumbar ganglia is hypersensitive on pressure. In loose kidney and involution of the appendix, the right lumbar ganglion is very tender on pressure. In pelvic irritation both lumbar ganglia are tender on pressure. In gall bladder cases neither one of the lumbar ganglia is tender on pressure. Spasm of the muscles of the abdominal wall may also aid in the diagnosis. Persistent discomfort at the "pit of the stomach" is characteristic of these cases. It may disappear for a day or two occasionally, but usually these patients say that they are aware of this discomfort day after day for months and years. Tenderness over the region of the gall bladder is usually present. The treatment consists of the separation of the adhesions and the removal of the gall bladder. In concluding he says: "In infection of the appendix, surgeons used to wait for abscess before operating. In infection of the gall bladder, they often wait until they are sure of the presence of gallstones before operating." F. G. C. SURGICAL TUBERCULOSIS. Mayo (Journal A. M. A., April 15, 1905) calls attention to the comparative frequency with which tuberculosis occurs in the abdominal cavity. In 1,888 operations for appendicitis, the Mayos have found localized tuberculous disease of that organ twenty-nine times. Kelynack, in 121 cases of cirrhosis of the liver, found that 10 per cent. had tuberculous peritonitis. That infected particles are carried to the liver for destruction is further shown by the embolic pneumonia which often follows gastric operations, on account of the communication through venous anastomosis about the cardiac orifice of the stomach, although its main channel of venous return is through the portal system. The liver and intestines under equal conditions are not subject to this disaster on acount of their limitation to a portal circulation. Woodhead, in 127 autopsies in children dead of pulmonary tuberculosis, found 100 with tuberculous mesenteric glands. In very many cases of tuberculous peritonitis in women the author has been able to prove the presence of tuberculosis of the Fallopian tubes. In general, it may be said that this article tends to show that tuberculosis may not improbably originate, in many cases, in infection acquired through the intestinal tract, and that the bacilli either produce primary foci of disease within the abdomen or are carried by means of the lymphatics to more distant parts of the body. The practical lessons with regard to tuberculous peritonitis are thus stated by the author: "From the narrative of facts and observations so briefly set forth, I think we are justified in the belief that the failure of simple laparotomy and evacuation of fluid exudate in tuberculous peritonitis to maintain a high place in surgery is due to reinfection from lesions in the mucous. membrane of the Fallopian tubes, appendix or some part of the intestinal tract. We have been treating a symptomatic perdisease. That many times the infecting itonitis instead of removing the source of lesion can not be discovered is true, and it is equally true that not all cases can be explained in this way. Experience teaches that, under expectant treatment, many of the primary lesions are cured by natural processes. Simple laparotomy and drainage aids recovery in a remarkable manner. Radical operation on the primary lesions in tuberculous peritonitis will greatly increase the percentages of cures and prevent reinfection of the peritoneum. "In conclusion, it seems reasonable to suppose that tuberculous peritonitis has. its origin in a local focus in practically every case, as is the fact in septic peritonitis. Peritoneal reinfection may be prevented if the local focus can be removed. Whether the patient will regain and maintain general well being must depend to a large extent on whether the local focus thus removed is primary or secondary and, if secondary, as to the possibilities of a cure of the chief seat of disease." O. M. S. THE BLOOD COUNT IN SURGICAL AFFECTIONS. Souden (Medical Record, March, 1905), from a study of 1,400 blood counts in surgical diseases, reaches the following conclusions: 1. A relative percentage of polynuclear cells below 70 with an inflammatory leucocytosis of any degree excludes the presence of gangrene or pus at the same time the blood examination is made, and usually indicates good body resistance toward infection. 2. An increased relative percentage of polynuclear cells with little or no inflammatory leucocytosis is still an absolute indication of the inflammatory process, and the percentage is a direct guide to the severity of the infection. In children, where the polynuclear percentage is normally lower than in adults, there may be pus or gangrene with the percentage as low as 73. In adults a purulent exudate or a gangrenous process is decidedly uncommon with less than 80 per cent. of polynuclear cells and the probability of their presence increases with the percentage. 3. An increased relative percentage of polynuclear cells with a decided inflam matory leucocytosis is the typical picture in most cases of inflammatory lesions. In general, therefore, it may be said that a marked leucocytosis indicates a good body resistance in cases in which the polynuclear count is relatively high. That is, the percentage of polynuclear cells is an index of the degree of the inflammatory lesion and the total leucocytosis should always be studied with it in mind. O. M. S. ETIOLOGY OF FISSURE IN ANO. Pennington (Medical Record, June 10, 1905) discusses the various theories of the causation of this disease that have been universally taught and accepted and claims that they are at least in many cases erroneous. The author presents a more comprehensive etiology, one furnishing better reasons why the little ulcer occurs with such frequency and regularity upon the dorsal surface of the anal canal. He believes that the chief predisposing factor in the etiology of this disease is anatomic, and that the sequential location of the fissure is due to the support given to the anal canal by the sphincters and levatores ani muscles. After carefully considering the embryology and anatomy of the anal region, his conclusions are: I. The dorsal surface is the most fre quent location of fissure in ano, the anterior the next, the sides the least. 2. The dorsal surface receives the least support from the muscular cylinder that surrounds the anal canal, the anterior the next, while the sides receive the greatest. 3. Experimentally, with and without anaesthesia, a conical anal dilator, when forced into the anal canal, tears the dorsal surface first and almost universally, the anterior occasionally, and the sides rarely. 4. From the foregoing it will be seen that the sequential points of muscular weakness, experimental tears, and location of fissure in ano correspond. O. M. S. SCOPOLAMINE AS A GENERAL ANAES THETIC. March 8, 1905) gives a brief review of the E. Rochard (Bull. Gen. de Therap., various reports on scopolamine as a general anaesthetic. As a rule, two injections each containing 0.012 gm. (1/5 gr.) of bromohydrate of scopolamine and 0.12 gm. (2 gr.) of bromhydrate of morphine are employed within a quarter of an hour. The patient will soon fall into a natural sleep and after the second injection the reflexes will be diminished and general vaso-dilation will set in. For long er operations, scopolamine will often not suffice and it may be necessary to give the patient a few whiffs of chloroform. The anaesthesia often persists so long that the patients will not need an injection of morphine the following night to bring on sleep. It is difficult to say if the accidents which are reported from time to time are due to the scopolamine, to the operation itself, or the chloroform which had been used. The general congestion which is often seen demands care in stopping hemorrhage. O. M. S. DEPARTMENT OF OPHTHALMOLOGY: MELVILLE BLACK, M. D., Editor. THE IMPORTANCE OF THE CORNEAL TEM- the cornea that they find it difficult to CORNEAL THERAPEUTICS. Angus McGillivray, C. M., M. D., F. R. S. E., Dundee (The Ophthalmoscope, July, 1905), refers to the work of Michel and Silex in the determination of ocular temperatures. "Silex summarizes as follows: 'Taking all circumstances into consideration, we are justified in saying that the conjunctival sac has a temperature of 2°C., corneal lamella 10°C., anterior chamber 6°C., lens 3°C., iris substance 0.36°C., and center of the vitreous 4°C. less than the rectal or body temperature.' These figures agree approximately with those given by Michel. In all inflammatory affections, Silex found that the temperature was elevated as compared with the healthy eye: in hypopyon keratitis as high as 1.45°C., and in acute iritis 1.56°C." The author takes the position that since pyogenic micro-organisms grow best at about the normal body temperature, their growth is inhibited in the anterior segment of the eye until the temperature of this portion is raised by closure of the eyelids. He also contends that nictitation causes such constant movement of the bacteria and so cleans the surface of grow. Prolonged closure of the eyelids, as in photophobia and blepharospasm from exposure of the epithelial plexus of nerves, such as is found in superficial ulcerations and abrasions, raises the corneal temperature practically to body temperature, and thus the natural inhibiting action enjoyed by the cornea during health becomes impaired. The author's treatment of corneal ulcerations and abrasions consists mainly of allaying the pain and photophobia, so as to enable the patient to open the eyelids. freely, and thus restore normal temperature and nictitation. For this purpose cocain is advisable, but not in watery solution, because of its desiccating action upon the corneal epithelium. He dissolves the cocain in oil, and claims that thus used it has no deleterious action, and that the eye is made comfortable for several hours, when it is used again. The patient is able to keep the eye open and normal corneal temperature and nictation are restored. The following ointment is recommended: Lanolini, 2 drams. Hydrargyri oxid flav. 2 grains. Apply in eye three times daily. Medical Department for Moffat Road. Dr. L. E. Lemen and Dr. Hugh L. Taylor are now at work organizing a medical depart ment for the Moffat railroad. All along the line resident physicians will be in charge of medical affairs in the various towns. |