normal in both types. The presence or absence of flat foot should be noted. "In cases of central origin the reflexes, particularly the patellar and Achilles, will be found exaggerated, especially during or after a paroxysm, at which time also the Babinski reflex may be present. The pulse is normal, the vasomotor disturbances, as cyanosis, paleness or coldness of the skin, do not occur, and commonly there is imperative micturition with disturbance of the sexual function. This spinal form is also likely to end in spastic paraplegia, probably by thrombosis of the vessels with secondary softening, unless vigorous antisyphilitic treatment is begun early. Too much stress cannot be laid upon exaggerated reflexes in making a differential diagnosis, because they are generally increased from a lowered state of nutrition due to obliterating arterial disease without central involvement. "While in most cases the upper limbs usually escape, yet it must not be forgotten they may be involved, either alone or in conjunction with the lower limbs. In such cases the attacks are brought on by lifting, throwing and the like, or, as in Erb's case, by knitting. Even involvement of the tongue has been reported. "In a few cases where the condition has been present for a long time and the obliterative changes are well marked, the patient may complain of continual pain or tender, swollen calf muscles even when inactive and resting in bed. I believe some of these cases may have been presenile gangrene. Erb has reported such atypical cases, adding that activity, instead of aggravating the symptoms, causes their amelioration. Treatment is seldom satisfactory. The iodides should be given if there is a history of syphilis. the nitrites if there is ex bladder should be classed as a surgical rather than a medical condition, the fact that the patient usually is first seen by the physician renders the subject of the diagnosis of the affection a proper one for consideration here. The following points are given by K. W. Monsarrat (The Practitioner, June, 1908): The first symptom is acute but illdefined abdominal pain, usually about the centre of the abdomen, sometimes even over on the left side. In the course of a few hours, however, as in the case of the pain of an appendix attack, it settles down in the neighborhood of the inflamed organ, i. e., in the epigastrium and the right hypochondrium, The temperature rises and the pulse quickens. Here, as in other abdominal acute inflammatory affections, the pulse is the most important general guide to the acuteness of the attack. Abdominal rigidity is usually localized, the right rectus is held in strong contraction, while the rest of the abdomen is comparatively relaxed. The abdominal parietes move on respiration, but the movement is shallow. As the patient breathes the tender gall-bladder moves, and from the efforts to restrict this movement arises the peculiar jerky type of respiration to which I have already drawn attention. At the end of inspiration there is a characteristic catch in the breath, and periodically, when respiratory needs call for a deepening of inspiration, the gap ends in positive reaction was obtained, while in the case of erythematous lupus the reaction was negative. "If one can deduce conclusions of value from the results obtained in so few cases, it would seem that the following might be justifiable: "1. The ophthalmic test is an aid of some value in the diagnosis of tubercu an exclamation of pain. This respiratory type is quite unlike that of extensive peritonitis where the whole abdomen is rigid, or of an appendix attack in which respiratory movements are restricted, but not associated with the acute recurring stab of pain which the movement of the inflamed gall-bladder causes. When the attack is definitely established, percussion will usually reveal a distended gall-lous conditions of the lungs, but in many bladder, but during the earlier stages this sign will not be present. The rigid right rectus usually prevents one feeling the distended gall-bladder, but palpation will show on area of exquisite tenderness underlying the upper part of the right semilunar line. The Tuberculin Oph- H. H. Pelton (New summarizes and concludes as follows: "In summarizing the results it seems. best to deal with the dermatological cases separately. Of the other patients all those in whom the diagnosis was assured either by the presence of distinct physical signs or by the demonstration of the presence of the tubercle bacillus in the sputum, a positive reaction was obtained, although in some instances two or more trials were necessary. The two patients in whom a tentative diagnosis of pulmonary tuberculosis was made reacted negatively; the control cases also gave negative results. "Of the dermatological cases, in all those, six in number, in whom the affection was one of tuberculous nature-for while necrotic granuloma is not of itself a tuberculous lesion according to the dermatologists, it seems to bear a constant relation to tuberculosis-an undoubted instances is unnecessary since the diag- "2. In lupus vulgaris and tuberculides of the type of necrotic granuloma the ophthalmic reaction seems to afford a very material help in the diagnosis of the condition." in Diabetes. The Clinical Value of Hewes and Adler Ammonia Estimation (Boston Medical and Surgical Journal, May 7, 1908) concluded a study of this subject as follows: I. Quantities of ammonia reaching 5 gm. in 24 hours indicate an extremely severe form of diabetes, which usually proves fatal within a year. 2. Patients under 40 years of age tolerate an acidosis estimated in terms of 4 to 5 gm. ammonia far better than those above 50 years tolerate an acidosis of 2.5 to 4 gm. ammonia. An acidosis in an individual above 50 years of age is of very serious prognostic import. 3. A knowledge of the ammonia excretion usually helps in the treatment of a case of diabetes, and generally, but not always, gives warning of impending dan ger. 4. The value of a knowledge of the ammonia excretion in the prognosis of a diabetic patient is enhanced by a knowl edge of the quantity of albumin and carbohydrate in the diet. 5. A lowering of the carbohydrate intake in a severe case of diabetes from a total of 80 gm. to 55 gm. in 24 hours produces little effect upon the acidosis. GENERAL AND ORTHOPEDIC SURGERY. UNDER THE CHARGE OF EDGAR A. VANDER VEER, PH.B., M.D., Lecturer in Clinical Surgery, Albany Medical College; Attending Surgeon, Albany Hospital. Fig. 1. Fig. 1.-Showing normal anteroposterior appearance of lower radioulnar articulation. Note how radius is joined to styloid process of ulna by the strong fibrocartilage. Fig. 2.-Section of bone at usual seat of fracture. Observe the thickness of the anterior wall. Fig. 3-If a crushing force is applied at D E, at right angles to the plane A B C, the apex D A E will yield much more readily than will the base and sides D B C E. Fig. 4. Impaction. Tilting outward of lower fragment. The radio" ulnar articulation is intact, and the styloid process remains in place. Fig. 4. Fig. 5.-Impaction, slightly greater, of external part of bone. Fig. 6.-Great impaction. Tilting outward of lower fragment. of ulna. The radio-ulnar articulation holds fast. Fig. 7.-Shows tipping backward of lower fragment, and greater damage of posterior part of bone. This is the cause of the "silver-fork" deformity. Fig. 8.--Radial displacement of lower fragment, tearing off styloid process of ulna. of the lower inch of the radius, almost invariably due to a fall on the heel of the extended hand. The radius breaks here at its weakest point, where the cancellous into the lower fragment. The outer part of the bone suffers more than the inner, because the inner is held fast by the ulna, and hence it swings up and receives more of the force of the blow. Not until the styloid process of the ulna is broken and the triangular fibrocartilage is dislocated is the internal portion of the bone exposed to impaction. The fall is also usually on the radial side of the hand. The posterior or dorsal aspect of the bone usually suffers most, and this fact is thus explained by Ely: A section at the usual seat of Fig. 9.-Showing how tipping backward of the lower fragment causes the "silver-fork" deformity. fracture shows the bone here shaped roughly as a right-angled triangle, with the hypothenuse forward. When a force is exerted on a line parallel to the hypothenuse, midway between it and the apex, the apex will yield much more readily than the broad base. Such a force the transverse line of the carpus exerts. Again the bone in the anterior part is much denser than that in the posterior. ms. Fig. 10.-Diffuse swelling sometimes seen. Pressure backward of the wrist causes it to assume the "silverfork" appearance. Pain and disability were marked in a recent case; pressure on the lower threefourths of an inch of the radius causes pain, and the finger feels a break in the contour. In case of simple slight impaction there will be. nothing characteristic beyond swelling and thickening of the radius. Fracture of the carpus, most fre quently of the scaphoid, is often mistaken for Colles' fracture. The main diagnostic point here is the extreme sensitiveness over the broken bone, usually in the region of the anatomic snuff-box. The d:-ability is not so great unless there is also semilunar dislocation. If the X-ray is used it is well to test both wrists, and sometimes an old fracture of the scaphoid cannot be differentiated from a Colles' fracture. The prognosis without treatment is not usually good.. The main indication is to break up the impaction and keep the fragments in place. The notion that an impaction should be let alone cannot be too strongly condemned. Ely insists on its reduction under anæsthesia, not by traction, but by working the fragments backward and forward on each other until crepitation is felt. For a splint he prefers the plaster of Paris sider a favorable effect of the operation upon early cases as excluded. The question of operative interference may arise in cases of lukæmia in which the splenic tumor is very distressing to the patient. Contraindications for interference are an advanced stage of the leukæmia, severe anæmia and extensive adhesions on account of the risk of fatal hæmorrhage. A palliative operation is considered as justifiable by the author in the presence of severe local disturbances in mild cases, without extensive adhesions, and where the general strength is good. He reports a case cured in this manner, and in which the diagnosis of splenic leukæmia had been rendered. F. R. Excision of the Scapula R. P. Rowlando for Enchondroma. (British Medical Journal) reports a successful case of excision of the scapula for enchondroma, and concludes as follows: I. That for suitable cases excision of the body of the scapula, with preservation of the processes and glenoid socket, is a much better operation than excision of the whole bone, because it leaves à limb far more perfect from the functional and the artistic points of view. 2. That the operation is especially suitable for innocent growths, which fortunately and frequently leave the processes and the shoulder-joint unaffected. 3. That it may be adopted in preference to complete excision of the scapula for some small and for some slow-growing malignant growths without increasing the immediate risk of death, and probably without increasing the danger of either local or general recurrence. 4. That it may be occasionally suitable for inflammatory diseases of the scapula when the shoulder-joint is unaffected. 5. That it is wise to tie the three main vessels as early as possible in the operation, and that this can be easily done through a suitably-arranged posterior Tshaped incision. 6. That the success of the operation largely depends upon careful asepsis, the sewing of some of divided muscles together, and the early adoption of systematic active and passive movements of the shoulder. Gastroenterostomy. B. G. Moynihan of ical Journal, May 9) concludes as follows an address on gastroenterostomy and its results: 1. Gastroenterostomy is a short-circuiting operation, and, like all such procedures, acts best when a gross mechanical obstruction exists in the normal path of the intestinal contents. 2. Experimental work shows that when the pylorus is normal and there is no impediment to the passage of food through it the opening made in the operation of gastroenterostomy does not allow of the escape of any of the gastric contents into the intestine. 3. The operation, therefore, gives the best results in cases where there is organic disease in the prepyloric or pyloric regions of the stomach or duodenum, or when performed on the cardiac side of a stenosis in the body of the stomach. 4. When an ulcer is found on the lesser curvature towards the cardia it should be excised if possible; gastroenterostomy is not necessary, and if performed is either almost useless or entirely harmful. |