Removal tube and ovary and appendix for ruptured ectopic and chronic Removal tube and ovary for ruptured ectopic. Removal tube and ovary, myomectomy, appendectomy, for unruptured Removal tube and ovary and exsection one tube, ventro suspension, normal appendectomy, for ruptured ectopic.. Bassini operation for inguinal hernia... Bassini operation under cocaine for inguinal hernia. Bassini and appendectomy same incision, for inguinal hernia, chronic appendicitis.. Bassini for strangulated inguinal hernia. Bassini for strangulated inguinal hernia and uræmia under cocaine.. Bassini, double salpingectomy, appendectomy, myomectomy, ventro sus- Mayo operation umbilical hernia . Repair ventral hernia.......... Supravaginal hysterectomy for fibroid of uterus. Supravaginal hysterectomy and normal appendectomy for fibroids 4 7 Supravaginal hysterectomy for fibroids complicated by pregnancy. 2 1 1 1 Total hysterectomy for persistent metrorrhagia. Total hysterectomy and appendectomy for fibroid and chronic appendicitis Supravaginal hysterectomy for profound and continuous metrorrhagia of Supravaginal hysterectomy for intraligamentary fibroid and dermoid of ovary Total hysterectomy for rupture of uterus incident to forced delivery. Total hysterectomy for infected submucous fibroid. Total hysterectomy for carcinoma of cervix.. Total hysterectomy for sarcoma of uterus.. Colpo hysterectomy for complete prolapse. 1 Porro operation for fibroid obstructing delivery. 1 Suprapubic cystotomy for cystitis from enlarged prostatė. Suprapubic cystotomy for retention from enlarged prostate and uraemia. Suprapubic cystotomy and retrograde catheterization of urethra with Cholecystotomy and partial removal for gangrenous cholecystitis and gall Cholecystotomy and repair of hernia for gall stones and ventral hernia. Internal Alexander, appendectomy for retrodisplacement and chronic appendicitis... 215 1 2 1 Ventro suspension, appendectomy for retrodisplacement and chronic appendicitis. 5 Ventro suspension, appendectomy, salpingectomy for retrodisplacement, 1 Ventro suspension and myomectomy for prolapse and subserous fibroids.. Exploratory laparotomy and evacuation of pus for intramural abscess. Exploratory operation, negative. Exploratory operation for supposed abscess of liver, found to be syphilitic hypertrophy.... Exploratory operation for encysted peritonitis complicating double pyosalpinx, drained through vagina... Laparotomy for tubercular peritonitis. Appendectomy for tubercular peritonitis involving appendix. Exploratory operation for abdominal symptoms following railroad injury . 2 2 1 9 1 1 Exploratory operation for carcinoma of liver... 1 Exploratory operation for inoperable carcinoma of colon.. Exploratory operation for inoperable malignant tumor ovary 1 1 Incision and drainage for abdominal abscess, due to cancer. 1 1 1 Incision and drainage abscess of liver.. Nephrolithotomy for stone in kidney. Open operation for undescended testicle.. Abdominal incision and drainage pyosalpinx. Posterior gastro enterostomy for duodenal ulcer.. Gastrostomy for feeding in impermeable stricture of oesophagus Resection of sigmoid for volvulus. Resection of coecum and portion of ileum for intussusception and gangrene Laparotomy for stab wound of abdomen with profound hemorrhage. 1 Laparotomy for gunshot wound of abdomen with hemorrhage. 1 1 from mesentery in railroad accident.. Resection of small intestine and enterostomy for rupture and separation Abdominal drainage for ruptured pyosalpinx. Median incision and release of strangulation for strangulated femoral hernia KIDNEY CONGENITALLY MISPLACED IN THE PELVIS- BY JAMES W. HENSON, M. D., Richmond, Va. Professor of Surgical Anatomy, and Lecturer on Principles of Surgery, University College of Medicine, Richmond; Surgeon to the Virginia, and to the William Byrd Hospitals, and to City Home, etc. In February, 1909, the writer was called to see Mr. M., aged 22, who is a native o Augusta County, Va., and had been accustomed to outdoor life until he began the study of pharmacy some months before the above date. He was suffering with a throbbing pain, and pronounced tenderness in the abdomen, in the upper part of the left side of the hypogastric region. There was a little nauseanot much. Bowels were not constipated. There seemed to be no change in the quantity of urine and urinalysis disclosed nothing abnormal. No record was kept of pulse rate or temperature, but neither were much above normal. There was no rigidity of the abdominal muscles, but physical examination revealed in the region above mentioned, a distinct mass, very tender and apparently at that time about the size and shape of a small cocoanut. The acute pain gradually disappeared by confinement to bed for a week or ten days, with laxatives, dieting and counter irritation, but the tenderness remained and the size of the mass was practically the same for about two weeks after getting out of bed, when it very rapidly disappeared, the patient believed. He thought it had disappeared, because he was unable to find it. The writer was able to feel the mass distinctly, though it was very much smaller. There was a history of several previous attacks-not less than four or five, each having the following characteristics more or less rapid onset, acute throbbing pain in the upper part of the left side of the hypogastric region, lasting from three to ten days, pronounced tenderness in the same region, which did not subside for several days after the acute pain was relieved, nausea which was more pronounced in the first attack and least so in the last, apparently little elevation of temperature and apparently no abnormality in the quantity or quality of urine. The enlargement or mass was not noticed in the first attack, but in all the others its presence was manifest early, though it apparently disappeared several days after the subsidence of the more acute symptoms. The first attack, in the autumn of 1905, was just after a hearty supper. The patient says, that at no subsequent time did there appear to be any relation between diet, drinks or condition of bowels and the attacks. The writer gave no postive opinion as to the nature of the enlargement, but advised exploratory incision, to which the young man readily agreed. Circumstances necessitated deferring the operation which was done by the writer May 27, 1909. The mass proved to be a congenitally misplaced kidney lying in the true pelvis, chiefly to the left of the median line. Since we now describe the sigmoid flexure of the colon as reaching to the middle of the sacrum, the kidney lay behind the lower end of this portion of the gut and the upper end of the rectum. To reach the organ the right layer of the sigmoid meso-colon was opened. The ureter was necessarily very short. The pelvis of the kidney was distended to the capacity of three or four ounces, but there was left a good deal of functionating kidney tissue. Periodic obstruction of the ureter, of course explained the symptoms. Nephrectomy was done. The writer regrets that he was unable to make a thorough examination of the ureter and that the blood supply of the kidney could not be traced to its source. On account of the position of the organ, and its relations, the consumption of time necessary to such investigation might have been prejudicial to the welfare of the patient. As it was necessary to drag the kidney upward to get a ligature around the vessels, and as the pedicle was very short, the presumption is that the blood supply came from the internal iliac artery. As there was no thought at the time of reporting the case, the specimen was unfortunately not preserved. The writer has since decided to bring the case to the notice of the profession, has written to several surgeons and some anatomists to get statistics from their experience and observation and wishes to gratefully acknowledge the courtesy received from these gentlemen. It has been but a short time since some of the letters of inquiry were written, but replies have been received from the following: Drs. J. B. Murphy and Albert J. Ocshuer of Chicago, Dr. W. J. Mayo, of Rochester, Minn., Dr. Wm. Keiller, Prof. of Anatomy, University of Texas, Dr. George A. Piersol, Prof. Anatomy, University of Pa., Dr. Geo. Peterolf, Demonstrator of Anatomy in the same institution, and Dr. R. H. Whitehead, of the University of Virginia. All of these are men who have abundant opportunity for observing anomalies. Several of them mentioned cases of misplaced and displaced kidneys that had been observed, but only one, Dr. W. J. Mayo, had seen this viscus congenitally misplaced in the true pelvis. Dr. Mayo cited two cases, both women, each operated on for pelvic tumor which was tender and painful. In each case the tumor was a congenitally misplaced kidney in the right side of the true pelvis. The writer found one case in literature. Guinard, in a French journal in 1893, reported this case, stating that the left kidney was congenitally misplaced in the pelvis to the left of the rectum, that the ureter was very short and the blood supply came from the bifurcation of the aorta. The evidence obtained clearly establishes the fact that this particular abnormal position of the kidney is an extremely rare one. When this fact is considered in connection with the above clinical history, remembering also, that in Dr. Mayo's cases, the tumor was tender and painful, one is apt to reach the conclusion that such a position of the kidney or the relations of the organ in this position must have some etiological bearing on the pathology in this case. 152 INFANTILE HYPERTROPHIC PYLORIC STENOSIS. INFANTILE HYPERTROPHIC PYLORIC STENOSIS—A CASE— OPERATION-RECOVERY. By MCGUIRE NEWTON, M. D., Richmond, Va. Professor of Pediatrics in the University College of Medicine, etc. Since the awakening of the members of the medical profession to the realization of the fact that the results to be obtained warrant as much care in the diagnosis of disease in children as in adults, there have appeared many reports of diseased conditions in early life which were hitherto unknown, or considered very rare. Such is the history of hypertrophic pyloric stenosis of infants, for the first report of a case, which was made in the latter part of the eighteenth century, remained as the only description of the condition for nearly one hundred years, while recently reports of its occurrence have been so numerous, that it can no longer be considered as a rarity. Of the cases so far reported, a large majority have terminated fatally. Where autopsy has been possible, examination has invariably disclosed the pylorus to be much enlarged and resembling cartilage, owing to the marked thickening of its wall, which encroaches on the lumen and as effectively closes it, as if atresia existed. This thickening is the result of hypertrophy of its circular muscle fibers, there being little if any increase in its other component tissues, and there is no evidence of inflammatory or other pathological change. The congenital origin of this hypertrophy is not an established fact, and as no record has ever been made of its existence in foetal life, or in the new born, and as its first symptoms do not usually appear before the end of the second week, I am inclined to agree with those who contend that this is not a congenital condition and that, therefore, it should be known as infantile, rather than congenital, hypertrophic pyloric stenosis. As to the cause, nothing is definitely known, but there are such a variety of theories that the most fastidious can be satisfied. In light of the fact that in a number of cases which have been reported, as well as in my own, excessive acidity of the vomit was sufficiently well marked to attract attention, I feel disposed to believe that the primary cause is some disturbance in the secretory function of the stomach resulting in hyperacidity of its secretion, which by its presence irritates the pylorus, stimulating it to spasmodic contraction. This may be intermittent and finally give way, or it may be continuous, resulting in hypertrophy of its circular muscle fibres. In the one case there is functional spasm; in the other organic stenosis. I, therefore, believe that so-called simple pyloric spasm and hypertrophic pyloric stenosis represent the extreme forms of the same condition. However, different the views concerning its causation may be, the clinical history is so nearly alike in all cases that its description admits of but little variation. Vomiting is the most important symptom; it is always the first to be observed, and it persists until the obstruction is relieved. It usually begins in the latter part of the second or during the third week after birth of an otherwise healthy infant; occasionally, it has begun as early as the first week, and likewise it has been delayed as long as the sixth week. At first it occurs only once or twice during the day, but the frequency soon increases until it follows nearly every feeding; those meals which are retained do not pass into the intestine but remain to be vomited with subsequent feedings. Its characteristics are that it is forcible or projectile, often coming through the nose; it is unattended by nausea, coated tongue, or other evidences of disturbed digestion; immediate relief follows; the appetite is unaffected, and it is not influenced by alteration of diet or the administration of the usual remedies; the vomit contains no bile, and frequently is excessively acid in reaction. The other symptoms are dependent on the vomiting, and are: constipation, the stools being small, greenish yellow in color, containing no fecal matter, but consisting of the intestinal secretions; diminished amount of urine; and wasting, the patient losing flesh rapidly with the early development of marasmus. Physical signs of great importance are disclosed by inspection and palpation of the abdomen. Owing to the empty condition of the bowels, the lower portion of the abdomen will be observed to be flattened or sunken, while its upper portion is prominent on account of the gastric distention. Stroking or irritating the skin will stimulate peristaltic movements of the stomach, which are plainly visible and often violent, the appearance being that of a small ball, rolling obliquely from left to right beneath the thin abdominal wall. On firm palpation, in cases which have been going on for a week or more, the pylorus can often be felt, giving to the finger the sensation of an enlarged lymph node. Where these signs and symptoms are presented, the diagnosis of pyloric obstruction is easy, though it is often difficult to determine whether there is simple spasm with temporary stenosis, or hypertrophy with permanent stenosis. Favoring the diagnosis of simple spasm would be periods of intermission in the vomiting, which are accompanied or followed by increase in frequency of the stools, which often contain curds; slight if any loss in weight; disappearance for a time of the visible peristaltic movements; and inability to palpate the pylorus. When the diagnosis of hypertrophy is positive, there is but one treatment, which is surgical, and that should be resorted to as soon as possible, for with every day's delay the chance of recovery is materially lessened. Of the operations that have been tried, viz: gastro-enterostomy, anterior and posterior; divulsion; pyloroplasty; and pylorectomy, the posterior gastro-enterostomy seems to be the most favored, though each of the others has its champions. When hypertrophy has occurred, the time for medication has passed, but it is possible that our drugs may prove effectual in preventing this condition, if we make a practice of examining the stomach contents in cases of persistent vomiting in young infants and resort to remedies to correct hyperacidity where it is found to exist. Case.-H. G. L. Jr., white, male, four weeks old, was seen by me on June 11th, 1909, in consulation with Drs. J. D. Osborne and H. G. Leigh, of Petersburg, Va. Family history negative. From a study of the chart, which had been kept by an exceptionally intelligent and capable trained nurse, who was with the mother during confinement, I learned that the delivery was normal; that artificial feeding with modified milk was begun on the third day, and that the infant did uncommonly well for the first seventeen days. During this time there was no spitting, vomiting, colic, nor other evidence of digestive disturbance. There were two or three stools very day, which were normal considering the character of his food. With the exception of an occasional soap suppository no treatment has been indicated or used. On the eighteenth day he vomited twice; with the record of this is the note "acid in reaction. After this the vomiting persisted and increased in frequency and on the twenty-second day, or the fifth day of the vomiting, the nurse wrote "vomited five times; there is no rule of retention, sometimes the food is vomited at once; sometimes retained until after the next feeding." From this time the frequency varied from five to nine times a day, with the exception of one day when the vomiting occurred only three times. There had been a steady loss in weight, amounting to twenty ounces in fourteen days. Very little urine had been voided. The number of stools had been reduced and were usually the result of enemata, and with a single exception had been recorded as "small, greenish yellow with mucus." This exception was on the day following that on which vomiting occurred only three times, when a stool was described as "containing very little soft curd." The usual remedies and variations in diet had been used without effect. On observing the patient for several minutes as he slept on the nurse's lap, there was nothing to arrest attention, other than the evident emaciation. Inspection of the abdomen showed it to be sunken or retracted in its lower part, while in the region of the stomach there was an apparent fullness or distention. Efforts at palpating the pylorus were unsuccessful, but the act of palpation stimulated violent peristaltic movements of the stomach, which were plainly visible. The diagnosis of pyloric obstruction was made, but in the absence of the palpable pylorus we were unable to determine whether this was due to simple spasm or hypertrophic stenosis. We decided to resort to rectal feeding, using enemata of completely peptonized skimmed milk, and to allow nothing in the stomach other than normal saline solution for three days. When I saw the child three days later I learned that he had vomited very little of the normal saline, which from his appearance and increase in weight (ten ounces in three days) had evidently been absorbed from the stomach and carried directly into the tissues with the production of general edema. The amount of urine had been further diminshed for one day and then considerably increased. The changes in the stools had been such as would be expected with rectal feeding. Through a catheter introduced into the stomach a considerable quantity of fluid was withdrawn; as some of this was wasted it could |