THE GERMAN SURGICAL CONGRESS.

1349 decide to take neither course, but to describe himself officially as M.D. (late R.U.I.). He can obtain official information on the matter by communicating with the Right Hon. Lord Chief Baron Palles, chairman of the National University Commission, Mount Anville House, Dundrum, county Dublin, or with His Honour Judge Shaw, K.C., chairman of the Belfast University Commission, 69, Pembroke-road, Dublin. Each of these gentlemen, with a few others from both commissions, will sit together in Dublin on May 14th to decide questions that affect the two universities, of which the subject raised in the above letter is, we should presume, likely to be one.-ED. L.

the motor

ganglia

of the brain

chromolytic

alterations and

degeneration were found 72 hours after the injection. After ten days a degeneration of the cord, especially of the posterior column, was found. The direct injection of the compound into the spinal marrow produced at once a total destruction, whilst injection of a saline solution was harmless. Professor KADER of Cracow reported 1907 cases of spinal analgesia, of which 1853 referred to tropacocaine. The method was used in operations from the neck down in every region of the body. He used a 2 per cent. solution which must be

freshly prepared for every injection. The quantity of cerebrospinal fluid allowed to escape must be twice that of the solution injected. He injected whilst the patient was in a stooping position, but he was placed in Trendelenburg’s position immediately after the injection ; the quantity injected was 0 - 07 gramme of tropacocaine in operations on the pelvis THE GERMAN SURGICAL CONGRESS.1 and the lower extremities, 012 gramme in operations above that region, and 0 ’ 14 to 0 - 16 gramme in operations on the (FROM OUR BERLIN CORRESPONDENT.) neck. As a rule the patients showed no undesirable but in four cases death occurred on the operating symptoms, THE Congress of the German Surgical Association was held table. The operations sometimes lasted for hours. In elderly at Berlin from April 14th to 19th, Professor RUMMELL of greater doses must be avoided. In 81 cases general ] people Hamburg being in the chair. ] narcosis became necessary. Twice syncope was observed, ’

,

Anæsthetics.in five cases severe headache occurred, and in three cases Professor NEUBER of Kiel made a report on a collective paresis of the ocular muscles followed, which, however, investigation concerning Anæsthesia during 1908. In all (disappeared later. 71.052 cases were registered, in 24 of which, or about 1 in Dr. ERHARDT of Konigsberg stated that the arabates of 3000, death, occurred. The mortality in anæsthesia by the anaesthetic alkaloids travelled higher up the spinal canal, chloroform exceeded that caused by ether; the latter, and that more quickly than the hydrochlorates ; in animals however, more frequently produced post-operative pneu- a total analgesia of the body, including the cornea, was monia. Chloroform, which in Germany was formerly used obtained without paralysis of the respiration. in 75 per cent. of the cases, was now used only in Dr. HOREMANN of Rostock spoke on the treatment of the 25 per cent. The combination of oxygen with chloroform, after-effects of spinal analgesia. The most frequent comadministered by the Roth-Draeger apparatus, had not plication was severe headache, which sometimes was present been so successful as, it appeared, the author had hoped. for many weeks and seemed to defy therapeutic treatment. The least harmful method was the combination of scopolamin He made exact estimate of the pressure of the cerebro-spinal and morphine combined with the ether drop method. Anass- fluid in the horizontal position after the method devised by thesia should be produced rather slowly and should not be so Professor Quincke. When the pressure was too high a certain intense as to cause total disappearance of the reflexes, but quantity of the fluid was drawn off ; when it was too low only be so deep that no pain is felt and that no move- a certain quantity of a saline solution was injected, the ments are made. Irritation is thus avoided before and results being very good. during the operation ; moreover, the danger of pneumonia Staff-Surgeon Dr. KÖHLER of Berlin discussed the possiis considerably decreased. bility of local analgesia in a war. He said that, owing to the Professor BiER of Berlin read a paper on the Actual State of uncertain effect of the method and the difficulty of securing Local and Spinal Analgesia. He said that for local analgesia asepsis in war, general ansesthesia by inhalation was the injection of cocaine in small doses as devised by Pro- preferable for operation on the battlefield and in the field fessor Schleich was the surest method. Also a combination hospitals. of novocaine with adrenalin gave good results, and enough Operatons on ciir. Ureter. could be given to produce sufficient anaesthesia for the Professor GARRÉ of Bonn said that the most frequent removal of even the thyroid gland or the larynx. He then reason for operation on the ureter was incarcerated calculus described his method of intravenous injections in the limbs which was generally situated either at the upper end of which was lately reported in these columns. Concerning the ureter or near its entrance to the bladder. When spinal analgesia by injection into the spinal canal, he said the ureter was totally blocked no time should be lost but that failures were rather rare with a careful technique, an operation should be at once performed. An incision was but that undesirable sequels might occur. After the injec- made from the twelfth intercostal space to the anterior tion of tropacocaine and adrenalin headache occurred in superior spine. Through this incision the surgeon must get 6 per cent. of the cases and vomiting in 5 per cent. The at the calculus by the retroperitoneal way. The calculus method was indicated in operations on the pelvis and the might be felt when the ureter was reached. An incision was lower extremity. The simultaneous administration of scopol- then made in the ureter and the calculus gently removed. By amin with morphine was very useful ; it was contra-indicated introducing a probe it could be ascertained whether other in cases where local anaesthesia was possible and in patients calculi or strictures were present. The incision was then It was unadvisable to insert the suffering from cerebral and nervous diseases. It must, how- closed by suture. ever, be considered that the method was still in the stage of ureter in the surrounding tissue because kinks and strictures an experiment. were liable to occur. Drainage of the ureter was contraProfessor REHN of Frankfort had made experiments in indicated. In cases of incarceration of calculi near the animals concerning the influence of lumbar injection on the entrance of the ureter into the bladder the sectio alta" spine and the brain. To study the physiological current of should be made. The diagnosis of calculi might be made the arachnoidal fluid 2 cubic centimetres of a sugar by radiography or by cystoscopy. A second indication for solution with methylene blue were injected into the lumbar operation on the ureter was the presence of injuries, especially part of the arachnoid cavity of a horse, the result being that in gynæcological operations ; the diagnosis was as a rule the methylene blue was present after from 10 to 25 minutes uncertain, but when an injury was certain an immediate within the ventricles of the brain. It was therefore obvious operation was advisable. The ureter was made accessible in that fluids of high specific gravity were carried by the physio- the retroperitoneal way and the wound was closed by logical stream upwards to the brain. Tropacocaine, novocaine, fine silk sutures. When the ureter was completely divided and stovaine solutions were still present after three hours an oblique union of the ends was preferable to a circular within the arachnoidal cavity. In the urine the above com- suture. A lateral anastomosis might hinder the urine from pounds appeared after 10, 20, and 26 hours respectively, so passing freely and it was thus preferable to make an that stovaine was the latest to be discharged. In the cells of invagination of the renal into the vesical end. The suture of 1

Our correspondent received valuable assistance in the preparation of this report from the editor of the Deutsche Medicinische Wochenschrift, whose courtesy we wish to acknowledge.

the ureter was impossible within the true pelvis, implantation being the standard method in such cases. Implantation is further indicated in prolapse, in growths of the bladder,

1350 and in ectopia. When an implantation could not be done method of Keating-Hart was one of the best proceedings for the following procedures might be considered: (1) removal the treatment of cancer. Combined with excision and of the kidney ; (2) anastomosis of both ureters; (3) nephro- shelling-out it might not only relieve the patient but might stomy ; (4) implantation into the sigmoid ; and (5) implanta- eventually bring about a cure. After excision of the growth The third the wound was"fulgurated " and a scar was produced ; and tion of an organic tube instead- of the ureter. indication for operation on the ureter was stricture with con- later granulation and epidermis often developed. He also secutive hydronephrosis. In such cases either resection with recommended the administration of a radio-active salt obtained from the Kreuznach springs. oblique sutures or invagination must be performed. Dr. COHN of Berlin said that according to his experiences Dr. VoLKER of Heidelberg read a paper on the Diagnosis of Dilatation of the Renal Pelvis. He proposed to fill the the Keating-Hart method did not destroy cancer but pro. pelvis with a solution of collargol through the ureter and to duced a very quick cicatrisation. use radiography. The ureteral catheter must be impregnated Wo2cnd of the Pulmonary Vein. with bismuth, so that it gave a shadow on the radiographic Professor vorl EisELSBERG of Vienna reported the case of a plate. Stab Wound of the Pulmonary Vein. The vein was made accessible by temporary resection of the third and fourth a paper on Operations for Dr. NOTZEL of Diffuse Peritonitis. He said that the prognosis did not rib and the wound was closed by six sutures. The operation within ten minutes. The patient, who was depend on the species of bacteria present. As a rule the was completed to the hospital in a moribund and pulseless state, bacterium coli was found in peritonitis; streptococci if present conveyed did not mean a worse prognosis. It was important for a recovered immediately ; the pulse in the radial artery successful result to remember that the peritoneum, like all appeared as soon as the wound was closed and the haemorthe large serous membranes, was able to destroy great masses rhage stopped. Unfortunately, the patient died after six of cocci. The object of thetreatment was to remove the weeks from empyema, which was probably metastatic, the primary cause being multiple abscesses in the skin due to cause of the peritonitis, to get rid of the pus, and to provide for thorough drainage. Therefore every case of diffuse injections of morphine. (To be eontinued.) suppurative peritonitis was to be operated on, large incisions For removal of the Dr. Notzel recombeing necessary. pus mended irrigation, which, moreover, had a tonic action on the heart and the intestine. The Trendelenburg position THE DRAINAGE OF CAIRO. must be avoided, the pelvis, on the contrary, being lowered. (FROM OUR SPECIAL SANITARY COMMISSIONER.) Drainage should be carried out by tubes and the wound closed by sutures to restore the abdominal pressure ; the (Concluded from p. 1279.) drainage tubes might be changed on the second day and replaced by smaller ones. In cases of paresis of the The L’diceational Influence of Good Sanitation.—The Complete intestines enterostomy had not given good results ; eventually Abolition of Cesspools.-A zVe7v ,System of Connecting and puncture of the intestines by small trocars might be Disconnecting the House Drains n?ith the Servers.-Tke performed. Mosque Latrines and the Publio Latrines.—Religious Dr. NORDMANN of Berlin said that the better results now Teaching and Cleanliness. obtained were partly due to the early date at which operations Cairo, for appendicitis were undertaken. An exact diagnosis was HAVING described the general scheme in regard to the rather difficult. Of 75 cases which occurred during the last public sewers, it is now necessary to consider its bearings year, six were not operated upon and died; of 69 cases upon the population, which amounted, according to the census operated upon, 23 died. Rigidity of the abdominal wall taken in April, 1907, to 644,000 souls. For sanitary purposes was not an absolutely sure symptom of peritonitis, for it this population has been divided into an upper and a lower was found also in enteric fever, meningitis, and Addison’s class. The former consists of 50,000 Europeans and 50,000 disease. Fæcal fistulas were less frequent since plugging had Egyptians. Among the 544, 000 belonging to the lower class been abandoned. Dr. Nordmann argued against the use of -and I took care to make particular inquiries in this sutures, because the fascia might become necrotic and sup- respect-there are a number of Europeans. It would be a puration of the abdominal wall might occur. Multiple in- great mistake to conclude that the sanitary difficulties are, cisions were no longer performed. The mortality in cases of and will be, created only by native Egyptians. The latter, paresis of the intestines was 75 per cent. Enterostomy and i for the most part, are taught) by their religion to be clean, injection of physostigmine were useless. though they are quite ignorant of the principles of sanitary Dr. SPRENGEL of Brunswick said that he avoided irrigation, engineering. But the lower class European has neither the dry method giving better results. He also entered a religious nor any other education that would lead him to protest against infusions of saline solution as useless ; large make proper and decent use of any sanitary accommodation doses, according to him, prejudiced the cardiac action. afforded. Therefore there are many Europeans, notably Enterostomy had been abandoned by him. Greeks, Italians, and Maltese, who, by reason of their Dr. BORCHARD of Posen said that in cases of diffuse peri- dirty habits and tendency to overcrowd, cannot be qualified tonitis after appendicitis he gave, after the removal of the otherwise than as belonging to the lower class, judged from appendix, injections of from 50 to 100 grammes of olive-oil. the sanitary point of view. The drainage scheme is based The results were good. not merely on this dual classification, but on the calculation Dr. HEiLE of Wiesbaden said that after the incision of the that in the course of the next 25 years the population will peritoneum he made a puncture of the intestine and injected increase to 940,000, including an upper class of 160,000. about 50 or 100 grammes of castor oil to produce peristaltic Against this last estimate I would enter an energetic movements. The small opening was then closed by a suture. protest as being too pessimistic. Should it prove correct, Dr. ROTTER of Berlin said that he preferred to close the then one of the best purposes of such a drainage scheme will abdominal wound by sutures in appendicitis with peritonitis. have miscarried. It will be noticed that in these figures the He had only twice observed an abscess in Douglas’s pouch proportion of the upper and the lower class in the enlarged after this method. But in general diffuse peritonitis he population is maintained with something approaching to warned his hearers against sutures. mathematical precision exactly as it now is. But one of the Dr. KOTZENBERG of Hamburg recommended irrigation most fruitful effects of a general drainage scheme is its eduand injection of a vioform (iodochloroxy-quinoline) emulsion. cational influence on the lower sections of the population. To produce peristaltic movements he administered strychnine "Are your drains in order? " is the inevitable question which, in large doses. He took the opsonic index, which, according all the world over, the sanitarian, the social reformer, and the to him, was valuable for the diagnosis, but without value in Lady Bountiful have on their lips as they penetrate the slums, prognosis. bringing enlightenment, help, and sympathy to the least Cancer. fortunate sections of the community. Thus some even of Professor VON CZERNY of Heidelberg said that an opera- the poorest classes are taught the importance of sanitation, tion was still the best remedy for cancer, but that in in- and from the sanitary point of view are raised to a higher operable cancer other methods must be tried ; he hoped that class by their knowledge. If to-day one out of every six eventually when the etiology of cancer was ascertained a inhabitants of Cairo may be ranked as belonging to a saniserum would be found against the disease. Actually the tary upper class, after 25 years of object-lessons given by

Volklingen read