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tions showed simple infiltration of the skin, whilst those of Daels reproduced the histology of the tubercle which he proved to be due to the presence of particles of dead bacilli in the tuberculin which he used. The tuberculin with which I worked had been thrice filtered through a Berkefelde filter of the fine flow and could, therefore, not have contained any of the particles of tubercles.
In one group of 24 cases, I applied both the human and bovine tuberculin by the scarification method. In 3 instances there was no reaction to either. In 9 reaction was more marked to the human; in 2 instances it was positive to the human and negative to the bovine; in 8 the reaction was the same in both, and in 2 instances it was more marked to the bovine. This latter point may be of no special significance, except that the bovine tuberculin is relatively weaker than the human, because the tuberculins are not prepared from weighed amounts. The cultures which are used are taken from the surface of the bouillon. The human culture grows much more luxuriantly than the bovine, in consequence of which the quantity of bacilli obtained is greater and will, therefore, produce a larger amount of tuberculin. Aside from this, in comparing these tests, I applied the human tuberculin to 2 points, whilst the bovine was applied to but one. I did this with the idea of acting to the disadvantage of the bovine tuberculin.
DR. WENTWORTH.-I would call attention to the positive reactions in the healthy cases. There are a good many tables published in the German literature of healthy persons giving a positive reaction. In one series one-sixth of the cases gave a positive reaction for the eye test and almost one-half for the cutaneous test. How they proved them to be non-tuberculous I am not sure.
Wolff-Eisner claims priority over Calmette for the eye test by several weeks. He referred to the matter in a discussion some weeks before Calmette published his article.
DR. L. EMMETT HOLT (closing discussion).-Dr. Park tells me that no deductions are to be drawn between the results of one man using 12 per cent. and another using i per cent. tuberculin, because it differs so in strength.
Regarding Dr. Wentworth's point as to a positive reaction in healthy persons, I wonder if he has seen the recent article in which statistics are given comparing the tests with an equal number of autopsies, the point being to determine the latent tuberculosis. In these cases the latent tuberculosis steadily rises from the first few months to past fourteen, and in the autopsy cases the frequency rises at fourteen years. We were very careful in our tests if we got a positive reaction to find out if the patient had tuberculosis or not. I would emphasize the importance of studying the sputum, going over the case again and again until certain.
Dr. Koplik raised an interesting point in connection with the possibility of getting the reaction in a non-tuberculous patient. That doesn't simply apply to the eye tests, but to all the tests. We are confronted with a difficult situation. We apply the tests and get a positive reaction; the child's symptoms clear up and he is apparently well; but that proves nothing, except that the disease he was having at the time was not due to a tuberculous lesion. I think it is important for the people to know so that they may be warned in time of the existence of a latent tuberculosis in order that they may take proper steps toward its treatment. We should apply the test in doubtful cases, but should be careful to discriminate between a latent tuberculosis and another existing infection.
A SIMPLE METHOD OF CIRCUMCISION IN THE
BY W. REYNOLDS WILSON, M.D.,
In carrying out the operation of circumcision in the newly born, simplicity in operation should be kept in view. By comparing the usual method with that about to be described it will be seen that the latter is to be recommended because it conforms to this requirement. Pursuing this comparison further we may note the disadvantages of the usual method, supposing this to be by clamping the prepuce and cutting away the redundant portion with a knife, the skin and mucous membrane afterward being secured by sutures. The first of these disadvantages lies in the incompleteness of the removal of the foreskin in instances where the latter is adherent to the glans. When the clamp is applied the prepuce becomes drawn forward in a roll; the knife may thus remove only a circular band of skin while that portion of the foreskin contiguous with the opening remains. This will, therefore, have to be trimmed away after removal of the clamp. It is, however, in the application of the sutures that the greatest disadvantage lies. The primary object of these is to secure the attachment of the skin to the mucous membrane. Incidentally the control of bleeding is accomplished by the pressure of the sutures. Unfortunately this is not always the case, and it may require a number of sutures to control the bleeding points. The sutures are thus placed irregularly and may have to be tightened to the point of unduly constricting the tissues. As a result edema occurs and the sutures begin to cut. The indentation of the coronal edge of the prepuce which follows and the persistent edema make the results of the operation unsightly. Should any of the sutures become infected a slough may form and the resulting granulation may be more or less difficult to deal with, owing to the adhesion of the dressing to the surface of the wound. The length of time also required for a painstaking suturing of the skin and mucous membrane prolongs the operation unduly, considering it as a simple operation.
In contrast to this the method about to be described presents many advantages. No claim for originality can be put forward in respect to this procedure, as it follows in technic that used in the Hebrew rite with a certain exception. According to the Hebrew method the foreskin is removed by a single sweep of the knife. This requires skill, and when properly done removes exactly that portion of the prepuce which has interfered with retraction. The writer has found, on the other hand, that it is more desirable to split the prepuce longitudinally on the dorsal aspect with a pair of sharp scissors. Preparatory to this the adhesion of the mucous membrane lining the prepuce to the glans is carefully broken by sweeping the point of the unopened scissors beneath the foreskin. Thus way is made for the introduction of the point of the scissors beneath the prepuce. The skin is first divided and the division of the mucous membrane to a point corresponding to the limit of the division in the skin follows. The mucous membrane is rolled back to the corona and rendered perfectly free. The scissors are now used to trim off the redundant fold of skin on either side of the incision. This is done carefully, while the field of operation is kept free from blood. The redundant roll of skin to the distal side of the frenum is likewise removed in order to avoid the edematous flap, which is often left at this point when enough tissue has not been removed. The skin is now drawn back and carefully inspected in order to deal with any discoverable irregularity in the cut edge. A tape of gauze, a half inch in width and cut so that the edges are frayed, is now applied, securing the roll of mucous membrane in position behind the corona and compressing the bleeding vessels. A tape of about ten inches in length is required in order to admit of several windings. The end of the glans should be left uncovered so that there may be no obstruction to the meatus. It is well to take in, however, the area just beneath the meatus in order to compress the severed frenal artery. One of the greatest safeguards against hemorrhage is to be found in using a coarse-meshed gauze cut with frayed edges in order that it may take up the blood and favor clotting. Over the gauze tape a dry gauze pad is placed and the napkin applied. The wrapping should be changed on the following day and daily thereafter. Otherwise the gauze, which becomes moistened by urine, may cause excoriation. After the second day, instead of the dry gauze, or that moistened by a mild solution of bichlorid or by boric acid solution, a gauze dressing thoroughly spread with vaseline should be applied. This will prevent adhesions of the dressing to the granulations. Should such adhesion occur it would lead to sloughing at the point of adhesion and consequently delayed healing. It is unusual for the swelling to persist after the second or third day.
The indications for the use of sutures in the usual procedure are the coaptation of the skin and mucous membrane and the prevention of hemorrhage. By the use of gauze wrapping the skin and mucous membrane are kept in place, while rapid granulation is favored by the even pressure of the dressing. The bleeding which results from circumcision in the newborn is usually slight, and a moderately firm gauze wrapping, when properly applied, is sufficient to control it. Thus the indications which suggest the use of sutures are fully met by the gauze wrapping. The chance of local infection by the irritation of the sutures when in place is also obviated by the more or less complete protection offered by the gauze.
The objection may be raised that this method is unsurgical, in that we are trusting to an insecure pressure to control hemorrhage and are substituting for sutures a displaceable dressing. These objections may hold in instances where the gauze tape is improperly applied, but only in such instances. Even the apparent unneatness of the dressing is not a valid ground for condemning it, as when the tape is properly cut and evenly applied, especially if it is applied after being moistened, its bulk may be kept within such limits as to make it a neat appearing dressing. If the tape is moistened it usually remains for twenty-four hours without being displaced, but in order to secure it the end of the gauze tape may be split and the two ends thus formed may be lightly tied, as in a finger bandage.
Dr. COTTON.-I believe I haven't circumcised a baby in eight or nine years, but earlier in our practice it was the fad to circumcise all male babies that would allow it. Twenty-five years ago I was invited to a ritualistic circumcision and I have attended a number since. That was the first operation I ever saw performed by a Jewish Rabbi and he did more circum