A NEW METHOD FOR RESECTION Dr. C. Zatti, of Bologna, Italy, base of the coronid process of the head The surfaces of the bones are now joined, the forearm being placed in a position of semi-pronation and semiflexion, so that the forearm rests now at a right angle upon the arm. The partic-gards the function of ankylosed forearm. ulars of the procedure are: The posterolongitudinal incision is made, followed by separation of the soft parts and the periosteum; the articular extremities are then exposed and dislocation produced, after the method of Langenbeck, the humerus being fixated by an assistant. A line is drawn which unites the lowest point of the external condyle with the lowest point of the internal condyle. This horizontal line divides. the posterior inferior articular surface of the trochlea in its median part. After this line has been marked out, the saw is conducted through it, being held obliquely, so to bring it out anteriorly at the inferior border of the coronoid cavity. Thus a surface is obtained which forms with the longitudinal axis of the humerus as an acute angle of forty-five degrees. If, however, the morbid process should involve more than the articular processes, the resection may be practiced more extensively, with the same facilities and equal results. As regards the bones of the forearm, the saw is applied about 1 cm. below the apex of the olecranon, and carried through obliquely below the articular cartilages of the glenoid and sigmoid cavities to come out at the The author finally remarks that this method of resection of the elbow-joint perhaps has been used by other surgeons, here and there, but as he has not found it stated in the textbooks, he thought it not inopportune to put it on record.-Annals of Surgery. TOTAL RESECTION OF THE CAR- a Dr. R. Gritti, Italy (Gazzetta degli Ospetali, No. 12, 1891), proposes method of performing total resection of the carpus in fungus of the carpal bones. The technique of the operation is as follows: The hand is washed carefully and rendered aseptic, the patient anæsthetized and an elastic ligature applied above the elbow. Two lateral incisions are made on the dorsum of the hand, one on the radial side, corresponding to the border of the second metacarpal bone, and the other on the ulnar side. They should extend from two centimetres above the lower end of the radius and ulna to two centimeters above the lower end of the radius and ulna to two centimeters beyond the heads of the metacarpal bones. These two incisions are then united by a central one running across the dorsum of the hand and forming with two preceding ones an H. This third incision severs the skin, the tendons of the second, third, fourth and fifth fingers from the extensor communis digitorum, that of the extensor proprius indicis, and extensor minimi digiti, and the nerves and veins of that region. The extensor longus pollicis is not cut, the tendon being drawn aside by means of a hook. The radial and ulna muscles are cut and left to themselves. This done, the severed tendons are separated into groups; firstly, the tendons of the extensor proprius indicis; secondly, those of the extensor communis digitorum of the second, third, fourth and fifth finfiers, and thirdly, that of the extensor proprius minimi digiti. Sutures are drawn through their ends in order that they may later be reunited without mistake. The ends of the radius and ulna are then sought for and sawed across slightly above the epiphyses, the saw being held a little more removed from the radius than the ulna. This must be done with great caution, in order not to wound the arteries and tissues beneath. The metacarpus is then cautiously detached in one single mass, care being taken not to open the sheath of the flexors or impinge upon the two radiopalmar arteries and the two palmar arteries. The pisiform and the unciform bones may be either enucleated or cut in two. On arriving at the trapezium the knife should be kept well up against the carpus in order not to open the articulation of the trapezium, with the first metacarpal, but be thrust in between the trapezium and trapezoid bones. Then the thumb with the carpometacarpal articulation remains undisturbed. Finally, the carpus is cautiously detached from its attachments below as far as one centimetre above the carpo-metacarpal articulation; the heads of the second, third, fourth and fifth metacarpal bones are sawed straight across and the carpus removed in one piece. The attending hemorrhage is usually but slight, as the palmar vessels remain uninjured. The sur face of the wound is cleansed and, if any sinuses or articular fungosities be present, they are curretted. The sur faces of the resected bones are then placed in contact and united by two metallic sutures, the ulna being joined to the fourth metacarpal and the radius to the second metacarpal bone. The ends of the tendons are then brought together and joined; firstly, the tendon of the extensor indicis, then those of the extensor communis digitorium, and, finally, that of the extensor minimi digiti. The tendons are not joined by simply bringing their cut surfaces together but by overlapping the ends by two centimetres. In this manner they are somewhat shortened, as the hand has lost some six centimeters in length. The wound is then closed, sutured and drained. After an antiseptic dressing has been applied the forearm is placed upon a well padded splint, while the hand is elevated by a cushion. The operation generally lasts an hour and does not present any especial difficulties. After the operation there is, as a rule, tactile insensibility of the dorsum of the hands and fingers. The writer then gives the details of three cases operated on, more or less successfully, by his method, and makes the following deductions: 1. The blood supply of the hand is not disturbed, as the arterial trunks running on the palmar surface of the hand are not cut. 2. The movements of extension of the fingers make their appearance generally about the tenth day. The movements of flexion are uninfluenced, although the hand is shortened about six centimetres. 3. The tactile sensibility, which is destroyed by the operative procedures, begins to be restored even before movements of the fingers are possible. It first appears in the cutis of the fingers and progresses up the hand. In one case it appeared ten days after the operation. 4. Bony ankylosis probably does not take place, but rather is a pseudo-arthrosis formed, which is more to be desired, as the freedom of movement of the hand is thereby greater than if an osseous fusion with immobilization would take place. In the first two cases operated on, there resulted an abduction of the hand, due to sawing the lower ends of the radius and ulnar straight across. Hence, the writer recommends holding the saw somewhat obliquely, in order to remove more from the head of the radius than from the ulna.—Annals of Surgery. VAGINAL HYSTERECTOMY FOR PELVIC SUPPURATION. Terrillon (Annales de Gynéc., November, 1891) spoke in favor of this extreme measure at a recent meeting of the Paris Société de Chirurgie. He has recently operated on four cases where there was old-standing suppuration, with exacerbations, hectic, and fistulæ in the rectum and vagina. In the first case the patient was twenty-seven years old, and had been ill for two years after a miscarriage. There was parametric infiltration under the parietes as high as the umbilicus, the uterus being firmly fixed in inflammatory deposit. Abdominal section was useless, the omentum could not be detached, and the intestines were so adherent that their liberation was not at tempted. At once, therefore, without removing the patient, the uterus was extirpated from the vaginal side. On the twenty-eighth day serious symptoms developed owing to retention of pus behind the vaginal cicatrix. The fever ceased when exit was given to the pus, but a vaginal fistula remained. In the second, a similar case, abdominal section was found impracticable, and eight days later vaginal hysterectomy was performed; tuberculosis existed. Cure was complete. The third case, aged forty-two, had been ill for nine years, and was troubled with a lichenous eruption, attributed by M. Besnier to chronic septicemia. Albuminuria, vomiting, and fever existed. Vaginal hysterectomy proved very severe, and much shock followed. Nevertheless, the patient recovered, and the lichenous eruption disappeared. Dr. Bollinger's experience in the Munich Pathological Institute from 1881 to 1886, and his further study of the question (Münchner Med. Woch.) has resulted in the following statistics as to the frequency of gall-stone disease: In Munich, 5.4 per cent.; Dresden, 7 per cent.; Basel, 8.8 per cent.; Strasburg, 12.3 per cent., or for the whole of central Europe, about 7 per cent.; so that out of every fourteen adults one is affected with gall-stone. The proportion of men affected stands to that of women as two to five for the first three cities, while the Strasburg statistics show that women are affected five times as frequently as men. The explanation of this is found in faulty dress, laced corsets, sedentary life, restricted mus cular work, pregnancy, etc., and as many of these conditions are prominent in advanced years, we find that from 25 to 35 per cent. of women over sixty years of age are affected with gall-stones. In the post-mortem of forty-five women with gall-stones there was found seventeen times, or 40 per cent., a constricted liver. The fact that in women under thirty years of age gall-stones are four times as frequent as in men, speaks more for the more tiguity of the head of the pancreas with the thoracic duct, which passes behind this gland and along the vertebral col An abnormal development of the pancreas would cause it to press upon the thoracic duct and consequently lead to its rupture and the passage of chyle into the peritoneal cavity. Rupture is not a necessary conséquence as extravasation might also take place by diapedesis. pathogenic influence of dress than of N. Y. Med. Record. CHYLOUS ASCITES AND CARCI NOMA OF THE PANCREAS. Dr. Santi Flavio, of Turin, Italy, (Gazzetti degli Ospetali, No. 11, p. 1891) says: All writers agree that the diagnosis of carcinoma of the pancreas is a matter of great difficulty. Prof. B. Mugnai in a recent monograph on the pancreas, (Collezione italiane di letture sulla medicina, Seeries v, No. 9) says that the diagnosis of this affection is "most difficult and rarely possible." Dr. N. Musineci, in a communication which appeared in the Gazzette degli Ospetali, Nos. 81, 82 and 83, 1890, came to the conclusion that a diagnosis in the majority of cases is hardly to be made, and that diagnosis by exclusion is the best method. Icterus, the presence of the tumor corresponding to the site of the pancreas, fat in the fæces and sugar in the urine are the most important symptoms. It would seem strange that a symptom so constant in these two cases should have been overlooked as yet by all observers. The writer is quite certain that it must have been present in many cases of cancer of the pancreas and yet passed unobserved. Ruggi (Giornale internazionale di scienze mediche, 1890) reports a case in which he noted the presence of ascites, but he speaks of this as of minor importance. In such cases the ascitic fluid might be largely serous and reqire the microscope to reveal the fatty globules.—Annals of Surgery. SPONTANEOUS DISLOCATION OF THE HAND. An example of this rare condition is. published in the Berliner klinische Wochenschrift, November 16, 1891, by O. Bode, who also gives a summary of the bibliography. The patient, a girl, aged fifteen years, who, in previous years had suffered from loss of power over the right side of the body, diagnosed to be hysterical in nature, came under treatment on account of weakness and deformity of the right wrist, which she attributed to the act of constantly turning a roller in the factory in which The writer calls attention to a symp- she was employed. So serious had the tom as yet unobserved in this disease, condition of her wrist become as to innamely, the presence of chylous ascites. capacitate her for her duty. On examAmong 3,233 cases treated from ination, a well marked deformity of the 1883-89 in the Ospedale Maggiore di right wrist was observable, presenting San Giovanni in Turin, Italy, there all the characters of a dislocation of the were only two cases of carcinoma of first row of carpal bones away from the the pancreas. Both of these were ac- articular surfaces of the radius and companied by chylous ascites; this ulna, the hand being displaced towards special form was not observed in any the palmar aspect, and the arm being other case. Hence, the writer does not shortened in the usual manner. Both regard it as a mere coincidence, but the dislocation and the shortening would explain its presence by the con- could be easily rectified, either by pressure on the carpal bones or by traction applied to the hand. Scarcely any pain accompanied the manipulation nor could any crepitation, callus, or inflammatory thickening be felt. The articular surfaces appeared perfectly smooth, no signs of caries being Miscellany. HEALTH DEPARTMENT OF Statement of Contagious Diseases WARD. Cases. Measles. Deaths. Cases. Scarlet Fever. Whooping Cough. | Cases. Diphtheria. Croup. Deaths. Typhoid Fever. Deaths. Cases. Deaths. Cases. present. The hand on the affected side for week ending January 1, 1892: The sputum 27. is collected in a test-tube or beaker and heated in a water bath for fifteen minutes. As the liquid cools, it is shaken, and the coagulated part carries Public Instituwith it to the bottom all the tubercle bacilli. The overlying liquid is opalescent and thin as water and can easily Last week.. be decanted. The cheesy sediment is then thoroughly rubbed in a glass mortar. In this method, one particle of the rubbed sediment contains about as many bacilli as another, and, the author claims, can in this way be used as a test as to whether the bacilli are increasing or decreasing in number in the patient's sputum. The author claims that this method is easier and quicker than that of Biedert.-University Med. Mag. Io 2 3 I 4 2 I I 3 27 3 3 143 10 4 312 I 2. 21 37 3 .. |