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Tenotomy by the ola method.-Frederick Treves, F.R.C.S. (The American Journal of Medical Sciences, January, 1893).Mr. Treves points out that the original method of dividing contracted tendons, as for instance, that of the sterno-mastoid, was by raising a flap of skin and cutting the contracted band “from without inward." This was done in 1670 by Roonhuysen, of Amsterdam, and with certain modifications the practice continued until the commencement of the present century, when it was abandoned for subcutaneous division, which offered then the prospect of far better results. "The reason of all this was that an open wound was a terror to the conscientious surgeon. Healing by first intention was rare; suppuration was the rule. The dressings applied were to the bacteria of the time what a tropical climate is to vegetation. The fussy attention which gave the wound no prospect of being left alone, and which encouraged the pouring into it of oil and wine, took away the few remaining prospects of success. Surgeons have never been famous for the publication of their failures; but one can imagine the suppuration that took place in the tendon sheaths, the abscesses that ran riot in the connective tissue, the joints that were disorganised, and the limbs that were lost in those picturesque times, when the surgeon wore knee-breeches and a furred cloak, and when aseptic surgery was yet without form and void." Such was tenotomy in those times by the open method, a practice very properly displaced by subcutaneous division, but as the necessity which led to the invention of the subcutaneous operation no longer exists Mr. Treves is of opinion that with modern precautions the old method should be practised in most cases. In dividing the tendo Achillis he still prefers the subcutaneous incision, not because it is safer, "but because the tendon can be quite as well severed through a small incision as through a large." If, however, the position of the tendon or band be such that its subcutaneous division is attended with the least uncertainty, he freely exposes it by turning back a suitable flap of skin.
Excision and Arthrectomy of the Knee.-Arthur E. Barker, F.R.C.S. (Clinical Journal, Feb. 8, 1893).—The author gives a
clear statement of his views as to the operative treatment of tubercular disease of this joint, and describes the details of his method of removing the disease. Operative interference is advised in all cases that do not improve quickly under the routine treatment of rest, etc. A formal excision is not advised, but arthrectomy, even in cases where there is extensive disease of the bones, is recommended as giving better results, and obviating the shortening seen after excision.
Before operating on a knee that has become flexed an attempt should be made by splints and extension to restore the limb as far as possible to a straight line, for unless this rule is followed it will occasionally be found that after removing the diseased synovial membrane it is impossible to bring the limb straight without the division of some tendon, or even removing more bone. In all cases a week or two of rest in bed is recommended as a good preparation for an excision. Mr. Barker points out the importance of having firm union in a slightly flexed position so that the patient may tread on the front of the foot instead of the heel, and that in order to prevent disappointment in these cases we must remember two things-" 1st. That in adults, after removal of the encrusting cartilage of the femur and tibia, either in formal excision, or more partially in the course of an arthrectomy, bony ankylosis is almost the rule. 2nd. That in children the ends of the femur and tibia having very little osseous tissue, bony union is not to be expected. It is, therefore, necessary to treat the two classes of cases quite differently. an adult, where, at the end of an operation, bone touches bone, there will be very firm union in a couple of months, and most likely bony ankylosis. In such a case supports of all kinds, at the end of a couple of months or so, can usually be dispensed with without any risk of subsequent flexion." In young children supports must be kept on for years, the best form being a plaster of Paris case from the nates to the ankle. No pegging or suturing the bones is considered necessary. The fundamental principle of the procedure is the complete and rapid mechanical removal of all tubercular material from the joint, by careful dis
section, combined with voluminous flushing with sterilised hot water, conducted upon the most perfect aseptic principles possible, and followed by absolute physiological rest during the process of healing. Working on these lines the author has treated by arthrectomy many joints that a few years ago would have been considered only suitable for excision, for he considers that for the removal of the disease quite as much can be done with the gouge as with the saw, and that without loss of length to the bone. An iodoform emulsion is used over the field of operation; salicylic wool being the dressing employed.
The Treatment of Severe Club-foot -W. J. Walsham, F.R.C.S. (British Medical Journal, February 18th, 1893). This paper, read in the section of Diseases of Children, at the annual meeting of the Association at Nottingham, deals very fully with the subject; and, after the various methods in vogue have been discussed, the author draws the following conclusions:
1. "That in the treatment of severe forms of club-foot in the infant, our aim should be to act on the bones rather than merely to stretch or divide the soft structures on the inner side of the foot.
2. "That to accomplish this object, the varus defect must not be too quickly overcome.
3 "That when the varus is cured, the foot should, if possible, be carried at once, after the division of the tendo Achillis, beyond a right angle with the leg, there being no danger of non-union of the tendo Achillis,
4. "That when the foot, after the division of the tendon, will not come up to or beyond a right angle, it is the result not, as a rule, of contraction of the posterior ligaments or of the astragalus being partially tilted out of its socket, but of a downward deflection of the astragaloid neck.
5. "That attempts are best directed to overcome this deflection by acting on the bone rather than by division of the posterior ligaments or soft structures in the sole of the foot.
6. "That in exceptional cases, even in the infant, we can prognosticate from the first that neither the varus nor the
equinus will be thoroughly overcome without a bone operation.
7. "That for such-but only after gentler means have been perseveringly tried-and for confirmed cases in older children, astragalectomy-with, if necessary, the removal of a further portion or portions of the tarsal bones--is, on the whole, the best operation."
BY GEORGE HEATON, M.A., M.B.. F R.C.S.
Washing Out the Stomach after Operations for Strangulated Hernia.-H. Lund (Lancet, vol. i., 1893, No. 5)-Three cases of strangulated hernia are related. 1. A man, aged 22, with a strangulated right inguinal hernia of three days' duration, the vomit being extremely fæcal. The intestine was reduced, the sac removed, and the pillars of the external rings sutured together. The stomach was then washed out with warm water until the washings returned quite clear. The patient, after the operation, had no sickness or nausea, and made an uninterrupted recovery. 2. Patient aged 33, with a left strangulated inguinal hernia. After herniotomy, the stomach was washed out repeatedly. There was no sickness or nausea after the cperation. 3. Right femoral hernia in a patient of 46, which had been strangulated for seven days. The stomach, after the herniotomy, was washed out with nine pints of warm water, and there was no after sickness or nausea.
The author wishes to draw attention to the good effect of washing out the stomach freely after there has been fæcal vomiting. The treatment, though not new, is not sufficiently used in his opinion. He has seen one case where he felt confident that washing out the stomach might have saved the patient.
The Treatment of Malignant Tumours by the Inoculation of Erysipelas.-W. B. Coley, M.D. (Amer, Jour, Med. Sc., vol. cv., No. 5).—The author was induced to try the efficacy of inoculation with cultures of the strepto-coccus of erysipelas on cases of malignant disease by a case of Bull's, in which an accidental
attack of erysipelas in a patient, who was
suffering from a round-celled sarcoma of the neck, had been followed by complete disappearance of the tumour without any recurrence seven years later.
He gives details of ten cases in which such inoculations were given. Three of them were cases of carcinoma beyond the reach of operative interference, and in all three cases there was a temporary improvement. In none of these cases was an attack of true erysipelas produced, but each injection was followed by a local inflammatory reaction, followed by diminution of the tumour.
The remaining cases were sarcomata, Two of them--periosteal sarcomata of bone-were benefited, but not cured, by the injections; but in neither case was an attack of true erysipelas produced. Of the remaining cases the effect produced, when true erysipelas followed the injections, was most marked, and, in two cases, resulted in the complete cure of the patient with total disappearance of the tumour.
The details of one of these cases are as follow:-The patient, 35 years of age, had been operated upon by Professor Durante in Rome, and a second time by Dr. Bull, when it was found that the growth was too extensive to remove. He had a sarcoma of the tonsil, and extensive secondary growths in his cervical glands. Inoculations were made by injecting small quantities of bouillon cultures of the streptococcus into the tumour. Each inoculation was followed by constitutional reaction and slight diminution in the tumour. Some two months later, when the tumours had regained their former size, a fresh culture was obtained, and 5 decigrammes were injected. An attack of true erysipelas followed within an hour, the temperature rose to 105°, and in twelve hours a patch of typical rash appeared on the neck and extended over the face and head. The disease ran a usual course. The tumour began to break down on the second day and discharged caseous material. He gained rapidly in strength and weight. In two weeks the tumour had disappeared, and, two years after, there had been no recurrence.