SURGERY.

By G. H. EDINGTON, M.D.

Treatment of Tuberculous Glands of the Neck with Minimal Scarring".?The disease is a local implantation, entrance being gained through the tonsil, and the treatment advocated is intended to attack the local condition, avoiding the unsightly scarring which results from a

cutting operation. The germs resist any agents or influences transmissible through intact skin,

e.</., percutaneous cataphoresis. The author, therefore, attacks the diseased glands by "cataphoric diffusion among them of nascent oxychloride of

mercury, developed in their midst by the electrolysis of metallic mercury held in contact with a small gold electrode." A small opening is made through the skin and into the gland, and into this opening is thrust a "sliver of amalga- mated zinc." This is the anode of a weak galvanic current (1?3 m.a.) which is turned on gradually, and maintained for a few minutes. The tract thus cauterised is kept patulous by impregnation of mixed oxychlorides of Zn. and Hg. The zinc electrode being withdrawn, an insulated gold electrode, with amalgamated point, is introduced, 2?10 m.a. of current turned on and maintained for ten minutes. The process is repeated at intervals of two or three days. The products of

dead bacilli and deposited chemicals drain through the sinus. The germicidal action apparently extends to the next gland in the lymphatic chain. The final result is the destruction of the tubercle bacilli, without necessarily

destroying all the gland-tissue not already destroyed by the disease. The

resulting scar is a mere point.?(G. Betton Massey in the Proceedings of Philadelphia County Medical Society, March, 1901.)

Subcutaneous Rupture Of Biceps.?Following on four cases in Von Bruns' clinique, O. Loos has brought together the statistical material on rupture occurring in the belly as well as in the tendon of the biceps. According to the conclusions drawn therefrom, it would seem that the common cause of the rupture is a stretching of the contracted muscle by the action of a strong force on the long lever formed by the fore-arm. The solution of continuity affects exclusively the long head, and mostly at

passage of the tendon into muscle ; ruptures of the muscle^ilone are rarer, and ruptures within the tendon are only very seldom met with. The aim of treatment is to favour the absorption of the effused blood, and

the approximation of the ends of the muscle so as to obviate atrophy. Union

by operation may also be considered. Prognosis is guided by the seat and

76 Abstracts from Current Medical Literature.

extent of the rupture. Of fourteen ruptures of the muscular belly of the long head, eight were followed by little functional implication ; of ten ruptures at the seat of transition of tendon to muscle, only two showed considerable disturbance as a result. Two cases of tendon-rupture showed, on the contrary, very great disturbance.?(Original paper in Bruns' Beitrage, abstract in

Centralblatt far Chirurgie, 1901, No. 13.)

Multiple Skin-Myomata.?The condition is very rare. Marschalko describes the case of a patient, aged 20. The tumours appeared with much itching. They were localised in one leg, both thighs, and in sternal region. They were very sensitive to touch, and patient also suffered, as is often

observed, extraordinarily severe spasms of pain twice or thrice daily ; the

spasms lasted some minutes.

Histological examination showed nothing new, but the observer believed that he had traced the origin of the tumours to the muscular fibres of the arrectores pilorum. No recurrence had been observed after excision.?(Marschalko, Monatshefte

fur prakt. Dermatologie, Bd. xxxi, No. 7, abstracted in Centralblatt fur Chirurgie, J 901, No. 18.)

Osseous Heteroplasty in the Closure of Defects in Skull.? Biidinger demonstrated the calvarium of a boy in whom he had, four years before death, implanted discs from the calcaneum of an old woman, in order to close the defects left by a tuberculous pachymeningitis.

In both places in question, hardly anything abnormal was to be recognised from the inner aspect of the skull. Even the branches of the middle meningeal artery had made a bed for themselves as usual. Externally were two shallow, dish-like depressions, in the deeper, middle portions of which the bone was thinned to about half its proper dimensions. The peripheral portions were equally thick with the rest of the skull, but somewhat irregular. A third small defect, which had purposely not been filled in by a bone-plate, appeared before death firmly filled in by bone. It was seen, however, after maceration, that while the gap had been diminished by about half by bone, the remaining portion was filled by a firm mass of fibrous tissue.

(The demonstration was given before the Medical Society of Vienna, in October, 1900, was published in the Wiener Klin. Wochenschrrft, 1900, No. 46, and abstracted in the Centralblatt fur Chirurgie, 1901, No. 19.)

Appliance for Use in Cutting Windows in Plaster of Paris. ?The appliance designed by Dr. Langemak, of Rostock, is designed to aid the surgeon in cutting a window in plaster of Paris applications, by marking accurately the seat of the desired opening. If no marker is used the window is generally cut too large, and this impairs the rigidity of the plaster case. A cork disc, with or without a needle or nail projecting externally, has

been used as a marker ; the cork, however, does not adapt itself to the uneven surface of bones and joints, and the surgeon's hand is apt to suffer by contact with the projecting nail or needle. Langemak's device consists of a disc of copper, 3"5 cm. in diameter and of

the thickness of a sixpenny-piece. In the disc are four slits extending from the margin to 3 mm. from a central opening. Into this opening is fitted a conical pin, made of brass, and measuring 3 cm. in length. The division of the disc into segments, by the slits, enables it to be adapted to any irregularity in the surface to which.it has to be applied ; the conical pin does not scratch the surgeon's hand ; and the apparatus, being made of metal, can be readily sterilised and applied to the wound direct, without the intervention of any dressing. lor use, it is held on the wound till one or two turns of bandage are taken

to fix it, after which it needs no further attention. The bandages readily pass on either side of the central pin.?(Centralblatt fiir Chirurgiet 1901, No. 20.)

Surgery. 77

Deficiency of Trapezius as a Cause of Congenital Upward- Displacement (Hochstand) of the Scapula.?W. Kausch com- municates the above from Mikulicz's clinique in Breslau. During the last year three cases of this displacement came into the clinique ;

in all of these, careful examination showed a deficiency of the lower segment of the trapezius. The cases otherwise resembled fully those described under the above name, and were, till the discovery of the muscle-defect, looked on as typical examples of Sprengl's deformity. Kausch has seen, in addition, two analogous cases outside the clinique ; but he is not permitted to give particulars of these. There were no reasons for looking on the trapezius-defect as secondary, or

as an accidental condition. He considers that the downward-dragging influence of the lower third of

the trapezius or the scapula renders it easy to bring the muscle-deficiency into an etiological connection with the displacement of the bone.

It is possible that, in a proportion of the published cases, the lower part of the trapezius has been affected. Accurate investigations into the integrity of this part of the muscle are very seldom made, and one cannot help thinking that a partial defect may be overlooked when not specially examined for, especially when complete integrity is not easily determined.

Details of the cases will be published later. The present note is intended only to draw attention to the condition of the muscle with regard to the

etiology of the deformity.?(Centralblatt fur Chirurgie, 1901, No. 22.)

Trichosis Lumbalis, associated with Spina Bifida Occulta. ?Spina bifida is found in many cases of trichosis lumbalis, and the condition was first described by Virchow. Kellner, of Hamburg-Eppendorf, now publishes a case of which the following is a summary :?

Boy, aged 14, an idiot, presented over the fourth and fifth lumbar vertebra? and upper part of sacrum a very well-developed tuft of hair. The circum- ference of the tuft at its base was 45 cm. ; diameter, 13 cm. ; and length, 30 cm. The skin of the hairy part was normal, neither thickened nor tender on pressure. The hair was pale and fine, was equally distributed throughout, and there was no recognisable vertebral arrangement. The tuft was present at birth, and grew in a fashion similar to that on the child's head, so that it required frequent clipping. By external examination, spina bifida could not be determined, but the Roentgen rays showed a complete cleft in arch of fifth, and a probable cleft in under part of the arch of the fourth lumbar vertebra. The paper is illustrated by two photographs and a skiagram.?(Centralblatt far Chirurgie, 1901, No. 22.)

Congenital Partial Deficiency and Malposition of Large Intestine combined with Acquired Stenosis?This condition was discovered by Reinbach when performing laparotomy on a man, aged 35 years, suffering from stenosis of the gut. The detailed account of the case is given in Bruns' Beitrage, Bd. xxx, Hft. 1 The appendix, caecum, and ascending colon were not to be found. The much dilated small intestine passed into the large gut at a point to inner side of gall-bladder region. From here the

large gut coursed as transverse, and then as descending colon downwards on the left side of the abdomen, ran upwards again to the right as far as the gall- bladder region, bent there sharply downwards, and so passed from the right to the pelvis. Between the two limbs of this last segment of bowel?to be considered as the sigmoid flexure placed on the right side?there were stretched-out cicatricial bands, encroaching also on the parietal peritoneum. The lumen of the intestine was in all probability narrowed in the ileo-colic region, and perhaps still further at the apex of the (sigmoid) flexure. A cure

was obtained after anastomosis between ileum and descending limb of the flexure.?(Centralblatt filr Chirurgie, 1901, No. 23.)

Perihepatic and Pleural Complications of Appendicitis.? L. Lapeyre, of Tours, writes a lengthy article on the above in the Revue de

78 Abstracts from Current Medical Literature.

Chirurgie. In addition to his own experiences, he deals with the literature 011 the subject, and formulates the following conclusions :?

A. Pathology.?1. There are two varieties of pleurisy due to appendicitis? (a) Of pysemic origin by embolic infarction, and indifferently left or right- sided ; (b) by extension, always right-sided.

2. Pleurisies by extension (j)ar propagation) are most often purulent, but one

may observe serous or even chronic dry basal pleurisies. 3. These pleurisies always follow a subphrenic abscess. Subphrenic or

subhepatic abscess may exist alone (isoU). The pleurisy is the ultimate

complication by perforation of the diaphragm, or by extension through lymph channels.

4. The path of extension is always by the peritoneum?along the right parieto-colic sinus. The first, retro-csecal abscess may be at a distance from the appendix, but from this first focus there is uninterrupted continuity up to the diaphragm.

5. The parietal lymphatics play only an accessory part in the extension ; they guide the intraperitoneal collection along the parietes and the inferior surface of the diaphragm.

6. The appendix may be of the ascending type, or applied along the postero- external surface of the caecum.

B. Symptomatology.?The complication bears no relation to the intensity of the appendicitis. Often at the end of forty-eight hours a peritoneal infection, almost generalised, supervenes. The hepatophrenic phase is always preceded by symptoms of inflammation in right iliac fossa, with gradual invasion of the entire right side of the abdomen from the fossa up to the hypochondrium. This invasion is accompanied by general malaise. Then from fourth to eighth day is constituted the hepatophrenic phase (Dieulafoy) ; general symptoms are accentuated ; pain worst in right hypochondrium and almost always radiat- ing to right shoulder, aggravated by respiratory movements ; dyspnoea; stitch and troublesome cough, indicating inflammation of diaphragm. As occasional symptoms, hiccough, sometimes persistent, and icterus may

be present. Physical signs vary with subphrenic or subhepatic situation of the abscess. (?) Subhepatic.?Sometimes oedema of abdominal wall; enlargement of

subcutaneous veins ; deep swelling below false ribs may be observed, and sometimes even fluctuation. Dulness is continuous with that of the liver, which appears increased in volume.

(?) Subphrenic.?(Edema not generally present, and fluctuation impossible to determine.

Percussion and auscultation give signs very similar to those of purulent pleurisy.

Pleural phase?indistinguishable from the preceding?and the advent of pleurisy cannot be definitely ascertained. Aggravation of general symptoms, and of cough and dyspnoea will point to it.

Prognosis very grave?condition generally terminates fatally from fifteenth to thirtieth day.

Diagnosis between subphrenic abscess and empyema is very difficult. The absence of friction and of segophony would point to the former. This difficulty is not of great importance, as the pleurisy is only a complication of the subphrenic abscess.

Treatment. The only really efficacious treatment of subphrenic abscess is

preventive, i.e., removal of the appendix at the first sign of the infective process, say within the first forty-eight hours.

Treatment of abscess.?If pleura not apparently involved, vertical incision along external border of right rectus. This allows of examination of sub-

hepatic region. If empyema is presumably existent, then transplural operation, with resection of ribs, is recommended : in this way the two collections of pus ?pleural and subphrenic?are evacuated by single operation.?(Rev. cle Chir.t April and May, 1901.)