THE PROGRESS OF MEDIGAL SCIENCE.

SURGERY.

THE TECHNIQUE OF MAXILLARY ANTRUM OPERATIONS.

H. H. Curtis (American Medicine, Aug. 28, 1903) says that the first thing is to determine whether a second bicuspid tooth or molar is the cause of the disease, and whether the discharge is acute or chronic. Irrigations through the natural orifices should be given trial. If the natural orifice cannot be used, and a tooth is suspected as the cause, then a tooth should be sacrificed, and the opening utilized for the irrigation. It is quite easy to make obturators of varying shapes out of gutta-percha. A sheet of guttapercha is dipped in boiling water, wrapped around a pencil, and after having been properly shaped, held in cold water until hard. An excellent irrigating fluid is composed of iodine one drachm, pyrogallic acid one-half drachm, and a saturated solution of boric acid sufficient to make a quart. The alveolar puncture is made for inspection, not for drainage. If the tooth is not suspected, other modes of entrance should be sought. Too many specialists are content with making an opening in the canine fossa, and then employing irrigation. In acute cases this might prove sufficient, but in more chronic ones it is absolutely necessary to inspect and explore thoroughly with the object of determining the exact pathologic condition present.

When a radical operation has been decided upon the patient should be told that the length of time consumed in effecting a cure was very problematic, but after a short time he would be comfortable and could attend to much of the treatment himself. The periosteum should be divided and turned back, and a chisel used to enter the antrum. The opening should be made sufficiently large to allow of the entrance of the bone forceps, and with the latter instrument the fenestration is completed. Strong carbolic acid and alcohol should be successively applied. The cavity can be still further cleansed by means of hydrogen dioxide followed by normal solution. A gauze packing is then employed. After the granulation process has become well established, worsted should be substituted for the gauze, because it can be introduced through a smaller opening. After from two to four weeks the worsted packing can be stopped and the peg inserted. This method is capable of giving good results, but often fails. A better

operation is that in which after making the fenestration as already described an opening is made into the nasal fossa. The larger the nasal orifice, the better will be the result. After the bleeding has been arrested the antrum is lightly packed with gauze or wool, and the wound in the canine fossa closed by two or three sutures. The packing should be removed preferably under anesthesia, and if there is a foul discharge, the antrum should be washed out. The opening in the canine fossa need not be so large in this operation as in the preceding operation. The operation through the inferior meatus is advantageous because it requires no anesthesia. It is therefore particularly applicable to patients who are not good subjects for anesthesia. With the electric trephine the anterior third of the inferior turbinate should be removed, and the perforation made about a quarter of an inch above the nasal floor. The fenestration should be made very smoothly.

ABDOMINAL PAIN IN PLEURISY AND PNEUMONIA.

J. B. Herrick (Journal of the American Medical Association, Aug. 29, 1903) says cases may occur in which at first it may be impossible to say whether the trouble is abdominal or thoracic. Each case must be judged on its own merits, and the decision as to immediate operation or waiting not settled by any hard or fast rule. Certainly in some doubtful cases with threatening abdominal symptoms it would be better to err on the side of operation and make a laparotomy than to let a possible ruptured appendix, gallbladder, stomach, or intestine go untreated for six or twelve hours. An exploratory abdominal incision could, perhaps, be made under local anesthesia or under laughing-gas. This would avoid the danger of adding bronchitis or aspiration pneumonia to an already existing pulmonary inflammation if such happened to be the primary trouble and the peritoneum is found normal. If peritoneal trouble is found ether or chloroform anesthesia can be added, and the reparative surgical procedure instituted.

But with care and circumspection doubt will seldom arise. The main safeguard in the diagnosis is to think of the possibility of a thoracic origin for the abdominal symptoms. It will then be generally found that there is some thoracic pain, as well as abdominal, or there will be cough or expiratory grunt, perhaps a bloody or rusty expectoration, or the respiration will be increased out of all proportion to the abdominal pain and tympany, or, as in Barnard's case, the temperature will rise too suddenly and too high for the supposed abdominal accident. These facts, if observed, will lead one to a careful examination of the chest,

which will in most cases, even early, reveal some loss of motion, friction, râle, dulness, or bronchial breathing that discloses the existence of an intrathoracic inflammatory condition, and makes it clear that the abdominal pain is a reflected one. The abdomen in these cases is often pseudo-tender; a light touch hurts. Quiet, steady, deep palpation with the flat hand does not increase the pain. And, as Barnard observes, at the beginning of inspiration there is a yielding of the abdominal wall that is seldom seen in true peritonitis. With care, then, most of these cases can be recognized.

FRACTURE OF THE PATELLA,

H. Baerlocher has published (Lancet, Aug. 15, 1903) an account of twenty-eight cases of fracture of the patella treated at the Cantonal Hospital St. Gall, Switzerland, from 1889 to 1902 by the same surgeon, Dr. Feurer. As regards etiology only one case could be proved to be due solely to muscular effort; in all the other cases there was a direct traumatic cause. There were two severe cases of compound fracture, and seven of comminuted fracture (Splitterbruch), but the majority were cases of simple subcutaneous transverse fracture. The operation was with one exception always performed within forty-eight hours after admission to the hospital. A longitudinal incision was made over the patella. The fractured ends of the bone were never found in apposition; they were often tilted, and in almost all the cases remnants of ruptured fascia or periosteum were found interposed between them. This amply explains the rare occurrence of bony union when fracture of the patella has been treated without operation. The joint having been sponged and carefully cleansed with sterilized material (Tupter), the fragments were united by sutures passed through the ruptured capsule and by parosteal, never by osteal, sutures. The leg was immobilized for an average of four weeks (from nineteen to thirty-four days); active and passive movements were then commenced, together with faradization of the muscles of the leg. In less than five weeks (from twentytwo to forty-two days) the patient got up and walked about. Twenty of these twenty-eight cases regained their normal condition. Two patients died from delirium tremens, one was discharged with ankylosis, and five had slighter complications. Dr. Baerlocher saw twenty of these twenty-eight cases, and took skiagrams of some of them. All these patients had practically useful limbs; they were in good health, and could continue their former occupations as laborers or handicraftsmen without any disability

whatever. It thus appears that direct suture of bone to bone can be dispensed with, and that the operation for fracture of the patella can be simplified.

PULMONARY EMBOLISM AND ABSCESS FOLLOWING OPERATION FOR APPENDICITIS.

Stone (American Gynecology, May, 1903) relates a case of operation on a previously healthy woman who had exhibited the characteristic symptoms of appendicitis for less than forty-eight hours. The extremity of the appendix, which contained a large fecal concretion, lay in a small collection of pus. The wound was drained. Symptoms of embolism set in suddenly fifty hours after the operation; the patient rallied after intravenous injection of saline solution. For a few days the patient did well, but the temperature and pulse remained above normal, although there was no evidence of peritonitis, and some pain was felt over the lower lobe of the right lung. On the eighth day after the attack an abscess ruptured into the right bronchus, causing severe dyspnea, collapse, and death within two hours. No necropsy was allowed.

Miller, discussing this case, thought that it was an instance of septic embolism. Bovée considered that lymphatic invasion explains such cases. He had observed it in a few cases which had died under nearly similar circumstances, though usually a little longer after the operation; the continuance of general febrile symptoms after the removal of the appendix was significant. Bovée believed that the secondary focus was present at the time of the operation.

THE SURGICAL TREATMENT OF FACIAL PARALYSIS BY ANASTOMOSIS OF THE FACIAL NERVE WITH THE SPINAL ACCESSORY.

At a recent meeting of the Paris Society of Surgery (Lancet, Aug. 22, 1903) M. Faure made an interesting communication upon this matter. He mentioned that the first operation of the kind was performed by Ballance in 1895. M. Faure recommended an anastomosis of the cut facial nerve with the trapezial branches. A lateral anastomosis could also be made of the trapezial branch of the spinal accessory nerve with the trunk of the facial after the latter had been refreshed, or the cut facial nerve might be united laterally to the refreshed trunk of the spinal accessory nerve. One or other of these operations had been carried out in fourteen cases; two of these were of too recent date for any deduction to be drawn from them. In none of the remain

ing twelve had there been absolute failure. In all the functions of the facial nerve had been more or less regained by means of the spinal accessory. Electrical reactions were established rapidly, but more power came back but slowly. Muscular tonus was always reëstablished more or less completely.

BULLET WOUNDS OF THE LUNG.

Koenig (Berliner klin. Wochenschrift, No. 32, 1903) made some observations, which he demonstrated by a number of clinical histories, as to active treatment of gunshot wounds of the lung with marked hemorrhage, and believes they should be treated similarly to hemorrhagic effusion of the joints. Shortly after the accident surgical intervention is seldom necessary. If in the course of two or three days, as his clinical histories show, dyspnea, fever, and cardiac depression evidence themselves, a thoracotomy should be made. Fever is usually due to a pneumococcus infection. In large hemorrhagic effusions this operation is advisable to hasten absorption. In performing a thoracotomy the strictest antiseptic precautions should be taken. If the effusion persists for months it may be relieved by repeated aspirations.

TETANY AND AUTOINTOXICATION.

Loebl (Wiener klin. Wochenschrift, No. 33, 1903) compared nine cases of so-called autointoxication with six typical cases of tetany, and arrived at the following conclusions: In typical autointoxications there is often found a number of the typical symptoms of tetany. In two-thirds of the autointoxications tonic cramps of the muscles of the extremities occurred, though they were not typical tetany contractions. Examination of the urine in tetany cases often showed disturbance of metabolism and. transitory acetonuria, albuminuria, and casts, although a chronic lesion of the kidney was not found in tetany. The author believes that tetany is a disease due to autointoxication, in which the toxins. have a special affinity for the nerve terminations of the muscles.

SURGERY OF THE PROSTATE.

P. Thorndike (Boston Medical and Surgical Journal, Aug. 13, 1903) discusses the present status of surgery of the prostate and concludes: (1) That no prostatic should be allowed to suffer for lack of proper treatment. (2) There is still a place for