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sary an operation for relief, a shoe of proper fit only giving relief to the cases of slight deformity. Resection of the metarsophalangeal joint is often practiced, also a wedge-shaped or simple osteotomy of the metatarsal bone, which will relieve some cases, but does not narrow the foot or remove the bunion if it is present. He also mentions other operations that have been devised, but goes on to describe the method he has employed for a number of years with success.

Operation.-A curved incision is made base down over the inner side of the metarsophalangeal joint, the skin being lifted in the flap, which is separated from the bursa. A curved incision, "horseshoe," is now made around the bursa with its base forward left attached to the base of the first phalanx, its inner surface being synovial membrane and continuous with the anterior surface of the joint.

The head of the metatarsal bone is then removed with heavy forceps, the section also removing two-thirds of the anterior portion of the bony hypertrophy on the inner side. The remainder of this projecting bone is cut away to the level of the shaft of the metatarsal. The cut end of the metatarsal bone is now rendered as smooth as possible by Rongeur forceps and the bursal flap turned in to the joint area in front of the bone, where it is held in place by one or two catgut sutures. We thus utilize an already formed bursa to secure and maintain a movable joint

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which works in a movable splint-the shoe-and thereby secure an immediate result, which is obtained with difficulty in other joints by transplanting fatty tissue into the joint area to prevent bony union. In some cases the tendon and sheath of the extensor proprius pollicis is best displaced by suture to the inner side of the midline of the toe. Catgut drainage through the flap, and the incision closed with horsehair or catgut, with a pad of gauze wet with 70 per cent. alcohol, completes the operation. In about two weeks the patient is often able to go about better than before operation.

In criticising the technique of this operation we would say that the above method is one of the best in use. It insures a good strong foot, relief from pain and a quick result. The turning in of a flap of bursa between the opposing ends of the bones making up the joint, to prevent anchylosis after resection of the head of the metatarsal bone, is hardly necessary, as anchylosis will not result if only the cartilage is removed from one bone making up the joint. After operating on many cases where resection was necessary, without the use of the bursal flap, we have yet to see one case of anchylosis of this joint. The periosteum should not be saved with this resected bony growth, but be removed with the bone. gether, this is a most satisfactory operation for the relief of a painful and ugly deformity.

OBSTETRICS AND GYNECOLOGY.

UNDER THE CHARGE OF

WALTER B. JENNINGS, PH.B., M.D.,

Alto

Formerly Assistant in Gynecology, New York Post-Graduate Medical School; Attending Physician (O. P. D.) St. Mary's Free Hospital for Children.

Motor Car.

Axis Traction Forceps Dr. J. K. Couch Versus Telephone and has an interesting article in the August number of the Medical Gazette, Sydney, Australia, in which he protests against

hasty and unnecessary meddlesome obstetrics. He further urges that more attention should be given to palpation, auscultation and the general practice of abdominal examination, together with pel

vimetry. He says that during the greater part of normal labor the obstetrician should be away from the patient, because there was a tendency to unnecessary interference. He also states that one should depend on the telephone and the motor car to save his own time and prevent the unnecessary application of high forceps. [EDITOR. The title of this paper is rather unusual. That there is a tendency among some physicians to "hasty and meddlesome" obstetrics cannot be denied. Conservatism should be the bywordconservatism in all things, particularly in obstetrics-but each case is or should be

a study in itself, and the time of applying instruments must be governed by that individual case, not by minutes or hours. In a paper read before the New York Academy of Medicine ("Delayed Labor") the editor brought out this very point, the relative time of applying forceps.]

The Paravertebral Tri- Dr. F. Smithies angle of Dullness states in the October (Grocco's Sign) in number of AmeriPregnancy. can Journal of Medical Sciences that Grocco and others have demonstrated satisfactorily that when there is a collection of fluid in one pleural sac dullness may be determined by percussion on the opposite side of the spine. This dullness is roughly triangular in outline, the spinal column forming its vertical side. Paravertebral dullness is also obtainable in conditions other than simple collections of fluid in the pleural sac. Such is the case in lobar pneumonia when the consolidation lies near the spine and with various new growths which involve the tissues of the mediastinum. The triangular form is less distinct with the latter than with pleural effusion. Paravertebral dullness is also obtainable in various conditions which are extra-thoracic,

and among them the author mentions pregnancy. Of the six cases reported, five were pregnant between the eighth and tenth months and one at the sixth month. The dull areas along the spine were roughly triangular, with a hypothenuse which was more or less convex, and all were to the left of the midvertebral line. The dullness is due to the abdominal tumor, which displaces other viscera upwards.

cies.

Hyperemesis in Two Dr. H. Grad of New Successive Pregnan- York reports two cases (New York Medical Journal, October 24, 1908), in which he says in part:

That there are cases of toxæmia without marked hepatic changes has been shown, but these findings do not necessarily argue that the toxæmia does not depend on disturbance with liver func

tion. The formation of urea is a liver function, and if the organ fails to functionate, a disturbance in the metabolism. must occur. Disturbed function, however, does not necessarily mean anatomical changes. The histological changes in the liver cells may be very minimal, while the oxidizing capacity of the organ may be greatly at fault. As Ewing remarks: "The anatomical lesions certainly follow and do not precede the disturbance of function, and there may very well be several steps between the loss of oxidizing capacity and the hydrolysis of fatty degeneration and necrosis of the liver cells."

It is because of the inconstancy of the histological changes in the liver in some cases of toxæmia of pregnancy that Herz, in 1898, elaborated the theory of "functional paralysis of the liver." According to this theory the liver fails to oxidize the products of digestion into urea because the hepatic cells are functionally para

lyzed. This paralysis is not easily explainable. Herz asserts that such a hepatic paralysis can be brought about experimentally by tying the ureters. It has also been stated that hepatic congestion is a frequent accompaniment of suppressed menses, irrespective of whether this suppression of menstruation is due to amenorrhoea, castration, menopause or

pregnancy. As a result of this circulatory disturbance hepatic enzymes fail to be produced, but no structural changes in the liver cells need necessarily occur. Under such a condition the oxidizing capacity of the liver will be at its lowest point, and this hepatic incapacity may continue for some time before histological changes occur in the lobules.

Heart Disease and In the September
Pregnancy.

number of American Journal of Obstetrics, Dr. J. C. Cameron says that the physician should forcast the probable effects of pregnancy and labor upon his patients who are suffering with heart trouble, and that the obstetrician.

should know the extent to which endocarditis and chronic valvular disease may modify or derange the course of pregnancy, labor, and the puerperium in those whom he may attend. One must remem

ber that different forms of heart disease affect pregnant women in different ways, and that it is important to make an exact

diagnosis before beginning treatment. The majority of patients with heart lesions may bear a living child with safety, but each recurring pregnancy aggravates the heart lesion. A cardiac lesion may exist before pregnancy, the latter condition then being a complication, or the heart lesion may be latent and be developed by pregnancy, or it may begin during pregnancy or the puerperium, being then a complication of pregnancy. With regard to the degree of danger heart lesions during pregnancy may be considered in the following order: Mitral stenosis, aortic insufficiency, mitral insufficiency, either alone or complicated with stenosis or some aortic lesion.

PEDIATRICS.

UNDER THE CHARGE OF

LOUIS FISCHER, M.D.,

Attending Physician to Willard Parker and Riverside Hospitals, New York.

Alimentary Intoxica- Finkelstein (Lahrb.

tion in Infancy.
f. Kinderheilkunde,
Vol. 65, 1908). The author designates.
as alimentary intoxications the condi-
tions suggestive of acute poisoning, which
are of such common occurrence in the
course of the nutritional disturbances of
infancy. The characteristic features of
this intoxication, which permit a differ-
entiation from similar affections, are sup-
plied by the combination of the following
constant symptoms:

I. Disturbance of consciousness.

2. Increased respiration.

3. Alimentary glycosuria.

4.

Fever.

5. Collapse.

6. Diarrhoea.

7.

8.

Albuminuria and cylindruria.
Loss of weight.

9. Leukocytosis.

Glycosuria is never absent, and constitutes the excretion of milk-sugar and galactose derived from sugar-containing articles of food. The manifestation of the intoxication varies according to the more or less pronounced development of the individual symptoms, and also according to the possible combination with other symptoms (nervous phenomena of irrita

tion or paralysis; scleroma.) The most common type resembles cholera; the hydrocephaloid type follows next in order of frequency. The differential diagnosis

from the other severe nutritional disturbances, and numerous infectious diseases (meningitis, typhoid fever, etc.) is based especially upon the demonstration of sugar and the severe disturbances of the respiration as well as the consciousness. The symptomatology of intoxication closely corresponds to that of diabetic coma, but this hardly ever enters into consideration in the case of infants. The onset of the intoxication may be anticipated in the affections of the digestive tract not only, but in any disease which influences the organism as a whole; especially the bacterial infections (pneumonia, scarlet fever, sepsis.) A feature which all cases have in common is the severity of the general disturbance. The intoxication is the expression of deepseated changes in the metabolism. Besides the insufficiency of the sugar-combustion, a disturbance in the disintegration of the fat is betrayed by the presence of typical acidose; and there exists a pronounced toxic decomposition of albumin. conditions akin to this alimentary intoxication are the great revolutions of the metabolism, such as uræmia, cholæmia, and especially diabetic coma. The causes of the intoxication are poisons of the body metabolism, instead of bacterial poisons; but bacterial diseases may cause the disturbance of the metabolism in the first place. F. R.

The Frequency of Tubercular Infection During Infancy.

The

Sehlbach (Munch. Med. Wchschrft No. 7, 1908). The author arrives at the following conclusions:

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Embolism of the Right Garlipp (Charité Brachial Artery Subse- Annalen, Vol. XXX, quent to Diphtheria 1906). The patient and Terminating in Recovery.

was a child two

years of age who developed embolism of the right brachial artery in connection with diphtheria. The embolic plug probably originated from a heart thrombus, which is found, according to Barber, in about one-half of all fatal cases of diphtheria, often giving rise to great cardiac weakness. In this case the closure was complete, so that the child's arm and hand became cyanotic, oedematous and cold. However, only a few individual portions of skin and the terminal phalanges of three fingers became necrotic, because a sufficient collateral blood supply was promptly estab lished. F. R.

NERVOUS AND MENTAL DISEASES. UNDER THE CHARGE OF

WILLIAM B. NOYES, M.D., Attending Neurologist, Demilt Dispensary.

The Treatment of Brockært de Beule Facial Neuralgia by (Revue Hebd. de Operation. Laryng.d'Otol. et d.

Rhinol., No. 2, 1908). The treatment-symptomatic in the first place-should be directed as far as feasible toward the cause. When surgical interference is indicated, one of three procedures may be adopted: (1) Sympathectomy, which yields unsatisfactory. results, for the reason that the superior cervical ganglion is not the only vasomotor center, and the neuralgia has a tendency to recur, the other two cervical ganglia assuming the function of the extirpated ganglion. (2) Neuro-sarcoleisis (Bardenhener's method), which is a rational procedure on account of the resulting relief of the congestion of the nerve vessels, but the indications of which are very limited. It is applicable only for the supra-orbital, infra-orbital and maxillary nerve, when the cause of the neuralgia is referable to these peripheral branches. (3) Direct interference with the peripheral sensory transmission, which may be accomplished either by extirpation of the Gasserian ganglion a very difficult, dangerous and unnecessarily severe operation; by avulsion of the nerve trunks at the base of the skull, or by division of the posterior root, the simplest and least injurious of these procedures. It is essential that the sudden avulsion and rupture of the nerve be done as high up as possible in the close vicinity of the Gasserian ganglion, because this results in the most complete destruction and modification of the nerve cells. Immediate and complete recovery followed in 26 patients treated by avulsion of the

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nerves at the base of the skull, the cure still persisting at the end of two years after the operation. The neuralgia is controlled as the result of permanent degeneration of the nerve, which is put definitely out of function. F. R.

The

Alkaloid and a Glucoside of Valerian.

Pharmaco-dy- Chevalier (Bull. Gén. namic Action of an de Thérap., No. 21, 1907). An alkaloid, a glucoside and a resin may be prepared from fresh valerian roots, and must be considered as active constituents, since their manner of action corresponds to that of the juice of the fresh root. The alkaloid and the glucoside are very unstable substances, undergoing partial changes and disappearing even in the course of dessication of the plants or during the customary preparation of the pharmaceutical compounds obtained from the root of valerian. Hence the preparation is very difficult and demands a great deal of care. The effect of the glucoside is less marked than that of the alkaloid; it acts only upon the central nervous system, but not upon the heart or the vessels. The injection of small amounts of the alkaloids into frogs is followed by an increase of the reflex irritability, as well as by a certain sluggishness and mild paresis of the animal. Larger doses give rise to tetanic twitchings, followed by rigidity. The poisoned animals present a paralysis of the cerebral functions. In warm-blooded animals the alkaloid acts as a violent poison. Even 3 centigrams per 2 pounds weight of the animal have a fatal effect under symptoms of rigidity and progressive paralysis. After smaller doses the animal falls

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