Epithelial Sowing; A New Method of Skingrafting.

F. von Mangoldt (of Dresden) has conceived a method of skin-grafting, to which he has given the name of "epithelial sowing," which, for ease of execution and certain other advantages, merits careful consideration.

The epithelial elements are obtained by simply scraping a healthy cutaneous surface.

For this purpose he prefers the external or internal surface of the arm. The chosen spot is carefully shaved and disinfected and then, with a sharp sterilized razor, held perpendicularly to the skin, the epidermis is scraped away until the papillary layer is reached. In this way a magma is obtained, composed of epithelial cells and extravasated blood, which is spread upon the surface to be treated and thoroughly pressed in with a spatula. This sowing is very simple in case of a fresh wound, provided that the blood has ceased oozing; but in case of an old or infected wound it is necessary to remove the granulations and thoroughly disinfect it.

In order to make sure that the epithelial elements adhere closely to the wound, it is advised to scarify it with a small and very sharp bistoury before spreading the scrapings upon it. The spot from which the epithelial has been borrowed is dusted with dermatol, covered with sterilized gauze and bandaged.

The grafted area is covered with strips of protective, over which an aseptic dressing is placed. The region from which the epidermis. has been removed resumes its normal appearance in a few days.

The transplanted area, during the days immediately following the operation, looks as if covered with a pseudo-membrane; it loses its primitive brick-red color and becomes yellowish gray, a change due to the coagulation of the fibrin. At the fifth to seventh day the fibrin begins to disappear and the color changes to bluish rose, the first sign of the proliferation of the epidermic the epidermic elements. Toward the middle or the end of the third week the surface is completely covered with epithelium.

After the fifth day the dressing is changed every two days, and the wound is gently irrigated with a sterile warm, normal salt-solution. After the tenth day boric acid is dusted on. The new epithelial layer is at first thin and glossy, later it thickens and begins to desquamate. This desquamation, probably due to the absence of the glands normally present in the skin, should be combated with ointments of fat or oil.

Not the least of the advantages of this

tissue are closed in by the new skin, as sometimes happens in grafting by the Thiersch method. Le Semaine Medical.

Nerve Suture and Regeneration.

At a recent meeting of the College of Physicians of Philadelphia, Dr. Thomas S. K. Morton presented a man, aged 34 years, who was admitted to the Pennsylvania Hospital, August 10, 1895. His left arm had been caught between a revolving wheel and its belt. An extensive crush and laceration had resulted. There was a wound of the inner aspect of the arm running from elbow to just below the axilla. The biceps was almost cut through, so also the triceps and brachialis anticus. The brachial artery was torn, the ulnar nerve cut across, and about two and a half inches of the median nerve stretched tightly across the wound free of all support save its sheath. A large chip of bone was bitten out of the inner aspect of the humerus. The main wound connected with a smaller one on the outer side of the arm. There were also several smaller wounds about the larger ones, and the whole extremity from axilla to nearly the wrist was much contused and "brush-burned." The arm below the wounds was perfectly cold and white and possessed no sensation except of the feeblest character in the median distribution. There was no radial or ulnar pulse.

Amputation was advised, but peremptorily rejected by the man and his relatives. Therefore, under ether, the wound was cleansed of considerable machine-oil and other foreign bodies; ends of frayed muscles and skin dissected away; the upper and lower ends of the brachial artery sought for and ligated; the torn muscles partially approximated by catgut sutures; the ulnar nerve carefully sutured with the same material; the whole cavity sponged out with 1:2,000 bichloride solution and then gently stuffed with iodoform gauze. No attempt was made to suture the cutaneous wounds. The arm was then done up in a copious gauze dressing wrung out of hot sublimate solution and placed under irrigation of the same in a position of slight flexion at the patient's side, while cotton batting and hotwater bags were kept constantly applied to the forearm and hand.

On August 12 the forearm had warmed up, and on the day following irrigation was suspended. On the 19th a feeble radial pulse could be distinguished and sensation in the ulnar distribution was fair. Wound had begun to rapidly fill with granulations. The exposed sheath of the median nerve had become covered with a mass of red granulations starting from its emergence from the tissues above and below the exposed portions. These increased

in bulk to half an inch in diameter and ultimately blended with those arising from the deeper portions to the height of the nerve bridge across the chasm of the wound.

Improvement continued uninterruptedly, and toward the end of September the wound finally closed. The cicatrix, while very large, does not at the present time interfere with free flexion and extension of the arm, although at one point attached to bone. The biceps and triceps are fairly strong and increasing in power. Sensation in the median distribution is perfect, and in the ulnar almost so and still improving. Annals of surgery.

Old Dislocation, With Fracture of the Neck of the Humerus.

At a recent meeting of the New York Surgical Society, Dr. B. Farquhar Curtis presented a boy, fourteen years of age, on whom he had operated four weeks after an injury resulting in dislocation of the shoulder with fracture of the neck of the humerus. The injury had taken place in November, but its severity was not understood, and until he saw the patient the treatment had consisted simply in putting the arm in a sling. Dr. Curtis found the head of the humerus dislocated below the coracoid process, and the surgical neck fractured. The arm was almost painless, but there was great limitation of motion. The elbow could not be raised from the side at all, scarcely any rotation was possible, slight antero-posterior movements alone could be made voluntarily at the shoulder-joint. Passive motion was somewhat more extensive. He made an incision, three or four inches long, vertically downward from the acromion, opening the capsule and exposing the head of the humerus. With a hooked instrument, like one described by Dr. McBurney, inserted into a drill-hole made in the upper fragment, he tried to replace the head, but the bone was too soft, the hook tore out so that the head could not be moved in this manner. He was, therefore, compelled to divide capsular bands freely wherever there seemed to be any tension, and by means of blunt instruments used as levers and with his fingers was finally able to force the head into the glenoid cavity. The shortening was considerable-two inches-the fracture was transverse, and he found it impossible to bring the fractured ends into correct apposition until he had removed about half an inch from each fragment. He then had broad bony apposition. The head of the bone was rotated inward, and as he could not rotate it outward he put the arm up in inward rotation, too. This explained why there is now greater inward rotation than normal, and outward rotation is limited. Primary union was obtained in ten days, slight passive movements were begun on removing

the dressing at that time, and were practiced more freely and systematically after three weeks. At present he could lift the arm fortyfive degrees from the vertical without motion of the scapula, and was constantly gaining. The attempts to secure motion had been interrupted for two or three weeks after he left the hospital by an accident to the elbow caused by a fall. It is now three months since the operation, and the functional result is excellent.-Annals of Surgery.

A Rare Sequela of Head Injury.

The

Gleich (Wien. med. Wochenschrift, May 23, 1896) records the following case. A man of 48 fell from a wagon and was run over; he did not recover consciousness till on the way to hospital, when he had no recollection of the accident, but appeared to have been drinking. There were two contused and incised wounds, one in the occipital region 14 inches long, but not reaching the bone; the other half the length, and implicating the auricular cartilage; both were covered with mud and filth. pulse was 56, and there was some paresis of both upper extremities. The scalp wound healed readily, that of the ear suppurated; the pulse improved, but the appetite was bad, and the patient became weaker. Four weeks after the accident, the ear wound being almost well, the man had a sudden rigor, with temperature 103.4 degrees Farenheit and pulse 80. There was pain over the temporal muscle, and slight swelling above and behind the mastoid process, with slight facial palsy and pain and limitation of movement in the neck. Next day the symptoms had somewhat improved, but he was still quite apathetic; the ear wound was apparently well. Sinus thrombosis or cerebral abscess following mastoid suppuration was diagnosed, and the mastoid was opened, 15 to 20 drops of thick pus escaping. The dura mater was apparently healthy, but as it showed neither pulsation nor respiratory movements, and area the size of a shilling was exposed without anything further being revealed. Nothing more was done, as it was considered that should fresh symptoms arise an extension of the wound would be very easy. Recovery was uninterrupted, and four days after the operation pulsation of the sinus and respiratory movements of the dura were observed for the first time. The patient, who had previously been morose, became cheerful, and though healing was slow, he was, at the time of writing, well except for slight paresis of the left upper arm. Gleich comments on the rarity of infection of the mastoid from a wound of the ear, and adduces this case as an instance in support of Bergmann's dictum that the limits of a cerebral operation should be not the skull bones, but the healthy dura.

Notices and Reviews.

The American Year-book of Medicine and Surgery. Being a yearly digest of scientific progress and authoritative opinion in all branches of medicine and surgery drawn from journals, monographs and text books of the leading American and foreign authors and investigators. Collected and arranged with critical editorial comments by J. M. Baldy, M. D., C. H. Burnett, M. D, Archibald Church, M. D., C. F. Clarke, M. D., J. Chalmers Da Costa, M. D., W. A. N. Dorland, M. D., V. P. Gibney, M. D., Homer W. Gibney, M. D., Henry A. Griffin, M. D., John Guitéras, M. D., C. A. Hamann, M. D., H. F. Hansell, M. D., W. A. Hardaway, M. D., T. M. Hardie, B. A., M. B., C. F. Hersman, M. D., B. C. Hirst, M. D., E. Fletcher Ingalls, M. D., W. W. Keen, M. D., H. Leffmann, M. D., V. H. Norrie, M. D., H. J. Patrick, M. D., William Pepper, M. D., D. Resman, M. D., Louis Starr, M. D., Alfred Stengel, M. D., N. G. Stewart, M. D., and Thomson S. Wescott, M. D., under the general editorial charge of George M. Gould, M. D. Profusely illustrated with numerous wood cuts in text and 33 handsome half-tone and colored plates. Philadelphia: W. B. Saunders, 1896. Pp. vi-17 to 1183. Price $6.50.

In the preface to this magnificent summary of the year's progress, the editor says: "The general design of the work is to give physicians in a compact form an annual epitome of the new and progressive medical truths or suggestions published during the months of the preceding year from July to June inclusive. It is at present almost or entirely impossible for the specialist, even as regards his own department, to keep himself conversant with the tremendous literature in all languages and in a thousand periodicals." The editor goes on then to draw a distinction between a "summary of medical progress" and the "literary review of all published matter," and adds briefly that he has not attempted the latter problem. Indeed, he says, "Thousands of excellent articles have not even been mentioned, because our task has been to epitomize our knowledge. not to review text-books (unless containing original researches, new suggestions, and so on) or to abstract articles not written for the sake of new truth. We have aimed only to mention those ways that are or may be contributory to the progress of medical science and art." That the design has been fully and satisfactorily carried out goes without saying when we have said that Dr. George M. Gould is the editor and that the following gentlemen have assisted him:

General medicine is cared for by William Pepper, M. D., and Alfred Stengle, M. D., both of Philadelphia; surgery by W. W. Keene, M. D., and John Chalmers Da Costa, M. D., both

of Philadelphia; obstetrics by Barton Cook Hirst, M. D., and W. A. Newman Dorland, M. D., of Philadelphia; gynecology by J. M. Baldy, M. D., and W. A. Newman Dorland, M. D.; Louis pediatrics by Starr, M. D., and Thompson S. West, M. D., of Philadelphia, Pa.; nervous and mental diseases by Archibald Church, M. D., and Hugh J. Patrick, M. D., of Chicago, Ill.; dermatology and syphilis by William A. Hardaway, M. D., and C. Finley Hersman, M. D., of St. Louis, Mo.; orthopedic surgery by Virgil P. Gibney, M. D., and Homer W. Gibney, M. D., of New York City; ophthalmology by Howard F. Hansel, M. D., of Philadelphia, Pa., and Chas. F. Clark, M. D., of Columbus, O.; etiology by C. F. Burnett, M. D., of Philadelphia, Pa.; diseases of the nose and pharynx by E. Fletcher Ingalls, M. D., and T. Melville Hardy, B. A., M. D., Chicago, Ill.; pathology and bacteriology by John Guitéras, M. D., and David Riesman, M. D., of Philadelphia, Pa.; materia medica, experimental therapeutics and pharmacology by Henry A. Grffin, M. D., and Van Horne Norris, M. D., both of New York City; anatomy by C. A. Hamann, M. D., of Cleveland, O.; physiology by J. N. Stewart, M. D., of Cleveland, O.;hygiene jurisprudence and chemistry by H. Leffmann, M. D., of Philadelphia, Pa. The departmental editors have not only made wise and judicious selections of material, but have in most cases given careful and studied criticism of the new suggestions and have passed the needed judgment upon matters in dispute. The department of general surgery, under the skilful handling of Drs. Keen and Da Costa of Philadelphia, is wonderfully complete and well written, and the critical comments of these able teachers make it delightful reading. The entire work is well illustrated, but chiefly with simple wood cuts. The paper and press work are excellent and no physician. can afford to be without the book. The chapter on general surgery alone is worth twice the cost of the book.

Rhymes of the States, by Garrett Newkirk, M. D., with drawings by Harry Fenn, after sketches by the author. New York: The Century Co., 1896. $1.00.

It is with peculiar pleasure that we acknowledge the receipt of this little volume for review, for every physician will certainly be glad to know that one of our number has written so

helpful a book for our children. Dr. Newkirk says in his preface: "It is no easy task to fix in mind the location, outlines, physical features and historical record of all the states of our American Union. The author has tried to reduce all these distinctive facts into the form of simple rhymes, easily impressed upon the memory, and accompanied by pictures which illustrate the ideas contained in the verses."

The verses are extremely simple but wonderfully descriptive. The sketches are truly artistic and many are particularly apt and suggestive and will undoubtedly aid greatly in impressing the geographical and historical facts. upon the minds of the youngsters for whom they are intended. Besides an outline map of each state, making prominent the name and location of the capital and other chief cities, there is given a caricature sketch of some animal or other object which the state might be said to resemble in form. In addition to the verses and pictures, which have appeared in St. Nicholas during the past two years, certain prose statistics are now published, greatly enhancing the value of the work for instructive purposes. Among the facts given in regard to each state are the area, the population, the rank of the state according to population, the number of counties, the representation in Congress, the number of electoral votes, date and location of first settlements, when admitted to the Union, value of chief industries, popular

name, etc.

The whole idea is quite unique and the book will be found equally attractive both to old and young. When we consider the number and quality of the illustrations we wonder how it is possible to publish the book for $1.00, for it is handsomely and durably bound and well printed on heavy calendered paper. The little volume will make an elegant and appropriate gift book and we predict for it a very large sale.

Blood Lavages in Surgical Infections.

P. Walton (Belg. Med., July 16) reviews this question. Dastre and Love have shown that a venous injection of salt solution, amounting to even two-thirds of the animal's weight, may be made without accident, provided the entry be slow and well regulated.

At 7 per cent, or even 10 per cent, there is no

toxic dose, but merely a toxic speed of introduction. Bosc and Vedel have shown that the addition of sodic sulphate to the solution has no advantages. By some surgeons enormous venous injections have been practiced. Lejars, in a septicæmic patient, injected 26 litres in five days without grave sequelæ. Michaux injects doses of 1,000, 1,500 and 2,500 grains a day. Péan and the author regard these as the maximum doses to be reached without serious risks, and Péan insists on the superior safety. of subcutaneous injections in prudent doses as opposed to intravenous injections. The question of their mode of action is difficult and complex. The first result of either method is to restore arterial tension to the normal, and to lessen the frequency of the heart beats. Secondly, diuresis is markedly increased. Michaux has seen a few slight and immediate consequences, dyspnoea and pain in the side, and in one case, where 2,000 grains were thrown in at once, abundant serous vomitings. Sometimes complaint is made of a feeling of heat and tension. For venous injections, which are preferable if a large quantity of fluid is to be introduced, Michaux uses a glass funnel furnished with a rubber tube, to which cannula No. 2 of Potain's aspirator is fixed. The skin is cleansed antiseptically, a cut made over the median cephalic or basilic vein, which is then laid bare, and its peripheral end closed with Péan's forceps. The cannula, previously freed of air, is introduced into a V-shaped opening made by scissors in the vein. A forcipressure forceps keeps the vein tightened over the cannula. The temperature of the injection varies between 38 and 40 degrees C. As to hypodermoclysis, unless very slowly performed, a painful swelling may be produced in the subcutaneous tissue. By introducing only about a litre an hour this is avoided. The skin of the abdomen is suitable, and a very fine trocar should be used. Colson has used the latter method in two desperate cases with great sucCase I: Male, 28, with articular abscess of right knee, temperature 40.7 C., dry tongue, delirium constant. Free incision, drainage and daily sublimate irrigations, a purgative, alcohol, quinine. After two days the temperature, which had fallen to 38.6 degrees, rose to 40.2 degrees C. Dry tongue, pulse 130, skin dry and burning, urine scarcely a pint daily. Subcutaneous injection of 1 litre of 7 per cent salt solution. Two hours later abundant sweating, sensation of comfort, more abundant urine. The next day the disquieting condition returned. Fresh injection of 1 litre. Renewed improvement of symptoms. The injection was repeated for five days, and recov ery ensued. In Case II the results were equally gratifying. Here 16 litres of salt solution were injected in the space of three weeks.-The British Medical Journal.

cess.