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A MODIFICATION OF THE WOLFE-KRAUSE METHOD OF SKIN-GRAFTING.
1405 undue raising of the price of articles of general " consumption by the " trusts of Roman times, the price of myrrh was fixed together with those of other botanical medicaments. Unfortunately, the figure at which it was ordered to be sold at as a maximum price is not legible in the copies which we have of the inscription. Epigathus used myrrh "post impetum (pituitae) lippitudinis," that is, to cure the mucous secretion of ophthalmia. He prescribes the same collyrium for aspritudines (which connoted the palpebral granulations of trachoma) which he considered it would remove, but in line 3 he proposes a variant remedy. This line, by reason of the new word horaeon, constitutes itself the crux of this oculist inscription. The word crocodes is merely saffron and therefore horaeon must be some adjective or qualifying word relating to that plant. The first editor of this seal, an Italian savant, considered it to be an erroneous spelling upon the engraver’s part and refers to the opScov of Pliny. But if we bear in mind how often upon these relics words derived from the Greek are inserted as a kind of commentary upon the medicaments used, such as basilinum, regal, hyginon, or ambrosium, it is possible that horaeon is derived from ’&ohgr;&rgr;&agr;&tgr;os, meaning ripe or seasonable saffron. The collyrium of the fourth line is an instance of another of those superlative titles for substances I, or mixtures just mentioned, &thgr;∈o&kgr;t&tgr;&sgr;to&ngr; meaning God-created, cf.lapis divinus.
prevent the
-
SENTIMENT IN DIETETICS. THE trite saying that "if you would enjoy your food keep out of the kitchen"implies, of course, that some, at all
events, of the preparatory processes of the culinary departsentimental grounds objectionable and that a with them is likely to engender a distaste for familiarity morsels which otherwise are highly relished. It must be admitted that the object of cooking is not merely hygienic but esthetic also, for the cooking improves the appearance of the food, develops new flavours, and makes it more attractive. A mental process begins at the sight of pleasing food which reacts on the gastric organs in such a way as to promote the digestion of that food. There are other circumstances which influence in one way or another the relish for food. There are not a few persons who would not drink milk if they saw it taken straight from the cow but who have no objection to it at all when it is taken from the jug on the tea table. Others do not care to eat the fish which they have caught themselves or the bird or hare which they have shot. The housekeeping wife as a rule enjoys her meals much more when she has taken no share in their selection or preparation. To her dining out means on this account more than it does to her husband who, perhaps, seldom knows of what his meal will consist until it is placed before him. The cook may see the caterpillar in the cabbage, the snail in the salad, If such disclosures in the or the beetle in the bread. kitchen (and they must often occur) are kept secret no harm need be done and no appetite need be spoiled. But should the cleansing process fail to remove the offending intruder and should it ultimately find its way to the table a feeling of horror overtakes the eater who has been unfortunate enough to come across it, a feeling which is quickly shared by others when the fact is brought to their notice. The sentiment which revolts at such happenings is sometimes very strong, yet the objection is more often of a sentimental rather than a hygienic kind. The fact that men tread the grapes with bared feet does not as a rule deter the epicure from enjoying his favourite wine, nor does the circumstance of a ripe Stilton swarming with mites detract from its qualities in the view of a good many people. Few, again, reject that delicacy the truffle because they may happen to know that its situation may have been discovered by the keen scent of the hog or that it may have been uprooted by the aid of
ment
are on
that animal’s snont. Some persons do not hesitate to eat with the greatest satisfaction meats that are almost pntrid ; the same persons would not think of touching the soup upon which there happened to float a tiny beetle. Yet the risk of harm accruing in the latter case is practically nothing compared with what might happen in the former. The fact is that sentiment in dietetics is oftentimes foolish and the ugly suggestions which it creates are frequently mythical. Still, it cannot be denied that the doctrine of clean food is an excellent one and more often justified than not. A
MODIFICATION OF THE WOLFE-KRAUSE METHOD OF SKIN-GRAFTING.
IN the Glasgow Medical Journal for October Dr. Archibald Young has described an important modification of the method of skin-grafting originally devised by Wolfe of Glasgow and modified by Krause of Altona. The skin required is removed from a suitable situation in the form of a long ellipse. The incision is made by a few bold sweeps down to the aponeurotic covering of the muscles. The flap thus includes skin and subcutaneous fat and is set aside in warm saline or borax solution. The wound is sutured and dressed. Every detail of asepsis is observed in this as in all subsequent procedures. The surface to be grafted is now uncovered. If it is a fresh wound made under aseptic conditions the only preliminary is the thorough checking of bsemorrbage. If thorough asepsis is not possible, as in the case of a burn, the granulating surface is gently irrigated with saline or borax solution and the surface is dried with sterile gauze. Any antiseptic used must be followed by abundance of saline solution and strong antiseptics must never be employed. The surface must be in a healthy state. All necrotic tissue and exuberant granulations should be removed some days previously. The surface should be level and of a healthy rosepink colour. The edges should be smooth and free from dried discharge and epithelial debris. The flap is taken from the warm solution and the fat is expeditiously removed. This is quickly done by turning it over on the palm and cutting away the fat with a scissors curved on the flat. If only a small surface is to be covered the graft need not be divided; when the surface is large it must be divided into as many pieces as are necessary for distributing over the surface at suitable intervals. After the application of the grafts the surface is covered with some protective material which will sufficiently resist or modify the pressure of the overlying dressings, yet will, when moistened, lie closely over the grafted surface, keep the grafts in place, and permit escape of discharge through its perforations or meshes. Perforated gutta-percha or oil-silk may be used but Dr. Young recommends "the protective gauze tissue" introduced by Dr. J. C. Renton and prepared by M’Millan of Glasgow. The protective need not be changed for several days but the whole dressing external to it must be changed daily, taking care not to disturb the grafts. Thus all discharge and soiled dressings (which would be detrimental) are removed. A moist external dressing is the best. It should be abundant and sufficiently absorbent. Plain smooth aseptic gauze soaked with sterile saline or borax solution (not boric acid which may prove irritating) is the most satisfactory. It should be covered with a sheet of gutta-percha tissue or other waterproof substance. The whole is then supported lightly, firmly, and equably with wool and bandages. In this operation there are several important modifications of the Wolfe-Krause method. The subcutaneous fat is removed with the flap -a procedure which can be performed in a minute or twoinstead of the tedious dissection of the skin. Moreover, it is a disadvantage to leave between the edges of the incision a mass of fat. This either limits the width of the flap which can be removed or necessitates undue traction or under-
1406
cutting of the edges in closing the wound. Contrary to the teaching of Thiersch the superficial layers of the granulating surface are not removed before applying the grafts-a procedure regarded as both unnecessary and disadvantageous. The use of special protective ganze, of a moist dressing, and the daily changing of the dressing are also features of this method. Dr. Young claims a greater certainty of success than under any other. In nearly every case the of the complete integrity grafts-epidermis, dermis, hairs, and glands-is preserved. Dr. Young describes and gives illustrations of 11 cases. The following is an example. On June 3rd, 1903, a girl, aged 14 years, was extensively burned on the trunk and limbs. On June 13th sloughs were
iron and metal hollow ware is prohibited. In addition such tinned articles may constitute a danger to those who use them as cooking utensils or for the purpose of containing food. The application of an efficient system of exhaust ventilation is also enjoined. Altogether there, are ten regulations applying to employers and two to persons employed. The experimental portion of the inquiry relating to the conditions of work in the tinning workshops contains account of the ingenious methods a very interesting for determining the quantities Mr. by Duckering employed of deleterious substances inhaled by workers in a tinning
tinning of
shop
per
day.
-
FLANNELETTE. the chest measuring 12 A CORRESPONDENT from Manchester writes: " With by 102 inches. On July 9th grafting was performed with skin taken from the thigh; this skin was divided into 11 pieces, reference to the interesting experiments by Mr. William from one to four inches in length, and distributed over the Thomson on the inflimmability of various samples of upper left portion of the raw surface. On the 15th skin from flannelette given in your issue of the 2nd inst. it would the left leg was applied in seven pieces to the right half of appear that this material has had to bear a worse character the surface. On August 12th skin from the leg was applied as to inflammability than it has deserved. The fact, howto the lower part of the left side. On Sept. 19th skin from ever, remains that many children are burnt to death when the thigh was applied to various points still uncovered. On wearing flannelette, if we are to believe the evidence given Oct. 9th healing was complete and there was no contraction. at inquests, not only in the Manchester district but all over the kingdom. But Mr. Thomson’s experiments seem to show that this mortality ought not to have occurred as not being THE TINNING OF METALS AND ITS DANGERS in accordance with the tests he applied to the accused TO HEALTH. material, and it must be acknowledged that these A VERY interesting report on the injurious processes contests seem to be practical and thorough, yet after nected with the coating of metal with lead or a mixture of all they were laboratory experiments, which often have lead and tin has been recently issued from the Factory a way of disappointing experimenters when they are reDepartment of the Home Office. A previous report issued in in the rough-and-ready methods of everyday life. 1902 had dealt with the conditions and results of employment peated The evidence as to how the children contrive to ignite in the enamelling of metals and tentatively on the tinning of this refractory material is almost always imperfect, metals, but the regulations proposed in that report applied but seeminglywith fire’ is to them a most fascinating game, only to enamelling processes and not to tinning processes. and playing to the younger oneswarming themselves’ is likewise a The writers of the report, Miss A. M. Anderson, the principal proceeding in which the lapse of a few seconds more or lady inspector of factories, and Dr. T. M. Legge, medical less is not to be regarded. Mr. Thomson’s advice, inspector of factories, state that at the beginning of 1903 however, as likely to the use of a mixture of cotton and wool they were not in a position to say with any certainty for children’s clothing is valuable. It already exists under either (a) how many processes in the tinning of the name of’union.’ The additional protection, however, of metals were clearly injurious or (b) what were the would probably save more lives than even the nature and extent of the regulations possible and neces- fireguards with flannelette." away doing For the purposes of the present report it was sary. found necessary to secure the help of a chemist with a PRIMARY BILATERAL MASTOIDITIS. knowledge of the industrial processes and equipped for the BILATERAL secondary mastoiditis is rare ; primary bilateral steady and long series of observations and experiments for the chemical For this is still rarer. Of course, when mastoiditis occurs mastoiditis required elucidating problems. the of Mr. services of G. E. evidence of otitis media, and is therefore called without purpose Duckering, inspector factories, were granted and Dr. T. E. Thorpe, F.R.S., the primary, it no doubt often is secondary to some slight inflamprincipal chemist of the Government laboratories, assisted mation of the middle ear which has passed away unobserved. both by discussing the scheme of chemical investigation and In the Montreal Medioal Journal for October Dr. P. G. Gold. by arranging for the analyses to be carried out by members smith has reported the following case of primary bilateral of his staff. The results of this portion of the inquiry are mastoiditis. A woman, aged 61 years, had a mild attack of embodied in sections of the report which are ably contributed what appeared to be influenza-a temperature of 102° F., by Mr. Duckering. The risks of the processes were un- cough, general aches and pains, and slight bronchitis. A expectedly made clear in a new way by the occurrence of week later she had a chill and rise of temperature to 104°, illness due to fumes, fortunately soon overcome, in the case of with a return of the catarrhal symptoms. This was Mr. Duckering himself during the time of his experiments. regarded as a relapse. On the following day the The sources of risk which raised the special problems for temperature fell to 99°. In the next four or five this report centre round (a) the molten metal, whether days she complained of much pain in the head, espe(1) in the tinning pit, or (2) on the still hot, fuming cially on the vertex and in the course of the posterior article, or (3) the dust formed by metallic oxides auricular nerve. The mastoid processes were not tender and in their vicinity; and (b) the cleaning agents and fluxes. there was no aural discharge. Both membranes were normal In tables prepared by Mr. Duckering the results are given of and hearing was not impaired but the posterior wall of the the estimation of the small amounts of lead compounds cartilaginous external auditory meatus was tender. Four which, inhaled continuously, result in chronic plumbism. days later the pain in the vertex persisted to some extent and The " wiping off " process exposes the workers to greater risk was associated with some tenderness over the mastoids. On than tinning. Occasionally a "wiper off" who has con- the next day the walls of the external auditory meatus on both tracted lead poisoning resumes work as a tinner, as this is sides were much swollen. Dr. Goldsmith then saw the patient considered a less dangerous operation. In the recommenda- and found slight tenderness over the right mastoid antrum tions the addition of le,d to the covering mixture in the and some indefinite tenderness over the left. The meatus was
removed. There
was a raw
surface
on
prevent the
-
SENTIMENT IN DIETETICS. THE trite saying that "if you would enjoy your food keep out of the kitchen"implies, of course, that some, at all
events, of the preparatory processes of the culinary departsentimental grounds objectionable and that a with them is likely to engender a distaste for familiarity morsels which otherwise are highly relished. It must be admitted that the object of cooking is not merely hygienic but esthetic also, for the cooking improves the appearance of the food, develops new flavours, and makes it more attractive. A mental process begins at the sight of pleasing food which reacts on the gastric organs in such a way as to promote the digestion of that food. There are other circumstances which influence in one way or another the relish for food. There are not a few persons who would not drink milk if they saw it taken straight from the cow but who have no objection to it at all when it is taken from the jug on the tea table. Others do not care to eat the fish which they have caught themselves or the bird or hare which they have shot. The housekeeping wife as a rule enjoys her meals much more when she has taken no share in their selection or preparation. To her dining out means on this account more than it does to her husband who, perhaps, seldom knows of what his meal will consist until it is placed before him. The cook may see the caterpillar in the cabbage, the snail in the salad, If such disclosures in the or the beetle in the bread. kitchen (and they must often occur) are kept secret no harm need be done and no appetite need be spoiled. But should the cleansing process fail to remove the offending intruder and should it ultimately find its way to the table a feeling of horror overtakes the eater who has been unfortunate enough to come across it, a feeling which is quickly shared by others when the fact is brought to their notice. The sentiment which revolts at such happenings is sometimes very strong, yet the objection is more often of a sentimental rather than a hygienic kind. The fact that men tread the grapes with bared feet does not as a rule deter the epicure from enjoying his favourite wine, nor does the circumstance of a ripe Stilton swarming with mites detract from its qualities in the view of a good many people. Few, again, reject that delicacy the truffle because they may happen to know that its situation may have been discovered by the keen scent of the hog or that it may have been uprooted by the aid of
ment
are on
that animal’s snont. Some persons do not hesitate to eat with the greatest satisfaction meats that are almost pntrid ; the same persons would not think of touching the soup upon which there happened to float a tiny beetle. Yet the risk of harm accruing in the latter case is practically nothing compared with what might happen in the former. The fact is that sentiment in dietetics is oftentimes foolish and the ugly suggestions which it creates are frequently mythical. Still, it cannot be denied that the doctrine of clean food is an excellent one and more often justified than not. A
MODIFICATION OF THE WOLFE-KRAUSE METHOD OF SKIN-GRAFTING.
IN the Glasgow Medical Journal for October Dr. Archibald Young has described an important modification of the method of skin-grafting originally devised by Wolfe of Glasgow and modified by Krause of Altona. The skin required is removed from a suitable situation in the form of a long ellipse. The incision is made by a few bold sweeps down to the aponeurotic covering of the muscles. The flap thus includes skin and subcutaneous fat and is set aside in warm saline or borax solution. The wound is sutured and dressed. Every detail of asepsis is observed in this as in all subsequent procedures. The surface to be grafted is now uncovered. If it is a fresh wound made under aseptic conditions the only preliminary is the thorough checking of bsemorrbage. If thorough asepsis is not possible, as in the case of a burn, the granulating surface is gently irrigated with saline or borax solution and the surface is dried with sterile gauze. Any antiseptic used must be followed by abundance of saline solution and strong antiseptics must never be employed. The surface must be in a healthy state. All necrotic tissue and exuberant granulations should be removed some days previously. The surface should be level and of a healthy rosepink colour. The edges should be smooth and free from dried discharge and epithelial debris. The flap is taken from the warm solution and the fat is expeditiously removed. This is quickly done by turning it over on the palm and cutting away the fat with a scissors curved on the flat. If only a small surface is to be covered the graft need not be divided; when the surface is large it must be divided into as many pieces as are necessary for distributing over the surface at suitable intervals. After the application of the grafts the surface is covered with some protective material which will sufficiently resist or modify the pressure of the overlying dressings, yet will, when moistened, lie closely over the grafted surface, keep the grafts in place, and permit escape of discharge through its perforations or meshes. Perforated gutta-percha or oil-silk may be used but Dr. Young recommends "the protective gauze tissue" introduced by Dr. J. C. Renton and prepared by M’Millan of Glasgow. The protective need not be changed for several days but the whole dressing external to it must be changed daily, taking care not to disturb the grafts. Thus all discharge and soiled dressings (which would be detrimental) are removed. A moist external dressing is the best. It should be abundant and sufficiently absorbent. Plain smooth aseptic gauze soaked with sterile saline or borax solution (not boric acid which may prove irritating) is the most satisfactory. It should be covered with a sheet of gutta-percha tissue or other waterproof substance. The whole is then supported lightly, firmly, and equably with wool and bandages. In this operation there are several important modifications of the Wolfe-Krause method. The subcutaneous fat is removed with the flap -a procedure which can be performed in a minute or twoinstead of the tedious dissection of the skin. Moreover, it is a disadvantage to leave between the edges of the incision a mass of fat. This either limits the width of the flap which can be removed or necessitates undue traction or under-
1406
cutting of the edges in closing the wound. Contrary to the teaching of Thiersch the superficial layers of the granulating surface are not removed before applying the grafts-a procedure regarded as both unnecessary and disadvantageous. The use of special protective ganze, of a moist dressing, and the daily changing of the dressing are also features of this method. Dr. Young claims a greater certainty of success than under any other. In nearly every case the of the complete integrity grafts-epidermis, dermis, hairs, and glands-is preserved. Dr. Young describes and gives illustrations of 11 cases. The following is an example. On June 3rd, 1903, a girl, aged 14 years, was extensively burned on the trunk and limbs. On June 13th sloughs were
iron and metal hollow ware is prohibited. In addition such tinned articles may constitute a danger to those who use them as cooking utensils or for the purpose of containing food. The application of an efficient system of exhaust ventilation is also enjoined. Altogether there, are ten regulations applying to employers and two to persons employed. The experimental portion of the inquiry relating to the conditions of work in the tinning workshops contains account of the ingenious methods a very interesting for determining the quantities Mr. by Duckering employed of deleterious substances inhaled by workers in a tinning
tinning of
shop
per
day.
-
FLANNELETTE. the chest measuring 12 A CORRESPONDENT from Manchester writes: " With by 102 inches. On July 9th grafting was performed with skin taken from the thigh; this skin was divided into 11 pieces, reference to the interesting experiments by Mr. William from one to four inches in length, and distributed over the Thomson on the inflimmability of various samples of upper left portion of the raw surface. On the 15th skin from flannelette given in your issue of the 2nd inst. it would the left leg was applied in seven pieces to the right half of appear that this material has had to bear a worse character the surface. On August 12th skin from the leg was applied as to inflammability than it has deserved. The fact, howto the lower part of the left side. On Sept. 19th skin from ever, remains that many children are burnt to death when the thigh was applied to various points still uncovered. On wearing flannelette, if we are to believe the evidence given Oct. 9th healing was complete and there was no contraction. at inquests, not only in the Manchester district but all over the kingdom. But Mr. Thomson’s experiments seem to show that this mortality ought not to have occurred as not being THE TINNING OF METALS AND ITS DANGERS in accordance with the tests he applied to the accused TO HEALTH. material, and it must be acknowledged that these A VERY interesting report on the injurious processes contests seem to be practical and thorough, yet after nected with the coating of metal with lead or a mixture of all they were laboratory experiments, which often have lead and tin has been recently issued from the Factory a way of disappointing experimenters when they are reDepartment of the Home Office. A previous report issued in in the rough-and-ready methods of everyday life. 1902 had dealt with the conditions and results of employment peated The evidence as to how the children contrive to ignite in the enamelling of metals and tentatively on the tinning of this refractory material is almost always imperfect, metals, but the regulations proposed in that report applied but seeminglywith fire’ is to them a most fascinating game, only to enamelling processes and not to tinning processes. and playing to the younger oneswarming themselves’ is likewise a The writers of the report, Miss A. M. Anderson, the principal proceeding in which the lapse of a few seconds more or lady inspector of factories, and Dr. T. M. Legge, medical less is not to be regarded. Mr. Thomson’s advice, inspector of factories, state that at the beginning of 1903 however, as likely to the use of a mixture of cotton and wool they were not in a position to say with any certainty for children’s clothing is valuable. It already exists under either (a) how many processes in the tinning of the name of’union.’ The additional protection, however, of metals were clearly injurious or (b) what were the would probably save more lives than even the nature and extent of the regulations possible and neces- fireguards with flannelette." away doing For the purposes of the present report it was sary. found necessary to secure the help of a chemist with a PRIMARY BILATERAL MASTOIDITIS. knowledge of the industrial processes and equipped for the BILATERAL secondary mastoiditis is rare ; primary bilateral steady and long series of observations and experiments for the chemical For this is still rarer. Of course, when mastoiditis occurs mastoiditis required elucidating problems. the of Mr. services of G. E. evidence of otitis media, and is therefore called without purpose Duckering, inspector factories, were granted and Dr. T. E. Thorpe, F.R.S., the primary, it no doubt often is secondary to some slight inflamprincipal chemist of the Government laboratories, assisted mation of the middle ear which has passed away unobserved. both by discussing the scheme of chemical investigation and In the Montreal Medioal Journal for October Dr. P. G. Gold. by arranging for the analyses to be carried out by members smith has reported the following case of primary bilateral of his staff. The results of this portion of the inquiry are mastoiditis. A woman, aged 61 years, had a mild attack of embodied in sections of the report which are ably contributed what appeared to be influenza-a temperature of 102° F., by Mr. Duckering. The risks of the processes were un- cough, general aches and pains, and slight bronchitis. A expectedly made clear in a new way by the occurrence of week later she had a chill and rise of temperature to 104°, illness due to fumes, fortunately soon overcome, in the case of with a return of the catarrhal symptoms. This was Mr. Duckering himself during the time of his experiments. regarded as a relapse. On the following day the The sources of risk which raised the special problems for temperature fell to 99°. In the next four or five this report centre round (a) the molten metal, whether days she complained of much pain in the head, espe(1) in the tinning pit, or (2) on the still hot, fuming cially on the vertex and in the course of the posterior article, or (3) the dust formed by metallic oxides auricular nerve. The mastoid processes were not tender and in their vicinity; and (b) the cleaning agents and fluxes. there was no aural discharge. Both membranes were normal In tables prepared by Mr. Duckering the results are given of and hearing was not impaired but the posterior wall of the the estimation of the small amounts of lead compounds cartilaginous external auditory meatus was tender. Four which, inhaled continuously, result in chronic plumbism. days later the pain in the vertex persisted to some extent and The " wiping off " process exposes the workers to greater risk was associated with some tenderness over the mastoids. On than tinning. Occasionally a "wiper off" who has con- the next day the walls of the external auditory meatus on both tracted lead poisoning resumes work as a tinner, as this is sides were much swollen. Dr. Goldsmith then saw the patient considered a less dangerous operation. In the recommenda- and found slight tenderness over the right mastoid antrum tions the addition of le,d to the covering mixture in the and some indefinite tenderness over the left. The meatus was
removed. There
was a raw
surface
on