THE OPERATIVE TREATMENT OF SIMPLE FRACTURE OF THE LONG BONES IN CHILDREN
433 speaking, I have not found age any contra-indication. It is sometimes convenient to take the graft from another person in the case of an infant or when there is much wasting. I employ the immediate graft whether suppuration exists or not. In cases of extradural abscess complicating chronic otitis for which one performs the radical mastoid operation, I employ a graft, and close the post-aural incision, just as one does in uncomplicated cases. Whether the whole of the graft adheres or only a
... adheres or only a portion of it, I am convinced of the saving of considerable time in the healing process. Again, in cases of post-operative suppuration where the immediate graft was applied the graft is not necessarily destroyed by the infective inflammation; even in quite unpromising-looking cases (which are fortunately not common) a considerable portion of the graft has been found to have adhered as the reaction subsides. Coming to labyrinth cases, I have no reason for not grafting over a simple fistula of the external semicircular canal when the labyrinth is functionating, but when a fistula of the labyrinth is accompanied by acute infective labyrinthitis, it is, in my opinion, not permissible to graft without first securing adequate drainage of the vestibule, and even then it is questionable whether a graft over the opened labyrinth is advisable. In such cases, 'and generally in operations on the labyrinth, when relatively deep-seated pockets have been made into the labyrinthine capsule, and are bridged across by the facial nerve (as, for instance, in extirpation by the double route of vestibulotomy), it is better to limit the graft to the meato-mastoid portion of the cavity, leaving the labyrinthine cavities to become filled by reparative material, and this soon becomes epithelialised if one can prevent proliferation beyond the general level of the grafted surface. Nor should I employ a graft over the labyrinth if the internal auditory meatus has been opened, as indicated by the escape of cerebro-spinal fluid, believing this escape of fluid acts as a safeguard and tends to prevent leptomeningitis. I have no objection to applying a graft to the meato-mastoid part of the cavity in such cases. To discuss the important question of the effect of grafting on the acuity of hearing would necessitate looking up a long series of cases, in order to give exact details. I must be content with saying that I avoid applying grafts to the inner tympanic wall in cases in which useful hearing has survived the prolonged suppuration, but when great deafness exists, and is unlikely to be relieved by the operation, I do not hesitate to graft over the promontory and fenestrae. II. My colleague, Mr. H. J. Marriage, aural surgeon to St. Thomas's Hospital, has sent me the following account, which is eminently practical, of his experience of epithelial grafting :-June 28th, 1912. In reply to your inquiries re the grafting of mastoids, it has been my practice for the last five years in all cases of chronic mastoid disease to graft the cavity at the time of the removal of the disease, but in cases of acute mastoid disease where the radical operation is necessary, I do the grafting about a week or ten days after the primary operation. The method I have adopted in the chronic cases is to thoroughly remove all trace of disease, then clean out the cavity with hydrogen peroxide (20 vols.) and apply one large graft which should be very thin. The graft is got into position by sucking out the air beneath in the mauner which was first recommended by you, and is kept in its place by one long sterilised plug of plain gauze ½ inch in width, which is covered with aristol powder to keep it from sticking to the graft; the end of the plug is brought out of the meatus, and the graft then wrapped over the plug and also brought out of the meatus so as to cover the cut edge of the meatal wall, and form a complete covering for the entire cavity. At first I used to leave the plug in for seven days, but now find that five days is sufficient for the graft to become adherent. After the removal of the plug the ear is syringed out daily with a weak solution of hydrogen peroxide, and a small piece of gauze put in to absorb the discharge; this is carried on for six or seven days, and afterwards patients are given hydrogen peroxide (10 vols.) to drop into the ear twice daily. The primary grafting, in addition to saving the patients the trials of a second operation, considerably shortens their stay in hospital, as usually they are able to leave at the end of about 12 days; it also saves them the pain of constant firm plugging, and is much less troublesome to the surgeon, as after they leave hospital it is only necessary for them to come up once a week for inspection and for the cauterisation of any small granulating areas which may be present. The majority of cases are healed by the end of six weeks, the last place to heal being usually the cut edge of the posterior wall of the meatus. Even when it has been necessary to expose the dura of the middle and posterior fosst, I apply a primary graft, as it grows on the dura extremely well. I have also grafted in the same way a dozen cases in which there was a bony fistula in the external semicircular canal with excellent results. , One case, a lady of 35, who had had otorrhcea for over 26 years, was sent to me as possibly a case of cerebellar abscess, as she had violent headache and very marked vertigo and was quite unable to walk straight. I diagnosed a fistula of the semicircular canal, and at the operation found that she had a large cholesteatoma which had eaten away the arch of the horizontal semicircular canal. I cleared away all the disease and applied one large graft in the usual way, and within six weeks the cavity was completely healed. About two months later I happened to meet her at a dance, and was able to prove for myself that she could dance through a long valse without any trace of giddiness. The operation was done four years ago, and there has been no recurrence of the disease or of the vertigo. GRADUATION IN THE UNIVERSITY OF VIENNA.-During the past academical year 960 students have received the degree of Doctor in the University of Vienna. Of these, 25 belonged to the theological faculty and 456 to the legal, all of whom were men. The philosophical faculty promoted 200 men and 22 women, and the medical 247 men and 10 women. A SUFFICIENT period has now elapsed since Mr. W. Arbuthnot Lane commenced operating on simple fracture at the Hospital for Sick Children, Great Ormond-street, to enable the end-results of his treatment to be collected and put upon record. It was in 1893 that Mr. Lane inaugurated a new departure in surgery by fixing the fragments in a simple fracture of both bones of the leg.l The first operation for simple fracture at the Children's Hospital was performed in 1907. Since that date 104 cases of fracture have been treated, and 72 submitted to open operation. For the sake of clearness the subject-matter has been divided into sections, and at the outset opportunity is taken to review the principles which guide us in the treatment 05 fractures.