John P. Adams

INTRAVENOUS REGIONAL ANESTHESIA IN HAND SURGERY.

We have found intravenous regional anesthesia, by the method of expressing the blood, applying a temporary tourniquet, injecting the lidocaine, then placing the second tourniquet on an anesthetized portion of the arm and removing the first tourniquet, to be a very simple and effective way to achieve anesthesia in operations on the hand. The quantities of lidocaine used seem to be well below the toxic amounts by several multiples (this would obtain if the tourniquet should fail). The quantities of lidocaine recovered in the systemic circulation were minute. We did not observe any clear-cut toxic reactions in thirty-six patients. Nerve-conduction studies tended to show that no motor impulses could be transmitted by the median nerve and that anoxia did not seem to play a major role in the production of the anesthesia up to twenty minutes. The usual precautions of availability of oxygen and appropriate drugs should be observed, as is customary when using local anesthetic agents, and the surgeon must be mindful of his selection of cases in regard to necessary operating time, since anesthesia depends on the continuous and uninterrupted presence of the tourniquet.

Experience with atypical mycobacterial infection in the deep structures of the hand

Two new cases of atypical mycobacterium infections of the deep structures are reported. With two reported previously by the authors and a review of 24 others recorded by others, the symptoms and signs are reviewed. Typically it occurs in the middle-aged person, some of whom give a history of a puncture wound within 6 weeks of onset of symptoms. Synovium in the finger is involved commonly and a carpal tunnel syndrome may be the result of involvement of the bursae. Fever does not occur and no systemic signs are present. Biopsy and cultures are essential for diagnosis, but a presumptive diagnosis indicates that, after synovectomy, treatment should be started with antituberculous drugs, isoniazid with ethambutol, Rifampin, or both and continued for 18 to 24 months, unless in vitro sensitivity tests indicate a change of medication. The usual organisms are M. kansasii, M. marinum, M. intracellulare, and M. avium.

Correction of Chronic Dorsal Subluxation of the Proximal Interphalangeal Joint By Means of a Criss-Cross Volar Graft

1. D&IFFEL, E. W. : Ijeber Knochenbildung in Verbrennungsnarben. M#{252}chener Med. Wochenschr. 83: 1468-1469, 1936. 2. HASS, G. M. : Pathological Calcification. In The Biochemistry and Physiology of Bone. Edited by G. H. Bourne. New York, Academic Press, Inc., 1956. 3. JOHNSON, J. T. H. : Atypical Myositis Ossificans. J. Bone and Joint Surg., 39-A: 189-194, Jan. 1957. 4. ZUPPINGER, A. : In Lehrbuch der Rbntgendiagnostik, by H. R. Sclminz, W. E. Baensch, E. Friedl, and E. Uehlinger. Ed. 5, Vol. 2, pp. 1767-1796. Stuttgart, Georg Thieme, 1950.

The blood volume in the lower extremities. A technique for its determination utilizing Cr-51 tagged red cells.

A technique for the determination of the total blood volume in the lower extremities has been presented. The average blood volume of a single normal lower extremity was found to be 9.3 x 100/95 per cent (± 3 per cent) of the total blood volume.

Foot problems in adults.

Probably the most common congenital and acquired disorders of the feet in adults are hammer toe and ingrown toenail, respectively. Most foot problems in adults are related to improper care of the feet. One pair of poorly fitting shoes worn during a period of rapid growth can cause many foot problems.

Observations in wringer injuries. An experimental study.

An experimental study of the effect of a wringer injury to the hind limbs of immature rats has been presented. The findings in this study indicate that injuries produced by wringers extending over various periods of time (for example, sixty seconds versus 300 seconds) are similar histologically and vary only in degree. The histological preparations indicate that hemorrhage, edema, venous dilatation, leukocyte infiltration, and muscle necrosis may occur and that the injury is more severe near the bone. The changes first appear in from three to five hours and reach their maximum intensity in from sixteen to twenty-four hours. During this period the animals lose their ability to perform in a rat wheel. Necrosis of striated muscle has been observed as well as late replacement of the necrotic muscle fibers by fibrous tissue. Regeneration of muscle fibers may occur after a wringer injury although the evidence in the present material is inadequate for this conclusion to be reached. We have postulated that the factors giving rise to increased capillary pressure produce a condition of reduced oxygenation and ionic exchange at the fiber level and that these changes may produce muscle necrosis.

The American Society for Surgery of the Hand's Leadership Role in the Development of the Field of Hand Surgery

My election as twenty-sixth President of the American Society for Surgery of the Hand proyoked many strong feelings: first, that of elation, with a feeling of thankfulness to and fellowship with the membership for this signal honor. As the year progressed, the realization that the responsibilities of heimsmanship were multiple and, in some instances, irreconcilable, gave rise to some frustration. However, this frustration was short-lived as I observed the various committees of this Society in the discharge of their responsibilities: their input and output can only be characterized as superb. The guidance of the council and of individual members has been steady and supportive. Finally, I feel humility in preparing this Presidential Address, begun while flying home from last year’s meeting and completed in its present form last evening. This Society was established by its founder members as a true academy, to impart education in surgery of the hand. Having made this proclamation, can we establish its validity? Has it truly succeeded? For this discussion, let education be considered an area that nurtures those whose goal is the search for truth and relevance. I believe all truth has relevance and that only artificial boundaries can be drawn between the two. It is accepted that there may be a lag in time between truth and relevancy, but we know that the world is approaching for the first time in its history an era in which this lag is no longer measured in centuries but in days or even hours. Last year I dined with a meteorologist who helped develop our present method of weather prediction with its now familiar formula of “There is a 40 per cent chance of rain”; such predictions are now done for a three-day period. When asked what enabled this breakthrough and what new natural laws had been discovered, he answered quite simply, “We applied Newton’s laws of thermodynamics”-and after a brief pause-”but we now have a computer to store the data and make the more than 6,000,000 computations necessary for a three-day prediction.” Thus truths centuries old have new relevancy today. In the arena of education, who are the performers and what is the condition necessary for learning to take place? We are fortunate to have emerged from a not too distant past in which the protagonist-antagonist role of teacher-learner did much to hinder education. We are now seeing greater degrees of freedom for the learner in planning his or her educational experience, without the teacher’s abdication of responsibility for his or her role of leadership in this experience. Our society participates, I believe, in what Professor William Griffiths defines as “adult” education. This is education by grouping based not on the age of the participants but on their acceptance of responsibility transcending the usual role of complete dependency. Certainly most, but probably not all, of our learners fall into this category. As an example, in psychological development one must progress through dependency to independency, from infancy to adulthood. Why is this transition important in adult education? It is important primarily because it separates the need for “the answer” into many possible answers; in the latter situation a degree of analysis, synthesis, and evatuation must be interposed between the problem and its solution. When this occurs, everybody benefits. Cognitive effort then transcends mere rote performance. Who are the teachers and who are the learners, and how do you measure the production of this fusion in the American Society for Surgery of the Hand? In many respects they are one. Their separation is tenuous. One has only to look down on these front rows to see the intense involvement of the senior members of this Society in each presentation and discussion to realize the narrow crevice that separates the teacher from the learner. It is also apparent that the lectern is often occupied by a non-member but not a non-teacher. Presentations before this Society have long been a prerequisite for membership. This Society had its formal founding in 1946 with thirty-five members, the original teachers. The membership is now over 200, and the majority of members now are from the learners group, although one-third of the founder members are still active in the society. The twenty-

Report of the Visit of the 1959 North American Traveling Fellows to Great Britain

The orthopaedic problems in Great Britain certainly are similar to those seen in this country, although their handling probably is more uniform because of the orthopaedic organization. The organization of regional orthopaedic centers, which are largely dominated by one institution, naturally reflects the feelings of the institution on the management of specific diseases. Throughout Great Britain we found that arthrodeses are much more commonly carried out on the major joints than they are in this country. Another contrast was the great individual experiences which many orthopaedic surgeons have had in treating particular entities. This is because of the concentration of patients in a given area where they are under the care of a small number of consultants. The number of patients seen and handled by an individual consultant is many times larger than that cared for by an orthopaedic surgeon in a comparable position in the United States and Canada. Tuberculosis is more common in Great Britain than in this country although its incidence is falling rapidly. The anterolateral approach for the drainage of abscesses is frequently utilized in the surgical treatment of tuberculosis of the spine. Time chemotherapeutical treatment in bone and joint tuberculosis varied a great deal throughout the areas visited. Two radically different views on the early management of spinal cord injuries were presented to us, yet the end results were similar. In Great Britain the emphasis is on a spinal injury centers as an integral unit within a general medical and surgical hospital. In the field of childrens orthopaedics there still is great emphasis on treatment of congenital dislocation of the hip, an entity that is seen much more frequently in Great Britain than in the United States and Canada. The staff at the Robert Jones and Agnes Hunt Orthopaedic Hospital presented several different concepts in time management of scoliosis, particularly of the infantile or childhood type. They have done a large number of epiphyseal arrests of the convex side of the curve with interbody fusion. Time end results, however, are of too recent duration for clinical evaluation. In conclusion, the Traveling Fellows wish to express their most sincere thanks to The American Orthopaedic Association and The Canadian Orthopaedic Association for sponsoring and arranging this tour. We have made many friendships which we will cherish for the remainder of our lives. On a personal basis the value of this tour to us will grow in the years to come. Although it is impossible to assimilate all the material presented to us in this relatively brief period, we are certain that exchange fellowships are tremendously important in fostering an exchange of information. The British Orthopaedic Association and all of its members were magnificent hosts and treated us with every possible courtesy and kindness. We wish to extend particular thanks to Mr. Norman Capener and Mr. John Crawford Adams for all of their efforts in preparing such an outstanding itinerary for us. Those of us who were privileged to participate in the tour this year sincerely hope that the Traveling Fellowship Exchange Program will be continued between North America and Great Britain.