which has descended even down to the present day by a device practised by him of converting arm-tissue into noses. To Tagliacozzi must I give the credit for what I am about now to attempt before you, the hint lying in his operation. From that time to the present I have lost no patient, neither had return of the disease where epithelioma has had a situation permitting of the practice suggested. The gentleman before us has epithelioma involving his lower lip where that part relates with the cheek. Already has the case been treated after the ordinary manner of operating, and already has the disease returned. It is a peculiar satisfaction to approach a case of this kind with a confidence inspired of success. I have told the patient I will cure him, and I am assured It is some twelve years since that a discovery, accidentally made, seems to have placed in my hands a radical cure for epithelioma. By referring to your text-book on Oral Surgery, page 992, you will find a cut representing an operation performed for the restoration of an eyelid which had to be removed in the treatment of the dis-out of my experience that I will. ease named. The case was one of inferred carcinoma; worse than that, there was a cancer history connected with the family. In designing the flap for that operation I found myself restricted for the part of replacement to the neighborhood of the oral angle. The new lid was cut from that part, while an intermediate triangular portion of the cheek was turned down to occupy the place from which the flap had been lifted. Now, the eyelid, as a locality for epithelioma, is a peculiarly unfortunate. and unpromising situation; all the chances are in favor of the disease, necessarily against the patient. It was resident in the common experience to expect a speedy return of trouble in this case. The ulcerative action did not, however, reappear; it has not reappeared to this day; the patient is as free from epithelioma as ever in his life. What I propose to do is,-first, cut away the ulcer from its base; second, replace the part removed by a flap taken from the hypothenar eminence of the left hand. The gentleman, himself as much interested in the operation as I am, proposes to endure the cutting without an anesthetic: he wants to understand the matter. I refer you to him as an example encouraging to men pursuing knowledge under difficulties. A little later I operated on a nephew of this patient for the same disease, situated on the left side of the nose. Several previous operations had been performed by a distinguished surgeon of Philadelphia, but in each instance the return of the trouble was more speedy than the healing of the wound made by the knife. For the restoration of the part removed in this case I used a flap taken from the extreme border of the forehead, the pedicle occupying the position of the supra-orbital artery of the distant side, and including that vessel. The disease did not return, and the gentleman has found himself able to secure, lately, an insurance on his life. Why the disease in these two cases, peculiarly operated upon, did not come back was a matter to attract attention. Was the cause in some catalytic influence brought about by the new relation of tissue? There seemed to be no other explanation. It was the one finally accepted. * We are now ready for the operation, and to the features of it I particularly recommend your attention. First, I remove the portion of face upon which the disease has fixed itself. I do this by means of an elliptic-shaped cut. This is now done, and I show you clearly exposed the depressed anguli oris muscle. The parts, as you see, are extra vascular; this they always are where this vice is present: vascularity is diagnostic. Three vessels are bleeding with a freedom which requires the use of ligatures. We tie them and dry the parts. This done, we wait for the process of glazing. The courage of the gentleman not being abated by this first step of the operation, we pass to the second. Having the hand firmly held, I repeat the incision by ellipse along the hypothenar eminence. Observe, however, I do not cut the piece entirely away from its attachments, as upon the face. I leave a pedicle: this with a view of temporarily feeding the ellipse. To cut about the hand is excessively painful. Our patient is without feeling, or, what amounts to about the same thing, is possessed of endurance stronger than pain. If, however, he can stand this work, assuredly we can: the courage is not at all in cutting, but in submitting to be cut. The third step implies the stitching of the flap from the hand into the place prepared for it upon the face. This is a feat not without difficulty. First, I place over the vault of the head a cap made to fit accurately. Next I attach a double bandage about the wrist of the hand operated upon. I now close with stitches of the interrupted suture the wound of the hand, leaving the flap pendent. Lifting the hand to the head and directing the palm to the side of the face, observe with what nicety I find myself able to adapt part to part. You wondered, perhaps, why I cut so long a pedicle. Had I not done that, I could never, as you must see, have accomplished the stitching now attempted. . . . The stitching is now finished to my entire satisfaction. The hand is next to be attached immovably to the side of the face. This with the means prepared is no difficult matter. I pass one roller obliquely over the vault and a second beneath the chin. I now proceed after the manner of a double Barton bandage,-a style of dressing with which you are all familiar. The hand and wrist firmly fixed, a succeeding step is the support of the elbow and forearm. A simple manner of accomplishing this is to button the patient's vest over the parts. A second plan-one I shall adopt this morning-is found in the use of the third roller of the Velpeau bandage. This done, nothing remains but to hope for the life of the flap and to separate it from the hand at the proper time,-a period that will vary from forty-eight to seventy-eight hours. Restlessness and irritability being associates of plastic operations, sedatives are indicated. In the present instance I will wait, however. The strength of resistance possessed by our patient may be proof against irritability. Opiates, where they do no good, always do harm; never use them unnecessarily. If restlessness supervene, I will prescribe thirty-grain doses of bromide of potassium. If the pulse run up, I will conjoin with this fivedrop doses of tincture of veratrum viride. If fever show itself, I will direct tablespoonful doses of a formula as follows: R Liquoris potassii citratis, 3iij; Spiritus ætheris nitrosi, 3ss; Antimonii et potassii tartratis, morphiæ acetatis, ää gr. j. Sulphate of morphia you all know as the great sedative; with it you can quiet to any degree, even down to the stillness of death itself. The dose is from oneeighth to half a grain repeated pro re nata. Many surgeons recommend that immediately after all operations of consequence a one-grain pill of morphia be given. If the medicine be exhibited in a vehicle of judgment, the prescription proves no bad one. In doing plastic operations, where immediate union is the summum bonum, never use chloroform. Chloroform interferes with the process of glazing, and without the glaze the promise is little. Another matter to look after in operations of the kind just done is maceration. Between the palm of the hand and the face I will lay a piece of old and soft linen. Maceration comes on very rapidly where the weather is warm enough to excite per spiration. From lack of such simple care as is expressed in the use of this little strip of cloth many otherwise perfect operations have proved blank failures. Do not overlook the fact that a flap does its utmost in preserving its vitality; never put unnecessary work on it. A flap doing well is to be let alone. Think not to make a well thing better. Where a diminishing vitality is seen, as shown by a flap growing dark, dry heat and other stimulants are to be employed; | not only local but constitutional stimulants. Preparation of a patient for a plastic operation is a matter not to be left unconsidered. A plethoric man is to be reduced, an anæmic one built up. With the first the lancet, or preferably, as a rule, sulphate of magnesia, is to be used; the latter demands iron, gentian, and similar tonics. Another very important—indeed, in a sense, all-important matter associates with plastic surgery; namely, calculation. Never do a new or an untried operation on a living face until you have first done it on a dead one, or, if this last be impracticable, do it upon a paper face. I have seen in my time a surgeon standing utterly confounded in the presence of a large class, a great wound before him, a flap and pedicle too short to fill up, nothing fitting. Make a blunder of that kind once, and you will never get over it; it will be found to have undermined your confidence, and without this quality a surgeon is nothing. Proposing to show to-day some operations in general surgery on other private patients, I now pass from the present case, directing your studies for the evening to the subject as illustrated in our text-book, pages 952 to 1008. I trust you will find much interest in the review. See if some of you cannot devise better manners of operating than you find there described. I will promise the vote of my chair to that one among you who succeeds in showing me an improvement in facial plastic surgery. [NOTE.-The flap was separated from the hand forty-eight hours after the operation. Two weeks later the patient was shown to the class, the union and relation of the parts being complete. The wound in the hand was getting well rapidly, part of this latter cure being necessarily by granulative action. The scar upon the face promises to be almost unobservable after a very short time.] Case II. The patient now seated before the class is afflicted with specific caries of the hard palate and alveolar process. I want you that are near to look into the mouth and observe the cribriform aspect of the mucous covering of the jaw. As you see, there are some half-dozen holes, each exposing bone. The hard palate and processes are pretty well destroyed; certainly they are beyond the power of selfrestoration. A very efficient practice to pursue in such cases will now be shown. The machine before you is the surgical engine,—a machine that will grow wonderful to you in proportion to your acquaintance with it. A little instrument held in my hand is what is known as a stoned rosehead; it is in reality a globe made up of chisel-edges. I attach this globe by means of its bitted mandrel to the hand-piece of the engine. Starting the engine, I revolve the rose-head before you, now fasterfaster still. The instrument is now apparently motionless. Its velocity is two thousand revolutions to the minute. It will cut now without hurting. The velocity maintained, I now pass the apparently motionless blades into the holes, one after the other. The patient makes. no complaint, yet I am cutting the roof of his mouth away. . . . Now he has neither hard palate nor alveolar process, yet the mouth looks about as it did before the operation was commenced. It is not unlikely that these breaks in the soft tissues will granulate and thus preserve perfectly the separability of mouth and nose. The following local wash will be prescribed, to be used several times during the day: B Acidi carbol. fl., gtt. vi; Tincturæ calendulæ, 3v; Aquæ, viii.-M. When the patient recovers from the effects of the present operation I will turn him over to the dental department, and he will there have fitted to his mouth an artificial palate with teeth attached, which will be made to articulate for purposes of looks and mastication with those in the lower jaw. I will show him after a few weeks made up about as good as new. SALICYLIC ACID AS AN ANTHELMINTIC.Dr. Tlyin has used this acid successfully in a number of cases of tænia. He begins with 3j of castor oil in the evening. In the course of the following day the patient takes from 3ss to 3j of salicylic acid, and in the evening another dose of castor oil. Only in a single case was it necessary to repeat the treatment.-New York Medical Record. TRANSLATIONS. nately, one is found more prominent than the other; at the same time palpation gives rise to slight pain, and causes the exit of a little stringy mucus, already clouded with pus. In the course of the next few days all these symptoms become more marked; local examination shows a small, hot, painful tumor between the labium minus and the labium majus. This is about the size and shape of a small pear, obliterates the vulvar orifice, is more prominent backward than forward, and below than above, ment of the labium majus, the upper portion of which remains unaffected. The tumor is smooth, shining, violaceous, and resistant to the touch. After several days, fluctuation is shown, and the abscess opens spontaneously through the vulvar mucous membrane in the neighborhood of or through the excretory duct itself. Ordinarily the pus is inodorous, but if blennorrhagia coexists it is fetid and nauseous. As so often happens in purulent collections situated near the digestive tube, a sort of osmosis takes place, and a fecal odor is at times perceived. The disease runs its INFLAMMATION OF THE VULVO-VAGINAL GLAND.—In an interesting lecture on this subject, published in La France Médicale, No. 58, 1880, M. Martineau refers to Huguier as the foremost authority. Following him, he remarks that the disease is usually observed between the years of seventeen and thirty; it is very rare before puberty and in aged women. In thirty-seven cases coming under M. Martineau's care, thirtyfive occurred between the ages of sixteen-corresponding, in fact, to the lower segand twenty-three years. The causes which may bring about this form of inflammation are excessive sexual indulgence, disproportion of the genitalia, menstruation, contagious affections, such as blennorrhagic vulvitis and vaginitis, traumatism of the genital organs, violation, difficult defloration, repeated manoeuvres of masturbation, sapphism, and friction of the vulva in working the sewing-machine. Of M. Martineau's thirty-seven cases twelve were due to excessive coitus. Huguier believes that functional super-activity of the organ, such as is produced by sexual excitement, may give rise to inflammation. The facts, how-course in eight or ten days, usually terever, do not support this hypothesis. In all probability the direct friction or pressure of the virile organ is at fault. With regard to inflammation of the vulvo-vaginal gland due to the use of the sewing-machine, M. Martineau gives a case occurring in a girl of twenty-four, and following ten hours' continuous work on the sewing-machine. A class of cases of considerable etiological importance is that where the inflammation is due to vulvo-vaginal blennorrhagia. Twenty-five of Martineau's thirty-seven cases were due to this cause. The affection usually attacks only one side; only in two cases was it double. Blennorrhagia appears to have a peculiar predilection for the vulvo-vaginal gland. It is well to know this, not only because the affection may easily escape attention and become the source of contagion unless one is on the lookout for it, but also because it is the source of frequent relapses by autoinoculation. It appears from Martineau's observations that inflammation of the vulvovaginal gland is more apt to occur about the menstrual period. The symptoms of the affection are as follows. At first there is a little heat and itching, with slight humidity of the vulva. If one and the other gland is palpated alter minating in induration of the gland, but occasionally leaving a fistula which may require surgical interference for its relief. From phlegmon of the labium majus the affection under consideration may be distinguished by the fact that the former protrudes outward, not inward; also that phlegmon is less circumscribed and not so apt to be unilateral. Phlegmon finally may occur in the labia minora, the clitoris, or the mons veneris. From cyst of the excretory canal, which resembles the tumor of vulvo-vaginal inflammation very closely, the diagnosis may be made from the fact that the cystic tumor is smaller, indolent, without inflammatory reaction, its greater diameter is transverse to the excretory canal, and pressure gives rise to the exit of a colorless, slightly viscous, non-purulent fluid. The treatment is simple. Emollient cataplasms of starch and baths of the same may be employed. Linseed poultices should not be used, because they are often irritant to the mucous membrane. The patient should be kept quiet. It is usually better not to open the abscess with the knife, as fistula is likely to form. If pain is severe, however, the knife may be used, the puncture being made in the nympho labial groove near the opening of the excretory canal of the gland. A small piece of charpie should be placed in the wound to prevent too rapid union. If a tendency exists to the formation of fistula, the canal should be touched with nitrate of silver. In certain cases this is not sufficient; the abscess returns repeatedly, and it becomes necessary to excise the gland. To do this, an incision is made in the nympho-labial groove, the lips of the wound are then lifted and the gland carefully dissected out. The arteries should be tied, or otherwise inconvenient hemorrhage may ensue. Charpie, soaked in one per cent. solution of chloral or a still weaker carbolic acid solution, may be used as a dressing. VARICOSE PHLEBITIS OF THE CALF THROMBOSIS OF THE LEFT FEMORAL VEIN-PULMONARY EMBOLISM OBSTRUCTING THE RIGHT PULMONARY ARTERY. Dr. Gautier reports (Le Progrès Médical, 1880, p. 593) the case of a patient admitted to the hospital for chronic alcoholism, who was seized with severe pain in the left calf, accompanied by slight swelling and oedema of the limb, and lasting a week. At the end of that time the patient returned to his work, but suffered lancinating pain in the limb after severe exertion, and, this increasing, a fortnight later he was again obliged to return to the hospital. On examination the leg was found slightly swollen and painful to the touch. No varicose veins could be observed, nor could any hard cord be felt in the line of the saphenous or of the femoral vein, which were not painful on palpation. No other abnormal symptoms throughout the body. Diagnosis, inflamed deep varices. Treatment, rest in bed, inunction with chloroform and oil of hyoscyamus, with envelopment in cotton. In the days following the right calf became the seat of similar symptoms, while the left grew better. At the end of a week the patient, contrary to orders, rose from his bed to go to the water-closet. While on his way he was suddenly seized with giddiness, fear of imminent death, and cyanosis, followed a little later, after going to bed, by extreme pallor, with a profuse cold sweat, and some vomiting of watery fluid. Next morning, examination failed to show anything wrong with lungs or heart. A few nights later the patient was waked by severe dyspnoea, with cyanosis, followed, as before, by pallor. No physical symptoms in lungs or heart. This dyspnoea became more constant in the succeeding week; a slight enfeeblement of the first sound of the heart became noticeable; respiration rose to seventy-two. Bleeding and blistering were employed without relief, and the patient finally succumbed. The post-mortem examination showed the right auricle of the heart greatly distended, filled with currant-jelly clots like those in the left heart. The auricle was filled with clots already somewhat old. On opening the pulmonary artery large clots were observed at its bifurcation, extending into the smaller branches. No disease of the artery could be observed at the point of origin of the clot. On examining the veins of the lower extremities the intra-muscular veins of the two calves were found filled with hard clots adhering to their walls and completely filling the calibre of the vessels. On the right side the saphenæ, the popliteal, the femoral, and the iliac veins were free. On the left side the saphene were free, but the other veins were filled by an old, hard, adherent clot, with empty spaces here and there, due to retraction. The coagulum terminated at the point where the iliac vein enters the vena cava inferior by a thin, snake-like, flattened head, which left the right primitive iliac vein quite free. The clot was soft and friable. TÆNIA FOUND LIVING AT AN AUTOPSY. -At a recent meeting of the Société Médicale des Hôpitaux (La France Med., 1880, p. 445), M. Laboulbène related the case of a patient who entered the hospital under his care for tænia and who died suddenly. The patient succumbed in a quarter of an hour, vomiting a small quantity of red blood, and was believed to have died from the rupture of an aneurism of the pulmonary artery. At the autopsy the tænia was found knotted together and extending along some nineteen inches of the small intestine. The head was found in the middle of the coil, but directed towards the superior extremity. A number of living lumbricoids were also found. The tænia when stretched out measured thirteen feet four inches. In the discussion which followed, M. Davaine cited some old observations on tænia solium found by accident in cadavera. The head was always directed towards the gastric extremity of the intestine, and the tail towards the anus. tail towards the anus. M. Damaschino |