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The patient being placed in the exaggerated | edge of that branch of the science of medicine; lithotomy position, and the perineum depressed that human anatomy was not a dead scienceby a Sims speculum, we seize the cervix with a mere closet study-but one full of practical vulsellum forceps, and bring it down to the and live interest, of everyday application in the vulva, and now you can easily see the nature practice of the surgeon and the physician; in and extent of the laceration. I first deepen the fine, that the physician or surgeon who was laceration by removing the cicatricial tissue in ignorant of human anatomy was not competent each angle, then pare the surfaces thus, and to meet the emergencies of his daily profesthe two lips fit perfectly together, by means sional life. To emphasize this he would, in of this rectangular needle, which is threaded every proper case, not only call the attention after the point has passed through both lips; of the class to the anatomical structure operated the needle being quickly withdrawn, and the upon and the relations they bore to other imstitch is planted in this way. I introduce portant structures, but would also call upon the three on each side. I use in this case the No. members of the class to describe the anatomy 3 catgut. of the parts involved in the operation, as well as the relations of the neighboring viscera, arteries, veins, etc.

Before tying the sutures I will use a curette on the endometrium, and remove a mass of polypoid excrescences, which have the appearance of profuse watery granulations seen upon the surface of an irritable ulcer. These, no doubt, furnish the cause for the menorrhagia.

The stitches are now securely tied, and the operation is completed. The patient will be kept in bed about seven or eight days, and usually needs but very little attention. The stitches being catgut need cause no anxiety, as they will either be absorbed or come away in the course of one or two weeks.

SURGICAL CLINIC AT JEFFERSON
MEDICAL COLLEGE HOSPITAL

OF PROFESSOR PANCOAST.

(Report No. 1.)

BY L. HARRISON METTLER, STUDENT.

It must certainly be of great advantage to the students of Jefferson Medical College to have the professors in their surgical clinics illustrate their teachings in this plain and practical manner. His colleagues and himself have thus the opportunity, from the standpoint of their different Chairs, of impressing upon their minds facts of importance in connection with their teachings, and those that they know to be of special practical value in their private practice.

After a few more pleasent words from the Professor by way of introduction, and a respectful and cordial greeting from the class, without loss of time, the first case was introduced.

CASE I. A child not one year old, yet with a soft fluctuating tumor, about the size of a walnut, over and extending somewhat below the posterior fontanelle. There was no history of a fall upon the back part of the head, or of

T the usual hour to-day for the surgical any other injury thereabouts. The tumor, to

A che, profesor William H. Pancoast the touch, seemed fluctuating, as if there were

fluid in it, but its integumentary covering felt somewhat thickened. There was no inflammation of the scalp over the tumor or in the surrounding tissue. The lecturer said that he thought the swelling contained either watery or bloody fluid. Its position so near the posterior fontanelle, might lead one to suspect that it communicated with the cavity of the skull, and that it might be a case of an open posterior fontanelle, with the coverings of the brain protruding to make the wall of the tumor as in a spina bifida.

appeared in the amphitheatre of the hospital to give the first of the lectures of his clinical course, in connection with his Chair as Professor of General, Descriptive, and Surgical Anatomy in the college. He stated that he would give the history of each case, the scientific description, and microscopical examination necessary, the diagnosis, prognosis, and treatment of the same; that he would pay especial attention to the surgical anatomy in every operation, so as to illustrate his didactic lectures upon that subject, and bring before the class the points of anatomy that they were Attention was called to cases of hydrocephastudying, thus proving to them the essential lus, and the lecturer referred to a specimen of and immediate necessity of a practical knowl-hydrocephalic skull that he had shown the

which had been quite widely adopted. Pure silk, dyed with iron, which is fixed in the silk, and the silk finished with acetic acid, is much less irritating than the ordinary white silk. A compress soaked in a 1 to 1000 solu

class in his anatomical lectures, where the watery effusion had pushed out the bones of the skull, making them thin from the pressure, enlarging the fontanelles, and making the cranium appear enormously large in contrast to the face. He pointed out the position of the bichloride of mercury was then tion of the occipital bone and its method of articulation with the two parietals posteriorly to make the posterior fontanelle, and asked some questions as to its position, impressing upon his hearers what he had previously taught, that the largest part of the occipital bone was on the inferior surface of the skull, and that it reached forward by its basilar process to articulate with the body of the sphenoid; that in this inferior part was the foramen magnum, through which passed the spinal cord.

To establish the diagnosis, whether the tumor communicated through the posterior fontanelle with the cranial cavity, the Professor took a delicate steel toilet-pin and passed it through the wall of the enlargement; with its point he carefully felt the bone beneath, and demonstrated that there was a bony floor to the tumor in every direction, and that it reached up and overlapped the posterior fontanelle. As the pin was withdrawn a drop of blood followed. The diagnosis was made of a vascular cyst or hæmatoma, probably present at the birth of the child.

bound neatly over the external wound. The lecturer said that he liked the bichloride of mercury antiseptic lotion very much for external dressings, but not so well for the frequent washing out of cavities; for, unless it was exceedingly weak, it was not judicious to wash out cavities freely and often with it. The patient was given the following prescription to quiet irritation and produce sleep :

R. Chloral hydrat.

Potass. brom.
Syr. zinziberi

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M. Sig. Half to one teaspoonful every hour for three doses, or until sleeping.

CASE II.-Boy about sixteen years of age, with a permanent contraction of the muscles of the right forearm, and forced flexion of all the fingers and thumb of the corresponding hand. Upon examining the arm there was found quite a large patch of cicatricial tissue, with the usual puckering, and appearance of such lesions. The history stated that this was the result of a gunshot wound received about two years ago, just above the inner condyle of the right arm,

where the cicatrix was now located. Part of the

With a curved bistoury, the Professor laid open the sac, from which some thick, seemingly clotted blood poured out. He then with for- biceps and brachialis anticus muscles had been shot away, and the consequent cicatrix had ceps and finger pulled out the sac, with its vascular lining, and the blood ceased flowing al-contracted down and compressed the nerves of the arm. There was great tenderness in the part most immediately. The child, having been sufficiently etherized, felt no pain. The cavity upon pressure. The Professor diagnosed here imwas then carefully syringed out with the plication of the median and ulnar nerves in the cicatrical mass, which was proven by the fact Professor's favorite antiseptic solution of the chloride of zinc, made by dropping some crysthat the fingers could all be gently extended tals of it into a basin of water until the latter by force, but quickly assumed the flexed position upon letting them go. was sufficiently saturated with it to turn blue litmus paper to a slightly red tint. The cavity of the wound was lightly packed with a piece of clean patent lint saturated in the solution, to prevent any oozing of blood. The edges were brought neatly together with some fine black silk sutures, leaving the lower end of it open, through which the end of the lint was seen, for the purpose of drainage and easy removal of the lint afterwards. The Professor spoke of the importance of draining deep wounds properly, and of the value of the black silk sutures that he had introduced into surgery, and

At present nothing will be done except rubbing the cicatrix with—

R. Ung. zinci oxidi,

Ung. aq. rosæ

aa 3ss.

Apply over the cicatrix the usual leadwater and laudanum lotion, and placing the forearm on a straight splint, flex it upon the arm with the fingers spread out upon a soft pad. The reason for flexing the forearm in the dressing is, that the more it is extended the tighter will be the flexion of the fingers. The Professor calls attention to the great care that must be taken not

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to injure the nerves in cutting down upon this tissue to set them free. Whether a neuroma has been formed here is questionable, but under all circumstances an operation is necessary, and the nerves must be set free, if possible.

CASE III.-Man; age about 40; complains of constant headache, increased upon any violent motion or jarring. The history stated that, being a bricklayer and climbing a ladder that extended to the second story of a house, he fell and struck the back of his head on the pavement. This happened about seven weeks ago. He was taken insensible to the Pennsylvania Hospital, where he remained five days, after which he got up and at once began going about. The Professor explained that in an injury of this sort there was a disturbance in the relation of the brain fibres produced by the severe concussion, and that rest, prolonged rest, was the first requisite in the immediate treatment of an injury of this kind. There was no internal strabismus or external symptoms of depressed bone, fracture of the skull, or evidence of compression of the brain, but, according to Dr. Tax's examination, there was a change in the optic disc, with marked retinal congestion; vision good, but not so sharp as formerly. The patient was told to stand upon his toes, and then to come down sharply upon the floor with his heels. This sudden jarring caused quick, shooting pains through the head, as well as pain down the back and sides, thus showing that most probably the spinal cord was also involved.

The treatment will consist of rest, with dry cupping up and down the sides of the spine, and after shaving off the hair the application of two wet cups to the head on each side of the middle of the sagittal suture, sufficient to draw two ounces of blood. This will abstract some of the blood from the cerebral membranes, through the parietal foramina. In post-mortem examinations, the Professor stated that he had seen the bone filled with blood from the action of cups, thus making it distinctly red in color. In a day or two, if necessary, the patient will again be cupped over each mastoid process, to draw about an ounce of blood from each side, and blisters will be applied to the top of the head and nape of the neck. But rest is the "sheet anchor" of our treatment here, and to assist in obtaining this the patient is to take internally twenty grains of potas. bromide every hour until asleep. The following mild cathartic

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M.-Ft. mas. in pil. divid. No. iv. Sig. One aperient pill at bedtime, followed by a saline, if necessary.

CASE IV.-Woman about 45 years of age, a widow with seven children, all healthy, came seeking treatment for a large, mobile swelling just at the umbilicus. She said that it began six years ago, after childbirth, and that she had suffered with more or less general pain all of that time.

Upon palpation the tumor seemed readily to sink back; there was marked crepitation, and the umbilical ring was distinctly felt by the Professor.

Diagnosis was umbilical hernia. Under the Professor's delicate manipulation the hernia was quickly reduced.

The scientific and descriptive name of this form of tumor is an entero-epiplocele, the hernia consisting of intestine and omentum.

After the reduction some oxide of zinc ointment was applied to the surface, and a neat, strong impromptu compress was made out of a piece of cork, covered with patent lint, and held in position directly over the umbilicus by adhesive strips. The patient was advised to get a truss, and to wear a broad flannel abdominal bandage, supported by suspenders from the shoulders.

Had the hernia been irreducible or strangulated, the operation would have been performed of cutting directly down upon the mass, incising the umbilical ring, and with strong black silk sutures drawing the ring together again after replacement of the bowel. The sutures would be cut short and left undisturbed, to become encysted or to come away. ternal wound would be united by separate interrupted sutures.

The ex

The truss and bandage that was proposed, Mr. Snowden, the surgical instrument maker, who was present, very kindly and generously offered to make for the patient. She will be shown at the next clinic with the truss and bandage applied.

CASE V.-Boy about 8 years old, attended by his mother, who is healthy, and with several children all equally hearty except this one.

In the hypogastric region of the abdomen, at the base of the penis, a red-looking opening existed, through which a catheter could be passed into the bladder. The glans penis and corpus spongiosum were all intact, and the scrotum and testicles normal, but the corpora cavernosa were absent, and the urethra was only indicated by a groove upon the corpus spongiosum leading into the bladder. The prepuce was well marked.

The Professor called the attention of the class to the fact that in a case of true exstrophy of the bladder, the anterior wall of that viscus was entirely wanting, while the posterior wall projected through the opening in the wall of the abdomen; but here, he continued, we have a case of epispadias, with absence of the urethral wall along its upper surface, and the remains of the urethra clearly traceable along the superior border of the undeveloped penis. Dr. Levis, upon examination, remarked, that practically for operation this was a typical case of exstrophy, though the integument over the bladder was perfectly whole. Professor Pancoast demonstrated that the epispadias was here the affection in reality, with a lack of complete development of the penis, but the operation would be similar to one for exstrophy of the bladder.

To alleviate this little patient's condition an operation will be necessary. The main purpose of this will be to cover in the exposed surface by means of flaps of integument dissected from the neighboring abdominal wall and then turned over and united so as to close the opening, in the hope that this integument will take on the character of mucous membrane and protect the anterior wall of the bladder and close the abdominal opening. This operation, together with the Professor's own modification of bringing down and exposing the diminutive penis for the sake of the moral effect upon the patient in after-life, will be performed at some future date.

To day, the preliminary operation, formerly introduced by Dr. Levis, was performed, of making a permanent opening through the base of the bladder into the rectum, through which the urine may flow and be retained by the sphincter ani muscles, though the lecturer said he had in previous operations found it difficult to keep the opening patulous, and to make perfect drainage through it, even with a large hollow tube through it.

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The patient being well etherized, a long curved trocar, with the point covered by the end of the canula, was gently introduced into the opening along the false urethra, the point suddenly exposed and the instrument plunged through the anterior wall of the rectum, so that the end of the tube after withdrawal of the point could readily be pushed through the anus. Through this a number of rubber strings were passed, to be tied and left in the canal after the removal of the canula. The parts were dressed in chloride of zinc, to guard against all septic infection. Thus ended the first part of the operation, and the patient was withdrawn.

CASE VI.-Man, about 25, with an old sebaceous tumor on the left cheek, just above lip; he had been operated upon before, but as the entire sac was probably not removed at the time, the tumor still remained red and inflamed. The lecturer said that this case proved the importance of removing the entire sac at an operation.

In lieu of ether, which the man refused to take, three hypodermatic injections of a two per cent. solution of cocaine were made in the neighborhood of the tumor.

Transfixing its base with a large-sized toiletpin, around which was tied a strong black silk ligature to prevent hemorrhage, the Professor quickly cut it out, removing the entire sac and a portion of the skin, making a clean incision in the line of the wrinkles of the face, and united the lips of the wound with fine black silk sutures, in a manner to prevent drawing the corner of the mouth upwards. Oxide of zinc ointment and chloride of zinc dressings, held in place by adhesive strips, were applied, and the patient dismissed.

CASE VII.-William C-, age 37; married two years; one child, apparently healthy; suffering from an ulcer of five months' duration on the outer side of the left ankle, measuring from two to three inches in diameter. The patient stated that he had had gonorrhoea several times, for which he had been treated. About three years ago he had a hard chancre, with the secondary eruption of syphilis appearing about six months after.

The Professor made the diagnosis of ulcer of syphilitic origin, with syphilitic periostitis.

Under ether the ulcer and surrounding tissues were well tapped with the sharp point of a curved bistoury with the antiphlogistic touch, and the part dressed with carbolized oxide of

zinc ointment, and kept well moistened with a
lotion of leadwater and laudanum.
The pa-
tient remained in the house, and was placed in
bed with the leg elevated. The bowels were
regulated, and a specific treatment, with the anti-
phlogistic tapping when needed, was ordered.

A gumma over the right knee was also tapped subcutaneously with the therapeutic knife.

CASES VIII. and IX.-Two men, one with gonorrhoea, and the other with supposed stricture, but in the latter case the diagnosis was uncertain, on account of the patient refusing to be examined. In the treatment of gonorrhoea, the Professor noted that while strong and irritating injections were very apt to produce stricture, we need anticipate no such result from the use of mild, slightly astringent applications; furthermore, by this means pain upon urination would be greatly alleviated. For this patient the following injection was recommended:

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R. Zinci sulphatis,
Plumbi acetat.
Morphinæ sulphatis
Aq. rosæ

āā gr. viij.
gr. j.
3ij.

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M. Sig. Commence with one teaspoonful to seven of water, as injection, three times a day.

A small syringe holding about an ounce, is the proper thing to inject the urethra with. If there is much pain, suppositories containing each about a half a grain of opium might be employed. In this affection the Professor likes and often uses the ready prepared capsules of copaiba, keeping the patient quiet, if possible, using hot baths and water applications around penis, scrotum, and perineum.

CASE X.-German girl, of age about seven. Here we had a case of periostitis of the middle of the right leg, involving all the neighboring soft parts, due probably to a specific cachexia. The history from the father was very obscure. Upon examination with a probe the bone was found bare, with the periosteum entirely gone. Under ether the part was thoroughly tapped with the Professor's favorite therapeutic knife and antiphlogistic method, making upwards of seventy-five or one hundred punctures, and letting out freely the dense, black blood.

ORIGINAL COMMUNICATIONS.

ON THE NERVOUS AND MENTAL
DETERIORATION PRODUCED
BY THE OPIUM HABIT IN THE
HIGHER CLASSES.

BY EDWARD C. MANN, M.D., NEW YORK.
Member Medical Society of the County of New York, New York
Medico-Legal Society, American Association for the Cure of
Inebriates, etc.

N the neurotic circle of society there is a

greatly augmented susceptibility to the action of stimulants and narcotics, and a greatly increased consumption of morphine, and of the great nerve sedative, tobacco. The circle of males and females who exhibit the disease of alcohol and opium inebriety is almost entirely confined to the neurotic circle, and this latter circle is increasing, we think, out of proportion to the increase of population. This is due to the influence of the conditions of modern life upon the nervous system, and through the nervous system upon the nutrition of the tissues. The outer relations of the modern American have become more numerous, complex, and heterogeneous than formerly, and his environments more varied and intricate. We therefore find the greatest amount of opium, chloral, and alcohol inebriety in towns and cities, where nervous diseases most abound, and not in the rural districts. Its growth is encouraged by the excitement of city life, and by the absence of the tranquilizing influences of nature met with in the country. The remote 'cause is not unfrequently educational pressure, unwisely applied to weakly children, which induces brain fatigue. A proof of this is found in the fact that the preponderance of opium, chloral, and alcohol inebriety is to be found in the refined and cultivated classes. There are vast reserves of hidden and unauthenticated cases of this kind, which reveal great unfathomed depths of nervous and mental unhealthiness in our metropolitan communities. The increase of suicides. also points strongly in this direction. The whole order of nervous diseases, not necessarily accompanied by mental disorder, but in many instances tending towards it, are widely prevalent amongst our population. Such diseases are epilepsy, paralysis, locomotor-ataxia, spinal

Oxide of zinc ointment was then applied gently over the surface, and the leg dressed and kept moist under an evaporating lotion of lead-irritation, neuralgia, hysteria, chorea, etc., and water and laudanum. The child was placed upon a tonic course of treatment and then dismissed.

of all these diseases I have treated at length in my work on "Mental and Nervous Diseases." A bodily derangement is responsible for every

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