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by standing on it. She complied and the bone yielded obedience to his weight; but when he stepped off the scapula came up. This operation was repeated several times, and as often did the refractory bone persist in having its own way. The question by this time became a square issue with the doctor. He must either stand on this lady's back always, or let the bone do the standing. He was positive that he had reduced the luxation, and that he had adjusted the relation of the origin and insertion of the muscles. Hence the stubbornness of the scapula was the more mysterious. He told her that nature would adjust this little deformity and all would be well in a few days. On leaving he requested her to call at his office in a week. She did so, and he called Dr. M., (above mentioned). They examined the shoulder, and decided it to be still dislocated. They again attempted to reduce the luxation but failed. They then examined the shoulder more closely, and declared that there was a fracture of the humerus near its head. They did the arm up in splints and sent her away, directing her to call in a week. She presented herself at Dr. G.'s office according to agreement. Drs. G. and M. called two other surgeons of their school, to assist them. They examined the case very minutely. Diagnosis shoulder dislocated. They administered ether, and attempted a reduction by main strength with the assistance of pulleys, but failed again and gave it up; Dr. G. agreeing to take her to Kansas City and have her shoulder fixed at his expense. The young lady refused to go, and was left to be a cripple for life.
In the course of time she employed an attorney to prosecute Dr. G. for malpractice. Acting by the direction of her attorney, she applied to Dr. P., (a liberal Allopathist) and me to ascertain the condition of the shoulder. We found the head of the humerus half-way between a sub-clavicular and sub-glenoid position, and supposed that it had been worked there by manipulation. We told her that it could be reduced. Accordingly, with her consent and that of her lawyer, we performed the operation with but little difficulty. This gave her good use of her shoulder and arm. The scapula dropped to its proper position and seemed to fit as nicely as if nature had intended it for the place.
The suit for malpractice was put off from time to time till several parties to it had left the county, and it was then thrown out of Court.
By T. HODGE JONES, M. D., Lamar, Mo.
Morioplastice is that branch of human surgery which treats of the restoration and formation of lost or absent parts of this body. Many names have been applied to operations of this kind, from the structure involved, by adding to the anatomical name of the part to be repaired the word plastic. The uses of the operation are to correct deformities and to give symmetry to ungraceful portions of the body. The necessity for it may arise from accident, from congenital malformation, or, as history asserts, from the results of a kind of punishment for certain crimes in barbarous nations.
The last-mentioned cause, it seems, has given rise to the operation. So many persons were mutilated for offending the law that physicians were importuned for relief. Hence, as early as A. D. 131, Galen, at Alexandria, in Egypt, is said to have practiced rhinoplasty, or the art of rebuilding the lost nose. In surgery many considerations are necessary to the successful performance of any operation. Plastic operation consists chiefly in transplanting healthy integument and tissue from some other portion of the body to the locality of a deficiency. The general health of the patient, the condition of the part needing repair and its locality, the state of the weather and temperature of the apartment wherein the operation is to be performed, should be well understood and adapted to the occasion.
The nature of the integument covering adjacent structures, should be examined as to thickness, color and pilosity; it must be healthy at the site selected to supply the grafts and possess as nearly as practicable the properties of the natural covering of the part to be reconstructed.
A cicatrix will not yield good grafts, and it is better to take them from the patient than another person. It may be stated as true that no such operation should be performed while the causes remain of the deficiency it is designed to supply. The preparation of the patient and attention to surroundings required will be suggested by the conditions in each case. The general health must be at its maximum, and the best-known means to keep it so adopted. It is of the minor operations only that I wish to treat in this essay.
Recently, Dr. D. J. Hamilton, of Edinburgh, Scotland, successfully grafted sponge, antiseptically prepared, into spaces left by the excision of tumors, and thus aided the filling-out of the loss of material consequent to the removal of the unhealthy substances.
Dr. McEwen, in The Lancet for May, 1881, reports a case wherein he successfully transplanted pieces of bone from one person to another, which made amends for the ravages of necrosis. Our authors have given very specific directions for modes of proceeding in correcting hare-lip, cleft-palate, perineal fistula, penile fistula, extrophy of the bladder, etc., seemingly to neglect of the class of smaller cases to which I shall refer. Many excrescences, spots, scars, moles, etc., disfiguring the face and neck; bald spots on the scalp, unsightly nævi, livid discolorations, powder-stains, etc., on the face or hands may require removal.
Ulcers of the leg are among the most intractable minor affections which we are called upon to treat. I suggest skingrafting as among the best means of correcting the conditions mentioned. In any plastic operation the skill and judgment of the operator will do much to modify his actions. For ulcers and tumors the unhealthy substance should be cleared away and granulation encouraged. The amount of tissue to be removed in such cases will depend upon the extent of the affected parts. The only safe rule is to extirpate the diseased matter. In cases of scalds or burns, where the skin slips off, there may be little material requiring removal. The objects of treatment are to hasten resolution and avoid contraction of the integument. Accidental injuries will furnish cases in
which no preparation of the patient can be had; but in ulcers from syphilis very careful hygienic measures will be necessary to give promise of success. For the performance of the many operations herein alluded to, a few measures are common and the judgment of the surgeon must supply the changes: First, careful preparation of the patient and apartments. Second, thorough removal of all the diseased or superabundant tissue. Third, the application of antiseptics and stimulants to hasten granulation. Fourth, when granulation is well established, the application of carefully-selected skin-grafts, to the raw surfaces. Fifth, covering the grafts with antiseptic cotton, held by adhesive strips.
For the stimulant and antiseptic wash and a general dressing, I suggest a solution of chloral hydrate, ten grains to the ounce, in a mixture of pure water and glycerine, equal parts. If the grafts do not take, it will be well to use a much stronger solution of chloral, in order to destroy unsound granulation; and at the proper time apply new patches or grafts as before. The grafts may be of very small size, or as large as a halfinch in diameter. I think that the plastic operation should be more generally practiced. It is useful in all wounds where the skin is not sufficiently loose to approximate and stitch, and when large surfaces are demanded. This is a field open for cultivation and improvement, worthy of diligent study and cautious experiment.
NOTES ON SYPHILIS.
By A. J. HOWE, M. D., Cincinnati, Ohio.
My object at this time is to make some practical remarks on the treatment of some phases of syphilis, and to do so without discussing theories in regard to the number of species or varieties of venereal disorders. Inasmuch as I am an avowed dualist, I will name a few who entertain similar views on that point, in order to show that I am in pretty good company. Once Ricord believed that soft and hard chancres came from
one virus, and that both kinds of sores needed mercury for their cure. Now the old syphilographer holds that the soft chancre is a local disease, and that the hard variety is constitutional; that the first-mentioned needs only topical treatment, and the latter systematic medicines-mercurials and "alteratives." Concurring in the same views, among the French, are Chomel, Dupuytren, Bassereau, Rollet, Diday, Guerin and Founier. English surgeons are divided on the question. Yet in favor of the dual existence of syphilitic poisons are Mr. Berkeley Hill, Drs. Drysdale, Barton, Lee, Patrick Watson, Aitken, Nevins, Prof. Longmore and Sir Henry Thompson. Belief in the dual theory is evidently on the increase at home and abroad; in fact, there are few surgeons of note who hold the old unicist dogma. However, I have no desire to force a theory beyond its legitimate limits. I have no individual interest to serve. This is an age of free discussion and independence of opinion. Let every one focus an incandescent light on every disputed point in science, and use lenses when they are of service. This is too late for strabismic opinions to prevail.
The importance of discussion rests here. If a venereal sore can be cured with topical applications, what is the use of wasting money on internal medicines, to say nothing of the harm they may do? Then, again, the harboring of an error cannot be otherwise than damaging to a physician. If a medical man believe in the protective influence of vaccination, and there be no immunity in the scheme as alleged, then the deceit is detrimental to him and to all to whom it pertains. On the other hand, if successful vaccination be protective to a valuable extent, those who entertain no faith in it are injuring themselves and the community in which they practice.
It has been affirmed by the champions of the single-virus theory that the medication of every case can do no harm even if the disease be local in its nature and manifestations. But an answer in part to such an assertion has already been given; and in addition it may be said that a patient is mentally disturbed by the thought that he is contaminated with a disease. believed to be transmissible from parent to offspring. I have