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 RD91 P93 1888 An aseptic atmospher 
 
 1HBH Prince. 
 
 Palatoplasty. 
 
 RECAP 
 
o 
 
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An Aseptic Atmosphere, 
 
 CLUB FOOT 
 
 A Rectal Obturator. 
 
 /PALATOPLASTY 
 
 By DAVID PRINCE, M. D., 
 
 JACKSONVILLE, ILL. 
 
 Jotirnal Press. 
 
 1888. 
 
WEBSTER LIBSARV 
 
 /Iff 
 
 An Attempt to Secure a Sterilized Air 
 
 FOR SURROUNDING THE WOUND AND ENTERING THE 
 PERITONEAL CAVITY IN 
 
 LAPAROTOMY, 
 
 By DAVID PEiyCE, M. D., 
 
 JACKSONVILLE, ILL. 
 
 The extent of the absorbing surface of the peritoneum, makes it undesira- 
 ble to subject it to .those antiseptic irrigations which are found to be so bene- 
 ficial in other wounds. It is supposed that a wound made in the amputation 
 of a limb, may be protected from the injurious contact of atmospheric dust 
 by irrigation, and that the spray of carbolic acid diminishes the tendency of 
 ge^ms to develop in the exudates. The skin and the mucous membranes con- 
 stitute a barrier to the entrance of floating material acting as a poison when 
 it gains access to the living solids and fluids. Some of these atmospheric 
 p -ents are capable of entering by the lungs, without a previous breach of sur- 
 lace, and the presence or absence of these agents in the air (like the conta- 
 gium of malarial fever), constitute an important element in the question of 
 the healthfulness of a dwelling place. Other agents, like the contagium of 
 erysipelas, may localize themselves in a habitation, so that the danger of in- 
 fection continues a long time after the apparent cause has been removed. 
 
 Until within a few years, and before the observations with which the name 
 of Joseph Lister is indissolubly associated, the infection inhering in the at- 
 mosphere of hospitals was a mystery. It eluded observation and investiga- 
 tion. It defied every attempt at removal by cleansing and the replacing of 
 wall paper and plastering; in short, everything except the complete destruc- 
 tion of the buildi'ng itself. The difficulty in keeping hospitals free from in- 
 fection, led many to the conviction that they should always be built with 
 reference to their being torn down after a temporary use. We now know 
 that the prevention of such inhering infection in a building, is the avoidance 
 of the first case of disease, or such management of it by antiseptic agents, as 
 will limit the production of the contagium to the smallest possible quantity, 
 and neutralize that which is unavoidably produced. By antiseptics and ven- 
 tilation, the problem as to house infection has been pretty well worked out. 
 
 The problem attempted to be solved in this paper, is to secure in an apart- 
 ment for any convenient length of time, an atmosphere more pure than the 
 outdoor air, so that a room, or any number of them, may continue, as long as 
 the machinery is in operation, to contain an atmosphere as pure as that of a 
 mountain top. 
 
 With the working out of this problem, it becomes practicable to open the 
 abdomen or other parts, and to keep it open an hour or more, and on closing 
 it, to have it in such condition as to material floating on the air, as it would 
 be in, if all the proceedings had been carried on subcutaneously. 
 
 The evidence is complete, that erysipelas and some other septic infec- 
 tions, are capable of being propagated by the products of a previous disease 
 of the same kind. 
 
 Prom the Transactions of the 9th International Medical Congress, Washington, Sept., 1887. 
 
The experimental evidence by inoculation may be illustrated by a quo- 
 tation. 
 
 In the " Monograph on Micro-organism and Disease," by Dr. E. Klein, p. 
 48 (McMillan & Co., 1884), Orth is quoted as having cultivated artificially 
 the micrococci of erysipelas, and afterward reproduced the disease in rabbits 
 by inoculation. Fehleisen found the micrococci only in the lymphatics of 
 the affected parts, and those he cultivated artificially for fourteen genera- 
 tions (which it took two months to do) on peptonized meat extract, gelatine, 
 and solid serum. The micrococci form a whitish film on the top of the nour- 
 ishing material, and when inoculated into the ears of rabbits, a characteris- 
 tic erysipelatous rash makes its appearance after from thirty-six to forty- 
 eight hours, and spreads to the roots of the ears and further on to the head 
 and neck. The animals do not, however, die from it. In the human subject, 
 he produced typical erysipelas after inoculation with the pure cultured mi- 
 crococcus in from fifteen to sixty hours. These inoculations were made for 
 the purpose of curing certain tumors, one of lupus, one of cancer, and one 
 of sarcoma. Fehleisen also in several instances carried out a second inocu- 
 lation successfully, within a few months. He found that a three per cent, 
 solution of carbolic acid and a one per cent, solution of mercuric bichloride 
 destroyed the vitality of these micrococci. 
 
 That the material is also capable of being transmitted through the air, 
 and of fixing itself upon wounds or abraded places, is proved by the strong- 
 est possible circumstantial evidence. This being admitted, the problem of 
 prevention resolves itself into that of exclusion of the matter from contact 
 with the susceptible part, or destroying it between the moment of contact 
 and the time of its development into disease. 
 
 The spray of carbolic acid as devised by Lister, acts probably not by de- 
 stroying the septic microbes, nor by excluding them, but by rendering the 
 conditions unfavorable for their development. The spray prevents the dry- 
 ing of the exposed wound surfaces; prevents the incipient changes which 
 precede apparent decomposition, at the same time that the germs themselves 
 are depriv d of the surroundings most favorable for their development. In 
 the meantime, the germs are destroyed by the white blood corpuscles before 
 they have developed the conditions of attack. The drip or douche of car- 
 bolic acid, or of mercuric bichloride, acts in the same way to wash away or 
 to neutralize the activity of such germs as may fall upon an exposed surface. 
 
 While this may be said of ordinary septic germs, it is not so certain that 
 pathogenic germs, like those of erysipelas, can be neutralized by the action 
 of a spray or a douche, if they are once implanted upon the surface of the 
 living tissue. 
 
 These methods are liable to failure in cases of wounds of irregular sur- 
 faces, on which it is difficult or impossible to secure an adequate application 
 to the whole surface, of sufficient intensity and duration to destroy the in- 
 vading virus. The exposure having been made, however, the chemical or 
 the germicide agent is the only thing that can be relied upon to prevent the 
 natural consequences. The perpetual drip of a weak solution of carbolic 
 acid (one per cent, solution) has been proved to be capable of preventing 
 the development of erysipelas, and of putrefactive changes detrimental to 
 the healthy healing of wounds. 
 
 , - The perpetual bath, antiseptically medicated, is applicable to the feet and 
 
 the fore-arms, and by tying in the water, it is applicable to the whole body, 
 except the upper part of the neck and the head. Some very satisfactory re- 
 sults have been obtained by this method of management. 
 
 It must be admitted, however, that many wounds do not admit of the pro- 
 longed application of this or of any other agent capable of neutralizing an 
 infection w T hose natural development is that of erysipelas or of putrefaction. 
 Among these are wounds of joints and of the peritoneal and the pleural 
 cavities and the cavity in the eye cnntainingthe acqueous humor. The agents 
 J of infection once introduced, the practitioner is at great disadvantage in the 
 treatment of the case. 
 
Much may be done by drainage and the introduction of disinfecting 
 liquids, but it is necessary that they shall be of feeble force, in order not to 
 irritate the delicate surfaces or not to poison the general system by absorp- 
 tion through the surfaces to which they are applied. It follows from these 
 considerations, that the prevention by disinfecting agents should be the least 
 favored method, and to be employed where the prevention by exclusion is 
 impossible or has been neglected. 
 
 The exclusion is of two kinds: the immediate and temporary; and the 
 permanent. 1st. The exclusion of those agents from the air which surrounds 
 the patient at the time of an operation, by means capable of purifying the 
 whole atmosphere of an apartment, or the portion of it which surrounds the 
 wound in the progress of formation; and 2d. The permanent exclusion of an 
 infected atmosphere by the mode of dressing. 
 
 This implies, that while the atmosphere of a whole room may be made 
 aseptic during the time in which an operation may be performed, it may be 
 too troublesome or too expensive to secure a perpetual purification of the 
 apartment occupied by the patient during his recovery. It is implied, that 
 the exposed wound surface may be effectually secluded from contamination 
 by such a character of the dressings as to make it certain that the infection 
 will be arrested or destroyed. 
 
 We have our subject classified by the nature of things; as 
 
 1. Antiseptic applications during the progress of cure. 
 
 2. The arrest of the access of infection during the progress of cure by 
 the -character of the dressing first applied and allowed to remain. 
 
 3. The purification temporarily of the air of an apartment in which a 
 surgical operation may be performed. 
 
 1st. The plan of the first method is that of a perpetual irrigation, or a 
 perpetual bath. 
 
 2d. The second plan is that of a dressing impervious to the floating ob- 
 jects in the air, and it includes the "Lister dressing." 
 
 It is found that it is of no advantage to have the dressing air-tight or 
 water-tight, but that a material with fine meshes, like that of cotton, will 
 answer the purpose. If the wound is exposed under a spray or douche, and 
 aseptic cotton, wool, or other similar material, be applied and retained, the 
 agents of septic changes cannot enter as long as the material of the dressing 
 is entirely dry. It is, therefore, convenient to have the cotton or other sub- 
 stance previously treated with a solution of mercuric bichloride or other 
 antiseptic, the water being dried out before the use of the material for dress- 
 ing. Otherwise the dressing, infiltrated with the exudations from the 
 wound, becomes putrid, requiring its removal sooner than is necessary with a 
 dressing capable of preserving from putrefaction any fluids that may get 
 into it. 
 
 In applications of gypsum it is convenient to wet it with a solution of 
 Hg. CI 2. 
 
 3d. The plan of the third class, is that of securing the freedom of a 
 whole apartment from floating minute particulate material of all kinds dur- 
 ing the time necessary for the performance of a surgical operation, or the ex- 
 clusion of air dust from the portion of air surrounding a wound and entering 
 into it. 
 
 It is exceedingly probable, that if the cavity of the peritoneum or any 
 other closed cavity, can be opened in an atmosphere free from floating ma- 
 terial, and closed again after a short period, the conditions will be the same 
 as though the work of removing a tumor, or other operation, had been done 
 subcutaneously, so as to exclude the contact of air. 
 
 The_ continued purity of animal and vegetable liquids sterilized and 
 placed in vessels closed by sterilized cotton, admitting free access of gases 
 but sifting out particulate material, affords the strongest probability to the 
 assumption that the septic changes occurring in wounds and in closed cavi- 
 ties into which air has entered, would not occur, if the air were free from 
 such material as might be filtered out by passing through cotton or other 
 
material having fine meshes. Reasoning from the general facts here referred 
 to, in relation to animal and vegetable fluids secluded from the floating ma- 
 terial of the air, it becomes in the highest degree probable that the material 
 of wounds would be equally exempt from change, if exempt from the con- 
 tact of this floating material, and that if thus secluded, putrefactive changes 
 would not occur. Wounds and injuries which are subcutaneous, show an ex- 
 emption from septic changes, though a great amount of vascular and nervous 
 disturbance may arise from the injury. 
 
 The use of douches and irrigations, is not for the purpose of purifying 
 the air, but for washing away these minute particles, or rendering them 
 inert by some influence upon them, thus rendering them less able to germi- 
 nate, or, for the purpose of affecting the living surfaces, increasing their ca- 
 pability of resistance. 
 
 I visited several cities of Europe in the summer of 1884, and had it in 
 mind to observe what provisions were made toward the end of exemption 
 from septic changes incident to surgical operations. I saw several new rooms 
 with non-absorbable floors, walls and ceilings, yet having doors opening into 
 the halls of hospitals. There were provisions for non-absorption of anything 
 floating in the air of the apartment, but no provision for purifying the air. 
 
 At Hamburg, in connection with the female department of the general 
 hospital, was a room just completed, having four outside walls, so that it was 
 necessary to go through six feet of open air, to get from the hospital into it. 
 There was evidence of great pains to secure the greatest possible degree of 
 cleanliness, but there was no provision for a better air than the outside at- 
 mosphere of a large city. I came home resolved to do something better than 
 the latest improvement in Hamburg. 
 
 The apparatus to be described is the result of my reflections upon the sub- 
 ject, and experience has suggested so many modifications that new cuts have 
 been necessary in order to illustrate the history of the development of the 
 idea, and the adaptations for hot and for cold weather. 
 
 For hot weather, the current of air cannot be secured by heat produced 
 in the operating room above, or in the room below, but must be obtained by a, 
 draft connected with a chimney operating as a vis a f route (which is practi- 
 cable in any hospital having a chimney which is in use in summer),or by a 
 fan, operating as a vis a tergo, blowing air into the basement, which is to 
 travel upward through the operating room. 
 
 Taking a hint from the observations recently made in Paris upon the 
 effect of rainy weather upon the number of microbes floating in the atmos- 
 phere, it occurred to ask, whether or not it is practicable to subject the air 
 entering an operating room to the influence of artificial showers in order to 
 precipitate to the ground, the whole or greater part of these enemies to 
 surgery. 
 
 They are known to be heavier than the air, because they entirely disap- 
 pear from the air within a tight box which has been several months in one 
 position. This principle of rest is of no use to us, for the purification of the 
 air of an operating room by this means is impracticable The commotion of 
 the air incident to the use of a room, must dislodge the minute particles 
 from the floors and walls, and set them floating again in the air, besides per- 
 mitting the entrance of common air from without. 
 
 The dry filtration by means of cotton or other substances to entangle and 
 arrest the particulate material floating in the air, was not thought practicable, 
 on account of the rapidity necessary in the entrance and exit of the air in 
 order to displace the agents entering from without during the progress of an 
 operation, and also those emanating from the occupants of the room. If, 
 however, we can cause the air entering the room to pass through several 
 showers of water, we have an expedient which may entangle these objects and 
 carry them to the ground. 
 
 This paper contains five illustrations of the progress of thought in this 
 direction. 
 
 The following cut illustrates the first development of the idea. 
 
5 
 
 Fie. 1. 
 
 A'~:\ 
 
 
 . . — 
 
 . __. : _J _ 
 
 »a isasasil 
 
 1. Basement. 
 
 On the right hand is an entrance ventilator 20 inches in diameter, in which is a steam jet 
 for the purpose of infiltrating the entering air with very fine globules of water. (2) (3). 
 
 The air thus moistened passes in the direction of the arrows under a screen which de- 
 scends near to the floor (4). It is then warmed by a stove (5). 
 
 The air then passes up and down' over the top of another screen and up through a series 
 of dripping shelves (li) and through a spray (V) into the operating room above. 
 
 The exit ventilation is from the floor through the shaft (9) communicating with an open- 
 ing in the roof. Under the entering flow of air (3) is pot (8) for burning sulphur, which is sup- 
 posed to combine with the condensed steam and form a disinfecting solution in exceedingly 
 fine particles. 
 
 It has been found that the smell of a moderate flame of sulphur may be thus entirely sup- 
 pressed so as not to be perceived in the room above. 
 
 This cut (Fig. 1) was first published in the St. Louis Medical and Surgical 
 Journal for February, 1885; afterward in the American practitionei and 
 News, in the Transactions of the American Surgical Association, and in the 
 Quarterly Compend. of Medical Science. Fig. 2 shows some modification 
 in the detail of the same plan. [Continued on page 9.] 
 
Fi°\ 2. 
 
 Pig. 1. Window admitting ontside air. 
 
 Fig. 2. Steam for moistening all floating particles. 
 
 Fig. 3. Sulphur pot, with Bunsen burner under it, for slow combustion. A more rapid 
 combustion is secured by mixing alcohol with the sulphur. 
 
 Fig. 4. Spray of water through which the air must pass in going to the next apartment. 
 
 Jng. 5. Stove for heating the air which has been once washed. 
 
 Fig. 6. Screen for forcing the air to pass from near the ceiling through the next 
 washer. ° a 
 
 • F J&- 1' Sne l ves of thin niuslin through which water drips from the spray in the opening 
 
 in the floor above. f s 
 
 Fig. 9. Entrance of the air of the room into the draught heated to hasten the rapidity of 
 
 tilO ''SCJip©. 
 
 Fig. 10. Stationary partition. 
 
 Fig. 11. Movable portion hinged above, and taking a horizontal position under VZ, to 
 close the exit through the roof, when the room is used without runnim* the ventillatin" 
 svstem. 
 
 Fig. 13. Sky-light. 
 
 The third figure illustrates the advancement of the idea toward the cotton 
 
7 
 Fig. 3. 
 
 Scale, One to Sixty. 
 1. Entrance of ontside air closed when the pipe (figure 2) is in use. 
 . 2. Entrance of air blown in by a fan run bv an engine for hot weather. Specific gravity 
 is relied upon in cold weather to secure atmospheric motion and change. 
 
 3. Steam Jet. 
 
 4. Sulphur Flames. 
 
 5. Reservoir for Solution of Corrosive Sublimate. 
 
 6. Screen or Partition open fifteen inches next the floor. 
 
 7. Spray of water through which the steamed air must pass. 
 
 8. Box for flame for heating water as it runs through the pipe. 
 ft. Stove. 
 
 10. Spray of Sublimate water for the second washing of the air which passes through 18 17 
 
 11. Screen, the arrows showing the course of the air. 
 
 12. Series of muslin shelves. 
 
 13. Spray producing the shower for the second washing of the air going to the room above. 
 
 14. Stove for increasing exit draft. 
 
 15. Screen separating the space around the stove from the general air of the room, obliging 
 the escaping air to go from the floor. B B 
 
 16. Table. 
 
 «' VU- P n pe for conv eying sterilized air to the region of a surgical operation. 
 IS. window. D ' 
 
 19. Skylight. The arrows everywhere show the course of the air. 
 
Fig. 4 
 
 c, c, c, 3 cotton filters for inlet- 
 
 cc, cc, cc, 3 cotton filters for exit. 
 
 da, da, da, 3 floors under the inlet filters. 
 
 dd, aa, dd, aa, dd, aa, 3 floors under the outlet filters. 
 
 a, Inlet pipe. 
 
 aa, Outlet pipe. 
 
 6, Ascending inlet pipe, 
 
 66, Descending outlet pipe. 
 
 E, Ascending inlet pipe. 
 H, Ascending surgical pipe. 
 
 0, Descending surgical pipe, to be raised or lowered. 
 K, Thermometer. 
 
 Under g and over gg is the oblique swr^'eaJ.branch of the inlet pipe. 
 Gas, Gas flame for regulating the temperature of the air escaping from O. 
 S, Steam jet for regulating the moisture of the same air. 
 g, At tne top of the straight pipe g is an eye looking at the flame below 
 
 curved end of the inlet pipe for the sanitary use of purified air. 
 gg, Over gg is a screen to interrupt the straight horizontal blow of the same air 
 EE, Descending outlet pipe. 
 
 F, Canopy. 
 
 FF, Canopy let down. 
 
 L, Surgical table in section. 
 
 M, Sanitary bed in section. 
 
 The important objects are in section. 
 
 Above g is the 
 
The next advance in the conception of the subject, was a combination, a 
 purification of the general air of the operating room, and another supply of 
 purified air to envelop a wound in the progress of its formation. 
 
 In the device for an additional and separate supply of air for the wound 
 itself, a difficulty arose in the conception of the means of getting it there 
 in such force as to effectually displace the other air of the room, and monopo- 
 lize the space about the wound. It seemed that for hot weather the force of 
 a fan must be necessary. 
 
 The dry filtration by means of cotton or other substances to entangle and 
 arrest the particulate material floating in the atmosphere was not in this 
 stage of the idea thought to be practicable on account of the rapidity neces- 
 sary in the entrance and exit of air in sufficient amount. 
 
 It is intended in figure 4 to illustrate the application of the principle 
 to sanitary as well as to surgical purposes. For sanitary ends the scheme 
 illustrates the protection of a person from the evil agents in general, out- 
 side of a room. For instance, in a ship passing through a harbor in a 
 locality infected with yellow fever on the one hand, and on the other hand 
 the protection of persons outside from the infection of a yellow fever patient 
 brought into a previously uninfected district. 
 
 On ship board, the ventilation is supposed to be secured by a fan run by 
 the steam apparatus ; on land some power most convenient. 
 
 The plan of filtration through cotton is illustrated in Fig. 4, for surgical 
 and sanitary purposes, and in Fig. 5, for surgical purposes alone. 
 
 The room in which this scheme has been worked out for surgical pur- 
 poses, has a capacity of 3,360 cubic feet. 
 
 The air is taken from outside the building and carried through nine 
 hundred and sixty square inches of cotton an inch thick by means of a fan or 
 blower which theoretically should change the whole air of the room once in 
 five minutes. Any object exposed under the tube is. shielded from the con- 
 tact of the general air of the room. 
 
 The blower (No. 00 of the Sturtevant manufacture) revolves 3,512 times in 
 a minute. This is a rate of speed which makes very little noise and is suffi- 
 cient for the purpose. At this rate of speed, it is estimated by the manufac- 
 turer, to carry 662 cubic feet of air in one minute. This rate of air supply 
 would completely change the air of the room in five minutes. 
 
 There are, however, three elements of loss, viz: the slipping of the band, 
 the escape by leakage through a long pipe, and the resisting influence of 
 friction by which the fans of the blower slip on the air which they propel. 
 It may be assumed that this loss amounts to one-half. The air of the room 
 would then be completely changed once in ten minutes. 
 
 The fifth figure illustrates the application of the principle to surgical 
 purposes alone, and has been executed especially for use in this presentation 
 of the subject. 
 
 A sufficient number of observations have been made upon substances capa- 
 able of decomposition, to show a great superiority in the freedom of this cot- 
 ton filtered air over the air of the same room and over the air of out doors and 
 also of that in other parts of the house. It is certain, therefore, that the en- 
 deavor has been successful, to the extent of securing for surgical purposes, an 
 atmosphere far superior to that of the open out door air. By this apparatus, 
 it is practicable to make a laparotomy in an amphitheater filled with specta- 
 tors, any number of whom may have just come from dissecting rooms and 
 wards having erysipelatous patients, while the air enveloping the wound in 
 progress of being made, shall be as pure as that of a snow covered mountain. 
 An observation commencing June 22, 1887, by Dr. Grant Cullimore, in 
 which nine tubes containing sterilized peptonized beef broth were exposed 
 (1) under the blower, supplying air which had passed through the cotton fil- 
 ter, seventeen minutes. 
 
 On the same day and under the same circumstances, nine tubes were ex- 
 posed seventeen minutes in each of three other rooms numbered (2), (3), (4). 
 No. 2 (cottage) is in a detached building of two rooms, unoccupied for several 
 
11 
 
 months. No. 3 (upper floor) has been unoccupied several weeks, but some 
 months before had in it, erysipelas, gangrene and diphtheria. Room No. 4 is 
 a dissecting room one month after its use ; the air being still from the close- 
 ure of door and window. The tubes, after exposure and sealing with cotton, 
 were kept in an incubator with a uniform temperature of 100° F. 
 
 Other observations employing liquids and also potato slices, have shown 
 a great superiority of the purity of the air thus filtered, over that of the open 
 air and that of rooms whether empty or occupied. 
 
 The observation of Dr. Grant Cullimore is sufficient to publish in detail 
 as an illustration: 
 
 23d. (1) The tubes exposed to cotton filtered air all remained clear. 
 
 24th. Same condition. 
 
 25th, 26th, 27th. No observation. 
 
 28th. Each of the nine tubes held up by the side of No. 9 of series (4) 
 shows a cleanness in great contrast. This tube of the fourth series was 
 slightly turbid and under the microscope showed the bacillis subtilis. 
 
 (2) This room (cottage) has been unoccupied several months, but the win- 
 dows have been left open. 
 
 23d. (2) Two tubes (Nos. 3 and 8) are turbid, showing long bacilli with 
 spore formation. 
 
 24th. Same condition. 
 
 25th, 26th, 27th. No examination. 
 
 28th. Tube No. 2 shows a small deposit at the bottom, clear in the mid- 
 dle portion. At the top a film hangs together and is not easily separated — of 
 a dirty brown color on top and white below. Among other microbes is that 
 of the yeast plant. Tubes numbered 1, 4 and 9 remain clear. 
 
 June 22d. (3) Nine tubes exposed seventeen minutes in room (3), upper 
 floor. 
 
 23d. Pour tubes, 1, 2, 3 and 5, are turbid. Two with vibratile bacilli of 
 medium length ; one shows rods without motion, and one a film which shows 
 microscopic bodies like crystals of cerium oxalate. 
 
 24th. Same condition. 
 
 25th, 26th, 27th. No observation. 
 
 28th. Tubes Nos. 1, 4, 6, 7 and 9 clear. Tube No. 2 shows mycelium, 
 bacilli and spores. 
 
 (4) Dissecting room. 
 
 June 22d. Nine tubes were exposed seventeen minutes. 
 
 23d. Two tubes, Nos. 6 and 8, have a thin pellicle at the top, easily broken 
 up. The microscopic appearance is like that of mycelium. Tube No. 5 
 showed bacillis subtilis ; 8 and 9 turbid. 
 
 24th. Same condition. 
 
 28th. Tubes Nos. 1, 2, 3, 4 and 7 remai>n clear. Tube No. 9 showed slight 
 turbidity from commencing development of micrococcus and was used for 
 comparison with the tubes of the first series expesed to sterilized air. 
 
 The good behavior of the air of this dissecting room is accounted for by 
 its stillness and the opportunity for its dust to settle. 
 
 Fig. 5. 
 
 a, b. Entering pipe seven inches in diameter. 
 
 c, c, c. Three cotton filters forty inches square, the cotton being an inch thick, over 
 ■which the air enters as indicated by the arrows. There is another set of filters in another 
 bos, making 9,600 square inches of cotton through which the air passes. 
 
 a a, d a, d a. Spaces from which the filtered air escapes. 
 
 E. Exit pipe collecting the filtered air from under the filters. 
 
 Gas. Gas jets for warming the air. 
 
 S. Steam spray for moisture. 
 
 g. Straight pipe for observation. 
 
 gg. Oblique portion. 
 
 H. Vertical portion. 
 
 O. A sliding portion to resrulate the height of the exit. 
 
 K. Thermometer. 
 
 L. Operating table. 
 
The question of microbic influence upon the results of wounds of closed 
 cavities, is further illustrated by a statement made before the French Sur- 
 gical Congress meeting in Paris, in April, 1885, {Revue de Chirurgie, March, 
 1885, page 359,) by M. Abadie of Paris. In the course of extended remarks 
 upon this subject, are the following paragraphs : 
 
 "A factor of the greatest importance is the microbic element. I can easily 
 demonstrate this by taking the experience of ophthalmic surgeons, when, 
 after an operation for cataract, there appears suppuration in the eye. This 
 complication should not be attributed to some influence of diathesis, but to 
 some infecting cause. The essential condition is local and external. 
 
 "Previously to antiseptic practices, it was remarked, that suppuration did 
 not occur after iridectomy, though a frequent accident after cataract extrac- 
 tion. The reason is, that after the operation for cataract, the aqueous humor 
 is modified so as to contain more albuminoid material, becoming a better 
 medium for culture, and of the multiplication of the micro-organisms of 
 suppuration. 
 
 "At this time, I think that sufficient care is taken of one's person, of those 
 of assistants, and of instruments, but the atmospheric medium of the opera- 
 tion is neglected. The best protective dressings are applied too late, if the 
 inoculation has already been made. 
 
 "The air in which we live is surcharged with microbes in innumerable 
 quantities, which hasten putrefaction and interfere with the regular devel- 
 opment of cicatrization." 
 
 This is an extravagant estimate of the exclusive evil influence of the air 
 dust entering the eye, because we know that eyes are lost from injuries in 
 which the external membranes are not ruptured and from diseases which 
 arise spontaneously. An operation made, however aseptically, upon an eye 
 about to go into destructive degeneration, must terminate disastrously. 
 
 There is no doubt, however, that most of the eyes that are lost after opera- 
 tions, might have been saved by the avoidance of the entrance of floating 
 atmospheric particulate material. 
 
 The following statistics are interesting in this connection: 
 
 Dr. Arthur E. Prince has made cataract extractions on thirty-five eyes in 
 this room since its opening in November, 1884, without a case of corneal 
 ulceration among them. In each case an ointment of iodoform, two parts in 
 a hundred of vaseline, was introduced into the conjunctional duplicatures 
 before the application of the bandage. 
 
 Of a series of sixteen cases performed successively in the patients' homes, 
 or in other rooms in this private hospital, the first and the last eyes were lost 
 through corneal destruction. In the last patient belonging to this list, a lady 
 85 years old, one eye did well and the other went into destructive inflamma- 
 tion, resulting in pain, high temperature and delirium, terminating in death. 
 The two lists added make fifty-one, of which forty-nine in succession were 
 successful. 
 
 The elimination from the estimate of dangers in laparotomy, of that of 
 septic contamination, has been accomplished by the employment of this ap- 
 paratus to such an extent, as nearly to place it outside of the estimated fac- 
 tors of danger in a contemplated case. 
 
 The necessity remains for attention to the fingers, the instruments, the 
 sponges or napkins, to drainage and the mode of dressing, but it is not in the 
 plan of this presentation to go into these questions. 
 
 It is not assumed that the technology of laparotomy is finished, by having 
 a sterilized air for the envelopment of a wound in the progress of formation. 
 The danger of shock, hemorrhage, obstruction of the bowels from inflam 
 matory adhesions, and from the subsequent entrance of putrefactive and other 
 infections, remains the same as before. 
 
 There is a question not often taken into consideration; that is, the extpnt 
 to which a wound may be poisoned by the dust of a surgeon's hair and the 
 breath of himself and his assistants. 
 
 In the position of one's head over a wound, it may be an easy fortuity for 
 
13 
 
 dust and sweat to fall in, and the dust from hair and head may be wafted 
 laterally by currents of air until they fall into the wound under treatment. 
 
 The breath of surgeons and assistants unavoidably enters a wound under 
 ordinary circumstances. It mingles with other air and enters an open peri 
 toneal cavity. In a perfect state of health it may be better than other sur- 
 rounding air, in consequence of leaving some of the floating particles along 
 the moist air passages. In case, however, of diseased surfaces, from mouth 
 and nose to lungs, it is easily conceived that particulate material from these 
 surfaces, including the germs of suppuration and septic development, may 
 be the true cause of complications not otherwise explained. 
 
 Some observations upon the particulate contents of the expired air have 
 been made by Shablovsky and Vargunin of St. Petersburg, Russia, Some 
 account of these appeared in the Philadelphia Medical News for November 
 24, 1887, from the Medical Chronicle for November, 1887. 
 
 According to these observations, the average number of microbes in the 
 expired air (those of the surrounding air being taken at 100 per cent.) amounts 
 to 54.18 per cent. According to this, 45.72 per cent, are lost in the air pas- 
 sages; and if these passages are healtby, the expired air ought to be purer 
 than the surrounding air. 
 
 The first half of the expired air has twice as many microbes as the last 
 half, showing that the air that has remained longest in the lungs has lost the 
 most. The microbes found in the expired air were found to be mould fungus, 
 yeast fungus and the bacillus subtilis, with a large number not differentiated 
 and named. The danger therefore is not in the microbes that have been 
 returned to the surrounding air, but in those that have originated from dis- 
 eased surfaces. The apparatus here described prevents the possibility of in- 
 fection from these causes, by blowing away all air not in its own current, and 
 monopolizing the field by its own cotton filtered air. It is a satisfaction to 
 know what kind of air enters a wound, and in searching for causes of suppura- 
 tion and septiccom plications; to be able to eliminate the atmospheric element. 
 
 Fingers and instruments, with the possible approach through the blood of 
 the patient, remain for consideration. The razor for- the hair of the hands 
 and arms; soap and nail scrapers, must receive proper attention at the same 
 time that the therapeutic fortification of the patient against suppurative dis- 
 eases is attended to. The surgeon treats his patient internally with iron, 
 quinine and laxatives, and treats his hands and his instruments externally, 
 trusting that the dust he raises will be blown away and replaced by the pure 
 air of the blower. The endeavor is to make all wounds behave as well as the 
 best; to aid the forces of Nature by lessening the number of her enemies, 
 thus securing a sense of safety in the management of the class of wounds in 
 which septic complications le"ad to death. 
 
 Drainage is a good or an evil, according to its management, whether or 
 not it lets out more enemies than it lets in. A mere drainage is not thorough 
 enough. Septic microbes will travel up the sluggish stream of a drainage 
 tube. The tube must be flushed often enough to remove or destroy the germs 
 which enter from the air. Theoretically, a cotton plug ought to be a sufficient 
 protection, but the management is not likely to be perfect. 
 
 A flushing once in three hours, with a sublimate solution, Cone to ten 
 thousand,) with a cotton plug in the drainage tube during the intermediate 
 time, constitutes the best protection. The sooner, after the exudation or effu- 
 sion of fluids from serous or wound surfaces, it is removed, the greater the 
 chances will be for organization of the solid remains: the completion of repairs. 
 
 Immediately after a laparotomy, the fluids seek the lowest places accord- 
 ing to gravity, but if these lowest places are occupied with fluid, the surfaces 
 or higher places will become the seats of fluid accumulations, and these 
 higher accumulations may be cut off from their descent by adhesions. Then, 
 when the lower accumulations are drawn off, the higher ones remain as ab- 
 scesses or the centers of putrefactive disseminations. 
 
 The word drainage is therefere misleading. The idea of draining should 
 be supplemented by the idea of flushing. 
 
 A weak solution of boric acid or of boroglyceride may be considered safe 
 as an immediate flushing in relation to constitutional injury from absorbtion 
 over large extents of peritoneal membrane. 
 
 The good behavior of wounds included in laparotomy, is usually assured 
 in three days, while slow septic complications often manifest themselves at 
 later periods, the infection being slow at first, but afterwards rapid. This 
 direction of thought leads to the plan of preventive drainage combined with 
 protective flmhaqe. 
 
CLUB FOOT. 
 
 [Reprinted from the St. Louis Medical and Surgical Journal for May, 1888.] 
 
 It will be borne in mind, that in most cases there is a doubling of the 
 foot at the waist, or at the joining of the calcaneum with the cuboid 
 bone on the outside of the foot, and of the astragulus with the scap- 
 hoid, and through this medium with the cuneiform bones on the upper 
 and inside. This arching of the instep becomes firm by means of short- 
 ening of the ligaments on the plantar surface, by which these bones are 
 held together. 
 
 (Fig. 1 illustrates this condition.) 
 They are entirely beyond the reach of 
 any cutting instrument, unless an open 
 dissection is made, and they are too 
 strong to be torn by any sudden force 
 which can be applied by the hand. 
 
 The indication is to apply force to 
 the plantar surface of the metatarsal 
 bones. The tibia is the fulcrum of 
 this lever and the shortened tendo- 
 achillis is the resistance. 
 
 As one of the objects to be accom- 
 plished is the straightening of the 
 crooked lever (the foot being the 
 lever) it is important that there should , 
 be a pretty firm resistance at the heel. ' 
 Any diminution of the force with ' 
 which the tendo-Achillis resists the 
 pressure upon the metatarsus, by so 
 far diminishes the only means by 
 which the surgeon accomplishes the straightening of the foot. The di- 
 vision of the tendo Achillis is therefore worse than useless, unless there 
 is an absence of the usual curvature at the waist of the foot, The high 
 instep which is often seen after the treatment of Talipes-equinius by 
 division of this tendon, is thus accounted for. Hereafter, with the gen- 
 eral abandonment of this treatment by tenotomy, a more natural shape 
 of the instep will be secured by the time the heel is brought down. We 
 are now ready to appreciate the principle which should control the con- 
 struction of apparatus. It is simply that of a lever. 
 
 Fig. 2 represents one of the forms which the lever may be made 
 to assume in the treatment of Talipes equinus. While the appa- 
 
 Fig. 1. From Little, 
 
15 
 
 ratus is attached to the sole of a shoe so as to bring the pressure under 
 the metatarsal bones, a strap passes over the waist of the foot which 
 throws the upper end of the apparatus forward of the leg. This upper 
 end is thus drawn back by means of a strap passing behind the leg. 
 
 Fig. 2. A very powerful traction upon 
 the tendo Achillis is thus obtained with- 
 out interfering with the locomotion of 
 the patient. Indeed, the motion incident to 
 walking is an advantage, as the ligaments 
 and tendons yield more readily to a tension 
 which is constantly varying than to a steady 
 pull. The reason of this is, that a much 
 greater tension can be endured for the 
 moment, followed by partial or complete 
 Fig. 2. rest, than where it is continuous. 
 
 a. The sole of a shoe. The tipper part to be imagined. 
 
 66. A flat, thin plate of iron attached to the sole. The turned np ends of this plate 
 are perforated for a joint. 
 
 cc. The angle of a metallic strap, the horizontal part of which is parallel with the 
 sole and the vertical part with the leg. 
 
 dd. The vertical portion of the strap. This is a lever with fulcrum at c. The resist- 
 ance at 6, while the power is applied around the leg. 
 
 c. The metallic bow which connects the two parallel levers at the top. A leather 
 strap passes across the instep and has its attachment at cc. 
 
 The cut (Fig..2j represents an easy method of meeting the mechanical 
 indication which has just been considered. It is the skeleton only of 
 an apparatus. Xeither the leather fastenings nor the enclosed foot are 
 shown. The imagination can see them. 
 
 The treatment of talipes varus, without the use of any cutting instru- 
 ment, is practicable in almost all cases, if undertaken before the period 
 of walking. 
 
 The parts are yielding and the metamorphosis of tissue is very rapid. 
 The new growth in the progress of treatment is in the forced direction, 
 in verifaction of the maxim: "As the twig is bent the tree is inclined." 
 It is a question of time, and as soon as the progress is at such a stage 
 that the act of walking comes in the ordinary development of growth, 
 the exercise of the natural function of the organ tends to confirm and 
 complete the restoration. 
 
 If one with his hands, takes hold of a foot congenitally deformed, 
 while the foot is yielding, as it is before it becomes stiffened in walking, 
 he can go a great way toward restoring the foot to its natural form. The 
 problem is to adapt appliances to imitate the action of the hand; — some- 
 thing that will not get tired, but will tire out the elastic resistance of the 
 muscles, the tendons and the connective tissue. 
 
 No satisfactory shoe has yet been contrived. It is to be remembered 
 that the parts will not endure long continued pressure, and a shoe will 
 press every day on the same place. 
 
 A person confined to the same position while undergoing treatment 
 for fracture of a bone without careful attention to the necessary changes 
 of places of greatest pressure upon the surface, gets a bed sore. 
 
 The deformed foot confined in a shoe which is made to press every 
 
16 
 
 day upon the same part, with sufficient force to alter its shape, is under 
 the same necessity for a change in the places of the greatest pressure; 
 otherwise there comes a sore corresponding with a bed sore. 
 
 The pressure can be intermitted by the temporary removal of the 
 shoe, but on re-applying it, the pressure comes back upon the same sur- 
 faces. On the other hand, some extemporised appliance, which is not 
 removed and reapplied as a whole, but in parts, making its greatest pres- 
 sure in a little different place with each application, gives the parts sub- 
 jected to the greatest pressure one day, an opportunity to rest the next, on 
 the change of the dressing and the consequent variation of pressure. 
 In talipes varus and equino-varus there are two principal . points to be 
 approximated. Some point on the outer, or outer and front of the leg 
 jnst below the knee, and the other point upon the outer surface of the 
 foot over the metatarsal bone of the little toe. This is ordinarily most 
 easily accomplished by binding to the leig by means of strips of adhe- 
 sive plaster a piece of tin having two hooks. There should be (Fig. 3) 
 more than one hook, in order to vary the point of application without 
 the removal of the tin. For the application to the foot, the best plan is 
 to bind to the sole of the foot some light shield of leather, gutta percha 
 or tin, in order to distribute the pressure and avoid uncomfortable pres- 
 sure on a small surface. This shield of tin or other substance 
 should have an eye or ear situated on the outside of the metatarsal bone 
 of the little toe, for the attachment of a cord which is to extend to one 
 of the hooks on the tin shield attached to the leg. In this cord, acting 
 as an extending brace between the distal part of the tarsus end the prox- 
 imal part of the leg, there should be intercollated some elastic material 
 in order to secure a perpetual moderate extension. (See Fig. 3.) The 
 apparatus illustrated in Fig. 2 is applicable to Talipes equinus or to 
 Talipes varus, after the deformity has been nearly or quite removed. For 
 Talipes equino-varus, constituting the greater portion of the cases of 
 congenital club foot, it is necessary to have some appliance which shall 
 roll the foot at the same time that the heel is brought down. The 
 places of pressure with each removal and replacement of dressing will 
 be a little different, so that pa» - ts pressed too much one day, will be 
 pressed a little less the next. 
 
 The tin under the sole of the foot is seen to be held 
 b} r stripe of plaster. 
 
 The tin upon the outer side of the leg is seen to be 
 held in the same way. 
 
 The elastic cord approximates the outer part of the 
 foot toward the outer part of the leg, performing the 
 functions of the peroneus longus and the peroneus 
 tertius. 
 
 Any apparatus which acts like the hand 
 renders unnecessary the division of any 
 other tendon than that of the heel. 
 
 The most yielding parts soon elongate, 
 
 Fig. 3. so that the whole force comes upon the 
 
 parts more unyielding — chiefly the short ligaments which bind the 
 
 bones of the tarsus and those of the ankle together. It greatly 
 
17 
 
 hastens the progress of cure to give the little patient ether, and with the 
 hand of the operator to rupture these most resisting ligaments and con- 
 densed layers of bundles of connective tissue. Then, in a few days, a 
 point of no progress will again be seem to have been reached, when 
 another etherization should be practiced and another set of resisting 
 parts ruptured by the force of hand. The resisting parts will usually 
 tear with a vibration felt by the hand, with a cracking sound. A very small 
 amount of irritation follows this apparently harsh treatment, if only the 
 foot is kept for a time immovable, by dressings that do not produce tension 
 of any part. This first dressing after this stretching should not be 
 elastic. It should be easy, but immovable, for a day or two, when the 
 elastic tension may again be resorted to, but it should never be to such a 
 degree as to be uncomfortable. 
 
 There is hardly any deformity, unless attended by active spastic or 
 irritative contraction, having its origin in the central nervous system, 
 which cannot be changed slowly by the careful application of moderate 
 force during a sufficiently long period. 
 
 The progress of the treatment on this plan undertaken after the be- 
 ginning of the period of walking is ordinarily so slow that it is more 
 satisfactory to take out a triangular portion of the tarsus, unless the cir- 
 cumstances are such that prolonged time and attention are not attended 
 with great inconvenience. 
 
 The following four cuts illustrate appliances and results worked out 
 several years ago; gutta percha being the agent employed. It was ap- 
 plied in the warm state and allowed to cool under the pressure of a pair 
 df calipers. 
 
 Fig. 5. 
 
 Fig. 6. 
 
18 
 
 Fig. 
 
 Fig. 8. 
 Fig. 8 ilustrates a form of brace intended 
 to counteract the moderate tendency of the 
 foot to turn over. It is rather preventive 
 of deformity than cunative. 
 
 TARSECTOMY. 
 
 A.mong the fruits of modern ideas in relation to the antiseptic treat- 
 ment of wounds, is that of daring to cut into the cavities of joints with- 
 out fear of septic troubles. 
 
 Progress in the methods of treatment of talipes, in persons beyond 
 the period of infancy, has been retarded by the fear of septic decompo- 
 sition of the fluids in the complicated joints of the tarsus with septic 
 absorption and consequent poisoning of the general system, endangering 
 the life of the patient. 
 
 Ablation of the cuboid bone in the treatment of club foot is supposed 
 to have been first suggested by Little in his work entitled "Deformities 
 of the Human Frame," p. 305. London, 1853. 
 
 This suggestion was put into practice without a satisfactory result, by 
 S. Solly in 1854. 
 
 Mr. Lund, of Manchester, remored the astragalus in the treatment of 
 club foot in 1872. (1.) 
 
 Resection of a wedge shaped portion of the tarsus is said to have 
 been first performed by Mr. Davies-Colley in October, 1875, and repeated 
 by Richard Davey in November, 1876. (2.) 
 
 In a discussion in the Copenhagen Congress, Ruprecht, of Dresden' 
 denominated the removal of a wedge-shaped portion of the tarsus. Tarso- 
 tomie de Poinsot. 
 
 In a letter dated January 31,1888, Mr. Richard Davey reported forty- 
 one cases of operation by himself, according to this method, with forty 
 cases of success and one death from septicaemia. Mr. Davey employs no 
 
 Proceedings Medical Society of London, Vol. IV., 1879. 
 (2.) Ibid. 
 
19 
 
 antiseptics, but relies upon clean water at first, and a dry blood clot after- 
 ward. 
 
 The little favor which tursectomy had secured at the time of writing 
 the article on orthopedic surgery by Frederick R. Fisher (of the London 
 Victory Hospital for Sick Children) in the 6th volume of Ashurst's En- 
 cyclopedia of Surgery, 1886, is shown by the remark that "the num- 
 ber of cases of club foot treated by excision of the tarsus may be num- 
 bered by tens, while the cases treated by the ordinary methods may 
 be numbered by thousands." 
 
 There is not anywhere on the limbs a more dangerous place for the 
 invasion of putrefactive agents than the joints of the tarsal bones. 
 
 The joints of the carpus are equally complicated, but they are not so 
 often a field for those surgical processes which expose them to the air. 
 There is a labyrinth impossible to explore completely with antiseptic 
 means for hunting out septic agents. The most effective searcher is per- 
 oxyde of hydrogen, but there are blind pockets, which easily resist the 
 pressure of the oxygen eliminated by the contact of pus. The septic 
 fluids are squeezed into corners, to expand again and renew their de- 
 structive war on the living tissues. 
 
 The exsection of portions of the tarsus for the relief of deformities 
 of the feet requires, for the most successful results, that the after dress- 
 ings be exclusively wet or exclusively dry. 
 
 The dry dressing is most convenient, requiring no attention for days. 
 
 The blood serum becomes squeezed out of the clot; absorbed by the 
 dressings, and the residual clot becomes penetrated by the proliferating 
 vessels until it is entirely replaced by new tissue. 
 
 When this process of the invasion of the clots by the blood cells and 
 blood vessels emanating from the adjoining tissues is complete: the 
 danger of infection bycontact with the air is nearly passed. 
 
 The contact of the germs of erysipelas, phlegmon, and of gangrene 
 may set up destructive changes, but with moderate washing the pus cov- 
 ering the granulating surfaces will remain laudable and cicatrization will 
 go on rapidly. 
 
 For the dry dressing to succeed, it is necessary that the implantation 
 of germs at the time of operation be avoided, or that they be sterilized 
 by the washes applied to the wound previously to the application of the 
 dressings. In this relation, the character of the blood clot is of some 
 importance. It is desirable that its solidity be not diminished by the 
 application of water. A squeezed sponge does not impart any water to 
 the surfaces to which it is applied, but it drinks up any fluid that may be 
 there, leaving dryer than before such clot as may remain. 
 
 Mr. Richard Davey of the Westminster Hospital, London, was in 1884 a 
 a disbeliever in the ideas now generally accepted with regard to antisep- 
 tics. In an operation by him for talipes varus upon a 12-year-old boy, wit- 
 nessed by the writer in 1884, he removed a wedge-shaped portion of the 
 tarsus by a saw working in the groove of a director passed over the 
 bones and under the soft tissues of the top of the foot. The wound was 
 dressed in its own blood without the application of water and a splint 
 applied to prevent motion. 
 
20 
 
 The notion of the excellence of blood as a wound dressing is an old 
 popular tradition, and there is some truth in it, but the exposure to the 
 air of non-putrefaction dressing impervious to floating atmospheric dusi 
 must be far superior to the surface of a blood clot with its aon-sterilized 
 
 retaining bandage. The surface of clot thus exposed, invariably becomes 
 putrid in this climate, and in dryness London can have no superiority over 
 us. That a dressing of undiluted blood may be better than non-sterilized 
 dressings may readily be conceived, but in this day it is a queer freak to 
 scoff at antiseptic agents and rely upon such a perishable defense against 
 atmospheric putrefaction as blood. It is true, blood is a natural dress- 
 ing, but the instinct of the dog leads him to lick it off. 
 
 The wet dressing, the lotion being carbolized or sublimated water, is 
 sure, but more troublesome. In this plan of management the omission 
 of fresh application of carbolic acid for some hours is disastrous. The 
 agents of decomposition pass readily through the damp dressings to the 
 wound and to its fluid or its solid or semi-solid contents. 
 
 The discontinuance of a sublimate wash after beginning on the wet 
 plan, leaving the dressings to become partially dry, is less dangerous. 
 
 The mercurial does not go off into the air like carbolic acid, but it 
 may be absorbed, or by dryness become inactive along the surfaces sur- 
 rounding a wound, permitting the microbes of decomposition to pass in 
 Constantly wet or constantly dry, should therefore be the maxim. 
 
 If, before the dressing is applied, the wound has become infected 
 with germs beyond the power of the exudates to digest and destroy 
 them, the dry method must be a failure. Only the frequent or perpetual 
 drip, or the bath, can insure against suppuration and putrefactive com- 
 plications. 
 
 In the case of long exposure to the air, as in accidental w r ounds, the 
 wet dressing should be employed so as to secure the perpetual presence 
 of the antiseptic until the time when the exudates upon the surfaces of 
 the wound have become replaced by organized material. After that, the 
 more convenient form of dry dressing may be employed with safety, the 
 purulent product being carefully w r ashed away sufficiently often. 
 
 From these considerations, the application of a dressing perpetually 
 wet with an antiseptic lotion must be the safest for wounds exposed a 
 considerable time to the air, and especially to gun shot wounds present- 
 ing irregular and ragged surfaces, some of which are likely to be ne- 
 crosed, though under a careful antiseptic drip or bath they need never 
 present any smell or other sign of gangrene. This is a distinction im- 
 portant to secure. The necrosed tissues following a gunshot injury or a 
 telipes operation, behaves like catgut ligatures. They are absorbed if 
 not too large or too resisting for the digestive powers of the lecucosytes, 
 or they remain for a gradual odorless maceration or final expulsion. If 
 exposed to the action of suppuration and putrefaction germs they mor- 
 tify and smell. 
 
 MANNER OF OPERATING. 
 
 For cases in which, on account of age or the degree an , resistance of 
 the deformity, it is necessary to remove a portion of the tr.rcal bones, the 
 following method is recommended: 
 
21 
 
 Richard Davey, of the Westminster hospital, says that he tried chisels 
 but abandoned them for the saw. 
 
 The writer tried the saw and abandoned it for chisels. 
 
 Only one opening of the skin is necessary, and four instruments are 
 enough — a knife, two chisels and a mallet. 
 
 After an antiseptic washing of the skin and the cleaning out of any 
 residual material between the toes and among the folds of the deformed 
 foot, an incision is made along the outer side of the foot. 
 
 Figs. 9 and 10 illustrate the form of the foot and the necessary place of 
 the incision. The dotted lines indicate the course of the chisel. 
 
 Fig. 9. Fi&. 10. 
 
 Fig. 10, left foot. The dark line indicates the incision and the dotted 
 lines, the passage of the chisels through the bones; when the chisels 
 come into, contact each helps the other to pry out the included portion of 
 the tarsus. 
 
 In Talipes varus, including nine-tenths of the whole number of foot 
 deformities, the incision is made along the outer edge of the foot from 
 the proximal end of the metatarsal bone of the little toe, to the cuboid 
 bone or, in extreme cases, to the calcaneum, as the intention may be to 
 make a larger or smaller amount of excavation. These two chisels come 
 into contact on the inner or medium side of the foot, and each serves as 
 a lever to lift out the portion of the tarsus included between the two 
 chisels. This is the principle of the proceeding, though in practice, the 
 bones and ligaments may require to be removed in smaller pieces than this 
 description implies. The exact amount of excavation is determined by 
 the extent necessary to restore the correct form of the foot by the 
 hands of the operator at the time. 
 
 If the case is one of Talipes varus, there is no advantage in dividing the 
 heel tendon, but if the equinus element is strong (Talipes equino-varus), 
 there is great advantage in dividing this tendon, as the first step in the 
 operation. In this case the tendon is put upon the stretch and the bistoury 
 
22 
 
 introduced on the median side. No stitches are taken in the foot because 
 the surfaces arc lcl'1 in the most raided condition possible: Fags of bone, 
 joint cartilage, ligamenl and connective tissue become surrounded by blood 
 clot. These loose ends are, most of them, in a condition to slough if left 
 to their own power of maintaining their circulation. Any plan which 
 fails to maintain the vital capability of the blood clot must be a failure. 
 Many of these fragments of tissue lie in the clot to be afterward per- 
 petuated in their vitality by the approach and penetration of the capil- 
 laries extending themselves through the clot from the adjacent surfaces, 
 which have been left in such relations as to maintain their full vitality. 
 
 (1.) Before the removal of the elastic bandage, which had been ap- 
 plied to the limb above in order to secure a bloodless operation, the dry 
 wound is washed with a warm sublimate solution, 1-1000. Then (2d) 
 sublimated lint is applied over the wound and the foot is brought into 
 the best approximation to the correct form, and retained by adhesive 
 plasters extending from the outer surface of the foot to the upper part of 
 the leg. A sufficient amount of sublimated absorbing material is then 
 applied to drink rip the blood and serum subsequently escaping. (3d.) 
 A gypsum plaster is then applied in order that the patient, on waking 
 from his narcosis, may throw his foot about without hurting it. After 
 this is clone (4th) the elastic bandage is taken off the leg, permitting the 
 wound to fill with blood and the serum to escape into the surrounding 
 absorbent material. 
 
 By this procedure, the blood escapes dilution by water, and its clot 
 is the most solid possible, free from the possibility of septic infection, 
 and best adapted to the preservation of its blood cells and to their subse- 
 quent restoration, and also to the penetration from the surrounding living 
 parts, of leucocytes and proliferating blood vessels. 
 
 The rule is to leave this dressing untouched for a week or more, till 
 there ordinarily comes some smell. By this time, the blood clot will 
 have become alive again with some power of resistance to the encroach- 
 ment of enemies. Afterward, elastic extension is kept up until the short 
 ligamentous connections about the ankle joint have adjusted themselves 
 under the influence of this perpetual tension. (See fig. 2 and explana- 
 tions.) It afterwards becomes necessary to wear a brace for a long time 
 in order to retain what has been attained, whether the treatment has been 
 executed with or without cutting. (See figures 2, 3 and 8). 
 
 Nothing is more common than the loss of some of the success of 
 treatment by neglect after the cessation of treatment. To avoid this loss, 
 it, is important that the deformity be over corrected before the active 
 treatment is discontinued. 
 
 In case of Talipes equinus, or Talipes equino-varus, the improve- 
 ment under treatment should be carried so far that the natural use of the 
 foot will tend to preserve the advantage that has been gained. It is never 
 safe to dismiss a case as cured until this degree of success has been 
 attained. 
 
 The manner of dressing should be further explained: Gypsum is 
 never employed except temporarily after some operation, with or without 
 cutting, in order to shield the part from the pain attendant upon move- 
 ment or to hold, for brief periods, some position forced upon it under 
 narcosis, hy pressure of the hands. In the latter case, a screw clam]) or 
 an elastic bandage over and around a splint is resorted to until after 
 the hardening of the gypsum. An elastic tension for changing the form 
 should not be employed until the soreness immediately following an 
 operation, by cutting or by force, has passed by. 
 
To retain form and to prevent pain are the functions of plaster. 
 
 To improve form is the function of elastic tension, and it is made 
 elastic in order that some imitation of the natural movements may he 
 permitted, thus securing an active circulation and a rapid change of nu- 
 trition through which short ligaments become elongated and those too 
 long become shortened. The discomfort of a perpetual position is re- 
 lieved by a little movement. If by any imperfection or mistake in man- 
 agement, the wound becomes putrefactive the perpetually wet dressing 
 must be resorted to and kept up until all odor hasTfor a considerable 
 time ceased to be produced. 
 
 The detail of this proceeding is very important. The affected foot 
 should be immersed for a considerable time in a warm bath, having 
 1-1000 Hg. C12 . 
 
 The wounds and its sinuses should be injected with this solution 
 diluted one-half by peroxyde of hydrogen. Afterward the foot is to be 
 enveloped in a dressing kept perpetually wet with a 1 per cent .solution 
 of carbolic acid. 
 
 If the invasion of putrefactive enemies is not promptly repelled by 
 antiseptic measures the result may be disastrous. The wound made in 
 the exsection of the tarsus unavoidable exposes the tendons of the 
 Flex, long policis, flex long digitorum tibialis anticus ext. longus digi- 
 torum and peroneous tertius which pass up the leg and afford a ready 
 passage for the fire of septic inflammation. If the life of the patient is 
 saved, yet great loss of time is experienced in the course of the treat- 
 ment. 
 
 INTBRNAL INCISION. 
 
 " OPEN INCISION AND FIXED EXTENSION." 
 
 " In the transactions of the International Medical Congress meeting 
 in Copenhagen in August, 1884, is a contribution by Dr. A. M. Phelps, of 
 Chateaugay, N. Y., advocating the treatment of obstinate Talipes varus by 
 an open incision on the inner side of the foot. 
 
 In the Medical News (Philadelphia) for January 21st, 1888, this opera- 
 tion is explained and illustrated by a wood cut by Dr. C. N. Dixon Jones, 
 of Brooklyn, N. Y. 
 
 The lines of the incision are seen upon the right foot in Fig. 10. 
 
 An incision is made from the internal malleolus to the tuberosity of 
 scaphoid, and from the center of this line, another incision is made verti- 
 cally downward, dividing everything that resists, until by forcible pres- 
 sure, the foot can be straightened out. 
 
 The artery and the nerve are drawn aside and held by a blunt hook as 
 the dissection goes on. The foot is held in its corrected position by gyp- 
 sum four weeks before the first dressing is removed. 
 
 The dissection of the inner side of the foot is favorably referred to in 
 the " Year Book " for 1887 by Dr. Philippson (Deutsch Zeits., f . Chirurg, 
 XXV. 287, for 1886-7. Dr. Gibney (Trans. Med. Soc. State of N. Y., 
 1886), p. 368, refers favorably to the Phelps method and states that Dr. 
 Bradford, of Boston, has been working at a machine which he calls a 
 Tarsoclast. 
 
 In the progress of treatment, with or without the division of bones 
 and tissues, it is convenient to employ not only the force of the hand, 
 but alsD the force of a screw in some form of apparatus in which a car- 
 penter's screw clamp constitutes the force which is to change the form of 
 the foot. 
 
 Apparatus other than that which can be extemporized at any time has 
 been worked at by Monier, as reported in the " Year Book," 1887, from 
 Gazette des Hoperaux No. 1, January, 1887. 
 
 It is doubtful, however, whether a permanent apparatus can be made 
 to do any better than an extemporized carpenter's clamp and two pieces 
 of wood and three roller bandages. 
 
st. i.ouis Medical and Surgical Journal, Pebrnary, i vv '. 
 
 A RECTAL OBTURATOR, 
 
 The basis of the following communication was presented to the St. 
 Louis Medical Society. Nov. 18th. 1882, exhibiting a rectal stopper or 
 obdurator. 
 
 1. For enabling the alimentary canal to hold two or three gallons of 
 
 water in cases of obstinate constipation, in cases of obstipation and of 
 strangulation: or. for the speedy and complete washing out of the ali- 
 mentary canal on any account. 
 
 '2. For the holding in the alimentary canal of comparatively large 
 amounts of nutritious fluids in cases in which the introduction of food 
 by the mouth is impracticable. 
 
 ANAL OR RECTAL OBTURATOR OR STOPPER IK POSITION UPON A WALES' BOUGIE. 
 
 3. For the holding in the large intestine of an adequate quantity of 
 alcoholic liquids introduced for anesthesia in surgical operations, or in- 
 juries, or for the alleviation of shock or terror from any cause or in all 
 conditions in which alcoholic anesthesia is desirable. 
 
 4. For the speedy dilution of the blood through the absorption of 
 water from the intestinal surfaces in order to stimulate the kidneys to 
 filter out any poisonous constituents of the blood, whether these impuri- 
 ties have been introduced by accident or design, or whether they have 
 developed in the blood and in the glands by the chemical process inci- 
 dent to disease. 
 
 5. For the reduction of temperature in lever and inflammation by the 
 more ready discharge, through the various emunctories, of irritating ma- 
 terial by the thinning of the blood through the introduction of water. 
 
 6. For the raising of the peritoneal floors of the pelvis, in order to 
 increase the facility in the removal of adherent ovaries, tubes or tumors. 
 approached from above by laparotomy. 
 
 I have taken great interest in the efforts of Dr. Wales, late Surgeon- 
 General of the United States Navy, to construct a bougie by which the 
 large intestine can be well distended in cases of intestinal obstruction; 
 
and in some cases of obstruction I have been unexpectedly successful iii 
 securing a movement of the bowels by an introduction of the bougie 
 high up. This is a specimen of AVales' bougie (showing the bougie); 
 but manage it as you may, the water is likely to leak out and the full ex- 
 tent of the desirable result may not be obtained. Reflecting upon this 
 subject, it seemed to me that if there were an obturator fitting inside the 
 sphincter, it would effectually prevent the regurgitation of the water 
 used, so that the large intestine would be completely filled and passing 
 the ilio-coecal valve, filling the small intestine also, I wrote to Mr. Stohl- 
 mann, of Tiemann & Co., telling him what I wanted, and a few days 
 ago I received this. This is to be filled with air or water (referring to 
 the obturator), and is intended to be of such a size as to fill the lower 
 part of the anus and act as a valve, so that the greater the pressure is 
 above, the tighter it will fit. In using this, according to this idea, it 
 should be placed upon the bougie previous to its introduction. The 
 bougie is then worked up as far as convenient and the obturator pushed 
 in through the sphincter, and after being inside the sphincter it should 
 be injected with water or blown up with air. It is probably better to use 
 water because it is not so likely to leak away as air; you then fasten to 
 the tube some kind of syringe and fill the large intestine. The practi- 
 cability of securing a disentanglement of a strangulated intestine, the ob- 
 struction being occasioned by a loop of intestine caught upon a bridge, 
 which may be the result of a previous inflammation, or occasioned by in- 
 tussusception, in which the upper portion of the intestine is drawn into 
 the lower — the practicability of this has been established by many suc- 
 cesses. Where the obstruction is below the ileo-coecal valve, there can 
 be no doubt of the ability, with the obturator, to fiil the large intestine 
 below the obstruction and exert an influence to disentangle it, It is not 
 to be supdosed that all the attempts will be successful, for ihere may be 
 such adhesions as to make it impracticable, as in the case of strangula- 
 tion, in hernia in the inguinal canal, or under the femoral arch. The 
 expedient might be supposed to fail in cases of strangulation of the small 
 intestine, on account oj the tight fitting of the ileo-coecal valve, but the 
 experiments made by Dr. Thomas Battey upon the dead subject, prove 
 that the ileo-coecal valve yields when the pressure becomes more than 
 moderate. 
 
 Water passed into the small intestines in three cases out of four ex- 
 periments by the writer upon the dead subject. In this fourth case the 
 valve was tight, resisting pressure sufficient to burst the colon. 
 
 Since the first publication in 1883, the apparatus has been improved 
 by Tiemann & Co.; and further use has established its value. 
 
 Within a few days, (March, 1888,) four days after the removal of an 
 ovarian tumor, there was a failure to secure a movement of the bowels 
 by liberal dosing with elaterium and croton oil. In a brief period after 
 the employmentTof the obturator and the distension of the large intestine, 
 there came a fecal evacuation. The danger in such a case is, that the 
 natural force of the muscular vermicular contraction of the intestine, 
 forcing gas and liquid down upon the part held by a recent adhesion, 
 may not be sufficient to straighten out the kink which stops the progress 
 of the intestinal contents. 
 
 A distension from the filling of the large intestine below, may bring 
 the strictured portion into such a position that the contracting forces may 
 straighten the small intestine and enable the vermicular force to tear the 
 exudate which was causing the arrest. 
 
PALATOPLASTY. 
 
 A paper explaining new instruments and new methods of operating 
 for Cleft of the Palate, was read before the St. Louis Medical Society, 
 November 28, 1874, published in the "St. Louis Medical and Surgical 
 Journal," January, 1875; copied with cuts in the "London Medical 
 Record," March 3, 1875, and revised and published with additions in the 
 " American Practitioner," for March, 1876. A report was also made to 
 the Illinois State Medical Society, in May, 1884, and to the International 
 Medical Congress, meeting in Copenhagen, in August, 1884. 
 
 Since the time of the first presentation, the methods have been im- 
 proved, and a new instrument devised. A new modification of the 
 quilled suture has been introduced, which will be described under the 
 name of the Bead Suture. 
 
 The employment of the new methods and instruments, is found very 
 much to shorten the duration, while the loss of substance is lessened, and 
 the probability of union by the first intention is increased. 
 
 The facility with which the two halves of the cleft palate may be 
 united is not generally understood. There is an equal want of apprecia- 
 ion of the advantage of an early operation, made before the expiration 
 of the imitative period of life. For illustration: the reason why adult 
 persons fail to learn to pronounce accurately, the peculiar sounds of a 
 foreign language, is not in the constitution of the organs of speech, but 
 in the inability to adapt muscular action to new results. The child varies 
 muscular movements until the exact sound is secured, and ever after, 
 ward, the muscles move so as to secure the same sound. The difficulty 
 experienced in learning a foreign language, applies more emphatically, 
 in the case of cleft palate. The muscular deficiency may be completely 
 removed, but the lack of muscular education, hinders the acquisition of 
 perfect speech. One of the difficulties in self-education, is in the fact that 
 the person speaking does not know that his pronunciation is wrong. It 
 is often noticed, for example, that a child which has acquired some pecu- 
 liarity in speaking, does not notice that its pronunciation is peculiar and 
 it is with the greatest difficulty that the habit can lie overcome. This 
 difficulty inheres in the habit of false pronunciation. 
 
 The same force of habit continues, alter an operation for the closure 
 
27 
 
 of a cleft palate. By careful drill, the defects of pronunciation can be 
 overcome, little by little, until the detail of speech becomes nearly or 
 quite perfect. It is probable, that much of the depreciation in which the 
 operation is held, is owing to this want of drill, after an operation which 
 is in itself perfect. 
 
 It follows from this, that the work is only half done when the closure 
 of the palate is secured, even in the most perfect manner. Many persons 
 will learn to execute the proper sounds when speaking slowly, and yet, 
 in ordinary rapid conversation, they will speak as badly as before. The 
 only remedy for this habit, is to forbid ordinary conversation, for a time, 
 and to permit speaking only under instruction, every mistake being cor- 
 rected on the instant. 
 
 At the meeting of the Illinois State Medical Society, in Chicago, in 
 May, 1884, a lad, ten years old, born with complete cleft of the palate, 
 both hard and soft, was presented, who read in a clear voice so as to be 
 distinctly heard at the farther end of the room, without any defect or 
 peculiarity of speech. The operation had been made in two sittings, when 
 five years old, the soft palate being first closed and the hard palate sev- 
 eral months later. 
 
 This lad has not only recovered perfect speech, but he can whistle. 
 This implies a very good closure of the palate against the posterior wall 
 of the pharynx ; otherwise, there would be too much leak of air through 
 the nostrils. 
 
 The ability to apply the palate to the posterior wall of the pharynx is 
 greatly aided by the careful drill of the patient. 
 
 The backward movement of the palate is effected by the palato- 
 pharyngeus muscle. The frequent effort induces an elongation of the 
 muscular fibres and a consequent expansion of the muscular curtain. 
 
 The patient if left to himself, if not very young, might never make 
 this effort and never be educated into the achievement of drawing the 
 palate far enough back to close the posterior communication with the 
 nostrils. 
 
 In regard to the operation ; in the progress of the study through 
 several years it was found that the division of the pillars of the fauces, 
 practiced by Fergusson,* is worse than useless. The muscular fibres of 
 the anterior pillars approximate the two halves of the palate, as the 
 genio-hyoglossus protrudes the tongue. The division of these muscles 
 is recommended upon the the false theory that they pull the two halves 
 of the palate asunder, The palato-glossus muscles really approximate 
 the two halves. 
 
 After the removal of a strip of membrane from the inner edge of the half 
 palate there was found, in practice, to be a tendency in the anterior mus- 
 cular layer to glide upon the posterior, in the act of introducing ordinary 
 needles. 
 
 *See*note in Gray's Anatomy in connpction with a description of the palate and its 
 connections. 
 
28 
 
 To prevent this occurence the needle was 
 constructed which is shewn in fitnire 1. 
 
 act Shaft and handle. 
 bb Thread. 
 
 c Sliding shaft for compressing the two layers of 
 the soft palate upon the point of the needle. 
 d Point of the needle. 
 
 In the use of this instrument the thread is 
 picked up by a tenaculum. 
 
 Through the ingenuity of Dr. G. V. Black, 
 an instrument has been constructed which 
 picks up its own stitch, thus saving much 
 time. 
 
 This needle is in two forms. 
 
 Figure 2 is the needle working direct: 
 
 AA Shaft and handle. 
 
 Foot piece of the shaft curved. 
 
 Fig. 1. 
 
 B Foot piece of the shaft curved. Its extreme 
 point has an orifice, the place of which is indicated by the 
 dotted line. The orifice is entered by the needle C carry- 
 ing the thread EE. 
 
 C Needle with thumb piece above and a point be- 
 low: curved so that the point will pass the eye indicated 
 by the dotted line. 
 
 DD Pick-up pin with a thumb piece above its sliding 
 shaft, and its fine point above the B. As the shaft (upper 
 D) goes down, the pin (lower D) moves horizontally and 
 at a right angle to its shaft, and picks up the thread car- 
 ried by the needle C. 
 
 EE Thread carried by the needle C, and picked up by 
 the stiletto or pin indicated by D. This is retained while the 
 needle is withdrawn, so that, on displacing the shaft AA, 
 with its foot-piece B, the thread is exposed, and can be 
 seized by a tenaculum or by the fingers. 
 
 The point of exit of the needle corresponds 
 with that of its entrance, and the stitch is easily 
 picked up. 
 
 It is convenient to introduce into the first 
 thread, a second thread looped so as to be 
 doubled. This is looped into the thread con- 
 nected with the needle, and drawn into position, 
 serving to introduce the silver wire with which 
 the stitch is finally completed. 
 
 The instrument working laterally is illus- 
 trated in figure 3. 
 
Fig. 3. 
 
 aa The main shaft of the instrument having the needle upon its distal end. 
 
 66 The movable shaft, a thumb piece at the proximal end, and an orifice at the 
 distal end to enclose the needle in the act of picking up the thread 
 
 c.c The pick-up stiletto which picks up the thread, having a thumb piece at the prox- 
 imal end and a point at the distal end. 
 
 d The curved needle, represented as having pierced the tissue intended to be 
 sutured. 
 
 ee The thread with which the needle is armed and which has been picked up by the 
 pick-up stiletto. 
 
 The pick-up portion of the instrument is in the position in which it is about to be 
 withdrawn toward the handle, so as to bring the thread within reach of the fingers on the 
 outside, when the instrument is employed in the mouth or other deep place. 
 
 Fig. 4. Needle acting in the re- 
 verse direction — the needle, which is 
 curved, passing behind the part to be 
 stitched, which in the cut is repre- 
 sented by p. 
 
 a a a The shaft having the handle 
 at one end and the needle at the 
 other. 
 
 6 6b Slide carrying the pick-up 
 stilletto, which in the cut is seen to 
 hold fast to the thread c which it is 
 about to release. 
 
 c c e The thread which has been 
 picked up after passing through the 
 tissue p to tenaculum holding the 
 thread as it is about to be released from 
 the grasp of the pick-up. 
 
 Fig. 4. 
 
30 
 
 By the use of these needles the time necessary for the operation is 
 greatly diminished. This is an important consideration in an operation 
 which is necessarily slow. 
 
 It lias until now been a desideratum to protect the shallow sutures 
 from the strain occasioned by the action of the tenosor palati muscles; 
 and for this purpose, Dieffenbach many years ago had practiced deep 
 vertical incisions. The dangerous hemorrhage occuring in some instances, 
 prevented the general adoption of this expedient. 
 
 The present writer has employed the platinum wire heated by the 
 galvanic current to secure a vertical parting of the substance without 
 hemorrhage. This plan is found to be attended with some loss of sub- 
 stance, and is on that account objectionable. 
 
 Since that time, it has been found that the use of the galvano-cautery 
 can be discontinued and the same object secured without waste of sub-, 
 stance, by the employment of a modification of the quilled suture, a plan 
 for which (with cut) may be found in the Annals of Anatomy and Surgery 
 for March, 1883, under the name of "The Bead Suture." This suture is 
 easy of introduction, and it performs the office of a splint — diminishing 
 the movements of the parts of the palate, and entirely taking the strain 
 off from the shallow stitches. 
 
 The necessity for wounding any of the deep vessels is entirely obviated, 
 and the parts are held so firmly together that failure to unite by the first 
 intention must be a rare exception- 
 
 The cut furnishes three illustra- 
 tions of the bead suture. 
 
 1 The completed suture, the beads ly- 
 ing upon the natural surface of the skin ;s?g 
 or mucous membrane. 
 
 2 At the bottom is the same stitch in- 
 complete. The bite of the forceps em- 
 ployed in twisting the silver wire is also 
 seen. 
 
 3 The middle figure shows the em- 
 ployment of two beads on a side for greater 
 breadth. The cut also shows a lateral in- 
 cision on either side for the better approxi- I 
 matron without tension. The beads lie in 
 the furrow made by this incision. 
 
 The suture admits of tighten- 
 ing up, if found to be too lax at 
 any time after its introduction. 
 
 The utility of the closure of the 
 cleft palate, both hard and soft, be- 
 comes apparent in every case. 
 Sounds which are impossible with 
 a permanently open communica- V 
 tion between the mouth and the N 
 pharynx, and especially between Pis. 14. 
 
 the mouth and nose, become executed with more or less approximation to 
 perfection. 
 
 
31 
 
 When the cleft is closed by operation while the patient is young, the 
 result is better than when closed later, simply because bad habits of 
 articulation are less fixed. 
 
 It will be readily understood, that the patient with cleft palate learns 
 to make substitutions for the true sounds by the movements of parts 
 different from those employed in natural articulation, 
 
 When the apparatus of articulation is restored, the patient must learn 
 anew how to use it. Unless the greatest care and caution are observed, 
 combined with instruction in minute details, the restored organs will 
 never attain a performance equal to their capabilities. 
 
 The same is also true where the communication is closed by vulcanite 
 obturators. The most careful drill in both cases is necessary in order 
 to secure the best results. When it is considered how difficult it is to cor- 
 rect bad habits of articulation and pronunciation vdiere the organs are 
 perfect, it will be readily admitted that the patient may not be a great 
 credit to his surgeon if left to talk as he may, without having some one 
 to point out his errors, to direct him how to correct them, and to insist, 
 day after day, on the best use by the patient of his restored articulating 
 apparatus. 
 
 M. Trelat relates a case of a boy with cleft palate coming from Rouma- 
 nia. Before leaving Paris he had learned a correct pronunciation of 
 French words, but he still retained some of his faulty habits of pronun- 
 ciation of his native language. He had his bad habits to correct, while 
 in relation to the language which was new to him he had no habits to 
 correct. 
 
 The early operation results in an approximation of the two sides of 
 the face through the approximating power of the muscles acting upon 
 the bones of the face. There are no antagonizing forces tending to 
 spread the face and hence a small force acting all the time, produces an 
 appreciable result. As the face is narrowed the material of the palate is 
 relatively greater and more capable of the perfect performance of its 
 functions and thus all objections are to some extent removed. 
 
 Besides, the skillful performance of the operation, occasions very 
 little loss of substance. 
 
APHLST BINDER I 
 
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