CONTRIBUTIONS TO PLASTIC SURGERY.

213 headache on the right side. Without any known cause it generally came on after midnight, when she was roused by it from her sleep, and then kept awake for several hours. Bicarbonate of soda, rhubarb, and small doses of morphia, gave her immediate, but only temporary, relief. About the end of January the palpitations ceased altogether, but the nocturnal headache increased in violence. The headache now regularly returned every night between two and half-past two o’clock. It was mainly situated in the right occiput and thence spreading to the forehead. There was a feeling as of a heavy pressure upon the eyes, a forcible pulsation of the right temporal arteries, and a

distinct rise of

temperature

on

on the neck, amidst shreds of muscles and integument and fragments of the shattered bone. The comminuted fragments of bone having been removed, the remains of the lip were brought together with a twisted suture, and an endeavour made to close the wound as far as possible. Sloughing, however, ensued, and a hideous gap resulted. Fig. 8 shows the appearance on Oct. 18th, sixteen days after the accident. On that date a plastic operation was

but, from want of support, hung down

the affected side of from

Gradually the pains subsided towards the morning. At my morning visits I found the patient greatly fatigued, and, as the sole objective symptom, an injection of the vessels of the right sclerotic, which, however, disap- z, peared in the course of the day. As the attacks seemed to be of a typical recurrence, I therefore ordered large doses of quinine, but without any benefit. Caffein not only gave The inno relief, put produced also nausea and sickness. duced current also failed, but the treatment by means of the constant current (stable current of from six to eight elements applied for from eight to ten minutes) seemed to be, for a time at least, most successful. During three weeks the electricity was applied about twelve times, and the intensity of the pain greatly diminished ; no attack appeared in the nights following the days on which electricity

0’3° to 0’4° C.

had

been used, and the intervals between the attacks also increased from three to four days. The treatment, however, was unfortunately interrupted, whereupon the headache returned with its former violence. Again the patient was roused between two and half-past two o’clock; again the pain started from the right occiput, radiated to several branches of the trigeminus, accompanied by a humming noise in the right ear, beating of the arteries, and rise of temperature on the right side. Again the constant current was applied, without, however, producing the same favourable results as before. Iodide of potassium and the nervine resolved on, which was divided into two stages : (a) restoratonics were then tried, but they failed to relieve the dis- tion of lip; (b) complete closure of wound. The following tressing symptoms. are the details. Upon the supposition that the case was an affection of the On Oct. 18th, 1877, healthy granulation having been estasympathetic nerve, and that the headache was due to a blished, the patient was placed under chloroform, and, the paralysis of the arteries, I had in February, 1874, begun to remains of the lower jaw being found necrosed as far as the give the ergotine de Bonjean, but the doses were small and angle on the right side and the socket of the first molar tooth the results not at all satisfactory. Meanwhile Eulenburg on the left, the bone was removed to that extent with saw had recorded (Bed. Ktin. Wochensch., 15, 1873) a case of and The cut extremities of the lower lip, having forceps. intermittent headache with disturbance of circulation been pared, were then brought together with a harelip pin cephalalgia vasomotoria-which was completely cured by and two silver sutures, and the wound strapped with court large doses of ergotine. As the symptoms of that case re- plaster. sembled those of the one just described, six grains of Oct. 23rd.-Outer bandages changed ; strapping on lip not ergotine were at one time given per diem, and this quantity interfered with. The exhibition was gradually increased to twelve grains. of one drachm and a half in the course of two weeks was followed by an abatement of the symptoms ; for though the headache returned every night, it was less violent than before. From the 15th of April, 1874, the daily quantity of ergotine was increased to fifteen grains, and after the patient had thus consumed two drachms more of the drug the attacks had a much shorter duration and were much less severe. The above dose of fifteen grains was continued for one month. During that time the ergotine produced no disturbance of the general health, while the headache gradually subsided, so that towards the middle of May the patient was discharged as cured. She had taken not less than seven drachms of in a very short time, and has ever since been free from any of the angio-paralytic symptoms. Aix-la,Chapelle. -

ergotine

CONTRIBUTIONS TO PLASTIC SURGERY. BY SURGEON-MAJOR J. M.

FLEMING, M.D.,

BENGAL MEDICAL DEPARTMENT.

(Concluded from p. 179.)

CASE 7. Pestoration

of the Chin. and Lower Lip. Harju, aged thirty, a hill-man, employed as a jhampanbearer, was brought to the Simla Dispensary on the evening 26th (eight days after operation).—Strapping removed for of Oct. 2nd, 1877, on account of a very severe gunshot injury first time. Complete adhesion of the lip has taken place. the of the face. The lower jaw was smashed, and the soft parts pin, being loose, was removed. Sutures allowed to covering it, including the right half of the lower lip, were remain. 31st.-Sutures removed. The lower lip has completely completely torn off. The tonguehad escaped uninjured, -

Harelip

214 and the wound beneath it is reduced to less than half its original size. Figs. 9 and 10 give the appearance on this date. After the union of the lip an opening into the mouth still

united,

and its edges granulating. covered with healthy granulations. extend from the

healthy,

Wound on cheek Skin beginning to

edges.

10th.—Flap elongating. Can now be drawn

across

lower

of wound. Granulations on cheek level with the skin. remained, of an irregularly triangular shape, and surrounded part Sprinkled lightly with burned alum. hard cicatricial as in shown the above sketches. tissue, by of the lower half of the wound has now 16th.-Union The gap measured 1-3 in. by 1-1 in., and allowed of the taken place by the second intention. Only a small triangular of cut of the the under which the ends protrusion tongue, space remains at the upper end, insufficient to admit the tip genio-hyo-glossus and genio-hyoid muscles could be seen. of the little finger. On the 31st October the patient was placed under chloroDec. 8th.-Wound quite closed. Cheek rapidly healing. form, and a flap of skin with a curved pedicle (of the size This man left the dispensary all but well, and has since and shapeshown in Fig. 10 a) was taken from the right been favourably reported of. Mrnia

THE PROPHYLACTIC TREATMENT OF POSTPARTUM HÆMORRHAGE. BY ALEXANDER M’COOK

to the edges of the wound, which had been incised and partly everted, so as to admit of accurate adjustment. Two twisted sutures were employed (at the upper and lower anterior angles), and one silver-wire suture near the latter, where there was a depressed cicatrix. The other adjustments were made with horsehair, introduced by means of a fine tubular needle. (Fig. 11, reduced from a sketch taken at the time, shows the appearance immediately after the operation.) Very little twisting of the pedicle was required, the flap being simply folded on itself until the two edges (Fig. 10 a*) came in contact. The or torsion of any vessel being haemorrhage was slight,

cheek, and carefully applied

ligature

unnecessary.

Nov. 4th.—Wound dressed.

Twisted suture at upper

angle, and some of the stitches along upper and anterior edge of flap, have given way. Anterior edge of flap deeply discoloured. Remainder looks healthy, and is in good position. 8th.-A slough, half an inch in breadth, has separated from the anterior edge of the flap. The remainder is quite

WEIR, M.D., &c.

MR. GROSE relates an interesting case in THE LANCET of November 17th last, in which the subcutaneous injection of ergotine (Bonjean’s) was successfully used in post-partum haemorrhage. In a postscript to the article in question will be found a decided reply to a query of mine published in THE LANCET some two years ago. This query had reference to the treatment of haemoptysis by the subcutaneous injection of ergotine, instead of the roundabout and uncertain methods usually adopted. Mr. Grose is equally positive on the reliable effects of ergotine thus given in uterine hæmorrhage and haemorrhages from the alimentary track. I am convinced, however, that there is yet much to be said on the prophylactic treatment of post-partum haemorrhage. No doubt the administration of chloroform had much to do with the extreme uterine inertia, and the temporary removal of the bandage (thus leaving the uterine walls unsupported, so to speak) was the immediate cause of the haemorrhage in Mr. Grose’s case. Latterly, and more especially since reading Dr. Playfair’s very excellent book, I have been in the habit of keeping up continuous uterine contraction during the conclusion of the second and until the end of the third stage of labour. This is a good general rule to adopt, and is not difficult to carry out in practice. If the labour be sufficiently advanced, and the pains, from any cause not within the scope of a digital examination, begin to hesitate, and finally disappear, I invariably administer a full dose of Richardson’s liq. secalis ammon., which can be repeated in about half an hour, provided one dose has failed to stimulate the uterus into action. This is a beautiful preparation of ergot, and is not disliked by patients ;it is void of the nauseating effects of other pre-