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Lecture INTRODUCTORY TO A COURSE OF CLINICAL STUDY OF DISEASES OF WOMEN.
MAY 25, 1878. pathology is limited by a line drawn between the anteriot superior spinous processes of the ilia, and that all below that line is unworthy of their attention-a deplorable error, perINTRODUCTORY TO A COURSE OF nicious in its consequences. It retards the progress of general ; it excludes the possibility of rightly appreciating CLINICAL STUDY OF DISEASES OF WOMEN. medicine the significance of many clinical phenomena. It incapacitates those who are under its dominion from forming a right, Delivered at St. George’s Hospital, even a candid, estimate of the professional merits of these who study and practise that branch of medicine to which the ROBERT BY BARNES, M.D., awkward word " gynaecology " is applied. OBSTETRIC PHYSICIAN TO ST. GEORGE’S HOSPITAL, CENSOR OF THE
Lecture
ROYAL COLLEGE OF PHYSICIANS.
(Reported by
Dr. FANCOURT
BARNES.)
method of clinical study is the same for all diseases, for all regions of the body. The body is a whole, made up of mutually dependent parts. The fable of Menenius Agrippa was not more true in its application to the body politic of Rome than it is to-day in its application to the body of medical science, and to the body of man or The indiwoman upon whom the medical art is exercised. visible unity of the parts of the body is seen, first, in the circulation. This is one : blood goes from the same source everywhere to every organ. If any organ is disordered, there results infallibly dynamic derangement, or tissue or nutrition disorder, which affects the quality of the whole mass of the blood. This indivisibility is again seen in nervous action. The nervous system is a whole. Disturbance of an organ entails nerve disorder, and the nerve-centres are affected ; the whole organism feels the blow. Disease may be, in its origin, local or general; that is, it may begin in an organ or tissue or in the blood. But whatever the original disease, be it local or general, the whole body and each individual organ and tissue is liable, sooner or later, to be affected in its structure, and therefore disordered in its function. In the case of original local disease, the organ or part primarily affected may for some time exhibit the most prominent change of structure and disorder of function. But this is not always true throughout. The organ first affected may not be one of vital importance. But, starting from an organ of secondary importance, the disease invades other organs in their structure, or impedes them in the performance of their functions. In this manner the primary seat of the disease may become masked. For example, cancer of the neck of the uterus, so long as it is limited to that region, may not be of vital consequence. Like the breast, it may be amputated. But let cancer spread to the bladder or rectum or glands, and the secondary conditions may kill. So far as the general pathology of cancer, tumours, struma, and allied diseases is concerned, what applies to these diseases, when they invade the ovaries and uterus, equally holds good when they invade other parts. The differences that call for particular study are - essentially clinical; in one sense they might be called accidental. Thus, if cancer attack the stomach, it will, according to its kind and the region of the stomach attacked, cause-(1) disturbance of the function of the stomach; (2) disturbance by pressure or by extension to neighbouring parts, inducing disorder of function of those parts ; (3) infection of the glands, bloodvessels, and the blood itself. Just so it is when cancer affects the uterus. The disease will produce certain clinical variations according to the nature and importance of the functions of the organ first attacked and to the nature and importance of the functions of the immediately associated or adjacent organs. This, then, is the key to the special pathology of the ovaries and uterus in so far as general morbid processes are concerned. But inasmuch as the ovaries and uterus have special functions to perform, have particular relations of function and position with other organs, and are themselves endowed with certain properties, of which I may now specify mobility, and variations of size and shape, we have to investigate the pathology of the ovaries and uterus from distinct, special points of view, medical and surgical. Now, it is my duty to tell you that ovario-uterine pathology, both general and special, are too much neglected by body of physicians and surgeons. Nodoubt this study is beginning to be better appreciated than it was twenty or thirty years ago. But there are still men of deserved eminence who seem to think that the domain of No. 2856.
GENTLEMEN,—The
thegeneral
I have taken several occasions to show that the solution, or the most instructiveillustrations, of many of the most interesting problems in general pathology, as fever, throm-
bosis, acute jaundice, glycosuria, albuminuria, pigmentation, convulsions, chorea, and other nervous disorders, will be found in the studv of menstruation and pregnancy. In the
whole range of physiology and pathology no such instructive opportunities of studying the play of the excito-motory system are found. This luciferous source of knowledge is practically repudiated. And it follows that science and humanity suffer. Ignorance may be bliss, but it is not the best foundation of the healing art. We cannot afford to neglect any source of knowledge. Medicine cannot be successfully studied bit by bit. Fragmentary medicine, maimed and imperfect, is the outcome of specialism. The real specialist is he who studiously fixes his attention upon one organ or tissue, ignoring the rest. But he is scarcely less a. specialist who speciallv neglects the conditions and reactions of any organ of the body. Let us now discuss the mode of diagnosis. That we may form a diagnosis it is essential that we possess a theoretical knowledge of disease. We must find out what the patient suffers from if ive want to relieve him by rational welldirected treatment. If it were true that every disease has its specific remedy-an exploded notion,-it would still be necessary to find out the disease in order to meet it by its appropriate remedy. And if we could not discover the disease, we might still, on the good old empirical plan, make a shot at it by firing into it a volley of remedies, counting that perchance one amongst them would hit the doubtful1 mark. " Every bullet has its billetshould be the maxim of the empirical practitioner. Since, however, we are not always able to realise the first rational indication, to detect the disease, we may for a time fall back upon the plan of observing how the whole system labours, and how any particular function is in difficulty. This will furnish a provisional indication in treatment. Medication on this principle is usually safe, and ought to be safe. Two or three rules of practice will carry you a long way. Thus, when in doubt, give salines. There is hardly any disease in which salines will not do good at the beginning. There is hardly any disease in which they will do harm. By giving salines you gain time for observation, for finding outthe’more precise indications for treatment. The next rule-it ought perhaps to be the first-is, enjoin rest. The Pharmacopoeia contains no remedy of so much value, of such universal application. In addition to its other advantages, it has the merit of giving time for leisurely observation. The third rule might be to relieve any organ suffering from difficulty in the performance of its function. But this rule requires to be followed with great discretion. For example, it is not always wise to purge because the bowels are not relieved. On the
contrary, opium may be indicated, as in intussusception. And you may often greatly relieve one disabled organ by inducing other organs to do at least a portion of its work. If you observe these three precepts, you will fulfil the fourth great maxim-the maxim, great in its positive good because great in its negation of harm, laid down by Hippocrates: If you do not see your way clearly to do your patient good, take care at least that you do him no harm. Your first interview with your patient is your opportunity. A mistake made at this critical moment may damage yourself as well as him ; and he may give you no opportunity of retrieval. Later on you may make a mistake, and the consequences, to yourself at least, may be less difficult to get Take care, then, of your first step. over. Start quietly ; Distrust proceed warily. Do not put your faith in intuition. those who "see through a disease at a glance."" They are shallow people, and are easily seen through themselves. The motto of the true physician is " Thorough." Now we may proceed to diagnosis. Guided by the principle that when a part of the body is diseased the whole suffers, we must examine the condition of the body in its parts and as a whole. This makes it necessary to examine
742 with method.
What is the best method ?
I do not think
in muscular power, and the want of muscular action inter-
myself competent to say. But I can point out one which feres with their prehensile function, and also induces a tenwill fairly answer in practice. The history, diathesis, in- dency for the saliva to run over the chin. The mucous herited or acquired, and the antecedent diseases stand on membrane is extremely liable to chronic inflammation, and the threshold of the inquiry. These disposed of, examine ulceration is induced by the slightest pressure against prothe functions and organs in a certain regular order :- minent or uneven teeth. The glands of the mucous meni(1) Aspect, plumpness, colour and state of the skin gene- brane of the mouth generally, as well as the salivary glands, rally ; (2) the circulation, pulse, respiration, and tempera- are usually hypertrophied. Again,2 he speaks of certain ture ; (3) nutrition, the tongue, appetite, digestion, stomach, semilunar folds of skin at the inner canthus of the eveintestines, defecation, and bile ; (4) the urinary organs, the folds which, he believes, are more frequently present in and bladder, as to pain, as to retention or other characters, as well as the characters of the urine itself ; (5) the nervous system, sleep, motor power, general languor or exaltation, excito-motory system, mental state, delirium, pain, and its seat and kind ; (6) In women, the sexual organs, the menstrual function, child-bearing, and the
feeble-minded children than in others, and which he describes as epicanthic folds. They are, according to his experience, marks of developmental degeneracy, and should always be looked for in doubtful cases. Then he remarks that the seat of implantation of the ear in idiots is usually placed further back in relation to the head and face than in normal children. The mouth is arched or gothic-shaped;.z. the tongue is increased in size. It is rugous, fissured, and its papillae are enlarged. Again, the angle of the jaw is more obtuse than usual. Perhaps the commonest observable congenital deformity of the face is harelip. Having written so recently on this subject, I have little to add to what has been already published ; but I may be permitted to dwell for a moment on one or two points in connexion with this deformity. 1st. Respecting the intermaxillary or premaxillary bones. I think there can be no doubt that when harelip is associated with a fissure of the hard palate, the fissure takes the place of the lateral incisor tooth of one or both sides, as the case may be. In other words, the lateral incisor is usually wanting. Figures 21 and 22 indicate these points, but the actual specimens, which I hand round, and some of ths photographs, I think, put the matter beyond doubt.
kidneys
secretions. All these phenomena should be, as far as possible, explored by the aid of manipulation, and the appropriate instruments of exploration. It is a dangerous thing to form a subjective diagnosis ; it is a dangerous thing to accept your diagnosis from the patient. Until recent times, however, all diagnosis of uterine disease was subjective. The result was hopeless ignorance, causing disastrous errors. And so it was to a great extent in nearly all diseases before the stethoscope, thermometer, sphygmograph, test-tube, and microscope came into practical use. The advantages of pursuing some such method as that which I have just pointed out to you are-1. You are not so likely to overlook what you are in search of. 2. You will not seldom detect complications; that is, associated diseases in addition to that, the most obvious and apparently urgent " one, which, as the French say, " scc2ste cczcx yeux. 3. You avoid the serious mistake of going over the ground two or three times-of beating about the bush. It gives a bad impression to your patient if you ask him the same question two or three times, when he has already answered it. He will be apt to conclude that you are talking at random, and have no clear idea of what you are about. You may ask, why have I, who am specially called upon to aid you in studying gynaecology, touched upon all this ? It is extremely rare to find a case of double harelip with Simply because there is, in truth, nothing more special in no fissure of the whatever, but such a case is now gynaecology than there is in the study of heart disease, lung under the care ofpalate Mr. Croft, at St. Thomas’s. my colleague, disease, or any other disease. All disease must be studied Hospital. on the same principle and after similar methods. A long 2nd. The hereditary character of harelip is occasionally process, you will say. But practice enables one to go through very striking. Thus Dr. Buck3 gives an account of a family much of this long inquiry quickly, and in the course of other in which there was a very remarkable hereditary history :inquiries. "Mrs. Molinieri and her three children (all girls) cameunder his notice in January, 1871. The mother herself bore the marks of a successful operation for harelip performed in Lettsomian Lectures childhood. She had a brother and sister with harelip; and besides the three living children above referred to, she had ON THE had four others, who had all died in early infancy; three of these had harelip, and the fourth one only was a perfect child. In other words, there were nine instances of the Delivered at the Medical Society of London, February 1878, deformity in two generations of a single family." 3rd. I may be permitted to make one or two practical remarks respecting the method of operation. The harelip BY FRANCIS MASON, F.R.C.S., pin with the twisted suture is very commonly employed to SURGEON AND LECTURER ON ANATOMY AT ST. THOMAS’S HOSPITAL; bring the edges together, but, without entirely discarding this HON. FELLOW OF KING’S COLLEGE, LONDON. method of approximating the parts, I feel sure that the usual interrupted suture of silk may in most cases be employed LECTURE III.-PART I. with great advantage, and I believe, with certain precautions, DEFORMITIES OF THE FACE. it is in many instances preferable; but whether the twisted or interrupted suture be used, the success of the operation disMR. PRESIDENT AND GENTLEMEN,—Having briefly mainly depends, first, on the soft parts being thoroughly I and of the of diseases the face, purpose, freed from injuries posed of the subjacent bone ; secondly, on the with your permission, in this, my concluding lecture, to the fissure so pared that a good broad raw surface is being describe some of the principal deformities that are met with left; and thirdly, that the patient be incessantly watched in this region, with their appropriate treatment. I shallfor three or four days by a skilled nurse, who should support pass over such congenital malformations as do not come the newly united surfaces by making continuous but gentle within the scope of the surgeoi1’s art; those I mean that pressure on each cheek. I have little confidence in the use of mechanical appliances after the operation ; for in nursing would be generally classified as monstrosities. the child they are apt to their and often do more In a paper " On the Relation of the Teeth and Mouth to harm than are, however, invaluable as aids in good. They Mental Development,"1 Dr. Langdon Down lays stress on the: bringing the two superior maxillae together if worn before characteristic features of the lips in congenital idiots. The: operative procedure is undertaken. Again, strapping is of especial service before the operation, but afterwards it cannot lips, he says, are usually thick, the thickness being greatlybe with safety solely relied on. In more marked in the lower than in the upper one. Besides the ordinary forms of harelip, fissures of the lips addition to the thickening they are often striated andl extend in other directions. Thus Mr. Ward describes a. marked by transverse fissures. They are frequently deficient 2 Trans. Obstet. Soc. of London, vol. xviii., 187& 1 Trans. Odontological Soc., vols. iii. and iv., 1871-72, p. 14. 3 Reparative Surgery, 1877, p. 130.
SURGERY OF THE FACE.
edges
,
,
shift
’
place,
Lecture
ROYAL COLLEGE OF PHYSICIANS.
(Reported by
Dr. FANCOURT
BARNES.)
method of clinical study is the same for all diseases, for all regions of the body. The body is a whole, made up of mutually dependent parts. The fable of Menenius Agrippa was not more true in its application to the body politic of Rome than it is to-day in its application to the body of medical science, and to the body of man or The indiwoman upon whom the medical art is exercised. visible unity of the parts of the body is seen, first, in the circulation. This is one : blood goes from the same source everywhere to every organ. If any organ is disordered, there results infallibly dynamic derangement, or tissue or nutrition disorder, which affects the quality of the whole mass of the blood. This indivisibility is again seen in nervous action. The nervous system is a whole. Disturbance of an organ entails nerve disorder, and the nerve-centres are affected ; the whole organism feels the blow. Disease may be, in its origin, local or general; that is, it may begin in an organ or tissue or in the blood. But whatever the original disease, be it local or general, the whole body and each individual organ and tissue is liable, sooner or later, to be affected in its structure, and therefore disordered in its function. In the case of original local disease, the organ or part primarily affected may for some time exhibit the most prominent change of structure and disorder of function. But this is not always true throughout. The organ first affected may not be one of vital importance. But, starting from an organ of secondary importance, the disease invades other organs in their structure, or impedes them in the performance of their functions. In this manner the primary seat of the disease may become masked. For example, cancer of the neck of the uterus, so long as it is limited to that region, may not be of vital consequence. Like the breast, it may be amputated. But let cancer spread to the bladder or rectum or glands, and the secondary conditions may kill. So far as the general pathology of cancer, tumours, struma, and allied diseases is concerned, what applies to these diseases, when they invade the ovaries and uterus, equally holds good when they invade other parts. The differences that call for particular study are - essentially clinical; in one sense they might be called accidental. Thus, if cancer attack the stomach, it will, according to its kind and the region of the stomach attacked, cause-(1) disturbance of the function of the stomach; (2) disturbance by pressure or by extension to neighbouring parts, inducing disorder of function of those parts ; (3) infection of the glands, bloodvessels, and the blood itself. Just so it is when cancer affects the uterus. The disease will produce certain clinical variations according to the nature and importance of the functions of the organ first attacked and to the nature and importance of the functions of the immediately associated or adjacent organs. This, then, is the key to the special pathology of the ovaries and uterus in so far as general morbid processes are concerned. But inasmuch as the ovaries and uterus have special functions to perform, have particular relations of function and position with other organs, and are themselves endowed with certain properties, of which I may now specify mobility, and variations of size and shape, we have to investigate the pathology of the ovaries and uterus from distinct, special points of view, medical and surgical. Now, it is my duty to tell you that ovario-uterine pathology, both general and special, are too much neglected by body of physicians and surgeons. Nodoubt this study is beginning to be better appreciated than it was twenty or thirty years ago. But there are still men of deserved eminence who seem to think that the domain of No. 2856.
GENTLEMEN,—The
thegeneral
I have taken several occasions to show that the solution, or the most instructiveillustrations, of many of the most interesting problems in general pathology, as fever, throm-
bosis, acute jaundice, glycosuria, albuminuria, pigmentation, convulsions, chorea, and other nervous disorders, will be found in the studv of menstruation and pregnancy. In the
whole range of physiology and pathology no such instructive opportunities of studying the play of the excito-motory system are found. This luciferous source of knowledge is practically repudiated. And it follows that science and humanity suffer. Ignorance may be bliss, but it is not the best foundation of the healing art. We cannot afford to neglect any source of knowledge. Medicine cannot be successfully studied bit by bit. Fragmentary medicine, maimed and imperfect, is the outcome of specialism. The real specialist is he who studiously fixes his attention upon one organ or tissue, ignoring the rest. But he is scarcely less a. specialist who speciallv neglects the conditions and reactions of any organ of the body. Let us now discuss the mode of diagnosis. That we may form a diagnosis it is essential that we possess a theoretical knowledge of disease. We must find out what the patient suffers from if ive want to relieve him by rational welldirected treatment. If it were true that every disease has its specific remedy-an exploded notion,-it would still be necessary to find out the disease in order to meet it by its appropriate remedy. And if we could not discover the disease, we might still, on the good old empirical plan, make a shot at it by firing into it a volley of remedies, counting that perchance one amongst them would hit the doubtful1 mark. " Every bullet has its billetshould be the maxim of the empirical practitioner. Since, however, we are not always able to realise the first rational indication, to detect the disease, we may for a time fall back upon the plan of observing how the whole system labours, and how any particular function is in difficulty. This will furnish a provisional indication in treatment. Medication on this principle is usually safe, and ought to be safe. Two or three rules of practice will carry you a long way. Thus, when in doubt, give salines. There is hardly any disease in which salines will not do good at the beginning. There is hardly any disease in which they will do harm. By giving salines you gain time for observation, for finding outthe’more precise indications for treatment. The next rule-it ought perhaps to be the first-is, enjoin rest. The Pharmacopoeia contains no remedy of so much value, of such universal application. In addition to its other advantages, it has the merit of giving time for leisurely observation. The third rule might be to relieve any organ suffering from difficulty in the performance of its function. But this rule requires to be followed with great discretion. For example, it is not always wise to purge because the bowels are not relieved. On the
contrary, opium may be indicated, as in intussusception. And you may often greatly relieve one disabled organ by inducing other organs to do at least a portion of its work. If you observe these three precepts, you will fulfil the fourth great maxim-the maxim, great in its positive good because great in its negation of harm, laid down by Hippocrates: If you do not see your way clearly to do your patient good, take care at least that you do him no harm. Your first interview with your patient is your opportunity. A mistake made at this critical moment may damage yourself as well as him ; and he may give you no opportunity of retrieval. Later on you may make a mistake, and the consequences, to yourself at least, may be less difficult to get Take care, then, of your first step. over. Start quietly ; Distrust proceed warily. Do not put your faith in intuition. those who "see through a disease at a glance."" They are shallow people, and are easily seen through themselves. The motto of the true physician is " Thorough." Now we may proceed to diagnosis. Guided by the principle that when a part of the body is diseased the whole suffers, we must examine the condition of the body in its parts and as a whole. This makes it necessary to examine
742 with method.
What is the best method ?
I do not think
in muscular power, and the want of muscular action inter-
myself competent to say. But I can point out one which feres with their prehensile function, and also induces a tenwill fairly answer in practice. The history, diathesis, in- dency for the saliva to run over the chin. The mucous herited or acquired, and the antecedent diseases stand on membrane is extremely liable to chronic inflammation, and the threshold of the inquiry. These disposed of, examine ulceration is induced by the slightest pressure against prothe functions and organs in a certain regular order :- minent or uneven teeth. The glands of the mucous meni(1) Aspect, plumpness, colour and state of the skin gene- brane of the mouth generally, as well as the salivary glands, rally ; (2) the circulation, pulse, respiration, and tempera- are usually hypertrophied. Again,2 he speaks of certain ture ; (3) nutrition, the tongue, appetite, digestion, stomach, semilunar folds of skin at the inner canthus of the eveintestines, defecation, and bile ; (4) the urinary organs, the folds which, he believes, are more frequently present in and bladder, as to pain, as to retention or other characters, as well as the characters of the urine itself ; (5) the nervous system, sleep, motor power, general languor or exaltation, excito-motory system, mental state, delirium, pain, and its seat and kind ; (6) In women, the sexual organs, the menstrual function, child-bearing, and the
feeble-minded children than in others, and which he describes as epicanthic folds. They are, according to his experience, marks of developmental degeneracy, and should always be looked for in doubtful cases. Then he remarks that the seat of implantation of the ear in idiots is usually placed further back in relation to the head and face than in normal children. The mouth is arched or gothic-shaped;.z. the tongue is increased in size. It is rugous, fissured, and its papillae are enlarged. Again, the angle of the jaw is more obtuse than usual. Perhaps the commonest observable congenital deformity of the face is harelip. Having written so recently on this subject, I have little to add to what has been already published ; but I may be permitted to dwell for a moment on one or two points in connexion with this deformity. 1st. Respecting the intermaxillary or premaxillary bones. I think there can be no doubt that when harelip is associated with a fissure of the hard palate, the fissure takes the place of the lateral incisor tooth of one or both sides, as the case may be. In other words, the lateral incisor is usually wanting. Figures 21 and 22 indicate these points, but the actual specimens, which I hand round, and some of ths photographs, I think, put the matter beyond doubt.
kidneys
secretions. All these phenomena should be, as far as possible, explored by the aid of manipulation, and the appropriate instruments of exploration. It is a dangerous thing to form a subjective diagnosis ; it is a dangerous thing to accept your diagnosis from the patient. Until recent times, however, all diagnosis of uterine disease was subjective. The result was hopeless ignorance, causing disastrous errors. And so it was to a great extent in nearly all diseases before the stethoscope, thermometer, sphygmograph, test-tube, and microscope came into practical use. The advantages of pursuing some such method as that which I have just pointed out to you are-1. You are not so likely to overlook what you are in search of. 2. You will not seldom detect complications; that is, associated diseases in addition to that, the most obvious and apparently urgent " one, which, as the French say, " scc2ste cczcx yeux. 3. You avoid the serious mistake of going over the ground two or three times-of beating about the bush. It gives a bad impression to your patient if you ask him the same question two or three times, when he has already answered it. He will be apt to conclude that you are talking at random, and have no clear idea of what you are about. You may ask, why have I, who am specially called upon to aid you in studying gynaecology, touched upon all this ? It is extremely rare to find a case of double harelip with Simply because there is, in truth, nothing more special in no fissure of the whatever, but such a case is now gynaecology than there is in the study of heart disease, lung under the care ofpalate Mr. Croft, at St. Thomas’s. my colleague, disease, or any other disease. All disease must be studied Hospital. on the same principle and after similar methods. A long 2nd. The hereditary character of harelip is occasionally process, you will say. But practice enables one to go through very striking. Thus Dr. Buck3 gives an account of a family much of this long inquiry quickly, and in the course of other in which there was a very remarkable hereditary history :inquiries. "Mrs. Molinieri and her three children (all girls) cameunder his notice in January, 1871. The mother herself bore the marks of a successful operation for harelip performed in Lettsomian Lectures childhood. She had a brother and sister with harelip; and besides the three living children above referred to, she had ON THE had four others, who had all died in early infancy; three of these had harelip, and the fourth one only was a perfect child. In other words, there were nine instances of the Delivered at the Medical Society of London, February 1878, deformity in two generations of a single family." 3rd. I may be permitted to make one or two practical remarks respecting the method of operation. The harelip BY FRANCIS MASON, F.R.C.S., pin with the twisted suture is very commonly employed to SURGEON AND LECTURER ON ANATOMY AT ST. THOMAS’S HOSPITAL; bring the edges together, but, without entirely discarding this HON. FELLOW OF KING’S COLLEGE, LONDON. method of approximating the parts, I feel sure that the usual interrupted suture of silk may in most cases be employed LECTURE III.-PART I. with great advantage, and I believe, with certain precautions, DEFORMITIES OF THE FACE. it is in many instances preferable; but whether the twisted or interrupted suture be used, the success of the operation disMR. PRESIDENT AND GENTLEMEN,—Having briefly mainly depends, first, on the soft parts being thoroughly I and of the of diseases the face, purpose, freed from injuries posed of the subjacent bone ; secondly, on the with your permission, in this, my concluding lecture, to the fissure so pared that a good broad raw surface is being describe some of the principal deformities that are met with left; and thirdly, that the patient be incessantly watched in this region, with their appropriate treatment. I shallfor three or four days by a skilled nurse, who should support pass over such congenital malformations as do not come the newly united surfaces by making continuous but gentle within the scope of the surgeoi1’s art; those I mean that pressure on each cheek. I have little confidence in the use of mechanical appliances after the operation ; for in nursing would be generally classified as monstrosities. the child they are apt to their and often do more In a paper " On the Relation of the Teeth and Mouth to harm than are, however, invaluable as aids in good. They Mental Development,"1 Dr. Langdon Down lays stress on the: bringing the two superior maxillae together if worn before characteristic features of the lips in congenital idiots. The: operative procedure is undertaken. Again, strapping is of especial service before the operation, but afterwards it cannot lips, he says, are usually thick, the thickness being greatlybe with safety solely relied on. In more marked in the lower than in the upper one. Besides the ordinary forms of harelip, fissures of the lips addition to the thickening they are often striated andl extend in other directions. Thus Mr. Ward describes a. marked by transverse fissures. They are frequently deficient 2 Trans. Obstet. Soc. of London, vol. xviii., 187& 1 Trans. Odontological Soc., vols. iii. and iv., 1871-72, p. 14. 3 Reparative Surgery, 1877, p. 130.
SURGERY OF THE FACE.
edges
,
,
shift
’
place,