OPERATOR.

Date.

Sex.

Age.

Mode and site of

operation.

Table of Cases of Paracentesis of the Pericardium since 1860, Additional to those Published in Monograph.

Recovery.

Death.

Time that

patient survived

operation.

REMARKS.

Complication.

Reference.

NOTE. Since the reading of this paper, I have found a report of two other cases of paracentesis of the pericardium, originally published by P. Kummell, in the Berliner klinische Wochenschrift, November 23, 1880. An abstract of his paper may be seen in the London Medical Record, July 15, 1880, p. 279. One case recovered; the other was tapped twice, and died six days after the first operation.

It will be observed by those having access to the literature of the subject, that I have not included all the cases mentioned by Hindenlang in his elaborate article, published during the same month as my book. This is due to the fact that several of the cases, already recorded by me in my monograph, he has attributed to different operators, because he confused the operator with the reporter, or the chief surgeon with the assistant. Allbutt's case (No. 31) was really Teale's, and is so described by me; Moore's (No. 44) should be Gooch's. The two cases described by Hindenlang, as operated upon by Ponroy (No. 32), and by Frémy (No. 34), are really one and the same case; and the history is given in my table as No. 33.

In the present table I have introduced from his article the operations of Bäumler and Kussmaul; and, from the original source, that of Gairdner, which he attributes to Gemmell (No. 37). The case which he ascribes to Löbel (No. 30) I have omitted, because his article and Schmidt's Jahrbücher, from which he evidently obtained it, give no details, and say the operation failed.

Dessault's and Larrey's cases were discarded by me in the very first of my investigations, because they were apparently not instances of pericardial tapping. In like manner Vigla's case (operated on by Roux) was rejected, because the diagnosis was reversed by the incision into the sac, and the patient died from dilated heart, without any reference to the operation.

ON SKIN-GRAFTING, WITH A REPORT OF SOME

INTERESTING CASES.

BY LAURENCE TURNBULL, M.D.,

PENNSYLVANIA.

HISTORY OF THE OPERATION.

ONE hundred years have passed since the celebrated anatomist, John Hunter, was successful in transplanting the spur of a young chicken from its leg to its comb, as well as into the comb of a second bird, where it lived and grew; and no one made use of this valuable fact until a French surgeon, M. Reverdin, of Paris, in October, 1869, succeeded in transplanting a small portion of skin from one part of a man's body to the granulating surface of a large sore, under which treatment the ulcer healed.

By the aid of time, position, local stimulation, and mechanical support, in healthy individuals, almost every variety of ulcer or granulating sore will heal, or be covered with skin; but in some instances, after weeks, months, and even years of treatment, there comes a time when this healing will cease, in spite of all the most approved efforts on the part of the surgeon and earnest efforts and co-operation of the patient.

The new process of skin-grafting was in the first instance applied to these difficult and chronic sores.

At a later period the process of skin-grafting was extended. to supply defective plastic, and other operations where, from contraction of the flap of skin in healing, the parts are not covered, or to prevent contraction, which is so apt to follow deep-seated burns, and prevent great deformity in the act of healing.

Another important application is, where it is necessary to remove cancer, chancroid, lupus, or in syphilitic ulcers on the face, or any exposed part of the body; the skin-graft fills the removed part with smooth tissue, and is often of the utmost. importance in its cosmetic effects.

PHYSIOLOGY OF SKIN-GRAFTING.

It has been found, by careful experiments, that by planting cells of healthy epithelium at various points on the granulating surface of a healthy sore, centres for the development of new skin are formed, and by multiplication and extension of these patches a sufficient amount of healthy skin can be cultivated to cover a very large amount of the surface of the body. M. Reverdin asks the question: "Is the growth of skin due to the effect of contact or neighborhood, or is it due to proliferation of the transplanted elements?"

To make this skin-grafting a success, it should include some superficial dermis or rete mucosum, with some of the deep liv ing cells which are found in the epithelial layer which possess conditions for propagation when placed in the natural pabulum, the healthy blood. If these cells continue healthy, they commence soon a process of proliferation, but no fat-cells are to be introduced, nor must there be simply scarfskin, which latter, being formed of horny, flattened scales, without nuclei, is incapable of growth.

Original plan of operating of M. Reverdin.

A small piece of epithelium, including some of the superficial dermis or rete mucosum, is taken from the healthy cutaneous surface on the inside of the arm, thigh, or face, by a fine forceps, and snipped out with a sharp scissors-each part not larger than the size of half a grain of hemp-seed. A small puncture in the raw surface is then made, and the small fragment of skin is carefully and accurately placed in it and protected by adhesive plaster.

Some suggestions in reference to the success of the operation.

The new skin-graft should be kept in position and not interfered with for several days; it should be lightly covered with a layer of cotton-wool and a bandage, for the purpose of maintaining its warmth and vitality.

If the grafts are placed on an ulcer on the extremities, the patient must be kept in bed for a few days.

Mr. Bryant, of Guy's Hospital, lays the graft on the surface of the ulcer, and states that he has not found any difference in the result.

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