The value of cocaine as a local anesthetic has become so well known that it seems but repetition to report more cases unless it be to increase the evidence in its favor.

Case 1st.-Mr. D. came to the college clinic on the 2d of December, 1885, with a tumor the size of an egg on the radial side of the left forearm about two inches above the wrist. He wished the tumor removed, but was very nervous about an operation, and did not wish to take an anesthetic. He was told the operation could be done without putting him to sleep or giving him pain; so he consented and was operated upon before the class. The skin over the tumors was first anointed with oleate cocaine 5 per cent., and when the sensibility had diminished six hypodermic punctures of 8 minims each of a 5 per cent. solution of cocaine were made around the tumor in the line of incision. After ten minutes the operation was begun and completed without the first expression of pain, although it took eight or ten minutes to make the necessary dissection The wound was dressed, and he arose from the table delighted with cocaine and its happy effect.

Case 2d.-Sarah G. presented herself with a tuberculous disease of the 2d joint of the left index finger; amputation was deemed advisable, and she was told of the anesthetic properties of cocaine, and consented to have it tried. A piece of small rubber tubing was placed around the hand, with a compress over the palmar arches, so as to arrest the circulation and control hemorrhage. The metacarpo-phalangeal joint having been decided upon as the seat of operation, six injections of 8 minims each of a 5 per cent. solution of cocaine were made around the line of incision, and in ten minutes the operation was performed, the woman not feeling the slightest pain-in fact, was surprised when told the finger was off.

Case 3d. This case, one of long standing, ingrowing toenail, was sent to me for operation by my friend, Dr. H. H. Steiner. The patient, a young man of 18 years, had not been able to wear a shoe for three years. An examination of the toe showed the nail, except a very small part of its centre, buried in painful, angry-looking granulations-in short, one of the worst of that class of painful troubles. It was so excessively painful that he was loth to have me do anything for him, but after assuring him that with cocaine it would not be painful, he consented, and the operation performed as follows: The toe was first ligated at its base with a piece of elastic cord, then the entire upper surface of the toe anointed with oleate cocaine 5 per cent. After waiting a few minutes four punctures of 10 minims each of 5 per cent. solution were made, one being along either side of the nail, one at its base over the nail and the other under the nail, none of these punctures giving pain. The scissors were then passed under the nail beyond the matrix and the nail split, either half being removed with the forceps. The granulations were then shaved off all around on

a level with the bed of the nail and the dressings applied. During the entire operation the patient did not wince or show the slightest evidence of feeling pain. The value of the ligature in localizing the cocaine in these operations was very evident, and in none of them was any constitutional effects noted.

AMPUTATION OF THE BREAST-DEATH FROM TETANUS ON THE

TENTH DAY.

In May, 1884, I was requested by Dr. E. C. Goodrich to see, with a view to operating, Caroline McC., a mulatto woman, weighing something over two hundred pounds. She had a scirrhus tumor of the right breast. The woman's breasts were very large, and the right one, occupied as it was by the tumor, was enormous. The operation was performed on the 3d of June, Drs. Goodrich, Doughty and Fargo present and assisting. Two elliptical incisions about nine inches in length were made from the top to the base of the gland, and the tumor carefully and slowly dissected out, all bleeding vessels being clamped and twisted as they were cut, so that the hemorrhage was small, although the operation lasted nearly three-quarters of an hour. The tumor, upon removal, weighed something over three pounds. The axillary glands were not at all implicated, so it was not necessary to go into that space at all. After the oozing had ceased, the wound, which was very large, was sponged out with carbolized water, 1 to 20, dusted with iodoform and closed with interrupted sutures and adhesive plaster. The line of incision was again dusted with iodoform and the wound covered with antiseptic gauze. On the fourth day the dressings were removed and primary union found, except at the center of the wound, where a piece of adhesive plaster had slipped and allowed some gaping. The suppuration, except at this

point, was nil. The woman continued to do well until the sixth day, when tetanus set in, and she died on the tenth day after the operation. Tetanus, after this operation, is rare; hence I thought it of interest to report the case, especially as will be noted no ligatures were used, and the axillary space, with its numerous nerves, was not invaded.

INCONTINENCE OF URINE AND REFLEX CONVULSIONS CAUSED BY CONGENITAL PHIMOSIS-CIRCUMCISION-CURE.

On April 18th, 1885, Willie J., aged about three years, was brought to my office with the following history: He had suffered with incontinence of urine since birth, but otherwise had been in good health until six days before, when he had a violent convulsion, which was repeated the next week. The convulsions continued increasing in number and severity, and when brought to me he was having three or four daily. Examination showed the preputial orifice very much contracted, scarcely admitting a pin-head, with adhesions between the glans and mucous membrane. With the assistance of Dr. J. B. Morgan he was chloroformed and circumcised, the mucous membrane torn from the glans, clipped off and its cut edges laid in opposition with that of the skin. A simple dressing of carbolized glycerine was applied and the little fellow sent home. The week following the operation he had a convulsion, but not severe; three weeks later he had another, but very slight. Since that time now about a year, there has been no return, and he is now in excellent health, cured of both his troubles.

In this connection it may be of interest to report a case of circumcision recently performed for Dr J. E. Green, of this city, on a patient of his, who was over 70 years of age.

THE CURETTE TREATMENT OF A CERTAIN TYPE

OF CUTANEOUS ULCERATION.*

BY HENRY WILE, M. D., ATLANTA, GA.

Cutaneous ulcerations are never primary lesions, but always follow an acute or chronic inflammation, and are attended with a varying amount of destruction of the corium. They may occur on any part of the body, exhibit as a rule little tendency to undergo reparative changes, and in the event of their healing, a cicatrix always results. These lesions are distinguished according to the nature of the primary process to which they owe their existence. Thus we differentiate between syphilitic, epitheliomatous, tuberculous and varicose ulcerations.

In olden times chronic ulcers were supposed to bear an intimate relation with certain conditions of the blood. The lesions were regarded as a means whereby poisonous materials were eliminated, which, if retained, or driven in by attempts to close up the natural outlet, might take refuge in some internal organ and cause disease, even death. In cases of amenorrhoea, it was supposed that the process was a sort of vicarious menstruation. These ideas, though still met with among laymen and some of the older practitioners, are, thanks to the works of modern investigators, being abandoned.

I wish to consider but one of these forms of cutaneous ulcerations, a form most frequently encountered in general

*Reported from the Section on Surgery for the Fifth Congressional District.