□;«,<%>« I LIBRARY OF CONGRESS. | $^*I.$2SIj*- -| | jm«// 3Ja. i i UNITED STATES OP AMERICA. J Mayer, Merkd i Ottmaim.Lith. '»+ QmrcU SOOT. A RECORD OF THE VBOICAL CLIIIC O F cv t t n| t Iforf |f «!«!»% Iff. J}„ HELD AT THE jj. 2- JOMCEOPATHIC JlEDICAL foLLEGE DM^rftS THE St§8t@NI OF I8?4-'?S. >/ PHILETUS eh STEPHENS, TO WHICH IS ADDED A SYNOPSIS OP THE CLINICS OF 18T3-'74. 1875. V 1>1 ctf> Entered according to Act of Congress, in the year 187P, By PHILETUS J. STEPHENS, In the office of the Librarian of Congress at Washington. To or TEE New Yoi 4 k J|on]oeo^ktl\ic Medidal dolle^ THIS WORK IS RESPECTFULLY SUBMITTED, BY PHILETUS J. STEPHENS. PREFACE Duking the last session of the New York Homoeopathic Medical College the undersigned was often struck with the brilliancy of the Surgical Clinics, and then determined, if he were spared another term, he would publish these Clinics, not onl}^ for the advancement of the college in which they were delivered, but for the good of the Homoeopathic cause generally. The method of conducting the lecture is as follows : the patients are sent from the Dispensary to the Amphitheatre and are introduced one by one to the class. There is not any selection of cases, or opportunity afforded for the lecturer to examine the patient, make up his diagnosis, select his remedy and prepare what apparatus is best; and for these reasons the author has endeavored to give the record in full, that the Clinics may appear, not dressed up with rhetoric and illustration, but as they really took place. The author also desires, at the request of Prof. Helmuth, to state that he (Prof. Helmuth) was unaware that these Clinics were being reported verbatim as they fell from his lips, until the session was almost over, and then he was for the first time made aware of the fact by the printed proof sheets being presented for his inspection. The author conceived that by keeping the matter entirely private during the term that he could more certainly offer to the students, the faculty of the college and the public the method in which Clinical Surgery is taught in the New York Homoeopathic College, which, he conceives, has no superior in this country. PHILETUS J. STEPHENS. SURGICAL CLINICS OF 1874-75 OF THE 3j{w lht\ Ijontttojiatfjit Jjfylttal fyo%$. The Session of the New York Homoeopathic Medical College for 1874 and 75 commenced October 10th, 1874, in the large and elegant Amphitheatre, under most favorable auspices. At the first Clinic there were present more than one hundred students, and more patients applied than could be attended to ; indeed, throughout the entire session, this has been the case. These Clinics are always lively, pleasant and attractive to students as well as physicians, and give entire satisfaction; they sparkle with humor, and reflect great credit upon Professor "Win. Tod Helmuth, who, Ave think, proves himself a perfect master of the art of surgery. The chief peculiarity of the Clinics are the pro- miscuous and rapidly given " quizzes." £w0fcul CUnw of ftjctotuv 10. A boy being brought in with his arm in a splint, Professor Wm. Tod Helmuth looked at it for a moment, and commenced to ques- tion the class as follows : What do we understand by the term fracture ? Answer. — A solution of continuity of the Osseous System ; or, in other words, a separation or breakage of the bones, by various causes, both di- rect and indirect. A fracture ma}' be known by pain, loss of power, and crepitus, or peculiar sensation from rubbing the ends of the broken bones together. What various divisions of fractures are recognized by surgeons ? Simple, Compound, Comminuted, Impacted, Complete, and Incom- plete Fracture. What is a simple fracture ? Is when the bone is broken at one point, without any wound of the flesh. 8 FRACTURE QUIZZES. What is a compound fracture ? Is one where there is a break- age of the bone, with a wound of the soft parts. "What is a comminuted fracture ? Is one where the bone lias been broken in more than one place, or cracked in many places. What is a compound comminuted fracture? One where the bone is splintered, or the breakage of bones into several fragments with, accompanying wounds of the soft parts. What is an impacted fracture ? One in which one extremity or portion of the bone is wedged or driven into the other. What is a complete fracture ? One in which there is an entire separation of the bone. What is an incomplete fracture ? One in which there is but a partial division of the osseous material. What terms are used to designate the directions in which the separation may occur ? Transverse, longitudinal, oblique or serrated fracture. What is a transverse fracture ? One which is directly across the bone. What is a longitudinal fracture ? One which runs lengthwise of the bone. What is an oblique fracture ? One in which the line of fracture runs from side to side in an oblique direction, or obliquely to the base of the bone. What is reduction? Petting a fracture: that is, bringing the ends of the broken bones together and adjusting them to each other in their natural position, embracing extension, counter extension, and coaptation. What is extension ? The taking hold of the limb below the fracture and making traction from the body* What is counter extension? Traction above the fracture towards the body, or steadying the body. Must this opposite traction be done at the same time ? Yes ; to overcome the force of the muscles, which contract and draw the ends of the broken bone over each other and so shorten the limb. Sometimes extension and counter extension are not required. What is coaptation? Adjusting the ends of the bones to each other. What would you do with a fractured limb ? Would set the bones : that is, restore the fragments as nearly as possible to CASE OF FRACTURE OF THE HUMERUS, ETC. 9 their natural position, keeping the ends of the broken bone in contact by mechanical contrivances, such, as bandages, pads, splints and rollers, so as to maintain them in such position that nature may have a fair chance to unite the broken bone together. What next would you do ? Prevent or allay constitutional or local disturbances. ;frr*«tttr* Dr. Helmuth (holding up a piece of flesh and hair in a bottle) said : There is the skin of a patient's chin ; this was a mother's mark. This girl's mother was four or five months gone in preg- nancy, and was very much frightened by seeing a mouse ; when the child was born, on the chin was this thing, covered with hair, and very dark hair it was. If you look at it sideways you will see it looks exactly like a mouse without a tail. The hair has turned white from being in alcohol, but it was perfectly dark when the growth was removed. The question arises, can the nervous influence of the mother be transmitted to a child ? I am just as certain that it can as I am that I am here. I know of a patient who was frightened with seeing a case of small pox, and her child was born with pustules on it. The first case to-day is that of Patrick Murphy, who was operated on two weeks ago for epitheloma of the lip. You will recollect that on the Monday following my last clinic the pins we;e withdrawn. It was rather an early day, but the union seemed so complete that I thought it advisable to withdraw the pins, and ordered adhesive straps applied. He was taken at night with a severe fit of coughing, which tore open the parts, and it was necessary to replace the pins. Last Saturday he was here, and other sutures used, but they came out. He came back on Tuesday, Dr. Thompson pared the edges afresh and applied new sutures, which are now to be removed. You will recollect how perfect the union seemed when those pins were removed on the third day. Of course, after the sutures have torn out, we have to be extremely careful. In plastic opera- tions like this, and in the operation for hare lip, the silk is often- times left after removing the pins, thereby affording considerable support. I have now removed the three pins, and the silk suture in the vermilion border of the lip. I should have taken the pre- caution to have had this man shaved, but now it is too late as the traction of the skin by shaving might break away the uniting points, I shall therefore leave his baard as it is, as it is now four or five days since he was shaved. I will now paint collodion upon the plaster. Very often after operations of this kind, and after that for hare lip, even after the parts have become almost perfectly united, I have known them torn apart by sneezing or coughing. Therefore, I usually take care, in operations of this kind in children, to paint the whole sur- face over with collodion. There are compressors which draw the parts together and take off the traction. In some instances incisions on the side are made to prevent the strain. John E. Jones, Aged 40. This patient comes from Poultney, Vermont. 40 CASE OF SUBCLAVIAN ANEURISM. When you examine a patient you must always do so carefully and thoroughly. The greatest error that I ever made in my life in a surgical diagnosis was because I made it in a hurry. When I enter upon fractures and dislocations I will tell you of the mistake that I made — since which time, I assure you, I have been more careful, and have taken more time for my examinations. There is an epidemic in suicides sometimes, and there are epi- demics often in labor cases. Sometimes there seem to be epidemics in deaths. I have not had an aneurism to treat for a considerable time, and now I have four on hand. We will get this man's history, and that as accurately as possible ; and, if I do not mistake, this will prove a very inter- esting case. If-you listen, with your ear at the root of the neck on the right side, you will not only hear pulsation, but you will hear a puff- ing sound, which is called the bruit. That is the peculiar puffing sound that you have in an aneurism. An aneurism is an enlargement of an artery in some part of its course, the cavity of which communicates with the long diame- ter of the vessel. In other words, an aneurism is an enlargement of an artery — either spherical or longitudinal — and presents pecu- liar and unmistakable signs, such, as the pulsation, which pulsa- tion is simultaneous with the beats of the heart and also bruit We have a variety of aneurism, in which only one side of the tube is enlarged ; and we have a fusiform aneurism, in which the whole circumference of the artery seems to be involved. As a general rule, however, it is only one side of the vessel which is dilated, and we detect in it the symptoms of pulsation simulta- neous with the beats of the heart, and the bruit, or puffing sound which you have heard. Aneurisms, as a general rule, begin suddenly, and often result from some sudden shock or strain. A person may be predisposed to them by certain diseases incident to the arterial coats, as ather- oma, which is a softening or deterioration of the internal coats of the artery. The patient states that his attention was first called to the swell- ing last August ; that he has not had any difficulty in breathing, although he has noticed an occasional accumulation of phlegm in the throat, and that his voice has become more husky than for- merly ; he had been working with a derrick, but does not recol- CASE OF ANGULAR CURVATURE OF THE SPINE. 41 lect that lie had been straining himself more than usual, but woke up in the morning and found a small lump, which pained him somewhat ; he has experienced no difficulty in swallowing ; but had slight cough. In the formation of aneurisms we always find what are called the active and the passive clot. As the blood is impelled through the aneurism by the beats of the heart, there is an effusion of fibrine which takes place around the circumference of the aneurismal sac, and this becoming partially organized forms itself into strata, be- comes of the color of currant jelly, and is termed the active clot In aneurisms about the aorta this clot sometimes becomes so large that the pulsation is almost indiscernable. Then, through the centre of this active clot, we have what is called the passive clot, or a clot which is thinner, and which allows the blood to pass through into the circulation. One of the methods of cure suggested by Sir William Fergusson is that of manipulation, in which this active clot is broken in pieces, and forced by the current into the channel of the artery. The subject of aneurism is possessed of so much importance, covers so wide a field in surgical literature, and has interested the minds of so many surgeons throughout the world, from a remote period to the present, that I propose to take up the subject in my next daily lecture (without waiting to arrive at diseases of the arteries in regular order), and, with this case before you, to lecture upon the subject of aneurism, properly so called. Then we will suggest the means of relief we think proper, after due consulta- tion. Several different methods have been proposed, and many of them followed with success; but it requires a great deal of judg- ment and thought — taking all the items of the case into considera- tion — to determine which method shall be adopted. I am glad to be able to bring this patient before you, because he seems willing and able to follow up the necessary treatment, and you shall see the result. ike Bf *&»* At the last clinic but one I showed you a case of Potts' dis- ease of the spine almost in its incipiency. This is a ease very 42 CASE OF potts' disease. much developed. In the other case the disease was lower down the spine ; here we have it in the dorsal vertebra. It is not necessary for me to add anything by way of description of Potts' disease of the spine. I simply need to say that there are certain medicines which act internally, according to the homoeopathic principle, which have a tendency to arrest the disease of the bone which is going on. Mechanical treatment, in this variety of dis- ease — whether it is Potts' disease of the spine, or curvature of the spine laterally, or disease of the hip — is always of great avail — of as much service as a splint, in a case of fracture ; but there, also, are certain internal medicines which, if properly administered and persevered in for a length of time, will be of decided benefit. I have known Potts' disease of the spine arrested in its incipiency without the use of a brace, in cases where you could keep the patient prone in the horizontal position. But the trouble is, that a majority of the patients who suffer from Potts' disease are scrofulous children. This is an exception, I think. It is this very vitiated condition of the consti- tution which is so admirably relieved and cured by the proper internal administration of medicine. Therefore, while you should as surgeons look into and understand all the recent improve- ments which belong to the mechanical appliances in surgery, it is just as important, and even more so, that you should under- stand the application of those medicines which, properly admin- istered, will eradicate the predisposition upon which this disorder depends. The splint on this patient is a much better one than that which I showed you on the last case of Potts' disease. The ob- ject is to support the upper part of the trunk and keep the weight from resting on the diseased vertebra. The internal ad- ministration of medicine is of great importance. In the investi- gation we have to be guided as much by constitutional peculi- arities, by the looks of the child, by the previous history of the parents, and other objective symptoms, as by the result of any minute inquiries with reference to the increase or diminution of the symptoms, which the patient, because of youth, may be unable to answer. There are some medicines, such as petro- leum, phosphate of lime, phosphorus, iodine, calcarea-carb., sul- phur, mezerium, which may be used to advantage, but I have seen more good results from the use of phosphate of lime, and ANGULAR CURVATURE OF THE SPINE. 43 from mezerium, than any other two of the medicines I have men- tioned. But do not understand me to say that these medicines are specifics for every case, because I do not. In these clinics I can only give you the names of the medicines from which you may select the special remedy applicable to a particular case. Therefore, I say that in a majority of cases I have found the phos- phate of lime and mezerium useful. In these cases the periosteum seems to be disordered rather than the bone itself; but when there is a good deal of pain, and. symptoms of fever set in, and the restlessness which follows any irritation of the system, you will soon discover the peculiar condition of the pulse which in- dicates an irritative fever. An irritative fever may be occa- sioned by any irritation going on in the system, from any occult cause. The patient wastes away, sweats, is pale, loses appetite, is fretful, peevish, the pulse stands at 120 ; he does not sleep at night and is depressed in mind. Whether it is a disease in the hip, or in the spine, or some other portion of the body, the symptoms point to an irritation in the system, which often begins in the first stages of Potts' disease, and before any local manifestation is looked for. Therefore it is that in these obscure cases, when you find an irritative fever, that the most careful examination be made in order that you may arrive at a correct diagnosis. Never be in a hurry to give a diagnosis. It is always a great deal better to wait, and especially never to put your ideas on paper until you are sure you are right. Many men have got themselves into a scrape by haste. When you are sure, then you may sign your name, but don't do it if there is a loophole by which somebody else can get hold of you and throw your diagnosis over. A man of inferior perception makes a good diagnosis in the advanced stage of the disease, and may thus, per- haps, outshine a more scientific or highly educated man who has seen the patient in the earlier stages of the same affection. Many a physician and many a surgeon has attended a patient straight through all the primary symptoms of disease, and has examined and studied up the case, yet could not tell exactly what was the matter, until the patient becomes dissatisfied ; and, perhaps, just as the disease develops itself, another doctor is called in, and re- ceives all the benefit of the diagnosis, because the symptoms are more perceptible to the senses. These are some of the injustices that may be done to the surgeon or physician. Therefore, I say that 44 MISTAKE IN SURGERY — MISTAKE IN MEDICINE. when you find an irritating fever, or symptoms indicating a certain amount of fever in the system, be careful how you make your diagnosis. A mistake in surgery is unfortunate. A mistake in medicine is frequently never known. The difference is this : the doctor attends a patient, makes a mistake, and the patient dies ; he has been attended for the wrong disease, but he dies and no- body is the wiser. A surgeon makes a mistake — makes a crooked arm, perhaps, which is held up before a jury for his damnation, and the result is that thousands of dollars are claimed for the mistake. Death covers a doctor's errors, but a surgeon's are held up before an illiterate jury. These suits for malpractice are beautiful ! I do not know of anything that makes a man sleep sounder at night than a suit for malpractice. Newman Meyer, 11 Years Old. The father states : " About a year ago I noticed that this boy did not play as usual. A little later he would wake up at night and come down stairs, saying that he could not sleep. Then we took him to Morrisville and had him examined by a physician. The doctor said that he had the " sciatica," and blistered him on his back, near the hips. A little later we employed two physicians. They still called it sciatica, and cupped his back, and gave him medicines of various kinds. Then they changed their opinion, and called it " spinal irritation." The boy got worse, and then we had a doctor by the name of Kelly, who introduced him- self to me, and said that he was sent to me by my brother-in-law. He said that there were no symptoms of spinal irritation, but that it was a perfect case of sciatica. We then went to doctoring him again for sciatica, but without any good results. Then that doctor left him, and I didn't know what to do next. I noticed that when the doctors would stay away from me, and I attended him, that he would seem to be easier. About four weeks ago a doctor by the name of Waterbury, formerly from New York, asked permis- sion to come over and mend up my boy. Said he, "I know more than all these doctors; I have had a good chance; I have been in the city, and I know all about it." Finally I consented CASE OF LATERAL SPINAL CURVATURE, ETC. 45 to have him come. He examined the boy. That was the first time the boy had been stripped and examined. He had been ex- amined only through his clothes before. The boy had, then, not walked for about ten weeks, but this doctor got him on his feet, and urged him to walk a little. After he examined him he said, "If old Dr. Sled was here he would call it 'worm palsy.'" Dr. Helmuth said, "I think the worms have not much to do with it, although they breed very fast in these cases." The patient continued : "He recommended an ' electrizing machine,' at first, and then he said that the boy would have to take opium continually and regularly. I did not like that, for I had about come to the conclusion not to give him any more preparations of opium, but he said that it would have to be done. Then he fixed up about a dozen pills, and put a little calomel in, so that they ' would not act upon the bowels.' I gave the pills to him that night, but the boy was worse. The following night I gave him the pills again, and still he seemed to be worse, and the same way with the next night. Then I went to see the doctor about it, and he told me to give him an ounce of opium — the clear stuff — the gum opium. By the time I got home my wife had given the boj 7 three of those pills, and he was still groaning with the pain. The pain is more severe at night than in the day time, and he cries a great deal at night. I then gave him a chunk of opium about as big as a a pea, in addition to the pills he had already taken. I usually went to bed as soon as I got home at night, and would sleep till about midnight, while my wife took care of the boy, and then I would get up and take care of him until morning. While I was in bed my wife gave him three more morphine powders, and he was still crying when I got up. I took him, then, and he con- tinued crying until daylight. My wife stated that she had also given him a double spoonful of paregoric to relieve his pain. He went to sleep about daylight, and slept all of that day and half of the next night. Then I said that that was the last opium he should take if he died for it." Dr. Helmuth said : This is certainly an obscure case. You can see from that boy's expression of countenance how he has suffered ; and you saw a moment ago, when I asked him to try to walk, what suffering the effort caused him. You must have respect for suffering whenever you see it; and when you see a human being Writhing the way that poor child did, and at the same time en- 46 TREATMENT OF LATERAL SPINAL CURVATURE. deavoring to conceal it, for jour benefit, you ought to be thankful to him, as I am. One of the peculiar characteristics of bone disease is the increase of pain at night. From the examination I have made of this case I take it for granted that there must be some pressure upon the spinal cord. This is a very aggravated case of curvature of the spine, differing from the other cases that have been before us in the greater number of vertebra affected. If I mistake not this condi- tion will go on until an abscess forms somewhere. The peculiari- ties of the pain that he has now, the loss of the power of motion, the pain of walking, the sufferings increasing at night — all seem to indicate a disease going on in the bony structure, and I believe in the spinal column, causing pressure upon the spinal cord, producing a certain amount of paralysis, and necessarily causing the patient great suffering and emaciation. The question is, what can be done in such a case as this ? I think that this boy can be benefited. In the first place he must have a proper apparatus, which shall take the weight off the hips as much as possible, and relieve the spinal column. I believe that if we could get the appropriate homoeopathic medicine it would relieve him. I will give him mezerium and let you know the result I will give it in the 200th potency. Put one powder in a tumbler two thirds full of water, and give him a tablespoonful every two hours until this evening, and then, if the pain augments ; give him a teaspoonful every fifteen or twenty minutes. In the meantime, I will try to have some appliance made which will have a ten- dency to take the pressure from the spinal cord, and prevent further deformity. With a proper appliance to take the pressure off the spine, we can, with the appropriate homoeopathic medicine, greatly relieve the pain. There is no class of diseases in which medicines of the higher potency seem to act as well as in those of the nerv- ous system. -» » ■»» Eliza Thomas, 4 Years Old. (The mother states that the child has been suffering from pro- lapsus ani, and that the bowels have been protruding for three or CASE OF PROLAPSUS ANI — TREATMENT. 47 four weeks.) The patient was exposed on the table, and a mass of bluish black intestine, four inches long, was found between the nates. It is wonderful that this bowel has not sloughed off before this. I do not know that I shall now be able to put it back as it should be done, but it must be returned pretty soon. The longer it is left out the worse the child will get. In reducing a prolapsed bowel you must do it gradually. With the fingers in this position, holding them as a cone, and lubricating them well, you push it up. (The bowel was then carefully returned.) When I get it in place I in- sert a sponge to hold it in position. It would be well to first soak the sponge in a strong solution of alum water, as that would have a tendency to make the bowels contract. I shall prescribe, as a medicine, nux vomica. I have had very excellent success attending its use in reducing prolapsed bowels. Administer nux vomica every two hours, and give only such articles of diet as will have a tendency to constipate the bowels. Give her chiefly boiled rice as food for the present. $m$m\ mmt of §mmbtx M, im. ( Continued.) Dr. Helmuth said : The patient we had here last Saturday is doing remarkably well. He returned on the following Monday, and upon a careful examination I find that he has a subclavian aneurism on the right side, I think in the second portion of the artery as it passes behind the scalenus anticus muscle. You all know the danger that is attendant upon aneurism of this artery, and you all understand the difficulties (or you will very soon, for I shall tell you) of its ligation. The subclavian artery has never been ligated successfully in the first part of its course on the right side, and on the left it is almost impracticable. The operation, I believe, has been performed only once, and then by J. Kearny Kogers, of the United States, some years ago. His patient did not survive. Taking into consideration the anatomical situa- tion and the disastrous results that arise from cutting off so large a supply of blood, you will see what a hazardous, difficult and dan- gerous operation it is to tie the subclavian artery on either side in the first part of its course. In the second part of its course, on the right side, as it passes behind the scalenus anticus, it may be ligated, but it is difficult on account of the division of the muscle upon which lies the phrenic nerve, and also the close proximity of the internal jugular vein, a hemorrhage from which would almost certainly prove fatal. In the third part of its course the vessel may be tied, and the operations have been comparatively successful ; I mean, perhaps 43 out of 100 have recovered. When I get further along in the treatment of aneurism I will give you the exact statis- tics. These operations should never be undertaken, knowing how hazardous they are, until you have given the patient the benefit of every other known remedy. When a man takes an anaesthetic, and lies down on the table and surrenders himself to the sur- TREATMENT OE ANEURISM. 49 geon's knife, to have one of these vessels ligated, it is almost like signing his death warrant. Therefore, I say, before any snch risk is taken, it behooves ns, as just men and good sur- geons, to give him the benefit of all the knowledge we have in his case before we subject him to a difficult and hazardous operation. The innominata has been t^ed, I think, about eleven times in all. To New York belongs the credit of having the first surgeon to tie this vessel. Valentine Mott was unsuccessful. I recollect reading an account of this case, and the intense interest that it presented to my mind. I remember the sentence in which, after describing how he had reached the innominata and the ligature was placed around the vessel, that he writes, "As I began tightening the ligature I never watched a human countenance with alternate feel- ings of fear and joy as I did that of the patient as I was drawing this ligature." He knew he was cutting off one-quarter the supply of the blood of the body, and he expected there would be great perturbation in the circulation, but such was not the case. Smyth, of New Orleans, has made the only successful ligature of the innominata, and he tied not only that vessel but the carotid, and checked the secondary hemorrhage, which came on from the sub- clavian, by means of small shot, which compressed the parts well. Hemorrhage, however, again recurring, the vertebral was tied and the patient recovered: I have ordered this patient to be given five drops of veratrum viride every four hours. His pulse is about 110, and I desire it kept down to 65 or 68. What does that do I It does not cut off the supply of blood, but it depresses the action of the heart, it lessens the vis a tergo ; it checks the flow into the artery and gives opportunity for a clot to form. If, instead of 110 strokes a minute, blood is forced into the vessel at the rate of 68 beats, you will see that there elapses between each beat a longer period, which affords time for the active clot to form. Besides this, I have ordered digital pressure of from five to eight minutes four or fixe times a day. It is perfectly unbearable at first ; the patient lies over and seems to writhe in agony, yet I fancy the tumor is harder, and that it is not as sensitive as it was, and that he suffers less pain. But I am not deluded by these appearances, and am prepared for emergencies. There are a great many other methods recommended for the cure of aneurism which it will be useless to try in this case. Suffice it to 50 OPERATION FOB SUBCLAVIAN ANEURISM. say, if, after having employed all tlie means in our power, the tumor increases, I will tie the subclavian ; but that will not be resorted to until we are positive that every other means is exhausted. This patient was removed to the hospital, and, after trying all means for relief without avail, Professor Helmuth tied the sub- clavian outside the scaleni.. The endeavor was made to reach the innominata; but a second aneurism, at the root of the carotid? pressed laterally on the trachea and forward on the sternum, to such a degree, that access to the great trunk was impossible. The patient died of rupture of the sac, on its posterior surface, on the eighth day. He was rapidly improving in health. The excruciat- ing pain had left his shoulder and arm, his pulse was fair, and temperature about 99. The accompanying cut will show the double aneurism which existed in this case and the surrounding structures. A — Innominata, "B — Subclavian, C — Common Carotid, D— Vertebral, E— Trachea. F — Larynx, G — Hyoid Bone, H — External Carotid, T — Subclavian Aneurism, J- Carotid Aneurism. 3pfey«» employ lateralincisions on each side, in order to make the flaps ap- proximate, but in no case should you make severe traction on the sutures or in the flap unless it almost comes together. I think this operation was advised by Warren, of Boston, but lately, within the last few months, Sir William Fergusson, having found great diffi- culty in closing thebony portions of these gaps, has devised another method of closing the hard palate, which he states is more suc- cessful than any other — that is, after having previously closed the soft palate, he introduces through the nostril a flue chisel, and divides the bony structure in such manner that the edges of the wound may be more readily brought together. I hope you will recollect the anatomy of these parts, the means of operation, and the different steps thereof, and we will endeavor to perform it for you at an early date. It is an operation that cannot be seen very well by the class ; it is too tedious and too prolonged. I would like you to recollect tins anatomy, because it is important in your practice. She was removed and operated upon in the hospital August Sissman, Aged Twelve Years, Going on Crutches Two Years. Prof. Helmuth said : In the last stage of hip disease the foot is turned inward; in the second stage it is turned outward. In the first stage there is not much change. This foot business is a great bugbear to students, and it always gives me great pleasure to give them such a case. In ninety-nine cases out of a hundred — and I do not believe I say too many — you will find that hip disease has been occasioned by injury ; this is the experience of medical men. But the injury is often so slight that the parents of the child, or those who have charge of him, do not notice it. A fall on the hip of a healthy child will be very apt, if it is not looked after, to produce this affection. Hip disease was formerly considered a scrofulous dis- order; it used to be considered a strumous affection of the joint,, but statistics prove beyond a doubt that it is persons who are not scrofulous — the most wild harum-scarum boys and girls, who are the HIP- JOINT DISEASE. TREATMENT. 61 most likely to be afflicted with the disease ; and, when you trace the case, you will find that there has been at some time a bruise, or an accident has occurred. £In this case the father said the child fell from a ladder, a distance of one story, when he was seven years of age, but did not mind the fall. When he came to grow in years his hip began to swell ; it enlarged a few months after the fall ; he ex- perienced a good deal of pain during the night, and the leg and hip then showed marks of extensive suppuration with several openings.] In all cases of developed hip disease, one of the characteristic peculiarities is that the gluteal fold of the affected side is lower than the other. In this case, there is not anchylosis, which makes & great deal of difference. You know if inflammation extends within the joint, after a time suppuration results, and abscesses open in different parts of the thigh, sometimes above and some- times below. Then Nature attempts the cure by anchylosis, by which I mean a stiffening of the joint. It may be spurious, formed by the ligaments and tendons, or it may be osseous. If the muscles around the vicinity of the joint can be made promi- nent by an attempt at motion, even if there is apparently no mo- tion of the joint itself, then you may be sure you have false anchy- losis. If, on the other hand, the muscles cannot be drawn into any degree of tension, and the tensors do not seem to rise up, then you have true anchylosis. One method of detecting the true from the spurious is the absence of pain after manipulating in the synostosis, and the contrary in spurious. There is a good deal of chance for this boy, but there is no hope of his ultimately recovering with a good leg. He will be a cripple, but I think, perhaps, he will get well of this condition and be able to move with moderate facility. But there must be care that he does not move too much. Let him be brought here this day three weeks. Give him silicea of the 30th, a powder every night. It is a question upon which I have not made up my mind, how much extension of the parts will do for him. Generally, traction relieves the pain. You see, as I pull the leg down, he does not suffer. It shows that the pressure is taken off' from the head of the bone, and that the caput femoris, although it may be diseased, is painful when pushed into the 62 HIP-JOINT DISEASE. acetabulum. As I thrust the leg up, you see it causes him pain. Give this hoy good, wholesome food, and give him the powders regularly. In the mean time, before the three weeks have passed, I will take pleasure in lecturing to you on this subject. There is nothing like impressing upon your mind, through all your senses, the differ- ent cases that are lectured upon. Therefore, I shall be able to go on with these cases with much more facility to myself and better understanding upon your part. In the mean time, I will see that appropriate mechanical treatment is provided. JJwgita! Clinic 0f gowmbcv Hih, 1874, Deg dOit#. John Spellman, Aged Twelve Years. Pkof. Helmuth : Here is a simple abrasion caused by the teeth of a dog. If it were now the heat of summer, and the hydrophobia mania was as rampant as it was during that season, we might, perhaps, con- sider and treat this as a case of incipient hydrophobia. A slight scratch -like this sometimes results very seriously. Even when the dog has no symptoms of rabies, if the constitution is impaired, the bite may, and sometimes does, give rise to very serious consequences. There seems to be a poison in certain varieties of saliva, which, when inoculated into the system, gives rise to very great disturbance. In fact, I have never yet known the bite of a man, when indicted upon the finger down to the bone, that did not result so seriously as to require amputation of the linger. It is astonishing how poisonous all these bites become, even in healthy persons. Among the lower classes, there are those who are so frequently engaged in fighting, that they become brutal, and snap like the lower animals ; and their bite seems to be very poisonous. I have amputated more than one finger for such a wound. I have seen very disastrous consequences result from such bites or simple scratches, because the constitution is out of order, or there appears to be some process going on in the blood tending to spread the virus through the system and produce bad results. We have cauterized this wound, so that if there is any poison in the bite it may be neutralized. The boy will be brought here again, and his constitutional symptoms will be carefully noted, and treatment applied accordingly. I think, however, that nothing further in this case will be required, but because it now appears so simple, there is no reason why it should not be care- fully scrutinized. 3p aroayefeia— Wfcii I o w* Mrs. Hall. — Felon on the Finger. History of Case. — [This disease appeared without any ap- parent cause. Does her own w T ork, and has her hands much in hot soap-suds. At first it had the appearance of a "run around," and the skin btoke, and there was severe itching and burning, and the swelling seems now to be extending into the arm.] Prof. Helmuth. — A felon, as we properly understand it, is an acute inflammation which affects the deeper tissues of the fingers and toes. Felons have been classified according to the depth of the structures which they attack. This woman states that she had an inflammation around the matrix of the nail, which is classified as the first variety of the affection. The disease commences under the cuticle near the root or side of the nail, the pus not being deep-seated is soon evacuated ; sometimes, however, the abscess takes place under the nail, in which case the pain is severe, and not unfrecruently shoots up as far as the external condyle of the humerus. The nail is sometimes punctured with a needle and the pus allowed to escape. In this case the pain is not very intense. In other varieties of felon, where the deeper tissues become affected — as the periosteum — it becomes very painful. In fact, I know of no more severe suffering than is found in the deep variety of felon. When they are in the palm of the hand the excruciating pain which the patient suffers is sometimes almost unbearable. In the earlier stages of felon it can sometimes be made to abort, that is, the inflammatory action may be subdued before suppuration is estab- lished. This may be accomplished by several means — one of these is the application of nitric acid; I have cured many in that way. Another by immersing the part in lye; another by keeping the finger in hot water ; and still another to wrap around the finger the skin of a hard-boiled egg^ which is between the white of the egg and the inside of the shell. At first the patient will experience aggravation of the symptoms, but, if the application be allowed to remain, or perhaps applied at intervals, the affection will often be arrested. NECROSIS OF THE TIBIA. 65 These means may be used provided it has not reached the third stage, or suppuration has not commenced. If suppuration has begun, then all of these applications are worse than useless. Again, if the inflammatory action has commenced under the periosteum, the pain is more intense. In such a case the incision must be made early ; but if it is above the periosteum, and espe- cially if it is in the palm of the hand, it is better to wait until the pus forms. In other cases the formation of pus is so slow, and the pain is so severe, that it is better to open down to the periosteum, and relieve the tension by allowing the exit of blood. This person has had, first, a simple " fester" on the end of her finger, and the inflammation from improper treatment extended up the arm, as you see in the red lines extending up the forearm. This is not exactly metastasis. We can have an extension of the inflammatory process by con- tiguity or by continuity. We know that there are certain organs in the body which, although at a remote distance, sympathize with each other. In such we have extension of disease by re- mote sympathy. We have also extension of inflammation by a continuous layer of tissue. There has been an inflammatory action in this finger, which has been, by the application of hot water, driven to the arm ; the in- flammation has taken a backward action by continuity of the tissues, and now you see it located in the long flexor of the thumb. I would advise the patient to localize the inflamma- tory action by means of a poultice. If the inflammation is con- fined to the finger it is all right, but if it extends up the arm it is all wrong. Give her arsenicum internally, the 30th, every four hours. Change the poultice once every three hours. Apply the poultice as hot as it can be borne and make it of ground flaxseed. Let the arm be supported, and I think that a cure will soon be effected. Operation by EsmarcKs Method. Emma Slack, Aged Ten Years. I have here an interesting case to show you ; and, before she is placed under the influence of the anaesthetic, I desire to say a few words to you about her. We have got through the inflammatory 5 66 NECROSIS OF THE TIBIA. process in our coarse of lectures, and also through some of the diseases which partake of the nature of inflammation. You will recollect that I told you that inflammatory action could extend in the bony system. We have periostitis, then osteitis, osteo- myelitis, caries and necrosis. Periostitis is not a disea.se of the bony structure itself, but of that strong fibrous covering which overlies the bone, and not only protects it but assists in its new formation. Then we have also an affection of the lining membrane of the medullary canal. A. step further we have caries of the bone, or ulceration ; and, finally, the complete death of the bone. The process bears the same relation to the bony structure that it does to the soft parts. In the soft parts we have dry and moist gangrene ; so in the bone we have the hard and the soft processes. History of Emma Slack's case, now before us. Her trouble began with a pain in her knee eight months ago. She had not injured it, so far as is known. She was treated for rheumatic fever, and was sick about four weeks. When she grew better there were some purple elevations on her leg. They swelled, and finally broke and discharged. Before they opened she had a great deal of pain. The pain was worse at night and better towards morning. During the first part of the night, and until three or four o'clock in the morning the suffering was very great. These ill-conditioned abscesses would break, then others would form, and, finally, two pieces of bone came out ; the largest was about two inches long and as broad as the finger. One side of the bone was smooth and the other w^as rough. She pulled the bones out herself. Prof. Helmuth. — Osteitis, or inflammation of the bone itself, gene- rally commences in the bone corpuscles, or in the calcified tissue which is around them. I have not time now to go into a de- scription of the cell formation of bone, and as you have already had that from two or three other members of the faculty, I hope you understand all about it. An acute attack of osteitis is a rare disease, but chronic osteitis, passing through all the different forms of caries or ulceration, is a very common affection. Of all the structures of the body the bones, as you are aware, are supplied with the smallest amount of blood vessels ; but the periosteum on the outside, and the medul- lary matter on the inside, and the membranes that line the medul- lary canal, are profusely supplied with blood. Therefore, although XECROSIS OF THE TIBIA. 67 it is rare to have a primary inflammation going on in the substance of the bone itself, yet inflammation of the periosteum or medulla is not an uncommon affection. You will find that the medullary membrane is the first to be inflamed, and afterward the disease extends to the bone. Just exactly as I have tolcl you, the process goes on in the soft parts, so we have it in the bone. We have a molecular death, and a degeneration of the bony tissue : the molecules are carried off with the discbarge, constituting caries. As I have told you before, the appearance of a carious bone very much resembles a lump of hard sugar which has been dipped for a moment in water ; it is granulated, and these small granules seem to pass off with the discharge itself. Then we have the true death of the part or necrosis. Necrosis is the entire death of bone up to a certain part. The sequestrum is that portion of the dead bone which has to be separated from the living. A sequestrum is not always a loose portion of the bone. On the contrary, a portion of the sequestrum may die and yet be attached to the living bone, which is supplied with blood vessels up to the point where the sequestrum is attached to the bcny surface. Then again, a sequestrum may die; nature, in endeavoring to repair the parts, may form around the dead portion a shell of bone, which becomes harder and harder, and which is called the involucrum, ■which encases the sequestrum. Through this the dead portions can be discovered by the probe, or through the cloacas. Sequestra are also sometimes cast off, the hue of which resembles that of ossific matter which has been for some time buried in the earth. When a sequestrum is discharged the disease may be considered at its height, for nature is throwing off the dead structure, which can no longer be of any service to the economy. Often at this period, by introducing a probe, several pieces of detached bone may be readily felt. This child has had some rheumatic affection or periostitis. Whether it resulted from an injury, or whether the child was scrofulous, I am unable to say. Certain it is that she had perios- titis, then caries, and then an entire death of some portion of the bone took place. She perhaps had acute caries. You know that in chronic necrosis a patient may get about for j T ears with one or two openings in the leg, and pieces of bone discharging ; but in acute necrosis the whole bone seems to be invaded, the inflammatory process spreads with rapidity, the entire structure, 68 NECROSIS OF THE TIBIA. up as far as the joint (and very frequently the joint itself), is involved, and there is a contraction of the tendons, and a partial necrosis of the bones in the vicinity. What shall we do in this case? When I first saw her this morning I was disposed to recommend an immediate amputation of the leg above the knee, because I know that these prolonged operations on the bone are sometimes extremely serious ; often they do not effect a cure, and, sometimes, after the best directed efforts, amputation has finally to be resorted to. Upon conversing with the mother she expressed a most decided objection to the removal of this leg. To one who does not look upon these things as we do, and to a mother in particular, who regards the child with all the affection which we naturally expect, there is something so repellant in the idea of amputation that opposi- tion is natural. To say to a mother that such and such a part of her child must be removed — no matter how great has been the extent of the inflammation which has been going on — is a com- munication, so awful to her, that it staggers her. When I suggest- ed to this mother that an amputation might be necessary, she at once rebelled against it. Kemembering what can be done by the method of Esmarch, and how much better we can operate by his mode than we formerly could, when the blood would pour out over all the parts, I have concluded to perform Esmarch's opera- tion for the removal of necrosed bone, and remove as much of the disease as I can — all of it, if possible. If I find that I cannot re- move all of it, and that amputation is necessary, I will remove as much as I can, close up the wound, and wait until the father of the girl can be consulted. I do not want to take upon myself the responsibility, nor give the college the reputation, nor homoeo- pathy the discredit of operating helter skelter, without the consent of the parties interested in the case. And, besides, it would not be a proper or a right thing to do. I would not thank anybody, in my absence, to take off the leg of my child without previously consulting me, no matter how bad it was. Therefore, I give the same right to the father of this girl which I reserve to myself. He lives in Mystic, Conn. I hope it may not be necessary to remove the leg; but I am sure that extensive disease of the bone will be found, and I am also sure that the operation will be a prolonged and difficult one, because when you commence you must do it thor- oughly. I propose, after the bandage is applied, to make a long NECROSIS OF THE TIBIA. 69 incision over the tibia, and see the extent of the disease, and how much can be removed. If it is caries, the bone may be scoped. If there is necrosis (and I think there is), I will remove as much of the dead bone as I can find. In the removal of diseased bone a great many instruments are required, particularly if the involucru n seems to close around the sequestrum ; because then it is not only necessary to use the tre- phine, but the hammer, chisel, saws and forceps as well. Here, for instance, are a pair of lion forceps of Fergusson. The fault with ordinary bone pliers is, that they do not have leverage enough when you want to divide a hard portion of bone. Here are chisels and retractors to hold back the skin, and " holding " forceps, to secure a piece of bone, while the saw is being used. I hope to be able to remove a portion of this bone with a single incision. "We will apply Esmarch's bandage over another band- age, to prevent it being soiled by the discharge. Then we will make a longitudinal incision, and see the extent of the disease, and afterwards pack the wound with tenax, or prepared tow. This prepared oakum or tenax is now specially prepared for surgi- cal dressing. Oakum, proper, is made from old tarred ropes. This substance is made from hemp, and the tar is afterwards put in especially for surgical dressing. It is much finer than oakum, and you get rid of the sticks and of the chunks of tar. Besides being a good disinfectant it is a good dressing for the leg. There is another article, made of fine hemp, which keeps much more moist, and has a softer feel. It is also much more impregnated with creosote, and is, therefore, a better disinfectant. In the absence of this prepared tow you may pack the wound with lint, or you may employ cotton. But cotton is not so good as lint, because it is too shreddy, and sometimes sticks, and is difficult to get out. I heard recently quite, an argument as to the propriety of using cotton as a surgical dressing. Cotton has been very highly recommended by several eminent surgeons; but there are other material that are a great deal better. If, however, you could not obtain other material, it would be proper to use cotton. In certain forms of suppurating diseases cotton seems to have a certain power over abrasions of the surface. By applying it to a burn you relieve the pain very much indeed, not only because of the exclusion of the air from the raw surf ice, but because there seems to be some property in the cotton applicable to the injury. 70 OPERATION FOR NECROSIS. [The patient was brought in, etherized, on a stretcher.] We put on this cotton bandage to prevent soiling the elastic one. Speaking in a general way, there are no operations more unsatisfactory than those on the bones ; but Es march has done a good deal towards simplifying them. One of the disad- vantages claimed for Esmarch's operation is this, that in wounds where there is a great deal of suppuration, and where there has been a profuse discharge of pus, there is danger of forcing the pus into the circulation. Another of the dangers which is charged against it is the oozing from the flaps, which is said to follow. The blood is withheld from the capillaries so long, that when the bandage is removed they do not contract, and injury to the flaps results. Now that the bandage has been applied you see that the leg resembles that of a dead person. I make the first incision — putting the knife in at the tub- ercle of the tibia and bringing it down to an inch above the ankle. You see that no blood flows. There would be very incon- venient bleeding were it not for this bandage, because the tissues are all congested, and the cavities are full of blood. As it is, there is no special hurry ; I cut through the tissues and down to the bone. I remove some of this slough with a sponge, and I see quite a large sequestrum. Now I will take a pair of forceps and see what I can do with it. (Eemoves bone, scrapes it.) Thisis the piece of bone that has caused the most of the trouble. The sequestrum is sur- rounded by an involucrum. Now I shall scrape the bone. The discharge is very foetid and offensive. There (demonstrating) is the new bone which has been forming around the old. I can feel it very distinctly. I will take a probe and put it down through the cloacae. In this other opening I find that the bone has entirely degenerated and softened, and I shall therefore scrape off as much of it as possible. The little blood that you see oozing comes from the medullary cavity. As soon as the bandage is loosened you will see the blood rush into the leg like a sponge, and then we shall have a smart hemorrhage for awhile. If this were my patient, and I had the consent of the father and mother, I should remove this leg at once. I find that the probe goes directly into the cavity of the knee joint ; but having given my word not to perform amputation to-day, I will do the next best thing I can. Here is another piece of loose bone, which I OPERATION FOR NECROSIS. 71 will cut out by using the chisel. There is not much chance that this operation will be successful ; but I will nevertheless try to save the girl's leg. This disease began in the membrane which lines the medullary canal and extended outward. The bone is not so much necrosed as you would expect to find, but it is soft- ened, degenerated and ulcerated. You know that an ulceration is a degenerated condition of the bone — a softening and breaking down of the structure. I will now pack the wound with tenax, bring the lips together as best I can, and await the result. I am very glad to show you the operation of Esmarch. It has been a perfect success so far as the operation goes. I think it is especially fitted for the removal of the necrosed bone. In such an operation as this, even with a tourniquet applied, we would have had hemorrhage which would have discommoded us greatly. The next point is to wash the wound thoroughly by introducing the nozzle of a syringe into the opening. This patient has been under treatment about five months, and I suppose has taken all the ordinary homoeopathic remedies. I shall put her on silicea immediately. That is my great remedy, and it has done more for me in cases of this kind than any other medi- cine I have ever used. In packing any cavity it is well to recollect one thing — that it is better to have the substance 3^ou wish to pack with in one con- tinuous piece, or else know just how many pieces are used ; because sometimes it is very difficult to remove them, and if }'ou leave one, disastrous results will follow. I was once called to operate for a case of necrosis at the lower end of the femur, and I found a piece of sponge that had been there for five years. It was about as big as the end of my finger. The wound had healed, but this sponge, acting as a foreign substance, had caused further irritation, which gave rise to disease after the necrosed portion of the bone had been removed. I want you to observe the condition of the parts after the blood is let into them. As the circulation is established again, and the veins fill up, it begins to bleed. We expect that there will be a considerable quantity of oozing from this wound. The question of amputation is one of the most serious that a surgeon has to entertain. Whether you shall or shall not remove a portion of the body is a question demanding a great deal of 72 CICATRIX. serious consideration and a great deal of actual experience. When this question relates to the saving of a limb, we are to inquire whether the leg, if saved, will be a serviceable one or not. It is better to get rid of a leg sometimes than save it, if the leg is to be of no service, in the way, and a deformity. If, however, j^ou think that you can preserve a limb and make a useful member of it — enabling the patient to use it in a measure — then, of course, it is better so to do. But I am of opinion that, in a great many in- stances, conservative surgery saves legs, arms, and fingers that are deformities, and are only in the way. In the present advanced state of mechanical surgery it is better to remove the member than leave a deformity. You can have a patent arm so perfectly constructed that a man can drive horses or eat with it. I have seen patent legs so well adapted to their place that, if it were not for the manner in which the boot fitted, }< ou could scarcely detect they were artificial. It is better to have an artificial leg, with which you can move about with comfort to yourself and everybody else, than have an unsightly limb which is always in the way. Susan Chrixe, Aged Seven Years. ( Con tinned from page 25. ) This girl was here four weeks ago. The sore has suppurated and discharged since then. This was one of the tendencies to sub- cutaneous ulceration for which we ordered silicea. She is now a great deal better in every way. Let her return in three weeks and I think she will be cured. Stmtfal mmt at §mmhtx mt> IBM, 8<*tt**+mai4'* Ra**< Mary McMullen, Aged Sixty Years. (The patient says she has a soreness and swelling below the knee ; don't know that she has strained the leg.) Prof. Helmuth. — Bursas sometimes enlarge and inflame and oc- casion great suffering. We frequently see them about the wrist joint and on the dorsal tendons of the hand. When an adven- titious bursa is formed along the course of a tendon the term ganglion is generally employed — and I do not know of any more difficult disorder to treat than the diffuse variety of bursas. So long as we have the synovial fluid contained in the sac, and there is but slight inflammation, there is merely an unpleasant feeling when the tendons or muscles play over the cyst ; but in other instances the contents of the sac increase in quantity and the fluid burrows down into the sheaths of tendons, and causes a great deal of inflammation and suppuration, sometimes resulting in gangrene and death. A bad case of eranelion is a most difficult thins: to manage ; but the ordinary bursas are not so troublesome. There are a great many ways of managing them. Recollect the distinction : First, you have the simple bursa, in its natural position ; then you have an enlargement of the bursa, which rises on one side of a tendon or the other ; and third, we have the diffuse bursa, in which the fluid extends along the tendons, and gives rise not only to excruciating agon}', but sometimes to the death of the part. A bursa in this place is frequent with women who do housework. Eesting on the knees for a considerable time appears to irritate the parts, and the cyst begins to inflame. A very simple treatment is to pass a seton through the sac and let it remain until a certain amount of irritation has set in. Dr. Thompson suggests stica pulmo. I have never used it, but will try it in the next case -we have. (The seton was then passed.) Henry Nichol, Aged Sixty-two Years. Prof. Helmuth. — This patient states that, up to this morning, he had not been able to get a drop of water down his throat for forty-eight hours. He has been afflicted since the first week in July last. He is a journeyman tailor by occupation. Up to the present he has always enjoyed good health. He used to carry his lunch to the shop, and about the first of July experienced difficulty in swallowing it. He could swallow liquids better than solids. He has fed on soups and broths, and has eaten no solid food since July. The food does not immediately regurgitate, but after he has eaten a little, the throat seems to contract, and whatever he happens to have in his mouth at the time he cannot swallow, and he has to eject it. For the last forty-eight hours the throat has been closed. Those of you who have entered into the anatomy of the oeso- phagus know that outside the mucous coat of the tube we have a certain variety of muscle. When I was speaking to you at a former clinic, with reference to the action of the muscles which enter into the formation of the pharynx, I told you that the tendency of these muscular fibres was to contract towards the centre, and that this motion occasions that peculiarity of cleft palate which enables a person so afflicted, in swallowing, to bring the edges of the cleft together, when we would expect that the gap would be widened. The same condition of the muscular fibres extends down the oesophagus. We have here a case of stricture of the oesophagus. You can divide this into two varieties. First, the spasmodic stricture ; and, secondly, the permanent organic stricture — the latter em- bracing the chronic induration and the malignant variety. In spasmodic stricture the circular muscular fibres are the seat of the affection; the disease occurs at intervals, the patient sud- denly finding himself incapable of swallowing, at the same time experiencing a sensation of choking ; added to this, there is not much emaciation, although there is generally great nervous irrita- bility of the whole system. The disease is more prevalent among females than males, and is amenable to internal medicines. One of the most interesting cases of this kind has been published STRICTURE OF THE (ESOPHAGUS. 75 in the North American Journal of Homoeopathy, from the pen of B. F. Joslin, Jr., of New York. The patient suffered extremely, and, notwithstanding the best directed efforts, finally succumbed to the disorder. The post mortem examination revealed a small, hard, osseous tumor, an inch long and half an inch in breadth, with various spiculae of bone projecting from it, situated just above the bifurcation of the trachea ; a nerve was found very in- timately connected with the anterior face of this tumor. Dr. Joslin considers this filament to have been a cardiac branch of the pneumogastric nerve, the irritation of which, by the presence of the tumor, caused the difficulty in swallowing. The writer says the bony tumor " did not press on the oesophagus, and was only loosely attached to the trachea; it was firmly adherent to the pos- terior portion of the vena cava superior ; it could only be impli- cated in the production of the symptoms by its relations with the pneumogastric nerve." In the one form — of organic structure — we have a vari ty of thickening almost similar to that which we have in organic stric- ture of the urethra; there is a deposit of plastic material which is thrown out around the interior of the oesophagus. Among the symptoms of this variety of stricture we see, first, the tendency to regurgitation of food ; occasionally the spasm seems to close up the opening for a considerable time ; and the effort to swallow any cold drinks creates a tendency to shut the oesophagus. In organic structure there is complete obstruc- tion and always accompanying indigestion ; you will also notice a peculiar expression of the face, the features being pointed and exhibiting the tokens of anguish and distress. You see, also, that the patient is considerably emaciated, and that not only the nerves that supply the oesophagus but also the inferior laryngeal nerve is affected. (A sound was then passed down to the stric- ture.) • What is best to be done in such a case as this? Some have been radically cured of spasmodic stricture of the oesophagus by properly administered homoeopathic medicine. The patent states that the throat contracts very suddenly on attempting to eat. Sometimes half a wine-glass of food will be swallowed and stay for some time, and then it is thrown off. It arrives at the constricted portion of the oesophagus and there it remains until further constriction throws it up. 76 CONGENITAL HERNIA. The first direction I give this patient is never to take anything cold — not even cold drinks. He should take liquid nourishment, and take it warm. And I would recommend that, before he begins to take food of any kind, he should envelop his throat in a hot bandage. Tie around his throat, before he attempts to eat, a piece of towel, or muslin, or canton flannel, which has been dipped in very hot water, and over that apply a dry bandage. These spasmodic strictures will sometimes relax under the influence of heat, I will give him the 30th of cocculus — a dose every three hours. In these cases of stricture of the oesophagus the patient some- times dies from lack of nutrition. Abraham Jones, About Fifty Years. History of Case. — (Has had hernia ever since he was a boy. Don't know what caused it. Has tried a number of trusses, but derived no benefit from any of them. Has employed several doctors, but none of them did him any good. Has no pain from it.) Prof Helmuth. — There are several varieties of hernia — the re- ducible ; the irreducible, in which coats of the sac are adherent to the surrounding tissues by fibrous deposits; then, again, we have incarcerated hernia, and we have strangulated hernia. We have also a division into the congenital and the acquired variety. Again, we have different varieties of hernia, according to the locality and the nature of the parts protruded, all of which are important to be known. This man has congenital hernia. The method of reducing her- nia by the hand is called taxis. There are a great many methods of performing it. This is an oblique hernia. By that I mean a hernia which passes through both rings. The gut passes down in front of the sheath of the conjoined tendon of the transversalis and internal oblique muscle and descends into the scrotum. One portion of it feels " doughy " and the other feels as an intestine should, making it an entero-epiplocele. In replacing the hernia you can always tell when it passes back, for it slips away from the fingers with a gurgle. There should FISTULA IX AXO. ARTERITIS. 77 never be any force applied in replacing a gut. A patient with a hernia can generally put it back himself, and do it even more satis* factorily than can a physician. This hernia is so old that the rings are very near together ; and, although you can replace it, as you see, it slips from under the fingers. (A proper truss was or- dered.) ^"i^^J^ in &np Abraham Baker, Aged Fifty Years. This man has what is called blind fistula — blind external fistula. By that I mean to say that he has a fistula which opens exter- nally and is blind internally. The terms " externally blind " and li internally blind " often give rise to a great deal of discrepancy of description. It is better to say that this is a fistula which is blind internally. It opens on the outside and not within the gut. There are cases upon record which have been cured by the inter- nal administration of medicine, but I have never \^et seen such, although I have endeavored to cure them by such means. My advice to this patient is to get on his knees and let me cut it right out for him. (The patient decidedly objected.) There is another way of getting rid of it — that is to introduce a ligature, tie it over a small pad, let the strings hang down, then tighten the knot from day to day. But the best plan is first to make this a complete fistula, cut it directly through, and allow it to heal from within. &¥t$¥iHm* Lewis Huttwohl, Aged Forty Years. There are certain diseases of the arteries which are obscure ; but there is one in particular which is caused by an irritation of the vessel. It comes under the head of aneurismal diathesis, but it seems to be a disease which affects the elastic coat of the tubes, and is generally preceded by some affection of the heart. 78 ARTERITIS. Whether this belongs to that class or not it is impossible for me to say on such an examination as I am now able to make ; but there seems to be a diseased action going on in the whole arterial system. When I apply my ear to his breast I hear that there is much regurgitation of blood. There is a blowing sound, show- ing that there is valvular irsufficiency. He has a thickening of the pericardium and an affection of the arterial system. Al- together it is a case of very rare interest. I should suppose that some of the preparations of ergotin would be advisable in this case ; but as he has already been before two of the other professors, I have nothing to say as to the treatment, but will consult with them in the case. Never be too certain in your diagnosis, when another physician has been before you, in an obscure case. If you desire to keep yourselves out of trouble in such cases, particularly when they have been prescribed for by other medical men, be sure that you call a consultation before you give a definite opinion. You do not know what damage you may do to yourselves, or to your profession, by expressing an opinion which may be directly at variance with that which has been already given by an-, other. As doctors differ so materially in their opinions of most cases, it is always well, if you are called upon by a patient who has been visited by another physician and asked, "What do you think of my case?" to say, " I will see your medical man about it." Never express your opinion, after a consultation, to the patient, but always to the doctor in attendance. Never, under any circumstance, give an opinion of a case that is in the hands of a brother physician, but always let him perform that duty. When you are called in consultation you must take your leave of the patient before the consultation is held, and not return. The family physician is to receive and express your opinion, and prescribe for the patient. That is the rule, and the correct one. This running up stairs again to see the patient, and saying to him, "If I had been here day before yesterday you would have been all right," is very reprehensible, although the practice is prevalent among some of the profession ; but they always come out at the small end of the horn. You cannot be too careful in your ethics. John Hart, J.(/ec? Twenty -nine Years. History of Case. — (The patient says when he was about two years old he took a large dose of arsenic by accident. At the age of five had hip disease, and suffered a great deal of pain. Then two abscesses formed, discharged and healed. At the age of fourteen the ab- scesses broke out in his leg again. He received an injury, when thir- teen, while splitting wood. The sore leg is now six inches shorter than the other ; he then got the foot fast between two sticks, and on turning around felt something snap in his hip, after which there was a large swelling inside of the thigh ; then two abscesses formed — one above and one below the swelling, 'then several places opened and healed — one sore after another — from that time to this. Has had no splints on the leg. Has taken only con- stitutional remedies, such as iodine and iron. Was in Bellevue Hospital for three months, under Dr. Hamilton, who used sponge tents, which gave relief for a time, so that he was able to go back to his work — that of compositor. Worked at the case until last July. No spiculae of bone have been discharged.) Prof. Helmuth. — That fact makes me think that there is more caries than necrosis, or if the latter, the sequestrum is not de- tached. Yon notice that the patient dresses the sores with paper. Paper has been largely introduced into certain hospitals as a dressing. It is not only very serviceable but it is cheap, and so easily ap- plied that it has superseded many other dressings. You see there are fourteen or fifteen openings on the buttock and thigh, and he has had as many as twenty-six. You see, also, that there are cicatrices all along the side of the hip. The diseased leg is now about six inches shorter than the other. This case is one of great interest. In the first place it shows what the human frame can suffer. When you look at that leg and see its attenuation, and remember the amount of pus that discharges from that poor fellow's thigh every day, you cannot but wonder at his power of endurance. He enjoys comparatively good health, his appetite is good, and his pulse regular. He has symptoms now coming up which resemble dropsy. This is the second or third case of hip disease we have had under treatment, and you 80 HIP JOINT DISEASE. will recollect what I told you of the different varieties of the complaint. In such a case as this we have, I suppose, not only an ulceration of the head of the thigh bone but caries, with perfora- tion of the acstabulum. You see here two openings on the anterior portion of the ab- domen. When, in advanced hip disease, we have these openings for the exit of matter on the anterior portion of the abdomen, the indications are, that there is some more extensive disease than that of the thigh bone itself. This affection has lasted for such a length of time that there can be no doubt about the head of the bone being very seriously affected, together with the ilium. [The doctor refuses the request of the patient to stay in the room and hear all that is said about his case.] It is not to be wondered at that this man wants to hear every- thing that is to be said about his case. He wants to know whether there is the slightest hope for him. He desires to know whether he will live or die. He wants to know whether an operation can be performed for his relief. Under the circumstances I do not think that there can be. I fear that there is very little chance for his life in this world, but we may be able to somewhat benefit him. An exploratory operation in such a case as this might be advisable under certain circumstances ; but not when the patient has run down so low that there is effusion taking place in the abdominal cavity, because in such the operation would not be successful, and would but add to his suffering. It seems to me, if anything can be done for him, it must be treatment which will build him up. If necessary, he may be relieved of the dropsy, and then, if the water does not reaccumulate, you may cut down to the head of the femur and perhaps exsect it. In his present condition, how- ever, any such operation is out of the question. Jftwgic&t (&Vaat of Qovmlm BStfo, l&M. Elizabeth Fitzgibbons, Aged Thirty -eight Years. (A bad foot ; married ; has Lad nine children ; youngest six years old.) Prof. Helmuth. — Here is a condition of the leg occasioned by an obstruction of the venous circulation. It is occasioned bj 7 conges- tion, probably of some portion of the liver, which obstructs the return of blood, thus the veins become varicose. Whenever there is an inequality between the arterial and the venous supply, whether in the leg or in the heart, or in any portion of the body, then the tissues suffer. In this case ulceration will probably take place. The parts are now in a state of congestion, and are just ap- proaching an inflammatory stage — a sub-acute inflammatory con- dition — which will result in ulceration, and then she will have reg- ular varicose ulcers. A VARICOSE ULCER is a variety of indolent ulcer which precedes or follows a varicose en- largement of the veins of the leg or thigh ; it generally makes its ap- pearance on the inner side of the leg, and is often very difficult to cure. It resembles an indolent ulcer in a somewhat advanced stage, the edges of the skin, however, bounding the sore are not tumid ; the part is blue or purple ; the sore is seldom deep, usually spreads along the surface, and is oval in shape. The branches and trunk of the vena saphemi are enlarged, and this varicose state prevents the ulcer from healing. A varicose limb becomes very much swollen, the coats of the veins are often thickened, the vital power is much impaired, the temperature is diminished, the parts assume that dark blue appearance to which we have already alluded, and are excessively prone to the inflammatory process, ending in ulcer- ation, which is generally of a tedious character, although we find that the irritable sore is often accompanied with varicose veins. The pain appears to be deep seated, and extends up along the course of the vessels, and is increased by maintaining the limb in the erect posture. 6 82 TREATMENT OF INDOLENT ULCER. Treatment — In the treatment of indolent ulcers it is necessary that the utmost cleanliness be observed ; and if the patient be one whose constitution has been impaired by unwholesome diet, ex- posure lo a foul atmosphere, or by intemperance, these obstacles should be overcome by the substitution of nutritious, easily di- gested food, proper ventilation, regularity of habits ; in fact, as far as possible, every effort should be made to effect the removal of the predisposing cause. The indolent sore is capable of cure under homoeopathic treat- ment — indeed, in some instances, without having recourse either to the bandage, straps or escharotics ; and it is not absolutely neces- sary that the patient be put to bed, although over-exertion tends to retard recovery. It is impossible to cure varicose ulceration without doing some- thing for the cause of the disorder. Varicose veins may be oblit- erated in many ways. U nfortunately, the persons afflicted with varicose veins are usually those who have to stand on their feet a great deal. If this woman could rest for awhile, the best way to treat her would be to take two hare lip pins, pass them just underneath the vein and bring them out on the other side of the skin, about an inch apart ; then twist a figure of 8 suture over each of the pins and introduce between them a tenotome flat- wise on the finger, under the vein, turn up the edge and cut through the vessel. That is the best way if a patient can rest. By this method you prevent the entrance of air into the vein as well as hemorrhage. But there are some people who object to operations on varicose veins, and dislike to have pins and needles thrust into them ; especially is this so in women. " Do you find this so ?" " Yes, sir." You very often find a varicose condition of the veins in women before confinement, because the blood is ob- structed in its return by the pressure of the foetus, and the veins either give way or their coats dilate, and thus form varicose veins. There are also other means of obliterating varicose veins. An excellent method is the application of a paste composed of equal parts of quick lime and caustic potash, ground together, and kept in a glass stopped bottle in your office, and moistened, when you wish to apply it, with a little alcohol. This may be put on with a glass rod once a week until a sufficient inflammation is set up to obliterate the vein. It is a very convenient and effectual applica- tion. Many is the vein that I have obliterated in that manner CHEILOPLASTY. 83 while treating varicose ulcers, and allowed the patient to go about his business. After allowing the escharotic to remain a few mo- ments wash the parts with vinegar, put on an elastic stocking and let the patient go. Eepeat this every three or four days. Don't let the paste stay on long enough to burn through the vein. I once applied it to a patient at a clinic and forgot it while lecturing, and hemorrhage was the result. There are some medicines, which, if internally administered, will have a specific action on the coats of the vein, and the best that I know of is the Witch Hazel. Cfe^ll^l^S^ Miss T ■, Aged about Twenty -three. This young woman was before the class two years ago. I have performed four or five operations for her. She came to us first with a perfect immobility of the lower jaw. During the five or seven years that her jaws had been closed she was not able to swallow anything but soup, which she took through a straw or a glass tube. Several of her teeth ulcerated and she swallowed them ; she could not spit them out. Then it was that she came to us with this cicatrix — perfect an- chylosis of the inferior maxillary, an eversion of the lower lip, and a dread- ful cicatrix from previous ulceration, which probably arose from the inju- dicious use of mercury. Fig. 1 shows somewhat the condition of the parts. The first operation, which was prolong- ed, tedious and bloody, was to open the jaws. Introducing a round pointed straight bistoury at the inner angle of the mouth, I divided, after a tedious dissection, all the cicatrices ; then, with a modification of the instrument of Scultetus, called Westmoreland's, I gradually broke up the ad- hesions within the joint, and restored partially its movements. She was then placed in bed, and a gutta percha plate introduced into the mouth, between the raw surface of the cheek and the jaw, and Fig. 1. 84 CHEILOPLASTY. Fisc. 2. hickory wedges were kept between the teeth, to prevent the great tendency to contraction which is always to be expected in these cases. After three months I performed a second operation, which was as fol- lows : First having ascertained the size of the flap, I marked its contour in the cheek. (See dotted line in fig. 2.) Then without hesitation I cut cleanly out all the cicatrical tissue. The flap was then dissected up — "jumped, 1 ' as it is called — in other words, twisted on its pedicle, and sewed in place. This was very satis- factory {vide fig. 2). The third opera- tion was performed about a year after- vvard, and consisted of cutting a lu- nated strip of mucous membrane and muscular fibre from the lower lip and bringing the edges of the wound together; then cutting a triangular portion from the angle of the lip, to restore as much as possible the contour of the mouth. Fig. 3 shows the result of the opera- tion. She now comes to us again with the cicatrix somewhat contracted and the parts grown down. I want to depress the angle of her mouth, and the first thing to be done is to dissect up these adhesions which have grown from the flap taken from the side of her face. The first thing to be done is to dis- sect up this from the mouth. I have used a great many substances between the jaw and the cheek in these different operations. The gutta percha did not answer; then I tried parchment ; that did not do. I have brought here to-day some silver foil, which I shall endeavor to slip in after Dr. Thompson has dissected this flap up. The trouble with all these operations about the jaws is the formation of what is called modular tissue, and the tendency of this tissue to reiurn. I cut the whole of that out in the former operation, and the success was quite re- Fig. HIP JOINT DISEASE. 85 markable. The instrument used in this case to hold the jaws apart was Westmoreland's. Plastic operations are those by which raw surfaces are brought together. The simplest form are operations for hare lip. In all procedures of this kind the object is to so unite the flap as to allow the circulation to proceed undisturbed. This girl has been very courageous ; she has suffered many operations ; and I hope that this will be the last one. I have had photographs of her taken at different stages of the cure.* I will bring -them to the clinic and let you see the changes. I am very anxious to make it a success. A surgeon must have eyes in the ends of his fingers. No other profession requires so much dexterity with the ends of the digits. A surgeon needs to educate not only the eye but the hand as well. A very good method of educating the fingers, and to improve the sense of touch, is to wind your watch every night in the dark — finding the key hole with your finger. Slip $$im>i JDiaea*** August Sissman, Aged Twelve Years. (Continued from page 60.) You will recollect that in speaking of this case, three weeks ago, I told you that in a majority of cases of hip disease you could trace the disease back to some injury. Formerly hip joint disease was characterized as a scrofulous affection of the joint; but more recent investigations have convinced us that in very many cases it can be attributed to injury; and we often find that healthy persons are afflicted with hip disease. You recollect the appear- ance of this boy when he first came here, and can see that he is in every way improved. I then prescribed silicea, 30th, and said that it was better that he should have an extension appa- ratus made, and that such apparatus would be required before he could be perfectly cured. The extension apparatus is made and he is to have it to day. The whole aspect of the patient has improved in three weeks. You will notice that the tendency of his foot is now to invert. In its earliest stages this disease is often very difficult * The wood cuts are accurate representations of the photographs. It will be seen that in the cuts the deformity is on the left side in Fig. 1, and shown on the right side in Figs. 2 and 3. The reason will be apparent when the fact is known that the photograph of Fig. 1 was taken from a photograph, while those of Figs. 2 and 3 were taken from the patient herself. 86 HIP JOINT DISEASE. to determine. Perhaps after a run, or a jump, a strain or a fall, a child that has been active will complain in the morning (if stiffness in the hip — a stiffness of so slight duration, and so slight in itself, that the parents will let it pass unnoticed ; or, v,s the day wears on, the pain and stiffness will disappear, and the child will not feel the irritation unless it is quiet for an hour or two. The irritation may continue, arid the pains increase until they become agonizing, especially at night ; the leg will then become apparently lengthened, and rotated outward. The rotation outward is caused by effusion into the cavity of the joint. You can see this effect illustrated by injecting into the capsule a certain amount of quicksilver ; you will find that when the joint becomes full the foot will turn outward. It is at this stage of the disease that it is so particularly trying. It is at the second stage of hip diserse that the patient frequently suffers the most excruciating pains. It is because of the strain on the fibrous capsule that envelopes the head of the femur. This joint being full of fluid, the internal ro- tator muscles cannot act, and the external rotator muscles turn the thigh outward. (Another patient is brought in with the same disease.) -*-*-► George Lee, Aged Eight Years. Here you have the two stages of hip disease. As the disease progresses abscesses form around the joint and discharge in differ- ent parts of the thigh, either in the immediate vicinity of the joint, or burrow between the muscles and find exit behind. As the dis- ease progresses further the head of the bone becomes carious, and sometimes, but very rarely, dislocates. It used to be considered, as one of the peculiarities of hip disease, that the thigh became dislo- cated ; but this did not take pluce nearly so often as was supposed ; more frequently the acetabulum gives way, or the head of the bone is pushed through the acetabulum. Here you see two cases of hip disease in their advanced stages. One has been existing much longer than the other. The amount of suppuration taking place in the elder o*:e is perfectly miraculous, and still more miraculous is the manner in which his system stands it. He has very much improved within the last week or ten days. COLD ABSCESS. 87 He feels better and stronger in every way. This bcyy goes to-day to the instrument maker to have the splint applied, which will allow of a certain amount of extension. There has been a great deal of improvement in both of these cases, and I hope to be able to bring them before you from time to time during the winter : if it is advisable we will make an exploratory operation upon the elder. He wants to see what can be done, and that is just what we all want. He has had a great deal of suffering. When you find abscesses in hip disease opening through the abdominal walls, it is not a favorable symptom as a general thing, because it shows that the floor of the acetabulum has been perforated, and the head of the bone must be thoroughly diseased. In such case excision of the hip cannot be performed with, the same facility or success as if the bone still remained in the cavitv. 0ol4 A1>*e*j»j»: Harriet Crossley, Aged Twelve Years. (Enlargement on the side of neck ; has been sick over a year; the first symptoms were a swelling of the neck, which extended to the breast.) Prof. Helmuth. — There is a gland which is caUed the parotid, beginning at the angle of the jaw and extending upward to the ear. This gland frequently becomes enlarged, and indurated, and then gives rise to a great deal of trouble. In other instances, where the cervical glands become enlarged they suppurate, and form cold abscesses. I mean by that, the suppuration which takes place is extremely slow, is unaccompanied by constitutional symptoms, and generally discharges some distance from the point where the inflam- mation commences. You will see that this is quite an interest- ing case. The inflammatory process began at the root of the neck, and you can see how the matter has burrowed and opened lower down. On her back she has another abscess forming, which con- tains fluid. I think that we can cure this girl, but it will take a good deal of time. Give her Hepar — -the third — about two grains to be put in half a glass of water, and a sp>onful taken four times every day for three or four weeks. There is no medi- cine that I know of that possesses such influence over the sup- purating processes as Hepar, particularly when the glands are in- 88 TREATMENT OF COLD ABSCESS. volved, and there is a tendency to suppuration in different parts of the body. By giving this medicine regularly, and following it up with silicea and sulphur, the disease may be radically cured. In cases like this I want you to bear in mind the importance of con- stitutional medication ; I do not mean constitutional general treat- ment, as implied bj r ordering iron, quinine, lime and stimulants. I mean that specific constitutional medication that applies itself to the specific condition of the disease. Study out the symptoms and give the appropriate constitutional medicine, and you will cure your patient. The tendency in these diseases which we see with our eyes, and which are appreciable to our senses, is to rely too much upon local treatment. Local treatment is all very well ; but I tell you, from actual personal experience, that these affections can be and are radically cured with very little local treat- ment, if you can select the right constitutional medicine — which is indicated by the symptoms of each particular case. The more you particularize, the more you scrutinize each particular case, and study the symptons of that case, and apply the medicines specifi- cally, the more speedily you will cure your patient. To be sure this is not an easy matter. It is a great deal easier to say that you will "build the patient up," by giving him tonics; but that is not the best ivay. You must study the symptoms of each particular case. It will weary you, and discourage you very many times ; there will be many drawbacks ; but the man who carefully studies the symptoms of each particular case, and applies the medicine accord- ing to the proper law of cure, he is the man who cures his patient ; and he is the man who can best instruct others in the law of cure which we profess, and believe, and know to be true. There is no denying this law of cure, because it has been tried. It has been put into the furnace and has come out pure gold. I believe that by the proper application of medicines according to our law, especially in bone diseases and this form of suppuration, can be effected in a majority of cases without the use of the knife. This may be bad for the surgeons, but we must be men enough to acknowledge the law and the facts as we find them. Don't be afraid to acknowledge a fact when you see it. It is all very well to sit clown and say, "This is not so ;" but the straight- forward conscientious man will never be afraid to acknowledge the truth wherever he sees it, and no matter by whom pronounced. That is the principle upon which I want you. all to act. Acknowl- HYPOCHONDRIASIS. 89 edge the truth wherever you find it, no matter whether it be in this or in that college ; no matter what profession, school or church, uphold it. Whenever you are convinced of a truth, and have the facts to back it up, then let the world storm as it likes ; you have the truth on your side, and — " Magna est Veritas" S. Michael M., Aged Fifty Years. Has a "tickling noise in his head," and his "chest feels bad;" has no cough ; no pain any where in particular, except sometimes in his head ; sleeps well at night. [The patient insisted on entirely undressing before answering any questions, saying that he wanted to have a " regular examina- tion."] Prof. Helmuth. — The diagnosis in this case is quite clear. He says that his appetite is good ; that he sleeps well. His pulse is at 96. He is scarred all over with the marks of syphilitic erup- tion. He says that his chief trouble is in his chest. There is only one medicine that I know of that will help him, and that is saccharum lactis. He will have to take it pretty frequently, and diet strictly. Let him take a powder three times a day, and I think he will get over this tickling in his chest. After the patient had retired the Doctor continued : There is nothing much the matter with that man, but he fancies there is. You will find that patients who have suffered severely from certain forms of syphilis, and have had these sores cured by mercury, do occasionally have a peculiar form of monomania. You could see when that man came in, and began to take his shoes and stockings off, preparatory to stripping himself stark naked before you, that he had something on his mind. His pulse beats a little too rapidly, and he says that he has a pain in his head ; but I think there is nothing in particular the matter. You may set it down as a rule that when a man says that he can sleep well at night, that there is very little acute suffering. People with acute pains very rarely sleep or eat well. This man is a hypochondriac. Such men may tell you that they are suffering great agony, and their statements might lead you astray if you relied upon them 90 HYPOCHONDRIASIS. alone. They may perhaps induce you to give medicines to relieve a pain when perhaps there is really no symptom to be relieved. They require mental treatment. This man fancies that he is very siok. We will give him no medicine ; and probably he will be back again. No class of men can exercise such an influence upon their fellows as physicians. When a physician once obtains the confidence of his patients, he can exercise over them an influence which no other man or woman can. It is often, by the exercise of this very influence on the mental condition, that you are able to perform very excellent cures. To prescribe for a. patient is not the only duty of a physician ; he should take a personal in- terest in every case ; and when the patient feels that an interest in his case is developed in his physician, he will feel bound to him, and will obey him. Many a man can go into an afflicted or distressed family, and with no medicine at all, but by his very presence ahme, and through the influence that he can wield by his mental power over the sick and the suffering, or over those who are in great trouble, make his presence like a sunbeam in the house. Recollect this, and try to cultivate elevation of the mind. Sir William Hamilton left on the walls of the old University at Edinburgh these lines — " On earth there is nothing great but man ; in man there is nothing great but mind." Act upon this principle, and you will be enabled to exert great influence over your patients ; and combine this with the proper administration of medicines, and you have in your hands a power which it is difficult to overestimate. j^utgical ffilinic of g} Member 6th, 1874 Prof. Helmuth commenced by quizzing the class. Q. Which side of the body is the innominate artery ? A. Generally, the right side. Q. Please describe this artery. A. The innominate artery (brachio-cephalic) [anonyma], the largest of the vessels which proceed from the arch of the aorta, arises from the commence- ment of the transverse portion of the arch, before the left carotid. From this point the vessel ascends obliquely toward the right, until it arrives opposite the sterno-clavicular articulation of that side, nearly on a level with the upper margin of the clavicle, where it divides into the right subclavian, and the right carotid artery. The length of the innominate artery is very variable, but usually ranges from an inch and a half to two inches. Q. Describe the branches of the arch of the aorta. A. They usually arise from the middle or highest part of the arch, in the following order : First, the innominate or brachio-cephalic artery, which soon subdivides into the right subclavian and the right ca- rotid arteries ; secondly, the left carotid ; and thirdly, the left subclavian artery. Q. What is an aspirator \ A. An apparatus for drawing fluids from the body by the means of suction or vacuum. Q. Describe the inter-columnar or spermatic fascia \ A. This fascia is derived from the tendon of the external oblique muscle of the abdomen. On passing forward through the opening in that tendon named the external abdominal ring, the spermatic cord receives a thin membranous investment which is, as it were, continuous with the layer of so-called intercolumnar fibres, pass- ing obliquely across the upper border of that opening ; this is called the intercolumnar fascia. It is attached above to the mar- gins of the external ring, and is prolonged downward upon the cord and testicles. It lies at first beneath the superficial fascia, but lower down beneath the dartos, and it is intimately connected with the cremaster muscle and cremasteric fascia. Dorsum XXii. Henry Head, Aged Two Years. Prof. Helmuth. — You remember this case, gentlemen ; eight weeks ago Dr. Thompson put on a plaster bandage at the hospital. It is that of dislocation of the femur backward and upward, which occur- red when the child was four months old ; he was twenty months old when the plaster was applied. Four weeks ago L>r. Thompson took off the first plaster, which had been on for eight weeks, and used another. You will see that one leg is as long as the other, and he can walk, which he could not before. I cannot find that he was injured at any time, but the thigh moved in all directions — backward, and forwaid, and downward; it was very easily re- duced by this motion of the limb. (Illustrating.) We reduced the dislocation, and this leg was then made as long as the other one. As soon as there was a slight contraction we immediately advised the plaster bandage for its relief, and it has been success- ful. As the child grows it will be necessary to take off this splint and put on a larger one. You see he walks now very well. When we come to classify dislocations, gentlemen, you will find we have those occasioned by accident and those which are spontaneous. Spontaneous dislocations may arise from several causes. They are caused by musclar contraction, shallowness of the cavity in which the head of the bone rests, and again from some disease between the head of the bone and its articular surface. The result of the treatment has been very satisfactory indeed. There is no disease about the bone ; it seems to be merely a dis- location backward and upward, and if you had seen it, you would have seen — what? A shortened leg, the knee of the affected side turned over towards the opposite knee. It was not only a perfect illustration of this dislocation, but it afforded, also, an illustration of the manipulation treatment of reduction. It could be reduced directly by this simple manipulation which is now being introduced so considerably into surgical practice, viz : Flexion adduction, circumduction, and extension. Since the introduction of anaesthetics there is no need, in the POTT'S DISEASE OF THE SPINE. 93 majority of cases, of applying the same force that was formerly necessary to reduce the hip, and it is found sometimes that gentle manipulation may succeed, even in a strong and powerful man, where the pulleys have not had any effect. It used to be the fashion to bleed or to administer tobacco infusion until the muscles were relaxed. This is all done away with ; there is little counter- acting tendency in the muscles and tendons in reducing dislo- cations. This case not only is a beautiful illustration of spontaneous dis- location, but it shows how easy is the reduction. You flex the leg upon the thigh and the thigh on the abdomen ; then grasp with your right hand the leg above the ankle, with the other hand take hold of the knee — you ad duct it, make rotation, and then extension. These manipulations can be employed in all dislocations, especially those of the hip. After this bone was reduced a plaster of Paris splint was applied, which in eight weeks it was necessary to remove. It is a very successful case, indeed, and a fine representation of what may be done with the immovable apparatus. Without this the patient would perhaps have become an invalid, or else would have been obliged^ to lie in bed with a weight at his foot. The plaster splint has effected a radical cure. You may recollect that in children the immovable apparatus is one of the very best that can be employed. Elizabeth Gerhardt, Aged Four Years. {Continued from page 24.) It is ten weeks to-day since she came here. She comes from Staten Island. This disease is certainly growing better all the time. She has now been taking calcarea for a considerable time, and I will continue it at least three weeks more. In these cases, of course, the improvement is extremely slow, and it takes years before a cure can be accomplished, but I have 94 POTT'S DISEASE OF THE SPINE. every reason to hope that you will see a diminution, in the projection of the spinous processes, and that the majority of the symptoms will be relieved. The object of the apparatus that you see bound to the back is to take off pressure, and that is accom- plished by these crutches, which support the arms and are attached at the waist. Now, in some instances, this variety of splint is unbearable, and we have to content oiu-selves with medicine. Then, again, there is another form of splint, which those in bet- ter circumstances can procure ; it is called " Darraeh's Wheel Chair Crutch." It resembles a woman's petticoat or hoops, held upright, and padded under the arms. You take a child and place it in the centre of the apparatus, and the padded parts come directly under the arms ; it takes the entire weight of the body off the spinal column. I know of three cases which have been cured by this apparatus. It was invented by Mr. Darrach for the cure of his own child. Dr. Burdick has now a case of Pott's Disease which has been un- der his care for two years. He will give you the history of the case. ¥m. Wood, Aged Six Years. Prof. S. P. Burdick. — Three years ago this little boy was first shown to me by his mother, and he was then suffering from the first indications of Pott's Disease. I advised a course of treatment, but, as this lady says, I " did not talk quite enough," always when you have any thing to say to the ladies be sure and do talking enough. The case was then submitted to Dr. Taylor, who is a very skil- ful physician, and he applied a splint, which the child wore for nearly a year, when the case was again presented to me without any perceptible improvement. I then advised the mother, as the brace had been properly adjusted, to continue its use, and placed the child under treatment. He has been under treatment for two years constantly; there has been no intermission, I believe. He has not failed, I think, a single day, to take the remedies which were prescribed in his case, and, during the past year, the mother STRICTURE OF THE (ESOPHAGUS. 95 tells me. she lias heard no complaint from the boy whatever, al- though he still wears the splint, and seems perfectly well. The remedies which he has taken, from the first to the last, have been calcarea carb., 200; one dose at night, six globules, and calcarea phosphorata in the morning, ten globules. This has been his treatment from the beginning to the end. At the time he first came under my care he was having from ten to twenty passages from his bowels a-day, which Dr. Taylor informed the mother would have to wait until the spinal trouble got well, and then the disease wouldd isappear. Under the treatment of calcarea he gained a visible improvement at the end of six weeks. The trouble has decidedly improved, and his general health and strength was, from that time to the present, greatly improving, without any in- termission whatever. Now, you see, the character of this brace is very much better adapted to the case than that of the patient you last saw, but this is a very much more expensive article. He was five years old last August, and he continues to grow tall. Henry Nichol, Aged Sixty-two Years. ( Continued from page 74.) The next case is that bad case of spasmodic stricture of the oesophagus. Prof. HelmuHi. — It is two weeks to-day since he was here. (To the patient) — Q. Can you swallow this morning I A. Yes, sir. If you recollect, I tried to explain to you the nature of these spasmodic strictures, and I prescribed then cocculus the 30th, and ordered hot applications about his neck, and that hot drinks be taken. He says his throat feels better. He has been taking coc- culus the 30th for about two weeks. There is an evident improve- ment in his CDndition, and, as I said before, cocculus has a specific influence on the muscles of the oesophagus and pharynx, and he states now, that from the relaxation of the upper part of his throat he begins to feel more comfortable. The law in medicine is, 96 STRICTURE OF THE (ESOPHAGUS. to let well enough alone, although the temptation is, when you have a case that is doing well, to change the medicine or to resort to other means. Particularly with young practitioners is this a strong temptation; they prescribe for a patient and think that the medicine must act in a short space of time, and if very deeply in- terested in the case, they think their reputation is at stake. I was so. When a young practitioner is called to a case, he is very anxious for its success, and he studies it up very thoroughly, and finds the medicine he thinks is proper ; he gives it to the patient, and expects to see immediate relief. If the expected improve- ment is not immediate, he takes down the books, supposes he has given the wrong medicine, and goes back the next morning and changes it. But I began to find out, as I grew older, that it was a good thing in medicine to let well enough alone, and to give the medicine opportunity to act. One reason why doctors can never treat their own families successfully in severe cases, is, that they knoiv too much. Yery often physicians think they overflow with wisdom, but when they come to prescribe for their own families their egotism falters. They give a dose of medicine to their child, they take out the books • and find another remedy which they think better than the first, and so they desire to change the prescription. There is another thing to be remembered ; when a patient is getting better by nature, if you have common sense, let nature continue, you can have the honor all the same. Don't interfere with it. The law is, and write it down, that when a patient is improving, continue the same medicine until you are sure it has exhausted itself, and when the patient begins to get worse, do not think it is an aggravation for the Lord's sake. Many split on this rock. Nothing makes me so angry as to have a person come into my office and say, " Doctor, I have been worse ever since I took that medicine," where I know medicine had nothing to do with it. As to this patient, he is getting better, and I believe cocculus will relieve this stricture, so I will continue it for two weeks more. We will go on and give you this medicine and you will come back in two weeks. He asks me if I am going to put something into his throat. I will not. I never, in spasmodic strictures, put instruments into cavities where there is a liability to spasm ; that very often aggravates the case. I say that it is a triumph of surgery if you can by internal administration of medicine cure a STRICTURE OF THE (ESOPHAGUS. 97 disease which formerly was treated only surgically. I do not mean to put any instrument in your throat to-day; but you must come back in two weeks. If you should get worse, come next Saturday ; but, if you think you are getting better, stay two weeks. The great fault of teaching in medical colleges is this — that you are led to believe, when you are called to see a case of disease, it will be easy to diagnose and to treat. The descrip- tions are so simple in the books that little difficulty is apprehended by the student as to his capability to perform professional duty. This is wrong. Often in diseases there is such a similitude that it takes the closest power of discrimination and the greatest wisdom to diagnose one from another. You think it is easy to diagnose a dislocation of the lower jaw. Yet even this has been mistaken. There are difficulties in all cases, but the man who overcomes the difficulties, makes the best physician. The greater the difficulty on the one hand, the greater should be the incentive to study on the other. Don't'you dare, when you have gone home after curing a simple case, to think that you are a great doctor ; because you are not, for diseases get well of themselves. Take a bad case and bring that through all right, and then you can prove yourself competent. When you are an M. D., when you think you have passed through the green room and are regularly em- powered to encounter all the diseases with which the world is affected, do not, because you cure one or two of them, think you are a great man. • The next case we will have is a small tumor over the eye. It is not much, but it is the little things in this life that make the great ones ; it is the atoms which make the world ; it is the motion of those particles which make light, heat and electricity, and the man that disregards the little things in life, is not the man that can overcome the great ones. Hattie Andrews, aged 15 years. Here is a tumor that lies directly over the external canthus of the eye. Sometimes these smail tumors which grow in the neigh- 98 OPERATION FOB SEBACEOUS TUMOR. borhood of the frontal bone, or skull, from the pressure they exert, have a tendency to absorb the bone, and a tumor like this one pressing down so on the bone may absorb it. This is a favorite way to remove them. Raise the skin, like that, and then enter the knife, with the back downward, and cut from within; that makes a clean cut down through the tissue. After you have made your incision, take a pair of forceps, and raise up the skin. These things stick very tight sometimes, and are some- times very difficult to get out. (The tumor was dissected out.) Sebaceous tumors have different kinds of sacs. In some yon have seen the envelope is very thin ; in other instances the sacs are perfectly firm and hard ; and still in other instances they ad- here not only to the superimposed structures, but also those below. This patient now should be principally treated with cold water dressing. No, do not give her any medicine. I know she will get well without, and if I were to give her medicine and she were to recover, I might s appose that I was very scientific. Common sense in medicine, is a great thing, gentlemen. The trouble is, we are apt to lose our common sense when we come to s[et too much science. It is not the most studious physician who makes the best practitioner. It is an acknowledged and ac- cepted fact that the most distinguished men in the profession for their learning, are often the least practical when they come to the bedside. Prof. Helmuth [To a student of the class] : Q. Now, sir, ether you say is an anaesthetic. Who introduced it ? A. Dr. Wells, of Hartford, Conn. Q. Are you sure it was Dr. Wells? What about Dr. Morton ? See page 17. Q. Who introduced chloroform? A. Prof. Simpson, of Edin- burgh. Q. What are the rules for giving ether. In the first instance, must the patient have a full or empty stomach when he takes ether? A. An empty stomach. Q. Then what is the next thing. This gentleman says they must let atmospheric air in where apatient is anaesthetized ? A. It is not necessary. The rule for the administration of ether is this : that if the ether be pure, there is no necessity for atmospheric air. The best precaution is to have the patient fast for at least three hours, and after fasting he should have, about half an hour ANAESTHESIA. 99 before administering the ether, a stimulus in the shape of brandy, or about eight to ten grains of bromine of potassa. Then the anaesthesia must be carried to insensibility. Spencer lays it down as a law, and as one of the principles, that he never pushes anaesthesia to more than insensibility. When a purple skin and stertorous breathing appear, then it is time that it should be suspended. With chloroform the case is very different. In chloroform there must be always an admixture of atmospheric air ; the patient to be watched carefully and very closely. Fluttering of the heart and spasmodic breathing are bad signs with chloroform, and the trouble is just here — a patient may pass from life to death before the operator is scarcely aware of it ; and a patient in apparently good health may take his seat in the chair, and the chloroform may affect him in such a manner as to make death imminent, or he may expire at once. It is for this reason that I am opposed to giving chloroform, except, perhaps, in cases where it seems to act remarkably well, such as the relaxation of the muscles in obstetrical practice. I argue that it is better for the operator, that the patient take ether, than to run the' risk of a sudden death. From ether you have the stage of insen- sibility coming slowly, it is true, but still it is a better and a safer practice to resort to than the use of chloroform. If I am operating on a patient under chloroform, I have to be thinking of the chloroform as well as the operation ; but if I am practicing with ether, I am free of care, and that is a great deal. Surgical filmic of Qmmbtt 12th, 1874. Prof. Helmuth to the Class. Q. What is the difference between phymosis and paraphymosis i A. Phymosis is a preternatural constriction with elongation of the prepuce, in front of the orifice of the urethra. Paraphimosis is the reverse of phymosis — the prepuce becoming retracted behind the corona glandis, leaving the glans uncovered. Q. How many stages of hip disease are there ? A. Three dis- tinct stages. Q. How is the foot in the first stage ( A. It is generally not much altered in position. Q. How is the foot in the second . stage % A. Abducted and rotated outward. Q. How is the foot in the third stage \ A. Assumes a posi- tion directly opposite to that noticed in the second stage. It is rotated inward, shortened and abducted; the toes only touch the ground. Q. What is the difference in the diagnosis between fractures and dislocations ? A. In fracture there is increased mobility, crepitus, and when the broken extremities are placed in apposition, they will not thus remain without external support ; while in dislocation or luxation there is unnatural rigidity, and the displaced part re- mains fixed. There is likewise discoloration, pain, and swelling; at times, temporary paralysis. The limb is shortened, very seldom lengthened. When the dislocated end of the bone can be felt, it will be found in an unnatural location, and a depression be detected in the place that the extremity of the bone occupied. Thomas Whiting, aged 26 years. History of Case. — Lost his arm ten years ago, by machinery;. The arm was caught in a belt and taken round a shaft. Amputation at the middle third took place three days after. The stump now NEURALGIA OF THE STUMP. 101 pains him all the time, and lias for the last two years. The suffer- ing is worse at night than in the day. The cicatrix has contracted on the end of the bone. There was no pain for a number of years after the operation ; but the parts began to be sensitive when the integument began to contract over the bone. At the time of the amputation, mortification was rapidly extending up the arm. Prof. Helmuth : . That arm is a very good text for two or three lectures. In the first place, it is a good, text to speak from, with reference to what is called traumatic gangrene.. You will recollect that, when I was speaking of the terminations of the inflammatory process, I stated that in dry gangrene or in the ordinary forms of mortifi- cation, it was necessary, before amputating, to wait for the line of demarcation, and that in other cases, it was just the con- trary ; and when we had traumatic gangrene, which extended rapidly, and the life of the patient was at stake, amputation should be performed, and the sooner the better. If you will put your finger on the end of this stump, you will feel that the bone lias been sawn off diagonally, that the bone is sharp at that ex- tremity, that the tissues have adhered thereto, and that there has been a contraction of the flap. There is a difference of opinion as to the period and point .of amputation in traumatic gangrene. Particularly in those injuries which result from machinery, where the parts are bruised, and crushed and lacerated to a pulp, and there is no way whatsoever to relieve the patient, and the gan- grene seems rapidly extending itself — then to wait for the line of demarcation is to wait for death, and to give the patient over to it. If, on the other hand, we have dry gangrene, then it is wrong to perform an amputation until the line of demarcation is fully formed. In such gangrene as this man had, amputation must be resorted to within one or two days. There may be a primary amputation performed; but after an amputation, no matter how skillfully performed, certain untoward results may follow. For a con- siderable period of time after an amputation a patient may con- sider himself cured; but some unhealthy action may take place in the stump, which gives rise to intense pain, which may be easily accounted for. There is a great tendency in all tissues during the healing process to contract, and during contraction there is a tendency to adhesion to the end of the bone. This patient says that for seven or eight years he enjoyed perfectly good health, 102 NKI RALGIA OF THE STUMP. and but little pain. Then, two or three years ago, he began to feel pain and soreness on the under surface of the firm, and then he referred his Buffering to the amputated fingers. There is frequently this peculiarity attending amputations — that the patient seems to have sensibility conveyed to his brain through the stump, as it was through the limb before it was taken off; and sensations at the end of the fingers are apparently felt as well as they were before the arm was amputated. Here has been a contraction of the cicatricial tissue, and an adherence to the bone; and as the tissues adhered to the bone, they embraced within them certain filaments of the median nerve. The median nerve on the under side of the arm is included in this cicatrix, and therefore he will tell you that he has all these nervous sensations. In other words, he has neuralgia of the stump, which is worse at night, which gives him apparent sensitiveness at the end of the fingers, and which is always aggravated in bad weather. He can tell by that stump when a storm is coming. The pain is always worse at night, and is then of a shooting and darting character. What can we do to relieve this neuralgia of the stump ? If it is simply idiopathic, and caused by the division of the nerves ^lone — if there are no mechanical troubles connected with it, there are medicines which will be of the greatest possible service to relieve the patient. I may mention here, that during the battle of Waterloo the Marquis of Anglesy had his leg shot off ; it was amputated on the spot, but for five years he suffered very severely from neuralgia of the stump, trying many remedies to relieve the pain, but all in vain ; and I assure you that this pain is almost unbearable at times. Finally he sought Hahne- mann in Paris, and by him was cured of the neuralgia by in- ternal medication. That is a fact in history, and there is no denying it. In a case like this, however, where the nerves are involved in the contracting tissue, other means may have to be resorted to, to produce the desired effect. Before I speak of the mechanical causes of this neuralgia of the stump, I will relate a case of the affection wdiich was cured by the use of a medicine but little known. I was called across the river to see a man suffering from neu- ralgia of the stump. He had recovered from a thigh amputation ; the stump had healed, and seemed sound, and yet the pain he TREATMENT FOR NEURALGIA OF THE STUMP. 103 suffered was perfectly appalling. He had tried a great many medicines, such as belladonna, the acetate of copper, ign., cicu., zinc;, hydrochlorate of amm., morphia, and others of that class of medicines which act upon the nervous system, and which, ac- cording to the symptoms in each particular case, will often produce relief. In this case, however, all the different remedies were tried without avail, and the patient was in such despair that he often thought of committing: suicide. He had tried manv doctors, of all schools, and had given himself up as a hopeless case. He was a great smoker, and as he stooped one clay to light his pipe from a scrap of French newspaper, he read of a case of neuralgia of the stump which had been cured by eating onions. He immedi- ately sent out and procured three large ones, and ate them ; and for the first night 'in two years he slept. He continued this treatment for several days, and was able to sleep every night. Then he thought he avouIcI try the tincture of allium cepa; and he took the tincture with almost the same effect. He got into the habit of eating an onion every night before going to bed ; and finally cured himself of the neuralgia. This medicine, therefore — allium cepa — must be put down as one of those for neuralgia of the stump, and it is w^ell to recollect it. With respect to the patient before us, it would seem that we must do something to prevent further contraction of that cicatrix. We will give him some internal medicine, and apply a lotion to the stump. If that does not do, and the pain becomes aggra- vating, the adhesions must be loosened from the bone by an operation. That will certainly relieve him, and then internal medicines must be given. If a mechanical obstruction is the cause of the neuralgia, we must resort to mechanical means for relief. I will prescribe for two weeks : the tincture of allittm cepa, five drops, to be taken four times a day in a tablespoonful of w T ater ; and I will have applied to his arm at night a simple onion poultice. Take a good sized onion, chop it up fine, put it into a rag, and tie it on to the stump at night. iProkea Needle* Maria Reed, aged 16 years. With a broken needle in her hand. She has the blunt end of the needle in her hand; and if it were within reach, and you could determine its position, it would be high time then to cut down and take it out. But now I cannot even feel the needle, and do not know where it is located, and it would be improper to make an exploratory operation in the palm of the hand in search of it, when we do not know in what direction to probe. Needles have entered the palm of the hand, and have come out at the shoulder ; they have entered at the knee, and I have taken them out at the chest. And so with bits of glass and splinters. Metallic substances, especially, have a tendency to wander through the system. Until this needle comes nearer the surface it would be wrong to meddle with it. She will feel it somewhere near the surface after awhile. It may move quite fast. As it does not give her any inconvenience, it is better to wait until it makes its location known. She need not worry herself about it, for it will not hurt her. This looking for needles when you don't know where to find them, is a very un- satisfactory thing, and very unsuccessful. Siy+^frittt $>i8*&*«c Katie Paulding, aged 3^ years. History of Case. — Has been lame since she had a fall, six months ago. She was standing in the door, a dog ran under her and pushed her legs apart, and she fell heavily on the floor. She im- mediately arose, but walked lame, and has been lame ever since. For two weeks she has not been able to walk at all. She has a great deal of pain at night. Prof. Helmuth : This is a rapid case of hip disease. You observe one foot is turned out, and the leg seems longer than the other. She com- plains a great deal of pain in the knee, and the mother supposed HIP-JOINT DISEASE. 105 that the injury was in her knee, until Dr. Thompson told her that it was in the hip. This patient fell and bruised the articular •cartilages, and from that time to this, inflammatory action has been taking place. The leg has a tendency to turn out, and is half to seven-eighths of an inch longer than the other. If this patient had been taken in hand the moment she fell, and put on her back, an application of arnica applied to the hip, and arnica administered internally, the disease would probably have been prevented. But the parents of the patient, not knowing the re- result of exercise in an injury to the hip, did not have any thing done, and permitted the child to exercise as usual. The pain increased and became aggravated at night, and it must now be looked after, because it is almost impossible to arrest the disease after it proceeds to the second stage. Tin's child must be kept on its back. Every pressure, every motion of the head of the bone in its socket, has a tendency to bring together two surfaces which are already inflamed and irritated. Put the patient in bed ; but for the present apply no extension, because I am not quite certain whether or not the effusion has yet taken place. Give the child perfect rest, Apply arnica on the outside and in ternally, and also the 3d trituration of lithia. This is recom- mended in the first stages of hip disease ; although I have not yet had any experience in the use of it. Hij^Joint Disease. Albert Sissmann, aged 12 years. {Continued from pages 60 and 85.) [Boy enters walking, and moving well.] You will recollect that this boy has been here before fur hip disease. I will to-day show you the principle upon which this splint acts. There are a great many splints which are made and applied for hip disease. This is a plain splint, and is what is called Bauer's splint. I use it very often for this class of cases, because many of the other splints require to be held in place by adhesive straps, and it takes a great deal of care to keep them adjusted. Here is a crutch, and a strap so arranged as to create counter extension. Here are two cylinders which are attached to 106 NuEVUS — HBfiNIA. the shoe, and are so arranged that by turning the key you can draw one from the other and thus make extension. You can see the foot move as I turn the key. He turns the key every day. Yon can see that his foot is now brought almost to the floor. You also see an immense improvement in his general health. There is another splint which is a very excellent one, and that is the splint of Dr. Taylor. In that, the foot does not come to the ground at all. An iron extends below the shoe, and the patient walks on the iron. There is no jar given to the foot, for all the weight comes on the iron bar. Then there is the splint of Dr. Sayre, made on the same principle, with the exception that it has no shoe nor bar, and is held by adhesive straps. Then there is the old splint of Dr. Davis, who was the originator of these splints^ and the first man who gave an impetus to the ap- plication of extension and counter-extension in hip disease. Ida Teller, aged 5 months. ( Contin uecl from -page 13.) We have here the child with the nsevus that was operated upon at the first clinic this winter. It has now been healed up for about three weeks. She is brought here to-day to satisfy your curiosity. It has certainly very much improved in condition since it was operated upon. John Thomas Parry, aged 6 years. Prof. Helmuth : It always gives me a great deal of pleasure to show a case of rupture, for it gives great facilities for " quizzing " you about it ; and as I have said before, I enjoy these examinations probably a great deal more than you do. This child was born with this rupture. It is not a hydrocele, for hydrocele begins at the bottom of the scrotum ; hernia begins at the top. Hydrocele has no cough impulse ; hernia has a cough HERN r A. 107 impulse. Hydrocele is translucent, when we hold a lamp behind it; hernia is not, except in certain cases. Inversion of the body sends the hernia up, but when the patient resumes his position the hernia returns. If you had hydrocele, you might hang by yoin- feet forty days and it would make no difference with the tumor. There is in this child a predisposition to hernia. He has congenital hernia. I should advise this patient, with such rings as those, to undergo an operation for its relief. You know that there is what is called the radical cure for hernia ; but it is not adapted to all the varieties.. But in such a case as this, where the. rings are so large, I think that it is" advisable to try the rad- ical cure operation. The ring is so extensive that, as. you see, I can pass my finger into the internal ring. It woidd be almost im- possible to keep this gut up with a truss, the rings are so distended. The method of performing the radical cure is simply this : You pass a needle, threaded with wire, through the internal pillar of the ring, bring it out, twist it; turn it back through the external ring, bring it up again and twist it. This sets up sufficient inflam- mation to invaginate the scrotum. That is after Wood's method. Wurtzer's method consists in taking a plug of wood made on pur- pose, with a needle to run through the block. You push the block into the scrotum and hold it there; then push the needle out through the abdominal wall, and screw a clamp on top of the needle in order to retain it until suppuration is established. What can be done in this case. If allowed to remain as it is, it will strangulate, and give him a great deal of trouble. If he grows up, it will still give him a great deal of anxiety. There- fore, I advise that an operation be performed on the child. He will have then to be kept very still. It is an operation not always free from danger; but, at the same time, it affords the best means of being permanently cured. Take the child home and talk to his mother about it, and then come and see us again. If you do not conclude to have it performed, we will then do the next best thing. But it has gone so far that I think the radical cure operation is the better. Recollect, that there is congenital hernia and acquired hernia; and that it is not necessary that congenital hernia should develop itself at birth. Sefcaeeous T%U»QSP» Hattik Andrews, aged 15 years. {Continued from jxuje 97.) Dr. Thompson says that lie was sent for on Sunday night to see the patient; found the right eye swollen up and closed, and suspected erysipelas; the pulse W T as at 120; and he prescribed aconite and belladonna. On Monday night, the eye was still more swollen. Forty-eight hours after the operation the inflam- mation had extended to both eyes. He withdrew the sutures, and there came away at least two tablespoonsful of sanguineous pus. The wound gaped open. At the time of the operation there was a small artery which bled considerably, and was not tied, hoping that the hemorrhage would stop without a ligature. But there was some secondary hemorrhage, and the wound filled with blood and pus, so that it was necessary to open it. Afterwards slight compression was made with plaster ; and now she is doing very well. She was brought here on Tuesday morning, and has been here ever since. She can now open her eye, and there is scarcely any swelling. These sebaceous tumors sometimes undergo a spontaneous cure. Sometimes an inflammatory action sets up in the sac and the contents are discharged. But then there generally remains an unsightly scar. Therefore make it a rule, in removing sebaceous tumors, to remove as much as possi- ble of the cyst wall, or else you may have a reproduction. But the cyst is not of sufficient importance for you to remove it altogether, if portions of it lie in very close proximity to im- portant structures, because, if you remove three-fourths of the cyst, in a majority of cases, the other one-fourth will pass off with the discharge. In the performance of the operation you must never injure any other part. That is a law, you must always fol- low, in whatever operation you perforin. jtargtatl ®ttn« of Qtttmbtv 19th, 1875. . _ ^-..- ---■.-. . < « > . . ^--^^^^- Prof. Helmuth quizzes the class on hernia abdominalis or abdom- inal hernia. Q. What do we understand by hernia! 1 A. Protrusion of the contents of any cavity of the body. Q. What is the difference between congenital and acquired hernia \ A. Congenital hernia may occur soon after birth. At this time the intestine or omentum passes out of the abdomen, ac- companies the testicle in its descent, and becomes lodged in the pouch of peritoneum which forms the tunica vaginalis testis before its communication with the general peritoneal cavity has become obliterated. Acquired hernia occurs from lifting, straining, or making violent muscular exertions of any kind. Q. What is an inguinal hernia? A. It is that in which the bowel protrudes at the groins or through the abdominal rings. Q. What is a direct inguinal hernia \ A. It is that in which the bowel protrudes through the abdominal wall and the external ring. Q. What is oblique inguinal hernia \ A. The bowel protrudes through both rings and through the inguinal canal. Q. What is the difference in the coverings of the oblique and direct inguinal hernia ? A. They are the same, except in the direct, the conjoined tendon is substituted for the cremasteric fascia. Q. If we find that we have a tumor beginning at the bottom of the scrotum, how would you diagnose whether it were a hernia or a hydrocele I 1. Hernia is almost invariably opaque, 1. Hydrocele simulates hernia, but dif- the only exception being in case of a large fers from it by being niore or less trans- fold of intestine distended with gas and lucent. covered by thin integument. 2. The tumor is always varying in size, 2. The tumor is constant, and can generally be made to disappear by pressure. 3. The cord can never be distinctly 3- A part of the cord can be felt dis- felt in any part. tinct from the tumor at its apex. , 4. The tumor is enlarged upon cough- 4. Hydrocele, unless congenital, does ing or exertion. not enlarge upon or feel the impulse of coughing or exertion of the muscles 5. The testicle can be felt distinct and 5. The testicle can scarcely be felt, if separate from the tumor at the lower at all. part of the scrotum. 6. Hernia appears suddenly, is de- 6. Hydrocele forms gradually, and is veloped from above and descends. developed from below upwards. 110 QUIZZES ON IIKKNIA. Q. How would you diagnose varicocele from hernia ( A. In the varicocele the swelling is not reducible, and has the feeling as of a bunch of worms. . Q. What is the difference between enterocele and epiplocele \ A. In the first the intestine alone is displaced ; in the latter, the omentum alone is displaced. Q. What is entero-epiplocele ? It is that in which both the intestines and omentum protrude. Q. What is encephalocele ( A. Hernia of the brain. Q. What is pneumocele '? A. Hernia of the thorax. Q. What is reducible hernia \ A. One in which the pro- truding bowel may be replaced into the cavity from which it came, either spontaneously or by taxis. Q. What is irreducible hernia \ A. When there exists a pro- trusion of the bowel which cannot be returned to the abdomen. Q. What is strangulated hernia \ A. It is that form of hernia in which the bowel is so pressed upon at the point where it passes through the walls of the abdomen," that it is strangled or constricted, which prevents the contents of the intestines from passing to the anus, and the venous circulation is impeded. Q. What is crural or femoral hernia ? A. It is a dropping down of the bowel behind Poupart's ligament, and appearing as a tumor at the upper part of the thigh. Q. What is the difference in diagnosis between femoral and inguinal hernia? A. In the femoral hernia the finder can be in- troduced into the inguinal canal. Poupart's ligament cannot be made out, even though the gut has ridden over it. An inguinal hernia lies inside of the spine of the pubis. Prof. Helm nth said : Psoas abscess may, in rare instances, be mistaken for femoral hernia. But the many presenting symptoms of spinal disease, the slow- ness and variability of progress, the fluctuation, and the part at which the abscess points, which, in the majority of cases, is out- side, of that which hernia protrudes, serve to form the distinctions necessary for diagnosis. An enlarged gland has been mistaken for hernia by most dis- tinguished surgeons. Hamilton records a case in which several days elapsed before the diagnosis was made out, the delay causing the death of the patient. Sir Astley Cooper also mentions two QUIZZES OX ANEURISM, HEMOSTATICS, AND TETANUS. Ill fatal cases of the kind. The absence of cough impulse, the sol- idity of the tumor, history of the case, and the constitution of the patient, must be our chief guides in these cases. Q. How would you diagnose sarcocele from hernia ? A. By absence of cough, impulse, and the non-implication of the sper- matic cord, and the history of the case. Q. What do you understand by the term Aneurism ? A. A pulsatory tumor, which is filled with blood, partly fluid and partly coagulated, and whose cavity communicates with the arterial canal. Q. "What do you understand by the term True Aneurism ? A. It is formed by the dilated coats of an artery forming a pouch, or sac ; this sac is composed of all the arterial coats. Q. What is the difference between a true and a false aneurism \ A. By true aneurism we mean a partial dilatation of all the coats of the vessel. By false aneurism we mean expansion of the one, the rupture of the other. Q. How is the dilatation of aneurism classified \ A. Into cylindr 'oicl, fusiform or sacciform. Q. What is the difference in these three dilatations of aneu- rism ? A. In cylindroid the expansion is abrupt and uniform. In fusiform the enlargement is spindle-shaped. In sacciform the. dilatation is partial, and arises from the side of the vessel. Q. What is hemostatics ? A. The arrest of bleeding. It may be natural or may be artificial. Q. What do we understand by torsion ? A. Twistino- of ar- teries to arrest bleeding. Q. What is tetanus i A. Permanent spasmodic contractions, or spasm of the voluntary muscles of a portion or nearly the whole of the bodv, rendering it stiff and straight. Q. How many kinds of tetanus are there ( A. Idiopathic, produced by exposure to cold; and traumatic, produced by bodily injuries, particularly the injury of a nerve. Q. What is trismus I A. When the spasm presents itself in the muscles of the neck, throat, and jaw. Q. What is opisthotonos ? A. When the muscles of the back are affected, the patient is drawn backward into the shape of a hoop, and rests on his head and heels. Q. What is emprosthotonos ? A. It is exactly an opposite condition of episthotonos, the body being bent or drawn forward. 112 CASK OF HYPOSPADIA AM) RETAINED TESTICLE. Q. What is pleiirosthotonos 2 A. It is wlien the muscles of the side of the body are affected with tetanic spasm. ttyjpoajp**** ■*«*<* Strained Q. What is hypospadias ? A. When the urethral opening ter- minates or exists in the course of the canal on the lower side of the penis. Q. If the urethra terminated on the upper portion of the penis, what would it be called ? A. Epispadias. I propose to present to the class to-day a case of hypospadia, with retained testicles, which has been operated upon once or twice, without success. I might say that all operations are nearly useless in this class of cases. This youno- man has been a student of medicine, but has been rendered unfit for work by this deformity. Both of his testicles are retained and sore. In a majority of instances the operations in such cases are unsuc- cessful. I bring him before you to show you an aggravated case of hypospadias, and at the same time to state a very peculiar fact,, which is this: that this man has all the sensation of passing semen, as if his parts were in a normal condition, and that the sensation is attributed or referred by him to the end of the penis. The semen and urine pass through an opening in the membranous portion of the urethra. The patient has been opera- ted on by Dr. Tiffany, of Baltimore, but the operation was not successful. The opening is now in the perinseum. The patient is very destitute, and I thought that I would bring him before the class, that you might have an opportunity of seeing the case;, and if any of you choose to assist him, with ever so little, he will be grateful. I shall therefore ask him to exhibit himself to you. It is rare that you can see such an aggravated case of hypospadia,, and this complicated as it is with by retained testicles. Patient is brought in. Henry Wilson, aged 37 years. Q. You have had this malformation from birth ? A. Yes, sir: from my birth. Q. Before you were operated upon, how far back in the COLD ABSCESS. 113 urethra was the opening through which you passed water I A. Three and a half inches. Q. As you came from boyhood to puberty, did von have sex- ual desire ? A. Yes ; and rather prematurely. Q. The scrotum was well developed before the operation i A. Not very well. There was some redundancy of tissue. The testicles never came clown. Q. When you have emissions of semen, do you have pain in + he testicles ? A. Not at all. Q. Do you have any unpleasant feeling in the testicles i A. Yes, preceding the emission. It makes the left testicle painful a long time before there is an emission. Q. Then you do not have any such trouble in the right testicle i A. I have no evidence of any right testicle having an existence. I was operated upon by Dr. Tiffany, in Baltimore. His object was to make a flap out of the scrotum. O0I4. 4*so0ssi Henry Pickett, Aged Five Year*. Has had a swelling on the lower jaw for about three weeks. His mother thinks he has a decayed tooth, but has not com- plained of the tooth-ache. Very often in children we find that where there are diseased fangs of a tooth, or where the alveolar processes of the inferior or superior maxillary bone are very thin, an irritation is aroused which extends along the root of the tooth, and connects itself to the periosteum and we have the formation of cold abscesses. This boy has a cold abscess, caused by an irritation at the root of the tooth, external to the periosteum, in tissues so yielding that very little pain is experienced. It is not yet time to do any thing with this abscess. The suppuration is slow, and has all the characteristics of a chronic abscess. There is very little pain, but the suppurating process is proceeding. I can detect slight fluctuation there now, and by introducing a needle perhaps I could withdraw the matter ; but that opening would not be suf- ficient ; the pus would not be fully discharged, and a second in- 114 CASK OF DEMENTIA. cision would be necessary ; and the desire of the mother is to avoid a scar. Therefore, I think that we will leave this as it is for several days. Bring him back at the end of a week ; if it has- fully suppurated, we will withdraw the pus and leave nothing but the puncture. Give the boy three powders per day of cal. carb., 30th trituration. Johanna Reglan, Aged Four Years. History of Case. — The child can use her hands, but does not know how to feed herself ; does not know how to walk ; has a vacant look ; is very quiet. Prof. Helmuth : Here is a case which does not properly belong to my depart- ment. There is no surgical disease here. There is a de- ficiency in mental development, of brain structure. There is such a lack of brain and nervous pow T er that the child, al- though it sees and hears, is not able to accomplish the simple act of prehension, and does not even know how to eat. She has the use of her hands, but does not understand how to take up food and put it in her mouth. In a case like this, nothing but a long course of treatment can be expected to do any good. The prognosis is extremely unfavorable in every way. The peculiarity is this: Here is a healthy woman, with a healthy husband, who has had several children that are perfectly well ; yet, without any known cause, she is delivered of a child mentally deficient. It is not my province to enter into this subject — which is very interesting; and I shall refer the patient to Dr. Lillienthal. There is nothing more lamentable than such a case as this. There is nothing so affecting as to see a case which is almost hopeless. That child is but little above an idiot. It can see and hear, but cannot comprehend . It seems, however, to be physically strong. In cases like this we must give an extremely guarded prog- nosis. No doubt there are institutions and courses of treatment, existing at the present day, whereby such a condition may be relieved. This child cannot talk ; scarcely knows how to swallow, and probably would not swallow, if it were not a partially in- voluntary act. Surgical dUttic of $anuaty 9th, 1875, Prof. Helmuth [holding up a probe] : Small as this instrument is, and insignificant as it appears to the eye, in the hands of surgeons who understand their business, and who have an edu- cated touch, it becomes of great diagnostic value. It assists us in forming diagnoses, which otherwise might be impossible. It will tell ns the direction of a fistula, or the course of a wound ; it will tell where a bone is diseased, and what is the condition of the tissues about a wound, whether soft or hard. In many other ways this little instrument renders such service that it cannot be dispensed with by either physician or surgeon. The exploring trocar is of great value for diagnosing the con- tents of cavities or tumors, and should be in every pocket-case. ^i^#J($i&i aOisgasfe, Philip Bound, Aged Five Years. History of Case.—FeM down stairs two months ago ; on Christmas day his father hung him up by the feet ; since then he has had a great deal of pain, and has not been able to walk. Prof. Helmuth : The left hip is affected. You will notice that the gluteal fold is lost on the affected side. There is a distinct line on one side, bnt it is entirely gone on the other ; one side is flattened, and the other appears to be bulging. Yon will find, I think, that his legs are of different lengths. He has had a great deal of pain since Christmas. We have had an opportunity during these clinics of seeing hip diseases in very many of its stages ; and I am glad to bring this child before you that you may see a case in its second stage. This case exactly illustrates the point that I wish to bring to your notice. I can make a great deal of traction on this leg, 116 HIP-JOINT DISEASE. and pull with a great deal of force, without increasing the suffering; you see it diminishes it rather than otherwise. Bear in mind that a majority of the children that are affected with hip disease are those having robust constitutions. The old-fashioned idea that hip disease was a strumous or scrofulous irritation of the joint is no longer held. Those who have had the most ex- perience in the treatment of these diseases state, as a fact, that you can generally trace them — in eight cases out of ten — to traumatic origin — to an injury of some kind. This patient three months ago, fell down stairs and injured his hip. If he had been put immediately to bed, and kept quiet, he would have recovered. As it was, the result is entirely different. The boy was allowed to run. The parents did not understand the nature of the disease; and the child was no doubt complaining, from time to time, of the injury. Then came a second injury ; and an acute inflammatory action set up between the head of the bone and its socket, the small blood blister or bruise that existed at the head of the femur became still more inflamed, and the consequence is, that we have the second stage of hip disease coming on, with a tendency to effusion, which gives him excessive pain (which is worse at night), and causes an apparent elongation of the limb. Suppuration may follow the inflammatory process ; an abscess may form and open on the outside ; and that may be followed by caries of the bone. Hip- Joint :fri»»ft»»» August Sissman, Aged Twelve Years. {Continued from page 60, 85. and 105.) You recollect how emaciated this boy looked when he first came here, how sick he appeared, and how painful it was to move him. He had hip disease in the third stage. I put on him a Bauer's splint, because it was the least expensive ; and was pre- ferable to those secured by plaster, because the latter sometimes slip. The object of the extension apparatus is to keep up trac- tion sufficient to draw the head of the bone from the cavity, and allow the body sufficient motion to enable the patient by exercise to keep up the general health. In many cases of hip disease the patient is placed in the recumbent posture, and a weight is applied to the foot. But during such treatment the constitution suffers so much from the confinement, that the ob- ANGULAR CURVATURE OF THE SPINE. 117 jeet we are attempting to accomplish is often thwarted. This boy has improved very much under the treatment. He states that he has a good appetite ; and you see that the roses are coming to his cheeks again. He then had a hectic flush ; now he has the tint of health. One of the openings in his hip is nearly closed, while the other is getting better. He has been taking silicea — 30th. Continue giving him the same medicine, and bring him back to-day three weeks. I think that 1 can say that by May you will have him pretty well cured, unless he gets a cold ; 1 mean that the abscesses will heal, and the boy will be comparatively comfortable. He will limp a little for a considerable time. — •^+-» — ( Continued front page 41.) (JVo name given.) You will recollect that this child had Potts' disease of the spine. She has been under treatment since October 1. We think that she is better; she certainly is no worse. Even if the child were to grow up with that slight protuberance on her back, it would scarcely be noticed. She has been taking cal. carb., 30th. Continue it and bring her back in four weeks. We shall then see a more visible improvement. Prof. Helmuth cpiizzes the class : Q. What do you understand by tumor, surgically speaking \ A. The term is restricted to an enlargement of part or structure caused by some specific morbid growth. Q. What are some of the diagnostic differences between an innocent and a malignant tumor \ INNOCENT. MALIGNANT. 1 . Harmless with reference to the snr- 1. The tumor is apt to destroy or in- rounding structures. volve surrounding structures. 2. Texture bears some resemblance to 2. Texture differs from the normal certain of the surrounding structures. structure of the human body. 3. Non-liability to return (excepting 3. Great disposition to return, recurrent fibroid.) 4. Liability to profuse bleeding. 4. Absence of hemorrhage. 5. Great tendency to soften. 5. Little disposition to soften. 6. Great tendency to ulceration. 6. Not much tendency to ulcerate. 7. Very offensive, ichorous or bloody 7. Earely accompanied by offensive discharge. discharges. 8. Infiltration of the parts on which 8. Non- infiltration of surrounding they grow, which is often entirely trans- structures, formed. 118 TUMOR A* T D ANKIK1SU QjUiZZEK Q. What is the color of tumors? A. They vary with the number of blood-vessels contained in them, and also with the amount of inflammatory action in the tumor, or in the superim- posed tissue. Q. What is the color of dsbvusI A. Purple. Q. Of fatty tumors ? A. Yellow. Q. Fibrous tumors? A. Whitish. Q. Cartilaginous tumors ? A. White and glistening. Q. What is the consistency of fibrous and scirrhous tumors ? A. Hard. Q. What of cystic tumors ? A. Soft. Q. What is a hypertrophic tumor ? A. Is one which consists of an enlargement or increase of the proper tissue of the part; some- times having a distinct capsule, and contained in the substance of an organ. Q. What glands are mostly attacked? A. Especially the tonsils and the prostate, meibomian, thyroid, and mammary glands. "Q. What is the simplest variety? A. Chronic enlargement of the tonsils. Q. What are fibro-cystic tumors ? A. Those in which cysts form in fibrous tumors, either by an accumulation of fluid in the insterstices or by local softening with serous effusion. Q. What are recurring fibroid tumors, and on what part of the body do they grow ? A. They are soft, fragile, lobnlated tumors, of fibrous structure, grow on the fingers, within glands, and in the jaw in close proximity to the bone. Q. How can you distinguish abscess from aneurism ? A. By the absence of the thrill, by the fluctuation, and previous history of the case. Q. Which is the most malignant and fatal variety of cancerous growth ? A. The encephaloid cancer. Q. What is diffuse aneurism ? A. It is formed by the blood escaping from a wound in an artery, into the surrounding cellular texture. Q. What arteries are most liable to aneurism ? A. The aorta and popliteal artery. Q. What are the diagnostic signs between an abscess and an aneurism ? A. From the earliest stage of abscess the tumor is hot, throb- FATAL ERROR IN LANCING AN ANEURISM FOR AN ABSCESS. 119 bing, hard, and incompressible ; in aneurism the tumor is of nat- ural temperature, and is soft and fluctuating. The skin covering: an abscess is inflamed and discolored ; that which covers an aneurism is of natural color, or perhaps paler. In abscess the formation of the tumor is much more rapid than in aneurism. In aneurism the tumor is pulsating ; in abscess it is fluctuating. Abscesses which he directly over arteries are lifted up every time the blood is driven along under them, and hence they pulsate like aneurisms ; but they do not pulsate when small, whereas aneur- isms do from the beginning of their growth. Aneurisms are soft ■at first, and hard afterwards ; whereas abscesses are generally hard at first, and finally soft. The enlargement in abscess cannot be diminished by pressure ; in aneurism the contrary is the case. {From Prof. Helmuitis work on Surgery.) The following is recorded of Dr. Dease, of Dublin : " He was called to see a case, supposed to be one of aneurism by all the physicians who had attended it, and, upon careful examination, determined it to be a large collection of pus, overlying an artery. Taking the responsibility, in spite of the advice of those who con- sulted with him, he plunged his knife into the pulsating mass. There was a gush of matter, and the patient, who looked a short time before upon his case as hopeless, was entirely relieved. Much credit was justly the meed of Dr. Dease, and great gratifi- cation must he have felt at thus relieving the unfortunate sufferer. 8ome time after, he was sent for to another case, which, like that just mentioned, had been regarded as an aneurism; and, as in the other, he decided that it was a collection of pus, and proposed relief in the same manner. This being assented to, he penetrated the tumor with his knife, when out rushed a torrent of blood, and with it the life of the patient. He had erred in his diagnosis. It was an aneurism — not an abscess ! Dr. Dease returned to his home, and on the nexr morning was found upon the floor of his chamber with his throat cut from ear to ear, by his own hand ! " ^urgwat fttinir of |anuarg 16tl>, 1875. Harry Pickard, Aged live Years. ( Continued from page 113.) Prof. Helmuth : On the side of this little boy's jaw you will recollect that there was a hard substance we thought indicated the formation of a cold abscess. There is a great deal of difference in the formation of pus, when inflammatory action seems to exist, and when there is none that is apparent. In fact, a large accumulation of pus can take place in a cavity of the body, and yet its formation be un- attended by the usual symptoms which belong to acute inflamma- tion; but, on the contrary, the system will be seriously affected by the symptoms which indicate constitutional irritation. You can have the formation of a large quantity of pus taking place in the body, or some occult spot and yet have none of those inflammatory symptoms which belong to acute forms of suppuration. Instead of having a high degree of inflammatory action, we may have a low, broken-down condition of the system — irritability, quick pulse, pale face, loss of appetite — and a gen- eral condition of the whole body indicating that there is a great deal of irritation ; and we may even find hectic fever, resulting in regular chills, which may be mistaken, on account of the regularity of the paroxysms, for intermittent fever. This is a simple case of cold abscess on the side of the cheek. There is nothing more difficult to diagnose than a cold abscess — that is to say, a chronic abscess — when there is a large quantity of matter involved. There are some pressure symptoms in ab- scesses, which are of a most perplexing nature. Small as this abscess appears, it offers a fruitful subject for a lecture ; but we have been over the subject quite fully, and I will only refer to the insidious nature of those abscesses which occur in different parts of the body — and especially in cavities Avhere the pressure symptoms give rise to a great many obscure symptoms. George W. Fleming, Aged Thirty Years. The patient, who has brought a card of introduction to me, states that he has been told that he has some trouble with the prostate gland ; has had symptoms of the disease for twelve years. After every stool, or the passage of urine, there is a dis- charge of a dirty, yellowish-white fluid from the urethra — about a thimblefull in quantity. Can remain all day and all night without urinating. Q. The chief symptom that you have now is the loss of some fluid after you pass water. Does that, and its train of symp- toms, make you feel badly, and weak at times ? A. I cannot say that it makes me feel badly. Q. Does it worry your mind? A. No, sir. Q. Does it make you feel weak, or give you any pain in the loins, or humming in the ear ? A. No. Q. You only desire to get rid of it, because of its unpleasant- ness ? A. That is the reason ; and because I thought it might become worse after a while. Q. Have you, in addition to this discharge, a loss of power I A. Yes; for the last four or live months. Q. Do you have any desire for sexual connection, or does the loss of desire and of power go together ( A. I have no desire at all now. Q. Does this discharge pass from you without any excitements A. Yes. Taking the age of the patient into consideration, the proba- bility is against there being a disease of the prostate gland, unless it be some disease of traumatic origin. You do not generally find disease of the prostate gland until forty-five or fifty years have passed. The enlargement of the prostate is, as Sir Henry Thompson says, the common heritage of mankind. Nine-tenths of the men (I except women) as they advance to the age of fifty or sixty, have more or less enlargement of the prostate gland. I do not know whether any of you have ever tried to dissect the prostate gland from the bladder; but if you should, you will find 122 SPERMATORRHEA. it very difficult to discover where the prostate begins and where the bladder ends. One seems to run directly into the other. The prostate seems almost to be a continuation of the bladder. There is something else the matter with this gentleman. He has not an enlargement of the prostate, but he has, I think, a re- laxation of the ejaculatory ducts. These ducts open on each side of the verumontanum. I will first examine the rectum. I feel the prostate gland distinctly. The better way in such an exam- ination is to put the patient on his side, introduce the finger and turn the ball of the finger up, because that is the most sensitive part. As I pass the finger along, I can feel his prostate gland. It is quite soft and flexible, and has not that stony hardness which belongs to certain forms of disease. I will now pass a catheter into the bladder. In doing this it is important, in the first place, that you select a catheter having the proper curve. If the man had a prostatic enlargement, this sound would not begin to pass the entrance. You would have to take one the arc of whose circle was at least an inch longer. The curve would have to be greater to carry the end of the instrument over the prostate gland ; but finding that the gland is not enlarged, I am quite sure that this catheter will enter. You place the patient either on his back, or leaning backward against the wall. Have the catheter well oiled, or, what is better, inject a small syringe-full of warm oil into the urethra. I have, on more than one occasion, entered the bladder and relieved men without the introduction of an instrument at all — after they had been tunneled half the night with an instrument — by simply injecting into the bladder a little warm oil. At all events, let the instrument be well oiled ; hold it between the finger and thumb of the right hand, the curved part downwards ; you can then introduce it in the way I now do it; then bring it up, so that the handle of the instrument is paral- lel with the abdomen ; then draw the penis up, with one hand on the instrument, and depress it between the legs of the patient. Do not use any force in the passage of the catheter. A steady, mild pressure, applied when the catheter meets an obstruction, will generally succeed better than any rough manipulation, be- cause there is. no portion of the human body so susceptible to spasmodic action as the urethra. If, in treating spasmodic stric- you fail to enter the bladder the first time, do not try any more that day; because every time an instrument passes along the PARALYSIS OF THE EJACELATORY DUCTS. 123 urethra and touches the part which is irritated, it will cause more violent contractions; and by using force to overcome the obstruc- tion, you may make a false passage, and necessarily render the patient a great deal worse. This patient has not an enlargement of the prostate gland, but he has a paralysis of the ejaculatory ducts, which open on either side of the veru-montanum. \That is the best medicine '. At one time there was a great deal of talk about cauter- izing, and for this purpose an instrument was used, consisting of a catheter with a cylinder at the extremity of the wire, at the bot- tom of which cylinder was placed some powdered caustic. You then draw this cylinder within the sheath of the instrument, and having introduced it into .the urethra, you push forward the cylinder, and allow it to come in contact with the floor of the urethra. The heat of the body then melts the tallow or po- made, and the caustic drops down. This treatment (Lallemand's was highly recommended for spermatorrhoea, or for loss of semen. I used it a great many times, but I must say, that I never saw the first shadow of good come from it, and I believe that is the general experience of physicians, if they would speak the truth. The treatment gives rise to a great deal of pain. Sometimes, when the first burning takes place, there may be an arrest of the symptoms, but as a general rule it is not in the end successful. But still it is highly recommended. Another method of treatment i.- by a pad : and these pads were sold by the quacks by thousand.-. There is no di-ease that is discussed in so inany vellow-covered books as spermatorrhoea. There is no disease that upsets a man's moral faculties more than a loss of semen or virile power. This loss of semen, whether from spermatorrhoea or mas- turbation, or from other causes — it makes no difference what — causes patient to become morbid. Although they do not like to own it, they are fearful, and are ready to grasp at any thing that appears to offer relief. They become morose, and desire to hide their condition from other people. They buy these yellow- covered books, which advertise a pad, or somebody's specific ; and they shut themselves up in a room and read it, and send a dollar to the publisher to procure a pad, or a prescrip- tion, but do not tell anybody what they have done. That is the course that is followed in nine-tenths of such cases ; and nobody is any the wiser. The only way that we can judge of 124 knlakcjkmknt of the SALIVAIiY <; LANDS. the extent to which this business is carried on, is by the fact that all the proprietors of these " specifics " grow rich. There are ten thousand men not far from here, who have these yellow- covered books secreted in a drawer, and a bottle of medicine,, or a pad, hidden away where no one can find it — simply because they do not want any one to know that they have this trouble. No one can estimate the amount of money that goes into the pock- ets of these outrageous quacks ; and we can only judge of the amount by the fine mansions and equipages they are able to support. As I have already said, I do not regard the caustic treatment as of much value, and I have given it, I think, a fair trial. But there are several medicines that will relieve this condition — such as phosphorous, phosphoric acid, opium,* and picric acid. We will give him picric acid, 3rd — four doses per day ; and every night let him sit for five or ten minutes m a basin of cold water in which has been dissolved two handfuls of salt. After taking the bath the parts are to be thoroughly rubbed. Take the medicine for two weeks, and then come back. I have never used picric acid, but it has the reputation of having cured some re- markable cases. We will give it a trial in this case to see how it acts. Lizzie Smith, Aged Eighteen Years. A Lump on her Throat. — Digestion begins in the mouth, in mastication and the admixture of the food with those substances which come from *the salivary glands. We have the parotid glands, the submaxillary, the sublingual, and the iiitralingual, emptying the saliva into the laced cavity. The parotid gland pours out three-fourths of all the saliva that we use. This gland some- times becomes diseased; and in some instances is affected with an enlargement called the mumps. The submaxillary gland lies lower down, on the inner side of the inferior maxillary bone. All of these glands are under the influence of the nervous system,, TREATMENT OF ENLARGEMENT OF THE SALIVARY GLANDS. 125 and they can pour out into the mouth their secretions bj a nervous act. For instance, if, when you were a boy, hungry and poor, you gazed into the window of a cake shop, the saliva would flow into your mouth; that is what is called "mouth-watering." It is by the nervous action on the glands that they are stimulated to secretion. These glands, which secrete the salivia, sometimes en- large. There are other diseases which are specific in their char- acter which I w T ill not now describe. An enlargement of the salivary glands, with a tendency to suppuration, can be entirely cured by the use of mercury. I hope that this will not suppurate, although it now presents many inflammatory symptoms. When you have a salivary gland which is enlarged and hard, and there is an increase in the flow of saliva, then, of course, mercurius is the medicine, because mercurius, taken by a healthy person, will cause an enlargement of the glands and increase the flow of saliva. In other cases, where there is an enlargement, but no increased flow of saliva, belladonna is the remedy. Other medi- cines are baryta, carb., conium., sulph. etc. Jjfotgual eiims of gamtary 23 wl, 1875. Prof. Helmuth being called suddenly to Stamford, Dr. Thomp- son, after reading a letter explaining the absence of the Pro- fessor, conducted the Clinic. Ltjcy Francis, Aged Five Years. Dr. J. H. Thompson : This is a case sent by Prof. S. P. Burdick. In July last she fell down and broke her arm at the elbow. It has been broken three times, and the elbow-joint is quite stiff. The second breaking of the arm was done by a physician, because it had been improperly set. This is the first that I have seen of the case. The physician put splints on, and kept them on for three weeks. When the splints were taken off he could not move the arm. Three weeks is an uncommonly short time for an arm to become stiff in a child ; but it is not too long to keep the splints on, in ordinary cases. The only way that I can account for this arm becoming stiff in that time, is by assuming that there might have been a fracture of the condyle, and an effusion thrown out ; in that case it might have become anchylosed in that time. I think that you could get some movement in this joint, if passive motion was persisted in. It would be well to put the patient under the influence of an anaes- thetic, and have those adhesions broken up. Unless this is done soon, she will have a stiff arm as long as she lives. Passive mo- tion is the only manner of cure and of preserving the joint, after a fracture at, or near the joint ; and it must be persisted in perse- veringly, but without using too much force. If you use too much violence in producing this passive motion, you do a great deal more harm than good. Therefore, to be beneficial, it must be persisted ENCYSTED TUMOR. 127 in for a long time, but not to such an extent as to throw the patient into a fever each time, as was done in this case. You will remember the case of the little boy, at the first Clinic of this season, whose arm was fractured at the external condyle. He came to my office a great many times after that, and I made pas- sive motion with the ,arm with the utmost care ; but I have not suc- ceeded in getting a perfect motion of the joint, and the motion is still somewhat impeded. So you will observe that it is not always a means of perfect restoration, even when properly attended to. In this case, perhaps, the passive motion was carried to too great an extent, and stiffness of the muscle, instead of flexibility, was the result. But the only chance of obtaining a movable joint is to place the patient under the influence of ether, break up these adhesions, and then carefully persist in passive motion for three or four weeks. Timothy Darly, Aged Forty-two Years. History of Case. — The patient states tha the has had this on his back for about twenty years ; has another smaller one near it which has been there for twenty-five years. The large one was lanced about a year ago and then healed up. It did not trouble the pa- tient much until then. It broke this morning. Before it broke it was smooth and round. Dr. J. H. Thompson : This is an encysted tumor. They will sometimes remain with- out much increase in size or occasioning inconvenience for a long time. About a year ago suppurative action set up in this tumor, and pus probably found its way to the surface, just within the membrane of the sac, under the skin. It was then lanced, and soon afterwards healed up. Since that time, suppuration has a^ain taken place ; and this morning the tissues became so thin that the sac ruptured. As I squeeze it you see all the contents of the tumor gush out. There is some pus mixed with it. The suppuration has probably destroyed the sac, and we will apply 128 HYDROCELE — ABSCESS — VARICOSE [JLCBR. strips of adhesive plaster, and I think very likely that adhesion may take place, and a spontaneous cure result without any opera- tive interference. £ ttyftrooelo George Campion, Aged Fifty-two Years. This is a hydrocele. I saw this patient in the dispensary on Tuesday, and requested him to come to my house that night, when I injected the compound tincture of iodine into the sac, without drawing off any of the serum. About two hours after I had done this, there was considerable inflammation set up, which continued until last night. On Thursday he called again to see me. The treatment which I adopted is a new one. The case is going on now very well, and I shall not do any thing further. I simply brought him here to-day to show you the result of the treatment. &W**&j$: Henry Turnherr, Aged Tiventy -eight Years. An abscess is forming in the lower jaw. The patient states that it resulted from a blow. Let it be poulticed every three hours, and let the patient return on Tuesday. ¥**£**•+ OT#^ Mary Kegan, Aged Thirty-two Years. I have brought this case to show you a varicose ulcer. This patient is a washerwoman, and stands on her feet a great deal. Varicose ulcers are frequent with such people. The blood passes down the limbs, the coats of the veins become dilated, so that the valves cannot perform their functions properly, the blood does not return freely, and you have congestion. Here you see HYPERTROPHY OF NOSE^ 129 the varicose veins. The foot is very much enlarged. The circu- lation becomes impeded, and finally an ulcer forms. She has been in this condition for twelve or fifteen years ; she has had this open sore for nine or ten years. It has occasionally healed up to within about a pin's head, and then it would break out again ; as the inflammation increased, the sore would gradually extend, until it finally got into the condition in which you now see it. By keeping her foot upon a chair for a while, and stop- ping work, it would partly heal up. The pain is always worse at night. The best treatment for this, in the first place, is rest ; but, as this disease generally appears in persons who cannot rest, it continues until it assumes the form you now see. If this patient could go to bed and keep the horizontal position for two or three months, this leg would get well. The palliative treat- ment, which is almost the only one you can use in this case, is to bandage the leg, or apply an elastic stocking. The elastic stock- ing is very valuable in such cases, as it keeps up a constant pres- sure on the foot or leg. It must be tighter below than it is above ; because, if you have it tight above and loose below, you will have a worse constriction than with the leg unbandaged. The radical cure is effected by the destruction of the vein with caustic potash or acupressure. I would recommend the patient, besides bandaging the limb, to apply to the sore an ointment, composed of Red Precipitate of Mercury, 1 drachm ; Simple Cerate, 1 ounce. Spread on a piece of linen. Dress the limb twice a day. By this treatment she can continue her occupation, and the limb may become very much improved. Mary G-aas, Aged Thirty-six Years. This patient has an ulcerated condition of the palatine portion of the mouth, in addition to lipoma of the nose. Lipoma comes in two forms — flattened and pedunculated. When pedunculated, it sometimes hangs down on the face to an extent of several inches. It occurs more frequently in man than in woman ; and generally 130 PERIOSTITIS. in men who are over fifty years of age, and who have been ad- dicted to high living, or to the use of alcoholic beverages. I do not know of any remedy that can be given internally that will have much effect upon this disease. The knife is the only resort,, and that is better resorted to in cases where the lipoma is pedun- culated than where it is flattened. This disease never interferes with the mucous structure or with the cartilage of the nose. Although it is with a great deal of difficulty that it can be removed, yet with care it can be done. I shall not undertake to operate upon this case to-day, because there is so much surface involved that I am afraid that we should not find material enough to make the flaps to cover the gap. If there should be any thing specific in the case, of which we have some indication in the pharynx, we should have a more unhappy result than if we left it in its present condition. It has been recom- mended by some that iodine should be employed locally ; and I will use it in this case. But, instead of applying the tinc- ture of iodine, which would give her a great deal of pain, I will prescribe an ointment of the iodide of potash. The prescrip- tion is thus written : "I^ : Ung. Potas. lod. §ij-" Spread the ointment on a piece of linen and apply it to the nose. 2p#¥i<»at&1£ji: Bridget Doyle, jLged Tvjenty-three Years. History of Case. — A felon on the end of the index finger of left hand. Has been sore three weeks. Does not remember bruising it in any way. She poulticed it for a while, and then opened it with a needle. It then became worse, and she went to a doctor, and had it opened with a knife, but not very deep. Dr. Thompson: This, as you know, is a form of felon — the fourth variety in which the pus forms under the periosteum; and in this case the bone has become diseased. In treating this disease where the PARALYSIS OF THE (ESOPHAGUS. 131 inflammation has affected the deep tissues, and there has been an effasion of pns under the periosteum, slight incisions do more harm than good. You must go down into and through the peri- osteum, to allow of the evacuation of pus underneath; for that is the cause of all the trouble. If you prick it lightly through the skin, you may perhaps find a little pus, which has formed under that tissue, but the discharge of that will give relief for only a few hours. If you wish to do the patient a real service and give permanent relief, you must cut down until you feel the bone with the point of the knife. If the patient had gone to a doctor in time, and had the finger thus opened, I have no doubt she would have saved the bone, which I now feel with the probe and easily remove. The end of the finger should be tightly bandaged every day, and the openings will soon heal. Sidney Fanning, Aged Fifty-Jive Years. The patient states : I was sent here by Dr. Kushmore, of Hempstead. My trouble is in my throat, above the entrance to the wind-pipe. It has been coming on for a year or more ; but more rapidly within the last four or six months. I have very great pain in swallowing, and frequent coughing. Dr. Rushmore said that it was an obscure case, and sent me here to find out what was the matter. After talking a little while, it hurts me. In eating, if I use soft food, the most of it will pass down. If I use hard foods it will remain in the throat. I make every effort to swallow, but it remains, and I can eject it, as I would phlegm. It seems sometimes almost impossible for me to swallow any hard food. I can exercise but very little. I gave out twice in coming up these stairs. The pain is only in the act of swallow- ing. I have no difficulty in breathing. At times it is very difficult for me to make any effort to swallow ; and I will go for hours without even swallowing spittle. I can drink warm fluids, if they are not too warm, better than cold. 132 ABSCESS. Dr. Thompson : I will refer this case to Dr. Houghton who will examine his throat with a laryngoscope. John Thomas, Aged Twenty-three Year*. Dr. J. H. Thompson : This patient was sent to my house on Thursday by Dr. Norton, suffering with an abscess just back of the anus. The skin over it was very thin, indeed, and I opened it and evacuated a large quantity of pus. I told him to poultice it, and he has done so, and took the poultice off this morning. This may be the beginning of a fistula. It was a very large abscess when I opened it. It does not hurt him at all now. I gave him Silicea, 30th trituration, internally, three times a day. He need not poultice it any more, but may continue the use of the silicea for a short time longer. j^wjical €\mk of famtaty 30th, 1875. Miss Yan Houghton. {Continued from page 55.) Prof. Helmuth : Gentlemen: You recollect I presented to yon a case of cleft pal- ate early in the session, and yon remember I stated at the time, that this class of cases was hardly the variety to operate upon before yon, because it would be impossible for you to see the steps of the operation, which is always tedious. This patient was therefore removed to the surgical hospital, and the opera- tion was performed with instruments with long handles, such as you see here. This was the operation : I pared the edges of the fissure ; Dr. Thompson put in the stitches, and Dr. Cranch took them out. It is always proper and necessary that you have instruments with long handles, and particularly that the knives shall have long shanks, and a short cutting edge. You should also have blades bent at right angles, to loosen the tissue from the palatine bones, and also a double-edged knife to insert under the edge of the palate, to divide the levator palati, in order that the flaps may fall together after you have pared them. Then you have scissors, with handles such as you see here, and a long needle-holder. The needles you use are the same as those for vesico vaginal fistula, sharp and round, with no cutting edge. They should be threaded with silk, and the wire hooked into that. Here is one of them, round, and curved at the end. If you have a long needle, it is almost impossible to draw it through one lip of the cleft, before you introduce it into the other. Now, holding the needle at an angle, you introduce it on one side about a quarter of an inch from the margin, and you push it through and catch it inside the cleft, draw it out, and draw the silk through. Then enter it on the other side, directly opposite, and draw it through. It is better to put in two or three stitches at once, before you draw them 134 PHLBBOLITHBS. together. If the case is a very severe one, as now shown you, you will have to perform two, and perhaps three operations. So far, this has been a successful operation, and, as you see, I prefer to bring in the patient after its performance, that you may observe for yourselves, rather than to keep you sitting in the amphi- theatre while the operation is going on. This would be tedious, you could see nothing and could learn nothing. [To the patient : Open your mouth.] You can seethe cleft is almost closed. There still remains an opening at the roof of the mouth. [The surgeon introduces a spatula into the patient's mouth.] Now you can view it very well, by looking at the roof of the mouth when the patient holds the head up. It is very nicely united, indeed. You observe the fissure is all closed except a little slit in the upper part of the mouth. The next operation for me to perform will be to close the top of the fissure, and, I hope, the effort will be success- ful. The stitches were allowed to remain five days before they were taken out. MlU^tiMft Prof. Helmuts:: I will now introduce to you Mr. Howell, who appears before you out of regard for the class, to show you a very peculiar and aggravated case ? of varicose veins of the right fore-arm. Q. Whatisvarix? A. Preternatural enlargement of the veins. History of the Case by the Patient. This condition was discovered when I was about a year old. It didn't bother me any. I had the full use of my arm. Prof. Helmuth: Q. This is a true case of varicose veins. , These have existed since birth, have they not ? A. Yes, sir. The arm was examined by Prof. Parker, of the Old School, when 1 was about 7, 8, or 9 years old. I could not stand the pressure he recommended. Q. You never had any hemorrhage from them ? A. ~No, sir. Q. Do they give you much pain ? A. No ; unless I am unwell ; then I feel pain. What I want to call your attention to is, you will feel all the way down the arms hard, bony deposits. PHLEBOLITHES. 135 By Prof. Helmuth: This is a peculiar condition of the veins. After they have become diseased for some time, and their coats seem to have be- come enlarged, a deposit takes place within them. These con- cretions are first cartilaginous, but finally an ossific deposit takes place in the coats of the vessels. By taking hold of the arm and pressing upon the larger veins, in the neighborhood of the valves, here and there, you can feel quite distinctly the presence of the foreign substance, which really seems to be bony. In some places it is cartilaginous certainly. Nature is trying to cure the disease. Now, this is simply an illustration of how long a disease may continue and the patient not be obliged to be confined, and also how a formation may exist in the veins themselves, and yet no manifest change be shown from the ob- struction of the circulation. Q. Do you have any numbness in that part ? A. No, sir. Q. Does it hurt you ? [Prof. Helmuth presses on the veins.] A. Yes, sir ; now it does. Q. It doesn't interfere with your general health I A. No, not at all ; and the more exercise I have the better it is. Q. You have given up treatment? A. I don't do anything, ex- cept I bathe it almost invariably in the morning with cold water. I have had a good deal of experience with it. I used to carry my arm up, but I noticed it would grow weaker ; and when I would lay it down a little, it would instantly pain me. Now I hold it hanging down, and never have any pain. Q. Do you find the condition increases ? A. No ; I don't think it does. Q. I have no doubt those veins will be obliterated if your health continues good. The valves will be shut down, and there will be ossific deposit. The outside ones may rupture, you may have severe hemorrhage, and, as I say, the veins will then become obliterated. This is a trial on the part of Nature to do away with this condition, and she is endeavoring to place obstacles that will obstruct the circulation, and she is doing it now. Q. Do you find these deposits grow 1 A. Yes; they are grow- ing — some of them I can feel increasing in size every day. This is a very rare case, and I am very much obliged to the gentleman for offering us the opportunity of inspecting it. In the ordinary treatment of varix there are a great many methods 136 CASE OF ONYCHIA MALIGNA. employed for the relief of the enlargement. By the application of caustic lime and soda, an eschar is produced. Another method is the passage of two pins underneath the veins, winding over them a silk suture to obstruct the circulation, then introducing a teno- tome, and dividing the veins between the pins. For instance, we have veins that are tortuous. We introduce a pin underneath the vein and bring it out there, and (illustrating on black-board) another pin there. Then we twist over the pins a figure 8 suture of silk ; then pass the tenotome underneath the veins flat- ways, turn up the edge, and cut it through. This is one of the very best methods of obliteration. The Patient : Do you think there is more than one vein im- plicated here ? Prof. Helmuts: : Oh, yes ; I think all the superficial veins of the fore-arm are involved. ¥m. Brown, Aged Five Years. Prof. Helmuts: Here is a patient who has disease of the toe-nail which has become inverted. The nail is dead, and it will be necessary to re- move it, and I will now proceed to do so. The patient is a little boy. Put him on the bed ; let his foot hang down over the end, that we may see the condition of the nail. It is dead, putrid — black ; but still it lies in the matrix, and there yet remains enough connection between the dead and living structure, to keep up a certain amount of unhealthy growth. The nail must be removed at its root. This is a different affection from the ordinary in- growing toe-nail ; in the one case the nail grows in and obstructs the circulation, and we have ulceration as from a foreign body. In this case, however, the disease is at the root of the nail itself. You see it smells like a piece of dead bone, and must be re- moved as soon as possible ; and we will therefore spray it with ether and produce local anaesthesia. Before the introduction of local anaesthesia, we often used to freeze portions of the body be- fore operating upon them, and in this way I have removed many tumors. The preparation principally used in those days was ice and ONYCHIA MALIGNA. 137 salt. Then came ether, and then local anaesthesia, as it is now used for many surgical operations, such as lancing a felon, the re- moval of small tumors, portions of toe-nail, etc. But there is a substance which readily chills the tissue to insensibility, and that is Rhigolene, introduced by Henry J. Bigelow, M. D., of Boston. It takes about three minutes to freeze the parts. [ Prof. Helmuth extracts the nail.] You see that, although the top of the nail was in a very diseased condition, still at its root it was quite healthy, there being sufficient action going on from the matrix to keep up a certain amount of healthy nutrition. The re- moval of nails is very painful, and the trouble arising afterwards is, that there is a tendency to the formation of unhealthy granu- lations, which ultimately result in a fungous growth. I will first stop the hemorrhage by pressure, as there will be considerable. I will then apply a plaster of oxide of zinc ; watch the parts very closely, and, if the granulations seem to be unhealthy, we will give nitric acid internally, and apply a solution to the parts. Let me explain to you a little how these nails grow. You all know that we have the skin divided into two layers, the cutis vera, or the true skin, being the inferior layer. It is com- posed of two layers, the corium and papillary body, and over the papillae lies the basement membrane, and then the epiderma. The office of the former is to generate cells, which, as they come to the surface, become scales and are cast off. The epidermis and the corium are reflected back on each finger, as you see there, and a groove is formed and the papillary body comes up to the groove. From the papillary body we have the basement mem- brane, and new cells are formed from the basement membrane, and this constitutes the matrix of the nail. The cell is formed in the groove of the epiderma, and the nail grows out as you see there. Now, in removing the toe-nail, you seize it with forceps and withdraw it by force ; but sometimes the granulations are so un- healthy, and there seems to be so much constitutional irritation, and the parts have become so exceedingly sensitive, that you have to use not only local, but general anaesthesia. Often in very aggravated cases of ingrowing toe-nail, you can cure your patient by taking a knife, holding it as if you were about to whittle, and, shaving off the tissues straight down to the nail, letting the nail remain as it is. Another excellent method is to scrape the nail on the top until it becomes sensitive, cut a notch into the centre of the apex of it, 138 RUPTURE OF THE CORAOO CLAVKTLAK LIGAMENT and elevate each side by tucking under it lead, such as you will hnd in tea boxes. Another method was contrived by a dentist, and is one not generally known. He simply bent a little piece of sil- ver wire into a curved shape, and turned in each end like a hook. He raised up the ends of the nail and hooked the ends of this spring under them, and the constant traction of the spring had a tendency to raise the nail from the sides and let it grow out. It is a very nice method, and you can make the instrument yourself. A little piece of watch-spring will answer the same purpose. You •can cover it with a piece of thread. It is astonishing how little pressure it takes to cause a nail to grow in the right direction. ■ lay X4ga*»e«rt &*» Sidney Fanning, Aged Fifty-five Fears. {Continued from page 131.) [The patient examined with a Laryngoscope.] Prof. Helmuth: This patient will explain his case to you very well, therefore I think I will allow him to tell his story. The Patient : I judge from the remarks of one of the pro- fessors of practice that mine is a case of inflammation of the larynx, and was of such a character, as I understood the doctor to describe Laryngitis Carcinomatous. I forgot the name for three or four days, and was thinking of the word cosmo, but knew that was not it, but I got it afterwards. Q. What did you say it was ? A. Laryngitis Carcinomatous. Q. What else was there about it ? A. Professor Houghton said it was inflammation of the epiglottis as thick as my finger ; all the cartilages were enlarged on account of the inflammation. [A student, who was present at the laryngoscopic examination, corrects the patient, and explains the nature of the disease.] Q. You say there was inflammation all around the perichon- drium 1 A. Yes, sir. 144 PARTIAL PARALYSIS OF THE (ESOPHAGUS. Q. Down to the vocal cord ? A. He could not see them very well, but the epiglottis was pressed back and very thick — as thick as my finger. Q. How long has this been going on ; did the doctor prescribe for you? A. He did. Q. Did you know what he did ? A. I could not say. Q. JSTow we will find out what the symptoms are. Can you tell us when this trouble first began ? A. Ten years ago. Q. You seem to speak better now than when you first came in ; how did it appear first ? A. As a hacking at different times. When in church, after singing one or two verses, I always had to go out, and would go this way [coughing]. I remember of that 15 years ago. Q. Did you become suddenly hoarse ; and would you be worse towards evening ? A. I don't remember. Q. Did you have any dryness in your throat, in the morning especially V A. I think I did. Q. Did you ever lose your voice entirely ? A. No, sir. Q. Does it hurt you to swallow ? A. Very much ; liquids, or any thing cold, or any thing approaching solids. Q. Suppose you were to take a warm semi-solid, like milk toast, could you swallow that % A. After swallowing a small portion, and trying a little, then I could gradually swallow soft milk toast. Q. Do you ever, after swallowing any thing, regurgitate it ? A. Not immediately after swallowing. I can swallow part. The other part will remain, and I try to swallow it. Q. You only get part down ? A. Yes, sir. Q. Do you ever choke when you swallow, and have the fluid come out of your nose ? A. Very often ; within the last three or four months that has been the trouble with me. Three months ago I could eat pretty well, but gradually after my meals, in attempting to ^wallow a mouthful of food, part would come through my nostrils, and part go into my wind-pipe, and I would be choked. Q. That is just the bother ? A. Yes, sir. Q. [To the Students.] This man has partial paralysis of the superior muscle of the pharynx, and besides that inflammation of the perichondrium. SUBACUTE THECITIS. 145 Q. Are you growing worse? A. Yes; gradually growing worse. Q. How old are you ? A. Fifty-five. Q. And you have enjoyed tolerably good health ? A. Yes, sir. Q. Did you, in your younger days, bolt your food ; do you now eat in a hurry ? A. Most generally, like men in business. Q. Yery hot and cold things make no difference to you ? A. No, sir. I swallow them all alike. Q. And then you run off to work with your mouth full? A. Yes, sir. (To the students.) This is a trouble which may result, sooner or later, in a stricture. He has partial paralysis of the superior muscle of the pharynx, which don't act, or at least does so only partially. He takes a drink, or a sup of fluid, and he gets half through swallowing, and the action stops. You have all noticed how the oesophagus contracts in the horse when drink- ing water, and so it does here. These different fibres of the mus- cles act consecutively one after the other, and being under control of the will, all goes well, but if one set of fibres does not act in unison with the others, we have a reverse action, and part of the food is ejected, and only part goes the right way. I should suppose electricity would be a good thing to be applied here to the neck, and I would also administer cocculus. I forgot you have been prescribed for ; therefore you will go on and take the medicines ordered. (The patient.) I am through with that prescription to-day. Q. How far do you live from here ? A. 20 miles. Q. When will you see Prof. Houghton again ? A. To-day. Q. Then I will see him about it, and hope hereafter you will not only be of service to us, but that we will be some benefit to you. . .» ♦ James Browk, Aged Fifty-two Years. Prof. Helmuth. — Tell me about your disease from the begin- ning. A. It occurred about three years ago. Q. This wrist became affected in the winter time ? A. Yes, sir, in October. 10 146 . SUBACUTE THECITIS. Q. Then you had some trouble about your hip ? A. Yes, sir. Q. What kind of trouble was it in your hip ? A. A severe pain. Q. Had you sprained your hip, or had you rheumatism in your hand ? A. I never did. Q. Have you had any falls on your hip, or have you hurt it ? A. No, sir. Q. Then, afterwards, did you take medicine to relieve the pain in your joint. A. Yes ; and a great deal of medicine. Q. You plastered your hip — and everything else ? A. Yes, sir. Q. You don't know whether you were salivated? A. No, sir. Q. How long did you have the pain of which you speak ? A. Three or four weeks. Q. Then, after that disappeared, this trouble began ? A. Yes, sir. Q. Now tell us about this. What is the trouble now ; does it pain all the time ? A. There is no pain at all. Q. Is there weakness ? A. Yes, sir. Q. You have no power to move the hand ? A. No ; I cannot work with it. Q. Have you ever slept this way, with your hand under your head ? A. No, sir. Q. It is not a habit of yours ? A. No, sir. (There is a disease occasioned by lying with the hand under the head, called wrist drop.) Q. You have no pain at all ? A. No, sir. Q. And that don't hurt you (making pressure) ? A. No, sir. Q. You have been among physicians ? A. Yes, sir. Q. And have taken a great deal of medicine ? A. Yes, sir. Q. Can you shut your hand? (The patient endeavors to squeeze Prof. Helmuth's hand.) Q. Is that the tightest you can shut it % A. Yes, sir ; and that makes me shake all over. He has subacute synovitis and thecitis ; not only a subacute inflammation of the membranes, but of the external and internal lateral ligaments of the joint, extending into the thecse. This is merely subacute inflammation, unaccompanied with pain — the same character of inflammation that might ultimately result in the formation of a cold abscess. Q. What have you applied to it ? A. Ice. SUBACUTE THECITIS. 147 Q. Croton oil ? A. Yes, sir. Q. Wet bandages ? A. Yes, sir. Q. And it don't get any better? A. No, sir. Q. Have you ever taken any homoeopathic medicine for it ? A. No, sir. Q. Have you had a dry bandage over it ? A. Yes, sir. He has had the wet bandage applied to his arm, according to directions, and a dry bandage over it, which is very good. Now I will put him on a high potency of rhus, and give him two powders a day, night and morning. (To the patient.) You must take this medicine, and do nothing else. I don't want you to mix it with any other prescription. If you are under two kinds of treatment neither one will do you auy good. jlutgial (&\\m of Jtffoiumj Gift, 1825. Dr. J. H. Thompson. — This case of encysted tumor, which you saw- two weeks ago, has had nothing done for it except the application of strips of adhesive plaster. The sides of the cyst have n6\v adhered, as I then told you that they probably would. The action which nature has set up here for the cure of this case has disintegrated the cyst so that it was not necessary to remove it. Nature has performed the entire cure, just as it would if the sac had been re- moved before it ruptured. T&&®$m?® ®i $%® Xttf e^l^r Mr. Paekee, Aged Thirty-six Years. Prof. Helmuth. — This patient voluntarily comes before you. He is a patient whom I attended for Dr. Belcher. As I have just lectured on fractures, I bring him before you in order that you may hear tiie history of the case and see the method of treatment. The patient states that his jaw was fractured a month ago. He was at work in an ice house, and while standing at the bottom of an inclined plane, down which the ice passed with great velocity, a block of it flew off the side, at a tangent, and struck him on the face. The jaw bone broke just at the angle v He was rendered insen- sible for twenty-three hours, and does not recollect anything about it, This large block of ice, coming with such velocity down the in- clined plane, must have struck him with tremendous force. For a long time after I first saw him he could not get up from the bed, because of giddiness, and a certain amount of confusion of the brain — all showing that he had received a very severe con- cussion. Now his health is very much better, and the bone is uniting finely. I will show you the method I use for band- aging fractures like this. I first take a square piece of tin, cut INJURY TO THE CAUDA EQUINA. 149 the corners off, and then divide it in the middle like this (cutting the tin with pliers). It is better to trim it oat on the edge that is applied next to the neck. Then bend over the top and bottom to make it fit the chin, in this shape (bending the tin into a box shape). Then I have a piece of buckskin sewed over the metal. The ad- vantage of using tin is that you can measure and cut until you can make it fit any sized chin. When it is on, you can hold it very tightly indeed; and when Barton's bandage is applied over it, }~ou have the parts very securely held. That is just as good a splint as you can make. I have treated a great many fractures with such a splint, and with good results. Two of the patient's teeth were knocked out by the blow, one of them came out and I replaced the other. When you are called to treat these injuries of the jaw, the first thing to be done is to look for loose teeth, and if you find any, remove them ; but if there is any tendency for them to be retained in their sockets, it is well to replace them and hold them in posi- tion. I have saved this man a tooth by replacing it. The patieut states that he now suffers chiefly from pain through the ear. That is a symptom of disease about the jaw. He now has the incipient symptoms of what may be called "spurious anchylosis," which is very easily overcome by the necessary movement. Charles Joseph Vander, Aged Ten Years. (Mrs.Vander states the history of the case.) This boy, when four years old, was taken with pain, and would complain of it on every attempt to move or play. A physician treated him for rheuma- tism and then for white swelling, and then he applied a splint- He coutinued to get steadily worse. He was then sent to Dr* Taylor, who immediately pronounced it the hip complaint, and said that a splint must be applied. He was under his care for six months. No abscess or swelling had then appeared. When the pain was very great the doctor directed the extension of the splint by means of the key. The doctor kept the splint on for four years — always promising to cure him. He would 'give an opiate- when there was an increase of pain, but in spite of the 150 INJURY TO TEE CAUDA EQUINA. opium he suffered greatly. It required from three to five drops of the liquid opium, once, twice, and sometimes five times in a night to get him to sleep. The doctor made plenty of promises He kept the splint on for three years, then took it off, and pro- nounced the boy cured, and directed that he be taken home and turned out and fed. Prof. Helmuih. — That is the way they use old horses when they turn them out to die. Mrs. Vander. — He still suffered a great deal of pain at times. By this time the pain had extended to both legs. It seemed like rheumatic pain. The boy was then taken to Dr. Schaeffer, and he also promised to cure him if put under his care, and said that he would have cured him before if the patient had been brought to him, and that it was a great pitj r that he had not seen him before. Dr. Schaeffer tried all the skill that he was possessed of, and continued adjusting the splint and giving medicine, and al ways promising. Prof Helmuih. — I shall be very careful how I promise anything. Mrs. Vander. — This continued until February, a year ago. Then Dr. Schaeffer told me that he could not fail after awhile to bet otally cured, but wanted me to get Dr. John Wood to tell him what was the matter ; but as Dr. Wood was in New York, and I live in Brooklyn, I preferred to go to a physician in Brooklyn. Dr. Schaeffer wanted to hold on to one leg with a splint, while I got Dr. Hutchins to attend to the other leg ; but I was not willing he should ; and so I had Dr. Hutchins to attend him for six months. He relieved him somewhat of the pain. He said the child was suffering from contraction of the muscles. Although he relieved him somewhat of pain, the lack of muscular power was just as bad. Dr. Hutchins then said that he had done all that he could, after treating him six months, and said that he would never be any better. Then I called in Dr. Lord. He used electricity for six months, and the consequence was that the muscles of the leg relaxed, and the pain became much easier. Before that the legs were held tightly together at the knee. He has had more motion since than he had before the application of electri- city. Dr. Lord gave him medicine at the same time, and I think that he was benefited quite a good deal by the treatment. There is still a great weakness in his spine. He can use his limbs, or turn, or roll around, but he cannot raise his body up without great pain. INJURY TO THE CAUDA EQUINA. 151 Prof. Helmuth. — This is one of those cases that need to be studied from beginning to end. The disease has been obscure from the very first day of its appearance ; and when we see it now, in its better developed form, we have no right to cast a shadow of reproach upon those other physicians whb have seen it in its obscure state, because we do not know when we may ourselves have to pronounce upon just such a condition. There are certain obscure diseases in surgery, whether in the formation of abscesses, imperfectly developed hip disease, or irritation of the spine, which are very difficult to diagnose until they are fully developed. It is not, therefore, our province to throw discredit on any one, because in the earlier stages of the disease the diagnosis was not made out as we now see that it ought to have been. Let us always keep this before us in surgery. Eather than now blame any treatment that has been applied, we will take it for granted that these gentlemen all did what they thought was best. No matter what school a man may belong to, we cannot believe that he is dishonest when he takes charge of a case of this kind, or that he does not do his best. It is the lack of proper attention which constitutes malpractice. We take it tor granted that the majority of respectable physicians, when they have a case of this character, do their very best. It is unfortunate when they do not succeed ; but it is not for us to sit in judgment upon what they do. Doctors, as a general rule, are honest, true hearted men, no matter to what school they may belong; and if ministers of the gospel would pay half as much attention to the members of their flocks as the generality of doctors do to their patients, then, in the day of judg- ment, the devil will be most egregiously disappointed. In examining this patient I shall first look to see if his prepuce is elongated. Sometimes the removal of the prepuce has great effect in alleviating these symptoms. There are cases on record where simulated hip diseases have been relieve! by the excision of the fore skin, strange as that may appear. You s :e that the prepuce of this patient is very much elongated. An adhesion has been formed on the side. Q. Did this child, when he was four years old, have any fall ? Mrs. Vander. — Yes; he fell out of his wagon. In going over a curbstone the wagon tilted and he fell out. I do not know where he struck. That was between the ages of three and four years. He appeared to be well afterwards. I do not know that he sus- 152 FRACTURE OF LOWER THIRD OF THE ULNA. tained any injury at the time, but it was during that year that he first began to show symptoms of disease. Prof. Helmuih. — My own little boy fell out of a wagon in the same way when lie was three years old, and he was paralvzed for two years afterwards. The splints are off now ; he is twelve years old, and he is getting well. You can trace this disease straight back to that injury. This child has no hip disease ; but he has disease of the Cauda equina, or nerves which go down on each side of the spinal marrow, and which cause contraction of the adductor muscles of the thigh. All of these muscles are very stiff. The use of electricity has done him a great deal of good — perhaps more good than anything else. I do not promise anything about this patient. I will have a consultation with Prof. Burdick about it. I do not think that the child has anything the matter with either hip. I think that the trouble is in the spine, resulting from the injury that the nerves received when he fell. "We move our bodies by the muscles that are supplied by the nerves that come from the spine ; and if you injure a part of those nerves, a species of paralysis of certain muscles usually follows. This boy has a variety of paralysis of the rotator muscles. These cases in their incipient stages are very difficult to diagnose — much more difficult than in an advanced stage like the present. Recollect what I told you about the elongation of the prepuce. The first thing, probably, that I shall do in this case will be to circumcise the patient. Winn* Julia Murray, Aged Forty Years. History of Case. — (On Sunday last, at about half past 11, as I was coming out of the Grand Hotel, I slipped and fell. My feet slipped out from under me, and I put my hard behind me and fell directly on the wrist. I went back to my hotel, and a gentleman stretched out my arm, and then told me to go to a doctor. I went to a physician on 31st street and Broadway. The doctor said that the bone was broken, and he set it. It gave me a great deal of pain.) Prof. Helmuth. — This is a fracture of the lower end of the ulna. CASE OF ANEURISM OF THE AORTA. 153 It does not extend down into the joint, but the bone is cracked obliquely. (Removes the bandage and splints.) You notice that the Doctor had put on the lower portion of this splint a compress, in order to raise the lower fragment. This was very well, but it has pressed it up most too high, and it has produced excoriation on the under surface. TYe shall apply on this a little tenax, put on a patent felt splint, and then the patieut will be more comfortable. In putting on the bandage we must be careful not to apply it so tightly as to arrest the circulation ; but it must be employed so as to prevent the friction of the splint, and because she has quite severe excoriations both above and below. We will use tenax on each side, and then put on a bandage before applying the splint. You must not understand this bandage to be the same kind that is used next to the skin before we apply a splint. It is merely a substitute for a lining to the splint, and that is all : as a rule, a bandage next to the skin, unless it be for the purpose of preventing ex- coriation, ought not to be used, for it sometimes causes a great deal of trouble and swelling. (The Professor asks a student to apply the bandage.) A little practice is worth all the talk in the world. It is easy to criticise a magnificent picture, and to say that this part and that are bad, but it is a very difficult thing to do the work yourself. It is very easy to criticise the work of others, and very often people criticise things that they could not begin to do themselves. The worst critics are generally the biggest asses. Now that the bandage is on we will put on Ahll's patent felt splint, and secure it with adhesive straps. A^^u^i^m p$ $%& A^Hi^i I now have a case which it gives me a great deal of pleasure to be able to show you. I am apt to be a little careful in my state- ments of what can, and what cannot be done by internal medica- tion. I am rather disposed to be skeptical, than otherwise, as you ail know ; but when I say that I have a case here, that I believe is almost cured, of aneurism of the arch of the aorta, I believe that I am stating very nearly the fact. At all events I now have a pa- tient to show you, who presented all the symptoms of aneurism of 154 ANEURISM OF THE AORTA. the arch of the aorta on the right side ; and who was cer- tainly sent home to die. The most peculiar train of symptoms were developed in his case, I think, that I have ever known ; yet here he is — able to go out; and with a beating of his heart that is almost natural. Mr. Porter was a resident of China. From what he tells me I infer that there are a great many cases of this form of disease in that locality. I do not know why it should be so, but so it is. He was first taken with intermittent fever at a towm on the Yang-Tse-Kiang River, and had it for nearly a month. After that, he suffered a great deal of pain all through his chest. Then the doctor ordered a change of climate. (That is always a bad sign — when a doctor orders a change of climate you may be sure that there is something the matter with the patient.) His trouble was called " Rheumatism of the heart." He then went to Shanghai and was attended by a French physician ; he stayed there a month and improved, but then the trouble began to develop again. He had great pulsation from the slightest cause, and all the time; he had also a great deal of neuralgia in the side of his head, and particularly on the left side. Motion became almost impossible, on account of the violence of the pulsation, which any attempt to move was sure to produce. He then went four hundred miles fur- ther south, but the trouble still continued. There he was treated by an English physician, who called the disease aneurism of the heart, but did not like to tell the patient any particulars. He was so weak that the doctor thought he would die before he could get to Japan. Then he went to San Francisco, and visited the Springs ; and nearly died while there. The doctor there gave him some medicine which relieved him ; for a time he thought that he was getting better, and then returned. He arrived there in June and had to leave in September. Then he came straight through to New York. He was brought to me by Dr. White, of Harlem ; and went into the hospital on the 15th of last October. When I saw him he had no radial pulse ; he had an enlargement on the upper side of the chest, and with a pulsation or bruit, which was very well marked, and of tremendous power. He was sleepless and restless, and suffered a great deal from neuralgia ; but never lost his appetite. His digestion has been good from the first. He felt so miserable that he did not care whether he lived or died. His heart is now beating rather louder than usual ; which I account for by the fact that he has not been about long, and coming to see ANEURISM OF THE AORTA. 155 you and telling his case has given him a little nervous palpita- tion. The bruit is now entirely gone. When he is resting in bed he is very comfortable. His neuralgia has all disappeared. His heart is beating about three times as loud as it generally does, be- cause he is a little excited. I gave this patient \ drachm of gallic acid three times per day — that is about 90 grains per day ; and five drops of sub-sulphate of iron three times per day on alternate days. Gallic acid has a spe- cific action on the blood, and has a tendency to coagulate it. It is one of the surest medicines that can be given to arrest internal hemorrhage. I gave him this because I knew of nothing else ; and because I had seen two reported cases of aneurism which were said to have been cured by its use. Two months before I had been consulted by a gentleman from Atlanta, Ga., who bore with him letters of several of the most distinguished gentlemen of New York, stating that he had aneurism of the aorta ; and who had taken iodide of potash in large quantities. I ordered him the same treatment I have stated, and have received favor- able reports from him. This patient had been under treatment at Atlanta, Ga., about a month, when I received this letter concerning him : Atlanta, Ga., Nov, 30, 74. WrLLiAM Tod Helmuth, M. D. My Dear Doctor — Dr. Cleveland requests me to write you, giving a statement of Mr. F. F. Coulter's case. He was kept on gallic acid and per sulph. ferri solution, as you advised, until the first of this month, when, upon careful examination, the heart's action was found to be perfectly normal. The sufflement spoken of in our first has entirely disappeared. Pulse 72 per minute. The sound of the pulsation of the heart perfectly clear. There yet remained that huskiness of voice and some torpidity of the liver. The sclerotica slightly tinged yellow. Discontinued gallic acid and per sulph. ferri sol., and put him on digitalis -^ dilu- tion, 10 drops three times a day for one week. Improvement set in again after second day's use. Sclerotica clear ; skin looking better ; tongue cleaned off nicely ; healthy in appearance ; hoarse- ness somewhat better ; continued second week digitalis. I think from his present condition he will make a perfect re- coven^. Eespectfully, F. F. Fabek, M. D. 156 ANEURISM OF THE AORTA. Having this case in my mind as this patient presented, I deter- mined to give this medicine another trial, and so far it has been successful. The perturbations of the nervous system which Mr. Porter endured, when under treatment with gallic acid were very remarkable. For instance, he would lose all control of cer- tain muscles or nerves. He would have a piece of beef on his fork, and try to put it to his mouth, but suddenly would lose con- trol of his arm, and the meat would go over his head. He did not appear to have any control over the nerves or the voluntary muscles. Before taking the acid his hands were constantly numb. I do not offer this treatment to you as homoeopathic. I do not know exactly where to put it — whether to call it chemical, me- chanical, or what not. I do not offer the remedies as infallible, nor do I know that, from the use of such large doses, harm does not result to the constitution ; but if in diseases like aneurism of the aorta, which is generally and uniformly fatal, and is so acknowl- edged, such amelioration as I have shown you can be secured by giving these doses; then, until we know of a better plan, it is our bounden duty to administer them. If we can employ an- other plan, then it will be better to adopt that which is safest. This gentleman comes to you of his own accord, at my sugges- tion, that I may illustrate the action of these two medicines in cases of aneurism of the aorta. I hope and believe, that with proper care and attention, he will ultimately recover entirely. Whether the pulse will ever return to its regular rate I cannot say, but he has none now. At the same time his circula- tion is sufficient to keep him in fair health. His spirits have been remarkably good. He has got along as well as any patient could possibly expect. But it you could have seen him when he first came to the hospital, when there was such rapid and tremendous pulsation, and he was suffering from neuralgia and sleeplessness, you would have thought the case a hopeless one. Now, I can scarcely believe him to be the same man, From the 3d to the 10th of November he expectorated a great deal of blood. This is one of the symptoms of aneurism about the larger vessels, particularly the aorta. For a number of days after he was put under treatment he spit this blood, accompanied with a great deal of phlegm, which nauseated him. That has all passed away, and he has been out riding in the park, and seems to take an interest in human life, and thinks that the best thing that he can now do — is to study medicine. pott's disease of the spine. 157 Anthony Eoul, Aged Four Years. We have here another case of spine disease. It seems to me that in large cities, spine diseases and affections of the joints — espe- cially among the poorer classes — are rapidly on the increase. I have had in my office this morning three cases of spine disease, and here is another. Whether it is the method in which people live, or whether it is the inability of certain classes to obtain the necessaries of life, or whether, in the rearing of children, people are more careless than they used to be, T am unable to say; but certain it is that, in this city, spinal diseases and joint diseases are rapidly on the increase. In the country you do not meet with them. This is a case of Pott's disease of the spine, in its incip- iency. This child had scarlet fever. The mother lost three from scarlet fever within a week, and this is the only one left. This disense made its appearance after the fever. The first thing to be done is to have a proper apparatus put on the child. Stephen O'Haka, Aged Fifty-four Years. (A felon on the third finger of the left hand, which the doctor opened). I will apply to this felon a solution of fluoric acid — one part to 25 — and one drachm of the solution to be mixed in a pint of water, and then apply it. The prescription is thus written : 9 — Fluoric Acid gtt ij. Aquae § j. M. Prof. Burdick. — You must be exceedingly careful to give your patients full directions about the use of prescriptions. I once gave this prescription to a patient with directions to apply it to the finger ; and he did so, without diluting it with water, and the con- sequence was he had a lively time. Prof. Helmuth. — There is a history connected with prescriptions, which of course you know ; and you know moreover that the first 158 CONGENITAL HERNIA. mark of the prescription — " I£" — is considered scientific, being a sign of the ancient astrologers or soothsayers. To show you how scientific some things may look, which are not scientific at all, 1 will write you a prescription — which you can take every two hours. 9 Spiritus Yini. Gall. fl. § ij. Tine. Gentian comp. fl. 3j. Sacch. alb. pulv. coch. min. j. Aquae frigidae fl. g iij. Misce bene, et adde corticis limoni sectionem parvulam. S Ter. die hauriendum. Peter Wedin, Aged Eight Years. History of Case. — (Hernia commenced when he was only a month old. A truss was worn for about twelve months, but it gave so much pain that it was then ^discontinued. The intestine remained within the abdomen for a while after the truss was taken off. Every time he would cry the protrusion would return.) Prof. Helmuth.- — This child has congenital enlargement of the inguinal canal. I think that he can be cured without very much trouble ; but he will have to wear a truss for some time. It must not be one with too hard a pad, nor one that will cause him any irri- tation. The abdominal rings in children of this age will generally close up. If this child could be kept on his back and take some such medicine as nux vomica it would hasten the cure. I recom- mend the elastic truss, made by Eainbow, which is supported from the shoulder. Give him nux vomica three times per day. gmyml €>Mt of Jetottwg Uth, 1825. (Continued from page 157.) Stephen O'Hara, Aged Fifty-four Tears, on whose finger a felon was opened one week ago, returns. Prof. Helmuth. — In this case we applied fluoric aoid in solu- tion (see page 157), and it has done a great deal of good. He has not had any trouble with the bone, but there was a considerable discharge. I only bring him now before you in order that you may see the condition of the hand. You will find in the treat- ment of felons that you can always afford a great deal of relief, when they begin to suppurate, by removing all of the dead skin, which, becoming thickened, from its unyielding character, gives a great deal of pain. By taking the scissors and removing this you will relieve the patient from much suffering. Sometimes, in he earlier stages, you can make these felons abort, by dipping the finger in ley, and sometimes by placing around the finger the thin white skin which is between the shell and the white of an egg. The application of nitric acid is said, also, to sometimes make a felon abort ; but when it has progressed so far that the inflamma- tion cannot be arrested, then it is better to accelerate the suppu- rating process. But in the earlier stages we can, no doubt, prevent the formation of pus. It is not necessary to wait until suppuration is complete before opening the felon. In this case the process was only beginning ; there was but a slight indication of the for- mation of pus ; but I endeavored to get the knife down to the side of the bone, and the operation has been a success. Fraetttr* ke the next day. When it first made its appearance, I put sweet oil on it, because I thought it was only a little pimple. Then I put on spermaceti ointment, to cure it. Then I was told to use Daily's salve. The inflammation still kept spreading." Prof. Htlmuth. — Here is a case of irritable ulcer, or, what should more properly be called in the wider classification, " an inflamed sore." You will recollect that this variety is different from the irritable, because the inflammatory action seems to extend to a greater degree around the former. When we have an inflamed sore we not only have the ulceration which INFLAMED ULCER. 163 is extending at the localized point, but we generally have a dif- fuse inflammatory action throughout the connective tissue Ultimately, this high degree of inflammatory action will disappear and the patient will seem to be better constitutionally ; but we will have a change taking place in the surface of the ulcer itself; and then will present the old fashioned variety of ulcer, with no disposition to heal, and with scarcely any granulation visible. These are the sores that we frequently see in persons of her position in life, who are unable to lay aside work. If she could go home and secure the right kind of treatment — which we will prescribe — keeping her leg in an elevated position for three or four weeks — that ulcer could be cared without the slightest difficulty. But if we have to strap it, and support the parts with a bandage, so that she can perform the ordinary avocations of life, it will be a very different thing to munage, and the cure will be tedious. The patient says that her foot hurts her more when it is elevated than when it is down. Why is this? Because the parts are in a congested condition ; but if she will persist in keeping the foot elevated, and let sufficient blood out of the distended capillaries, then the reverse will be true ; and she will have less pain when the foot is elevated than when it is de- pendent; for when it hangs the blood will rush into it and it will begin to throb, and beat, and burn. In such a condition as this, the first thing to be done is to allay the local irritation. The diffuse inflammatory action is extending along the connective tissue and renders any pressure upon the foot almost unbearable. The best thing to reduce this inflammation is a simple cold water application. She must keep the leg elevated ; then take a piece of canton flannel, or old muslin, and fold it four times upon itself; dip this compress in cold water, wring it sufficiently to prevent its drip- ping, and envelop the leg therewith ; over that, wrap a piece of dry canton flannel, and over that, a piece of oiled silk, and tie it on with three or faur tapes. I venture to say, that she will not have the wet bandage on that sore but a few minutes before the rag will be so dry that it will have to be rewetted. She will have to keep rewetting it as often as it becomes dry. As the inflammatory action disappears, it will take longer for the bandage to dry. For the first day or two it will have to be wet two or three tiaies in an hour. She must keep her leg on a chair, and the water by 164 TRAUMATIC GANGRENE. her side, and as often as the bandage becomes dry, remove it, wet, and apply it over and over again. Internally, she had better have aconite. After the inflammation has subsided we will then come to the treatment of the ulcer. What shall we do with that? Put mud or dry earth on it. The wet earth treatment is almost as good as the dry. If you apply earth after the inflammatory action has subsided you will find that in less than four days you will have a granulating surface where there is none now. During the first three days the foetor and the discharge will increase, then a slough will separate from the centre of the sore, and you will have a granulating surface appearing. You can continue ap- plying the earth, and if you desire to hasten the cure you can strap it every day, and give internally silicea, calcarea, mercurius, or any of the medicines which the constitution seems to indicate. But in the first stages you must give medicines to subdue the con- stitutional disturbance and keep the blood out of the capillaries ; then give something to stimulate the ulcer, and, finally, promote the process of granulation and cicatrization. I expected that I would have an amputation to perform this morning, but the case would not keep. It was a bad case of trau- matic gangrene — worse than I had any idea of — and as soon as I saw it, though it was at night, I was obliged to remove the arm. As I told you, when speaking of traumatic gangrene, you are never to wait for the line of demarcation. The accident in this case occurred on Monday night. On Tuesday I received a telegram, asking if I could come over and see it. I telegraphed back to bring the patient to the hospital. He was caught between two cars, he does not know exactly how, and the arm was terribly mangled I did not see the case until Thursdaj' at half past four in the afternoon, and then the gangrene was rapidly extending. In three hours it had increased two inches; and, at half past seven in the evening I could barely find flap enough to make Larrey's amputation at the shoulder joint ; however, I succeeded in so doing. When I took hold of the tissues I could feel them crepitate in my fin- gers. The veins across the shoulders were very much enlarged, HIP JOINT DISEASE. 165 showing that the gran gene was invading those parts. I do not now know what will be the result of the case. When I heard of it I thought it was one which would keep for a few days, and that I could bring it before the class; but it was ordained other- wise. The man would not have lived through the night. AUGUST SiSSMAN, Aged Twelve Years. (Continued from pages 60, 105, 116 and 142 ) Here is our friend August Sissman. I told him to come at the last clinic, and here he is. He is very much improved in every way. (Holding up the splint which the boy had taken off.) The counter extension in these splints is made by means of the perineal band, which passes up into the perinaeum and fastens to the crutch at the top. The extension in this case is made from the shoe. In Dr. Taylor's splint the extension is kept up contin- ually, and there is a bar that goes across under the foot, In Dr. Sayres' splint there is no shoe, but the extension is maintained by bands of adhesive plaster, which have a tendency to draw the leg down. Recollect that the Bauers' splint has the shoe ; Tay- lor's, the bar of iron under the shoe ; Sayres', held in situ by adhesive plasters. You see that these sores have nearly healed, and, if it were not for the friction of this splint, the larger one would be closed en- tirely. The openings behind are not yet quite cured. You will recollect what an aggravated case this was. You see that his leg has come down about two inches and a half. This was a case in the third stage of hip disease ; the improvement so far has been quite remarkable. There is some diseased bone there yet, which may ultimately necessitate an excision of the head of the femur. Dur- ing the time he has been under treatment the leg has lengthened ; his appetite is good, he sleeps well at night, he has less pallor, and no hectic flush. Taking all of these symptoms into consideration, we can say that there has been a general improvement i.i his case, which is indicated by these favorable constitutional symp- toms. We can say, that the hopes of recovery are good, when we see that the constitutional tendency of the patient is to improve. 166 CONCLUDING REMARKS. If he was run down like the man Hart, whom you saw, there would be but little lope. Hart, you will remember, had two or three openings into the scrotum. In such a case an operation would have been entirely out of the question. He died in a most miserable condition, worn out by the constitutional irrita- tion and the profuseness of the discharge. At the time he was here he had twenty-eight openings. The discharge was so great that when he would raise up he would leave about two quarts of pus in the paper which was used as a dressing. This patient is a great deal better in every way. He has had nothing internally but calcarea and silicea. Prof. Burdi'ck, of the obstetrical department, proposes next week to honor us with the presentation of his prizes, which will assist to leave pleasant memories not only of these clinics, but of all who have taken part in them. I hope that when you come to the practical part of your profession — particularly in the obstetri- cal department — you will be able to know a head presentation from a wind bag ! Our clinics this session have been remarkably well attended and supplied with patients. They have been attended not only by the gentlemen of the class, but by outside physicians, and by mem- bers of the faculty, who have been regularly present. I regard this, not only as complimentary to you, but also as a compliment to myself. We were carried a little cut of our usual line in clinics, by the case of subclavian aneurism, and, because of our attention to that subject, we were not able to lecture much on amputations. I believe that when we have finished with the latter we will have gotten through a pretty complete surgical course. When we take into consideration the number of patients we have had at these clinics, I think we may congratulate our- selves, that the facilities in the surgical department of the Homce- pathic College have been equal to those of any institution extant. I do not say this as a boast ; I only mean to say that I am supplied with facilities for teaching, and it affords you opportunities for seeing, the practical results of medicines administered according to the homoeopathic law. I long ago made it a rule never to perform operations before the class which all could not see, because those operations are not only uninteresting to lookers on, but they become very tedious. Therefore, while I have lectured upon, and shown you CONCLUDING REMARKS. 167 cases of cleft palate, fistulas, and diseases of the nose, I have per- formed the operations at the hospital and brought the patients here to you afterwards that you might see the results. I trust, therefore, gentlemen, that though you have all had a great deal to do this winter, that you have had some pleasant times at these clinics. Next Monday week is the birthday of Washington, and is properly regarded as a national holiday ; I shall, however, con- tinue my lectures on amputations, and, although I do not make the attendance at all compulsory, I would like to see as man}' of you as possible here, because I have been unavoidably detained from lecturing on that subject, having so much to teach on aneur- ism. After I had lectured to you on the case of cleft palate I took the patient to the hospital and operated. Probably only two or three could have seen it had I closed the cleft here. I always endeavor to bring before the class all the operations which can be seen ; but those which are tedious I prefer to do elsewhere, and bring the report of the case, with the patient, or perhaps the specimen, before the class, so that you may know the result. Of all the lectures that I deliver I regard the clinics as the most agreeable. I like them, because I endeavor to make them a little free and easy for you, and because I can vary a little in the subject. If there is anything that I do dislike, it is to occupy an entire hour talking on one dry subject, without variation. Many a time I have stopped and told a story, when I have seen a man nodding. Just as soon as the little narrative begins, he wakes up and is as bright as a dollar. As this is the last clinic before examination I have to thank you very kindly for your attendance, and for the decorous manner in which you have always conducted yourselves in my presence, not only in the clinics, but everywhere else. So far as I know, not a single unpleasant circumstance has occurred between us, to mar the harmony of our friendship, which I hope will long continue to exist. If, at any time hereafter, when you have received your "sheepskins," and enter upon professional life, I can be of the slightest service to you in surgery, you can always write to me, and I will do all that in me lies for you. But do not be egotistical. Do not, if called to a case you do not understand, endeavor to treat it entirely yourself. If you do not send for me, call for some one who makes such cases a specialty. Rscollect it is no disgrace to 168 CONCLUDING REMARKS. say " I do not know." It is a great deal better to say " I do not know, but I will call a consultation," than it is to be sued for $10,000 damages. Nine tenths of the suits for malpractice could be avoided, if consultations were called at the proper time. Young men have very erroneous ideas about consultations. They think that summoning a brother physician in counsel, proves derogatory to their wisdom as doctors. So they hold on to a case in the hope that it will all come right in the end. Although dame Nature does a great deal for surgery, and helps the doctor out of a great many scrapes, it is better not to urge her too far. Therefore, when you have an obscure case, do not be afraid to ask advice ; and if you cannot get it where you are, you will always readily receive it from the New York Homoeopathic Medical College. Whether I am here or not, you may be sure the desired assistance and infor- mation will come. But if you disregard your Alma Mater, some- time she may disown you. Gentlemen, when you return to your homes, and look back upon this course of lectures, I trust that you may consider these clinics as among the pleasantest hours of your student days. To Prof. S. P. Btjkdick, Dr. J. H. Thompson, and to all who have assisted us in these surgical clinics. Gentlemen — For the students and myself I tender you our best regards, wishes, and many thanks for the obligations we are under for the valuable services you have rendered to the class ; and for the many interesting cases you have presented for our instruction. We regret that the end of the clinical term has come, but trust we shall see you at our next session of 1875-76, which promises in every respect, to prove equal, if not superior in clinical facilities, to the one which is now passed. New York, February 25th, 1875. To Prof. Helmuth. My Dear Doctor — I offer to you this Eeport of jour Surgical Clinics as a token of my regard and respect for you, and for your ability as a Clinical Teacher. I have no expectation of pecuniary or other reward from you or the New York Homoeopathic Medi- cal College for the labor I have undertaken, save the approval of yourself and the Faculty. Yours, very truly, PHILETUS J. STEPHENS. REPORT OF THE SURGICAL CLINICS HELD AT THE NEW YORK HOMCEOPATHIC COLLEGE BY WM. TOD HEL- MUTH, M. D, FOR THE SESSION OF 1873 and 1874. Acute ffi®®&®mim* Josephine Walsh, Aged Nine Years, was taken three months ago with swelling of cheek, with general febrile condition. Four teeth were extracted by a dentist, which aggravated the symptoms. She then had a very offensive breath, with profuse discharge of saliva and pus. Five weeks ago an abscess formed and discharged itself under the chin, after which the breath was not so offensive. Probe introduced, rough- ened and loose bone encountered. Pronounced acute necrosis of inferior maxillary. Merc, proto- iodide 30, grs. ij., night and morning for one week, and parts syringed twice a day with Lister's sol. carbolic acid. Nov. 1, Better. Treatment continued. Empyema* James B. Corkey, Aged Twenty -one Years. Pleuritic abscesses on left side below nipple, the lower one admitting probe one half inch ; discharge freely; have existed fifteen months ; oedema of both legs ; mother died of phthisis. Pronounced empyema caused by pleurisy. Sulphur 30 trit., powder every night, with injections of carbolic acid. The differences between empyema, emphysema and hydro- thorax were pointed out, and the causes of the dropsy explained. Allusion was also made to the immense amount of purulent formation which could accumulate and be discharged. The method of puncturing the thoracic walls with the aspi- rator, an instrument which has of late attracted great attention from the profession, was explained. 172 CLINICAL RECORDS. Amjmt&tion ot Breast Mrs. Cunningham, Aged Forty-eight Years. Encephaloid tumor of left mamma, size of walnut, hard, purple and unbroken. Etherized, and tumor dissected out down to ribs and sternum, leaving an opening several inches in diameter. She had been operated on by Prof. II. sixteen months ago for a similar tumor, and was then told that it would return. Pre- vious to first operation the tumor had almost disappeared under conium mac, prescribed by Dr. Dunham, when an injury reproduced it. Wound sprayed with carbolic acid, packed with carbolized cotton, and adhesive straps applied. Wound showed healthy granulations, and good recovery expected. It was strapped firmly to bring edges of wound together, and Fowler's solution, gtt. ij., twice a day, ordered. The only unfavorable symptoms following the operation were intermittent pulse, found to be idiopathic, and retention of urine, which was relieved by aeon, and canthar. Strangury, retention of urine and intermittent pulse often follow operations, and the last may be a bad indication, and dangerous in inverse proportion to the strength of patient's constitution. In a few days more the patient left the hospital, the wound having healed very kindly. Tilling Jtqtti&e+Vara** Wm. Dohn, Aged Four Years, Talipes equino-varus, operated upon one year ago, but opera- tion rendered fruitless by the patient not wearing the proper shoe. Tendo Achillis and tibialis anticus divided subcuta- neously, and shoe ordered to be worn at once. Bridget McNally, Aged Fifty-four Years. (See Page 30.) Passed climacteric ten years ago. Two years since a small hard lump appeared in right mamma; it was painful ; the nipple was retracted. The integument then ulcerated, and the peculiar REPORT OF SURGICAL CASES. 173 granular appearance, with occasional hemorrhages, which belong to epithelioma, was noticed. The two different varieties of epi- thelioma, superficial and deep seated, were explained, and the arguments for and against operative measures in cancer pointed out. The value of ars., hydrast, conium, sepia, and phytolacca were noted, and the patient promised to return at the next clinic. Margaret Cauldwell, Aged Forty-eight Years. Sebaceous tumor of the scalp, situated in the occiput; appeared two years ago. It gave but little inconvenience, but was growing rapidly ; it had actained the size of a large walnut. Dissected out entire. The various forms of cystic tumors were mentioned. Mrs. K., Aged Foity-five Years. This case was a very aggravated one, had existed for a number of years, was accompanied by anal spasm, and rendered the patient very miserable. Hemorrhoids removed by the platina wire brought to a white heat by the galvano-caustic battery. There was no hemorrhage. The fissures were divided throughout their extent. The cure of fissures and cracks about the anus may be sometimes accomplished by the forcible dilatation of the sphincter. Jos. Brotherfield, Aged Five Years, Brought here supposed to be tongue tied, but it was discovered that he had nursed well, could talk fairly, and project tongue. Slight impediment in speech, due to lack of education of certain muscles. No operation required. 174 CLINICAL RECORDS. Sjpurious Anchylosis of XZn.ee Lena Elcesse, Aged Six Years, Two years ago fell and injured her knee, which became very much swollen. Iodine was applied, then she was put in bed, and extension by means of a two pound weight kept up. Spurious anchylosis took place nine months ago, and Professor Helmuth divided tendons of external hamstring, and ordered motion. She can now walk fairly, but there is still much swelling of the joint, with atrophy of muscle of the leg. Rhus tox. internally. Anchy- losis splint ordered. Rachel McPherson, Aged Fourteen Years. Spurious anchylosis of right shoulder. Humerus closely adhered to scapula, which latter had great latitude of motion ; crepitus fell on motion ; pain worse in winter. Had taken rhus tox 3, one year ago without effect. Anchy- losis from chronic rheumatic arthritis. Operation recommended. Mks. S., Aged Forty -two Years. Tumor beneath middle third of clavicle ; came two months ago. Pains like sticking with a needle; no pain from pressure; firmly adhered to subjacent structures. Pronounced enchondroma, and she is to return in a fortnight for removal. The peculiarities of cartilaginous growths were mentioned, their connection with bones, and those most obnoxious to their formation were alluded to. REPORT OF SURGICAL CASES. 175 Joanna Schanahan, Aged Twenty-four Years. Sebaceous tumor of the scalp, which was already suppurating, was left to take care of itself. Very often, either from injury or from efforts of nature to remove abnormal formation, suppuration occurs in cysts, and cures may be spontaneous. In this case such a process is going on, and a cure may probably result. Adhesion, either taking place within the walls of the sac or the cyst wall, being removed by ulceration. John Forsythe, Aged Nineteen Years. Tumor of right little finger, palmar surface hard, movable ; is accustomed to lift heavy packages ; noticed first appearance about a year ago, after a sprain ; feeling of crepitation along flexor tendons of the wrist when exercised. Pronounced enlarged bursa of flexor tendon, with diffuse ganglion at wrist. The contents of a bursa vary ; sometimes it is a straw colored fluid, sometimes of the consistence and appearance of honey ; sometimes it resembles the vitreous of the eye; sometimes there are cartilaginous formations, which are discharged, which resemble the seeds of a melon ; this variety of growth is called a melon seed bursa. A ganglion is an adventitious bursa. Bursse are subject to inflammation, which may terminate in suppuration, and even gangrene. Sometimes bursas rupture spontaneously. The methods of treatment are: sudden forcible pressure; puncture with scarification of sac internally to cause adhesions; painting with iodine externally and internally; longitudinal incision along palm of hand to relieve traction ; insertion of seton through the sac. In this case a seton was passed through the sac, and cantharides applied to palm to blister. Some improvement ; crepitation partially disappeared. Can- tharides collodion continued. 176 CLINICAL RECORDS. No improvement since last week. Palm so hard cannot be blistered by cantbarides. Apply croton oil ; take internally iodide of potash, and use continued pressure. This case returned in a week, being very much relieved. The treatment continued. John S., Aged Sixty -six Years, About two months] since injured his head by striking it foroibly against a door. Periosteal inflammation was set up ; pain severe, worse at night. Now a node presents itself, which is painful on pressure, and fluctuates. On lancing, there exudes blood, and a very fetid pus, produced by caries. Pronounced periostitis and caries. Ordered wound to be packed with lint saturated with — I£ Carbolic acid, 3 j. Sweet Oil, 3 v. Water, 3iij. Grace Brinkendal, Aged Eight Months. Capillary naevus on forehead ; operated on five months ago, but has returned. Operation performed by placing suture pins through the tissues under the nsevus in the form of an X, and drawing tense a ligature under these pins. If nitric acid is applied as soon as the red spots appear it will destroy the nsevus, if small. Con- tinued pressure is another means used to kill nsevi. The methods by galvanic puncture, vaccination, etc., were explained. Pat Whalen, Aged Fifty-six Years, Thrown from a wagon two months since, striking his shoulder, in which joint there is dull, aching pain, worse at night. He was made to go through the motions which diagnose dislocation, and the various positions explained to the class. There were no signs REPORT OF SURGICAL CASES. 177 of luxation, and the affection was pronounced synovitis. Rhus tox. topically and internally. Synovitis may, unless treated, pro- ceed to spurious anchylosis ; but the timely administration of nudicine and passive motion will, in the majority of cases, prevent such a result. The diagnosis between spurious anchylosis and true synostosis was entered upon and explained at length. Mr. Turner, Aged Sixty-four Years. About five years ago inflammation began at inner canthus of left eye. Gradually the erosion has extended, now involving the lower lid. Resembles epithelioma. Diagnosis obscure. Pus must be examined for epithelial cells with microscope. A portion of the discharge was obtained for this purpose, and, in the meanwhile, prescribed hydrastis 6m. Hugh Kelley, Aged Thirty -six Years. Operated on seven years ago at Brooklyn Hospital. Owing to- imprudence the cut has never properly healed. The sinus was slit up and the fissures divided at the bottom. The wound was packed with prepared lint. The first appearance of fistulae, their varieties, and methods of treatment, by knife, ligature, paralyzing the sphincter, and internal medication, were detailed to the- class. Edmonis Walker, Aged Twenty Years. Fungus growth and ingrowing toe nail of left great toe, which, had existed for several years. On cutting into the fungus it was found to be an osseous growth from the phalanx, probably pro- duced by irritation by the ingrowing nail. The whole outgrowth 12 178 CLINICAL RECORDS. was excised, with the ingrown portion of the nail. Usually a very good treatment for ingrown tee nail is to shave its middle with glass, cut a notch at the apex of the nail, and raise the edges by placing underneath them small bits of lead. Antoine Lavelle, Aged Thirty-three Years. Diffuse adventitious bursa at wrist. About three months since wrist sprained and bruised by a fall ; has gradually increased in size ; crepitation present. Apply pressure and blister. Intro- ducing seton would in this case probably cause contraction of tendons. Much better under cantharides application. 8-&a&d*&ftid*j» R&*$: Miranda Koy, Aged Twenty-nine Fears. Housemaid's knee is an enlargement of the bursa under the ten- don of the extensor muscles of the thigh. It had not proceeded to ulceration. Ordered compress and cantharides, with leg as much as possible in horizontal position. May become necessary here- after to inject iodine to excite adhesive inflammation. " House- maid's knee," "weaver's bottom," "miner's elbow," "bunion," and the enlargement found in severe cases of talipes equino-varus, were described. CaviiSag*** Albert Swan, Aged Sixteen Years. Disease of knee joint. Ten years ago fell on the ice. Inflamma- tion and suppuration followed, and spiculse of bone came out. Has improved very much for the last six months under silicea, which is continued. In the first stage of this disease, when caused REPORT OF SURGICAL CASES. 179 as above, a blood-blister is formed, and, although there is little pain, then is the time to commence treatment. If no care is exercised, inflammation proceeds to suppuration. All pressure must be taken from the joint, and the patient not allowed to walk. Tttme? ®m Sfo*3t* August GtRIESS, Aged Thirty-four Years. Tamor of the size of an orange on left side of neck, under superficial fascia ; lobulated ; supposed to be cystic : fluctuation detected. Began to grow about eight months since. Operation postponed at request of patient. A. B., Aged Twenty-six Years. In hypospadias the outlet of the urethra is on the under sur- face of the penis, in epispadias the opening is on the upper sur- face ; the disease is congenital. In this case the opening is in middle third of the corpus spongiosum, no normal meatus being present. There is also fissure of the glans. Penis is bent as in chordee. Urethroplasty may be performed for the cure of this affection, but in this case no operation was desired by the patient. Katie Ward, Aged Twelve Years. Swelling of left mammary gland ; not painful. Has been painted with iodine, and improved under it. Prescribed phos. 30 once a day for a week. The use of this medicine in hypertrophy of the mammas, as well as in mammary abscess, was highly extolled. 180 CLINICAL RECORDS. Denis McDonald, Aged Forty six Years. Fistulous opening in right thigh, lower third, from caries of femur. "When a bo} 7 , injured the thigh, and spiculae of bone came out. Two years ago last May a small tumor appeared on outside of thigh, which grew, and, in about four months, burst, and from it exuded pus, which has continued since. Probing discovers caries, but not necrosis. Prescribed silic. 20 °- Hopes to cure without use of knife. Carious bone under the probe has a granular feel. Above case has been at other college clinics without benefit. Wunt of urine escaped through the perineal wound for three days, since which none had escaped, and the purplish spot was nearly gone. Attention was called to the fact that there is more danger of in- filtration of urine when the triangular ligament is divided, as in this operation, than in other operations for the urethral calculus. Jan. 3 1st. At this time all the urine was passed through the urethra, the purplish, appearance of the scrotum was all gone, and the boy prenounced cured. Cured by Digital Compression in 72 Hours. Chas. D. (colored), Aged Fifty Years. Before this man was brought into the theatre, attention was called to the following particulars : An aneurism is a tumor containing blood and communicating with the cavity of an artery. The ordinary or encysted aneurism is sub-divided into several classes, thus ; it is called fusiform, when the whole circumference of the artery was expanded ; pedunculated, when there is a small opening between the aneurism and the artery ; true, when all the coats of the artery are expanded ; false, where the internal and middle coats are up- turned ; diffuse, when the sac walls are formed by cellular tissue ; dissecting, when the blood passes between the coats of the artery. Any sudden and rapid strain of a joint may give rise to an aneur- ism ; a clot forms on the wall of the sac, becoming almost organ- ized, which thickens the coat of the artery and is called after Brocca, the active clot; this sometimes proceeds to such an extent as to cure the aneurism and is Nature's method of cure. The " passive clot" is a currant jelly-like substance found in the centre of the aneurism. The method of cure of Antyllus, which is the oldest, is to ligate the artery above and btdow the aneurism, cut down on the sac and empty it of its contents. AneVs method was to ligate the artery on the cardiac side near the aneurism. Hunter s method was to ligate the artery on the cardiac side at some distance from the aneurism. Wardrop and Brasdors 1 method was to ligate the 200 CLINICAL RECORDS. artery on the distal side of the aneurism. Other methods are by tourniquet to arrest the flow of blood from behind and thus allow a fibrinous clot to form and obliterate the sac. Both a single and double ball tourniquet have been used, but the latter is the better, as it allows a change of pressure from one spot to another and thus relieves the patient. The manipulation method is devised to com- pel the u active clot" to change its position, to enlarge, fill up and obliterate the sac. Sometimes ulceration and sloughing occurs spontaneously in the aneurismal tumor. Forced flexion ; acupres- sure, used by Sir James Simpson, and digital compression are all employed by surgeons at the present day, but the latter method, when there are intelligent assistants at hand, is the best This compression may be continued from four to seventy-five hours, as may be necessary ; one case at least is on record where the pa- tient effected a cure by compression with his own hands in four or five hours. Strange to say popliteal aneurism often occurs in negroes, and the symptoms are, after undue exertion of the leg, a sudden pain, snap and faintness, and a pulsating tumor is found in the popliteal space; sometimes a fibrinous clot forms on the walls of the sac, making the pulsation less distinct and even finally imperceptible. If the ear is applied over the aneurism, a blowing or rasping sound is heard, called the bruit; the pressure on the surrounding veins causes them to become varicose. This man was in the habit of carrying a heavy sick woman from her carriage to her room ; on one occasion he felt a snap and a severe pain down his left leg, and found the next day a tumor behind his knee and the veins of the leg swollen and the leg stiff. Pulsation could not now be felt very distinctly, on account of the active clot. Thirty of the class having volunteered to make digital compres- sion as long as necessary for the cure of this case, they were divided into six classes of five each, each class to remain on duty three hours and each member to compress twelve minutes of each hour. Pressure was begun at 6 P. M. ; patient's temperature in the axilla at this time way 98-£°, the temperature of the tumor was 96, and his pulse was beating 80 per minute. 8 P. M. pulse came up to 88, at 9 P. M. going back to 80 ; the pain at this time became unbearable, requiring the use of morphine. At 11.40 p. M. he was seized with severe rigors lasting but a short time, his REPORT OF SURGICAL CASES. 201 temperature running down to 94£° and his pulse to 81, remaining till morning between 71 and 76. Jaic. 11th. At 8 A. M. his pulse came up to 84, and his tem- perature to 98£° ; by noon the pulse reached 94. Only slight pul- sation could now be detected in the tumor. At 3 P. M. the pulse was 104, decreasing gradually, reaching 88. At 5.40 P. M. the patient was quiet and suffering no pain. At 6 P. M. pressure was taken off for a moment, the pulsation found to be very slight and a movable clot plainly discernible. Between 9 P. M. and morning the patient slept a little during each pressure, waking at every change; at 10.30 P. M. there was some subsaltus tendinum. Jan. 12th. At 1 a. m. the patient's temperature was 98J°, pulse 100 which decreased to 92 by 6 A. M. At 3.15 A. M. there was further subsultus tendinum ; at 9 A. M. his pulse was 94, his tem- perature 99J° and that of the tumor 94J°, and he was suffering no pain. At 3 P. M. his pulse was 105: at 4 P. M. it was 98 and temperature of the tumor 96|°. At 6 P. M. his temperature was 99f ° and that of the tumor 98£. -Jan. 13th. At 4 a. m. his pulse was 91, gradually reducing to 84 by 6 A. M., when his temperature was 99° and that of the tumor 98f°. At 3 P. M. his pulse was 92, his temperature 99 \° and that of the tumor 96£°. At 9 A. M. his pulse was 82, his temperature 98^° and that of the aneurism 98^°, at which time, after 75 hours' pressure, it was discontinued. Prof. Helmuth had taken great interest in the case, visiting the patient daily at 9 A. M.. noon and midnight, and leaving nothing undone that could contribute to success. Great credit was due the class for their kindness and attention. The patient slept well all night and woke in good condition, though exhausted. Jan. 14th. The tumor was carefully examined by Prof. Hel- muth, Thompson and Eobinson, Drs. Baldwin and McYicar, and others, and no pulsation could be detected, and the tumor was found to be gradually reducing and hardening ; the collateral cir- culation had been growing better day by day, and was now very well established, pulsation being distinct in the articular arteries. An examination was made daily and no pulsation detected. Jan. 17th. Prof. Helmuth reported in the clinic that he regarded the patient as cured ; but, for fear there was a small stream passing through the sac, ordered pressure to be resumed on the 18th at 9 A. M. and kept up for 12 hours, to be again re- 202 CLINICAL RECORDS. sumed on the 19th at 9 A. M., and kept up for twelve hours, which was done. Up to the 24th inst. no pulsation could be detected, the tumor was two thirds gone, and the patient was brought into the amphitheatre and questioned. In reply, he stated that he had been walking around for two days and felt no pain in the knee, whereas before the operation for weeks he had suffered most ter- rible agony, had been unable to lie down at all, or put his foot on the ground, and had used opium and every thing he could get, to relieve his pain, without any relief. He was instructed to go home on the 26th and to keep up pres- sure every morning and night for fifteen minutes, and to return in three weeks ; and was pronounced cured. On the 26th Prof. Helmuth came to the hospital with his carriage to take the patient home, for fear he might injure himself if he went home on the crowded street cars, and found the patient had climbed over the transom of the door of his room, and, taking a crowded car, had fled. Feb. 2d. Prof. Helmuth reported that the patient was able to put his heel within a half inch of the ground, was able to work, and was earning his living. W. H. Post, Aged Forty-one Years. This gentleman was sent here by his physician to satisfy him- self that his diagnosis was correct. A year and a half ago he had typhoid fever : a year ago his right breast became hard and sore, and then discharged freely both blood and pus for three months, but during the last nine months pus alone ; neither air nor bits of bone had ever been discharged at any time ; he had been in good health for months and was getting flestry. The probe entered the opening beneath the nipple an inch and a quarter. It was pronounced Empyema, and silicea was ordered. Mary H., Aged Sixteen Years. Adventitious bursa of ulnar side of left wrist. Contains trans- parent fluid. Passed a seton. REPORT OF SURGICAL CASES. 203 Matilda B., Aged Eleven Years. Attention was first called to the following operation for naevi : 1st. Electrolysis, which is not always successful. 2d. By placing two pins at right angles beneath the naevus and li gating it with thread beneath the pins, being careful to insert and withdraw the pins in sound tissue, which causes less hemorrhage aud insures better succes?. 3d. By Perchloride of Iron. 4th. By Nitric Acid. 5th. By Pressure. 6th. By Vaccination. 7th. By a thread soaked in Nitric Acid and drawn through. 8th. By passing two cords beneath the naevus in one direction, two others beneath it at right angles to the former two, then tying and constricting the naevus in quarters and allowing it to slough away. This being a typical case, operated on once before by electrolysis unsuccessfully, the last mentioned method was employed after etherization. Atten- tion was called to the use of nitric acid to cauterize any twigs that may reappear: if done at once it avoids another operation ; also to the fact that some naevi are so large as to occupy one side of the face and require the ligation of the common carotid ; also to the primary and transient anaesthesia caused by ether very soon after its administration, during which minor and brief opera- tions can often be performed, and the secondary and more pro- found anaesthesia following. Jan. 24th. Patient was brought in doing nicely ; the mother was instructed to dress it with simple cerate and return to the Dis- pensary in three days. Isaac R, Aged Fifty -one Years. This was a case that has given rise to some discussion among surgeons, and the man has been before all prominent American surgeons and in many College Clinics. He carried certificates from many surgeons, most of whom pronounced it an aneurism of the thoracie and abdominal costa, and with these certificates he was able to secure a living. His history and symptoms were as fol- lows : two and a half years ago he was working at his trade, steel pen making, when he noticed a swelling in his back which 204 CLINICAL RECORDS. annoyed him in lying down, causing a choking feeling and increas- ing till he had fainting spells ; his abdomen then began to swell, chiefly on the left side, and he began to pass blood with his stooL He now passes about three table spoonfuls with every stool, can- not lie down at all, and is about the size of a woman with child at term. Attention was again called, to the subject of aneurism — to the false variety, where the external coat only of the artery is ex- panded, the internal and middle being ruptured, to the true variety where all the coats are expanded, to the dissecting, where the blood passes between the laminae of the middle coat usually, after pass- ing down the course of the artery, rupturing the internal coat and connecting again with the circulation. Prof. Helmuth expressed the belief that this was a dissecting aneurism ; one peculiarity of the case was that no pulsation could be felt. The man is liable to death at any moment, but may yet outlive his physicians. C. W. S., Aged Three Months, The mother of this baby, who seemed perfectly posted as to the case, stated that when the child was three weeks old she first noticed that it had a hydrocele on the right side, and that a rupture descended every four or five days, swelling the scrotum like an egg and causing the child much pain ; she was about to have a truss fitted to the child, thinking that it would cure both affections. Examination showed translucency and that it was not a hydrocele of the tunica vaginalis, because the scrotum could be drawn down readily and was not evenly distended, but was an encysted hydrocele of the cord accompanied by oblique inguinal hernia. An exploring needle was very carefully used and the fluid drawn off, which will probably excite sufficient inflammation to produce a cure; and she was instructed to have a truss fitted after two or three days. INDEX A. Abscess 128, 132 Treatment of 128, 132 Aneurism.— Difference in diagnosis between an Abscess and Aneurism. 119 Acute Necrosis 171 Treatment of 171 Amputation of the Arm 164 Breast 172 Finger 182 Anaesthesia 16, 99 Local 137 Anaesthetic Ether 16 Anchylosis of Knee Joint 174 Treatment of 174 Lower Jaw 83, 126, 180, 187 Operation for 84, 180, 187 Treatment of... 84, 126, 180, 187 Eight Shoulder 174 Treatment of 174 Aneurism 77, 203 Aorta, of the 153 Treatment of 155 Quizzes on 110, 118 Popliteal, of the 149 Treatment by Digital Compression 200 Subclavian, of the 39, 48 Treatment of 49 Ligature in 50 Angular Curvature of the Spine 24, 41, 93, s 94, 117 Treatment of.. 25, 42, 93, 95, 117 Anus, Fissure of 173 Operation for 173 Aorta, Aneurism of 153 Treatment of 153 Bursae 73, 175, 178, 181, 202 Treatment of 73, 175, 178, 181, 202 Breast, Amputation of 172 c. Cancer of the Lip 19 Operation for 23 Treatment of 23, 89 Mamma 171 Operation for 172 Treatment of 172 Caries of Femur 180 Treatment of 180 Cartilages, movable 140 Operation for 141 Cartilaginous Tumor 174, 187 Cartilages, Ulceration of the Articular 178 Treatment of 178 Cauda Equina, injury to the 149 Treatment of 152 Chloroform 16 Administration of 99 Cheiloplasty 83 Cicatrices 25, 72 Treatment of 26 Cleft Palate 55, 133 Operation for 59, 133 Cold Abscess 87, 113, 120 Treatment of 87, 114 Colles Fracture 196 Concluding Remarks 166 Condylomata? and Enlarged Clitoris. . . 185, 189 Treatment of, 185, 189 Congenital Hernia 76 Congestion— Quizzes on 28 Cynanche Tonsillaris 33 Treatment of 84 Cystic, Sebaceous Tumor 187 Treatment of 187 Cystic Tumor 179 I>. Dementia 114 Dislocations.— Difference in the diagnosis between Fracture and Dislocation 100 Dislocation of the Femur on the Dorsum Ilii 93 Dog Bite 63 Treatment of 63 E. Earth Treatment of Ulcer 164 Empyema 172, 202 Treatment of 173, 202 Encephaloid Tumor of Left Mamma 172 Operation for 172 Treatment of 172 Enchondroma 174 Encysted Tumor 126 Hydrocele 184 Treatment of 184 Epithelioma of the Lip 19, 32 Treatment of . . . 23, 39 Operations for 23 of Mamma 171 Treatment of 171 Tongue 194 Treatment of 194 Epulis 54 Operations for 54 Erosion of Laner Canthus 177 Treatment of . . 177 Eruption, Pustular 184 Treatment of 184 Ether 1« Administration of 98 Exostosis of Great Toe 177 Treatment of 177 Felon 64, 130, 157, 159 Treatment of 64, 131, 167, 159 Femur, Caries of 180 Treatment of 180 Fistula in Cheek 189 Treatment of 189 inAno 173, 177 Operations for 176, 177 Frsenuin Lingua?, Malformation of the — 188 Operation for 188 Fractures.— Difference in the diagnosis be- tween Fracture and Disloca- tions 100 Mode of Repair in 160 Union in Compound Fracture. 161 206 INDEX. PAGE. Fracture of the Humerus 9, 31 Inferior Maxilla 148 Paterson Case 12 Potts 186 Treatment of 186 Quizzes on 7, 8, 9 of the Lower Extremity of the Ka- dius 9P> of the lower third of the Ulna.. 152, 159 G. Ganglion 175 Treatment of . 175 Gangrene Traumatic 164 H. , Hemorrhage, internal '. 173 Hsemostatices— Quizzes on 110 Hemorrhoids removed by Platina wire 173 Hernia, Congenital 76, 106, 157 Treatment of 158 Double Scrotal 183 Treatment of 183 and Hydrocele 204 Operation for 204 Quizzes on 109, 110, 111 Oblique Inguinal 195 Treatment of 195 Hip Joint Disease, 60, 79, 85, 86, 104, 105, 115 116, 142, 165 Treatment of .61, 85, 86, 105 117, 165 Housemaid's Knee 73, 178 Treatment of 73, 178 Hydrocele 128, 196 Treatment 128 Operation for 197 Hypertrophy of Clitoris 185, 189 Treatment of... 185, 189 Mamma 179 Treatment of 179 in Boy 184 Treatment of 184 Tonsils 33 Treatment of 34 Nose 129 Treatment of 130 Parotid Gland 190 Treatment of 190 Hypochondriasis 89 Treatment of 89 Hypospadias 179, 181 and retained testicle 112 I. Impediment in Speech 173 Inflamed Ulcer 162 Treatment of 163 Indolent Ulcer 85 Treatment of 37 Inflammation— Quizzes on 28 Injury to the Cauda Equina 149 Treatment of.. 152 Innonimata, Ligature of 49 Inferior Maxilla 185 Treatment of 185 Jaws, Lower, Anchylosis of... 83, 126, 180, 187 Operations for 84, 180, 187 Joints, Anchylosis of Elbow 126 Treatment 126 Loose Cartilage in 140 Operation for 141 K. Knee, Housemaid's 73, 178 Treatment of 73 Knee Joint, Disease of 178 Treatment of 178 L. Lateral Spinal Curvature 44 Treatment of 46 Ligament Rupture of the Coraco, Claviclar Ligament, and Bruised Capsular Liga- ment 138 Ligation of the Innominata 49 Subclavian 50 Lithotomy 198 Lip, Epithelioma of 19, 32 Operation for 23 Lipoma Nasi 129 Lockjaw— Quizzes on 110 Loose Cartilages in Joint 140 Operation for 141 Lower Jaw, Fracture of 148 31. Mamma, Cancer of 30, 171 Mammary Gland, Preternatural Enlarge- ment of 179 Treatment of 179 Hypertrophy 184 Treatment of 184 Mother's Mark 38 Movable Cartilage 140 Operationfor 141 N. Nasal Passages— Obstruction of 191 Treatment of 192 Nevus 13, 19, 106, 203 Treatment of 14, 15 Operationfor 15, 18, 203 Capillary 176 Necrosis, Acute 171 Treatment of 171 of the OsFrontis 183 Treatment of 181 Jaw 181, 186 Treatment of 181, 186 Tibia 65 Operationfor 70 Frontal Bone 31 Treatment of 82 Needle, broken 104 In wrist , . 187 Neuralgia of the Stump 101 Treatment of 103 Node 176 Treatment of 176 Nose, Hypertrophy of 129 o. Oblique Inguinal Hernia 195 Treatment of 195 Obstruction of Nasal Passages 191 Treatment of 192 Onychia Maligna 136 Operation for 137 Oesophagus, Stricture of 74, 95 Treatment of 76, 95 P. Paralysis of the Ejaculatory, Ducts 123 OEsophagus 131, 143 Treatment of 145 Traumatic 29 Treatment of 29 INDEX. 207 Partial Paralysis 195 Treatment of 195 Pharaphvmosis 100 Paronychia 64, 130, 159 Treatment of 64, 131, 159 Parotid Gland, Scrofulous Enlargement of. 190 Treatment of 190 Paterson Case, Fracture 12 Periostitis 130 Treatment of 131 Periostitis and Caries 176 Treatment of 176 Phlebolithes 134 Phymoses 51, 100, 188 Operation for 52, 188 Pleuritic Abscesses 171 Treatment of 172 Popliteal Aneurism 199 Treatment bv Digital C mpression of 200 Pott's Disease of" the Spine, 24, 41, 93, 94, 117, 156 Treatment 42, 93, 95, 117, 156 Fracture 186 Treatment of 186 Preternatural Mobility , 10 Prolapsus Ani 46 Treatmentof 47 410, Quizzes— Abscess, Aneurism. . . . Aneurism Aorta Congestion Fracture 7, Dislocation Fracture of Lower Jaw Heruia 109, 110, Hip Joint Disease Inflammation Innoniinata Artery Inter-columnar Fascia Suppuration 29, Tetanus Ulceration R. Repair in Fracture — Remarks, concluding. 119 118 91 }, 9 100 162 111 100 28 91 91 162 110 37 166 s. Salivary Glands.— Enlargement of Glands.. 124 Treatment of 125 Scirrhus 30 Treatment of 30 Scrofulous Enlargement of Parotid Gland . . 190 Treatment of. 190 Sebaceous Tumor of Scalp 173, 187 Treatment of 175, 187 Sebaceous Tumor 97, 108 Operation for 98 Section of the Nerve and Tendon of the Thumb. 192 Treatment of. 192 Specific Ulcer , — 182 Treatment of 182 Spermatorrhoea 121 Treatment of 124 Spine, Angular Curvature of 24 Sprain of Ankle 191 Treatment of 191 PAGE. Spurious Anchylosis of Knee Joint 174 Treatment of 174 Right Shoulder.... 174 Treatmentof 174 Staphyloraphy 59, 133 Stricture of the Oesophagus 74, 95 Treatment of.. 76, 95 Subacute Thecitis 145 Treatment of 147 Subclavian Aneurism 39, 48 Treatment of 49 Ligature of 50 Suppuration— Quizzes on 29, 162 Synovitis 53, 176 Treatment of 53, 176 T. Talipes Equino- Varus , Operation for Tetanus— Quizzes on Testicles Retained Thecitis, Subacute Treatmentof Toe Nail— Disease of 136, Operation for Tongue Tie Operation for .' Epithelioma of the Treatmentof Tonsillitis Treatmentof Tumor Cartilaginous 174, Cystic Enchondi-omaous 174, Treatment of Encysted Treatment of Encysted Hydrocele Treatmentof.. Quizzes on 117, Sebaceous 97, 108. Treatment of Traumatic Gangrene Paralysis Treatmentof u. Ulcer, Indolent Treatment of How to apply Straps. Inflamed Treatment of Specific Treatment of Varicose Operation for Ulceration Ulcer Varicocele , Operation for Varicose Ulcer 81, Treatment of 82, Varicose Veins w. Whitlow 64, 130, 157, Treatmentof 64, 131, 157, Wound of Mouth 172 172 110 1T2 145 147 177 1ST 1SS 188 194 194 1S7 179 187 187 126 126 184 184 118 173 98 164 29 29 35 162 163 182 183 81 82 27 27 192 193 128 129 134 159 159 180