S



Entered according to Act of Corless, in the year 187.N,
RY PHILETUS J. STEPHENS,
In the office of the Librarian of Congress at Washington.



Thi  arn lty aund  Trattvs
OF.THE
ew et  ok Xf o rLeov o iptid  XediIl -olleg'e
THIS WORK
IS RESPECTFULLY SUBMITTED,
BY
PHILETUS J. STEPHENS.



PREFACE.
DURING the last session of the New York Homeeopathic 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 only for the advancement
of the college in which they were delivered, but for the good of the
Homceopathic 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; aud 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 froin
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-'7.5
OF THE
THE Session of the New York Homceopathic 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 Wm.
Tod Helmuth, who, we think, proves himself a perfect master of
the art of surgery. The chief peculiarity of the Clinics are the promiscuous and rapidly given " quizzes."
Qrgi 1a       i 01hli  of  lrtober il.
A boy being brought in with his arm in a splint, Professor Wm.
Tod Helmuth looked at it for a moment, and commenced to question 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 direct and indirect. A fracture may 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 Incomplete 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 breakage of the bone, with a wound of the soft parts.
What is a comminuted fracture?  Is one wlhere the bone has
been broken in more than one place, or cragked in many places.
What is a compound comnminuted 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 anll 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.
~Wvhat is reduction?  Setting  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.
-7ihat 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 bonie over each other and so shorten
the limb.
Sometimes extension and counter extension are not required.
-What is coaptationl?  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.
Vr$^4vi ro   ae 0"i X3% 0 sm$cre$
JOHN A. POWERS, Aged Five Years.
The first case to-(day is one of fracture.  By fracture, I
mean a breakage of the bone, or ossific matter-a solution of
continuity in any or the bony structures o(f the human body.
It is always of great importance when looking at a fracture and
making your dialgnosis to find out, if you can, the position of the
patient at the time that the injury was received. In a patient so
young as this we will be unable to discover how he fell, whether
on his arm or not.
The next thing to be dole when a. patient is brought to you
with a fracture is to look for the three signs thereof, which are
almost always present.  These tlhree symptoms are crepitus, preternatural mobility and deformity. There are other symptoms, but
these are the three generally found, and these demand attention.
It is always important in a case of friacture to try to ascertain, if
we can, if crepitus be present-and by the term crepitus we understand the sound which is produced and emitted when the fractured
extremities of a bone are rubbed together, or the grating together
of the two ends of a fractured bone, and the peculiar sensation
that is felt by a surgeon during a careful examination.
True crepitus, in itself, is always diagnostic of a fracture. When
I say crepitus, I mean true crepitus. You must be careful not to
mistake true for false crepitus, which you often find in that peculiar rubbing noise that may be distinctly heard in the irritated
sheaths of tendons and joints, or fiom accumulation of air in the tissues. True crepitus is not only felt, but often heard. It resembles, as
closely as possible, to the ear the sound produced by the rubbing
together of two pieces of loaf sugar.  If you have a patient brought



10      FRACTURE, PRETERNATURAL MOBILITY, ETC.
to you with supposed fracture, and you can find true crepitus, you
do not wlant anything else.
You must also bear in mind an importnllt fact, that a fracture
may exist without crepitus.  Thus, in the so-called impacted fractures, or iil those where str)cng muscular coatractio'n draw asun(ler
the frcagrments, there may not be a trace of the sound, and I would
have this point strongly imnpressed upon the nintld.
PRETERNATURAL MOBILITY. —l'his symptom is generally present in fractures, altllouglh, in the bones of the leg and, fo: erm,
wlhen oine bone only is the seat of injury, the ilncreased motion
mayi be very slight, as may also be noticed in the irnmpacted
variety; but by gras.t,itg the fractured bone above the contusion
and holding it firlml y  and moving tile lower portion of tile bone in a
lateral direction, all unnatural motion may be generally observed.
This pretern(atural mobility may also be difficult to recognizeespecially when the bony lesion takes place in the vicinity of a
joint alnd there is muclh contusion of the soft parts which may be
torn or lacerated.
Preternatural mobility is more frequently found in the shafts of
bones than in fractures in the vicinity of the joints, because when
you have a fracture in the vicinity of the joint there is generally
so much swelling that there is less mobility than usual.  But
if you have a fracture in the shaft of the humerus, or if you have
both bones of the forearm  broken, then, of course, there will be
mobility, when, under ordinary circumstances, there would be
none.
We have not time now to enter into a discussion of fractures
and the different methods of treatment.  It is very interesting, but
would occupy too much time.
It is always well when you have to treat a fracture to act with
the utmost delicacy, otherwise you are very apt to bruise tihe tissues.
IIere is a fracture which is somewhere in the vicinity Of the
elbow joint-and fractures in the vicinity of the elbow joint are
sometimes the most difficult that you have to deal with.  I thilik
that Gross says in his work that he never approaches a surgical
case with as much fear and misgiving as lie does fractures in the
vicinity of the elbow, no matter how slight, because ill eight cases
out of ten they are liable to be followed with a certain amount of
deformity. More or less stiffniess in the joint is a result which,
even under the most careful treatment, cannot be prevented.



14          CASE OF N./EVUS-TREATMENT, ETC.
vessels; noevi are flat, slightly elevated, and of a red or purplish
hue; they are usually small, and occur most frequently on the head,
face, neck and arms.  The contained blood may be arterial or
venous, or a mixture of the two.
As a general rule their growth does not attain a size much
larger than an egg.
The appearance is sometimes called " mother's mark." A true
aneurism is different from a nmevus. A  nmevus is an enlargement
of the capillaries of the arteries and veins, whereas a true aneurism
by anastomosis is nothing more nor less than an enlargement of
the arterial capillaries rather than of the veins.
Nrevi are sometimes very difficult to treat. They are generally
found at birth. In fact I have never yet heard of one which was
not present at birth.  They vary in size, from that of the head of
a large pin to several inches in diameter. They are caused by an
enlargement of the smaller blood vessels of the part, and by an increased action of the heart and vessels tending to throw the blood
to'that part. The capillaries are enlarged, and, not having the
power of passing the blood through them, the parts become
enlarged and reddened.  These Lnevi are always worse when the
child cries, because then an additional amount of blood is thrown
into the tissues.
There are a variety of methods employed for the relief of these
nevi.  A simple nMvus may be removetl, when it consists of a
red spot, by vaccination, or by application of collodion with
pressure.  When situated over a bone the tumor may be treated
by compression with pads of ivory or other hard substances. Or
you take a needle and thread it with an ordinary piece of silk, dip
the silk in dilute nitric acid, run the needle beneath the nmvus
and let the ends of the ligature hang. Injections of persulphate
or perchloride of iron, sulphate of zinc, acetate of iron, matico,
tannin and ether astringents may prove useful.
Dr. Gross speaks highly of the topical application of Vienna
paste. Dr. Valentine Mott advised puncture with red hot needles,
or acupressure pins.  Perhaps the best method of treating mevi is
by electrolysis or galvano puncture. Many successful cures are
on record. Some surgeons prefer nitrate of silver or the actual
cautery. Or you may apply collodion over the surface. This has
a tendency, from its contractile powers, to force out the blood,
and it is a very excellent dressing after an operation for



TREATMENT OF NcEVUS, ETC.                  15
n3evus has been performed. Allother method is the introduction
of pins deep clown under the tumor, and strangling the growth
by ligature underneath the pins.  There is another method —by
passing a double thrqad under the base of the tumor, leaving the
strands lbanCging out in opposite  directions, then passing  the
needle  through  at right angles, cutting  the  strands, and
tying those above and those below.  Another practice is to ligate
the main vessel giving the supply of blood. I have myself employed this treatment for a nevus occupying half the side of a
chil(i's head. The growth had attained the size of half all ordinary sized melon, for which I ligated the common carotid below
the omo-hyoid after failure by other means. At first the tumor
diminishe(l one half, then remained stationary for a tim(e, and has
since disappeared.  But one of the best methods known you will
see employed to-day.  This child has been operated on twice
with a red hot iron, the marks of which you can see.
This nimvus is a larg, one, and is in a very peculiar position —
on the nose. It is not in a position where the parts are all smooth,
and you have a plain surface to work upon, but it is so situated
as to require a great deal of care in the operation, and the process
itself is by no means devoid of danger.
The operation which Dr. Thompson proposes to perform is this:
He has prepared a round needle-and the reason that a round one
is used is because these broad, cutting needles often give rise to
a great deal of hemorrhage; the needle is very sharp, and it is
threaded with a long piece of silk thread (made of new braided
silk, wlhich will not kink or break), about six feet in length, one
half of which  is black and the other white.  Thread  the
needle upon the middle of this cord. I will give you the history
(of the operation, and then you will see it done. You enter the
needle at about one quarter of an inch from the end of the tumor,
and pass the needle several times beneath the nevus. The loops
should be three quarters of an inch apart and the last one be
brought out through the healthy tissue, beyond the tumor.  Thus
we have double loops-one white and one black-on each side.
Cut the white loops on one side and the black on the other, or at
the top you keep all the thread of one color and at the bottom you
keep all the thread of the other color. Then tie firmly the white
threads on one side and the black on the other side, and the nsvus
is effectually strangulated.



16          CASE OF NIEVUS, ANESTHESIA, ETC.
The prognosis in the case cannot be said to be remarkably
favorable, but nevertheless we will 1have to (lo the best we can. But
it is certain that unless an operation is pterformed there can be no
help for the child. A profuse hemorrhage would soon result.
This is the only means left to save the life of this child.  It is a
perfectly well understood matter between the parents and the
operator that they assume all the responsibility in this case.  The
father has been told all about it. IHe knows that it is a dangerous
operation, but he wishes it performed because he ktnows that it is
the only thing. thl:.t can be done, and he is willing to assume all
the responsibility; he is anxious to have the child live; there is
no doubt of th:t.  It is in just such cases that surgery steps in.
The question arises-Is there anything in medicine that will do
this child good?  Will tll the medicine of all the schools be able
to cure this nsevus? 1 do not think there is a chance for it in
medicine.  Wlhen  the physicians get iiito trouble they often
come to the surgeon, and when the surgeon fails there is no
power on earth to save.
This nevus has been extending daily.  In this operation wv:
shall use an ansesthetic.  You all know, gentlemen, that aniesthesia is the next step to death.  It simulates death.  It takes but
a very little more of the anmsthetic agent to step from a previous
life into death.  Therefore, it behooves us when we would administer such an agent to select that one which is the best.
When I say the " best," I mean that agent which is safest, and not
that which is the quickest, unless the quickest is the safest. Of
course, you know that the discovery of ether belongs to America.
The discover/ of chloroform, or, more properly speaking, the iiitroduction of chloroform, belongs to England.  Wells and Morton
claim  priority of discovery in this country, while Simpson lays
claim to it in England.
The American Medical Association, at its meeting held at
Washington  in 1870, passed the following  resolution: "Dr.
IHorace Wells, of Hartford, Conn., was the discoverer of arnesthesia."  Very distinguished gentlemen, while giving the discovery
of nitrous oxide ansesthesia to Dr. Wells, accord priority of the sulphuric ether ansesthesia to Dr. Wm. T. G. Morton, of Boston.
Not many years since one of the greatest surgeons, Velpeau, of
Paris, told his medical pupils that although enthusiasts at different
times had vainly imagined that some means might be adopted to



ANESTHESIA.                       17
allay the pain of surgical operations, yet that such an idea was entirely chimerical, and must ever remain so. The thing, he said,
was impossible, and all hope of it but a vain delusion. In five
years from that hour Velpeau, of Paris, amputated limbs and performed other grave operations whilst his willing patients were sleeping from anesthesia. An American dentist, Dr. Horace Wells, of
Hartford, Conn., conceived the idea of preventing the pain of surgical operations, and took the ether himself to have a tooth
extracted. He devoted years to this discovery, with an enthusiasm not excelled among ancient or modern inventors, but was
ridiculed and abused. He was so disheartened by ingratitude
that he died by his own hands in 1848. Dr. Morton finally
died, discouraged, disheartened and penniless.  His remains rest
in Mount Auburn Cemetery, near Boston, " without a stone to
mark the spot." What a homily could be read on this history!
\What a lesson does it teach us!
There can be no doubt when we compare the symptoms occasioned by the use of the two anmsthetics, that chloroform  is decidedly the more pleasant. Patients succumb to its influence a
great deal quicker. There is none of the excitability which attends
tile use of ether, and it probably takes less than one fourth the
time to chloroform a patient that it does to bring him under the
influence of ether. In the one case the danger to life is comparatively great, while in the other it is reduced to a minimum. The
temptation to the surgeon to administer chloroform is very strong,
when he knows —as is generally the case-that a patient will go
through tthe various stages of intoxication if ether be given.
Chloroform will very often bring a patient under anmesthetic influence with extreme rapidity, but you scarcely know when your
patients are in a dangeroas condition if it be administered; and
the deaths are numerous that can be attributed to its use. Although I have given chloroform a thousand times or more without accident, on two occasions I was on the verge of losing the lives
of patients-once in Buffalo and once in St. Louis-and I have abjured the use of this agent from  that time to the present as a
general rule. I only use it occasionally.  Ether produces all that
we want, and if it is properly applied, can be made almost as
serviceable as chloroform. If, before taking the ether, the patient
is allowed to fast, and a stimulant given twenty minutes before
the inhalation commences, the ether takes effect with much
2



18                      ANAESTHESIA.
greater rapidity.  If you do not desire to give stimulants in the
shape of brandy or wxhiskey, you can give ten grains of the bromide
of potash, which accelerates the influence of ether with most
remarkable facility, and then there is no danger.  I say that
it is better to have the trouble, if any, with the patients alive
on the table, and let them squeal, and vomit and kick if they like,
and talk all kinds of nonsense, and occupy a great deal of
your time-it is better to have your trouble th~ n, than have it in
a court of law afterwards, when the operator may be subjected to
the most distressing self-reproaches if he has happened to lose a
patient. I do not believe that any feeling ever passes through
the mind of the conscientious surgeon which is more painful
to himself, or renders him more miserable, than that of
seeing  a patient die on the  table, while  taking  an  anMesthetic-particularly when he knows, or thinks, or believes that if
he had used another agent the result might have been different. There are, however, some surgeons who prefer to use the
nitrous oxide to any other anoesthetic.  It is an  excellent
method so long as it lasts, but it is too evanescent in its effect. It
passes off in a very short space of time, and if you were to use it
in general practice you would require a dray to go behind your
carriage to carry the bags. For short operations it is very nice,
but for tedious ones, it is not desirable, unless in a hospital where
you can manufacture it, and then it is necessary to have it always
made pure.
This child has been twice tried with chloroform, but the effects
were bad; it lost its breath immediately; therefore it is better to
use etlher, and take a longer time, if necessary.
The parents state that this nevus was as large as a three cent
piece when the child was born, and that when it was three or four
weeks old the noevus was twice treated with a hot iron.  This
treatment is not desirable, as it is not so successful as the other
methods I have referred to.
(Dr. Thompson then continued the operation.)
You wvill notice in this operation that the black threads come
together, and the white ones also.  We draw and tie the threads
very tightly.
This operation is a very serious one, and we do not know exactly what will be the result. We hope, however, it is for the best.



PATRICK MURPHY, Aged Eqhty-five.
Here is a patient brought to us from  Bridgeport, Conn., for
treatment for Epithelioma, or Epithelial Cancer, which is one of
the mildest forms of cancer, and affects often the lower lip, as
in the present case.
Some authors have styled this disease semi-malicgnant, or cancroid.
In fact, it occupies a somewhat anomalous position, closely resembling innocent growths in cell structure, while in all other respects
it is essentially malignant. Gross is inclined to think that it is
"merely a formn of. scirrhus, modified in its character by the
nature of' the structure in which it occurs."  It was formerly
classed with lupus, but the later pathologists regard the latter as
belonging to ulcers rather than tumors.
In regard to the causes of this disease but little is known. According to Paget, only one twentieth of the cases are referable to
hereditary taint.  External injury, long continued pressure and
local irritation, may serve as exciting causes; for example, epithelioma of the lips may be induced by the pressure of the pipe,
and the "chimney sweeper's cancer" is supposed to be caused
by the irritation of soot lodged in the folds of the scrotum.
Epithelioma attacks men more frequently than women, and
seldom  occurs before the age of thirty-five  or forty.  It generally affects mucous and cutaneous tissues, especially the lips,
tongue and f.ic-; but it may also invade deeply seated structures, and be found in the bones, muscles, lymphatics, liver, lungs
scrotum, anus and penis.
It generally begins as a s;nall wart, crack or tubercle on the
skin, hard, movable, and  tender on pressure.   As it advances
in growth it may assume several different shtapes, sometimes con.sistingr of small rounded masses, half imbedded in the skin; sometimes projecting in warty, cauliflower-like excrescences of a florid
color, and extreme vascularity. Again, the tumor may assume



20                      EPITHELIOMA.
a conical shape, and be covered by a thick laminated scab, like
syphilitic rupia; and, lastly, these morbid growths may be peniulous, and attached to the integument by narrow bases.
On dissection epithelial cancer is found to consist of a firm, grayish or white substance, possessing considerable vascularity;
unlike the varieties previously described, it has no stroma.
According to Druitt, "Microscopical examinations show:
1. The epidermic layer to be composed of epithelium, arranged
in concentric layers around and between the papillae.
2. The papillve and dermis are composed of white, intermingled
with yellow fibrous tissue, everywhere abundantly infiltrated with epithelial cells, and with their nuclei and fibroplastic matter. In the papillae, the epithelium is seen to be
arranged symmetrically in concentric layers amongst
the scanty fibrous elements, and this arrangement may
penetrate to some depth within the cutis, from which
elongated and imbricated rolls of epithelium somewhat
resembling the heads of young asparagus, can be extricated.
3. Within the cutis and subjacent tissue the epithelium is
found sometimes in concentric pellets like comedones
or grubs, or inspissated contents of sebaceous follicles,
sometimes in rings formed within obstructed ducts or
follicles, but usually in large, irregular quantities infiltrated amongst the fibres of the cutis and of the subcutaneous areolar tissue."
The cancer cells which Druitt describes as epithelial, differ
greatly from  those of scirrhus and encephaloid; in fact, they
closely resemble the cells of pavement epithelium, they may be
"round, oval, annular, fusiform or elongated," and they generally
contain one or two nuclei, sometimes they are arranged in layers,
and again they may be enclosed in cysts. Upon pressure, the cut
surface of the cancer yields a clear serous fluid containing cells,
nuclei, oil globules, and crystals of cholestearine.
In its growth, epithelioma gradually attacks and infiltrates all
surrounding structures.  At length ulceration sets in, the surface
cracks at several points, and there exudes a purulent, sanious
fluid, which dries in a scab, this is soon thrown off as a slough,
and we see a deep, excavated ulcer, with hard base, and rough,



22                 CASE OF EPITHELIOMA.
methods of treatment for the cure of the disease, or the eradication
of it from the system.  The old fashioned doctrine that cancer is
hereditary or constitutional, begins to shake at its foundation.  The
microscope has begun to uproot marny of these older notions; and
it is thought that in very many cases it can be proven that malignant diseases, and especially the different forms of cancer, are local,
and that it is only after a time that the constitution begins to
suffer; in other words, that the toxemia is the secondary, and
the local manifestation is the primary cause, whereas we have
been taught that there was a constitutional predisposition to cancerous disease, which had a tendency to render any little bruise result
in some form of cancer.  This is, however, uncertain as yet.
El)ithelioma may assume a most sudden and rapid growth, and
may so undermine the constitution that life may be in danger, and
death result from what is termed vegetating epithelioma or cauliflower excrescence.
IThis case of epithelioma undoubtedly arises from smoking a clay
pipe. Tt:e pipe becomes very hot, dries away the tissues, and so a
tendency to the disease is produced.  It generally begins as a
hard pimple under the skin-a hard nodule under the skinwhlich gradually comes nearer the surface, and is accompanied by
peculiar stinging or burning pains, but not so much burning as we
find in the true varieties of cancer. Finally, it ulcerates, and the
ulceration is peculiar, consisting of elevated papillae.
I think that, with the exception of the head of the penis, there
is no more setsitive structure of the human body, than is the lip.
I am now going to cut out tile side of this lip, and the question is,
what structures do I expect to go through. The lips are formed
of mucus membrane, and chiefly of the muscle called the orbicularis oris, to which muscle is attached a great many other muscles.
For instance we have the anguli oris, the levator menti, the zygomatic major and zygomatic minor, the buccinator or trumpeter's
muscle.  These are all more or less blended with the orbicularis
oris, and all assist in the free play of the lips, moving them in
many ways.  By the lips we mould speech; we use wind instruments, we talk, we sing.  They perform  various functions. If it
were not for the lips we would never be able to give sweet kisses
-and that is a very important function-necessary sometimes to
be performed, but always better in private than in public; be,
sure, hoewever, that you have a proper subject to operate upon.



OPERATION FOR EPITHELIOMA.                   23
We have also in the lips the coronary arteries, which are
branches of the facial. The facial artery comes up in this direction, crosses diagonally an(d divides into two-the superior and
inferior coronary; and it is this inferior coronary artery which
will be cut across in this operation.
In removing epithelioma, it is very necessary that you cut out
enough of the structure; and it is really quite remarkable how
much can be removed. and how good an operation can be made by
taking out a large quantity of' the lip. Those who were here at
the last year's clinics will recollect that nearly the whole of the
chin was taken off at one operation.  I expect a patient here today from whom I removed the whole integument of the chin in
extirpating a large mark which the girl had since her birth.
Her mother was frightened by seeing a mouse, and when she was
born she had on her chin an oblong, black spot, full of hairs,
which resembled exactly the back of a mouse. It was taken
out, leaving the vermillion border of the lip intact.  It extended
around the chin and covered so much of the surface that when
the lips of the wound were drawvn together the centre of the
lips almost touched the nose; but nature has belhaved so well to
the surrounding structures that the lip has come down in such a
manner that you can now scarcely see any deformity.
Here is a specimen showing the position of the muscles we shall
have to cut through.  HIere you see the orbicularis oris, the zygomatic major and minor, the labii inferiororis and the anali oris
muscles; and here you see the arteries —the facial coming up on
this side, winding around the jaw and dividing into the superior
and inferior coronary.
The first incision that I shall make in this case is the one nearest the medial line. There is a good deal of hemorrhage about this
operation. You see how the artery spurts. I will now make an
incision directly down in this waiy.  These arteries do not generally require ligation. If you do not twist them the blee(lin  ceases
when the cut surfaces are approximated. You can make very
nice, clean work of this. It is important that these sutures
should be taken down very deep. I shall take the stitch nearly
a quarter of an inch back, and bring it out like thzat. Then draw
up the lip as nearly as you can.
We will now apply one part of calendula to four of
water. Keep it on for about two days, and remove the lint the



CASE OF CICATRICES.                   25
hand, there is an antagonism between these muscles-if one set of
them seems to have a tendency to draw the column to one side,
then we have as the result, a lateral curvature of the spine. If the
disease attacks the bodies of the vertebrre, and extends itself to the
intervertebral substance, then there is a tendency in the front part
of the vertebra to drop down, and the spinous processes push
directly backward. This deformity is called Potts' disease of the
spine, or, angular curvature of the spine. It arises chiefly
from  a carious condition of the bodies of the vertebrae, wherever you find it, and is accompanied in a great many instances by
disorder of digestion. We find it chiefly in children having
light hair and blue eyes, and a tendency to an enlargement of the
glands-in other words, in scrofulous children generally.
On looking at the back of this child, as you now see it, you
would scarcely detect anything out of the way, but if you take a
profile view of it you can plainly detect the curvature.
The mother states that when the child was seven or eight months
old she fell down some steps, and ever since that time has had a
tendency to carry her head sideways.
There is one peculiarity about angular curvature of the
spine which I wish to mention; it is, that in the majority of instances you can trace it to some injury received in years gone by,
but that if the child grows, and the general health is sustained,
the disease is likely to be cured, leaving, however, some deformity.
The object of the splint which I now apply is to lift the
weight from the superincumbent part-from the sore, inflamed,
irritable vertebrae. There are two pads attached to it, which
make a pressure on each side of the column. This splint must
be worn night and day.
The next case is
SussN CHRINE, Aged Seven.
(The mother states that nearly seven years ago the child was
burned on the cheek by the side of the eye).
This is a very peculiar case. This sore has for some time been
suppurating and discharging, occasionally healing over and then
gathering again.  There are certain  varieties of inflammatory
action which seem  to undermine the tissues from  place to



26              TREATMENT OF CICATRICES.
place-in fact, to have a disposition  to spread by reason of
contiguity of surface.  Here was an unhealthy action which
began with a burn. Inflammatory action went on in one direction  and the process of repair  went on with it in another.
Inflammation covers not only the process of repair, but it covers
the process of disintegration, and even the death of the part.
At the same time that the pus is forming, there may be a reparative process going on in the same structure.  We find this same
thing in that variety of ulcers which are called serpiginous
ulcers. They seem to extend in a circle, and as fast ns one part
heals another is destroyed. Now, the question is, what is the
best remedy to apply?
(The mother states that the child has taken no medicine).
There is no medicine that acts on cicatrices so well as silicea.  Wherever and whenever, under any circumstances, you
can apply the appropriate homceopathic medicines for surgical
disease and cure your patient according to the homceopathic law, it
is better than operative interference; true, it does not make such
a brilliant appearance but it is better surgery, and it redounds
more to the credit of the school than using the knife.
Give this remedy of the 30th dilution three times per day.



28     CASE OF ULCER, INFLAMMATION, CONGESTION.
hot and cold water. On the 12th day of November he sent for Dr.
H., who is a physician, seventy-two years of age, and has been
practicing homeeopathy for twenty-five years and allopathy for the
same time. He immediately told him  that he thought it was
a constitutional sore, and to adopt constitutional treatment, and
to apply arnica and water. For ten days, up to the 22d of November, the sore became worse, the black and blue spot began to
suppurate and to bleed. Around and about the bottom of the ulcer
three, or four, or five vesicles made their appearance. Then the
doctor made a solution of nitrate of silver (he had practiced a
good deal in the country., and he always carried a stick in his
pocket); applied it around the sore and upon its sutrface; it pained
a great deal when the solution was applied. The ulceration then appeared to be stationary, the slough was apparently separating from
the centre, anmd a yellowish pus was being discharged. But the
patient became dissatisfied, and, through some outside influence,
called in another surgeon. About the 1st day of January this other
surgeon called, and what he did I don't know; I know the ulcer
was discharging around the edges, and carbolic acid was applied, and the secretion was immediately arrested; the sore grew
worse, and  went on  enlarging from  the 1st of September
to the 7th day of April, when the leg was amputated above
the knee. The patient then sues Dr. H. for ten thousand dollars
damages; stating that it was the application of the nitrate of silver
that brought about the condition which resulted in amputation of
the leg. All manner of questions were put to me on my crossexamination, many of them foolish in the extreme, and having
no bearing whatever upon the case, which, however, terminated
favorably for our side.
Q. What is inflammation?
A. Inflammation, when fully established, consists in an engorgement of the capillary vessels, dependent on their diminished action,
and the relaxed condition of their coats, together with more or less
accelerated motion of the heart and arteries. From such an abnormal condition arise the well known characteristic symptoms-pain,
heat, swelling and redness.'(Dolor, calor, tumor, rubor.)
Q. What is congestion?
A. Congestion is the preternatural increase of blood in tle capillary vessels, or excessive local fulness of the small blood vesselsan unnatural accumulation of blood in any part of the body, or
any subordinate system.



CASE OF TRAUMATIC PARALYSIS-TREATMENT.              29
Q. What is suppuration?
A. Suppuration is a pure process of luxuriation, by means of which
superfluous parts are produced, which do not acquire that degree
of consolidation, or 1permanent connection with one another, and
with the neighboring parts which is necessary for the existence of
the body. Pus is not the dissolving, but the dissolved, i. e., transformed tissue. A part becomes soft and liquifies while suppurating, but it is not the pus which occasions this softening, on the
contrary, it is the pus which is produced as the result of the proliferation of the tissues.
Q. Suppose a part to be suppurating, and something is applied to
that part which suddenly checks the formation of pus, is that a good
or bad sign?  Bad; it drives the pus into the blood. Any sudden
check of suppuration, set it down as a rule, is bad.
PETER CARTER, Aged Twenty-four.
This man fell and injured the musculo-spiral nerve, so he has
no use of his armn
Q. Have you applied electricity?  A. Yes.
Q. How many times have you taken electricity? A. Three
times a week.
Q. For how long a time? A. From ten minutes to a quarter of
an hour.
Q. Did you hlave any feeling as the current passed down the
arm? A. Yes, sir.
Q. Do you feel it any more now than you did when it was first
applied? A. Yes.
Q. Do you have any numbness in your hands? Yes, sir.
Q. Does that sensation of numbness increase or diminish? A.
It is about the same.
Q. Are you sensitive to the cold-can you feel cold and heat?
A. Yes, sir.
The sensory nerves appear all right; he has a good appetite.
He has been taking Rhus Toxicodendron three times a day
This man has also a large red spot on his left leg. There appears to be fluctuation in the tissue, but whether there is pus
in it, or whether it is serum, it is pretty hard to detect. I have



30                   CASE OF SCIRRHTUS.
a notion it is serum. I believe that should the parts be opened
Kwith an incision, probably it woul~d be a long time before the
wound would heal.  Ile should be allowed to keep himself quiet,
arnd elevate the foot and keep it bandaged.  The idea is to
prevent local congestion.  The part may be either strapped or it
may be bandaged.  I think I will strap it; I will show  you how
to strap a sore. In applying plaster it is always necessary that
it should be put on as smoothly as possible, an(l that each strap of
plaster should be drawn uniformly tight; if you put on one strap
tolerably tight-, and the next one a little tighter, the one below loses
its efficacy —it rufls up. Now, this strapping is very excellent
treatment in certain classes of indolent ulcer where the limb needs
a great deal of support; it equalizes the circulation. In the first
place, let me tell you about straps.  In order to put straps on
properly you must have the part shaved. You saw me try to put
some straps upon a man who lhad his beard on, and the result was
that there was no support to the part, and the wound separated.
Where there is bristly hair, such as you have on the recently
shaved chin, the straps stick like the mischief, and give a great
deal of pain when removed. In the first place, to cover that sore
it must be perfectly dry.  I will take the strap this way and let it
go all the way over. I then reverse the manner of -application and
begin on the other side, allowing one strap to cross the other at
the centre of the sore.  The idea is to put them on alternately and
nake them come in a line.
BRIDGET MCNALLY.
Thic woman carne to us with a cancer in her breast, and I cut
it out. She had it removed with the expectation of getting married.
To the patient:
Q. Did you go and do it? A. No, sir.
Q. You have been a great deal better, haven't you, Jane    A.
Yes, sir.
That wound looks very well; there is no indication of a return
of the disease.  From  appearances I should suppose that there
is a ten(lency to abscess, and I think that Hepar would be a very
excellent medicine.  I ill give it to her in the 30th dilution.



CASE OF NECROSIS OF FRONTAL BONE.                31
She looked in a most miserable condition when she came here,
now she seems to be getting better.  Slhe has an axil]ary abscess
and a severe cold.
Q. Can you put your hand to your head'? A. Yes, sir.
Q. Good app)etite? A. Yes, sir.
Q. You were very fond of a little drink once in a while, were
you not?  A. Oh, very fond, indeed.
JOHN A. POWERS.
JOhN A. POWERS, see page 9, arm. It has been two weeks
to-dtly since he was here.  Now  let me see the other hand,
one is about as dirty as the other. I will move his hand; now
put it out straight again; touch your hlead with it; now turn it
over this way, now back. There is nothing so grateful to a
patient with a broken arm as good bathing after taking the bandages off. rThe arm is doing well.
ROBERT DAILY, Aged Tweenryfive.
Q. Whlat is your name?  A. Robert Daily.
Q. How ol(l are you?  A. Twventy-five years old.
This is:nll affection of the forehead, which has been troublesome
since April, and was caused by being kicked by a horse.  A Dr.
Moore opened it.
Q. Did any spiculve of bone come out? A. No, sir.
Q. Have you been anywhere else for treatment?  A. No, sir.
There is a peculiar appearance about a wound from  which
a piece of bone comes out, or where there is a sequestrum; the
parts are puckered; seems to protrude.  The appearance is like
an unhealthy granulation, and there is puckering around it. This
bone is exposed, I can feel it distinctly; but it is not loose, there
appears to be a small piece of bone that wants to come out. (To
the patient.) I will pull that out for you.
Necrosis bears the same relation to the osseous system that mor



32     TREATMENT FOR NECROSIS, EPITHELIOMA.
tification does to the soft parts. Caries is an ulceration; Necrosis
is the death of the bone. What is the difference between ulceration andl mortification? The difference between ulceration and
mortification is this-that in the ulcerative process there is no
regular death en masse, but in mortification there is. It is astonishing how small a piece of diseased bone will give rise to extensive suppuration; a small piece of bone underneath the skin
may give rise to a great deal of inflammatory action. I shall take
hold of that bone once more; I think it is not large, but it is fast.
I find that is firmly attached. It would be a wrong process to take
a larger pair of forceps and remove it. You must go home and have
the part poulticed. I will give him silicea 30th, which he will
take three times a day, and I think that by next Saturday the
bone will be loose, and can be removed. Until the bone comes
away there will be no us- in attempting to cure the wound. I pull
it with all my might, but it does not move.  He is to use simply
a bread and milk poultice.
PATRICK MURPHY, Aged Eighty-five.
(Continued from page 19.)
You all saw on Monday afternoon this patient was in a most
excellent condition, and the reason that I removed the pins on
this day, which is rather sooner than it is usually done, wvas
because there was beginning suppuration about the pins, and
the threads were beginning to cut through. Whenever that
happens, it is always a rule to extract the pins. We put on a
strap, but that did not hold, because he had not been shaved.
Then Dr. Boynton and others in charge of it applied silver
sutures. Here is a man eighty-five years of age, and he comes
here and has his cancer cut out because he wants to live.  Life
is sweet to all of us.
Q. Do you feel better? A. Yes, sir.
Q. I-low old are you now? A. 85 years.
Q. Where were you born? A. In Ireland.



A. H. B., Aged Nineteen.
Q. What is your name? A. H. B.
Q. How old are you?  A. Nineteen.
This young gentleman has had, since he was eight years old,
Tonsillitis, or Cynanche Tonsillaris.
This term denotes an inflammatory affection of the fauces, chiefly
resident in and around the tonsils. It is ordinarily the result of
atmospheric exposure, and is characterized by swelling and redness of the back part of the throat, accompanied with difficulty
of swallowing, impeded respiration, difficult articulation, marked
alteration of the voice, fever and other ordinary constitutional
accompaniments, according to the intensity of the inflammatory:action.  In the acute form suppuration often results, and we have
Quinsy. In other instances, as the present, the disease is chronic,
and the tonsils remain enlarged.
Q. Have you done much for this affection? A. Yes, sir.
Q. Taken a good deal of medicine? A. Yes, sir.
Q. Do you know what medicines you have taken, or who has prescribed for you? A. My father.
Q. He is a physician? A. Yes, sir.
You have taken, perhaps, all the homlcepathic remedies, and it
is a question now, what shall we do in the case? Here is a gentleman who has been under the treatment of a skilful physician,
and still he is no better.
The tonsils (tonsille, amygdalae) are two prominent bodies,
which occupy the recesses formed, one on each side of the fauces,
between the anterior and posterior palatine arches.
They are usually about eight lines in length, and four in width
and thickness, but they vary much in size in different individuals.
The outer side of the tonsil is connected with the inner surface
of the superior constrictor of the pharynx, and approaches very
near to the internal carotid artery.  Its inner surface, projecting
into the fauces between the palatine arches, presents from twelve
tofifteen orifices, which give it a perforated appearance.  These
orifices lead into recesses in the substance of the tonsil, from which
other and smaller orifices conduct still deeper into numerous compound crypts or follicles, the whole being lined with continuations
3



CASE OF INDOLENT ULCER TREATMENT.                35
lime is kept on hand. When an application is to be made to the
tonsils, a little of the powder is put into a small porcelatin cup, a
few drops of absolute alcohol, which is kept near at hand, are
ad(ded, the two are carefully mixed with a glass rod, when the
paste is ready for use. The patient must be placed in a good light,
a tongue depressor used, and the paste applied and allowed to remain for several seconds, until an eschar be produced. Then the
paste is washed off and the parts allowed to slough, when the
paste must again be applied. Care must be taken that the paste
is applied only to affected parts. It is likely, if too much is
placed upon the rod, that some of it will drop off, which causes
great excoriation.
Dr. Morrell Mackenzie, of London, reports 200 cases in his own
practice which he has absolutely cured. I think we will apply
this preparation to this patient about once every three days.
Note.-The treatment was carried on for some time; and during the vacation at
Christmas the outside of each tonsil was shaved off-a perfect recovery followed.
JANE R. S., Aged 38.
There have been many classifications of ulcers attempted from
time to time, and I think these may be simplified by dividing them
into the simple, the indolent and the irritable ulcer. In the latter
we generally have the symptoms which indicate a vitiated state of
the constitution and disorders of digestion. We find the irritable
sore in the upper ranks of society, among high livers, club men,
men who dine out as a business, drink a great deal of wine and eat
highly seasoned food. The edges of this sore are jagged, undermined and serrated.  The face of the ulcer is uneven and wormeaten, the discharge is unhealthy, thin and sanious, the granulations
are flabby and bleed easily, the blood being of a dark grumous
color.
The medicines that have proved most effectual in removing this
form of ulcer are arsen., asaf., carbo-veg., lye., hepar, merc.-sol.,
nit.-acid, silic., mez., con., sulph., thuja, staphys.
Gentlemen, look at this sore. You perceive the edges are elevated and smooth, not serrated, as in the form I have just shown



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 weze 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 operations like this, and in the operation for hare lip, the silk is oftentimes 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 precaution 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 beard as it is, as it is now four or
five days since lie 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 surface 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 R. 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 epidemics 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 interesting 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 puffing 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 diameter of the vessel. In other words, an aneurism is an enlargement
of an artery-either spherical or longitudinal-and presents peculiar and unmistakable signs, such as the pulsation, which pulsation 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 simultaneous 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 atheroma, which is a softening or deterioration of the internal coats of
the artery.
The patient states that his attention was first called to the swelling 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 formerly; he had been working with a derrick, but does not recol



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 disease-whethler 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 firacture; 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 constitution 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 improvements which belong to the mechanical appliances in surgery, it
is just as important, and even more so, that you should understand the application of those medicines which, properly administered, 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 object is to support the upper part of the trunk and keep the
weight from resting on the diseased vertebra. The internal administration of medicine is of great importance. In the investigation we have to be guided as much by constitutional peculiarities, 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 patients because of youth, may
be unable to answer. There are some medicines, such as petroleum, phosphate of lime, phosphorus,, iodine, calcarea-carb., sulphur, mezerium, which may be used to advantage, but I have
seen more good results from the use of phosphate of lime, and



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 nobody 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 himself 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 permission 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 examined 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 fills 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 boy 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 continued 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 your 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 condition will go on until an abscess forms somewhere. The peculiarities 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, andl 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 tendency 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 honoeopathic 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 nervous system.
ELIZA THOMAS, 4 Years Old.
(The mother states that the child has been suffering from prolapsus 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 wras then carefully returned.)  When I get it in place I insert 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,?2ux 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.



flu~lroa OXinkOi of OJmber 7th, 1874.
(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
aneurisin 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
Rogers, of the United States, some years ago.  His patient
did not survive. Takino into conisideration the anatomical situation and the disastrous results that arise from cutting off so large a
supply of blood, you will see what a hazardous, difficult and dangerous 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 statistics.
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 anesthetic, and
lies down  on the table and surrenders himself to the sur



50        OPERATION FOR SUBCLAVIAN i ANEURISM.
say, if, after having employed all the means in our power, the tumor
increases, I will tie the subelavian; 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 subclavian 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 excruciating 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,        F-Larynx,
B-Subclavian,        G-Hyoid Bone,
C-Common Carotid,    H-External Carotid,
D —Vertebral,        — Subclavian Aneurism,
E-Trachea,           J-Carotid Aneulism.



A. X., Aged Twenty-three Years.
The first patient that I shall introduce to your notice this
morning is a case of phymosis, and a very bad case, too.
Phymosis is congenital or acquired. Congenital phymosis is
that variety in which at birth the prepuce is elongated. When it
is acquired it comes from preternatural causes. This man stated
to me that he had never been able to draw his prepuce backward
any further than one-eighth of an inch (illustrating), and that
lately he has had a very severe inflammation of the glans penis,
and that then there was some discharge of foetid matter, and that
since he has been unable to draw back the fore-skin at all. Now,
in order to prevent fresh inflammatory action and adhesion of the
under surface of the prepuce and the upper surface of the glans,
I propose to circumcise him this morning. I can simply slit the
prepuce with the scissors; it is a very easy operation, but it does
not make as nice a cure. A man does not enjoy the appearance
of a slit prepuce. In this instance I shall cut off the projecting
part of his fore-skin; you will find, then, that there will be an exposure of the mucous membrane. I shall snip it at four corners
and turn it over and stitch it. This is a pretty thick prepuce and
we will have a little more hemorrhage than usual.
Now, you see, I hold the prepuce forward in that manner, and
the glans away from it; then I take a knife and shave it off at
the top. There is the mucous membrane; the skin is off; the
mucous membrane is not touched yet.
Now we divide this and turn it up on end; I shall then trim it
down on one side, and take the other end off by paring it upward.
Then I make nicks in it in four places around, as I shall show
you when I get through, and loosen it, thus making a kind of
flap or curtain; we just put a stitch in each one of these and the
operation is finished.
There are many different kinds of operations proposed for the.
relief of phymosis, but this will make the nicest cure, because we
have the mucous membrane turned over. It is very important
in these operations that you remove enough of the mucous membrane, because, if you do not, you will have contraction; unless



CASE OF SYNOVITIS-TREATMENT.              53
Sometimes, in operating for phymosis,we remove the stitches a
little too soon, from some irritation in the system or from some
other cause, an inflammatory action is set up in the lips of
the wound, between the mucous membrane and the skin, and
unhealthy granulations and fungoid growths appear, which give
a great deal of trouble. Therefore, it is well not to remove these
stitches for at least a week.
JOSEPHINE LYON, Aged Five Years.
History of Case. —Here is a lame leg; a sore appeared upon
the ankle, and the mother put something upon it to draw it;
then pus oozed from it; it has been discharging pus and serum;
the probe goes into the joint; her physician had given her silicea,
but there has been no change in her condition; the patient walks on
the affected foot; the attending physician had not seen her father
before her appearance in,the lecture room, a little boy having
come with her every time.
Prof. Helhnuth said: This is a case of synovitis-inflammation
of the synovial membrane, which lines the cavity of the joint,
and this membrane is liable to inflammatory action. We generally find that synovitis comes from an accident, or a bruise,
or an injury of some kind. This child, her father says, turned
her foot, which is a very common cause of synovitis in children.
There is no disease that seems to be more curable by proper internal administration of medicine than this one. The trouble is,
that the child walks too much. Every time she places her foot
down the weight of her body falls on the diseased membrane,
and when she moves it friction results. Therefore, I say that
perfect rest, combined with the internal administration of proper
medicines, should be used immediately and c*ontinued.  Dr.
Thompson has had her in charge two or three mlonths, and the
treatment has been most judicious, but she will not get better unless she is kept still. She will continue with the, medicine she
has been taking, and come here again in three weeks.
Synovitis is generally curable, provided a certain amount of rest
is obtained-but if, on the other hand, the inflammation is allowed
to extend to the cartilages, we have a very serious disease,



54        CASE OF' AND OPERATION FOR EPULIS.
viz., an ulceration, which it is a very difficult matter to cure. The
cartilages are supplied with blood from tufts of vessels lying upon
them, and friction after bruising is liable to produce inflammation,
therefore it is, that rest is necessary, if you wish to restore the part
to its original integrity.  The pressure and friction which belong
to motion have a tendency to keep up the irritation of these articular cartilages.
JOHN BOWDEN, Aged Eighty-four Years.
_Iistory of case.-Health pretty good; swelling in the mouth,
growing apparently from the gum.
After an examination, Prof. Helmuth said: Here we have a
fibroid tumor or fibroid growth, properly so called; it is generally pedunculated and not sessile. A sessile growth is flat and
broad. This is a fibroid tumor of the gum, which is called epulis;
it bears a strong resemblance in its forms to myeloid growths, or
that variety of tumor known as a myeloid tumor, and which, also,
generally springs from the surface of the bone. As you see, these
tumors can generally be handled with very little pain to the
patient, and they can easily be removed by scraping to the
bone. I shall take a pair of scissors and cut this off, and if
the bone is diseased I shall scrape it.  It will not take long to
excise it.  Or, we may put a ligature about it and let it slough
off. I think it is better to cut it off and then apply nitric acid.
This variety of growth solnetimes attains great magnitude; sometimes they not only involve the gum itself, but they extend into
the face and cause the eye to protrude, and sometimes take away
a portion of the bone. It is pretty difficult, in the earlier stages
of these epuli, to distinguish between them and a myeloid formation, which is more cancerous in its nature. This has been growing about a year. Epulis is very likely to grow from the socket
of tooth, and it often appears on the alveolar process. It is a
disease generally of middle life, although we some times find it in
the aged. In this case there is a broken tooth, from which there
arises a certain amount of irritation, and from that irritation the
fibrous growth rapidly increases. (The tumor was cut off and the
bone scraped.)



MIss VAN HoUrGHTON, Aged Twenty Years.
Prof. Helmuth said: Through the kindness of Dr. Houghton I
have a very important case to show you, which I shall take notice
of quite at length.
We have every reason, gentlemen, to feel proud of our clinics,
and to feel thankful to those of the profession who interest them-:selves in our behalf. The fdur cases that will constitute this clinic
are all interesting; some of them, indeed, not often encountered.
Aneurism of the subclavian, phymosis, epulis, and cleft palate
furnish sufficient material for a course of lectures. I must, therefore, be brief and practical in my remarks.
Perhaps there is no subject which has interested the attention of
surgeons much more than this, of cleft palate. It may seem a very
simple thing, whereas it is a subject of a very great deal of impor-tanlce. The difficulties that surround it are numerous. We have
not only the miserable condition of the patient, but we have also
-the uncertainty of the means of relief; as well as the fact that, after
these operations, the condition of the patient is not always improved.
We will look at this lady, as I will have her go round and
show you the cleft palate, and then I will call attention to the anatomny of the parts and to the different practices recommended for
its cure.
The patient was here introduced.
You will recollect that the hard palate is used not only in
deglutition but in enunciation.  Both the hard and the soft
palate not only serve as a fulcrum for deglutition, but mould
the sounds that come from the larynx and give them sweetness
of tone and reverberation.  The first sound of G, as in "go," is
always hard to articulate with a cleft palate, simply because there
is no fulcrum upon which the tongue can rest, as you will see
in this case, although this is an imperfect cleft. If we examine a
fcetus at the sixth week the whole cavity of the mouth, the cavity
of the nose, and the cavity of the pharynx is one vacuum. At the
end of a few weeks more, there seems to grow from the margin of
this cavity a membranous partition, which divides the nares above
from the mouth below. Then fiom this lembranous formation a



CLEFT PALATE.                     57
I have drawn on the blackboard a couple of diagrams in order to
let you see as nearly as I can the relation of the parts; I have
endeavored to show here a view of the bones looking from behind,
as if the head were sawn off directly at the posterior nares. (Explains diagram.)  Arising from the under surface of the eustachian tube and from  the apex of the basilar surface of the
petrous portion of the temporal, we have a mass of muscular fibres
that come -down and pass above the superior constrictor, thus
forming that portion of the soft palate. The apex of the petrous
portion of the temporal bone being a fixed point, you will see,
when deglutition takes place, the action of this muscle is to draw
up the palate, therefore it has its name, the levator or elevator of
the palate. On the other side, I have endeavored to give you the
two muscles-one the tensor pcalati, and the other the levator palati just mentioned. The tensor palati is a small muscle which
lies outside the preceding and is attached to the base of the internal pterygoid plate, and winds around underneath the hamular
process, and has a tendency to draw the muscle tight. (Explains
the diagram.) Now,' you see, these all being fixed points, whenever the act of deglutition takes place, as you swallow, the palate
is drawn up. There are two other muscles which I will show you
directly. Look now at the patient; when she makes an effort to
swallow, you see the two sides of the cleft come together. I would
like to ask you how it comes, that, with the tensor palati to lift
them up, and the circumflex palati to pull them apart, that,.
when she swallows, instead of separating, the clefts come together especially when we have the palato pharyngeus and theD)alato glossus muscles having a tendency also to draw the parts.
downward and outward. These dots represent the fixed points to
which these muscles act when they contact in unison.
I will tell you why-and the observation that I am  about
to make had eluded the most accurate observation of most
distinguished surgeons of the times, until Sir William Fergusson
discovered the reason. It was strange that Roux, Warren, and
Velpeau, and those men who carefully examined into this subject, liever seemed to arrive at the cause of this peculiarity.
The reason is this: you have all seen a horse put down his head
to drink at a trough, and you have seen, as he drinks, his oesophagus contracting from above until the water gets down. Now,there
are three muscles, circular muscles, that enter into the construction



58                     CLEFT PALATE.
of the pharynx, and the superior one of these is termed the superior constrictor. (Illustrating.) Let that represent the basilar
process of the occipital bone, and let this represent the larynx,
which is cut open from behind; and that represent the posterior
nares, and this represent the palatine muscles; here we have the
levator palati, the tensor palati, the palato pharyngeus which come
down on the pharynx.  These muscles are all associated above
with this muscle which is cut open, and which is the superior con-,strictor of the pharynx. These muscles all being connected with
the last named, when swallowing begins to take place the
edges of the cleft come together from the action of the superior,constrictor.
I have entered a little minutely into this description of the
anatomy of cleft palate, because, after the cleft is closed, these
muscles, the tensor palati, the levator palati, the palato glossns,
ana the palato pharyngeus then act in unison, as they ought to have
done, and the tendency is to stretch the palate apart. Therefore,
it is necesaary to divide the levator to avoid traction upon the
sutures.
There are five varieties of cleft palate.  The first, when there
is a cleft on each side of the nostril, through the hard and soft
palate, associated with hare-lip. This is the most severe variety.'There are two clefts, one, generally in each nostril; you never, or
very rarely, see a cleft in the centre.'If the intermlaxillary bones
are only partially formed, you will often find there is a protrusion
in the centre of the cleft.
The second variety, is where there is a single cleft through the
alveolar process, extending backward through the palate process
of the superior maxillary and palate bones, and also through the
soft palate.
Then we have the third variety, in which the front of the mouth
is all right and the parts intact, but there is a cleft extending
through from the posterior portion of the alveolar process back
through the entire palate, hard and soft.
The next variety is that which we now have under consideration, when but half of the bony palate is involved, and the entire
soft palate.
The last variety is that in which the soft palate alone is involved.
Fortlhe relief of these deformities a great deal can be done. Five



STAPHYLORAPHY.                     59
or six years ago it was considered almost impossible to close a
cleft palate in a young subject, and many times I have suggested
that patients be taken away and postpone the operation until they
attain their growth. But late observations have convinced many
surgeons that early operations are rather preferable than those that
are deferred; because, if you have to deal with an entire cleft
palate, where the bony surface of the palate is involved, in early age,
the bones are not ossified, and there is not so much deposit of
calcareous matter; they yield readily, and, since chloroform can be
given, such operations are preferable. It formerly was supposed
that you could give no chloroform or ether in this operation, on
account of blood dropping down into the throat, but it has been
proved that anaesthetics may be administered and restoration of
the palates of young children may be effected.
The operations for cleft palate are performed with knives with
long handles, and the patient must be able to tolerate a foreign
substance in the mouth for a considerable time, and it is well to
educate them in that regard. Then the first step is to pare the
edges of the cleft. You take hold of one side with long forceps
and with a knife, generally bent at right angles, you shave off the
margin; then you seize one of the margins and draw it out,
and you pass your knife through, inward and upward, and divide
the body of the levator palati muscle. You can feel the process
in the back of your own mouths if you try, and if you enter the
knife a little anterior to the second molar tooth, in the upper
jaw, and pass it upward and inward until its point appears in
the cleft by moving the handle upward and downward,
you will make a very little incision in the mucous membrane
and you will divide the levator palati almost completely. Then
it is necessary, in a majority of instances, with a pair of blunt
scissors to divide the posterior and anterior arches of the
pharynx. You will see how this will relax the edges of the
cleft and how they will drop down. Then stitches should be
applied. In an extensive cleft of the palate, you must never
try to close the hard and soft palates with one operation. In the
first place, it is exceedingly tedious; second, the patient is wearied;
and in tile third place, the parts have not become accustomed to
the traction, and thereby may readily tear out. When you close
the hard palate and you find that you cannot bring the edges
of the parts in apposition, then you must take a long knife with a



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 experienced 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
a great deal of difference. You know if inflammation extends
within the joint, after a tinle suppuration results, and abscesses
open in different parts of the thigh, sometimes above and sometimes 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 prominent by an attempt at motion, even if there is apparently no motion of the joint itself, then you may be sure you have false anchylosis. 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. Hlie 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 boy 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 different 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.



Mrs. HALL.-Felon on the F'inger.
hfistory of Case.-[This disease appeared without any apparent cause. Does her own work, and has her hands much in
hot soap-suds. At first it had the appearance of a "run around,"
and the skin broke, and there was severe itching and burning,
and the swelling seems now to be extending into the hrm.]
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 unfrequently 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 affectedas 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 established. 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
periosteumn, the pain is more intense. In such a case the incision
must be made early; but if it is above the periosteum, and especially 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 contiguity 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 remote 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 inflammation 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 inflammatory action by means of a poultice. If the inflammation is confined 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 Esmarch's 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 anesthetic, I desire to say a few
words to you about her. We have got through the inflammatory
5



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 Nwe 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
Fwith 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 opposition 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 infllmm:ttion which has been going on-is a communication so awful to her, that it staggers her. When I suggested to this mother that an amputation might be necessary, she at
once rebelled against it. Remembering 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 operation 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 remove 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 homceopathy 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 thoroughly. 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 b )ne may be scraped.
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 dise used b:ne a great rnaiy instruments are
required, particularly if the involucru n semrns to close around the
sequestrum; because then it is not only necessary to use the trephine, 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 portioa 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 bandage, 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 surgical 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 w\ould be proper to use cotton.
In certain forms of suppurating diseases cotton seems to lhave a
certain power over abrasions of the surface.  By applyilng it to
a burn you relieve the pain very much indeed, not only because
of the exclusion of the air from the raw surftlce, 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 Esmarch has
done a good deal towards simplifying tlhem. One of the disadvantages 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 awithheld 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 kga resembles that of a dead person.
I make the first incision-putting the knife in at the tubercle of the tibia and bringing it down to a.n inch above the
ankle. You see that no blood flows. There would be very inconvenient bleeding were it not for this bandage, because the tissues
aIre all congiested, 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. (Removes bone, scrapes it.) Thtis is the piece of bone
that has caused the most of the trouble. The sequestrum is surrounded by an involucrum.  Now I shall scrape the bone. The
discharge is very fcetid and offensive.
There (demonstrating) is the new bone which has been forming
around the ol(3. 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 odce. 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 softened, 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 thie 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 homceopathic 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 medicine I have ever used.
In packing any cavity it is well to recollect one thing-that it is
better to have the substance you wish to pack with in one continuous piece, or else know just how many pieces are used; because
sometimes it is very difficult to remove them, and if you 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, you think
that you can preserve a limb and make a useful member of itenabling 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 instances, 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, you 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 CHRINE, Aged Seven Years.
(Continuedfrom page 25.)
This girl was here four weeks ago. The sore has suppurated
and discharged since then.  This was one of the tendencies to subcutaneous 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.



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. Helm-uth. —Burse sometimes enlarge and inflame and occasion great suffering. We frequently see them about the wrist
joint and on the dorsal tendons of the hand. When an adventitious 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 bursee.  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 ganglion is a most difficult thing to
manage; but the ordinary bursie 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, wve have the diffuse bursa, in
which the fluid extends along the tendons, and gives rise not only
to excruciating agony, but sometimes to the death of the part. A
bursa in this place is frequent with women who do housework.
Resting 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 n'ext
case we have. (The seton was then passed.)



HENRY NICHOL, Aged Sixty-two Years.
Prof Ielmuth.-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 cesophagus 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 embracing 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 suddenly 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 irritabilitv 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



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 sometinies dies from lack of nutrition.
ABRAHAM JONES, About Fjfiy 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. 1Has no pain from it.)
Prof. [Helmuth. —There are several varieties of hernia-the reducible; 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 varietis of hernia, according to the
locality and the nature of the parts protruded, all of which are
important to be known.
rhis man has congenital hernia. The method of reducing hernia by the hand is called taxis. There are a great many methods
of perfbrming 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



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, showing that there is valvular irsufficiency.  He has a thickening of
the pericardium  and an atfection of the arterial system.  Altogether 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 p)rescribed 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 another.  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, Aged Twen ty-nine Years.
Hzstory 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 abscesses broke out in his leg again. HIe received an injury, when thirteen, 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.'Ihen several
places opened and healed-one sore after another-from that time
to this.  Has had no splints on the leg.  Has taken only constitutional remedies, salch 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 spiculke of bone have been discharged.)
Prof Helmnuth. —That fact makes me think that there is more
caries than necrosis, or if the latter, the sequestrum is not detached.
You 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 applied 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 perforation of the ac-tabulum.
You see here two openings on the anterior portion of the abdomen. When, in advanced hip disease, we halve these openinks
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 everything 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.  Hie 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 w 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, however, any such operation is out of the question.



CHEILOPLASTY.                      83
while treating varicose ulcers, and allowed the patient to go about
his business.  After allowing the eschlarotic to remain a few moments wash the parts with vinegar, put on an elastic stocking and
let the patient go. Repeat this every three or four days. Don't
let the paste stay oil 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.
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 anchylosis of the inferior maxillary, an
eversion of the lower lip, and a dreadful cicatrix from previous ulceration,
which probably arose from the injudicious use of mercury. Fig. 1 shows
somewhat the condition of the parts.
The first operation,which was prolonged, 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
Fig. 1.        dissection, all the cicatrices; then,
with a modification of the instrument
of Scultetus, called Westmoreland's, I gradually broke up the adhesions within the joint, and restored partially its movements. She
was then placed in bed, and a glltta percha plate introduced into
the mouth, between the raw surface of the cheek and the jaw, and



HIP JOINT  DISEASE.                       85
markable.  The instrument used in  this case to hold the jaws
apart was Wcstmoreland's.
Plastic operations are those by which raw surfaces are brought
together. The simplest formn 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 darkfinding the key hole with your finger.
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 appearance 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 apparatus made, and that such apparatus would be required before he
could be perfectly cured. The extension ap)paratus is mnade an(l he
is to hiave it to day. The whole aspect of the patient has improved
in tlhree 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.



COLD ABSCESS.                      87
He feels better and stronger in every way. This boy goes to-day
to the instrument maker to thave the splint applied, which will allow
of a certain atnount 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
he bone still remained in the cavity.
14HARRIET ROSSLE, Aged Twelve Years.
HXIAIET 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 HIelmuth.-There is a gland which is called 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 inflammation commences. You will see that this is quite an interesting case. The inflammatory process began at the root of the neck,
and you can see how the matter has burrowed and opened l(ower
down.  On her back she has another abscess forming, which contains 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 )on ful taken
four times every day for three or four weeks. There is no medicine that I know of that possesses such influence over the suppurating processes as Hepar, pirticularly 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
Awith silicea and sulphur, the disease may be radically cured. In
cases like this I want you to bear in mind the importance of constitutional medication; I do not mean constitutional general treatment, as implied by 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 treatment, 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 specifically, 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 way. 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 according to the proper lasw of cure, he is the man who cures his patient;
andl 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 ackqowledge a fict when you see it. It is all
very well to sit down and say, " This is not so;" but the straightforward cnscientious 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."
MICHAEL M., Aged FfRQy 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 examination."]
Piof. 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 eruption. Ile 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:
l'lhere 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 monominania. 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 verv 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



HENRY HEAD, Aged 7Two Years.
Prof. Ielmuth. —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 occurred when the child was four months old; he was twenty months old
when the plaster was applied. Four weeks ago Dr). 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 anlly time, but the thigh moved in all directionsbackward, and forward, and downward; it was very easily reduced 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 successful. 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 dislocation 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 counteracting tendency in the muscles and tendons in reducing dislocations.
This case not only is a beautiful illustration of spontaneous dislocation, 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 adduct it, make rotation, and then
extension.
These manipulations canl 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.
v't*$u$ ro (Of4. it.. s- pz*-    #        o
ELIZABETH GERHARDT, Aged Four Years.
(Continuedfrom 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 accomplished 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 ourselves with medicine.
Then, again, there is another form of splint, which those in better circumstances can procure; it is called "Darrach'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 under his care for two years. He will give you the history of the case.
rWM. WooD, Aged  x       u Year(s.
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 skilful 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. Hie 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 CESOPHAGUS.              95
tells me, slie has heard no complaint from the boy whatever, although 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 intermission 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 S?'xty-two Years.
( Continued from page 74.)
The next case is that bad case of spasmodic stricture of the
cesophagus.
ProJ: Helmuth.-It is two weeks to-day since he was here.
(To the patient)Q. Can you swallow this morning?  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 cocculus the 30th for about two weeks. There is an evident improvement in his condition, and, as I said before, cocculus has a specific
influence on the muscles of the cesophagus 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 interested 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 improvement 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
know too much. Very 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. DIon'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 descriptions 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 friom 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 IM. D., when yoll think
you have passed through the green room and are regularly empowered 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 ini 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 cantlhus of
the eye:  Sometimes these smnall tumors which grow in the neigh



98          OPERATION FOR 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 sometimes very difficult to get out.  (The tumor was dissected out.)
Sebaceous tumors have different kinds of sacs.  In some you
have seen the envelope is very thin; in other instances the sacs
are perfectly firm and hard; and still in other instances they adhere 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 suppose 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 get too inuch science. It is not the most studious physician
who makes the best practitioner. It is an acknowledged and accepted.fact that the most distinguished men in the profession for
their learning, are often the least practical when they come to
tie bedside.
PROF. HELMUTH [To a student of the class]:
Q. Now, sir, ether you say is an anesthetic.  Who introduced
it 1 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 Edinburgh.
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 anesthetized? 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, anld after fasting lie should have, about half an hour



AN1ESTHESIA.                         99
before administering the ether, a stimulus in the shape of brandy,
or about eight to ten grains of bromine of potassa.  Then the
anoesthesia must be carried to insensibility.
Spencer lays it down as a law, and as one of the principles,
that he never pushes anesthesia 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
irmminent, 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 insensibility 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
hllloroform as well as the operation; but if I am practicing with
ether, I am fiee of care, and that is a great deal.



NEURALGIA OF THE STUMP.                  101
painis him all the time, anld lhas for the last two years.  The suffering is worse at night tllan ii 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:
Thlat arm is a very good text for two or three lectures.  In tle
first place, it is a good text to speak from, with reference  to
wlhat is called trlaumatic 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 mortific.altion, it'was necessary,   beoLre anipultatilg, to wait for the
line of demarcation, and that in other cases, it was just the contrary; and when we had traumatic gangrene, which extended
rapidly, and the life of the patiellt was at stake, amputation.should be performed, and thle sooner tile better.  If you will put
yoiur finger on thle end of this stump, yon will feel that the bone
has been sawn off diagonally, that the bone is sharp at that extremity, that the tissues have adhered thereto, and that there hlas
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 froml 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 gangrene 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.
It;f, on tile other hand, we have dry gangrene, then it is wrong to
perform an amputation until the line of demarcation is fillly formed.
In such gangi'ene as this mani had, amputation must be resorted to
within one or two days.  Tlhere may be a primary amputation
performed; but after an amputation, no matter how skillfully
performed, certain untoward results may follow.  For a considerable period of time after an amputation a patient may consider 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 sevene or eighlt years he enjoyed perfectly good health,



102             NEURALGIA OF'rTHE STUMIP.
and but little pain.  Then, two or three years ago, lhe began: to
feel pain and soreness on the under surface of the arm, and then
he referred his suffering 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 fillgers 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 Inedian nerve.  The median
nerve on the under side of the arin is included in this cicatrix,
and therefore ]le will tell you that lie 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 whicil 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 neluralgia of the stump?  If
it is simply idiopathic, and  caused by the  division of the
nerves alone-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 Marolis 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 Ilahnemann in Paris, and by him was cured of the neuralgia by internal mledication.  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 which was cured by the use of a medicine
but little known.
I was called across the river to see a man suffering from  neuralgria of the stump. He had recovered from a thigh amputation;
the stump had healed, and seemed sounId, 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.j
zinc, hydrochlorate of amm, morphia, and others of that class of
medicines which act upon the nervous system, and which, according 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 many doctors,
of all schools, and had given himself up as a hopeless case. He
was a great smoker, and as he stooped one day 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 immediately 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 hlie would try the tincture of allium cepa; and lie 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 well to recollect it.
With respect to the patieint before us, it would seem that we
must do something to prevent further contraction of that cicatrix.
We will give himi some internal medicine, and apply a lotion to
the stump. If that does not do, and the pain becomes aggravating, 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 we.eks: the tincture of allium
cepa, five drops, to be taken four times a day in a tablespoonful
of water; 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.



MARIA REED, aged 16 yeas.
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 determnine its position, it would
be high time /ten to cut down and take it ont. 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 ulsatisfactory thing, and very unsuccessful.
KATII PAULDING, aged 3~ years.
Hislory 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 immediately 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 complains a great deal of pain in the knee, and the mother supposed



tIATTIAE ANDREWS, aged 15 year's.
(Continuedfro.  parge 97.)
Dr. THOMPSON says that lie was sent for Oll Sunday  night to
see the patient; found the right eye swollen up and closed, and
suspected erysipelas; the pulse was at 120; and he prescribed
aconite and belladonna.  On Monday night, the eye was still
more swollen.  Forty-eight hours after the operation the inflammation had extended to both eyes. He withdrew the sutures, and
there came away at least two tablespoonsfiul 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 tile 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 remeains an unsightly scar. Therefore make it a
rule, in removing sebaceous tumors, to remove as much as possible 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 important structures, because, if you remove three-fourths of the
cyst, in a majority of cases, the other one-fourth will pass off with
the discharg(e.  In the performance of the operation you must
never injure any other part. That is a law, you must always follow, in whatever operation you perform.



110                QUIZZES ON HERNIA.
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
omentumn 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 pneumnocele? A. Hernia of the thorax.
Q. What is reducible hernia?  A. One in which the protruding 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 protrusion 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 tumnor 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 finger can be introduced 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. HIelmuth said:
Psoas abscess nmay, in rare instances, be mistaken for fernoral
hernia.
But the many presenting symptoms of spinal disease, the slowness and variability of progress, the fluctuation, and the part at
which the abscess points, which, in the majority of cases, is outside of that which hernia protrudes, serve to form the distinctions
necessary for diagnosis.
An enlayrged giand has been mistaken for hernia by most distinguished 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 ON ANEIURtISM, H1EMOSTATICS, AND TETANUS. Ill
-fatalcases of the kind. The absence of cough impulse, the solidity 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 fiom hernia? A. By
absence of cough, impulse, and the non-inplication of the spermatic 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 terfr  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 mnean expansion of the one,
the rupture of the other.
Q. How is the dilatation of aneurism  classified? A. Into
cylindroid, fusiform or sacciforvm.
Q. What is the difference in these three dilatations of aneurism?  A. In cylindroid the expansion is abrupt and uniform.
In fusiform  the enlargement is spindle-shaped.  In sacciformn
the dilatation is partial, and arises from the side of the vessel.
Q. What is hoemostatics?. A. The arrest of bleeding.  It
may be natural or may be artificial.
Q. What do we understand by torsion?  A. Twisting of arteries to arrest bleeding.
Q. What is tetanus?  A. Permanent spasmodic contractions,
or spasm of the voluntary muscles of a portion or nearly the
whole of the body, rendering it stiff and straight.
Q. Iow many kinds of tetanus are there? A. Idiopathic,
produced by exposure to cold; and tranumatic, produced by bodily
injfiries, particularly the injury of a nerve.
Q. What is trismus? A. When the spasm presents itself in
the muscles of the neck, throat, and jaw.
Q. What is episthotonos? 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, tile body being bent oor drawn forward.



112    CASE OF HYPOSPADIA AND' RETAINED TESTICLE.
Q. What is pleurosthotonos?.A. It is when the muscles'of
the side of the body are affected with tetanic spasm.
Q. What is hypospadias? A. When the urethral opening teriminates or exists in the course,of the canal on the lower side of
the penis.
Q. If the urethla terminated on the upper portion of the
penlis, 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 young 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 unsuccessful.  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 operated on by Dr. Tiffany, of Baltimore, but the operation was not
successful.  The opening is now in the perineum.  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, lie 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 rmalformation from birth? A. Yes, sir;
from my birth.
Q. Before yol were operated upon, how  far back in the



COLD ABSCESS.                    113
urethra was the opening through which you passed water?
A. Three and a half inches.
Q. As you came from boyhood to puberty, did you have sexual desire? A. Yes; and rather prematurely.
Q. The scrotum  was well developed before the operation?
A. Not very well. There was some redundancy of tissue. The
testicles never came down.
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? 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?
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.
HENRY PICKETT, Aged Five Years.
Has had a swelling on the lower jaw  for about three weeks.
His mother thinks he has a decayed tooth, but has not complained 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               -CASE 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 department.  There is no surgical disease here.  There is a deficiency in mental development, of brain structure. There is
such a lack of brain and nervous power that the child, although 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 notling 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 prognosis. 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 involuntary act.



ANGULAR  CURVATURE OF THE SPINE.                    1 17
ject 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 I
can say that by  May you  will have him  pretty well cured,
unless he gets a cold; I mean that the abscesses will heal, and
the boy will be comparatively  comfortable.  He will limp a
little for a considerable time.
Angular Auxv^*raxF Atf tot Sbpin**
(Continued from _page 41.)
(No 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 quizzes 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.
]. Hrrmless with reference to the sur-   1. The tumor is apt to destroy or inrounding structures.               volve surrounding structures.
2. Texture bears some resemblance to    2. Texture differs from the nprmal
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. Rarely accompanied by offensive  discharge.
discharges.                          8. Infiltration of the parts on which
8. Non-infiltration of surrounding  they grow, which is often entirely transstructures.                        formed.



118          TUMOR AND ANEURISM QUIZZES.
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 superimposed tissue.
Q. What is the color of n'evus? 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; sometimes 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 gtow? A. Thev are soft, fragile, lobulated 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 fiom 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 ao'ta
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



rtrUiCalt (1Qinit of banaru a     10t1,  18Th.
HARRY PICKARD, Aged five Years.
(Continued from page 11 3.)
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 unattended by the usual symptoms which belong to acute inflammation; 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 general 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 abscessthat is to say, a chronic abscess-when there is a large quantity of
matter involved. There are some pressure symptoms in abscesses, 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 tle 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 where the pressure
symptoms give rise to a great many obscure synmptoms.



GEORGE W. FLEMING,.Aged Thir'ty Years.
The patient, who has brought a card of introduction to me,
states that he has been told that lie 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 discharge 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 symptoms, 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 unpleasantness?  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.
A. Yes; for the last four or five 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
a1ll OW.
Q. Does this discharge pass from you without any excitement?
A. Yes.
Taking the age of the patient into consideration, the probability is against there being a disease of the prostate gland, unless
it lbe 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 HenryThompson 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



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 passive motion with the arm with the utmost care; but I have not succeeded 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 patient 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 without 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
again 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 pts mixed with it. The
suppuration has probably destroyed the sac, and we will apply



130                    PERIOSTITIS.
in men who are over fifty years of age, and who have been addicted 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 pedunculated 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 recommended by some that iodine should be employed locally; and
I will use it in this case.  But, instead of applying the tincture of iodine, which would give her a great deal of pain, I
will prescribe an ointment of the iodide of potash. The prescription is thus written:
"I': Ung. Potas. Iod.  ij."
Spread the ointment on a piece of linen and apply it to the
nose.
BRIDGET DOYLE, Aged Twenty-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. TaHOMPsoN:
This, as you know, is a form of felon-the fourth variety in
which the pus forms under the periosteuin; and in this case the
bone has become diseased. In treating this disease where the



PARALYSIS OF THE CESOPHAGUS,            131
inflammation has affected the deep tissues, and there has been an
effusion of pus under the periosteum, slight incisions do more
harm than good. You must go down into and through the periosteum, 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 hifty-ive Years.
The patient states: I was sent here by Dr. Rushmore, 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 swallowing. 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.



'u# ginti    CliniE  of #anuaj 30th,  1875.
MISS VAN HOUGHTON.
( Continued from page 55.)
PROF. HELMUT H:
Gentlemen: You recollect I presented to you a case of cleft palate early in the session, and you remember I stated at the time,
that this class of cases wad hardly the variety to operate upon
before you, 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 operation was performed with instruments with long handles, such
as you see here. This was the operation: I pared the jedges 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



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 flatways, 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 inlplicated here
PROF. HELMUTH: Oh, yes; I think all the superficial veins of
the fore-arm are involved.
WM. BROWN, Aged Five Years.
PROF. HELMUTH:
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 remove 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, putridblack; 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 ingrowing 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 removed as soon as possible; and we will therefore spray it with
ether and produce local anaesthesia. Before the introduction of
local anesthesia, we often used to freeze portions of the body before operating upon them, and in this way I have removed manytumors. The preparation principally used in those days was ice and



ONYCHIA MALIGNA.                   13 7
salt. Then came ether, and then local anaesthesia, as it is now
used for many surgical operations, such as lancing a felon, the removal 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 removal of nails is very painful, and the trouble arising afterwards
is, that there is a tendency to the formation of unhealthy granulations, 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 composed 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 membrane, 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 unhealthy, 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 CORACO CLAVICULAR LIGAMENT
and elevate each side by tucking under it lead, such as you will
find in tea boxes. Another method was contrived by a dentist, and
is one not generally known. He simply bent a little piece of silver 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.
2rtpiste (of *he (Cor^4ov 114viv*o
I'm(Ca]  ai Z, gamerus*
WILLIAM SPELMAN, Aged Sixty-eight Years.
Q. Where were you born? A. Philadelphia.
Q. Blackberry alley? A. No, sir; at the corner of Sixth
and Lombard streets.
Q. I was your neighbor. Did you know Doctors Helmuth and
Sims? You have come to the right place at last? A. I cannot
raise this arm.
Q. [To the Students.] Are any of you, gentlemen, prepared
to diagnose this case —you who are looking for those glossy
sheepskins? We have been lecturing a good deal of late on shoulder affections, and this will be quite interesting.
Q. [To the Patient.] Now tell me about your trouble. Stand
face to face. Does that hurt you (moving arm upward)? A. It
pains.
Q. Where does it pain you? A. Under my shoulder.
Q. Stand straight-put your elbow on your chest-now put
your harid up here (on opposite shoulder). Ile has now his elbow
down to his chest and his hand on the opposite side. Now we
will see what else is the matter. I will examine his shoulders
firom bellind. There is a little difference in their contour, the uninjured one being a little higher. Put your hand behind you



MOVABLE CARTILAGE.                 141
Q. Does the pain come suddenly? A. No, sir.
Q. Does it catch you?  A. No, sir..
Q. It is hard to the touch? A. No, sir; soft.
Q. Judging from the character of this disease, and from the
manner this tumor appears and disappears, the sudden character
of the pain, and the stiffness of the joint when he attempts
to move, I should say, perhaps, there is a loose cartilage within
the joint. There are in the cavity of the joints, and more especially in the knee-joint, movable cartilages, which wander
from place to place.  They seem to originate from the synovial
membrane by the side of the joint, and are generally attached
to it by a pedicle until some motion of the patient has a
tendency to loosen them, and then they move within
the joint. There is a good deal of surface between several
bones which enter into the formation of the knee, and a cartilage of no very ordinary size-even that of a marble-will move
about from place to place, and give rise to little inconvenience
except when it comes between the condyles of the femur
and the head of the tibia, and pressure is made on it; then the
pain is sudden, and the patient even sinks down. The peculiarity
of these cartilages, when you come to examine them, is simply this:
They bear a close resemblance to healthy cartilage, and perhaps
the same relation as the sesamoid bones to the bony portions,of the body. They seem to be developed in the joint and grow
from the synovial membranes.  They are pedunculated at first,
and afterwards become loose, and fall in the cavity of the jbint.
There are several methods which have been recommended for the
relief of this affection, and I know one case which was cured entirely, or said to be, by the internal use of rhus. I also gave rhus
to a member of the class, a patient, but I don't know that it produced much effect. I know, however, of a patient that was cured
through internal administration of medicine. If drugs do not
effect a cure, the removal of the offending substance may be
effected, by having a strong iron ring made to press down over the
cartilage, and making an incision through the diameter of the ring,
at the same time pressing on the parts and allowing the foreign
substance to pop out; the object being chiefly to prevent air from
entering the joint. We will therefore prescribe for this patient
for the present.



PARTIAL PARALYSIS OF THE (ESOPHAGUS.         143
[Parent.] He goes out every day a couple of hours to stretch
his leg; for exercise.
Continue with the medicine. I desire you to bring him here
once more, about the last of February, and then we don't want:to
see him again until next October. I want you to bring him then,
as I think by that time he will be nearly cured, and I wish to have
him appear before the class.
[To the Students.] One reason that this patient has done so well
is because his parents have taken such an interest in his case.
In nine, out of every ten such cases, no benefit results, because the
treatment is so tedious, and requires such constant watching, that
even parents themselves, become negligent in the bestowal of
proper attention, such as looking after the splint, giving the limb
the requisite amount of rubbing, etc.
SIDNEY FANNING, Aged Ffty-five Years.
( ontinuzedfiron page 131.)
[The patient examined with a Laryngoscope.]
PROF. IIELMUTH:
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 professors 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 Carcinomnatous.  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 perichondrium? 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. Now 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? 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 swallow 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. Very 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. Hie 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 cesophagus contracts in the horse when drinking water, and so it does here. These different fibres of the muscles 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 fSar 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 BRowN, Aged -Fifty-two Years.
Prof. Helmuth.-Tell me about your disease from  the beginning. A. It occurred about three years ago.
Q. This wrist became affected in the winter time? A. Yes, sir,
in ()ctober.
10



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 homceopathic 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 any good.



fUvogical Q11uic of  tebruarp  th, 1875..Dr. J. T. Thompson. —This case of encysted tumor, which you saw
two weeks ago, has had notliing done for it except the application of
strips of adhesive plaster. The sides of the cyst have now 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 removed before it ruptured.
MR. PARKER, Aged Thirty-s'x Years.
Prof. fIelmuth.-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
miaay hear tile history of the case and see the method of treatment.
T~he 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.  He was rendered insensible for twenty-three hours, and does not recollect anything about
it. This large block of ice, coming with such velocity clown the inclined 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 concussion. Now his health is very much better, and the bone is
uniting finely.  I will show you the method  I use for bandaging fractures like this. I first take a square piece of tin, cut



INJURY TO THE CAUDA EQUINA.                  151
Prof. tI-elmuth.-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 who 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,
imperfectl y 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.  Rather 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 manr may belong to, we cannot believe that
he is dishonest when he takes cliarge 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 for granted that the majority
of respectable plhysicians, 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,
tas a general rule, are honest, true hearted men, no matter to what
school they may belong; and if iministers of the gospel would
pay half as much atteiition to the members of their flocks as the
generality of doctors (ldo to their p-atients, then, in the d.ay of judgment, 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 symptons.  There are ceses on record
wh}ere simulate,  hip diseases have been relieved by the excision
of' tile fore skisn, strange as that may appear.  You s:e that the
prepuce of this patient is very much elolngated.  An adhesion has
been formed on the side.
Q. Did this child, when he was four years old, have any fall?
Mrs. Vanider.-Yes; he fell out of his wagon. In going over a
curbstone the wagon tilted and he fell out. I do rinot know where
he struck.  Thlat was between the ages of three and four years.
Hie 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 Helmuth. —My own little boy fell out of a wagon in tile same
way when he was three years old, and he was paralyzed 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.'I'his
child has no hip disease; but he has disease of the canida Pquinln,
or nerves which go down on each side of the spinal mnariow, an(l
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 anythinc  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, na 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 thle present.  Recollect what I told you
about the elongation of the prepuce. Tile first thing, probably,
that I shall do in this case will be to circumcise the patient.
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, an(l I put my hard behind me and fell dirctly
on the wrist. I went back to my hotel, and a gentleman stretched
out lny 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 Helmut/t. —This is a fracture of the lower end of the ulna.



ANEURISM  OF THE AORTA.               155
you and telling his case has given him a little nervous palpitation. 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, because he is a little excited.
I gave this patient i drachm of gallic acid three times per daytihat 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 specific 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 favorable 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.
WILLIAM TOD HELMUTH, M. D.
fiy Dear Doctor-Dr. Cleveland requests me to write you,
giving a statement of Mr. F. F. Coulter's case. IIe was kept on
gallic acid and per sulph. ferri solution, as you advised, until the
first of this month, when, upon careful examinaltion, the heart's
action was found to be perfectly normn:il. 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; hoarseness somewhat better; continued second week digitalis.
I think from his present condition he will make a perfect recovery.
Respectfully,
F. F. FABER, M. D.



(Countinued from page 157.)
STEPHEN O'IIARA, Aged Fifty-four Years,
on whose finger a felon was opened one week ago, returns.
Prof. Helmuth. —In this case we applied fluoric acid in solution (see page 157), and it has done a great deal of good.  Hle 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 treatment 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
t 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 inflammation cannot be arrested, then it is better to accelerate the suppurating process. But in the earlier stages we can, no doubt, prevent
the foraiat!oi 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 formation of pus; but I endeavored to get the knife down to the side
of the bone, and the operation has been a success.
JULIA MURRAY, Aged Forty Years,
(Continued from page 152.)
who was before the class at the last clinic with fracture of the
ulna, returns to have the arm redressed.
Prof: fHel7nuth. —The bone is healing as well as it can. I can



FRACTURE OF LOWER THIRD OF THE ULNA.   161
stance may also be poured out, though in a lesser degree, in the
medullary canal, thus giving support both externally and internally to the fractured ends of the bone. This substance gradually, and in different ways, is transformed into the so called provisional or intermediate callus.
This substance is not bone; but in the deposit around the
fracture, points of bone begin to be deposited, the fibrine poured
out, becoming first cartilage, and then receiving into itself phos.
phate of lime, it becomes bone.  A  similar work is going on
within, in the part called the medullary canal.
Then begins the third stage, which goes to the end of the sixth or
eighth week. During this period the external and the internal
deposits become completely ossified and firm, though the ends of
the bone are not yet grown together.
The fourth stage extends to the end of the fifth and sixth month.
During this time the external or provisional callus becomes covered with a periosteum, and the ends of the bones themselves are
fastened together by a bony deposit.'The fifth stage extends from the fifth or sixth, to the twelfth
month. During this time the ends of the bone become grown
together so strongly that the bony ring or provisional callus is no
longer wanted, and it becomes absorbed and disappears —in other
words, having no further use for it, nature takes off her splint.
The point of fracture is now as strong as any other part.
The union of compound fractures takes place in a different manThe union of compound fractures takes place in a different manner from that of the simple fracture just described. In this case
there is suppuration, and the bones remain disunited several weeks,
and there is no provisional callus formed. But after some time
the ends of the bones soften and granulate; and when the production of pus declines, the granulations are gi adually changed
into bone.
Prof. Helmuth. —To a student of the class:
Q. Can you describe fracture of the lower jaw? A. It generally takes place near the chin. It may occur also near the
angles of the jaw. It may be simple or compound, and is
known by the pain, the swelling, the inability to move the jaw, the
11



162                  INFLAMED ULCER.
indentation felt by the finger, the irregularity of the teeth, and the
grating sensation felt while moving the jaw with the hand placed
on the back fragment.
Q. In a fracture of the lower jaw, what is the best bandage to
be applied? A. The figure 8 bandage.
Q. Who introduced the figure bandage? A. John Rhea Barton
one of the most promising surgeons that the United States ever
knew; and who made himself immortal by the operation for anchylosis of the knee joint, which bears his name.
Q. When suppuration is progressing, does the patient sweat? A.
When suppuration is going on in the body, particularly if there is
any amount of pus forming, there is profuse sweating. This is one
of the symptoms of the disease. Not only is this sweat profuse,
but the character of the coldness and shivering is peculiar, and
appears at regular intervals.  Many a case of suppuration in
malarious localities has been mistaken for intermittent fever. A
chill comes on in the afternoon, followed by fever and profuse
sweat; and these are the symptoms which may lead you astray
when suppuration is about to commence. It is by means of these
symptoms that we diagnose the formation of cold abscesses in obscure places.
SOPHIA BARTLETT, Aged Forty-one Years.
History of the Case.-" I have had this sore on my leg for about
a month. At first there came an inflammation extending about
three or four inches.  Then three or four purple marks came
around it, and it spread rapidly. It br,)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 Dally's salve. rThe
inflammation still kept spreading."
Prof. Helmuth. —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, becaase 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 diffuse 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 ofthe 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 folr weeks- that ulcer could be cured 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 manage, 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 dependent; 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 inflamm:,tion is a simple cold water
application.
She must keep the leg elevated; then take a piece of canton
flannel, or old nmuslin, arnd fold it four times upon itself; dip this
compress in cold water, wring it sufficiently to prevent its dripping, and eavelop the leg threvwith; over that, wrap a piece of dry
canton flannel, and over that, a piece of oiled silk, and tie it on
with three or four 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 banda e to dry. For
the first day or two it will have to be wet two or three times 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 applying 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 constitutional 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 traumatic 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 Thursday 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 fingers. The veins across the shoulders were very much enlarged,



1 66              CONCLUDING REMARKS.
If he was run down like the man Hart, whom you saw, there
would be but little } ope. 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 irritation 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 be 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. Burd;ck, of the obstetrical department, proposes next
wecek 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 obstetrical 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 members 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 cat 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 ourselves, that the facilities in the surgical department of the Homoepathic 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, fistule, and diseases of the nose, I have performed 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, continue my lectures on amputations, and, although I do not make
the attendance at all compulsory, I would like to see as many of
you as possible here, because I have been unavoidably detained
from lecturing on that subject, having so much to teach on aneurism. 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 callel 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. R3collect 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 iwill always readily receive
it from the Nlew York Homoeopathic Medical College. Whether
I am here or not, you may be sure the desired assistance and information will come. But if you disregard your Alma Mater, sometime 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. BURDICK, 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 Report of your 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 Homceopathic Medical College for the labor I have undertaken, save the approval of
yourself and the Faculty.
Yours, very truly,
PHILETUS J. STEPIHENS.



172                 CLINICAL RECORDS.
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. TI. sixteen months ago for
a similar tumor, and was then told that it would return. Previous 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 acon. 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.
fss1lt"a                4 0 b""*tatu"
WVM. DOHN, Aged Four Years.
Talipes equino-varus, operated upon one year ago, but operation rendered fruitless by the patient not wearing the proper
shoe.  Tendo Achillis and tibialis anticus divided subcutaneously, 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 epithelioma, 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 attained the size of a large walnut. Dissected out
entire. The various forms of cystic tumors were mentioned.
se$ assu ins tR. Ane earg
MRS. R., Aged 1%o ty-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.
2su IaOU$s A)40hylvi (Orlee
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. Anchylosis 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 felt on motion; pain worse in
winter. Had taken rhus tox 3, one year ago without effect. Anchylosis from chronic rheumatic arthritis. Operation recommended.
MRS. 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.
Bursae are subject to inflammation, which may terminate in
suppuration, and even  gangrene.  Sometimes bursae 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.  Cantharides collodion continued.



176                 CLINICAL RECORDS.
No improvement since last week. Palm so hard cannot be
blistered by cantharides.  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 forcibly
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 withI: Carbolic acid, 3j.
Sweet Oil, 3 v.
Water, 3 iij.
GRACE BRINKENDAL, Aged Eight Jfonths.
Capillary naevus on forehead; operated on five months ago, but
has returned. Operation performed by placing suture pins through
the tissues under the nrevus in the form of an X, and drawing
tense a ligature under these pins. If nitric acid is applieJ as soon
as the red spots appear it will destroy the naevus, if small. Continued 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, proceed to spurious anchylosis; but the timely administration of
ml, dicine 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 produced by irritation by the ingrowing nail. The whole outgrowth
12



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.
AUGUST GRIESS, Aged T'hirty-four Years.
Tumor 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 surface 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 mammae, as well as in mammary abscess, was highly
extolled.



REPORT OF SURGICAL CASES.                183
Prescribed iodide of potash, grs. ij., four times a day internally,
and topical application of carbolic acid spray (Lister's sol.). In
this case the constitutional taint was inherited from the father.
Among the antidotes for the syphilitic poison iodide of potash is
certainly one of the very best.
J. E. II., Aged Five Years,
has double oblique inguinal hernia, which has become scrotal.
Cough impulse perceptible, tumor opaque, congenital. Hernia
maybe confounded with hydrocele, which may also be congenital.
The following are a few of the points of differential diagnosis:
CONG. HERNIA.                   HYDROCELE.
1. Appears  from  the top of 1. Appears first at bottom  of
scrotum.                       scrotum.
2. Is generally opaque.        2. Is more or less translucent.
3. TIas cough impulse.         3. Has none.
4. Testicle felt at bottom of scro- 4. Testicle scarcely felt, if at all.
tum, distinct from tumor.
The testicle, in its descent through the ingunial canal, may
lodge at the ring and simulate hernia. To determine whether
this be the case, interrogate the scrotum.  Taxis was employed,
and the hernia readily reduced. An appropriate truss was ordered,
and nux vom. given internally.
GEO. R. M., Aged Fifty.one Years.
About twenty months ago there appeared, from constitutional
causes, at a point one and a half inches above left temple, an
abscess, which increased until it became the size of an egg. Slough
came out, and the abscess remained open, suppuration continuing
this morning a sequestrum about an inch square was discharged,



184                SURGICAL RECORDS.
consisting of the external table of the bone, the underlying diploe
presenting healthy granulations, with profuse secretion of fetid pus.
Ordered the parts dressed with Lister's sol. carb. acid, and to be
taken internally, silicea 200. Care must be exercised to keep the
hair from the wound in all injuries to parts covered with hair.
"y>~t*r$a^tDp8~f aft ME$aN ra Aa 8%,
JOHN W., Aged Nine Years.
Two years ago, without known cause, the left breast began to
enlarge, with burning, stinging pains, worse at night and in damp
weather. The breast is soft, and nearly as large as a woman's.
There is neither hardness nor soreness.
Phos. 30 was prescribed, it being peculiarly adapted to such
cases.
ELIZA A., Aged Seventeen Years.
Has pustular eruption on middle finger of right hand, caused
by wearing a ring. Eruption appeared about two years ago.
Commences as pustules, which degenerate into a squamous condition. Burns after scratching. Resembles impetigo.
Sulphur every night and morning.
HARVEY D., Aged Six Years.
The tumor in scrotum was first noticed about three months ago.
There is no cough impulse; testicle distinctly felt at bottom of
scrotum; translucency distinct when applying a lighted taper;
the pains are paroxysmal, so that he screams during motion.
Exploring needle is followed by exuding of serous fluid. Hydrocele in children may be cured by puncturing, to allow escape of
fluid and the internal administration of medicine. In adults, however, an injection of iodine or a seton is usually necessary.
Prescribed rhododendron 30, night and morning. The sac was
punctured and the fluid withdrawn.



REPORT OF SURGICAL CASES.                185
MARTHA P., Aged Thirty Years.
Been married three years; has three children. Contracted
syphilis from her husband. This case is a most remarkable one.
The nymphae are enormously enlarged, and project beyond the
external labia, which are also swollen. The clitoris is singularly
cylindrical in shape, having a length of three inches and a diameter of one and one half inches. Several pedulnculated condylomatous growths, varying in length from one to three inches,
appear, arising from the labia minora. The perineum is thickly
studded with these growths, which extend backward to the anus.
Complicated with this affection are painful external hemorrhoids.
Goes for weeks without an evacuation and is in constant distress.
Prescribed thuya 3, gtt. v. three times a day, topically:
1)    Thuya, 3 j.
Aquae, S vj.
M.
Farinaceous diet ordered, also sitz bath night and morning, after
which the above application is to be made. Must be kept quiet
and in recumbent position. If these means are not productive of
good, surgical measures will be resorted to. The use of nitric acid
and the bichloride of mercury in the treatment of such diseases was
pointed out.
Bursa at little finger dissected out, it not having yielded to previous treatment. Crepitation at wrist gone.
MRS. P., Aged Thirty-four Years.
About a year ago there came a swelling on left side of face, just
anterior to and below the ear, accompanied by neuralgic pains,
which were worse in damp weather. Has earache constantly.
Has had diseased teeth, which were extracted. It was very sensitive, especially at one point. Has grown steadily to the present
time.
Prescribed Hecla lava 3, three powders daily for a week.



186                 SURGICAL RECORDS.
There are two forms of exostosis-cancellated and ivory; the
former usually attacking the epiphyses of the long bones; the
latter, by far the most formidable, appears in the flat bones,
especially those of the head and face. The causes are constitutional, rarely local. In the case above cited the predisposition
already existing (the decayed teeth) may have been the exciting
cause, while the neuralgia may have been the result of pressure
of the tumor upon the nerves of the part.
GEO. PIERCE (Sailor), Aged Ffity. one Years.
(Continued from page 181.)
For the last week has not been improving. Is alternately
better and worse.  Within the past two weeks several spiculae of
bone have been discharged from the wound. Were these portions
larger, the indications would be more favorable. Recommends
scraping the bone. To which patient objects.
Prescribed silicea.
CHAS. J., Aged Twenty-six Years.
Right leg injured three months ago by falling plank.  Began
to swell, the swelling going and coming every week. There is
considerable pain, which is greater in damp weather. Has had a
fracture of the lower third of the fibula, with partial rotation of
the astragalus, and rupture of external lateral ligament. The foot
is somewhat everted. There is some deformity and stiffness of the
joint.  Ordered an elastic stocking for the leg, and prescribed arnica
externally and internally. The prolonged use of too strong a
solution of arnica will often produce a condition closely resembling erysipelas.



REPORT OF SURGICAL CASES.                 189
MARY M., Aged.Eight Years.
Fistulous opening on right cheek, caused:by scrofula, with enlarge.
ment of the glands of the neck. Pus exudes; face pale; has scrofulous cachexia. Has pain, which is worse atnight. Loses flesh. In
persons afflicted with scrofula, there is always a tendency to leucothbemia. Probe discovers no caries. Prescribed calc. 30, twice
daily. Baryta also is often indicated in this condition.
V  4
MARTHA PINCKNEY, Aged Thirty Years.
(Continued from page 185.)
This was a peculiarly aggravated case of condylomata and
enlarged clitoris and labia, which were so large as to completely cover the vaginal and anal openings and the perineum; they were from  the size of a bean to that of an egg,
and, if removed, would have filled  a two quart measure.
The patient was born in Virginia, was married to a man from
whom she had contracted syphilis, to whom  she bore three
children; she was finally compelled to leave him on account
of his vices. Strange to say, however, this woman was earning
her living at service, being obliged to stand upon her feet most of
the time; she suffered terrible pain during urination, with severe
aching in her bones, chiefly at night. She was also much exhausted from the bleeding of the tumors.  The condylomata and
the clitoris were pedunculated and covered with unhealthy mucus,
and, owing to the irritation consequent upon walking, were constantly bleeding.
She was ordered (until she could be received into the hospital)
to have frequent sitz baths, farinaceous food, no meat, compresses
saturated with one part of tincture of thuja to eight parts, of
water externally, and thuja 3d internally, gtt. iii. three times a
day.
Attention was called to the use of the following agents for the
refibroid tumors, hemorrhoids, condylomata, and 6ther soft parts,



190                 SURGICAL RECORDS.
viz: the ecraseur, invented by Chassaignac, nitricacid, mercurius
corrosivus ( 3 j. to ~ j. collodion) and the galvano-caustic wire, after
which, the patient being etherized, the enlarged clitoris was removed by the ecraseur with no subsequent hornorrhage; two small
candylomata beneath the clitoris were then ligated with a double
thread and cut off by the scissors.
These two ligatures and the one through the pedicle of the clitoris were left in, to guard against secondary hemorrhage.  The
patient was then placed in the hospital and the previous treatment
continued.
The patient was reported to be doing well.
Tlhe patient, being etherized, was placed in Sims' position, and
three anal condylomata were ligated with a double thread and cut
off with the scissors.
T'wo large condylomata were ligated and left to slough away;
they were all found to be very tough and vascular; it was then
ordered that the wounds be dressed at once with cold water, then
for two days with styptic cotton, which is cotton dipped into a
solution of tannin, persulphate of iron, benzoic acid and alum.
Only three condylomata now remained.
Prof. Helmuth reported that the patient was doing very well,
and that he had searched the records and found but few similar
cases, and these were not so severe as this.
MARY J. M., Agent Eight Years.
This child was light haired, pale faced, nervous, puffy under the
eyes, had dilated pupils and presented a general scrofulous appearance, though the parents and the other children were said to be in
fair health.
Eight weeks ago a hard swelling appeared under the right inferior maxillary, causing the child to cry a great deal, chiefly at
night, which finally discharged pus externally, since which time she
has lost flesh. She has had no other glandular swellings, neither
has she been salivated. There was no disease of the bone, but
simply a scrofulous enlargement of the parotid gland. Air, exercise, and calcarb. 30th, a powder three times a day, were ordered.



REPORT OF SURGICAL CASES.                 191
ANTHONY W., Aged FiPteen Years.
This lad suffered from a sprain of his left ankle with severe,
deep pain, occurring without any known cause, unless due to a
slight mis-step eight weeks ago; he had suffered eight weeks since
with rheumatism.
A sprain was described as an accidental rupture or wrenching
of the parts about the joint, often with dislocation suddenly
taking place which the muscles at once reduce. The patient had,
probably, from subacute arthritis, weakened the joint, thus predisposing to the accident.
There was neither a fracture nor a rupture of the internal
lateral ligaments. Having been preceded by disease of the joint
it was ordered that he rest as much as possible, using a crutch
when it was necessary for him to walk; he should not touch his
foot to the ground for six weeks, and must not be exposed to dampness or be out at night. A cold compress was applied at night,
covered by flannel and oiled silk, and rhus tox. 3d. gtts. x. in half
a glass of water, a table spoonful every three hours was ordered.
He was told that if not properly taken care of, effusion in the
joint might result and finally fibrous anchylosis.
ERNEST D., aged 7 months.
This babe presents a peculiar case: its mother states that the
child snores " terribly " and has great difficulty in breathing during
sleep and nursing; when sucking the respirations can be heard all
over the room. Attention was called to the fact that any obstruction in the posterior portion of the mouth, as swelling of the tonsils or a polypus, or an enlargement of the turbinated bones, might
cause obstruction to breathing. The tonsils or velum palati did
not seem enlarged, and an attempt was made to pass a small bougie into the nostrils, which failed; a small probe was, however,
with effort passed to she posterior nares of either side, and it was



192                 CLINICAL RECORDS.
found that the turbinated bones were enlarged and the schneiderian membrane thickened, thus closing the passages. The mother
was instructed to use a syringe with a fine nozzle to throw warm
water through the nares, and have the probing repeated every
week or two, gradually increasing the size of the instrument,
and IHecla-lava was ordered to be administered at night.
MARY B., Aged Ni;neteen Years.
Three years ago a playmate pushed a barbed crochet needle
from over the extensor tendon of the right thumb through to the
inner and fleshy side of the thumb. Her physician broke off the
protruding barb and drew the needle back through the point of
entrance. Since then she has suffered with pain in the thumb
during bad weather, and with frequently recurring numbness. It
was pronounced that the nerve and tendon of the thumb had
been divided, and a simple electrical apparatus was ordered to be
used once or twice a day as follows: apply a ring of zinc around
the thumb and one of copper around the wrist, connect these
with a copper wire and put a little vinegar under the copper ring.
This is also an excellent appliance in bed sores and obstinate
ulcers.
C. M., Aged Twenty-two Years.
An operation for varicocele being about to take place, the following very opportune explanation of varicocele and its operations was given:
The tunica vaginalis is a peritoneal investment of the spermatic
cord and testicle: the spermatic cord is made up of the spermatic
artery and veins, and vas deferens, the latter carrying the semen
to the vesiculce seminales; the pampiniform plexus is the collection
of veins which pass through the spermatic cord.
Varicocele usually occurs on the left side, because the right



REPORT OF SURGICAL CASES.                193
spermatic vein enters the vena cava acendens at an acute angle,
while the left spermatic vein enters the efferent vein of the kidney
at a right angle, and also the valves of the right vein do not open
as readily as those of the left.
T'he symptoms of varicocele are, a feeling of weight in the
testes, pain in the small of the back, and a depressed mental condition; the patients usually are strong, robust young men, of good
habits, accustomed to hard work and long continued standing.
The treatment is palliative and radical. The first is by means
of a suspensory bandage. The second aims to obliterate the enlarged veins by either of the following methods, viz:
1st. Pass a needle armed with a cord behind the vein, making
the point of exit of the needle near the point of entrance; then
twist the ends of the cord and you thus compress the veins.
Thirteen of fourteen cases treated in this way were cured; the
fourteenth died of phlebitis.
2d. Remove a crescentic piece of the scrotum, then sew up the
wound and thus cause compression.
3d. Make an incision through the scrotum and ligate the veins.
4th. Inject perchloride of iron.
5th. Put a truss and pad over the external abdominal ring
through which the veins pass up, and by this means irritate the
veins and effect a cure.
T''hat method is the best which excludes the air from the veins.
It must, also, be borne in mind that ligating the spermatic artery
will result in atrophy of the testis, and this accident has occurred
to di stinguished surgeons, one of whom was murdered for having
made a mistake and included the spermatic arteries in his ligature.
It is better, then, remembering that the vas deferens feels like
a ligamentous cord; that the artery can be known by its gentle
pulsation, and the veins by their feeling like a bundle of earth
worm s,
6th. To get the vas deferens between the thumb of the left hand
and the os pubis; the artery between the first and second fingers,
thus leaving the veins clear for ligation as follows: pass a curved
needle armed with a double thread with the loop near the eye of
the needle, in front of the thumb through the integument behind
the veins; cause it to reappear in front of the first finger and remove the needle; then enter the unthreaded needle at the same
point of entrance as before, carry it j st beneath the srotal wall
13



REPORT OF SURGICAL CASES.                195
powder three times a day, unless it became worse, requiring
removal by the ecraseur or galvano caustic wire. Bread and
milk, mush, rice and hominy, and mutton broth were ordered, and
to wash the ulcer with warm water. This patient returned to the
hospital to have the entire tongue removed, but before the appointed time, left without assigning any reason.
RANDOLPH R., Aged Eleven Years.
This child had a swelling which appeared suddenly in his scrotum five months ago, and no effort had been made by his parents
to have it attended to, though it had sometimes become " almost
black." It gave cough impulse, hence was not encysted hydrocele of the cord; it was not infantile, because the testicle was at
the bottom and was pronounced a congenital oblique inguinal
hernia still reducible. The gut was returned without difficulty,
and it was ordered that the child wear a truss and have nux
vom.30th, a powder every night, to strengthen the muscles of the
abdominal wall.
J. BURNS, Aged Four Years.
This man reports that he began to suffer with stinging pains in
his hips during walking three years ago; in the course of a year
his right leg became a little lamc, and is now smaller and shorter
than the other; his leg "goes to sleep " and becomes cold very
easily; he is unable to raise his foot, and suffers with severe pains
shooting down the anterior surface of the leg. HIis symptoms are
ail worse in damp weather, and his appetite very poor. His
physician had called it sciatica, cupped him, and gave him medicine with no benefit; he has also used rhus tox. for ten days without effect. He had never had a blow upon his back or a strain,
nor suffered with pain in the knee.



196                 CLINICAL RECORDS.
It was pronounced a threatened paralysis, and electricity to be
the best treatment, but, since we are unable to furnish him with
this for the present, he was given colocynth to be taken every
fifteen minutes during his severe pains, and ordered to moisten a
flannel rag in alcohol, having a tablesponful of salt to the pint,
and to rub his leg with this night and morning, also to take plenty
of out door exercise.
The internal medicines were rhus tox. at first, and afterward
strychnine.
D AVID G., Aged Seventeen Years.
This young man had fallen through a hatchway ten weeks ago,
and sustained a Colles' fracture,viz., a fracture of the lower extremity of the radius, with dislocation of the ulna, which had
been treated with a pistol splint, and he probably came to see if
it had been properly managed. He was told that it was not necessary to break the bone over again, and that time, friction and
exercise would help him regain the normal motion of the joint.
J. L. S., Aged Thirty-eighlt Years.
The following diagnosis of hydrocele and description of the
methods of cure were made before the operation. Hydrocele of
the tunica vaginalis is a collection of serous fluid between the
tunica vaginalis testis and the tunica communis.
This man's trouble began seven years ago, and is a hydrocele,
because the swelling began at the bottom; it gives no cough
impulse, he has severe pains in the back and groin, is very depressed, mentally; the tumor is translucent and irreducible; while
hernia comes from above, has cough impulse, can usually be
reduced by taxis, and is opaque.
Varicocele, on the other hand, has the peculiar earth worm feeling of the veins.



198                 CLINICAL RECORDS.
syringe, and the needle was withdrawn from the scrotum, and
thus the whole operation, consisting of the removal of the contents of the tumor, the injection into the cavity, and the removal
cf lthe injectioin, was accomplished by one capillary puncture.
JOHN D., Aged )Four Years.
This boy had teen troubled with a vesical calculus, which had
become lodged in the prostatic portion of the urethra, causing
great difficulty in urination, and at times suppression; there was
danger of rupture of the urethra and extravasation of urine; his
prepuce was elongated, symptomatic of calculus, and he had also
the frequent inclination to urinate which belongs to the disease.
As to the operation: If possible the stone was to be removed
through the urethra by a fine pair of urethra forceps. The patient was etherized and the extracton attempted, but it was unsuccessful; recourse was then had to the removal through the perineum, which was successfully done by the lateral operation, and a
stone the size of a bean removed; the incision was made high up
in the perineum on account of the position of the calculus; some
little difficulty was experienced in securing a small deep artery,
cut during the operation.
After the operation the boy was removed from the hospital.
Jan. 17th. Prof. Helmuth reported that on the 12th inst. the
boy had been removed without his knowledge to his home in New
Jersey, and that, as soon as he discovered it, he had written to a
physician there to see him daily and report. He had done so, and
all went xwell till the 16th inst., when it was found there was infiltration of urine into the tissues of the scrotum, which were
pu;plish in color.
The Professor had him  returned to the hospital, and he finds
that he passes about one half of his urine this morning through
the urethra. It was ordered that the scrotum be strapped up by
adhesive plaster attached to the abdomen, and he be carefully
watched. The Professor stated that it was possible for one to recover after losing one half the scrotum  from this cause.  No catheter was to be used in this case.



REPORT OF SURGICAL CASES.                199
Jan. 24th. After the scrotum llal been strapped up a very
small am)unt of urine escapel throughl 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 infiltration of urine when the triangular ligament is divided, as in
this operation, than in other operations for the urethral calculus.
Jan. 31st. 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 fus?/form,
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 upturned; dftuse, 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 aneurism; a clot forms on the wall of the sac, becoming almost organized, 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 "pas.sive
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 below the aneurism, cut down on
the sac and empty it of its contents. Anel's method wvas 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 Brasdor,' method was to ligate the



REPORT OF SURGICAL CASES.               201
temperature running down to 94j~ and his pulse to 81, remaining
till morning between 71 and 76.
JAW. 11th. At 8 A. M. his pulse came up to 84, and his temperature to 98j~; by noon the pulse reached 94. Only slight pulsation could now be detected in the tumor. At S r. x. 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 subsultus tendinum.
JAN. 12th. At 1 A. M. the patient's temperature was 98~O, 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 temperature 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 961~. At 6 P. M. his temperature was
993~ and that of the tumor 981.
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 981~. At 3 P. M. his pulse was 92, his temperature 99j~
and that of the tumor 96~0. 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. Helmuth, Thompson and Robinson, Drs. Baldwin and McVicar, and
others, and no pulsation could be detected, and the tumor was
found to be gradually reducing and hardening; the collateral circulation 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



REPORT OF SURGICAL CASES.                203
MATILDA B., Aged Eleven Years.
Att ention was first called to the following operation for nlevi:
1st. Electrolysis, which is not always successful. 2d. By placing
two pins at right angles beneath the naevis and ligating it with
thread beneath the pins, being careful to insert and withdraw the
pins in sound tissue, which causes less hemorrhage aud insures
better success. 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 nsevus
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. Attention 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 nalvi 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,anestllesia caused by ether very
soon after its administration, during which minor and brief operations can often be performed, and the secondary and more profound anaesthesia following.
JAN. 24th. Patient was brought in doing nicely; the mother
was instructed to dress it with simple cerate and return to the Dispensary in three days.
ISAAC R., Aged FSjty-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.  IHe 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 follows: 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 increasing 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, cannot 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 expanded, 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 passing 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.



206                                            INDEX.
PAGE.                                                 PAGE.
Fracture of the Humerus................9, 31                                  K.
Inferior Maxilla.......... 148
Paterson Cae...................  12  Knee, Housemaid's.....................73, 178
Potts.............................  186                          Trea tment of...........  73
Treatment of..................... 186  Knee Joint, Disease of.................... 178
Quizzes on.................... 7, 8, 9                               Treatment of.           178
of the Lower Extremity of the Radius............................  9                               L
of the lower third of the Ulna..152, 159
Lateral Spinal Curvature.................   44
Treatment of.....  46
Ligament Rupture of the Coraco, Claviclar
Ligament, and Bruised Capsular LigaGanglion.......................... 175     ment.............:...................... 138
Treatment of.................. 175  Ligation of the Innomihnta................   49
Gangrene Traumatic..................... 164                           Subclavian.................  50
Lithotomy...............................   198
~H                            Lip, Epithelioma of......................19, 32
Operation for.........................  23
Hemorrhage, internal..................... 173  ipoma  Nsi.............................. 129
Hiemostatices-Quizzes on................110  Lockjaw —Quizzes on.....................   110
Hemorrhoids removed by Platina wire.... 173  Loose Cartilages in Joint............... 140
Hernia, Congenital................. 76, 106, 157                                 Operation for        141
Treatment of..................'.. 158  Lower Jaw, Fracture of................... 148
Double Scrotal................... 183
Treatment of.................... 183                                  ].
and Hydrocele................... 204  Mamma, Cancer of.................. 30, 171
Operation for.2................ 204  1Mammary  Gland, Preternatural EnlargeQuizzes on.............   109, 110, 111       ment of................................. 179
Oblique Inguinal......195.......                        Treatment of................. 179
Treatment of...................... 195                  Hypertrophy.. 184
Hip Joint Disease, 60, 79, 85, 86, 104, 105, 115                   Treatment o         f..................184
116, 142, 165   Mother's Mark...........  38
Treatment of.61, 85, 86, 105  Movable Cartilage....................... 140
117, 165                       Operationfor............ 141
HouEemaid's Knee..................... 73, 178
Treatment of....... 73, 178                            N.
Hydrocele.........1................  128, 196
Treatment....................... 128  Nasal Passages-Obstruction of............ 191
Operation for................... 197                          Treatment of............ 192
Hypertrophy of Clitoris.............. 185, 189  Naevus................   13, 19, 106, 203
Treatment of... 185, 189             Treatment of..................... 14, 15
Mamma....................   179             Operation for............... 15, 18, 203
Treatment of.............. 179              Capillary........................... 176
in Boy.................... 184  Necrosis, Acute........................... 171
Treatment of.............. 184                 Treatment of.................... 171
Tonsils.................... 33                of the Os Frontis................ 183
Treatment of...............  34                Treatment of.................... 181
Nose....................... 129                Jaw........................181, 186
Treatment of............... 130                Treatment of.........                186
Parotid Gland............ 190                  Tibirement of................. 181, 1865
Treatment of............ 190                 Operation for....................  70
Hypochondriasis..........................89           Frontal Bone.........31
Hyp s.Frontal Bone....................  31
Treatment of..............  89               Treatment of.....................  32
Hypospadias....................... 179, 181  Needle, broken............................ 104
and retained testicle.......... 112             In wrist........................... 187
Neuralgia of the Stump................... 101
I.                                                      Treatment of..... 103
Node....................................  176
Inflamed Ulcer........................... 162  Nose, Hypertrophy of...................... 129
Treatment of............ 163
Indolent Ulcer.............................  85                               0.
Treatment of................  37
Inflammation-Quizzes on................. 28   Oblique Inguinal Hernia................... 195
Injury to the Cauda Equina..       14                               Treatment............ 14195
Treatment of.. 152  Obstruction of Nasal Passages............ 191
Innonimata, Ligature of................... 49                                         Treatment of 192
Inferior Maxilla.............                  185  Onychia Maligna.......................... 136
Treatment of.............. 185                          Operation for............. 137
(Esophagus, Stricture of................. 74, 95
Treatment of...............76, 95
P.
Jaws, Lower, Anchylosis of...83, 126, 180, 187
Operations for 84, 180, 187  Paralysis of the Ejaculatory, Ducts........  123
Joints, Anchylosis of Elbow............... 126                         (Esophagus........... 131, 143
Treatment......................  126                        Treatment of.............. 145
Loose Cartilage in............         140              Traumatic.......................  29
Operation for.... 141              Treatment of.................... 29



INDEX.                                                  207
PAGE.                                                     PAGE.
Partial Paralysis.............;....... 195  Spurious Anchylosis of Knee Joint.....                       174
Treatment of........... 195                                     Treatment of...... 174
Pharaphymosis..                    100                                Right Shoulder.... 174
Paronychia....... 64, 130, 159                                  Treatment of...... 174
Treatment of.......... 64, 131, 159   Staphyloraphy...................                    59, 133
Parotid Gland, Scrofulous Enlargement of. 190  Stricture of the (Esophagus.............74, 95
Treatment of.............. 190                                        Treatment of..76, 95
Paterson Case, Fracture...................  12   Subacute Thecitis...................                         145
Periostitis..130                                         Treatment of............ 147
Treatment of............. 131   Snbclavian Aneurism....................89, 48
Periostitis and Caries.................... 176                                 Treatment of........  49
Treatment of........ 176                                Ligature of..........  50
Phlebolithes.....................   134   Suppuration-Quizzes on................ 29, 162
Phymoses...................... 51, 100, 188   Synovitis..........................                       53, 176
Operation for...............  52, 188                   Treatment of................. 53  176
Pleuritic Abscesses........................ 171
Treatment of.......... 172                                  T
Popliteal Aneurism........................ 199
Treatment by  Digital C,:mpression of 200   Talipes Equino-Varus.............e.......   172
Pott's Disease of the Spine, 24, 41, 93, 94, 117,                                     Operation for....... 172
156   Tetanus-Quizzes on................ 110
Treatment........... 42, 93, 95, 117, 156   Testicles Retained....................... 112
Fracture.......................... 186  Thecitis, Subacute.....................  145
Treatment of.........                     186                         Treatment of............       147
Preternatural Mobility....................  10   Toe Nail-Disease of................... 136, 177
Prolapsus Ani.............................  46                        Operation for.................. 137
Treatment of................  47   Tongue Tie........... e....................  188
Operation for.................. 188
O_.-                                          Epithelioma of the............. 194
Treatment of.................. 194
Quizzes —Abscess, Aneurism.............. 119   Tonsillitis...............................  38
Aneurism.....................11, 118                       Treatment of..................  38
Aorta.............................   91   Tumor Cartilaginous..........                        74 1... 87
Congestion........................  28                  Cystic........................... 179
Fracture.................7, 8, 9                 Enchondromaous............. 174, 187
Dislocation.................... 100                                          Treatment of.... 187
Fracture of Lower Jaw............ 162                   Encysted.......................... 126
Hernia.................. 109, 110, 111                             Treatment of............. 126
Hip Joint Disease.............. 100             Encysted Hydrocele............... 184
Inflammation.....................  28                                          Treatment of.. 184
Iunominata Artery...............  91                    Quizzes on...................  117, 118
Inter-columnar Fascia............  91                   Sebaceous................. 97, 108. 173
Suppuration.................29, 162                              Treatment of............  98
Tetanus.........................   110   Traumatic Gangrene...................... 164
Ulceration....2..........   27                      Paralysis.......................  29
Treatment of..........  29
R.                                                         U.
Repair in Fracture......................... 160   Ulcer, Indolent.....................                        35
Remarks, concluding............... 166              Treatment of......................  37
How to apply Straps...............  30
S.                                      Inflamed.......................   162
Treatment of....................   163
Salivary Glands.-Enlargement of Glands.. 124                       Specific......................... 182
Treatment of.........      2.. 25           Treatment of....................... 183
Scirrhus................................    30                    Varicose...........................  81
Treatment of......................  30                  Operation for............  82
Scrofulous Enlargement of Parotid Gland.. 190   Ulceration................................  27
Treatment of. 190   Ulcer................................  27
Sebaceous Tumor of Scalp............. 173, 187
Treatment of 175, 187                                V.
Sebaceous Tumor......................97, 108
Operation for............  98   Varicocele.................192
Section of the Nerve and Tendon of the                               Operation for.................... 193
Thumb. 192   Varicose Ulcer........................ 81, 128
Treatment of. 192                        Treatment of.............82, 129
Specific Ulcer.........................,.. 182   Varicose Veins............................ 134
Treatment of................. 182
Spermatorrhea......................                121..... 121
Treatment of............... 124
Spine, Angular Curvature of...............  24   Whitlow......................64, 130, 157, 159
Sprain of Ankle.......................... 191                       Treatment of........64, 131, 157, 159
Treatment of.............. 191  Wound of Mouth.......................... 180