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I guarded myself against the possibility of misinterpretation by stating that when these cases were advanced it was exceedingly difficult to discriminate, because the symptoms offered were much more referable to mere destruction of the organs than to the destroying agent. If you find the disease begins in the lower part of the lung and progresses slowly upward and has been marked by fever and prostration and loss of flesh and strength and colour, if you find the summits of the lung free, you may safely say you are dealing with an ordinary case of fibroid phthisis. If, on the other hand, you find none of these things, if you find the summit of the lung affected, I know of no means except the history of the case to distinguish between the two. The history of the case, if it were one of sudden origin, of a presumable inflammatory character would lead to the conclusion that it was fibroid ; the insidious origin of the disease would suggest tubercular. Further, if fibroid phthisis is not always confined to one Inng, it is in the majority of cases. I have, even in cases of tubercular phthisis, the appearance of a secondary fibroid combination. So much is this the case,

that some people dealing with tubercular phthisis, recommend their patients to become drunkards to prolong their lives.

Dr. OsLER asked for a sketch of a few of the principles of the treatment of phthisis.

DR. CLARK said: I am afraid I shall lose what little character I may possibly have gained. I pretend to no special knowledge of the treatment of phthisis. Whenever I encounter any chronic disease, I deal with it on this principle. Every organism has a righting, a repairing, and a resisting power, and it exercises these powers in proportion as we give them fair play, I proceed always in a chronic case to determine what will be fair play for the organism suffering under this chronic malady. Hence, diet, air, attention to the general functions, form always the first points of treatment in such case. Whilst we are ready enough to give a liberal supply of medicines, we too often overoverlook those minute details of daily life which, in the end, make and unmake life. Of tubercular phthisis, I have very little to say. The main affair is the general health. Lowering the tendency to resistance permits the advance of the disease with

which the patient is threatened. If I can keep him free from colds and consequently pneumonias, I am practically doing as much for my patient as I can. There are no principles in medicine ; it is one of the most unprincipled of arts. Every organism is somehow or other different from every other, and it contains within itself the laws for its own management. The wise man, he who has the gift as well as the knowledge of healing, is he who with an instinct is ready to discover the laws of the organism with which he is dealing and governs himself accordingly. It would be foolish to say in detail how I should deal with a case of tubercular phthisis. Regulated diet, moderate use of alcohol, air, exercise, avoiding colds are the principal means to be used. I have tried this medicine and the other, hypophosphites, arsenic, iron, &c., but I cannot say, looking at the whole with an honest, critical eye, I can lay my finger on any remedy with any specific influence in it.

As regards caseous pneumonic phthisis, I believe in the efficacy of treatment. In an acute case, I have great faith in treatment. I put my patient to bed and keep him there nntil the temperature falls below 100° however long that may be. The second rule in case where the secretions are scanty, the tongue dry, temperature high, pulse quick, I satisfy myself with a free use of salines and with counter irritation. If I find the patient remaining feverish, I give up my citrate of potash, and put a drachm of antimonial wine into a tnmblerfull of water and make him sup that during twenty-four hours. The skin breaks out into perspiration, tongue becomes moist, expectoration usually begins ; then I immediately stop and treat my patiennt with effervescing alkaline salines with quinine and citric acid. I next feed him with milk and beef tea. We often forget, practically, that liquid food goes quickly to the lung. In cases where exudation is going on in the lung, we minister to it by filling our patients with fluid food at short intervals. In rapidly extending pneumonia, I have seen exudation hurried to a fatal end by the administration of fluids every half hour. Food should be giveu in a more solid form and not oftener than every four hours. This is one of the forms in which I believe alcohol to be extremely useful. In cell proliferation, alcohol is useful, and I would extend it to scrofulous diseases generally.


Professsor of Clinical Surgery, McGill University.

(Read before the Medico-Chirurgical Society of Montreal.)

I have now employed the very ingenious instrument of Dr. Paquelin, known as the Thermo-Cautère, or Gas Cautery, in such a number and variety of cases in both hospital and private practice, and have obtained such admirable results, that I feel bound to advocate its claims as a valuable surgical instrument before the members of this Society. Too great praise, I think, cannot be awarded Dr. Paquelin for his invention, as now we are in a position to obtain the excellent results that no doubt followed the employment of the actual cautery in the hands of the older surgeons, without the dread inspired by the preparation and general surroundings of the fer-rouge.

The instrument I show you is manufactured by Messrs. Collin & Co., 6 Rue de l'Ecole de Medicine, Paris, and cost me there the sum of one hundred and forty francs. It consists, as you see, of an ordinary spray-bellows, a spirit lamp, and a flask furnished with a perforated rubber cork, in which benzoline is held. This is a hollow handle, insulated with wood to protect the hands, and to which can be attached any of these platinum heads corresponding to the cautery irons found most useful in practice. Each of these parts is hollow, and must be first heated to blackness in the flame of the spirit lamp, when with the aid of the bellows a blast of benzoline vapour is introduced, which has the remarkable property of maintaining the platinum in a condition of vivid incandescence. This heat can be maintained for an indefinite time by a continuous slight compression of the bellows. Every instrument is generally supplied with three platinum heads, namely, a probe or stylet for touching minute points of ulceration, or for cauterizing sinuses, &c., a hammer for coarser work, and a blunt knife for cutting purposes. This form of knife, with a sharp cutting edge at the point (the gift, by the way, of my kind friend Dr. Ross), is a more recent addition, and will be found very useful for dividing pedicles or searing nævous growths. Curved knives, scissors, and an ecraseur or guillotine, may now be obtained from makers in good standing. The whole apparatus is packed in this neat box, and will be found exceedingly handy and portable.

There are many little points in connection with the working of the instrument, such as the amount of heat required for a certain purpose, and the pressure that should be used, which experience only can teach. Thus in order to divide skin and muscular tissue, a red heat is required; while for the sealing up of bleeding vessels, an almost black heat is the best. It is surprising what little pain is experienced after the destruction of even a large surface of tissue. In fact, I believe this is the most paiuless of all escharotics, not excepting nitric acid which hitherto, perhaps, has held the palm.

The following cases have been taken indiscriminately from a number of clinical reports in my possession, although some of them are the most important I have had, as illustrative of the uses to which this valuable instrument can be put in surgery :

CASE I.Lupus—(Reported by Mr. Mills.)—Moses Fried man, aged about 40, was admitted into the General Hospital November 23, 1877, under my care, on account of a number of lupoid sores, one nearly as large as the palm of the hand, situated over the left back. The scars of an extensive ulceration, confined to that side, were very marked. There was no history of syphilis. Chloroform being administered, the knife of the cautery was applied in a cutting manner to the patches, and lead lotion, followed in twenty-four hours by poultices subsequently applied. The sloughs separated in three or four days, and healing rapidly went on, although it was thought advisable, in about ten days, to reapply the cautery to some suspicious spots. Within three weeks from the time of operation he was fit to be discharged.

Case II.Prolapsus Recti.—(Reported by Messrs. Gardner and Smith).—Catherine Devine, aged 60, was admitted October 29, 1877, suffering from an enormous prolapse having the



character more of an invagination of the gut. She attributed the condition to obstinate constipation, alternating at times with diarrhoea. The bowel protruded fully four inches, the sphincter being of necessity very much distended. Chloroform was administered, and the part scarred in several places with the platinum knife in the long axis of the tumour, care being taken to go through the entire thickness of the mucous membrane, The protrusion was then returned, a large tent of lint soaked in carbolic oil was introduced into the bowel, and the buttocks strapped closely together with adhesive plaster and a pelvic belt. A grain of opium was given night and morning. On the tenth day an enema was administered, and a copious stool obtained without disturbance of the bowel. The patient was discharged on the fifteenth day, with instructions to attend to the condition of the bowels:

This woman was sent to me by Dr. Reddy about a fortnight since with a return of the prolapse, but not nearly to the same extent as beföre. A few days ago I scarred the protruding gut thoroughly, and then performed an operation for narrowing the anal orifice, which promises to be very successful. I made two incisions extending from the transverse diameter of the anus to the tip of the coccyx, removing the skin, subcutaneous tissue, and perhaps a few fibres of the sphincter. The edges of the gaps were brought together with wire sutures. Where before the entire hand could be passed into the bowel with ease, two fingers are now with difficulty introduced, and when union is more complete the contraction will still be greater.

Case III.-Sciatica—(Reported by Mr. Sutherland.) - Mary Foley, servant, aged 20, was admitted June 6th, of this year, having suffered pain for some weeks in the course of the sciatic nerve. The ordinary remedies had been tried with little benefit. The cautery was applied in lines down the course of the nerve nearly to the knee. The pain rapidly disappeared, and she was discharged cured on the seventeenth day.

CASE IV.-Amputation of the Penis.—An old FrenchCanadian, aged 72 years. was admitted July 2d, having an extensive epithelioma of the penis, involving the organ up to within

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