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to notice a deficiency of breath on exercise. This has progressively increased, but it did not occasion sufficient inconvenience to oblige him to quit work until a few days before he entered the hospital. Such is the account which patients, especially of the so-called laboring classes, frequently give when they first come to a hospital or a physician with disease of the heart. The first symptom is want of breath. This is at first slight, and they do not give to it much attention. It gradually increases, and labor involving muscular exertion becomes difficult. Finally, they find themselves unable to work longer, and then they seek for medical relief. Palpitation is sometimes complained of, but this symptom is often wanting, as in the present case. Our patient has not suspected that the heart is at fault. Naturally enough he has inferred from the want of breath on exercise, that there is something wrong in the breathing apparatus, and he says he thought he was falling into a consumption.

I now introduce the patient. He is up and dressed, and able to walk about without difficulty. He disclaims, indeed, being sick, and says he only lacks wind to enable him to work. When he is quiet or exercises moderately, there is no trouble in breathing whatever. The respirations are not accelerated nor labored. As you perceive, he is not emaciated, and does not present a notably morbid aspect. His appetite is excellent, and the bowels are regular. He has a slight cough, with a small expectoration. But if you examine the countenance closely, you will observe certain appearances which are significant. The prolabia are distinctly livid. The mucous membrane within the mouth is of a dark red color, and the face generally has a dusky hue. There is also slight tumidity around the eyes. What occasions this discoloration? It is due either to deficient oxygenation of the blood, or to congestion of the systemic venous capillaries, or to both these conditions combined. If caused by the first of these conditions, viz. deficient oxygenation of the blood, should we not have associated with it dyspnoea, or suffering from the want of more oxygen? Not necessarily. It is a curious fact that the system is sometimes remarkably tolerant of blood deficient in oxygen. This is more likely to be the case when the condition has been very gradually brought about, as it has been in this instance. But there is reason to think, as will presently appear, that the lividity in this case is due in a great measure, if not chiefly, to the stasis of blood in the veins. If so, the condition is that which is supposed to give rise to the lividity in certain congenital malformations of the heart, constituting the blue disease or cyanosis.

Directing attention now to the lower extremities, the body generally, and the cavities of the abdomen and chest, we find that the patient is affected, in a moderate degree, with general dropsy. The feet and ankles, as you see, are somewhat swelled, and pit on pressure. Exposing the belly, you notice a deep indentation caused by the waistband of his pantaloons. This shows oedema of the abdominal walls. Making pressure over the sternum with the finger, the pitting distinctive of oedema is here apparent. The peritoneal sac contains some liquid. I make percussion as the patient stands, and I find dulness extending from the pubes to the umbilicus, and tympanitic resonance, due to gas in the intestines, above a horizontal line drawn through the umbilicus. Causing the patient to lie down on the back, I find the dulness below the umbilicus has disappeared, and the tympanitic resonance extends quite to the pubes. This shows the presence of liquid, which changes its level with the change of position. It is more reliable evidence of dropsical effusion into the peritoneum than a sense of fluctuation; and the latter in this case is not very available, owing to the oedematous state of the abdominal walls. By precisely the same method of examination, we have evidence of a moderate amount of effusion into the pleural cavities. Percussing from above downwards when the body is in a vertical position, we have the pulmonary resonance extending a little below the nipple; then percussing when the patient is recumbent, on the back, the

pulmonary resonance is found to extend nearly to the bottom of the chest. This shows the presence of liquid, which obeys the laws of gravitation in this situation as it does in the abdominal cavity.

We have already obtained certain facts which point significantly to cardiac disease. Lividity and general dropsy constitute ground for strong suspicions as to the seat of the disease, but they are not adequate to a positive diagnosis. We must interrogate the central organ of the circulation, by means of auscultation, percussion, and palpation. I seek first for the apex-beat of the heart. I find it with difficulty, the impulse is so extremely feeble. It is in the sixth intercostal space, about half an inch without the nipple. It is therefore lowered and carried to the left of its normal situation. I apply the stethoscope over the apex, and I discover a very distinct and rather rough murmur, which just precedes the first or systolic sound of the heart. This murmur ends abruptly and completely when the first or systolic sound occurs. There is no murmur accompanying or following the first sound. The only murmur heard in this situation is the pre-systolic murmur. This murmur is heard only within a circumscribed space over and within the apex. It is not heard without the apex. This is a mitral direct murmur; so called because it is produced by the direct current of blood through the mitral orifice from the auricle to the ventricle. It is rather a rare murmur, but not so rare as some writers have stated. The reason why it is considered to occur so seldom is, I believe, that it is often confounded with the mitral regurgitant murmur-a murmur due to the current of blood from the ventricle to the auricle-a regurgitant current. Now, what does this mitral direct murmur signify? It denotes a lesion of some kind seated at the mitral orifice, and generally a lesion which involves obstruction at this orifice. The murmur, in this case, has a peculiar quality. It resembles the blubbering sound produced when air is expelled through the mouth, the lips being passively thrown into vibration. Hence, I have been accustomed to style the murmur a blubbering murmur. I suspect that it is due to union of the two curtains of the mitral valve at their sides, leaving a contracted button-hole aperture-a kind of lesion which we know occurs not infrequently.

Is this the only murmur in the case? On careful auscultation I discover a second murmur near the left margin of the sternum, between the third and fourth ribs. It is a feeble, soft murmur, which accompanies the second or diastolic sound of the heart. This is an aortic regurgitant murmur. It shows some insufficiency of the aortic valve, and consequent regurgitation from the aorta into the ventricle after the contraction of the latter, when the recoil of the arterial coats takes place, giving rise to the second sound of the heart.

Listening now to the sounds of the heart, I find the first or systolic sound over the apex, distinct, but short and valvular, like the second sound; the element of impulsion is wanting. The second sound at the base on the left side of the sternum is notably more intense than on the right side; showing either the sound due to the pulmonic valve to be increased, or that due to the aortic valve to be weakened, or that both these alterations exist-the latter being probably the true explanation in this case. are nice points in auscultation, but some of you, as I know, are already familiar with them, and to others, although at present obscure, they will be sufficiently intelligible byand-by.

These

Let me now practise percussion in the præcordia. Percussing on a horizontal line from the sternum, in the direction of the left nipple, marked dulness extends to the latter, and three-fourths of an inch beyond it. I can easily define the boundaries of this dulness, which I indicate on the chest with ink. On the right side percussing on the same horizontal line, the dulness extends about two inches beyond the right margin of the sternum. The heart is evidently enlarged, and the width of the dulness at the base leads me to think that the auricles are especially dilated.

The apex beat of the heart, as we have seen already, is scarcely perceptible. In fact it is more readily seen than felt. There is no heaving of the præcordia, nor is any impulse elsewhere than at the apex to be felt. This fact, taken in connexion with the shortness and valvular quality of the first sound, leads me to think that dilatation of the heart predominates over hypertrophy.

The conclusions, then, based on the physical signs developed by the examination, are, that lesions exist at the mitral and aortic orifices-at the latter orifice giving rise to regurgitation, and probably causing obstruction at the former orifice; that the heart is enlarged by predominant dilatation; that the auricles especially are dilated; and that the right ventricle is hypertrophied, augmenting the intensity of the pulmonic second sound. Let us now see how these conclusions accord with another very interesting sign in the case, and also with certain symptoms.

I now cause the patient to lie upon the back, and I will ask you to direct your attention to the left external jugular vein. You see the vein is considerably enlarged and filled with blood. It is much more distended when the patient is recumbent than when he sits or stands. You perceive that the vein pulsates. The pulsation is so marked that it must be apparent to those on the highest benches in the amphitheatre. The pulsation is also felt to the touch; in fact it is quite strong, much stronger than the pulsation in the carotid artery-the latter being felt with some difficulty. Perhaps you are not at once satisfied that the pulsation apparent in the vein is in reality venous. I will prove to you that it is so by a very simple expedient. I now place my finger on the vein at the lower part of the neck, just above the clavicle, and I make pressure sufficient to interrupt the flow of blood in the vein. The pressure is light, and entirely insufficient to interrupt the flow of blood through a large artery. You see that I arrest immediately the pulsation, which returns directly my finger is removed. I can arrest it at will by preventing the flow of blood in the vessel. This suffices to prove that it is a venous not an arterial pulsation. It is due to a retrograde current of blood through the vena cava, and the larger veins which are tributary thereto. It is apparent on the right as well as on the left side of the neck, but, contrary to the rule, is much more marked on the left side.

(To be continued.)

Original Communications.

ON THE USE OF PESSARIES.

BY P. STEWART, M.D.,

OF PEEKSKILL, N.Y.

Ir cannot be denied that fashion has more or less influence in determining the use of remedial agents. From twenty to thirty years ago, it was the fashion to treat almost every case of prolapsus uteri with the pessary, and nearly all the schools in this country, at least, inculcated that as the true doctrine.

Being strong in the faith, I entered upon the duties of my profession, armed and equipped with these supposed indispensable utero-vaginal agents, with the teachings of Prof. Dewees fresh in my memory, and his book under my arm. If I mistake not this faith held almost universal sway in the profession until within the last ten or twelve years; when considerable scepticism began to prevail in regard to its utility, and I had fain hoped their use was fast becoming unfashionable. In some discussions recently held in the Academy of Medicine, however, I learn that such is not the fact; at least, in some quarters. Their use was there advocated by some whose names very justly have great influence; and the earnestness and zeal with which the claims of the pessary were set forth may well induce those who

have arrived at different conclusions to re-examine the foundations of their faith and practice.

It is not the intention of this communication to enter into an elaborate discussion of the merits or demerits of the pessary, nor indeed any discussion at all, but simply to relate the results of my own experience, in a village and country practice of more than twenty years.

My first patient was a young girl about eighteen years of age, who had worn an oval-shaped gum elastic pessary for a period of nearly two years, by the direction of a respectable practitioner of medicine. I found on examination of this case great tenderness and thickening of the mucous membrane of the vagina and profuse leucorrhoea, with constant necessity for the catheter to evacuate the bladder, and habitual constipation. As the instrument had not been in a single instance removed since its first introduction, nearly two years, this operation was accomplished as soon as practicable, and a strong decoction of oak bark, sometimes as an injection, and sometimes by means of a saturated sponge, introduced into the vagina, was adopted as a substitute, and the horizontal posture was more or less enforced, but alternated with appropriate exercise. These things, together with an appropriate bandage, for the support of the abdominal viscera, and general tonics, constituted the treatment. The pessary had become such a horror to the patient that it was never reintroduced. Under this treatment, persevered in for about two years, the patient completely recovered, married, and bore children.

The history and result of this case rather tended to shake my implicit faith in the pessary, which my young patient regarded as an instrument of torture; or more properly, I may say, it led me to inquire whether the other means adopted might not in most cases be relied upon instead. However, I was so much attached to my authority, that I tried the pessary in some subsequent cases, but it did not please me. Either soreness, or leucorrhoea, or some other inconvenience, was so troublesome and annoying, that in every case I soon abandoned their use, and resorted to the method indicated in my first case, and with very satisfactory results. I do not question the utility of the pessary in the hands of others, but in mine it certainly failed of its object. But it must be confessed that my experience is more of a negative than a positive character, and in favor of another, and I think a much pleasanter method of treat

ment.

During my professional career numerous cases of prolapsus have fallen under my treatment, though in honesty I am bound to say that I have seen but two cases in which the os uteri presented at the external orifice. Mine have therefore nearly all been incomplete cases of prolapsus, many of them, however, so painful as to prevent the patient from walking or taking any exercise for the improvement of the general health. My treatment in all these cases has been such as I have described above, in direct application of astringents by means of the syringe or the sponge, repeated several times in a day, the horizontal position, alternated with riding in an easy carriage, for the invigoration of the general health, enema to keep the bowels free, an appropriate bandage to support the superincumbent viscera, and general tonics. Of course this general outline is modified to suit the exigency of each case. The best evidence of its success is the fact, that to-day, "to the best of my knowledge and belief," not a single patient that has submitted fully to this treatment under my direction is suffering any inconvenience from the malady. The sponge I make use of is so small that it passes readily through the os externum, so that the nurse or the patient herself may remove and re-apply it several times in a day. The object is not so much to support the womb as to keep the astringent remedy more constantly in contact with the relaxed tissues. I am aware that Prof. Barker recommends it for the former purpose; but as his method would require the almost daily attendance of the physician to re-apply it, the inconvenience of doing it has deterred me from adopting his method. Besides the uniformly satisfactory results for

a period of twenty years make me somewhat tenacious of the old paths.

Perhaps I might say that I regard the bandage as a sine qua non in the treatment. The one I use is made in the following manner. A piece of thin sole leather, from eight to ten inches long, and from three to three and a half inches wide, is taken and made to fit nicely immediately over the pubes. Another soft pad is placed over the spine, corresponding to the front one, each furnished with loops; two strips of saddler's webbing pass around the hips, through these loops, one above the other, and fastened in front, the lower one being a little the shortest, that the pressure may be exerted from below upwards. Another strap, made with rolled cotton, passes around the inside of the head of each thigh and fastened to the other pad, by means of a small ring and an elastic. There is nothing new in this treatment; and if its results should be as satisfactory to others as they have been to myself, the use of that unpleasant instrument, the pessary, would be entirely superseded.

ON THE USE OF LOOPED WIRE

IN THE REMOVAL OF FOREIGN BODIES FROM THE AIR-PASSAGES,
WITH A REPORT OF TWO CASES,
BY J. J. TOMSON, M.D.

OF DAVENPORT, IOWA.

SOME time in the month of May last, a lad about eight years old, whose parents reside in this city, accidentally inhaled into the trachea a piece of clay pipe-stem, about one and a half inches long, and of large size. Dr. Maxwell saw the patient, and used the probang, hoping thereby to dislodge the foreign body and enable the boy to cough it up. After using the probang, with some other means, the boy was relieved, and it was hoped that he had coughed the pipestem up, and perhaps swallowed it into the stomach. He was quite relieved for some six days, running and playing

as usual.

On the sixth day after inhaling the pipe-stem, one of his playmates threw a stone which accidentally struck him upon the back. From this time he became rapidly worse, with all the symptoms of a foreign body within the airpassages. A council of physicians was called, who agreed that there was a foreign body in the trachea, and that an operation was the only probable means of relief to the boy. The operation was performed by Dr. Adler, assisted by Drs. Baker, Maxwell, Fountain, and myself. After the operation, a variety of instruments and means were used, which were not successful in removing the foreign body. In the afternoon of the same day, and the morning following, Drs. Adler and Maxwell made other attempts with no better success. On the afternoon of the second day, about thirty-six hours from the time of the operation, and more than one week from the time of the inhalation of the pipestem, I was requested by Dr. Adler to visit the patient, with himself and Dr. Maxwell. The patient was rapidly failing, and we felt that he would certainly succumb, unless the foreign body was soon removed. After trying the forceps, hooks, etc., I suggested the use of a looped wire. A piece of small wire, about two feet long, was obtained, and looped in the middle, of sufficient size to embrace the end of the pipe-stem (on the same principle as removing corks from a bottle with a string). The patient's head being well thrown back, I proceeded to introduce the looped wire. On passing it down to the right bronchus, it came in contact with the foreign body. At this point, I raised the end which I held in my hand, and pressed the end next the foreign body back towards the spine, so as to pass my wire behind the pipe-stem. The pipe-stem was firmly impacted in the bronchus, so that it required some force to push the wire between it and the walls of the bronchial tube. The wire was passed some two inches or more below the point of obstruction, and then, on gently withdrawing

it, the loop came in contact with the lower end of the pipestem, which was thus easily removed. The orifice of the trachea was closed, and the boy made a rapid recovery.

On the twenty-fifth of last month, my partner, Dr. Maxwell, and myself, were sent for by Dr. Carpenter of BlueGrass, to assist him in removing a grain of corn from the trachea of a child about one year old. The operation was performed by Dr. Maxwell: after which, I passed the loop of wire as in the other case. It was passed down the right bronchus, and passed quite easily the point of obstruction; and on its removal, it brought the kernel of corn into the trachea, which soon after made its appearance at the orifice, and was easily removed.

I wish to call the attention of the Profession to this simple, cheap, and harmless instrument, from the fact that I believe it will succeed in some cases where nothing else will. It can be used with perfect freedom by any one who is acquainted with the anatomy of the lungs, in searching far into the air-passages for small bodies, with little or no risk of producing serious irritation. There are other cogent reasons for its trial which will suggest themselves to the mind of every medical man. I submit its trial, with the cases above reported, to the Profession, hoping that it may be found of some service in such painful and unfortunate

cases.

SUCCESSFUL LARYNGOTOMY FOR TONSILLITIS
INDUCING CEDEMA OF GLOTTIS.
BY RALPH N. ISHAM, M.D.,

PROFESSOR OF SURGICAL ANATOMY AND OPERATIVE SURGERY IN THE LIND
UNIVERSITY, CHICAGO.

R. P., aged about ten years, is a bright healthy lad, who has been subject to cynanche tonsillitis so frequently that those glands have become indurated and enlarged; upon the least accession of cold he has an attack of "quinsy," which usually lasts for three or four days, but has never heretofore produced any alarming symptoms. Tuesday night, Dec. 18, he had a chill; the afternoon of this day he skated, and it was supposed that he thus received his cold by some imprudence when heated from the exercise. Wednesday, the tonsils became much swollen, but no symptoms arose which led to the supposition that it would differ from scores of previous attacks. I first saw him that afternoon; he was sitting up, with some difficulty of breathing, some febrile excitement, and upon examination, I found that with the utmost difficulty he could breathe through the mouth, and that the respiration was through the nose with comparative ease; there was slight deafness, hence I inferred that the swelling was confined to the tonsils, which encroached upon the eustachian tube, producing the deafness. Upon examining the fauces, the opposing surfaces of the tonsils were in apposition, the uvula pushed backwards. The treatment prescribed at this time was the use of sulph. magnes, and ant. et potass. tart., with topical applications to the throat.

Thursday morning, I was sent for at half past six o'clock; found the patient in the upright position in bed, with the respiration very labored, diaphragmatic, with heaving of the chest, and indentation of the intercostal spaces upon inspiration; quick pulse; great exhaustion from difficult respiration during the night. Upon examination, it was decided to apply a 60 grain sol. of nitrate of silver to larynx, if possible. This was attempted without success, owing to the condition of the tonsils, but the effect was evidently bad. He suffered so from the application that I saw no time was to be lost in opening the larynx or trachea. I hastened for my instruments, and returned to find the patient nearly suffocated; countenance anxious and dusky, and death imminent. But little time was lost in opening the larynx, through the crico-thyroid membrane, by means of a trochar, and inserting the tube; relief was instantaneous and great; the color was gradually restored, patient became quite conscious, and sank into a quiet sleep

for a few moments.

To avoid what I consider the greatest danger from this operation, viz. inflammation of the lungs from the admission of cold air, I ordered sponges, wrung out of hot water, to be kept constantly applied to the orifice of the tube during the whole time he wore it. These were changed as often as twice a minute, and the little patient soon learned to insist upon its faithful performance for his own comfort. By means of this expedient, the air inhaled was tempered by heat and moisture to about the same degree as when inhaled through the natural passages. Cough and spasm of the bronchial tubes were also thus avoided, for it was observed if at any time the sponge was too cool, those symptoms were excited. The room was kept at the proper degree of temperature. Tuesday the 23d, I removed the tube as there was no further difficulty of breathing from disease. The wound slowly closed, and for a couple of days gave exit to mucus, sometimes quite inspissated. The patient has recovered without a single unpleasant symptom.

The rapid closure of the glottis I con-ider was hastened by the agitation, excitement of the circulation, and spasm, consequent upon the attempt to apply the nitrate of silver to the parts affected, but only anticipating by a short time what would inevitably have taken place from the disease extending to the glottis.

Upon a review of this case it might be suggested that the proper treatment in the emergency should have been scarification of the glottis, according to Dr. Gurdon Buck's method. This expedient occurred to me, but was precluded by the swelling of the tonsils to that extent that the finger could have scarcely been pushed beyond without the greatest difficulty.

Reports of Hospitals.

ST. VINCENT'S HOSPITAL.
DISEASES OF KNEE-JOINT.

[Reported by WILLIAM O'MEAGHER, M.D., Resident Physician and Surgeon.]

Case 1.-W.C., a youth about 17 years old, by occupation a physician's servant, was admitted May 5th, 1860, under the care of Dr. Van Buren, with chronic disease of the knee-joint of three years' standing, and not produced by injury, as far as he knew. His general appearance indicated confirmed cachexia, and a physical examination of the chest revealed positive symptoms of phthisis, to which he was subject by hereditary transmission; the rational symptoms-cough, purulent expectoration, night-sweats, nausea, anorexia, insomnia, and general emaciation-were also appa

rent.

The condition of the knee-joint was equally unpromising, being very much enlarged, and exhibiting that peculiar doughy appearance indicative of advancing strumous disorganization. The limb itself, from the middle of the thigh to the toes, was quite oedematous; and from a fistulous opening, situated about two inches from the joint on the posterior and outer aspect of the leg, sero-purulent matter continually issued. Motion or touch produced considerable pain; the limb was bent almost to a right angle, and he lay in bed on the sound side with a pillow supporting the affected joint, a position which produced only a trifling alleviation of his discomfort. At first, resection of the joint was intended, as soon as the patient should be in a condition suitable for such an operation. For this purpose he was directed good diet, with milk-punch, beef-tea, codliver oil, with syrp. iod. ferri, tr. iodinii locally to the oedematous extremity, and moderate pressure by means of bandages. But in consequence of the excessive irritability of the stomach only an inadequate amount of nourishment could be taken, and the oil also had to be abandoned for. other medicines.

The local treatment produced a slight diminution of

the oedema, but an abscess collected in the popliteal space, aggravating still more the sufferings of the patient. He grew rapidly worse; so much so, that now the only thought was to alleviate his sufferings as much as possible by anodynes, locally and internally. He continued to sink in spite of everything in the way of nourishment or good nursing, all idea of a resection having long since been abandoned, and for that matter, any hope of saving his life being very faint indeed until the 5th of July, when amputation of the thigh, which had been previously agreed on at a consultation, was performed by Dr. Thebaud, who was then on service. After the operation, notwithstanding the free use of beef-tea, stimulants, and tonics, no healthy reaction supervened; the pulse up to the end being as high as 140. When the first dressing was removed, the wound presented an unhealthy appearance, partial and very imperfect union having taken place, and the end of the bone denuded of periosteum protruding for about an inch, while the integuments and other soft tissues up to the abdomen were filled with offensive ash-colored pus. The quantity of this increased from day to day until he died exhausted on the 12th, two months after admission.

Case 2.-Thomas McI., a single man, aged 31 years, was admitted June 29, 1860, during the service of Dr. Thebaud. This patient is a stout healthy man, of middle size and good constitution, with no acquired or hereditary tendency to disease. About nine years previously to admission, while engaged in playing at foot-ball, he received a kick from one of the players on the lower and outer part of the left thigh, in the vicinity of the knee-joint. This produced inflammation and swelling of the soft tissues, together with effusion into the joint; sloughing of the injured part soon followed, and an artificial opening was made in addition, in order to permit the free evacuation of matter, which continued to be discharged for about eight weeks, when the parts began to resume their former condition, or nearly so, the only impediment observed being a slight weakness of the joint after walking or working. Five months after this, while at his occupation as laborer, he sustained a second injury to the knee by a severe bruise, from which, also, he recovered after a time, while the joint continued in its former weak condition, being occasionally swelled and painful. For two and a half years subsequently, during which the condition of the joint remained the same, he had had no medical treatment. But on the voyage to this country it again became affected, this time more seriously than before; and on landing, he was sent to the State Hospital, where he was treated by blisters and other counter-irritation. From this he was discharged very much improved, and continued so for nine months, when he went to work for the first time. Nothing occurred for eight months subsequently until the following winter, when the knee began to trouble him again, and he was obliged to leave off work in addition, he had several falls on the ice, which aggravated the disease. As soon as he got better, he obtained the situation of coachman in the country, where he remained for six months. At this period he noticed that change of weather always affected his knee more or less. Here again, another accident obliged him to give up this occupation too, and he again entered the State Hospital, where he remained eight months, counter-irritant treatment failing this time to make any improvement, and then left.

On admission to St. Vincent's Hospital shortly afterwards, he was laboring under a slight bronchitis only, without any symptom of tubercular disease, or indeed of any other constitutional affection whatever. Wet cups, leeches, fomentations, and rest, were directed to be repeated at intervals; and in a short time the heat and swelling subsided. The knee was enlarged, stiff, swelled, and painful, with the feeling as if of loose cartilages partially detached, and considerably interfering with the mobility of the joint. The patella, also, was almost immovable, and the ligaments were contracted and indurated: but as the relief was expected to be only temporary, resection was proposed as a final remedy. He declined, however, and soon after left.

He returned again, October 29th, under the care of Dr. A. B. Mott. While out, he had been under the care(?) of a quack, who applied several caustic issues to the part, and injured him greatly. This time the treatment has been solely by forcible extension through the means of a thick band of adhesive plaster, applied as in fractures of the femur, with a weight attached. Under this treatment, a remarkable change for the better has taken place; and the joint has resumed something of its natural condition, while its mobility is very much improved. The only difficulty in the treatment is caused by the frequent breaking of the adhesive strap, and the pain produced by constant weight, which, at the present time (November 30), is twenty-four pounds.

Case 3.-James H., 25 years of age, a married man from the country, was admitted during the service of Dr. Thebaud, May 9, 1860. This was an idiopathic, scrofulous case, somewhat similar to the first, had not existed so long, and of course did not present such an amount of disorganization. The knee presented the usual appearance of chronic effusion and inflammation having existed without any known exciting cause for about two years, and with occasional intervals of exemption from the prominent symp

toms.

The treatment prescribed was, rest in bed, wet cups, subsequently leeches, with fomentations or poultices, until both pain and swelling were considerably subdued. In a short time these seemed to have a good effect, and in order to keep it up a fluid blister was applied, which still further tended to improve the condition of the joint; so much so, that the patient was allowed to sit up and rest the affected limb on a chair. But a serious complication already existed, namely tubercles in the lungs, attended by cough, hectic (at first supposed to have been an attack of intermittent to which he was liable), night sweats, and general emaciation, and in addition he was laboring under acute nephritis. In consequence of this, the local treatment, though not abandoned, was deemed of minor importance, and generous constitutional regimen at once directed. After a while this had the desired effect, and he grew stronger; but occasional exacerbations of the lesion in the joint forbade the hope of an eventual cure; resection was accordingly proposed after an irregular consultation, but the patient was unwilling, and subsequently left the Hospital. I afterwards heard that he had consulted a practitioner outside, who had the joint encased in straps of empl. ammon. c. hydrarg, and prescribed large doses of iodide of potassium internally.

Case 4.-Thomas McC- —, aged 20, apparently of scrofulous constitution, but without the characteristic development, was admitted May 11, 1860, during the same service. His family were all healthy, and he himself had enjoyed good health, with the exception of an attack of intermittent fever. Five weeks previously to admission he had had an attack of rheumatism in the right knee and left elbow, which got so well in a few days under regular medical treatment that he began to walk about, but the knee again became swelled and painful. This time, of his own accord, he used various stimulating liniments, which he thought only aggravated the complaint. The same local depletion as in the former cases was here also practised, and cod-liver oil mixture with quinine ordered in addition; under this treatment a gradual improvement took place, until at the end of a month he was discharged at his own wish with a splint to the posterior part of the limb, as a safeguard. He subsequently returned by request, when the knee was found to be restored to its natural symmetry and function.

Case 5.-Michael K- —, laborer, married, was admitted under the care of Dr. A. B. Mott, June 30, 1860, with chronic inflammation and effusion of the right knee-joint. His general health had been a good deal broken down in consequence of a purulent discharge from a sinus on the outer and lower part of the thigh, within about two and a half inches of the articulation. This sinus and the discharge

had existed for eighteen months, but the origin of the disease dated as far back as his seventh year. He could not say whether or not he had then sustained any injury to the part; but the lower part of the thigh, and also the kneejoint, became enlarged and painful suppuration followed, and the abscess broke; finally, discharging a large quantity of purulent matter. Eleven spicule of bone also came away with the discharge, and then the part healed up entirely for eighteen years, until five years previous to the date of admission, when the pain and swelling returned and continued for more than three years. At the end of this period the discharge recommenced and continued up to the time of admission to the hospital. On examination, a probe introduced into the sinus seemed to pass through the medullary canal, and the bone itself was considerably enlarged in the situation of the sinus to the extent of several inches. The usual methods were used to reduce the swelling and inflammation, and in a short time the local and constitutional condition was so much improved, that an operation to remove the supposed carious portion of the femur was decided on, after a consultation. Accordingly, on the 24th of July, Dr. A. B. Mott proceeded to trephine the bone. A longitudinal incision of about five inches was made in the part down to the bone, and the trephine applied in two places. The intervening bridge was removed by a bone nippers, and the medullary canal exposed to view. In the lower part of this were found about half an ounce of pus, and a small spicula of necrosed bone. Apprehension was now felt lest the pus had penetrated into the joint; but a careful examination failed to discover any intercommunication. The wound was then

filled with shredded lint, and a light roller bandage applied. After the first dressings were removed a copious discharge of pus followed, and this continued without abatement for some weeks, until the wound gradually closed up by healthy granulation, without the occurrence of any bad symptoms. He left the Hospital about the latter end of September in very good condition, being able to walk about with the aid of a stick; the knee also resumed its natural condition and some of its former strength.

Case 6.-Mary C, aged 36, married, the mother of several children, was admitted March 29, 1860, during the service of Dr. Finnell, with left knee-joint in an advanced state of strumous disorganization. Two months previously she received a slight accidental blow on the knee from one of her children, and next day the joint was somewhat painful, and soon became so swelled, also, that she was obliged to abstain from household duties and take to bed. But notwithstanding medical treatment and previous good health, it grew gradually worse. The extremity from the middle of the thigh was oedematous, and fluctuation was felt particularly above and around the joint. Accordingly, an incision was made on the outside of the joint in a depending position, and warm poultices were directed. During the following night, blood and matter were discharged with some relief; but a subsequent opening had to be made in order to remove the collected pus, which the first opening failed to do, and from this an immense quantity of purulent fluid continued to flow. Generous regimen was directed from the first, and stimulants were freely used; still the discharge continued, and the other symptoms were only relieved, without at all presenting any improvement in the condition of the joint. In this case, amputation of the hip-joint was thought of by Dr. Thebaud, whose service succeeded, but the low condition of the patient put this out of the question, and it was soon apparent that surgery or medicine could do nothing to stay the ravages of the disease. A physical examination of the lungs indicated tubercular softening in both, evidenced also by cough, purulent expectoration, and profuse sweats. Soon the swelling extended up to the groin, which aggravated the patient's sufferings a good deal, and the discharge continued as profuse as ever until death occurred.

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