and but a slight stretching of the ligaments; there is no denuded bone and I hope for improvement. Chronic Mammary Abscess. Our next patient, whom you have seen in the wards, has a chronic mammary abscess. She has made no improvement, and has therefore been brought in for treatment. Two months ago she was confined with her first child. Within six weeks she had the so-called "broken breast," and has been three weeks in the hospital. At present the question is, What is the speediest method of arresting the suppuration and healing the abscesses? The trouble is in the right breast, which, you will notice, is not much larger than the other, for it is going through the process of shrinking. It still has milk. In the left breast are the marks of leech bites and the cicatrix of a small abscess, now healed. In the right the abscess has existed for six weeks. Ordinarily the simplest form of abscess arises under the skin near the nipple; another variety forms deep in the breast between the lobes of the gland; and a third, beneath the breast, creates a sac, upon which the former floats. The difficulty here is that although milk is still secreted, pus continues to burrow in various directions. A free incision should at once be made. How do we make this incision? If necessary to incise near the nipple, we cut parallel with the milk ducts, which run into the nipple precisely as the spokes of a wheel enter the hub. If we cut the ducts, or if the abscess break into them, we have a lacteal fistula, and milk and pus mingle in the same discharge. Here only pus flows from the abscess. Incisions have already been made, but the burrowing of the pus still continued. We then tried compression by strapping, leaving openings opposite the sinuses, but, with the exception of the shrinkage of the breast, this treatment effected nothing. Two days ago the director went a long distance into sinuses, which to-day the patient has given us permission to open. Sometimes I should use the seton, because it seems to wake up healthy inflammation in the sinus into which it is introduced. When this change has occurred we withdraw the seton, and the sides of the sinus come together, granulate, and heal. This is a very obstinate case. I take the director, and here find a skin sinus, which does not require a seton but the knife. Here, just under the skin, I find a collection of pus, - here another sinus going down deep into the gland, and here still another skin sinus, - altogether quite a variety of openings and sinuses, namely, three under the skin, one going to the base of the gland, and one which has been opened and has healed. At present I do not think it advisable to use the seton unless I should make some new discovery. Certain of these openings may communicate with others; some of them run deeply and do not seem to come out again. Consequently, I think it wise to slit up the skin sinuses and widen the mouths of the deeper ones, and afterward strap again. When the patient came into the hospital she had a dark, cutaneous eruption, which suggested a specific origin, and, although we can get no history of syphilis, I propose to give her the following: gr. i. This forms a combination of specific and tonic, and will do her good. I have now opened a suppurating tract, which is covered by a false mucous membrane, and is secreting pus. The incision, together with exposure to air and application of pressure will probably change its character and cause it to heal. Here is a milk duct which has been perforated by the abscess, and through this opening milk exudes. So that we have not only a sinus, but a milk fistula as well. Slitting up the skin sinuses of course does not interfere with the future usefulness of the gland. From the deepest sinus of all comes the exuding milk. I propose to enlarge the opening by means of the sinus dilator. In tissues of this kind dilatation is preferable to cutting. I find that this sinus goes beneath the breast to the pectoral muscles. Probing now the other deep sinus, I make the discovery that at the bottom these two sinuses are very near together. I make them one, and pass in a seton, which I finally conclude will here be most useful. This is a very instructive case, because it is like those we meet in private practice, and which last so long that they sometimes lead the patient to fear that cancer is the real source of trouble. We shall poultice this breast for a few days, and let it discharge through the sinus we have left. At the end of a fortnight we shall find that a great change has taken place. Solid Tumor under the Pectoralis. It has always struck me as being a very curious thing that cases of similar nature often come to us in groups. This is frequently the experience in private practice. For example, you will recall the case of the other day in which there was a swelling beneath the left breast and in the axilla that proved to be a suppuration. That patient is nearly well. Here, now, is another similar case. The condition of the breast indicates that there never has been any trouble in the gland. Meanwhile, under the pectoral muscles and in the axilla is a condition identical with that found in the case of a fortnight ago, namely, enlargement of veins, high pulse, swelling, etc. What is odd here is that the swelling has come and gone for nine months, while the other case has a history of a few days only. During the last two weeks the patient has had cough and headache, but no marked chills. On the 15th the temperature was 101° A. M., 103° P. M.; 16th, nearly normal; 17th, 101°; and so it has varied, accompanied by fever, which has now disappeared. The history, then, is that of constantly alternating processes. The swelling is more lobulated than that in the other case, and although it is probably composed of enlarged lymphatics and an abscess, it may be something else. In fact, now that the patient is under ether, and I can freely handle the enlargement, I find it feels more like a solid tumor than it did before I was able to examine it as I now can. I did propose aspiration, but the tumor being a hard mass I of course abandon that form of treatment. What should be done is enucleation of the tumor, but having until now had no time to complete my examination of the growth, I could neither inform the patient of the necessity of an operation, nor secure her permission to perform it. There is nothing to do, then, but reserve the case for another day. [Three days later, under ether, a free crucial incision was made in the axilla, the pectoralis lifted, and a large lobulated mass of lymphatic glands excised. The operation was done under antiseptic spray.] Syphilitic Constriction of Pharynx. - This patient is an extremely interesting one. He was brought into the hospital three weeks ago with such an extraordinary syphilitic constriction of the throat as to be barely able to swallow or breathe. At his request I at once performed tracheotomy, which has relieved his respiration. When not under ether, he breathes very comfortably. The case is similar to one shown you last week, except that the other had not gone so far as this has. To-day I propose to dilate the constriction, which is so extreme that the tip of my forefinger, will not pass up to the posterior nares, while the opening into the throat will not admit the end of my little finger. The strictures are very firm both above and below, and the pharynx has lost its mobility. I first try a conical urethral bougie, which passes to a certain distance, then bends; substituting another loaded with lead, I find it goes through the stricture and into the oesophagus. I now take larger, rectal bougies, and now my finger, dilating as much as I deem prudent. [One week later.] The constriction has improved to such a degree that the forefinger now passes easily up into the posterior nares. The opening downward, which would not admit more than the little finger's tip, now receives the end of my forefinger. The wall of the constriction, both above and below, seems to have become lessened by absorption, and the patient eats and drinks with more ease. He was rendered so uncomfortable by the ether administered last week that to-day I shall dilate without anæsthetic. Beginning as before with the conical bougie, I next take the rectal bougie, and finally my forefinger, which I succeed in passing quite beyond the stricture, which appears to be a firm zone about two inches in depth. Systematic dilatation will undoubtedly do much to relieve the patient. He still wears a tracheal tube, the first one having been replaced by a second, which is goldplated and very comfortable. OBSERVATIONS ON THE MECHANICAL TREATMENT OF DISEASE OF THE HIP-JOINT. BY CHARLES FAYETTE TAYLOR, M. D., NEW YORK. IN my intercourse with medical men I am so impressed with the amount of misconception of the means used and the paramount object aimed at by the advocates of mechanical treatment for disease of the hip-joint, that I desire briefly to set forth my own views in regard to some of the ideas and the more important methods which considerable experience has seemed to establish as controlling in such cases. The subject may be introduced in the form of the following propositions, namely: First. All organs while in a state of disease require rest from the performance of their functions in the direct ratio of the amount, quality, and intensity of the abnormal movements. Second. What is rest for an organ in one condition is not necessarily rest for it in another condition; that is to say, an organ, in a certain degree of progressive inflammation, presents conditions essentially different from the same organ in the same relative degree of inflammation in the retrogressive stage. The so-called "mechanical" treatment of hip-joint disease, so far as I understand it, is simply the working out to practical conclusions of responses to indications to which the above propositions give the keynotes. The difficulty with the non-specialist in these cases is that he is apt to give altogether too much importance to appliances and too little to the varying states of the disease. While he is contemplating different kinds of "splints" the disease is carrying off his patient. If he would seek only for the exact indications, the best means for responding to them would be likely to suggest themselves, and he would be surprised to find how simple and easy it would be to effect his object. The mechanical treatment of hip-joint disease is not a question of splints, nearly everything can be accomplished by cheap and home-made appliances, once the condition is clear in the mind, but one of different conceptions of symptoms. The particular means of answering the indications must follow the conception. They do not, or at least they ought not, to precede it. Now, heeding the logic of hip disease, we attempt first to ascertain and then to answer all the indications. The first is to give rest to the diseased joint. The plaster-of-Paris and other dressings, sand-bags, and similar means give rest only in part, and the lesser part at that. This is our conception of the case. For rest from motion is relief from only the minor labor of a diseased hip-joint in the acuter stage. The pressure from irritated muscles at this time is a much greater evil than motion alone could be. To overcome the injurious pressure from irritated muscles is, then, imperative. Hence, we must stretch them, and we find that practically a splint is more efficient than any other means, because by a splint we can secure the more definite and concentrated effect of counter-extension, and a splint also enables us to enforce a better hygiene. There seems to be a general quandary in regard to the amount of extension which ought to be employed. There never was a question more easy to answer. We must carry extension until the muscles relax, and then we must maintain the extension until they lose their irritability and the inflammation in the joint has been given time to become retrogressive. This process will require, on an average, from three months to eight or twelve, depending on circumstances. But there are indications for extension so long as the muscles are rigid, and until there is evidence of material subsidence of the inflammatory action. Then, with the setting up of the reparative process, there should be motion in the joint in order that the reparation shall be accomplished under the stimulus of motion. For, when the retrogressive process has advanced to a certain stage, immobility, which in the acuter stage secured one kind of rest to the joint, becomes with the altered condition of that organ a burden or a labor, tending first to retard and then seriously to modify the nature of the reparative process going on in the joint. Long before the articular surfaces can bear pressure without injury they require the stimulus of motion for the perfection of the reparation going on within them. Immobility at this stage stimulates plastic exudation and union between the joint surfaces, while motion determines the formation of reparative tissue similar to and to answer the purposes of that which was injured or destroyed. If immobility of a healthy joint causes plastic exudation and anchylosis, of which there are many examples, then much more ought we to expect, when a previously diseased joint is motionless, that adhesions of the joint surfaces would take place. And this, in my experience, is actually the case. In other words, if immobility of a healthy joint causes a morbid process to be set up, we ought to expect that such a process would be set up in opposition to the reparative process when a corresponding stage is reached in recovering. The lim Thus we see that "extension can cover, as a means of treatment, but a certain portion of the time through which an inflammation of the hip-joint must pass in its several stages. There are positive indications for extension, but there are as positive limitations to its use. itation is reached at the point of time when the muscles have become soft and compressible, and the interstitial movements have become completely retrogressive. From this moment reflex irritation of the muscles ceases entirely, and with it the necessity for extension. Motion, also, which might do injury — was sure to do injury if there had been the least pressure in the joint-at a previous stage, becomes now a necessity to a perfect articular hygiene. So that the indications become completely changed, and the methods which had been efficient up to |