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medullary canal not being opened, the danger of pyæmia is said to be lessened, and the risk of purulent infiltration diminished by the presence of the synovial lining of the flaps, serving as a barrier between the joint and surrounding parts.
In contrast with this example of conservation is the aggressive one of extirpating the entire larynx for malignant forms of disease, as practised by Billroth and others. It will require a much larger number of cases than we yet possess to determine whether such a procedure is legitimate or rash. The operation is based upon the sole consideration of an uncertain period of comfort. It is said that a man suffering from so horrible a disease eagerly accepts the most desperate alternative. There are cases, it is true, which, like scales oscillating toward a possible equilibrium, demand some venture, the surgeon may, Brennus like, cast the scalpel into the balance, and gain the day; but these are cases in which the cure is not against experience. It is said that an operation is vindicated from all charges of raslıness when a patient is rendered more comforta ble, though his life may be shortened by its performance. I do not accept this statement, nor is there any moral sanction for such a doctrine.
A few months since I published a short notice of a new mode of amputation, adapted to portions of both the upper and lower extremities. It may be considered a compromise between the cutaneous and musculo-cutaneous flap methods. It is designed to obviate the objections urged against the tegumentary flap, that of hazarding its vitality from the distance of the blood supply, an objection not without foundation; and, on the other hand, avoiding a defect in the musculo-tegumentary flap, which is due to the unequal retraction of the two constituents of the flap, and by which the muscles protrude below the level of the skin, requiring that the former be tucked under, in order to secure the apposition of the integument. The operation consists in raising two oval flaps of integument from the deep fascia on opposite aspects of the limb for a short distance, say one inch, or to an extent sufficient to compensate for the difference of retraction, and then dividing the muscles obliquely backwards from the base of the reflected skin to the bone, or transfix and cut the same structures from within outwards. In the few cases in which I have made a practical application of the method, the result has been most satisfactory, securing as it did a very accurate and even adjustment of the parts, followed as a consequence by quick union.
Within the last year I have had an opportunity, in three cases, to test the practical value of an anatomical fact which I pointed out
some time since, namely, that when in the ligation of arteries from inexperience or morbid changes, the proper inter-muscular space cannot be recognized; the surgeon by noticing the points where the cutaneous vessels pierce the deep fascia will be able to proceed without hesitation, as these branches lead unerringly to the vessel in question.
The subject of urethral stricture and its treatment is one on which men differ widely in practice and teaching. Caustics, incision, dilatation, and disruption have all had their advocates. How to prevent a relapse or return of the constriction has been, perhaps is still, the problem for solution. Dr. Otis, of New York, believes he has solved this vexed question, and that the whole secret consists in being able to ascertain exactly the normal size of the urethra, and then after dividing the stricture, stretch the affected portion of the canal to the required or normal degree. The doctor by repeated measurements has found that there is an undeviating relation between the circumference of the flaccid penis and the calibre of the urethra, the difference being expressed by the bougies of the French scale-as, for example, a penis measuring 3 inches in circumference should receive without any sensible resistance a number 32 bougie. The instruments which constitute the armamentarium of Dr. Otis are the following: a urethrometer consisting of a long canula terminating in six steel springs, which can be opened or closed at pleasure by a screw attached to the handle; and in front of which there is a scale, the figures on which correspond to the number of the bougie plate. After being conducted into the tirethra, the springs are expanded until the patient begins to realize some resistance, or as long as the bulb moves freely in the canal; the degree of expansion is registered by the index on the scale, and the operator has now the number of the bougie which the canal should receive. The next step consists in conducting into the urethra after the removal of the first a second instrument, which combines the means for dilatation, incision, and measurement. It is carried through the stricture, its blades screwed asunder until the dial-plate records the normal expansibility of the canal, when the blade of the urethrotome is made to divide the constriction. The novelty of the method consists in ascertaining the natural dimensions of the urethra, and maintaining the same by dilatation and incision. The results obtained by Dr. Otis are very flattering, but without any disposition to decry or under-estimate the statements of this distinguished member of our profession, I may be allowed to express my conviction, that after all it will be the old story, that of having occasionally to employ the bougie to prevent relapse.
In the treatment of fractures, a subject of the greatest interest to both physician and surgeon, I find nothing demanding any special notice. In regard to fractures of the thigh, there has been the usual clamor over the merits of immovable dressings, and the treatment by adhesive plaster, weights, and sand-bags. For universal application, the latter I regard as in every way preferable. The ground over which the whole battle between plaster and adhesive straps has been fought, is about a quarter or three-eighths of an inch in extent; a matter so far as the usefulness of the limb is concerned, amounting absolutely to nothing. In the management of fractures, I have always aimed at simplicity in dressing, and would notice, in passing, a splint which I have devised for the treatment of fractures of the patella, and which from its simplicity seems to be worthy of mention. The two advantages which it possesses, are readiness of construction, requiring a minimum of mechanical skill for its preparation, and the absence of all necessity for a change of dressing until the cure is completed. See Fig. 1.
Explanation.-This splint being padded, is placed beneath the limb, and adhesive strips applied above and below the broken bove. These strips are passed around the pegs, the shoulders of which are eight-sided to fit into openings of a similar form in the sides of the splint, and which serve to prevent their slipping. Once adjusted, the stripe can be readily tightened by withdrawing the pegs a little, giving them a turn, and then pushing them into the holes where they become fixed.
Whatever is calculated to throw light upon obscure injuries of the hip-joint is always worthy of notice. Dr. Allis, of this city, has suggested a new mode of measurement with a view to establish the differential diagnosis between dorsal dislocation of the femur and fracture of its neck. It consists in placing the limbs at right angles with the body recumbent. If the case is one of fracture there will be little resistance in carrying the leg to the required position, and the shortening as compared with its fellow will not exceed one inch, whereas, if it be one of luxation upon the dorsum of the ilium, it will require considerable force to bring the limb to the required right angle position, and, when accomplished, the shortening will be not less than two or three inches.
I have, gentlemen, thus rapidly passed over a wide domain, gathering here and there what has been deemed worthy of preserration and perpetuation. That omissions have been made I doubt not; enough, however, has been gleaned to show that as each year rolls by, the patrimony of medicine is enlarged. The specialism of the day has contributed largely to the increase of our medical possessions. This outgrowth is not an excrescence, but a purely philosophical development of general medicine. It is only a repetition of what belongs to the great commonwealth of literature, and entirely consorts with the doctrine of original differences in the primary qualities of mind conferring special aptitudes for different lines of thought. Addison, though master of the English language, was no orator; Cicero, though he could move senates like the swaying trees of a forest before the march of a tornado, had no poetic fancy; and Sterne, while his pathetic and descriptive powers could throw a charming sadness over the mind, always became common, if not contemptible, when he essayed the humorist. And so in the profession of medicine, there is no genius so universal, flexible, versatile, and far reaching as to subjugate and chain to its triumphal car every department of medicine; any one will prove more than a sufficient field for the most zealous and industrious worker. Better let it be proclaimed of the doctor, what Madame de Staël has so beautifully said of a sculptor, “the history of his life was the history of one statue.”
THE ADDRESS IN HYGIENE.
BY BENJAMIN LEE, A.M., M.D.
MR. PRESIT ENT AND GENTLEMEN :
The views which I put forth in the address which I had the honor to deliver before you last year, upon the possible causation of typhoid fever by polluted water and milk, were received, to my astonishment, with so much incredulity—nay, I may say provoked such determined opposition—that I feel it my duty to make a renewed effort to compel the acquiescence of every intelligent, thinking man among us, in this fundamental dogma of the sanitarian. Thinking to proclaim a well-accepted truth, I found myself then looked upon as "a setter-forth of strange doctrine,” a “pestilent fellow," poking my nose into other people's wells. It is my desire to embrace the present opportunity accorded me by your kind courtesy, to procure a reversal of this decision.
To this end, I shall make use of the valuable matter contained in the reports of county societies sent in at the last meeting, and since published in the Transactions for 1875, and of such facts, recorded by trained and thoroughly reliable observers both in this country and abroad during the past year, as have a direct bearing upon the subject. And, in this connection, let me say that, as a member of the publishing committee and thus led to look over the reports of many of the county societies with some care, I feel that the State Society does itself an injury in invariably turning these reports over to the committee without hearing or discussion. There is much material in them provocative of thought, and calling for the expression of opinion. This is the legitimate channel for the introduction of topics of scientific interest, and a session might be given up to their consideration with infinitely more profit than to determining questions of ethics, and settling angry personal disputes between rival practitioners. And yet the proposal that a portion of a county report be read, always appears to be looked upon as an unwarrantable piece of impertinence—the reading itself as an intolerable infliction. Asking your indulgence for this digression, I now call your