deposit of bone at a time when he was in comparative good health. During the next three or four years after this, while at school, he from time to time would get his shins bruised and the inflammation and deposit were continued. Meanwhile other bones had been bruised: the ulna, radus and frontal bone. Finally, a blow on the jaw produced the first necrosis. The necrosed portion of the jaw, including the alveoli and four teeth, I removed, five years ago, from which he made a good recovery. For three years after this he remained comparatively healthy and well, excepting the inflammation and deposit of bone that continually took place wherever there was a bone near enough to the surface to be injured. Two years ago his system became reduced from a prolonged attack of typhoid pneumonia. Soon after getting on his feet again, he received another blow on the shin that re-established the inflammation; and the vitality being low, caries intervened, the skin ulcerating away, leaving the bone exposed. I put the patient under the influence of an anæsthetic and removed the superficial deposit of dead bone for eight inches up and down the central portion of the tibia and more than half of its circumference, leaving all of the original bone divested only of its periosteum, which had ulcerated away.. Now came the slow process of healing up and covering over the bone with flesh. This was the work of months. It became necessary to chisel away the edges, keeping up a fresh and living surface for the flesh to grow over; in doing which more than half the bone was removed. Skin refused to grow over the newly-made flesh, however, which made it necessary to graft in new skin. I took from a healthy subject from twelve to twenty grafts twice a week until a new cuticle was formed. At this junction the young man's recovery seemed quite probable, when albuminuria set in, changing the whole character of the case. With rapidly declining strength came a renewal of the necrosis of the superficial deposit both above and below the limits of the original trouble, extending down to the marrow above, and below, extending into the ankle-joint. The limb was now destroyed, and there was but one thing to do; that was to amputate. This operation I performed three months ago, using Esmarck's bloodless bandage. The arteries were ligated with the antiseptic catgut ligature; antiseptic sutures were used to hold the flaps together, and the stump was dressed with the antiseptic gauze covered by the protective. The wound healed by adhesion, and the patient was on an artificial leg within two months from the time of the amputation. OSTITIS is sufficiently common to require our most careful study. It is not sufficient to content one's self with pronouncing a case periostitis and prescribing for it as such, without first thoroughly investigating and being fully assured that the bone is not likewise seriously involved. In a diffuse periostitis it is also important to distinguish carefully the diagnostic features so that its true character may be known at the earliest moment, for the destruction of bone-tissue takes place rapidly. Should it be regarded rheumatic when it is diffuse periostitis, the delay of a month may cost the loss of a limb. A case bearing upon this point may be interesting to mention; a young man suffering from what was supposed to be inflammatory rheumatism and treated as such even when the real disease was apparent. In consultation one of the physicians expressed an adverse opinion in the patient's presence, and thereby defeated an intended exploration of the tumor, until a destruction of bone had taken place to such an extent as to compel the removal of the limb. Diffuse periostitis should be dealt with boldly; cupping, blisters, leeches, painting with iodine and if these fail to give relief, time should not be lost; but a bold incision should be made, taking off the tension of the parts and giving exit to the pent-up accumulations whether they be blood, serum or pus. "There are few diseases in which art can do so much and nature so little" in the relief of incessant pain and destruction of tissue. Constitutional treatment is also important; barks, wine, iron, iodide of potassium or iodide of sodium in full doses in conjunction with Stillingia, Sarsaparilla, etc. OSTEO-MYELITIS is a disease difficult of diagnosis and equally difficult to treat. Its symptoms are deep, continuous, boring pain attended with rigors, fever and all the characteristic features of periostitis except the fact that it lies deeper, there being no effusion under the periosteum. The diagnosis is not generally made clear until after amputation or death. Chronic Abscess was first described by Sir Benjamin Brodie. The symptoms are dull, heavy, aching pain in the parts, and like most bone-troubles worse at night than during the day; the pain is circumscribed with slight tumefaction of the soft parts immediately above it, and perhaps some enlargement of the bone. After these symptoms have resisted the most energetic treatment, and after the exclusion of every other disease, the diagnosis is presumed and the trephide is then brought into requisition. Should no pus be found it is not proof positive that there is no abscess, as it may be separated by a thin layer of bone. The walls should be pierced in various directions with a small pointed instrument; and if pus should be discovered, even if it be but a drop, an opening should be made with a chisel, sufficiently large to give it free exit. Necrosis when extensive occurs as a consequence of impeded circulation in its vicinity, as we find in gangrene of the soft parts, impeding the supply of the nutritive plasma. In these cases, where the supply is cut off and a stasis exists, there is nothing for the bone to do but die. The whole bone, however, may be involved and the entire shaft removed; when, should the periosteum remain intact, a process of filling up by bony deposit takes place and the bone is reproduced. Where a large blood vessel is involved there is danger of its being pierced with spicule of sequestered bone, or it may ulcerate, pouring its contents out among the tissues, producing a diffuse aneurismal sac. When the main artery of a limb is involved amputation may be required; but should it be one of the minor arteries, an attempt should be made to take it up and tie it. If it is too rotten for the ligature to hold, the next resort should be to cut down on the artery higher up, and ligate. When the whole bone is diseased, the probabilities are that a cachectic state exists that would so hazard the life of the patient as to make it advisable to leave the cure to the powers of nature, aiding by treatment rather than by operation. Mercury has been an active agent in producing necrosis. In syphilitic cases it is not always easy to determine whether the disease produced the necrosis, but when given for intermittent and other trival affections, its dire results may be traced. I recall at this time an instance in which a dose of calomel was given to a child in an ordinary attack of intermittent fever; ptyalism supervened, and with it necrosis of the alveolar processes of both upper and lower jaws on the right side, resulting in partial anchylosis, so that the person has been fed for years on semi-fluids with a tea-spoon. The course usually followed in getting rid of the diseased bone depends largely upon where the bone is situated. Where the periosteum is destroyed, the bone actually comes away of itself in form of an exfoliation. If it is beneath the periosteum, however, it is generally found invaginated with a casement of new bone, and requires to be cut down upon and removed after separation has fully taken place. A CASE OF STRANGULATED FEMORAL HERNIA, IN WHICH FOUR INCHES OF THE ILEUM WAS DISSECTED OFF, AND THE PATIENT RE- (COPYRIGHT RESERVED.) By S. P. TAFT, M. D., Newark, N. J. I was called January 11th, 1880, in consultation by S. W. Taylor, M. D., to Mrs. Theodore Munn, of Newark, N. J., at 9 o'clock Sunday evening. After making trial by taxis for reduction about half an hour, we partially succeeded in reducing a large knotty tumor, but there remained a hard resisting mass the size of half a goose-egg, to which we called the attention of the patient and her mother, who was present. We asked them if a tumor had existed there previous to this time, similar to the one remaining. We were answered in the affirmative, that one had existed for two years, fully as large as the one still remaining. Having learned that the patient had used a truss for four years, we requested to see it. When we saw the instrument the whole story of the facts in the case were at once revealed. The truss was a straight inguinal, which only properly applies for inguinal hernia above Poupart's ligament. But femoral hernia comes out below Poupart's ligament, and under it one and one-half inches below the inguinal. Therefore the truss permitted frequent protrusions of the viscera until the present enlargement had been established. Hence the gland which covers the saphenous opening had become much enlarged by the omentum and ileum pressing against it and thus irritating it. The omentum had also become thickened outside of the saphenous opening and adherent to the ileum as we afterward learned. Under these circumstances it was impossible to insert our fingers under the enlarged gland, so as to bear directly on the protruding viscera. As what had been done gave partial present relief, we hoped by morning the signs of strangulation might disappear, as the tumor was no larger than it had been for two years. We, therefore, gave a carminative and left the patient for the night, with the intention of applying a truss with a concave pad, to the hard tumor, on the morrow, to cause its absorption by pressure, as we had done in some previous cases. The next day we procured a proper truss, but on visiting the patient we found her still laboring under the symptoms of strangulation, and the tumor was so very sore that it was impossible for her to bear the pressure of the instrument. We were compelled to let the case go on and trust to antiseptic treatment for the reduction of inflammation. We hoped that we might yet reduce the strangulation; but if finally found to be absolutely necessary we should resort to the knife. In two or three days as the symptoms continued to grow worse, we began to think seriously of an operation. But the large inflamed tumor prevented the usual means of knowing where to cut down on the stricture of the neck of the sack, for this may vary in different cases. The stricture may be at the crural ring or at the arch of Gimbernat's ligament, which is at the inner end |
