CLINICAL REPORTS.
Pennsylvania College, Ninth below Locust street. Service of
Professor Gilbert.
Reported by AV. H. Gobrecht. M. D,
Dec. 22d. George W. S-----, (Case L.) Varus of both feet, ex-
hibited, apparatus removed, and re-applied. The feet show a
much less decided tendency to their abnormal position than at
the last dressing.
Anna J. S-----, (Case XLIX, Operation for effects of Burn,')
reported progressing as favorably as possible under the unfa-
vorable influenza complication.
Dec. 2Sth. John P----, (Case XXVII,) Tenotomy.—The arm
and hand are found nearly in a straight line, without any ten-
dency to a return to the abnormal position. The splint is ordered
to be entirely dispensed with, and the use of the fingers and
wrist restored by passive motion. The wrist is found much en-
larged in its antero-posterior diameter. This results from a
change in the form of the carpal bones, the effect of the anterior
muscular contraction, which withdrew them from their normal lo-
cation, subjecting them to such alteration. As a consequence of
this alteration in the configuration of the carpus, when restored
to its proper situation, some deformity must exist, but which in
such a youthful subject disappears by the progress of growth.
The case should be occasionally looked to, and if any tendency
to the old deformity re-appears, the splint should be again re-
sorted to.
Case LIII. Chronic Pharyngitis.—Michael K------, aged 39.
Marble polisher. (Was a soldier in the Mexican War.)
This patient complains of pain in the throat, which is dry, whilst
he is quite hoarse. An elongation of the uvula which existed
was snipped off by his previous attendant. Whilst in Mexico he
had obstinate Diarrhoea, and has had Dyspepsia for a long time.
On examination of the throat, chronic inflammation of the mucous
membrane of the pharynx is found to exist, which inflammation
has extended into the larynx.
Prof. Gilbert states that ho has seen and treated very many
cases of this kind, occurring in clergymen and theological students,
and has always found that there is accompanying gastric disturb-
ance ; he therefore administers remedies addressed to the stomach,
as, one-fourth of a grain of Nitrate of Silver, thrice daily for several
months. This treatment is then replaced by Sulphate of Copper,
Sulphate of Zinc, and Iodide of Potassium, successively, in alte-
rant doses, after which the Nitrate of Silver is again resorted to.
The patient is ordered :
JJ. Argenti nitrat. gr. x.
Mic. panis q. s.
M. ft. in pil. No. XL.
S. One thrice daily.
When the stomach has its proper tone restored, the throat will
return to its normal state.
The diet should be farinaceous, with milk, and is to be taken
in moderate quantities at regular periods.
Moderate exercise should be resorted to in good weather.
Case LIV. Contusion of Right Shoulder—Justus S--------, aged
one year. This patient was sent to us under the belief that the
injury was a luxation of the humerus, but examination, notwith-
standing considerable swelling exists, proves that the bones oc-
cupy their proper relative positions; whilst the inability to elevate
the arm, results from severe contusion of the deltoid, which is
painful on pressure. The following liniment was ordered to be
rubbed twice daily upon the contused parts :
Ji. Linamenti Ammoniac	f.^ij.
Tinct. Opii	f3ss.
and a bandage applied to restrain motion of the arm.
Jan. Sth, 1853. The tumefaction has subsided and luxation is
proved not to have existed.
Case LV. Varicose Ulcer.—Michael N---------, aged 48. This
patient has an ulcer on the anterior part of right leg, above the
ankle, of long standing, resulting from varicose veins in that limb.
In any case, so long as this condition of the veins, which are both
enlarged in calibre and thickened in their coats, exists, no cure of
the ulcer can be effected; and should we find, as we most frequently
do,that the elastic laced stocking fails to support the vascular walls,
or to prevent their rupture, we must employ some method to pre-
vent the return of blood through the superficial veins, and change
its direction into a deeper channel. To do this, caustic has been
applied to the principal venous trunk; the ligature has also
been employed, but the best plan is to pass a pin beneath
the principal vein, and then to apply a figure of eight ligature
about its projecting extremities; the pressure thus produced on
the sides of the tube shuts off entirely all communication of the
lower with its upper portion, and the pin, if allowed to remain, will
cut itself out, thus completely dividing the vessel; but the estab-
lishment of inflammation usually effects obliteration of veins, and
this is sufficient. A needle was then passed beneath the internal
Saphenous vein of the right side, just above the knee, by pinch-
ing up the skin and superficial fascia containing it, and intro-
ducing the instrument from before, backward, close to the posterior
wall of the vessel. The ligature was then applied. Dressed
with an adhesive strip.
Sth. The needle still remains, the veins have much diminished
in calibre, the ulcer is moist with pus, and the edges are cica-
trizing.
Sth. Needle removed to day, and the following application
ordered for the ulcer :
$. Cretao. ppt. 5ij.
Cerat. simp. ji.
M. ft. in ung.
S. As directed.
The ulcer is still improving, granulations are abundant, and
cicatrization progressing. The varicose veins have disappeared
entirely. In these cases the blood returns through the deep
seated veins.
Case LVI. Result of lacerated wounds, with comminution of
bones of foot.—Jacob B------, aged 23, about five years since, had
his left foot caught and crushed between two canal boats; there
was bad compound fracture of the metatarsus, and extensive lacera-
tion of the soft parts. With great care, however, the foot was
saved, but there has been a loss of much of the soft tissues in the
sole, whilst the breadth of the foot is diminished. Since the period
of primary cure, some exfoliations of the metatarsal bones have
occurred—two or three orifices now existing in the outer part of
the plantar aspect of the foot, communicating with the metatar-
sus, which lies immediately beneath the integument. The foot,
however, whose articulation with the leg is perfect, will doubtless
become much more useful than any artificial limb could be, for by
adapting to the sole an elastic air or other cushion, pressure upon
the bones will be obviated, and thus repeated ulcerations pre-
vented. Prof. Gilbert stated that this patient was treated origi-
nally by his friend Dr. Case, of Liverpool, Pa., whose efforts to
save the foot have been eminently successful.
Jan. 5th, 1853. Case LVII. Paralysis of right side of face.
—This patient, a colored man, states that he had Mumps, and a
resulting abscess was lanced, since ’which time his right 'eye
has remained constantly open, and none of the muscles of that
side of the face, wdrich is perfectly flat, move at all, neither is there
much feeling about it. The portio dura, (the nerve of motion
of the face,) has evidently been divided in this operation, and
hence the paralysis. "Whilst no treatment will be available, no
danger is to be apprehended from this condition of things.
Case LVIII. Tremor of left Cheek. Eliza D--------, aged 20.
This enlargement in the substance of the left cheek was first no-
ticed about four weeks ago, since which time it has gradually
increased; it is quite moveable, having contracted no adhesions
with the surrounding structures. On examining the teeth, two
in the lower jaw, immediately opposite the tumor, were found de-
cayed ; believing that this tumor arose from inflammation at lhe
roots of these teeth, resulting in the formation of pus, and an at-
tempt at the establishment of a sinus, for its escape from the
alveoli, the decayed fangs were extracted, and Tincture of Iodine
painted over the surface of the enlargement. The patient is now
brought forward, to show the diminution of the external swell-
ing, both from the establishment of a proper outlet within, for
the pus formed, and the absorption of the effused lymph as a re-
sult of the Iodine application. If the progress of this case had
not been thus arrested, an opening for the discharge of the abscess
would have been formed in the lower border of the cheek, and
this would have become fistulous, -with continued discharge of pus
from the diseased fangs and alveoli.
Contusion of Hip. Salone T-----------, (Case XLVIII.) In this
case the bandages have been entirely removed, all tenderness of
the joint has subsided, and the patient walks perfectly well,
devoid of any lameness. The most important element in the
treatment of all articular affections, viz., rest, in this case, by
means of the immoveable dressing, has been the efficient means
by which this successful result has been attained.
Case LIX. Tinnitus Aurium. James R--------------, aged 35,
states that about three years since he first noticed a constant
noise in the left ear like the blowing off of steam, which has ex.
isted ever since, with more or less intensity. It was supposed
to arise from a severe cold, which he had contracted at that
time. Prof. Gilbert mentions an instance of the same symptom
following concussion of the brain, in a case treated by him re-
cently. It is probable that in this instance inflammation of
the external ear has extended itself through the internal ear to
the membranes at the base of the brain.
Creasote, as a counter-irritant, was painted freely over the
mastoid process of the temporal bone, and Calomel, 10 grains,
prescribed, to be followed in two hours by Magnesia, a drachm.
Jan. Sth. Not much relieved. (This patient works in a fac-
tory as a weaver, where there is a constantly aggravating noise
around him.) Creasote re-applied, and another purge prescribed.
Case LX.—Dislocation of right thumb. William A--------, aged
26, presents himself with a dislocation of the right thumb into the
palm at the metacarpo-plialangeal articulation, occurring eighteen
days since, during which time two unsuccessful attempts have,
been made for its reduction. The patient being seated, the clove
hitch was applied to the first phalanx of the thumb, for extension,
whilst the arm, semi-flexed, was grasped above the elbow, for coun-
ter-extension ; the external lateral ligament of the affected joint
was then divided by Ilypodermatomy, and the proper forces
steadily and perseveringly applied by means of the hands of as-
sistants, without much effect. The twisted rope was then attached
to the clove-hitch, whilst the arm was secured by a folded sheet
to a fixed point, and the forces re-applied with greater intensity,
when, but little benefit following, the internal lateral ligament
was divided, and then the thumb was brought very nearly, but
not altogether, into its proper position.
At this time it was deemed advisable to make no further ef-
forts at the reduction. A splint was applied and the cold water
dressing ordered.
Case LXI.—Convergent Strabismus of right eye, in Elizabeth
B-----, aged 20, was operated upon, -with perfect relief resulting.
The deformity in this case was unusually great. Section of the
tendon of the internal rectus, with the intermuscular fascia above
and below it, was sufficient without interfering with any of the
adjoining tendons.
The success of this operation depends upon the complete
division of the tendon. Sometimes the blunt hook slips be-
tween the longitudinal fibres, and these, when undivided, if
ever so small, will prevent the eye from returning to its normal
position. There is very little after treatment necessary. The
eye need not be covered; if painful apply cold water.
Case LXII______Congenital, oblique inguinal Hernia, occurring
in Thomas H-------, aged 8 years, was exhibited, and Hull’s truss
applied. In these cases there is no proper hernial sac, but the
intestines pass down into the cavity of the tunica vaginalis testis
■which is continuous -with the general peritoneal cavity, the con-
tinued existence of the hernia having prevented the early oblite-
ration of the peritoneal canal connecting them.
Jan. 8th. Abscess beneath fascia lata of left thigh, (Case XLV.)
This patient, Ellen C-----, has walked imperfectly for several
weeks past, complaining, however, of no pain. A superficial ulcer
has appeared near the opening of the abscess, and one or two
elsewhere, evidently strumous in character. She is ordered good
and nutritious diet, fresh air, daily ablution with warm water
and friction with a coarse towel; also,
B. Liq. Iodinii comp. (Lugol’s sol.)
S. gtt. vj. thrice daily.
Case LXIII.—Congenital varus, right foot, in Robert C----.
aged 1 month, to.be operated for on 12th inst.
The subject of the Etiology of Varus is interesting, as it is in-
volved in doubt. Under it we have to consider the question of He-
reditary transmission, as well as the influence of the mother’s mind
during gestation. Upon these points many confirmatory facts
are adduced, which have undoubted weight, although authors ge-
nerally stand aloof from a participation in their consideration.
But however we may view this matter in the present case, it is
stated that the child’s grandmother on the mother’s side had club-
foot, and that the father, (Case LXVII.) often during the last
three years, had violent cramps in the right leg, which the mother
(being pregnant) held and rubbed, frequently much frightened
by their great violence.
Such facts are being made known to us constantly, and if they
have no participation in the production of club foot they certainly
form with it very singular coincidences.
12th. The operation for subcutaneous section of the tendo
Achillis was performed in the usual manner, and Prof. Gilbert’s
apparatus applied.
15th. The puncture in the integument is found closed, the
tendon elongated, and the foot very nearly in its normal position.
Case LXIV.—Ptosis. Robert R--------, aged 37. This patient
has Ptosis, or falling, in his case, of loth upper eyelids, the effect
of a blow which occurred seven years ago, by the falling of
a piece of timber, 'weighing about a hundred pounds, from a height
of some eight feet, striking the upper and back part of the head in
the median line, cutting the scalp and felling him, upon which the
patient arose at once, but immediately fell again, being insensible
for some time thereafter. lie states that no especial treatment was
resorted too, so that concussion, most probably, existed only in
the first and second stages, the third or Inflammatory stage not
supervening.
In about a year from this accident the Ptosis appeared. On
examining the point of injury in the cranium, we discover a slight
depression. It is possible that this affection may be the remote
result of contre coup, or that there may have been a portion of
the inner table of the skull detached, (since the patient often
perceived a sensation as of a loose foreign body beneath the
injured point,) effecting this change by producing remotely a
paralysis of the nerve supplying the levator palpebrse.
In some instances, Ptosis results from disorder of the digestive
functions, and is removed by abstracting the cause. This condi-
tion is not found here. In this patient the relief of the affection
would be obtained by removing an elliptical portion of the integu-
ment of the upper lid, and then bringing the lips of the wound
together by the twisted suture ; in this manner the occipito-fron-
talis would be made to act more directly upon the lid and perform
the function of the paralyzed muscle, which indeed it does to a
great extent at the present time. But as the ptosis, in this in-
stance is so slight, the patient seeing quite w’ell by throwing the
head a little backward, the operation is not recommended unless
it should become worse.
Jan. 12th. Case LXV. Enlarged Lymphatic Clands.—
Amanda M--------, aged 25, of scrofulous diathesis, is shown to
have enlarged lymphatic glands on the left side of the neck.
Foi' which the external application and internal administration
of Iodine is directed.
19th. Improving.
Case LXVI.—Sinus in Left Cheek.—Delia M------------, aged 20.
This patient has a sinus in the left cheek, whose external open-
ing, through a fungus excrescence, is found at the middle of the
left side of the base of the lower jaw, the result of an abscess
which formed here a short time since. On examination of the
mouth, a decayed fang of the first molar is found in the lower
jaw, which has doubtless been the origin of the succeeding af-
fection. Inflammation has been set up at its apex, and suppu-
ration following, the pus has forced a passage through the
alveoli, formed an abscess in the cheek, and discharged exter-
nally. As long, therefore, as the fang plugs up the socket, this
fistula will remain, whilst adhesions will be contracted between
the now consolidated integument and the bone, demanding at
length a more extensive operation than mere extraction of the
offending fang, -which is always necessary, viz : extirpation of the
fistulous tract.
The fang was then removed, and a poultice ordered to the ex-
ternal orifice of the sinus.
19th. Inflammation in the sinus is much diminished, and the
case is progressing favorably.
Jan. \5tli. Case LXVII. Spinal Irritation.—Robert C-----,
aged 32. Carpet weaver. Some three years and a half since,
this patient was first troubled with convulsive motions of his right
leg, which gradually increasedin intensity until about six months
after their commencement, when he had cramps in both legs,which
finally became general, almost amounting to a convulsion. Such
attacks as these have recurred at uncertain intervals, of two, four
or six weeks, up to this time. (Edema of the right leg exists
to some extent: the appetite is good, and the action of the
bowels normal. The patient is slowly emaciating, although the
spasmodic attacks are not increased in frequency.
Pressure over the spine in the lumbar region produces decided
pain in the right knee and thigh, from which we infer that the con-
vulsive movements are dependent upon chronic inflammation of the
meninges of the spinal cord, the nerves being unduly compressed
at their exit from the canal. From the long standing of this
case the best counter-irritant will be a Seton placed in the lum-
bar region. This was accordingly introduced by plunging a
common straight bistoury through the base of a fold of integu-
ment raised up on the right side of the spinous processes, and the
passage of a tape by means of an eyed probe. Iodide of Potas-
sium, in 5 grain doses, which the patient has been using, it is
thought proper to continue. Comparative rest is also de-
sirable.
In regard to the amount of pain developed by pressure on
the vertebral column in spinal irritation, it may be stated that in
females the spine being more yielding than in males, the bones
are made to act more readily upon the cord and its nerves, in
the former than in the latter case, and pain in proportion to the
flexibility of the column would result.
Case LXVIII. Medullary Fungus.—James McC-----------, aged
60. A scirrhous lump existed in the lower lip of this patient,
noticed first as a small desquamating surface, and from this pro-
gressing to a tumor of an inconvenient size ; twelve months since
it was removed, and about six months after the operation the
glands at the base of the jaw, on the right side and in the throat,
enlarged and eventually ulcerated, presenting the unfavorable ap-
pearance now exposed. The cachectic look of the patient, his ad-
vanced age, the rapid growth of the tumors, the extended ulcera-
ting and fungous surface, the firm base of the diseased mass at-
tached to the bone and tissues, and the persistent pain, forbid any
idea of relief by operative means. In such a malignant disease
as this with which we are called to contend, palliatives are our
only measures.
There is therefore prescribed as a local appliance,
R. Acidi Arseniosi, gr. iv.
Pulv. Opii,	gr. xii.
Zinci Oxidi,	^ss.
Cerat. Simp.	3ii.
M. ft. in ung.
S. Apply twice daily.
Bowels to be kept open and nutritious food eaten.
This case is precisely similar to Case LI, Mr. G--------•, except
that it is further advanced, having reached the ulcerative
stage.
Case LXIX. Strabismus.—James C-----------, aged 27. Has
convergent strabismus of the left eye, which is non-congenital,
but has existed as long as he can remember, and is extreme in
its degree. The operation was performed in the usual manner,
and the tendon of the internal rectus muscle entirely divided;
notwithstanding this, however, the parallelism of the globes was
not quite restored. It is directed, in order to establish their
proper relation, that the sound eye be closed, and the affected
eye alone used for a time ; thus a habit of turning it outward
will be established, and the proper tone of the external rectus
restored ; then the eyes will, it is hoped, be found to have re-
gained their parallelism.
No external applications made; cold water directed only, if
inflammation be set up, or a tendency thereto is shewn.
Jan, ISth. Case LXX. Cleft Palate_________Deformities of this
kind depend upo'n arrest of development during intra-uterine
existence, and may arise from imperfection in the elaboration of
the male semen or in the formation of the ovum, from deficiency
in the structure of the maternal organs, or accidents during gesta-
tion. The body being formed of symmetrical halves, an arrest of
their union in the median line, or an imperfect development of
either half, and other changes, may result in a great number of
congenerous deformities, as spina bifida, hare lip, and other fis-
sures. There may be deficiency of the extremities, or adhesion of
the lower limbs throughout their entire length, (as seen in a speci-
men in the College Museum,) there may be closure of the orifices
of the rectum, vagina, etc. These affections, as before stated,
are the result of a -want of the proper development which should
occur during intra-uterine life ; growth being the extra-uterine
condition in life.
This patient, Jacob M------, aged 11, has a cleft in the soft
palate principally; the posterior part of the bony arch only
being affected; the uvula is divided in the mesial line, the late-
ral halves being perfect.
If this patient was old enough to co-operate with us in the
treatment, we might pare the edges (of the lateral halves of the
uvula) which present to the median line, and bring them in appo-
sition by ligatures; but so much is dependent on the quietude of
the patient, and his just conception of the importance of the
operation and its results, as a guide to his conduct, that we
shall not recommend any decided measure until he has attained
a greater age.
Case LXXI. Eczema.—John Mcl-------------, aged 10. This dis-
ease made its appearance some four years since, the eruption now
existing principally about the nates and posterior part of the
thighs. No previous treatment has had much control over it.
Ordered,
Liq. Arsenici et Ilydrargyri Iodidi.
S. Three drops, thrice daily.
And Jt. Ung. Picis Liquidae.
S. Apply to eruption daily.
Case LXXII. Double Cataract. Margaret G--------------, aged 59.
Patient states that about nine years since, the sight in the right
eye failed somewhat, and double vision followed. Strong applica-
tions were made to the part; violent inflammation followed, and
vision failed still further. This was lost first in the upper, and
then in the outer part of the eye, and objects at first seen double
were now tripled. Sight was then lost, in this, and soon the
left eye became similarly affected. She can nowT distinguish the
light of the sun and that of candles.
The left eye is chosen for operation.
From the history of this case it would seem that an inflamma-
tory condition of the eye is liable to be set up by any irritating
cause, more readily than is usual. The color of the cataract is
dark grey, so that we shall probably find it fluid or soft, and this
must be discharged into the anterior chamber.
The eye is of good form, however, and we shall use a very fine
straight needle; the patient has also been purged gently as a
preparative; by these means we hope to obviate any inflamma-
tory accession.
Sclerotonyxis was then performed with a fine straight needle,
nearly in the axis of the ball on the outside, and one and a half
lines posterior to the corneal margin. Rather more external hae-
morrhage than is usual followed the puncture; the cataract was
found soft, and was broken up and dispersed with but little diffi-
culty.
Prof. Gilbert states, that in persons of this age, we expect to
succeed in four out of five cases, whilst in young subjects we
succeed in nineteen out of twenty. A favorable result has fol-
lowed the operation, in his hands, in several cases over the 75th
year.