CLINICAL REPORTS.
Pennsylvania College, Ninth below Locust street. Service of
Professor Gilbert.
Reported by W. H. Gobreciit, M. D,
Feb. Sth.—Abscess—Thomas C-------, (Case LXXVII.) The
abscess is filling up, and as far as the injury is concerned, the
patient is improving. The case, however, is complicated with
slight anasarca in a strumous diathesis ; for which is ordered :
B. Pil. Ilydrargyri No. ii.
To be followed by:
R. . Potassae bi-tartrat.	siij.
Pulv. Jalapae.	9ij.
M. S. Take a teaspoonful every three hours until pur-
gation results.
Case LXXXIII—Inverted toe-nail, in Rachel B---------, aged
15. Ingrowing nail occurs more frequently in the foot than in
the hand, the great toe being oftenest affected. It is caused by
the pressure of tight boots or shoes upon the soft parts of the
toes, forcing them up against the edges of the nail, thus burying
it in their substance. The pressure thus produced by the edge
or edges of the nail, causes inflammation and ulceration, and
finally painful granulations arise, which overlie it, besides being
impinged on by its edge, giving rise to so much pain that loco-
motion can not be performed. Moreover, these ulcerations may
assume a cancerous character, if long neglected.
In treating inverted toe-nail, loose shoes should be ordered,
and if the case be mild it may be cured, or at least much pal-
liated, by gently stuffing cotton beneath the sharp edge of the
nail to relieve its pressure, and applying caustic to the exuberant
granulations. In bad cases, however, we can only cure by taking
either the affected side or the whole of the nail away.
The patient presented had inversion of both lateral edges of
the left great toe-nail, with ulceration and exuberant granulations
about them.
It was removed according to the method of Dupuytren, that
is, by introducing one blade of the sharp pointed scissors beneath
the anterior edge of the nail at its centre, keeping close to it and
passing down to the matrix. The blades being brought to-
gether and the nail divided, each half was wrenched from its bed
by strong forceps. The ulcer remaining was dressed with
Simple Cerate. This very painful operation was performed
during partial Anaesthesia, induced by the inhalation of a mix-
ture of Chloroform and Ether.
Double Cataract—Margaret G---------, (Case LXXII.) This
patient is still improving. She sees faces but cannot distinguish
them well. Pupil dilated in the presence of class with aqueous
solution of Atropia.
16th. As this patient is anxious to return to her home in the
country, it is thought proper to furnish her with a cataract glass,
which is much more convex than those usually employed as spec-
tacles, and is intended as a substitute for the absorbed lens. A
number of such were presented, from which that best fitted to
the peculiarities of her eye was selected, and by means of which
she was enabled to see quite distinctly. She wras directed not
to use this for six or seven months to come, to avoid irritation and
inflammation, or other changes of the retina, from the unac-
customed concentration of light upon its surface, -which might
result in the production of amaurosis.
Case LXXXIV. Hare lip with cleft palate.—Rebecca ,
aged 22. In this case very great deformity exists; the lip is
not only deficient, but the cleft extends through the left superior
maxillary and palate bones, whilst the aveolar processes and
several teeth project at its anterior extremity, giving the patient
an exceedingly unpleasant appearance, and materially affecting
her powers of eating and speaking.
Besides the very great congenital deficiency of material to
work with here, it is stated that an unsuccessful operation for
relief had been previously performed; large cicatrices of a firm,
fibrous character resulting.
The fraena existing on both sides of the fissure were de-
tached, and the left side of the lip and ala of the nose freely
dissected from the superior maxilla ; a small wooden spatula
was then placed successively beneath each margin of the cleft
in the soft parts, upon w’hich the fibrous edges were fully cut
away by a sharp scalpel, the incisions being made concave to the
fissure to ensure a horizontal margin to the new lip, which -was
then formed by the apposition of the cut edges by means of
two large gold needles in the substance of the lip, and one
smaller, just at its edge, the twisted suture being formed about
them.
A broad adhesive plaster was then applied to each cheek as
far back as the ear; each anterior extremity extending to the
oral angle of its own side, was doubled upon itself, (thus forming
a thick edge,) and connected with its fellow of the opposite side
by ligatures passing between them ; these ligatures being drawn
tightly, the tension of the buccinator and other muscles of the
cheeks was effectually controlled.
16th. The small needle was removed on the third, and both the
largest at the end of the fourth, whilst the threads adhered
until the fifth day.
To-day, on completely redressing, adhesion is found perfect in
nearly every part, though granulation must occur at some points.
Isinglass plaster was applied directly over the wound to defend
the new material from the action of foreign matters ; adhesive
strips, similar to those previously employed, were used in a like
manner; whilst pressure of the connecting threads upon the lip
was prevented by placing a roll of lint beneath the anterior ex-
tremity of each strip.
Feb. 12th. Spinal Irritation.—Robert C----, (Case LXVII.)
Has had no spasm since his last appearance here.
Whenever an extra veratria pill is taken, the tingling sensa-
tion, indicative of its action, results. The patient is evidently
improving. The veratria is discontinued, to be resumed if
necessary.
Case LXXXV. Lumbago.—Hugh L---------------, aged 21, boat-
man, presented himself as a surgical patient, but is discovered to
have lumbago only, for which is prescribed :
$	Potassii Iodidi,	3i.
Vini Colchici Sem.	f^i.
Aqum Menthse virid.	fgii.
M. S. A tea spoonful thrice daily, ceasing when it purges.
Porrigo.—Christiana S------, (Case LXXVII.) Improving
under treatment.
Case LXXXVI. Porrigo.—Francis S------------, aged 10. The
disease in this case appeared at the eleventh month, just after
vaccination, the mother attributing it to the use of improper
virus in the operation ; this is, however, doubtless an error.
The affection has continued up to this time, and during the course
of it, ophthalmia tarsi, which is a chronic inflammation of the
edges of the lids, extending into the Meibomean follicles, from
which a viscid abnormal secretion results, has arisen. The
mother states that every variety of treatment has been employed,
with low diet. There is prescribed free exercise in the open air,
warm salt bath, followed by frictions with a coarse towel, and
full diet; also,
]£. Hydrarg. oxid. rubr. gr. x.
Cerat. simp.	~i.
M. ft. ung.
S. To be applied to the edges of the lids nightly.
Case LXXXVII. Supposed polypus nasi—Mr. L------------, aged
41, has been troubled for five or six years with a gradually in-
creasing stoppage of the left nostril, attended by an alteration
of the voice, and a polypus apparently existed upon the septum
narium on the left side, an unusual spot for its development.
On the application of the forceps, however, enlargement of the
mucous membrane and periosteum were found to exist, but no
polypi.
Case LXXXV1II. /S'trafo'smws.—Caroline F---------, aged 6,
has convergent strabismus of the right eye. It was stated that,
in cases of such an age, surgical attempts at relief were perhaps
of doubtful propriety, inasmuch as although the patient would
be perfectly willing to enter into the operation, the subsequent
struggles might be very embarrassing. The anxiety, however,
of the parents for its cure, led the Surgeon to the performance
of the operation, which was done in the usual manner, and with
entire success, although, as expected, the struggles of the child
were exceedingly annoying.
Case LXXXIX. Inflammation of the Hand—Martha
I<----, aged 20, being affected with tetter, wras recommended
by her friends to apply corrosive sublimate made into an oint-
ment with butter, which she did on the 8th inst. The quantity
employed was large, and its application was followed by intense
pain, swelling, redness and loss of sleep from the irritation set
up, which has lasted, although now abating, to the present time.
The case is shown as an example of the results, following
the injudicious appliance of remedial means on popular recom-
mendation.
A poultice was ordered as the only treatment necessary.
Feb. lQth. (Case LXXV.) Amaurosis—Albion D. S-------------.
Reported as recovering vision rapidly.
19th.—Can now see with both eyes, though least with the
right. The Iritis which existed in it is yielding rapidly and is
almost subdued. The calomel powders are continued with oc-
casional purgation.
The patient is informed that he must change his occupation
to one requiring less stooping, since this aids in the production of
congestion of the head, caused also by holding the breath during
the exertion of hauling upon ropes, which he must pursue as a
boatman and oyster dredger.
Case XC.—Congenital double Inguinal Hernia, occurring in
James B------, aged 5 months.
Remarks upon the pathology of this disease were given, and ,
a double truss applied, which is to be worn for three or four
months.
23d.—Truss removed and re-applied ; child doing very well.
Case XCI. Subacute Conjunctivitis.—John II----------, aged
33, wTas seized with inflammation of the eyes, about two weeks
since, and this has now assumed the subacute form. The con-
junctivae alone are involved. Besides local treatment, his di-
gestive organs require correction.
His tongue being enlarged, with a -white coat upon it, appe-
tite poor, and the bowels somewhat constipated, ordered
Mass. Pil. Ilydrarg. gj.
Pulv. Aloes	gss.
Pulv. Rhei	9ss.
M. ft. in pil., No. X.
S. Three to be taken at bed time. The others as required.
If the three pills do not move the bowels, a seidlitz powder is
to be taken the next morning.
As a local application to the eye,
JL Zinci Chloridi gr. ss.
Aq. Rosae foj.
M.
S. Apply to conjunctivae once a day.
Case XCII. Parotitis.—Wm. S---------, printer, aged 22. The
swelling of the left parotid gland commenced on the 13th inst.,
since which time it has been increasing in size, being hard and
painful. He is directed to apply linim. ammonias to the part,
to be purged freely with magnes. sulphat., and to be restricted
in diet.
Case XCIII. Epiphora—James P----------, aged 44. This re-
sults from obstruction in the nasal duct. Creasote is painted
over the lachrymal sac and the course of the duct as far as prac-
ticable.
Feb. 23<Z. Case XCIV. Fracture at and Luxation of right elbow
joint.—Thos. McGr-----, aged 7. The injury was sustained by this
patient 23 days since, and 16 days after its occurrence he appeared
for treatment, when the right fore-arm was found rigidly extended ;
the coronoid process was fractured and drawn up on the arm an-
teriorly, whilst the olecranon was drawn upward posteriorly, the
ulna of course following it. The fore-arm was first drawn down-
ward by means of extension and counter-extension, and then
flexed; the parts being thus properly adjusted were retained in
position by a splint with a movable angle, controlled by a
Stromeyer’s screw, at the elbow, applied on the anterior aspect
of the limb.
The following sedative lotion was ordered to be applied to the
joint by wetted cloths.
JL Plumbi Acetat. jij.
Morphine Acetat. gr. x.
Aquse	Oj.
M. ft. lot.
The angle of the splint, after some little time has elapsed, to
be changed frequently, but gently and gradually, and if anchy-
losis seems inevitable, it is to be allowed in the flexed position
only, since the arm is not then useless, as it is if rigidly ex-
tended.
In concluding this series of reports, the history of a case
presented to the class on Dec. 11th, 1852, will be given, as omit-
ted at that time.
Dec. IliZz. Case XCV. Hydrocele of the Neele.—Mrs.
M------, aged 50, is presented, with a large tumor, of 18
years’ growth, involving the entire anterior and lower portion of
the neck; on examination this is found to project downward be-
hind the sternum, to either side beneath the sterno-cleido mas-
toidei muscles, and upward as high as the upper edge of the thy-
roid cartilage. It would thus involve important structures, and
might arise from several causes ; our diagnosis must therefore be
accurate. It is found to have pulsation and thrill, but this
doubtless arises from overlying the carotid arteries, inasmuch
as when the tumor is pressed away, the vessel of the relieved
side can be distinctly felt, whilst no thrill and but very indistinct
pulsation is communicated to that portion of the tumor. This
also occurs when the other side is examined, besides which we
cannot either diminish the size or empty it by pressure; it is
therefore not an aneurism. It is not bronchocele, for its history
tells us that it commenced in the median line and in the lower
part of the neck. Now, had it been bronchocele, the lobes of
the thyroid body would in all probability have been first affected,
and this higher up than the present disease commenced ; besides
which, goitre is usually hard, whilst this is soft, especially upon
the left side, and fluctuation is very evident upon palpation. It
As, therefore, doubtless filled with fluid, (which so readily trans-
mits the impulse of the vessels to the fingers,) and is a hydro-
cele;—a cyst,—whose contents are increasing, since they are
secreted more rapidly than absorption is performed. Such tu-
mors are generally located beneath the platysma myoides m.,
and upon the larynx. The removal of this tumor or the dimi-
nution of its size is important, since, being of 18 years’ standing,
it is large, and now increases rapidly, producing great deformity,
whilst it presses on the trachea, keeping up a chronic congestion (
of the air passages, rendering breathing difficult, and thus, es-
pecially during the summer, rendering the slightest forms of
labor very difficult for her performance.
On account of the size of this tumor, and the number of im-
portant parts involved, the operation here indicated would be
exploratory in its character, the fluid would then be withdrawn,
and if the sac was in a proper state, iodine injection would be
resorted to, with the intention of producing adhesion between its
walls.
This patient, as previously stated, will present herself in fu-
ture for operation.