CLINICAL REPORTS.
Pennsylvania College, Ninth below Locust street. Service of
Professor Gilbert.
Reported by W. H. Gobreciit, M. D.
Jan. 22d. Congenital Varus.—Robert C----, (Case LXIII.)
Dressings re applied. A gaiter was ordered to be made upon
the steel sole, to lace in front, and to have a good catch on the
heel, so that it may be easily applied and effectually w’orn.
Spinal Irritation—Robert C----, (Case LXVII.) This pa-
tient has greatly improved since the introduction of the seton,
having had but two paroxysms, and those of a lighter character
than usual, since his last visit. There seems to be, however,
some slight epileptic complication, and as Prof. Gilbert has
found great benefit to result from the use of Veratria in nervous
affections, especially in neuralgia, given until the production of
tingling in the fingers and nausea, the Iodide of Potassium is
discontinued, and the following prescription ordered :
If Veratriae gr. ij.
Ft. in pil. No. xvi.
S. one thrice daily.
When the patient feels that a paroxysm is approaching, an
additional pill is to be taken.
Feb. 5th. Has had no decided spasm since his last appearance,
and but slight tremors twice only; he walks better, looks better
and has now no headache. ITe is directed to take a Veratria pill
four times, instead of thrice daily, and an additional pill if any
premonitory tremors are noticed; but if much nausea results,
the medicine should be suspended.
Strabismus.—James C-------, (Case LXIX.) Some pain being
set up in the eye after the operation, the patient was purged
and cold water applied with relief.
The parallelism of the globes is perfect.
Case LXXIII. Results of extensive injuries—James F---------,
aged 11 years, whilst flying a kite on a three storied house,
during the last summer, fell to the pavement and incurred a dislo-
cation of the right radius and ulna, backward, at the elbow-joint,
with fracture of the coronoid process, also a compound fracture of
the same bones below the joint, with anterior protrusion ; there
was a luxation of the left wrist backward, with compound frac-
ture of radius and ulna near the elbow joint. In the considera-
tion of the question of amputation, the almost utter helplessness
of the patient which would follow the removal of both superior
extremities, or if one only should be sacrificed, the serious im-
pediment to success in the treatment of its stump from the con-
dition of the other, determined an attempt to save both, which
resulted thus : The right elbow is perfect, the radius is a very
little impeded in rotation, and the length of the forearm undimi-
nished. In regard to the left extremity, about an inch of the
shaft of the radius was lost during treatment; there is partial
rigidity of the fore and mid fingers, but good use of the thumb,
ring and little fingers, so that the patient can grasp with some
facility, which doubtless will increase.
The treatment pursued after reduction and dressing the
wounds, was by means of wooden splints padded with cotton.
These were subsequently cut so as to afford access to the sup-
purating wounds, to which poultices were applied. Constitu-
tional treatment of a rigidly antiphlogistic character became
necessary during the first two weeks, after which there was no
sympathetic fever.
Case LXXIV—Tumor on the Eye.—Olivia C---------, aged 49.
Married. This tumor, about the size of a common white bean, is
situated beneath the conjunctiva of the right eye, at the outer
margin of the cornea, and in the antero-posterior axis of the
globe ; it seems to be firmly attached to the tissues beneath,
and perhaps involves the cornea, which it partially overlies. Its
appearance is that of a fibrous growth, although we may perhaps
find it to be of a heterologous character. Its history is briefly
this : When a child, the patient was struck and injured slightly
in the spot now occupied by the tumor, with a stick, which caused
no noticeable unpleasant result. About fifteen years since, the
adventitious growth was first perceived, and gradually increased.
Five years ago, Dr. Geo. M’Clellan removed it; the remaining
ulcer cicatrized well, and nothing further was feared; however,
it has recently reappeared, and for the last six months has grown
more rapidly than at any previous time, causing, by its presence
much irritation and frequent attacks of inflammation.
The patient is informed that its removal endangers the integ-
rity of the eye, which may be pierced during the operation ;
besides which it may return, even if the procedure Ts successful.
Nevertheless, if the tumor is allowed to remain, destruction of
the organ is inevitable.
The patient being seated, a fine tenaculum was passed into the
adventitious mass, but cut out at once; it was then shaved off
by a sharp scalpel, and Nitrate of Silver applied to the cut
surface.
The tumor is doubtless a fungous degeneration of a fibrous
growth, having a deep-seated base, and we fear may eventually
involve the entire eye, demanding its extirpation.
26th. Eye somewhat irritated, but no unpleasant symptoms.
Nitrate of Silver reapplied.
Jan 29th. Case LXXV. Amaurosis.—Albion D. S------------, san-
guineous temperament, aged 29, oyster dredger, was seized,
three weeks since, with pain in the temples, and glimmering of
vision, which became at first lightly and then more densely
foggy, until, although able to see light, he has become unable to
distinguish objects, the left eye failing first. His appetite is
good and bowels regular.
Loss of vision may result from several causes, as from cataract,
an opacity of the crystalline lens ; from glaucoma, a disease of
the vitreous humor; or from amaurosis, an affection of the
retina.
In this case however, the pupil is dilated and is of a natural
color, hence neither cataract nor glaucoma exist; no acute
symptoms have been present, indicating retinitis ; and no general
paralysis indicating nervous disease, is found; thus, doubtless,
amaurosis has resulted from mere congestion of the vessels of
the retina. Moreover, there is a little motion in the iris, which
is not usually the case in confirmed amaurosis.
Venesection was ordered, the flow of blood to be continued
almost to fainting. Then
R. Hydrarg. chlo. mit. gr. x.,
to be followed in two hours with
Magnesiae sulphat. gss.
Sennae	jj.
Aq. bullient.	f. ^iv.
S. To be taken at one dose.
After the operation of the cathartic, to take the following :
B. Hydr. chlo. mit. gr. xvi.
Potass, nitrat.	gij.
Ant. et Potass. Tart. gr. ij.
M. ft. in chart No. xvi.
S. one thrice daily.
He was also directed to apply to the eye externally by satu-
rated cloths:
R. Plumbi Acetat. 3j.
Aquae fontis 3viij.
M. ft. in lot.
Feb. 5th. As we see him to-day, vision has greatly improved
in the left eye, but some iritis exists in the right, for which he is
directed to renew the calomel, nitre and antimony, and take as
before directed ; besides which a seton is passed in the back of
his neck as a powerful counter-irritant. Diet moderate, and oc-
casional purging.
Case LXXVI.—Cystic-sarcoma of the left testicle, congenital,
in Wm. Henry B------, aged 3 years. This tumor which existed at
the birth of the child as above stated, has grown with his growth,
but has not increased in size, relatively to the body. Its external
appearance is well represented in the cut, (by Gihon, from a
drawing by Mr. J. Wilson,) as extending from near the abdominal
ring of the left side, very nearly to the knee, filling up the entire
scrotum and drawing down the integument of the abdomen to such
an extent as to obliterate any appearance of a penis, the extremity
of the prepuce only being visible.
It corresponds very well to the description of tumors in this
situation which occur in warm climates.
It is not hydrocele, since there is neither translucency nor
fluctuation. It is not enterocele, since there is no well marked
connexion with the abdominal ring, and it is too firm for such a
tumor. It is not epiplocele, since it is not doughy and very un-
equal, but is quite elastic and hard.
The operation is entered into with the expectation of finding,
either a fibrous tumor of the scrotum, or the testicle itself.
The removal was effected by the Surgeon, standing on the
right, as follows: A single incision was made, commencing
below the external abdominal ring of the left side, and carried
along the side of the body and around the fundus of the mass
to a corresponding point on the right side. A strong tenaculum
was now placed in the tumor at its fundus in the line of the in-
cision, and sufficient traction exerted by an assistant to ensure
an easy dissection of the integument and fascia from its surface.
This was readily accomplished, but upon arriving at its upper
and posterior aspect, a distinct but delicate funicular connection
with the external ring was noticed ; about this cord, high up, a
ligature was thrown, below which its vessels were cut at about
an inch from the tumor, which was doubtless the left testicle.
The amount of haemorrhage was unimportant. The abdomi-
nal integument retracted at once, and the form of the penis was
re-developed; the scrotum became corrugated, and the cremaster
muscle of the right testis was alternately retracted and relaxed,
no such movements occurring upon the left side. The edges of
the incision, (now very much diminished in length,) were brought
together by four twisted sutures, and the scrotum supported by
strips of adhesive plaster.
The case was taken charge of by Dr. Fussell of this city, who
also assisted in the operation.
Feb. 2d. Symptoms of local inflammation, with symptomatic
fever, were fully developed on the second day after the opera-
tion, requiring the application of ten leeches, and the internal
exhibition of Hyd. Chlor. Mit., followed by Magnes. Sulph.
Subsequently,
JL Potass. Nitrat., ^ss.
Ant. et Potass. Tart, gr, i.
Aquae font.
S. A tea spoonful every two hours.
This treatment reduced the local and general symptoms in a
few days ; since which they have entirely subsided.
The tumor, as here shown (in a cut by Gihon, from a drawing
by Mr. J. Wilson,)
is inches in length. It is enclosed m a firm fibrous structure,
which has a serous covering. Several vessels enter its upper
and posterior aspect.
On dividing the mass longitudinally, it is found composed of
tortuous crypts of variable size filled with a transparent gluti-
nous fluid, separated by fibrous bands, dotted here and there
with black; from one cyst larger than the rest at the lower
angle, some apparently strumous flocculi were discharged. The
tumor is, in all probability, a cystic sarcoma of the testis, which
is rare, a very few such cases being reported. The cysts are
enlargements of the tubuli semeniferi, quite analogous to the
condition which exists in cystic sarcomata of the breast. The
following is a microscopic analysis of its contents, by Prof. F. G.
Smith, of this Institution:
Calcareous deposits in the tunica vaginalis testis.
Cholesterine and fat cells.	t
Pus globules and glandular tissue.
Melanotic cells.
Colloid matter, no cancer cells, but large inorganic globules,
granulous matter.
We must conclude, therefore, that whilst there is no positive
malignancy in this tumor, that it is proper to follow the case
closely, and observe if there be any further developements.
Case LXXVII. Porrigo favosa.—Christiana S------------, aged
19 months. This is the most common form of scald head. It
consists of favous pustules, resulting in scabs, and is con-
tagious.
The scabs are circular and cup-shaped ; they enlarge gradu-
ally, and multiply until a great part of, or the whole scalp,
may become involved; the contiguous cup-shaped depressions pre-
senting the appearance of a honey-comb, from which resem-
blance the affection has received a part of its name, favosa.
This case is one of moderate severity.
It was directed that the scalp should be well cleansed with
soap and water, by means of a fine sponge, and that Tar oint-
ment should be applied morning and evening.
The following was prescribed for internal use :
$. Potassii lodidi, gr. vi.
Iodinii,	gr. iii.
Aquae fontis, fgi.
S. 15 drops thrice daily.
Feb. 2d. Sinus in Left Cheek.—Delia M--------, (Case LXVL)
The inflammation and swelling seem here to continue unusually
long, so that, in all probability, some portion of a decayed fang
still remains. On examination of the jaw, such a fang was found,
and removed.
Case LXXVIII. Contusion resulting in Abscess_________Thomas
C-----, aged 40. This patient, whilst running, about two weeks
since, fell upon a curb stone, severely bruising his right elbow
and arm. This injury has resulted in an abscess on the outsid©
and back of the forearm, just below the elbow. Upon opening
this abscess by a straight bistoury, in its most prominent part,
as far from the joint as possible, pus of a strumous character
was evacuated. Poultice ordered.
Case LXXIX. Cataract, left eye, formative stage_______Mr.
W------, aged 55. The sight of the left eye in this person be-
gan to fail some eight months back, since which time the ob-
struction to vision has gradually increased. At present he can
see that persons are before him, although he cannot distin-
guish them. In cloudy weather his vision is by far the best,
(this is one of the surest diagnostic marks of cataract.) The
pupil is of normal size, and presents a nebulous appearance. No
operation would be justifiable at present.
Ordered purgatives and moderate diet, with protection of the
part from cold.
Case LXXX. Fracture of left clavicle.—George McC---------,
aged 20. The fracture occurred seven weeks ago, just above
the coracoid process of the scapula, and as no very great dis-
placement results from such an injury at this point, the patient,
unalarmed, did not apply for surgical aid until three weeks after
the accident, when it seems that the ordinary treatment was pur-
sued. The case is presented for the observation of the symptoms
and results of this peculiar fracture. From the manner in which
the clavicle is bound to the coracoid process, the fragments were
but slightly displaced, and the patient, supposing a contusion
only, was not startled until subsequent swelling came on from
formation of callus. The injured clavicle is found, on measuring
from the centre of the sternum to its acromial extremity, to be a
half inch shorter than its fellow; the fractured ends do not per-
ceptibly project upward, a mass of callus being found surrounding
them.
Double Cataract. Margaret G------, (Case LXXII.)—In this
case inflammation set in about 36 hours after the operation, for
which she was bled from the arm to approaching syncope, after
which a brisk purge was given, which operated well. The in-
flammation not yielding entirely, and becoming aggravated, on
the ensuing day twenty leeches were applied to the temporal
region of the same side, and the following powders ordered :
B- Hyd. chlor. Mit. gr. xvj.
Potass. Nitrat.	gij.
Ant. et Potass. Tart. gr. ij.
M. ft. in chart. No. xvj. S. One every four hours. These
were continued until slight constitutional effects were had. The
case resulted in a perfect cure.
Case LXXXI. Chronic Erythema—Charles M---------------, aged
65, a turner, always had good health, has chronic erythema
of the dorsum of left foot and anterior part of leg, extending
from the toes to just below the knee, with subcutaneous effusion.
The following ointment was ordered :
B. Plumbi. Acetat.	3ij.
Cerat. Simp.	^ij.
M. ft. ungt. S. To be applied on a cloth, evenly spread,
and retained by a bandage from the toes up.
Case LXXXII. Orchitis.—Charles H-----------, aged 27. Has
subacute inflammation of the right testis, arising from cold, he
was ordered:
B. Hydrarg. Chlo. Mit. gr. v.
To be followed in two hours by :
B. Magnesise Sulphat. 3j-
And adhesive strips were rather firmly applied to the affected tes-
ticle in the presence of the class, in the manner ordinarily directed.