of the preceding; yet I have found it effective. The enlarged bursa is punctured with a grooved needle, such as is used for exploring tumors and swellings of a doubtful character. After evacuation of the contents, pressure is applied by means of soap-plaster and bandage. This is renewed from time to time, and puncture of the sac also repeated, if necessary. The result is generally a permanent and safe cure. Even in cases where the bursæ are inflamed, and the skin over them red, I should prefer the puncture now noticed to making any incision into the tumors or supposed abscesses. You will have observed that incisions were made by the house-surgeons in both the cases related to you, and that a considerable quantity of purulent matter was discharged through the wounds. This is not conformable to my practice. In one case it appeared to have answered well; but in that of Susan S- the patient's life was very seriously endangered by extension of the inflammation to the joints and the neighboring parts." (B) CONCERNING WOUNDS AND ULCERS. ART. 89.- On the Diagnosis and Treatment of Syphilis to its primary forms. By Mr. HENRY THOMPSON, Assistant-Surgeon to the University College Hospital. (Lancet, July 3, 1858.) Mr. Thompson commences this paper by demonstrating the importance of deciding promptly upon the nature of the primary forms of syphilis, in relation to treatment and prognosis, and stated that our knowledge of syphilis had greatly advanced during the last few years, thanks to numerous observers in this country and abroad; but that to Ricord the merit is pre-eminently due of having defined the great laws which its phenomena exhibit. Without giving his adhesion in every respect to all the dicta of that illustrious observer, the author of the paper asserted that a careful examination of the subject compelled him to declare his conviction, that on almost, if not on all important points, his doctrines were supported by the phenomena of syphilis in this country. Primary syphilis was defined as a specific disease communicated by a virus, of which the earliest manifestation is a chancre; and secondary syphilis as a constitutional affection, which, excluding hereditary transmission, originates always from a chancre, and manifests itself by characteristic symptoms, which follow, with more or less regularity, a certain order of evolution. Two distinct varieties, and two only, of chancre were stated to exist-the soft or non-infecting, and the indurated or infecting chancre. Either of these might be attacked with phagedæna or sloughing, although much more commonly the former; but these conditions are the results of external circumstances, and not of any inherent quality in the sore itself. He laid down, as a principle, that, on seeing a sore in the early stage, we might, in five cases out of six, positively state to the patient, at the outset, a distinct prognosis as to the occurrence of secondary symptoms or the contrary, without risk of error; and that, in consequence, we might select the appropriate treatment at once, and pursue it with confidence. Mr. Thompson defined the external characters of the indurated or infecting chancre; contrasted them with those of the soft or non-infecting chancre; pointed out that the first was invariably attended with indurated, painless lymphatic glands in the groin, which attested the nature of the sore after the latter had disappeared; and stated that constitutional syphilis was certain to follow sooner or later, the induration of the sore itself being, in fact, the first sign of the systemic infection. Next, he described the character of the soft chancre, which was not necessarily, nor, indeed, most commonly associated with any bubo at all, but if so, the bubo was inflammatory and would suppurate. In this case it was almost certain that secondary symptoms would follow. He then considered the sores of a doubtful character, that is, those respecting which it was difficult at first to determine the nature, and showed how the two varieties might, nevertheless, in most cases, be distinguished by attention to known causes of error. The treatment of primary syphilis, in these two forms, then succeeded. The employment of caustic, which, if sufficiently powerful, and applied early, would prevent constitutional infection, was strongly recommended. The potassa cum calce, on the whole, was regarded as the best. In the soft chancre, which was met with three or four times as often as the indurated chancre, there could be no occasion for mercury and iodine, as it was a purely local, not a constitutional disease. Local astringents or antiseptics, and if it was slow to heal, fifteen or twenty-grain doses of the potassio-tartrate of iron, twice or thrice a day, formed the best treatment. Such formed the bulk of the cases so frequently reported as examples of syphilis cured without mercury; in fact, whatever the treatment of these sores, no constitutional symptoms would manifest themselves. In the well-marked indurated chancre, small doses of the iodide of mercury, such as three quarters of a grain or a grain, guarded by about two grains of Dover's powder, appeared to suit more generally than any other form. The gums to be but very slightly touched, and the patient carefully preserved from salivation; this condition to be maintained for a considerable period. Where any intolerance of mercury by mouth was exhibited, inunction or fumigation should be substituted. Nothing, however, could be more obvious than the good effects of mercury in these truly infecting sores and early constitutional symptoms, provided its administration be kept within the limits recommended. A tabular form, exhibiting the characters and tendencies of the two varieties of chancre by way of contrast, was presented, for the purpose of diagnosis, and showing the salient points of the subject at a glance. A copy of it follows here: Diagnostic characters of the two varieties of venereal sores. THE SOFT CHANCRE. Anatomical characters.-Form: rounded, often irregularly so. Edges: sharp, well defined, as if cut with a punch; rather overhanging; not adhering closely to subjacent tissues. Surface: flat, but irregular, "worm-eaten;" often with yellowish or grayish matter adhering. No induration of tissues around, unless caused by caustic or other irritant; in which case the thickening is not defined in its limits, but shades off into the surrounding tissues, and has more or less the aspect of inflammatory action. Pathological tendencies.-The secretion is contagious, purulent, and plentiful; hence these chancres are rarely single; often, perhaps most commonly, multiple, one giving rise to another. It is usually slow to heal, has a tendency to spread, and is liable to take on phagedænic action. The soft chancre appears, from the records of practice, to occur with a frequency about four times as great as the indurated chancre. Characteristic gland-affection.-In many cases (but not in the majority) the inguinal glands are affected; in which case, one gland, usually, rapidly inflames and suppurates, and an open bubo is the result. The pus, at first, is inoculable, and capable of producing a soft chancre. 66 Prognosis.-The well-marked soft chancre is always a local affection, and does not affect the system; and no specific" treatment (mercury and iodine) is required. THE INDURATED CHANCRE. Anatomical characters.-Form: rounded. Edges: sloping, not sharply cut; hard, sometimes a little elevated, closely united with subjacent tissues. Surface: hollowed or scooped out, but smooth, as if varnished; often grayish at the centre. Induration well defined, incompressible, like a cup of cartilage let into, or set upon, the tissues beneath, and movable over them; no inflammatory areola; usually makes its first appearance between the fifth and tenth day, never after the twentieth; generally long survives ulceration. Induration varies in degree somewhat with the situation; but, when slight, is nevertheless always defined. Pathological tendencies.-The secretion is scanty, rather serous than purulent, and is not very readily inoculated; hence the sore is usually single, rarely multiple, and if so the sores appear simultaneously. It is indolent, but less so perhaps than the soft chancre; rarely takes on phagedæna. Either sore propagates by inoculation; invariably produces its like. Characteristic gland-affection.-It is invariably followed by slight swelling and marked induration of the inguinal glands on one or both sides (the sore being on the genital organs); usually several glands are affected; they are hard, incompressible and roll under the finger, are painless, and do not inflame or suppurate; except, in rare instances, from over-exertion, in scrofulous subjects, &c., but then the pus is not specific and not inoculable. The induration of the gland coincides in time with that of the chancre itself. The primary sore having disappeared, or being denied, the gland-induration is an invaluable sign for purposes of diagnosis. Prognosis.-Constitutional syphilis will certainly declare itself sooner or later. Mercury will retard, modify, or prevent the evolution of secondary symptoms. (c) CONCERNING FRACTURES AND DISLOCATIONS. ART. 90.-On the reproduction of Bones. By Dr. TOLAND. (Charleston Med. Journal and Review, July, 1858.) In this paper Dr. Toland endeavors to show that entire bones and joints may be restored by proper management. "In 1853," says Dr. Toland, "when I took charge of some wards in the State Marine Hospital, I found in the fourth ward, No. 12, a Mexican who had long been suffering from caries of the inferior maxillary bone. Finding the bone destroyed anteriorly, and the remainder diseased, incisions were made on the inside of the mouth, and the entire submaxillary bone removed. In a few weeks bony matter was deposited, and the motion of the jaw perfect. He left the hospital but little disfigured, and if the teeth had not been lost, the reproduced jaw would have been as perfect as the original. Dr. Reilly was then the resident physician, assisted in the operation, and witnessed the result. "I was much gratified to find, in the July number of the Charleston Medical Journal,' a case reported in the 'Moniteur des Hôpitaux,' by Maisonneuve, of a similar character: The entire lower jaw was excised for an enormous fibrous tumor developed upon and involving the bone. In extracting the jaw, the periosteum was left in situ. A rapid cure was obtained-nearly the entire incision healing by the first intention. So little deformity results, that it requires a practised eye to detect the absence of this important bone. The movements of the mouth are all preserved; the tongue has recovered all its movements; speech is clear and distinct; swallowing is effected with great facility, and one month after the operation a dense substance was forming from the periosteum, which was expected in time to form a useful bony mass." "In 1853 a millwright, from Contra Costa, was admitted into the State Marine Hospital with a comminuted fracture of the great toe of the right foot. Finding, at the expiration of a month, that the bones were diseased, and believing, from the result of the treatment in the former case that the bones would be restored, instead of amputating the toe, they were removed. In four weeks they were reproduced, and the toe was as useful as before the injury-although I was not aware that the articulations were restored, supposing that a ligamentous substance supplied, imperfectly, the place of joints. Dr. Reiley assisted in this operation. "In June, 1856, James Clark, who lives near the corner of Filbert and Battery Streets, consulted me respecting the propriety of having the middle finger of the right hand amputated. He had been under the care of a physician, who thought its removal necessary. 66 The first and only half of the second phalanges being diseased, and believing they would be restored, I advised their removal; for if the first joint was even destroyed, the finger would still be useful. Assisted by Mr. Lindop, an incision was made from near the junction of the second and third phalanges, and extended under the nail to the same point on the opposite side. The soft parts were then dissected from the bones, and the second phalanx divided about a quarter of an inch anterir to the joint. The wound was then closed by the interrupted suture, and the soft parts retained in a proper position by pasteboard splints and a bandage. "In four weeks the bones were not only restored, but a joint had also been formed, the motion of which was as perfect as the original. Being a porter, and having used the finger before the ligaments were sufficiently strong to resist the force applied, there is a slight lateral curvature; but, in every other respect, the finger is as useful and perfect as the one on the other hand. "Mr. M'Gowan, employed at Newland's stable, on California Street, was advised in June, 1856, to have the forefinger of the right hand removed at the second joint, and he came to my office for the purpose of complying with instructions. Instead of amputating the finger, the first and second phalanges were removed, and then treated as the preceding case. "In a few days he resumed his occupation, and I did not see him for several months. His finger has recently been examined: the second joint is perfect, and the entire phalanx restored. The first phalanx, in consequence of the soft parts being allowed to contract, is shorter than the original-although a joint exists, and the finger is as strong and useful as before the operation. "Mr. Shannon, a cooper, who resides at No. 6, Jackson Street, had a whitlow on the right forefinger, involving only the first phalanx, which was removed by a lateral incision. He resumed his business in a few days after the operation, and, although not subjected to the proper treatment, the bone was reproduced, and the motion of the joint is as perfect and the finger as strong and useful as before. "Mr. Collins, who lives in this city, on Stevenson Street, between First and Second, had suffered for three months from a whitlow involving the whole of the right thumb. Before he became my patient, free incisions were made without affording relief. The thumb was enormously enlarged. The first and second phalanges were diseased, and the flexor tendon near the extremity destroyed. "Notwithstanding its excessively diseased condition, I determined to remove the bones, although confident that the thumb would not be as useful and perfect as it would have been if he had received proper attention at an earlier period. "On the 1st of April, 1857, the first and second phalanges were removed by a single incision, and the wound closed by the interrupted suture. Pasteboard splints and a bandage were then applied, and continued until cured. "In six weeks the soft parts were healthy, and the bones and joints restored. Notwithstanding the destruction of a portion of the tendon, he has control even over the first joint, and the strength and motion of the thumb are daily increasing, which would not be the case if the tendon had not been reproduced. "Mr. Littlejohn, who resides at Redford City, had suffered greatly for several weeks from a similar difficulty. He was operated upon on the 18th of April. An incision was made on the external side of the thumb, and both bones removed. This case progressed much more rapidly than that of Collins --and in four weeks the bones and joints were reproduced. The thumb is now as strong, and the motion as perfect, as before the occurrence of the difficulty. "Mr. Blaisdell, who now resides in San Francisco, had the great toe of the left foot injured by a stick of timber. When examined, I found the second phalanx carious, although the first was healthy. "In December, 1857, an incision was made upon the external side, extending from the articulation with the metatarsal bone to the extremity; both phalanges were removed, which was unnecessary, and the wound closed as usual. In four weeks from the time the operation was performed he could wear a boot without inconvenience. Both bones, with joints, have been restored, although the first phalanx was not diseased, which can only be accounted for by sup posing that the periosteum detached from the second phalanx furnished a sufficiency of body matter for the restoration of both. "Elizabeth Gallman, who lives with Mr. Grey, North Beach, had suffered for three weeks from a whitlow of the right middle finger. The first phalanx was removed in presence of Dr. Raymond, and the finger examined in a few days by Drs. Sheldon and Hewer, which, although slightly enlarged, is as useful as before the operation, and the motion of the joint as perfect. "Mrs. Cunningham had a needle broken in the first joint of the right forefinger, which produced caries of the first and half of the second phalanges. On the 1st of September, 1857, they were removed in the presence of Dr. Hewer. In five weeks she could use a needle with facility; and now, with the exception of a slight diminution in the length, the finger is perfect. She lives on Yerba Buena Street, and has recently been examined by Drs. Fitch and D. L. D. Sheldon. "Recently, in the case of Mrs. Stone, of Sacramento, one-third of the second phalanx and two-thirds of the third were diseased, and the remainder healthy. The diseased bones, including the second joint, were removed in presence of Drs. Fitch and Hewer. Fifteen days have elapsed since the operation was performed, and the case is progressing favorably. 66 Believing that the same course of treatment would be found equally suc cessful when longer bones are implicated, during the summer and fall of 1856, assisted by Dr. Lind, the resident physician of the U. S. Marine Hospital, more than half of the clavicle, the os calcis, and portions of the os femoris and tibia, were removed with a similar result; but being unable-as they were sailors to specify their place of residence, their cases will not be given in detail, although they were as successful as any that were previously or have since been subjected to the same treatment. "On the 3d of December, 1857, James Allen, a gentleman from Crescent City, was examined, who had received a gunshot wound, ten months before. The ball passed through the wrist, and he had suffered excessively. Finding all the carpal bones and those of the wrist, with which they were connected, extensively diseased, I determined to remove them, it being the only course of treatment which could save the hand. Assisted by Drs. Fitch and Hewer, an incision was made in the direction of the metacarpal bone of the forefinger, which was removed, with half of the metacarpal bones of the other fingers, as well as the trapezoides, magnum, unciforme, and pisiforme. But one incision was made in the soft parts, and great care taken not to divide either the tendons or large blood vessels. He has suffered but little since the operation. The constitutional disturbance is considerable; the hand is not swollen; the wound presents a healthy appearance, and no doubt is now entertained of saving the hand, and restoring it to usefulness. 66 'Although I have been engaged in the investigation of this subject for several years, even my personal friends were not apprised of the fact, until a sufficient number of cases could be presented to remove all doubt upon the subject. I am now satisfied that the proper course has been pursued, for the above cases not only prove the restoration of bone, but also that articulations sufficiently perfect have been and will invariably be reproduced." (D) CONCERNING DISEASES OF JOINTS. ART. 91. The restoration of Motion by forcible extension and rupture of the uniting medium in partially anchylosed surfaces. By Mr. BRODHURST, A8sistant Surgeon to the Royal Orthopedic Hospital. (Pamphlet, Adlard, 1858.) In a former volume ('Abstract,' XXV., p. 122) we gave an abstract of a paper in which Mr. Brodhurst recounts several cases of partial anchylosis of the hip, knee, and elbow-joint, in which the uniting medium had been ruptured, and where, after a varying amount of time, the power of motion had been successfully and safely established. In the present pamphlet some ad |