several ounces were slowly evacuated, no irrigation being employed; a good sized rubber tube was finally inserted, dressing applied and patient returned to bed, his condition at that time being very critical.

He rallied splendidly, however, after several days of careful nursing. Following operation, the temperature quickly sank to normal, and has remained there, the discharge continuing profusely.

Jan. 24, 1893.--Patient returned to his home in neighboring State; is rapidly regaining strength. The drainage tube is still in abscess. (Twenty-one days since operation.)

Jan. 26, 1893.-Has returned to hospital to have tube reinserted, the opening having become so narrow as to force tube out.

Bacteriological examination of pus shows clear cultures of bacilli coli communœ.

The next case is that of a man 30 years of age, single, occupation a stone-cutter. When a young boy resided in a malarial district in the south, and for the following ten years had frequent manifestations of malaria. About eight years ago began to have symptoms of acid urine, with occasional pain in region of left kidney; this continued for two years, his condition then being made worse, as the result of following the occupation of a painter for several months. Shortly after, began to have attacks of renal colic, and later passed small calculi; can remember having a daily attack with passage of the stone for 73 consecutive days, the paroxysms lasting about forty-five minutes, the trouble being in the left kidney. A condition of polyuria existed at times, no doubt as a result of the irritation. Left side began to bulge about this time, had chills, high temperature and rapid pulse, was said to have an abscess, involving kidney and surrounding structures, also at this time passed considerable pus with urine. An operation was urged, but patient would not submit to it. This state of affairs continued for two years, the condition finally becoming so aggravated that consent was obtained to open abscess, and large quantities of pus were evacuated.

The discharge continuing after some time, Dr. Park was called July 9th; at that time he did a nephro-lithotomy, removing several calculi from pelvis of kidney, and scraped out abscess cavity.

Marked improvement followed, for several months, when trouble again became apparent; abscess again formed and broke, about an ounce of pus discharging daily, the man's condition in the meantime becoming weaker. As a last resort he entered hospital for further operative procedure, Jan. 23, 1893.

On examination, he was found to be pale, emaciated and weak, pulse rapid and soft, temperature 99.6, respiration 22; urine loaded with pus, kidney epithelum and casts, and the sinus in side discharging quantities of pus.

After several days of stimulating treatment, chloroform was administered and an oblique incision, about five inches in length, was made over region of left kidney preparatory to a nephrectomy.

The kidney proper was buried in a mass of dense cicatricial tissue from which it could be but partially released; a silk and also an elastic ligature were then passed around pedicle, which was about two inches in diameter, and kidney structure beyond ligatures cut away.

The elastic tubing was now removed and the renal artery caught with forceps and separately ligated, after which the stump was cauterized by means of a Paquelin cautery.

During the various manipulations, a rent was made in the peritoneum, exposing the colon, but after disinfecting the opening with peroxide of hydrogen, it was closed by a continuous catgut suture. Left protruding from the wound were the ends of the silk ligature, in order that the pedicle could be brought into view, in case of secondary hoemorrhage. Zinc gauze was used to pack the wound, and sublimate dressing applied. Great relief has followed the operation, his temperature has ceased to fluctuate and is normal, pulse and respiration are much improved, albumen is no longer traceable in urine, his strength is being slowly regained, and he is on the high road to recovery.

January 24, 1893. Silk ligature removed from pedicle, wound filling in rapidly.

Continues to improve in health.

Naked eye appearance of specimen: On section, multiple abscesses through organ, with destruction of most of kidney substance.

No. 510 DELAWARE AVENUE, BUFFALO, N. Y.

T

A CASE OF CONSERVATIVE SURGERY.

A. B. BRIGGS, M. D.

HE patient, A. C., a boy about twelve years of age, was brought to my office one evening some three months ago, with the story that while playing with a fulminate cap, he conceived the idea that it would be good fun to deposit it in the kitchen stove, which idea he immediately put into execution. The results were as follows: The end of the thumb of the right hand was blown off to the base of the nail, the second phalanx being shattered and about one-third of its tip gone, the index finger had been used in much the same way, all of the soft parts having been blown off to a little below the base of the finger nail, the third phalanx being left bare for about two-thirds its length, but was not splintered, the soft parts on the palmer surface over the first phalanx were carried away.

The middle finger had been used rather more severely, all of the soft parts had been torn down almost to the articulation of the second and third phalanges, the bone being very badly shattered, the soft parts of the palmar side of the finger were gone to the articulation of the second with the third phalanges, and very badly shredded.

The ring finger had come out of the explosion in rather better condition, the fleshy part of the tip having been torn from the bone about half way across, but the bone was not injured, the cap was easily replaced over the phalanx, and made rather a nice looking finger.

The palm of the hand was torn across over the metacarpal bones just below their articulation with the phalanges, the flesh being badly lacerated and the wound filled with small pieces of bone, finger nails, ashes, etc. The flesh over the whole palmer surface of the hand was black and quite badly burned; the ends of the index and middle fingers and of the thumb presented what might be called a tasseled appearance, the tissues hanging in shreds, very black and in places burned. It had been three hours since the accident occurred and already the hand was considerably swollen.

At first examination it looked as if it would be necessary to amputate the thumb at the articulation of the first and second phalanx, the index finger at the second and third, and the middle finger at the articulation of the first and second phalanges.

Upon further deliberation, however, it was decided to try the antiseptic treatment and if the hand could be saved, to try and save as much of the thumb and fingers as possible. Accordingly the soft parts were slipped down as much as could be done easily, and the bone cut off with bone forceps, all shreds, lacerated and burned tissues were carefully trimmed off, the parts thoroughly cleansed with warm carbolized water, all hemorrhage checked with hot water, the wound in the hand cleansed and all foreign substances removed with care, after which all lacerated parts were dusted with iodoform, covered with iodoform cotton, bichloride gauze, and a bandage.

The next day the dressing on fingers and thumb was removed, as there had been considerable oozing of blood, and the same form of dressing re-applied. There had been but very little pain and the swelling had not increased. On the third day the dressings were all removed, there had been but little pain, swelling less, the wound in the hand looked well, but the fingers and thumb showed that the burnt tissues were much more extensive than had at first been supposed. It was evident that much tissue would slough and the iodoform dressing was re-applied. Two days later upon dressing, the fingers and thumb had discharged very freely, but the wound in the hand was doing well. After cleansing with hot carbolized water, peroxide of hydrogen, Mer

chands, was applied full strength, and a dressing of iodoform cotton and gauze applied.

From that time on, the wound in the hand gave no trouble, with the exception that some ten days afterwards a small abscess formed near the metacarpo-phalangeal articulation of the middle finger, which when opened discharged a small piece of finger nail.

The subsequent treatment consisted of careful strapping of the tissues so as to get the best shape possible in the fingers and thumb with the iodoform dressing, and whenever there was a disposition to excessive granulations with increased suppuration and an inclination to oozing of blood, the peroxide of Hydrogen was used freely, which in every instance had the desired effect of checking the granulations, etc.

The results have been very gratifying to the physician and to all parties interested, and we have the satisfaction of knowing that quite a considerable length has been saved in the thumb and two fingers at least, and I feel that in a great measure the results were due to the thorough antiseptic treatment that was pursued.

TREATMENT OF CARBUNCLE BY HYPODERMIC INJECTIONS OF CARBOLIC ACID.

By CHARLES O'LEARY, M. D.

INCE August, 1881, I have treated carbuncle with hypodermic injections of carbolic acid into the tissue surounding carbuncle. In

Sjections

that year and the year previous, I had two cases of carbuncle of the utmost severity. They were the largest I had ever seen either in private or hospital practice. They were, as one consultant remarked, entitled to the prestige of being patriarchs of carbuncle. The patients had both enormous necks, affording enormous necks, affording rich pasture for bacilli. Both were treated on the standard methods, vigorous and heroic, and mildly with poultice as recommended by Paget; both were fatal. Shortly after, a man from Centredale, in this State, came to me with incipient carbuncle on the neck, just resembling one of the cases that proved fatal, as it first came into my hands. I knew that Dr. Post, of New York, had aborted a case of carbuncle by piercing it with red hot wires, so he told me when speaking to him on this subject. resolved, instead of actual cautery, to try carbolic acid in full strength. So I submitted to the patient the treatment I should follow, and left it to his choice to submit or not to such treatment.

He was willing to undergo treatment.

I injected by hypodermic syringe the liquefied acid at three points

along edge of carbuncle that was on the neck. He called three days subsequently, and I observed the carbuncle stationary and aborted where the acid had been injected. I then injected at six points-equal amount at each point as I had in the three points at first experiment. He returned in three days. The carbuncle was entirely arrested and what had been the carbuncle was a hard dead core, without any sensation or circulation, Subsequently he came, when I dissected it out as a dry fibrous mummified mass. The cavity left, healed quickly by granulation. Since that time I have treated all carbuncles in the same way with invariable success. I am confident, that had I treated one of the severer cases referred to that came to me in the incipient stage, I would have saved the man's life.

It might be asked, what is the strength and what the amount of acid I use. In strength I use the liquefied acid, full strength. As to quantity I was at first guarded, and used only the hypodermic syringe full, in all. I subsequently increased this to double the quantity, and have recently, in a patient with diabetes, where carbuncle occurred twice in the months of May and November used treble the quantity. That is, I have taken six points on the outside limit of the carbuncle, and injected one syringe full into each two points, three syringe fulls at once. I have seen no poisonous effects in any way, and I had to repeat this no less than four times.

I believe if the same amount of carbolic acid sufficiently diluted as to cause no injury by contact with the tissues, were taken into the stomach, the toxic effects would be very dangerous if not fatal.

If other agents are more dangerous in their effects by being administered hypodermically, such as morphine, than if taken by the stomach, I have experience that it is not so with carbolic acid.

No. 7 JACKSON STREET.

THE BUSY PHYSICIAN.

Who looks so deep into the very depths of the human soul as the physician—I mean the physician who can see, observe and is familiar with the mental as well as physical make-up of man.

No man has to carry so much ready knowledge as the doctor. He must decide questions involving life and death in a minute. The lawyer has "briefs between his briefs," when he can look up his case and his authorities and prepare himself for the hearing. The minister can choose his time for preparation and take his week to get ready for Sunday. The druggist can look up his questionable points in the dispensary or pharmacopoea behind the prescription counter and let the patient wait for the medicine until he gets time to prepare it properly. So with the chemist. He has ample time to consult authorities. In fact, every scientist-save the physician-has time to look up what he needs as he goes. Not so the doctor. He must be ready to tie an artery; to perform tracheotomy, etc. on short notice, and if he does not decide right, he is scorned by a thoughtless multitude and abused, and talked of, to say the least, disrespectfully.