M5 Delegates to National Medical Convention, Clinical Lecture on Abscess of the Tibia. By Foreign Intelligence. - Case of Fractured period: the soft parts will stretch, bones sent lecture, is one of considerable interest, & ings are consequently more severe, and they are protracted for a very much longer period. In the year 1824, I was consulted by a I need not tell you that bones are organ- (stant pain in the part, generally of a mode- Published Monthly by LEA & BLANCHARD, Philadelphia, at One Dollar a year, and sent GRATUITOUSLY to all subscribers of the American Journal of the Medical Sciences, who remit the annual subscription, Five Dollars, in advance. See Prospectus in full on the Supplement to the Number for July. In no case will this work be sent unless the money is paid in advance. other set of symptoms in addition to those which were the direct consequence of the local malady. The disease had been going on for 12 years. He had consulted a number of surgeons respecting it, and had used a vast variety of remedies, but had never derived benefit from anything that was done. However, about a year afterwards, in August, 1827, there was a recurrence of the pain; the enlargement of the tibia, which had in some degree subsided, returned, and it continued to increase. In the enlarged tibia there was one spot a little below the knee, where there was exceeding tender Instead of getting better, he every year be-ness on pressure. I need not describe the came so much worse. I tried some reme-symptoms more particularly; it is sufficient dies without any advantage, and at last to say, that they bore a very close resemrecommended that he should lose the limb. blance to those in the last case; the only Mr. Travers saw him with me, and agreed difference being that, as the disease had in this opinion. Amputation was performed, and the amputated tibia is now on the table. You will see how much the lower end of it is enlarged, and that the surface of it pre- { I concluded that there must be an abscess sents marks of great vascularity. The bone in the preparation is divided longitudinally, and just above the articulating surface there is a cavity as large as a small chestnut. This cavity was filled with dark coloured pus. The inner surface of it is smooth. The bone immediately surrounding it is harder than natural. The examination of the limb explained all the symptoms: there was an abscess of the tibia, stretching the bone in which it was formed, or rather, if I may use the expression, trying to stretch it, and thus causing the violent pain which the patient suffered. On observing these appearances, I could not help saying, that if we had known the real state of the disease, the limb might have been saved. A trephine would have made an opening in the tibia, and have let out the matter. It would have been merely applying the treatment here that we adopt in the case of abscess elsewhere. You open a painful abscess of the arm with a lancet; you cannot open an abscess of the bone with a lancet, but you may do so with a trephine. been of shorter duration, the pain was less severe, and that the tibia was affected in the upper instead of the lower extremity. in the centre of the bone, and applied the trephine to the tender spot. I used the common trephine made for injuries of the head, which, having a projecting rim or shoulder, would penetrate only to a certain depth. However, it enabled me to remove a piece of bone of sufficient thickness to expose the cancellous structure. Then with a chisel I removed some more of the bone. Presently there was a flow of pus in such quantity as completely to fill the opening made by the trephine and the chisel. It seemed as if the bone had been, to a certain extent, kept on the stretch by the abscess, and that, as soon as an opening was made into it, it contracted and forced up the matter. The patient was well from that time; the wound healing very favourably, and he has never had any return of the disease. Some time after this I was consulted by a gentleman who had an enlargement of the lower end of the tibia. He suffered constant pain, but every two or three weeks there was an exacerbation of it, and it was then very excruciating, almost intolerable. About two years after the occurrence of These attacks sometimes lasted two or this case, I was consulted by another pa-three hours; sometimes one or two days. tient, 23 years of age, who had an enlarge- This patient when he came under my care ment of the upper end of the tibia, extend- was 34 years of age; he traced the disease ing to some distance below the knee. He back for eighteen years, and stated that it suffered a great deal of pain, the part was began in the following manner: on going to very tender, and there were all the symp-bed one evening, he felt a sudden pain in or toms of chronic periostitis. I made an in- just above the ankle-joint: the next day cision over the part, dividing everything there was a swelling in this situation, he down to the bone, and found the periosteum was laid up with inflammation, and two very much thickened. There was a new abscesses burst in succession, but afterdeposit of bone under the periosteum, softerwards healed. He continued well for some than the bone of original formation. This considerable time, and then he was again operation, as in other cases of chronic peri-seized with pain in the ankle. This pain ostitis, relieved the tension and the pain, was not constant, but occurred at intervals. and the patient was supposed to be cured. Sometimes there were several months during which he was quite well. (These points are worthy of notice with respect to the diagnosis, as I shall show you presently.) After some years, however, the pain was never absent, and he got into the state in which he was when he sought my advice. On examining the ankle I found the tibia considerably enlarged. The motion of the joint was perfect, but there was one tender spot on the inside of the bone that seemed his admission was so severe that he could not sleep at night. It affected his health; he had lost flesh, and could take little or no food. I concluded that there was probably an abscess in the tibia, but as the disease had only been of short duration, I thought it might be better to treat it as if it were merely chronic inflammation in the first instance, having recourse to some other remedies before I performed the operation. I to indicate the seat of an abscess. I applied prescribed, therefore, calomel and opium, a trephine here, and penetrated into a cavity { sarsaparilla, and iodide of potassium, one large enough to receive the end of the fin-after the other. At last, there being no ger. There gushed out a quantity of matter, amendment, I applied the trephine at that perhaps a drachm, or more. The inner spot where the bone appeared more tender surface of the cavity was exceedingly ten- than elsewhere, and thus exposed an abder, so that he could not bear the introduc-scess, which contained two or three drachms tion of the finger, or even of a probe. On of pus. The relief was immediate, and soon the following day there was a good deal of afterwards the patient left the hospital cured. inflammation in the neighbourhood of the I will mention another case. In the year part in which the operation was performed; { 1841, a young lady came to consult me on in the course of a few days an abscess form-account of pain in the lower end of the ed, which burst externally, just below the tibia. It began in the spring of 1835, when ankle, and then the inflammation subsided. she had an attack of what appeared to be The opening made by the trephine became inflammation in that bone. The pain was filled up with granulations, and the wound healed favourably. This took place many years ago; I have seen the patient every now and then since, and he has continued perfectly well. I have had two cases of this kind under my care in this hospital. One was a boy, who had a considerable enlargement of the lower end of the tibia, attended with a great deal of pain. I trephined the bone, and let out nearly half an ounce of matter. The other was a man, whose case I will give you a little more in detail. His name was Mow at first confined to the lower end of the tibia, but afterwards she had, in addition to it, other pains, apparently of a nervous character, extending up the limb to the hip. She was of an hysterical constitution, which might, perhaps, make the diagnosis of the disease a little more difficult, the hysterical pain being mixed up with the other. However, I found her having occasional attacks of most severe pain in the lower end of the tibia, the bone being enlarged and tender to the touch; and, after a most careful examination, I was satisfied that there must be bray, and he was admitted in October, 1838, an abscess in the bone. Accordingly, I rebeing then 24 years of age. He had an en-commended the application of the trephine. largement of the upper end of the tibia, & She could not then stay in town, and, either extending to the distance of 21⁄2 inches be- because her surgical attendant in the counlow the knee. The circumference of the leg try did not accord with me in opinion, or at this part was about an inch more than because she would not submit to it, the opethat of the leg of the other side. The skin { ration was not performed. She dragged on over the enlarged bone was tense, and there { a very uncomfortable existence for four years was a blush of dark redness on the inside. more. In the interval she was married, He said that six years ago there took place traveled abroad, had various opinions, tried some enlargement of the head of the tibia, & different remedies both here and elsewhere, attended with a dull pain. Leeches were { but nothing afforded here any relief. Last applied, and some other treatment was had { August she again came under my care: the recourse to; I know not what. The pain tibia was then very much enlarged: at times continued for about six months; it then sub- she was quite free from pain, at other pe {riods she had severe attacks of it, so that she could not sleep at night. I was still of opinion that there was a collection of matter sided, and he became quite free from it, until about three months before he came to the hospital, when it returned, and the bone began to enlarge. The pain at the time off within the tibia. Mr. Travers and Mr. 4 SKETCHES AND ILLUSTRATIONS OF MEDICAL DELUSIONS. Key saw the patient with me, and it was agreed that I should perforate the bone with the trephine. Accordingly I performed the operation. The bone was excessively vascular, so that there was a good deal of bleeding; and, towards the end of the operation, a quantity of what appeared to be sero-purulent fluid gushed out from beside the trephine, mixing with the blood. At and quack system, in vogue; and by the obscenity and cheating in which quackery is involved; they, only, comprehend to the full the injury inflicted on the public by the host of ignorant meddlers with health and disease, in the shape of unqualified practitioners, dealers in quack medicines, and the other descriptions of charlatans, who may be literally said to be engaged in a traffic in the bottom of the bone removed by the in-human life; and they, only, understand the strument there was a cavity that would just hindrance which the rapacious quacks offer receive the end of the finger, and from to the progress of medical knowledge, by which the fluid had escaped. After this she impoverishing the profession, and by throwhad considerable pain for some time, but {ing odium upon it, because of the inability evidently of an hysterical character. She of the public to separate true medicine from * **** * went into the country, and I have been just the quackeries which vaunt themselves as now informed that the wound has been for true. It ought, therefore, to be a sacred some time healed, and that she is free from duty with the profession to uproot this all her former symptoms. The piece of monster evil. Every bone that was taken away is upon the table; honest man in the profession should bethink it is more hard and compact than it ought to himself of the evils around him, and bestir be just above the ankle, where, in the natu- himself to make them known to his fellows ral state, there is a mere cancellous struc-and to the public. If each individual noted ture. You will perceive on its under surface, one corner of the cavity in which the sero-purulent fluid was lodged. (To be continued.) the most urgent symptoms of this evil which came under his observation, here a simple falsehood, there a downright perjury; now the murder of the sick by omission or commission, then the promotion of abortion or (infanticide; at some times the mortality in a lunatic Bastile, at others, the deaths in a Quackery. The attitude of all true lovers hydropathic bagnio; in one place a forgery, of their profession, at the present time most in another, provocations to obscenity and especially, is offensive and defensive against vice; at this time a quack-pill murder, at quackery. The profession should bend it-that, a criminal trial:-if these and all the SKETCHES AND ILLUSTRATIONS self with one will towards its exposure and legion of similar things were noted and reentire rejection. They are called to do this corded, we should soon have a body of eviby the very highest considerations that can dence which would render it impossible for urge men to the zealous prosecution of the the legislature to refuse the suppression of most noble object. Their own rights, and the present system of quackery. These are the individual weal of the members of the { not melodramatic horrors, but actual events. profession, are the least motives that can be placed in the scale. Public morality, public safety, and the advance of true me. dical knowledge, the legitimate art of healing, should be the mainsprings of action in the war of the medical mind with the huge social pest. Its extermination is, we say, the special province and duty of medical The public, ignorant of all that relates to medicine, ignorant of the evils resulting from quackery, and possessed with } by the existence of others of a more spethe spirit of credulity that is natural to this cious kind, the end of the thing would twofold ignorance, can scarcely be expected { speedily arrive. Wherever, then, and whento take any part in the matter. But profes- { ever, legitimate and scientific medicine is men. But we must, at the same time, or even first in order, pluck the beam from the professional eye; for we fear there are many, who, without intending it, or knowing it, are themselves the abettors of some of the milder forms of quackery which they so feelingly and so properly deplore, and which rob them and their children of their lawful bread. And if these viler quackeries be not defended, as it were, and rounded off, sional men know the injury to public morals by the enormous lying which is required to keep every quack, and every quack nostrum opposed, then and there is quackery. Whenever any one of that triad of cheateries, mesmerism, homœopathy, and hydropathy, |