CASE II.-PROGRESSIVE DYSPNEA AND APHONIA— CASE III-OLD DISLOCATION OF BOTH BONES OF CASE I.-Irritative Cough from Elongated Uvula-Operation. GENTLEMEN: This child, about seven years of age, presents an illustration of a persistent dry cough without any pulmonary disorder. The explanation, however, is at once apparent upon directing our attention to the throat. An elongated uvula rests upon the base of the tongue, and constantly titillates the entrance of his larynx, thus setting up spasmodic cough. From debility of the parts, which is generally accompanied by more or less inflammation or chronic sore throat, the soft palate becomes relaxed, and the uvula drops down upon the tongue; or the uvula itself may be hypertrophied and elongated, as in the present case. This condition is most likely to be set up in young subjects, although it may occur at any time of life, and is often found associated with a strumous diathesis and a delicate constitution. This apparently trifling affection may produce considerable inconvenience. Hawking, coughing, constant irritation, sense of strangulation during sleep, and nightmare, are among the immediate results; among the later ones may be feared the occurrence of tubercular deposit in the lungs. If the disorder be due simply to relaxation of the soft palate, which often occurs in consumptives and dyspeptics, the use of astringent gargles, and applications-among the best of which may be named nitrate of silver solution, gr. xx to gr. xxx, applied with a swab twice a week-may be followed by relief from the symptoms. But when there is a marked hypertrophic elongation of the uvula, the proper remedy is the removal of a considerable portion of the organ, which is readily accomplished with the scissors. For this little operation no chloroform will be needed, except where the patient refuses to co-operate with the surgeon. Sometimes in young children much trouble is experienced from their active struggling, and then the operation is greatly facilitated by a little of the anæsthetic. I have now performed the operation upon this young lad, and would have accomplished it more satisfactorily if he had not resisted me. No hæmorrhage will occur after gargling with a little cold water or vinegar and water. I shall insist upon the importance after this operation of his using a liquid diet for a few days, and of being careful not to catch cold. Remarks upon Chloroform. In In regard to the administration of the anæsthetic, you should not forget that chloroform should never be given with the patient in an erect, nor even in a semi-recumbent posture. Owing to the tendency to syncope and heartfailure, the head should not even be raised from the pillow, nor the neck bent. Of course, you would not give chloroform nor any anæsthetic immediately after a full meal, on account of the danger of incomplete vomiting and strangulation. No food should be given for at least four hours before the administration of chloroform. The assistant in charge of the anesthetic should devote his entire attention to watching its effects upon the patient, and should not look at what the surgeon is doing. The administration must not be hurried; chloroform must not be crowded, but given deliberately and with plenty of atmospheric air. regard to the amount necessary to be used, in the case of an infant, you have noticed that only a few drops are placed upon the centre of a folded towel, in the manner in which you have frequently seen it done by my experienced assistant, Dr. Hearn; for an adult the amount may be increased to half a drachm at first, to which a few drops are added from time to time to supply the loss by evaporation. The clothing must be loose about the chest and the abdomen, during the administration. Should a change be noticed in the pulse or appearance of the patient, the chloroform must be at once removed and the patient turned upon his side, the tongue drawn forwards and the face dashed with cold water; and the chest, or, in the case of a child, the nates, well whipped with a fringed towel wet with ice-water. If the patient do not revive, the foot of the table may be elevated so as to allow the head to hang down, or the patient may be lifted by the heels, or "inverted," while artificial respiration is attempted. The vapor of nitrite of amyl, or spirits of ammonia, may be cautiously given, which sometimes has a remarkable effect. With care in administration a fatal result may generally be averted, especially if the tendency to syncope be borne in mind, and prompt measures taken to overcome it. By pursuing the methods just laid down, I have successfully administered chloroform in probably more than five thousand cases without a single fatal result. Chloroform should be administered with especial care to habitual drink-¦ ers, and to those who are the subjects of heart or kidney disease. It seems to be particularly applicable to young and middle-aged persons. In strong adults, it occasionally happens that we cannot make them unconscious with ether, and we are obliged to give them a small amount of chloroform in addition. Although chloroform does not commonly cause vomiting, and is much more pleasant and efficient than ether, I do not now use it as frequently as formerly, but have yielded my preference in deference to popular opinion, which at present holds the surgeon responsible if any accident should happen. I therefore employ the safer but less agreeable agent to a very great extent, as a substitute for the chlo roform. CASE II.-Progressive Dyspnea with Aphonia -Stenosis of Glottis caused by Intra-laryngeal Growths-Tracheotomy. I have here a very interesting patient, sent in by Dr. Cohen from the Out-patient's Department, he having presented himself at the Laryngoscopic Clinic a few days ago. Dr. Cohen will read his history, and tell us what has been revealed by laryngoscopic examination. "Charles M. I., 63 years of age, applied last week for advice in regard to an obstruction in the larynx, which had commenced to be troublesome six months before, but had progressively increased until his voice is reduced to a hoarse whisper; he was also subject to severe attacks of dyspnoea. He stated that he came to this hospital a year ago for some local trouble in his throat, and was informed that he had growths in his larynx, but I do not remember having seen him before. However this may be, examination now reveals marked stenosis of the glottis, the edges of the vocal chords being agglutinated by inflammatory adhesions. In addition to this, there are evidently some papillomatous growths below. The stenosis has changed the shape of the glottis so that the opening, instead of being from before backwards, runs obliquely; on account of the great enlargement of the left wall of the larynx, which encroaches upon the canal. This enlargement is probably due to a malignant growth." Dr. Cohen further said that he considered the patient in danger of suffocation during one of his attacks of dyspnoea, and that the only treatment to be thought of, at present, was tracheotomy, which would enable him to breathe freely. After opening the trachea as high up as possible, perhaps enlarging it so as to perform laryngo-tracheotomy, by dividing the cricoid cartilage and crico-thyroid membrane, it is possible that the operation might be extended so as to remove some of the growths. It was requested that no anesthetic should be given on account of the dyspnoea. A tracheotomy tube would have to be inserted after the operation, which he will have to wear during the remainder of his life. Professor Gross remarked while proceeding to perform the operation, that laryngotomy is easily performed under ordinary circumstances. An incision is made through the skin and fascia, in the middle line, extending along the front of the thyroid and cricoid cartilages, exposing the crico-thyroid membrane, which is then divided, and the tracheotomy tube inserted. A small artery-the crico-thyroid-sometimes requires ligation before opening the larynx. Tracheotomy, how ever, is more difficult, and in order to accomanaesthetic is generally required, especially in plish the operation satisfactorily the aid of an the case of a struggling and crying child. I do not know of any operation in the whole range of surgery which I dread more than that of tracheotomy in a child with a fat neck. In the present case the neck is thin, and as the patient will not oppose the operation, I do not anticipate any serious trouble. In performing tracheotomy, the patient being placed in the recumbent position, with the head thrown far back and the neck elevated, a median incision through the skin is carried from the cricoid cartilage nearly to the top of the sternum. The fascia, in the middle line, is taken up on a grooved director and cut, the sterno-hyoid and sterno thyroid muscles being cautiously separated from those of the opposite side with the handle of a scalpel. The thyroid plexus of veins should be pushed to one side, and held out of the way; the middle thyroid artery will Occasionally require a ligature. Whenever there is much embarrassment in breathing, the veins of the neck are generally distended, and considerable hæmorrhage may ensue if they are accidentally divided. This bleeding should be entirely checked befor opening the trachea, or it might cause suffocation. After the operation, the tube, which for convenience of re-introduction after cleansing is surrounded by a canula, is inserted, and an anodyne is administered. The patient must now breathe moist, warm air, at a temperature not lower than 75 to 80° (F.). The tube should be taken out three or four times in the twenty-four hours in order to clear away mucus and blood; and for the first few days the constant attention of a special nurse is required. What the effect upon the growth may be I cannot tell, but one of the most troublesome features in the case will doubtless be greatly relieved by the operation we have just performed. (The patient rallied well after the operation, but sank at the end of a week from exhaustion. There was no pulmonary involvement. A macroscopic examination of the larynx confirmed the diagnosis.-F. W.) (To be continued.) A CLINICAL CONFERENCE HELD BY PROFESSOR DA COSTA AT THE COLLEGE HOSPITAL. A CLINICAL Conference with the members of the graduating class, was held on December 18th, 1879, at which cases were presented by Messrs. William H. Ziegler, Edwin Rosenthal, L. W. Steinbach, and C. L. Mitchell; Professor Da Costa participating in the discussion, and confirming the physical examination and the diagnosis. This is the first regular conference that has been held since Dr. Da Costa has filled the Chair of Principles and Practice, although they were formerly held on several occasions, with considerable success, while he was lecturer on Clinical Medicine at this College. The present trial was entered into with much interest by the students, who hope that these conferences will now continue to be a regular feature in the course of instruction, as it brings them directly in contact with the patients, and gives experience that they greatly need, in analysis of symptoms, in physical examination, and in the presentation of a case to a consultant. The patients were brought successively before the class, and reports made as follows: Mr. Steinbach presented the following case of Obstructive Jaundice. GENTLEMEN: The name of the patient whose case I am permitted, through the kindness of our Professor, to discuss before you, is Robert S. He is 27 years of age, single; his occupation is that of a street-car conductor. He comes to us complaining of debility, dyspepsia, and palpitation of the heart. Upon questioning him I have elicited the following history: Previous to the present complaint, which began three months ago, he considered himself a healthy man, with the exception of an infecting sore, which he contracted four years ago, and which was followed by alopecia and sore throat; these, however, had yielded to specific treatment. His occupation caused him to be greatly exposed to the vicissitudes of the weather, but he had never suffered from ma laria. He smokes a good deal, takes moderate amounts of tea and coffee, but during the past summer has indulged rather freely in the use of malt liquors. He has lost strength, becomes exhausted on the slightest exertion, feels a weight in the right hypochondriac region, and his heart palpitates violently; for these reasons he had to abandon his occupation. He is depressed and gloomy, has occasionally a slight headache, sleeps poorly, has no appetite, but does not feel nauseated nor does he vomit. The bowels are constipated, the stools, as far as noticed, are of a dark color, the urine is normal as to quantity, but is rather dark. His hands and feet are cold, and he has lost flesh. On examination, I found a sallow countenance, and a conjunctiva slightly tinged with yellow; the pulse is weak, 120 to the minute; the temperature is 100° F. The impulse of the heart is forcible, the area of percussiondulness is normal, there are no murmurs. The respirations are 20 per minute, but the lungs are clear, and auscultation reveals nothing abnormal. His tongue is coated, flabby, and shows the marks of the teeth; the breath is heavy. The liver-dulness extends about one and a quarter inches below the inferior margin of the rib on the right side; the spleen is very slightly enlarged; there is no tenderness over the gastric region. The nitric acid test reveals the presence of a small quantity of bile-pigment in the urine, by the characteristic play of colors around the margin of the drop of liquid, where it comes in contact with the acid upon a white porcelain surface. ance. In making the diagnosis of the case, I am safe in excluding the view that this train of symptoms is the manifestation of the syphilitic poison, nor does the cardiac examination warrant anything more than mere functional disturbI, therefore, conclude that the primary affection is in the liver, and it remains only to be decided whether I am dealing simply with a temporarily deranged organ, or whether there is an underlying organic affection. The former view is favored by many of the symptoms present, and more particularly by the irritable heart and rapid pulse; but since no functional disorder alone can give us an enlarged organ, I have to adopt the fact that the case before us is one of hepatic congestion, with chronic catarrhal inflammation of the bile-ducts. This view at once explains the symptoms as well as the physical signs, and there is certainly no cause why we should not ascribe the origin to an exposure, to which his occupation so eminently subjects him. The pathology of the case, in my opinion, is this: The biliary ducts have become inflamed and congested, the bile, which cannot pass through the wholly or partly occluded duct, has been re-absorbed and circulates in the blood, imparting to the skin and transparent conjunctiva the icteroid hue, and produces the depression of spirits and other nervous symptoms by its influence on the brain. Moreover, those articles of food, the assimilation of which depends on the biliary secretion, pass through the alimentary canal undigested, which deprives the system at large of a good portion of nutriment; and this again manifests itself by an impoverished state of the blood, the loss of strength, and the various dyspeptic symptoms. The indications for treatment are primarily of a hygienic character. The patient should take a moderate amount of exercise in the open air, be well clad, and in order to promote the action of the skin he might take a tepid bath once a day. His food should be, light, unstimulating; milk should form a large portion of his diet, meat only in small quantities, but alcoholic and malt liquors avoided. For the medical treatment a pill consisting of resin of podophyllum, compound extract of colocynth, and powdered capsicum, to prevent griping, This case is Frank Anderson, age 45; occupation, laborer. On inquiry I find he never had rheumatism, that he never had malaria, is of asserted temperate habits, and has never had any serious illness. He came here complaining of pain in the back, which he had since last Saturday (December 13th), that is, for five days. He said he got this pain from straining in lifting a heavy stone, and that he has had the same sort of pain once before; he is also troubled with pain of the right arm, in the muscles near the shoulder, which he believes is also from con stant use of this arm in the heavy work in which he is exposed to all sorts of weather. On examination, I find that the pain is in the lumbar region on the right side, the left being unaffected; this pain is aggravated by any movement of the body forward, and is completely relieved when he assumes the erect posture. On pressure, the parts are tender, and more painful at the insertion of the muscles. His temperature is normal, and he passes a regular amount of urine, which the clinical assistants say is not albuminous but filled with phosphates. The diagnosis is myalgia. On account of the unilateral character of the pain I thought this might be neuralgia, but he has never had malaria; and the pain here being so different from that of neuralgia, ceasing upon relaxing the muscles and aggravated on movement, whilst in neuralgia the pain is not increased by muscular movement and is generally intermittent, so I excluded neuralgia. As there is no impairment in his gait nor spinal tenderness, we exclude disease of the vertebra. I also exclude rheumatism, because there was no increase in temperature, and the urine is not acid. He never had previous attacks of rheumatism, and this immediately followed a strain, and is strictly located in one muscle, whilst rheumatism comes after exposure to damp and cold, and affects the whole muscular system generally. Professor Da Costa accepted the diagnosis as myalgia, and inquired the prognosis, which was considered favorable. The lecturer concluded his remarks by stating that the best treatment would be rest in bed, local counter-irritation, and warmth to the parts, but as the patient is unable to do this he shall have hypodermic injections of atropia, gr. th (.001 gm.), or he take belladonna, either in extract or tincmay region affected. ture, and wear a belladonna plaster over the The next one was presented by Mr. Mitchell. Cystitis and Supposed Disease of the Kidney, due to Strictures of the Urethra. Charles D. Marquette, age 34 years, by occupation a tailor. His family history is good, he being one of a family of fourteen children, twelve of whom are living. He has been a sufferer for nearly fifteen years, his complaint being, as he terms it, "pain in his kidneys." These pains are felt most severely in the lumbar region, often shooting down the back and towards the groin, and also felt sometimes in the umbilical and supra-pubic regions. They generally occur in paroxysms more or less severe in character, the pain being sometimes sharp and lancinating, at others a dull heavy ache. They are much influenced by posture, he being unable to sleep on his back at night, and often being obliged to lie on his face all night in order to obtain relief. He also is troubled with frequent and painful micturition, and is obliged to rise several times during the night in order to pass his water. He cannot localize the pain, in passing water, at any particular spot, but complains of a general tenderness along the urethra. He says he thinks his trouble originated in an injury received during the war, which confined him in hospital for several weeks, during which time he passed bloody urine. He has been under treatment by various physicians but with indifferent success. He has never had syphilis, but 12 years ago contracted a gonorrhoea, which lasted several weeks. He says he has had attacks of swelling of the feet and ankles, although at present there is no sign of any such trouble. There is some headache, his appetite is poor, and his bowels constipated; this latter, however, is probably owing to his occupation. There is a history of malaria. An examination of the patient shows a man of apparently fairly good health. His temperature is normal, pulse 74, respiration regular, and the lungs show no sign of impairment. The first sound of the heart is rather heavy, but otherwise there is nothing abnormal. Its percussion dulness is not increased, nor is that of the liver and spleen. There is tenderness on pressure over the region of the kid neys. The urine shows a turbid fluid of a rather disagreeable odor, strongly alkaline in its reaction to test-paper, and of a specific gravity of 1.027. Its quantity is not increased. It contains a heavy whitish sediment, amounting to about 8th of its bulk. A chemical examination of this shows it to consist of muco-pus, phosphates, and urates. Under the microscope are found crystals of the phosphate of lime and triple phosphates, and urates of ammonia, etc., in great quantity. Also numerous large epithelial scales from the bladder undergoing fatty and granular degeneration. There are no casts. The clear liquid, separated from the sediment, was tested with nitric acid by Heller's test, when a faint cloud of albumen was obtained. An examination of the urethra made by the surgeon has shown the presence of two tight strictures in the spongy portion of the canal. Diagnosis.-Chronic cystitis, affecting the bladder, ureters, and kidneys, caused by an organic stricture of the urethra. Treatment. This should be primarily devoted to the stricture of the urethra, which should be subjected to radical means for its cure, either by gradual dilatation, divulsion, or internal urethrotomy. A steel sound should be Medicines should also be given which exercise a specific action on the genito-urinary mucous membrane, such as ol. santali, copaiba, or oil of turpentine, which are best administered in the form of capsule. This case is very interesting, as it shows a source which was not previously recognized for the pain and urinary trouble. Dr. W. H. Ziegler presented the following Report upon a Case of Pulmonary Tuberculosis. John Stilling, aged 25 years, single, by occupation a lithographic printer. Eighteen months ago he had a hæmorrhage. This came on after exposure to cold and damp, he at that time being, as he expressed it, run down in health by not taking care of himself. This hæmorrhage was his first symptom, and from the account he gives I believe it was of pulmonary origin. The blood came up in mouthfuls, at first dark in color, afterward frothy and light-colored, to the amount of half a cupful. He at this time became so debilitated as to be compelled to stop work. Repeated hæmorrhages, less in amount, continued for some six weeks, during which time he had nightsweats together with a hacking cough. Under treatment all these symptoms, excepting the latter, disappeared, when he resumed his former employment. About six months ago he had another hæmorrhage, which, together with his debilitated condition, again obliged him to quit work (for the last three weeks had been tending bar). Lifting was necessitated by his occupation. His family history is good. Mother died at 55; father still living. To-day he presents himself as a man poor in health, more or less emaciated, with a history of a hacking cough and an expectoration of mucus streaked with blood, complaining of dyspnoea on slight exertion, and a loss in body weight. He has a pulse of 98, a temperature of 100° F., respirations 26 per minute, tongue is slightly coated, appetite is good, bowels slightly constipated. He has flushes of heat daily over the body and |