Periostitis. John H., Irish, aged fifteen, painter. The patient is a poorly nourished lad, who, his parents state, has no hereditary taint, and whose only previous sickness was scarlet fever, which he had seven years ago. One and a half years ago, the boy received a blow on the left tibia from a shinney stick, but at the time was not apparently much injured. Three months afterwards he was taken with severe pains in the leg, which lasted some two or three months, and which were worse at night, keeping the patient awake until two or three o'clock in the morning. There have been five or six such attacks, with intervals of two or three months. Is suffering from one now, which commenced three weeks ago. The leg has gradually enlarged from the first, but only to a slight degree of late. On examination find the left tibia enlarged forward along the whole extent of the crest, thus increasing its anteroposterior diameter. There is a slight, lateral enlargement, but it is confined to its lower extremity. Strong percussion elicits pain, which is greatest near the ankle. This is a rare form of periostitis, rare in the shape of the enlargement it has produced. A healthy lad, free from disease except the attack of scarlet fever seven years previous, receives a blow on the skin, which was not painful, when three months afterwards it began to pain and enlarge. (The pain at the ankle is probably sympathetic.) We frequently encounter these enlargements, but not in this form. On grasping the tibia it is found that it is not enlarged laterally except at its lower part. The question, however, is whether we have hypertrophy or abscess. We frequently have enlargements from bone abscesses, but they increase the diameters in all directions, while the enlargement is more localized. Hypertrophy with abscess, also frequently occurs, and is also more circumscribed than in the present case. Periostitis with hypertrophy, is not usually so painful as abscess, having painful periods with exacerbations. The pains in this case have been nocturnal for two months at a time. Have trephined for three cases, at times removing large de posits of pus, at others only obtaining a drop or two, and again not demonstrating that there was an abscess, yet in all giving relief. Think that the nocturnal pains point to an abscess, but it would be difficult to find the point in the bone to strike it, although there are several which seem suspicious. It is thought that an incision through the periosteum might afford relief. The patient was anesthetized, and an incision about eight inches in length made through the integument, along the crest of the tibia, down to the periosteum, which was then incised by five parallel incisions co-extensively with the incision in the integument. As the incisions were made in the periosteum, some half a dozen or more enlarged periosteal vessels spurted very freely, showing its abnormally vascular condition. The edges of the incisions gaped and the periosteum was found thickened and spongy. After hemorrhage had ceased, the wound in the integument was brought together and secured by interrupted sutures. Warm water dressings were ordered. The pain which had been regular up to the time of the operation, ceased, and has not yet returned, the patient sleeping the first night and every night since. The wound healed kindly and rapidly, and the patient has resumed his occupation. CHICAGO MEDICAL COLLEGE CLINIC. SERVICE OF PROF. S. J. JONES. [Reported by S. O. RICHEY, M. D.] A Case of Clonic Blepharo-Spasmus. February 28th, 1877. Mr. C., a railroad employe, has been a clerk for fifteen years past, working continually, much of the time by artificial light. Hard work, inability to get sufficient sleep to recuperate his strength, and an immoderate use of tobacco combined to produce marked nervous depression. In both eyes vision is normal (v-8). There is violent spasmodic action of the upper lids of both eyes, which, besides the annoyance it gives, interferes with the performance of his duties, because his eyelids will close at the most critical time. He is advised to secure all the sleep possible, to eat good nutritious food, to rest the eyes, and to give up the use of tobacco and stimulating drinks. A shower bath for the eyes, and the elixir of calisaya, iron and strychnia are prescribed for him, with twenty grains (gr. xx) of bromide of potash, daily, when going to bed. March 2d. He returns improved; the spasm of the lids has ceased, he sleeps better, eats more heartily and seems more vigorous. March 5th. The improvement continues, the change being perceptible even in his complexion. March 20th. The patient has been seen several times since the 5th inst., each time being stronger than before. He has had no return of the spasm. The spasm of both lids, the absence of local inflammation, with the other symptoms mentioned, directed attention to the condition of the general system as the cause of the affection, the spasm being a local evidence of general nervous debility. NOTES FROM PRIVATE PRACTICE. Congenital absence of Uterus and Vagina: Simply as a matter of record, I report the following case of congenital absence of the uterus and vagina, which lately came under my observation. Miss H.-aged 19-nationality, Irish-third child in a family of six children, four of whom were boys. She says there is no deformity or arrest of development, either in any of the other children, or anywhere else among any of her other relatives; that all are perfectly formed and healthy. She has never menstruated, but about once a month she has some headache and a sense of fullness in the abdomen. She was first led to believe that "something was wrong" with her about a year ago, from the fact that she "did not have her courses as other girls do." She says she enjoys the society of the opposite sex she "supposes the same as any girl does." Apparently she is a perfect specimen of young womanhood-tall, well developed, robust and active. Examination (afterwards confirmed by Dr. W. H. Byford of this city) showed, the parts well covered with hair; labia majora and nymphæ, as well as clitoris and hymen well developed and natural. Meatus urinarius normal in position. Mammæ large and also well developed, but the most careful and rigid examination failed to find either vagina or womb. There is, however, no reason to doubt the existence of the ovaries. Chicago, June, 1877. A. W. GRAY, M. D. Local anesthesia. In the following communication, I wish to call the attention of the reader to a simple method of producing local anesthesia in some operations of minor surgery, as in opening an abscess, excision of inverted toe-nails, etc. The contrivance is a very old one, yet it is not so thoroughly appreciated by practitioners, as in my opinion, it ought to be, for it is extremely simple and reliable. The principle upon which the method is based, is the fact, that a mixture of equal parts of ice or snow, and common salt produce a very high refrigerating action of from 0° to 17° C from 32° F to 0° F (according to Hager's text-book). The way to make use of this physical fact in surgery is as follows: = one part (spoonful,) Put both on a soft rag (musquito netting); mix it to form a kind of poultice and press it quickly against the skin, where you intend to make an incision. In a very short time the skin freezes and becomes absolutely insensible and bloodless, thus affording the double advantage of avoiding any pain and of preventing the blood from obscuring the field of operation. As to the length of time this state of the skin might be main tained without endangering its vitality, I have made no experments; but I think it may be continued a longer time, than is required for the performance of any minor operation. As the temperature begins sinking the moment the ice and the salt are brought in contact, all that is necessary for the performance of the operation must be ready before making the mixture. Special care must be taken to have the knife as sharp as possible, for the frozen skin is remarkably tough, and resists the instrument to a high degree. I may add, that, if the fingers or toes be the parts on which an operation is performed, the ice-salt-poultice seems the best method of applying the refrigerating mixture, because we can cover the finger or the toe all around with ice; but on the other hand, if a larger surface (for instance, the breast in a case of mastitis suppurativa) be the object of operation, we best proceed by putting on the spot, previously selected for incision, a piece of ice as large as a hickory-nut, that is then sprinkled with salt. Almost instantly the skin beneath the ice freezes; then we take away the ice and salt and make the incision. That the size of the ice-salt poultice in the one case, and the size of the piece of ice in the other depends, after all, upon the length of the intended incision, is hardly necessary to be mentioned. The following two cases may be reported to confirm the above statements: 1. Some time ago I was called to a woman, who received a splinter of wood under the nail of the right thumb, while she was washing the floor. I saw the patient 3 days after the accident; the splinter which had advanced as far as the root of the nail was broken short at the edge of the nail, in consequence of previous attempts at pulling it out. A diffuse swelling, throbbing and burning indicated that inflammation had already set in; the patient was nervous and feverish, and was so excited by fear of the knife, that she would hardly allow me to touch the finger. But being assured she would not feel any pain from the operation, she submitted to it. I applied an ice-salt poultice (as described) close around the nail phalanx of the thumb. After some 2 or 3 minutes the thumb was frozen |