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CLINICAL REMARKS ON CASES OF EXCISION OF DISEASED BONE,
917
members of the same family vaccinated from CLINICAL REMARKS the same source might be differently affected; ON CASES OF one, for instance, would not cease from while or OF DISEASED BONE, occupation, another, EXCISION meals, pastime,
particularly if older, would be indisposed for several days. Neither the number nor the magnitude of the vesicles seemed to de-
DELIVERED AT
KING’S COLLEGE HOSPITAL
termine the amount of the primary disturbBY ance. If properly developed, small vesicles MR. FERGUSSON. often gave rise to marked constitutional symptoms, and the most splendid vesicles CASE 1.—EXC!S!ON OF A PORTION OF THE were often seen with trivial, sometimes SCAPULA. scarcely appreciable disturbance." " The secondary symptoms were often as HENRY PARRY, aetat. 2S, a sailor, was active with three or four as with six or admitted under Mr. Fergusson October 10, eight vesicles. Acceleration of the pulse 1842. Twelve months ago, being then in was frequently noticed when no other symp- Calcutta, had an attack of what he calls tom appeared ; both primary and secondary rheumatism of the right shoulder; the parts symptoms11 very commonly showed a remitting swelled much, accompanied with great pain, type." In no case, excepting that of Mr. and he was uuable to use the arm, which Taylor, was there any attendant eruption." consequently became much emaciated. In Other observers besides Mr. Ceeley have the course of a few weeks the swelling and succeeded in performing variolo-vaccination, pain partially subsided, becoming, however, and have recorded the results of their expe- more remarkable on the posterior surface of riments. Dr. Basile Thiele, of Kasan, in the joint. Fluctuation being felt, an opening, South Russia, remarks that the effects pro- two inches and a half in length, was made, duced by this lymph were more intense than and exit was given to a large quantity of fetid those which resulted from ordinary vaccine pus. The wound has never entirely closed, lymph. Sometimes there were two febrile and six or seven pieces of bone have been attacks, the one between the third and fourth discharged at intervals, the last about three day, the other between the eleventh and months ago. There are now two sinuses, one just below fourteenth ; and these severe effects not lost until the sixth remove. In one case and behind the acromion, the other a little the lymph produced an attack oftruevariola, lower, from which there is a constant disand lymph taken from the pocks of this I charge of thin fluid ; there is also an opening patient and inoculated in the arm of an- in front of the shoulder, an abscess having other reproduced vaccinia. This latter ex- formed in that situation. All movements in periment is a marked illustration of the the shoulder-joint have ceased, and he has become totally unfit for service. The spine identity of variola and vaccinia. In concluding the interesting and import- and acromioa scapulae are considerably ant subject of vaccination, and the considera- thickened, and a probe passed along one of tion of the defeiaces against small-pox, I may the sinuses over these parts grates against mention a singular statement made by Dr. bare bone. ]8. To-day a free incision was made, Lichtenstein, and published in Hufeland’s Journal for 1841. The paper in which this which permitted a more complete examinastatement occurs is entitled, " On the tion of the spine of the scapula, and with the Sources from which Matter preservative aid of the gouge and forceps, a portion of against the Small-pox has been derived," necrosed bone was removed from a shelland the author asserts that limpid lymph like cavity in the spine, formed by a depositaken from the pustules produced by tarta- tion of ossific matter around the necrosis. rised antimony and inoculated in a person The cavity and wound were stuffed with who has not been vaccinated, occasions a lint; cold was applied to check the oozing pock that cannot be distinguished from vac- of blood, and on the succeeding day warm cinia. These pocks, he states, are equally water dressings were used over clean charpie, protective against small-pox, and the lymph with which the wound was filled daily. may be transmitted from person to person in Granulations soon occupied the space, and the same manner with cow-pox. Dr. Lich- as cicatrisation became complete the relief tenstein inoculated and reinoculated thirty- from pain and facility of moving the shoulder one persons from this source, and none of became more and more apparent. The these persons took the small-pox, although puncture in front of the shoulder showed no they mingled freely with the infected during disposition to heal, and from time to time, the epidemic prevalence of small-pox. under the impression that there might be a portion of dead bone in this situation, a THE glands, properly so called, separate probe was introduced, which, however, fluids from the body, and discharge them by failed to indicate any such condition. At a duct. They are all situated on the head last, after the occurrence of some additional or trnnk,-Dr. Alison. inflammation in this locality, a piece of bone
were
918
detected, and then remored with a small the above interval the heel has caused great pair of dissecting forceps. In a few days distress, and at the patient’s urgent request all pain having ceased, and the opening Mr. F. has to-day made a crucial incision beingabout closed,the patient was discharged over the bare portion of bone, and thus was
’ scooped it away with the gorget. The remarked, that there wound has been stuffed with lint; cold has was difficulty in deciding whether the origi- been applied, and fomentation ordered for’ the nal disease had commenced in the shoulder- evening. Feb. 6. Pain in heel has been considerjoint or actually in the scapula. When the patient first came to the hospital, however, able since the operation, and the wound has it was evident that it had ceased in the arti- granulated with a copious suppuration. culation, having ended in anchylosis, but To-day a small portion of bone, somewhat that without surgical interference it was im- larger than a pin-head, has been detected possible to foretell when it might get well lying loose in the bottom of the sore, and otherwise, for the separation and discharge has been removed with dissecting forceps. of diseased or dead portions of bone were Warm water dressings and occasionally
cured.
In this
case
it
was
processes of great uncertainty. The steps which had been taken showed their advantage by the speedy relief from pain which resulted, and also by the rapidity of the cure. The patient had suffered for twelve months, and years might have elapsed before the dead portion of the scapula had been discharged, if, indeed, that could ever have happened under the circumstances. It was impossible to determine from what part the piece of bone removed from the sinus in front of the joint had separated ; it might have come from the head of the humerus, or from some contiguous part of the scapula; but if from the part of the spine of that bone from whence a large portion had been removed, il must have taken a singular course to react the surface.
a strap of adhesive plaster sometimes drawn across the sore to promote contraction. 21. Pain has gradually ceased, and the sore is now about healed ; little tenderness
unguentum cetacei ;
pressure, and no appearance of further disease either in the heel or knee; health much improved.* After the operation Mr. F. remarked, that such a proceeding was often of great service in bringing about a speedy cure of an otherwise Tery tedious disease. He had frequently adopted a similar practice in other cases of the kind, and had succeeded in curing a dis. ease of several years standing in the course of a few weeks. He believed that the advantage of such treatment was not sufficiently understood, and that much benefit might accrue from its more frequent adoption. He had operated in this instance at an earlier CASE II.—DISEASE OF OS CALCIS.-ExCIperiod than he thought altogether eligible, SION. but had been induced to do so from the wishes of the patient, and also beJane Gilbert, setat. 29, admitted November 22, 1842. Five months ago experienced cause he imagined that even then he could great pain in the left heel and across the in- afford relief to her sufferings with a fair step, and shortly after felt similar sensations prospect of a cure. He would have prein the knee of the same limb. A hard pain- ferred waiting until there was evidence that ful swelling formed on the outer side of the a portion of bone had become loose, or, at all heel a little below the malleolus, and a sore events, until the acute stages of the disease broke out on the skin over the part, which had seemingly ceased. In the operation he has gradually increased till now, when it had found the lower and outer margin of the may be described as an irritable ulcer, with bone in a state of necrosis, but not yet sepahighly inflamed and swollen edges, and a rated from the neighbouring osseous tissue. thick slough in the centre. The slightest In scooping it away his principal guide in touch with the probe causes a copious flow determining when he had done enough, was of blood, but no bone can be detected. There the oozing of blood from the sound part of is a point which may be covered with thei the bone. It was often difficult in these opetip of the finger over the external condyle of rations on the bones, more especially in the femur, which is exquisitely painful, and caries of the spongy parts, to determine effusion into the joint is conspicuous; patient when all the disease had been removed. to be kept in bed; knee and heel to be Sometimes the surgeon being guided by the poulticed. appearance of the portions removed, some26. Slough has separated from the sore * on the heel, and left the bone exposed. March 14. Shortly after the last date Dec. 1. An issue with caustic potash this patient began to move about the ward. formed over the painful part of the knee. The erect position caused considerable Jan. 29, 1843. Since 1st December ult., swelling in the foot, and some pain in the pain in the knee has gradually ceased, effu- vicinity of the cicatrix. A small portion of sion has been absorbed, and there now only the wound has not yet healed, but there is no remains a small superficial sore, resulting sinus, nor any evidence of diseased bone been left.-Rep. LANCET. from the application of the caustic. During on
earnest
,
having
919
by the hardness in the parts where the mit the part to be handled without suffering cutting instrument has been last applied, in as he did before. Now the wound has all instances the appearance of blood being nearly closed, he has no pain, and can move about freely. The size of the stump is a good test. greatly diminished. After the operation and at subsequent CASE III.-NECROSIS OF FEMUR AFTER AM-
times
visits Mr. F. stated that necrosis sometimes PUTATION ;OPERATION. followed even the best performed amputaJames Churchill, setat. 48, a sailor, ad- tions. This result had followed in this inmitted Jan. 25, IS43. In March, 1838, had stance, but the chief circumstance to be dehis right knee crushed at sea, and was sub- plored was that the patient had suffered so jected to various modes of treatment until long when the surgeon had the remedy in the summer of 1839, when amputation in the his power ; it would have been improper to thigh was performed at the Dreadnought have interfered previously to the loosening of Hospital Ship, where he remained until the sequestrum; when that had happened November, when he left with the wound he could not say, but he supposed that a prostill open. A portion of bone had been cut ceeding similar to that which he had folaway subsequent to the operation. He lowed might have been had recourse to at an stayed at home, continuing to poultice the earlier period. It had been imagined by stump, until February, 1840, when he went some who had seen the case before that a into Guy’s Hospital, where he was kept two malignant disease existed, and when he himyears and seven months. During all this self had been asked his opinion an idea was period he suffered great pain in the part; a entertained that a second amputation very small portion of bone had been discharged, high up, possibly at the hip-joint, would be and a swelling at the under and back part requisite. The history of the case and the of the stump had been punctured with a condition of the stump led him to conclude knife sixteen different times, a little blood that a sequestrum was the cause of all the only escaping on these occasions. In Sep- distress. He had satisfied himself that such tember last he was discharged from that in- it really was, and came to the conclusion stitution, and was under the impression that that a reasonable attempt might be made to nothing could be done to allay his sufferings. extract the dead portion of bone by making Has for some time been an inmate of the aproper opening at the end of the stump. Wandsworth Union Workhouse, and has The result spoke for itself, and afforded a latterly experienced great and constant suf- good example of judicious interference on fering, being unable to move or permit the the part of the surgeon, when it had become part to be touched without experiencing evident that the sequestrum would never acute pain. The stump is of great size, pa- separate by natural means. tient being large and corpulent; on the end there is an open ulcer through which bare bone can be felt with the probe or finger. CHOLERA FROM EATING BARBEL The scars of the former punctures are quite ROE. visible. There is a small sore on the skin THERE seems to be no doubt that the roe over the trochanter major, which discharges matter. The amputation has been per- of this fish (the cypi-inus barbus) has, as formed about the middle of the thigh. Sauvages, Kopp, Marx, &c., have asserted, a Jan. 26, l843. To-day Mr. Fergusson poisonous quality, which is especially manimade a free crucial incision on the end of fest on children. The symptoms caused by the stump, and raised the soft parts with it, which show themselves soon after it has the knife so as to enable him to expose the been swallowed, are frequent bilious vomitend of the femur. Hethen introduced a ings, precordial anxiety, diarrhoea with pair of strong sequestrum forceps, and with tenesmus, profuse perspirations, and convula continued application of some force (ap’ sive movements of the limbs. In process of plied downwards in the axis of the bone) time the features become altered, and hiccup extracted a sequestrum five inches in length, with syncope ensues. Before any violent which, at the lower end, included the whole 1 vomiting comes oc, an emetic of ipecacuanha circumference of the femur, and gradually is advantageous; but after this symptom tapered to a point above. The operation has set in, Trusen recommends the employcaused great pain, every movement of the ment of revulsives to the cardiac region, and sequestrum calling forth screams of agony ; that lemonade should be given in large quanthe bleeding was copious, but no vessel re- tities. Another authority advises the use of quired a ligature. The wound was stuffed caustic spirit of ammonia, in doses of from with lint, cold cloths were applied, and fifteen to twenty drops, in a glass of water, warmth was ordered in the evening. every five or ten minutes.-Hufeland’s Feb. 27, 1843. Patient required opiates Journal. The treatment suitable in this case for several nights after the operation. In a would probably be identical with that in few days the tenderness in the stump wore other cases in which poisonous fish had been off, he could move himself in bed, and per- taken.
members of the same family vaccinated from CLINICAL REMARKS the same source might be differently affected; ON CASES OF one, for instance, would not cease from while or OF DISEASED BONE, occupation, another, EXCISION meals, pastime,
particularly if older, would be indisposed for several days. Neither the number nor the magnitude of the vesicles seemed to de-
DELIVERED AT
KING’S COLLEGE HOSPITAL
termine the amount of the primary disturbBY ance. If properly developed, small vesicles MR. FERGUSSON. often gave rise to marked constitutional symptoms, and the most splendid vesicles CASE 1.—EXC!S!ON OF A PORTION OF THE were often seen with trivial, sometimes SCAPULA. scarcely appreciable disturbance." " The secondary symptoms were often as HENRY PARRY, aetat. 2S, a sailor, was active with three or four as with six or admitted under Mr. Fergusson October 10, eight vesicles. Acceleration of the pulse 1842. Twelve months ago, being then in was frequently noticed when no other symp- Calcutta, had an attack of what he calls tom appeared ; both primary and secondary rheumatism of the right shoulder; the parts symptoms11 very commonly showed a remitting swelled much, accompanied with great pain, type." In no case, excepting that of Mr. and he was uuable to use the arm, which Taylor, was there any attendant eruption." consequently became much emaciated. In Other observers besides Mr. Ceeley have the course of a few weeks the swelling and succeeded in performing variolo-vaccination, pain partially subsided, becoming, however, and have recorded the results of their expe- more remarkable on the posterior surface of riments. Dr. Basile Thiele, of Kasan, in the joint. Fluctuation being felt, an opening, South Russia, remarks that the effects pro- two inches and a half in length, was made, duced by this lymph were more intense than and exit was given to a large quantity of fetid those which resulted from ordinary vaccine pus. The wound has never entirely closed, lymph. Sometimes there were two febrile and six or seven pieces of bone have been attacks, the one between the third and fourth discharged at intervals, the last about three day, the other between the eleventh and months ago. There are now two sinuses, one just below fourteenth ; and these severe effects not lost until the sixth remove. In one case and behind the acromion, the other a little the lymph produced an attack oftruevariola, lower, from which there is a constant disand lymph taken from the pocks of this I charge of thin fluid ; there is also an opening patient and inoculated in the arm of an- in front of the shoulder, an abscess having other reproduced vaccinia. This latter ex- formed in that situation. All movements in periment is a marked illustration of the the shoulder-joint have ceased, and he has become totally unfit for service. The spine identity of variola and vaccinia. In concluding the interesting and import- and acromioa scapulae are considerably ant subject of vaccination, and the considera- thickened, and a probe passed along one of tion of the defeiaces against small-pox, I may the sinuses over these parts grates against mention a singular statement made by Dr. bare bone. ]8. To-day a free incision was made, Lichtenstein, and published in Hufeland’s Journal for 1841. The paper in which this which permitted a more complete examinastatement occurs is entitled, " On the tion of the spine of the scapula, and with the Sources from which Matter preservative aid of the gouge and forceps, a portion of against the Small-pox has been derived," necrosed bone was removed from a shelland the author asserts that limpid lymph like cavity in the spine, formed by a depositaken from the pustules produced by tarta- tion of ossific matter around the necrosis. rised antimony and inoculated in a person The cavity and wound were stuffed with who has not been vaccinated, occasions a lint; cold was applied to check the oozing pock that cannot be distinguished from vac- of blood, and on the succeeding day warm cinia. These pocks, he states, are equally water dressings were used over clean charpie, protective against small-pox, and the lymph with which the wound was filled daily. may be transmitted from person to person in Granulations soon occupied the space, and the same manner with cow-pox. Dr. Lich- as cicatrisation became complete the relief tenstein inoculated and reinoculated thirty- from pain and facility of moving the shoulder one persons from this source, and none of became more and more apparent. The these persons took the small-pox, although puncture in front of the shoulder showed no they mingled freely with the infected during disposition to heal, and from time to time, the epidemic prevalence of small-pox. under the impression that there might be a portion of dead bone in this situation, a THE glands, properly so called, separate probe was introduced, which, however, fluids from the body, and discharge them by failed to indicate any such condition. At a duct. They are all situated on the head last, after the occurrence of some additional or trnnk,-Dr. Alison. inflammation in this locality, a piece of bone
were
918
detected, and then remored with a small the above interval the heel has caused great pair of dissecting forceps. In a few days distress, and at the patient’s urgent request all pain having ceased, and the opening Mr. F. has to-day made a crucial incision beingabout closed,the patient was discharged over the bare portion of bone, and thus was
’ scooped it away with the gorget. The remarked, that there wound has been stuffed with lint; cold has was difficulty in deciding whether the origi- been applied, and fomentation ordered for’ the nal disease had commenced in the shoulder- evening. Feb. 6. Pain in heel has been considerjoint or actually in the scapula. When the patient first came to the hospital, however, able since the operation, and the wound has it was evident that it had ceased in the arti- granulated with a copious suppuration. culation, having ended in anchylosis, but To-day a small portion of bone, somewhat that without surgical interference it was im- larger than a pin-head, has been detected possible to foretell when it might get well lying loose in the bottom of the sore, and otherwise, for the separation and discharge has been removed with dissecting forceps. of diseased or dead portions of bone were Warm water dressings and occasionally
cured.
In this
case
it
was
processes of great uncertainty. The steps which had been taken showed their advantage by the speedy relief from pain which resulted, and also by the rapidity of the cure. The patient had suffered for twelve months, and years might have elapsed before the dead portion of the scapula had been discharged, if, indeed, that could ever have happened under the circumstances. It was impossible to determine from what part the piece of bone removed from the sinus in front of the joint had separated ; it might have come from the head of the humerus, or from some contiguous part of the scapula; but if from the part of the spine of that bone from whence a large portion had been removed, il must have taken a singular course to react the surface.
a strap of adhesive plaster sometimes drawn across the sore to promote contraction. 21. Pain has gradually ceased, and the sore is now about healed ; little tenderness
unguentum cetacei ;
pressure, and no appearance of further disease either in the heel or knee; health much improved.* After the operation Mr. F. remarked, that such a proceeding was often of great service in bringing about a speedy cure of an otherwise Tery tedious disease. He had frequently adopted a similar practice in other cases of the kind, and had succeeded in curing a dis. ease of several years standing in the course of a few weeks. He believed that the advantage of such treatment was not sufficiently understood, and that much benefit might accrue from its more frequent adoption. He had operated in this instance at an earlier CASE II.—DISEASE OF OS CALCIS.-ExCIperiod than he thought altogether eligible, SION. but had been induced to do so from the wishes of the patient, and also beJane Gilbert, setat. 29, admitted November 22, 1842. Five months ago experienced cause he imagined that even then he could great pain in the left heel and across the in- afford relief to her sufferings with a fair step, and shortly after felt similar sensations prospect of a cure. He would have prein the knee of the same limb. A hard pain- ferred waiting until there was evidence that ful swelling formed on the outer side of the a portion of bone had become loose, or, at all heel a little below the malleolus, and a sore events, until the acute stages of the disease broke out on the skin over the part, which had seemingly ceased. In the operation he has gradually increased till now, when it had found the lower and outer margin of the may be described as an irritable ulcer, with bone in a state of necrosis, but not yet sepahighly inflamed and swollen edges, and a rated from the neighbouring osseous tissue. thick slough in the centre. The slightest In scooping it away his principal guide in touch with the probe causes a copious flow determining when he had done enough, was of blood, but no bone can be detected. There the oozing of blood from the sound part of is a point which may be covered with thei the bone. It was often difficult in these opetip of the finger over the external condyle of rations on the bones, more especially in the femur, which is exquisitely painful, and caries of the spongy parts, to determine effusion into the joint is conspicuous; patient when all the disease had been removed. to be kept in bed; knee and heel to be Sometimes the surgeon being guided by the poulticed. appearance of the portions removed, some26. Slough has separated from the sore * on the heel, and left the bone exposed. March 14. Shortly after the last date Dec. 1. An issue with caustic potash this patient began to move about the ward. formed over the painful part of the knee. The erect position caused considerable Jan. 29, 1843. Since 1st December ult., swelling in the foot, and some pain in the pain in the knee has gradually ceased, effu- vicinity of the cicatrix. A small portion of sion has been absorbed, and there now only the wound has not yet healed, but there is no remains a small superficial sore, resulting sinus, nor any evidence of diseased bone been left.-Rep. LANCET. from the application of the caustic. During on
earnest
,
having
919
by the hardness in the parts where the mit the part to be handled without suffering cutting instrument has been last applied, in as he did before. Now the wound has all instances the appearance of blood being nearly closed, he has no pain, and can move about freely. The size of the stump is a good test. greatly diminished. After the operation and at subsequent CASE III.-NECROSIS OF FEMUR AFTER AM-
times
visits Mr. F. stated that necrosis sometimes PUTATION ;OPERATION. followed even the best performed amputaJames Churchill, setat. 48, a sailor, ad- tions. This result had followed in this inmitted Jan. 25, IS43. In March, 1838, had stance, but the chief circumstance to be dehis right knee crushed at sea, and was sub- plored was that the patient had suffered so jected to various modes of treatment until long when the surgeon had the remedy in the summer of 1839, when amputation in the his power ; it would have been improper to thigh was performed at the Dreadnought have interfered previously to the loosening of Hospital Ship, where he remained until the sequestrum; when that had happened November, when he left with the wound he could not say, but he supposed that a prostill open. A portion of bone had been cut ceeding similar to that which he had folaway subsequent to the operation. He lowed might have been had recourse to at an stayed at home, continuing to poultice the earlier period. It had been imagined by stump, until February, 1840, when he went some who had seen the case before that a into Guy’s Hospital, where he was kept two malignant disease existed, and when he himyears and seven months. During all this self had been asked his opinion an idea was period he suffered great pain in the part; a entertained that a second amputation very small portion of bone had been discharged, high up, possibly at the hip-joint, would be and a swelling at the under and back part requisite. The history of the case and the of the stump had been punctured with a condition of the stump led him to conclude knife sixteen different times, a little blood that a sequestrum was the cause of all the only escaping on these occasions. In Sep- distress. He had satisfied himself that such tember last he was discharged from that in- it really was, and came to the conclusion stitution, and was under the impression that that a reasonable attempt might be made to nothing could be done to allay his sufferings. extract the dead portion of bone by making Has for some time been an inmate of the aproper opening at the end of the stump. Wandsworth Union Workhouse, and has The result spoke for itself, and afforded a latterly experienced great and constant suf- good example of judicious interference on fering, being unable to move or permit the the part of the surgeon, when it had become part to be touched without experiencing evident that the sequestrum would never acute pain. The stump is of great size, pa- separate by natural means. tient being large and corpulent; on the end there is an open ulcer through which bare bone can be felt with the probe or finger. CHOLERA FROM EATING BARBEL The scars of the former punctures are quite ROE. visible. There is a small sore on the skin THERE seems to be no doubt that the roe over the trochanter major, which discharges matter. The amputation has been per- of this fish (the cypi-inus barbus) has, as formed about the middle of the thigh. Sauvages, Kopp, Marx, &c., have asserted, a Jan. 26, l843. To-day Mr. Fergusson poisonous quality, which is especially manimade a free crucial incision on the end of fest on children. The symptoms caused by the stump, and raised the soft parts with it, which show themselves soon after it has the knife so as to enable him to expose the been swallowed, are frequent bilious vomitend of the femur. Hethen introduced a ings, precordial anxiety, diarrhoea with pair of strong sequestrum forceps, and with tenesmus, profuse perspirations, and convula continued application of some force (ap’ sive movements of the limbs. In process of plied downwards in the axis of the bone) time the features become altered, and hiccup extracted a sequestrum five inches in length, with syncope ensues. Before any violent which, at the lower end, included the whole 1 vomiting comes oc, an emetic of ipecacuanha circumference of the femur, and gradually is advantageous; but after this symptom tapered to a point above. The operation has set in, Trusen recommends the employcaused great pain, every movement of the ment of revulsives to the cardiac region, and sequestrum calling forth screams of agony ; that lemonade should be given in large quanthe bleeding was copious, but no vessel re- tities. Another authority advises the use of quired a ligature. The wound was stuffed caustic spirit of ammonia, in doses of from with lint, cold cloths were applied, and fifteen to twenty drops, in a glass of water, warmth was ordered in the evening. every five or ten minutes.-Hufeland’s Feb. 27, 1843. Patient required opiates Journal. The treatment suitable in this case for several nights after the operation. In a would probably be identical with that in few days the tenderness in the stump wore other cases in which poisonous fish had been off, he could move himself in bed, and per- taken.