Original Communications. FIVE CASES OF STRANGULATED HERNIA BY ERSKINE MASON, M.D., DEMONSTRATOR OF ANATOMY, COLLEGE PHYSICIANS AND SUR- -- I immediately after the operation. Small doses of opium were given at intervals for the first two days, every thing progressed favorably, and on the sixth day after the operation his bowels moved naturally. Many months afterwards I saw this patient and found the canal completely closed. He is still I believe following his occupation, and rejoicing in a radical cure. Looking over the literature of this subject, I have been unable to meet with an example of femoral hernia passing down inside of the vein, and assuming the position which this case did. CASE II. OBLIQUE INGUINAL HERNIA.-June 28, 1865-This evening I was requested by Dr. Withers to see Mr. R., aged 57, who was suffering from a strangulated oblique inguinal hernia of the right side. This patient had always led an active life; except during the last two or three years, in which he had been engaged in keeping store. He has had this rupture for the past ten years, but has always been able to effect its reduction while sitting in a rocking-chair. His habit has been to wear a truss, but lately had left it off, owing to its not fitting properly. On the evening of the 27th, while taking a walk, an immense quantity of intestine came down, which he was unable to return. He did not suffer, except from slight uneasiness, until the following afternoon-attending to business as usual up to that time. I found the patient with his scrotum the size of an infant's head, not very painful, nor combilicus. The countenance wore a somewhat anxious expression, and he was troubled with hiccough and had vomited a great deal of "greenish matter." Bowels had moved during the morning. Ether being administered and a trial made at reduction by taxis without success, I proceeded with the operation, assisted by Drs. Withers and S. P. P. White. A single incision was made along the tumor, beginning just about an inch above the external ring and extending downwards the extent of two inches. The various coverings were divided till the sac was reached; and the stricture being discovered just above the external ring, a director was passed through the ring and the stricture divided, without opening the sac-the sac containing both intestine and omentum. No impediment was made after the division of this stricture, to speedy reduction. The wound was dressed as usual in these cases, and the patient, who had been placed upon a table for the operation, was removed to bed. This first night after the operation was rather a restless one, and he had several movements from the bowels. Everything went along rapidly towards recovering, and he was up on the twelfth day after the operation. CASE I. FEMORAL HERNIA.-January 22, 1865 was sent for by Dr. Loomis to see Mr. C., aged 55, by occupation a carman, who was suffering from strangulated femoral hernia. When I saw the patient his pulse was exceedingly rapid and small, countenance anxious and expressive of great suffering, bowels tympanitic, and so painful upon pressure that his limbs were drawn up to keep off the weight of the bed-clothes. The surface of the abdomen was very red, as also the hernial tumor, from the effects of a mustard poultice which had been applied for the purpose of alleviating his pain. In his right groin, directly below Poupart's ligament, and running parallel with it, was a tumor about the size of a pullet's egg; tender to the touch, elastic and somewhat movable upwards and downwards. The patient stated that he always had enjoyed good health, and been perfect-plaining of much abdominal tenderness, except at the umly temperate as to his habits. Nine years ago, while suffering from a constipated condition of his bowels, he noticed a small swelling in his right groin, which he was not able to reduce, and giving him no trouble, he thought but little about it. Two days before I saw him, his horse fell and he was thrown forward from his dray. At that time his hernia increased in size, and he felt a little sick, though he kept on with his work. The following morning he had a movement from his bowels, and walked out a short distance to have his horse shod, but feeling sick at his stomach, returned home and went to bed, when he began to suffer with pains in the chest and bowels, together with frequent attacks of vomiting. Later in the day hiccough made its appearance, which, together with great restlessness,continued throughout the night. All attempts at reduction by taxis having failed, the patient being under ether, I proceeded to operate at 12 M., in the presence and with the assistance of Drs. S. S. Crane, Loomis, Morrel and White, all of whom had first attempted reduction by taxis. I made the incision over the centre of the tumor at a right angle with Poupart's ligament, and proceeded cautiously until the sac was reached, intending to liberate the gut by dividing the stricture without the sac if possible. The sac was found to be bent upon itself, and lying under the falciform process of the saphenous opening. The flaps were dissected off the tumor, so that all could obtain a perfect view of the hernia as it rested in this novel situation. I proceeded to nick Gimbernat's ligament with the hernia knife, a few adhesions which bound down the fundus of the sac being broken away, and the tumor brought down so as to occupy the usual position of femoral hernia. It was found necessary to divide a few fibres of Poupart's ligament before reduction could readily be made; which was accomplished without wounding the sac. After which the sac was also returned. The wound was dressed in the usual manner, and the patient placed in bed. Upon coming from under the effects of the ether he vomited great quantities of stercoraceous material, and troublesome hiccough continued for some time, though the pain in the abdomen rapidly diminished under two grs. of opium, which was administered CASE III. FEMORAL HERNIA.-November 19, 1867I was called this morning at 8 o'clock, to see N. G., aged 45, and a printer by occupation, whom I found to be suffering with a strangulated femoral hernia of the left side. Upon entering his room, he informed me he had been suffering from colic all night, had his bowels move once, but vomited frequently. During the night his wife had administered a dose of oil, which was immediately rejected. His surface was cold, his expression that of a person in great pain. Finding the bowels exceedingly tympanitic, I asked him if he had a rupture, to which he replied, No! Upon turning down the bed-clothes to examine for myself, I found a small tumor about the size of a small egg, just below Poupart's ligament. This was somewhat tender and firm to the touch, and according to his statement had never been there before, which fact was corroborated by his wife. Upon questioning him more closely, he stated that last evening he was wrestling with a friend, but did not know of making unusual exertion. He re turned home about 8 o'clock in the evening, and was then taken with pain in his bowels and vomiting. The nature of this tumor being explained to him, and a fruitless attempt having been made under ether with taxis, I proceeded to operate at 9 A.M., with the assistance of Dr. Carmalt. Both Gimbernat's and Poupart's ligament had to be slightly nicked before reduction could be accomplished, which was done without opening the sac. The intestine was filled with fæces, which had to be pressed out before the gut returned; after this the sac was pushed up into the canal. Everything did well, and the patient made a rapid recovery. The bowels moved naturally, and without pain, on the afternoon of the third day. Some time after this patient was about, I examined him and found the canal had become completely closed by lymph, an indurated mass being all there could be discovered. I believe he will have a radical cure. CASE IV. FEMORAL HERNIA.-June 16, 1868.While making my visit this afternoon at Charity Hospital, I was asked by Dr. Gouley, one of the House Physicians, to see a patient who had been brought into his ward, whom he believed to be suffering from strangulated hernia. The following account I received from the Doctor in charge. "S. T., born in Germany, cigar-maker, aged 38. On admission the patient presented a very anxious and pinched expression of countenance; his skin was cool and moist, and devoid of elasticity, so that a portion of it pinched up would remain in that condition several minutes. During the day he had vomited incessantly stercoraceous material. His bowels had not been moved for eight days. Pulse was 120 and weak, and complained of cramps in the calves of his legs and jaws, also in the abdomen." When I saw the patient he was suffering no pain, mind clear, surface moist, extremities quite cool, and his fingers were pitted as if they had been in warm water for some time. Upon examining the abdomen, I found it hard and flat, no tympanites, and considerable pressure gave rise to but little pain. A small tumor was found just below Poupart's ligament, which he had had for about a year and a half, and was at times smaller than at present. He gave me the history of having suffered from strangulated hernia for a period of four days. So prostrated was his condition, that I feared he would not survive the operation, but this being his only chance, I deemed it but right to proceed. I omitted to state that but the slightest impulse could be discovered in the tumor when he coughed; the tumor being hard and but slightly tender when firmly grasped. Before giving ether, which was administered with great care, by Dr. Black, one of the house staff, I gave the patient a little whiskey and water, which was instantly rejected, together with large quantities of stercoraceous material. Upon coming down to the sac, I determined to divide the stricture without injuring the same if possible. Some of the fibres of Poupart's and Gimbernat's ligaments being divided, I seized the sac preparatory to examining the contents more closely, which presented a dark purplish hue, when suddenly the sac, together with its contents, passed up into the cavity of the abdomen. The hernia had, I believed, been reduced en masse, which indeed was found to be the case. Passing my left forefinger up the canal, I could distinctly feel the sac, and was fortunate in being able to retain it in position, while with a pair of forceps in the right hand, I was enabled to seize the sac and draw it out again. A few fibres surrounding the neck of the sac were then divided, and warm sponges being applied, the intestine began to assume its natural color, when without any further difficulty the hernia was reduced. The patient came from under the influence of ether slowly. He passed a restless night, complaining of some abdominal pain, which was relieved with morphia, and an opium suppository, together with turpentine stupes over the bowels; he took some whiskey, beeftea and carb. ammon. during the night, and had no vomiting after the operation. When the house physician made his visit in the morning, he seemed to have rallied, and hopes were entertained of his recovery. At 11 A.M., however, he suddenly sank and died. Autopsy 24 hours after death. Abdomen slightly tympanitic. On opening the abdomen but little peritonitis was discovered, and that principally upon the peritoneum covering the left iliac fossa and the abdominal wall. The intestines were but little injected; no fluid in the cavity. The portion of ileum, which had been strangulated, was not gangrenous, and presented upon its surface only one small patch of ecchymosis. The sac was found to be uninjured. Fearing lest the intestine might have been wounded by the forceps in drawing it out of the cavity after its reduction in mass, I had it filled with water, but no laceration was found either in the gut or sac. This specimen was presented at the Path. Society, June 24. Death assumed to be due to the great prostration, produced perhaps from the excessive vomiting, which had taken place for two days previous to the operation. The kidneys were apparently healthy, and no albumen was found in the urine removed from the bladder after death. CASE V. OBLIQUE INGUINAL HERNIA (Congenital). Feb. 27, 1865.—I was called this afternoon to see a colored boy, aged 18 years, servant of Rev. Mr. M. I found him suffering from a strangulated hernia on the left side. This hernia he has had all his life, he informed me, could always be reduced by himself, except last summer while at Saratoga it "became caught," and was reduced by Dr. Allen of that place. The day previous he had carried a young lady up stairs, and thinks he then strained himself. This afternoon symptoms of strangulation appeared, the most constant of which he describes as like a cord drawn around the body, in the region of the abdomen. While employing taxis, a portion of intestine went back with a gurgle, when he exclaimed, "Doctor, it has all gone up and I feel all right now." I applied a compress and bandage, but did not feel satisfied that the reduction was complete, owing to an appearance of fulness about the scrotum. I directed that I should be sent for, did any other symptoms show themselves. At 8 that evening I was sent for. When I reached the patient, I found him suffering greatly from pain in the abdomen and the inguinal canal, together with the scrotum greatly enlarged. With the assistance of Drs. J. J. Crane, White and Gillette, after all attempts at reduction by taxis had failed, I proceeded with the cperation at 9 P.M. A stricture was found in the canal, which was laid open, and divided without injury to the sac. Still that portion of intestine and omentum which were in the scrotum, could not be reduced. The scrotum was consequently laid open, when the hernia was found to be within the cavity of the tunica vaginalis. Just at the point where the tunica vaginalis is usually occluded, there was a ring of indurated tissue within the sac, thus producing a stricture. I presume this was formed by the truss which he frequently used. Not wishing to injure the peritoneum, I made a small opening at the bottom of the tunica vaginalis, through which I passed my finger, and with the finger as a guide, I introduced the hernia knife, and nicked this indurated ring. After which reduction was easily effected. All passed along very well, till one evening, by moving about in bed, the edges of the wound became very much separated. I did not bring them together again, believing that if the wound was left to granulate, he would obtain a radical cure. A few days after this, he had an attack of epididymitis, together with an abscess of the scrotum; all of which he rapidly recovered from. This patient was under my observation for a long time, and had a perfect cure following the operation, the inguinal canal having been completely closed from this union by granulation. Perhaps this case may not be regarded as one in which the sac was unopened, yet I would call particular attention to this fact, that the peritoneal sac was not wounded; the only serous membrane that was cut being the tunica vaginalis, which is not prone to give rise to serious inflammation, when wounded, as is the peritoneum. These five cases I have transcribed from my notebook, for the purpose of showing the readiness, even in small, as well as in large hernia, with which the operation of not opening the sac can be performed, as well as its giving promise of far better success, than when the sac has been opened, the gut exposed to the air, and subjected to handling. So seldom do we find the stricture to be contained inside the sac, and so rarely does real necessity occur for the opening of its peritoneal covering, that I think we can rarely be justified in choosing any other operation than the one advocated in this paper. It has been contended by some, that this operation might lead to the reduction of the gut, when in a gangrenous condition. This objection, it appears to me, might be used with equal justice against the employment of any means to effect reduction short of a cutting operation. Should the contents of the sac be such as to forbid their reduction, this could be determined both by the eye and by the sense of smell, in the majority of cases, without wounding the sac. If not, then it would be time enough to resort to the old method of operation. In one case we were tempted to resort to this practice from the dark appearance of the intestine, and portions of the sac, but warm applications by means of sponges wrung out in hot water proved sufficient, after the stricture was divided, to restore the parts to their normal appearance. The majority of deaths occurring after the operation for strangulated hernia, are due to peritonitis, and this certainly seems far more likely to follow after the sac, which is so often inflamed, is wounded, and the intestines and omentum subjected to digital manipulation, than where these are carefully protected from such exciting causes. Again, should any vessels, as the epigastric or obturator, become wounded, the risk of hemorrhage taking place into the peritoneal cavity is avoided; and the patient's chances for recovery thus increased. Looking at these facts, and as we shall show from statistics the very favorable results of this operation, it seems surprising that surgeons should ever think of practising any other, when the case would at all admit of it. This operation is the one I believe now advocated by English surgeons, but as yet not so much practised in this country. Prof. Gross, in his System of Surgery, when speaking of this operation, remarks that "in this country it has probably not attracted as much notice as it deserves." As far as I have been able to learn, but little has appeared in our literature upon this subject, and we are almost wholly indebted to English surgeons for what has been written upon it. Some few years ago, Dr. Henry B. Sands published the histories of some cases in the New York Medical Times, wherein he had performed this operation, together with remarks on the same; with this exception I do not remember ever having seen this operation treated of in our medical journals, though case after case of various kinds of hernia has been published, operated upon after the old method. The oper ation of dividing the stricture without the sac is generally supposed to be due to S. L. Petit; but according to South in his notes to Chelius' System of Surgery (American Reprint, page 303), both Franco and Pare "had cut into the abdominal ring, and did not open the hernial sac, except when reduction could not be effected." To Jean Louis Petit, however, is due the honor of first generally recommending this operation. According to Lawrence, this operation was performed by Petit in 1718, who not only advised it in old and large hernias which were adherent to the sac, but also recommended its more general employment. In 1750 this procedure was brought forth as entirely new by Ravaton in a Treatise on Gunshot Wounds, and he speaks of having operated with success in three cases. Monro the second was also an advocate of the operation, his first operation being in 1770. Sir Astley Cooper recommends this method in his work upon hernia, in all old ruptures, and believes surgeons will employ it more generally when they have learned its advantages from experience. The revival of this operation must be ascribed to Mr. Aston Key, who in 1833 published a memoir on the "advantages and practicability of dividing the stricture in strangulated hernia on the outside of the sac." Prior to this date, however, he called the attention of the profession to this method in a clinical lecture, published in 1829. (London Med. Gazette, vol. 4, p. 193.) Mr. Luke, also, strongly urges the practice of Petit, and gives the results of this operation in his own hands (London Med. Gazette, vol. 1, 1839-40, and Medico-Chirurg. Trans., vol. 31, 1848.) Mr. Luke says: "I have attempted the performance of Petit's operation in eighty-four cases. Of this number the operation was completely successful without opening the sac, in fifty-nine. In twenty-five it was necessary to open the sac to effect a reduction of the hernial contents, the operation generally varying in extent from one-half to one-quarter of an inch. With respect to the mortality amongst these patients, of the fifty-nine in whom the sac remained unopened, seven died; of the twenty-five in whom the sac was opened, eight died. These cases included those of femoral, umbilical and inguinal. In three of these cases he states that Petit's operation was successfully completed; but the sac was opened after the reduction of the strangulated parts into the abdomen, to remove some doubts as to their perfect liberation. The proceeding in each case, however, was ascertained to be wholly unnecessary. Mr. Erichsen, in his System of Surgery, p. 728, states that of seventy-seven operations for hernia, reported by Sir A. Cooper, 36 proved fatal; and of 545 cases recorded in the journals, and collected by Dr. Turner, 260 are reported to have died. The result, therefore of Mr. Luke's operation is most favorable, when contrasted with such as these." According to the experience of those who have written upon this subject, the operation appears to be more successful in femoral hernia, owing to the stricture being found frequently in the neck of the sac in the inguinal variety. In all cases it would appear to me that this operation should first be attempted, and then, if found unsuccessful, only that portion of the sac opened which involves the stricture. Certainly no operation has ever held out greater inducements than the one so strongly advocated by Petit, Key and Luke, 118 West 44th st. FEES FOR TESTIMONY.-A physician in Chicago, Ill., refused to give his testimony as an expert in a railroad case without a fee. The judge ordered the company to deposit $20 with the clerk of the court, to abide the décision of the point raised. The physician then testified. SOME REMARKS ON PARONYCHIA. BEING A PAPER READ BEFORE KINGS COUNTY MEDICAL SOCI- ASSISTANT-SURGEON LONG ISLAND COLLEGE HOSPITAL. PARONYCHIA is an inflammatory condition of the finger or thumb. It not unfrequently affects more than one finger at the same time, even appearing on a finger of each hand. And it may invade the palm of the hand, going up the front of the wrist to the forearm. Paronychia generally makes its appearance on the palmar aspect of the hand, in one or more of the anatomical elements from the skin to the bone. It may be confined to the skin and subcutaneous cellular tissues; it may be limited to the tendons and their sheaths; it may begin in the periosteum; it may attack the bone; it may implicate all the structures of the finger or thumb. More than once have we seen it make a joint the chief point of attack. It is destructive, and often perils the integrity of the hand, unless arrested by appropriate treatment. Whatever may be the origin of this affection, there are various opinions in regard to its nature. A consideration of some of these opinions will, doubtless, aid us in an attempt to arrive at a better understanding of the subject. Mr. Druitt says that paronychia "signifies an abscess of the fingers.' If this be true, paronychia cannot signify an ordinary abscess, for it has no wall of "limiting-fibrins”—at any rate, we have never seen one that did. Prof. Miller, after describing a mild form [of paronychia] limited to the surface," says "a somewhat more serious action is found to pervade the subcutaneous cellular tissue, as well as the skin, bearing the same analogy to the former affection [superficial Paronychia] as phlegmonous erysipelas does to erythema." Prof. Gross describes paronychia as "an affection of the thumb or finger, commencing in inflammation, which soon terminates in suppuration, and sometimes even in gangrene." 'How this disease is produced, or what its real character is, is still a mooted question. The most plausible conjecture is that it is a bad form of inflammation, not unlike carbuncle, occurring in a constitution more or less depraved, in consequence of a disordered state of some of the secretions, particularly those of the digestive apparatus." sui generis, affecting the finger or thumb, sometimes ertending to the hand and forearm. And we should never forget that it occurs in those constitutions which are below the standard of perfect health. Prof. Erichsen says that "whitlow is a frequent affection in old and young people; " while Professor Gross says that "it is most common between the ages of twenty and thirty-five." This difference of opinion must be accounted for on the supposition that different facts were recorded by different observers. Fifty-seven cases were admitted as out-patients of the Long Island College Hospital from January, 1866, to October, 1867. Thirty-four of these were females, and twenty-three males. These cases were admitted for treatment at all stages of the disease; but the majority of them applied at about the end of the first week of attack. The earlier the treatment was begun, the more speedy was the recovery. If the treatment was begun late, the recovery was delayed. If there is anything well established in medicine or surgery it is this: that paronychia can be cut short by treatment. The youngest case was nine; the oldest was sixty years of age; and both were females. There were thirty-four females and twenty-three males. If one less of each had been admitted, there would have been three females to every two males. According to this record females are more liable to Paronychia than males; and it also appears that Paronychia is most common from twenty to twenty-five; next, from fifteen to twenty; next, from twenty-five to forty; next, from ten to fifteen, and from forty to fifty; next, from fifty to fifty-five; and least frequent under ten and over fifty-five. Causes.-Paronychia is very frequently traumatic. One of the worst cases we ever saw followed the scratch of a rusty pin. A very severe case originated in an abrasion made by an old piece of sheet lead. "Inoculation of the part with poisonous or putrescent matters" not unfrequently gives rise to this inflammation. "Washerwomen, and other persons who have their hands habitually immersed in water, are particularly obnoxious to it."-Gross. It is apt to affect the fingers of laborers who handle barrels by the chines. Sewing girls suffer from it quite frequently. This affection not unfrequently follows slight bruises or contusions. "It is common in the spring of the year, when, indeed, at times it appears to be epidemic."—Erichsen. Prof. Gross informs us, that Paronychia, a few years ago, was epidemic in various sections of the Union. "That whitlow," writes Erichsen, "is truly an ery- Symptoms.-The affected finger becomes painful, and sipelatous affection of the fingers appears to be the case the pain, marked at the outset, rapidly increases; the for the following reasons:-1stly. Because the causes, patient cannot sleep, and walks about his room sufferwhether of season, infection, or local irritation, appearing the greatest torture. The pain is constant, tensive, to be the same in both affections. 2ndly. The consti- throbbing-even increasing in severity, and is referred tutional disturbance is always very severe for so slight to the palmar aspect of the finger. At first there is a disease, and assumes the same character of speedy very slight redness and swelling of the palmar surface; depression that we observe in erysipelas. 3dly. The as the disease progresses, these two symptoms become inflammation of the affected finger is invariably diffuse, more marked. Subsequently, the dorsal surface, not never being bounded by adhesions, but always tending unfi equently, becomes the most distinctly red and to terminate in suppuration and sloughing. And lastly, swollen. The finger will tend towards flexion, so as to so soon as the disease spreads beyond the affected relax the skin, tissues and tendons, as much as possible, finger it assumes a distinctly erysipelatous appearance thereby, to some extent, mitigating the patient's sufferand character." ing. One author says, that paronychia "signifies an abscess We have now arrived at the third and fourth day of of the fingers; another thinks it is analogous to ery- the attack; and, if the disease is not arrested by apsipelas; another "conjectures that it is not unlike car-propriate treatment, it may invade the palm of the buncle;" and another affirms that it "is truly erysip-hand, or even go up the front of the wrist to the foreelas of the fingers." When there is a difference among arm; in which case the constitutional disturbance will the doctorum reges, who shall be able to decide? and be of a more marked character. whose opinion shall prevail? In our opinion paronychia is a diffuse inflammation, When suppuration takes place, the pus is not confined by a wall of "limiting-fibrine," but diffuses itself through the tissues and burrows beneath the tendons and periosteum. Sometimes the tendon dies and protrudes through the opening made by nature or the surgeon. A portion of the flexor tendon may thus slough, when the extensor tendon keeps the finger in a straight position. In addition to this, the bone may perish; and sometimes the entire finger may be lost. tack, the more beneficial will be the poultice. But & poultice without the scalpel is of but little use. In the third place, on leaving off the poultice, apply a wash: B. Zinci Sulphatis gr. iv.-xvi.; Sp. Lavandulæ Comp. 3i.-iv.; Aquæ pur. vel. Aquæ Rose 3 viii. M. S. Red wash. Saturate a piece of old muslin or linen with this wash, In the severer forms of paronychia the fever often and keep it constantly applied to the diseased part. runs high, especially at night, when the patient is sleep-Continue the use of this remedy till recovery is comless. Delirium sometimes occurs-generally during the plete. night, when there is more fever and more pain. Prognosis.-This affection has been known to terminate fatally; but such an event must be extremely It may peril the integrity of a part or the whole of the hand. Too often the utility and symmetry of the hand are permanently impaired. Destruction, anchylosis, and other deformity are, indeed, too often the effects of this truly dreadful malady. rare. In the fourth place, give the patient from ten to thirty minims of muriated tincture of iron three times a day in a little sweetened water. This remedy should be taken just before meals-and the mouth always washed with cold water immediately after taking it, to prevent the action of the iron on the teeth. Begin to give this preparation of iron, as soon as possible after seeing the patient, and continue it till recovery takes place. In addition to this, it may be necessary in some cases to give the sulphate of quinia. Commentary.-The knife evacuates the pus; depletes locally; relieves tension; and abolishes pain. The poultice promotes molecular change, and soothes the inflamed tissues. The zinc acts as a disinfectant, as local astringent and nerve tonic; iron improves the appetite, invigorates the blood, and seems to prevent the extension of diffuse inflammation. Prognosis of the above-mentioned fifty-seven cases: One only lost a finger, and she had been treated elsewhere until it was impossible to avoid amputationwhich was performed on the day she applied for treatment. One other case-that of a young man-applied with a paronychia of the index finger, that had been opened on the palmar surface, in one of the New York City Dispensaries. I removed the ungual phalanx from the extremity of the finger through a small incision; a new phalanx grew, and the patient had a useful finger. In the other fifty-five cases the recovery was complete. The prognosis is more favorable, when the knife is used In the first place, the scalpel is the sine quâ non. If it is improperly used it does harm,—but if properly used, it is indispensable. Always use a scalpel; a thumb-lancet, never. A thumb-lancet is made for puncturing; a scalpel is made for cutting. A puncture will not benefit a paronychia. Never place the finger upon a tableon the dorsum—and then cut at random into the palmar surface-the patient drawing away the hand; noth-early. ing can be more unscientific and unskilful. If the tendon be not already destroyed, you may put it in a way never to recover. Instead of this, take a towel in the left hand, and then with this seize gently, but firmly, the affected finger; tell the patient that the operation is necessarily painful, and that you will be obliged to hurt him; therefore, you do not deceive him; select a point upon the lateral surface about midway betwixt the tendon and the artery; put the point of the scalpel on this point; now cut down-without haste-to the bone in a line parallel with the tendon, making the incision about two-thirds the length of the phalanx implicated by the disease. Try to spare both the artery and tendon; if you must sacrifice one of them, by all means sacrifice the artery-the tendon, never. The hæmorrhage can be controlled; the symmetry and utility of the finger are not impaired by the loss of an artery; but destroy the tendon, and they are gone for ever. Use the knife, therefore; use it early, use it properly, and you will have the satisfaction of benefiting your patient. He The following instance will show the practicability and usefulness of early opening in this affection: A young man with paronychia applied within thirty-six hours after the commencement of the attack. He had to support his mother and himself by daily labor, and could not afford to lose much time. I told him that he would sooner recover if his finger were opened. consented; the knife was used; the blood flowed freely; a poultice was applied, and the next day there was suppuration. The sulphate of zinc and the muriated tincture of iron completed the cure toward the end of a week; and the patient returned to his work. This case is not included in the above account. All of these fifty-seven cases were treated upon the plan herein recommended, and with the most satisfactory results. Since writing the above, I have received a communication from Professor Frank H. Hamilton, in which he has pointed out some valuable statistical information, and kindly suggested an approved nomenclature of this interesting subject. To stop here is to leave one's work half done. And In the first place, you will find, page 257, vol. xi., of we have abundant experience to prove that a parony-the Buffalo Medical Journal, "An Analysis of Eightychia, after having been opened, has not continued to improve, until the remedies we shall presently describe have followed the employment of the scalpel. Over and over again have we seen this happen. In the second place, after opening a paronychia, apply a warm flaxseed poultice for a few hours-not exceeding twenty-four. If the poultice be too long applied it will do harm. Sometimes it may not even be necessary to use a poultice. The more recent the at one Cases of Paronychia Benigna," made by Austin Flint, Jr., and taken from the private records of Dr. F. H. Hamilton. According to this record, “The most frequent causes, however, are exposure of the hands to hot water, as in washing dishes, or a slight hurt or bruise." Again, Professor Hamilton reports, page 710, vol. v., of the Buffalo Medical Journal, the Reconstruction of an Entire Phalanx of the thumb. He says, "We have |