VERY Physician Knows the Merits of EVER BEST McArthur's Syrup PREPARATION Hypophosphites IN ELEGANCE AND (Lime and soda) COMP, EFFICIENT AND RELIABLE in THROAT AND LUNG AFFECTIONS and General Debility. Pamphlet on the CURABILITY OF CONSUMPTION, Free. Chemically Pure. MCARTHUR HYPOPHOSPHITE CO., FOR Slow But Sure. Goldbeck's Malt Extract. DRUCCISTS Fine Old Stock Ales. ONLY. Fine Old XX Brown Stout. BOSTON. FOR DRUCCISTS BREWED AND PUT UP IN PINT AND QUART BOTTLES EXPRESSLY FOR THE DRUG TRADE. Why pay fancy prices for an inferior domestic article, sold under a foreign label? Send us a trial order for any of the above goods and you will keep them in stock thereafter. Terms and prices mailed on application. JOHN F. BETZ & SON, Limited, 415 to 427 Callowhill St., Philadelphia. Highest award for Ales and Stout at Centennial Exhibition, 1876; at Cotton Centennial Exhibition at New Orleans, 1884, and 5 medals of highest award at World's Fair. PROF. W. W. KEEN'S West Roxbury Sanatorium, NEW ASEPTIC POCKET CASE. FOR THE TREATMENT OF CHRONIC DISEASES By Swedish Movement and Massage and The Sanatorium is located in one of the healthiest and most beautiful suburbs of the city of Boston, two hundred feet above the level of the ocean. The air is superb and of a most invigorating quality. The view from the Sanatorium is magnificent and cheerful, and the "Park-way" connecting the great public parks of Boston will pass close to the Sanatorium. Patients can obtain sunny and airy rooms, finely furInished, with excellent board, and have full treatment right in the same building, all attended to by the director and his trained attendants. It is especially to be recommended for those suffering from Nervous Affections, Dyspepsia, Indigestion, and Constipation; General Debility, Headache, Chorea; Paralysis and Rheumatism; Curvature of the Spine, Muscular Weakness, Sprains, etc.; Weak Lungs and Poor Circulation of the Blood; Women in Feeble and Delicate Health, etc. The Director, Prof. Hartvig Nissen, Instructor of Physical Training in Boston Public Schools, is well-known as the author of "Swedish Movement and Massage Treatment," and as the former Director of the Swedish Health Institute in Washington, D. C. The advise and orders of physicians sending patients will be promptly followed. Correspondence invited. Address, NISSEN, Newburg Street, Roslindale, Mass. Black Morocco Case. Size, 54 x 2 x . If Ordered by Mail Send 15 Cts. Additional for Registered Post. WM. V. WILLIS & CO., Surgical Instruments, Invalid Articles, & Sick-Room Supplies, 134 S. IIth ST., PHILADELPHIA. DESCRIPTIVE CIRCULAR FREE. SUPPURATION, FROM A MEDICO-LEGAL STAND-POINT. THE recent publication by a distinguished professor of a brochure upon the Treatment of Wounds will bear a double significance to all who are concerned in the wellbeing of patients submitting to surgical operations at their hands. It will be evident, to those who are aware of the author's wide field of observation, that the raison d'etre of his book is the conviction that a considerable number of the medical profession are not acting quite up to their lights; in other words, that they either fail to appreciate or are lagging in their adoption of the newest, simplest, and most efficient forms of Listerism. The seriousness of which assumption is abundantly evinced by the legend which appears upon its title-pages. Here it is boldly and clearly stated that "suppuration occurring in a wound made by the surgeon through unbroken skin is the result of some error or oversight on his part" themselves considered capable of evolving a perfectly aseptic saponaceous product, irrespective of the purity and cleanliness of its primary elements, will hardly be claimed at this day. On the other hand, we may assume, from the popularity of soaps holding well-combined and palpable proportions of carbolic acid, terebene, and coal-tar, particularly among German surgeons, that either the soap itself was questionably safe in surgical cases, or that these antiseptics are thought to contribute essentially to the general procedure as against septic organisms. However this may be, one can take it as agreed that the soaps used by surgeons and nurses preparatory to operations are indispensable, and should therefore be not only absolutely pure in their component parts, but be entirely unsophisticated, i.e., free from every substance which is foreign to soap, quá soap; and, secondly, that if it is believed useful to combine antiseptics with soap, these should be present in known and efficient ratio to the Further on the writer reiterates his postulate in yet whole mass. more decided terms. "The more experienced a surgeon becomes with this work (the antiseptic treatment of wounds), and the greater care he takes, the less likely is he to have suppuration; and at the present day pus in a wound made by a surgeon through the unbroken skin is a thing which ought not to be seen." "If it does occur the fault is the surgeon's [the italics are ours], and he must look to it that the fault is not committed again; for it must be remembered that the presence of pus implies the presence of pyogenic organisms, and that these, while they locally set up suppuration, are able also, when they penetrate into the body under suitable conditions, to set up the terrible septic diseases which were formerly the scourge of surgery." Such a declaration, made by such a surgeon, must profoundly affect the whole fraternity in a medico-legal sense. | It is not likely that we have heard the last of it in its mere enunciation. For our present purpose further quotation is unneces sary. Surgeons inform us that enough has been said to incite every conscientious and prudent man to a careful review and a close scrutiny of every detail in the chain of measures designed to attain the perfect asepsis of wounds. Such a detail is the "toilet" of the skin of a surgical patient preparatory to incision. Authorities, insular and continental, agree that a more or less prolonged soakage of the skin with bactericidal lotions is essential, more especially in parts like the axilla, | where hair is abundant and the sebaceous glands numerous. And by all a well-administered local "scrubbing with soap and nail-brush" is considered a necessary premise; but by none, so far as we are aware, is any caution given as to the quality and purity of the soap to be used. From our present stand-point it cannot be a matter of indifference to the surgeon that the fats and oils to be saponified for his use were derived from the off scourings of woolen mills, the skimmings of sewage-polluted streams, or the refuse from cod-livers or other fish-oil. But even under the more favorable circumstances where soaps are made from fats extracted from the grease-barrel of restaurants and butcher-shops, the soaps are attended with grave risks. The smell of a fat-rendering factory often savors of the mortuary, and is sufficient to reveal the truth. Nor would it seem to be unimportant in dealing with delicate skins at their most vulnerable points, that a surgeon's soap shall be free from sugar, toffee, the various silicates, china-clay, fullers' earth, glue, or common salt, all of which are found as "make-weights" in the commoner and cheaper sorts. Then, too, many of the products denominated "antiseptic" contain scarcely a modicum of the ingredient from which they derive their name: usually there is just sufficient to mask, by its odor or color (as in tar-soap), the smell of rancid fats or decomposing nitrogenous material. The course most expedient to pursue-since all cannot be analysts-is that surgeons should insist that the soaps to be used prior to every operation, whether in hospital or in private practice, should be procured from well-known sources, made by reputable manufacturers in a large way of business, and guaranteed by their recognized imprint or trade-mark. We feel confident that the medical and, indeed, scientific public generally have long since awarded us a prominent place among such houses, and that our soaps, made with the purest and best of materials, with a maximum of technical care, and being exactly what they are represented to be, cannot fail to satisfy the most discriminating That any of the processes of soap-manufacture are by demands. BLONDEAU et CIE., Makers of Carbolic, Terebene, Coal-Tar, and Other Pure Soaps. CLINICAL LECTURE. ABSTRACT OF A CLINICAL ABSTRACTED BY A. M. PHELPS, M.D., Professor of Orthopaedic Surgery, Post-Graduate School and City of New York, and Surgeon to New York City Hospital. SPASTIC PARALYSIS; TALIPES EQUINO-VARUS. THE No. 3 he attempted to walk, contact between his foot and the ground caused spasmodic contraction of the muscles to take place, and he walked in the manner characteristic of spastic paraplegia, as I will demonstrate shortly in another case. He walked with stiffened legs, scraping his toes along the ground. In this boy the spastic paraplegia was not extremely well marked, but it was sufficiently obvious. There was spasmodic contraction of the calf-muscles particularly, causing elevation of the heels, so that as he walked his toes were constantly catching on the ground. Moreover, the feet were constantly extended and inverted, in the position of talipes equino-varus. The question was, What could be done for him? Through some early disease of the antero-lateral columns of the cord he had lost inhibition in his leg- and feet- centres, and it was altogether a most unpromising case for treatment. But we thought we would give the boy a chance by the open operation of Phelps, of New York, for talipes equino-varus. The result is that he now stands with his feet perfectly flat; there is neither inversion nor eversion, and, although there is still some claspknife action, he walks, so far as my part of the business is concerned, a perfect plantigrade. You will see the high stepping action as he goes along the floor, but, fortunately, his cen HE next case I have to show is a very interesting one. T. G., 11 years of age, came into the hospital in May, 1893. He was then 101⁄2 years of age, and was the subject of spastic paraplegia,-that is to say, the reflex. action in his lower extremities was uncontrolled because of some affection of the spinal cord. The cells of the anterior cornu of the gray crescent of the cord are in connection with two sets of filaments,-motor and sensory. The gray crescent is, in fact, a small, independent brain, responsible to the supreme authority of the encephalon. If we cut off the connection between the gray matter and the encephalon there can evidently be no longer any direct control of the gray nervetissue; thus, for instance, on gently pinching the leg we get spasmodic and uncontrolled contraction of the muscles of the limb. The reflex action is ordinarily controlled by inhibitral nervous affection has greatly improved. tory filaments running from the brain to the The case has made a considerable impression gray matter of the cord through the antero upon me, because, from a surgical point of lateral column of the cord, and if anything view, it was extremely unpromising. I can happen to interfere with the integrity of these remember the time when a surgeon would filaments the reflex acts lose inhibition and have refused to operate upon a case of talipes run riot. They had run riot in this boy. As equino-varus, or any other form of talipes which was secondary to central nervous disease, because the outlook was so poor. All * Delivered by Mr. Edmon Owen, of London, Eng., in St. Mary's Hospital. [The last paragraph does not quite state all. The other reason, and by far the most important, is that the skin, cellular tissue, and fibrous tissue on the inner side of the foot are short, and these tissues must be lengthened either by cutting, tearing, or stretching, before the foot can be brought to a supercorrected position, and cutting is the least harmful and most rapid, hence the open cut.-PHELPS.] such miserable cripples were, therefore, left | amount of inversion as well as extension of the without efficient treatment, and were allowed foot. I would, therefore, strongly advise, in to drift on from bad to worse. I would not every case, division of that structure first. have operated on this boy had I not been par- That is a great point, but not an original one, ticularly conversant with the operation of in Phelps's operation. It is characteristic of Phelps, a man who has done a great deal for Phelps's operation that, instead of dividing the orthopedic surgery, and who is, by the way, a inverting structure subcutaneously, the open general surgeon, not a special orthopædist. I method is employed, so that the surgeon can think the time is coming when all bad cases of see exactly what he is doing, and thus divide talipes equino-varus, except in very young chil- nothing that does not require division and dren, will be operated upon by this open method. everything that does. It seems, to me at least, to be inevitable. Here, truly, is a happy result of the thorough opera. tion. All the credit of it is due to the large view and bold treatment of my American colleague, Dr. A. M. Phelps. I am not depreciating specialism altogether, but I have no hesitation in saying openly that I think specialism is going a little too far. May I here remark that probably the greatest advance that has been made in recent years, in connection with the treatment of skin disease, was made by a general, not a special, physician, the treatment, namely, of inveterate cases of psoriasis by thyroid extract. If a man work within too narrow limits he is apt, I think, to lose sight of great principles and take a contracted view of his surroundings. I do not say that he is, but certainly he is apt to be, like a man working in a valley. And in his work he is apt to develop a certain amount of professional myopia. PHELPS'S OPERATION. The incision is made, as I show you in this other child, from the dorsum of the foot across the inner side, just over the head of the astragalus, and is carried down to the sole. The internal saphenous vein is possibly divided, though it is often seen and avoided. The deep fascia has then to be cut, as it covers the abductor hallucis; then the tendon of the tibialis posticus, which supports the head of the astragalus, and the tendon of the flexor longus digitorum underlying the head of the astragalus. Going a little farther, the surgeon opens a joint between the astragalus and scaphoid. Now A word or two with regard to Phelps's comes what I consider to be the most imporoperation : The old-fashioned and orthodox treatment of club foot consisted in the subcutaneous division of tendons and fascia,-division of the tibialis posticus, the flexor digitorum, and, perhaps, the plantar fascia. Then, with a good deal of subsequent manipulation and tedious working with a mechanical Scarpa shoe, the foot was got into a more or less satisfactory position. Afterward the tendon of Achilles was divided. This large tendon, you remember, was divided last of all. It was left for the purpose of acting as a fixed point, so that from it the surgeon might be able to exert, with a Scarpa shoe, a certain amount of flexion and eversion. But if you happen to be deal ing with a slight case of talipes equino-varus, it will very likely suffice if you divide only the tendon of Achilles. When this is effected you may be able to correct a very considerable tant point in the whole operation,—the anterior part of the internal lateral ligament is freely cut. You remember how this ligament is arranged. The anterior fibres are not connected with the astragalus, but run over it to be attached to the scaphoid bone. The anterior part of the internal lateral ligament is peculiarly tight and resistant in talipes equinovarus, and, more than any other structure, requires attention. As soon as that is done the foot is everted and the joint between the astragalus and scaphoid opened up. The other resisting structures in the foot are then divided. Amongst them will come, I dare say, the middle piece of the plantar fascia, which is the strongest part, and, very likely, the flexor brevis digitorum. Then the inferior calcaneo scaphoid ligament has to be divided because it is holding the tuberosity of the scaphoid up against the sustentaculum tali. The position of the foot is be improved by in- | Only to-day the second dressing was taken off, creasing the length of the inner border, and two weeks having elapsed since the first was that can only be done by opening the joints removed. When the dressing was removed between the astragalus and scaphoid, a measure the wound was almost healed, and, as you will which is impossible without the division of the see, it must have been an extensive one origiinferior calcaneo scaphoid ligament. After nally. Mr. Kellock, who, with me, operated every cut the surgeon wrenches the foot into a on one of this boy's feet some time ago, sugslightly improved position; he goes step by gested and carried out an ingenious modificastep, feeling his way, as it were, with the tip tion in the detail: As soon as the foot is of his finger and the end of his scalpel. Per- lengthened out there is a considerable amount haps before the foot can be got into the proper of slack skin upon the dorsal and outer aspect position the long and the short calcaneo- of the foot; so, after the deep operation-wound cuboid ligaments have to be divided. After on the inner side of the foot had begun to that the surgeon gives another wrench and granulate, Mr. Kellock raised a large flap of gets the foot into an overcorrected position. He this redundant integument and slipped it into dresses the wound lightly with some antiseptic the wound. This graft has done well, and its gauze, loosely filling the large cavity, and then growth has materially expedited the healing. he secures the foot in lateral splints of houseflannel and plaster of Paris. It may not be amiss to compare for a moment, in passing, this operation with other radical operations on the foot which consisted in the removal of the wedge shaped piece from the outer border of the foot. If the apex of the wedge is brought far enough inward and the base is sufficiently wide, the foot can then be straightened out and brought flat. But this improvement is obtained at the expense of the length of the foot. Different varieties of these operative procedures bear the names of different surgeons, Davies Colley and Richard Davy. And there is yet another, -and a very excellent one it is,-which consists in the removal of the astragalus: it bears the name of a well-known provincial surgeon, -Lund, of Manchester. These various procedures have emanated during the last few years from pioneers in orthopedic surgery, all of whom, by the by, were general surgeons. [No matter how wide the wound has gaped, in my experience it has always filled in perfectly within six weeks, and within a short time the redundant skin on the outside of the foot has been absorbed. With these observations in mind, I think I would hardly resort to a plastic operation in any case, although I would not condemn the practice.-PHELPS.] The old treatment by Scarpa's shoe required a great deal of attention on the part of the surgeon, who required, in private practice, to make almost daily visits to see how the case was going on, to assure himself that the foot was bearing the restraint, and to alter the screws. According to the new procedure the foot is put up in plaster of Paris and so left for three or four weeks, the patient being allowed to walk about within a week of the operation. [Mr. Owen is right in teaching that contraction following paralysis should be lengthened by operation. The senseless, prolonged, painful, stretching treatment followed by some ortho All of these operations, useful as they have been in the evolution of the surgery of club-pædists is to be deplored. It will be abandoned foot, effected their improvement by shortening the external border or sacrificing some part of the foot; but Phelps's operation improves the position of the foot,-not by shortening or sacrificing anything, but by lengthening the internal border of the foot,—and I am satisfied that it is of a very great importance. The wound having been dressed in the case of this boy, operated on as described, on May 16th, the foot was wrenched around into the overcorrected position and incased in lateral splints of house-flannel and plaster of Paris. Then for five weeks it was not interfered with. These in the near future. It is as unscientific to attempt, by machines, to stretch these contracted muscles and tendons as it is to follow the same plan of mechanical treatment with the remunerative tendo Achillis, Dupuytren contraction and plantar fascia, now so popular in the circles of certain mechanicians. paralyzed muscles should be lengthened by interposing an abundance of new tissue, and not by stretching. The latter nearly always relapses, making it remunerative for the mechanic, while the cases operated upon do not -or at least very seldom-relapse, and the |