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and presented considerable dilatation of the left ventricle;
the aortic insufficiency was complete; the aorta itself,
sensibly dilated at its ascending portion, was studded by
atheromatous deposit, and the curtains of the mitral valve,
tough, rigid, and uneven, could no longer close the en-
larged orifice.
Postcript. The translator would remark that many
points of detail alluded to had already been pointed out
by him in his memoir on "Insufficiency of the Aortic
Valves, in connection with Sudden Death, with Notes,
Historical and Critical," published by Davies (Hardwicke),
1861. For some years prior to the thesis of Mauriac, he
had been investigating the mechanism of the cardiac cir-
culation in health and disease, and had advocated the
view of the repletion of the coronary arteries during
the period of ventricular diastole. This view was
adopted by the late Dr. Snow, in his work on "Chloro-
form," published in 1858, and, indeed, is now generally
adopted.

He had, moreover, shown that there are, practically, three well marked stages of aortic insufficiency. First, the irritative stage-here, in many cases, the earliest symptoms are those of obstruction and general cardiac excitement, from the impediment offered to the onward passage of the blood, by the tumid state of the aortic valves, and it is only after a certain interval, when this tumid state subsides, that the process of contraction of the valves begins; they then permit regurgitation of the blood into the cavity of the ventricle, causing it to dilate. The speedy accession of hypertrophy of the chamber compensates the disorder thus induced, and forms the second, or physiological stage, which, in many cases, if rightly managed, may persist for years, and maintain the proper balance of the circulation. Sooner or later, according to circumstances, the third, or degenerative stage occurs, and in its train, the symptoms so well described by Jaccoud, as those of asystole. This stage, the translator has shown, may, in some cases, often be foreshadowed by the gradual lessening of the collapse of the superficial arteries--a fact occasionally noticed even by non-professional observers of the cases.

the consumptive-now under my charge in the hospital, no less than twenty-eight present disorders of the parts indicated, thus giving the result of 65 per cent.

The chief relations which have been held to subsist between these throat disorders and pulmonary consumption, are four in number-1. That of a precursor; 2. That of a coincident; 3. That of a sequela; and 4. That of a simulator. These relations are all worthy of note, but in this paper most attention will be given to the fourth relation-viz., that of a simulator.

Precursor.-As a precursor, the disorders above-named perform a comparatively unimportant part. In many cases of phthisis declaring itself soon after the advent of the disorders referred to, I am satisfied the priority was more apparent than real, and that tubercle in the lung was really present before the disorders of the trachea were manifested, and that diligent search for the physical signs of tubercle instituted at the first departure from health would have resulted in the discovery of physical evidence of tubercular disease of the lung. I have met with numerous examples of pulmonary consumption in the history of which, it has been declared by the patient that, the first disordered condition was that of the throat and voice, and that the chest was only secondarily affected. These cases have come before me in large numbers, but I have generally found that the amount of disease in the lungs at my first examination has been so great, as to suggest its comparatively long duration, and the probability of its having been really the primary disorder. In fact, the evidence in a large proportion of cases of phthisis in which throat affections have been held as precursors, the pulmonary disease was the real and primary one, and the supposed precursor was truly a secondary one.

In one sense throat affections may be regarded as precursors-viz., as antecedents, for, of course, persons suffering, or who have suffered, from these complaints are, like all others, more or less liable to become affected with phthisis. Many persons who have suffered from throat complaints become the subjects of pulmonary consumption, but these disorders are more truly antecedents merelythat is, independent prior disorders, performing no In concluding this Lecture the Translator feels specially part in the production of tubercle in the lung. Primary called upon to acknowledge the great and ready courtesy tubercle of the trachea, if it ever occur at all, we have reason of Professor Jaccoud and Monsieur De la Haye, in per- to believe, is an exceedingly rare affection, and the ordinary mitting its publication. The work from which it is ex-inflammatory disorders of the trachea and the congested and tracted- "Lecons de Clinique Medicale," Paris, 1867cannot be too strongly commended to the attention of our countrymen as equally calculated by its rare excellence to sustain the high character of the School of Medicine of Paris, and to enhance the reputation of one of its most

brilliant teachers.

Original Communications.

MORBID CONDITIONS

OF THE THROAT IN THEIR RELATION TO PULMONARY .CONSUMPTION: THEIR DIAGNOSIS AND TREATMENT.

BY S. SCOTT ALISON, M.D. EDIN.,

FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS, LONDON, AND PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, BROMPTON, AND THE SCOTTISH HOSPITAL.

No. I.

THE importance of a knowledge of the relations of the disorders of the trachea and adjacent parts, including the larynx, the tonsils, and the pharynx, to pulmonary consumption, has been long admitted by practical physicians.

Before I joined the Consumption Hospital at Brompton, I was sensible of the importance of these relations, but it was after this that its real magnitude was duly impressed upon my mind. Disorders of the trachea and the adjacent parts above indicated have been observed in a very large proportion of the entire cases coming under my care in the hospital. Amongst the forty-three patients-not merely

hypertrophied conditions of the mucous membrane are very different in their nature from tubercle, and seldom or never give rise to it either in the parts primarily disordered or in the lungs. Such is my experience, and such is that of most enlightened practical physicians and pathologists of the present day. True it is, in non-professional parlance, we often hear of neglected colds of the throat spreading down into the lung and producing consumption, and in some not highly esteemed professional writings we read of the same relation. It was Dr. Hunter, of inhalation notoriety, who most recently pressed upon the public this error and false induction. A Coincident.-Affections of the trachea and adjacent parts do occasionally manifest themselves by hoarseness and other throat indications at the same time that pulmonary consumption gives signs of its development, and the two classes of disorder seem to arise at the same time.

We see this alliance or double development to hold almost exclusively in cases of acute pulmonary consumption. But even in cases of acute consumption signs of tracheal complication seldom develop themselves until the pulmonary and more grave form of disease, together with constitutional disturbance, has held in a marked manner for days or weeks. Therefore as a coincident (beginning at the same time) of pulmonary consumption, tracheal disorder is of comparatively little import.

Sequela. It is as a sequela of pulmonary consumption that tracheal disorders assume their most grave aspect. Including all forms of pulmonary consumption, and all its stages, we may safely say that few cases are met with which do not present some material evidence of tracheal disturbance.

In the first stage of phthisis the non-implication of the trachea and adjacent parts is most common, but even in such cases a majority will show a not entirely healthy condition of the parts in question. In the second stage a much larger proportion of cases is found to be implicated with these minor affections; and in the third, nearly every case reveals, either by the voice or by respiratory auscultatory signs, evidence of the implication of the windpipe. The task of connecting the disorder of the trachea with the more grave disease of the lung in such cases is, on the whole, an easy one. If there be any difficulty it is in cases of phthisis in its first stage. The aberrations from the healthy amount and quality of the respiration sounds of the chest, serve at once, in the later stages of pulmonary consumption, to indicate the dependence of the minor disorders upon pulmonary mischief.

Of twenty-six cases of all forms of phthisis in all stages of the disease now in the Hospital at Brompton, under my care, nineteen, or 73 per cent., give full evidence of disorder of the upper air-tube apparatus.

Some of the local complications are grave, while others are of less serious significance.

Of eighteen cases of phthisis in the third stage, only three are free from implication of the trachea, and other parts of the upper air-tube apparatus. These figures give a percentage of 83.

The diseases of the trachea, larynx, and adjoining parts, which we observe in pulmonary consumption, are almost invariably found to hold this relation, viz.-that of sequela. In examples of acute pulmonary consumption, it is consistent with my observation to say, that the disorders of the windpipe, &c., that occur, depend upon the extension to the parts first involved, of that tubercular vascular over-action which originated in the lungs. This morbid action is propagated by continuity of structures. In chronic cases of phthisis, the disorders of the trachea, larynx, and adjoining parts, seem to proceed from the production of congestive action from neighbouring irritative disease, and in the second and third stages from inflammatory conditions, sometimes simple and sometimes tubercular, caused by the actual passage of irritant secretions, and the debris of destroyed material from the diseased lung, over hitherto healthy parts.

The morbid alterations of structure which I have observed in the trachea and the adjacent parts, in pulmonary consumption, are various. These conditions are often simply an injected and turgid, and somewhat swollen state of the mucous membrane of the rima of the glottis, the epiglottis, the tonsils, and the posterior wall of the pharynx, and of the larynx and trachea. These parts may be all equally affected, but it is more frequently the case that only some parts are materially involved. In the more advanced cases of phthisis the larynx and trachea are chiefly diseased, but in many examples, rapidly progressing to a fatal issue, all parts are implicated. Red and injected conditions, with small elevations of swollen glandules of the posterior wall of the pharynx are common. Indented or serrated conditions of the epiglottis are often presented, and a thin and shaven-off like edging is not unfrequent. A red and scarlet state of the epiglottis, resembling the petal of a scarlet geranium, is often met with. The larynx is often inflamed, congested, ulcerated, and totally, or almost totally, deprived of its vocal cords. A very general condition, in extremely bad cases, is one of total loss of the cords, with deep ulceration between the thyroid and cricoid cartilages, and a general ulceration, and rough or granulated surface of the entire mucous membrane of the larynx.

The symptoms during life attending the allied disease of the trachea, &c., are, in slight cases, huskiness and occasional hoarseness, sense of irritation in the throat, and more or less frequent attempts to clear the parts of mucus, producing a sound like the word "hem," more or less forcibly formed. The hoarseness frequently becomes continuous, and when ulceration of the larynx is extensive, aphonia or whispering is produced. When the vocal cords

are totally destroyed, the aphonia is complete, and the attempt to speak simply produces a roaring and inarticulate sound, very painful to hear. In these latter cases deglutition is painful, and when the epiglottis is greatly ulcerated, particles of food are wont to fall into the larynx and to give rise to partial suffocation, and to severe local convulsive efforts.

An oedematous state of the rima glottidis is occasionally found in the last stages of pulmonary consumption, and this gives rise to great difficulty of respiration. The lung is not duly inflated, and it is impeded in the expulsion of its ariform contents. The voice is destroyed, or becomes whispering, and the sound of respiration, heard through the medium of the open atmosphere, or through the stethoscope placed upon the neck, is hissing and constricted. The greater intensity of the hissing or constriction at the immediate region of the glottis, points to the seat of the constrictive disease.

Tubercular matter, grouped in masses even so small as mustard-seeds, I have never seen in the larynx and trachea, and this product seems, when deposited, to affect very fine forms, scarcely visible to the naked eye, such as I have observed in the aorta and pulmonary artery. The distinct masses of tubercle which we find imbedded in the mucous membrane of the bowels, both small and large, I have never seen imitated in the mucous membrane of the tubular apparatus leading to the lungs. The addition of important throat affections to pulmonary consumption adds seldom to the danger of the patient, but exposes him to grave inconvenience. Difficulty of swallowing tends to hasten dissolution.

The discovery of even advanced disease of the lung is in some cases impeded by the presence of strongly marked signs of disorder of the trachea, &c. The coarse and loud constrictive respiration sound through the upper portion of the air-tube apparatus, tends by descending into the lung structure to mask fine and single humid crackles in cavernules and in cavities. The cavernous voices is with some difficulty made out in cases marked by partial aphonia, and weak and whispered voice. The articulated voice, superficial and very near so valuable as a sign of cavity is, of course, lost in cases of aphonia. I have seen several cavity cases in which, even after very diligent exploration, I have been left in doubt until a second examination has been made. The proportion of such cases is small, for careful listening will generally detect some amount of crackling, either cavernulous or cavernous, and the voice over the diseased lung will generally show an unusual amount of distinctness and nearness. Besides in advanced softening and in cavity cases, the motion is reduced, and the percussion is either dull or of manifestly short duration. Coughing will sometimes give the requisite evidence. In cases of tubercular, perforation of the pleura, the amphoric respiration and voice, and the clear percussion at first throughout the diseased side, and in the stage of effusion the clear percussion above, and the absolutely dull percussion below will almost always suffice to lend certainty to the judgment.

It is right, however, to mention that cases of cavity do sometimes present themselves in which the cavity has been altogether overlooked when such oversight is scarcely to be justified, and this has happened from the marked character of the throat complication causing the chest to be exempted from all exploration. Since very much attention has been given to the laryngoscope, and so much time expended upon its use, these over-lookings seem to have become more than usually frequent. Perhaps this is in some measure to be explained by the fact that the laryngoscope has been largely adopted, and most usefully too, by some members of the profession, who had not previously seen much disease of the chest, or been familiar with the methods of exploration of that portion of the body. Such oversights are not only an injustice to the patient, but discredit the medical attendant, and are likely to prove injurious to him. To avoid all chance of such results it should be made a rule that, in cases of throat disease of any im

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portance, either through the urgency or intractability of local symptoms, or suffering of the general health, the entire chest should be subjected to the tests of expansion, percussion, and auscultation, I would almost say of differential auscultation. With this chest examination such errors will not often occur, and should disease subsequently manifest itself, it will be felt that non-discovery did not rest upon culpable neglect.

that if I knew of no other means to alleviate the pain, to get the thumb amputated forthwith.

I ordered immediately- Tinct. aconiti, i. Quinine bisulph. 3ss. Acid sulph. dil, 3i. Aq. ad. viiim. 3ss. stat. et rept. omni secr. hora, directing that if anything unusual occurred to send for me at once, but that I'd see her early the next morning. I did so, and to my astonishment, for I thought the amount of relief I might have afforded the old lady, never would have satisfied her. She expressed herself very thankful to me, and I saw at a glance that she

ON THE ACTION OF ACONITE AND QUININE was much better. Questioning her regarding any sensation

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(A paper read before the Cork Medical Association.) GENTLEMEN,—It is not with a view to enunciate any new theory regarding the action of a drug often experimented with before by such men as Pereira, Gesner, Fleming, and others, that I bring these few remarks under your notice, nor to propound any new doctrine on its therapeutic effects, but being struck often, while conversing with medical men on the action of aconite, by their dislike to administer it internally at all, I was tempted to bring the following case under your notice to-night.

she might feel, she complained of numbness and tingling in her fingers and toes; she had had a few hours sleep in the night after four or five doses of the mixture, and it was after the sleep she awoke so much relieved. She apologised for being, as she said, so like a mad woman on the previous evening. I now ordered the mixture to be given only every third hour, and seeing her the same evening so much better, I discontinued the use of the aconite, and reduced the dose of the quinine. She then recovered completely, and I have not since seen her. I tried the strength of the tincture. I used it in this instance, as follows:-I selected a fine buck-rabbit, and having kept it some hours previously without food, gave it ten drops of the tinct.

1st. Ten drops--no effect.

2nd. Ten drops, one hour after: spasms about the throat and twitchings about its mouth set in. 3rd. Ten drops, one hour after last: more spasms, limited to the mouth and throat.

more spasms, limited

4th. Ten drops, one hour after last to the mouth and throat. 5th. Twenty drops, half-an-hour after; great difficulty of breathing, and spasms of jaws.

Now, it has not been the ardour of the young physician, nor the love of new and extraordinary means of aid that has occasionally led me to use it, but that like others, struck as a student with the startling effects of aconite, I subsequently became practically convinced of its thera peutic value, and have not been afraid to administer it in ternally when cases presented themselves which demanded its use. I now wish to allude to its action in neuralgic affections only, and shall illustrate any remarks I make by rather a curious case which I attended this year. Increased in energy. cases where as yet I have had to use aconite, such as in the varying shades of facial neuralgia, cephalagia, &c., have invariably combined it with quinine, and with astonishing good effect, that is to say, cases that quinine was administered in without any result, on combining aconite with it, I afforded relief.

Thus, having often seen the good results from the combination of these two powerful drugs, I determined to use them as a first means on this particular instance, and then thought that it might be a good example to add to the list of those brought before the profession of the use of aconite.

6th. Half-an-hour after, twenty drops; same result, in

7th. Twenty drops, half an hour after: violent conIvulsions of all the body, jerkings of head and hind limbs, the latter thrown alternately out, and gaspings; death in about half a minute after the dose, so that less than ii of this tincture produced death, divided over a period of more than four hours. We may notice, in this case I have quoted a few points :-1st. The effects of severe cold in developing a disorder latent for so many years, as also that the thumb had recovered the effects of the injury, it was the part to originate the general disorder of the nerves of the arm, shoulder, and face. 2nd. The rapid subsidence of such severe pain under the combined influence of aconite and quinine.

Mrs. H., aged 72, apparently very strong and robust, I saw on January 16th, 1867, about six P.M., suffering the most excruciating torture, quite unable to speak coherently and shrieking dreadfully from pain. Her daughter explained to me that this had come on violently since three P.M. of the same day, but that for a few days previously, she had suffered slight neuralgic attacks in the arm and side. The old lady writhing in agony directed my attention to her thumb, and from her daughter I learned the following history-Twenty-five years previously she had injured her hand; the bones of the thumb got affected, and Sir P. Crampton wished to take away a piece of one. This she would not consent to, and five years subsequently, during a period of extreme cold and frost, she got a bad attack of neuralgia, and went to her physician, requesting him to amputate the thumb, so bad was the pain in it.

Though shaken greatly in her general health, she had no return of neuralgia for a period of twenty years, until the severe frost of January of this year again brought it on. I was on the point of examining the thumb, but the moment I touched it, she screamed most violently, and got into such a state, that it completely prevented any further examination, and I refrained, satisfied that she suffered from pure nervine pain propagated by the old lesion in the thumb, and fostered by the extreme cold-she having gone out each day to chapel notwithstanding her daughter's entreaties. My visit was hurried, as I saw that her suffering was so intense, and all she could now say was

Now, before answering the question as far as pathology and physiology will allow us: How do aconite and quinine combined, or aconite alone, effect an neuralgic patient? We nrust first decide what is neuralgia? and here is the first difficulty; without entering into varied discussions we may take as the results of the researches of those interested in this curious affection, that it is due to some morbid change in the nerves of parts often not recognis able after death, as slight thickening, vascularity, or pressure from tumours in their immediate neighbourhood, these changes being the active causes which are set in motion by external or internal agencies, as atmosphere in the first case, or stomach and intestinal disorders in the second, both alike giving rise to intense suffering traceable often to no cause, but this external or internal agency which produces, in some unknown manner, a state of increased sensibility of the nerves of sensation of certain regions not even evidenced by any visible changes in these parts, or again to some low state of vitality of certain peripheral nerves, consequent on a disordered condition of surrounding structures, or the direct result of any injury.

Looking, now, practically as to the manner in which aconite given internally can be a remedy for any of those morbid states:-1st. As a contro-stimulant, either by a direct action conveyed to parts by the blood, as evidenced by the numbness and diminished sensibility, this influence being felt by parts preternaturally excited before acting

on the system generally (Fleming). 2nd. By a direct | anæmic or otherwise, no practical physician having failed
sedative action on the circulation as shown by its action to observe the relation that exists between neuralgia,
on the heart's pulse. 3rd. By diminished power of sensi-
bility of the brain-it being, as Bouchardat states, a stupi-
fying agent, less powerful than belladonna or opium. We
may thus make a two-fold division of its mode of action
on a neuralgic part.

1st. Reducing any increased vascularity and excitability. 2nd. Exercising a healing influence on the nerves of the part, and deadening sensibility in the nerves of the affected region, both effects being increased in proportion as it influences the nervous system generally through the brain; and, as Dr. Fleming remarks, "if an organic lesion, resulting from an injury, be not present, our cure may be permanent," if it is only temporary, the physician, always remembering the physiological action of aconite, must seek for those states of the system which contro-indicate its use, and not stigmatise a drug as noxious and dangerous, which, if given in congested states of organs, lungs, or otherwise, will decidedly verify his worst anticipations; or if in anæmic states of the system we give this powerful drug, we must only blame our own rashness, if its indiscriminate use leads us into trouble.

To enter into the vexed question of the exact way in which quinine acts, whether it is a tonic, acting simply by catalysis (Headland) on the blood, or by giving to it some essential ingredient in which it is deficient. For my part, I must confess myself an advocate of the logical conclusions drawn by Dr. Headland on this matter in his recent able edition on the "Action of Medicines," believing quinine to be a restorative medicine, not directly neurotic, and adducing in evidence the discovery of Dupré and Jones by means of the fluorescent test, which establishes the presence of a substance in the blood similarly constituted to quinine. Certain it is that quinine is not excreted in any quantity, and it requires very large doses to detect its presence in the urine. To satisfy myself of this fact, I obtained some pure quinia from the Apothecaries' Hall, Dublin, and gave, at intervals, to a healthy man (a pensioner) 33 grains in the 24 hours. He suffered from pains in the loins, head, and back. I got him to pass urine immediately before the first dose, and obtained, then, all he passed in the 24 hours, amounting to 54 fluid ounces. It was quite clear and healthy. I first took two ounces and rendered it slightly acid with tartaric acid, evaporated to dryness, dissolved in absolute alcohol, and evaporated in a water-bath, filtered, and extracted the residue, and repeated this process three times. I then extracted the residue with more alcohol, to which remainder, by this time very minute and colourless, I added solution of carbonate of potash, and got a white precipitate, perfectly soluble in æther, but failed to get the chlorine and ammonia test on the evaporation of the ether. On again peating the same process with four ounces of this urine, I got the green with chlorine and ammonia, but from the quantity I obtained altogether from the six ounces, I should say that not more than a few grains passed entirely through the urine. We may thus look on quinine as producing a permanent change in the blood, either filling up some deficiency, or producing some change in its integral constituents, and so altering the existing state, and conclude that quinine acts through the blood, and that its effects in nervine disorders are due to this blood-action, which is restorative in character. So that it is indicated in any deranged state of the system which clinical experience shows to be the result of certain morbid states of the blood, originating in a deficiency or change in its ingredients, as evidenced by a certain class of affections that follow those particular changes.

debility, and hysteria; often do we find all three co-existing in the same individual, and as surely as chlorosis and hysteria are allied, so is neuralgia and other debilitated states. The question arises, then, does not quinine, by altering this morbid state, relieve the condition that it has induced? and this I believe to be its true action. And so we may use it as a valuable adjunct to aconite-1st. In neuralgia occurring in anæmic or debilitated patients, without any apparent nerve-lesion or exciting cause. 2nd. In old cases of neuralgia, where the primary disease has induced a state of the circulation at the part affected not in accordance with health. 3rd. In all cases where, to a temporary relief, we would add permanency of cure.

I trust the society will pardon the time I have taken up on this apparently trivial subject; but I offer my excuse in the words of Dr. Headland, when he says that "it must be confessed that in the action of medicines and their agency in curing disease, we do not so much excel our ancestors;" and he rightly attributes it to the want of united medical testimony on the action of drugs, so that the doubts and difficulties which are now clearing away before the efforts of a few, may be finally dissipated by the energies of all."

Hospital Reports.

CITY OF DUBLIN HOSPITAL.

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REMARKABLE AND VERY RARE CASE OF SPREADING GAN

GRENE OF THE LEFT UPPER EXTREMITY, RESULTING
FROM DISLOCATION OF THE HEAD OF THE HUMERUS
INTO THE AXILLA-FATAL TERMINATION—POST-MORTEM
APPEARANCES.

UNDER THE CARE OF MR. CROLY.

J. S., aged 73 years, a bricklayer, a powerfully muscular
man, and unusually active for his time of life, residing a
few miles from the city, was admitted into the Hospital
under Mr. Croly's care, on the evening of the 29th of May,
on the recommendation of a medical gentleman:-

History. He was working at a gentleman's house on
the 26th of May, and accidentally fell from a ladder; he
struck his left arm in the fall, and immediately lost all
power of the limb, which swelled rapidly; he felt a cold-
ness and tingling in his fingers. He was visited in two
hours by a practitioner of long experience, who at once re
cognized a luxation of the left shoulder-joint, and was
forcibly impressed by the unusual amount of swelling, not
only of the hand and forearm, but of the entire upper ex-
re-tremity. The patient was placed on the floor, the sur-
geon (having taken off his boot) put his heel into the
axilla, and grasped the wrist; with the utmost facility the
head of the bone was returned into its natural position,
and the arm was bandaged to the side.

Is not, then, neuralgia often the result of such changed conditions of the blood? Pathology, in many instances, can assign no cause for it! Morbid anatomy looks in vain for any state to account for the life symptoms, and though we may have palpable causes during life, and apparent after death, still, in many instances, we can assign no reason for suffering but some debilitated state of the blood,

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May 27th. On visiting the patient he observed that the swelling had not diminished since the reduction, and on examining the shoulder-joint he felt a depression beneath the acromion process, as if the head of the bone had again left the glenoid cavity.

29th. The patient complained of coldness and total loss of sensation in the fingers. He was then removed to hospital.

Condition of Patient and appearance of limb on admission.-Countenance cheerful and natural; pulse (at right wrist) 80 in the minute; tongue clean; left hand cold and very much swollen; nails blue; no sensation in the fingers; forearm swollen and congested, upper arm at least twice the size of the sound limb; no pulse can be felt at the wrist or in the brachial artery. The shoulder-joint (when the elbow is kept in to the side) presents a naturally rounded appearance, but on abducting the arm a depression is observed (beneath the acromion), into which the fingers sink upon pressure.

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There is a large soft tumour filling the entire axillary cavity, not diminished in size by compressing the axillary artery in its first stage, and an enormous ecchymosis extending from the superior costa of the scapula to the gluteal region posteriorly, and laterally from within two inches of the dorsal vertebræ to the nipple of the breast.

Treatment.-Hand and forearm enveloped in wadding cotton and supported on a pillow. A liberal supply of nourishment was ordered, and opium with quinine prescribed.

May 30th.-Patient slept well; does not complain of pain; tongue clean; pulse strong and natural in sound arm. There is great tension and infiltration of all the affected limb. There are dark-coloured bullæ on the back of the hand, which presents a bluish appearance.

Mr. Croly consulted with his colleague on duty (Professor Hargrave), who agreed with him as to the propriety of making superficial incisions into the forearm and arm, to relieve tension. This was accordingly done; serous fluid escaped, and the angles of each wound were plugged with strips of lint steeped in turpentine, to prevent hæmorrhage. Immediately after the incisions were made the axillary tumour disappeared.

One of the incisions was made over the course of the brachial artery, and the fascia was opened; but neither Professor Hargrave nor Mr. Croly could feel any pulsation

in the vessel.

31st.-Patient in the same cheerful spirits, and apparently not suffering from any constitutional disturbance. Hand of a bluish-black colour; the discoloration has extended as far as the dorsal aspect of the forearm above the wrist. The integuments above the gangrene present a purplish-red appearance on the dorsal aspect, and a mottled look on the anterior part of the forearm, extending obliquely upwards and inwards nearly as high as the elbowjoint.

June 1st.-Patient passed a good night, and has taken eggs beaten up with whiskey, a chop, strong beef-tea, and a liberal supply of wine each day since admission. His countenance is natural, and he is, as usual, very cheerful and hopeful. Pulse full and strong. He passes urine freely, which is not discoloured. A number of flaccid bullæ containing gas and dark fluid have formed on the forearm, and there is a gangrenous odour from the limb.

Mr. Croly drew a line with ink around the forearm, for the purpose of observing the extension of the gangrene.

2nd.-Patient was restless during sleep last night, yet his countenance is not indicative of any distress. Pulse 88, and full. He was ordered a turpentine enema, with tincture of assafoetida, as the bowels were not freed for two days. No tympanites. Continues to enjoy his food, and passes water freely. The gangrene has not extended above the ink-line on the dorsal aspect of the limb, but there are dark streaks above the line marked on the anterior surface. Much of the extravasated blood in the scapular region has been absorbed. Phlyctena on limb larger. Temperature of hand and forearm, 75°

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upper arm,

95°

3rd. Patient passed a tolerably good night. Countenance not so bright or cheerful; face sallow; pulse not so strong, and more frequent. The gangrene has spread about three inches above the ink-line. He could not pass water this morning. Mr. Croly introduced the catheter, and drew off healthy-looking urine.

A consultation was held at twelve o'clock noon, and it was decided that amputation at the shoulder-joint should be performed at half-past three o'clock, which proposal the patient and his friends agreed to.

At half-past three o'clock Mr. Croly visited the patient (who was most anxious that something should be done to give him a chance of his life), but found a marked change for the worse in the short time which elapsed since the consultation at noon. The countenance became anxious, respiration accelerated, with dyspnoea; the pulse was rapid, and the patient seemed partly unconscious.

Mr. Croly at once abandoned the idea of operation. The patient expired at eight o'clock P.M.

AUTOPSY SIXTEEN HOURS AFTER DEATH.

Mr. Croly (assisted by his colleagues Professor Hargrave, Mr. Tufnell, and Dr. Hewitt, and in the presence of the class), made a careful dissection of the shoulder-joint and axillary region in the following manner:

An incision was made, commencing at the centre of the clavicle, and carried in a curved direction to the insertion of the deltoid muscle, and from that point upwards and backwards to the spine of the scapula. On dissecting up the integuments a large quantity of dark-coloured blood was observed infiltrating the subcutaneous tissue. The deltoid muscle, which was largely developed, was reflected upwards so as to expose the joint; large black clots of blood were seen beneath the muscle; the dissection was carefully continued so as to expose the axillary artery and vein. On abducting the arm, an enormous quantity of dark clotted blood was observed, filling the axillary cavity between the subscapular muscle and the ribs. The clots were removed in handfuls, and when the parts were sponged, the axillary artery, at the termination of the third stage of its course, was opened, and a gum-elastic catheter passed through the vessel up to the clavicle, to ascertain if it was wounded. A catheter was also passed through the vein with the same object. The axillary artery and vein were thus carefully examined throughout their three stages, and no lesion of either vessel could be discovered, nor was there any atheromatous deposit in the artery. The subscapular vein (a very large trunk) was found lacerated at its junction with the axillary vein, thus accounting for the hæmorrhage and gangrene. There was not any lesion of the brachial plexus.

On examining the shoulder-joint, the capsular ligament was found divided at its inferior part so fully, that on abducting the arm the head of the humerus could be luxated into the axilla with the greatest facility, the portion of the head of the bone corresponding to the laceration of the capsular ligament, and subscapular vein, presented a well-marked appearance of chronic rheumatic arthritis. | A chisel-shaped osseous stalactite of about an inch in length, was developed on the bone at the internal part of the anatomical neck. The upper arm was infiltrated with serum and blood. There was not any rupture of the muscles discovered, and no trace of the long tendon of the biceps could be found in the joint.

Remarks. The post-mortem examination in this interesting case explained the remarkable facility with which the dislocation was reduced, the joint having exhibited the morbid appearances characteristic of chronic rheumatic arthritis. The chisel-shaped osseous stalactite (an adven titious growth found on the anatomical neck of the hume rus) caused the extensive laceration of the capsular ligament.

This peculiar condition of the joint, and the destruction of the articular portion of the long tendon of the biceps usual in this affection, allowed of unnatural mobility of the head of the bone.

The subject has been recently brought under the notice of the profession in an able article by Dr. Adams in the pages of this Journal.

The sudden and enormous swelling and tension of the entire upper extremity, and the subsequent extensive ecchymosis of the scapular region and the side, were found to be the result of laceration of the subscapular vein (a vessel of considerable size), evidently produced by the sharp ridge on the neck of the bone. The gangrene which soon followed was caused by th venous extravasation, which intercepted the circulation through the limb (venous hæmorrhage being probably a more frequent cause of gangrene than arterial lesion). Being an example of spreading gangrene, in which not any appearance of a line of demarcation was observable, the question of amputation was discussed (a procedure recom mended in such cases by Larrey, Guthrie, and the lat

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