13. ABDOMINAL DROPSY, WITH PREGNANCY.•

We have frequently directed the attention of our brethren to this subject, and we believe we have collected more information on the complication in question than can be found in any other work. We add the particulars of the following case to those already on record.

Mrs. A. aged 40, robust, and the mother of three children, stated that she miscarried on the 15th Jan. 1825, being the third accident of this kind, and always at the end of the third month. Having caught cold at this period, she soon began to feel a fulness of the abdomen, which gradually increased. Though the catamenia continued regular, yet she supposed herself pregnant. On the 11th July, when she applied to Mr. K. she was the size of a woman in the 5th or 6th month of utero-gestation-countenance sallow-urine scanty-bowels costive-shooting pains in the left side-general health not affected. The abdomen became more and more distended, and, by the 1st October, it was necessary to draw off the water, when 27 pints were evacuated. In a short time she was able to do the duties of the house. Still she suffered pain in the left side, and the fluid began to collect in a few weeks afterwards. By the 30th January, 1826, she was as large as before. She now stated that she felt something like the motion of the child, but, from the anasarcous state of the abdomen, it was impossible for Mr. K. to determine the point. The lower extremities were much swelled, and one of them gave way. The catamenia had not returned since June.

On the 11th February, she was suddenly delivered of a small living child, of 7 months. After delivery, the abdomen was very little reduced in size. On the 21st Feb. she complained of general pain in the bowels, short breathing, cough, inability to lie on the left side. She now became affected with hiccup, high fever, black vomit, and all the symptoms of puerperal peritonitis. Yet she struggled through, and got so far recovered as to be able to move about. But the dropsical swelling increased, and, on the 19th of June, she was again tapped. Only one quart could be got to flow, from what cause was then unknown. After this, the patient's health gradually declined, and she died on the 29th June.

Dissection. Thirty-six quarts of water were drawn off by the trocar. On opening the abdomen, an immense sac appeared, covering completely all the viscera. It was easily detached by the fingers, except where it was connected with the broad ligament of the uterus. There it required the scalpel. A great quantity of shreddy matter adhered to the inside of the sac. The ovarium of the left side was enlarged, and enveloped in a mass of hydatids. The right ovarium was not so much enlarged, but equally enveloped in hydatids. The other viscera were healthy. It was now discovered that the trocar had not entered the sac in the last operation. There can be no doubt that the sac was an hydatid.

14. DISEASE OF THE BRAIN WITHOUT CORRESPONDING SYMPTOMS.

When we find disorganization of a part in the dead body, where few or no symptoms revealed its existence during life, we are always surprized; but when this part happens to be the brain, the 'sensorium commune, we are confounded in all our calculations.

A man was received into one of our public hospitals for an accident-a fracture, which got well, or nearly so, in due time, and when he was on the eve of departure, he suddenly expired in his bed, before any assistance could

Mr. Kesson.' Ed. Journal Med. Science, No. 4.

be offered to him. On dissection, all the viscera of the body were sound, except the brain. Here was unequivocal evidence of chronic inflammation of the arachnoid, that membrane being thickened and opake. The pia mater was infiltrated with serous effusion, and more than four ounces of water were found in the lateral ventricles. No symptoms during life indicated the existence or progress of such a disorganization; and we can only account for such a circumstance by the slowness of its march. Instances of this kind are recorded by many observers, and they teach us humility in our prognostic and diagnostic enunciations.

15. EXCISION OF THE HEAD OF THE HUMERUS.

This severe operation has been lately performed by Mr. Syme, of Edinburgh, in the case of a woman, who had a diseased shoulder-joint of several years' standing. The operator made a perpendicular incision from the acromion, through the middle of the deltoid, extending nearly to its insertion, and traversing an old sinus. On introducing his finger, he felt that the disease was almost entirely confined to the head of the humerus; he, therefore, formed, by a semilunar cut, a flap from the scapular portion of the deltoid-exposed the joint-insulated the head of the bone-protruded it-and sawed it off, without any injury to the soft parts. The glenoid cavity of the scapula was found quite sound, except that it was deprived of its cartilage. A portion of the acromion was bare and rough; it was, therefore, removed by the cutting plyers. There was a smart hæmorrhage at first; but the only artery of consequence which was divided was the posterior circumflex. This was compressed with the finger till the operation was finished, and then tied. The flap was now replaced, and retained in perfect apposition by five or six stitches of the interrupted suture. Simple dressings were applied-the whole operation occupying ten minutes. Some fever followed, and was met by proper antiphlogistic measures. Erysipelas and some degree of sinking required stimulants, and the cure went regularly on to a favourable termination. The limb is shortened about an inch, and the shoulder-joint is sus ceptible of distinct motion in all directions by means of its own muscles, while all the other joints of the limb are as serviceable as they ever were. This bold operation is creditable to Mr. Syme, who has thus remedied a disease of the shoulder-joint that had existed for seven years, rendering the arm entirely useless-embittering the patient's life-and threatening to destroy it altogether. This operation, originally performed by Mr. White, of Manchester, and by one or two other surgeons, has, for a great many years, fallen into disuse. Perhaps Mr. Syme's case may excite the attention of surgeons to it once more.-Ed. Journ. July, 1826.

16. WANT OF PERICARDIUM.⚫

There are many cases on record where the pericardium is said to have been wanting; but, as most of these observations were made at a time when inflammations of the heart and its envelops were not much known, it is supposed that many of the cases related by authors, were those of adhesion between the free and reflected sheets of pericardium. This may be true; but still, to assert with Haller, that this error was always committed, is not in accordance with M. Breschet's experience. The following is one of M. Breschet's reasons for questioning the scepticism of Haller.

*Repertoire, No. 1. M. Breschet.

Case 1. A young man, 28 years of age, tall and thin, enjoying habitual good health, was received into the Hôtel Dieu on the 5th Dec. 1825, for a severe intestinal inflammation. He evinced no symptom of any affection of the chest, functional or structural. The abdominal inflammation resisted every measure, and the patient died three days after he was received into the hospital. The symptoms were those of acute dysentery.

Dissection. The coats of the intestines were found thickened and ulcerated. There was no trace of pericardium, the heart appearing free in the left side of the chest. The heart, lungs, and large vessels were carefully taken out, and laid before M. Breschet, who examined them with the greatest care, and avers that the pericardium was completely wanting. It was supported in its place entirely by the vessels which arose from it. The preparation was presented to the Philomathic Society, and examined by many anatomists, all of whom concurred in the statement of Breschet.

Our author cites several cases from former writers, and especially the case related by Dr. Baillie, in support of the opinion which he has given in opposition to Haller.

17. REMARKABLE CASES OF DYSPHAGIA.

1. An interesting case of this kind lately occurred in Guy's Hospital, the patient being a young woman from the country. Her difficulty of swallowing being very great, and yet the œsophagus not presenting any obstruction to the introduction of a bougie, the medical officers had some suspicion of imposture. The young woman had much cough and profuse expectoration, which, with the dysphagia produced rapid emaciation. The patient left the hospital without relief, and soon afterwards died in the country, being literally starved by the inability of swallowing food. The body was examined after death, and the morbid parts shewn by Dr. Burue to the Physical Society of Guy's Hospital, on Saturday night, the 21st October. There was a fistulous communication between the trachea (a little above its bifurcation) and the oesophagus, an inch in diameter, the edges being perfectly cicatrized. There was no disease, either in the trachea or œsophagus. The lungs were tuberculated, and purulent depôts existed there.

The great curiosity of this case is, the possibility of swallowing at all, without a portion, at least, of the aliment, whether solid or fluid, getting into the trachea at each attempt. For our own parts, we believe that some of the aliment did get into the air passage, since it was observed in the hospital, that every attempt to take food was accompanied or followed by great distress-generally by vomiting and coughing. It was argued in the Society, that Nature had made some effort to obviate this accident, in the same way as she does when the epiglottis is destroyed by ulceration, and where the power of swallowing still continues. But the cases are not analogous. The muscles about the rima glottidis have the power of shutting that aperture, when any thing else than air is presented; but this could not have been the case, where a breach was made between the trachea and œsophagus. Our conviction is, therefore, that the dysphagia arose from this very circumstance—namely, the escape of matters from the gullet to the air passage, causing the distress that was complained of. How long this unnatural aperture had existed, could not be ascertained, but we understood that the dysphagia had been complained of for some years. We should suppose that the aperture was caused by ulceration, and remained fistulous afterwards from the transit of matters through it.

2. DYSPHAGIA, WITH ORGANIC DISEASE.

In one of the late sittings of the Royal Academy of Medecine in Paris, M. Kerkaradec presented a curious case of organic disease of the pharynx, with dysphagia. A woman, 60 years of age, of melancholic disposition, was subject to a convulsive action of the pharyngeal and laryngeal muscles, on attempting to swallow food, which threatened suffocation. After spitting out precipitately the first morsels of food, she was then able to swallow pretty well. These attacks were at first separated by long intervals; but these gradually decreased, and a sore throat supervening rendered deglutition of solids almost impracticable. When she did swallow, she was obliged to lie down in the horizontal position. Nothing could be seen in examining the throat, and the disease was considered to be spasmodic; but the poor woman continued to waste away, while a considerable salivation was established by the habit of spitting out for fear of the attempt to swallow the saliva. To the dysphagia was now added a difficulty of inspiration, as if the breath was mechanically impeded. The inspiration was accompanied by a hissing noise. The region of the larynx, on the sides, became rather tumefied, and then the medical attendants began to fear they had something more than spasm to combat. Moxas were applied, and mercurial with

iodine ointments were rubbed on the neck. These and various other remedies were inefficacious, and after four months of impending asphyxia, death kindly put an end to her sufferings.

The larynx was found healthy, except that it was rather narrower than usual at its inferior part. The internal membrane of the glottis was a little red and swelled, and at its upper and posterior part there were whitish vegetations, apparently springing from the pharynx. The pharynx itself was covered with vegetations, so that its lining membrane could not be distinguished. These vegetations had the cauliflower appearance. In the neck were a number of small encysted tumours containing a suetty substance. M. Kerkaradec considered the vegetations and these encysted tumours to be of the same nature, but varying in appearance, in consequence of the different textures in which they were developed. He asked if they were not all of a tuberculous nature? No answer seems to have been given; and the probability, we think, is, that the disease was tubercular.

The above was a case where much benefit would have been derived from a careful introduction of bougies, and a regular application of the solution of nitrate of silver, proportioned in strength to the varying susceptibility of the parts. We wonder that these means were not tried for the relief of the unfortunate patient.

Two other cases of perforation of the oesophagus and stomach were read in the same Society, by M. Léveillé.

Case 1. A man, æt. 22, was bitten in the right hand by a dog which he thought mad. The wound healed, but six weeks after the bite, he was suddenly seized with violent pain in the right shoulder and side of the chest ; sense of suffocation, difficult deglutition, vomiting, delirium and death in the course of the night. On dissection the oesophagus was found perforated, with extravasation into the posterior mediastinum.

Case 2. A man, æt. 55, suffered for a year from occasional syncope, succeeded by constipation and symptoms of disease of the stomach, without, however, vomiting or apparent tumour. Violent pain in the hypochondrium came on, one night; belly distended-death. Dissection. An oval opening on the anterior surface of the stomach, near the pylorus. On the borders

of this perforation were several yellow tubercles about the size of barleycorns, and the contiguous mucous membrane was destroyed. The left auricle of the heart was double its natural size, and from the septum, between it and the right, grew a medullary tumour, forty-five lines in circumference.

18. DIABETES MELLITUS.

Dr. Bardsley, of Manchester, has lately detailed, with great minuteness, a rather interesting case of this disease. The patient was a weaver, 38 years of age, who was admitted into the infirmary making at the rate of 19 pints of sweet urine in the 24 hours. It was attended with the usual symptoms-dry skin, voracious appetite, thirst, pain and weakness in the loins, spongy ulcerated gums, constipated bowels, &c. He was put upon a strictly animal food diet, with drink containing the nitric acid. Leeches were also applied to the loins. By this plan the symptoms were much relieved, and the urine diminished to five or six pints per diem. He thought himself so well that he requested to leave the hospital. In the course of a few months he relapsed, not being able to procure a sufficient supply of animal food. The bleeding plan was then put in force, and a fair trial given to it, but it completely failed. Then Dr. Bardsley had recourse to opium, a grain of which was given three times a day, the diet being the usual run of the house. This also failed. The original plan of animal food diet was accordingly resumed, and steadily persevered in, till the urine was reduced to five or six pints, with very little saccharine quality, and he was ultimately discharged, apparently cured. He returned several times afterwards to make report of his continuance of health.

As far as one case goes, this affords satisfactory evidence of the superiority of the animal food regimen over the other plans of treatment mentioned above. Where there is no unsound organ, as the lungs, we shall occasionally succeed in curing diabetes; but unfortunately it does not often happen that such uncomplicated cases present themselves to our notice.-Ed. Journ. Med. Science.

19. CLINICAL OBSERVATIONS. BY DR. BLAND.*

Case 1. Cerebral Hæmorrhage. On the 29th August, at 7 o'clock in the morning, Jean D——, aged 68 years, was found in the court-yard of his residence stretched out, with his head lower than the rest of his body, being insensible and motionless, his face puffed and livid. He was instantly carried in, and a few minutes afterwards he revived, but with hemiplegia of the left side. When Dr. B. visited him half an hour after this, the facial tumefaction had subsided-the left side of the lips was a little depressedthe tongue inclined to that side—the upper eye-lid, on the left side, drooped, and could not be raised, and that eye was rather dull. He pronounced with difficulty, yet the intellectual functions appeared free. The left side was paralyzed the upper more than the lower extremity. The natural sensibility of the paralyzed parts was unaffected. The pulse was 90 in the minute, and full-the heat natural.

The patient reported that, having been very much constipated, he had strained violently at stool, when he was seized with vertigo, and was unconscious of what occurred subsequently. Bled to 12 ounces, and 20 leeches applied behind the right ear. In the evening, the tongue was more free-the lower extremity less paralyzed, and even the upper extremity; beginning to

Bibliotheque Medicale, Septembre, 1826.