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during life from leucorrhoea, bearing-down pain, or other troubles usually associated with them; but the fact that the two sometimes, perhaps often, stand in the relation of cause and effect, is a sufficient reason why the uterus should always be examined in every case where the vomiting can not be controlled by general remedies, that any abnormal condition may be rectified by appropriate treatment.-[Boston Journal.
Subcoracoid Luxation of the Humerus, with laceration of the Axillary Artery and Paralysis of the Arm. By T. ROUYER.—(Rev. Méd. Chirurg., Sept. 1855.)-Translated for the Western Lancet, by Dr. KRAUSE.
In May of 1855, the author had the opportunity to observe in the clinical department of Nelaton, a luxation of the humerus with complications so rare, that he regards the case itself, as well as the remarks by Nelaton, worthy of publication.
On the 15th of May a man was admitted to the Hospital des Cliniques, who had received a severe injury 75 days before. A Subcoracoid luxation of the humerus could at once be diagnosed on the left paralyzed arm. The patient, a workman, stated that his left arm when flexed and elevated, had been caught in the turning-wheel of a machine. The wheel pressed his body against the axle-tree and pulled his arm violently. Immediately after the injury he was brought to the hospital of Marly, where the surgeon did, not attempt to replace the dislocated limb until after 22 days. He did however, not succeed even with the power of 10 assistants. During the next eight weeks, neither the position of the arm nor its usefulness had improved. On examination the shoulder was found remarkably flattened. The head of the dislocated humerus could distinctly be felt close under the coracoid process. The acromion appeared very prominent and a depression below it. The anterior wall of the axifla had a less extent, than on the other healthy side. Though some writers set down a prolongation of the anterior axillary wall as a symptom of subcoracoid luxation, the inserting point of the pectorallis major muscle being lowered with the dislocated head of the humerus, yet this sign holds good only for recent luxations. For in old cases the muscle becomes atrophied, the anterior wall of the axilla proportionally shortened. The head of the humerus felt uneven so much so as to render stalactiform deposits of bone on it very probable. In front of the head of the humerus the brachial plexus of nerves was situated, a pressure on which caused stinging pains extending along the arm. In following the course of the arteries down the injured arm the axillary artery was distinctly perceptible from the clavicle to the head of the humerus below which pulsation ceased. It was wanting also in the brachial, radical and ulnar arteries. About the acromion be
neath the skin a large pulsating artery was felt, which was traceable to the middle of the humerus. The whole upper extremity was highly oedematous, the cedema in the axillary region hard and resistant. The arm hung down near the chest, the muscles of the humerus and forearm were paralyzed, only the extensor muscles of the fingers, especially of the thumb, had retained some mobility. This case, therefore, was an instance of a very rare injury. The axillary artery was torn, (?) though no aneurism tumor was present. Instances of laceration of arteries by the luxating power are not common. It takes place much more frequently in consequence of the force applied by the surgeon, particularly in cases of long standing. The artery is either torn completely, or, it happens, that only the two internal membranes are divided, while the external sheath of the artery remains intact in the form of a distended cylinder. The related case seems to range among the latter class. The absence of an aneurismal tumor is very remarkable. Malgaigne has collected 12 cases of the laceration of arteries by powerful attempts at reduction. Among these is a case of Nelaton, occurring to an aged lady with subglenoid luxation of the humerus. The reduction of the recently luxated arm had been easily effected. Soon after, however, a tumor formed in the axillary cavity, gradually increasing in size so as to present the appearance of an aneurism. The ligation of the subclavian artery did not arrest the growth of the tumor; a few days after the operation it burst and proved fatal. The post mortem showed, that the aneurism communicated with the dorsalis scapula, rendering thereby the ligation of the subclavian artery of no avail.
Another very uncommon complication in the case related, is the paralysis of the upper extremity. The paralysis, following luxation did not attract the attention of the profession till after the beginning of this century. Boyer first noticed the paralysis of the deltoid muscle. Paralysis of the whole extremity, however, has been accurately observed but recently. The paralysis as well as the lesion of the arteries, are either brought about by the luxating or reducing power, causing laceration, compression, contusion or excessive stretching of the nerve. Laceration of the nerve is of extremly rare occurrence. It has been observed only a few times in consequence of two powerful attempts at reduction in old cases. Compression of nerves, though mentioned by Van Sweiten and Desault, seems to have been presumed only on theoretical grounds. There is at least not a single instance on record, where it was proven beyond doubt. Contusion and stretching of the nerves is most frequently observed, immediately after the luxating power has ceased to act. The plexus of the nerves or a single branch is stretched beyond measure and contused by the dislocated head of the humerus, and the paralysis is proportionate in degree to the lesion of the nerve. Sometimes the paralysis may have been caused by a power, acting but momentarily upon the nerves in a similar
manner, as paralysis of the arm without luxation falls under observation, subsequent to a fall on or blow at the shoulder.
The question, whether in a case like that reported, anything is to be done, in order to improve the usefulness of the limb, is, indeed, difficult to answer. In regard to the reduction, it is not to be tried for several reasons. The hard oedema of the upper arm indicates that the exudation at this place has organized to such an extent that the reposition of the head of the humerus would be possible only at the expense of an extensive tearing of the soft parts. The other complications present, moreover, the rupture of the artery and the lesion of the nerve, might give rise to more serious accidents, if a very powerful force, as required in all probability, should be brought into action; gangrene of the extremity might even be a consequence. It is likely, that also in this case a spurious articulation will gradually be formed, which will allow a freer use of the limb. The muscles of the arm are completely paralyzed with our patient. Some favorable effect might therefore be expected from the use of Electro-magnetism, if it should become evident, that the paralyzed muscles contract under this stimulus. Without the use of this agent the muscles will probably undergo fatty degeneration. The patient, we are sorry to say, left the hospital after 2 days.
A case of Vesico- Vaginal Fistula, treated with the Button Suture of Dr. Bozeman. By T. WOOD, M. DA
Mrs. C. B.- æt. 26, was brought to bed with her fourth child on the 27th of June last. She was attended by a woman who cannot give any definite account of the labor further than that "it was slow, and that the child's head was in the bones about twelve hours before it was born." The child was still-born. One week after her confinement I was called to see her and found her with a
dry parched tongue, full quick pulse, hot dry skin, and bowels constipated, with a constant dribbling of urine from the vulva, and extensive excoriation of the pudendum and nates from the irritating discharge.
On examination per vaginam the uterus was found intact, with the os tolerably well closed, but the lips were swollen and of a dull florid hue. The entire mucous membrane lining the vagina appeared inflamed, and was very sensitive to the touch of the speculum or finger. A small spot about the size of a dime, at the left side of the median line and about mid-way between the caruncula myrtiformis and the os tincæ, was white and ragged, and at this point the urine could be seen issuing from the bladder into the vagina. Through this point the forefinger passed readily into the bladder, and the white appearance proved to be cellular tissue that had lost its vitality, but was still attached to the living parts.
On inquiry, I learned that the patient had been unable to pass
any urine for about five days after her confinement, and had suffered much from that cause, but it had suddenly burst away, giving immediate relief from the pain of retention, but ever after she was unable to restrain the flow.
The history and examination clearly revealed the nature of the difficulty, and she was at once advised that the only hope of relief was in an operation.
A cathartic was ordered, and a dilute solution of the acetate of lead directed to be thrown into the vagina several times a day. In a few days the sloughing process was completed, and the inflammation of the vagina had disappeared, except around the margins of the fistulous orifice.
From this time her general health improved and she suffered no inconvenience, except the painful scalding from the urine on the skin.
For the purpose of securing efficient attendance I had her admitted into the Commercial Hospital to undergo an operation, and just six weeks from her confinement, the button suture of Dr. Bozeman was applied to the fistula.
For a description of the button suture the readers of the Lancet are referred to the May number of the Louisville Review (page 76), where a valuable article appears, from the pen of Dr. Bozeman, of Montgomery, Alabama.
The various stages of my operation did not vary in any essential particular from the method of Dr. Sims, except in the application of the button suture. After the operation, absolute rest and a low diet were strictly enjoined, and the bowels, which had been freely opened by oil the day before the operation, were quieted by occasional doses of opium. The operation gave rise to no constitutional disturbance, and at each daily visit, until the seventh day, she uniformly replied to inquiries, that she felt perfectly well. On the seventh day, I found her with cold feet and hands, her countenance somewhat flushed, and some pain in the head.
Her bowels had not moved since the operation, and supposing the constipation to be the cause of the headache, I ordered her a dose of oil.
The next day the disturbance in the circulation had disappeared with the operation of the medicine. As no urine had passed through the fistula, after the operation, I felt pretty well assured that the union was complete, and, therefore, removed the sutures, when I found my hopes fully realized. Union throughout the seam, about three-fourths of an inch in length, was perfect and firm.
My main motive in giving this hasty report, is to offer my humble testimony in favor of the ingenious and simple contrivance of Dr. Bozeman. I believe that it possesses many advantages over all other methods that have been recommended, and, in my hands, it has fully justified all that has been said of its talented inventor. [Western Lancet.
On the Prevention of Pitting in Small Pox, by a Strong Solution of Nitrate of Silver. By ALEXANDER ROWAND, M. D., Physician to the Marine and Emigrant Hospital, Quebec.
John Henry Smith, lumberman, aged 20; well proportioned and athletic, was admitted under my care, at the Marine and Emigrant Hospital, Quebec, on the 23d April, 1856. Three days after admission, an eruption of small pox made its appearance, which soon became confluent. Three days after the eruption presented itself, I applied a solution of nitrate of silver all over the face, of the strength of one drachm of the salt to an ounce of water, which was much stronger than I had heard of having ever been employed before. This was done with the view of preventing pitting, which appeared inevitable, from the severity of the disease and its tendency to confluence. For, in addition to high fever and constitutional excitement, the cutaneous inflammation ran a severe course, in some parts assuming an erysipelatous character, terminating in subcutaneous abscesses. The patient experienced a grateful sense of cooling from the application, which also reliev ed the distressing itching, and tension from which he suffered, and he begged earnestly to have the wash again applied. The practice was pursued daily till the 13th May, when it was discontinued. The blackened cuticle now began to peel off, leaving the face perfectly free from pitting, while the hands, in which the disease had been purposely allowed to follow its course, were deeply and numerously scarred.
Other striking and beneficial effects were observed to follow the use of this strong solution, besides the prevention of pittingthe inflammation about the face and head became diminished, and the itching and heat were lessened, whilst the application caused no pain, gave rise to no disagreeable odor, and was not followed by any secondary fever. The patient recovered completely from the disease, and is now a servant in the hospital.
In addition to the above advantages, I believe an important step is attained towards the patient's safety by so materially diminishing the intense inflammatory action about the head, and in such close proximity to the brain; and I am so strongly impressed with its utility in this respect, that I shall apply it not only to the face, but all over the scalp, in all future cases.
Having every reason to be gratified with the result of treatment iu the foregoing case, I mentioned the circumstance to my friend Capt. Reeve, the commandant at Grosse Isle quarantine station, and strongly urged him to recommend a trial of the same plan in the quarantine hospital, when an opportunity should occur.. He did so, and it was accordingly tested in four cases, during the following months of June and July, with the most satisfactory results.
These cases have been reported in the October number of the