83Dr. Chowne considered it difficult to say whether her con-

dition, partaking essentially of hysterical characters, mightbe influenced by mental impressions, partly involuntary, butat the same time under morbid impression partly encouraged.

She, in addition to making those references, produced asmall pamphlet, requesting Dr. Chowne to read it, as it re-lated to a case more like her own than any she had seen.

IThis was a memoir of a poor woman stated to have been for

several years dumb, and who, like herself, conversed by point-ing to the letters of an alphabet, and who was many yearsbed-ridden, but to whom ultimately the Lord gave speech."The pamphlet, which is of a religious character, is written inan extremely exciting strain; it was printed in 1848.

Dr. Chowne stated that he regarded this case as being ofan essentially hysterical nature, and one of the class thesymptoms of which are generally complicated, often perplex-ing, and sometimes, if not illusory, actually inexplicable. Hehad watched the case with interest; and although he cer-tainly had not been without surmises, instigated by seemingwant of uniformity between the patient’s representationsand facts which were either visible or within the reach ofreasonable deduction, yet he was not prepared to affirm adecided opinion that those surmises are correct. With re-gard to prognosis, he was the less sanguine as she had beenfor a very long time under the care of physicians distin-guished for great skill. Whether the passive state of themuscles of the arm and leg, the closed jaws, and the silenttongue, are the result of hysteria, or of more formidable dis-ease, or of morbid volition, he considered the facts peculiar,and that they presented subjects of pathological interest.She was subsequently put under the use of magnetism,

administered so as to produce slight sensations and actionsof the muscles; she said that her affected arm and leg acquireda permanent extra warmth and a better state of feeling fromthe use of the current. But no lasting benefit was obtained;and the patient was discharged about six months after admis.sion, without any change in her original state.

ST. THOMAS’S HOSPITAL.

Severe Neuralgia arrested by Surgical Operation.(Under the care of Mr. MACKMURDO.)

THE severe neuralgic symptoms which are sometimesobserved in stumps are well known to practitioners; the latterare at the same time aware how difficult it is to control thepain, such a decisive measure as cutting out the bulbs of thenerves often failing in giving relief. An example of thisobstinate kind of neuralgia was reported in a former Mirror,"(THE LANCET, vol. i. 1852, p. 281,) and we now desire tomention another case of the same nature, but of a muchmilder variety than the first; it will, however, show equallywell that the division of either the trunk or the expansion ofa nerve may be followed by intense neuralgia. Still, as manynerves are thus severed without any unpleasant results, it maybe supposed that either the mode of cicatrization or a

peculiarity of the patient has a large share in the subsequentdistressing nervous symptoms. vVe sincerely hope that thepatient whose case we are going to relate, from the notes ofMr. Crosby, may not have to apply again on account of a re-currence of the neuralgia.

Catherine B-, aged fifteen, of dark complexion, regularfeatures, and intelligent countenance, was admitted into

Lydia ward, Jan. 17th, 1852, under the care of Mr. Mackmurdo,complaining of severe neuralgic pain in the thumb of the lefthand, extending upwards along the arm to the shoulder. Thepatient states that when two years old her brother accidentallychopped off about half an inch of the extremity of her thumb;the parts healed, but, instead of a single nail, two made theirappearance. These continued to grow side by side. Thérehas always been more or less pain in that thumb when it wasused in any exertion, and especially whilst sewing. Variousmeans were employed to relieve the distressing sensations towhich the girl was subject, but with very little result. Atlast (in October, 1851) she was admitted for the first timeunder ..B1 r...Bl.1ckmurdo, seeking relief from the severe pain shewas enduring.The two nails were then of an angular shape, -and pressure

over them caused considerable pain, which extended up thearm and shoulder. Mr. Mackmurdo removed the nails, anddissected off the integument down to the bone, as it appearedto him that the nails were irritating the nervous expansionsituated beneath them. Water-dressing was applied, thewound gradually healed, and the patient left the hospitalentirely free from pain, and expressing much gratitude for the

relief she had obtained. A few weeks after the girl’s dis-charge, the two nails began to grow again, the severe pain re-curred, and she applied for re-admission. Mr. Maekmurdonowthought that the neuralgia might be dependent on uterinesympathy, the patient not having yet menstruated; he there-fore ordered steel and other tonics, with leeches to the breastoccasionally. These means were persevered in for two orthree weeks, but without the least benefit, the pain remainingvery severe. Mr. :1Blackmurdo therefore removed the firstphalanx of the thumb, so as to prevent all possibility of theappearance of any irritating growth. The wound healedkindly, and the patient left the hospital quite well and freefrom any pain.

It has been ascertained by inquiries, that up to the presenttime (about three months having elapsed since the operation)no recurrence of the neuralgic pains has taken place. Mr.

Quekett has examined the ungual phalanx, and found it topresent a carious appearance under the microscope.

It is important to bear in mind, that severe neuralgia mayalso occur from lesion of the nerve by violent inflammation ofthe surrounding parts, which lesion is made worse by thecompression which the nerve subsequently suffers from thethickening of the parts around. We lately saw an exampleof this kind of neuralgia in a patient of Mr. Avery’s, at Charing-cross Hospital. The subject is a young girl, about twentyyears of age, who was attacked with severe inflammation ofthe theca and flexor tendon of the index-finger. Deep in-cisions were made, and on the subsidence of the acute symp-toms, the first phalanx had become strongly flexed upon thefinger, which latter was stiff, painful, and almost useless.The neuralgic pain was very intense, and the loss of powercomplete. These symptoms having lasted some time, Mr.Avery considered it urgent to remove the last phalanx of theindex-finder. This operation, performed at the commence-ment of February, 1852, was followed by great improvementin the symptoms; the neuralgic pains have disappeared, and itmay be hoped that the affection has been subdued by thistimely surgical interference.We noticed very recently a case of some analogy with the

preceding, at Guy’s Hospital. Mr. Hilton removed, June 23,1852, the middle finger of the left hand of a woman, whoseveral years before had wounded the extremity of thatfinger, the injured spot having ever since been the seat ofintense neuralgic pain. The finger was carefully examinedafter amputation, and a distinct fusiform bulb was noticed onone side of the last phalanx, the bone being in the same situa-tion somewhat carious. This woman was so overcome by theinhalations of chloroform, that she remained for four hours

after the operation in a very precarious state, in spite of themost active revivifying means.GUY’S HOSPITAL.

Cases of Amputation at the Shoulder-joint.(Under the care of Mr. COCK and Mr. POLAND.)

IT must be allowed that the capital operations of surgeryhave, since the introduction of anaesthetic agents, lost a greatdeal of their formidable character; for, if we mistake not, theshock of these operations had a large share in the occasionalfatal results by which they were followed. This cause of £failure is now removed, and the principal accidents we haveto guard against are haemorrhage, profuse suppuration, forma-tion of abscess, and necrosis of bone. From the cases whichhave been recorded; and from those which we so frequentlysee in the hospitals of London, we might perhaps infer thatthese untoward circumstances are, in tolerably healthy sub-jects, of rare occurrence; and we suspect that the careful andjudicious dressing, the generous diet, and good ventilation ofwards, have no small share in these favourable results.With these facts before us, it is natural that we should in-

quire whether amputation at the hip joint will ever be per-formed with as many chances of success as is now done forthe shoulder. Perhaps it will; at least we do not see why thecontrary should be the case. No one will, of course, deny thatthe surfaces acted upon are far more extensive hi the latterthan in the former instance; but as the r&ks of the shock arenow removed, it is plain that the two operations are on thesame footing in this respect. The external iliac artery is notmore liable to secondary hsemonhagc than the subclavian,and the cotyluid cavity not more obnoxious to necrc1sis thanthe glenoid; so that the two pathological manifestationswhich would really create hazard at the hip, as comparedwith the shoulder, are, formation of abscesses and profusesuppuration. But careful dressing and attention to diet and

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ventilation would certainly exert as beneficial an influence inhip cases as when the amputation takes place at the shoulder;and thus one might almost venture to predict that operationsat the coxo-femoral articulation will in future days be morereadily performed than hitherto. There is, however, one cir-cumstance which will ever render both amputations (and infact the removal of a great portion of a limb wherever it istaken off) somewhat dangerous-viz., the congestion of in-ternal organs consequent upon the removal of a large portionof the frame. That pneumonia, apoplexy, &c. &c., do not morefrequently follow such operations, is probably owing to theloss of blood inseparable from the ablation of limbs; but thereis sometimes so little lost, that the absence of congestivesymptoms must be partially referred to the drain occasionedby the secretion of pus. At all events, it is plain that thehaemorrhage which accompanies amputation, and the suppu-ration attending upon the healing of the stump, need not belooked upon with apprehension, except the patient be veryweak and exhausted by previous disease.We must in some degree apologize for alluding too largely

to amputation at the hip-joint; but in reviewing the cases ofencephaloid cancer of the upper part of the femur which werereported in a late "Mirror," (THE LANCET,voI.i!. 1852,p. 7-10,)we could not help noticing that removal of the limb at thehip-joint might have afforded a shade more hope as to thenon-recurrence of the affection. Regarding the shoulder,surgeons now do not hesitate one moment when disease oraccident imperatively call for the operation. We merelywish, therefore, in mentioning the following cases, to adducefacts which are likely to strengthen principles of practicealready pretty firmly established. The first case was treatedby Mr. Cock, and from Mr. Pininger’s notes we gather thefollowing particulars :-H. S——, aged 30, a leather-dresser, was admitted July, 12, I

1851, into Luke ward, under the care of Mr. Cock, in conse-quenceofasevere gun-shot wound of his right arm. The patientstates that on the morning of the accident he was shootingrooks, when, having occasion to get over some railings, heplaced his gun (which was loaded, but not cocked) on the innerside of, and leaning against, the railing. When he hadclimbed over the latter, he drew the gun through it by themuzzle, and the trigger, being directed downwards, came tobe partially raised by being pulled against a bar. The gununfortunately went off, and its contents (common shot) passedthrough the man’s right arm, close to the shoulder.Upon examination, the humerus was found completely

shattered, from about half an inch below its head to four inchesdown the shaft; there was extensive laceration of the softparts around the limb, but the axillary artery and plexus ap-peared to have escaped injury. The men who brought thepatient to the hospital said that he had lost much blood; andas the haemorrhage was still going on, Mr. Cock amputated atonce at the scapular articulation, though the man was still ina state of collapse. The operation was speedily completed,the patient being, in the mean time, kept up by the adminis-tration of brandy. The greater part of the deltoid muscle hadbeen destroyed, but a tolerable, although somewhat scanty,flapwas obtained from each side. The margins of the wound werebrought together in the usual manner after the vessels weresecured; and when reaction had set in, half a drachm oflaudanum was given to the patient.The progress of the case was marked by two principal

features-cough and the formation of abscesses: of the latter,some formed about the latissimus dorsi, others in the axilla,and one even about the crest of the ilium; but by good diet,tonics, the successive opening of the purulent sacs, and carefuldressing, the patient left the hospital with a good cicatrix, Iabout three months after the operation. I

Severe injury to the upper part of the Arm by Machinery.Amputation at the Shoulder-joint.

(Under the care of Mr. POLAND.)The following particulars were noted by llr. Morris:—George C-, aged seventeen, a healthy lad, of regular

habits, and employed for some years in a paper factory, wasadmitted October 4, 1851. It appears that whilst the boywas pursuing his occupation at the mill, on the day of admis- Ision, his left hand and arm were caught in the machine, 1

whereupon the wheel completely crushed the arm in itsupper third, tearing the integuments and muscles for someway above that region. There was little or no haemorrhage atthe time, and, after a temporary dressing, he was sent to I,Guy’s Hospital, where he arrived about three hours after the Iaccident. J

On admission, the boy had somewhat rallied from theshock; the arm was unbound, and the following conditionobserved:-The whole of the left upper extremity wasirregularly torn off about the insertion of the deltoid; the bonewas obliquely and jaggedly broken, the integuments on theinner side hanging in long shreds, with the brachial vesselsand nerves exposed to the extent of an inch. On the outerside the integuments and muscles were lacerated and torn offmuch higher up. Immediate amputation was evidentlyunavoidable; and it was determined to remove the remainingportion of the limb at the shoulderjoint, as there was not suffi-cient soft parts to form a covering to the bone if an endeavourwere made to save any part of the head of the humerus.Mr. Bransby Cooper entirely coincided with this view, andtook charge of the subclavian artery during the operation.As much outer flap as could be made was taken from the

deltoid; but there was only sufficient to form one-third of thestump; consequently the inner flap had to be made from thesoft parts of the arm, including the brachial vessels andnerves. After the ligatures were applied to the vessels thepatient was put to bed, scarcely any loss of blood havingtaken place. About three hours afterwards the flaps werebrought evenly together and maintained by eight sutures,with suitable support by means of well-adjusted strips ofplaster. The patient was ordered eight ounces of wine, onepint of porter, and a chop, daily.The case progressed favonrably, without a bad symptom;

the stump was dressed about every fourth day, and great caretaken that no collection of pus should be formed. Thesutures were removed on the sixth day, and the ligaturescame away on the third week; the stump healing, partly bygranulation, and partly by first intention, in the space of onemonth.

’ At the end of the fourth week the boy’s appetite began tofail, he had chilling sensations, and looked pale. As therewere two cases in the ward dying of phlebitis, it was fearedthat the patient might become the subject of this fearfulaffection; he was therefore immediately despatched into thecountry, where he soon regained his failing appetite, andbecame stout and hearty. He presented himself at thehospital two weeks afterwards, in perfect health, and the stumpnearly cicatrized.The next case, treated by Mr. Coulson, will afford an inter-

esting illustration of the dependence of success on the state ofhealth previous to the accident, as also on the age of thepatient. It will likewise be seen, in Mr. Coulson’s case, (aswas observed in the two preceding ones,) that, after accidentsabout the shoulder, the surgeon must take his flaps, notaccording to methodical directions, but do the best he can toform a satisfactory stump from parts often sadly lacerated.

’

ST. MARY’S HOSPITAL.

Injury to the upper part of the Left Arm; Amputationat the Shoulder-joint; Death.

(Under the care of Mr. COULSON.)TnE notes of this case were taken by Mr. Bullock, house-

surgeon to the hospital.E. BL——, aged four years and eight months, who is stated to

have been an unhealthy child, and to have suffered fromchest affection, was admitted at nine A.M., March 8th, 1852,under the care of Mr. Coulson, with a compound comminutedfracture of the left arm. It appeared that the girl had beenrun over by an empty railway truck about fourteen milesfrom the hospital, and was brought up by railway. She was

considerably collapsed, the surface of the body was pale, andthe feet cold; the child was perfectly quiet; she had been sosince the accident; and she had not lost any blood.On examination, a lacerated wound was perceived, which

extended nearly the whole length of the arm on its anteriorand inner surface; the bone was extensively comminuted fromthe elbow-joint (into which the fracture extended) to withinan inch and a half of the shoulder-joint, the muscles beingnearly all torn through, except at the posterior part. Theartery seemed to have escaped; the wound extended nearly upto the acromion process, but the child could move her fingers.No haemorrhage had occurred. At eleven A.31., the littlepatient had somewhat rallied, and amputation at the shoulder-joint was therefore performed, chloroform having been pre-viously administered by Mr. Trotter. No definite mode ofperforming the operation could be adopted, on account of thelaceration of the integuments; the principal flap was made ofthe deltoid, and a smaller inner one was taken from the softparts towards the chest. The subclavian artery was com-