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ROYAL FREE HOSPITAL. TUMOUR OF THE TIP OF THE TONGUE, EXISTING SIXTEEN YEARS; INEFFECTUAL USE OF...

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597 WESTMINSTER HOSPITAL. NECROSIS OF THE WHOLE SHAFT OF THE TIBIA IN A BOY, WITH EXTENSIVE IMPLICATION OF THE SOFT STRUCTURES; REMOVAL OF A LARGE SEQUESTRUM; CURE. (Under the care of Mr. HOLT.) IF necrosis is one of the most common affections implicating such bones as the tibia, femur, and humerus, it is an exceed- ingly fortunate circumstance that in the majority of instances the epiphyses, or articular extremities, remain nnaffected. But we do meet with instances of the latter now and then, and amputation offers the only means to save life. The chosen seat of this affection, when a joint becomes involved, is the head of the tibia. Upon this point we quote the following observations from Mr. Stanley’s excellent work on " Diseases of the Bones :’’-" Necrosis is of frequent occurrence in the ca,ncellous texture of the head of the tibia. There appears, indeed, to be something in the structure and function of the head of the tibia especially disposing it to the invasions of dis- ease ; for here, not only necrosis, but also abscess, is frequent; and here, also, the malignant affections of bone are frequently developed."—p. 70. Of necrosis of the femur we saw Mr. Hilton, at Guy’s, in June last, remove portions of the bone from three different sinuses, leading to the lower part of the bone at its posterior aspect, followed by good results. We have witnessed the same result in cases of Mr. Fergusson’s, at King’s, several times. That gentleman removed a large sequestrum from the shaft of the humerus of a boy, a few months back, for disease of some years’ standing. This patient had but one leg, the other having been amputated, so far as we could learn, many years before, for necrosis of the tibia. Mr. Erichsen, last year, at University College, removed the entire ulna, all but an inch of its upper end, from the arm of a woman, for necrosis. We may mention, en passant, that Mr. Jones, of Jersey, removed the ulna, in a state of necrosis, from a patient, with good results (see p. 569 of this volume). Mr. Fergusson and Mr. Partridge, at King’s; Mr. Cock, at Guy’s; Mr. Wordsworth, at the London; Mr. Erich- sen, at University; Mr. Stanley, at Bartholomew’s; Mr. Solly, at St. Thomas’s, and many other hospital surgeons, we have seen, many times, remove either sequestra or portions of diseased bone from the tibia, most generally in chronic cases. In July last, Mr. Cock used the trephine with success in ex- tracting portions of a sequestrum. Three weeks ago, a pecu- liarly interesting case was witnessed in the theatre of King’s College Hospital, of a girl with necrosis of the tibia, from whom. Mr. Fergusson removed portions of the new shell of bone to get at the dead within, in which he perfectly snc- ceeded ; but the greater part of the interior of the shaft of the tibia was filled with a lardaceous substance, of cheesy consist- ence, resembling tuberculous matter, a good deal of which he got rid of, stating at the time that this was an occurrence of great rarity, not having before, in a very extensive experience, witnessed anything of the kind. Not less interesting was a case of elephantiasis, under Mr. Cooke’s care, at the Royal Free Hospital, in which the tibia had been chronically necrosed for many years, with several openings leading to dead bone. Mr. Cooke’s intention was to have removed the dead portions of bone, but the patient would not submit to any operative measures. While on the subject of necrosis, we may mention that we s&w Mr. Fergusson remove, in June last, a large portion of dead bone from the spine of the scapula of a young man, with beneficial results; in fact, as any one may witness for himself who follows the practice of our London hospitals, the abstrac- tion of portions of dead bone is almost invariably followed by the best results. In Mr. Holt’s case, the subjoined brief abstract of which was kindly furnished us by Mr. Alfred Marshall, the house-surgeon to the Westminster Hospital, the boy was sent up from the country to have his leg amputated; and it was one of those which many surgeons, even now, would not have hesitated to remove, without much consideration, so extensive was the disease in its implication of the soft structures, as well as the entire bone itself. Like the preceding case of Mr. Coulson’s, the ankle was apparently inflamed, but in reality not So, and the disease would seem to have depended more upon a scrofulous diathesis. The same form of operation was per- formed as in Mr. Coulson’s case: an extensive incision the whole length over the line of the tibia, and one of the largest sequestra we have ever seen was removed, its socket being formed by the mere shell of bone remaining behind. This has contracted slowly and gradually, the sides of the large wound approximated, and although now and then the granulations were rather exuberant, the process of healing has gone on very efficiently, two or three ulcerated surfaces having yet to skin over, but now quite unconnected with any dead bone. William M_____, aged eleven years, admitted May 28th, 1856. Is an ana?mic boy; has been subject to enlarged glands about the neck for years; general health very indifferent and very much emaciated and worn away. Eight months since, the inner aspect of the left leg near the ankle became swollen, red, and painful. A few days subsequently an incision was made, and pus evacuated of a fetid, sanious character. Since that date several ulcers have formed in the interval between the head of the tibia and the inner malleolus; there are now seven or eight, from which, at different times, about a dozen fragments of necrosed bone have been eliminated. The inner malleolus is not implicated, neither is the head of the tibia. May 3lst.____An incision was made from an inch or two below the knee to a short distance above the ankle, over the line of the tibia, and nearly the whole shaft of that bone was removed, a mere shell only being left behind. Nov. 15th.—Small pieces of dead bone have since come away, one so late as yesterday. The wound has healed, with the ex- ception of two surfaces about the size of half-a-crown, which look healthy, and secrete but a small quantity of bland pus. The boy’s general health is good, and a perfectly satisfactory cure may very shortly be expected. ROYAL FREE HOSPITAL. TUMOUR OF THE TIP OF THE TONGUE, EXISTING SIXTEEN YEARS; INEFFECTUAL USE OF CAUSTICS; REMOVAL BY LIGATURE. (Under the care of Mr. WEEDEN COOKE.) A FORTNIGHT ago we reported a case of tumour of the tongue, removed by Mr. Wood, at King’s College, with success, wherein the disease was supposed to be non-congenital. To-day we give another instance, in which a growth of a totally different character,-most probably an hypertrophy of the muscular structure of the tongue itself,-existed for sixteen years. A microscopic examination would have determined the most in- teresting feature of the case-its intimate structure. We be- lieve, however, that it was hypertrophy of the organ. This condition, without any tenderness or structural disease, gene- rally depends upon an attack of acute inflammation, which may be completely overlooked as the cause producing it. Roki- tansky considers hypertrophy in the voluntary system of muscles, to an extent that would be called morbid, and that would essentially disturb the functions of the part, as extremely rare; he, however, excepts the tongue and a few of the respi- ratory muscles alone. In studying hypertrophy of the tongue, our readers must recollect that it may be limited to its mus- cular substance, to its mucous covering, or to its papillas ; the former variety, as has been already observed by Dr. Gross, of Louisville (U. S.), although sometimes congenital, commonly appears some time after birth, and is now and then witnessed in adults, either without any assignable cause or as the result of glossitis. An histological feature of some interest in the history of hypertrophied papillary muscles especially, is the dichoto- mous division of the primitive fasciculi, which, if carefully traced, are found to terminate in very slender branches ; and very often may be seen an anastomoses of some of the muscular fibres, which are thus dichotomously divided. Anne R-, aged twenty-eight, a healthy young woman, has had a superabundant portion of tongue, the size of a fil- bert, with a broadish base attached to the tip of the tongue, for sixteen years. It distresses her very much; she has under- gone much treatment for it in America, her native place, as well as in this country, to which she came expressly to get it cured. Caustics of various kinds have been employed, but only to distress her. Mr. Cooke proposed to remove it by ligature, to which she acceded. She was accordingly admitted into the hospital; and on the 21st of January, 1856. a needle was passed, carrying silk, through the centre of the base of the growth, which was isolated by tying the silk tightly on both sides of the needle. Perfect death of this part was produced, but from want of power in the patient, total separation did not ensue until after twelve days. The remaining ulcer healed kindly with the use of a borax lotion, and two or three touches with nitrate of silver. She went out greatly pleased, with the intention of returning to her home in America. Save a weakly and somewhat hysterical condition, there was no evidence of £ disease in this patient; there was no scrofula or cancer; and from the exact resemblance of the excessive growth to the rest 597
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Page 1: ROYAL FREE HOSPITAL. TUMOUR OF THE TIP OF THE TONGUE, EXISTING SIXTEEN YEARS; INEFFECTUAL USE OF CAUSTICS; REMOVAL BY LIGATURE. (Under the care of Mr. WEEDEN COOKE.)

597

WESTMINSTER HOSPITAL.

NECROSIS OF THE WHOLE SHAFT OF THE TIBIA IN A BOY,WITH EXTENSIVE IMPLICATION OF THE SOFT STRUCTURES;REMOVAL OF A LARGE SEQUESTRUM; CURE.

(Under the care of Mr. HOLT.)IF necrosis is one of the most common affections implicating

such bones as the tibia, femur, and humerus, it is an exceed-ingly fortunate circumstance that in the majority of instancesthe epiphyses, or articular extremities, remain nnaffected.But we do meet with instances of the latter now and then,and amputation offers the only means to save life. The chosenseat of this affection, when a joint becomes involved, is thehead of the tibia. Upon this point we quote the followingobservations from Mr. Stanley’s excellent work on " Diseasesof the Bones :’’-" Necrosis is of frequent occurrence in theca,ncellous texture of the head of the tibia. There appears,indeed, to be something in the structure and function of thehead of the tibia especially disposing it to the invasions of dis-ease ; for here, not only necrosis, but also abscess, is frequent;and here, also, the malignant affections of bone are frequentlydeveloped."—p. 70. Of necrosis of the femur we saw Mr.Hilton, at Guy’s, in June last, remove portions of the bonefrom three different sinuses, leading to the lower part of thebone at its posterior aspect, followed by good results. Wehave witnessed the same result in cases of Mr. Fergusson’s,at King’s, several times. That gentleman removed a largesequestrum from the shaft of the humerus of a boy, a fewmonths back, for disease of some years’ standing. This patienthad but one leg, the other having been amputated, so far aswe could learn, many years before, for necrosis of the tibia.Mr. Erichsen, last year, at University College, removed theentire ulna, all but an inch of its upper end, from the armof a woman, for necrosis. We may mention, en passant,that Mr. Jones, of Jersey, removed the ulna, in a state ofnecrosis, from a patient, with good results (see p. 569 of thisvolume). Mr. Fergusson and Mr. Partridge, at King’s; Mr.Cock, at Guy’s; Mr. Wordsworth, at the London; Mr. Erich-sen, at University; Mr. Stanley, at Bartholomew’s; Mr. Solly,at St. Thomas’s, and many other hospital surgeons, we haveseen, many times, remove either sequestra or portions ofdiseased bone from the tibia, most generally in chronic cases.In July last, Mr. Cock used the trephine with success in ex-tracting portions of a sequestrum. Three weeks ago, a pecu-liarly interesting case was witnessed in the theatre of King’sCollege Hospital, of a girl with necrosis of the tibia, fromwhom. Mr. Fergusson removed portions of the new shell ofbone to get at the dead within, in which he perfectly snc-ceeded ; but the greater part of the interior of the shaft of thetibia was filled with a lardaceous substance, of cheesy consist-ence, resembling tuberculous matter, a good deal of which hegot rid of, stating at the time that this was an occurrence ofgreat rarity, not having before, in a very extensive experience,witnessed anything of the kind. Not less interesting was acase of elephantiasis, under Mr. Cooke’s care, at the Royal FreeHospital, in which the tibia had been chronically necrosed formany years, with several openings leading to dead bone. Mr.Cooke’s intention was to have removed the dead portions ofbone, but the patient would not submit to any operativemeasures.

While on the subject of necrosis, we may mention that wes&w Mr. Fergusson remove, in June last, a large portion ofdead bone from the spine of the scapula of a young man, withbeneficial results; in fact, as any one may witness for himselfwho follows the practice of our London hospitals, the abstrac-tion of portions of dead bone is almost invariably followed bythe best results.

In Mr. Holt’s case, the subjoined brief abstract of which waskindly furnished us by Mr. Alfred Marshall, the house-surgeonto the Westminster Hospital, the boy was sent up from thecountry to have his leg amputated; and it was one of thosewhich many surgeons, even now, would not have hesitated toremove, without much consideration, so extensive was thedisease in its implication of the soft structures, as wellas the entire bone itself. Like the preceding case of Mr.Coulson’s, the ankle was apparently inflamed, but in reality notSo, and the disease would seem to have depended more upona scrofulous diathesis. The same form of operation was per-formed as in Mr. Coulson’s case: an extensive incision thewhole length over the line of the tibia, and one of the largestsequestra we have ever seen was removed, its socket beingformed by the mere shell of bone remaining behind. This hascontracted slowly and gradually, the sides of the large wound

approximated, and although now and then the granulationswere rather exuberant, the process of healing has gone on veryefficiently, two or three ulcerated surfaces having yet to skinover, but now quite unconnected with any dead bone.William M_____, aged eleven years, admitted May 28th,

1856. Is an ana?mic boy; has been subject to enlarged glandsabout the neck for years; general health very indifferent andvery much emaciated and worn away. Eight months since,the inner aspect of the left leg near the ankle became swollen,red, and painful. A few days subsequently an incision wasmade, and pus evacuated of a fetid, sanious character. Sincethat date several ulcers have formed in the interval betweenthe head of the tibia and the inner malleolus; there are nowseven or eight, from which, at different times, about a dozenfragments of necrosed bone have been eliminated. The innermalleolus is not implicated, neither is the head of the tibia.May 3lst.____An incision was made from an inch or two below

the knee to a short distance above the ankle, over the line ofthe tibia, and nearly the whole shaft of that bone was removed,a mere shell only being left behind.Nov. 15th.—Small pieces of dead bone have since come away,

one so late as yesterday. The wound has healed, with the ex-ception of two surfaces about the size of half-a-crown, whichlook healthy, and secrete but a small quantity of bland pus.The boy’s general health is good, and a perfectly satisfactorycure may very shortly be expected.

ROYAL FREE HOSPITAL.TUMOUR OF THE TIP OF THE TONGUE, EXISTING SIXTEEN

YEARS; INEFFECTUAL USE OF CAUSTICS; REMOVAL BYLIGATURE.

(Under the care of Mr. WEEDEN COOKE.)A FORTNIGHT ago we reported a case of tumour of the tongue,

removed by Mr. Wood, at King’s College, with success, whereinthe disease was supposed to be non-congenital. To-day wegive another instance, in which a growth of a totally differentcharacter,-most probably an hypertrophy of the muscularstructure of the tongue itself,-existed for sixteen years. Amicroscopic examination would have determined the most in-teresting feature of the case-its intimate structure. We be-lieve, however, that it was hypertrophy of the organ. Thiscondition, without any tenderness or structural disease, gene-rally depends upon an attack of acute inflammation, which maybe completely overlooked as the cause producing it. Roki-tansky considers hypertrophy in the voluntary system ofmuscles, to an extent that would be called morbid, and thatwould essentially disturb the functions of the part, as extremelyrare; he, however, excepts the tongue and a few of the respi-ratory muscles alone. In studying hypertrophy of the tongue,our readers must recollect that it may be limited to its mus-cular substance, to its mucous covering, or to its papillas ; theformer variety, as has been already observed by Dr. Gross, ofLouisville (U. S.), although sometimes congenital, commonlyappears some time after birth, and is now and then witnessedin adults, either without any assignable cause or as the result ofglossitis. An histological feature of some interest in the historyof hypertrophied papillary muscles especially, is the dichoto-mous division of the primitive fasciculi, which, if carefullytraced, are found to terminate in very slender branches ; andvery often may be seen an anastomoses of some of the muscularfibres, which are thus dichotomously divided.Anne R-, aged twenty-eight, a healthy young woman,

has had a superabundant portion of tongue, the size of a fil-bert, with a broadish base attached to the tip of the tongue,for sixteen years. It distresses her very much; she has under-gone much treatment for it in America, her native place, aswell as in this country, to which she came expressly to get itcured. Caustics of various kinds have been employed, butonly to distress her. Mr. Cooke proposed to remove it byligature, to which she acceded. She was accordingly admittedinto the hospital; and on the 21st of January, 1856. a needlewas passed, carrying silk, through the centre of the base of thegrowth, which was isolated by tying the silk tightly on bothsides of the needle. Perfect death of this part was produced,but from want of power in the patient, total separation didnot ensue until after twelve days. The remaining ulcer healedkindly with the use of a borax lotion, and two or three toucheswith nitrate of silver. She went out greatly pleased, with theintention of returning to her home in America. Save a weaklyand somewhat hysterical condition, there was no evidence of £disease in this patient; there was no scrofula or cancer; andfrom the exact resemblance of the excessive growth to the rest

597

Page 2: ROYAL FREE HOSPITAL. TUMOUR OF THE TIP OF THE TONGUE, EXISTING SIXTEEN YEARS; INEFFECTUAL USE OF CAUSTICS; REMOVAL BY LIGATURE. (Under the care of Mr. WEEDEN COOKE.)

598

of the tongue, as well as from the ineffectual treatment by caustics, there was no room for doubt that this was nothingbut an abnormal growth of the tissues of the tongue itself.

CENTRAL LONDON OPHTHALMIC HOSPITAL.

FALLING OF THE UPPER EYELID OR PTOSIS, AS AN EFFECT OFPARALYSIS OE THE CHIEF MOTOR NERVE OF THE MUSCLES OF

THE ORBIT; CONDITIONS FORBIDDING SURGICAL INTERFE-

RENCE; CASE ILLUSTRATING WHEN PRACTICAL SURGERY ISADMISSIBLE. CONGENITAL PTOSIS AS CONTRASTED WITH THE

ABOVE. RESULT OF OPERATIONS ON BOTH EYES SYMME-

TRICALLY AFFECTED.

(Under the care of Mr. HAYNES WALTON.)A DISTINCTION has been made between drooping of the eye-

lid, although to an extent that the pupil is concealed, and thatfalling by which it is in actual contact with its fellow. Itwould not be difficult to prove the superiority of including inthe term ptosis, any degree of dropping from whatever causes,and there are several of them. Indeed under any other arrange-ment there must necessarily be much confusion and complica-tion in description. The subject is full of interest, physiolo-gically, medically, and surgically; but in the present instance,however, we intend to confine ourselves to what relates onlyto the practical surgery of it, so far as is required in two verydistinct states-ptosis the result of paralysis, and as a con-genital malformation. We venture to premise a little respect-ing the distribution of the third nerve, which is here so muchconcerned. It supplies the levator palpebras, the superior, in-ferior, and internal recti, and the inferior oblique muscles, and,through the lenticular ganglion, the iris.

In the large majority of cases, paralysis of the third nerve isthe cause of the lid drop, and therefore when it alone is affected,with inability to raise the eyelid, the patient cannot move hiseye upwards or downwards or inwards, and as the externalrectus supplied by the sixth nerve is unaffected, the eyeball isturned outwards. Besides, the pupil is fixed and more or lessdilated. In this state of things, when the lid is raised, andboth eyes are used, vision is double and indistinct. When thesound eye is closed, objects do not appear double, but still in-distinct. Now, it is obvious that, so long as one eye is affected,and the other not similarly implicated, an operation is inad-missible. The cases in which it may be undertaken, of courseonly after the power of medicine is unavailing, are those inwhich the levator palpebræ only is paralysed, the other musclesof the orbit being intact, which is rare, or where the patienthas double ptosis, or but one eye, and that affected.A miserable-looking needlewoman, aged twenty-six, applied

at the hospital to he relieved from the deformity caused byfalling of the eyelid of the left eye, and the hindrance to visionthat it occasioned. Nearly the entire cornea was covered;hence the eye was virtually useless. The levator palpebræwas the only muscle affected, for the eyeball could be usedfreely, nor was the pupil unnatural. When the eyelid was raised, vision proved to be excellent; and there was no double 1

sight. _ _ _ _ _ _ _ _

The history was very unsatisfactory; we could merely learnwith certainty, that at a period probably six years previous,this eye was in all respects like the other, and by a suddenattack the eyelid fell into complete ptosis. In all probabilitythe whole of the third nerve had been implicated; but thiscould not be ascertained. The only additional fact gleanedwas that, after treatment, the eyelid so far recovered that itraised so as to discover a slight portion of the cornea.

Mr. Walton pointed out the peculiar favourableness of thecase for opetation, especially as the patient could, with someeffort, exercise a degree of volition, although slight, on thelevator palpebræ, independently of the secondary effect of theoccipito-frontalis; and as there was not at this period of thecase-nine years since the eyelid had got to its present posi-tion-any other hope for further improvement.The principles of the operation, and certain essentials necessary

for success, are so well and concisely expressed in Mr. Walton’swork, that we quote his own words:-,, The remedial measureis simple ; it consists in taking away a portion of the palpebralskin, the extent of which should be determined according tothe class to which the case belongs. Where there is partialloss of power, the removal of a portion of skin, merely to tuckthe lip up, is sufficient, where the levator palpebræ is motion-less, or nearly so, the lid must be brought under the influenceof the occipito-frontalis, to supply its movements, and for whichit must be more shortened than in the other instance, by theloss of a much larger bit of skin. Under one or other of these

598

r must all cases of ptosis fall which can bf remedied by opera- tion. To ensure success, there should be integrity of the orbi-

cularis palpebrarum, for it is called upon to exercise exagge-rated power to overcome the defect occasioned by the shorten-ing of the lid, and the closure of the eye being principallyeffected by raising the lower eyelid above the ordinary levelto meet the upper. Without that the lids would be more orless permanently open, and the eyeball exposed. Besides thedifference of circumstances in the two kinds of cases to guideus in the amount of skin to be removed, and the varying de-grees of the depression, or falling of the lids, in these classes,the conditions of the skin itself must be taken into account,whether it is unnaturally thickened, or healthy, or loose orbaggy. Of kindred importance also, is the state of the lowerlid, whether lax or tense, and the usual action of the occipito-frontalis of the individual; for, in some persons, it seems

motionless, while in others, its contractions are as remarkable.From inattention to these points must be attributed the un-satisfactory results that are sometimes said to attend the opera-tion. The portion whence the slip is to be taken should be as nearthe edge of the orbit as circumstances will permit, or else theedge, rather than the body of the lid will be influenced. Thedissection should be made with a scalpel; the skin merelyraised, and the orbicularis left as entire as possible, for in pro-portion to its destruction must the power of closing the lids bereduced. "

These details were fully carried out in the removal of anoval strip of skin, and the wound being brought together withfour or five sutures. The union was complete; indeed, italways is in these cases, when cut surfaces are accurately ad.justed. The success was as considerable as such a case admitsof, for the deformity was almost removed, and the patientfully satisfied.

In remarkable contrast to the above is a case of congenitalv ptosis, the cause of which was totally different.

A very fine child, eighteen months old, was sent to Mr.Walton, at the hospital, during the month of October, withsymmetrical falling of both upper eyelids, causing almost, butyet not complete, closure of the eyes. There was total inabilityto move the tarsal cartilages. The occipito-frontalis did notact because of the age of the patient. The recti muscles werein full integrity, and the pupils were natural and acted well;the vision, too, seemed perfect. There was no oscillation ofthe eyeballs. The defect was observed at birth. The childhad already acquired a remarkable habit of holding his headup, and twisting it from side to side to see objects. There wasvery apparent that atropic condition of the eyelids that hasbeen pointed out by Dr. Mackenzie, as due either to the de-ficiency of the levator muscle or wasting of it from disease.Mr. Walton decided to operate on one eye at a time, and, underthe peculiar circumstances, to remove a large portion of skin;also, to take it directly from beneath the eyebrow. The righteye was first done. The degree of elevation was sufficient, andthe occasional examination made by him during the subsequenttwo weeks satisfied him that too much integument had notbeen taken away, as he had seen the eyelids nearly closed.This being a guide, he endeavoured to operate precisely in thesame manner on the left eye; and, so far as we could judge,he effected it, for the child has both eyes open to the samedegree. There is not at present (a month since the last opera-tion) a scar on either eyelid.

Medical Societies.MEDICAL SOCIETY OF LONDON.

SATURDAY, NOVEMBER 22ND, 1856.DR. CHOWNE, PRESIDENT, IN THE CHAIR.

MR. HANCOCK exhibited the femur of a patient, aged twenty-four, from whom he removed the limb at the hip-joint, fiveweeks ago, for necrosis. The patient is now well.MR. ROGERS HARRISON related the case of a healthy man,

who suddenly, after the extraction of a decayed tooth, whichhad kept him awake two nights, fell into a most profoundsleep, which continued two hours. He was quite consciouswhen roused, but was unable to keep awake. He had nottaken chloroform, or any stimulant previously.

Dr. SNOW remarked, that this case showed the importanceof care in arriving at a conclusion. Had this man taken chlo-


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