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out pain. There is still some swelling (partly fluid) in theham. No pulse to be felt in the ham nor behind the internalmalleolus of the right leg. Round the knee-joint of the affectedlimb the measurement is fourteen inches and a half; round thesound limb thirteen inches and a half.March lst.-Slight fulness in the popliteal space; veins of

natural size; no pain felt in ham nor in any part of the leg; nopulse to be felt in ham nor behind the internal malleolus. Hewill be discharged in a few days, and recommended for lightduty.

History of the Treatment.-From the 28th of November, 1858,to the 31st of January following, adequate doses, at first ofbitartrate of potash and tartar emetic, afterwards of Epsomsalts and tartar emetic, to act three or four times a day on thebowels, or once a day. Draughts containing tincture of opiumand sulphuric ether. The lotion of the acetate of lead and opiumwas locally applied for the first eighteen days.From the 6th to the 13th of December, pressure by means of

the common tourniquet was occasionally applied to the femoralartery, and the patient was instructed to moderate the flow ofblood through the vessel by occasionally making pressure onthe artery where it crosses the brim of the pelvis. He wasalso directed to remove the tourniquet when he felt it uncom-fortable, and it was never applied during the night-time. Sub-sequently to the 14th of December, nothing of a local naturewas attempted. On the evening of that day, on consultationwith the other medical officers of the battalion, Dr. Dycer andMr. Graves, I decided to tie the artery on the following day;but on its arrival, surgical interference was found to be un-necessary.According to Dr. Alison, everyone who undertakes the prac-

tice of medicine should be prepared to explain the grounds ofhis opinions, and the principles of his practice. (See Intro-duction to Alison’s "Pathology.") I may not be able satis-factorily to comply with the instructions of my teacher, but Ishall try to explain the modes by which the remedies used inthis case may have aided the operations of Nature.

Bitartrate of potash, Epsom salts, and tartar emetic, aresedative evacuants. (See Dr. Billing’s " Principles of Medi-cine.")

Tartar emetic, and some of the neutral salts, are believed topromote the change (the vital chemistry) that takes place inthe capillaries-probably particularly the destructive changeand consequent absorption of adventitious textures. (SeeSimon’s Lectures " On Pathology. ")

Tartar emetic is also believed to possess power as a narcotic,a property sometimes pretty distinctly observed when this me-dicine is given for the cure of delirium tremens according toDr. Graves, of Dublin, and for the cure of some forms andstages of remittent fever, according to my own observations.

Tincture of opium was given as a narcotic, and sulphuricether was given for the antispasmodic virtues it is supposed topossess.The lotion of acetate of lead and opium is believed to be

sedative and astringent.The sedative eliminants, by inducing absorption of portions

of lymph recently effused at the sac, may have caused dis-placement of less-recently effused lymph or blood, and may,in this way, have caused obstruction of the artery; or the in-termittent compression of the femoral may have caused inflam-mation of the artery, and consequent obliteration; or mani.pulation at the sac, which, however, was never rude, or prac-tised with’the notion of its being curative, may have causeddisplacement of a portion of effused blood or lymph, leading toinflammation and obliteration.From the 8th to the 14th of December, there was inflam-

mation at the sac. On the 15th the event of inflammation-effusion of lymph-had occurred, and the obstruction of theartery was complete.Pembroke Dock, South Wales, March, 1859.

HEAT-APOPLEXY.SUMMARY OF A REPORT* OF SIXTEEN CASES IN HER MA-

JESTY’S 19TH REGIMENT, BARRACKPORE.

(Published by permission of the Director-General.)

* By Thos. Longmore, Esq., Surgeon to Her Majesty’s 19th Regiment.

Tns sanitary condition of our troops on duty in hot climateshas lately engaged the most serious attention of the ArmyMedical Department. The solicitude of the Director-General:!:tas been warmly reciprocated by medical officers on duty at

foreign stations, and in no respect have their mutual exertionsbeen more meritorious than in their endeavour to prevent dis-ease, by ameliorating the hygienic condition of the soldier,The importance of peculiar barrack accommodation, and of

dress, in conformity with the requirements of a hot climate, are,in respect to the prevention of heat-apoplexy, proved conclu-sively by the observations of Mr. Longmore, who has recentlyforwarded an able report thereon from the head-quarters ofthe 19th Regt., stationed at Barrackpore. It appears that noless than 16 cases of heat-apoplexy occurred in that regimentat that station, between May 23rd and June 14th, 1858, andMr. Longmore’s report " exhibits the leading facts connectedwith the history, treatment, results, and, in fatal cases, thepost-mortem appearances of all these cases of heat-apoplexy."

With respect to barrack accommodation, " the soldiers of the19th Regt. were quartered in nine different detached buildings,four of them being hired bungalows-an arrangement neces-sarily causing more exposure, and involving less constant super-vision, than if the regiment had been.quartered in an ordinarybarrack." "

This predisposing cause of heat-apoplexy was favoured bythe co-operation of other subsidiary causes of the disease. Thus,"the nature of the duties and habits attached to differentranks is of some interest. Of the 16 seizures, 5 occurred innon-commissioned officers, and 11 in privates of the regiment.No case occurred amongst the commissioned officers." The pro-tection afforded by a dress adapted to a hot climate is, wethink, suggested by the total immunity of the commissionedofficers. These gentlemen wore " solar helmets, while themen wore the ordinary forage-caps." " The suffocating effect ofa confined barrack rather than exposure is indicated by thefact, that "of the privates, 8 were attacked by the diseasewhile within doors, and only 3 while on duty. It should,however, be mentioned that the ordinary number of sentrieswas considerably reduced in the daytime during the prevalenceof the hot weather."7m respect to age.-" 21 years was the youngest, 34 years the

oldest age, at which a seizure took place."Flabits.-" Intoxication does not appear to have acted as an

exciting cause.Date and time of seizure.-" No case occurred at night, and

only 1 in the morning, at eleven A.M. ; 10 cases occurred be-tween two and five P.M.; the remaining 5, between five andhalf-past nine r.M." The direct influence of high temperatureis, therefore, clearly apparent. This conclusion is verified byreference to Mr. Longmore’s " Meteorological Notes." Theweather throughout the period included in the return was ex-cessively hot, sultry, and oppressive. The highest tempera-ture, as indicated by Fahrenheit’s thermometer placed in oneof the hospital wards, varied, at four P.M., from 912° to 97°.About the time that 7 of the cases occurred, the thermometerwas standing at 97° or above, and above 950 at the time when12 of the cases happened. Mr. Longmore remarks: " I amless inclined to attach importance to a degree or two more orless of temperature than I am to the duration of the high tem-perature, and to the dry and rarefied state of atmospherewhich co-existed with it." Thus, " the first heavy fall of rainwhich occurred in conjunction with great electrical disturbanceon the afternoon of the 11th of June, may be said to have puta stop to cases of apoplexy, as it did to the occurrence of re-mittent fever. Only 1 case of apoplexy occurred subse-quently, and this was three days afterwards-on the 14th ofthe month."

! Mr. Longmore proceeds to notice that, of " other diseasesprevalent," fevers were the most common. During the periodin which the cases of heat-apoplexy occurred, there were ad-

mitted into hospital no less than 94 cases of remittent fever.! Of these, 90 were admitted between the 23rd of May and the

llth of June-the day on which the storm appeared to arrestthe progress of the disease. The applications to be relievedfrom constipation were frequent at the same time.The foregoing remarks throw light on the probable causes of

heat-apoplexy: " There can be little doubt that prolongedhigh atmospheric temperature was the essential cause of these

.

attacks, though other causes were associated which determinedtheir occurrence in the particular individuals subjected to them.Nervous depression, resulting either from solar exposure, fromfatigue, or from previous illness, evidently co-operated as a

i cause in some of the cases. Perhaps relative fulness of blood-vessels, in men labouring under nervous depression, may be

one of the conditions predisposing to this disease." " We have

’

already noticed the combined influence of an oppressive dress,; and of close and contaminated barracks, as exciting causes of

heat-apoplexy; and, guided by our knowledge of its etiolosv.

316

we are prepared to anticipate the symptoms, and in some mea-sure understand the pathology, of this disease.Symptoms.-" No case occurred of sudden sun-stroke, or

coup-de-soleil-that is, of insensibility instantly induced bythe direct rays of the sun--in a man previously healthy. Ofthe 16 cases, the attack may be said to have been direct in 11cases-that is, to have come on without other preliminarysymptoms than those of the apoplexy itself; and in only 5cases to have supervened on previous illness. When the attackwas direct, the leading symptoms varied according to its in-tensity. If it were gradual in its advance, then listlessness,torpidity, tendency to lie down, drowsiness, perhaps headache,and desire to micturate frequently, preceded the more gravesymptoms for several hours. If its approach were more rapid,then faintness, sense of great oppression, or sudden pain aboutthe head and chest, vertigo, &c., quickly led to the more urgentsymptoms. In the cases (5) where the apoplexy supervenedon previous fever, the symptoms of the last stage appearedsuddenly, without any preliminary indications of their ap-proach." "Advanced stage of the disease.-" Intense heat of skin, greatly

exceeding that of fever; mania; partial unconsciousness; ex-cited and irregular action of the heart; dixcult 1’espiration;contracted pupils ; convulsions of the extremities ; these

speedily ushering in complete coma and death. In nearly allthe fatal cases there were occasional convulsive muscular move-ments un to the time of death."Mr. Longmore specially calls attention to a symptom, im-portant from its constancy and early manifestation-we meanirritability of the bladder. In the case of Lieut. -Colonel S-," the first thing of which he complained was irritability of thebladder. If this symptom should prove to be a general pre-cursor of the attack, it might be rendered valuable as an indi-cation of the approaching danger, which, by early and propercare, might then probably be averted; and its presence at atime when heat-apoplexy was prevalent would make the sur-geon alert to obviate the more serious symptoms which mightbe expected to follow." The doctrine here implied is that ofthe local warning (symptoms) of disease in operation at, per-chance, a remote distance in the body, and which, being itselffar removed from the scene of its local manifestation, wouldnot appeai- to be the cause of such topical disturbance. Thisdoctrine, in its important relation to diagnosis, is fully enun-ciated in a work just published.* At page 11 of that work,Mr. Gant observes-" Irritability of the bladder, for instance,arising from some morbid condition of the urine, may prove tobe the local warning to an individual, which first directs hisattention to that condition, itself due to a far more grave dis-ease of the kidneys, the stomach, or the nervous system. Hencethe value of many symptoms, which, although themselves com-paratively insignificant, may nevertheless guide us to discoverlatent disease in some distant and hitherto unsuspected organ."

Appearances on examination after death.-" In all the casesmuch the same appearances were presented as if the patientshad died asphyxiated from some cause. Thus excessive engorge-ment of the lungs, amounting generally to complete obstruc-tion of the pulmonary circulation, and, in parts, having all theappearance of true interstitial apoplexy, was most remarkable.The cerebral congestion, less marked in character and less con-stant in amount, seemed to me secondary to the failure of thedue performance of the act of respiration, and, perhaps, re-

sulted from loss of tone in the vessels, and from enfeebledaction of the heart consequent upon the imperfectly oxygenizedblood it was receiving." In conformity with these post-mortemobservations of heat-apoplexy, Mr. Longmore would term thisdisease " heat-asphyxia;" and the treatment which provedmost successful would seem to corroborate this view of itspathology.

Treatment.-" Cold affusion by mussucks of water pouredover the head, chest, and along the spine; counter-irritationby means of mustard poultices to the chest, purgative enemata,and afterwards, when the head remained oppressed, blisteringto the nape of the neck." V ellesection was not found useful,but topical bloodletting seemed advantageous when there wasmuch fulness of the superficial veins about the head and neck.The duration of the disease presented two extremes. " Of the7 fatal cases, 1 died in one hour, and 1 in forty-six hours, afterthe attack."Such are the chief features of Mr. Longmore’s able report.

The observations on which that report is founded were neces-sarily conducted under circumstances of great discomfort, andeven neril. While- therefore. we accept with thankfulness

* The Irritable Bladder; its Causes and Curative Treatment. By FrderiekJ. Gant, :&bgr;I.R.C.S., Surgeon to the Royal Free Hospital.

this meritorious contribution by Mr. Longmore to practicalmedicine, we cannot fail to recognise in his exertions the spiritwhich animates the army medical officers, who, under disad.vantageous circumstances at foreign stations, are faithfullydoing their duty.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et moriorum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

MIDDLESEX HOSPITAL.

EPITHELIAL CANCER OCCURRING IN THE CICATRIX OF A

BURN ON THE ARM, NECESSITATING AMPUTATION AT THE

SHOULDER-JOINT; RECOVERY.

Under the care of Mr. FLOWER.)AMONGST the large number of surgical operations constantly

performed at our hospitals, it may be said that disarticulation.of the shoulder is comparatively rare, as the cases in which it.is required seem to be but few. Those in which we have seenit done were principally for extensive injuries, or the destruc-tion of the limb from hospital gangrene or erysipelas. It has,,however, within the past few weeks, been resorted to for

malignant disease of the arm: in one patient, at St. George’sHospital, for a tumour in the site of a fracture, short details ofwhich follow the present case; in another, for epithelial cancerof the arm in the cicatrix of an old burn. Both cases have.done well so far. The operation, notwithstanding its magnitude,.is generally a successful one, and when required, may be un-dertaken with confidence by the surgeon, speedy recoveryusually ensuing, as in both of the patients whose cases werecord to-day. Whilst Mr. Johnson’s patient is likely toremain free from a return of the disease, on account of its com-plete removal, we fear its recurrence, sooner or later, in Mr.Flower’s patient, from the great amount of glandular diseasewhich was present before the operation.A woman, aged twenty-seven, pale, and delicate-looking,

but said to have enjoyed good health generally, applied at theout-patient department of the hospital, on the 13th of March,on account of an ulcer on the arm. On examination, extensivecicatrices of burns were found over the right arm, shoulder,back, chest, and neck, the result of an accident which occurredwhen she was nine years of age. On the inside of the arm wasan open sore, with elevated, thickened edges, very offensiveodour, and bearing all the characters of epithelial cancer. Itextended from about two inches above the elbow almost to theaxilla, and in breadth occupied nearly one-third of the circum-ference of the limb. The glands in the axilla were enlarged,forming a tumour, over the middle of which the skin hadulcerated to about the size of a shilling; this sore had ragged.edges, and led to a deep cavity, from which a thin, purulentfluid exuded. No enlarged glands to be felt above the clavicleexcept a very small superficial one on the side of the neekybut which was not tender.The history she gave of her complaint was, that four months

ago she observed a small pimple in the dense cicatricial tissueon the inner side of the arm. She poulticed it, ulceration took,place, and the disease gradually extended to its present condi.tion. The glands in the axilla began to enlarge a month ago,and for a fortnight have been discharging. She continued towork at her needle until the condition of the axilla preventedher using her arm, and has had no treatment beyond poultices,not having applied anywhere for medical assistance.On the following day (March 14th) she was admitted into

Laffan ward, under the care of Mr. Flower, and, as the diseasewas advancing rapidly, there was no choice but to remove the-arm at the shoulder-joint, and dissect out the affected glands,