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NOTES ON A CASE OF EMBOLISM ASSOCIATED WITH EXOPHTHALMIC GOITRE.
206 follow his usual employment, and made an urgent request for his discharge, which was complied with. It was evident, on examination, that very considerable regeneration of the removed bone had taken place, and was likely to result in a serviceable, if not very elegant clavicle. The patient was cautioned not to use his right arm any more than was positively necessary, and left the hospital in excellent
ON A CASE OF
EXCISION AND REGENERATION OF THE ENTIRE CLAVICLE. BY JOHN WM.
IRVINE, L.R.C.S. EDIN.,
HONORARY SURGEON TO THE LIVERPOOL DISPENSARIES, AND SURGEON TO WEST DERBY UNION HOSPITAL.
aged sixteen, a wood-turner, residing in admitted into the male surgical ward of Hygeia-street, the West Derby Union Hospital on the 18th of June, 1866, in consequence of serious disease of the right clavicle, the central portion of which was completely exposed. The patient stated that he was attacked with rheumatic fever on April 3rd, and after trying various remedies of popular notoriety, sent on the 10th for my friend Dr. Lodge, who adopted the alkaline method of treatment, and with such success that in three weeks the rheumatic affection had yielded. Unfortunately, however, at that time the boy was seized with local inflammatory symptoms of a very acute character over the centre of the right clavicle. This inflammation was accompanied with almost intolerable pain, and a great amount of swelling. The pain continued steadily, and the swelling increased rapidly until May 13th, when there occurred a spontaneous discharge of a great quantity of pus. Complete exposure of part of the clavicle followed this evacuation of purulent matter, and the boy experienced considerable relief from pain. The pain, however, returned in a few days after the abscess opened, and may be imagined, as to its extent, when I say that the poor fellow got scarcely more than half an hour’s rest at a time up to the date of his admission. The purulent discharge continued, and, according to the boy’s mother’s statement, amounted to more than a gallon. The mischief was attributed to an effort made to lift a very heavy weight, but there was no evidence whatever of any passive violence to the clavicle. On admission the patient was in a very exhausted state, having symptoms of hectic, and a constant purulent discharge from a wound which left an inch and a half of the central portion of the right clavicle perfectly denuded of periosteum, and of a glistening white appearance. He was put upon good diet, and such tonics as were calculated to bear up his strength; but, in spite of all efforts, he continued to lose flesh, and became more and more depressed in spirits, until July 2nd, when abscesses began to show themselves near the sternum and scapula, and I determined to resect the clavicle. Chloroform having been administered, I made an incision over the entire length of the bone, and then, as far as possible, dissected the periosteum from its superficial surface. I then disarticulated the sterno-clavicular end, and so placed a spatula as to elevate the bone, proceeding to further separate the periosteum, which, to my delight, I found practicable without very great difficulty. I found it necessary to dissect with extreme care owing to the painfully perceptible pulsation of the subclavian artery, but with perseverance I managed to remove the clavicle comparatively free from its periosteal covering. During the removal, haemorrhage occurred from seven sources. Three vessels were controlled by torsion, and I found it necessary to apply four ligatures. The wound was brought together by eight wire sutures, the arm was confined at right angles across the chest by means of bandages, and cold water dressings
spirits.
An examination of the clavicle after removal convinced me and every other surgeon who saw it that any operation short of entire extirpation would have proved unavailing. The scapular end of the diseased bone, especially its under surface, was found to be most affected, but the sternal end was considerably disorganised. The articular surface of the sternum
GEORGE W-, was
were
applied.
After the operation the patient was allowed a plentiful supply of porter, beef-tea, nutritious broths, and every dainty which the governor of the workhouse was requested to supply. No secondary haemorrhage occurred, and in a week the scapular end of the wound had healed by the first intention, and the arterial ligatures had been removed. The abscesses which had threatened to point near the sternum and scapula had discharged themselves at the line of incision. The sternal end of the wound, which was healing by the granulating process, had a tendency to gape, but filled up very satisfactorily; the patient being confined to his right side, and havinghis head thoroughly
elevated. On September lst, two months after operation, the entire wound had cicatrised, and the patient had gained more than He had been a stone in weight from the date of operation. able to sit up, and use his arm in playing dominoes, for ten
days past. On
September
20th he
expressed himself
as
quite
able to
was
healthy.
On the 31st of December, six months after operation, I had an opportunity of seeing the patient for the first time after his discharge, and found that he had meanwhile been actively employed at his own business, and had for some weeks been able to use his right arm as perfectly as ever. Occupying the place of the resected clavicle is a new bone, of rather beyond the normal length, and considerably wider, but more flat and thinner, than the original one. This regenerated clavicle plays its part with perfection, allowing the boy to use his arm as efficiently as though no disturbance of the parts had taken place. It is interesting to notice the accuracy with which the limits of attachment of the clavicular muscles can be clearly defined when muscular efforts are made. Very few reports of resection of the entire clavicle are on record, so far as I can learn. Of the few cases mentioned by writers, I find only a single instance similar to the one I have narrated. It is reported in Mém. de l’Academie Roy. de Méd., t. xiv., p. 56, by D’Angerville, who says that Moreau. removed the whole clavicle in a young man on account of necrosis, and had the satisfaction of seeing the removed bone replaced by a new one, which enabled the arm to regain its former usefulness. The original wound in this case, as in mine, healed very quickly. So far as the actual operation is concerned, I consider it right to say that I found no inordinate difficulty in its performance, further than that which was caused by the proximity of important structures, and my desire to preserve the periosteum. Liverpool, Jan. 14th, 1867. NOTES ON
A CASE OF EMBOLISM ASSOCIATED WITH
EXOPHTHALMIC GOITRE.
I,
BY EDWARD
DRUMMOND, M.D. EDIN.,
HOUSE-SURGEON,
COUNTY
HOSPITAL,
YORK.
IN the early part of last year I published in THE LANCET in which embolism occurred, and was diagnosed at the termination of cirrhosis and its consequent dropsy; but in which the embolism did not appear to have been the cause of, or to have accelerated, the fatal issue.* Ithen stated that I regarded it as the attendant accident rather than the cause of death, and that such I believed to be frequently the case. " Death appearing to the physician sufficiently accounted for by other causes, he makes no post-mortem examination, and the embolism escapes detection." I am fortunate in now being able to report a case in proof of this, and one which possesses other points of sufficient interest to warrant my giving a brief statement of it. On the 16th of August last Mary Ann D-, aged twentythree, from the neighbourhood of Malton, was admitted into the York County Hospital, under the care of Dr. Matterson, suffering from exophthalmic goitre. The patient was healthy until four years ago, when she became anagmic, and goitrous enlargement of the thyroid gland took place. She has been ailing ever since, and has derived no benefit from any kind of treatment. Her appearance is very remarkable : she is small in stature and thin; whites of the eyes icteric-looking ; is very voluble as to her case, and seems of somewhat weak intellect; the protrusion of the eyeballs is very marked, and appears due to intraocular pressure ; eyesight unaffected; has considerable at times, especially when there is any increase in the of the neck. This is of considerable hardness at cera case
dyspnœa
I tumour
*
THE
LANCET, vol. i. 1866, p. 457.
207 but is elsewhere soft and elastic. Complains of from which she had suffered for some time prior to the commencement of the goitre; palpitation of the heart for some months; has distinct soft bruit with the first sound, OF THE PRACTICE OF traceable along the great vessels ; second sound muffled; skin cool; pulse 100, weak; bowels regular; urine pale, less in MEDICINE AND quantity than natural, and of specific gravity 1020; is nervous and excitable, but sleeps well-indeed, more than is natural; IN THE appetite good. Ordered a drachm of the syrup of the iodide of HOSPITALS OF LONDON. iron three times a day, and iodine paint to the tumour. She improved for a time. In consequence of an attack of facial neuralgia, she was ordered citrate of iron and quinine in Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum five-grain doses three times a day, and iodide of potassium et dissectionurn historias, turn aliorum, turn proprias oollectas habere, et inter se comparare.-MORGAGNI De Sed. et Cau8. Morb., lib. iv. Proœmium. ointment instead of iodine paint to the tumour.
tain
points,
debility,
(
A Mirror
SURGERY
I
Sept. 7th.—Much worse; has palpitation and precordial pain. To have a saline mixture, with digitalis, and sinapisms to the chest. 10th.—Very ill; evidently sinking ; precordial pain continues ; frottement heard obscurely; bruit still audible. 12th.-Died suddenly at six o’clock this morning. Autopsy fourteen) hours after death.—Thyroid gland enlarged and hypertrophied. Lungs healthy, and free from tubercles. Pericardium inflamed. Flakes of lymph here and
GUY’S HOSPITAL. CASE IN WHICH PERSISTENT PRIAPISM WAS CAUSED BY EXTRAVASATION OF BLOOD INTO THE CORPORA CAVERNOSA OF THE PENIS.
(Under the care of Mr. JOHN BIRKETT.) CASE,’ of persistent priapism are exceedingly rare. Many there on the surface of the heart, whose muscular structure writers on the special diseases of the male genital organs do In the vena cava superior was healthy and firmly contracted. not even allude to the complaint, and in the records of English was a flat thick concretion of unusually large size, moulded to the cavity and partially contained in the right auricle. On surgery there are only two instances. T. V-, a labourer in the country, forty-four years old, opening the right ventricle, a flat concretion of fibrin, four lines in breadth, was found attached to the tricuspid valve, its was admitted into Lazarus ward on the 14th January, 1865. attached extremity being split into two lamellae, which enclosed He stated that he had been suffering from continued priapism between them one portion of the valve; it extended through for ten days. The only statement he made was, that after the ventricle and along the infundibulum into the pulmonary copulation the penis remained permanently erect. During the artery, which it accompanied in its ramifications, branching as first week he felt passionate venereal desires, which subsided, the vessel branched, and constituting a large arborescent con- and have not recurred. The cavernous bodies seemed to be cretion. To the mitral valve was connected a coagulum two the chief seat of the lesion, for the glans penis and corpus inches in length, of a rounded form, about as thick as a goose- spongiosum were not turgid. The man suffered great pain in quill, having a rounded free extremity, and being attached to the part, which was increased by the least attempt at pressure the valve by numerous processes of fibrin. These concretions or depression of the organ. He appeared to be cachectic and were all composed of firmly coagulated fibrin, with masses of much out of health, although he stated that he had not been red blood-clot occupying the interstices between the layers; at all so. There was not the slightest evidence of any disease such being the essential characters of these concretions in in any other organ of his body, each of which was carefully examined, especially the brain. general. In this case the existence of the embolism was not recognised A common embrocation was immediately applied, and two during life; the cardiac affection being apparently but a part days after admission Mr. Birkett introduced a bistoury through of that remarkable group of symptoms to which the French the fibrous tissue of the penis into the cells of the corpora have assigned the term "maladie de Graves,"but which would cavernosa in two places on each side. Dark, thick, blood-like be with more justice associated with the name of Dr. James fluid flowed, resembling that which escapes from a large blood Begbie. swelling when punctured. The whole process of nutrition in this patient had been imJan. 18th. -The penis rather œdematous, especially the paired for years, the blood being poor and deficient in red glans ; pain in the part less ; priapism scarcely altered. 20th.-On the right side the swelling was more than on the corpuscles, and the heart’s action feeble and irregular, maintaining a languid circulation of impoverished and imperfectly left, and there was a distinct sensation of fluctuation. An invitalised blood-conditions under which, perhaps of all others, cision was made, but only the same kind of bloody fluid as concretion of fibrin in the vascular system most frequently before escaped, with a trace of pus. Warmth and moisture happens. As I have already observed, I do not consider that were applied by means of wet lint and gutta-percha. embolism was the cause of death in this case, but was, more 23rd.—More punctures were made on both sides, as the man correctly speaking, a part of the dying process. bitterly complained of pain, and the penis had not diminished Conceiving that these formations might occasionally originate in size. Warmth and moisture continued. the murmurs that attend exophthalmos, I communicated with 27th.-Bloody fluid and a little pus escaped from the puncDr. Begbie on the subject, who, however, informs me that he tures ; less pain in, and diminished rigidity of, the penis. has not before met with the two conditions in conjunction. I Complains of pain in the perineum. During the whole of the therefore regard the case as doubly interesting, as tending to time to which this report refers he passed urine without any illustrate both conditions, and accordingly place it on record. difficulty, and with only slight pain. Feb. 4th.-Not so much pain ; the erection is less, the corJan. 1867. pora cavernosa being no longer rigid and hard, although there ARMY STATISTICS.—The total strength of the army, remains an œdematous state of the glans. Pressure by means of strips of soap plaster employed. There has been very slight January 1 st, 1866, was 200,966 ; effectives, 194,549. The constitutional disturbance. During the early part of this month casualties in a single year amounted to 23,008-viz., 16,086 the man progressed favourably, and was able to leave his bed and the 3519 3403 deaths. In 1864 desertions, discharged, about; but towards the end of it suppuration took mortality in the army at home and abroad, exclusive of the and walk colonial corps, per 1000 strength, was 10’0 in the United place in the left corpus cavernosum. An incision was made into about an inch below the glans, and pus and some sloughs Kingdom, 6’9 in the Mediterranean, 23’1 in British America, it, came away. The finger could be passed into the fibrous cap13’9 in the West Indies, 7’5 in St. Helena, 8’7 in the Cape of Good Hope, 11’7 in the Mauritius, 34’6 in Ceylon, 22’7 in sule, and towards the crus into the perineal region. Strapping Australasia, 45’3 in China and Japan, 19’0 in India, and 11’5 continued. March.-During the whole of this month pus escaped from on board ship. the openings in the sides of the penis, which were carefully JOINT COUNTIES LUNATIC ASYLUM, ABERGAVENNY.— kept open, whilst the sides of the organ were compressed by At a meeting of magistrates of Herefordshire, Hereford City, strips of plaster. Water-dressing was applied over the aperMonmouthshire, Brecknockshire, and Radnorshire, it was una- tures. nimously resolved that it was desirable that the present April.--Suppuration continued, rather profusely at times, asylum should be used by Monmouthshire and Brecknockshire, during this month, and about the middle of it an incision was and that Herefordshire, Hereford City, and Radnorshire should made in the left crus penis behind the scrotum, in order that have a separate asylum. the pus might escape more readily by gravitation. This was
ON A CASE OF
EXCISION AND REGENERATION OF THE ENTIRE CLAVICLE. BY JOHN WM.
IRVINE, L.R.C.S. EDIN.,
HONORARY SURGEON TO THE LIVERPOOL DISPENSARIES, AND SURGEON TO WEST DERBY UNION HOSPITAL.
aged sixteen, a wood-turner, residing in admitted into the male surgical ward of Hygeia-street, the West Derby Union Hospital on the 18th of June, 1866, in consequence of serious disease of the right clavicle, the central portion of which was completely exposed. The patient stated that he was attacked with rheumatic fever on April 3rd, and after trying various remedies of popular notoriety, sent on the 10th for my friend Dr. Lodge, who adopted the alkaline method of treatment, and with such success that in three weeks the rheumatic affection had yielded. Unfortunately, however, at that time the boy was seized with local inflammatory symptoms of a very acute character over the centre of the right clavicle. This inflammation was accompanied with almost intolerable pain, and a great amount of swelling. The pain continued steadily, and the swelling increased rapidly until May 13th, when there occurred a spontaneous discharge of a great quantity of pus. Complete exposure of part of the clavicle followed this evacuation of purulent matter, and the boy experienced considerable relief from pain. The pain, however, returned in a few days after the abscess opened, and may be imagined, as to its extent, when I say that the poor fellow got scarcely more than half an hour’s rest at a time up to the date of his admission. The purulent discharge continued, and, according to the boy’s mother’s statement, amounted to more than a gallon. The mischief was attributed to an effort made to lift a very heavy weight, but there was no evidence whatever of any passive violence to the clavicle. On admission the patient was in a very exhausted state, having symptoms of hectic, and a constant purulent discharge from a wound which left an inch and a half of the central portion of the right clavicle perfectly denuded of periosteum, and of a glistening white appearance. He was put upon good diet, and such tonics as were calculated to bear up his strength; but, in spite of all efforts, he continued to lose flesh, and became more and more depressed in spirits, until July 2nd, when abscesses began to show themselves near the sternum and scapula, and I determined to resect the clavicle. Chloroform having been administered, I made an incision over the entire length of the bone, and then, as far as possible, dissected the periosteum from its superficial surface. I then disarticulated the sterno-clavicular end, and so placed a spatula as to elevate the bone, proceeding to further separate the periosteum, which, to my delight, I found practicable without very great difficulty. I found it necessary to dissect with extreme care owing to the painfully perceptible pulsation of the subclavian artery, but with perseverance I managed to remove the clavicle comparatively free from its periosteal covering. During the removal, haemorrhage occurred from seven sources. Three vessels were controlled by torsion, and I found it necessary to apply four ligatures. The wound was brought together by eight wire sutures, the arm was confined at right angles across the chest by means of bandages, and cold water dressings
spirits.
An examination of the clavicle after removal convinced me and every other surgeon who saw it that any operation short of entire extirpation would have proved unavailing. The scapular end of the diseased bone, especially its under surface, was found to be most affected, but the sternal end was considerably disorganised. The articular surface of the sternum
GEORGE W-, was
were
applied.
After the operation the patient was allowed a plentiful supply of porter, beef-tea, nutritious broths, and every dainty which the governor of the workhouse was requested to supply. No secondary haemorrhage occurred, and in a week the scapular end of the wound had healed by the first intention, and the arterial ligatures had been removed. The abscesses which had threatened to point near the sternum and scapula had discharged themselves at the line of incision. The sternal end of the wound, which was healing by the granulating process, had a tendency to gape, but filled up very satisfactorily; the patient being confined to his right side, and havinghis head thoroughly
elevated. On September lst, two months after operation, the entire wound had cicatrised, and the patient had gained more than He had been a stone in weight from the date of operation. able to sit up, and use his arm in playing dominoes, for ten
days past. On
September
20th he
expressed himself
as
quite
able to
was
healthy.
On the 31st of December, six months after operation, I had an opportunity of seeing the patient for the first time after his discharge, and found that he had meanwhile been actively employed at his own business, and had for some weeks been able to use his right arm as perfectly as ever. Occupying the place of the resected clavicle is a new bone, of rather beyond the normal length, and considerably wider, but more flat and thinner, than the original one. This regenerated clavicle plays its part with perfection, allowing the boy to use his arm as efficiently as though no disturbance of the parts had taken place. It is interesting to notice the accuracy with which the limits of attachment of the clavicular muscles can be clearly defined when muscular efforts are made. Very few reports of resection of the entire clavicle are on record, so far as I can learn. Of the few cases mentioned by writers, I find only a single instance similar to the one I have narrated. It is reported in Mém. de l’Academie Roy. de Méd., t. xiv., p. 56, by D’Angerville, who says that Moreau. removed the whole clavicle in a young man on account of necrosis, and had the satisfaction of seeing the removed bone replaced by a new one, which enabled the arm to regain its former usefulness. The original wound in this case, as in mine, healed very quickly. So far as the actual operation is concerned, I consider it right to say that I found no inordinate difficulty in its performance, further than that which was caused by the proximity of important structures, and my desire to preserve the periosteum. Liverpool, Jan. 14th, 1867. NOTES ON
A CASE OF EMBOLISM ASSOCIATED WITH
EXOPHTHALMIC GOITRE.
I,
BY EDWARD
DRUMMOND, M.D. EDIN.,
HOUSE-SURGEON,
COUNTY
HOSPITAL,
YORK.
IN the early part of last year I published in THE LANCET in which embolism occurred, and was diagnosed at the termination of cirrhosis and its consequent dropsy; but in which the embolism did not appear to have been the cause of, or to have accelerated, the fatal issue.* Ithen stated that I regarded it as the attendant accident rather than the cause of death, and that such I believed to be frequently the case. " Death appearing to the physician sufficiently accounted for by other causes, he makes no post-mortem examination, and the embolism escapes detection." I am fortunate in now being able to report a case in proof of this, and one which possesses other points of sufficient interest to warrant my giving a brief statement of it. On the 16th of August last Mary Ann D-, aged twentythree, from the neighbourhood of Malton, was admitted into the York County Hospital, under the care of Dr. Matterson, suffering from exophthalmic goitre. The patient was healthy until four years ago, when she became anagmic, and goitrous enlargement of the thyroid gland took place. She has been ailing ever since, and has derived no benefit from any kind of treatment. Her appearance is very remarkable : she is small in stature and thin; whites of the eyes icteric-looking ; is very voluble as to her case, and seems of somewhat weak intellect; the protrusion of the eyeballs is very marked, and appears due to intraocular pressure ; eyesight unaffected; has considerable at times, especially when there is any increase in the of the neck. This is of considerable hardness at cera case
dyspnœa
I tumour
*
THE
LANCET, vol. i. 1866, p. 457.
207 but is elsewhere soft and elastic. Complains of from which she had suffered for some time prior to the commencement of the goitre; palpitation of the heart for some months; has distinct soft bruit with the first sound, OF THE PRACTICE OF traceable along the great vessels ; second sound muffled; skin cool; pulse 100, weak; bowels regular; urine pale, less in MEDICINE AND quantity than natural, and of specific gravity 1020; is nervous and excitable, but sleeps well-indeed, more than is natural; IN THE appetite good. Ordered a drachm of the syrup of the iodide of HOSPITALS OF LONDON. iron three times a day, and iodine paint to the tumour. She improved for a time. In consequence of an attack of facial neuralgia, she was ordered citrate of iron and quinine in Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum five-grain doses three times a day, and iodide of potassium et dissectionurn historias, turn aliorum, turn proprias oollectas habere, et inter se comparare.-MORGAGNI De Sed. et Cau8. Morb., lib. iv. Proœmium. ointment instead of iodine paint to the tumour.
tain
points,
debility,
(
A Mirror
SURGERY
I
Sept. 7th.—Much worse; has palpitation and precordial pain. To have a saline mixture, with digitalis, and sinapisms to the chest. 10th.—Very ill; evidently sinking ; precordial pain continues ; frottement heard obscurely; bruit still audible. 12th.-Died suddenly at six o’clock this morning. Autopsy fourteen) hours after death.—Thyroid gland enlarged and hypertrophied. Lungs healthy, and free from tubercles. Pericardium inflamed. Flakes of lymph here and
GUY’S HOSPITAL. CASE IN WHICH PERSISTENT PRIAPISM WAS CAUSED BY EXTRAVASATION OF BLOOD INTO THE CORPORA CAVERNOSA OF THE PENIS.
(Under the care of Mr. JOHN BIRKETT.) CASE,’ of persistent priapism are exceedingly rare. Many there on the surface of the heart, whose muscular structure writers on the special diseases of the male genital organs do In the vena cava superior was healthy and firmly contracted. not even allude to the complaint, and in the records of English was a flat thick concretion of unusually large size, moulded to the cavity and partially contained in the right auricle. On surgery there are only two instances. T. V-, a labourer in the country, forty-four years old, opening the right ventricle, a flat concretion of fibrin, four lines in breadth, was found attached to the tricuspid valve, its was admitted into Lazarus ward on the 14th January, 1865. attached extremity being split into two lamellae, which enclosed He stated that he had been suffering from continued priapism between them one portion of the valve; it extended through for ten days. The only statement he made was, that after the ventricle and along the infundibulum into the pulmonary copulation the penis remained permanently erect. During the artery, which it accompanied in its ramifications, branching as first week he felt passionate venereal desires, which subsided, the vessel branched, and constituting a large arborescent con- and have not recurred. The cavernous bodies seemed to be cretion. To the mitral valve was connected a coagulum two the chief seat of the lesion, for the glans penis and corpus inches in length, of a rounded form, about as thick as a goose- spongiosum were not turgid. The man suffered great pain in quill, having a rounded free extremity, and being attached to the part, which was increased by the least attempt at pressure the valve by numerous processes of fibrin. These concretions or depression of the organ. He appeared to be cachectic and were all composed of firmly coagulated fibrin, with masses of much out of health, although he stated that he had not been red blood-clot occupying the interstices between the layers; at all so. There was not the slightest evidence of any disease such being the essential characters of these concretions in in any other organ of his body, each of which was carefully examined, especially the brain. general. In this case the existence of the embolism was not recognised A common embrocation was immediately applied, and two during life; the cardiac affection being apparently but a part days after admission Mr. Birkett introduced a bistoury through of that remarkable group of symptoms to which the French the fibrous tissue of the penis into the cells of the corpora have assigned the term "maladie de Graves,"but which would cavernosa in two places on each side. Dark, thick, blood-like be with more justice associated with the name of Dr. James fluid flowed, resembling that which escapes from a large blood Begbie. swelling when punctured. The whole process of nutrition in this patient had been imJan. 18th. -The penis rather œdematous, especially the paired for years, the blood being poor and deficient in red glans ; pain in the part less ; priapism scarcely altered. 20th.-On the right side the swelling was more than on the corpuscles, and the heart’s action feeble and irregular, maintaining a languid circulation of impoverished and imperfectly left, and there was a distinct sensation of fluctuation. An invitalised blood-conditions under which, perhaps of all others, cision was made, but only the same kind of bloody fluid as concretion of fibrin in the vascular system most frequently before escaped, with a trace of pus. Warmth and moisture happens. As I have already observed, I do not consider that were applied by means of wet lint and gutta-percha. embolism was the cause of death in this case, but was, more 23rd.—More punctures were made on both sides, as the man correctly speaking, a part of the dying process. bitterly complained of pain, and the penis had not diminished Conceiving that these formations might occasionally originate in size. Warmth and moisture continued. the murmurs that attend exophthalmos, I communicated with 27th.-Bloody fluid and a little pus escaped from the puncDr. Begbie on the subject, who, however, informs me that he tures ; less pain in, and diminished rigidity of, the penis. has not before met with the two conditions in conjunction. I Complains of pain in the perineum. During the whole of the therefore regard the case as doubly interesting, as tending to time to which this report refers he passed urine without any illustrate both conditions, and accordingly place it on record. difficulty, and with only slight pain. Feb. 4th.-Not so much pain ; the erection is less, the corJan. 1867. pora cavernosa being no longer rigid and hard, although there ARMY STATISTICS.—The total strength of the army, remains an œdematous state of the glans. Pressure by means of strips of soap plaster employed. There has been very slight January 1 st, 1866, was 200,966 ; effectives, 194,549. The constitutional disturbance. During the early part of this month casualties in a single year amounted to 23,008-viz., 16,086 the man progressed favourably, and was able to leave his bed and the 3519 3403 deaths. In 1864 desertions, discharged, about; but towards the end of it suppuration took mortality in the army at home and abroad, exclusive of the and walk colonial corps, per 1000 strength, was 10’0 in the United place in the left corpus cavernosum. An incision was made into about an inch below the glans, and pus and some sloughs Kingdom, 6’9 in the Mediterranean, 23’1 in British America, it, came away. The finger could be passed into the fibrous cap13’9 in the West Indies, 7’5 in St. Helena, 8’7 in the Cape of Good Hope, 11’7 in the Mauritius, 34’6 in Ceylon, 22’7 in sule, and towards the crus into the perineal region. Strapping Australasia, 45’3 in China and Japan, 19’0 in India, and 11’5 continued. March.-During the whole of this month pus escaped from on board ship. the openings in the sides of the penis, which were carefully JOINT COUNTIES LUNATIC ASYLUM, ABERGAVENNY.— kept open, whilst the sides of the organ were compressed by At a meeting of magistrates of Herefordshire, Hereford City, strips of plaster. Water-dressing was applied over the aperMonmouthshire, Brecknockshire, and Radnorshire, it was una- tures. nimously resolved that it was desirable that the present April.--Suppuration continued, rather profusely at times, asylum should be used by Monmouthshire and Brecknockshire, during this month, and about the middle of it an incision was and that Herefordshire, Hereford City, and Radnorshire should made in the left crus penis behind the scrotum, in order that have a separate asylum. the pus might escape more readily by gravitation. This was