which naturally led my attention to the stomach. During the first few weeks, careful examination detecting no hardness or swelling, and the symptoms not being constantly present, I did not think there was cancer of that organ; but during the last few days, the repeated vomiting of blood, and the great pain and tenderness of the epigastrium, and in that region only, made me express an opinion that there was most probably cancer of the stomach. The difficulty of swallowing, and the vomiting of blood were, however, satisfactorily accounted for by the ulceration and sloughing of the œsophagus and pharynx; but whence arose the marked pain and tenderness exactly over the stomach; which were more complained of by the patient than any other symptom, and existed even at the times when there was a temporary cessation of nausea?

"Looking to the highly-expanded state of the fibres of the right pneumogastric nerve, is it not very probable that the symptoms in question depended upon this circumstance, the pain being referred (as with pressure on the spinal nerves) to the part where the nerves are finally distributed below the seat of pressure and irritation, which would in this case be chiefly the pyloric end of the stomach?

"I think I never saw the larynx so much turned out of its natural course by any tumour, as in this case, and dissection showed us also a cancerous degeneration of the side of the rima glottidis, and an ulcerated opening into the trachea; but yet the difficulty of respiration was never urgent till just before his death, and cough was very little complained of throughout the whole illness. He could always expand the chest freely, and without pain, and the stethoscopic signs showed only bronchitic effusion at the times that the obstruction about the glottis was more marked than usual. In fact, where there has been no pleuritic effusion, and no scirrhous alteration of the pleura, the little distress occasioned by encephaloid tubercles scattered through the parenchyma of the lungs is often very remarkable." 35.

The paper is concluded by some observations on the comparative frequency of scirrhus and encephaloid disease of the thyroid gland. The following is an appendix to the foregoing paper.

CASE OF SCIRRHUS OF THE THYROID GLAND. By R. Wilson
Brown, Esq.

Mr. G, aged 60, of active habits and previous good health, began, in December, 1842, to suffer from uneasiness about the larynx and slight cough and hoarseness, all of which symptoms became aggravated before Christmas. "A hard swelling presented itself in the situation of the left lobe of the thyroid gland. The swelling was not prominent nor welldefined externally, but appeared to extend internally, and press upon the œsophagus, causing great uneasiness, and great difficulty of deglutition. Mr. G. remarked that his throat seemed to be bound, as it were, with an iron hoop. The integuments in the neighbourhood became thickly studded with hard tubercles of a cancerous character.

"Internally the disease continued to make progress, the difficulty of deglutition increased, the cough became more violent, convulsive, and almost incessant, with copious muco-purulent expectoration, streaked with scarlet blood."

He died in June, 1843, after much suffering. The body was examined thirty-eight hours after death.

"The emaciation was very considerable. Numerous hard tubercles were seated in the skin, covering the throat and part of the chest and abdomen. The

seat of the principal disease was in the left lobe of the thyroid gland, which was somewhat enlarged, and converted into a mass of carcinomatous structure, white, hard as cartilage, and with some gritty particles dispersed through it. The chain of lymphatic glands in the neighbourhood, on both sides, had undergone a similar change, and by these the œsophagus was compressed and reduced in diameter, and the larnyx so firmly fixed in its situation, as to prevent any change of its position.

"There was not any ulceration of the inner surface of the oesophagus, nor any communication between it and the trachea. There was some thickening of the epiglottis, but not any disease of the trachea." 39.

Hard carcinomatous tubercles were also found in the lungs, and liver, in the glands surrounding the stomach, and in the skin on the surface of the chest and abdomen.

So few cases of carcinoma originating in the thyroid gland are on record, that these cases are valuable additions to the history of cancer. The disease is not likely to be mistaken for ordinary bronchocele, which is a complaint of early life, whereas carcinoma is usually developed in persons somewhat advanced in age, according to Mr. Hawkins, from the period of forty-five to sixty-five. The tumour too is harder, and has a more irregular surface than a bronchocele, and also makes more rapid progress. Mr. Hawkins states that in the scirrhous tumour the motion of the larynx is itself interfered with, and therefore it not only rises less freely, but respiration and deglutition of the patient are more affected than with most other tumours even when of much larger size. A large bronchocele may, however, seriously interfere with both these functions, so as even to cause death, but such extreme cases are very rare in this country. When the swelling extends laterally, these distressing symptoms are partly occasioned by the restraint of the sterno-cleido mastoideus muscle.

VI. ALARMING SYNCOPE, FROM THE ADMISSION OF AIR INTO A VEIN DURING AN AMPUTATION AT THE SHOULDER JOINT. By Bransby B. Cooper, F.R.S.

Eliz. Cousins, æt. 19, was admitted into Guy's Hospital for malignant disease of the right humerus. Mr. Cooper came to the conclusion that the only chance of saving life was by amputating the limb at the shoulderjoint. On the 23d of May, the operation was performed by making a double flap, the subclavian artery being commanded by presure upon the first rib it occupied less than a minute; there was no loss of blood, and the patient bore it with great fortitude.

"The subclavian artery was immediately secured; but compression was still retained upon the first rib as there were small vessels requiring ligature. I then proceeded to remove a gland from the axilla, which was somewhat enlarged, and while dissecting it from its cellular attachments, I distinctly heard a peculiar gurgling noise, like air escaping with fluid from a narrow-necked bottle, and at the same instant the patient fell into a state of collapse, threatening immediate dissolution: the countenance was deadly pale, the pupils fixed, and inobedient to light; the pulse quite small and fluttering, although at intervals regular; the respiration hurried and feeble, and, at irregular intervals, attended with a deep sigh. The patient was directly placed in the horizontal posture, the flap covered over the wound, and retained by plaister. Cold water was dashed over her face,

ammonia held to the nostrils, and a sponge filled with wine applied to the lips; but an hour elapsed before she was sufficiently recovered to be removed from the Operating Theatre.

"Upon being placed in bed, she passed her fæces and urine involuntarily ;some wine and camphor julep, with half a drachm of laudanum, were given to her. During the reaction coming on, she uttered a continual whining cry, and maintained a constant motion of alternate flexion and extension of the right leg, while the left remained perfectly quiescent. She continually complained of pain, extending up the right side of the head and neck. Her feet being cold, warm bottles were applied, and twenty drops of liq. opii sedativus given. At four o'clock the wound was dressed, when some small vessels were secured, and a nerve liberated which had been included in one of the ligatures and to which, perhaps, the pain in the neck and head might be partly attributed. The edges of the wound were brought together and maintained in apposition by silk sutures and adhesive plaister. Twenty drops of laudanum were ordered to be repeated if necessary.

"Wednesday, eight o'clock, a. m.-When she awoke, all the symptoms were much relieved; pulse 150, small, irregular, and compressible. Tongue moist and white; profuse perspiration over the whole body-keeps her eyes constantly closed. "Two, p. m.-The symptoms much the same as in the morning: still continual action in the right leg, with apparent loss of motion in the left. Pulse 140, feeble-scems inclined to doze, but answers perfectly coherently when spoken to -pupils still somewhat dilated-tongue moist-diaphoresis not so profuse. Beeftea and arrowroot with wine ordered for her, when she desired it, as she takes nourishment freely.

"Eight, a. m., Thursday.-Has had a better night; dozing, but waking up at intervals with a whining cry-continues to keep her eyes constantly closeddiaphoresis less-pulse 140-still irregular and feeble-tongue moist-bowels have not been opened since the operation, but she voids her urine freely-action of the right leg continues; the left still motionless.

"On the 26th the stump was dressed-pus of an unhealthy character exuded from the wound, which, however, at the upper part had united for two inches.

"Her state was variable for the following six or seven days; the nights were restless, and there were occasional febrile exacerbations. The action of the right leg continued, and, on one occasion, there were involuntary flexions of the left, which she had not the power of extending.

"Opium was given freely with much relief, and she was allowed a nourishing diet.

"On June 3d, she was much better, and from that time rapidly improved. Tonics and support of every kind were freely exhibited; the stump continued progressively to heal; and on the 20th day after the operation, the ligature came away from the axillary artery.

"On the 25th day she was able to sit up in a chair and take her dinner. Complains of great numbness and loss of power in the left leg, which she drags after her; but it is as sensitive as the right, and while lying in bed, if pinched, she forcibly draws it up. On the 3d of July, she was sufficiently recovered to leave the hospital, having no other unfavourable symptom than a slight dragging of the left leg." 46.

This patient was re-admitted into the hospital the latter end of November, 1843, for a tumour of the left scapula, of a similar morbid structure to that in the right arm. This tumour increased and destroyed life, by encroaching on the right side of the chest and on the spine, producing paraplegia. She died at the end of January, 1844.

This is a very satisfactory case of recovery from the alarming syncope

consequent upon the accidental introduction of air into a large vein during an operation. The occurrence, though fortunately very rare, is one which the operating surgeon should be prepared to encounter, and to treat with energetic remedies. Mr. Cooper has appended to the above case a brief account of the results of the inquiries made by a Commission, instituted by the Royal Academy of Medicine, to investigate the circumstances of this accident. The author states that, the attention of surgeons was first invited to this subject by M. Beauchêne, but at what date he omits to mention, and adds in a note, " it seems, however, that the fact of an injurious influence from the admission of air into the veins was known to Morgagni as long back as 1517, but had been forgotten, notwithstanding he has related a case." The date must be a misprint probably for 1715, since Morgagni wrote in the eighteenth century, not in the sixteenth. The statement is nevertheless interesting, but would have been more satisfactory if a reference had been given to the authority upon which it is made.

VII. ACCOUNT OF A HORN DEVELOPED FROM THE HUMAN SKIN; WITH OBSERVATIONS ON THE PATHOLOGY OF CERTAIN DISORDERS OF THE SEBACEOUS GLANDS. By Erasmus Wilson, Esq.

Mr. Wilson commences this paper by a description of the mode of production of the sebaceous secretion and its microscopic appearances. He remarks:

"The sebaceous substance is secreted from the blood, through the agency of the cells which compose the epithelial lining of the gland, as is the case probably with all the secretions of the body; but there is this difference between the sebaceous and other secretions, namely, that the former is semi-solid, while the rest are fluid; the solidity or density of the sebaceous matter being due to the great number of empty and more or less distended cells which compose its mass." 53.

The quantity of this matter varies in different individuals as to its density and apparent composition, and its cells undergo changes in accordance with the state of health of the skin, or of the individual, and perhaps also in conformity with the chemical constitution of the blood. Mr. Wilson alludes to two of these changes, one which occurs in molluscum contagiosum, a disease consisting in the development upon the skin of small sebaceous tumours in variable numbers. In this affection the tumour results from the solidity of the contents of the cells of the sebaceous secretion, the solidity being so great as to preserve the form of the distended cells, and consequently to dilate the follicle with the ducts of the sebaceous glands. There is besides, a deficiency of oil globules and of albuminous fluid, and consequently the impacted substance is dense and dry. The contents of the cells in this disease are chiefly coagulated albumen in a granular form. The second modification in the constituents of the sebaceous cells is that which was described by Mr. Dalrymple in the last volume of the Society's Transactions. In this case the sebaceous cells were flattened, having the ordinary appearance of epi

thelial scales, and containing phosphate and carbonate of lime in their interior. The author next alludes to another pathological state consequent on imperfect secretion of the sebaceous substance, in which, from the torpid action of the skin, or from the nature of the contents of the cells, or from both causes acting together, the sebaceous substance collects within the follicle, becomes impacted, and acquires an abnormal degree of density.

"In this situation the impacted mass exerts so great an amount of pressure on the vascular walls of the follicle, as to abrogate its special function, and the peculiar elements of the sebaceous secretion cease to be produced. The formation of epithelium, however, still continues, and layer after layer of epithelial scales are developed, until the mass acquires considerable size. Tumours of this kind, from the nature of the position of the sebaceous follicle, namely, within the corium, rarely acquire a large size as compared with tumours in other situations. They are prevented from pressing inwards by the deep stratum of the corium; the same structure opposes their increase outwardly or laterally. Nevertheless, I have seen a tumour of this kind which measured three-quarters of an inch in diameter, but not more than a quarter of an inch in thickness. The aperture of the follicle remains open, and is more or less distended in proportion to the extent of the tumour; but from the nature of the collection, there is no tendency to its escape. I have called such tumours sebaceous accumulations. Certain minute tumours, commonly met with in clusters around and upon the eyelids, sebaceous miliary tubercles, are of the same pathological nature with the sebaceous accumulations, but in these the excretory follicle is closed.

"The peculiar pathological character of the tumours just described is their laminated texture, and the identity of structure of their contents with epidermis, most, if not all, of the peculiar constituents of sebaceous substance being absent."

"If now, in the cases above recited, we imagine the upper wall of the laminated tumour to be removed, and the accumulated substance exposed to the influence of the atmosphere, any moisture retained by the epithelial lamina would soon become dissipated, and the whole mass would acquire the consistence and hardness of epidermis of equal thickness; in other words, it would be converted into horn.

"Such a case as that which I am now supposing does sometimes in reality occur. The aperture of the follicle acquires an unusual degree of dilatation, and some of the hardened contents of the tumour are pressed through the opening. By the addition of fresh layers from below, (the formative power having increased by the removal of superficial pressure,) the indurated mass is still further forced outwards, dilating the aperture as with a wedge, and finally increasing its size to that of the entire base of the hypertrophied follicle. The process of formation of new epithelial layers by the walls of the follicle (now become the base of the mass) will go on, unless interrupted by surgical means, for years, and in this manner those singular bodies, of which so many remarkable examples are on record, horns, are produced." 59.

Mr. Wilson relates a well-marked example of horn in a female servant fifty-seven years of age. At the age of five-and-twenty, "she observed a small elevation, like a pimple, on the site of the present growth; the pimple increased in size, was somewhat painful, and in about ten years from its first appearance burst, and discharged a quantity of matter resembling mashed potatoe.' From this moment a cavity always remained, from the bottom of which some scurfy' matter could be raised by the finger nail. At the beginning of the current year the present growth made its appearance in the situation of the cavity, and increasing in size, gave