Clinical Review.

ST. GEORGE'S HOSPITAL.

REPORT OF SOME CASES OCCURRING UNDER THE CARE OF MR. HENRY JAMES JOHNSON, Assistant Surgeon.

SOME years ago, I related, in this Journal, several cases of an affection of the Deltoïd Muscle, and made some observations on its nature. Although those observations were founded on the cases I had actually witnessed, they made no claim to absolute originality, a paper being published on the same subject about that time, or just prior to it, in the Midland Journal. As the complaint does not appear to be generally understood, no apology, perhaps, will be considered due, for attention being again directed to it.

It essentially consists in loss of power, more or less complete, in the deltoïd muscle, accompanied with pain in the attempt to use it.

The arm hangs, or is supported by the side. It can be moved, or rather swung, backwards and forwards in a limited degree, but more forwards than backwards. The elbow can be carried to a small distance only from the side, the attempt to elevate it to a horizontal plane with the shoulder, being not only painful, but impracticable. The hand, of course, cannot be raised to the head, nor can it be carried back to the spine, and the want of power to effect these movements is evidently due, in some degree, to pain, felt in the deltoïd, generally at its insertion, and often felt, too, on the front and side of the humerus.

It is clear, on inspection, and indeed from this description, that the deltoïd is the muscle principally concerned. It is usually found to be attenuated, the wasting being in the ratio of the severity of the complaint or its duration. Sometimes one portion of the deltoid is more affected than another; the central and posterior divisions suffer most. Pressure on the muscle gives some uneasiness over its insertion-it may even give pain.

But it is not, in all cases, the deltoid alone that is at fault. Other muscles around the joint may be involved. It would be difficult to particularise them with accuracy. I have found the coraco-brachialis very obviously affected, and have thought that the biceps was implicated.

With the progress of the disease, the wasting of the deltoid extends to the whole limb, the paralysis grows more complete, the shoulder is almost fixed, and the movements of the extremity are limited to those of the hand and fore-arm. The pain ultimately diminishes or disappears, and the use of the shoulder-joint is lost.

So far as I have seen, the subjects of this affection have commonly attained middle life, or passed it. I do not remember having seen a patient under twenty years of age. They are for the most part of a rheumatic or gouty habit, and the general health has been such as might be expected from this circumstance-not absolutely bad, nor very good.

The apparent cause of the disease, is, in most instances, exposure to wet and cold; to that, at least, the patients have attributed it. And such is probably the case, although a predisposition must, I apprehend, be looked for in a gouty or rheumatic constitution. I am led to this opinion, partly from the history of the cases themselves, and partly from this consideration :-Persons of a gouty habit frequently suffer from pain in the shoulder, aggravated by the attempt to bring the deltoid into play, and sometimes even temporarily rendering it useless. Such persons cannot raise the arm, or carry it backwards without actual suffering. No. LXXXII.

M M

The attack lasts for a day or two, or for a much longer period-occasionally, even, for weeks. These persons are also annoyed by fugitive pains in other parts of the body, particularly in the site of the extensor tendons, on the wrist, and on the instep. Their arthritic character is proved by the supervention, in some instances, of a fit of gout or rheumatism, as well as by the general habit of body. The transition from a slight case of this character to the paralysis of the deltoid that I have described is by easy and obvious gradations.

It does not appear obvious why the deltoid muscle should be peculiarly the seat of this affection. It is not more exposed to atmospheric influences than other muscles of the body, nay it is not so much exposed as some, for example, the great pectoral. As I never had the opportunity of examining the state of the limb, after death, I am unable to say what element of the muscle is the one affected. Is it the fascial envelope-or the interstitial and investing cellular tissue of the fasciculi-or is it the muscular fibre itself? Analogy and probability would point to the fascia and cellular membrane. One circumstance should not be lost sight of. The posterior circumflex nerve, a large one, is situated between the muscle and the bone, where it suddenly and profusely subdivides and is lost in the muscle itself. The nerve in its course, and at its subdivision, is immersed in a quantity of cellular tissue. It is difficult to suppose that this anatomical fact exercises no influence in the affection. It is possible that it may in some degree determine the liability of the muscle to the complaint-it is probable that it is the great cause of the extreme pain and the consequent paralysis. If any are disposed to doubt this explanation, they would do well to think of sciatica.

The treatment is, in the main, what would be naturally suggested by the character of the disorder, Persistent pain in any organ, aggravated by the exercise of its ordinary function, is in most cases, a sufficient reason for the employment of counter-irritation. And counter-irritation, actively and resolutely followed up, is what I have found of the greatest service. It is to blister after blister-the tartar emetic, in ointment or in plaister-and, last not least, the moxa, that we must seek, and shall find, the most efficient remedies. Colchicum and the iodide of potassium are of service, in fair and steady doses. We may begin by purging and lowering somewhat, but we must not (for it is useless) pull the patient down too much, and after a while I have found my account in the exhibition of sarsaparilla. The vapour bath, almost always of advantage in this sort of case, may be beneficially resorted to, and, when the pain has subsided, frictions with liniments containing belladonna, electricity, and passive motion should be had recourse to.

I have hitherto said nothing of the exhibition of mercury. Yet, in an early stage of the complaint, when the suffering is acute, and the system strong, calomel and opium (the latter in good quantity) may be given so as to touch the mouth.

The affection is obstinate-the treatment seems, for a time, unsatisfactory-but if carried out judiciously and patiently, it is ultimately, I believe, in most instances, successful. I was formerly less sanguine than I now am, of the issue. The real difficulty is to persuade the patient to submit, long enough, to the counter-irritation, that is requisite. That demands nerve, which some have not, and in them I should apprehend a less fortunate result than is desirable-permanent loss of power of the arm.

I subjoin one or two cases-not enough to bear out all the foregoing remarks, or furnish a clinical history of the affection, but merely those which have lately occurred, under the eyes of the pupils. A reference to one or two others will

close this notice.

CASE.-Sarah Armstrong, married, aged 52, Feb. 15, 1843. Complains of much pain in the left deltoid muscle, on attempting to put it into action. Is unable to raise the elbow in the least, nor can she carry the hand backwards.

The deltoïd is somewhat wasted. The other muscles of the arm appear unaffected, and she has perfect power over the fore-arm and hand.

She has been suffering from the complaint for the last year and a half. She attributes it to cold. She looks thin and rather out of health, but has no prominent general indisposition.

Pil. hyd. c colocynth. gr. v. o. 3tiá nocte.

Infus. gent. 3x. Trae ejusd. 3j.

Magnes bicarb. gr. x. magnes. sulph. 3ss, o. 3tio mane.

Emp. canths. humero.

25th. No relief from the blister.

Emp. belladonna humero. Adde misturæ vin. colchici. m x.
P. c pil.

March 1st. Rept. emp. lyttæ.

11th. Mouth rather sore from pills-shoulder no better.

B. Pot. iodidi, gr. v.

Dec. sarza co. 3ij. bis die.

Ext. col. co. gr. x. p. r. n.
Rept. emp. belladonna.

April 18th. Suffers more pain in shoulder, and is worse altogether than she was-she is to have electricity applied to the shoulder twice a week.

23rd. Electrified to-day for the first time, as she did not like the idea of it before much debility.

Haust. quinæ bis in die.

Ext, col. co. gr. x. p. r. n.

May 23. Has had electricity applied, but, at present, without benefit.

June 3. Can raise her arm a little, and but a little, from the side now. The moxa to be applied, so as to produce a superficial eschar.

24th. Much improved-has an ulcer on the front of shoulder, from the moxa, which discharges freely.

July 1. Can raise her hand to her head now, but cannot carry it backwards. P. c moxa.

22nd. Can carry her hand back a little way behind her head. P. č moxá. The patient continued to attend up to the 9th September. Her general health was pretty good, but she had gone on taking the quina, as she was very weak. The power of raising the arm was, in a great degree regained; she could carry it much better, but not well, backwards and upwards. She complained much of general debility and looked out of health. Being so far recovered, she took a great dislike to the longer application of the moxa and discontinued her attendance.

The above case has been reported just as it was recorded in the out-patient book. Nearly at the time at which it was under my care, there was another female, of middle-age, with the same affection of the right shoulder. She derived great benefit from two applications of the moxa, when, alarmed at it, as very many people are, she too ceased to attend.

One of the most striking cases which has occurred to me was that of Colonel C. He had been exposed to weather in Ireland, and was of a family proverbial for gout. The left shoulder was first affected, and in spite of very active treatment, the use of that arm was temporarily lost. The other shoulder was then attacked, and the right arm, also, became paralysed. By long-continued counter-irritation, medicines adapted to the gouty diathesis, and a prolonged employment of vapour and shampooing baths, he gradually regained the power of the limbs, and when I saw him, the other day, had scarce a trace left of the complaint.

II. CASE OF CYST, CONTAINING GLAIRY FLUID ON THE GUM.

Ann Downey, aged 46, married, with three children, Nov. 4th, 1843. Cyst the size of the end of the thumb on the outer and upper surface of the lower jaw, occupying the places of the right canine and two bicuspid teeth. She has had it for six months, and it is increasing in size. The bicuspides have been drawn-the stump of canine tooth left-no teeth exist behind the cystgeneral health good. This began to form shortly after having had a tooth extracted. Having punctured it with a grooved needle, and let out some yellowish glairy fluid, I passed a curved needle, armed with strong silk, through the cyst, and the ligature thread was loosely tied in, so as to act like a seton. 7th. Discharge of sanguineo-purulent matter from the interior of the cyst-no pain.

21st. Seton-thread removed, for stump of canine tooth to be extracted—which was done.

28th. Cyst still discharges, but much reduced in size, and the walls seem thickened-gum tender where tooth was drawn.

Dec. 8th. Seton-thread re-applied.

Feb. 14th. Continued seton in cyst till to-day, when it was withdrawn, as the cyst had quite disappeared, and its former situation was only marked by a line of thickening in the course of the thread. She subsequently presented herself well.

The case resembled ranula, in the character of the cyst, and the appearance of the fluid, save that it was yellower. It was treated with success, by what generally answers best for ranula-the seton.

III. RUPTURE OF THE INTER-ARTICULAR FIBRO-CARTILAGE BETWEEN THE LOWER EXTREMITIES OF THE RADIUS AND ULNA.

This is not, so far as I am aware, a common accident. I have seen only two cases of it. The following presented itself at the hospital-the other occurred in private practice.

Case 1.-Ann Sargeant, aged 62, March 8, 1844. Five weeks ago she fell, with her whole weight, on her right hand. The hand "dropped" immediately after the accident, and was quite useless. Inflammation about the wrist supervened, but subsided after a week's surgical treatment. She is unable now to use her hand in the least degree, and there is considerable swelling remaining, as of effusion into the sheaths of the flexor tendons of the wrist. The shafts of both radius and ulna are perfectly entire, but there is unnatural mobility forwards and backwards of the lower ends of the ulna. The carpal extremities of the radius and ulna are separated from each other, the former projecting forwards, and the wrist presenting very much the appearance of oblique fracture of the lower end of the radius. To have Scott's bandage firmly applied to the wrist. Ext. col. co. gr. v., p. r. n.

28th. Hand feels stronger, and she can use it a little. Scott's bandage still firmly applied.

April 20th. Much more power over her hand-still keeps the bandage on. May 4th. Has removed the bandage, and uses her hand freely, but cannot lift anything very heavy with it. To pump cold water over it every day, and subsequently employ friction, with a stimulating liniment.

She did not attend any more, but she was accidentally seen a week or two ago. The wrist was still weak-the deformity inconsiderable.

Case 2.-A gentleman, when hunting, was thrown from his horse, and fell on

the right hand and arm. He applied to the nearest surgeon, who examined the wrist, and pronounced that there was no fracture nor dislocation. On that evening, or the next day, he was seen by the family-surgeon, who considered that a fracture of the radius had occurred. He immediately came up to town to put himself under my care. When I saw him, the fore-arm and the wrist were so swollen, that it was inexpedient to meddle with the limb, and impossible to determine the nature of the accident. It had the aspect of oblique fracture of the lower end of the radius. By leeches and cold lotions the tumefaction was reduced in the course of a few days, and I was enabled to make an examination.

As in the former case, the lower end of the radius projected forwards, and this it was that occasioned the peculiar resemblance to oblique fracture of the lower end of the radius, where a projection always exists on the palmar aspect of the wrist. But the distinctive feature of the case was the prominence backwards of the lower end of the ulna, and its unnatural mobility. This proved, or seemed to prove, that the great bond of union between it and the radius, the inter-articular fibro-cartilage was torn. There was no fracture of bone.

With splints, bandages, and after three or four weeks' passive motion, with cold douche, and friction, all deformity was obviated, the ruptured cartilage appeared to unite, and perfect command of the wrist was restored.

I presume it must be admitted that, in these cases, the nature of the accident was such as I have supposed it to be. If so, the characteristic symptoms will be, great swelling-projection, towards the palmar aspect of the fore-arm, of the radius-unusual mobility of the lower end of the ulna.

IV. CACHECTIC ULCERATION OF THE TONGUE.

The following is a not uncommon sort of case. It is occasionally mistaken for secondary venereal ulceration, and is probably confounded at times with malignant changes of structure.

Case. Richard Green, aged 43, Dec. 6, 1843. The tongue is red, glazed, and irregularly fissured the median line is occupied by a deep ravine of ulceration. The largest ulcer is situated on the right side of the tip of the tongue, not very deep, and of a yellowish brown colour-great induration surrounding the ulcers -that on the right side of the tip of the tongue is as large as a thumb-nail. There is not much pain-the articulation is thick, and the tongue feels too big for the mouth. General health tolerable, but has a cachectic aspect. The complaint began gradually three months ago. Has not had syphilis-has taken some mercury at different times.

Ext. col. co. gr. v. o. n.

Haust. potassii iodidi bis die.

9th. Speaks better, and ulcers look improved.

Perstet.

Lotio zinci sulph. gr. ij. ad 3j. pro linguá.

19th. Ulcer nearly healed-less induration. P.

29th. Great improvement.

Jan. 1, 1844. Ulcer at right side quite healed-considerable indurationtongue glazed, very moist, and clean.

Perstet.

12th. Ulcers healed-less induration-tongue irregular, but not so red and glazed.