Mr. Toynbee adds;-"It must appear remarkable that, in thirty-nine specimens of the organ of hearing, taken promiscuously, there should be so large a majority which present appearances indicative of disease. I must observe, however, that in several dissections, and more particularly those in which there exist delicate membranous bands, connecting together various portions of the mucous membrane, without the latter being thickened, the deviation from the healthy state is so very slight, that it may be presumed there was not any accompanying derangement of the functions of the organ. The large proportion of specimens which are undoubtedly in a diseased state is very surprising, but it may be less so perhaps when I state that many persons whom I have examined, and who have considered that they hear perfectly well, cannot distinguish the ticking of my watch at a distance of two feet and a half, and in some cases, of four or five inches only; though the same watch can be heard distinctly by a healthy ear seven or eight feet from the head. I am thus induced to believe that the function of the ear is impaired much more frequently than is generally supposed; but that such impaired function is not detected without special inquiry. It would be interesting to know whether such derangements are dependent upon the peculiar conditions of the investing membrane of the tympanic cavity, which I have had ocasion so frequently to notice in my relation of the above dissections."

"Since the above Paper was read, my attention has been directed to a paper published in the 110th volume of the Philosophical Transactions, entitled, "On Sounds inaudible by certain Ears, by William Hyde Wollaston, M.D., F.R.S.' The object of the author is to show that there is a very distinct and striking difference between the powers of hearing of different individuals. I am inclined to believe that the deficiency of the power depends upon some pathological condition of the ear, perhaps of a nature similar to that which I have pointed out. Dr. Wollaston states that it never occurred to him to find this defect in any person under twenty years of age-a fact which favours the opinion of its being dependent upon disease or derangement of the organ." 211.

From what we know of Mr. Toynbee, we are satisfied that whatever subject he takes up, he will do ample justice to. We may expect some additions to our knowledge of the pathology of the ear.

XV.

TWO CASES OF DISLOCATION OF THE TENDON OF THE LONG HEAD OF THE BICEPS HUMBRI FROM ITS GROOVE. By John Soden, Jun., esq., Surgeon, Bath.

Case 1-In May, 1839, J. Cooper was engaged in nailing down a carpet, when, on rising hastily from his occupation, his feet slipped, and he fell backwards on the floor; in order to break the force of his fall, he involuntarily placed his arm behind him, and, by so doing, received the whole weight of his body upon the right elbow; that joint, however, though the only part struck, received no injury, for the shock was instantly transmitted to the shoulder, and there the whole effects of the accident were sustained.

Acute pain was immediately experienced, and the man supposed that he had suffered either a fracture or dislocation, but, finding that he could raise the arm over his head, he felt re-assured, and endeavoured to resume

his work. The pain, however, compelled him to desist, and he went home. When Mr. Soden saw him on the following morning, the joint was greatly swollen, tender to the touch, and painful on very slight motion; there was then no possibility of his placing his arm over his head, as he said he had done immediately after the accident. Mr. S. thought the case one of severe sprain. Unusually active means were required to subdue the inflammation, and, at the end of three weeks, though the swelling was much reduced, the tenderness in front of the joint, and pain on certain movements of the limb, were scarcely less than on the day after the occurrence of the accident.

On comparing the joint with its fellow, now that the swelling had subsided, a marked difference was observable between their respective outlines; the injured shoulder was evidently out of drawing, but without presenting any glaring deformity. When the man stood erect, with his arms dependent, the distinction was very manifest, but difficult to define there was a slight flattening on the outer and posterior parts of the joint, and the head of the bone looked as though it were drawn up higher in the glenoid cavity than it should be. Examination verified this appearance in two ways: 1st, on moving the limb, with one hand placed upon the shoulder, a crepitating sensation was experienced under the fingers, simulating a fracture, but, in reality, caused by the friction of the head of the humerus against the under surface of the acromion; 2ndly, on attempting abduction, you found that the arm could not be raised beyond a very acute angle with the body, from the upper edge of the greater tubercle coming in contact with that of the acromion, and thus forming an obstacle to all further progress. The head of the bone was also unduly prominent in front, almost to the amount of a partial dislocation.

For all useful purposes the arm was powerless-the man was unable to raise the smallest weights from the ground, on account of the severe pain induced by any exercise of the biceps muscle; otherwise, the underhand motions were not limited, the arm could be readily swung backwards and forwards, and the patient could grasp an object firmly, and without pain, so long as he made no attempt to raise it. The locking of the humerus and acromion on abduction, in the manner before alluded to, of course formed an insuperable opposition to all the overhand motions.

The pain caused by the action of the biceps was described as very acute, and extending through the whole course of the muscle, but felt chiefly at its extremities, the lower equally with the upper; when not excited by muscular action, it was referred to the front of the joint, and confined to the space between the coracoid process and the head of the humerus, which spot was marked by extreme tenderness and some puffy swelling.

The patient being of a rheumatic habit, inflammatory action of that character was soon established in the joints, so that the peculiar symptoms of the injury were masked by those of general articular inflammation, which added greatly to the man's sufferings, and materially augmented the difficulty of the diagnosis.

On Nov. 9, 1839, the patient met with a compound fracture of the skull, and died.

On examining the joints, the accident was found to be a dislocation of the long head of the biceps from its groove, unaccompanied by any other

injury. The tendon was entire, and lying enclosed in its sheath on the lesser tubercle of the humerus; the capsule was but slightly ruptured; the joints exhibited extensive traces of inflammation; the synovial membrane was vascular and coated with lymph; recent adhesions were stretched between different parts of its surface, and ulceration had commenced on the cartilage covering the humerus, where it came in contact with the under surface of the acromion; the capsule was thickened and adherent, and in time probably anchylosis of the joint would have taken place.

Mr. Soden thinks that the biceps may act as an antagonist to those muscles of the shoulder-joint, which tend to pull the humerus up. With this consideration, he says, of the tendon of the biceps in its capacity of a capsular muscle, we can understand why, when the tendon is ruptured or displaced, the head of the bone should rise upwards and forwards,—a precisely opposite direction to that in which the tendon would, when in situ, tend to direct it.

Case 2.—William Mountford, ætat. 55, was admitted into the Bath United Hospital, on the 24th of April last, having been severely injured by a quantity of earth falling upon him. He had sustained, in addition to some severe contusions, a dislocation forwards of the humerus, and fractures of some of the ribs on the same side. The man lingered for a few days, and died from hæmorrhage in the cavity of the chest, in consequence of the lung having been perforated by a fractured rib.

Unusual difficulty had been experienced in the reduction of the dislocation, which was very high up, but it had been at last effected.

On examining the joint, a rent was discovered in the capsule on its inner side, through which the head of the bone had passed; the sheath was torn up, and the tendon having escaped, had slipped completely over the heads of the bone, and was lying at the inner and posterior part of the joint.

I consider that the difficulty of reduction was attributable to the complication of the injury of the biceps, for the inferences from the former case would lead us to expect that, had the tendon been in situ, it would have aided the return of the bone; but its influence being removed, the resistance of the upper capsular muscles became doubled, and twice the amount of force was consequently required to overcome it. This may be considered as a rule applicable to all dislocations forwards, where the head of the bone is not thrown below its original level.

XVI. AN ACCOUNT OF TWO CASES OF ANEURISM OF THE SUPERIOR MESENTERIC ARTERY, IN ONE OF WHICH JAUNDICE WAS INDUCED BY PRESSURE OF THE SAC. By James Arthur Wilson, M.D., Physician to St. George's Hospital.

Case.-Ann Pinchin, widow, aged 24, admitted under Dr. Wilson's care, Feb. 24, of this year. She had been ill four months, and her general appearance was that of great depression and exhaustion. The case in its progress presented the usual symptoms of jaundice in a very aggravated degree; it was very little influenced by the means employed for its relief,

and was remarkable principally for the severity of the pain complained of between the shoulders, along the track of the six or eight lower dorsal vertebræ. There was also occasional pain in the epigastrium and right hypochondrium,* both of which regions were carefully examined from time to time, without any information being thus obtained as to the immediate cause of the disease.

There was great dejection of mind, with entire loss of appetite and want of muscular power; the skin became more intensely coloured as the case advanced to its termination, and the saliva voided at this period of the disease stained the linen, on which it was received, of a deep yellow colour; there was also distinct evidence of the same tint in the menstrual flux, which occurred twice during the seven weeks that the patient passed in the hospital. She died April 12, in a state of great general exhaustion, much aggravated by a mercurial salivation, following the administration of some small doses calomel and opium.

The body was examined April 13th, twenty-four hours after death.

On removing the integuments, a stain of yellow was observed generally throughout the fat, and the exposed inner structures of the body. In the duodenal region, on raising the liver from the subjacent viscera, a large globular tumor was seen extending itself from behind the head of the pancreas upwards, forwards, and outwards, to the right side of the body, in the direction of the ductus communis choledochus, so as to occupy the greater part of the space usually defined by the laminæ of the small omentum. The tumor was smooth on its surface, of firm texture, and was found to be the sac of an aneurism, situated in the trunk of the superior mesenteric artery, commencing about an inch from its origin, and extending itself in the directions mentioned.

The ductus communis was in close and prolonged contact with the walls of the sac, by which it was compressed in its whole extent; it was, however, pervious to the probe, and bile could readily be squeezed from its orifice into the duodenum.

The liver was of a dark livid tint, but was healthy in its general structure; its pori biliarii were universally enlarged and greatly distended with bile, so that the diameter of many of these vessels exceeded that of the larger gall ducts in ordinary cases. The gall-bladder contained a large quantity of healthy bile, with a few small gall-stones.

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Dr. Wilson very judiciously observes :—

'Although the instance I have described of jaundice depending on aneurism of a large branch of the aorta be a solitary one, yet, by the recollection of it, in protracted and intractable cases of the disease, we may be the more impressed with the necessity for making close and frequent examination of the upper region of the abdomen, by the ear as well as by the eye and the hand, during the continuance of the symptoms.

It may likewise teach us caution in our estimate of the probable duration of cases of this disease, and in our conjectures as to the mode of their termination.

If jaundice be occasionally the effect, simple and direct, of pressure on the

The pain was very severe, and returned in paroxysms with marked intervals of suspension,

gall-ducts by an aneurism of a large branch of the abdominal aorto, then, in the treatment of cases classed under this name of jaundice, it will be well to remember that they may sometimes close with the awful suddenness of hæmorrhage from the main trunk of the circulation.

For such possible termination of a disease, chronic in its general character, and not usually considered as dangerous, the friends of the patient, in all cases warranting suspicion, should surely be prepared.

I am, moreover, willing to hope, that the relation of this case may tend to establish one caution the more against the mischievous routine of practice, now happily less frequent among reflecting physicians, of administering mercury in all cases of supposed 'liver affection,' and of jaundice, as included among such 'affections." " 225.

Case 2-William Frost, coachman, aged 42, admitted Feb. 11, 1835, complaining principally of a tumor pulsating in the epigastric region. It was of the size of a small orange, and, as he lay flat on his back, was observed to project rather to the left of the scrobiculus cordis. It was painful on pressure, and was moveable in nearly every direction, but most easily so towards the left side.

When the patient turned on this side, the tumor "fell at once under the ribs," and could no longer be felt.

On his turning to the right side, the tumor fell over in the same direction, and could still be distinctly felt in the front and to the right of the epigastric region.

Two or three months before his admission, he had suffered much from shortness of breath, with pain in the loins, and "between the shoulders," along the lower dorsal vertebræ. In a fortnight after his admission, he became very costive, and was attacked by cough, with profuse hæmoptysis, for the first time since his illness. From this time until the death of the patient on July 10th in the same year, large quantities of blood were frequently brought up by cough, and latterly by vomiting. The blood drawn from the arm subsequently to these attacks, and for the relief of other symptoms, was always more or less cupped and buffed; the pulse was never irregular, and generally of moderate frequency. As the case advanced, the costiveness became obstinate, the appetite failed, the pain between the shoulders, along the lower dorsal vertebræ, became more severe, and there was much occasional suffering from cramps in the legs, with numbness and tingling in them, as in the arms and hands.

The tumor became more and more tender to the touch, and, some weeks before death, was observed to have changed its position from the left to the right side of the epigastrium.

Towards its close, the case presented many phthisical symptoms, and under these the patient gradually sank.

On examination after death, the aneurismal sac in this case, as in the other, was found to be situated in the trunk of the superior mesenteric artery. It was large, kidney-shaped, extending upwards, forwards, and outwards, to the right side of the body, thus raising with it the pancreas, which viscus lay on the upper boundary of the tumor.

The walls of the sac, especially in front, were firm and thick, and were enveloped by a transparent layer of peritoneum. The sac communicated directly with the aorta, by a long and wide opening with a smooth edge.