BRITAIN, IRELAND, AND THE COLONIES. GENERAL INFII.AI%, WORCESTER. CASE OF RAYNAVD's DISEASE FOIJOWING DPHTHERIA. (Under the care of br. HYDN.) [Reported by ALLmAN Powmzr, . B., House-Srtrgeon.] C. P., aged 48, was admitted'dn July '14th, 1584. He gave the following history of his case. He served in the Royal Horse Artillery as rough rider for twenty-two years, and subsequeitly as Orillinstructoiy to police for ears. During all thi tim6e, his health had been excellent. He had never had any

more »

... s bf more than a day's durOtion unnil about eight months before admission, 'when he had two or three severe "colds," contracted from wet feet when on night-duity. He had not been abroad, had always lived well, his habits had been repular, and he had tot suffered' frm syphilis, gout, or rheumatism. His family history was ve7r satisfactory, the majority of his Ielatives being remarkable from their longevity. On May 12th, he reported himself ill with soie throet. This was followed, in a week's time, by sudden loss of voice for *hich he was treated by a prkctitioner, Who said he suffered from diphtheria. During his convalescence, three weeks later, when dressing in the morning, he discovered his nose had become blue and swollen during the night, "in fact, resembling an overgrown mulberry." This va followed, fix a day or two afterwards, by a similar appearance in the pulps of the fingers of his right hand and in his ears. In the 'following week, the ring and little fingers of the left hand were attacked in the same manner, and gave him considerable pain. The discoloration of the fingers steadily increased until, at the end of three weekL, they were quite black along their entire length. The blackness then receded to the middle joints, where blebs formed. between the sound flesh and mortified parts. Subsequently, black patches formedl on the second and third toes of the right foot, and along its outer margin. His niouth and tongue became swollen and pailful, the latter being' livid, and an ulcer forming near the tip. His nose was stopped so that he could not breathe through it, and was only cleared by sneezing out some tQugh brown stuff, which came away with much difficulty. Careful examination on the day after admission showed that in general he was a well built man, above the average size, and fawiy healthy looking, although he stated tat. he had lost much flesh' and beeome much weaker during his present, illness. His hair. was grey, but otherwise lie looked fiesh for his age. Hehad no arcus senilis, nor had he any aigns qf general ansinia. His nose was cold. and livid. The edges of the helices of both ears wvere blue, a small dry slough separating from the left. The ung al,nd part of the middle phalanges ?f the ring and little ingers of the left hand, and of all the fingers of the right,. were. black, dried up, and completely mummified. The remaining fingers of the left hand and both thumbs were cold, glossy, devoid of hairs, and of a dusky red colour at the tips. The ungual phalanges of the second and third toes of the right foot were also sphacelated. The sphacelated portions of the fingers were separated frqm the sound flesh by bllbe containing turbid serum, but there was no distinct line of demarcation. Careful physical excamination of the 6hest did not reveal anytiing abnormal, nor' could aay diseas be detected in the radial, alnar or posteior tibil areie of either si4e& There ws .no pawlysis, senory iorrmotoa His.voice had bo.ego Eined, The tornperatur. was normwl Tis. nuo ootained a little albumen, but nX casts nor sugar, The blood, 9aarf ed under tb*h microscope, showed an.increase of the wbite pqrpusql"4 ...The digstive functons were wel1 performedLHe complinp ed ft, uothing but slight paiu and tingling in the fingers oeciqionally.i Under liberal dietetic and tonic treatment he increased rapidly in weight, and his general condition sufficioutly improved for him to go to the country for change of sir on Septeinber 8rd, and ou hip return, a month lator, Mr. Hyde, Cndtng a well defined line of deoageration, amputated the gangrenoua fings, The slougbs separated from, tXh ear ami toes without interference, leaving grs*ulating sutiaces ;ndero neatb, which rapidly healed, The stumps of the gangrenous XAngers were slow in healing, and his thumbs and ears were still cold aind slightly discoloured, but he was sufficiently well to resunme his duity as instructor of police. RuE.xs BY DLW ALLJMAN POWILL.-The above case of synimetrical gangrene is interesting as having occurred after diphtheria, when the vaso-motor" or trophic, lesions which occasioped the gangrene would appear to have taken the place of post-diphtheritic paralysis. That the case was, one of diphtheria, I ascertained from the practitioner who attendpd him before admi*eon. The fact that he had eaten the same baker's bread for aix years and that no onie else in the house suffered, excluded ganigrene from ergotism. The absence of any general aniamia, or of any disease or feebeienns8 of the circulation, the presence of swelling-prior to the shiivelling of the gangrenous parts, and the occurrence of the disease in sunmmer, nmke the case more remarkable. August 19th. I met this patient on duty at tho assizes a short time ago;h looked an(d expressed himself as in excellent healtb. of headache and dimpess of vision (vision,"). There was no hystcria, but thero was evident anenia. She had occasional vomiting. By the shadow-test, the refraction was found to be ndrmal. By the 1irect method of ophthalmoscopic examination, the optic discs of both eyes were seen to be hazy and swollen (optic nieuritis). No huennorrhage could be detected, but this condition of the discs was sufficient to excite considerable concern as to the cause of the affection and as to the prognosis and treatme-nt. On carefully going into the case, we' rould find no definite sign of intracra l disease, no localising symuptom, but it was ascertainedL that the catamenia had disappeared for nearly a year, and that the synii ptoms complained of dated nearly as far back as this. Treatment was therefore directed to the disordered menstruation, the catamenial flow was re-established, rhe headAche 4iappeared, the vision improved, and the optic discs became nearly normal again. RasMaAnEs BY ML JULEL-Here there was a case, by no means uncommon, of optic neuritis in the early stage associated with amenorrhwea; and I venture to think that the early us'e of the ophthalmoscope enabjed us to realise the importance of the case, and ,at once to grapple with the cause of the affection. Had the amenorrhaia continued, tihe neuritis would probably have increased, and have terminated in partial or complete blindness. CASE II. Optic Neuritis: Ast;grnatton.-Annie B., aged 12, a delicate child, was brought on account of defective vision (,%) and seyfre headache on attempting to read. She had suffered from measles six months before, and had been at school since that time. On ophthalmoscopic examination by the direct method, we found double olptic neuritis as in the last ease;* and by' the shadow-test, it was found that she had considerable hypermetropie astigmatism. 'By the same shadow-test, the error was corrected, and suitable glasses prescribed. A tonic plan of treatment was also adonted. Tho result was most satisfactory; the headache-disappered, the' vision improved so that it became nearly normal (), ad tihe optic discs only presented a slight woolly appearance. REMARKS BY MU. JUVE& -I believe this to be an example of a large class of cases in which astigmatism, combined with debilitating causes, is the means of setting up optic neuritis, and that it would be well if physicians would make more extensive use of the simple and easy shadow-test in order to ascertain the refractive condition of~n I