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MEDICO-CHIRURGICAL
TRANSACTIONS.
PUBLISHED BY
THE ROYAL
MEDICAL AND CHIKURGICAL SOCIETY
LONDON.
VOLUME THE SIXTI-NINTH.
LONDON :
LONGMANS, GttEEN, AND CO.,
PATERNOSTER ROW.
1886.
ft
Ml>> .
MEDICO-CHIRURGICAL
TRANSACTIONS.
PUBLISHED BY
THE ROYAL
MEDICAL AND CLTIRURGICAL SOCIETY
OF
LONDON.
SECOND SERIES.
VOLUME THE FIFTY-FIRST.
LONDON :
LONGMANS, GREEN, AND CO.,
PATERNOSTER ROW.
1886.
I-RINTED BY J. K. U>1 \KI>, HAHIIIilLKMKW CLOSB.
KOYAL
MEDICAL AND CHIEUKGICAL SOCIETY
OF LONDON.
PATRON.
THE QUEEN.
OFFICERS AND COUNCIL,
ELECTED MARCH 1, 1886.
VICE-PRESIDENTS.
TREASURERS.
SECRETARIES.
LIBRARIANS.
OTHER MEMBERS
OF COUNCIL.
GEORGE DAVID POLLOCK.
c JOHN WILLIAM OGLE, M.D.
\ HERMANN WEBER, M.D.
) THOMAS BRYANT.
I MATTHEW BERKELEY HILL.
< CHARLES BLAND RADCLIFFE, M.D.
{ TIMOTHY HOLMES.
( WALTER BUTLER CHEADLE, M.D.
I HOWARD MARSH.
f WILSON FOX, M.D., F.R.S.
1 JOHN WHITAKER HULKE, F.R.S.
THOMAS BUZZARD, M.D.
WILLIAM SELBY CHURCH, M.D.
THOMAS HENRY GREEN, M.D.
JOHN WICKHAM LEGG, M.D.
WALTER MOXON, M.D. (deceased).
HENRY COOPER ROSE, M.D.
MARCUS BECK.
EDWARD BELLAMY.
JEREMIAH McCARTHY.
L WALTER RIVINGTON.
THE ABOVE FORM THE COUNCIL.
RESIDENT LIBRARIAN.
JAMES BLAKE BAILEY.
A LIST OF THE PRESIDENTS OF THE SOCIETY
FROM ITS FORMATION.
ELECTED
1805. WILLIAM SAUNDERS, M.D.
1808. MATTHEW BAILLIE, M.D.
1810. SIR HENRY HALFORD, Bart., M.D., G.C.II.
1813. SIR GILBERT BLANE, Bart., M.D.
1815. HENRY CLIXE.
1817. WILLIAM BABINGTON. M.D.
1819. SIR ASTLEY PASTON COOPER, Bart., K.C.H., D.C.L
1821. JOHN COOKE, M.D.
18-2.3. JOHN ABERNETIIY.
1825. GEORGE BIRKBECK, M.D.
1827. BENJAMIN TRAVERS.
1829. PETER MARK ROGET, M.D.
1831. SIR WILLIAM LAWRENCE, Bart.
1833. JOHN ELLIOTSON, M.D.
1835. HENRY EARLE.
1837. RICHARD BRIGHT, M.D., D.C.L.
1839. SIR BENJAMIN COLLINS BRODIE, Bart., D.C L.
1841. ROBEKT WILLIAMS, M.D.
1843. EDWARD STANLEY.
L845. WILLIAM FREDERICK CHAMBERS, M.D., K.C II.
1847. JAMES MONCRD3FF ARNOTT.
1849. THOMAS ADDISON, M.D.
1851. JOSEl'II HODGSON.
1853. JAMES COl'l. AND, M.D.
is.",. CiESAR HKNKV HAWKINS.
1857. SIB CHARLES LOCOCK, Bart., M.D.
1859. FREDERIC CARPENTEB 8KEY.
1861. BENJAMIN GUY BABINGTON, M.D.
1863. RICHARD PARTRDDGE.
1865. SIK JAMES LLDERSON, M. I).. D.C.L.
1867. SAMUEL SOLLY.
1869. SIR GEORGE BURROWS, Bart., M.D., D.C.L.
1871. THOMAS BLIZARD CURLING.
1878. CHARLES JAMES BLASDJS WILLIAMS. M.D.
1-7.-.. SIR JAMES PAGET, Baet., D.C.L.. LL.D.
1877. CHARLES WEST M D
1879. JOHN ERIC ERICHSEN.
1881. ANDREW WHYTE BARCLAY, M.D.
1882. JOHN MARSHALL.
1884. GEORGE JOHNSON, M.D.
ism;. GEORGE I) WID POLLOCK.
FELLOWS OF THE SOCIETY APPOINTED BY
THE COUNCIL AS REFEREES OF PAPERS.
FOR THE SESSION OF 1880-87.
BAKER, WILLIAM MORRANT.
BASTIAN, HENRY CHARLTON, M.D., F.R.S.
BRUCE, JOHN MITCHELL, M.D.
BRUNTON, THOMAS LAUDER, M.D., F.R.S.
CAYLEY, WILLIAM, M.D.
CREIGHTON, CHARLES, M.D.
CROFT, JOHN.
CURNOW, JOHN, M.D.
DICKINSON, WILLIAM HOWSHIP, M.D.
DUCKWORTH, SIR DYCE, M.D.
DUNCAN, JAS. MATTHEWS, M.D., LL.D., F.R.S.
ERICHSEN, JOHN ERIC, LL D., F.R.S.
FAYRER, SIR JOSEPH, K.C.S.I., M.D., F.R.S.
FENWICK, SAMUEL, M.D.
GALABIN, ALFRED LEWIS, M.D.
GANT, FREDERICK JAMES
GEE, SAMUEL JONES, M.D.
GERVIS, HENRY, M.D.
GODLEE, RICKMAN JOHN.
HARLEY, JOHN, M.D.
HEWITT, GRAILY, M.D.
HUTCHINSON, JONATHAN, F.R.S.
LANGTON, JOHN
MACNAMARA, CHARLES.
MARCET, WILLIAM, M.D., F.R.S.
MOORE, NORMAN, M.D.
MORRIS, HENRY.
ORD, WILLIAM MILLER, M.D.
PAGE, HERBERT WILLIAM, M.A., M.C.
POWELL, RICHARD DOUGLAS, M.D.
RALFE, CHARLES HENRY, M.D.
SMITH, THOMAS.
STURGES, OCTAVIUS, M.D.
WILLETT, ALFRED.
WILLIAMS, JOHN, M.D.
WOOD, JOHN, F.R.S.
TRUSTEES OF TIIE SOCIETY.
SIR GEORGE BURROWS, Babt., M.D., D.C.L., F.R.S.
THOMAS BLIZARD CURLING, F.R.S.
JOHN BIRKETT, F.L.S.
TRUSTEES OF TIIE MARSHALL IIALL MEMORIAL FUND.
WALTER BUTLER CHEADLE, M.D.
WILLIAM OGLE, M.D.
THOMAS SMITH.
LIBEAET COMMITTEE FOR TIIE SESSION OF 18SG-87.
THOMAS LAUDER BRUNTON, M.D., E.R.S.
WILLIAM CATLEY, M.D.
FRANCIS HENRY CHAMPNETS, M.A., M.B.
CHARLES ELAM, M.D.
WILLIAM R. GOWERS, M.D.
WILLIAM WATSON CHEYNE.
CHARLES MACNAMARA.
1 1 ERBEET WILLIAM PAGE.
ROBERT WILLIAM PARKER.
JOHN K No W'SLEY THORNTON.
_ (WALTER IU TLKR CHEADLE, M.D.
7/0"-^-(Ih»WAKI» MAKSH.
(WILSON FOX, M.D., F.R.S.
Son (JOHN WHITAKEE IIULKE, F.R.s.
FELLOWS
OF THB
ROYAL MEDICAL AND CHIRURGICAL SOCIETY
OF LONDON.
EXPLANATION OF THE ABBREVIATIONS.
P. — President. V.P. — Vice-President.
T. — Treasurer. S. — Secretary.
L. — Librarian. C. — Member of Council.
The figures succeeding the words Trans, and Pro. show the number of Papers
which have been contributed to the Transactions or Proceedings by the
Fellow to whose name they are annexed. Referee, Sci. Com., and Lib. Com.,
with the dates of office, are attached to the names of those who have
served on the Committees of the Societv.
OCTOBER, 188G.
Those marked thus (f) have paid the Composition Fee in lieu of further
annual subscriptions.
Amongst the non-residents those marked thus (*) are entitled by
composition to receive the Transactions.
Elected
1846 *Abercrombie, John, M.D.
187/ Abercrombie, John, M.D., Assistant Physician to, and
Lecturer on Forensic Medicine at, Charing Cross Hos-
pital ; 23, Upper Wimpole street, Cavendish square.
1885 Abraham, Phineas S., 40, Elgin Road, St. Peter's Park.
1851 *Acland, Sir Henry Wentworth, K.C.B., M.D., LL.D.,
F.R.S., Honorary Physician to H.R.H. the Prince of
Wales ; Regius Professor of Medicine in the University
of Oxford ; Broad street, Oxford.
X FELLOWS OF THE SOCIETY.
Elected
J 885 Acland, Theodore Dvke, M.D., Assistant Physician to the
Hospital for Consumption and Diseases of the Chest,
Brompton ; 7, Brook street, Hanover square.
1847 Acosta, Elisha, M.D., 24, Rue de Luxembourg, St.
Honore, Paris.
1852 +ADAMS, William, Surgeon to the Great Northern Hospital
and to the National Hospital for the Paralysed and Epi-
leptic ; Consulting Surgeon to the National Orthopaedic
Hospital, Great Portland street ; 5, Henrietta street,
Cavendish square. C. 1873-4. Trims. 3.
1867 AiKlN, Charles Arthur, 7, Clifton place, Hyde park.
1837 *AlNSWOB.TH, Ralph Fawsett, M.D., Consulting Physician
to the Manchester Royal Infirmary; Cliff Point, Lower
Broughton, Manchester.
1839 Alcock, Sir Rutherford, K.C.B., K.C.T., K.T.S., D.C.L.,
late II.M.'s Envoy Extraordinary at the Court of Pekin.
Trims. 1.
18(56 Allbutt, Thomas Clifford, A.M., M.D., F.R.S., Physician
to the Leeds General Infirmary; 35, Park square,
Leeds. Trans. 3.
1^7!) Allchin, William Henry, M.B., F.R.S. Ed., Physician
to, and Lecturer on Medicine at, the Westminster
Hospital; 5, Chandos street, Cavendish scpiare, W.
1863 Altiials, JULIUS, M.D., Senior Physician to the Hospital
for Epilepsy and Paralysis, Regent's park ; 48, Harley
street, Cavendish scpiare. Trans. 2.
1884 Anderson, Alexander Richard, Resident Surgeon,
General Hospital, Nottingham.
1881 Anderson, James, A.M., M.D., si, Wimpole street, Caven-
dish square.
1862 ANDREW, EdWYN, M.D., 12, St. John's Hill, Shrewsbury.
1862 Andrew, James, M.D., Physician to, and Lecturer on Medi-
cine at, St Bartholomew's Hospital ; 22, Harley street,
Cavendish square. S. 1878-9. C. 1881-2, Trans. 1.
1820 Andbew8, Thomas, M.D., Norfolk, Virginia.
L880 *Appleton, Henry, M.D., Staines,
FELLOWS OF THE SOCIETY. XI
Elected
18/4 Aveling, James H., M.D., Physician to the Chelsea Hos-
pital for Women; 1, Upper Wimpole street, Cavendish
square.
1851 *Baker, Alfred, Consulting Surgeon to the Birmingham
General Hospital ; 3, Waterloo street, Birmingham.
1873 *Baker, J. Wright, Senior Surgeon to the Derbyshire
General Infirmary; 102, Friargate, Derby.
1865 Baker, William Morrant, Surgeon to, and Lecturer
on Physiology at, St. Bartholomew's Hospital; Con-
sulting Surgeon to the Evelina Hospital for Sick
Children ; Examiner in Surgery at the University of
London ; 26, Wimpole street, Cavendish square. C.
1878-9. Referee, 1886. Lib. Com. 1876-7. Trans. 7.
1869 Bakewell, Robert Hall, M.D., Ross, Westland, New
Zealand.
1839 fBALFOUR, Thomas Graham, M.D., F.R.S., Surgeon
General; Coombe Lodge, Wimbledon Park. C. 1852-3.
V.P. 1860-1. T. J872. Lib. Com. 1849. Trans. 2.
1885 Ballance, Charles Alfred, M.S., 56, Harley street,
Cavendish square. Trans. 1.
1848 fBALLARD, Edward, M.D., Inspector, Medical Department,
Local Government Board ; 12, Highbury terrace,
Islington. C. 1872. V.P. 1875-6. Referee, 1853-71.
Lib. Com. 1855. Trans. 5.
1866 *Banks, John Thomas, M.D., Physician in Ordinary
to the Queen in Ireland ; Physician to Richmond,
Whitworth, and Hardwicke Hospitals ; Regius Pro-
fessor of Physic in the University of Dublin ; Member
of the Senate of the Queen's University in Ireland ;
45, Merrion square, Dublin.
1879 Barker, Arthur Edward James, Surgeon to University
College Hospital, and Assistant Professor of Clinical
Surgery and Teacher of Practical Surgery at University
College, London ; 87, Harley street, Cavendish square
Trans. 4.
xii FELL0W8 OF THE SOCIETY.
Elected
1882 Barker, Frederick Charles, M.D., Surgeon-Major,
Bombay Medical Service [care of Arthur E. J.
Barker, 87, Harley street].
1833 fBARKER> Thomas Alfred, M.D., Consulting Physician to
St. Thomas's Hospital; 109, Gloucester place, Port-
man square. C. 1844-5. V.P. 1853-4. T. 1860-2.
Referee, 1 84 8-5 1 . Trans. 6.
1876 Barlow, Thomas, M.D., B.S., Physician to University
College Hospital ; Physician to the Hospital for Sick
Children, Great Ormond street, and Assistant Physician
to the London Fever Hospital; 10, Montague street,
Russell square. Trans. 1.
1881 *Barxes, Henry, M.U., F.R.S. Ed., Physician to the Cum-
berland Infirmary ; 'i, Portland square, Carlisle.
1861 Barnes, Robert, M.D., 15, Harley street, Cavendish
square. C. 1877-8. Referee, 1867-76. Lib. Com.
1869-73. Trans. 4.
1864 Barratt, Joseph Gillman, M.D., 8, Cleveland gardens,
Bayswater.
1880 Barrow, A. Boyce, Assistant Surgeon to King's College
Hospital, to the Westminster Hospital, and to the Wesl
London Hospital; 17, \Yelbeck street, Cavendish
Bquare.
is 10 Barkow, BENJAMIN, Surgeon to the Royal Isle of Wight
Infirmary ; Southlands, Ryde, Isle of Wight.
1859 Barwell, Richard, Surgeon to, and Lecturer on Surgery
at, the Charing Cross Hospital; 55, Wimpole street,
C. 1876-77. V.P. 1883-4. Referee, 1868-75, 1879-82.
Trans. 1 1.
1868 Bastian, Henri Charlton, M.A., M.D., F.R.S., Professor
of Clinical Medicine and of Pathological Anatomy in
University College. London; Physician to University
College llo.-pital ami to the National Hospital for the
Paralysed and Epileptic; 20, Queen Anne street.
Cavendish square. Referee, 1886. C. 1885. Trans. 1.
187.") Beach, Fletcher, M.B., Medical Superintendent, Metro-
politan District Asylum, Darenth, Dear Dartford, Kent.
FELLOWS OF THE SOCIETY. Xlll
Elected
1883 Beale, Edwin Clifford, M.A., M.B., Assistant Physician
to the City of London Hospital for Diseases of the
Chest ; and Physician to the Great Northern Hospital ;
23, Upper Berkeley street.
18G2 Beale, Lionel Smith, M.B., F.R.S., Professor of the
Principles and Practice of Medicine in King's College,
London, and Physician to King's College Hospital ;
61, Grosvenor street. C. 18/6-77. Referee, 1 873-5.
Trans. 1.
1860 *Bealey, Adam, M.D., M.A., Oak Lea, Harrogate.
1856 Beardsley, Amos, F.L.S., Bay villa, Grange-over-Sands,
Lancashire.
1871 Beck, Marcus, M.S., Professor of Surgery in University
College, London, and Surgeon to University College
Hospital ; 30, Wimpole street, Cavendish square.
C. 1886. Referee, 1882-5. Lib. Com. 1881-5.
1880 Beevor, Charles Edward, M.D., Assistant Physician to
the National Hospital for the Paralysed and Epileptic ;
33, Harley street, Cavendish square. Trans. 1.
1 858 Begley, William Chapman, A.M., M.D., late of the Middle-
sex County Lunatic Asylum, Hanwell ; 26, Saint Peter's
square, Hammersmith. C. 1877-8.
1871 Bellamy, Edward, Surgeon to, and Lecturer on Anatomy
at, Charing Cross Hospital ; Lecturer on Artistic
Anatomy to the Science and Art Department, South
Kensington ; Examiner in Surgery in the Victoria
University, Manchester ; 17, Wimpole street, Cavendish
square. C. 1886. Referee, 1882-5. Lib. Com. 1879-
81. Trans. 1.
1847 Bennet, James Henry, M.D., The Ferns, Weybridge, and
Mentone.
1880 Bennett, Alex. Hughes, M.D., Assistant Physician to the
Westminster Hospital ; 76, Wimpole street, Caven-
dish square. Trans. 1 .
Xiv FELLOWS OF THE SOCIETY.
Elected
1883 Bennett, Stoker, Dental Surgeon to, and Lecturer on
Dental Surgery at, the Middlesex Hospital ; Dental
Surgeon to the Dental Hospital of London j 17, George
street, Hanover square.
1877 Bennett, William Henry, Assistant Surgeon to, and
Lecturer on Anatomy at, St. George's Hospital; 1,
Chesterfield street, Mayfair.
1845 j-Berry, Edward Unwin, 17, Sherriff road, West Hamp-
Btead.
1885 Berry, James, Assistant Demonstrator of Anatomy, St.
Bartholomew's Hospital; 27, Upper Bedford place.
1820 Bertin, Stephen, Paris.
1872 Beverley, Michael, M.D., Assistant Surgeon to the Nor-
folk and Norwich Hospital ; 63, St. Giles's street, Nor-
wich.
18G5 *Bickersteth, Edward Robert, Surgeon to the Liverpool
Royal Infirmary, and Lecturer on Clinical Surgery in
the Liverpool Royal Infirmary School of Medicine ; 2,
Uodnev street, Liverpool. Trans. 1.
1878 Bindon, William John Vlreker, M.D., 48, St. Ann's
street, Manchester.
1854 Bird, Peter IIinckes, F.L.S.
1856 BlKD, William, Consulting Surgeon to the West London
Hospital ; Bute House, Hammersmith.
1849 fBiRKETT, Edmund Lloyd, M.D., Consulting Physician to
the City of London Hospital for Diseases of the Chest;
48, Russell square. C. 1865-6. Referee, L851-9.
1851 fBlRKITT, John, F.L.S., Consulting Surgeon to Guy's
Hospital; Corresponding Member of the "Sonctr
de Chirurgie" of Paris ; Inspector of Anatomy for the
Provinces in England and Wales; 62, Green street,
Grosvenor square. L. 1856-7* S. 1863-5. C. 1867-8.
T. 1870-78. V.P. 1879-80. Referee, 1851-5, 1866,
1869, Sci. Com. 1863. Lib. Com. 1852. Tratu.8.
1866 Bibiior, Edward, M.D.
FELLOWS OF THE SOCIETY. XV
Elected
1881 Biss, Cecil Yates, M.D., Assistant Physician to the
Hospital for Consumption, Brompton, and to the
Middlesex Hospital; 135, Harley street, Cavendish
square. Trans. 1.
1865 Blanchet, Hilarion, Examiner to the College of Physicians
and Surgeons, Lower Canada ; 6, Palace street, Quebec,
Canada east.
1S65 Blandford, George Fielding, M.D., Lecturer on Psycho-
logical Medicine at St. George's Hospital; 71, Gros-
venor street. C. 1883-4.
1867 Bloxam, John Astley, Surgeon to, and Teacher of Opera-
tive Surgery in, Charing Cross Hospital ; Surgeon for
Out-Patients to the Lock Hospital ; Junior Surgeon to
the West London Hospital ; 8, George street, Hanover
square.
1823 Bojanus, Louis Henry, M.D., Wilna.
1846 fBosTocK, John Ashton, C.B., Hon. Surgeon to H.M. the
Queen; Surgeon-Major, Scots Fusilier Guards; 73,
Onslow gardens, Brompton. C. 1861-2. V. P. 1870-71.
Sci. Com. 1867.
1869 Bourne, Walter, M.D. [care of the National Bank of India,
80, King William street, City] ; Archaco, France.
1882 Bowlby, Anthony Alfred, Surgical Registrar to St. Bar-
tholomew's Hospital ; 75, Warrington crescent, Maida
hill. Trans. 1.
1870 * Bowles, Robert Leamon, M.D., 8, West terrace, Folke-
stone.
1841 fBowMAN, Sir "William, Bart., LL.D., F.R.S., F.L.S.,
Consulting Surgeon to the Royal London Ophthalmic
Hospital, Moorfields ; 5, Clifford street, Bond street.
C. 1852-3. V.P. 1862. Referee, 1845-50, 1854-6.
Lib. Com. 1847. Trans. 3.
1884 Boyd, Stanley, M.B., Assistant Surgeon to the Charing
Cross Hospital ; 27, Gower street.
1862 Brace, William Henry, M.D., 7, Queen's Gate terrace,
Kensington.
Xvi FELLOWS OF THE SOCIETY.
Elected
1874 Bkadshaw, A. F., Surgeon-Major ; Surgeon to tlie Rt. lion.
the Commander in Chief in India ; Army Head Quar-
ters, Bengal Presidency. [Agent: Vesey W. Holt, 17,
Whitehall place.]
18S3 Bradshaw, James Dixon, M.B., 30, George Street,
Hanover square.
1867 *Brett, Alfred T., M.D., Watford, Herts.
1876 Bridges, Robert, M.B., Manor House, Yattendon, New-
bury, Berks.
1867 Bridgewater, Thomas, M.B., Harrow-on-the-Hill, Mid-
dlesex.
1868 Bkoadbent, William Henry, M.D., Physician to, and
Lecturer on Medicine at, St. Mary's Hospital; Consulting
Physician to the London Fever Hospital ; Examiner in
Medicine at the University of London ; 34, Seymour
street, Portman square. C. 1885. Referee, 1881-4.
Trans. 5.
1851 -J-Brodhurst, Bernard Edward, F.L.S., Surgeon to the
Royal Orthopedic Hospital ; 20, Grosvenor street.
C. 1868-9. Lib. Com. 1862-3. Trans. 2. Pro. 1.
L872 Brodie, George Bernard, M.D., Consulting Physician-
Accoucheur to Queen Charlotte's Hospital ; 3, Chester-
field street, Mayfair. Trans. 1.
1860 Bkown-Si'uiakd, Charles Edouard, M.D., L.L.D., F.R.S.,
Laureate of the Academy of Sciences of Paris ; Professor
of Medicine at the College of France ; Professor of
General Physiology at the Museum of Natural History;
Paris. Sci. Com. 1862.
1878 Broun i ■;, Sir James Grichton, M.D., LL.D., F.R.S., Lord
Chancellor's Visitor in Lunacy ; 7, Cumberland Ter-
race, Regent's Park.
1NSU Browne, JaMES WILLIAM, M.B., 8, Norland place, Hol-
land Park.
lssi Browne, John Walton, M.D., Surgeon to the Belfast
Ophthalmological Hospital; 10, College square N.,
Belfast.
FELLOWS OF THE SOCIETY. XV11
Elected
1881 Browne, Oswald A., M.A., M.B., Casualty Physician to
St. Bartholomew's Hospital and Physician to the
Royal Hospital for Diseases of the Chest ; 30a, George
street, Hanover square.
1874 Bruce, John Mitchell, M.D., Physician to, and Lecturer
on Materia Medica at, the Charing Cross Hospital;
Assistant Physician to the Hospital for Consumption,
Brompton ; 70, Harley street. Referee, 1886. Trans. 1.
1871 Brunton, Thomas Lauder, M.D., F.R.S., Assistant Physi-
cian to, and Lecturer on Materia Medica and Thera-
peutics at, St. Bartholomew's Hospital; Examiner in
Materia Medica in the University of London ; 50,
Welbeck street, Cavendish square. Referee, 1880-80.
Lib. Com. 1882-6.
1860 Bryant, Thomas, Vice- President, Surgeon to, and Lecturer
on Surgery at, Guy's Hospital ; 53, Upper Brook street,
Grosvenor square. C. 1873-4. V. P. 1885-6. Sci.
Com. 1863. Referee, 1882-4. Lib. Com. 1868-71.
Trans. 10. Pro. 1.
1855 Bryant, Walter John, Consulting Physician to the Home
for Incurable Children, Maida vale ; 23a, Sussex square,
Hyde park gardens.
1823 Buchanan, B. Bartlet, M.D.
1864 Buchanan, George, M.D., F.R.S., Medical Officer of the
Local Government Board ; Member of the Senate of the
University of London ; 24, Nottingahm place, Maryle-
bone road.
1864 Buckle, Fleetwood, M.D.
1876 Bucknill, John Charles, M.D., F.R.S. ; E 2, The Albany,
Piccadilly, and Hill Morton Hall, Rugby.
1881 Buller, Audley Cecil, M.D., Oxford and Cambridge Club,
Pall Mall.
1833 fBuRROws, Sir George, Bart., M.D., D.C.L., LL.D., F.R.S.,
Physician in Ordinary to H.M. the Oueen ; Consulting
Physician to St. Bartholomew's Hospital; Member of
the Senate of the University of London ; 18, Cavendish
square. C. 1839-40, 1858-9. T. 1845-7. V. P.
1849-50. P. 1869-70. Referee, 1842-6, 1850-7,
1861-68, 1875-81. Lib. Com. 1836. Trans. 2.
vol. lxix. b
XV111 FELLOWS OF TTIE SOCIETY.
Elected
1885 Butler-Smythe, Albert Charles, Senior Surgeon to the
Grosvenor Hospital for Women and Children ; 35,
Brook street, Grosvenor square.
1873 Butlix, Henry Trentham, Assistant Surgeon to, and
Demonstrator of Practical Surgery and of Diseases of
the Larynx at, St. Bartholomew's Hospital ; 47, Queen
Anne street, Cavendish square. Trans. 3.
1871 Butt, William F., 48, Park street, Park lane.
1883 Buxton, Dudley Wilmot, M.D., B.S., 82, Mortimer street,
Cavendish square.
1868 Buzzard, Thomas, M.D., Physician to the National Hos-
pital for the Paralysed and Epileptic ; i>6, Grosvenor
street, Grosvenor square. C. L885-6.
1851 #Cadge, William, Surgeon to the Norfolk and Norwich
Hospital; 49, St. Giles's street, Norwich. Trans. 1.
1885 Cahill, John, 26, Albert Gate, Hyde park.
1875 Carter, Charles Henry, M.D., Physician to the Hospital
for Women, Soho square ; 45, Great Cumberland place,
Hyde park.
1853 Carter, Robert Brudenell, Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, St. George's
Hospital ; 27, Queen Anne street, Cavendish square.
Trans. 1.
1845 -j-Cartyvrigut, Samuel, late Professor of Dental Surgery at
King's College, London, and Surgeon-Dentist to King's
College Hospital ; Consulting Surgeon to the Dental
Hospital; 32, Old Burlington street. C. 1860-1.
Sci. Com. 1863.
1879 Cartwright, S. HAMILTON, Professor of Dental Surgery at
King's College, London, and Surgeon Dentist to King's
College Hospital; 32, Old Burlington street.
1868 Cavafy, John, M.D., Physician to St. George's Hospital;
2, Upper Berkeley street, Portman square. 'Trans. I.
1871 C.vvi i y, WlLLIAH, M.D., Physician to, and Lecturer on
the Principles and Practice of Medicine at, the .Middlesex
Hospital ; Physician to the London Fever Hospital
and to the Nbrth-Eastern Hospital for Children; 27,
Wimpole street, Cavendish square. Referee, 1886.
Lid. Cum. 1886. Trans. 2.
FELLOWS OF THE SOCIETY. XIX
Elected
1884 Chaffey, Wayland Charles, M.B., 28, Cedars road, Clap-
ham Common.
1845 fCHALK, William Oliver, 3, Nottingham terrace, York
gate, Regent's park. C. 1872-3.
1844 fCHAMBERS, Thomas King, M.D., Hon. Physician to
H.R.H. the Prince of Wales ; Consulting Physician
to St. Mary's Hospital and to the Lock Hospital;
Shrubs Hill House, Sunningdale. C. 1861. V.P. 1867.
L. 1869-72. Referee, 1851-60, 1866. Lib. Com. 1852,
1868. Trans. 1.
1879 Champneys, Francis Henry, M.A., M.B., Obstetric Phy-
sician to, and Lecturer on Midwifery at, St. George's
Hospital ; Examiner in Obstetric Medicine in the
University of London ; 60, Great Cumberland place.
Lib. Com. 1885-6. Trans. 7.
1859 Chance, Frank, M.D., Burleigh House, Sydenham Hill.
1849 Chapman, Frederick, Old Friars, Richmond Green,
Surrey.
1885 Chapman, Paul Morgan, M.D., Physician to the Here-
ford General Infirmary, 1, St. John street, Hereford.
Trans. 1.
1877 Charles, T. Cranstoun, M.D., Lecturer on Practical
Physiology at St. Thomas's Hospital ; 9, Albert Man-
sions, Victoria street, Westminster.
1881 *Chavasse, Thomas Frederick, M.D., CM., Surgeon
to the Birmingham General Hospital ; 24, Temple Row,
Birmingham. Trans. 2.
1868 Cheadle, Walter Butler, M.D., Secretary, Physician to,
and Lecturer on Medicine at, St. Mary's Hospital ;
Senior Physician to the Hospital for Sick Children ;
19, Portman street, Portman square. S. 1886. Referee,
1885.
1879 Cheyne, William Watson, M.B., Assistant Surgeon to
King's College Hospital, and Demonstrator of Surgery
in King's College, London ; 14, Mandeville place,
Manchester square, W. Lib. Com. 1886.
1873 *Chisholm, Edwin, M.D., Abergeldie, Ashfield, near Sydney,
New South Wales.
XX FELLOWS OF THE SOCIETY.
Elected
1865 Cholmeley, William, M.D., Physician to the Great
Northern Hospital, and Consulting Physician to the
Margaret Street Infirmary for Consumption; 63, Gros-
venor street, Grosvenor square. C. 1881-2. Referee,
1873-80.
18/2 Christie, Thomas Beith, M.D., Medical Superintendent,
Royal India Asylum, Ealing.
1866 Church, William Selby, M.D., Physician to, and Lecturer
on Clinical Medicine at, St. Bartholomew's Hospital ;
130, Harley street, Cavendish square. C. 1885-6.
Referee, IS 74 -81.
1S60 Clark, Sir Andrew, Bart., M.D., LL.D., F.R.S., Physician
to, and Lecturer on Clinical Medicine at, the London
Hospital; 16, Cavendish square. C. 1875.
1879 Clark, Andrew, Assistant Surgeon to, and Lecturer on
Practical Surgery at, the Middlesex Hospital; 11),
Cavendish place, Cavendish square, W.
1839 -j-Clark, Frederick Le Gros, F.R.S., Consulting Surgeon
to St. Thomas's Hospital ; The Thorns, Sevenoaks.
S. 1847-9. V.P. 1855-6. Referee, 1859-81. Lib. Com.
1847. Trans. 5.
1882 Clarke, Ernest, M.D., B.S., 21, Lee terrace, Blackheath.
1848 -^Clarke, John, M.D., 42, Hertford street, May Fair. C.
18 66.
1S81 CLARKE, W. Brick, M.B., Assistant Surgeon to, and
Demonstrator of Anatomy at, St. Bartholomew's
Hospital ; 46, Harley street, Cavendish square.
1S42 ^Clayton, Sir Oscar Moore Pas set, Extra Surgeon-in-
Ordinary to ILK. 11. the Prince of Wales, and Surgeon-
in-Ordinary to 11. II. II. the Duke of Edinburgh; 5,
Harley street, Cavendish square. C 1865.
1879 fCLUTTON, Eenbi Hi i.n, M.A., M.B., Assistant Surgeon to,
and Lecturer on Forensic Medicine at, St. Thomas's
Hospital ; 2, Portland place.
1857 Coatks, Cn aim i IB, .M. I)., Consulting Physician to the Bath
General aud Royal United Hospitals; 10, Circus, Bath.
FELLOWS OF THE SOCIETY. XXI
Elected
1868 Cockle, John, M.D., F.L.S., Physician to the Royal Free
Hospital; 8, Suffolk street, Pall Mall. Trans. 2.
1885 Collins, William Maunsell, M.D., 10, Cadogan place.
1865 Cooper, Alfred, Consulting Surgeon to the West London
Hospital; Surgeon to the Lock Hospital and to St.
Mark's Hospital ; 9, Henrietta street, Cavendish square.
1868 Cornish, "William Robert, Surgeon-Major, Madras Army ;
Sanitary Commissioner for Madras ; Secretary to the
Inspector-General, Indian Medical Department.
1860 *Corry, Thomas Charles Steuart, M.D., Ormean Ter-
race, Belfast.
1864 Coulson, Walter John, Surgeon to the Lock Hospital,
17, Harley street, Cavendish square.
1860 fCouPER, John, Surgeon to the London Hospital; Assist-
ant Surgeon to the Royal London Ophthalmic Hospital;
80, Grosvenor street. C. 18/6. Referee 1882-3.
1877 Coupland, Sidney, M.D., Physician to, and Lecturer on
Practical Medicine at, the Middlesex Hospital; 14,
Weymouth street, Portland place.
1862 Cowell, George, Surgeon to, and Lecturer on Surgery
at, the Westminster Hospital ; Surgeon to the Royal
Westminster Ophthalmic Hospital ; Surgeon to the
Victoria Hospital for Children ; 3, Cavendish place,
Cavendish square. C. 1882-3.
1841 Crawford, Mervyn Archdall Nott, M.D., Millwood,
Wilbury road, Brighton. C. 1853-4.
1868 Crawford, Sir Thomas, K.C.B., M.D., Director General,
Army Medical Department ; 6, Whitehall yard, and 5,
St. John's park, Blackheath.
1873 Creighton, Charles, M.D., 11, New Cavendish street.
Referee, 1882-6. Trans. 1.
1869 *Cresswell, Pearson R., Dowlais, Merthyr Tydvii.
1874 Cripps, William Harrtson, Assistant Surgeon to St. Bar-
tholomew's Hospital ; 2, Stratford place, Oxford street.
Trans. 1.
XX11 FELLOWS OF THE SOCIETY.
Elected
1882 Crocker, Henry Radcliffe, M.D., Physician to the Skin
Department, University College Hospital ; Physician
to the East London Hospital for Children ; 28, Welbeck
street, Cavendish square. Trans. 1.
1868 Croft, John, Surgeon to, and Lecturer on Clinical Surgery
at, St. Thomas's Hospital ; 48, Brook street, Grosvenor
square. C. 1884. Referee, 1885-86. Lib. Com. 1877-
8. Trans. 1.
1862 Crompton, Samuel, M.D., Brookmead, Cranleigh, Surrey.
1837 Crookes, John Farrar, 45, Augusta gardens, Folkestone.
1872 Crosse, Thomas William, Surgeon to the Norfolk and
Norwich Hospital ; 22, St. Giles's street, Norwich.
1849 *Crowfoot, William Edward, Beccles, Suffolk.
1879 Cumberbatch, A. Elkin, Aural Surgeon to St. Bartholo-
mew's Hospital ; Aural Surgeon to the Great Northern
Hospital; 17, Queen Anne street.
1846 Curling, Henry, Consulting Surgeon to the Margate Royal
Sea-Bathing Infirmary ; Augusta Lodge, Ramsgate,
Kent.
1837 fCuRLiNG, Thomas Blizard, F.R.S., Consulting-Sur-
geon to the London Hospital ; 27, Brunswick square,
Brighton. S. 1845-6. C. 1850. T. 1854-7. V.P.
1859. P. 1871-2. Referee, 1844-6, 1851-3, 1858,
1865-70, 1875-9. Sci. Com. 1863. Lib. Com. 1839.
Trans. 13. Pro. 1.
1873 Curnow, John, M.D., Professor of Anatomy in King's
College, London, and Physician to King's College
Hospital ; 3, George street, lLumver square. Referee,
1884-6.
1847 Currey, John Edmund, M.D., Lismore, County Waterford.
1822 Cusack, Christopher John, Chateau d'Eu, France.
1872 Dalby, Sir William Bartlett, M.B., Aural Surgeon to,
and Lecturer on Aural Surgery at, St. George's Hos-
pital ; IS, Sjivile row. Trans. '■'<.
1884 Dallaway, Dknnis, Whitgift House, Croydon.
FELLOWS OF THE SOCIETY. XX111
Elected
1877 Darbishire, Samuel Dukinfield, M.D., Physician to
the Radcliffe Infirmary, Oxford; 60, High street,
Oxford.
1879 Darwin, Francis, M.B., F.R.S., The Grove, Huntingdon
road, Cambridge.
1848 Daukeny, Henry, M.D., San Remo, Italy.
1874 Davidson, Alexander, M.D., Physician to the Liverpool
Northern Hospital ; 2, Gambier terrace, Liverpool.
1853 Davies, Robert Coker Nash, Rye, Sussex.
1852 Davies, William, M.D., 2, Marlborough buildings,
Bath.
1876 Davies-Colley, J. Neville C, M.C., Surgeon to, and
Lecturer on Anatomy at, Guy's Hospital ; 36, Harley
street, Cavendish square. Trans. 2.
1878 Davy, Richard, F.R.S. Ed., Surgeon to, and Lecturer on
Surgery at, the "Westminster Hospital; 33, Welbeck
street, Cavendish square. Trans. 1.
1882 Dawson, Yelverton, M.D., Heathlands, Southbourn-on-
Sea, Hants.
1867 Day, William Henry, M.D., Physician to the Samaritan
Free Hospital for Women and Children ; 1 0, Manchester
square.
1878 Dent, Clinton Thomas, Assistant Surgeon to, and
Lecturer on Practical Surgery at, St. George's Hospital ;
6 1 , Brook street. Trans. 2.
1859 fDicKiNSON, William Howship, M.D., Physician to, and
Lecturer on Medicine at St. George's Hospital, and
Consulting Physician to the Hospital for Sick Children ;
9, Chesterfield street, Mayfair. C. 1874-5. Referee,
1869-73, 1882-6. Sri. Com. 1867-79. Trans. 13.
1839 fDixoN, James, Consulting Surgeon to the Royal London
Ophthalmic Hospital, Moortields ; Harrow Lands,
Dorking. L. 1849-55. V.P. 1857-8. T. 1863-4.
C. 1866-7. Referee, 1865. Lib. Com. 1845-8.
Trans. 4.
XXIV FELLOWS OF THE SOCIETY.
Elected
1862 Dobell, Horace B., M.D., Consulting Physician to the
Royal Hospital for Diseases of the Chest, City road ;
Streate place, Bournemouth. Trans. 2.
1845 Dodd, John.
1879 Donkin, Horatio, MB., Physician to the Westminster
Hospital ; Physician to the East London Hospital for
Children ; 60, Upper Berkeley street, Portman square.
1877 Doran, Alban Henry Griffiths, Assistant Surgeon to the
Samaritan Free Hospital ; 9, Granville place, Portman
square. Trans. 1.
1863 Down, John Langdon Haydox, M.D., Physician to, and
Lecturer on Clinical Medicine at, the London Hospital ;
81, Harley street, Cavendish square. C. 1880.
Trans. 2.
1867 Drage, Charles, M.D., Hatfield, Herts.
1884 Drage, Lovell, Hatfield, Herts.
1879 Drewitt, F. G. Dawtrey, M.D., Assistant Physician to
the West London Hospital and to the Victoria Hospital
for Children ; 52, Brook street, Grosvenor square.
1880 Drury, Charles Dennis Hill, M.D., Bondgate, Darling-
ton.
1805 Drysdale, Charles Robert, M.D., Physician to the Far-
ringdon Dispensary ; Assistant-Physician to the Metro-
politan Free Hospital ; 23, Sackville street, Piccadilly.
1865 ^Duckworth, Sir Dyce, M.D., Physician to, and Lecturer
on Clinical Medicine at, St. Bartholomew's Hospital ;
11, Grafton street, Bond street. C. 1883-4. Referee
1885-G. Trans. 1.
1876 Dudley, William Lewis, M.D., Physician to the City Dis-
pensary; 149, Cromwell road, South Kensington.
1845 Duff, George, M.D., High street, Elgin.
1885 Drummond, David, M.D., 7, Saville Place, Newcastle-on-
Tyne.
1 S7 1 Duffin, Alfred I'wnakd, M.D., Professor of Pathological
Anatomy in King's College, London, and Physician to
King's College Hospital; 18, Devonshire 6treet, Port-
land place.
FELLOWS OF THE SOCIETY. XXV
Elected
1871 Doke, Benjamin, Windmill House, Clapham common.
1871 *Dukes, Clement, M.D., B.S., Physician to Rugby School,
and Senior Physician to the Hospital of St. Cross,
Rugby ; Sunnyside, Rugby, Warwickshire.
1867 Dukes, M. Charles, M.D., Wellesley Villa, Wellesley
road, Croydon.
1880 Dunbar, James John Macwhirter, M.D., Hedingham
House, Clapham common.
1877 Duncan, James Matthews, M.D., LL.D., P.E.S., Obstetric
Physician to, and Lecturer on Midwifery and Diseases
of Women at, St. Bartholomew's Hospital; 71, Brook
street, Grosvenor square. Referee, 1881-6. Trans. 1.
18S4 Duncan, William A., M.D., Assistant Obstetric Physician
and Teacher of Operative Midwifery, Middlesex Hos-
pital; 6, Harley street, Cavendish square.
1863 Durham, Arthur Edward, F.L.S., Surgeon to, and Lecturer
on Surgery at, Guy's Hospital ; 82, Brook street,
Grosvenor square. C. 1876-7. Referee, 1880-1. Sci.
Com. 1867. Lib. Com. 1872-5. Trans. 5.
1874 Durham, Frederic, M.B., 82, Brook street, Grosvenor
square.
1843 Durrant, Christopher Mercer, M.D., Consulting Physi-
cian to the East Suffolk and Ipswich Hospital; North-
gate street, Ipswich, Suffolk.
1872 Eager, Reginald, M.D., Northwoods, near Bristol.
1868 Eastes, George, M.B.Lond., 69, Connaught street, Hyde
park square.
1883 Edmunds, Walter, M.C., 79, Lambeth Palace road, Albert
Embankment. Trans. 2.
1883 Edwardes, Edward Joshua, M.D., 17, Orchard street,
Portman Square, W.
1884 Edwards, Frederick Swinford, Surgeon to the West
London Hospital ; 93, Wimpole street, Caveudish
square.
XXVI FELLOWS OF THE SOCIETY.
Elected
1824 Edwards, George.
1869 Elam, Charles, M.D., 75, Harley street, Cavendish square.
Lib. Com. 1886.
1848 Ellis, Geokge Viner, late Professor of Anatomy in Uni-
versity College, London ; Minsterworth, Gloucester.
C. 1863-4. Trans. 2.
1868 Ellis, James, M.D., the Sanatorium, Anaheim, Los Angeles
County, California.
1854 *Ellison, James, M.D., Surgeon-in-Ordinary to the Royal
Household, Windsor ; 14, High street, Windsor.
1842 IErichsen, John Eric, LL.D.,F.R.S., Surgeon Extraordi-
nary to H.M. the Queen ; Emeritus Professor of
Surgery in University College, London, and Consulting
Surgeon to University College Hospital ; 6, Cavendish
place, Cavendish sq. C. 1855-6. V.P. 1868. P.1879-80.
Referee, 1866-7, 1884-6. Lib. Com. 1844-7, 1854.
Trans. 2.
1879 Eve, Frederic S., Pathological Curator of the Museum,
Royal College of Surgeons ; Assistant Surgeon to the
London Hospital ; 15, Finsbury circus. Trans. 2.
1877 Ewart, William, M.D., Assistant Physician to, and Lec-
turer on Physiology at, St. George's Hospital ; 33,
Curzon street, Mayfair.
1875 *Fagan, John, Surgeon to, and Lecturer on Clinical
Surgery at, the Belfast Royal Hospital; 1, Glengall
place, Belfast.
1869 Fairbank, Frederick Royston, M.D., 46, Hallgate, Don-
caster.
1862 Faruuharson, Robeht, M.D., LL.D., M.P., Migvie Lodge,
Porchester gardens, Hyde park ; Finzean, Aboync,
Aberdeenshire, and the Reform Club, Pall Mall. Lib.
Com. 1876-80.
18 14 f^ARRE, Arthur, M.D., F.R.S., Physician Extraordinary to
H.M. the Queen ; Physician-Accoucheur to H.R.II. the
Princess of Wales ; 18, Albert Mansions, Victoria street,
Westminster. C. 1857. V.P. 1864. Referee, 1848-54,
1861-3, 1865-6. Sci. Com. 1863. Lib. Com. 1847.
FELLOWS OF THE SOCIETY. XXV11
Elected
1872 Fayreii, Sir Joseph, K.C.S.I., M.D., F.R.S., Honorary
Physician to H.M. the Queen, and to H.R.H. the Prince
of Wales, and Physician to H.R.H. the Duke of Edin-
burgh ; late Surgeon-General Bengal Medical Service ;
Examining Medical Officer to the Secretary of State for
India in Council ; President of the Indian Medical
Board; 53, Wimpole street, Cavendish square. Referee,
1881-6.
18/2 *Fenwick, John C. J., M.D., Physician to the Durham
County Hospital ; 25, North road, Durham.
1863 Fenwick, Samuel, M.D., Physician to the London Hospital ;
29, Harley street, Cavendish square. C. 1880. Referee,
1882-6. Trans. 4.
1S80 Ferrier, David, M.D.,LL.D., F.R.S., Professor of Forensic
Medicine in King's College, London, and Physician to
King's College Hospital ; Physician for Out-patients
to the National Hospital for the Paralysed and Epilep-
tic; 34, Cavendish square. Trans. 2.
1852 *Field, Alfred George.
1849 fFiNCHAM, George Tupman, M.D., Consulting Physician
to the Westminster Hospital; 13, Belgrave road,
Pimlico. C. 1871.
1879 Fixlay, David White, M.D., Physician to, and Lecturer
on Forensic Medicine at, the Middlesex Hospital ;
Physician to the Royal Hospital for Diseases of the
Chest ; 9, Lower Berkeley street, Portman square.
1866 Fish, John Crockett, B.A., M.D., 92, Wimpole street,
Cavendish square.
1866 Fitz-Patrick, Thomas, M.D., M.A., 30, Sussex gardens,
Hyde park.
1842 Fletcher, Thomas Bell Elcock, M.D., Consulting Physi-
cian to the Birmingham General Hospital ; 8, Claren-
don crescent, Leamington. Trans. 1.
1864 *Folker, William Henry, Surgeon to the North Stafford-
shire Infirmary ; Bedford House, Hanley, Staffordshire.
1877 de Fonmartin, Henry, M.D., Parkhurst, Isle of Wight.
XXV111 FELLOWS OF THE SOCIETY.
Elected
1848 j-FoitBES, John Gregory, Egerton House, Egerton, Ashford,
Kent. C. 1868-9. Lib. Com. 1855. Trans. 2.
1865 Foster, Sir Balthazar Walter, M.D., Professor of Medi-
cine at the Queen's College, Birmingham, and Physician
to the Birmingham General Hospital; 14, Temple row,
Birmingham.
1883 Fowler, James Kingston, M.A., M.D., Assistant Phy-
sician to, and Lecturer on Pathological Anatomy at,
the Middlesex Hospital, and Assistant Physician to th
Hospital for Consumption, Brompton ; 35, Clarges
street, Piccadilly.
1859 Fox, Edward Long, M.D., Consulting Physician to the
Bristol Royal Infirmary ; Church House, Clifton, Glou-
cestershire.
1880 Fox, TnoMAS Colcott, B.A., M.B., Physician to the Skin
Department of the Paddington Green Hospital for
Children, and Assistant Physician to the Victoria
Hospital for Children; 14, Harley street, Cavendish
square. Trans. 1 .
1858 Fox, Wilson, M.D., F.R.S., Librarian, Physician-Extra-
ordinary to 11. M. the Queen ; Physician in Ordinary
to the Duke and Duchess of Edinburgh ; Holme
Professor of Clinical Medicine in University College,
London, and Physician to University College Hospital ;
67, Grosvenor street. C. 1875-6. L. 18S3-6. lie/eree,
KS69-74. Lib. Com. 1866-70, 1S74. Trans. 3.
1871 Frank, Philip, M.D., Cannes, France.
1884 *Franks, Krnd.vl, M.D., Surgeon to the Adelaide Hospital
and to the Throat and Ear Hospital, Dublin ; 69, Fitz-
william square, Dublin.
1843 Fraskr, Patrick, M.D. C. 1866.
1868 Freeman, William Henry, 21, St. George's square, South
Belgravia.
1836 tFrench, John George, 10, Cunningham place, St. John's
Wood road. C. 1852-3.
FELLOWS OF THE SOCIETY. XXIX
Elected
1884 Fuller, Charles Chinner, 10, St. Andrew's place,
Regent's park.
1883 Fuller, Henry Roxburgh, M.D., 45, Curzon street, May
Fair.
1876 Furner, Willoughby, Assistant Surgeon to the Sussex
County Hospital ; 2, Brunswick place, Brighton.
1864 *Gairdner, William Tennant, M.D., LL.D., Physician in
Ordinary to H.M. the Queen in Scotland; Professor of
the Practice of Medicine in the University of Glasgow ;
Physician to the Western Infirmary, Glasgow ; 225,
St. Vincent street, Glasgow.
18/4 Galabin, Alfred Lewis, M.A., M.D., Obstetric Physician
to, and Lecturer on Midwifery and the Diseases of
Women at, Guy's Hospital ; Assistant Physician to the
Hospital for Sick Children ; 49, Wimpole street,
Cavendish square. Referee, 1882-6. Lib. Com. 1883-
4. Trans. 2.
1883 Galton, John Charles, M.A., F.L.S., 45, Great Marl-
borough street.
1885 Gamgee, Arthur, M.D., F.R.S., Fullerian Professor of
Physiology in the Royal Institution of Great Britain ;
11, Warrior square, St. Leonard's-on-sea.
1865 Gant, Frederick James, Senior Surgeon to the Royal Free
Hospital; 16, Connaught square, Hyde park. C. 1880-
81. Referee, 1886. Lib. Com. 1882-5. Trans. 3.
1867 Garland, Edward Charles, Yeovil, Somerset.
1867 Garlike, Thomas W., Malvern Cottage, Churchfield road,
Ealing.
1854 fGARROD, Alfred Baring, M.D., F.R.S., Consulting Phy-
sician to King's College Hospital; 10, Harley street,
Cavendish square. C. 1867. V.P. 1880-81. Referee,
1855-65. Trans. 8.
1879 Garstang, Thomas Walter Harropp, The Heath, Knuts-
ford, Cheshire.
XXX FELLOWS OF THE SOCIETY.
Elected
1851 fGASKOiN, George, Surgeon to the British Hospital for
Diseases of the Skin ; The Priory, Caerleon, Mon-
mouthshire. C. 1875-6. Trans. 2.
1819 Gaulter, Henry.
18G6 Gee, Samcjel Jones, M.D., Physician to, and Lecturer on
Medicine at, St. Bartholomew's Hospital ; Consulting
Physician to the Hospital for Sick Children ; 54,
Wimpole street, Cavendish square. C. 1883-4. Sri.
Com. 1879. Referee, 18S5-6. Lib. Com. 1871-6.
Trans. 1.
1885 Gell, Henry Wielixgham, Balliol College, Oxford.
1878 Gekvis, Henry, M.D., Obstetric Physician to, and Lecturer
on Obstetric Medicine at, St. Thomas's Hospital ;
40, Harley street, Cavendish square. Referee, 1884-G.
1884 Gibres, Heneage, M.D., Physician to the Metropolitan
Dispensary; Lecturer on Morbid Histology, Westmin-
ster Hospital ; 44, Charleville road, West Kensington.
1880 Gibbons, Robert Alexander, M.D., Physician to the
Grosvenor Hospital for Women and Children ; 32,
Cadogan place.
1877 Godlee, Rickman John, Surgeon to University College
Hospital, and Teacher of Operative Surgery in University
College, London ; Surgeon to theXorth-Eastern Hospital
for Children, and to the Hospital for Consumption,
Brompton ; 81, Wimpole street, Cavendish square.
Referee, 188G. Trans. 2.
1870 Godson, Clement, M.D., Assistant-Physician-Accoucheur
to St. Bartholomew's Hospital ; Consulting Physician
to the City of London Lying-in Hospital ; !), Grosvenor
street, Grosvenor square.
1886 Golding-Bird, Cuthbert Hilton, M.B., Assistant Surgeon
and Lecturer on Physiology at Guy's Hospital ; 13,
St. Thomas street, Southwark.
1 s r» l Goodi Ki.inw, Stephen Jennings, M.D., Consulting Phy-
sician to the Middlesex Hospital ; Swinnerton Lodge,
near Dartmouth, Devon. C. 1864-5. Referee, 1860-3.
Lib. Com. 1863. Trans. 2.
FELLOWS OF THE SOCIETY. XXXI
Elected
1883 Goodhart, James Frederic, M.D., Assistant Physician to,
and Curator of the Museum at, Guy's Hospital ; Phy-
sician to the Evelina Hospital for Sick Children ; 25,
Weymouth street, Portland place.
1877 Gould, Alfred Pearce, M.S., Assistant Surgeon to the
Middlesex Hospital; 16, Queen Anne street, Cavendish
square. Trans. 1.
1873 Gowers, William Richard, M.D., Assistant Professor of
Clinical Medicine in University College, London, and
Physician to University College Hospital ; Physician
for Out-patients to the National Hospital for the Para-
lysed and Epileptic ; 50, Queen Anne street, Cavendish
square. Lib. Com. 1884-6. Trans. 6.
1851 fGowLLAND, Peter Yeames, Surgeon to St. Mark's Hos-
pital ; Surgeon-Major Hon. Artillery Company; 34,
Finsbury square.
1846 Gream, George Thompson, M.D., Physician-Accoucheur to
H.R.H. the Princess of Wales; Mixbury, Eastbourne,
Sussex. C. 1863.
1868 Green, T. Henry, M.D., Physician to, and Lecturer on
Pathology at, Charing Cross Hospital; Assistant-Phy-
sician to the Hospital for Consumption, Brompton ;
74, Wimpole street, Cavendish square. C. 1886.
Referee, 1882-5.
1875 *Greenfield, William Smith, M.D., Professor of General
Pathology in the University of Edinburgh ; 7, Heriot
row, Edinburgh. Sci. Com. 1879. Referee, 1881.
1843 -j-Greenhalgh, Robert, M.D., Consulting Physician to the
Samaritan Free Hospital for Women and Children,
and to the City of London Lying-in Hospital ; 35,
Cavendish square. C. 1871-2. Referee, 1876-7.
Trans. 1.
1860 Greenhow, Edward Headlam, M.D., F.R.S., Consulting
Physician to the Middlesex Hospital ; and Consulting
Physician to the Western General Dispensary ; Castle
Lodge, Reigate. C. 1876-7. Referee, 1870-5. Trans. 3.
XXX11 FELLOWS OF THE SOCIETY.
Elected
1882 Gresswell, Dan Astley, M.B., 87, Queen's crescent,
Haverstock hill.
1885 Griffith, Walter Spencee Anderson, M.B., Physician
to the Samaritan Free Hospital for Women and
Children ; 114, Harley street, Cavendish square.
1884 Griffiths, Herbert Tyrrell, M.D., 57, Brook street.
1868 Grigg, William Chapman, M.D., Assistant Obstetric Phy-
sician to the Westminster Hospital ; Physician to the
In-Patients, Queen Charlotte's Lying-in-Hospital ;
27, Curzon street, Mayfair.
1852 Grove, John, Fyning, Austen road, Guildford.
1860 Gueneau de Mussy, Henri, M.D. ; 15, Rue du Cirque,
Paris. Lib. Cum. 1803-5.
1849 fGuLL, Sir William Withey, Bart., M.D., D.C.L., LL.D.,
P. U.S., Physician-Extraordinary toH.M.the Queen; and
Physician in Ordinary to U.K. II. the Prince of Wales;
.Member of the Senate of the University of London ;
Consulting Physician to Guy's Hospital ; 74, Brook
street, Grosvenor square. C. 1864. V.P. 1874.
Referee, 1855-63. Trans. 4.
1885 Gulliver, George, M.B., Assistant Physician to, and Lec-
turer on Comparative Anatomy at, St. Thomas's Hos-
pital ; 16, W'elbeek street.
1883 Gunn, Robert Marcus, M.B., Assistant Surgeon to the
Royal London Ophthalmic Hospital, Mooriields ; ."i 1,
Queen Anne street, Cavendish square.
1854 tHABEKSIION» Samuel Osborne, M.D., 70, Brook stmt,
Grosvenor square. S. 1867. C. 1869-70. V.P.
L881-2. Referee, 1862-6, 1868, 1871-80. Trans. 3.
1885 IIaig, Alexander, M.B., Casualty Physician to St. Bartho-
lomew's Hospital ; 30, Welbeck street, Cavendish
square.
1881 Hall, Francis de Havilland, M.D., Assistant Physician,
and Physician to the Throat Department, and Lecturer
on Forensic Medicine at the Westminster Hospital;
Physician to St. Mark's Hospital ; 47, Wimpole street,
Cavendish square.
FELLOWS OF THE SOCIETY. XXX111
Elected
1885 Halliburton, William Dobinson, M.D., Assistant Pro-
fessor of Physiology, University College, London ; 135,
Gower street.
18/0 Hamilton, Robert, Surgeon to the Eoyal Southern Hos-
pital, Liverpool ; 1 Prince's road, Liverpool.
1874 Hardie, Gordon Kenmure, M.D., Deputy Inspector
General of Hospitals ; Florence road, Ealing, and Duff
House, Banff, N.B.
1856 fHARE, Charles John, M.D., late Professor of Clinical
Medicine in University College, London, and late Physi-
cian to University College Hospital ; Berkeley House,
15, Manchester square. C. 1873-4.
1857 Harley, George, M.D., F.R.S. 25, Harley street, Caven-
dish square. C. 1871-2. Referee, 1865-70, 1873-6.
Sci. Com. 1862-3. Trans. 1.
1864 Hakley, John, M.D., F.L.S., Physician to, and Lecturer on
General Anatomy and Physiology at, St. Thomas's
Hospital ; 39, Brook street, Grosvenor square. S.
1875-7. C. 1879-80. Referee, 1871-4, 1882-6. Sci.
Com. 1879. Trans. 10.
1880 Harris, Vincent Dormer, M.D., Assistant Physician to the
Victoria Park Hospital; Demonstrator of Physiology
at St. Bartholomew's Hospital; 31, Wimpole street,
Cavendish square.
1870 Harrison, Reginald, Surgeon to the Liverpool Royal
Infirmary, and Lecturer on Clinical Surgery in the
Victoria University; 41, Rodney street, Liverpool.
Trans. 1.
1854 Haviland, Alfred.
1870 Haward, J. Warrington, Surgeon to, and Lecturer on
Clinical Surgery at, St. George's Hospital; 16, Savile
row, Burlington gardens. C. 1885. Lib. Com. 1881-4.
Trans. 1.
1838 f Hawkins, Charles, Inspector of Anatomical Schools in
London; 9, Duke street, Portland place. C. 1S46-7.
S. 1850. V.P. 1858. T. 1861-2. Referee, 1859-60.
Lib. Com. 1843. Trans. 2.
vol. lxix. c
XXXIV FELLOWS OF THE SOCIETY.
Elected
1885 Hawkins, Francis Henry, M.B., Physician to St. George's
and St. James's Dispensary ; 22, Henrietta street,
Cavendish square.
1848 IHawksley, Thomas, M.D., Consulting Physician to
the Margaret street Dispensary for Consumption and
Diseases of the Chest; 1 1 , Albert Mansions, Victoria
street, and Beomands, Chertsey, Surrey.
18/5 Hayes, Thomas Crawford, M.D.. Physician-Accoucheur
and Physician for Diseases of Women and Children to
King's College Hospital ; 1", Clarges street, Piccadilly.
18G0 Hayward, Henry Howard, Surgeon Dentist to, and
Lecturer on Dental Surgery at, St. Mary's Hospital ;
38, Harley street, Cavendish square. C. 1 5S78-9.
1SG1 Hayward, William Henry, Corby, Grantham.
1848 *Heale, James Newton, M.D.
1865 Heath, Christopher, Holme Professor of Clinical Surgery
in University College, London ; and Surgeon to Uni-
versity College Hospital ; 36, Cavendish square. C.
1880. Lib. Com. 1870-3. Trans. 3.
1850 Heaton, George, M.D., Boston, U.S.
1882 Hensley, Philip John., M.D., Assistant Physician and
Lecturer on Forensic Medicine to St. Bartholomew's
Hospital ; 4, Henrietta street, Cavendish square.
1821 Herberski, Vincent, M.D., Professor of Medicine in the
University of Wilna.
1877 Herman, George Ernest, M.B., Obstetric Physician to,
and Lecturer on Midwifery at, the London Hospital ;
7, West street, Finsbury circus. Trans. 1.
1877 Heron, George Allan, M.D., Physician to the City of
London Hospital for Diseases of the Chest, Victoria
Park; :>7, Harley street, Cavendish square.
1883 Herringiiam, Wii.mot Parker, M.B., 22, Bedford square.
FELLOWS OF THE SOCIETY. XXXV
Elected
1843 IHewett, Sir Prescott Gardner, Bart., F.R.S., Serjeant-
Surgeon to H.M. the Queen ; Surgeon in Ordinary
to H.R.H. the Prince of Wales ; Consulting Surgeon
to St. George's Hospital; Corresponding Member
of the "Academie de Medecine," and of the " Societe
de Chirurgie," Paris ; Chesnut Lodge, Horsham, Sussex.
C. 1859. V.P. 1866-7. Referee, 1850-8, 1860-5,
1868-83. Sci. Com. 1863. Lib. Com. 1846-7. Trans. 7.
1855 Hewitt, "W. M. Grailt, M.D., Professor of Midwifery in
University College, London, and Obstetric Physician to
University College Hospital ; 36, Berkeley square. C.
1876. Referee, 1868-/5, 1877-86. Lib. Com. 1868,
1874.
1880 Hicks, Charles Cyril, M.D., Wokingham, Berks.
1873 Higgens, Charles, Assistant Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, Guy's Hospital ; 38,
Brook street, Grosvenor square. Trans. 2.
1862 Hill, M. Berkeley, M.B., Vice-President, Professor of
Clinical Surgery in University College, London, and
Surgeon to University College Hospital ; Surgeon to the
Lock Hospital , 66, Wimpole street, Cavendish square.
C. 1878-9. S. 1881-4. V.P. 1885-6. Trans. 1.
1867 Hill, Samuel, M.D., 22, Mecklenburgh square.
1861 *Hoffmeister, Sir William Carter, M.D., Surgeon to
H.M. the Queen in the Isle of Wight ; Clifton House,
Cowes, Isle of Wight.
1843 fHoLDEN, Luther, Consulting Surgeon to St. Bartho-
lomew's Hospital, to the Metropolitan Dispensary, and
to the Foundling Hospital ; Pinetoft, Ipswich. C.
1859. L. 1865. V.P. 1874. Referee, \866-7. Lib.
Com. 1858.
1879 Holland, Philip Alexander, M.A.
1868 Hollis, William Ainslie, M.A., M.D., Assistant-Phy-
sician to the Sussex County Hospital ; 8, Cambridge
road, Brighton.
XXXVI FELLOWS OF THE SOCIETY.
Elected
1861 Holman, William Henky, M.B., 68, Adelaide road, South
Hampstead.
1856 Holmes, Timothy, M.A., Treasurer, Surgeon to St. George's
Hospital; Corresponding Member of the " Societe de
Chirurgie," Paris; 18, Great Cumberland place, Hyde
park. C. 1869-70. L. 1873-7. S. 1878-80. V.P.
1881-2. T. 1885-6. Referee, 1866-8, 1872, 1883-4.
Sci. Com. 1867. Lib. Com. 1863-5. Trans. 8.
1846 flloLT, Barnard Wight, Consulting Surgeon to the
Westminster Hospital ; Medical Officer of Health for
Westminster, 14, Savile row, Burlington gardens. C.
1862-3. V.P. 1879-80.
1846 -J-IIoltiiouse, Carsten, 35, Essex street, Strand. C. 1863.
Referee 1870-6. Lib Com. 1859-60.
1878 Hood, Donald William Challks, M.D., Senior Physician
to the North-West London Hospital ; Physician to the
West London Hospital ; 43, Green street, Park lane.
1883 Horsley, Victor Alexander Haden, F.R.S., Assistant
Surgeon to University College Hospital, and Assistant
Professor of Pathological Anatomy in University Col-
lege, London ; Superintendent of the Brown Institution,
Wandsworth road ; b0, Park street, Grosvcnor Square.
1878 Houghton, Walter B., M.D., Church Villa, Warrior
square, St. Leonards-on-Sea.
1865 Howard, Benjamin, M.D., New York, U.S.
1881 Howard, Henry, M.B., abroad [6, The Terrace, Mount
Pleasant, Cambridge].
1S74 IIowse, IIknky Gitr.r.NW \v, .M.S., Surgeon to, and Lecturer
on Anatomy at, Guv's Hospital ; Surgeon to the Evelina
Hospital for Sick Children ; 10, St. Thomas's street,
Southwark. Set. Com. 1879. Trans. 2.
1886 Hudson, Charles Leopold, Middlesex Hospital.
1884 Huggard, William R., M.D. [Place de la Synagogue,
2, Geneve.]
FELLOWS OF THE SOCIETY. XXXVll
Elected
1857 Hulke, John Whitaker, F.R.S., Librarian, Surgeon to
the Middlesex Hospital ; Surgeon to the Royal London
Ophthalmic Hospital, Moorfields ; 10, Old Burlington
street. C. 1871-2. S. 1876-7. L. 1879-86. Sci.
Com. 1867. Lib. Com. 1864-8. Trans. 8.
1844 tHUMBY> Edwin, M.D., 83, Hamilton terrace, St. John's
wood. C. 1866-7.
1855 Humphry, George Murray, M.D., F.R.S., Surgeon to
Addenbrooke's Hospital ; Professor of Surgery in the
University of Cambridge. Trans. 6.'
1882 Humphry, Laurence, M.B., 3, Trinity street, Cambridge.
1873 Hunter, Sir W. Guyer, M.D., M.P., Hon. Surgeon to H.M.
the Queen ; late Principal of, and Professor of Medicine
in, Grant Medical College, Bombay ; Surgeon-General
Bombay Army; 21, Norfolk crescent, Hyde park.
1849 Hussey, Edward Law, Consulting Surgeon to the County
Lunatic Asylum and the Warneford Asylum ; 24, Win-
chester Road, Oxford. Trans. I.
1856 Hutchinson, Jonathan, F.R.S., Consulting Surgeon to,
and Emeritus Professor of Surgery at, the London
Hospital ; Consulting Surgeon to the Royal London
Ophthalmic Hospital, Moorfields ; and Surgeon to the
Hospital for Diseases of the Skin ; 15, Cavendish
square. C. 1870. V.P. 1882. Referee, 1876-81,
1883-6. Lib. Com. 1864-5. Trans. 13. Pro. 2.
1820 Hutchinson, William, M.D.
1840 -(-Hutton, Charles, M.D., 26, Lowndes street, Belgrave
square. C. 1858-9.
1847 Image, William Edmund, Herringswell House, Milden-
hall, Suffolk. Trans. 1.
1856 Inglis, Cornelius, M.D., Cairo. [Athenaeum Club, Pall
Mall.]
1871 Jackson, J. Hughltngs, M.D., F.R.S., Physician to the
London Hospital ; Physician to the National Hospital
for the Paralysed and Epileptic ; 3, Manchester square.
XXXV111 FELLOWS OF THE SOCIETY.
Elected
1841 f Jackson, Paul, 51, Wellington road, St. John's Wood.
C. 1862.
1863 Jackson, Thomas Vincent, Senior Surgeon to the Wolver-
hampton and Staffordshire General Hospital; 4 7,
Waterloo road, south, Wolverhampton.
1883 Jacobson, Walter Hamilton Acland, B.A., M.B., Assis-
tant Surgeon to Guy's Hospital; Surgeon to the Royal
Hospital for Children and Women; 41, Finsbury
square. Trans. 1.
1825 James, John B., M.D.
1883 *Jenkins, Edward Johnstone, M.D., The Australian
Club, Sydney, New South Wales.
1851 tJenner, Sir William, Bart., M.D., K.C.B.,D.C.L., LL.D.,
F.R.S., Physician in Ordinary to H.M. the Queen, and
to H.R.H. the Prince of Wales; Emeritus Professor of
Clinical Medicine in University College, London ; and
Consulting Physician to University College Hospital ;
Member of the Senate of the University of London ;
63, Brook street, Grosvenor square. C. 1864. V.P. 1875.
Referee, 1855, 1859-63. Trans. 3.
1884 Jennings, Charles Egekton, M.S., M.B., 75, Park street,
Grosvenor square.
1881 Jennings, William Oscar, M.D., 8, Rue Roy, Paris.
1884 Jessett, Frederic Bowreman, Surgeon to the Royal
General Dispensary ; 1(3, Upper Wimpole street.
1883 Jessop, Walter II. H., M.B., Demonstrator of Anatomy at
St. Bartholomew's Hospital ; 73, Ilarley street.
1851 Johnson, Edmund Charles, Corresponding Member of the
Medical and Philosophical Society of Florence, and of
" l'lnstitut Genevois."
1S47 fJoiiNsoN, George, M.D., F.R.S., Consulting Physician to
King's College Hospital; Member of the Senate of the
University of London ; 11, Savile row, Hurlington gar-
dens. C. 1S62-3. V.P. 1870. P. 1884-5. L. 1878-80.
Referee, 1853-61, 1864-9. Lib. Com. 1860-1. Trans.
10. Pro. 1.
FELLOWS OF THE SOCIETY. XXXIX
Elected
1881 Johnson, George Lindsay, M.A., M.D., Cortina, Netherhall
terrace, South Hampstead, and 14, Stratford place,
Oxford street.
1884 Johnston, James, M.D., 40, Brook street, Grosvenor
square.
18-18 Johnstone, Athol Archibald Wood, Consulting Surgeon
to the Royal Alexandra Hospital for Sick Children, St.
Moritz House, 6), Dyke road, Brighton. Lib. Com.
1860. Trans. 1.
1876 Jones, Leslie Hudson, M.D., Liraefield House, Cheetham
hill, Manchester.
1875 * Jones, Philip Sydney, M.D., Consulting Surgeon to the
Sydney Infirmary ; Examiner in Medicine, Sydney
University; 10, College street, Sydney, New South
Wales. [Agents: Messrs. D. Jones & Co., 1, Gresham
buildings, Basinghall street.]
1859 Jones, William Price, M.D., Claremont road, Surbiton,
Kingston.
1865 Jordan, Furneaux, Surgeon to the Queen's Hospital, and
Professor of Surgery at the Queen's College, Birming-
ham ; Gate House, Edmund street, Birmingham.
1881 Juler, Henry Edward, Assistant Surgeon Royal West-
minster Ophthalmic Hospital ; Junior Ophthalmic Sur-
geon to St. Mary's Hospital ; 77, Wimpole street,
Cavendish square.
1816 *Kauffmann, George Hermann, M.D., Hanover.
1882 Keetley, Charles R. B., Senior Surgeon to the "West
London Hospital ; Surgeon to the Surgical Aid Society;
10, George street, Hanover square.
1872 Kelly, Charles, M.D., Professor of Hygiene in King's
College, London, and Medical Officer of Health for the
West Sussex Combined Sanitary District; Broadwater
road, Worthing, Sussex.
1818 *Kendell, Daniel Burton, M.D., Heath House, Wakefield,
Yorkshire.
Xl FELLOWS OF THE SOCIETY.
Elected
1884 Keser, Jean Samuel, M.D., Surgeon to the French Hos-
pital, Leicester place; 60, Queen Anne street.
1877 *Khory, Rustonjee Naserwanjee, M.D., Physician to the
Parell Dispensary, Bombay ; Girgaum road, Bombay.
1857 Kiallmark, Henry Walter, 5, Pembridge gardens, Bays-
water.
1881 Kidd, Percy, M.A., M 1)., Assistant Physician to the
Hospital for Consumption, Brompton ; GO, Brook street,
Grosvenor square. Trans. 3.
1851 •j-KiNGDON.JoHN Abernethy, Surgeon to the City of London
Truss Society, and Consulting Surgeon to the City
Dispensary ; 2, New Bank buildings, Lothbury. C
1866-7. V.P. 1872-3. Sri. Com. 1S67. Trans. 1.
1885 Klein, Edward Emanuel, M.D., F.R.S., Lecturer on
Physiology, St. Bartholomew's Hospital ; 94, Philbeach
gardens, Earl's Court.
1883 Knapton, George, Strathgyle, Portswood, Southampton.
1840 fL-ANE, Samuel Armstrong, Consulting Surgeon to St.
Mary's Hospital and to the Lock Hospital; 49, Norfolk
square, Hyde park. C. 1849-50. V.P. 1865. Referee,
1850.
1884 Lane, William Arbuthnot, M.S., Assistant Surgeon to
the Hospital for Sick Children ; 14, St. Thomas's
street, Southwark. Trans. 1.
1882 Lang, William, Ophthalmic Surgeon to, and Lecturer
on Ophthalmic Surgery at, the Middlesex Hospital ;
Assistant Surgeon to the Royal London Ophthalmic
Hospital, Mooriields; 26, Upper Wimpole street,
Cavendish square.
1865 Langton, John, Surgeon to, and Lecturer on Anatomy
at, St. Bartholomew's Hospital; Surgeon to the City
of London Truss Society; 2, Harley street, Cavendish
square. C. 1881-2. Referee, 18S5-6. Lib. Com.
1879-80.
FELLOWS OF THE SOCIETY. xli
Elected
1873 *Larcher, 0., M.D., Laureate of the Institute of France,
of the Medical Faculty, and Academy of Paris, &c. ;
97, Rue de Passy, Passy, Paris.
1862 Latham, Peter Wallwork, M.A., M.D., Downing Pro-
fessor of Medicine, Cambridge University ; Physician
to Addenbrooke's Hospital, Cambridge; 17, Trumping-
ton street, Cambridge.
1816 Lawrence, G. E.
1884 Lawson, George, Surgeon-Oculist to H.M. the Queen ;
Surgeon to the Royal London Ophthalmic Hospital
and to the Middlesex Hospital; 12, Harley street,
Cavendish square.
1880 Laycock, George Lockwood, M.B., Physician to the
Paddington Green Children's Hospital ; 12, Upper
Berkeley street, Portman square.
1882 Ledwich, Edward l'Estrange, Lecturer on Surgical and
Descriptive Anatomy in the Ledwich School of Medi-
cine, Dublin ; 23, Upper Leeson Street, Dublin.
1843 fLEE, Henry, Consulting Surgeon to St. George's Hos-
pital; 9, Savile row, Burlington gardens. C. 1856-7.
L. 1863-4. V.P. 1868-9. Referee, 1855, 1866-8. Sci.
Com. 1867. Trans. 14. Pro. 2.
1884 Lee, Robert James, M.D., Assistant Physician to the
Hospital for Sick Children ; 6, Savile row.
1883 Leeson, John Rudd, M.D., CM., 6, Clifden road,
Twickenham.
1869 Legg, John Wickham, M.D., Assistant Physician to, and
Lecturer on Pathological Anatomy at, St. Bartholomew's
Hospital; 47, Green street, Park lane. C. 1886.
Referee, 1882-5. Lib. Com. 1878-85. Trans. 2.
1836 Leighton, Frederick, M.D.
1872 Liebreich, Richard, Consulting Ophthalmic Surgeon to
St. Thomas's Hospital ; Paris.
1878 Lister, Sir Joseph, Bart., D.C.L., LL.D., F.R.S., Surgeon
Extraordinary to H.M. the Queen ; Professor of Clinical
Surgery at King's College, London ; and Surgeon to
King's College Hospital; 12, Park crescent, Regent's
park.
Xlii FELLOWS OF THE SOCIETY.
Elected
1872 *Little, David, M.D., Senior Surgeon to the Royal Eye
Hospital, Manchester; 21, St. John street, Manchester.
1871 Little, Louis Stromeyer, Shanghai, China.
1819 Lloyd, Robert, M.D.
1820 Locher, J. G., M.C.D., Town Physician of Zurich.
Trans. 2.
1881 Lockwood, Charles Barrett, Surgeon to the Great
Northern Central Hospital, and Demonstrator of
Anatomy and Operative Surgery at St. Bartholomew's
Hospital; 19, Upper Berkeley street. Trans. 1.
18G0 Longmokk, Sir Thomas, C.B., Hon. Surgeon to H.M. the
Queen ; Surgeon-General, Army Medical Staff, and
Professor of Military Surgery, Army Medical School,
Netley, Southampton ; Woolston Lawn, Woolston,
Hants. Trans. 2.
1836 Lowenfeld, Joseph S., M.D., Berhice.
1871 Lowxds, Thomas Mackford, M.D., late Professor of
Anatomy and Physiology at Grant Medical College,
Bomhay ; Egham Hill, Surrey.
1881 Lucas, Richard Clement, Senior Assistant Surgeon to,
and Demonstrator of Operative and Practical Surgery
at, Guy's Hospital ; Surgeon to the Evelina Hospital
for Sick Children; 18, Finshury square.
1883 Lund, Edward, Professor of Surgery, and Member of
Senate, Victoria University, Manchester; Consulting
Surgeon to the Manchester Royal Infirmary ; 22,
St. John street, Manchester.
1857 Lyon, Felix William, M.D., 7, South Charlotte street,
Edinburgh.
1867 MabBRLY, George Frederick, Mailai Valley, Nelson, New
Zealand.
1873 MacCartiiy, JEREMIAH, M.A., Surgeon to the London
Hospital and Lecturer on Physiology at the London
Hospital Medical College; 15, Finshury square. C.
1886. Lib. Com. 1882-5.
FELLOWS OF THE SOCIETY. xlHi
Elected
1867 Mac Cormac, Sir William, M.A., Surgeon to, and Lecturer
on Surgery at, St. Thomas's Hospital ; 13, Harley
street. C. 1884-5. Trans. 1.
1862 *M'Donnell, Robert, M.D., F.R.S., Surgeon to Steevens'
Jervis street Hospitals ; 89, Merrion square west,
Dublin. Trans. 2.
1880 *Macfarlane, Alexander William, M.D., Consulting
Physician to the Kilmarnock Fever Hospital and
Infirmary, and Examiner in Medicine and Clinical
Medicine, University of Glasgow ; Walmer, Kilmarnock,
N.B.
1866 Macgowan, Alexander Thorburn, M.D., Vyvyan House,
Clifton, near Bristol.
1880 McHardy, Malcolm Macdonald, Ophthalmic Surgeon
to King's College Hospital, and Professor of Ophthalmic
Surgery in King's College, London ; Surgeon to the
Royal South London Ophthalmic Hospital; 5, Savile
row.
1822 Macintosh, Richard, M.D.
1859 *M'Intyre, John, M.D., Odiham, Hants.
1873 MacKellar, Alexander Oberlin, M.S. I., Surgeon to
St. Thomas's Hospital; Surgeon-in-Chief to the Metro-
politan Police Force ; 22, George street, Hanover
square.
1881 Mackenzie, Stephen, M.D., Physician to the London Hos-
pital, and Lecturer on the Principles and Practice of
Medicine at the London Hospital Medical College ;
Physician to the Royal London Ophthalmic Hospital ;
26, Finsbury square. Trans. 1.
1885 Mackern, John, M.D., Assistant Physician to the Chelsea
Hospital for Women ; 30, Cambridge street, Hyde
park.
1876 Mackey, Edward, M.D., Assistant Physician to the Sussex
County Hospital ; 1, Brunswick road, Hove, Brighton.
1854 *Mackinder, Draper, M.D., Consulting Surgeon to the
Dispensary, Gainsborough, Lincolnshire.
Xliv FELLOWS OF THE SOCIETY.
Elected
1879 Maclagan, Thomas John, M.D., Physician-in-Ordinary
to their R.H. the Prince and Princess Christian of
Schleswig-Holstein ; 9, Cadogan place, Belgrave square.
1876 Macnamara, Charles N., Surgeon to, and Lecturer on Sur-
gery at, the Westminster Hospital ; Surgeon to the
Royal Westminster Ophthalmic Hospital ; Surgeon-
Major Bengal Medical Service ; Fellow of the Calcutta
University; 13, Grosvenor street. Referee, 1884-6.
Lib. Com. 1886.
1881 Macready, Jonathan Forster Christian Horace, Sur-
geon to the Great Northern Hospital ; 51, Queen Anne
street, Cavendish square.
1880 Maddick, Edmund Distin, 2, Cliandos street, Cavendish
square.
1886 Maguire, Robert, M.D., Warden of St. Mary's Hospital
Residential College ; 33, A\restbourne Terrace.
1880 Makins, George Henry, Assistant Surgeon to the Evelina
Hospital for Children ; 2, Queen street, May Fair.
1885 Malcolm, John David, M.B., Surgeon in charge of Out-
Patients, Samaritan Free Hospital ; 2-4, Bryauston
street, Portman square.
18/6 Mallam, Benjamin, Rose Bank, Blackall road, Exeter.
1855 Marckt, William, M.D., F.R.S. ; 39, Grosvenor street.
C. 1871. Referee, 1866-70, 1883-6. Sci. Com. 1863.
Lib. Com. 1866-8. Trans. 3.
1867 Marsh, F. Howard, Secretary, Assistant Surgeon to, and
Lecturer on Anatomy at, St. Bartholomew's Hospital ;
Surgeon to the Hospital for Sick Children, Gnat
Ormond street ; 30, Bruton street, Berkeley square. C.
1882-3. S. 1885-6. Lib. Com. 1880-1. Trans. A.
1838 Marsh, Thomas Parr, M.D.
1851 fMABSHALL, John, F.R.S., Professor of Anatomy to the
Koyal Academy of Arts ; Emeritus Professor of Surgery
in University College, London, and Consulting Surgeon
to University College Hospital ; 10, Savilerow, Burling-
ton gardens. C. 1866. V.P. \^j:>-6. P. 1882-3.
Referee, 1867, 1871-4, 1877-81. Trans. 3.
FELLOWS OF THE SOCIETY. xlv
Elected
1884 Martin, Sidney Harris Cox, M.D. ; 135, Gower street.
1883 Maudsley, Henry, M.D , Resident Medical Officer, Univer-
sity College Hospital, Gower street.
1839 Meade, Richard Henry, Consulting Surgeon to the Brad-
ford Infirmary ; Bradford, Yorkshire. Trans. 1.
18/0 Meadows, Alfred, M.D., Physician-Accoucheur to, and
Lecturer on Midwifery and Diseases of Women and
Children at, St. Mary's Hospital ; 27, George street,
Hanover square. Lib. Com. 18/5-7.
1865 Medwin, Aaron George, M.D., Consulting Dental Sur-
geon to the Royal Kent Dispensary, 34, Bruton street,
Berkeley square, and 11, Montpellier row, Blackheath.
1880 Meredith, William Appleton, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children ; G,
Queen Anne street, Cavendish square.
1874 Merriman, John J., 45, Kensington square.
1815 Meyer, Augustus, M.D., St. Petersburg.
1840 Middlemoue, Richard, Consulting Surgeon to the Bir-
mingham Eye Hospital ; The Limes, Bristol road,
Edgbaston, Birmingham.
1854 Middleship, Edward Archibald.
1885 Millican, Kenneth William, B.A., 58, Welbeck street.
1882 Mills, Joseph, 15, Henrietta street, Cavendish square.
1873 Milner, Edward, Surgeon to the Lock Hospital; 32, New
Cavendish street, Portland place.
1883 Money, Angel, M.D., Assistant Physician to the Hospital
for Sick Children, Great Ormond Street, and to the
City of London Hospital for Diseases of the Chest,
Victoria park ; 24, Harley street. Trans. 4.
1873 Moore, Norman, M.D., Assistant Physician and Warden of
the College, and Demonstrator of Morbid Anatomy, St.
Bartholomew's Hospital ; the College, St. Bartholo-
mew's Hospital. Referee, 1886.
Xlvi FELLOWS OF THE SOCIETY.
Elected
1S.57 Morgan, John, 3, Sussex place, Hyde park gardens.
C. 1880-1. Lib. Com. 1862-3. Trans. 1.
18GI Morgan, John Edward, Ml)., Physician to the Manchester
Royal Infirmary, and Professor of Medicine in the
Victoria University, Manchester ; 1, St. Peter's square,
Manchester.
18/8 Morgan, John Hammond, M.A., Assistant Surgeon to the
Charing Cross Hospital, and to the Hospital for Sick
Children, Great Orniond street ; 08, Grosvenor street.
Trans. 1 .
1874 Morris, Henry, M. A., Surgeon to, and Lecturer on Sur-
gery at, the Middlesex Hospital; 2, Mansfield street,
Portland place. Referee, 1S82-6. Trans. 9.
1879 Morris, Malcolm Alexander, Surgeon to the Skin De-
partment of, and Lecturer on Dermatology at, St.
Mary's Hospital; 63, Montagu square.
1885 Mott, Frederick Walker, M.B., Lecturer on Physiology,
Charing Cross Hospital ; Meadowlead, Gayton Road,
Harrow.
1879 Munk, William, M D., Ilarveian Librarian, Royal College
of Physicians ; Consulting Physician to the Royal
Hospital for Incurables; 40, Finsbury square.
1873 Murray, J. Ivor, Ml)., F. R.S.Ed. 24, Huntriss How,
Scarborough.
1880 Mdrrell, William, M.D., Assistant Physician to the Royal
Hospital for Diseases of the Chest; Assistant Physician
to, and Lecturer on Materia Medieaand Therapeutics at,
the Westminster Hospital ; 38, Weymouth Btreet, Port-
land place. Trans. 1.
18G3 Myers, Arthur Bowed Richards, Surgeon to the I si
Battalion, Coldstream Guards; 3, Park Terrace,
Windsor. C. 1878-9. lib. Com. [877.
1882 Mvi:i;s, Arthur Thomas, M.D., Medical Registrar, St.
George's Hospital ; 9, Lower Berkeley street, Port man
square.
FELLOWS OF THE SOCIETY. xlvii
Elected
1881 Nall, Samuel, M.B., Disley, Stockport, Cheshire.
18/0 Neild, James Edward, M.D., Lecturer on Forensic Medi-
cine in the University of Melbourne; 166, Collins
street east, Melbourne, Victoria.
1835 INelson, Thomas Andrew, M.D., 10, Nottingham terrace,
York gate, Regent's park. Lib. Com. 1841.
1877 Nettleship, Edward, Ophthalmic Surgeon to, and Lecturer
on Ophthalmology at, St. Thomas's Hospital ; Assistant
Surgeon to the Royal London Ophthalmic Hospital ;
Ophthalmic Surgeon to the Hospital for Sick Children ;
5, Wimpole street, Cavendish square.
1843 -(-Newton, Edward, 85, Gloucester terrace, Hyde Park.
C. 1863-4.
1868 Nicholls, James, M.D., Senior Medical Officer, Essex and
Chelmsford Infirmary and Dispensary ; the Old Infir-
mary, Chelmsford, Essex.
1849 Norman, Henry Burford, Portland Lodge, Southsea,
Hants. Lib. Com. 1857.
1847 *Nourse, William Edward Charles, Bouverie House,
Exeter.
1864 Nunn, Thomas William, Consulting Surgeon to the Middle-
sex Hospital ; 8, Stratford place, Oxford street.
1870 Nunneley, Frederick Barham, M.D. Trans. 2.
1884 Oakes, Arthur, M.D., 99, Priory road, West Hampstead.
1880 O'Connor, Beknard, A.B., M.D., Physician to the North
London Hospital for Consumption; 17, St. James's
place.
1847 O'Connor, Thomas, March, Cambridgeshire.
1880 Ogilvie, George, M.B., Lecturer on Experimental Physics
at the Westminster Hospital ; Physician to the Hos-
pital for Epilepsy and Paralysis, Regent's Park ; 13,
Welbeck street, Cavendish square.
1880 Ogilvie, Leslie, M.B., Lecturer on Comparative Anatomy
at the Westminster Hospital; 46, Welbeck street,
Cavendish square.
xlviii FELLOWS OF THE SOCIETY.
Elected
1858 Ogle, John William, M.D., Vice-President, Consulting
Physician to St George's Hospital ; 30, Cavendish
square. C. 18/3. V.P. 1886. Referee, 1864-72.
Trans. 4.
1855 *Ogle, William, M.A., M.D., Physician to the Derbyshire
Infirmary ; The Kims, Duffield road, Derby.
18G0 Ogle, William, M.D., Superintendent of Statistics in the
Registrar-General's Department, Somerset House; 10,
Gordon street, Gordon scpiare. S. lb68-70. C. 1876-7.
Lib. Com. 1871-5. Trans. 5.
1870 Oldham, Charles Frederic, India [Agents: Messrs.
Grindlay and Co., 55, Parliament street].
1883 *Oliver, Thomas, M.D., Lecturer on Practical Physiology,
University of Durham ; and Physician to the New-
castle-upon-Tyne Infirmary; 12, Eldon square, New-
castle-upon-Tyne.
1871 *0'Neill, William, M.D., Physician to the Lincoln Lunatic
Hospital, Silver street, Lincoln.
1873 Ord, William Miller, M.D., Physician to, and Lecturer
on Medicine at, St. Thomas's Hospital ; 7, Upper Brook
street, Grosvenor square. Ref<ree, 1884-6. Trans. 6.
1877 Ormerod, Joseph Arderne, M.D., Assistant Physician to
the National Hospital for the Paralysed and Epileptic,
Queen square, and to the City of London Hospital for
Diseases of the Chest, Victoria Park ; 25, Upper Wim-
pole street. Trans. 1.
1885 Ormsby, L. Hepenstal, M.D., Lecturer on Clinical and
Operative Surgery and Surgeon to the Meath Hospital
and County Dublin Infirmary ; Surgeon to the Chil-
dren's Hospital, Dublin ; 1)2, Merrion square west,
Dublin.
1875 Osborn, Samuel, 10, Maddox street, Regent street, and
Maisonnette, Datchct, Bucks.
1S7U Owen, Edmund, Surgeon to St. Mary's Hospital; Surgeon
to the Hospital for Sick Children ; 49, Seymour street,
Portman square. Truns. 1.
FELLOWS OF THE SOCIETY. xlix
Elected
1882 Owen, Herbeet Isambard, M.D., Assistant Physician to,
and Lecturer on Materia Medica and Therapeutics
at, St. George's Hospital ; 5, Hertford street, May
Fair.
1874 Page, Herbert William, M.A., M.C., Surgeon to, and
Joint Lecturer on Surgery at, St. Mary's Hospital ;
146, Harley street, Cavendish square. Referee, 1884-6.
Lib. Com. 1886. Trans. 2.
1840 fPAGET, Sir James, Bart., D.C.L., LL.D., F.R.S., Sergeant-
Surgeon to H.M. the Queen ; Surgeon-in-Ordinary to
H.R.H. the Prince of Wales ; Consulting Surgeon to
St. Bartholomew's Hospital ; Vice-Chancellor of the
University of London ; Foreign Associate of the
' Academie de Medecine,' Paris; 1, Harewood place,
Hanover square. C. 1848-9. V.P. 1861. T. 1867.
P. 1875-6. Referee, 18-14-6, 1848, 1851-60, 1862-6,
1868-74. Sci. Com. 1863. Lib. Com. 1846-7.
Trans. 12.
1858 *Paley, William, M.D., Physician to the Ripon Dispen-
sary ; The Old Residence, Ripon, Yorkshire.
1847 Parker, Nicholas, M.D., Paris.
1873 Parker, Robert William, Surgeon to the East London Hos-
pital for Children ; 8, Old Cavendish street. Lib. Com.
1885-6. Trans. 3.
1885 Parker, Rushton, M.B., Professor of Surgery, University
College, Liverpool (Victoria University) ; Assistant
Surgeon to the Liverpool Royal Infirmary ; 59, Rodney
street, Liverpool.
1883 Pasteur, William, M.D., Medical Registrar to the Middle-
sex Hospital ; Physician to the North-Eastern Hospital
for Children ; 19, Queen street, May Fair.
1865 Pavy, Frederick William, M.D., F.R.S., Physician to
Guy's Hospital; 35, Grosvenor street. C. 1883-4.
Referee, 1871-82. Trans. 1.
ltfu'9 Payne, Joseph Frank, M.D., Senior Assistant-Physician
to, and Lecturer on Pathological Anatomy at, St.
Thomas's Hospital ; 78, Wimpole street, Cavendish
square. Sci. Com. 1879. Lib. Com. 1878-85.
VOL. LXIX. d
1 FELLOWS OF THE SOCIETY.
Elected
1879 Peel, Robert, 120, Collins street east, Melbourne,
Victoria.
1856 Peirce, Richard King, Woodside, Windsor forest, Berks.
1830 Pelechin, Charles P., M.D., St. Petersburg.
1855 *Pemberton, Oliver, Senior Surgeon to the Birmingham
General Hospital, and Professor of Surgery at the
Queen's College, Birmingham ; 1 2, Temple row, Bir-
mingham. Trans. 1.
1874 Penhall, John Thomas, 5, Eversfield place, St. Leonard's
Sussex.
1870 Perrin, John Beswick, Vernon House, Leigh, Lanca-
shire.
1879 *Pesikaka, Hormasji Dosabhai, Marine Lines, Bombay.
1878 *Philipson, George Hare, M.D., M.A., D.C.L., Pro-
fessor of Medicine at Durham University ; Senior
Physician to the Newcastle-upon-Tyne Infirmary ; 7,
Eldon square, Newcastle-upon-Tyne.
1883 Phillips, Charles Douglas F., M.D., F.R.S.Ed., 10,
Henrietta street, Cavendish square, W.
1884 Phillips, George Richard Turner, 24, Leinster square,
Bayswater.
1867 Pick, Thomas Pickering, Surgeon to, and Lecturer on
Surgery at, St. George's Hospital; 18, Portman
street, Portman square. C. 1884-5. Referee, 1882-3.
Sci. Com. 1870. Lib. Com. 1879-81.
1841 tPITMA?s Sir Henry Alfred, M.D., Consulting Physician
to St. George's Hospital ; 28, Gordon square. L.
1851-3. C. 1861-2. T. 1863-8. V.P. 1870-1.
Referee, 1849-50. Lib. Com. 1847.
1884 Pitt, George Neavton, M.D., Medical Registrar and
Demonstrator of Practical Medicine at Guy's Hospital ;
34, Ashburn place, South Kensington.
1885 Poland, John, Demonstrator of Anatomy, Guy's Hospital ;
16, St. Thomas's street, Southwark.
1884 Pollard, Bilton, M.D., Surgical Registrar, University
College Hospital ; 50, Torrington square.
FELLOWS OF THE SOCIETY. ll
Elected
1871 Pollock, Arthur Julius, M.D., Senior Physician to, and
Lecturer on the Principles and Practice of Medicine at,
Charing Cross Hospital; Physician to the Foundling
Hospital ; 85, Harley street, Cavendish square.
1845 tPollock, George David, President, Surgeon-in-Ordinary
to H.Pv.H. the Prince of Wales ; Consulting Surgeon to
St. George's Hospital ; 36, Grosvenor street. C. 1856-7.
L. 1859-62. V.P. 1870-1. P. 1886. Referee, 1858,
1864-9, 1877-85. Trans. 5.
1865 Pollock, James Edward, M.D., Consulting Physician to
the Hospital for Consumption, Brompton ; 52, Upper
Brook street, Grosvenor square. C. 1882-3. Referee,
1872-81.
1871 Poore, George Vivian, M.D., Professor of Medical Juris-
prudence in University College, London ; Physician to
University College Hospital ; Consulting Physician to
the Royal Infirmary for Children and Women, Waterloo
road ; 30, Wimpole street. Trans. 1.
1885 Port, Heinrich, M.D., Physician to the German Hospital ;
48, Finsbury square.
1846 Potter, Jephson, M.D., F.L.S.
1842 Powell, James, M.D.
1867 Powell, Richard Douglas, M.D., Physician to, and
Lecturer on Practical Medicine at, the Middlesex Hos-
pital; Physician to the Hospital for Consumption and Dis-
eases of the Chest, Brompton ; 62, Wimpole st., Caven-
dish sq. S. (Oct.) 1883-5. Referee, 1879-83, 1886.
Trans. 2.
1867 Power, Henry, Senior Ophthalmic Surgeon to, and Lecturer
on Ophthalmic Surgery at, St. Bartholomew's Hospital ;
37a, Great Cumberland place, Hyde park. C. 1882-3.
Referee, 1870-81. Sci. Com. 1870. Lib. Com. 1872-8.
1857 Priestley, William Overend, M.D., LL.D., Consulting
Physician to King's College Hospital, and to the St.
Marylehone Infirmary ; 1 7, Hertford street, Mayfair.
C. 1874-5. V.P. 1884-5. Referee, 1867-73, 1877-83.
Sci. Com. 1863.
Hi FELLOWS OF THE SOCIETY.
Elected
1883 Pbixgle, John James, M.B., CM., Assistant Physician
to the Middlesex Hospital, and Physician to the Royal
Hospital for Diseases of the Chest ; 35, Bruton street,
Berkeley square.
1874 Purves, William Laidlaw, Aural Surgeon to Guy's
Hospital ; 20, Stratford place, Oxford street. Trans. 2.
1878 Pye, Walter, Surgeon (with charge of out-patients) to
St. Mary's Hospital and to the Victoria Hospital for
Children ; 4, Sackville street, Piccadilly.
1877 Pye-Smith, Philip Henry, M.D., F.R.S., Physician to, and
Lecturer on Medicine at, Guy's Hospital ; Member of
the Senate of the University of London ; 54, Harley
street, Cavendish square.
1850 fQuAlN, Richard, M.D., F.R.S., Consulting Physician to the
Hospital for Consumption, Brompton ; Member of the
Senate of the University of London ; 67, Harley street,
Cavendish square. C. 1866-7. V.P. 1878-9. Sci.
Com. 1863. Trans. 1.
1835 tQuAiN, Richard, F.R.S., Surgeon-Extraordinary to H.M.
the Queen ; Emeritus Professor of Clinical Surgery,
University College, London, and Consulting Surgeon to
University College Hospital ; 32, Cavendish square.
C. 1838-9. L. 1846-8. T. 1851-3. V.P. lSi>6-7.
Referee, 1845-6, 1848, 1858-9. Lib. Com. 1846.
Trans. 1. Pro. 2.
1852 fRADCLlFFE, Charles Bland, M.D., Treasurer, Consulting
Physician to the Westminster Hospital ; Physician to
the National Hospital for the Paralysed and Epileptic ;
25, Cavendish square. C. 1867-8. V.P. 1879-80.
T. 1881-6. Referee, 1862-6, 1870-8.
1871 Ralfe, Charles Henry, M.D., M.A., Assistant Physician
to the London Hospital, and late Physician to the Sea-
men's Hospital, Greenwich ; 26, Queen Anne street,
Cavendish square. Referee, 1&85-6.
1857 RaNKE, Henry, M.D., 3, Sophienstrasse, Munich.
1854 Ransom, William Henry, M.D., F.R.S., Physician to the
Nottingham General Hospital, Nottingham.
FELLOWS OF THE SOCIETY. Hii
Elected
1869 Read, Thomas Laurence, 11, Petersham terrace, Queen's
gate.
1858 Reed, Frederick George, M.D., 46, Hertford street, May-
fair. Trans. 1.
1821 Reeder, Henry, M.D., Varick, Seneca County, New York,
United States.
1857 Rees, George Owen, M.D,, F.R.S., Physician Extra-
ordinary to H.M. the Queen, Consulting Physician to
Guy's Hospital ; 26, Albemarle street, Piccadilly. C.
1873. Referee, 1860-72, 1875-81. Trans. 1.
1882 Reid, James, M.D., Resident Physician to H.M. the Queen,
Windsor Castle.
1884 Reid, Thomas Whitehead, Surgeon to the Kent and
Canterbury Hospital ; 34, St. George's place, Canter-
bury.
1855 Reynolds, John Russell, M.D., F.R.S., Vice-President,
Physician-in-Ordinary to H.M.'s Household ; Con-
sulting-Physician to University College Hospital ; 38,
Grosvenor street. C. 1870. V.P. 1883. Referee,
1867-9.
1865 Rhodes, George Winter, Surgeon to the Huddersfield
Infirmary ; Queen street soutb, Huddersfield.
1881 Rice, George, M.B., CM., Sutton, Surrey.
1852 Richardson, Christopher Thomas, M.B., 13, Nelson
crescent, Ramsgate.
1845 fRiDGE, Benjamin, M.D., 8, Mount street, Grosvenor
square.
1863 Ringer, Sydney, M.D., F.R.S., Professor of the Principles
and Practice of Medicine in University College, London,
and Physician to University College Hospital ; 15,
Cavendish place, Cavendish square. C. 1881-2.
Referee, 1873-80. Trans. 6.
1871 Rivington, Walter, M.S., Surgeon to, and Lecturer on
Surgery at, the London Hospital ; 22, Finsbury
square. C. 1885-6. Trans. 4.
liv FELLOWS OF THE SOCIETY.
Elected
1871 *Roberts, David Lloyd, M.D., Obstetric Physician to the
Manchester Royal Infirmary, Physician to St. Mary's
Hospital, Manchester; 11, St. John street, Manchester.
1878 Roberts, Frederick Thomas, M.D., Professor of Materia
Medica and Therapeutics in University College, London ;
and Physician to University College Hospital ; Phy-
sician to the Hospital for Consumption, Brompton ;
102, Harley street, Cavendish square.
1857 Robertson, John Charles George, Medical Superinten-
dent of the Cavan District Lunatic Asylum ; Monaghan,
Ireland.
1873 Robertson, William Henry, M.D., Consulting Physician
to the Buxton Bath Charity and Devonshire Hospital ;
Buxton, Derbyshire.
1885 Rockwood, "William Gabriel, M.D., Colombo, Ceylon.
1850 Roper, George, M.D., Consulting Physician to the Eastern
Division of the Royal Maternity Charity ; Physician to
the Royal Infirmary for Children and Women, Waterloo
Bridge road; 19, Oviugton gardens. C. 1879-80.
1857 Rose, Henry Cooper, M.D., F.L.S., Consulting Surgeon
to the Hampstead Dispensary ; Penrose House, Hamp-
stead. C. 1886. Trans. 1.
1883 Rose, William, M.B., Surgeon to King's College Hospital
and to the Royal Free Hospital ; 50, Harley street,
Cavendish square.
1882 ROUTH, Amand Jules McCoNKEL, M.D., B.S., Physician
to the Samaritan Free Hospital for Women ; Assistant
Obstetric Physician to the Charing Cross Hospital ;
Obstetric Physician to the St. Marylebone General
Dispensary; G, Upper Montagu street, Montagu square.
1849 fltoUTii, Charles Hi. sky Fklix, M.D., Consulting Physician
to the Samaritan Free Hospital for Women and
Children; 52, Montagu square. Lib. Cunt. KS5-1-5.
Trans. 1 .
FELLOWS OF THE SOCIETY. lv
Elected
1863 Rowe, Thomas Smith, M.D., Senior Visiting Surgeon to
the Royal Sea-Bathing Infirmary ; Cecil street, Margate,
Kent.
1882 Roy, Charles Smart, M.D.,F.R.S., Professor of Pathology
in the University of Cambridge ; Trinity College, Cam-
bridge.
1871 Rutherford, William, M.D., F.R.S., Professor of the
Institutes of Medicine in the University of Edinburgh ;
14, Douglas crescent, Edinburgh.
1886 Sainsbury, Harrington, M.D., Assistant Physician and
Pathologist to the Royal Free Hospital ; 63, Welbeck
street, Cavendish square. Trans. 1.
1856 Salter, S. James A., M.B., F.R.S., F.L.S., Basingfield, near
Basingstoke, Hants. C. 1871. Lib. Com. 1878.
Trans. 2.
1 849 fSAXDERsox, Hugh James, M.D., 26, Upper Berkeley street,
Portman square. C. 1872-3. Lib. Com. 1862-3.
1855 Sanderson, John Burdon, M.D., LL.D., F.R.S., Wayn-
flete Professor of Physiology in the University of
Oxford; 50, Banbury road, Oxford. C. 1869-70.
V.P. 1882. Referee, 1867-8, 1876-81. Sci. Com.
1862,1870. Lib. Com. 1876-81. Trans. 2.
1867 Sandford, Folliott James, M.D., Market Drayton,
Shropshire.
1879 Sangster, Alfred, B.A., M.B., Physician to the Skin
Department, and Demonstrator of Skin Diseases at the
Charing Cross Hospital ; 6, Savile row. Trans. 1.
1847 fSANKEY, William Henry Octavius, M.D., Boreatton
park, Baschurch, near Shrewsbury.
1869 Sansom, Arthur Ernest, M.D., Senior Physician to the
North-Eastern Hospital for Children ; Physician (with
charge of out-patients) to the London Hospital ; 84,
Harley street, Cavendish square. Trans. 2.
1845 -j-Saunders, Sir Edwin, Surgeon-Dentist to H.M. the Queen,
and to their R.H. the Prince and Princess of Wales ;
13a, George street, Hanover square. C. 1872-3.
lvi FELLOWS OF THE SOCIETY.
Elected
1834 Sauvan, Ludwig V., M.D., Warsaw.
1879 Savage, George Henry, M.D., Medical Superintendent
and Resident Physician to the Bethlem Royal Hospital,
St. George's road, Southwark.
1859 Savory, William Scovell, F.R.S., Surgeon to, and Lec-
turer on Surgery at, St. Bartholomew's Hospital ;
Surgeon to Christ's Hospital ; 66, Brook street,
Grosvenor square. C. 1871-2. L. 1878. V.P. 1883-4.
Referee, 1865-70, 1873-77, 1879-82. Sci. Com. 1862,
1867, 1870. Lib. Com. 1866-8. Trans. 7.
1883 Schafer, Edward Albert, F.E.S., Jodrell Professor of
Physiology, University College, London ; University
College, Gower street.
1861 *Scott, William, M.D., Senior Physician to the Hudders-
field Infirmary ; Waverley House, Huddersfield.
1882 Scriven, John Barclay, Brigade Surgeon, Bengal (retired),
late Professor of Anatomy, Surgery, and Ophthalmic
Surgery at the Lahore Medical School ; 95, Oxford
gardens, Notting hill.
1863 Sedgwick, William, 12, Park place, Upper Baker street.
C. 1884-5. Trans. 3.
1877 Semon, Felix, M.D., Assistant Physician for Diseases of the
Throat to St. Thomas's Hospital ; 39, Wimpole street,
Cavendish square. Trans. 1.
1875 Semple, Robert Hunter, M.D., Physician totheBloomshury
Dispensary; 8, Torrington square. Sci. Com. 1879.
1873 *Shapti:u, Lewis, B.A., M.B., Physician to the Devon and
Exeter Hospital ; the Barnfield, Exeter.
1882 Sharkey, Seymour John, M.B., Assistant Physician, Joint
Lecturer on Pathology, and Demonstrator of Morbid
Anatomy, to St. Thomas's Hospital; 2, Portland place.
Trans. 2.
1840 Sharp, William, M.D., F.R.S., Horton House, Rugby.
Trans. 1.
FELLOWS OF THE SOCIETY. lvii
Elected
1836 fSHAW, Alexander, Consulting Surgeon to the Middlesex
Hospital; 136, Abbey road, Kilburn. C. 1842. S.
1843-4. V.P. 1851-2. T. 1858-60. Referee, 1842-3,
1846-50, 1855-7, 1865. Lib. Com. 1843. Trans. 4.
1886 Shaw, Laureston Elgie, M.D., 3, Newton grove, Bedford
park.
1884 Sheild, Arthur Marmaduke, M.B., B.S., House Surgeon,
St. George's Hospital.
1859 Sibley, Septimus William, 7, Harley street, Cavendish
square. C. 1882-3. Sci. Com. 1863. Trans. 4.
1848 fSiEVEKiNG, Sir Edward Henry, M.D., Physician-Extra-
ordinary to H.M. the- Queen; Physician-in-Ordinary to
H.R.H. the Prince of Wales ; Physician to St. Mary's
Hospital; 17, Manchester square. C. 1859-60. S.
1861-3. V.P. 1873-4. L. 1881-2. Referee, 1855-8,
1864-72, 1875-80. Sci. Com. 1862. Trans. 2.
1842 fSiMON, John, C.B., D.C.L., LL.D., F.K.S., Consulting
Surgeon to St. Thomas's Hospital ; 40, Kensington
square. C. 1854-5. V.P. 1865. Referee 1851-3,
1866-81. Trans. 1.
1857 Siordet, James Lewis, M.B., Villa Preti, Mentone, Alpes
Maritimes, France.
1882 Smith, Charles John, 54, Old Steyne, Brighton.
1879 Smith, E. Noble, Senior Surgeon and Surgeon to the
Orthopaedic Department of the Farringdon Dispensary ;
Orthopaedic Surgeon to the British Home for Incurables ;
24, Queen Anne street, Cavendish square.
1881 Smith, Eustace, M.D., Physician to H.M. the King of the
Belgians ; Physician to the East London Children's
Hospital, and to the Victoria Park Hospital for
Diseases of the Chest ; 5, George street, Hanover
square.
1885 Smith, James Greig, M.B., CM., F.R.S.Ed., Surgeon to
the Bristol Royal Infirmary ; 1 6, Victoria square,
Clifton.
lviii FELLOWS OF THE SOCIETY.
Elected
1872 Smith, T. Gilbart, M.A., M.D., Assistant-Physician to the
London Hospital ; Physician to the Royal Hospital for
Diseases of the Chest, City road ; 68, Harley street,
Cavendish square. Trans. 1.
1866 Smith, Heywood, M.A. M.D., Physician to the Hos-
pital for Women ; Physician to the British Lying-in
Hospital ; 18, Harley street, Cavendish square.
1838 fSMiTH, Spencek, Consulting Surgeon to St. Mary's Hos-
pital; 92, Oxford terrace, Hyde Park. C. 1854. S.
1855-8. V.P. 1859-60. T. 1865. Referee, 1851-3,
1862-4, 1866-78. Lib. Com. 1847.
1863 Smith, Thomas, Surgeon to, and Lecturer on Clinical
Surgery at, St. Bartholomew's Hospital ; 5, Stratford
place, Oxford street. S. 1870-2. C. 1875-6. Referee,
1873-4, 1880-6. Sci. Com. 1867. Trans. 3.
1873 Smith, W. Johnson, Surgeon to the Seamen's Hospital,
Greenwich.
1874 *Smith, William Robert, M.D., D.Sc, F.R.S.Ed., 74,
Great Russell Street, Bloomsbury.
1868 Solly, Samuel Edwin, Colorado Springs, Colorado, U.S.
1865 Southey, Reginald, M.D., Commissioner in Lunacy ; 32,
Grosvenor road, Westminster. C. 1881-2. S. 1883.
Referee, 1873-80. Trans. 1.
1844 Spaceman, Frederick Robert, M.D., Consulting Physician
to St. Alban's Hospital, Harpeiiden, St. Alban's.
1875 Spitta, Edmund Johnson, Ivy House, Clapham Common,
Surrey.
1851 fSPITTA, Robert John, M.D., East Side, Clapham Com-
mon, Surrey. C. 1878-9. Trans. 1.
1885 Squire, John EdWABD, M.D., Assistant Physician to the
North London Hospital for Consumption ; 23, Seymour
street, Portmau square. Trans. 1.
1882 Stbavenbon, William Edward, M.D., Electrician to St.
Bartholomew's Hospital ; Physician to the Alexandra
Hospital for Children ; 39, Welheck street, Cavendish
square.
FELLOWS OF THE SOCIETY. lix
Elected
1854 Stevens, Henry, M.D., Inspector, Medical Department,
Local Government Board, Whitehall.
1884 Stewart, Edward, M.D., 16, Harley street.
1859 Stewart, William Edward, 16, Harley street, Cavendish
square.
1879 *Stirling, Edward Charles, late Assistant Surgeon and
Lecturer on Physiology at St. George's Hospital ;
Adelaide, South Australia [care of T. Gemmell, Esq.,
11, Essex street, Strand],
1856 Stocker, Alonzo Henry, M.D., Peckham House, Peckham.
1865 Stokes, Sir William, M.D., M.C., Surgeon to the
Richmond Surgical Hospital ; 5, Merrion square north,
Dublin. Trans. 1.
1884 Stonham, Charles, Curator of the Pathological Mnseum,
University College, London, and Assistant Surgeon to
the Cancer Hospital, Brompton ; 109, Gower street.
1843 Storks, Robert Reeve, Paris.
1871 Strong, Henry John, M.D., Surgeon to the Croydon
General Hospital ; Whitgift House, George street,
Croydon.
1863 fSTURGEs, Octavius, M.D., Physician to, and Lecturer on
Medicine at, the Westminster Hospital ; Physician
to the Hospital for Sick Children ; 85, Wimpole street,
Cavendish square. C. 1878-9, Referee, 1882-6.
1871 fSuTHERLAND, Henry, M.D., Lecturer on Insanity at the
"Westminster Hospital ; 6, Richmond terrace, Whitehall.
1871 Sutton, Henry Gawen, M.B., Physician to, and Lecturer
on Pathology at, the London Hospital, and Physician
to the London Hospital ; 9, Finsbury square. Trans. 1 .
1883 Sutton, John Bland, Assistant Surgeon, Lecturer on Com-
parative Anatomy, and Senior Demonstrator of Anatomy
to the Middlesex Hospital ; 22, Gordon street, Gordon
square. Trans. 3.
1861 *Sweeting, George Bacon, Consulting Surgeon to the
West Norfolk Hospital ; King's Lynn, Norfolk.
h
FELLOWS OF THE SOCIETY.
Elected
1886 Symonds, Charters James, M.S., Assistant Surgeon to
Guy's Hospital; 26, Weymouth street, Portland place.
1878 *Sympson, Thomas, Surgeon to the Lincoln County Hos-
pital ; 3, James street, Lincoln.
1870 Tait, Lawson, Surgeon to the Birmingham and Midland
Hospital for Women ; 7, The Crescent, Birmingham.
Trans. 4.
1864 Taussig, Gabriel, M.D., 70, Piazza Barberini, Rome.
1875 Tay, Waren, Surgeon to the London Hospital, to the Royal
London Ophthalmic Hospital, to the North Eastern
Hospital for Children, and to the Hospital for Skin
Diseases, Blackf'riars ; 4, Finsbury square.
1873 Taylor, Frederick, M.D., Physician to, and Lecturer
on Materia Medica at, Guy's Hospital ; Physician to tbe
Evelina Hospital for Sick Children ; 11, St. Thomas's
street, Southwark. Trans. 1.
1845 fTAYLOR, Thomas, Warwick House, 1, Warwick place, Grove
End road, St. John's wood.
1859 Tegart, Edward, 49, Jermyn street, St. James's.
1874 Thin, George, M.D., 22, Queen Anne street, Cavendish
square. Trans. 9.
1862 Thompson, Edmund Symes, M.D., Senior Physician to the
Hospital for Consumption, Brompton ; Gresham Pro-
fessor of Medicine ; 33, Cavendish square. S. 1871-4.
C. 1878-9. Referee, 1876-7. Trans. 1.
1857 Thompson, Henry, M.D., Consulting Physician to the
Middlesex Hospital ; 53, Queen Anne street, Cavendish
square.
1852 fTiiOMPsoN, Sir Henry, Surgeon-Extraordinary to II. M.
the King of tbe Belgians ; Emeritus Professor of
Clinical Surgery in University College, Loudon ; and
Consulting Surgeon to University College Hospital ;
Corresponding Member of the " Socidte de Cbirurgie,"
Paris ; 35, Wimpole street, Cavendish square. C.
1869. Trans. 7.
FELLOWS OF THE SOCIETY. lxi
Elected
1862 Thompson, Reginald Edward, M.D., Physician to the
Hospital for Consumption, Brompton ; 47, Park street,
Grosvenor square. C. 1879. S. 1880-82. V.P. 1883-4.
Referee, 1873-8. Sci. Com. 1867. Trans. 2.
1881 Thomson, William Sinclair, M.D., 40, Ladbroke grove,
Kensington park gardens.
1876 Thornton, John Knowsley, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children ;
22, Portman street, Portman square. Lib. Com. 1886.
Trans. 3.
1883 Thursfield, Thomas "William, M.D., Physician to the
Warneford and South Warwickshire General Hospital ;
26, The Parade, Leamington.
1848 fTiLT, Edward John, M.D., Consulting Physician to the
Farringdon General Dispensary and Lying-in Charity ;
27, Seymour street, Portman square. Referee, 1874-81.
1880 Tivy, William James, 8, Lansdowne place, Clifton, Bristol.
1872 Tomes, Charles Sissmore, M.A., F.R.S., 37, Cavendish
square. Lib. Com. 1879.
1867 Tonge, Morris, M.D., Harrow-on-the-Hill, Middlesex.
1882 Tooth, Howard Henry, M.B., Assistant Demonstrator of
Practical Physiology, St. Bartholomew's Hospital ;
34, Harley street, Cavendish square.
1871 *Trend, Theophilus W., M.D., Raeberry Lodge, South-
ampton.
1879 Treves, Frederick, Surgeon to, and Lecturer on Anatomy
at, the London Hospital ; 6, Wimpole street, Cavendish
square. Trans. 3.
1881 *Treves, William Knight, Surgeon to the National Hos-
pital for Scrofula; 31, Dalby square, Cliftonville, Mar-
gate.
1867 Trotter, John William, late Surgeon-Major, Coldstream
Guards ; 4, St. Peter's terrace, York.
1859 Truman, Edwin Thomas, Surgeon-Dentist in Ordinary to
Her Majesty's Household ; 23, Old Burlington street.
Ixii FELLOWS OF THE SOCIETY.
Elected
1862 Tuke, Thomas Harrington, M.D., Manor House, Chiswick,
and 37, Albemarle street, Piccadilly.
1875 Turner, Francis Charlewood, M.A., M.D., Physician
to the North-Eastern Hospital for Children, and to the
London Hospital; 15, Finsbury square.
1873 Turner, George Brown, M.D., San Remo, Italy.
1882 Turner, George Robertson, Visiting Surgeon to the
Seamen's Hospital, Greenwich ; Demonstrator of Ana-
tomy and Joint Lecturer on Practical Surgery at St.
George's Hospital ; 49, Green street, Park lane.
1881 Tyson, William Joseph, M.D., Medical Officer of the
Folkestone Infirmary ; 10, Langhorne gardens, Folke-
stone.
1876 Venn, Albert John, M.D., Obstetric Physician to the
Metropolitan Free Hospital ; Physician to the Victoria
Hospital for Children, Chelsea ; and Assistant Physician
for the Diseases of Women, West London Hospital ; 8,
Upper Brook street, Grosvenor square.
1870 Venning, Edgcombe, 30, Cadogan place.
1865 Vernon, Bowater John, Ophthalmic Surgeon to St. Bar-
tholomew's Hospital and to the West London Hospital ;
14, Clarges street, Piccadilly.
1867 Vintras, Achille, M.D., Physician to the French Embassy.
and to the French Hospital, Leicester place; 19a,
Hanover square.
1828 Vulpes, Benedetto, M.D., Physician to the Hospital of
Aversa, and the Hospital of Incurables, Naples.
1854 Waddington, Edward, Hamilton, Auckland, New Zealand.
1870 WADHAH, William, M.D., Physician to St. George's Hos-
pital ; 14, Park lane.
1886 Wainewkight, Benjamin, M.B., CM., 6, Harley street.
Cavendish square.
1864 Watte, Chaules Derby, M.B., Consulting Physician to the
Westminster General Dispensary ; 3, Old Burlington
street.
FELLOWS OF THE SOCIETY. lxiii
Elected.
1884 Wakley, Thomas, jun., 96, Redcliffe gardens.
1868 * Walker, Robert, Honorary Surgeon to the Carlisle Dis-
pensary ; 2, Portland square, Carlisle.
1883 Waller, Augustus, M.D., Lecturer on Physiology, St.
Mary's Hospital ; 29, Abbey road, St. John's wood. '
1867 *Wallis, George, Surgeon to Addenbrooke's Hospital,
Corpus Buildings, Cambridge.
1873 Walsham, William Johnson, CM., Assistant Surgeon to,
and Demonstrator of Practical and Orthopaedic Surgery
at, St. Bartholomew's Hospital ; Surgeon to the
Metropolitan Free Hospital ; 27, Weymouth street,
Portland place. Lib. Com. 1882-5. Trans. 3.
1852 fWALSHE, Walter Hatle, M.D., Emeritus Professor of the
Principles and Practice of Medicine, University College,
London ; Consulting Physician to the Hospital for
Consumption and to University College Hospital ; 41,
Hyde park square. C. 1872. Trans. 1.
1883 *Walters, James Hopkins, 15, Friar street, Reading.
1851 fWALTON, Haynes, Consulting Surgeon to St. Mary's Hos-
pital, 1, Brook street, Grosvenor square. Trans. 1.
Pro. 1.
1852 Wane, Daniel, M.D.
1821 Ward, William Tilleard, Tilleards, Stanhope, Canada.
1846 Ware, James Thomas, Tilford House, near Farnham,
Surrey.
1866 Waring, Edward John, CLE., M.D., 49, Clifton gardens,
Maida vale. Referee, 1881-5.
1877 Warner, Francis, M.D., Assistant Physician and Lecturer
on Botany to the London Hospital ; 24, Harley street,
Cavendish square. Trans. 1.
1861 Waters, A. T. Houghton, M.D., Physician to the Royal
Infirmary ; 69, Bedford street, Liverpool. Trans. 3.
1879 Waters, John Henry, M.D., CM., 101, Jermyn street.
1878 Watney, Herbert, M.D., 1, Wilton crescent, Belgrave
square, and Buckhold, Basildon, Reading.
lxiv FELLOWS OF THE SOCIETY.
Elected
1861 fWATsoN, William Spencer, M.B., Surgeon to the Great
Northern Hospital ; Surgeon to the Royal South
London Ophthalmic Hospital ; 7, Henrietta street,
Cavendish square. C. 1883-4. Trans. 1.
1879 de Watteville, Abmand, M.A., M.D., B.Sc, Medical
Electrician to St. Mary's Hospital ; 30, Welbeck street,
Cavendish square.
1854 Webb, William, M.D., Gilkin View House, Wirksworth,
Derbyshire.
1840 Webb, William Woodham, M.D., 82, Avenue des Termes,
Paris.
1857 Weber, Hermann, M.D., Vice-President, Physician to
the German Hospital ; 10, Grosvenor street, Grosvenor
square. C. 1874-5. V.P. 1885-6. Referee, 1869-73,
1878-84. Lib. Com. 186 4-73. Trans. 6.
1844 fWEGG, William, M.D., 15, Hertford street, Mayfair.
L. 1854-8. C. 1861-2. T. 1873-80. Lib. Com.
1851-3.
1878 Weiss, Hubert Foveaux, Assistant Surgeon to the West
London Hospital ; 1 1, Hanover square.
1874 Wells, Harry, M.D., San Ysidro, Buenos Ayres, S.
America.
1854 fWELLS, Sir Thomas Spencer, Bart., Surgeon-in-Ordinary
to H.M.'s Household ; Consulting Surgeon to the
Samaritan Free Hospital for Women and Children ; 3,
Upper Grosvenor street. C. 1870. V.P. 1831.
Trans. 13. Pro. 1.
1842 fWEST, Charles, M.D., Corresponding Member of the
Academy of Medicine of Paris ; 55, Harley street,
Cavendish square. C. 1855-6. V.P. 1863. P. 1877-8.
Referee, 1848-54, 1857-62, 1864-76, 1880. Sci. Com.
1863. Lib. Com. 1844-7, 1851. Trans. 2.
1877 West, Samuel, M.D., Physician and Pathologist to the
City of London Hospital for Diseases of the Chest,
Victoria Park; Physician to the Royal Free Hospital;
Medical Registrar and Medical Tutor to St. Bartholo-
mew's Hospital ; 15, Wimpole street, Cavendish square.
Trans. 3.
FELLOWS OF THE SOCIETY.
h
Elected
1882 Wharry, Charles John, M.D., Resident Superintendent,
Government Civil Hospital, Hong Kong.
1881 Wharry, Robert, M.D., Physician to the Westminster
Dispensary ; 6, Gordon square.
1878 Wharton, Henry Thornton, M.A., Honorary Surgeon to
the Kilburn Dispensary ; 39, St. George's road, Kilburn.
1828 Whatley, John, M.D.
1875 Whipham, Thomas Tillyer, M.B., Physician to, and Lec-
turer on Pathology and Practical Medicine at, St.
George's Hospital; 11, Grosvenor street, Grosvenor
square.
1849 White, John.
1881 White, William Hale, M.D., Assistant Physician to
Guy's Hospital ; 4, St. Thomas's street, Southwark.
Trans. 1.
1881 ♦Whitehead, Walter, F.R.S. Ed., Surgeon to the Man-
chester Royal Infirmary ; Senior Surgeon to the Man-
chester and Salford Lock and Skin Hospital ; 24, St.
Ann's square, Manchester. Trans. 1.
1885 *Whitla, William, M.D., Physician to, and Lecturer in
Medicine at, the Belfast Royal Hospital ; Consulting
Physician to the Ulster Hospital for Women and Chil-
dren ; 8, College square north, Belfast.
1877 Whitmore, William Tickle, Surgeon to the Westminster
General Dispensary ; 7, Arlington street, Piccadilly.
1852 Wiblin, John, M.D., Medical Inspector of Emigrants and
Recruits; Southampton. Trans. 1.
1870 *Wilkin, John F., M.D., M.C., The Warren, Beckenham
park, Kent.
1883 *Wilkinson, Thomas Marshall, Surgeon to the Lincoln
County Hospital and to the Lincoln General Dis-
pensary ; 7, Lindum road, Lincoln.
1837 Wilks, George Augustus Frederick, M.D., Stanbury,
Torquay.
VOL. lxix. e
lxvi FELLOWS OF THE SOCIETY.
Elected
1863 Wilks, Samuel, M.D.,LL.D.,F.R.S., Physician in Ordinary
to their Royal Highnesses the Duke and Duchess of
Connaught, and to H.R.H. the Duke of Edinburgh ;
Consulting Physician to Guy's Hospital, and Member of
the Senate of the University of London ; 72, Grosvenor
street, Grosvenor square. Referee, 1872-81. Sci.
Com. 1.
1883 *Willaxs, William Blundell, Great Hadham, Herts.
1865 fWiLLETT, Alfred, Surgeon to St. Bartholomew's Hospital ;
Surgeon to St. Luke's Hospital ; 36, Wiinpole street,
Cavendish square. C. 1880-81. Referee, 1882-6.
Trans. 2.
1864 Willett, Edmund Sparshall, M.D., Resident Physician,
Wyke House, Isleworth, Middlesex.
1840 fWiLLiAMS, Charles James Blasius, M.D., F.R.S.,
Physician-Extraordinary to H.M. the Queen; Consulting
Physician to the Hospital for Consumption, Brompton
[47, Upper Brook street, Grosvenor square] ; Villa de
Rocher, Cannes. C. 1849-50. V.P. 1860-1. P.
1873-4. Referee, 1843-4. Sci. Com. 1862. Trans. \.
1859 *Williams, Charles, Surgeon to the Norfolk and Norwich
Hospital ; 4S, Prince of Wales road, Norwich.
1866 Williams, Charles Theodore, M.A., M.D., Physician
to the Hospital for Consumption and Diseases of the
Chest, Brompton; 47, Upper Brook street, Grosvenor
square. C. 18S4-5. Lib. Com. 1880-3. Trans. 4.
1881 Williams, Dawson, M.D., Assistant Physician to the East
London Hospital for Children ; 4, Oxford and Cam-
bridge Mansions, Marylebone road.
1872 Williams, John, M.D., Obstetric Physician to University
College Hospital ; Examiner in Obstetric Medicine
at the University of London ; 11, Queen Anne street,
Cavendish square. Referee, 1878-86. Lib. Com.
1876-82.
1 868 Williams, William Rhys, M.D., Commissioner in Lunacy ;
13, Gloucester street, Warwick square.
FELLOWS OF THE SOCIETY. lxvii
Elected
1863 Wilson, Robert James, 7, Warrior square, St. Leonard's-
on-Sea, Sussex.
1850 *Wise, Robert Stanton, M.D., Consulting Physician to
the Southam Eye and Ear Infirmary; Beech Lawn,
Banbury.
1825 Wise, Thomas Alexander, M.D., Thornton, Beulah Hill,
Upper Norwood.
1879 Woakes, Edward, M.D., Senior Aural Surgeon to the
London Hospital ; 78, Harley street, Cavendish square.
1885 Wolfenden, Richard Norris, M.D., Assistant Physician
to the North-West London Hospital; 19, Upper
Wimpole street.
1851 fWooD, John, F.R.S., Professor of Clinical Surgery in King's
College, London, and Senior Surgeon to King's College
Hospital; 61, Wimpole street, Cavendish square. C.
1867-8. V.P. 1877-8. Referee, 1871-6, 1880-86.
Lib. Com. 1866. Trans. 3.
1848 fW°0D> William, M.D., Physician to St. Luke's Hospital
for Lunatics; 99, Harley street, Cavendish square.
C. 1867-8. V.P. 1877-8.
1883 Wood, William Edward Ramsden, M.A., M.D., Eock-
hampton, Queensland.
1881 * Woodman, Samuel, Consulting Surgeon to the Ramsgate
and St. Lawrence Royal Dispensary; 5, Prospect terrace,
Ramsgate.
1879 Woodward, G. P. M., M.D., Deputy Surgeon-General;
Sydney, New South Wales.
1878 Yeo, Gerald Francis, M.D., M.C., Professor of Physiology
in King's College, London ; Examiner in Physiology,
University of London ; King's College, Strand.
[It is particularly requested that any change of Title, Appointment, or
Residence, may be communicated to the Secretaries before the 1st of
October in each year, in order that the List may be made as correct as
possible.]
IXVlll FELLOWS OF THE SOCIETY.
HONORARY FELLOWS.
(Limited to Twelve.)
Elected
1847 Chadwipk, Edwin, C.B., Corresponding Member of the
Academy of Moral and Political Sciences of the Insti-
tute of France ; Park Cottage, East Sheen.
1883 Frankland, Edward, M.D., D.C.L., Ph.D., F.R.S., Cor-
responding Member of the French Institute ; The Yews,
Reigate Hill, Reigate.
18G8 Hooker, Sir Joseph Dalton, C.B., M.D., K.C.S.I.,
D.C.L., LL.D., F.R.S., Member of the Senate of the
University of London, Director of the Royal Botanic
Gardens, Kew ; Corresponding Member of the Academy
of Sciences of the Institute of France ; The Camp,
Sunningdale.
1868 Huxley, Thomas Henry, LL.D., D.C.L., F.R.S., Professor
of Natural History in the Royal School of Mines ;
Secretary to the Royal Society ; Corresponding Member
of the Academies of Sciences of St. Petersburg, Berlin,
Dresden, Sec. ; 4, Marlborough place, St. John's wood.
1878 Lubbock, Sir John, Bart., M. P., D.C.L., LL.D., F.R.S.,
High Elms, Hayes, Kent.
1847 Owen, Sir Richard, K.C.B., D.C.L., LL.D., F.R.S., late
Superintendent of the Natural History Departments in
the British Museum ; Foreign Associate of the Academy
of Sciences of the Institute of France ; Sheen Lodge,
Mortlake.
1883 Parker, William Kitchen, F.R.S., Crowland, Trinity road,
Upper Tooting.
FELLOWS OF THE SOCIETY. lxix
Elected
1873 Stokes, George Gabriel, M.A., D.C.L., LL.D., F.R.S.,
Lucasian Professor of Mathematics in the University
of Cambridge ; President of the Royal Society ; Lens-
field Cottage, Cambridge.
1 8G8 Ttndall, John, D.C.L., LL.D., F.R.S., Professor of Natural
Philosophy in the Royal Institution ; Corresponding
Member of the Academies and Societies of Sciences of
Gottingen, Haarlem, Geneva, &c. ; Royal Institution,
Albemarle street, Piccadilly.
lxx FELLOWS OF THE SOCIETY.
FOREIGN HONORARY FELLOWS.
(Limited to Twenty.)
Elected
1878 Baccelli, Guido, M.D., Professor of Medicine at Rome.
1883 Bigelow, Henry J., M.D., Professor of Surgery at Harvard
University, and Surgeon to the Massachusetts General
Hospital.
18/6 Billroth, Theodor, M.D., Professor of Surgery in the
University of Vienna ; Vienna.
1883 Charcot, J. M., M.D., Physician to the Hopital de la Salpe-
triere, and Professor at the Faculty of Medicine of
Paris ; Member of the Academy of Medicine ; Quai
Malaquais 1", Paris.
1864 Donders, Franz Cornelius, M.D.,LL.D., Professor of Phy-
siology and Ophthalmology at the University of Utrecht.
1883 DuBois Reymond, Emil, M.D., Professor in Berlin ; N. W.
Neue Wilhelmstrasse 15, Berlin.
1866 Hannover, Adolph, M.D., Professor at Copenhagen.
1873 Helmholtz, Hermann Ludwiq Ferdinand, Professor of
Physics and Physiological Optics ; Berlin.
1873 Hofmann, A. W., LL.D., Ph.D., Professor of Chemistry,
Berlin.
1868 Kolliker, Albert, Professor of Anatomy in the University
of Wiirzburg.
1856 Lanoenbeck, Berniiard, M.D., late Professor of Surgery
in the University of Berlin.
FELLOWS OF THE SOCIETY. lxxi
Elected
1868 Larrey, Hippoltte Baron, Member of the Institute of
France ; Inspector of the " Service de Sante Militaire,"
and Member of the " Conseil de Sante des Armees ;"
Commander of the Legion of Honour, &c. ; Rue de
Lille, 91, Paris.
1883 Pasteur, Louis, LL.D., Member of the Institute of France
(Academy of Sciences).
18/8 Scakzoni, Friedreich Wilhelm von, Eoyal Bavarian Privy
Councillor, and Professor of Medicine in the University
of Wiirzburg.
1856 Virchow, Rudolph, M.D., LL.D., Professor of Pathological
Anatomy in the University of Berlin ; Corresponding
Member of the Academy of Sciences of the Institute
of France ; Berlin.
LIST OF RESIDENT FELLOWS
ARRANGED ACCORDING TO
DATE OF ELECTION.
1833 Sir George Burrows, Bt., M.D.,
F.R.S.
Thomas A. Barker, M.D.
1835 Richard Quain, F.R.S.
Thomas A. Nelson, M.D.
1836 Alexander Shaw.
J. George French.
1837 Thomas Blizard Curling, F.R.S.
1838 Charles Hawkins.
Henry Spencer Smith.
1839 T. Graham Balfour, M.D., F.R.S.
Fred. Le Gros Clark, F.R.S.
James Dixon.
1840 Chas. J. B. Williams, M.D., F.R.S.
Charles Hutton, M.D.
Samuel A. Lane.
Sir James Paget, Bt., F.R.S.
1841 Sir Henry A. Pitman, M.D.
Sir William Bowman, Bart., F.R.S.
Paul Jackson.
1842 Charles West, M.D.
John Simon, C.B., F.R.S.
John Frichsen, F.R.S.
Sir Oscar M. P. Clayton.
1843 Robert Greenhal^h, M.D.
Sir Prescott G. Hewett, Bt., F.R.S.
Henry Lee.
Luther Jlolden.
Edward Newton.
1844 Arthur Fane, M.D., F.R.S.
William Wegg, M-l>.
1844 Thomas King Chambers, M.D.
Edwin llumby.
1S45 Samuel Cartwright,
George D. Pollock.
1845 Thomas Taylor.
Sir Edwin Saunders.
William Oliver Chalk.
Edward U. Berry.
Benjamin Ridge, M.D.
1S40 John A. Bostock.
Barnard Wight Holt.
Carsten Holthouse.
1847 W. H. O. Saukey, M.D.
George Johnson, M.D., F.R.S.
1S4S Sir Edward H Sieveking, M.D.
Edward Ballard, M.D.
William Wood, M.D.
Thomas Hawksley, M.D.
Edward John Tilt, M.D.
John Clarke, M.D.
John Gregory Forbes.
1549 Hugh J. Sanderson, M.D.
C. H. F. Rout h. M.D.
Edmund L. Birkett, M.D.
George T. Finehain, M.D.
Sir William W. Gull, Bt., M.D.,
F.R.S.
1550 Richard Quain, M.D., F.R.S
George Roper, M.D.
1851 Sir Wm Jenner, Bt,, M.D., F.R.S.
H. Haynea Walton.
John Birkett.
John A. Kingdon.
Peter ^i . Gowlland.
John Marshall I'.R.S.
John Wood, P.R.S
Bernard F. Brodhurst.
Robert J. Spitta, M.D.
( 'eorge Gaskoin.
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
lxxi
1853
1854
1855
1856
1857
1852 C. Bland Radcliffe, M.D.
Walter H. Walshe, M.D.
William Adams.
Sir Heiiry Thompson.
Robert Brudenell Carter.
Alfred Baring Garrod, M.D., F.R.S.
Samuel 0. Habershon, M.D.
Sir Thomas Spencer Wells, Bt.
W. M. Graily Hewitt, M.D.
J. Burdon Sanderson, M.D., F.R.S.
J. Russell Reynolds, M.D., F.R.S.
Walter John Bryant, M.D.
Charles J. Hare, M.D.
William Bird.
Jonathan Hutchinson, F.R.S.
Timothy Holmes.
Alonzo H. Stocker, M.D.
William Overend Priestley, M.D.
George Harley, M.D., F.R.S.
Henry Thompson, M.D.
Hermann Weber, M.D.
George Owen Rees, M.D., F.R.S.
John Whitaker Hulke, F.R.S.
John Morgan.
Henry Cooper Rose, M.D.
Henry Walter Kiallmark.
1858 Fred. George Reed, M.D.
William Chapman Begley, M.D.
John William 0?le, M.D.
Wilson Fox, M.D., F.R.S.
1859 Wm. Howship Dickinson, M.D.
William Scovell Savory, F.R.S.
Edwin Thomas Truman.
Richard Barwell.
Edward Tesart.
Septimus William Sibley.
William E. Stewart.
1860 Sir Andrew Clark, Bt., M.D., F.R.S.
William Ogle, M.D.
Thomas Bryant.
John Couper.
Henry Howard Hayward.
1861 Robert Barnes, M.D.
William Spencer Watson.
William Henry Holman, M.B.
1862 James Andrew, M.D.
Lionel Smith Beale, M.B., F.R.S.
Thomas H. Tuke, M.D.
Edmund Symes Thompson, M.D.
Reginald Edward Thompson, M.D.
William Henry Brace, M.D.
George Cowell.
Robert Farquharson, M.D., M.P.
M. Berkeley Hill.
1863 Octavius Sturges, M.D.
John Langdon H. Down, M.D.
Samuel Wilks, M.D., F.R.S.
Samuel Feuwick, M.D.
Julius Althaus, M.D.
Sydney Ringer, M.D., F.R.S.
Thomas Smith.
Arthur B. R. Myers.
Arthur E. Durham.
William Sedgwick.
1864 George Buchanan, M.D., F.R.S.
Charles Derby Waite, M.B.
John Harley M.D.
Walter John Coulson.
Thomas William Kunn.
Jos. Gill man Barratt, M.D.
1865 Charles Robert Drysdale, M.D.
James Edward Pollock. M.D.
William Cholmeley, M.D.
Reginald Southey, M.D.
George Fielding Blandford, M.D.
Sir Dyce Duckworth, M.D.
Frederick W. Pavy, M.D., F.R.S.
William Morrant Baker.
John Langton.
Frederick James Gant.
Alfred Willett.
Bowater John Vernon.
Alfred Cooper.
Christopher Heath.
1866 Thomas Fitz-Patrick, M.D.
Samuel Jones Gee, M.D.
Charles Theodore Williams, M.D.
Hey wood Smith, M.D.
John Crockett Fish, M.D.
William Selby Church, M.D.
Edward John Waring, M.D.
1867 William Henry Day, M.D.
Achille Vintras, M.D.
Richard Douglas Powell, M.D.
F. Howard Marsh.
Henry Power.
Sir William MacCormac.
Thomas Pickering Pick.
John Astley Bloxam.
Charles Arthur Aikin.
Samuel Hill, M.D.
1868 H. Charlton Bastian, M.D., F.R.S.
William Henry Broadbent, M.D.
Thomas Buzzard, M.D.
John Cavafy, M.D.
Walter Butler Cheadle, M.D.
John Cockle, M.D.
Sir Thos. Crawford, K.C.B., M.D.
lxxi\
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
1868 T. Henry Green, M.D.
William Rhys Williams, M.D.
William Chapman Grigg, M.D.
John Croft.
George Eastes.
William Henry Freeman.
1869 Joseph Frank Payne, M.D.
Arthur E. Sansom, M.D.
John Wickham Legg, M.D.
Charles Elam, M.D.
Thomas Laurence Read.
1870 Alfred Meadows, M.D.
William Wadham, M.D.
J. Warrington Haward.
Edgcombe Venning.
Clement Godson, M.D.
1S71 William Cayley, M.D.
Charles Henry Ralfe, M.D.
Arthur Julius Pollock, M.D.
Thomas L. Brunton, M.D., F.R.S.
Henry Gawen Sutton, M.D.
J. Hughlings Jackson, M.D.,F.R.S.
Henry Sutherland, M.D.
George Vivian Poore, M.D.
Walter Rivington.
Marcus Beck.
Edward Bellamy.
William F. Butt.
Benjamin Duke.
1872 Gilbart Smith, M.D.
Thomas B. Christie, M.D.
George B. Brodie, M.D.
John Williams, M.D.
Sir J. Fayrer, M.D., F.R.S.
Charles S. Tomes, B.A., F.R.S.
Sir William Bartlett Dalby.
1873 William Miller Ord, M.D.
Frederick Taylor, M.D.
Norman Moore, M.D.
John Curnow, M.D.
William R. Gowcrs, M.D.
Sir Win. Guyer Hunter, M.D., M. P.
Charles Creighton, M.D.
Jeremiah McCarthy.
Wm. Johnson Smith.
Robert William Parker.
Alex. O. McKellar.
Henry T. Butlin.
Charles Higscns.
William J. Walsham.
Edward Milner.
1874 Alfred Lewis Galabin, M.D.
George Thin, M.D.
Alfred B. Dulliu, M.D.
1874 James H. Aveling, M.D.
John Mitchell Bruce, M.D.
Henry Morris.
William Laidlaw Purves.
William Harrison Cripps.
Henry G. Howse.
Herbert William Page.
Frederic Durham.
John J. Merriman.
William Robert Smith, M.D.
1875 Thomas T. Whipham, M.B.
Francis Charlewood Turner, M.D
Robert Hunter Semple, M.D.
Thomas Crawford Hayes, M.D.
Charles Henry Carter, M.D
Fletcher Beach, M.B
Samuel Osborn.
Waren Tay.
Edmund J. Spitta.
IS 76 Thomas Barlow, M.D.
John C. Bucknill, M.D., F.R.S.
Wm. Lewis Dudley, M.D.
Albert J. Venn, M.D.
John Knowsley Thornton.
Charles Macnamara.
JohnN. C. Davies-Colley.
1877 Felix Semon, M.D.
Sidney Coupland, M.D.
Francis Warner, M.D.
William Ewart, M.D.
Alfred Pearce Gould.
Rickman J. Godlee.
Alban H. G. Doran.
George Ernest Herman, M.B.
Samuel West, M.D.
John Abercrombie, M.D.
J. Matthews Duncan, M.D., F.R.S.
Henry de Fonmartin, M.D.
George Allan Heron, M.D
Joseph A. Ormcrod, M.D.
P. Henry Pye-Smith, M.D., F.B.8.
Edward Nettleship.
William Henry Bennett.
William T. AVhitmore.
1S7S Sir Jas. Crichton Browne, M.D.
Fred. T. Roberts, M.D.
Sir Joseph Lister, Bart., F.R.S.
Clinton T. Dent.
John 11. Morgan.
Walter Pye.
Gerald F.'Yco, M.D.
Donald W. Oharlea I Km,!, Ml;
Henry Gervis, M.D.
Herbert Watney, M.D.
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
lxxv
1878 Richard Davy.
Hubert Foveaux Weiss.
Henry Thornton Wharton.
1879 Alfred Sangster, M.B.
Edward Woakes, M.D.
Armand de Watteville, M.D.
Malcolm A. Morris.
A. E. Cumberbatch.
Edmund Owen.
Arthur E. J. Barker.
Frederick Treves.
Horatio Donkin, M.B.
Thomas John Maclagan, M.D.
David White Fiulay, M.D.
Andrew Clark.
S. Hamilton Cartwright.
John H. Waters, M.D.
Francis Henry Champneys, M.B
William Watson Cheyne.
William Munk, M.D.
George Henry Savage, M.D.
H. H. Clutton, M.A.
Frederic S. Eve.
E. Noble Smith.
William Henry Allchin, M.B
F. G. Dawtrey Drewitt, M.D.
1880 Robert Alex. Gibbons, M.D.
David Ferrier, M.D., F.R.S.
Vincent Dormer Harris, M.D.
Edmund Distin Maddick.
Jas. John Mac Whirter Dunbar ,M.B.
James William Browne, M.B.
William Appleton Meredith, M.B.
Alexander Hughes Bennett, M.D.
Malcolm Macdonald McHardy.
A. Boyce Barrow.
William Murrell, M.D.
Bernard O'Connor, A.B., M.D.
Leslie Ogilvie, M.B.
George Lockwood Laycock, M.B.
George Ogilvie, M.B.
Charles Edward Beevor, M.D.
Thomas Colcott Fox, M.B.
George Henry Makins.
1881 Francis de Havilland Hall, M.D.
Robert Wharry, M.D.
Cecil Yates Biss, M.D.
Richard Clement Lucas.
Stephen Mackenzie, M D.
James Anderson, M.D..
William Hale White, M.D.
Eustace Smith, M.D.
William Sinclair Thomson, M.D.
Percy Kidd, M.D.
1881 Oswald A. Browne, M.A.
Audley Cecil Buller.
W. Bruce Clarke, M.B.
Dawson Williams, M.D.
George Lindsay Johnson, M.A.,
M.D.
Henry Edward Juler.
Jonathan F. C. H. Macready.
C. B. Lockwood.
1882 Philip J. Hensley, M.D.
Ernest Clarke.
John Barclay Scriven.
George Robertson Turner.
Howard Henry Tooth, M.B.
Herbert Isambard Owen, M.D.
Charles R. B. Keetley.
Joseph Mills.
A. T. Myers, M.D.
Anthony A. Bowlby.
Amand J. McC. Routh, M.D.
Seymour J. Sharkey, M.B.
William Lang.
Henry Radcliffe Crocker, M.D.
William Edward Steavenson, M.D.
D. Astley Gresswell, M.B.
1883 Edwin Clifford Beale, M.A., M.B.
James Kingston Fowler, M.D.
James Frederic Goodhart, M.D.
John Charles Galton, M.A.
Walter Hamilton Acland Jacobson.
Edward Joshua Edwardes, M.D.
Walter H. Jessop, M.B.
Walter Edmunds, M.C.
Victor A. Horsley, F.R.S.
Dudley Wilmot Buxton, M.D.
Charles Douglas F. Phillips, M.D.
Angel Money, M.D.
John James Pringle, M.B.
Henry Roxburgh Fuller, M.D.
Wilmot Parker Herringham, M.B.
Augustus Waller, M.D.
William Pasteur, M.D.
Edward Albert Schafer, F.R.S.
John Bland Sutton.
William Rose, M.B.
Storer Bennett.
Henry Maudsley, M.B.
Robert Marcus Gunn, M.B.
James Dixon Bradshaw, M.B.
1884 George Newton Pitt, M.D.
Charles Stonham.
Stanley Boyd, M.B.
William Arbuthnot Lane, M.S.
Dennis Dallaway.
lxx
VI
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
1884 Thomas Whitehead Reid.
Arthur Marmaduke Sheild, M.B.
Frederic Bowreman Jessett.
Sidney Harris Cox Martin, M.B.
Way land Charles Chaffey, M.B.
George Lawson.
Heneage Gibbes, M.D.
Thomas Wakley, Jun.
Robert James Lee, M.D.
F. Swinford Edwards.
Herbert Tyrrell Griffiths, M.D.
James Johnston, M.D.
Arthur Oakes, M.D.
Edward Stewart, M.D.
William A. Duncan, M.D.
Charles Chinner Fuller.
Lovell Drage.
Jean Samuel Keser, M.D.
Charles Egerton Jennings, M.S.
George Richard Turner Phillips.
Bilton Pollard.
1885 Alexander Haig, M.B.
Wm. Dobinson Halliburton, M.D.
Theodore Dyke Acland, M.D.
Kenneth William Millican.
Frederick Walker Mott, M.B.
William Maunsell Collins, M.D.
James Berry.
John Cahill.
Francis Henry Hawkins, M.B.
John Poland.
James Greig Smith.
John Mackern, M.D.
George Gulliver, M.B.
Heinrich Port, M.D.
Edward Emanuel Klein, M.D.,
F.R.S.
R. Norris Wolfenden, M.D.
A. C. Butler-Smvthe.
Arthur Gamgee, M.D., F.R.S.
Charles Alfred Ballance, M.S.
Walter Spencer Anderson Griffith,
M.B.
John Edward Squire, M.D.
John D. Malcolm, M.B., CM.
Phineas S. Abraham.
18S6 Robert Maguire, M.D.
Harrington Salisbury, M.D.
Cuthbert Hilton Golding-Bird, M.S.
Benjamin Wainewright, M.B. .CM.
Charles Leopold Hudson.
Laureston Elgie Shaw, M.D.
Charters James Symonds, M.S.
CONTENTS.
PAGB
List of Officers and Council . . . ▼
List of Presidents of the Society . . . . vi
Referees of Papers .... vii
Trustees of the Society ..... viii
Trustees of the Marshall Hall Memorial Fund . viii
Library Committee ..... viii
List of Fellows . . . . . ix
List of Honorary Fellows .... lxviii
List of Foreign Honorary Fellows . . . lxx
List of Resident Fellows, arranged according to Date of Election lxxii
List of Plates ..... lxxxi
Woodcuts ..... lxxxii
Advertisement . . . . . lxxxv
Regulations relative to ' Proceedings ' . . lxxxvi
I, Address of George Johnson, M.D., F.R.S., Presi-
dent, at the Annual Meeting, March 1st, 1886 . 1
II. Diffuse Lipoma. By W. Morrant Baker, F.R.C.S.,
Surgeon to St. Bartholomew's Hospital ; Consulting
Surgeon to the Evelina Hospital for Sick Children ;
and Anthony A. Bowlby, F.R.C.S., Surgical
Registrar and Demonstrator of Surgical Morbid
Anatomy at St. Bartholomew's Hospital . 41
III. A Case of Ligature of the Left Common Carotid
Artery wounded by a Fish-bone which had pene-
trated the Pharynx ; with Remarks and an Ap-
pendix containing Forty-five Cases of Wounds of
Blood-vessels by Foreign Bodies. By Walter
Rivington, M.S.Lond., F.R.C.S.Eng., Surgeon to
the London Hospital, and Lecturer on Surgery at
the London Hospital Medical College . . 63
lxxviii CONTENTS.
PAGE
IV. Scarlatinal Albuminuria, and the Pre-albuminuric
Stage, Studied by Frequent Testing. By R. Ste-
venson Thomson, B.Sc., M.B., late Senior Resi-
dent Assistant Physician to the City of Glasgow
Fever Hospital. (Communicated by Dr. W. T.
Gairdner, Glasgow.) . . .97
V. On Some Points regarding the Distribution of Bacil-
lus Anthracis in the Human Skin in Malignant
Pustule. By Arthur E. Barker, F.R.C.S., Sur-
geon to University College Hospital and Teacher
of Practical Surgery and Assistant Professor of
Clinical Surgery at University College Hospital . 127
VI. A Case of So-called Actinomycosis of the Liver. By
John Harley, M.D.Lond., F.R.C.P., F.L.S., Phy-
sician to, and Lecturer on General Anatomy and
Physiology at, St. Thomas's Hospital . . 135
VII. A Case of Destruction of a Portion of the Axillary
Artery by Sarcoma. By Wm. S. Savory, F.R.S.,
Senior Surgeon to St. Bartholomew's Hospital . 157
VIII. Amputation at the Knee-joint by Disarticulation ;
with Remarks on the Amputation of the Leg by
Lateral Flaps. By Thomas Bryant, F.R.C.S.,
Senior Surgeon to Guy's Hospital . .It!:;
IX. On the Increase in Number of White Corpuscles in
the Blood in Inflammation, especially in those
Cases accompanied by Suppuration. By T. P.
Gostling, M.R.C.S., L.R.C.P., Diss, Norfolk.
(Communicated by Dr. Ringer, F.R.S.) . 183
X. A Communication on the Removal of a Growth from
the Brachial Plexus, affecting the Roots of the
Eighth Cervical and First Dorsal Nerves at their
Emergence from the Intervertebral Foramina. By
Edward Bellamy, F.R.C.S. . . .211
XI. Statistics of Mortality in the Medical Profession.
By William Ogle, M.D.Oxon., F.R.C.P. . 217
XII. On the Tapetum Lucidum. By Henry Lee. Con-
sulting Surgeon to St. George's Hospital . 239
CONTENTS. lxxix
XIII. Enteric Fever at Suakin, with Some Cases of Mala-
rial-enteric, or Typho- malarial Fever. By J.
Edward Squire, M.D., M.R.C.P., lately Senior
Medical Officer to the Red Cross Society in the
Eastern Soudan .... 247
XIY. A Case of Thoracic Aneurism treated by the Intro-
duction of Steel Wire into the Sac. By William
Cayley, M.D., Physician to, and Lecturer on the
Principles and Practice of Medicine at, the Middle-
sex Hospital ; Physician to the Fever Hospital and
to the North-Eastern Hospital for Children . 267
XV. On the Changes which Occur in Bone and Soft
Tissues after Amputation of a Limb, and from
certain other Conditions. By George Pollock,
F.R.C.S., Consulting Surgeon to St. George's
Hospital . . . . .275
XVI. A Case of General Seborrhoea or " Harlequin " Foetus.
By J. Bland Sutton, F.R.C.S. . . 291
XVII. On Cardiography, with Special Reference to the
Relation of the Time of Duration of Ventricular
Systole to that of Diastolic Interval. By Paul
M. Chapman, M.D.Lond., M.R.C.P., Physician to
the Hereford General Infirmary . . 297
XVIII. Two Cases of Bronchiectasis treated by Paracentesis,
with Remarks on the Mode of Operation. By C.
Theodore Williams, M.A., M.D.Oxon.,F.R.C.P.,
Physician to the Hospital for Consumption and
Diseases of the Chest, Brompton ; and Rickman
J. Godlee, M.S., F.R.C.S., Surgeon to University
College Hospital; Surgeon to the Hospital for Con-
sumption and Diseases of the Chest, Brompton . 317
XIX. On Supra-pubic Lithotomy. By Richard Bar-
well, F.R.C.S., Senior Surgeon to Charing Cross
Hospital ..... 341
XX. A Case of Encysted Vesical Calculus of Unusually
Large Size removed by Supra-pubic Cystotomy.
By Walter Rivington, M.S.Lond., F.R.C.S.Eng.,
Surgeon to the London Hospital, and Lecturer on
Surgery at the London Hospital Medical College . 361
CONTENTS.
PAGE
XXI. A Case of Supra-pubic Lithotomy, with Remarks on
the Operation. By W. H. A. Jacobson, F.R.C.S.,
Assistant Surgeon, Guy's Hospital ; Surgeon, .
Royal Hospital for Women and Children . 376
XXII. The Chemical Pathology of Respiration in Cholera.
By William Sedgwick, M.R.C.S. . . 385
XXIII. Two Cases of Splenectomy. By J. Knowsley
Thornton, M.B., CM., Surgeon to the Samaritan
Free Hospital . . . .407
XXIV. On the Development of Mammary Functions by the
Skin of Lying-in Women. By Francis Henry
Champneys, M.A., M.B.Oxon., F.R.C.P., Obstetric
Physician to St. George's Hospital . .419
XXV. The Ligation of the Larger Arteries in their Con-
tinuity. An Experimental Inquiry. By Charles
A. Ballance, M.S., F.R.C.S. ; and Walter
Edmunds, M.C., F.R.C.S. . . 443
XXVI. Congenital Absence of Hair and Mammary Glands
with Atrophic Condition of the Skin and its Appen-
dages, in a Boy whose Mother had been almost
wholly Bald from Alopecia Areata from the age of
Six. By Jonathan Hutchinson, F.R.S. 473
XXVII. The Morbid Anatomy and Pathology of Encysted and
Infantile Hernia. By C. B. Lockwood, F.R.C.S..
Demonstrator of Anatomy and Operative Surgery
in St. Bartholomew's Hospital ; Surgeon to the
Great Northern Hospital . 179
XXVIII. On a Case of Multiple Neuromata. By Thomas F.
Chavasse, Surgeon to the Birmingham General
Hospital . . . . .517
XXIX. Some Statistics of Pneumonia, with especial Refer-
ence to the Relations of Delirium and Temperature.
By Angel Money. M.D., M.R.C.P. 527
Index . . . . .539
LIST OF PLATES.
PAGE
I and II. Diffuse Lipoma. (W. Morrant Baker and A. A.
Bowlby.) . . . . .62
III. Distribution of Bacillus Anthracis in the Human
Skin in Malignant Pustule. (A. E. Barker.)
Fig. 1. Diagram of transverse vertical section
through the malignant pustule. Fig. 2. Vertical
section of skin through the malignant pustule.
Fig. 3. Yertical section of skin . . 134
IV. A Case of So-called Actinomycosis of the Liver.
(John Harley, M.D.) Fig. 1. Section of the
liver. Fig. 2. Cavities containing granules.
Fig. 3. Isolated granules . . .156
V. Ditto. Radiate granules, surrounded by leucocytes 156
VI. Ditto. Fig. 1. A minute composite, radiate
granule. Fig. 2. Three lobules invaded by
leucocytes, &c. .... 156
VII. Enteric Fever at Suakin. (J. Edward Squire,
M.D.) Figs. 1—3. Temperature charts . 266
VIII. Ditto. Figs. 1—3. Temperature charts . 266
IX. On the Changes which Occur in Bone and Soft
Tissues after Amputation of a Limb, and from
certain other Conditions. (George Pollock.)
Upper portions of two thigh-bones from the
same subject .... 290
X. A Case of General Seborrhoea or " Harlequin "
Fcetus. (J. Bland Sutton.) . . 296
XL The Ligation of the Larger Arteries in their
Continuity. An Experimental Inquiry. (C. A
Ballance and Walter Edmunds.) Fig. 1.
Carotid of sheep 21 days after being ligatured
with kangaroo tendon ; (low power). Fig 2.
Ditto (high power) . . . 472
VOL. I.XIX. f
lxxxi
PLATES AND WOODCUTS
XII. Ditto. Fig 1. Carotid of a horse 51 days after
being ligatured with chromic catgut (low power)
Fig 2. Ditto (high power)
XIII. Ditto. Figs. 1 — 3. Chromic catgut ligatures
Fig. 4. Kangaroo tendon ligature .
XIV. Case of Multiple Neuromata. (T. F. Chavasse.)
472
472
526
Woodcuts.
Case of Ligature of the Left Common Carotid Artery wounded
by a Fish-bone which had penetrated the Pharynx.
(Walter Rivington.) Fish-bone as seen entering
the artery ......
Amputation at the Knee-joint by Disarticulation ; with
Remarks on Amputation of the Leg by Lateral Flaps.
(Thomas Bryant.)
1. Incisions for Stephen Smith's operation
2. Ditto. Appearance of flaps immediately after dis-
articulation
3. Ditto. Posterior view of stump .
4. Ditto. Amputation by mixed method
5. Ditto. Stump after ditto
6. Ditto. Artificial limb adapted to stump
On the Tapetum Lucidum. (Henry Lee.) Tapetum of cat .
Case of General Seborrhoea or " Harlequin " Fajtus. (J. Bland
Sutton.) Section from skin of scalp
On Cardiography. (Paul M. Chapman, M.D.)
1. Normal tracing
2. Faintness in Turkish bath
3. Normal tracing
4. Nitrite <>f amy] (slight effect)
5. Ditto (full effect)
6. Tracing of F. J—
7. Irregular heart
8. Effect of digitalis on same bear)
i). Effect of convallaria
175
17G
177
17:>
170
182
213
293
293
3( '7
309
310
311
313
313
;;i t-
woodcuts. lxxxiii
PAGE
Two Cases of Bronchiectasis treated by Paracentesis. (C.
Theodore Williams, M.D., and R. J. Godlee.) .
1. Chest diagram of Case 1 . . . 319
2 and 3. Chest diagrams of Case 2 . . 326-7
Case of Encysted Vesical Calculus, of unusually large size,
removed by supra-pubic cystotomy. ("Walter Riving-
ton.) Calculus extracted : natural size . . 369
The Morbid Anatomy and Pathology of Encysted and Infantile
Hernia. (C. B. Lockwood.)
1. Diagram of infantile (or encysted) hernia (Wood) . 486
2. Diagram of infantile hernia (Holmes) . . 488
3. Diagram of assumed condition of the parts in an
infantile hernia (Holmes) . . . 492
4. Infantile hernia (St. Thomas's Hospital) . . 493
5 and 6. Encysted Hernia (Guy's Hospital) . 495-8
7. Drawing to show the fold which connects the testis
with the caecum .... 502
8. Encysted hernia (St. Mary's Hospital) . . 510
Multiple Neuromata. (T. F. Chatasse.) .
Microscopic sections of the tumour . . . 524
ADVERTISEMENT.
The Council of the Royal Medical and Chirurgical Society
deems it proper to state that the Society does not hold
itself in any way responsible for the statements, reasonings,
or opinions set forth in the various papers which, on grounds
of general merit, are thought worthy of being published in
its ' Transactions/
VOL. LXIX.
Regulations relative to the publication of the ' Proceedings
of the Society/
That, as a general rule, the ' Proceedings ' will be issued every two
months, subject to variations dependent on the extent of matter
to be printed.
That a Copy of the ' Proceedings ' will be sent, postage free, to every
Fellow of the Society resident in the United Kiugdom.
That the ' Proceedings of the Society ' may be obtained by non-
members at the Society's House, 53, Berners Street, on pre-
payment of an annual subscription of five shillings, which may
be transmitted either by post-office order or in postage-stamps ;
— this will include the expense of conveyance by post to any
part of the United Kingdom; to other places they will be Bent,
carriage free, through a bookseller, or by post, the receiver
paying the foreign charges.
That a notice of every paper will appear in the ' Proceedings.' Auth< irs
will be at liberty, on sending their conmiuni< ations, to intimate
to the Secretary whether they wish them to appear in the ' Pro-
ceedings' only, or in the ' Proceedings ' and 'Transactions;' and
in all cases they will be expected to furnish an Abstract of the
communication.
The Abstracts of the papers read will be furnished to the Journals
as heretofore.
ADDRESS
GEOBG-E JOHNSON, M.D., F.R.S.
PRESIDENT,
ANNUAL MEETING, MAECH 1st, 188G.
Gentlemen, — The preparation of the annual address
with its obituary notices, at all times an anxious and a
difficult task, has this year been rendered more than
usually so by the fact that, unhappily, since the last anni-
versary meeting the number of our Fellows who have
been taken from us by death is unusually large.
You will have learnt from the report of the Council
that during the past year twenty-one Fellows of the
Society have died. Of these six were resident Fellows,
namely, Dr. Maclean, Mr. Arnott, Dr. Harris, Mr. John
Gay, Dr. Wotton, and Dr. Sutro. Eleven were non-
resident Fellows, namely, Dr. William Johnson Smith, Mr.
Egerton, Dr. Livingston, Mr. Fortescue, Dr. Edward
Howard, Dr. Wardell, Dr. James Russell, Dr. Scott, Mr.
Tufnell, Mr. Page, and Dr. Maule Sutton.
To this list have to be added one Honorary Fellow, Dr.
Carpenter, and three Foreign Honorary Fellows, namely,
Professor Henle, Dr. Noel Gueneau de Mussy, and Pro-
fessor Milne Edwards.
vol. lxix, 1
2 PRESIDENT S ADDRESS.
I propose now to refer to our deceased Fellows, resident
and non-resident, in the order in which their deaths
occurred, reserving for subsequent notice the names of the
Honorary Fellows of the Society.
I have no doubt that each of my predecessors in this
chair, while engaged in the responsible task of briefly
sketching the lives and the professional work of those
Fellows of the Society who had recently died, has, like
myself, been influenced by the desire that his obituary
notices should be animated by the same spirit of equity
and of charity — equally remote from unmerited eulogy and
from unfair criticism — as he would wish to be displayed by
some future President when referring to his own profes-
sional career.
In preparing these biographical sketches I have derived
much assistance from obituary notices which have appeared
in the various public journals. In some instances, too, I
am indebted to private friends and relatives of the deceased
for information with which they have favoured me, and
which I could not otherwise have obtained.
Dr. WilUam Johnson Smith, of "Weymouth, who was
elected a Fellow of this Society in 1847, was born in
October, 1813. He was educated in the University of
Edinburgh, where he graduated M.D. in 1842.
In 1844 he became a member of the Eoyal College of
Physicians, and afterwards settled at Weymouth, where
he obtained a large practice. He there established the
Weymouth Sanatorium for the treatment of diseases
peculiar to women and children, which, from small
beginnings, became in course of years a large and flou-
rishing institution. In ]>>:! tln> friends of the Sanatorium
placed in the entrance hall a marble bust of the founder.
a1 a cost of £150. During the lasl two years of his life
Dr. Smith suffered much from acute gout iu his feet. He
gradually became weaker, and died on the 12th of April,
1S,w."i, in his seventy-third year.
At his funeral, which was quite of a public character, a
large number of friends and former patients attended to
president's address. 3
pay their last tribute of respect and esteem for one whom
they had learnt to look upon as a great public bene-
factor.
Mr. Charles Chandler Egerton1 was born on the 13th
of April, 1798, at his father's vicarage, Thorncombe, in
Dorsetshire. Dr. Chandler, one of the physicians of Guy's
Hospital, was his uncle, and Mr. Egerton received his
medical education at the then united Guy's and St.
Thomas's Hospitals, under Sir Astley Cooper, Mr. Travers,
and others.
In May, 1823, he was appointed by the East India
Company Assistant Surgeon on the Bengal establishment
to practise as an oculist, and especially to take charge of
the Lower Orphan School, composed of Indo-European
lads who had contracted disease of the eyes ; and at the
end of the following month he sailed for Calcutta. Mr.
Egerton dealt successfully with the epidemic in the Orphan
School, and during his stay in India he held the first posi-
tion as an oculist, first at the Eye Hospital, which was
established under his own immediate care, and afterwards
at the Medical College Hospital. He was a very skilful
operator and a good surgeon.
He was appointed the first Surgeon at the Calcutta
Medical College Hospital, and he held that appointment
until he retired from the service. He had much influence
in carrying out the plan of the Bengal Medical Retiring
Fund when Lord Wni. Bentinck was Governor-General,
and he assisted in the establishment of the Medical
College for teaching the natives human anatomy by dis-
section.
Mr. Egerton left India at the end of 1846, or the begin-
ning of 1847 and, having retired from practice, he went
to live on his paternal estate, Kendal Lodge, Epping, where
he died on the 4th of May last, at the age of eighty-seven.
In 1858 he was placed on the Commission of the Peace for
the county and until within five or six years of his death
1 For the particulars of Mr. Egerton's work in India I am indebted to
Dr. John Jackson, the well-known retired Indian practitioner.
4 PRESIDENT S ADDRESS.
lie was one of the most regular attendants on tlie bench.
One of his neighbours. Dr. Fowler, of Epping, who had
known him for twenty years, says of him, in a note with
which I have been favoured, " He was a man of no ordi-
nary type ; firm, resolute and self -relying, yet kind, hospi-
table, and benevolent. He was highly respected by his
neighbours and by all who knew him, and warmly admired
by his numerous friends." Mr. Egerton was elected a
non-resident Fellow of this Society in 1823.
Dr. John Maclean was born at Shiels, near Renfrew, on
the loth of March, 1817. He was educated at the University
of Glasgow and graduated M.D. in 1838. He became a
member of the Royal College of Physicians in 1859, and
was elected a Fellow of this Society in I860. In 1845
he was appointed by the late Sir James Graham an Assis-
tant Inspector of Prisons in the home district and, while
holding this office, he was the author of numerous
prison reports which were presented to both Houses of
Parliament.
In 1847 Dr. Maclean was appointed Chief Medical
Officer of the Mutual Provident Alliance Office, and in
1848 Physician to the Provident Life Office. His life
office experience enabled Dr. Maclean to supply Mr.
Gladstone, when Chancellor of the Exchequer, with sta-
tistics in aid of the Government scheme of life assurance.
This service was acknowledged by Mr. Gladstone in his
speech in the House of Commons, on introducing the
Government Annuities and Assurance Bill in 1N64.
Sir Spencer Wells, in a note with which he has favoured
me, says that twenty years ago he often met Dr. .Maclean
on life assurance business, and he adds, " I was always
impressed by the great care he devoted to this branch of
the profession."
Dr. Maclean died on the 28th of April last, aged sixty-
eight.
Mr. Jamt 8 Moncrieff Arnott* was born at Cupar-Fife on the
15th of March, 1794, where his father and his grandfather
1 ' British Med. Journal,' June 80th, I885i
PRESIDENTS ADDEESS. 5
had been in practice before him. He "was educated, first
at the grammar school of his native place and subsequently
at the High School and the University of Edinburgh. He
entered the medical classes in 1809, passed the Edinburo-h
College of Surgeons in 1813, and the following year
obtained the M.D. of the University at the age of nineteen.
Mr. Arnott then came to London for a year and attended
Abernethy's lectures on anatomy at St. Bartholomew's
and Astley Cooper's on surgery at Guy's. He also became
a pupil at St. George's. In 1814 he went to Paris for a
year, where he attended the classes of Pelletan and Dupuy-
tren at the Hotel Dieu and those of Roger and Roux at La?1
Charite. He afterwards studied at Vienna for a year, chiefly
under Beer, the ophthalmologist, and Hildebrand, the then
famous teacher of clinical medicine. In 1817 Mr. Arnott
returned to London and became a member of the Royal
College of Surgeons. For many years he occupied him-
self by seeing the poor at his own house and often operating
upon them at their homes. During these years he was a
frequent visitor at the great hospitals on operation days.
At length, in 1831, Mr. Arnott was elected Assistant
Surgeon to the Middlesex Hospital, and two years later he
became full Surgeon. In 1836, while continuing to hold
office as Surgeon at the Middlesex, he was appointed
Professor of Surgery at King's College. This office he
resigned in 1840, when, at the opening of the new King's
College Hospital, he had to choose between the resigna-
tion of his Chair and that of his surgical appointment at
the Middlesex. At that time his King's College pupils,
of whom I was one, presented him with an illuminated
address expressing their admiration of his character and
his teaching and their extreme regret for his resignation.
In 1848 Mr. Arnott resigned his office at the Middlesex
on being appointed Professor of Surgery at University
College and Surgeon to University College Hospital. Two
years later, in 1850, he retired from University College, and
from that time he held no hospital appointment.
Mr. Arnott became a Fellow of the Royal College of
6 PRESIDENT'S ADDRES9.
Surgeons iu 1843, and an Examiner in 1S47. He was
twice elected President of the College — in 1850, and again
in 1859. It was chiefly through his exertions that the
College obtained the Government grant of £15,000 towards
the rebuilding of the Hunterian Museum, and, aided by
his former pupil, Mr. John Tomes, he did much to establish
the license in dental surgery. In recognition of his
services to the College, the Council, in 1852, voted the
marble bust which may now be seen in the College.
He joined this Society in 1819, and since the death of
Dr. Billing, five years ago, he had been our Senior Fellow.
He held in succession nearly every office in the Society,
and in 1847 he became President.
And here I am tempted to refer to a matter which
occurred during his Presidency, his method of dealing
with which seiwes, I think, to illustrate his good sense
and discretion. In June, 1847, it happened that my friend
and former colleague Mr. John Simon and I communicated
each a separate paper on the same subject, namely, " In-
flammation of the Kidney." The chief interest of the
papers, and the only point of difference between the
authors consisted in the interpretation of the microscopic
appearances associated with the development of cysts in
the kidney. The drawings which accompanied the papers
were essentially alike, but the interpretation of the ap-
pearances by the respective authors was entirely different.
In these circumstances, as I learnt afterwards from the
President, some members of the Council suggested that
both papers should be returned to the authors until they
had found the means of reconciling their differences. Mr.
Arnott, on the contrary, maintained that both papers sh raid
be published, together with their illustrations, so that facili-
ties might be given for future observers to investigate the
points in dispute The President 'a arguments prevail) <1 and
the two papers, with their illustrative drawings, were pub-
lished in the thirtieth volume of our ' Transactions/
Mr. Arnott contributed eight papers to our 'Transac-
tions;' of these the most important is entitled "A Patholo-
PRESIDENT S ADDRESS. 7
gical Inquiry into the Secondary Effects of Inflammation of
the Veins." In this paper, which occupies 131 pages of
the fifteenth volume of the f Transactions/ after a full and
complete reference to previous writers on the same subject,
including not only English, but also French, German, and
Italian authors, he gives a number of cases, and from the
details of these he concludes that the fatal results of inflam-
mation of the veins are due, not, as John Hunter had sur-
mised, to the extension of the inflammation along the veins
to the heart, but to the fact that the secondary abscesses in
the viscera, the joints, and elsewhere are the result of con-
tamination of the blood by pus and other morbid secretions.
He insists on the resemblance between the secondary results
of phlebitis and those diseases which are known to result
from the inoculation of a morbid poison, and in this con-
nection he makes especial reference to the local and con-
stitutional symptoms which result from poisoned wounds
received in dissection. And, lastly, he maintains that the
secondary abscesses which sometimes result from injuries,
whether of the extremities or of the head, and those which
have not seldom followed parturition, have the same
pathological origin, namely, the existence of phlebitis in
the part of the body primarily affected, and the consequent
transfer of infecting morbid materials to various remote
parts.
Mr. Arnott was elected a Fellow of the Royal Society
in 1843.
He held in succession various Royal appointments ; he
was Surgeon-Extraordinary to the late Queen Adelaide,
Surgeon-in- Ordinary to the late Prince Consort, and
Surgeon-Extraordinary to the Queen. In 1865 he retired
from active practice on succeeding to an old family estate
at Chapel in Fifeshire.
During the last two years of his life, Mr. Arnott occa-
sionally asked me to see him on account of some disturb-
ance of the circulation which was associated with evidence
of atheromatous degeneration of the arteries and with a
loud systolic murmur over the apex of the heart. In the
8 president's address.
early part of last year his only daughter, who was his
constant companion, noticed that he was losing colour and
strength, and when he came to London in the spring, Mr.
Sibley and I were asked to consult together upon his con-
dition. We found him greatly changed in appearance,
without discoverable organic disease, other than the state
of the circulation before mentioned. He continued to
lose flesh and colour until he was suddenly seized with
urgent dyspnoea and extreme restlessness, symptoms
which led us to the conclusion that a clot in the right
side of the heart or in the pulmonary artery was obstruct-
ing the flow of blood through the lungs. After a few
hours of acute suffering he died on the 27th of May in the
ninety-second year of his age.
His funeral in Kensal Green was attended by Mr. Cooper
Forster, then President of the Royal College of Surgeons,
and b}r many friends.
Mr. Arnott was universally held in the highest esteem
not onry for his acknowledged professional skill and ac-
quirements, but also for his unswerving integrity. I can
bear personal testimony to the high appreciation of his
clear and emphatic teaching by those who attended his
lectures.
I remember once being much impressed, in common
with my fellow-students, by the candid manner in which
he acknowledged an error of diagnosis. AW' had gone to
the Middlesex Hospital to see him operate ; and a testicle
believed to be medullary was removed. After the patient
had been carried out, Mr. Arnott sliced the testicle, ami
turning at once to the class, without a moment's delay or
hesitation, he said, " Gentlemen, we have been mistaken;
that which we took for malignant disease of the testicle we
now find to be a hematocele."
Mr. George Fortescue was a native of Cornwall, ami in
L840, when scarcely two years of age, was taken by his
parents to Tasmania, where, at Christ's College, h<
1 'Australian Medical Otazette,' June 15th, 1885.
PRESIDENT S ADDRESS. V
received his primary education, and subsequently he
returned to complete his education in England.
In 1857 he entered the Medical School of King's
College, where in 1858 he obtained a junior scholarship,
in 1859 a prize in Chemistry, and in 1861 he was
appointed House Surgeon. He was a general favourite
amongst his contemporaries, and was greatly admired for
his splendid physique. The museum of King's College
contains a cast of his right arm, displaying a magnificent
muscular development, and there is a tradition that on
one occasion a fellow-student, having insulted him, was
seized and held at arm's length over the baluster of the
hospital staircase, with a threat that if the offence were
repeated he should be dropped upon the pavement below.
Having obtained the M.R.C.S. in 1860, and graduated
M.B. London in 1861, he soon afterwards returned to
Australia, and for near a quarter of a century he was one
of the leading practitioners of Sydney. For many years
he was Surgeon of the Sydney Infirmary, and subse-
quently Surgeon of the Prince Alfred Hospital, from its
foundation to the time of his death, which occurred on the
Paramatta River near Sydney on the 1st of June, 1885, at
the age of forty-seven, from an attack of typhoid fever.
Mr. Fortescue was highly esteemed in the community
amongst whom he had lived and worked. Respected for
his skill in the profession he for so many years adorned,
he was no less beloved in private life, for the many kindly
and genial qualities he possessed. His own saying that
absolute " sanity " is the highest human quality, is said
to have been thoroughly exemplified in his character.
He was elected a Fellow of this Society in 1877.
Dr. John Livingston, whose death at the age of forty-
five occurred suddenly from apoplexy on the 10th of June
last, was educated at the University of Glasgow, where
he graduated M.D. in 1861. For a number of years Dr.
Livingston had a large practice at New Barnet, where I
have occasionally met him in consultation, and was much
impressed by his intelligence and his energy. Amongst
10 president's addeess.
other appointments he held that of Medical Officer of the
Great Northern Railway. Dr. Livingston was elected a
Fellow of this Society in 1870.
Dr. Edward Howard was M.R.C.S. 1838, L.S.A. 1839,
M.D. Giessen, 1844, M.R.C.S. London, 1860.
He was appointed Assistant Surgeon in the 20th
Regiment of Foot in 1842. He became Surgeon in 1854,
and Surgeon-Major in 1802. In 1867 he retired on half-
pay with the honorary rank of Deputy Inspector- General.
For more than twenty years Dr. Howard was on foreign
service in various parts, Bermuda, Canada, Turkey, and
the East Indies. For his services in Tui'key he received
the Order of the Medjedie (5th Class). The Director-
General of the Medical Department of the Army, to whom
I am indebted for the particulars of Dr. Howard's ser-
vices, states that " this officer was highly esteemed by his
brother officers, and his duties were always performed to
the satisfaction of the Director-General."
I learn from Dr. Goldsmith, who had attended Dr.
Howard for many years, that he caught a terribly severe
epileptiform neuralgia in the trenches before Sebastopol,
and that this malady clung to him for the remainder of
his life. He died at Bedford on the 28th June of last at
the age of sixty-nine. He was elected a Fellow of this
Society in 1865.
Dr. John Richard Wardell was born at Pickering in
Yorkshire in September, 1819. After receiving his early
education at a private school in Doncaster he began the
study of Medicine in the University of Edinburgh, where
he graduated M.D. in 1844. During his residence in
Edinburgh he filled the offices of Assistant Pathologist and
Resident Physician at the Royal Infirmary. He was also
President of the Royal Physical and Hunterian Societies.
In 1859 he became a Member of the Royal College of Phy-
sicians, and in 1807hewas elected a Fellow of the College.
He was elected a Fellow of this Society in lb58.
During the earlier part of his professional life Dr.
1 ' British Medical Journal,' Sept. 6th, L886
president's address. 11
Wardell acted as private physician to a gentleman of
rank, upon whose decease he commenced practice at
Tunbridge Wells. There until within four years of his
death he continued to practise, and was acknowledged as
the chief consultant of the town and neighbourhood. As
Physician to the local Infirmaiy he devoted much time to
laborious and careful clinical research, the good results of
which are apparent in his numerous professional writings.
Four years ago he was struck down by illness and com-
pelled to relinquish practice. He wrent for rest and
change to Brighton, where for a time he was restored to
a moderate state of health, but a few days before his
decease the symptoms became aggravated, and he died on
the 21st of August. Throughout his prolonged illness
his mind remained clear and active, and during the last
year of his life he collected and published in a large
octavo volume of 800 pages entitled c Contributions to
Pathology and the Practice of Medicine,' some of his
numerous and varied professional writings. The volume
consists of fifty chapters on a great variety of subjects,
affording conclusive evidence of great industry, extensive
reading, careful clinical observation, close and accurate
reasoning and great practical skill in the prevention and
treatment of disease. The longest and most elaborate
chapter is that on relapsing fever, which is based on the
author's observation of that disease in Edinburgh during
the epidemic of 1842-3, and which, as he says, he was
induced to republish mainly by a remembrance of the
value which the late Dr. Murchison put upon the facts
and statistics there given. One of the most interesting
and instructive chapters in the book is that entitled " A
Thorn in the Flesh," in which the author gives a graphic
account of his own prolonged and severe suffering from
inflammation and abscess in the lower part of the thigh,
by which the loss of the limb wTas threatened, and which
was ultimately found to have been caused by a thorn, an
inch and a half long, which he concluded must have pene-
trated the thigh five years before, when his horse fell in
12 president's addt
leaping a hedge. The removal of the foreign body was
at length followed by a complete cure.
Br. Francis Harris was born on December 1st, 1829, at
Winchester Place, in Southwark. His father, who had
for some time represented the borough in Parliament, died
while the son was very young-. After his earliest schooling
and some later studies at King's College, London, he
entered at Caius College, Cambridge. He graduated B.A.
in 1852. After leaving Cambridge he entered as a student
at St. Bartholomew's. He graduated M.B. in 1854. From
November, 1856, to August, 1857, he was House-Surgeon
to the Hospital for Sick Children in Great Ormoud Street.
In 1857 he was admitted M.R.C.P. London. In the same
year he went to Paris for six months and afterwards to
Berlin, where he attended Virchow's lectures, and he sub-
sequently visited Saxon Switzerland, Dresden, Prague,
and Vienna in company with Dr. Chance. Returning to
England after an absence of about a year, he was
appointed Demonstrator of Morbid Anatomy at St. Bar-
tholomew's ; he was also elected Obstetric Physician to the
St. George's and St. James's Dispensary, and Assistant
Physician to the Hospital for Sick Children in May, \bo(J.
The same year he took his degree of M.D., and chose for
his academical disputation " The Nature of the Substance
found in the Amyloid Degeneration of Various Organs in
the Human Body." This essay, which was printed in
1860, was his only published work. He was elected ;i
Fellow of the College of Physicians in 1803. The dispen-
sary he soon gave up and with it any intention he may
have had of practising obstetrics. After Dr. Malv's acci-
dental death in 1861 Dr. Harris was elected Assistant
Physician to St. Bartholomew's and, about the same time,
he was appointed Lecturer on Botany, a science in which
he took a deep interest to the end of his life. In L865 he
resigned the Children's Hospital and the Lectureship on
Botany, and bought an estate which was situated partly
1 For the particulars of Dr. Harris's career 1 am indebted to a memoir
by Dr. Gee, in the ' St. Bartholomew's Hospital Reports/ vol. xxi.
president's address. 13
in Lamberhurst aucl partly in Brenchly parish, in the Weald
of Kent. His love of a country life drew him more and more
away from London and fx'om the pursuit of his profes-
sion. In 1863 he was elected Physician to St. Bartholo-
mew's. At that time he had retired from all medical
woi'k except at the hospital, and he lived as much as
possible on his estate, taking especial pleasure in his
garden, his orchard house, his vinery, and latterly in his
orchid houses, where he turned his botanical knowledge
to good account and made numerous successful experi-
ments in crossing orchids.
In 1874 ill-health compelled him to resign his hospital
duties. Two or three years before this time he began to
suffer from progressive emphysema and pulmonary catarrh
connected with a disposition to gout, and these infirmities
gained upon him somewhat quickly. During the last
three or four years of his life dyspnoea was almost con-
tinual and sometimes very severe. In June, 1882, he had
an attack of pneumonia, and a recurrence of this disease
put an end to his life on September 3rd, 1885. His death
was felt to be a great loss by many friends both in town
and country, to whom his kind and hospitable spirit had
made him dear.
One friend and former pupil (Dr. Andrew) bears testi-
mony to Dr. Harris's high qualities and success as a
teacher of pathological anatomy, — " the severity of study
being relieved by his ready wit and sense of humour."
Another friend (Dr. Chance) says, " That he might have
made a large practice is undoubted. His presence was
good and calculated to inspire confidence. All that he
wanted was energy, ambition, and lack of money. If he
had had no money he would have made it ; but even then
he would have stopped when he thought he had sufficient."
Dr. Chance adds, " I used to go to him not only for the
sake of his conversation, but to ask him for advice, for I
considered his judgment to be very sound."
Mr. John Gay1 was born at Wellington, Somerset, in
1 ' Lancet ' and • British Medical Journal,' Sept. 26th, 1885.
14 president's address.
September, 1813, and began the study of his profession
under the late Mr. Bridge in his native town. In 1833
he entered at St. Bartholomew's, where he was clinical
clerk to Dr. Latham and dresser to Sir "William Lawrence,
and where he was at the head of the prize list. In 1834
he became a Member of the Royal College of Surgeons,
and in 1843 an Honorary Fellow. In 1836 he was elected
Surgeon to the Royal Free Hospital, an appointment which
he held with great credit to himself and advantage to that
institution until the year 1853, when he became Senior Sur-
geon to the Great Northern Hospital, an appointment which
he continued to hold during the remainder of his life.
Mr. Gay obtained a considerable practice in the City,
and he was the author of various original and important
contributions to the science and practice of surgery. Of
these one of the earliest and most valuable was a treatise
' On the Anatomy, Pathology, and Surgery of Femoral
Hernia," published in 1848. The main object of the
author was to deprecate too free incisions into the
hernial sac, by which not only is the immediate risk of the
operation greatly increased but a future return of the
hernia is rendered probable. The principles of Mr. Gay's
operation " consisted in reaching the seat of stricture when
external to the sac by a small incision made through
healthy structures and in such a situation that the hernial
mass shall not be injured or disturbed thereby." Sir
William Fergusson said of this proposal, " By tins simple
difference a vast improvement has been effected in the
operation for crural hernia."
In 1855 Mr. Gay published ' A Memoir on Indolent
Ulcers and their Surgical Treatment.' In this treatise he
advocated the practice of making free incisions through
the indurated tissues, the object being t>> relieve tmsion
and so to favour cicatrisation. The practice is said to be
good and successful.
In the Lettsomian Lectures delivered at the Medical
Society of London in L867-8 and subsequently published,
Mr. < lay discussed the trcatmenl of varicose veins and allied
president's addeess. 15
disorders. He maintained that the common practice of
treating this troublesome condition by prolonged rest and
permanent bandages tends to increase congestion of the
skin and the subcutaneous tissues, and to cause an injurious
dilatation of the deeper veins. The lectures were illus-
trated by numerous elaborate dissections.
Mr. Gay's last contribution to surgical literature was a
paper " On certain points connected with the Anatomy of
the Venous System/' which was read before the Medical
Society of London in November, 1883. In addition to
the publications before mentioned, Mr. Gay from time to
time communicated to the medical societies and to the
medical journals papers of high practical value on various
important points in surgery.
In 1869 Mr. Gay was elected a Member of the Council
of the Eoyal College of Surgeons. In 1877, when his term
had expired, he failed to secure his re-election, but in the
following year he was successful.
He joined this Society in 1848 and served on the
Council in 1874-5.
In the autumn of 1883 Mr. Gay had an attack of hemi-
plegia. From this illness he never recovered, and for some
months before his death, to the distress of his family and
numerous friends, he remained in a condition of semi-con-
sciousness. At length he died tranquilly on the loth of
September, 1885, in the seventy-second year of his age.
Mr. Gay had a large circle of friends both in and beyond
the limits of his profession. He was held in the highest
esteem not only on account of his honorable and successful
surgical career, but his bright intellect, his varied accom-
plishments, and his admirable social qualities endeared
him to all his intimate associates.
Dr. James Russell, who was a descendant of one of the
oldest and most influential Nonconformist families of
Birmingham, was born in that city on the 1st of April, 1818.
His father practised in New Hall Street, Birmingham, for
more than half a century, and was highly esteemed as an
able practitioner, and a most conscientious and benevolent
16 ** president's address.
man. His great-uncle, William Russell, of Showell Green,
was one of the Nonconformists whose houses were pillaged
and burnt during the disgraceful Church and King Riots
in 1791, at the same time that the philosophic Priestley
was driven from the town.
James Russell received his early education under the
Rev. E. Bristowe, and in addition he took mathematical
lessons from the Rev. W. Lawson, of Moseley.
In 1835 he entered at the then newly-established
" School of Medicine/' now known as Queen's College,
whence in 1840 he removed to King's College, London,
where I made his acquaintance, which led to a lifelong
friendship. His choice of King's College as a school,
notwithstanding his staunch Nonconformist principles, was
doubtless in great part determined by the fact that three
distinguished Birmingham men, and more or less intimate
friends of himself and his father, were then on the
teaching staff of the College. Mr., now Sir William, Bow-
man, was Demonstrator of Anatomy and Assistant Sur-
geon to the hospital, the late Mr. Partridge was Professor
of Anatomy and Surgeon to the Hospital, and the late Dr.
William Allen Miller, while pursuing his medical studies
with a view of obtaining the M.D. of London, was acting
as Assistant to the late Professor Daniel], whom he after-
wards succeeded in the Chair of Chemistry.
During his pupilage at King's College James Russell
was held in the highest esteem, both by his teachers and
by his fellow-students, amongst whom his irreproachable
character, his great intelligence, his untiring industry and
devotion to duty, his unswerving truthfulness, and, in
spite of an occasional combativeness in argument and
brusqueness of manner, his genuine kindness of heart and
his tolerance of diverse opinions, were thoroughly and
very generally appreciated.
At the end of his student career he held, Eor the usual
period of six months, the oiliee of House Physician of the
hospital, and 'luring this period I had the privilege of
being his colleague as House Surgeon.
president's address. 17
He passed what is now called the Intermediate, and
the M.B. examination at the University of London in the
same year, 1842, and at the latter examination he was
second in the list of honours in surgery. He graduated
M.D. in the first division, in 1848.
Originally intending to practise surgery he was elected
one of the Honoi'ary Surgeons of: the Birmingham General
Dispensary in 1841, but he was soon induced to change
his views, and in three months, having resigned his sur-
gical appointment, he henceforth devoted himself entirely
to the study and practice of medicine ; and as a prepara-
tion for practising as a physician he went to Paris and
pursued his studies there for a considerable period. On
his retui'n in 1847 he commenced practice in Temple Row.
He became a Member of the Royal College of Physicians
in 1859, and in 1867 he received the well-deserved honour
of the Fellowship.
In 1848 he was elected Honorary Physician to the
General Dispensary, an appointment which he held for
five years.
In 1850, when the Sydenham College Medical School
was established, Dr. Russell was appointed Lecturer on
Therapeutics in the Materia Medica course, a position
which he occupied with marked success for a period of
sixteen years. He then joined Dr. Bell Fletcher as
co-lecturer on the Practice of Physic, of which subject he
retained the Professorship after the amalgamation between
the Sydenham and Queen's Colleges had been accomplished.
In 1859 Dr. Russell was elected one of the Physicians of
the General Hospital, where one of his former colleagues (Mr.
Alfred Baker) says of him : — " His painstaking interest
in the regular instruction of students in attendance was
on a par with his unflagging attention to the wants and
comforts of the sick. His hospital labours were assiduous
and thoughtful, contributing to the stability, high cha-
racter, and popularity of the Institution. The medical
periodicals testify to his research, his accuracy of obser-
vation, his diagnostic skill, and his cautious conclusions ;
vol. lxix. 2
18 president's address.
qualities that are very notable in his comments on intri-
cate nervous maladies, which were always interesting
subjects of his study. "
At the commencement of last year failing health com-
pelled him to resign his hospital appointment, when his
past and present pupils, to the number of 109, subscribed
to a testimonial fund, and the subscribers and friends of
the hospital commissioned Mr. Papworth to execute a
marble bust.
Dr. Eussell, as a townsman, was a steady supporter of
all educational movements and of all public sanitary
measures. He also devoted much time to the manage-
ment of various charities. His nomination as a borough
magistrate in 1880 gave satisfaction alike to the profession
and the public.
About a year before his death Dr. Eussell discovered
that he was the subject of a serious form of Bright' s
disease, and, with a full knowledge of what this involved,
he, for a time, kept almost complete silence on the subject
— confiding the fact only to . one or two of those from
whom it was not prudent and scarcely possible to conceal
it — his object being to prevent the lives of others from
being darkened by the cloud of sorrow before the stern
necessity arose. He suffered much during the last mouths
of his life from that distressing form of dyspnoea which so
often results from the later stages of the disease, but his
intellect remained unclouded until the last. At length on
the oth of October, 1885, he was released from suffering.
Of all the men whose friendship I have had the privi-
lege of enjoying, I know of no one who appeared to me to
act more consistent ly upon the maxim, " Whatsoever thy
hand findeth to do, do it with thy might," than Dr.
James Russell, who since the year 1845 had been a
Fellow of this Society.
Mr. Thomas JolUfft TufnellJ the well-known Dublin
Surgeon, was a younger sou of Colonel Tufncll, of
Lachlam House, Chippenham, Wilts, where he was born
1 ' Cancel ' and ' Medical Times and Gazette,' Dec. 5th, 1886
president's address. 19
in 1819. In 1836 lie was apprenticed to Mr. Lirnscombe.
of Exeter, and subsequently entered at St. George's
Hospital. In 1841 lie became a Member of the College
of Surgeons, and soon after entered the Army as Assist-
ant Surgeon of the 44th Regiment, which was then
serving in India. On his arrival at Calcutta to join his
regiment he was ordered to take charge of the troops at
Chinsura, and thus he escaped the massacre of the British
forces in the disastrous retreat from Cabul. On his
return home he was appointed Surgeon to the Dublin
District Military Prison. When the Crimean War broke
out Mr. Tufnell again went on foreign service, and
during that campaign he obtained an extensive practical
knowledge of military surgery. After his return to
Dublin he retired from active service, and was appointed
Surgeon to the City of Dublin Hospital ; and when, after
mauy years, he resigned the office of Visiting Surgeon, he
was unanimously elected Consulting Surgeon to the Hos-
pital. He was for some years Professor of Military
Surgery in the School of the College of Surgeons, and
also an Examiner in that institution. In the year 1873
he was elected Vice-President, and the following year
President of the Dublin Eoyal College of Surgeons.
Mr. Tufnell was the author of several monographs on
surgical subjects. Of these, the earliest was entitled
1 Practical Remarks on the Treatment of Aneurism by
Compression/ 1851. In 1864 he was elected a Fellow of
this Society, and in 1873 he communicated a paper, which
is published in the 57th vol. of the ' Transactions/ " On
the Successful Treatment of Aneurism by Position and
Restricted Diet." This paper contains the history of
two cases of aneurism of the abdominal aorta and one of
popliteal aneurism, in each of which a cure was effected.
These cases are republished, with coloured illustrations, in
the author's treatise on ' The Successful Treatment of
Internal Aneurism by Consolidation of the Contents of
the Sac,' 2nd edition, 1875. In one of the cases of
cured abdominal aneurism (that of John Kelly, pp. 29 to
20 president's address.
34) the patient is reported to have died some weeks after-
wards of Bright's disease. But the excellent coloured
illustration which accompanies the case shows, I think,
that the different morbid conditions of the two kidneys
were not due to Bright's disease, but were an indirect
result of the aneurism which implicated the aorta at the
place of origin of the renal arteries. The right kidney
was " rather smaller than natural," and has obviously
been invaded by embolic particles of fibrine from the
interior of the aneurism. The left kidney, on the other
hand, was " greatly enlarged, measuring five inches in
length and three and a half inches in width." The renal
veins are not represented in the drawing nor is their
condition described, but there can, I think, be no doubt
that the structural changes in the enlarged left kidney
were caused by compression of the vein in its passage
over the large aneurism towards the vena cava. Although,
therefore, the aneurism was filled by firm fibrinous coagula,
the cure was not effected before serious structural
changes had occurred in both kidneys, but more especi-
ally in the left.
In 1879 Mr. Tufnell published a paper on " The Con-
solidation of Internal Aneurism/' in which he rightly
maintained, in opposition to Dr. AVilliam Colics, that the
fibrinous layers within an aneurismal sac are the result of
successive deposits from the blood, and not an exudation
from the walls of the aneurism.
Amongst other papers by the same author may be
mentioned one " On Luxation Downwards and Backwards
of the three Internal Metatarsal Bones, a form of Dis-
location of the Foot not previously described," L854.
" Practical Remarks upon Stricture of the Rectum, espe-
cially in relation to its connexion with Fistula in Ano
and Ulceration of the Bowel," 1860. "On the Radical
Cure of Varicocele by Subcutaneous Ligature of the
Spermatic Veins" from the ' Dublin Journal/
Mr. Tufnell died on the 27th of November last utter a
tedious illness at the age of Bixty- seven. Ee was highly
president's address. 21
esteemed by all classes, not only for his professional
abilities and attainments, but also for his upright and
honorable character and his kind and courteous dis-
position.
Dr. John Moore Johnston Scott1 was born in Belfast,
December 4th, 1850. He jDassed his matriculation exami-
nation and commenced his medical studies in Queen's
College of his native city in 1869, where he is said to
have secured the esteem and affection of his fellow-
students.
After the breaking out of the Franco- German war,
although he had not yet completed his full course of study,
he was induced by a love of adventure and a desire to
increase his professional knowledge and experience, to
apply for, and through the interest of Sir William Mac
Cormac, he obtained, the appointment of Assistant Surgeon
to the Anglo-American Ambulance Corps. In this capacity
he worked with his corps in aid of the French troops at
Sedan. For his services during the war he received a
bronze medal and a flattering testimonial from the French
Government. After returning home he resumed his studies,
and in 1842 he passed his examination in medicine,
surgery, and obstetrics, and graduated M.D. in the Queen's
University.
. Soon after this he commenced practice in Belfast where
he was highly successful. But in 1878 an eligible opening
having occurred in Lurgan, Co. Armagh, Dr. Scott deter-
mined to take advantage of it. There his genial dispo-
sition gained for him an early and hearty admission to
the good graces of all classes and creeds of his fellow-
townsmen. Though a pi-ominent Conservative and an
energetic Orangeman, he never allowed his political or his
religious opinions to intei'fere with his private relations or
his professional duties.
In 1881 his popularity was shown by his return at the
head of the poll as a candidate for a seat at the local
Municipal Board. In 1882 he was elected a Guardian
1 ' Lurgau Times,' Dec. 5th, 1S85.
22 president's address.
of the Lurgau Union, and in that position his exertions
on behalf of both the ratepayers and the poor were
unceasing and well-directed.
Dr. Scott, though to outward appearance in robust
health, had for some time been aware that his heart was
unsound, and on the 30th of November last, which was
the day appointed for the parliament aiy election in Lurgan,
while conversing in the street with some friends on the
prospects of the election, he suddenly staggered and fell
backwards, his head, however, not coming in contact with
the ground. He was immediately carried into a neigh-
bouring office, where he retained consciousness until the
arrival of Dr. Adamson, who happened to be near the
spot, and whom he requested to examine his heart. In
a few minutes, however, the pulse and breathing had ceased.
At his funeral, although a hearse had been procured,
his brethren, the Town Commissioners, insisted on carrying
the coffin to the grave ; and, notwithstanding the inclem-
ency of the weather, his fellow-townsmen of all class -
assembled to pay the last tribute of respect to one whom
they had learned to regard with feelings of the closest
personal attachment.
Dr. Scott had been a Fellow of the Society since 187o.
Dr. Henry l\'otton received his medical education at
University College. He became a Member of the Royal
College of Surgeons in 1859, and a Fellow by examination
in 1864. He was elected a Fellow of this Society in 1865.
In 1878 he graduated M.D. at St. Andrews.
He was Surgeon-Accoucheur to the West London
Lyiug-In Institution, and he practised at Kensington,
where he died suddenly on Christmas Day last at the age
of forty-six. The verdict of the coroner's jury was
" Suicide during temporary insanity." Such a catastrophe
as we know may overtake the wisest and the best of men.
" This trail bark of ours, when sorely triedi
.May wreck itself without the pilot's guilt,
Without the captain's knowledge."
Tennyson, " Aylmer's Field."
president's address. 23
Mr. William Bous field Bage,1 who died at St. Ann's,
Carlisle, in his sixty-ninth year, on the 5th of January last,
was born at Ashford in Kent in the year 1817.
He belonged to an Essex family, who have long had
their seat at Southminster Hall, where they still reside.
He received his medical education at the London Hospital,
became a Member of the College of Surgeons and of the
Apothecaries' Society in 1841, and a Fellow of the College
in 1856. At the early age of twenty-four, on the recom-
mendation of Mr. John Scott, then one of the Surgeons
of the hospital, Mr. Page was appointed Surgeon to the
Cumberland Infirmary, which had been recently estab-
lished. He arrived in Carlisle on New Year's Day, 1843,
an entire stranger to the city, but being possessed of
courage and tact, as well as skill, he set to work with great
energy and soon found many influential friends. He had
not been three days in the city before he was summoned
to attend a member of the Bishop's family, and in the
course of a few years he became the trusted adviser of
all the cathedral dignitaries and of the leading county
families. During the London season he had so many of
his county patients here that he had serious thoughts of
settling in the metropolis ; notably in 1851, when Sir B.
Brodie advised him to apply for the appointment of Sur-
geon to the then recently opened St. Mary's Hospital. This
appointment, however, he left for his eldest son at a later
period to obtain.
Mr. Page rendered important services to several of the
great railway companies. In this service his promptness
and his organising power had full play, and in the distress-
ing scenes of a great accident his self-possession and his
skilfully applied surgical resources animated all around.
With regard to subsequent claims for compensation his
advice, which was always implicitly relied upon, often
resulted in an equitable arrangement without resort to
costly and uncertain legal proceedings.
1 The 'Carlisle Patriot,' Jan. 8th and 15th, 1886; 'Lancet,' Jan. 23rd,
1886.
24 president's address.
In connection with his work at the Infirmary, Mr. Page
induced Bishop Percy to institute a system of boarding
out convalescents, which in time resulted in the estab-
lishment of the Sanatorium at Silloth. He was also the
prime mover in the measures which led to the enlarge-
ment of the Infirmary, which now contains 100 beds, one
of the wards, in well-deserved compliment to him, being
named " The Page Ward."
In 1877 he resigned the office of Surgeon to the
Infirmary, when he received a cordial vote of thanks for
his distinguished services, and at the same time he was
appointed Consulting Surgeon and a Vice-President.
Among other public appointments Mr. Page was for
many years Surgeon to the Gaol and Consulting Sur-
geon to the Lunatic Asylum. In 1877 he resigned his
office in the Gaol, and at the ensuing Quarter Sessions he
received a cordial vote of thanks for his valuable services
to the county and for his disinterestedness in relinquishing
his right to a pension.
For more than a quarter of a century Mr. Page was a
Justice of the City of Carlisle, and in 1878 he was appointed
a Magistrate for the County of Cumberland. Apart from
his profession he took a lively interest in all local works
of public benefit, and he was always a wise and munificent
supporter of charities.
He was elected a Fellow of this Society in 1847, and
he contributed two papers to the 'Transactions/ one on
" Cases of Ununited Fracture successfully treated " (vol.
xxxi), and the other " On Excision of the Os Calcis in
Incurable Disease of the Bone as a substitute for Ampu-
tation of the foot" (vol. xxxiii). In the earlier years of
his practice he contributed various papers to the medical
journals.
He was a bold and successful operator. The ' Lancet '
of April 5th, I N !•.>, contains the firsl account of his success
as an ovariotomist , ami as long ago as I 8 l<> he had obtained
complete success in two cases of excision of the knee-joint.
Mi-. Page had been in good health until within nine
25
months of his death, when his strength began and con-
tinued to fail from a progressive anaemia, the starting-
point of which seemed to be the shock of a heavy personal
sorrow.
The large and distinguished assembly at his funeral,
including the bishop of the diocese, who took part in the
service, afforded a striking demonstration of the high
estimation in which he was held by those who were best
able to appreciate his character and his public services.
It is a remarkable circumstance that within forty-eight
hours of Mr. Page's death his only brother died, after a
short illness, and the two brothers were buried together.
Dr. John Maule Sutton,1 who was born in 1829, was a
great grandson of Mr. Daniel Sutton,2 the famous inocu-
lator for small-pox in the last century, to whom in 1767
King George III granted a patent of arms.
Dr. Sutton, having when young been left an oi'phan,
was educated under the care of his grandfather, the late
Mr. John Sutton, of Lee, Kent. He received his medical
education at Queen's College, Birmingham, and at St.
Thomas's Hospital.
Amongst other legal qualifications he obtained the
following: F.R.C.P. Edin., 1853; M.R.C.P. Lond., 1859;
M.D. St. And., 1853 ; M.R.C.L. Eng., 1851 ; L.M., 1853 ;
L.S.A., 1853. He must therefore have had a full share
of medical examinations.
Dr. Sutton, after serving the office of Resident Physi-
cians' Assistant at the Brompton Hospital for Consumption,
commenced practice in Bath, and was elected Physician to
the Eastern Dispensary, and on resigning the appointment
to take up his residence in Pembrokeshire — where some
landed property had come into his possession — he was
made a Life Governor in recognition of his services.
Having settled at Tenby he devoted himself assiduously
1 For the particulars of Dr. Sutton's career I am indebted to Mr. Joseph
Chambers, chief clerk in the Officer of Health's Department, Oldham.
1 " The fnoculator or Suttonian System of Inoculation,' by Daniel Sutton,
Surgeon, 1796 ; ' The Tryal of Mr. Daniel Sutton for the High Crime of pre-
serving the lives of His Majesty's Subjects by Inoculation/ 2nd ed., 1767.
26 president's address.
to his profession, and took a prominent part in public
affairs. He was three times elected mayor of Tenby,
and subsequently he was appointed a Justice of the
Peace for the Borough of Tenby and for the County
of Pembroke. He also became Deputy-Lieutenant of the
county.
In 1863 he was elected Physician to the Queen's Hos-
pital, Birmingham, and Professor of Clinical Medicine.
About that time the inhabitants of Pembrokeshire pre-
sented him with a service of plate at a public dinner, which
was presided over by Captain Ramsay, R.N., C.B., after-
wards Earl of Dalhousie, the father of the present earl.
In 1865, on the death of his aged grandfather, under
whose will he obtained an increase of fortune, Dr. Sutton,
who had never taken up his residence in Birmingham,
resigned his appointment at the Queen's Hospital and
retired from private practice.
Soon after this he invested largely in a colliery yielding
" anthracite coal," and as the colliery not long after-
wards became flooded and had to be abandoned, he thereby
lost the greater portion of his fortune.
In 1873 Dr. Sutton was appointed the first Medical
Officer of Health, under the Public Health Act, for the
Borough of Oldham. There he organised most thoroughly
the Sanitary Department, and soon, by his genial disposi-
tion, drew round him a host of friends and supporters.
In 1877 an epidemic of smallpox having broken out, he
made it the occasion for founding the AVestholnie Hospital
for Infectious Diseases, winch, having been subsequently
enlarged, now contains 100 beds.
Dr. Button during his ten years' tenure of office is said
to have treated in that hospital upwards of 600 patients
with great care, skill, ami kindness.
The subject of infant mortality was one to which he
devoted much attention and upon which he published a
treatise; and another on " Day Nurseries and thea* bearing
upon Public Health."
Dr. Sutton devoted much attention to the means of
president's address. 27
abating the " Smoke Nuisance." He contributed to the
'Lancet' (1871) a paper on the " Deodorisation and
Utilisation of Town Sewage." He founded a Meteoro-
logical Observatory in the Alexandra Park, Oldham,
where during the last ten years observations have been
regularly taken ; and as a Governor of the Oldham
Infirmary he established the Hospital Saturday Collection,
from which the Institution now receives a considerable
annual sum.
After ten years of great public service to the borough
ill-health compelled Dr. Sutton to resign his office in
September, 1883. He then went to reside at Hoylake, a
small village on the coast of Cheshire, where he died from
disease of the heart with dropsy on the 20th of January
last, at the age of fifty-sis. He has left a large circle of
sorrowing friends.
Dr. Sutton was elected a Non-Resident Fellow in 1855.
Dr. Sigismund Sutro was born in Bavaria in 1815. He
studied medicine at Heidelberg and Munich, and at the
latter University he obtained his degree of Doctor of
Medicine in 1840. Soon after this he came to London,
and in 1845 he was appointed Physician to the German
Hospital when that institution was in its infancy. He
resigned that office in 1877, and was then appointed Con-
sulting Physician.
In 1859 Dr. Sutro became a Member of the College of
Physicians, and in 1873 he was elected a Fellow. He had
a considerable knowledge of the Spas of Europe, and espe-
cially those of Germany, and he was the author of a prac-
tical work on the subject, a second edition of which was
published in 1865. Dr. Sutro's advice was highly valued
by his countrymen, and especially by his co-religionists of
the Jewish persuasion. He was in active practice up to
the time of his death, which occurred on the 19th of Feb-
ruary from an attack of apoplexy.
Dr. Sutro was elected a Fellow of this Society in 1860.
Dr. William Benjamin Carpenter1 was born at Bristol in
1 ' Times,' Nov. ]lth, 1885; ' Lancet ' and ' Brit. Med. Jour.,' Nov. 14tb.
28 president's address.
1813. He was the son of Dr. Lant Carpenter, an eminent
Unitarian minister, under whose superintendence the son
was educated. Dr. Carpenter's medical education was
commenced at Bristol, but at the age of twenty he entered
the Medical School of University College. He became a
Member of the College of Surgeons and a Licentiate of
tli^ Apothecaries' Company in 1835, after which he went
to Edinburgh, where he graduated M.D. in 1839. Dr.
Carpenter then returned to Bristol, where he was
appointed Lecturer on Forensic Medicine in the Medical
School, and where he commenced the practice of his pro-
fession ; but in 1843 he came to London with the intention
of devoting himself to the pursuit of physiological science.
He was soon appointed Lecturer on Physiology at the
London Hospital Medical School, and later he became
Professor of Medical Jurisprudence at University College,
and Examiner in Comparative Anatomy and Physiology
in the University of London. In 1856 he was appointed
Registrar of the University of London, which office he held
with great advantage to the University until the year
I B79, when he retired with a pension, and at the earliest
vacancy he was appointed by the Crown a member of the
Senate, in which capacity he continued to the last to
exert a powerful and most beneficial influence.
Dr. Carpenter was the author of numerous well-known
and highly popular works. While in Edinburgh he con-
tributed Beveral papers to the medical and scientific
journals, and in 1830 was published his prize graduation
thesis ' On Physiological Inferences from the Structure
of the Nervous System in Invertebrated Animals.' In
the same year appeared his earliest systematic work on
'The Principles <>f General and Comparative Physiology,'
B new edition of which wa- called for in 1841. In later
editions the subjeel was divided, and in 1842 'The Prin-
ciples of Human Physiology ' was published as a separate
work, the ' Principles of Comparative Physiology/ hence-
forth appearing also as a distinct work. Until these works
and the' Manual of Physiology,' which was first published
president's address. 29
in 1846, passed through several editions, as did also the
well-known and popular work on f The Microscope and
its Revelations/ which first appeared in 1856. The last,
and one of the most important of Dr. Carpenter's physio-
logical works, was that entitled ' Principles of Mental
Physiology,' 1874. In this work he discusses in the
spirit of a true philosopher the strange and perplexing-
subjects of so-called "mesmerism," "table-turning,"
" thought-reading," and other phenomena of what is com-
monly known as "spiritualism." With a large amount of
success he laboured to separate the authentic facts from
the results of fraud and imposture, and while he denounced
the latter he showed that the former, incredible as they
may at first sight appear, admit of a strictly physiological
explanation.
Dr. Carpenter contributed to the ' Philosophical Trans-
actions' several papers on the " Foraminifera " and
other subjects. He also took an active part in promoting
the expeditions for deep-sea exploration, for which
purpose the " Challenger " was despatched. His reports
of these expeditions are contained in the ' Proceedings of
the Royal Society ' and the ' Journal of the Royal Geo-
graphical Society.' For several years Dr. Carpenter was
the editor of the f Medico -Chirurgical Review.' He was
elected a Fellow of the Royal Society in 1844, and in
1861 the Society voted him a Royal Medal for his physio-
logical researches. The University of Edinburgh con-
ferred on him the honorary degree of LL.D. in 1871. In
1872 he was President of the British Association at its
Brighton Meeting. In 1873 he was elected a corre-
sponding member of the Institute of France, and in 1875
he was created a C.B. in recognition of his services to the
University of London. In 1883 he was elected an
Honorary Fellow of this Society.
Dr. Carpenter's last published writing was a letter
which appeared in the ' Times,' in which he contended
against the arguments employed by certain opponents of
vaccination. Few men were so well qualified as he was
30 president's address.
to expose the fallacious statements of anti-vaccination
fanatics.
Dr. Carpenter's death, which occurred on the 10th of
November last, was the result of accidental burns occa-
sioned by the overturning of the lamp of a hot-air bath.
It scarcely need be added that Dr. Carpenter was univer-
sally held in the highest esteem, not only for the extent
and variety of his scientific attainments, but also on
account of his high principles and his stainless life.
Professor Frederick Gustavus Jacob Henle1 was born at
Fiirth in Bavaria, in 1809. When twenty-one years of
age he became a pupil of Rudolphi and afterwards of
Johannes Muller. When Muller was appointed Professor
in the University of Berlin Henle became his Prosector,
and taught not only anatomy and physiology, but also
pathological anatomy and pathology. In 1840 Henle was
appointed Professor of Anatomy at Zurich, and four years
later he obtained the Chair of Anatomy and Physiology at
Heidelberg, where again he taught pathology in addition
to anatomy and physiology. Once more, in 1852, he
migrated from Heidelberg to Gottingen, where he con-
tinued to work for the remaining thirty-three years of his
long and laborious life. He died on the 13th of May last
in the seventy-sixth year of his age. He was elected a
Foreign Honorary Fellow of this Society in 1859. The
name of Henle, and his great reputation as an Anatomist,
Physiologist, and Pathologist must be familiar, not only
to every anatomist but to almost every practitioner of
medicine throughout the civilised world.
In addition to numerous important separate papers and
reports, including his aunual reports of the progress of
anatomy and physiology in the ' Zeitschrift fur rationelle
Medicin/ Henle was the author of several works of
greal value. Of these the first in the order of publication
wa- his 'General Anatomy' ('Allgemeine Anatomic '),
I g ii. N,\! the ' Handbook of Rational Pathol
■ Bandbucli drr rational leu 1 'athologic '), 2 vols., bv Iti — 53.
1 * Proceedings oj the 1 B N
president's address. 31
Then the ' Handbook of Systematic or Descriptive Ana-
tomy ' (' Handbuch der systematischen Anatomie des
Menschen '), 3 vols., 1855 — 71. In 1862 appeared his
' Monograph on the Anatomy of the Kidney ' (' Zur
Anatomie der Mere'). In this treatise the author
described the looped tubes which have been named after
him, and which he supposed to be connected with the
Malpighian bodies, but to have no openings into the
pelvis of the kidney, while he concluded the urine-
secreting open tubes to be unconnected with the Mal-
pighian bodies. Most competent observers who have
investigated this question are agreed that Henle's con-
clusions were erroneous1 and that he greatly exaggerated
the number of the looped tubes in the cones of the
kidney.
One of the most interesting and important of Henle's
anatomical discoveries was that of the muscularity of the
middle coat of the arterioles, which he clearly described
and figured in his ( Allgemeine Anatomie ' in 1841 (p.
498, Plate III, figs. 8, 9, and 10). This discovery formed
the anatomical basis for the experiments and conclusions
of Brown- Sequard and Bernard which led to our present
knowledge of the regulating function of the muscular
arterioles and of the vaso-motor nerves. And assuredly
until this knowledge had been acquired we were but
imperfectly acquainted with the forces which are con-
cerned in effecting and regulating the circulation of the
blood. It has now been proved to demonstration that the
muscular force possessed by these Lilliputian canals is so
great that the united forcible contraction of the pulmonary
or of the systemic arterioles is more than equal to the
propulsive power of the corresponding right or left
ventricle of the heart, and in consequence the onward
movement of the blood may be thereby arrested.
This arrest of the circulation by the contraction of the
muscular arterioles is most easily demonstrated in the
lungs. When, from any cause, the aeration of the blood
1 See Dr. Beale on ' Kidney Diseases, &.c.,' 1S69, p. 10.
32 president's address.
is prevented, the animal dies in a few minutes and the
chest being opened immediately after death, the right
cavities of the heart are found to be enormously distended,
while those on the left side are nearly empty. The
immediate cause of death has been the arrest of the blood
by the forcible contraction of the pulmonary arterioles.
Physiologists all agree in teaching that the function of
the arterioles is to regulate the blood-supply to the tissues,
— to exert, in short, what I have ventured to call a " stop-
cock " action upon the blood stream. But there is not
the same agreement amongst pathologists.1 Thus the
learned and eloquent Bradshawe Lecturer at the Royal
College of Physicians, last August,2 maintained, in opposi-
tion, as he admitted, to the teaching of modern physiolo-
gists, that the now generally recognised hypertrophy of
the muscular arterioles in cases of chronic Bright's disease
is the result, not of over-action in opposition to the heart,
but of an " effort of the entire muscular element of the
circulatory system to forward a fluid to which the absorp-
tive or appropriative powers of the tissues are ill adapted.''
It is unnecessary to say that if this doctrine of the propel-
ling power of the muscular arterioles is true the physiolo-
s are all wrong. And in reply to Dr. Goodhart's
objection to the " stop-cock " theory, that there is no such
antagonism in nature as that would imply, I need only
refer to the notorious fact that muscular antagonism, in
the case of both voluntary and involuntary muscles, with
resulting physiological harmony is of constant occurrence.
Amongst voluntary muscles there is the orderly antago-
nism of flexors and extensors, abductors and adductors,
pronators and supinators. In the case of muscles only
partly voluntary, those of inspiration and expiration, the
sphincters and detrusor muscles are opposed, while amongsl
So tittle acquainted are some controversialists with the physiology of the
circulation that they refer to the doctrine of contraction of the arterioles as a
itin^r influence, a^ it' it were a theory of my own, and they actually com«
it with Cullen's hypothesis "t" spasm of the extrem
J ' Lancet,' August 22nd, L885.
president's address. 33
purely involuntary muscles the radiating and circular fibres
of the iris, though directly antagonistic, work together
with perfect harmony. And so, it is probable, do the
propelling heart and the regulating muscular arterioles
co-operate in carrying on the circulation of the blood
both in health and in disease.
A consideration of the many important physiological and
pathological phenomena which depend for their solution
upon a knowledge of the structure and function of the
muscular arterioles suffices to show that Henle, by this
single anatomical discovery, conferred a great benefit upon
mankind. In his doctrine of the etiology of contagious dis-
eases, Henle anticipated in a general way the more exact
discoveries of later years. He maintained that the material
of contagium is not only organic, but organised and living,
and that it must consist of " parasitical beings which are
among the lowliest and smallest, but the most productive
which are known."
Dr. Noel Gueneau de Mussy1 was a highly distinguished
and accomplished French physician, whose death in Paris,
at the age of seventy-two, after a long and painful illness,
occurred in May last. After a brilliant student career he
became Chomel's Chef de Clinique in 1839, Physician to the
Hotel Dieu in 1842, Assistant Professor of the Faculty of
Medicine in 1847, and Member of the Academy of Medicine
in 1867. This Society elected him a Foreign Honorary
Fellow in 1878.
He is said to have been a highly successful clinical
teacher, while the dignity of his character, the extreme
affability of his manner, and his scientific ability rendered
him, for a number of years, one of the leading physicians
of Paris. He was connected with England by the tie of
marriage, and he was a frequent attendant at the meetings
of the British Medical Association and a valued contri-
butor, on French topics, to the ' British Medical Journal.'
The subject of this notice was the cousin of Dr. Henri
1 ' Medical Times and Gazette,' Jane 13th, 1885 ; * British Medical Journal,
June 6th, 1885.
VOL. LXIX. 3
3i president's address.
Gueneau de Mussy, who, after the French revolution in
1848, came with the exiled Orleans family to Loudon,
where he was a highly esteemed and successful physician,
until, after the deposition of the late Emperor Napoleon,
he again returned to Paris.
Professor Henri Milne Edwards1 was born at Bruges in
October 1800. Having completed his elementary studies
in Belgium he studied medicine in Paris, where he
graduated in 1823. While continuing through life to take
an interest in medical subjects he soon gave up the
practice of his profession and devoted himself to the study
of natural history, and especially to researches among the
lower forms of animal life.
During the years 1826 and 1828, in company with his
friend and fellow-labourer, Audouin, he made a careful
study of the various vertebrates on the coasts of Granville,
around the isles of Chaussey, and as far as Cape Frehel.
A member of the French Academy wns at thai time engaged
on some hydrographical work off this coast, and lie assisted
tin' two naturalists by enabling them to use the dredge in
deeper water than they could reach from a row-boat.
The results of these investigations were laid before the
Academy of Sciences in 1829 and formed the subject of an
elaborate laudatory report by Baron Cuvier, which was
presented to the Academy in November, 1830. The
arches thus commenced were continued by Milne-
Edwards throughout his long life.
In 1841 he was appointed Professor of Natural History
in the College Royal de Eenri IV, and about the same time
he held the Chair of Zoology and Comparative Physiology
.-it the Faculty of Sciences, of which Faculty lu- was after-
wards the Dean. On his friend Audouin's death he became
Professor of Entomology at the Museum of the Jardin des
Plantes. Aboul this time he published numerous original
memoirs in the 'Annates des Sciences Naturelles/ of which
famous periodica] Milne-Edwards was for fifty years one
of the editors.
1 • Nature,' Aug. 6th, I
president's address. 35
In addition to his reputation for original research he
became widely known and popular by the publication of
his elementary works on zoology. His ' Elements de
Zoologie,' published in 1834, was reissued in 1851 under
the title of ' Cours Elementaire de Zoologie.'' This
work had a very large circulation and was translated into
several languages.
Amongst his more important separate works may be
mentioned his ' Histoire Naturelle des Crustaces,' 1834-40,
in which he was assisted by his friend Audouin ; the
' Histoire Naturelle des Coralliaires,' 1857-60, with
which was associated another friend, Jules Haime. The
1 Lecons sur la Physiologie et l'Anatomie comparee
de l'Homme et des Animaux,' published between 1857 and
1882 in fourteen volumes, were dedicated to his friend,
M. J. Dumas. ( Recherches Anatomiques et Physiologiques
pendant un Voyage sur les Cotes de la Sicile, &c./ forms
a quarto volume of more than 850 pages, illustrated by
nearly 100 coloured plates.
For a number of years Milne Edwards was one of the
leaders of zoological science. He was one of the first
naturalists who made prolonged visits to the sea coast to
study the living forms of animal life and to investigate
their habits. His investigation of the lower forms of
invertebrate animals led him to the theory of there being
distinct centres of creation, and this theory is said to have
prevented his full and complete acceptance of Darwin's
wider generalisation.
In 1838 he was elected a Member of the Academy of
Sciences, in the section of Anatomy and Zoology. He
was made an Officer of the Legion of Honour in 1847, and
a Commander of the Order in 1801. In 1862 he succeeded
Geoffroy Saint- Hilaire as Professor of Zoology at the
Jardin des Plantes, and soon afterwards he became
Assistant Director of the Museum. He was elected an
Honorary Fellow of this Society in 1876, and he was a
member of most of the learned societies of Europe and
America. He died in Paris on the 29th of July last.
36 president's address.
If, now, for a moment, we contemplate the work accom-
plished by the twenty-one men who have recently been taken
from our midst, who shall estimate its value ? While some
— a minority it must be confessed — with a genius for disco-
very, were enabled to extend the boundaries of our know-
ledge, and so to confer untold benefits upon all future ages
of mankind, there is not one amongst them who has not, in
proportion to his ability and his opportunity, been a public
benefactor, and as such has earned the gratitude of his
contemporaries. Now we trust " that they may rest from
their labours, and their works do follow them.'"
It will be in the recollection of the Society that in my
address last year I referred to the subject of the lighting
and ventilation of this room as one which would demand
the attention of the Council. Without loss of time the
Council appointed a sub-committee to inquire and report
upon this important matter. And, in the first instance,
the question of lighting by electricity was carefully con-
sidered. We felt that if the products of gas combustion
could be got rid of we should secure the double advantage
of a more wholesome atmosphere throughout the building,
and a diminished annual expenditure for bookbinding.
We therefore obtained from two firms an estimate of the
primary cost and the annual expenditure that would be
incurred if lighting by electricity were adopted. The
estimates given by the two firms were almost identical,
and they were to this effect : — The immediate outlay for
machinery and fittings would bo about £500, and the
annual cost of gas for the engine would be somewhat in
excess of that which is entailed by our present consump
tion of gas.
Then, in reply to our inquiry, it was admitted that the
vibration and noise caused by the gas engine, which would
have to be placed in the basement immediately bene;ith
the floor of this room, might be a source of annoyance
during our meetings. Therefore, after due consideration,
the Council unanimously decided not to incur the large
expenditure and the probable annoyance which the scheme
president's address. 37
of electric lighting would at present involve. And they
had the less difficulty in arriving at this decision from the
consideration that probably at no very distant period the
means of electric lighting will be supplied by public com-
panies at a comparatively small cost and without the noise
and vibration attending the generation of electricity by
an engine working on our own premises. I have no doubt
that this decision of the Council will be confirmed and
approved by the Society.
Meanwhile we had to consider the best means of
improving the lighting and ventilation of this room.
The outside metal tube which conveys the products of
combustion from the sun-light had become coiToded and had
broken off. It was necessary that this should be renewed,
and in doing this the opportunity was taken to increase
the number of burners and at the same time to improve
the ventilation by giving additional facility for the escape
of the heated air.
The increased illumination which has thus been obtained
from the sun -light enables those who sit at this table to
dispense with the two large gas burners which have always
hitherto been in use, and as a result the heating and con-
tamination of the air have been very materially lessened.
In the adjoiningback room the illumination has been much
improved. Some years since two sun-lights were fixed im-
mediately beneath the ceiling, in fact so close to the ceiling
as to expose the floor above to the risk of ignition. This
danger was felt to be so great that from the first the use
of those sun-lights was forbidden. Now the burners
have been brought down to a distance of about twelve
feet from the ceiling, and the products of combustion are
effectually carried off by trumpet-shaped tubes suspended
above them. By this change, while improved ventilation
and increased illumination have been obtained, the risk of
overheating the ceiling and floor above has been entirely
removed.
It will be observed that the expense of these alterations
following upon the large expenditure involved in the im-
38 president's address.
portant drainage works last year leaves us in debt to our
bankers ; but as tlie receipts of the annual subscriptions
will restore the balance in a few weeks, and as no such
extraordinary expenditure is likely to be called for in
future, the Council have deemed it undesirable to sell out
stock, the annual income of the Society being about
£200 in excess of the ordinary expenditure.
The discussion on cholera, which in my last year's
address I announced that I had undertaken to initiate,
occupied two evenings during the month of March, and
brought together a large number of Fellows and Visitors,
many of win mi took part in the debate.
The discussion, if it did not materially increase our
knowledge of the subject, served to bring into view the
very contradictory opinions which are held not only with
regard to the etiology, the infectiousness, the patho-
logy, and the treatment of the disease, but also with
reference to such easily demonstrable and often demon-
strated anatomical facts as the relative amount of blood
on the two sides of the heart when tho chest is opened
soon after death during the stage of collapse.1
Amongst the subjects which excited most interest and
which were most fully discussed was that of Dr. Koch's
comma-bacillus and its relation to the disease. Upon
thai question I did not then venture to express any
opinion, but Dr. Koch's later observations and experi-
ments, as related by him in his speech at the opening of
the Cholera Congress at Berlin in May last," many of
which have been repeated and confirmed by Mr. Watson
Cheyne8 and other competent and trustworthy observers,
appear to render it at least highly probable thai the
comma-bacillus is not only constantly associated with
Asiatic cholera, but that it is tlie morbific agent by which
the disease is propagated.
1 Sir tin report "i' the discussion, ' Proceedings of tlie Royal Med. and
Cliir. Soc.,' new series, vol. i. ]>j>. 892—420.
- British Medical Journal,' .Ian. 2nd and 9th, L886.
-1 " Reports t" the Scientific Qranta Committee <>f the British Medical
ition," • British Medical Journal,' April 25th it teq., ls^"'.
president's address. 39
After a series of carefully conducted experiments Dr.
Koch discovered a certain method of inducing cholera in
guinea-pigs by introducing the bacilli into the stomach of
the animal. And one of the most interesting and prac-
tically instructive facts which he records is that, in order
to ensure the deadly action of the infecting material, it is
necessary to prevent its too rapid escape from the intes-
tinal canal by the narcotic effect of opium injected into
the cavity of the peritoneum, the object being to arrest
or retard peristaltic movement, and so to render it
possible, as he says, " for the comma-bacilli to remain
longer and gain a footing in the intestine." The result
of this experiment of Koch's is quite in accordance with
my own observation that the abrupt arrest of choleraic
diarrhoea by opium prevents or retards the escape of the
poison, and is often followed by fatal collapse. Addi-
tional evidence of the pathogenic power of the cholera
bacilli is afforded by the case of a physician who got a
sevei'e attack of cholera at a time when the only possible
source of infection was the incautious manipulation of the
cholera bacilli in Dr. Koch's laboratory. The intestinal
discharges in that case contained very numerous cholera
bacilli.
It will be seen from the report of the Council that the
attendance of Fellows and visitors at the meetings and
the number of those who have taken part in the discus-
sions during the past year have been above the average,
while the last volume of our ' Transactions ' will bear
comparison with its predecessors for the intei-est and
importance of the papers which it contains. The
Council, too, have received a large number of interesting
papers for future reading and discussion.
The publication of the discussions on the papers which
are read before the Society in the ' Proceedings/ a prac-
tice which was initiated during my predecessor's tenure
of office, has proved a complete success, and has added
greatly to the value and interest of the ' Proceedings.'
In now retiring from the Presidential Chair, which by
40 president's address.
your favour I have been privileged to occupy during the
past two years, I do so with a very grateful sense of the
honour which has thus been conferred upon me, and with
a most fervent and heartfelt wish for the continued
prosperity and usefulness of this the greatest of the
medical societies in the United Kingdom.
DIFFUSE LIPOMA.
W. MORRANT BAKER, F.R.C.S.,
SUEGEON TO ST. BARTHOLOMEW'S HOSPITAL; CONSULTING SURGEON TO
THE EVELINA HOSPITAL FOR SICK CHILDREN.
ANTHONY A. BOWLBY, F.R.C S.,
SURGICAL REGISTRAR AND DEMONSTRATOR OF SURGICAL MOHBID ANATOMY
AT ST. BARTHOLOMEW'S HOSPITAL.
Received March 10th— Read October 27th, 1885.
The term diffuse lipoma is applied by the authors to
certain cases in which there is a great local increase of
the subcutaneous fat, without any distinct boundary or
capsule such as is usual in the more common forms of
circumscribed lipomata.
These growths are generally symmetrical, and are most
common over the mastoid processes, in the nape of the
neck, and in the submaxillary regions. As will be seen
by reference to the cases about to be described they are,
however, met with in other situations.
In the f Transactions of the Pathological Society of
London/ vol. xxx, 1879, p. 417, a case is recorded by one
of the writers (Mr. Morrant Baker) in which the patient
was the subject of these tumours which occupied the upper
and back part of the neck and the submaxillary regions.
42 DIFFUSE LIPOMA.
The tumours are thus described : " There are two
tumours in the scalp, symmetrically situated, one on aud
behind each mastoid process ; two, also symmetrical, in
the neck — one in each anterior triangle — and a fifth at the
back of the neck, in the median line. When the patient
was first seen, about two months ago, the tumours over the
mastoid processes were of about the size of a small Tan-
gerine orange ; those in the anterior triangle, less defined
at their margins, occupied the upper two thirds of this
space ; and the post-cervical tumour, of a circular outline,
and less prominent than either of the others, had a diameter
of about three inches.
"All the tumours have the same general characters.
They are soft, almost fluctuating, yet not tense ; apparently
seated in the subcutaneous tissue, yet not easily movable
on subjacent parts. The skin over them, with which
they seem continuous, is not altered in colour or texture,
and they are not in the least degree tender. Their con-
sistence seems to lie somewhere between that of a soft
fatty tumour and a subcutaneous ncevus ; the tumours
cannot, however, be obliterated so completely by pressure
as the latter, nor are they lobulated like the former.
Their texture feels most like that of the soft, semi-
fluctuating, fatty lumps in the lower part of the neck
which accompany the condition known as sporadic creti-
nism."
In a postscript, dated May 24th, 1870, it is noted that
" the tumours have suddenly undergone a great alteration.
The post-mastoid tumours now feel almost as tense as if
thej were distended by fluid, a ml the post-cervical median
tumour, from a state in which it was scarcely distinguish-
able from the surrounding subcutaneous tissue, is imw in
all respects indistinguishable from an ordinary well-defined,
firm and Lobulated, Eatty tumour. Were it the only
tumour present, and were the history unknown, no surgeon
could hesitate for a moment in diagnosing it as an
ordinary Eatty tumour."
From the great variations in size to which theso
DIFFUSE LIPOMA. 43
tumours were subject in this particular case, from their
want of definition, and from the condition of the general
health of the patient, it seemed probable that they were
rather lyrnphadenoinatous than fatty. A short time before
the patient's death, which occurred from some obscure dis-
ease of the lungs, a year or two after his exhibition to the
Pathological Society, the tumours were said to have almost
completely disappeared. It seemed probable at the time
that there might be some pathological connection between
the tumours in the neck and the persistent bad health of the
patient, which ended in death ; but examination of many
subsequent cases of similar tumours, without accompanying
general disease, suggests that in the first recorded case
the connection may have been only accidental.
The description of the tumours quoted above is applicable
to all the cases now to be recorded, but in no subsequent
individual case have the variations in size and consistence
been so noticeable. In no case, moreover, has the affec-
tion of the general health been so marked, with the excep-
tion of Case No. 6, in which the patient was the subject
of advanced phthisis. In most of the cases, too, the
tumours have been larger and more tense, and in some
of the post-mastoid tumours the bases have been so hard
as to suggest the presence of much fibrous tissue.
A glance at one of the drawings will give a much
better idea of the general aspect of a case than any verbal
description. (See Plates I and II.)
Although the disease is seen in its most typical form
in the neck and occiput it is not confined to these regions.
The tendency to the growth of adipose tissue is in many
of the cases observable in the arms and forearms, the
scrotum, abdominal wall, and the inguinal and hypogastric
regions. In one case large masses of fat were found in
the mammary regions (Plate II, fig. 2). This is the only
case in the series in which the post-mastoid tumours were
so small as to be scarcely noticeable.
The total number of cases observed by us is thirteen.
44 DIFFUSE LIPOMA.
Case 1. — N. D — (Jan. 25th, 1883), a strong, healthy
looking man, set. 45, says he has always enjoyed good health.
He is employed as an ostler; has no visceral disease, but
owns to drinking a great deal of beer, and some gin, and
other spirits. He does not get drunk, but is often
tippling ; occasionally vomits in the morning, and more
often simply retches. His tongue is tremulous, raw, and
inflamed, a typical drunkard's tongue.
At the back of the neck and extending over each mas-
toid process are symmetrically-placed swellings, limited
above by a line prolonged backwards from the zygoma,
and below less distinctly limited. Their upper portion
is firm, fixed, and resistant, and their outline smooth
and rounded ; below they are softer, and more inclined
to be lobulated. The swelling is largest on the right side,
and measures h\ inches in its transverse diameter, by o\
inches from above downwards. On the opposite side the
measurements are respectively 5 inches and 3 inches.
The submaxillary region is occupied by a soft pendulous
mass, largest under the right side of the lower jaw,
looking like a double chin (Plate I, fig. 2). Its consistence
is irregular, and in some places hard masses like enlarged
glands can be felt. The right groin presents a small
swelling over the femoral glands; the left groin one about
twice the size of its fellow ; the glands themselves cannot
be distinctly felt.
There are no tumours in any other parts of tho body.
Some of these masses have been noticed by the patient for
about twelve months, but those in the groin had not
attracted his attention. Ho says the swellings increase
in size, but vary at different times.
Urino and blood normal.
March 8th. — The patient has been under Dr. Andrew,
of Hendon, and has taken Liquor Potassai without much
change in the swellings. They are perhaps a little softer.
Case 2. — J. C — , a)t. 40, is in good health, works hard
;it a wine and spirit merchant's, mostly as a warehouse-
DIFFUSE LIPOMA. 45
man, and says he can easily carry two hundredweight on
his back. No visceral disease; says he drinks a great
deal of gin. Urine normal. On the back of the neck,
over the upper cervical vertebras, is a large swelling
occupying each side of the sub-occipital region, extend-
ing equally over the mastoid processes, and having a
marked median groove along the line of the spine ; the
appearance indicates that the tumour commenced in two
lateral growths, which subsequently met across the middle
line. The upper limit of the swelling on each side is
about on a level with the tip of the ear. The dia-
meter transversely is 7^ inches ; from above downwards 4|
inches.
The whole of the submaxillary region is occupied by a
large, semi-fluctuating mass, which extends upward over
each cheek, and presents no median division. Its
measurement from one cheek to the other is 12 inches ;
the upper boundary is harder to the touch than is the
lower part of the swelling ; the skin over it is slightly
red.
Masses similar to the above are found on the upper
arms, more especially on the left, the circumference of
which is 16 inches, that of the right being 14^ ; the supra-
clavicular regions are free.
In both groins, particularly the right, it seems as if the
glands were embedded in swellings, which feel as if com-
posed of tissue similar to that forming the growths in
other parts. On the outer side of each thigh are tumours
of a similar nature, though small ; and below the umbilicus
there is a collection of a like material.
The patient can give no very definite history, but says
that the various lumps began to grow about four years
ago. He thinks that some of them, especially those on
the neck, are still increasing.
Case 3. — J. M — , set. 51, is in good health. Thoracic
viscera normal. A little pale and pinched about the face,
but has a good deal of subcutaneous fat about the body.
46 DIFFUSE LirOMA.
Urine acid, and contains a trace of albumen. Says he
drinks a great deal of gin. Digestion bad.
In the centre of the back of the neck is a large tumour
of a rounded shape (Plate I, fig. 1). It extends about an
equal distance on each side of the middle line, the situation
of which is marked by a barely perceptible groove. The
transverse diameter measures 5 inches, and the thickness
of the tumour is about 3 inches.
Higher up the neck on each side, behind the ears and
over the mastoid process, are two swellings of a similar
kind. That on the left side is the larger, and is about 5
inches in diameter ; its outline is nearly circular, and the
skin over it is red, and rather tender, though not in any
way indicative of impending suppuration.
The tumour on the opposite side is about 3 inches in
diameter, also of a rounded shape, and covered by normal
skin. Neither tumour encroaches on the middle line of
the neck.
The patient says that the large tumour has been
growing for seven years, the smaller ones four or five
years. In his opinion they are at some times smaller
than at others. No similar swellings exist in other parts
of the body.
Case 4. — D. L — , aet. 38, car-driver, has Buffered from
chronic bronchitis for about four years, but is otherwise
healthy. Drinks a great deal of beer and spirits. Appe-
tite bad. Pain in loins. Urine acid ; contains a good
deal of albumen.
Symmetrically placed on each side of the upper part of
the luck, and over the posterior portion of each mastoid
process, are two lumps — each about twice the size of a
small lien's egg — slightly crossing the middle line, along
which is a deep Longitudinal groove. The upper boundary
ach lump is a line drawn backwards from the zygoma.
Their measurements are 4 inches long by 3 wide.
Under the skin in the submaxillary region is a soft
dill use swelling, not extending into the cheeks. A small
DIFFUSE LIPOMA. 47
swelling about the size of a walnut is placed on each
zygomatic arch immediately in front of each ear, that on
the right side being rather the larger. Lumps of similar
size are found on each side of the spine in the lumbar
region.
In each groin the glands appear hidden and involved in
similar growths. The scrotum is enlarged by the pre-
sence of similar soft growths, and is pendulous. Both
arms and forearms are very much, enlarged and misshapen
by diffuse soft masses in the subcutaneous tissue, feeling
like fat. In the left arm the lumps are much more
circumscribed below the elbow. The greatest circum-
ferences of the arms and forearms are .as follows :
R. arm . 12^ inches; R. forearm . H^ inches.
L. arm . 14 inches ; L. forearm . 12| inches.
The history the patient gives is that the mass on the
right side of the nape of the neck began to grow three
years ago, and was soon followed by the appearance of
its fellow ; the submaxillary region, groins, and arms were
then affected in order, the swellings in the latter being
noticed eighteen months ago. He is not sure that the
tumours are still growing, and says that they vary in size.
This latter statement is certainly correct, for a week after
the above description was written the tumours in the neck
were distinctly smaller and less tense.
Case 5. — J. C — , ast. 48, has been a healthy man, but
owns to having drunk much spirits, chiefly rum, often as
much as eight glasses a day ; has not drunk so much
lately. No appetite for food ; suffers from nausea.
For two years he has noticed lumps on his neck, which
have become much larger during the last six mouths, and
which he thinks are still growing. He thinks they vary
in size ; they cause no pain.
On the back of the neck on each side are two large
masses very nearly equal in size — that on the right being
rather the larger — and partly subdivided by a transverse
groove. Their greatest diameters are in the long axis of
48 DIFFUSE LIPOMA.
the body, and measure A\ inches each ; transverse diameter
of the right 2, inches, of the left 2\ inches. In front of
each car is a small swelling on the zygoma, that on the
left side being the larger, and about as big as half a
walnut.
Has no swellings in other parts of the body.
February 9th. — Has been taking Liq. Potassas for the
past month, with the result that the swelling over the
right mastoid process is smaller and softer. No other
change.
March 12th. — Has continued Liq. Potassao. No im-
provement.
Case 6. — C. S — , pig-slaughterer, set. 33. Married, and
has two children, aged five and four years. Says he has
been a fairly healthy man, but has lately been troubled
with cough. Has drunk much, chiefly beer and spirits.
Hand tremulous; tongue glazed and superficially ulcerated.
Phthisis at right apex. Liver enlarged. Urine acid,
loaded with blood, which has been present for the past
week. Pain in the loins. Fistula in ano of five months'
duration.
On the upper part of the back of the neck are two
symmetrically placed swellings, each 4.' inches long by
about 2\ inches wide, limited above by a line prolonged
backwards from the zygoma, and each partially subdivided
into two equal portions by a transverse groove, which is
most marked on the right side ; the portion of the tumour
above the groove is firmer and more elastic than that
below, which is softer and less defined. The left sub-
maxillary region is occupied by a large, soft, pendulous
mass, ill-defmed in all directions, the right side of the
neck being but slightly affected. The lymphatic glands
in each groin are hidden by soft tumour-like masses of
an apparently similar nature to those in the rest of the
body, but of small size. There is a slight swelling on
* :t<h side just above the pubes, about the size of a
marble.
DIFFUSE LIPOMA. 49
The patient thinks the lumps have been growing for
about two years, but is not certain. He thinks they vary
in size.
Case 7.— W. H— (Nov., 1883), a healthy man, set. 29,
of healthy parents. Drinks about six quarts of beer daily,
three quarts of milk, and half a pint of gin. Eats little
meat, and is fond of sucking raw eggs to the amount of
five or six a day. No visceral disease. Digestion and
general health good. Has noticed swellings on the breast,
abdomen, and in the groins for twelve months. They all
appeared simultaneously and are increasing. They do not
vary in size. A lump on the left side of the neck
appeared at the same time as the others.
The pectoral regions are occupied by large globular
swellings, leading one to suppose at first sight that the
patient has unusually developed mammary glands. They
are of equal size, each about as large as the average
mamma of an unmarried woman (Plate II, fig. 2).
Over the middle line of the abdomen are large rounded
swellings, limited laterally by the lineae semilunares, and
transversely constricted by the lineae trans versae. There
is a soft mass over the pubic bone. The glands in each
groin and in the right axilla are embedded in soft swel-
lings.
The upper and inner part of each arm is occupied by
a soft pendulous outgrowth, the whole limb being in each
case much enlarged, so that the greatest circumference
of the right arm is 14, inches, that of the left 14~ inches.
In the left submaxillary region is a swelling as large as
an egg, irregular in outline, and pendulous. From the
hyoid bone to the lobule of the left ear the measurement
is 65 inches, a similar measurement on the right side being
5 inches. There are two symmetrical swellings in the
scrotum, one behind each testis.
All the tumours have a soft doughy feel, and are evi-
dently composed of fat. The skin over them is mostly
vol. lxix. 4
50 DIFFUSE LIPOMA.
adherent, especially over tbose on the arms, and dimples
when pinched up. There are symmetrically-placed swel-
lings behind the mastoid processes, bat of small size, and
hardly noticeable.
February 16th, 1884. — All the swellings have greatly
increased. In each pectoral region is a large rounded
mass, as big as a full-sized female breast, and with the
nipple in its centre. General health good. Says he has
given up spirits, but drinks beer.
Case 8.— F. B— , set. 41 (September 29th, 1883), a
weak, unhealthy-looking man. Is said to be of tem-
perate habits. For two years has noticed swellings in his
neck, and says that for the last year they have been very
painful. In the middle line of the neck in the sub-
maxillary region is a large, soft, pendulous swelling.
Behind each mastoid process is a rounded swelling, ex-
tending from the superior curved line of the occipital bone
to the sixth cervical vertebra. These swellings are united
across the middle line in the lower half of their extent.
Extending along the middle line, and on each side of it,
from the first to the fourth dorsal vertebra, is a similar
mass of soft tissue feeling like fat. At their upper boun-
dary the tumours are of firm consistence.
The patient was treated with Liq. Arsen., but did not
improve.
Case 9. — W. P — , net. 38, hairdresser, admitted into St.
Bartholomew's Hospital under the care of Mr. Willett,
March 2nd, 1885. A wasted, unhealthy-looking man.
Family history of phthisis. Winter cough for some yen-
past. No material pulmonary disease. Urine normal.
Has lateral curvature of the spine.
For many years he has been in the habit of drinking
largo quantities of spirits, often as much as half a pint to
a pint of brandy daily. He also drinks beer. The spirits
arc consumed at frequent intervals in small quantities, and
he says he is never intoxicated.
Behind each mastoid process is a swelling the size of
DIFFUSE LIPOMA. 51
half an egg, rounded and smooth to the touch, firm above,
where it is limited by the superior curved line of the
occipital bone, but more soft and less well defined at its
lower border.
In each parotid region, immediately in front of the ear,
is a small rounded swelling as big as a walnut, soft,
painless, and compressible.
Symmetrical swellings of similar size to those in the
parotid region are found in the upper part of the scrotum.
They are freely movable.
In the perinaeum is an irregular and very ill-defined
soft mass, extending from the scrotum to the anus, sym-
metrically distributed on each side of the middle line, and
with its long axis in an antero-posterior direction. It is
distinctly lobulated, and though movable on the deeper
structures is in parts adherent to the skin.
Over each external abdominal ring is a rounded softish
swelling about an inch in diameter, the skin over which
is partly adherent.
In the abdominal wall, on each side of the middle line,
below the umbilicus, are symmetrical swellings each as
large as half an orange.
The preceding cases, ten in number, including the one
already described in the Pathological Society's ' Transac-
tions,' have been observed by us at St. Bartholomew's
Hospital. For the following we are indebted to Dr.
Allchin, Dr. de Havilland Hall, and Mr. Henry Morris.
Case 11. (From Mr. Henry Morris.) — E. R — , set. 63,
steward on board a steam-packet, is suffering from cancer
of the mouth and tongue. For thirty-seven years has
noticed the tumours about to be described. Twenty years
since Mr. Cock removed two of the smaller ones from the
neck ; the others continued to grow until ten years ago.
There are now three tumours at the back of the neck,
one on the right and two on the left side of the well-
marked and easily felt ligamentum nuchas. There is also
an enormous, soft, pendulous, almost diffluent mass, which
52 DIFFUSE LirOMA.
extends from below the ear on one side, beneath the chin
to the same point below the other ear. It hangs over the
top of the chest.
Case 12. (From Dr. de Havilland Hall.)— J. L— , jet. 44,
has been a healthy man until the last three years. Since
then he has suffered from cough, with much expectoration
and occasional haemoptysis. Has been a heavy drinker,
taking large quantities of both beer and spirits, often half
a pint to a pint of gin daily. Latterly he has not drunk
so much spirits, but still consumes large quantities of beer.
Is subject to headaches.
A year ago he noticed swellings in the neck ; since
then they have increased, but are sometimes smaller than
at others.
Present condition. — Symmetrically placed behiud the
mastoid processes are two firm, rounded swellings, each as
large as a Tangerine orange, similar to those already de-
scribed in the previous cases. In the submaxillary region
is a soft pendulous swelling not large enough to be very
noticeable. In each groin is a soft, fatty mass, which
apparently extends into the femoral canal, as it gives a
distinct impulse on coughing.
Dr. Allchin has kindly forwarded the note of the
following case.
Case 13. — C. St. Q — , oat. 36, was for several months
under my observation at the Westminster Hospital during
1884.
Has been a cavalry soldier, and was for some years in
India, where he drank freely, chiefly brandy, rarely the
native spirit. He has quite ceased drinking for the last
few years. The tumours commenced whilst he was
drinking.
Says lie had syphilis in 1 807, but it appears question-
able whether it was an infecting chancre, Eor he states he
had no secondary manifestations ; was treated \n ith Fowler's
solution and iodide of potassinm.
DIFFUSE LIPOMA. 53
In June, 1875, tumours were first noticed behind the
ear. Their appearance was attended with slight pain, and
were at first small and hard, as if the bone were growing
out. Says his mastoid processes were always prominent.
These swellings continued to increase in size, and to
become softer. They attained their present dimensions in
December, 1879, since which time they have remained
stationary.
The next tumour to appear was the one on the cervical
spines four years ago. This reached its full development
in two years, and has, like the preceding, remained stationary
since that time. Patient's attention was drawn to this
tumour by the chafing of his collar.
The fulness under his chin has existed eighteen months ;
it is not increasing.
A year ago the swelling in front of the left ear just
below the zygoma was pointed out to the patient, who
had not previously been aware of its existence. It is not
increasing in size.
A few weeks since (i. e. about last May), patient first
noticed swelling in the right arm. This is more flabby,
and not so circumscribed as the other tumours.
Patient was discharged from the army in October, 1879,
on account, as he says, of the tumours in the neck, which
were attributed to syphilis.
For some two or three years patient has noticed an
impairment of general health, and a failing memory, with
muscular weakness and loss of weight. But this may, in
part, be attributed to bad circumstances and poor living,
and in greater part to the effect of taenia, from which he
was found to be suffering whilst in the Westminster
Hospital.
No treatment was administered for the tumours, and
patient left hospital in no way altered, so far as they were
concerned.
In vol. xiii of ' St. Thomas's Hospital Reports ' Sir
William Mac Cormac has reported four cases similar to
54 DIFFUSE LIPOMA.
those just described. In one of these he removed a
portion of the post-mastoid fatty tumours with ultimate
benefit to the patient, who was very pleased with the
result. But Sir W. Mac Cormac remarks that the re-
moval of the tumours was very tedious, the hemorrhage
copious, and the wound extensive.
At the meeting of the Pathological Society, March 20th,
1883 (' Brit. Med. Journ/ 1883, i, p. 623), " Mr. Jonathan
Hutchinson showed a mass of fatty tissue removed from
the back of the neck of a man, who had large masses in
that situation quite symmetrically arranged. The patient
also had tumours symmetrically placed on both arms, and
he appeared to have symmetrical hypertrophy of the parotid
glands, or the appearances might be due to small masses
lying over the glands. On March 19th he had attempted
to remove one of the masses, but had not found any
distinct limit to the mass, which appeared to be a hyper-
trophy of the subcutaneous fat, not at all encapsuletl, and
not therefore to be removed. The mass consisted of very
firm fatty tissue, with firm fibrous meshes/'
At the meeting of the Ophthalmological Society, July
3rd, 1884,1Mr. Jonathan Hutchinson narrated the history of
a patient, a Hindoo gentleman, in whom proptosis, first on
one side and subsequently on the other, occurred in con-
junction with a puffy condition of the face and submaxil-
lary region. The proptosis appeared to be due to an
increase of the orbital fat, but no symmetrica] enlargements
of the nock or elsewhere were noted. Mr. Hutchinson
expressed his opinion that this case was analogous to that
shown by Mr. Baker at the Pathological Society.
At the time that Mr. Morrant Baker exhibited his
patient to the Pathological Society he was not aware that
other cases had been recorded, but his attention has been
since called to the fact thai Sir Benjamin Brodie has
placed on record examples of the Bame disease. Sis
observations on the subject may be here quoted: —
"There is another kind of fatly tumor which occurs
Transactioni of the Ophthalmological Society,' voL W, p. 3G.
DIFFUSE LIPOMA. 55
occasionally, but which has not been, as far as I know,
described by surgical writers. In the cases to which I
allude the tumor is not well defined ; in fact there is no
distinct boundary to it, and you cannot say where the
natural adipose structure ends and the morbid growth
begins. I will relate to you the history of one of several
cases of this kind that I have met with, and this will
explain as much as I know of the matter. A man came
to this hospital several years ago having a very grotesque
appearance ; there being an enormous double chin (as it is
called) hanging down nearly to the sternum, and an
immense swelling also on the back of his neck, formed by
two large masses one behind each ear, as large as an
orange, and connected by a smaller mass between them.
He said that the enlargement had begun to show itself
three or four years before, and had been increasing
ever since. They gave him no pain ; nevertheless they
made him miserable, and in fact had ruined him. The
poor fellow was by occupation a gentleman's servant, and
having so strange an appearance no one would take him
into his service. I gave him half a drachm of the liquor
potasses three times a day, and gradually increased the dose
to a drachm, dissolved in small beer. When he had taken
the medicine for about a month the tumors were sensibly
diminished in size. He went on taking the alkali, and the
tumors continued to decrease. It was just then that
iodine began to have a reputation, much indeed beyond
experience has proved it to deserve, for the cure of morbid
growths, and I left off the liquor potassoz, and prescribed
the tincture of iodine instead. The effect of this change of
treatment wras remarkable. The patient lost flesh, while
the tumors increased in size. Of course I omitted the
iodine and prescribed the liquor potassa a second time.
Altogether he took a very large quantity of the latter
medicine, and left the hospital very much improved, with
directions that he should continue to take it, with occa-
sional intermissions. I had lost sight of him for some
time when it happened that I was requested to visit a
56 DIFFUSE LIPOMA.
patient in Mortimer Street. I did not observe the servant
who opened the door, but as I was leaving the house he
stopped me, saying that he wished to thank me for what
I had done for him. It was this very patient. He was
so much improved in appearance that he was enabled to
obtain a situation as footman. There were still some
remains of the tumours, but nothing that was very
remarkable. I have seen some other cases of the same
kind in which the exhibition of very large doses of liquor
potassa appeared to be of great service. But I have not
had the opportunity of trying it, or of knowing the
results in every case ; and I am informed that in some
cases it has been given to a considerable extent without
manifest advantage." (Lectures on Pathology and Sur-
gery, 1846, p. 275.)
Remarks. — All the cases hitherto observed have been
males, the ages varying from twenty-nine to sixty-three
years ; the majority of the patients being between thirty-
five and forty-five years of age at the time the tumours
commenced to grow. We believe that all these swellings
have a similar structure, being composed simply of adipose
tissue ; for in the cases in which the tumours were sub-
mitted to operation by Mr. Hutchinson and Sir William
Mac Cormac, the growths removed consisted of fat. And
in several of our own cases the diagnosis has been con-
firmed by the microscopical examination of portions of
the growth removed by Dr. Charcot's " emporte piece
histologique."
The development of these tumours is somewhat rapid.
Thus, in case No. 7 they had attained a considerable
size within twelve months. The rate of growth, however,
varies much in individual cases. Another noticeable tart
is that in aome instances the swelling varies in size from
time to time. Of this tart several of the patients were
very certain, and in some we woe able to verity their
statements. Whether the tumours ever entirely disappear
in l lie absence of any wasting disease we cannot certainly
affirm.
DIFFUSE LIPOMA. 57
With regard to the anatomical position of the swellings
we have no doubt that they are situated in the subcuta-
neous cellular tissue, and we cannot agree with Sir W.
Mac Corrnac that in the neck they are beneath the fascia
of the trapezius muscle.
In support of our opinion we would point out firstly,
that in Mr. Hutchinson's case the fatty mass is specially
mentioned as being found to be subcutaneous at the time
of operation ; and secondly that the entirely analogous
fatty masses in the submaxillary regions, in the forearms,
abdominal wall, &c, are evidently entirely independent
of fascial attachments in their growth, being essentially
diffuse, absolutely unlimited in any direction and occasion-
ally distinctly attached to the skin.
The manner in which the growths in the post-mastoid
regions are limited may also be readily explained without
reference to the attachments of the fascia of the trapezius.
They are limited above by the superior curved line of the
occipital bone, because beyond this limit there is no subcu-
taneous cellular tissue in which the fat can be developed.
In a downward direction these growths are not definitely
limited, but in the middle line of the neck there is a more
or less well-marked depression, simply due to the fact,
which is easily demonstrable, that in this situation the
skin is closely bound by strong fibrous bands to the sub-
jacent aponeurosis, and that the subcutaneous tissue is
very dense and tough. Nevertheless, the growths may
certainly pass across the middle line (see, amongst others,
Case No. 2), a condition which would be impossible if they
were subfascial.
Sir W. Mac Cormac, indeed, in another part of his paper
— possibly by an oversight — says, whilst speaking of the
operation, " The mass appeared to consist simply of
diffuse subcutaneous fat."
Another point to which we would direct attention is the
fact that these fatty masses are prone to develop in the
regions occupied by lymphatic glands. Thus they are
found behind the ear, in front of the pinna, in the sub-
58 DIFFUSE LIFOMA.
maxillary and inguinal regions ; although they are also
frequently present in other situations which have no
special connection with the lymphatic glands. Whether
the latter glands are ever involved in the growth we are
not in a position to state with certainty ; but we have not
felt them to be definitely enlarged.
Beyond the discomfort produced by the deformity, no
symptoms specially referable to these fatty tumours have
been observed ; and the expression of a wish on the
part of one or two of the patients to have an operation
performed has arisen only from the unsightliness of t ho
disease.
Internal remedies have apparently little or no effect.
In one or two cases, however, the administration of arsenic
with steel seemed slightly beneficial. In accordance with
Brodie's suggestion we have tried the effect of Liq.
Potassae, but have not hitherto found it beneficial in reduc-
ing the size of the growths. We have administered the
above-mentioned drugs, as well as iodide of potassium
and mercury, in several cases for some months.
As the cases accumulated we had hoped to find some
definite conditions which might help in determining the
nature or cause of the disease. But the only circumstance
which seems to give any clue to its cause is (so far as we
have been able to observe) that, with one or two possible
exceptions, the patients have been hard drinkers.
Of course this may be an accidental concomitant and even
if connected with the disease may be only one element in
iis further development. But, as will be seen in reading
the notes of the individual cases, the fact' is too marked a
feature to be overlooked. In Sir William Mac Cormac's
cases no statement is made with regard to sobriety, but
we may remark that the two patients whose occupations
were recorded, were, the one a butler, the other a
waiter.
The value of alcohol as a fat-forming Eood is too well
known t<> need much emphasis, but is worthy of notice.
It, however, affords no explanation of the great tendency
DIFFUSE LIPOMA. 59
seen in these cases towards the development of fat in
certain regions and not in others.
Appended is a table of the cases to which reference has
been made.
(For report of the discussion on this paper, see ' Proceedings
of the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 5.)
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DIFFUSE LIPOMA.
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DIFFUSE LTPOMA.
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I— 1
DESCRIPTION OF PLATES I and II.
(Diffuse Lipoma, by W. Morrant Baker and A. A. Bowlby.)
Plate I.
Fig. 1.— J. M— , Case 3, see p. 45.
Fig. 2.— N. D— Case 1 see p. 44.
Plate II.
Fig. 1.— C. S— , Case 6, see p. 48.
Fig. 2.— W. H-, Case 7, see p. 49.
Plate I
: Trans Vol LXIX
Plate II
A CASE
OF
LIGATURE OP THE LEET COMMON
CAROTID ARTERY
WOUNDED BY A FISH-BONE WHICH HAD
PENETRATED THE PHARYNX.
REMARKS AND AN APPENDIX CONTAINING FORTY-FIVE CASES
OF WOUNDS OF BLOOD-VESSELS BY FOREIGN BODIES.
WALTER RIVINGTON, M.S. Lond., F.R.C.S. Eng.,
SURGEON TO TUB LONDON HOSPITAL, AND LECTURER ON SURGERY AT THE
LONDON HOSPITAL MEDICAL COLLEGE.
Received April 14th— Read October 27th, 1885.
Penetration of some part of the alimentary canal by
sharp-pointed foreign bodies which have been swallowed,
and arrested in their passage, is not a very uncommon
occurrence. Apart from obstruction to the passage of air
to the lungs, or food along the alimentary tract, it is
familiar to the surgeon as the cause of two main and dis-
tinct kinds of mischief ; on the one hand of inflammatory
mischief, more or less severe, prolonged, and critical
according to the nature of the organ or tissue involved in
the imprisonment or migration of the foreign substance,
and on the other hand of mischief to adjacent blood-
vessels, too often terminating in rapid death from sudden
and uncontrollable hasinorrhage. The relative frequency
64 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
of the different kinds of fatal lesions due to the arrest of
foreign bodies in the pharynx and oesophagus may be
gathered from Adelman's table.1 Out of 314 cases 109
proved fatal, 43 from lesions of the respiratory organs,
25 from ulceration of the oesophagus and inflammatory
processes in the neighbouring parts, and 31, or less than
one third, from implication of blood-vessels. To the last
source of danger attention will mainly be confined in this
paper. In the Appendix will be found abstracts of 44
cases in which lesions of blood-vessels occurred through
the agency of foreign bodies penetrating the alimentary
canal, 43 of these proving fatal. Arranged according to
the vessels injured the cases comprise :
23 instances of lesion of the thoracic aorta.
11 instances of lesion of one or more of the carotid
arteries.
1 instance of lesion of the left ascending pharyngeal
artery.
1 instance of wound of an abnormal right subclavian.
1 instance of wound of the pulmonary artery.
1 instance of lesion of an azygos vein.
1 instance of wound of the heart and right coronary
vein.
3 instances of lesion of one or more of the vensa
cavas.
1 certain instance of lesion of the inferior thyroid
artery, or one of its branches.
2 doubtful instances of ditto.
45
The different divisions of the alimentary canal enjoy
different and unequal liabilities to injury from sharp-
pointed foreign bodies.
In the pharynx needles, pins, bristles, and fish-bones
readily find a temporary resting-plaoe. Generally they
are speedily dislodged and pass along the alimentary
1 ' Vierbeljahrachrift fur die praktuche Beilkande,' vol. xevi, p. 66.
LIGATURE OF THE LEFT COMMON CAROTID ARTERY. 65
canal ; sometimes they continue impacted, and, working
their way through the walls of the cavity, either by
penetration or ulceration, produce results of a serious or
fatal character through inflammatory affections of neigh-
bouring structures, or implication of neighbouring blood-
vessels ; and these very results may be ensured or
aggravated by injudicious procedures adopted for the
displacement of the impacted or adherent substances.
The part of the pharynx where foreign bodies are most
likely to lodge is at its junction with the oesophagus.
The pharynx also is liable to be directly perforated, with
accompanying wound of one of the carotid arteries by
sharp-pointed instruments, or other bodies, such as tobacco
pipes thrust through it from the mouth. For some
instructive cases of this kind reference may be made to
Mr. Durham's able article on ' ' Injuries to the Neck " in
Holmes and Hulke's ' System of Surgery,' vol. i, and to the
Appendix to this paper.
The narrowness of the oesophagus renders it more
especially liable to injury from the lodgment of foreign
bodies. The arrest may occur in any part of the tube,
the most frequent site being about opposite the point
where the left bronchus crosses the aorta. If they are
arrested in the neck, the common carotid, and especially
the left common carotid, is exposed to danger, and after
the carotids one of the oesophageal branches of the
inferior thyroid artery. In the thorax the aorta is by far
the most frequently injured, but occasionally one of the
venae cavas, the pulmonary artery, one of the large vessels
springing from the arch of the aorta, an azygos vein, or
even the heart itself, and one of the coronary arteries or
veins may be implicated. Within the abdomen the
impaction of foreign bodies is not specially related to
lesions of blood-vessels, and I am not acquainted with
any cases of wounds of arteries giving rise to fatal
hasmorrhage in that cavity. In one case the vena cava
was involved. A young woman died in the Middlesex
Hospital, after having been ill for fifty-three days, with all
VOL. lxix. 5
66 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
the symptoms of hectic fever, and after having presented
the signs of coagulation in the veins of both lower limbs
(phlegmasia alba dolens). Throughout the case she
complained of aching pains in various regions of the
spine. At the autopsy a needle was found in the lower
part of the vena cava, and around it a thrombus had
formed. There was an opening in the back of the vein
about an eighth of an inch in diameter. The iliac and
femoral veins on both sides were obstructed. A second
needle was found in an abscess to the left of the third
lumbar vertebra.1
If they reach the rectum, pointed bodies like fish-bones
are recognised as occasional causes of ischio-rectal abscess
and fistula.
It is a well-known fact that swallowed needles may
penetrate the alimentary canal, migrate through the mus-
cles without transfixing any blood-vessel, reach a remote
part of the body, and be extracted through the skin.
Some remarkable cases of this kind are on record."
1 Dr. Henry Thompson, • Brit. Med. Journ.,' 1874, vol. ii, p. 571.
2 Poulet gives the following: — 1. A stepmother, desiring to rid herself of
her little daughter, made her swallow at different times a certain number of
needles. After a long suffering the needles made their exit from different
parts of the hody, and especially from the arms. 2. A needle which had been
swallowed and lodged in the oesophagus penetrated the muscles, and a month
later was found behind the right ear, where it was extracted by an incision. 3.
A child had swallowed a needle, which lodged in the oesophagus and pierced its
walls; it became embedded in the muscles of the neck. It was extracted by
an incision and the aid of a magnet (Kerckringius, ' Spicileginm Anatomicum,'
Obs. 44). Lavaeherie ('Bull, de l'Acad. Med. de Beige/ L848) also mentions
the case of a young woman who had a foreign body in the fauces, which,
after the lapse of a year, appeared under the skin near the Bterno-claviculai
articulation, whence it was extracted by an incision three months later.
Poulet adds in a note : — " Vigla has collected the must interesting of these
cases of migratory foreign bodies, I levin quotes several cases in which corn-
stalks were extracted from abscesses of the thoracic walls thirteen to fifteen
days after their ingestion. Bonnet, 1 lelmontius, and VolgnaiiuS have report) d
similar facts j the hitter saw B cornstalk emerge through the axilla. In
Polisius' case the stalk made its exit three months afterwards from an abscess
in the back. Bally (' Rev, de Med.,' ii, L825) reports the ingestion of a stalk j
three mouths later peripneumonia, abscess upon right side of the thorax,
LIGATURE 0E THE LEFT COMMON CAROTID ARTERY. 67
Of the 45 cases of lesions of blood-vessels placed in the
appendix 19 resulted from swallowing pieces of bone, 4 were
due to sewing needles, 3 to coins, 2 to tobacco pipes, 1 to
a puncture by a parasol, 2 to tooth plates, Guthrie's case of
wound of both carotids to an ingenious suicidal machine
made of corks and pins, whilst 12, including my own case,
were caused by fish-bones. In 6 of the 12 the vessel
implicated was the thoracic aorta, viz. the cases of Theron,
Auvert de Moscou, Bousquet, Dr. Waters, of Liverpool,
Dr. Ram skill, and one related in the Catalogue of the
Museum of St. Bartholomew's Hospital. I may mention
that I witnessed the post-mortem examination on Dr.
Raniskill's case, and it was recalled to my mind when I
was asked to see the patient whose case forms the basis of
this paper. Five of the remaining 6 cases are instances of
wound of a carotid, viz. a second case given by Auvert de
Moscou, a case briefly referred to by Mr. Cripps in the dis-
cussion at the Clinical Society on 24th May, 1878, on Dr.
McKeown's paper on a successful case of cesophagotomy
for the removal of a set of artificial teeth impacted in the
oesophagus, Dr. Reid's case occurring in 1837, my own case,
and one under Dr. Cresswell Rich at the Liverpool Royal
Infirmary. Some months after the occurrence of my own
case, while I was attending the meeting of the British
Medical Association at Liverpool in 1883, I saw in the
Annual Museum of the Association a specimen showing
"perforation of the oesophagus by a fish-bone with
rupture into the left common carotid artery." Through
the kindness of Mr. Reginald Harrison, to whom I applied
for the particulars, Mr. Paul, and Dr. Cresswell Rich I
have been able to append the details of this interesting
case, and through the same channel I received the parti-
culars of the case of peivforation of the aorta under Dr.
Waters above referred to. The sixth case is the well-
known case related by Dr. Andrew where a fish-bone
penetrated the stomach close to the oesophagus, then the
between the second and third ribs, through which the foreign body emerged."
(' Treatise on Foreign Bodies,' vol. i, p. 84.)
G8 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
diaphragm and pericardium and posterior surface of the
heart, and finally inflicted a jagged wound in the middle
of the septum immediately over the right coronary artery
and vein, penetrating the latter vessel. The pericardium
was filled with a pint and a half of fluid blood.
It is worth while remarking that out of the 12 cases
of lesions of vessels due or ascribed to fish-bones, the
offending bone itself was not certainly discovered in more
than 4, viz. Bousquet's, Dr. Andrew's, the case at St.
Bartholomew's Hospital, and my own. It was not found
in either of the Liverpool cases, the reason doubtless
being that it had been washed away by the copious haemor-
rhage from the considerable opening at the seat of injury
to the artery into a lower part of the alimentary canal.
In Dr. Waters's case the opening in the oesophagus was
large enough to admit the little finger, and that in the
aorta at the junction of the transverse and descending
aorta would have admitted a No. 10 catheter, whilst the
stomach and duodenum were distended with blood-clot
weighing 2\ lbs., and forming an accurate cast of their
cavities. In the case of wound of the carotid, the per-
foration in the anterior wall of the gullet was circular
with perpendicular edge, and of a size to admit a No. 8
catheter, and the opening in the artery was of the same
size as that in the gullet. The large bowel was full of
altered blood. Most probably the fish-bones were con-
cealed in the blood in the intestinal canal.
Among the other freaks of fish-bones one or two are
worthy of mention. Morel 1 Mackenzie1 records a remarkable
case which he saw some years ago with Dr. Turtle at Wood-
ford. A fish-bone had accidentally found its way into an
infant's throat, and a very careful examination failed to
discover it. The infant wasted and died at the end of a
It w months. It was then found that the fish-bone had
passed through an intervertebral snbstance and wounded
the cord.
In the following case a fish-bone was instrumental in
' ' Diseases of the Throat and Nose,' vol. ii, p. 192.
LIGATURE OF THE LEFT COMMON CAROTID ARTERY. 69
causing intestinal obstruction. In the museum of the
Royal College of Surgeons of England is a very interest-
ing specimen (No. 2569), taken from a case under the care
of Mr. Coulson. It shows an annular stricture of the
rectum six inches above the anus and a small piece of
fish-bone sticking in its inner ulcerated surface. The
gravid uterus pressed on the foreign body, causing great
irritation and effusion of lymph, and complete occlusion
of the bowel resulted. The patient was a woman, thirty-
four years of age, in good health and more than four
months pregnant, who was seized with sickness, con-
stipation, pain, and distension of the abdomen. Faecal
vomiting supervened with more distension and continued
constipation. Injections were immediately expelled, and
death resulted on the third day from the commencement
of the attack.
The preceding remarks will suffice to introduce the
subject, and I now append the particulars of my own case.
R. B — , a badly-nourished boy, aet. 9, with glandular
enlargements, was admitted into the London Hospital on
November 14th, 1882, under the care of Dr. Sutton.
On November 8th, that is to say six days previously,
he was eating plaice, and swallowed a small bone. He
ran into the yard, followed by his mother, who put her
finger down his throat and made him vomit. It was
thought that the fish-bone had been ejected, but as pain
continued he was taken to a neighbouring doctor, who
advised him to go to the hospital. This advice he carried
out the next day. In the receiving room of the London
Hospital he was seen by the house surgeon and a member
of the staff. Saliva was freely dribbling from the mouth.
After a careful examination of the mouth and throat a
probang was passed, and as the passage was clear he was
sent home. Not being relieved he came back to the
hospital as a medical out-patient, and was then admitted
as an in-patient. His symptoms were pyrexia, stiffness
of the neck, oedema of the upper eyelids, profuse salivation,
70 LIGATURE OF THE LEFT COMMON CAROTID AETEEY.
and a small tender lump on the left side of the neck
opposite the cricoid cartilage. When examined the fol-
lowing day he was in the same condition. His pulse was
120, his temperature 101*3,° and his respirations 22. The
tenderness and rigidity of the neck continued, but he
could not swallow solid food. On the 17th it was noted
that the patient was very drowsy, that blood flowed from
the mouth, and that the sound of the voice was thicker
than usual. He complained of earache. He had two
attacks of haemorrhage on the 17th. On the 18th he was
easy. Saliva still flowed from his mouth. The pulse was
128, and the temperature 98°. There was no haemorrhage.
On Sunday, the 19th, haemorrhage suddenly supervened.
Blood flowed in a stream from the patient's mouth, and
was received into a spittoon holding a pint. The blood
half filled the vessel. Mr. E. H. Fenwick, then house
surgeon, now assistant surgeon at the hospital, sent me a
note detailing the history and requesting me to see the
case. I found the patient in bed lying on his right side,
with difficulty in turning round, and the other symptoms
previously mentioned. He Avould not answer questions.
Dr. Charlewood Turner saw the patient with me. I came
to the conclusion, which I believe Mr. Fenwick had already
drawn, that the fish-bone swallowed on the 8th had been
arrested in the pharynx, had passed through its walls,
and wounded one of the left carotid arteries, that the
haemorrhage proceeded from the wounded vessel, and that
it would recur and prove fatal if an operation were not
performed. I therefore advised an exploratory operation,
and in this advice Dr. Turner concurred. I expected to
find the fish-bone, and the wound in the artery, in the
situation of the lump in the neck. The patient was taken
to the theatre, ami chloroform was given by my house
surgeon, Mr. Hingston. As I was on the point of com-
mencing the primary incision, my colleague -Mr. James
Adams, happened to come into tin- theatre. He kindly
stayed and gave me valuable assistance during the opera-
tion.
LIGATURE OF THE LEFT COMMON CAROTID ARTERY. 71
An incision was made along the edge of the sterno-
mastoid for several inches. The muscle was found to
be glued to the subjacent parts by recent adhesions.
After separating and retracting the muscle, the omohyoid
was recognised enclosed in a sheath. Above its anterior
belly there was a dark patch about the size of a four-
penny piece caused by extravasated blood looming
through the fascia. Although it was not absolutely
necessary, at Mr. Adanis' suggestion, I divided the
omohyoid to ensure sufficient room. Having divided the
fascia over the large vessels I passed a probe deeply into
the cavity which contained the clot, and the left index
finger through the mouth into the pharynx, but I could
not feel the probe thi'ough the wall of the pharynx. I
then turned out some clot, aud, introducing my finger,
ascertained that the probe was in a cavity hollowed out
behind the vessels and in the inner side. Having examined
the common carotid artery lower down for pulsation I
could not very clearly detect any, but once or twice there
seemed to be a feeble stream. This indicated that the
carotid below the site of the probable wound was blocked
with clot, but I deemed it advisable for greater security
against haemorrhage to place a temporary ligature on the
artery opposite the divided omohyoid. This was effected
with some difficulty owing to the uniform discoloration
of artery, vein, nerves, fascia and areolar tissue by the
extravasated blood. I could scarcely recognise the struc-
tures met with, all being dark and equally stained. I
did not see the descendens noni, and though I looked
carefully for it I could not distinguish the pneumogastric
nerve. Hence it was with some anxiety that I proceeded
to turn out more clot from the cavity above for the pur-
pose of finding the wound in the vessel, and applying
ligatures above aud below the aperture. As this was
effected each clot was carefully examined, and in the
centre of one the fish-bone was found. Owing to the
difficulty in recognising and discriminating one structure
from another my colleague suggested that I might include
72 LTGATURE OF THE LEFT COMMON CAROTID ARTERY.
all in a common ligature, but being anxious to proceed
secundum artem, and keep the operation free from any
avoidable complications, I preferred endeavouring to isolate
the artery. More clot was removed and then a free gush
of arterial blood took place evidently proceeding from the
distal end. Pressure arrested the flow, and the further
emission of blood was prevented for the moment by my
colleague pulling forward the vessels with a blunt hook.
I was then able to find the wounded vessel, and with
an aneurism needle to pass a ligature, as I thought, closely
round it above and below the seat of injury. Owing to
some firm adhesions the upper ligature was passed at a
little distance from the wound. In consequence of this
necessity — for I had no time to make a prolonged dissec-
tion owing to the danger of subjecting the patient to
further loss of blood, of the liability to which we were
reminded by an occasional jet from the distal end as the
hook was shifted or pressure relaxed — I deemed it prudent
to divide the artery at the seat of wound to make sure that
no branch was given off between the ligatures. When
this was done I recognised on the cut section some nerve-
fibres, and the question arose whether they belonged to
the descendens noni or to the pneumogastric. As they
were in front of the vessel, closely adherent, and appeared
scarcely numerous enough for the vagus, 1 came to the
conclusion that they belonged to the descendens noni.
It will be seen that they belonged to the vagus, which,
instead of lying between and behind the artery and vein,
took, or had been pressed into, an unusual position in front
of the artery, and owing to the inflammation induced by
the injury had become firmly adherent to the vessel for
some little distance above and below the aperture in the
artery. Externally the nerve was stained of tin1 same
dark colour as the artery, and only in the centre after
section were the white nerve-fibres to be recognised.
Relieving it to be the descendens mini I made n<> attempt
to disengage it or unito its extremities as I should have
dmie if I had known that it was really the vagus. The
LIGATURE OF THE LEFT COMMON CAROTID ARTERY. 73
temporary ligature on the trunk of the carotid below was
removed, the edges of the wound were dusted with iodo-
form and approximated, and the patient sent to bed. After
the operation he was very restless and thirsty, with diffi-
culty in swallowing. His pupils were equal. He coughed
a good deal and vomited two ounces of milky fluid con-
taining coffee grounds. On the 20th his pulse was 140
and respirations 22. He had passed a good night. He
took milk, beef tea, and brandy mixture, and was con-
stantly asking for drink. On the 21st he was less rest-
less and more drowsy, with decided weakness in the right
arm. Up to the 25th he took his nourishment exceed-
ingly well, but then he began to fail. He lay cm-led up
on his left side with his legs out of bed and his left hand
on his left ear and he became very drowsy. He could
be roused by opening his eye, and pressing on the con-
junctiva, and every now and then he tried to get out of
bed. A systolic murmur was heard at the apex. He
coughed occasionally but had no return of the vomiting.
He was partially paralysed on the right side. He sat up
in bed and looked over a picture book on Tuesday, the
28th, but this appearance of improvement was deceptive,
for he died exhausted at 1 a.m. on the 29th of November,
ten days after the operation. The wound remained healthy
throughout. The post-mortem was made by Dr. Sutton.
The heart and lungs and other internal organs were
healthy. On opening the membranes the brain surface
in the middle and upper regions of the left hemisphere was
seen in two places to be of a green colour and much
softened, with pus oozing out. There were two abscesses,
each containing green pus, three quarters of an inch and
one inch in diameter respectively. The pus was enclosed
by a defined boundary, but not by a distinct lining mem-
brane. Tne surrounding brain was rather softened but
not much congested. There was no sign of clotting in
the surface vessels of the brain. There was no pus in the
left ear. Mr. Hingston removed the pharynx and blood-
vessels of the neck, and made a careful examination
74 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
of the parts. The ligature had come away from the upper
end of the artery and included nerve, leaving a small
round aperture filled with clot. On laying open the
vessel the clot was found to be small in quantity, about a
quarter of an inch in length, and just sufficient to prevent
haemorrhage. The pneumogastric was adherent for a
considerable distance. Some portion of the upper part
of it was dissected off the carotid by Mr. Hingston, but
more than a quarter of an inch still remains attached
thereto. The lower ligature remained round the artery
only, and only separated after being cut with the scissors
when the artery was laid open. The clot here was
abundant, more than an inch long, dark red but decolor-
ized at the tapering end. The small wound in the pharynx
made by the fish-bone had contracted and almost closed,
but the spot could be recognised by a depression and
congestion round it. In the preparation the place of
perforation is visible as a small thinned area of mucous
membrane with a pin-hole aperture in it situated at the
back of the cricoid cartilage and to the left. The seat
of the wound in the carotid was three quarters of an inch
below the bifurcation. The artery has been laid open.
The clot in the lower part of the divided vessels decolor-
ised by the action of the spirit is still present, whilst tin-
scanty clot in the upper part has nearly disappeared.
The pneumogastric nerve is seen closely adherent to the
upper segment, and looking externally like a branch of the
artery. (See woodcut, p. 75.)
Remarks. — Several reflections are suggested by the
case itself.
1. The diagnosis was tolerably clear. We had tho
history of a swallowed fish-bone, the continuance of pain,
the visit to the hospital receiving-room with the passage
of a probang by which it was rendered probable that the
bone had been pushed through the mucous membrane,
tho local pain and inflammatory symptoms, tho pyrexia,
and the indications of interference with the carotid artery
LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
/O
and adjacent nerves, viz. the lump in the neck opposite
the cricoid cartilage, the oedema of the eyelids, tenderness
and rigidity of the neck, inability to swallow solid food,
the profuse salivation, the earache on the left side, and,
lastly, the attacks of haemorrhage by which the patient's
life was endangered.
2. The diagnosis being established, surgical interference
was necessary to prevent death by recurrent haemor-
rhage.
a. Left common carotid artery.
b. Pneumogastric nerve, adherent to artery below.
c. Internal jugular vein.
d. Fish bone. This should have been represented as hanging clown
obliquely and entering the artery at a rather lower point.
7(5 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
3. The operation was undoubtedly a difficult one, partly
by reason of the relatively small size of the parts in a
patient only nine years of age, but mainly because of the
preceding inflammation, formation of adhesions, and that
staining of all the tissues of a uniformly dark colour by
imbibition of blood which rendered it almost impracticable
to distinguish one vessel from another, and, in the absence
of pulsation, nerve from blood-vessel. Add to this the
necessity imposed upon the operator to ligature the artery
as speedily as possible, so soon as the clot which tempo-
rarily arrested the haemorrhage was removed.
Under conditions of this kind it is a great advantage
to be able to command the services of a skilled assistant
who knows what to do, and does it without instruction,
and I acknowledge with pleasure the assistance rendered
to me by Mr. Adams.
4. It was suggested by Dr. Sutton from the appear-
ances presented by the abscesses in the brain that they
had commenced to form before the operation, and this
view is corroborated by the previously existing drowsiness
and the difficulty experienced by the patient in turning
round in bed. Moreover, clot had abundantly formed at
the site of the wound in the vessel and round the fish-bone,
and some particles may have been carried up to the brain
and arrested in the smaller vessels.
5. I cannot trace any marked ill-effects to the inclusion
of the adherent vagus in the ligature, and its subsequent
section. Slight cough and some difficulty in swallowing
may be attributed to the occurrence, but I do not think
thai it either determined or hastened the fatal termination.
Death resulted from the gangrenous abscesses in the
brain, and if these were already in progress prior to the
operation, nothing remains but the amounl of blood Losl
at the operation to be placed on the debit side of the
account. There were cue OT two free gushes of blood
from the distal side of the wounded artery bet'.. re it was
secured, but whilst admitting the difficulty of an accurate
estimate I do not think that more than four or five ounces
LIGATUEE OF THE LEFT COMMON CAROTID ARTERY. 77
were lost during the operation. The loss prior to the
operation was far more serious, the patient being as thin
and ill-nourished a subject, and as ill adapted for a loss
of the kind, as one generally meets with in hospital prac-
tice.
6. The slight effects beyond the local paralysis resulting
from section of a single vagus, the absence of lung mischief,
oedema, and dyspnoea, accord with the results of experi-
ment, and with the negative effects in Mr. Savory's case
of " Abscess in the Neck"1 which, in its course, destroyed
a large portion of the carotid artery, jugular vein, and pneu-
mogastric nerve on the left side. Nevertheless, it seems
desirable to call special attention to the inclusion of the
pneumogastric in the ligature, because the occurrence may
furnish a useful hint for future operations. The liability
to the formation of adhesions between the vagus and the
carotid by inflammatory action set up by a foreign body,
and to displacement of the nerve forwards by the pressure
of accumulating clot may be usefully remembered by those
who are called upon to undertake ligature of the carotid
under similar or analogous circumstances.
7. Another point suggested is the danger involved in
incautiously passing bougies or probangs for the purpose of
clearing the pharynx or oesophagus of a fish-bone or other
sharp-pointed body. The history of the case seems to
justify an inference that the probang produced the injury
to the carotid by pushing the fish-bone through the wall of
the pharynx. A similar indictment must be brought
against this routine method in Dr. Cresswell Rich's case
of perforation of the carotid and in Dr. Waters's case of
perforation of the thoracic aorta by a fish-bone. In both,
oesophageal bougies or probangs had been employed in the
usual manner with aggravation of the symptoms. In Dr.
Waters's case a dessert-spoonful of blood was brought up
by the patient on the evening of the day on which the
probang was passed. The same point might be illustrated
1 ' Medico-Chirurgicnl Transactions,' vol. lxiv, 1861, p. 21.
78 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
from other cases in which propulsion was attempted.
"Wagret's case is the most striking. " After a physician
had made attempts at the propulsion of the bone, the
patient experienced entire relief, and said to his benefactor
that he thanked him very much, and that he had saved
his life. A few days later the patient died from per-
foration of the descending aorta."1
Improved methods of illumination of the pharynx and
oesophagus, the more general use of the laryngoscope and
cesophagoscope, exploration with the finger, and the em-
ployment of appropriate forceps, may be expected to limit
the area within which probangs have wrought mischief.
The value of the cesophagoscope invented by Mackenzie
is shown by the case which he relates, where at a second
sitting he was able to detect and remove from the anterior
wall of the oesophagus, about two inches below the cricoid
cartilage, a flat lamella of bone about four millimetres
square with a small piece of decayed meat adherent to it."
At pi'esent the chief drawback to the use of the cesophago-
scope is the irritation occasioned by its introduction, and
this is so pronounced that patients who have once experi-
enced it have declined to submit to it again. For sur-
mounting this obstacle a general anesthetic is not applic-
able as it then becomes difficult to place the patient in a
favorable position for tin- illumination of the oesophagus.
Better hopes, perhaps, may be entertained of the now
local anaesthetic, cocaine, which has already been employed
with success in iniuor operations in the nasal pas-
mouth, pharynx, larynx, and rectum, as well as on the
conjunctiva. Pending the extraction of the offending body
or its passage into the Btomach the die! of the patienl
should be carefully regulated. Hard solid substances
should be prohibited ami the patienl should be restricted
to slops, bread and milk, arrowroot, gruel, &C. The ex-
hibition of demulcents like barley water, glycerine, cod-
liver and other oils might assist materially in disengaging
1 Ponlet, ' Foreign Bodiea in Surgery,' vol. i, i>. '.'3.
3 Op. tit., vol. ii, p 198.
LIGATURE OF THE LEFT COMMON CAROTID ARTERY. /9
a small foreign body like a pin or fish-bone clinging to
the mucous membrane. If it is necessary to use a pro-
bang, the least objectionable and most efficient is the ex-
panding probang or ramoneur for withdrawing the body
through the mouth. On looking over the cases in the
Appendix, and comparing them with each other and
with my own case, the following considerations are sug-
gested :
1. The cases which bear the closest resemblance to the
one I have related are the cases of Dr. Reid, Mr. Cripps,
and Dr. Cresswell Rich, in which the carotid was per-
forated by fish-bones, and that related by Mr. Bell, of Barr-
head, in which a fine sewing needle transfixed the oesophagus
and right carotid. In none of these cases, however, was
an operation performed.
2. The nature of the foreign body and the size of the
vessel injured mainly determine the period at which
haemorrhage appears and death takes place.
(a) When the foreign body is very sharp and pointed,
or has a sharp pointed projection or a cutting edge, and
the artery implicated is the aorta or one of its large
branches, death may occur suddenly or in the course of
twenty-four or forty-eight hours.
Mr. Colles's patient, a man fifty-six years of age, entered
St. Stephen's Hospital on March 30th, 1855. Whilst eating,
the patient had experienced a sensation of rupture in the
chest, and this pain increased very much during degluti-
tion. Almost immediately afterwards he began to spit
blood in large quantity, at first black and then ruddy ;
the day following the accident he vomited a bone, about
an inch long, irregular and with cutting edges, and died
the same day at 9 o'clock. A vertical rupture of the pos-
terior wall of the oesophagus was found, corresponding to
a rent in the wall of the aorta.
Dr. Hume Spry's patient swallowed a piece of bone.
Two days afterwards he was very ill, pale, anxious, and
with severe radiating pain, and in the evening he vomited
an enormous quantity of blood and fell back on his pillow
80 LIGATURE OF THE LEFT COMMON CAROTID ARTERY.
dead. The spicule of bone had perforated the oesophagus
and wounded the arch of the aorta, and it was found in
situ.
In other cases an interval of a few days elapses before
spitting or vomiting of blood occurs, the fatal issue
ranging in its date from six or eight days to two or three
weeks from the accident. In one or two cases where the
vessel was opened by a gradual process of ulceration the
duration of the case has been proportionately lengthened.
(h) If the body is rounded and blunt the implication
of an important vessel is usually the effect of ulceration,
and does not occur, perhaps, for some months after
impaction. In the case of Mr. C. L. Bradley's " smasher "
the impaction of a counterfeit half-crown in the oeso-
phagus occasioned death from sudden and profuse haemor-
rhage from the aorta eight months after the coin had
been swallowed, and Mr. Erichsen has recorded an inter-
esting case in which a piece of gutta percha, belonging to
a masticatory apparatus was arrested in the oesophagus,
and opened a large oesophageal vessel, six months after
the patient had swallowed it.
(c) Even with a blunt body, however, retained in the
oesophagus, fatal haemorrhage may occur in fourteen or
fifteen days. This happened to the unfortunate Corporal
M — , who had been in the habit of swallowing six-franc
pieces for the amusement of his comrades, usually evacua-
ting them in a few days after a dose of salts. Ho
repeated the experiment once too often, and perished from
abundant vomiting of blood on the fifteenth day. The
coin was found in the oesophagus, opposite the bifurcation
of the trachea, lying on edge between two erosions, one
of which communicated with the aorta.
3. Forcible efforts at extraction of the foreign body, or
at propulsion into the stomach, may act injuriously in
several ways. They may cause the foreign body to BCrape
or lacerate the mucous membrane, and lay the foundation
for subsequent inflammation and ulceration into a neigh-
bouring and perhaps adherent blood-vessel ; they may
LIGATURE OP THE LEFT COMMON CAROTID ARTERY. 81
push the body through the coats of the pharynx or oeso-
phagus and make it penetrate a vessel which otherwise might
have escaped injury ; they may enlarge a pre-existing
laceration of the alimentary canal, and a puncture of a
wounded vessel, and lastly they may displace the foreign
body from the opening which it is partly plugging and
thus hasten the fatal issue.
4. The chief points and symptoms which will assist
the surgeon in coming to a right conclusion as to the pre-
sence of a foreign body in the pharynx or oesophagus, in
determining the situation of the body, and in deciding
upon the measures to be taken for its removal, are the
following : A definite history of a foreign body having
been swallowed ; persistence of pain and more or less
fixed pain referred to one spot, although radiating twinges
may be felt in other directions ; dysphagia, and especially
continued inability to swallow solids ; salivation and
dribbling of saliva from the mouth ; failure of the foreign
body to pass per anurn or to be returned through the
mouth ; expectoration or vomiting of blood, passage of
blood by stool, and fainting fits due to hasmorrhage into
the alimentary canal. When the foreign body is situated
in the neck there will probably be added some local swel-
ling and tenderness or more marked inflammatory signs
along the course of the affected vessel.
5. I think it may be concluded that foreign bodies like
needles, pins, bristles, and fish-bones which are ai'rested at
the commencement of the oesophagus ought to be capable
of extraction by the aid of artificial illumination and for-
ceps, and, failing these, by the ramoneur.
Lower down, as at the root of the neck or opposite the
arch of the aorta, the continued presence of a foreign body
which cannot descend into the stomach under the general
means of management indicated above, and which cannot
safely be pushed onwards or withdrawn through the
mouth, ought to lead the surgeon to the eai-ly consideration
of the question of an exploratory oesophagotomy. On
this subject M. Nevot wrote in 1879 that he believed that
vol. lxix. 6
82 LIGATURE OF THE LEFT COMMON CAEOT1D AIMEI'.Y.
cesophagotomy could render great service in a large
number of cases, and he adduced the following instructive
instance of its utility : — " On the 14th of February, 1848,
M. Lavacherie was called to attend a man named Pascal
Dombat, who had swallowed a bone. He practised ceso-
phagotomy with success, found the oesophagus perforated,
and the point of the bone in relation Avith the left common
carotid, which was still undamaged. There can be no
doubt that in this case the operation rescued the unfortu-
nate Dombat from certain death."1
G. The brief duration of many of these cases, then-
rapid course after haemorrhage has appeared, and their
almost invariably fatal issue, prove the necessity for the
utmost promptitude and sagacity on the part of the
medical attendant. When haemorrhage has commenced
the life of the patient will hang upon a thread, and the
best and only hope of recovery will lie in immediate sur-
gical interference if the wounded vessel can be reached.
The services of the surgeon should be sought without
further delay, before any considerable quantity of blood
has been lost, and before the foundation has been laid for
embolism of the cerebral arteries, blood-poisoning, or
abscess of the brain, which would nullify all his efforts
to rescue the sufferer from impending death.
1 " Dc la Perforation de Vaisseaux par les corps ctrangcrs de I'GEsophage,"
' These de Paris,' 187!', p. 50.
(For report of tin' discussion on this paper. ?<■<• ' Proceedings "fthe
Royal Medical and Ohirurgical Society,1 New Series, voL ii, p. 8.)
APPENDIX. 83
APPENDIX.
Cases Nos. 1—10, 14, 21, 25, 26, 28, 29, and 42—44 were taken
from Nevot's treatise, and the details are quoted from hiin. The
references, however, have been verified and corrected.
I. Perforations of the Aorta.
1. Wagret, Obs. de Med. et de Chir., 1718.
Male, set. 38, swallowed a large bone with a pointed extremity.
Rent in mid part of oesophagus and aorta. Bone found in jejunum.
2. Laurencin (' Arch. gen. de Med.,' 1824, t. vi, p. 302).
Male, who had swallowed bone eight or ten days before, entered
the hospital with symptoms of left pneumonia. On tenth day
vomiting of blood and death in five minutes. (Esophagus perforated,
and ulceration of aorta, two inches from the great curvature.
3. Dubreuil de Brest (' Journ. Universel,' t. ix, 18] 8, p. 357).
Soldier swallowed bone. On night of fifteenth or sixteenth day
vomiting of bright red blood. Sudden death. (Esophagus and aorta
perforated half an inch below the arch. Bone found between oeso-
phagus and aorta.
4. Bevolat (' Ann. de Soc. de Med. Prat, de Montpellier,' t. iv, p.
114).
Grenadier swallowed bone ; after twenty-one days copious vomit-
ing of blood, and death. Stomach full of blood ; two perforations,
one at the superior fourth of the oesophagus, and the other towards
the cardiac orifice of the stomach. The vessel which had furnished
the blood was not looked for.
5. Lavacherie (' Mem. de l'Acad. de Med. Beige,' t. ii, 1848, p. 91).
Male, aet. 18, swallowed a fragment of bone 29th May, 1839.
Immediate catheterism discovered nothing. Six days later nausea
and vomiting of blood. A small fragment of bone found in a
vomited clot. June 10th, two fainting fits. June 16th, abundant
vomiting of blood, lasting for two hours and followed by death.
6. Hugues (' Lyon Medicale,' t. v., 1870, p. 552).
Mule, 3et. 32, swallowed a flat triangular bone, apparently without
knowing it. Some days after he came into hospital complaining of
some ill-defined malady. Fourteen days later vomiting of blood and
84 APPENDIX.
hemorrhagic stools. Death next day. Perforation 01 oesophagus
and aorta. Bone found in situ.
7. Theron (' Gaz. des Hopitaux,' 1862, p. 182).
Male, a;t. 2:2, swallowed something, probably a fish-bone. Ulcera-
tion of oesophagus followed at length by that of the aorta.
Duration of case some months.
8. Stetter (' Langenbeck's Archiv,' Bd. xxii, 1878.. p. 959).
Male, set. 26, swallowed bone in soup. Sharp pain, which swallow-
ing increased. (Esophageal sound introduced. At fifth attempt it
was pushed strongly and penetrated into the stomach. The patient
said he no longer felt anything. Three days later he returned
complaining of pain between the shoulders. The sound passed
easily, only causing pain in the middle of the oesophagus. Patient
went into hospital and left nine days later, saying he was quite
cured. He returned to work. Three days later copious hamate-
mesis and death in five and a half hours. Double perforation of the
oesophagus at level of bifurcation of the bronchi extending from
right to left, and very small perforation of the descending aorta
2 \ centimetres from the left subclavian. An angular thin piece of
bone was found there. Stomach and intestines filled with blood.
9. Miennee (' Gaz. des Hopitaux,' 1851, p. 89).
Soldier, set. 25, swallowed bone whilst eating soup. Pain in
deglutition. Seven days after, vomiting of red frothy blood and
bloody stools. Death in the evening. Perforation of the oeso-
phagus and aorta below the arch by a flat triangular piece of bone
3 centimetres in diameter.
10. Bawrnwn f'Rec. de Med. Mil.,' 1825, t. rvi, p. 245).
Male swallowed piece of bone an inch long, eight or ten days
before going into the hospital. There were Bymptoms of left pneu-
monia, and a painful spot behind near the vertebral column. On
the tenth day he was seized with cough, vomited blood, and died in
five minutes. In the middle of the cheat there was an opening in
the oesophagus as large as a twenty-aoua piece, and an ulceration of
the aorta two inches below the arch. A small bone an inch in
length, with a pointed extremity, was found to the right of the aortifl
opening.
(N.B. This case is certainly identical with Laurencin's above
given.)
11. C. Laurence Bradley (,' Med. Times and Gazette,' vol. ii, 1SG8,
p. 447).
APPENDIX. 85
Male, set. 21, swallowed a counterfeit coin. This was followed by
vague pains in tlie chest and other symptoms, which were regarded
as dyspeptic. He also had a slight cough without expectoration.
Eight months after the coin had been swallowed death occurred from
sudden and profuse haemorrhage from the aorta.
12. Martin (' Pecueil de Medecine Militaire,' t. xx). Poulet,
(translation") vol. i, pp. 75 and 94.
Corporal M — had several times swallowed six-franc pieces for
the amusement of his comrades, evacuating them in a few days after
a dose of salts. He repeated the experiment, and perished from
abundant vomiting of blood on the fifteenth day. The coin was found
in the oesophagus opposite the bifurcation of the bronchi, lying on
edge between two erosions which communicated with the aorta.
13. Lancet, Nov. 24th, 1877, p. 789.
In November, 1877, Dr. "White, City Coroner for Dublin, held an
inquest at the Richmond Lunatic Asylum on the body of an inmate
named Nolan, aged forty-seven, who had died suddenly in that insti-
tution. After the evidence obtained, the jury found that the
deceased came by her death in consequence of haemorrhage from a
punctured wound in the aorta caused by a sewing needle which she
had swallowed. Part of the sewing needle was found embedded in
the oesophagus, covered with rust.
(In Poulet's work, vol. i, p. 91, Nolan is called Yolon and the sex
is changed.)
14. M. Denonvilliers (' Bull. Soc. de Chir.,' t. vi, 1856, p. 349).
Male swallowed in jest a five-franc piece. The foreign body caused
ulceration of the oesophagus and perforation of the aorta. Copious
vomiting of blood carried off the patient. The coin was found
resting partly in the oesophagus and partly in the aorta.
15. Duncan ('Northern Journal of Medicine,' 1844, vol. i, p. 15).
Male, aat. 22, swallowed in his sleep a gold plate carrying some
artificial teeth. He suffered from dysphagia, fixed pain, and expec-
toration of small quantities of blood. Soon after the accident he
consulted Mr. Syme, who detected the foreign body in the oesophagus
with a probang, and subsequently, when the patient had been
removed to the hospital, made an attempt to draw it up with threads
passing through the bulb of the probang. Nothing was detected or
removed by this manoeuvre, and the patient experiencing consider-
able relief it was believed that the plate had found its way into the
stomach, and it was considered inexpedient to make any further
86 APPENDIX.
examination. Ten days after the accident the patient vomited the
tooth-plate, but a few minutes afterwards expired from haemorrhage.
An ulcei-ated perforation, communicating with the arch of the aorta,
half an inch below the origin of the left subclavian artery, was found
in the anterior wall of the oesophagus.
16. Hume Spry (' Path. Trans.,' vol. xix, p. 219) .
Male swallowed a sharp spicula of bone. Two days afterwards he
was very ill, pale, anxious, and with severe radiating pain, and in
the evening he vomited an enormous quantity of blood and fell back
on his pillow dead. The spicula of bone had perforated the oesophagus
and wounded the arch of the aorta and it was found in situ,.
17. William Colles ('Dub. Quart. Jour, of Med. Science,' 1855,
vol. xix, p. 325).
Male, ait. 56, entered Steeven's Hospital on March 30th. ls.V>.
Whilst eating, the patient had experienced sensation of rupture in
the chest and this pain increased very much during deglutition.
Almost immediately afterwards he began to spit blood in large quan-
tities, at first black ami then ruddy. The day following the accident
he vomited a bone about an inch lung, irregular, and with cutting
edges. He died the same day at 9 o'clock. Blood was found in the
pleura, pericardium, and posterior mediastinum, blood in the stomach
and small intestines, and a vertical rupture of the posterior wall of
the oesophagus half an inch long corresponding to a rent in the wall
of the aorta.
18. BamsMl (' Lancet,' 1ST1, i. p. 016).
Male swallowed a fish-bone wliieh lodged in his throat. He went
at once to the London Hospital, but returned without having had it
removed. On reaching home he took to his bed, and complained of
pain in his chest. He soon afterwards felt sick and began t.i retch
without actually vomiting. The day before admission, feeling some-
what better, he sat up for a couple of hours, but on returning to bed
felt much worse and complained of great pain across the region of
the stomach. He passed a very restless night, and in the morning
whilst coughing vomited a quantity of dark-coloured coagulated
blood, amounting to three quarts, according to the estimate of his
friends, lie was taken to the hospital and admitted under Dr.
l; tmskill, but died the same evening, alter bringing up a greal quan-
tity of arterial blood together with blood-clot. At the post-mortem
examination Dr. Sutton found at the level of the fourth dorsal
vertebra two perforating ulcers in the oesophagus; one on the left
side communicated with the aorta by an opening which admitted a
APPENDIX. 87
probe, whilst the other had extended through the oesophagus and
caused thickening round the vena azygos, which was plugged with
blood-clot.
19. Museum of St. Bartholomew's Hospital (Catalogue).
No. 1376 is a preparation showing a ragged laceration of the aorta
beyond the origin of the left subclavian involving more than half its
circumference. It was taken from the body of a middle-aged man,
who after eating some fish complained of constant pain behind the
first bone of the sternum. Every day he spat up blood, for the most
part bright red, sometimes dark, and a large quantity passed per
anum. He died from exhaustion. At the post-mortem a lance-
shaped fish-bone was found transfixing the oesophagus and the arch
of the aorta. It was evident that the lacerated wound of the vessel
had been produced by the movement of the artery as it pulsated on
the point of the fish-bone.
20. Auvert (' Selecta Praxis Med. Chi.,' Paris, 1851).
Male swallowed a fish-bone. All the symptoms of a foreign body,
and some expectorations of blood. On the third day copious haemor-
rhage carried off the patient. Anterior wall of oesophagus perforated
and the aorta near the arch.
21. Bousquet (' Bull, de la Soc. Anat.,' 1877, p. 317).
Soldier entered the hospital for pleuro-bronchitis of six days'
standing, on 20th March, 1877. On the 11th April, he asked to be
allowed to go out, but his medical attendant declined. Next day he
had vomiting of blood, and bloody stools. He died on the 13th.
The oesophagus aud aorta were both perforated, and the former con-
tained a sharp-edged fish-bone 2 centimetres long.
22. Dr. Waters, Liverpool Royal Infirmary, 1879. Communicated
by Mr. Paul.
Mary Hazelton, aet. 55, swallowed a fish-bone, which became
impacted in the oesophagus, four days before her admission into the
Royal Infirmary. On admission, 26th November, 1879, she com-
plained of great pain in the chest, opposite the lower end of the
sternum. Deglutition was very painful and difficult. An oesopha-
geal bougie was passed without a hitch, but she brought up a dessert-
spoonful of blood the same evening. Nov. 29th, temp. 103-4°, dulness
and tubular breathing in the interscapular region. Nov. 30, 8 p.m.,
temp. 1048°. At 11 p.m., a sudden, small haemorrhage from the
mouth followed by death, almost immediately, from syncope. Post-
mortem examination. — Stomach and duodenum distended with blood-
88 APPENDIX.
clot, weighing 2| lbs., and forming an accurate cast of their cavities.
Jast at the junction of the transverse with the descending part of the
arch of the aorta was a perforation that would have admitted a No.
10 catheter ; the opening passed into a foetid, inflammatory swelling
between it and the oesophagus and surrounding the parts about the
roots of the lungs, accounting no doubt for the dulness noticed in
the interscapular region. The opening passed directly through this
foetid cellulitis into the oesophagus, where it was large enough to
admit the little finger. No fish-bone could be found. Probably it
had been washed away in the gush of blood.
23. Aschenb&rn (' Berliner klin. Wochens.,' 1S77. t. xiv, p. 725),
'Lond. Med. Record,' vol. vi, 1878, p. 21, quoted by Durham, in
Holmes and Hulke's ' System of Surgery,' vol. i, p. 787.
A young man swallowed a hard morsel of bread containing, appa-
rently, a needle two inches long. The oesophagus was penetrated
and the aorta transfixed. Blood was passed by stool on the ninth
and tenth days, and the patient succumbed in a few minutes on the
eleventh day from a copious hajinorrhage from the mouth.
II. Perforation of an Undetermined Artery.
24. Erichscn (' Science and Art of Surgery,' 8th ed., vol. ii, p. GG1).
Male swallowed a piece of gutta percha, part of an artificial masl i-
catory apparatus. A few days after examined by a Burgeon, who
could not detect any foreign body. Inability to swallow solids. Six
months later examined by Mr. Erichsen, who (ailed also to disc \.r
the body. One day while at dinner the patient suddenly vomited a
large quantity of blood, and fell down dead. The gutta jiereha had
formed for itself a bed in the wall of the oesophagus, and lay parallel
with the inside of the tube. The oesophageal vessel opened was not
ascertained. The carotid arteries and jugular veins were 1 1> «t i in j li-
cated. The surface of the gutta percha, which looked towards the
(esophagus, being constantly covered and BmOOthed over by niueus,
ami protected by a rim of swollen mucous membrane, had allowed
the probang to glide smoothly over it.
III. Perforation of (Esophageal Artery.
25. Monesiier ('Bull, de la Boo. Anal.." vol. viii. 1 -:::;. p. .:
Young female eating cabbage, swallowed a piece <■! the verb
of a pig. This caused a slough involving an oesophageal artery.
APPENDIX. 89
On the separation of the slough slow effusion of blood took place
into the stomach, which relieved itself from time to time by
vomiting and stool. The patient died suddenly at the end of three
weeks.
IY. Perforation of Inferior Thyroid.
26. Pilate ('Bull, de la Soc. Anat. de Paris,' 1867, p. 648).
Female, set. 55, swallowed a piece of bone ; slight pain in swallow-
ing. Eight days later she entered the hospital. Soon after haema-
temesis and frequent and copious bloody stools. Death in a short
time. A piece of bone 3 centimetres long and 3 millimetres broad,
with one end pointed, lay horizontally across the oesophagus at the
inferior border of the cricoid cartilage. The lateral walls of the
cesophagus were perforated and the adherent thyroid gland formed
the base of the oesophageal ulcerations. One of the branches of the
right inferior thyroid was involved.
Y. Perforation of Carotid.
(a) Left Carotid.
27. Begin, quoted by Dr. James Duncan, ' Northern Journal of
Medicine,' vol. i, p. 20.
Male, while eating soup, swallowed a piece of bone, which stuck
in the oesophagus ; attempts to push it on towards the stomach were
made and appeared to be successful. No further inconvenience was
experienced till a month later, when he had sharp pains on the left
side of his neck which continued with slight intermissions for some
time. Everything seemed to be going on well, when he suddenly
threw up large quantities of blood, perhaps to the amount of several
pounds The hasniorrhage presently ceased, but the next day it
returned and proved fatal. On examining the body there was found
in the cesophagus, about its upper third part, two parallel ulcerations,
that on the right side nine lines in breadth, that on the left twelve;
opposite the latter there was an adhesion between the oesophagus
and the corresponding part of the carotid. In this vessel erosion
had produced a small opening, about a line in diameter, which
proved to be the source of the haemorrhage. In all probability the
ulcerations were due to scraping or tearing the mucous membrane
during the operation of pushing the bone into the stomach with a
probang.
28. Auvert, op. cit.
Perforation of oesophagus and left common carotid. Death.
90 APPENDIX.
29. Dumoastier (' Recueil de Mod. Militaire,' 1828, t. viii, p. 231).
Male swallowed a beef-bone while eating soup. He entered the
hospital on 18th April. 1820, complaining of sharp pain in the upper
third of the oesophagus. Attempts at propulsion were made, great
i mprovement followed, and patient left on the 18th of May. He came
again on June 14th and stayed a few days. On 18th July he again
returned ; since accident he had experienced pain at anterior part
and left of neck. No fresh symptom till 27th, when copious ha^ma-
temesis occurred, recurring on 28th ; he died on the 29th. At the
upper third of the oesophagus were two parallel ulcerations, and
there was a small hole in the left carotid united to the oesophagus
by adhesions.
30. Beid (' Ed. Med. and Surg. Journal,' vol. xlviii, 1837, p. 95).
George B — , set. 27, tailor, was eating fish when a bone was arrested
in his thi-oat. The following day, he saw a surgeon who did not think
there was any bone in the case, but attributed the pain and irritat i < «ii
to inflammation of the parts brought on by a fit of intemperance.
At this time there was much pain and some tumefaction in the throat,
and the patient could not swallow his spittle, which flowed from the
angle of his mouth into a cup as he lay on his side. The next day
he was twice bled to a soup-plate full, and on the fourth day was
blistered over the sternum. On the fifth day there was tumefaction
over the whole of the cervical region and he was bled again to a soup-
plate full. On the eleventh day he was sick and vomited about a
pint of fluid blood, not in the least coagulated. The sickness and
vomiting <>f Mood recurred the following morning. At 5 a.m. on
the thirteenth day he awoke from Bleep very Bick, and just as he was
al» mt tn gel a c u] > fu] of tea he gave a groan and immediately expired.
without external symptoms of haemorrhage. At the post-mortem
the stomach was found filled with blood. An inch above the left
stcrno-clavicular articulation two slightly ulcerated openings were
found on each side of the tube. The Left carotid adhered to the
OB80phagUS and had in it a longitudinal opening to the extent of a
quarter of an inch. The right carotid was sound. The fish-bone
was not found.
31. H. C. Johnson, Durham, op. eit., p. 745.
Boy, a;t. 7, sustained a penetrating wound on the left side of the
pharynx, through falling whilst he held the sharp end of a parasol in
his mouth. The point was thrust so forcibly hack wards tliat it
nearly nunc' its appearance through the skin at the Bide of the neck.
Considerable lueniorrhage took place at once, and recurred at night.
About the 7th or 8th a slough came from the interior of the mouth.
APPENDIX. 91
and arterial haemorrhage to the extent of five ounces, and was
arrested by external pressure. Soon afterwards the boy was admitted
into St. George's Hospital, and a fluctuating swelling as large as half
a hen's egg below and behind the left ear was opened, giving exit to
pus and blood-clot. Two days later a gush of arterial blood followed
a fit of coughing. Mr. H. C. Johnson tied the common carotid. No
farther haemorrhage occurred, and the patient was discharged cured
twenty-seven days after the operation.
32. Dr. Cresswell Rich and Mr. Paul, Liverpool. Preparation in
museum of Liverpool School of Medicine.
Boy, aat. 6, had fluke for dinner on February 23rd, 1883. An hour
afterwards he complained of something sticking in his throat. He
was taken to a dispensary and told that the bone had been pushed
down by an instrument. He continued unable to eat solids. Five
days after the accident castor-oil was given to him, and an hour
after taking it he vomited clotted blood. He was taken to the Infir-
mary, vomiting blood all the way. On reaching the hospital he was
in a faint, the surface of the body and the face being livid and blue.
Ergotine was subcutaneously injected. He became alternately con-
scious and unconscious and continued to vomit blood at intervals
till death took place on the following day.
Post-mortem examination. — Well -nourished boy. On anterior wall
of gullet, opposite the commencement of the trachea, there was a
perforation of the size to admit a No. 8 catheter. It was circular,
had a punched-out appearance, with perpendicular edge raised inside,
and of a purplish red colour. There was neither discoloration of the
surrounding mucous membrane nor undermining or separation of
the coats of the oesophagus. There was no adhesion between the
gullet and the left common carotid artery, but there was an opening
in the vessel of the same size as that in the gullet. The vein was
not injured. All the organs were very anasmic. No fish-bone or
other foreign body was found ; it had probably been washed away in
a gush of blood. The mucous membrane of the alimentary canal was
healthy, and there was no sign of any haemorrhage from it. The
large bowel was full of altered blood.
33. Rivington, 'Med.-Chir. Trans.' (Case described in present
paper.)
(b) Not stated, but probably Left Carotid.
34. Cripps (' Lancet,' 1878, vol. i, p. 834).
In the discussion at the Clinical Society on the 24th May, 1878,
92 APPENDIX.
on Dr. McKeown's paper on a successful case of oesophagotomy for
the removal of a set of artificial teeth from the oesophagus, impacted
at the lower part of the neck, Mr. Cripps related a case in which a
small fish-bone had been swallowed. Some pain was felt for a week,
but no other inconvenience, when suddenly a short time after
severe pain occurred, followed by a gush of blood from the mouth
and rapid death, which was found to have been due to the bone
having perforated the oesophagus and caused ulceration of the
carotid at its bifurcation.
35. Fingerhuth, quoted by Mackenzie, 'Diseases of Throat and
Nose,' vol. i, p. 109. Quoted also by Durham, op. cit.; p. 78-t.
A piece of tobacco pipe was lodged in the side of the pharynx, and
after an interval of eight months occasioned fatal hajuiorrhage by
wounding the carotid in a sudden movement of the head.
(c) Left Ascending Pharyngeal.
36. Mr. Morrant Baker (' St. Bartholomew's Hosp. Reports,' vol.
xii, 1876, p. 163).
Man, a?t. 23, fell with a clay pipe in his mouth. Two days after-
wards he applied at St. Bartholomew's Hospital for sore-throat.
The case was at first thought to be medical, but was subsequently
transferred to the house surgeon as a case of abscess of the tonsil.
The supposed abscess was punctured and only blood escaped. In the
evening several more ounces of blood escaped from his mouth. Two days
afterwards nearly a pint of blood was lost and a cavity found in the left
side of the pharynx was plugged. The next day haemorrhage recurred,
and on examination under anesthesia a piece of tobacco pipe three
quarters of an inch Long was found in the tonsil. This was removed
and the cavity plugged. The common carotid was then tied, but th.«
patient died in three hours. At the post-mortem an irregular cavity
was found above and behind the left tonsil. The interna] carotid
lay about one eighth of an Inch away from the cavity and h.ul not
been wounded. Into the cavity no artery could be traced, hut the
ascending pharyngeal appeared to terminate abruptly just at its
edge and was stained by perchloride of iron.
(t/) Bight Carotid.
37. Bell, of Barrhead ('Lond. Med. Gas.,* n.B.,vol. i, L843, p. 694).
Lad, Bet. Is1. swallowed a sharp body (as he thought, a pin) whilst
he was eating sonic oatmeal porridge, and fell it sticking in Ins
throat. He began to Bpit blood on the ninth day at t> p.m.. and at
APPENDIX. 93
11 p.m. brought up a soup-plate full. He kept spitting up mouth-
fuls till the next morning, when he vomited a large quantity, and
died. The cesophagus was transfixed opposite the middle of the
thyroid cartilage by a fine sewing needle three inches long, its
point resting against the right common carotid artery. The walls
of the vessel were destroyed, and a considerable opening, communi-
cating with the oesophagus, had been made in the vessel, the internal
coat of which had disappeared for one and a half inches, and was
quite rotten. An ounce of pus and blood was found between the
cesophagus and the artery.
(e) Both Carotids.
38. Guthrie (' Wounds and Injuries of Arteries,' p. 77).
A soldier swallowed an instrument composed of two half phial
corks, fastened together with strong thread and with three pins
thrust through each, so that the pins projected on each side. This
machine became entangled at the commencement of the cesophagus,
and caused death from haemorrhage after the lapse of some days.
The patient at first complained of some difficulty of breathing and
uneasiness in the chest. The fauces became slightly reddened and
inflamed and he was utterly incapable of swallowing anything but
liquids. This was followed by ptyalism and soon by spitting of
blood of a light scarlet colour, without any cough ; increasing in quan-
tity daily, until he brought up six or eight ounces. A day or two
afterwards the blood poured out of his mouth so rapidly that Guthrie
was sent for. He arrived in time to see the blood fill a chamber-pot,
when the patient fell back, dead. The instrument rested across the
cesophagus so that the points of the pins were close to the carotid
arteries, and having by degrees given rise to ulceration of the oeso-
phagus, wounded them on both sides. Every elongation or pulsation
of the arteries had brought them against the point of one or more of
the pins, the marks of which were observable in several small holes
of different sizes on the sides of the vessels. As one or two of these
became larger from the constant attrition, blood came through into
the cesophagus, and as they again increased by ulceration, larger
holes were formed from which the sudden and fatal haemorrhage
took place. Guthrie adds, " The instrument and the arteries I sent
from North America to the late Dr. Hooper, and they ought to be in
the museum of King's College."
94 APPENDIX.
VI. Perforation op Right Subclavian (abnormal).
39. Kirby (' Dublin Hospital Reports,' t. ii, p. 224).
A poor woman, one of those miserable creatures who feed in the
streets of Dublin upon the mixed offal which they receive from ser-
vants, was greedily enjoying such wretched fare, when a morsel
stuck in the oesophagus. She was taken to St. Peter's and St.
Bridget's Hospitals, but died before Mr. Kirby arrived. Trache-
otomy and artificial respiration were of no service. At the post-
mortem two large morsels of food were found in the oesophagus, one
below the cricoid cartilage and the other as low down as the upper
extremity of the sternum. The latter morsel contained a piece of
bone, an inch and a half long, one of its ends being sharp and pointed.
The bone lay obliquely across the oesophagus, transfixing it at its
left and posterior part, and woundiug the right subclavian artery,
which, contrary to its usual course and origin, lay in this situation
as it passed from the left of the arch of the aorta, where it an >se
towards the i-ight shoulder. The surrounding cellular tissue was
filled with blood, which, accumulating principally at the sides of the
neck, had produced a remarkable fulness there noticed during the
previous examination of the patient.
VII. Perforation of Pulmonary Artery.
40. Bernast ('Jour. hebd. des Sci. Med.,' 1S33, also 'Lond. Med.
Gazette,' May 11th, 1833, p. 175, and Duncan, op. cit. .
A young soldier swallowed a sharp bone while taking soup. He
entered the Toulon Hospital, continued in great pain for some days,
and threw up some ounces of blood. He died on the eighth day. A
flattened sharp-pointed bone was found in front of the (esophagus,
which it had perforated, and there was a minute opening in the
pulmonary artery at its bifurcation. A large quantity ofextravasated
blood was found in the chest.
VIII. Perforation of Heart and Right Coronary Vein.
41. Andrew (' Lancet,1 vol. ii, 1860, p. 186 .
A woman was found on a doorstep in a dying Btate, and taken to
University College Hospital. The previous history could not be
gathered. At the post-mortem it was found that a fish-bone had
penetrated thestomach close to the oesophagus, then the diaphragm
and pericardium, and the posterior surface of the heart, and finally
inflicted a jagged wound in the middle of the septum immediately
Over the right coronary artery and rein, penetrating the latter vessel.
The pericardium was filled with a pint and a half of fluid bl< >0 1.
APPENDIX. 95
IX. Perforation of Demi-Azygos Yein.
42. Saucerotte (' Ann. de la Soc. de Med. pratique de Montpellier,'
t. ii, p. 247).
Carbineer swallowed a piece of bone. Sharp pain towards cardiac
orifice. Eight days afterwards Saucerotte introduced a wax bougie.
The bone was dislodged and returned by vomiting with much blood.
Death next day. The oesophagus was divided vertically for 3
centimetres at the level of the sixth rib, and a large vein, believed by
Saucerotte to be the demi-azygos, was implicated.
X. Perforations of Vena Cava, Superior and Inferior.
43. Laurent Lovadina ('Jour. Complem. du Diet, des Sciences Medi-
cales,' t. i, 1818, p. 93).
Male, set. 42, swallowed a bone, which was arrested at the back of
the throat and required much time and effort to make it descend into
the oesophagus. Angina, sharp pains at each respiration, and efforts
at vomiting persisted for ten days, when the patient, whilst raising
himself to make water, was seized suddenly with vomiting of blood
and expired.
Autopsy. — Great gangrenous patches upon the soft palate, pharynx,
and oesophagus. A little below the orifice of the gullet there was a
great rent, which was thought to have been produced by the sharp
angles of the bone. On the outer and towards the anterior part of
the vena cava superior was a rent an inch long and about an inch
from the right auricle. Another less extensive rupture was found
on the anterior face of the vena cava inferior before its entry into
the pericardium.
44. Coester (' Berliner klin. Wocb.,' 1870).
Male, oet. 56, complained on Nov. 11th of great pain radiating
from the epigastrium, loss of appetite, and oppression. Castor-oil
gave some relief. On the 17th the painful crisis returned, followed
by vomiting of blood and sudden death. The pleura and stomach
were found filled with blood. The oesophagus was perforated half
an inch above the diaphragm. In the perforation a rather large
pointed and cylindrical piece of bone was engaged. The descending
cava had contracted adhesions to the oesophagus and was perforated
like it.
45. Dr. H. Thompson (' Brit. Med. Journal,' 1874, vol. ii, p. 571),
quoted in text, p. 65.
SCARLATINAL ALBUMINURIA, AND THE
PRE- ALBUMINURIC STAGE,
STUDIED BY FREQUENT TESTING.
BY
E. STEVENSON THOMSON, B.Sc, M.B.,
LATE SENIOE BESIDENT ASSISTANT PHYSICIAN TO THE CITY OF GLASGOW
FEVEE HOSPITAL.
Communicated by De. VV. T. GAIRDNER, Glasgow.
Received April 11th— Read November 10th, 1885.
I purpose giving in the following paper a detailed
account of observations conducted upon 180 consecutive
cases of scarlet fever in the wards of the City of Glasgow
Fever Hospital. The ages of the patients ranged from
two to thirty-five years, the great majority (84 per cent.)
being under fifteen years of age. Of the cases examined
twelve died from all causes. The period of observation
extended over one year (1882-83) and involved the exa-
mination of upwards of 35,000 specimens of urine. Three
specimens of urine from each case under observation were
examined daily from the day of admission till dismissal
from hospital. The minimum period of residence imposed
by the sanitary authorities was fifty-six days,1 calcu-
Patients were occasionally dismissed a day or two before the completion
of their term, but more frequently they were kept beyond it.
VOL. LXIX. 7
98 SCARLATINAL ALBUMINURIA, ETC.,
lated from the first appearance of fever. In a few
chronic cases the investigations extended over a period of
from five to six months. Careful notes of the condition
of the urine were made daily till all traces of albumen
and blood-colouring matter had disappeared ; in one or
two instances, however, the patient was dismissed before
the return of the urine to its normal conditiou. The
samples were collected at 6 a.m., before breakfast ; at 12
noon, just before dinner ; and at 8 p.m. In this way the
slightest trace of any abnormal constituent could be
detected within a few hours of its appearance. Every
precaution as regards the cleanliness of vessels was taken
to ensure accuracy in the results. To eliminate as fully
as practicable errors arising in individual cases from so-
called " alimentary " albuminuria, the diet was made
uniform for each stage of the disease. The same object
was kept in view when the above-mentioned hours were
selected for collecting the urine. When thought neces-
sary specimens of urine were examined every three or
four hours; such cases were, however, exceptional.
The special interest of the investigation centred round tho
detection of minute quantities of blood-colouring matter,
of albumen, and of organic deposits of renal derivation.
For the detection of the first of these I for some time
employed both the spectroscope and the guaiacum test, but
soon gave up the former on account of tho difficulty
attending the detection by its means of very minute
quantities of blood in turbid urino. The difficulty is not
diminished when we turn to the microspeetmscopc, for
although with it a single red corpuscle will give the
characteristic bands, yet the time necessarily expended in
the search is too great for ordinary purposes. The guaia-
cum test on the other hand is exceedingly delicate, simple,
convenient, and reliable.1
1 The method employed in using the guaiacum test was thai usually fol-
lowed in the Glasgow School of Medicine (see ' Finlayson's Manual*): — To a
few drops of urine from the bottom of the orine-glasa a drop of tincture of
guaiacum is added; ozonic ether is then gradually poured into the tube until
STUDIED BY FREQUENT TESTING. 99
In testing for albumen, nitric acid in the cold was
chiefly relied upon on account of its convenience and the
rapidity with which a large number of specimens could be
tested in a comparatively short time. This test was
applied by a pipette very much in the same way as in the
case of the picric acid test described below. Before this
inquiry was begun I had, while resident assistant in the
Glasgow Western Infirmary, had ample opportunities for
studying the nitric acid test for albumen and all its well-
known fallacies. In cases where there was any doubt the
testing was checked by boiling with the after-addition of
acetic acid and also by the use of the picric acid test.
Of these tests picric acid is the most delicate, and nitric
acid in the cold seems to be inferior, as a rule, to the
boiling test. The best results were obtained with picric
acid when the urine to be tested was allowed to flow from
a pipette, the point of which rested on the bottom of a
test-tube containing a quantity of a saturated solution of
the acid, so that it fell to the bottom without much admix-
ture. The result was confirmed by boiling.
While working at this subject I instituted a series of
comparative experiments of specimens of presumably nor-
mal urine, and in but few instances did I detect an
appearance which could be readily confounded with that
caused by albumen ; yet it must be confessed that picric
acid shares with the other two tests the peculiarity of caus-
ing, under certain circumstances, a precipitate (mucin ?)
very like that due to albumen. In most cases this cloud
is at a little distance from the contact-surface, but occa-
sionally the resemblance is so misleading that it might
be best to reserve the picric acid test for a confirmation
of the other tests or for demonstrating negative results.
In certain cases when nitric acid in the cold and the test
by boiling failed to detect albumen, picric acid gave the
the precipitate formed by the action of the urine on the guaiacum is com-
pletely dissolved. If blood be present a blue colour varying in intensity is
developed. This seems to me the most delicate method of using tbe guaiacum
test.
100 SCARLATINAL ALBUMINURIA, ETC.,
characteristic reaction, and its correctness was in most
cases confirmed by evaporating the m*ine to a small bulk
and employing the first two tests when each gave confir-
matory results. Throughout the investigations I assumed,
in any doubtful case, that albumen was present in a speci-
men of urine when characteristic appearances were got
with all these tests.
I will discuss the subject under the following heads :
I. The period of occurrence of albuminuria in scarla-
tina.
II. The frequency of albuminuria in scarlatina.
III. The relations which blood and albumen bear to
each other in the urine of scarlatinal nephritis.
IV. The so-called " pre-albuminuric stage " in scarla-
tinal nephritis.
V. Treatment.
I. Period of Occurrence.
For purposes of convenience it will be best in discussing
this subject to divide the cases into two classes :
1. Cases of what may be called " Initial Albuminuria."
2. Cases of " Late Albuminuria."
Whether these two classes are due to the same patho-
logical changes in the kidney, or whether the first is due
to the primary febrile disturbance, and the second to
recognisable, though it may be minute, vascular and
cellular changes in the kidney, is a subject which,, should
opportunity offer, I hope to investigate Further. In the
meantime the various periods ai which this complication
of scarlet fever most frequently occurs will occupy our
attention.
1. In the first class arc included all those cases in
which albumen was detected in the course of the first week
of the illness ; in the second those in which it appeared at
,-i later period, after the primary scarlatinal symptoms had
begun to subside. This subdivision is justifiable on the
STUDIED BY FKEQUENT TESTING.
101
ground that patients with scarlet fever frequently suffer
from two attacks of albuminuria, separated by a well-
marked interval. No hard and fast line can be drawn
between these two classes of cases, and it must be con-
fessed that the distinction as regards their exact period of
occurrence is arbitrary. My object in drawing the dis-
tinction is to emphasize the frequent occurrence of an
interval between the two.
Table showing Duration of the Interval between "Initial "
and " Late " Albuminuria.
Number of case Interval between " Initial '
Number of case Interval between " Initial !
in table.
and " Late " albuminuria.
in table.
and " Late " albuminuria.
No. 10 .
. Days 3 (5th— 9th)
No. 20 .
. Days 5 (7th— lltli)
„ 11 .
„ 10 (8th— 18th) ..
„ 21 .
„ 3 (6th— 9th)
„ 12 .
„ 8 (7th— 15th) ..
„ 22 .
„ 25 (6th— 31st)
„ 13 .
„ 4 (6th— 10th) ..
„ 23 .
„ 3 (8th— 11th)
„ 14 .
. „ 9 (7th— 16th) ..
„ 24 .
„ 8 (7th— 15th)
„ 15 ..
. „ 3 (9th— 12th) ..
„ 25 .
,. „ 20 (3rd— 23rd)
» 16 ..
„ 17 (5th— 22ud) ..
„ 26 .
. „ 12 (5th— 19th)
„ 17 .
. „ 4 (8th— 12th) ..
„ 27 .
„ 12 (9th— 21st)
» 18 ..
. „ 8 (7th— 15th) ..
„ 28 .
. „ 15 (4th— 19th)
„ 19 ..
. „ 6 (4th— 10th) ..
„ 29 .
. „ 5 (9th— 14th)
Of cases of " Initial " albuminuria I have no fewer
than 40 to record out of a total of 112 cases of albu-
minuria of all kinds in 180 cases of scarlatina. These
cases again admit of subdivision into three classes :
a. Cases running on to " Late " albuminuria without a
break — 9 cases. (See table, p. 116, Nos. 1 — 9 inclusive.)
b. Cases followed by " Late " albuminuria after a
variable interval — 21 cases. (See table, p. 11 G, Nos. 10 —
30 inclusive.)
C. Cases not followed by " Late " albuminuria — 10
cases. (See table, p. 118, Nos. 31 — 40 inclusive.)
" Initial " albuminuria does not of itself seem to be a
cause for great anxiety, even when the urine is for the
first few days loaded with albumen and blood. It is only
when it shows a tendency to join hands with " Late "
albuminuria that it becomes serious, and it is only then
102 SCARLATINAL ALBUMINURIA, ETC.,
that one would be inclined to take into consideration the
possibility of its bringing about of itself a fatal result.
Cases of malignant scarlet fever are no doubt almost in-
variably complicated with nephritis, and the blood and
albumen may be even very abundant, yet the nephritis
appears to take a very subordinate part, in comparison
with many of the other lesions, in bringing about a fatal
termination. I have seen only one case of malignant
scarlatina without accompanying albuminuria. This case
was peculiar in other respects, and will be noticed later
on. (See " Dropsy without Albuminuria ;" p. 106.)
Nine out of the 40 cases of " Initial " albuminuria ran
on without intermission to " Late " albuminuria. These
were all more or less severe, like those of the next class,
and in one of the latter the last traces of albumen had
not disappeared on the 140th day.
In 21 cases " Late " albuminuria followed after an
interval of some days, during which the urine was quite
free from albumen or blood.
In 10 cases the " Initial " albuminuria passed off com-
pletely, the patient showing no further sign of nephritis
after the ninth day of the fever.
2. " Late " albuminuria may come on at any time
between the ninth and forty-eighth day, but is much more
common at certain periods in the course of the fever than at
others, and seems to have a preference for the beginning
of the second, third, and, in a less degree, the sixth week.
Table showing the Number of Cases of "Late" Alhu-
mmuria, not preceded by "Initial" Albuminuria,
occurring at Various Dates of the F<v> r.
Day of dumber of cases occurring
illness. at given date of fever.
9th ... 5
10th ... 4
11th ... 1
12th ... 4
13th ... 3
14th ... 5
Pay of
Number
of enses occurring
illness.
at
JW
:n date of fever.
15th
:•
16th
5
17th
<;
lSlh
i
L9th
2
20th
1
STUDIED BY FREQUENT TESTING.
103
Day of
Number of cases occurring Day of
Number of cases occurrin
illness.
at given date of fevei
illness.
at given date of fever.
21st
2
32nd
3
22nd
2
3nth
3
23rd
1
36th
2
24th
1
37th
1
25th
2
39th
1
26th
1
40th
1
27th
1
46th
1
29th
1
47th
1
30th
1
48th
1
31st
1
Table showing the Number of Gases of <e Late " Albumi-
nuria, preceded by " Initial " Albuminuria (with an
interval between) occurring at Various Dates of the
Fever.
Day of
Number of cases
occurring
Day of
Number of
cases occurrin
illness.
at given date
of fever.
illness.
at given
date of fever.
9th
2
18th
1
10th
2
19th
2
11th
2
21st
...
1
12th
2
22nd
1
14th
1
23rd
1
15th
3
...
31st
1
16th
1
It will be observed that the numbers cluster about the
ninth and fifteenth days. Cases arising at these periods
seem the most characteristic, the albuminuria running a
course usually of some length and often of great severity.
Albuminuria occurring at other periods would appear to
last, at most only a few days, and now and again its
presence is shown merely as an occasional trace of albumen
in the urine.
Illustrations
of Very Slight
and
Transient Albumen or
Blood in
Urine.
Number on
table.
Day of fever.
Total duration of albumen or blood.
46
21st
Trace on one occasion.
102
22nd and 23rd
On two days only.
82
27th
Trace on one occasion.
64
...
29th till 53rd
Trace occasionally.
76
...
31st till 33rd
Trace for three days.
87
40th and 46th
Trace on two occasions.
104 SCARLATINAL ALBUMINURIA, ETC.,
II. Frequency.
Of the 180 cases examined 112 or 63*2 per cent., showed
signs of renal affection by the presence of albumen or
haemoglobin i. e. blood, in the urine, with or without dropsy,
as the case might be. In some cases, however, the evi-
dence of kidney mischief was so slight and evanescent
that but for careful and frequent testing the presence of
these substances would no doubt have been overlooked.
Two cases, or 1*1 per cent, in the 180, presented
anasarca, without albumen showing itself in the urine.
Sixty-six cases, or only 36*7 per cent, of the whole, escaped
entirely.
Of the 112 cases of nephritis 55, or 49*1 percent., were
cases of pure albuminuria, wrhile 57, or 509 per cent .,
came under the class haernaturia.
Anasarca was observed in only 24 of the 180 cases
examined. Of these, 22 suffered from very decided
albuminuria, while the urine of the remaining 2 cases did
not at any time show the slightest trace of albumen or
blood, though these were sought for with the greatest
care.
It is perhaps unnecessary to point out that 180 cases
form far too narrow a foundation on which to base con-
clusions as to the probable frequency of the renal affec-
tion in any given epidemic of scarlel Fever. The ulnae
statistics can therefore apply only to that group of cases
upon which the investigations were couducted.
III. Relations wnicn Blood and Albumen beau to each
other in the ultlne of scarlatinal nephritis; and
Dropsy without Albuminuria.
The abnormal constituents present in the urine of
scarlatina patients are not the same in every case. The
presence of albumen is of coarse the principal evidence <>t'
STUDIED BY FREQUENT TESTING. 105
renal disease ; but in many cases haemoglobin is added in
varying proportions ; and in a few of these last, albumen
is apparently absent altogether. From this point of
view I would subdivide all cases of scarlatinal nephritis
as follows :
1. Those cases in which there is albumen from begin-
ning to end without there being at any time the slightest
trace of blood-colouring matter in the urine : 55 cases, or
49*1 per cent. (See in table on p. 116 all cases except those
referred to in the following two classes.)
2. Those in which blood only seems to be present, and
in which the albumen and blood-colouring matter increase
and diminish in quantity pari passu, so that these con-
stituents seem to be in the same relative proportion as in
blood itself. It is in this class of cases that we sometimes
find what has been called a " pre-albuminuric stage," and
in which there sometimes also exists what might with
equal propriety be called a " post-albuminuric stage ;" 28
cases, or 25 per cent. (Nos. 16, 20, 22, 27, 40, 41, 42, 43,
44, 45, 55, 56, 58, 64, 65, 70 ?, 76, 77, 79, 83, 86, 90, 92,
94, 96, 99, 101, 103).
3. Those in which we have blood, as in the last class,
but in which there is an excess of albumen in addition to
that due to the blood. In this class of cases there is no
" pre-albuminuric " and usually no " post-albuminuric
stage." In a few of the cases which I have included in
this class, the excess of albumen seems to disappear, leaving
some blood lingering behind, and so giving rise to a " post-
albuminuric stage," but in the majority of the cases the
albumen appears before, or simultaneously with, the blood-
colouring matter, and continues in appreciable quantity
after all trace of haemoglobin has disappeared from the
urine : 29 cases, or 25-9 per cent. (Nos. 1, 4, 7, 10, 12, 15,
17, 21, 26, 28, 29, 49, 50, 60 ?, 61, 62, 63, 69, 71, 73, 78,
81, 88, 95, 98, 100, 104, 106, 108).
There is a group of cases (Nos. 40 — 45) which at first
sight one would be inclined to place together as a fourth
class. I refer to those in which haemoglobin is detected by
106 SCARLATINAL ALBUMINURIA, ETC.,
the guaiacum test but in which albumen cannot be found
in any stage by the ordinary methods of testing. The
difference between these cases and those I have grouped
above as Class 2 is only apparent, and in every case
albumen can be detected by appropriate means. The
majority present only an occasional trace of haemoglobin,
and it is only after careful concentration of the urine to a
very small bulk that albumen can be demonstrated.
Sometimes a trace of haemoglobin can be detected over a
period of several days, but my experience has not furnished
me with a single case of true haemoglobinuria, i. e. of a
urine with a quantity of haemoglobin without any blood-
corpuscles, although in one or two cases a deceptive
resemblance to this was caused by the presence of a small
quantity of blood in a highly-coloured urine.
Dropsy without Albuminuria.
It is well known that some curious cases of scarlet fever
occur, in which oedema of certain parts of the body is found,
while no evidence of kidney mischief can be detected on
examining the urine. Of such cases I have seen only two
in which the swelling was at all well marked. One of
these was a boy, four years of age, who was admitted to
the hospital with measles. From this he was making a
good recovery, when he was attacked with scarlet fever of
a most malignant type, from which he died utter an ill-
ness of only a few days. Two days before death the face,
limbs, and trunk, presented very considerable swelling.
Not a trace of albumen or blood was found in the urine,
although these were very carefully and frequently tested
for. The urine was scanty, high coloured, turbid and
loaded with urates. There was no post-mortem exami-
nation. The second case presents! very decided swelling
of the face and legs, commencing on the ninth day, and
lasting for from five to six days ; yet the most careful
testing of the urine failed to reveal the minutest trace of
STUDIED BY FREQUENT TESTING. 107
albumen or blood. The patient made a good recovery, and
in fact this complication seemed to cause no inconvenience
whatever. Although these are the only two cases I have
seen in which there could be no doubt about the existence
of oedema without albuminuria, I am inclined to believe
that slighter cases of the same kind are not uncommon.
I have frequently seen, or perhaps I should say suspected,
puffiness of the face during convalescence from scarlatina,
but so slight that two observers might probably have
differed about its presence. In these cases there was, of
course, no albuminuria to assist in coming to a conclusion
on this point.
Leaving out of sight the first case quoted, in which the
alteration in the constitution of the blood, caused by an
overwhelming dose of scarlatinal poison, might have been
the cause of death, almost all such cases seem to make a
good recovery,1 i. e. the attack of nephritis (if the oedema
be due to this) is very slight. Everyone who makes a
practice of examining the urine of scarlatinal patients, even
once a day, is familiar with the fact that now and then
the detection of albumen in the urine is preceded, often for
a day or more, by the occurrence of oedema, — of the face
more particularly. If at this point the nephritis become
arrested we have a case of " dropsy without albuminuria.'"
Nephritis without albuminuria is an uncommon condition,
yet one of the existence of which there can be no doubt,
and it would seem very reasonable to look upon cases of
dropsy without albuminuria as simply slight cases of
nephritis which have rapidly resolved, just as occurs in so
many cases where the nephritis is characterised by mere
traces of albumen and no dropsy. This is the more probable
since we are aware that albuminuria is by no means the
earliest sign of nephritis, the first rise in arterial pressure
revealed by the sphygmograph preceding it, in some cases,
often by a considerable interval. It is very probable
that the vessels of some individuals are predisposed to
permit exudation of their contained fluids into the cellular
1 ' Nieineyer's Practical Medicine,' Art. " Scarlatina."
108 SCARLATINAL ALBUMINURIA, ETC.,
tissue on the slightest irritation by the ursemic poison,, and
it may be in some such manner as this that dropsy with-
out albuminuria is produced.
IV. It will be convenient at this point to discuss the
phenomena of the so-called " Pre-albuminuric Stage. "
By this term I understand that what is usually meant is a
stage in nephritis characterised by increased vascular
tension and, as a result, the presence of blood crystalloids
in the urine before albumen makes its appearance. The
present investigations would lead me to the opinion that
such a stage does not really exist, in so far at least, as the
absence of albumen in the earliest stages of the nephritis
is concerned. I greatly regret the loss of a number of
pulse tracings which I made and of which I am uuable to
give copies ; what was observed would lead me to agree
with those who maintain the existence of a very early
stage in this affection, characterised by the arterial pressure
rising steadily for a period of twenty-four hours or more
before anything abnormal can be discovered by an exami-
nation of the urine. I cannot therefore see my way to
recognise the existence of a " pre-albuminuric stage"
characterised by a rise in the blood pressure, that rise in
pressure being accompanied or followed by the presence
of haemoglobin in the urine before albumen can be detected.
As my table at the end of the paper shows, only ten of all
the cases of nephritis observed had a " pre-albuminuric
stage " within the latter meaning, whereas mosl cases 1 have
observed present a rise in blood pressure before albumen
or blood appears. In short, there is a " pre-albuminuric
stage" in which the blood pressure rises, and this seems
to exist indifferently,^ In t her the case subsequently becomes
one of albuminuria pure and simple or one of luematuria,
and this even when the attack is mild. This fact alone is,
I think, quite sufficienl to lead us torejeel the theory thai
albuminuria in its earliest staire is to be accounted for by
the increase in blood pressure alone, and thai this stage is
characterised by the presence of blood crystalloids. It
seems to me much more reasonable to look upon the rise
STUDIED BY FREQUEXT TESTING. 109
in the blood pressure as a secondary phenomenon, perhaps
due to inefficient innervation of the vascular system, and
to regard the extravasations found in the tissues of scarla-
tinal patients as a result of degeneration of the capillaries
and smaller vessels. As above mentioned, only ten of all
the cases of nephritis examined showed traces of hemo-
globin before albumen could be detected by the ordinary
methods. I say by the ordinary methods, for that albumen
is present in the urine along with the first traces of hgeuio-
globin I shall now endeavour to show. If the urine of
the so-called " pre-albuminuric stage " of Mahomed1 be
rapidly evaporated in a current of cold, dry air, then
filtered and tested, 1st with nitric acid in the cold, 2nd by
boiling, and 3rd with picric acid as previously described, in
almost all cases the characteristic reaction of albumen will
be obtained. In one or two cases where nitric acid failed,
after evaporation, to give the usual ring, the presence of
albumen was indicated by the boiling and picric acid tests.
In one or two cases, picric acid indicated a trace of albu-
men, while nitric acid and boiling failed to demonstrate its
presence even after concentration. In these cases, how-
ever, the quantity of urine available for examination was
limited, and I am confident that if the evaporation had
been carried further the urine would have given charac-
teristic reactions with all three tests. I am of opinion
that if a test could be found for albumen as delicate as
guaiacum is for blood, the former substance would be
invariably detected in the urine of the " pre-albuminuric
stage," without any concentration. This opinion is further
justified by the existence of what might be called a " post-
albuminuric stage." This condition was found in twenty
of the patients examined. In these cases traces of blood-
colouring matter were detected in the urine, long after all
traces of albumen had ceased to be detected by ordinary
means. In one or two cases this stage extended over a
period of neai'ly two months, the quantity of hasmoglobin
varying from time to time ; but it was always noticed that
1 "^Etiology of Bright's Disease," ' Medico-Chirurg. Trans.,' vol. lvii.
110 SCARLATINAL ALBUMINURIA, ETC.,
when the quantity of haemoglobin increased beyond a
trace, albumen put in an appearance with the ordinary-
tests, thus indicating that it had probably been there all
along. This stage I regard as entirely analogous to the
" pre-albuminuric stage." The apparent absence of albu-
men in the " pre-albuminuric M and " post-albuminuric "
stage is paralleled by what is often seen on examining
the urine of menstruating women and by what one finds
on direct experiment. From observations conducted upon
a number of women whose urine was tested several times
daily with great regularity, it was found that in some of the
cases, at the menstrual periods, the guaiacum test revealed
the presence of blood before nitric acid indicated the
presence of albumen. The same peculiarity wTas observed
as the menstrual flow was passing off. There can be no
doubt that in the urine of these women albumen as well
as haemoglobin was present, the blood being altered in
some of its properties, yet containing these two consti-
tuents. It cannot be doubted, I think, that the urine
contained blood pure and simple, and yet only haemoglobin
could be detected by the guaiacum test, while nitric acid
failed to give any reaction at all. On concentration of the
urine albumen was found. The same conclusion is proved
by the following experiment : If a drop of fluid blood
be placed in a conical glass and normal urine gradually
added, as dilution goes on albumen will be found to cease
to give a reaction with nitric acid some time before the
guaiacum test ceases to react with the haemoglobin, it
being understood that the mixture is allowed to rest after
each dilution and that the urine to be tested for hemo-
globin is taken from the bottom of the glass. This early
apparent disappearance of the albumen is what one would
naturally expect, even if the nitric acid and guniiu-um tests
were equally delicate ; for, while the albumen is dissolved
and diffused throughout the fluid, the corpuscles contain-
ing the colouring matter (haemoglobin) sink to the bottom,
only a small quantity of the luvmoglobin being dissolved
out by the uriue. To my thinking, the facts noted above
STUDIED BY FREQUENT TESTING. HI
are pretty strong evidence in favour of the existence of
traces of blood pure and simple in the so-called " pre-
albuminuric " and ' ' post-albuminuric " stages, even if the
presence of albumen had not been demonstrated by the
method of concentration.
The next point of inquiry is as to the sediments present
in the urine of the " pre-albuminuric stage." The sedi-
ment of urine passed during this stage contains both blood-
corpuscles and tube-casts. In the first place the presence
of corpuscles is to be expected where we have both albu-
men and haemoglobin. The actual presence of corpuscles,
however, is not so easy to determine by the microscope,
and this is not to be wondered at when we remember that
a very considerable quantity of urine of the " pre-albu-
minuric stage " is necessary sometimes to give the reaction
with guaiacum in spite of the great delicacy of that test.
It is often trying to one's patience to have to search
through two or three drachms of urine, drop by drop, for
corpuscles, and the difficulty is increased by the fact that
if the urine be allowed to settle for too long a period, the
corpuscles become altered, sometimes almost beyond
recognition ; yet even in these cases I have usually found
a patient search rewarded by the discovery of red corpus-
cles, in sufficient numbers to account for the sediment
reacting with guaiacum, without having to assume the
presence of dissolved haemoglobin. If such urine be
repeatedly filtered through a thick layer of cotton wool
and then allowed to settle, it will be found that the urine
from the bottom of the glass has ceased to react with
guaiacum, while the cotton wool used as the filtering
medium gives the characteristic reaction, i. e. the cotton
has separated the solid corpuscles from the fluid portion
of the urine.
The following experiments indicate that the colouring
matter is chiefly contained in the first instance within
some protective covering, such as a cell wall or proto-
plasmic mass, and is only slightly in solution shortly after
the urine has been passed. If urine from a case such as
112 SCARLATINAL ALBUMINURIA, ETC.,
we are now considering be put into a test-tube and a little
of it examined, the same quantity of haemoglobin will be
found at whatever depth the urine may be taken from.
If the tube be now allowed to stand for some time and the
urine be again tested, the examination being conducted at
different levels, it will be found that the upper layers give
a less decided reaction than the lower, and that the depth
of the blue colour increases as we approach the bottom,
the quantities of urine and reagents being the same in
each experiment. This would seem to indicate that the
colouring matter is solid or of greater specific gravity
than the fluid. If now the tube be shaken up every hour
for a period of ten or twelve hours, and then be allowed
to settle over night, it will be found that the upper layers
give a reaction with guaiacum which is much more decided
than that obtained with the same reagent after the urine has
merely been allowed to stand for the same length of time.
This seems to show that corpuscles contain the colouring
matter, that these first of all settle gradually towards the
bottom of the vessel, and that after a time a great part of
the hasinoglobin is dissolved out, and diffuses itself
throughout the fluid.
Of the many sediments besides blood-corpuscles found
in the urine of scarlatinal patients, we are interested
mainly in tube-casts. These I observed only three or four
times in the urine passed in the " pre-albumiuuric stage/'
They were mostly epithelial in character, and were
noticed usually only a few hours before the time at which
albumen was first detected. In one case tube-casts (epi-
thelial and blood) were found very abundant in the urine
six days before the detection of albumen by the usual
methods. During this period guaiacum indicated the
presence of blood, and white and red corpuscles were
detected microscopically. In this case there was no
history of previous kidney mischief.
STUDIED BY FREQUENT TESTING. 113
V. Treatment.
To this I shall refer very briefly. I have not been able
to satisfy myself that the action of purgatives is really
specific in preventing the occurrence of albuminuria.
Almost every case admitted to my wards had castor oil
administered every third day, so that the bowels were
kept moderately free, and yet albuminuria occurred in a
large proportion of the cases. Some of these were very
severe, and in a few death resulted. One may be misled
in regard to the efficacy of purgatives by the occurrence
of what is not uncommon in scarlet fever, viz. the appear-
ance of blood or albumen for perhaps only a few hours,
which disappears without any treatment whatever. If
purgatives have been used in such cases one would be
apt to refer to the action of the medicine what is really
part of the natural course of the disease.
Warmth and rest seem, after all, the most efficient guards
against albuminuria, although these frequently fail in
their object.1
I may mention here that I was in the habit of confining
my patients to bed during the first four weeks of the
fever, and that they were not allowed to leave the ward
till a week later. By confining the diet to milk and
farinacea during the first two or three weeks of the
scarlatina, and allowing beef broths, &c, only when
convalescence began to be established, I attempted to
ward off nephritis. In thirty cases milk and farinacea
were continued till the middle of the fifth week, yet nine
of these cases showed signs of albuminuria ; in most cases
these were slight, one only being a well-marked case of
scarlatinal dropsy. Whether this diminished percentage
of albuminuria was due to the mild nature of the diet, or
to accident, all the cases having occurred in early autumn,
1 The temperature of the wards, built on the pavilion system with efficient
through and roof ventilation, was maintained as near 60" Fahr. as possible.
VOL. LXIX. 8
114 SCARLATINAL ALBUMINURIA, tTC;
I cannot say. The converse of this experiment I did not
care to try.
After albuminuria has attacked a patient the usual
treatment with purgatives and packs seems very effective
in most cases.
Convulsions are best combated by chloral and chloro-
form, but these agents can check only the more urgent
symptoms and afford time for more routine remedies to
act. Benzoic acid in large doses (twenty grains every
two hours) seemed to have a powerful influence, at least
in some cases, in preventing the occurrence of convul-
sions.
In recapitulation I would recall the following points :
I. All cases of scarlatinal albuminuria may be subdivided
into :
(a) " Initial " albuminuria.
(h) " Late " albuminuria.
This distinction is to some extent arbitrary, but the
actual conditions found in many cases seem to justify it.
II. All cases may be subdivided into three classes :
{<>) Cases of simple albuminuria.
(I>) Cases of simple hasmaturia.
((.-) Cases in which there are both blood and albumen,
but in which albumen is in excess.
III. There is no condition of the urine which justifies the
use of such a phrase as " pre-albuminuric stage. " If such
a term is to be used at all it should refer to the condition
of the vascular system only.
IV. Lastly, red and white corpuscles and tube-casts
are commonly found in the urine during the so-called
"pre-albuminuric sta{
(For a report of the discussion on this paper, see 'Proceed-
ings of tbo Royal MedioaJ and Ohirurgical Society/ New Series,
vol. ii. p. 11.)
TABLE
Giving details of Observations made upon the Urine
of 112 Cases of Scarlatinal Nephritis.
116
SCARLATINAL ALBUMINURIA, ETC.,
Table giving details of Observations made up
Min. tr. = minute trace; far. = trace; dist. = distinct; con. = considerable; abdt.
from one date to another ; (a.m.) or (p.m.) added to a date indicates that the album
otherwise it was pres;
A. Cases of " Initial Albuminuria
No.
of
case.
Date
of
admission.
Age. Sex.
Day of illness.
Periods at which albumen was detected. Number day
of illness. Abbreviations as above.
Adm. Dism.
1
2
3
4
5
6
7
8
9
Dec. 15
Dec. 26
Jan. 23
Jan. 30
Feb. 3
Feb. 7
Jan. 23
Apr. 5
Apr. 16
22
7
6
3
11
5
-1
4
6
F.
F.
F.
F.
F.
F.
F.
F.
M.
2nd
5th
3rd
7th
5th
2nd
1st
2nd
3rd
54th
90th
60th
64th
59th
54th
57th
81st
16th
4th tr., 5th abdt., 6th— 10th tr., 41st tr.
8th (a.m.) — 70th varying from tr. to con.
5th (p.m.)— 14th (a.m.) tr.— dist.
8th (a.m.) min. tr., 9th (p.m.) dist. 10th, 11th'
36th (a.m.)— 38th (a.m.) tr., 58th (p.m.) tr.
5th— 10th con., 35th (p.m.)— 41st (a.m.) di
50th, 52nd tr.
4th (a.m.) — 32ud (p.m.) varying from tr. — con. ■
7th (p.m.), 9th (a.m.) dist., 10th (a.m.)— 14th (p.i
21st (p.m.), 24th (p.m.), 27th (a.m.), 32nd (p.D
33rd (p.m.), 34th (p.m.), 36th, 37th, 39th (p.nj
40th (p.m.) tr.
3rd (p.m.), 4th (p.m.), 8th (p.m.), 11th (a.in.),l'
(p.m.), 18th (p.m.) tr.
4th— 8th (p.m.) tr., 8th (p.m.)— 13th dist.]
10
Aug.
17
6
M.
11
Nov.
10
3
F.
12
Dec.
12
Ki
M.
13
Jan.
23
SO
F.
14
Jan.
23
6
F.
15
Jan.
23
8
F.
16
Feb.
21
22
M.
17
Mar
2
6
M.
18
Mar
3
19
F.
19
Mar.
15
4
M.
20
Mar.
26
7
M.
B. Cases of "Initial Albuminuria" folhwm
5th 54th 5th abdt., 9th (p.m.)— 29th tr.— abdt.
3rd 24th 8th tr., 18th— 21st con., 22nd— 24th tr.
6th 6(>tli 7th (a.m.) tr., 15th (a.m.) dist., 39th (p.m.) tr.
2nd 56th 6th (a.m.), 10th (a.m.) tr.
3rd 66th 3rd— 7th con., 16th (a.m.) tr., 18th (a.m.)
I 22nd tr., 25th, 26th (a.m.) tr., 34th (a.m.
48th (p.m.) min. tr. — dist.
66th 4th— 9th (p.m.) tr., 12th (a.m.), 13th (a.m.), 1
I (p.m.), 18th (p.m.), 21st (p.m.) tr., 23rd (a.
i — 51st (p.m.) tr.
3rd, 4th, 5th dist., 22nd— 38th tr.— dist.
3rd
2nd
5th
6th
3rd
21st
84th
f)7th 6th— 8th dist., 12th (p.m.) dist.
55th 6th, 7th tr., loth (p.m.) con., 27th tr., 2Sth
60th 1th (p.m.), 10th (a.m.) min. tr., 13th— 19tl
I tr. — (list.
94th 3rd— 7th tr., 11th (a.m.), 13th (a.m.) mil
22nd (a.m.)— 24th dist.
STUDIED BY FREQUENT TESTING.
117
e Urine op 112 Cases op Scarlatinal Nephritis.
ndant; oc. = occasional; in. = initial. A dash — indicates continuance of the albumen
i only found in the morning or evening
sample of that day as the case may be ;
ill three testings.
ming on to " Late Albuminuria.
>>
semoglobin detected,
Duration
" Pre-albu-
"Post-albu-
number day of
of
minuric
minuric
Dropsy.
Result.
Remarks.
illness.
nephritis.
stage."
stage."
5th dist.
5 days
None
None
Con.
Well
None
62 days
None
None
Con.
Well
None
9 days
None
None
None
Well
58th (p.m.) tr.
4 days oc. tr.
None
None
None
Well
None
5 days and oc.
tr.
28 days
None
None
None
Well
None
None
None
None
Well
d (a.m.) min. tr.,
8 days and oc.
None
None
None
Well
frd (p.m.), 36th
tr.
.m.) dist., 37th
.m.), 39th (p.m.),
»tb (p.m.) tr.
None
Oc. tr.
None
None
None
Well
None
9 days (?)
None
None
None
Died
jate Albuminuria " after a vary
',ng interval.
dist., 9th— 24th
Date 20 days
None
None
Dist.
Well
tr. — dist.
None
7 days
None
None
None
Died
44th (a.m.) tr.
Oc. tr.
None
None
None
Well
None
Tr. on 2 oc.
None
None
None
Well
None
32 days
Init. 5 days
None
None
None
Well
3th (p.m.)— 48th
41 days, in.
None
None
Con.
Well
(p.m.) tr.
5 days
d— 70th tr.— dist.
58 days, in.
3 days
None
52 days
None
Well
2th (p.m.) con.
3 days
None
None
None
Well
None
In. 2 days, oc.
tr.
7 days and oc.
tr.
43 days
None
—
None
Well
None
None
None
None
Well
t. — tr. from 3rd —
None
21 days
None
Well
Long "post-albu-
>th, 50th min. tr.
minuric stage."
Long - continued
presence of haemo-
globin and occa-
sional alb.
118
SCARLATINAL ALBUMINURIA, ETC.,
No.
of
case.
21
22
23
24
25
26
27
28
29
30
Date
of
admission.
Age.
Sex.
Day of illness.
Periods at which albumen was detected. Number day
of illness. Abbreviations as above.
Adm.
Dism.
April 5
April 17
May 2
May 6
May 11
June 30
July 2
July 2
Aug. 22
Feb. 1
22
19
6
6
11
15
35
26
18
7
F.
M.
F.
F.
F.
M.
M.
M.
F.
M.
2nd
2nd
1st
6th
3rd
1st
5th
4th
5 th
21st
57th
150th
54th
26th
57th
?
56th
66th
?
94th
3rd — 6th dist., 9th (a.m.) min. tr., 22nd — 24
dist.
2nd — 6th tr., 31st (a.m.) min. tr., 56th min. t
57th dist,, 58th— 63rd dist.
7th (a.m.), 8th (p.m.) tr., 11th (p.m.)— 15th (p.r
tr., 17th (p.m.) tr., 18th (p.m.) tr., 36th (a.i
— 46th (p.m.) tr. — dist.
6th and 7th tr., 15th (p.m.)— 20th (a.m.) tr.— co
3rd tr., 23rd (a.m.) dist., 28th (p.m.), 29th (p.i
dist., 34th (p.m.) con., 36th (a.m.) min. tr., 3',
(p.m.) — 53rd (p.m.) tr. — dist.
1st, 2nd dist., 3rd min. tr., 5th (a.m.) min. t
19th— 84th dist.— abdt.
5th— 9th tr.— dist., 21st (p.m.) tr., 23rd (p.nJj
4th (p.m.) tr., 19th (p.m.) — 40th (p.m.) con.— abc
41st — 52nd tr., 64th (p.m.) min. tr.
5th (p.m.)— 9th (a.m.) tr., 14th, 15th tr., 16tt
41st tr. — dist.
3rd— 7th tr., 11th (a.m.), 13th (a.m.) min. tr., 22
(a.m.), 24th (a.m.) dist.
c. Cases of " Initial Album oniric
31
82
33
34
35
36
37
38
39
40
Dec. 26
Jan. 29
Feb. 21
April 25
June 7
June 28
July 2
July 4
Aug. 14
Aug. 28
16
22
27
7
35
27
13
26
3*
28
?
3rd
4th
3rd
6th
4th
5th
2nd
5th
2nd
? 7th (p.m.) dist., 8th (a.m.) and (p.m.) tr.
62nd 4th— 6th (p.m.) dist., 7th (a.m.) tr.
54th 4th— 8th dist.
55th 8th (a.m.) min. tr.
57th
55th
56th
56th
56th
55th
7th (a.m.) tr.
4th con., 5th tr.
7th— 9th tr.
2nd — 5th tr. — con.
7th (p.m.) tr.. 8th (a.m.) tr.
2nd con., 3rd dist., 4th (a.m.) tr.
41
Dec. 9
2
F.
10th
65th
•12
Feb. 21
9
.M.
10th
62nd
43
March 1
62
V.
14th
56th
44
April 24
6
F.
3rd
.Mini
45
Jane ~\
8
-M.
7th
62nd
i»;
Jane 21
11
P.
51 li
59th
d. Cases of ILvmoglobin
None
None
None
None
None
None
STUDIED BY FREQUENT TESTING.
119
. Haemoglobin detected,
Duration
" Pre-albu-
"Post-albu-
number day of
of
minuric
nimuric
Dropsy.
Result.
Remarks.
illness.
nephritis.
stage."
strtge."
7th (a.m.) tr.
4 days, in. 4
None
None
None
Well
days
'id— 3rd dist., 3rd
103 days
None
43 days
Con.
Well
p.m.) — 57th (a.m.)
;r., 57th — 65th
p.m.), dist., 66th—
L06th tr.
None
10 days and
oe. tr.
None
None
None
Well
None
5 days, in. 22
days
None
None
None
Died
Malignant.
None
20 days and
oc. tr.
None
None
None
Well
>th — 65th min. tr.
61 days, in.
None
None
Con.
Well
— abdt.
5 days
21st (p.m.)— 24th
4 days
None
24 hours None
Well
(p.m.) tr.
J.9th— 66th (p.m.)
47 days
None
14 days
None
Well
Case sent to
tr. — con.
country.
'h tr., 8th tr., 14—
36 days
None
None
None
Well
, 20th tr.— dist.
Sd— 45th dist.— tr.,
43 days
None
25 days
Slight
Well
Long " post-albu-
50th min. tr.
minuric stage."
H followed by "Late Albuminuria.
None
None
None
None
None
None
None
None
None
None
2—3 days
4 days
5 dajs
2 days
3 days
4 days
2 days
3 days
None
None
Dist.
Died
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
Malignant.
rine without obvious Albumen.
1th tr. — dist.
!th tr.
'th tr.
'th min. tr., 18th 40 hours
a.m.) dist., 18th
p.m.) min. tr.
id — 4th (a.m.), min.
r.
1st (a.m.) tr.
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
None
None
None
Well
No albumen detected
till urine coucen
trated.
120
SCARLATINAL ALBUMINURIA, ETC.,
e. Cases no.
No.
of
case.
Date
of
admission.
Age.
Sex.
Day of illness.
Adm. Dism
Periods at which albumen was detected. Number day
of illness. Abbreviations as above.
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
Nov. 10
9 F.
Nov. 13 10
Nov. 17 7
Nov. 17 7
12
Nov. 22
Nov. 23
Nov. 28
Nov. 28
Nov. 29
Dec. 2
Dec. 2 23
Dec. 6
Dec. 6
Dec. 7
Dec. 7
62 Dec. 8
63
64
65
66
Dec. 8
Dec. 10
L2
Dec. 12 3
Dec. 12
F.
F.
M.
M.
M.
F.
F.
M.
M.
,M.
M.
M.
M.
F.
V.
M.
61st 35th, 37th, 40th, 42nd, 47th, 49th, 55th (a.m.) tr.
51st, 52nd, 53rd, 55th (p.m.), 56th, 59th, 61st con
11th 62 nd 32nd— 39th tr.
1st 57th 39th tr.
4th 57th
3rd
7th
7th
7th
56th
12th— 16th, 20th, 22nd, 23rd, 24th, 27th, 30tl
tr., on other days from 12th till 30th dist.
17th, 23rd, 24th min. tr.
56th 14th tr.
56th 19th (p.m.) and 31st (a.m.) tr.
59th 29th (p.m.), 35th (a.m.), 42nd (p.m.), 43rd (a.m.
con., 46th tr., 50th (p.m.), 53rd (p.m.) tr.
3rd 76th 32nd (p.m.) tr., 33rd abdt., 34th— 38th vary., 36t
tr., 3Sth till 42nd vary., 47th — 76th vary.
2nd 142ud 16th (p.m.) tr., then abdt. till 77, then'oc. til
101st
7th 162nd
4th
54th
fith 58th
20th tr., 21st— 48th abdt., 49th— 57th dist., 58t
—64th con., 65th— 84th dist., S5th— 162ud tr
37th (a.m.), 40th, 41st, 43rd (a.m.) tr.
16th (p.m.) dist.
6th 17th 15th (a.m.) tr., loth (p.m.) till end con.
4th 56th 36th (p.m.) dist., 40th (a.m.) dist., 42nd (a.m.) t
1th 82nd
5th
4th
14th
Weeks
1J
76th
55th
68th
36th (p.m.)— 73rd (p.m.) tr. to dist.
35th (a.m.), 49th, 52nd, 54th, 58, 59th (p.m
dist.
15th (a.m.) tr., 31th (p.m.) tr., 35th (p.m.) dirt
37th (p.m.) dist., 38th (a.m.) dist., 46th (p.m
dist.
L5th (a.m.) tr., L'Jn.l (p.m.) con.. 23rd (a.m.) tr
f\ b (a.m.) dist., 39th (p.m.) tr., 15th (a.m.) tr
52 (p.m.) tr.
31st 16th till aid ab.lt.
STUDIED BY FREQUENT TESTING.
121
'rictly classified.
Haemoglobin detected,
Duration
" Pre-albu-
"Post-albu-
number day of
of
minuric
minuric Dropsy.
Result.
Remarks.
illness.
nephritis.
atage."
stage."
None
26 days
None
None None
Well
Albumen occurred
only 8 p.m., except
when noted.
None
2 oc. tr.
None
None None
Well
Traces morning.
None
Once tr.
None
None None
Well
7th, 28th, 29th,30th, 19 days
None
1 day on None
Well
Albumen all at
31st tr., 35th tr.
35 tr.
night.
26th tr.
Thrice tr.
None
None None
Well
Albumen all at
night.
None
Once tr.
None
None
None
Well
None
Twice tr.
None
None
None
Well
None
Occasionally
None
None None
Well
None
44 days
None
None None
Well
5th tr. and dist.,
122 days
36 hours
36 days \ Con.
Well
During " post-albu-
16th till 77th abdt.
and con., 77th —
mninriP ofofro "
minute traces
of albun:
en were observed
occasionally. Duration of
139th tr.
" post-album
nuric sta£
'e " uncertain, patient being dismissed with
trace of blooc
I.
9th (a.m.) — 21st
142 days
24 hours
24 hours
Con.
—
(p.m.) tr., 22nd
dismissed
(a.m).— 44th ahdt.,
with tr.
45th — 75th dist.,
of blood
76th— 162nd tr.
None
Oc. tr.
None
None
Slight
25th
day
None
Well
16th (p.m.) dist.,
Once tr.
None
12 hours
Well
17th (a.m.) tr.
None
3 days
None
None
Abdt.
Died
Malignant.
19th, 20th dist.
Oc. tr.
None
None
None
Well
Blood and albumen
to usual tests ap-
peared at different
times.
.6th (p.m.) tr., 36th
37 days
None
None
Slight
Well
Except on 35th al-
(p.m.)—51st (p.m.)
35th,
bumen always at
min. tr. — dist.
41st
night.
15th (p.m.) dist.,
Oc. tr.
None
None
None
Well
16th (a.m.) tr.
.3th (p.m.) — 15th
Oc. tr.
None
None
None
Well
(a.m. and p.m.) and
16th (a.m.) tr.
-9th (p.m.) — 23rd
112 hours and
72 hours
16 hours
None
Well
(a.m.) dist., 23rd
oc. tr.
(p.m.) tr., 35th (a.m.)
tr., 37th (a.m.) tr.
15th tr., 16th till end
?
1 day
?
Con.
Died
cons.
122
SCARLATINAL ALBUMINURIA, ETC.,
No.
Date
Day of illness.
-
Periods at which albumen was detected. Number day
of illness. Abbreviations as above.
of
case.
of
admission.
Age.
Sex.
Adm.
Dism.
67
Dec. 12
1(1
M.
3rd
71st
9th (p.m.) — J 1th (a.m.) vary, from min. tr. — cons.
68
Dec. 13
4
F.
7th
75th 17th (p.m.) tr., 45th (p.m.) dist., 5Gth (p.m.) tr.
69
Dec. 14
4
F.
4th
65th 15th (p.m.) tr., 24th (a.m.) dist., 52nd (a.m.) con.,
53rd (p.m.) dist., 56th (p.m.) tr.
70
Dec. 14
7
M.
3rd
20th
12th, 13th (p.m.) tr., 13th, 14th (a.m.) dist., 14th
(p.m.) — end, abdt.
71
Dec. 14
14
M.
4th
57th
35th (p.m.), 39th (a.m.) tr.
72
Dec. 14
13
F.
8th
82nd
15th— 30th dist.— cons., 35th— 44th (p.m.) tr.,
47th— 52nd tr., 59th, 61st tr., 68th— 70th min.tr.
73
Dec. 15
8
F.
1st
53rd
23rd (p.m.) tr.
71
Dec. 17
8
M.
2nd
55th
25th (a.m.) tr.
75
Dec. 27
8
M.
2nd
72nd
15th (a.m.) min. tr., 21st (a.m.) tr., 28th (a.m.) tr.,
35th (a.m.) tr., 37th (a.m.) tr., 3Sth (a.m.) tr.,
47th (a.m.) tr.
76
Dec. 27
6
M.
8th
50th
10th (a.m.) tr., 16th (a.m.) tr., 21st, 27th (p.m.)
tr., 35th (a.m.) tr., 39th (p.m.) tr., 44th— 49th
dist.
77
Dec. 26
21
F.
4th
56th
32nd tr.
78
Dec. 29
7
F.
4th
68th
15th (p.m.) — 33rd (a.m.) vary .from cons. — min.tr.,
41st (a.m.) dist., 52nd (p.m.) min. tr.
79
Dec. 30
10
M.
3rd
58th
nth (a.m.), 10th (p.m.) min. tr.
80
Feb. 3
4
F.
8th
59th
12th (a.m.), 19th (.a.m.) tr.
81
Feb. 10
6
F.
4th
153rd
11 — 109th very vary, from abdt. — min. tr.
82
Feb. 7
9
F.
2nd
64th
L'7tli tr.
83
April 2
7
F.
14th
122nd 22nd (p.m.)— 35th (a.m.) con., 35th (p.m.) tr., 39th
dist., 40th — 13rd (p.m.) tr.
84
April 14
7
P.
2nd
60th
47th (p.m.), 52nd (p.m.) tr.
85
April 23
8
F.
2nd
55tfa
16th (p.m.) tr., Mm (a.m.) tr.
86
April 25
•1
M.
2nd
63rd
12th (a.m.) dist., 12th (p.m.)— 17th (p.m.) abdt.,'
18th (a.m.), 19th (p.m.) dist,, 20th (a.m.) tr.
87
April 28
5
P.
3rd
57th
10th (p.m.) dist.. 46th (a.m.) min. tr.
88
May 8
14
P.
3rd
55th
15th (p.m.) tr., list (a.m.) — 53rd (p.m.) tr. — coub.
STUDIED BY FREQUENT TESTING.
123
Haemoglobin detected,
Duration
' Pre-albu-
'Post-albu-
number day of
of
minuric
minuric
Dropsy.
Result.
Remarks.
illness.
nephritis.
stage."
stage."
None
35 days
None
None
Slight
Well
Albumen usually
most abdt. in m.
None
Oc. tr.
None
None
None
Well
None
Oc. tr.
None
None
None
Well
17th (p.m.) — end dist.
8 days ?
None
None
Slight
Died
Uraemia (death).
14th (p.m.), 34th
Oc. tr.
None
None
None
Well
Occasional trace of
(p.m.), 48th (a.m.)
albumen and blood.
min. tr.
15th— 50th tr.
56 days
None
None
None
Well
None
Once tr.
None
None
None
Well
22nd (p.m.) tr.
Once tr.
None
None
None
Well
None
Frequent tr.
None
None
None
Well
Albumen, when pre-
sent, always in
morning.
None
Frequent tr.
None
None
None
Died
Times at which al-
bumen appeared
very various.
31st— 33rd tr.
3 days
1 day
1 day
None
Well
Note continued pre-
sence of blood.
15th (p.m.) — 43rd
28 days
None
10 days
None
Well
(p.m.) dist. — tr.,
52nd (p.m.) — 56th
tr.
7th (p.m.) tr.
Twice tr.
None
None
None
Well
None
Twice tr.
None
None
None
Well
17th— 135th very
124 days
None
26 days
Slight
Well
vary.,abdt.to min.tr.
None
Once tr.
None
None
None
Well
21st (a.m.) and (p.m.),
25 days
24 hours
4 days
Dist.
Well
22nd (a.m.) tr., 22nd
(p.m.), 30th (p.m.)
con., 31st (a.m.) —
36th (a.m.) tr., 39th
(a.m.) — 47th (a.m.),
tr.
None
Twice tr.
None
None
None
Well
None
Twice tr.
None
None
None
Well
11th tr., 12th dist.,
10 days
24 hours
16 hours
None
Well
13th (a.m.), 17th
(p.m.) cons., 18th
(a.m.)— 20th (a.m.)
dist., 20th (p.m.)—
21st (a.m.) tr.
None
Twice tr.
None
None
None
Well
15th (p.m.) dist., 20th
12 days and
None
None
None
Well
(p.m.), 21st (a.m/
oc. tr.
min. tr., 21st (p.m. ]
dist.
124
SCARLATINAL ALBUMINURIA, ETC.,
No.
of
case.
Date
of
admission.
Age.
Sex.
Day of illness.
Periods at which albumen was detected. Number day
of illness. Abbreviations as above.
Ad id.
Disra.
89
90
May 14
June 2
14
18
M.
M.
8th
3rd
47th
169th
31st (a.m.), dist.
21st (a.m.), 27th (p.m.) tr., 28th (a.m.), 31th
(p.m.) cons., 35th (a.m.) — 58th (a.m.) tr.— dist, ;
85th (p.m.) tr.
91
92
93
June 9
June 19
June 21
14
8
8
M.
F.
M.
7th?
10th
10th
10th?
18th
115th
6th— 10th dist.
10th— 18th abdt.
10th— 50th tr., except 16th, 17th dist.
94
June 21
4
F.
4th
58th
16th (a.m.)— 27th (a.m.) tr.— con.
95
June 25
6
F.
6th
140th
16th tr., 17th (a.m.)— 68th con.— abdt., 69th—
76th dist.
96
June 26
10
M.
3rd
78th
30th (p.m.), 33rd (p.m.) ruin. tr.
97
98
June 27
June 30
7
8
F.
M.
2nd
3rd
56th
59th
42nd (a.m.) tr.
25th (p.m.) vary, from min. tr., 30th (a.m.), 32nd
(p.m.) min. tr.
99
100
101
102
103
104
July 3
Aug. 14
July 3
July 21
July 25
Aug. 7
7
3*
6
6
6
8
M.
M.
M.
M.
M.
M.
14th
10th
5th
4th
21st
7th
56th
88th
61st
23rd
88th
109th
14th, 15th, 16th tr., 18th (p.m.) min. tr., 241
32nd tr. — con.
loth— 53rd tr.— abdt.
11th (p.m.), 27th abdt— tr.
22nd (p.m.) tr., 23rd con.
15th— 30th tr.— con.
17th (p.m.)— 51th tr.— abdt.
105
Aug. 13
7
F.
9th
33rd
9th (p.m.) con., 10th (a.m.) dist., 11th— 18th tr.,
18th— 24th con., 24th— 33rd abdt.
106
Aug. 13
5
M.
10th
58th
10th— 20th (p.m.) tr.— dist.
107
108
Aug. 17
Aug. 22
15
s
M.
M.
4th
10th
55th
60th
18th (a.m.), 19th (p.m.) tr.
11th— 16th tr., 16th— 34th tr.— con.
109
110
111
112
Aug. 22
Aug. 28
Aug. 28
Aug. 28
9
10
?
5
F.
F.
F.
F.
4th
7th
10th
5th
54th
55th
B8rd
56th
14th— 22nd tr.— dist.
L8th tr.
17th (p.m.) — 33rd tr. — con.
.ith tr.
STUDIED BY FREQUENT TESTING
125
Haemoglobin detected,
Duration
" Pre-albu-
"Post-albu-
number day of
of
minuric
minuric
Dropsy.
Result.
Remarks.
illness.
nephritis.
stage."
stage."
None
Once tr.
None
None
None
Well
16th (a.m.), 31st
72 days
5 days
28 days
Con.
Well
(p.m.) tr., 32nd
(a.m.) — 52nd (a.m.)
dist., 52nd (p.m.) —
87th (p.m.) tr.
None
5 days
None
None
Abdt.
Died
10th— 18th ahdt.
8 days
?
None
None
Died
None
40 days
None
None
None
Well
Note in this case in-
crease of albumen
on 16th day.
15th (p.m.) tr.,16th—
16 days
1 day
3 days
None
Well
28th tr.— dist., 29th
— 31st (p.m. )min. tr.
16th (a.m.) — 41st
59 days
None
None
None
Well
(p.m.) dist. — con.,
42nd, 50th tr., 62nd
(a.m.) min. tr.
6th (a.m.) min. tr.,
46 days
14 days
27 days
None
Well
15th (p.m.), 29th
(p.m.) tr., 30th—
33rd dist., 34th
(a.m.) — 61st (p.m.)
min. tr. — tr.
None
Once tr.
None
None
None
Well
20th— 21st (p.m.) tr.,
11 days
None
None
None
Well
23rd (p.m.), 34th
(a.m.) min.tr. — dist.
14th— 37th tr.— con.
23 days
None
5 days
Con.
Well
21st— 40th tr.— con.
38 ? days
?
None
None
Well
14th— 20th tr.— dist.
13 days
None
None
None
Well
None
2 days
None
None
None
Died
Malignant.
None
Doubtful
None
None
None
Well
28th (p.m.) — 32nd
37 days
None
None
Con.
Well
(p.m.) min. tr.
9th— 19th tr., 20th—
24 days
?
None
None
Died
Note absence of
21st dist., 22nd—
dropsy with abdt.
33rd con.
alb.
13th (p.m.)— 17th
10 days
None
None
None
Well
(a.m.) dist., 18th
(p.m.) min. tr.
None
2 days
None
None
None
Well
17th — 22nd dist.,
20 days
None
None
None
Well
23rd— 25th tr.
None
7 days
None
None
None
Well
None
Once tr.
None
None
None
Well
None
16 days
None
None
None
Well
None
Once tr.
None
None
None
Well
112 cases of albuminuria.
2 cases of dropsy without albuminuria.
66 cases without dropsy or nephritis.
180 total consecutive cases of scarlatina.
ON SOME POINTS
BEGABDING THE
DISTRIBUTION OF BACILLUS ANTHRACIS
IN THE HUMAN SKIN
IN
MALIGNANT PUSTULE.
BY
ARTHUR E. BARKER, F.R.C.S.,
SUBGEON TO TTNIYEBSITY COLLEGE HOSPITAL AND TEACHEB OF PBACTICAL
ST7BGEBY AND ASSISTANT PBOFESSOB OF CLINICAL SUBGEBY
AT TTNIYEBSITY COLLEGE HOSPITAL.
Received May 11th— Read November 24th, 1885.
The observations which I wish to bring under the notice
of the Society are based upon the following case, the
notes of Avhich have been condensed as far as possible.
E. G — , set. 29, by occupation a maker of knife-cleaning
machines, was admitted into University College Hospital,
on June 7th, 1884. The diagnosis of malignant pustule
had been already made by the Resident Medical Officer,
Dr. Maudsley, before I was sent for, and I had only to
confirm the diagnosis on seeing the patient. The man,
though of good physique, looked very ill ; his expression
was heavy and anxious, the skin of his head and neck
looked dusky and greasy ; his tongue was coated and his
voice was thick. On the left side of the neck, lying upon
128 DISTRIBUTION OF THE BACILLUS ANTHRACIS
the sterno-mastoid muscle about an inch and a half
below the ear, there was a large zone of vesicles surround-
ing a central eschar of dark brownish colour. The latter
was hard, dry, and slightly depressed below the level of
the belt of vesicles. These ranged in size up to that of
a large split pea, and were filled with turbid yellowish or
pink serum ; they were very tense and hard. Beyond
them the skin was much indurated, the whole sore
measuring about 3x2 inches, the long axis of the oval
lying across the neck. There was no great local heat, but
much tenderness. Around this focus of disease the whole
of the left side of the neck was much swollen, indurated,
tense, and shining, the hardness reaching upwards beyond
the ear and on to the cheek, downwards over the clavicle
and across the middle line both in front and behind.
The hardness was peculiar in its distinctness and unlike-
ness to ordinary oedema. There was considerable diffi-
culty in swallowing and breathing, owing to the swelling
having affected the inner surface of the pharynx. The
patient's mind was quite clear and he had had no delirium ;
he seemed, however, worn out from want of sleep and
food ; there was a tendency to relaxation of the bowels.
He gave the following account of his illness :
On Wednesday, May 28th, 1884, he noticed a pimple on
the left side of his neck, which was red and itched a little.
On the following Saturday ic a small black head " having
developed he squeezed out the contents. At this time-
there was no particular swelling or redness around ; but
this was noticed two days later, and poultices were applied.
On June 5th he became very feverish, and small vesicles
appeared at the point of greatest swelling. These soon
burst and discharged pale straw-coloured or pink serum.
On the 6th, there was increase of difficulty in swallowing,
this having been first noticed on the 2nd ; the breathing
had also become somewhat embarrassed. There were also
marked restlessness, insomnia, and headache. Pain was
not limited to the affected spot, but was felt all over the
body and to a marked extent in the loins. There had
IN THE HUMAN SKIN IN MALIGNANT PUSTULE. 129
been anorexia and increasing weakness since the fifth day,
and on the ninth day he had two rigors, followed by two
more on each of the succeeding days.
He lived at St. John's Wood, but worked near the
Tower. He had a good deal of handling of horsehair,
bristles, and buff leather, but never raw hides. His own
impression was that he had contracted the disease at a
barber's where he had had his hair cut and had been
shaved ; the barber also lived near the Tower.
There was no hesitation as to the treatment. Before
operating, however, I carefully examined the serum of the
vesicles and the blood for bacilli in the usual way, over
and over again, but with a negative result. Still there
could be little doubt as to the diagnosis. I therefore
directed that a large piece of skin, including the whole
area of vesiculation and half an inch beyond, should be
excised in its whole thickness. The base of the resulting
wound was mottled with dark patches, apparently plugged
vessels. It was freely treated with the actual cautery
and dressed with iodoform.
The morning after the operation the temperature was
normal and the patient much better ; he made a rapid
recovery from this time. Three days after the operation
the blood and discharges were examined, but no bacilli
were discovered. The patient left hospital on June 24th,
with a small healthy wound still open.
Although the clinical history of true anthrax, both in
animals and man, has now been written with completeness
in this country by Mr. Davies-Colley,1 and in Germany by
Bollinger,2 some points regarding its minuter pathology
still appear to require further study in different cases.
Among these may be mentioned, first, the general distribu-
tion of the bacilli anthracis in the affected skin round the
point of inoculation in man, and next, their relation to the
production of the vesicles and eschar so characteristic of
i « Med.-Chir. Trans.,' vol. lxv, 1882.
2 Ziemssen, ' Handbuch der speciellen Pathologie,' Band iii (Translation,
vol. iii).
VOL. LXIX. 9
130 DISTRIBUTION OF THE BACILLUS ANTHEACIS
the disease. In reading the literature of the subject, one is
struck with the small amount of attention which these two
points appear to have received in this country, indeed, with
the exception of Dr. Charlewood Turner's admirable report
of the microscopic appearances in Mr. Davies-Colley's
case, I am not aware of any native source of information
regarding them. The case now recorded offers such a
good opportunity of studying the local disease that I
have thought it not unworthy the notice of the Society.
Generally speaking, it shows a close resemblance to the
condition of things described by Dr. Turner. But there
are some points regarding the distribution of the bacillus
in which the two cases appear to differ, and there are
others again a study of which in this case enables us
perhaps to carry our observations a little further than Dr.
Turner has done.
It is not improbable that the organisms may behave
differently in and about the locality of inoculation, in
different cases, or may vary in their habits at various
stages of the disease. It is only by an accumulation of
data bearing upon these questions that we shall be able to
explain the very remarkable fact, now firmly established,
namely, that free excision of the diseased area around
the malignant pustule is followed, in a large proportion of
cases, by rapid disappearance of all constitutional disturb-
ance and by complete recovery. This was almost a start-
ling feature in the present case. The disease had reached
the eleventh day, the constitution was evidently profoundly
affected, there had been several rigors, there were in-
somnia, anorexia, and great depression lasting for days,
besides which the whole side of the neck was in a
state of the most intense hardness, and yet after removal
of the piece of skin, including the circle of vesicles, imme-
diate disappearance of the constitutional and local sym-
ptoms resulted, and the patient was practically well next
day.
This is a fact most difficult to explain. Many hypotheses
may, of course, be advanced in an effort to clear it up ;
IN THE HUMAN SKIN IN MALIGNANT PUSTULE. 131
but it appears to me that, before everything, we need facts
regarding the local habits of the bacilli anthracis in and
about the malignant pustule, accumulated from the care-
ful examination of a large number of cases occurring in the
human subject. One very significant point is noticeable
in this case, and is also alluded to by Dr. Turner, namely,
that the bacilli appear to have a strong predilection for
the most superficial parts of the skin, and for them only.
If this rule should hereafter be shown to hold good in
numerous other cases, it will strengthen the hypothesis
that the organism can only attain to its fullest degree of
virulence in the presence of light and air, and that though,
it may be carried to deeper parts of the body and perhaps
increase there in a measure, nevertheless the original
colony around the focus of inoculation on the surface may
remain the principal, if not the only, generator of the
actual poison, whatever it may be, which depresses the
vital powers so powerfully. At present, however, I should
prefer to pass by such hypotheses and to range myself
with those who are endeavouring simply to accumulate
such data as those to which I have just alluded.
The diseased skin immediately after excision was dropped
into absolute alcohol and when hardened was frozen, cut,
and stained in the usual way. The resulting microscopi-
cal sections were particularly satisfactory and from them
I made the accompanying drawings (see Plate III) while
the colours were vivid and sharply defined.
The first point noticed with the naked eye about the
portion of skin excised was a peculiar dark mottling of
its under surface corresponding to the area of the malig-
nant pustule (fig. 1). This mottling appeared to be
produced by either an intense congestion with some
extravasation of blood, or, what seemed equally probable,
a thrombosis of vessels with staining around them. The
same appearance was noticed on the surface of the wound
left by the excision of the skin. The next point notice-
able was a distinct swelling of the diseased area, so that
the corium was about twice as thick here as elsewhere.
132 DISTRIBUTION OF THE BACILLUS ANTHRACIS
This swelling diminished rapidly at the outer margin of
the vesicles. The latter were of the flattened variety and
covered an oval area around the central, dark, dry eschar
(fig. 1). They were filled with pinkish serum for the most
part. Their size was greater towards the advancing margin
as if they had dwindled towards the dai'k, central area. The
latter, on section, was drier and tougher than the rest of
the skin.
On examination with the microscope, one is first
struck with the great abundance of bacilli immediately
under the vesicles and their fewness beneath the dry area
of the eschar. In the larger vesicles they appear in
smaller number than in the more minute, probably owing
to their having been, for the most part, washed out in
preparation of the sections. In some of the small com-
mencing vesicles, on the other hand, they are packed as
closely as possible and form a^ dark mass filling the space
completely.
In the deeper layers of the rete mucosum and at the
apices of the papillas they are more abundant than any-
where else (fig. 2, b). Here they are seen by the hun-
dred, packed so closely that under a low power they form
a continuous, dark, waving streak following the outline of
the papillas. They are also seen to descend along the
root sheaths of the hairs and are there in particularly largo
numbers (fig. 3, c). In contrast to all this, the bodies of
the papillas themselves show so very few bacilli as to
suggest that any that are present have only been deposited
there in the process of section cutting (fig. 2, h, e). Again,
in the vessels of the papillae I have not been able to find
any organisms, though they have been carefully looked
for.
The mode of formation of the younger vesicles is well
seen in several of the sections, e.g. fig. 2. The irritation
of the organisms in bhe deeper layers of the rete has caused
an outpouring of serum among the cells underlying the
epidermis, which has gradually forced the latter upward.-
forming loculi filled with iluid, between which delicate
IN THE HUMAN SKIN IN MALIGNANT PUSTULE. 133
columns of rete cells may be seen (fig. 2, a, a) . Between
these columns or bands of cells the bacilli are aggregated
in dense masses in the smaller loculi, but in the larger
they are found generally only around the borders, having
apparently been washed out from the centre of the space
in the process of preparation of the sections. Where no
vesicles have yet formed, the apices of the papillae are seen
to swarm with bacilli and appear softened and somewhat
broken up in consequence. Though the vessels of the
papillae and deeper parts of the cutis are well seen and
contain blood-cells and debris I have nowhere been able
to find organisms in them. Nor does the cuticle, or hair
substance, appear to be in the least invaded by them.
From all this it would appear that the bacilli have a strong
predilection for the most superficial parts of the true skin
and remain for a long time limited to this region ; also
that they spread superficially along the tract of the soft
cells of the rete mucosum. Again, it appears not impro-
bable that when the vesicle bursts, the production of an
ordinary suppurating sore is hostile to the life of the
bacillus, possibly through the introduction and antagonism
of other organisms. Numerous masses of what I take to
be micrococci are to be seen in the borders of the area
corresponding to the eschar.
These facts, pointing, as it would appear, to the at
first purely local distribution of the organisms, help to
explain the now common experience of the favorable
results of excision of the diseased area even many days
after inoculation.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 17.)
DESCRIPTION OF PLATE III.
(On some points regarding the Distribution of Bacillus Antbracis
in the Human Skin in Malignant Pustule, by Arthur E. Barker,
F.R.CS.)
Fig. 1. — Diagram, natural size, of transverse vertical section
through the malignant pustule, showing central, dry, thrombosed,
dark area surrounded by vesicles, and outside these the healthy
skin.
Fig. 2. — Vertical section of skin through the malignant pustule.
Hartnack, obj. 4 X 3 = X 90.
a. Horny layer of epidermis of collapsed vesicle.
bbb. Papillae of cutis covered at their apices and sides by
swarms of bacilli.
c c. Inflamed cutis infiltrated with leucocytes but showing
few bacilli.
On the surface of the papillae the rete is seen in the process of
developing small vesicles, some of which have just become con-
fluent.
Fig. 3. — Vertical section of skin. Hartnack, obj. 7 x 3= x 330.
a. Horny layer of epidermis.
b. Deeper layers, with vesicles commencing to form.
c. Root-sheath of hair with bacilli descending along its
boundaries.
d. A large vesicle formed by l-aised cuticle.
e. Clusters of bacilli located chiefly on the surfaces of the
papillce and deeper layers of the rete mucosum.
/. Clusters of bacilli in individual cells.
•
" :! ^%
:
-
«*«£-©&■* *
A CASE
OE SO-CALLED
ACTINOMYCOSIS OF THE LIVER.
BY
JOHN HARLEY, M.D. Lond., F.E.C.P., F.L.S.,
PHYSICIAN TO, AND LECTURES ON GENERAL ANATOMY AND PHYSIOLOGY
AT ST. THOMAS'S HOSPITAL.
Received November 10th— Read November 24th, 1885.
On October 1st, 1884, my friend Mr. J. Grossman, of
the Wandsworth Eoad, London, sent Joseph Robert W —
into the Arthur Ward of St. Thomas's Hospital.
The patient was thirty years old, and a joiner by occu-
pation. He was very pallid, about five feet eight inches
high, much emaciated, and weighed only seven stone. A
very painful tumour, about the size of an orange, pro-
jected forwards from the left hypochondrium ; the skin
covering it was distended, shining, and pale ; and the
swelling was very painful to pressure. It was obviously
connected with the left lobe of the liver, for it was limited
above, below, and to the right by a hard and dull surface
continuous with the liver, and it was strongly affected by
the pulsations of the aorta.
The enlargement of the liver was chiefly confined to the
left lobe. There was general slight impairment of chest
136 ACTINOMYCOSIS OF THE LIVER.
resonance, but the breath-sounds were fairly healthy, the
only abnormality being a faint occasional crepitation at
the left apex and clicking at the end of inspiration at the
sides. There was neither cough nor expectoration ; the
heart-sounds were normal, and the impulse in the fifth
space. The tongue was tender, and the epithelial covering
transparent — a condition predisposing to aphtha, which,
indeed, appeared very soon after and continued, with occa-
sional recessions (from treatment), up to the time of his
death. The rest of the alimentary canal remained healthy,
but the digestive power was feeble.
He died ten weeks after admission into the hospital,
his general condition undergoing very little change, and
his weight varying only a few pounds ; it attained its
maximum, seven stone four pounds, about five days before
his death. The temperature ranged usually, with great
regularity, between 97° F. to 98° at 8 a.m., and 101° to
102° between 8 p.m. and midnight; on four occasions
only the night temperature attained 103° to 103-6°.
During the last nine days of his life the temperature
declined, and on the last three, instead of rising in the
evening, as usual, it fell to 95°. Nocturnal (between 3
and 5 a.m.) sweating was for the first four months of his
illness a troublesome symptom.
Apart from his hereditary tendencies, the patient's
antecedents were good. He had had measles in child-
hood, but no other disease, and had led an industrious
and temperate life.
The patient states that he was in perfect health seven
months before his admission. A month later he came
under my friend Mr. Grossman's care for an attack of
acute inflammation, and he kindly furnishes me with the
following information :
"Family History, — The father, a3t. 7", lias suffered for
many years from asthma and chronic lung disease, and at
times severe functional disease of the liver. The mother has
also suffered from considerable derangement of the stomach
and liver, from piles and epistaxis, one attack of the latter
ACTINOMYCOSIS OF THE LIVER. 137
being so severe as to require plugging of the anterior and
posterior nares. Two sisters have been under my treatment,
one dying at the age of twenty-seven years, after about six
months' illness, of acute phthisis ; and the other is now
under occasional treatment for the same complaint, and
the prognosis is extremely unfavorable. The two brothers
I have not seen.
" The patient came under my care on February 23rd,
1884. He had returned from his work and was suffering
acutely from ' severe pain in the bowels/ which had been
preceded by shivering. There was neither vomiting nor
nausea, and the temperature then, and for some days after,
never exceeded 102* 5° nor fell lower than 100 "5°. Even
when the patient lost most of the pain and fever the
temperature never fell to the normal standard. During
the first weeks of his illness there was an anxious expres-
sion of face ; pain on moving in bed, and more or less pain
over the abdomen. At one time a blister was applied over
the left epigastric region (the part most complained of),
and afforded relief. The base of the right lung from the
first gave signs of pneumonia, and this continued for some
days, and then slowly cleared up. The urine was normal
in quantity and character. The liver area was normal ;
the heart weak but sounds healthy. In about eight or ten
days his condition became chronic wTith intermissions and
accessions of pain and feverishness. During most of the
time the respirations were short and painful, accompanied
with a hacking cough but with no serious expectoration.
The patient always maintained a stooping posture in
walking. There were no symptoms of jaundice, but a
constant colourless condition of conjunctiva, much loss of
flesh and great depression of spirits. After the first
month there was improvement but no signs of permanent
recovery, and in April, when a change was made into the
country, the patient returned very little better. On
May 5th, contrary to my advice, he recommenced work
and continued it for several weeks. The day before
he entered St. Thomas's I saw him and found for the
138 ACTINOMYCOSIS OF THE LIVER.
first time an abscess, tense and extremely painful, on the
anterior surface of the liver. He Avas advised at once to
proceed to the hospital for operation."
The swelling was characteristic of the disease. It was
pallid, arose up suddenly from the parts beneath, and was
surrounded by a uniformly firm base in the liver.
These characters sufficiently distinguished it both from
an ordinary abscess and from hydatid disease.
I incised it at once and freely, but was disappointed
with the result, for not more than two ounces of pus aud
blood could be removed. It had a slightly offensive
odour, and our house-surgeon, Mr. Makins, on introducing
the finger, found that the floor of the abscess was just
within the surface of the liver, which moved up and down
Avith the diaphragm.
Drainage-tubes were inserted, and an opening main-
tained up to the time of his death. Great relief followed
the operation, but the subsequent course showed plainly
that we had to do with a lowly organised disease. The
discharge was never free, and although the cavity was
freely and frequently injected Avith aromatic antiseptics
(eucalyptus and thymol) it was for a long time very
offensive.
The painful edges of the wound were long in showing
any disposition to granulate, and when they did so the
granulations were poor and pale. Very little pus
appeared upon the poultices ; but a small teaspoonful of
smooth, homogeneous, very thick, cream-coloured matter
could at any time be extruded sloAvly by pressing firmly
upon the indurated base of the abscess.
On the thirty-third day after admission a diffuse,
painful, fluctuating tumour was discovered in the right
loin. It was opened the folloAA-ing day, aud about two
ounces of offensive pus discharged; the twelfth rib,
covered however by its periosteum, could be felt in the
abscess cavity. Pus of the Bame character continued to
be discharged freely for a feAv days, and the absoess then
gradually contracted, bul never completely healed.
ACTINOMYCOSIS OP THE LIVER. 139
About the time of the formations of this abscess he
had a slight cough, with a little clear bronchial expecto-
ration, and the nocturnal sweatings which had much sub-
sided were again troublesome. On the evening of the
fifty -ninth day the cough suddenly increased, and during
the night he expectorated about sixteen ounces of rather
offensive and slightly rusty muco-purulent matter. This
was attended by signs of congestion (dulness, diminished
breath-sounds, and crepitation) of the lower and hinder
part of the right lung. Beyond the severe and distress-
ing cough, there were no other symptoms. The expecto-
ration ceased as suddenly as it appeared, and after
twenty-four hours he was in his usual condition with
scarcely any cough remaining.
But for the nature of the expectoration, one would
have supposed that he had emptied some internal abscess
by the lung. The general condition now improved a
little, and once more the mouth became free of aphtha3
(stomatitis fungosa — oidium albicans of the usual form).
The improvement, however, was only temporary. After
signs of increasing weakness for a day or two the patient
suddenly collapsed, and died on the seventieth day after
his admission into the hospital.
Post-mortem Examination. — The body was pale and
much emaciated, the abdomen not appreciably enlarged.
The contour of the hypochondrium was but slightly
raised, the prominency of the tumour having gradually
subsided. A pale, imperfectly granulated surface, about
the size of a florin, with a narrow cicatricial margin, and
a central aperture admitting a No. 5 elastic catheter, were
the remains of the original incision into the most promi-
nent part of the tumour. Firm continuous pressure on
the margins of the sinus caused the extrusion of a few
drops of very thick creamy, homogeneous pus.
Another sinus existed in the right loin, and com-
municated with the old abscess cavity in that situa-
tion.
The peritoneal surface of the left lobe of the liver was
140 ACTINOMYCOSIS OF THE LIVER.
thickened and adherent to the abdominal wall in front,
for an area of about two inches around the sinus, and
above to the diaphragm and pericardium.
The sinus communicated with a cream-coloured,
rounded, shreddy, boggy mass, the interstices of which
were occupied by a thick creamy pus. The whole mass
resembled a huge anthrax about the size of a large
orange.
Pus could be squeezed out of any divided part, but it
was for the most part retained in the shreddy interstices
of the tumour.
The liver was enlarged, weighing 5 lb. 3| oz. ; its
substance generally was quite normal. It stained black
when soaked in 1 per cent, solution of osmic acid ; the
bile and faecal matters were typically healthy in appear-
ance. A number of globular masses of morbid deposit
were scattered through the gland, two of them being
nearly as large as the one which had pointed externally ;
several were of the size of Tangerine oranges ; the
smallest were aggregations of a few tubercles the size of
hemp seeds. The smallest and youngest were co-exten-
sive with the hepatic lobule, and they were almost as soft
as brain substance. Where a dozen or more such
tubercles were aggregated the intervening liver tissue was
replaced by a coarse soft stroma, white and shreddy, but
near the surface often discoloured by post-mortem stain-
ing. Sections of these smaller tumours presented an
appearance exactly similar to that of caseous tubercle in
red hepatised lung.
The larger masses were always spherical, and their
central portions more or less softened ; being somewhat
confined by the surrounding liver, they bulged a little
beyond it when they lay near the surface.
These tubercular masses were scattered throughout the
liver, the larger and more advanced being in the thickest
part of the gland, and here two of them, each nearly three
inches in diameter, were separated by a band of liver
barely a quarter of an inch thick,
ACTINOMYCOSIS OF THE LIVER. 141
The youngest of the morbid deposits were found in the
thinner and marginal parts of the gland.
The disease was thus seen in all its stages from the
invasion of a single lobule of the liver, to the large puru-
lent mass which had been incised.
The liver-substance immediately surrounding both large
and small masses was dark and congested, and this
exaggerated what would have been otherwise a very sharp
line of demarcation between the healthy and morbid
structures.
The diaphragm was adherent to the surface of the
liver by recent inflammatory action. A few scattered
yellow tubercles the size of hemp-seeds pervaded both
lungs.
The right lung weighed 1 lb. 14± oz., and by its base
was adherent to the pericardium.
The left lung weighed 1 lb. 7 1 oz. Both lungs were
cedematous.
The pericardium was the seat of a chronic inflammation ;
it was thickened and adherent both to the pleurae and
diaphragm — to the latter in the immediate neighbourhood
of the incised mass ; and here it was reddish as if sharing
in a continuous inflammation. The cavity contained 25
ounces of serum, and both visceral and parietal layers were
thickly covered with a shaggy lymph. The heart weighed
13\ oz. and was quite healthy.
With the exception of the vermiform appendix, the
intestines were healthy. The appendix was long and
wide, and lay turned up along the attached part of the
ascending colon. Here it was inflamed and adherent to
the abdominal wall, which itself formed the limits of the
lumbar abscess. I am doubtful whether there was any
communication between them, there was certainly no trace
of pus in the appendix, the summit of which contained a
little soft faecal matter.
The kidneys were rather large, weighing together 15
oz., but they were apparently normal in structure, as was
the spleen (9- oz.) and the rest of the organs.
142 ACTINOMYCOSIS OF THE LIVEE.
Nimite Examination of the Liver. — Sections preserved in
spirit are extremely instructive and interesting. The
morbid masses are distinguished by their paler, almost
white colour, and a netted appearance (PI. 4, fig. 1). In
the smaller and younger masses the apertures of the net-
work— cavities, as I will call them, are circular, average the
one twenty-fifth of an inch in diameter, and are regularly
placed, the intervals being usually equal to the width of
the cavities. In sections of the older masses many of the
cavities are larger, some the eighth of an inch broad, and
are evidently formed by absorption of the partitions.
Some of the cavities are elongated and more or less
acutely elliptical or slit-like, sections, in fact, of bending
tubes.
Many of the cavities appear as mere cup-shaped depres-
sions, others are deep and winding ; all but the smallest
present secondary depressions or rounded ridges, some-
times faintly, sometimes strongly, marked ; they also pre-
sent a number of minute pin-hole apertures upon their walls,
but sometimes the cavities communicate by wide openings.
The stroma or framework of the morbid mass is composed
of the thick walls of these cavities and their intercommu-
nicating passages. It is a compact, dense, fibro-elastic
tissue, yellowish white where it lines the cavities, but
greyish and faintly diaphanous in the intermediate portion.
This stroma forms everywhere a complete investment,
being continued around the mass as a sinuous border,
soon blending with the liver substance and streaking it
as it does so with faintly marked concentric lines.
It is clear from this description that the framework of
the nioi'bid mass contains within its walls a system of
rounded cavities freely communicating throughout by fine,
and occasionally by large, passages; in brief, it is a close
network of fine thick -walled tubes, presenting compara-
tively wide dilatations or cavities at frequent and pretty
regular intervals ; — a structure approaching that of ordi-
nary erectile tissue
The question at once arises, what is the origin and
ACTINOMYCOSIS OP THE LIVER. 143
what the relationship of this network of enormously
thickened vessels ?
Sections taken from any part of the liver show the
hepatic canals (PL 4, fig. 1, b), and also the sublobular
veins to be perfectly healthy, even when the former lie
within half an inch of the main foci of the disease, and
the latter ramify within its area. But the reverse is
the case with the portal canals ; both arteries and veins
are everywhere enormously thickened, and the intervening
connective tissue proportionately increased (PL 4, fig. 1, c).
Further, these thickened vessels could be traced into
direct continuity with the network of vessels which forms
the stroma of the tubercular mass. It thus appears that
the afferent vessels — the portal vein, and the hepatic artery,
are those which are engaged in the morbid process ; the
hepatic vein escaping any implication.
Whatever share the lymphatics may have had originally
in the morbid process, they appear to have no place in the
dense, almost tendinous tissue in which the vessels are
now embedded. The bile-ducts also appear to be oblite-
rated. Of the two vessels, the portal vein and the hepatic
artery, thus associated with the disease, it will doubtless
be conceded that it is the artery which takes the principle
share in the process. Yet it is not certain that any new
vessels are formed ; I do not think it is necessary to assume
so, for the main bulk of the vascular stroma may be
regarded as the confluent interlobular plexuses of the
morbid areas. The cavities, however, have a different
origin, these I regard as the thickened capsules of the
invaded hepatic lobules — each of the smaller cavities re-
presenting an excavated lobule, its wall being formed of
the hypertrophied connective tissue of the interlobular
spaces, and perforated by the branches of the interlobular
plexus, which naturally enter the lobule. Thus is formed
a network of blood-vessels of an average diameter of the
^th of an inch, communicating freely with little cavities
continuous with them, measuring about the ^th of an
inch in diameter. As the disease advances to its purulent
144 ACTINOMYCOSIS OP THE LIVER.
stage these cavities may be enlarged by dissolution of the
intervening walls.
Further proof of this view of the origin of these
cavities is furnished by microscopical examination (see
p. 145).
I proceed now to describe the contents of these cavi-
ties— these sites of the original hepatic lobules. Turning
again to the sections preserved in spirit, and using a slight
magnifier, it will be observed that these little spaces are
partially filled (PL IV, fig. 2), each by a little yellow,
glistening, rounded granule lying naked in the recess, or
partially embedded in a little soft matter which is easily
washed away by a drop or two of water. The larger
cavities, those formed by confluence are usually occupied
by aggregations of these granules, which often resemble
in contour a microscopical raspberry.
These minute granules vary much in size, the smallest
are scarcely visible to the naked eye, while the largest some-
times attain the T'0th of an inch in diameter; the majority
are about the ^th of an inch (PL IV, fig. 3).
Characters and Structure of the Granules. — As may be
inferred from the above description, the granules lie loose
in the cavities containing them, and they may be readily
shaken or picked out of the cells ("cavities") which are
exposed in the section. Availing myself of this fact, I
have been able to collect and examine them thoroughly.
They are of a straw-yellow colour to the naked eye, but
under the microscope they are often stained of a deep
brown colour ; they are spherical, oval, pyriform, reniform,
and even sub angular in outline, and obviously composed
of aggregations of smaller granules about ^th of an inch in
size. Each constituent granule has a smooth continuously
curved surface, but the aggregation is convoluted like a
nodule of haematite, and like many renal calculi they present
sometimes one or two nipple-like elevations. Exposed to
the air they turn of a rich brown colour on drying, they
are quite solid and apparently quite homogeneous, and
have an average sp. gr. of 125 ; they have the consistence
ACTINOMYCOSIS OP THE LIVER. 145
of soft cheese, being" friable, and easily compressed by the
microscopic covering glass ; many, however, give indi-
cations of slight grittiness. They stain well and easily,
both with watery and alcoholic solutions of the dyes, and
they become dark in 1 per cent, solution of osmic acid.
Treated successively with nitric acid and ammonia they
give the xantho-proteid reaction. Thus treated and dis-
integrated a number of oil spherules are set free. Ex-
posed to combustion, they shrink very much, and leave a
small quantity of white ash, soluble in dilute HC1 and
giving when neutralised a precipitate with oxalate of
ammonia.
It appears, therefore, that they are composed of a
proteid substance associated with a little fat and calcic
carbonate.
Microscopical Structure of the Morbid Deposit. — Sections
of the morbid area showed that here the hepatic lobules
were in some places completely occupied by leucocytes, and
in others by leucocytes with the granules above described
(PL VI, fig. 2). The interlobular spaces were sometimes
obliterated by the coalescence of the lobules, and some-
times they formed very wide bands of nucleated connec-
tive tissue pervaded by dilated, and often varicose, thick-
walled vessels, sometimes loaded with red corpuscles.
Thus wide barren fields, the ^th of an inch and sometimes
more, composed wholly of leucocytes to the complete out-
crowding of liver- cells and blood-vessels, were presented
to the view (PI. VI, fig. 2). The leucocytes were well
formed — granular spherical corpuscles varying from the
g^gth to the r^'ooth of an inch in diameter, the majority
being the o^th- In the older tubercles these corpuscles
occasionally presented degenerative changes, becoming
clear and glistening, and staining imperfectly (PI. VI,
fig. 1, a).
The appearances described were in successful sections
prettily varied by the granules (see PI. V), which formed
bold groups of islands in the general waste of leucocytes,
for they are composed of a denser material, and present
vol. lxix. 10
146 ACTINOMYCOSIS OF THE LIVER.
in section a radiated structure like concrete crystals of
calcic carbonate (PI. V, VI).
The usually aggregate condition of these bodies is well
seen in sections. The simple spherical granules of which
the majority are composed vary in size from the -'.th to
the ^th of an inch, but in the progress of the disease do
not long remain isolated. In section the larger composite
granules have sometimes an angular outline flanked by
rounded bastions (PI. V, fig. 1).
The granules are embedded in and adherent to the
surrounding leucocytes, but there does not appear to be
any continuity of structure between them, for the granules
readily fall out of the sections, and after rinsing in fluid
present a very smooth surface. Still in fresh specimens
the adhesion is tolerably firm. In the older tubercles,
where the leucocytes have begun to soften, it is difficult
to retain the granules in sections, and their place is
usually occupied by a wide lumen.
Under a low power (x 120) sections of these simple or
composite granules present a radiated structure, in some
faintly indicated, in others very distinct. The centres of
some are diaphanous, or even luminous, the lumen being
circular (PI. YI, fig. 1), or from pressure subangular.
Some of these openings are the -'-th to the ~-th of an
inch. The centres of other granules are dense and pre-
vent the passage of light. Usually, however, the centres
are lighter than the rest of the granule, and present an
irregularly netted appearance (PI. VI, fig. 1), as if due to
a fine scanty stroma, which stains more readily than the
adjacent tissue. The radiations proceed from the central
clear space, or the apparenl nucleus, with regularity, as
straight or occasionally very slightly curved lines, and
terminate without alteration in the surface of the granule,
aud thus impinge upon the leucocytes which are adherent
to it. Under high powers, and when every detail in the
structure of the leucocyte is clearly define 1, the radiated
masses gain nothing in appearances. The radiations
remain soft, glistening, and wanting in sharp outline.
ACTINOMYCOSIS OF THE LIVER. 147
The netted centre -which I have described above as
stroma is in some granules more clearly seen than in
others (PL VI, fig. 1).
Twelve or more of these granules, some simple, some
composite, are frequently seen forming patches or colonies
occupying a considerable portion of the site of a lobule
(PI. VI, fig. 2). For a time they are separated by the
intervening leucocytes ; as, however, they enlarge and
coalesce, the leucocytes undergo degeneration; they withei*,
and, if they do not pass into pus, become reduced to a
diaphanous tissue, sprinkled with fine molecules, and
difficult to stain (PI. V, fig. 1) .
Changes also occur in the granules themselves. As
they grow older and larger they present a thick clear
cortical portion, destitute of striation, which, commencing
apparently upon its surface, may be occasionally seen
stretching far away into the tissue formed by the degene-
rating leucocytes (PI. V, fig. 2). The morbid deposit in
the lobules of the lungs presented exactly the same
features, but here the action was more limited, being
confined to single lobules.
Pathology. — It would appear that the first step in the
morbid process is the extrusion of leucocytes. Is it a
mere arrest of them in the liver, or is the lymph tissue in
this organ too active in generating them ? Of these two
suppositions, the former is perhaps nearer the truth, for we
know that the liver, like the lungs, is constantly receiving-
large numbers of leucocytes, and as they do not pass out
of the efferent vessels of these glands we must assume
either that they are used up in the chemical processes
going on in these glands, or that they are converted into
red corpuscles. If the latter be the case, then it is easy
to explain the plethora of leucocytes in the hepatic capil-
laries, by assuming a diminution of the oxydising pro-
cesses— a diminution of arterial blood. The question sug-
gest itself : Would partials ligature of the hepatic artery
result in the development of tubercle in that gland ?
Whatever may be the cause, a plethora of leucocytes
148 ACTINOMYCOSIS OF THE LIVER.
is one prominent fact, and, apart from any obstruction to
the hepatic artery, we can understand how a plethora
of these white corpuscles, by outcrowding the red, and
standing between them and the liver-cells, would lead to
a depression of the chemical action in the liver.
As an effect of the foregoing plethora and subsequent
effusion of the leucocytes, the liver-cells wither and ulti-
mately disappear, together with the intralobular plexus
of blood-vessels. Severe congestion of the interlobular
plexus is the result in these areas at first ; then follows,
with increasing obstruction, dilatation and thickening of
these vessels ; and when the obstruction in the lobules is
complete, stasis and, perhaps under the attendant irrita-
tion, plugging. In a large branch of the portal vein
I detected an old clot sending branches far and wide
into the small lateral vessels. Under the microscope this
shrivelled clot was seen to be spangled with colourless
crystals of calcic carbonate in spherical radiated masses,
and in aggregated prisms.
In marginal sections of the diseased liver the smallest
arteries are seen to be early affected. Leucocytes invade
their walls and stand in single and double file around
them ; while others are stationed between the rows of liver-
cells.
If the view which I have taken of the formation of the
cavities of the stroma be the true one, it follows that the
granules are formed in the interior of the lobules. When
the leucocytic invasion of these is complete the blood
current is of course entirely cut off, and the central parts
of the lobule, being farthest removed from nutrition, slu>\v
the first indications of degenerative change.
The deposit of a little calcic carbonate in the nucleus
of a leucocyte may be the starting-point of the granule,
its subsequent development being due to the extension of
the calcareous deposit into the surrounding tissue, the
leucocytic surrounding furnishing nutrition to the growing
granule just as the mucous membrane supports the growth
of a urinary or biliary calculus.
ACTINOMYCOSIS OF THE LIVER. 149
"Whatever the morbid action may be, there can be no
doubt, I think, that it originates in the lobule, for it is
here that its effects are most obvious, while they are at the
same time farthest removed from the first stages.
When these tubercular masses soften down, the pus is
of course wholly contained in the vessels of the stroma.
In the early stages the vessels, for the most part at least,
remain pervious and partially filled with leucocytes,
escaped, we may assume, from the lobules.
In the later stages they are filled with pus, and the diffi-
culty of evacuating this is explained by the fact that in
every cavity there is a granule, and sometimes in the aper-
tures of that cavity a corresponding number of nipple-like
projections from the granule : the smallest and simplest of
these granules forming therefore a great, and the larger
and more complex ones a complete, obstruction to the
outward flow of pus.
Having now finished my history of the case, I pass to
the consideration of a question of great interest in refer-
ence to the disease which I have described.
Those who are acquainted with the history of actino-
mycosis, and have heard my story and looked at my
illustrations, will be ready to say, " It is a genuine and
typical case of actinomycosis."
I am bound to admit that it agrees in many particulars
with most of the typical cases of this disease which have
been recorded, and my figures correspond exactly with
those of Lebert,1 Israel,3 and others, and yet I am per-
fectly satisfied, and hope to prove to the Society, that
there is no fungus whatever necessarily associated with my
case. If this be so, then much if not all of the so-called
actinomycosis disease must be relegated to its old, and, as
I believe, its proper place, namely, " tubercle."
There can be no doubt then that we have under con-
sideration an example of what has been described and
illustrated by several authors as actinomycosis, and it is
1 Traite d'anatomie pathologique,' Atlas; Tome i, pi. ii, fig. 16. Paris, 1857
' ' Archiv fur path. Anat, und Physiol.,' Virchow, Bd.74, 1878, Taf. ii.iii, iv.
150 ACTINOMYCOSIS OP THE LIVEE.
necessary that I should state the facts which lead me
to reject the fungus theory of the production of the
disease.
It will be conceded that the present case furnishes a
complete illustration of the disease from its first origin as
a few escaped leucocytes in the centre of a lobule of the
liver, to the ripe, purulent mass which projected exter-
nally. If the disease be due to a fungus, the fungus is
here accessible to our observation and readily capable of
demonstration. Simpler still, the fungus is confined to
the granules, and it is these,1 therefore, to which I must
invite attention.
These granules may be regarded as typical examples of
caseous degeneration of tubercular deposit.
I have stated that they are composed of a solid albu-
minous matter containing a little fat and calcic carbonate.
The inorganic matter has been very long recognised as
a constituent of tubercular nodules, and when it is in suffi-
cient abundance to make them gritty, there is no denying
its presence. But I am not aware that the advocates of
the fungus origin of this disease will allow that any por-
tion of the radiation in such a case as I have described is
due to crystalline structure. They regard the rayed
appearance as being due to the club-shaped asci of the
fungus. In the present case nothing is easier than to
disprove this view. If a section of a granule, or an aggre-
gation of them, be selected for the boldness and distinc-
tion of its rayed appearance, and treated with strong
acetic acid, while it is observed under the microscope, the
radiations will melt away rapidly and, except perhaps in
an old granule here and there, completely disappear, thus
proving that they are due to crystalline matter soluble in
the acid. It is in fact a delicate impregnation of an albu-
minous and fatty basis with calcic carbonate, which, like
the organic basis of bone, may be removed without
affecting the integrity of the matrix in which it is deposited.
' A Urge pumber of these Uolaljed granjnli i wtpe qghjhited to the Society.
ACTINOMYCOSIS OP THE LIVER. 151
This simple test is decisive, for if any fungus were
present its finest portions would be brought out conspicu-
ously in a specimen cleared by strong acetic acid.
Granules or their sections may be rendered perfectly
transparent and subsequently disintegrated by means
of acetic or the mineral acids, by caustic potash and
ammonia, and when examined in this state by the highest
powers ( x ~--) they have failed to furnish me with
the faintest trace of fungoid growth.1
Turning now to the physical conditions of the fungus,
let us see what presumption these afford of the presence
of a fungus. First, as to its position in the body. We
find it in a flourishing condition, according to the descrip-
tions, in the very centre of the morbid mass, where it is
bathed in carbonic acid, and shut off from oxygen — a
condition, as far as we know, incapable of supporting the
growth of a fungus, which more than all other vegetables
wants a free access of oxygen.
Again, the granule is not a mere mouldy mass like a
bit of mouldy cheese, with its cavities, cracks, upheavals,
and erosions, but a compact solid body with a smooth
surface like a nodule of hasruatite. Cut it which ever way
we will, we fail to recognise sections of the filaments or
asci, which, if any such existed, would be, according to the
measurements given of them, as plainly visible as the
cross sections of fibres in a medullated nerve-bundle.
The outer ends of asci are represented as not being all on
the same level at the circumference of the actinomycosis
mass, but my granules give no indication of such irregu-
larity ; they have, as I have said, a smooth and rounded
surface.
Having examined the youngest and oldest of the isolated
granules with the same result, I have explored a large
quantity of debris, obtained by washing out the cells of
the stroma with spirit.
This debris was composed (a) of granules ; (b) of whiter
1 See Appendix.
152 ACTINOMYCOSIS OF THE LIVER.
and lighter flocculent masses of leucocytes, in which the
granules were embedded, and (c) a very small heavier residue
composed of crystals. No trace of fungus was found in the
lighter portions of the debris. The crystals were very
minute, none more than the j^th of an inch in size, and
as they all dissolved in acetic acid with escape of bubbles
of gas, I assume that they were all calcic carbonate ; a few
were thick and rhomboidal like Iceland spar, a few others
were smooth, spherical, or elliptical masses, the majority
were clusters of a few coarse or many fine prisms. Some
of the latter were beautiful rosettes, and when treated
with acetic acid they separated into their constituent
prisms, which had a strong resemblance, on account of
their clavate form, to the conidia or asci of the actino-
myces.1 Sometimes two crystals were united, causing a
forked appearance, which gave a still stronger resemblance.
Soon, however, they melted in the acetic acid and totally
disappeared. All these crystals were bright and colour-
less.
Scanning the field, on one occasion, with a very high
power and a too thick covering glass, I caused it to slide
as I was passing over some thin plates of cholesterin, when
all at once the looked-for fungus, as I thought, appeared.
Everywhere in the field long distinct filaments with
expanded ends lay in bundles, and on all sides arborescent
and feathery forms.
I mention this because, if a similar displacement had
occurred in a fragment of cholesterin overlying one of the
radiated masses, its meaning could only have been inter-
preted by the use of a solvent, of which there are so few
for cholesterin.
Are we now to assume from this case that fungi are
secondary and therefore non-essential developments in the
cases of actinomycosis which are recorded. This, I think,
would not be assuming too much. Fungi may spring up
anywhere in the body when there is a free surface and a
supply of oxygen, or in any fluid of the body, and there
1 Israel, ' Vircbow's Archiv,' 1878, t. iii, fig. 5.
ACTINOMYCOSIS OF THE LIVER. 153
is perhaps no more likely place than the sinus of an old
abscess — nay, more, the surface of the granules them-
selves when they are thrown out into the sinuses may
become clothed with fungi. A patient of mine died of
phthisis many years ago in Kings' College Hospital, and
at the post-mortem examination two of the papillas of one
kidney were found ulcerated ; on examination T found the
Oidium albicans luxuriantly developed for some distance
along the straight tubules. But the conditions in such
cases, as I have just mentioned, are very different from
those of the so-called actinomycosis, in which the fungus
is assumed to develop in a solid mass without disturbing it.
The striations which I have described and figured
are, I maintain, nothing more than the earliest indications
of that calcareous and fatty degeneration to which caseous
tubercular deposits are so liable, and have no more con-
nection with fungoid growth than a gall-stone has.
Appendix.
On the occasion of the reading of this paper my late
Demonstrator of Physiology, Dr. Theodore Acland, who
has taken a most laudable interest in this case, exhibited
some specimens of mycelium obtained from it which he
observed only two or three days previously when he was
looking for bacilli. After the lapse of a year from
the death of the patient, I naturally concluded that the
fungus was a post-mortem development. Nevertheless,
I have thought it my duty to reinvestigate the matter.
Knowing how prone such matters as caseous tubercle are
to fungous invasion, I was careful in making my original
investigations to select the smallest and youngest of the
tubercular masses, and to avoid those which had any
communication with the external sinus, which had existed
for many weeks and was frequently injected with fluids
from without. In these, as I have stated, I have failed
to detect any trace of a fungus.
154 ACTINOMYCOSIS OP THE LIVER.
In renewing my search the only material left to me was
the museum specimen and the slice which is represented
in PI. IV. This includes the ripest portion of the disease
and that which lay in contact and continuity with the in-
cised mass, and also some of the youngest deposits as seen
at d, PI. IV, fig. 1. The specimen had been kept immersed
in methylated spirit in a glass dish, covered loosely by a
plate of glass, and it had been drained and exposed upon
a glass plate several times for the purpose of examination
and delineation. It is this portion of the liver which I
have examined. I took the granules promiscuously,
removing some from their natural position in the cells of
the stroma, and collecting others which had fallen out
into the preservative fluid. They were stained and
mounted by the most approved methods for demonstrating
micro-organisms.
In this way I have examined great numbers of these
granules, and the result is that in a very few I have found
traces of an extremely fine mycelium-like structure, but
none of the club-shaped asci which are regarded as cha-
racteristic of the Actinomyces horns.
Now, under the circumstances it will be conceded, I
think, that the complete absence of fungoid growth would
have been more remarkable than its presence, and this
renewed examination has confirmed me in my former
opinion that the fungus is not of the essence of the disease,
but merely an occasional and accidental associate. With
due deference to those who regard the fungus as the
essence of the disease, I would ask them, as opportunities
occur, to direct their attention to those portions of the
diseased structures which have no communication with
the surfaces of the body, and to the very earliest develop-
ments of the morbid action, and by this moans exclude the
question of accidental and secondary contamination.
The case above narrated is, I believe, the first of the
kind which has been noticed in this country, and it is
certainly not a common form of disease. I have regarded
it from the first as an example of tubercular disease from
ACTINOMYCOSIS OF THE LIVEK.
155
which the liver is so remarkably free ; and the close exa-
mination which I have given the case confirms me in this
view. {May, 1886.)
(For a report of the discussion on this paper, see 'Proceed-
ings of the Royal Medical and Chirurgical Society,' New Series,
vol. ii, p. 20.
DESCRIPTION OF PLATES IV, V, and VI.
(A Case of so-called Actinomycosis of the Liver. By John
Haeley, M.D.)
Plate IV.
Fig. 1. — Section of the liver as it appeared in methylated spirit
(natural size).
(a) One of the principal masses,
(fc) Hepatic veins.
(c) Portal canals ; vessels much thickened.
(d) Youngest deposits.
Fig. 2. — A portion of (a) Fig. 1, showing the cavities, some con-
taining granules, x 3.
Fig. 3. — A heap of isolated granules. X 2.
Plate V.
Figs. 1 and 2. — Radiate granules, surrounded by leucocytes, x 60.
Plate VI.
Fig. 1. — A minute composite, radiate granule, showing variations
in the central parts; in one a circular lumen, in others a nuclear
matter, and in the largest a netted stroma. This granule is sur-
rounded by leucocytes, some of which (b) are partially, and the rest
(a) wholly, degenerated, x 150.
Fig. 2. — Three lobules invaded by leucocytes (a, a), interspersed
with radiate granules, darker, and separated by thick walls of fibrous
tissue, containing thick-walled blood-vessels, x 12.
Hate IV.
Med. Chir. Trans. Vol . LXLX.
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A CASE
OP
DESTRUCTION OF A PORTION OF THE
AXILLARY ARTERY
BY
SARCOMA.
¥M. S. SAVOEY, F.R.S.,
8ENIOE SUBGEON TO ST. BARTHOLOMEW'S HOSPITAL.
Received May 15th— Read December 8th, 1885.
A labourer, aged thirty- three, a fine, powerful man, came
to the hospital in November, 1884, with a large tumour in
front of the chest on the right side, plainly visible by its pro-
minence, although situated beneath the pectoral muscles.
It extended from beneath the clavicle to the axilla, where
it could be seen and felt with a well-defined border,
immediately behind and somewhat beyond the lower mar-
gin of the pectoralis major. The mass was uniformly
soft ; to some suggesting even fluid, but to most of us a
texture like fat or cellular tissue. There was no pain or
any material uneasiness in the part, but the pulse in the
arm of that side was much smaller than in the opposite
one. The man himself had been aware of something
wrong for about nine or ten weeks, and during the fort-
night or so that it was under observation the tumour
manifestly increased.
158 DESTRUCTION OF A PORTION OF THE
It was decided to attempt the removal of the growth.
I exposed its outer extremity by a free incision along the
lower margin of the pectoralis major where it appeared,
through the fat of the axilla, by the well-defined surface
of a distinct capsule, but a little further dissection clearly
showed it to be a soft sarcoma. The pectoralis major
first, and then the minor, were divided so as to reach the
upper portion of the tumour, which extended to the large
vessels, and was found completely investing them for at
least some three or four inches of their course. All that
part of the tumour which lay below the vessels was easily
removed, but it was determined to make no attempt to
detach the portion which invested the vessels, and we
proceeded to secure some small and insignificant arteries
which had been divided in the operation. While thus
engaged it was observed that the haemorrhage, which up
to that time had been but slight, began to increase con-
siderably from the region of the upper portion of the
tumour, but no particular vessel, as its source, could be
distinctly seen. However, even every touch with the
sponge seemed to make matters worse, and in a few
seconds more there was such a gush of arterial blood that
it was with the utmost difficulty controlled by Mr. Marsh,
who dexterously grasped the bleeding mass. An en-
deavour was made to assist him by pressure on the sub-
clavian above, but this had very little or no effect. In
order to obtain a clearer view of the bleeding orifice I
exposed for a short distance the axillary vein, a small
part of which could be just seen, placed two ligatures on
it, divided it between them, and turned the ends up and
down. Then we could discover no artery in the situation
where the axillary ought to have been found, but it was
plain that the blood came from the place which it should
have occupied — both from above downward and from
below upward. After two or three ineffectual attempts, I
succeeded in grasping the upper orifice with pressure
forceps, which arrested the hemorrhage in that direction,
but the abundant haemorrhage from below still continued
AXILLARY ARTERY BY SARCOMA. 159
until the lower orifice was in like manner secured. When
the immediate danger from this cause was over we could
with more leisure secure two or three other bleeding
points in the immediate neighbourhood by additional
forceps, but no ligature would hold, and after one or two
futile attempts to apply them, we were compelled to leave
the forceps as they had been placed on the vessels.
Around them, for additional security, some strips of lint,
soaked in a solution of perchloride of iron, were carefully
packed, and the wound was partially closed. It had
become evident to us all that the integrity of the main
artery had been destroyed by the disease ; for in no
other way could the furious haemorrhage be explained, as
the knife had never been used in that region at all, and
when the vein was divided no trace of the vessel in its
place could be found.
The man was in a state of collapse for some time, but
he gradually rallied, and for just a week after the opera-
tion he went on as well as possible. There was no sign
of any recurrence of the haemorrhage, and his only com-
plaint was of some numbness in the tips of one or two of
the fingers. But then, on a sudden, there was a violent
gush of blood from the wound, and before it could be
arrested the man was dead.
The axillary artery was traced from below upward in a
natural state, until it arrived at the substance of the
tumour, into which it passed. When this was laid open,
an irregular aperture was found in the artery just above
the lower border of the tumour, and from this point
upwards, for another few lines, the artery was completely
broken up and rapidly disappeared, so that, for about two
and a half or three inches, no further trace of arterial
wall could be discovered. The boundary of the cavity
beyond, through which the blood must have passed,
appeared to be simply the substance of the tumour, until
at its upper part, just below the clavicle, arterial wall
was again found, and this was continued, surrounded by
the tumour, into the subclavian artery.
160 DESTRUCTION OF A PORTION OF THE
The substance of the arterial wall, especially of its
lower portion, was infiltrated with the sarcomatous growth,
and was thus rendered soft and easily lacerable. Round
cells, in abundance, were crowded through the whole
thickness of the arterial tunics. The termination of the
artery, below and above, in the tumour was very indefi-
nite. The tissue of one blended with that of the other, so
that it became impossible to define exactly where the
artery ended and the growth began. The lower portion
of the artery, for an inch and a half from the orifice, was
occupied by firm pale clot, evidently of some duration.
Mr. D'Arcy Power has been good enough to favour me
with the following note of the histological appearances
presented by the axillary artery at a point immediately
below the seat of rupture.
" The artery is embedded in a mixed-celled sarcoma,
which has infiltrated the tunica externa in such a manner
as to render it impossible to separate the vessel from the
tumour. The middle coat is thickened by an increase of
its fibrous tissue, and intermixed with the elastic fibres
are a large number of sarcoma cells, most of them round,
others fusiform. A distinct band of sarcoma tissue occu-
pies the centre of the middle coat. The internal coat is
reduced to a thin elastic membrane, which has, in some
places, given way, thus allowing the sarcomatous tissue to
extend into the lumen of the vessel. The same changes
are visible in sections of the thoracic axis."
The axillary vein, which had been divided in the
operation, was found to be but little altered — perhaps
somewhat dilated where it passed through the substance
of the tumour ; but there was no breach of its continuity.
It was filled with recent clot.
The nerves of the brachial plexus were found in a
normal state.
The tumour itself presented all the characters of a
round-celled sarcoma.
Another case like this is not within my experience,
nor can I find a similar one on record. Of course, in-
AXILLARY ARTERY BY SARCOMA. 161
stances of malignant tumours — both sarcoma and cancer —
and others, involving large vessels, and even completely
including them, have been frequently met with. Nay,
instances are not very rare in which such vessels, by such
means, have been seriously obstructed, and even pene-
trated or otherwise much damaged by the invasion of the
growth. But here a considerable portion of the axillary
artery was completely destroyed, and, for more than two
inches, the blood stream must have passed through a
channel whose walls were formed of the substance of
sarcoma only. I suppose it would be generally affirmed
that the arterial tunics are remarkable among tissues for
the resistance they offer to destructive action of any kind.
We all are familiar with cases in which they have been
seen traversing long tracks of disease that has destroyed
the surrounding structure, still in their integrity. There
are indeed, I need not say, notable exceptions to this.
For one, I may refer to a case recorded in the sixty-fourth
volume of our ' Transactions/ in which several inches of
the common carotid artery, as well as of the jugular vein
and pneumogastric nerve, had disappeared in an abscess.
But the present case is remarkable, and to me singular,
in that there was not only complete destruction of a large
portion of an artery, and this by a malignant growth, but
that no other structure invaded by the tumour appeared
to have suffered in any considerable degree.
The specimen is preserved in the museum of St. Bar-
tholomew's Hospital.
(For report of the discussion on this paper, see ' Proceedings of the
Royal Medical and Chirurgical Society,' New Series, vol. ii, p. 25.)
VOL. LXIX. 11
AMPUTATION AT THE KNEE-JOINT BY
DISARTICULATION ;
WITH REMARKS OS
AMPUTATION OF THE LEG BY LATERAL FLAPS.
THOMAS BR¥ANT, F.R.C.S.,
SENIOR SURGEON TO GTTY'S HOSPITAL.
Received August 31st — Read December 8th, 1885.
Amputation by disarticulation at the knee-joint was
first performed in England by Mr. S. Lane at St. Mary's
Hospital in 1857 (' Lancet/ 1857, vol. ii). The operation
was first prominently brought before British surgeons in
an able paper by Mr. G. D. Pollock1 and more recently by
Mr. P. Pick, in an interesting communication read before
the Medical Society of London.2
I have practised the operation since the year 1868.
In America it has found able advocates in Dr. Stephen
Smith, of New York,3 Dr. Markoe, of New York,4 Dr.
John H. Brinton, of Philadelphia,5 and Dr Staples.6
i ' Med.-Chir. Trans.,' vol. liii, 1870.
2 ' Med. Soc. Proceedings,' vol. vii, 1884.
3 ' New York Journal of Medicine,' Sept., 1852, and ' American Journal of
Medical Sciences/ Janviary, 1870.
4 ' New York Medical Journal,' January, 1856, and March, 1868.
5 ' American Journal of Medical Sciences,' April, 1868.
lb., January, 1872.
164 AMPUTATION AT THE KNEE-JOINT
Yet, in spite of this advocacy, the operation is not fre-
quently performed. By the majority of surgeons it is still
regarded with suspicion.
It is difficult to estimate how far this dislike of the
operation is due to a want of experience of its advan-
tages and how far to the groundless dread of leaving arti-
cular cartilage upon the bone, under the mistaken impres-
sion that it will probably undergo degenerative changes,
and so retard repair. I would also give, as an additional
reason for the neglect of the operation, the personal liking
which surgeons have recently shown for what I, for the
sake of clearness, prefer to call the condyloid operation of
Velpeau, or the supracondyloid amputation of Stokes.
It is clear that the operations of Velpeau and Stokes,
are applicable to cases of disease or destruction of the
knee-joint itself, whereas the operation of amputation
by disarticulation at the knee-joint can only be per-
formed when the disease, or injury, for which the amputa-
tion is practised is localised to the leg ; when the condyles
of the femur are unaffected or but slightly involved ; and
when there is a sufficiency of healthy soft parts below the
knee, from which good flaps can be made. With these
conditions present, the operation of amputation by disar-
ticulation should, for reasons to be given presently, be
performed.
I will now proceed to consider the value of the operation
as shown from my own practice.
BY DISARTICULATION.
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BY DISARTICULATION. 169
Analysis of cases. — Thirty cases have been tabulated,
and of these, nineteen were amputations performed for
disease or for reasons of expediency, and eleven for injury.
In the group of nineteen amputations for disease, one
patient only died from the operation (Case 8), a man
aged thirty-two, suffering with epithelial cancer involving
the tibia. He sank on the fourth day from kidney disease.
Of the eleven traumatic cases six died (Nos. 1, 5, 7, 9, 10,
11), and of these it is fair to say that the operation simply
failed to save life, since it was performed in Case 1 for
gangrene due to obstruction of the external iliac artery,
the result of over- stretching of the vessel by a displaced
fragment of a broken pelvis ; in Case 9 as a primary
amputation of a limb, crushed by the passage of a tramcar
over it, in a child aged eight who had lost much blood
before the operation ; and in Cases 5, 8, and 10 as a
secondary amputation for compound fracture of the leg in
a woman aged sixty-one, and in men respectively fifty-two
and sixty-eight years of age. Case 11 was remarkable,
since death took place on the thirty-third day from secon-
dary hemorrhage, the result of an abscess in the extremity
of the popliteal artery, which had been twisted at the
time of operation. The patient was a man aged thirty,
for whom a secondary amputation had been performed for
compound fracture. The stump had healed, with the
exception of one sinus, which evidently led down to the
popliteal artery. I give an account of the preparation
obtained after death from the pen of my friend, Mr. John
Poland : " The stump presented on either side an almost
level granulating surface, and on the posterior aspect
another granulating surface running vertically upwards.
At the upper end of this there was a sinus leading into a
small abscess cavity in the position of the end of the
popliteal artery. From this sinus a good- sized stream of
water flowed when the common iliac was injected by means
of a syringe. The walls of the abscess cavity were com-
posed of soft shreddy slough, and there was an entire
absence of granulation tissue. About the middle of
170 AMPUTATION AT THE KNEE-JOINT
this abscess the divided end of the popliteal artery lay,
presenting a most interesting condition. Suppuration
had taken place between its middle and inner coats,
burrowing upwards in such a manner as to completely
separate the two for a distance of an inch and a half, so
that the internal coat lay like a cast in the middle of the
tube, and looked not unlike a coagulum. The upper part
of this inner coat was thin and papery, and the upper limit
of its separation from the outer coats abrupt and well
denned. The lower three fourths of an inch, shaggy,
softened, and sloughing, lay loose in the cavity. Above
this presented the opening into the interior of the tube-
like inner coat, which for a distance of an eighth of an
inch contained the remains of some broken-up adherent
coagulum. It was from this orifice that the hasruorrhage
had taken place into the suppurating cavity and sinus.
Corresponding to the whole length of the suppuration
between the coats, the outer coats were found to be
thickened by inflammatory material to double their normal
size, and this condition extended upwards for a quarter of
an inch above the upper limit of separation of the coats.
Above this all the arterial coats appeared to be healthy.
Below, the outer coats were continuous with that lining
the abscess cavity and ended indistinguishably in it.
" The femoral vein was plugged for a distance of five
inches with firm adherent clot. The suppuration between
the coats of the popliteal artery being directly continuous
with the cavity below, was clearly due to an inflammatory
affection extending from the latter to the coats of the
vessel, setting up a diffused suppurative arteritis. This
inflammatory process is of an exceedingly unhealthy
character, as shown by the sloughy condition of the wound
and twisted end of the artery.
" I believe that all cases of secondary hasniorrhage at
the present day will be found to be directly traceable to
this particular inflammatory condition of the wound impli-
cating the arterial coats. That this is a so-called septic
form of inflammation I am not inclined to believe, but
BY DISARTICULATION. 171
rather that it may be dependent, to a very great extent,
on some particular tendency of the patient."
Remarks. — Upon the whole, the operation, with respect
to its dangers, must be regarded with favour. Of nineteen
cases of amputation for disease, one only, or about 5 per
cent., died ; and of the traumatic cases about 50 per cent,
were fatal, whilst the causes of death in these fatal cases
were, in all the examples tabulated, due rather to general
causes than to any condition which can be directly
attributed to the operation itself.
On sloughing of the flaps. — With respect to this question,
as determined by the cases tabulated, sloughing took
place in four of the nineteen cases of amputations for
disease.
In Case 2 the slough was enough to expose a portion
of one condyle of the femur from which the cartilage
exfoliated.
In Case 7, that of a man aged fifty, who had epithe-
lioma of the leg involving the tibia, amputation was
performed with an anterior flap of median length and a
posterior flap. A small slough on the anterior flap took
place, but with no detriment to the patient.
In Case 13, amputation was performed in a man aged
seventy, for a useless and ulcerated stump of the leg after
an operation done nine years previously for some injury.
Lateral flaps, after Stephen Smith's method, were adopted.
Some sloughing of one flap took place, and exposed the
inner condyle from which the cartilage exfoliated ; but a
good stump was subsequently secured.
In Case 15, that of a man aged sixty-two, with epithe-
lioma of the skin and tibia, lateral flaps were also made.
One of these sloughed and exposed the corresponding
condyle of the femur, which underwent superficial necrosis.
But in this case, as in the preceding, a good stump was
secured.
Sloughing also followed in two of the five successful
amputations for injury ; but in both it was very limited,
172 AMPUTATION AT THE KNEE-JOINT
and proved in no "way detrimental to the usefulness of the
stump. In one of these — Case 4 — a primary amputation
was undertaken in a boy aged fifteen, for crushed foot
and leg ; lateral flaps were made, and a small slough
formed in the posterior angle of one of the flaps from the
pressure of a splint.
In Case 6, one of secondary amputation for compound
fracture in a woman aged forty-four, a slough, the size of
half a shilling, took place in one of the flaps, but a good
stump resulted.
It occurred also in two of the fatal cases, but was in
no way to be attributed to the operation (Cases 1 and 9).
Regarding the sloughing process with respect to the
nature of the operation performed, it may be stated that
of three cases in which the long anterior flap was employed
(two for disease and one for injury), there was sloughing
to a degree in two. In one of these, however (Case 1 in
the table) gangrene had already resulted from plugging of
the external iliac artery.
In six of the cases (all pathological) an anterior flap was
made of medium length — about three inches and a half —
extending from the posterior margin of the condyles down-
wards to a point an inch below the tubercle of the tibia.
This was combined with a posterior flap of about two inches
reaching down to the level of the tubercle of the tibia. In
these six cases there was sloughing in one only (Case 7),
in which, however, the process was very limited.
In the remaining twenty-one cases the operation was
performed with lateral flaps, after the method of Stephen
Smith. Eleven of these were amputations for disease. In
two (Cases 13 and 15) sloughing occurred; whilst ten
were traumatic cases, in three of which (Cases 4, G, and
9) there was sloughing, but in the last case (0) the
sloughing process was unconnected with the form of
amputation.
Out of the whole thirty cases sloughing to a degree
took place in eight. But if we eliminate Cases 1 and 9
in the traumatic table, in which the sloughing process
BY DISARTICULATION. 173
had no relation to the operation itself, the number is
reduced to six, or to one in every five cases.
In none of the successful cases did sloughing take
place to any extent, and it never materially interfered
with the subsequent value of the stump.
In the cases in which there was no sloughing an excel-
lent stump was obtained. No trouble was ever experi-
enced from the articular cartilage over the condyles of
the femur during the healing process, and when the
stump had healed, the soft parts moved freely and loosely
over the end of the bone. The cicatrix in all the cases
was placed well behind the femur (vide Fig. 3, p. 177).
In all but the first three operations the patella was
preserved ; the removal of this bone I found to be quite
unnecessary.
Patients after this operation are usually able to bear
any amount of pressure upon the stump, and they can
walk with greater facility than can patients after any
form of amputation through the thigh. This result is
probably due to the fact that the attachments of the
muscles of the thigh, and particularly of the adductors,
are less interfered with than they are in supracondyloid
amputations.
For my own part, I know of no great operation which
is followed by less shock, which repairs so rapidly and
with so little constitutional disturbance, which forms
a better and more useful stump, and which enables a
patient to walk so well with an artificial leg.
The Operation. — Three different methods have been
advocated,— 'the long anterior flap of Pollock, the lateral
hooded flaps of Stephen Smith, and the lateral flaps of
Pick.
The first operation, as described by Pollock,1 is as
follows : " I make it a rule to feel for the interval between
the edges of the condyle and head of the tibia, and to
commence my incision at that point, and immediately
behind the edge of the hamstring muscle, as it crosses that
1 ' Med.-Chir. Trans.,' vol. liii, 1870,
174 AMPUTATION AT THE KNEE-JOINT
space. I take especial care never to commence my inci-
sion higher than the margin of the condyle. The incision
should be carried perpendicularly downwards on the side
of the leg till nearly five inches below the lower edge of
the patella, then gradually brought across the front of
the leg, and when crossing the tibia should be quite five
inches below the patella ; then carried up the inner side to
a point corresponding exactly to that from which the inci-
sion commenced. If the knife is introduced higher up
than at the point mentioned, the incision will not only be
longer than requisite, but the blood-vessels on each side,
which pass from behind forwards, are unnecessarily divided
at the base of the flap, and consequently its arterial supply
is diminished by so much, and sloughing or ulceration
of some portion of its extremity rendered more probable.
I usually make the posterior flap by cutting from without
inwards ; it should not be too short, and should consist
merely of integument. As soon as the flaps are completed
all the structures round the joint should be divided at
a right angle with the limb."
Pick's operation is described as follows •} " An incision
was commenced at the upper border of the patella, and
carried down the middle line of the limb as low as the
tubercle of the tibia ; it was then curved outwards over
the outer side of the leg to the back, and carried upwards
along the middle line to a point corresponding to the com-
mencement of the incision on the front of the leg. A
similar incision was carried round the inner side of the leg,
and thus two somewhat quadrilateral flaps with rounded
corners consisting only of skin and subcutaneous tissue
were mapped out. The lowest point of these flaps wa-
about an inch and a half below the level of the tubercle of
the tibia. They wero dissected up as high as the articu-
lation, the patella was removed, and the various structures
around the joint divided by a circular sweep of the knife. "
Pick claims for his operation tho following advantages :
that better drainage is secured than by that of tho long
1 'Proceedings of Medical Society of London," vol. vii. 1884 p« 184
BY DISARTICULATION.
175
anterior flap ; that the flaps are less liable to slough ; and
that the cicatrix is placed in the intercondyloid notch
between the two prominent condyles of the femur, and is
not therefore subjected to any direct pressure from the
artificial limb. These claims, when compared with
Pollock's long anterior flap are just.
Mr. Stephen Smith's amputation is described as
follows : — " The incision is commenced about an inch
below the tubercle of the tibia (Fig. 1), and carried down-
Fig. l.
ward and forward over the most prominent part of the side
of the leg, until it reaches the under surface, when it is
curved towards the median line. When that point is
reached, it is continued directly upward to the centre of
the articulation. A second incision begins at the same
point as the first, and pursues a similar direction upon the
opposite side of the leg, and meets it in the median line
in the posterior part. The line of incision upon one side
is seen in Fig. 1. The following points," adds Stephen
Smith, " should be remembered, viz. the incisions should
incline moderately forwards down to the curve of the side
of the leg, to secure ample covering for the condyles ; and
176
AMPUTATION AT THE KNEE-JOINT
that upon the internal aspect should have additional ful-
ness for the purpose of ensuring sufficient flap for the
internal condyle of the femur, which is longer and larger
than the external. In the dissection the skin, fascia, and
cellular tissue are raised and the ligamentum patellas is
divided, allowing the patella to remain. The appearance
of the flaps immediately after disarticulation is seen in
Fig. 2. It will be noticed that the extremity of the femur
Fig. 2.
Appearance of flaps immediately after disarticulation.
is already completely covered, and the line of union of the
flaps will ho between the condyles and over the intracon-
dyloid notch. When cicatrisation is complete the cicatrix
sinks into this notch and disappears from the face of the
stump, and offers no point of contact with the artificial
appliance. The appearance of the stump on recovery is
given in Fig. 3. In the process of repair, it will be found
BY DISARTICULATION.
177
that the drainage is so perfect that all the anterior portion
of the wound remains dry and frequently heals by imme-
diate union.
" This method of amputation need not be limited to the
knee. The advantages of drainage, and the removal of
the cicatrix from the face of the stump to its posterior
part, equally adapt it to amputation in the leg or thigh.
I have frequently amputated at both of these points by
this method and obtained the most satisfactory results.
The wound heals with remarkable rapidity, and the final
perfection of the stump leaves all that can be desired. In
Fig. 1 the line of incisions is given in amputation of
the leg and thigh by this method. The incision on the
Fig. 3.
iJi\tekJkui —
Posterior view of stump.
posterior part of the leg should extend upwards to the
point where the bone is to be sawn through, and there the
muscles are divided circularly."1
1 ' American Journal of Medical Sciences,' January, 1870.
VOL. LXIX. 12
178 AMPUTATION AT THE KNEE-JOINT
I have described this operation in Dr. Stephen Smith's
own words, and illustrated it with copies of his original
woodcuts, Figs. 1 and 2, in order to do his operation full
justice, and that there should be no misunderstanding as
to his method. I endorse all his remarks fully, and would
urge the application of his method of operating at the
knee to the leg as strongly as I can. Indeed, I may say
that his operation upon the leg, with but slight modifica-
tions, has been practised at Guy's Hospital for more than
forty years, although it is difficult to discover with whom
it originated. My friend, colleague, and teacher, Mr.
E. Cock, whose memory goes back to Sir A. Cooper, is
unable to say when it was introduced, and I am rather
disposed to think that the line of incision was Mr. Cock's.
That excellent surgeon, however, has always included the
muscles of the leg in his flaps, and, I am bound to add,
with a good result. This practice of including muscle in
the flaps has not, however, been adopted by all his col-
leagues or followers. In thin subjects it has been the
rule, in others it has been the exception. The muscles
are then divided by a circular cut. The stumps that
result from this form of amputations in the leg, as in the
knee, are perfect, and are certainly better than those
obtained by the majority of other forms of amputation.
In an examination at a certain university, where a candi-
date performed the operation, it was condemned, the
examiners, having regarded it as a fancy measure, being
unaware that it had been extensively practised at Guy's
Hospital, and that it had also been for years beforo the
profession in the pages of a student's text-book which
has passed through many editions. I repeat here the
two drawings which have illustrated the operation
since 1872 (Figs. 4, 5). This ignorance of its value is
to be regretted, and if these lines will help its pro-
gress towards more general adoption their author will be
satisfied.
Of the three methods advocated for amputation at the
knee, that of Stephen Smith is greatly to be preferred,
BY DISAKTICULATION.
179
since it provides a better covering for the condyles of the
femur than is obtained by any other method, and the
Fig. 4.
Fig. 5.
flaps are far less prone to slough than in the long five-
inch anterior flaps advocated by Pollock. This view is
180 AMPUTATION AT THE KNEE-JOINT
supported by the fact that of my own twenty-one cases,
in only four, or in one out of every five cases, could it be
said there was any sloughing, and in all of these the
process was of a limited extent ; whereas, out of Mr.
Pollock's five cases in which this operation was performed
there was sloughing in three ; and out of twenty-nine
other cases tabulated by Pick from the St. George's
Hospital records, sloughing occurred in sixteen, or, taking
the whole number of cases in which a long flap was made
as thirty-four, sloughing followed in nineteen, that is, in
55 per cent., or more than half.
The method advocated is likewise to be preferred to
Mr. Pick's operation, from the fact that in the former the
incision is commenced one inch below the patella, and, as
a consequence, the cicatrix is eventually placed entirely
behind the condyles and out of harm's way ; whereas, in
Pick's operation the incision starts from a point above the
patella and the cicatrix lies in the intercondyloid notch.
With Stephen Smith's flaps, moreover, there is no place
for bagging of fluids after the operation ; for, with the patient
on his back, and with the femur horizontal, the edges of the
flaps when brought together present downwards towards
the plane of the body, and consequently the stump is in
the best position for drainage. The flaps at the same
time form a complete hood to the condyles.
In performing this operation I have, on four occasions,
after completing the skin flaps, and — with the knee flexed
upon the femur — making an incision along the anterior
border of the head of the tibia, so as to divide the
coronary ligaments, and expose the joint, found the
semilunar cartilages closely encircling the condyles of
the femur. So tightly did they do so that on the two
occasions on which I removed them they had to be dis-
sected from their position. In the two other cases they
were left in situ, to the great advantage of the patients.
Indeed, I would suggest that this latter practice should be
the one followed where it can be, for by this means the
upper part of the synovial capsule is held down firmly to
BY DISARTICULATION. 181
the condyles of the femur, and thus all the soft parts are
kept well in place.
Since writing the above I find Dr. Brinton, so early as
1872, advocated this practice1 in the following words : " I
divide the coronary ligaments so as to allow the semilunar
cartilages to remain upon the articular end of the femur
and in the stump. By thus leaving them in position I
have a cap fitted upon the end of the femur, which pre-
serves all the fascial relations, eventually prevents retrac-
tion and guards against the projection of the condyles.
I insist somewhat strongly upon this retention of the
semilunar cartilages, since I regard it as having an
important bearing upon the future wellbeing of the
stump/5
It is more than probable that this displacement of the
interarticular fibro-cartilages may take place under other
circumstances as by some accidental rupturing of the
coronary ligaments, and if so, some of the cases of injury
to the knee now registered under the title of internal
derangement may be explained.
There is but little bleeding in this operation, and, with
the exception of the popliteal and two superior articular
arteries, there are none to twist. The popliteal vein had
better be tied by a carbolised gut ligature. The condy-
loid origins of the gastrocnemius muscle had better be
removed.
By way of conclusion, the advantages of this form of
operation over amputation through the thigh may be
stated as follows : —
1. The lessened shock of operation.
2. The lessened section of tissues and the non-exposure
of the muscular interspaces of the thigh.
3. The escape from the necessity of sawing the femur,
with its attendant risks.
4. The preservation of the attachments of the thigh
muscles, and consequently the greater mobility of the
stump.
1 ' Philadelphia Medical Times,' December 23th, 1872<
182
AMPUTATION AT THE KNEE-JOINT, ETC.
5. And last but not least, the useful character of the
resulting stump.
Fig. 6.
Artificial limb adapted to stump after operation.
(For report of the discussion on this paper, see ' Proceedings
of the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 27.)
ON THE INCREASE
IN NTJMBER OF
WHITE CORPUSCLES IN THE BLOOD
IN INFLAMMATION,
ESPECIALLY IN THOSE CASES ACCOMPANIED
BY SUPPURATION.
T. P. GOSTLING M.R.C.S., L.E.C.P.,
Diss, Noefolk.
(Communicated by Db. RINGER, F.R.S.)
Received October 23rd, 1885— Read January 12th, 1886.
Dr. Ringer, in speaking to ine of inflammation, men-
tioned the fact that although various writers had observed
and recorded the increase of white blood-corpuscles in this
condition, still this increase had never apparently been
observed in a systematic manner in a series of cases, and
he suggested that I should make the following observations.
Before doing so, however, I looked up the previous
works on this point, and I found that the observers men-
tioned tbelow had recorded this increase. Unfortunately,
they have not all used the same method of counting, some
of them having used diluted and others undiluted blood,
while some have given their results per cubic millimetre,
and others in the relative numbers of the corpuscles only.
184 ON THE INCREASE IN THE NUMBER OF WHITE
Piorry in 1837 x concluded from experiments on coagula-
tion of the blood in pneumonia that the white blood-
corpuscles were increased in that disease. Virchow2 states
that he has found an increased number of white blood-
corpuscles in severe inflammations, especially in pneumonia,
the typhoid state, and puerperal fever, and Nasse is quoted
as having corroborated this statement as far as some cases
of pneumonia are concerned. Concerning the chronic
inflammatory conditions, it is stated3 that Nasse has found
this increase in phthisis, and Virchow and Gulliver have
also recorded it in chronic diseases accompanied by hectic.
But Malassez,4 in 1873, published estimations of conclu-
sions from a series of cases which are so interesting that I
venture to quote them rather more fully. In looking over
the results recorded by Malassez, however, it must be
remembered that he takes 8000 white blood-corpuscles
and 5,000,000 red blood-corpuscles as the normal number
of corpuscles in a cubic millimetre of blood, which gives
the relative number as 1 white to 625 red blood-corpuscles.
He first quotes four cases of facial erysipelas without any
complication, and gives estimations made during (1) the
continuance of the rash, (2) during convalescence, (3) after
complete recovery.
Case 1. — Woman, set. 53.
Estimations during the eruption
„ convalescence
after recovery
1 WVB.C. to 333 R.B.C.
1 W.B.C. to 533 E.B.C.
1 W.B.C. to 535 R.B.C.
1 W.B.C. to 9S6 R.B.C.
1 W.B.C. to 644 R.B.C.
1 W.B.C. to 525 R.B.C.
Case 2. — Woman, set. 32.
Estimation during the eruption . . 1 W.B.C. to 480 R.B.C.
convalesceuce . . 1 W.B.C. to 895 R.B.C.
after recovery ... 1 W.B.C. to 488 R.B.C.
1 ' Traite des Alterations du Sang.'
3 ' Gesammelte Ahhandlungen zur wissens. Med.,' 1856, p. 180.
1 Loc. cit.
• ' Bulletin de la Socicte Auatomique,' 1&73, p. 141.
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 185
The other two cases are not complete, but they confirm
the above figures.
From these cases Malassez concludes that there is :
1. An increase of white blood-corpuscles during the erup-
tion of erysipelas.
2. A decrease of white blood-corpuscles when the eruption
disappears.
3. A return of the white blood-corpuscles to their normal
number during the week following convalescence.
But the above apparent increase is only relative, because
in Case 1, during the eruption, the red blood-corpuscles
fell from 4,100,000 per cubic millimetre to 3,600,000,
although, when the eruption faded, the white blood-cor-
puscles were actually decreased, but not so much as the
proportion indicates, because at that time the number of
red blood-corpuscles only amounted to 4,000,000 per cubic
millimetre.
In Case 2 also the red blood-corpuscles rose at the end
of the disease from 3,700,000 to 4,100,000 per cubic milli-
metre.
Malassez next quotes a case of facial erysipelas followed by
suppuration near the sterno- mastoid muscle in which, during
the eruption, there was 1 white blood- corpuscle to 400 red
blood-corpuscles ; when the abscess was forming 1 white
blood-corpuscle to 342 red blood-corpuscles ; when the
abscess had increased in size 1 white blood-corpuscle to
295 red blood-corpuscles ; after the pus was removed 1
white blood-corpuscle to 345 red blood-corpuscles, 1 white
blood-corpuscle to 385 red blood-corpuscles.
So that in this case of facial erysipelas complicated with
suppuration there was no greater increase in the number of
the white blood-corpuscles than in an ordinary case of ery-
sipelas, so long as it alone existed, but a further increase
was at once observed when suppuration commenced, " and
this only ceased when the pus escaped."
Two cases of erysipelas are then related in subjects
suffering from chronic enlargement of the cervical glands,
which confirm the above observations.
186 ON THE INCREASE IN THE NUMBER OP WHITE
In the same article it is stated that Vulpian and Troisier
had examined three cases of erysipelas, and although these
experiments were made with undiluted blood they found
that the white blood-corpuscles were increased in each
case, and in one of them, in which an abscess was opened
at the same time that the erysipelas -\Yas cured, the number
of white blood-corpuscles in each field of the microscope
fell from 25 to 10.
Liouville and Behier have also observed the increase of
white blood-corpuscles in erysipelas, and Berger, quoting
from Klebs, says that the white blood-corpuscles are in-
creased both in suppuration and in pneumonia.
Nicati and Tarchanoff: l compare the increase in the num-
ber of white blood-corpuscles caused by severe and slight
inflammations, and they show that the more severe the
inflammation the greater is the increase in the number of
the white blood-corpuscles. In comparing the number of
white blood-corpuscles contained in the venous blood re-
turning from an inflamed area with the number in the
venous blood generally of the body of a rabbit, they found
a large increase in the former and a relative increase in the
latter.
English writers appear to doubt this increase, if the
following passage from Erichsen's ' Surgery ' may be taken
as fairly expressing their views : — f ' As to the white cor-
puscles we know that they are present in augmented num-
bers in the vessels of the inflamed part; whether they are
really more numerous in the blood in inflammation is
doubted by Paget, Simon, and others."
The observations recorded by myself in this paper were
made with a Gowers' ha3mocytometer, as described in
Quain's f Dictionary of Medicine/ p. 5G1. But after
some experience I found that practically it was quite
sufficient to count the number of red blood-corpuscles in
four squares of the cell instead of in ten as Gowers recom-
mends, :is this gave in the end the stum' average number
of red blood-corpuscles per square as when the larger
1 ' Archives do Physiologic norniiilo ct pathologique,' L875j p. ~<\ I.
CORPUSCLES IN THE BLOOD IN INFLAMMATION.
187
number of squares were counted, provided that the blood
was thoroughly mixed with the diluting fluid. I have also
in the following estimations, when counting the white
corpuscles, slightly lowered the focus, and have then
counted the white blood-corpuscles as dark coloured spots.
This plan I have found to be easier, quicker, and quite as
correct as that recommended by Growers, in which the focus
is slightly raised and then the white corpuscles counted as
bright points.
The results are given in percentage number of red, and
relative number of white, blood-corpuscles.
The average number of corpuscles contained in a cubic
millimetre of blood is given by Dr. Growers as 15,000 white
and 5,000,000 red blood-corpuscles, which gives a propor-
tion of 1 white blood-corpuscle to 333 red ones.
Case 1. — Case of iliac abscess, elastic, but not fluctuating
at commencement of observations.
Date.
Temp.
Feb.
a.m.
A .
p.m.
Per cent. No.
of B..C.
Relative No
of W.C.
10
... 99-8° .
. 101°
... 90 ...
1 to 139
12
... 100
. 99-4
... 93 ...
1 to 202
15
... 99-2 .
. 100
... 88 ...
92 ...
90 ...
1 to 137
1 to 138
1 to 139
18
... 99-4 .
. 99-8
... 92 ...
1 to 86
Abscess increasing in size fluctuation can now
20
... 99-2 ..
. 99
... 86 ...
1 to 110
21
... 98-6 .
. 100-6
... 86 ...
1 to 86
22
... 996 ..
. 100*2
... 86 ...
1 to 104
24
... 98-4 ..
. 100
... 98 ...
1 to 91
25
... 99-6 ..
. 100-4
... 86 ...
1 to 124
26
—
. 98
... 90 ...
lto 96
\ Average 1 to 160.
- Average 1 to 101.
Operation at 2.30 p.m. on Feb. 26, immediately after last observation.
Large amount of pus escaped when abscess was opened.
Free discharge of pus and serum in first 24 hours after incision.
27 ..
100-2 .
. 101-8 .
. 94 .
. 1 to 383 "i
28 ..
97*8 .
. 98-6 .
. 90 .
. 1 to 270
March
1 ...
98
. 98-2 .
. 88 .
. 1 to 304
2 ...
—
98-2 .
. 98 .
. 1 to 245
188 ON THE INCREASE IN THE NUMBER OF WHITE
Date.
Temp.
March
3 .
4 .
Constipation present
p.m.
98-6°
992
Per cent. No.
of R.C.
... 92 ...
... 96 ..
Relative No.
of W.C.
1 to 230
1 to 105
v, Average 1 to 203.
5 ... _ ... 103 ... 94 ... 1 to 114
6 ... 99" ... 98-4 ... 88 ... 1 to 158
7 ... 103 ... 102 ... 84 ... 1 to 161
8 ... 98-8 ... 102-4 ... 86 ... 1 to 150
10 ... — ... 99'4 ... 92 ... 1 to 184
11 ... 98-4 ... 98-6 ... 96 ... 1 to 240
12 ... — ... 98-4 ... 96 ... 1 to 300
13 ... 98-6 ... 99-4 ... 90 ... 1 to 250
14 ... 98-4 ... 984 ... 92 ... 1 to 287
15 ... 99-6 ... 101 ... 94 ... 1 to 213
16 ... 98-4 ... 98 ... 88 ... 1 to 314
17 ... 98 ... 98 ... 90 ... 1 to 287
19 ... 98-4 ... 97-8 ... 92 ... 1 to 286
20 ... — ... 9S-2 ... 94 ... 1 to 313
21 ... 98 ... 98-2 ... 94 ... 1 to 335
22 ... 97-8 ... 98 ... 98 ... 1 to 272
23 ... 98-4 ... 98-2 ... 96 ... 1 to 320
24 ... 98-4 ... 98-2 ... 90 ... 1 to 264
26 ... 98-4 ... 97-8 ... 94 ... 1 to 361
27 ... _ ... 97-8 ... 94 ... 1 to 40S
March 27th. — Drainage changed for one half the
original diameter and length. Discharge almost
stopped.
Average 1 to 223.
• Average 1 to 252.
28 ...
98-4
... 97
.. 96 ... 1 to 300
31 ...
99
... 98-4 .
.. 96 ... 1 to 320
April
2 ...
98
... 97
.. 90 ... 1 to 450
4 ...
—
... 97-4 .
.. 96 ... 1 to 400
Drainage-tube 2
inches long.
discharge nil.
8 ...
—
... 98
.. 90 ... 1 to 346
22 ...
—
... 97-4 .
.. 88 ... 1 to 315
Patient
got up
on 19th April
The drainage-tube
Average 1 to 358.
wound had completely closed by the 21st, the patient leaving the hos-
pital on April 22nd.
This case is oiie of iliac abscess coining on about four
months after a confinement. On admission to Univer-
COEPUSCLES IN THE BLOOD IN INFLAMMATION. 189
sity College Hospital there was an elastic, tender, and
painful swelling in the left iliac fossa reaching two inches
above Poupart's ligament. The glands in the groin were
enlarged although the skin was not red over the swelling.
Observations were made on ten days between February
10th and 26th. During the first half of this period the
average relative number of white blood-corpuscles was 1
to 160, and during the last half, when there was fluctua-
tion in the swelling, 1 to 101, which shows that there was
a decided tendency to increase. All this time the swelling
was increasing in size, and on February 26th the white
blood-corpuscle3 had reached the relative number of 1
to 96.
On the following day (February 27th) the abscess was
opened and there was an immediate fall to 1 to 383.
After this the white blood-corpuscles increased in number,
the average of daily estimations made from February
28th to March 6th (inclusive) being 1 to 203 ; from
March 5th to March 10th there was slight fever, which
was supposed to be caused by constipation, but it is
quite possible that this rise in temperature was due to a
slight increase of inflammation in the walls of the abscess ;
and, if this was the cause, the rise in the number of the
white blood-corpuscles mentioned above would be accounted
for. After March 6th the white blood-corpuscles showed
a gradual decrease in number, the averages obtained from
two periods of seven days each being 1 to 223 and 1 to 252.
By March 23rd, the abscess cavity had almost entirely filled
with granulation tissue, the discharge had almost ceased,
and the white blood- corpuscles had become normal in
number, viz. 1 to 320.
From this date to April 22nd, when the wound had been
closed fourteen days, the white blood-corpuscles continued
to have a normal relation to the red corpuscles, the average
being 1 to 358.
190 ON THE INCREASE IN THE NUMBER OP WHITE
Case 2. — Case of pelvic cellulitis,
right iliac region, large one in pelvis.
Small swelling in
Date.
Feb.
18
21
22
24
26
Temp.
a.m.
99°
99-8
1006
100-4
100
p.m.
1004
101-6
102-4
102-6
103-4
Per cent. N'o.
of R.C.
... 90 ...
... 92 ...
... 82 ...
... 96 ...
Relative No.
ofW.C.
1 to 124
1 to 153
1 to 153
1 to 147
1 to 167
Average 1 to 148.
March
1 ... 100-2 ... 103-6 ... 96 ... 1 to 168 1
Temperature from March 1st to 10th varied from
98-8° a.m. to 103-4° p.m.
10
14
15
16
17
19
20
22
23
24
26
101
101
101
102-2
100-8
100-8
99-4
99-2
99-6
103
103-8
102-4
103-4
102-4
102
102
100
99-6
99-4
86
94
86
80
76
70
80
74
88
76
74
1 to 159
1 to 204
1 to 187
1 to 166
1 to 126
1 to 112
1 to 129
1 to 142
1 to 244
1 to 165
1 to 154
Average 1 to 172.
Observations from March 26th to May 4th were lost,
but they showed a large and persistent increase of
white blood-corpuscles. Patient is improving, but
in above interval temp, varied from 99'8J to 103 .
May
4 ..
100
. 101-2 .
. 82 .
. 1 to 186
5 ..
—
. 101
. 92 .
. 1 to 135
6 ..
100-4 .
. 101
. 82 .
. 1 to 151
7 ..
99-4 .
. 101-2 .
. 82 .
. 1 to 128
8 ..
99-8 .
. 101-2 .
. 84 .
. 1 to 168
9 ..
98-6 .
. 100-2 .
. 82 .
. 1 to 164
10 ..
100
. 100-2 .
. 92 .
. 1 to 191
11 ..
100
. 101-2 .
. 86 .
. 1 to 186
13 ..
99-8 .
. 100-4 .
. 80 .
. 1 to 166
Average 1 to 150.
Average 1 to 158.
Average 1 to 167.
Improvement continued, but at this date it Middenly increased.
On May 17th patient got up after 18 weeks in bed. and left the hospital
on May 22nd.
Date.
May
15
17
19
21
COEPUSCLES IN THE BLOOD IN INFLAMMATION.
Temp.
191
98-8°
98-6
p.m.
99°
99-4
99-2
100
Per cent. Xo.
ofK.C.
Average 1 to 296.
This is another case of pelvic cellulitis, accompanied
by -well-marked fever and increase in the number of the
white blood-corpuscles. The cellulitis came on after an
abortion, and when the observations were commenced
there was a large tumour in the pelvis, which could be felt
both per vaginam and by abdominal palpation. The tem-
perature in this case varied between 99° a.m. and 103*8°
p.m.
The relative number of white blood-corpuscles from
February 18th to May 13th was as under, each number
given being the average of five observations made on sepa-
rate days.
1 . . . . 1 to 148.
1 to 172.
1 to 150.
1 to 158.
1 to 167.
During the above period there was abdominal pain, ten-
derness, loss of appetite, flesh, and strength, but on May
15th the temperature became normal and the symptoms
disappeared ; during the next few days the patient rapidly
became convalescent, and it was found that the swelling in
the pelvis was certainly smaller.
On the same date (May 15th) the relative number of
white corpuscles decreased to 1 to 250, and they continued
to decrease until, on May 19th, there was only 1 white to
366 red blood-corpuscles, the patient leaving the hospital
cured on May 22nd.
On looking at this case and observing the sudden fall of
temperature, accompanied by loss of symptoms and dimi-
192 ON THE INCREASE IN THE NUMBER OF WHITE
nution in the size of the swelling, we may infer, with the
physician who had charge of the case, that an abscess had
discharged itself into the bowel, an opinion that he formed
without knowing that the white blood-corpuscles had been
counted, and we may also presume that the diminution in
the number of the white blood-corpuscles, which occurred
at the same time, was due to this escape of pus, and that it
corresponds with the diminution seen to occur in Case No.
1 when the abscess was opened.
Case 3. — Case of suppurating white leg. No observa-
tions until there was distinct fluctuation.
Date. Temp.
, " , Per cent. No. Relative No.
March a.m. p.m. ofR.C. of W.C.
2 ... 99° ... 103-8° ... 68 ... 1 to 145
Abscess opened antiseptically ; about 5 ounces of blood-stained pus escaped
from beneath the soleus.
3 ... 100-2 ... 102-6 ... 74 ... 1 to 133 -i
4 ... 100 ... 102 ... 90 ... 1 to 122 I Average 1 to 143.
5 ... 98-2 ... 101-2 ... 81 ... 1 to 175 J
Drainage not altogether perfect, but wound is granulating. Wound quite
superficial. Patient to leave hospital on March 23rd.
22 ... 98-4 ... 98-2 ... 88 ... 1 to 338
The whole of the right leg was swollen, cedematous, and
tender, with distinct redness over the centre of the calf
where deep fluctuation could be obtained.
The temperature ranged, as is shown in the above table,
from 99° a.m. to 103-8° p.m.
Before the pus was evacuated there was one white blood-
corpuscle to 145 red ones, while the average for three days
immediately following its evacuation was one to 143.
During these days there was a fair amount of fever, the
highest point reached during this time being 102-6°; but
eventually, when the temperature became normal, the
number of white blood-corpuscles became normal also.
This case appears to confirm what we have seen in part
of Case 1, in which after the abscess had been opened, there
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 193
was a slight rise of temperature accompanied by an increase
in the number of white blood-corpuscles ; but there was an
important difference in the two cases, because while Case 1
was perfectly sweet, Case 3 at this time was slightly foetid
and badly drained.
Case 4. — Case of double suppurative tonsillitis. First
observation on fifth day of illness.
Date. Temp.
Per cent. No.
Relative No,
of R.C.
of W.C
.. 98 ...
1 to 326
.. 96 ...
1 to 287
May a.m. p.m.
22 ... 99-9° ... 102°
23 ... 99-8 ... 101-4
Left tonsil discharged pus at 3 a.m. on May 24th.
Observation made at 7 a.m.
24 ... 98'4 ... 102-2 ... 98 ... 1 to 204
Right tonsil discharged pus at 7 a.m. on May 25th.
Observation made at 8 a.m.
25 ... 101 ... 102-2 ... 96 ... 1 to 369
26 ... 98-8 ... 98-8 ... 92 ... 1 to 270
28 ... 98-2 ... 98 ... 100 ... 1 to 500
Patient discharged well on May 28th.
No treatment used in course of case except ice to suck.
This case shows a slight but gradual increase in the number
of white blood-corpuscles while the abscesses were forming,
and this continued until both had discharged their contents
when the number of white blood-corpuscles at once fell to
normal ; the case also apparently confirms that which we
may infer from the previous ones, viz. that the increase in
the number of white blood-corpuscles is less in cases in
which there are small, than in those in which there are
large, abscesses.
Thus in Case 1, pelvic abscess, the highest average was
1 to 101 ; in Case 2, small pelvic abscess, the highest
average was 1 to 150; in Case 3, small abscess in calf,
the highest number was 1 to 145 ; while iu Case 4,
suppurative tonsillitis) the observation which shows the
VOL. lxix, 13
194 ON THE INCREASE IN THE NUMBER OF "WHITE
largest number of white blood-corpuscles only gives 1
white to 204 red corpuscles.
The following estimations were made in two cases in
which the actual cautery was applied for white swelling —
one of the knee, the other of the shoulder.
Case 5. — Case of white swelling of knee treated by
actual cautery. First observation made five hours after
operation.
Date. Temp.
f • v Per cent. No. Relative No.
Feb. a.m. p.m. of R.C. oMY.C.
19 ... 98-4< ... 100-2' ... 92 ... 1 to 129 j
21 ... 98-4 ... 101-4 ... 94 ... 1 to 220 J
Marks left by cautery are now secreting pus; they are dressed with savin
ointment.
22 ... 100-6 ... 102 ... 88 ... 1 to 304 -i
24 ... 99-4 ... 99-8 ... 92 ... 1 to 328 I Average 1 to 321.
26 ... 99 ... 99 ... 96 ... 1 to 332 J
r
>
Feb.
a.m.
p.m.
19 ...
98-4 ..
. 98-2
20 ..
9S-I ..
. 99-8
21 ..
98-4 ..
. 996
Case 6. — Case of strumous disease of the shoulder-joint
treated by actual cautery. First observation four hours
after operation. After operation the shoulder was kept at
absolute rest. No irritation applied.
Date. Temp.
Per cent. No. Relative No.
of R.C. ofW.C.
... 98 ... 1 to 220 -j
... 98 ... 1 to 294 L Average 1 to 235.
... 94 ... 1 to 200 J
Marks left by cautery discharging pus.
22 ... 97-8 ... 99-2 ... 96 ... 1 to 308 -i
24 ... 98-4 ... 98-4 ... 96 ... 1 to 286 I Average 1 to 299.
26 ... 98-6 ... 99 ... 88 ... 1 to 304 J
In Case 5 there was rather more inflammation, as shown
by the temperature which reached 1002°, than there was
in Case 6, where it only reached 99*8°, but in Case 5 there
was also a much larger increase in the number of the white
corpuscles after the operation than in Case 6, the average
number in Case 5 being 1 t<> 174, while the average in
Case G was 1 to 235.
Both cases were suppurating freely on the fourth day after
CORPUSCLES IN THE BLOOD IN INFLAMMATION.
191
cauterisation, and there was no retention of discharge in
either case. In both on the fourth day there was a marked
decrease in the number of white blood-corpuscles.
In Case 5 they fell from 1 to 220, to 1 to 304, and in
Case 6 they fell from 1 to 200, to 1 to 308.
After this day the averages show a near approach to the
normal number of white blood-corpuscles, being in Case 5
1 to 321, and in Case 6 1 to 299.
I will next quote four cases of empyema in which obser-
vations were made both before and after the chest was
drained.
Case 7. — Case of empyema ; about ten ounces of sero-
purulent fluid removed by aspiration before admission to
hospital. Aspiration repeated on April 27th and 29th,
and about two ounces of pus removed each time, but on
each occasion the needle became blocked by flaky lymph.
Observations before aspiration showed a large increase of
white corpuscles, but the figures have been lost.
Date. Temp.
, * ^ Per cent. No.
of R.C.
, 82 ...
82 ...
May a.m. p.m.
4 ... 100-2° ... 100° .
5 ... 100-4 ... 99-6 .
Well-marked retraction of side.
Relative No.
ofW.C.
1 to 132
1 to 132
6
7
8
9
10
100-4
99-4
99-2
99-8
99-4
99-4
99
98-6
98-4
99
84
88
90
82
82
1 to 155
1 to 275
1 to 150
1 to 132
1 to 186
Average 1 to 168
V Average 1 to 177.
Abscess pointing in 9th space, mid-axillary line.
11 ... 99-6 ... 99-6 ... 80 ... 1 to 202
12 ... 99-6 ... 98-4 ... 92 ... 1 to 200
13 ... 99-8 ... 97-4 ... 83 ... 1 to 148 /
Abscess opened with Listerian precautious, drained, half inch of rib removed
on the 13th, after observation. Dressed on the 14th.
14 ..
. 99-2 .
99-4 ... SO ... 1 to 307 1
15 ..
99-2 .
. 99 ... 84 ... 1 to 350
16 ..
. 99
. 99-8 ... 82 ... 1 to 273 [ Average 1 to 315.
17 .
. 99-2 .
99 ... 82 ... 1 to 315
19 ..
. 98
99 ... 86 ... 1 to 330 J
Dressing changed.
Retraction much more marked.
196
ON THE INCREASE IN THE NUMBER OF WHITE
Date.
Temp.
May a.m. p.m.
20 ... 99*2° ... 98-6°
21 ... 98-6 ... 99
22 ... 98 ... 99-4
23 ... 99 ... 98-4
24 ... 98-2 ... 99
25 ... 98 ... 99
26 ... 99 ... 99-4
28 ... 996 ... 98*6
30 ... 99 ... 998
Dressing changed May 31st.
June
1 ... 99 ... 998
4 ... 99 ... —
6 ... 99 ... 99-2
Dressing changed June 7th.
8 ... 98-6 ... 99-4
11 ... 99-6 ... —
Per cent. No.
ofR.C.
... 96 ...
... 98 ...
... 92 ...
... 80 ...
... 94 ...
... 84 ...
... 84 ...
... 98 ...
92
100
94
Relative No.
ofW.C.
1 to 436
1 to 300
1 to 281
1 to 285
1 to 313
1 to 280
1 to 233
1 to 258
1 to 338
1 to 400
1 to 328
1 to 366
1 to 454
1 to ISO
Average 1 to 325.
Average 1 to 301.
j> Average 1 to 332.
Wound completely closed on June 24th.
This case occurred in a child, aged seven, in whom the
signs of fluid in the right pleural cavity were well marked.
On admission to the hospital, although about ten ounces
of sero-purulent fluid had been previously withdrawn by
aspiration, very little fluid could be obtained ; repeated
attempts to aspirate were made both with and without an
anaesthetic, on each occasion the needle becoming blocked.
Observations were made daily from May kh to 13th as to the
number of white corpuscles, and it was found that the first
five days gave an average of 1 to 108, and the second five
days an average of 1 to 177, results which are practically
the same.
At the commencement of this series of observations,
which was about fourteen days after admission, there was
well-marked retraction of the whole of the right side of
the chest. On May 9th it was noticed that the empyema
was pointing, and on May 13th the chest was opened and
drained, half an inch of rib being removed and a large
amount of thick curdy pus being evacuated. The day
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 197
before the operation the relative amount of white to red
corpuscles was 1 to 148 ; the day after, it had fallen to 1
to 307, the temperature remaining as before, just above
normal, *. e. 99*2° a.m. and 99*4° p.m.
The average relative number of white corpuscles from
May 14th to May 19th, which were the days immediately
following the evacuation of the pus, was 1 to 315, which
contrasts strongly with the averages before the operation.
From May 19th until June 11th nineteen observations were
made on separate days, and averages from these, divided
into four periods, are given below :
1 . . . . 1 to 315
2 . . . . 1 to 325
3 . . . . 1 to 301
4 . . . . 1 to 332
figures which show a very close approach to the normal
number.
On June 24th the patient left the hospital, the wound
being completely closed.
Case 8. — Case of empyema. Left side. Aspirated on
May 7th. The average relative number of white blood-
corpuscles was 1 to 187 before the chest was opened.
Date. Temp.
May
7 ..
I " V
a.m. p.m.
98-4J ... 101°
Per cent. Ivo.
of R.C.
... 92 ...
Relative No.
ofW.C.
1 to 242 \
8 ...
(7.30 a.m.
, 98-9 ... —
)
... 98 ...
1 to 181
Y Average 1 to 187.
8 ..
— ... —
... 94 ...
1 to 140 J
(3 p.m.)
Abscess opened May 8th, drained, 50 ounces of pus removed.
Dressed first time on 9th.
9 ..
. 98-6 ... 99-8
... 92 ...
1 to 200 1
10 ..
99-2 ... 99-6
... 88 ...
1 to 258
11 ..
. 100-2 ... 101-2
... 90 ...
1 to 300 V Average 1 to 273.
12 ..
. 100-6 ... 101-4
... 92 ...
1 to 328
Dressed on lltii and 13th before estimations.
198
ON THE IKCEEASE IN THE NUMBER OP WHITE
Date.
Maj
13
14
15
16
17
Temp.
a.m.
100-4°
101-8
100-2
100-8
100-2
p.m.
1014c
101-4
101-4
100-2
100-2
Dressed ou loth and 18th.
19 ... 99-8 ... 99
20 ... 99-2 ... 99-8
Dressed on 21st.
22 ... — ... 99-6
23 ... 99-4 ... 99-4
24 ... 99 ... 99
25 ... 99 ... 98-6
26 ... 99 ... 99
Dressed.
28 ... 99-6 ... 98-2
30 ... 99 ... 99-2
June
1 ... 99-6 ... 99-2
Dressed on June 3rd.
4 ... 99-6 ... 100
6 ... 99-8 ... 100
8 ... 99 ... 99-2
11 ... 98-8 ... —
Per cent. No.
ofR. C.
88 ..
94 ..
98 ..
94 ..
92 ...
94 ...
86 ..
'.'2 ..
Relative No.
of W.C.
1 to 244
1 to 2
44 ^
.-76
1 to 288 i- Average 1 to 273.
1 to 276
1 to 2S7
7 J
90
90
84
88
70
96
80
90
86
1 to 392
1 to 390
1 to 306
1 to 338
1 to 244
1 to 300
1 to 409
1 to 350
1 to 314
1 to 291
1 to 400
1 to 266
1 to 409
1 to 307
Average 1 to 334.
y Average 1 to 333.
Average 1 to 345.
After the operation, however, although there was a con-
siderable fall in the number of white blood-corpuscles, they
did not fall to normal, the average obtained from nine
daily observations, from May 9th to 17th, niter the chest
was opened and drained, being 1 to 273. Possibly this
might be accounted for by the fact that in this case the
patient was an adult, and as no bone was removed the
chest did not drain satisfactorily at first.
After May 17th, however, the proportion of white to red
corpuscles again fell, the averages for three periods of
five days each being: 1 to 884, 1 to 333, 1 to 345, which
figures show even a closer approach to the normal than
was obtained in Caso 7.
The observations were continued until June 11th, when
the patient was Lost sight of, as he left the hospital,
although there was still a small sinus.
CORPUSCLES IN THE BLOOD IN INFLAMMATION.
199
Case 9. — Case of empyema in a child, following on pneu-
monia.
Date.
June
30
»
July
1
Temp.
a.m.
98-4°
99-
p.m.
102°
100
Per cent. No.
ofR.C.
... 70 ...
... 84 ...
... 88 ...
... 82 ...
Relative No.
of W.C.
1 to 125 "1
1 to 140
}> Average 1 to 143.
1 to 162
1 to 146 j
July 1st. — Free incision, 8 oz. of pus evacuated ; half inch of rib removed
Next observation 8 hours after operation.
July
1 ... — ... — ... 84
Immediately after operation.
2 ... 97-4 ... 98 ... 80
4 ... 98-4 ... 98 ... 80
17 .., — ... — ... 96
1 to 247 ^
|
1 to 363 J» Average 1 to 360.
1 to 488
1 to 342 J
This case corresponds almost exactly to Case 7, the pro-
portions being as under.
Previous to operation the averag'e of four estimations
made on two days was 1 to 143.
After operation the average of four estimations made on
four separate days was 1 to 360.
In this case also the fall in the number of white blood-
corpuscles was observed the day after the operation, the
number the day before being 1 to 146, and the number the
day after being 1 to 363.
Case 10.
Date.
-Case of right empyema in a puerperal woman.
Temp.
Per cent. No
ofR.C.
Feb. a.m. p.m.
12 ... 104 ... 103 ... 84 .
14 ... 100 ... 101 ... 88 .
Pus evacuated by incision ; a large amou
16 ... 100-8 ... 98-8 ... 84 .
18 ... 97-4 ... 97-4 ... 88
19 ... 98-8 ... 99-6 ... 92
Death occurred on Feb. 19.
At post-mortem no further collection of pus was found.
Relative No.
of W.C.
1 to 189
1 to 198
it removed.
1 to 180
1 to 190
1 to 192 .
f Average 1 to 193.
Average 1 to 187.
200 ON THE INCREASE IN THE NUMBER OF WHITE
Case 10 is an empyema that occurred in a puerperal
woman; it is only useful to show the increase of white
blood-corpuscles in the presence of a collection of pus, the
average relative number being 1 to 193.
The chest was opened four days before death, but this
could hardly be expected to diminish the number of the
white blood-corpuscles in a patient in such a condition, the
average obtained from the estimation made after the opera-
tion being 1 to 187.
The observations made on these four cases of empyema
corroborate those made on the cases of suppurative cellu-
litis, viz. that wherever there is a collection of pus there is
an appreciable increase in the relative number of white
blood-corpuscles, which falls as soon as this pus is
evacuated.
The next three cases, 11, 12, and 13, are a series of
observations made on phthisical patients with cavities and
free expectoration; these all show a slight increase in
white blood-corpuscles, as has been previously recorded by
Nasse.
Case 11. — Phthisis cavities over the whole of right lung,
copious muco-purulent expectoration.
Date. Temp.
Feb.
, ' \
a.m. pni.
Per cent. No.
(if R.C.
Relative No.
ofW.C.
9 .
. 101-6 .
. 103-6°
1 a.m. 92...
J p. in.'.1 I ...
1 to 350 "
1 to 297
12 .
. 101-4 .
. 104
... 90 ...
1 to 368
18 .
24 .
. 100-6 .
. 103-6
. 102
... 86 ...
... 88 ...
1 to 298
1 to 264
■ Average 1 to 290
March
1
. 101
. 102-4
... 96 ...
1 to 216
4 .
99
. 103
... 74 ...
1 to 237
Case 12. — ridhixis cavity at left apex, moderate amount
of muco-purulent expectoration^
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 201
Date. Temp.
, " N Per cent. No. Relative No.
Feb. a.m. p.m. ofR.C. ofW.C.
8 ... 100 ... 101 ... 89 ... 1 to 225
10 ... 101 ... 101-4 ... 94 ... 1 to 257 \ Av<
19 ... 100-6 ... 100-2 ... 88 ... 1 to 208
I Ave
Case 13. — Phthisis cavities at both apices, muco-purulent
expectoration. Spinal caries, psoas abscess, open, badly
drained.
Date. Temp.
Feb.
r
a.m.
p.m.
Per cent. Ao.
of R.C.
Relative No.
ofW.C.
10 ..
. 102
.. 1034
... 84 ...
1 to 171 -)
12 ..
. 100-2 .
.. 102-2
... 86 ...
1 to 153
• Average 1 to 180.
19 ..
. 101
.. 101-6
... 82 ...
1 to 217 J
Cases 11 and 12 are comparable to the case of iliac
abscess which is recorded as Case 1.
This similarity is found in the fact that after the abscess
in Case 1 was opened we have three patients in each of
whom there is a cavity or cavities (although in different
parts of the body) secreting pus in considerable quantities,
the pus in each of the cases having comparatively free exit.
It is also shown in the relative numbers of the white blood-
corpuscles which are given below : ■
Averages from Case 1.— 1 to 203, 1 to 223, 1 to 252.
Average from Case 11. — 1 to 290.
Average from Case 12.— 1 to 230.
Case 13 was, however, complicated by an open, badly-
drained psoas abscess depending on spinal caries, and in this
case we find that the relative number of white blood-cor-
puscles is increased not only above the normal, but also above
the increase found in Cases 11 and 12, which are ordinary
cases of phthisis ; just as one might be led to expect from the
observations made in Cases 3 and 8, in both of which there
were abscess cavities badly drained.
In Case 13 the proportion of white and red corpuscles is
1 to 180 ; in 11 and 12 it is 1 to 290, and 1 to 230 ; while
in Cases 3 and 8, whilst they were badly drained, it was 1
to 143, and one to 272.
202
ON THE INCREASE IN THE NUMBER OF Willi h
Case 14. — Left pleurisy with serous effusion. Friction
on April 27th. Serous fluid obtained on May 6th, which
coagulated spontaneously. Movements diminished. Vocal
fremitus absent. Breath-sounds absent. Heart's impulse
on right of sternum.
Date.
May
5
6
7
8
9
10
11
12
Temp.
a.m.
100-6C
101-2
100-6
100-6
100-6
102-6
100-6
101-4
p.m.
103-6-
1036
102-6
1032
103-2
103-4
103
103-4
Per ceut. No.
ofR.C.
... 90 ...
... 82 ...
... 86 ...
... 92 ...
... 92 ...
... 88 ...
... 86 ...
... 98 ...
Relative No.
ofW'.C.
1 to 264 '
1 to 292
1 to 330
1 to 306
1 to 383
1 to 400
1 to 390
1 to 326
Average 1 to 336.
Heart's impulse still on right of sternum. Vocal fremitus at level of nipple,
in anterior inaxillary fold. No V.F. below this. Friction present.
13
14
15
16
17
100-8
100-4
100-2
99
98
102-2
101
100-6
100-8
100-6
92
92
86
90
1 to 400
1 to 353
1 to 418
1 to 390
1 to 500
► Average 1 to 412.
No pulsation on right of sternum,
side, inside nipple. No friction.
Heart's apex beat felt in 4th space, left
Vocal fremitus felt quite to tbe base.
19 ..
20 ..
-I
22 ..
23 ..
24 ..
26 ..
30 ..
Patient
base,
side.
98-6
98-6
98-6
98-6
98-6
98-6
98-4
98-4
99
98-8
! I! I
:>'.>
98
98-8
99-4
96
88
96
98
90
80
86
1 to 480
1 to 440
1 to 436
1 to 445
1 to 321
1 to 400
1 to 430
- Average l to 421.
was discharged on June 1st, with slight deficient resonance at left
also with slight deficient movement and slight retraction of loft
Here there was no increase in the number of tin* white
blood-corpuscles whilst any fluid remained, the relative
number being, from an average of eight observations, 1 to
336.
CORPUSCLES IN THE BLOOD IN INFLAMMATION.
203
During convalescence, however, there was a decided
diminution in their number, the averages being, during a
period of five and seven days respectively, 1 to 412 and 1
to 421.
Here we have a case in which there was a considerable
amount of inflammation, as is evident from the large
amount of serous fluid which was present, and which was
accompanied by high fever, the temperature varying from
10O6° a.m. to 103'6° p.m., but in which there was no
increase in the number of white blood-corpuscles.
May we therefore infer from this that a special variety
of inflammation is necessary in order to cause their increase ?
Case 15. — Case of left serous pleurisy with effusion.
Aspirated on May 4th after estimation. Fifty-two ounces
of fluid withdrawn.
Date.
Temp.
May
t
a.m.
., Per cent. No.
p.m. ofR.C.
Relative No.
of W.C.
4
... 102°
103-4° ... 74 ...
1 to 217?
5
... 101-2
103 ... 84 ...
1 to 300 ")
6
... 101-2
102-6 ... 80 ...
1 to 307 I Average 1 to 302
7
... 101
103-2 ... 84 ...
1 to 300 J
6 oz.
of fluid wi
thdr
awn by the aspirator.
8
... 101-6
103 ... 92 ...
1 to 383 "
9
... 102
103-6 ... 90 ...
1 to 346
10
... 101-2
102 ... 84 ...
1 to 466
■ Average 1 to 385.
11
... 100-6
102-2 ... 90 ...
1 to 409
12
... 101
102-4 ... 90 ...
1 to 321 „
Vocal fremitus felt at extreme base. Slight dulness at left base. Breath-
sounds heard at extreme base. Slight cough and mucoid expectoration,
streaked with blood.
13 .
. 101
. 102-4 .
. 78 .
. 1 to 433 ^
14 .
. 101-2 .
. 102-4 .
. 86 .
. 1 to 430
15 .
. 99-8 .
. 102-6 .
.. 90 .
. 1 to 450
. Average 1 to 440
16 .
. 100-4 .
. 102-2 .
. 92 .
. 1 to 511
17 .
. 101-6 .
. 101-8 .
. 86 .
. 1 to 377
19 .
. 100-2 .
. 100-6 .
. 84 .
. 1 to 381 *
20 .
. 99
. 100-8 .
. 82 .
. 1 to 410
22 .
. 99-6 .
. 99-6 .
. 88 .
. 1 to 366
> Average 1 to 378
23 .
. 99-2 .
. 99-2 .
. 88 .
. 1 to 314
24 ..
. 99-2 ..
. 99-8 .
. 84 ..
. 1 to 420 J
204
ON THE INCREASE IN THE NUMBER OF WHITE
Date.
Temp.
Per cent. No.
Relative No.
ofR.C.
of W.C.
... 84 ...
1 to 420
... 80 ...
1 to 500
May a.m. p.m.
25 ... 99-4° ... 99-8°
26 ... 98-2 ... 99-2
Patient got up on May 28th for the first time.
28 ... 98-6 ... 98-6 ... 92 ... 1 to 460
30 ... 98-2 ... 9S8 ... 90 ... 1 to 409
Patient discharged well on June 2nd.
This case is similar in all its characters to the last, except
that here aspiration was employed twice, and fifty-two
ounces and thirty-six ounces of fluid were withdrawn on
the respective occasions, while in Case 14 this was not
done.
In this case the averages are, while fluid was present, 1 to
302 and 1 to 385 ; during convalescence, 1 to 440, 1 to 378,
and 1 to 447.
These two cases form a very marked contrast with the
cases of empyema previously spoken of, in which the white
blood-corpuscles were very largely increased.
Case 16. — Case of lobar pneumonia, left base. Illness
commenced on May 30th. Observations commenced on
June 3rd, being fifth day of disease.
Date.
June
3
4
5
Temp.
a.m.
102
101-2
103-4
p.m.
103-6
105
98-6
Per cent. No.
ofR.C.
... 96 ...
... 92 ...
... 80 ...
Crisis on early morning of eighth day.
6
7
8
9
11
98-6
98-2
98-6
97-8
99-2
97-6
98
98-8
974
80
82
90
94
Relative No.
of W.C
1 to 369
1 to 242
1 to 166
1 to 571
1 to 410
1 to 281
1 to 180
1 to 191
Average 1 to 259.
1
- Average 1 to 314.
Patient left hospital on June 15th cured.
This case is one of a different class, the observations
having been made in a pneumonic patient. It shows a
curious increase in number of the white blood-corpuscles
up to the crisis of the disease as they gradually increased
from 1 to 309 to 1 to 100.
CORPUSCLES IN THE BLOOD IN INFLAMMATION.
205
At the crisis of the case there occurred a very sudden
decrease in their number, the table showing a fall from 1 to
166 to 1 to 571, and then a gradual rise during resolution
until they reached 1 to 191.
This may be the usual course in pneumonia, but it is the
only case of this disease which I have estimated, and while
it confirms the opinions of Virchow and Nasse as to the
increase of white blood-corpuscles in pneumonia it can be
taken as proving nothing further.
Case 17. — Case of typhoid fever, with constipation. Ob-
servations commenced on first day of illness.
Temp.
Date.
March
8
10
15
17
24
i a.m.
p.m.
... 102-4° .
. 103-2° ..
... 100-2 ..
. 102-8 ..
... 99
. 103
... 101-2 .
. 103-4 ..
... 98
. 100-4 ..
Per cent. No.
of R.C
90 ...
96 ...
92 ...
94 ...
76 ...
Relative No
of W.C
1 to 300
1 to 436
1 to 511
1 to 313
1 to 542
1
\ Average 1 to 420.
i
J
After a relapse temperature became normal on March 26th.
there was slight periostitis of tibia.
April
On April 7th
9 ... 98-6 ... 99-2
10 ... 98-4 ... 99-2
10 5.30 p.m. abscess opened
11 ... 98-4 ... 98-4
12 ... — ... 98-4
92
92
92
98
1 to 287
1 to 418
1 to 490
1 to 383
1 to 376
Average 1 to 390.
Case 18. — A case of typhoid, accompanied by high fever,
great delirium. Death on twenty-second day of illness.
Post-mortem showed extensive and well-marked ulceration
of intestine. Observations commenced on twenty-second
day of disease.
Date.
T
;mp.
Per cent. No.
ofR.C.
Relative No
of W.C
June
t
a.m.
■N
p.m.
3 ..
99
.. 104
.. 100 ...
1 to 652
4 ..
102-2
.. 103-6 .
.. 86 ...
1 to 537
5 ..
103
.. 104-6 .
.. 86 ...
1 to 537
6 ..
103-6
.. 104-2 .
.. 80 ...
1 to 363
7 ..
101-6
.. 104
.. 96 ...
1 to 480
8 ..
102
.. 104-2 .
.. 98 ...
1 to 445
9 ..
. 1032
.. 105-2 .
.. 88 ...
1 to 366
11 ..
102
.. 104-2 .
.. 82 ...
1 to 512
^ Average 1 to 486.
206
ON THE INCREASE IN THE NUMBER OF WHITE
Cases 17 and 18 are two ordinary cases of typhoid fever,
both of which show a very decided decrease in the relative
numbers of the white blood-corpuscles, in Case 17 the pro-
portion being 1 to 420, and in Case 18 1, to 486.
But again, these results depend on two cases only, and as
the patients were in each case delirious, some difficulty was
experienced in obtaining the blood necessary for the esti-
mations, so that an error may easily have occurred. This
may account for the fact that the above results differ from
those given by Virchow, who states, " that the white cor-
puscles are increased in the typhoid state."
Case 19. — Case of acute rheumatism,
left wrist and left ankle.
Slight effusion in
Date.
Temp.
Per cent. No.
Relative No.
March
a.m.
p.m.
of R.C.
ofW.C.
24 ...
101-8° ..
. 102°
... 88 ...
1 to 366 ""
26 ...
98-8 .
. 98-4
... 94 ...
1 to 313
27 ...
28 ...
98-2 ..
98-2 .
98-2
99
... 84 ...
... 88 ...
1 to 420
1 to 314
* Average 1 to 345.
29 ...
986 .
. 98-4
... 94 ...
1 to 427
31 ...
99-8 .
. 100-2
... 84 ...
1 to 233 J
April
1 ...
99-8 .
. 100-4
... 90 ...
1 to 225 ~|
2 ...
100-2 .
. 101
... 72 ...
1 to 156
3 ...
4 ...
99
99-2 .
. 101-2
. 101-6
... 96 ...
... 76 ...
1 to 252
1 to 316 Average 1 to 244
5 ...
99-8 .
. 100-4
... 86 ...
1 to 252
8 ...
99
—
... 96 ...
1 to 266 .
This last case is one of rheumatic fever, in which
there was slight effusion into the left wrist and ankle.
In the first half of this case there is no increase at all in
the number of the white blood-corpuscles, which for six
estimations on separate days gives an average of 1 white
to 345 red corpuscles, while in the latter half of the case
there is a slight increase in their number, the average of
six observations being 1 white to 24 I red corpuscles.
It is only included in this paper because to a certain
extent it corroborates the new suggested by Cases 1 I and
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 207
15 that serous inflammations do not cause an appreciable
increase in the relative numbers of white blood-corpuscles.
The preceding are the cases in which I have made esti-
mations of the number of white corpuscles ; they include,
as we have seen, the following :
Case 1. Iliac abscess.
„ 2. Pelvic cellulitis and probably abscess.
„ 3. Suppurating white leg.
„ 4. Suppurating tonsillitis.
„ 5, 6. White swelling treated by the actual cautery.
„ 7, 8, 9, 10. Empyema.
„ 11, 12, 13. Phthisis.
„ 14, 15. Serous pleurisy.
„ 16. Lobar pneumonia.
„ 17, 18. Typhoid fever.
„ 19. Acute rheumatism.
In Cases 1 to 4 (abscesses), and 7 to 10 (empyemas),
where there was suppuration with pent-up pus, we have in
each individual case a marked increase in the number of
the white blood-corpuscles so long as this tension remained,
but as soon as the pus was evacuated and free drainage
established, the number of white corpuscles returned prac-
tically to normal.
In Cases 11 and 12 (phthisis) we have suppuration with
fairly efficient, but not complete, drainage, and there is
corresponding slight increase in the white blood- corpuscles
such as we have seen in Case 1 while the abscess cavity
was closing by granulation.
However, if we turn to Case 13 (phthisis and psoas
abscess), we at once see a much larger relative increase,
due probably to the inefficient drainage, for we have seen
this same increase in Cases 3 and 7, which were acknow-
ledged to be badly drained.
If we now look at the cases of inflammation of serous
membranes accompanied by serous or sero-fibrinous exuda-
tion we find very different results.
Cases 14 and 15, which are serous pleurisies, and Case
208 ON THE INCREASE IN THE NUMBER OF WHITE
19, which is a single case of acute rheumatism, show that
not only is there no increase in the white corpuscles, but in
the pleurisy cases there is even actual decrease during con-
valescence.
Case 16 (pneumonia) stands by itself, and I can offer no
explanation concerning it, as the patient left the hospital
and was lost sight of while he still had a large increase of
white blood-corpuscles.
In the typhoid cases (Nos. 17 and 18) there was, as we
have seen, a large decrease in the numbers of the white
blood-corpuscles ; this may be usual, but I have explained
previously one very possible source of error in these cases.
Cases 5 and 6 are recorded, not to show that there is any
increase in the number of the white corpuscles in cases of
white swelling, but to show the effect of severe local irrita-
tion, and in both we see a decided increase, while the acute
inflammation lasted, but this was lost as soon as free sup-
puration was established.
The above observations confirm the opinions of the
continental observers quoted at the commencement of this
paper as far as pneumonia and phthisis are concerned, and
especially the single observation by Malassez on the decrease
in the number of the white corpuscles when tension is
removed.
On looking at these results, I think that we are justified
in drawing the following conclusions :
1. That white corpuscles are increased in number in
suppurative inflammations, especially when accompanied
by tension.
2. That they are slightly increased in parenchymatous
inflammations.
3. That they are not increased in inflammations accom-
panied by serous or sero-fibrinous exudations.
Concerning the pathology of the above increase, I do
not propose to offer any details, but I would suggest that
it may be due to absorption of leucocytes from the inflamed
area in the neighbourhood of the abscess.
It. lias also i.ccunvil t.. mi; that the increase noticcl in
CORPUSCLES IN THE BLOOD IN INFLAMMATION. 209
the number of white corpuscles in the case of an empyema
might be of diagnostic value if it proves on further obser-
vation to be constantly present.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 37.)
VOL. LXIX. 14
A COMMUNICATION
ON THE
REMOVAL OF A GROWTH FROM THE
BRACHIAL PLEXUS,
AFFECTING THE ROOTS OF THE EIGHTH CERVICAL AND
FIRST DORSAL NERVES AT THEIR EMERGENCE
FROM THE INTERVERTEBRAL FORAMINA.
BY
EDWAKD BELLAMY, F.R.C.S.
Received September 9th, 1885— Read January 12th, 1886.
Tumours associated with the large nerve-trunks of the
cervical and brachial plexuses are comparatively rare, and
a successful removal, with complete restoration of functions,
possibly still more so.
The following case has therefore been considered worthy
of record — not only surgically, but as having several
points of physiological interest.
On Nov. 11th, 1884, I saw, in consultation with my
colleague, Dr. Mitchell Bruce, a lady, fifty-four years of
age, of considerable embonpoint, who suffered from a
growth in the root of the neck.
The swelling occupied the right side of the neck, and
212 REMOVAL OF A GROWTH FROM THE BRACHIAL PLEXUS.
sprang from the base of the subclavian triangle, and was
evidently very deeply seated. It was of doubtful mobility,
and caused the patient very great pain when manipulated,
however gently. I learned that, for several years past,
the patient had complained of tingling and pain shooting
down the arm and rendering it useless, whilst her health
was becoming seriously affected.
About two years ago she noticed the present growth,
appearing just above the centre of the right clavicle, and
becoming especially evident when the shoulder was
depressed. It steadily but very slowly increased in size.
All the muscles supplied by the ulnar nerve appeared to
be affected, both in the forearm and hand, whilst the areas
supplied by the cutaneous branches of this nerve, and
indeed of the entire inner cord of the brachial plexus, were
excessively sensitive.
There was, moreover, extreme sensibility on the lateral
aspect of the thorax ; apparently corresponding with the
intercosto-humeral nerve.
The integument supplied by the cutaneous branches was
cedematous and shiny, and the veins somewhat congested.
The exact diagnosis of the nature of the case was
manifestly difficult, — whether there was a tumour of, or in
some portion of, the brachial plexus ; whether the sym-
ptoms were the result of pressure from a growth disso-
ciated with the nerves ; or whether the swelling was
possibly due to a consolidated aneurismal sac. The sym-
ptoms, however, pointed to a growth involving the root
of the ulnar nerve.
It was deemed advisable to discover the real nature of
the growth, and if possible to remove it.
Operation. — On November 1 7th, assisted by Mr.
Stanley Boyd, after drawing down the integuments, I
made a linear incision along the clavicle, as in ligature of
the subclavian, but finding I had no room, I converted
this into a _L incision, the vertical portion of which ran up
along the posterior border of the sterno-mastoid. Some
few superficial veins were cut ami tied. Arrived at the
REMOVAL OF A GROWTH FROM THE BRACHIAL PLEXUS. 213
omohyoid, I hooked it up out of the way, and proceeded
to define the growth with my fingers. Some portions of
the plexus came into view, clearly placed over it, and
apparently somewhat " frayed ,; out. On these nerves
being hooked aside an encapsuled growth, smooth on
the surface, in shape like a chestnut, and having one pole
adherent to the scalene muscles was exposed. This pedicle
was cut through with scissors, when a small nerve was
divided. The under surface of the growth partly rested
on the first rib and pleura, and partly encroached upon
the combined cords of the last cervical and first dorsal
nerves, at their emergence from between the scalene.
The growth was then readily peeled off a nerve of no
great size, perhaps the suprascapular, perhaps the anterior
thoracic, but certainly not one of the great cords, whilst
the subclavian artery lay at its base inside. This vessel
was carefully hooked on one side. The chief attachment of
the growth was towards the scalene muscles. Owing to the
fatness of the neck the tumour was very deep, but the
entire operation occupied but a very short time. A
drainage-tube was put in, the edges of the wound approxi-
mated, a pad of salicylic wool placed over all, and the arm
brought across the chest. (The wound was completely
healed on the seventh day and the temperature never rose
above 99° F.). On the day after the operation the patient
stated that, although in some pain, it was of a very
different character to that she had experienced before the
operation was performed.
Progress of the Case. — Shortly after the operation
some symptoms of paralysis of the muscles of the arm
and shoulder came on. The patient could not grasp writh
the fingers nor rotate the elbow-joint, and she was unable
to lift the arm from the side. As this condition became
more marked, it was decided to apply the constant current,
and this was obtained by the ordinary Leclanche battery,
thirty cells' strength. Galvanism was at first productive of
little or no good. But under the care of Dr. Risk, of Har-
row, by great attention to the application of the current, the
214 REMOVAL OF A GROWTH FROM THE BRACHIAL PLEXUS.
functions of the arm began slowly to return. At the
present date (July, 1885) the patient has complete control
over the arm, forearm, and hand, perfect sensibility, and
complete freedom from pain.
Nature of the Growth. — The following is the account of
the examination of the tumour by my colleague, Mr.
Stanley Boyd :
" The tumour has the shape of a flattened sphere, one
inch in its longest diameter, well encapsuled, smooth on
the surface, having one pole adherent to the scalene
muscles, and it was at this point on cutting through
its pedicle with scissors, that a nerve seemed to be divided.
A few nerve-fibres were found spread out on the superior
aspect of the growth, but none penetrated the capsule,
and there was no trace of nerve-structure in it on section.
" The section had a greyish or yellowish, more or less
translucent appearance, the soft tissue being intersected
by distinct bands of fibrous tissue, stronger and better
marked inferiorly than elsewhere ; superiorly almost all
the tissue was soft and translucent. A scraping examined
in water showed the tumour to consist largely of round
cells, about as large on the average as white corpuscles.
The nucleus was rarely seen, and most of the cells contained
a few fat cells ; granular oval cells were common, perhaps
representing spindle-cells with processes torn off. Small
shreds consisted chiefly of closely-packed cells, arranged
in groups separated by bands of fibrous tissue or of
spindle-cells.
" A section stained and examined under the microscope
shows the growth to consist of closely-packed cells of the
above form, the spindle-cells forming broad bands between
groups of round or of spindle-cells cut transversely. For
the most part the substance between the nuclei is in
small amount and obscurely fibrillated, thus producing
the whitish bands visible to the naked eye. In this denser
tissue small irregular spaces, formed probably by mucous
degeneration and containing clear coagula, are BOmetimea
seen. The vessols are tolerably numerous, and of con-
REMOVAL OF A GROWTH FROM THE BRACHIAL PLEXUS. 215
siderable size ; their walls are formed by the tissue of the
growth. No nerve-fibres were detected.
" The tumour is therefore of the common connective -
tissue type, showing' but a slight departure from the embry-
onic condition. Had it infiltrated surrounding tissues it
would unhesitatingly be classed as a sarcoma, but if this
is its anatomical position the presence of a capsule and
the ease with which the growth shelled out, afford ground
for believing* that it will not recur."
Since the above was written I have received the fol-
lowing note from the patient's medical attendant in the
country :
" On Feb. 20th, this year (1885), she had an attack of
hemiplegia (right) owing to an embolic plugging of her
left cerebral artery.
" The result of this was a return to nearly a similar
condition of the arm as when she first came under my care.
By the end of July, however, with the aid of occasional
applications of the electric current, &c, she was able to
sew, cut up her food, and write with a pen very fairly
well, besides having considerable muscular power. From
that date brain- irritation began to show itself, and finally
culminated in an attack of acute mania. She died about
the end of October from the effects of another grave brain-
lesion, I believe in all probability profuse haemorrhage into
the medulla oblongata.
" But for these important complications I believe the
case would have been ultimately successful."
Note by J. Mitchell Bruce, M.A., M.D., F.E.C.P.Lond.
The leading feature of this case was pain, either of the
nature of " a sort of soreness," increased by movement,
so that the forearm had to be supported by the other
hand, or of " a sudden, jerking, neuralgic " character,
confined to the ulnar area of the hand. This pain was
216 REMOVAL OF A GROWTH FROM THE BRACHIAL PLEXUS.
accompanied by violent aching of the whole hand and fore-
arm when muscular movements were attempted. There
was also some itching of the ulnar border of the hand.
No muscles were ascertained to be affected beyond those
supplied by the ulnar nerve ; but both the degree and the
progress of the paralysis were difficult or impossible to
determine exactly, on account of the severe pain which
prevented or limited voluntary movements. No affection
of the pupil was ever observed.
There can be no reasonable doubt but that the patient's
death was entirely unconnected with the tumour or with
the operation, and that it was due either to embolism or
to cerebral haemorrhage. The patient had been for an
indefinite period the subject of aortic obstruction, and the
cardiac action was irregular during the whole of the time
she was under our observation. She had several attacks
of incomplete paralysis, with disturbances of consciousness,
before the fatal seizure ; in one of them there was marked
aphasia. {May, 1886.)
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, v. .1. ii.
p. 41.)
STATISTICS OF MORTALITY IN THE
MEDICAL PROFESSION.
BY
WILLIAM OGLE, M.D. Oxon., F.R.C.P.
Received October loth, 1885— Read January 26th, 1886.
The mortality of tlie medical profession is a matter in
which we are doubly concerned, having in it a personal as
well as a scientific interest, so that no apology is required
for bringing the subject before this Society; although I
fear that some of the figures which I shall have to pro-
duce are scarcely calculated to give us much satisfaction.
When the census was taken in April, 1881, there were
present in England and Wales 15,091 medical men, with
the age-distribution shown in the first line of figures in
Table 1. When the census was over, the death-registers
for the whole of England and Wales were carefully gone
through for three entire years, namely, 1880, 1881, and
1882, and the deaths of all males of fifteen years of age and
upwards were abstracted with distinctions of age and occu-
pation. In the second line of Table 1 are seen the results of
this process so far as concerns medical men. On these data
it is of course an easy matter to calculate the mean annual
death-rate in each age-period, and the rates thus obtained
are given in the last line of the table. The deaths thus
recorded at the several age-periods give a total rate of
25*53 deaths annually to 1000 medical men of all ages
218
MORTALITY IN THE MKDICAL PROFESSION.
over twenty years. The mean annual death-rate of medical
men between twenty and twenty-five years of age was 7*40
per 1000; between twenty-five and forty-five was H'57
per 1000 ; between forty-five and sixty-five was 28'03 per
1000, and over that age was 102-85 per 1000.
Table 1.
Medical men.
Age-periods.
20-
25-
45-
65-
All ages.
Enumerated in 1S81 .
Died in 1880-1-2
810
18
8300
288
4435
373
1546
177
15091
1156
Mean annual mortality"!
per 1000 . . . J
7-40
11-57
28-03
102-85
25-53
1
Now, the first question which naturally suggests itself
is whether this death-rate is a high or a low rate, and
this question again divides itself into two ; firstly, Is this
rate, which is based on the records of the three years
1880-1-2, high in comparison with the mortality rate of
medical men in former times? and secondly, Is it a high
rate as compared with the death-rate of men engaged in
other occupations ?
To the first of these two questions the data collected
in 1861 and in 1871 by Dr. Fa it, my distinguished pre-
decessor at the General Register Office, enable us to frame
an answer. The annual death-rates deduced from those
data are given in Table 2, and it will be seen in the last
column of that table thai while the annual death-rate of
medical men over twenty years of age w;is 23'6S in 1860-1,
it was 24-99 in 1871, and finally rose to 25*58 in L880-1.
These death-rates, let it be observed, are corrected for
any difference ra age-distribution at the successive periods j
they are the death-rate for 1000 medical men, having the
same age-distribution as existed in 1881.
MORTALITY IN THE MEDICAL PROFESSION.
219
Table 2. Mean Annual Death-rates, per 1000, of Medical
Men at Successive Dates.
Age-periods.
Per 1000
Date.
with ag -
distribution
20-
25- 45-
65-
as in 1881.
1860-1 .
5-86
12-78
23-47
91-69
23-63
1871 .
11-17
13-85
24-56
93-30
24-99
1880-1-2 . . . .
7-40
11-57
28-03
102-85
25-53
It thus appears that there was a progressive increase
in the mortality of the medical profession in the interval
between 1861 and 1881, and our first question is therefore
answered. The death-rate of the profession in 1880-1-2,
was a high rate as compared with that of earlier periods.
It will be noted, however, on looking at the figures in
Table 2, which gives the death-rates at each period of life,
that the rise of the death-rate in 1880-1-2 as compared
with 1871 was entirely due to an increase of mortality at
the later periods of life, and that the mortality fell among
medical men under forty-five years of age, while it rose in
those of more advanced age. The same is also practically
true when the 1880-1-2 rates are compared with those of
1860-1 ; for, though the death-rates of those who were
between twenty and twenty-five years of age was lower
in 1860-1 than in 1880-1-2, yet the proportionate number
of medical men of that age is so small, only 54 in 1000,
that the changes in the death-rate at that age scarcely
affect the total result, that is to say are barely appreciable
in the death-rate per 1000 at all ages over twenty.
It appears then that the mortality of medical men has
increased at the later ages, namely, after forty-five years,
while it has diminished at the earlier ages. The increase
at the later ages has, however, been greater than the
diminution at the earlier ages, and consequently the total
result has been an increased death-rate.
220 MORTALITY IN THE MEDICAL PROFESSION.
This increase of mortality at the later ages, and this
decrease of mortality at the earlier ages, was not peculiar
to the medical profession. A similar increase and decrease
occurred in the mortality of many, and indeed of most,
other professions and industries, and was in fact the most
noticeable phenomenon pi'esented by the mortality of
males generally in this country in the last decennium.
What was exceptional in the medical profession as com-
pared with most other occupations was this, that in that
profession the increased mortality at the later ages was
greater than the diminution at the earlier ages, whereas
in most other occupations, and among the male population
generally, independently of occupation, the contrary was
the case, and the lives saved at the earlier ages were in
excess of the lives lost at the later ages.
To the question, which cannot but present itself, why
it is that there has been this strange increase of mortality
among the male population of this country at the later
age-periods coincidently with a decrease of mortality in
the earlier stages of life, only a conjectural answer can be
given. Two causes can be pointed out that must almost
certainly have contributed to produce this result, and that
not impossibly may account for the whole of it. Firstly,
there is the increased wear and tear of adult life, brought
about by the growth of population and by the keener
struggle and competition which this growth necessarily
brings with it. Secondly, the very efforts that have been
made with such marked success to improve the sanitary
condition of the country, while they have enormously re-
duced the mortality of the young, may very probably
have tended to increase the mortality at the later ages;
for a large number of comparatively weak lives, which in
pre-sanitary times would have perished in infancy or
childhood, have been preserved, and by their survival
must have diminished the average vitality of the popula-
tion of more advanced ages. The <|iu'stion, however, of
the causes of the strange changes thai have occurred in
the male death-rates, though it is one which it was im-
MORTALITY IN THE MEDICAL PROFESSION.
221
possible to pass over altogether in silence, in reality lies
almost outside the present inquiry ; for the changes affect
the whole male population, whereas the present inquiry
relates specially to the medical profession.
Let us pass on therefore to the second part of our first
question, Was the mortality of medical men in 1880-1-2
not only high when compared with their mortality in
former times, but also high as compared with the mor-
tality of men engaged in other occupations ?
The answer to this question will be found in Table 3,
which gives in the first column of figures the annual
death-rates in 1880-1-2 for a number of different profes-
sions and trades, the death-rate being in each case cal-
culated for 1000 males over twenty years of age, with an
age- distribution similar to that of the medical profession.
Table 3. Mean Annual Death-rates of Males in different
Occupations corrected for Differences in Age-Distri-
bution. 1880-1-2.
Annual death-rate
Annual death-rate
Profession, Trade, or
per 1000.
Profession, Trade, or
per 1000.
Males 20
Males
Males 20
Males
Industry.
years of
25 to 65 ! industry.
years of
25 to 65
age and
years of
age and
years of
upwards.
age.
upwards.
age. j
All occupations .
22-83
15-42 jWatch, Clock, Philo-
Medical Profession .
25-53
17*30 sophical Instrument
Clerical „
15-93
8-57 Maker, Jeweller
21-20
14-36
Legal „
2023
1297 Printer
2375
16-51
Schoolmaster
1990
11-09
Bookbinder
2536
18-00
Clerk (Commercial
Earthenware Manu-
1 and Law)
21-10
15-61
facturer
35-98
26-83
Commercial Traveller
20-06
14-61
Cotton Manufacturer
27-19
16-76
Farmer
17-49
9-73
Woollen, Worsted
Agricultural Labourer
18-28
10-80
Manufacturer
26-47
15-91
Gardener .
15-08
9-24
Mason, Bricklayer,
Innkeeper, Publican .
29-02
23-47
Builder .
22-29
14-94
Brewer
29-23
20-99 ! Carpenter, Joiner
19-30
12-64
Chemist
22-52
15-66 i Painter, Plumber, Gla-
Shopkeeper
1943
13-52
zier
25-95
18-53
Butcher .
25-89
1805
Cutler
28-52
20-18
Baker
21-87
14-77
Blacksmith
23-14
14-99
Tailor
22-45
16-21
Quarryman
26-42
17-29
Shoemaker
20-66
1420
Coalminer
23-97
13-72
222 MORTALITY IN THE MEDICAL PROFESSION.
A glance at this table at once shows that the death-rate
in the medical profession is far in excess of the death-rate
in any one of the other professions which can be most
fitly put into comparison with it. Thus the death-rate in
the clerical profession is only 15*93, in the legal profession
is 20*23, in the scholastic profession is 19*90, while in the
medical profession, as before stated, it is no less than
25*53. Nor is the medical death-rate higher only than
the rate in the other learned professions ; it is higher than
the rates in most trades and industries, higher, for instance,
than those of chemists, shopkeepers, bakers, tailors, shoe-
makers, blacksmiths, carpenters, coalminers, and of many
other groups in the table, and is only itself exceeded by
the rates in certain trades and occupations that are
notoriously unhealthy.
There is, it is true, some little unfairness in the com-
parison of the death-rates in the medical and other learned
professions with the death-rates in other occupations. A
medical man, or a clergyman, when he has once adopted
his profession, remains in it, as a rule, for the rest of his
life ; and at whatever age death may overtake him it will
almost certainly find him still calling himself a member
of his profession, though he may have abandoned all
practical exercise of it. The death of a medical man,
therefore, or of a clergyman, will almost certainly be re-
gistered as such, however old the deceased may have
been. But with most other occupations such is not the
case ; a man engaged in one of them, when he becomes
incapacitated for active work by disease or old age, gives
up the occupation, and with it very often gives up the
name. The death of such a man would be registered
without specification of the occupation which he had fol-
lowed in his active days. On this account, as also for
some other reasons which it is unnecessary hore to state,
it is better, when comparing the death-rates in differenl
occupations, to limit the comparison t<> males in the great
working period of lit''', namely, in the four decennia that
lie between 'he completion <>t' the twenty-fifth and the
MORTALITY IN THE MEDICAL PROFESSION. 223
sixty-fifth years of life. A column has consequently been
added to the table in which are given the death-rates in
each profession and trade per 1000 males in this period
of life, the age-distribution being as before assimilated to
that which existed in 1881 in the medical profession.
That is to say in each case the death-rate is that of 1000
males, of whom 652 were in the first half (25 — 45) and 348
were in the second half (45 — 65) of the whole age-period
of forty years. The relative mortalities in the several
occupations, as shown in this column, differ in some in-
stances very considerably from the relative mortalities for
the more extended age-period, as given in the earlier
column. But the results, so far as our present purpose
is concerned, remain unaltered ; the medical death-rate,
as before, is far in excess of the rates in the other learned
professions, and also of the rates in most trades and in-
dustries. Do then what we may, we cannot avoid the
unpleasant conclusion that the death-rate of medical men
is excessively high, and this whether we compare it with
the death-rate in the same profession at earlier dates, or
with the death-rates of men engaged in other professions
and in most trades and industries.
There are, of course, within the compass of the medical
profession sub-groups of practitioners that differ very
widely from each other in the social and other conditions
under which they live. The life and habits, for instance,
of a London physician or surgeon differ enormously from
the life and habits of a practitioner in some out-of-the-
way rural district, and these again from the life and
habits of a surgeon in the army or in the navy ; and were
it possible to separate these sub-groups accurately from
each other and to calculate their death-rates severally it
would assuredly be found that such rates would present
wide differences of amount ; and in this connection it may
be pleasant to the Fellows of the Eoyal Medical and
Chirurgical Society to be reminded, that, some thirty or
more years ago, the records of the Society from its esta-
blishment in 1805 to the beginning of 1851 were inves-
224 MORTALITY IN THE MEDICAL PROFESSION.
tigated by a distinguished actuary, the late Mr. F. G. P.
Neison,1 and that it appeared from his calculations, that
the mortality in the Society approximated very closely to
that of the male population of England and "Wales, or
indeed was fractionally below it, the actual number of
deaths among the Fellows having been 96, whereas it
would have been 97*1 had their rate of mortality been
equal to that of all males of corresponding ages in England
and Wales. In strong contrast with this were the death-
rates among the medical men in the army. Here the
mortality, as calculated by Mr. Neison, was very greatly
above that of the whole male population, the general
result of his inquiries being, that out of equal numbers
living and having the same age-distribution, there were
for the general male population 100 deaths, for the army
medical men 162 deaths, and for the Fellows of the Royal
Medical and Chirurgical Society 99 deaths.
The existence of such differences of mortality within
the profession itself is of course a matter of considerable
interest and importance. The data, however, on which
the present inquiry is based do not permit of any breaking
up of the medical profession into sub-groups, and con-
sequently in this paper the profession can only be dealt
with in the aggregate, and treated as a homogeneous
whole.
Having now seen that the mortality in the medical pro-
fession is extremely high, let us proceed to consider what
are the causes to which this is attributable, or rather
what are the diseases under which the excess of mortality
occurs.
Let me first state what are the data by means of which
I propose to examine this question. The local registrars
of deaths throughout the country have directions, when-
ever they register the death of a medical man, to send up
a full copy of the entry to the Medical Register Office, in
order that the Medical Register may be duly corrected by
the erasure of the deceased man's name. As a check on
1 Cf. 'Contributions to Vital Statistics' (1867), p. lei'.
MORTALITY IN THE MEDICAL PROFESSION.
225
the local registrars, who are paid half-a-crown for each
such entry when transmitted, copies of such entries are
also forwarded to the General Register Office at Somerset
House, and I have availed myself of the accumulations of
these copies of entries for my present purpose, and have
been thus enabled to present to the Society a table which
is, I think, unique, no similar table existing either for the
medical or any other profession or industry.
Table 4. Registered Causes of Death, with Ages, of 3865
Medical Men.
Age-periods.
All
Causes of death.
B5
ages.
20-
25-
35-
45- 55- 65-
75-
and up-
ward-.
Smallpox .
1
1
2
Scarlet Fever .
6
2
1 ...
9
Typhus ......
4
5
1
1
... 1
12
Diphtheria . . . . .
3
3
2
...
... 1
9
Simple continued Fever .
2
1
1 1
5
Enteric Fever . . . . .
1
18
8
5
9 5
1
47
Cholera ......
1
1 ...
2
Diarrhcea . . . . .
4
1
2
3
7
8
i
29
Malarial Fever .
2
1
4
7
Erysipelas . . . . .
3
6
8
2
6
1
26
Pyaemia, Septicemia
2
2
3 2
2
11
Venereal Affections . . . .
1
1 ...
1
3
Alcoholism .
"s
13
4 2
• , ,
27
Rheumatic Fever and Rheumatic
Affections of Heart
1
5
9
8 6
1
30
Rheumatism . . . . .
1
1 2
3
1
s
Gout
1
1
9 13
11
9
44
Cancer ......
11
15
42
55
10
133
Phthisis ......
13
88
83
37
31
10
1
263
Diahetes Mellitus . . . .
3
g
15
19
1
43
Inflammation of Brain .
2
3
3
2
3
1
14
Softening of Brain .
1
2
6
13
25
35
19
1
102
Apoplexy . . . . .
7
14
32
52
83
41
8
237
Paralysis . . . . .
1
6
12 34
45
31
2
131
Paraplegia, Disease of Cord
5
4
10 12
16
2
49
Epilepsy
8
9
1 6
8
2
37
Insanity, General Paralysis of Insane
6
20
11 8
7
3
55
Other or undefined Diseases of Ner-
vous System . . . .
6
13
8
17
16
5
1
60
Endocarditis, Valvular Disease, Peri-
carditis . . . . .
1
9
8
13
22
32
11
1
97
Hypertrophy of Heart
1
3
6
1
11
Angina Pectoris .
1
1
"o
9
13
5
34
VOL. LXIX.
15
226
MORTALITY IN THE MEDICAL PROFESSION.
Age-periods.
Causes of death.
All
85
iges.
.
25- 35-
15-
55-
65-
75-
and up-
wards.
Aneurysm J
4
11
7
6
4
32
Embolism
...
3
3
2
i
...
9
Other or undefined Diseases of Heart
and Circulatory System
lb 22
49 123 143
7s
11
in
Bronchitis .....
6 14 11 32 48
54
14
179
Pneumonia .....
2
24 46 2'.'
31
36
9
1
181
Pleurisy
3
3 1
5
4
1
1
18
Asthma, Emphysema
3
2 5
7
10
4
31
Laryngitis .....
...
1
4
1
1
2
1
1
11
Other and undefined Diseases of Re-
spiratory System ....
9
n
7
13
13
14
5
7«
Ascites
...
3
2
1
...
"
Gall-stones
6
2
1
o9,
Cirrhosis of Liver ....
3
20 3
27
9
90
Other or undefined Diseases of Liver
i
13
31
32 31
35
14
2
Diseases of Stomach
...
5
4
11
s
11
6
N
Hteraatemcsis, Melsena .
1
5
4
1
5
16
Enteritis .....
...
2
1
2
1
"i
2
9
Ulceration of Intestine .
2
3
4
2
5
...
16
Ileus, Obstruction, Stricture, Stran-
gulation of Intestine .
3
4
13
9
2
31
Hernia ......
1
1
...
2
Fistula ......
...
...
"l
2
...
...
3
Peritonitis
...
2
2
1
1
3
...
...
9
Otber or undefined Diseases of Di-
gestive System •
2
3
4
3
3
...
15
Nephritis .....
2
2
1
2
1
1
...
9
Bright's Disease ....
"i
7
30
33
35
34
12
...
L52
Calculus ......
...
2
3
6
1
1
13
Hsematuria
1
1
3
1
6
Suppression of Urine, Uraemia
3
3
"i
1
3
2
19
Diseases of Bladder and Prosl
2
1
11
12
3s
2
96
Other or undefined Diseases of Uri-
nary System ....
6
!l
7
8
9
3
2
44
Caries and other Affections of Bonce
and Joints ....
:
2
3
5
3
...
16
Carbuncle ....
...
2
1
6
...
9
Old age
... 2
B2|182
68
254
Accident ....
1
18
33
2\ L<
20
6
2
120
Suicide
s
14
11
L6 •'
4
9
55
Other or undefined causes
. 2
1
16
23 36 21
2L
3 i n
Total
85!
52C
:,:(;
761
944
:»7i
137 3865
Age-periods .
. 20-
25-
86-
45-
55-
65-
75-
and up- •*"
mid!. a»e»-
MORTALITY IN THE MEDICAL PROFESSION. 227
This table gives the registered causes of death in com-
bination with age for no less than 3865 medical men, who
died at some time within the ten years 1873-82, and the
certificates of whose deaths have been preserved.
Seeing how large a number 3865 is, and seeing that
these deaths came from all parts of the country indiffer-
ently, and were moreover spread over a period of ten
years, we may assume with much confidence that they are
a perfectly fair sample, representing with close accuracy
the bulk of the mortality of medical men, when distributed
by causes and by ages. Now, it has already been shown that
the mean annual mortality of medical men in 1880-1-2 was
25*53 per 1000, or — as it will be convenient to avoid the use
of decimals — 25,535 per million. We can therefore divide
out the 25,535 deaths, which occur annually among a
million living medical men, in the proportions given us
by the 3865 deaths of which we have the causes ; and by
so doing we shall of course have the annual death-rate per
million from each separate cause so dealt with.
The results are given in the first figure column of
Table 5 • while the second column of figures gives for
comparison the corresponding rate for all males in England
and Wales irrespectively of occupation, due correction
having been made for difference of age- distribution. That
is to say, the rates for all males are the annual rates for a
million males, with the same age-distribution as existed
in the medical profession in 1881. That distribution was
as follows :
20 and under 25 years = 53,674
25 „ 45 „ =549,997
45 „ 65 „ =293,884
65 and upwards =102,445
Total . . 1,000,000
228
MORTALITY IN THE MEDICAL PROFESSION.
Table 5.
Annual deaths per
millioii
males over 20
Annual deaths per
million living
males
Causes of death.
years
»f age.
Causes of death.
years of age.
men.
General
popula-
tion.
Medical
men.
General
popula-
tion.
Smallpox .
Scarlet Fever
13
59
73
16
Diseases of Circulatory
System .
4112
2934
Typhus
79
38
Diseases of Respira-
Diphtheria.
Simple or ill-defined
59
14
tory System
Liver Diseases .
3237
1744
4408
744
Continued Fever
33
40
Other Diseases of Di-
Enteric Fever
311
238
gestive System
973
632
Diarrhoea, Cholera
205
274
Calculus
86
30
Malarial Fever .
46
11
Diseases of Bladder
Erysipelas .
172
136
and Prostate .
634
287
Alcoholism .
178
130
Other Diseases of Uri-
Gout
Rheumatic affections .
29]
251
78
215
nary System .
Hernia
1520
13
665
88
Malignant diseases
879
790
Accident .
1105
Phthisis
L738
3145
Suicide
363
238
Diabetes
284
108
All other causes .
2S69
2121
Diseases of Nervous
System .
4565
-
Total from all ca
25,535
22,829
It will at once be seen that the figures in the two
columns differ very widely ; and the general result of
the comparison is to show that, with very few exceptions,
the mortality of medical men is higher under every
heading than the mortality of males generally, and that
under some of the headings the medical mortality is twice
or thrice, or even more times, greater than the average.
There are altogether in the table twenty-seven head-
ings, and in only seven out of these is the medical death-
rate lower than that of males generally. Moreover, of
these seven headings under which the advantage is on the
side of the medical men, there are but three of any nume-
rical importance, viz. phthisis, die i the respiratory
organs, and accident. Again, as regards the Last-men-
tioned of these, namely, accident, although the mortality
of medical men is very considerably below the aver
this is only beean-r the average is raised by the inclusion
MORTALITY IN THE MEDICAL PROFESSION. 229
in the general population of men employed in a small
number of highly dangerous occupations, and, when these
exceptionally dangerous industries are left out of the
account, the death-rate of medical men from accident is,
as will be shown later on, a high one. Thus there
remain only two headings in the table, namely, phthisis
and diseases of the respiratory system, under which the
medical mortality is in any important degree lower than
the average. The medical mortality from phthisis is 45
per cent., and from diseases of the organs of respiration
27 per cent., below that of the general male population.
The advantage thus enjoyed by medical men is in all
probability due rather to their social than to their profes-
sional position ; phthisis and lung affections being dis-
eases which are especially destructive among the classes that
suffer from destitution ; and the medical profession being
of course, as compared with the general male population, a
class in easy circumstances. Something also may fairly
be put to the credit of the knowledge of the healing art
which medical men who fall ill have at their command ;
and it is to this latter advantage, combined with the
absence from their occupation of the necessity for any
severe muscular strain or exertion, that the much smaller
mortality of medical men, as compared with the general
population, from hernia, is to be ascribed. The figure
under this heading is for males generally 88, but for
medical men only 13. To medical knowledge must also
be attributed the fact that while the mortality of the
general male population from smallpox is 73 per million,
the mortality of medical men from that disease is only
13 per million. Medical men are not likely to be led
astray in their own persons by the statements of anti-
vaccinationists, and consequently, though they are of
course much more exposed to the chance of infection,
their mortality from smallpox is scarcely more than one
sixth of the average ; and this fact is the more striking,
inasmuch as the reverse is the case with all those other
infectious diseases against which no similar prophylactic
230 MORTALITY IN THE MEDICAL PROFESSION.
remedy is known, such as scarlet fever, diphtheria, typhus,
enteric fever, and erysipelas. Under all these headings
the mortality of medical men, as might be anticipated, is
in considerable excess of the average. The slightly lower
figure for medical men under the heading " Simple or
ill-defined Forms of Continued Fever" is probably due
to more than average accuracy of diagnosis, and more
than average carefulness in statement of cause in the case
of deceased medical men, who will scarcely ever have died
without the presence of a brother practitioner.
The more than average mortality of medical men from
remittent and intermittent fevers is attributable with much
probability to the foreign element in the profession, that
is to say, to the fact that a considerable number of army,
navy, and other medical practitioners return to England
from India and the colonies with diseases contracted in
those parts.
Possibly the same explanation may account in some
degree for the excessively high mortality of medical men
from cirrhosis and other diseases of the liver, a mortality
which is considerably more than twice as high as that of
the general male population ; but, seeing how great also
is the excess of mortality in the profession under such
headings as gout, alcoholism, and calculus, not to speak
of diseases of other digestive organs than the liver, it
becomes difficult to resist the conclusion that the main
part of the enormous mortality from hepatic diseases is
due, despite of the indignant protest of Professor Casper
to the contrary, to the neglect on the part of medical men,
as a body, of those wise rules of diet which they lay down
for the guidance of their patients.2
1 'Aunales d'Hygieue Publiqne,' xi, L834 p. 884
a That doctors arc prone to neglect in their own persons the rules of ab-
stemiousness which they lay down for others is a charge of great antiquity
as is shown by the following fragment of Philemon :
TiKfii'iptov it, Tore tarpoic <'i<"' tybt
VTTlp iyKpCLTSUtC riur VOOOVOl ft' (r$6tipa
-iiiTin; \a\o?l'Tdi;, nr' lav TTTitirroiai ri,
iroioiivrac di/rot'c nai&' da' uvk iiwv rort
tripoig.
MORTALITY IN THE MEDICAL PROFESSION. 231
Scarcely smaller than the excess under the heading
Liver Diseases is the excess of mortality in the profession
from diseases of the urinary system. The liver-disease
excess above the average for the general male population
is 134 per cent.; the excess under the urinary headings
is 128 per cent., or practically the same, for in calculations
such as these, small differences are of course without much
value. On the other hand the excess of mortality from
diseases of the organs of circulation is only 41 per cent.,
and from diseases of the nervous system only 7 per cent.,
above that of the general population. Another disease
in the table under which there is a remarkable excess is
diabetes, the medical mortality from this disease being
284 per million living, while that of the general male
population is only 108. The numbers are small, and con-
sequently too much importance must not be attached to
them ; but I may point out that Dr. Richardson, I do not
know on what basis of observed facts, mentions1 diabetes
as a disease to which medical men are especially liable,
and explains this liability by the excessive nervous fatigue
incident to a medical practice ; and that other writers
speak2 of diabetes as a disease more common among the
well-to-do classes than among the comparatively poor, who
of course form the great bulk of the general population
with which the medical profession is contrasted in our table.
There remains one other group of diseases in the table,
namely, cancer and other malignant tumours, which
requires notice before passing on to the mortality from
violence. The medical mortality from cancer or malignant
disease is 879 per million living, while the figure for
the general male population is only 790, a difference of
about 11 per cent. This apparent difference is not more,
however, than can be rationally explained by the fact that
the diseases to which medical men succumb are almost
certain to be more accurately diagnosed and more care-
fully stated in death-certificates than the fatal diseases of
the general population. A cancerous or malignant
1 ' Diseases of Modern Life,' p. 408. 3 ' Ziernssen's Cyclop.,' xvi, 863.
232
MORTALITY IX THE MEDICAL PROFESSION.
tumour which proves fatal to a medical man will almost
certainly be diagnosed as such, and its nature stated by
his brother practitioner in the death-certificate, whereas
among the poorer classes it too often happens that the
nature of the tumour is not made out, and the cause of
death is simply given as " abdominal tumour " without
further specification.
Let us now pass on from the mortality caused by
disease to the mortality from violence, accidental or
suicidal. The table shows an annual mortality from
accident for medical men of 793 per million living, while
the figure for the general male population is 1105. But,
as Avas previously mentioned, the figure for the general
population is unduly raised by the inclusion of men
engaged in a small number of highly dangerous occupa-
tions, such as mining, quarrying, and sea-fishing ; and,
as is shown in Table G, which gives the annual mortality
of males between twenty-five and sixty-five years of age
in various trades and industries, the medical accident-rate
is in reality high, for of the twenty other occupations in the
table there are but eight in which the rates are higher.
Table G. — Mean Annual Mortality from Accident per
Million Males , from Twenty-five to Sixty-fivt Years of
Age,1 in iliffmnt ()rrnj,(iti,,)isf 1881-2-3.
Occupatiou.
million.
Occupation.
Rate per
million. <
Miners . . . .
2785
Commercial Trav<
557
Fishermen
2351
Butchers .
511
Quarrymen
2290
Agricultural Labourers
511
Cabmen .
L299
Farmers .
464
Painters, Plumbers, and
Cotton Workers
464
Glaziers
1129
Wool, Worsted Workers
lis
Blacksmiths
758
Gardeners
871
Builders, Masons, and
Pottery Workers
371
Bricklayers .
696
Bakers .
325
Innkeepers, Publicans
696
Tailors
278
Medical Men
644
Shoemakers
868
( larpenters, Joiners .
588
1 The rates in this table are for males between twenty-five and sixty-five
MORTALITY IN THE MEDICAL PROFESSION.
233
To what forms of accident is this high mortality among
medical men to be ascribed ? To this question it is
impossible to give a thoroughly satisfactory answer, owing
to the inadequate manner in which the nature of a fatal
accident is too often stated in a coroner's certificate.
The following- table gives, however, the registered causes
of the 120 fatal cases of accident that occurred among the
3865 deaths tabulated on pages 225, 226.
Registered Causes of 120 Deaths of Medical Men front
Accident.
Railway accident
. 7
Laudanum, morphia
18
Carriages or horses
. 17
Chloroform ....
6
Cut .
. 2
Nitrous oxide (tooth extraction)
1
Fall from height
1
Chlorodyne ....
1
Fall downstairs .
. 4
Chloral hydrate
9
Other falls .
. 7
Prussic acid ....
9
Burn
. 2
Carbolic acid ....
2
Gas explosion
. 1
Poison (kind unstated) .
2
Lightning .
. 1
Fracture ....
11
Sunstroke .
. 1
Kind of accident not stated .
8
Gelatio
. 1
Drowning .
. 7
Total
120
It will be seen that a not inconsiderable proportion of
the 120 deaths, namely 17, were caused by accidents with
carriages or horses, a kind of accident to which medical
men, especially in rural parts, are, of course, much more
exposed than the average of men ; very probably, more-
over, many of the fatal fractures and injuries, of which
the causes are not given, may have been due to similar
kinds of accident. But the most notable feature in the
table is the overwhelming amount of accidental death
from poison. In no less than 49 out of the 120 accidental
deaths, or in 40 per cent, of the whole, the death was
caused by poison, and in the great bulk of these cases
years of age, and are based on the data given in the ' Supplement to the
Registrar-General's 45th Annual Report ;' whereas the rates in Table 5 are
for all males over twenty years of age.
234 MORTALITY IX THE MEDICAL PROFESSION.
the poison was either some or other form of anodyne or
prussic acid. It must be remembered that in all cases
in which a person is found dead; without distinct evidence
of the circumstances under which the death occurred, the
death is considered to be accidental ; but that some, at
any rate, among these numerous deaths from poison were
not accidental can scarcely, I think, be considered an
improbable or uncharitable hypothesis.
It remains to consider the mortality from suicide. The
mean annual death-rate among medical men from this
cause is given in Table 5 as 363 per million, while the
figure for the general male population of corresponding
ages is only 238, thus showing an excess of 52 per cent,
on the side of medical men. Moreover, if in place of
dividing out the total medical death-rate to the separate
headings by means of the 3865 deaths in Table 4, which
are spread over ten years, 1873 — 1882, the calculation of
the suicide rate be made directly (as it chances there are
means for doing) upon the deaths in the six years
1878 — 1883, it is found that suicide is apparently on the
increase in the profession, for by this fresh calculation
the suicide-rate for medical men rises to 464 per million
instead of 363. The rate in Table 5, being based on a
longer period of years, is doubtlessly the more trustworthy
of the two ; but I have been induced to give also the rate
for the later and shorter period, because I am able for
this period only to draw a comparison between the medical
and the clerical and Legal professions. The mean annual
death-rate from suicide in the six years 1878 — 1883 was
123 among clergymen, priests, and ministers ; 354 among
barristers and solicitors; and, as already stated, l»'>I
among medical men ; in each case per million living and
with the age-distribution of medical men in 1881.
It must, of course, not be forgotten that in treating of
the annual mortality in any single occupation from suicide,
as also from several others of the causes in the table, we
are dealing with a small number of actual deaths, and thai
under such eircumstances too much weight must not be
MORTALITY IN THE MEDICAL PROFESSION. 235
given to slight differences or slight fluctuations. But
while on this account it would be unwise to insist upon
the figures now given being taken as representing the
constant proportions of suicides in the three great profes-
sions, they can, I think, be accepted without hesitation as
showing that this mode of death is far more common in
the medical than in the other professions. The figures
represent accurately the proportions for six years, and
in all probability the proportions would not be found
very different if we had the data for a much longer
period.
As regards the methods of self-destruction selected by
medical men the most notable point is their preferential
choice of poison. Out of the 55 cases of suicide in Table 4
26, or 47 per cent., were brought about by poison, and in no
less than 15 of these 26 the poison used was prussic acid.
This is what might have been expected, for medical men
have free access to poisons, are familiar with their effects,
and know which are the most expeditious and cause the
least suffering.
Such are the statistics, so far as I have been able to
ascertain them, of the mortality in recent years among the
members of our profession. The figures, as was said at
the beginning of this paper, are not such as to give us
unmixed satisfaction. The ancient belief, which for ages
was accepted by the general public and was supported by
the theses of learned writers, that the life of a medical
man was as a rule longer and freer from disease than that
of an ordinary individual, inasmuch as, when in health,
he guided his steps by the laws of hygiene, and when in
sickness had the advantage of the best advice, after scarcely
surviving the ridicule of Voltaire, received its death-blow
so soon as the pitiless test of statistical inquiry was applied
to the subject. But though figures, such as those I have
brought before the Society this evening, are utterly incom-
patible with that ancient optimistic view, it is at any rate
not unsatisfactory to note, that my figures give on the
whole a much less gloomy view of the condition of the
23G MORTALITY IN THE MEDICAL PROFESSION.
profession than those put forth by some previous inquirers.
Thus, Escherich,1 writing some thirty years ago, stated
that 75 per cent, of medical practitioners die before they
reach the age of fifty, and more than 00 per cent, before
they have completed their sixtieth year. But the figures
given in my 4th Table show that instead of 75 per cent,
dying before the age of fifty only 37 per cent, die before
the more advanced age of fifty-five ; and that instead of 01
per cent, dying before the age of sixty only 57 per cent, are
gone before the age of sixty-five. Professor Casper2 gives
figures which are somewhat less appalling than those of Dr.
Escherich, but nevertheless are much less favorable than
those given in this paper. Casper, writing in 1834 of
medical men in Germany, states that only 24 per cent, of
them reach the age of seventy, this being a smaller percentage
than in any other liberal pi'ofession. My figures (Table 4)
show that 42 '8 per cent, reach the age of sixty-five, and 18*3
per cent, the age of seventy-five-; and calculating from the
most recent life-table3 this would mean a survival of 30*7
per cent, at the end of the seventieth year of life instead of
only 24 as in Casper's estimate. Again, the average dura-
tion of life of the 024 medical men who formed the basis
of Casper's calculation was 50*4 years, while the average
duration of life of the 3865 medical men in my table was
59'8 years.1 It is not then forbidden us to hope that
some future statistician, when another few decennia shall
have passed away, may find that the figures of his date
may present a like improvement upon those which I have
1 Cf. ' Diet. Encycl. des Sc. Medicates,' 2nd Sect., Tome v. 576.
• ' Annales d'Hyg. Publ.,' xi, 1834, p. 375.
3 Cf. 'Suppl. to -loth Ann. Rep. of the Registrar-General,' p. vi.
4 Dr. Guy (' Journ. of Statist. Soc/ ix, 846) gives Bgurei "t apparently a
much more favorable character than any quoted in the text. Bnl Dr. Guy's
calculations as to the mean duration of medical life were based exclusively en
the deaths recorded in the Annual Register; and these would, as a rule, be
ouly the deaths of bucd medical men as had attained some eminence in their
profession, who, of course, would on the whole he el more than a.
agi .
MORTALITY IN THE MEDICAL PROFESSION. 237
given, and that the sting may by that time have vanished
from the old proverb — Physician, heal thyself.
(For a report of the discussion on this paper, see ' Proceed-
ings of the Royal Medical and Ohirurgical Society,' New Series,
vol. ii, p. 45.)
ON THE TAPETUM LUCIDUM.
HENEY LEE,
CONSULTING SURGEON TO ST. GEORGE'S HOSPITAL.
Received November 2nd, 1885— Read January 26th, 1886.
No satisfactory account has yet been given of the use
of the tapetum lucidum, nor has its disposition in different
animals been accurately described.
The tapetum has generally been examined after the eye
has been removed from its socket. It is then difficult to
replace it in its exact natural position, and it has con-
sequently been generally loosely described as irregularly
placed at the back, or outer part of the back of the eye.
In order to ascertain the exact position of the tapetum,
in its relation to surrounding parts, it should be examined
in situ, before the eyeball is removed. For this purpose
the upper part of the orbit may be taken away, leaving
the eye in its natural position. The anterior part of the
eye, including the iris, must also be removed, any colouring
matter that may have escaped from the choroid must be
washed out with a thin stream of water, and the retina,
which becomes opaque a few hours after death, must be
removed in the same way. The tapetum will then be
fully exposed, and the light reflected from its surface
240 ON THE TAPETUM LUCIDDM.
will be seen to have a very definite direction, adapted to
the habits and instincts of the different classes of animals
which possess it.
In the ox and in the sheep the tapetum is seen princi-
pally on the upper and outer part, in relation to the
socket of the eyeball ; whereas in the dog and the cat it
is seen rather on the inner side.
The eyes in the ox and the sheep are placed on the sides
of the head. In the lion, the dog, and the cat the eyes
are placed more forward, and they can therefore use both
eyes at once. In relation to the eyeball itself, the tapetum
is found to occupy a different position in these different
classes of animals. Taking the entrance of the optic
nerve as a given point, the tapetum in the ox and in the
sheep is seen principally on the upper and outer part.
In the dog and the cat it is situated above the optic
nerve and extends to about the same distance inwards and
outwards.
The direction of the rays of light reflected from the
tapetum is very remarkable. In the ox and in the sheep
they are brought to an ill-defined focus ; in the cat and
the dog they are nearly parallel. This may even be ob-
served without dissection. The reflection from the tapetum
in a recently killed cat may be seen from the end of a
room if the pupil be dilated. In the ox and in the sheep
it can be best seen when the eye of the observer is
near the animal's nose. When the anterior part of the
eye, including the iris, is removed, the direction of the
reflected rays becomes much more apparent, especially
when the experiment is made some hours after the animal's
death.
Ufoperiment I. — In a calf's head, the roof of the orbit
was taken away and the anterior part of the eyeball
removed behind the ciliary ligament. The vitreous humour,
some pigment which had escaped, and the retina were
washed away. The tapetum was UOW seen, accurately
and sharply defined, to occupy exclusively the upper and
outer quadrant of the posterior half of the eye, with the
ON THE TAPETDM LUCIDUM. 241
exception of a spur with a bulbous extremity which pro-
jected inward.1 The tapetum had a bright metallic
lustre, resembling mother-of-pearl. A light was now
thrown on it in a room otherwise darkened, and the rays
were reflected so as to be brought to an ill-defined focus
about three inches to the outer side of the animal's nose.
This focal concentration of light was very apparent on a
black surface.
Experiment II. — A sheep's head was prepared in the
same way as in the first experiment, and a light was
thrown into the eye. The reflected rays from the tapetum
were now found to come to the same kind of ill-defined
focus, not on the side of the nose, but three or four inches
in front of it.
In connection with these two experiments it is remark-
able that the ox grazes from side to side ; the sheep,
forward.
Experiment III. — A cat was placed in a box with
some chloroform. When it was dead, the pupils were
found to be greatly dilated. The reflection from the
tapetum could be seen in ordinary light from any part of
a large room. It was visible, however, in one direction
only, and that was in a line slightly diverging from the
median plane laterally, and nearly parallel to the nose
downward. The roof of the orbit was now removed and
the anterior part of the eye taken away, as in the two
former experiments. The reflection of light from the
tapetum, which before was of a light yellow colour, now
appeared of a very light green, of the brightest metallic
lustre. The reflected rays of light did not here come to
a focus as in the ox and the sheep, but were projected
forwards and downwards, very much in the same direction
as they were before the anterior part of the eye was re-
moved. The tapetum was found to be situated altogether
above the entrance of the optic nerve, extending nearly
equally to its inner and outer side. It had a very sharp
1 This spur varies in shape in different specimens, and is hetter developed
in the sheep than in the ox.
VOL. LXIX. 16
242 ON THE TAIT1TM LUCJDUM.
well-defined outline, about the size and shape of a longi-
tudinal section of a kidney bean, with its slightly convex
edge upward. In relation to the orbit the tapetuui ap-
peared in great part on its inner side, and could only be-
partially seen from the median plane.
Experiment IV. — A young cat was chloroformed ; the
nictitating membrane and the eyelids being removed, the
bright yellow glare from the tapetum was seen with
nearly the same brilliancy from any part of the room.
The cornea, iris, and lens were now removed, and the
tapetum was seen in this instance to be of a bright yellow
lustre. It was on the inner side of the orbit, so that,
viewed from the median line, the whole of it could not be
seen.
These experiments have been repeated in various ways,
always Avith the same general results.
In the horse the tapetum is very well developed, and
that part which is to the inner side of the entrance of the
optic nerve is larger than in the ox. When the anterior
half of the eye is removed and the vitreous humour washed
out, the reflection from the two portions of the tapetum
is seen of a very bright lustre. The light, however,
from the two portions is not reflected in the same direc-
tion, nor can both be well seen at once. That from the
outer portion is directed downwards and inwards, as in the
ox — that from the inner portion, downwards and forwards.
The reflection from the outer portion is best seen at
about a foot distant; that from the inner is seen clearly
at the distance of six feet.
The tapetum in the horse when spread out measures
fully two inches in its transverse diameter. From its ex-
tent the reflected light is thrown over a larger area than
in the ox, and the rays are not parallel to each other as
in the cat.
This extended reflecting surface, with a prominent and
moveable eye, must give the horse the assistance of a con-
siderable range "I vision in twilight (or, as it appears to
us, in the dark) from reflected light.
ON THE TAPETUM LUCIDUM.
243
In dogs the disposition of the tapetum is very much
the same as in cats. The lustre has appeared not so
bright as in cats, but brighter than in the ox.
Fig. 1.
Fig. 2.
Fig. 3.
Fig. 4.
Figs. 1 and 2 represent the tapetum, in situ, in the
two eyes of the same cat. They were necessarily drawn
separately, as they could not be fully seen together with-
out removing the nasal bones. Viewed from the front,
where the whole of the tapetum could be seen, it appeared
almost circular. The rays of light from the natural con-
cave surface were reflected in nearly parallel lines within
an area that would allow the whole to pass through a
dilated pupil.
Figs. 3 and 4 represent the tapetum in two eyes of
another cat, after they had been removed from their
sockets. More of the anterior parts of the eyes had been
removed than in those represented in Figs. 1 and 2. The
tapetum in Figs. 3 and 4 is represented as it lay expanded
on a flat surface. The transverse diameter therefore
appears longer than it would in its natural concave position.
The ox and the sheep, having their eyes placed on the
244 ON THE TAPETUM LDCIDUM.
sides of the head, see an object accurately with one eye
only. The dog, the cat, and the lion having their eyes
placed more forward, can use both at once. If the tapetuni
in the cat had been placed on the outside of the eyeball,
as in the ox, the rays of light reflected from its surface
would have fallen on the nose, or crossed each other im-
mediately above it. In any case the reflected light could
have been thrown on the same object from one eye only
at the same time, and that in a different direction to that
which is required by the animal's instincts. On the other
hand if the tapetuni of the ox had the same relative
position as in the cat, it would be of little use as far as
grazing is concerned.
The ox and the sheep have both very large pupils in
the transverse diameter. All the rays of light reflected
from the ground within a given area, which impinge upon
the tapeturu in these animals, are collected as from a con-
cave mirror and again reflected in a concentrated form
directly on their food. This provision must enable them
to feed in the dim twilight with comparative comfort and
safety from the admixture of foreign matter, alive or
dead. The concave mirror situated within the eye itself
acts the part of the concave mirror in an ordinary ear
speculum.
In the daylight the pupil of the cat is often contracted
to a mere line from above downward, but when the cat is
excited the pupil becomes round and fully dilated. The
glare of a cat's eyes when met in a dark passage has long
been noticed, and from the fact that this is seen equally
on both sides, it appears that the cat has the power of
directing the reflected light from both eyes to the same
object at the same time. The degree of convergence of
the optic axes may therefore give the cat the power of
estimating accurately the distance of its prey before
making its spring.
The glare of the lion's eye was not unknown to
Shakespeare. In his description of the dreadful night
on the eve of the idea of March, he makes Casca say : —
ON THE TAPETUM LUCIDUM. 245
" Against the Capitol I met a lion,
Who glar'd upon rne."
The tapetum is situated in front of the choroid and
may be dissected off it, leaving the choroid of its natural
colour. This colour, according to Hunter, presents in
different animals every shade from nearly white to black.
A coloured choroid may therefore be mistaken for a true
tapetum.
Among the eyes that I have examined I have found
that the tapetum does not exist in the hare, rabbit, rat,
sea-gull, heron, plover, rook, common fowl, landrail,
moorhen, hawk, owl,1 Egyptian vulture {Neophron pereop-
terus), &c. The tapetum does not exist in the eyes of
any fish which I have been able to obtain.
The conclusions arrived at are : —
1. That where the tapetum exists, the eye has, by re-
flected light, an illuminating power.
2. That this power can be utilised only at compara-
tively short distances, and that the eyes of fish and of
birds (which have the longest and keenest vision) have
it not.
3. That in animals which possess the tapetum the
light reflected from its surface is directed in different
classes of animals respectively in accordance with the
wants and instincts of each.
1 The eyeball of the owl is peculiar ; it somewhat resembles a very small
opera-glass. In common with the eagles and the hawks, the owl takes its food
in its claws. Mice and rats generally take it in their fore paws; rabbits and
hares eat deliberately and slowly, and masticate their food as they take it.
None of these require the assistance of a tapetum either in catching their prey
or in avoiding any foreign matter that might accidentally be mixed with their
food.
(For report of the discussion on this paper, see ' Proceedings of the
Royal Medical and Chirurgical Society,' New Series, vol. ii, p. 50.)
ENTERIC EEVER AT SUAKIN,
WITH SOME
CASES OF MALARIAL-ENTERIC, OR TYPHO-
MALARIAL FEVER.
BY
J. EDWARD SQUIRE, M.D., M.R.C.P.,
LATELY SENIOR MEDICAL OFFICER TO THE RED CEOSS SOCIETY IN THE
EASTERN SOUDAN.
Received October 17th, 1885— Read February 9th, 1886.
The study of any outbreak of enteric fever is always a
matter of interest, and when occurring under conditions
differing widely from those found at home the interest is
increased. We do not as yet know all about this disease.
Wide differences of opinion will always exist as to its
origin ; and even the means by which it spreads are still
subjects of controversy.
The majority of medical men in civil practice in this
country, I believe, incline strongly to the opinion that
enteric fever is due to a specific poison, and that its de-
velopment in any individual must be from the absorption
of a specific particulate poison resulting from some pre-
vious case of the same disease. With us the contamina-
tion of drinking-water is so frequently traced as the
248 ENTERIC FEVER AT SUAKIN.
carrier of infection that other modes of its diffusion run
the risk of being slighted.
Among medical men in the army there seems to be a
pretty general impression that enteric fever may, and
often does, originate de novo, the aggregation of a large
number of young persons in a tropical climate being quite
sufficient to determine an outbreak of this disease, without
any necessity for specific germs. Some authorities in the
service, and medical officers who have served in India
and in other tropical climates, incline to the view that
there is more than one disease which produces the sym-
ptoms and the lesions which we are accustomed to consider
peculiar to enteric fever. The results of my tropical ex-
perience, fortunately not very prolonged, as now brought
forward, will, I think, serve to strengthen the view of
specific infection, while they subvert the idea that con-
taminated drinking-water is its only mode of conveyance.
First as to the question of the cases of fever met with
at Suakin being really enteric. Our Indian medical
authorities point out some differences and difficulties in
the way of diagnosis.
Dr. Gordon, C.B., late chief of the medical service in
the Madras Presidency, is quoted by Sir J. Fayrer in his
' Croonian Lectures' (p. 173) to the effect that "if a
non-specific fever in the tropics occurs in a young delicate
lad, it will almost to a certainty become complicated sooner
or later in its course by diarrhoea or dysentery ; and
ulceration will be found in the small or large intestines,
Peyer's glands included. Is it meant," asks Dr. Gordon,
"to call it 'enteric' in a sense that it is pythogenic f It"
so, I believe that the designation is wrong."
A probable explanation of the non-specific u enteric"
fevers of tropical climates is given by Dr. Hall, of the
General Hospital, Calcutta, who thus writes to Sir J. Y\\\ per
('Croonian Lectures,' 1882, p. 175) : — "I believe that a
large proportion of cases returned as typhoid fever have
no risrhi to that name, [fa man die in India after having
ENTERIC FEVER AT SUAKIN. 249
an elevated temperature, and an ulcer can be found
in his intestine, the case is at once called typhoid. But
it takes a good deal more than an intestinal ulcer
to make a typhoid fever. I have seen many cases that
could not with any certainty be referred to any type of
fever, but which had on the whole more resemblance to
remittent than to any other, and which were found after
death to be coincident with intestinal ulceration, but an
ulceration distinctly not typhoid. It was an irregular
ulceration by no means selecting the site of Peyer's
patches, and very often encircling the intestine ; and my
experience is that this form of ulceration often occurs in
cases that would better bear the name of ' remittent ' than
anything else." I shall presently refer to one case of
this kind with no ulceration at all (Case 4). The setting
in of the rains is stated to be the time for commencement
of this non-specific " enteric " fever, and its spread is not
due to contagion (Fayrer, loc. cit., p. 177).
It would be presumption on my part to pretend to
decide, on the small experience of a four months' campaign,
whether non-specific enteric fever is a reality or not ; but
the cases which came under my notice have some bearing
on this question. I hope to show in this paper that the
outbreak at Suakin was true enteric fever, that it could
easily be accounted for on the specific theory of causation,
and that instead of attacking first the young newly-arrived
troops (represented by the Guards) it began with the
seasoned troops who had been some time in hot climates.
With regard to the spread of the disease, the peculiar
nature of the water supply — viz. condensed — gives a special
interest to this outbreak. Some of the cases will, I think,
show clearly that the climatic conditions of the locality
produced modifications of the disease not met with in
England, and contribute something to the elucidation of
the typho-malarial type of fever recognised in the Eoyal
College of Physicians' nomenclature. My own cases, which
may be classed as typho-malarial, are too few to affect the
question whether they were enteric fever modified by
250 ENTERIC FEVER AT SUAKIN.
malarial influence or really a special and most dangerous
idiopathic disease.
My appointment at the Base Hospital at Suakin from
the commencement of the active operations in the Eastern
Soudan this spring, enabled me to see much of the rise
and spread of fever among the troops engaged in the ex-
pedition, and to collect some observations which I hope
may be thought worthy of record. The Base Hospital
was the largest hospital in the camp, containing accommo-
dation for about 300 sick, each ward-tent having eight
beds. Here was also the best place for observing what
were the most prevalent diseases amongst the force, for
almost all the more severe cases had to pass through
this hospital. The system carried out in the arrangement
of hospitals had for its object the prevention of over-
crowding of the hospitals in the front, by the constant
transference of patients to the rear. The Base Hospital
was a kind of collecting station for all the troops, and
the cases we had under treatment there would give a fair
idea of the prevalent diseases amongst the whole force.
By the courtesy of the other medical officers of the hos-
pital I was able to observe cases in every division of the
Base Hospital, and I was frequently asked to see medical
cases in consultation with the officers under whose care
these cases were. During the latter half of the campaign
I had the charge of a division which contained eighty
beds, and it was into this division that a large proportion
of the cases of enteric fever were admitted. By these
means I have been able to collect the temperature charH
of some seventy cases.
Every precaution was taken to ensure a pure water
supply to the troops, with no risk of contamination daring
its distribution. From the scarcity of water in the
desert, the brackish quality of much of the well water
that is found, and the risk of contamination .>t' these
sources from the filthy habits of the natives, it. was neces-
sary to supply the troops witli condensed water. The
supply <>!' condensed water was continuous^ and was
ENTERIC FEVER AT SUAKIN. 251
generally sufficient for all requirements. By the use of
pure water thus secured for the troops, we might expect
that diarrhoea and dysentery would be kept in check, but
the admissions from these causes were considerable ; for
instance, the admissions to the Base Hospital for diarrhoea
and dysentery for the week ending April 3rd, were 22
and 9 respectively ; the week following they were 39 and
19, and for the next week the numbers are 39 and 15.
These diseases occurred among officers and men alike, and
certainly to some who never drank any but distilled water.
It is evident therefore that climatic influence has much to
do with the production of these ailments.
Suakin is built on an old coral reef; the pores of the coral
are partly filled up with carbonate of lime, and in some
parts converted into solid blocks like marble. The inter-
stices between the coral are filled up with sand, and the
whole covered with a layer of loose sand like that on the
desert beyond. The coral extends about three quarters
of a mile inland, and then the foundation becomes rock.
The Base Hospital was on the coral, as were all the camps
at the commencement of operations. After a time some
of the camps were moved on to the rocky ground towards
Handoub.
After March the temperature during the twenty-four
hours ranged about 80° F., the average daily variation
being 23-5° ; the greatest variation being 35°. The air
was dry, with heavy dews towards sunrise ; the prevailing-
wind N.E., comparatively cool, with occasional hot southern
winds.
Thus we see that the soil was porous and quickly
absorbed moisture, and the rapid desiccation of excreta and
refuse from the heat would favour the dissemination of
particles into the air. The falling tide left dry much of
the shallow lagoons which bordered the deep harbour,
giving a broad stretch of damp ground covered with
excreta. Here the native population always resorted to
the shallow water for the act of defecation. The early
morning dew gave moisture enough for the existence of
252 ENTERIC FEVER AT SCAKTN.
malarial germs, while the heat was the cause of many men
being- invalided from exhaustion and sunstroke. The great
variations in temperature were also trying to men used to
a more temperate climate and were probably the cause of
the attacks of acute tonsillitis that occurred. With regard
to malaria, the general impression amongst the army
surgeons seemed to be that Suakin ought not to be con-
sidered a malarious situation.
Very few cases of ague were admitted into the Base
Hospital. I had only two or three in my division, and
these occurred in men who had previously suffered from
malaria in India. But there was a form of fever which
attacked men who had never been in any malarious district,
which, as far as my personal experience went, began
usually about 5 o'clock in the afternoon with a feeling of
soreness all over the body, with headache and a tendency
to giddiness and slight elevation of temperature (100° to
102° F.). This had completely disappeared by next
morning, but returned in the evening. After two or three
attacks it might show itself in the morning and persist nil
day. During one such attack my temperature was 102°
F. before noon. I could detect no periodicity in the
attacks, which have since recurred, but I found large doses
of quinine of great service. I think it likely that these
feverish attacks may be really of malarial origin.
Before commencing to discuss more particularly tin-
outbreak which occurred among onr troops, it may lie as
well to give what proof s I am able that the disease was in
reality enteric fever. In the first place tin- Bymptoms
were in every respect similar to those which are seen in
enteric fever in this country. Of course many ci
showed modifications, and there were some in which the
diagnosis remained doubtful for pari or tin- whole of tin'
illness. But there was a sufficient number of cases which
pri'scntctl symptoms which left DO doubl ;i- i" their nature.
The onsc-t was gradual, the men usually bring
admitted after a tow days' illness, with increased tempera-
ture and diarrhoea. The tongue in some oases was typi-
ENTERIC FEVER AT SUAKIN. 253
cally dry and brown, the stools presented the ochre colour
or light brown " pea-soup " character ; and splenic enlarge-
ment with tenderness in the right iliac fossa and gurgling
were present. A difficulty was found with regard to the
recognition of the specific eruption, in that the body was
often spotted with sudarnina, which were generally most
abundant over the abdomen in consequence of the flannel
belt which all the men wore night and day. Some cases
showed no sign of the specific eruption. The progress of
the cases also resembled that of enteric fever in this
country, and the temperature charts will be seen to show
similar curves to those met with here. In order to com-
pletely satisfy myself of the nature of the disease I made
a small number of post-mortem examinations ; but the
rapidity with which decomposition set in, and the dis-
comfort of making autopsies on the floor of a bell tent
with the temperature above 90° F., caused me to confine
the examination to the intestines.
The first autopsy was in the case of Private J. H — ,l
get. 24, 2nd East Surrey Regiment, who was taken ill
about the 20th of March. He was admitted to hospital on
the 31st, and died on the 18th of April, or about the
thirtieth day of illness. Post mortem there was found much
ulceration of Peyer's patches in the lower part of the
small intestine, the ulcers having the undermined edges
and other characters of ulcers in enteric fever. There was
also some hypostatic congestion of the lungs. No perfora-
tion of the intestines had occurred. The diarrhoea in this
case was to the extent of about four to six stools daily,
but the temperature was most irregular, running up
unexpectedly three or four degrees and coming down as
suddenly as it rose. The highest temperature was 104*6° F.
(Chart i).
The next case is that of Private J. G — , East Surrey
Regiment, a?t. 23, who was taken ill on April 7th, and was
admitted on the 14th. Rose spots were noticed on the tenth
day, and the patient died from exhaustion on the thirteenth
1 See Temperature Chart, PL VII, tiy. 1.
254 ENTEEIC FEVER AT SUAK1N.
day. The temperature was persistently higli during liis
stay in hospital, ranging from 103° to 105 F. Post
mortem infiltration of Peyer's patches was found, and great
enlargement also of the solitary glands.
Many of the cases went through the disease without any
marked deviation from the typical course of enteric fever.
I have records of seventy-three cases which I believed
to be enteric fever. Of these, forty-four were under
observation for the whole illness, and twelve died ; and the
remaining thirty-two were sent to England convalescent.
Of the twenty-nine cases which had to be sent out of the
Base Hospital before they could be fairly said to be conva-
lescent, nine had been ill for more than three weeks, and
in most of these the temperature was gradually coming
down and they were nearly convalescent. Another nine
had been ill over two weeks, and all but two of these
were improving satisfactorily. Seven more had been under
observation less than a fortnight, of these three had only
I. ecu in hospital three or four days and no certain diagnosis
was possible. There remain three cases which I have kept
separate because of the diagnosis put against them. Serg.
E — , set. 34, of the Medical Staff Corps, was diagnosed
" febricula " ; Private S — , set 25, 5th Lancers, was dia-
gnosed "simple continued fever" ; and Sapper McX — , R.E.,
set. 26, is entered as " sunstroke." Yet on comparing the
temperature charts of these cases with those of undoubted
cases of enteric do great difference will be seen, and I sus-
pect that enteric fever wonld have been a truer diagnosis.
In looking over the complications that were met with
during the course of the cases, we find epistaxis with
hypostatic congestion occurring both early and late in the
disease in several cases, and in one case there was the rusty
expectoration of pneumonia, but without any stethoscopic
signs. Vomiting of bilious matters occurred in three
cases. These cases, where vomiting was a prominent and
early symptom, died, thus illustrating the seriousness of
such cases. In ' Quain's Dictionary of Medicine' they are
referred to as " Bilious Typhoid." Involuntary micturition
ENTERIC FEVEK AT SUAKIN. 255
occurred in some of the more severe cases, while reten-
tion was noticed in two.
Private H — , set. 22, a Mounted Infantry man, who was
ill for thirty-one days without his temperature falling to
the normal, had at last the whole body covered with suda-
mina, every square inch, including* the face, being thickly
studded. During the last week or ten days before he was
transferred, a bedsore had formed on the shoulder ; but
this was the only bedsore I observed in the hospital.
Haemorrhage from the bowel only occurred in two of
my own cases.
Private E — , of the Grenadier Guards, seems to have
had some peritonitis on admission, and to have died from
perforation. There was no autopsy.
Five of the more serious cases are, I believe, instances
of " typho-rnalaria/' or more strictly " malarial enteric
Fever," and these I will now give more fully.
Case 1 is Mr. R — / a correspondent, aet. 25, whose
duties involved a good deal of exertion. He was laid up
for a few days in the beginning of April, but resumed his
work. On April 27th he was again admitted with diar-
rhoea and a temperature of 103*6° F. in the evening. He
said he had then been ill three days. The temperature
remained constantly high — between 102° and 104° F., and
he was much depressed. Soon great restlessness and
anxiety came on, followed by delirium, at first only at
night, but finally by day as well. Soon after admission
a large purpuric blotch about the size of the hand, like a
big bruise, was noticed on the left forearm, and later
others appeared on the legs and trunk. He gradually
sank, and died on May 15th, the twenty-first day of the dis-
ease. In this case the probability of scurvy seems excluded,
as Mr. R — was able to get every variety of diet, and lived
well, either in the town or in the Head Quarter Camp,
until ho was taken ill.
A similar appearance was seen in Case 2. Private E — ,3
1 For Temperature Chart, see PI. VII, fig. 2.
2 For Temperature Chart, see PL VII, fig. 3.
256 ENTERIC FEVER AT SUAK1N.
Eet. 22, Grenadier Guards, was admitted on the 10th of
May, having been ill five days. His temperature on
admission was 103'4o F., but rose the next evening to
105-6° F., and he was delirious at night. On May 13th —
the eighth day of illness — some purpuric spots were
noticed, which on the eighteenth had increased, till the
condition at that time was as follows. The upper and
lower eyelids of both eyes were purple, giving the appear-
ance of ordinary " black eye " from a blow. There was
subconjunctival haemorrhage on the inner half of both eyes,
causing the conjunctivas from the pupil to the inner can-
thus to be bright red. Other spots and blotches also
appeared on the arms and trunk. This patient died on
May 22nd, the seventeenth day of illness. Here it may
be noted that oranges were given to the troops when pos-
sible, and lime juice was also served out, and as no scurvy
was noticed amongst the troops it is impossible to consider
the appearance noticed in these two cases as due to that
condition. In further considering the cases with a view to
see if any malarial influence can be detected in any of
them, I find one which presents a markedly remittent
character (Case 3). This patient, Private M — ,* set. 21, of
the Shropshire Regiment, was admitted on April 20th, his
temperature that evening being 103'8o F. The next day
he had vomiting and abdominal pain, with a temperature
of 105° F., and a pulse of 108 per minute. The general
Bymptoms led to a diagnosis of enteric fever being formed.
On the 24th of April — after four days' illness — the tem-
perature fell rapidly till it reached, on the next day, 90°
F. He was now feeling much better, and being able
to answer questions gave the following history. He
had been stationed with his regiment in Malta, and
during a severe epidemic of enteric fever in the island in
the summer of last year — in which his regiment alone lost
forty men — he was taken ill. and admitted to hospital there
on November 27th. He was in hospital for three months,
Buffering from enteric Eever, and when the regiment left
1 For Temperature chart, tee PL VIII, fig. l.
ENTERIC FEVER AT SUAKIN. 257
for the Soudan he was still unfit to accompany it. He
followed, however, on March 21st, arriving* at Suakin
about April 7th. Soon after passing Suez his diarrhoea
commenced again, and continued till his admission to the
Base Hospital. On April 18th, whilst on duty guarding
the railway, he became giddy and had to go back to camp,
whence he was brought to the hospital next day. On the
21st the motions were liquid and light coloured, having
the character of enteric fever stools. The temperature,
after remaining low for two days, again rose on the 25th
and remained high for three days, falling again till it
reached 97"6° F. on the 1st of May and then rising again.
Here it is probable that the remissions were due to mala-
rial influences to which he had been subjected in Malta.
This case may, I think, fitly be classed as malarial
enteric. It will be noticed that the patient had been in
hospital for three months in Malta with an illness that
was there described as enteric fever. His attack at Suakin
certainly was not a relapse, and second attacks of enteric
fever are rare. The malarial influence in this case is in-
contestable, and I can answer for the existence of enteric
symptoms — sometimes absent in cases published as typho-
malaria.
There now comes a case (4) which I must mention on
account of the symptoms resembling these entero-malarial
ones, and from the autopsy showing us an unexpected
state of the alimentary canal.
Private J — / get. 25, Coldstream Guards, was admitted
on April 24th with an evening temperature of 102 "8° F.
He was a big, florid man, and the symptoms led to the
diagnosis of enteric fever. On April 27th, the ninth day
of illness, there was vomiting which recurred frequently
up to the time of his death. On the tenth day of illness
rose spots were seen on the abdomen. On the twenty-
fifth day of illness he diedrather suddenly about 2 p.m.,
and I made an autopsy the same afternoon. Instead of
finding, as we expected, extensive ulceration of the lower
1 For Temperature Chart, see PI. VIII, fig. 2.
VOL. LXIX. 17
258 ENTERIC FEVER AT SUAKIN.
ilium, wo could not discover a single ulcer ; while the
whole ilium showed marked injection of the vessels, with
hemorrhagic spots in the mucous lining of the intestine.
This case at once brings to our mind the two cases
(Private E — and Mr. R — ,) in which subconjunctival and
cutaneous haemorrhages were found, and suggests that
possibly post-mortem examination in those cases also
mig-ht have shown a modification of the lesions in the
alimentary canal. These cases in fact cannot easily be
referred to any type of fever with which I am familiar.
Typhus may be at once excluded; for not only were the
petechial extravasations entirely unlike the mottled marks
of this fever, but these cases were apparently in no way
contagious.
How far the heat of the climate was concerned is
worthy of consideration. Heat alone can hardly have
been the only modifying cause, and is not likely to have
produced the illness. Cases of typical sunstroke and
heat apoplexy were comparatively rare ; and among the
very numerous cases of heat exhaustion the temperature
was almost always low, and only in one or two cases rose
to over 100° F. In most cases of this kind recovery was
rapid, and no petechias were noticed. In the fever of
tropical acclimatisation diarrhoea is not, I hear, a prominent
feature, as it was in this case.
Such fevers attack those who arrive in India during the
hot season, when perspiration is checked by the moist air
he monsoon; this is not of malarial origin, for it has
no intermittent character, and does not recur. As far as
I am aware hemorrhagic patches, such as I have
described, are not met with in these cases, nor is vomiting
a frequent or persistent characteristic. Heat alone will
produce diarrhoea, but it is a diarrhoea nol attended by
lever ; in fact ill some cases of simple diarrhoea in which
I took the temperature it was rather subnormal, as it was
■,\}<n in one or two cases of simple catarrh (cold in the
head). Heat and chill may be important factors in the
production of dysentery, hut the-.' eases have no re-em-
ENTERIC FEVER AT SUAKIN. 259
blance to that. The possibility of some malarial influence
in this case is suggested by an intermittent character in
the temperature chart. To use the term " bilious remit-
tent " is to beg the main question. To me it seems that
enteric fever is chiefly indicated, but modified either by
some malarial or by some climatic causes. If we have
not in these cases some disease which cannot be referred
to any of the classes usually recognised and described,
but merely enteric fever modified by climatic conditions, the
modification which will cause the absence of the ordinary
ulceration of the intestine, even after three weeks' illness,
as was the case with this patient, is one of unusual
importance.
In connection with these cases, I must mention one (Case
51) which occurred during* the voyage home. The patient
was one of the railway navvies, a big powerful man of
about thirty years of age. He reported himself sick with
headache and diarrhoea on May 28th, soon after leaving*
Suakin. It was first supposed to be merely indisposi-
tion from the heat, but the diarrhoea continued and the
illness became more marked. We had left a man behind
at Suakin who had been ill on board with enteric fever,
and had already two or three other cases in the ship
which looked like the same disease. This man, S — , was ill
all the voyage, and I almost despaired of his reaching
England. He appeared to me to be suffering decidedly
from enteric fever, but the temperature chart shows in a
marked degree the large variations which I attribute to a
malarial influence. During the course of his illness he
got some pulmonary complication, which, however, was not
severe. This was in the second week. On several occa-
sions I gave him quinine, but never in sufficient quantity
to have any marked effect on the temperature. Diarrhoea
was a marked feature of the illness, and the prostration
was extreme.
He recovered after an illness of about thirteen weeks.
If this man had been left at Suakin I believe that he
1 For Temperature Chart, see PI. VIII, fig. 3.
260 ENTERIC FEVER AT SUAKIN.
would not have recovered, and that the removal into a
healthy climate gave him his only chance.
The long continuance of this case and that of Case 3,
both with recovery, and the absence of enteric lesion in
Case 4, suggest the question whether the special processes
of enteric fever may be modified by malaria; and again,
may not Cases 1, 2, and 3 be really not cases of enteric
fever at all; and the two cases of " bilious typhoid"
be partly owing to malaria ? It would appear that the
existence of undoubted enteric fever does not necessarily
prevent a lowering of temperature to nearly 99° F. in the
first week, when there is no reason to suspect any malarial
influence; and that in those cases where convalescence is
prolonged, it is the evening rise, rather than the morning
fall, which characterises the irregularity.
I will add a short analysis of my cases and a few words
in conclusion on the origin and spread of the epidemic at
Suakin and on some points concerning the etiology.
The following table shows the number of cases of which
I have records. It will be seen that the majority went
through the whole illness under observation at the Base
Hospital ; and of the uncompleted cases the majority
were in a fair way towards convalescence when they were
transferred to the hospital ships.
(Died . . . .12
. . alescent .
ft
Completed Cases (44) < ~ '
(^ Convalescent.
Over 3 weeks ill
Uncompleted Cases (29) «
o_
9
9
7
Over 2 weeks ill
Under 2 weeks ill .
Probably enteric but vari-
ously named . . 4
Deaths = 12 in 73, or about 1 in 6. Total 7;:
Although this number of deaths cannot be taken as the
whole mortality for the 73 cases, I think it will not be very
far short.
In looking at the ages of those who came under my
ENTERIC FEVER AT SUAKIN. 261
notice for enteric fever, with a view to discover if age
influenced the mortality, I find that of the 73 cases there
were
2 cases with no deaths over 30 years of age.
22 „ 5 „ 25 „ „
39 „ 6 „ 20 „
4 „ 1 under 20 „ „
And in 6 cases the age is not stated.
It must be remembered that by far the majority of the
troops were from 20 to 25 years of age and very few were
over 30.
From the following table it will be seen that, though
more cases occurred among the younger men, the mortality
was greater among those over 23 years of age than in
those below that age.
A?e. Cases. Deaths. Mortality.
19 to 23 . . 36 . . 5 . 1 in 7*2
24 to 27 . . 26 . . 7 . 1 in 3-7
28 and over . 5 .0
Not stated . . 6 . .0
Or, to divide them differently,
23 years and under, 36 cases with 5 deaths, or 1
in 7-2.
Over 23 years, 31 cases with 7 deaths, or 1 in 4*4.
The disadvantages of youth in this disease, on which so
much stress is laid by the Indian and other army medical
officers, is not therefore apparent in these cases.
Nor did the new-comers suffer most ; the seasoned
regiments furnished some of the earliest cases.
At Suakin the first dozen cases admitted into the
hospital came from the Marines, the East Surrey Regiment,
and the Commissariat Corps — chiefly from the Surrey men
— and cases had been admitted from all these corps a full
fortnight before any men were admitted from other regi-
ments. Of these corps the Marines and Commissariat had
had men at Suakin for the previous twelve months, and
the East Surrey came straight from Cairo, where there is
262 ENTERIC FEVER AT SUAK1N.
always enteric fever to be found, having been stopped on
their way home after several years in India. Thus, they
all had spent some months in the country before the
Guards arrived in March. As the Guards came straight
from England it was to be expected that, if the " aggrega-
tion of young soldiers in a tropical climate ' ' is sufficient
to start an epidemic of enteric fever which " chiefly
attacks the new-comers" (Sir J. Fayrer, ' Cr. Lect.,'
p. 176) the Guards would have furnished the early cases.
As a matter of fact, however, no case occurred in the
Brigade of Guards till three weeks later than the first
cases in all the regiments mentioned above and not until
they had been six weeks at Suakin.
The question as to which regiments supplied the first
cases of enteric fever is of importance as furnishing a
guide to the origin of the epidemic. It is time enough
to be content with a theory of spontaneous origin when
we can find no trace of a cause which will satisfy the more
generally accepted specific origin of the disease. But here,
I think, we shall have very little trouble in tracing the
epidemic to pre-existing enteric fever elsewhere. Of
course when once introduced the disease Bpread rapidly.
The regiment which furnished the first cases was the
East Surrey Regiment. They arrived at Suakin from
Cairo, about February 20th, and on March 31st they had
a patient admitted to tho Base Hospital, suffering from
enteric fever (Private J. H — ). In this case the nature of
the disease was not open to doubt, as the result was fatal,
and the autopsy showed typhoid ulcers in the intestine (see
page 253). This is the first case in point of time, and
we find that at Cairo enteric fever existed at the time
when the regiment left. There is another point about this
regiment which deserves notice. Early in March they
were encamped to the northward of Suakin and for the
first throe or four days of their being there drank well
water, until a tank was placed for them to keep a supply
of condensed water. This is tho only instance I heard
of men drinking well water. The first case from the
ENTERIC FEVER AT SUAKIN. 263
Berkshire Regiment was admitted on April 14th, though
they arrived at Suakin in January. The first case from
the Shropshire Regiment was admitted on April 20th ;
from the Guards Brigade on April 24th, and from the
Cavalry on April 25th, which allows sufficient time for all
of these to have become infected from the East Surrey
Regiment, which had sent a man to hospital with enteric
fever a fortnight before. As regards the Australians they
had a case of enteric fever on board when they arrived at
Suakin, the man having been taken ill soon after passing
Aden.
Perhaps the most interesting point, however, with
regard to the etiology of enteric fever which this epidemic
presents is connected with the spread of the disease. The
care taken to prevent the men drinking contaminated
water, by the constant supply of condensed water, makes
it almost impossible that the disease could have been
propagated by the drinking-water in the manner so fre-
quently looked at as the chief mode of infection. The
most natural inference from a consideration of the circum-
stances is that the infection was conveyed by the air ; and
strong probability exists in my opinion that it was by this
means that the disease spread. All the camps had latrines
formed by digging a trench about two feet deep and two
feet wide, into which all the excrement was passed. From
the heat of the sun this was soon dried, and pulverised
particles could easily be carried by the wind. Defsecation
was by no means limited to the trenches prepared for the
purpose. From the cases I have quoted it will be seen
that most of the patients had been ill some days before
admission to hospital ; and in one case (Private G. H — , set.
24, Berkshire Regiment) the patient, who was a mess orderly
at the Head Quarter Camp, had been ill for three weeks
before he reported himself sick. Until admission to hos-
pital these men would use the common latrine, perhaps
sitting beside some other man or being immediately fol-
lowed by one who might place himself directly over the
source of infection. When it is remembered that soldiers
264 ENTERIC PBVEB AT SUAKIN.
have a peculiarity of remaining for a considerable time on
the latrines, so much so that in one military hospital in
Egypt I saw a sentry placed over the latrines with orders
to turn any man out who remained as much as an hour —
it would seem possible that infection might be caught in the
latrine. Another fact in favour of infection having taken
place by particles in the inspired air is seen in the large
number (nine) of the Medical Staff Corps orderlies who were
attacked. Nearly all these men were on duty at the Base
Hospital and in charge of fever tents ; and whereas the
earliest case from them was admitted on April 24th, by
which time we had over a dozen cases in the hospital, the
majority of the cases were not admitted till the second
week in May. These orderlies performed all the duties of
nurses to the patients, including, of course, the removal of
the bed-pans. They were also expected to wash, and soak
in disinfectants, all soiled linen from the fever cases before
sending it to the laundry. They were very hard worked,
many of them never getting more than six hours off duty
at a time for six weeks, and in some cases they had, like
all the other tent orderlies, to sleep on the ground in the
tent for which they were responsible. They were thus
constantly exposed to the air contaminated b}- the exhala-
tions from the patients ; though they were not allowed to
drink anything which had stood in the fever tents, or even
to use for themselves the water from the filters in those
tents. The constant visits of the Sisters and medical
officers to the tents acted as a check on infringement of
these orders.
It may of course be urged that infective particles
might have been carried in the air and settled in the
water which was stored in the tanks for the use of the
troops; but this was hardly possible as the tanks were
usually carefully covered with an iron lid.
In reference to the probability of the infection being
taken in by the inspired air, J am reminded of a case
which occurred to mo when 1 first wenl into residence at
University College Hospital as house physician in 1881.
ENTERIC FEVER AT SUAKIN. 265
Two or three of the attendants in one ward which I took
over had been attacked with enteric fever, and I reported
the ward sinks as unsatisfactory. On examining these
it was found that the special sink, for emptying the con-
tents of the bed-pans into, was choked at the trap, and
that the dejecta consequently lodged there. There were
cases of enteric fever in the ward and the stools were
emptied down this sink, and it seemed then that the
nurses might have contracted enteric fever from inhaling
the exhalations from matters blocked in this pipe and
rising into the scullery.
This outbreak of enteric fever at Suakin is thus in-
teresting from its bringing out the following points :
1. The disease was imported. The infection was
brought from Cairo and no theory of spontaneous origin
is necessary.
2. It spread by infection, the medium of transmission
of the infection being the air. The use of condensed
water for all drinking and cooking purposes made trans-
mission by the water almost impossible, and thus makes
the history of this epidemic a valuable addition to our
facts on the mode of conveyance of enteric fever infection.
4. The mortality was not proportionally greater in the
younger men, although the majority of those attacked
were young. The troops engaged were mostly young.
5. The climatic conditions produced in some cases
modifications of the disease, which seems to justify the
term malarial enteric fever.
6. In addition to a modified form of enteric fever, there
would seem to be justification for the term typho-malarial ,
as applied to cases (such as Case 4) in which no typhoid
ulceration is found after death.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 52.)
DESCRIPTION OF PLATES VII and VIII.
(Enteric Fever at Suakin. By J. Edward Squire, M.D.)
Plate VII.
Fig. 1. — Temperature Chart. — J. H — (see page 253).
2. — „ Mr. R — (see page 255).
3. — .. Private E — (see page 255).
Plate VIII.
Fig. 1. — Temperature Chart.— Private M — (see page 256).
2.— „ Private J— (see page 257).
3.— „ S— (see page 259).
Rate VII
Med. Chir. Trans."
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A CASE OP THOEAOIC ANEURISM
TREATED BY THE
INTRODUCTION OF STEEL WIRE INTO THE SAC.
WILLIAM CAYLEY, M.D.,
PHYSICIAN TO, AND LECTURER ON THE PRINCIPLES AND PRACTICE OP
MEDICINE AT, THE MIDDLESEX HOSPITAL; PHYSICIAN TO THE FEVER
HOSPITAL AND TO THE NORTH-EASTERN HOSPITAL FOR CHILDREN.
Received December 8th, 1885— Read February 23rd, 1886.
Thos. B — , set. 48, a publican, was admitted into the
Middlesex Hospital, June 5th, 1885, under the care of Dr.
Cayley.
Patient, who was formerly a sailor, had not had good
health for some years. He had been subject to rheumatic
gout, and what he described as liver complaint, and had
probably been a pretty free drinker. In 1858 he had
syphilis, and in I860 an attack of fever at Calcutta.
In November, 1884, he began to suffer from symptoms
of thoracic aneurism, and attended the Middlesex Hos-
pital as an out-patient under Dr. Fowler, but it was not
till five days before his admission that a visible tumour
made its appearance at the root of the neck.
On admission, he was a well-nourished man of good
muscular development and rather florid complexion. He
complained of a constant aching pain over the upper part
of the chest, which prevented sleep ; he had a clanging
268 THORACIC ANEURISM TREATED BY THE
metallic cough with inspiratory stridor, and there was
some difficulty in swallowing.
There was an oval elastic swelling about the size and
shape of a hen's egg, situated above and behind the right
sterno-clavicular articulation, which was bulged forwards ;
the tumour rose about three inches into the neck and
encroached upon the sternal notch. It had a very dis-
tinct expansile pulsation, and on auscultation the heart-
sounds were very plainly audible over it ; but there was
no bruit. There was dulness on percussion over the
tumour and for some distance below it over the sternal
region. The heart-sounds were normal, but the heart was
a little displaced downwards and to the left. There was
no difference in the radial pulse on the two sides ; the
pupils were equal and normal. The air entered both
lungs equally ; the breathing was attended by much
tracheal stridor. Pulse 84, resp. 20, temp. 98*4°.
He was directed to keep constantly in the recumbent
posture, and was ordered a diet consisting of milk six
fluid ounces, beef tea six fluid ounces, meat five ounces,
and bread five ounces, with two eggs, and he was given
twenty grains of iodide of potassium three times daily ;
this was gradually increased to sixty grains three times
daily. He was also given opium to procure sleep.
Under this plan of treatment the tumour rapidly
increased, and it was evident that it must soon burst
externally or become diffused among the tissues of the
neck.
A consultation was held with my colleagues, and it was
decided to treat the aneurism by introducing wire into it,
as was practised by the late Mr. Charles Hewitt Moore in
a case published in vol. xlvii of the Society's ' Trans-
actions.'
I was induced to urge this course from having made
the post-mortem examination of Mr. Moore's case, which
satisfied me that the fatal termination was due entirely to
pviemia, the result probably of some septic poison having
been introduced into the sac. fto far as the aneurism was
INTRODUCTION OP STEEL WIRE INTO THE SAC. 269
concerned the operation had been successful, consolidation
having been effected.
In the present case there was some doubt as to the
point of origin of the aneurism, whether it might not
spring from the innominate artery and so be amenable to
distal ligature. Aneurisms of the innominate are, how-
ever, very rare as compared with those of the arch ; in this
case, too, the carotid artery seemed to come from behind
the tumour ; moreover, Dr. Fowler, who had treated the
patient at the onset of the symptoms, then considered it
to have been aortic.
My own opinion was that the introduction of wire into
the sac was under any circumstances a less dangerous
proceeding than distal ligature of the subclavian and
carotid arteries.
Mr. Hulke having concurred with me that this opera-
tion would, under the circumstances, give the patient the
best chance, it was accordingly determined on.
A long coil of fine steel wire, prepared by winding it
in a very close spiral on a mandril, was cleaned by placing
it for twelve hours in strong Liquor Potassae in order to
remove adherent grease and render it antiseptic.
I believe that steel wires are liable to have adherent to
them grease which is used in tempering them, and this
might readily be the means of introducing septic material,
and to this, or to the trocar and cannula not having been
thoroughly disinfected, I am disposed to attribute the
occurrence of pyaemia in Mr. Moore's case.
The coil of wire thus cleansed was placed on a brass
cylinder of a half an inch in diameter. The spirals were
consequently very small, and though this rendered the
introduction of the wire more troublesome, it had the ad-
vantage of causing it to coil up in the neighbourhood of
the puncture instead of passing to a greater distance in
indeterminate directions.
On June 28 the patient was anaesthetised and Mr.
Hulke introduced a fine trocar and cannula, the lumen of
which was just sufficient to easily transmit the wire, into
270 THORACTC ANEURISM TREATED BY THE
the aneurism an inch above and a little to the outer side
of the right sterno-clavicular articulation, and after with-
drawing the trocar passed forty feet of the wire through
the cannula into the sac. Strict antiseptic precautions
were observed, including the passage of the wire, as it
was drawn off the cylinder, between two folds of sponge
wet with a 2\ per cent, solution of carbolic acid.
On withdrawing the trocar a little blood spurted from
the cannula, and during the passage of the wire some
oozed by its side. When the cannula was withdrawn a
localised hasmatoma formed under the skin.
No constitutional disturbance followed the operation ;
the temperature remained normal and the pulse unaffected.
The pain at the root of the neck, of which he had pre-
viously complained, much abated. The following day it
was noticed that the pulsation of the tumour was much
less marked.
The hamiatoina gradually absorbed, and the tumour
became converted into a hard mass with a slight com-
municated pulsation. The clanging cough, laryngeal
stridor, and occasional attacks of dysphagia continued.
On July 3rd an irritable pustular rash appeared on the
thighs, due probably to the iodide of potassium ; this was
accordingly discontinued.
In August signs of extension of the aneurism to the
left and backwards showed themselves.
August 9th. — It was noted that the tumour on the
right side was quite hard and free from pulsation. To the
left of the tumour in the sternal notch, and behind the
left sterno-clavicular articulation there was distinct pulsa-
tion. There was dulness on percussion over the upper
part of the sternum reaching an inch to the left of its
left border. Over this region the sounds of the heart
were abnormally distinct, but there was no bruit.
There was much stridor with the breathing, and frequent
attacks of coughing accompanied by severe dyspnoea,
during which the face became much congested. Some
glairy mucus was expelled with great difficulty.
INTRODUCTION OF STEEL WIRE INTO THE SAC. 271
It was now evident that the aneurism would soon prove
fatal from pressure on the trachea, and I thought it might
be possible to cause consolidation of that part of the sac
which was causing this pressure by a repetition of the
operation.
Accordingly, on September 10th, the patient was anaes-
thetised, and Mr. Gould, in the absence of Mr. Hulke, who
was away for the autumn vacation, introduced a trocar
and cannula into the sac above and to the left of the left
sterno-clavicular articulations, directing the instrument
somewhat obliquely inwards towards the middle line, and
passed in thirty-four feet nine inches of wire. At first the
wire met with some resistance, but this soon ceased and
it passed easily. At the end resistance was again felt
and the wire was then cut short and the end pushed down
the cannula into the sac by passing a blunt trocar. About
a fluid drachm of dark blood escaped during the operation.
Some hours after the operation the patient vomited after
taking food. At 5 p.m., eight hours after the operation,
the temperature was 99*4° ; at 10 p.m., 98"2°. He passed a
pretty good night, but coughed several times and had diffi-
culty in expectorating. During the next four days he con-
tinued much in the same state as before the operation,
still having attacks of cough and dyspnoea ; the temperature
varied from 99"4°to 98*2.° He also continued to complain
of a good deal of pain over the upper part of the chest,
which was perhaps more severe than before the operation.
The pulsation over the upper part of the sternum and
to the left of it did not appear to be much altered.
September 16th. — He complained of a good deal of pain
about the region of the last puncture, passing through to
the shoulder and down the left arm. The attacks of
coughing and dyspnoea were more severe and frequent.
Temperature continued to fluctuate between 99"4° and 98"6.°
It was thought there was some increased pulsation over
the aneurism. An ice-bag was applied and morphia
administered subcutaneously.
The next day the pain was less, but the temperature
272 THORACIC ANEURISM TREATED BY THE
rose at night to 102*4. The attacks of cough and dyspnoea
continued to recur.
September 18th. — The temperature had fallen to 98*2°.
September 19th. — Temperature at 10 a.m., 97*6°. In
the evening he was seized with a severe attack of dyspnoea,
during which his face became congested and cyanosed. He
was given a hypodermic injection of morphia, but without
relief. He became unconscious, with twitchings of the
muscles of the face and limbs, and died in about two
hours.
On post-mortem examination a large aneurism was
found to spring from the ascending part of the arch of the
aorta, which was generally dilated and atheromatous.
The aneurism, which communicated with the artery by a
very large opening, extended up behind the sternum into
the neck, reaching on the right side to three inches above
the sterno-clavicular articulation. The walls of this part
of the tumour were only formed by a little condensed
connective tissue about the sixth of an inch in thickness.
The upper part of the sac was filled by a firm pinkish
clot, embedded in which were the two coils of wire.
Below this for some distance the cavity was occupied by
softer blackish clot ; then there was a layer of decolorised,
fibrine which separated this part of the sac from the lowest
part which was in immediate continuity with the dilated
vessel. This lowest part of the sac contained no clot, and
corresponding to it the trachea, a little above the bifurcation,
was flattened by pressure and its mucous membrane much
reddened and inflamed. The bronchial tubes and the
lower part of the trachea contained much viscid mucus.
The upper part of the sternum was eroded and its inner
surface exposed in the aneurismal sac. The heart itself
was normal. The branches of the arch were not impli-
cated in the aneurism.
The other organs presented nothing abnormal. X"
embolisms were discovered.
In this case the first operation produced the desired
effect of consolidating that part of the aneurism which
INTRODUCTION OP STEEL WIRE INTO THE SAC. 273
projected into the neck, the rupture of which was imminent.
The second operation only completed the consolidation of
the upper part of the sac, but had no effect on the lower
part which was compressing the trachea. This part of the
sac communicated with the aorta by so large an opening,
and was in such immediate connection with the main blood-
stream, that even if the wire could have been passed down
so far it could hardly have failed to cause embolisms.
This case, with others that have been treated in a similar
manner, shows, I think, conclusively that the method is
free from any great amount of risk. But its value as a
means of effecting a cure of those aneurisms which
usually fall within the province of the physician, as being
considered inaccessible to surgical treatment, has still to
be estimated.
The following are all the cases of this mode of treat-
ment which I have been able to discover :
(1) Mr. Moore's case, already referred to, where the
patient died of acute endo-arteritis and endocarditis with
pyaemia.
(2) Dr. Baccelli1 treated two cases of thoracic aneurism
by the introduction into the sac of fine spring- wire. Both
cases terminated fatally, but in neither did any ill effects
follow the operation ; in one, death seems to have been
caused by incautious pressure on the sac by the stetho-
scope in auscultation.
Dr. Baccelli attached great importance to the point
whether the communication between the aorta and the sac
be small or large, and he appears to have laid down rules
for ascertaining this, but as only a brief abstract of his
paper is published in the Bulletin these are not given.
He considered that the operation was only likely to succeed
where the communication was small.
(3). Professor Loreta, of Bologna, in 1885, introduced
twenty-two yards of silvered copper wire into a large
abdominal aneurism, first making an abdominal section ;
the aneurism consolidated and became reduced to the size
1 « Bulletin de l'Acad. de Med.,' 1878, p. 18.
VOL. LXIX. 18
274 THORACID ANEURISM, ETC.
of a walnut, and the patient was discharged, apparently
cured, on the seventieth day. On the ninety- second day
he died suddenly from a rupture just at the junction of
the sac and the aorta.1
Besides these cases, distal aneurisms have been treated
in a similar manner, but these are foreign to the subject
of the present communication.
It thus appears that up to the present time no case of
aortic aneurism has been cured by this operation, and I
am disposed to agree with Dr. Baccelli that it is only where
the communication between the aorta and the aneurism
is small that this is to be expected. But I think that it
affords us the means of consolidating any portion of the
sac within reach, and thus we may safely and easily prevent
external rupture where this is impending, and may perhaps
in some cases relieve pressure on the trachea or other
important structures.
1 ' Memorie della Accad. delle Sci. dell 1st. di Bologna,' vol. vi, 18S5.
(For a report of the discussion on this paper, see ' Proceed-
ings of the Royal Medical and Ohirurgical Society,' New Series,
vol. ii, p. 59.)
ON THE CHANGES
WHICH OCCTJE IN
BONE AND SOFT TISSUES AETER
AMPUTATION OE A LIMB,
AND FROM CERTAIN OTHER CONDITIONS.
GEORGE POLLOCK, F.R.C.S.,
CONSULTING SUKGEON TO ST. GEOBGE'S HOSPITAL.
Received December 8th, 1885— Read February 23rd, 1886.
The changes which take place in bone after amputation
of a portion of a limb present some interesting features,
and are, I have ventured to think, of sufficient importance
pathologically, and perhaps to some extent practically, to
render the subject worthy of consideration by the Fellows
of the Society.
The subject is not a new one. Some of the changes
to which attention will be drawn have been remarked on
already, but certain other conditions do not appear to have
been particularly noticed ; and it is this which has led me
to hope that a discussion of the subject will not be con-
sidered useless or wasteful of time.
276 CHANGES WHICH OCCUR IN BONE AND
The changes referred to are not, however, confined ex-
clusively to bone tissue ; to some extent they affect the
softer structures.
They are not only found to occur in the bone of a
stump of an amputated limb, but also in limbs or parts
affected by paralysis. But changes in a marked degree
will also be observed, though in a different form and due to
a different cause, in bones of parts which have to undergo,
or take upon themselves, an extra amount of work, to
compensate for the loss of other parts with which they
were originally associated and had to act.
My attention was first drawn to this subject by an
opportunity afforded me of examining the body of a very
old man, who many years previously had undergone ampu-
tation of one leg, a short distance above the knee, and
had evidently long suiwived the operation. The subject
had been received in the dissecting room of St. George's
Hospital ; no history could be obtained as to the cause of
the amputation, or as to the date of the operation, nor of
the subsequent occupation of the individual. Suffice it
to say that the stump was well healed and sound, and
the cicatrix was evidently of considerable age.
The observations, therefore, as regards this individual
case, are simply confined to the description of the more
interesting points exemplified in the specimens of bone
figured on Plate IX. These consist of the upper portions
of two thigh-bones from the same subject, with the head,
neck, and great trochanter complete in each. For the
illustrations of these specimens I am indebted to my friend
Mr. John H. Morgan, Assistant Surgeon to Charing Cross
Hospital. The characteristics of the two specimens are
accurately represented, and the differences between the
bone of the amputated leg and that of the entire femur
made very clear.
To indicate accurately the comparative changes illus-
trated in the drawings, and the specimens themselves, tin-
thigh-bone of the sound side has been sawn through, al a
point to make it correspond in length with that of the
SOFT TISSUES AFTER AMPUTATION OF A LIMB. 277
amputated side, measured from the upper edge of the
great trochanter.
It will be observed, on an examination of the specimens,
that the contrast between them is most marked. The
general appearance, the thickness, weight, obliquity of
neck, and the respective positions of the head of each
femur, — all these points tell without trouble which portion of
femur must have been taken from the amputated limb,
and which belonged to the sound side.
The difference in weight of the two bones is very-
marked. That taken from the sound side weighed 6 oz.
gr. xx. The corresponding portion from the stump
weighed 3 oz. ^iij.
The difference in the obliquity of the neck of the femur of
the two sides which occurs after an amputation of a limb
through the thigh-bone, is perhaps one of the most
interesting and prominent features to be noted, so far as
the bone is affected by conditions entirely dependent on,
and occurring subsequent to, the loss of a leg above the
knee.
It has been found, from the examination of many speci-
mens, that if the subject has lived some few years after
an amputation through the thigh, the neck of the muti-
lated femur will become by degrees very oblique. In the
specimen exhibited this is seen to have taken place to a
remarkable extent : in contrast to this the neck of the
femur of the perfect bone has gradually been brought
down to a right angle with the shaft, and lies horizon-
tally between the head and the trochanter. The head of
the femur on the side of operation, as compared with the
upper edge of the trochanter, is nearly an inch higher
than in the opposite limb. The shaft in one is thin and
light in weight. The shaft of the other is thickened,
hardened, and increased in size beyond its natural growth ;
more in character with that of a femur of middle age
than of one taken from the body of a man eighty years
of age.
A most interesting contrast is thus exhibited in these
278 CHANGE* WHICH OCCTK IN BONE AND
two specimens. Not only is the neck of the femur of the
amputated side seen to be extremely oblique, but that of
the sound limb has not only assumed the horizontal posi-
tion, but the bone itself, neck and shaft, has become
thickened, strengthened, and hardened. The extra weight
imposed on the sound limb by the amputation of the
opposite one, to a great extent, no doubt, assisted to pro-
duce this alteration in the neck j the necessary extra
muscular action of the sound limb and consequent increased
blood-supply was most probably the chief cause of the
addition to the substance of the bone. It will thus occur
that the increasing obliquity of the neck of the femur
on the amputated side gradually adds to the length of
the remaining portion of the bone ; consequently, for
some time after an amputation has been performed, there
is a tendency for the stump to become gradually more and
more conical, unless precautions have been taken to obviate
such an occurrence by the removal of a sufficient portion
of the shaft, a fact which should not be lost sight of in
the performance of amputation through the thigh.
On the other hand, it will be found that the height of
the individual who has undergone amputation through
the thigh will diminish to a slight extent, from the cir-
cumstance that the neck of the femur on the sound side
gradually yields to the extra pressure from above until it
has assumed the horizontal position.
The increased obliquity of the neck of the femur after
amputation through the thigh is probably due to more
than one cause. The removal of the natural weight of
the trunk from the head of the bone may exert some
influence ; but probably more may be due to the fact that
the bone is no longer supported from below, but is
suspended, as it were, from the cotyloid cavity ; it may
also be partly owing to the daily decreasing support from
the surrounding muscles of the stump. The deterioration
observed to take place in the bone after an amputation of
the thigh is not, however, limited to that portion of the
bone left to form the stump. Similar conditions of marked
SOFT TISSUES AETEB AMPUTATION OF A LIMB. 279
diminished nutrition, and consequent wasting of structure,
are found to extend their influence to the pelvis of the
amputated side. Specimens of this condition have been
kindly brought for exhibition by Dr. Humphry, of Cam-
bridge, and Mr. Howard Marsh.
Dr. Humphry was able to secure a specimen of the
pelvis with the stump and perfect thigh-bone, from a sub-
ject in which he had amputated through the middle of
the femur some years previously. In this instance, the
evident loss of substance of the pelvis, on the side corre-
sponding to the mutilated femur, can be at once detected ;
so marked is it, that no one could hesitate, without exami-
nation of the thigh-bones, to pronounce on which side
the amputation had been performed.
In the specimen exhibited to the meeting by Mr.
Howard Marsh, similar conditions to those seen in the
preparation from the Cambridge Museum are to be
observed. It shows a diminution in size and thinning on
the side which corresponds to the amputated thigh. The
history of the case is not recorded. The specimen is
from St. Bartholomew's Hospital.
In a living subject who has undergone amputation
through the femur certain alterations may be detected,
such as are borne out by the examination of these parts
after death. I had the opportunity of examining a case
under the care of Mr. Henry Morris, in Middlesex Hospital,
of which the following are the brief particulars :
W. W — , ast. 49, had had his left leg amputated about
the junction of the middle with the lower third of the
femur, for disease of the knee-joint, when about ten years
of age. The following were the measurements of the re-
spective parts : —
On the amputated side, the measurement round the upper
part of the thigh was twenty and a half inches, that on the
sound side was twenty-two inches. The measurement of the
right half of the pelvis, from the median line of the sacrum
behind, to the linca alba in front, was fifteen inches. The
corresponding measurement of the opposite side was four-
280 CHANGES WHICH OCCUR IN BONE ANI»
teen inches and a half. From the anterior superior spine
of ilium on the sound side to the middle line of symphysis
pubis was six inches and an eighth, while that of the
opposite side was only five inches and five eighths.
The trochanter of the amputated limb was much less
prominent than that of the perfect extremity and could
not be very readily distinguished. It was on a lower level
than that of the entire femur. In another case in Middlesex
Hospital the patient had had his leg amputated for disease
of the knee-joint, some four years previously. The
measurement from the median line behind to the linea
alba in front on the amputated side, was twelve inches and
five eighths. That on the sound side was thirteen inches.
I am not aware that attention has been drawn to the
occurrence of this alteration in the aspect and conditions
of the pelvis, following on amputation of the thigh. Mr.
Hilton1 some years ago drew attention to a somewhat
similar alteration of the pelvis following on hip- joint
disease in children, though I cannot find that any allusion
is made to the changes referred to, which occur after
amputation. He writes : " I have ascertained by exami-
nation that the os innominatum on the side of the disease
does not grow so rapidly, and finally is not so large as its
fellow ; hence the area of the pelvis is not symmetrical,
and thus may interfere with parturition at the full period
of gestation. I may add that this pelvic deformity is
most conspicuous when the hip disease occurs in, or con-
tinues into, the period of early menstruation."
The deformity here described is, however, to be alone
attributed to some arrest of growth, whereas that which
takes place after an amputation of the thigh, may occur
after growth has ceased, and then can alone be the result
of absorption of bone tissue, the partial result probably of
diminished action of all muscles attached to that portion
of the pelvis.
Similar conditions of wasted or wasting bone structure
are to be observed underother circumstances, but nil bearing
1 ' Best aud Pain,' 2nd edit., p. 320.
SOFT TISSUES AFTER AMPUTATION OF A LIMB. 281
on the same principle, and illustrative of the fact that
wherever there is diminished action there is reduced
nutrition, and wherever we find extra action there will be
found increased growth.
Loss of substance of bone occurs in many conditions of
disease ; the wasting of the jaws when all teeth have been
parted with, as often seen in advanced life ; thinning of
bone under conditions of infantile paralysis ; or that which
is attendant on anchylosis of a joint ; all these conditions
manifestly indicate a diminished blood supply and dimi-
nished nutrition followed by a gradual absorption of bony
tissue.
To illustrate somewhat practically and more precisely
some of the conditions to which the foregoing remarks
apply, I cannot do better than quote Mr. Hilton's observa-
tions when referring to these changes in a case of disease
of the shoulder- joint : "The anchylosis and its remote
effects manifested themselves in this way : the humerus
and scapula were dwarfed and moved rigidly together,
and, in addition to the rigidity of that joint, the clavicle
was short, as compared with the other side, and the chest
on the left or shoulder-disease side was not so much
developed as on the other ; hence the left lung and
chest-wall were not in true concord as a part of the respi-
ratory apparatus" (loc. cit., p. 319).
Through the kindness of Mr. Henry Morris I am
able to exhibit a very interesting specimen of the wasting
of bone in association with paralysis. The preparation
consists of the bones of a right upper extremity with
scapula and clavicle, all showing extreme atrophy ; all
the bones are very light and fragile. The shaft of the
humerus is not thicker than a fibula and is twisted.
The radius and ulna are rounded and about equal in
diameter to a goose-quill. Both extremities of the hu-
merus and lower end of the radius have been fractured.
The case was no doubt that of an adult, as all the epiphyses
are ossified to the shafts of their respective bones.
We not only may observe these changes as taking
282 CHANGES WHICH OCCUR IN BONE AND
place in bones, but the soft tissues, such as muscle, &c,
are equally influenced as regards waste or increase under
similar circumstances. The- waste or increase of muscle
may be observed under many conditions.
In the case of a patient the subject of an amputation
through the femur we may detect both the one and the
other slowly progressing side by side. On the amputated
side we find wasting of muscle consequent on diminished
muscular action, and lessened blood supply ; on the sound
side, the substance of the thigh is found to have increased
in bulk and the muscles have become largely developed.
A gentleman under the care of Mr. Henry Morris, was
the subject of popliteal aneurism of the left leg. The
right leg had been amputated by Mr. Nunn eight years
previously for ruptured popliteal aneurism. I was
requested by Mr. Morris to see the case in consultation
with him late one evening. For reasons which need not
be entered into it was decided that the femoral artery
should be tied without delay. The operation was most
successfully performed by Mr. Morris the following
morning.
The left thigh had become very stout and muscular,
the patient having made constant active use of it, with
the aid of crutches and an artificial leg.
When examining the case before the operation, it was
found difficult to command the circulation through the
aneurism without using considerable pressure over the
femoral just below Poupart's ligament. This difficulty
was evidently occasioned by the quantity of soft tissue
between the skin and the artery, and this accumulation
of fat rendered treatment by pressure of the artery out of
the question. The amount of pressure necessary to
command the circulation would most certainly have
shortly produced slough or ulceration of the skin.
The art try was tied in Scarpa's triangle. When the
sartorius mascle was drawn to one side its increased si/.e
was a very marked object of attention ; its breadth being
quite twice that of the usual size of this muBcle. Similar
SOFT TISSUES AFTER AMPUTATION OF A LIMB. 283
enlargement was observed in the deeper muscles, so that
the femoral sheath lay deeper than I had ever previously
observed it.
Mr. Morris kindly allowed me to take measurements of
the respective sides a few days after the performance of
the operation. On the sound side the measurement
round the thigh close to the groin was 23 inches and }£ths.
On the amputated side the measurement round the stump
equally near the groin was 21 inches and -^ths, a differ-
ence of nearly two inches.
The trochanter on the amputated side was lower than
that of the perfect leg, but its outline could not be very
clearly defined.
Sir Benjamin Brodie, to whose teaching I owe not a little,
drew attention to the wasting of bones when limited in
their natural movements. He writes, " You will observe
that all bones in a state of inaction lose a great part of
their phosphate of lime."1 I cannot, however, find any
allusion to the compensatory growth and thickening that
takes place in bones that have a double duty imposed on
them.
Sir James Paget also remarks, " We have seen that
when a part is, within certain limits, over-exercised, it is
over-nourished ; so, if a part be used less than is proper,
it suffers atrophy."2
Mr. Curling drew attention to the changes which occur
in bones after injury, but I cannot find that he refers to
the alteration of shape, or increase of growth due to
pressure or over- exertion.3
The contrast between the injured and sound bones is
well illustrated in Cheselden's ' Osteographia.' Mr. Cur-
ling adds " that bones as well as soft structures fade and
waste away when their activity is diminished or their
functions suspended. This is seen in the bones of stumps
after amputation, and in bones of anchylosed limbs. In
1 ' Lectures on Pathology and Surgery,' 18-16, p. 409.
2 ' Surgical Pathology,' p. 86, 1863.
3 « Med.-Chir. Trans.,' vol. xx, 1837, p. 341.
284 CHANGES WHICH OCCUR IN BONE AND
the new museum adjoining the Ecole Pratique at Paris,
founded by Dupuytren, there is a remarkable skeleton of
an adult in which all the bones in the body are anchylosed,
excepting the lower jaw and the bones of the shoulder-
articulations. The bones of the extremities are very
much atrophied, the thigh bones being scarcely larger than
an ordinary radius/'
When we come to estimate the results likely to be
observed after the amputation of a limb through the thigh-
bone we have to consider (1) the function and the action
of the muscles, (2) the weight of the body exerting an
extra pressure (on the sound side), and (3) the entire
removal of all pressure from the stump.
No longer of much use, no longer pressed upon, no
longer exercised in proportion to the opposite limb, the
whole stump and corresponding side of the pelvis become
affected in a somewhat similar manner. On the sound
side the bone has to support more than its natural weight,
the muscles have to undertake more than their natural
duty ; the limb in fact has to perform all, if not more
than, the work of two legs ; and so bone and muscle are
proportionally increased in size, and to some extent altered
in shape, while the vascular supply is rendered equal to
the demand.
I must again refer to a remark of Mr. Curling's in con-
nection with the rather rapid absorption of bone from
non-use. He says in reference to the case quoted from
Cheselden, that the late Mr. John Shaw attributed the
thinning of the femur to the want of exercise ; but adds
that " the wasting had taken place to too great an extent,
in a short time to be accounted for in this way alone."
I venture to express the opinion that though the wast-
ing of bone under such circumstances as we have consi-
dered is necessarily slower than that of muscle, in both it
is often more rapid than may be generally supposed. We
witness the rapid falling away of muscle in the early
stages of hip-joint disease, and had we the power or means
to test the waste of bony structure in its commencement,
SOFT TISSUES AFTER AMPUTATION OF A LIMB. 285
and eai'ly stages of deterioration, my impression is that
we should find the process of absorption, simply as the
result of inaction, sufficiently active to account for the
changes observed in Cheselden's case.
I further venture to express the opinion, after some
little observation, that bone tissue and muscular fibre,
under certain circumstances, take on more rapid increase
than is often suspected.
In an instance in which the first, second, and fourth
fingers were removed by me for an accident, the thumb
and remaining third finger soon became so mobile that the
mutilated hand might be said to be almost as useful as the
original one. Within a few months both thumb and
finger were decidedly larger, broader, and longer than the
corresponding portions of the fellow hand, and in the
course of some year and a half a marked increase in size
and length in both had taken place.
We are all aware that the slow changes which are con-
stantly going on in bones from birth till death are
regulated and modified, so as not to interfere with the
form, substance, and strength of their respective parts, so
long as healthy action is permitted, and maintained. But
as age advances and movement becomes more limited, bone
commences to lose its solidity and becomes more oily and is
rendered more brittle.
What, however, appears to me to be the most interest-
ing and important question in connection with the speci-
mens figured in Plate IX is the fact that we find in one
and the same subject and at the same time two very dis-
tinct conditions in the thigh-bones of the opposite limbs ;
two very distinct and different processes, carried on from
the time of the amputation of one limb, to the death
of the individual who is certified to have lived over
eighty years. On the amputated side the remains of the
femur are thinned, oily, and brittle. On the sound side
the bone is thick, compact, and firm. In the first, motion,
and consequently nutrition, have been interfered with, and
we witness the progress of decay. In the second, muscular
286 CHANGES WHICH OCCUR IN BONE AXI>
action has not only been well preserved, but greatly
increased, and here we find the part equal to all the con-
ditions of bone in earlier life.
If such conditions are found to occur under certain
known circumstances, is it unreasonable to assume that
these facts may, with some slight advantage, be borne in
mind in the treatment of certain affections of the osseous
system, dependent, not on disease, bufc on general consti-
tutional disorder ? So that, by a careful combination of
exercise, position, and rest, combined with the judicious
use of mechauical appliances, we may accelerate the im-
provement of whatever defects such conditions produce.
Subjoined is a short table of specimens illustrative of
deterioration of bone, consequent on amputation, para-
lysis, &c.
LIST OF SPECIMENS ILLUSTRATIVE OF DETERIORA-
TION OF BONE, CONSEQUENT ON AMPUTATION,
PARALYSIS, &c.
1. S. D., 51, St. Thomas's Hospital Museum.
A right hip-joint, showing complete bony anchylosis ; a section
has been made through the bones from side to side. Externally the
form of the joint is but little, if at all, altered ; the margin of the
acetabulum may be traced without much difficulty. The cut surfaces
show such intricate union that the crusts and cancellous tissues of
the bones are continuous, and it is impossible to distinguish their
boundaries. The bones are very heavy and their crust is very com-
pact and ivory like. The pelvis in tliis case shoivs evident (him
of ilium in centre.
2. S. D., 20, St. Thomas's Hospital Museum,
An elbow-joint, in which the total destruction of the articular
cartilages and partial absorption of the articular end of the humerus
had been followed by firm ligamentous anohylosis, more especially
between the humerus and ulna. But chronic inflammation, accom-
SOFT TISSUES AFTER AMPUTATION OF A LIMB. 287
panied by growth of irregular bony spiculee from the ends of the
bone, and the repeated formation of abscesses, gave rise to constitu-
tional irritation, sufficiently severe to render amputation necessai-y.
The preparation shows evident toasting of bone from non-use.
3. S. C, 62, St. Thomas's Hospital Museum.
Preparation shows obliquity of neck of femur well marked, after
amputation thi-ough thigh. No history.
4. S. C, 2, St. Thomas's Hospital Museum.
Atrophy of humerus after fracture; upper half of bone remark-
ably atrophied. Cancellous structure of ununited epiphysis of the
bead is to a great extent removed, and replaced by soft fat. From
this point to the middle of the arm the shaft is exceedingly slender,
measuring in the thinnest part a quarter of an inch from before
backwards, and rather less from side to side ; the long circumference
and the medullary cavity appear to retain their proportional size.
In the lower half the bone ha9 been fractured in three places. There
i3, however, no osseous union between the fragments ; but they are
surrounded on the outer side by an adherent periosteum, and thick-
ened and condensed fibrous tissue, which is also prolonged between
their extremities, and unites them more or less perfectly to one
another. The same kind of tissue is prolonged into their medullary
cavities. The fragments are much thicker than either the tipper or
lower portions of the humerus.
5. S. C, 51, St. Thomas's Hospital Museum.
Upper part of femur after amputation. The end of the stump is
rounded and for some short distance above this, especially on the
posterior aspect, the thickness of the bone is increased by new perios-
teal deposit. There is well-marked obliquity of neck.
6. S. C, 4>\
Upper part of femur after amputation. The bone gradually tapers
towards its lower extremity. Obliquity of neck well marked.
7. S. C, 42.
Upper part of femur, after amputation, immediately below lesser
trochanter. The section that has been made shows well the atro-
phied condition of the bone, and the closed medullary canal.
Obliquity of the neck of the femur very marked.
288 CHANGES WHICH OCCUR IN BONE AND
8. Spec. 347, Middlesex Hospital Museum.
A vertical section of the greater part of a left tibia and fibula, with
the tarsus and metatarsus, showing extreme atrophy from disease
of leg (paralysis ?). The compact tissue is reduced to thin shell, and
in places perforated by foramina, due to its total conversion into
spongy bone. The greatly expanded medullary cavities, in the
recent state, were filled with a pinkish-yellow fatty material from
the degenerated medulla. The growth of the bones ha3 been re-
tarded, and the tibia and fibula are markedly curved, the convexity
being forwards.
9. Spec. 34.8, Middlesex Hospital Museum.
The upper portion of a tibia and fibula from an amputated stump.
The bones, especially the fibula, are much atrophied and very light.
Their sawn ends are united by bone, and pointed. This was in the
case of an adult, as the epiphyses are ossified.
10. Sp. 3-49, Middlesex Hospital Museum.
The bones of a right upper extremity, with scapula and clavicle
showing extreme atrophy. All the bones are very light and fragile.
The shaft of the humerus is not thicker than the fibula of a boy,
and is twisted. The radius and ulna are rounded, and about equal
in diameter to a large goose-quill. Both extremities of the humerus
and the lower end of the radius have fractured, possibly in removing
or mounting the specimen. An apparent deformity of the hand
is probably due to the same cause. This case was no doubt that
of an adult, as all the epiphysial points are ossified to the shafts
of bone.
Series 1, 2, St. Bartholomew's Ho$2)ital Museum.
A scapula and part of a humerus. The arm had been amputated
long before death, and through disease the bones are atrophied, but
the humerus in a much greater degree than the scapula. The shaft
of the humerus has less than half its natural diameter and taperB
to a slender cone, at the end of which is some rough bone. The
marks of the attachments of muscles on it are nearly obliterated,
and its texture is high and dry. The head of the humerus is flat-
tened ami almost entirely absorbed, and there is a '/"it. ponding
diminution and change of form in the glenoid cavity.
SOFT TISSUES AFTEK AMPUTATION OF A LIMB. 289
Series 1, 3, St: Bartholomew)' s Hospital Museum.
Sections of a stump of a humerus, exhibiting the results of atrophy
from bony disease after amputation. Its sawn end tapers to a cone ;
the walls of the shaft are less than a pin in thickness, light and dry ;
and nearly all the osseous part of its cancellous tissue being re-
moved, the medullary tube appears, after maceration, like a smooth -
walled cavity.
S. 1, 4, St. Bartholomew 's Hospital Museum.
Pelvis and lower extremities of a young man. All the bones of
the right side are atrophied. The several prominences on the right
os innominatum are less marked, and its iliac fossa is more shallow
than the corresponding parts on the left side. The bones of the
right thigh and leg are all shorter, less in circumference, softer, and
lighter than those of the left limb. From the hip-joint to the ankle
there is a difference of nearly two inches in the length of the limbs.
In compensation for this difference the left foot is directed almost
vertically, so that in the erect position of the body (in imitation of
which the bones are arranged) the extremities of both limbs are at
the same level. All the bones of the right foot are slender, small,
and soft. The arch of the sole is much increased by the posterior
part of the os calcis projecting more than usually downwards. The
shaft of the left femur is enlarged by external deposit of new bone.
The muscles of the right limb were small and in a state of fatty
degeneration. The limb had probably been affected by infantile
paralysis.
(For a report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 65.)
VOL. LXIX.
ly
DESCRIPTION OF PLATE IX,
On the Changes which occur in Bone and Soft Tissues, after
amputation of a limb, and from certain other conditions. By
George Pollock, F.R.C.S.
Upper portions of two thigh-bones from the same subject. For
full description, see p. 276.
Plate K.
Med . Chir . Trans . Vol . LXIX .
U^0r'
:' Sj
-
, "*s"'-
Mint err. Bros . Ltk.
A CASE OF GENERAL SEBORRHEA
" HARLEQUIN " E(ET US.
BY
J. BLAND SUTTON, F.E.C.S.
Received December loth, 1885— Read March 9th, 1886.
The condition presented by the foetus, the subject of
this paper, although a very rare one, has received a variety
of names, e. g. : — Congenital Ichthyosis (Hebra), Intra-
uterine Ichthyosis, Congenital Hypertrophy of the Epidermis
(Sievruk), Diffuse Keratoma (Kyber), Cutis formatio prae-
ternaturalis (Vrolik). Dr. Wilks refers to it as the " har-
lequin " foetus, a term by which it is usually recognised
and one worth retaining, but as the name General Seborrhoea
expresses the nature of the disease, it has been placed at
the head of the paper.
The present specimen was sent to me by my former
pupil, Mr. CUttings, who is in the habit of furnishing
me with foetuses presenting* abnormal conditions. The
history of the mother and the circumstances of the preg-
nancy have no bearing on the case, except to note that
she had previously borne several healthy children.
The foetus was born at full time, and is of the average
292 GENERAL SEBORRHEA OR " HARLEQUIN " FflETUS.
size, weight, and measurement. At a glance, the appro-
pinateness of the term " harlequin " foetus strikes one (see
Plate X). Dr. Wilks1 describes it thus: — "The impression
which is first conveyed to your mind by looking at them
is, that the skin had ceased to grow at a certain period,
while the tissues within, continuing to increase, had caused
distension even to bursting, and thus the integument is
cracked and fissured on the most prominent parts of the
body." For the most part the fissures maintain a direc-
tion transverse to the long axis of the body, but are inter-
sected at right angles by vertical fissures, so that an
appearance is produced not unlike that presented by a
brick wall. The fissures are most marked on the head,
trunk, and trunk end of the limbs. The skin of the
bands and feet is free from cracks, but presents a curious
cere-like appearance, and the toes are tucked in and seem
as though drawn together by the contraction of the skin,
giving them a peculiar hide-bound look. The reddish-
coloured tissue at the bottom of the fissures is true skin,
and if the thickened patches be gently scraped they
easily separate from the dermis beneath. The hair on
the scalp is matted together by the morbid material, the
eyelids are widely open, the tarsal margins are in a
condition of lippitudo, and al birth presented a red line,
as if of inflammation. The ears are almost obscured by
being surrounded with the morbid material. The corneas,
mucous membranes, and viscera, are to all appearances
normal.
Microscopical examination of the skin shows that the
changes are confined alumst exclusively t<> the epidermis,
which in some place-, especially on the scalp, exceeds us
uormal depth about ten times. The superadded tissue is
for the mosl pari homogeneous, but iu the trunk a Lami-
nated arrange menl is obvious. < >n teasing, oily material
and epidermal debris cmud the field of the microscope.
Tlir thick crust-like masses on the scalp are very in-
structive \\ lu'ii examined in sections. For the examination
1 • Pathological taatouty,' 2nd ed., p. 696.
GENERAL SEBORRHEA OR " HARLEQriN " FCETFS. 293
throws important light on the nature of the disease.
The " plaques " on the scalp are, as in other parts of
the body, entirely in relation with the epidermis, but
instead of the lanugo passing directly through the whole
thickness of these crusts the individual hairs are coiled
and strewn about them in the utmost disorder, exactly as
one would expect to find them if a quantity of melted wax
were suddenly poured and allowed to set on a hairy scalp.
/4VS
££££
£
Section from the skin of the scalp of a harlequin fcetns.
a. Thickened epidermis, b. Bent hairs, c. Sebacious glands.
d. Thickened hair sheaths, e. Fat. f. Papilla.
From a careful consideration of the facts I am con-
vinced that Ave have in these cases to deal with increased
activity of the sebaceous glands, which, about the fourth
and fifth months of intra-uterine life, are normally excep-
tionally active. The secretion of these glands mixed
with desquamating epidermis constitutes the well-known
'• smegma embrvonum " or vernix caseosa, which instead
294 GENERAL SEBORRHEA OR " HARLEQUIN " FCETUS.
of being shed into the amniotic fluid, cakes or solidifies on
the skin and produces the remarkable condition seen in
the specimen. Of course it is possible that there is a co-
incident dermatitis.
That the abnormal thickening of the skin is due to the
vernix caseosa receives support from the circumstance
that it is most abundant in those parts of the body where
this secretion is most copiously formed, viz. the scalp, the
ears, on the trunk, especially the flexor aspect, the axilla,
flanks, and the neighbourhood of the external genitals.
If this view of the disease be correct, it would be less
confusing and more scientific to retain the name " general
seborrhcea " to denote the condition, whilst " harlequin
foetus " may be used as an excellent clinical term to serve
the purpose of ready recognition.
As the condition is so rare, and our English literature
contains no original drawing of the disease, I have been
induced to record and figure the present example as well
as to append as far as possible a reference to all the
recorded cases.
The specimen described in this paper is preserved in
the museum of the Royal College of Surgeons.
References.
Kyber. — Eine Untersuchung iiber das universale dif-
fuse congenitale Keratom der menschiichen Haut.
(' Medizinische Jahrbiicher/ Wien, 1880, p. 3(.'7.
Sievruk. — De congenita epidermis hypertrophia. (See
Kyber, page 408.) (The account refers to two specimens
preserved in spirit iu the museum of Moscow University.
Locherer. — Aertzlicher Intelligenzblatt, Jahrgang xxiii.
Munchen, 1876.
Houel et CiiAMr.AKn. — Hull, do la > A.natoinique,
4me ser. ; tomeiii, L878, pp. 574, 575; Microscopical and
histological examination of ;i case of congenital ichthyosis.
Vrolik. Tabula' ad illastrandam embrj ogenesin hominia
et inammalium. Lipsise, L849. On Tab. 92 are drawings
GENERAL SEBORRHEA OR " HARLEQUIN " FCETUS. 295
admirably illustrating the naked-eye appearances of a
foetus presenting "cutis forniatio praeternaturalis."
Wilks and Moxon. — Pathological Anatomy, 2nd edit.,
1875, p. 596. Four specimens are preserved in the
museum of Guy's Hospital.
There is a specimen preserved in the museum of the
London Hospital.
Nayler. — Treatise on Diseases of the Skin, p. 07.
1874. Refers to the specimens in Guy's Hospital.
Jonathan Hutchinson. — Lectures on Clinical Surgery,
vol. i. 1879.
Thomson. — Practical Treatise on Diseases affecting the
Skin, edited by Parkes, 1850. Refers on page 348 to a
case observed by Simon.
Bateman. — Practical Synopsis of Cutaneous Diseases.
8th ed., 1836.
Hebra (F.). — Diseases of the Skin (New Syd. Soc.
Trans.), 1800, vol. i, p. 111. Refers to cases by Stein-
hausen, Behrend, and Schabel. In the German edition
(Heft 3, Taf. 9, Fig. c) there is a figure given under the
name Ichthyosis congenita.
Ziemssen. — Handbook of Diseases of the Skin. 1885.
Keiller. — Lond. and Ed. Monthly Med. Jnl., vol. iii,
1843, p. 094.
Dr. Hermann Lebert, in his work Uber Keratose.
Breslau, 1804, p. 94, gives references to cases reported
by Richter, 1792, Hinze, 1820, Steinhausen, 1828, Houel,
1853, H. Miiller, Okel, 1855, and Souty, 1842.
The following cases have been observed in calves :
Gurlt. — Mag. fur die gesammte Thierheilkunde.
Berlin, 1850.
Liebreich. — Two Cases, Diss. Inaug. Halle, 1853.
Harpeck. — Arch. f. Anat. Physiol, und wissens. Med.,
1802, p. 393.
I am much indebted to Dr. T. Colcott Fox for several
of these references.
(For report of the discussion on this paper, see ' Proceedings of the
Royal Medical and Chirurgical Society,' New Series, vol. ii. p. 76.)
DESCRIPTION OF PLATE X.
(" Harlequin " Foetus. By J. Bland Sutton, F.R.C S.
-
■H^.
A V
Mr
■
-'-.*', •'.- •■ '
ON CARDIOGRAPHY,
WITH SPECIAL BRFEBENCE TO THE
RELATION OF THE TIME OF DURATION OF VENTRICULAR
SYSTOLE TO THAT OF DIASTOLIC INTEPvVAL.
PAUL M. CHAPMAN, M.D Lond., M.R.C.P.,
PHYSICIAN TO THE HEREFORD GENERAL INFIEMAET.
Received November 10th, 1885— Read March 9th, U
The object of the present paper is to bring forward
the subject of cardiography, with special reference to the
relation of the time of duration of ventricular systole to
the time of diastolic interval ; to give a short account of
some former work in this direction ; and to make public
so much of the present state of the subject as is due to
my own observations. It may also create an interest in
the matter which may lead to good results in the future.
At the present moment I believe that I am, most unfor-
tunately, the only physician in this country who habitually
uses the cardiograph clinically ; I myself have only been
able to employ it with advantage since I have established
a certain basis of comparison to work by. These pre-
liminary experiments and observations having been made,
the cardiograph should now come into ordinary use in
medicine, and not remain solely an item of the physio-
logical laboratory.
298 ON CARDIOGRAPHY.
The particular instrument by means of which my ob-
servations have been made, and one which is capable of
producing- very beautiful tracings, is that of Marey as
modified by Dr. Burdon-Sanderson ; an air-tight tympanum,
shaped like a kettledrum in miniature, from the moveable
surface of which projects a button which is adjusted to
the point of maximum impulse of the heart. The interior
of the tympanum is connected by means of a piece of
elastic tubing with a second tympanum, to which is
attached a lever which marks on a revolving drum trac-
ings of the impulses transmitted from the apex of the
heart by means of the cardiograph.
The time occupied by a single revolution of the drum
being known, the duration of time occupied in the produc-
tion of any part of the tracing may of course be measured,
by means of ordinates curved according to the length
of the lever, which is the radius of the curve. The time
occupied in the production of any part of the tracing may
be measured quite easily to the 200th part of a secoud.
a. Auricular systole, b. Ventricular Bystole. <■. Cessation of ventricular
contraction and fall of lever, d. Gradual filling of ventricle previous to
auricular contraction.
In Fig. 1 a normal tracing is given. I may inci-
dentally mention, in order to Bhow hoy tracings
may be taken with practice, thai it is an exact ropy of
one taken by myself from my own heart, without assist-
ance in managing the apparatus. The whole cardiac
ON CARDIOGRAPHY. 299
revolution occupies '9230", of which the ventricular sys-
tole occupies '3260" and the diastole *5970". The pulse-
rate is 65 per minute ; the auricular systole occupies
•0650", about one fifth of the ventricular systole.
Experiments were made, to determine the duration of
the various parts of the heart revolutions, by Dr. Landois,
and published by him ten years ago.1 Dr. Landois made
out an elaborate table of measurements for a single heart
revolution at a pulse-rate of 55 per minute. Briefly, his
duration of ventricular systole is '346", corresponding
almost absolutely to my own measurement of '343" ; but
he places the duration of auricular systole at "170",
which, according to my own experiments, is too long,
as I have not found it to exceed '100", while it is usually
less.
Dr. Landois does not attempt to determine the dura-
tion of ventricular systole at different pulse frequencies.
Any experimenter would soon find that the duration of
ventricular systole declines with any increase of frequency
of the pulse, and it becomes obvious that, before it would
be possible to use the cardiograph for clinical purposes,
and to estimate any alterations in disease, it would be
necessary to make out by what regular manner, if any,
the duration of ventricular systole declines.
It will be within the memory of many that details of
experiments were published in the year 1871 by Dr. A.
H. G-arrod 2 to establish the duration of ventricular systole
for different rapidities of pulse. His experiments were
made with the earlier instruments of Marey. It is
incumbent on me to criticise his results as I have found
them to be valueless. The very tracings he published
are not in my estimation satisfactory ; and the mathe-
matical formula given by him for determining the duration
of ventricular systole at any given pulse frequency is not
only vexatiously troublesome to use, but is based on
1 ' Graphische Untersuchungen iiber deu Herzschlag/ Berlin, 1876.
5 ' Journal of Anat. and Phys.,' vol. v [second series, vol. iv], pp. 17 — 27.
300 ON CARDIOGRAPHY.
incorrect observations, and necessarily furnishes incorrect
results.
Dr. Garrod's statement, in his own words, is this : —
" On comparing traces of different rapidities, it was found
that the length of the first part varied very definitely,
inversely as the rate ; not so quickly, but as its square
root ; and the number of measurements that have been
made seems to justify the law that, in health, the length of
the first part of the heart's beat varies, for a given position
of the subject, inversely as the square root of the rapidity."
Further, in a paper l on the " Mutual Relations of
the Apex Cardiograph and the Radial Sphygmographic
Trace," Dr. Garrod makes the following statement : —
" The first cardiac interval is that which occurs between
the commencement of the systolic rise and the point of
closure of the aortic valve, in cardiograph traces. The
number of times that this interval is contained in its
component beat is represented by y. The law as to its
length may be stated thus : xy = 20 \/ x," x representing
the frequency of beat per minute.
The calculation of the length of the systole for any
given pulse-rate by means of this very cumbrous formula
could scarcely be tolerated were the result correct, as it
involves several separate calculations. If, when the sum
is worked out, we find the result is not in accordance with
measurements obtained by experiment, the whole formula
may be dismissed with a sense of relief. I should, how-
ever, before doing so, justify myseli by furnishing some
calculations published in Dr. Garrod's paper {' Proceed-
ings of the Royal Society ') :
Rapidity of pulse.
Length of 1st cardiac interval.
( if minute.
Of second
.
. -0083033
•r.>S19
1'.' .
. -00714286
■4286716
64 .
. '00625
•375
81 .
. -005
•888
LOO .
. 008
•800
L21 .
. -0046
■27l'7
1 • Proceedings of the Royal Society,' Feb. 23rd, L871.
ON CARDIOGRAPHY.
301
Following- his formula, I have calculated out what
would be, according to Dr. Garrod, the duration of systole
in parts of a second, for every 10 beats increase of fre-
quency per minute from 50 to 130.
2-rate 50
Dm
atioii of
systole
•424"
60
>>
■384"
,, 70
»
•357"
80
>>
•333"
90
„
•317"
100
>j
•300"
110
«
•287"
„ 120
9>
■273"
„ 130
J9
•263"
My own table is the result of experiments conducted
on upwards of 150 different healthy people, all recumbent.
Many of these, again, were caused to vary the pulse-rate
by means of exercise, or a bath (the latter leading to
various fallacies), or were observed under excitement
which quickened the pulse. This table, which has been
indispensable to me, and will be so, I hope, to others
whom I trust I may attract into this field of investigation,
is based upon no theory, but is entirely the result of ex-
periment. Before giving it, I must state, and emphasize
the fact, that variations from it are constantly noticed in
healthy people, and even in the same person under dif-
ferent conditions, and that these variations may take
place within a limit of '02" either above or below the
measurement given, though I consider this to be the
maximum variation in health. I may with confidence
and safety state that any variation exceeding this limit
may justly be put down as abnormal, and that for high
pulse-rates I do not allow a maximum of "02" above the
duration of systole set forth in the table. The maximum
is usually obtained with the lower pulse-rates, and I do
not allow that for a low pulse-rate it should be less than
what 1 have given in my table.
302
ON CARDIOGRAPHY.
Table of duration of 1
(including auriculae
of pulse.
Pulse-rate.
Systole.
45
•3600"
50
•3515"
55
•3430"
60
•3345"
65
•3260"
70
•3175"
75
•3090"
80
•3005"
85
•2920"
90
•2835"
95
•2750"
100
•2665"
105
•2580"
110
•2495"
115
•2410"
120
•2325"
125
•2240"
130
•2155"
135
•2070"
140
•1985"
145
•1900"
150
•1815"
Hon of ventricular systole and of diastole
auricular systole) of heart, for different rates
Diastole.
Total.
•9733"
1-3333"
•8485"
1-2000"
•7479"
10909"
6655"
1-0000"
•5970"
•9230"
•5395"
•8570"
•4910"
•8000"
•4495"
•7500"
•4140"
•7060"
•3831"
•6666"
•3566"
•6316"
•3335"
•6000"
•3121"
•5701"
•2959"
•5451"
•2807"
•5217"
•2675"
•5000"
•2560"
•4800"
•2460"
•4615"
•2374"
•4444"
•2301"
•4286"
•2238"
•4138"
•2185"
•4000"
The table represents, in decimal parts of a second, the
time occupied by systole, or by dia stole, of the heart in
health for every increase in frequency of 5 beats per
minute between 45 and 150. It will be observed that,
for every 5 beats increase in frequency per minute, there
is a constant decrement in the duration of ventricular
systole of *0085", my measurement of the duration of
ventricular systole at a pulse-rate of 55, viz. •:> Io0", almost
exactly corresponding with that of Dr. Landois, which
was •34G0".
Though my measurements do not agree with those of
Dr. Garrod between 80 and 100, yet 1 should notice that
the decrement between 80 and 100 is the same in both
cases.
ON CARDIOGRAPHY. 303
I must point out certain facts which can be calculated
from this table, and which bring to light very forcibly
the importance of the diminution of the time of persistence
in contraction of the ventricle being a regular and con-
stant quantity. It should be well understood by every
physician, that the fact that the time occupied by the ven-
tricular systole diminishes by a constant quantity with
increased rapidity of pulse, is one of the greatest impor-
tance to the welfare of the economy. By means of the
table the time daily spent in work by the heart, and the
period of rest which it enjoys will be for the first time
made manifest ; the amount of work done being to a great
extent a separate question, but being also to a great
extent connected with the time expended in labour.
By multiplying the duration of systole for one cardiac
revolution by the pulse-rate we get the time the ventricle
expends in contraction per minute. At 75 the expenditure
is 23" 175" in the minute, at 80 it is 24-040". Thus, for
an increased pulse frequency of 5 in the minute, between
the pulse-rates of 80 and 85, we find there is an increase
in the time expended in contractions per minute of "865",
or nearly one second.
Now, at a pulse-rate of 120 the duration of ventricular
systole is •2325" ; the time expended in ventricular con-
traction per minute being 27"90". At a pulse-rate of. 125
the duration of ventricular systole is "2240", with an
expenditure of time in contraction per minute of 28"00".
That is to say, for an increased pulse frequency of 5 in
the minute, between 120 and 125, there is an increase in
the time expended in contraction per minute of "1", or
only one tenth of a second.
Thus, owing to the constancy of the decrement in the
duration of each systole as the cardiac revolutions increase
in frequency per minute, we find that the total duration
of contraction in the minute is increased but very slight I y
when we pass from one high pulse-rate to another still
higher.
By this provision the whole period of diastole or of
304 ON CARDIOGRAPHY.
rest in health, is never diminished to less than half of the
twenty-four hours. At a pulse-rate of 130, the period of
rest is twelve and three quarter hours out of the twenty-
four. The period of ventricular labour in health, there-
fore, never reaches half the day.
I have prepared a table in which the periods of labour
and of rest of the ventricles during twenty-four hours are
set forth for easy reference. It will be observed that,
as the pulse-rate increases, and the need of rest grows
more urgent, the period of rest lessens less rapidly ; and
that, after a pulse- rate of 130 is reached, the period of
diastole, or of rest, actually increases.
Time occupied in
8yi
dole or d\
'a stole of
ventricle
twei
ity-fow
hotirs.
Pulse-rate.
Diastole.
-
l.->
17M-:'
6H8'
50
L6h54
7'Mi'
55
L6h24'
7'';;tj'
(JO
l<i''0'
^''«»'
65
I .",''31'
8h29
70
i.V'.y
8»>55
75
ii»17'
80
1 1*24
9h36'
85
llH'
: •''.'.' ;'
'JO
IBHT
...
10h13'
'.'.".
1&2T
100
L3h20'
LOHO
105
I3h7'
L0h53'
11"
L3hl'
1 « •i'-_,-. .
115
L2h54
ii'w;'
120
1 2h50
UMo'
125
L2I>48
llh12
*180
I2''I7
ll1' 13'
la.")
I2''l!t'
IP' 11
1 to
L2b58
11 "7
1 1.".
L2h58
I l _
L50
12P6
10*54
dit)
"J
It would be better at this juncture to meni i« hi that these
facts can bo considered in relation with the heart-sounds,
and thai certain departures from the normal condition znai
ON CARDIOGRAPHY. 305
be roughly estimated by the stethoscope. The first sound
of the heart indicates commencement of ventricular sys-
tole, the second sound follows immediately after cessation
of ventricular contraction, a slight pressure forward of the
descending line probably being due to shock of closure of
the semilunar valves. Now, in great aberrations from the
relative length of systolic and diastolic interval the rhythm
of the heart-sounds is different from that in health. Small
deviations are of course only made apparent by measure-
ment of a skilfully-taken cardiography tracing, and could
not possibly be detected by the ear.
To consider the healthy rhythm. Where the total
cardiac revolution occupies l'O" the ventricular systole, or
(speaking roughly for the purpose I have in hand) the
interval between the first and second sounds of the heart
occupies •3345", or almost exactly one third of the total
cardiac revolution :
•3345" -33275" -33275''
12 3 12
On auscultation we can clearly distinguish the rhythm
of the sounds in such a normal heart, and could distinctly
count " three " in the middle of the pause ; the rhythmical
recurrence to " one " falling on the first sound of the next
revolution. The sounds of a healthy heart beating rapidly,
say at 120, do not take the same rhythm. Normally, for
a pulse-rate of 120 the time interval between the first and
second sounds is '2325", that of diastolic rest is "2675",
the difference in time in favour of diastole being only 2>\
hundredths of a second, which would be inappreciable
by the ear. We may therefore in this case assume that
the duration of systole and diastole are equal, and that
the first and second sounds of the heart would fall thus :
1 2325" 2 -2675" 12 12
VOL. LXIX. 20
306 ON CARDIOGRAPHY.
It is to be observed from these facts that in the healthy
heart the interval is always less between the first and
second sounds than it is between the second and first
sounds, even for high pulse-rates ; and that therefore aus-
cultation of the healthy heart in no case reveals any depar-
ture from the utmost regularity of interval between the
sounds, except in the increased interval between the
second and first sounds, ?'. e. in diastolic interval, when
the pulse rate is low. I have formulated this into a law,
stated thus :
In a healthy heart the time interval betiveen the first and
second sounds is never less than one third, nor exceeds one
half, of the time occupied by an entire cardiac revolution.
In disease obvious discrepancies of rhythm will soon
become noticeable to those who make a stethoscopic exa-
mination, bearing in mind the law I have enunciated.
To return to my table. I have to indicate the kinds of
abnormal cases which show some distinct departure from
the measurements there laid down. They are broadly
separable into two classes, one in which duration of ven-
tricular systole appears to predominate over diastolic
interval, and another in which diastolic interval appears
to predominate unduly over duration of ventricular sys-
tole. These, again, would each have to be divided, did
knowledge permit of it, Class 1 into cases in which the
duration of ventricular systole is actually increased, and
cases in which the duration of ventricular systole is appa-
rently increased owing to shortening of diastole ; Class -
into cases in which the ventricular systole is actually
shortened, and cases in which the shortening is apparent
owing to lengthening of diastole.
Abnormalities.
1. I will take first the case in which diastole abnormally
predominates over systole. In my experiments on patients
who were placed in the dry air (or Turkish) bath, at a
ON CARDIOGRAPHY. 307
temperature of about 140° F., and sometimes kept there
for an hour or more, I found that the duration of ven-
tricular systole occupied less time than it did in the same
patient at the same pulse-rate when the tracing was taken
under normal conditions. I at first attributed this to the
lessened blood-pressure, owing to the dilatation of the
capillaries of the skin, thinking a priori that if the heart
had less obstruction to overcome the systole of the heart
would probably be less prolonged. If patients were
brought out of the bath and subjected to a cold douche
the systole immediately lengthened, with a reduction of
the pulse frequency it is true, but regaining the normal
duration for the pulse-rate in question.
This I attributed to increased blood-pressure, owing to
the contraction of the capillaries and tonic action on the
heart by reflex shock.
Faintness in Turkish bath. Systole -210". Diastole '450. Pulse-rate 90.
I induced two young men to submit themselves to
simultaneous compression of the large vessels, including
the abdominal aorta, but without succeeding in increasing
the duration of systole. I also took digitalis for two
days, and have subjected a willing patient for three days
to the influence of digitalis in large doses, and although
I succeeded in decidedly reducing the frequency of con-
traction I did not increase the duration of systole,
allowing for the reduced pulse-rate.
It then occurred to me that possibly the temperature of
the blood might reduce the duration of systole, as I had
an idea in great simplicity that the contraction of a
308 ON CARDIOGRAPHY.
muscle in a warm chamber was more sudden and sooner
over than is the case when the muscle is in a cooler
medium ; and, with this view, I took the temperature of
the body after long subjection to the bath, and found that
I often got a temperature of about 102° F. This again
is not to be made much of, since in the case of fevers the
systole of the heart is not necessarily shortened in time ;
and I do not attach much importance to it.
In cases of great exhaustion and prostration I have
found the duration of systole very markedly shortened,
and my attention was turned to the condition of the
patients I had subjected to the Turkish bath. I found
that this shortening was most marked in those cases in
which the patient was feeling very faint, though it was often
unaccompanied with any complaint of faintness. When
fainting is imminent, however, it is very marked ; and I
have found the duration of systole less than normal by
more than ^0ths of a second ("073").
It was pointed out to me by Dr. Broadbent, to whom I
am indebted for many suggestions and much information,
that the cases in which the most marked discrepancy
from the normal rhythm of heart-sounds was noticeable
by the stethoscope, in the direction of excessive predomi-
nance of diastolic over systolic time, were those in which
dilatation of the heart was present. Although I do not
think this could be demonstrated in every case of dilata-
tion, I certainly have noticed many cases in which, with
regular rhythm, the diastolic pause is abnormally long,
the systole being short, sudden, and feeble. These cases
will improve under treatment, that is to say, as the
patient improves in health the rhythm (which is not
necessarily irregular) approximates more and more to the
normal rhythm. For the first suggestion of these facts,
as regards dilatation, I am wholly indebted to Dr. Broad-
bent, who assured me that under iron and strychnine
patients would improve in this particular respect, as in
others ; and, as was to be expected, I have found Dr.
Broadbent's observations to be entirely correct. On the
ON CARDIOGRAPHY.
309
whole I am inclined to think, on consideration of the
many cases of comparatively short systole which I have
studied, that this condition is not to be attributed to
lessened blood-pressure, nor in fever to increased tempe-
rature of the blood, but to be immediately due to weak-
ness of the heart muscle and exhausted or defective
innervation.
I am strengthened in this conclusion by my observa-
tion of the action of nitrite of amyl, the administration oi
which is attended by dilatation of peripheral vessels and
great fall in blood-pressure. The effect on the heart is
very well and prettily shown in a tracing taken by myself
from my own heart. The height the lever attains is
Normal. Systole -3220". Diastole -4715". Pulse-rate 75. Height of initial
ascent of level' 8 mm.
reduced, first to 7 mm., then to 3 mm. ; the heart is
greatly accelerated (from 75 to 116 beats per minute),
but it will be observed that the duration of systole is not
Nitrite of Amyl (slight effect). S. -2760"
Height 7 mm.
D. 3335". Pulse-rate 98.
310 ON CARDIOGRAPHY.
lessened out of proportion to the increased rapidity of the
pulse, but is rather increased in duration.
As I have mentioned the action of nitrite of amyl I
ought to say that under its influence the heart tracing
sometimes exhibits the phenomenon of dicrotism. There
Niteite OF Amyl (full effect). S. '2545". D. "2530". Pulse-rate 116.
Height 3 mm.
appears to be a curve or dip during systole in the tracing
taken from myself which may possibly mean oncoming
dicrotism. I would discuss the question of dicrotism, but
the limits of my paper are short and I must confine myself
strictly to the matter in hand, viz. the relations between
systolic and diastolic interval.
2. To pass to the other class of cases ; those in which
there is relative excess of systole over diastole. How
much this may be due, on the one side, to shortening of
diastolic interval, on the other to prolongation of contrac-
tion, one cannot say. Using the word fancy to express
my lack of scientific proof, I fancy that in most cases it
is the shortening of diastolic interval which gives apparent
length to the systole. The whole of this subject is of
great interest and importance, especially as regards the
administration of drugs with a view to their remedial
effect. A high pulse-rate need not be immediately
dangerous, but let me point out that in these abnormal cases,
when systole greatly predominates over diastole, one of
the chief things to apprehond is the exhaustion of tho
patient's cardiac strength. In some cases, in which on
auscultation the second sound immediately precedes the
first sound (the interval between the first and second sound
appearing to be perhaps twice as long as that between tho
second and first), the heart may be doing forty-eight more
ON CARDIOGRAPHY. 311
hours' work in the week than it should be doing. In these
cases to attempt to slow the heart by prolonging systole
might be a grave error. I can give a very interesting,
while very short, account of a patient which will bring out
these points strongly.
F. J — , a boy set. 6, was admitted under my care into
the Royal Hospital for Women and Children, on March
26th, 1885. Three months previously he had had pains in
the knees and ankles, which slightly swelled. He said he
was then in bed a fortnight and suffered from sweating.
He remained well till a fortnight before admission, since
which time he had had pains in the legs and wrists and
could not sleep. He looked pale and thin. There was
no appreciable swelling of wrists. Temperature 100"8°.
The pulse-rate was nearly 150 in the minute. On auscul-
tation a slight systolic murmur was heard at the apex of
the heart extending into the axilla.
The sounds of the heart, though rhythmical, did not
follow the normal rhythm, which would give an equal
interval between both first and second and second and
first sounds. The rhythm was altered in such a way
that, on listening with the stethoscope, the first sound
followed close upon the second sound, the interval between
the first and second being about twice as long as that
between the second and first.
Two days after, on March 27th, I obtained a tracing
from the heart, which I here publish :
HUD «■
IBB
EBfe
I
EBB
F. J—, ret. 6. Systole -2990". Diastole -1035". Pulso-rate 119.
312 ON CARDIOGRAPHY.
The time occupied by diastole was so inadequate for
rest, and the period of labour was so prolonged in pro-
portion, that, on merely looking at the tracing, I observed
to the house surgeon that unless some alteration in the
character of the tracing took place the strength of the
heart must inevitably fail and the boy would gradually
die. I saw him twice afterwards. The state of the heart
remained the same. He took digitalis and citrate of
potash. Subsequently, on April 1st, complaining of pains
in the joints, he took salicylate of soda, which was stopped
as he could not retain it. I feared the digitalis harmed
him and gave him no more, but tried to support his
strength. My treatment was more miserably inefficient
than I hope it would be in a future case. The tempera-
ture only twice reached 101°, was mostly about 100°, and
gradually fell to normal during the 28th, 29th, and 30th,
though it rose very slightly during the next few days.
There was no albumen in the urine. On my next visit
(April 4) the following notes were read to me by the
house surgeon :
" Patient began to sink this morning gradually, lasting
over many hours. No convulsions, no pain, no insensi-
bility. At 1 p.m. he was almost pulseless and brandy
was given. He was very restless for half an hour and
said he could not breathe. Was then quiet for a short
time, after which he again suffered from dyspnoea. He
was again quiet till 2.30, when he again became very
restless, and died at 2.40. " No P.M. was allowed by the
relatives.
Now, I would call attention briefly to the tracing. The
period of rest at pulse-rate 149 should be thirteen out of
twenty-four hours. The period of rest in my patient was
6 h. 10". During the week of 168 hours during which he
was under my care he had had only forty-three hours' ven-
tricular rest, instead of the ninety-one hours he should have
obtained (it tlw same pulse-rate had all else been normal.
That is to say, his heart had been doing exactly forty-eight
hours' more work in the week than it should have done
ON CARDIOGRAPHY.
313
I regret now that I did not largely increase his digitalis
to slow the pulse, or administer aconite, the action of
which, however, I have not yet worked out.
Digitalis. — Digitalis I have since investigated cardio-
graphically, and find, contrary to what I had been led to
expect, that it does not lengthen the duration of systole
of the ventricles. In the accompanying tracing its action
is well seen. The heart was not beating quite regularly
before the administration of the drug, the cardiac revolu-
tions are reduced in frequency per minute, the action is
regulated, the initial shock seems not to be so great, and
there is a gradual rise to the end of systole, which well
persists. Thus both systole and diastole are lengthened,
the lower pulse-rate itself affording the heart more rest,
as can be immediately seen by referring to my second
table. Digitalis seems to affect a regulatory nervous
apparatus ; its salutary effect is best seen in the irregular
heart of mitral disease ; and I believe it deserves the name
of a heart tonic in that respect, and not so much in the
iKBhGULAR Heaet. Ventricular systole -3335" to "3L0b". Diastole "■±600"
to •7360" (varying interval -2760"). Average pulse-rate 67.
Effect of Digitalis on sahe Hkaht (I/O minims of the tincture were
taken in forty-eight hours). Ventricular systole (constant) -3680". Dia-
stole -7130" to -8740" (varying interval 1610"). Pulse-rate 50.
314
ON CARDIOGRAPHY.
sense of increasing the force and duration of ventricular
contraction. I have succeeded by its administration in
even making the heart irregular as if by exhaustion of the
said regulatory centre.
Convallaria is a heart tonic which probably differs
from digitalis in not only slowing the heart, but
in actually lengthening the duration of systole of the
ventricle. The tracing which I give of the action of
Effect of Convallaeia. Ventricular systole "3795" (constant). Diastole
•5900" to -6555"- Pulse-rate 60 to 63. (Normal systole -3400").
convallaria is taken from my own heart, with which I am
exceedingly familiar. I took several large doses of the
tincture of convallaria in this experiment, thirty to forty
minims every half hour for two hours in the morning. I
had diarrhoea and a feeling of precordial constriction in
the afternoon, with some giddiness. It will be seen at
once, on comparison with my table No. 1, that there is a
very perceptible increase in the duration or persistence of
ventricular contraction. I have no time to discuss the
respective therapeutic advantages of these drugs.
I shall hope to make the action of other drugs on the
human heart the subject of future papers.
Besides bringing forward my results I am anxious to
popularise the cardiograph. It is an instrument which
every physician might have in his consulting room ; it is
very easy to apply and I have no doubt that a good in-
strument maker, if he put himself to it, could turn out
thoroughly convenient and accurate instruments of this
nature at a reasonable price, if there were a demand for
ON CARDIOGRAPHY. 315
them. Though I do not like to say my table of measure-
ments will require no alterations whatever, I yet believe
that it will, for practical purposes, stand any reasonable
test. This, the most laborious part of the work, the
establishing a basis to work by, has now, to my mind,
been done; and I should welcome with great pleasure
other workers into a field wherein I feel somewhat soli-
tary.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 78.)
TWO CASES OF BRONCHIECTASIS
TBEATED BT
PARACENTESIS,
WITH REMARKS ON THE MODE OF OPERATION.
BY
C. THEODORE WILLIAMS, MA, M.D.Oxon., F.R.C.P.,
PHYSICIAN TO THE HOSPITAL FOB CONSUMPTION AND DISEASES
OF THE CHEST, BKOMPTON ;
AND
RICKMAN J. GODLEE, M.S., F.R.C.S,
SUBGEON TO UNIVEBSITY COLLEGE HOSPITAL ; SUBGEON TO THE HOSPITAL
FOE CONSUMPTION AND DISEASES OF THE CHEST, BEOMPTON.
Received November 10th, 1885— Read March 23rd, 1886.
Case 1. — Mr. C — , set. 67, a gentlemen of literary pur-
suits and of spare wiry frame, consulted Dr. Theodore
Williams February 3rd, 1885. He had contracted bron-
chitis at the close of 1882, which persisted through the
winter and was accompanied by emphysema, and in April,
1883, he had dry pleurisy of the left lung. After this
attack the expectoration, hitherto moderate in amount,
became profuse, reddish, and purulent, and continued so
up to the time of the operation. Patient states that on
one occasion he felt something give way in his lung and
that he expectorated yellowish fluid for several hours. He
spent two months at Malvern and Bournemouth without
improvement, the cough increasing, and returned to London
in November, and was pronounced by his medical advisers
318 BRONCHIECTASIS TREATED BY PARACENTESIS.
no better. During the following winter a great variety
of medicines and inhalations were tried, but with no per-
manent benefit, and during the summer and autumn of
1884 the patient seems to have lost faith in remedies and
to have discontinued them altogether. He had lost flesh
and strength and declared that life was not worth having
under the circumstances.
At present his cough is exceedingly troublesome, espe-
cially at night, when the paroxysms last for an hour and
necessitate getting up and pacing the room. He has an
anxious, worn look, and his breath is short on the slightest
exertion, the expectoration exceeds one pint a day in
amount and consists of frothy pus somewhat sanguinolent
and nummular in character. It contains no tubercle
bacilli or lung-tissue, but putrefactive bacteria in abun-
dance. Inspection of the chest shows lowering of the left
shoulder, with flattening of the anterior left wall, and
some deficiency of movement is visible on that side. The
heart's impulse is felt in the fourth interspace. The right
chest is hyper-resonant and harsh breathing is audible
throughout. The left side shows anteriorly considerable
flattening, with resonance over the whole surface. Over
the lower third of this resonant area vocal vibration is
absent and little or no respiration is audible. Over the
upper two thirds respiration sounds are harsh.
Posteriorly, dulness commences immediately below the
level of the seventh rib behind the mid-axillary line, and
following the direction of that rib back to the spine
extends then downwards to the base of the lung. The
dulness does not vary with change of position, is nowhere
strongly marked, and gives the impression of being due to
an adherent pleura, and some retraction of the spaces is
visible. Vocal vibration is absent over this area, and this
absence extends as high as the top of the scapula. Crepi-
tation is occasionally to be heard over the dull area and in
one spot (c) about tho size of a half crown, situated in
the eighth interspace about three inches from the spine,
immediately below the scapular angle, some distant tubular
BRONCHIECTASIS TREATED BY PARACENTESIS.
319
sound can be detected. Harsh breathing is heard over the
rest of the lung. Tape measurements at the level of the
nipple give the left chest a smaller circumference than the
right, by two and a quarter inches.
Two days later Dr. Williams saw the patient in consulta-
tion with Dr. Orton, of 30, Lower Phillimore Place, who
had had the care of him previously, and a second examina-
tion not only confirmed the result of the former one, but
also discovered another area of tubular sound, about the
same size as the first, situated in the eighth interspace
about three inches to the outside of the first (see Fig. 1).
Fig. 1.
A. Area of slight dulness, scattered crepitation and retracted intercostal
spaces. B. Area of hyper-resonance and harsh breathing, c and D areas of
cavernous sound. + puncture spot.
The diagnosis arrived at was emphysema of both
lungs from chronic bronchitis ; partial adhesions of the
320 BRONCHIECTASIS TREATED BY PARACENTESIS.
left pleura, from dry pleurisy, causing contraction of the
side, and displacement of the heart's apex ; and extensive
dilatation of the bronchi in the lower lobe of the left lung-.
The adhesion of the pleura over the lower third of the
left lung being well ascertained, the next question was as
to the number of bronchiectases and their distance from
the surface of the lung. From the few and limited areas
of tubular sound, and the distant character of that sound,
it was concluded that they were limited to the lower lobe
of the lung, and were situated at some depth from the
surface.
Considering the miserable condition of the patient and
the possibility of reaching the bronchiectasis by puncture,
the question of an operation in all its bearings was laid
before the patient and his wife, and their consent being
obtained, Mr. Godlee was requested to perform the
operation.
Dr. Williams marked the two areas before described,
and directed Mr. Godlee to try the first one, viz. that
situated below the angle of the scapula, in the eighth
interspace ; and to pass a good-sized trocar and cannula
to the depth of four or five inches from the skin, directing
it forwards and slightly inwards. The patient was
anaesthetised by Dr. Orton, and at the innermost of the
two spots, viz. in the eighth interspace just below the
angle of the scapula, a puncture was made with an
exploring trocar about two inches in length, but nothing
definite was ascertained. A large aspirator cannula was
then inserted to a greater depth, and on making a
vacuum, mucus and pus were drawn through it into the
bottle. The spray was then turned on, and a T-shaped
incision was made through the soft parts, while the
cannula was left in situ, so that the exact position in the
intercostal space which it had occupied might be followed.
When this was definitely ascertained the cannula was
withdrawn and a scalpel was passed through the inter-
costal space at the spot. It entered a cavity at a short
distance from the ribs, though the exact distance was not
BRONCHIECTASIS TEEATED BY PARACENTESIS. 321
clear ; it was certainly not more than, if so much, as an
inch. The opening was dilated with dressing forceps,
and an attempt was made to introduce the finger, but the
ribs were too close together to allow of this being done.
A tube was accordingly introduced about four inches long
with the usual flange, and through this a considerable
quantity (an ounce perhaps), of membranous shreds1
and pus was forcibly ejected. The tube passed almost
directly forwards. Before the patient awoke from the
chloroform he began to cough up blood with the expecto-
ration. There was no foetor about the contents of the
cavity ; the ordinary gauze dressings were accordingly
applied. One grain of opium was administered at night.
February 12th. — Patient has slept well and has scarcely
any cough. The expectoration is free from blood, and
consists of two or three greyish pellets of mucus. The
discharge from the wound has been profuse, soaking
through the gauze dressings and reaching the bed. It
appears to be thinner and contains a large number of the
membranous shreds.
14th. — Yesterday the tube slipped out through the
movements of the patient, and, although it has been
replaced, the discharge is very slight. The expectoration
is of a brick-red colour, somewhat pneumonic in character,
with a few streaks of bright hue. Pulse 72, temp. OS^0 F.,
resp. 20. Crepitation is audible over the lower fourth
of the left front chest. A longer tube was then intro-
duced through which the discharge was tolerably free.
25th. — The wound is dressed once in four days, and the
dressings found to be quite sweet, though soaked through
with thin watery fluid, which scarcely stains them. The
tube is extruded by fresh granulations, and has to be
shortened half an inch. The sinus has a depth of three
and a half inches.
March 2nd — The patient is up most of the day, and
has scarcely any cough or expectoration. The dressings
1 These were examined microscopically by Dr. Percy Kidd and found to
contain no cellular elements, but to consist of amorphous material.
VOL. LXIX. 21
322 BRONCHIECTASIS TREATED BY PARACENTESIS.
are changed once in five days, and always found to be
sweet ; the discharge being still watery and soaking
through the gauze. The tube has been again shortened.
Pulse 72, temp. 98° F.
17th. — The sinus had contracted so much that a shorter
tube of smaller diameter had to be inserted, and to-day
the increase of granulations has pushed this outside the
ribs. Discharge very slight. The tube was removed
altogether and the wound dressed antiseptically.
31st. — The patient has gained flesh and looks well.
Cough and expectoration absent except on rising in the
morning, when two or three pellets of greyish mucus are
raised. The wound has healed up.
Physical sigiis. — The left shoulder is markedly lower
than the right, and the movement of the whole side is very
deficient. There is curvature of the spine towards the
right. Anteriorly the left chest is resonant throughout,
n.nd vocal vibration is felt tq the very base. Breath-sounds
are weak. Posteriorly there is marked flattening, specially
from the eighth rib downwards. Here also vocal vibration,
formerly absent, is felt to the base, but is not so marked
as at the apex or even over the opposite lung. The
dulness has disappeared except at the extreme base, and is
replaced by marked resonance. Fine dry crackle, chietly
accompanying inspiration, and quite characteristic of em-
physema, is heard over the whole posterior surface, bu1 is
mosl marked in the mid-axillary line. No tabular sounds
audible anywhere. The righi chest remains the same.
May 2nd. — The patienl 1ms no fresh symptoms. He
lias returned to his ordinary habits and drives oul on fine
days, and also takes walks, lie 1ms grown stouter and
Looks in excellent health. Cough and expectoration nil.
Measurement of the chest at the mammary level shows the
left side to be two and three quarter inches smaller than
the right, showing ;i shrinking of the left side, since the
operation, of hall an inch. There is more resonance and
crackling sound at the left posterior base, showing farther
development of emphysema.
BRONCHIECTASIS TREATED BY PARACENTESIS. 323
•July, 1886. — Patient remains in excellent health, and
walks four miles at a stretch. He has passed through
the late inclement winter without fresh symptoms.
Remarks. — The history of this case rendered the exist-
ence of bronchiectasis extremely probable, for it may be
noted that the expectoration, at first moderate in amount,
after the attack of dry adhesive pleurisy became profuse
and altered in character, and it is likely that in the lower
lobe of the left lung, the wall of the bronchus having been
infiltrated during the prolonged bronchitis, had lost its
elasticity, and yielding to the inspiratory efforts, and still
more to the traction outwards of the adherent pleura, as
Hamilton1 has most ably demonstrated, had become dilated
and had lost the power of easily expelling its contents.
This explains the limited character of the lesion, and the
cessation of the expectoration after the successful tapping
of the cavity — the dilatation of the bronchi being limited
to the portion of the lung underlying the recent pleurisy.
The physical signs indicated bronchiectasis, rather than
localised empyema, for the dulness at the left posterior
base was nowhere so marked as in effusion, in fact was
very slight, and did not vary with change of posture.
Moreover, the breath-sounds were not entirely absent any-
where and crepitation of a purely intra -pulmonary charac-
ter could be heard over the dull area. The intercostal
spaces were distinctly retracted. On the other hand vocal
vibration was absent, but this was the case not only over
the dull spot, but also over nearly two thirds of the poste-
rior surface of the left chest reaching nearly to the top of
the scapula, where no dulness existed. The expectoration
also had not the character of that of an empyema bursting
into the bronchus, which is generally very purulent and
rather liquid, whereas this was partly froth and partly
nummular pus, streaked with blood, and, for some days
after the operation, was distinctly pneumonic. The dia-
gnosis of bronchiectasis was confirmed by the appearance,
alter the operation, in the discharge from the cavity, of
l • Pathology of Bronchitis,' p. 86.
324 BRONCHIECTASIS TREATED BY PARACENTESIS.
membranous shreds, which are quite characteristic of
bronchial dilatation. In addition to other points of
difference, the absence of tubercle bacilli precluded
phthisis. The operation appears to have set up some local
pneumonia of the neighbouring lobules : as evidenced by the
sputum, but had no effect on the patient's temperature,
which never rose above 99° F. The entire disappearance
of the tubular sounds from the second area after the opera-
tion indicated that they originated in the tapped cavity
and were conducted through a patch of consolidation to the
surface, thus giving rise to sounds similar to those heard
over the first area, and as the expectoration practically
ceased, we may conclude that only one important bron-
chiectatic cavity existed and that this was effectually
drained. This is no doubt the explanation of the com-
plete success in this case, and although the patient was
advanced in years, he had an excellent constitution and was
of the lean and wiry kind, which withstands operations
well.
Case 2. — Mary E — , ast. 21, single, domestic servant,
was sent to the Brompton Hospital for admission under
Dr. Theodore Williams by Mr. Hugh Smith, of Faming-
ham, April 1st, 1885.
Her family history was good, with the exception of the
death of a paternal aunt from phthisis.
The patient's illness began with typhoid fever eight
wars ago, followed by cough and expectoration which
had persisted ever since ; during the last six years the
cough had gradually become worse, and the expectoration
increased in quantity and factor. Seven years ago she
had haemoptysis two or three times, amounting, on one
occasion, to a pint, but none since.
The patient had been prevented from taking a situation
for some years by the fcetor of her breath.
On admission by Dr. Percy Kidd, in Dr. Williams's
absence, she appeared a fairly-nourished but unhealthy-
Looking young woman. Cough very troublesome. Bxpec-
BRONCHIECTASIS TREATED BY PARACENTESIS. 325
toration abundant, 13 to 16 oz., partly frothy and partly
muco-purulent and exceedingly foetid. On examination
it contained no tubercle bacilli or lung-tissue. Tempera-
ture was 103° F. Pulse 100.
Dr. Kidd's examination of the chest showed on the right
side hyper-resonance with some bubbling rales at the base,
and on the left side less resonance and bubbling rales
throughout. The fcetor was so great that she had to be
placed in a private ward.
She improved under treatment, the cough becoming less
troublesome, the expectoration diminishing to 4 or 5 oz.,
and being slightly less foetid, the temperature falling to
99° F., and the patient gaining in weight ; but about the
middle of June, in spite of vigorous antiseptic treatment,
the expectoration increased and grew more foetid, and the
cough more troublesome and convulsive.
Dr. Williams made several examinations of the chest
and noted as follows : — The chest is flattened in the upper
left front. The right side is hyper-resonant, with fair
breathing except at the posterior base, where a few rales
are to be heard. On the left side there is a remarkable
absence of vocal vibration ; slight dulness and diminished
movement extend downwards from the lower border of
the third rib in front and from the seventh rib behind the
demarcation line, crossing the sixth rib in the axilla, as
seen in Diagram 2. The dulness is nowhere strongly
marked as in effusions. Above this line there is resonance,
and in the axilla, hyper-resonance. The bubbling rales
have disappeared from the upper portion of the lung, but
coarse crepitation is heard in front from the fourth rib
downwards, and behind over about the same area as the
dulness. In the sixth and seventh interspaces are two
spots (Fig. 3, d and e), each about the size of a half-
crown, situated in the axilla, and a third one (p) in the
eighth space immediately below the scapular angle. Over
these the crepitation is very coarse indeed, especially after
coughing. The heart is not displaced. Tape measure-
ments of the two sides give :
326
BRONCHIECTASIS TREATED BY PARACEXTKsls.
Right.
14* in.
Left.
14 in.
13A ii
At the level of the third rib .
At the ensiform level .... 13^ in.
Showing a slight contraction of the upper left chest.
The diagnosis was chronic bronchitis and emphysema
of both lungs, followed by pleurisy and fibrosis of the
lower lobe of the left lung and consequent dilatation of
Fig. 2.
a. Space of dnlness, diminished movement! and coarse crepitation.
b. Hyper-resonance.
tlir bronchi of* that side. Dr. Williams was of opinion
thai several bronchiectases existed, but that three large
ones were situated beneath the three areas above described
;it a considerable distance Erom the chest surface. Ee
w;is also of opinion fchal the dnlness was caused by (I)
pleuritic adhesion and ("2) by fibrosis of the Lung. Ji was
BRONCHIECTASIS TREATED BY PARACENTESIS.
327
thought that a deep puncture might lay open one of the
dilatations and that the other large ones which appeared
to lie at no great distance might be connected afterwards
and all drained by one tube, although there would be
obviously great difficulties in reaching these cavities. The
nature and prospects of the operation were duly explained
to the patient, who readily consented.
Fig. 3.
A. Shaded space to indicate area of dulness and crepitation. B. Area of
marked resonance and harsh breathing, c. Crepitation. D, E, F. Areas of
very coarse crepitation. G. Hyper-resonance.
June 29th, 5.30 p.m. — The patient was placed under
an anaesthetic, and Mr. G-odlee first passed a small explo-
ratory trocar, one inch in length, into the marked spot of
the sixth interspace about two and a half inches to the
left of the left nipple, and obtaining no result, repeated
328 BRONCHIECTASIS TREATED BY PARACENTESIS.
the process on the marked spots in the seventh and eighth
interspaces with like effect, this operation showing that
the pleura contained no fluid. He then inserted a large-
sized trocar and cannula of considerable length into the
seat of the first puncture (sixth interspace), directing it
inwards to the depth of four inches. The trocar was then
withdrawn and the cannula connected with an aspirator.
Nothing followed at first, but on withdrawing the cannula
to a depth of about two inches and exhausting again, some
membranous shreds similar to those described in the first
case appeared in the receiver. Mr. Godlee now proceeded
to open this cavity, but during a paroxysm of the patient's
cough the clinical assistant let slip the guiding cannula
and the track to the seat of those shreds was lost, and all
efforts to regain it failed. Mr. Godlee then with antiseptic
precautions made an incision of an inch in length ami
two inches in depth and passed his finger into the lung,
but was unable to discover the cavity. Some free haemor-
rhage followed. The wound was washed out with chloride
of zinc, and plugged with boracic acid lint soaked in car-
bolic acid lotion. The antiseptic gauze and pad were
then applied.
July 9th. — The discharge not continuing, the tube was
withdrawn, and under antiseptic dressing tin' wound was
nearly healed. The expectoration still continues foetid
and cough troublesome. The patient appears to have quite
recovered from the operation, eats and Bleeps well, and is
up and about. Pulse 90, temp. 98'8C P.
Physical signs. — The dulness-area has increased : bron-
chial breathing is heard over a small spot in the eighth
interspace about three inches from the spine, at the same
level as the former incision. This spot was carefully
marked.
July 16th. — The wound has healed and the patient
appears generally lanly well, but the expectoration Is
unchanged. On examination, the physical signs were con-
firmed and the area of bronchial breathing again marked.
It was decided to make another attempt to reach one or
BRONCHIECTASIS TREATED BY PARACENTESIS. 329
more bronchiectases, and accordingly the patient was given
an anaesthetic, and Mr. Godlee passed a fine curved trocar
and cannula into the marked spot to the depth of at first
three inches and then of five inches, the curve beinor
directed towards the median line, so as, if possible, to
intercept some dilatation of the bronchial tree. Nothing
followed but blood. The same trocar and cannula were
passed into the old wound and directed first upwards and
then inwards, but with no result. Mr. Godlee then, under
carbolic spray, made an incision and laid bare the eighth
rib, and excised about an inch of it in order to approach
nearer to the bronchi before again attempting to puncture.
The pleura was carefully examined and found adherent.
The trocar and cannula were passed to the depth of five
inches. On withdrawing the trocar, a few drops of pus
oozed from the cannula. Mr. Godlee then cut down
along the cannula and introduced a drainage-tube. No
more pus followed at the time, but a good deal of blood.
The patient, who had been expectorating the usual
foetid pus, suddenly began to spit clots of blood, evidently
coming from the wound. The tube was fixed in and the
wound dressed antiseptically.
July 18th. — The wound has been dressed under carbolic
spray ; the discharge from the tube is distinctly purulent,
and has soaked through several layers of the gauze.
July 20th. — The patient is doing fairly. Before the
dressings were removed to-day the characteristic odour of
the expectoration was noticed to come from them, and
was still more marked when they were undone. Discharge
profuse and foetid ; wound granulating and healthy.
July 23rd. — Discharge less foetid to-day. At 5*45
p.m. patient had haemoptysis, ten ounces, and appeared
rather excited. Pulse fairly good. Temp. 98° F.
The haemoptysis continued for three days, the patient
bringing up nine and eight ounces of blood on the second
and third days respectively. The blood was bright coloured
and had no fcetor. The temperature rose to 103° F.y but
has fallen to-day to 100° P. The sputum is now blood
330 BRONCHIECTASIS TREATED BY PARACENTESIS.
stained and eight ounces in amount. Pulse 02, fair. The
discharge is scanty and not foetid, wound healthy.
August 5th. — The haemoptysis recurred to the amount
of three ounces on July 29th, and to a less amount on the
31st, and lastly, there was a small quantity on August 4th.
On the last two occasions the amount was small, but on
one it was accompanied by slight lividity of the face, cold
and moist extremities, a rapid and compressible pulse,
and some mental excitement. These symptoms, however,
all subsided.
27th. — The patient has improved greatly in appearance,
and has gained four pounds in weight, though she lost
several during the haemoptysis. The wound has healed up.
Cough is much less troublesome. The expectoration varied
from four to six ounces for some days, but has now fallen
to two ounces, and is sometimes foetid and sometimes
quite free from odour. The temperature is 98'2° F. Pulse
74, good. The patient sleeps soundly and has an excel-
lent appetite, and declares she feels quite well.
The following chest measurements were taken :
At the level of the third rib
At the ensiform level
These show some increase at the upper level, but a
diminution at the lower one, in the region of the opera-
tions. There is marked flattening and contraction in tho
neighbourhood of the cicatrices on the left side, and more
dulness at the base posteriorly. Fine crepitation is audible
in parts, but no bronchial sound anywhere in the dull
area. Some tubular sound is heard in the interscapular
region, over a space the size of a half crown. Over the
anterior surface there is fair resonance, the breathing is
much freer, and the moist sounds have entirely disappeared.
Remarks. — In this case we had to deal with disease of
apparently long standing, and of constitutional origin, for
the symptoms of bronchiectasis followed closely after
typhoid fever, eight years previously, and the patient
Right.
Left.
in in.
14| in
134 in.
13 in.
BRONCHIECTASIS TREATED BY PARACENTESIS. 331
showed signs of marked cachexia. The probability of
bronchiectases in the left lung -was easily recognised from
the fcetor of the expectoration, and the amount of chronic
pneumonia present at the base. The slight dulness and
flattening enabled us to trace the line of adherent pleura.
But to determine the number of dilatations and their
exact position was most difficult, partly from the amount
of congestion at the base of the lung, and partly from the
presence of emphysema, which existed in the upper parts
of the lung. In both operations Mr. Godlee had to punc-
ture in several directions, and in the second, to incise the
lung freely before the bronchiectasis was reached.
Though this patient was sent up to the hospital with
the view of operative interference, by Mr. Hugh Smith,
who had seen one of Dr. Williams's former cases, she was
kept in the hospital for two months, and treated with
antiseptics, and it was only when these remedies entirely
failed and her symptoms became worse, that operation
was resorted to. The extensive haemorrhage which
followed the second operation appeared to be due to some
ulcerative process set up by the presence of the tube, and
not to the operation itself. This led to an increased
infiltration at the base of the left lung. The diminution
in the amount of sputum and the fact of its being only
intermittently foetid, combined with the general improve-
ment of the patient, are the results claimed for the
operation, but the presence of bronchiestases in other
parts of that lung, and possibly in the right lung also,
precluded complete success.
However, where both cough and expectoration are
reduced and the patient's life is rendered fairly tolerable,
we may claim a moderate success.
Remarks by Dr. Williams. — The subject of paracentesis
of cavities has been of late years brought before this
Society by Dr. Douglas Powell and Mr. Lyell (vol. lxiii),
and by Dr. Cecil Biss (vol. lxvii), and also by Dr. Cay ley
and Mr. Pearce Gould, in the latter volume. As Dr.
332 BRONCHIECTASIS TREATED BY PARACENTESIS.
Powell's and Dr. Biss's papers contain an account of the
principal literature on the subject, I need not enter upon
it, but will refer the Fellows of the Society to their
papers, confining myself to a short account of my own
experience.
Dr. Cayley's case in vol. lxvii, and his case in vol. xii
of the ' Clinical Transactions/ were instances of gangrene
of the lung treated by paracentesis with relief, and on one
occasion with recovery.
Dr. Powell's and Dr. Biss's cases, as well as those two
just related, are examples of bronchiectasis, and it is in
reference to operative interference in this class of patients
that I would direct attention, as, having had in all six
cases of bronchiectasis treated by paracentesis, the subject
is one of considerable interest to me.
Two of these cases have just been related, and three of
the other four have been published elsewhere.1
In all these three the cough was convulsive and harassing,
and the expectoration so foetid as to necessitate the isola-
tion of the patient. Various kinds of antiseptic treatment,
both general and local, were persistently tried, and failed,
before the operation was had recourse to.
The sixth case, hitherto unpublished, was that of a boy,
aged thirteen, who had a history of chronic cough and of
foetid expectoration of three years' standing, accompanied
on one occasion by hasmoptysis. A good deal of emphysema
was present, and signs of bronchiectasis were detected in
the left side, especially in the first and second interspaces
in front, and posteriorly over the eighth and ninth spaces
below the scapula. After the patient had been in the
hospital several months, without improving under various
kinds of treatment, at my request Dr. Hicks made a
vertical incision two and a half inches in length, involving
the eighth and ninth intercostal spaces below the scapula,
where the gurgling sounds were loudest, and punctured
1 'Clinical Transactions,' vol. xii, p, 17 ; "Lectures on Bronchiectasis"
' Brit. Med. Journ.,' vol. i, 1881, p. 837 ; ' Proceedings of Medical Society,'
vol. vi, p. 323; aud ' Lancet,' vol. ii, 1882.
BRONCHIECTASIS TREATED BY PARACENTESIS. 333
first the eighth space and then the ninth. The second
puncture was successful in reaching the excavation, and a
discharge was established through a tube. This continued
for some time but did not reduce either the fcetor or the
amount of the expectoration, and after a while the dis-
charge ceased. Another attempt was then made to reach
the principal cavity from the same wound by deepening
the puncture. At the depth of four and a half inches
the bronchiectasis was reached and a drainage-tube intro-
duced. Scarcely any matter flowed at the time, but the
following day the dressings of the wound were soaked
through and through with it ; air could be heard whistling
in and out, and on coughing some very tenacious foetid
muco-pus escaped from the tube. The discharge con-
tinued for about three weeks to the amount of two or three
ounces a day, but the expectoration did not greatly
diminish in quantity though it was less foetid. At the
end of this time profuse haemorrhage occurred from the
wound, apparently due to ulceration from the pressure of
the right tube. This was stopped, but it recurred on the
introduction of a flexible tube, which it was found neces-
sary to remove altogether, and the wound was allowed to
heal up. Later on the patient was attacked with pyaemic
periostitis of the left forearm, which was incised, and a
good recovery followed. Under these circumstances no
attempt was made to reach the other bronchiectases whose
position had been detected. Considerable contraction of
the punctured side followed the operations and the patient
left the hospital, his cough less troublesome and the
expectoration less foetid. He was ascertained to be alive
two years afterwards.
In three out of these six cases the diagnosis of bronchi-
ectasis was confirmed by post-mortem examinations, and
there is every probability that it was correct in the other
three ; the general aspect of the patients and the sym-
ptoms of the disease amply confirming the physical signs.
The post-mortem examinations in the three fatal cases
indicate clearly the mode of death in bronchiectasis. It
334 BRONCHIECTASIS TREATED BY PARACENTESIS.
seems to be from some form of septicaemia. In two of
my cases, and in Dr. Powell's, it was from septic pneu-
monia of the healthy lung through inhalation of foetid
secretion. As a proof of this, in eaoh of my cases I was
able to trace the membranous shreds from the dilated
bronchi into the smaller bronchi of the pneumonic lung.
Sometimes the septic material enters the stomach and
intestines and gives rise to diarrhoea, and sometimes it
passes into the circulation, causing pyueinic abscesses.
Abscess of the brain was the cause of death in one of my
cases and in Dr. Biss's. Another of my patients suffered
from pyaemic periostitis. The danger of septic pneumonia
from reinhalation is greater than is generally supposed,
though undoubtedly many cases of bronchiectasis go on for
years without its occurrence ; yet I have rarely witnessed
this immunity where the expectoration is very foetid.
This point ought to be borne in mind in regulating the
posture, and especially the decubitus, of these patients.
The mode of death is certainly one strong argument in
favour of the operation. Another, which has been
advanced by Dr. Powell, is that much of the secretion
and the efforts made to expel it from the bronchi are due
to the great irritation which the passage of the foetid
matter causes to the bronchial membrane, and this was
well shown in Mr. C — 's case, where the whole expecto-
ration diminished from a pint a day to a few pellets
immediately on the establishment of the external dis-
charge.
A third argument in favour of this operation is the
comparative invulnerability of tin* lung-tissue, for it has
been repeatedly demonstrated that the lung may lie
punctured to a considerable depth without giving rise to
;m\ serious symptoms or marked physical signs. At one
i. f the autopsies we endeavoured to truer ;i puncture made
in the eighth interspace below the scapula to a considerable
depth, ;i few days before death, and entirely failed, the
Lung having apparently completely recovered. Such
recuperative power does the lung display when irritated.
BRONCHIECTASIS TREATED BY PARACENTESIS. 335
In most of these cases the lung-tissue had undergone
fibrosis, and puncturing this tissue seems to promote its
growth and subsequent contraction.
One accident that these operations are liable to is
inoculation of the pleura with septic material, leading to
pleuritic effusion or empyema. This happened in one of
my cases, on the withdrawal of the aspirator needle (though
a fine one) from the bronchiectasis. Unfortunately the
pleura which was adherent over the greater part of the lung
was not adherent over the region of the cavity, and hence
the accident. As a rule, however, this can be ascertained
by observing the state of the intercostal spaces on deep
breath, and of course no operation should be attempted if
there is any doubt about adhesion.
One accident of these operations is haemorrhage, which
occurred in two of my cases, and was rather troublesome in
Case 2 (Mary E — ). I allude not only to the haemorrhage
accompanying the operation, but that which followed. It is
quite possible that the pressure of the tube against the fresh
granulations during the various movements of the patient
gave rise to ulceration. In such cases the indication is at
once to withdraw the tube.
It will be noted that in all six cases the diagnosis of
the cavity was sufficiently accurate to enable us to reach
it, and the difficulty consisted less in localising its situa-
tion than in ascertaining its distance from the chest wall.
In more than one case it was found necessary to deepen
the puncture considerably, before it was successful.
The two principal difficulties in the diagnosis of a
bronchiectasis cavity, are (1) The presence of emphysema,
which invariably accompanies the globular form of bron-
chial dilatation and often entirely masks the physical
signs of a cavity, even when the patient's sensations and
the amount and character of the expectoration point to the
presence of a bronchiectasis in a certain portion of the
lung.
(2) The character of the cavernous sound heard over
bronchial dilatations. This is so jarring in tone that it is
336 BRONCHIECTASIS TREATED BY PARACENTESIS.
audible over a far larger area of chest wall than that imme-
diately overlying the cavity ; and it is not rare on this
account that the size of the bronchiectasis is thought to
be larger than it eventually proves. This jarring note is
more common in bronchiectasis associated with interstitial
pneumonia and fibrosis and assuming the cylindrical form,
than in the globular bronchiectasis accompanied with
chronic bronchitis and emphysema.
The success of the operation seems mainly to depend
upon whether the bronchiectasis is single, or at any rate
confined to one lobe of a lung the pleura of which is ad-
herent, or whether it is multiple, and affects the bronchi
of both lungs. In the former case operation gives the
greatest possible relief, and may, as in Case 1, effect a
cure. In the latter case, and especially where there are
indications that the whole bronchial tree is more or less
dilated, no advantage can be looked for and the operation
cannot be advised.
To sum up, paracentesis in bronchiectasis seems to me
to be indicated under the following circumstances :
1. In cases where antiseptic treatment of all kinds,
having failed to correct the fcetor of expectoration and to
allay the harassing nature of the cough, death by septic
pneumonia seems imminent.
2. Where all evidence goes to prove that the bronchi-
ectases are confined to one lung, are situated in the lower
lobe, and have overlying them an adherent pleura.
It is not indicated where multiple bronchiectases exi-t
in both lungs, where they are surrounded by emphysema,
and where the pleura is non-adherent.
Remarks by Mr. GIodlee. — The surgical aspect of the
first case presented no difficulty whatever from beginning
to end ; the cavity being single and the position accurately
localised by Dr. Williams, and verified uninistakeably by
the preliminary puncture with the aspirator needle ; there
was a clear indication for cutting down with this as a
guide and making a free opening. The pleura was ad-
BRONCHIECTASIS TREATED BY PARACENTESIS. 337
herent, and the cavity at a short distance from the surface
of the lung, so that here again all was straightforward,
and in the further progress of the case the sudden diminu-
tion in the amount of expectoration and the rapid closure
of the cavity, as shown by the decrease of the discharge
in the dressing, left no doubt as to the advisability of
shortening and ultimately withdrawing the tube.
The second case, however, illustrates most of the diffi-
culties that the surgeon is likely to meet with in dealing
with cases of bronchiectasis.
First, the lung containing possibly the ramifications of
one or more branched or labyrinthine cavities and the
intervening pulmonary tissue being consolidated, the phy-
sician is not always able with certainty to define the exact
limits of the cavity which it is desired to open, though
he may indicate its position generally. The preliminary
punctures are thus frequently most unsatisfactory, for
it must be remembered that while the individual branches
of the cavity may be comparatively small, the bronchi
themselves contain a material of a precisely similar nature
to that in the bronchiectasis ; confusion may therefore
easily arise either from just missing an elongated cavity
which gives very obvious physical signs, or puncturing
and subsequently cutting down upon a bronchus, because
some pus has been drawn out of it into the aspirator.
Again, some timidity is naturally felt in introducing a
large aspirator needle to a great depth into the lung. It
must not be forgotten that the nearer the root of the lung
is approached the larger the pulmonary vessels become,
and that a puncture through a branch of the pulmonary
artery of some size into a bronchus might conceivably lead
to very serious symptoms.
Secondly, in this case the pleura was closed by adhe-
sions, but they were so soft that they easily broke down
with the finger, so that the lung could be pushed away \o
some extent from the ribs. If the two layers of the
pleura be not adherent two difficulties present themselves
(and it must be remembered that however great the pro-
vol. lxix. '-'-
338 BRONCHIECTASIS TREATED BY PARACENTESIS.
lability may be that adhesion has taken place we can
never be absolutely certain of it until the incision has been
made through the chest wall) ; in the first place, it is
impossible to puncture the lung with any amount of
accuracy or definiteness, because it recedes before even
the sharp point of the needle ; and in the second place, if
we do succeed in laying open the suspected cavity we run
the risk of setting up a septic pleurisy. It is not likely
that the lung will be in a condition to collapse very much,
for it is probably in a more or less solid state, and it is
not likely that the pleura will be found quite free from
adhesions, so that a general pleurisy need not be antici-
pated ; still, if the condition mentioned be found, it is
safer to stitch the surface of the lung to the opening in
the parietal pleura. This is not, however, a very satis-
factory proceeding. I have done it on one occasion where
the suspected adhesions were not found, but though I
succeeded in bringing the lung out to the chest wall, the
two surfaces of the pleura did not unite very well, and
after a few days it was possible to pass a probe freely
into what remained of the pleural cavity, some of the
stitches having no doubt cut out through the friable lung-
tissue.
Thirdly, there may arise difficulties in connection with
the haemorrhage. The incision of the lung-substance,
solidified as it is in these cases, does not in my experience
often lead to much bleeding; but it is impossible t<> avoid
the risk of opening a large vessel, at ;i depth from the
surface which would render the application of a ligature
out of the question, and it seems to me highly probable
that a case will some day arise in which very serious
haemorrhage will occur. In Case 2 the bleeding wasvery
fnc, but there was no difficulty in controlling it by ping-
ing the wound. This is clearly the only line of treatment
to be adopted, and as Ear as I have yi li always
in the free hemorrhage which follows incision of the
parenchyma of the liver) proves to lie successful. Bui
haemorrhage may also take place into a bronchus and then
BRONCHIECTASIS TREATED BY PARACENTESIS. 339
cause considerable haemoptysis. I have now seen this
occur three times from the puncture of an aspirator
needle, which has no doubt passed either completely-
through a bronchus into a neighbouring vessel, or through
a vessel into a bronchus. This accident it seems impos-
sible to guard against, but it suggests the inadvisability
of producing profound insensibility with the anaesthetic,
so that the patient may by coughing be able to get rid of
the blood from the air passages. In all these cases the
haemorrhage quickly stopped, but in estimating the risks
of the operation it must be remembered that M. E — had
severe haemoptysis on several occasions, at a subsequent
period in the case; though we must not forget the history
of large haemoptysis before admission.
Another very real danger of which I have seen a
striking example is that during the coughing which
occurs whilst the anaesthetic is being administered, the
bronchi may become dangerously obstructed by the pus
which previously filled the cavities. This not only renders
the diagnosis of the position of the cavity for which search
is being made extremely difficult, but produces more or
less asphyxia, which, when added to the narcotic effect of
the anaesthetic, may sensibly imperil the safety of the
patient.
The indication is to give the anaesthetic slowly so that
coughing may be avoided, and in order to prevent the
pus from finding its way from the affected to the sound
lung, to keep the patient as much on the back as possible.
It is perhaps presumptuous to attempt any general con-
clusions on the advisability of surgical interference with-
out more extended experience, but the following opinions
may be hazarded provisionally.
First, when the physical signs point clearly to the
existence of a cavity on one side only and to its being
moderately localised, the indication is to operate. But
it is wise to make quite sure by preliminary puncture of
its exact position before an incision through the chest wall
is made, even if this involve exploration on more than one
340 BRONCHIECTASIS TREATED BY PARACENTESIS.
occasion. Secondly, if the physical signs indicate very
extensive mischief on one side only, though the prospect
is much less promising, some good may result from opera-
tion. If in such a case the preliminary puncture has
apparently revealed the presence of a cavity which the
further exploration fails to open, the patient will probably
suffer no serious consequences from the operation. It is
even possible that the incision into the lung and the
interference with the natural rigidity of the chest wall
may aid in the contraction of the cavity in the neighbour-
hood of the puncture; while it is just possible that the
cavity may have been only just missed, and that by u
process of ulceration it may at a later' period discharge
itself into the actual opening. Thirdly, if the physical
signs point with anything approaching to probability t<>
the presence of bronchiectases in both lungs it is wisest
to abandon all thought of surgical interference.
(For report of the discussion on this paper see ' Proceedings of
the Royal Medical and Chirnrgical Society,' New Series, vol. ii.
p. 85).
ON SUPRA-PUBIC LITHOTOMY.
RICHARD BARWELL, F.R.C.S.,
SENIOR SUBGEON TO CHABING CEOSS HOSPITAL.
Received December 8th, 1885— Read March 30th, 1886.
The high or supra-pubic operatiou for stoue in the
bladder has had a singular history. Its first performance
may perhaps date from the second century, but the earliest
reliable case is that of Pierre Franco who, in 1561, thus
succeeded, after the failure of some other method (pro-
bably "on the grip") in extracting a large stone from
the bladder of a child. The patient recovered easily.
Franco, however, ends his account of the case by saying,
" I do not advise any man to do the like."1
Nevertheless in 1590 Rosset published a remarkable,
and for the period a very advanced essay on this subject,
which was unjustly blamed and criticised by Hildanus in
1682. Other writers, notably John Douglas,2 described
this operation, but it obtained no repute until Cheselden
took it up in 1722, during which year he cut "nine
patients this way." They were of various ages, from
four to nineteen years. Two died, one of renal calculus,
1 Pierre Franco, ' Traite" des henries,' p. 139, Lyons, 1561.
3 ' Lithotomia Douglassiana,' 1723.
342 SUPRA-PUBIC LITHOTOMY.
there being renal calculus and abscess, the other of some
fever, either fortuitous or pyseniic. But the histories
record one after another the ease and comfort of the
patient, together with the facility of recovery. Yet
Cheseklen, who about this time was emulous of the success
obtained by an imitator of Frere Jacques (Rau, of Amster-
dam) abandoned the high for a perineal operation, and
soon after perfected the manner now known as "lateral."
Since that time the supra-pubic method has only been
resorted to when the stone has been diagnosed as very
large. It may, however, well be doubted whether surgeons
are right in regarding the high operation as one only to
be used in exceptional cases, and indeed since 1851, when
Gunther published his well-known work,1 there seems to
be some disposition to reconsider the question.
My thoughts were more especially led in this direction
by a rapid sequence in my clinic of cases of vesico-vaginal
fistula. I had under my care in seven months (the latter
part of 1883 and beginning of 1884) three cases of this
affection, all originating in the extraction of calculi during
infancy and youth by different surgeons. Such fistulas are
very recalcitrant to treatment by operation, for they lie in
the midst of hard, thick cicatricial tissue. The bladder is
much diminished in capacity. In two of the cases the
fistulas were very high, and in the thickened state of parts
the uterus could not be drawn down." I do not know how
or why these cases should have all come under my notice
in such rapid succession, but they made a great impression
on my mind, and I determined that when any female
child came under my care with a stone too large and
1 ' Dor hohc Stcinschnitt,' Leipzig, 1851.
2 One of these women, aged nineteen, I succeeded after two operation! in
curing; another, aged twenty-four, had been thrice Babjeoted to operation
before I saw her. I gave a guarded prognosis concerning the result of any
fresh attempt and have not seen her sinee. One is incurable, the fistula lying
close to the os uteri, which, in the almost cartilaginous hardness of partSj
cannot be brought down. She is approaching the menopause; when that
occurs 1 sliall occlude the vagina.
SUPRA-PUBIC LITHOTOMY. 343
hard to be extracted per urethrarn either whole or in
fragments, it should be taken out above the pubes.
Case 1. — Eose A — , get. 9, came under my care on 6th
February, 1885.
No history was obtainable. The parents simply left
the child and did not come again.
She was greatly emaciated and exceedingly fretful.
During both night and day she had to micturate very
frequently, suffering greatly in doing so. A good deal of
urine came away involuntarily, or at all events not
restrained. The urine was alkaline, sp. gr. 1019, pale
and opalescent from slight admixture of mucus. A little
albumiuous cloud appeared on boiling. There was a
deposit (quarter of glass) which consisted in part of
amorphous powder, but very largely of oxalate of lime,
chiefly in octahedral crystals.
When a sound was passed into the bladder it imme-
diately impinged on a large stone ; if the instrument was
pressed further in the same direction a little urine flowed,
as though the calculus acted as a valve over the urethral
exit ; but by a little manoeuvring the instrument could
be made to pass behind the stone. Examination per
rectum revealed little, a good thickness of soft structures
intervening between the finger and the stone. Vaginal
examination showed that the calculus occupied nearly all
the breadth of the pubes and reached a good way upwards.
February 12th. — The child was placed under the influ-
ence of ether. A further examination caused me to con-
clude that the stone was even larger than it at first seemed.
About 3| oz. of carbolized water was injected, when
percussion gave dull notes to rather less than half way
to the umbilicus. Requesting my assistant to place a
finger in the vagina to steady the stone forwards, and at
the same time to compress the urethra against the pubes
to prevent any outflow of urine, I made an incision about
three inches long strictly in the middle line, and after
twisting two small vessels, divided the linea alba, taking
344 SUPRA- l'DBIC LITHOTOMY.
care to cut from above downwards. The recti and
pyramidales were held apart by broad retractors ; but the
peritoneum was not in view.
The peculiarly soft yielding tissue which lies between
the bladder and the abdominal wall was now divided, and
the bladder punctured ; when a little water had oozed
from the bladder it was opened in a downward direction
to the extent of about two inches. The stone thus laid
bare was gripped in a small pair of straight lithotomy
forceps. They slipped twice, but on the third attempt
the calculus was brought about half way out of the bladder.
The edges of the recti, however, held it, and the linea alba
was therefore divided a little further in an upward direc-
tion with a probe-pointed bistoury, supei*ficial to the peri-
toneum, and the stone was easily extracted. It weighs
2\ oz. minus 5 gr. ; that deficit would be more than out-
balanced by the chipping from its upper end. Its length
is 2£, one short diameter 1^, the other short diameter
1^ inches.
As the bladder contracted and emptied itself the anterior
fold of peritoneum slowly descended and came into view.
The cavity examined by the finger was found free from
any fragments or detritus ; the incision was closed with
four catgut sutures. Three quill sutures were passed
through the whole thickness of the abdominal wall, bring-
ing together the upper five sixths of the wound ; a good-
sized drainage-tube was placed behind the recti and pro-
truded at the lower corner of the incision, the skin was
sewn with wire, and a catheter passed per urethram.
13th. — Passed a very good night. Temp. 99, c pulse
100. The dressings were found sopped with urine ; none
passed by the catheter. The lowest superficial stitch
removed, a larger tube passed. A larger catheter (winged)
substituted.
1 4th. — Removed the deep Butures ; wound closed ezcepl
where the drain enters.
It would answer no purpose to follow out the daily
notes of tin-; case. The child had DO pain QOr any
SUPKA-PUBIC LITHOTOMY. 345
trouble ; her peevishness and fretfulness entirely passed
away, and after the second day she became joyous and
laughter loving.
26th. — Urine ceased to come by the wound, the dres-
sing remaining dry ; nevertheless I thought it wise to
retain the catheter a little longer.
March 4th. — Removed drainage-tube and catheter. The
child is well and has gained flesh very considerably.
The operation was performed under the carbolic spray,
and the wound was dressed always with the same precau-
tions.
Case 2. — William W — , get. 60, came into Charing Cross
Hospital under my care 20th April, 1885, with frequent
and painful micturition. The man was weakly, looking
older than his stated age, and said that in consequence
of having to pass water frequently he had but little sleep.
I passed a sound and immediately detected a stone.
The bladder felt somewhat roughened, but the prostate
was very large. Although the whole manipulation was
very gentle considerable hematuria followed and continued
for sixty-three hours.
24th. — I injected the bladder and measured the stone.
I succeeded in obtaining three diameters, viz. 1^, i| and -^
inch respectively. Again hgeniaturia continued for some
days and the man suffered a good deal after micturition.
In consequence of this condition and of the large size of
the prostate, I determined to perform the high operation,
to prepare him for which I caused a flexible catheter to
be passed daily and the bladder to be injected with a
solution of carbolic acid one in sixty until a sense of dis-
tension was experienced.
30th. — When the patient was under the influence of
ether the bladder was slowly filled with 16 oz. of the
same solution. The catheter was plugged and a broad
piece of tape tied round the penis. Notwithstanding the
amount of fluid in the bladder, percussion gave clear
notes down to, or very nearly down to, the pubes.
346 SUPRA-PUBIC LITHOTOMY.
I made an incision three inches long- in the middle
line from above downwards and cautiously divided the
linea alba and fascia transversalis. This fascia, the recti
and the skin, were held apart by two broad retractors, and
now placing my forefinger on the front of the bladder I
pushed up the fold of the peritoneum, placed upon it a
broad retractor, and confided it to Mr. Cantlie, who was
assisting me. I met with no resistance whatever in thus
pushing upward the peritoneum ; it glided quite smoothly
and easily from the anterior face of the bladder. The
prevesical fat was now incised ; two veins required ligature.
With the edge of the knife directed downwards I made a
small opening in the bladder as high as seemed desirable
and placed a blunt hook in it to prevent the organ, as it
emptied itself, from sinking into the pelvis ; then with
successive touches of the knife, the bladder was incised.
The attached surface of the mucous lining was marked
with large distended veins. Most of these were avoided,
but two had to be tied, and three arteries in the thickness
of the vesical wall were twisted. The organ was laid
open to the extent of about two inches. I passed in my
fore and middle fingers, and, gripping the stone between
them, easily removed it. The Avail of the bladder still
oozed, and I was reluctantly obliged to apply a hasmostatic
(one part of Liq. Ferri perchloridi to six of water). After
this the bladder and other parts were sewn up and treated
as in the former case.
May 1st. — The patient passed a good night, almost
entirely free from pain. Temp. 99*2°. Urine came by the
wound, which was perfectly healthy ; it was syringed out
with carbolic acid solution. A larger catheter (the one
passed yesterday having become plugged) was introduced.
2nd. — Quill suture removed, wound healed except at
site of drainage-tiil"'.
Ill,, — Some small shreds of sloughed tissue stained
with the perchloride came away. The man has had do
pain nor Eever.
10th. — All the wound has been healed for the last three
SUPKA-PUBIC LITHOTOMY. 347
days save an opening that might perhaps admit an ordi-
nary cedar pencil through which some urine flowed, though
by far the largest part came by the catheter.
17th.— The opening above the pubes much smaller.
He complained of some soreness in the urethra, probably
produced by the catheter. This was removed on the 15th.
To-day he passed urine by the urethra. The fluid, as usual
in these cases, caused a good deal of scalding.
He went out quite well in the middle of July.
On 24th March, 1886, I received a note from Dr.
Hughes, of Deal, who sent me this last patient, from which
the following is quoted : " The old man, William W — ,
for whom you performed supra-pubic lithotomy, is in
robust health and able to do a good day's work."
Remarks. — I would direct attention to the ease and
facility with which these patients recovered, reminding the
Society that this is especially the characteristic of Chesel-
den's, Petersen's, Giinther's and other patients. My first
case, the little girl, had no pain or trouble from the hour
of operation. In my second case the fistula lasted some
weeks. The man was somewhat troubled in mind on this
account, although I was able to assure him that the opening
would close within a moderate interval, which in fact it did.
The objections urged against the high operation are
found, on examination, to be untenable or exaggerated.
They are these :
1. The danger of wounding the peritoneum.
2. The danger of urine collecting and putrefying in the
wound.
3. The danger of establishing a urinary fistula.
4. The fear that the bladder may become adherent to the
abdominal wall and that thus its function may be impaired.
I propose to examine the first of these objections at the
end of this communication, since it involves many points
in the method of operating, in the preparation of the
patient and certain matters regarding the position of the
peritoneum in different states of the bladder and rectum.
:J4> SUPRA-PDB1C LITHOTOMY.
These I, as well as certain other surgeons, have made the
subject of experiments recorded in an appendix.
We pass on to the second objection, — the fear that urine
may collect and putrefy in the wound, and with that sub-
ject we may consider the after-treatment.
Fresh urine that is not ammoniacal does no harm to a
recent wound ; on the contrary it is a non-irritating irriga-
tion ; and I submit that by careful use of antiseptics we
can prevent it becoming ammoniacal in all parts accessible
to an injection. Now, the peritoneum on the bladder
leaves uncovered a triangular surface, bounded on each side
by the hypogastric arteries to which it is firmly attached.
This space, when the organ is distended, is (in the adult)
from two to three inches long and a little more than an inch
wide at its base ; but when the bladder contracts it becomes
very small, and as urine cannot pass beyond the lateral
boundaries, all implicated parts in a properly conducted
operation are perfectly within reach of an injected fluid.
But it may be questioned whether the after-treatment
I adopted is the best. Such cases have been dressed in
every possible manner. By T-shaped drainage-tubes
and by simple meshes of hemp introduced through the
wound into the unsewn bladder and with only the
upper edge of the skin wound sewn ; by no dressing
at all save wool or tow to absorb the urine ; by position,
namely, on the side a little turned to the front, and many
others ; I do not find that the statistics of one method
have any advantage over the others; yet it appears to me
that by suturing the whole thickness of the abdomiual
wall one probably diminishes whatever tendency there may
be to a subsequent hernia. Also it would seem that by
stitching the bladder a more rapid healing must follow ;
indeed in three out of his four cases, Petersen procured
primary union.
Gunther says1 that a catheter passed per orethram
prolongs recovery. Other Burgeons doubt this assertion.
The danger of establishing a urinary fistula need hardly
1 • Dor hohe BteiPBohnitt,' p. 80, Liii»zig, 1851.
SUPRA-PUBIC LITHOTOMY. 349
detain us; sucli mishap has never, I believe, occurred. My
case, No. 2, is an instance of the longest duration of such
a fistula, viz. eleven weeks. It is doubtless a long period
for recovery from lithotomy ; but knowing as I do the
state of this man's bladder and prostate, as also his weak
and senile condition, I conceive that he recovered quite as
quickly as he would have done from a lateral lithotomy,
and that he ran infinitely less risk of not recovering at all.
The danger that the bladder may lose the power of
emptying itself by becoming adherent to the abdominal
wall was disproved by Cheselden in these words1 : " Joseph
Reynolds, who was cut May the twenty-second, 1722, and
dischai'ged cured, in the beginning of July, was about the
middle of October following taken ill of a fever, with
violent vomitings, of which he died in a few days, having
enjoyed perfect health from the time of his cure to this
illness. I opened him, and found his kidneys and bladder
free from any disorder, and the wound in the bladder
united with a firm, smooth cicatrix, the outside of the
wound being joined to the wound made through the integu-
ments, it was perfectly empty of water, which shows this
connection of the bladder to the integuments was not
inconvenient on that account ; and not only this patient,
but all others have been able to contain as much urine in
their bladders at once, as persons that have not been
out."
The danger of wounding the peritoneum has been very
much exaggerated. I am, of course, aware that this
mishap has occurred to certain operators ; yet my experi-
ence on the living, and my numerous experiments on the
dead, subject cause me unhesitatingly to say that such
misfortune can always be avoided.
The height above the upper edge of the os pubis at
which the lower margin of this membrane in front of the
bladder lies, varies somewhat in different individuals,
even with pelvic organs equally full or empty. In chil-
3 'A Treatise on the High Operation for Stone,' by William Cheselden,
1723, p. 20.
350 SUPRA-PUBIC LITHOTOMY.
dren it is practically out of the way, as in rny case of
Rose A — (see also Appendix).
In some adults when both bladder and rectum are
empty, this fold lies a line — occasionally even two lines —
below the upper margin of the pubes ; but it more
commonly lies above, even considerably above, that bone ;
but wherever it may be while the bladder is empty, it
always rises when from 6 to 16 oz. of fluid are injected,
and that to a height quite compatible with a safe high
lithotomy.
A device for pushing up the bladder still further,
namely, distension of the rectum with an india-rubber bag,
was devised and practised by Dr. Petersen, of Kiel,1 It
may be granted that when the true pelvis becomes
thus forcibly occupied by a foreign body, the bladder will
to some extent be extruded, a change which as Dr.
Garson2 has shown can only take place by stretching — even
to double its length — of the prostatic urethra ; a process
which can hardly be free from danger in elderly persons.
But I am able to state from a series of experiments, in
twelve only of which were perfectly accurate measure-
ments taken, (see Appendix), that distension of the rectum
makes but very little difference in the position of this
peritoneal fold ; never more than a quarter of an inch,
oftener an eighth of an inch, and sometimes its elevation
was barely perceptible.
I fear I must also say that Dr. Petersen must have
been misled in his experiments by a faulty method of
procedure. A glance at his table will show this, Bince
he assigns to this fold a position which is anatomically
impossible. Out of ten cases there were seven in which
this fold is stated to lie at two finger-breadths, and in
one case at three finger-breadths below the pubes, that is
to say at least one and a halt' and two and a quarter inches
respectively.
This slight influence of rectal distension is confirmed
by Dr. Garson's experiments. Table II, p. 350 is a copy
1 ' Langenbeck'a Archiv,' vol, \w, i>. 752.
: 'Edinburgh Medical Journal,' Oct., 1S78.
SUPRA-PUBIC LITHOTOMY. 351
of all that part of his table which refers to this fold of
peritoneum. The important portions are cases 1, 2, 3,
and 6, 7, 8. Nos. 1 and 6 have the same amount in the
bladder ; in the former the rectum is full, in the latter
empty ; yet the peritoneal fold lies in both at the same
level. Such is also the condition in Nos. 2 and 7, and
again this fold lies at precisely the same height ; while
in No. 8, with a like amount in the bladder, but with an
empty and contracted rectum, this fold lies six tenths of
an inch higher than in any case in which the rectum
is full.
My own experiments, twelve in number, are added in
an appendix. In summing up their result I would say that
I never found distension of the rectum raise the peritoneum
more than a quarter of an inch, oftener only an eighth of an
inch, and sometimes its elevation was barely appreciable ;
the conclusion being that distension of the rectum,
though it may be dangerous, is useless in high lithotomy.
These facts being fixed, I may say a few words as to
the mode of operating. A catheter should be first passed
into the bladder ; it may be either metallic or flexible.
An operator with but little experience may prefer a metal
one, as in a later stage it may serve as a guide to
opening the bladder. Through the catheter the bladder
is to be injected with such amount of an aseptic solution
as previous experience shows the patient is able to bear.
If a metal catheter be used it must be plugged; if a flexible
one it must be removed ; in either case if the patient be
a male a fillet is to be tied round the penis; if a female a
finger-tip introduced a little way per vaginam may be used
to compress the urethra against the pubes, thus effectually
preventing micturition ; or, should it seem desirable to
steady the stone, the tip of the finger may do so, while
the front of the first or second phalanx will prevent
escape of the injected fluid.
All incisions should be made from above downwards.
To cut through the linea alba without opening the perito-
neum is very easy, and is constantly done by all who
352 SUPRA-PUBIC LITHOTOMY.
practise abdominal surgery. The fascia transversalis
should be incised just above the pubes, and a director,
kept close to its deep surface, passed from below upwards.
The triangular interval left by the two sides of the perito-
neal fold now comes into view ; the bladder being concealed
by a layer of very soft fat. Should the interval not be
large enough a mere touch of the finger will increase it ;
the peritoneum lies on, without being attached to, this
part of the bladder. The veins in the fat are easily seen
and may as a rule be avoided.
The opening of the bladder is best begun above by a
little quick thrust of the bistoury, and before carrying
the incision further it is well to pass in a blunt hook
behind the knife, thus obviating too rapid contraction and
collapse of the organ into the pelvis.
When possible the stone should be removed with the
fingers.
Were not this paper already, I fear, too long several
other points might be discussed.
For female children, probably for females of all ages,
whenever lithotomy is necessary the high operation is
preferable to all other methods ; it is quite as safe and
cannot lead to any form of urinary fistula.
Lateral lithotomy in boys gives excellent results when
the stone is not large; nor have I seen anj- of the evils
alleged to result from division of the vas (Jeferena within
the prostate. I cannot, however, but think that am ste.no.
large enough to render laceration of the prostate probable
during its removal by the perineum, should be taken oul
above the pubes. The route to the bladder is shorter,
through less important and vascular tissues, and there is
no danger from hamiorrhage. The results obtained by
Chesclden and by other more modern operators show the
remarkable ease of recovery after a eectio alba.
For adult males the high operation is probably to
he limited to stones n\' a certain size and to some oases
of diseased prostate and bladder. I consider, however,
SUPRA-PUBIC LITHOTOMY. 353
that the limit of size has been placed too high, and that
a stone weighing 2 oz. is, unless amenable to lithotrity,
most safely removed by the high operation. Save
in a few very rare cases distension of the rectum is
unnecessary. Should the peritoneum, when exposed, be
found to lie very unusually low, the surgeon could intro-
duce a bag per rectum if he deemed it desirable.
For tumours of the bladder, unless situated very close
to the urethral orifice, high section of the bladder is
especially indicated, and if such tumour lie at the back
of the organ that portion may be advantageously raised
and fixed by distension of the rectum.1
The objects of this Appendix are — 1st, to explain why
the experiments herein detailed were made; 2nd, to explain
the method of conducting them.
In studying the question of supra-pubic lithotomy a
very important point is the position, in different states of
the pelvic viscera, which may be assumed by that fold of
peritoneum lying between the anterior abdominal wall
and the bladder.
In 1880 Dr. Petersen, of Kiel, published an account of
ten experiments made to ascertain the relative position of
the anterior fold of the peritoneum and of the upper
border of the os pubis. He proceeded thus. He made " an
incision through the linea alba just below the umbilicus.
The position of the prevesical peritoneal fold was then
estimated by the introduction of a finger/'
It is only fair to add that Petersen acknowledges these
measurements to be not quite certain (nicht ganz sicher).
1 A plate was banded round showing a position employed by Trendelenburg
(see * Langenbeck's Arcbiv/ Bd. 31, p. 514), and which tbe autbor of tbe
present paper recommends as well adapted for exploration of tbe fundus of
tbe bladder.
2 " Ueber Sectio alba," ' Langenbeck's Arcbiv,' vol. xxv, p. 757.
VOL. LX1X. 23
354 SUPRA-PUBIC LITHOTOMY.
But I fear we must go further. The professor found that
when both bladder and rectum were empty this fold lay
in one case level with, in another one finger-breadth, in
seven two, and in one three finger-breadths below the upper
margin of the os pubis.1 Now, the average of ten measure-
ments of five finger-breadths (index and middle) is a little
over an inch and a half.
The average of ten measurements of the depth of the
pubes, or, in other words, of the length of the symphysis,
is one and seven tenths of an inch. Therefore, according
to these experiments the fold of peritoneum lay within
two lines of the margin of the pubic arch.
Considering that, however contracted, the bladder must
occupy more than two tenths of an inch behind the pubes,
the condition of affairs thus described appeared to me
impossible ; more especially when Petersen gives one case
in which the prevesical fold lay three finger-breadths, i. e.
just over two and a quarter inches below the upper
margin of the os pubis, I cannot but feel great doubt
as to his results, more especially as Dr. Garson says that
when the bladder and rectum are empty, the peritoneal
fold usually lies a few millimetres ahove the margin of
fche pubes.
Dr. Garson2 has also studied this question by
personal experiment, and by measurements taken from
engravings of frozen subjects in PirogofPs and Braune's
Atlases. In his conclusion No. 3, he says "that the
raising of the peritoneum can also be produced by simple
distension of the rectum." It is to be regretted that Dr.
Garson gives no instance of this. His table of thirteen
cases contains none in which the bladder is empty ami
tlic rectum full. Moreover with all the diffidence that
1 must feel in combating the conclusions ft' BO eminent an
authority, it must be stated that his results do not tally
1 I Bubjoin a copy of his table, with French converted into English measures.
1 may add thai tin1 average distance of the internal orifice of the urethra is
under two inches from the upper margin of the pubes.
'-' • Edinburgh Medical Journal,' October, ts7s.
SUPRA-PUBIC LITHOTOMY.
355
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356
SUPRA-PUBIC LITHOTOMY.
with his deduction. Cases 1 and 2 have the bladder
distended and have also the rectum " much distended."
Now, in them the distance of this fold above the pubis is
given as forty and fifty-five millimetres ; but Case 3 with
an equally full bladder, but with a rectum only
" moderately distended," the distance is fifty millimetres
i. e. two tenths of an inch less than Case 2, and four tenths
more than Case 1. Evidently in these three cases rectal
distension had no effect.
Table II. — Garson's Table, the metric system being reduced
to English measure.
No. of
case.
10
11
12
Condition of bladder.
Much distended1
Fully distended
Much distended
Condition of rectum.
Much distended2
Fully distended
Moderately distended
Instance of
peritoneum above
pnbea.
Cases where Bladder and Rectum were empty.
Almost empty
Absolutely empty
Absolutely empty and contracted
Almost empty
Cases with empty Rectum and distended Bladder.
Much distended
Distended
Half filled
Absolutely empty and contracted
Empty ami contracted
»» »>
Empty
Cases with moderately distended Bladder and Rectui
Moderately full Moderately full
Half full * Half full
Moderately lull Moderately full
1-57 inch.
216 „
1"96 „
0-19 inch.
0-
1-57 inch.
216 „
8-76 ..
0079 „
0*8 inch.
0-79 ..
062 „
1 Bladder filled with 8 oi. .') dr». (240 grammes of fluid.)
5 Rectum distended by bag containing loj oz. (300 grammes) of Said ; its
circumference being 9*84 inches (26 cm.).
SUPRA-PUBIC LITHOTOMY. 357
Again, when we compare Cases 1, 2, and 3 with Cases
6, 7, and 8,1 we find the following. The former series are,
as stated, cases with distended bladder and rectum ; the
peritoneal fold lies forty, fifty-five, and fifty millimetres
respectively above the pubes. Cases 6, 7, 8 have the
bladder equally distended, the rectum " empty and con-
tracted." The fold lies forty, fifty-five, and seventy milli-
metres above the pubes, that is on an average seven milli-
metres higher when the rectum is empty than when it is full.
In the table subjoined I have reduced these measures to
inches — seventy millimetres is two and three quarter inches,
and this was obtained when the bladder was distended (not
" much distended ") and the rectum empty and contracted.
Surely these cases, 6, 7, 8, show, when compared with
Cases 1, 2, and 3, that distension of the rectum has no
effect on the anterior fold of the peritoneum.
Wishing to gain a definite insight into the true state of
the case with regard to this fold I instituted a series of
experiments the result of which is subjoined. They were
conducted in the following manner :
The bladder was emptied by the catheter and the rectum
by washing it out with water. An incision was then made
through the linea alba and fascia transversalis. The posi-
tion of the lower border of the prevesical fold was
measured.
In Series I the bladder only was filled with varying
amounts of water.
In Series II the bladder was filled first, then the
rectum.2
In Series III the rectum was filled first and then the
bladder ; subsequently, while the bladder was still full, the
rectum was emptied.
In each one of these different conditions the position of
the fold was carefully noted.
1 In Garson's table, Case 7, the particular point in question is not marked.
I have therefore omitted it and changed (after 7) the numbering.
2 By means of a distensible india-rubber hag and a Higginsou's syringe.
358
SUPRA-PUBIC LITHOTOMY.
Table III. — Experiments (Barwell),
Cases in which Bladder only was filled.
No.
Subject.
Age.
Bladder.
Rectum.
Relation of fold to
pultes.
1
Child
2*
J" Empty
L 2 oz.
Empty
n
f inch above
H ., „
2
Child
4
/ Empty
\ 4 oz.
Empty
?, inch above
1| >i i.
3
P.
62
f Empty
\ 8oz.
1 16 oz.
Empty
>>
ft
^ inch below
i „ above
2 ,i
4
M.
39
f Empty
\ 10 oz.
[ 16 oz.
Empty
ii
i inch above
H „ ,.
2i „ „
5
M.
32
f Empty
\ 10 oz.
L 14 oz.
Empty
Level
1 inch above
1* „ „
In i
}hich Bladder was filled
first, then Iiectu
n.
6
M.
30 \
f Empty
J 6oz.
] 10 oz.
1 15 oz.
f Empty
J 6 oz.
] 10 oz.
L 15 oz.
Empty
»
12 oz.
i>
ii
>i
\ inch above
* » »
H » „
•* i « ii ii
J inch above
1 »
H „ „
2* „ „
7
M.
34
f Empty
\ 10 oz.
[ 10 oz.
Empty
10 oz.
£ inch above
i „ „
8
M.
35
f Empty
J 10 oz.
I i<; oz.
1 16 oz.
Empty
10 oz.
J inch above
U » ,,
2» „ „
2i „ „
9
M.
32
f Empty
\ I:'../.
[ 12 oz.
Empty
12 oz.
Level
1-j " incli above
1 1 *
118 II "
SUPRA-PUBIC LITHOTOMY.
In ivhich Rectum was filled first, then Bladder.
359
No.
Subject.
Age.
Bladder.
Rectum.
Relation of fnld to
pubes.
f Empty
Empty
8oz.
\ iuch above
10
M.
72
\ 8 oz.
8 oz.
1 „
16 oz.
8 oz.
^4 j> y>
t 16 oz.
Empty
2 „
Empty
Empty
6 oz.
f inch above
i „ „
11
Boy,
immature
14
2 oz.
' 4 oz.
6 oz.
6oz.
Is » i>
2-1-
and small
4 oz.
4 oz.
3 oz.
Empty
2TV »
1| „ „
Empty
Empty
10 oz.
f\j inch below
Level
12
—
—
. 10 oz.
13 oz.
10 oz.
10 oz.
f inch above
If „
16 oz.
10 oz.
-■■4 » }>
L. 16 oz.
Empty
H „ „
The conclusion seems inevitable that distension of the
rectum produces no such elevation of tlie peritoneum as
would be of any value to the operator, nor does it appear
that there is any object to be gained in lithotomy by press-
ing forward the back of the bladder, as a stone, unless very
small, is quite within reach. If cystotomy be performed
for the removal of a growth the rectum should certainly
be distended.
(For report of the discussion on this paper, see 'Proceedings
of the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 94.)
A CASE
OF
ENCYSTED VESICAL CALCULUS OF
UNUSUALLY LAKGE SIZE
REMOVED BY SUPRA-PUBIC CYSTOTOMY.
WALTER RIYINGTON, M.S.Lond., F.R.C.S.Eng.,
SUEGEON TO THE LONDON HOSPITAL, AND LECTUBEE ON 6UEGEEY AT
THE LONDON HOSPITAL MEDICAL COLLEGE.
Received March 9th— Read March 30th, 1886.
Thomas K — , get. 61, soldier, was admitted ou the 13th
January, 1885, into the London Hospital, suffering osten-
sibly from stricture and cystitis. While in the army, from
which he had retired with a pension, he had served in
various parts of the world, including the Crimea. He
had been treated for stricture in Ceylon. He had not
worked for two years. For sixteen years he had suffered
from occasional stoppage of the water, combined with con-
siderable pain in the loins and at the end of the penis.
For six years there had been slight haemorrhages at times.
Latterly he had failed in health and lost flesh, and the
urinary complaint had become more troublesome. On
admission he complained of not being able to hold or pass
3G2 SUPRA-PUBIC CYSTOTOMY.
his water properly. The bladder was very irritable.
Signs of cystitis were present, the urine being ainmoniacal
and containing pus. There was not more albumen than
the pus would account for.
The bladder was washed out, at first with a weak solu-
tion of carbolic acid (1 in 400), and afterwards with iodo-
form in mucilage, and he was ordered some infusion of
buchu and tincture of hyoscyamus three times a day, as
well as two drachms of confection of senna to be taken
every morning. Under this treatment, combined with
rest, he improved. The pain diminished in severity, the
bowels acted better, and he was able at times to pass his
urine more naturally.
On examination per rectum a large round smooth
swelling, very firm and hard, was felt anteriorly in the
situation of the prostate gland, and suggested either an
unusually enlarged prostate or the presence of a prostatic
calculus. Nothing could be detected, either in the pros-
tatic urethra or in the bladder, by means of the sound.
The patient was asked to make water into a porringer,
and the stream was found to drop from the end of the
penis, as it does in cases of enlarged prostate. It was
decided to advise an examination under an anaesthetic,
and a median urethrotomy for the purpose of exploration
and subsequent drainage of the bladder, any further pro-
cedure being dependent on the result of the examination.
The patient gave his consent to any procedure that might
be considered desirable.
On the 24th of February he was taken to the operating
theatre and anaesthetised. Nothing could be detected
with the sound. A grooved staff was then passed into
the bladder, and, the patient having been placed in the
ordinary lithotomy position, an incision about an inch
long was made in the middle of the perineum, and the
membranous urethra was opened in front of tho pros-
tate. Exploration with the finger failed to detect any-
thing abnormal in the prostate, but it was ascertained
that the hard, rounded mass was not connected with the
SCPEA-PUB1C CYSTOTOMY. 363
prostate, and that it was covered by the left wall of the
bladder, which was pushed towards and even beyond the
median line. It was also found that the mass overlapped
the prostate and that the finger placed in the rectum
could be pushed between it and the prostate gland, which
was not at all enlarged. By supra-pubic examination it
was evident that the mass was of considerable size, and
not very moveable, and it became a question whether it
was an encysted calculus or a growth from the pelvic
walls. By further examination with the sound pushed in
up to the hilt, a stone was struck far back in the bladder,
and with a pair of lithotomy forceps I succeeded in
grasping the end of the stone without being able to shift
its position. It now seemed evident that I had to deal
with a calculus or calculi either in a pouch or in a sepa-
rate division of the bladder, and I determined to open the
bladder above the pubes.
Having released the patient from the lithotomy position
I passed a well-curved staff into the bladder, and made
an incision in the middle line above the pubes about three
inches in length, and carefully divided the structures close
to the pubes until I could feel the point of the staff
through the bladder wall. My colleagues, Mr. Reeves
and Mr. E. H. Fenwick, assisted me. The bladder was
reached and opened above the pubes, and the opening
cautiously enlarged, chiefly downwards. A vein in front
of the bladder, which has been named by Mr. Fenwick
the inverted Y vein, was divided and tied. A loop of
silk was passed through the bladder wall on each side, to
enable my dressers to hold aside the edges of the vesical
wound and to steady the bladder. The end of a stone
could now be felt and seen to pass out of an aperture
towards the back of the bladder. It was grasped with
forceps, but very little impression was made on its posi-
tion, even after passing a lithotomy scoop between the
calculus and the wall of the pouch in which it lay.
Lithotrites were useless. Under these circumstances there
were two alternatives, viz. either to abandon the operation
364 SUPRA-PUBIC CYSTOTOMY.
or to break up the calculus. It occurred to me that divi-
sion of the calculus might be effected with a chisel and
mallet, and I decided to make the attempt. As the
calculus below was perfectly smooth and fitted well into
the pelvis, I did not think that any injurious bruising of
the base of the bladder would result from the concussion
of the stone, and I guarded against this by introducing a
lithotomy scoop between the calculus and the wall of the
pouch, and supporting the calculus during the taps of the
mallet by resting the handle of the scoop against the wall
of the abdomen and using it as a lever of the first kind.
The chisel cut the stone readily enough, and severed it
into several large fragments, more or less wedge shaped,
which were extracted piecemeal.
There was one circumstance which I had not antici-
pated, viz. free oozing of blood from the congested
mucous membrane of the bladder and its pouch during
the manipulations for breaking up, and removing the
segments of the calculus. Another event was the escape
from the pouch, as soon as the stone had been shifted, of
a quantity of most fetid urine. After the removal of the
last portion of the calculus the bladder and its pouch wero
carefully washed out with an antiseptic solution, and all
ascertainable fragments were removed. A few chips,
however, escaped detection, doubtless having been enve-
loped in blood-clot. At the suggestion of Mr. Fenwick I
sewed up the wound in the bladder, using fine silk intro-
duced with the glover's suture, and a second suture was
introduced at the lower angle of the vesical wound. The
recti muscles were united with interrupted sutures, ami
lastly the skin and fascia. In order to guard against
urinary infiltration, a drainage-tube was inserted between
the lips of the superficial wound, reaching down to the
anterior surface of the bladder. A silver tube without a
sponge was inserted into the bladder through the perinea]
wound, the supra-pubic wound was dressed with cotton
wool ami gauze, and the patient was sent to bed. The
operation had lasted an hour and a half. The patient was
SUPRA-PUBIC CYSTOTOMY. 365
not so much exhausted by the operation as was expected,
nor did his temperature show any marked rise during the
first twenty-four hours. He complained of wind and
some pain. A hypodermic injection of morphia was
given. The urine passed freely through the tube. He
was not sick, and was able to take milk and brandy
mixture.
26th. — Patient passed a fairly good night, sleeping for
some hours. Very little pain ; sensation of fulness in the
bladder ; forty-five ounces of urine were collected. Pulse
100, temp. 99°. Bladder washed out with solution of
thymol.
On February 28th I found an extending red blush
at the edges of the wound, and the drainage-tube dis-
placed. Believing that this must be caused by some
pent-up discharge, probably mixed with urine, I opened
up the wound, and having mopped out some urinous
fluid mixed with pus, powdered the surface of the
cavity with iodoform, and covered it with cotton wool.
There had been a free discharge of urine by the perineal
wound through the drainage-tube amounting to forty-two
ounces of collected urine during the twenty-four hours.
The temperature was 99°, and pulse 96. Milk, beef-tea,
and brandy and egg mixture were taken freely. The sur-
face of the wound cavity above the pubes was sloughy,
and underwent a gradual process of removal of slough and
granulation. It was cleansed daily, irrigated, and pow-
dered with iodoform.
The notes on the 3rd of March, state : " Very restless
night, acute pain at times, smell of upper wound very
fetid. Thick grey slough on surface, and some sur-
rounding inflammation. Patient wanders slightly and
picks at the bedclothes. No vomiting and no sign of
peritonitis." During the next few days he improved
materially, and the wound began to granulate healthily
after the separation of the slough.
On the 9th the silver lithotomy tube was removed from
the perineal wound, and a large india-rubber tube was
366 SUPEA-PDBIC CYSTOTOMY.
substituted. Most of the urine came away below, but
occasionally some would well up behind the pubes.
Patient was no longer delirious. His temperature was
normal and his pulse 80. One of the ligatures came
away in the silver tube with some thick matter and slough.
16th. — Patient slept seven and a half hours last night ;
thirty ounces of urine collected in the night, sixty ounces
altogether in the twenty- four hours. A long slough in the
tube.
19th. — Very restless. Has had very little sleep. Tube
got blocked up with slough or membrane, and the urine
ran over the pubes. The tube was taken out and
cleansed. A soft flexible catheter was introduced above
the pubes and withdrew a large quantity of foul urine.
Great pain in right lumbar I'egion. Temperature 101 "5°.
I had to make an opening in the scrotum for drainage as
a pouch had formed there containing urine.
20th. — Much better. Temperature normal. Pain
abated. Tongue clean. Pulse 80. Being very anxious
to be allowed to be out of bed, and confident that he
would benefit by the change, he was placed in a chair
and wheeled about for half an hour or an hour.
April 1st. — Since the last note he had been going on
well, passing a fair amount of water by the tube. The
anterior wound was gradually closing, and was syringed
out daily with thymol solution. The bladder was also
washed out, the solution running freely through the peri-
neal tube. He slept fairly well. His appetito had
improved and he took meat and potatoes.
On the 17th the house surgeon, who with Mr. Llaynes,
the dresser, had been very attentive to the patient,
finding that the abdominal wound had closed over the
aperture leading to the bladder, withdrew the perinea]
tube. I had intended retaining the tube till the wound
had soundly healed, but when I saw the patient in the
afternoon the perineal opening had contracted so much
that I could not have reintroduced the tube without
placing the patient under an ana'sthct ie, and, as I thought
SUPEA-PUBIC CYSTOTOMY. 367
that this might possibly do him more harm than the tube
would do good, I reluctantly abandoned the tube alto-
gether. The patient was now in very fair condition, able
to walk and pass his water with a considerable jet, and
he was extremely proud of his capabilities in this matter.
Unfortunately a little grit, part of the remaining debris
of the calculus became impacted in the urethra, and the
obstruction caused the passage from the bladder to the
wound above the pubes to reopen so as to again admit a
small catheter. If the tube had been retained, according
to my instructions, this would not have occurred, and the
opening would have soundly closed. At this time the
patient had practically recovered from the operation. He
sat up daily, took his food well, his urine was clear, and
on warm days he went into the garden in a chair.
Early in May the supra-pubic wound had nearly healed,
leaving only a small fistula. The patient was kept in the
hospital because I was anxious to close the opening, and
for this purpose his water was drawn off with a flexible
catheter two or three times a day.
About the middle of May he fell down in the ward,
and, as he felt fatigued with being up so long, and was
not gaining strength, I advised him to remain in bed
during the greater part of the day, draw off his water,
and see if the fistula would close.
At the end of May a fresh attack of cystitis developed.
His urine became strongly alkaline, turbid, and ammo-
niacal, and contained pus. There was a considerable
discharge of pus from the opening above the pubes, and
an abscess formed and opened over the tendon of the
adductor longus in the right thigh. His appetite failed.
Diarrhoea set in. Exploration of the region of the wound
disclosed some bare bone near the symphysis. He
became comatose, and died on June 4th, more than three
months from the date of operation. With considerable
difficulty I obtained permission to inspect the abdomen
only, and this limited post-mortem wras performed on the
5th of June.
368 SUPRA-PUBIC CYSTOTOMY.
Post-mortem. — The bladder was fairly capacious, and
its walls were thickened from muscular hypertrophy.
Coming off from it behind and above the trigone by a
rounded opening was the large pouch in which the stone
had been contained. This ran first outwards and then
forwards, and when distended reached beyond the margin
of the prostate gland. Its walls were thick and comprised
the mucous, muscular, and fibrous coats of the bladder.
The left ureter was closely connected with the pouch,
winding round it and externally appearing to terminate
in it ; but a bent probe passed from above downwards
through the left ureter, was seen to emerge by the side of
the trigone of the bladder proper. From the lateral
position of the pouch parallel to the bladder, from the left
wall of the bladder running directly backwards from the
middle of the prostate, from the collection of ammoniacal
urine in the pouch found at the operation, and from an
evident filling of the pouch afterwards, I had thought it
not improbable that the pouch was an integral portion of
the bladder. The mucous membrane of the bladder and
pouch was inflamed, and the ridges were coated with
muco-pus mixed with phosphates. The edges of the
wound in the bladder were puckered, coated with phos-
phatic rnuco-pus, and firmly adherent to the posterior
surface of the pubes. An opening which had enlarged
slightly by ulceration during the last few days of life led
to the surface, and also by means of a branching canal to
the perineum and to the opening in the right thigh. The
left pubic bone was bare of periosteum and superficially
necrosed. There was an abscess deep in the perineum
on the right side. Most of these changes occurred at the
latter end of May and the beginning of June. The kidneys
were of unequal size. The right kidney was larger than the
left and larger than a normal kidney. It appeared healthy,
but had some cysts on its surface. On cutting into the left
kidney some thin purulent matter escaped from a small
cavity in the cortex, and there was evidence of interstitial
nephritis running on to suppurative nephritis. The cap-
SUPRA-PUBIC CYSTOTOMY.
369
sule did not strip off readily, and the organ was puckered.
The pelvis of the left kidney was slightly enlarged as well
as the upper part of the left ureter. The right ureter
Calculus extracted ; natural size.
was normal. The calculus when removed from the bladder
was weighed by Mr. Fenwick. Excluding a considerable
quantity of lost debris its exact weight in the moist state
was 23 oz. 2 drachms and 17| grains avoirdupois. The
vol. lxix. 24
370 SUPEA-PDBIC CYSTOTOMY.
nucleus weighed 65 grains. The fragments being stained
of a dark colour the stone appeared to be composed of
lithic acid and lithates, but in reality it is composed of
fusible phosphates. After the operation the large segments
were most skilfully put together by Mr. Taylor, the
museum assistant at the Medical College. The stone now
weighs, without nucleus and lost debris, 22| oz. avoirdupois.
A section has been made and shows a large cavity in the
centre of the calculus due to the lost debris. The correct
weight of the calculus must therefore be regarded as
exceeding 23 oz., or 1 lb. 7 oz. avoirdupois. The dimen-
sions are as nearly as possible 4J inches long, 3£ wide,
and 3 inches in thickness ; its larger circumference 13
inches and its lesser 10 inches. The size of the pouch
may be inferred from the size of the stone, which exactly
filled it, and the size of the orifice of the pouch from the
size of the base of the projection from the stone. The
orifice through which the stone had to be extracted was
about the size of half a crown.
Remarks. — With regard to the size of the calculus there
are a few instances of larger vesical calculi on record,
some removed from the bladder after death and some
during life. To the post-mortem category belong :
1. The calculus seen by Morand weighing 6 lbs.
2. The calculus seen by Deschamps weighing 51 oz.
3. Tho well-known phosphatic calculus 44 oz. in weight,
and measuring in circumference 10 inches by 14, which
Cline attempted to remove from Sir Walter Ogilvie, who
died on the tenth day.1
4. The lithic acid calculus, now in the pathological
museum of the University of Cambridge, measuring 15
by 13^ inches in circumference, and weighing 32 oz. 7
drachms, originally 33 oz. 3 drachms and 30 grains troy.
The stone was taken from the wife of Thomas K — , a lock-
smith in Bury, after her death, by Mr. Gutteridge, a
1 'Catalogs of Calculi (Part I, II,„ p. 116) of Museum of Royal College of
Surgcous of England.'
SUPRA-PUBIC CYSTOTOMY. 371
surgeon of Norwich, and was presented to Trinity College,
Cambridge, by Mr. Samuel Battley, who was M.P. for Bury
and had possession of the stone after the woman's death.1
5. The uric acid calculus, weighing 25 oz., and measur-
ing 4| inches in its long axis by 3^ in its short, and in
circumference 12^ by 10| inches, taken from the body of
Sir Thomas Adams, who died on February 24th, 1667, at
the age of eighty-one. The stone remained in possession
of the family for years and was ultimately presented to the
museum of St. Thomas's Hospital.2
6. A case has been recorded by Mr. Paget, of Leicester,
in which a stone weighing 27 oz. was removed after death
from the bladder of a woman forty-seven years of age. It
was accompanied by innumerable small calculi some as
large as peas and others smaller. The large stone was of
a light ash colour, rough on its surface, and of a flattened
oval shape. It had occasioned prolapse of the bladder,
the viscus covered by the vaginal mucous membrane pro-
truding between the labia. The external surface of the
calculus was marked by a sulcus occasioned by the pres-
sure of the distended labia pudendi.3
To the category of large stones removed during life
belong :
7. Uytterhoeven's calculus, the cast of which measures
16^ by 12^ inches in circumference. The patient lived
eight days.4
8. A calculus reported on the authority of Dr. W. B.
Hunter, of Londonderry, as having been removed by
Surgeon Joseph Hunter, I.M.S. The patient was a native
in the Madras Presidency ; the supra-pubic operation was
performed, the stone weighed 25 oz., and the patient lived
three days.5
1 Dr. G. M. Humphry, ' Lancet,' July 25, 1885.
* Pathological Society's ' Transactions,' vol. xxi, p. 267. A woodcut show-
ing the size of the stone is given.
3 ' Lond. Med. and Phys. Journ.,' vi, p. 391.
4 Erichsen, ' Surgery,' vol. ii, p. 986.
* ' Lancet,' Jan. 16, 1886.
372 SUPRA-PUBIC CYSTOTOMY.
A calculus has lately been reported to the Northum-
berland and Durham Medical Society as having been
removed by Dr. Morrison from a sailor, set. 52, and weigh-
ing lib. 6| oz. (whether troy or avoirdupois is not stated).
In the report this is euphemistically styled " the largest
stone ever removed during life." It is, however, not
quite equal in weight to my own. The composition and
dimensions of the calculus are not given in the account
which I have seen. The patient lived twelve days and
then died suddenly. No post-mortem examination was
permitted.1
Among calculi of smaller size the most noteworthy was
one which Sir H. Thompson removed by supra-pubic cysto-
tomy on the 29th April, 1885, from a man set. 62. It
was a uric acid calculus weighing 14 oz. avoirdupois, mea-
suring 4^ inches in length by 3 inches in breath and cir-
cumferentially almost 12 inches by 8 inches. The patient
made an excellent recovery.
1 . It will be observed that the case stands by itself in this
particular that the calculus was contained in a pouch from
which only a small projecting process protruded. This
rendered the operation far more tedious and difficult than
any of the other recorded operations for large calculi, as
the calculus had to be broken up through a comparatively
small aperture and removed piecemeal. Great care had bo
be exercised not to damage the bladder by contusion or
perforation, and there was free oozing of blood from the
congested mucous membrane whenever the calculus was
disturbed. Extraction of the segments was also not a very
easy matter.
2. It may fairly be asked would it have been better to
leave the calculus alone when its exact position was made
out, or was it better to attempt extraction and carry it
through ? Against leaving it the following considerations
1 since this paper was read Mr. Thomas Smith has presented t o the museum
of the Royal College of Burgeons a east of a ealculus, wei^hinij- — i i <>/.,
which he successfully removed by the supra-pubic operation from a male
patient.
SUPRA-PUBIC CYSTOTOMY. 373
may be adduced. The patient's health was failing from
the presence of the calculus and its projection into the
bladder proper. He was suffering pain from the calculus
whenever he took exercise. He had chronic cystitis with
occasional hemorrhages. The urine had become decom-
posed and ammoniacal, and ammoniacal urine pent up in the
pouch was a constant source of contamination to the freshly
secreted urine. He could not pass his water properly, and
the left kidney was being damaged by interstitial nephritis.
The disadvantages of removing it were that it subjected the
patient to a long and difficult operation not free from
danger. The difficulties were surmounted satisfactorily,
but the main disadvantage of removing the calculus con-
sisted in the fact that the pouch in which the stone was
lodged had to be left behind, and would necessarily form a
receptacle for urine, and would never, perhaps, be properly
emptied. At the time, however, it was not clear whether
the compartment containing the stone was a hernial pouch,
or whether it was an integral part of the bladder and
received the left ureter. Undoubtedly if a patient enjoy-
ing good health was known to have a large encysted
calculus which gave rise to comparatively little inconveni-
ence or urinary disturbance I should not be inclined to
advise interference, but when it has begun to emerge from
the pouch and has become the occasion of constant pain,
cystitis, and decomposition of urine the question of inter-
ference may fairly be entertained. If the pouch could be
removed a great advantage would be gained. It did not
occur to me to ascertain if this would have been feasible
in my own case. If attempted it would, I think, have to
be done from inside the bladder by inversion of the pouch
and either ligature or excision and suture of the wound.
3. With regard to the details of the operation a few
remarks are necessary.
(a) The valuable addition to the supra-pubic operation,
for which surgeons are indebted to Garson and Petersen,
could scarcely have been applied in the present case,
owing to the perineal opening and the size and situation of
374 SUPRA-PDBIC CYSTOTOMY.
the stone. By keeping close to the pubes I avoided the
risk of wounding the peritoneum.
(b) Seeing how readily a calculus may be broken up by
means of a chisel and mallet, I think that the same method
might be adopted wherever a calculus has attained so
large a size that it cannot be extracted entire without risk
of tearing the peritoneum, or unduly bruising or lacer-
ating the bladder and enlarging the vesical wound. A
very large calculus would almost certainly prove to be
phosphatic. It is not difficult to guard against injuring the
bladder walls in the process, and the chief objection lies in
the risk of leaving some small chips behind to cause irritation
or act as the nuclei of future stones. This risk is greater
where there is a pouch than where the calculus is free in
the bladder itself.
(c) Sewing up the bladder wound was done rather
tentatively than from absolute conviction of its certain
utility. To guard against danger from escape of urine,
if the sutures should prove inefficient, a drainage-tube
was placed in contact with the sutured opening. Doubt-
less the necessary contusion of the edges of the wound
during the long operation prevented immediate union of
any considerable part of the wound. Whether any part
of the wound united in consequence of the sutures I
cannot say. The sutures themselves separated and wore
discharged, one through the silver tube, and the other
through the external wound, after being for some time
adherent. I am inclined to think that the stitches did no
good, but rather the reverse, as their retraction determined
more sloughing of the edges of the vesical wound, and in
another case I should not suture the vesical wound unless
I had a clean cut to deal with which had not been
subjected to any bruising. I think also that the stitches
determined the adhesion of the opening to the posterior
surface of the pubes.
There is another method of dealing with the wound in
the bladder which might in some cases be advisable, and
that is stitching its edges to the edges of the superficial
SUPRA-PUBIC CYSTOTOMY. 375
wound. I am not sure that this might not have been pre-
ferable to the course which I actually adopted. It would
effectually guard against extravasation of urine and would
permit the bladder to be thoroughly washed out.
(d) I am convinced that the perineal tube was of
primary importance to the patient in this case, and I
regret that I did not reinsert it after it had been removed
prematurely by my house surgeon. It gave exit to the
thick pus and a few pieces of slough which came away
from the bladder after the operation. It drew off the
major portion of the daily urine, only a little occasionally
running off by the upper wound. It allowed the bladder
to be washed out, and it prevented accumulation of the
urine in the pouch. Hitherto surgeons have regarded
infiltration of urine as one of the two chief risks of the
supra-pubic operation, and deaths have not unfrequently
resulted from this cause. Sir Henry Thompson, who has
had marked success with this operation, thinks that there
is very little risk of infiltration in ordinary cases, unless
there be interference with the cellular connections low
down between the anterior surface of the bladder and the
pubic arch. In such cases, and in exceptional cases like
my own, I believe that the insertion of a large soft tube
in the bladder through a median perineal opening will
prove more efficient than keeping a catheter in the bladder
or inserting a drainage-tube above the pubes, and not
only add nothing to the risk of the operation but will
contribute materially to ensure the safety of the patient.
(For report of the discussion on this papei*, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 94.)
A CASE
SUPRA-PUBIC LITHOTOMY,
REMARKS ON THE OPERATION.
BY
W. H. A. JACOBSON, F.R.C.S.,
ASSISTANT STTBGEON GUY'S HOSPITAL; STTBGEON BOYAL HOSPITAL FOB
WOMEN AND CHILDBEN.
Received March 23rd— Read March 30th, 1886.
A. F — , set. 19, an Essex labourer, was sent to the
writer at Guy's by Dr. Day, of Harlow, January 21st,
1886, for stone in the bladder. Irritability of the
bladder, day and night alike, had been present all his
life ; symptoms of stone had been well marked for over
five years, and for the last twelve months cystitis had
been present. A stone was readily felt at the neck of the
bladder ; so closely did it fit here, and so readily did it
return after being pushed away, that considerable eleva-
tion of the pelvis was required before a lithotrite could be
made use of. Both this and the sound gave evidence of
more than one stone.
It was decided to perform lithotomy rather than litho-
trity on account of the multiple calculi, the hardness of
378 SUPRA-PUBIC LITHOTOMY.
one calculus, arid its constant position at the neck of the
bladder. As to the size of the stone, this, as appeared
later, had been twice correctly gauged as a very moderate
one, one and a quarter inches in its long diameter. With
regard to this the writer was inclined to think that this was
the short diameter owing to the rectal examination giving
the impression of a larger stone. Both in this case and in
one in which Prof. Humphry performed supra-pubic litho-
tomy for a stone which actually weighed about 1£ oz.,
the coats of the bladder, no doubt thickened, somewhat
closely embraced the stone, and thus gave an impression
that the latter was larger than it really was.
Lithotomy being decided on, the supra-pubic opera-
tion was preferred on account of the age of the patient,
the fact that the symptoms of calculus had certainly lasted
over five years, and perhaps throughout life, that thus it
was not improbable that the structure of the kidneys was
impaired, and if so, it seemed reasonable to think that an
incision made into the anterior surface of a bladder dis-
tended with antiseptic fluid and brought safely into reach
would be more successful, in the long run, than one into
the neck of the bladder, with its complicated surroundings
and far more abundant vascular and nervous supply.
January 30th. — The operation was performed on the
lines laid down by Sir H. Thompson in his recently pub-
lished book. The patient being under ether, one of Sir
H. Thompson's bags was introduced well coated with
eucalyptus and vaseline, pushed quite above the sphincters
and then distended with 10 oz. of warm water ; 8 oz.
of warm carbolic acid, 1 in 100, were then intro-
duced into the bladder, the catheter withdrawn, and a
•Jaques' india-rubber catheter tied round the penis. The
bladder could now bo both Been and felt distended for
two thirds of the distance between the umbilicus and
pubes. An incision, three inches long, was then made in tho
middle line down to the symphysis. After division of the
I in i a alba and fascia transversal is, an abundant layer of
fat with veins bulged up into the lower angle of the
SUPRA-PUBIC LITHOTOMY. 379
wound ; this being carefully torn through with a director,
the anterior surface of the bladder, pink-red and showing
clearly detrusor fibres, came into view. The peritoneum
was never seen, and could only be very indistinctly felt.
A tenaculum being passed into the bladder, and a scalpel
introduced at this spot, the left index was inserted and at
once felt a stone ; the opening being dilated with the other
index finger the stone was removed between them. In
this dilatation the bladder was felt to tear readily, but
without haemorrhage. Careful and repeated search, includ-
ing the parts of the bladder behind the pubes and behind
the prostate, failed to detect the other calculi whose
existence was suspected. While it appeared at the time
that the bladder cavity was immediately under reach, and
that every part had been explored, the writer thinks that
his failure to detect the two other calculi, which were,
after all, present, arose from the bladder being full of the
antiseptic fluid. The writer being desirous that, as the
bladder emptied itself over the recently cut tissues,
the first flow should be of antiseptic fluid, he allowed too
little fluid to escape during the exploration. The weight
of the two smaller calculi, when in fluid, must have been
very slight, and stones so small and so light may have
been easily displaced in currents set up in so much fluid,
and thus rendered very difficult to find and seize. The
only other explanation which occurs to the writer is that
10 oz. of fluid in the rectal bag may not have been suffi-
cient to raise the bladder evenly and completely, and thus
some depression or pouch may have been temporarily
formed, and not reached by the finger.
No attempt was made to unite the wound in the bladder
owing to the previous cystitis and the somewhat prolonged
examination ; two deep stitches (carbolised silk) were
placed in the linea alba and two more superficially.
There was never the slightest sign of extravasation or
cellulitis, but the healing was retarded by an attack of
pneumonia following the operation, and due, in part, to
380 SUPRA-PUBIC LITHOTOMY.
the ether, and, in part, to the bitter weather of this
winter.
On the fourth day the wound and urine were amnio-
niacal, and this lasted for thirty-six hours, but yielded
at once to washing out the bladder with Thompson's
fluid.
Two weeks after the operation and when the wound was
rapidly granulating up the patient felt as if he was passing
water per urethram. It was then found that considerable
haemorrhage had taken place both from urethra and wound.
It was venous in character and was readily stopped by the
introduction of a small bit of sponge, well powdered with
iodoform and steel sulphate, pushed firmly down into the
wound. A few hours later, on the removal of the sponge,
a small smooth calculus was found in the lower angle of
the wound.
Two days later a second but much smaller haemorrhage
took place — yielding at once to ice — and a second small
calculus came away.
Three weeks after the operation 5 or 6 oz. of urine
were passed naturally, this quantity gradually increasing
till the fifth week, when all the urine was passed the
right way.
Remarks. — While the above case cannot be considered
such a good test of the value of the operation as one in
which a larger stone and an older patient are dealt with.
it yet presents some features of interest. The immunity
from any symptom of cellulitis or extravasation from first
to last was absolute ; in fact, local inflammatory symptoms
were never present ; there was a little tenderness the first
night around the wound, but this was all.
The ammoniacal condition of the wound on the fourth
day was due, in part, to the previous cystitis, and, in part,
to the fact that just at this time the patient was Buffering
from pneumonia; he was dull and apathetic, and when
turned on to his Bide Bank as far as possible on to his
back again. The way in which this ammoniacal con-
dition yielded at once as soon as the fluid which bears
SUPRA-PUBIC LITHOTOMY. 381
Sir H. Thompson's name was used, saturated boracic acid
solution having been used for thirty-six hours without
good result, was very noteworthy.
The haemorrhage which occurred can in no way be
put down to the operation. It was due entirely to the
writer having failed to find the two smaller calculi. As
these made their way out through tender granulations,
still at that time bathed in urine, they easily caused con-
siderable bleeding.
A few of the most important points connected with the
operation will now be considered.
The distension of the rectum. — Care should be taken that
the bag used for this purpose be of sufficient strength.
M. Guyon1 mentions one case in which the bag being of
thin india rubber did not support the bladder sufficiently
firmly, and in which the organ, yielding on this account
to the pressure of the fingers, was difficult to open. In
other words a thin india-rubber bag will raise the bladder
but not support it steadily when it is cut down upon.
The bag, well coated with eucalyptus and vaseline,
and introduced in a folded state above the sphincters, is
slowly distended by means of its tube and a syringe with
about 1 2 oz. of tepid water. Sir H. Thompson gives the
amount as "12 or 14 oz/'2 The writer would advise
operators to be content with the smaller amount in most
cases, unless the rectum be extremely capacious or it be
desirable, in case of a large stone, to give extra eleva-
tion and steadiness to the bladder. Even after disten-
sion of the bag with 12 oz. thrown in steadily and gently,
a little blood-stained mucus followed its withdrawal at
the close of the operation. No subsequent trouble fol-
lowed, but it is evident that in injection of larger
amounts some risk is run of damaging the rectal mucous
membrane.
Injection of the bladder. — By means of a full-sized, soft
catheter, an india-rubber bottle or a good-sized syringe
1 'Annales des Maladies des Organes Genito-urinaires,' Tom. i
2 M. Guyon, loc supr. cit., gives 450 to 500 cc., or 15J oz. to 17J oz.
382 SUPRA-PDBIC LITHOTOMY.
8 or 10 oz.1 of some antiseptic fluid are gently thrown
in. By this double distension of rectum and bladder
the latter will probably be both seen and felt reaching two
thirds of the way between the umbilicus and pubes. The
catheter should now be withdrawn from the bladder and
a Jaques' india-rubber catheter tied round the penis. If
the bladder does not seem to be sufficiently prominent a
little more fluid may be thrown into the rectal bag and
into the bladder.
The writer would conclude with the following proposi-
tions :
1. That supra-pubic lithotomy, as recently modified,
has a future of revived usefulness before it, and that
while, as an operation, it can never contrast with the
rapid brilliancy of the lateral operation, it will be found
of great value by those who only have to deal with stone
occasionally, and who find themselves face to face with
calculi of considerable size in adults.
2. That, to give other and more individual instances,
the operation will be found useful in (a) many cases
of hard stones of one and a half inches in diameter j
(b) in multiple hard stones ; (c) in cases of calculus not
phosphatic, occurring with enlarged prostate ; (J) in some
cases of foreign body in the female bladder with abun-
dant calculous deposit (Sir H. Thompson).2
In the rarer cases of (e) a state of urethra which will
not admit of the use of a lithotrite ; (/) in a very deep
perineum ; (y) in a child with deformed pelvic outlet ; (h)
in a patient with ankylosed hip-joint not admitting of his
boing placed in the usual lateral lithotomy position (Sir
H. Thompson).3
3. That at present, till a larger number of cases of the
improved operation have been collected, it will be wiser
not to attempt to close the bladder with sutures.
1 M. Guyon, loc. supr. cit. gives 2o0 to 800 CC, or 8| oz. to 10J oz. These
amounts given here and in a preceding note for bladder and rectum correspond
to those of Dr. Fehleisen (Berlin), 'Arch, fur kiln. Chir.,' Bd. xxxii, Hft. iii.
' Loc. Bupr. cit., p, 12. ' Loc. supr. cit.
SUPRA-PUBIC LITHOTOMY. 383
4. That in reviving an abandoned operation these two
questions call for an answer:
a. Do we stand in a better position towards the opera-
tion than did our predecessors ?
This question can only be answered in the affirmative
after the work done by Dr. Garson, Prof. Petersen, and
Sir H. Thompson.
b. On what grounds was the operation abandoned ?
The chief of these appear to have been : (1) The absence
of any means of certainly avoiding the peritoneum. (2)
The difficulty of sufficiently and painlessly distending the
bladder in pre-aneesthetic days. (3) The absence of anti-
septic fluids. (4) The fact that the operation was usually
reserved for very large stones, and that it was often
performed for such stones after lateral lithotomy had
been recently attempted either on the same or the pre-
ceding day.
(For report of the discussion on this paper, see ' Proceedings
of the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 94.)
THE CHEMICAL PATHOLOGY
RESPIRATION IN CHOLERA.
BY
WILLIAM SEDGWICK, M.R.C.S.
Received December 8th, 1885— Read April 13th, 1886.
It lias been often asserted, and even still more often
assumed, that cyanosis is not only distinctive of choleraic
collapse, but that it is due to an excess of carbonic acid
in the blood ; and many useless, if not injurious, attempts
have in consequence been made to increase the amount of
oxygen in the blood of the pulmonary veins by the inhala-
tion of hyperoxygenated air during the stage of collapse.
The exceptional importance which has been ascribed to
cyanosis in relation to cholera has not only led to much
error both as regards diagnosis and treatment, but also to
a widespread and an almost unquestioning belief that
the disease is essentially associated with defective oxyge-
nation of the blood. As regards diagnosis it will be
sufficient for me to refer to one of my papers " On some
Physiological Errors connected with Cholera,"1 in which
i ' Lancet,' Nov. 11th, 1871, pp. 670, 671.
VOL. LXIX. 25
386 THE CHEMICAL PATHOLOGY OF
it has been shown that cyanosis is liable to occur during
the collapse resulting from rapidly fatal poisoning by
croton oil, by arsenic, by corrosive sublimate, and other
prepai*ations of mercury ; by the mineral acids ; from per-
foration of the stomach ; and from obstruction, strangula-
tion, rupture, and perforation of the small intestines. In
such cases, which often closely simulate cholei'a, it lias
been observed that the skin is not unfrequently cyanosed,
and is sometimes " even more blue than is usual in cases
of true cholera." This occurrence of cyanosis in connec-
tion with gastro-intestinal affections had been fully
recognised early in the present century by Broussais ;
and later and special writers on the subject have appro-
priately grouped some of these cases together under the
heading of " gastro-intestinal cyanosis."1
In the above-quoted paper, " On some Physiological
Errors connected with Cholera," attention was particularly
directed to the fact that " there is a local disappearance
of cyanosis during choleraic collapse, when galvanism is
applied to a limb, which is independent of any effect pro-
duced on the pulmonary circulation." This influence of
galvanism on the cyanosis of cholera is in no respect
exceptional, for it will be found on referring to the join!
report of Drs. Russell and Barry, dated " St. Petersburg,
|-| duly, 1831/'' that, on the first introduction of the
disease into Europe, it had been observed that " frictions
remove the blue colour for a time from the part rubbed."
The effect produced on these occasions by galvanism and
by frictions evidently canuot be ascribed to any conse-
quent increase of oxygen in the blood, for the only internal
respiratory change which could result from thus urging on
the blood through the tissues, would be a local increase
of oxidation ; as the oxygen already present in the blood
would by such means be more quickly withdrawn from it
1 Cited by I'. Gh Boisseau, " Bf6moire Bur la Cyanose Choleriqae," ' Journal
I'niv. c( Hebdom. de M&L el de < 'liir. Prat.,' L8S2, tome ix, pp. 277 898.
Ibo P. .1. V. Broussais, ' Le Cbollra-Morbus Bpide'mique, observe* et
traite* Belon la Mlthode Pbysiologique,' L882, j>i>. 7">, 7G.
RESPIEAT10N IN CHOLERA. 387
and used in that process of tissue change which is repre-
sented by an increased formation of carbonic acid. Before
concluding these preliminary remarks it will be useful to
direct attention to the fact, that even the normal change
of colour from red to dark, which is chiefly effected in the
capillary circulation, cannot be physiologically assigned to
the larger quantity of carbonic acid which venous blood
contains ; since it has been shown by Pfliiger, that " if
equal quantities of oxygen be added to two portions of
blood, and if carbonic acid be added to one of them,
the colour is not changed/'1 Consequently, as the
cyanosis of cholera fails to indicate the extent to which
the aeration of the blood either has or has not been per-
formed, it becomes necessary to analyse the air expired
during life, and to examine the lungs after death in order
to prove whether there is or is not any connection between
this so-called asphyxia and choleraic collapse.
Those who are familiar with the literature of cholera
know that it is very rich in evidence which proves that
during the stage of collapse the respiration is usually
much diminished, and that after death, in the case of
those who die before reaction has begun, the lungs are
always more or less collapsed. But when, in addition to
such evidence, attention is directed to the numerous and
exact analyses which have been made of the expired air,
it will be found that the net result of the pulmonary
interchange of gases in this disease has always been a
relatively large gain in the amount of oxygen received
by the blood in exchange for carbonic acid, as compared
with that which is relatively gained by such interchange
of gases during health. When referring to the works of
those observers who have specially devoted their attention
and skill to this subject, a decided preference should be
given to M. Doyere's ' Memoire sur la Respiration et la
Chaleur Humaine dans le Cholera ' (1863), as it is founded
1 Cited by Landois, 'A Text-Hook of Human Physiology,' translated from
the fourth German edition. With additions by William Stirling, M.D., Sc.D.,
vol. i, 1885, p. 60.
388 THE CHEMICAL PATnOLOGY OP
on a very large number (nearly 300) 1 of careful observa-
tions made in 1849 : as the results then obtained were
confirmed by a second series of observations made in
1854, under the direction of a committee appointed for
that purpose by the French Academy of Sciences, but of
which the literary results were unfortunately lost ; and,
lastly, as the great value of the work was authoritatively
recognised in 1858 by a subsequent committee, composed
of MM. Serres, Velpeau, CI. Bernard, Jules Cloquet,
Jobert de Lamballe, and Andral, and whose report in its
favour led to a prize of 5000 francs from the Breant
foundation being awarded to M. Doyere early in the fol-
lowing year (March 14th, 1859). Previous to the dates
of these researches it had been analytically proved in 1819
by Dr. John Davy and Mr. Finlayson,2 during an epidemic
of cholera in Ceylon, that the air expired during choleraic
collapse is " very deficient in carbonic acid ; " the amount
of carbonic acid, as compared at the time with that expired
1 ' Coraptcs-rendus Hebd. des Seances de l'Acad. des Sciences,' October
22nd, 1849, p. 454.
3 The importance of investigating the composition of the air expired by
cholera patients was first recognised by Dr. John Davy at the Later end of
April. L819; and it was soon after this date that be bad the opportunity of
personally communicating bis ideas on the subject to bis "very intelligent
and worthy friend, Mr. Finlayson," whose early death was due to phthisis,
which was contracted duringthe following year in Siam. The first analysis of
the air expired by a cholera patient was made jointly by these observers, and
Dr. Davy states thai " ai my desire, Mr. Finlayson was so good as to continue
the inquiry at a time I bad no opportunity of continuing it myself." The
results of these analyses were communicated to Dr. Davy in a letter dated
•' bandy, 4th June (1819)." ' Report on Cholera, as it occurred in Ceylon in
1819' (published from a copy in the author's possession), by John Davy,
M.D., F.R.S., 4c. j 'Medical Times,' Aug. 31st, I860, pp. 224 22<; ; and
also in his work ' On Borne of the mere important Diseases of the Army, with
contributions to Pathology,' 1862, pp. 113 — 122. Although this report
rem lined unpublished tor considerably more than thirty yean after its trans-
mission from Ceylon to the Medical Hoard of the Army, yet it was not
immediately shelved ; tor Sir Gilbert Diane had the opportunity of reading it
in manuscript soon after its arrival in this country, and he gave a summary
of its contents at a meeting of the Medical and Chirurgical Society on
June 6th, i^<» (' Med.-Chir. Trans..' vol. si, 1820, pp. 157—164).
RESPIRATION IN CHOLERA. 389
by a healthy person of the same country and race, having
been found in the first case to be only one fifth; in the second,
case one third ; and in the several other cases examined,
to be much below the normal standard. Whilst M. Rayer,1
physician to " la Charite " Hospital, Paris, analytically
recognised, in 1832, that there is a diminished, quantity of
oxygen absorbed. But it was reserved, for M. Doyere to
prove that in addition to these important but detached
facts, which simply indicate a great reduction in the inter-
change of gases in the lungs, that there is a relatively
large amount of oxygen absorbed, which, as regards the
respiratory quotient of health, is constantly and sometimes
very greatly in excess of that which can be accounted for
by the carbonic acid eliminated.2 Since the date of M.
Doyere's researches there have been other, and some
improved, methods for ascertaining the relative amounts
of oxygen absorbed and of carbonic acid eliminated, both
as regards health and disease ; in consequence of which
the respiratory quotient of health, according to the best
PO / 4*38 \
authorities of the present day, "tt^I = a.-q.-) ) =0'900,3
expresses a larger proportion of oxygen than that given,
as the mean of twenty-one analyses, by M. Doyere in
1849, 7Tl2( = 4^-)=0'977-4 But tnis does not affect tne
1 " Examen comparatif de l'air expire par des Hommes Sains et des
Choleriques, sous le rapport de l'oxygeue absorbe," ' Gazette Medicale de
Paris/ 26 Mai, 1832, pp. 277, 278.
2 Notwithstanding this relatively large excess of oxygen aborbed, it was
assumed by M. Doyere, in his introductory remarks, that asphyxia is "the
constant phenomenon of cholera." The chief evidence, according to M.
Doyere, in favour of asphyxia, is "the diminution of the proportion of
carbonic acid produced and of oxygen absorbed ; " and he proceeds to add, in
accordance with the prevailing opinion of his day, that " the symptom most
intimately associated with choleraic asphyxia is, 1 have hardly need to say,
cyanosis."
3 Dr. P. Landois, op. cit., p. 225.
4 M. Doyere's observations in 1849, on the average amount of oxygen
absorbed during healthy respiration, 447 per cent., agree very closely with
those of M. Rayer in 1832, who found the mean of thirteen analyses to be
445 per cent.
390 THE CHEMICAL PATHOLOGY OF
general results of his researches as regards the relatively
larger amount of oxygen absorbed in proportion to the
carbonic acid eliminated during cholera, as compared with
the relation between these two gases observed by him in
the air expired during health. In the case (No. 6), for
example, of a lad, set. 1G, who was admitted into the
Hotel Dieu, Paris, at 4 p.m., on April 28th, 1849, in a
state of " extreme algidity," with strongly marked cya-
nosis and suppression of urine since the previous evening,
the analysis of the air expired thirty minutes after admis-
sion showed that there was a reduction in the interchange
of gases in the lungs to considerably less than half of the
normal amount ; and, at the same time, a relatively large
excess of oxygen absorbed in proportion to the amount
of carbonic acid eliminated. It was moreover observed
during the progress of this case, in which, between April
28th and May 7th, fourteen observations were made on
the composition of the expired air, that there was a rela-
tive excess of oxygen, associated with an absolute reduc-
tion in the pulmonary interchange of gases, both during
reaction as well as during collapse.
This important fact in the chemistry of respiration in
cholera shows that the blood which is conveyed to the
lungs by the pulmonary arteries becomes relatively more
oxygenated during its passage onwards to the pulmonary
veins than is the case during health ; and it has been fully
established b}' numerous and trustworthy analyses of the
air expired during cholera, that however low the absolute
amount of oxygen absorbed may tall during the pulmonary
interchange of gases, it is always relatively, ami b< tmetimes
very largely, in excess of the amount of carbonic acid
eliminated. For it has been clearly demonstrated that
the lilddd which is brought to the lungs during choleraic
collapse for the purpose of aeration, gives up a relatively
diminished amount of carbonic acid in return Eor the
oxygen taken in, owing to the formation of carbonic acid
in the system having been greatly reduced, ami that con-
sequently when it leaves the lungs by the pulmonary
RESPIRATION IN CHOLERA. 391
veins, it is relatively far richer in oxygen than is nor-
mally the case. This has been satisfactorily illustrated
in the following case (No. 31), observed by M. Doyere,
of a journalist, get. 33, who was admitted into the Hotel
Dieu on May 24th, 1819 at 2.30 p.m., and who died,
during choleraic collapse, at 9.15 p.m. on the same
day. In this typical and rapidly fatal case of cholera
there was, throughout the progress of the disease, a
relatively large excess of oxygen absorbed in comparison
with the amount of carbonic acid eliminated, as is well
shown in the following series of analyses of the expired air.
At 3 p.m., or thirty minutes after the patient's admission,
the respiratory quotient was found to be ~^r( == 0To o )
= 0-72 ; at 4 p.m., ^-2(= ~) =0-70; at 4-45 p.m., ~2
/ 1'62\ n^n , r _ CO.,/ l-57\
{= 2-32J= 0'70' aud at "25 P'm-' 0"( =2057= °'73'
The average quantity of carbonic acid eliminated from the
lungs in this case, according to these four analyses, was
consequently reduced to 37 per cent., whilst the oxygen
absorbed was only a fraction below 54 per cent, of the
normal amount. When the concluding observation of the
air expired in this case was made at 8.5 p.m., and when
the temperature in the armpit was 37*8° C, there was
found, as the mean of three analyses, to be a very much
greater disproportion between the amount of oxygen ab-
sorbed and the amount of carbonic acid eliminated, for
CO, / *23 \
the respiratory quotient was then only -~r2 1 = T~^\ ) =0'18.
Consequently at the time of this last observation, which
was made one hour and ten minutes before death, the
carbonic acid eliminated from the lungs was not more
than about 5j per cent., whilst the oxygen absorbed was
29 per cent, of the normal amount ; or, in other words,
the oxygen absorbed was equal to nearly six times the
carbonic acid eliminated. A correspondingly large excess
of oxygen absorbed shortly before death was also
392 THE CHEMICAL PATHOLOGY OF
very noticeable in other cases, and especially in that
of a wood-sawyer ret. 37 (No. 12), who died during
collapse sixteen hours after the commencenieut of the
disease. Five minutes before death, and when the tem-
perature of the armpit had risen to 38*3° C, the respiratory
CO,/ -84 \
quotient, ~7T"I = oTTo ) =(^'40, snowe(l that whilst the
carbonic acid eliminated was only 20 per cent., the oxygen
absorbed was 47 per cent, of the normal amount.
There is no evidence, derived from the chemistry of
respiration in cholera, in favour of the supposition tbat in
well-marked and typical cases of the disease, carbonic acid
is either accumulated in the system during collapse, or
that there is an exceptional excess of it in the venous blood
waiting, as it were, to escape through the lungs as soon as
reaction should occur. On the contrary, it has been
observed that in the same way that the first urine passed
after its previously more or less prolonged suppression is
deficient in urea, so the air expired during well-marked
reaction is correspondingly deficient in carbonic acid j and
such deficiency is observable both in those cases in which
reaction ends in death, as well as in those cases in which
recovery occurs ofter a more or less prolonged and well-
marked stage of convalescence. In the case (No. 2) of a
young man, ast. 24, who was admitted into the Salpetriere
Hospital, Paris, on April 17th, 1849, with well-marked
reaction consequent on a very severe algide stage of the
disease, the pulse was 70 and fairly good, ami there were
only 20 to 22 very natural inspirations per minute, although
the cyanosis was still very pronounced. The analysis
of the air expired in this case, soon after admission,
showed that the Carbonic acid eliminated was only half of
the normal quantity, whilst the oxygen absorbed was
relatively in great excess, the respiratory quotient being
| —~_ 1=0*75. On April 20th. about thirtv-t'oiirhours
O \ 2-78/ r J
previous to death, and when the pal ten! had been in a very
grave typhoid state Bince the previous day, n was found,
RESPIRATION IN CHOLERA. 393
on analysis, that the carbonic acid eliminated was reduced
to one third of the normal quantity, whilst the oxygen
absorbed was relatively in almost the same decree of
excess as in the preceding analysis, the respiratory quotient
being ~~7rM = p^ ] ="74. In like manner, when the stage
of reaction is followed by recovery, there is a correspond-
ing reduction, as regards the interchange of gases, with a
relatively more or less considerable amount of oxygen
absorbed, as occurred in the preceding case, in which
death occurred during reaction. This has been well illus-
trated in the case (ISTo. 3) of a woman, ast. 30, who was
admitted into the same hospital and on the same day as
the last cited case ; and who, at the time of her admission
was in the stage of commencing but very decided reaction,
with 28 inspirations per minute, and with a slight return
of the urinary secretion. The analysis of the air expired
in this case, soon after admission, showed that the car-
bonic acid eliminated was only half of the normal quantity,
whilst the oxygen absorbed was relatively in decided excess,
. , . C00/ 217\
the respiratory quotient being —^r[ —^77^ I =0-88. Three
days later on, when reaction had been succeeded by con-
valescence, and the urinary secretion had been completely
restored, the carbonic acid eliminated was still barely more
than half of the normal quantity, whilst there was rela-
tively a large excess of oxygen absorbed, the respiratory
, . CO,/ 234\ n _
quotient being ~tt"I =^Tq^) =0'79.
These observations on the chemistry of respiration in
cholera, and especially as regards the period of reaction,
are strictly in accordance with the thermometric observa-
tions of MM. Briquet and Mignot, and of other recognised
authorities on the subject. From the carefully tabulated
observations of MM. Briquet and Mignot1 on eighty-six
patients suffering from the disease, it appears that although
the period of reaction is usually accompanied by a compara-
1 « Traite Pratique et Analytique du CholeVa-Morbus,' lSJO, pp. 209, 300.
391- THE CHEMICAL PATHOLOGY OF
tively small elevation of temperature, which " at the most
is not more than 2° to 3° Cent., more often 1°, and even
only some tenths of a degree;" yet some of their obser-
vations have served to show that " there exists, not only
during the algide period, but even during all the continu-
ance of the choleraic phenomena, a tendency to coldness,
in virtue of which the reduction of temperature is in some
cases more pronounced at the period of reaction than in
the cyanic period."
If any further evidence were needed to prove that
cholera is unconnected with defective oxygenation of the
blood, it would be unnecessary to do more than refer to
that afforded by the pulmonary interchange of gases when
the urinary secretion has been restored. For it has been
clearly demonstrated that whilst the previously prolonged
suppression of urine has always coincided with a great
reduction in the amount of carbonic acid eliminated, and
with a relative excess in the amount of oxygen absorbed,
the restoration of the urinary secretion is not preceded,
nor even for some days necessarily followed, by any cor-
responding difference in the interchange of gases in the
lungs. In the case (No. 6) already cited, of a lad, sat.
16, in which the urine was completely suppressed from
the evening of April 27th to the evening of April 29th,
the lowest respiratory quotient during the intervening
CO / 1 58\
time was found to be ^2( = T. qo ) = 0'82 ; showing that
whilst the carbonic acid eliminated was only 30} per cent.,
the oxygen absorbed was 43 per cent, of the normal amount.
When the urinary secretion in this case had been restored
about twelve hours (April 30th, 9 a.m.), the respiratory
CO.,/ i'95\ _ , ' , .
quotient -pr— (=o7e7;) = 0'78, showed that the carbonic
acid eliminated was 45 per cent., and the oxygen absorbed
was 56 per cent, of the normal amount. Three days later
on, May 3rd, 9 a.m., when the urine had become abundant,
COo/ 209\ B ,
the respiratory quotient, ~ ( = . J = O'oo, showed
RESPIRATION IN CHOLERA. 305
tliat the carbonic acid eliminated was 48 per cent., and the
oxygen absorbed was 55 per cent, of the normal amount.
Finally, on May 7th, at 5.30 p.m., when the last analysis
was made, the respiratory quotient, — ~( = - ) — 0"92,
showed that the carbonic acid eliminated was 62£ per
cent., and the oxygen absorbed was 67 per cent, of the
normal amount. It will be sufficient to add that in cases
like this, which is typical of what occurs both during and
subsequent to choleraic collapse, neither the previously
prolonged suppression, nor the succeeding abundance, of
the urinary secretion could have been influenced by any
variations in the interchange of gases in the lungs ; for
during the ten days that the case was under special obser-
vation, the relative and continued excess of oxygen ab-
sorbed was limited to the comparatively narrow range of
4^ to 11 per cent, above the standard proportion of health.
The chemistry of respiration during the stage of
choleraic convalescence has been as yet very imperfectly
studied. But there is some evidence to show that the
tendency to excess in functional activity, which, as regards
the renal secretion, leads to temporary glycosuria, may
also lead, as regards the pulmonary function, to an absorp-
tion of oxygen which may, for a comparatively short time,
be absolutely greater than the standard of health. In
one of M. Doyere's cases (No. 7) it was noted, fourteen
days after the commencement of the disease, when the
pulse was 64 per minute, and the health appeared to be
" perfectly re-established," that the respiratory quotient
was ~ft^\ = jTqs/ ^^ ' SDOwmg that the carbonic
acid eliminated was still only 78 per cent., whilst there
wTas an absolute excess of oxygen absorbed to the extent
of 11^ per cent, above the normal standard. In two other
cases (Nos. 8 and 14) moderate reaction from slight
collapse was observed to lead to an absolute excess in the
absorption of oxygen, which, in each case, was also above,
although only to a small extent, the normal standard
39G THE CHEMICAL PATHOLOGY OP
(analyses 43 and 66). Whilst in a fourth case (No. 38)
it was observed during a convalescent period of five days,
extending from the eighteenth to the twenty-third day
after admission into the hospital, when the average
temperature of the armpit was 37° C, and the average
pulse was 57 per minute, that the amount of oxygen
absorbed, although not quite up to the normal standard,
was relatively very large ; for the respiratory quotients,
CO.,/ 3-40\ C02/ 3-57\ n QQ CO,/ 355\
CO.,/ 3'39\
= 0-83, and -^r\ — 7T7 ) = 0*82, showed that the average
amount of carbonic acid eliminated was still below 80 per
cent., when that of the oxygen absorbed was 96 per cent,
of the normal standard. It is important also to note in
this last case that during the succeeding eleven days
which the patient continued to pass under special obser-
vation, when the average pulse was 63 per minute, and
the average temperature was 37"4 C, there was a relative
excess instead of a relative deficiency in the amount of
carbonic acid eliminated ; and at the same time loss of
appetite instead of the previous desire for food. These
observations on the chemistry of respiration during
choleraic convalescence, like those on the occurrence of
temporary glycosuria as a sequel to cholera,1 show that
" the tendency to excess daring recovery from a centra]
arrest of nutrition " does not readily cease.
There are some physiological facts connected with the
chemistry of respiration in health which may with advan-
tage be referred to in connection with the chemistry of
respiration in this disease. It will be sufficient, however,
for me on this occasion to state that the quantity of oxygen
absorbed in the lungs is only to a very small, if any, extent
influenced by an artificially produced excess of oxygeu in
the air for inhalation ; and that if the deficiency of car-
bonic acid in the air expired l>y cholera patients daring
collapse, and to a less extent during convalescence, be
1 ' Medico-Chirurgica] Transactions,' vol. li\, ls7l, pp. G3 — 93.
RESPIRATION IN CHOLERA. 397
considered in connection with this as well as with other
and allied physiological facts/ there will be less difficulty
in understanding why such deficiency cannot be referred
to any unsatisfied demand of the blood for oxygen. For
whilst the analysis of the expired air demonstrates that
the net result of the pulmonary interchange of gases is
relatively very favorable as regards a clear gain of oxygen,
all attempts to still further oxygenate the blood by the
inhalation of additional supplies of oxygen have signally
failed during each successive outbreak of the disease.
Somewhat more than fifty-four years have passed since it
was recorded by Dr. W. B. O'Shaughnessy,2 whose name
was at one time well known in connection with the chem-
ical pathology of cholera, " that the inhalation of oxygen
gas has failed remarkably in achieving the desired end is
unhappily too notorious." This failure, it may be added,
has not been due to any difficulty as regards inhalation,
but simply to the absence of any demand on the part of
the coloured blood-corpuscles for additional supplies of
oxygen beyond what is contained in atmospheric air.
For it has been very clearly shown that the great and
remarkable affinity for atmospheric oxygen, which physio-
logically characterises the coloured blood-corpuscles, or
rather the haemoglobin which constitutes more than nine
tenths of their bulk, instead of being lessened is increased
in this disease.
1 («) That the amount of oxygen normally present in arterial blood is barely
more than half the amount of carbonic acid; the proportion being 17 volumes
of oxygen to 30 volumes of carbonic acid in 100 volumes of such blood.
(b) That the blood, in becoming venous, does not gain more per ceut. than
from 5 to 7 volumes of carbonic acid, whilst it loses from 8 to 12 volumes of
oxygen ; and that consequently the oxygen absorbed during the subsequent
aeration of the blood in the lungs, is normally in excess of the carbonic acid
eliminated.
(c) That during hybernation, when the pulmonary interchange of gases is
extremely reduced, the oxygen absorbed (Jj) is almost double the amount
(7\) of the carbonic acid eliminated.
1 " Proposal of a New Method of Treating the Blue Epidemic Cholera by
the Injection of highly-oxygenated Salts into the Venous System," ' Lancet,'
Dec. 10th, 1831, p. 367.
398 THE CHEMICAL PATHOLOGY OF
In thus attempting to recapitulate, as concisely as pos-
sible, some of the more important observations which have
been made and recorded in connection with the chemistry
of respiration in cholera, attention must be chiefly directed
to the fact that whilst the absolute amount of interchange
of gases in the lungs is always much reduced, in conse-
quence of the formation of carbonic acid in the system
having been partially arrested, that there is in this
disease, and more especially during its stage of collapse,
a relatively large amount of oxygen absoi'bed, which, as
regards the amount of carbonic acid eliminated, is usually
much above the staudard proportion of health. This
relative excess of oxygen absorbed necessarily leads to an
almost exhaustive elimination of carbonic acid from the
lungs, and to the blood, in its passage onwards to the
pulmonary veins, becoming, as already stated, surcharged
with oxygen. The great reduction in the supply of car-
bonic acid to the lungs, which is strictly in accordance
with the continued ability of the patient, even during
profound collapse, to make a moderately full inspiration,
and also with the comparatively favorable character of the
auscultatory signs of respiration, which indicate that there
is no obstruction to the entrance of air, appears to be
essentially connected with each stage of the disease.
One of the earliest changes affecting the respiratory move-
ments in cholera, and which is primarily due to this
deficiency in the supply of carbonic acid to the lungs, is
the inefl'ectual prolongation of the inspiratory murmur,
and the exceptional shortening of the expiratory murmur,
which lead to diminution, and ultimately to more or Less
complete failure of the voice. The duration of the inspi-
ratory murmur has been observed, in a large number of
cases of cholera, to be about twice as long as the expira-
tory murmur, during prolonged and well-marked collapse.
In one of the cases specially noted by the late Dr. Parkes,1
the relation between the two was as 12 to 5 ; in another
1 ■ Researches into the Pathology and Treatment of the Asiatic or AJgide
Cholera,' 1847, p. 07.
RESPIRATION IN CHOLERA. 399
case, as 6 to 4 ; and in a third case it was twice as long ;
whilst the respiratory rhythm of health is as 6 to 7 or 8.
This failure of the voice has been very commonly spoken
of as the vox cholerica, but it is decidedly incorrect to
refer to it as. a diagnostic sign of choleraic collapse; for
a corresponding failure of the voice, amounting in some
cases to complete aphonia, has been noted by myself and
by other observers in gastro-intestinal cases, in which
there has been collapse simulating that of cholera. In
such cases, as in cholera, there is a well-marked and
characteristic change in the respiratory function during
life, and, not unfrequently, a collapsed state of the lungs
after death, which must be ascribed to a diminished
supply of carbonic acid to the lungs, consequent on a pre-
viously diminished formation of carbonic acid in the system.
This failure from reduced production of carbonic acid,
combined with the relative excess of oxygen absorbed, is
moreover in accordance with the very decided influence of
cholera on the dyspnoea of phthisis, which has for a long
time attracted much attention ; owing to the pathological
effect of phthisis on the lung, as an organ for the elimi-
nation of carbonic acid, being necessarily to reduce its
efficiency. For it has been carefully noted by MM.
Briquet and Mignot1 who, in common with other trust-
worthy observers, have had favorable opportunities for
observing the not unfrequent occurrence o£ cholera in con-
junction with this disease, that "in all our phthisical
patients we have constantly seen the dyspnoea diminish,
and the expectoration nearly or completely cease."
The physical signs of respiration and the analysis of
the expired air show that the much reduced amount of
blood supplied to the lungs continues to be well oxygenated
during choleraic collapse. But it is chiefly by means of
exact examinations after death of the extremely contracted
lungs themselves, in those cases in which death has
occurred before any reaction has commenced, that the
extent to which carbonic acid has been eliminated during
1 Op. cit., 1850, p. 360.
400 THE CHEMICAL PATHOLOGY OF
life can be fully estimated. With regard to the condition
of the lungs after death, it should be noted that when
attention was first directed to their contracted appearance
in these cases, it was somewhat hastily, but not perhaps
very unreasonably, assumed by some observers, that their
condition must be due to the presence of air m the pleural
cavities, which was thought to be alone capable of so
completely overcoming the atmospheric pressure. At an
early period in the first great epidemic of the disease in
the Madras Presidency, an able observer, Dr. Pollock, of
H.M's. 53rd Regiment, availed himself of an opportunity
for opening, within two hours after death, the thorax of
the dead body of a cholera patient under water ; and as
no gas was extricated, it became evident that the con-
tracted condition of the lungs was not due to this, but to
some intra-pulmonic cause.1 Before however, any other
suggestion on the subject could be reasonably offered, it
obviously became important to demonstrate the exact
nature as well as the extent of the pulmonary collapse ;
and this work has been satisfactorily done by the late
Dr. Parkes,2 whose researches have been fully confirmed
by Dr. Sutton, by myself, and by very many other observers.
Dr. Parkes has demonstrated that the lungs in these cases
are less crepitant than usual, and that their specific gravity
is diminished ; showing that there is not only absence of
air, but also of blood. The extent of the pulmonary col-
lapse was found to be very considerable ; for of thirty-
nine cases in which the condition of the lungs was very
carefully investigated by Dr. Parkes, it was ascertained
that " in fourteen cases the lungs were completely col-
lapsed, appearing in some cases almost like the lungs of a
foetus. In three cases they were considerably, and in
eight cases they were slightly collapsed; and in the
remaining fourteen eases, the collapse was in some cases
altogether, and in other cases partially prevented by old
1 Scot (W), 'Madras Report on Cholera,' L824, p. 225, and Preface,
p. xxxiii. See also Dr. I'.irkes, op. tit.. is 17. p. 121.
- Op. .it., is 17, pp. 11—17.
RESPIRATION IN CHOLERA. 401
adhesions." Dr. Parkes states, as the result of this col-
lapsed condition, that " in twenty-four cases, the crepita-
tion was totally abolished ; in fifteen cases it was notably
diminished in some part of the lung", and in one of these
abolished completely in the upper lobes. The want of air
was not owing to mechanical impediment, as on artificial
respiration air passed readily in, distended the before
collapsed lung, and partially or wholly restored the crepi-
tation. This/' Dr. Parkes proceeds to state, " I proved by
many trials." Whilst the diminution of weight in the
case of both lungs, consequent on reduced supply of
blood, was found by Dr. Parkes to average 20 oz. ;
assuming the healthy standand weight for both lungs in
males to be, according to Dr. Clendinning 46 oz.
The abolition of crepitation would thus appear to be
both coextensive and coincident with the reduced supply
of blood, and to be consequent on the smaller ramifica-
tions of the air-vessels having been gradually contracted
so as to exclude the atmospheric air, at the same time
that the previously reduced supply of carbonic acid has
been more or less fully eliminated from the blood conveyed
by the pulmonary arteries for aeration ; and which passes
onwards through the pulmonary veins, with a relative
excess of oxygen to the left side of the heart. For whilst
the relative excess of oxygen absorbed during health has
the effect, so far as the pulmonary function is concerned,
of assisting to promote the passage of blood through the
lungs, the relatively larger excess of oxygen absorbed,
during the collapse resulting from cholera and from allied
conditions of the system, assists in still more effectually
promoting the pulmonary circulation, which by this means
is continued under great and increasing difficulties until
the slowly diminishing supply of carbonated blood to the
lungs almost or finally stops. The abolition of crepita-
tion, like the diminished amount of blood, is in the same
manner due simply to failure as regards both supply and
demand ; for although the well-known tendency to diffusion
between the carbonic acid passing outwards from the air-
vol. lxix. ii « »
402 THE CHEMICAL PATHOLOGY OF
vesicles and the oxygen passing inwards from the bron-
chial tubes is relatively still unchecked, yet the chemical
interchange of gases in the blood of the pulmonary
capillaries steadily decreases with the advancing collapse,
until, like the passage of the blood through the lungs, it
slowly and completely fails. From the numerous observa-
tions which have been made on the progressively reduced
frequency of breathing which immediately precedes death
during choleraic collapse, it will be sufficient to select a
fairly typical case reported by Dr. F. Paschall,1 in which
the respirations were specially timed " during the last five
minutes of life, and were as follows : first minute 20 ;
second 15 ; third 12 ; fourth 6 ; 5th 1 deep inspiration."
The resulting collapse of the lungs in such cases would
therefore be due not to any morbidly excited contraction
of the parietes of the smaller subdivisions of the pulmo-
nary blood-vessels or of the air vessels, but to the natural
elasticity of the lungs themselves, which specially favours
the exclusion but not the entrance either of blood or of
air, when the formation of carbonic acid in the system
has been more or less extensively checked. From the
thoroughly trustworthy observations of Dr. Parkes it is
evident that as the lungs after death in some cases of
cholera are so completely collapsed as to appear " almost
like the lungs of a foetus," the previous interchange of
gases must have become less and less before it quite
ceased ; and that as the supply of blood sent to the lungs
for aeration is to a great extent dependent on the amount
of carbonic acid which it contains, this excretory product,
which qualifies, as it were, the blood for aeration, must in
like manner have been previously very much reduced
before the pulmonary circulation could have so completely
tailed as to leave the lungs almost without blood as well
as almost without air. The fact observed by Prof, Grie-
singer, that percussion during choleraic collapse gives a
-mall area of cardiac dulness, shows that this failure in
the supply of blood to the lungs is associated with a dimi-
i 'The Cholera Epidemic of 1878 in the United States,' 1876, pp. is, 19.
RESPIRATION IN CHOLERA. 403
nislied amount of carbonated blood in the right cavities of
the heart, and consequently in the pulmonary arteries,
during life ;* whilst the relative excess of oxygen, which
is conveyed by the blood from the lungs to the left side
of the heart, accounts not only for the remarkable inte-
grity of the mental faculties during collapse, but also for
the state of the left ventricle after death, which " is often
found so firmly contracted that it must have closed for-
cibly on the last drops of blood that entered it." 2 The
presence moreover of such relative excess of oxygen in
arterial blood, thus stimulating into increased activity the
vaso-motor centre, supplies a more satisfactory explanation
of the emptiness of the brachial and other large arteries
during advanced periods of collapse, which has been ex-
perimentally demonstrated by Magendie, Dieffenbach, and
other observers, than the increased venosity of the blood,
to which the general emptiness of the arteries after death
has been very commonly referred. For this increased
venosity of the blood, which occurs both shortly before as
well as after death, is a capillary and not an arterial
change ; and it can therefore only have a secondary and
an altogether indirect influence in contributing to any
arterial expulsion of blood.
The not unfrequent association of collapse closely re-
sembling that of cholera in cases such as those which
have been referred to in my paper " On some Analogies
of Cholera, in which Suppression of Urine is not ac-
companied by Symptoms of Uraemic Poisoning/' 3 with
a similarly contracted condition of the lungs after death,
shows that such pulmonary contraction is not only inde-
pendent of any cause which is peculiar to cholera, but
that it is necessary to seek elsewhere than in the lungs
themselves for the primary change which has led to this
result ; and, in thus following analogy as a guide, we
may not unreasonably expect that it will lead us to recog-
1 Cited by Mr. Simon, ' Ninth Report,' 1866, p. 429, note.
a Dr. Parkes, op. cit., 1817, pp. 105, 106.
3 ' Bfed.-Chir. Trans.,' vol. li, 1868.
404 THE CHEMICAL PATHOLOGY OF
nise that in the same way that the non-appearance of
urine in the bladder is due to deficiency and arrest of
urea formation in the system, and is independent, at least
to a very great extent, of the kidneys ; so, in like man-
ner, the reduced interchange of gases and subsequent
condition of pulmonary collapse are due to a corresponding
deficiency and partial arrest of carbonic acid formation in
the system, and are independent of any morbid condition
of the lungs themselves. The greatly reduced but continued
formation of carbonic acid during collapse, when that of
urea has been thus almost if not completely stopped, is
undoubtedly due to carbonic acid being a lower compound
than urea, which, from a more or less strictly chemical
point of view, might conveniently be i*eferred to as a dia-
mide of carbonic acid, or simply as a carbamide ; and if,
in accordance with recent progress in chemical science,
we adopt one of these newer titles for urea, it would per-
haps be more easy to recognise why, during choleraic
collapse, the formation on a greatly reduced scale of car-
bonic acid in the tissues, or possibly in the blood itself,
should continue, and the formation of a diamide of car-
bonic acid should cease.
It is perhaps almost unnecessary to add that the above
cited facts connected with the chemistry of respiration in
cholera do not admit of being otherwise explained. The
greal function of respiration is secured by being made to
depend on simple and physical conditions, and it is there-
fore comparatively safe from such destructive influence
of disease as is able in cholera i" wreck tlif functions of
those organs which are associated with initiation, and
which are affected, not by physical, but by peculiarly
vital operations. This essential dist inet ion between the
function of the lungs on the one side, and the functions,
for example, of the liver and the kidneys on the other,
becomes still more noticeable when we pass from the
consideration of the physicalK secured function of respi-
ration, and from the vitally insecure and consequently
wrecked functions connected with nutrition, to the rela-
RESPIRATION IN CHOLERA. 405
tive influence of cholera on those structures and organs
which are either directly or indirectly associated with
reproduction. As this part of the subject has been already
somewhat fully illustrated in my paper " On the Con-
tinuance of the Mammary Secretion during Collapse,"1 it
will be sufficient to state that the relative exemption
there referred to is not limited to cases of this disease,
but that it has been carefully noted in other cases in
which there has been a central arrest of nutrition, and in
which consequently the collapse has simulated that of
cholera ; as, for example, in acute poisoning by sulphuric
acid.2
There remain to be noticed, and that very briefly, the
great reduction of animal heat during collapse, and the
remarkable increase of temperature shortly before death,
which are both in accordance with the facts elicited by
the chemical investigation of the respiratory function
during life, and with the comparatively exsanguine and
non-crepitant state of the lungs observed after death.
As regards more especially the rise of temperature, which
has been often recognised not only immediately before,
but also after death, it is, as the result, at least to a very
great extent, of temporarily increased oxidation, evidently
dependent on a previous accumulation of oxygen. For it
ha3 been shown, by repeated analyses, that oxygen is
continuously admitted into the system and to a great
extent unconsumed during collapse ; and therefore it
would be ready to be thus used when life was becoming
or had become extinct, and when consequently physical
change was either ceasing or had ceased to be any longer
checked by vital influence.
1 ' British Medical Journal,' Sept. 19th, 1868.
2 Casper, ' A Handbook of the Practice of Forensic Medicine, based upon
Personal Experience,' translated from the third edition of the origiual bv
George William Balfour, M.D.St. Andrews, vol. ii, 1862, pp. 83, Si.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 102.)
TWO CASES OE SPLENECTOMY.
J. KNOWSLEY THORNTON, M.B., CM.,
SURGEON TO THE SAMARITAN FEEE HOSPITAL.
Received December 15th, 1885— Read April 13th, 1886.
On April 16th, 1884, E. R— , set. 19, single, was
admitted under my care at the Samaritan Hospital on the
recommendation of Dr. McRitchie, of Huntingdon.
Condition. — Anaemic, but not emaciated, tongue covered
with creamy fur, papillae prominent, appetite good, does
not suffer from flatulence, bowels confined, lungs, heart
and kidneys healthy. Left side of abdomen distended by
a smooth kidney-shaped fluctuant tumour which is dull all
over its surface and is not overlapped by intestine. This
tumour is very mobile. When the patient is at rest on
her back, its upper part extends about two inches above
and to the left of the umbilicus, and its lower part occupies
the whole of the left side of the abdomen, and extends
below the umbilicus well into the right iliac region. It
can be . pushed up under the ribs of the left side, so
that its lower border is only slightly below the navel ; this
position causes pain and a dragging sensation far back in
the left side of the abdomen.
Family history. — Unimportant.
History. — Has never had any serious illness. Two years
408 SPLENECTOMY.
back had an attack of pain in the lower abdomen and was
examined by Dr. Walker, of Peterborough, who discovered
a swelling just to the left of the navel. Nine months later
had a succession of severe attacks of pain, accompanied by
difficulty in micturition. Has been steadily failing in
health since, but has had no return of severe pain, and no
further difficulty in micturating. For the last three
months the swelling has occupied the lower abdomen, and
has been steadily increasing in size. It sometimes moves
up higher and then gives her the same dragging pain
which she complains of when it is pushed up.
Menstruation began at fifteen, and was regular and
painless, but for about a year the periods have been very
scanty and the intervals prolonged ; the last period is over
about ten days and came on after an interval of seven
weeks.
There was no tumour to be felt in the pelvis, and no
evidence that the uterus was connected with the abdominal
swelling.
Diagnosis. — I was in doubt as to the nature of the
tumour, thinking that it might possibly be a dermoid
ovarian with a long pedicle, but rather inclining to the
view that it was a cystic kidney, though there were no
distinct evidences of renal disease of any kind. I did not
think it was the spleen because I could not feel the notch,
and it seemed to me altogether too low in the abdomen.
On April 22nd I explored the abdomen by the ordinary
median incision. When the tumour was exposed I at first
thought that it was the left kidney, as the exposed part
had not the colour of any splenic tumour I had seen, but
on passing in my hand I found the left kidney in its proper
situation, but could not find the spleen, and on extending
the incision upwards it was evident that it was a cystic
spleen. The omentum was adherent to the lower part of
the tumour and this had been the cause of the dragging
pain when the tumour was pushed up. I separated the
omentum and ligatured its torn surface in two parts by
t ransfixiou. The lower part of tho tumour was so thin
SPLENECTOMY. 409
that a dark fluid with scales of cholesterine could be dis-
tinctly seen through its walls, and at one part there was
a small protrusion about as large as a filbert which appeared
to be a fluid hernia. Having turned the lower part of the
tumour out of the abdomen, I grasped its pedicle between
my left thumb and forefinger and transfixed it with a No. 3
Chinese silk ligature. Having tied it in two portions with
these locked ligatures I passed another separate one
round the whole pedicle, tied it, and cut them all short.
On drawing down the pedicle to divide it the patient
became cyanotic and so alarmingly collapsed that the
pillows were removed from under her head and brandy
was injected subcutaneously. She did not revive, and in
order to cover up the abdomen, I cut the tumour away
and took the strain off the pedicle, when she at once
improved and I proceeded with the operation. No blood
was lost during the ligature of the pedicle and separation
of the tumour. There was very little sponging of peri-
toneum necessary. The usual silk sutures were used to
close the incision, and the dry carbolic gauze dressing with
adhesive straps was applied. No drainage. The opera-
tion lasted nearly an hour and the patient was slow in
completely rallying, the pupils remaining dilated for
nearly an hour after she was placed in bed. The vaginal
temperature just after the operation was 97*4° and the
pulse 88.
The tumour weighed 1 lb. 11 oz., the greater part being
a dark red serum with much cholesterine floating in it.
The upper part (about a third in bulk) was the unaltered
spleen, the lower part a large globular cyst with the little
hernial sac already mentioned projecting from its surface.
At its upper part were several pouches of irregular shape
and size, projecting into the splenic tissue.
The patient was treated just as if ovariotomy had been
performed, i. e. she had 3 oz. rectal injections of strong
beef-tea every three hours, with twenty drops of laudanum
in every other injection. Sickness was troublesome for
twenty-four hours, and then she began to take a little
410 SPLENECTOMY.
clear beef-tea and bread by the mouth. There was a
trace of albumen in the first urine and then it became
loaded with urates, and remained so till convalescence was
fairly established on the fifth day after operation. On
the operation evening the temp, rose to 101*6°, pulse 120,
resp. 32. On the next day the highest point was a
degree lower, with corresponding fall in pulse and resp.,
on the second day another degree lower, on the third day
it was stationary, and on the fourth day it was normal,
with a pulse of 92. A sharp metrostaxis came on on the
evening of the second day and ceased on the evening of
the fourth day. The only unusual symptom was pain
about the pedicle accompanied by occasional difficulty in
breathing for the first few days.
The bowels were cleared on the sixth day by enema,
and the sutures were removed on the seventh day, the
wound having united well by first intention. On the eighth
day she was carried down into the convalescent ward, and
the move was followed by a slight rise of temp. 100*8°,
pulse 104. On the ninth day she was a little sick, and
then continued to make an ordinary recovery, with prac-
tically normal temp, and pulse, till she got up on the
eighteenth day after operation. Two days later the
temp, rose and pulse quickened, and there was much pain
over the pedicle ; this continued more or less, and she was
occasionally sick for about ten days, then she had occa-
sional chills and a nose bleeding, and no progress was
made. On the thirty-first day the temp, reached 103*4- ,
with pulse 120; on the thirty-second day it was 104'2°
for a few hours, with a pulse of 128, it then suddenly
fell, and in two more days was normal. Then in a few
days there was a slight relapse, and slight phlebitis in the
left leg; this passed off quickly, and she was up again,
and after remaining some time in hospital, for fear of a
relapse, went to the convalescent home quite well on the
sixt v- fourth ihvy after operation.
During the convalescence the blood was examined
occasionally, and at first there was a slight excess of white
SPLENECTOMY. 411
corpuscles, but there was never any perceptible enlarge-
ment of the thyroid, or of any of the lymphatic glands.
She is now in perfect health, and able to do her work as
a domestic servant. I have not seen her, but hear from
those who have, that she has a good colour, is stout, and
in all respects healthy. The tumour was shown at the
Pathological Society, and all that I have to say as to its
pathology will be found on page 385 of the thirty-fifth
volume of the ' Transactions/
On July 23rd, 1884, E. M — , married, set. 25, mother
of three children, was admitted under my care at the
Samaritan Hospital on the recommendation of Drs.
Herman and Turtle, believed to be suffering from an
ovarian tumour.
Condition. — Healthy-looking brunette, with bright
fresh-coloured cheeks. Tongue furred, appetite bad,
much troubled with flatulence, bowels very costive, has
been unable to lie down for the last three weeks from pain
in both hips ; lungs and heart healthy, urine pale and of
low specific gravity, but not albuminous. Menstruation
at long intervals, and then has profuse and prolonged dis-
charge. The last period lasted for five weeks.
Family history. — Father, mother, and one brother died
of lung diseases, and another brother of brain disease ;
three other brothers and two sisters are healthy.
History. — After birth of last child, a year and a half
back, had low fever with diarrhoea, which laid her up for
three months. Just after this she first noticed a hard
lump in her left side ; this enlarged downwards, and is
still growing fast.
Examination. — The abdomen is greatly distended with
a firm elastic swelling which occupies the whole of the
left side of the cavity, and extends below the umbilicus
some distance into the right side ; this portion of the
swelling is covered with intestine. The left flank is dull
right back to the spine. The tumour is trilobed ; the
upper, smaller, and harder lobe lies partly under the ribs
on the left side, and the middle and larger lobe extends
412 SPLENECTOMY.
from half way between the ensiform cartilage and the
umbilicus, down to the left iliac crest and pubes ; the
third lobe is partly divided from this by a distinct notch
at the navel, and extends chiefly to the right of the linea
alba. Both these lower lobes are much softer than the
upper one, and give an indistinct sense of fluctuation.
The lower portion of the tumour is found by vaginal
examination to occupy the whole pelvis, pushing the
uterus upwards and somewhat behind the pubes. The
uteinne cavity measures two and a half inches, and there
does not appear to be any close connection between this
organ and the tumour.
Diagnosis. — Very doubtful ; it is more like a cysto-
sarcoma of the mesentery that I once removed than any-
thing else, or an inflammatory retroperitoneal tumour.
Spleen and kidney cannot, however, be excluded.
On July 23rd, 1884, I made an exploratory incision
outside the left rectus (Langenbuch's) , as 1 thought that
would give me better access to the deeper parts of the
growth. On fully exposing the tumour it was at once
evident that it was a case of greatly hypertrophic! 1 spleen,
and encouraged by the success obtained in the case re-
corded above, I determined to remove it. The pedicle
was very broad, but thin aud membranous, containing
enormous vessels. The pelvic portion Avas dislodged with
some difficulty, and the omentum was extensively adhe-
rent all over its anterior surface. I separated the latter,
cutting each separate portion between two ligatures, as
the vessels passing between the spleen and omentum
were, many of them, large. 1 then transfixed the pedicle
in two places, locking the three ligatures, and tying the
outer loop first, then the inner, and the middle one last.
Before catting away the tumour, I put on two large
curved pressure Eorceps so as to secure the main vessels
it' the ligatures were not tight enough. I then cut the
tumour away, |>ut a separate ligature round the whole
pedicle, and .-ponged out the peritoneum. There was no
hemorrhage and everything seemed perfectly secure.
SPLENECTOMY. 413
While I was putting in the sutures, some dark blood
began to ooze up beside the flat sponge, and when I
moved it the whole omentum and mesentery seemed sud-
denly to have filled with blood, the pressure being so
great that the vessels burst as we watched them, and the
blood was effused into the cellular tissue. At the same
time, the patient's face became deeply congested, and
then the parietal peritoneum and the edges of the incision
became purple and oozed all over. I pulled up the pedicle
which had been dropped and could find no bleeding point,
but applied another ligature a little behind the others and
round the whole. Finding it impossible to check the
general oozing, I rapidly finished the operation, hoping-
that the condition would pass off, and the circulation
become natural, and that the effused blood might then be
reabsorbed. The pulse was very bad and flickering at
this time, but steadied soon after she was placed in bed
to 104, and shortly after was quite good at 96. Her
appearance also became normal. She was in bed at 4.15,
and at 5.30 a cold perspiration broke out, and pulse and
temperature rose quickly. Two ounces of urine were
obtained from the bladder at 7. At 9 the temperature
was 102*2°, and the pulse hardly to be counted. At 9.45
she died quietly.
Mr. Malcolm made a post-mortem the next day, and
found that a very small artery had retracted from the middle
loop of the first ligatures, and great haemorrhage had taken
place between the layers of the omentum, and so completely
behind the pedicle and exposed parts that it could hardly
be seen till they were removed. I conclude that the
suffusion of face and general congestion were due to
pressure of this enclosed blood upon the sympathetic
plexuses causing paralysis of the vessels, the condition
passing off when the sac burst and the blood became more
generally diffused. In this connection it is interesting to
note the condition of my first case while the pedicle vraa
dragged upon by the tumour and also the attacks of
414 SPLENECTOMY.
dyspnoea with pain about the pedicle during the first few
days after operation.
The mistake I made was in tying the two outer loops of
a locked chain before the middle one, as when I tied the
latter there were two fixed points on each side of it, and
the small membranous portion of the pedicle which it
enclosed was not sufficiently tightly constricted. My
reason for tying the outer and inner loops first was that
all the largest vessels were enclosed in these two loops.
In face of this sad accident it is useless to speculate on
what might have been, but from the ease and rapidity
with which the operation was performed, the perfect
immunity from hasinorrhage in separating the adhesions
and removing the tumour, and the satisfactory condition
of the patient till the haemorrhage occurred, I thiuk there
is every probability that the operation would have been
successful. I should not hesitate to operate if I met with
a similiar case with symptoms equally demanding relief.
There are now a sufficient number of successful
splenectomies on record to show that in proper cases it is
a justifiable operation, and if it stood alone my first case
would prove that not only is recovery possible, but that
the removal of this organ when diseased is followed by a
marked improvement in health and by no troubles which
can be associated with the loss of the organ.
The following tables give all the cases of splenectomy
which I have been able to find, and I have to acknowledge
with thanks much assistance from my friend Dr. Pinter, of
Pesth, in collecting them. Crede gives them nearly all in
a fable in a paper published in ' Langenbeck's Archiv/
vol. xxviii, p. 404, but makes a curious mistake in
attributing a case to Baker Brown in 1881, i. c. eight years
after he died. He omits the case by the same operator in
L866j BO possibly it is only B mistake in the date. Crede
gives leukaemia as the disease for which the operation was
performed j my authority, the late Dr. Tanner, says that it
was hypertrophy.
It is qnite clear from an analysis of these tables that
SPLENECTOMY. 415
cases in which the spleen is either itself injured or merely
protrudes through a wound in the side, generally do well
if treated by complete removal of the organ, or by re-
moval of the injured or protruding portion.
The removal of " simple wandering " spleens is also a
safe operation. One in which hypertrophy was also
present was unsuccessful.
All the three cases of extirpation of cystic spleens also
recovered.
Simple hypertrophy is a much more dangerous con-
dition, most of the deaths being due to haemorrhage. The
large size of the mass to be removed, and the broad
pedicle, with its enormous vessels, expose the operator to
such accidents as I have recorded above, but we only
want experience and greater care in ligaturing the pedicle
to make these cases successful. From the account given
by Sir Spencer Wells of his second case I should doubt
if Crede was right in giving leukgemia as the disease, and
certainly the case in 1876, when I assisted at the operation,
and made the post-mortem afterwards, was one of simple
hypertrophy. Of fourteen cases operated upon for simple
hypertrophy, including the "wandering spleen" named
above, ten died and four recovered.
All the cases of leukasmia (thirteen out of the total of
thirty-four) died, and they make up the great mortality
of the operation, so that it is quite clear that when this
disease is present it is not justifiable to operate. Ex-
cluding them the mortality is still nearly 50 per cent.,
but it will doubtless be much lower with care in dealing
with the pedicle, and with increased experience.
To these complete splenectomies we may add four
cases in which an injui'ed spleen was partly removed ; all
recovered.
Twelve of the thirty-four splenectomies have been per-
formed in Great Britain, and my first case is the only
successful one. Italy is to the front with four cases with
only one death.
416
SPLENECTOMY,
Successful Splenectomies.
No.
Date.
Operator.
Place.
Disease.
Reference.
1
1549
Zacarelli
Naples
Hypertrophy
' Tanner's Practice of Me-
dicine,' vol. ii, 6th ed.,
1869, p. 151.
2
1711
Feirerius
St. Carignan
Spleen lying
in a peri-
toneal abscess
' Opuscula Medica et
Physiologies Fantoiii,'
Geneva, 1738,
3
1855
Schultz
Darmstadt
Spleen pro-
truding from
wound in side
4
1867
Pean
Paris
Cyst
' L'Union Medicale,' p.
340, Paris, Nov. 26,
1867.
5
1876
Pean
Paris
Hypertrophy
' Clinique Chirnrgicale,'
1875-6, Paris, 1879.
6
1877
Martin
Berlin
"Wandering"
' Brit. Med. Journal,'
1878, vol. i,p. 191.
7
1878
Czerny
Heidelberg
" Wandering"
' Wiener ined. Woch>
ensch.,' vol. xxix, L879.
8
lsys
Volney
d'Orsay
America
Hypertrophy
' Albert's Lehrhuch der
Chir.,' vol. iii, p. 472.
g issi
Franzolini
Udiue
Hypertrophy
10 1881
Crcde
Dresden
Cyst
' Laugenbeck's Archiv,'
vol. xxviii, 1883, p. 404.
11 1884
Knowsley
Thornton
London
Cyst
• Trans. Pathological Soc.,'
vol. xxxv, pp. 385-6.
Succe
ssful case
s of Partia
I Removal of Injured Spleen.
l
1678
Mathias
—
Was well 6J
years after
2
1738
John
—
Complete
' Philosophical Trans.,*
Ferguson
recovery
vol. ix, p. 149, London,
1717.
3
1815
Letihossek
—
Was well
3 years after
Becker's ' Annalen,1 Ber-
lin, 1S28.
4
IS II
Berthet
Lived 13 years
■ Archives Generalea de
Medecine,' 1844, p. 510.
I
Tnsuccessfu
I Splenectomies.
1
L826
Quitten-
bautn
Rostock
Hypertrophy
■ Commentatio de Splenis
Hypertrophic, ic.,' Bob*
tock, 1826.
2
18.-1.-)
Kiiehler
Darmstadt
Hj pertrophy
• K\t irpal ion fines Mil/.-
tuinars.' Dannst.ull . I 866.
3
isc:
Spencer
Weill
London
Hj pertrophy
' Ahdominal Tnmonrs,'
1885, pp. 182—189.
SPLENECTOMY.
417
No.
Date
Operator.
Place.
Disease.
Reference.
4
1866
Bryant
London
Leukaemia
' Guy's Hospital Reports,'
3rd series, vol. xii, p. 444,
London, 1866.
5
1866
Baker
Brown
London
Hypertrophy
Tanwer's ' Practice of Me-
dicine,' vol. ii, p. 151,
6th edition, 1869.
6
1867 Bryant
London
Leukaemia
' Guy's Hospital Reports,'
3rd series, vol. xiii, ]>. 411,
London, 1868.
7
1867
Koeberle
Strasburg
Leukaemia
' Gazette Hebdoinadaire
de Medecine et de Chi-
rurgie,' p. 680, Paris.
Oct. 25, 1867.
8
1873
Urbinato
Cesana
Hypertrophy
of wandering
spleen
9
1873
Koeberle
Strasburg
Hypertrophy
10
1873
Spencer
Wells
Birmingham
Hypertrophy
See above, Case 3.
11
1873
Heron
Watson
Edinburgh
Leukaemia
12
1876
Spencer
Wells
London
Hypertrophy
See above, Case 3.
13
1877
Billroth
Vienna
Leukaemia
' Wiener med. Wocb.,'
1877, No. 5.
14
1877
Billroth
Vienna
Leukaemia
15
1877
Langley
Browne
—
Leukaemia
16
1877
Fuchs
Behas
Leukaemia
Crede's table, Case 20.
17
1877 Simmons
Sacramento
Leukaemia
18
1878 Czerny
Heidelberg
Leukaemia
1 Wiener med. Wochen-
schrift,' vol. xxix, 1879.
19
1878
i
Arnison
—
Leukaemia
British Medical Journal,'
1878, vol. ii, p. 723.
20
L878
Geissel
Essen
Leukaemia
21
1881
Haward
London
Leukaemia
Clinical Society's Trans.,'
1882, and ' B. M. J.,' vol.
i, p. 462, 1882.
22
1883
Spanton
—
Hypertrophy '
British Medical Journal,'
1884, vol. i, p. 14.
23 :
L884'
Billroth
Vienna
Sarcoma
24 ]
[8841]
{.Thornton
London !
hypertrophy j
STow first published
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii
p. 103.)
VOL. LXIX.
27
ON THE
DEVELOPMENT OF MAMMARY FUNCTIONS
BY THE
SKIN OF LYING-IN WOMEN.
FRANCIS HENRY CHAMPNEYS, M.A.,
M.B. Oxon., F.R.C.P.,
OBSTETEIC PHYSICIAN TO ST. GEOBGE'S HOSPITAL.
Received December 29th, 1885— Read April 27th, 1886.
The subject of numerical abnormalities of the breasts
and nipples has from time to time received considerable
attention under the titles of supernumerary mammas and
nipples ; it has been referred to by Sir James Simpson/
it has been treated by Dr. Mitchell Bruce2 in an excellent
paper, and, most exhaustively, by Professor Leichtenstern.3
Cases have also been recorded by Dr. Handyside,4by Dr.
Matthews Duncan,5 by Mr. Cameron,6 and by others.
The cases recorded by these observers have included
numerical abnormalities of nipples, of nipples with mam-
mary glands, and of mammary glands with pores and
without nipples. With these we are now only indirectly
1 ' Obstetric Works,' vol. ii, p. 325.
a 'Journal of Anatomy and Physiology,' vol. xiii, 1878-9, p. 425.
3 « Virchow's Archiv,' Baud 73, 1878, s. 222.
4 ' Journal of Anatomy and Physiology,' vol. vi, 1873, p. 56.
* ' Obstetrical Journal,' vol. i, 1873, p. 516.
8 ' Journal of Anatomy and Physiology,' vol. xiii, 1878-9, p. 149.
420 DEVELOPMENT OF MAMMARY FUNCTIONS
concerned, indeed, only so far as to include certain speci-
mens which have come under my personal observation,
and which serve as a contrast to those cases which I pro-
pose to describe, cases which, so far as I know, are new.
These supernumerary structures, described by many
authors, are in the great majority of cases situated below
the normal mammge and are a little nearer to the middle
line ; when they are above the mammas they are always
(says Leichtenstern) more external than the normal
manirnse. But this situation is so rare that out of 105
cases collected by him only 5 were situated in the axilla,
while 2 were on the back and 1 on the acromion.
In the case of the five axillary mammee (S. 254) they
were all provided with nipples, often more or less rudi-
mentary, from which milk or colostrum exuded. In 2
cases the side affected was the left ; in 3 both sides were
affected. Thus, the left side was affected in all in 5 cases,
the right in 3.
Mr. Cameron's case, which is not included in Leichten-
stern's 5 cases, and, indeed, is somewhat different, is
briefly as follows : A married woman, ast. 33, pregnant
with her sixth child, observed a swelling under the left
arm after over- exerting herself at a fire, when in her
alarm she seized several buckets and carried them till she
was exhausted. After her confinement milk could be
squeezed from the tumour.
When examined a soft tumour was found in the left
axilla behind the fold of the pectoral is major ; the mass
was easily moveable and not connected with the breast of
the same side. Its boundaries were difficult to define as
the edges appeared to go under some structure and eludo
the fingers, reminding one somewhat of a hernia. This
seemed to lead to the inference thai there was originally
a capsule or investing membrane which had burst on the
occasion mentioned above as a resuH of over-exertion.
This appeared all the more probable us no tumour was
suspected before that occurrence, and from its size when
examined, and the intelligence of the patient, this seemed
BY THE SKIN OF LYING-IN WOMEN. 421
hardly credible, unless some change then took place in its
condition or surroundings.
The length of the tumour may be roughly stated at
about three inches by about one and a half in breadth.
The skin over it was slightly darker in tint than that in
the neighbourhood. The tumour was not painful or
tender, nor had it given any trouble while suckling the
last child. At the time the examination was made the
patient was again pregnant, and milk could be drawn
from the breast. A small orifice was found at the upper
and anterior part of the tumour (but nothing like a
nipple) ; from this a fluid could be squeezed which under
the microscope proved to be milk, thus showing the true
nature of the tumour.
Since the patient was under observation she has been
confined, and it was observed during lactation that milk
flowed freely from the tumour, and that whenever the
breasts were allowed to become full the tumour swelled
coincidently.
Cameron quotes a case related to him by Mr. Bicker-
steth, in which a somewhat similar tumour, as large as a
cricket ball, was removed from the right axilla ; it had at
first been as large as a walnut and had steadily increased
in five years to the size of a cricket ball. It was removed
from a distinct capsule and proved to be an adenoma, such
as is found only in mammary tissue. The conclusion was,
therefore, that the tumour was an adenomatous super-
numerary mamma.
The value of this case lies in the microscopical exami-
nation, but the great increase of the tumour in size was
pathological.
Mr. Bickersteth (says Cameron) had observed a some-
what similar case in an unmarried woman, get. 33. The
tumour was about the size of a fist ; it had developed with
the development of the breast, but had not increased in
size since puberty. It was not interfered with.
Leichtenstern found the left side much oftener affected
with supernumerary mammas and nipples than the right
422 DEVELOPMENT OP MAMMARY FUNCTIONS
side in the proportion of seven to two. He remarks that
he cannot explain this, but that the left breast is usually
the larger. Dr. Mitchell Bruce found them also more
frequently on the left side.
The cases which I have to describe were observed in
the General Lying-in Hospital and (not including cases
like some of those above) number thirty, three of them
during Dr. Williams's months of office. He has kindly
allowed me to incorporate them.
The first included in the series concerned a patient
admitted Oct. 9th, 1882, and the last concerned a patient
admitted Nov. 27th, 1884. During this timo the total
number of patients observed in the hospital was 712.
As will be seen by the table annexed, the appearances
were observed far more frequently during some periods
than others, they were not uniformly distributed in time,
and no percentage represents the facts accurately. Indeed,
the regular observations began Oct. 1st, 1883; this makes
the total number of patients during this series 377, in 27
of whom these swellings were found.
As to the side affected — the right side was affected in
14, the left in 1, both in 15. Thus the total number
of times in which the right side Avas affected was 29, the
left 16. This is at variance with the proportion observed
in supernumerary mammas and nipples.
When bilaterally situated the lumps in the right side
were the larger in 7 ; the left in 3 ; they were of equal
size in 5. Thus the right side predominated both in fre-
quency and in size.
It now remains to give —
I. A description of these bodies :
1. They are situated iu the skin of the axilla, which
cannot be pinched up freely over them. On attempting
to raise the skin, it seems to be tied to the lumps by
fibrous septa.
2. They can be raised and isolated from the deeper
structures, and are not in the situation or of the shape
and feeling of glands.
BY THE SKIN OF LYING-IN WOMEN. 423
3. The skin over them is usually quite natural in
appearance.
4. They are limited to the hair-covered surface.
5. They are usually soft, and somewhat elastic except
when swollen.
6. They are usually somewhat flattened, their vertical
diameter being the smallest.
7. They do not possess any nipple, pore, or duct.
8. Their size varies from the smallest perceptible, to
that of an egg, or perhaps larger. (As to the compara-
tive size of those in the right and left axilla, see above.)
II. As regards the course :
1. They are most commonly first noticed on the third
or fourth day after delivery, at the time when the breasts
fill. But they can very often be found, if looked for, at
the time of labour, and the patient is sometimes conscious
of their presence continuously from her first pregnancy.
2. They sometimes, when once established, become
larger and occasionally painful at the beginning of preg-
nancy, sometimes at quickening, sometimes later in preg-
nancy, but most commonly not until after delivery.
3. Their course during lying-in usually coincides gene-
rally with that of the breasts, enlarging and becoming
tense and sometimes tender about the third day, softening
as the breasts soften, and becoming much smaller, or even
almost imperceptible, by the end of a fortnight. As a rule,
however, their size and tenseness does not coincide with
the diurnal variations of the breasts in this respect.
III. As regards their secretion :
1. In the first 11 the mode of obtaining the secretion
had not been discovered.
2. In the remaining 19 (with one exception) secretion
of some kind was obtained.
3. In no case did secretion flow spontaneously, as
described in some cases of axillary mammas.
4. To obtain secretion it was necessary to firmly squeeze
the lump between the fingers, from the deeper and towards
the superficial aspect, as in evacuating a comedo.
424 DEVELOPMENT OF MAMMARY FUNCTIONS
5. The secretion was of three principal kinds : — (a)
Granular debris, like the secretion of sebaceous follicles ;
(6) colostrum ; (c) milk.
6. The above was usually the order in which the
various secretions appeared.
7. Colostrum, milk, and granular debris might dis-
appear and reappear within a few days.
8. At the same time various follicles would produce
various secretions. The whole lump was not always uni-
form in its secretions at the same time.
9. The secretion was expressed from the situation of
the sebaceous follicles as marked by the situation of
the hairs. Before the secretion exuded for the first time
from a follicle which was being squeezed, the follicle was
usually seen to swell up, become prominent, whitish in
colour, and often to discharge a fluid like thin gum, after
which other secretions might follow.
10. The whole surface of the lump produced secretion ;
there was no centralisation.
In one case (No. 200, admitted August 25th, 1884)
belladonna seemed to soften the lump and to promote
escape of secretion, as in the case of the breast.
In order to reduce scepticism to a minimum, invitations
were sent to many competent observers, and the appear-
ances were seen by Drs. Braxton Hicks, Matthews Duncan,
Gervis, John Williams, Herman, and Mr. Clutton, as well
as by the author and by Drs. E. S. Tait and Boxall, who
were successively house physicians, and from whose careful
notes I quote below.
The following well-marked cases are described at length ;
the main facts of the others are set forth in the table.
Axillary Lumps without Nipples or Pores.
No. 200.— Admitted August 25th, 1884, ret. 30, 3-para.
Lumps in both axilla) were noticed on admission.
On the second day the following note was taken :
" In the right axilla at the apex, extending in about
BY THE SKIN OF LYING-IN WOMEN. 425
equal proportion on the inner and outer wall, is a lump in
the skin three inches long, one and a half inches wide, and
three quarters of an inch thick, thicker towards the chest
than elsewhere ; of even contour ; firmly united to skin,
and freely moveable on subjacent structures. Skin cannot
be pinched up over it, but can be brought together under
it, except where it is too thick to allow of it. Surface is
covered by a few hairs ; hair-covered surface is co-
extensive with lump. Not painful, but a little tender on
manipulation. No redness of surface, no duct to be seen.
On squeezing, a little fluid exudes from a follicle with a
hair in the centre, and others swell up, but do not rup-
ture. In the opposite axilla is a similar lump, to which
the above description equally applies, except that it is less
defined and somewhat softer. Patient first noticed the
lumps two or three months before her first confinement ;
smarting in the armpits drew her attention to them.
They were smaller then than now ; they got bigger and
more painful till confinement and then went away,
beginning to get smaller directly after labour, and
had entirely gone at the end of a month. They were
never then as large as now. The same series of events
happened in the second pregnancy and after labour, but
the lumps were larger than before and more painful. In
this pregnancy they were noticed first about eight months
ago, the aching pain drew attention to them, and she
thought an abscess was forming. They have gradually
got bigger and more tender up to the present time."
On the fourth day the lumps were noticed to be rather
harder and more tender. Glycerine of belladonna applied.
On the fifth day the lumps were relieved by the bella-
donna. " On squeezing the lumps the follicles of the skin
over them enlarge, and fluid oozes up around the hairs."
On the seventh day, " the lump under the right arm
was squeezed, the follicles swelled up and fluid exuded
around the hairs. This was collected from three different
follicles ; from one it came in great abundance and looked
quite like milk both to the naked eye and under the
426 DEVELOPMENT OF MAMMARY FUNCTIONS
microscope ; it was perfectly typical, with a few colostrum
corpuscles. Another specimen from another follicle showed
many very well-formed colostrum corpuscles and milk
globules, and a third specimen from another follicle
showed a few colostrum corpuscles and a few globules Like
dilute milk. Of its character there can be no doubt."
On the ninth day the lumps were softer, smaller, and
much less tender. " Milk from the other (left) lump was
examined microscopically. It proved to be typical milk
with excellent colostrum corpuscles."
On the tenth day, " the lumps keep much the same.
When asked if they are still painful, patient volunteers
the information, f Only when the draught comes into the
breast, they get hard at the same time, but subside with
the breast.' "
On the fourteenth day, " says the lumps get hard at
night when the child is put to the breast, but soon sub-
side when the breast is emptied. Knows when she is in
the family way by pain being felt in the lumps."
No. 239.— Admitted October 16th, 1884, aet. 33, 4-para,
On the second day the following note was made :
" In either axilla is a soft lump in the skin, so soft at
present that it cannot well be defined. That on the left
side is harder than that on the right ; they are limited to
the hair-covered surface. The skin beneath them can be
nearly, but not quite, pinched together, as the lump is of
considerable thickness ; it cannot be pinched up upon it.
No redness, throbbing, pain or tenderness. No duct can
be seen. Not noticed before."
On the third day, " each lump is about the size of a
large walnut, harder and more defined than yesterday."
On the fourth day, " the lumps rather larger, but not
much harder. On squeezing them the follicles in the
skin swell and exude fluid."
On the fifth day, " the breasts became hard in the night
and so did the lumps. The breasts are now full, and the
lumps are hard and well defined.
On the sixth day, "both lumps and breasts softer."
BY THE SKIN OF LYING-IN WOMEN. 427
On the eighth day, " the breasts are soft and so are the
lumps. The lump in the left axilla was squeezed firmly,
and the hair-follicles swelled up as white points, looking
something like small pustules with a hair in the summit
of each. Some fluid begins to exude around the hairs in
seven or eight places. This fluid collected on a cover-
glass and examined under a microscope is seen to consist
mainly of granular epithelial debris, much of which is
freely floating with a few free oil-globules and a consider-
able number of colostrum corpuscles."
On the eleventh day, " lump in either axilla hardens
whenever breast of same side gets hard and full/'
On the twelfth day, " microscopic specimen made of
fluid from lump in right axilla proves to be similar to that
from the opposite side on eighth day. Both lumps are
much softer to-day, and the breasts are soft too. Now
says she noticed the lumps soon after first confinement,
and they ran a similar course. The doctor in attendance
also noticed them, and told her she had a small tumour
in either armpit, and requested her to go to him again
after she got about, but she did not do so."
No. 287.— Admitted November 29, 1884, under Dr.
Williams, get. 39, 8-para.
On admission very soft lumps were noticed in both axillee,
not easily defined at present, that in the right the larger.
On the second day, " at the apex of either axilla, is a
lump in the skin, very soft at present, so that its area
cannot well be defined. It is commensurate apparently
with the hair-covered surface, and is three inches long by
two inches broad, the long diameter running from the
chest in the direction of the axis of the limb. It appears
to be about half-an-inch thick, and is of barely firmer
consistence than an accumulation of fat would be. There
is no abnormal appearance on the skin, no redness, and
no duct. The lump forms a visible fulness in the apex
of the axilla. It is of fairly even contour, a little tender
on manipulation ; the skin can be pinched almost but
not quite together under it owing to its extent and thick-
428 DEVELOPMENT OF MAMMARY FUNCTIONS
ness, but cannot be pinched up over it ; it is freely move-
able on the subjacent structures. On squeezing the lump
the follicles in the skin over it swell, and a small quantity
of fluid exudes from several hair-follicles around the hairs.
This effect is produced by very little squeezing. On col-
lecting this fluid from several follicles for microscopical
examination, it looks opalescent between glass, and on
further examination it is seen to consist mainly of granular
debris with a few oil globules of varyiDg size floating
freely in a clear liquid, and in another part of the specimen
are many globules with several large, well-defined colos-
trum corpuscles. The lump on the left side is rather
smaller and softer than on the right. These lumps were
noticed on admission and have become rather larger,
harder, and more defined since. She herself was unaware
of their existence, and knew of none in her previous
pregnancies or lyings-in, but the axillas have, after each
confinement, but not before, "become tender till the flow
of milk came in, and I thought it was from throwing my
arms about when I was confined. "
On the third day, " lumps scarcely altered, perhaps that
on right side a trifle harder, that on left side is rather
larger and harder, so as to more nearly equal that on the
opposite side. Fluid from left expressed and examined
in same way as that from right, shows same characters in
a much more marked degree. In one portion of the
specimen is almost pure granular debris, with here and
there a colostrum corpuscle ; in another is an innumerable
colony of perfect colostrum corpuscles without any ad-
mixture; and in another oil-globules of varying size with
a few colostrum corpuscles and granular debris intermixed.
Dr. Herman saw the lumps this evening, and fluid was
expressed from the right and examined by him."
On the fourth day, " lumps the same ; it is difficult to
separate the breast-gland from the lump on the left side,
.Hid on the right they become almost contiguous. The
situation between the lumps and breasts on either side is
tender."
BY THE SKIN OP LYING-IN WOMEN. 429
On the fifth day, " Dr. Matthews Duncan saw the lumps
last evening and also saw the same microscopical speci-
men as Dr. Herman. He thought the colostrum corpus-
cles were small, and had too defined an outline. A fresh
specimen was made in his presence from the lump in the
right axilla, and it proved to be milk with two or three
of the same kind of corpuscles. Of the milk he had no
doubt. The lumps are both rather larger in area and
thicker than they were ; they measure 3£ x 2| in. (right
side) ; 3 x 1\ (left side). Their consistence remains un-
altered. They are decidedly less tender than they were/'
On the sixth day, " lumps same in size and feeling but
not tender on manipulation. Dr. Gervis saw the lumps
this afternoon. The fluid expressed from the outer por-
tion of the left lump showed under the microscope mainly
granular debris with a few oil globules and colostrum
corpuscles/'
On the tenth day, " lumps are getting decidedly softer.
Dr. Braxton Hicks saw the lumps this afternoon. Very
little fluid could be expressed, but sufficient for micro-
scopical examination. It proved to consist mainly of
granular debris and colostrum corpuscles."
On fourteenth day the patient was discharged, with
" the lumps scarcely altered.''
The following cases, which were observed concurrently
with the others, are here inserted by way of contrast,
and to show that the author was on the look-out for all
varieties of mammary abnormalities.
A. Extension of Mammce into Axillse.
No. 16.— Admitted January 17th, 1884.
On third day a projection from the mammae was
observed to extend into the apex of each axilla ; its
greatest breadth was two inches. It was nodular and in
all respects like the breast tissue. It joined the outer
border of each breast at a tangent. It was fairly move-
430 DEVELOPMENT OF MAMMARY FUNCTIONS
able on subjacent structures, the skin over it was freely
moveable and could be pinched up. There was no acces-
sory nipple or unusual appearance in the axilla. No
secretion could be expressed.
On the fifth day it was noted that the left breast had
been sucked and was soft, and so was the axillary exten-
sion ; that the right breast was harder, and so was the
axillary extension.
No. 146.— Admitted July 6th, 1884.
On sixth day the following note was taken :
" In either axilla on the inner wall is an extension of
the mamma as far as the apex, it is soft and feels like
mammary substance, evidently connected with the breast,
and freely moveable on the deep structures. The skin
can be pinched up over it. No duct or nipple can be
found." No secretion could be expressed.
No. 156.— Admitted July 11th, 1884 (see also " axillary
lumps").
On second day it was noted that in each axilla, running
up from the side of the breast along the inner wall towards
the apex, was a prolongation of the breast, glandular and
nodular in feeling, and softer than the " axillary lump "
in the skin of the right axilla, which it met at an angle
at the apex of the axilla. No duct or nipple could be
found and no secretion expressed.
B. Separate Axillary Ma/mmsB with Axillary Nipples,
Pores, or Ducts.
No. 136.— Admitted June 27th, 1884.
On the second day the following note was taken :
" In either axilla at the apex is a supernumerary
mamma. That in the right is more distinct and as large
as a pigeon's egg, at present soft and tender. A bail
from this runs down the arm half an inch to an inch, and
is a little harder than t He rest. The skin can everywhere
be pinched up over it, and it is fairly moveable on the
subjacent structures. It opens by a duct m the anterior
BY THE SKIN OF LYING-IN WOMEN. 431
axillary fold, the opening projects slightly, is perhaps
faintly erectile, and out of it a bead of juice can be
expressed. A similar lump is found in the opposite axilla
with the following differences : — It is softer; has no tail,
and out of the duct colostrum can be pressed. No colos-
trum can be obtained from either breast."
On the third day colostrum could be squeezed from both
axillary mammae.
On the fourth day both were rather harder and dis-
tinctly nodulated like breast substance ; milk could be
squeezed from both.
On the sixth day the right axillary mamma was larger,
and a second pore was found, from which milk could be
squeezed.
No 152.— Admitted July 10th, 1884.
On the third day the following note was taken :
" In the right axilla is a lump which feels glandular,
rather softer than the breast of the same side, nearly the
size of a pigeon's egg, but too soft to define. It runs
from the apex towards the deep structures at the margin
of the breast, its surface is covered by hair, it is freely
moveable on the subjacent structures, the skin can be
pinched up over it. At the anterior border, i.e. at the
anterior axillary fold, a minute duct can be found, espe-
cially on pinching up the skin, when it becomes retracted
in that spot ; it projects slightly, and is of a little more
pigmented colour than the surrounding skin. Scarcely
any moisture can be expressed from it. It is not painful.
In the opposite axilla is a similar body, but softer and
half the size, with a less distinct duct in a corresponding
situation. She had a painful lump in either axilla three
days after her first confinement, it went away when the
milk was dried up a week later."
On the seventh day milk was expressed from the duct
in the anterior fold of the right axilla.
No. 106.— Admitted May24th, 1884, under Dr. Williams.
On the third day the following note was taken :
" In the left axilla, on the costal wall, close to the apex
432 DEVELOPMENT OF MAMMARY FUNCTIONS
a lump can be felt just beneath the skin, which can be
pinched up over it except at one spot where there is a
minute hole, a little pinkish and pigmented, just visible
to the naked eye, but its position is readily ascertainable
by pinching up the skin over the lump, wrhen a dimple is
produced at the spot, showing it to be bound down to the
deeper structures in that situation. There is no projec-
tion of the surface. The lump is about the size of half a
nutmeg, round, freely moveable on the deeper structures,
and apparently continuous with the glandular substance
of the breasts, the connecting medium being an isthmus
about one inch long, one third of an inch broad, and one
third of an inch thick. The consistence of the isthmus
and of the lump corresponds with that of the breast, un-
dulating on the surface. None was found in the left
axilla on examination yesterday, and none is apparent
now in the right axilla. On squeezing the lump, out of
the small pore a drop of fluid was expressed, which the
microscope showed to be milk and colostrum."
On the fifth day, " in the right axilla is a small papilla
corresponding in situation to that on the opposite side,
and a little more distinct than it, standing up one six-
teenth of an inch above the surface, and of a brownish-
pink colour. In the centre is a duct, out of which
milk can be squeezed. It is attached to something
beneath, like that on the opposite side, but no lump can be
felt. The margin of the breast is distant about one inch."
C. Supernumerary nipples (without special gland
substance) .
No. 301.— Admitted December 12th, 1884, under Dr.
Williams.
On the third day the following note was taken :
" Immediately below the left nipple, one and a half inohes
from the lower margin of the breast, is a nipple-like wart,
as large as a pea, with a small pedicle, quite short, and
surrounded by a bronzed areola one sixteenth of an inch
BY THE SKIN OF LYING-IN WOMEN. 433
wide. No opening can be found in it, there appears to
be no gland tissue beneath."
No. 317.— Admitted November 28th, 1883.
On the fourth day the following note was taken :
" Below each breast is a pigmented wart suggestive of
a supernumerary nipple. That on the left side is verti-
cally below the nipple and situated on the costal arch ; its
diameter is about an eighth of an inch ; it projects about a
sixteenth of an inch from the surface, has a central depres-
sion and is surrounded by a pigmented area. It is dis-
tinctly erectile on irritation, but no moisture exudes on
pressure. On the right side is a similar body midway
between the nipple and costal arch, that is, lying over
about the seventh rib, two and a half inches from the costal
margin, and one and a half inches from the circumference
of the breast. It is like the other in all respects, but is
about twice as large, and a serous moisture exudes on pres-
sure. No gland substance can be felt, nor any elevation
of the skin. Says her sister has similar bodies. Thinks
they are a little darker than they used to be."
Copy of a letter from patient's sister :
" I have only one small, round place about the size of
a small pea, smooth and a brown colour, a small hole in
the middle and just below the left breast. I believe I
have had it from my birth ; not like a nipple/'
No. 181.— Admitted August 8th, 1884.
On the second day the following note was taken :
" At the lower margin of each breast, almost vertically
below the nipples but one inch towards the middle line, is
a rudimentary nipple projecting about one sixteenth of an
inch, consisting of distinctly erectile tissue, of brownish-
pink colour and faintly pigmented around for a quarter of
an inch. Each has a depression in the centre and looks
exactly like a diminutive nipple. That on the left side is
a little the more pronounced. There is no swelling
beneath to indicate gland substance. On drawing up the
skin, the depression in the centre becomes very evident."
No. 186.— Admitted August 10th, 1884.
vol. lxix. 28
434 DEVELOPMENT OF MAMMA.RY FUNCTIONS
This was a remarkable case, having a typical " axillary
lump " (see Table) in the skin of the right axilla, and also
three small axillary lumps on the right side, and three rudi-
mentary nipples, two on the right side and one on the left.
On admission the following note was taken :
" At the circumference of the right breast, vertically
above the nipple is a small rudimentary nipple of pinkish-
brown colour, apparently erectile, with a dimple in the
centre, made most distinct by pinching up the skin ; at
the side and at the lower border is a still smaller but
similar structure. Three axillary lumps close together in
the right axilla, none in the left, each the size of a cherry
stone, on the outer wall, close to the apex. The skin over
them is red (says it feels tender when washed) ; the
follicles on the surface are distended, and become more so
when squeezed, and ultimately give way in several places,
exuding slightly opalescent fluid, which under the micro-
scope is seen to consist of granular and fatty epithelial
detritus/'
On the second day an indistinct axillary lump was felt
in the right axilla in addition to those described above
(see Table).
On the 9th day the following note was taken :
" Lumps in axillae gone. At the circumference of the
left breast also (see condition on admission) is a still
more marked rudimentary nipple, situated vertically below
the nipple, of a brownish-red colour, decidedly erectile,
with a depression in the centre, out of which milk readily
exudes (confirmed by microscope). None obtained from
the others described on the right breast."
No 196.— Admitted August 23rd, 1884.
On the second day the following note was takes i
"Three inches and three quarters vertically below the
right nipple is a rudimentary nipple of brownish colour
with a faint areola round, and slightly erectile, with a
depression in the centre. None on the opposite side.
No secretion."
No. L98. — Admitted A.ngust 25th, L885
BY THE SKIN OF LYING-IN WOMEN. 435
On admission a rudimentary nipple was found at the
upper margin of the right breast.
No. 200.— Admitted August 25th, 1885.
On admission a doubtful rudimentary nipple was found
at the lower margin of the right breast.
The cases which I have described, and which I believe
have not been hitherto recognised, seem to prove that in
lying-in women the sebaceous follicles of the skin are
capable of producing true mammary secretions. The
transition from granular material, through colostrum to
true milk, is distinct and unmistakeable. They confirm
the opinion that the breast is a highly specialised aggre-
gation of highly specialised sebaceous follicles. The least
specialised form (1) is that here described, where the
skin is merely thickened, and the sebaceous glands may
produce true mammary secretions. The next form is (2)
that where there is an aggregation of the ducts, which is
open by one or more external pores. The highest rudi-
mentary form (3) is where a nipple, or more, is super-
added to the last variety. It is also well known that
nipples may be developed independently.
I have not yet had an opportunity of making a micro-
scopical examination, but these structures are so far from
rare that, when attention is once directed to them, oppor-
tunities are sure to arise sooner or later. The secretions
were too scanty for chemical analysis. It is far from
improbable that they may share the pathological affections
of the breast, and even be the seat of abscess.
Verneuil has described lumps in the skin of various
parts of the body, which he concludes to be situated in
the sweat-glands. One of the favourite places is the
axilla, another the mammary areola. Other situations,
such as the region of the anus, are not like those
which I have described. Not a word is said of any
secretion, nor of their connection with pregnancy and
lying in. Some parts of their characteristics are never-
436 DEVELOPMENT OF MAMMARY FUNCTIONS
theless so much like those above that they are given
below. It will be seen, however, that the details are
comparatively scanty, and that their situation remained a
matter of opinion.
Verneuil's papers are to be found in the ' Arch. gen. de
Med./ v serie, tome 4, 1854, p. 447. (" Etudes sur les
tumueurs de la peau ; de quelques maladies des glandes
sudoripares.")
(Ibidem, ibidem, p. 693.)
(Ibidem, vi serie, tome 4, p. 537.) Sudoriparous
abscesses are common in the mammary areola, in the
axilla, and round the anus. They were called " absces
tuberiformes ou tuberculeux " first by Velpeau, but their
seat was unknown to him. Verneuil calls them " Hidros-
adenite."
(Ibidem, ibidem, p. 542.) These abscesses are rarely
idiopathic, and are nearly always secondary to local or
general causes. Predisposing conditions are to be found
in the acrid and profuse sweats of the axilla, anus, scrotum,
&c, especially in hot weather.
(Ibidem, ibidem, p. 544.) In the absence of local
causes the affection may be due to general causes, such as
scrofula. It is equally common in the two sexes ; it is
common in adult life.
(Ibidem, ibidem, p. 545.) The affection may be situ-
ated anywhere except on the palms of the hands and
soles of the feet, where the thickest part of the epidermis
seems antagonistic to it.
(Ibidem, ibidem, p. 546.) In the axilla, where tin
sudoriparous glands are most developed, their size may
equal that of a pigeon's egg.
(Ibidem, ibidem, p. 547.) They are isolated from the
deep parts of the axilla by fascia, whereas the skin is
distensible.
(Ibidem, ibidem, p. 548.) Septa pass from the skin to
the fascia.
(Ibidem, vi serie, tome 5, p. 327 and p. 437.)
i'. I 12. It tin' skin be loose, thin, and movable, the
BY THE SKIN OP LYING-IN WOMEN. 437
induration can be raised in a fold between the finger and
thumb . . . . ; if the induration be somewhat extended the
skin can be pinched up in front of it ; it is painless or
only causes very slight prickling. Direct pressure, or
pressure between the fingers on the other hand, is painful.
The following case, for which I am indebted to Dr.
John Williams, suggests that these axillary lumps may
be subject to the same sympathetic affections as the
breasts.
E. C — , set. 22, married, had one child twenty months
before she was seen on September 14th, 1885, at Univer-
sity College Hospital, complaining of pain and a dis-
charge apparently the result of inflammation after her
confinement.
She spontaneously complains of a little pain in the left
axilla. When she was between nineteen and twenty she
thinks she had a small swelling there during a menstrual
period.
In the last month or two of her pregnancy she had pain
in the left axilla and felt a lump there ; it went away soon
after her confinement. At the present time her attention
has been again attracted to the same spot, but she has
been unable to find any lump. She is now near the end
of a menstrual period, and a little thickening of the skin
covered by the hairs can be felt.
During her pregnancy she had pain in the left breast,
but not in the right, and during the present menstrual
period she has had it again. As a rule she has had no
pain in the breast except at the menstrual period.
(For report of the discussion on this paper, see 'Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 106.)
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THE
LIGATION OF THE LARGER ARTERIES
IN THEIR CONTINUITY.
AN EXPERIMENTAL INQUIRY.
BY
CHARLES A. BALLANCE, M.S., F.R.C.S.
AND
WALTER EDMUNDS, M.C., F.R.C.S.
Received January 12th— Read May 11th, 1886.
I. — Object of Paper.
The object of this communication is to show that, in the
ligature of a large artery in its continuity, it is neither
necessary nor advisable to tie the ligature so tightly as to
rupture the coats of the vessel ; and, further, to demon-
strate that a small round ligature possessed of certain
qualities and used with the least possible disturbance of
the sheath of the vessel is the best for the purpose.
With reference to the occlusion of the smaller arteries,
such as the radial, and to the ligature of the cut ends
of arteries large or small in an amputation stump, we are
not now concerned. In the former case such vessels do
not require any special precautions or methods in order
to ensure their safe obliteration, and in the latter the
question must be looked at from a different point of view.
444 THE LIGATION OF THE LAEGER
II. — Historical Sketch.
Centuries before the discovery of the circulation1 of the
blood the ligation of arteries for wounds2 and aneurisms3
was practised. A great diversity of opinion has always
existed as to the best method of performing the operation.
The practice of surgeons from the earliest times to the
present day seems to have been based on one or other of
two great opposing principles :
1 Harvey, * De motu cordis et sanguinis,' 1618.
2 Celsus (book v, chapter 26, paragraph 21) : — " But if pressure and astrin-
gents are ineffectual to restrain the haemorrhage, the bleeding vessel is to be
taken up, and a ligature having been applied on each side of the wound in it,
the vessel is then to be divided; the two parts of the vessel will become
united by anastomosing branches, and the orifices will become obliterated."
8 Galen (Kuhn's edition, chap. 23, vol. xi, p. 313) : — " If the artery be large,
and if it be cicatrized beyond the aneurism, the whole of it should be cut
through, and oftentimes that very practice prevents the danger from haemor-
rhage; for it appears plainly that when a complete transverse division is
made both portions of the artery retract on either side, the one above the
part, the other below." Pare (Works, 1579, translation by Johnson, 1665,
p. 323), was the great advocate of the ligature after Galen. He says,
concerning the stanching of bleeding in amputation : " The ends of the
vessels lying hid in the flesh, must be taken hold of and drawn with this
instrument (forceps) forth of the muscles, whereinto they presently after the
amputation withdrew themselves. In performance of this work, you need take
no great care, if you together with the vessels comprehend some portion of
the neighbouring parts, as of the flesh, for hereof will ensue no harm ; but
the vessells will so be consolidated with more ease, than if they being bloodlesse
parts should grow together by themselves." P. 325 : — " Wherefore I must
earnestly entreat all Chirurgeons, that leaving this old and too cruel way of
healing [actual cautery], they would embrace this new, which I think was
taught me by the special favour of the sacred Deity ; for I learnt it not of my
masters, nor of any other ; neither have I at any time found it used by any ;
only I have rend it in Galen, that there was no speedier remedy tor stanching
of blood, than to bind the vessels (through which it flowed) towards their roots,
to wit, the liver and heart. This precept of Galen, of binding and sowing the
veins and arteries in the new wounds, when as I thought it might be drawn
to thesr whirli arc made by the amputation .if member*, I attempted it in
many." Ambrose Pare, 1582 (Pare, Works, Lyon, 1641, quoted by Erichsen): —
" Divide the skin above the aneurism, and, separating t ho artery, pass a seton
needle armed with a strong thread under it, and allow the ligature to fall of
itself. Nature will then generate Beth which will block up the artery."
ARTERIES IN THEIR CONTINUITY. 445
1. That of tying with considerable force in the belief
that damage to the arterial wall was either essential to
obliteration or a necessary safeguard against hseruorrhage.
2. That of treating the artery with gentleness in the
endeavour to cause its obliteration without inflicting the
least injury to it.
The earlier surgical writers, G-alen,1 Paul us iEgineta,2
and others recommend the application of two ligatures
and the division of the artery between them ; an opera-
tion which now bears the name of Abernethy3 (1827), but
many others have practised it. This way of tying an
artery probably originated in the observation that arteries
in amputation stumps are less prone to secondary hemor-
rhage than those tied in continuity ; a fact which explains
the favour with which the operation has lately been
received, and gives the reason for its attempted revival.4
The validity of this analogy was questioned by Sir Charles
Bell5 sixty years ago, and the procedure appears unneces-
sarily severe.
The earlier surgeons belong to the severer school, and
with them must be placed Jones6 (1805), who from experi-
ments upon the lower animals considered that he had
demonstrated conclusively that the tunics should be
ruptured in tying an artery in its continuity. He advo-
cated also the isolation of the vessel and the use of the
small round ligature. He says you must divide the
two inner coats because if you do not adhesion will not
take place, and, as the ligature ulcerates through, hasmor-
1 Loc. cit.
2 Paulus /Egineta (seventh century) : — " The artery having been cleared of
the surrounding parts is to be exposed with the same scalpels with which the
membranes have been divided; a needle being then passed under it, the
artery is to be tied with a double ligature, having previously been punctured
in the middle ; suppuration must then be promoted till tbe ligatures fall out."
(' Observations on Aneurism,' collected and translated by John Erichsen,
Sydenham Society, 1844.)
3 Abernethy, Surgical Works, new edit., 1827.
4 Walsham, ' Brit. Med. Journ.,' 1883, vol. i, p. 660.
* Bell, 'The Great Operations of Surgery,' 1821.
6 Jones, 'On Haemorrhage,' 1805, p. 170.
446 THE LIGATION OF THE LARGER
rhage will occur. And again, " I cannot be expected to
illustrate these opinions by cases, nor would it be easy
to confirm them on dogs, for whom nature does so
much." Thus Jones made no experiment upon the effect
of not dividing the coats ; he inferred it from the process
of repair in nature in wounded arteries, but if the coats are
not cut the artery is not wounded. It is upon this insecure
basis that the established rule of the present day, with
regard to the treatment of the wall of the vessel, rests.
The majority of English surgeons adopted the views of
Jones. In 1813 and 1815 Travers1 reported his experi-
ments to this Society and recommended the employment
of the temporary ligature, and also, as an indispensable
condition of obliteration, the rupture of the tunics.
The milder treatment of the wall of the artery has,
however, long had its advocates. Alexander Monro2
(1725) employed a wide ligature not drawn very tight to
avoid injuring the vessel. Benjamin Bell3 (1787) writes,
in his * System of Surgery/ " There is no occasion what-
ever for making the ligature so tight on arteries as to run
any risk of dividing them ; a much less degree of pressure
than is commonly applied, or could have any influence in
hurting them, being fully sufficient for compressing them
in the most effectual manner." The best known advocate
of gentleness is Scarpa* (1817), who was investigating the
subject in Italy about the same time that Jones was at
work in England. To him is undoubtedly due the honour
of demonstrating that the rupture of the coats of an artery
is not necessary for its obliteration by ligature. Ho
employed a tape ligature to avoid damage to the arterial
wall, and inserted a cylinder of lint between the ligature
and the vessel, so as to flatten the latter. The ligature
and cylinder were removed on the third, fourth, or fifth
i ' Metl.-Chir. Trans.,' vol. iv, 1813, ami vol. vi, 1815.
- .Monro, collected winks, 1725.
3 Bell, ' System of Surgery,' 1787, vol. i, p. 61.
4 Scarpa, ' Mem. sulla Legatura delle principali Arteri degli Arti, con
append) Mill' Anearismi,' 1817.
AETERIES IN THEIR CONTINUITY. 447
day. By this method Scarpa and his followers obtained
numerous successful results. In this country, however,
Jones's views were already accepted, and consequently the
Italian surgeon had scarcely any English adherents. But
in 1821 Sir Charles Bell1 published his work entitled
1 The Great Operations of Surgery/ and in it directs that
" the loop and knot of the ligature be sunk into the coats
sufficiently to prevent the pulsation of the vessel shifting
the ligature, but not drawn so tight as to cut the inner
coats of the artery."
Many years before the discussion between the adherents
of Jones and Scarpa (as to the best treatment of the wall
of the artery) had become acute, the great advance of
cutting ligatures short was attempted. This, it would
appear, was first carried out by two assistant surgeons of
the Eoyal Navy, Mr. Lancelot Haire2 and another at the
Haslar Hospital about the year 1 780. To Lawrence3
(1814) is due the development of this practice, which was
not wholly satisfactory, for, as in Haire's cases, though the
wounds healed by first intention yet subsequently the liga-
ture almost always suppurated out. The next step was
the trial by Astley Cooper* (1817) of catgut with the ends
1 Bell, 'The Great Operations of Surgery,' 1821.
2 Lancelot Haire, ' London Med. Journal,' vol. vii, 1786 : — " An intimate
friend of mine, a surgeon of great abilities, proposed to cut the ends of the
ligatures close, and thus leave them to themselves. By following this plan
we have seen stumps healed in the course of ten days. The short ligature,
thus left in, commonly made its way out by a small opening, in a short time,
without any trouble, or tbe patient being sensible of pain."
3 ' Med.-Chir. Trans.,' vol. vi, 1814.
4 Catgut was first used on account of its absorbable qualities by Sir A.
Cooper. See ' Surgical Essays,' by Sir A. Cooper and Benj. Travers, vol. i,
p. 125. A man, aged 80, with popliteal aneurism; ligature of femoral artery
witli catgut ; ends cut short ; wound healed by first intention in four days ;
patient up and about in three weeks. He remarks, " I confess that this case
gave me much pleasure j the great age of the patient, the simplicity of the
operation, the absence of constitutional irritation and consequently of danger,
and his rapid recovery, lead me to hope that the operation for aneurism may
become, at some future period, infinitely more simple than it has been rendered
to the present moment " (ib., p. 129). Prof. Physick used buckskin in 1814 as
an absorbable ligature.
448 THE LIGATION OF THE LARGER
cut short. He tried to get the ligature absorbed. His
first case was a brilliant success, but his second case did
not do well and he abandoned the practice. It is true
that Galen1 had long before recommended catgut, but he
only did so if hemp or silk was not obtainable, and he
says that the substance of the ligature should be such
that it will not readily dissolve. To Lister2 (1881) we
are indebted for a method of preparing catgut which
avoids the risk of its being absorbed too soon, and so
makes it trustworthy.
The recognised practice at the present time may be said
to be the use of the aseptic silk or catgut ligature so
applied as to cut the coats of the vessel.
Lastly, it will be in the recollection of the Fellows that
Mr. Barwell8 (1879) has recently brought before the
Society his plan of using tape-shaped animal ligatures for
the ligation of arteries for the cure of aneurism. In his
hands the practical application of this method has been
most successful. Very recently Mr. Bennett May4 has tied
the innominate artery for subclavian aneurism with a liga-
ture composed of six strands of catgut. The latter was
1 Galen (' Metliodns medendi,' liber xiii, ch. 22), speaking about bleeding,
says, " But if, on laying bare the vessel, it should appear to you large, and
to pulsate strongly, it is safer for the operator to put a (double) loop round
it and to divide between; and let these ligatures be of a material that will
not readily decompose. Such a material in Rome can be got from the Gaietaus,
who bring it from the country of the Kelts and sell it in the Via Sacra, which
leads from the Temple of Roma to the markets. This is the easiest thing t<>
get in Rome, for it is sold very cheaply there; but if you are practising your
art in another city prepare for yourself some of tin threads known as silk;
rich women have these in many parts of the Roman empire, and especially in
tlic large cities. It' you cannol get this, choose the material least liable to
decompose from among those that you can get where you are, such as tine
catgut, for materials which easily decompose fall quickly out of the vessels,
but we wish the knot only to fall out when the vessels have been well covered
round with flesh, for the flesh which grows up in the parts of the vessels
which has been cut oft acts as a covering and stops its mouth, and when that
has happened is the time for ligatures to separate without danger."
3 ' Lancet, vol. i, 1881, p. 201.
' Med.-Chir. Trans.,' vol. lxii, 1879.
4 ' Lancet,' vol. i, 1886, p. 1064.
ARTERIES IN THEIR CONTINUITY. 449
drawn sufficiently tight to arrest all pulsation in the
tumour, but not so tight as to impair the integrity of the
arterial wall. There are few surgeons of the present day
who practise the gentle treatment of the wall of the vessel,
but to-night we desire to support their position from the
experimental stand-point, and to recommend the employ-
ment of the small round absorbable ligature.
III. — Opinion of the Present Day.
The statement occurs or is implied in the language
made use of in all recent text-books of surgery, that in the
operation of ligature of an artery in its continuity the aim
of the surgeon should be the complete division of the
internal and middle coats of the vessel ; and further, many
and diverse ill results, such as hseniorrhage, or return of
pulsation in the sac of the aneurism, are foretold as the
probable consequence of any failure on the surgeon's part
in carrying out this cardinal rule.
It is only necessary to refer to current surgical litera-
ture under the head of " Directions for the Operation/'
and whether the work of Bryant,1 Erichsen,2 Farabeuf,3
Heineke,4 Holmes,5 or Mac Cormac6 be consulted, the opera-
tor is told alike by each and all to tie the ligature strongly
and steadily in order to divide the internal and middle
arterial tunics. In most books, however, there is to be
found evidence of considerable hesitation in the discussion
of the subject. Heineke4 is very uncertain, not knowing
to which view to give the preference ; he says, " It is only
necessary that the artery be tied so tightly that the folds
of the intima come in contact, but the ligature may
1 ' Practice of Surgery,' 3rd edit., vol. i, p. 413.
2 ' Science and Art of Surgery,' 9th edit., vol. i, p. 415.
3 ' Manuel Operatoire,' 1881, pp. 24, 25.
1 Billroth und Leiicke, ' Deutsche Chirurgie,' Band 18, p. 94.
4 Holmes, ' System of Surgery,' 3rd edit., vol. iii, p. 101.
' Surgical Operations,' Part I, 1885, page 19.
VOL. LX1X. 29
450 THE LIGATION OF THE LAEGER
without disadvantage be drawn more tightly, in which
case the inner coats are generally ruptured." Holmes
and Erichsen give facts and arguments bearing on both
aspects of the question. The former1 says, " I have used
Mr. Barwell's ligature myself with great success ;" and
again, " It is therefore probable enough that Mr.
Barwell's view may be correct, but it cannot be said to
be proved as yet, and I confess that I have always felt
safer in drawing the ligature as tight as possible."
Mr. Erichsen,2 after mentioning the great danger of
haemorrhage subsequent to ligature of the first and second
parts of the subclavian artery, concludes with the remark,
" that the operation ought to be banished from surgical
practice unless further experience shows that absorbable
ligatures can be applied with certainty in such a way as
to occlude the artery without division of its coats." Mr.
Bryant8 observes, when discussing the sloughing away of
the portion of an artery included in a silk ligature, " that
herein lies the weakness of the treatment by ligature."
Lastly, Sir W. Mac Corniac* makes the following state-
ments, which are germane to the object of this paper :
" With some surgeons it is even now a question, as it was
in Scarpa's day, whether or no it is desirable or necessary
to divide by the ligature the internal and middle coats ;"
and again, " This practice has probably a better chance
of success now than formerly as absorbable material is
used."
IV. — Authors' first Vu ws.
It is some years ago now that we first privately dis-
cussed the question of the ligature of an artery in
continuity. The experiments of Scarpa and his contem-
poraries, and also those of the younger Cline and South
1 Loc. cit., 3rd edit., vol. iii, p, 101.
a Loc. cit., 9th edit., vol. ii, p. 201.
3 Loc. cit., vol. i, p. 461. * Loc. cit., p. 28.
■ • I Itaelioa1 Surgerj .' transit tod l>v South, 1817. vol. ii, p. 221 -.—" A thread
ARTERIES IN THEIR CONTINUITY. 451
(which show that by applying a ligature quite loosely
around the carotid of a large dog the vessel becomes per-
manently occluded), seem to indicate that, by division of
the coats of a vessel when not absolutely necessary to
attain the end in view, surgeons are departing from that
salutary law which precludes during operative measures
any unnecessary injury to the tissues of the body. The
evidence in this direction has gradually accumulated, and
has led to the belief that the importance attached to
damaging the arterial wall has been exaggerated and mis-
stated, aud that the operation of ligation in continuity
ought to be reviewed in the light of recent advances in
surgery and pathology.
V .—Experimental Investigations.
By the kind permission of Prof. Birch Hirschfeld and
Dr. Hiiber we put our views to the test of experiment in
the pathological laboratory of the University of Leipzig.
The experiments were made on sheep and horses, and we
ligatured altogether sixteen carotids in sheep and three
in horses. Strict antiseptic precautions were adopted ;■
corrosive sublimate and carbolic acid being used for this pur-
pose. The former answered best. The ligatures employed
were kangaroo tendon from one twentieth to one twelfth of
an inch in width, chromic catgut Nos. 3 and 4, and the green
sulphurous catgut about No. 3 size. Except in Experi-
ments 5, 6, 15, 16, 18 and 19 the ligature was drawn upon
until pulsation on the distal side was arrested. The
cavity of the artery is completely blocked in Specimens
No. 15 and No. 19. It is much encroached upon in
artery No. 18, but is scarcely involved at all in Specimens
Nos. 5, 6, and 16. Excluding the above exceptions the
applied around the carotid artery of a dog so loose as not to interfere with
the passage of the blood, is sufficient to cause inflammation, which will block
it up completely, as was proved by an experiment made by my able master
the younger Cline, and which I myself have repeated with the like result."
452 THE LIGATION OF THE LARGER
vessels were tied so that the luniina were nearly or wholly
obliterated without any injury to the walls of the vessels.
All the wounds in the sheep healed by first intention and
remained aseptic throughout. Those in the horses sup-
purated more or less. The animals were killed at such
periods as to allow of the vessels being removed at times
varying from nine hours to seventy-three days. It will
be observed that most of the vessels were removed from
the bodies of the animals within three weeks. It was
desired first to demonstrate the action of the small round
ligature in occluding a vessel without damage to its wall,
and to show that such an operation was easy and practi-
cable. If a longer period had been selected it would
have been difficult to convince everyone that the walls of
the vessels were not ruptured, because the plastic process
after a time obliterates the normal outline and the usual
landmarks. Having proved the ease with which, by the
small round ligature, ligation in continuity without rupture
of the tunics can be done, we hope at some future time
to make further experiments of a like kind, but with the
arteries removed from the bodies of the animals at longer
periods after ligature. Experiment 19 illustrates this
point, but at present it stands alone. The carotid of a
horse is seen permanently occluded on the fifty-first day.
Experiments 5, 6, and 16 taken together are very
important. In No. 6 the artery is contracted and pervious
after seventy-three days. In No. 5 (fifty-eight days) and in
No. 6 (forty-four days) the vessels are filled with clot which
is not adherent to the wall and which shows no evidence of
organising changes. In each of these cases the v
was scarcely, if at all, constricted by the ligature, and the
tunica intima was thickened on account of its proximity to
the clot. In all three a coagulum had formed which in
one case had been washed away, whilst in the other tun
it would soon have met with the same fate. We can
conclude therefore from these three experiments : —
That South and Cline were mistaken when they Btated
that an artery became permanently occluded by having a
ARTERIES IN THEIR CONTINUITY. 453
lig-ature placed loosely around it ; though a coagulum does
form which lasts for about sixty days.
The kangaroo tendon was tied with the reef-knot, the
catgut with the " double hitch " or surgical knot.
The majority of the vessels were immersed for preserva-
tion in equal parts of glycerine and absolute alcohol and
brought to England for further examination, but some
(six) were placed in carbolic solution (1-20). The alcohol
caused the vessels to shrink to about a quarter of their
original size.
Each vessel was split longitudinally through the middle
of the knot of the ligature, so that the portion of the
arterial wall subjacent to the knot and most exposed to
injury comes well into view. One half was saved to be
mounted as a naked-eye specimen in glycerine jelly, and
the other part was reserved for the microscope.
"We have much pleasure in thanking Mr. Horsley for his
kindness in allowing us to use the Brown Institution for
the purpose of working up our material.
VI. — Specimens described and considered.
Scheme of Experiments. — The following carotids of sheep
were tied with kangaroo tendon. The ligature was applied
except in the two cases mentioned below, so as to arrest
the current of blood.
Exp. 1. — Carotid seven days after ligature. Lumen
not quite obliterated. Commencing organisation of new
material which is taking the place of the clot.
Exp. 2. — Carotid ten days after ligature. Lumen not
quite obliterated. Organisation in clot more evident.
Exp. 3. — Vessel fourteen days after operation. Lumen
occluded. Increasing development of new material in
coagulum.
Exp. 4. — Vessel twenty-one days after operation.
Lumen nearly occluded. Near the ligature the organisa-
tion of plastic material extends across the clot joining the
opposite intiinse. (See Plate XL)
454 THE LIGATION OF THE LARGER
Exp. 5. — Carotid fifty-eight days after operation. The
ligature was placed loosely around the vessel without any
attempt being made to control the passage of blood through
it. The endothelial lining of the innermost coat is much
thickened. The surface of the ligature is commencing
to give way before the attack of the leucocytes. A clot
fills the vessel which is not adherent, in which no organ-
isation is taking place, and which would have been washed
away in the blood stream if the animal had been allowed
to live. This point is illustrated by the next experiment.
Exp. 6. — Carotid seventy-three days after ligature. As
in the last case so in this, the ligature was applied around
the vessel without any attempt being made to control the
passage of blood through it. The ligature can still be
seen with the naked eye. There is evidence that it
slightly constricted the arterial wall. With the microscope
its outline appears irregular ; this is caused by absorption
by the cellular invasion. In a very short time more,
without doubt, it would have entirely disappeared. The
vessel itself is contracted and diminished in size but
pervious. The internal tunic is much thickened, especially
the endothelial layer. It is certain that it was for some
time obstructed by a coagulum which has been carried
away by the blood stream.
The following carotids of sheep were tied with catgut,
Macfarlan's No. 3 chromic catgut was employed except in
the instances detailed. Each ligature (except in Experi-
ments 15 and 16) was intentionally pulled upon until on
its distal side the pulsation in the artery had ceased.
Exp. 7. — Vessel nine and a half hours after operation.
Chromic catgut No. 4 was the Ligature used. Lumen
obliterated by the ligature.
Exp. 8. — Carotid twenty-tour hours after operation.
Green Bulpho-chromic catgut No. 3 was used. Lumen
occluded.
Exp. 9. — Vessel three days after operation. Calibre
obliterated by the ligature.
Exp. 10. — Vessel seven days after operation. Lumen
ARTERIES IN THEIR CONTINUITY. 455
not quite obliterated. Commencing organisation of clot
near seat of ligature.
Exp. 11. — Vessel nine days after ligature. Lumen
nearly occluded.
Exp. 12. — Vessel ten days after ligature. Calibre
nearly obliterated.
Exp. 1 3. — Carotid fourteen days after operation. Calibre
obliterated. Progressive organisation in clot.
Exp. 14. — Vessel twenty-one days after ligature.
Calibre obliterated by ligature. Extensive organisation
of plastic material in clot near the seat of ligation.
Exp. 15. — Vessel thirteen days after ligature. Complete
obliteration by the ligature of the lumen of the vessel.
Exp. 16. — Vessel forty-four days after ligation. No
attempt was made in this case to arrest by the ligature
the passage of blood through the artery. A coagulum is
present which is not adherent and which in the speci-
men has mostly fallen out. It shows no evidence of vital
changes, and if the animal had been allowed to live would
without doubt have been carried away in the blood stream.
The tunica intima is much thickened. The catgut liga-
ture is still holding its own. It must have been excep-
tionally well prepared to resist absorption for so long.
The leucocytes, however, are working their way in from
the surface, but yet the ligature would probably have
remained unabsorbed for another fortnight if the sheep
had been allowed to live.
The following carotids of horses were ligatured :
Exp. 17. — Vessel ten and a half days after ligature with
kangaroo tendon. Lumen not quite obliterated. Com-
mencing organisation in clot at the seat of ligation.
Exp. 18. — Carotid fourteen days after operation. Cat-
gut Macfarlan's No. 3 was used. No attempt was made
to completely arrest the flow of blood at the ligatured
point. The lumen is encroached upon but not nearly ob-
literated by the ligature. In the specimen the clot has
dropped out except at the point of ligation. Much sup*
456 THE LIGATION OF THE LABGfiE
puration took place, hence the great amount of plastic
exudation. The ligature is being rapidly absorbed.
Exp. 19. — Carotid fifty-one days after operation.
Chromic catgut No. 3 was the ligature used. The calibre
at the ligatured point was evidently not quite obliterated.
Organisation in the clot in the neighbourhood of the liga-
ture is complete, for a fibrous union extends across the
interval which had previously been occupied by coagulum
from the inner coat of one side to the inner coat of the
opposite side. The ligature is absorbed. No trace of it
is visible.
The macroscopic1 and microscopic examination of the
specimens show :
1. That in no instance were the arterial coats injured
by the ligature.
2. That except in three cases (Experiments 5, 6, and
16), in which the arteries were only slightly constricted,
the lumina of the vessels were either wholly or nearly
occluded. In other words, at the point of ligature either
the internal coat of one side was in apposition with the
internal coat of the opposite side, or a thin strand of clot
blocked the lumen of the tube at the point of constriction
and was continuous with the main body of the clot both
above and below.
3. That external to the artery, surrounding the ligature
and extending a short distance on either side of it, was a
small amount of constructive exudation-material, due to
the presence of the ligature and the disturbance of parts
which was a necessary coincidence of the operation.
When suppuration took place, as in Experiment 18, the
amount of plastic exudation thrown out was much
greater.
4. That the ligature, whether of tendon or catgut, to
the naked eye is practically unaltered, is not producing any
irritation, and is holding well at the end of twenty-one
I be macroscopic specimens are preserved in the museum of the Royal
College of Surgeons.
ARTERIES .IN THEIR CONTINUITY. 457
days. In Experiment 19, fifty-one days after operation,
the catgut ligature has disappeared. In Experiment 6,
seventy-three days after operation, the tendon ligature is
almost entirely dissolved.
5. The gradual diminution and contraction of the vessel,
which was most marked on the proximal side of the liga-
ture. (Those arteries which were taken from the bodies
of the animals twenty-one days after operation, were
discovered by measurements taken immediately after death
to have shrunk to less than half their diameters at the
time of ligature.)
6. The decolorisation and absorption of the clot and the
organisation of plastic material which is taking its place,
is well seen in the neighbourhood of the ligature when
the latter wholly or nearly obstructs the cavity of the
vessel, and in three weeks by this process the proliferating
endothelium of one side is in vital union with the prolifera-
ting intima of the opposite side — the clot space being
thus rapidly bridged across. When the vessel is only
slightly constricted a coagulum forms but it remains a
" foreign body " destitute of vital action until it is carried
away by the blood-stream.
7. A careful investigation of this series of experiments
demonstrates clearly —
1. That when an artery is only slightly constricted it
becomes temporarily blocked for a considerable time — from
fifty to seventy days. It then, much diminished in size,
resumes its function as a carrier of blood.
2. That when an artery is wholly or nearly occluded
by the ligature, plastic processes (which can be readily
traced from their commencement a few hours after ligation
to their completion fifty days later in the microscopic
sections) supervene which permanently block the lumen
of the vessel, which unite the inner coats of opposite sides
and which practically finally convert the artery at the seat
of ligature into a solid fibrous band.
458 THE LIGATION OF THE LAEOBE
VII. The Coagulv in .
The clot which forms above and below the seat of liga-
ture is not in any sense a necessary part of the process
by which an artery is obliterated. Ziegler,1 Cornil and
Ranvier" and others3 have advocated this view. Travers4
experimentally proved its non-essential nature though
many before his day had combatted the doctrine of Petit.5
The coagulum within a deligated vessel is as much a
foreign and dead substance as the clot on the flap of an
amputation stump. It, like the aseptic animal ligature
encircling the artery, is gradually absorbed. Its function
is to act as a barrier or buff er between the impulse of the
blood-stream and the seat of ligature where the important
plastic actions are in progress which might otherwise be
disturbed or interrupted ; and also, perhaps, in the vicinity
of the ligatured point to afford some support — ladder- like
— to the plastic6 effusion as the latter climbs across the
cavity of the vessel. Whether the tunics be ruptured or
not, the coagulum takes no part in the adhesive process by
which the final occlusion of the vessel is secured, but upon
its deficient formation, when the arterial wall is damaged,
may depend an attack of secondary haemorrhage, especially
if a large collateral branch be close to the deligated point.
The adhesive changes only involve the clot in the imme-
diate neighbourhood of the ligature. The remainder of
the clot, which is the greater part, after some time dis-
appears and its place is occupied with fluid blood again.
'rinse changes always end in a permanent diminution of
1 Ziegler, ' Pathological Anatomy,' pt. 2, pur. 235.
2 Cornil et Ranvier, ' Manuel d'Histol. Pathol.,' 1881, vol. i, p. 601.
i Spence, 'Lectures on Surgery,' p. 515 j Farabeuf, 'Manuel Operatoire,'
1881, p. 28.
' Loc. cit.
6 Petit (1710) was the fu-.-t to conduct experiments on the ligature of arte*
Be thought the coagulum was the chief factor in the arrestment of
hemorrhage and the process of obliteration.
''■ John Bell,' Principles of Surgery,1 L801, eol. \\ Jones, loc cit., p. 160
ARTERIES IN THEIR CONTINUITY. 459
the calibre of the vessel above and below the ligatured
point.
Our specimens illustrate these views. In each case in
which the vessel cavity was entirely or almost entirely
obliterated by the ligature, the microscope shows that a
cellular infiltration is taking place into the wall of the
vessel around the ligature and into the clot. The longer
the interval which elapsed between ligation and the death
of the animal so much the more organised is the plastic
effusion. By means of these cells the clot near the ligature
is decolorised and with the ligature is at last completely
absorbed. Vessels developed from the formative material
which is taking the place of the clot are to be seen at the
end of a fortnight or three weeks passing across from the
proliferating intima, or plastic effusion, within the intima of
one side to the intima of the opposite side. In other
words the inner coats of opposite walls are commencing
to be adherent. Already there is a living connection, and
the intervening space is filled with a tissue which only
requires a short time more for its perfect development.
The same adherent changes are evident in the thin
strand of clot, which in some instances is visible at the
point of ligation, as are seen in the main body of the clot
just above and below the ligature when the lumen of the
vessel is obliterated. In those sections in which the tunica
intima of one side is shown approximated to the tunica
intima of the other, there is a direct vital adherence with-
out the assistance of any intervening material, but depend-
ent upon, as in the former case, the plastic cellular extra-
vasation. This is of the utmost importance, for it proves
that it is of comparatively little moment whether the
ligature which does not damage the coats completely or
almost completely closes the lumen of the vessel. In
Experiment 19 the carotid of a horse which was not com-
pletely closed by the ligature is converted at the seat of
constriction into a solid fibrous band.
Keidel1 is said to have made the inner surfaces of an
1 Quoted by Eieglerj ' Pathol. Anat ' (Eng, trans.), vol. ii, p. 14.
460 THE LIGATION OF THE LAR'.I I.
artery cohere by multiplication of the opposed endothelial
cells without the formation of clot. Of the accuracy of
this observation we have grave doubts. Any alteration
in the endothelial lining would certainly lead to the
formation of a coagulurn, and the endothelial multiplication
in our specimens is always accompanied by a leucocytic
extravasation, the latter apparently being of more import-
ance than the former. A long time after ligation the
clot disappears and leaves the interior of the vessel — on
either side of the ligatured point — in shape something like
a hollow cone. This may possibly be the explanation of
the statement of Reidel.
The time at which the clotting took place in these
experiments is a matter of doubt, but it probably super-
vened soon after the operations were over. The shortest
time which elapsed between ligation and the death of an
animal was nine hours. Here the clot was perfectly
formed. When the coats are ruptured the clotting com-
mences at once on the infolded edges of the cut tunics, but
in these arteries no such cause was present and the
development of the coagulum must be attributed, not to
the stasis of the blood current, but to the change in the
vital state of the arterial wall due to the pouring out of
lymph at the point of ligature.
VIII. — The Ligature.
Experiments upon arteries in the post-mortem room
show :
1. That the effects produced by the use of a silk or
other ligature applied in the ordinary way are not uniform.
The middle coat is sometimes only partly cut through but
in other instances a mere strand of tissue representing the
outer coat almm remains, which remnant is thinnest and
quite transparent under the knot of the ligature. Here
then is ample reason for the occasional occurrence of
ARTERIES IN THEIR CONTINUITY. 461
haemorrhage ; for not only is the wall of the vessel nearly-
divided at every point but in the knot region the outer
tunic has almost given way. During last autumn the
opportunity was afforded of dissecting a case in which
secondary heemorrhage, preceded by some suppuration,
occurred after ligature of the carotid. The wall of the
vessel had given way at its weakened and most disabled
point, i. e. nearest the skin under the knot.
2. That there is no difficulty in tying an artery with a
small round ligature sufficiently tight to make it imper-
meable to water without the least damage to the coats. The
occlusion is caused by a longitudinal wrinkling of the wall.
3. That a tape-shaped animal ligature a quarter of an
inch in width will rupture the coats of an artery if force
be used. The knot of such a ligature is clumsy and the
tape does not lie flat in the neighbourhood of the knot.
The choice of material for the ligature has been much
debated.
1. It is not easy to make silk aseptic. This is prob-
ably on account of the presence of recesses in which
bacteria can lodge. When employed outside the peri-
toneum there is some uncertainty as to what will happen
to it. It may become encysted or it may ulcerate out.
The question in the past has been one of gangrene at the
seat of ligature and of inflammation on either side ; now
suppuration in such a wound is and ought to be the excep-
tion. Senn1 has shown that a silk ligature applied to an
artery in its continuity without damaging the tunics always
cuts its way through the vessel and frequently becomes
encysted by the side of it. Dr. Kolliker, of Leipzig, informed
us that of eighty amputations antiseptically performed in
which he had carefully searched for the silk ligature used
for the main vessel, he had only succeeded in finding it
in about one third of the cases. He supposed that some
of the ligatures had escaped his observation and that it
was fair to estimate that one half remained encapsuled in
'Trans. Amer. Surg. Assoc.,' vol. ii, 1885, p. 345.
462 THE LIGATION OF THE LARGE!-;
the stumps and one half came away in the discharges.
Silk1 then hardly fulfils our ideal of a perfect ligature for
aseptic wounds.
2. Of late years catgut has been extensively used.
Lister2 lays stress upon its preparation, specially insisting
upon the scraping off of the mucous and peritoneal sur-
faces of the bowel from which it is made ; and upon the
fact that it is absorbed from the surface. Our microscopic
preparations demonstrate, however, that our catgut had not
had the mucous coat removed for villi and mucous
follicles are to be seen. To the naked eye there is no
change visible even at the end of twenty-one days. With
the microscope at the end of the third day the dendriti-
form arrangement of villi and mucous follicles can be
easily made out following certain wavy lines which cross
the section of the catgut. On the seventh day after liga-
ture this appearance is not nearly so clearly defined, and
there are some cracks or splits running from the surface
towards the centre. Along these splits leucocytes are
gathering. Fourteen days after operation the dendr iti-
form picture has disappeared and the cracks are wider
and deeper ; and at the end of twenty-one days the fis-
sures are still more marked and the circumference of the
catgut and the sides of the cracks bear evidence at
several points of the eroding and absorbing influence of
the surrounding leucocytes. (Plate XIII.)
In Experiment 18, in which profuse suppuration followed
the ligature of the carotid of a horse, the ligature — catgut
— is breaking up rapidly at the end of fourteen days. In
Experiment 10, in which the vessel was removed fifty-one
days after operation, there is no trace of the ligature. In
the microscopic sections of artery No. 16 the catgut,
which is apparently exceptionally good, is holding well
after forty-four days. We think that well prepared
chromic catgut will last for one month or mere; and,
as a Ligature upon an artery in continuity, will not give
1 Holmes, ' Surgery, its Principles and Practice, ' p. 94,
Loc. cit.
ARTERIES IN THEIR CONTINUITY. 463
way in a less time unless very profuse suppuration
occur.
3. The tendon used by us has several points in its
favour :
a. The structure is continuous throughout, and there
are no spaces as there are in catgut, due to twisting in its
preparation.
b. It does not split or crack during absorption, which
takes place " from the surface/'
c. It is easily made aseptic.
d. It is only gradually, and after a long time, acted
upon by the living materials which encompass it.
Kangaroo tendon is very convenient for practical use,
being strong, of ample length, and becomes as supple as
silk by soaking for half an liour in tepid sublimate
solution.
The tendon ligature shows scarcely any absorption on
the surface at the end of twenty-one days. Leucocytes
are collecting, as in the catgut specimens, in a dense mass
on the outer side. In Experiment No. 5 the tendon is
seen fifty- eight days after operation and does not exhibit
much change except on the surface microscopically. In
Specimen No. 6 the tendon seventy-three days after liga-
ture shows unmistakeable signs of disappearance. The
circumference is deeply indented and wavy in outline.
We consider that kangaroo tendon ligature may be
looked upon as trustworthy for at least two months.
IX. Objections discussed.
The following are some of the objections which maybe
raised :
1. That conclusions based upon the ligature of the caro-
tids of sheep, and ivhich are intended to be a guide to
practice, are founded upon an analogy which is not wholly
supported by the facts, because ;
464 THE LIGATION OF THE LARGER
A. The circulation in sheep and other herbivora is not
so vigorous as in man.1
b. The carotid of a sheep is not quite so large as a
human carotid.
To meet this objection the carotid artery of the horse
was ligatured in three instances. This vessel is much
larger and the blood pressure is much greater than in the
corresponding artery of man. The macroscopic and
microscopic preparations of these three horse carotids
show exactly the same changes as are seen in the ligatured
carotids of sheep; and in Experiment 19 the carotid of a
horse at the end of the fifty-first day is converted at the
ligatured jjoint into a solid fibrous mass.
2. That it does not matter under the Listerian sysU m
ivhether the tunics be ruptured or not; that there is no
danger involved in the division of the coats, and th<tt the
result cannot be (ivith primary union of the wound) ilisas-
trous to the patient.
There can be no dispute about the supreme desirability
of obtaining perfect asepsis, but to the belief as stated
above we cannot subscribe, because :
a. It is not justifiable to do more than is absolutely
necessary to attain the end in view.
b. It cannot be expected that wounds will always heal
by first intention and remain aseptic throughout. Though
most cases of ligature of arteries in their continuity with
strict antiseptic precautions are successful, it is not well
1 The relative blood-pressure in the carotid of man, compared with that in
the same vessel of other large mammals, is as follow s :
Horse ..... 160 — 220 mm. of mercury.
Sjieep 155—210 mm.
Man 150—200 nun.
Large dog .... 140 — 180 mm. „
From private letter (Mr. Langley, >>f Cambridge).
The relative size of the dead carotid of man, compared with the Bame vessel
of the horse and slice]), is as follows:
Outside diameter. Inside diameter. Thickness of coat.
Sorse . . 12 mm. ... 9 mm. ... Li mm.
Man ... 7 mm. ... 5 mm. ... 1 mm.
Sheep . \&\ mm. ... 4 mm. ... mm.
ARTERIES IN THEIR CONTINUITY. 465
to trust too much to asepsis. It has already been shown
what may happen if asepsis be not perfect.
The minimum of unsuccessful cases may probably be
greatly reduced by the employment of means which, while
efficiently occluding the vessel, do not at the most critical
moment, and at the situation of greatest strain, destroy the
strength of the arterial wall.
3. That it is more difficult to tie a vessel without
damaging its coats than to tie it in the ordinary way. — To
this statement a denial must be given, for we are sure
from experiments upon dead arteries that it is just as easy
to learn thus to tie an artery as to ligature one by main
force.1 It is always possible to tell at once when the
ligature must not be drawn any tighter, for a certain
resistance is felt by the fingers which, if overcome, is
overcome suddenly and with a snap, and means the giving
way of the two inner coats of the vessel ; and further, the
cessation of pulsation in the artery or its branches beyond
the ligatured point, or in the case of aneurism the cessa-
tion of pulsation of the tumour, is an important indication
to the operator to abstain from tightening much more the
knot of the ligature.
4. That it is not easy perfectly to occlude an artery
xoithout rupturing its coats. — This, however, is not the fact.
It is quite easy in the post-mortem room to tie an artery
with an ordinary silk ligature without any damage to
the tunics and yet so completely to occlude the vessel as
to prevent the passage of any water even when the latter
is forced in by means of a syringe. The specimens show
moreover that it is not necessary that the tunica intima
of one side should be in apposition with the tunica ifitima
of the opposite side, though in some instances this perfect
approximation does obtain. Supposing the lumen of the
artery not to be completely closed by the ligature and a
small space to remain through which blood could find its
way in small quantity, clotting must inevitably soon take
place. But even if coagulation were delayed for some
1 Farabeuf, loc. cit., p. 26.
VOL. LXIX. 30
466 THE LIGATION OP THE LARGER
hours the trickling of a little blood through the vessel at
the ligatured point would be by no means disadvantageous
from the point of view of the formation of a firm clot in
the sac of the aneurism.
5. That the ligature may rapidly dissolve so that the cir-
culation through the vessel becomes quickly re-established. —
This has happened in actual practice1 with carbolic catgut.
Such a result is not surprising, considering that ligatures
of badly prepared catgut may separate and be found in
the discharges thirty-six or forty-eight hours after an
operation.
Our specimens show that properly prepared chromic
catgut or kangaroo tendon possesses great powers of
resistance to the action of living tissues and prove there-
fore that with well-selected materials an untoward event
of this sort could not happen.
6. That the vessels may become pervious after a more or
less lengthened period by absorption of the ligature and
canalisation of the clot or new material at the point of
ligature. — To this objection it may be urged :
a. That aseptic ligatures can only be absorbed or en-
capsuled. That the former would certainly have happened
in our cases but that the materials used would have been
entirely absorbed, only after some months when all sur-
rounding parts would have changed into fibrous tissue.
b. That though a clot, when it remains at the point of
ligature simply as a lifeless mass (as in those instances in
which the arterial wall is only slightly constricted) must
be ultimately carried away in the blood stream, yet when
organisation does occur to the extent of bridging over
the iaterval occupied by the coagulum, it must continue
until the " new material " is changed into a permanent
fibrous mass.
c. That granting for the sake of argument that the
circulation would be re-established in some modified
degree, it is obvious that such an event could not occur
1 Bryant, 'Surgery,' 3rd edit., vol i, p. 414; Treves 'Brit. Med. Journ./
vol. i, 1881, p. 232.
ARTERIES IN THEIR CONTINUITY. 467
except after the lapse of many weeks, and that supposing
e. g. that the operation was performed for the cure of
aneurism, the re-establishment of the circulation would
be heralded long before by the effectual cure of the disease
as far as the cure was dependent upon the passage of
blood through the vessel tied.
7. That if suppuration occur in the wound the patient
would he placed in a position of greater danger than if the
arterial wall had been dealt with in the usual way. — We
are, however, convinced from the study of the history of
ligature before and since the antiseptic era, that the
danger to the patient is greatly augmented by the division
of the two internal layers of the arterial wall. We have
dissected a case in which the popliteal artery passed safely
through the centre of a large abscess cavity, suffering
only a slight thickening of its sheath and outer coat, and
had there been any artificial injury to the barrier of the
arterial wall the chances of a disastrous termination from
haemorrhage would have been very much magnified. In
St. Thomas's Hospital museum are the carotids of horses
tied with rupture of the tunics by Travers. In several
of these cases severe secondary haemorrhage occurred,
in one case to syncope. On looking at our three specimens
it will be seen that haemorrhage could not occur, for the
vessel wall in each case is intact, though suppuration
supervened, and in Experiment 18 was most profuse.
The strongest section of the arterial wall, when the coats
are uninjured, is at that point where it is strengthened
by a scaffolding of ligature plus the sheath of plastic
exudation material which is rapidly developed into young
fibrous tissue.
8. That1 plastic lymph is effused as a consequence of the
injury done to the coats, and upon the amount and vitality
of the effusion depends the safe closure of the vessel. That2
the injury done to the intima is of cardinal importance for
the formation of thrombus and the development of adhesive
1 Mac Cormac, loc. cit., p. 25. 2 lb., p. 29.
468 THE LIGATION OF THE LAEGEB
inflammation. That1 if these coats are not lacerated it is
probable that no lymph will unite their opposed surfaces. —
The naked-eye and microscopic preparations of the vessels
in our experiments, however, show an effusion of lymph
which is ample for the purpose in view, viz. the occlusion
of the vessel, so that the plastic exudation cannot be said
to be dependent in quality, though possibly in quantity,
upon rupture of the tunics.
9. a. — That when two endothelial surfaces are brought
into contact they unite ivith difficulty, and that therefore it
is necessary to interrupt the continuity of the tunics.
b. — That it is an advantage to bring, by means of the
cutting ligature, the adventitia of one side into close relation
with that of the opposite side, because union between areolar
structures is rapidly effected.
Our preparations clearly demonstrate that these are
theoretical issues having no foundation, and that union is
obtained as firmly and as rapidly, and more safely, when
the tunics are undamaged than when they are divided.
Other endothelial surfaces when in contact are known to
adhere on the least provocation. Ziegler* says " that a
blood-vessel has an anatomical analogy to the serous
cavities " and that " the process by which a thrombus
is organised resembles most closely the plastic inflam-
mation of a serous membrane.' ' The presence of a ligature
even when loosely applied round an artery is sufficient to
cause a slight deviation from the normal nutrition of the
part, accompanied by plastic effusion, proliferation of the
endothelium, and coagulation of the blood.
Ziegler figures an organising thrombus from the femoral
artery of an old man. The tunics had been ruptured and
the examination was made three weeks after ligature.
Let this picture be compared with the process as seen in
a sheep's carotid twenty-one days after operation without
division of the coats. In the latter case the process of
organisation is much more advanced than in the former,
1 Holmes's * System of Surgery,' 3rd edit., vol. iii, p. 101.
1 Loc. cit., p. 11.
ARTERIES IN THEIR CONTINUITY. 469
for in the human femoral the blood-cells of the clot are
visible and the large fusiform and ramified cells are only
beginning to be formed near the endothelium and to
extend inwards between the cells of the coagulum ; but
in the sheep's carotid a network of these formative cells
has already extended from the inner tunic of one side across
the clot to the inner tunic of the opposite side, and
the individual cells of the coagulum cannot be distinguished.
In other words, the constructive process as seen in the
plastic effusion, proliferation of the endothelium and dis-
appearance and absorption of the blood-cells and fibrin of
the clot may be said to progress at any rate as rapidly
when the integrity of the arterial wall is secured as when
it is destroyed.
X. Conclusions.
The conclusions at which we have arrived may be briefly
stated as follows : —
1 . That the operation of ligature of a large artery in its
continuity should be performed without damage to its wall.
2. That the rupture of the coats of an artery during
ligation in continuity is a useless and dangerous proceeding.
Useless because the surgeon can secure the effectual
attainment of his object, viz. the occlusion of the vessel,
by a measure at once safer and less severe ; and danger-
ous on account of the possible occurrence of some untoward
event, such as haemorrhage or secondary aneurism at the
seat of ligature, which could not happen if the wall of the
vessel were uninjured by the ligature.
3. That if the wall of the artery be diseased, the
advantages attending ligation without rupture of the
tunics are much magnified. It sometimes happens that
the surgeon on cutting down upon a large artery observes
a state of atheroma so extensive that he is obliged to close
the wound and ligate a vessel nearer the heart and thus
expose his patient to considerably increased risk. There
is no escape from such a dilemma under the system which
470 THE LIGATION OF THE LARGE fi
declares that the arterial coats must be divided ; but with
a non-irritating aseptic ligature so applied as not to lessen
the power of the arterial wall but actually to be a
source of additional strength to it where it is most desir-
able to conserve this quality, the question of ligation is
seen under entirely new auspices, and the occlusion of a
diseased artery would be undertaken with an assurance of
success almost equal to that which obtains when a healthy
vessel is in question.
4. That when the coats of an artery are uninjured by
the ligature, the danger of ligation near a large collateral
branch is wholly avoided, because —
a. No danger can accrue from hemorrhage when the
wall of the vessel is intact.
b. The formation of clot upon which the safety of the
patient so much depends, if the wall of the vessel be
damaged, has really nothing to do with the adhesive
changes which take place in a ligatured vessel.
c. The plastic actions which proceed at the place of
ligation are practically alike whether the tunics be ruptured
or not. In the former case, however, any retardation of
the constructive process, especially when in the vicinity of
a large collateral branch (on account of the general con-
dition of the patient or from accidental slight septicity of
the wound) may be attended with grave risk to life— a
risk which can by no means be made light of even when the
course of events in the wound is apparently favorable. On
the other hand when the tunics are undamaged the
nearness of a collateral branch and suppuration in the
wound are comparatively immaterial, and the reparative
and adhesive efforts of nature as seen in the effusion and
organisation of lymph develop, even when delayed, an
additional stay to the unweakened and living arterial wall.
5. That the ligatures employed in this series of experi-
ments were probably in all cases larger than was abso-
lutely necessary to secure the obliteration of the vessels to
which they were applied. Comparatively speaking they
were not large. It would appear that a small round
ARTERIES IN THEIR CONTINUITY. 471
aseptic ligature which will not become absorbed in a less
time than three weeks, and which during that period holds
firmly so as to cause a constriction of the arterial wall,
and complete or almost complete obstruction of the cavity
of the vessel will so influence the nutrition of the part
that permanent occlusion will follow.
6. That it is no more necessary to use a flat tape-
shaped ligature (as recently revived by Mr. Barwell for
the purpose of preventing damage occurring to the arterial
wall during ligation) than to rupture the coats of the
vessel. The small round ligature is the most easy to
manipulate, and it is not difficult to learn to apply it in
the manner here indicated.
7. That the essentials to be observed in the ligature of
arteries in their continuity are :
a. Complete antiseptic precautions to ensure the pri-
mary union of the wound.
b. A non-irritating aseptic ligature such as kangaroo
tendon or chromic catgut, which will remain for a con-
siderable period without becoming appreciably altered by
the temperature and tissue environment of the living
body.
c. The application of the ligature so as to close or
almost close the lumen of the vessel without causing the
least injury to the arterial wall.
The sum up, we venture, though fully conscious of the
incompleteness of the experimental proof which is placed
before the Society to-night, to advocate —
1st. The use of antiseptic precautions.
2nd. The employment of the small round absorbable
ligature.
3rd. The maintenance of the integrity of the arterial
wall.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii
p. 112).
DESCRIPTION OF PLATES XI, XII, and XIII.
The Ligation of the Larger Arteries in their continuity: an
Experimental Inquiry, by Charles A. Ballance, M.S., and
Walter Edmunds, M.C.)
Plate XL
The carotid of a sheep tsventy-one days after being ligatured with
kangaroo tendon.
JPig. 1. — Under low power, showing that the wall of the vessel is
uninjured. The spot from which the high power drawing (fig. 2)
was taken is marked by lines.
Fig. 2. — Section taken through the clot from one side of the
vessel to the other in the immediate neighbourhood of the ligature.
The cellular invasion and the proliferating endothelium are well seen.
The blood-cells of the coagulum have become indistinguishable. The
new material which is absorbing the clot, and taking its place, is
already so far developed as to form a vital connection between the
intima? of opposite sides.
Plate XII.
Carotid of a horse fifty-one days after being ligatured with chromic
catgut.
Fig. 1. — The lumen of the vessel was, as far as can be made out,
not quite obliterated by the ligature. There is no trace of the catgut
to be discovered, even with the microscope. The place of the clot is
taken by connective-tissue material, which has completely fused with
the intimas of opposite sides. Spot from which high power drawing
(fig. 2) was taken is marked by lines. *Probable position of ligature.
Fig. 2. — High power drawing of part enclosed by lines in fig. 1.
Complete fibrillation of new material which is taking the place of
the clot, and fusion of new material with the wall of the vessel on
either side. The organisation is more advanced nearer the ligature.
Plate XIII.
Fig. 1. — Chromic catgut (No. 3) removed from a sheep three days
after being used for tying the carotid. A dense mass of leucocytes is
collecting on the outer side of the ligature. The mucous coat has
not been removed in the manufacture of the ligature. The intestinal
villi and crypts are clearly visible.
Fig. 2. — Showing rapid destruction of chromic catgut used for
the ligation of the carotid of a horse fourteen days pi-eviously.
Fig. 3. — Chromic catgut ligature forty-four days after being em-
ployed for ligaturing a sheep's carotid. It is still holding, and likely
to last for some time longer. This piece of catgut is exceptionally
good ; it was probably prepared with care.
Fig. 4. — The remains of a kangaroo tendon ligature seventy-three
days after ligation of a sheep's carotid.
Plate XI
Med. Chir . Trans . Vol . LXIX
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■'"'
CONGENITAL ABSENCE OE HAIR AND
MAMMAEY GLANDS
ATROPHIC CONDITION OF THE SKIN AND ITS APPENDAGES
A BOY WHOSE MOTHER HAD BEEN ALMOST WHOLLY BALD
FROM ALOPECIA AREATA FROM THE AGE OF SIX.
BY
JONATHAN HUTCHINSON, F.K.S., LL.D.
Received January 12th— Read May 11th, 1886.
The subject of this case, a boy set. 3^ presented a very-
peculiar withered or old-mannish look, all his features
being thin and pinched. His fingers were shrivelled, and
dusky, and their nails, which also were remarkably thin,
were curved backwards so as to present more or less of
hollow in the middle. His head was large and the ante-
rior fontanelle not quite closed ; the scalp was exceedingly
thin, and with the exception of a quantity of down,
was quite bald. It looked semi-transparent and tight,
and the veins coursing in it were everywhere conspicuous.
The veins were probably larger than natural. A large
trunk came down the forehead on each side of the eye-
brow and communicated by a transverse branch at the
474 CONGENITAL ABSENCE OF HAIR AND MAMMiE.
root of the nose. The inosculations across the middle
line of the scalp were many. There was a peculiar blue
tinge about the lips ; it involved the skin and not the pro-
labium only. At first I thought that this was due to
accidental staining ; but after he had been half an hour
in my room it much diminished, as did also the turges-
cence of the veins of his scalp. His lips were exceedingly
thin. His teeth were all cut and were tolerably regular,
but his incisors did not stand quite straight, most of them
had some slight inclination into the mouth. On his
shoulders he was so thin that his coracoids and the
outlines of his acromion processes could be easily seen ;
the skin over them being not much thicker than brown
paper. The tightness of skin was nowhere very con-
spicuous excepting on the scalp ; thus, on the abdomen,
arms, and thighs the integument was quite loose but every-
where very thin. His muscular development was slight in
all parts excepting the thighs, which felt hard and had
muscles quite out of proportion to the rest of his body
(this remark does not apply to the buttocks). His genitals
presented a very remarkable contrast to the rest of his body.
The parts about the pubes and upper part of the scrotum
were so full and plump that a suggestion occurred that
he must have double hernia. This, however, was not borne
out by examination, and I believe the simple fact was that
the scrotum and adjacent parts of skin were in the state
of those of a normally stout child, whilst everywhere
else the skin, subcutaneous cellular tissue, and panni-
culus adiposus were almost absent. The true scrotum
was small, naturally corrugated, and occupied only the
lowest part of the genital pouch which I have described.
I do not think that there was anything very unusual in
this state in a child, but must admit that possibly there
was some excess of subcutaneous development about the
pubes and root of penis. His testes were well placed and
of normal size. His penis, except that there was phimosis,
was quite natural. His toes and their nails were in the same
condition as his fingers. He did not walk quite perfectly,
CONGENITAL ABSENCE OF HAIK AND MAMM-E. 475
always keeping his knees a little bent, but I could not make
out any definite muscular defect. One other remarkable
feature remains to be mentioned, he had no nipples and
their sites were occupied by little patches of scar. These
scars were exceedingly superficial and slightly marked,
but I am sure that they were there. Nothing like a
mammary gland could be traced.
The history which the mother gave me of the child was
that he had had no ailments since his birth, was of cheerful
disposition, and very intelligent. It had been necessary
from cross presentation to turn during delivery, and for
some days after birth he had been very blue, probably in
a state of partial cyanosis. He was still liable to vary very
much in blueness in connection with the temperature and
states of excitement, but never now presented anything
approaching a cyanotic condition.
I have now to relate the very extraordinary fact which
is possibly explanatory of the singular condition of things
just described. It will have been noticed that the chief
defects present in the child were, an atrophic condition
of the appendages of the skin and its accessory cellular
tissue and fat, which became especially conspicuous in the
absence of the scalp hair. With this we had a well-deve-
loped condition of the male sexual organs and an absence
of the mammary glands and nipples. Now the mother
of this child from the age of six to the present time had
worn a wig on account of alopecia areata. At the age
mentioned she began to lose her hah*, which had previously
been plentiful, in patches. She described the usual course
of things, how the patches increased, and the whole scalp
became smooth and bald, and how subsequently the eye-
brows and eyelashes fell. After a considerable time her
eyebrows and eyelashes grew 'again, and a few tufts of
hair appeared on the scalp. But she had never regained
her scalp hair sufficiently to dispense with her wig, and
her eyebrows were still so poor that she was obliged to
colour them. Excepting this alopecia she had no signs of
deranged nutrition, being a florid, comely, well-developed
476 CONGENITAL ABSENCE OF HAIR AND MAMM£.
woman. The little boy was her first and only male child,
but he had five sisters, all older than himself and all of
whom had excellent development of hair.
Very curious speculations suggest themselves in con-
nection with Darwin's theory of pangenesis. Under this
hypothesis it may perhaps be possible that the germinal
elements of the child's cutaneous system, and especially
for his scalp, were derived from his mother, and were, in
connection with her long baldness, very defective in vigour.
With this would fit the entire absence of the mammary
glands and their nipples ; with this also would fit the
normal development of the male genital organs and their
skin, since he would be supposed to take these from his
male parent. The fact that all his sisters had good deve-
lopment of scalp hair may be supposed to be explained by
the suggestion that they inherited chiefly from their father.
It is to be added that the marriage was not one of
consanguinity, and that no baldness or defects of develop-
ment had been known in the family previously.
I may have perhaps a little over-stated the general
absence of subcutaneous fat. Excepting on the head
and hands, it was nowhere quite absent ; and this remark
especially applies to the abdomen and back. The
deeply placed fat was less affected than the superficial.
Thus, lumps of it could be detected at the root of the
neck. The skin was everywhere destitute of natural
elasticity and plump firmness, and where not dusky had an
earthy pallor. The eyelashes were present but very weak.
The eyebrows almost entirely absent.
I was indebted to Dr. Jago, of Mulgrave Place,
Plymouth, for the opportunity of seeing this child and for
some facts as to its history.
Remarks. — I prefer, for the present at least, to leave
the above remarkable case without attempting to contrast
it with other examples of congenital alopecia on record.
From all these it differs, so far as I am aware, in the fact
that the female sex organs (the marnnia?) were absent,
whilst the skin of the male sex organs was the only part
CONGENITAL ABSENCE OF HAIR AND MAMM.E. 477
of the integument in a normal condition. These peculiari-
ties become of the greatest possible interest when we
remember that he appeared to inherit his defect from his
mother. I am well aware that the explanation hinted at
is a mere conjecture, and that there are a multitude of
facts which might seem to militate against it. We cannot
afford, however, in investigating the very difficult subject
of hereditary transmission, to neglect any hint which the
facts of pathology may offer. I need scarcely say any-
thing as to the well-known law that defects, the result of
disease or injury occurring in the parent and not congeni-
tal, are not transmitted to offspring. Everyone knows
that circumcised fathers beget children in whom the pre-
puce shows no modification. To this law the case I have
recorded seems to offer an exception, for there was not
the slightest doubt that the mother's loss of hair waa
caused by the common form of alopecia areata, and did
not begin till she was six years old. In fact, her hair
grew again several times after its first falling, and again
came off. Some will probably be inclined to oonsider that
the mother's condition and that of her only son were
associated as a mere coincidence and that the one was in
no way dependent on the other. It is indeed precisely
because this connection seems so probable, whilst it is in
flat contradiction to received opinions, that I have thought
the case worthy the attention of the Society.
(For report of the discussion on this paper, see ' Proceedings
of the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 116.)
THE
MORBID ANATOMY AND PATHOLOGY
OF
ENCYSTED AND INFANTILE HERNIA.1
C. B. LOCKWOOD, F.R.C.S.,
DEMONSTRATOR OF ANATOMY AND OPERATIVE SURGERY AT ST. BARTHOLO-
MEW'S HOSPITAL ; SURGEON TO THE GREAT NORTHERN CENTRAL HOSPITAL.
Received January 22nd— Read May 25th, 1886.
Considerable surgical importance may be claimed for
anything which pertains to the subject of hernia. Hardly
any affection is so common or more frequently demands
surgical interference, and the simplest case may, when
operated upon, present the most disconcerting peculiarities.
It might be urged that some of these are so rare as not
to be of practical importance, but if such an argument as
this possesses any weight it would not apply to encysted
hernia.
Every wrfter upon general surgery describes this variety
of the disease, and testifies how interesting it is to all
who are engaged in the practical duties of their profession.
The history of this affection is by no means difficult
1 The terms " encysted " and " infantile " are in the following pages con-
sidered to indicate a purely anatomical condition.
480 MORBID ANATOMY AND PATHOLOGY OP
to trace, for unlike that of congenital hernia it has never
been the subject of any dispute. Sir William Lawrence
says1 that it was first described by Hey, who met with an
example of it in 1764. Sir Astley Cooper,2 in his
magnificent work, alludes to Hey's observations and
depicts what may be considered to be a typical specimen.
Writing in 1838 Sir William Lawrence does not allude
to any other observations except these, and the knowledge
of this author was so profound that it may be assumed
that none other existed. Chelius,3 and it may be said
South,3 writing in 1847, merely refer to the authors which
have been mentioned, and make no addition to the
subject, and the same may be said of Meckel,4 whom they
quote. Since that time, although a diligent search has
been made, I am unable to ascertain that any fresh know-
ledge has been gained.5 Recent authors may have made
here and there new statements, but not such as will bear
strict investigation. Indeed, a critical examination of the
most authoritative accounts of the anatomy and pathology
of encysted hernia reveals many discrepancies and leaves
much to be explained. In order to justify this assertion,
and because their statements are often misrepresented, it
may be best to note, as briefly as is consistent with
exactitude, the views which the most eminent writers have
formulated, and at the same time an adequate idea may
be formed as to what is usually meant by the term
" encysted hernia." Fortunately this, so far as authori-
ties are concerned, is not a very formidable undertaking.
It may be deemed sufficient if I mention what Hey and
1 Lawrence, Sir William, ' A Treatise on Ruptures,' 5th cd., 1838, sec. 2,
p. 576.
3 Cooper, Sir Astley, ' The Anatomy and Surgical Treatment of Abdominal
Hernia,' 2nd ed., 1827, p. 74, pi. xi, fig. 1.
3 ' Chelius' System of Surgery,' South, vol. ii, p, 59, 1847-
4 Meckel, ' Handbuch der pathologischen Anatomie,' vol. xi, pi. 1, pp. 379
and 380, Leipzig, 1816.
J This applies to the writiugs of Vidal, ■ Traite de Pathologie Externe,'
tome iv, 1861, and to those of Th. Kocher, ' Handbuch der Kinderkrauk-
heiten,' Tubingen, 1880, " Articles on Hernia," i, 747, et teq.
ENCYSTED AND INFANTILE HERNIA. 481
Cooper have said and then refer to more recent writers.
The case which Mr. Hey1 met with, and to which he gave
the name " infantile hernia/' was that of a child fifteen
months old, and after remarking that the caecum and
beginning of the ilium were contained in the hernia, this
author proceeds to say, " I found that the tunica vaginalis
was continued up to the abdominal ring, and inclosed the
hernial sac ; adhering to that sac, by a loose cellular sub-
stance, from the ring to within half of an inch of its
inferior extremity The interior or true hernial sac
was a production of the peritoneum as usual, and con-
tained only the caecum or head of the colon. . . . Having
removed the proper hernial sac I examined the posterior
part of the exterior sac ; and found it connected with the
spermatic vessels in the same manner as the tunica vagi-
nalis is, when the testis has descended into the scrotum."
Everything that this eminent surgeon says about the
tunica vaginalis in this description is quite clear and
precise, but as regards the true hernial sac his remarks
are, so far perhaps, slightly wanting in precision. For
instance, it is not said whether its walls were constructed
of one or more than one layers of peritoneum, and yet it
will be seen presently that this is a most important
question. However, Hey explains the pathology of the
disease in the following way :2 " In the foetus a process of
the peritoneum is brought down, through the ring of the
external oblique muscle of the abdomen, by the testicle as
it descends into the scrotum ; which process forms an
oblong bag communicating with the cavity of the abdo-
men, by an aperture in its upper part. This aperture is
entirely closed at, or soon after, birth. The upper part of
the bag then gradually contracts itself, till the communi-
cation between that portion of it which includes the superior
and greater part of the spermatic chord, and the lower part
of the bag, which includes the testicle and a small share
of the chord, is obliterated. The lower part of the process
1 Hoy, ' Practical Observations on Surgery,' 3rd ed., 1814. An account of
an uncommon species of scrotal hernia, p. 226, et seq. ' Ibid., pp. 228 and 229.
VOL. LXIX. 31
482 MORBID ANATOMY AND PATHOLOGY OF
or bag retains its membranous appearance, and is called
tunica vaginalis testis propria ; while the upper part covers
an irregular cellular substance, without any sensible cavity,
diffused amongst the spermatic vessels, and connecting
them together.
" In the hernia which I am describing, the intestine was
protruded after the aperture in the abdomen was closed ;
and therefore the peritoneum was carried down along with
the intestine, and formed the hernial sac. It is evident,
also, that the hernia must have been produced while the
original tunica vaginalis remained in the form of a bag as
high as the abdominal ring : on which account that tunic
would receive the hernial sac with its included intestine ;
and permit the sac to come into contact with the testicle.
The proper hernial sac, remaining constantly in its pro-
lapsed state, contracted an adhesion to the original process
of the peritoneum which surrounded it, except at its
inferior extremity : there the external surface of the hernial
sac was smooth and shining, as the interior surface of the
tunica vaginalis is in its natural state."
Before making any comments upon this very clear
statement perhaps it will be best to recount the views
of another writer whose name has been prominently asso-
ciated with this subject.1
Sir Astley Cooper,2 describing what he terms an
encysted hernia, says : " On opening the tunica vaginalis,
instead of the intestine being found lying in contact with
the testicle, a second bag or sac is seen inclosed in the
tunica vaginalis, and enveloping the intestine. This bag
is attached to the orifice of the tunica vaginalis, and
descends from thence into its cavity ; it generally oontraota
a Eew adhesions to the tunica vaginalis, while its interior
bears the character of a common hernial sac.
1 Mr. Kirkctt, article on " Hernia" in ' Holmes's System,' 3rd ed., vol. ii,
1883, p. 807, &c., says that " Infantile hernia of Hey and encysted hernia of
the tunica vaginalis of Astley Cooper \\rv synonymous terms" (see also
Mr. Wood's remarks at p. 485).
1 Cooper, ' Anatomy and Surgical Treatment of Abdominal Hernia,' pt. 1,
2nd edit., 1827, p. 79.
ENCYSTED AND INFANTILE HERNIA. 483
" The idea which I have formed of the nature of this
variety of hernia is, that the tunica vaginalis, after the
descent of the testis, becomes closed opposite the abdominal
ring, but remains open above and below it. The intestine
descends into the upper part, and elongates both the
adhesion and tunica vaginalis, so as to form it into a bag,
which descending into the tunica vaginalis below the
adhesion, and becoming narrow at its neck, though wide
at its fundus, receives a portion of the intestine, which in
the following case was too large either to be returned into
the abdomen, or to retain its functions whilst it continued
in the sac."
The cases which Sir Astley quotes were met with by
his colleagues in patients upon whom they operated, but
only one of these was verified by a post-mortem examina-
tion. It will not be necessary to repeat Forster's descrip-
tion, which Sir Astley quotes. He concluded it by saying
that after he had opened the tunica vaginalis, and turned
back its edges, there was1 " exposed a hernial sac
pendent from the ring, and descending towards the tes-
ticle." In addition Sir Astley Cooper remarks that two
other encysted herniae were met with at Guy's about that
time, one during an operation, the other during dissection.
It seems by no means improbable that the latter is the
actual specimen which he described and depicted in his
great work, and which is still to be found in the museum
of Guy's Hospital.2
If we compare what Hey and Cooper said, it will be
allowed that their views are not dissimilar. They both
agree in stating that the tunica vaginalis, in the case of
encysted hernia, becomes closed at its upper part, and thev
both attribute the formation of the hernial sac to intestinal
protrusion, but neither of them makes an explicit state-
ment concerning the composition of the hernial sac,
whether it consisted of one layer of serous membrane, or
i Ibid., p. 80.
* Sir William Lawrence says that such a one was placed in the museum
by Sir Astley Cooper (see Plate xi, fig. 1, Cooper on " Hernia").
484 MORBID ANATOMY AND PATHOLOGY OF
of more than one. There is, however, one very important
circumstance to which I would draw attention. Hey, in
desci-ibing the closure of the tunica vaginalis, says nothing
whatever about adhesions, but simply states that " it
gradually contracts itself." Cooper, it will be remembered,
says, " The tunica vaginalis, after the descent of the testis,
becomes closed opposite the abdominal ring, but remains
open above and below.'* Nothing so far has been said
about adhesions, but in the next sentence he remarks,
" The intestine descends into the upper part (i. e. of the
tunica vaginalis), and elongates both the adhesion and
tunica vaginalis, so as to form it into a bag, which, de-
scending into the tunica vaginalis below the adhesion,
&c." Although this account may not be free from
ambiguity, yet it implies that adhesions closed the tunica
vaginalis, and that they actually entered into the formation
of the hernial sac. Without assuming that this interpre-
tation of Sir Astley Cooper's statement is correct, I will
proceed to quote what has been written by authorities who
have succeeded him, but before doing so it is significant
to observe that Sir "William Lawrence neither refers to,
nor passes any opinion upon, Sir Astley Cooper's state-
ment. Mr. Birkett,1 moreover, simply says that the vein ra 1
orifice of the processus vaginalis becomes closed, " but
the canal persisting from that point to the testis. The
hernia slowly pushes before it the parietal peritoneum of
the abdomen into this sheath, and when the parts are
dissected it is seen that the tunica vaginalis is continued
up to the abdominal ring, and encloses the hernial sac, as
Mr. I lev describes." Air. Birkett, it is superfluous to
point out, does not mention adhesions in connection with
the true hernia] sac, and merely remarks incidently thai
it is made of serous membrane ; he does not give a de-
tailed account of its structure.
Although at the risk of wearying the reader by constant
repetition, yet since it is conducive to a clear conception
i Birkett, • Holmes's System of Surgery,1 8rd ed., 1888, p. 807, si w?.,
vol. ii.
ENCYSTED AND INFANTILE HERNIA. 485
I would venture to quote more authorities upon this sub-
ject.
Writing in the present year (1885), Mr. John Wood1 says
as follows: " The canal of Nuck [processus vaginalis testis]
becomes closed first at the deep ring, leaving a cicatrix
which is always more or less traceable. The obliteration
extends down the cord to within half an inch of the testi-
cle. The serous membrane degenerates and is transformed
into connective tissue, which more firmly binds together
the elements of the cord. Sometimes the obliteration
extends only to the parts near the deep ring. Then, while
the cicatrix is still weak, some violent crying or coughing
efforts of the child protrude the bowel, pushing and dila-
ting the cicatrix before it, and a fresh sac of peritoneum
is invaginated from above into the upper part of the
large tunica vaginalis, which is pushed before it into the
scrotum. We have thus formed that kind of children's
rupture with a double sac which is called infantile
[or encysted] hernia, fig. 1130 (v. Fig. 1, p. 486). In this
there are three layers of serous membrane placed in front
of the bowel in the scrotum, viz. two layers of the in-
vaginated tunica vaginalis, and one of the fresh, or real
sac of the hernia.
The expression " pushing and dilating the cicatrix
before it," which Mr. Wood uses in describing the way
in which the extruded bowel forms the hernial sac,
certainly leaves an impression upon the mind that the
hernial sac may be formed, in part at least, of cicatricial
tissue. The very clear figure (Fig. 1, p. 48G) which
accompanies the description would seem to show that the
sac which contained the hernia consists of two layers of
serous membrane, and that the original communications
between the tunica vaginalis and the peritoneal cavity had
become entirely obliterated, in truth, it answers perfectly
to the graphic description of Forster" "A hernial sac
1 Article on "Hernia," Ashhurst's ' Encyclopedia,' vol. v, p. 1132, fi<_r.
1 I :iO, 1S85. I am indebted to Mr. Wood tor permission to reproduce this
diagram (i>. Pig. 1, p, 486). 2 Cooper, loc. cit., p. 79, et seq.
486 MORBID ANATOMY AND PATHOLOGY OF
Fig. 1.
(%
Diagram of infantile (or encysted) hernia. Copied from fig. 1130. Ashhurst,
vol. v (Wood).
pendent from the ring, and descending towards the
testicle."
It can hardly be denied that a perusal of these various
quotations leaves an impression that the authors of them
seem to imply that, in some way or other, cicatricial
tissue enters into the composition of the sac of an
encysted hernia, but should any doubt remain upon this
point it may be dissipated by referring to the writings of
Mi-. Timothy Holmes. Speaking of this variety of hernia
this author says,1 " This may occur in consequence of adhe-
sions having obstructed the neck of the infundibuliform
process and formed a membrane. This membrane being
distended by the protruding bowel, forms a hernial sac
for it."
Leaving aside for a moment the question of the cica-
trix, it cannot be doubted that Mr. Wood and Mr. Holmes
describe and delineate that which most surgeons would
1 • .\ Treatise on Surgery/ T, Holmes, 1882, p. 647, lig. 312. The diagrams
which Mr. Holmes L'ives are, hy his kind permission, introduced in Figs. 2
and 8, pp. 188 and 192,
ENCYSTED AND INFANTILE HERNIA. 487
consider a representative encysted hernia.1 However this
may be, Mr. Erichsen depicts and describes quite a
different variety. Since Mr. Erichsen's account is a very
brief one perhaps it may be given. " Encysted hernia of
the tunica vaginalis, or infantile hernia, as it has been
somewhat absurdly termed, occurs in those cases in which
the funicular portion of the tunica vaginalis is partly
obstructed by a septum, or by being converted into fila-
mentous tissue, but in such a way as to leave a pouch
above, which is protruded down behind or into the tunica
vaginalis, so that it lies behind the cavity."
The last sentence certainly admits two alternatives ; in
one event the hernial pouch may bulge into the tunica
vaginalis, and in the other simply lie behind it ; the
latter is probably the case which he depicts.2 But,
although the words " septum " and " filamentous tissue "
are met with in this account, used in connection with the
method of closure of the funicular portion of the tunica
vaginalis, yet it is not clearly stated what those struc-
tures may have to do with the formation of the hernial
sac. In any case, judging from the diagram, we have now
to deal with a hernia quite different from that which, up
to this point, has been referred to, unless it be thought
that Mr. Erichsen's account tallies with that which has
been quoted from Hey.
A glance at Mr. Erichsen's diagram shows how much
it differs from that which has been taken from Mr. Wood's
writings. It would not appear necessary to attempt to
reconcile these conflicting authorities, for, according to
Mr. Timothy Holmes,3 they are both correct. This author
figures and describes two varieties of encysted hernia ;
one, already mentioned, like Mr. Wood's, a hernial sac
pendant from the ring, the other, like Mr. Erichsen's, a
pouch behind the open processus vaginalis.
1 See also Bryant, ' The Practice of Surgery,' ed. iv, vol. i, 1884, p. 732,
fig. 264.
* Erichsen, ' The Science and Art of Surgery,' vol. ii, ed. 8, p. 816, fig. 797.
■ Loc. cit., p. 647, figs. 311 and 312 (for copies, see Figs. 2 and 3, pp. 488
and 492).
488 MORBID ANATOMY AND PATHOLOGY OP
Fig. 2.
Diagram (copied from Holmes) whose description is as follows: — " Another
variety of infantile hernia (the encysted form). The bowel instead of passing
behind the closed funicular process has distended the membrane which closes
its upper end, and has pushed itself into the funicular process, the upper or
back wall of which envelopes it. In this case, therefore, the hernial sac is
furnished by the funicular process itself, and only two layers of peritoneum
cover the intestine."
There can be little doubt but that Mr. Holmes has
expressed the usually accepted views upou this poiut ; and
most surgeons and pathologists would concede that there
are, in fact, two varieties of encysted hernia. Mr. E.
Owen,1 who met with an example of the disease, which
will be mentioned presently, is of this opinion, and his
book upon children's diseases affords very clear diagrams
of the two varieties. In order to avoid confusion it will
be best to mark each of these varieties of encysted hernia
with a definite name. Those which Mr. Holmes uses,
although perhaps open to objection, will serve the pur-
pose.2 In the first place the term "encysted hernia"
will be applied to the condition in which, when the
unobliterated processus vaginalis is opened,3 a hernial sac
is seen pendant from the internal ring ; and secondly,
the term " infantile hernia" will be applied to those cases
in which, when the unobliterated processus vaginalis has
1 ' The Surgical Diseases of Children,' 1885, p. 345, figs. 57-8.
Holmes, p. 647, tigs. 311 and 312.
3 The term " processus vaginalis" is applied to the process of peritoneum
which accompanies the transition of the testis, and which afterwards becomes
tonics vaginalis propria and rninss processus vaginalis.
ENCYSTED AND INFANTILE HERNIA. 489
been opened, a hernial sac or pouch is found behind it,
and bulging into it.
Without endeavouring at present to determine to which
of these varieties the hernise described by Hey and Cooper
belonged, it may be remarked that most of the authorities
who have been mentioned confine themselves, so far as I
can judge, to the elucidation of the anatomy and pathology
of the encysted form. With regard to the other sort,
the infantile, it is true that Mr. Erichsen figures it, but Mr.
Holmes throws a certain doubt upon its genuineness, for
he says that the diagram which he gives is intended to
represent " the assumed condition of the parts in infantile
hernia." However, he proceeds to discuss the manner of
its formation, and says, " In this form the communication
between the peritoneal cavity and the infundibuliform
process leading into the tunica vaginalis is obstructed at
or about the external (or superficial) ring, but the process
itself is not obliterated, so that the cavity of the tunica
vaginalis extends up to the external ring. Then a hernia
comes down and generally slips behind this upper pro-
longation of the tunica vaginalis (fig. 31 l)."1 (See fig. 3,
p. 492.)
This completes a summary of the current views upon
the subject of encysted and infantile hernia. With all
due deference one cannot help saying that when they are
submitted to a critical examination they will be found
wanting in scientific precision. In order to support this
opinion I will confine myself, for the present, to the
pathology of encysted hernia, and without further pre-
liminaries, discuss a question which seems to go to the
very root of the matter ; and it is this : What has cicatricial
tissue to do with the formation of the hernial sac ? It
cannot be denied that although Hey said nothing what-
ever about cicatrices, adhesions, or septa, yet we find them
mentioned by Sir Astley Cooper and succeeding authors,
until at last the greatest importance seems to be attached
to them.
1 Ibid., p. 618, fig. 811.
490 MORBID ANATOMY AND PATHOLOGY OF
In order to determine this most important question two
methods of investigation are open to us : in the first place,
to inquire whether the upper part of the processus vagi-
nalis is ever closed by adhesions or cicatrices capable of
forming a septum suitable for the creation of a hernial
sac ; and next, to see whether the sac has the appearances
which it might be expected to possess had it been formed
of cicatricial tissue.
With regard to the first part of this inquiry, it seems
very hard to discover upon what exact basis of fact the
actual existence of the septum, which is assumed to close
the processus vaginalis, rests.
I have been unable to discover that any author says that
he has actually seen such a thing. Although it is a hope-
less task to try and prove a negative, yet it cannot be with-
out influence upon this argument to notice that Wrisberg,1
Seiler and others investigated the processus vaginalis with
great industry, and that none of them mention such a
thing, and it is hardly in accordance with our general
knowledge of tubes with endothelial linings to conceive of
their closure by septa. The function of the processus
vaginalis is to give passage to the testicle, and when it
has done this it not only ceases to grow, but undergoes
retrograde atrophic changes. Under the circumstances
we are considering, in which it becomes the receptacle for
an encysted hernia, the very opposite occurs ; the pro-
cessus vaginalis grows and its lumen increases, a fact
which diminishes the likelihood of its occlusion by a septum.
It must be confessed that an inspection of Cloquet's draw -
ings2 suggests \ ery strongly, whatever normal anatomy may
afford or a 2^iori reasoning suggest, that, nevertheless,
hernial sacs may be partitioned by septa. From a septum
in a hernial sac to one in the processus vaginalis is not a
1 " De testiculorum ex abdomine in scrotum descensu, etc.," ' Comment.
Soc. Reg. Scient. Gotting.,' 1800, p. 173, et seq. 103 examinations are
recorded by Wrisberg, and Mr. Hirkett attributes 54 to Camper and 21 to
Seiler (art. in ' Holmes's System,' 3rd edit., vol. ii).
5 ' Kecbercbes %\ir les causes et l'anatomie des hernies abdominales,' Paris,
1819.
ENCYSTED AND INFANTILE HERNIA. 491
long leap. However, an examination of Cloquet's speci-
mens themselves, which are in the Dupuytren Museum,1
shows that any partial septa which are present in them
are really due to pleats in the walls of the hernial sac,
each accompanied by a corresponding constriction upon the
exterior, and very like the folds of the large intestines.2
It would not be right to draw definite conclusions from
these specimens, because they are simply hernial sacs
which have been dried and varnished, but they hardly
suggest the existence of septa of cicatricial tissue. It is
true that they show complete constriction of the hernial
sac ;8 but even in this case, I do not think it has ever been
argued seriously that an encysted hernia could be pro-
duced by an intussusception of one part into another, for,
owing to the gradual nature of the constrictions, this would
seem an impossibility.
It is not for a moment pretended that the arguments
which have just been adduced, prove the impossibility of
the processus vaginalis ever being occluded by a cicatricial
septum, but it can hardly be denied that they suggest the
improbability of such an event. However this may be,
under these circumstances it seemed best that they should
be stated, for the sequel will show that the pathology of
encysted hernia depends more upon the whole weight of
evidence than upon any particular fact. The reason for
this will be clear when we begin to array the evidence
which has been afforded by an examination of the various
specimens of encysted hernia which are to be found in the
various London museums, and owing to the very great
kindness and courtesy of the curators, I have been per-
mitted to dissect and examine them at my leisure. In
order to avoid the embarrassment which the multiplication
of intricate details sometimes causes perhaps I may be
permitted to begin with a general statement of results.
Just for the moment it may be said that the various
1 Cloquet's specimens are Nos. 269 to 315.
2 See Specimens 236 and 306.
3 See Specimens 310, 312, 314, and 315.
492
MOKBID ANATOMY AND PATHOLOGY OF
specimens seem to belong to two very distinct types. In
both of these it is an essential feature that the sac of the
tunica vaginalis should be very large, reaching almost, if
not quite, as far as the peritoneum ; but the question of its
communicating with the cavity of that membrane is a point
which will be discussed presently. This much having been
premised, it may be stated that the two apparent varieties
are those which have been already spoken of as " encysted
Fig. 3.
Diagram (copied from Holmes, fig. 311) of the (assumed) condition of the
parts in an infantile hernia. The tunica vaginalis (1) is closed above, at or
near the external inguinal ring, but its funicular portion is open. The
bowel in the hernial sac lies behind this funicular portion, and is represented
in the diagram as having made its way between the funicular process and the
cord. The relation of the sac to the cord seems, however, to be variable.
The bowel is covered in cutting down from the skin by three layers of peri-
toneum, viz. 1 and 2, the opposite surfaces of the funicular process, and 3
the anterior layer of the peritoneal hernial Bac.
hernia " and ''infantile hernia." Specimens 2407 and 294760
in the Guy's Hospital Museum (v. Figs. 5 and G, pp. 495
•.md 498) and Specimen C. D. 20 in the Museum of
St. Mary's Hospital (v. Fig. 8, p. 510) may be considered
representative of the encysted. Indeed, there is not much
doubl but that one of them, Specimen 2497 , Guy's, is the
\ci\ one which Sir Astley Cooper depicted j1 whilst the
Si. Mary's specimen was described as an encysted hernia
1 Cooper "ii " Hernia." plate \i, fig. 1.
ENCYSTED AND INFANTILE HERNIA.
493
in the British Medical Journal.1 The second variety of
encysted hernia which the museums contain is clearly of
the sort which has already been described under the name
Fig. 4.s
Drawing of an infantile hernia, specimen R. 24, in the St. Thomas's
Hospital Museum. The bulging of the hernial sac into the tunica vaginalis
is shown and also the fold (plica vascularis), which extends from lower
extremity of the sac to the epididymis. In the catalogue the specimen is
named, " encysted." A, mouth of sac.
of infantile, and which consists of a pouch or bag of peri-
toneum pushed down behind the greatly enlarged tunica
vaginalis.3 Specimens 248850 in the Guy's Hospital
1 'British Medical Journal,' Aug. 1, 1874, p. 140, E. Owen.
2 I am indebted to the kiuduess of Mr. Shattock for permission to examine
and draw this specimen.
3 As Hey describes.
494 MORBID ANATOMY AND PATHOLOGY OP
Museum and Specimen R. 24 in the Museum of St.
Thomas's Hospital (v. Fig. 4, p. 493) may be considered
representative of this class.
It may be remembered that the current views as to the
pathology of these two sorts of encysted hernia have
already been stated. With regard to the first, it has been
shown that there is a strong impression that cicatricial
tissue enters largely, if not entirely, into the formation
of its sac. Two arguments have already been advanced
to show the unlikelihood of this being true ; first, the a
priori improbability of a growing processus vaginalis, the
lumen of which has been enlarged, ever being occluded
by a septum of cicatricial tissue, suitable for becoming a
hernial sac ; secondly, the fact that such a septum has
never actually been seen. Now, since it can hardly be
denied that the specimens which have been chosen are
typical, we may proceed to inquire whether they confirm
or contradict the preceding propositions. The two speci-
mens in the Guy's Hospital Museum1 show no indication
that cicatricial tissue has entered into the construction of
the hernial sac, and the same may be said of the St.
Mary's specimen,2 which will be referred to afterwards
at length. So far as I can ascertain two distinct layers
of serous membrane form the sac walls of these encysted
hernia?. Of these two layers, that which lines the interior
of the sac is continuous with the peritoneal cavity, whilst
that which covers its exterior is continuous with, and forms
part of, the tunica vaginalis."
The real importance of this observation will be clearer
after awhile, but for the moment we may pause to meet
an argument which readily suggests itself, namely, whether
after a time even a septum of cicatricial tissue might not
n^sume the characters of the serous membranes in its
neighbourhood.
Figs. 5 and 6, pp. 106 and 198.
5 Fig. 8, p. 510
3 Approximating very closely the condition described bj Hey, v. :i. pp. 481
and 482.
ENCYSTED AND INFANTILE HERNIA.
495
There is no proof that such an event takes place under
any circumstances, and an examination of the specimens
(Figs. 5, 6 and 8) affords no evidence in its support. Not
only are the two layers of serous membrane of which the
Fig. 5.1
Description of Fig. 5 of "encysted hernia" (v. Catalogue), No. 2497, Guy's
Hospital Museum. The two layers which form the sac wall are shown and
also the band which passes from the epididymis to its extremity. In the
interior of the sac of this hernia, behind, there is a curious pouch made by a
transverse fold of serous membrane. B, hernial sac. A, band with spermatic
artery in its midst, c, testicle and epididymis.
true hernial sac is composed quite distinct, but there is
muscular tissue between them ; a point which will be
explained later.
1 Dr. Goodhart kindly permitted me to examine and draw this and other
specimens.
496 MORBID ANATOMY AND PATHOLOGY OF
If it is clear that the sacs of these encysted hernias
consist not of cicatricial tissue but of a double layer of
serous membrane we may now proceed to investigate the
crucial question, whether the tunica vaginalis in these
cases of encysted hernia communicates with, or has been
shut off from, the peritoneal cavity. Allowances must be
made, in investigating this, for alterations produced by
previous dissection or by operations. The possibility of
adhesions having been destroyed by this means is too
obvious to need pointing out. Without doubt the front
of the upper edge of the hernial sac in the St. Mary's
specimen (v. Fig. 8, p. 510) was closely applied, perhaps
adherent, to the wall of the tunica vaginalis, but I am of
opinion that in it the processus vaginalis communicated
with the peritoneal cavity by a wide opening, and I think
the same statement may be made with regard to another
of these encysted hernias (No. 2497, Guy's), see fig. 5. In
a specimen which more than any other might be called a
" hernial sac pendant from the ring " (v. Fig. 6, p. 498,
Sp. 249750, Guy's), the tunica vaginalis is open right up to
the neck of the sac, but at that point its walls adhere
to one another. This adhesion is so slight and the
continuity of the serous membrane is so palpable, that
if the smallest pressure were made with a probe the
attachments would be loosened, and the specimen as
regards the relations of the neck of the sac made like an
infantile hernia (v. Figs. 3 and 4, pp. 492 and 493).
Having now ascertained the condition of the tunica
vaginalis in the mosl typical encysted hernias, it is unneces-
sary to say that the opinions which have been quoted
concerning the pathology of this disease are unacceptable.
If the various specimens of encysted hernia were dia-
grammatically represented, it would be seen that they
belonged to the infantile type (Fig. 3).
In either case the hernial Bac consists of an outer and an
inner layer of aerous membrane, one formed by a protrusion
from the peritoneum, the other by the tunica vaginalis.
The differences which are present depend upon the degree
ENCYSTED AND INFANTILE HERNIA. 497
to which the hernial sac may have bulged into the tunica
vaginalis and not to any difference in their actual con-
struction.
Of course this takes for granted that the existence of
the infantile variety is admitted and its morbid anatomy
acknowledged, but, upon this point, an inspection of the
specimens in the various museums leaves absolutely no
doubt, and the facts which have been mentioned tend to
justify this assertion. The truth of the statement that
all the specimens of encysted hernia belong to the sort
called infantile, would not be at all obvious if it depended
upon a comparison instituted between what may be called
exaggerated instances : for example, if an infantile hernia
which hardly bulges at all into the tunica vaginalis be
compared with one which protrudes excessively (e. g.
compare Figs. 4 and 6).
But between these extremes intermediate grades exist,
and from these a series may be constructed to illustrate the
progression from one to the other. Perhaps it is unneces-
sary at present to do more than mention a specimen of
infantile hernia (Sp. R. 24, St. Thomas's Hosp., Fig. 4)
which, although typically belonging to the infantile variety,
has many of the characters attributed to the so-called
encysted.
Before concluding this account of the morbid anatomy
of the encysted hernias, their relation to the posterior wall
of the tunica vaginalis may be mentioned. It has been
stated that the degree in which the hernial sac protrudes
into the tunica vaginalis varies in different specimens, and
so far, perhaps, as concerns those which bulge least,
nothing requires to be said. However, when the protrusion
is considerable, the cyst-like sac is attached to the posterior
wall of the tunica vaginalis by a mesentery which extends
along the whole length of its posterior surface. This
may have been so in Hey's case, although he assumes
that the attachment was merely an adhesion formed after
the occurrence of the hernia (vide p. 482). It may be
added that it is usual to find that the lowest part of this
VOL. LXIX; 32
498
MORBID ANATOMY AND PATHOLOGY OF
mesentery attaches the hernial sac to the epididymis,
forming a fold (plica vascularis) the importance of which
will be explained.
Only one specimen seems to contradict this assertion
Fig. 6.
" Encysted Hernia " (v. Catalogue), Xo. 2497s", Guy's Hospital Museum.
Showing attachment of sac to the posterior wall of the processus vaginalis;
also muscular fibres turning round fornix between t!i«' sac and vaginal
process. A curious little pouch is seen upon the wall of the hernial sac.
m, muscle-fibres; V, neck of sac; O, contents, gut; B, cord; S, hernial
sac ; t. testis, (This is probably the specimen delineated by Sir Astlcy
Cooper, Plate xi, tig. 1.)
and it is depicted in Pig. <*>, but the difference ia more
apparenl thai] real, and is due to the extraordinary way in
ENCYSTED AND INFANTILE HERNIA. 499
which the sac has been protruded into the tunica vagi-
nalis.
That this view is correct will, I think, be clearly shown
when the pathology of this affection is discussed.
Having endeavoured to describe the morbid anatomy of
the most typical examples of encysted hernia, and having
sought to show that they belong to the infantile variety,
perhaps it may be as well before advancing any facts con-
cerning their pathology to recapitulate the arguments which
have been used to contradict the usual opinions upon the
subject.
1. The absence of proof that the processus vaginalis is
ever closed by a septum of cicatricial tissue.
2. The improbability of a septum being formed in a
processus vaginalis which has presumably grown, and the
lumen of which has increased.
3. That the sac of an encysted hernia does not consist
of cicatricial tissue, but of two layers of serous membrane.
4. That it is doubtful whether the processus vaginalis is
invariably shut off from the peritoneal cavity in these cases,
or if it be shut off, the closure is effected in such a way
as to exclude the possibility of a septum of cicatricial
tissue having existed.
To these destructive arguments may be added the con-
structive ones which are contained in the descriptions of
the various specimens, and as we proceed to discuss their
pathology others will be forthcoming.
The various authors who have written upon the
pathology of these herniae have confined their remarks to
speculating on the causation of the encysted variety. As
far as I am able to judge, the tendency has been to attribute
the latter to modifications which take place in cicatricial
tissue which is supposed to obstruct the processus vaginalis.
Assuming that this " theory " has, in the preceding pages,
been disproved, and that it has been substantiated that all
the specimens belong, in reality, to the infantile variety,
we may now proceed to inquire how infantile hernia is pro-
duced. With the exception of Mr. Hey's observations,
500 MORBID ANATOMY AND PATHOLOGY OF
already quoted, and which probably apply to this condi-
tion, authorities say but little. Mr. Holmes says that
their origin is a hernia which slips behind the upper pro-
longation of the tunica vaginalis. This is hardly an
explanation of the pathology of infantile hernia, and, in
the absence of any other, nothing remains but to consult
the various specimens for information as to their elucidation.
Whatever help clinical history may afford in other cases,
in this it is valueless. It is true that Mr. Hey's and
Mr. Owen's cases happened in infants, but, as Mr.
Birkett points out, infantile hernia may seem to originate
for the first time during adult life. Many facts, more
particularly the state of the tunica vaginalis, irresistibly
suggest that infantile hernia is due to some peculiarity in
the process of development. It has been remarked already
that it is an essential feature in this disease that the cavity
of the tunica vaginalis be of large size and either in com-
munication with the abdomen or separated from it by the
apposition and adhesion of its walls opposite the neck
of the hernial sac.
Those who are acquainted with hernia into the tunica
vaginalis (congenital hernia) will at once perceive that
this is a condition with which they are familiar. Without
doubt in cases of hernia into the tunica vaginalis the
patency of that membrane is the predisposing cause of the
rupture, and it must be exceedingly rare, as Kocher points
out, for a protrusion to occur early enough to prevent the
closure of this funicular process.
However this may be, well authenticated cases of hernia
into the tunica vaginalis show that the congenital defect
of patency existed long before the rupture, so that, even
if it be clearly substantiated that in the case of an infantile
hernia, the rupture had not shown itself until adult life, it
would not invalidate the assumption that its predisposing
cause was a developmental defect. An examination of
tin' specimens of infantile hernia (including the en-
cysted in this term) creates a very strong impression
thiit events connected with the transition of the testicle
Encysted and infantile hernia. 501
have a predominating influence upon the origin of the
disease.
It seems reasonable, therefore, to begin with a review
of the various events which are associated with that act,
and afterwards inquire whether they throw any light upon
this subject.
Few questions have been studied with so much care and
diligence as the transition of the testis, and the result has
been set forth in a formidable literature. It seems un-
necessary in this place to endeavour to reconcile the con-
flicting statements of various authorities ; they have been
excellently summarised in the elaborate monograph of
Godard.1
For the purpose of this inquiry, Mr. Curling's account"
of the transition of the testis may be taken as a basis, for
it is most in accordance with that which can be seen.
As far as it seems possible to investigate this subject by
dissection Mr. Curling has succeeded, and unless new
methods had been adopted, little would remain to be
added to his description. It is not proposed to enter into
an elaborate and detailed account of the results which
have been obtained by the examination of more than
twenty human foetuses of various sizes. It has been
implied that, so far as concerns dissection, they confirm
nearly all that Mr. Curling has said. In addition, the
question has been studied in the following way, whole
foetuses were placed in a large quantity of a solution of
chromic and hydrochloric acid until the soft tissues were
hardened and the bones were decalcified. The whole
pelvis was then suitably embedded in paraffin, and a series
of thin sections cut with a large microtome.
Having mentioned these particulars, we may now pro-
ceed to sketch the result of the various investigations, but,
since it is proposed to discuss this subject at greater
1 Godard, " La Monorchidie et la Cryptorchidie chez riiomme," • Comptes
Rendus,' 1856, p. 315.
' A Practical Treatise on the Diseases of the Testicle,' T. B. Curling, 4th
ed., 1878, p. 17, et seq.
502 MORBID ANATOMY AND PATHOLOGY OF
length at another time, the narrative will be kept as free
as possible from controversy. It will be sufficient for
present purposes if the position and attachments of the
testicles, as they are usually found at the seventh month
of intra-uterine life, be first described.
At this time, as Fig. 7 shows, the testis is situated
Fig.
Drawing made from a seven or eight months foetus to show the fold (plica
vascularis) which connects the testis with the caecum.
T, testicles; E, epididymis ; P, psoas; V, vas deferens; a, plica guborna-
trix, disappearing into processus vaginalis ; P.v, plica vascularis; c, caecum;
s, spermatic artery ; I, ilium.
in the iliac fossa, a little above the internal abdominal
ring, and is attached to the front of the psoas muscle
by the mesorchium, which is simply a fold of peri-
toneum about one third of an inch wide. In its free
border the body of the testicle and epididymis lie a little
way apart, the latter being nearer the attachment. In
addition, the mesorchium has two folds which extend
upwards and downwards from the testicle. The upper
contains the spermatic vessels and a quantity "I anstriped
muscle-fibres, and may be called the "plica vascu-
laris."
1 All statements made in tins paper concerning muscular fibres have been
repeatedly verified by microscopic examination.
ENCYSTED AND INFANTILE HERNIA. 503
The muscle1 belongs to the gubernaculum testis, and
will be fully described hereafter. The upper part of the
plica vascularis of the right side, as Wrisberg2 states, ends
either upon the vermiform appendix, the mesentery, the
csecum, or the ileum. Without doubt the main portion
passes to the common mesentery, which, at this period,
belongs to the cascum and ileum, the remainder being
subsidiary ; on the left side the plica vascularis passes to
the sigmoid flexure. The inferior fold of the mesorchium
is called the plica gubernatrix, because it contains the
testicular end of the gubernaculum testis. In an eight
months' foetus the lower end of the plica gubernatrix dis-
appears into the orifice of the processus vaginalis, which
has commenced to be formed. The way in which a sort
of test-tube of peritoneum accompanies the transition of
the testicle is too well known to call for comment, but the
manner of its production requires to be described. It
seems natural to suppose that the serous membrane
accompanies the gland on account of their mutual adhe-
sion. Although this may be an element in the case,
another factor must be taken into consideration, for there
can be little doubt that the processus vaginalis moves
towards the scrotum in advance of the testicle.3 As a
rule, the peritoneal test-tube does not precede its contents
by many lines, but the distance may be so palpable as to
preclude the possibility of the testicle having pushed or
dragged its serous covering towards the scrotum. A
certain degree of support is afforded to these observations
by the well-known fact4 that when the testis is un-
descended a process of peritoneum may reach towards the
scrotum. This is shown in many museum specimens (e. g.
233930, 233950, 233925 in the Guy's Hospital Museum,
1 This may be the fold sometimes named after Seiler, see Banks, ' On the
Wolffian Body, &e.,' Edinburgh, 1864, but Sappey calls the whole mesorchium
" Seller's fold," 'Traite d'Anatomic,' vol. iv, p. 604.
2 Loc. cit., p. 230.
3 Quain's ' Anatomy,' 9th ed., vol. ii, p. 008.
4 Lawrence, p. 569, also Cloquet, p. 23 {' Lea Causes,' &C.).
504 MORBID ANATOMY AND PATHOLOGY OF
also Sp. 91, S. IX in the St. George's Hospital Museum).
Since in some of these cases the testicle is adherent in
the iliac fossa, it is obvious that it could not have pushed
down the peritoneum. If the superior terminations of
the gubernaculum be examined, both anatomically and
microscopically, the reason why the processus vaginalis
moves in advance of the testicle is explicable. The fibres
of that muscle are inserted, not only into the epididymis,
vas deferens and testicle, but also into the peritoneum.
At about the seventh month of intra-uterine life, muscular
fibres may be seen inserted into the extremity of the pro-
cessus vaginalis, and, moreover, many of them are pro-
longed up the mesorchium into the plica vascularis, and
so onwards to the peritoneum which lines the posterior
wall of the abdomen. The lower attachments of the
gubernaculum are described so clearly by Mr. Curling that
a detailed description seems unnecessary. It is generally
recognised that it has three main attachments ; one to the
abdominal wall ; another to the pubes, the lower part to
the sheath of the rectus and the root of the penis ; and a
third to the bottom of the scrotum. Repeated dissections
substantiate these statements. Perhaps it may be men-
tioned that some of the fibres of the portion which
mingles with the wall of the abdomen pass downwards
into Scarpa's triangle and are not unimportant in afford-
ing a plausible reason for the occasional passage of the
testicle into the thigh.1 It is quite unnecessary to say
that the function of pulling the testicle into the scrotum is
attributed to these divisions of the gubernaculum. The
first pulls it as far as the internal abdominal ring, the
second to the pubes, and the third deposits it in its final
resting place.
If we proceed to consider the various events which
accompany the transition of the testicle, I think it will be
admitted that the gubernaculum must exert a certain
1 Mr. McCarthy mention! this occurrence, but attributes it to abnormal
fibres of the gubernaculum, Quain's ' Dictionary of Medicine,' 1882,
p. 1606.
ENCYSTED AND INFANTILE HERNIA. 505
amount of force. For instance, if a foetus be chosen in
which the gland is about to pass through the abdominal
wall, and traction be made upon the gubernaculum, it is
clear that as the testicle travels towards the scrotum not
only the mesorchium and its contents and the processus
vaginalis, but the peritoneum which lines the posterior
wall of the abdomen, moves with it. In consequence of
this locomotion of the serous membrane, the caecum and
ileum on the right side, and the sigmoid flexure upon the
left, attain a lower position in the abdomen, a circumstance
upon which both Scarpa1 and Wrisberg2 have commented.
That the transition of the testicle has an important influ-
ence upon the movements of the viscera is suggested by
the fact that in the cases of retained testicle the caecum
may fail to complete its descent into the iliac fossa3.
The exact contrary of this may happen, and the caecum or
the ileum be dragged with the testicle into the scrotum,
producing a congenital caecocele. Wrisberg,4 Scarpa5
and Cloquet6 mention such cases and say that the caecum
was attached to the testicle by a fold which they identify
as the plica vascularis, but without naming it. I have been
so fortunate as to find a congenital caecocele in a very
young infant. In it the plica vascularis had entirely
disappeared, but upon the back of the hernial sac there
was a quantity of muscular fibres and fibro-areolar tissue,
which passed from the back of the testicle upwards to the
caecum.7 These bands were parallel to and adjoining the
spermatic vessels, and without doubt the hypertrophied
representatives of those of the gubernaculum which before
1 'A Treatise ou Hernia/ translated by Wishart, Edinburgh, 1814,
p. 38.
- Loc. cit.., p. 230.
3 See a paper by author, ' Br»t. Med. Journ.,' Sept., 1882, p. 575, " Abnor-
malities of the Cajcum and Colon with Reference to Development."
* Loc. cit., p. 233.
5 Loc. cit., p. 203.
6 ' Causes, &c., des Hernies,' p. 23. See also Cruveilhier, ' Anatomie
Pathologique,' vol. iii, p. 307, Paris, 1849.
7 My friend Mr. D'Arcy Power kindly verified this fact.
50G MORBID ANATOMY AND PATHOLOGY OF
birth normally exist in this situation. It would be illogical
to argue that because these were present therefore they
e responsible for the abnormal descent of the caecum,
but it is not impossible. This specimen is important in
other respects and will be mentioned again. Assuming
it is true that a general locomotion of the peritoneum of
the back of the lower part of the abdomen accompanies
the transition of the testicle, it remains to be decided
whether the gubernaculum is capable of such an effort.
Judging from the amount of its muscularity this question
may be answered in the affirmative, but it is doubtful
whether all of its attachments are adequate. It is easily
appreciated that the portions which adhere to the abdo-
minal walls and to the pubes may, by their contraction,
move onwards the testicle and peritoneum, because they
spring from definite fixed points, but the part which arises
from the bottom of the scrotum seems entirely deficient
in this respect. Doubtless the scrotal fibres influence
the ultimate destination of the gland, but properly
prepared specimens show that the actual work of tran-
sition is performed by a band of fibres which originates in
the perinaeum. This is exceedingly well displayed in an
infant in whom I found a congenital hernia of the caecum.
In this case the perinaeuni is occupied by a quantity of
unstriped muscular tissue, continuous behind, with the
external sphincter and tissues over the tuber ischii, whilst
in front its fibres mingle with those of the scrotum, and
those which have been mentionedas passingup the posterior
wall of the hernial sac to the caecum. It is not impossible
that in this case the dissection was facilitated by the muscle
being hypertrophied. It is never easy to follow bands of
unstriped muscle with the scalpel, and although the foetal
perineeum always contains them in abundance, it would
be rash, without the aid of microscopic sections, to make
explicit statements concerning them. However, the com-
bined methods show thai I his portion of the gubernaeulmn
after emerging from the perinamrn is attached to the
extremity of the processus vaginalis, the testiele, and
ENCYSTED AND INFANTILE HERNIA. 507
epididymis, and, moreover, that its fibres extend up the
posterior surface of the processus vaginalis towards the
peritoneum which lines the back of the abdomen.
Clearly these are the muscular bands which have been
already (p. 502) notified in the plica vascularis.
The preceding statements derive a certain degree of
support from the fact that when the testicle exceeds
its proper excursion, and passes into the perinseum, it
has been seen attached to the tuberosity of the ischium
by a band which required division before replacement
into the scrotum could be achieved. Both Oloquet1
and Mr. McCarthy2 mention a case of this sort, and Mr.
Treves has informed me of a similar one under his
care. It is not impossible that the perineal fibres of
the gubernaculum may in a degree persist throughout
life, for in an exceedingly well-developed subject the
subcutaneous tissue in that region contained large quan-
tities of unstriped muscle-fibres.
With regard to the part of the gubernaculum testis which
extends up the back of the processus vaginalis and into the
plica vascularis, it is interesting to note that, as Cruveil-
hier3 points out, the spermatic cord contains numerous
longitudinal bands of unstriped muscle, which he calls the
"internal creniaster." I would identify these as being
the upward prolongation of the gubernaculum testis, whose
importance in relation to infantile hernia will be shown in
what follows. Before discussing this branch of the sub-
ject, a last word may be spoken upon the question of the
locomotion of the peritoneum.
It may be remembered that it has been repeatedly said
that only the serous membrane which clothes the back of
the abdomen moves towards the groins. But before this
is accepted it is necessary to solve the question why other
portions are not involved. The problem seems purely
anatomical. The peritoneum which lines the inner surface
1 Loc. cit., p. 24, 5. This case was verified by dissection.
5 Loc. cit., p. 1606.
3 Cruveilhier, ' Traite d'Anatomie,' 1874, vol. ii, p. 381, fig. 253.
508 MORBID ANATOMY AND PATHOLOGY OF
of the transversalis fascia and muscle is, both in the
foetus and in the adult,1 so closely attached to those
structures that its displacement is practically impossible.
In this situation in the foetus, sub-peritoneal tissue is
almost absent, and the serous membrane is evenly dis-
tributed and devoid of pleats and folds. The contrary is
the case with that which lines the iliac fossae and back of
the abdomen, for in this situation, as John Hunter2 points
out, its laxity is so great and its connections so loose,
that ample folds may easily be seized and dragged in any
direction. Histological specimens show that everywhere
in the region of the psoas muscle the serous sac is under-
laid by a great quantity of the most delicate connective
tissue, and that an ample cushion of this is prolonged
behind the advancing processus vaginalis into the scrotum.
A final reason for the displacement of this particular part
of the peritoneum is that the fibres of the gubernaculum
are especially distributed to it.
Before endeavouring to apply these anatomical and
developmental data to infantile hernia, perhaps the most
important may be recapitulated.
a. That the lowest attachments of the gubernaculum
are in the perinreuru.
b. That the gubernaculum is inserted into, and draws
the processus vaginalis into the scrotum.
C. That the gubernaculum is prolonged above the
testicle to the peritoneum of the posterior wall of the
abdomen, and produces an extensive locomotion of it.
If we now return to inspect the various specimens of
infantile hernia which have been mentioned, it is pal-
pable that either a fold of peritoneum, or a well-marked
fasciculated band of tissue extends from the upper part
of the epididymis to the inferior extremity of the hernial
sac.
Cloquet makes a similar observation :»s repanls adults, ' Recherche*
Anatomiques snx lea Henries de L' Abdomen,' p. 41.
! ' Observations »u Certain Parts of the Animal CEconomy,' by John
Hunter, L786. A description of the situation of the testicle, p. 8.
ENCYSTED AND INFANTILE HERNIA. 509
This fold is exceedingly well shown in a specimen of
infantile hernia which is in the museum of St. Thomas's
Hospital (v. Fig. 4), and, owing to the manner in which it
arises at the upper end of the epididymis, there is not
the slightest difficulty in recognising it as the remains of
the plica vascularis. Under ordinary circumstances that
reduplication of serous membrane almost entirely dis-
appears, but an examination of the various specimens of
congenital hernia in the London museums shows that it
has a very great tendency not only to persist, but to
attain considerable size and stretch far up the posterior wall
of the sac. This point is clearly shown in one of
Camper's plates1 and in a specimen of congenital
hernia which I obtained from a pig. It is of considerable
practical importance because the fold indicates not only
the position of the spermatic vessels, but also distin-
guishes certain adhesions which are found in congenital
hernia. The plica vascularis has already been mentioned
in connection with ceecocele, and its relation to the disease
has been noted. It seems unnecessary to say at length
how essential a knowledge of the structure is to the
practical surgeon.
In reading accounts of operations upon congenital hernias
one is struck by the frequency with which adhesions of
the gut to the back of the sac, and to the testicle, are
mentioned, and often the significant remark is added that
when the adhesion was severed, the spermatic vessels were
divided.2 If an opinion may be formed from morbid
anatomy specimens this disaster may be avoided by simply
ascertaining whether the fold or adhesion is the plica
vascularis, and to decide this question it is only necessary
to trace the band towards the testicle and observe its
relation to the epididymis. After this digression the rela-
tion of the plica vascularis to the pathology of infantile
1 Camper, ' Icones Herniaruin,' ed. by S. J. Soenimerring,' 1801, Tab. iii,
figs. 3 and 4.
2 E. g., Pott's ' Chirurgical Works,' vol. ii, p. 159. 1779; also Vidal, ' Traite
de pathologie Externe,' tonic iv, 1861.
510 MORBID ANATOMY AND PATHOLOGY OF
hernia may be resumed. It has been stated that "Wrisberg
and others consider the fold, which I have ventured to call
the plica vascularis, an important factor in the causation
of congenital hernia of the caacuni and sigmoid flexure, and
Fig. 8.
Specimen of "encysted hernia" in the Museum of St. Mary's Hospital,
Sp. C. D. 20. Shows band passing from epididymis to bottom of sac. The
spermatic artery is seen amongst its fibres. The vas deferens passes over sac
and was probably at one time closely attached to its walls.
T, testicles; B, epididymis ; v, vas deferens ; 8, hernial sac; B, band with
spermatic artery upon it; b. m. Cut edge of serous membrane.1
sinco it is present in this case o\' infantile hernia (Fig. 4),
it might be supposed to have something to do with its
' i am indebted to the kindness of Mr. K. Owen and Dr. Silcock for per-
mission to examine and draw this specimen.
ENCYSTED AND INFANTILE HERNIA. 511
formation. Before accepting this inference the absence
of the plica vascularis in the case of congenital csecocele
already mentioned (p. 505) entails caution and suggests
that the fold, in itself, need not be an essential cause.
However, it may be remembered that in its place a quantity
of muscular fibres and fibro-areolar tissue passed upon the
posterior wall of the hernial sac to the ceecum and probably
performed the role which, in other cases, has been assigned
to the plica vascularis. The pertinence of these remarks
will be clearer as the peculiarities of certain cases of
infantile hernia are investigated. In the two specimens
which are depicted in Figs. 5 and 8, the plica vascu-
laris is not apparent, having, I think, been removed ;
but, in its place, a strong fasciculated band extends from
the epididymis to the lower extremity of the hernial sac.
The drawings show that the spermatic artery is intimately
associated with this structure, which is proved by the
microscope to consist of unstriped muscle-fibres and fibro-
areolar tissue. In the St. Mary's specimen the origin of
the muscular fasciculi may be traced far down the back of
the epididymis, possibly to the scrotum, and in either case
they terminated above upon the inner wall of the hernial
sac, many of them ascending between the two layers as
far as its neck. If the relations of these muscular fibres
to the epididymis, spermatic vessels and serous membrane
be compared with those which have already been attributed
to the upward prolongation of the gubernaculum testis the
likeness is manifest, and without doubt they are identical
structures. The moment it has been admitted that the
band of muscle-fibres, which extends from the epididymis
to the sac of these infantile hernias, is part of the guber-
naculum, an explanation of the pathology of that disease is
possible. I have already endeavoured to prove that the
muscle in question has a most important influeuce in pro-
ducing the processus vaginalis and in drawing down
the peritoneum, and, if this has been allowed, there can
be little difficulty in conceiving that it may, under certain
circumstances, produce an additional sac. Before adduc-
512 MORBID ANATOMY AND PATHOLOGY OF
ing evidence to support this proposition a circumstance
which is common to congenital and infantile hernia may
be commented upon. Under ordinary conditions the
processus vaginalis, after it has served for the transition of
the testicle, ceases to grow and develop except at its lowest
part; which, stimulated by the presence of the testis, becomes
larger and thicker. However, it occasionally happens that
the processus vaginalis, instead of undergoing those retro-
grade atrophic changes, grows and develops, and its lumen,
instead of ceasing to exist, increases. When this happens the
enlargement is not confined to the serous membrane alone,
but, as specimens in the Dupuytren museum show, its
blood-vessels, and in all probability other structures, parti-
cipate. In this way the persistence of the plica vascularis
in congenital hernia, being part of a general effect, may be
explained ; and it is not unlikely that the hypertrophied
condition of the upper part of the gubernaculum (internal
cremaster) in cases of infantile hernia is related to it.
Long ago Cloquet put it upon record that the guber-
naculum could create1 by its traction the sac of an ordinary
hernia and Sir William Lawrence2 testifies to the import-
ance of this observation by quoting it in extenso. If this
be so, there is no difficulty in believing that the guber-
naculum assists in the production of the sac of an infantile
hernia. The morbid anatomy of the disease points strongly
to the probability of this assumption. The portion of
peritoneum from which the sac is formed, that which lines
the back of the abdomen, has already been shown to be
loose and easily displaced, and, moreover, it has been
affirmed that normally the gubernaculum is inserted into
it. Therefore, from an anatomical point of view, the idea
is tenable. But before accepting this conclusion, that the
sac of infantile hernia? is caused by the traction of the
•julu niaculum testis, the specimens themselves ought to
be examined to see whether tiny lend any support to it.
The following points may be noted : a, that the sac is
1 Cloqaet) ' Causes, &c, ilea Hernics,' p. 23, ei seq.
■ l,:iu Tcmr on 'Hernia,' p. \M, et teq.
ENCYSTED AND INFANTILE HERNIA. 513
always closely related to the posterior wall of the open
processus vaginalis and usually bulges into it ; b, that the
sac is formed from the loose and yielding peritoneum of
the back of the abdomen ; c, that a band of muscular
fibres closely connected with the spermatic vessels is
inserted into the inferior extremity and surface of their
sac wall. Although these are cogent reasons yet it might
be anticipated that a sac, which owes its birth to tractive
force, would betray its origin by its conical shape. None
of the infantile hernige which have been mentioned are par-
ticularly pointed. In one case (Guy's 2497, Fig. 5, p. 495)
the posterior wall of the hernial sac exhibits a suggestive
pouch which descends behind, and parallel to, the main
sac, but in other respects their shape is very like that ordi-
narily produced by pressure from within. These facts do
not forbid the supposition that at the commencement these
sacs may not have been originated by the gubernaculum
and afterwards modified by pressure, and a specimen which
I have dissected countenances this view (Specimen 2140B,
St. Bartholomew's Hospital Museum) . In it the processus
vaginalis was represented by a long tube which extends
from the internal abdominal ring to just above the epidi-
dymis. This tube communicates with the general cavity
of the peritoneum by a small aperture, a quarter of an inch
in diameter, which occupies the usual position of the internal
abdominal ring external to the epigastric artery. A probe
introduced into this opening showed that the processus
vaginalis was occluded an inch from its upper end, but in
the remainder of its extent its cavity was almost half an
inch in diameter, above, and one and a half below. Behind
the superior part of this serous tube a hernial sac protruded
from the peritoneum in such a way that its anterior wall
bulged slightly into the cavity of the processus vaginalis.
Attached to the lower extremity of this protrusion and to its
posterior wall were strong bands of unstriped muscle-fibre
intimately related to the spermatic vessels. The end of the
sac to which these were attached was conical and sharply
pointed.
vol. lxix. 33
514 MORBID ANATOMY AND PATHOLOGY OF
It seems hardly requisite to enumerate the reasons why
this case should be included in the category of infantile
hernia, and it clearly shows by its shape that the hernial
sac was caused by the traction of the gubernaculum testis.
This specimen also demonstrates that in infantile hernia
the processus vaginalis need not necessarily communicate
with the cavity of the tunica vaginalis, because in it the
latter was shut off from the former, in the same way as
in funicular hernia. This fact seems also to be displayed by
other specimens of infantile hernia in the museum of St.
Bartholomew's Hospital (Sp. 2140c and 2140a), but as I
have not yet dissected these no other assertions will be
made concerning them.
The conclusion arrived at, after studying these data, is
that the sac of an infantile hernia owes its origin to the
action of the gubernaculum testis, but that afterwards it
may be considerably modified by pressure from within. In
this way may be explained a circumstance which seems to
militate against many of the previous assertions. A glance
at Fig. 6, p. 408 shows that the sac of this hernia protrudes
in the open processus vaginalis like a cyst pendent] from
the ring and that there is no trace of muscular fibres
reaching from its extremity to the epididymis. However,
when this beautiful specimen is viewed in profile it is clear
that its attachment to the posterior wall of the vaginal
process is quite an inch long, and although no muscle-
fibres are attached to the bottom of the sac, numerous
bands may be perceived running upwards behind the
serous membrane (vaginal process), and when they arrive
at the fornix, which is formed by the junction of the
vaginal process with the outer layer of the hernial sac,
they turn forwards and insinuate themselves between the
two layers of serous membrane which constitute its walls.
The construction of the sac of this hernia, and the condi-
tion of the peritoneum at its neck have already been dis-
cussed, v. a., and it has been decided that it belongs to the
infantile variety. This being the case, although it is evi-
dent that pressure From within has profoundly affected its
ENCYSTED AND INFANTILE HERNIA. 515
sac, yet it cannot be denied but that it may have had
something to do with its beginning.
Before concluding these observations reference may be
made to a point which has not yet been touched upon. In
nearly all the cases of infantile hernia which have been
mentioned the upper edge of the hernial sac is formed by
the posterior margin of the aperture by which the pro-
cessus vaginalis communicates with the cavity of the peri-
toneum. It seems natural to ask by what means this
acquires its immobility. In the St. Mary's specimen
this portion of serous membrane is exceedingly thick
and strong, and attached by a species of alse to the peri-
toneum of the front wall of the abdomen, which has been
shown to be comparatively immobile. In the specimen in
the museum of St. Bartholomew's Hospital which has just
been described a not dissimilar condition exists, and besides
the serous membrane exhibits many old scars and thicken-
ings ; but, at the present, it would be premature to
express any definite opinions upon this point, for there is
reason to think that the neck of the sac may sometimes
be produced in a different manner. In conclusion, perhaps,
I may be permitted to recapitulate the results arrived at
by this inquiry :
a. That the London museums contain no specimen of
encysted hernia such as is usually described.
b. That the various specimens designated by that name
belong to the infantile variety.
c. That the latter owe their origin to the tractive power
of the gubernaculum testis.
(For a report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p. 118.)
ON A CASE OF MULTIPLE NEUKOMATA.
THOMAS F. CHAVASSE, M.D., CM. (Edin.)
SUBGEON TO THE BIRMINGHAM GENERAL HOSPITAL.
Received February 9th— Read June 8th, 1886.
Margaret E — set. 30, admitted into the General Hos-
pital, Birmingham, July 18th, 1885.
History. — Four years ago was treated as an out-patient
for what was then considered to be an enlargement of the
cervical glands on the right side. An abatement in the
size of the tumour apparently resulted, and no further
increase in size took place until three months before ad-
mission. At first some large glands also existed on the
left side of the neck, but these gradually disappeared.
The patient now sought advice at the hospital because the
tumour was growing, and caused pain down the arm on
the affected side.
On admission. — There is a tumour as large as a duck's
egg in the right posterior triangle of the neck, movable
and seeming to all intents and purposes of a lymphomatous
nature. The patient was short and stout, and slightly
anaemic, but the general health appeared normal, and the
various functions of the body were naturally performed.
Operation, July IMli. — A longitudinal incision was made
over the growth, and, on reflecting the skin and fascia, a
large nervous cord was found running over its upper
518 MULTIPLE NEUROMATA.
surface and required to be dissected off. The tumour
itself extended deeply, dipping down behind the clavicle,
and at its upper part was found attached by a pedicle,
the thickness of the little finger, to the vertebral column.
During manipulation this pedicle was torn across close
to the spine, and the step was followed by a gush of
blood. A rounded aperture into which the tip of the
finger could be inserted was left by the removal of the
pedicle, and had to be plugged by a strip of boracic lint
to stop the hemorrhage. The wound was then drained
and its edges approximated.
The evening temperature was 101° F., and the patient
complained of violent headache.
July 25th. — Patient was semi-conscious, but could be
roused, when she complained of her head aching. The
arms and legs were constantly tossed about. There were
twitchiugs of the facial muscles, and the urine passed in-
voluntarily. Pupils slightly contracted and sluggish ; the
temperature varied between 102° and 103'4C F.
Next day the patient was quite sensible and remem-
bered nothing of the previous day. On dressing the
wound and removing the plug about two drachms of a
clear-looking fluid escaped.
July ~st It. — There was a rigor, followed by delirium
and marked rigidity of the neck and head. This con-
dition continued until July 31st, when muscular tremors
and slight clonic spasms became marked. The pupils
were widely dilated, and coma supervened, and the patient
died in the evening.
Post-mortem August 1st. — Body very bloodless; rigor
mortis slight.
Neck. — An incision three inches long existed parallel
to 1 1 1 1 • edge of the Bterno-mastoid muscle, in the right
posterior cervical triangle. This opened into an irregular
cavity, one and a halt' inches in diameter, that led back-
wards and inwards to the spinal column, and at its very
bottom was a round intervertebral foramen (fifth) empty
of its nerve and containing pus. All the structures bound-
MULTIPLE NEUROMATA. 519
ing this cavity were thickened and adherent from inflam-
matory exudation.
Nervous system. — Brain weighed 52 oz. The mem-
branes were smooth and shining ; no sign of meningitis
either on the vertex or at the base. The ventricles were
distended with a thin clear fluid, and their walls were
softened. This was the only abnormal change found in
the brain-substance.
The spinal cord and plexuses were removed entire.
The posterior surface of the cord was deeply congested,
and thinly coated with a soft layer of dirty, yellowish-
brown fibrin. This began at the fifth cervical nerve, and
extended down the cord, but it did not pass to the front
or ascend to the brain. There was a considerable quantity
(half an ounce approximately) of thin semi-purulent fluid
in the cavity of the arachnoid, which escaped when the
latter was opened. The pia mater on the front of the cord
was deeply congested, but there was an entire absence
of lymph. The cervical enlargement was soft and pulpy,
especially opposite the sixth nerve, and, on section, the
substance was discoloured, the white matter being of a
greyish tint, and the grey matter less defined than usual.
The fifth cervical nerve was discoloured and thickened on
the right side from inflammatory changes. The sixth
nerve had been torn off, the root giving way inside the
dura mater, so that the ganglion went with the torn
portion. The ends of the anterior and posterior roots
were found within the dura mater. All the nerves that
could be examined were found to be irregularly enlarged.
Surrounding them were various sized tumours contained
within the nerve- sheath, and apparently having the nerve
running through them like an axis. Most of them were
fusiform, a few globular, and, on section, they appeared
white, glistening, senii-translucent, and extremely firm.
The nodulation began as soon as the nerve left the dura
mater, and was first seen in the ganglion of the root
which, all down the cord, was greatly enlarged.
Inside the dura mater the nerves were quite normal.
520 MULTIPLE NEUROMATA.
The trunks of the nerves were much increased in size by
a sort of diffusion of the tumour, so that, for example, the
sciatic was one and a quarter inches broad and proportion-
ally thick, and the anterior crural half as large again as
the normal sciatic. Even the small nerves, e. g. the genito-
crural, were affected, and on them, the nodules were much
larger in proportion to the diameter of the nerve, than
was the case with the larger ones. The sympathetic
nerves were similarly affected, and the fine filaments in
the rectum could be easily traced by means of the nodules.
They could also be seen beneath the mucous membrane of
the tongue and the pharynx.
The pneumogastrics were equal to a penholder in size.
The phrenic nerves appeared like a string of dahlia
roots. The various thoracic and abdominal viscera were
healthy.
Similar cases of so-called multiple neuromata appear to
be somewhat rare. Lebert has collected seventeen cases,
and Prudden,1 of New York, has extended these to forty-
one. From such records, the clinical histories being
extremely meagre in seven, the following facts may be
deduced :
I. The male appears to be more prone to this develop-
ment than the female. The sex is recorded in thirty-two
instances, and of these twenty-four were men, eight were
women.
II. The middle period of life is most liable to the
atYeetion, but in some of the cases I'rudden's opinion is
that the tumours were undoubtedly congenital.
III. The duration of the disease has not been deter-
mined. In twenty-three cases, where the age at death is
stated, the fatal termination occurred, on an average,
between thirty-three and thirty-four years.
W'lini Lebert terms the second stage of development,
and tins appears fco be the period of pronounced swellings,
is stated t" be, five or six months.
1 American Journal of Mod. Sc.,' July, 1880.
MULTIPLE NEUROMATA. 521
IV. Clinically no constant symptoms are manifest in
cases of multiple neuromata.
In twenty-six instances where the history is fully
enough reported, twelve had no symptom pointing to a
nerve lesion.
In three there was more or less paralysis, but this
by no means in proportion to the size and number of the
tumours.
Pain was only experienced in thirteen patients ; this
varied much ; in some it is described as being spontaneous,
in others it was elicited by pressure or atmospheric
changes. This absence of pain seems remarkable, con-
sidering that both the mixed and sensory nerves were
covered with tumours. Typhoid fever appears to be
badly borne in this class of case, five deaths being attri-
buted to it in a mortality of twenty-seven.
Three patients died of phthisis ; in one recorded by
Dr. Wilks,1 the writer thinks that it is possible that the
condition was due to the lesion of the pneumogastric
inducing the pulmonary changes.
In many cases, nutrition of the body is reported to have
been interfered with, yet on post-mortem examination no
organic disease of the viscera was found. Most authors
agree that the prognosis in this disease is unfavorable.
V. The tendency of the condition is to appear in several
members of a family. Nicaise2 thinks there is sufficient
evidence to show that it is frequently congenital and here-
ditary. Hitchcock3 has reported cases in which the
mother, her son and daughter all exhibited multiple
neuromata. Generisch4 cites an instance in which the
patient, whose mother had suffered from numerous
tumours diagnosed as neuromata, died of pneumonia.
At the post-mortem, tumours of various sizes were
found on nearly all the nerves of the body. Four years
1 ' Transactions of the Pathological Society of London/ vol. x.
2 ' International Encyclopaedia of Surgery/ vol. iii.
1 ' American Journal of Med. Sciences,' vol. xliii, 1862.
* Virchow's ' Archiv,' Band 49, 1870.
522 MULTIPLE NEUROMATA.
afterwards the brother of the preceding case died of
tetanus, and neuromata were then found to exist every-
where. Both vagi and the phrenics were affected. The
roots of the spinal nerves were normal.
Brums1 reports a case in which death was caused by
haemorrhage from the carotid artery. Many tumours,
some the size of a pigeon's egg, were found on the nerves.
The patient's brother had congenital elephantiasis with
plexiform neuromata about the head and neck, and the
mother is said to have had wart-like tumours in the skin.
VI. Operative interference is badly borne. This is
exemplified by the following cases :
(a) One of the tumours removed from the left radial
nerve. Death in five weeks from pyseniia.
(b) Amputation of right leg for ulceration and gangrene
of toes. Died in two days of pneumonia.
(c) Tumour near clavicle the size of a hen's egg and
another small one near the lip were enucleated and did
not return. According to the statement of the patient
the tumours in the other parts of the body increased in
number more rapidly after the operation.
(d) Removal of tumour, six and a half by three and a
half inches in size, from the right ulnar nerve, the nerve
itself being severed in the operation. The wound healed ; a
year later disarticulation at the shoulder-joint was performed
for a return of the growth. The stump did not heal.
Death from exhaustion seven months later.
(e) Removal of tumour the size of a clenched fist.
Vagus divided. Died on the tenth day, haiinorrhage
taking place from ulceration of the carotid.
(i) Attempt made to remove a tumour from the back.
Died of pyasinia.
(g) A portion of the lesser sciatic nerve excised in an
endeavour to check the growth of many tumours corre-
sponding to the branches of the nerve. Wound healed
by suppuration. After four months many of the swellings
disappeared and the rest gave no trouble.
1 Virchow'a ■ Arcliiv,' Baud 50, 1870.
MULTIPLE NEUROMATA. 523
VII. The tendency of the disease to become malignant.
This appears to be rare. In Hitchcock's third case
the tumour removed from the ulnar nerve, after existing
for upwards of twenty years, presented on section the
characters of a doubtful neoplasm. A year later, after
amputation of the limb for its recurrence, it was certified
to be of an encephaloid nature, and the patient died a
few months later with a return in the cicatrix.
In Genersich's1 case, multiple tumours having existed for
some time, ten weeks before death a rapidly growing
neoplasm appeared in the right buttock. Examination
after death showed that some of the tumours were fibro-
mata, some sarcomata, and others myxomata.
In both these cases there was a hereditary tendency to
neuromata, and the mother of the second case had carci-
noma of the mamma.
VIII. The position of the tumours.
In twenty- seven cases the peripheral nerves were
affected.
In ten cases special groups of nerves were implicated.
In sixteen cases the sympathetic and in twenty-two the
vagi were involved.
As a rule, however, special nerves appear to be unaffected
and the nerves of the hands and the feet are free from the
lesion.
Microscopic Examination of the Tumour itself.
The tumour is composed of anastomosing and branching
bundles of white fibrous tissue, which intersect one another
at varying planes. Between the fasciculi are embedded
numerous fusiform, oval, and round cells, resembling the
embryonic connective-tissue corpuscles. No elastic fibres
are to be seen and no well-defined stellate or branching
connective-tissue cells. There is no evidence of fully
developed nerve-fibrils in any of the sections. (See Wood-
cuts on page 524.)
1 Virchow's ' Archiv, Bd. 49, 1870.
524
MULTIPLE NEUROMATA.
VNV^I
. .
I
a. Spiudle-cclls and connective tissue cut transversely, with some round-
cells ; b, spindle-cells in delicate connective tissue.
■it
a. Spindle-cells and fibrous tissue cut longitudinally, with a few
round-cells; b, spindle-cells and connective tissue cut transversely.
with some round-cells.
Litkratiim:.
Baekow. — Acad. Cobs. Leop., Nova Acta, Bd. 14, 1828,
p. 5] I,
Bbuns.— VirohoVa Archiv, Bd. 50, 1870, p. 80.
Coukvoisier. — Die Neuronic L886. (Contains a full
bibliography oi Neuromata.)
MULTIPLE NEUROMATA. 525
Czerny. — Archiv fur klin. Chirurg., Bd. 17, 1874, p. 357.
Genersich. — Virchow's Archiv, Bd. 49, 1870, p. 15.
Gerhardt. — Deuts. Archiv Mr klin. Med., Bd. 21, 1878,
p. 268.
Gunsburg. — Comptes Rendus de l'Academie des
Sciences, torn. 17.
Heller. — Virchow's Archiv, Bd. 44, 1868, p. 338.
Heusinger. — Virchow's Archiv, Bd. 27, 1863, p. 206.
Hitchcock. — American Journal of the Medical Sciences,
vol. 43, 1862, p. 320.
Kosinsky. — Centralblatt fur Chirurgie, July 18th, 1878.
Lebert. — Mem. de la Societe de Chirurgie de Paris,
torn. 3, 1853, p. 249.
Nicaise. — The International Encyclopsedia of Surgery
(Ashhurst), vol. iii.
Odier. — Manuel de Medecine Pratique, 1811.
Prudden. — American Journal of the Medical Sciences,
vol. 80, 1880, p. 134.
Schipfner. — Med. Jahrbiich. Oester. Staats, Bd. 4,
1818, p. 77; Bd. 6, 1820, p. 44.
Serres. — Comptes Rendus de l'Academie des Sciences,
tomes 16, 21, 22.
Sibley. — Medico -Chirurgical Trans., vol. 49, 1866, p. 39.
Smith (Robert W.). — A Treatise on the Pathology,
Diagnosis, and Treatment of Neuroma, Dublin, 1849.
Smith (Thomas) . — Trans, of the Pathological Society of
London, vol. 12, 1860, p. 1.
Wegener. — Berliner klin. Wochenschrift, 1870, p. 24.
Wilks. — Trans, of the Pathological Society of London,
vol. 10, 1859, p. 1.
Wood (William). — Trans, of the Medico-Chirurgical
Society of Edinburgh, 1829, vol. iii, Part 2.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii,
p-1125.)
DESCRIPTION OF PLATE XIV.
Multiple Neuromata. By T. F. Chavasse, F.R.CS.
a. Smallest splanchnic.
b. Genito-crural.
Plate XIV.
Med. CHr. Trans. Vol .
. rv Bros liUn.
SOME STATISTICS OP PNEUMONIA,
WITH ESPECIAL EEFEEENCE TO THE
RELATIONS OF DELIRIUM AND TEMPERATURE.
BY
ANGEL MONET, M.D., M.R.C.P.
Received March 9th— Read June 8th, 1886.
The following statistical tables have been drawn up from
an investigation of the cases of pneumonia recorded in
the University College Hospital case books during the
past twelve years. I am indebted to Sir William Jenner,
Dr. Russell Reynolds, Dr. Wilson Fox, Dr. Sydney
Ringer, Dr. Charlton Bastian, and Dr. F. T. Roberts for
permission to make use of cases that had been under their
care.
The plan that I have pursued has been to make a con-
cise abstract of the cases, paying every attention to the
notes on the temperature and state of the nervous system.
From these abstracts a table, not here presented, was
constructed, and its various factors have been carried
through a kind of permutation and combination, the
results of which processes are here recorded. I have in
a few places ventured on some suggestions, and notably
in connection with the unexplained circumstance that
delirium is so frequent with pneumonia of the upper lobes
of the lungs.
528
SOME STATISTICS OF PNEUMONIA.
Table I gives age and sex of all the cases.
Age.
Years.
1—10
11—20
21—30
31—40
41—50
51—60
61—70
Male.
41
Female.
14
Total.
55
Percentage
27o
24
17
41
205
30
16
46
230
21
6
27
135
16
4
20
10-0
6
2
8
40
1
1
2
1-0
139
60
199
Table II, showing site of lung affected and the sex of
all the cases.
Lett lino.
Upper lobe
Male ... 9
Female... 2
Both
luhgs.
20
13
The right lung alone was the seat of pneumonia in 96
cases, or a percentage of about 48. Bleuler gives the
percentage at 52. The left lung alone was affected 70 times,
or 35 per cent. Bleuler gives 32 per cent. There was
double pneumonia 33 times, or 16 per cent., which also
agrees with Bleuler.
Table III, showing the number of cases according to age,
sex, and site of pneumonia.
Kn.iii
LUNG.
Left
LUNG.
HflTH
1 1 Ni.v
1—10 ..
Male.
16
Female
5
Hale
21
Female
. 5
Hale.
3
Female
l
11—20
12 ..
6
10
5
1
1
21—30
17
7
6
5
5
.. 3
31—40
9
1
8
2
5
.. 2
41—50
10
3
1
1
2
.. —
51—60
5 ..
1
1
1
—
—
61—70
—
1
1
. —
—
.. —
69
24
51
19
19
13
93
70
32
SOME STATISTICS OF PNEUMONIA. 529
Fallacies of statistics. — No one can be more aware of
the fallacies of statistics than I am. To reject statistics
altogether, though perhaps the most logical proceeding,
appears to me to be uuadvisable. That statistics have
introduced many false facts into medicine I do not doubt,
but I cannot but believe that we have also benefited by
them.
The statistics which are here presented seem to me to
be suggestive rather than positively instructive, and will
serve the purpose more of indicating lines of future study
than of laying down fresh propositions. At the same
time, as a solid contribution to our collection of facts
concerning pneumonia, the author submits that this
paper must necessarily possess some value in and of
itself.
The apparent discrepancies in numbers is to be explained
by bearing in mind that all the cases were not always
available for every table.
The cases are all cases of lobar pneumonia. The
majority of the cases are simple ones of primary pneu-
monia. A few cases are interspersed in which there were
marked complications, or in which acute pneumonia super-
vened on another disease. I have retained these cases
for comparison and with a view to their throwing light
on the symptoms in primary pneumonia.
From the total number of cases, 199, we subtract the
following (17) in which the pneumonia was not the only
disease :
1. Case 54, man, aged 23, pneumonia of the whole of
the right lung complicated by pleurisy and acute Bright's
disease, fatal.
2. Case 55, woman, aged 37, pneumonia of left lower
lobe, mitral disease, recovery.
3. Case 84, man, aged 20, pneumonia of right lung,
complicated by peritonitis, death.
4. Case 121, delirium tremens, man, aged 27, Bright' s
disease, fatal.
VOL. lxix. 34
530 SOME STATISTICS OF PNEUMONIA.
5. Case 128, man, aged 30, right base affected, Bright's
disease, recovery.
0. Case 129, female, aged 10, double pneumonia, rheu-
matic fever, recovery.
7. Case 158, female, aged 15, rheumatism, double pneu-
monia, fatal.
8. Case 189, male, aged 02, complicated by pericarditis,
pleuro-pneumonia of left lower lobe, fatal.
In these 8 cases delirium was present.
9. Case 2, female, aged 42, left lower lobe pneumonic,
mitral disease, death.
10. Case 4, female, aged 19, double pneumonia, Bright's
disease, death.
11. Case 32, infant, lethargic, aged 1, pericarditis, left
lung pneumonic, fatal.
12. Case 35, male, aged 11, lethargic, left lower lobe
pneumonic, rheumatic fever, recovery.
13. Case 04, male, aged 0, right lower lobe pneumonic,
meningitis, mental dulness, death.
14. Case 75, male, aged 50, left lower lobe pneumonic,
pericarditis, fatal.
15. Case 101, female, aged 29, mitral disease, double
pleuro-pneumonia, recovery.
10. Case 102, female, aged 29, rheumatic fever, mitral
disease, right lower lobe pneumonic, recovery.
17. Case 188, male, aged 55, right lower lobe pneumonic,
pericarditis, death.
The above 9 cases had no delirium.
Of 182 cases of primary pneumonia there were 56 in
which delirium was present, or a percentage of 30.
Il.inze (' Arcliiv der Eeilkunde/ 1808, p. 49) has
studied the relations of marked mental symptoms to
the temperature in pneumonia and has arrived at the
conclusion that the mere pyrexia had little or nothing to
say in the matter. My investigations tend in the same
direction. But the consideration cannot bo lost sight of
that prolonged pyrexia and high transitory fever must
SOME STATISTICS OF PNEUMONIA. 531
exercise some direct and indirect deteriorating influence
on the grey matter of the brain and spinal cord, and
must therefore predispose to delirium and other signs
of exhaustion of the nervous matter.1
Of 17 available cases sometimes (4) the delirium coin-
cided with the greatest rise in temperature ; rarely (2) it
preceded the acme of fever, and most frequently (11) the
delirium came on with the fall of temperature.
Heinze draws attention to the much greater frequency
of delirium, or rather, marked mental change in pneumonia
of the upper lobe of the lung. Of 317 cases the upper
lobes were involved 117 times; the lower lobes were
alone affected 200 times. Of the 98 cases showing
delirium, 47 were cases of pneumonia of the upper lobe
and 51 of the lower lobe. The contrast is made more
striking by a detailed statement of the facts (loc. cit.,
P. 57).
I think it safest and least liable to error if a com-
parison be made between cases which affect the upper lobe
alone and those which affect the lower lobe alone.
Thus, of 25 available cases in which the upper
lobes were alone diseased, I find that 12 are reported
as delirious, or a percentage of 48, which is 7 per cent,
higher than Heinze's estimate. When the lower lobe
was alone involved in 110 available cases, I find that
there was delirium 28 times, or a percentage of 25*5.
These results are practically identical with those of
Heinze.
Liebermeister believes that one of the reasons for the
above difference is to be found in the longer duration of
pneumonia of the upper lobe. Heinze adduces evidence
to show that this conclusion does not hold good. My
notes so far as they go suppoi^t the contention of Heinze.
Thus, in Case 8, the onset was on November 6th, and
the fever had disappeared by the 13th ; the temperature
was frequently 105°; the unconsciousness lasted till the
1 Sec a paper by author ou " Reflex Actious, &c," 'The Lancet,' vol. ii
1835.
532 SOME STATISTICS OF PNEUMONIA.
9tli ; there was some " after " fever on the night of the
13th, which had ceased by the 15th; the temperature
remained quite normal after the 23rd. Case 9 began on
March 12th and ended on the 19th ; no mention was made
of delirium.
Case 58, the man had suffered from epilepsy ; it was a
fatal case of pneumonia of the right apex which began on
July 30th and ended on August 9rh. Case 69 lasted only
seven days (August 1st to 8th). Case 78 began on May
9th and terminated on May 1 7th. Case 12'.' began on May
22nd and ended on May 29th. Case 130 lasted from
August 22nd till August 30th. Case 140 commenced on
February 9th and ended fatally on February 13th.
In several other instances there are no notes to fix the
date of onset, but the course and height of the fever on
admission and attendant circumstances would lead one to
suppose that the duration Avas not abnormally long.
Further, the temperature of cases of pneumonia of the
upper lobe alone does not appear to be higher than in
pneumonia of the lower lobe. And though my notes
show that the temperature was generally high and sus-
tained in cases of pneumonia of the upper lobe, yel a
comparison of the number "of cases according to site of
disease and temperature gives no certain indication that
there is any remarkable difference in the degree of p\ rexia
in pneumonia of the upper as contrasted with that of the
lower lobe*.
II ciu/.e brings forward some figures to show that the
rate of mortality in pneumonia of the upper lobe is higher
than in pneumonia of the lower Lobe. Taking again only
those cases in which the disease was confined to the upper
or the Lower Lobe my statistics give the following results:
— Five deaths in 25 eases of pneumonia of the
upper Lobe alone, and ten deaths in 110 cases of pneu-
iii' ma of the lower lolie al^ne, or a percentage of about
2»l ill the former and !(> in the hitler. The numbers are
small; but the difference is great. Of the 12 eases of
delirium with pneumonia of the upper lobe, but 2
SOME STATISTICS OF PNEUMONIA. 533
proved fatal (16*6 per cent.) ; of the 28 cases of delirium
with pneumonia of the lower lobe, 4 proved fatal (14'3 per
cent.). The difference here is not nearly so great as that
given by Heinze, whose numbers are 34 per cent, aud
21 "5 per cent, respectively. This author seeks for a
satisfactory explanation of the greater frequency with
which delirium occurs in pneumonia of the upper lobes
and finds none. He examines the age, sex, drinking
habits, month of the year of all the cases of delirium, and
all to no purpose.
After a careful survey of the statistics that I have col-
lected, I have arrived at the following position :
The determination of delirium in any particular case
probably depends on at least several factors or elements
in the case. The age of the patient probably has some
influence, but I think not much, except in this way.
Delirium is disorder of the intellectual faculties and
inextricably mixed up with the functions which are
engaged in the process of speech. Infants, therefore, are
incapable of delirium in the ordinary sense of the term,
for the reason that they are not in possession of the orga-
nised elements on which intellectual actions depend. But
that the mental or cerebral functions are greatly dis-
turbed in infants a glance at the collected facts readily
proves. A little consideration will show also that sex can
have but little to say in the matter.
Previous habits and social conditions probably play
some share in the production of delirium. Some of the
most powerful causes are alcohol, tea, and tobacco. The
prolonged and excessive use of these articles of con-
sumption probably deteriorates considerably the structures
on which intellectual processes depend.
Unquestionably a neuropathic disposition, however
brought about, would be a potent element in the causation
of delirium.
Is there anything special in the nature of pneumonia
which tends to produce delirium ? I do not think so. I
do not think that pneumonia is associated in any way
534 SOME STATISTICS OF PNEUMONIA.
with the production of any substance which has " deliriant"
properties like belladonna.
That some cases of delirium in pneumonia may be
dependent on the absorption into the circulation of an
autogenetic alkaloid is possible. But the action of alka-
loids formed in the tissues in pneumonia (such as have
been found by MM. Villiers, Lepine, and Guerin) is
unknown.
l>ut one more suggestion I have to make in connection
with the greater frequency of delirium in pneumonia of
the upper lobes. I make the suggestion that the proximity
of the intense inflammation to important and extensive
nervous structures in the neck is an element in the
explanation. An intense process like lobar pneumonia
must influence by radiation the structures in its vicinity.
There are the brachial plexus and the cervical sympathetic
nerves. The cervical sympathetic watches over the
calibre of the arteries supplying the head. I suppose
that the arteries supplying the brain are under the
dominion of its influence.
Let it be imagined that pneumonia of the apex is
capable by its action on the cervical sympathetic of inter-
fering with the supply of blood to the brain. An impair-
ment in the cerebral blood supply, whether as hyperemia
or in the direction of anaemia, must damage or tend to
damage the nervous tissues on which cerebral functions
are dependent.
Phthisis is well known to be associated with a hopefal
state of mind. Phthisis is most frequent at the apices of
the lungs. All cases of phthisis are not in a state of
hope. Does the difference depend on the site of the
Le8iOD '( I merely make suggestions, ami am fully aware
that I am on unsafe ground. Abdominal disease iSj as a
rule, associated with mental depression. I hardly like 1"
write the following Crude attempt at an explanation, as it
is open to so many logical objections. Disease of the
apices of the lungs irritates the sympathetic and causes
hyperemia of the brain; joy fulness and hopefulness are
SOME STATISTICS OF PNEUMONIA. 535
said to be associated with increased supply of blood to
the brain. Abdominal disease irritates the abdominal
sympathetic, opens the floodgates of the abdominal vessels,
and drains blood away from all parts of the body, including
the brain. A deficient supply of blood to the brain is
said to go with mental depression and apathy.
It would be very interesting and might be very instruc-
tive if we had some accurate information concerning the
relations of delirium to the collective amount of sleep which
the patient enjoyed.
Table IV shows the number of cases of delirium at different
temperatures (the highest recorded temperature in each
case) .
Temp 98°+ 99°+ 100°+ 101°+ 102°+ 103°+ 104°+ 103° +
No.of cases ... — — 2 2 6 11 26 9
Table V shows the number of cases without delirium at
different temperatures.
Temp 98°+ 9y°+ 100°+ 101°+ 102°+ 103°+ 104°+ 105°+ 106° +
No. of cases... 3 1 7 12 19 27 34 14 2
A comparison of these tables appears to show that the
number of cases with delirium is largest at the tempera-
ture of 104° and 105°. This comparison is rendered more
apparent by Table VI, which contrasts nearly equal
numbers of cases with and without delirium.
Table VI.
Temp 98°+ 99°+ 100°+ 101°+ 102°+ 103°+ 104°+ 105°+ 106° +
No. of cases with
delirium _ _' 2 26 11 26 9 —
No. of cases with-
out delirium... 15 1-5 35 6 95 13-5 170 7 1
It would seem, therefore, that the temperature does
exercise some, though probably small, influence.
Of the 199 cases there were 42 deaths = about 20 per
cent.
)36 SOME STATISTICS OF PNEUMONIA.
Table VII. — Fatal cases with delirium.
There was 1 fatal case when the highest temperature recorded was 100° +
1 „ „ ,, ioi° +
were 4 „ cases „ „ 102° +
5 „ „ „ „ 103° +
7 „ „ „ „ 10l° +
was 1 „ case ,. ,. 105 +
Table VIII. — Fatal cases without delirium.
There were 2 fatal cases when the highest recorded temperature was 100° +
„ was 1 „ case „ „ 101° +
,, were 3 ,, ea-rs ,, „ 1U2° +
2 „ „ „ „ 103° +
7 „ „ ,. „ 104° +
4 „ „ „ „ 105° +
3i „ „ „ „ 106° +
From an examination of these tables it seems clear that
the presence or absence of delirium exerts no influence on
the mortality. A temperature above 105°, whilst not
necessarily causing delirium, seems to be of grave signifi-
cance ; the three fatal cases at this temperature were
infants, who are incapable of delirium in the ordinary
sense of the term.
Table IX. — Number of cases of delirium with recovery at
diffen ni temperatures.
Temperature 100°+ 101°+ 102°+ 103°+ 101°+ 105° +
X. ..of cases 1 1 3 10 21 9
Table X. — Number of cases without delirium with recovery
at different temperatures.
Temperature... -100°+ 100"+ 101 f 102° + 103° + 104 + 106 +
No. of cases ... 4 7 10 is 28 2:' 1 I
1 Case 32, male infant, aged 1 year, highest temperature 106*2 ; left lung
pneumonic j the child was lethargici
Cue L40, male infant, 9 months, highest temperature 106*8 ; right apex
pneumonic.
Case 132, female infant, 10 months, temperature 1(>7'2' ; double pneu-
monia.
SOME STATISTICS OP PNEDMONIA.
537
Table XI, showing the age, highest temperature, and number
of Gases of delirium in pneum,onia.
Age.
Temp.
1—10
11—20
21—30
31—40
il
—50
51—60
Above
100°+ ..
—
.. — .
. 1
.. — .
— ..
—
.. 1
101°+ ..
— .
.. — .
. 1
.. — .
1 ..
—
.. —
102°+ ..
— .
2 .
. 2
1 .
1 ..
—
.. —
103°+ ..
—
4 .
. 2
.. 6 .
1 ..
1
.. —
104°+ ..
2 .
.. 7 .
. 9
.. 6 .
1 ..
2
.. —
105°+ ..
1 .
.. — .
. 3
2 .
2
. —
106°+ ..
1 .
1 .
. —
—
—
.. —
From this table we may state that the third decade,
when the temperature goes beyond 104°, seems to be most
fertile in the production of delirium. Such a statement is
open to several fallacies, and probably means but very
little : for an examination of other tables and statistics
shows that this period of life and this degree of fever
probably yield the greatest number of cases of pneumonia.
The right lung was affected 69 times without delirium,
and of these cases 11 proved fatal. The left lung was
involved 50 times without delirium, and 7 proved fatal.
Both lungs were affected 17 times without delirium, and
of these 5 ended in death.
There were 27 cases in which the right lung was
affected and the patients were delirious, a fatal termina-
tion taking place 9 times. The left lung was affected in
20 cases, delirium being present, and 2 of these died.
Sixteen times the pneumonia was double and the
patients delirious ; 8 of these succumbed.
The fatal cases of double pneumonia associated with
delirium cousisted of 2 males in the second decade and
1 female ; 1 male and 1 female in the third decade, 1
female in the fourth, and 1 male in the fifth.
Four of these cases were uncomplicated double pneu-
monia, 1 was complicated with rheumatism, another with
slight empyema, another with Bright' s disease and delirium
tremens. In one of the uncomplicated cases the delirium
vol. lxix. 35
538 SOME STATISTICS OF PNEUMONIA.
was of violent character, with a falling temperature, and
in another case of violent delirium the highest temperature
recorded was but 102'6 .
Of the 2 fatal cases of pneumonia of the left lung
associated with delirium 1 occurred in the fourth and the
other in the seventh decade. Of the 9 fatal cases of
pneumonia of the right lung associated with delirium 2
occurred in the second decade of life, 3 in the third, 1 in
the fourth, 1 in the fifth, and 2 in the sixth.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' New Series, vol. ii.
p. 127.)
INDEX.
These Indices to the annual volumes are made on the same principle as,
and are in continuation of, the General Index to the first fifty -three volumes
of the ' Transactions.7 They are inserted, as soon as printed, in the Library
copy, xohere the entire Index to the current date may always be consulted.
ACTINOMYCOSIS of the liver, so-called, case of (John
Harley) . . . . .135
Notes of case, 135-9 ; post-mortem, 139-41 ; minute examination
of the liver, 142-4; characters and structure of the granules, 144-5 ;
microscopical structure of the morbid deposit, 145-7 ; pathology,
147-9; discussion of fungoid origin of the disease, 149-53; ap-
pendix, 153-5.
ALBUMINTTEIA, scarlatinal, and the pre-albuminuric stage,
studied by frequent testing (E. Stevenson Thomson)
97
Tests, &c, used in present investigation, 97-100; period of occur-
rence, 100-3; frequency, 104; relations of blood and albumen to
each other in urine of scarlatinal nephritis, 104—6 ; dropsy without
albuminuria, 106-7; phenomena of so-called "pre-albuminuric
stage," 108-12 ; treatment, 113-14 ; table of observations on urine
of 112 cases of scarlatinal nephritis, 115-26.
ALOPECIA AEEATA, see Hair, Congenital absence of.
AMPUTATION, on the changes which occur in bone and soft
tissues after amputation of a limb (G. Pollock) . 275
— at the knee-joint by disarticulation ; with remarks on
amputation of the leg by lateral flaps (T. Bryant) . 163
References to previous writers, 163-4; table of cases of amputa-
tion at knee-joint by disarticulation, 165-8; analysis of cases,
169-70; sloughing of flaps, 171-3; operations of Pollock, Stephen
Smith, and Pick, 173-80; conclusions. 181-2.
540 INDEX.
ANEURISM, thoracic, a case of, treated by the introduction
of steel wire into the sac ( W. Cayley) . . 267
State of patient on admission, 267-8; account of operation, 269-71 ;
post-mortem report, 272 ; record of similar cases, 273-4.
ANTHRAX, see Pustule, malignant.
Arnott, James Moncrieff, obituary notice of .4
ARTERIES, the ligation of the la.bgeb, in their continuity ;
an experimental inquiry (C. A. Ballance and W. Edmunds)
443
Object of paper, 443-4; historical sketch, 444-9 ; opinion of the
present day, 449-50; authors' first views, 450-1; experimental
investigations, 451-3 ; specimens described and considered, 453-7 ;
the coaguluni, 458-60; the ligature, 460-3; objections discussed,
463-9; conclusions of authors, 469-71.
ARTERY, axillabt, a case of destruction of a portion of the,
by sarcoma CW. S. Savory) . . 157
Note of case, 157 ; operation, 158-9 ; post-mortem examination of
arterv and tumour, with histological note by Mr. d'Arcy Power,
159-61.
— left common CABOTID, case of ligature of the, wounded
by a fish-bone which had penetrated the pharynx, with
remarks and an appendix containing forty-five cases of
wounds of blood-vessels by foreign bodies (Walter
Rivington) . . . .63
Introductory remarks on injuries to alimentary canal and blood-
vessels by foreign bodies, 63-9; account of present case, 69-70;
operation, 71-3; post-mortem, 73-4; remarks, 74-9; conclusions
from comparison of this case with those in appendix, 79-82; ap-
pendix of 45 cases of wounds of blood-vessels by foreign bodies,
83-95.
BACILLUS ANTHRACIS, on some points regarding the dis-
tribution of, in the human skin in malignant pustule (A. E.
Barker) . . . .127
Notes of case, 127-9; distribution of bacilli anthraoie in the
affected skin, &c, 129-81; naked-eye and microscopical appear-
ances, 131-3.
BAKER, W. Morrant and Anthony A. Bowlbi/
Diffuse lipoma. . .11
BALLANCE. Charhy A., and Walter Edmunds.
The ligation of flic Larger arteries in their continuity; an
experimental inquiry . . .11::
BARKER, Arthur E.
On Borne points regarding the distribution of bacillus an-
thracis in the human skin in malignant pustule L27
INDEX. 541
BAB WELL, Bichard.
On supra-pubic lithotomy . . . 341
BELLAMY, Edward.
A communication on the removal of a growth from the
brachial plexus, affecting the roots of the eighth cervical
and first dorsal nerves at their emergence from the inter-
vertebral foramina . . .211
BLOOD, on the increase in number of white corpuscles in the,
in inflammation, especially in those cases accompanied by
suppuration (T. P. Gostling) . . . 183
BLOOD-VESSELS, wounds of, by foreign bodies, see Foreign
bodies.
BONE and soft tissues, changes which occur in, after amputa-
tion of a limb and from certain other conditions (G-.
Pollock) . . . . .275
Description of specimens showing changes after amputation
through the thigh, 276-9 ; wasting of bone and muscle from non-
use, &c, 280-6; list of specimens illustrative of deterioration of
bone, consequent on amputation, paralysis, &c, 286-9.
BOWLBY, Anthony A., see Baker and Bowlby, diffuse lipoma.
Boyd, Stanley.
Eeport of examination of tumour removed from brachial
plexus by Mr. Bellamy . . . 214
BEAOHIAL PLEXUS, removal of a growth from the, affecting
the roots of the eighth cervical and first dorsal nerves at
their emergence from the intervertebral foramina (Edward
Bellamy) . . . . .211
Note of case, 211-12; operation and progress of case, 212-13;
examination of tumour by Mr. Stanley Boyd, 214-15; subsequent
history of patient, 215; note by Dr. Mitchell Bruce, 215-16.
BRONCHIECTASIS, two cases of, treated by paracentesis,
with remarks on the mode of operation (C. Theodore
Williams and Hickman J. Oodlee) . . 317
Notes of Case 1, 317-20; operation, 320; subsequent history,
321-3 ; remarks, 323-4. Notes of Case 2, 324-6 ; operation, 327-9 ;
subsequent history, 329-30 ; remarks, 330-1 ; reference to cases by
Dr. Powell, Dr. Biss, Dr. Williams, &c, 331-2. Report of another
case under Dr. Williams, 332-3 ; remarks on the operation by Dr.
Williams, 333-6; remarks on the surgical aspect by Mr. Godlee,
336-40.
Bruce, J. Mitchell, M.D.
Note to case of removal of growth from the brachial plexus
by Mr. Bellamy .... 215
542 INDEX.
BRYANT, Thomas.
Amputation at the knee-joint by disarticulation ; with
remarks on amputation of the leg by lateral flaps . 163
CALCULUS, encysted vesical, of unusually large size,
removed by supra-pubic cystotomy (W. Rivington) 361
CARDIOGRAPHY, with special reference to the relation of
the time of duration of ventricular systole to that of dias-
tolic interval (Paul M. Chapman) . 2: >7
Object of paper and instrument used, 297-8; experiments by Dr.
Landois and Dr. A. H. Garrod, 299-301 ; duration of systole and
diastole for different pulse-rates, 302-6 ; abnormal excess of diastole
over systole, 306-10; excess of systole over diastole, with case of
F. J — , 310-12 ; effects of digitalis and convallaria, 313-15.
Carpenter, William Benjamin, M.D., Hon. Fellow, obituary
notice of . . .27
CATLET, William, M.D.
A case of thoracic aneurism treated by the introduction of
steel wire into the sac . . . 267
CHAMPNEYS, Francis Henry, M.B.
On the development of mammary functions by the skin of
lying-in women .... -119
CHAPMAN, Paul M., M.D.
On cardiography, with special reference to the relation of
the time of duration of ventricular systole to that of
diastolic interval .... 297
CHAVASSE, Thomas F.
On a case of multiple neuromata . .517
CHOLERA, chemical pathology of respiration in (W. Sedgwick)
3,s5
Cyanosis in relation to choleraic collapse, 385-7; pulmonary inter-
change of gases in cholera, 387-95; respiration in choleraic conva-
lescence, 395-6; chemistry of respiration in health, 396-7; respi-
ratory and inspiratory mnrmnra and Failure of voice in cholera,
398-9 j contraction of lungs observed after death, 400-8 j collapse
resembling that of cholera, 103—1; reduction of auimal heat during
collapse. 10.").
COBPUSCLBS, white, Bee Blood.
CYSTOTOMY, 81 PEA.-P1 BIC, Bee Lithotomy, Supra-pubic.
DIASTOLIC INTERVAL, Bee Cardiography.
EDMUNDS, Walter, see Ballance ami Edmunds.
The ligation of the larger arteries in their continuity .
index. 543
Edwards, Henri Milne, M.D., of Paris, Foreign Eon. Fellow,
obituary notice of . . .34
Egerton, Charles Chandler, of Epping, obituary notice of . 3
ENTERIC FEVER at Suakin, with some cases of malarial-
enteric, or tvpho-malarial fever (J. Edward Squire) 247
Discussion of origin of enteric fever, 247-50 ; water supply, soil,
&c, at Suakin, 250-2; proofs that outbreak was really enteric
fever, 252-4; reports of five cases, 255-60; analysis of cases re-
corded, 260-1 ; origin and spread of epidemic, 261-5 : conclusions,
265.
FEVER, enteric, see Enteric Fever.
— malarial-enteric, or typho-malarial, see Enteric Fever.
FISH-BONE, ligature of left common carotid artery for wound
by (Walter Rivington) . . .63
FOREIGN BODIES, notes of forty-five cases of wound? of
blood-vessels by (Walter Rivington) . . 63
see Fish-bone.
Fortescue, George, M.B., of Sydney, obituary notice of . 8
Gay, John, obituary notice of . . .13
GOBLEE, BicTcman J., see Williams and Godlee, two cases of
bronchiectasis treated by paracentesis
GOSTLING, T. P.
On the increase in number of white corpuscles in the blood
in inflammation, especially in those cases accompanied by
suppuration .... 183
Gueneau de Mussy, Noel, M.D., of Paris, Foreign Hon. Felloiv,
obituary notice of . .33
HAIR, congenital absence of, with atrophic condition of the skin
and its appendages, in a boy whose mother had been
almost wholly bald from alopecia areata from the age of
six (J. Hutchinson) .... 473
Description of present case, 473-75; discussion of question of
heredity, 475-7 .
" HARLEQUIN " FffiTUS, a case of (J. Bland Sutton) . 291
HARLEY, John, M.D.
A case of so-called actinomycosis of the liver . 135
Harris, Francis, M.D., obituary notice of .12
HEART, see Cardiography.
544 INDEX.
Heale, Frederick G-ustavus Jacob, M.D., of Gotlingen. Foreign
Hon. Felloio, obituary notice of . . 30
HERNIA, encysted and infantile, morbid anatomy and
pathology of (C. B. Lockwood) . . 470
History and references to modern authorities, 479-89 ; morbid
anatomy, &c., of encysted hernia, with description of specimens in the
London museums, 489-99; influence of transition of the testis on
infantile hernia, 500-14; conclusions, 515.
Howard, Edward, M.D., obituary notice of . 10
HUTCHINSON, Jonathan.
Congenital absence of hair and mammary glands, with
atrophic condition of the skin and its appendages, in a
boy whose mother had been almost wholly bald from alo-
pecia areata from the age of six . . 173
INFLAMMATION, on the increase in number of white cor-
puscles in the blood in, especially in those cases accom-
panied by suppuration (T. P. Gostling) . . 183
References to work by previous observers, 184-6; reports of
observations on number of white corpuscles in 19 cases, 187-207 ;
summary, 207-9.
JACOBSON, W. II. A.
A case of supra-pubic lithotomy, with remarks on the
operation ..... 377
JOHNSON, Georye,M.D., P.B.S.
Annual Address as President, March 1, 1886 . 1
KNEE-JOINT, amputation at, bv disarticulation (T. Bryant)
1G3
LEE, Henry.
On the tapetum lucidum . . . 289
LEG, amputation of, by lateral Haps (T. Bryant ) . L68
LIGATURE of the larger arteries in their continuity (O. A.
Ballauce and W. Edmunds) . .448
— see Artery {left common euro/ id).
LIPOMA, diffuse (\V. Murrain Baker and Anthony A. Bowlbj I
'll
Introductory remarks and account of ■ case published in ]s7;<,
41—8 ; reports of L8 cases, 1 1-68 ; reference to cases by Sir W.
MacCormao, Mr. Jonathan Butchinson, and Sir Benjamin Brodie,
53-56; structure, rate of growth* and anatomical position of the
swellings, 56-8 j treatment! 58 -. tahlo of cases, 60-1.
INDEX. 545
LITHOTOMY, supra-pubic (Richard Barwell) . 841
Historical note, 341-2; report of two cases, 343-7; reply to
objections urged against the operation, 347-9 ; experiments on
rectal distension by Dr. Petersen, Dr. Garson, and the author,
350-1; mode of operating, 351-3; appendix, containing tables of
Dr. Petersen, Dr. Garson, and the author, with remarks, 353-9.
A case of encysted vesical calculus of unusually large
size, removed by supra-pubic cystotomy (W. Rivington)
361
Case, 361-2 ; operation and subsequent history of patient, 362-7 ;
post-mortem, weight and size of calculus, 368-70 ; account of other
large stones, 370-2 ; remarks on the present case and on the supra-
pubic operation, 372-5.
case of, with remarks on the operation (W. H. A.
Jacobson) . . . . 377
Account of case, 377-8; operation and subsequent history of
patient, 378-80; remarks on distension of rectum and injection of
bladder, 380-2 ; conclusions, 382-3.
LIVER, case of so-called actinomycosis of the (John Harley)
135
Livingston, John, M.D., of New Barnet, obituary notice of 9
LOCKWOOD, C. B.
The morbid anatomy and pathology of encysted and infan-
tile hernia ..... 479
LYING-IN WOMEN, development of mammary functions by
the skin of (F. H. Champneys) . . 419
Maclean, John, M.D., obituary notice of .4
MALARIAL-ENTERIC FEVER at Suakin, see Enteric Fever.
MAMMARY FUNCTIONS, on the development of, by the skin
of lying-in women (F. H. Champneys) . . 419
Numerical abnormalities of mamma} and nipples, 419-21 ; descrip-
tion, course, and secretion of bodies referred to in present paper,
422-4. Cases — axillary lumps without nipples or pores, 424-9 ;
extension of maminaj into axilla?, 429-30; separate axillary mamma;
with axillary nipples, pores, or ducts, 430-2 ; supernumerary
nipples without special gland substance, 432-5; references to papers
by Verneuil on lumps in various parts of body, 435-7; table of
author's cases, 438-42.
— GLANDS, congenital absence of (J. Hutchinson) . 473
546 INDEX.
MEDICAL PROFESSION, statistics of mortality in the (W.
Ogle) . . . . .217
Death-rate in age-periods for 1880-1-2, 217-18; meau annual
death-rates per 1000 at successive dates, 219-21 ; death-rates of
males in different occupations, 1880-1-2, and comparison of that of
medical with other professions, 221-3; death-rate of Fellows of
Royal Medical and Chirurgical Society, 1805-51, 223 ; causes of
death, with ages, of 3865 me deal men, 225-7 ; comparison ot deaths
of medical men with the general population. 228-32; mortality
from accident and suicide, 232-5 ; comparison of tables in present
paper with those of Bscherich and Casper, 236-7.
MONEY, Angel, M.D.
Some statistics of pneumonia, with special reference to
the relations of delirium and temperature . 527
MORTALITY in the medical profession, statistics of (W. Ogle)
217
NEUROMATA, multiple, a case of (T. F. Chavasse) . 517
Notes of case and of operation, 517-18 ; post-mortem report,
518-20 ; facts deduced from previously recorded cases, 520-3 ;
microscopic examination of tumour removed, 523-4; literature,
524-5.
NEPHRITIS, scarlatinal, table of observations on urine of
112 cases (R. Stevenson Thomson) . . 115
Obituary notices of deceased Fellows of the Society, 1885-86.
Arnott, James Moncrielf . 4 , Howard, Edward, M.D. . . 10
Carpenter, William Benja- Livingston, John, M.D., of New
miii, M.D. {Honorary Fel- Barnet . . . . .9
low) . . . . 27 .Maclean. .John, M.D. . . . 4
Edwards, Henri Milne, M.D., Page, William Bousfield, of Car-
of Paris, Foreign Honorary lisle . . . . .23
Fellow . . . . 34 [ Russell, James, M.D., of Binning-
Egerton, Charles Chandler, ham . . . . .15
of Epping . . .31 Scott, John Moore Johnston, M.D.,
Fortescue, George, M.B., of of Lurgan . . . .21
Sydney . . . . 8 Smith, William Johnson, M.D., of
Weymouth . . . .2
Sutro, Sigismond, M.D. . . 27
Sutton, John Manic, M.D., of
Oldham 25
Tuinell, Thomas Joliffe, of Dublin 18
Wanl.H, John Richard, M.D, of
Tunbridge JFel/s . . . lu
Wot t.m, Henry, M.D. . . 22
Gay, John . . . .13
Gaeneaa de Blussj Noel.
M.D., of Paris, Foreign
Honorary Fellow . . 33
Harris, Francis, M.D. . . 12
llenle, Frederick Gnstavus
Jacob, M.D., of Qdttingi a,
Foreign Honorary Fellow 80
OGLE. IV, 1 1 una, M.D.
Statistics of mortality in the medical profession -17
Page, William Bo US field, of Carlisle, obituary notice of 'S.i
INDEX. 547
PAEACENTESIS, two cases of bronchiectasis treated by, with
remarks on the mode of operation (C. Theodore Williams
and Rickman J. G-odlee) . . . 317
PHARYNX penetrated by fish-bone, see Fish-bone.
PNEUMONIA, some statistics of, with special reference to the
relations of delirium and temperature (A. Money) . 527
Plan pursued in preparing tables, 527 ; tables of (1) age and sex,
(2) showing site of lung affected and sex of all the cases, (3) cases
according to age, sex, and site of pneumonia, 528; fallacies of
statistics, 529 ; cases in which pneumonia was not the only disease,
529-30; cases witu delirium, and tables, 530-6; age, highest tempe-
rature, and number of cases of delirium in pneumonia, 537 ; lung
affected, 537-8.
BOLLOCK, George.
On the changes which occur in bone and soft tissues after
amputation of a limb, and from certain other conditions
275
Power, D'Arcy.
Note on histological appearances of Mr. Savory's case of
portion of axillary artery destroyed by sarcoma . 1(30
President's Address, see Johnson, George.
PUSTULE, malignant, on some points regarding the distribu-
tion of bacillus anthracis in the human skin in (A. E.
Barker) . . . . .127
RESPIRATION in cholera, chemical pathology of (W. Sedg-
wick) ..... 385
RIVING TON, Walter.
A case of ligature ol the left common carotid artery
wounded by a fish-bone which had penetrated the pharynx,
with remarks, and an appendix containing forty-five cases
of wounds of blood-vessels by foreign bodies . 63
— A case of encysted vesical calculus ol unusually large size
removed by supra-pubic cystotomy . . 361
Russell, James, M.D., of Birmingham, obituary notice of . 15
SUPRA-PUBIC LITHOTOMY, see Lithotomy.
SARCOMA, a case of destruction of a portion of the axillary
artery by (W. S. Savory) . . . 157
SAVORY, W. S.
A case of destruction of a portion of the axillary artery by
sarcoma ..... 157
548 INDEX.
SCAELATINAL ALBUMINURIA, see Albuminuria.
Scott, John Moore Johnston, M.D., of Lurgan, obituary notice of
21
SEBORRHCEA, general, or " Harlequin " Foetus, case of (J.
Bland Sutton) . . .291
Description of specimen, 291-2 ; microscopical examination of
skin, 293; cause of disease, 293-4; literature, 294-5.
SEDGWICK, William.
The chemical pathology of respiration in cholera . 385
SKIN of lving-in women, development of mammary functions by
(F. H. Champneys) . . . .419
— atrophic condition of, and its appendages in a boy whose
mother had been almost wholly bald from alopecia areata
from the age of six (J. Hutchinson) . . 473
Smith, William Johnson, M.D., of Weymouth, obituary notice
of . . . . .2
SPLENECTOMY, two cases of (J. Knowsley Thornton) . 407
Account of Case 1, 407-10 ; Case 2, 411-14 ; remarks, 414-15 ;
table of cases, 416-7.
SQUIRE, J. Edward, M.D.
Enteric fever at Suakin, with some cases of malarial-enteric
or typho malarial fever . . . 247
STEEL WIRE, see Wire.
SUAKIN, enteric fever at, see Enteric Fever.
Sutro, Sigismuud, M.D., obituary notice of . . 27
SUTTON, J. Bhmd.
A case of general seborrhoea or " harlequin " foetus . 2i > 1
Sutton, John Maule, M.D., of Oldham, obituary notice of. 25
S\ fS TOLE, ventricular, see Cardiograph;/.
TAPETUM LUCIDUM, on the (Henry Lee) . . 239
Position, Ac. of tapetnm, 289-40 j experiments on animals, 240-
44; conclusions, - 15.
THOMSON, /.'. Stevenson.
Scarlatinal albuminuria, and the prc-albuminuric Btage,
studied by frequent testing . . . !>7
THORNTON, ■/. Rnowtley
Two cases of splenectomy . . 407
INDEX. 549
TISSUES, soft, changes which occur in, after amputation of a
limb, and from certain other conditions (G-. Pollock)
275
Tufnell, Thomas Joliffe, of Dublin, obituary notice of . 18
TUMOUR, removal of a, from the brachial plexus (E. Bellamy)
211
TTPHO-MALAEIAL FEVER at Suakin, see Enteric Fever.
URINE of 112 cases of scarlatinal nephritis (R. Stevenson Thom-
son) ..... 115
Wardell, John Richard, M.D., of Tunbridge Wells, obituary
notice of . . . . .10
WILLIAMS, G. Theodore, M.D., and Rickman J. Qodlee.
Two cases of bronchiectasis treated by paracentesis, with
remarks on the mode of operation . . 317
WIRE, steel, case of thoracic aneurism treated by the intro-
duction of, into the sac (W. CayJey) . . 267
Wotton, Henry, M.D., obituary notice of .22
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