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MEDICO-CHIRURGICAL
TRANSACTIONS.
PUBLISHED BY
THE HO Y AL
MEDICAL AND CHIEUEGICAL SOCIETY
OF
LONDON.
VOLUME THE SEVENTY-THIRD.
(SECOND SERIES, VOLUME THE FIFTY-FIFTH.)
LONDON :
LONGMANS, GEEEN, AND CO.,
PATERNOSTER ROW.
1890.
Issued from the Society's House at 20, Hanover
Square, W.
October, 1890.
PRINTED BY ADLARD AND SON, BARTHOLOMEW CLOSE.
ROYAL
MEDICAL AND CHIHUEGICAL SOCIETY
OF LONDON
PATRON
THE QUEEN
OFFICERS AND COUNCIL
ELECTED MARCH 1, 1890
VICE PRESIDENTS
HON. TREASUREllS
HON. SECRETARIES
HON. LIBRARIANS
OTHER MEMBERS OF
COUNCII.
TIMOTHY HOLMES
r ROBERT BARNES, M.D.
\ J. LANGDON DOWN, M.D.
\ ALFRED WILLETT
L JOHN CROFT
( CHARLES JOHN HARE, M.D.
i JOHN ASHTON BOSTOCK, C.B.
r FREDERICK TAYLOR, M.D.
1 J. WARRINGTON HAWARD
f SAMUEL JONES GEE, M.D.
[ JOHN WHITAKER HULKE, F.R.S.
f WALTER BUTLER CHEADLE, M.D.
WILLIAM MILLER ORD, M.D.
A. JULIUS POLLOCK, M.D. {deceased)
GEORGE VIVIAN POORE, M.D.
T. GILBART SMITH, M.D.
WILLIAM HARRISON CRIPPS
CLINTON THOMAS DENT
HENRY GREENWAY HOWSE
HENRY WALTER KIALLMARK
■ HERBERT WILLIAM PAGE
RESIDENT LIBRARIAN
J. Y. W. MAC ALISTER, F.S.A.
FELLOWS OF THE SOCIETY APPOINTED BY
THE COUNCIL AS REFEREES OF PAPERS
FOR THE SESSION OF 1890-91
HENRY CHARLTON BASTIAN, M.D., F.R.S.
MARCUS BECK
WILLIAM HENRY BROADBENT, M.D.
JOHN MITCHELL BRUCE, M.D.
THOMAS BUZZARD, M.D.
JOHN CURNOW, M.D.
J. NEVILLE C. DAVIES-COLLEY
SIR DYCE DUCKWORTH, M.D.
SAMUEL FENWICK, M.D.
ALFRED LEWIS GALABIN, M.D.
FREDERICK JAMES GANT
HENRY GERVIS, M.D.
RICKMAN JOHN GODLEE, M.S.
WILLIAM RICHARD GOWERS, M.D., F.R.S.
JOHN IIARLEY, M.D.
GRAILY HEWITT, M.D.
M. BERKELEY HILL
JONATHAN HUTCHINSON, F.R.S.
JOHN LANGTON
JEREMIAH MacCARTHY
SIR WILLIAM MacCORMAC
STEPHEN MACKENZIE, M.D.
CHARLES MACNAMARA
F. HOWARD MARSH
NORMAN MOORE, M.D.
JOSEPH FRANK PAYNE, M.D.
SIDNEY RINGER, M.D., F.R.S.
ARTHUR ERNEST SANSOM, M.D.
EDWARD ALBERT SCHAFER, F.R.S.
HENRY GAWEN SUTTON, M.D.
FREDERICK TREVES
WILLIAM HALE WHITE, M.D.
C THEODORE WILLIAMS, M.D.
JOHN WILLIAMS, M.D.
JOHN WOOD, F.R.S.
TEUSTEE8 OF THE SOCIET'E
SIR ANDREW CLARK, Eart., M.D., LL.D., F.R.S
WALTER BUTLER CHEADLE, M.D.
CHRISTOPHER HEATH
TEUSTEES OF TUE MARSHALL HALL MEMORIAL EU>D
WALTER BUTLER CHEADLE, M.D.
WILLIAM OGLE, M.D.
THOMAS SMITH
LIBRARY COMMITTEE EOU TUE SESSION OF 1890-9]
JOHN MITCHELL BRUCE, M.D.
JOHN CAVAFY, M.D.
FRANCIS HENRY CHAMPNEYS, M.A., M.B.
JOSEPH FRANK PAYNE, M.D.
KOBERT AVILLIAM PARKER
PHILIP HENRY PYE-SMITH, M.D , F.R.S.
WILLIAM WATSON CHEYNE
JOHN LANGTON
CHARLES MACNAMARA.
JOHN KNOWSLEY THORNTON
„ „ (-FREDERICK TAYLOR, M.D.
0)1. ecs.^^ WARRINGTON HA WARD
„ J., ( SAMUEL JONES GEE, M.D.
Hon. Libs. <
I JOHN WHITAKER HULKE, F.R S.
SCIENTIFIC COMMITTEE
Appointed to investigate the Medical Climatology and Balneology of
Great Britain and Ireland
WILLIAM MILLER ORD, M.D., Chairman
ARCHIBALD EDWARD GARROD, M.A., M.D., Hon. Sec.
EDWARD BALLARD, M.D., F.R.S.
JOHN MITCHELL BRUCE, M.D.
WALTER BUTLER CHEADLE, M.D.
WILLIAM HOWSHIP DICKINSON, M.D.
WILLIAM EWART, M.D.
MALCOLM ALEXANDER MORRIS
WILLIAM MURRELL. M.D.
FREDERICK TAYLOR, M.D
EDMUND SYMES THOMPSON, M.D.
FREDERICK TREVES
HERMANN WEBER, M.D.
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.H.
18)3. SIR GILBERT BLANE, Bart., M.D.
1815. HENRY CLINE
1817. WILLIAM BABINGTON, M.D.
1819. SIR ASTLEY PASTON COOPER, Bart., K.C.H., D.Cl..
1821. JOHN COOKE, M.D.
1823. JOHN ABERNETHY
1825. GEORGE BIRKBECK, M.D.
1827. BENJAMIN TRAVERS
1829. PETER MARK ROGET, M.D.
1831. SIR AVILLIAM 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. ROBERT WILLIAMS, M.D.
1843. EDWARD STANLEY
1845. WILLIAM FREDERICK CHAMBERS, M.D., K.C H.
1847. JAMES MONCRIEFF ARNOTT
1849. THOMAS ADDISON, M.D.
1851. JOSEPH HODGSON
1853. JAMES COPLAND, M.D.
1855. C^SAR HENRY HAWKINS
1857. SIR CHARLES LOCOCK, Bart., M.D.
1859. FREDERIC CARPENTER SKEY
1861. BENJAMIN GUY BABINGTON, M.D.
1863. RICHARD PARTRIDGE
1865. SIR JAMES ALDERSON, M.D., D.C.L.
1867. SAMUEL SOLLY
1869. SIR GEORGE BURROWS, Bart., M.D., D.C.L.
1871. THOMAS BLIZARD CURLING
1873. CHARLES JAMES BLASIUS WILLIAMS, M.D.
1875. SIR JAMES PAGET, Bart., D.C.L., LL.D.
1877. CHARLES WEST. M.D.
1879. JOHN ERIC ERICHSEN
1881. ANDREV/ WHYTE BARCLAY, M.D.
1882. JOHN MARSHALL
1884, GEORGE JOHNSON, M.D.
1886. GEORGE DAVID POLLOCK
1888. SIR EDWARD HENRY SIEVEKING, M.D., LL.D.
1890. TIMOTHY HOLMES
HONORARY FELLOWS.
(Limited to Tn'elve.)
Elected
1887 Flower, William Henry, C.B., LL.D., F.R.S., Director
of the Natural History Department, British Mustum,
Cromwell road.
1887 Foster, Michael, LL.D., F. U.S., Professor of Physiology
ill the University of Camhridge.
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.
1868 Hooker, Sir Joseph Dalton, C.B., M.D., K.C.S.L,
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., late
Professor of Natural History in the Royal School
of Mines; Corresponding Member of the Academies
of Sciences of St. Petersburg, Berlin, Dresden, &c. ; 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.
I8i7 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,
East Sheen, Morllake.
Vin FELLOWS OF THE SOCIETY.
Elected
18/3 Stokes, Sir George Gabriel, Bart., M.A., D.C.L., LL.D.,
F.R.S.,M.P., Lucasian Professor of Mathematics in the
University of Cambridge ; President of the Royal
Society ; Lensfield Cottage, Cambridge.
18S7 Turner, Sir William, LL.D., D.C.L., F.R.S., Professor of
Anatomy in the University of Edinburgh.
18fi8 Ttndall, John, D.C.L., LL.D., F.R.S., Honorary Professor
of Natural Philosophy in the Royal Institution ; Cor-
responding Member of the Academies and Societies of
Sciences of Gottingen, Haarlem, Geneva, &c. ; Hind
Head House, Siiotter Mill, near Petersfield.
FELLOWS OF THE SOCIETY. IX
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.
1887 Billings, John S., M.D., D.C.L.Oxon., Surgeon U.S.Array ;
Librarian, Surgeon-General's Office, Washington.
1876 Billroth, Theodor, M.D., Professor of Surgery in the
University of Vienna ; 20, Alger Strasse, 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 7, Paris.
1883 DuBois Reymoxd, Emil, M.D., Professor in Berlin ; N. W.
Neue Wilhelmstrasse 15, Berlin.
1887 Esmarch, Friedrich, M.D., Professor of Surgery in the
University of Kiel.
1866 Hannover, Adolph, M.D., Professor at Copenhagen.
1873 von Helmholtz, Hermann Ludwig 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 Wurzbur^.
X FELLOWS OF THE SOCIETY.
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).
1878 ScANZONi, Friedreich Wilhelm von, Eoyal Bavarian Privy
Councillor ; Professor of Midwifery 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 ; 10, Schellingstrasse, Berlin.
FELLOWS
OP THE
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 Society.
SEPTEMBER, 1890.
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
184G *Aberceombie, John, M.D.
1877 t-^BERCKOMBiE, JoHN, M.D., Assistant Physician to, and
Lecturer on Forensic Medicine at. Charing Cross Hos-
pital ; 23, Upper Wimpole street, Cavendish square.
Trans. 1.
1885 Abbaham, Phinkas S., M.A., M.D., Lecturer on Physi-
ology and Histology at the Westminster Hospital;
2, Henrietta street. Cavendish square.
1851 *AcLAND, Sib, Henry Wentworth, Bart., 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.
Xll FELLOWS OF THE SOCIETY.
Elected
J 885 AcLAND, TnEODORE Dyke, M.D., Assistant Physician to St.
Thomas's Hospital and to the Hospital for Consumption
and Diseases of the Chest, Brompton ; 7, Brook street,
Hanover square.
1852 f 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. Trans. 3.
1867 AiKiN, Charles Arthur, 7, Clifton place, Hyde Park.
1839 Alcock, Sir Rutherford, K.C.B., K.C.T., K.T.S., D.C.L.,
late H.M.'s Envoy Extraordinary at the Court of Pekin.
Trans. 1.
1866 Allbutt, Thomas Clifford, A.M., M.D., LL. D.Glasgow,
F.R.S., Commissioner in Lunacy ; Consulting Physician
to the Leeds General Infirmary ; 3, Melbury Road,
Kensington. Trans. 3.
1879 Allchin, William Henry, M.B., F.R.S. Ed., Physician
to, and Lecturer on Medicine at, the Westminster
Hospital; 5, Chandos street, Cavendish square.
1863 Althaus, Julius, M.D., Senior Physician to the Hospital
for Epilepsy and Paralysis, Regent's Park ; 48, Harley
street. Cavendish square. Trans. 2.
1884 Anderson, Alexander Richard, Surgeon to the General
Hospital, 5, East Circus Street, Nottingham.
1881 Anderson, James, A.M., M.D., Assistant Physician to the
London Hospital and to the National Hospital for the
Paralysed and Epileptic; 41, Wirapole street, Caven-
dish square.
1888 Anderson, John, M.D., C.I.E., Physician to the Seamen's
Hospital, Greenwich; 105, Gloucester place, Portman
square.
1862 Andrew, James, M.D., Vice-President, Physician to, and
Lecturer on Medicine at, St. Bartholomew's Hospital ;
22, Harley street. Cavendish square. S. 1878-9. C
1881-2. V.P. 1888. Trans. 1.
1880 *Appleton, Henry, M.D., Staines.
FELLOWS OF THE SOCIETY. XIU
Elected
1888 Arkle, Charles Joseph, M.B.
18/4 AvELiNG, James H., M.D., Physician to the Chelsea Hos-
pital for Women ; 1, Upper Wimpole street, Cavendisli
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.
186.5 Baker, William Morrant, Surgeon to, and Lecturer
on Physiology at, St. Bartholomew's Hospital ; Con-
sulting Surgeon to the Evelina Hospital for Sick
Children ; 26, Wimpole street, Cavendish square. C.
1878-9. V.P. 1889. Referee, 1886-8. Lib. Com. 1876-7.
Trans. 7.
1869 Bakewell, Robert Hall, M.D., Ross, Westland, New
Zealand.
1839 t^ALFOUR, Thomas Graham, M.D., F.R.S., Honorary
Physician to H. M. the Queen; Surgeon General;
Coombe Lodge, Wimbledon Park. C. 1852-3. V.P.
1860-1. T. 1872. Lib. Com. 1849. Trans. 2.
1887 Ball, James Barry, M.D., 54, Wimpole street, Cavendish
square.
1885 Ballance, Charles Alfred, M.S., Senior Assistant Sur-
geon, West London Hospital ; Assistant Surgeon,
Hospital for Sick Children, Great Ormond street ;
Assistant Surgeon for Skin Diseases, St. Thomas's Hos-
pital; 56, Harley street. Cavendish square. Trans. 1.
1848 fBALLARD, EDVi^ARD, M.D,, F.R.S., Inspector, Medical
Department, Local Government Board ; 12, Highbury
terrace, Islington. C. 1872. V.P. 1875-6. Sci. Com.
1889. Referee, \Qb3-7\. Lib. Com. \855. Trans. 5,
1866 *Banks, Sir John Thomas, M.D., K.C.B., Physician in
Ordinary to the Queen in Ireland ; Physician to Rich-
mond, Whitworth, and Hardwicke Hospitals ; Regius
Professor of Physic in the University of Dublin ;
Member of the Senate of the Queen's University in
Ireland ; 45, Merrion square, Dublin.
XIV FELLOWS OF THE SOCIETY.
Elected
1886 Banks, William Mitchell, M.D., Surgeon to the Liver-
pool Royal Infirmary ; 28, Rodney street, Liverpool.
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. 6.
1882 Barker, Frederick Charles, M.D., Surgeon-Major,
Bombay Medical Service [care of Arthur E. J.
Barker, 87, Harley street].
183.3 -j-Barker, 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, 1848-51. Trans. 6.
1876 Barlow, Thomas, M.D., B.S., Physician to University
College Hospital, to the Hospital for Sick Children,
Great Ormond street, and to the London Fever Hos-
pital; 10, Wimpole street, Cavendish square. Trans. 2.
1881 *Barnes, Henry, M.D., F.R,S. Ed., Physician to the Cum-
berland Infirmary ; 6, Portland square, Carlisle.
1861 Baknes, Robert, M.D., 15, Harley street. Cavendish
square. C. 1877-8. V.P. 1889-90. Referee, 1867-76.
Lib. Com. 1869-73. Trans. 4.
1864 Barratt, Joseph Gillman, M.D.
1880 Barrow, A. Boyce, Assistant Surgeon to King's College
Hospital, to the Westminster Hospital, and to the West
London Hospital; 17, Welbeck street, Cavendish
square.
1840 Barrow, Benjamin, Surgeon to the Eoyal Isle of Wight
Infirmary ; Southlands, Ryde, Isle of Wight.
1859 Barwell, Richard, Consulting Surgeon to the Charing
Cross Hospital; 55, Wimpole street. C. 1876-77.
V.P. 1883-4. Referee, 1868-75, 1879-82. Trans.
11.
FELLOWS OF THE SOCIETY. XV
Elected
1868 Bastian, Henry Charlton, M.A., M.D., F.R.S., Professor
of Medicine in University College, London ; Physician
to University College Hospital and to the National
Hospital for the Paralysed and Epileptic ; 8a, Man-
chester square. Referee, 1886-8. C. 1885. Trans. 2.
18/5 Beach, Fletcher, M.B., Medical Superintendent, Metro-
politan District Asylum, Darenth, near Dartford, Kent.
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.
1862 Beaxe, 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. 1876-77. Referee, 1873-5.
Trans. 1.
1860 *Bealey, Adam, M.D., M.A., Oak Lea, Harrogate.
1856 Beardsley, Amos, F.L.S., Bay villa, Grange-over-Sands,
Lancashire.
IS71 Beck, Marcus, M.S., Professor of Surgery in University
College, London, and Surgeon to University College
Hospital ; 30, Wimpole street. Cavendish square.
C. 1886-7. 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.
1871 Bellamy, Edward, Senior Surgeon to, and Lecturer on
Surgery 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. Co7n. 1879-
81. Trans. 1.
1847 Bennet, James Henry, M.D., Mentone, Alpes Maritimes,
France.
Xvi FELLOWS OF THE SOCIETY.
Elected
1880 Bennett, Alex. Hughes, M.D,, Physinian to the West-
minster Hospital ; 7Q, Wimpole street, Cavendish
square. Trans. 1.
1883 Bennett, Stoker, Dental Surgeon to, and Lecturer on
Dental Surgery at, the Middlesex Hospital ; Dental
Surgeon to the Dental Hospital of London ; 17 George
street, Hanover square.
1877 Bennett, "William Henry, Surgeon to, and Lecturer on
Anatomy at, St. George's Hospital; 1, Chesterfield
street, May fair. Trans. 4.
1889 Bentley, Arthur J. M., M.D., 9, Somers place, Hyde
Park.
1890 Berry, David Anderson, M.B., CM., 117, Groldhawk
Koad.
1845 fBERRY, Edward Unwin, 17, SherriflFroad,West Hampstead.
1885 Beery, James, Assistant Demonstrator of Anatomy, St.
Bartholomew's Hospital ; 60, Welbeck street. Caven-
dish square.
1820 Bertin, Stephen, Paris.
1872 Beverley, Michael, M.D., Assistant Surgeon to the Nor-
folk and Norwich Hospital ; 54, Prince of Wales road,
Norwich.
1865 *Bickersteth, Edward Robert, Surgeon to the Liverpool
Royal Infirmary, and Lecturer on Clinical Surgery in
the Liverpool Royal Infirmary School of Medicine ; 2,
Rodney street, Liverpool. Trans. 1.
1878 BiNDON, William John Vereker, M.D., 48, St. Ann's
street, Manchester.
1856 fBiRD, William, Consulting Surgeon to the West London
Hospital ; Bute House, Hammersmith.
1849 tBiEKETT, Edmund Lloyd, M.D., Consulting Physician to
the City of London Hospital for Diseases of the Chest ;
Westbourne Rectory, Emsworth, Hampshire. C. 1865-6.
Referee, 1851-9.
FELLOWS OF THE SOCIETY. XVU
Elected
1851 fBiRKETT, John, F.L.S., Consulting Surgeon to Guy's
Hospital ; Corresponding Member of the " Societe
de Cliirurgie" of Paris ; Inspector of Anatomy for the
Provinces in England and Wales; 62, Green street,
Grosvenor square. L. 18.56-7. S. 1863-5. C. 1867-3.
T. 1870-78. V.P. 1879-80. Referee, 1851-5, 18G6
1869, Sci. Com. \SG3. Lib. Co?n. 1852. Trans. Q.
1866 Bishop, Edwaed, ]M.D.
1881 Biss, Cecil Yates, M.D., Asisstant Pliysician to, and
Lecturer on Materia Medica at, the Middlesex Hospital,
and Assistant Physician to the Hospital for Consump-
tion, Broiupton ; 135, Harley street. Cavendish square.
Trans. 2.
1865 Blanchet, Hilakion, Examiner to the College of Physicians
and Surgeons, Lower Canada; 6, Palace street, Quebec,
Canada east.
1865 Blandford, George Fielding, M.D., Lecturer on Psycho-
logical Medicine at St. George's Hospital; 48, Wiin-
pole street. Cavendish square. C. 1883-4.
1846 fBosTOCK, John Ashton, C.B., Treasurer ; Hon. Surgeon
to H.M. the Queen; Deputy Surgeon-Geueral ; 73,
Onslow gardens, Brompton. C. 1861-2. V.P. 1870-71.
T. 1888-90. Sci. Com. 1867.
1890 BosTOCK, R. Ashton, 73, Onslow gardens, Brompton.
1869 Bourne, Walter, M.D. [care of tiie National Bank of India,
80, King William street. City] ; Arcachon, France.
1882 BowLBY, Anthony Alfred, Surgical Registrar to St. Bar-
tholomew's Hospital ; 75, Warrington crescent, Maida
hill. Trans. 3.
1870 *Bowles, Egbert Le.amon, M.D., 8, West terrace, Folke-
stone. Trans. 1.
1841 powMAN, Sir William, Bart., LL.D., F.R.S., F.L.S:,
Consulting Surgeon to the Royal London Ophthalmic
Hospital, Monrfields ; 5, Clifford street. Bond street.
C. 1852-3. V.P. 1862. Referee, 1845-50, 1854-6.
Lib. Com. 18-17. Trans. 3.
VOL. LXXIII. h
XVlll FELLOWS OF THE SOCIETY.
Elected
1886 BoxALL, Robert, M.D., Physician to the General Lying-in
Hospital ; 6, Chandos street, Cavendish square.
1884 Boyd, Stanley, M.B., Assistant Surgeon to, and Demon-
strator of Anatomy at, Cliariug Cross Hospital; 134,
Harley street, Caveudish square.
186*2 Brace, Willtah Henry, M.D., 7, Queen's Gate terrace,
Kensington.
1890 Bradford, John Rose, M.B., D.Sc, 52, Upper Berkeley
street, Portman square.
1874 Bradshaw, A. F., Surgeon -Major; Surgeon to tlie Rt. Hon.
the Commander in Chief in India ; Army Head Quar-
ters, Bengal Presidency. [Agent: Vesey W. Holt, 17,
Whitehall place.]
1883 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.
1890 Brtntos, Roland Danvers,M,D., 8, Queen's Gate teirace.
1868 Broadbent, William Henuy, M D., Phy>ician to, and
Lecturer on Clinical ]\Iedicine at, St. ]\lary's Hospital ;
Consulting Physician to the London Fever Ho.spital ;
34, Seymour street, Portman square. C. 1885. Referee,
1881-4. Trans. 5.
1851 fBRODHURST, Bernard Edtvard, F.L.S., Surgeon to the
Royal Orthopaedic Hospital; 20, Grosvenor street.
C. 1868-9. Lib. Com. \SQ2-^. Trans. 2. Pro.\.
1872 Brodie, George Bernard, M.D., Consulting Physician-
Accoucheur to Queen Charlotte's Hospital; 3, Chester-
field street, May fair. Trans. 1.
1860 Brown-Sequard, Charles Edouard, M.D., LL.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. Coin. 1862.
FELLOWS OK THE SOCIETY. XIX
Elected
1888 Browne, Henky Langley, Moor House, West Bromwicli.
1878 Browne, Sir James Crichton, M.D., LL.D., F.R.S., Lord
Chancellor's Visitor in Lunacy ; 7, Cumberland ter-
race, Regent's Park.
1880 Browne, James William, M.B., 7, Norland place, Hol-
land Park.
1881 Browne, Joun Walton, M.D., Surgeon to the Belfast
Ophtlialmological Hospital ; 10, College square N.,
Belfast.
1881 Browne, Osw'ald Auchinleck, M.A., M.B., Physician to
the Royal Hospital for Diseases of the Chest.
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,
Brorapton ; 70, Harley street. Sci. Com. 1889. Referee,
1886.8. Lib. Com. 1888. Trans. 1.
1871 Brunton, Thomas Laudeb, M.D., F.R.S., Assistant Physi-
cian to, and Lecturer on Materia Medica and Thera-
peutics at, St. Bartholomew's Hospital ; 10, Stratford
place, Oxford street. C. 1888-9. Referee, 1880-87.
Lib. Com. 1882-7.
1860 Bryant, Thomas, Consulting Surgeon to Guy's Hospital ;
Corresponding i\Iember " Societe de Chirurgie, Paris ;"
65, Grosvenor street, Grosvenor square, C. 1873-4.
V. P. 1885-6. Sci. Com. 1863. Referee, 1882-4.
Lib. Com. 1868-71. Trans. 11. Pro. 1.
1864 Buchanan, George, M.D., F.R.S., Medical Officer of the
Local Government Board ; Member of the Senate of the
University of London ; 27, Woburn square.
1864 Buckle, Fleetwood, M.D.
1889 Bull, William Charles, M.B., 35, Clarges street, Picca-
dilly.
1831 Buller, Audley Cecil, M D.
Ib85 Butler-Smythe, Albert Charles, Senior Surgeon to the
Grosvenor Hospital for Women and Cliildren ; 35,
Brook street, Grosvenor square.
XX FELLOWS OF THE SOCIETY.
Elected
1873 BuTLiN, IIexry Trentham, Assistant Surgeon to, and
Demonstrator of Practical Surgery and of Diseases of
the Larynx at, St. Bartholomew's Hospital ; 82, Harley
street. Cavendish square. C. 18S7-8. Trans. 3.
1871 Butt, William F., 1, Southwick crescent, Hyde Park,
1883 Buxton, Dudley Wilmot, M.D., B.S., Administrator, and
Teacher of the Use, of Ansesthetics, in University College
Hospital ; Ausestlietist to the Hospital for Women, Soho
Square, and to the London Dental Hospital; 82, Mor-
timer street, Cavendish square.
1868 Buzzard, Thomas, M.D., Physician to the National Hos-
pital for the Paralysed and E[)ileptic ; 7^, Grosvenor
street, Grosvenor square. C. 1885-6. Referee. 1887-8.
1851 *Cadge, William, Surgeon to the Norfolk and Norwich
Hospital; 49, St. Giles's street, Norwich. Trans. 1.
1890 Cagney, James, M.D., II, Welbeck street, Cavendish
square. Trans. 1.
1885 Cahill, John, 12, Seville street, Lowndes square.
1887 Calvert, James, M.D., 36, Queen Anne street, Cavendish
square.
1888 Carless, Albert, M.B., B.S., Assistant Surgeon to King's
College Hospital ; 15, Stratford place, Oxford street.
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.
1888 Carter, William Jeffreys Becker.
1845 j-Cartwright, Samuel, Consulting Surgeon to the Dental
Hospital ; 32, Old Burlington street. C. 1860-1. Sci.
Com. 1863.
1879 Cartwright, S. Hamilton,
1888 Cautley, Edmund, M.B., B.C., 15, Upper Brook street.
FELLOWS OF THE SOCIETY. XXI
Elected
1868 Cavafy, John, M.D., Physician to St. George's Hospital;
2, Upper Berkeley street, Portman square. C. 1887.
Lib. Com. 18SS. Trans. 1.
1871 Cayley, William, IM.D., Pliysician to, and Lecturer on
the Principles and Practice of ]\Iedicine at, the IMiddlesex
Hospitiil ; Physician to the London Fever Hospital
and to tlie Norih-Eastern Hospital for Children; 27,
Winipole street, Cavendish square. C. 1888. Ueferee,
lsSG-7. Lib. Com. 1886-7. 'I runs. 2.
1884 Chaifey, Waylaid Charles, M.D., Physician to the
Royal Alexandra Hospital for Children; 13, Mont-
pellier road, Brighton.
1879 Champneys, Francis Henry, M. A., M.B., Obstetric Phy-
sician to, and Lecturer on Midwilery at, St. George's
Hospital; 60, Great Cumberland [ilace. Lib. Com.
1885-8. Trims. 7.
1859 Chance, Frank, M.D., Burleigli House, Sydenham Hill.
1885 Chapman, Paul Morgan, M.l)., Physician to the Here-
ford General Inhrniary, 1, St. John street, Hereford.
Trans. 1.
1877 Charles, T. Cuanstoun, ]\l.D., Lecturer on Practical
Physiology at St. Thomas's Hospital; Albert Mansions,
106, Victoria street, Westminster.
1881 *Chavasse, Thomas Frkdeuick, M.D., CM., Surgeon
to the Birmingham General Hospital; 24, Temple row,
Birmingiiam. Trans. 3.
1868 Cheal>le, Walticr Bltler, ]\I.D., Trustee; Physician
to, and Lecturer on Medicine at, St. Mary's Hos-
pital; Senior Physician to the Hospital for Sick
Children; 19, Portman street, Portman square. S.
18S6-8. C. 1890. Sci. Com. 1SS9. Referee, 1885.
Trans. I.
1879 Chevne, William "Watson, M.B., Surgeon to King's
College llos[)ital, and Demonstrator of Surgery
in King's College, London ; 59, Welbeck street.
Cavendish square. Lib. Com. 1886-8.
1890 Childs, Christopher, M.D., 2, Eoyal terrace, Weymouth.
XXU FELLOWS OF THE SOCIETY.
Elected
1873 *Chisholm, Edwin, M.D., Abergeldie, Ashfield, near Sydney,
New South AVales.
1865 Cholmeley, William, M.D., Physician to the Great
Nortliern Hospital ; 63, Grosvenor street, Grosvenor
square. C. 1881-2. iie/e;-ee, 1873-80.
1872 Christie, Thomas Beith, M.D., CLE , Medical Superin-
tendent, Royal India Asylum, Ealing.
1866 Church, William Selby, M.D., Physician to, and Lecturer
on Clinical ]\[edicine at, St. Bartholomew's Hospital ;
130, Harley street. Cavendish square. C. 1885-6.
Be/eret, 1874-81.
1860 Clark, Siii Andrew, Bart., M.D., LL.D., F.R.S., Trustee,
Vice-President, Pliysician to, and Emeritus Professor of
Clinical Medicine at, the London Hospital; 16, Caven-
dish square. C. 1875. V.P. 1888.
1879 Clark, Andrew, Surgeon to, and Lecturer on Practical
Surgery at, the Middlesex Hospital ; 71, Harley street,
Cavendish square.
1839 fCLARK, Frederick Le Guos, F.R.S., Consulting Surgeon
to St. Thomas's Hospital ; The Thorns, Sevenoaks.
S. 1847-9. V.P. 1855-6. i2e/e?-ee, 1859-81. Lib. Com.
1847. Trans. 5.
1882 Clarke, Ernest, M.D., B.S., Surgeon to the Miller Hos-
pital, and Senior Assistant Surgeon to the Central
London Ophthalmic Hospital; 21, Lee terrace. Black-
heath.
1848 fCLARKE, John, M.D., 42, Hertford street, May Fair. C.
1866.
1888 Clarke, Robert Henry, M.B., Clarence Lodge, Redhill,
Surrey.
1881 Clarke, \V. Bruce, M.B., Assistant Surgeon to, and
Lecturer on Anatomy at, St. Bartholomew's Hospital;
46, Harley street, Cavendish square.
1842 fCLAYTON, Sir Oscar Moore Passey, C.M.G., Extra
Surgeon-in-Ordinary to H.R.H. the Prince of Wales, and
Surgeon-in-Ordinary to H.R.H. the Duke of Edinburgh ;
5, Harley street. Cavendish square. C. 1865.
FELLOWS OF THE SOCIETY. XXlll
Elected
1879 f Glutton, Henry Hugh, M.A., M.B., Assistant Surgeon to,
and Lecturer on Forensic Medicine at, St. Thomas's
Hospital ; 2, Portland place.
1 8") 7 CoATES, Charles, ]\I.D., Consulting Physician to the Bath
General and Royal United Hospitals ; 10, Circus, Bath.
1888 Cock, Frederick William, M.D., 1, Porchester Houses,
Porchester Square.
1868 Cockle, John, M.D., F.L.S., Consulting Physician to the
Royal Free Hospital; 8, SuflFolk street, Pall Mall.
Trans. 2.
1885 Collins, William Maunsell, M.D., 10, Cadogan place.
18G5 Cooper, Alfred, Consulting Surgeon to the West London
Hospital; Surgeon to tlie Lock Hospital and to St.
Mark's Hospital ; 9, Henrietta street, Cavendish square.
1868 Cornish, William Robert, C.I.E., late Surgeon-General,
Madras Army; Hon. Physician to H.M the Queen;
8, Cresswell gardens, Tiie Boltons.
1860 *CoRRY, Thomas Charles Steuart, M.D., Ormeau Ter-
race, Belfast.
1889 Cosens, Charles Henry, St. Bartholomew's Hospital.
1860 fCouPER, John, Surgeon to the Royal Loudon Ophthalmic
Hospital; 80, Grosvenor street. C. 1876. Referee,
1882-3.
1877 CouPLAND, Sidney, M.D., Physician to, and Lecturer on
Practical Medicine at, the Middlesex Hospital ; 1 6,
Queen Anne street. Cavendish square.
1862 fCowELL, 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., Hon. Surgeon to
H.M. the Queen ; late Director-General, Army Medical
Department; 5, St. John's Park, Blackheath. C. 1887.
XXIV FELLOWS OF THE SOCIETY.
Elected
1869 *Cresswell, Pearson R., Dowlais, Merthyr Tyclvil.
1874 Cripps, William Harrison, Assistant Surgeon to St. Bar-
tholomew's Hospital ; 2, Stratford place, Oxford street.
C. 1S90. Trans. 1.
1882 Crocker, Henry Radcliffe, ]M.D., Plivsicinn to tlie Skin
Depaitiuent, University College Hospital ; Physician
to the East London Hospital for Cliiklren j 121, Harley
street, Cavendish square. Travis. 3.
1868 Croft, John, Surgeon to, and Lecturer on Clinical Surgery
at, St. Thomas's Hospital ; 48, Brook street, Grosvenor
square. C. 1884. V.P. 1890. Referee, 1885-88.
Lib. Com. 18/7-8. Trans. 2.
1862 Crompton, Samuel, IM.D., Brookmead, Cranleigh, Surrey.
1837 CiiooKES, John Faerar, 45, Augusta gardens, Folkestone.
1872 Crosse, Thomas \\'illiam, Surgeon to the Norfolk and
Norwicii Hospital ; 22, St. Giles's street, Norwich.
1890 Crowle, Thomas Henry Rickard, 3, Campden Hill
road.
1888 Cullingworth, Charles James, JI.D., Obstetric Physician
and Lecturer on Midwifery at St. Thomas's Hospital ;
46, Brook street, Grosvenor square.
1879 Cumberbatch, A. Elkin, Aural Surgeon to St. Bartholo-
mew's Hospital, and to tlie Great Northern Hospital;
17, Queen Anne street, Cavendish square.
1873 CuRNOW, John, M.D., Professor of Anatomy in King's
College, London, and Physician to King's College
Hospital ; 3, George street, Hanover square. Referee,
1884-8.
1886 Dakin, William Radford, M.D., 57, Welbeck street,
Cavendish square.
1872 Dalby, Sir William Bartlett, M.B., Aural Surgeon to,
and Lecturer on Aural Surgery at, St. George's Hos-
pital ; 18, Savile row. Trans. 3.
1884 Dallaway, Denkis, 5, Duchess street, Portland place.
1877 Darbisdire, Sam^Iel Dukinfield, M.D., Physician to
the Radcliffe Infirmary, Oxford.
.<^
FKLLOWS OF THE SOCIETY. XXV
Ehcled
1879 Darwix, Francis, M.B., F.R.S., The Grove, Huntingdon
road, Cambridge.
1874 Davjuson, Alexander, IM.D., Pliysician to tlie Liverpool
Northern Hospital ; 2, Ganibier 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 AVestiuinster Hospital; 33, Welbeck
street, Cavendish square. Trans. 1.
1882 *Dawson, Yelverton, M.D., Heathlands, Southbourue-ou-
Sea, Hants.
1867 Day, "William Henry, M.D., Physician to the Samaritan
Free Hospital for Women and Children ; 10, Manchester
square.
1889 Dean, Henry Percy, M.B., B.S., 60, Gower street.
1889 Delepixe, Sheridan, B.S., M.B., 6, Chapel place. Caven-
dish square.
1878 Dent, Clinton Thomas, Assistant Surgeon to, and
Lecturer on Practical Surgery at, St. George's Hospital ;
61, Brook street. C. 1890. Trans.?,.
1859 f Dickinson, William Howship, M.D., Physician to, and
Lecturer on Medicine at, St. George's Hospital, and
Consulting Physician to the Hospital for Sick Children ;
Honorary Fellow of Caius College, Cambridge ; 9,
Chesterfield street, Mayfair. C. 1874-5. V. P. 1887.
Referee, 1869-73, 1882-6. Sci. Com. 1867-79, 1889.
Trans. 13.
1839 fDixoN, James, Consulting Surgeon to the Royal London
Ophthalmic Hospital, Moorlields ; Harrow Lands,
Dorking. L. 1849-55. V.P. 1857-8. T. 1863-4.
C. 1866-7. Beferee, 1865. Lib. Com. 1845-8.
Trans. 4.
XXVI FELLOWS OF THE SOCIETY.
Elected
1889 DoDD, Henry Work, 47, Kensington Park gardens.
1845 DoDD, John.
1888 DoNELAN, James, M.B., M.C., 2, Upper Wirapole street,
Cavendish square.
1879 DoNKiN, IIoRATio, MB., Physician to the Westminster
Hospital ; Physician to the East London Hospital for
Children ; lUS, Harley street, Cavendish square.
1877 DoRAN, Alban Henry Griffiths, Surgeon to the Samaritan
Free Hospital; 9, Granville place, Portman square.
Trans. 1.
1863 Down, John Langdon Haydon, M.D., Consulting Phy-
sician to the London Hospital; 81, Harley street,
Cavendish square. C. 1880. Y.P. 1890. Trans. 2.
18G7 Drage, Charles, M,D., Hatfield, Herts,
1884 Drage, Lovell, M.B., B.S., The Small House, Hatfield,
Herts.
1879 Drewitt, F. G. Dawtrey, M.D., Physician to the West
London Hospital and to the Victoria Hospital for
Children ; 52, Brook street, Grosvenor square.
1885 Drummond, David, M.D., 7, Saville Place, Newcastle-on-
Tyne.
1880 Deury, Charles Dennis Hill, M.D., Bondgate, Darling.
ton.
18G5 Drysdale, Charles Robert, M.D., Physician to the Far-
ringdon Dispensary ; Assistant-Physician to the Metro-
politan Free Hospital ; 23, Sackville street, Piccadilly.
1865 f Duckworth, Sir Dyce, M.D,, Physician in Ordinary to
H.R.H. the Prince of Wales ; Physician to, and Lecturer
on Clinical Medicine at, St. Bartholomew's Hospital;
11, Grafton street, Bond street. C. 1883-4. Referee
1885-8. Trans. 2.
1876 Dudley, William Lewis, M.D., Physician to the City Dis-
pensary; 149, Cromwell road. South Kensington.
1874 DuFFiN, Alfred Baynard, M.D., Professor of Pathological
Anatomy in King's College, London, and Physician to
King's College Hospital; 18, Devonshire street, Port-
land place.
FELLOWS OF THE SOCIETY. XXVU
Elected
1871 Duke, Benjamin, Windmill House, Clapham Common.
1871 *DuKES, Clement, i\I.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.
1889 *DuNCAN, John, M.D., St. Petersburg, Russia.
1884 Duncan, William, M.D., Obstetric Physician to, and Lec-
turer on Midwifery at, the Middlesex Hospital ; 6,
Harley street, Cavendish square.
1887 Dunn, Hugh Percy, Assistant Ophthalmic Surgeon and
Pathologist at the West London Hospital ; 2, Henrietta
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. V. P. 1887. Referee,
1880-1. Sci. Com. 1867. Lib. Gotn. 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.
1887 Easmon, John Farrell, M.D., Assistant Colonial Surgeon,
Gold Coast Colony, and Acting Chief Medical Officer
of the Colony ; Accra, Gold Coast, West Africa.
1868 Eastes, George, M.B.Lond., 35, Gloucester place, Hyde
Park.
1888 Eccles, Arthur Symons, M.B., C.M.,34, Leinster square.
1883 Edmunds, Walter, M.C, 75, Lambeth Palace road, Albert
Embankment. Trans. 2.
XXVlll FELLOWS OF THE SOCIETY.
Elected
1883 Edwardes, Edward Joshua, M.D., IG, Acacia road, St.
John's Wood.
18S4 Edwards, Fredeuick Swinford, Surgeon to the "West
London Hospital, and to St. Peter's Hospital for
Stone ; 93, Wimpole street. Cavendish square.
1824 Edwards, George.
1887 Elliott, John.
1848 Ellis, George ViNER, Minsterworth, Gloucester. C. 1863-4.
Trans. 2.
1868 Ellis, James, M.D., the Sanatorium, Anaheim, Los Angeles
County, California.
18.54 *Ellison, James, M.D., Surgeon-in-Ordinary to the Royal
Household, Windsor; 14, High street, Windsor.
1889 Elliston, William Alfred, M.D., Manor House, Ipswich.
1842 fERiCHSEN, 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, 1866-8, 1884-7. Lib. Com. 1844-7, 1854.
Trans. 2.
1879 Eve, Frederic S., Assistant Surgeon to the London
Hospital; 125, Harley street, Cavendish square.
Trans. 2.
1877 Ewart, William, M.D., Physician to St. George's Hospital ;
33, Curzon street, Mayfair. Sci. Cum. \^'S9. JVans.l.
1875 *Fagan, John, Surgeon to, and Lecturer ou Clinical
Surgery at, the Belfast Koyal Hospital ; 1, Glengall
place, Belfast.
1869 Fairbank, Frederick Royston, M.D., 46, Hallgate, Don-
caster.
1862 Farquharson, Robert, M.D., LL.D., M.P., Migvie Lodge,
Porchester gardens, Hyde park ; Finzean, Aboyne
Aberdeenshire, and the Reform Club, Pall Mall. Lib.
Com. 1876-80.
FELLO\YS OF THE SOCIETY. XXIX
Elected
1872 Fayrer, Sir Joseph, K.C.S.I., M.D., F.R.S., Honorary
Physician to H.jNI. the Queen, and to H.R.H. the Prince
of Wales, and Physician to H.E.H. the Duke of Edin-
burirh ; Surgeon-General, India OfBce ; Physician to
the Secretary of State for India in Council ; President
of the Indian Medical Board ; 53, "NVimpole street,
Cavendish square. C. 1888. Referee, \^'d[-7 .
1887 Feeny, Michael Henry, Les Avants, Montreux, Switzer-
land.
1872 *Fe\wick, John C. J., M.D., Physician to the Durham
County Hospital ; 25, North road, Durham.
18G3 Fenwick, Samuel, M.D., Physician to the London Hospital ;
29, Harley street. Cavendish square. C. 1880. Beferee,
1882-8. Trans. 4.
1880 Ferrier, David, M.D., LL.D., F.R.S., Professor of Forensic
Medicine in King's College, London, and Pliysician to
King's College Hospital ; Physician for Out-patients
to the National Hospital for tlie Paralysed and Epilep-
tic ; 34, Cavendish square. Trans. 2.
1852 *FiELD, Alfred George.
1889 Field, George P., Aural Surgeon to, and Lecturer on Aural
Surgery at, St. Mary's Hospital ; 34, Wimpole street,
Cavendish square.
1879 FiNLAT, Datid 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.
Trans. 2.
1866 Fitz-Patrick, Thomas, A.M., M.D., 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, Ilanley, Staffordshire.
1877 DE FoNMARTiN, Henry, M.D., 1, Anchor Gate terrace,
Portsea, Hants.
XXX FELLOWS OF THE SOCIETY.
Elected
1865 Foster, Sir Balthazar Walter, M.D., M.P., Professor of
Medicine at the Queen's College, Birmingham, and Phy-
sician 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 the
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.
1887 Fox, Richard Hingston, M.D., 23, Finsbury square.
1880 Fox, Thomas Colcott, B.A., M.B,, Physician to the Skin
Department of the Paddington Green Hospital for
Children, and Assistant Pliysician to the Victoria
Hospital for Children; 14, Harley street, Cavendish
square. Trans. 1.
1871 Frank, Philip, M.D., Cannes, France.
1884 *Franks, Kendal, M.D., Surgeon to the Adelaide Hospital
and to the Throat and Ear Hospital, Dublin ; 69, Fitz-
■william square, Dublin. Trans. 1.
1843 Fraser, Patrick, M.D., C. 1866.
1889 Frbeman, Henrt William, 24, The Circus, Bath.
1868 Freeman, William Henry, 21, St. George's square. South
Belgravia.
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. Trans. 1.
FELLOWS OF THE SOCIETY. XXXI
Elected
1874 fGALABiN, Alfred Lewis, M.A., M.D., Obstetric Physician
to, and Lecturer on Midwifery and the Diseases of
Women at, Guy's Hospital ; 49, Wimpole st.. Cavendish
square. Referee, ISS'l-^,. i?6. Co/«. 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.
1865 Gant, Frederick James, Senior Surgeon to the Royal Free
Hospital; 16, Connaught square, Hyde Park. C. 1880-
81. Referee, 1886-8. Lib. Com. 1882-5. Trans. 3.
1867 Garland, Edward Charles, Yeovil, Somerset.
1867 Garlike, Thomas W., Malvern Cottage, Churchfield road,
Ealing,
1854 -j-Garrod, Sir Alfred Baring, M.D., F.R.S., Consulting
Pliysician to King's College Hospital ; 10, Harley street
Cavendish square. C. 1867. V.P. 1880-81. Referee,
1855-65. Trans. 8.
1886 Garrod, Archibald Edward, M.A., M.D., Assistant Phy-
sician to tlie "West London Ho.*|)ital ; 9, Chandos street,
Cavendish square. Sci. Com. 1889. Trans. 3.
1879 Garstang, Thomas Walter Harropp, Headingley House,
Knutsford, Cheshire.
1889 *Gaskell, Walter Holbrook, M.D., F.R.S. , Lecturer on
Pliysiology, University of Cambridge ; Petersfield
House, Parkside, Cambridge.
1819 Gaulter, Henry.
1887 Gay, John, 119, Upper Richmond road, Putney.
1866 Gee, Samlel Jones, M.D., Librarian, Physician to, and
Lecturer on Medicine at, St. Bartholomew's Hospital;
Consulting Physician to the Hospital for Sick Children ;
31, Upper Brook street, Grosvenor square. C. 1883-4.
L. (June) 1887-90. Sci. Com. 1879. Referee, 1885-7.
Lih. Com. 1871-6. Trans. 1.
XXXll FELLOWS OF THE SOCIETY.
Elected
1885 Gell, Henry Willingham, M.B„ 43, Albiou street, Hyde
Park.
18/8 Gervis, Henry, M.D., Consulting Obstetric Physician to
St. Thomas's Hospital ; Consulting Physician to the
Royal Maternity Charity ; 40, Harley street, Cavendish
square. Referee, 1884-8. Trans. 1.
1884 GiBBES, Heneage, M.D., Professor of Pathology in the
University of Michigan ; Ann Arbor, Michigan, U.S.A.
1880 Gibbons, Robert Alexander, M.D., Physician to the
Grosvenor Hospital for Women and Children ; 29,
Cadogan place.
1877 GoDLEE, RiCKMAN JoHN, Siirgeon to University College
Hospital, and Teacher of Operative Surgery in University
College, London ; Surgeon to theNorth-Eastern Hospital
for Children, and to the Hospital for Consumption,
Broinpton ; 81, WiiDpole street. Cavendish square.
Referee, 1886-8. Trans. 5.
1870 Godson, Clement, M.D., Assistant-Physician-Accoucheur
to St. Bartholomew's Hospital ; Consulting Physician
to the City of London Lying-in Hospital; 9, Grosvenor
street, Grosvenor square.
1886 GoLDiNG-BiRD, Cuthbert Hilton, M.B., Assistant Surgeon
and Lecturer on Physiology at Guy's Hospital ; 12,
Queea Anne street, Cavendish square.
1851 GooDFELLOW, STEPHEN Jennings, M.D., Consulting Phy-
sician to the Middlesex Hospital ; Swinnerton Lodge,
near Dartmouth, Devon. C. 1864-5. Referee, IS&Q-Z.
Lib. Com. 1863. Trans. 2.
1883 GooDHART, James Frederic, M.D., Physician to, and
Lecturer on Pathology at, Guy's Hospital ; Phy-
sician to the Evehna Hospital for Sick Children ; 25,
Weymouth street, Portland place.
1889 Goods ALL, David Henry, 17, Devonshire place, Upper
Wimpole street.
FELLOWS OF THE SOCIETI. XXXlll
Elected
1877 Gould, Alfred Peaece, M.S., Assistant Surgeon to the
Middlesex Hospital ; 10, Queen Anne street, Cavendish
square. Trans. 2.
1873 GowERS, William Richard, M.D., F.R.S., Consulting
Physician to University College Hospital ; Physician
to the National Hospital for the Paralysed and Epi-
leptic ; 50, Queen Anne street, Cavendish square.
Referee 1888. Lib. Com. 1884-6. Trmis. 7.
1851 fGowLLAND, Peter Yeames, Surgeon to St. Mark's Hos-
pital; Surgeon-Major Hon. Artillery Company; 34,
Finsbury square.
1868 Green, T. Henry, M.D., Physician to Charing Cross Hos-
pital, and to the Hospital for Consumption, Brompton ;
7 A, Wimpole street, Cavendish square. C. 1886.
Referee, 1882-5.
1889 Greene, G-eorge Edward Joseph, "The Dell," Bally-
carney Ferns, County Wexford.
1875 *GREENriELD, William Smith, M.D., Professor of General
Pathology in the University of Edinburgh ; 7, Heriot
row, Edinburgh. Sci. Com. 1879. Referee, 1881.
1882 Gresswell, Dan Astley, M.B., Melbourne, Victoria,
1885 Griffith, Walter Spencee Anderson, M.B., Physician
to the Samaritan Free Hospital for Women and
Children ; 114, Harley street, Cavendish square.
1889 Griffiths, Joseph, M.B., CM., 16, Panton street, Cam-
bridge.
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, 15, Johnstown street, Bath.
1889 GuBB, Alfred Samuel, 29, Gower street.
1860 GuENEAU DE MussY, Henri, M.D. ; 15, Rue du Cirque,
Paris. Lib. Com. 1863-5.
VOL. LXXIII. C
XXXIV FELLOWS OF THE SOCIETY.
Elected
1885 GuLLivEK, George, M.B., Assistant Physician to, and Lec-
turer on Comparative Anatomy at, St. Thomas's Hos*
pital ; 16, Welbeck street.
1883 GuNN, Robert Marcus, M.B,, Assistant Surgeon to the
Royal London Ophthalmic Hospital, Moorfields ; Oph-
thalmic Surgeon to the Hospital for Sick Children,
Great Ormond Street ; 54, Queen Anne street, Caven-
dish square.
1886 Habershon, Samuel Heebeet, M.D., Casualty Physician
to St. Bartholomew's Hospital ; 70, Brook street,
Grosvenor square.
1888 Hadden, Walter Baugh, M.D., Assistant Physician and
Demonstrator of Morbid Anatomy at St. Thomas's
Hospital ; Assistant Physician, Hospital for Sick
Children; 21, Welbeck street. Cavendish square.
1885 Haig, Alexander, M.D., Casualty Physician to St. Bartho-
lomew's Hospital ; 30, Welbeck street. Cavendish
square. Trans. 5.
1890 Hale, Charles Douglas Bowdich, M.D., 8, Sussex
gardens, Hyde Park.
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.
1885 Halliburton, William Dobinson, M.D., Professor of
Physiology, King's College, London ; 25, Maitland
Park Villas, Haverstock Hill.
1870 Hamilton, Robert, Surgeon to the Royal Southern Hos-
pital, Liverpool ; 1 Prince's road, Liverpool.
1889 Handfield-Jones, Montagu, M.D., 24, Montagu square.
1874 Hardie, Gordon Kenmure, M.D., Deputy Inspector
General of Hospitals; Florence road, Ealing, and Duff
House, Banff, N.B.
FELLOWS OF THE SOCIETY. XXXV
Elected
1856 fHARE, Charles John, M.D., Treasurer, late Professor
of Clinical Medicine in University College, London, and
Consulting Physician to University College Hospital ;
Berkeley House, 15, Manchester square. C. 1873-4.
T. 1887-90.
1857 Harley, George, M.D., F.R.S. 25, Harley street. Caven-
dish square. C. 1871-2. Beferee, 1865-70, 1873-6.
Sci. Coin. 1862-3. Trans. 1.
1864 Harley, John, M.D., F.L.S., Physician to, and Lecturer on
General Anatomy and Physiology at, St. Thomas's
Hospital ; 9, Stratford place, Oxford street. S.
1875-7. C. 1879-80. i2e/eree, 1871-4, 1882-8. Sci.
Com. 1879. Trans. 10.
1880 Harris, Vincent Dormer, M.D., Physician to the
Victoria Park Hospital; Demonstrator of Physiology
at St. Bartholomew's Hospital; 31, Wimpole street,
Cavendish square.
1870 Harrison, Reginald, 6, Lower Berkeley Street, Portman
square. Trans. 1.
1 854 Haviland, Alereu.
1890 Haviland, Frank Papillon, M.B., B.C., 57, Warrior
square, St. Leonard's-on-Sea.
1870 Haward, J. Warrington, Secretary; Surgeon to, and
Lecturer on Clinical Surgery at, St. George's Hos-
pital; 16, Savile row, Burlington Gardens. C. 1885.
S. 1888-90. Lib. Com. 1881-4. Trans. 2.
1838 fHAWKiNs, Charles, Inspector of Anatomical Schools in
London; 9, Duke street, Portland place. C. 1846-7.
S. 1850. V.P. 1858. T. 1861-2. Referee, 1859-60.
Uh. Com. 1843. Trans. 2.
1885 Hawkins, Francis Henry, M.B., Physician to St. George's
and St. James's Dispensary and to the North London
Hospital for Consumption ; 59, Wimpole street, Caven-
dish square.
1848 fHAWKSLEY, Thomas, M.D., 11, Albert Mansions, Victoria
street, and Beomands, Chertsey, Surrey.
XXXVl FELLOWS OF THE SOCIETY.
Elected
1875 Hayes, Thomas Crawford, M,D., Physician-Accoucheur
and Physician for Diseases of Women and Children to
King's College Hospital ; 17, Clarges street, Piccadilly.
1860 Hayward, Henry Howard, Surgeon Dentist to, and
Lecturer on Dental Surgery at, St. Mary's Hospital ;
38, Harley street. Cavendish square. C. 1878-9.
1861 Hayward, William Henry.
1848 He ALE, James Newton, M.D.
1865 Heath, Christopher, Trustee, 'Ro\n\e Professor of Clinical
Surgery in University College, London ; and Surgeon
to University College Hospital; 36, Cavendish square.
C. 1880. V.P. 1889. 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.
1877 Herman, George Ernest, M.B., Obstetric Physician to,
and Lecturer on Midwifery at, the London Hospital ;
20, Harley street, Cavendish square, Trans. 1.
1877 Heron, George Allan, M.D., Physician to the City of
London Hospital for Diseases of the Chest, Victoria
Park; 57, Harley street. Cavendish square.
1883 Herringham, Wilmot Parker, M.D., 13, Upper Wimpole
street. Cavendish square. Trans. 1.
1843 Hewett, Sir Prescott Gardner, Bart., F.R.S., Serjeant-
Surgeon to H.M. the Queen ; Surgeon in Ordinary
to H.B.H. the Prince of Wales ; Consulting Surgeon
to St. George's Hospital ; Foreign Associate of the
" Academie de Medecine," and Corresponding Member
of the " Societe de Chirurgie," Paris; Chesnut Lodge,
Horsham, Sussex. C. 1859. V.P. 1866-7. Referee,
1850-8,1860-5,1868-83. Sd. Com. 1863. Lib. Com.
1846-7. Trans. 7.
1887 Hewitt, Frederic William, M.D., 10, George street,
Hanover square.
FELLOWS OF THE SOCIETY, XXXVll
Elected
1855 fHEWiTT, W. M. Grailt, M.D., Emeritus Professor of
Midwifery in University College, London, and Consult-
ing Obstetric Physician to University College Hospital ;
36, Berkeley square. C. 1876. Referee, 1868-75,
1877-88. 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., Professor of Clinical Surgery
in University College, London, and Surgeon to Uni-
versity College Hospital ; Surgeon to the Lock Hospital ;
66, Wimpole street, Cavendish square. Referee, 1888.
C. 1878-9. S. 1881-4. V.P. 1885-6. Trans. 1.
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, 1866-7. 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 j 8, Cambridge
road, Brighton.
1856 fHoLMES, Timothy, M.A., President, Consulting 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. 1885-7. P. 1890. Referee,
1866-8, 1872, 1883-4. Sci. Com. 1867. Lib. Com.
1863-5. Trans. 8.
1846 fHoLT, 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 fHoLTHOUSE, Carsten, 1, Bath terrace, Richmond. C.
1863. Be/eree 1870-6. Lib. Com. 1859-60.
XXXVm FELLOWS OF THE SOCIETY.
Elected
1878 Hood, Donald William Chaeles, 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, Surgeon to the
National Hospital for the Paralysed and Epileptic ;
Professor of Pathology in University College, London ;
Superintendent of the Brown Institution, Wandsworth
road ; 80, Park street, Grosvenor Square. Trans. 1.
1865 Howard, Benjamin, M.D. [New York, U.S.] Trans. 1.
1881 Howard, Henry, M.B., abroad. [6, The Terrace, Mount
Pleasant, Cambridge.]
1874 HowsE, Henry Greenway, M.S., Surgeon to, and Lecturer
on Anatomy at, Guy's Hospital ; Surgeon to the Evelina
Hospital for Sick Children ; 59, Brook street, Grosvenor
square. C. 1890. Sci. Com. 1879. Referee, 1887-8.
Trans. 2.
1886 Hudson, Charles Elliott Leopold Barton, Surgical
Registrar, Middlesex Hospital ; Warden of the College.
1884 HuGGARD, William R., M.D. [Place de la Synagogue,
2, Geneve.]
1857 tHuLKE, 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. 1879-90. Sci.
Com. 1867. Lib. Com. 1864-8. Trans. 9.
1889 Humphery, Francis William, M.A., M.B., 63, Prince's
gate, Hyde park.
1855 Humphry, George Murray, M.D., F.R.S., Surgeon to
Addenbrooke's Hospital; Professor of Surgery in the
University of Cambridge. Trans. 8.
1882 Humphry, Laurence, M.B., 3, Trinity street, Cambridge.
1889 Hunter, William, M.D., 61, Wimpole street. Cavendish
square.
FELLOWS OF THE SOCIETY. XXXIX
Elected
1 873 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 Oxford
County Lunatic Asylum and the Warneford Asylum ;
24, Winchester Road, Oxford. Trails. I.
1856 fHuTCHiNSON, 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,
1883-8. Lib. Com. 1864-5. Trans. 14. Pro. 2.
1888 Hutchinson, Jonathan, Jun., Assistant Surgeon to the
London Hospital; 16, Finsbury circus.
1820 Hutchinson, William, M.D.
1847 Image, William Edmund, Herringswell House, Milden-
hall, Suffolk. Trans. 1.
1856 Inglis, Cornelius, M.D.
1871 Jackson, J. Hughlings, M.D., F.E.S., Physician to the
London Hospital ; Physician to the National Hospital
for the Paralysed and Epileptic ; 3, Manchester square.
C. 1889.
1841 fJACKSON, Paul, 51, Wellington road, St. John's Wood.
C. 1862.
1863 Jackson, Thomas Vincent, Senior Surgeon to the Wolver-
hampton and Staffordshire General Hospital ; Whet-
stone House, Waterloo road south, Wolverhampton.
1883 Jacobson, Walter Hamilton Acland, B.A., M.B., M.S.,
Assistant Surgeon to Guy's Hospital ; Surgeon to the
Royal Hospital for Children and Women ; 66, Great
Cumberland place, Hyde Park. Trans. 1.
1825 James, John B., M.D.
Xl FELLOWS OF THE SOCIETY.
Elected
1883 *Jenkins, Edward Johnstone, M.D., The Australian
Club, Sydney, New South Wales.
1851 fJENNER, Sir William, Bart., M.D., K.G.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 ;
Greenwood, Bishop's Waltham, Hants. C. 1864. V.P.
1875. Referee, 1855, 1859-63. Trans. 3.
1884 Jennings, Charles Egerton, M.S., M.B., 15, Upper Brook
street, Grosvenor square.
1881 Jennings, William Oscae, M.D., 35, Eue Marboeuf,
Avenue des Champs-Elysees, Paris.
1884 Jessett, Frederic Bowreman, Surgeon to the Royal
General Dispensary; 16, Upper Wimpole street.
1883 Jessop, Walter H. H., M.B., Demonstrator of Anatomy at
St. Bartholomew's Hospital ; 73, Harley street.
1851 Johnson, Edmund Charles, Corresponding Member of the
Medical and Philosophical Society of Florence, and of
" rinstitut Genevois."
1847 t Johnson, George, M.D., F.R.S,, Physician Extraordinary
to H.M. the Queen ; Consulting Physician to King's
College Hospital ; Member of the Senate of the Uni-
versity of London; 11, Savile row, Burlington gar-
dens. C. 1862-3. V.P. 1870, P. 1884-5. L. 1878-80.
Beferee, 1853-61, 1864-9. Lib. Com. 1860-1. Trans.
10. Pro. I.
188 1 Johnson, George Lindsay, M.A., M.D., Cortina, Netherhall
gardens, South Hampstead, and 14, Stratford place,
Oxford street.
1889 Johnson, Harold J., Senior Assistant, Gloucester County
Asylum.
1889 Johnson, Raymond, M.B., B.S., 123, Gower street.
FELLOWS OF THE SOCIETY. xH
Elected
1884 Johnston, James, M.D., 11, Chester place, Hyde Park
square.
1848 Johnstone, Athol Archibald Wood, Consulting Surgeon
to the Royal Alexandra Hospital for Sick Children, St.
Moritz House, 61, Dyke road, Brighton. Lib. Com.
1860. Trans. 1.
1887 Jones, Henry Lewis, M.D., Casualty Physician to St.
Bartholomew's Hospital ; 6, ^Yest street, Finsbury
Circus.
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, and Fellow
of the Senate, Sydney University; 10, College street,
Sydney, New South Wales. [Agents : Messrs. D. Jones
& Co., 1, Gresham buildings, Basinghall street.]
1865 Jordan, Furxeaux, Consulting Surgeon to the Queen's
Hospital, Birmingham; Selly Hill, Birmingham.
1881 JuLER, Henry Edward, Junior Ophthalmic Surgeon to St.
Mary's Hospital ; 77, Wimpole street, Cavendish square.
1816 Kauffmann, George Hermann, M.D., Hanover.
1882 Keetlet, Charles R. B., Senior Surgeon to the "West
London Hospital; 56, Grosvenor street, Grosvenor
square.
1872 Kelly, Charles, M.D., Professor of Hygiene in King's
College, London, and Medical Oflacer df Health for the
West Sussex Combined Sanitary District; Ellesmere,
Gratwicke road. Worthing, Sussex.
1848 *Kendell, Daniel Burton, M.D., Heath House, Wakefield,
Yorkshire.
1890 Kerr, J. G. Douglas, M.B., CM., 6, The Circus, Bath.
1884 Keser, Jean Samuel, M.D., Surgeon to the French Hos-
pital, Leicester place; 11, Harley street. Cavendish
square.
1877 *Khory, Rustonjee Naserwanjee, M.D., Physician to the
Parell Dispensary, Bombay ; Girgaum road, Bombay.
Xlii FELLOWS OF THE SOCIETY.
Elected
1857 fKiALLMARK, Henry Walter, 5, Pembridge gardens. Bays-
water. C. 1890.
1881 KiDD, Percy, M.A., M.D., Assistant Physician to the
Hospital for Consumption, Brompton ; 60, Brook street,
Grosvenor square. Trans, 4.
1851 -|-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. Set. Com. 1867. Trans. 1.
1885 Klein, Edward Emanuel, M.D., F.R.S., Lecturer on
Physiology, St. Bartholomew's Hospital; 19, Earl's
Court square.
1883 Knapton, Geoege, 4, Clivedon place, Eaton square.
1888 Kynsey, William Raymond, C.M.G., Inspector-General
of Hospitals, Colombo, Ceylon.
1889 Lancaster, Ernest le Cronier, M.B., B.Ch., Demon-
strator of Anatomy at St. George's Hospital ; 22, Hill
street, Knightsbridge.
1840 t^ANE, Samuel Armstrong, Consulting Surgeon to St.
Mary's Hospital and to the Lock Hospital ; St. Mary's,
Madeley road, Ealing. C. 1849-50. V.P. 1865.
Referee, 1850.
1884 Lane, William Arbuthnot, M.S., Assistant Surgeon to
Guy's Hospital and to the Hospital for Sick Children ;
8, St. Thomas's street, Southwark. Trans. 3.
1882 Lang, William, Ophthalmic Surgeon to, and Lecturer
on Ophthalmic Surgery at, the Middlesex Hospital ;
Assistant Surgeon to the Royal London Ophthalmic
Hospital, Moorfields ; 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 ; 62, Harley street. Cavendish
square. C. 1881-2. Referee, 1885-8. Lib. Com.
1879-80, 1888. Trans. 2.
FELLOWS OF THE SOCIETY. xlui
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.
1890 Lawrence, Henry Cripps, 12, Sussex gardens, Hyde
Park.
1888 Lawrence, Laurie Asher, 125, Harley street, Cavendish
square.
1890 *Lawrie, Edward, M.B., Indian Medical Department;
Hyderabad, Deccan.
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., Melbourne, Victoria,
Australia.
1886 *Lediard, Henry Ambrose, M.D., Surgeon to the Cum-
berland Infirmary; 41, Lowther street, Carlisle.
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, Egbert James, M.D., 6, Savile row.
1883 Leeson, John Rudd, M.D., CM., 6, Clifden road,
Twickenham.
1869 Legg, John Wickham, M.D., C. 1886. Referee, 1882-5.
Lib. Com. 1878-85. Trans. 2.
1836 Leighton, Frederick, M.D.
xliv FELLOWS OF THE SOCIETY.
Elected
1886 Lewers, Arthur Hamilton Nicholson, M.D., Assistant
Obstetric Physician to the London Hospital and Physi-
cian to Out-patients of Queen Charlotte's Lying-in
Hospital ; 60, Wimpole street, Cavendish square.
1872 LiEBHEicH, Richard, Consulting Ophthalmic Surgeon to
St. Thomas's Hospital ; Paris.
1878 Lister, Sir Joseph, Bart., D.CL., 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.
1872 *Little, David, M.D., Senior Surgeon to the Royal Eye
Hospital, Manchester; 21, St. John street, Manchester.
1889 *Little, James, M.D., Physician to the Adelaide Hospital;
14, Stephen's Green North, Dublin.
1889 Little, John Fletcher, M.B., 60, Welbeck street. Caven-
dish square.
1871 Little, Louis Stromeyer, Shanghai, China.
1819 Lloyd, Robert, M.D.
1820 LocHEE, 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,
1860 LoNGMORE, 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 ; Foreign Associate " Academie
de Medecine;" Woolston Lawn, "Woolston, Hants.
Trans. 2.
1836 LowENFELD, JosEPH S., M.D., Berbice.
1871 LowNDS, Thomas Mackford, M.D., late Professor of
Anatomy and Physiology at Grant Medical College,
Bombay ; Egham Hill, Surrey.
FELLOWS OF THE SOCIETY. xlv
Elected
1881 Lucas, Richard Clement, B.S., M.B., Surgeon to, and
Lecturer on Anatomy at, Guy's Hospital ; Surgeon to
the Evelina Hospital for Sick Children; 18, Finsbury
square.
1888 Luff, Arthur Pearson, M.B., B.Sc, 35, Westbourne ter-
race, Hyde Park.
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.
1887 Lush, Percy J. F., M.B., 8, Fitzjohn's avenue, South
Hampstead.
1857 Lyon, Felix William, M.D., 7, South Charlotte street,
Edinburgh.
1867 Maberly, George Fredekick, Mailai Valley, Nelson, New
Zealand.
1889 MacAlister, Donald, M.A., B.Sc, M.D., Physician to
Addenbrooke's Hospital ; Lecturer on Medicine, St.
John's College ; University Lecturer in Medicine ; St,
John's College, Cambridge.
1873 fMAcCARTHY, Jeremiah, M.A., Surgeon to the London
Hospital and Lecturer on Physiology at the London
Hospital Medical College; 15, Finsbury square. C.
1886-7. Lib. Com. 1882-5.
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.
1887 Macdonald, George Childs, M.D.
1880 Macfarlane, Alexander William, M.D., Examiner in
Medical Jurisprudence, University of Glasgow ; 6, Man-
chester Square.
1866 Macgowan, Alexander Thorburn, M.D., Vyvyan House,
Clifton, near Bristol.
xlvi
FELLOWS OF THE SOCIETY.
Elected
1880 McHaedy, 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., LL.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 ; 79, Wimpole street, Cavendish
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 Eoyal London Ophthalmic Hospital ;
18, Cavendish square. Trans, 1.
1885 Mackern, John, M.D., St. Germain's Lodge, Shooter's Hill
road, Blackheath.
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.
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.
1889 MacLehose, Norman MacMillan, M.B., CM., 24, Devon-
shire street, Portland place.
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, 1884-8.
Lib. Com. 1886-8.
1881 Macready, Jonathan Forster Christian Horace, Sur-
geon to the Great Northern Hospital ; 51, Queen Anne
street, Cavendish square.
FELLOWS OF THE SOCIETY. xlvii
Elected
1880 Maddick, Edmund Distin, 2, Chandos street, Cavendish
square.
1886 Maguire, Robert, M.D., 4, Seymour street, Portman square.
1880 Makins, George Henry, Assistant Surgeon to St. Thomas's
Hospital and to the Evelina Hospital for Children ; 2,
Queen street, May Fair. Trans. 1.
1885 Malcolm, John David, M.B., Surgeon in charge of Out-
patients, Samaritan Free Hospital ; 24, Bryanston
street, Portman square. Trans. 1.
1888 Mapother, Edward Dillon, M.D., 32, Cavendish square.
1855 Marcet, William, M.D., F.R.S.,Flowermead, Wimbledon
Park, and Athensum Club, Pall Mall. C. 1871.
Referee, 1866-70, 1883-6. Sci. Com. 1863. Lib. Com.
1866-8. Trans. 3.
1867 Marsh, F. Howard, Assistant Surgeon to, and Lecturer
on Anatomy at, St. Bartholomew's Hospital ; 30, Bruton
street, Berkeley square. C. 1882-3, 1889. S. 1885-7.
Lib. Com. 188'o-l. Trans. 4.
1851 fMARSHALL, John, F.R.S., Professor of Anatomy to the
Royal Academy of Arts ; Emeritus Professor of Surgery
in University College, London, and Consulting Surgeon
to University College Hospital ; 92, Cheyne walk, Chel-
sea. C. 1866. V.P. 1875-6. P. 1882-3. Referee,
1867, 1871-4, 1877-81. Trans. 3.
1884 Martin, Sidney Harris Cox, M.D. ; 10, Mansfield street,
Portland place.
1883 Maudsley, Henry Carr, M.D,, 11, Spring street, Mel-
bourne, Victoria.
1839 Meade, Richard Henry, Consulting Surgeon to the Brad-
ford Infirmary ; Bradford, Yorkshire. Trans. 1.
1865 Medwin, Aaron George, M.D., Consulting Dental Sur-
geon to the Royal Kent Dispensary, 34, Bruton street,
Berkeley square.
Xlviii FELLOWS OF THE SOCIETY.
Elected
1880 Meredith, William Appleton, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children ; 6,
Queen Anne street, Cavendish square. Trans. 1.
1874 Merriman, John J., 45, Kensington square.
1815 Meyer, Augustus, M.D., St. Petersburg.
1840 Middlemore, 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.
1882 Mills, Joseph, 28, Queen Anne street. Cavendish square.
1873 Milner, Edward, Surgeon to the Lock Hospital; 32, New
Cavendish street, Portland place.
1887 MivART, Frederick St. George, M.D., Beaumont Lodge,
Worple road, Wimbledon.
1883 Money, Angel, M.D., Assistant Physician to University
College Hospital, 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, Cavendish square. Ti'ans. 4.
1873 Moore, Norman, M.D., Assistant Physician and Warden of
the College, and Lecturer on Pathology at, St. Bartho-
lomew's Hospital ; The Warden's House, St. Bartho-
lomew's Hospital. Referee, 1886-8.
1857 Morgan, John, 3, Sussex place, Hyde park gardens.
C. 1880-1. Lib. Com. 1862-3. Trans. 1.
1861 Morgan, John Edward, M.D., Physician to the Manchester
Royal Infirmary, and Professor of Medicine in the
Victoria University, Manchester ; 1, St. Peter's square,
Manchester.
1878 Morgan, John Hammond, M.A., Surgeon to the Charing
Cross Hospital and to the Hospital for Sick Children,
Great Ormond street ; 68, 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. C. 1888-9. Referee, \^'d2-7 . Trans. 10.
FELLOWS OF THE SOCIETY. xlix
Elected
1879 MoBKis, Malcolm Alexander, Surgeon to the Skin De-
partment of, and Lecturer on Dermatology at, St.
Mary's Hospital ; 8, Harley street, Cavendish square.
Sci. Com. 1889.
1885 MoTT, Frederick Walker, M.D., Lecturer on Physiology,
Charing Cross Hospital ; Meadowlead, Gayton road,
iianow.
1879 MuNK, William, M.D., Harveian Librarian, Royal College
of Physicians ; Consulting Physician to the Royal
Hospital for Licurables ; 40, Finsbury square.
1888 f Murray, Hubert Montague, M.D., 27, Savile row, Bur-
lington gardens.
1873 Murray, J. Ivor, M.D., F.R.S.Ed. 24, Huntriss row,
Scarborough.
1880 Murrell, William, M.D., Assistant Physician to the Royal
Hospital for Diseases of the Chest ; Assistant Physician
to, and Lecturer on Materia Medicaand Therapeutics at,
the Westminster Hospital ; 38, Weymouth street, Port-
laud place. Sci. Com. 1889. Trans. 1.
1863 Myers, Arthur Bowen Richards, Brigade-Surgeon,
Brigade of Guards ; 43, Gloucester street, Warwick
square. C. 1878-9. Lib. Com. 1877.
1882 Myers, Arthur Thomas, M.D., 9, Lower Berkeley street,
Port man square.
1889 Napier, Francis Horatio, M.B., 31, Lower Seymour street,
Portman square.
1881 Nall, Samuel, M.B., Disley, Stockport, Cheshire.
1870 Neild, James Edward, M.D., Lecturer on Forensic Medi-
cine in the University of Melbourne; 166, Collins
street east, Melbourne, Victoria.
1889 Nevins, Arthur Edward, Eastwood place, Hanley, Staf-
fordshire.
vol. lxxiii. d
1 FELLOWS OF THE SOCIETY.
Elected
1 877 Nettleship, Edward, Ophthalmic Surgeon to, and Lecturer
on Ophthalmology at, St. Thomas's Hospital ; Assistant
Surgeon to the Royal London Ophthalmic Hospital ;
5, Wimpole street. Cavendish square.
1843 fNEWTON, Edward, 85, Gloucester terrace, Hyde Park.
C. 1863-4.
1868 NiCHOLLS, James, M.D., Trenanen, Newquay, Cornwall.
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 NuNNELEi, Frederick Barham, M.D. Trans. 2.
1884 Oakes, Arthur, M.D.
1880 O'Connor, Bernard, A.B., M.D., Physician to the North
London Hospital for Consumption ; Greenhill Park,
Harlesden.
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 ; 22,
Welbeck street, Cavendish square.
1880 Ogilvie, Leslie, M.B., Physician to the Paddington
Green Children's Hospital ; 46, Welbeck street, Caven-
dish square.
1858 Ogle, John William, M.D., Consulting Physician to St.
George's Hospital; 30, Cavendish square. C, 1873.
V.P. 1886. Referee, 1864-72. Trans. 4.
1855 *Ogle, William, M.A., M.D., Physician to the Derbyshire
Infirmary ; The Elms, Duffield road, Derby.
1860 Ogle, William, M.D. , Superintendent of Statistics in the
Registrar-General's Department, Somerset House ; 10,
Gordon street, Gordon square. S. 1868-70. C. 1876-7.
V.P. 1887. Lib. Com. I'd! 1-5. Trans. 5.
FELLOWS OF THE SOCIETY. ll
Elected
18/0 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-on-Tyne. Trans. 1.
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; 37, Upper
Brook street, Grosvenor square. C. 1889-90. Sci.Com.
1889. Referee, 1884-8. 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 ; 92, Merrion square west,
Dublin.
1879 Owen, Edmund, M.B., Surgeon to, and Joint Lecturer on
Surgery at St. Mary's Hospital ; Senior Surgeon to the
Hospital for Sick Children, Great Ormond street ;
64, Great Cumberland place, Hyde park. Trans. 2.
1882 Owen, Herbert Isambard, M.D., Assistant Physician to,
and Lecturer on Forensic Medicine at, St. George's
Hospital ; 40, Cuvzon 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. C. 1890.
Referee, 1884-8. Lib. Com. 1886-8. Trans. 4.
1887 Paget, Chaeles Edward, North Bentclifi'e, Eccles, Lan-
cashire.
lii FELLOWS OF THE SOCIETY.
Elected
1840 fPAGET, Sir James, Bart., D.C.L., LL.D., F.R.S., Sergeant-
Surgeon to H.M. the Queen ; Surgeon-in-Ordiuary 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
'Academic de Medecine,' Paris; 1, Harewood place,
Hanover square. C. 1848-9. V.P. 1861. T. 1867.
P. 1875-6. Referee, 1844-6, 1848, 1851-60, 1862-6,
1868-74. Sci. Com. 1863. Lib. Coin. 1846-7.
Trans. 12.
1886 Paget, Stephen, 57, Wimpole street. Cavendish square.
1858 *Paley, William, M.D., Physician to the Ripon Dispen-
sary ; The Old Residence, Ripon, Yorkshire.
1887 Pardington, George Lucas, M.D., 47, Mount Pleasant
road, Tunbridge Wells.
1873 Parker, Robert William, Surgeon to the East London Hos-
pital for Children ; 8, Old Cavendish street. C. 1888-9.
Lib. Com. 1885-7. Trans. 4.
1885 Parker, Rushton, M.B., B.S., Professor of Surgery,
University College, Liverpool (Victoria University) ;
Surgeon to the Liverpool Royal Infirmary ; 59, Rodney
street, Liverpool.
1889 Parsons, J. Inglis, M.D., 3, Queen street, May Fair.
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., Consulting
Physician to Guy's Hospital ; 35, Grosvenor street.
C. 1883-4. Referee, 1871-82. Trans. 1.
1869 Payne, Joseph Prank, M.D., Physician to, and Lecturer
on Pathological Anatomy at, St. Thomas's Hospital ;
78, Wimpole street, Cavendish square. C. 1887. Sci.
Com. 1879. Lib. Com. 1878-85, 1889.
1879 Peel, Robert, 120, Collins street east, Melbourne,
Victoria.
FELLOWS OF THE SOCIETY. liii
Elected
1856 Peirce, Richard King, Laggan House, Maidenhead.
1830 Pelechin, Charles P., M.D., St. Petersburg.
1855 *P£MBERTON, Oliver, Senior Surgeon to the Birmingham
General Hospital, and Professor of Surgery at the
Queen's College, Birmingham ; 11, Temple row, Bir-
mingham. Trans. 1.
1874 Pen HALL, John Thomas, The Cedars, Broadwas-on-Thema,
Worcester.
1887 Penrose, Francis George, M.D., Assistant Physician to
St. George's Hospital ; 24, Clarges street, Piccadilly.
1890 Perry, Edwin Cooper, M.D., The College, Guy's Hospital.
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-tpon-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.
1888 Phillips, John, M.B., Assistant Obstetric Physician, King's
College Hospital ; Physician to the British Lying-in
Hospital; 71, Grosvenor street, Grosvenor square.
1889 Phillips, Sidney, M.D., Senior Physician to Out-patients
at St. Mary's Hospital, and Assistant Physician to the
London Fever Hospital ; 62, Upper Berkeley street,
Portman square.
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 fPiTMAN, Sir Henry Alfred, M.D., Consulting Physician
to St. George's Hospital ; Cranbrook, Bycullah park,
Enfield. L. 1851-3. C. 1861-2. T. 1863-8. V.P.
1870-1. Referee, 1849-50. Lib. Com. 1847.
liv FELLOWS OF THE SOCIETY.
Mected
1884 Pitt, Geouge Newton, M.D., Assistant Physician to, and
Pathologist at, Guy's Hospital; 24, St. Thomas's street,
Southwark.
1889 Pitts, Bernard, M.B., M.C., 31, Harley street. Cavendish
square.
1885 Poland, John, Demonstrator of Anatomy, Guy's Hospital ;
4, St. Thomas's street, Southwark.
1884 Pollard, Bilton, Assistant Surgeon and Surgical Registrar
to University College Hospital, Surgeon to the North
Eastern Hospital for Children ; 24, Harley street,
Cavendish square. Trans. 1.
1845 fPoLLOCK, George David, Surgeon-in-Ordinary toH.R.H.
the Prince of Wales ; Consulting Surgeon to St. George's
Hospital ; 36, Grosvenor street, 0.1856-7. L. 1859-62.
V.P. 1870-1. P. 1886-7. Referee, 1858, 1864-9,
1877-85. Trans. 5.
1 865 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. C. 1890. i?e/?ree, 1887-8.
Trans. 2.
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 Extraordinary
to H.M. the Queen, Physician to, and Lecturer on
Practical Medicine at, the Middlesex Hospital; 62,
Wimpole street, Cavendish square. S. (Oct.), 1883-5,
C. 1887-8. Referee 1879-83, 1886. Trans. 3.
FELLOWS OF THE SOCIETY. Iv
Elected
1887 Power, D'Arcy, M.A., M.B., Demonstrator of Practical
Surgery at St. Bartholomew's Hospital ; Surgeon to
Out-patients at Victoria Hospital for Children ; 26,
Bloomsbury square.
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 fPRiESTLEY, William Overend, M.D., LL.D., Consulting
Physician to King's College Hospital, and to the St.
Marylebone Infirmary; 17, Hertford street, Mayfair.
C. 1874-5. V.P. 1884-5. Beferee, 1867-73, 1877-83.
Sci. Com. 1863.
1883 Peingle, John James, M.B., CM., Assistant Physician
to, and Physician in Charge of Skin Department at,
the Middlesex Hospital, and Physician to the Royal
Hospital for Diseases of the Chest ; 35, Bruton street,
Berkeley square. Trans. 1.
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. Lib. Com. 1887-8.
1850 tQuAiN, Richard, M.D., LL.D.Ed., F.R.S., Physician Extra-
ordinary to H.M.the Queen; 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.
Ivi
FELLOWS OF THE SOCIETY.
jElected
1871 Ralfe, Charles Heney, 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. C. 1889. Referee, 1885-8.
1857 Ranke, Henry, M.D., 3, Sophienstrasse, Munich.
1890 Ransom, "William Bramwell, M.D., The Pavement,
Nottingham.
1854 Ransom, William Henry, M.D., F.R.S., Physician to the
Nottingham General Hospital, Nottingham.
1869 Read, Thomas Laurence, 11, Petersham terrace, Queen's
gate.
1858 fREED, Frederick GEORaE,M.D., 46, Hertford street, May-
fair. Trans. 1.
1882 Reid, James, M.D., C.B., Resident Physician in Ordinary
to H.M. the Queen, Windsor Castle.
1884 Reid, Thomas Whitehead, Surgeon to the Kent and
Canterbury Hospital ; St. George's House, Canter-
bury, Kent.
1855 fRETNOLDS, John Russell, M.D., F.R.S., Physician-in-
Ordinary to H.M.'s Household ; Consulting-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 south, Huddersfield.
1881 Rice, George, M.B., CM., Sutton, Surrey.
1887 Richardson, Gilbert, M.D., Hawthorne House, Putney.
1863 Ringer, Sydney, M.D., F.R.S., Holme Professor of
Clinical Medicine in University College, London,
and Physician to University College Hospital ; 15,
Cavendish place, Cavendish square. C. 1881-2.
Referee, 1873-80. Trans. 6.
1889 Rivers, W. H. Rivers, M.D., National Hospital, Queen
Square.
1871 RiviNGTON, Walter, M.S., Cousulting Surgeon to the
London Hospital ; 22, Finsbiiry square. C. 1885-6.
Trans. 4.
FKLLOWS OF THE SOCIETY. Ivii
Elected
1871 *RoBEiiTs, 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, Fredeeick 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.
1889 Roberts, Hugh Leslie, M.B., CM., 31, Rodney street,
Liverpool.
1889 Roberts, Sir William, M.D,, B.A., F.R.S., 8, Manchester
square. Trans. 2.
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.
1888 ^Robinson, Frederick William, M.B., CM., Huddersfield.
1889 Robson, Arthur William Mayo, Hillary place, Leeds.
Trans. 1.
1885 RocKwooD, William Gabriel, M.D., Colombo, Ceylon.
1850 Roper, George, M.D., Consulting Physician to the Eastern
Division of the Royal Maternity Charity ; and to
the Royal Infirmary for Children and Women, Waterloo
Bridge road; Oulton Lodge, Aylsham, Norfolk. C
1879-80.
1857 t^osE, Henry Cooper, M.D., F.L.S., Consulting Surgeon
to the Hampstead Dispensary; 53, Rosslyn hill, Hamp-
stead. C 1886-7. Trans. 1.
1883 Rose, William, M.B., Professor of Surgery at King's
College, Surgeon to King's College Hospital and to the
Royal Free Hospital ; 1 7, Harley street. Cavendish
square.
1889 Ross, Daniel McClure, 54, Upper Berkeley street,
Portman square.
Iviii FELLOWS OF THE SOCIETY.
Elected
1888 RouGHTON, Edmund Wilkinson, M.B., B.S., 60, Gloucester
place, Portman square. Trans. 1.
1882 RouTH, Amand Jules McConnel, M.D., B.S., Physician
to the Samaritan Free Hospital for Women ; Assistant
Obstetric Physician to the Charing Cross Hospital ;
14a, Manchester square.
1849 fRouTH, Charles Henry Felix, M.D., Consulting Physician
to the Samaritan Free Hospital for Women and
Children ; 52, Montagu square. Lib. Com. 1854-5,
Trans. 1 .
1863 Rowe, Thomas Smith, M.D., Senior Visiting Surgeon to
the Eoyal 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., Physician to the Royal
Free Hospital and Assistant Physician to the City of
London Hospital for Diseases of the Chest ; 63, Wel-
beck 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.
1849 fSANDERSON, HuGH James, M.D., 26, Upper Berkeley street,
Portman square. C. 1872-3. Lib. Com. 1862-3.
1855 fSANDERSON, JoHN BuRDON, M.D., LL.D., D.C.L. Durham,
F.R.S., Waynflete Professor of Physiology in the Uni-
versity 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.
FELLOWS OF THE SOCIETY. Ux
Elected
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.
1869 Sansom, Arthur Ernest, M.D., Senior Physician to the
North-Eastern Hospital for Children ; Physician (with
charge of out-patients) to the Loudon Hospital ; 84,
Harley street, Cavendish square. C. 1887-8. Trans. 2.
1886 Sauxdby, Robert, M.D., Physician to the General Hos-
pital, and Consulting Physician to the Hospital for
Women, and to the Eye Hospital, Birmingham ; 83a,
Edmund street, Birmingham.
1845 f 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.
1834 Sauvan, Ludwig V., M.D., Warsaw.
1879 Savage, George Henry, M.D., 3, Henrietta street. Caven-
dish square.
1859 Savory, Sir William Scovell, Bart., F.R.S,, Surgeon
Extraordinary to H.M. the Queen, Surgeon to, and
Lecturer on Surgery at, St. Bartholomew's Hospital;
Surgeon to Christ's Hospital ; 66, Brook street, Gros-
venor 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. 8.
1883 ScHAFER, Edward Albert, F.E.S., Jodrell Professor of
Physiology, University College, London ; University
College, Gower street. Referee, 1888.
1887 Scott, Harry, M.D., 28, Great Smith street, Westminster.
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.
Ix FELLOWS OF THE SOCIETY.
Elected
1863 Sedgwick, William, 101, Gloucester place, Portman
square. 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. I .
1 875 Semple, Robert Hunter, M.D., Consulting Physician to the
Bloomsbury Dispensary ; 8, Torrington square. Sci.
Com. 1879.
1873 *Shapteb, Lewis, B.A., M.B., Physician to the Devon and
Exeter Hospital ; the Barnfield, Exeter.
1882 Sharkey, Seymour John, M.D., 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.
1886 Shaw, Lauriston Elgie, M.D., Assistant Physician, Medical
Registrar, and Demonstrator of Practical Medicine at
Guy's Hospital ; 10, St. Thomas's street, Southwark.
1884 Sheild, Arthur Marmaduke, M.B., B.S., Assistant Sur-
geon, Charing Cross Hospital; 20, Stratford place,
Oxford street. Trans. 1.
1859 Sibley, Septimus William, 7, Harley street, Cavendish
square. C. 1882-3. Sci. Cmn. 1863. Trans. 4.
1887 SiDEBOTHAM, Edwaed John, M.B„ 123, Pall Mall.
1848 tSiEVEKiNG, Sir Edward Henry, M.D., LL.D., Physician-
in-Ordinary to H.M. the Queen ; Physician-in-Ordinary
to H.R.H. the Prince of Wales ; Consulting Physician
to St. Mary's Hospital; 17, Manchester square. C.
1859-60. S. 1861-3. V.P. 1873-4. L. 1881-2. P.
1888-9. Referee, 1855-8, 1864-72, 1875-80. Sci.
Com. 1862. Trans. 2.
FELLOWS OF THE SOCIETY. Ixi
Elected
1886 SiLcocK, Arthur Quauuy, M.D., B.S., Surgeon in charge
of out-patients, St. Mary's Hospital ; Assistant Surgeon,
Royal London Ophthalmic Hospital ; 52, Harley
street, Cavendish square.
1842 tSiMON, Sir John, K.C.B.,D.C.L.,LL.D.,r.E.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.
1890 Smale, Morton, 22a, Cavendish square.
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; 15, Queen Anne street. Caven-
dish square.
1866 Smith, Heywood, M.A. M.D., 18, Harley street, Cavendish
square.
1886 Smith, Howard Lyon.
1885 Smith, James Greig, M.B., CM., F.R.S.Ed., Surgeon to
the Bristol Royal Infirmary ; 1 6, Victoria square,
Clifton, Bristol.
18/2 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. C. 1890. Trans. 1.
1889 Smith, Eobert Percy, M.D., B.S., Bethlem Royal Hos-
pital.
1838 fSMiTH, Spencer, 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.
Ixii FELLOWS OF THE SOCIETY.
Elected
1863 Smith, Thomas, Vice-President, Surgeon to, and Lecturer
on Clinical Surgery at, St. Bartholomew's Hospital ;
5, Stratford place, Oxford street. S. 1870-2. C.
1875-6. V.P. 1887-8. Referee, \873-4, 1880-6. Sci.
Com. 1867. Trans. 4.
1873 Smith, W. Johnson, Surgeon to the Seamen's Hospital,
Greenwich.
1874 *Smith, William Robert, M.D., D.Sc, F.R.S.Ed., Pro-
fessor of Forensic Medicine at King's College, London ;
74, Great Russell Street, Bloomsbury. Trans. 1.
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 Spackman, Frederick Robert, M.D., Consulting Physician
to St. Alban's Hospital, Harpenden, St. Alban's.
1889 Spencer, Herbert R., M.D., B.S., 10, Mansfield street,
Portland place.
887 Spencer, Walter George, M.B., Assistant Surgeon to the
Westminster Hospital ; 94, Wimpole street, Cavendish
square.
1888 Spicer, Robert Henry Scanes, M.D., Physician to the
Department for Diseases of the Throat, St. Mary's
Hospital ; 28, Welbeck street, Cavendish square.
1890 Spicer, "William Thomas Holmes, M.B., 6a, Bedford
square.
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 Edward, M.D., Physician to the North
London Hospital for Consumption ; 53, Hariey street.
Cavendish square. Trans. 1.
FELLOWS OF THE SOCIETY. 1X111
Elected
1882 Steavenson, William Edwakd, M.D., Electrician to St.
Bartholomew's Hospital ; Physician to the Alexandra
Hospital for Children; 15, Mansfield street, Portland
place.
1854 Stevens, Henry, ¥.D., Inspector, Medical Department,
Local Government Board, Whitehall ; Mitcham House,
Mitcham, Surrej'.
1884 Stewart, Edward, M.D., 8, Upper Wimpole street, Caven-
dish square.
1859 Stewart, William Edward, 16, Harley street. Cavendish
square.
1879 *Stirling, Edward Charles, Adelaide, South Australia
[care of Messrs. Elder and Co., 7, St. Helen's place].
1856 fSTOCKER, Alonzo Henry, M.D., Peckham House,
Peckham.
1865 Stokes, Sir William, M.D., M.C., Surgeon to the
Meath Hospital ; 5, Merrion square north, Dublin.
Trans. 1.
1884 Stonham, Charles, Assistant Surgeon to the Westminster
Hospital, and Curator of Anatomical Museum, Univer-
sity College, London ; 62, Welbeck street. Cavendish
square.
1843 Storks, Robert Reeve,
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, V.P. 1889. Referee,
1882-8.
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 ; 9, Finsbury
square. Referee, 1888, Trans. 1.
Ixiv FELLOWS OF THE SOCIETY.
Elected
1883 Sutton, John Bland, Assistant Surgeon, Lecturer on Com-
parative Anatomy, and Senior Demonstrator of Anatomy
to the Middlesex Hospital ; 48, Queen Anne street,
Cavendish square. Trans. 5.
1890 Syees, Henry Walter, M.D., 3, Devonshire street, Port-
land place.
1886 Symonds, Charters James, M.S., Assistant Surgeon to
Guy's Hospital; 26, Weymouth street, Portland place.
1890 Sympson, E. Mansel, M.A., M.B., B.C., 5, James street,
Lincoln.
1878 *Sympson, Thomas, Surgeon to the Lincoln County Hos-
pital ; 3, James street, Lincoln.
18/0 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, Waeen, 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, Blackfriars ; 4, Finsbury square.
1873 Taylor, Frederick, 'M.D., Secretary ; Physician to, and
Lecturer on Medicine at, Guy's Hospital ; Physician
to the Evelina Hospital for Sick Children ; 20, Wim-
pole street, Cavendish square. S. 1889-90. Sci. Com.
1889. Referee, 1887-8. Trans. 1.
1890 Taylor, Seymour, M.D., 16, Seymour street, Portman
square.
1845 fTATLOR, Thomas, Warwick House, 1, Warwick place, Grove
End road, St. John's Wood.
1886 Teale, Thomas Pridgin, M.B., F.R.S., Consulting Surgeon
to the Leeds General Infirmary ; 38, Cookridge street,
Leeds.
1859 Tegart, Edward, 49, Jermyn street, St. James's. C. 1888-9.
1874 Thin, George, M.D., 22, Queen Anne street, Cavendish
square. Trans. 9;
FELLOWS OF THE SOCIETY. IxV
Elected
1862 Thompson, Edmund Stmes, M.D., Senior Physician to the
Hospital for Consumption, Brompton ; Gresham Pro-
fessor of Medicine ; 33, Cavendish square. 8.1871-4.
C. 1878-9. Sei. Com. 1889. Referee, 18/6-7. Trans. 1.
1852 f Thompson, Sir Henry, Vice-President, Surgeon-Extra-
ordinary to H.M. the King of the Belgians; Emeritus
Professor of Clinical Surgery in University College,
London ; and Consulting Surgeon to University College
Hospital ; Member of the " Societe de Chirurgie,"
Paris ; 35, Wimpole street, Cavendish square. C. 1869.
Trans. 8.
1862 Thompson, Reginald Edward, M.D., Physician to the
Hospital for Consumption, Brompton; 47, Park street,
Grosvenor square. C. 1S79. S. 1880-82. V.P. 1883-4.
Referee, \S:2,-S. Sci. Co?n. 1867. Trans. 2.
1881 Thomson, W^illiam Sinclair, M.D., late Senior Consulting
Surgeon to Peterbro' Hospital, and Medical Officer of
Health for Peterbro' ; 1, Palace court, Notting Hill
gate.
1876 Thornton, John Knowsley, M.B., CM., Consulting Sur-
geon to the Samaritan Free Hospital for Women and
Children; 22, Portman street, Portman square. Lib.
Com. 1886-8. Trans. 5.
1853 Thursfield, Thomas William, M.D., Physician to the
Warneford and South AV^arwickshire General Hospital ;
Selwood, Beauchamp square, 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.
1889 Tirard, Nestor Isidore Charles, M.U., 28, Weymouth
street, Portland place.
1S80 TivY, William James, 8, Lansdowne place, Clifton, Bristol.
1872 Tomes, Charles Sissmore, M.A., F.R.S., 37, Cavendish
square. C. 1887. Lib. Com. 1879.
1867 ToNGE, Morris, M.D., Harrow-on-the-Hill, Middlesex.
VOL. lxxiii. e
Ixvi FELLOWS OF THE SOCIETY.
Elected
1882 Tooth, Howard Henry, M.D., Assistant Medical Tutor
St. Bartholomew's Hospital ; 34, Hp.rley street, Caven-
dish square.
1871 *Trend, Theophilus W., M.D,, 1, Grosvenor square,
Southampton.
1879 Treves, Frederick, Surgeon to, and Lecturer on Anatomy
at, the London Hospital ; 6, Wirapole street, Cavendish
square. Sci. Com. 1889. Trans. 5.
1881 *Treves, William Knight, Surgeon to the National Mos-
pital for Scrofula; 31, Dalhy square, Cliftouville, Mar-
gate.
1867 Trotter, John William, late Surgeon-Major, Coldstream
Guards ; 4, St. Peter's terrace, York.
1859 Truman, Edavin Thomas, Surgeon-Dentist in Ordinary to
Her Majesty's Household ; 23, Old Burlington street.
18S9 TuRNBULL, George Lindsay, M.B., 121, Ladbroke grove.
187.5 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., Vernon House, Ryde, Isle
of Wight.
1882 Turner, George Robertson, Visiting Surgeon to the
Seamen's Hospital, Greenwich ; Assistant Surgeon
to, and Joint Lecturer on Practical Surgery at, St.
George's Hospital ; 49, Green street, Park lane.
1888 Tylden, Henry John, M.B., 38, Harewood square.
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 for the Diseases
of Women, West London Hospital ; 1 22, Harley street,
Cavendish square.
1870 Venning, Edgcombe, 30, Cadogan place.
FELLOWS OF THE SOCIETY. Ixvii
Elected
1SG5 Vern'ON, Bowater John, Ophthalmic Surgeon to St. Bar-
tholomew's Hospital and to the West London Hospital ;
14, Ciarges street, Piccadilly.
1867 ViNTRAS, AcHiLLE, M.D., Physician to the French Emhassy,
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.
18.54 AA'addington, Edward, Hamilton, Auckland, New Zealand.
1886 Wainewright, Benjamin, M.B., CM., 67, Grosvenor
street, Grosvenor square.
1864 Waite, Charles Derby, M.B., Consulting Physician to the
Westminster General Dispensary ; 3, Old Burlington
street.
1884 Waklet, Thomas, jun., 5, Queen's Gate, South Kensington.
1868 *Walker, Robert, Honorary Surgeon to the Carlisle Dis-
pensary; 2, Portland square, Carlisle.
1887 Wallace, Edward James, M.D., Holmbush, Grove road,
Southsea.
lSb3 Waller, Augustus, M.D., Lecturer on Physiology, St.
Mary's Hospital; Weston Lodge, 16, Grove End road.
1888 Wallis, Frederick Charles, M.B., B.C., 18, St. James's
street.
1867 Wallis, George, Surgeon to Addenbrooke's Hospital,
Corpus Buildings, Cambridge.
1873 Walsham, William Johnson, CM., Assistant Surgeon to,
and Demonstrator of Practical and Orthopsedic Surgery
at, St. Bartholomew's Hospital ; Surgeon to the
Metropolitan Free Hospital ; 27, Weymouth street,
Portland place. C. 1888-9. Lib. Com.\S^2.^. Trans, b.
18.")2 fWALSHE, Walter Hatle, M.D., LL.D.Edin., 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. I.
Ixviii FELLOWS OF THE SOCIETY.
Elected
1883 *\Yaltetis, James Hopkins, Surgeon to the Royal Berk-
shire Hospital; 15, Friar street, Reading.
1 886 Ward, Allan Ogier, M.D., 1, Brook place. Lower Totten-
ham.
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, \^d>\-b.
1877 Warner, Francis, M.D., Assistant Physician and Lecturer
on Botany to the London Hospital ; 5, Prince of
Wales Terrace, Kensington Palace. Trans. 1.
1889 Washbourn, John Wychenford, M.D, Assistant Physician
to Guy's Hospital; 14, St. Thomas's street.
1861 Waters, A. T. Houghton, M.D., Physician to the Royal
Lifirmary ; 69, Bedford street, Liverpool. Trans. 3.
1861 f Watson, 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, Armand, M.A., M.D., B.Sc, Physician in
Charge of the Electro-therapeutical Department at
St. Mary's Hospital ; 30, Welbeck street. Cavendish
square.
1840 Webb, William Woodham, M.D., Neuilly-sur-Seine,
France.
1857 Weber, Hermann, M.D., Physician to the German Hos-
pital ; 10, Grosvenor street, Grosvenor square. C.
1874-5. Y.P. 1885-6. Sci. Com. 1880. Beferee,
1869-73, 1878-84. Lib. Com. 1864-73. Trans. 6.
1844 fWEGG, William, M.D., 15, Hertford street, Mayfair.
L. 1854-8. C. 1861-2. T. 1873-80. Lib. Com.
1851-3.
FELLOWS OF THE SOCIETY. Ixix
Elected
1878 Weiss, Hubert Foveaux, Assistant Surgeon to the West
London Hospital ; 11, Hanover square.
1874 "Wells, Harry, M.D., San Ysidro, Buenos Ayres, S.
America,
18.54 f Wells, Sir Thomas Spencer, Bart., Surgeon-in-Ordinary
to H.M.'s Household ; Consulting Surgeon to the
Samaritan Free Hospital for Women and Children ;
Corresponding Member, " Academie de Medecine,"
Paris; 3, Upper Grosvenor street. C. 1870. V.P.
1881. Trans. 14. Pro. 1.
1842 -fWEST, Charles, M.D., Foreign Associate of the Academy
of Medicine of Paris; 55, Harley street, Cavendish
square. C. 1855-6. V.P. 18G3. 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., Assistant Physician to St. Bartholo-
mew's Hospital ; Senior Physician to the Royal Free
Hospital; 15, Wimpole street, Cavendish square^
Trans. 4.
1888 Wetheked, Frank Joseph, M.B., 34, Queen Anne street,
Cavendish square.
1882 Wharry, Charles John, M.D.
1881 "Wharry, Robert, M.D., Physician to the Westminster
Dispensary ; 6, Gordon square.
1878 Wharton, Henry Thornton, ^I.A., Honorary Surgeon to
the Kilburn Dispensary ; " Madresfield," Acol road,
Priory road, West Hampstead.
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.
IXX FELLOWS OF THE SOCIETY.
Elected
1881 White, William Hale, M.D., Senior Assistant Physician
to, and Lecturer on Materia Medica at, Guy's Hospital ;
65, Harley street, Cavendish square. Referee, 1888.
Trans. 2.
IftQO White-Cooper, G. 0., M.B,, 5, Cranley gardens, Brompton.
1881 *Whitehead, Walter, F.R.S. Ed., Senior Surgeon to the
Manchester Koyal Infirmary, and to the Manchester
and Salford Lock and Skin Hospital ; 499, Oxford
road, 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 Whitmoee, William Tickle, Surgeon to the Westminster
Gen'eral Dispensary ; 7, Arlington street, Piccadilly.
1852 WiBLiN, John, M.D., Medical Lispector of Emigrants and
Recruits; Southampton. Trans. \.
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.
1 863 WiLKS, S \muel, 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 Physiciaii 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 *WiLLANS, William Blundell, Great Hadham, Herts.
1890 WiLLCOCKS, Frederick, M.D., 14, Mandeville street,
Manchester square.
1865 fWiLLETT, Alfeed, Surgeon to St. Bartholomew's Hospital ;
Surgeon to St. Luke's Hospital ; 36, Wimpole street,
Cavendish square. C. 1880-81. V.P. 1890. Referee,
1882-8. Trans. 2.
FELLOWS OF THE SOCIETY. Ixxi
Elected
1887 WiLLETT, Edgar William, M.B., 60, Welbeck street,
Cavendish square.
1SG4 WiLLETT, Ed-MUXd Sparshall, M.D., Resident Physician,
Wyke House, Isleworth, Middlesex.
1888 Williams, Campbell, 62, Welbeck street, Cavendish square.
18.59 *WiLLTAMs, Chakles, Surgeon to the Norfolk and Norwich
Hospital ; 48, 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 ; 2, Upper Brook street, Grosvenor
square. C. 1884-5. Referee, 1888. Lib. Com. 1880-3.
Trans. 5.
l!581 Williams, Dawson, M.D., Assistant Physician to the East
London Hospital for Children ; 25, Old Burlington
street.
1872 Williams, John, M.D., Physician Accoucheur to H.R.H.
thePrincess Beatrice; Professor of Midwifery, University
College, London ; Obstetric Physician to University
College Hospital ; 63, Brook street, Grosvenor square.
Referee, 1878-88. Lib. Com. 1876-82.
1868 Williams, William Rhys, M.D., Linden House, Bertie
road, Leamington.
1890 Wills, William Alfred, M.B., 52, Davies street, Berkeley
square.
1887 Wilson, Arthur Hervey, M.D., 504, Broadway, Boston,
U.S.A.
1889 Wilson, John Henry Parker, H.M.'s Military Prison,
The Avenue, Brixton Hill.
1863 Wilson, Robert James, 7, Warrior square, St. Leonard's-
on-Sea, Sussex.
1889 Wise, A. Tucker, M.D., Kursaal de la Maloja.
1850 *WiSE, Robert Stanton, M.D., Consulting Physician to
the Southam Eye and Ear Infirmary ; Beech Lawn-
Baubury.
1879 WoAKES, Edward, M.D., Senior Aural Surgeon to the
Loudon Hospital ; 78, Harley street, Cavendish square.
Ixxii FELLOWS OF THE SOCIETY.
Elected
1885 WoLFENDEN', RicnARD NoRRis, M.D., Assistant Physician
to the North- West London Hospital; 19, Upper
Wimpole street.
1851 f\A'ooD, JoHK.F.R.S., 61, Wimpole street, Cavendish square.
C. 1867-8. V.P. 1877-8. Referee, 1871-6, 1880-88.
Lib. Com. 1866. Trans. 3.
1887 Wood, Thomas Outterson, M.D., 40, Margaret street,
Cavendish square.
1848 fWooD, 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., The
Priory, Roehampton.
1879 Woodward, G. P. M., M.D., Deputy Surgeon-General;
Sydney, New South Wales.
[It is particularly requested that any change of Title, Appointment, or
Kesideuce, may be communicated to the Hon. Secretaries before the 1st
of September in each year, in order that the List may be made as correct
as possible.]
LIST OF EESIDENT FELLOWS
ABEANGED ACCOEDING TO
DATE OF ELECTION.
1S33 Thomas A. Barker, M.D.
1838 Charles Hawkins.
Henry Spencer Smith.
1839 T. Graham Balfour, M.D., F.R.S.
Fred. Le Gros Clark, l.K.S.
James Dixon.
1840 Samuel A. Lane.
Sir James Paget, Bt., F.R.S.
ISil Sir Henry A. Pitman, M.D.
Sir William Bowman, Bart., F.R.S.
Paul Jackson.
1842 Charles West, M.D.
Sir John Simon, K.C.B., F.R.S.
John Erichsen F.R.S.
Sir Oscar M. P. Clayton, C.M.G.
1843 Sir Prescott G. Hewett, Bt., F.R.S.
Henry Lee.
Luther Holderi.
Edward NewiOQ.
1844 William Weg^, M.D.
1845 Samuel Cartwright.
George D. Pollock.
Thomas Taylor.
Sir Edwin Saunders.
Edward U. Berry.
1846 John A. Bostock.
Barnard Wight Holt.
Carsten Holt house.
1847 George Johnson, M.D., F.R.S.
1848 Sir Edward H Sieveking, M.D.
Edward Ballard, M.D., F.R.S.
William Wood, M.D.
Thomas Hawksley, M.D.
Edward John Tilt, M.D.
1848
1849
1850
1851
1852
1853
1854
1855
1856
1857
John Clarke, M.D.
Hu?h J. Sanderson, M.D.
C. H. F. Kouth, M.D.
Edmund L. Birkett, M.D.
Richard Quain, M.D., F.R.S
Sir Wm Jenner, Bt., M.D., F.R.S.
John Birkett.
John A. Kingdon.
Peter Y. Gowlland.
John Marshall, F.]{.S.
John Wood, F.R.S.
Bernard E. Brodhurst.
Robert J. Spitta, M.D.
Walter H. Walshe, M.D.
William Adams.
Sir Henry Thompson.
Robert Brudenell Carter.
Sir Alfred Baring Garrod, M.D.,
F.RS.
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.
William Marcet, M.D., F.R.S.
Charles J. Hare, M.D.
William Bird.
Jonathan Hutchinson, F.R.S.
Timothy Holmes.
Alonzo H. Stocker, M.D.
William ' )verend Priestley, M.D.
George Harley, M.D., F.R.S.
Hermann Weber, M.D.
John Whitaker Hulke, F.R.S.
John Morgan.
Ixxiv
CHRONOLOGICAL LIST OF RESIDENT FELLOWS,
1857 Henry Cooper Rose, M.D.
Heury Walter Kiallmark.
1858 Fred. George Reed, M.D.
John William O^le, M.D.
1859 Wm. Howship Dickinson, M.D.
Sir William Scovell Savory, Bart.,
F.R.S.
Edwin Thomas Truman.
Richard Barwell.
Edward Teg-art.
Septimus William Sibley.
William E. Stewart.
1860 Sir Andrew Clark, Bt.,M.D.,r.R.S.
William Ogle, M.D.
Thomas Bryant.
John Couper.
Henry Howard Hayward.
1861 Robert Barnes, M.D.
William S|)eucer Watson.
1862 James Andrew, M.D.
Lionel Smith Beale, M.B., F.R.S.
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 Slurges, M.D.
John Langdon H. Down, M.D.
Samuel Wilks, M.D., F.R.S,
Samuel Fenwick, 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.
Thomas William Nunn.
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 Morraut Baker.
John Langton.
Frederick James Gant.
Alfred Willett.
Bo water John Vernon.
Alfred Cooper.
1865 Christopher Heath.
1866 Thomas Fitz-Patrick, M.D.
Samuel Jones Gee, M.D.
Charles Theodore Williams, M.D.
Pleywood Smith, M.D.
William Selby Church, M.D.
Edward John Waring, M.D.
Thomas Clifford AUbutt, M.D.,
F.R.S.
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.
Cluirles Arthur Aikin.
1868 H. Charlton Bastian, M.D., F.R.S.
William Henry Broadbent, M.D.
Thomas Buzzard, M.D.
John Cavafv, M.D.
Walter Butler Cheadle, M.D.
John Cockle, M.D.
Sir Thos. Crawford, K.C.B., M.D.
T. Henry Green, 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.
Thomas Laurence Read.
1870 J. Warrington Haward.
Edgcombe Venning.
Clement Godson, M.D.
Reginald Harrison.
1871 William Cayley, M.D.
Charles Henry Ralfe, 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 Riviugton.
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.
CIIKONOLOGICAL LIST Ol' RESIDENT FELLOWS.
Ixxv
1872 Charles S. Tomes, B.A., F.R.S.
Sir William Bartletl Dalby.
1873 William Miller Ord, M.U.
Frederick Taylor, M.D.
Gorman Moore, M.D.
Jolin Cuniow, M.D.
William R. Gowers, M.D., F.R.S.
Sir Wm. Guyer Hunter, M.D., M.P.
Jeremiaii McCarthy.
Wm. Johnson Smith.
Robert William Parker.
Alex. O. McKellar.
Henry T. Butlin.
Charles Hig^ens.
William J. Walsham.
Edward Milner.
lS7i Alfred Lewis Galabin, M.D.
George Thin, M.D.
Alfred B. Duffin, M.D.
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 Seniple, M.D.
Thomas Crawford Hayes, M.D.
Charles Henry Carter, M.D
Fletcher Beach, M.B
Waren Tay.
Edmund J. Spitta.
1876 Thomas Barlow, M.D.
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.
Rickmau J. Godlee.
Alban H. G. Doran.
George Ernest Herman, M.B.*
Samuel West, M.D.
John Abercrombie, M.D.
George Allan Heron, M.D
1877 Joseph A. Ormerod, M.D.
P. Henry Pye-Smith, J\1.D., F.R.S.
Edward Nettleship.
William Henry Bennett.
William T. Whitmore.
1878 Sir Jas. Crichton Browne, M.D.
Fred. T. Roberts, M.D.
Sir Joseph Lister, Bart., F.R.S.
Clinton T. Dent.
John H. Morgan.
Walter Pye.
Donald W. Charles Hood, M.B.
Henry Gervis, M.D.
Richard Davy.
Hubert Foveaux Weiss.
Henry Thornton Wharton.
1 879 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 Joiin Maclagan, M.D.
David White Finlay, M.D.
Andrew Clark.
Francis Henry Champneys, M.B.
William Watson Cheyne.
William Munk, M.D.
George Henry Savage, M.D.
H. H. Chilton, M.A.
Frederic S. Eve.
E. Noble Smith.
William Henry AUchin, 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 MacWhirterDunbar,M.B.
James William Browne, M.B.
William Appleton Meredith, M.B.
Alexander Hughes Bennett, M.D.
Malcolm Macdonuld McHardy.
Alexander Wm. Macfarlane, M.D.
A. Boyce Barrow.
William Murrell, M.D.
Leslie Ogilvie, M.B.
George Ogilvie, M.B.
diaries Edward Beevor, M.D.
Thomas Colcott Fox, M.B.
George Henry Makins.
1
1:
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
1881 Francis de Havilland Hall, M.D.
Robert Wharry, M.D.
Cecil Yates Biss, M.D.
Ricliard Clement Lucas.
Stephen Mackenzie, M.D.
James Andersoii, M.D.
William Hale White, M.D.
Eustace Smith, M.D.
William Sinclair Thomson, M.D.
Percy Kidd, M.D.
Oswald A. Browne, M.A.
W. Bruce Clarke, M.B.
Dawsou Williams, M.D.
Georce 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, J\I.D.
John Barclay Scriven.
George Robertson Turner.
Howard Henry Tooth, M.D.
Herbert Isambard Owen, M.D.
Charles R. B. Keetley.
Joseph Mills.
A. T. Mvers, M.D.
Anthony A. Bowlby.
Amand'^J. McC. Routh, M.D,
Seymour J. Sharkey, M.D.
William hhng.
Henry Radcliffe Crocker, M.D.
William Edward Steavenson, M.D.
1883 Edwin Clifford Beale, M.A., M.B.
James Kingston Fowler, M.D.
James Frederic Goodhart, M.D.
John Charles Gallon, M.A.
Walter Hamilton Aclaud Jacobson.
Edward Joshua Edwardes, M.D.
Walter H. Jessop, j\I.B.
Walter Edmunds, M.C.
Victor A. Horslev, 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.D.
Augustus Waller, M.D.
William Pasteur, M.D.
Edward Albert Schafer, F.R.S.
John Bland Sutton.
William Rose, M.B.
Storer Bennett.
1SS3 Robert Marcus Gunn, M.B.
James Dixon Bradshaw, M.B.
George Knapton.
1884 George Newton Pitt, M.D.
Charles Stonham.
Stanley Boyd, M.B.
William Arbuthnot Lane, M.S.
Dennis Dallaway.
Thomas Whitehead Reid.
Arthur Marmaduke Sheild, M.B.
Frederic Bowreman Jessett.
Sidney Harris Cox Martin, M.B.
Wayland Cliarles Chaffey, M.B.
George Lawson.
Thomas Wakley, Jun.
Robert James Lee, M.D.
F. Swinford Edwards.
James Johnston, M.D.
Edward Stewart, M.D.
William Duncan, M.D.
Charles Chinner Fuller.
Lovell Drage, M.B., M.S.
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 A eland, M.D.
Kenneth William Millican.
Frederick Walker Mott, M.D.
William Maunsell Collins, M.D.
James Berry.
John Cahill.
Francis Henry Hawkins, M.B.
John Poland.
James Greig Smith.
George Gulliver, M.B.
Heinrich Port, M.D.
Edward Emanuel Klein, M.D.,
F.R.S.
R. Norris Wolfenden, M.D.
A. C. Butler-Smythe.
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, M.D.
Henry Willingham Gell, M.B.
1886 Robert Maguire, M.D.
Harrington Sainsbury, M.D.
Cuthbert Hilton Golding-Bird, M.S.
Benjamin Wainewright, M.B.,C.M.
CHRONOLOGICAL LIST or RESIDENT FELLOWS.
Ixxvii
1886 Charles Elliott Leopold Barton
Hudson.
Lauriston Elgie Shaw, M.D.
Charters James Symonds, M.S.
Robert Boxall, M.D.
Allau Ogier Ward, M.D.
Archibald Edward Garrod, M.D.
Steplieii Pallet.
William Radford Dakin, M.D.
Samuel Herbert Habershou, M.D.
Arthur Quarry Sdcock.
Arthur Hamilton Nicholson
Lewers, M.D.
1887 Walter Ueorge Spencer.
Thomas Outterson Wood, M.D.
Richard Hingston Fox, M.D.
Edgar William Willett, M.B.
Henry Lewis Jones, M.D.
Francis George Penrose, M.D.
Hugh Percy Dunn,
Charles Edward Paget.
F'rederic William Hewitt, M.D.
Harrv Scott, M.D.
James Barry Ball, M.D.
Gilbert Richardson, M.D.
Edward James Wallace, ALD.
D'Arcy Power, M.B.
John Gay.
Edward John Sidebotham, M.B.
James Calvert, M.D.
Percy J. F. Lush, M.B.
1883 Robert Henry Scanes Spicer, M.D.
Jonathan Eutchinsou, Jun.
Campbell Wdliams.
Walter Baugh Hadden, M.D.
James Donelan, M.B., C.M.
John Anderson, M.D., CLE.
Laurie Asher Lawrence.
Arthur Pearson Luff, M.B., B.Sc.
Albert Carless, M.B., B.S.
Henrv John Tylden, M.B.
Frede'rick Charles Wallis, M.B.,
B.C.
Charles James Cullingworth, M.D.
Edmund Cautley, M.B., B.C.
H. Montague Murray, M.D.
Arthur Symons Eccles, M.B.
Frank Joseph Wethered, M.B.
Edmund Wilkinson Rougliton, M.D.
Edward Dillon Mapother, M.D.
Frederick William Cook, M.D.
John Phillips, M.B.
Robert Henry Clarke, M.B.
1888 George Lindsay Turnbull, M.B.
iSS'J Montagu Handtield-Jones, M.D.
Norman MacMillan MacLehose,
M.B.
David Henry Goodsall.
Raymond Johnson, M.B.
Hugh Leslie Roberts, i\I.R.
Joiin Fletcher Little, M.B.
Henry Work Dodd.
W. H. Rivers Rivers, M.D.
Sir William Roberts, M.D., F.R.S.
Sidney Phillips, M.D.
Ernest le Cronier Lancaster, M.B.
William Charles Bull, M.B.
George P. Field.
Francis Horatio Napier.
John Wychenford Washbourn, M.D.
John Henry Parker Wilson.
Francis William Humphery, M.A.,
M.B.
Arthur J. M. Bentley, M.D.
Ciiarles Henry Cosens.
Henry Percy Dean, M.B., B.S.
Sheridan Delepiue, B.S., M.B.,
C.M.
Alfred Samuel Gubb.
William Hunter, M.D.
J. Inglis Parsons, M.D.
Bernard Pitts, M.B., M.C.
Daniel McClure Ross.
Robert Percy Smith, M.D., B.S.
Herbert R. Spencer, M.D., B.S.
Nestor Isidore Charles Tirard,
M.D.
1890 John Rose Bradford, j\r.B.
Roland Danvers Brinton, M.D.
James Cagney, M.D.
Charles Douglas Bowdich Hale,
M.D.
Edwin Cooper Perry, M.D.
Morton Smale.
Frederick Willcocks, M.D.
R. Ashton Bostock.
Henry Cripps Lawrence.
V\ illiam Thomes Holmes Spicer,
M.B.
David Anderson Berry.
Thomas Henry Crowle.
William Bramwell Ransom, M.D.
Henry Walter Syers, M.D.
Seymour Taylor, M.D.
William Alfred Wills, M.B.
G. O. White-Cooper, M.B.
CONTENT S.
List of Officers and Council . . . . iii
Referees of Papers . . . . . iv
Trustees of the Society . . . . . t
Trustees of the Marshall Hall Memorial Fund . . v
Library Committee . . . . . v
Scientific Comuiittee on Medical Climatology and Balneology . v
List of Presidents of the Society from its formation . . vi
List of Honorary Fellows .... vii
List of Foreign Honorary Fellows . . . ix
List of Fellows . . . . . xi
List of Resident Fellows, arranged according to Date of Election Ixxiii
List of Plates ..... Ixxxii
Woodcuts ..... Ixxxiii
Regulations relative to * Proceedings ' . . Ixxxv
Advertisement ..... Ixxxvi
Address on the occasion of the First Meeting in the New
House on Tuesday, October 22, 1889. By Sir Edward
H. SiEVEKiNG, M.D., LL.D., F.R.C.P., President . Ixxxvii
Proceedings at the Annual Meeting, March 1st, 1889, with
Report of the Council for 1888-9 . . , xcix
Address of Sir Edward H. Sieveking, M.D., LL.D., F.R.C.P.,
President, at the Annual Meeting, March 1st, 1890 . 1
PAPERS.
I. An Analytical and Clinical Examination of Lead-
Poisoning in its Acute Manifestations. By Thomas
Oliver, M.A., M.D., F.R.C.P., Professor of Phy-
siology, University of Durham, and Physician to
the Royal Infirmary, Newcastle-upon-Tyne 33
II. ACaseof Tubal Pregnancy, with remarks on the cause
of Early Rupture. By J. Bland Sutton, F.R.C.S.,
Assistant Sui-geon to the Middlesex Hospital . 55
III. A Case of Cholecystenterostomy. By A. W. Mayo
RoBSON, F.R.C.S., Hon. Surgeon Leeds General
Infirmary ; Lecturer on Practical Surgery at the
Yorkshire College ; and Examiner in the Victoria
University . . . . .61
IXXX CONTENTS.
PAGE
IV. On Blood Tumours (Angeiomata and Angeiosarco-
mata) of Bone. By Edmund Roughton, B.S.Lond.,
F.R.C.S. . . . . .69
V. Successful Removal of the entire Upper Extremity
for Osteo-Chondroma. By Thomas F, Chavasse,
M.D., C.M.Edin., Surgeon to the General Hospital,
Birmingham . . . . .81
YI. The Mechanism of Suspension in the Treatment of
Locomotor Ataxy. By James Cagne y, M. A., M.D.,
Demonstrator of Anatomy at St. Mary's Hospital ;
Physician to the Out-Patient's Hospital for Epi-
lepsy, Regent's Paik . . . . 101
VII. A Case of Hernia of the C^cum, entirely wanting in
a Peritoneal Sac, in which Strangulation at the
Internal Abdominal Ring co-existed with an Intus-
susception through the Ileo-csecal Valve. By
William H. Bennett, F.R.C.S., Surgeon to St.
George's Hospital .... 129
VIII. Rheumatism, its Treatment Past and Present; with
special reference to recent Experimental Research
on Salicylic Acids and their Salts. By Matthew
Charteris, M.D., Professor of Therapeutics and
Materia Medica, University of Glasgow. (Commu-
nicated by Dr. Mitchell Bruce.) . . 141
IX, On the Symptomatology of Total Transverse Lesions
of the Spinal Cord ; with special reference to the
condition of the various Reflexes. By H. Charlton
Bastian, M.A., M.D., F.R.S., Professor of Medi-
cine in University College, London; Physician to
University College Hospital, and to the National
Hospital for the Paralysed and Epileptic . . 151
X. Analysis of 964 Cases of Operation for Calculus in the
Bladder by Lithotomy and Lithotrity, with Re-
marks. By Sir Henry Thompson, F.R.C.S.,
M.B.Lond., Surgeon-Extraordinary to H.M. the
King of the Belgians ; Consulting Surgeon to
University College Hospital ; and Member of the
Societe de la Chirurgie of Paris, &c. &c. . . 219
CONTENTS. Ixxxi
PAGE
XI. On tbe History of Uric Acid in the Urine, with
reference to the Formation of Uric Acid Concre-
tions and Deposits. By Sir William Roberts,
M.D., r.R.S. . . . . .245
XII. A Study of Fifty consecutive Cases of Operation for
the Radical Cure of Non-strangulated Hernia?.
By Arthur E. Barker, F.R.C.S., Surgeon to
University College Hospital . . . 273
XIII. Salicin compared with Salicylate of Soda as to effect
on the Excretion of Uric Acid, and value in the
Ti'eatment of Acute Rheumatism ; with some de-
ductions as to the Causation of the Disease. By
A. Haig, M.A., M.D.Oxon. . . .297
XIY. On the Condition of the Reflexes in Cases of Injury
to the Spinal Cord ; with special reference to
the Indications for Operative Interference. By
Anthony A, Bowlby, F.R.C.S.Eng., Surgical
Registrai" and Demonstrator of Pi'actical and Ope-
rative Surgei-y, and of Surgical Pathology at St.
Bartholomew's Hospital; Assistant Surgeon to the
Metropolitan Hospital ; Surgeon to the Alexandra
Hospital for Hip Disease . . .31
XV. Senile Hypertrophy and Senile Atrophy of the Skull.
By George Murray Humphry, M.D., F.R.S.,
Professor Surgery in the University of Cambridge . 327
XVI. A Contribution of the Chemistry of Gout. By Sir
William Roberts, M.D., F.R.S. . . 339
XYII. On Four Hundred Cases of Amputation performed at
St. George's Hospital, from October, 1874, to June,
1888; with especial reference to the diminished
Rate of Mortality. By C, T. Dent, F.R.CS.,
Assistant Surgeon to the Hospital ; and W. C.
Bull, M.B., F.R.C.S., late Surgical Registrar to
the Hospital . . . . .359
Index . . • . . .371
vol. lxxiii, /
LIST OF PLATES.
PAGE
I. On Blood Tumours (Angeiomata and Angeiosarcomata)
of Bone. (Edmund Rotjghton, B.S.Lond., E.R.O.S.).
Fig. 1. Blood-cyst of tibia (from the Museum of St.
Bartholomew's Hospital). Fig. 2. Blood-cyst of
lower end of femur, a. Thin layer of sarcomatous
tissue, b. Cavity filled with blood. (After Max
Oberst). Fig. 3. Blood-cyst of head of tibia (the case
of L. C — ). Section of cyst-wall, showing blood-
corpuscles exuding from thin-walled blood-vessels
into smTOunding tissues . . . .80
II. Successful Removal of the Entire Upper Extremity for
Osteo-chondroma. (Thomas F. Chavasse, M.D.,
C.M.Edin.). Fig. 1. Half-length portrait of subject,
showing tumour growing from right humerus. Fig. 2.
Half-length portrait, showing subject after recovery , 100
III. Calvarial Part of Skull of an Alcoholic Man, get. 50, who
died of apoplexy, showing congestion of the inner
table, which, at parts, was very marked. At all these
pai'ts the interior of the skull was thickened by bony
deposit causing elevations of the inner lobe . . 337
IV. Fig. 1. Section of the same. Fig. 2. Skull, showing
depressions on parietal bones between sagittal parts
and tubera parietalia, also one in middle line. Fig. 3.
Section of the same through the median and lateral
depressions. Fig. 4. Effects of extensive absorption
taking place somewhat irregularly on parietal bones.
The j)atient, a woman set. 90, died from fractures
through the thinned bones caused by a fall. The view
is from behind, and the fore part is much fore-
shortened ..... 338
Figures in the Text.
PAGE
Lead Poisoning Cases. (Thomas Oliver.)
Charts . . . . .47, 50, 52
Tubal Pregnancy. (J. Bland Sutton.)
Fig. 1. — The distended Fallopian tube showing the
situation of the rupture ; ovary with corpus luteum 58
Fig. 2. — Apoplectic ovum from the Fallopian tube . 58
Fig, 3.— Distorted head of the foetus. About seventh
or eighth week of gestation . . .58
The Mechanism of Suspension in the Treatment of Locomotor
Ataxy. (J. Cagney.)
Fig. 1. — To show the vertebral curves with the spinal
canals exj)osed .... 104
Fig. 2. — Dissected and dried spinarcolumn . . 115
Fig. 3. — The lower part of the thoracic curve, with
spinal column exposed . . . 117
Fig. 4. — Showing axis of rotation and point of applica-
tion of muscular force in the dorsal region . 123
On the Symptomatology of total Transverse Lesions of the
Spinal Cord. (H. Charlton Bastian.)
Fig. 1. — Section of spinal cord . , . 166
Figs. 2, 3, 4.— Ditto ... 175
Salicin compared with Salicylate of Soda' in the Treatment ot
Acute Rheumatism. (A. Haig.)
Fig. 1. — Chart of uric acid excretion by salicylate of
soda ..... 298
Fig. 2. — Chart showing that 45 grs. of the sodium salt
has six times the excretive power of 100 grs. of
salicin, or weight for weight thirteen times the
power ..... 299
Regulation's relative to the publication of the ' Proceediugs
of the Society/
The ' Proceedings ' are issued after eacli Meeting.
Tbey are sent, postage free, to every Fellow of the Society who, in
writing, expresses a wish to receive them.
They may be had by others at the Society's House, on payment (in
advance) of an annual subscription of five shillings and eight-
pence, which may be sent either by post-oflice order or in
postage-stamps ; — this will include the expense of conveyance
by post to any place within the Postal Union. For places
beyond tbe Postal Union special arrangements must be made.
A notice of every paper will appear in the ' Proceedings.' Authors
will be at liberty, on sending their communications, to intimate
to the Secretaries whether they wish them to appear in the
' Proceedings ' only, or in the ' Proceedings ' and ' Transactions ;*
and in all cases they must furnish an Abstract of the com-
munication.
The Abstracts of the papers read are sent to the Journals as here-
tofore.
i
I
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/
A D D E E S S
ON THE OCCASION OF THE
FIRST MEETING IN THE NEW HOUSE OF THE ROYAL MEDICAL
AND CHIRURGICAL SOCIETY, No. 20, HANOVER SQUARE,
ON TUESDAY, OCTOBER 22, 1889.
SIR EDWARD H. SIEVEKmG, M.D., LL.D., F.R.C.P.,
PEESIDENT.
Fellows of the Royal Medical and Chiruegical Society
Welcome to our New Home !
The new phase which our Society is this day entering
upon, not only appears to justify, but to call for a brief con-
sideration of the admirable work performed by our founders
and predecessors, as well as of the duties which we have
undertaken to medical science and to humanity. The
small beginings which ushered in the first formation of the
Society have been nurtured and fostered, until gi^eater ex-
pansion became imperative; and we have now entered upon
what, as far as we can see into the future, promises to
remain the home of the Royal Medical and Chirurgical
Society for many future generations. The wishes which are
now, thanks to the admirable management of the Building
Committee and the energy of the Fellows, on the eve of ful-
filment, have for some years been in the hearts and mouths
Ixxxviii ADDRESS TO THE FELLOWS AT THE
of all our supporters. We have long felt cramped in our
Berners Street residence, "where at last, all the ingenuity
that could be brought to bear, failed to make room for
the work that we were called upon to do, and to house
the ever-increasing library, our most precious heir-loom
and possession.
No history of our Society is at present available. The
following notices therefore, gathered together from authen-
tic records, may not be without interest; and though neces-
sarily meagre and disjointed, may prove useful to the future
writer possessed of the ability and leisure to exhibit the true
development of the Society, as displayed by. the scientific
growth that has characterised it, and by the fostei-ing
care with which it has watched over medicine and surgery.
On May 22nd, 1805, an inaugural meeting was held at
Freemasons' Tavern,^ Dr. Saunders, F.E.S., F.K.C.P., in
the chair, at which it was determined :
1. That a Society comprehending the several branches
of the Medical Profession be established in London, for
the purpose of conversation on professional subjects, for
the reception of communications, and for the formation of
a library.
2. That this Society be denominated the Medical and
Chirurgical Society of London.
3. That its meetings be held in some central situation.
4. That its affairs be conducted by a President, four
Yice-Presidents, a Treasurer, three Secretaries (one of
whom shall be Foreign Secretary) and a certain number of
members, who together shall constitute a Council and shall
be elected annually.
5. That no gentleman sliall be eligible to the office of
President or Vice-President for more than two years in
succession.
G. That a certain number of the Council go out annually.
7. That six guineas be the sum subscribed on admis-
1 This is still iu existence in Great Queen Street, Lincoln's Inn Fields,
thongh much altered. I am, however, informed by the manager that some
of the old rooms belonging to the original building are in existence.
FIRST MEETING IN THE NEW PREMISES. Ixxxix
sion, and that three guineas annually be subscribed for
the use of the Society.
8. That after the organisation of the Society all admis-
sion into it be by ballot, and that no person be declared
elected unless he have in his favour at least three fourths
of the numbers voting*.
These are the main points determined upon at this
preliminary meeting, and their wisdom cannot be better
demonstrated than by the fact that they continue to rnle
our conduct. Twenty-six gentlemen were at once inscribed
as regular members, and Dr. Yelloly was requested to act
as Secretary of the Committee nominated for the purpose
of preparing a plan of further operations. This Committee
consisted of eighteen of the original members.
The first meeting of the Society was held at No. 2,
Verulam Buildings, Gray's Inn, in December, 1805, but
it was not till 1809 that the first volume of our * Trans-
actions ' was published, a publication which, as we believe
it to redound to the honour of the Society, we hope has
been profitable as well as honourable to the ancient and
respected fi.rm of publishers,^ who from the commencement
have behaved to the Society with liberality.
Before going any further it may be interesting to you
to know the intellectual basis upon which our Society was
founded. The members of the first Council, which held
the reins of office from 1805 to 1807, were all men who
have contributed largely to the advancement of medical
science, and no futui-e history of our profession will be
complete without an admiring record of much of the work
performed by them. Many of their names are even yet
household words among us. The following may be re-
garded as the founders as they were the first rulers of
the Medical and Chirurgical Society' : — William Saun-
ders, M.D., F.R.S., President; John Abernethy, Esq.,
F.R.S., Vice-President ; Charles Rochemont Aikin, Esq.,
^ Messrs. Longman and Co.
• The sequence of the names is that given in the first volume of the
' Transactions.'
VOL. LXXIII. g
XC ADDRESS TO THE FELLOWS AT THE
Secretary ; William Babington, M.D., F.R.S., Vice-
President ; Mattliew Baillie, M.D., F.R.S. ; Thomas Bate-
man, M.D., F.R.S. ; Gilbert Blaine, M.D., F.R.S. ; Sir
William Blizzard, F.R.S., Vice-President ; Astley Cooper,
Esq., F.R.S., Treasurer; James Curry, M.D., F.R.S.;
Sir Walter Farquliar, M.D. ; John Heaviside, Esq.,
F.R.S. ; Alexander Marcet, M.D , F.R.S., Foreign Secre-
tary ; David Pitcairn, M.D., F.R.S. ; Henery Revell Rey-
nolds, M.D., F.R.S.; H. Leigh Thomas, Esq., F.R.S.;
James Wilson, Esq., F.R.S., and John Yelloly, M.D.,
Secretary.
The only material diiference that suggests itself be-
tween this list and the lists that you are familiar with, is
the elimination of the Foreign Secretary. The greater
intercourse which has existed between this country and
the Continent has doubtless increased the accomplish-
ments of our more recent secretaries to such an extent
that they have not for many years required the aid of a
special official to enable them to carry on a foreign corre-
spondence.
The first volume of the ' Transactions ' appeared in
1809, and had the distinction of being reprinted for a
third time in 1815. It opens with a paper by Astley
Cooper on a case of Aneurism of the Carotid Artery,
followed by one of Dr. Stauger on Violent and Obsti-
nate Cough ; on the Treatment of Whooping-Cough by
Dr. Pearson ; a paper by Dr. Bostock, of Liverpool, on
the Gelatine of the Blood ; one by Thompson Forster,
a case of Lithotomy ; and by Dr. Marcet on the Effects of
Large Doses of Laudanum and their Remedies. These
are dated 1806. The following belong to the years 1807
and 1808 : — An Account of a Peculiar Disease of the
Heart by David Dundas, Sergeant- Surgeon ; a case of
Exposure to the Vapour of Burning Charcoal by Dr.
Babington ; on Gouty Concretions by Mr. Moore ; a case
of Artificial Dilatation of the Female Urethra by Mr.
Thomas ; a case of Hydrophobia by Dr. Marcet ; three
cases of Sudden Death, with Post-mortem, by M. Cheva-
FIEST MEETING IN THE NEW PREMISES. xci
Her ; a case of Intussusception by Mr. Blizzard, and a
description of Two Muscles surrounding tlie Membranous
portion of the Uretlira by Mr. J. Wilson. This is
followed by a case of Tumour of the Brain by Dr.
Yelloly, and a second case of Carotid Aneurysm by Astley
Cooper ; then we come upon a case of a Foetus found in
the Abdomen of a Boy by Geo. Will. Young ; two cases
of Smallpox Infection communicated to the Foetus in
Utero under Peculiar Circumstances by Dr. Jenuer, and
an historical account, by Dr. White, of Philip Howorth,
a boy in whom signs of Puberty commenced at an Early
Age, which was communicated by Dr. Yelloly, conclude
this catalogue. A list of works given by Baillie,
Hunter, Astley Cooper, and others, and which formed
the nucleus of the magnificent library we now possess,
ends this first volume of the ' Medical and Chirurgical
Transactions.'
From this time forth the Society's ' Transactions ' have
appeared, with very few interruptions, annually up to the
present day, and have contributed in no small degree to
give an excellent stamp to its fellowship and to British
medicine at large. The Society steadily increased in
numbers and in influence, but it was evidently cramped
at first by the res angusta domi, for we find that in these
early days the Council resolved that Mr. Nichols (Clerk)
be allowed to occupy '' the library when it is not other-
wise wanted, and to procure a press-bedstead at the
Society's expense for his accommodation, to stand in the
further corner of the meeting room."
In the year 1810 No 3, Lincoln's Inn Fields became
the home of the Society, which it occupied in conjuction
with the Geological Society, from whose President, on the
security of three Fellows, the Medical and Chirurgical
Society borrowed £200. The two societies did not sepa-
rate till 1816. Nos. 30 and 57, Lincoln's Inn Fields^ were
' It appears that No. 57, Lincoln's Inn Fields was taken conjointly with
the Astronomical Society from Miclsunim(;r Day, 1821, on a 7, 14, or 21 years'
lease, terminable at the option of either party on giving six months' notice.
XCll ADDRESS TO THE FELLOWS AT THE
temporarily our liome until, in 1834, for a long series of
years the property of tlie Society was naoved to No. 53,
Berners Street. The first meeting assembled in this
locality on February 3rd, 1835, the last on June 11th,
1889.^ Although difficulties occasionally surrounded the
Society, especially in the early part of its existence,
nothing appears materially to have checked its work and
steady growth. For the first time, in 1812, we find the
Society associating with itself Foreign Honorary Members ;
their names are still mentioned with veneration : Blumen-
bach, Cuvier, Rush (of Pennsylvania), Sommering, Cor-
visart, Odie'r, Scarpa, and Vieussieux (of Geneva) } It
may be mentioned that the year 1834, during which the
removal from Lincoln's Inn was effected, and the cost of
which was defraj^ed by voluntary subscriptions' of the
Fellows, was marked by the absence of a volume of the
' Transactions,' owing to the confusion necessarily arising
from the migration. At this time the agitation for a
Royal Charter was successful, and since then we have
been incorporated as the Royal Medical and Chirurgical
Society of London,^ of which the Sovereign (in the first
instance, William the Fourth) is Patron, by which name
we shall '' have perpetual succession and a Common Seal,"
with such other rights and privileges as belong to any
other body, politic and corporate, in " our United King-
dom of Great Britain." It was not without a struggle
that this Charter had been obtained ; the Society had
made great efforts during the years 1812, 1818, and 1814
to achieve this object of their ambition. In the month
* The last meeting of Council was held at 53, Berners Street, in Mr.
MacAlister's rooms on Oct. 15tli, 1889.
^ The first proposal paper, still in our possession, is in manuscript. It was
that of Thomas Young, M.D., F.R.S., Physician to St. George's Hospital, and
is signed by Alex. Marcet, Henry Halford, Robert Bree, J. Yelloly, and
P, M. Roget. He was proposed Nov. 12th, 1812, and balloted for on Jan.
5th, 1813.
» They amounted to £346 9^.
■* This charter was granted to Dr. Elliotson, Sir Astley Cooper, Bart., and
Dr. Yellolp.
FIRST MEETING IN THE NEW PREMISES. XClll
of February, 1812, ''in consequence of the gracious re-
ception accorded by H.R.H. the Prince Regent to an
application of Sir Henry Halford," who was at that time
President of the Medical and Chirurgical Society, a peti-
tion for a Charter was sanctioned by the Society ; after
having been signed by Sir H. Ilalford, President, Drs.
Saunders and Baillie, past Presidents, by Sir Walter
Farquhar, Drs. Marcet and Yelloly, and Messrs. Clive,
Abernethy, and Cooper, the Trustees of the Society, it
was laid before H.R.H. the Prince Regent in Council. I
regret to say that the Royal College of Physicians, under
the Presidency of Sir Francis Milman, objected to the
grant, stating in their counter-petition that they would
be materially aggreived by the grant of a Royal Charter
of Incorporation to the Medical and Chirurgical Society.
The grounds upon which the College based its opposition
would be unintelligible to the present generation, but as
an item in the history of British medicine, I think it right
to place before you some of the arguments employed on
behalf of the College. It was said by its defenders that
'' by certain Regulations or Bye-Laws of the said College,
any tract or treatise on medical subjects, written by any
Fellow or Candidate of the said College, or by any person
licensed by the said College to practise physic, may be
read at certain meetings of the said College, and if ap-
proved of, in manner as by such Regulations and Bye-
Laws is required, will be directed to be printed at the
expense of the said College ;" and again, " that the esta-
blishment of such Society by Royal Charter will be the
means of depriving the College of Physicians of such
tracts upon medical subjects as shall be written by those
members of the College who shall likewise be members
of the Medical and Chirurgical Society."
The Attorney- General and Solicitor-General took the
part of the College of Physicians, and in spite of a long
correspondence, the Privy Council agreed, at the Court at
Carlton House, the 19tli March, 1814, present H.R.H. the
Prince Regent in Council : — " That they do not see suffi-
Xciv ADDRESS TO THE FELLOWS AT THE
cient grounds for recommending tlie grant of a charter to
tlie Medical and Chirurgical Society/'
Of this report the Prince Regent was pleased to ap-
prove^ and the charter accordingly was not granted.
Let us hope that if Sir Francis Milman and his co-
adjutors were alive now, they would, in the favourite lan-
guage of the College in those days, repentantly join us in
exclaming, " O coeca mens mortalium ! "
Our Society seems to have for some time been exercised
by the desire of bestowing prizes upon distinguished Fel-
lows ; we find references to this matter in 1822 and again
in 1837, but nothing was ever done in this direction, until
the foundation, by voluntary subscription, of the Marshall
Hall Prize, in 1872, as a memorial to a great man ; and
which has been since awarded to three distinguished
workers in the same field as that in which he laboured so
successfully : Drs. Hughlings Jackson, Ferrier, and Gas-
kell. — The whole question of pi-ize-giving is one that may
be discussed from various points of view, but if there is a
difference of opinion in regard to some aspects of the
question, it can scarcely be doubted that it is a high func-
tion for a society like ours to perform, to award a tangible
proof of its appreciation of good work done in the cause
of science under the restrictions such as those surround-
ing the Marshall Hall Prize. You will remember that
this is a quinquennial prize bestowed for work not
necessarily done in connection with our Society. This was
not the former object of the Society, for we read in the
'Transactions' of 1823 the resolution, "that the Council
shall adjudge out of the funds of the Society a prize to the
author of the paper that shall appear to them most de-
serving of that honour, amongst those that shall have been
read to the Society during the session."
It is to be assumed that the Council were satisfied
that they had sufficient pecuniary means at their disposal
or they would not have made such a proposition. It is
easily intelligible that the great variety of subjects treated
by different Fellows, would render it very difficult to judge
FIRST MEETING IN THE NEW I'REMISES. XCV
of their productions according to any common standard.
Although I have no definite data to rely upon, I have little
doubt that this was the rock on which the good intentions
of the Council were wrecked. Whenever our Treasurers
report an ample credit balance, and we are again tempted
to establish prizes, let us profit by the experience of
the past. There are ample methods of spending our money
for the advancement of science, and so long as we appoint
good working committees for the special investigation of
questions bearing upon medicine and surgery we need
never be at a loss as to spending our money for the pro-
motion of the objects defined by our Charter.^
Our removal to Berners Street, and our receiving the
honour of a Royal Charter of Incorporation, was marked
by the termination of the first series of eighteen volumes
of our ' Transactions ' and by the commencement of the
series which is still running on. It will be a question
for your consideration whether it may not be well to mark
the great event of our emigration to a new home in a
similar manner as was done by our predecessors. I, for
one, see certain advantages in defining in a society like
ours, the footsteps of time ; and, as far as my judgment
guides me, I do not apprehend any counteracting drawbaks.
When I had the honour of serving the ofiice of Secretary
to the Society there was a prolonged agitation on the
subject of establishing a fusion of the numerous societies
formed for the promotion of distinct branches of the
medical profession. I cannot say that I saw my way to
removing the various difiBculties in the way of the execu-
tion of a plan which, theoretically, promised very well.
Nor do I think that the difiiculties are less now or that
there would be a greater prospect of success if the different
societies took up the question at the present day. But it
does suggest itself to me that as six societies of a scientific
character and one with philanthropic purposes, all closely
' The Society's Charter states that " the Society was formed for the culti-
vation and promotion of phy>ic and surgery, and of the branches of science
connected with them."
XCVl ADDRESa TO THE FELLOWS AT THE
associated with the medical profession^ will in future
occupy rooms under our roof, there will be many oppor-
tunities of carrying out objects that an Academy of Medi-
cine would have in view, but which would be perhaps even
more energetically and beneficially realised by the co-opera-
tion of Societies that are now distinct in their objects, their
means, and their government. There are many questions
of medical science and medical government which would
be more completely solved and more actively prosecuted
by joint committees of the six scientific societies working
with the Royal Medical and Chirurgical Society than
could be achieved by any one of them carrying on their
labours alone.
But a few words more and I will call upon the Secre-
tary to initiate the regular work to which our assemblies
are devoted. If we are deeply indebted to our predeces-
sors for what they have done in establishing this Society
on a broad and firm basis, we must not forget the debt
of gratitude we owe to those of our contemporaries who
have made it possible for us to enter into possession of
this palatial edifice, a home that Medical Science will
claim as its own, we trust, for centuries to come, and where,
" widening down from precedent to precedent,^' true and
beneficial knowledge may find expansive and increasing
power for good through many future generations of Britons.
Some unavoidable .delays have prevented the house being
as far advanced towards completion as your Council had
reason to expect when the contracts were first signed, but
the Building Committee and your Council were equally of
opinion that it would be better to assemble even in the
present condition of the rooms than to seek a temporary
home. It is only right to mention that the Medical Society
of London through its President, Dr. Theodore Williams,
who is also a distinguished Fellow of this Society, knowing
of some difficulties that beset us, offered us the use of their
rooms. The fraternal spirit that suggested this offer is
an admirable illustration of the good feeling and harmony
that pervades the republic of science.
I
FIRST MEETINQ IN THE NEW PREMISES. SCVU
Much^ however, lias been achieved in the brief space
of time that has been at our disposal, and it is only right
that you and future Fellows of the Society should know
upon whom the chief burden and anxiety has fallen. The
members of the Building Committee, to whom the Council,
with your sanction, have delegated the great responsibility
of carrying out this important work, are Mr. Timothy
Holmes (Chairman), Dr. Cheadle, Dr. Gee, Dr. Hare, Dr.
Isambard Owen, Mr. Warrington Haward, Mr. R. W. Parker,
and Mr. A Willett. Our architect is Mr. Flockhart. I
am quite sure that I only echo the opinion of every Fellow of
the Society if I couple with this distinguished list of names,
that of a gentleman who, though not a member of the
Building Committee, has from the first inception of the
plan shown an amount of tact, zeal, and ability which has
materially lightened the labours of the Committee and
Council, I mean our Resident Librarian, Mr. MacAlister.
It now only remains for me to express a hope that I am
sure you will all echo, that God may bless the Royal
Medical and Chirurgical Society in its new home, and
prosper its work, carried on for the advancement of science
and for the benefit of our countrymen and of humanity at
large.
ANNUAL MEETING OF THE SOCIETY,
SATURDAY, MARCH 1st, 1890.
Sir Edward Henry Sievekinq, M.D,, LL.D., President, in
tlie Chair.
Frederick Taylor. M.D., • „ „
' Hon. bees.
J. Warrington Haward, F.R.C.S
Present — 101 Fellows.
,}
The President nominated Dr. Stephen Mackenzie and
Mr. W. A. Meredith to scrutinise the results of the election
of officers and Council for the ensuing year, and declared
the ballot open for one hour.
The President then called upon Mr. Warrington Haward
(Hon. Sec.) to read the
Report of the President and Council.
The President and Council have this year to present to
the Society a more than usually important Report, inas-
much as since the last Annual Meeting a change of resi-
dence has been determined upon and carried out.
It had for some time past been felt that the premises
in Berners Street occupied by the Society since the year
1834 had become both inconvenient and inadequate. Every
year there was increasing difficulty in placing the books
of the constantly growing Library. The room used for
the Society's meetings, the Council room, and the Com-
mittee rooms all contained books ; and as the meeting-
C REPORT OF THE COUNCIL.
room was the only place available for study, its furniture
had to be rearranged for every meeting that took place.
The small reading-room was very crowded and uncom-
fortable, and had no sufficient space for the display of the
current journals. Moreover, during recent years an in-
creasingly large number of the Fellows of the Society
had moved towards the west of London, so that the situa-
tion of the Society^s house was in this relation far from
central.
It had also become apparent that the state of the house
necessitated a considerable expenditure upon repairs,
besides the alterations needful for providing for the books
in a manner which was at the best but inconvenient and
temporary, as well as expensive.
All these considerations pointed to the desirableness of
seeking other and more commodious premises, in favour
of which was also the fact that the lease of the Berners
Street house had only sixteen years to run, and was there-
fore becoming yearly less saleable.
But, on the other hand, there was the great difficulty
of finding appropriate rooms for the Society's needs in a
suitable locality and at an attainable price, and inquiries
made from time to time had only made the difficulty more
apparent.
At the beginning of 1889, however, it came to the
knowledge of the Council, through the assiduous inquiries
of our Resident Librarian, Mr. Mac Alister, that the house
No. 20, Hanover Square, had come into the hands of two
gentlemen who were about to enter into contracts for a
complete reconstruction of the building, but that these
gentlemen were open to an offer for the property if made
at once and before their proposed contracts were signed.
The house was a freehold, and, with the land attached
to it, seemed so admirably suited for the purposes of the
Society, that a Special Meeting of the Council was held
on February 20th, 1889, to consider the matter, and a
Committee was appointed for the purpose (a) of obtaining
information and reporting to the Council concerning the
REPORT OF THE COUNCIL. CI
exact terms on which the house could be obtained ; (6) of
obtaining a valuation of the property by an expert ; (c) of
preparing a financial statement showing the present and
prospective liabilities of the Society.
As the result of their investigations the Committee
ascertained —
(1) That No. 20, Hanover Square, was a freehold house
on the west side of the square, with a frontage of rather
more than fifty feet.
(2) That the house consisted of four floors, containing
in all twenty-three rooms, besides a very extensive arched
basement ; that beyond the house was a garden 50 feet
broad and 140 feet long, at the end of which was a nine-
stalled stable with coach-house and rooms over, to which
was an entrance from Bond Street. The freehold pro-
perty extended only to about the first 100 feet of the
garden, the remaining portion of garden and the stables
being held on lease from the Corporation of London, at
the annual rent of £5 15s., 37^ years of the lease being
unexpired.
(3) That Messrs. Elgood, having valued the property,
advised that £22,000 or £23,000 would be a reasonable
price for it.
(4) That the lowest sum the owners would accept for
the property was £23,000.
This information was laid before the Council in a report
of the Committee presented on February 27th, together
with a financial statement prepared yviih the assistance of
Mr. Francis Cooper (professional accountant).
With these facts before them, the Council, at a special
meeting on February 27th, 1889, after taking all the cir-
cumstances into careful consideration, and having regard
especially to the exceptional opportunity offered of obtain-
ing suitable freehold premises, decided to recommend the
purchase of the premises. No. 20, Hanover Square, for a
sum not exceeding £23,000.
A Special General Meeting of the Society to consider
this recommendation of the Council was held on March 4th,
CU EEPOET OF THE COUNCIL.
1889 ; Sir Edward Sieveking, President^ in the Chair, at
which the following resolutions were passed :
(1) That the recommendation of the Council to purchase
the house, No. 20, Hanover Square, be and is hereby
approved by the Fellows of the Royal Medical and Chirur-
gical Society of London in Special General Meeting as-
sembled, and that steps be immediately taken to carry
this recommendation into effect.
(2) That the Council of the Royal Medical and Chirur-
gical Society of London be and is hereby authorised to
do one or all or several of the following acts for and on
behalf of the Society, namely :
(i) To acquire the freehold and leasehold property in
the premises at No. 20, Hanover Square, by purchase,
for a sum not exceeding £23,000, such property to be
vested in the Trustees of the Society.
(ii) To lease, sell, or mortgage the leasehold premises
now occupied by the Society at No. 53, Berners Street.
(iii) To raise such funds as may be required for the
acquisition of the premises in Hanover Square, and for
such additions and alterations as may be required — ■
(a) By mortgage of the Society^s leasehold and of the
property to be acquired.
(h) Or by the issue of bonds among the Fellows of the
Society.
(c) Or by such other means as may seem to the Council
most advantageous to the interests of the Society.
(iv) To do all such acts and employ such persons as
are necessary or advisable for the carrying out of these
purposes.
(8) That the Council of the Royal Medical and Chirur-
gical Society of London be and is hereby authorised to
instruct the Trustees of the Society to sell out the secu-
rities now vested in their names, and to pay the proceeds
of such sale to the Treasurers.
(4) That the Council of the Royal Medical and Chirur-
gical Society of London be and is hereby authorised to
appoint a Building Committee to complete the purchase
REPORT OF THE COUNCIL. Clll
of the new premises, and under the direction of the Council
to carry out such alterations and repairs as are required
therein, and that such Committee consist of the following
gentlemen : Dr. Cheadle, Dr. Gree, Dr. Hare, Dr. Isambard
Owen, Mr. Timothy Holmes, Mr. Alfred Willett, Mr. R.
W. Parker, and Mr. Warrington Ha ward, and that the
Council have power to add to to the number of the Com-
mittee if they think it necessary.
To this Committee was subsequently added Mr. Clinton
T. Dent, to whom the Society is greatly indebted for his
valuable aid in regard to the electric lighting.
These resolutions were confirmed (in accordance with
Bye-Laws, Chap. XVIII, Sec. 5) at a Special General
Meeting of the Society held on March 11th, 1889.
The funds for carrying out these purposes were soon
subscribed by 120 Fellows of the Society, and on March
20th and April 16th, 1889, meetings of the subscribers to
the Debenture Fund were held, at which it was deter-
mined—
(1) That Dr. Thomas Barlow, Dr. Gee, Dr. C. Theodore
Williams, and Mr. Warrington Haward be appointed
Trustees, to whom the Society's freehold and leasehold
property is to be mortgaged for the security of the Deben-
ture holders.
(2) That in addition to this security, Debentures should
be issued to the Subscribing Fellows, acknowledging the
Society's indebtedness to the extent of the several amounts
advanced.
(3) That the Loan be issued in £50 Debentures, to be
redeemed at the end of fifty years ; that the interest at 4
per cent, be paid by half-yearly Coupons to Bearer ; that
the Society reserves to itself the right to pay off any
Debentures at any time on three months' notice being
given ; that for five years no repayment of principal should
be guaranteed, but that after five years from the date of
the Loan the formation of a Sinking Fund should be com-
menced, to which yearly additions should be made for the
ultimate repayment of the Loan.
CIV EEPOET OF THE COUNCIL.
(4) That the Debentures be issued to, and in favour of,
the Fellows of the Society contributing to the Loan, and
that the form of Debenture and Trust Deed be such as to
provide that Debentures shall not, without consent of the
Council, be assigned to any one not being a Fellow, except
in case of the death of a registered holder, in which case
the right thereto shall be vested in his executor or admi-
nistrator for the purpose only of assigning to and vesting
the same in any specific Legatee or Legatees thereof or
(if there shall be no such Legatee) in some person being
a Fellow of the Society, unless in the meantime the same
shall be drawn for payment.
A Committee of Subsci-ibers to the Loan, consisting of
Sir Andrew Clark, Dr. Thomas Barlow, Dr. Gee, Dr. C.
Theodore Williams, and Mr. Alfred AVillett, was appointed
to settle, in consultation with the Solicitor to the Society,
the form of the Debenture and Trust Deed.
This Committee decided that not more than £30,000 was
to be thus raised.
The Building Committee appointed at the Special
General Meeting on March 11th, 1889, immediately com-
menced their work, and Mr. Holmes was appointed
Chairman.
Messrs. Lake, Beaumont, and Lake were requested to
act as Solicitors to the Society, and Mr. William Flock-
hart as Architect.
Mr. Flockhart was requested to prepare plans and
obtain estimates for the required alterations and additions.
The Society then petitioned the Corporation of the City
of London for a more secure and advantageous tenure of
that part of the property held on lease from the Corpora-
tion, and on which it was desired to build ; and Deputa-
tions, consisting of the President and other Fellows of the
Society, attended in support of that petition. The matter
having been referred to the City Lands Committee, the
Corporation decided, in consideration of the scientific
character of the Society, to grant a lease of eighty years
at the annual rent of £30 ; and the Council desire to ex-
REPORT OF THE COUNCIL. CV
press their grateful appreciation of the consideration and
liberality of the Corporation.
On April 17th the Committee accepted an offer of £450
a year for the remainder of the Society's lease of the pre-
mises in Berners Street, from Messrs. Phipps and Dawson,
electrical engineers, possession to be given on September
29th, 1889.
The purchase of the property in Hanover Square was
completed on May 10th.
The decision of the Corporation as to the Leasehold
portion was received on June 13th.
The builders' estimates for the alterations were received
on June 25th, and that of Mr. Nightingale for £6840 was
accepted. The contract for the work according to the
plan and specifications of Mr. Flockhart was signed on
July 9th, and the work was commenced forthwith.
It will be seen, therefore, that no time was lost in pre-
paring the new premises for the use of the Society, and
the builder's contract provided for the completion of the
work by October 7th.
Unfortunately various events which it was impossible
to foresee interfered with the speedy completion of the
work which had been hoped for. Prolonged and unavoid-
able delay was caused, soon after the work was begun, by
the Dock Strike, which interfered with the delivery of im-
portant iron- work without which it was impossible to pro-
ceed. Subsequently legal difficulties were raised by the
occupant of the adjoining premises, with regard to the
new North Eoom, and the arrangement of this matter
caused some delay.
Moreover, as the work progressed certain alterations in
the original plan became inevitable.
The Council greatly regret the inconvenience which the
Fellows must necessarily have suffered from the delay
in the completion of the premises, and especially from the
prolonged closure of the Library, which the most unre-
mitting efforts on the part of the Building Committee were
unable to prevent.
VOL. LXXIIl. h
CVl KEPOET OP THE COUNCIL.
But the Council also believe that the Fellows of tlie
Society will appreciate the many difficulties to be overcome,
in adapting, altering, aud adding to a large house, in ac-
cordance with the somewhat complicated requirements of
the Society and its tenants, and that it will be felt that no
labour or care has been spared by the Building Committee
to bring the work to a satisfactory completion in the
shortest possible time.
The Council are glad to be able to announce that the
Societies which had been accustomed to meet in the rooms
of the Royal Medical and Chirurgical Society at Berners
Street have all become tenants in Hanover Square, and
that numerous additional Societies have also been accom-
modated.
Arrangements have also been made for building, on the
site of the stables, premises which will be rented by
Messrs. Webb Miles & Co.
The following is a list of the tenants which the Society
has provided for :
The Pathological Society, -
The Clinical Society,
The Royal Microscopical Society,
The Gynaecological Society,
The Obstetrical Society,
The Quekett Microscopical Club,
The Society for Relief of Widows and Orphans of
Medical Men,
The British Nurses' Association,
Messrs. Belcher and Pite, architects,
Mr. Edwin Ashdown, music publisher (basement),
Messrs. Webb Miles (site of stables),
producing a yearly rental of £1432 10s. ; 53, Berners
Street being let to Messrs. Phipps and Dawson for the
remainder of the lease at an annual rental of £450.
The large hall, as well as the North Room, can be let
when desired for meetings without interfering Avith the
ordinary business of the Society.
REPORT OF THE COUNCIL. CVll
The annexed plan will show tlie arrangement of tlie
premises.
The lighting is by electricity, a low-tension (100 volts)
current being produced by a Kapp-Allen dynamo, worked
by a 6-horse power Eobey's steam engine. The electricity
is stored in an accumulator of 53 cells. The ground-floor
is also supplied with gas.
A fire main and hose is provided on every floor.
The drainage has been completely renewed in accord-
ance with the best sanitary requirements.
The Council wish to express their cordial appreciation
of the great courtesy and liberality with which the Medical
Society, through its President, Dr. C. Theodore Williams,
offered the use of its rooms for the meetings of the Royal
Medical and Chirurgical Society, and the Pathological
and Clinical Societies during October and Novembei', an
offer which the Council would have gratefully accepted
had it not been possible to make temporary provision for
the meetings in the front Library Room at 20, Hanover
Square.
The Council also wish to acknowledge the courtesy
wdth which the Pathological and Clinical Societies deferred
their first meetings, and their kind toleration of the tem-
porary arrangements necessarily made for the fii'st few
meetings of the Session.
The Council wish to draw attention to the very liberal
donation of Dr. Quain to the Society ; who, when the
necessary funds were being raised for the purchase and
alteration of the new house, wrote as follows :
''I enclose a cheque for £50 as a contribution to the
funds of the Roj'al Medical and Chirurgical Society.
My hope is that I shall be thus rendering more
useful service to the Society than by becoming a
bondholder."
On the receipt of this a resolution was unanimously
carried " That the warmest thanks of the Council be given
to Dr. Quain for his kind donation to the Royal Medical
and Chirurgical Society."
Ground Plan or
TiiE Royal Medical s. Chirurgical Society's Uousb
d
W~! FLOCKHART
-A r c tl L.
HANOVER SQUARE
REPORT OF THE COUNCIL. CIX
At a subsequent meeting of the Council it was resolved
tliat Dr. Quain's donation of £50 " be invested as the
nucleus of a fund to be called the '^Permanent Endovt^-
ment Fund ;" that the interest of that fund be used in
such a manner as the Council shall from time to time
order^ but that the capital of the fund shall under no
circumstances whatever be alienated.'"
This resolution having been communicated to Dr. Quain,
he again wrote expressing his gratification that his dona-
tion of £50 was to be devoted to the foundation of an
Endowment Fund, and offering for the acceptance of the
Society a further contribution of £50 to be added to his
previous donation.
This the Council most gratefully accepted, and were
thus enabled to start the " Permanent Endowment Fund "
with the amount of £100.
To this the Council have the pleasure of announcing
there has recently been added £50 by Mr. Edward Law
Hussey, of Oxford, who has most generously made over
to the Endowment Fund the £50 which he had advanced
as a bondholder.
It is needless to point out the great advantage to the
Society of possessing a fund of this kind, of which only
the interest can be used, and to which any one wishing
to add to the permanent stability and welfare of the
Society can make either gift or bequest.
Its establishment may also perhaps help to dispel the
erroneous idea that seems to some extent to have pre-
vailed, that the Society was already possessed of funded
capital.
The Council have also the pleasure of acknowledging
the valuable gift by Sir Edward H. Sieveking, President,
of a jewel consisting of a copy in gold and enamel of the
Society^s seal surmounted by a crown, to be worn as a
badge of office by the President whenever he presides over
or represents the Society.
The Council have decided that the retiring President, as
his last oflBcial act, shall invest his successor with the badge.
ex REPORT OF THE COUNCIL.
Particulars of the income and expenditure of the Society
are set forth in the accompanying Statement of Accounts,
(p. cxxii).
The number of subscriptions received during the past
year was 368, and seven composition fees have been paid.
Forty-three new Fellows have been elected, of whom
thirty-two are resident and eleven non-resident. One
Fellow has resigned. The Society has lost during the
same period seventeen of its Fellows by death.
The total number of the Fellows is at present 793.
The Hon. Librarians report as follows :
Report of the Honorary Librarians, Samuel J. Gee, M.D.,
and J. W. HuLKE, F.R.S.
" Of the ordinary work of the Library for the year
1889 there is little to record.
" At the very time that last year's Eeport was pre-
sented the movement had begun which, though
for the great ultimate advantage of the Library,
had the immediate effect of interfering with its
work. Trusting that the terms of the Building
Contract would be faithfully carried out, and that
the new Library Rooms would be ready for occu-
pation at the end of September, we instructed the
Resident Librarian to make early arrangements
for the packing of the books during the August
Recess.
" This work was carried out with great care, and in
such a manner that had the new rooms been
ready by the time promised, the books could have
been placed and ready for use within the space of
a fortnight.
" But all our arrangements were rendered valueless
when, instead of moving the books to Hanover
Square, it became necessary to warehouse them
with Messrs. Taylor, of Pimlico. As soon as a
single room of the new house was ready no time
EEPOET OF THE COUNCIL. CXI
was lost in filling it with books and throwing it
open to the use of Fellows ; but as it was impos-
sible to make a selection of books without reducing
the Library to chaos no great advantage was de-
rived from this effort, though the use of the cur-
rent English journals seems to have been appre-
ciated by many. The period of deprivation is
now, however, we trust, at an end, and we hope
that by the time this Report reaches the hands
of the Fellows all the books will be upon the
shelves, and that all the privileges of the Library
will be fully available.
*' When all the advantages of our magnificent new
premises are appreciated by the Fellows, we feel
sure the privations of the last few months will
seem but a trifling price to pay for so great a
boon. For years those actively interested in the
work of the Library have looked forward with
somewhat gloomy foreboding to the time when the
last shelf should be filled; and there seemed no
chance that the res angusta domi of the Society
would ever permit us to pull down our old barns
and build greater.
"And now, the reflection that in less than a year we
have exchanged increasingly inadequate premises,
held on an almost extinguished tenure, for a free-
hold house, capable of accommodating 200,000
volumes, is surely a cause for gratifying encou-
ragement to all those who rightly regard our
Library as the most precious possession of the
Society.
" The financial aspect of the change will be referred
to in the general report, but we may be permitted
to congratulate the users of the Library on a fact
of hopeful significance in this connection, viz.
that the excellent management of the Building
Committee has placed the Society in its new
house absolutely rent free.
CXll REPORT OF THE COUNCIL.
" We cannot close this report without placing on
record our deep sense of the invaluable services
the Eesident Librarian, Mr, Mac Alister, has ren-
dered to the Society under very exceptional and
most trying circumstances/'
Samuel J. Gee,
J. W. HULKE,
Hon. Librarians.
By a recent decision of the Council the Library will in
future be open from 2 to 7 instead of as heretofore from
1 to 6, w^hich it is hoped will be for the convenience of
the Fellows.
During the past session a Scientific Committee has been
appointed (in accordance with Bye-Laws, Chap. XV) for the
purpose of investigating questions of importance in refer-
ence to the climatology and balneology of Great Britain
and Ireland.
The following is a list of the members of this Com-
mittee : — Dr. Ord (Chairman), Dr. A. E. Garrod (Secre-
tary), Dr. Ballard, Dr. Mitchell Bruce, Dr. Cheadle, Dr.
Dickinson, Dr. W. Ewart, Dr. Maguire, Dr. Norman
Moore, Dr. Murrell, Dr. Penrose, Dr. Fredk. Roberts, Dr.
Fredk. Taylor, Dr. Symes Thompson, Dr. Hermann Weber,
Dr. Theodore Williams, Mr. Malcolm Morris, Mr. Fredk.
Treves.
The Council have had under their consideration the
mode of dealing with papers submitted to the Society for
reading, in consequence of the following letter received
from Dr. R. J, Lee : —
" 6, Savile Row, W. ;
March 30th, 1889.
" To Warkinqton Haward, Esq.,
Hon. Sec. of the Roy. Med. Chir. Soc.
" Dear Mr. Secretary, — I venture to draw the atten-
tion of the President and Couucil of your Society
REPORT OP THE COUNCIL. CXIH
to the subject of the standing orders which refer
to the reading of papers presented to the Society.
On the presentation of a paper to the Society it is
provided by No. II, Chap. X, p. 8, Standing Orders
that ' the Secretaries shall present all papers re-
ceived by them to the next ensuing Council, but
may, if they deem it expedient, previously submit
them,' &c.
" According to the Bye-Law of the Society, p. 24
(Chap. XIII, Sec. VI), it is quite clear that the
referees are appointed by the Council ' to report
to them confidentially on the merits of papers
READ before them.' There is no distinct provision
made here in regard to papers not yet read, beyond
the voluntary action of the Secretary implied in
the words 'may, if they deem it expedient, pre-
viously submit them,' &c. This power given to
the Secretary requires consideration, as it leaves
the Secretary open to possible suspicion, in regard
to the reading of a paper, unfair to him and pre-
judicial to the interests of the Society. On the
presentation of a paper to the Society —
" 1. Acknowledgment of its receipt ought to be made
by the Secretary.
" 2. The paper should be laid before the Council before
being submitted to any referee.
" 3. Eeferees ought to be named by the Council to
report upon whether the paper is likely to con-
tribute to the purposes for which the Society was
instituted, as defined by Section I (Bye-Law XI,
Chap. I) .
" 4. No alteration should be made in paper previous to
reading, providing that the paper contains no
objectionable matter and is not too long — that is,
beyond the length agreed upon by the Council.
It does not seem desirable that referees on a paper
should have the power to suggest any alterations
in the form of a paper. It is proper that the
CXIV KEPOET OF THE COUNCIL.
author should submit to the criticism which he
will receive when the paper is read, and that no
criticism should be allowed by referees previous
to the reading of the paper.
" I leave this matter in your hands as agreed upon in
our interview previous to the last Annual Meeting.
" I am, dear Mr. Secretary,
Ever truly yours,
RoEEfiT J. Lee."
A Committee was appointed to report upon the matters
referred to in this letter, and this Committee was subse-
quently added to, and the scope of its inquiiies enlarged so
as to include other questions connected with the selection
of papers for reading and publication.
As the result of the reports of the Committees and of
the careful consideration of the matter by the Council, it
was resolved to recommend to the Annual Meeting the
following addition to the Bye-Law No. VI, Chap. XIII, page
24 : — " And in special cases as to whether papers forwarded
to the Society are suitable for readiug before the
Society,^' which will then include in the duties of the
referees the consideration of papers at the discretion of
the Secretary or Secretaries before they have been pre-
sented to the Council for acceptance.
The Council did not think it desirable to make any
other changes in relation to this matter.
Finally, the Council desire to express their appreciation
of the great services rendered to the Society by those gen-
tlemen who have undertaken the arduous duties of the
Building Committee, and especially to Mr. Holmes, the
Chairman of that Committee ; and in this respect also to
record in the most emphatic manner the unfailing energy,
the incessant care, and the unremitting devotion to the
interests of the Society disj)layed by the Resident
Librarian, Mr. J. Y. W. Mac Alister, to whom, as already
stated, it is greatly due that the Society has obtained its
present residence.
ANNUAL MEETING. CXV
Mr. BosTOCK (Treasurer) ■wished to explain that the
account presented by his colleague and himself was neces-
sarily deficient, inasmuch as it gave no statement of the
expenditure upon the building. It had been thought to
be only misleading to give a tentative statement on this
subject, and that it would be better to reserve the whole
until the building operations were completed and an accu-
rate and final account could be prepared. The amount
expended was somewhat in excess of that anticipated, but,
on the other hand, the income secured by such expendi-
ture was about double of the amount originally estimated.
Dr. Hare (Treasurer) observed that the Fellows might
be surprised at noticing the abnormally large balance which
remained to credit of the general account, but he trusted
they would not run away with the idea that this was a
genuine surplus ; for though it was true that owing to the
Library having been closed for nearly a year the expenses
under that head had been curtailed, there had been expenses
on other matters which quite swallowed up any such saving.
The simple explanation of the balance was that a consider-
able amount of bills remained unpaid at the end of the year
when the balance was struck, chiefly owing to the difiiculty
of getting them in and dealing with them during the ex-
ceptional pressure of unusual work upon the officials.
With regard to the Building Account, as was always the
case with building accounts, the expenditure had exceeded
the estimate ; but he was happy to be able to assure the
Fellows that in this caseevery penny expended brought them
a most substantial and profitable return. The Committee
could have completed its work without expending a penny
beyond that originally estimated, and have done all that
was asked of them ; but more than once they had before
them the inducement of obtaining such an excellent return
for a slight excess on the sum originally estimated, that
in the interests of the Society it would have been penny
wisdom and pound foolishness to have hesitated. Mr.
Mac Alister had proved an excellent agent in securing pro-
fitable tenants ; for example, it had actually been decided
CXVl ANNUAL MEETING.
to let tlie leasehold stables at tlie back for £120 when
Mr. Mac Alister secured a tenant wlio^ after some negotia-
tion^ agreed to pay the Society £350 a year if they would
build him new premises on the same site at a cost of some
£1300 — that is to say, a net increase of £230 was secured
on a lease of sixty-seven years for an expenditure of
£1300, Surely there could be no question as to the
wisdom of accepting such an offer, though it meant ex-
ceeding the amount of the Debenture Fund. As they
were limited to £30,000 for this fund, it would probably
be necessary to find the balance elsewhere ; but there
would be no difficulty on that score. Dr. Hare also
referred to the Permanent Endowment Fund which Dr.
Quain^s gift had enabled the Council to establish, and
which had since been added to by the gift of his deben-
ture by Mr. Hussey, of Oxford, and he urged that the
example of the last-named gentleman was an admirable
one which might be commended to the attention of other
debenture holders, who would thus save themselves the
anxiety and trouble of looking out every half-year for the
interest cheque of his colleague and himself.
Sir William Savory said he had great pleasure in
moving '' That the Report of the President and Council,
together with the Treasurers' audited statement of ac-
counts, be adopted and published in the next volume of
the * Transactions.' " He was sure those present heartily
congratulated the Council upon thus meeting in their new
home.
Dr. Stephen Mackenzie seconded the resolution, which
was carried unanimously.
The President moved " That the very hearty thanks
of the Royal Medical and Chirurgical Society be given to
the members of the Building Committee for their arduous
services and the unremitting care which they had devoted
to the interest of the Society ; services which had resulted
in placing the Society in possession of magnificent premises
in every way adapted to its requirements and upon the
most advantageous terms."
ANNUAL MEETING. CXvii
Mr. HuLKE expressed the pleasure he had in seconding
the resolution. He remarked that the premises in which
the Fellows were now assembled formed the best testi-
mony to the Councirs work during the past year, and
nothing he said could improve upon the eloquence of that
fact.
The resolution was carried by acclamation.
Dr. Julius Pollock said he had been asked to move the
following resolution, which had already been mentioned in
the Report of the Council, viz. : '' That the following addi-
tion be made to the Bye-Laws, Chapter XIII, sect, 6 : —
' And in special cases as to whether papers forwarded to the
Society are suitable for reading before the Society.'' " This
might not seem much to have come out of several meet-
ings of a sub-committee, and the careful consideration of
certain matters very properly brought before the notice of
the Council by Dr. Eobert Lee ; but it was hoped that the
proposed alteration would meet the views of the Society,
and there did not appear to be any reason or advantage
in making further changes.
Dr. R. J. Lee, in seconding the resolution, said it was
important for the Fellows to understand distinctly the object
of the change in the Bye-Laws proposed by the Council.
It was to give certain powers to the Secretaries and the
Referees which they did not at present possess. The
Referees were appointed to decide whether papers
which, had already been read should be printed in the
' Transactions ' or not ; but they had nothing to do with
papers which had not been read. It was now proposed
that before a paper was read it should be within the
power of the Secretaries to submit it to the Referees, to
decide whether it should be read or not. It remained with
the Fellows to decide this question as they considered best
for the interest of the Society, and he was sure that before
making the proposal the Council had given the matter their
long and serious consideration.
The resolution was then put to the meeting and car-
ried.
CXVm ANNUAL MEETING.
The President then delivered his Annual Address.'
Dr. QuAiN said that the privilege had been given him of
proposing a vote of thanks to the President for the address
to which they had just listened. The address testified to
the care and the ability with which the biographical details
in the lives of deceased Fellows had been compiled, whilst
those present recognised the feeling and the eloquence with
which these details were brought before them. Dr. Quain
congi^atulated the President on having held office during
this great event in the history of the Society, namely its
movement into its present grand abode. He had the
greatest possible pleasure in moving '' That the hearty
thanks of the Society be given to the retiring President,
Sir Edward Sievekiag, M.D., LL.D., for his conduct in
the Chair during his term of office, for his zealous and
valuable services to the Society, as for the Annual Address
now delivered.'"
Mr. Geoege Pollock stated that he heartily echoed
Dr. Quain's congratulations. During his own term of
office in the Chair he had himself made some enquiry
with a view to the Society purchasing the house in which
they were now established, but at that time there were
difficulties in the way which seemed insurmountable.
He was delighted that a way had been opened so soon.
He had special pleasure in seconding Dr. Quain's resolu-
tion.
Dr. QuAiN then put the resolution to the meeting, and
it was carried by acclamation.
On the motion of Dr. Cheadle, seconded by Mr. Langton,
it was carried " That the best thanks of the Society be
given to the retiring Vice-Presidents, Dr. Octavius Sturges,
Mr. Morrant Baker, and Mr. Christopher Heath for their
services to the Society during the past year.^'
On the motion of Mr. Macnamara seconded by Dr.
Bdzzard, the following resolution was carried unanimously :
— " That the best thanks of the Society be given to the
retiring members of Council, Dr. Lauder Brunton, Dr.
' See p. 1 of this volume.
ANNUAL MEETING. CXIX
Huglilings Jackson, Dr. Ralfe, Mr. Howard Marsh, Mr.
Henry Morris, Mr. E. W. Parker, Mr. Edward Tegarfc, and
Mr. W. J. Walsliam for their valuable services to the
Society during tlieir respective terms of office. ^^
The Peesident then declared that the ballot showed the
following gentlemen as duly elected Officers and Council
for the ensuing year : —
President. — Timothy Holmes.
Vice-Presidents. — Robert Barnes, M.D. ; J. Lang-
don Down, M.D. ; Alfred Willett ; John Croft.
Treasurers. — Charles John Hare, M.D. ; John
Ashton Bostock, C.B.
Honorary Secretaries. — Frederick Taylor, M.D. ;
J. Warrington Haward.
Honorary Librarians. — Samuel Jones Gee, M.D. ;
John Whitaker Hulke, F.R.S.
Other Members of Council. — Walter Butler Cheadle,
M.D. ; William Miller Ord, M.D. ; Arthur Julius
Pollock, M.D. ; George Vivian Poore, M.D. ; T. Gil-
bart Smith, M.D. ; William Harrison Cripps ; Clinton
Thomas Dent ; Henry Greenway Howse ; Henry
Walter Kiallmark ; Herbert William Page.
He then called the President elect, Mr. Timothy Holmes,
to the platform, and addressed him as follows :
" Mr. Timothy Holmes, permit me in the first instance
to congratulate you on your election to the Presidency of
this Society ; and in the second to obey the directions of
the Council by investing you with the badge which it is
intended that, in the future, the President of the Royal
Medical and Chirurgical Society should wear at all meetings
of the Society, and whenever on public occasions he repre-
sents our commonwealth. It is my fervent wish that you
and your successors, when you quit office, may always leave
the Society more flourishing than it was when the insignia
of Presidency were conferred upon you.'^
The President then invested Mr. Holmes with the badge,
nii'l |»iMC!«»il.»w| \i, Imim fi, Rilvor MiiiHl.Mf luiy I'mc Mim iif,«i ».!'
l('(»M«f'll »tM'l IliM I'iiImio I'lMHidMiiM^ »(l l.liM Honln(,y, lJi<> f/ill.
fiT MiM I(|'c;|)Im(||. l/ilMfll'iMM.
Mr, TlM'crnV ll(il,M|r,fl, in I'-ply, Mdul Im» (f.nl-l liml iiM
M(l»'(j(m,l,n wni'dw In wlilnli (/(» »i}i|M'RMrt hlw l'n»illn^M ((f ^mM-
I.IhIm for MiM IIIM>ii|*Mrt|.»Ml (MmI IIIMlMHMrVfMl linlinllt' wlll(!ll
llu\y lirtil iImik^ liJMi liy «>l(M'Miif( liiiii Iri Imi Minic i'l'oi^idniiL
lln IiimI lJiiiM{(lir lliiil. III". |ii'>l<- "'^loiiiil hln vvrti4 ovfif, himI
fill i(li>M. mI |ii'nri>MmiinFil ilmliiM'hnn ImmI |iri»^M(l iiwoy I'i'niri
Itin iiiiiiil vvlinii iJin (IniiiM'il liiiil iiiin^ |ini^iM(|ly n,nl<oi| liiiri
i(M)(W'll|iV ill'* |lM<l|i| |i<i>lliM|| III VvllH'll lin linil jllHir llMMtl
r»1fi(t|.(w| liy Mm MiM'inly, 'riioiijrli UMiiWdluMrt nl' \\\» nwit
ilniMMi'il.n, JiM f'liiiM iiMJ, I'Ml'iiF^d, liiil ill wnn iinl, tiiilJI MhiI<
MiiiliMMil. IImiI/ Iik r<'ll^ Id ilM lull mHiiiIi Mim woii^lili til' llin
Imii'iIi'Ii Iim IiimI liilotii ii|miii IiiihmmII', II< wtin iiX iKiMitliiitM'y
|ii<t'lii)| ill IliM liinloi'v fil' IliM MMnlnl/y iJifii lui iIiMmiiiiimiI
iilDiHi, n |inrl(itl iwiMiMiPMitlti^ ill I'liiil' I'MMiii nil Hull, (4vniilii|^.
'riiity vvni'M nttiliiM'Miifr ii|iiiii m. iipw cnii'iMw, imhI, Iimiimi'iiJiI(<|
ii»i>l'iil, iMiil Miiri*t<F4nriil iin Mipit' (Miiit'Md lind Immiii in Mm |iiiif4i,
III wn<n liiiiMinnililn In iivoiil I'opliii^ lJiiiil< ^i'(iii.l<i<i' I liiii(/M wdiild
lin n<<|iP(*roil ol' Miniti in Mm riiMii'n, lln rdl. iiJiinmli i^lViiJil
wlmti Im I'MlUnOml ii|»>n Mm MiiiiliMniiiiJ Imii'<Iiiii ilinii Mm
('i.iiiiiil IhkI Iftiil n|iMii Ml" (4(M'iMly, M. Iiiii'tlnii iimhIi ln«(t,vini'
lliiMi llicy IiimI cvmi Iimihh linl'iirn. r'nr liiw own |tiirl,, Im
witiild niidniiviiiii' Id |iiMiiiul,n Mm iiilt'inwlfi nT Mm MiM'inl.y
til Mm ni'iimf^li nl' lil» |iM\vni'F4, iliiiI Im Mimiild n-ly ii|imii Mm
ivnniniiuirn nl' iJm ( liiiiiii'il ntidor Mm l^dliivvF) iii ilini i'i<M|iMt'L
Up itininlnd ii|hiii Mm iiii|int'rn,ii(io nl' dnliif^ Mmir iiMimnt U\
iimrniiBn Mm iiiiiiiIm'i "I Mmii' |i"idl(iw« liy nvoi'y InyiMiiiivIn
iimiuipt. Tlmii* |Mi»il.iiiii vviif4 t\. ^t'nnl. liiid n nM'iiii^; oiin, luid
dim ill wlilidi Ihi litiid (iviM'y imMMildd itntilldrMtms Inil) itli ilio
Biiiim linm il \vii,M imli itw ynl iillMfrnliMM' n. ri'ciii'p mm. Tlmy
IiimI ^nim In M< vnry ^riMii nH|i(MiF4i^ in Iniildin^, I'm* wliitdi
Im wniild null ii|Miliif{iNP, fni' Im witi^ niiin lliid) (Jm nxpniidl'
Ini'P liiiil Imcn M: iimBl. nptnlnl mm in nvnry " 'M '• liml.
Imwnvin', lid'l. Mmin willi n. Imiivy |inriiniii.rv ImihIimi, imd
iMndi l''nllnw niip;lil. In litlMtiir iMmwiMttiilinnwIy In (MirtJtln Mm
Mnriily In Rii|i|inrl Mimi r('fi|H.iit(i|)ili|.y, OFt|m(Mnlly liy tililnin
VNNI'M MlillilTINM
VS\\
lllft' IIIMV l'\i||ti\VM Tllli IllMII Willi 'III lllll< llllll lu> WHIlId
iimI iliiliiiii (lii>in nitii'ii Hunt In lumiitti llii< I*'ii||ii\vm lu^mit
lllilt ItiM liitHt hiM'VlOiHi wniilil liii tliiyntiMl In (lio lMliMi>H|h
i)|' iJlt* SiMiioty, III' umilil wini Willi |iihli> Mill liiMiill lllil
IMIiIiImIII Willi Wllloll llinll' liillllllft riiui|i|ii||| llllll IIIVtiilltMJ
llllll, until lio mIihiiIiI Iid itiilli>il n|iMii In liiuiil II tivi>i In ii
tiiinii wml liy niiiiOOMMtiri
'I'liii iiii>ii|iiift lliiiii iiinuluiiloil
Vnl,, INNIII.
CXX ANNUAL MEETING.
and presented to liim a silver master-key for the use of
himself and the future Presidents of the Society, the gift
of the Resident Librarian.
Mr. Timothy Holmes, in reply, said he could find no
adequate words in which to express his feelings of grati-
tude for the unexpected and undeserved honour which
they had done him by electing him to be their President.
He had thought that his professional life was over, and
all idea of professional distinction had passed away from
his mind when the Council had unexpectedly asked him
to occupy the proud position to which he had just been
elected by the Society. Though conscious of his own
demerits, he could not refuse, but it was not until that
moment that he felt to its full extent the weight of the
burden he had taken upon himself. It was at no ordinary
period in the history of the Society that he assumed
office, a period commencing in that room on that evening.
They were embarking upon a new career, and, honorable,
useful, and successful as their course had been in the past,
it was impossible to avoid feeling that greater things would
be expected of them in the future. He felt almost afraid
when he reflected upon the additional burden that the
Council had laid upon the Society, a burden much heavier
than they had ever borne before. For his own part, he
would endeavour to promote the interests of the Society
to the utmost of his powers, and he should rely upon the
assistance of the Council and of the Fellows in that respect.
He insisted upon the importance of doing their utmost to
increase the number of their Fellows by every legitimate
means. Their position was a great and a strong one, and
one in which he had every possible confidence, but at the
same time it was not as yet altogether a secure one. They
had gone to a very great expense in building, for which
he would not apologise, for he was sure that the expendi-
ture had been a most useful one in every way. It had,
however, left them with a heavy pecuniary burden, and
each Fellow ought to labour conscientiously to enable the
Society to support this responsibility, especially by obtain-
ANNUAL MEETING, CXXl
ing new Fellows. The hour was so late that he would
not detain them more than to assure the Fellows again
that his best services would be devoted to the interests
of the Society. He would wear with pride the beautiful
emblem with which their retiring President had invested
him, until he should be called upon to hand it over to a
more worthy successor.
The meeting then terminated.
VOL. LXXIIl.
Abstract of Receipts and Payments : for
To Balance in hand on January 1st, 1889 :
Ciish in hand
Dr.
£ s. d.
24 17
21 11
,, at Bankers
,, on Deposit do.
,, Subscriptions, Fees, Sec. :
326 Annual Subscriptions at £3 3s.
41
32 Admission Fees at £6 6s.
4 Composition Fees for ' Transactions ' (1 at £6 6s., 3 at £8 8s.)
3 Life Composition Fees . .
Fines
,, ' Transactions,' Sec- :
Sold by Messrs. Longmans . .
,, Society . .
Catalogue . . . . . . • • ' • •
' Proceedings ' . .
,, Rents :
Pathological Society
Clinical Society
Obstetrical Society
Society for Relief'of Widows and Orphans
Stables
„ Interest :
On Consols
„ Deposit (Rank)
Less Subscriptions, &c , for 1890, paid in advance in 1889, and
included in Subscriptions for 1890
Due to Librarian on account of Petty Cash . ,
46
26
300
8 5
13 10
0 0
1026
129
201
31
45
0
18 0
3 0
12 0
10 0
3 0
3 0
14 7
12 6
7 6
1 10
15 0
15 0
8 0
0 0
10 0
90
6
5 10
3 0
373 2 3
1434 9 0
46 16 5
254 8 0
96
8
10
2205
24
4
17
6
2
2180
31
7
10
4
11
£2211
i§_
3
Charles J. Hake, \ m
J. A. BobTOCK, J-"
•easurers.
To Dr. Quain's Uonation
„ Mr. Hussey's Donation
PERMANENT
Dr.
£
.. 100
.. 50
s.
0
0
d.
0
0
£150
0
0
MARSHALL
£
. . 599
16
s.
7
19
d.
0
5
£616
6
0
To amountof Stock, December 31st, 1888
„ Dividends for 1889 . .
Dr.
THE Year ending December 3Jst, 1889.
Cr.
By House Eent, Taxes, ^c. :
Ground Kent (less tax)
Imperial Taxes . .
Parish Eates
Water Rate
Insurance
„ Lighting and Heating :
Gas, Coal, and Chandler
„ Eepairs, Furniture, iUcc.
„ Meeting Expenses :
Refreshments, Waiters, Microscopes, and Lamps
„ Stationery, Postage, See-
,, Salaries and Wages
„ Library :
Books, Binding, and Parcels
„ ' Transactions ' and ' Proceedings '
„ Sundry Petty Cash Disbursemints
,, Bank Charges
„ Cash :
In hand
At Bankers
,, on Deposit
£ s. d,
13 13 0
12 13 0
18 7 4
4 0 7
7 6 0
33 3 S
971 19 6
300 0 0
i) o>. d.
00 19 11
■10 10 11
72 4 4
18 19 2
38 8 10
527 0 9
40 2 0
102 15 6
9 8 10
1 4 10
1305 3 2
£2211 18 3
Audited and found to be correct, 11th Februarj-, 1890.
OcTAvius Stukges, I John H. Morgan.
Robert Wm. Parker. | H. Montague Murray.
Frederick Taylor, Hon. Sec.
ENDOWMENT FUND.
Cr.
By Purchase of New South Wales Four per Cent. Stock
„ Balance in Treasurers' hands
f s. d.
100 0 0
50 0 0
£150 0 0
HALL FUND.
Or.
By Costs of purchasing Stock (£16 17s. Id.')
„ Stock, 3l3t December, 1889
£ s. d.
0 2 3
616 4 2
£616 6 5
ADDEE SS
SIE EDWAUD H. SIEYEKING, M.D.,
LL.D., F.R.C.P.,
PRESIDENT,
ANNUAL MEETING, MARCH 1st, 1890.
Fellows op thk Royal Medical and Chirurgical Society !
When we last assembled on the 1st of March, I ad-
verted to the change which was then only looming before
us, but which your energy, and the admirable manage-
ment of the Building Committee appointed by you at
the suggestion of the Council on the 4th of March of last
year, has made a reality. I trust that you all agree with
me that in selecting this new home we have no reason
for regret, but that, on the contrary, the larger habitation
and the greater convenience of our library and assembly-
room, will be a permanent stimulus to all Fellows to more
careful study, to more efficient work, and a means of the
cultivation of union and strength in our profession. But
whatever our trust and confidence in the future of our
Society, our first duty now is to recall to our sorrowing
memory the work and achievements of those Fellows
who have passed away from us to their eternal home
since the last Anniversary Meeting.
The first death that I have to record is that of William
VOL. LXXIII. 1
PRESIDENT S ADDRESS.
Henry Octavius Sanhey, M.D.Lond., F.R.G.P., who at the
age of seventy- five breathed his last at Boreatton Pai'k,
Baschurch, Salop, on March 8th last. He became a
Fellow of the Royal Medical and Chirurgical Society in
1847, but although a man of eminence, owing to his resi-
dence out of town never filled any ofiice amongst us. Dr.
Sankey was the son of a medical man who practised at
Wingham, in Kent. He studied medicine at St. Bartho-
lomew's Hospital, and after practising for a time at Mar-
gate became resident medical officer at the London Fever
Hospital. He here worked much with Sir William Jenner,
whom he assisted in his important researches, which are so
well known, in regard to the differentiation of the various
forms of continued fever. By his special investigations
into cerebral pathology at this hospital Dr. Sankey laid
the foundation for his subsequent reputation as a specialist
in the treatment of insanity. A valuable paper in the
January number of the ' Medico- Chirurgical Review' of
1853, on the specific gravity of the brain, was the result of
researches which he carried on with great care for seven
consecutive years. I am happy to be able to quote Sir
William Jenuer's opinion, that Dr. Sankey was a man of
considerable mental vigour and thoroughly honest in
searching after truth, well formed in his profession,
kind of heart and most estimable.
In 1854 Dr. Sankey left the Fever Hospital and took
charge of the female side of the Middlesex County Lunatic
Asylum at Hanwell, where he was the intimate and staunch
disciple of Connolly, with whom he co-operated to the utmost
to establish the humane treatment of the insane advocated
by that distinguished physician. In a controversy^ raised
at that time, Connolly, in consequence of a paper written by
Dr. Sankey pointing out that harsh words were asinadmissible
in the treatment of lunatics as corporal punishment, said to
him in a letter, " You indeed really understand what non-
restraint means; there are very few that do." Dr. Sankey
' Communications from Dr. H. R, O. Sankey, the son of the subject of this
notice.
president's address. 3
was never a robust uiau, and the work required of him
at Hanwell so told upon him that after a period of ten
years he resigned, and practised privately at Landywell
Park Lunatic Asylum, in Gloucestershire. Shortly after
leaving Hanwell he was appointed Lecturer on Mental
Diseases at University College, London, an office that he
held for many years. In 1882 he quitted Landywell
Park, and removed all his patients to Boreatton Park,
Shrewsbury. In 1884 he published the second and very
much enlarged edition of his lectures, which first appeared
in 1866 under the title of Lectures on Mental Diseases, a
work that is still a high authority on the subject it deals
with, and during his life made many contributions to
medical journals both in England and France.
For several past years Dr. Sankey suffered from some
obscure and very painful hepatic disorder, probably biliary
calculi. But of late his health had somewhat improved.
His death was due to an attack of pneumonia of a few
days' duration. His mantle has descended upon his son
Dr. H. R. 0. Sankey,^ who is Superintendent of the Con-
nolly Asylum at Hatton, Warwick.
The second obituary notice that I have to submit to
you is that of a man who, both in this Society and in the
world of medical science, has occupied a very prominent
position, Charles James Blasius Williams, M.D.Edin.,
F.R. S.jwhoat the advanced ageof eighty-four endedhis use-
ful life on March 24th, 1889, at the Villa du Rocher, Cannes.
Dr. Williams was elected a Fellow of the Royal Medical
and Chirurgical Society in 1840, held the ofiices of Coun-
cillor in 1849 and 1850, of Vice-President in 1860-1, and
of President in 1873—4 ; he also served as Referee in
1843—4 ; he was Chairman of the Scientific Committee
on Suspended Animation in 18G2, and he communicated
one paper to the Transactions.^ It is impossible in the
' Title of Dr. C. J. B. Williams' paper in the Transactions, vol. Ivii,
1874 : " On the Acoustic Principles and Construction of Stethoscopes and
Ear-trumpets."
■ Dr. H. R. O, Sankey has now taken his father's place at Boreatton.
4 president's address.
brief space at my disposal to do full justice to the work
and influence of Dr. Williams ; the former has certainly
made an epoch in British Medicine, and will ever constitute
an important landmark in the enormous strides of the
present century. Dr. Williams, as we gather from his
own record/ was the youngest but one of nine children
of the Eev. David Williams, for forty years perpetual curate
of the Collegiate Church of Heytesbury, in Wiltshire. In
1820 the subject of this memoir went to Edinburgh, where
he was specially attracted by Professor Hope, the Lecturer
on Chemistry, and by Dr. Alison, the Professor of Medi-
cine. In 1824 he took his degree, presenting as his
thesis^ De sanguine ejusque mutationibus, in which he
gives a summary of the most recent researches on the pro-
perties of the blood and its composition, with the results
of his own experiments. In 1825 Dr. Williams went to
Paris, where he remained for fourteen months, attending
the practice andteachingof Majendie,Dupuytren, Thenard,
and others, but especially that of Laennec, to whom the
world is mainly indebted for having taken up and deve-
loped Auenbrugger's discovery of the value and uses of
auscultation. It is interesting to note that Laennec in
general maintained the sufficiency of a simple cylinder of
wood for a stethoscope, perforated or hollowed out at the
pectoral end (whether conically or parabolically did not
matter), and fitted with a stopper to be used for certain
purposes. As a guide to a better understanding of the
works of Laennec, Williams in 1828 published A Rational
Explanation of the Physical Signs of Diseases of the
Chest. After a temporary residence in the country Dr.
Williams in 1827 settled in Loudon, where he enjoyed the
friendship of Sir James Clark and Dr. (afterwards Sir) John
Forbes. After two trips in chai'ge of invalids, to Madeira
1 Memorials of Life and Work. By C. J. B. Williams, M.D., F.R.S.,
1884.
' A copy of the thesis is in ouv library. It may he stated that his first puhlica-
tion, On the Low Comhustion of a Candle, Visible in the Dark, appeared
in the Annals of Philosophy, Jnly, 1823.
PRESIDENT'S ADDRESS. 5
and to Switzerland, he took a house in Half-moon Street,
married, and became a Licentiate of the Royal College of
Physicians ; of this body he was elected a Fellow in 1840,
gave the Goulstonian and Lumleian lectures, and held the
offices of Censor and Councillor. Soon after settling in
London Dr. Williams wrote several articles for the Cyclo-
pajdia of Practical Medicine of Forbes, Tweedie, and
Connolly, dealing chiefly with the organs of respiration.^
In 1833 a second edition of his Diseases of the Chest ap-
peared. It was at this time that the profession were much
exercised b}" the discussion as to the causes of the sounds
of the heart, Williams maintaining that the first sound was
due to muscular contraction ; Hope, on the other hand,
attributing this sound to collision of the particles of the
blood in the ventricles. In 1835 a third edition of this
work issued from the press, and in this year the author
was elected a Fellow of the Royal Society. For two years
Dr. Williams lectured at the Kmnerton Street School of
Medicine, and in 1839 he was appointed successor to Dr.
Elliotson (who had created great animosity by the enthu-
siasm with which he took up the subject of Animal
Magnetism) as Professor of the Principles and Practice of
Medicine, as Professor of Clinical Medicine at University
College, and as Physician to University College Hospital.
The fourth edition of his work on the chest appeared in
1840, and in his Goulstonian Lectures at the College of
Physicians in 1841 he dealt with topics in general patho-
logy, which he afterwards embraced in his important work
entitled Principles of Medicine ; of this the British and
Foreign Medical Review said at the time : We hail its
appearance not only on account of the value we are ready
to attach to any production of its accomplished author,
but also as the indication of a vast improvement in medical
teaching, which must operate most favorably at no dis-
tant date upon medical practice, besides giving a stimulus
1 The chief articles were on Bronchitis, Catarrh, Coryza, Expectoration,
Irritation and Counter-irritation, Malformations of the Heaii;, Obesity,
Pneumonia, and the Stethoscope.
6 president's address.
to many active and intelligent minds to follow out tlie
inquiry wliicli it has so successfully opened. Those
whose studies date back to this period will, I believe, be
ready to endorse this opinion. The year 1841 was also
marked by the opening of the Hospital for Diseases of the
Chest, in Brompton, the foundation of which Dr. Williams
had energetically assisted, and of which he was elected
Consulting Physician, an appointment which he held to
the end of his life. Events that it is unnecessary to
dwell upon here led to his resigning the Professorship of
University College in 1849, and in 1851 he removed from
Holies Street, where he had resided since 1839, to Upper
Brook Street, where he remained until he withdrew from
practice and from la hrumeuse Angleterre, to seek renewal
of life on the sunny shore of the Mediterranean.
The day after Dr. Williams ended his career, our dis-
tinguished Honorary Fellow, Franz Cornelius Bonders,
died, on the 25th March, 1889, at Utrecht, in Holland,
accepted not only in his own country, but wherever his
works penetrated, as one of the greatest physiologists and
scientific ophthalmologists of the age. He was born on
May 27th, 1818, at Tilburg, in the south of Holland, the
youngest child and only son of his parents. Up to his
seventh year his mother was his instructress. The school
education which followed appears to have been very in-
efficient, especially in regard to mathematics. In 1835
Donders commenced his medical curriculum at the Univer-
sity of Utrecht, and at the Military Medical School of the
same town. Five years later he was appointed Lecturer
on Anatomy and Physiology at the latter institution, and
after the lapse of another lustrum he became one of the
Professors of the Medical Faculty of the University,
Schroeder v. d. Kolk still retaining the chair of Anatomy
and Physiology. Donders now established a physiolo-
gical laboratory, where he taught General Physiology,
from which he successively advanced to General Pathology,
Forensic Medicine, and Ophthalmology. The last subject
forced him, nolens volens, into medical practice. The
president's address. 7
International Exhibition of 1851 caused him to visit
London^ where he made the acquaintance and secured the
permanent friendship of his great confreres, Bowman and
von Grate. In 1858 Professor Donders founded an oph-
thalmic hospital.^ In 1863, after the decease of Schroeder
V. d. Kolk, he took entire charge of the physiological teach-
ing of the University, and a large proportion of his prede-
cessor's other work. In 186G the University established
a physiological laboratory, which was opened in 1867, and
of which Professor Donders remained Director till 1888.
His countrymen, who called him " groot en goed " (great
and good), particularly appreciated the fact that, although
he received numerous invitations to transfer his services
to other universities, he remained faithful to the last to
his Alma Mater, the University of Utrecht. Donders, as
his biographer Dr. Landolt informs us, possessed in a high
degree all the qualities which constitute a perfect teacher ;
learning as profound as it was extensive, an excellent
memory, a capacity of placing himself in perfect sym-
pathy with his audience, a power of making abstract
questions intelligible, facility of expression, a sonorous
and flexible voice, and an expressive and dignified de-
livery.
Donders' first great professional merit consisted, not,
as has been said, in discovering astigmatism, which must
be attributed to Helmholtz, but in rendering Helmholtz's
discoveries applicable to practice. The New Sydenham
Society deserves the credit of having introduced Donders
first to the Medical Profession of England by publishing
in 1864 his work On the Anomalies of the Refraction and
Accommodation of the Eye. Donders was early in life an
adherent and expositor of the then scarcely recognised
doctrine of the conservation of force. In 1845 he pub-
lished an essay on The Exchange of Material as a Source
of Heat in Plants and Animals. This was followed in
1848 by an inaugural dissertation on The Harmony of
Animal Life, in which he anticipates some of the doc-
' Nederlandsch Gaslhuis voor Ooglijders.
8 president's address.
triues more fully and completely elaborated by Darwin.
His micro-cliemical researches, published conjointly with
Maiden (1844-7), are the first of their kind, and were
followed by numerous other works of greater or less extent,
which have all served to establish Donders'^ claim to be
regarded as one of the most scientific and at the same time
practical men of his day. The following remarks, with
which Dr. Brailey has favoured me, are an echo of the
reputation which Donders enjoys in Great Britain :
In appreciating the scientific labours of Donders it is
necessary to bear in mind that, starting as a pure physio-
logist, he was led to transfer very largely his energies to
physiology in its bearing on ophthalmic practice — a field
less widely known, and therefore less appreciated. Phy-
siology as applied to the phenomena of vision was indeed in
its infancy. Even myopia was most imperfectly under-
stood ; knowledge of hypermetropia was absolutely want-
ing ; and astigmatism, though known through the labours
of our own Thomas Young and Airy, was absolutely un-
appreciated in its relation to curative medicine. But not
only was little understood of the refraction of the eye, but
even its movements were very imperfectly comprehended,
and the entire mechanism of accommodation also was in-
volved in mystery. The prolonged labours of Donders
showed the alteration which the vertical meridian under-
goes in different movements of the eye and head, and de-
fined the effect of individual muscles. Donders was the
first to explain the relation of refractive errors to concomitant
squint, a subject of enormous and daily increasing import-
ance in relation to the cure of this condition. One of the
practical results of his labours was his suggestion regard-
ing tests of colour for railway and marine services at the
International Congress at Amsterdam in 1879, of which
Donders was President. His investigations on the histo-
logy of elastic tissues, and on the rapidity of transmission
of nervous impulses, testify to work which alone would
' I refer those who desire a fuller account of Professor Donders' life and
works to Warlomont's Annales d'Oculistique, tome cii (14* Serie, t. ii).
PRESIDENT S ADDRESS. V
have raised him to a high place iu the roll of science.
The fact of his being elected a foreign Fellow of the
Eoyal Society, and one of the four honorary members of
the Ophthalmological Society, shows that this country did
not fail to appreciate him ; while the universal esteem
which he enjoyed was demonstrated by the celebration
which was held on the occasion of his retii-ement from the
Professorship of Physiology in 1888, when men of science
from all parts of the civilised world assembled at Utrecht
to do him honour. A sum of over c€3000 was presented
to Donders (£300 of which came from here) on this occa-
sion, which he devoted to the foundation of a travelling
fellowship, to be awarded at intervals of eight years to
promising students of ophthalmology and physiology.
The next loss sustained by the Society was that of a
most accomplished and genial Fellow, personally known to
many of you — Charles Bland Radcliffe. The scion of
an ancient family long settled in the Isle of Man, he
was born in 1822 at Brigg, in Lincolnshire, He received
his first training from his father, who was a clergy-
man. Young Radclilfe is stated to have had so much
success at the very outset of his studies that at the age of
seven years he was able to read Horace in the original.
After studying his profession at Leeds, Paris, and London,
Dr. Radcliffe took his degree of M.B, at the London
University in 1845, and (having obtained the license of
the Royal College of Physicians in 1848) the M.D. in
1851, when he married, and was appointed Assistant
Physician to Westminster Hospital. With this institu-
tion and with the Queen Square Hospital for Paralysis
and Epilepsy, to which he was appointed in 1863, Dr.
Radcliffe was associated to his end.
The College of Physicians early recognised the merits
of Dr. Radcliffe by electing him to the Fellowship in 1858,
and appointing him Goulstonian Lecturer in 1860 and sub-
sequently Croonian Lecturer in 1873. He there also held
the offices of Councillor and Censor. He joined this
Society in 1852, was member of the Council in 1867— 8, Vice-
10 president's address.
President in 1879 and 1880, Treasurer from 1881 to 1886,
and for many years a Referee. Always a great worker,
Dr. Radcliife was indefatigable to tlie end ; lie was able on
the very last day of bis life to see several patients at borne
in tbe morning, called for a few minutes at tbe bospital in
Queen Square in tbe afternoon, and paid a sbort visit to
tbe Britisb Museum on bis way home. He dined quietly,
and was engaged in reading wben a varicose vein burst ;
and altbougb tbe b^morrbage was arrested, deatb ensued
speedily, probably from shock and failure of tbe heart.
He died at bis bouse in Cavendish Square on tbe 18tb
June, 1889.
Dr. Radcliffe's professional career was chiefly marked
by his labours and works in connection with diseases of
tbe nervous system. His book on Epileptic and other
Convulsive Affections of tbe Nervous System went
through several editions, and he wrote important articles
for Reynolds' System of Medicine, on Diseases of the
Spinal Cord, on Cboi'ea, and on Locomotor Ataxy.
Everywhere be exhibited a thorough knowledge of the
subjects be bandied, and much originality in his views,
which are perhaps nowhere so much shown as in his
Vital Motion a Mode of Physical Motion (published in
1876), and in his Behind the Tides, which has only,
as yet, been printed for private circulation. In the
last essay his object is to prove that there is a tidal
wave in tbe landbearing a definite relation to tbe tidal wave
in the sea, and that the deep-seated subterranean beat also
has a definite tidal movement. Dr. Radcliffe was an earnest
student of vital dynamics, many of the phenomena of
which be solved by reference to electrical force. His
fundamental doctrine, as stated in an appreciative estimate
by Dr. Burdon Sanderson,^ was that all the functions or
activities of the nervous and muscular systems were essen-
tially electrical. In the fact, he writes, that muscular
action is directly proportionate to the development of heat
and the exhalation of carbonic acid there is nothing to
• ' Brit. Med. Journal,' June, 1889.
president's address. 11
justify the notion that heat is transformed into muscular
force, or that electricity may not be developed along
with heat in the combustion of force-fuel within the
system, and that electricity may not do the work that
has been ascribed to muscular force. . . . In a word,
you may with little or no trouble satisfy yourself that
muscular force and nervous influence must share the same
fate, and that the only intelligible agent that is left in
possession of the field is electricity. Dr. Radcliffe
accordingly looked forward to the time when the words
irritability, irritation, stimulation, and the like, will be re-
placed by other words which show that the idea of irrita-
bility is resolved into that of natural electricity.
Dr. Radcliffe's creed, writes an old friend of his, em-
braced medicine, philosophy, and religious thought ; but
his sympathies were not confined to either of his high
subjects. He was interested in the work done by all
sorts and conditions of men ; and while defending his own
views of things, which were at least strikingly original, he
was tolerant of the opinions of others. He could appre-
ciate a good novel and delight in a good sermon, and he
gained the friendship of many classes of society. The
extent and variety of his reading were remarkable, and
gave a charm to his conversation that can never be for-
gotten by those who knew him intimately.
The next Fellow to whose death I have to draw atten-
tion was a gentleman of great acquirements, of remarkable
independence of character, and one who, but for a singular
misfortune, would undoubtedly have long occupied a very
prominent position in the profession — Dr. Thomas King
Chambers ; who died after long suffering on August 15th,
1889, at the age of seventy-one. The son of a London police
magistrate, and the grandson of Sir Robert Chambers, Chief
Justice of Bengal, he received his early education at
Rugby under Arnold, and at Shrewsbury under Butler.
He graduated in honours as B.A. of Christ Church, Oxford,
and took the degree of M.D. at the same University in 1846.
His medical curriculum at St. George's enabled Chambers
12 PRESIDENT'S ADDRESS.
to publish the first work which attracted the attention
of the medical profession, the Decennium Pathologicum,
giving an analysis of the hospital post-mortem records for
ten years. It appeared in a series of papers in the British
and Foreign Medico-Chirurgical Review, a periodical now
unfortunately extinct, to which Dr. Chambers before and
during my editorship was a frequent and valued con-
tributor. The vigour and sincerity of his style was to me
always very refreshing. Having been elected to the
Fellowship of the College of Physicians in 1848, he was, at
the opening of St. Mary's Hospital in 1851, appointed one of
three Senior Physicians, and from the opening of the school
shared in the chair of Medicine. At the College of Physi-
cians Chambers held the Goulstonian Lectureship in 1850,
the Lumleian in 1863, and delivered the Harveian Oration
in 1871. After the death of Dr. Rolleston, Dr. Chambers
was in 1881 appointed the representative of Oxford on the
Medical Council ; but his health had already at that time
been undermined, so that he was no longer able to bring to
bear on educational questions the energy and clear-sighted-
ness which had long made him a valued adviser on this and
allied subjects. Among his experiences should be men-
tioned his journey with the Prince of Wales in 1859, whom
he accompanied as physician through Italy, Spain, and the
north of Africa, and who, on the establishment of his
household, appointed him his Honorary Physician. The
outcome of this expedition was a small book on the Cli-
mate of Italy ; but Dr. Chambers' chief claims to literary
and professional distinction rest upon several works in
which he treated of diseases of the stomach, of diet, and
regimen. This Society enrolled him as a Fellow in 1844,
and he contributed to its Transactions one very interest-
ing paper, in 1854, on Mollities Ossium. He successively
filled the offices of Councillor, Vice-President, Librarian ;
and for many years was a Referee. Much as there was
in Dr. Chambers to admire as a physician, as a teacher,
as a professional and general writer, as an author and
artist (for he was eminent as a draughtsman, painter.
president's address. 13
and sculptor), notliing is so touching in his life and
character as the heroism with which he bore the dis-
appointment to which he was doomed, and the sufferings
that he was called upon to undergo. In this, as in general
culture, he may serve us all as a model. In the year 1864,
having previously alarmed his friends occasionally by
symptoms connected with an enfeebled vascular system,
he was found to have a popliteal aneurysm, which necessi-
tated the removal of the left leg. Undaunted by a loss
that would have utterly cast down men of a feebler mental
constitution. Dr. Chambers continued the active pursuit of
his profession, serving as Examiner at Oxford and Durham,
attending the Hand-in-Hand Assurance Company, assisting
at the Medical Council and at the Medical School for
Women in Henrietta Sti'eet, Brunswick Square, and work-
ing loyally and energetically wherever he could be of use,
until, nine months before his death, the carotid arteries
both exhibited aneurysms, while at the same time serious
cardiac complications declared themselves. From this
time to his death, in spite of every care and attention, his
life was one prolonged agony, during which, we cannot
doubt, his strong religious convictions were a solace, and
opened out to him a brighter and more enduring refuge.
Those who were most intimately acquainted with Dr.
Chambers traced a distinct resemblance between his
character and that of Oliver Cromwell, who was one of
his direct ancestors. John of Gaunt, " time-honoured
Lancaster," was another man of great power who occurs
among the ancestry of our friend. We who knew Dr.
Chambers personally feel assured that, like all assiduous
workers, he would join with Browning in saying :
I count that heiiven itself is only work
To a surer issue.
Dr. Chambers in 1847 married the second daughter of
Mr. Maitland, of Loughton Hall, Essex, who with two
daughters, one of whom is married to Mr. Ouless^ the
Academician, survives him.
14 president's address.
A pupil of Dr. Chambers, and therefore a mucli younger
man, follows liim in the funereal list that I have to sub-
mit to you. Walter John Coulson, F.B.C.8., died, after
a brief illness, on April 30th, 1889, at the early age of
fifty-five. He received his medical education at St. Mary's
Hospital, where he successfully filled the offices of House
Surgeon, Curator to the School, and Assistant Surgeon.
He was also attached to the Lock Hospital. Being
specially attracted by a branch of surgery in which his
uncle, Mr. William Coulson, formerly Senior Surgeon to
St. Mary's Hospital, was eminent, he assisted in the foun-
dation of St. Peter's Hospital for Stone, of which at the time
of his death Mr. Coulson was Senior Surgeon. Besides
editing his uncle's work on Diseases of the Bladder and
Prostate, he published, in addition to other surgical papers,
a work entitled : Stone in the Bladder ; its Prevention,
Early Symptoms, and Treatment by Lithotrity, as well as
A Treatise on Syphilis. Besides enjoying an excellent
reputation as a surgeon and writer, Mr. Coulson's character
and amiability secured him many attached friends, who
deeply deplored his early demise. Having inherited a
a large fortune from his uncle, it is the more to his credit
that he was devoted to his work, while it enabled him to
enjoy thoroughly the various sports which can only be
legitimately indulged in by those whose income does not
depend only upon professional sources. His chief charac-
teristics, an intimate friend of his informs me, were his
buoyant spirits, his love of outdoor exercises, and his ex-
treme generosity, which he indulged in largely. He had a
remarkable influence over his patients, and a large number
of them became his warm friends. To this Society Mr.
Coulson was elected in 1864.
The next loss sustained by this Society and by the Pro-
fession of Medicine was that of 8amuel Osborne Haber-
shon, M.D., F.B.C.P., first a distinguished pupil of Guy's,
and subsequently one of the most eminent of the physicians
of that world-renowned hospital. He was born in 1825
at Eotherham, in Yorkshire, and died on the 22nd August,
pkesident's address. 15
1889, of ulceration of the stomach, at the age of sixty-
three. Dr. Habershou had the advantage of belonging
to an excellent stock. Some of his ancestors emigi-ated
to America, where at least two of them occupied prominent
posts in the early days of the Noi*th American republic.
He himself entered at Guy^s Hospital in 1842, and there
and at the University of London subsequently, he enjoyed
continued success. In the first M.B. examination at the
latter institution he secured no less than three gold medals
and two exhibitions. His further successes at the second
M.B. and at the M D. examination secured him the Lecture-
ship on Comparative Anatomy at Guy's in 1851 ; he
subsequently became Lecturer on Pathological Anatomy,
and in 1851 was appointed Assistant Physician to the
hospital. After his teacher Dr. Addison's death, he be-
came Senior Physician in 1873, and Lecturer on Medicine.
A painful conflict between the authorities of the hospital
and the medical staff regarding the internal administra-
tion of the Institution, into the details of which it is un-
necessary to enter, caused in 1880 the resignation by Dr.
Habershou and Mr. Cooper Forster of their connection with
Guy's, a severance which appeared unavoidable at the time,
but in which the sympathy and approval of the entire
medical profession were with the medical officers. Among
the many offices that Dr. Habershou occupied, apart from
his hospital, it is specially our duty to remember him here,
where, besides giving three important papers to our Trans-
actions,^ he filled the post of Secretary in 1867, that of
Councillor in 1869-70, and of Vice-President in 1881— 2, and
was Eeferee almost through the whole period of his connec-
tion with the Society, when not holding a post with which
this latter office is incompatible. This alone is a clear sigil
1 The titles of Dr. Habershon's papers in our Transactions are — On the
Etiology and Treatment of Peritonitis, vol. xliii, 5 ; Clinical Observations
illustrating the Effects produced by the Implication of Branches of the
Pneumogastric Nerve in Aneurismal Tumours, vol. xlvii, 35 ; and Acute
Poisoning by Phosphorus, Jaundice, Death on the Fifth Day; Fatty Degene-
ration of the Liver, &c., vol. 1, 87.
16 PEESIDENT^S ADDRESS.
of the estimation in which his knowledge^ his integrity,
and judgment were held.
The College of Physicians showed their recognition of
Dr. Habershon^s merits by electing him to the Fellowship
in ]856. He served the various offices of Examiner, Coun-
cillor, and Censor at different times, and was Vice-Presi-
dent of the College in 1887. He delivered the Lumleian
Lectures On the Pathology of the Pneumogastric Nerve,
at the College of Physicians in 1876, and the Harveian
Oration in 1883. Besides numerous contributions to the
Guy's Hospital Reports, which all exhibited much care-
ful observation and research, Dr. Habershon attracted
the special attention of the medical profession by his
various works connected with abdominal disease, among
which his Pathological and Practical Observations on
Diseases of the Abdomen, and his work On Diseases
of the Stomach, are probably the most widely known and
appreciated. Not satisfied with the many claims that his
professional position made upon him. Dr. Habershon
devoted both time and money to the furtherance of chari-
table work, to which his strong religious convictions espe-
cially impelled him. Never robust, he enjoyed fair health
until a year and a half before his death, when he was
attacked by severe dyspepsia, from which he was recovering
when his wife's death in April caused a relapse, and this
ended in ulceration of the stomach, haemorrhage, and death.
One son and three daughters survive to deplore the loss
of an excellent father, an eminent physician, and a self-
sacrificing citizen.
Dr. Charles Elam, F.R.C.P., died on the 20th July,
1889, at the age of sixty-five. Born in Birstall, near Leeds,
his father, a Wesleyan minister, supervised his early educa-
tion. He went through his medical curriculum at the Leeds
School of Medicine, and took the degree of M.D. at the
London University in 1850, where he distinguished him-
self in physiology and comparative anatomy, in surgery,
in medicine, and in midwifery. After graduation, Dr.
Elam served in the Leeds Infirmary as House Surgeon, and
president's address. 17
then settled for twenty years at Sheffield, where he lec-
tured on medicine and physiology at the School of Medi-
cine, and was appointed Physician to the Infirmary. In
1868 Dr. Elam migrated to London, where for a short
time he was connected with the Hospital for Paralysis in
Queen Square. In 1869 Dr. Elam became a Fellow of
this Society, and served on the Library Committee in
1886-8. In 1870 he was elected to a Fellowship of the
Royal College of Physicians, of which he had become a
member in 1860. Throughout his life an ardent student.
Dr. Elam was a frequent contributor to the literature of
our profession, and his works, though occasionally the
cause of controversy, had many admirers. He wrote nume-
rous papers on subjects connected with disorders of the
nervous system for the Journal of Psychological Medi-
cine. On Illusions and Hallucinations, A Physician's
Problems, On Cerebi'al and other Diseases of the Brain,
The Gospel of Evolution, are some of the more import-
ant works from his pen. Judging from what I have
read of Dr. Elam's writings, I consider him a man of large
and extensive gifts, possessing sound classical knowledge,
while capable of appreciating and estimating modern
science at its true value. A Physician's Problems would
be a valuable addition to the library of all well-educated
persons, and I would specially recommend its perusal
to every member of the Society for Psychical Research.
His last illness, which commenced in November, 1888,
was a long and weary one, born with fortitude and gentle-
ness. It commenced with solid oedema of one leg, due
to phlebitis of the deeper veins ; the superficial veins becom-
ing involved caused much suffering, and the disease gradu-
ally extended to the other leg, and then to the upper
extremities. There was little constitutional disturbance
throughout, and Dr. Elam retained full possession of his
faculties till within a few days of his death.
Dr. Cumberbatch, who was only admitted to the Fellow-
ship of the Royal Medical and Chirurgical Society in the
year of his decease, died on the 18th August last, after an
VOL. LXXIll. 2
18 president's address.
illness of but a few hours' duration, of angina, apparently
the result of the overwork which is so frequently the cause
of fatality in our ranks. Laurence Trent Cumberhatch,
born in Barbadoes on May 1st, 1824, studied medicine at
Dublin, became M.R.C.S.Eng. in 1848, and after joining
a general practitioner at Chipping Norton, came to London,
where his ability and tact were speedily recognised, and
brought him into an extensive, chiefly obstetric, practice.
Sir Charles Locock, having a high opinion of him, put
many opportunities in his way. He took the degree of
M.D, at St. Andrews in 1866, and in the same year
became a M.R.C.P. About seven years ago he found
that work was undermining his powers, and, under
advice, abandoned a large portion of his practice ; but
this and the greater relaxation he allowed himself did
not suffice to stave off the fatal issue at the compara-
tively early age of sixty-five. Dr. Cumberbatch was
much appreciated in and out of the profession ; generally
liked on account of his thorough honesty, honorable con-
duct, unselfish and kindly disposition and demeanour ; his
sympathetic and successful behaviour to his patients espe-
cially endeared him to the denizens of the sick room.
Dr. Cumberbatch leaves a widow, two married daugh-
ters, and three sons to mourn his loss.
The 7th November, 1889, was the day on which Henry
Haynes Walton, F.R.C.8., breathed his last at his house
in Brook Street, where he had resided over thirty years.
The youngest son of the Provost-Marshal of Barbadoes, he
was born in that island on March 3rd, 1816. His mother,
the daughter of General Haynes, was remarkable for talent
and force of character; the energy and perseverance which
characterised the subject of this brief memoir are supposed
to have been especially derived from her. Great reverses
in the family compelled him to enter upon a more lucra-
tive profession than that he had been intended for, and
he was, after his widowed mother had come to London,
entered as a student at St. Bartholomew's Hospital, where
his diligence and perseverance soon brought him under
president's address. 19
the notice of Sir William Lawrence, who thought and
spoke highly of him. After filling the post of House Sur-
geon at St. Bartholomew's, Walton in 1851 became Asist-
ant Surgeon to the then recently established St. Mary's
Hospital ; subsequently Lecturer on Anatomy and Opera-
tive Surgery at the School, Lecturer on Ophthalmic Sur-
gery, and, after his withdrawal in 1886, Consulting Surgeon
to the Hospital. When he accepted the post of Surgeon
to the Ophthalmic Department of St. Mary's, Walton gave
up his connection with the Central London Ophthalmic
Hospital in Calthorpe Street, which he had founded about
1851, and of which he remained Consulting Surgeon to
the last. Although he published numerous papers on
surgical subjects, and was distinguished as a general sur-
geon, his special taste, as may be gathered from what has
preceded, lay in the direction of the ophthalmic branch
of the profession. His chief work, entitled A Practical
Treatise on Diseases of the Eye, went through three
editions, the first appearing in 1853, the second in 1861,
and the last, very much enlarged, in 1875. In an ela-
borate article on Mr. Walton's first edition, by Dr.
Mackenzie, in the Medico- Chirurgical Review of 1853,
it is spoken of in the following terms : — In the whole
range of ophthalmological literature we know of no work
which, on the whole, better deserves a place in the library
of the surgeon than the treatise of Mr. Haynes Walton.
It is full of sound practical views, and shows the rapid
advances which are being made in this department of the
medical art. Most of the cases related have occurred to
the author himself, and prove him to be an observing and
able practitioner. His style is good, being perspicuous
and unaffected. A leading professor of ophthalmology
of the present day essentially confirms these views of
Walton's work, stating what as a physician I should con-
sider high praise, that he regards the diseases of the eye
from a general point of view, and not from a special one.
In regard to his writings generally it may be said,
the same authority concludes, that the descriptions
20 peesident's address.
o£ disease and the mode of performing operations are
concise and clear, whilst the treatment advised is always
sound and good. Without being a great, he was an intelli-
gent, thoroughly reliable, and honest ophthalmic surgeon.
Of this Society Mr. Walton became a Fellow in 1851, and
he gave one paper to the Transactions, entitled Patho-
logical Remarks on the kind of Palpebral Tumour usually
called in England Tarsal Tumour.
A distinguished hospital surgeon who was on intimate
terms with him for many years speaks of his knowledge
of regional anatomy and his skill as an operator with the
highest praise. He remarks that Walton enjoyed unusual
success in his operations, and that his judgment in dia-
gnosis was remarkable. His advice in railway cases was of
great value, and as surgeon to the Brighton and South
Coast Railway he is said to have saved the Company
many thousands of pounds by the readiness with which he
detected fraud and malingering, an item that has so often
to be reckoned with after railway accidents. As a clinical
teacher his style was short and impressive, and consisted
for the most part (as I have been informed by a distin-
guished surgeon who has attended them) in the giving forth
of practical hints which were the offspring of his own
wide personal experience. He would hit off the promi-
nent features of an obscure or interesting case, and suc-
ceed in putting them before the student in such a way as
to make a lasting impression.
Mr. Walton was a man of robust physique and fond of
hunting. Twice married, his first wife, the daughter of
the Hon. John Reed, of New Court, Gloucestershire, bore
him numerous children, four of whom died, at different ages,
of diphtheria. Three sons and one daughter survive.
Eleven years ago he lost his first wife, and subsequently
married Miss Keelan, the daughter of a retired officer of
the Naval Medical Department. She also survives him.
On his return from his summer vacation in 1889 Mr.
Walton suffered from a feverish indisposition, which he
attributed to the insanitary condition of the localities he
PRESIDENT S ADDRESS.
21
had visited. This, however, did not yield to home care
and treatment ; symptoms developed which unmistakably
pointed to the liver being the seat of serious mischief,
probably acute yellow atrophy, under which, retaining his
mental capacity till within a few days of his death on the
7th November, he sank. He was too ill when we assem-
bled in this building for the first time to attend, but ex-
pressed his very warm interest in the event, and his regret
at being forced to be absent.
The month of November was also fatal to another of
our Honorary Fellows, Professor Volkmann, of Halle, in
Prussia, one of the most scientific of German surgeons.
Richard von Volkmann was born at Leipzig on August
17th, 1830. His father, in 1843, was appointed Professor
of Anatomy and Physiology to the University of Halle,
and being a man of great general culture, as well as dis-
tinguished in his special science, three times filled the
office of Rector Magnificus of the University. After en-
joying an excellent preliminary education Richard entered
the University in 1850, and after taking his degree became
assistant to Professor Blasius at Halle. He at once appears
to have attracted a large practice, so that his German
biographer regards it as marvellous that he could make
time for his scientific investigations, his microscopic work,
and his extensive and carefully executed professional
drawings. His first important monograph. Observations
on Certain Tumours that are to be distinguished from
Cancer, appeared in 1858. This was followed by papers
On the New Formation of Haversian Canals in Osseous
Tissue, and in 1865 by his master-work. The Diseases
of Bones and Joints. After taking a professional part
in the Austro-Prussian war, Volkmann was made Profes-
sor of Surgery in the place of Professor Blasius, who retired
superannuated. From this time Volkmann' s surgical
reputation grew from day to day, and his professional
work was only interrupted by the Franco-German war,
during which he occupied important positions at Mouzon,
at Versailles, and at Soisy. He relieved the tedium of the
22 president's addeess.
siege by sending home, under the title : Dreams by
French Firesides/ poems which have since been published
and are much liked in Germany. After the war was over,
Volkmann had ample opportunity of examining and care-
fully testing the antiseptic theory and practice of our great
compatriot Joseph Lister. Sceptical at first, he soon became
the prominent advocate of Listerism in Germany, of which,
at the International Medical Congress in London in 1881,
he said, that the new doctrine which has wrought a
universal change in surgical treatment, and the new and
difficult method which has multiplied the responsibilities
of the practitioner extremely, has an assured triumph
throughout the civilised world. England, Richard von
Volkmann remarks in the address he delivered on
that occasion — England may feel proud that it was
one of her sons whose name is inseparably associated
with the greatest advance ever made by surgery. All
other nations may without jealousy award him the crown.
For the long, noiseless work which made the ripening of
the seed possible, and which we are now harvesting in
rich abundance, has been of an international character, and
both France and Germany have contributed their share.
No one has more liberally acknowledged the value of ante-
cedent workers than Joseph Lister.^
Indefatigable in his profession, there was scarcely a
year, from the date of his diploma thesis, De pulmonum
gangrasna, in 1854, to that of his death on November
28th, 1889, that he did not produce some important con-
tribution to surgical literature. His last effort was an
address delivered on October 31 st of last year On the re-
section of the Ribs in certain cases of Scoliosis, at the
Society of Surgery in Berlin. Volkmann is described as
having been a very handsome man, of imposing mien and
engaging manners ; and though devoted to his profession,
' Traumereien an franzosischen Kaminen, under the pseudonym Eichard
Leander.
' See Report of the Fifth General Meeting of the International Congress
in London, in 1881.
president's address. 23
able in his vacations and on his travels to devote himself
with all his ardour to poetry and the arts^ in which he
also excelled. He appears to have been a sincere friend
and much beloved by his students ; his loss^ after a
brief attack of pneumonia, is deplored by all classes in
his own countr}^ Our hearty sympathy unites with theirs
in revering his memory.
The first Fellow who was called away from among us
during the present year was one well known and appreci-
ated by your seniors, but who, owing to advancing age and
physical incapacity, has not been seen among us for fifteen
years. Alexander' Shaiv, F.R.C S., died in his eighty-sixth
year on January 18th. Eminent as a surgeon and as a
contributor to medical literature, his special claim to be re-
membered with gratitude by his professional brethren lies
in the fact that his elder brother John and he ^ assisted
Sir Charles Bell, subsequently their brother-in-law, in
carrying out the experiments which constituted Bell the
founder of modern neurology. Having been educated in
his profession at the Great Windmill Street School and
at Middlesex Hospital, Shaw's first work, entitled A Nar-
ration of the Discoveries of Sir Charles Bell in the Nervous
System, appeared in 1828, eleven years after he had
become a Member of the Royal College of Surgeons, and
gave a full account of Sir Charles Bell's experiments and
conclusions. Although already Galen had asserted that
there were distinct nerves for the functions of motion and
sensation, the actual demonstration of the existence ot
these two classes of nerves was given, to the satisfaction
of the medical profession, for the first time by Sir Charles ;
and Mr. Shaw disposes, I think conclusively, of any claims
that were raised in behalf of Majendie and others to the
priority of discovery.
1 Mr. John Shaw had been for fourteen years Sir Charles's pupil and
assistant when he wrote his paper On Partial Paralysis. I find no evidence
of Mr. Alexander's having occupied quite as important a position. Sir C.
Bell's essay On the Anatomy of the Brain, in which he first announces
his discovery of the nerves of motion and sensation, was published in 1811.
(See John Shaw's paper in Med.-Chir. Transactions, 1822.)
24 president's address.
Mr. Alexander Shaw became a Fellow of this Society in
1836^ and had therefore been connected with it for nearly
fifty-three years when he died. He contributed four papers
to the Transactions/ and successively held, the ofiices of
Councillor^ Secretary, Vice-President, and Treasurer, be-
sides serving as a member of the Library Committee, and
repeatedly during his long career as Referee. One who
is well able to judge states that Mr. Alexander Shaw's
contributions to our knowledge of rickets form an indis-
pensable part of the classics of that subject, which were
afterwards embodied in a valuable article in Holmes'
System of Surgery. Mr. Shaw, though an able surgeon
and an eminently studious man, was not a voluminous
writer. His taste was fastidious in the extreme, and his
self-criticism severe, so that his corrections were often as
voluminous as the original manuscript ; but the value of
his work was proportioned to the care with which it was
produced. He long formed one of the ornaments of the
school of Middlesex Hospital, where he had the reputation
of having even higher qualities than his public career in-
dicated.
His accomplished brother John died early, but a sister
survives at the age of ninety-one, and two of his brothers
died very recently at an advanced age. His declining
years were soothed by the affection of his wife, who sur-
vives him, but his only child died young.
Those who were honoured by Mr. Shaw's friendship
were always welcome to him, and had an opportunity of
seeing how happy a good man may be in his decline, and
how the memory of a well- spent life can light up the
dreary hours of old age and infirmity.^
1 The following are Alexander Shaw's contributions to the Transactions : —
On a Peculiarity in the Conformation of the Skeleton in Rickets, vol. xvii,
434 ; On the Effect of Rickets upon the Growth of the Skull, vol. xxvi,
336 ; Description of a Specimen of Dislocation of the Atlas upon the Ver-
tebra Dentata, attended with Contraction and Distortion of the Vertebral
Canal, vol. xxxi, 289; Case of Popliteal Aneurism successfully treated by
Continued Flexion of the Knee-joint, vol. xlii, 209.
^ Mr. Alexander Shaw came of a long-lived race well known in Ayrshire;
president's address. 25
The estimation in wliich 8ir William Gull, Bart.,
who is the next Fellow who has recently ended his earthly-
career, was held by the general as well as the professional
public, has been more emphatically shown by the tributes
paid to him in the press than I remember to have seen
under similar circumstances. There was much, both in
the man and in the course he ran, to fascinate and to
command homage. Great natural endowments, combined
with energy and perseverance in all he undertook, raised
Gull to the high position he for many years occupied in
the medical pi'ofession.
He was born at St. Leonard's, Colchester, on December
21st, 1816, and died, after an illness of above two years'
duration, on the 29th January, 1890. Owing to the
limited means of a widowed mother — the father having
died when the subject of this brief memoir was ten years
old — his school education was of a scanty kind, and, like
many other men who have risen to eminence, he attributed
much of his after success to the training he received from
his mother, who is stated to have been endowed with great
intelligence. The flow of the tide which carried him
eventually to the pinnacle he attained, commenced when
the then all-powerful Treasurer of Guy's Hospital, Mr,
Benjamin Harrison, paid a visit to some hospital property
in Essex, where he made the acquaintance of young Gull,
and was struck by his activity and innate politeness.
Finding that he was usher in a village school, and that he
bore a high character in the locality, he induced him to
come to Guy's Hospital, where in the first instance he
assisted the apothecary, Mr. James Stocker, at a salary
his grandfather, David, was for sixty years minister of Coylton, in that
county, and his great-grandfather for fifty-two years minister of Edenkillie,
in Morayshire. Mr. Alexander Shaw's father, Charles, was for many years
clerk to the Justices of the Peace for Ayr, an office which has just passed
through his son and his grandson to another David. Many of our deceased
Fellow's near relatives distinguished themselves in various walks of life. He
himself, after studying at Glasgow, proceeded to Downing College, Cam-
bridge, but left in 1827 before attaining his degree, in order to take the place
of his deceased brother John as assistant to Sir C. Bell.
26 president's address.
of £1 a week, in making up tlie medicines. Living accom-
modation was found for him in a couple of rooms, occu-
pied now by batlimen, where lie had a daily chop prepared
for him by the midwife, then in partial charge of the
maternity department.
It is unnecessary for me to follow further the gradual
development of Gull's career at Guy's Hospital Whatever
he did was to his credit, and aided in his gradual but sure
advancement. In 1841 he gi-aduated as M.B. at the Uni-
versity of London, and in 1846 the same University, con-
ferred upon him the full degree of M.D., with a gold
medal for a commentary on a case in medicine.
As a teacher at Guy's of physiology and clinical medi-
cine he is said to have been earnest to enthusiasm ; and
my informant, for many years connected with the hospital,
states that the students, to a man, adored him. One
point in connection with Guy's that has not been mentioned
in the many biographies that have been devoted to Gull
is, that he is the only physician to the Hospital who has
ever been appointed one of the Governors, an honour con-
ferred upon him in 1887.
Long previously successful in drawing patients to his
consulting-room, he was summoned in 1871 to attend
H.K.H. the Prince of Wales in a severe attack of typhoid ;
and Sir William Jeuner and Gull were successful in carry-
ing the royal patient through all its phases to complete
recovery ; in reward for this the latter was created a
baronet -^ until his paralytic seizure in 1887 he was prob-
ably as much, if not more sought after as a physician than
any other Fellow of the Royal College of Physicians has
been.
Sir William was elected a Fellow of this Society in 1849,
he was a member of Council in 1864, Vice-President in
1874, Referee from 1855 to 1863, and he contributed four
papers to the Transactions.^ An important paper of
1 Sir William Jeuner on the same occasion received the dignity of K.C.B.
" The following are the titles of Gull's contributions to the Transactions: —
Cases of Phlebitis with Pneumonia and Pleurisy from Chronic Disease of
president's address. 27
his on acquired cretinism entitled, On a Cretinoid State
supervening in Adult Life in Women, is to be found in
the Transactions of the Clinical Society.^ The Fellow-
ship of the Royal College of Physicians was conferred upon
Gull in 1848; he filled the offices of junior and senior Censor,
and was several times a member of the Council. In 1849
he delivered the Goulstonian, and in 1870 the Harveian
Lectures. In 1854, in conjunction with the late Dr. Baly,
he published, under the direction of the Eoyal College of
Physicians, a voluminous and comprehensive report on
Cholera.
Time would not allow me to enter more fully into the
details of Sir William Gull's remarkable career, and to esti-
mate the influence he has exercised on the profession.
We have all known him, and the data to enable you to
form your judgment have in one form or another been
placed before you. Sir William Gull leaves a widow, the
daughter of Colonel Lacy, to whom he was married in
1848, one son, and a daughter to mourn his loss.
In the necrology of last year four names escaped my
notice, to which I must ask your permission to revert :
they are those of Br. Robert M'Donnell, F.R.8., Surgeon
to Steevens and Jervis Street Hospitals, Dublin, who be-
came a Fellow in 1862, and contributed two papers to our
Transactions f the date of his decease was May 6th, 1889,
when he was sixty-one years old ; Dr. John Crockett Fish,
whose Fellowship dates from 1866, and who died on June
the Ear, vol. xxxviii, p. 157 j Cases of Paraplegia associated with Gonor-
rhcea and Stricture of the Urethra, vol. xxxix, p. 195 ; Remarks on the
Natural History of Rheumatic Fever, by W. W. Gull, M.D., and H. G.
Sutton, M.B., vol. lii, p. 43 ; On the Pathology of the Morbid State com-
monly called Chronic Bright's Disease with Contracted Kidney, ' Arterio-
capilhiry Fibrosis,' by Sir W. Gull, M.D., and H. G. Sutton, M.B., vol. Iv,
p. 273.
1 Transactions of the Clinical Society, vol. vii, p. 180.
^ The titles of Dr. M'Donnell's papers in the Transactions are —
Observations on S. Gordon's Case in which Trephining of the Spine was
performed, vol. xlix, p. 21 ; On a Case of Double Facial Palsy, with
Observations on the Physiology of the Nerves supplying the Forepart of the
Tongue, vol. Iviii, p. 369.
28 PRESIDENT S ADDRESS.
29tli last, at the age of fifty-four ; Dr. John Edmund
Currey, who died, aged seventy, on July 15tli last, and
whose Fellowship dated from 1 847 ; and Dr. Thomas
Alexander Wise, whose Fellowship dates from the Lincoln's
Inn phase of our Society, he having been elected to the
Fellowship in 1825 ; he quitted this life at the mature
age of eighty-eight, on the 23rd of July, 1889.
Dr. M'Donnell graduated at Dublin, and served as a civil
surgeon in the Crimean war, receiving the thanks of his
superior for his devotion to duty. On his return he was
appointed teacher of anatomy and physiology at the
Richmond School of Medicine, and in 1866 was elected
Surgeon to Steevens Hospital. He was considered a most
remarkable man, and enjoyed the approbation of his con-
freres. He was twice married, first to Miss Molloy, and
secondly to Miss M^Causland, by whom he had one son,
who survives.
Dr. Wise graduated in Edinburgh in 1824, and entered
the Bengal Medical Service in 1 827 ; after a long period of
service at Dacca as civil surgeon, where he showed much
ability and was greatly respected, he left India in 1851,
and spent many years in retirement at Norwood. He wrote
a very learned Commentary on the Hindu System of
Medicine, which was published in Calcutta in 1845 ; and
he occupied the evening of his life in antiquarian researches,
which would possess special attractions for those specula-
tive historians who deal with the mythical ages.^
The ordinary work of our Society has been carried on
during the past year, in spite of numerous difficulties, with
the same zeal as ever, and our numbers show the increasing
appreciation that prevails in the profession of the many
advantages offered by the Royal Medical and Chirurgical
' The following is the title of Dr. Wise's last work : — History of Paganism
in Caledonia, with an Examination into the Influence of Asiatic Philosophy
and the Gradual Development of Christianity in Pictavia. By Thos. A.
Wise, M.D., F.R.S.E., F.R.A.S., F.S.A.Scot., &c. London, 1885. Pp. 259.
Largely illustrated. It should be studied in connection with Du Chaillu's
recent work on the Viking Age.
president's addeess. 29
Society. It is no small credit to cur secretaries and our
resident librarian that^ although the resolution of last March
the 4th necessitated for many months the subversion of
all our library and other arrangements^ they have succeeded
in bringing out the eighty-second volume of the Trans-
actions in as satisfactory a condition as any of its prede-
cessors. Our thanks are specially due to them for this
and much else that they have done in the service of the
Society ; for if they had followed the precedent of 1834,
when the Society moved from Lincoln's Inn to Berners
Street, no Transactions would have been issued. I have
on a former occasion, when we first met in this house,
dwelt on the labours of the secretaries and of the Building
Committee ; and you, though you can scarcely know all the
diflBculties and disappointments they have experienced, see
before you the magnificent result of the decision at which
you arrived shortly after the last Annual General Meeting.
Among the various acts which our new birth had given
rise to is one that specially deserves to be signalised on
this occasion, the more so as it may serve as an example
to be followed; it is the establishment of an Endowment
Fund, which was considered by the Council as the best
use to which £50 presented to the Society by Dr. Quain
could be put. This has already been increased by further
donations, and constitutes a nucleus which will, I trust,
before the jubilee of our last migration is celebrated, be
augmented by many thousands. For it is not to be sup-
posed that we are rich, or that good work can be done
without cost. We are already taxed individually to an
enormous extent, in the shape of gratuitous work per-
formed for the community. It is not just that we as a
Society, should ask our Fellows to devote their scant
leisure to the advancement of science at a pecuniary cost
to themselves. And if our scientific committees are to
carry out their investigations to a satisfactory conclusion,
the least we can do is to facilitate by all legitimate means,
the researches that involve not only the exercise of much
brain-power, but a considerable pecuniary outlay. This
30 peesident's address.
is one impediment to the appointment of Scientific Com-
mittees— of which one^ that on British Climatology and
Balneology, has been most zealously labouring since it
was appointed^ and some of the results of their inquiries
and observations will doubtless soon be brought before
you. This committee involves not only a large correspond-
ence, but an outlay for travelling and for scientific instru-
ments which our present cramped means have some diffi-
culty in meeting. Another scientific committee has been
much talked of, and is required to supplement and correct
the report of the former Committee on Suspended Anima-
tion, but the res angusta domi has not as yet allowed it
to come into operation. May the new Council see its way
to complete the inquiry, which we are almost pledged to
carry out, and which the lapse of twenty-eight years^
renders a great desideratum on account of the practical
issues involved.
Our credit as a scientific society depends on the
work we continue to perform ; and with the increase of
knowledge an increasing demand will be made upon us and
our successors, which dare not be ignored except at a sacri-
fice of the high position established by our predecessors.
" Science, '^ to use Professor Bunge's words, "will con-
tinue to ask and to answer ever bolder questions. Nothing
can stop its victorious career, not even the limitation of our
intellect. This, too, is capable of being made more per-
fect. There is no rational ground for thinking that the
continuous progression, development, and ennoblement of
type which has been going on for centuries on this
planet should come to an end with us. There was a time
when the only living creatures were the infusoria floating
in the primeval sea ; and the time may come when a race
will dominate the globe as superior to ourselves in intel-
lectual faculties as we are to the infusoria."
Fellows of the Royal Medical and Chirurgical Society,
I See Report of the Committee appointed to investigate the Subject of
Suspended Animation, Transactions, vol. xlv, 18C2, p. 249.
president's address. 31
my faith in our future is firm. We individuals pass away ;
but though
" The old order changeth, yielding place to new,"
we may be assured that there will be a certain harvest
where a good seed has been sown ; it is our duty to see
that the grand legacy we have received from our prede-
cessors is handed down to our descendants not only un-
diminished, but strengthened, increased, and beautified.
With what words can I better close this address than
with those of thanks to you who have placed me in this
chair, and have for two years leniently and kindly borne
with my shortcomings ? How can I adequately express,
on my retirement from office, my gratitude to all the
officials with whom I have been brought into contact ?
I will not detain you with aay emotional remarks, but
you will, I am sure, pardon me if I congratulate you on
your choice of my successor, eminent alike as a writer
and as a surgeon, and especially qualified by his long
services to this Society, and his intimate knowledge of
all the processes connected with its new birth, to direct
its further growth and development. I particularly
congratulate you upon the retention of your excellent
treasurers. Dr. Hare and Mr. Bostock, of your inde-
fatigable secretaries. Dr. Taylor and Mr. Warrington
Haward, and of your learned librarians. Dr. Gee and Mr.
Hulke ; by their aid, and that of the distinguished members
of the new Council, under the guidance of Mr. Timothy
Holmes, I can have no hesitation in prognosticating the
continued progress of the Royal Medical and Chirurgical
Society. I cannot add anything more forcible in praise
of the resident librarian, Mr. Mac Alister, to what has
been said in the report of the Council ; but I am confident
that I am only echoing your sentiments if I express a
hope that in his new surroundings he may find the reward
for the great anxiety and the labours that our migration
has entailed upon him.
Fellows of the Royal Medical and Chirurgical Society,
I bid you farewell.
AN ANALYTICAL AND CLINICAL EXAMINATION
LEAD-POISONING IN ITS ACUTE
MANIFESTATIONS.
THOMAS OLIVEE, M.A., M.D., P.E.C.P.,
PROFESSOR OF PHYSIOLOGY, UNITEHSITY OF DURHAM, AND PHYSICIAN TO
THE EOYAL INFIRMARY, NEWCASTLE-UPON-TYNE.
Received October 15th— Read October 22iid, 1889.
Newcastle-upon-Tyne and the surrounding district have
been for long the home of the lead trade. At the present
time the amount of lead and silver ore raised in the
counties of Northumberland, Durham, and Cumberland
is considerably less than formerlj^, but this is counter-
balanced by the very large imports into the Tyne of a
richer lead ore from Spain, and thus it is that there is
greater activity in the lead industries to-day than there
ever has been. As an illustration, in the year 1862 the.
amount of white-lead alone manufactured was 7500 tons,
and in 1887 it was 14,000 tons.
Of all the industries on Tyneside, lead-making is the
one which has unfortunately gained for itself a bad
name. Lead workers are not as a rule a healthy class of
people. Too soon, in spite of precautions which, it must
VOL. LXXIII. 3
34 LEAD-POISONING.
be admitted, are not always attended to by the workpeople,
many of tliose who are engaged in the process become
indisposed. It is the workers amongst irhite-\en.d rather
than red-\ea.d that suffer the more frequently and severely,
although the lead-smelter and separator of the ore may
suffer. No local industry sends to the Newcastle Infir-
mary such human wrecks as lead-works do. On looking
over our Infirmary Registers for the last five years I find
that 135 cases of lead-poisoning were admitted as in-
patients. Of these, ninety-one were women, and forty -four
were men ; eight died, three men and five women. Most
of the women were young, and died soon after being
exposed to the influence of lead. The eight deaths re-
ported do not represent the total number of deaths from
the effects of lead-poisoning, but only those who died from
the immediate or primary effects of lead.
The danger to the individual from the inhalation of
lead begins with the process of smelting. The lead miner
never suffers. Animals that graze in the neighbourhood
where lead-smelting is carried on suffer from colic and
other symptoms of lead-poisoning. In Weardale this fact
has long been known to the farmers who from time to
time have received compensation for the injury thus in-
flicted upon their cattle. Within the last few years a hood
has been placed in front of the furnace in the lead-mills,
and since then smelters have not suffered. I have known
smelters suffer most severely from the effects of lead-
poisoning. In one case, to my knowledge, four sons in
one family, all stalwart men, died from the effects of lead-
poisoning through the development of kidney disease — a
circumstance which, supported by other experience, makes
me believe in the existence of not only an individual, but
a family predisposition to plunibism.
The worst effects of lead ai-e met with amongst the
vhite-lend workers. Women and girls suffer not only
much more severely, but much earlier from the effects of
lead than men. In a few days in some instances, or at
the most after a few weeks' exposure to lead, either in
LEAD-POISONING. 35
what is known as the " white beds " or the stoves, there
is produced an anemia which goes on rapidl}^ increasing".
Colic and headache are complained of, and occasionally
vomiting and disturbances of sight, amongst wliich I would
mention double vision and amaurosis.
The excellent system which prevails at our lead-works
of a weekly inspection of the workers by medical men is
one of the best preventives of lead-impr(^nation that I
know of. The slightest indication of lead-contamination
noticed by the medical examiner is made the occasion of
a recommendation to the employers for a three months'
suspension from labour on the part of the lead-workers.
Knowledge of this fact, however, not only causes the work-
people not to complain when inspected by the doctor, but
to insist upon feeling quite well, although an hour or two
after the inspection they may be found suffering from colic
and unable to follow their occupation. The high wages
tempt them to deceive not only the doctor, but also the
employer. Lists of the workpeople who are suspended
on account of illness are circulated amongst the lead manu-
facturers of the district. A woman suspended at one
place, having as she thinks recovered her health and un-
willing to be idle for three months, applies at another
factory in the district for emploj^ment, using a false name.
It is only by the most careful discrimination on the part of
the manager and examination on the part of the doctor
that this rule is not more widely broken. It was on looking
over the lists in the factories of workpeople who have been
suspended, when I have so very frequent!}^ seen the names
of girls who were sisters or cousins to each other, all of
whom had suffered from lead-poisoning, that I have been
led to believe in the existence of a family predisposition
to plumbism.
In spite of all the precautions possible that are taken
by the employers to prevent contamination of the work-
people, the fact remains that every now and then a girl of
from eighteen to twenty-three years of age works only a
few weeks or months in a lead factory when symptoms of
36 LEAD-POISONING.
acute lead-poisoning are noticed, namely, colic, constipa-
tion, vomiting, headache, pains in the limbs, and incom-
nlete blindness. In a few days, with or without treatment,
she becomes convulsed, and dies in a state of coma, the
death being so sudden that we cannot but regard it as
due to an acute toxaemia, and in some way or other de-
pendent upon the influence of lead. In most of these
cases albuminuria is absent, and at the post-mortem no
organic change is found save a hydrsemic and anaemic con-
dition of the brain ; and on chemical analysis, as shown in
the charts, lead is found in the various organs, e. g. the
brain, liver, and kidneys.
It is not so much my wish to give in detail the physical
signs and symptoms of lead-poisoning as to draw atten-
tion to some peculiarities connected with them, and above
all to the pathology of the acute cases.
The presence of a blue line on the gums is a physical
sign of very great importance when present. In some of
my cases, however, it has been absent, and yet the patients
have suffered not only from colic, but from symptoms of
lead encephalopathy. In a paper published in the ' Brit.
Med. Journal ' for October, 1885, I stated that I had
found a blue line present in 13 out of 18 cases — or in 72
per cent. A few weeks ago I visited one of the lead fac-
tories in my neighbourhood, and examined 38 women of all
ages from eighteen to seventy-two, taken at random and en-
gaged in various departments, and I found a blue line present
in 28 out of these 38, or in other words 73 per cent. As
these two numbers almost tally, I take it that this is about
the usual percentage. It is a sign not always to be relied
upon ; as we have seen, it may be absent, when other
svmptoms of poisoning are present. I have seen the blue
line well marked in girls who have worked only one week
in the factory. Here, however, we must be careful to dis-
tinguish between a blue line due to the deposition of sul-
phide of lead in the gum and the discoloration which
occurs by the simple deposit of lead dust on the surface of
the gum seen in girls who have been only a day or two in
LEAD-POISONING. 37
the factory. The latter easily disappears after washing
and cleansing the mouth. That the blue line is due to
the action of sulphuretted hydrogen upon lead circulating
in the blood is confirmed by a circumstance such as this, that
in one of my patients — not a lead-worker — two drachms of
acetate of lead were taken with suicidal intent, and on the
following day a distinct blue line had developed in the gum,
which persisted for several days. Dr. Inglis, of Jarrow,
has found in many old lead-workers, in addition to the
blue line, dark discoloured patches inside the lip opposite
ragged canine teeth ; these patches are as a rule irregular
in shape, and seem to depend upon blocking of the fol-
licular glands by particles of lead. In one of his cases
presenting this sign the woman has worked almost con-
tinuously for seven years without suffering-. The same
observer also tells me that he has frequently met with dark
blue lines and stains in the middle portion of the small
intestine, and with large patches of staining in the large
intestine. The presence of these patches is with difficulty
explained, unless it be that they are dependent upon
hardened pieces of fsecal matter strongly impregnated with
lead having lain for a considerable time there, so as to
allow of absorption taking place. The stain, it is to be
remembered, is beneath the mucous membrane.
Of such signs as wrist-drop and paralysis I shall say
nothing, save that the paralysis occasionally extends to
muscles of the arm other than those supplied by the mus-
culo-spiral nerve : these all undergo atrophy. I have
seen the peroneal muscles affected.
Nor of colic shall I say anything except that it is a most
common symptom, frequently obliging the lead-worker to
desist from his or her occupation whilst no other indication
of poisoning is present. It is difficult to explain this colic.
The metal is undoubtedly present in the tissues, but, as
will be seen on referring to the table which deals with
the amounts of lead found in the various tissues after
death, the quantity found in the intestine is small. I
have never found the wall of the intestine thickened, as
38 LEAD-POISONING.
some writers maintaiu ; uor will a general ischgemia explain
the colic, though a partial ischtemia may. The pain is
dependent upon muscular spasm of the intestinal wall.^
Knowing the tendency of the nervous system to become
rapidly affected by lead, and some parts more quickly and
profoundly than others, it is just possible that the abdo-
minal sympathetic ganglia are variably affected ; some
more than others, and some, perhaps, not at all. The
result, then, would be incomplete paralysis of some seg-
ments of the intestine and over-action of others.
People who have been long exposed to the influence of
lead sulfer as time goes on from renal disease — followed,
it may be, by disease of the heart; and death comes
either from albuminuria being followed by exhaustion and
allowing of the development of some intercurrent affection,
or from uraemia or cerebral haemorrhage.
But I would call attention especially to certain cases
of acute lead-poisoning. For example, a girl works, it
may be, only a few weeks or months in a lead factory,
when, after having been noticed by her friends to have
been rapidly becoming anaemic, she complains of colic,
constipation, headache, dimness of vision, and in a few
days afterwards develops convulsions, or becomes delirious
and dies comatose. As the symptoms are so rapidly deve-
loped, and as no organic change is found post mortem, the
death can only be attributed to toxaemia. Death in
these cases is analogous to death from sti'ychnine-poison-
ing. From the bydraemic condition of the brain found
after death, the inference is that there has been irritation
of the vaso-motor centre, and spasm of tlie cerebral
arteries ; and that these conditions are caused either by
the lead itself acting as a poison to the nervous system,
' To this extent I follow Harnack, who also states that the colic is due
to irritation of the intestinal ganglia. In man, he says, the result of this
irritation is a spasmodic contraction of the intestine producing constipation ;
whilst in animals, we are told, the same cause produces increased peristalsis
and diarrhoea. I find in this an explanation of the increased general
arterial tension which may be present, but not of the colic which is always
more or less localised.
LEAD-l'OISONINQ. 39
or by the poisouiug of the blood from retention and cir-
culatiou of effete material due to lead interfering with the
function of the emunctorics.
When we come to analyse the symptoms in these cases,
what we find is that in them as in the less acute cases, and
my remarks now will apply to both, there have been colic,
vomiting, headache, and constipation, and that for some
time past the patient has been very anaemic. There is no
doubt about the autemia, or saturnine cachexia, as it is
called : hiemocytometric observations show a very marked
disappearance of red, and a slight increase of Avhite, blood-
corpuscles. What the aneemia is due to is another thing, —
one, too, very difficult to explain. All the women en-
gaged in this industry suffer sooner or later from dis-
ordered menstruation : young gii'ls at first from excessive
menstruation, and married women also from monorrhagia ;
these exhibit a marked tendency to abort if pregnant ; others
suffer from amenorrhoea. In exactly one half of the women
questioned at the factory, between the ages of eighteen and
forty-five, the menses were excessive ; in one menstruation
had been for years suppressed ; in the rest it was regular. We
may therefore find a partial explanation of the angemia in
this excessive menstruation, which I certainly regard as
one of the peculiar and pernicious influences of lead upon
women ; and it is just possible that in this disordered and
excessive menstruation lies the secret of women suffering
more than men from lead-poisoning. But one half of the
women have regular menstruation, and are yet antemic :
men, too, suffer from this cachexia. We are therefore
obliged to admit that lead exercises a very prejudicial
effect upon the blood itself or upon the blood-making
organs.
Accompanying the headache is dimness of vision. Two
or three of my patients had diplopia. In these cases where
vision is obscured the most marked optic neuritis is
found, and this at a time when, as no albumen is present in
the urine, the change in structure must be due to some
peculiar influence of lead upon nerve. The signs are those
40 LEAD-POISONING.
uf ordinary optic neuritis. This is very quickly followed
by atrophy in some instances, and permanent blindness
may be left : in many, on the other hand, the optic neu-
ritis quite clears away. In all, however, it is an indica-
tion of the severity of the lesion and a measure of the
danger. Later on, when albuminuria has been developed,
there have been superadded to the physical signs of lead
neuritis those frequently noticed in kidney disease.
The brain symptoms are such as we might expect in
toxaemia, viz. headache, vomiting, delirium, convulsions,
and coma. In one of my cases there was right hemi-
plegia with aphasia ; in another the most, marked tremor
of arm and leg. As a symptom aphasia has not been much
noticed. Dr. Inglis, whose experience amongst lead- workers
is great, met with one case of aphasia which was followed
by eclampsia. The aphasia lasted for nine months, and
was accompanied by agraphia. Speech returned, but rather
imperfectly. The patient is now married, and has several
healthy children. In this case eclampsia and aphasia oc-
curred without there being albumen in the urine. The
tendency is, however, for the kidneys to become affected
as time goes on. The organs are small as a rule, and
microscopical examination shows a marked increase of the
interstitial tissue.
Although in nearly all our cases of lead-poisoning in
Newcastle the kidneys are found to be contracted, and
resembling the gouty kidney, though not so red, gout is
practically unknown amongst our lead-workers. In only
a very few instances have I met with rheumatic arthritis,
and in only two have I met with gout, and this was in
the case of a young girl who was a lead-worker, and
whose father and mother had also both worked in the lead
factory and had suffered. The absence of gout in our
neighbourhood amongst lead-workers is a subject of more
than passing interest, it is one of great physiological im-
portance. I have discussed it with many of the London
physicians who have come to Newcastle as Examiners in
Medicine for the University of Durham, and with no satis-
LEAD-POISONING. 41
factory explanation. They see the association of gout and
lead so frequently in London that they are forced to admit
the relationship. In the treatise on gout recently published
by Sir Dyce Duckworth the subject is discussed at con-
siderable length. His own experience^ as well as that of
others, is given ; amongst which is the interesting case of
Dr. Lauder Brunton, where a few grains of lead and opium
pill given for diarrhcBa to a painter previously healthy
were followed in a few days afterwards by a distinct deve-
lopment of gout. Opposed to this relationship of gout
and lead is the testimony given by many physicians of
provincial and Scottish hospitals. Amongst the former is
the opinion of my colleague Dr. Drummond, who also
states that in the north this relationship is never noticed.
Our opinion is that in the north of England gout is practi-
cally unknown as a symptom of lead-poisoning ; it is the
last symptom I should either look for or expect to find.
It is to be remembered, however^ that gout, generally speak-
ing, is not a common disease with us. I have tried to find
an explanation of the absence of gout amongst our lead-
workers, but have hitherto failed. I do not think it is
altogether a question of malt liquors being drunk by the
London workmen, and of whisky by those in the north.
What it is I do not at present know. Climatic conditions
may have an influence. What we believe is that lead in
some way or other so influences the metabolism of the tis-
sues that the ordinary nitrogenous waste is either improperly
formed or imperfectly eliminated. In most of my cases
there has been a marked diminution in the daily discharge
of urea, 200 to 250 grains being the average : in some of the
cases under treatment the amount rose to near the normal,
whilst in others it diminished. It is to the amounts of
uric acid eliminated daily that I would invite attention.
Here I admit we are dealing with a diSicult subject, since
we do not know definitely what diurnal variations of uric
acid elimination are consistent with health, but it is upon
this point that almost everything centres so far as the
development of gout is concerned. Physiologists give
42 LEAD-POISONING.
varying umounts for the daily discharge of uric acid ;
Flint says 6 — 9 grains, McKeudrick 13 grains, Brubaker
8 grains, Kirkes 8"5 grains, Landois 7 — 10 grains, Ralfe
7 grains, and Foster 7 — 8 grains.
Now of four cases the details of Avhich were worked
out for me by Dr. Bedson, Professor of Chemistry in the
Dui'ham College of Science, the following are, roughly speak-
ing, some of the average eliminations.
McNay — for some days before treatment the average
quantity was 5*9 grains, and after treatment the average
of several days was 7*7 grains.
Miller — before treatment 16*7 grains, after treatment
8*4 grains.
Buglas — before treatment 12'5 grains, after treatment
14*57 grains.
Ruddy — before treatment 7*7 grains, after treatment
7*1 grains.
The methods used by Professor Bedson were for urea the
hypobromite of soda ; for uric acid Haycraft's method ;
and for estimating the amount of lead in the urine and
tissues the colorimetric test.
In only one of these cases, therefore, was the daily dis-
charge of uric acid below the amount stated by physio-
logists as the normal. Admitting the correctness of the
uric acid theory of gout, there were not in existence in
these cases the conditions that lead up to the development
of gout, unless circumstances arose to check the elimina-
tion of uric acid. On looking again at the charts it will
be seen that the daily discharge of viric acid was occasion-
ally twice, sometimes thrice, what it ought to have been.
Lead has therefore some peculiar influence upon the forma-
tion of uric acid in the system.
Another interesting point is that lead was found daily
in the urine of patients under observation ; and that under
treatment by potassium iodide the amount of lead thrown
out daily by this channel increased in quantity. In nearly
every case the amount of lead discharged was doubled or
trebled.
LEAD-POISONINQ. 43
In Buglas's case the amouut of lead tor several days at
first was '0126 grain ; it rose to •334 grain.
Ruddy, from '0208 to •0297 parts of a grain.
Miller, from ^042 to "073 parts of a grain.
McNay, from -0035 to -0301.
The charts also show another interesting point as re-
gards these eliminations : every now aud then there seems
to have been a kind of explosive elimination of lead and
uric acid, and it would appear as if they stood in an in-
verted relationship to each other. Nothing occurred to
predict these sudden rises and falls, nor was anything
noticed to follow them.
The other tables show that a very small amount of lead is
met with in the tissues after death ; that a small amount
after all has been absorbed, and yet has been capable
of causing death. Less than one grain of lead found in
the brain after death ! this seems a small amount to have
caused such terrible suif ering and an early death ! True,
it represents metallic lead, and we know nothing of how
it is combined with the tissues, or even in what chemical
form it exists, although there is much to lead us to infer
that it exists in some peculiarly complex molecular form.
Still I cannot but think that the death is from acute
toxaemia, analogous to but not identical with uraemia ;
the individual is poisoned by the products of her own
metabolism ; her cachexia points to a rapid disintegration
of blood, and the presence of lead in the bones and spleen
after death lends weight to the opinion that a deep wound
has been inflicted upon the blood and blood-making
organs.
Can nothing be done to diminish this tendency to lead-
poisoning and rapid death ? The blame, I admit, is not
altogether due to lead-making. There is an individual
predisposition to plumbism. There is a class of women
too easily affected by lead, but what that type is it is diffi-
cult to say. All I can say here is that many of them are
ill-fed, badly housed, and lead a questionable life, and
thus, owing to starvation and exposure, may be regarded
44 LEAD-POISONING.
as subjects likely to break down quickly under the influ-
ence of lead. But to many these remarks will not apply,
and consequently these conditions, whilst predisposing or
tending to aggravate symptoms when present, cannot be
the cause of them.
I would summarize my opinions thus :
1. That women suffer much more frequently and se-
verely than men.
2. That women suffer at an earlier age than men : that,
for example, of the 135 patients admitted into the New-
castle Infirmary, whilst up to the age of twenty-three no
men were affected, forty-nine women had already suffered ;
that after the middle term of life men suffer more than
women.
3. That acute lead-poisoning attended by cerebral sym-
ptoms is much more fatal amongst women than men.
4. That the most fatal period of lead-poisoning is that
time in a woman's life when the menstrual function is
extremely active, that this is one of the functions of the
body most apt to be quickly disturbed, and that in this
way an explanation may be found of the greater preva-
lence of lead-poisoning amongst women.
5. That death in the acute stage is due to toxaemia, and
in chronic plumbism is due to organic changes in the
kidneys and nervous system.
6. That gout in the north of England is a very infre-
quent accompaniment of lead-poisoning.
7. That cardio-renal changes are the most frequent
consequences of slowly developed lead-poisoning. That
whilst the paralysis known as " wrist-drop " is more fre-
quently met with amongst men than women, women suffer
much more frequently from the acute cerebral symptoms.
LEAU-POISONING. 45
Cases.
Case 1. Sudden death in lead-poisoning. — Elizabeth Ann
T — , aet. 22, single, admitted into the Newcastle Infirmary
July 18th, 1889 ; worked two and a half years at the
" white-lead.'^ After the first three months she was
obliged to leave off work for three weeks, owing to colic.
She returned and worked for seven weeks, when she was
again obliged to leave on account of colic. In August,
1888, she had severe pain in the head, which was followed
by partial blindness. She did not return to the factory
for two months. Gradually she regained her eyesight, and
has since then worked off and on at the lead-works. She
began to menstruate at the age of fifteen ; her menses,
which have been regular, have been scanty since she went
to the lead factory. At present the patient is menstruat-
ing. For the last few days she has complained of pain in
her joints and loss of eyesight. Urme normal, free from
albumen. The patient died in a convulsion early on the
morning following the day on which she was admitted.
The history of the case was obtained from the mother
after the death of the patient.
Post-mortem. — Body that of a well-developed female.
Blue line on gums. No oedema. Pupils half dilated.
Lungs healthy. Pericardium healthy, contains about two
drachms of serum. Heart healthy, weighs 10.^ oz. Eight
ventricle — walls flaccid, cavity empty. Left ventricle —
wall fairly thick, chamber empty, aortic valve competent.
Endocardium healthy, valves all healthy. Liver smooth,
healthy, weighs 60^ oz. Gall-bladder contains fluid bile in
small quantity. Liver-tissue on section is seen to be pale.
Spleen tears easily, is soft and pulpy, weighs 6^ oz. Left
kidney 5j oz. Capsule is removed with ease. On section
the veins in cortex and medulla are seen to be injected ;
otherwise nothing abnormal is detected. Right kidney 5^
oz. Capsule removed with ease. A small quantity of pus is
seen exuding from pelvis of kidney, but the lining mem-
46
LEAD- POISONING.
bratie is not noticed to be injected. Kidney substance
rather injected, but healthy. Vagina — hymen absent.
Uterus — cervix eroded and granular. Interior of uterus
covered with a red slimy material, which may be menstrual.
Ovaries — right ovaiy enlarged, contains two or three
corpora lutea, one yellowish, the others rather red, but evi-
Name of organ.
Total lead iu parts
per million.
Weight of organ.
Grains of lead per
weight of organ.
Lung .
7-6
29-0 ounces
0-0964
Heart .
412
105 „
0-0189
Liver .
37-8
60-5 „
1-000
Spleen .
120
6-5 ,.
0-0341
Kidneys
100
5-25 „
0-0229
Cerebrum
9-8 -j
51-5
0-779
Cerebellum .
24-8 J
Pons
22-6
Spinal cord .
116
Large intestine
37-7
Alcoholic
extract,
lead in
milligrms.
Ethereal
extract,
lead in
milligrms.
Aqueous
extract,
lead in
milligrms.
Ash,
lead in
milligrms.
Total
lead iu
milligrms.
Lead,
parts per
million.
Pons .
014
0-35
00
61
0-59
226
Cerebellum .
0-25
0-4
00
1-15
1-80
24-8
Brain .
0-3
00
0-0
1-35
1-65
9-8
dently not recent ; left ovary smaller, and somewhat cystic.
Stomach healthy, small ecchymoses near pylorus in upper
wall. Large intestine — longitudinal and circular muscular
fibres well developed, mucous membrane distinctly injected.
Brain — dura mater slightly adherent at vertex. Sub-
LEAD-POISONING,
47
^
^
Ci
- 00
=5^ oo
■TS
'«
«
e
■■■■■■■■■i
^■■■■■■■■K
m\
mm
ggiliilliii
^■■■■■■■■■s
^■■■■■■■■■E
|BiBg!inHl
^■■■■■■■Hi
BBagansiin
^■■■■■■■■Bl
^■■■■■■■■■i
^■■■■■■■■■S
^■■■■■■■■MK
^■■■■■■■■Kil
^■■■■■■■■Bi
□■■■■■■■■isi
§■■■■■■■■■£
^■■■■■■■■■fi
^■■■■■■■■3ie
^■■■■■■■■3lB
^■■■■■■■■KS
gggginsiiaB
mm
SBBBBBBBBISa
BBBBBBBVaai
SBBBBBBBBKB
eBBBBBBBKBB
BBBBBBBBICBfi
BBBBBBBaBBB
gBBBBBBK^BH
BBBBBBBSSBB
BBBBSSBBBBB
iSSBBBBBBBa
BBSBBBBBBBS
SBBiSBBBBBBEQ
BB»flBBBBBBII]
BBBBBlBDlsS
SBBBBBBBBBU
nBBHBBnaHBH
^m
48 LEAD-POISONING.
araclinoid fluid has accumulated to excess in the inter-
peduncular space ; pons and cerebellum extremely pale
compared with rest of brain, the pallor being particularly
noticeable in the pons. The surface of the brain is
healthy ; vessels not unduly injected. Coi'pus Ccallosum
very pale, as also brain-tissue generally ; very few puncta
hsemorrhagica. Each lateral ventricle contains two or
three drachms of serum. Membranes of brain other than
stated above are healthy, and there is no effusion. Spinal
cord feels extremely hard and is pale.
Case 2. Rapid death in lead-poisoning . — Catherine H — ,
set. 21, single, admitted June 28th, 1889, complaining of
pain in the abdomen of eight days' duration. Was always
a very healthy girl. She has worked at intervals in the
lead factory during the last twelve months, and has
suffered thi'ice from colic during that period. Only
three weeks ago she returned to the factory. Her pre-
sent illness commenced eight days ago with pain at the
vertex ; her appetite became bad and her bowels con-
stipated. On admission patient appeared to be very ill.
She was extremely restless and moaned a great deal,
owing to the headache and abdominal pain. She was
quite conscious ; was very pale. A blue line was noticed
on the gums. On the same evening from 6 to 7 p.m.
patient had three fits ; after 7 p.m. she became quieter.
It was noticed that during the fit the left arm moved
most. On the following day she was comatose ; the pupils
were half dilated and reacted slowly to light. Knee-jerk
present, slightly exaggerated on left side. Pulse 80,
slow; respirations 20 per minute. Heart — first sound over
mitral area prolonged, second aortic sound accentuated.
She is quite insensitive to pain. Urine, removed by
catheter, measured 20 oz., not albuminous, sp. gr. 1010.
Treatment proved unavailing, the patient never regained
consciousness, and she died on June 30th.
Post-mortem. — Brain weighs 48 oz. ; the convolutions of
both hemispheres are flattened; the veins of the membranes
LEAD-POISONING.
49
are gorged with blood. On section the brain substance
is seen to be pale^ a3dematous, and soft. There is slight
excess of Hiiid in the lateral ventricles. Heart — cavities
are empty, valves and orifices all healthy. Langs — left,
adherent at places ; upper lobe oedematous, lower lobe
congested : right lung, lower lobe congested. Spleen
1
Name of organ.
Total lead iu parts
per milliou.
Weight of organ.
Grains of lead on total
weight of organ.
Heart .
0-5
7'5 ounces
00016
Liver .
41-6
45-0 „
0-819
Kidnej's
13-3
4-5 „
00261
Spleen .
390
5-0 „
0-0883
Cerebrum
21-6
Cerebellum .
Brain with cere
bellum
}
8-59
480 „
0-634
30-19
Alcoliolic
extract,
lead in
milligrms.
Ethereal
extract,
lead in
milligrms.
Aqueous
extract,
lead in
milligrms.
Ash,
lead in
milligrms.
Total
lead in
milligrms.
Lead,
parts per
million.
Brain .
0-6
0-6
0-91
13
3-41
21-6
weighs 5 oz., is soft, and is studded with a large number
of minute htemorrhages. Liver weighs 40 oz. ; smooth on
the surface, pale on section ; otherwise presents nothing
abnormal. Gall-bladder contains | oz. of yellow bile.
Kidneys — capsule is readily removed ; on section they ex-
hibit nothing abnormal. Intestine normal.
Case 3. — Mary M — , ?et. 20, single, a lead-worker, ad-
mitted August 3rd, 1889, complaining of pain in the
abdomen, of headache, and of vomiting. Family history
good. Four years ago the patient went to the lead fac-
VOL. LXXIII. 4
50
LEAD- POISONING.
Case 3. Mary M — . — Daily Elimination of Urine, Urea,
Uric Acid, and Lead by the Kidneys.
UREA URIC LEAD URINE
GRS-Pr ACID GRAINS OUNCES
DIEM GRAINS
fill
m
22-10 u
vumwsm
400 20 -09 URINE
I 18 -08 60
300 lb -07
^WMiHiniii'
200 12 -05 40
100 8 -03
A B C D PE
LEAD-POISONING. 51
tory. After working there for three months she was
obliged to desist. For the next two and a half years she
was employed as a hawker of fish. A year ago she re-
turned to the lead factory, where she was employed in
the " white beds and stoves." Three months afterwards
she was again obliged to give up work on account of colic
and headache. She was away from the factory for five
months, but again returned, only, however, to suffer ; for
after eight weeks' employment she was again the victim
of colic, headache, and vomiting. She is pale, and her
features are somewhat full and I'ounded. Menses appeared
when patient was fourteen years of age, and she continued
to menstruate regularly until a year ago, when after re-
turning to the lead-works menstruation became profuse,
on two occasions the loss being so great that she could
not leave the house. This was followed by amenorrhoea,
which lasted three months. Since then the menses have
been regular but scanty. Pulse 76, soft, compressible.
Eyesight is not so good as formerly. Ophthalmoscopic exa-
mination by Mr. Williamson, August 4th : Left eye, disc
woolly ; large myopic crescent surrounding it ; slight rem-
nant of old choroiditis. Right eye, old choroiditis better
marked here than in the other eye ; disc woolly. Patient
has never been diplopic, and tells us that her eyesight has
never been perfect. Temperature normal. Urine 1027,
no albumen, acid, 35 oz. daily average. Patient has ex-
cellent teeth, and only the faintest trace of a blue line is
noticed on the gum. Tongue moist, clean. Lungs
healthy. Heart, beyond slight reduplication of the first
sound over the mitral area nothing abnormal is detected.
There is a venous hum in the neck. In the abdomen
nothing abnormal is detected. Treatment consisted prin-
cipally of sulphate of magnesia with hyoscyamus and
tincture of ginger, and in a fortnight all her pains had
disappeared, and her eyesight had considerably improved.
Case 4. — Elizabeth B — , aet. 26, married, admitted into
the Newcastle Infirmary October 30th, 1886, complaining
52
LEAD-POISONING.
Case 4.— Elizabeth B— ,
■■■■■■■■■■■■■■■■■BaBBI
00 |>0 l-'^t- <NI O ,00 <5
CO CO CO CO CO M N
BUSBSa^l^HH
LEAD-POISONING. 53
of obstinate constipation, pain in the abdomen, and sickness.
She is a pale anteniic woman, with rounded features ; very
distinct bhie line on the gums ; internal squint of left eye,
the pupil of which is slightly more dilated at times than the
right. Has been manned four years ; never miscarried ;
has never had children. Menstruation began when four-
teen years of age, and has been quite regular ; never had
menorrhagia. Seven weeks ago she went to a lead factory,
where she was engaged in the '^ stoves," carrying and
drying white-lead. Was perfectly healthy when she went
there ; has since lost much of her colour. After working
two weeks in the factory she had epistaxis. This con-
tinued more or less for more than half a day. Previous to
this she had been losing her appetite; she was scrupulously
careful in regard to washing her hands before eating, and
took freely of the acid drinks provided. During the third
week she began to suffer from pains in the abdomen,
accompanied by distension and constipation. This was
followed by vomiting every time she sat down to a meal.
A disagreeable taste in her mouth too Avas felt, and her
gums now^ showed the blue line. Urine alkaline, sp. gr.
1022, no albumen ; contains phosphates ; GO oz. of urine
passed daily on an average. Lungs healthy. Heart —
first mitral sound reduplicated, otherwise the sounds are
healthy. Abdomen — pain is felt over the transverse
colon, relieved by pressure. Blood contains 2,620,000
corpuscles in 1 cubic mm. ; there is one white corpuscle
to 261 red. The patient was treated by means of bismuth,
morphia, and belladonna, and made a good recovery.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Cbirurgical Society,' Third Series, vol. ii,
p. 11.)
A CASE OP TUBAL PREGNANCY,
WITH REMARKS ON THE CAUSE OF EARLY
RUPTURE.
BY
J. BLAND SUTTON, F.R.C.fS.,
ASSISTANT STRGEON TO THE MIDDLESEX HOSPITAL.
Received October 14th— Read November 12tli, 1889.
It would be superfluous to occupy the time of this Society
with the details of a successful operation for ruptured
tubal preguancy, were it not that the case presents some
exceptional features, and enables me to offer a few remarks
on some points in the pathology of the accident.
Emma B — , set. 37, came under my care in the Middlesex
Hospital, August 26th, 1889. Patient has been twice
married, her matrimonial life extends over a period of
seventeen years. Has never been pregnant or suffered
from gonorrhoea, and has always been regular with regard
to the catamenia until three months before her admission,
when she missed two periods. Five weeks before admis-
sion patient was seized with sudden violent pain in the
abdomen. Dr. Clegg, of Stratford, was sent for, and on
56 TUBAL PREGNANCY.
arriving found the woman collapsed. Slowly she reacted
and refused to allow any vaginal examination to be made.
In the course of a few days a swelling appeared on the
riffht side of the abdomen. At the end of five weeks she
was sent to me at the Middlesex Hospital.
On admission I found a swelling occupying the right
iliac fossa, extending upwards to the costal arch and
inwards as far as the middle line. The uterus was normal
in position, and the sound entered three inches. The
right side of Douglas's fossa was occupied by an ill-defined
swelling, firm to the touch ; a rounded moveable nodule,
of the bigness of a Tangerine orange, . lay behind the
uterus. No breast signs or history of vomiting. There
was great tenderness over the abdominal aspect of the
tumour. During the next twelve days the temperature
ranged from 99° in the morning to 101° in the evening.
On September 6th (twelve days after admission) I opened
the abdomen, and came upon a quantity of putrid, dark-
coloui^ed blood-clot filling the pelvis and right iliac fossa,
and extending upwards to the liver. This was quickly
removed, as well as the rounded moveable nodule in
Douglas's fossa. As soon as the clot was turned out some
smart bleeding came fi'om the right broad ligament. This
was quickly stopped by transfixing the ligament with a
double silk ligature close to the uterus, afterwards cutting
away the debris of the tube and ovary. The cavity of the
pelvis and peritoneum were washed out with eight quarts
of water at 110° — 115°. I then examined the left broad
ligament, but the parts were so matted together that it
was impossible to distinguish ovary or tube. The uterus
was normal in size, shape, and position. A glass drainage-
tube was inserted and retained for three days. The
temperature varied from 98° to 99*4° during the six days
following the operation, then rose somewhat as the track
of the drainage-tube suppurated. The patient made an
excellent recovery, due, I believe, to the use of the drainage-
tube.
On examining the parts removed I was able to recog-
TUBAL PREGNANCY. 57
nise the remnants of an enlarged Fallopian tube, the
ovary contained a corpus luteum of pregnancy. The
rounded moveable mass consisted of what is known as an
apoplectic ovum, and on washing the clot the cephalic
extremity of an embryo was fouud, corresponding to the
seventli or eighth week. An exaniinatiou of the membranes
is of interest, as it throws some light on the cause of these
early ruptures in tubal pregnancies.
Obstetriciansare familiar with rounded masses discharged
from the uterus of pregnant women accompanied by profuse
haemorrhage. Such rounded masses are known by a
variety of names — blighted ovum, carneous mole, apoplectic
ovum, cystic or tubercular ovum. They are so common
that every pathological museum contains many specimens.
In the middle of a blighted ovum a cavity exists, usually
lodging an ill-developed, misshapen embryo of about the
fifth, sixth, or eighth week of pregnancy : occasionally
only the stump of the cord is detected. A blighted or
apoplectic ovum is an early embryo with its membranes,
into which haemorrhage has occurred. The extent of the
extravasation varies; sometimes the whole of the membranes
are infiltrated, and occasionally the blood invades the
amniotic cavity and overwhelms the embryo.
The specimen I show to-night is an apoplectic ovum from
the Fallopian tiihe, and a glance at the drawing (Fig. 1)
will be sufficient to establish its identity. This is the key,
I think, to some of these early ruptures in tubal pregnancy.
For instance an ovum (using this term to include an
embryo and its membranes) the size of a walnut is
suddenly enlarged to the size of an orange by haemorrhage
into its membranes. When lodged in the uterus this
event causes sufficient disturbance to bring about expul-
sion of the ovnm, accompanied by free bleeding : in the
Fallopian tube this accident produces rupture, with dis-
charge of the ovum into the peritoneal cavity, accompanied
by profuse htemorrhage ; sometimes the extravasation
takes place into the broad ligament, but in early cases this
appears to be uncommon.
58
TUBAL PREGNANCY.
I do not base this opinion on one case. A few weeks ago
I made a report on a similar specimen, and as the details
Fig. 1. — The distended Fallopian tube showing the situation of the
rupture; o, ovary with corpus luteum.
Fig. 2.
Fio. 3.
Fig. 2.— AiHiplectic ovum from the Fallopian tube, represented in Fisf. 1.
Fig. 3. — Distorted head of the fcetua. About seventh or eighth week of
gestation.
of the case will probably be published shortly, further
remarks upon it must not come from me.
TUBAL PREGNANCY. 59
Specimeus of iutra-peritoneal haematocele, as they are
called, have been recorded and shown at societies, as
examples of ruptured tubal pregnancies, but no embryo
or membranes were found. I am strongly of opinion that
no case should be regarded as due to ruptured tubal preg-
nancy unless membranes, or foetus, or both, are forth-
coming", however suggestive the clinical evidence.
The most noteworthy clinical facts in the case of
Emma B — were these :
1. She had not been pregnant previously, although
married seventeen years, yet the first pregnancy was tubal.
2. The rupture, though intra-peritoneal and accompanied
by profuse bleeding, was not fatal.
3. The absence of the conspicuous signs of pregnancy
such as enlarged breasts and vomiting.
4. This is, I believe, the first example in which an apo-
plectic ovum has been recorded as occurring in the
Fallopian tube.
Note. — Shortly after this case was communicated to the
Society the track of the drainage-tube reopened and dis-
charged pus for a few weeks, until the three silk ligatures
with which the pedicle was tied came away ; it then
closed, and has given rise to no further trouble.
May 23rd. — I saw Mrs. B — to-day, and found her in
the best of health, and able to attend to household duties
as formerly.
Addendum. — Since this paper was written and placed
in the hands of the secretary I have, with the aid of the
light it appears to furnish, re-examined a specimen of
haematocele which has, I regret to say, been wrongly inter-
preted. As it admirably supports the contention of this
paper I will briefly describe it.
Alice H — , aet. 25, came under the care of my colleague
Dr. W. Duncan in August, 1886. She was married, had
three children, the youngest being, at the time of her
admission, two years old. Since the last confinement the
60 TUBAL PREGNANCY.
patient had suffered from pelvic pain and painful inenor-
rhagia. Vaginal examination revealed an elastic swelling
the size of a Tangerine orange to the left of the uterus.
The swelling was regarded as a dilated Fallopian tube.
In September, 1886, after consulting with my colleagues,
I opened the abdomen and removed the uterine appendages.
Tlie left ovary was adherent to a fold of omentum which
contained coagulated blood, and constituted the swelling
which could be felt by the vagina. The ovaries were
cystic, and the haemorrhage was attributed to rupture of
one of the enlarged follicles. The patient made an admir-
able recovery, and I preserved the htematocele as a patho-
logical curiosity. My interest in the matter induced me
to re-examine the specimen, with the following result :
One inch from the abdominal ostium of the Fallopian
tube there is a rupture exposing for some distance the
mucous membrane of the tube. Close beside this, em-
bedded in laminated clot, is an apoplectic ovum of the
bigness of a chestnut, and a few delicate fringes project
from it. These, when examined microscopically, show tlie
dendritic arrangement of the villi of the chorion. The
heematocele in this case was not due to the rupture of a
follicle, but to a ruptured tubal pregnancy of very early
date (probably fourth or fifth week). It is the smallest
apoplectic ovuto I have as yet examined. From the his-
tory it is impossible to decide the date of the accident,
but the hematocele had been noticed for many w^eeks pre-
viously to the operation, and there was no evidence of peri-
tonitis beyond the few adhesions between the ovary, tube,
and the omentum which immediately encysted the blood-
clot.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 18.)
A CASE OF GHOLECYSTENTEKOSTOMY.
A. W. MAYO ROBSON, F.R.C.S.,
HON. SUKGEON LEEDS GENEKAL INFIKMAUY ; LECTUEEK ON PRACTICAL
SURGERY AT THE YORKSHIRE COLLEGE ; AND EXAMINEE
IN THE VICTORIA UNIVERSITY.
Received September 21st— Read November 36tb, 1889.
For the notes from wliicli the history of this case has
been abstracted I am indebted to my house surgeon^ Mr.
F. Hudson.
Mrs. V. B — , set. 42^ was admitted into the Leeds
General Infirmary January 9th, 1888^ on account of a
tumour on the right side of the abdomen, which was
accompanied by symptoms of acute peritonitis. She had
had abdominal section performed a year previously by me
for pelvic disease of several years' standing, which had
produced confirmed invalidism, and after the removal of
the cause, a right pyosalpinx, she had been able to resume
her work, and for several months had enjoyed excellent
health, and been able to perform very arduous duties as a
general servant in a large family, her menstrual functions
being regular and painless. Three weeks before admis-
sion she began to experience pain in the right side of the
abdomen without apparent cause ; she then noticed a small
rounded swelling, tender on pressure, in the right hypo-
chondriac region ; there was no jaundice, and the bowels
62 CHOLECYSTENTEROSTOMY.
were regular. The swelling and pain increased, and
compelled her to give up her work. She was seen by her
medical man, Mr. Loe, three days before admission, when
there was very marked tenderness over the swelling, which
seemed to be decidedly increasing. Her general condition
became rapidly worse, and nothing could be retained on
the stomach, the vomit being of a dark brown colour.
She suffered from great pain and intense thirst, the abdo-
men being tympanitic and the pulse frequent and weak.
On admission to the infirmary on January 9th the
patient had an anxious expression, and lay on her back
with the knees drawn up. She complained of great pain
in the right side of the abdomen, markedly increased by
pressure, deep respiration, or turning on her side. There
was a distinct sense of resistance in the right hypochon-
driac and iliac regions, with dulness on percussion ; but
on account of the extreme tenderness, palpation was
rendered difficult. Respirations 30, pulse 130.
The fffices had a normal colour. The urine was normal
except that it gave Gmelin's reaction for bile-pigment.
On January 13th, 1888, she became jaundiced. It now
became evident that she would soon die unless relieved by
operation, and on January 14th abdominal section was
performed through the upper part of the right linea semi-
lunaris, exposing a large cyst with thickened walls, which
yielded by aspiration eight ounces of foetid pus. After
the gall-bladder had been emptied it was incised, and then
explored, sponges having been previously packed round
it. The finger was passed along the peritoneal surface of
the cystic duct as far as possible, and beyond this, but
inside the duct, was passed a long metal probe, this ex-
ploring as far as the junction of the cystic with the
hepatic duct ; the finger was also passed along the outside
of the common duct as far as the duodenum, but no gall-
stone or other obstruction could be felt. Around the
common duct, as well as over the cystic duct, plastic
lymph had been thrown out ; and this probably explains
the subsequent course of events.
CHOLECYSTENTEROSTOMY. 63
The gall-bladder was stitched to the skin, and a drainage-
tube inserted, the remainder of the wound being closed by
silk sutures passed through all the layers of the abdominal
wall, including the peritoneum.
For the first twenty-four hours the discharge remained
clear, colourless, and mucoid ; in the second twenty-four
hours it became slightly tinged witii bile, and on the
third day the discharge appeared to be pure bile. On
the fourth day a smaller drainage-tube was inserted, and
the stitches were removed on the seventh. The jaundice
had quite disappeared forty-eight hours after the opera-
tion. The patient made an uninterrupted recovery with
the exception of having a biliary fistula, through which
apparently the whole of the bile was discharged ; for both
the faeces and the urine showed no trace of biliary matter,
either by inspection or on chemical examination.
During the fifteen months subsequent to the operation
the patient's digestion was unimpaired unless she took
too much fatty matter, and then she became sickly and
lost her appetite, and rather more fat than normal was
passed in the motions ; the bowels were quite regular
without the use of aperients, and the odour was in no wise
different from that of healthy fseces. Repeated measure-
ments were made of the whole of the bile discharged
during twenty-four hours, and a careful analysis of the
bile thus collected was made.
The details of these and other observations will be con-
sidered in a separate paper, and may, I think, have an
important bearing on the physiology of the bile, as may
also observations made on the action of certain drugs on
the biliary secretion have a bearing on biliary thera-
peutics.^
Now, although the patient was in good health, her
condition was a very miserable one, since no apparatus
could be made to fit sufficiently accurately to catch the
whole of the bile, except when she was in bed. When
• Paper read before Royal Society (London), April 24th, 1890, and pub-
lished in the ' Proceedings ' of the Royal Society for 1890.
64 CHOLECYSTENTEROSTOMY.
out of bed she had to catch the overflowing bile in absor-
bent cotton, which was retained in position by means of a
bandage, thus necessitating her frequently changing her
dressings and clothes. On one occasion, when she was
unable to change the wool, the wearing of her bile-satu-
rated garments gave her a severe chill, which resulted in
an attack of pelvic cellulitis.
She was so miserable at the prospect of having to go
through life with her fistula, that when I mentioned to her
the possibility of again turning the bile into the bowel,
she said she would risk anything to be rid of her trouble.
I asked my colleagues to see her with me, and they
agreed that cholecystenterostomy was perfectly justifiable
if its risks were fully explained to the patient.
Her consent was at once granted, and on March 2nd,
1889,1 opened the abdomen in the right linea semilunaris
through the old scar, in the centre of which was the
fistula, prolonging the opening two inches beyond the
lower end of the cicatrix. The gall-bladder was detached
from the parietes, and found to be much contracted and
thickened. There was so much matting of the viscera
that it was found impracticable to bring up and fix the
duodenum or jejunum to the gall-bladder as at first
intended ; hence the hepatic flexure of the colon, lying
near, was raised and encircled by an elastic ligature, after
its contents had been squeezed upwards and downwards.
Convenient spots having been selected on the gall-bladder
and colon, a circle the size of a florin was marked by a
scalpel on each viscus. Along these lines, sutures of fine
chromicised catgut were passed, about an eighth of an
inch apart, by means of curved sewing-needles, but these
were not tightened until openings a third of an inch in
diameter had been made in the centre of the circles, quite
through all the coats of the two viscera concerned, and
the cut edges of the mucous membrane of the colon had
been sutured by a number of interrupted stitches of fine
catgut to the edge of the mucous membrane of the gall-
bladder. The closed blades of a pair of Spencer Wells'
CHOLECYSTENTEROSTOMY. 65
pi-essure forceps were passed through the opening from
the gall-bladder into the bowel, in order to see that it was
thoroughly patent after the ligatures had been tightened.
The outer row of ligatures, only involving the serous and
muscular coats, were tied and cut off short.
The refreshed edges of the old fistula were then brought
together by means of a continuous catgut suture, the
serous surface being tucked in and a number of Lembert^s
sutures being further applied over the line of union.
The elastic ligature was removed from the bowel, and
the circulation became immediately re-established. The
sponges which had been packed below and around the
colon and gall-bladder had prevented soiling of the peri-
toneum.
A glass drainage-tube was placed in the right kidney
pouch, and brought out at the lower end of the wound in
order to guard against any accident of sutures giving way.
Lastly, silk sutures were employed to bring together
the parietal incision in the usual manner. The patient
had a little pain, but no sickness or distention.
On the night of March 3rd a tinge of bile appeared on
the dressings, showing that the over-tense sutures on the
outer surface of the gall-bladder had given way, but,
thanks to the drainage-tube, without any dangerous result.
On the following day the bile came freely through the
drainage-tube, and on March 5th feecal matter made its
appearance mixed with bile, after which, up to the 18th,
fseces and bile continued to be discharged, and then bile
alone, the wound granulating and ultimately completely
closing on May 6th, when the motions were noticed to have
fully regained their normal colour.
The patient, who was sent to a Convalescent Home,
rapidly gained strength and weight, and reported herself
in July as in perfect health. When she left the infirmary
she weighed 8 st. 4^ lbs., and in July her weight was
9 St. 6| lbs.
She was shown to the members of the British Medical
VOL. LXXIII. 5
66 CHOLECYSTENTEROSTOMY.
Association in Leeds in August, and then said that she
had never been in better health.
During the time the fistula was open the menstrual
functions were in abeyance. After its closure the menses
returned, and have continued to recur regularly.
While the bile was being discharged externally Mrs.
B — had a dislike to fat, to meat, and to sweet food, and
a craving for acids such as lemons and pickles.
The operation of cholecystenterostomy was first per-
formed by Winiwarter, who suggested its application in
cases of irremediable obstruction in the common bile-duct.
It has since been performed by Monastyrki, Kappeler,
Socin, and Bardenheuer, but hitherto it has not been done
in England. I think it has never previously been per-
formed for biliary fistula.
The fact of the patient having within the space of four
years undergone three abdominal sections is, perhaps, al-
most unique. Her first operation, the removal of a pyo-
salpinx, restored her to health and comfort after several
years of distress and incapacity, besides relieving her from
the constant danger of suppurative peritonitis. The second
operation, cholecystotomy,for empyema of the gall-bladder,
undertaken when she was apparently dying of peritonitis,
undoubtedly saved her life. The third operation, chole-
cystenterostomy, performed for a condition which rendered
her life wretched, has restored her to a condition of abso-
lutely perfect health, for she is now strong, well, and
healthy in every respect.
Numerous interesting questions arise in the case.
1st. On the benefit derived from removing diseased
uterine appendages ; and in this case only the diseased
one was removed, the apparently sound one being retained,
the menstrual functions being afterwards continued regu-
larly and painlessly, except during the time the biliary
fistula was open, when there was amenorrhoea.
2nd. On the advisability of operating during acute peri-
tonitis in order to find out the cause, and, if possible, re-
mo\;e it.
CHOLECYSTENTEEOSTOMY. 67
ord. Ou the treatment of distended gall-bladder by
cholecystotomy^ and not by cholecystectomy.
4th. On the cause of empyema of the gall-bladder.
5th. On the frequency or otherwise of fistula after
cholecystotomy.
Gth. On the apparent harmlessness to the system of the
loss of the whole of the bile over so long a period as fif-
teen months, making it appear as if the bile were simply
an excretion.
7th. The physiological experiment to which the patient
voluntarily submitted herself, which will be discussed in
another paper.
I Avould draw attention to some of the details in the
operation described.
The cause of the fistula was apparently a cicatricial
contraction of the duct. It was, therefore, hopeless to
attempt to secure a return of the bile to the intestine by
the ordinary channel, and on opening the abdomen it was
found impossible, on account of the old adhesions, to stitch
the gall-bladder to the small intestine in the region of the
duodenum. It was therefore sutured to the colon. Instead
of using the ordinary intestinal clamps, or passing liga-
tures through the mesentery and around the boAvel, a loop
of colon, after its contents had been squeezed out, was
simply drawn up and secured at its base by an ordinary
piece of elastic drainage-tube, which was fixed by a pair
of pressure forceps. This tourniquet both prevented any
escape of gas or feecal matter, and rendered the intestine
almost bloodless — in fact, it simplified the operation very
considerably, and was applied in a few seconds ; hence in
future I shall never think of using any other intestinal
clamp.
There is nothing calling for mention in the mode of
application of the sutures, which were applied after the
Czerny-Lembert method.
The loss of tissue from the outer surface of the gall-
bladder, where it had been stitched to the skin for so long
a period, rendered it necessary to apply more tension than
68 CHOLECYSTENTEROSTOMY.
was desirable in order to secure exact apposition of serous
surfaces. I therefore thought it wise to insert a glass
drainage-tube into the right kidney pouch in case of the
escape of any bile or faeces. This precaution prevented
a catastrophe when the tense sutures gave way.
As I assumed that the escape came from the outer sur-
face of the gall-bladder, and not from its junction with
the intestine, I felt confident that the fistula would ulti-
mately close by granulation, and that then the bile would
be able to flow through the new channel. I am glad to
say that this prognosis was justified by the course of events.
I must apologise for giving the history at some length,
but I hope the interesting questions raised by this some-
what unique case may afford a sufficient excuse.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 28.)
ON
BLOOD TUMOURS (ANGEIOMATA AND
ANGEIOSAECOMATA) OF BONE.
BY
EDMUND EOUaHTON, B.S.Lond., F.E.C.S.
Received November 1st— Read December lOtb, 1889.
Blood tumours of bone are of great rarity, but never-
theless of considerable interest and importance, as their
nature is very little understood, their diagnosis very diffi-
cult, and their treatment consequently not directed upon
any definite lines.
The disease has received various names from different
authors, having been called osteo-aneurism, capillary
aneurism, hsematoma of bone, sarcoma of bone, &c., these
names expressing the different views which have been held
with regard to its nature.
Its almost exclusive seat is the cancellous ends of the
long bones, especially the head of the tibia and the con-
dyles of the femur. On examination the tumour is found
to be composed of a cyst-wall and contents. The cyst-wall
is usually formed by a thin expanded shell of bone covered
by thickened periosteum, to which the surrounding tissues
are more than usually adherent. On opening the tumour it
is found to contain little else but blood, partly fluid, partly
70 ON BLOOD TUMOURS (aNQEIOMATA
coagulated. Sometimes a thin layer of tissue is found lining
the interior of the cyst-wall, and sometimes the bony shell
is quite destitute of any lining. In some specimens the
bone is so destroyed that there is complete loss of con-
tinuity between the portion of bone above and below the
disease (see Fig. 1). In the last edition of one of the
standard text-books of pathology^ I read that these tu-
mours *'are now known to be in the majority of cases
soft round-celled or spindle-celled sarcomata
They are exceedingly malignant, and hence the recogni-
tion of their sarcomatous nature is all-important.'^ That
this statement is not true of all cases is clearly proved by
the following case which I had the opportunity of ob-
serving very carefully.
Lilian C — , eet. 4, was admitted into St. Bartholomew's
Hospital on May 26th, 1886, under the care of Mr. Langton,
to whom I am indebted for permission to publish the notes.
The only history the mother could give was that ten months
previously the child had fallen and hurt her leg. Since
then she had noticed that her gait had altered somewhat,
and that her left leg was gradually swelling just below
the knee.
On admission her general health seemed excellent, and
there was no evidence of any constitutional disease : the
left leg was swollen below the knee, the circumference of
the limb opposite the tubercle of the tibia being an inch
and a half greater than that of the other limb. The
swelling seemed to involve the upper three or four inches
of the tibia and to expand it, for on pressure egg-shell
crackling could be easily detected. There was complete
absence of pain, tenderness, redness, and oedema ; the
knee-joint was natural, and there was no glandular en-
largement to be discerned anywhere. The thigh was
slightly wasted, pi'obably from disuse. It will be gathered
from the above account that the cause of the swelling was
something inside the head of the tibia expanding it ; that
was sufficiently evident, but the nature of the " something
1 Green's ' Pathology,' 1889.
AND ANGEIOSARCOMATA) OF BONE. 71
inside " could only be guessed at. Thinking that the
case was probably one of myeloid sarcoma^ it was resolved
to make an exploratory incision^ and deal with the case
according to the conditions found. This was done on
June 14thj 1886^ and it was discovered that the upper end
of the tibia contained a cavity capable of holding about
two ounces of fluid.
The wall of the cavity was composed of bone destitute
of any lining, and in front_, where the opening had been
made, was not more than one tenth of an inch thick. Very
little bone seemed to intervene between the cavity and the
knee-joint. The contents consisted of a dark red fluid,
looking like altered blood and serum, and a very little
solid matter, which proved on microscopic examination to
be blood-clot. The cavity was stuffed with oiled lint. In
a few days it became lined by granulation tissue, and began
to contract.
On August 18th the child developed scarlet fevei*, which
necessitated her removal from the hospital ; the cavity,
however, continued to contract slowly, and by March, 1887,
was completely obliterated, a healthy scar remaining in
the site of the operation wound.
The patient is now perfectly well. There is a healthy
scar in the site of the operation wound, and the bone
seems quite consolidated. All the measurements of the
two limbs are so nearly equal that no difference can be
detected.
This case presented features so peculiar, and so unlike
everything I had hitherto believed about such tumours,
that I was induced to peruse the literature of the subject
to see if I could discover anything* like it. Although I
could find no record of a similar case, yet I found accounts
of others which I think throw very great light upon the
nature of these tumours. I propose, therefore, to give
short notes of those cases I have been able to find which
have most bearing upon the subject.
The most malignant type of blood tumour of bone is
nothing more or less than an endosteal sarcoma, in which
72 ON BLOOD TUMOUES (aNGEIOMATA
blood-vessels liave burst and caused extravasation of blood.
In this variety tliere still remains enough solid new growth
to be at once recognised, even by the unaided eye, and on
microscopic examination the nature of the tumour is suffi-
ciently evident.
But sometimes the amount of sarcoma tissue is so re-
markably small that it may easily escape detection. As
an excellent example of this, I might quote the following
case recorded by Max Oberst.^
A man twenty-one years old had noticed a swelling
upon the inner side of his knee for three mouths. When
first seen by Oberst the tumour was as large as two fists,
and was fluctuating in some places. An incision was
made into it and blood escaped, partly fluid and partly
coagulated. The finger introduced through the aperture
impinged upon the internal condyle of the femur, greatly
destroyed. The limb was immediately amputated. On
examining the limb the sac of the tumour was composed
partly of the cancellous tissue of the lower end of the
femur, and partly of a thin shell of bone greatly expanded
and covered by thickened periosteum. The cyst-wall was
lined inside by a thin layer of tissue, most marked in the
interior of the femur. On microscopic examination this
was found to be sarcoma tissue rich in large round-cells.
There were a few giant-cells containing from five to fifteen
nuclei. Only a very few layers of cells next to the peri-
phery of the sac were intact ; all the others were more or
less disturbed and separated by effusion of blood.
The patient died subsequently with metastatic deposits
of soft aiid vascular myeloid sarcoma, containing true ossi-
fications in the periphery, and having a tendency to apo-
plexy.
Here, then, is a case presenting all the clinical characters
of a sarcoma, but being peculiar in that the tendency to
effusion of blood was far greater than the power of the
tissue itself to grow, and hence the naked-eye appearances
of the tumour on dissection.
^ ' Deutsche Zeitschrift t'iir Cliinir^ie,' Band xiv, 1881.
AND ANQEIOSARCOMATA) OF BONE. 73
The following is a case in which the progress of the
disease was arrested for seven years by tying the main
artery of the limb. I have made the following abstract
from Breschet,^ who quotes the case from the practice of
M. Dupuytren in the Hotel Dieu.
Clement Nicholas R — , set. 32, suffered from a pulsatile
tumour expanding the upper end of the right tibia. He
had noticed it for a year before his admission to the hospital
on February 9th, 1819. Dupuytren regarded it as a case
of osteo-aneurism, and tied the femoral artery on March
16th. The next day the tumour diminished in size, and
on the sixth day the pulsations ceased. The patient left
the hospital on April 80th, the " aneurism " having dis-
appeared, leaving only a little tumefaction in the site
formerly occupied by it. A long time afterwards the
tumour grew again, and assumed a considerable size. On
August 1st, 1826 (seven years after the operation), he
again presented himself at the hospital, the tumour having
attained such dimensions that the leg measured thirty-two
inches in circumference. Dupuytren amputated above the
knee, and the patient made a good recovery. The speci-
men was examined by Breschet. The limb was enormous
owing to the extraordinary development of the upper end
of the tibia, the condyles of which were expanded and
divided by compartments into numerous cells like a pome-
granate ; the walls of the cavity were lined with a vascular
network distended by injection, which had been forced
into the arteries of the limb. Some of the cells contained
a yellowish-black substance, others contained strata of coa-
gulated blood. The cartilages, almost intact, were loosened
from the osseous surfaces, and moveable in the middle of
the disease.
The following case related by Roux^ is even more re-
markable.
A man, set. 25, suffered from a pulsatile tumour ex-
' ' Repertoire Generale d'Auatomie et Physiologie Pathologique, et de
Clinique Chirurgicale,' tome ii, Paris, 1826.
" ' Quarante annees de pratique chirurgicale,' tome ii, p. 456=
74 ON BLOOD TUMOURS (aNGEIOMATA
panding the upper end of tlie tibia. After ligature of the
femoral artery the turaour disappeared^ and the bone re-
turned to its normal condition. The patient was seen
twenty years afterwards, and was then in good health.
In this case it would seem that the inherent vitality of the
new growth was so slight, that after a certain time it be-
came arrested either by pressure of the extravasation of
blood, or by arterial starvation following the ligation of
the femoral artery, or both.
The following case related by Dr. Lagout d'Aigueperse^
confirms the preceding case, which if it stood alone might
be open to doubt.
The '^ aneurism " was situated in the upper end of the
tibia. It diminished greatly in size, and its pulsation
ceased after ligature of the femoral artery, but the bone
did not return to its natural condition. It was in the same
state eight years afterwards.
I will now quote a case in which the tendency to pro-
gress was so slight that it was arrested without any opera-
tive interference.
Dr. McDonnell," in reading a paper on pulsating tumours
of bone before the Royal Academy of Medicine in Ireland,
detailed the case of a lady who had been sent to him by
Mr. Erichsen nearly five years previously. She then
suffered from a pulsating tumour over the upper part of
the fibula, which he and Mr. Erichsen agreed in regard-
ing as probably a h^matoid sarcoma of bone. It con-
tinued for some time to increase in size. Operation was
deferred on account of the lady's pregnancy, but she was
directed to wear an elastic stocking. She suffered after
delivery from phlegmasia of the other limb, which caused
her to remain in bed for neai'ly six months — still, however,
wearing the elastic stocking. When she came again under
Dr. McDonneirs care some time after her parturition the
tumour was found to have disappeared.
In the absence of any pathological examination of the
1 ' Bulletin de la Societe de Chirurg.,' t. ix, p. 258, 1858-9.
' 'Laucet,' Dec, 1888, p. 1130,
AND ANGEIOSARCOMATA) OF BONE. 75
tumour it is impossible to be absolutely sure of the nature
of tlie case ; yet, taking into consideration the facts of the
case, and bearing in mind that it was under the care of
excellent observers, one can, I think, only infer that it was
an innocent blood-cyst of bone, in which the newly formed
tissue had such little power of growth that it was arrested
by the pressure of an elastic stocking.
Here, then, we have a series of cases of blood tumour of
bone presenting very vai'ying clinical characters. Arrang-
ing them in order of malignancy, they may be briefly re-
capitulated thus :
1. Max Oberst^s case. A highly malignant endosteal
sarcoma.
2. Dupuytren's case. Arrested for seven years by tying
the main artery of the limb.
3. Roux's case. Permanently cured by tying the main
artery.
4. Lagout's case. Similar to the preceding.
5. The case recorded by myself, in which the growth
was arrested by simple incision.
6. McDonnell's case. Cured by the pressure of an
elastic stocking.
We must now turn to the microscopical characters of
these tumours in order further to elucidate their nature.
In Oberst's case the microscope showed that the tumour
was a myeloid sarcoma in which a large number of blood-
vessels with very weak walls had burst, and caused exten-
sive extravasation of blood, which had, so to speak,
swamped and destroyed most of the solid tissue. It is to
be regretted that the other cases in which the specimens
were examined occurred before the days in which myeloid
tumours had been recognised.
The piece of bone removed from the wall of the cyst in
the case of Lilian C — was examined microscopically by
my friend Mr. Bowlby, and by him and other authorities
pronounced to contain myeloid sarcoma tissue. The section
presents different appeai-ances in different places. In some
parts trabeculge of bone are seen being eroded by small round
76 ON BLOOD TUMOURS (aNGEIOMATA
nucleated cells. In other places large giant-cells containing
many nuclei are clearly seen^ whilst the bulk of the tissue
appears to consist of spindle-shaped cells very much like
those of spindle-celled sarcoma. The blood-vessels of the
tumour, however, are the most interesting and important.
Many of them appear to be only spaces in the tissue with
no wall of any sort, and from them red blood-corpuscles may
be seen exuding into the surrounding tissues and crowding
out the cells of the tissue itself (Fig. 3). Others have a
very thin wall, still allowing considerable exudation.
Others, chiefly the smallest, have a wall of considerable
thickness, and containing many large nuclei crowded to-
gether. These blood-vessels are so numerous and large
that one is at once led to inquire why they are present in
such large numbers. Surely not because the tissue re-
quires a great deal of nourishment, for we see plenty of
examples of other tumours growing much more rapidly, and
yet being much more poorly supplied with blood-vessels.
I am, therefore, forced to conclude that the blood-vessels
are an essential part of the tumour. But then it may be
asked, how is it that these blood-vessels are mixed up
with other structures which are evidently in many cases,
at any rate, decidedly sarcomatous, both in microscopical
appearance and in clinical deportment ? I think the
answer to this question is that these blood-vessels grow
mainly, if not entirely, from the giant-cells of the bone-
marrow, and may present every degree of developmental
perfection, from the most imperfectly formed vessels in-
capable of containing blood up to the perfectly formed
vessels of an ordinary angioma. This statement I am
unable to prove, but there are many considerations tending
to confirm my view.
Thus, firstly, Heitzmann^ has described the formation
of blood-vessels from the giant-cells found in the marrow
of healthy cancellous bone. I am not aware that those
observations have been confirmed by other observers, but
1 Heitzmann, " Riick- und Neu-bildung v. Blutgef. im KnocLen," ' Wien.
ined. JaLrb.,' 1873.
AND ANGEIOSARCOMATA) OF BONE. 77
Dr. Klein tells me that although lie has not actually ob-
served the process himself, yet he thinks it highly pro-
bable on a lyriori grounds that it does occur ; certainly,
blood-vessels are developed from similar cells in other
situations : thus in the area vasculosa of the chick large
multinucleated cells may be seen becoming vacuolated and
forming blood-vessels, and in the subcutaneous tissue of
rats large multinucleated connective-tissue corpuscles may
be observed to be undergoing the same changes. Although
one cannot actually see blood-vessels developing from
myeloid cells in the sections of the tumour I have de-
scribed, yet there are appearances very suggestive of it,
especially the capillary vessels with richly nucleated walls
already described.
Secondly, these tumours only occur in those parts of
bone where myeloid cells are found in health.
Thirdly, in several cases of blood tumour of bone, of
which I have read the notes, great stress is laid upon the
fact that the sac of the tumour contained a vast number
of thin- walled vessels. Thus Breschet, in describing the
tumour amputated by Dupuytren, says '' the walls of the
cavity are lined with a vascular network greatly developed.
Over the membrane which lines some of the cells are seen
vascular networks distended by the injection forced into
the arteries.'^ Scarpa,^ in describing a blood tumour of
the tibia for which he amputated the limb, says the
^' aneurismal sac was quite covered with arterial vessels
of a much greater size than those of the proper arteries
of the cellular substance and those of the periosteum.
After cleaning thoroughly the inside of the
aneurismal sac it was wonderful to see from how great a
number of arterial orifices the wax injected into the popli-
teal artery had been effused into the cavity of the aneu-
rism.'^ Eichet^ observed the same appearances, and thought
that these tumours were pure vascular tumours of bone,
and denied that they contained any sarcomatous elements.
' ' Suir Aneurisma/ fol., Patav., 1804.
'' Richet, ' Archiv. Gen. de Med.,' 1864 and 1865,
78 ON BLOOD TUMOURS (aNGEIOMATA
Fourthly^ pure angeiomata of bone are occasionally
met witli. Dr. Mapotlier^ has recorded a case in which
a blow upon the shin was followed by the development of
a tumour, the size of a walnut_, in the tibia ; there was
distensile pulsation, thrill, and bruit. He removed the
cuticle by potassa f usa^ and then applied a cautery. After
an interval of ten days intense haemorrhage occurred :
in a few days a " nsevoid matter " came away, leaving a
granulated surface which rapidly healed. The patient was
well sixteen years afterwards. A similar case also occurred
to Dr. Bickersteth, of Liverpool. In these cases there was
no blood tumour because the blood-vessels were sufficiently
strong and fully developed to hold blood without bursting.
From the above facts and arguments I think it follows
that not only do these blood tumours present different
degrees of malignancy, but that they also differ in struc-
ture, some having very embryonic blood-vessels, others
more fully developed ones ; and it would appear that the
more embryonic these vessels are, the more malignant are
the clinical features of the tumour in which they occur ;
and conversely, the more the vessels approach to the type
of fully developed structures, the less malignant the
tumour. This notion is fully in accord with what is so
well known about fibrous tumours, spindle-celled and
round-celled sarcomata.
My conclusion, then, with regard to the nature of blood
tumours of bone is that they are tumours of blood-vessels,
some innocent and some malignant in nature. I would
therefore suggest that they be called angeiomata and
angeiosarcomata of bone.
Turning now from the pathological to the clinical aspect
of these cases, we are still met by great difficulties.
Owing to their great rarity they are seldom suspected,
and hence usually unrecognised until they are subjected
to surgical treatment. Their general symptoms have
been sufficiently referred to in the preceding cases to
need no further description. The most important thing
1 ' Lancet,' Dec, 1888.
AND ANGEIOSARCOMATA) OF BONE. 79
is to distinguish between innocent and malignant cases,
for on this diagnosis must depend to a great extent our
prognosis and treatment. On comparing the innocent
and the malignant cases, the only difference discoverable
between the two is that in the former the progress of the
disease is slower than in the latter. As far as I can
ascertain, there is no other difference which will help us
to decide this very important point. Age seems to have
no influence, nor do the characters of the tumour or its
constitutional effect on the patient afford the least clue to
its degree of malignancy.
How then should such cases be dealt with ? The
golden rule of cutting into the tumour before removal of
the limb or affected bone should certainly be followed.
If the tumour be found to contain a large quantity of
solid sarcomatous-looking tissue there will be no chance
for the patient except from very free removal, and this
usually necessitates amputation. If, however, the contents
of the tumour consist entirely of blood, or if only a very thin
lining of tissue be found, I would suggest that the latter
be scraped carefully away, and the cavity stuffed and
allowed to granulate up. Of course there is a risk of
dangerous haemorrhage from the interior of the cyst-wall.
In two cases, however, which I have seen opened (the
one related above, and the other under the care of Mr.
Cripps in St. Bartholomew's Hospital) no heemorrhage
occurred. Should it occur, one would not anticipate
great difficulty in arresting it.
Should the future progress of the case indicate that we
have to deal with a malignant growth we can still resort
to amputation, and with scarcely less favorable prospect
than if we had resorted to it in the first instance, while
we have the satisfaction of having given the patient the
chance of recovering with a sound limb.
Although ligature of the main artery of the limb has
been practised in a few cases with success, I should not
be disposed to try it, as, having regard to the great diffi-
culty in distinguishing between an innocent and a malignant
80 ON BLOOD TUMOURS OF BONE.
tumour, we may be wasting valuable time in performing
a useless operation whicli is not devoid of dangers peculiar
to itself.
The other methods of treatment which have been used,
such as injection with coagulating fluids, compression, &c.,
need only be mentioned to be condemned.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 42.)
DESCRIPTION OP PLATE I.
On Blood Tumours (Angeiomata and Angeiosarcomata) of Bone
(Edmund Roughton, B.S.Lond., F.R.C.S.).
Fig. 1. — Blood-cyst of tibia (from the Museum of St. Bartholo-
mew's Hospital).
Fig. 2. — Blood-cyst of lower end of femur.
a. Thin layer of sarcomatous tissue.
h. Cavity filled with blood.
(After Max Oberst.)
Fig. 3. — Blood-cyst of head of tibia (the case of L. C — ).
Section of cyst-wall, showing blood-corpuscles exuding from thin-
walled blood-vessels into surrounding tissues.
Plate i.
MED. CHIR. TRANS., VOL, LXXIIL
Fig2
Figs
DanIELSSON & Co. LiTHO.
SUCCESSFUL REMOVAL
OF THE
ENTIRE UPPER EXTREMITY EOR OSTEO-
CHONDROMA.
THOMAS F. CHAVASSE, M.D., C.M.Edin.,
SUEGEON TO THE GENERAL HOSPITAL, BIEMINGHAM.
Received November 19tli, 1889— Bead January Utli, 1890.
On the recommendation of Dr. de Denne, of Cradlej, a
carter, fet. 40, was admitted into the General Hospital,
Birmingham, January 16th, 1889, under my care, for a
large tumour growing from the right humerus which ten
years before had been first noticed below and external to
the shoulder-joint. In spite of treatment the growth was
steadily maintained, and the increase in size caused pain
in the neck and forearm, but it was only during the last
eighteen months that the surface became irregular and
the growth perceptibly more rapid.
Three months before admission softened patches ap-
peared at the lower part, and one week previously one
such patch had given way and an oily fluid constantly
drained from the opening. Up to the last the affected
arm, with the aid of a sling, was used for driving, and there
was no deterioration of the general health.
On admission. — A tumour twelve inches long, with a cir-
voL. Lxxni. 6
82 SUCCESSFUL REMOVAL OP THE ENTIRE
cumference of twenty-eight inclies at its widest part and
resting internally upon tlie thoracic wall, was found im-
plicating the shaft of the humerus from a point immedi-
ately above the condyles, but the shoulder-joint was
moveable.
Its surface was very irregular, and presented numerous
bosses and depressions ; most of the prominences were
quite hard, but at the upper and outer aspect there was
a fluctuating area, and at the lower part an ulcerated
surface the size of a shilling. Numerous large dilated
veins were seen running over the tumour.
The various internal organs of the body were apparently
healthy.
January 19th. — There was a free oozing of venous blood
from the ulcerated surface, but it was arrested by the
application of an ice-bag, until the early morning of the
21st, when the haemorrhage became so free that the ice
failed to exert any beneficial influence, and the house
surgeon was obliged to resort to the thermo-cautery.
This reduced the bleeding to a slight ooze.
At 11 a.m. (January 21st) the following operation was
performed :
Subperiosteal resection of the middle third of the
clavicle by means of an incision carried along its shaft
from the sterno-mastoid muscle to the acromion process
of the scapula. The original intention was to tie the third
part of the subclavian artery and vein with double liga-
tures, but, owing to free venous oozing resulting from divi-
sion of some of the dilated veins, the first part of the
axillary vessels were laid bare by carrying an incision
from the middle of the clavicular one down the inner side
of the tumour, and then backwards to the tip of the angle
of the scapula, reflecting inwards the skin and dividing
the pectoral muscles. The vessels were then divided,
after the application of double silk ligatures, and the cords
of the brachial plexus, together with the muscles forming
the posterior axillary fold, severed. By turning the pa-
tient on the sound side and drawing the affected arm
UPPER EXTREMITY FOR OSTEO-CHONDROMA. 83
across the chest, a posterior flap was formed by making
an incision from the tip of the acromion process backwards
to the angle of the scapula, and reflecting the skin to the
posterior border of the bone. A division of the muscles
attached to i1 s upper and posterior borders permitted the
removal of the scapula, the outer third of the clavicle,
and the arm, en masse.
The exposed surfaces were irrigated with corrosive sub-
limate lotion, and the flaps brought together without ten-
sion by silver wire sutures. A dressing of iodoform and
corrosive sublimate wool was applied, and the patient re-
moved to bed.
By the following day (January 22nd) he had quite re-
covered from the effects of shock, and took light nourish-
ment freely.
February 7th. — The upper portion of the wound had
healed and the lower was granulating rapidly, but in the
afternoon the patient, who had been sitting up in bed,
experienced a shooting sensation in the wound, and imme-
diately afterwards the dressings and adjacent bed-linen
were found saturated with blood, the man becoming
blanched and collapsed. The dressings were at once re-
moved, but the wound presented no bleeding point, merely
two small clots were visible in the position of the artery.
An anaesthetic was administered, and the wound enlarged
at its upper end by an incision an inch and a half long,
parallel to the cicatrix of the former wound. It was then
seen that the axillary artery was merely plugged with a
small clot ; this becoming dislodged a gush of blood took
place. An aneurism needle, with a stout silk ligature,
was then passed round the artery as it lay embedded in a
mass of granulation tissue, and having been tied the ends
of the silk ligature were left long.
On the 12th, the patient having completely rallied,
as the pulsations of the artery were quite distinct down
to the ligature, it was deemed prudent to reopen the
wound made on the 7th, to saw off half an inch from the
end of the clavicle, divide the deep cervical fascia and
84 SUCCESSFUL REMOVAL OP THE ENTIRE
secure the subclavian artery immediately behind tlie
scalenus anticus. A silk ligature, witli tlie ends left long,
was employed.
The progress of the case from this date was un-
interrupted.
On February 14th the ligature came away from the
first part of the axillary artery in a very sloughy condi-
tion, but that from the subclavian did not separate
until February 24th.
On March 6th the patient was able to get up, but for
some time experienced a good deal of difiiculty in
balancing himself.
April 25th. — Dismissed.
Up to the present time (June, 1800) he has remained
well and become considerably stouter.
The limb in its entirety was forwarded to Mr. Charles
Cathcart, of Edinburgh, for the purpose of a cast being
made according to his own method ; and when that had
been done to make a section of its growth. His report
is as follows :
" The preparation consisted of the right upper limb,
including the scapula and part of the clavicle, of a man.
The weight of the preparation was 21 lbs. ; that of the
tumour about 18 lbs. The circumference of the tumour
at its widest part was twenty-eight inches. The tumour
was nodular in outline and of a firm elastic consistence,
except at one or two places where it had softened and
become cystic. In cutting the tumour the knife was
greatly obstructed by calcareous nodules, and the saw and
knife had to be used alternately.
" Nalxed-eye ap'pearance of fresh section. — The tumour
consisted essentially of nodules of clear cartilage, varying
in size from that of a pea to that of a walnut. The smaller
nodules were firm and transparent, like the substance of
a crystalline lens. The larger ones were yellowish and
somewhat opaque, and in some cases had softened in the
centre. Eound the nodules there was a delicate stroma
of connective tissue containing blood-vessels.
UPPER EXTREMITY FOR OSTEO-CHONDROMA. 85
"From the blood-vessels a deposit of calcareous salts
had taken place in the periphery of the nodule^ in some
cases surrounding the nodule with a calcareous shell.
Here and there, where several calcareous nodules in close
proximity had formed a large mass, the structure of can-
cellated bone was distinctly visible, ossification having
taken place.
" The upper and outer portions of the shaft of the
humerus were thickened and sclerosed. The interior of
the bone was apparently unaffected.
" Judging, therefore, from the specimen, the tumour
would seem to have started from the periosteum at the
upper end of the shaft of the humerus, towards the back
and outer side ; afterwards to have grown more and more
away from the bone, pushing the soft parts before it.'^
MicroscojncaUy the tumour was found to be composed
of hyaline cartilage, with no features of special in-
terest.
Removal at one operation of the entire upper extremity
and part of the clavicle, as a method of treatment in cases
of neoplasmata situated in the region of the shoulder-
joint, was first practised in 1838. From that date to
1863 four records only have been published. But since
Mr. Syme's case in May of the last-named year there has
been a steady increase in the number of records, and the
operation is now a recognised procedure ; a table of forty-
four operations is herewith appended.
In 1882 M. Paul Berger, as the result of his observa-
tion and experimental investigations, was led to suggest
that the operation should be systematically performed as
follows :
1. Resection of the middle third of the clavicle. Pro-
fessor Oilier in 1884 suggested that, as a safeguard against
wounding the vessels, the resection should be made sub-
periosteally.^ This he successfully performed, but Mr.
' Practically the subperiosteal resectiou is not to be recommended, as the
periosteum left obscures the subclavius muscle, and has to be immediately
divided.
86 SUCCESSFUL REMOVAL OF THE ENTIRE
Lund had previously in 1879 carried out this step in its
entirety.
2. Double ligature of the third part of the subclavian
artery and vein, and division of the vessels between the
ligatures.
3. The formation of two oval skin flaps, an antero-in-
ferior and a postero-superior, and removal of the entire
limb with the remaining external portion of the clavicle
en masse.
The advantages of following this order in the perform-
ance of the amputation are —
1. No haemorrhage from the axillary artery and its
branches can take place.
2. Entrance of air into the large vein is guarded against,
and oozing from the vessels of the neoplasm is minimised.
3. An almost bloodless section of the pectoral muscles
and the cords of the brachial plexus is permitted, whilst
division of the posterior muscles, where the ai'terial supply
has not been cut off, is reserved for the last step of the
operation.
4. The flaps are readily approximated, and while there
are no spaces for the pocketing of discharges, the facili-
ties for drainage are excellent.
5. It permits a free and wide division of the various
structures, this being of special importance when a malig-
nant growth has to be dealt with.
6. The resulting stump readily admits of the applica-
tion of an appai^atus to hide the deformity.
Accepting this method as a basis, in the case here re-
corded two points are mainly brought into prominence :
1. The shock to the patient.
2. The securing of the vessels.
1. The sJiock. — During the operation this was marked
when the large cords of the brachial plexus were severed.
On removal from the table the effects were speedily rallied
from. The general shock was apparently much less severe
than that which has been noted in cases where amputation
at the hip-joint has been undertaken for malignant tumours
UPPER EXTREMITY FOR OSTEO-CHONDEOMA. 87
connected with the femur. This observation confirms the
experience of Berger and Bennett May.
The table appended shows that shock per se is not much
to be dreaded.
2. Securing the vessels. — If from the nature of the
tumour there be free venous oozing on incising the super-
ficial tissues, or if there be structural displacement from in-
vasion by the growth, it would seem to be better, after re-
section of the clavicle, to proceed at once to the formation of
the upper portion of the antero-inferior flap, division of the
two pectoral muscles, and fully to expose the axillary artery
and vein. These can then be readily traced up to the
scalenus anticus muscle, and the subclavian artery and
vein secured.
Both Berger and May have found that in proceeding to
direct double ligature of the vessels, after removal of the
clavicle, considerable care was necessary to secure the vein
in two ligatures ; this would be obviated by tracing it
from below upwards.
In this case the first part of the axillary artery was tied
and divided above the acromio-thoracic branch, yet on the
seventeenth day there was secondary hasmorrhage, and
dissection showed patency of the main vessel. A ligature
placed higher failed to diminish the pulsation of the artery,
whilst tying the subclavian behind the scalenus anticus
proved successful.
This experience seems to point to primary ligature of
the subclavian as offering the best security against secon-
dary hsemorrhage, for by this means the arterial supply
is arrested as far as possible from the edges of the flap
and sources of irritation.
It should, however, be noted that in the cases operated
upon by Syme and Southam (Nos. 5 and 44) the axillary
vessels were tied without any complication resulting.
Statistics! — The number of cases tabulated, in which
the entire upper extremity has been removed for neoplas-
mata, is 43, and in one (No. 25) the operation was per-
88 SDCCESSFUL REMOVAL OF THE ENTIRE
formed for caries and osteo-myeliLis, inakiug a total of
44. For statistical purposes No. 28 may be excluded, as
the operation not only consisted of removal of tlie scapula^
but also of excision of the breast and portions of several
ribs^ thereby laying open the thoracic cavity.
From the immediate effects of the operation there were
nine deaths. Of these, five were attributed to shock. Two
(Nos. 9 and 24) succumbed the same day ; two on the
second day, No. 8 having fatty degeneration of several
internal organs, and No. 18 having previously been a
man of very intemperate habits ; one (No. 41) died at the
end of fifty-six hours, although the effects of the opera-
tion had apparently been recovered from.
Haemorrhage caused two fatalities, No. 13 being due to
loosening of the ligature securing the main vessels on the
fifth day. No. 15 died the day after the operation.
Septicsemia (two), No. 7 on the fifth day ; No. 17 on
the sixth.
Fourteen cases recovered from the operation, to die at
a later date with secondary deposits ; one (No. 16) in three
years; one (No. 12) in eighteen months ; one (No. 32) in
sixteen months; eleven (Nos. 1, 2, 19, 22, 30, 31, 35,
36, 37, 39, and 44) within the year.
One (No. 26) died of phthisis five months afterwards.
Ten cases may be counted as cured. No. 5 was living
twenty-six years afterwards; No. 3, nine years; No. 21,
six years ; No. 20, five years. No. 23 lived three years,
and death was not connected with the neoplasm. Nos.
6 and 11 were living two years after; Nos. 27, 42, eigh-
teen months after. No. 25 was undertaken for caries from
osteo-myelitis.
Uncertain, 10. For three (Nos. 14, 29, 38) no subse-
quent history is given ; one (No. 40) was alive seventeen
months after the operation ; one (No. 43), thirteen months ;
two (Nos. 10, 34), twelve months; two (Nos. 4, 33) were
living some months and three months respectively.
upper extremity for osteo-chondkoma. 89
Rekkkences.
Amerirnn.
Gross, Samuel D. — A System of Surgery, 1872, vol. ii.
American Journal of the Medical Sciences, vol. Ivi, 1868
(Stephen Rogers).
Annals of Surgery, 1888, ii, 1890, i.
Journal of the American Medical Association, March
2nd, 1889.
New Yoi'k Medical Journal, vol. viii, 1869.
New York Medical Record, 1871-2.
English.
Bell, Joseph. — Manual of Surgical Operations, 6th
edition, 1888, p. 70.
Jones, Thomas. — Diseases of the Bones, 1887, p. 334.
Syme, James. — Excision of Scapula, 1864.
British Medical Journal, vol. ii, 1880; vol. ii, 1886;
vol. ii, 1889.
Edinburgh Medical Journal, December, 1 869 ; February,
1884.
Indian Medical Gazette, January, 1 884.
Lancet, vol. ii, 1867; vol. i, 1874; vol. i, 1878 ; vol. i,
1884 ; vol. i, 1890.
Medical Times and Gazette, vol. ii, 1865.
French.
Berger, Paul. — L'amputation du Menibre Superieur
dans la contiguite du Tronc, Paris, 1887.
Langenhagen. — Contribution k I'etude clinique des Tu-
meurs du Scapulum, Paris, 1883.
Bulletin de Therapeutique, Nos. 11 and 12, 1885.
L'Union Medicale, January 1st, 1884.
Lyon Medical, tome xviii, 1885.
90 SUCCESSFUL REMOVAL OF THE ENTIRE
German.
Bramspeld^ F. — Ueber eiuige Falle vou Scliulterblatt
exstirpation, In. Diss., Berlin, 1888.
Heydenreich, Fr. — Ueb. Exstirp. der Scapula, In. Diss.,
Kiel, 1874.
Veit, Jell. — Exstirpat. von Schulterblatt und Arm, In.
Diss., Berlin, 1874.
Archiv fiir klinische Chirnrgie von Langenbeck, Bd.
xxxvii, 1888 (Adelmaun).
Wiener med. Presse, No. 19, 1887.
Zeitschrift fiir Chirnrgie, Bd. xxvii, 1888.
Italian.
Bulletino delle Scienze Mediclie di Bologna, Sec. vi,
vol. xxi, 1888.
II Morgagni. Agosto, Ottobre, 1885.
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DESCRIPTION OF PLA.TE II.
Successful Removal of tlie Entire Upper Extremity for Osteo-
cliondroma (Thomas F. Ohavasse, M.D., O.M.Edin.).
Fig. 1. — Half-length portrait of subject, showing tumour growing
from right humerus.
Fig. 2. — Half-length portrait, showing subject after recovery.
THE MECHANISM OF SUSPENSION
TREATMENT OF LOCOMOTOR ATAXY.
BY
JAMES CAGNET, M.A., M.D.,
DEilONSTBATOB OF ANATOMY AT ST. MAEY'S HOSPITAL; PHYSICIAN TO
out-patients' hospital fob epilepsy, eegent's PAEK.
Received December 6th, 1889— Read January 14th, 1890.
The treatment of locomotor ataxy by suspension has
engaged so much attention of late, and has been advocated
and attacked with so much energy on either side, that a
serious effort to assign it a rational basis would have been
at any time a welcome contribution to the discussion. It
does not appear, however, that such an effort has been
made hitherto ; and this is the more strange because the
dangers to which the proceeding is open are very gene-
rally admitted, while at the same time the benefit with
which it is occasionally attended is supported by ample
testimony.
Thus it happens that the matter is invested with a double
interest, and from either point of view it is highly impor-
tant to attain to a right understanding of it.
If, moreover, it could be shown that the danger of the
operation is not inseparable from its admitted advantages,
but rather that the latter can be better ensured by elimi-
nating the element of risk, a practical conclusion of some
102 THE MECHANISM OF SUSPENSION IN THE
consequence will result. To establish such a conclusion is
the object of this paper. It further pretends to show the
methods of reasoning and observation by which the writer
has been compelled to dissent fi'om the views of others
more competent to judge than he is, but perhaps in some
cases without the same opportunities of testing the truth
of their convictions.
It cannot be said that the suspension treatment is with-
out its theory. Charcot in France, and de Watteville in
England, to whom belongs the credit of its adoption in
their respective countries, left the matter open. Charcot
suggested that the effect might be due to a stretching of
the spinal cord, or of the nerve-roots, but he thought it
possible also that it might be caused by changes in the
spinal blood-supply. A stretching of the cord, however,
would seem to be the condition aimed at in practice. The
origin of the treatment is known to everyone. The phy-
sician of Odessa who first resorted to it did so on the
grounds of an apparent cure in the case of a patient who,
in addition to tabes, had caries of the spine ; and in that
case no doubt the cord, or rather its membranes, were
stretched in the process. There is no need to point out
that for the pui'pose in hand the analogy fails, in an im-
portant particular, between those instances where caries of
the vertebrae exists and those where it does not. Perhaps
it is this coincidence which has biassed men's miuds
and made the assumption very general of a fact which
is far from self-evident. That the assumption is general
appears sufficiently from the reports of cases, where con-
siderable elongation of the vertebral column is recorded,
and improvement or disaster accounted for thereby.
From those who reject the procedure little is heard of the
formidable danger of dislocation, and a great deal of
hidden menace from tampei^ing with the cord. By its
supporters the prospect of a cure is openly or tacitly re-
ferred to the same indefinite agency. The theory was
boldly enunciated in England by Dr. Althaus. Writing
in the ' Lancet' April 13th, 1889, he says : " Part of the
TREATMENT OF LOCOMOTOR ATAXY. 103
influence of suspension by which the cord is efficienthj
stretched is owing to the breaking down of adhesions due
to chronic meningitis;" and again: '^ by the process of
stretching the spinal cord, the overgrown and unduly har-
dened neuroglia may be loosened and broken down.'^ This
theory was endorsed by Prof. McCall Anderson ; speak'
ing at Glasgow in October, he referred to it as the best
yet announced.
We need not pause to ask whether the symptoms of
locomotor ataxy may be held to depend in any degree
upon meningitis, or whether the most powerful stretching
would be adequate to change the character of a sclerosis ;
but does the needful stretching occur, or is it not rather
a deus ex inachind ? To answer this question it will be
necessary to consider the evidence upon which the belief
may be thought to rest. The writer knows of no other
than certain measurements made during life. Some of
these partake of the marvellous. Thus Dr. Bianchetti, of
Padua, by suspending certain heavy men extended the
vertebral column (by which, of course, the line of the
spines is meant) as much as 4 centimetres (nearly 1|-
inches). At the same time, in three cases out of eight
amaurosis was induced, and this leaven of mischief amidst
much good was ascribed to an extension of the cord in
some degree comparable to the above-mentioned elonga-
tion behind it.
The reputed fact and the inference are not in logical
sequence, but we are concerned now with the statement.
Taken for what it implies — an absolute elongation of the
column to that extent — it is incredible. The vertebral
column is not straight, but deflected in curves (Fig. 1), and
the first effect of the force represented by the weight of the
body is to straighten out these curves. Not till straight-
ening has occurred will any considerable elongation of a
convexity take place. Now the dorsal curve is much the
largest, and its convexity is behind, where measurement
has to be taken. To obtain so much as 4 centimetres,
therefore, would be needed either a formidable extensibility
104
THE MECHANISM OF SUSPENSION IN THE
of the powerful ligaments which knit together the spines,
lamina, and transverse processes in the cervical region,
Fig. 1. To show the vertebral curves with the spinal canals exposed.
(Drawn from the skeleton.)
or such a hiatus between the bodies of the dorsal ver-
tebrae anteriorly as the imagination fails to supply.
TREATMENT OP LOCOMOTOR ATAXY. 105
Very little experience suffices to show the direction
from which misconceptions of this kind arise. During
life the vertebral column can be measured only along the
summits of the spinous processes. How far an inference
is warranted from such a measurement to the condition of
the cord will be considered presently. The limitations of
the process of measurement itself demand some notice now.
In flexion of the head the spines from the first to the
seventh cervical are separated, so that a tape placed along
their summits will measure upwards of eight inches. When
the head is thrown back the spines and laminae overlap,
so that the same points are approached within three inches.
Similarly in stooping the dorsal spines will spread over
an area exceeding by three or four inches their extent when
approximated by muscular action. Again, extension and
depression of the occiput will cause a notable difference.
It is always extremely difficult to ascertain differences due
to muscular tension, and consequently to place the body in
a position in this respect similar to that which it assumes
when suspended. When an effort is made the decision
must be in any event purely arbitrary. The difficulty
described must have been appreciated by everyone who
has conscientiously endeavoured to obtain the measure-
ments required, and he will have satisfied himself that an
error of more than two inches can be accounted for in
this way. After much experience, I am convinced that
comparative measurements of this kind taken on the living
body are but little reliable. There is great difficulty in
ascertaining the points chosen ; and the time during which
suspension is tolerated, at any rate where the patient is
not supported from the axillge, hardly suffices to make sure
of them. In the statistics which I have prepared I have
done what I could to obviate this defect. I have secured
the assistance of skilled anatomists, considered with them
every chance of fallacy, and controlled the results by
others derived from observation on the dead body. Pro-
ceeding in this way I have come to the conclusion that
in the living subject there is a decrease in the length
106 THK MECHANISM OF SUSPENSION IN THE
measured along tlie spines from the second cervical to the
last lumbar vertebra of less than one third of an inch ; that
the portion of the column which is occupied by the dorsal
curve is contracted by about half an inch, and that conse-
quently the apparent lengthening takes place entirely in
the neck. Apparent lengthening is said, because it is im-
possible to be sure that in the original estimate the proper
state of muscular equilibrium has been maintained.
The patient is instructed to stand erect, with the chin
and occiput inclined in a suitable manner. The observer
then measures with a tape the entire length of the vertebral
column, following the prominence of the spines. This is
noted. The spine of the axis is then made out, and the
distance from its lower border to that of the fifth lumbar is
measured and written down. The same points are taken
while the patient is suspended. The process is somewhat
tedious, and in the last case is apt to be hurried, which
itself adds an element of ambiguity. Some of the results
obtained by me are appended. In no case were marks on
the skin trusted to, but the bony point aimed at was deter-
mined by the finger on each occasion.
The results obtained in this way are so much at vari-
ance with others reported elsewhere that I feel called upon
to point out the probable sources of error. Allusion has
already been made to that which depends upon muscular
action. Measurements of the neck, which is so much
more freely movable than the back, are especially open
to fallacy of this kind — so much so indeed that figures
connected with it are but little trustworthy. On the living
body my estimate, conjointly with that of others, has varied
in successive experiments on the same person. Accord-
ingly I attach but little importance to the result of obser-
vations on this part. I hope, however, to make it appear
that variations in the length of the neck are of minor con-
sequence, and I have endeavoured to attain securer data
by experiments upon the dissected subject.
The objection indicated does not apply with equal force
to careful measurements of the dorsal and lumbar curves.
TREATMENT OF LOCOMOTOR ATAXY. 107
but neither are these devoid of difficulty. Thus it is not
always easy to determine the points chosen. In the
statistics produced here the lower border of the spine of
the first dorsal vertebra was invariably chosen as a fixed
point, because that spine is the most prominent. But here^
even in persons in whom the bony points stand out well,
an error is very apt to arise. In such persons the ob-
server has satisfied himself that his finger tip was on the
extreme border, and when the patient was told to flex
his back the true poiut proved to be a quarter of an inch
loAver down. When the body is suspended the point in
question is most prominent. The difiiculty then occurs
in the preliminary measurement, and it can be surmounted
with care. It depends upon the obliquity of the spinous
processes. The posture assumed with the body erect is
practically the same under all circumstances, so far as the
dorsal curve is concerned. Consequently it is possible,
though not easy, to secui'e absolute certainty in measuring
that region. The same is true of the lumbar curve. But
it appears that an error of a quarter of an inch may
occur in determining one fixed point and as much in de-
termining the other, not to speak of grosser mistakes, such
as taking the first lumbar for the last dorsal spine, or the
fourth for the fifth ; and, since variations in the length of
the dorsal and lumbar regions together seldom exceed
half an inch, the need of accuracy will be appreciated.
In order to supply this we have controlled our observa-
tions on the living body by dissections of the dead. The
results are appended of only six cases chosen from amongst
many, because they were judged to be most nearly correct,
and because they were obtained with the assistance of
others.
108 THE MECHANISM OP SUSPENSION IN THE
October SOth, 1889. Regent's Park Hospital,
Cases 1 and 2. — Dr. Cagney suspended by Mr.
Rougliton.
Posterior measurements :
Suspended.
(a) Standing.
(A) Occip. — chin.
(c) Occip. — axillae
i. 2 C. to 4 L. (spines) .,
,. (22) 221 in.
22iin.
22 in.
ii. 2C. to 1 D. „
3i
4i
... 4i
iii. 1 D. to 4L.
.. (18f) 181
m
... m
Analysis. — Questionable decrease on the whole in (6)
and (c). Absolute increase of about 1 in. in cervical
region, similar diminution in dorsal. The dorsal region
was still more shortened in (c), where the axillae were
supported.
Case 3. — Mr. Eougbton suspended by Dr. Cagney.
Posterior measurements :
(a) Standing. (6) Suspended from occip. and chin,
i. 2 C. to 4 L. (spines) ... (22i) 21| in. ... 21f in.
ii. 2C. to 1 D. „ ... 3t ... 31
iii. ID. to 4 L. „ ... ISi ... 18
Analysis. — Total diminution of ^ in. Increase of ^ in.
(?) in cervical, diminution of j in. in dorso-lumbar curves.
Mr. Koughton fainted when taken down.
Case 4. — Wm. B — , est. 47. Tabes. Often suspended
before. Reports having fainted first time. Has a con-
siderable lateral curvature.
Posterior measurements :
Standing.
Suspended (occip. — axill
i. 2 C. to 1 D. (spines)
3i in.
3^ in.
ii. 1 D. to 4 L.
m
17i
iii. 2 C. to 4 L.
20i
20^
Analysis. — Total elongation of | in. Increase of | in. (?)
in cervical, | in. in lumbo-dorsal region.
This is the only instance met with in which the dor&al
region was stretched, and it is remarkable that the patient
had curvature of the spine.
TREATMENT OF LOCOMOTOR ATAXY. 109
November bth.
Case 5. — Wm, D — , pet. 40, cook. Paraesthesia of
trunk. First suspension.
Posterior measurements :
(a) Standing before suspension.
(i) Suspended
i. 2 C. to 1 D. (spines)
4iin.
4i in.
ii. 1 D. to 5 L, „
151
15i
Analysif^-. — Increase in cervical region of | in. (?),
diminution in dorsal of ^ in. Total increase of | in. (?).
Case 6. — Ch. H — , ataxic. Fourth suspension.
Posterior measurements.
{a) Standing before suspension.
(6) Suspended
i. 2 C. to 1 D. (spines)
4 in.
3i in.
ii. 1 D. to 5 L. „
16i
16i (?)
Analysis. — Diminution of ^ in. in cervical region
and total diminution of ^ in. Dorsal measurements
somewhat doubtful.
Reference has been made to the uncertainty of measure-
ments of the neck during life. It is illustrated here by
the alteimative figures quoted in two cases. Both sets
were thought to indicate the distance along the spines
with the head as erect as possible. The difference is so
great that no conclusions can be drawn from the figures,
and they have been retained because they seemed the
most nearly accurate that could be found, and also because
they tally with others more reliable derived from the
dead body. Read in connection with these, certain infer-
ences may be based upon them.
The measurements of the dorsal and lumbar regions may
be regarded as quite exact in all but one case.
The subjects of experiments were in some cases healthy,
in others they suffered from spinal disease.
In every instance except one there was a contraction in
the dorso-lumbar region, not an elongation. In this excep-
110 THE MECHANISM OP SUSPENSION IN THE
tional instance it was noted beforehand that the patient
(a tabetic) had an extensive lateral curvature. The elon-
gation in this case did not exceed I in. In another case
the dorso-lumbar measurement was invariable^ 16^ in. from
the first dorsal to the fifth lumbar spine both before and
during suspension. The greatest contraction occurred in
the writer's own case when he was suspended^ and the
notes were made by his colleague, Mr. Edmund Roughton,
Demonsti'ator of Anatomy at St. Mary's. The tape indi-
cated a diminution of 1 in. distance from the first dorsal
to the fourth lumbar spine when suspended from the
occiput and chin alone, and there was a further decrease
of J in. in this region when support from the axillas was
added. The latter fact is very significant, and it agrees
entirely both with what may be seen on the dead body,
and with the views on the subject of muscular action,
which shall be stated presently. Mr. Roughton was well
satisfied of the accuracy of the figures.
It is difficult to obtain a subject sufficiently tolerant of
the position to allow good measurements to be taken while
suspended from the occiput and chin, and there remain
the data in but one other case, that in which the writer
suspended a colleague. There occurred then a contraction
in the dorso-lumbar curve of j in., an increase in the
cervical apparently of less than ^ in., and a total contrac-
tion of I in. In the writer's own case, when suspended
by the head alone, the total length of the column was
unaltered, an elongation of 1 in. in the cervical compen-
sating for a similar contraction in the dorsal district.
When again suspended both from the head and axilla the
dorsal shortening was I in. more, while the length of the
neck remained the same, a total shortening then in this
instance of one quarter of an inch. In these three cases,
therefore, there was a total shortening throughout the
column of J in. to ^ in. A shortening of the dorso-lumhar
curve was invariable, ranging from j to 1 j in., and averag-
ing nearly 1 in. It was judged, moreover, that the lumbar
curve was in all cases unaffected. The result of the re-
TREATMENT OF LOCOMOTOR ATAXY. Ill
maining three cases was generally the same. In all the
dorso-lumbar line was shortened, Avith the single exception
alluded to. In all except this instance a shortening of
the whole column was found. In only one case was there
apparent shortening of the neck. But it has been said
that no positive statement can ever be made upon that
point. One fact only has been ascertained beyond doubt,
namely, that the neck is less elongated by the process in
those who have been several times suspended than in
those who are submitted to the operation for the first
time.
The uncertainty of this class of measurement impressed
me so strongly that I determined to make others under
like conditions in the dissecting room, and on the dead
body. These were necessarily quite accurate. The mus-
cles were removed from the back — the bony points cleaned
and exposed to view — and ample time was available to
carry out the experiment with precision. The measure-
ments obtained in this way tallied remarkably with the
average of those taken during life. Where they differed
the discrepancy was referable to the uncertainty already
alluded to as to what position of flexion or extension
should be given to the head in the original estimate. The
results are instructive in many particulars, and they are
appended.
Dissecting room, St. Mary's Hospital, October 26th,
1889.
Case 7. — Body suspended. The limbs had been re-
moved, and the thorax and abdomen dissected. The
dorsal muscles were carefully cleaned off, all the liga-
ments remaining. The body was then suspended from
the chin and occiput and the first series of measurements
along the spines was taken. Three heavy bricks (17 lbs.)
were then attached to the pelvis while the body hung,
and the spines were measured a second time.
112 THE MECHANISM OP SUSPENSION IN THE
a. Before adding weights.
i. Upper border of 2 C. to lower border of 1 D.= 4g in.
ii. Lower border of 1 D. to lower border of 1 L. = 10^ in.
b. After weights were added.
i. As before = 4^ in.
ii. As before = 9 L| in.
Therefore there was a stretching in the cervical region
of -^ in., and a contraction in the dorsal of ^ in. ; a total
stretching of j^q in.
The anterior measurements were not taken, but it was
apparent that the anterior common ligament was greatly
extended. The cervical and dorsal curves were nearly
abolished. The splanchnic nerves were stretched like
fiddle-strings.
An incision was made separating the anterior common
ligament and detaching the intervertebral disc beneath
the third cervical vertebra. The aperture did not gape,
though the weights remained on.
The body was then taken down and the laminae and
pedicles removed, while the body was supported on the
table by a block under the thorax. As disclosed in this
position, the cord and nerve-roots were stretched tense.
The body was then hung up as before with weights. The
cord enclosed in dura mater then bulged out towards the
back, being very loose and relaxed. The dura mater was
wrinkled transversely. The course of the nerve-roots from
their origin to the intervertebral foramina was much
shortened, and they were in sinuous curves. This effect
was equally pronounced in every region. In the cervical
region, as elsewhere, the apparent origin of each nerve
was well above its point of exit from the spinal canal.
Dissecting Room, St. Mary's Hospital, November 6th.
Cases 8 and 9. — Body suspended. The lower limbs
were attached, but the feet had been removed. The
arms were off. The brain was removed. The thorax and
TREATMENT OF LOCOMOTOR ATAXY. 113
abdomeu were dissected. The dorsal muscles were cleaned
off and the spines and laminge exposed. Anterior and
posterior measurements were taken along the bodies and
spines — (1) with the body on the table; (2) suspended
by occiput and chin; (3) two heavy bricks (11| lbs.)
being attached in the latter case.
I. — A. Antei'ior measurement (body lying on its back on
the table and extended to tiie utmost) :
(1) i. From basilar pr. to lower border of 1 D. . = 7i in.
ii. From lower border of 1 D. to lower boi'der of 5 h. = 16i in.
B, Posteriorly (on table)
(1) i. From tubercle c
ii. Dorso-Iumbar as
II. — A. Anteriorly
(1) i. From tubercle on atlas to lower border of 1 D.= G iu.
ii. Dorso-lumbar as before .... =181 in.
i. As before
ii. As before
(2) Simply suspended.
5f in.
161 in.
(3) Weiglits added
6 in.
17 in.
3, Posteriorly :
i. As before
ii. As before
5| in.
18iin.
5f in.
18i in.
Analysis. — Anteriorly : The discrepancy of If in. be-
tween the first and second measurements shows that a
suitable position of the neck had not been obtained, and
indeed, this can never be made certain of. Dorsal
stretching f in. The addition of heavy weights stretched
the cervical region only ^ in., and the dorsal ^ in. more.
Posteriorly : Cervical region contracted J in. when sus-
pended first, and this underwent no change when weights
were added. Dorso-lumbar first stretched ^ in., and again
contracted to previous length.
(a) Body suspended simply :
Cervical ?
Dorsal extension f in.
Cervical contraction J in.
Dorsal extension, ^ in.
VOL. LXXIII.
> anteriorly.
> posteriorly.
114 THE MECHANISM OP SUSPENSION IN THE
(6) Weights added :
Cervical extension 4 in. I ^ . ,
* >• anteriorly.
Dorsal extension ^ in. J
Cervical unaffected
Dorsal contractioi
cted 1 , ■ 1
> posteriorly,
tion i in. J
The value of these experiments depends on the fact
that they were done under conditions which entirely got
rid of muscular tension. They represent the effect of sus-
pension on the osseo-ligamentous skeleton stripped of its
coverings. The bony points were exposed, and measure-
ments were made under the most favorable circumstances.
The same uncertainty as before attaches to figures which
deal with the posterior surface of the neck, but in a less
degree. Those taken in the dorsal and lumbar region are
absolute and reliable.
In the first experiment (Case 7) the addition of weights
to the body already suspended caused a shortening along
the summmit of the dorsal and lumbar spines — a shorten-
ing in this case of I in. Under the same circumstances
the cervical spines were separated by a total distance of
^ in., the length of the column remaining unaltered. The
measurement of the cervical region in this case, being
made under like circumstances before and after the addi-
tion of weights, is presumably correct. At the same time
the movements of the vertebrae amongst themselves could
be watched. The cervical and the dorsal curves straight-
ened out by extension of the postei^ior ligaments above, and
of the anterior ligaments below, and by separation of the
bodies below. The appearance of the dura mater when
the spinal canal was opened under these circumstances
will be referred to later.
In the second experiment (Cases 8 and 9) the anterior
measurements were taken as well as the posterior. The
results of the latter were in the main those obtained
under all other conditions, but modified in a very in-
teresting manner. The line along the dorsal and lumbar
spines was stretched ^ in. when the truncated and evis-
cerated body was simply suspended. When, however, a
TREATMENT OF LOCOMOTOR ATAXY.
115
Fig. 2. Compounded from two photog^raphs of dissected and dried
specimen (exhibited). The specimen was suspended first simply and after-
wards with 18 lbs. added below. Two strings were stretched horizontally
in front of the specimen. In the first photograph the strings crossed
the points A A, in the second the points B b. bbIs a greater distance
than A A. This shows a slight relaxation of the spinal cord which is
exposed. The specimen is from the museum of St. Bartholomew's Hos-
pital, and it was dissected by Mr. Roughton.
116 THE MECHANISM OF SUSPENSION IN THE
weight of 11 J lbs. was added^ tlie line contracted to its
original length. There was thus no elongation^ but
rather, perhaps, a shortening. The 5 in. gained on sus-
pending the body is very likely the expression of an error
due to the fact that the unsupported vertebral column
collapsed a little when laid on the table, its curves
straightening and the spinous processes in the dorsal region
approaching one another in a somewhat concentric manner.
This probably explains another anomaly — the apparent
shortening of the spinous surface in the neck, which
stretched again to its original length when weight was
added. The collapse of the curve in the cervical region
when the body lay on the table would have the effect of
expanding the spines in a fan -like manner. The weight
of the body was sufficient to overcome this malposition,
and the further weight of lOf lbs. acted not by stretching
the posterior ligaments, as was the case with the body
prone, but by compression of the intervertebral discs ante-
riorly. This is a fact of great importance, and Avill be re-
ferred to again. The total result was to leave the spinous
surface unaffected when the light body was suspended and
a subsequent contraction of ^ in. when weight was added.
All this contraction, as before, occurred in the dorsal region.
The results of the anterior measurement ai'e very sug-
gestive. The basilar process having been taken as the
upper fixed point for the cervical region makes one series
of figures unreliable. Uncertainty as to the proper degree
of flexion of the head is the cause, and the doubt is illus-
trated by so great a discrepancy between the length along
the vertebree when the body was on the table and when
it was simply suspended — a discrepancy of If in. The
comparison in this case, therefore, does not hold. When
weight was added to the suspended body the cervical curve
expanded ^ in. In the dorsal and lumbar regions together
the effect of suspension was to stretch the anterior surface
of the column | in., and when weights were added a fur-
ther stretching of ^ in. took place, a total elongation of
this aspect in the weighted body of | in. This appeared
TKEATMENT OF LOCOMOTOR ATAXY.
117
to come exclusively from the dorsal curve. If it be re-
membered now that the line of the spines at the same
time shortened, it will appear that the effect of suspending
the weighted body was to straighten out the dorsal curve
by a movement of the vertebrae each around, an axis whicli
corresponds to the situation of the posterior border of tbe
bodies. The anterior common ligament was stretched, tbe
Fig. 3. The lower part of the thoracic curve, with spinal canal exposed.
The left-hand figure is drawn from the skeleton, the right-hand figure
from a specimen which was forcibly straightened.
ligaments of the post-neural segments were relaxed, and the
spinal canal, since it lies behind the axes of rotation, must
have been shortened. At tbe same time the interverte-
bral foramina are approximated.^ From both facts it
follows that the spinal cord would be relaxed, and most on
^ See the writer's paper on " The Disposition of the Vertebral Column in
Hanging and Swinging Postures," ' Journ. of Aiuit. and Physiol.,' 1890.
118 THE MECHANISM OF SUSPENSION IN THE
its dorsal surf ace (Fig. 3) ; the nerve-roots would be relaxed
with it, and still more so by the approximation of the inter-
vertebral foramina by which they leave the spinal caual.
The cervical cui've was stretched anteriorly | in. and
probably about as much between the spines. The curve
tended to straighten by overlapping of the laminae in
front. It would seem probable that so slight a change
does not in any way affect the cervical portion of the cord^
which besides is disposed to accommodate itself to the
freest range of movement. The changes that occur are to
some extent compensatory ; for while the absolute elonga-
tion of I in. on both back and front would tend to render
the dura mater, if not the cord, tense, straightening of
the cui've will act in the opposite direction, since the cord
lies in its concavity. My own belief is that it is impossible
in this way to stretch the dura mater without dislocating
the neck. This view is strongly confirmed by observa-
tion of the cord m situ with the spines and laminae re-
moved.
The absence of the soft parts would obviously modify
the conditions of extension or relaxation. Here, therefore,
are tabulated the measurements in two cases taken in the
post-mortem room without dissection.
November 12th, 1889. Post-mortem Room, St. Mary's
Hospital.
Case 10. — Body of a man, ast. 35, who died of Bright's
disease.
] . Anterior measurements :
i.
2 C. to 1 D.
Lying prone after long suspension,
atjout 2 hours.
5iin.
Suspended.
5i in.
ii.
1 D. to 12 D.
9iin.
10 in.
iii.
12 D. to 5 L.
7i in.
6| in.
I
Posterior measurements :
i.
2 C. to 1 D.
Prone before suspension.
3f in. (5)
Suspended.
3iin.
ii.
1 D. to 12 D.
min. (12)
lOi in.
iii,
, 12 D. to 5 L.
4| in. (4f)
4| in.
TEEATMENT OF LOCOMOTOR ATAXY. 119
The figures in brackets indicate measurements taken
when a block was under the thorax. The others give
results without the block. This body was suspended
without the viscera ; and the cranium had not been opened.
While suspended the spinal arteries were injected from the
following trunks : abdominal aorta in two places, above and
below the coeliac axis ; right vertebral, left vertebral, and
left ascending cervical. It was cut down after two hours
and the entire cord removed This is specimen marked
Cord A.
Anteriorly
Analysis.
Cervical .... stretched 5 iu.
Dorsal . . . . „ ^ in.
Lumbar .... contracted J in.^
Posteriorly :
Cervical .... stretched ^ in.
Dorsal .... contracted | in.
Lumbar .... unaffected.
The significance of these tables is modified by the fact
that the first measurements (anteriorly) were taken after
two hours^ suspension. They indicate that a certain re-
silience will occur after death. As an indication of the
effect of suspension the difference in the antei'ior measure-
ments is probably too small.
Without making allowance for this, the gross result is :
Anteriorly
Cervico-dorsal region . . stretched | in.
Lumbar „ . . contracted 4 in.
Posteriorly :
Cervico-dorsal region . . contracted 5 in.
Dorsal region alone . . . „ | in.
' This was repeatedly verified. The fact is very significant.
120 THE MECHANISM OF SUSPENSION IN THE
November 12tli. Post-mortem Room.
Case 11. — Body of a boy, set. 15, who died of typhoid
fever.
1. Anterior measurements :
(a) Lying proue on table. (6) Suspended.
i. 2C. to 1 D. ... 4|in. ... 4^ in.
ii. 1 D. to 12 D. ... Sfin. ... 9i in.
iii. 12 D. to 5 L. ... 6^ in. ... 6^ iu.
2. Posterior measurements :
i. 2C. to ID. ... 4i in. ... 3^ in.
ii. ID. to 12 D. ... 91 in. ... 9i in.
iii. 12 D. to 5 L. ... 5i in. ... 5^ in.
In measuring the cervical region the head was supported
in a position judged to be the same as that assumed in
suspension, and it was drawn outwards. This body had
the brain and viscera removed before suspension. The
weight was supplied by attaching 11 lbs. to the legs.
Analysis.
Anteriorly :
Cervical region unaltered -i
Dorsal „ stretched i in. I' stretching | in.
Lumbar „ unaltered J
Posteriorly :
Cervical region ? -i
Dorsal ,, contracted i in. I- contraction i in.
Lumbar „ unafPected. J
The experiments, of which a detailed account has been
given, appeared to furnish collectively all the available
data. They comprise measurements taken under three
classes of circumstances : namely, those upon the living
body, those upon the dead body with the bony points and
ligaments exposed, and those upon the dead body undis-
sected. Each of the series is instructive in its way, and
each tends to illustrate the others. One fact stands pro-
minently forward. So far from finding the great elonga-
tion of the dorsal region of the spine reported by others,
I have only once, either in the living body or in the dead,
TREATMENT OP LOCOMOTOR ATAXY. 121
met with auy lengtliening at all, aud that was in a case of
lateral curvature. The remarkable consistency amongst the
results in this particular goes to prove that the same forces
are at work upon the vertebral column, alike in the living
aud the dead body. In the former case there are other
forces added, e. g. the effect of muscular tension, which
remains to be considered. The posterior measurement, that
along the summits of the spines, is the only one which
can be obtained under all conditions.
An analysis of the eleven experiments recorded would
show that the result of suspension is to cause an average
extension posteriorly in the cervical region of -^ in., a con-
traction in the dorsal region of more than ^ in., no effect
upon the length of the lumbar curve, and a total con-
traction of rather less than -^ in., throughout. Anterior
measurements can be had only on the dead body. Aver-
ages compiled from the tables show an increase of ^ in. in
the cervical region, of -i-| in. in the dorsal, and of |-|- or 1
in. in the tAvo taken together. At the same time there
is a diminution of ^ in. in the lumbar curve.
Something has already been said of the manner in
which these effects are produced, but they need a little
further consideration. The statistics show that the
chief result of suspension on the dead body, is a
straightening out of the cervical and the dorsal curves.
But in the two districts this takes place in a different
way. In the dorsal region, where the convexity lies
behind, straightening takes place by lengthening of the
anterior surface (Fig. 3). The anterior common ligament
and the marginal attachment of the intervertebral discs give
way, and the bodies separate to the extent, on an aver-
age, of -f-| in. At the same time the spines approach
one another. There is consequently a point of rota-
tion somewhere between. This is doubtless in the situa-
tion of the posterior border of the bodies of the verte-
brae, which are thicker there than in front. In the cer-
vical curve the case is different. Not one or two, but
several strong ligaments are present to resist the stretch-
122 THE MECHANISM OF SUSPENSION IN THE
iug of tlie concavity which occurs readily enough lower
down.^ On the other hand^ the bodies of the vertebrsa
are not thicker towards the convexity in front, but the
intervei'tebral discs are thick in that situation, and inde-
finite compression is possible. It is probable that it takes
place, and that the curve tends to straighten out at the
expense of its anterior surface — the convexity — which
actually shortens. The diflSculty of making accurate
measurements in the neck renders it impossible to show
this point in figures, but in addition to the anatomical
facts mentioned, there are others which support the view :
the remarkable lip-like projection on the lower border of
eacli body appears calculated to guide the upper border of
the body below in the direction required, and finally some
such appearance is presented when the dissected body is
suspended. Again, the fact recorded in one of the dis-
secting-room experiments, when the anterior common liga-
ment was separated and the incision did not gape, lends
countenance to the view. Beyond this, however, there is
the fact that actual shortening of ^ in. to ^ in, does occur in
the lumbar region in which the curve is similarly situated,
and there also it must be by compression of tlie interver-
tebral discs in front. In the cervical region the spinal
cord occupies the concavity of the curve. If, then, this
straightens out without separation of its extremities, the
cord is relaxed thereby. The process which we have
traced in the dorsal region is obviously attended with
shortening of the spinal canal and consequently relaxation
of the cord in that situation. At the same time the ap-
proximation of the intervertebral foramina still further
shortens the nerve-roots. This, I believe, is the process
in the dead body.
It remains to consider the effect of muscular tension,
— and first where the body is suspended from the axillae
in the usual manner. Suspension from the axillse, in
so far as it is effective, is suspension from the scapulae
and clavicles, and ultimately from the muscles which
' Op. cit., ' Jouru. of Anat. and Physiol.,* 1890.
TREATMENT OF LOCOMOTOR ATAXY.
123
connect those bones with the trunk. These muscles may
be divided into two classes : first, those (the trapezius and
rhomboids) which take origin from spinous processes ;
secondly, those (serratus magnus, and pectorals) Avhich
arise from the ribs or some part in front of the vertebra.
Muscles of the first class tend to approximate the spines
directly, and so aid the action of gravity as seen in the
dead body (Fig. 4, b). Again, the muscles which arise from
ribs do so too, because they raise the ribs which are firmly
attached to the transverse processes by the costo-ti-ansverse
ligaments, while they are free to move on the articulation
Fig. 4. To show the axis of rotation and the point of application of
muscular force in the dorsal region.
A. The dotted line indicates the axis of rotation under the influence of
muscular action.
B, a. The direction in which the muscles act which are attached to
the ribs; b. The direction of muscles attached to spinous pro-
cesses; c. The axis of rotation.
of their heads with the bodies of the vertebras. They con-
stitute, therefore, a set of levers of the second order, the
weight being at the transverse processes. Since, however,
the transverse processes are situated behind the axes of
rotation mentioned above (Fig. 4, a), musculartension in this
case also acts in the same direction as gravity, and with
it helps to relax the spinal cord by shortening the spinal
124 THE MECHANISM OP SUSPENSION IN THE
canal. This view is further supported by figures. When
the writer was suspended from the head by Mr. Roughton
there was a contraction of 1 in. posteriorly in the dorsal
region, and when support was given from the axilla a
further contraction of j in. ensued.
The question of muscular tension in the neck is more
complicated, and that of forced muscular action still more
so. When a patient is first suspended, especially if it be
by the head alone, he commonly hangs with the body
thrown back, so that the legs are well behind the plumb-
line from the point of support. At the same time the
back is curved in the direction of opisthotonos. This is
an effect of muscular action, and it originates in an in-
voluntary ejEfort to resist straightening of the cervical
curve. For this purpose the muscles of the neck contract
powerfully. So do the erectores spin^e and their con-
tinuations in the back. Under these circumstances the
maximum of posterior shortening occurs, and doubtless
also the greatest possible elongation along the bodies of
the vertebrae in front. It is then that syncope, vomiting,
and diarrhoea have followed suspension. These may find
their explanation in the stretching of the splanchnic nerves,
which I have repeatedly seen on the dead body. Whether
this be so or not, I am convinced that the splanchnics are
the only nerve-structui'es which are stretched.
It appears, at all events, that the spinal cord and its
nerve-roots are not stretched but relaxed. This conclu-
sion results alike from measurements, from a priori ana-
tomical considerations, and from actual demonstration on
the dead body with the spines and lamina3 removed.
Is it possible to attribute to this relaxation any of the
curative effect of suspension ? Doubtless it is. Those
who have assumed that stretching of the cord might be
competent to break down adhesions and overgrown
neuroglia have forgotten important facts of anatomy.
The dura mater is a highly inextensible membrane ; it is
connected to the bony walls which enclose it, not only
above aud below, but also by means of strong processes
TREATMENT OF LOCOMOTOR ATAXY. 125
to each pair of intervertebral foramina. Any movement
which it admits is checked in this way, and it cannot be
extended indefinitely from one segment to another. The
most effectual way to stretch the dura mater is to bend,
not to straighten, the spine, as can be shown when the
cord is exposed in situ. Again the movements of the
cord within the dura mater are controlled both by the
connection of the nerve-roots with the latter at the inter-
vertebral foramina, and by the processes of the ligamentum
denticulatum. Finally the vertebral column is admir-
ably constructed to defend the cord from the action of
excessive force such as it has been attempted to exert.
But how would extension of the cord, if it were possible,
affect a patch of sclerosis ? Injuriously if at all. Tension
on a rope does not tend to loosen its fibres ; but active
relaxation, as by doubling up the rope, does. The white
matter of the cord is formed of strands of nerve-fibres
derived from the nerve-roots. In sclerosis, these are
shrunken, compressed, and cemented together. Adhe-
sions amongst the fibres will be broken down, if indeed
they can be broken down mechanically — best by relaxation,
such as it is contended occurs. This may be a part of
the modus medendi, but far more efficacious must be the
concomitant effect on the spinal blood-vessels and lym-
phatics. Sclerosis is associated with and maintained by
mal-nutrition. The vessels are thickened and choked by
pressure from the contraction of surrounding fibrous tissue.
If this be opened up and relaxed, more blood will enter.
The posterior columns will be flushed. There is a possi-
bility that, with freer circulation, morbid products will be
removed, regeneration of tissue promoted, and suspended
function restored. I have injected spinal cords while the
body was suspended. The naked-eye appearances favour
the view stated here and it is hoped that microscopical
sections will throw further light on the subject. Some of
these are now in course of preparation and others are ex-
hibited. It must not be forgotten, however, that there
remains the possibility that vital changes, not demonstrable
126 THE MECHANISM OF SUSPENSION IN THE
on the dead body, have their share in the result. Allusion
has been made to the stretching of the splanchnics. When
this is excessive, as it most probably is in those eases
where the body is curved backwards, stretching may cause
a temporary paralytic lesion, whence possibly arises pain
in the epigastrium, syncope, vomiting, diarrhoea, and, it
may be, death. A slighter degree of extension might
constitute an irritative lesion, and it is conceivable that
such would have its role in the therapeutics of suspension.
The conclusions to which I have been led may be briefly
summed up.
1st. A stretching of the cord would give no rational
explanation of the effects sought, but this stretching does
not occur.
2nd. A considerable and effective relaxation, both of
the cord and its nerve-roots does occur in suspension.
Relaxation is competent to account for the benefit sought.
It takes place to the greatest extent in the dorsal curve,
where also the tabetic lesion is always and chiefly situated,
and more in the posterior than in the antei'ior columns of
the cord.
3rd. This effect is produced by the weight of the body
alone, and is aided by muscular tension when the body is
suspended from the axillae.
4th. Muscular tension, like the force of gravity, acts
beneficially most, if not only, in the dorsal region. Relaxa-
tion of the cord in the neck is impossible, and cervico-occi-
pital suspension is not only dangerous and unpleasant, but
unscientific and inoperative.
5th. It follows, therefore, that measures should be
directed towards the dorsal region alone. For the old
and infirm, the present method of suspension from the
axillse, but from the axillae alone, will probably remain
the best. No strain should ever be put upon the head.
If relaxation of the cervical portion of the cord be aimed
at, this can be obtained in no way better than by poising
the head upon the vertebral column in the natural position
of ease. If these views are correct, the best plan of all,
TKEATMENT OF LOCOMOTOR ATAXY. 127
where it cau be adopted — as in younger men — would be
found in a judicious course of gymnastics, which should
have for their object a moderate and associated contrac-
tion of the muscles of the back combined with tension of
those which connect the scapula and clavicle with the
trunk. Simply to hang by the arms from a point above
the head for a short time would probably be attended
with better consequences than are attained by the use of
the cumbrous apparatus at present in vogue.
(Since writing the last paragraph I have made trial of
this plan, and in two cases I have obtained results not less
remarkable than those published elsewhere.)
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 53.)
A CASE or HEENIA OE THE CAECUM,
ENTIEELY WANTING IN A PERITONEAL SAC,
IN WHICH
STRANGULATION AT THE INTERNAL ABDOMINAL RING
CO-EXISTED WITH AN INTUSSUSCEPTION THROUGH
THE ILEO-C^CAL VALVE.
BY
WILLIAM H. BENNETT, F.R.C.S.,
SUEGEON TO ST, GEOEGE's HOSPITAL.
Received December 9th, 1889— Read January 28tli, 1890.
The following communication is, I regret to say, neces-
sarily imperfect, inasmuch as it was impossible, although
the patient died, to obtain a post-mortem examination of
the parts involved. At the same time I trust that the
rarity of the case described will be sufficient to justify
its publication.
On the evening of October 26th, 1889, W. K— , a
labourer, aet. 52, walked leisurely into St. George's Hos-
pital complaining that an old-standing rupture, with which
he was afflicted, and which he had been previously able
at all times to replace with ease, had become irreducible.
The hernia, he said, had existed for eighteen years, but
he had worn a truss during the last two years only, and
VOL. LXXIII. 9
130 HEENIA OF THE C^CUM.
even during that period with much irregularity. The
truss when in use kept the rupture up, as a rule ; and if
by chance it came down behind the instrument, reduction
was easily effected, being always accompanied by the
ordinary and characteristic " gurgle/'
Upon inquiry it was further elicited that the scrotum
was always considerably larger and harder than normal
on the affected side, in spite of the apparent completeness
of the reduction of the hernia.
Twenty-four hours before the patient came to the hos-
pital (the rupture " being up " at the time, to the best of
his knowledge, although the truss was not in use) he
noticed, whilst lifting a heavy basket, soine discomfort
about the scrotum, of a kind he had never before felt.
Upon examination he found that the rupture was
larger than he had previously seen it, although he had
experienced none of the usual sensations warning him of
a sudden descent of gut.
In spite of this he continued his work, the size of the
hernia gradually increasing in a manner quite different
from anything he had before noticed. This gradual
descent and steady increase of the rupture are significant
facts, as will be subsequently seen.
Considerable pain of a burning nature soon supervened,
which was entirely confined to the scrotum. He was
therefore compelled to leave his work. He returned home,
and having failed to reduce the tumour himself in the
ordinary way he called in a medical man, who after
repeated attempts was equally unsuccessful. Shortly
after this he vomited. The night which followed was
restless, and vomiting occurred at frequent intervals up
to the time of his coming to the hospital. The bowels
acted for the last time on the morning of the 24th.
The house surgeon, finding that the hernia was obviously
irreducible and strangulated, at once sent the patient to
bed. The buttocks were well raised, and ice applied to
the rupture.
In spite of this proceeding the tumour very slowly
HERNIA OF THE C^CUM. 131
increased iu size, and I was summoned to see the man
soon after midnight (about six hours after his admission),
when I found the condition of things as follows.
The man was stout and " full-blooded.'^ The expres-
sion was somewhat anxious, the skin moist, and the pulse
quick, regular, but inclined to be small. The tempera-
ture was subnormal. There was an entire absence of
pain, umbilical or otherwise. There was nausea, but no
vomiting.
The right side of the scrotum was occupied by a pyri-
form swelling, about the size of two closed fists, which
ran upwards along the inguinal canal. This tumour was
dull and full, but not extremely tense. There was no
impulse on coughing. There was no abdominal distention,
the parietes were flaccid, and no tenderness of any kind
was present excepting at the extreme upper limit of the
scrotal swelling.
Although the case appeared to be without doubt one of
strangulated hernia, there was something about the general
aspect and feel of the tumour which was not exactly like
anything of the same kind which I had previously seen,
so much so that I told Mr. Higgins, my house surgeon,
that I fully expected to find an unusual state of affairs
upon performing herniotomy, which was clearly necessary.
The patient having been an^sthetised, I cut down upon
the hernia in the ordinary way, and ultimately exposed a
somewhat tense tumour, obviously containing fluid, which
at first sight seemed likely to be the sac of the rupture,
although it had not the appearance of such as commonly
seen. Upon pinching up this apparent sac there could
be felt inside it a mass which slipped away from between
my fingers, precisely as a tense knuckle of gut often does
when felt in this manner inside a not very greatly dis-
tended peritoneal sac.
Although I was in much doubt about the structure ex-
posed being the sac, for it struck me at the time, and I
so stated my feeling to those present, that the tumour
was not unlikely to be gut which was uncovered by peri-
132 HERNIA OF THE C^CUM.
toneum, I decided to open it ; for not only was it entirely
irreducible in spite of free division of all surrounding soft
parts which could be divided apparently with safety, but
the masSj which could be felt inside, led me to suspect
the existence possibly of a polypoid tumour of some kind,
if the structure with which I was dealing proved to be
actually bowel.
I must, however, confess that the possibility of the
mass being an intussusception did not occur to me at this
time.
A small incision having been made into the tumour,
there spurted out with some force a quantity of clear
watery fluid precisely like that which commonly escapes
upon opening an ordinary sac in the course of herniotomy.
This, for the moment, made me think that my appre-
hensions were unfounded, and that after all it was merely
a peritoneal sac that had been opened.
The walls of the tumour, however, as its contents es-
caped, were seen to contract actively ; moreover, the last
portions of the fluid discharged were opaque, and had a
fascal smell ; finally, there could be seen protruding from
between the lips of my little incision some mucous mem-
brane.
It was clear, therefore, as I had half anticipated, that
I had opened the gut. It was equally obvious, as will be
presently seen, that the gut was quite devoid of a peri-
toneal investment.
As the mass, which has been mentioned as having been
felt inside, remained unchanged, the incision in the bowel
was freely enlarged, and the following conditions of parts
revealed.
The structure which had been laid open was the caecum.
Projecting from the upper and inner part through the
ileo-C£ecal valve, the margins of which could be felt grasp-
ing its base, was an intussuscepted piece of the ileum
about three inches long.
Passing from the upper and outer part of the herniated
ceecum could be seen the opening of the colon, which was
HERNIA OF THE C^CUM. 133
tightly constricted by a band of tissue crossing it at the
internal ring. At the inner part could also be made out
the opening of the vermiform appendix, the lumen of
which seemed to pass upwards and backwards.
The calibre of the intussusception was so small, in con-
sequence apparently of external constriction, that it would
admit a single finger only with some difficulty.
After the division of the tight band which crossed the
hernia at the internal ring, and which had escaped my
notice before opening the gut, the bowel generally was
so much liberated that the lumen of the colon appeared
of normal size, and the intussusceptum admitted three
fingers with ease, a quantity of flatus and a little faecal
matter being expelled at the same time.
Upon turning up the ceecum, which was of course now
flabby and collapsed, the most careful examination failed
to detect anything upon the surface of the gut which was
in the least degree suggestive of the presence of peritoneum;
but behind it there was seen passing down into the scro-
tum, and adherent to the testicle, a slender, rather oede-
matous piece of omentum, lying in a perfect and rather
thin peritoneal sac, which, there is little doubt, had also
contained the original hernia which the patient had been
in the habit of reducing from time to time.
Upon passing the finger upwards, behind the caecum,
along the surface of this sac, it was arrested just at the
point from which the appendix seemed to spring, where
all the parts appeared hopelessly matted together.
The intussusception which showed, after the division of
the constricting band mentioned, very little indication of
congestion, and was but slightly swollen, was quite irre-
ducible. There seemed also not the least chance of the
hernia itself being made in an}^ way reducible, excepting
by the performance of extensive abdominal section, which
the desperate condition of the patient at this time
rendered entirely unjustifiable. The only proceeding
available, therefore, was to suture the edges of the wound
in the bowel to the margins of the scrotal incision — making,
134 HERNIA OF THE C^CUM.
in fact, a temporary artificial anus with a view to abdo-
minal section, redviction of the gut, and restoration of its
canal on a future occasion, if the patient should rally
sufficiently — an occurrence which appeared highly impro-
bable.
The existence of the intussusception entailed of course,
under these circumstances, no danger of obstruction, for
if it were not sufficiently patulous to allow spontaneous
evacuation of the intestinal contents, the removal of any
flatus or faecal material which might accumulate could be
easily effected by the passage of a tube through the in-
vaginated gut.
For twelve hours after the operation the patient rallied
to some extent, but did not gain sufficient strength to
justify further operative measures.
Subsequently he gradually sank and died, apparently
of asthenia, at 3 p.m. on October 29tli.
The operation was followed by no abdominal distention,
the parietes remained quite flaccid, and there was neither
pain, tenderness, nor discomfort of any kind.
Nourishment was taken freely, and from time to time
a little flatus and feculent matter came from the intussus-
ception, which was perfectly patulous.
On the evening of October 28th, in order to make certain
that no accumulation was taking place, a long tube was
passed through the invaginated bowel, and about a quarter
of a pint of liquid fasces withdrawn.
Remarks.
I. As to the herniated csecum. — The occurrence of hernia
of the caecum without a peritoneal sac appears to have
been formerly accepted by common consent as a fact which
in itself was not in any degree remarkable.
It was also, I believe, rather extensively taught, even up
to comparatively recent times, that on this account cEecal
hernia was frequently ii-reducible.
HERNIA OF THE CiECUM. 135
Recently, however, the researches of Treves and others
tend to show that the peritoneal relations of this viscus are
such that extra-peritoneal hernia of the caecum must of
necessity be so rare that the possibility of its existence is
hardly worth consideration.
This view is strongly supported by the absence hitherto,
so far as I can ascertain, of a precise record of any
instance of csecal hernia devoid of a sac, which has actually
been met with in practice.
A careful search through the notes of 565 cases of
strangulated hernia, successively recorded in the register
of St. George's Hospital, fails to afford a single instance
of this condition, although several varieties of caecal
hernia occur.
Another point of some interest, in connection with the
subject under discussion, shown by these 565 miscellaneous
cases is the sigularly small number of examples of strangu-
lated hernite of all kinds in which the caecum formed any
part of the hernial tumour, for in these 565 cases the
caecum was present in nine only (that is, 1*59 per cent.) ;
and of these nine instances all were of a complicated
nature excepting two, one of which was a remarkable
case in which the ceecum occupied a hernial sac in the
left groin.
Some further particulars of these nine cases will be
found in the accompanying table (p. 138).
It will be seen that a complete peritoneal sac existed
in all, with the exception of the one now recorded. In
the whole series of 565 miscellaneous hernige there was no
case in which the contents of the sac were wanting in a
complete peritoneal investment.
The case I have described in this communication is
without doubt a genuine instance of the extra-peritoneal
form of hernia ; for, as has been pointed out, there was
not a vestige of peritoneum or anything approaching to
it in appearance, either in the form of a sac or as an
immediate visceral investment.
The escape of clear watery fluid, when the gut was
136 HERNIA OF THE CAECUM.
opened, is worthy of attention, since it is an unusual
occurrence which might at any time be liable to mislead.
The presence of such a fluid was, I presume, caused by
excessive secretion from the congested and swollen mucous
membrane in the tightly constricted bowel, which, at the
time of strangulation, was free from fgecal contents.
I have had no previous experience of clear watery fluid
coming from a knuckle of strangulated gut, but 1 have
seen in the post-mortem room a case in which the vermi-
form appendix was greatly distended by a precisely
similar fluid, in consequence apparently of its opening into
the large intestine having been blocked. Instances of the
same kind have been observed, I have no doubt, by
others.
II. Afi to the intussusception. — This afforded a fair
example of intussusception of the ileo-colic variety, i. e.
invagination through the ileo-ca3cal valve, which, accord-
ing to the accepted authorities, is met with in only 8 per
cent, of all cases of this affection.
An interesting point here arises with reference to the
relation of the intussusception to the production of the
hernia, and vice versa.
The general aspect of the invaginated bowel, the dis-
appearance of all congestion after the division of the
external constriction, together with its patulous state, and
the absolute irreducibility, are facts which seem to point
to the condition being chronic.
On the other hand, the very gradual descent of the
rupture, the unusual kind of pain, and the general sensa-
tions experienced, which were just such as might have
been caused by a piece of gut making its way through
loose connective tissue, point to the probability of the
hernia being of a different kind from that which had pre-
viously troubled the patient.
This probability was converted into something very
like a certainty by the discovery of the old and independ-
ent sac containing adherent omentum, but no bowel,
which is referred to in the description of the case.
HERNIA OF THE CECUM. 137
The evidence in this respect, therefore, seems to indicate
that the presence of the caecum in the hernial tumour
was quite a recent condition.
At the same time it is, of course, fair to admit that the
caecum might possibly have occupied the same position
previously without giving rise to any noticeable symptoms
until the state of affairs became altered by the occurrence
of the intussusception.
III. As to the case generally. — Under this head there is
little to be said. Taking all the circumstances into con-
sideration, the case is the most complicated example of
strangulated hernia which in the course of a considerable
experience I have yet had to deal with.
The treatment adopted seems to have been the only
rational proceeding which was available. The issue from
the first was hardly doubtful, and the death from asthenia
was only what could have reasonably been expected.
Finally, it appears to me that, setting aside certain
minor points of interest, the co-existence in this patient
of two such conditions as extra-peritoneal hernia of the
ca?cum and the least frequent form of intussusception
(ileo-colic) presents a case w^hich, if it is not unique, as I
suspect it to be, must at least be of such singular rarity that
I have ventured to bring it to the notice of this Society.
138
HEENIA OP THE C^CUM.
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the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 56.)
EHEUMATISM, ITS TREATMENT PAST
AND PRESENT;
WITH SPECIAL EEFERENCE TO RECENT EXPERIMENTAL
RESEARCH ON SALICYLIC ACIDS AND THEIR SALTS.
MATTHEW CHAETERIS, M.D.,
PEOFESSOE OF THEEAPEUTICS AND MATEEIA MEDICA, UNIVEESITY
OF GLASGOW.
(Communicated by Db. MITCHELL BRUCE.)
Received January 22nd— Read February 11th, 1890.
In the treatment of rheumatism we observe five distinct
epochs: (1) the antiphlogistic, (2) the alkaline, (3) the
blistering, (4) the expectant, (5) the salicylate.
The antiphlogistic treatment in English medicine was
inaugurated by Sydenham, and was bold, comprehensive,
and decisive. It dominated practice until Dr. Fuller, of
St. George^s Hospital, recommended the administration of
alkalies in such doses as to maintain an alkaline reaction of
the urine. The chief rival to this treatment was that of
Dr. Herbert Davies, who advocated the application of blis-
ters to all the inflamed joints. Then came as the reaction
to these methods the " expectant treatment '' of Lebert,
which was further supported by Sir William Gull and Dr.
Sutton in 1866.
142 RHEUMATISM, ITS TREATMENT PAST AND PRESENT.
For the next ten years tlie therapeutics of rheumatism
was in a state of chaos, which was terminated by the
rise of the salicylate treatment, the history of which is
peculiarly interesting.
In 1874 Kolbe obtained a crystalline acid (salicylic) by
the combination of the elements of carbolic acid with those
of carbonic acid. Attention was directed to this com-
pound by its subsequent employment for antiseptic dress-
ing. Later on the internal administration of this acid,
and especially of its salt, sodium salicylate, speedily evinced
their antipyretic properties.
When given in large doses they reduced the tempera-
ture in enteric fever, phthisis, erysipelas, and other affec-
tions of a febrile character. Much was expected from
their use as antipyretics, but impartial observers showed
that the reduction of the temperature was not attended by
any modification of the local morbid process, nor by any
lessening of the mortality. There was one noteworthy
exception to this unfavorable statement, for it was found
that when they were administered internally in acute
rheumatism the temperature was speedily reduced, and
the pain and swelling of the joints disappeared.
In Great Britain, about the same time, and pursuing
an independent line of reasoning. Dr. Maclagan tried
salicin in the same disease, and with equally satisfactory
results in regard to the fever and the affection of the
joints.
The connection of the action of the two remedies was
shown by Senator to consist in salicin being split up in
the living organism by ferments, first into saligenin and
subsequently into salicylic acid.
Gradually yet steadily since 1876 the salicylate treat-
ment of rheumatism has grown into professional favour in
all lands. Dr. Fagge's words on this point are striking and
suggestive : " When I made trial of these drugs I was
for a little while sceptical as to their value. The patients
rapidly recovered, but I could not forget that I had some-
times seen the administration of other medicines followed
RHEUMATISM, ITS TREATMENT PAST AND PRESENT. 143
by results which appeared very striking. But when case
after case recovered with scarcely a failure I became satis-
fied that I had a most potent remedy in my hands, and
all further experience has strengthened me in this con-
viction. The immense majority of practitioners and
physicians now, I think, entertain a similar opinion."
Now we come to a crucial point. Granted that salicin
is changed by the ferment into salicylic acid, is its action
superior to or different in any way from that obtained from
artificially prepared salicylic acid and its salt of sodium ?
All experience shows that in a case of acute rheumatism
without complications either method will reduce the tem-
perature and relieve the pain within forty-eight hours.
Apart from nausea, which is sometimes occasioned by both
preparations, there has been a steadily growing conviction
that artificial salicylate of sodium — the salt generally
given — is depressing, and further that in certain cases
there is cerebral excitement culminating in delirium, the
patient, it may be, shouting and struggling to get out of
bed.
Any hospital physician trying salicin and artificial sali-
cylate of sodium on two rheumatic cases in the same ward,
at the same stage of the fever, and in proportionate doses,
will find in a given time the patient treated by the sali-
cylate to be weak, exhausted, and perhaps delirious, while
the patient to whom salicin has been administered will only
suffer, if at all, from slight deafness. True, if the salicylate
treatment is discontinued, the patient becomes rational in a
few hours, but what would happen if one were to insist on
the continued administration of the drug on the human
subject I do not know, although after the experimental
investigation on animals to which I shall now allude I
cannot fail to guess.
The research on the natural and the artificial salicylates
on animals was begun in June last, and the results were
published in the ' British Medical Journal ' of November
30th, 1889. The experiments showed —
1. That salicin in a dose of thirty grains seems to have
144 RHEUMATISM, ITS TREATMENT PAST AND PRESENT.
no injurious influence on the liealth of a rabbit, but that
it causes a reduction of the temperature about 1°.
2. That salicylic acid obtained from natural sources has
no deleterious effect in 10-grain doses.
3. That salicylate of sodium from the natural salicylic
acid is not lethal in 32 -grain doses, but causes some
prostration and lowering of the temperature.
On the other hand, it was demonstrated that —
1, Artificial salicylic acid in a 10-grain dose caused
paralysis of the flexors and death.
2. Artificial salicylate of sodium in 18-grain doses
causes not merely paralysis of the hind limbs, but para-
lysis of the fore-limbs and entire loss of control over mus-
cular movements ; and death supervenes in a short time
from exhaustion, in some cases being preceded by convul-
sions.
Further, it was shown that salicylic acid and the sali-
cylates of sodium in ordinary use contained an impurity
— probably creasotic acid — five grains of which when in-
jected into a full-grown rabbit caused slow respiration
and intense prostration, followed by death.
The article referred to concluded with the remark
that '^ in a further communication we shall state the phy-
siological action of the acid from which the impurity has
been removed.''^ I must state frankly here what happened.
We obtained from the chemical laboratory of the Uni-
versity of Glasgow an acid from which all impurities had
been apparently removed. It had a melting-point of 156°
C, and was in fine acicular crystals, corresponding to those
described in the British Pharmacopoeia. But when we
injected five grains of it thrice at intervals of fifteen
minutes into a rabbit weighing 2^ lbs. the animal died.
We further tried a sample of the salicylic acid of
Scbuchardt, of Berlin, guaranteed pure, and the same
lethal action was the result of the same doses in a rabbit
of similar weight.
The conclusion seemed irresistible that ai-tificial salicylic
acid could not be purified so as to stand the physiological
EHEUMATISM, ITS TRKATMENT HAST AND PRESENT. 145
test, and Dr. MacLeunaii and myself moodily reflected that
our efforts of four mouths had been in vain, and that we
had detected an impurity, but could not entirely remove it.
Our attention was shortly afterwards directed to an
article published by Mr. John Williams in the ' Pharma-
ceutical Journal' of June, 1878. In this article Mr.
Williams stated that he had detected a foreigm acid in
samples of artificial salicylic acid, which was much moi-e
soluble in water than calcium salicylate. On this fact he
based a method of separating it, which consisted in satu-
rating a boiling solution of salicylic acid with calcium car-
bonate, and causing the salicylate of calcium to crystallize
out as completely as possible. Upon acidulating the
mother liquor the foreign acid was obtained.
" Regarding the medicinal properties of this acid/'
Mr. Williams writes, " I can say nothing as yet. It may
be, like parabenzoic acid, inert, and would then be only a
diluent of salicylic acid, or it may be active as an anti-
septic, or it may be mischievous ;" and he concludes by
stating that *' until this foreign acid could be removed,
neither salicylic acid nor its salts should be used in medi-
cine."
So far as I am aware Mr. Williams did not follow up
his investigations, but he had distinctly proved that sali-
cylic acid could be so purified, and that its appearance
then was similar to that of the acid obtained from natural
sources. This was the key-note of our further research.
We resolved to go upon the lines laid down by Mr.
Williams. We set free the salicylic acid by the action of
hydrochloric acid on the calcium salicylate, and we
simplified his process by slowly crystallizing the acid
from hot solutions three or four times repeated. We
were thus able without the aid of alcohol, as Mr. Williams
recommended, to produce purified acid resembling the
natural acid in its appearance, and in no way differing
from it by the test of the melting-point, which is 156 C.
Specimens of these purified crystals, and also of those
of salicylic acid from natui'al sources, I now show to
VOL. LXXIII. 10
146 RHEUMATISM, ITS TREATMENT PAST AND PRESENT,
this meeting, as verifying the statements wliicli have been
made.
On three different occasions, December 19th and 20th,
1889, and on January 19th, 1890, we tested the pli3'sio-
logical action of these pvirified specimens. The result was
most satisfactory. We gave three injections of five grains
each to rabbits weighing 2^ lbs., and we found " there was
no paralysis, and no depression, but that on the contrary
the animals were neither up nor down, but able to run
about with ease after the last injection.'"
For the purpose of estimating the loss by purification,
and the time involved in the process, we weighed out one
ounce (480 grains) of the salicylate of sodium, and we
found that out of the corresponding 414 grains of salicylic
acid, 140 grains were first obtained, but by working up the
mother liquor nearly the whole of the apparent loss of
274 grains was recovered. Time, ten days.
We weighed out half an ounce of Schuchardt's sali-
cylic acid, and out of the 240 grains 183 grains were
obtained, showing a loss of 57 grains by purification.
Time, two days.
These facts show that the process of purification, even
on a small scale, is not tedious or difficult, and in all pro-
bability it could be done easily and thoroughly on a
large scale with less loss of time, and at only a slightly
increased cost, as compared with the present method.
It may now be asked, " Can no pure specimens of arti-
ficial salicylic acid be purchased ? " So far we had found
none able to stand the physiological test, except those
which had been purified at our laboratory. But on
January 1st, 1890, unsolicited, a Berlin firm communicated
with me through their agents in London. This letter
bears incisively on many practical points. They stated that
the great bulk of the artificially prepared salicylates used
in pharmacy in this country came from their principals ;
that they guarantee the superior qualities to be free from
cresotonic acid, which they believed in reality to be the
lethal property discovered in the specimens under our
RHEDMATISMj ITS TREATMENT PAST AND PRESENT. 147
observation ; that their factory passed no acid Avliich did
not show a melting-point of 156° C. ; that the products
of ordinary purity should not be dispensed in pharmacy ;
and that for every ten pounds of the salicylate of sodium
only one pound of it was asked for as manufactured
from the purest crystals/'
The letter concluded by proposing to send me speci-
mens of their salicylic preparations for my examination
and report.
The proposal contained in this letter I accepted, and
specimens were received of —
1. Acidum salicylicum extrafein in krystallnadeln.
2. Salicylic acid chemically pure.
3. Sodii salicylas cryst.
On January 11th we subjected these two acids to the
experimental test.
1. Acidum salicylicum extraf. 5 gr. were dissolved in
20 minims of rectified spirits and injected into a rabbit at
11. oO a.m.
At 11.45 a.m. the animal passed urine which gave the
characteristic reaction with the tincture of the perchloride
of iron. It was noted then that the animal looked some-
what dazed and was very quiet.
At 11.55 a.m. the injection was repeated, and at
12.10 p.m. it looked very dazed. No paralysis.
At 12.25 p.m., injection of 5 gr. repeated. The animal
assumed a prone position, with the legs stretched out ;
in five minutes there supervened absolute general paralysis,
and at 1.30 p.m. the breathing became extremely shallow
and slow, with slight twitchings about the mouth, but
no convulsions. Half an hour afterwards it died in a
collapsed condition. Ten days later we repeated this
experiment with the same acid of the Berlin firm on the
rabbit which had stood the test of our purified acid, and
we found that this time it was not fatal, but that it caused
marked prostration and slight paralysis, which lasted for
two hours. The recovery, though slow, was complete.
2. The chemically pure salicylic acid was injected in the
148 KHEUMATISM, ITS TREATMENl' PAST AND PRESENT,
same doses and at tlie same intervals as in the previous
experiment. After the third injection the rabbit became
somewhat prostrate and lay with its legs stretched out,
but on being roused it was able to move about, though
with some difficulty. Its recovery in this case also was
complete but slow.
We were rather surprised that these results followed
on the use of acids which so closely resembled in appear-
ance the ordinary artificial variety. We made in conse-
quence a few experiments with them in solutions of differ-
ent strengths, and we found that their small crystallirie
form depended on the rapidity of their crystallization.
When this was slow, the crystals became large and well
defined, thus showing they had evidently lost the traces
of impurity which tbey had contained. But in the form
in which we received them, though guaranteed pure, they
were not innocuous. In one instance death was the result,
and in the other two abnormal symptoms appeared, which,
however, in time passed away. In the artificial variety,
which we had purified so as to resemble the natural, these
symptoms were entirely absent.
From these experiments we were forced to the conclu-
sion that a high melting-point is not the only or even the
best test of purity. Something, more is required, and
this is that the artificial crystals should be identical with
those of the natui-al variety. Similarity of crystallization
seems to be absolutely essential to secure a uniform and
harmless physiological action. Pharmaceutical chemists
may not have the means or the time for applying the
melting-point test, but they can all observe easily the
difference between well-defined crystals like those of strych-
nine and others which present an appearance like quinine.
For internal use in medicine they should demand the large
crystalline form of the artificial acid, and from this alone
should the salicylate of sodium be prepared.^
^ Since reading this paper the firm in question, Messrs. Schering, have
submitted to me samples of purified salicylic acid in the form of white acicular
prisms, and I was able to satisfy myself that their physiological action was
KHEUMATlSMj ITS 'IKEATMEM' PAST AND PRESENT. 149
We trust that the editors of the ' British Pharmacopoeia/
in the new Addendum which they are now preparing, will
see their way to act on the suggestions we now venture to
give.
1. Under "Characters and Tests of Acidum Salicylicum"
we would substitute for "white acicular crystals/' "the
natural acid, in large crj^stals resembling those of strych-
nine, but slightly yellowish in colour. The crystals of the
artificial acid are similar in form but smaller and whiter.
Both acids should have a melting-point of 156^ C."
2." Under " Sodii Salicylas : Characters and Tests/' in-
stead of " small colourless or nearly colourless crystalline
scales/' we should say " in large pearly plates."
3. Other varieties of artificial salicylic acid should be
termed Poisons, solely intended for external use.
It is rather apart from the object of this paper to say
anything about salicylic acid except so far as it is used in
pharmacy, but I wish to draw attention to the fact that,
owing to its slight taste and powerful antiseptic properties,
it is employed for preserviug beer, wine, milk, lime and
lemon juice, gum, and other fluids. The French seem to
have detected its noxious qualities, and have forbidden its
use for preserving articles of food ; and the Germans lately
have acted in a similar manner, and have made it unlawful
to use it in the preparation of beer. True, our propensity
for drinking beer is not so marked as that of the Gei'mans,
yet our brewers should understand that if the acid must
be pure when used in medicine, it should be equally pure
when placed in this common and pleasant beverage of
everyday use.
similar to that of the acid olitaiued from natural salicylates, and therefore of
such purity as to be equally eligible for medical use. I have myself found
this pui ilied salicylate of sodium very efficacious in the treatment of acute
rheumalism. — 'Lancet,' May 31st, 1890.
(For I'eport of the discussion on this paper, see 'Proceedings of
the Royal Medical and Cliirurgical Society,' Third Series, vol. ii,
p. 62.)
ON THE SYMPTOMATOLOGY
OF
TOTAL TEANSVERSE LESIONS OE THE
SPINAL COED;
WITH SPECIAL REFERENCE TO THE CONDITION
OF THE VARIOUS REFLEXES.
BY
H. CHAELTON BASTIAN, MA., M.D., F.E.S.,
I'EOFESSOB OF MEDICINE IN UNIVEESITY COLLEGE, LONDON; PHYSICIAN
TO UNIVERSITY COLLEGE HOSPITAL, AND TO THE NATIONAL
HOSPITAL FOK THE PAEALYSED AND EPILEPTIC.
Received February lltli— Read February 25tb, 1890.
The symptomatology of total transverse lesions affecting
tlie spinal cord either in tlie cervical or in tlie upper dorsal
region is a subject of great interest both for the physio-
logist and for the physician. The physiologist, by reason
of his observations upon certain of the lower animals, seems
to have instilled into the minds of clinical observers the
notion that when the spinal cord is absolutely cut off from
communication with the encephalon the reflexes dependent
upon the spinal cord below the point of section will, in
the course of a very short time — that is, as soon as the
immediate effects of shock resulting from the operation
152 ON THE SYMPTOMATOLOGY OF TOTAL
liave subsided — exhibit themselves in an exaggerated man-
ner. This general conclusion has perhaps also found favour
because of certain other observations upon man himself
tending to show that' the brain exerts an inhibitory or re-
straining influence over the reflex activity of the spinal
cord. The latter conclusion under ordinary circumstances
is undoubtedly quite true, yet it would not be safe to infer
that it would also hold good under such very unnatural
conditions as must exist when the spinal cord is absolutely
cut off from all influences that, under other circumstances,
may be exerted upon it by some portions of the cerebrum
or of the cerebellum.
As to the observations made by physiologists upon the
spinal reflex actions manifested by some animals in whom
the spinal cord has been severed from all connection with
the brain, I am quite aware that they are at first sight
favorable to the notion that in cases of total transverse
lesions of the spinal cord occurring in the human subject
the reflexes dependent upon the lower portions of the spinal
cord would, to say the least, not be diminished. I know
quite well that even purposive acts in response to cutaneous
stimuli may be manifested by decapitated frogs — acts so
complicated and precise as to have given rise to the notion
that the spinal cords of these animals must be the seat of
a kind of conscious intelligence, capable of accurately
adapting response to stimulus. Again, it may be perfectly
true that in rabbits and in dogs, in whom the brain has
been severed from the spinal cord, reflex actions of a
simpler kind are freely elicited, which could only have been
produced under the influence of this severed spinal cord.
Still, that is not enough to give us a safe warrant for the
conclusion that in cases of total transverse lesions in the
spinal cord in the human subject the reflexes would, after
shock had subsided, become exaggerated. There can be
no doubt that the autonomy of the spinal cord diminishes
as we ascend in the vertebrate scale. Many of the powers
pertaining to it in lower animals are gradually in part taken
on by the more developed encephalic centres possessed by
TRANSVERSE LESIONS OF THE SPINAL CORD. 153
animals higher in the scale. How complicated are the
muscular acts producible by decapitated frogs is now a
matter of common knowledge. But experiments which,
have been made in recent years as to the effects of ablation
of the so-called '' motor centres " from the cerebral cortex
of rabbits, dogs, and monkeys respectively, have also made
it abundantly clear that the division between encephalic
and spinal functions likewise continues to vary in them
very considerably.
Such facts as these are abundantly sufficient to instil
into our minds the necessity of exercising great caution
before we allow our expectations as to what should occur
in man to be guided too exclusively by the results of ex-
periments made upon lower animals. I shall not, therefore,
pause to consider what precise amount of warranty has
been afforded to us by the experiments of physiologists for
the general conclusion which undoubtedly prevails in the
minds of medical men, to the effect that in patients suffer-
ing from total transverse lesions of the spinal cord the re-
flexes are, after the effects of shock have subsided, subject
to some amount of exaggeration. The question which is
of more special importance for us is, what does clinical
observation teach us upon the subject ?
As long ago as 1882 I expressed a very definite opinion
upon this subject, because I had, up to that time, had the
opportunity of examining over prolonged periods three
typical cases of this kind which had been under my care.
In Quain's ' Dictionary of Medicine ' I spoke thus con-
cerning the symptomatology of " Complete Transverse
Softening involving the mid-dorsal region of the Spinal
Cord " (p. 1480) : — " The temperature in the axilla usually
varies between 98° and 100° F., though with an extension
of the pathological process, or towards the close of the
disease, it may rise to 101°, 102°, or even higher. Mean-
while the lower extremities themselves are often distinctly
cold to the hand, the temperature being in some cases
more or less subnormal. It is important to note this, be-
cause it might have been supposed that hypereemia and a
154 ON THE SYMl'TOMATOLOGY OF TOTAL
slightly elevated temperature would exist, owing to the
vaso-motor nerves of the limbs being paralysed.
" The motor paralysis of the lower extremities is abso-
lute, and the abdominal muscles are also powerless. The
feet as the patient lies in bed are extended and often in-
verted, so that the great toes cross one another. The
skin after a time tends to become dry and scurfy. The
muscles feel flabby to the hand, but they waste only to a
slight extent, and continue week after week to show only
a small amount, if any, of diminution in the degree of their
irritability to faradic and to galvanic currents.
•^'The sensibility of the limbs is completely abolished
both for tactile and painful impressions, as well as for
differences of temperature and tickling. A like abolition
of sensibility exists over the trunk up to the level of the
*ensiform area,' whilst above this level the sensibility
becomes quite natural. The upper limit of anaesthesia may
be quite sharply defined, and in these cases of complete
transverse softening there is often no distinct ' girdle
sensation.'
" The muscles of the lower exti-emities may show some
slight irritability when they are forcibly tapped, and when
the soles of the feet are strongly tickled there may be
very slight movements of the toes ; but beyond this there
is often an entire absence of all reflex movements — there
is no ankle-clonus, no kuee reflex, and a similar absence
of the cremasteric and abdominal reflexes. In the initial
stages of the affection, however, and especially when the
softening is not completely transverse, all these reflexes
may be extremely well marked for a time, though they
tend gradually to diminish.
" For the first ten days or a fortnight there is often
complete retention of urine, but after this time, when the
lumbar region of the cord again becomes capable of mani-
festing to some extent its centric functions, the initial
retention gives place to incontinence of urine. This fluid
may be discharged at intervals of two to three hours in
small quantities, owing to the occurrence of reflex contrac-
TRANSVERSE LESIONS OF THE Sl'lNAL CORD. 155
tions of the bladder whenever it attains a certain degree
of fulness. The passage of a catheter, however, in these
cases will often show that the bladder is never completely
emptied, two to four ounces remaining after the reflex
contractions. Unless special precautions are taken the
urine in these cases speedily becomes ammoniacal, and more
or less loaded with mucus.
" The boAvels are usually constipated, and relieved only
after the administration of aperients or enemata. At
these times there is generally incontinence of faeces, the
patients having no power of controlling the reflex actions
concerned in defascation when they have once been strongly
excited. The actual passage of the motion is, moreover,
often unfelt.'^
Other authorities in this country, however, as well as
abroad, are not in accord with me in regard to the condi-
tion of the reflexes in such affections. Thus, limiting the
references to the principal recent writers in this country
on the subject of diseases of the spinal cord, I will briefly
refer to the opinions expressed by Drs. Ross, Bramwell,
and Gowers, in relation to the points in question.
In the second edition of his work ' On Diseases of the
Nervous System,' published in 1883, Dr. Eoss speaks (vol. i,
p. 162) of " the general law that diminution of cerebral
influence, other things being, equal, increases the reflex
activity of the cord.'' Again, whilst referring to the
'' morbid physiology " of Acute Diffused Myelitis, he says
(vol. ii, p. 103) : " When a portion of the grey substance
is separated from its connection with the brain by a mye-
litis situated higher up the cord, reflex actions become
increased." A few pages further on he discusses a
variety of this disease as " acute transverse myelitis " and
concerning it, which is the condition with which we are
now more particularly interested, he gives as symptoms
for the disease situated in the " dorso-lumbar region " the
following (p. 107) : — " The paralysed limbs are rigid ;
the reflexes, both cutaneous and deep, are exaggerated; and
there is a tonic spasm of the sphincters. After a time
156 ON THE SYMPTOMATOLOGY OF TOTAL
the lower extremities become oedematous, and their muscles
undergo a diffused atrophy ; the bladder becomes para-
lysed, and the urine ammoniacal ; acute bedsores appear
over the sacrum and trochanters ; intermittent fever
supervepes, and the patient dies from marasmus.'^ Then
he adds, in reference to the disease when it is situated a
little higher up in the cord, " In acute dorsal transverse
myelitis, however, there is complete absence of bedsores,
the bladder is unaffected, and consequently the septicasmia
and marasmus are absent." These latter statements are
as much at variance with my experience as are the former ;
it is difficult, indeed, to believe that Dr. Ross can mean
these symptoms to refer to the disease where it involves
the whole thickness of the cord in either situation ; yet
he mentions no such limitation, and gives no other account
that I have been able to find of the effects of total trans-
verse softening or myelitis.
In the second edition of Dr. Byrom Bram well's 'Diseases
of the Spinal Cord ' (1884), in the enumeration of the
symptoms of " Total Transverse Lesions,^' there occurs the
following statement (p. 61): — ''The reflexes passing
through the inferior segments are exaggei-ated. With the
occurrence of secondary degeneration, the paralysed
muscles, supplied by inferior segments, become tense and
rigid. ^' From what is said on the following page, also,
he appears to think that it is the rule to meet with a
"band of hyperaesthesia extending round the trunk in the
form of a belt,'' and also with a girdle sensation, so that
the " patient feels as if a tight band were drawn round
his body."
Dr. Gowers, in his ' Diseases of the Nervous System '
(1886), where speaking of "Acute Transverse Myelitis,"
says (vol. i, p. 225), " The state of reflex action varies, and
depends on the position of the disease, in accordance with
the laws already stated. An acute lesion in any part of
the cord may cause an initial inhibitory loss of reflex
action in the part below, but if the lesion is above the
lumbar enlargement reflex action returns in the course of
TRANSVERSE LESIONS OF THK SPINAL CORD. ] 57
a few hours. Frequently there is no initial depression.
Subsequently the reflex action becomes excessive, that
from the skin rapidly, that from the muscles more slowly.
Ultimately each attains a high degree of exaltation. . . .
The muscles of the limbs are at first flabby and toneless
during the stage of initial depression of reflex action,
doubtless from the same influence. This condition soon
passes off if tlie lesion is above the lumbar enlargement,
and as reflex action becomes active the muscles regain
their tone.^^ (See also loc. cit., pp. 136 and 149.)
Elsewhere, when speaking of the determination of the
lower level of the lesion in the spinal cord, Dr. Gowers
says (loc. cit., p. 156), ''To ascertain it we have to exa-
mine the functions of the cord as a central organ, and to
ascertain how far they are impaired in the paralysed region
— to examine especially muscular nutrition and reflex
action. The state of muscular nutrition and irritability
indicates how far the anterior cornua are injured
The integrity of reflex action indicates the integrity of
the reflex loops, and the study of the superficial reflexes
of the trunk is especially instructive in this respect."
And then he adds, " Excess of superficial reflex action
indicates withdrawal of the cerebral controlling influence
of the reflex centres, and marked excess of the muscle-
reflexes suggests the existence of a descending degenera-
tion in the latei'al columns, since it implies impaired func-
tion of the lowest pai't of the pyramidal tracts."
In my work ' Paralyses : Cerebral, Bulbar, and Spinal,'
published a few months earlier, I had already called atten-
tion to what I considered the untrustworthy nature of
the second test referred to by Dr. Gowers as a means for
indicating the lower level of damage in cases of total
transverse lesions of the spinal cord. Referring to this
subject, I there said (p. 538), " In cases where exten-
sive transverse lesions exist, situated higher in the cord
than the nerves upon which any of these reflexes depend,
such reflexes are commonly supposed to be exaggerated
in intensity. This is, however, far from being always the
158 ON THE SYMPTOMATOLOGY OF TOTAL
case.'^ After referring to two other possible sources of
fallacy in regard to this test I say^ '' Again, with a
total transverse lesion in the lower cervical region, nearly
all reflexes dependent upon lower portions of the cord are
abolished rather than exaggerated.'' This being so, it is
clear that under certain conditions the " cerebral con-
trolling influence " may be withdrawn with an effect the
very reverse of an exaggeration of reflexes ; and, on the
other hand, it is equally clear, as we shall see, that under
similar conditions the most marked descending degenera-
tions may exist in the lateral columns with a complete
absence rather than a '^ marked excess of muscle-reflexes."
I will now give pretty full details concerning four cases
of total transverse softening of the spinal cord which have
come under my care at University College Hospital during
the last eleven years. They are in no sense picked cases.
They are, in fact, the only cases in which the lesion has
been completely transverse, and where this fact has been
verified by an autopsy. In all but one of these cases
(No. 3) it was perfectly obvious that the softening through
a certain limited part of the lower cervical or of the upper
dorsal region of the cord was a total transverse one, see-
ing that the cord substance thereat was completely difflu-
ent throughout its whole thickness. All the spinal cords
were carefully examined after they had been hardened in
a solution of bichromate of ammonia. In case No. 3 it
was found that both ascending and descending secondary
degenerations were just as fully developed as they were
in either of the others ; and seeing that the symptoms
during life were almost precisely similar, it seems safe to
conclude that the wider extent though lesser degree of
softening which had here existed in the mid-dorsal region
had almost sufficed to cut off all encephalic communica-
tions with the lower dorsal and lumbar regions of the
spinal cord.
Case 1. — Mary ¥ — , a;t. 38, a nurse, unmarried, was admitted into
University Coilege Hospital under my care April 20th, 1881.
TRANSVERSE LESIONS OV THE SPINAL CORD. 159
Family history. — Nothing of significance could be ascertained in regard
to this.
Past personal history. — The patient had been a governess for twelve
years, but six years ago she had to give up this work owing to ill-health.
Since this time her occupation has been that of a nurse. She has been
very much worried during the last eight yeai-s, owing to family troubles.
She had always been in good health till six years ago, when she suffered
from some nervous complaint, occasioned, as she thinks, by overwork.
Under medical treatment she was greatly relieved, and her health con-
tinued to improve till May, 1880, when she noticed a lump in her right
breast. On account of it she was admitted to this hospital in the follow-
ing June. She was under Mr. Heath's care, and was treated for
" scirrhus of the breast." The breast was removed, and her health
greatly improved after the operation. She did not resume her occupa-
tion, however, till four months ago. Very soon after this date she began
to suffer from great pains in the right shoulder, and soon afterwards in
the left shoulder, lasting about half an hour each time : they were very
severe at night, and of a lancinating character. The neck and back were
subsequently involved in pains of still greater severity ; these passed down
both arms as far as the elbows : pains were also felt in both thighs, passing
from the knees up to the hip-joints. She sought medical advice only
three weeks ago, and was soon recommended to come to this hospital.
Present state (April 23rd). — Patient is a rather stout, plethoric woman,
lying on her back, and unable to lie on either side on account of pain.
She complains of pain in the right breast, in the cervico-dorsal region of
the spine, in the shoulders, elbows, and thighs ; and of inability to stand
or walk. The pains are constant, but paroxysmally worse, and sometimes
they ai"e so severe that she shivers.
The skin is everywhere florid ; temperature varies from 99° to 98°.
The right mammary gland has been removed, and in its place is a
piickered irregular scar about three inches long. The cicatrix is adherent
to the chest wall, and the tissues for some distance around are indurated
and hard — evidently infiltrated with new growth. Between the scar and
the sternum there is a hard nodule in the skin about the size of a bean,
and the skin covering it is red. Above the cicatrix there is a similar
nodule in the skin ; and over the sternum are three other nodules, each
about the size of a pea. The tissues in the axilla are somewhat thickened,
and there are one or two hard tender glands under the pectoralis muscle.
The scar is tender, and is the seat of more or less persistent stabbing pain.
The left breast contains one large, rather hard lump about the size of a
small orange ; but there is no puckering of skin or retraction of the nipple,
and the gland is freely moveable on the pectoral muscle. There is no
enlargement of cervical or axillary glands on this side.
Spinal column. — The seventh cervical vertebra is rather prominent.
No other unnatural prominence or curvature exists. There is consider.
160 ON THE SYMPTOMATOLOGY OF TOTAL
able tenderness over tlie lower cervical and upper dorsal region of the
spine ; and there is also a great deal of pain referred to the same region.
Nervous system. — No head symptoms or evidence of defective function
on the side of any of the cranial nerves.
Sensory apparatus. — There is no loss of tactile sensibility, or inability
to appreciate the prick of a pin or to distinguish between heat and cold.
She complains of more or less constant burning pains in the elbow-joints,
shoulders, and hip-joints, and of a stabbing pain starting in the lower
cervical and upper dorsal region of the spine, and passing down through
the shoulders to the elbows.
Motor apparatus. — Upper limbs : On the right side she can move her
shoulder-, elbow-, and wrist-joints perfectly. She can also ilex and
extend the fingers. Grasp nil. Movements on left side similar to those
on right side. Grasp 10. Lower limbs : Patient is unable to stand or
walk. She can raise both legs from the bed, and flex hip-, knee-, and
ankle-joints perfectly but not very powerfully. Flexion of toes perfect.
She cannot raise herself into the sitting posture without assistance.
Reflexes — Plantar reflex normal on both sides. Abdominal, epigastric,
and gluteal reflexes not obtained. Slight ankle-clonus on both sides.
Knee-jerk exaggerated on both sides. She complains of occasional jerk-
ings of the thighs.
Previously to yesterday she had had no diffieulty in micturition, but
yesterday she had retention of urine for eighteen hours, though the blad-
der acted after a hot fomentation to the lower part of the abdomen, and
she has since passed urine twice. The bowels have not been opened for
seven days.
The examination of the thorax and abdomen revealed nothing very
imnaturai, with the exception that the respirations were 24 per minute,
and that the breathing was chiefly abdominal, very little movement of
the chest occurring; whilst the pulse was 112, small, regular, and com-
pressible.
April 26th. — The pain in the cervico-dorsal region of the spine, in the
shoulders, and elbows has continued persistently, though paroxysmally
worse, since admission. The pain is relieved by morphia gr. \ adminis-
tered every four to six hours. She has also been taking six grains of
iodide of potassium with an ounce of infusion of calumba three times a
day. Diet : Fish or oysters, with ox-tail soup, custard pudding, and
wine 3^.
May 1st. — For the last thirty-four hours she has had retention of
urine. A catheter was passed this morning, and 36 oz. of acid urine
were drawn off. Bowels have never been opened except by an enema,
which is administered daily. She can flex the hip-, knee-, and ankle-
joints and toes very feebly ; and she can only just raise the legs from
the bed. No anaesthesia. No ankle-clonus exists now on either side.
Patellar reflex less marked than on admission. Plantar reflex very slight.
TRANSVERSE LESIONS OF THE SPINAL CORD. 161
Temperature at 7 a.na. 97-8° ; at 11 a.m. 99-2° ; and at 6 p.m. 98-6°. The
iodide of potassium has been increased to 15 grs. in infusion of calumba
3J, three times a day.
3rd. — There is complete motor paralysis of the lower limbs, which has
come on since yesterday. Tactile sensibility is also diminished below the
knee on both sides. Eetention of urine still continues, so that it has to
be drawn off three times a day. The pains continue to be of about the
same severity. Temperature at 7 a.m. 98'2° ; at 11 a.m. 99'2° ; and at
7 p.m. 98"8°. It has not reached 100° since admission.
6th. — Motor paralysis still persists in lower limbs. Tactile sensibility
now lost below hip-joints. Abdominal, epigastric, gluteal, and scapular
reflexes absent on both sides. Plantar reflex now abolished on both sides.
Ankle-clonus also absent. Knee-jerks very slight.
8th. — The patient was placed upon a water-bed yesterday. On the lower
part of back on each side of coccyx the skin is red, and there are three
dark discoloured bullae to be seen. No pain or tenderness over the red-
dened skin. Tactile sensibility lost between the lower dorsal vertebrae
and the umbilicus. Motor paralysis of lower extremities continues.
Pains as before. Temperature 98'2°. Pulse 120, small, feeble, and com-
pressible. Tongue clean. Retention of urine. Bowels opened by ene-
mata, and she is perfectly conscious of the act.
11th. — The redness of skin over sacrum has not increased, and no new
bullae are seen. Old bullae same as at first appearance. Pulse 120, ex-
tremely feeble and weak. During the last two days the pains have
passed down the arms to the palms of the hands. She shivers a great
deal, and complains of twitchings in her back and legs, but no jerkings
of the legs have ever been noticed by the nurse. Legs feel cold. Iodide
of potassium mixture omitted, and one containing ether and tinct. of
digitalis with effervescing saline to be taken three times a day.
13th. — Motor power : Complete paralysis of lower extremities. Abdo-
minal muscles somewhat flaccid and apparently paralysed. No move-
ments of elevation or expansion of chest ; breathing is entirely diaphrag-
matic. Considerable weakness of upper limbs. Movements of shoulders
limited on both sides, and accompanied by severe pain. Flexion of
elbows perfect ; extension not farther than an angle of 120°. Move-
ments of wrist perfect. Cannot flex the fingers into the palm or grasp
the dynamometer.
19th. — Since last note the pain has been less severe, but of the same
character as before. The upper limbs are much weaker ; she can only
move her arms a few inches from her side. Other movements much as
before. She lies with her arms close to her side, her elbows bent at a
right angle, the wrists semi-pronated, and the phalangeal joints semi-
flexed. The lower limbs, completely paralysed, are extended and flaccid,
and the feet are inverted. There is now complete loss of tactile and
painful sensations below the xiphoid cartilage and the ninth interspace.
VOL. LXXIII. 11
162 ON THE SYMPTOMATOLOGY OF TOTAL
All superficial reflexes, including the plantar, are abolished. There
is also no ankle-clonus or knee-jerk to be obtained on either side. Com-
plete retention of urine exists. The catheter is passed three times a
day. The urine is acid. She has been unable to retain an enema since
last note. Her bowels have been opened twice with castor oil, and on
each occasion she has been unconscious of the act and has passed the
motions into the bed. Pulse 70—80, much less weak than formerly.
Temperature 99° ; it has only once since admission reached 100° ; it mostly
ranges between 97"5° and 99'5°.
21st. — Since last note patient's temperature has varied from 99° to
1026°, Pulse 90. Respiration 24. No cough ; no expectoration ; no
dulness in front of chest, and breath-sounds as on admission ; no rales.
Back not examined. Yesterday the urine began to dribble away about
four hours after the catheter was passed. Bowels opened by purgatives ;
she cannot retain an enema. She is unconscious of the passage of faeces
and of urine. There is complete loss of tactile and painful sensations as
high as the fifth interspace. No loss of tactile sensibility in upper
limbs. Complete paralysis of intercostal muscles below the fifth inter-
space, and of abdominal muscles. All the muscles of the lower limbs
contract when tapped with a stethoscope. There is also a slight plantar
reflex when the soles of the feet are sharply tapped. No abdominal or
epigastric reflex. No ankle-clonus and no knee-jerks. She takes very
little food.
28th. — The loss of tactile and painful sensibility reaches as high as the
fourth interspace. Temp. 99°. From date of last note up to yesterday
it has ranged between 100° and 101'5°. Bladder washed out twice daily
with a weak quinine solution.
June 3rd. — There is a considerable amount of dyspnoea this morning.
Expiration is short and forcible, and accompanied by bubbling rales in
the throat and all over the chest. No retraction of lower part of chest.
Pulse very feeble and thready. Ordered a mixture containing ammonia,
ether, and digitalis, together with two ounces of brandy in the twenty-
four hours.
4th. — Patient is considerably easier this morning. Breathing quieter.
Breath-sounds over front high pitched and accompanied by loud bubbling
rales. The prick of a pin is not now felt below the level of the third
rib. Has required rather more moj'phia to deaden the burning and other
pains from which she suffers. On May 31st her temperature again rose
to 101°, and from that time to the present it has ranged between 100°
and 102-6°.
12th. — Patient has had considerable difficulty of breathing during the
last three days, owing to the amount of mucus which has accumulated in
the bronchi. Pains very severe, morphia only controlling them for a very
short time, seldom for more than an hour. Temp. 98'8° ; since June 5th
it has only once risen as high as 100°.
TRANSVERSE LESIONS OF THE SPINAL CORD. 163
13th. — Difficulty of breathing increased to-day. She was ordered a
hypodermic injection of ^ gr. of apomorphia, and this was administered
at 4.55 p.m. Previousl}' to injection the pulse was 92. After fifteen
minutes, without any feeling of nausea, the pulse fell to 76, and became
feeble and irregular. An enema of §ss brandy in ^ij of beef-tea was
given. Pulse 72, and then 80. No sickness at 5.15, so the fauces were
touched with the finger, which induced some retching and the expectora-
tion of a little viscid mucus. Some brandy was given by the mouth.
Pulse remained at 80, small and occasionally intermitting. At 5.25
pulse fell to 54, was very weak and almost thready ; at 5.34 to 58 ; at
6.40 to 52, very thready, with respiration embarrassed, hands cold and
clammy ; expression of moribund type. Ether 1T\xvi was now injected
over chest, and the pulse slowly but progressively recovered. At about
6 o'clock she began to bring up large quantities of frothy mucus (and for
an hour or two afterwards she brought up gulps of mucus at intervals —
as though from contraction of bronchi ; no vomiting). The breathing
afterwards improved materially. At 7 p.m. the pulse was good, about 90,
and the patient comfortable.
14th. — Considerably easier to-day. Breathing much better. Pain
continues about the same, but is rather more readily controlled by
morphia.
17th. — This morning at 3 a.m. patient had a fit of dyspnoea, lasting
about fifteen minutes. She became dusky in the face; no coughing;
breathing short and shallow. At the commencement of the fit she
flexed both arms on to the shoulders, the fingers were also flexed, and the
head was bent over on to the left shoulder.
19th, — This morning at 5 a.m. patient had a similar attack of dyspnoea,
which commenced in exactly the same manner, and lasted about the same
time. But for these attacks the patient has been much more comfort-
able, and her breathing much easier since the apomorphia. The affection
of sensibility over the front of the chest is not appreciably altered ; the
prick of a pin is still not felt below the level of the third rib. But this
afternoon patient complained of a sensation of tingling all over the body
and legs. The bedsore has increased, and the tissues around are dark.
There is a sore also on one heel to-day.
28th. — Patient was easier during the night. At 7.30 she had an
injection of morphia. At 8 a.m., when turned over on to right side
to have bedsore dressed, she turned pale, became cyanosed, and died
quietly a few minutes later. Ether was administered hypodermically
without any effect upon the pulse ; and the pupils became widely dilated
just before death.
Autopsy (six hours after death). — After removal of the vertebral
arches nothing unnatural was seen ; but on cutting through the spinal
cord just below the bulb and reflecting it, a slight angular curvature was
found at the level of the fourth or the fifth cervical vertebra, though
164 ON THE SYMPTOMATOLOGY OP TOTAL
involving one vertebra only. In this situation no new growth was seen,
but immediately above the angle the substance of the vertebra felt
decidedly softer than natural when pressed upon by the finger. After
removing the dura mater, which presented nothing unnatural, the spinal
cord, about two inches from the point of section, and at a site corre-
sponding with the slight projection above mentioned, was found, for a
length of three quarters of an inch, to have only about half the width and
depth natural to it in this situation. It was here also soft and flaccid,
contrasting notably in this respect with the cord substance above and
below. Independently of these signs of softening and atrophy there
was no abnormal appearance on the anterior surface of the cord, which
presented an average amount of vascularity. Its posterior surface showed
the same evidence of atrophy at the site above referred to, but no
unnatural vascularity above, below, or over the wasted region. On
cutting through the cervical segment of the cord above the wasted
portion, the grey matter presented a fair amount of vascularity, not in
any way excessive. There was a slightly altered tint in the columns of
Goll and in portions of the lateral columns, but otherwise nothing
unnatural was seen. On cutting through the softened and atrophied
portion of the cord, it was here found to be reduced to a semi-fluid pulp.
On making sections through the cord for about two inches below this
atrophied and softened region there was distinct evidence of central
softening involving the grey matter, since when cut across the central
portions swell up above the level of the surrounding white columns.
Sections through the remaining dorsal and through the lumbar regions of
the cord showed no evidence of softening, nor was any other morbid
appearance to be recognised except that the grey matter was rather more
anaemic than natural.
Heart : Right side of heart thickly covered with fat. Mitral valve
slightly thicker and more opaque than natural. Walls of left ventricle
slightly paler than natural, and consistence slightly diminished. Left lung:
No adhesions ; about three ounces of yellowish serum in the pleura. Upper
lobe on section found to be semisolid and oedematous. Portions of the
upper and middle regions of this lobe as well as the lowest portion of the
lower lobe were in a state of more or less well-marked collapse. Nearly
a quarter of the tissue in this lung was in such a condition. Right lung :
Adhesions extensive. No fluid in pleura. Large portions of the surface
of this organ were emphysematous, but on section it presented a healthy
appearance throughout. There was no collapse and no new growth. Liver
rather smaller than natural and adherent to under surface of diaphragm.
In different parts of its substance were found five nodules of white new
growth, varying in size from a small bean to a medium-sized chestnut.
Otherwise the cut surface of the organ was rather pale, its lobules were
indistinctly marked, and its consistence was slightly above par. Spleen of
medium size. No appearance of new growth either superficially or within.
TRANSVEKSE LESIONS OF THE SPINAL CORD. 165
Cut surface very dark, and consistence rather softer than natural. Left
Jcidney extremely congested ; cut surface of deep claret colour throughout.
Capsule stripped off easily, leaving surface uniformly congested. No new
growth. Right hidney presented similar characters ; congestion just as
well marked, but on the surface there was one small patch distinctly
paler in colour, which was found to extend for a slight distance into the
substance of the organ. (It appeared to be a commencing patch of new
growth.) Stomach and intestines presented nothing abnormal. Ovaries :
Both hard and cartilaginous to the touch ; not distinctly larger than
natural. On section they were found to be both tough, and showed an
excess of fibrous tissue in their interior. Uterus considerably enlarged ;
cavity not lengthened ; walls thickened and very tough. From posterior
part of fundus, on left side, a peduncular growth of the size of a small
orange projected. It was nodulated and extremely hard, and on section
was seen to consist almost wholly of fibrous tissue. On the right side of
the body of the uterus, and completely obscuiing its outline, there was a
very tough, hard encapsuled growth, about the size of a small orange.
The capsule was vascular and about one third of an inch in thickness, and
on section the tumour presented similar characters to those of the pedun-
culated growth above referred to. Brain and its 7nembranes showed
nothing unnatural. There was no new growth or focal lesion of any
kind.
An examination of tte spinal cord after it had been
hardened in a solution of bichromate of ammonia showed
the follovsring lesions :
A total transverse softening with greatly diminished
bulk of the cord substance existed for a length of about
three quarters of an inch_, beginning near the middle of
the cervical swelling.
A section just above the cervical swelling shows well-
marked ascending secondary degenerations in the columns
of Goll and in the superficial portions of the lateral tracts.
A section one inch below the lower border of the trans-
verse softening shows descending secondary degenerations
in both crossed pyramidal tracts, and to a slight extent in
the anterior columns. In addition there are two large,
definitely circumscribed, opaque white patches (Fig. 1), the
larger of which (a) is situated in the central half of the
posterior columns, though it does not occupy much of this
portion of the column on the right side. The smaller patch
(6) is oval, and situated just outside the right posterior
166 ON THE SYMPTOMATOLOGY OF TOTAL
coruu. In a section lialf an incli lower down tlie latter
patch no longer exists, and the one in the posterior
columns is smaller and confined to their central region.
Fig. 1.
Half an inch lower still a triangular patch exists in the
same situation, which has here broken down into a cavity,
and is found to extend downwards for about a quarter of
an inch.
Farther down — that is, two and a half inches below the
lower level of transverse softening — only descending de-
generations appear in the posterior parts of the lateral
columns, in the '' comma-shaped tracts,^' and (though very
slightly marked) in the inner parts of the anterior columns.
One and a half inches lower — that is, about the mid-
dorsal region — descending degenerations are seen in similar
situations, being still quite well marked in the " comma-
shaped tracts. '^
In the upper part of the lumbar swelling the descend-
ing degenerations are also very well marked in the poste-
rior parts of the lateral columns, and there is a trace of
degeneration in the anterior columns, but that of the
" comma-shaped tracts " has disappeared.
In the middle of the lumbar swelling the appearances
are similar, whilst in the lower third of the lumbar swell-
ing only greatly diminished areas of degeneration in the
lateral columns exist.
All through the lumbar swelling, as well as through the
lower half of the dorsal region, the grey matter of the cord
presents a healthy appearance.
TRANSVERSE LESIONS OF THE SPINAL CORD. 167
There is no record of an examination of tlie cervical ver-
tebrae with the view of ascertaining the nature of the
disease which led to the softening and projection of a por-
tion of the body of one vertebra, opposite the softened seg-
ment of the cord. Nor was the precise pathogenesis of
the latter softening quite clear. The projection certainly
was not sufficiently great to have caused much pressure
upon the cord, though it may have set up primarily an
irritation of the anterior columns. At the time of the
autopsy there were no appearances in the cord, or in its
membranes contiguous to the softened region, in the least
indicative of an inflammatory process ; nor, on the other
hand, was there any evidence of arterial thrombosis.
The pains from which the patient suffered were very
severe in the upper extremities, and, strangely enough,
severe pains were felt also in the thighs, as well as burning
pains in the hip-joints. These latter severe pains are not
easily to be explained. From the note of May 19th it
would appear that the arms were then in very much the
same position as that described by Dr. Thorburn {' Brain,'
October, 1888, p. 293) as resulting from disease high
enough to paralyse the deltoids, viz. at or just above the
level of the fifth cervical nerve. The patient seemed dying
from suffocation at the time of the injection of the apo-
morphia, and it was only ordered in view of the inevitable
consequences if the rapidly accumulating mucus could not
be expelled. The danger was undoubtedly great from
the remedy, but the subsequent relief was no less striking.
Strangely enough, too, the great bulk of the mucus was
not expelled by vomiting, but rather by what appeared to
be successive contractions of the bronchial tubes. From
the note made on May 21st it will be seen that the limbs
were completely flaccid and paralysed, that all the reflexes
(superficial and deep) were absent, but that the idio-mus-
cular contractility was present in all the muscles of the
lower extremities when they were tapped with a stetho-
scope ; and possibly what is called in the notes a *' slight
plantar reflex " was produced in this manner. This idio-
168 ON THE SYMP'JOMATOLOGY OF TOTAL
muscular contraction is now generally considered to be
quite distinct from a reflex action.^ According to Schiff,
Kiiline, and others, it is supposed to be due to tlie proper
excitability of the muscular tissue itself. Funke and
Weber have been able to produce the phenomenon in the
human corpse even twenty-four hours after death, though
Onimus could not elicit it later than eight hours after
death.
Case 2. — M. A. W — , set. 24, a dressmaker, was transferred to my care
at University College Hospital on October 14th, 1880, from one of the
surgical wards, to which she had been admitted a week previously. She
was suffering from recurrent cancer of the left breast with secondary
disease of the spine, affecting the spinal cord and causing paraplegia.
The patient's father died of apoplexy, a^t. 79, and there is no other
history of nervous disease. Her grandmother died of cancer, and her
mother, set. 80, has a tumour of the breast.
Personal history. — The patient is a single woman, there is no specific
histoiy, and until a tumour appeared in her breast she never had any
illness except " intermittent fever " when seventeen years old. About
four years ago she first noticed a tumour in her breast. She was
operated upon by Mr. Barker at University College Hospital on April 7th,
1880. When she left she knew that she had some enlarged glands in the
left armpit, that the operation had failed in its chief purpose, and that
she might expect a return of the growth ; and this very soon occurred in
the cicatrix and neighbouring skin. About three months after the
operation (middle of July) she began to have pains between her shoulder-
blades and in both shouldei-s, though they were neither constant nor
very severe. About the same time she also began to have numbness in
the inner part of the left wrist and arm, and in the ring and little
fingers. This numbness was soon succeeded by severe pain, which kept
her " awake for a fortnight." Then it gradually subsided, leaving the
whole hand numb. About six weeks ago (beginning of September) she
began to feel numbness in the right ring and little fingers and along the
inner border of the hand, though to a less marked extent than on the
opposite side. About September 24th she began to experience a feeling
of numbness in the perinaeum, and very soon after in the legs, and then
pari passu with the increase of the numbness, and equally on both sides,
she lost power over her lower limbs. Thus, without any distinct onset
or sudden exacerbation, she found increasing diflBculty in moving, so that
^ See " Note sur le contraction idio-musculaire chez les epileptiqucs," pa?
MM. Ch. Fere et H. Lamy, 'Archives de Physiol.,' Juillet, 1889, p. 570.
TRANSVERSK LESIONS OK THE SPINAL CORD. 169
bj October 1st she was quite unable to move her hiwer limbs, even in bed.
Towards the end of the first week of the paralytic symptoms she had
retention of urine, and this persisted for two daj's after admission to the
hospital, so that she suffered from retention for about ten days, and this
was svicceeded by incontinence. She says also that for about two days
before admission the numbness began " to creep up from her waist to
her chest."
From the surgical notes it appears that on the patient's admission to
the hospital there was a " commencing bedsore on the right side of the
sacrum," but this was healed before she was transferred. It is also noted
on October 12th that the " patellar tendon-reflex was present and not
diminished."
Present state (October 19th). — Some extracts only as to her condition
at this time will be given, as the loss of sensibility was far from com-
plete, and therefore at this period a total transverse softening could not
have existed.
Although she had lost flesh, she is still a fairly well-nourished woman ;
and with the exception of the scar and new growth described below there
is no affection of the skin, which is warm, moist, and of a healthy colour.
The left breast is absent, and in its place is a long scar which extends into
the axilla, and ends in a loose fold of skin. The scar is nowhere entirely
adherent to the chest. There is much hard thickening of the skin in the
neighbourhood of the scar, and also upwards to the summit of the
shoulder. The tissues in the axilla are indurated so as to form a hard
mass there. Temperature varying between 98° and 99° since admission.
Spine. — There is an unusual prominence of the last one or two
cervical and of the first three or four dorsal vertebrae. There is likewise
some tenderness to percussion over them, as well as hypersesthesia to
touch, to pin-prick, and to heat and cold.
There is absolute loss of all power of voluntary movement in the lower
extremities. There is no wasting of any of the muscles, and the elec-
trical reactions are about normal. In the upper limbs there is no evident
wasting of any miascles, except to a slight amount in the ball of the
left little finger. Most of the muscles respond rather more readily on the
right than on the left side. She can execute any movement with either
arm or forearm except flexion of the wi-ist on the left side, and on that
side the power of flexion of the fingers is so much diminished that she
cannot close her hand sufficiently to grasp at all. Grasp, right 19, left 0.
No action of abdominal muscles either voluntarily or during respiration.
There is greatly diminished but not abolished sensibility, in all its
modes, over the whole of the left hand, but especially over the little
finger and the palmar and inner side of the ring finger. A similar con-
dition exists on the right side only over the little and ring fingers.
Similar defects in sensibility exist over both lower extremities, over the
abdomen, and over the thorax as high as the fourth interspaces on both
170 ON THE SYMPTOMATOLOGY OF TOTAL
sides. Above this level sensation to touch, pain, and heat and cold
appears to be quite natural.
Reflexes. — The patellar tendon -reflex is absent on both sides. No ankle-
clonus usually, though occasionally one may be obtained. Plantar reflex
very slight. Abdominal reflexes absent.
Bowels habitually constipated ; knows when they are about to act, but
has no sensation when faeces are actually passing the anus. Urine is
voided in gushes at frequent intervals, unaccompanied by sensation. The
urine is alkaline and offensive.
November 3rd. — Patient has been complaining for the last twenty-four
hours of a good deal of pain down her left arm. The arm and elbow are
cedematous and brawny. Temp. 98'8°, pulse 84, resp. 22. Belladonna
and glycerine applied to the arm.
The patient was put upon a water-bed a few days after admission, but
in spite of every care a bedsore began to form again about the end of the
first week in November. About this period also the bladder was ordered
to be washed out twice daily with a weak quinine solution. Up to this
time the patient's temperature was mostly normal, only occasionally
rising to 99'4° ; her appetite also continued good, and she slept fairly
well.
December 13th. — The general condition of the patient was carefully
re-investigated at this date. From the notes then made I quote the
following pai-ticulai-s :
Occasionally she has a little pain in the left thumb, but nowhere else.
The left arm is still swollen and cedematous. Her power of moving the
upper limbs is decidedly less than it was on admission (especially in
the left). On this left side the only movements which remain are some
amount of flexion and extension at the elbow-joint (not beyond 90°
in one direction or 150° in the other). On right side can raise hand to
head and execute all other movements, but has very little power. Grasp
practically nil ; when she attempts to grasp the extensors overcome the
flexors. Sensibility in the upper limbs is still only affected in the
same ai'ea as before, and the degree of impairment is not very notably
increased.
Lower limhs. — The skin of the lower extremities is remarkably dry
and scui-fy. Sensibility is now almost completely lost throughout the
whole of both lower limbs. Even when the whole hand grasps the thigh
or leg no impression is produced. A pin forcibly driven into the thigh
produces no distinct sensation ; she thinks " there is something moving,
but is not sure." [It was noted at an earlier period that " over the
anaesthetic areas a pin-prick draws little or no blood."] Heat and cold
produce no impression.
There is still complete inability to move any part of either lower ex-
tremity. Reflex action is also entirely abolished in each limb, with the
TRANSVERSE LESIONS OP THE SPINAL CORD. 171
exception that forcible scratching of the soles of the feet causes slight
movement of the corresponding toes. Terap. 98-5°, pulse 62, resp. 18.
A bedsore has been forming on the sacrum during the last ten days, which
has been dressed with an ointment containing 12 grs. of carbolic acid to
an ounce of vaseline, and subsequently with iodide of starch daily.
January 6th, 1881. — The patient was again carefully examined at this
date. The condition of the upper extremities was found to be not ap-
preciably different from that recorded above, except that the power of
moving the left limb was rather less. It could not be moved at all from
the shoulder, and at the elbow there was only a slight power of flexion
through 30° (from 60° to 90°). Very slight movement at wrist and
metacarpo-phalangeal articulations ; none at phalangeal articulations.
In the lower limbs, however, sensibility was now completely abolished ;
and the note made concerning the reflexes was as follows : — " No reflex
action on tickling soles of feet, but on tapping soles of feet smartly with
a stethoscope, contraction of muscles of front of leg followed. The same
thing occurred on tapping the muscles directly. No ankle-clonus. No
patellar reflex."
The reflex evacuation of the bladder, however, still continues. The
notes say, " Patient passes her urine in gushes about every two hours."
There is now loss of all modes of sensibility on the trunk of the body
as high as the fouth interspace ; also of movement of abdominal muscles
and of intercostals to the same level. The breathing is entirely diaphrag-
matic.
During the last three weeks the patient has lost flesh considerably, but
she has not sufEered pain, and has slept without morphia. Her appetite
for the last two or three days has been very poor, the tongue being coated
with a light fur and rather dry.
Over sacrum the bedsore is deeper and more extensive, and covered with
slough. The skin around is red and brawny. On the right heel there is
a sore about the size of a shilling (which began about two weeks ago),
from which a slough is separating. On left heel there is no sore, but the
tissues are indurated. Pulse 68, temp. 99'6° ; since December 29th it has
risen to 101° or 100" nearly every day.
19th. — Patient has been still losing flesh since last note, and is sinking
gradually. The bedsore over sacrum is spreading, and at one part is
covered with a black slough. She has complained of more pain again
in the left arm, and has had a quarter of a grain of morphia twice a day.
Anorexia is extreme. Pulse 76, resp. 26, temp. 101"2°. The urine has
been free from albumen throughout. For the last five days she has been
taking extra strong beef-tea, and port wine ^iv daily. The latter is now
changed to brandy ^iv.
26th. — Since last note patient has been complaining of pain In the right
arm from shoulder to thumb, similar to the pain on the other side. She
is scarcely able to raise this hand to the head. She can move the elbow
172 ON THE SYMPTOMATOLOGY OP TOTAL
and wrist, but is unable to grasp. There is still no loss of tactile
sensibility except on the ulnar side of the hand. Patient is sinking ;
she takes very little food and is very di'owsy. She often complains of
feeling as if she were choking. Since the 18th inst. her temperature has
risen nearly every day to some point between 100° and 101°.
28th. — Patient died last night, sinking very gradually.
Autopsy (14 hours after death). — Whilst opening the spinal canal it
was found that at the bottom of the neck and between the shoulders
there was a very thick layer of subcutaneous fat, over an inch in some
parts, and amongst the fat a whitish new gi'owth. The muscles beneath
were not infiltrated in any way, nor were the arches of the vertebrae,
though these seemed to be rather unnaturally soft. The posterior and
external surface of the spinal dura mater presented a natural appearance
throughout ; it seemed natural also on transverse section of it (with the
spinal cord) just outside the skull. But it was found to be unduly ad-
herent to the bodies of the vertebrag for a length of about five inches in
the lower cervical and upper dorsal regions, the adhesion being due to a
new growth of whitish colour connecting it with the posterior part of the
bodies of the corresponding vertebrae. On opening the dura mater
laterally and anteriorly the new growth was found not to have made its
appearance on the inner surface of this membrane. The lower two
thirds of the cervical swelling of the Spinal Cord felt decidedly softer
than natui'al, and opposite its lower extremity (corresponding with the
lower margin of adhesion o£ the dura mater to the bone) the cord showed
evidence of extreme wasting ; it was here notably flaccid and atrophied,
and had an appearance suggestive of pressure, though nothing was found
that could have caused pressure. For a distance of about four and a half
inches below this point the cord presented a very irregular appearance,
owing to the existence of two other areas in which its substance was distinctly
softened and atrophied. This was most marked about three and a half
inches from the lower end of the cervical swelling, where the cord seems
to be even softer and more flaccid than it was above. Immediately below
this point, for a distance of about one inch, the cord was also somewhat
softer than natural ; but below this latter level its consistence seemed to
be that of health. On the anterior surface of the cord no large vessels
were seen, nor was there any unnatural vascularity ; but on examining its
posterior surface the cervical and upper dorsal regions were found to be
decidedly more hyperaemic than natural. On this posterior aspect of the
cord depressions and irregularities were to be seen similar to those found
on its anterior surface.
On cutting through the cervical swelling about its middle, the surface
of the section seemed to be decidedly softer than natural ; whilst in
another section through its lower third all parts of tlio white substance
were found to be somewhat diSluent. In some parts here a semi-fluid
pulp could be easily scraped from the cut surface, whilst the grey matter
TRANSVERSE LESIONS OF THE SPINAL CORD. 173
was extremely indistinct on both sides. There was, however, no excessive
amount of vascularity.
On making another section just below the cervical swelling, at the
region of atrophy with softening, the whole substance of the cord was
found to be diffluent throughout : it was represented by a thick yellowish,
white fluid. On cutting through the lower atrophied portion, the cord
(though softened, flaccid, and atrophied throughout) was found to be not
absolutely diffluent.
When sections were made through the cord in the lower dorsal and
lumbar regions it was found to be of fairly good consistence throughout.
All the sections were, however, decidedly paler than natural, the blood-
vessels existing in the grey matter being either smaller or less numerous
than usual.
Thorax: On cutting through the integuments it was found that the
hardened tissues about the base of the scar corresponded with an infil-
trating new growth which has caused distinct adhesion to the ribs. On
the inner side of the chest, at about the level of the second and third
ribs, the pleura was afEected with a whitish growth, and the corresponding
portion of the lung was adherent to it ; but when torn across the adhe-
sions were found to consist only of fleecy connective tissue. This left
pleura contained about twenty ounces of yellowish serum. The lower
lobe of the corresponding lung was much compressed and airless, and the
lower and posterior parts of the upper lobe were in a very similar state.
Only the upper and anterior portions of the upper lobe float in water,
other portions sink at once. The riglit lung presented an old pigmented
and puckered patch about three quarters of an inch in diameter at the
apex, but there was no other phthisical change, old or recent, nor was there
any other notable change about this lung. No trace of cancer exists in
either organ. Heart of medium size, containing some ante-mortem clots
in the right cavities. Mitral valves slightly thicker than natural ; aoi-tic
valves healthy. Muscular substance of left ventricle paler than natural,
and its consistence below par. Liver smaller than natural, and some
parts of it are unduly tough ; no distinct pathological change. Kidneys
rather small, somewhat congested, and slightly tougher than natural.
Spleen of medium size, rather firm ; on section it is seen to be of a
uniform dark colour. Uterus .• This organ has a small fibroid growth
attached to its fundus. Ovaries very thick ; fibroid capsules exist, and
some whitish cicatricial-like patches within. No distinct evidence of
cancer. Bladder ; This shows no ulceration, but the mucous membrane
presents some distinct patches of inflammation. These do not occupy
more than one seventh or one eighth of the whole surface of the bladder.
Brain and its membranes fairly healthy ; no cancer found in any part
of them.
On sawing vertically through the spinal column the bodies of the
vertebrae, from the fifth cervical to the second dorsal inclusive, were
174 ON THE SYMPTOMATOLOGY OF TOTAL
found to contain a yellowish-white, firm growth. This occupied the
centre of each body, and was surrounded by soft bone. The body of the
seventh cervical vertebra had almost entirely disappeared, its place being
taken by new growth adherent to the dura mater ; part of this was
torn away during removal of the cord from the spinal canal. The bodies
of the vertebrae above and below were normal, being firm and of pink
colour, and contrasting strongly with those that were diseased. The ribs
were not infiltrated with new growth, and there was no distinct evidence
to show whether or not the growth in the vertebrae had spread by continuity
from the axilla, either along the ribs or along the intercostal spaces.
A mass of lymphatic glands lying in front of the vertebrae below the
pancreas was very considerably enlarged. Externally they had a whitish
colour, and on section presented all the appearance of being infiltrated
with a cancerous new growth. Chains of glands, less enlarged, also ex-
tended downwards along the iliac veins into the pelvis.
After the spiaal cord had remained in a solution of bi-
chromate of ammonia for some time and had become tho-
roughly hardened^ it was again examined^ and with the
following results :
Throughout the cervical region of the cord well-marked
ascending areas of secondary degeneration are seen in the
columns of Goll and in the direct cerebellar tracts ; but in
addition^ from about the commencement of the lower third
of the cervical swelling up to rather above its middle, there
is a continuous longitudinal tract of softening which occu-
pies the central extremity of the left posterior column,
together with the hinder part of the grey commissure and
the inner part of the posterior grey cornu on the same side
(Fig. 2, a) . This area is rather larger below, and dimi-
nishes somewhat in its diameter above. The central por-
tions of the area are now occupied by a cavity, whilst at
its periphery degenerated cord substance is seen.
A section through the lower third of the cervical
swelling shows, in addition to the area above described,
three other morbid patches, irregular in shape but having
very much the same sectional area (Fig. 2). One occu-
pies an area on the right side closely corresponding with
that already described on the left side of the cord, though
with no central solution of continuity {h) . Another occu-
TRANSVERSE LESIONS OF THE Sl'INAL CORD.
175
pies tLe hinder portion of tlie right lateral column (c) ;
while the third is a wedge-shaped area with its base out-
wards, and coming to the surface about the middle of the
left lateral column {d).
Fig. 2.
-c
Fig. 3.
Fig. 4.
Just below the cervical swelling the cord substance is
much wastedj and is diffluent throughout its whole thick-
ness.
For nearly one and a half inches lower down the cord
shows no localised lesions except secondary degenerations,
though these occupy the greater portion of the white
columns of the cord, as both descending and ascending
degenerations exist in their most typical form.
The ascending degenerations are due to the fact that a
second total transverse softening exists two and a half
inches below that in the uppermost dorsal region.
But about one inch above the level of this lower soft-
ening the cord begins to show on section, in addition to
the above-mentioned areas of secondary degeneration, a
number of small opaque white foci (nine in all), agreeing
in relative size and distribution with those represented in
Fig. 3.
Below the second area of softening for a distance of
about one inch the sections of the cord show, in addition
to well-marked areas of descending secondary degeneration,
a number of very small localised foci of an opaque white
colour, very similar in appearance to those which exist
above this softened area. In a section three quarters of
176 ON THE SYMPTOMATOLOGY OF TOTAL
an inch below the softening they have such a disposition as
is represented in Fig. 4.
In a section three quarters of an inch below that last
described no localised areas of change are seen except
areas of descending degeneration, and this holds good for
all lower portions of the cord — that is to say, for the last
four inches of the dorsal region, and for the whole of the
lumbar swelling. The secondary degenerations are pre-
sent in the lateral columns throughout, and in the dorsal
region they are also present in the inner part of the ante-
rior columns, but other portions of the white columns and
the grey matter show no signs of disease.
This is an interesting case in very many respects. As
to the actual cause of the softening nothing very definite
can be said. There were no marks of inflammation about
the cord ; there was no evidence of thrombosis in any of
the larger vessels capable of initiating the softening ; and
there was no evidence of pressure of any kind, although
cancer had obviously involved the lower cervical vertebrae
and the corresponding outer surface of the dura mater.
On October 19th all movements of the upper limbs were
possible except flexion of the wrist on the left side. At
this date also it will be observed that although the lower
extremities were completely paralysed, sensibility was
only greatly impaired. Under these circumstances it is
important to remark that the reflexes were not altogether
abolished. By December 13th the left arm had become
greatly swollen and oedematous, and all movements were
abolished except slight flexion and extension at the elbow.
At this date, though motor power in the legs was completely
lost, sensibility to painful impressions was not quite abol-
ished ; whilst as to the reflexes it is said, " Eeflex action is
also entirely abolished in each limb, with the exception that
forcible scratching of the soles of the feet causes slight
movement of the corresponding toes." By January 6th,
however, there was complete sensory as well as motor para-
lysis of the lower extremities, and now also all the reflexes
TRANSVERSE LESIONS OF THE SPINAL CORD. 177
were completely abolished ; though the notes say that on
tapping the soles of the feet smartly with a stethoscope,
contraction of the muscles of the fi-out of leg followed —
the same thing occurring, however, on tapping the mus-
cles dii"ectl3\ These were doubtless only two different
modes of bringing about a simple idio-muscular contrac-
tion. Reflex evacuation of the bladder still occurred,
the urine escaping " in gushes at intervals of about two
hours." Neither in this nor in the previous case is there
any mention of the existence of a girdle sensation. The
immediate cause of the patient's death here was exhaus-
tion and fever resulting from sloughing bedsores.
Case 3. — H. E — , set. 51, was admitted into University College
Hospital under my care on November 26th, 1884, complaining of loss of
power in both legs, but mainly in the right.
Past history. — He has been married twenty-five years ; no distinct
histoiy of syphilis. He owns to excesses " in drink," especially during
his younger days, though they have also occurred occasionally, he says,
up to within the early part of this year. In other respects his habits
have been regular, and he has always been well fed and clothed. He
comes from a healthy and long-lived stock, and there is nothing in his
family history to throw light upon his present disease. Till within the
last few weeks he has always been a strong, healthy, and well-nourished
man, except for two or three slight symptoms referred to below which
have been of longer duration.
He says that two years ago, whilst going to his work, he trod on some
slippery substance, his right heel slipped, and he fell heavily to the
ground. This gave rise to great trembling and faintness at the time.
He also says that for a long time, " perhaps two years," he ha-s noticed
tremors in the right foot, especially when the heel has been raised, as in
resting the toes on a ledge, and that he has for a considerable time com-
plained of pain in the back and a feeling of weakness in the loins.
But the symptoms which have more particularly attracted his attention,
and for which he can fix a definite date (viz. the first week in October
last), are these : — (1) Bladder troubles ; viz. a feeling of tightness about
the bladder, and difficulty in expelling his water. (2) The right leg
showing a tendency to give way beneath him, and this foot dragging in
walking, together with a burning sensation in the right foot and leg —
troubles which have since extended to the left limb. (3) Coincidently with
these symptoms he began to feel a constant desire to defaecate, with
inability to do so ; but during the frequent severe straining efforts to
micturate (often causing sweating and tremors of the whole body) there
VOL. LXXIII. 12
178 ON THE SYMPTOMATOLOGY OP TOTAL
was an occasional involuntary evacuation of faeces. On October 15th,
after drinking a pint and a lialf of ale, he first noticed that his water ran
away from him, and it has continued to do so ever since. Previous to his
admission he has never been confined to bed ; but he has had two rigors,
one about five weeks and the other about three weeks since.
Present state} — Patient is a well-built, well -nourished, and fairly
healthy-looking man. Temp. 97 6°. He walks with a staggering,
uncertain gait, and would soon fall unless suppoiied. He keeps both
legs stiff, and brings the heels to the ground first. He raises the right
foot with most difficulty. He can sit up and turn over in bed readily.
He flexes the knees with little force, especially the right. Movements at
all the other joints are more natural. Dynamometer, right hand 72,
left 56. Sensibility to touch and pain normal over the whole body, but
he confuses impressions of heat and cold all over the lower extremities.
Plantar reflexes normal on both sides ; cremasteric, abdominal, and epi-
gastric cannot be obtained. Ankle-clonus well marked, and knee-jerk
exaggerated on bpth sides. Patient feels a desire to micturate, but has no
control whatever over the act. He always passes his water involuntarily
directly he begins to move. He is rather costive, but experiences desires to
defsecate, and also has some slight voluntary control over the act. His
sexual desires are unimpaired, but erections are rare. There are no
tremors or wasting of the muscles, but there is great rigidity in those of
the lower extremities, especially on the right side. All muscles respond
to faradisation, but those of lower not so readily as those of upper extre-
mities. Patient suffers no pain of any kind ; he sleeps well, his memory
is good, and he has no unnatural cerebral symptoms. The functions of
all the cranial nerves are unimpaired. There are no signs of thoracic or
abdominal disease.
December 6th. — Patient on getting out of bed last night found himself
unable to stand ; his legs were so extremely stiff that he could move
his ankles and his knees only to a very slight extent. He also com-
plained of considerable numbness in both legs, but more especially in the
right, where the sensation extended as high as the lower part of the
abdomen. This morning a soft French catheter was passed, and fifteen
ounces of normal acid urine were drawn off. Temp. 98'4°, pulse 68.
7th. — Yesterday after a dose of saline aperient he had an involuntary
evacuation of the bowels, of which he was quite unconscious. Neither is
he conscious now when his urine passes. This morning he complains of
a band-like constriction across the abdomen just below the umbilicus,
beneath which level his sensibility is less acute than it is above. His
legs are extremely stiff", and tend to get drawn up beneath him — and after
this occurs they are with difficulty re-extended. At 2 p.m. a soft
catheter was again passed, and 5 oz. of offensive urine were drawn off.
' Taken on November 29th.
TRANSVERSE LESIONS OF THE SPINAL COKD. 179
His temperature, which had previously been normal, soon after this began
to rise, so that at 6 p.m. it was 100-8° ; at 9.45 it was 101-2°, and at 10.20
it had reached its liigliest point, viz. 103-6°. The patient then had a
rigor, after which the temperature gradually' fell, with profuse sweat-
ing.
8th. — On examining the patient this morning the knee-jerks and ankle-
clonus are found to have disappeared. All rigidity of the legs has like-
wise disappeared, and they are both now completely paralysed. The
pupils, which were equal on admission, have now become unequal, the right
being much the smaller of the two. At 3 p.m. the patient shivered, and
his temperature, which had dropped to 100°, rose to 102'6° by 5 p.m.,
though it had again fallen to 99° by 10 p.m. At 7 p.m. a catheter was
passed, and a small quantity of urine drawn off, which was rather offensive
but distinctly acid. He was ordered an effervescing saline three times a
day, and to omit a mixture containing iodide of potassium and liq.
ai-senicalis, which he had previously been taking. Spoon diet.
9th. — He has slept fairly well, but he passed one or two motions into
the bed during the night. Temp. 996°. This morning he was placed on
a water-bed, and his present state was again taken for comparison with
that of November 29th,
He has now no voluntary power whatever in his lower extremities, and
can neither sit up nor turn over in bed. Movements of upper extremities
and of head and neck normal, but the right hand shakes a little when
held out. Dynamometer, right hand 65, left 56. Has a feeling as of
a constricting band over the abdomen, below the umbilicus, which does
not extend to the back. He has complete loss of painful and tactile
sensations all over lower extremities and over abdomen as far as margin
of thorax in front, and to about the ninth intercostal space in the mid-
axillary line. Over the same area he is also dead to thei-mal impressions.
At the upper level there is a narrow zone in which impressions are but
faintly appreciated. The upper limit of the anaesthetic area has risen
considerably within these last few days. Reflexes : plantar can be
obtained on both sides ; abdominal, cremasteric, and epigastric not
obtainable ; ankle-clonus and knee-jerks are now completely abolished.
Patient has no control whatever over the sphincters ; urine dribbles away
at short intervals, and he is unconscious of action either of bladder or
rectum. He sleeps well. There is no affection of voice or deglutition ;
he is not emotional, and does not suffer from delirium, coma, or vertigo.
He has, however, slight occasional shooting pains over the vertex. The
muscles of the lower limbs are completely relaxed ; they are not wasted,
and there ai-e no tremors ; they respond slightly to the weakest faradic
current, and readily to a stronger current. Appetite good, no excessive
hunger or thirst, no vomiting, tongue clean and fairly moist.
10th. — Patient slept well last night. Temperature this moi-ning 99° ;
pulse quiet, 72 ; plantar reflexes decidedly exaggerated. Right pupil still
180 ON THE SYMPTOMATOLOGY OF TOTAL
suiallor than left. Siuce his legs were tested yesterday with the faradic
current they have heen the seat of some twitchings.
11th. — This morning some of the urine which had slowly dribhled into a
test-glass, and was therefore perfectly fresh, was examined. It was very
slightly but distinctly alkaline, smelt offensively, and contained a slight
trace of albumen.
15th. — Slept well last night, and is fairly comfortable this morning,
with the exception of a constncting pain over the xiphoid cartilage.
Temperature is now normal, and since the last note it has ranged betweer
97° and 99°. He has had no more rigors, but continues to be troubled
with the twitchings in his legs. This morning patient was given a glass
to collect urine, but it took an hour and twenty-five minutes before any
was obtained (showing improvement in bladder reflex) ; and when it did
come it was nearly normal in character, distinctly acid, pale, and with no
deposit or offensive odour. Has been taking middle diet for the last
two days.
17th. — Patient passed a restless night, only dozing off for slight
intervals, and this morning he thought he had a slight rigor soon after
7 am., but it soon passed off. Temp. 98'4°, pulse 76.
19th. — Patient has not had much sleep during the night, being troubled
a good deal with cough. He expectorates with great difficulty. Temp.
100°, pulse 104. Surface temperature of right leg 93°, of left leg 93-6°,
and of right arm 97°. Mist. Ammon. c Mih. ^j, ter die.
22nd. — Patient about the same ; cough still very ti-oublesome. Temp.
101"8°, tongue furred, pulse 96. Hot fomentations to chest, together
with spoon diet, ordered.
23rd. — About the same. He passed a restless night. Temp. 102"4°,
pulse 120, resp. 28-
24th. — Patient is rather worse ; still sleeping badly. The urine has
again become offensive. A bedsore over the sacrum, which has been
forming for the last few days, had to be poulticed last night, and this
morning it is beginning to slough. Temp. 101'6°, pulse 120, resp. 48.
At 6 p.m. the temperature had risen to 103°, after which it again fell.
Brandy two ounces.
26th. — During the last few days patient has been getting much weaker,
though he still takes liquid nourishment fairly well. He has also of late
been taking Mist. Ammon. c ^th. every three hours. He has not
complained of any pain, though he speaks of a girdle sensation (now
higher) about the level of the ensiform cartilage. His cough has been
very troublesome though not so incessant as it was, and there is great
impairment of resonance and bronchophony at both bases. He lies on
his back in a semi-apathetic condition, constantly groaning. He does not
sleep, bromides and chloral at night producing no effect. The urine has
been flowius away at more frequent intervals, and has been ammoniacal
for the last two days. The bladder has also during the same time been
TRANSVEUSE LL'SIONS OP THE SPINAL COIiD. 181
washed out with weak Coiid3''s fluid night and morning. Plantar reflex
almost abolished on both sides, and both ankle-clonus and knee-jerks still
absent on both sides.
At 7 p.m. patient suddenly expired, when being raised to be washed.
Autopsy (fifteen hours after death). — On opening the spinal canal
nothing unnatural was seen except that the dura mater in the mid-dor.sal
region, for a distance of about two inches, was distinctly more vascular
than natural, and than it was above and below this level. Large vessels
were here seen ramifying over its surface. The anterior surface of the
• dura mater, however, presented a normal appearance throughout.
AVlieu the dura mater was reflected the anterior surface of the spinal
cord was, perhaps, rather unnaturally pale, from just beiow the cervical
swelling down to about one inch above the lumbar swelling. The vessels
throughout this region were rather less numerous than they were either
above or below it, except that near the mid-dorsal region there were some
enlarged vessels over the right antero-lateral aspect of the cord. Its
posterior surface along its whole length seemed rather paler than natural,
except for one enlarged vessel filled with coloured clot just below the
mid-dorsal region.
The sjiiual cord for a distance of two inches, beginning a little above
the mid-dorsal region, was greatly diminished in consistence in its whole
thickness.
On section through this region of maximum softening the cord
substance was found to be somewhat pultaceous throughout its whole
thickness, though there was no actual difiluence. The section presented
an opaque white colour all over, except that the outline of the grey
matter could just be detected. No cut vessels could be seen. On section
of the cord an inch and a half lower down its substance was found to be
still distinctly softer and more flaccid than natural, but the outline of the
grey matter was now well defined. Below this, in the lowest part of the
dorsal region and throughout the lumbar swelling, sections of the cord
presented a normal appearance but for the fact that it looked distinctly
anaemic ; its consistence was also normal.
When sections wei"e made through the middle of the cervical swelling
the gvey matter and the antero-lateral columns presented a normal
appearance, but the columns of GoU were of a more opaque white colour
than natural. A section just below the cervical swelling showed two or
three large cut vessels in the central region of grey matter and in the
right anterior column ; and the column of GoU was altered as above
mentioned. A section made two inches and a half below the cervical
swelling showed the right anterior cornu to be distinctly more vascular
than natural, whilst the outline of the grey matter on the opposite side
was not apparent. Another section made about an inch above the com-
mencement of marked softening showed the whole surface to be pale and
bloodless and of an opaque white colour, resembling that of the columns
182 ON TUE SYMPTOMATOLOGY OF TOTAL
of Goll in the cervical region. A section slightly lower down presented
similar appearances except that three enlarged vessels were seen cut
across, two in the central end of the left posterior column, and one in the
left lateral column.
The lyrain and its membranes presented nothing unnatural save an
undue fulness in the vessels of the former, both on its surface and
throughout its substance (this congestion being doubtless due to the
patient's mode of death).
The great veins and right cavities of the heart were much distended
with blood, and the nght ventricle, in addition, contained a large ante-
mortem clot which extended for a short distance into the pulmonary
artery. Mitral and aortic valves slightly thicker and more opaque than
natui-al ; otherwise nothing unnatural about the heart. Right lung :
No adhesions and no fluid in pleura. Posterior border and entire lower
lobe of lung were deeply congested and more solid than natural. Section
of the upper lobe revealed nothing abnormal ; but section of the lower
lobe showed it to be of a very dark purple colour, semi-solid, and for the
most part non-crepitant. A dark reddish fluid exuded from the cut
surface, and excised portions of this lobe sunk in water. Left lung :
Posterior part of left lower lobe covered with recent lymph, slightly
uniting pleural surfaces ; no old adhesions of any kind. Upper lobe
presented no unnatural appearances. Lower lobe was in much the same
state as that of opposite side, though it was even more completely solid
in many parts, and had about the consistence and friability of splenic
tissue. Liver : Weight 4 lbs. 4 oz. No thickening of capsule. Its cut
surface was almost uniform in appearance and paler than natural. Its
substance broke down readily on pressure. Right Mclney : Weight 7ioz.
It was congested and its capsule stripped off readily, but its substance was
slightly tougher than natural. Left kidney : Weight 8| oz. ; congested ;
its capsule stripped off readily, but its upper portion was extremely dense,
resisting the firmest pressure of thumb-nail. Spleen of medium size ;
presented nothing unnatural. Bladder : Mucous membrane intensely
congested ; no ulceration.
On examination of the spinal cord after it had been
hardened in bichromate of ammonia it was found that for
a length of two or three inches, partly above and partly
below the mid-dorsal region^ diffuse softening existed
through the whole of its transverse area, though the
diiferent regions were found to be unequally affected in
the successive sections that were made. There seemed,
in fact, within this longitudinal region of the cord to be
a number of small foci of softening affecting different
portions of the transverse area of the organ. The effect.
TRANSVERSE LESIONS OF THE SPINAL CORD. 183
however, upon tlie cord above and below the region of
softening above mentioned was almost the same as if the
whole cord had undergone a total transverse softening in
some part of the same region — that is to say, in the lower
one and a half inches of the dorsal portion of the cord,
and in the lumbar swelling, well-marked and typical areas
of descending degeneration were found in the lateral and
anterior columns ; whilst in the upper dorsal region,
through the cervical swelling, and on to the bulb equally
typical areas of ascending degeneration were found in the
columns of Goll, and in the direct cerebellar tracts. But
for the presence of these areas of secondary degeneration
the cord seemed quite healthy throughout the lowest dorsal
and the lumbar regions, as it did above in the upper
dorsal and cervical regions.
For about a week after this patient was admitted to the
hospital, whilst the motor paralysis of the lower extremi-
ties was incomplete, and their sensibility was but little
affected, marked ankle-clonus was present, and the knee-
jerks were distinctly exaggerated ; the plantar reflexes,
however, seemed to be about normal, while the cremasteric,
abdominal, and epigastric were not to be obtained. By
December 9th he had become completely paralysed in
both lower extremities ; and the marked rigidity which
previously existed in them, had now given place to com-
plete relaxation. At this date, according to the notes,
sensibility was wholly abolished in both lower extremities
and over the greater part of the abdomen. As to the
reflexes, both ankle-clonus and the knee-jerks were com-
pletely abolished, though plantar reflexes could still be
obtained on both sides. I am inclined to think, however
— judging from what occurred in the other cases as well
as from the condition of the cord found after death, — that
the abolition of sensibility may not have been quite com-
plete in this case. This view is supported by the fact
that on the following day the plantar reflexes had become
distinctly exaggerated ; whilst the notes also say, " Since
his legs were tested yesterday with the faradic current
184 ON THE SYMPTOMATOLOGY OF TOTAL
they have been the seat of some twitchings." And as hite
as December 15th there is another note to the effect that
he was still troubled with '' twitchings in his legs." After
this he became very ill, with lung symptoms, and no further
note was made concerning twitchings, sensibility, or re-
flexes, except that on the day of his death it is said,
" Plantar reflexes almost abolished on both sides, and both
ankle-clonus and knee-jerks still absent on both sides."
In this case there was a partial girdle sensation encom-
passing the anterior, but not the posterior part of the body.
Although the softening here was extensive in its area it
was not carried to the extent of diflBuence, and was, in
fact, less advanced than in either of the other cases. The
cord and its membranes presented no external evidences
that the softening was due to an inflammatory process.
The death of the patient was brought about in the main
by a low hypostatic pneumonia.
Case 4. — Stephen T. H — , set. 41, a town traveller, was placed under
my care in University College Hospital on January 27th, 1880, having
been transferred from a surgical ward.
There is nothing of importance in his family history.
Past history. — Patient was formerly an ironmonger, but latterly he
has been a town traveller. He married at 24, and his wife has had
seven children. He has always been fairly well off, well fed and
clothed. He has not had much business anxiety.
Eight years ago patient had smallpox. He has never had rheumatism
or scarlet fever. There is no history of syphilis. In June, 1879, he had
some pain in his left groin for which he was treated at this hospital, and
in the middle of August, whilst stepping into a high gig, he felt a stab-
bing pain in this groin. At night he discovered a small opening, and a
quantity of watery discharge about his dress. He was admitted as an
in-patient in October, and left on December 4th. While in the hospital
an abscess formed, the size of the palm of the hand, over the lower ribs
on the left side, which was opened. When he left the hospital patient
says he could walk perfectly well, and had no pains or numbness in any
part of his legs.
His present illness began on January 14th. While he was washing
himself he suddenly felt his legs give way and he fell down. Both legs
failed him, but the left a little more than the right. He was carried to
bed, though he afterwards found that he could manage to get out of bed
and stumble about for anything he wanted. He could not stand steadily.
TRANSVERSE LESIONS OP THE SPINAL CORD. 185
He says he had both pains and burning sensations in his legs, especially
the left, though he conld feel anything touching him as well as ever.
Two days after this attack the sensibility of both legs began to be im-
paired simultaneously, though the loss was much greater in the left leg
than in the right. The numbness in his legs kept getting worse, and
crept up from the knee to the thigh. Patient also now found that he
could not bear any weight upon his legs, though when he was lying in
bed he could kick them about freely.
He was readmitted into the surgical ward on January 24th, 1880. So
far as motility was concerned, he was then in the state above described.
He could still feel anyone touching his legs, though not distinctly. The
following day he pa.ssed his motions involuntarily into the bed. He had
paralysis of the bladder also, and a catheter was passed. Startings of
the left leg occurred first on the day of his admission, and on January
26th stai-tings were also noted in his right leg. On this same day
" exaggerated reflexes " were noted on both sides, as well as loss of sen-
sibility up to the ribs. On the following day he was transferred to
my care.
His present state was not thoroughly investigated till January 31st,
but the following notes were taken.
January 27th. — Patient has only slight power of voluntary motion in
the legs, but there are frequent spasmodic twitchings in both limbs, the
legs being forcibly flexed at the knees and hips, and also adducted at the
hips. There are sudden reflex movements of the legs when the soles of
the feet are tickled. The knee-jerks are exaggerated. Ankle-clonus is
exceedingly well marked on both sides, though both it and the knee-
jerk are rather freer on the right side. There is retention of urine.
29th. — There is absolute paralysis of both legs. There is loss of
tactile sensibility in front of both thighs, and on the abdomen as high
as midway between the umbilicus and the xiphoid cartilage on the right
side and as high as the costal margin on the left side. There is slight
sensibility of the soles of the feet, legs, and backs of the thighs. There
is no sensation produced by the prick of a pin on the front of the thighs,
or over the abdomen in the region above indicated. The prick of a pin
is felt, but not as pain, in the feet, legs, and backs of the thighs. These
pricks cause reflex movements of the legs. The knee-jerks are absent,
and there is no ankle-clonus. Bowels confined, and retention of urine
still exists.
30th. — There are spasmodic movements of both legs, though they are
much less marked than they were on the 27th. There are no pains or
other sul)jective symptoms. Temp. 101°, pulse 110, resp. 28.
31st. Present state. — Patient is a well-nourished, well-developed man,
though he says he has been stoi;ter than he is at present. He has
no general symptoms of disease. There are no scars or eruptions on
the skin except a longitudinal scar running parallel with the ribs, and
18G ON THE SYMPTOMATOLOGY OF TOTAL
situated between the ninth and tenth ribs on the left side. This was
caused by an incision made in November last to let out pus. There is
also an opening of a sinus between the left thigh and the scrotum, which
still discharges an ichorous fluid.
There are no affections of the cerebral nerves or of the upper extremities.
He is absolutely vinable to move either leg at any joint. The muscles
are fairly well developed, moderately firm, and equally so on the two
sides. The muscles of thigh, leg, and special muscles of the foot all
i-eact well to both faradic and constant currents, and their reactions ai-e
equally good on the two sides. Above the umbilicus there is a slight
reaction of both recti to both currents. Below the umbilicus no move-
ments of the recti can be obtained with either current. The oblique
muscles react fairly well.
Patient feels the touch of the finger on the left foot, leg, and back of
the thigh. Similar results are obtained on the right side. The prick of a
pin is not felt on the front of the left foot, leg, or thigh, but on the ba«k
of the thigh he sometimes feels it as a touch. On the right side he feels
the prick of a pin pretty shai-ply — in fact, as acutely as in the arm.
Except on the dorsum and occasionally on the sole of the right foot, he
does not feel either heat or cold, and when he does feel them he mistakes
heat for cold.
Over the abdomen the touch of the finger is not felt below the level of
the umbilicus ; sensation is also impaired between the costal margins
and the umbilicus. The prick of a pin is not felt below the um-
bilicus on the left side. On the right side it is felt as low as midway
between the umbilicus and the pubes. Above the umbilicus he can feel
the cold spoon applied. A hot spoon he can distinguish as warm. He
can feel the cold more distinctly, but is not sure whether it is hot or
cold. There are no subjective sensations of numbness or pain except
some pain in the right knee and the right shoulder, both of which are
also painful on movement. There are occasional starting movements of
the legs, but these are slight. The knee-jerk and ankle-clonus are absent
on both sides. Tickling the soles of the feet and pricking the legs with
a needle, although not felt by the patient, cause starting movements of
the legs. Otherwise cutaneous reflexes in the legs and abdomen are
absent. Temp. 101'1°, pulse 122, respirations 23.
February 3rd. — The urine is distinctly alkaline. Temp. 102"6° in
mouth, 102-6° in left axilla, and 102-4° in left ham.
7th. — The urine now passes vei-y frequently ; it does not drop away,
but comes in small quantities. Patient still complains of pain in the
right shoulder and knee.
8th. — The bowels were opened yestei-day several times as the result of
an aperient. Patient was not aware when they were i;olng to act. The
urine is still voided frequently whenever small quantities collect, but
the whole is not expelled, for the catheter passed soon afterwards draws.
TKANSVERSE LESIONS OF THE SPINAL CORD. 187
ofE two or three ounces. The urine is less ammoniacal than it was, and
it does not contain so much mucus. The calf-muscles are flabby ; they
do not react so energetically to the fai-adic current as they should do, but
reaction to the constant current is about normal.
loth. — The right knee-joint is swollen and contains fluid. It gives
no pain. Patient now feels a touch on the dorsum of the right foot and
on the front of the right leg, also slightly on the front of the right thigh.
On the back of the right leg and thigh he occasionally feels a touch.
Over the whole of the left limb the touch is not felt as well as on the
right side. He occasionally feels it, but often saj's he feels when no one
is touching him. The prick of a pin is felt on the right side rather
acutely over the whole limb. He feels it most acutely on the calf and
back of the thigh, and least on the front of the thigh. On the left side
the prick of a pin is felt acutely on the front of the leg. It is felt, but
not as a prick, on the front of the thigh, but on the back of both leg and
thigh he feels it slightly. He feels the prick slightly to midway between
the umbilicus and the puhes, though more acutely on the left side.
Above this, sensibility is normal. Patient can now move both legs very
slightly, the left a little better than the right. On the left side the
movement is caused chiefly by flexing the thigh, slightly by flexing the
knee. The movement is very slight, and he cannot lift the limb from
the bed. On the right side the movement is caused only by flexing the
hip. It is just enough to draw the heel up the bed for about two inches.
Tickling the soles of the feet causes marked reflex actions in both legs.
There is a slight knee-jerk on the left side, but none on the right.
There is also no trace of ankle-clonus on the right side, but on the left
side a slight quivering of the foot is felt, though it is hardly enough to
be seen. The bladder is still washed out daily with a solution of quinine ;
the urine has now no ammoniacal odour, and its reaction is acid.
14th. — Patient still retains a slight power of movement in the legs ;
that of the right leg is very slight, whilst that of the left is more marked.
Tactile sensibility is now good in both feet and legs, as well as over
backs of thighs. There is slight sensibility on the front of the thighs.
This is absent or very slight on lower part of abdomen as high as midway
between the umbilicus and pubes. Painful impressions are felt acutely
on the right leg and thigh, and slightly on the lower part of the abdomen.
These are felt badly on the left leg and thigh and lower part of abdomen;
Both the legs move when pricked and when the soles of the feet are
in'itated. There is a slight knee-jerk on both sides to-day ; and there is
also a slight ankle-clonus on the right side. Micturition is now performed
voluntarily. Patient feels the sensation of wanting to pass water, and
has time to get the bottle. He can also pass his water voluntarily when
only a small quantity has collected. He now knows also when he is going
to have a motion, and has some slight control over the act.
15th. — To-day there is a well-marked knee-jerk on both sides, and
188 ON THE SYMPTOMATOLOGY OF TOTAL
ankle-clonus has also returned on both sides. The power of moving the
legs is not so good ; at the time of the examination the patient could not
move them at all. When the catheter (which is a soft india-rubber one)
is being passed there are rather violent movements of both legs. There
are also spontaneous spasmodic movements of the legs.
17th. — Patient has lost all power of movement in both legs. Sensi-
bility to light touches seems perfect over the whole limb on the right
side. Over the left side a touch can be felt, but not so distinctly as on
the right side. The slight prick of a pin is felt over the whole of the
front of the right leg. He says he feels it more acutely than on the arm.
He feels the prick over the whole of the left limb also, but over the front
of the thigh it is not felt as pain. Tickling t)ie soles causes well-marked
reflex movements of the limbs. Ankle-clonus is well marked, and knee-
jerks are exaggerated on both sides. Temp. 99'6°, pulse 120, resp. 18
(taken at 10 a.m., but temp, at 6 p.m. 101°).
March 7th. — Since last note patient's temperature at 6 p.m. has rarely
been as low as 100° ; it has mostly varied between 100'5° and 102"5°.
To-day at the same hour it was 103°. Patient was sick three or four
times yesterday, and felt sick all day. There was a considerable flow of
pus from the sinus in left groin this morning.
17th. — A small bedsore has appeared on the inner side of the left
ankle. Sensibility to tactile impressions is now lost in both lower
extremities, and is much impaired over abdomen and chest to the level
of nipples. Sensibility to painful impressions is very much impaired over
the same area of abdomen and chest, so that as a rule the patient does not
feel the prick of a pin. In the lower extremities a deep prick is now and
ao-ain felt, at other times not, but there is no area to be made out where
the sensibility is less impaired than it is at others. The impairment of
sensibility is much more marked than it is over the abdomen. There is
complete loss of voluntary power over both legs, and very little power in
moving the trunk. There is only very slight expansion of the lower part
of the chest during inspiration. The knee-jerk is absent on both sides.
Ankle-clonus is absent on the right side, but the very slightest quiver of
the foot is felt on the left side. The prick of a pin in both legs now and
then causes reflex movements. Since the 11th inst. the temperature in the
evening has been a trifle under 100° ; but to-day at 6 p.m. it was 101°.
April 28th. — The abscess is discharging again after it had ceased for
about a week. The temperature during the last fortnight has been higher,
several times reaching 102° and 101° in the evening. The pulse has
mostly ranged between 120 and 130. Has been taking brandy ^iv daily
for the last week.
May 14th. — The patient suffered from a profuse perspiration which
lasted through the night, and he seems much exhausted this morning.
Temp. 99-8°, pulse 144, resp. 40.
21st.— Patient has been getting gradually weaker for some days. He
TEANSVERSE LESIONS OF THE SPINAL CORD. 189
has had some delirium and the pulse has been failing rapidly. The
bedsore over the right trochanter (which has existed for more than a
month) has become rapidly worse during the last ten days or more ; it is
now very deep and sloughy. That over the left trochanter is only a little
less bad. There is also now a very extensive bedsore over the sacrum
exposing the bone. Plantar reflexes, knee-jerks, and ankle-clonus were
all absent on both sides two days ago. Patient gradually sank and died
at 7 p.m.
Autopsy (sixty-six hours after death). — On opening the spinal canal the
left side of the arches of some vertebrse in the lower cervical and mid-
dorsal region were, on their inner surface, found to be slightly carious,
the erosions being filled up by a soft yellowish-white material. A thin
layer of a similar material, looking like half-dried pus, was found also on
the corresponding external surface of the spinal dura mater. Otherwise
the membranes of the cord presented nothing unnatural.
The spinal cord itself was damaged during the opening of the spinal
canal in the upper dorsal region. In this region it was found to be
reduced to a pultaceous mass, and a.s this was probably the seat of the
main pathological change it was difficult to say how much of the softening
was due to damage and how much to disease. The external surface of the
cord presented no hyper- vascularity, either anteriorly or posteriorly.
On section through the spinal cord at various parts of the cervical
swelling there was no distinct evidence of undue softening in any part.
The grey matter possessed its usual amount of vascularity. In the upper
part of the dorsal region the cord substance was extremely soft and
pultaceous throughout its whole thickness, for a length of more than one
inch ; whilst above this, as far as the lower end of cervical swelling, the
cord seemed rather softer than natural (it might, however, have been due
only to the lateness of the autopsy). Sections made through the lower
dorsal and the upper lumbar region seemed to show an unnatural amount
of softness in the lateral and posterior columns, though it was thought
that this also might be a mere post-mortem change owing to the number
of hours between death and the autopsy. Sections through the lower
part of the lumbar region presented a fairly natural appearance. Viewed
externally the lumbar enlargement had a somewhat atrophied appearance.
Brain and its membranes. — The arachnoid was unusually thickened,
and generally more opaque than natural. There was also an excess of
subarachnoid fluid. The gi'eat arteries at the base of the brain were
fairly healthy. The brain showed no naked-eye appearances of disease.
Heart. — The pericardium contained l^ oz. of blood-stained fluid.
Mitral and aoi^tic valves rather thicker and more opaque than natural.
Right lung: This organ was very firmly adherent to the parietes
throughout, and there was a thick layer of lymph on the posterior part
of the parietal pleura. The upper lobe was more solid than natural, and
on section it was found to be very oedematous, and its tissue very
190 ON THE SYMPTOMATOLOGY OF TOTAL
undiilj tongli. In the lower part of this lobe there was a large
patch, about an inch in diameter, thickly studded with miliary tubercles.
The lower lobe was somewhat solidified throughout, and more congested
and friable than natural, but contained no tubercle. Left lung: This was
firmly adherent about the apex to the parietal pleura. The upper lobe
was unduly hard and semi-solid, and was here and there puckered
on its surface. On section at a distance of three inches from the apex
and downwards, the lung tissue was studded with a number of discrete
and aggregated miliary tubercles, the latter forming indurated patches
about three quarters of an inch in diameter. In the lower part of this
lobe there were also two small, thick-walled cavities, about half an inch
in diameter, like the remains of old abscesses. No tubercle in other
parts of this lung ; but the lower lobe was somewhat congested and
solidified throughout, the tissue being also more friable than natural.
Liver of medium size, almost uniformly pale everywhere, except for a
few areas in which there was some congestion. Consistence below par,
and its substance feels greasy. Spleen small, very flaccid ; cut surface
mottled and grumous-looking. Substance distinctly softer than natural.
Kidneys extremely flaccid and unduly pale. The left organ showed
considerable inflammation of the pelvis, with deposits of calcareous
matter on some portions of its mucous membrane. The left ureter
also showed well-marked inflammation throughout. Bladder : It con-
tained a quantity of thick purulent urine. Walls slightly thickened.
No ulceration, but radiating away from its neck were lines of slightly
inflamed mucous membrane.
Sinuses. — The sinus opening in the left groin just beneath the sper-
matic cord ran upwards for four inches between the tendons parallel
with Poupart's ligament. It was continuous with another sinus running
downwards and outwards for about two inches beneath the fascia lata
of the left thigh. On cutting through the spermatic cord there was
seen, about half an inch from middle line, a sloughy opening, at the
bottom of which the probe came into contact with dead bone. Also
communicating with this opening there was a sinus which turned round
the edge of the adductor longus and there divided into two parts, one
running into the adductor magnus, the other arm communicating with a
large cavity beneath the addiictor longus. This cavity was filled with
dirty brown very foetid pus. It was irregular in form, and lay between
the mass of the adductors and the femur. The tip of the small tro-
chanter projected into it, and seemed slightly eroded. A branch of the
cavity also passed backwards beneath the neck of the femur, but no
" dead bone " could be felt in that situation.
Examination of the spinal cord after it had been hard-
ened in bichromate of potash :
Portions of this cord are unfortunately missing. It
TRANSVERSE LESIONS OF THIC SPINAL CORD. 101
must have been examined at some previous period either
by myself or by one of my assistants, and now no notes
as to the results of this examination are to be found, I
will, however, enumerate the portions of the cord which
remain, and state the nature of the changes of which they
are the seat.
(1) A part of the upper third of the cervical swelling-.
Sections through this part show well-marked ascending
degeneration in the columns of Goll and in the lateral
columns.
(2) A portion of cord about four inches long from the
lower cervical and upper dorsal region, which is much
crushed and partly softened.
Sections through the least damaged portions of this
show opaque tracts of degenerated tissue occupying in
several places the greater part of the transverse area of
the cord. On account of the crushing of the cord during
its removal, it was impossible to define the extent of the
original lesion. From the nature of the lesions above and
below, however, in the form of secondary degenerations, it
is highly probable that it must have involved the whole
thickness of the cord over a certain extent.
(3) The lower dorsal portion of the cord for three
inches above the lumbar swelling.
(a) Sections through the upper portion of this frag-
ment show well-marked areas of secondary degeneration
in the lateral columns posteriorly, but scarcely any in the
anterior columns. The substance also looks white and
unhealthy in the peripheral third of both posterior columns.
The morbid area is ill-defined in outline, and gradually
shades away centrally into healthy-looking tissue.
(&) Asection madeaninch andahalf lower down presents
a very similar appearance. It looks as if there had been
slight softening in the peripheral portions of the posterior
columns.
(c) A section just above the lumbar swelling shows a
similar state of the lateral and of the posterior columns.
No distinct change is to be seen in the anterior columns.
192 ON THE SYMPTOMATOLOGY OF TOTAL
in tlie grey matter, or in any other portion of tlie
cord.
(4) The upper portion of the lumbar swelling-.
Sections hei*e show some distinct softening of the peri-
pheral third of the posterior columns, in addition to well-
marked secondary degenerations in the posterior part of
the lateral columns.
(5) Rather more than the lower third of the lumbar
swelling.
Sections through this present a healthy appearance,
except for very small areas of secondary degeneration in
the lateral columns. There is no evidence here of soften-
ing of the posterior columns, and the grey matter presents
a healthy appearance.
Nothing is known by me as to the cause of the original
pain in the groin in June, 1879, and the discharge which
first occurred therefrom two months later. The results
of the post-mortem examination showed that the opening
in the groin was in connection with several very extensive
sinuses associated with foul collections of pus and with
necrosed bone. It was made probable also that the large
abscess that formed over the lower left ribs during his
stay in the hospital previous to December, and which was
opened at that time, was connected with an offset from
the same sj'Stera of sinuses. Subsequently there came the
softening of the spinal cord and the developmeut of tuber-
cle in the lungs, as well as a suppurative caries of the
laminae of some of the cervical and upper dorsal vertebraa.
How far either of these processes had to do with the
actual development of the softening of the spinal cord is,
of course, altogether uncertain. It is worthy of notice,
however, that the veiy abrupt onset of the symptoms of
paralysis on June 14th, in the absence of all post-mor-
tem evidence of a haemorrhage, pointed strongly to these
first symptoms being due to a vascular occlusion of some
kind. No conditions favouring embolism were met with
after death ; but it seems just possible that there may
have been a thrombosis occurring rather suddenly, and
TRANSVERSE LESIONS OF THE SPINAL CORD, 193
due^ perhaps, to endarteritis set up in connection Avith
some amount of blood-poisoning, consequent upon the
unhealthy suppuration in the sinuses. Certainly in this,
as in the other cases, there were no external signs of an
inflammatory process in connection with the upper dorsal
region of the cord or its membranes.
The extent of the original lesion in the upper and mid-
dorsal regions of the cord could not be determined, owing
to tlie damage which it had received at the time of removal,
as w^ell as to the fact that I could find no record of the
previous examination, doubtless made, of certain portions
of the organ that were missing. As it happens, this is of
comparatively little importance in regard to my main
purpose in this paper, because of the fact that a super-
ficial softening of the posterior columns of the cord (the
only lesion, apart from descending secondary degenera-
tions, existing in the last three inches of the dorsal region)
also extended into the upper third of the lumbar swelling.
For though the grey matter in both the upper and the
lower parts of the lumbar swelling presented no appear-
ance of disease, this case will not, 23erhaps, be considered
to have the same cogency as either of the others. Yet
in some respects it has supplied very important evidence
as to concomitant variations between slight degrees of
sensibility persisting and slight manifestations of reflex
activity. Thus, when the paralysis was incomplete there
was rigidity of the lower extremities, together with dis-
tinctly exaggerated reflexes ; but by January 31st the
motor paralysis had become absolute, and sensibility in all
its modes had become very greatly impaired, and at this
date the knee-jerks and ankle-clonus were absent on both
sides, though starting movements of the legs could be
induced by pin-pricks on the legs, or by tickling the soles
of the feet. Later on, while the motor paralysis was
absolute on February 17th, sensibility had very greatly
improved. The notes say, " Sensibility to light touches
seems perfect over the whole limb. Over the left side a
touch can be felt, but not so distinctly as over the right
VOL. LXXIII. 13
194 ON THE SYMPTOMATOLOGY OP TOTAL
side ; " and with this state of things knee-jerks, ankle-
clonus, and plantar reflexes had become well marked on
both sides. By March 1 7th, however, sensibility was again
almost completely abolished in both lower extremities ;
that to tactile impressions was in fact completely lost, but
the sensibility to a deep prick was not absolutely destroyed.
There was still complete motor paralysis, but in regard to the
reflexes the notes say, " The knee-jerk is absent on both
sides. Ankle-clonus is absent on the right side, but the
very slightest quiver of the foot is to be felt on the left
side. The prick of a pin in both legs now and then
causes reflex movements." Unfortunately no mention is
made as to the plantar reflexes, but this may not unfairly
be taken as an indication of their absence ; had they been
present it would almost certainly have been recorded.
Death occurred in the main from exhaustion with bad
bedsores after the paralysis had lasted for seventeen
weeks. During the course of this illness there were fre-
quent high temperatures, due in part to the unhealthy
suppuration going on (together with other changes in the
extensive system of sinuses), and partly to the development
of tubercle in the lungs.
It has recently come to my knowledge that the state-
ments I had made in 1882, and aftei'wards in my work on
' Paralyses ; Cerebral, Spinal, and Bulbar,^ as to the con-
dition of the reflexes in complete transverse lesions, had
been received by some with not a little incredulity. It
seemed desirable, moreover, that the detailed evidence on
which the statements were founded should be published.
I accordingly undertook this task.
Three classes of objections, belonging to one or other
of the following categories, have been raised by different
friends.
(1) It has been said that abolition of the reflexes in
total transverse lesions would be a direct consequence of
shock, and that if the patient only lived long enough after
the establishment of the lesion the reflexes would return ;
TRANSVERSE LESIONS OF THE SPINAL CORD. 195
further, that with the establishment of well-marked second-
ary degenerations in the lateral columns, more or less of
rigidity would supervene in the previously flaccid limbs.
To this objection the cases now recorded (even without
the support which will be given by several other cases
about to be referred to) seem to me to afford a complete
answer. The duration of shock in most cases of disease
or injury to the spinal cord may fairly enough be said to
vary between a few hours and, at most, a few days. But
in the four cases here recorded anything like shock was
a very unobtrusive feature, and the patients remained
under observation for considerable but variable periods ;
it was with them a question of weeks rather than of days.
Thus, in Case 1, the duration of the paralysis was eight
weeks ; in Case 2 it was seventeen weeks ; in Case 3 it
was nineteen days ; and in Case 4 it was seventeen weeks.
And although there is not in all of the cases a record of
the condition of the reflexes up to the termination of the
illness, my memory enables me to say most definitely that
the limbs in all remained in a condition of flaccid para-
lysis, with no sign of rigidity, even up to the end.
(2) It has been said, again, that no such abolition of
reflexes would occur unless the lumbar region of the cord
had been also the seat of damage ; some have even seemed
inclined to go so far in support of their opinion as to say
that the fact of the reflexes continuing to be abolished
after the effects of shock had passed off was of itself evi-
dence that the lumbar swelling had also been the seat of
some lesion, so sure were they as to the truth of their
general principles. A reasoner of this latter type is often
hard to be convinced. I venture to think, however, that
I have brought forward some valid evidence to show that,
at all events in three of my cases, the lumbar swelling
was free from disease even though the reflexes were
abolished, and all signs of shock had entirely disappeared.
This kind of objection is, however, even more completely
met by a record of what has happened in certain cases of
fracture' dislocation occurring in previously healthy persons
J 96 ON THE SYMPTOMATOLOGY OF TOTAL
in the cervical or upper dorsal region of the cord, to which
I shall presently refer. Here a localised traumatism only
has existed in one of these regions, and there has been no
reason for supposing the existence of an independent lesion
or disease in the lumbar region of the cord.
(3) Lastly, incredulity has been expressed in regard
to the truth of my statements, on the alleged grounds
that no such flaccidity of limbs and abolition of reflexes
had existed in cases either known to or previously under
the care of such critics ; there had rather been, they said,
the very opposite condition of things, viz. i"igidity with
exaggeration of reflexes. In regard to objections of this
order, all I can say is that when these critics have been asked
to give me the references to any such cases as they have
described, either published or unpublished, the cases to
which my attention has been called have, as yet, always
proved unsatisfactory — that is, there has been evidence
either of a clinical or of a pathological order to show that
the cases referred to have not been in reality cases of
total transverse lesion. In some of them it has appeared
from the notes of such cases that sensibility has only been
" impaired," not abolished ; whilst in others post-mortem
evidence has shown only a partial transverse destruction
of the cord at the seat of disease, and the existence of
many more or less normal nerve-fibres surrounded by others
which have become broken up, or else by a more or less
developed overgrowth of connective tissue in the cases
that have been of a moi*e chronic order.
The necessity of accepting any such cases as these last
referred to, only with the greatest reserve, is shown by the
records of a very remarkable case of so-called " compres-
sion-myelitis" described by Charcot. The patient referred
to died two years after she had been cured of a
paraplegia which had been associated with vertebral dis-
ease and angular curvature, and the condition revealed
by the autopsy is thus described. Charcot says,^ ''The
' • Ledoiis sur les uiaLidies da systeme iicrveux,' tome ii, 3iiie ed., p. 93,
1880.
TKANSVERSE LESIONS OF THE SPINAL COED. 197
spinal cord in this woman at the level where compression
had existed in consequence of Pott's disease was no
larger than a goose-quill, and when cut its section was not
more than about one third of that of a healthy spinal cord
examined in the same region. Its consistence was very
firm, and its colour grey; in short, the spinal cord pre-
sented all the appearance of the most advanced sclerosis
(pi. iii, fig. 1, d) Above and below this nar-
rowed portion the white columns were occupied by grey
tracts of secondary degeneration Between
the appearances presented by the narrowed portion of the
cord when examined by the naked eye only, and the phe-
nomena observed during life, there existed, as it seemed,
a most striking and singular contradiction. The restora-
tion of functions, as I have said, had been perfect at the
time of death, and yet at this time the cord, if we were
not to rely wholly upon the information yielded by micro-
scopical examination, was the seat of lesions so profound
that it appeared literally interrupted at one point in its
course by a cord of sclerosed tissue, in which one would
have thought that every trace of nerve-element had dis-
appeared Histology, however, shows us
that the contradiction is not real. The connective-tissue
substitution is here only apparent. In the midst of the
very thick and dense tracts of fibrous tissue which gave
to this portion of the spinal cord its grey colour and its
dense consistence, the microscope showed a pretty large
quantity of nerve-tubes provided with their axis-cylinder
and their envelope of myeline, and consequently quite
regularly and normally constituted It was
by the intermediation of these nerve-fibres that, during
life, the behests of the will and sensory impressions had
been conducted."
This case of Charcot's is undoubtedly a very remark-
able one, and difficult enough in many ways (as he points
out) to understand ; but it sufiices admirably to show the
very great reserve with which cases of this order should
be regarded as cases of total transverse lesions when we
198 ON THE SYMPTOMATOLOGY OF TOTAL
are concerned witli the strict estimation of the symptoma-
tology of this latter condition. It is clear that we must
not, as I was myself originally disposed to do, accept the
mere fact of the existence above and below a given lesion
of the best developed ascending and descending secondary
degenerations as evidence that the lesion in question was
a total transverse one. A very little reflection suffices to
show the fallacy of this view, and that such well-developed
secondary degenerations in the white columns may exist
with all degrees of partial destruction of grey matter ;
nay, it is conceivable, though not likely ever to occur,
that such secondary degenerations should exist in their
fullest development without any primary disease of the
grey matter at all.
Thus it becomes clear that there are two classes of
cases more especially in which we may search for the re-
velation of the true symptomatology attaching to total
transverse lesions of the spinal cord. The first of these
classes would comprise the cases (a) in which a condition
of diffluence, or something approaching thereto, has been
induced through the whole thickness of the spinal cord in
some limited portion of the cervical or upper dorsal re-
gion, either by simple thrombotic softening or by actual
acute myelitis, provided that in such cases the patient
lives sufficiently long after the establishment of the dis-
ease. This is the class of cases which I have hitherto
considered in this paper. I have, as yet, not been for-
tunate enough to find a record of any similar cases by
other observers, and possibly very few will be found.
The first case that occurred in my practice in 1879 struck
me very much, and it sufficed thoroughly to rouse my
attention in each subsequent case, simply because the
phenomena were quite contrary to what I should have ex-
pected to occur. I sought, therefore, to obtain good evi-
dence, during life, as to the degree of preservation of
the reflexes in conjunction with different degrees of anaes-
thesia ; and, after death, as to the degree of completeness
of the lesion. In the clinical examination of these cases
TRANSVERSE LESIONS OP THE SPINAL COKD. 199
I was aided by a series of excellent observers who were,
at tlie periods referred to, my house-physicians. The ob-
servers thus associated with me in the investigation of
these cases, and to whom I am indebted for many accu-
rate and painstaking- notes, were Mr. Bilton Pollard,
Dr. Dawson Williams, Dr. Henry Carr-Maudsley, Dr.
William Pasteur, and Dr. J. Walter Carr. I say that
possibly few such observations will be found on record
because, in the fii'st place, we should be limited to obser-
vations that may have been reported during the last ten
or twelve years. We could not go back to older records
— to periods, that is, when it was not the custom sys-
tematically to detail the condition of the various reflexes.
Again, for evidence bearing upon this question we should
be limited to such cases as lived suflBciently long to enable
us fairly to eliminate the possible effects of shock ; to
cases which were, moreover, fully reported from the point
of view of the exact condition of the reflexes in associa-
tion with different degrees of impairment or abolition of
sensibility ; and lastly, to cases in which there had been
an autopsy and a determination of the question whether
the lesion had or had not been one of the total transverse
order.
Since the above was written my colleague Dr. Ormerod
has kindly brought to my notice one such case of total
transverse softening, which occurred last 3ear in the prac-
tice of Dr. Gee at St. Bartholomew's Hospital, and in
which he had made the autopsy. I have to thank Dr. Gee
for permission to use the notes of this case, for an abstract
of which I am indebted to Dr. Ormerod.
Case 5. — A. M. F — , set. 26, a draper's assistant, was admitted on Feb-
ruary 26th, 1889. On February 21st he had complained of pain in the
middle of the back, with a feeling of constriction around the chest.
Two days afterwards he was worse, and on the evening of February 24th
his legs became weak, and soon afterwards numb, whilst the paralysis
in two to three hours became complete. There was also letention of
urine, and constant vomiting, previous to admission.
State on admission. — Paraplegia reaching to about third dorsal nerve ;
200 ON THE SYMPTOMATOLOGY OF TOTAL
aii£Estliesia to the same level. No superficial or deep reflexes. Retention
of urine. Bedsore (third day).
[The above is Dr. Gee's " clinical abstract." What follow, Dr. Ormerod
tells me, are extracts from the house-physician's notes — Mr. Rivers up to
April 1st, afterwards Mr. Symonds, "both very careful and good ob-
servers." Di'. Ormerod adds, " The absence of the knee-jerks did, as I
know, attract particular attention."]
March 5th. — Incontinence of urine began.
8th. — Patellar reflex present, but very slight. No plantar reflex.
10th, 12th, and 14th.— No knee-jerks obtained. The electrical reactions
of the anterior tibial muscles gave the following results : — Faradic irrita-
bility fairly good, rather stronger current required than normal ; reac-
tion not quite so good as on admission. Some increase of galvanic
irritability, but K.C.C. greater than A.C.C., though the difference between
them is less than in a normal musele.
16th. — Knee-jerks present this morning, more in right leg.
19th. — No knee-jerk.
22nd. — Legs jerk a little on being washed.
23rd. — Plantar reflex well marked. More sensation in legs.
April loth. — Reflex movements of legs increased ; they often become
drawn up when not being touched. Little or no sensation in legs. No
knee-jerks.
[In reference to the notes conceniing sensibility on March 23rd,
April 10th, and May 12th, Dr. Ormerod writes, " This appears to refer
to sensation of touch ; no special note was made as to sense of pain, tem-
perature, &c."]
May 12th, — Involuntary contractions of the legs, causing them to be
completely flexed, are more marked ; they move at the least irritation to
the skin. No knee-jerks. No sensation in legs. The anaesthesia now
reaches up to the lower border of the sternum. Skin reflexes on abdo-
men not present.
June 1st. — No knee-jerks.
lOth. — Patient died of exhaustion in connection with bedsores and
bladder troubles. " The autopsy showed softening of the cord, involving
the whole section apparently, the maximum amount being at the level
of the third dorsal segment." It extended in length for about two
inches. After hardening the cord. Dr. Ormerod says, " The lumbar
region was found to be normal except for descending degenerations."
This case affords a valuable confirmation of the truth
of my observations. The state of the lower extremities,
and their condition as to reflexes and twitching movements,
agrees in the closest manner with what was found at
different times to exist in my Cases 3 and 4, where it
seems certain that the loss of sensibility though nearly
TRANSVERSE LESIONS OF THE SPINAL CORD. 201
was not absolutely complete. There was the same kind
of spontaneous drawing up of the legs, with tAvitchings
when the limbs were touched or pricked. Then, again,
some return of tactile sensibility was noted in Dr. Gee's
case on March 23rd ; and, as Dr. Ormerod points out, no
special notes were made as to the patient's insensibility to
painful impressions. The notes of my own Case 4, for
March 17, however, show that such movements of the legs
co-existed with an incompletely abolished sensibility to
pain. Yet in my case, as in Dr. Gee's, there was at the
autopsy, " appai'ently ^' a total transverse lesion. No
rigidity of limbs seems to have existed in this case : in
reply to my question Dr. Ormerod writes, " No rigidity
at first ; no mention of rigidity afterwards, unless the
* involuntary contractions ' be taken as a form of rigidity.'"
But, as above pointed out, thei'e is reason to believe that
these involuntary contractions co-existed with a severance
not quite complete of the spinal coi'd from the brain.
Further, in my Cases 1 and 2, in which the severance of
the cord from the brain was undoubtedly complete, the
limbs were altogether flaccid, and showed neither spon-
taneous nor reflex contractions of any kind.
The second class of cases in which we may expect to
obtain the true symptomatology of total transverse lesions
of the spinal cord is represented by {h) fracture- disloca-
tions of the vertebree, associated with complete but limited
crushing lesions of the cord, in patients who live long
enough for the immediate effects of shock to subside.
The following are recorded cases of this type which I
have met with, together with three unpublished cases that
have been kindly brought to my notice by my colleague.
Dr. Tooth.
1. A case recorded by Dr. Tooth (' St. Bartholomew's Hospital Eeports,'
vol. xxi, 1885, p. 140) of a rnau who had fallen from a scaffold, resulting
in a fracture-dislocation of the fifth and sixth dorsal vertebrae with com-
plete transvei-se crushing of the cord opposite the former vertebra. " It
had the appearance of having been cut across without injury to the mem-
branes." This man lived twenty weeks and four days after the accident.
202 ON THE SYMPTOMATOLOGY OF TOTAL
During life there was total paralysis, with loss of sensibility, in the lower
extremities, and in the trunk to the level of the sixth ribs, " No knee-
jerk, ankle-clonus, cremasteric or abdominal reflex could be elicited on
admission, but the epigastric reflex was present on the right side.
Two months after admission it was noted that on pinching the lower
pait of the thigh the hamstring muscles contracted, but there was
no sole reflex. The state of the deep reflexes was unfortunately not
noted at this time."' Towards the close of his paper Dr. Tooth adds
these words : " A curious and liithei-to unexplained point in the sympto-
matology is the complete abolition of all reflexes, superficial and deep,
below the lesion shortly after the injury."
2. A case recorded by Kahler and Pick (' Archiv f iir Psychiatrie,' 1880,
p. 297). J. J—, set. 65, on March 9th, 1878, fell from a height and struck
the back of his neck against a beam, whereby he sustained a fracture-dis-
location at about the level of the sixth cervical vertebra.- His lower extre-
mities and trunk were at once completely paralysed. Sensibility was at
first lost to the level of the knees, but the anaesthesia spi-ead upwards
during the next two or three days. On examination ten days after the
accident (March 19th) his upper extremities were found to be partially
paralysed. His breathing was diaphragmatic, and the lower extremities
were absolutely paralysed. There was no rigidity ; all the muscles were
quite flaccid, though not wasted. All modes of sensibility were abolished
to the level of the upper part of the thorax. All the reflexes were
abolished in the lower extremities except the plantar, which were very
weak. The cremasteric and abdominal reflexes were also absent. No
subsequent record as to reflexes. Death occurred on the seventeenth, day,
and at the autopsy the spinal cord was found completely compressed
between the sixth and the seventh cervical nerves. There was no damage
to the lower parts of the cord, which appeared to be in all respects healthy.
3. Dr. Thorburn's Case 1, recorded in ' Brain,' January, 1887, p. 511.
This was also a case of fracture-dislocation, in which there was complete
paralysis of all nerves below the fifth cervical, with corresponding loss of
motion and sensibility. The man lived for twenty-five days after the
accident, and it is said concerning this patient, " Both cutaneous reflexes
and tendon reactions were absent throughout." At the autopsy the cord
was found to be compressed for a quarter of an inch, and softened for
one to two inches above and below, but, it is said, " the rest of the cord
was healthy."
4. Dr. Thorburn's Case 3, recorded in ' Brain,' October, 1888, p. 294.
This was a case of fracture-dislocation between the fifth and sixth cervical
vertebrae, caused by a fall from a waggon. There was absolute paralysis
of the legs and trunk, with anaesthesia extending to the level of the third
rib in front. He was carefully examined by Dr. Thorburn between
> In my cases ankle-clonus and knee-jerks have always disappeared before
the sole reflex.
TRANSVERSE LESIONS OF THE SPINAL CORD. 203
eighteen and twenty hovirs after the accident and immediate onset of the
paralysis, there having heen no loss of consciousness at the time. At
this time his temperature was normal, the skin was dry and warm, the
pulse was 66 and feeble, whilst the respirations were 18 per minute.
All signs of shock seem then to have passed off, but the condition of the
reflexes was thus noted : — " The knee-jerk and plantar, cremasteric,
gluteal, and epigastric reflexes were absent." He was operated upon
about twenty-four hours after the injury, and just within a subsequent
similar period he died. At the autopsy it was found that " the dura
mater was uninjured, but the cord was flattened opposite the seat of in-
jury, and was much contused for about an inch above and below, contain-
ing haemorrhages in its substance and in the central canal ; elsewhere its
structure was normal."
5. Dr. Thorburn's Case 4, recorded in * Brain,' October, 1888, p. 296.
This man, about 2.30 p.m. on March 25th, 1887, had another man seated
upon his shoulders, when he was pushed backwards against a high
counter, and his neck was twisted by the man falling from his shoulders.
" For the first few minutes he only noticed pain in the back of the neck,
but then his legs began to feel weak, and he lay down ; within ten
minutes the lower limbs were completely paralysed and insensitive, and
he found that he could not straighten the left forearm." The tempera-
ture at 4 p.m. was 94"2°, at 8 p.m. 97'6°, at midnight (that is, nine and
a half hours after the injury) it was 99"2°, near which point it remained
for some days. The motor paralysis was complete, but the loss of sensa-
tion was not absolute in the lower extremities. Below the third ribs
" there was absolute analgesia, but a vague sensation was conveyed by
tickling." The above notes were made on the following morning — viz.
about twenty hours after the injury ; and for the same period there is
this record : " There were no superficial reflexes nor tendon reactions."
From the eighth to the eleventh day after the injury, it was noted that
" sensation in the trunk and lower limbs seemed to improve slightly."
No subsequent note was made as to the sensibility, but on the fifteenth
day there is a note saying, " We found distinct knee-jerk on the right
side, and on the left a slight reaction could be obtained."' A few days
after this the patient's temperature began to rise, and he soon died from
pneumonia. At the autopsy the body of the fifth cervical vertebra was
found to be slightly dislocated forwards. Some blood was effused into
the spinal canal at this level, and the cord was here also compressed for
about one inch, but in other parts of the cord nothing unnatural was
found. In this case all shock seemed to have passed ofi: at the time the
note was made concerning the reflexes ; their return to some extent at a
later period, coincidently with some improvement in sensibility, is quite
in accordance with my own observations.
I It is quite possible, therefore, that some amount of sensibility still per-
sisted.
204 ON THE SYMPTOMATOLOGY OB' TOTAL
6. Dr. Thorburn's Case 7, recorded in ' Brain,' October, 1888, p. 305. This
man, when intoxicated, had fallen from a gallery ten feet in height. He
was examined bj Dr. Thorburn nearly twenty-four hours after his admis-
sion, when, apparently, symptoms of shock had passed off, seeing that his
pulse was 80, and his temperature 99"4°. The lower limbs and trunk were
completely paralysed, the respiration being diaphragmatic. The lower
limbs were also said to be completely anaesthetic, as well as the trunk to the
level of the second rib in front. " Superficial and tendon-reflexes were
all absent." On the following morning, some twelve or more hours
later, the patient being in a very similar general condition, the following
additional note was made concerning the reflexes : — " The plantar, cremas-
teric, abdominal, and epigastric reflexes, and the tendon reactions at the
ankle, knee, wrist, and elbow, were all absent." This patient died on the
tenth day, but no further notes were recorded as to the reflexes. At the
autopsy the seventh cervical vertebra was found to be displaced forwards,
and the " cord was compressed at the level of the first dorsal vertebra,
and softened for a short distance above and below the site of compression,
its centre being occupied by an effusion of blood reaching as high as the
fifth cervical nerve-roots, in the form of a narrow cone."
7. Case of A. P — , a?t. 18, admitted into St. Bartholomew's Hospital
under the care of Mr. Willett on June 17th, 1886. This young man
had fallen from a height, and had sustained a fracture-dislocation of the
seventh cervical vertebra (see 'Lancet,' 1887, pt. ii, p. 261 ; and Tooth,
'On Secondary Degenerations of the Spinal Cord,' 1889, p. 30).
On admission there was some loss of sensation and paresis in the arms,
but complete loss of sensation and paralysis below a line drawn round
the body about three inches above the nipples. The absolute loss of sen-
sibility is strongly attested by the fact that manipulation of a fracture
of the thigh, sustained at the same time as the spinal fracture, gave rise to
no signs of pain. There was complete loss of all reflexes below the lesion —
knee-jerks and the cremasteric and plantar reflexes having been particu-
larly looked for. This absence of reflexes continued to the end, rather
over six months. No trace of rigidity of muscles was observed, and no
note was made of the existence of involuntary twitchings. Death
occurred on January 26th, 1887, and at the autopsy a total transverse
lesion was found between the eighth cervical and the first dorsal nerve-
roots (see Tooth, loc. cit., Fig. 7), whilst in the lower portions of the cord
only well-marked secondary degenerations existed.'
8. Case of E. T — , set. 42, admitted into St. Bartholomew's Hospital
under the care of Mr. Langton on October 17th, 1887. The patient had
sustained a fracture-dislocation of the sixth cervical vertebra, and on
1 For additional details concerning this case, as well ns for the notes of
the next two cases, which I have received permission from Mr. Langton and
Mr. Willett to make use of, I am indebted to the kindness of my colleague.
Dr. Tooth.
TRANSVERSE LESIONS OF THB SPINAL COKD. 205
ndniission the lower limbs were said to be quite pai'alysed and anajsthetie.
There was also absence of rellexes. On November 7th it was noted that
the sole reflexes were well marked, and that the right knee-jerk had
returned, but feebly ; the left was not tried. Death occurred on Novem-
ber 24th, and in regard to the spinal cord Dr. Tooth says, " On section
at the point of injury the cord appeared to be completely crushed, and no
fibres could be seen in carjnine-stained specimens ; Weigert's method was
not used." (This is not a very conclusive case, I merely quote it for
what it is worth ; it at least suffices to show that there was no exaggera-
tion of reflexes.)
9. Case of T. B — , aet. 45, admitted into St. Bartholomew's Hospital
under the care of Mr. Willett on August 7th, 1888. This was a case of
fracture-dislocation at about the fourth cervical vertebra. There was
complete paralysis of the lower extremities, and more or less of the upper
extremities. Complete anesthesia existed below the level of the fifth
rib, and there was also considerable affection of sensibility in the arms.
There was a total absence of tendon-jerks in the arms and legs. This
patient died more than six weeks after admission (on September 25th), but
in the notes furnished to me Dr. Tooth says, " Neither sensation,
motion, nor reflexes returned. No note is made as to rigidity, but Mr.
Bowlby is quite sure that there was none. Owing to the great difficulty
in obtaining a post-mortem examination the cord was not all removed.
Mr. Bowlby removed it to the level of the fifth cervical vertebra, thinking
that that would include the lesion, but on examination the cord showed
only descending degenerations. There was therefore no opportunity of
examining the crushed spot." The lumbar region was, however, found
to be quite healthy except for descending degenerations.
If we were to look at these cases of fracture dislocation
alone, there might be reason to fear that in some of them
at least the suppression of the reflexes had been entailed
by shock. The fact, however, that in other of these cases
a similar abolition persisted long after there could have
been any reasonable grounds for attributing the pheno-
mena to shock, tends to eliminate our reserve in this
direction, as also does the fact that the same abolition
persisted week after week in the cases of disease which I
have recorded, as well as in Dr. Gee^s case, where from
first to last there had been no symptoms of shock at all.
Similarly, if we were to look to my cases alone it would
be open to the hypercritical — in spite of all appearances
to the contrary — to maintain that there mig-ht have been
lesions more or less minute in the lumbar swelliua: of the
206 ON THE SYMPTOMATOLOGY OF TOTAL
cord, to which the abolition of the reflexes was really to
be ascribed. But such an explanation loses much of any
force that it might have possessed when applied to supei--
ficially observed cases, and becomes almost wholly invalid
when applied to the other series of cases, viz. those in
which previously healthy persons become the subjects o£
a local and purely accidental damage to a part of the
spinal cord far removed from the lumbar region.
The two sets of cases, therefore, mutually illustrate
one another, and by their combination tend all the more
strongly to support my position that in total transverse
lesions of the spinal cord we may expect, contrary to pre-
vious views, to find that both superficial and deep reflexes
will be abolished.
It will be needless for me now to sum up and recapitu-
late the symptoms of such lesions as they occur in the
mid-dorsal region. I have nothing definite to add, and
no distinct alterations to make in the account, based upon
careful and repeated observations, given in Quain's ' Dic-
tionary of Medicine ' in 1 882, and which is in part repro-
duced here on pp. 153 — 155. I would only call attention to
the fact that the plantar reflex, as a rule, disappears after
ankle-clonus and the knee-jerk in cases where all three
have pre-existed — that it is, in fact, the last of the super-
ficial or deep reflexes to be obtained ; and that what is
termed " idio-muscular contractility '^ (p. 167) may be met
with even long after the plantar reflex has ceased to be
obtainable. Then, again, in regard to the organic reflexes,
it seems clear that two of them not unfrequently persist
in these cases of total transverse lesion. We have seen,
for instance, that in many cases when a certain amount of
urine has collected in the bladder, this organ will contract
sufficiently to expel its contents in pai't — the urine thus
escaping '' in gushes " at intervals of two or three hours.
Again, though obstinate constipation is the rule in these
cases, and there is no evidence that the mere accumula-
tion of its own proper excreta will, as in the case of the
bladder, lead to reflex contractions of the intestinal tube
TEANSVERSE LESIONS OF THE SPINAL CORD. 207
adequate to bring about even partial expulsion of its
contents, yet, when a stronger stimulus is added, in the
form of some purgative or large enema, the reflex activity
of the intestine becomes adequately roused — it is roused,
moreover, under conditions where all cerebral control is
lost, so that complete incontinence results so long as the
extra stimulus lasts.
Besides its importance as a mere scientific problem in
symptomatology, this question as to the persistence or
abolition of reflexes in lower parts of the body in cases of
total transverse lesions of the spinal cord is also one of
great interest and importance in reference to a point in dia-
gnosis, and no less so in regard to the pathogenesis of cer-
tain nervous states hard to be explained.
The problem in diagnosis is, as to the means which we
possess of ascertaining during life the lower limits of a
lesion in the spinal cord, where either it or another higher
up has produced, at a particular level, a total transverse
destruction of the organ. The conclusion to which we
have now arrived, in regard to the conditions under which
reflexes are abolished, impose limits upon our powers in
this direction not hitherto anticipated. To this question,
however, I have already referred (p. 157).
The question of pathogenesis is one which I have else-
where^ treated somewhat at length in a section entitled
" The causation of contracture, ankle-clonus, and exag-
gerated knee-jerk; and the extent to which they are de-
pendent upon cerebellar influence.'^
The first person, I believe, to start the notion that un-
restrained cerebellar influence was largely concerned with
the production of rigidities and exaggerated reflexes was
Dr. Hughlings Jackson. This was done in a very brief
communication in the ' Medical Examiner ' for April 5th,
1877, though he has since referred to and developed the
same doctrine in two or three other communications.^
1 'Paralyses; Cerebral, Bulbar, and Spinal,' 1886, pp. 216—229.
^ ' Med. Examiner,' March 28th, 1878; ' Med. Times and Gaz.,' Feb. 12th,
1881.
208 ON THE SYMPTOMATOLOGY OF TOTAL
The difficulties standing iu the way of the acceptance
of some such hypothesis as this of Dr. Hughlings Jackson
wei'e greatly diminished, I venture to think, by my ob-
servations as to the abolitiou of rigidity aud exaggerated
reflexes in total transverse lesions of the spinal cord.
When cerebral motor influence alone is cut off, it is an
admitted fact that we soon have to do with conditions of
rigidity and greatly exaggerated reflexes in the paralysed
parts ; but as soon as the remaining connections of the
encephalon with the lower half of the spinal cord are
completely severed, as they are in total transverse lesions,
there is at once an abolition of all rigidity and of the su-
perficial and deep reflexes. What can be the cause of
this complete change in the condition of the limbs ? Seeing
that the cerebral motor influence was previously cut off,
it would seem that the abolition of the rigidity and of the
reflexes must now have been due to the severance of the
influence of some other encephalic motor organ, whose
previous unchecked activity was the cause, either indirectly
or directly, of the rigidity aud exaggerated reflexes. But
what other organ of the kind is there — that is, what other
motor organ — save the cerebellum ? It was under the
influence of such considerations, and after a careful com-
parison of the various hypotheses which have been started
to explain these phenomena, that I came to the conclusion
that a notion closely akin to that of Dr. Hughlings Jackson
was most capable of explaining all the facts. Yet, as I
have pointed out (loc. cit., p. 224), my reasons in detail,
dependent upon views as to the precise modes of activity
of the cerebellum, were rather different from those which
he has set forth.
The doctrine that has hitherto found most favour has
been that of Bouchard, Charcot, Brissaud, and others. It
starts with certain positions which are common to both
explanations of exaggerated tendon reactions and rigidity.
These are («) that exalted tendon reactions depend upon
an exalted condition of " tone ^' in the muscles concerned ;
and [h) that the rigidities with which exalted tendon re-
TRANSVERSE LESIONS OF THE SPINAL COKD. 209
actions are often associated are only higher manifestations
of similar phenomena, produced in an essentially similar
manner.
It is here, however, that the two principal explana-
tions that have been given of these phenomena part com-
pany. According to the view of the French school, which
has been so widely adopted in this country, the pheno-
mena are held to be immediate consequences of the de-
generative changes set up in the " crossed pyramidal
tracts " by injuries to these tracts higher up, either in
the brain or in the spinal cord itself. The degenerative
changes in the terminal portion of these fibres are supposed
to cause an irritative over-action in the related great
ganglion-cells of the anterior cornua, and thus to lead to
an e.xaggerated condition of " tonus " in the muscles, and
the production of the phenomena in question.
Great difficulties formerly stood in the way of explain-
ing many of the facts without the aid of some such views
(although grave objections could always be alleged against
them) ; hence the few adherents which the counter ex-
planation of Dr. Hughlings Jackson has hitherto been
able to command. Now, however, it seems to me that
the new facts established in this paper will be found to
be altogether opposed to the fashionable views above cited,
and to be just as much in favour of some modification
of the doctrine of Hughlings Jackson.
One grave objection which always seemed to me much
opposed to the view of Bouchard, Charcot, and others, was
the fact that exalted tendon reactions and contracture are
to be met with in many cases where there is every reason
to believe that no such causative structural changes as the
hypothesis assumes exist in the crossed pyramidal tracts, —
as, for instance, for a time after attacks of Jacksonian
epilepsy j^ again, in cases where mere temporary pressure
is exerted upon the antero-lateral columns of the cord ;
and lastly, in many functional conditions, hysterical or
1 See Dr. Hughlings Jackson's paper, "On a Case of Temporary Left
Hemiplegia," 'Med. Times and Gaz.,' Feb. 12tli, 1881.
VOL. LXXIII. 14
210 ON THE SYMrTOWATOLOGY OF TOTAL
other. Now, however, there appears a graver objection
still ; it is that in cases of total transverse lesions of the
cord, as we have seen, the supposed cause exists to its
fullest extent, viz. degeneration in the crossed pyramidal
tracts, and yet, instead of exalted tendon reactions with
rigidity, even after many weeks in some of the cases there
is a total absence of reflexes, and a flaccid condition of the
limbs. Here, then, as it seems to me, is the death-blow
to the hitherto commonly accepted hypothesis.
Now let us look to the other mode of interpretation ;
let us see what can be said in favour of the view that
" tonus " is in the main due to some encephalic influence
exerted upon the spinal cord, seeing that tlie cutting this
organ off from all encephalic influence leads to abolition
of rigidity and of reflexes. This general position, as I
have formerly urged, would seem to be pretty well estab-
lished by my observations. Further, it seems highly pro-
bable that the potent encephalic influence which is thus
cut off, in cases of total transverse lesions of the spinal
cord, is that of the cerebellum. We cannot immediately,
however, come to such a conclusion.
All that we are entitled to infer at once is that the
severance of the cord from the brain greatly diminishes,
at all events, what is known as " tonus," — that is, dimin-
ishes it to such an extent that phenomena acknowledged
to depend upon it can no longer be produced. Of this
broad fact two explanations seem possible : thus it might
be said (1) that owing to the mere fact of the complete
severance of the lower half of the cord from the brain the
nervous tension, so to speak, or degree of molecular
activity in the grey matter of the severed portion of the
cord, is so lowered as to lead to such a diminution of tonus.
That is to say, that mere vague and diffused nerve impulses
habitually passing between the brain and the spinal cord
may be essential to the proper functional activity of the
centres contained in the latter ; that such impulses may
maintain a condition of receptivity with correlative power
of reaction, which in the absence of such conditions be-
TRANSVERSE LESIONS OF THE SPINAL CORD. 211
comes lost. This is a kind of explanation that might
suffice to account for the negative phenomena, the mere
loss of the reflexes and of rigidity, but it is powerless for
the explanation of other related positive phenomena ; that
is to say, of and by itself it furnishes no explanation
whatever of the fact that when the influence of the cere-
bral hemispheres alone is cut off we have the production
of greatly exaggerated tendon reactions with more or less
of rigidity or contracture.
It is, therefore, the insufficiency of the first mode of
explanation that compels us to seek for another. Now,
the other explanation, that which I have previously offered
(loc. cit., p. 219), is this : We may suppose (2) '^ that
the condition known as muscular tonus is mainly due to
cerebellar influence acting upon and through the spinal
centres ; then it may well be that the removal of cere-
bral influence from certain parts of the spinal cord may
allow cerebellar influence to reach such parts of the cord
much more freely than natural — that is, as Hughlings
Jackson would say, we should have to do with an un-
antagonised, or, as I would rather say, an unrestrained
influx of cerebellar energy."^ Further evidence bearing
upon the relative merits of this and of the other hypothesis
was offered in the following remarks : — " The fact that
such muscular irritability, in patients suffering from slight
contracture, is increased if they take strychnia, has been
commonly held to prove that this irritability is dependent
upon changes or conditions existing within the spinal
grey matter alone. But if we bear in mind that the
muscular irritability in such cases is similarly exalted by
mental activity or excitement, or by the performance of
voluntary movements, and that it is often notably dimin-
ished by sleep, we may see in these facts reasons for
' In addition to the facts already urged in support of such a view, I cited
what had occurred in regard to reflexes in a remarkable case of complete
thrombosis of the basilar artery, as well as in a case of ingravescent apoplexy.
These f.icts, however, as I now recognise, are of doubtful cogency, because it
cannot with certainty be said that the loss of the reflexes might not have
been effects due to shock.
212 ON THE SYMPTOMATOLOGY OF TOTAL
believing that the excitability of the cord increases or
diminishes with the excitement or the reverse of some
encephalic centi-es^ and that an excessive influence of some
kind^ producing increased tonus in the paralysed muscles,
must reach the related ganglion-cells of the spinal cord
through other channels than the damaged pyramidal tract/'
Another question now presents itself. Supposing the
cerebellum does exercise some such influence as I have
postulated upon the various centres in the spinal cord, it
may naturally be asked, through what channels are we to
imagine this influence to be conveyed ? There would seem
to be only two possible routes ; that is, either through the
'* comma-shaped tracts," which is to my mind very un-
likely, or else diffusely through the grey matter itself, in
the same sort of way that impressions of pain are conveyed
in the reverse direction.
Now, first of all in regard to the " comma-shaped
tracts." I mention them because they are the only out-
going tracts at present known in the cord, the functions
of which are sufficiently uncertain to make it just possible
that they are accustomed to convey cerebellar incitations
to the muscles, and because the views of Dr. Hughlings
Jackson are based in part upon the supposed existence of
some definite outgoing cerebellar channels in the spinal
cord. Thus he says {' Medical Examiner,' March 28th,
1878), *' The hypothesis starts with the assumption that
the spinal centres receive impulses from both the cerebrum
and the cerebellum, which impulses in health interfere
with one another (inhibit one another)." His meaning
is made clearer by what follows : " In other words, loss
of cerebral influence on the spinal centre may permit the
rigidity, for then the cerebellar influence is no longer
interfered with, and, metaphorically speaking, ' flows into
the parts deserted by the cerebral influence.' Hence it is
better to say ' unantagonised cerebellar influx ' than
'increased cerebellar influx.'" For my own part, I
cannot believe that the motor cells in the spinal cord are
habitually the seat of antagonising activities emanating
TRANSVERSE LESIONS OF THE SPINAL CORD. 213
from the cerebrum and the cerebellum respectively ; and
the fact that the fibres of the " comma-shaped tracts "
seem to terminate principally in the upper half of the
spinal cord, and to disappear before the lumbar region is
reached, is also opposed to the possibility that this as yet
unallotted tract of outgoing fibres should have any such
function.^
The only other channel, therefore, along which the
slight molecular pulses could habitually pass from the
cerebellum to the spinal cord (whose existence I postulate)
is through the grey matter. These molecular pulses,
whatever else they may do, may be supposed to be in-
strumental in maintaining the tonus of muscles through-
out the body ; while in various morbid states the amount
of energy flowing along their habitual channels from the
cerebellum (especially when the usual restraining influence
of the cerebrum is withdrawn) may be very notably in-
creased, so as to lead to rigidities and contractures. The
notion that the grey matter is the channel along which
these influences emanating from the cerebellum pass, I
am not able to support by any more definite evidence than
is to be found in the following facts.
We know that with absolute paralysis of the lower
extremities, so long as sensibility is intact (as is so often
the case in the paralysis associated with Pott's disease),
the knee-jerks are greatly exaggerated, ankle-clonus is
present, and there is more or less of rigidity with spas-
modic twitchings. This condition of things existed also
in the eai'ly stage of my Case 3. On the other hand, where
there is more and more loss of sensibility, including loss
of painful as well as of tactile impressions, the clinical
picture changes :^ after a time we gradually lose the
^ Concerning the topography of the " comma-shaped tract," see Tooth,
"On Secondary Degeneration of tlie Spinal Cord," 1889, p. 37.
* What follows does not hold good for the effects of unilateral paralysis
with anaesthesia. I have now, for instance, a young woman under my care in
the National Hospitid, in whom the right arm and leg are completely para-
lysed, all modes of sensibility being also lost; but the paralysed limbs are
more or less rigid, and the knee-jerk is greatly exaggerated.
214 ON THE SYMPTOMATOLOGY OP TOTAL
rigidities, the spontaneous twitchings, and ankle- clonus ;
while with still graver impaii'ments of sensibility the
knee-jerks and the reflex movements of the limbs when
the muscles are pricked may also disappear ; or, finally,
these last may continue, together with some slight amount
of plantar reflex, so long as even a slight amount of sen-
sibility to painful impressions persists.^ This last condi-
tion was seen in my Case 2 on December 13th, and in
Case 4 on March 17th. But we know that painful im-
pressions are likewise conducted through the grey matter
of the cord. Thus it would seem that the preservation
of even the smallest bridge of grey matter may permit
some preservation of painful impressions, and may at the
same time permit the passage of cerebellar energy in
the reverse direction. I have found, moreover, a remarkable
case recorded by Dr. Thorburn,^ some details of which are
subjoined, and which bears in a very interesting manner
upon this question as to the channel by which the encephalic
influence that serves to maintain tonus in the muscles is
conducted.
10. J. B — , set. 34, was admitted into hospital on December .SOth, 1885.
He was a carter, and whilst loading a waggon a " tippler " full of coal
fell upon him, throwing him upon his face, while the coal struck him
between the shoulders. On examination several hours after the accident
there was absolute paralysis of both lower extremities, with deficient
action of the intercostal and anterior abdominal muscles in respiration.
Both legs were completely anaesthetic as high as the knees, but thence
upwards he had some sensation, although there was distinct numbness as
high as a line drawn round the abdomen about two inches below the
umbilicus. The plantar reflexes were noted as " almost absent." " On
the following day there was still absolute paralysis of the lower limbs,
but there was now no anaesthesia. . . . The superficial reflexes and
tendon reactions were everywhere absent. . . . The temperature was
98'6° F. in the morning, and 99*8° F. in the evening." On the follow-
' In proof of these statements I would refer to what is stated as to Case 3
on p. 178, and in the notes for December 9th ; and I would ask the reader to
compare what is said on pp. 200 and 201 with the notes made as to Case 1 on
May 19th (p. 161) when sensibility was completely abolished.
2 ' A Contribution to the Surgery of the Spinal Cord,' 1889, p. 48.
TKANSVKRSE LESIOXS OF THK SPINAL CORD. 215
ing day the signs of lung troubles with accumulation of mucus became
severe, and the day after, January 2nd, 1886, he died. At the autopsy
the membranes of the cord were seen to be quite normal, as was the ex-
ternal appearance of the cord itself, but " on section there was found to
be a dark black ha?morrhage into the central grey matter in the lower
cervical and upper dorsal regions. This hsemorrhage, which measured in
its vertical extent from I5 to 2 inches, was in the greater part of its ex-
tent situated centrally, occupying the whole of the central grey matter,
and extending but little into the white substance, which in its neigh-
bourhood was merely softened and of a faintly yellow tinge. At the
lower part, for a very short distance, the hjemorrhage was limited to the
anterior cornu of the right side, while the corresponding left horn appeared
to be perfectly healthy. Elsewhere the cord was firm, and presented no
abnormality."
Now tliis case seems to liave for me almost all the value
of a well-devised experiment. On the second day, when
all the reflexes were still absent, though, as the notes say,
" there was now no anaesthesia,^' all signs of shock seem
to have disappeared. This continued absence of the
reflexes with the return of sensibility seems to be distinctly
opposed to the teaching of the cases that I have brought
forward in this paper. In reality, however, I believe it
to be the kind of seeming exception which tends to prove
very fully the truth of many of the conclusions at which
I have arrived. It tends to show almost conclusively
tbat analgesia is the kind of defective sensibility which is
most potential in bringing about a diminution or loss of
the reflexes, and therefore the great importance of record-
ing the state of a patient's sensibility to painful as well
as to mere tactile impressions; for it can scarcely be doubted
that in this case, where the autopsy showed a lesion limited
to and invading the whole of the grey matter of the cord
for a certain extent, there must have been, though it is
not recorded, loss of sensibility to painful impressions.
As we have seen, there was here certainly loss or very
great diminution of " tonus " in the muscles, seeing that
the " superficial reflexes and tendon reactions were every-
where absent."
I would only say a few words in conclusion as to the
216 ON THE SYMPTOMATOLOGY OF TOTAL
functional relations existing between the cerebrum and the
cerebellum, and as to the conditions under which an excess
of cerebellar influence becomes drafted into the spinal cord.
"'In my opinion, the weakening or removal of cerebral
influence from the spinal cord leads to the weakening or
removal of an inhibitory influence which (operative pro-
bably in the pons Varolii) usually regulates or restrains
the outflow of cerebellar energy through its median
peduncles. I would not in the present state of knowledge
attempt to define in what precise way the cerebrum and the
cerebellum co-operate with one another in their possible
actions upon the different muscles of the body.^ In the
performance of the most automatic actions the cerebellum
may come into play to a considerable extent independently
of the cerebrum, and such neuro-muscular processes are
comparatively little interfered with by unilateral lesions
of the cerebrum. In the performance of the least auto-
matic actions, however, the cerebrum takes the lead, and
the cerebellum acts only as it is solicited or permitted to
act, in directions indicated by the outgoing cerebral incita-
tions. The withdrawal, owing to unilateral lesions, of
cerebral influence from muscles which are principally called
into action voluntarily is, therefore, well calculated greatly
to interfere with ' the balance of power ' usually capable
of being brought to bear upon such muscles, and may lead,
as it seems to do, to their being acted upon in excess by
the cerebellum, even when in a state of rest, in conse-
quence of which there is increased tonus, carrying with it
exaltation of deep reflexes or even muscular rigidities. '^^
Such effects do not usually manifest themselves to their
fullest extent at once ; they are immediately increased to
some degree, but they go on increasing to an indefinite
extent, so that it may be some days before anything like
distinct rigidity shows itself. But, as I have said else-
where,^ " it may be that in such cases the extra leakage
1 See 'The Brain as an Organ of Mind,' pp. 503—510.
' 'Paralyses; Cerebral, Bulbar, and Spinal,' p. 222.
' Loc. cit., p. 225.
TRANSVERSE LESIONS OF THE SPINAL CORD. 217
of cerebellar energy, whicli tlie cerebral lesion permits
after the shock occasioned by its occurrence has had time
to resolve, has a tendency to go on increasing up to a
certain point, because of the gradually lessening resistance
(probably in the pons) opposed to any such overflows of
cerebellar molecular energy. All nerve actions, whether
normal or abnormal, become easier and recur all the more
readily the more frequently they are repeated."
(For repoi't of the discussion on this paper, see ' Proceedings of
the Royal Medical and Cliirurgical Society,' Third Series, vol. ii,
p. 71.)
i
ANALYSIS OF 964 CASES
OF
OPERATION FOn CALCULUS IN THE
BLADDER
BY
LITHOTOMY AND LITHOTRITY,
WITH REMARKS.
BT
SIR HENRY THOMPSON, F.R.C.S, M.B.Lond.,
SUEGEON-EXTEAOEDINAHT TO H.M. THE KING OF THE BELGIANS; CON-
SULTING SURGEON TO UNIVERSITY COLLEGE HOSPITAL; AND
MEMBER OF THE SOCIETE DE LA CHIRURGIE OF
PARIS, ETC. ETC.
Received December 10th, 1889— Read March lllli, 1890.
In the year 1878 I had the honour of presenting to the
Society a record of 500 cases of operation for stone in the
bladder of the adult male.^ I now beg to offer a further
record of 464^ in all 964 cases, and constituting my entire
experience from the first case in 1854 to the end of 1889 ;
besides which are four cases of operation for the removal
of foreign bodies unassociated with calculus, comprising
a total of 968 cases.
Respecting all these I beg leave to repeat a statement
made on the occasion referred to, viz. that I possess full
' See ' Transactions * Roy. Med. and Chir. Soe., vol. Ixi, p. 159.
220 OPERATION FOR CALCULUS IN THE BLADDER
notes of every one recorded at the time of its occurrence,
on a system adopted at the outset and never subsequently
changed ; while founded on these is a printed catalogue
(private) containing the chief particulars of every one, a
copy of which accompanies this paper. The name of the
medical man who sent me the case or who was present at
tlie operation, for such there almost invariably was, is
there given, as well as the after history, often embodying
observations extending over several years. Every fact
named can be verified by evidence under my hand. I
have adopted this plan as satisfactory at all events to
myself, desiring before all things to make a clear ex-
position of my entire experience, having often in past time
regretted the want of details relating to that of some
skilled and practised operators who have left no numerical
statements, and only imperfect records or general impres-
sions of the results they obtained. Whatever I offer
here may be accepted as the outcome of my entire work
in this depai'tment of surgery. Not a single case has been
omitted. My object has been to present here an accurate
although necessarily very brief study of the data obtained,
chiefly in relation to treatment and its consequences ; and
respecting this it may be permissible to state at the out-
set that I am not conscious of having entertained undue
predilection for any particular method, and have there-
fore employed the knife and the lithotrite indifferently,
according to my judgment, for the requirements of each
individual patient.
These 964 calculous cases have occurred in the follow-
ing proportions in regard of sex and age : in adult males
933, in females 15, in youths and boys 16.
The operations which I have employed are lithotomy
by various methods, and lithotrity ; and, for a few among
the female cases, dilatation and extraction,
1. Lithotrity. — Eegarding lithotrity, the first case of
which, that of a girl, bears date of 1854, I may say that
I adopted at the outset the method of my friend Civiale,
then in vogue. At this time the sittings for a stone of
BY LITHOTOMY AND LITHOTRITY. 221
moderate size were short and numerous^ and generally with-
out anaesthesia ; the debris being permitted to issue for the
most part by the natural act of micturition, assisted
occasionally by washing out the bladder with a syringe
through a large silver catheter. For the first seven years I
employed his instruments, which were much superior to
those then used here, having learned to do so during two or
three visits to him at Paris for the purpose, circumstances
which led to a very friendly intercourse terminated only
by his death. Previously to that event, however, I had
designed the first lithotrite with a cylindrical handle, an
idea which Messrs. Weiss and Son carried out for me ;^
and Civiale himself during the last year or two of his
life approved and employed my new instruments, made
for him at his own request by that firm.
It was early in 1865 that Mr. Clover designed and
carried out his idea of removing the debris produced by the
lithotrite by means of an exhausting india-rubber bottle
and silver evacuating catheter. I used it for the first time
in April, 1865, for a patient (Case 51 in the catalogue)
whom I saw with my friend Mr. C. A. Aikin, Hyde Park,
and I continued to do so more or less for about twelve or
thirteen years. As my experience increased I employed
it more freely than at first, and thus diminished materially
the number of sittings before considered necessary.
Hence the value of an anaesthetic became obvious, and I
always advised it when the " bottle,^' or, as it was subse-
quently termed, the " aspirator,'^ was employed, since the
action was more painful to the patient than that of the
lithotrite. After 1872 I rarely operated without it, and
therefore preferred the aid of chloroform, which was in-
variably administered by Clover. But previously to the
last-named date I was in the habit, whenever severe
cystitis appeared in a case undergoing lithotrity, of em-
ploying an aneesthetic at once, that I might empty the
bladder at one sitting ; having learned by experience that
the best way to treat the cystitis was to remove every
' See letter from Messrs. Weiss, ' Lancet,' August 20th, 1864, p. 229.
222 OPERATION FOR CALCULUS IN THE BLADDER
fragment of calculus, accomplisliirig this chiefly by means
of Clover's aspirator. This principle of procedure I
strongly advocated in my lectures here ; I also made it
the subject of clinical remarks after operating for stone at
Hopital Neckar, in Paris (1876-7), at my friend Dr.
Gruyon's request, before a large number of students there.
I contended that the plan of emptying the bladder at a
final sitting under these circumstances constituted a great
improvement on the method by baths, demulcents, rest,
and waiting for irritation to subside, always employed for
cystitis during lithotrity at that time, especially in Paris.
But it never occurred to me that this pi'actice would be
advisable in every case of calculus, as was, soon after this,
to become apparent.
In 1878 Professor Bigelow, of Harvard, U.S., introduced
his method by a single sitting, based on the assumption
that less injury was sustained by the bladder from pro-
longed manipulation, provided the whole stone was re-
moved at once, than by the irritation caused through pro-
longed contact with numerous fragments left therein for
several days to await subsequent sittings. I was quite
prepared to accept this principle, and, testing it without
delay, soon recognised its importance and value. Since
that time I have adopted it, with two or three exceptions
only, for all those cases to which I considered lithotrity
applicable, using, however, the same lithotrites as before,
namely, those made on the model designed by myself, with
the cylindrical handle, &c. I have made various modi-
fications which experieuce has suggested from time to
time in the apparatus for removing debris, arriving finally
at the aspirator which I have used during the last few
years. Hence, having employed the same instruments for
crushing, and the same system for removing the material
crushed since 1878 as before that date, I have felt myself
unable to adopt a new name to denote the improved
method which Professor Bigelow proposed. I have con-
tinued to perform " lithotrity,-" the term originated by the
illustrious inventor of the crushing operation, adding, in
BY LITHOTOMY AND LITHOTRITY. 223
order to indicate the essential change made by Bigelow,
" at one sitting," instead of by several.
In connection with the specimens preserved here it is
necessary to point out that in endeavouring to collect the
calculous matter removed by lithotrity of the early type, that
is by numerous sittings, it was never possible to obtain and
preserve the whole of the debris. A certain quantity was
always lost, the task of collecting having been necessarily
confided chiefly to the nurses, not always sufficiently atten-
tive to this part of their duty. Among such, however,
the specimens may be taken as representing about three
fourths of the calculus in each case. It is advisable, when
the debris of a stone removed by lithotrity is to be pre-
served, that it should be first dried, then weighed, and the
result recorded. Since adopting the method by a single
sitting, which renders the proceeding easy, this has been
done in every instance. Accordingly almost every case
catalogued here, from No. 503 (1878) to the end of the
series, has been so reported.
Each one of these calculi has been placed in a glass
cell, and is marked by a number corresponding with that
in the catalogue, which indicates the case to which the
calculus belongs, with its particulars, so that reference
can be readily made from the specimens to the particulars,
and vice versa.
There is one feature in the collection of which I have
to say a few words. Although it contains many large
calculi, including a few of remarkable size, there is a con-
siderable proportion of small ones, when compared with
most of the old existing collections, obtained only by
lithotomy, brought together as they were before the middle
of the present century. When the knife was the only
means available to remove the stone, few patients ven-
tured to encounter the risk of operation until after some
years of sufi"ering, while the surgeon himself rarely recom-
mended it until the stone had attained certain proportions.
But as soon as the great superiority of lithotrity, particu-
larly for cases where the calculus is small, had become
224 OPEKATION FOE CALCULUS IN THE BLADDER
evident, the idea wliicli dominated my practice and my
teaching was the extreme importance of discovering the
stone in the early stage, since the dangers incurred by
the patient with a large stone, either from repeated sittings
by lithotrity or from the knife, were thus to be avoided.
I lost no opportunity of seeking for the calculus when re-
cently developed, and learned slowly, with surprise, how
much more frequently it was to be found in the bladders
of elderly men than I had been taught to expect. So far
from the stone being more common in children than in
adults, according to the universal belief at the period re-
ferred to, justified as it was by the records of hospital
practice, I was soon in a position to affirm that stone was
more common among men of sixty years of age and up-
wards than at any other period of life. For let it be re-
membered that all existing records of practice, whether
found in museums or reported by the operators themselves,
from all sources previous to the middle of the present cen-
tury, showed that half the total number of operations for
calculus occurred in childhood and youth. The truth
nevertheless is that a very large majority of calculous
cases was then, as now, to be found in persons above fifty
years of age ; but the fact was then unknown ; the calculi
were simply overlooked, not being' suspected to exist, and
one obvious cause of the oversight is to be found in the
fact that the early symptoms in elderly subjects are ex-
tremely slight — a rule with only few exceptions, — contrast-
ing strongly with the marked and painful symptoms rarely
absent in the young.
Thus, the slight irritation scarcely felt by elderly
patients unless considerable exercise is taken was natu-
rally attributed to commencing enlargement of the prostate,
to undue acidity of the urine, to " irritation consequent on
gout," &c. Hence examination of the bladder for cal-
culus had usually been deemed for such slight symptoms
unnecessary. But further, at the period referred to, when
such cases were examined by an instrument, as sometimes
happened, it was obvious, on observing the method usually
BY LITHOTOMY AND LITHOTRITY. 225
followed, that tlie sounds employed^ as well as the method
of using them, were only adapted to find large calculi, and
that a formation about the size of a bean or an almond
covild only be struck by the merest chance, and had in-
deed never been seriously sought for or thought of. Such
can only be detected with certainty by light and delicate
handling with the small curved or beaked sound, at that
time unknown, and of which I availed myself some time
after its introduction by Mercier, of Paris. Yet it is
manifest that no greater boon could be conferred on the
calculous patient than that of finding his stone while it is
still small, and I venture to regard the keen pursuit of this
object, and its realisation in several hundred cases of
elderly men, as one of the most important results illus-
trated by this collection. Of small uric acid calculi alone,
including a few oxalic acid, but not reckoning phosphatic
calculi so frequent in age — that is, weighing from twenty
grains to a drachm, and occurring among men of advanc-
ing age, say from fifty -five to seventy-five years — there are
no less than 200 in this collection. The fact that a very
large number of patients could thus be freed from calculus
almost without risk was one of the highest importance.
But there was another result not less valuable which sub-
sequently appeared, namely, that such patients could
almost invariably be prevented from forming fresh calculus
by adopting dietetic precautions at an early period, before
the morbid tendency had become too strongly marked ; and
this has, I confess, been to me a source of extreme satis-
faction. I possess a great number of subsequent records
concerning patients on whom I have operated once for uric
acid calculus, who, having followed instructions in respect
of diet and regimen, have had no return ; while, on the
other hand, the instances in which a fresh acid formation
has taken place have occurred among those who have con-
tinued to indulge habits of diet favouring its reappearance,
or those in whom such habits have existed for many years,
or, lastly, in constitutions tainted by marked hereditary
influence.
VOL. LXXIII. 15
226 OPERATION FOR CALCULUS IN THE BLADDER
But at an earlier stage stilly calculous matter may not
infrequently be detected and removed, while existing only
in the form of "gravel" or '^ concretion/' We may
often remove these small bodies by the aspirator only, par-
ticularly those of uric acid, weighing two or three grains
or even larger; or we may occasionally dispose of them
by a single crushing of a lithotrite. In connection with
this subject I may remark that it has long been customary
to employ certain terms to describe these bodies according
to their size and importance — the visible crystalline de-
posits as " sand/' and the ovoid or irregularly shaped
bodies, like grains of wheat, peas, or small beans, as
" gravel " and " concretions."
The object in employing these terms has hitherto been
to convey general impressions respecting the small forma-
tions, and to reserve the word " stone " for bodies of
greater size and importance. Nevertheless all these
expressions, including even the last named, are sometimes
very loosely employed. No doubt it is diflficult, perhaps
impossible, to define precisely the limit of their meaning
in regard of size and weight. But in order to conform
as far as possible to the practice of our predecessors I
have invariably refused to recognise as " stone " the small
bodies described above, maintaining for them a well-
defined class of " gravel " and " concretions ;" and espe-
cially because the removal of small calculous bodies, now
that a formidable operation by the knife is no longer
necessary, is a matter of extremely small difficulty and
gravity. Hence I have uniformly declined to enter in the
series of " stones " removed from adult patients any
calculous bodies weighing less than about twenty grains.
When a smaller one has been met with I have described
it as ''gravel " or ''concretion."^ I know that the dis-
' Thus, some years ago, I washed out from a patient's bladder some five
hundred minute uric acid formations, about the size of a pin's head. The
total weight was 2f drachms. Smaller quantities I have frequently removed,
of which examples are presented here. But it never occurred to me to regard
these as instances of " stone in the bladder," or to enter them as cases of
operation.
BY LITHOTOMY AND LITHOTRITY. 227
tinction is quite arbitrary, but I contend that any weight,
whatever it may be, which is agreed to as marking the
limit between " stone ^' and " gravel '' must be equally an
arbitrary one. Still it is desirable that a distinction should
be drawn, and if possible agreed to, or we may have the
washing out of tiny bits of gravel of one or two grains
even in the adult individual represented and recorded as an
operation for " stone in the bladder V ^ Taking what I
venture to believe may be regarded as a common-sense view
of the question, I have adopted the twenty-grain limit for
myself. Had I reckoned the removal of uric acid and
oxalate of lime formations of the size just named, I should
have very largely augmented my number of cases ; and still
more so had I thus regarded the phosphatic concretions
which are so often crushed and removed from the bladder
of prostatic patients who have long passed all their urine by
catheter. Many persons live, subject to this condition, in
tolerable comfort for ten or twelve years or more. Such
a one after some months of freedom from pain gradually
becomes the subject of calculous symptoms, often severe,
due to the presence of a phosphatic concretion, weighing
perhaps ten or fifteen grains, too large to wash out, but
which a single introduction of the lithotrite suffices to re-
move. This proceeding may be performed sometimes
once or twice a year, and thus, for a single individual, the
surgeon may have to repeat the process many times.
Had I included all these examples in my series the total
number would have reached at least two or three hundred
cases more than it now does.
2. Lithotomy. — Regarding the series of operations by
lithotomy, I commenced with the ordinary lateral opera-
tion for the largest calculi, employing the median for
those which five-and-twenty years ago were regarded
as just outside the scope of lithotrity. Subsequently I
tried the medio-bilateral of Civiale and the bilateral of
Dupuytren for the first named, not acquiring any marked
* This actually has taken place. See ' Brit. Med. Journ.,' 1887, vol. ii,
p. 1376.
228 OPERATION FOR CALCULUS IN THE BLADDER
preference for any one of these methods. It so happened
that during the first fifteen or twenty years of my expe-
rience no calculus of very unusual size presented itself. I
met with several weighing from one and a half to three
ounces, and usually removed them by the lateral operation.
The supra-pubic operation I performed for the first time in
1864, not for a calculus, but for a foreign body in the
bladder of a young woman in University College Hospital.
It was a hair-pin lying across the bladder, tightly im-
pacted in this position and defying any fair attempt to
remove it by the urethra. The next occasion was in 1 877,
for a gentleman whose legs were immoveable and extended
as the result of spinal disease. The position for lateral
lithotomy being impossible, I performed the supra-pubic
in this, as in the preceding case, on a staff, the method
adopted at that time for removing a large uric acid calculus
(Case 456 in the catalogue).
But in the year 1883 I became acquainted with the
modification of this operation made by Petersen, of Kiel,
and from my experience of its results in the hands of
Guyon, of Paris, and others, I advocated its merits in my
lectures at the Royal College of Surgeons in 1884. Imme-
diately afterwards a case of large calculus presented itself,
and I performed the new supra-pubic operation, for the
first time in this country, in July of that year. The cal-
culus was one of pure cystine, and weighed 2f oz., the
largest of that product I have ever seen. The patient is
now living and well (see Case 690). Several other exam-
ples soon came under my notice, one of pure uric acid
reaching the weight of 14 oz. j and this method, which I
have employed seventeen times for stone patients, yielded
me results which surpassed any before obtained from the
lateral operation, considering the size of the calculi re-
moved. In connection with this subject it may be per-
missible to add here that I have also performed the same
operation eleven times for the purpose of removing tumours
of the bladder, none of which cases of course appear here,
with only one death following the proceeding, viz. from
BY LITHOTOMY AND LITHOTRITY. 229
septicaemia. With such an experience I should never again
adopts in ordinary circumstances, any other form of litho-
tomy for a large stone in the bladder.
The whole of the calculi extracted by all the methods
above named are, with only two or three exceptions, sys-
tematically arranged in a cabinet, and have been pre-
sented to the Eoyal College of Surgeons for preservation
in the museum there, accompanied by the catalogue re-
ferred to.
The following tables summarise the leading facts re-
lating to the sex, age, nature of calculus, operations em-
ployed, their results, &c,, in regard of the patients who
have come under my care both in hospital and in private
practice from the first case down to the end of 1889.
The last table, giving a general view of the whole, is sus-
pended in the room.
Table I. — Cases operated on in University College Hospital,
London, hel'iceen 1854 and 1874.
Adult males.
Youths and bovs.
Girls.
Total number
of patients.
79
13
1
93
Cases of
operation. D
Deaths.
The 79 male adults were treated —
24 by perinaeal lithotomy, median, medio-bilateral,
bilateral, but chiefly by the lateral operation .24 ... 10
55 by lithotrity, by several sittings. A few of these
were operated on again at a later period, fur-
nishing in all . . . . .63 ... 6
The 13 youths and boys were treated —
10 by lithotomy . . . . . 10 ... 1
3 by lithotrity . . . . . 3 ... 0
The 1 girl ^ was treated —
1 by lithotrity . . . . . 1 ... 0
Total . . . . .101 ... 17
Extraction of foreign bodies :
1 girl lithotomy, supra-pubic.
1 Tills was a patient in the infirmary of Marylebone, the only case of stone
occurring there while under my care as visiting surgeon, and hence, ranking
as a hospital patient, is placed with the University College Hospital cases.
230
OPERATION FOR CALCULUS IN THE BLADDER
Table II. — Cases operated on in private practice only
between 1857 and December ^Ist, 1889.
Adult males. Youths and boys. Females.
739 ... 3 ... 14
Cases of
operation.
The 739 male adults were treated —
91 by periiiEBal lithotomy, median, and medio
bilateral, but chiefly by lateral
1 supra-pubic (old) operation
17 supra-pubic (modern) opei-ation .
630 by lithotrity, nearly half being at a single sitting
Several cases were operated on a second time, a
few a third time, and in six cases four times
The 3 youths and boys were treated —
2 by perinajal lithotomy
1 by supra-pubic lithotomy .
The 14 women were treated —
9 by incision, 1 chiefly by dilatation
5 by lithotrity and extraction
Total number
of patients.
756
Total
91
1
17
737
Deaths.
33
1
4
40
2
0
1
0
9
1
5
0
863
79
On examining tlie above table and the total shown in
No. Ill, which follows, it will be seen that the proportion
of children to adults is very small. Among these only 16
males fell to my lot, 13 being in hospital practice ; 3 were
cases in private — a fresh proof of the rarity of calculus in
the children of parents among the middle and upper ranks
of life. Sir William Fergusson stated that he had but
once received a fee for operating on a child. Deschamps
in the latter part of last century stated that he had never
seen an example among families in easy circumstances.
The number of females operated on was 15 (14 adults
and 1 girl), and of these little need be said here. Hence
I shall now deal with male adult cases only, and shall beg
you to bear this in mind throughout all subsequent re-
marks. Deducting these two series of 16 and 15 respec-
tively from 964, the number of male adults remaining is
933, 800 by lithotrity and 133 by lithotomy.
BY LITHOTOMY AND LITHOTRITY.
281
Table III. — Total of all cases of stone in the bladder
operated on in hospital and in private practice
hetiveen 1857 and December Slst, 1889.
Total number of cases of operation .
Total number of patients ....
Male adults —818. Youths and boys — 16.
. 964
. 849
Females — 15.
Hospital. Private.
Total.
o ^
t- ■*^
S'l
55
24
79
3
10
1
|1
63
24
87
3
10
1
6
10
16
1
Number of
patients.
Number of
operations.
n
40
33
1
4
78
1
Number of
patients.
Cases of
operation.
o
a S
46
43
1
4
94
1
1
96
Male patients (adults) :
Lithotrity . . . .
Lithotomy (perinsBal)
Lithotomy (supra-pubic) :
Old method . " .
New method .
Youths and boys :
Lithotrity . . . .
Lithotomy (perinseal) .
Lithotomy (supra-pubic) .
Female patients :
Lithotrity (adult)
(girl)
Lithotomy and dilatation
(adult) . . . .
630
91
1
17
739
2
1
2
12
737
91
1
17
846
2
1
2
12
685
115
1
17
818
3
12
1
2
1
12
849
800
115
1
17
933
3
12
1
2
1
12
964
Foreign bodies in the bladder :
Removed by lithotrite
(males) . . . .
Removed by supra-pubic
operation, old method
(female) . . . .
1
1
1
3
3
—
3
1
3
1
1
232 OPERATION FOR CALCULUS IN THE BLADDER
Respecting these operations it will be seen that they
were performed on 818 individuals, due to the fact that
several of the patients operated upon by lithotrity formed
fresh calculi subsequently, and required fresh operations
for their removal. As before observed, such proceedings
have been strictly limited to the removal of considerable
formations, evidently newly produced, and not to the re-
curring concretions already referred to.
Next it should be stated that there were six patients
among the entire number who were operated on by me at
different periods of their lives and for different stones,
both by peringeal lithotomy and by lithotrity, but in each
case at a more or less considerable interval of time.
These cases are numbered in the catalogue as follows : 170,
233, 341, 396, 474, 714.
Among the 800 cases of lithotrity in the male adult the
sum-total of hospital and private practice —
There were 6 patients who had the operation performed
four times for different calculi, with considerable intervals
of time (several years) between each.
There were 10 patients operated on three times, and 77
patients operated on twice.
Hence there tvere 592 patients operated upon by lithotrity
once only, at all events by myself j a very few of these have
to my knowledge been operated on a second time by some
other surgeon, but almost the entire number have remained
free from stone-formation subsequently.
3. Nature of the Calculi removed. — The calculi re-
moved from male adults in hospital practice were 87 in
number, 24 by perineal lithotomy and 63 by lithotrity = 87.
The calculi removed from male adult patients in private
practice are 846 in number, as follows : 91 by perinseal
lithotomy, 18 by supra-pubic lithotomy, and 737 by
lithotrity = 846.
Hospital.
Private.
Total.
Uric acid / ^f ^^*^^P^6 ^^^culi
Uric acid j g.^gjg ^^^j^^^,. _
• 8 = 53 ..
• 45
379
. 535
Uric acid and phosphate .
. 8 ..
82 .
. 90
Oxalate ....
. 3 ..
29 .
. 33
BY LITHOTOMY AND LITHOTRITY. 2oij
ospital.
Private.
Total
4
29 ..
. 33
—
15 ..
. 15
18
207 ..
. 225
1
2 ..
3
87
846 ..
. 933
Oxalate and urate .
Oxalate and phosphate
Phosphates
Cystine .
The calculi in 15 female cases (one a girl) were —
Uric acid ......... 11
Uric and phosphate 2
Phosphates 2
The calculi in 16 cases of male children were —
Uric acid 10
Urate and phosphate 3
Oxalate ......... 1
Oxalate and urate 1
Phosphate ]
— 31
Total number of cases 964
4. The Age of Male Patients with calculus will be next
examined. I have already referred to the very large pro-
portion of elderly men who are affected with calculus^ in
calling attention to the circumstance that this important
fact has been in former time greatly overlooked. The
following table forcibly illustrates this view.
Of the entire record of 964 cases, the number of male
patients (adults and children) operated on was 949.
Their ages are shown in the following table, which pre-
sents them in five classes for reasons which will appear.
Class 1 contains all from the earliest age to puberty,
say from the first to the fifteenth year.
Class 2, the period from 15 to 25 years, at which stone
is most rare.
Class 3, from 25 to 50, during which it gradually
becomes more frequent.
Class 4, from 50 to 70, when stone, especially uric
acid, abounds.
Class 5 contains all cases above 70 years, when stone
is also frequent, but the proportion of vesical phosphatic
formations is greater than in the preceding class.
234 OPERATION rOR CALCULUS IN THE BLADDER
Below 16 16 to 2-1 25 to 50 51 to 70 Above 70
years. years. years. years. years. Total.
In the hospital . 13 ... 5 ... 22 ... 56 ... 4 ... 100
In private . . 3 ... 8 ... 89 ... 565 ... 184 ... 849
Total . . 16 ... 13 ... Ill ... 621 ... 188 ... 949
The mean age of the entire adult male cases occurring
in hospital and private practice is within a fraction of
62| years. The greatest age at which I have operated is
91 years, by lithotrity, for a stone of considerable size
(Case 797), occurring in January, 1888; the patient, who
passes all his urine by catheter, was greatly relieved, and
was living (1889) free from his calculous symptoms, and
in fair health for his age.
5. Number and Nature of the Fatal Cases. — I have made
it a rule to accept as a " fatal case " any instance in which
death took place within six weeks of the operation from
any cause; four instances excepted, in three of which it
suddenly and instantaneously occurred from failure of the
heart's action, the result of long-standing organic disease ;
the patient in each case being completely convalescent
and in apparently good health. In the fourth the death
occurred in similar circumstances from acute bronchitis
acquired within that period. I am satisfied that this rule
is too stringent, but I have preferred to err if at all in
accepting a full proportion of deaths.
In considering the question of death it is of course
absolutely necessary to deal with children and adults in
separate classes. The different degree of risk incurred
from lithotomy in childhood and in manhood is so great as
to render practically useless any numerical inferences re-
g-arding the mortality of cases in which this distinction
of age is not kept clearly in view. The number of
children is so small in this collection that my remarks
will be brief. There were 16 male children and one
female. Four were treated by lithotrity, and 13, being
mostly large stones, by lithotomy, one of them being very
large by the supra-pubic method. I commenced on the
principle of employing lithotrity for children whenever
BY LITHOTOMY AND LITHGTRITY. 235
the calculus could be crushed at one sitting, and the very
first case of stone which fell to my lot occurred in a girl,
and was thus crushed, in 1854.^ Three other cases fol-
lowed, the first being in the year 1860, at University
College Hospital, all successful. This treatment I enforced
at some length in my first work on Calculus, published
in 1863, alluding to the practice adopted in the Children's
Hospital in Paris, where large calculi were crushed at
numerous sittings, with very unsatisfactory results." Among
the 13 lithotomies in children there was one death, a case
of deformed pelvis from rickets, exhibited at the Royal
Medical and Chirurgical Society in 1863, in which with
great diflBculty I removed the calculus through a preter-
naturally contracted outlet.^ Had I been aware of the
fact beforehand, I should certainly have performed a supra-
pubic operation.
Hence I have first to deal briefly with the mortality
following 933 cases of operation in the male adult only,
800 treated by lithotrity, and 133 by lithotomy.
At the middle of the present century, soon after which
my series commenced (the first case just referred to
dating 1854, although there were practically none, that is
only three, before 1860), the relation between lithotomy
and lithotrity was that of rival systems for the relief of
the calculous patient, the respective claims of which for
preference were under consideration by the profession.
Sir B. Brodie had declared in favour of lithotrity for cases
in which the calculus was small, and the passages favor-
able and healthy (Royal Medical and Chirurgical Society,
1855). The practice, however, then and for ten years
after was to employ lithotomy as a rule, and lithotrity only
in exceptional instances. It was much later than this
before even half the cases were generally submitted in
this country to the crushing operation. When Sir W.
Fergusson in 1865 gave a summary of his entire experi-
1 Vide * Lancet/ 1854, October 21st.
' ' Practical Lithotrity and Lithotomy/ Churchill, 1863, pp. 207—211.
3 ' Trans./ vol. xlvii, p. 11.
236 OPERATION FOE CALCULUS IN THE BLADDER
encGj the total number of liis cases was 219, namely, 110
of lithotomy, and 109 of lithotrity — an equal division
between the two methods, although the latter had occurred
in an increasing ratio during the later years of his prac-
tice. My observation of Civiale's practice in Paris, who
performed lithotrity in fully seven eighths of the calculous
cases which at the rate of about fifty a year passed
through his hands, convinced me that this proportion
offered far better results than those attained by the
English practice, provided Civiale^s instruments and pro-
cedure, both at that time much superior to our own, were
adopted. This conclusion was also shared by Mr. William
Coulson, of St. Mary's Hospital, who acted on it towards
the end of his career.
But the present relations between lithotomy and litho-
trity have gradually been changed. There is no longer
any rivalry between the two systems ; one operation is
complementary to the other. Lithotrity has in fact
superseded lithotomy for all ordinary cases of stone,
whatever may be the age of the patient ; and a cutting
operation of some kind is now only necessary or desirable
in certain exceptional conditions, extreme size and hardness
of the stone being- those which chiefly render it necessary.
I commenced practice under the influence of impressions
received from Civiale, reserviug only my own opinion that
lithotomy might occasionally have been adopted with
advantage for some of the calculi crushed in Hopital
Neckar at that time. Accordingly, among my first 200
patients, lithotrity was employed in the proportion of
about 4 or 5 cases to 1 of lithotomy. In my next 300
it rose to about 8 to 1. And for the last ten years, during
which cases of large calculi have been sent to me in an
unusual number, the ratio of lithotrity has slightly dimin-
ished, the latter five years having furnished 17 cases of
high operation in the adult, which, as already said, I have
substituted for the lateral with considerable advantage.
In relation to this proportion of large calculi it is neces-
sary to note in passing, that one of the results to an
BY LITHOTOMY AND LITHOTRITY. 237
operatoi' of large experience in calculous disease is the
attraction to him of advanced and difficult cases. Hence
the proportion of patients demanding lithotomy on such
grounds increases during the third period of his career,
as compared with his experience in the middle and early
periods.
But with the large proportion of cases just referred to
treated by lithotrity, 800 in number — and let it be remem-
bered that adult cases alone are now referred to, — it neces-
sarily followed that a group of very unpromising patients
was formed by lithotomy, differing widely from the average
cases formerly operated on by English surgeons, and con-
stituting the bulk of lithotomy records in this country
before lithotrity was practised ; much also from the litho-
tomy cases performed by surgeons who submitted only a
half or at most two thirds of their patients to lithotrity.
Then it should be further stated here that I have
rarely refused to any applicant the last chance of life
which an operation might afford him, having done so in
fact but j&ve times throughout my career. These were
patients who were obviously unfitted by disease and ex-
haustion to undergo any surgical proceeding whatever.
The group of exceptionally hazardous cases thus set
apart in my series for operation by the knife amounted
in number to 133, of which 115 were dealt with by peri-
neeal lithotomy, one by the old supra-pubic, and 17 cases
by the modern supra-pubic operation.
The series of lithotrity cases compi'ises 800 operations.
Of these, 475 were performed by the old method of one or
more sittings according to the size of the calculus, and 325
by the modern method of one sitting only. The mortality,
reckoned on the principle laid down above, was as follows :
In 475 of lithotrity by multiple sittings were 33 deaths,
or 7 per cent.
In 325 of lithotrity by a single sitting were 12 deaths,
or a little over 3^ per cent.
In 115 of perinaeal lithotomy were 43 deaths, or rather
over 1 in 3 cases.
238 OPERATION FOR CALCULUS IN THE BLADDER
The mortality of the 17 cases of supra-pubic operation
by the new method was 4 cases ; 3 of these occurred in
patients whose condition was exceptionally bad : one had
been for six years the subject of vesico-intestinal fistulaj and
his death was certainly not due to the operation, although it
was hastened thereby ; while the other two would certainly
have been rejected by me for peringeal lithotomy, but I
gave them the chance of the less formidable supra-pubic
operation. But it may be mentioned here that 11 cases
of the same operation for vesical tumour already referred
to were followed by death in one case only, making 28
cases of the modern supra-pubic operation, as employed
for all purposes, in the adult with 5 deaths.
I beg permission here to recall the fact that in report-
ing the first 500 cases presented to the Society in 1878 I
carefully investigated the causes of death, which occurred
in 61 cases, and recorded them under several heads in a
tabular form. The technical distinctions there employed
have been somewhat changed in dealing with the mortality
in the 434 cases which have passed through my hands
since that date, in accordance with the progress of patho-
logical knowledge. The following table will show the
later results in three columns : deaths after lithotrity,
after perinaeal lithotomy, and after supra-pubic lithotomy.
Causes of death occurring in 434 male adult cases operated
on since preceding report of 500 cases in 1878.
Supra-pubic
Litliotrity. Lithotomy. lithotomy.
i. Septicseniia, with deposits in various
parts of the body . . . . 2 ... 3 ... 1
ii. Acute nephritis, with purulent de-
posit in the kidneys . . . 3 ... 0 ... 0
iii. Chronic disease of the kidney, with
dilatation of the pelvis and ureters
iv. Peritonitis .....
V. Acute cystitis
vi. Exhaustion in feeble and aged
patients, no other cause of death
being obvious ....
vii. Haemorrhage . . . .
5 ..
1
0
0 ..
1 .
. 1
0 ..
1
. 0
3 ..
4 .
.. 2
0 ..
1
. 0
BY LITHOTOMY AND LITHOTEITY. 239
viii. Delirium tremens .
ix. Erysipelas . . . .
X. In confirmed diabetic patients
Lithotrity.
. 0 .
Litliotomy.
1
Snpra-pubic
litliotomy.
.. 0
. 0 .
1
.. 0
. 1 .
1
0
14 ... 14
It will be manifest tliat tlie death-rate is considerably
less in tlie 433 cases operated on since 1878 than in the
500 cases which occurred before that date^ and this in
spite of the influx of more formidable cases. This satis-
factory result is in great part, although not entirely, due
to the increased safety of lithotrity by one sitting, as com-
pared with that by several sitttngs, and to the marked
superiority of lithotomy by the supra-pubic route for
large calculi to that by the peringeum.
Lithotrity in the male adult.
Series I. — Cases reported to the Royal Medical and
Chirurgical Society in 1878 •} 422 cases with 32 deaths,
mortality 7| per cent.
Series II. — Cases since that date now reported : 378
cases (325 by one sitting) with 14 deaths, mortality
rather over 3^ per cent.
I may note also that among this small number of deaths
following lithotrity. Series II, I include one which I was
sent for into the country to finish for an aged and worn-out
patient (No. 619), whose stone had been already crushed
three times by my friend who summoned me, the case
being one of unusual difficulty. I emptied the bladder
at this sitting, removing a large quantity of calculous
matter, and the patient gradually sank from exhaustion.
I accepted this case as a fatal one for my own list, cer-
tainly not with satisfaction, excepting that which arises
from the consciousness of adhering strictly to a principle
laid down, however hardly it may sometimes apply.
It is worthy of observation also that no accident in
^ Vide ' Trans.,' vol. Ixi.
240 OPERATION FOR CALCULUS IN THE BLADDER
operating has been met witli in the present series ; such
as perforation of the bladder by the staff in lithotomy —
the breaking of a lithotrite — and the impossibility of
withdrawing an over-impacted lithotrite, of each of which
an example was described in the first series. The first
named was of course fatal ; the second and third were
successfully dealt with.
6. Unusual Cases. — I shall now very briefly advert to
some examples in the collection of calculus formed under
conditions rarely occurring, and therefore of unusual
interest.
Thus in Case No. 66, an adult, the nucleus of the
calculus, which was removed by lithotrity, is constituted
by a portion of dead bone, most probably exfoliated from
the pelvis. Some years before the operation the patient
had been the subject of chronic hip-joint disease, then
cured, and considerable exfoliations had taken place from
the surface of the hip, several cicatrices being visible.
But I also found a large exfoliation in the bladder, the
result of hip disease, in a youth. Case 878, whom I cut
by the lateral method, consisting of a great part of the
head of the femur thickly covered with phosphates,
believing it to be simply a large phosphatic calculus, until
subsequent examination showed that it was the bone in
question. This must have gradually made its way through
the pelvic bone and entered the bladder, remaining there
long enough to have acquired a large deposit before sym-
ptoms rendered an operation necessary. This case, like
the preceding, made a good recovery ; both were treated in
University College Hospital.
Several examples of encysted calculus have been met
with, cases in which the condition was demonstrable at
the time of the operation by digital exploration. Two
occurred in female patients, and were felt by the medical
men present : in one case. No. 883, the stone itself shows
by its form the portion which was encysted. This I
turned out of its bed by means of my finger without
difficulty ; the other, No. 887, was almost entirely en-
BY LITHOTOMY AND LITHOTRITY. 241
capsuled, and gave some trouble to remove. Dr. Smith,
of Dumfries, wlio brought the patient to town, was present ;
both of the patients recovered. Another example in a male
subject (No. 193) lay just within the neck of the bladder,
and was only felt by me after I had, by lateral lithotomy,
removed one from the cavity ; when on searching I thought
I felt another, but found on introducing my finger into
the rectum that it was absolutely fixed, almost the entire
formation lying outside the cavity.
In Case 653 two pyriform calculi, each the size of a
large nut, occupying a cavity close to the neck of the
bladder, were turned out by the finger and a director,
Dr. Macnab of Bury St. Edmunds being present.
One very remarkable case is that of a patient set. 64,
No. 714. He was the subject of lithotrity in 1885, having
for some years previously passed all urine by catheter.
Seven months after, being again a sufferer, and no stone
felt by sounding, I explored the bladder by incision from
the periuEeum, and detected in the neck a number of small
calculi in a sac. I opened this by the knife and removed
six, each about the size of a large pea, facetted by close
contact. I drained the bladder, and the wound healed
slowly. Next year his symptoms again became more
severe, and the catheter was required every hour. The
prostate was very large ; phosphatic matter could be felt,
but no defined stone. I performed supra-pubic lithotomy,
cleared out a quantity of phosphatic matter firmly adhering
to the inner coat of the bladder attached by fibrinous deposit,
and then established a constant opening, so as to dispense
with the use of the catheter in future. Fitted with a
well-curved tube and silver plate, he lived for three years
in comfort, travelling abroad and taking considerable
exercise ; never used the catheter again. He died in
August, 1889, efficiently served by his tube to the last.
Of course the well-known cases of facetted calculi lying
closely packed in front of the bladder, occasionally met
with, and composed chiefly of phosphate of lime, are not here
referred to, as these are more common than calculi really
VOL. LXXIII. 16
242 OPERATION ¥0R CALCULUS IN THE BLADDER
encysted within the vesical cavity^ whicli are extremely
rare.
I shall refer to the largest calculus in the series, No.
717, as more remarkable for its structure even than for
its size. It is composed of uric acid with a small propor-
tion of alkaline base, but without any phosphatic deposit
whatever, either internally or externally, notwithstanding
that it weighs no less than fourteen ounces. I have never
seen in any collection a calculus nearly approaching in
size to this unmixed with phosphate,^ }
Let me observe that when a calculus has been cut in
its largest plane it is easy to trace somewhat roughly the
patient's history, reading it, so to speak, from and "be-
tween the lines" exposed by the section. Thus a pure
uric or oxalic acid nucleus is mostly seen, and if the
patient's circumstances permitted him to avoid much exer-
cise, because found by experience to be painful, he escapes
cystitis and alkaline urine, and the acid deposit continues.
But an attack with muco-purulent urine sooner or later
leads to phosphatic deposit, a ring of which appears in the
calculus to mark the fact ; and another fact, viz. that he
was then kept quiet for a time, is indicated by subsidence
of the phosphate followed by a fresh ring of uric acid
deposit. Similar changes of deposit again appear, and
furnish the outline of a history which I have often found
interesting, but which cannot be further illustrated here.
I subsequently learned from this patient that as soon
as symptoms became painful he assumed the horizontal
position, and maintained it night and day for a period of
somewhat more than ten years, and thus escaped an attack
of cystitis and phosphatic urine. Moreover, the stone is
seen to have occupied during, at all events, the latter
portio-n of that period an unchanged position in the bladder,
for each side of its base is deeply indented by the flow of
Cheselden's largest calculus weighed seventeen ounces. It is largely
composed of uric acid, three separate calculi originally, united to form one
through being cemented together by a considerable proportion of phosphatic
matter. It is now in the Royal College of Surgeons, No. A.c. 7.
BY LITHOTOMY AND LITHOTRITY. 243
urine issuing from the corresponding ureter, several layers
of the crust being thus worn through ; illustrating, by the
way, the truth of an observation made some tiuie ago, that
fresh, pure, healthy urine exercises some solvent power on
certain calculous formations. The patient's age was sixty-
two when I performed the high operation for him in 1865.
He made a good recovery and married about a year after,
and wrote me last summer that he was enjoying good
health and an active life. He was sent to me by Mr.
Atkinson, Bennington, Boston, Lincolnshire.
Among somewhat rare calculous cases should be named
three cases of cystine. Of these one was crushed (Case
127) for a gentleman of eighty years of age, who lived to
be ninety. Another (Case 690) is the largest I have ever
seen ; it weighs two ounces and three quai^ters, and was
removed by the high operation in 1884. The patient is liv-
ing and well. The third (Case 274) was cut by the lateral
method in the hospital and made a good recovery.
The two following cases illustrate an incident which
seldom occurs. In No. 253 I performed lithotomy for a
large uric acid calculus in which spontaneous fracture had
recently occurred, producing formidable cystitis. Case
333 was an instance in which fracture of calculus took place
on sounding, and a similar case is alluded to in the notes
thereon in the catalogue.
Case 7 was that of a man fet. 22, whom I cut in
the hospital in 1861 ; a phosphatic stone which had a
piece of sealing-wax about an inch long as its nucleus,
which he stated that he had used as a bougie about six
months before. He left the hospital, and I saw no more
of him until two years ago he called upon me to report
himself well, twenty-eight years after the event.
Lastly, I shall only name four cases operated upon for
the removal of a foreign body strictly so regarded, no
calculous matter being present, since the object had been
introduced into the bladder within a few days before com-
ing under observation. Three of these were successfully
dealt with by the lithotrite. The fourth, occurring in a
244 OPERATION FOB CALCULUS IN THE BLADDER.
girl in University College Hospital in 1865_, I was com-
pelled to deal with by the old supra-pubic operation, the
course and results of which appeared to be quite satis-
factory, but death suddenly occurred through the bursting
of a peritoneal abscess, when she had resumed active habits
after supposed complete recovery.
Two were hair-pins, purposely introduced, and two were
broken catheters.
Here I must close this somewhat lengthy record. I
would gladly have entered on the perhaps more interest-
ing subject of practical lessons in relation to treatment
deducible therefrom ; but this it was manifestly impos-
sible to do as part of the present paper, and if ever accom-
plished must form a communication by itself.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 79.)
ON THE
HISTORY OF URIC ACID IN THE UEINE,
WITH EEFEKENCE TO THE FORMATION OF URIC
ACID CONCRETIONS AND DEPOSITS.
BY
SIR WILLIAM EOBEETS, M.D., F.E.S.
Received February 5tli— Read March 2Sth, 1890.
The occurrence of uric acid in human urine seems to
be somewhat of an anomaly. As a vehicle for the elimi-
nation of nitrogen it is not needed. Its place is taken by
urea^ which adapts itself perfectly, by its bland character
and easy solubility, to the mammalian plan of a liquid
urine. In birds, serpents, insects, and the great majority
of invertebrate species, which void a solid or semi-solid
urine, uric acid forms the sole and appropriate medium
for the excretion of nitrogen, and is therefore physio-
logically indispensable. But uric acid is not indispensable
to the mammal. The pig is said to void none ; and the
large herbivorous quadrupeds, during the greater of their
life, discharge a urine which is free from uric acid. The
information we possess on this subject indicates that the
occurrence of uric acid throughout the mammalian class
is fitful and inconstant ; and the inference seems to be
246 HISTORY OF URTC ACID IN THE URINE.
justified that it is not an essential element in mammalian
metabolism. These considerations lead tip to the conjec-
ture that the continued presence of uric acid in mammalian
urine may be a vestigial phenomenon, analogous to the
persistence of rudimentary structures. On this view uric
acid should, perhaps, be regarded as a reminiscence of
some far distant link in the chain of mammalian descent,
and as a remnant of an ancestral path of metabolism, now
fallen into disuse, and superseded by a better path, more
perfectly adjusted to the requirements of the mammalian
type.
But although uric acid be thus physiologically of
trivial account, it is, from a pathological point of view, by
far the most important component of the urine. It owes
this prominence not to any inherent deleterious quality,
but to its clumsy behaviour in liquid media. All the
trouble with uric acid arises apparently from its sparing
solubility, and the sparing solubility and unstable consti-
tution of its compounds. Thereupon depends its tendency
to form deposits and concretions, which act as irritating
foreign bodies in the tissues and urinary passages. Were
it not for the occurrence of these deposits — of sodium bi-
urate in gout, of free uric acid in gravel, and of the amor-
phous urates as a sediment in the urine — we should not
probably be more cognizant, clinically and pathologically,
of uric acid than we are of kreatinine, which is voided in
about the same proportion with the urine.
The history of uric acid is here considered under the
following headings :
1. Spontaneous precipitation of uric acid in normal
ui'ine.
2. Composition and reactions of the amorphous urate
deposit, and of its natural and artificial analogues.
3. Chemical explanation of the spontaneous precipita-
tion of uric acid in urine.
4. The ingredients in the urine which inhibit or retard
the precipitation of uric acid in the normal state.
5. Summary of the history of uric acid within the
HISTORY OF URIC ACID IN THE URINE. 247
urinary channels (a) in the normal state, (h) in the sub-
jects of uric acid gravel.
6. The factors which determine the occurrence of uric
acid concretions and deposits.
1. Spontaneous Precipitation of Uric Acid in Normal
Urine.
Uric acid exists in urine in a state of combination with
bases as urates. In the course of its transit through the
urinary channels it encounters a diversity of physical and
chemical conditions, which are calculated to affect the
stability of the urates. The urine is generally secreted
with an acid reaction ; but it is often alkaline, especially
after meals. It is sometimes pale, watery, and poor in
salts ; at other times it is concentrated, rich in salts, and
high-coloured. These variations may occur in quick suc-
cession, so that there accumulates in the bladder a mix-
ture of urines of all these several characters. In perfect
health uric acid maintains itself in solution amid all these
various changes, not only so long as the urine is detained
in the urinary passages, but even for some time after it
has been dischai'ged. But in certain abnormal states this
continuity of solution is broken. In the subjects of gravel
uric acid is often thrown down in the kidneys or bladder,
or is precipitated soon after the urine is voided, while it
is cooling, or within an hour or two after emission. Or
precipitation may occur somewhat later — in the course of
four or six hours, in the form of copious urinary deposits.
But this is not all. Numerous observations have led me to
the conclusion that every urine which has an acid reaction
tends to the eventual liberation of its uric acid. I found
that acid urines kept with antiseptic precautions^ invariably
deposited uric acid sooner or later — except when the propor-
tion of that substance was so small that, were it all in the
free state, the volume of urine was suflBcient to hold it in
' This was usually effected by adding a few drops of chloroform to the
test-tubes or phials iu which the urines were kept.
248 HISTORY OF URIC ACID IN THE URINE.
solution. The time of tlie occurrence of tlie precipitation
varied greatly. It usually began within twenty-four houi-s
after emission, sometimes in a day or two, and sometimes
not for five or six days, or even later. It took place with
equal certainty whether the urine was kept in the warm
chamber at blood-heat, or was kept at the temperature of
the air.^ The duration of the process varied with the
earliness or lateness of its onset. Speaking roughly, urine
which began to deposit uric acid in a few hours completed
the process in a few hours longer ; but if the onset was
delayed for some days the deposition of crystals went on
slowly for several days subsequently. When the process
was at length completed — whether that were early or late
— all the uric acid had disappeared from solution. The
filtered supernatant uiune gave not the least precipitate with
hydrochloric acid, nor could there be detected in it, on
evaporation to a small bulk and with careful search, any
trace of uric acid. This was, at least, the result arrived at
with urines of medium density in which free precipitation
had taken place.
Neutral and alkaline urines, such as are voided after
meals, did not precipitate uric acid, nor any form of urate,
however long they were kept. In like manner, urines
which were kept without antiseptic precautions, and con-
sequently, after a time, underwent the ammoniacal fer-
mentation, did not precipitate uric acid, unless the occur-
rence took place early, and before ammoniacal fermenta-
tion set in.
We must, therefore, recognise in normal acid urine an
inherent tendency to the spontaneous liberation and preci-
pitation of its uric acid. This tendency only assumes a
morbid significance when the event occurs prematurely,
while the urine is still sojourning in the kidneys or bladder.
Viewed in this light pathological gravel may be regarded
1 In the latter case the urine often threw down amorphous urates. By
this occurrence the urates were in some degree withdrawn from the operation
of the disintegrating forces; but this only caused delay. Ultimately the
deposit changed entirely into crystals of uric acid.
HISTORY OF URIC ACID IN THE URINE. 249
as due to an exaggeration of conditions which prevail, in
a less pronounced degree, in the normal state ; hence an
elucidation of these conditions may be reasonably expected
to throw a light on the aetiology of gravel and calculus,
and perhaps furnish hints which may be turned to thera-
peutical uses. Before entering on this inquiry it is,
however, necessary to clear up certain points in the
chemistry of uric acid and the urates concerning which
current views require considerable revision.
2. Composition and Reactions of the Amorphous Urate
Deposit and of its Natural and Artificial Analogues.
Uric acid is a bibasic acid ; it is represented by the
formula H2(C5H2N^03). It forms, like other bibasic
acids, two regular orders of salts : namely, neutral urates,
with the general formula M2(C5H2N^03) ; and acid urates
or biurates, with the general formula MH(C5H2N^03).
But, in addition to these, uric acid forms a series of hyper-
acid combinations of more complex character, of which the
hypothetical formula is (MH[C5H2N403],H2[C5H2N403]).
To these hyperacid combinations Dr. Bence Jones gave
the name of quadrurates.
The neutral urates were obtained by Allan and Bensch^
by saturating cold solutions of the caustic alkalies, free
from carbonate, with uric acid, and boiling down the
solution in a retort until crystals made their appearance.
The neutral urates are very unstable, and are decomposed
in the presence of carbonates, and even by the carbonic
acid of the air. The neutral urates are quite unknown
except as laboratory products, and their reactions and
mode of preparation are such that it is scarcely conceiv-
able that they should ever exist in the animal body, or
play any part in the physiological or pathological history
of uric acid.
The acid urates or biurates are the most stable and
' Liebig's 'Annalen,' Band Ixv, p. 184.
250 HISTORY OP URIC ACID IN THE URINE.
best known salts of uric acid. Tliey readily assume the
crystalline form, and are easily obtained in a state of
chemical purity. They can be prepared artificially under
conditions which are germane to those existing in the
animal body ; and they ai'e encountered pathologically in
gouty concretions, of which they form the distinctive
constituent.^
The quadrurates appear to be much more widely diffused
than the biurates. They are present physiologically in
the urine, and probably also in the blood. They are
unapt to assume the crystalline form, and are difficult to
obtain in a state of chemical purity. Their special and
distinctive characteristic is that they are decomposed by
pure water, with emission of free uric acid. They exist
in nature in the form of the amorphous urate sediment of
human urine, and as the essential constituent of the
urinary excretion of birds and serpents. They can, more-
over, be produced artificially under conditions which
closely correspond to those prevailing in the living body.
These three varieties of quadrurate require separate
consideration.
A. TJie amorphous urate deposit. — The amorphous urate
deposit has usually been regarded as consisting of biurates
— as a mixture of the biurates of potassium, sodium, and
ammonium, in varying proportions. This view is, how-
ever, quite untenable. The amoi-phous urate deposit differs
essentially in its reactions from the biurates. The biurates
are not decomposed by water. They simply dissolve in
water, and are again deposited unchanged on evaporation.
In order to study the effect of water on the amorphous urate
deposit it must first be separated from the other ingredients
with which it is mingled in the urine. This is done by
filtering off the sediment and washing it on the filter with
rectified spirit and drying. If a minute speck of such
^ Directions for the preparation of sodium biurate iu a pure state are
given in a footnote to the first section of a paper by the author on the
" Chemistry of Gout " which is printed in the present volume.
HISTORY OF URIC ACID IN THE nRINE. 251
purified deposit be intimately mixed with a large drop of
distilled water and observed under the microscope, it is
seen to be slowly decomposed. In a few minutes — five to
fifteen — crystals of uric acid begin to make their appear-
ance. These grow and multiply until, in the course of
half an hour or an hour, the field of vision is thickly
studded with them ; and the process goes on, provided
the preparation be kept from drying, until the amoi-phous
matter appears to be almost entirely transformed into
crystals of uric acid.
Another way of separating the deposit from its asso-
ciated urinary ingredients is the following. The sediment
is taken up in a pipette, and five or six drops are allowed
to fall in slow succession, and on the same spot, on a pad
of blotting-paper. The liquid parts of the urine are im-
bibed all round by the blotting-paper, and there remains
in the centre a little heap of damp deposit. If a portion
of this be picked off on the point of a pen-knife, and exa-
mined in the manner described with a drop of water under
the microscope, the same scene of transformation will be
observed.
This mode of examination — observation of the behaviour
of a speck of deposit with a large drop of distilled water
under the microscope — will be again adverted to in the
course of this paper, and it may be conveniently referred
to as the ^^ speck experiment."^
It was known to Berzelius and Lehmann that when the
amorphous urate sediment was repeatedly washed on a
filter with cold water, crystals of uric acid made their
appearance on the filter ; but it was reserved for Bence
' The speck experiment should by preference be performed with distilled
water; but ordinary drinking water will generally answer equally well.
This is, however, not always the case. Drinking waters are sometimes a
little alkaline, and then the demonstration is apt to miscarry. I found that
the Mancliester pipe water answered the purpose as well as distilled water,
but the London water does not do so. The London pipe water — or, at least,
that which is supplied to the district wherein I reside by the West Middlesex
Water Company — is slightly alkaline from dissolved carbonate of lime, and
it acts very slowly and imperfectly on the amorphous urate deposit.
252 HISTOEY OF URIC ACID IN THE URINE.
Jones to furnish a rational explanation of the phenomenon.^
Bence Jones made a minute quantitative analysis of three
specimens of amorphous urate deposits^ purified by wash-
ing with alcohol, and found that the amount of uric acid
contained in them greatly exceeded the quantity required
to form biurates with the sum of the bases present. He
also found, when the purified amorphous urate was treated
with water, that a portion of the uric acid was set free
and deposited, and that the remainder went into solution
as true biurate. Moreover, he succeeded in preparing
artificially an imitation of the amorphous urate sediment
by dissolving uric acid in weak potash or soda ley, and
then adding acetic acid until a slight acid reaction was
produced. A dense white precipitate was thus thrown
down. This precipitate, when washed with alcohol and
dried, presented the properties and reactions of the amor-
phous urate sediment. It had a finely granular character,
it was decomposed by water, and the part which went
into solution had the composition of true biurate.
On the ground of these observations Bence Jones con-
cluded that the amorphous urate deposit consisted of a
complex compound, in which biurate was united in loose
combination with an additional atom of uric acid, and
that when the compound was treated with water the loosely
combined uric acid was thrown out, and the associated
biurate passed into solution. Writing of the potash com-
pound thus artificially produced, he says, ''This granular
substance may be considered to resemble the quadroxalate
of potassa, which differs from the acid oxalate by containing
double the amount of oxalic acid, and following this nomen-
clature it may be called quadrurate of potassa." The
formula for this compound according to this view, therefore,
would be KH(C5H2N4p3),H2(C5H2N^03).
Bence Jones, however, qualified his statements respect-
ing the amorphous urate deposit in a way which greatly
detracted from their conclusiveness ; and this is probably
1 " On the Composition of the Amorphous Deposit of Urates in Healthy
Urine," ' Journ. of Cliem. Soc.,' 1862.
HISTORY OP URIC ACID IN THE URINE. 253
the reason why his investigations thereupon have attracted
so little attention. He declared that the amorphous urate
deposit was not always composed exclusively of the
unstable compound which was decomposed by water, but
often contained, in addition, a larger or smaller admixture
of true biurates ; and that in some instances even the
deposit was entirely composed of biurates, and did not
throw out any uric acid when treated with water. In the
final summary of his results he says, " In conclusion,
then, it appears that the amorphous deposit of urates in
the urine has no constant composition. It is a mixture
of different acid urates modified in crystalline form by
other substances in the urine. . . . Moreover, uric acid is
occasionally found in combination with these acid urates,
forming quadrurates, and thus rendering the deposit still
more liable to vary in its composition."
In the last three years I have examined a very large
number of specimens of the amorphous urate sediment,
and have invariably found that they were decomposable
by water and exhibited the characteristic reaction with
the speck experiment. Sometimes, however, urate de-
posits are encountered which resist the decomposing
effects of water for a considerable time. The cause of
this variable resistance to water appears to depend on
some kind of contamination. Sometimes it seems due to
the varying quantity, and perhaps the varying quality, of
the pigment, which adheres so obstinately to the deposits.
In other cases it seems to be due to some saline impurity
which imparts a slight alkalescence or a slight acidity to
the sediment. I doubt whether it is ever due to an admix-
ture of biurates ; because, as will hereafter appear, the
biurates cannot exist unchanged in normal urine. The only
condition in which, so far as I know, true biurate ever
appears as a deposit in urine, is when the urine has under-
gone the ammoniacal fermentation. Under these circum-
stances biurate of ammonia is thrown down, and may be
sometimes recognised under the microscope (mixed with
the amorphous and crystalline phosphates) as slender dumb-
254 HISTORY OP URIC ACID IN THE URINE.
bells or globular masses, which are wholly undecomposable
by water. ^
B. Urinary excretion of serpents and birds. — Serpents
and birds eliminate their nitrogen exclusively as uric acid
— in the form of a white semi-solid mortar-like urinary
excrement. When this substance is examined in the fresh
state under the microscope with a drop of spirit, or of
normal urine, it is seen to consist of innumerable minute
spheres. These spheres present a radiating crystalline
structure, and are, for the most part, about the size of
the white blood-corpuscles ; some are double this size, and
a great many very much smaller. If, instead of a drop
of spirit or of urine, the spheres are examined with a drop
of distilled water, they are observed to undergo speedy
decomposition, with abundant emission of uric acid crystals.
If the mode of examination be varied, and the mortar-like
substance be treated with a large quantity of distilled
water, the same results follow as in the case of the amor-
phous urate sediment. A portion of the uric acid is set
free and remains undissolved, and the rest goes into solu-
tion as biurate. The urine of serpents and birds, in fact,
is entirely composed of quadrurates, mixed with more or
less mucus. The urinary secretion of the large serpents
is easily obtained from our Zoological Gardens in large
solid masses and in a condition of great purity. There
are, however, some necessary precautions to be used in
collecting serpents' urine for scientific examination. The
excretion should be obtained fresh and uncontaminated
with water, and should at once be dried at 100° C. Col-
lected in this way serpents' urine may be preserved in
stoppered vessels unchanged for an indefinite period, and
' Au artificial imitation of the amorpiious urate deposit can be produced at
will in the following manner. A normal alkaline urine, such as is voided
after food, or a urine which is rendered slightly alkaline by the addition
of alkaline carbonates or phosphates, is heated with excess of uric acid, and
filtered hot. The filtrate is cooled rapidly under a running tap of cold water
or on ice. An abundant precipitate falls, which is an exact counterpart of
the natural amorphous urate sediment.
HISTORY OF URIC ACID IN THE URINE. 255
furnishes au abundant and almost pure supply of natural
quadrurate. The common notion that the urine of ser-
pents and birds consists of biurate of ammonia, mixed
with varying proportions of free uric acid, has arisen from
the excretion having been collected and kept without
precautions, and having, consequently, undergone diverse
decomposing changes which have entirely altered its chemi-
cal and physical constitution. Qualitative testing indi-
cated that serpents' urine contained no chlorides, phos-
phates, nor other salts — or only such traces as might be
accounted for by the admixed mucus. Small masses of
uric acid crystals were occasionally found. The presence
of these may be assumed to be due to secondary changes
in the quadrurate spheres.
c. Artificially prepared quadrurates. — The quadrurates
may be produced artificially in a variety of ways. When
uric acid is digested at blood-heat with weak solutions of
the alkaline carbonates, or of the dipotassic or disodic
phosphates, or of the alkaline acetates, it enters into solu-
tion as quadrurate. Under favorable circumstances the
quadrurate can be directly precipitated from these solu-
tions by rapidly cooling them, especially by cooling them
on ice. The quadrurates may also be prepared by treat-
ing solutions of the crystalline biurates with the alkaline
superphosphates. This latter method involves a reaction
which comes into play in the spontaneous precipitation of
uric acid in urine, and will be again adverted to. In one
or other of these ways I succeeded in producing quadrurates
of potassium, sodium, ammonium, calcium, and magnesium.
Potassium quadrurate was prepared by dissolving uric
acid in a hot 5 per cent, solution of potassium acetate,
filtering hot, and cooling rapidly under a running tap of
cold water until a copious precipitate was produced. This
was collected on a filter, washed w^ith alcohol, and dried.
Sodium quadrurate was prepared in a similar manner with
the sodium acetate — but the proceedings have to be
carried out very quickly, otherwise the product is apt to
256 HISTORY OP DRIC ACID IN THE URINE.
be contaminated witli free uric acid. Ammoniu^n quadru-
rate was prepared by boiling a gram of uric acid with
200 c.c. of a 1 per cent, dilution of tlie strong liquor
amraouiae. The solution was filtered hot, and then rapidly
cooled. Through the cold liquid an abundant stream of
carbonic acid was passed until a bulky precipitate was
produced. This was at once filtered off and quickly
washed with alcohol. The whole process must be carried
out rapidly — otherwise the quadrurate passes into biurate.
Calcium quadrurate was prepared by dissolving half a
gram of uric acid, in the cold, in 100 c.c. of lime water.
To the filtered solution acetic acid was added drop by drop
until neutralisation was approached. An abundant pre-
cipitate was then thrown down, which was treated in the
usual way. Magnesium quadrurate was prepared by
digesting uric acid and calcined magnesia — both in excess
— with distilled water at blood-heat, with frequent agita-
tion for about ten minutes. The mixture was filtered
warm, and the filtrate immediately cooled under a running
tap. A dense flocculent precipitate formed, which was
quickly washed with alcohol and dried.
Summary of the properties and reactions of the quadru-
rates. — The quadrurates present themselves usually as
granular amorphous substances. They readily assume the
colloidal modification, and when examined under the micro-
scope in this state appear as large translucent globules.
The spheres of birds' and serpents' urine are, however, dis-
tinctly crystalline, and, as was pointed out by Sir Alfred
Garrod, polarize light. Owing to their instability the
quadrurates are very difficult to obtain in a state of chemical
purity; they are apt, when produced artificially, to be mixed
either with free uric acid or with biurates, and in all cases
to be contaminated with traces of foreign saline matters.
They cannot be dissolved unchanged in any simple men-
struum. In is therefore impossible to purify them, as most
other substances are pui-ified, by repeated solution and re-
precipitation. They are extremely unstable ; and they
HISTORY OF UlilC ACID IN THE URINE. 257
tend to change in two opposite directions. In weak solu-
tions of the alkaline carbonates or of the dimetallic phos-
phates they slowly take up an additional atom of base,
and are converted into biurates. On the other hand, in
water, and in watery solutions of the neutral salts, they
are quickly split up into free uric acid and biurate.
The only appropriate solvent of the quadrurates is
healthy urine. In acid urines they dissolve pi'etty freely
with the aid of heat, and are again precipitated unchanged
on cooling. Such solutions, however, are not quite stable ;
after a time their uric acid is slowly and at length com-
pletely liberated. The quadrurates are much more freely
soluble in warm alkaline (not ammouiacal) urines, and in
these media they continue permanently unaltered if guai'ded
against septic changes. When such solutions are made
at boiling heat, and are saturated, they throw down on
cooling bulky deposits which are identical in appearance
and reactions with the natural amorphous urate sediment.
With regard to the chemical constitution of these com-
pounds I have adhered to the views and nomenclature of
Bence Jones. Quantitative analyses of the artificially pre-
pared potassium and sodium compounds, and of a purified
specimen of the natural amorphous urate sediment, yielded
to me results which were strictly conformable to the for-
mulae of the quadrui"ates above given.
The general conclusions arrived at with regard to the
composition and the physiological and pathological rela-
tions of uric acid and the urates are concisely exhibited
in the following table :
Table I. — Showing the composition and physiological and
pathological relations of uric acid and the urates.
fNot known in the free state in the body
Uric acid . . H2(C5H2N403)-^ nor in the urine, except pathologically
1^ as gravel and calculus.
I Not known physiologically nor patho-
Neutral urates . IVl2(C5H2N403)-| logically. Only known as laboratory
[_ products.
VOL. LXXIII. 17
258 HISTORY OP DRIC ACID IN THE URINE.
'Known pathologically in gouty conire-
tions. Known in urine only after the
Biurates . . MH(C5H2N403) j secretion b.is undergone ammoniacal
fermentation. Doubtful whether they
ever exist physiologically in the body.
'These are specially the physiological salts
of uric acid. They exist normally in
the urine, and probably also in the
„ , . . / MH(C5HoN403) J blood. They constitute the urinary
L Ho(C5H2N403) excretion ot birds and serpents.
All the morbid phenomena of uric acid
arise from secondary changes in the
quadrurates.
3. Chemical Explanation of the Spontaneous Precipi-
tation OF Uric Acid in Urine.
We are now in a favorable position for considering the
chemical reactions which occur in the spontaneous precipi-
tation of uric acid in acid urine. The amorphous urate, or
quadrurate, is the only combination of uric acid which can
be actually shown to exist in normal urine. The amorphous
urate is not unfrequently deposited from the urine on mere
cooling. When not thus spontaneously deposited it may
be often made to appear by cooling the urine still further
by the application of ice. When this is insufficient its
presence may be revealed by first evaporating the urine
to a small bulk on a water-bath, and then cooling it on ice.
By this last method the amorphous urate may be demon-
strated to exist even in alkaline urine. Moreover, as I
shall presently show, the biurate — the only other combina-
tion of uric acid which could conceivably be present in
ui'ine — cannot maintain its integrity in normal urine, but
is forthwith transformed into quadrurate. The analogy
of the urinary secretion of birds and serpents also points
strongly in the same direction.
We may therefore, I think, conclude with certainty
that the quadrurate is the form, and the only form, in
HISTORY OF URIC ACID IN THE URINE. 259
which uric acid exists in normal urine, and may draw the
further conclusion that when uric acid makes its appear-
ance therein in any other guise, such an event is due to
secondary changes in the quadrurate.
On the other hand, the urine in which this compound
is dissolved is an aqueous fluid, containing, besides urea
and pigmentary and other extractives, a number of salts.
Among the salts the most important in this connection are
the phosphates. These regulate, in the main at least, the
reaction of the urine. The phosphates easily oscillate be-
tween the monometallic forms (superphosphates) which
have an acid reaction, and the dimetallic forms which have
an alkaline reaction. When the foi-mer preponderate, as
is usually the case, the urine is acid ; when the latter pre-
ponderate the urine is alkaline.^
We have, therefore, in an acid urine the quadrurate
existing in the presence of water and of superphosphates.
These conditions ensure the ultimate complete liberation
of the uric acid. The first step in the process is the split-
ting up of the quadrurate by the action of the water of the
urine into free uric acid and biurate. By this reaction
half the uric acid is set free. This decomposition is repre-
sented by the subjoined equation :
(MHCCsH.N.OjI.HoCCsHoNA]) + Aq. = MH(C5H.,NA) + HsCC^HoNA)
Quadrurate. Biurate. Free uric acid.
But the biurate resulting from this reaction is imme-
diately retransformed, in the presence of superphosphate,
by a double decomposition, into quadrurate. Two atoms
^ It is now generally agreed tViat the normal acidity of urine is due,
not to a free acid, but to the preponderance of acid phosphates. The alka-
lescence of normal alkaline urines is certainly generally due to preponderance
of dimetallic phosphates, and not to carbonates. In the alkaline urines
voided after meals 1 have repeatedly tested the point. These do not usually
evolve any carbonic acid when treated with acids. In certain cases carbo-
nates are, however, abundantly present in alkaline urines, especially when
carbonates, or salts of the vegetable acids, have been medicinally adminis-
tered.
260 HISTORY OF UKIC ACID IN THE UFUNE.
of biurate witli one atom of monometallic phosphate
change into one atom of quadrurate, and one atom of
dimetallic phosphate, according to the following equa-
tion :
2(MH[C5H.3N^03]) + (MH^PO,)
Biurate. Monometallic phosphate.
= (MH[C5H,NA]>H,[C5H,N,03]) + (M^HPOJ
Quadrurate. Dimetallic phosphate.
These alternating reactions — breaking up of quadrurate
by water into biurate and free uric acid, and recom-
position of quadrurate by double decomposition of biurate
with monometallic phosphate — go on progressively until
all the uric acid is set free.
That these are the actual steps of the process whereby
the totality of the uric acid is eventually liberated in acid
urines may be deduced from the following considerations
and experiments. The first step — the breaking up of the
quadrurate into free uric acid and biurate by the action
of the water of the urine — is in accord with what has been
already shown to be the reaction of water Avith quadrurates.
The occurrence of the second step — the transformation
of biurate in the presence of superphosphate into quadru-
rate-— is directly established by the following experiments.
A saturated solution of potassium or sodium biurate is
made in hot water and then allowed to cool. When to
this solution a strong solution of one of the alkaline super-
phosphates is added drop by drop, a dense white pre-
cipitate is thrown down, which, on examination, is found
to possess all the reactions of the quadrurates. A similar
result is obtained when the experiment is repeated with
an acid urine instead of a solution of superphosphate.
If the biurate solution is mixed with about one third of
its bulk of an acid urine of medium density, a copious
precipitate forms. This precipitate has the usual cha-
racters and the reactions of the amorphous urate deposit,
or quadrurates. That the result in this latter case is not
due to the precipitation of quadrurate pre-existing in the
HISTORY OF URIC ACID IN THE URINE. 261
urine is proved by repeating the experiment with the
same urine after it has been deprived of all its uric acid
by repeated filtration through uric acid.^ It still throws
down amorphous urate abundantly witli the biurate
solution.
The transformation of biurate into quadrurate in the
presence of superphosphate explains why true biurates
never appear as a deposit in normal and undecomposed
urine. ^ It also explains why in the spontaneous precipita-
tion of uric acid in urine the process goes on^ not merely
until a moiety, but until the whole of the uric acid is set
free and deposited.
4. On the Ingredients in the Urine which inhibit or
retard the breaking up op the quadrurates in the
Normal State.
It has just been shown that uric acid exists in the
urine in the form of the amorphous urate or quadrurate,
and that when the urine is secreted acid — that is to say,
for some sixteen or twenty hours out of the twenty-four —
this compound exists amid conditions which, if they stood
1 It is a curious fact tliat acid urines are entirely deprived of their uric
acid by piissing them two, three, or four times througli a filter on which a
little heap of pure uric acid has been placed. This result is, I believe,
brought about in the same vvuy as the spontaneous precipitation of uric acid
in acid urines, as already explained ; but the process is greatly accelerated by
the superadded force of crystalline aggregation. I have given an account
of this matter in a paper " On Pfeiffer's Test for Latent Gout," in the
' Lancet ' for January 4th, 1890.
^ This transformation of biurate into quadrurate takes place even in alka-
line (not ammoniacal) urines. This was proved by adding a solution of
potassium biurate to a urine which had first been deprived of its uric acid by
being passed repeatedly through the uric acid filter, and then rendered
slightly alkaline by the addition of dimetallic phosphate or bicarbonate. A
urine so treated, when evaporated to a small bulk, and then cooled, threw
down a dense amorphous precipitate, which possessed the properties of quad-
rurate, and was decomposable by water.
262 HISTORY OF UKIC ACID IN THE URINE.
alone and uncontrolled, would lead to speedy precipi-
tation of uric acid in the free state. But in the normal
course no such early precipitation occurs ; it only occurs
as a remote and postponed event after the urine has been
voided. It is obvious, therefore, that the urine contains
certain ingredients wbich inhibit or greatly retard the
water of it from breaking up the quadrurates. Were it
not for the presence of these inhibitory ingredients uric
acid would be thrown out daily in the urinary passages,
and everyone would be subject to gravel. Hence an
inquiry into the nature of these inhibitory agents has a
pathological as well as a physiological interest, and bears
directly on the aetiology of calculous disorders. The
inquiry is not a simple one. The urine is a very complex
fluid. It contains, besides urea, a number of saline con-
stituents, together with pigmentary and other extractives.
Where among all these are the inhibitory agents to be
found ?
Salts of the urine. — Attention was first directed to the
saline constituents. It was found that when urine was
dialysed, whereby its crystalline ingredients were for the
most part removed, it lost to a considerable extent its
power of retarding the decomposition of the quadrurates.
This observation indicated that the inhibitory power
resided, partly at least, in the crystalloids of the urine.
The chief crystalloids of the urine are urea, and the
chlorides, phosphates, and sulphates of potash, soda,
ammonia, lime, and magnesia. Solutions of these several
substances in distilled water were prepared, and their effect
on the quadrurate was tested by the speck experiment in
the following manner. A speck of a purified specimen of
the amorphous urate deposit was placed on a glass slide, and
intimately mixed with a drop of the solution to be tested.
The covering glass was then applied and the result watched
under the microscope. The time at which crystals of uric
acid began to make their appearance was taken as a
measure of the activity of the tested solution in decomposing
the quadrurate. The standard of comparison was distilled
HISTORY OF UEIC ACID IN THE DRINE. 263
water, wliicli usually caused crystals to appear in five
minutes. Solutions of urea of various strengths acted
precisely with the same speed as distilled water. The
chlorides and sulphates^ in the proportion of one per cent,
and upwards, imparted to water a considerable power of
retarding the appearance of crystals. The potash salts
were found to have more effect in this respect than the
corresponding salts of soda and ammonia. The common
disodic phosphate (rendered perfectly neutral to test-paper
by the addition of phosphoric acid) showed about the same
inhibitory power as sodium chloride. None of these solu-
tions nor any admixture of them approached the natural
urine in power of postponing the decomposition of the
amorphous urate. More pronounced effects were obtained
with the dipotassic phosphate. A solution of this salt
containing only 0*2 per cent., and perfectly neutralised,
appeared to act almost as slowly on the deposit as a normal
acid urine. Urines which were alkaline from fixed alkali
had absolutely no decomposing effect on the amorphous
urate.
Pigments of the urine. — Attention was next turned to
the colouring matters of the urine. The amorphous urates
have an intense affinity for urinary pigment ; the pigment
cannot be removed from them by any solvent which does
not, at the same time, destroy their integrity. I had
noticed that deeply tinted urates were more slowly decom-
posed by water than pale-coloured urates. It had also
been noticed that artificially prepared quadrurates and
the quadrurates which constitute the urinary secretion of
birds and serpents, all of which are devoid of colouring
matters, are much more quickly broken up by water than
the natural amorphous urate, which is always more or less
tinted. Moreover, it was found that a urine which had
been filtered through animal charcoal, and thus deprived
of its pigment, acted very much more rapidly on the
amorphous urate deposit than the same urine before it
had been filtered through charcoal.
It can therefore scarcely be doubted that the pigments
264 HISTORY OF URIC ACID IN THE URINE.
of the urine play an important part among the ingredients
which impart to normal nrine its remarkable power of
retarding the decomposition of the amorphous urate. In
the febrile state, and in other wasting disorders, the urine
is sharply acid and rich in urates, and yet such urines
are not prone to deposit uric acid, though very prone to
deposit amorphous urates. In these cases the urine is
always deeply coloured ; and the pigments are probably
the chief agents which prevent the precipitation of free
uric acid under these circumstances.
These observations do not, I think, exhaust this part
of the inquiry. It is not improbable that, besides the
salts and pigments, there are other components of the
urine which contribute to retard the liberation of its uric
acid. Moreover, urinary pigments are of several kinds,
and they may not be all alike in regard to their power of
protecting the integrity of the quadrurates.^
5. Summary op the History of Uric Acid within the
Urinary Channels; (a) in the Normal State, (b) in the
Subjects of Uric Acid Gravel.
Uric acid exists primarily in the urine as a quadrurate.
The history of this substance from its birth in the kidneys
to its final expulsion — taking a complete cycle from
micturition to micturition, with the interposition of a meal —
proceeds, as may be gathered from the foregoing observa-
tions, on something like the following lines.
(a) In the normal state. — Starting with a period of
fasting, the urine is secreted and accumulates in the
bladder with an acid reaction. During this period incipi-
1 It was observed in the case of artificially prepared quadrurates and of
serpents' urine — both of which are either free or comparatively free from
organic admixtures of any kind — that weak solutions (containing O'l per cent,
to 0'2 per cent.) of the alkaline bicarbonates or dimetallic phosphates slowly
decomposed them and threw out uric acid, in spite of these solutions having
a distinctly alkaline reaction with litmus-paper. Such a result never followed
in the case of the natural amorphous urate deposit.
HISTORY OF URIC ACID IN THE URINE. 265
eut decomposition of the quadrurate goes on with slow
liberation of uric acid, but the process does not go far
enough to induce actual precipitation. Then follows a
meal and digestion of food. This is attended with a change
in the reaction of the urine, which now becomes alkaline.
As the alkaline stream descends into the bladder, the
contents of that viscus become first neutral, and at length
alkaline. During this period the decomposition of the
quadrurate is arrested, and the previously liberated uric
acid is recompounded into quadrurate. As the effects of
the meal pass off, the acidity of the urine is restored, and
the collected product in the bladder, when finally voided,
presents a neutral or slightly acid character ; and the
quadrurate contained in it is discharged in its original
state of complete, or almost complete, integrity.
(b) In the subjects of uric acid gravel. — Starting as
before with a fasting state and an acid urine, the process
of uric acid liberation proceeds more rapidly, and results
in actual precipitation of crystals in the kidneys or bladder.
In the slighter cases of the disorder, and in the milder
phases of the more severe ones, the deposited crystals are
redissolved on the advent of the alkaline tide after a meal,
or they are swept out of the bladder at the next micturi-
tion. No permanent concretions remain, and no calculous
symptoms are engendered, or only slight and transient
renal pains. In severer cases the deposited crystals fail
to be entirely dissolved by the alkaline tide ; on the con-
trary, they aggregate into minute but permanent concre-
tions in the kidneys. This event marks an adverse change
in the risk of precipitation. The already formed concre-
tions operate — according to a well-known law of chemical
physics — as soliciting foci, and give a great additional
impulse to the tendency to precipitation. The concretions
thus go on increasing until at length the phenomena of
renal gravel are fully developed. In severe cases of gravel
the alkaline tide after meals is sometimes markedly re-
duced in strength, or even, as I have occasionally observed,
entirely abrogated.
266 HISTORY OP URIC ACID IN THE URINE.
6. The Factors which determine the Formation op Uric
Acid Concretions and Deposits,
Tlie more remote and predisposing causes of urinary
precipitations do not come within tlie scope of tlie present
inquiry.^ Wliatever these causes may be, they must be
translated into changes in the composition of the urine
before they can determine the occurrence of calculous
accidents. No amount of morbid proclivity to uric acid
gravel can take effect if the urine be alkaline, nor if the
proportion of uric acid in it fall below a certain point.
The causes which will be here considered are those which
lie exclusively in the chemical constitution of the urine
itself.
In the preceding section proof was given that the
salines and pigments of the urine exercise a protective
influence against premature precipitation of uric acid ;
and it may hence be inferred that a diminution of these
salines and pigments may sometimes act, in a negative
manner, as a determining factor in the production of
gravel and stone.
Poverty in the salines of the urine is probably an influ-
ential factor in the disproportionate frequency of stone
among the children of the poor as compared with the
children of the easier classes. The prevalence of stone
among the natives of India is also probably to be explained
in the same way. The children of the poor are fed largely
on farinaceous articles, bread, gruels, oatmeal, and potatoes,
^ It would be of some interest to ascertain whetlier anatomical deviations
in the kidneys, such as exaggerated pouching of tlie infundibula or calyces, do
not sometimes act as predisposing causes of renal gravel. If such abnor-
malitit'S occur, they would obviously occasion uudue detention and stagnation
of the urine in the purlieus of the kidney, and thus give opportunity to a
tendency, otherwise insufficient, to determine deposition of uric acid. More-
over, slight anatomical differences of this kind between the two kidneya
might account for what is so often observed, namely, the unilateral incidence
of the symptoms of renal gravel. So far as I know this point has not
hitheito been investigated.
HISTORY OF URIC ACID IN THE URINE. 2G7
with but a scanty allowance of milk, meat, and fish.
Wheat-Hour contains only 0*5 1 per cent of mineral matter
in proportion to the totality of the dry substance ; oat-
meal only 2*50 per cent. ; potatoes only 2*50 per
cent. ; whereas milk contains 5'50 per cent., and the
various forms of meat and fish 5 to 5*50 per cent. Rice,
which forms so large a part of the diet of the natives of
India, only contains 0'39 per cent, of mineral matter in
proportion to the totality of the dry substance of the
grain. These enormous differences in the amount of
saline ingredients in the articles of food must, of course,
make a corresponding difference in the proportion of the
saline constituents of the urine. On the other hand, the
well-known immunity enjoyed by sailors from stone and
gravel depends, no doubt, as Mr. Plowright has shown,
on the prodigious quantity of salt which seafaring men
habitually consume with their food. The same observer
has pointed out that the dwellers in a district of Norfolk
called Marshland, where the drinking water is brackish,
are singularly free from stone, as compared with their
less fortunate neighbours in the adjacent districts of that
county.^
Deficiency of jpigment in the urine. — In chronic Bright's
disease with contracting kidneys the urine is con-
spicuously pale, and is often indeed almost entirely
devoid of pigment. There is no excess, but rather a
diminution of uric acid in the urine in these cases; never-
theless deposits of uric acid are by no means uncommon,
and sometimes actual renal gravel occurs. The percentage
of salines is also low, and this doubtless contributes to
the result ; but probably the prepotent factor in the pre-
1 See a paper by Mr. C. Plowii^rlit, of King's Lynn, in the ' Medical Times'
for Octobtr lOtli, 1885. Mr. Piowright, on tlie evidence of some experiments
by Mr. H. C. Krown, attributes tlie good effect of salt to its alleged property
of iucreiising tbe solvent power of water on uric acid. This is, however, I
am satisfied, on the ground of very exact determinations both by myself and
others, not the correct explanation. The real action of the salt is, I believe,
as a retarder of the decomposition of the quadrurates.
268 HISTORY OP URIC ACID IN THE URINE.
cipitation of uric acid in these cases is the deficiency of
pigment in the urine.
Poverty of the urine in salines and pigments, however^
only accounts for certain limited groups of calculous cases.
There are other and larger groups in which the urine is
neither defective in salts nor in colouring matters. The
subjects of calculous disorders among the easy classes —
especially those of a gouty type — usually void a urine
which is full-coloured and abundantly rich in salts. In
these cases the chief determining factors — and the only two
which I shall here consider- — are the grade of acidity of
the urine, and the proportion of uric acid contained in it.
The speck experiment was found unsuitable for inves-
tigating the influence of these factors. For this purpose
another mode of experimentation — one that approximates
more nearly to the conditions of the actual clinical problem
— was adopted. In the beginning of this paper I drew
attention to the fact that all urines with an acid reaction
precipitated their uric acid sooner or later, and the infer-
ence was drawn that this inherent tendency was the same
in kind (though less pronounced in degree) as the tendency
existing in actual gravel. On this view it might be reason-
ably conjectured that whatever helped or hindered in the
one case would equally help or hinder in the other case —
in other words, that the conditions which hasten or retard
the precipitation of uric acid in a sample of urine pre-
served in a test-tube would, if they could be made appli-
cable, hasten or retard the precipitation of uric acid in the
urinary passages. The proceeding followed was to charge
a series of test-tubes each with 10 c.c. of a normal acid
urine. One of these was a control tube, and had no addi-
tion made to it. To the others additions were made of
known quantities of various substances, of which it was
desired to know the effects on the time of onset of uric
acid precipitation. The contents of the tubes were pro-
tected from decomposing changes by the inclusion of a
few drops of chloroform. They were then corked and
kept in the warm chamber at blood-heat. The tubes
HISTORY OF URIC ACID IN THE URINE.
269
■were frequently examined, and the time when uric acid
began to be deposited was noted. When the experimeut
was finished the acceleration or postponement of precipi-
tation in the several tubes, as compared with the control
tube, was computed.
Grade of acidity of the urine. — The degree of acidity
of the urine exercises^ as might have been expected, a
potent influence on the time of precipitation of uric acid.
In some cases of gravel I found the acidity of the urine
fully twice as high as the normal average. In two
such cases the urine as tested by the speck experiment was
found to act on the purified amorphous urate as rapidly
as distilled water ; but when the acidity was reduced to
its normal level by the addition of sodium carbonate, it
had then no more power in this respect than healthy
urine, showing clearly that in these cases the determining
factor in the disorder was solely excess of acidity. It
was also found, experimenting in the way described above,
that the addition of an exceedingly minute quantity of an
alkaline carbonate postponed the time of precipitation
very notably. The following table displays some of the
results obtained by this method :
Table II. — Showing postponement of precipitation of uric
acid by the addition of minute quantities of alkaline
carbonates to the urine.
Additions made to the urine.
Time wlien uric
acid began to be
precipitated.
Postponement
of
precipitation.
No. 1. Urine alone — control tube
2 hours
—
„ 2. Urine + 0-04% Pot. Bicarb.
4 „
2 hours
„ 3. Urine + 004% Sod. Bicarb.
5 »
3 „
„ 4. Urine + 0-04% Lith.Carb.
10 „
8 „
The quantities of the alkaline carbonates added in this
270 HISTORY or URIC ACID IN THE URINE.
experiment were so small that tlie reaction of the urine,
as tested by litmus-paper, was not sensibly affected ; and
yet the postponement of precipitation was very consider-
able— considerable enough, had the events occurred in the
urinary passages, to make the difference between the
occurrence and non-occurrence of gravel. It will be
observed that the sodium carbonate acted more powerfully
as a retarder than the potassium carbonate, and that the
lithium salt acted more powerfully than either. This,
however, was solely due to the difference in their atomic
weights. When these salts were used in quantities pro-
portionate to their saturating power no difference could
be detected between them. It need scarcely be said that
if the carbonates were added in sufficient quantity to render
the urine neutral or alkaline no precipitation of uric acid
took place.
When the neutral salts, chlorides, sulphates, and phos-
phates were tested by this method, the results obtained
were conformable to those obtained by the speck experi-
ment. The potash salts were found to be superior as
retarders of uric acid precipitation to the soda salts, but
all were incomparably inferior in this respect to the
carbonates.
Prvportion of uric acid in the urine. — It is a common
notion that uric acid gravel depends simply on an excess
of uric acid in the urine ; and the frequent appearance of
copious sediments of this substance in the urine in such
cases naturally lends support to this presumption. I am,
however, not aware of any reliable analyses which show that
the subjects of uric acid gravel have always or even gene-
rally a higher percentage of uric acid in their urine than
other persons, or that they render a larger amount per
day. It is at any rate certain that individuals may
habitually discharge a urine rich beyond the average in
uric acid, and yet be quite free from the symptoms of
gravel.
Cases are sometimes encountered in which the urine is
caught, as it were, in the very act of depositing uric acid
HISTORY OF DRrC ACID IN THE URINE. 271
gravel — cases in wliicli the urine, as it is voided, sparkles
with crystals of uric acid. On four occasions I have
been able to estimate the uric acid in such urines. The
results are shoAvn in the following table :
Table III. — Shoicing the percentage of uric acid in four
urines which were in the act of depositing uric acid at
the time of emission.
No. 1 contained 0'084 per cent, of uric acid.
„ 2 „ 0-076
„ 3 „ 0032
„ 4 „ 0-022 „ „
In the first and second cases the percentage of uric
acid greatly exceeded the average ; in the third case it
was slightly below the average ; and in the fourth case it
was greatly below the average.
The average proportion of uric acid in normal urine is
about 0"04 per cent., and during the prevalence of the
alkaline tide after meals it often runs up to 0"10 per cent.
— without, of course, involving any risk of precipitation.
It would, therefore, appear probable that in clinical gravel
the concui'rence of other favouring conditions — high
acidity and poverty in salines and pigments — is of more
importance than mere excess of uric acid.
The general results of this part of the inquiry may be
summed up in the following propositions. The conditions
of the urine which tend to accelerate the precipitation of
uric acid are — (1) high acidity; (2) poverty in salines;
(3) low pigmentation ; and (4) high percentage of uric
acid. And conversely, the conditions which tend to post-
pone precipitation are — (1) depressed acidity ; (2) rich-
ness in salines, especially of potash salts ; (3) richness in
pigments; and (4) a low percentage of uric acid. On the
interaction of these factors the occurrence or non-occur-
rence of gravel appears to depend ; and probably the
most important of these factors is the grade of acidity.
(For report of the discussion on this paper, see ' Proceedings of the
Royal Medical and Chirurgical Society,' Third Sei'ies, vol. ii, p. 87.
A STUDY OF EIFTY CONSECUTIVE CASES
OF
OPERATION FOR THE RADICAL CURE OF
NON-STRAINGULATED HERNIiE.
ARTHUE E. BAEKER, F.E.C.S.,
SUEGEON TO UNIVERSITY COLLEGE HOSPITAL.
Received March 11th— Read April 8th, 1890.
A STUDY of fifty consecutive cases of operation for the
radical cure of non-strangulated hernias, including all the
first fifty I have performed, cannot, I venture to think, fail
to be of some interest, although the ultimate results of the
procedure should not be pronounced upon finally until
several more years have elapsed. I have undertaken this
study, I believe, without any strong preconceived notion,
and simply with a view to learn as much as possible from
the series for my own future guidance, and to impart the
facts learned as fully as may be to others interested in
the subject.
The surgical interest of this procedure centres, I think,
round the following considerations :
1. Is it called for ?
2. Is it safe — [a) as regards the patient's life ; [b]
as regards the contents of the scrotum ?
3. Does it secure against a return of the hernia?
VOL. LXXIII. 18
274 OPERATION FOR THE RADICAL CURE
These are all vital questions, which can only be answered
when we have had a much larger experience. In the
meantime nothing can contribute so much to our forming
an accurate estimate of the place which this class of opera-
tion is to take among the recognised procedures of surgery
as the careful analysis and publication of completed series.
In putting these cases together I have purposely ex-
cluded operations for radical cure performed on hernise
already strangulated. The latter belong to a totally dif-
ferent category. And although my statistics would be,
in some respects, favorably influenced if these were in-
cluded, it has been considered more advisable to keep
them out.
To the first question, whether operations for the radical
cure of herniae are called for, I think most surgeons now-
adays would feel inclined, for a large group of selected
cases, to give an affirmative answer. The dangers of
ruptures, especially among the less favoured members of
the community, are amply shown by the large number
which are daily operated on for strangulation. The dis-
comforts of the condition, too, and the disabilities entailed
upon those suffering from it, are also so well known as to
need no comment.
We must all admit, then, that some means of getting rid
of hernige are urgently called for in some cases at all
events, if the cure can be accomplished with safety to the
patient. Indeed, it may be urged that a certain amount
of risk may be accepted by the patient afflicted with this
defect and who desires an operation for his cure, seeing
that, if nothing is done, he has daily to face the dangers
of strangulation.
Admitting, then, that the cure of this condition is most
desirable, what are the risks as to life which the patient
has to face who is anxious for an operation for the radical
cure of a non-strangulated hernia ?
I think upon this point the series of cases now before
us gives clear evidence as far as it goes.
There has not been a single death among the whole
OF NON-STRANGULATED HERNIiE, 275
fifty operations^ though some were very troublesome. And
though in my next series of fifty additional cases^ which
will not be complete for some time, there will be at least
one death, occurring in a peculiarly complicated case, the
fact that in half a hundred operations on patients suffering
from all the various forms of hei-nia not one death has
occurred, shows that under the newer conditions of wound
treatment the risks of operating for the conditions in
question are very small.
Let us now glance at the question whether the state of
these patients immediately after the operation and during
the healing of the wound was at any time critical.
And first as regards suppuration. It is well to be
clear as to what is meant by one of these wounds suppurat-
ing. In the first place, if a stitch is left a little longer
than necessary and a drop of discharge forms round it in-
dependently of the rest of the wound, which has healed by
first intention, this ought not to be described as a case of
suppuration of the wound. Such a state of things after
a hare-lip operation would not be so called.
Again, if a drain-tube is used and is left under a dry
dressing say for ten days or a fortnight, and some soft
aseptic lymph is then found in it or in its track, the rest
of the wound being soundly healed, this, I presume, should
not be called a suppurating case.
But if, on the other hand, any part of the wound has
failed to unite, and from out of the field of operation pus
is escaping even in small quantity, such a case is here
described as suppurating, whether the temperature shows
a corresponding rise or not.
Of such cases as the last there are in this series only
two, Nos. 39 and 41 : both of these suppurated beyond
question, although they did well otherwise, and were none
the worse of the delay in healing. All the rest healed
by first intention. In No. 15, after union had taken place
two deep sutures were discharged from a small chink at
the upper end of the incision, and their escape was preceded
by a few drops of discharge. In No. 30 the wound had
276 OPERATION FOR THE RADICAL CURE
healed per primam, and the stitches had been taken out
on the seventh day ; but the patient was a very wild little
fellow, who was constantly pulling the dressings off and
romping about, until he was at last tied down in the bed.
Before this, however, on the eleventh day he had to some
extent forced open the edges of the recently healed in-
cision, and of course this spot had to granulate up, which
it did rapidly.
There were, then, only two bond fide cases of suppura-
tion. This is undoubtedly two too mapy. But the fact
that thirty-nine cases were operated on before the first
wound broke down, and that after the forty-first all
healed as one would have desired, justifies the hope that
in a second series of cases still better results may be
obtained.
Having got rid of suppuration, almost all other sources
of anxiety were eliminated after operation. Shock was not
noticed ; haemorrhage was of course absent ; and nothing-
was seen of the accidental wound infections, such as ery-
sipelas, pyaemia, &c. As to the temperature in these cases,
it varied ; but in many cases it rose a few degrees within
the first thirty-six hours, especially in the case of children,
even where everything was otherwise satisfactory. In
No. 6, an exceedingly fat and intemperate woman, an
attack of jaundice with rheumatic or gouty swellings of
some of the joints retarded convalescence, but the state
of the wound at the umbilicus gave no anxiety. In No. 15
pneumonia appeared on the day after operation, and
ran a normal course in nine days.
These and one of measles are the only cases of inter-
current affections to be noted.
Accidents during operation occurred in two cases. In
both after the sac had been tied, but before the rings were
closed, a sudden struggle of the patient forced down several
coils of intestine between the patient's thighs. The gut
was in each case washed, dried, and reduced without diffi-
culty, and not the least ill effect followed.
The duration of time until the removal of the skin
OP NON-STKANGULATED HERNIA\ 277
stitches was usually from tlie tenth to the fourteenth day,
at which time healing may be said to have been complete
and fii'tn in nearly all cases. A few cases required a longer,
but most a shorter period.
From this surv^ey it would appear that the risks to the
patient^s life and general health from operations for the
radical cure of hernia may be very slight indeed if due
care is observed.
As regards the contents of the scrotum, no ill effects at
all, either to the cord or testis, were observed to follow
this operation so far. But it is interesting to note that
in two cases with double herniEe the patients had been
operated on by Mr. Wood on one side by the subcutaneous
method before they came to me for operation on the opposite
side. In both complete atrophy of the testicle was found
on the side operated on by Mr. Wood, the other testicle
remaining normal up to date.
The ages of the patients ranged from three months to
seventy years. Three were under six months ; two be-
tween six months and one year ; thirteen were between one
and five years ; six between five and ten ; one between
ten and twenty ; eight between twenty and thirty ; two
betvveen thirty and forty; six between forty and fifty, and
one over seventy.
Several varieties of rupture are included in this series.
The largest number were inguinal, as might be expected.
Of these, thirty were on the right, ten on the left side, in-
cluding double herni£e, of which there were four cases.
Of umbilical hernias there were three, of femoral two
cases — one right, the other left. The caecum was found in
the sacs of two right inguinal cases.
The list includes forty-two patients, of whom four had
double herniae, and four were operated ona second time after
recurrence. In these last four cases of re-operation the rings
were sutured, in two with silk, in one with chromic gut,
and in one with kangaroo tendon at the first operation.
The operation performed for inguinal herniee was in
twenty-eight cases the same. It was one designed by the
278 OPERATION FOR THE RADICAL CURE
wi'iter several years ago, and has been sufficiently described
elsewhere. Five cases of recurrence are credited to this
operation as now performed.
In one case Macewen's operation was done.
In the three umbilical cases I adopted in two a measure
also designed by myself and published some years ago.
One remained firm two years after operation, the second
recurred.^ In the third a less elaborate procedure was
followed, and in this case recurrence was speedy.
Of the femoral cases, my own method of securing the
stump of the sac was employed in one ; in the other the
latter was simply reduced within the ring, which was
closed with silk sutures.
In most of the earlier cases the carbolic spray was em-
ployed throughout the whole proceeding, but not for the
last year or two, and nothing has been lost by the omis-
sion, all other precautions to secure asepsis having been
taken with increased care.
Drainage, too, has become less and less necessary as the
details of drying the wound before the last act of suture
has become better understood. I rarely now go beyond
leaving a strand of twisted silk in the lower angle of the
wound until the first dressing is removed, and then only
when there has been an extensive dissection. As a rule
the stitches in the skin are all inserted before the sponge
is removed from the wound, and if the latter is then seen
to be quite dry no sort of drain is used, and the threads
are knotted firmly. In the majority of cases the first
dressing on its removal about the tenth day has been found
practically quite dry, and I always regard myself now as
having been very remiss in some detail if such is not the
case.
For the deep sutures in the rings I venture to think
that carbolised silk ought always to be preferred. It is
strong, easily sterilised, pleasant to work with, and gives
a very secure knot. If it is tied too tightly round the
' Patient heard of since writing; is now said to be quite well (August,
1890).
OF NON-STRANGULATED HEKNIiE. 279
fibrous tissues which it includes, it occasionally, however,
works to the surface ultimately, even if perfectly sterile ;
but this is not common. On this point the present series
of cases gives some interesting evidence. But it must be
remembered that all these patients were up and about a
few weeks after operation without any truss, and many
undertook very heavy labour soon after leaving bed, and
also without truss.
In Nos. 2, 13, 15, 46, 48, and 50, one or more deep
stitches worked their way to the surface, but without
giving any further trouble at a period ranging from the
thirteenth day to the ninth month. Considering that at
least 200 deep stitches must have been left in the tissues
in these fifty cases, the percentage which came away may be
considered small. I think the fault has usually been
attributable to using too much force in tying them on the
included tissues, and for this reason I am now content if
the edges of the openings are simply brought firmly
together. If this is so the percentage of stitches which
come away in the next series will probably be smaller.
As regards the efficiency of these operative procedures
as a means of preventing the return of ruptures, we must
wait for a final judgment until a much longer time has
elapsed. But as far as they go I have spared no pains to
find out the ultimate result. This, as is well known, is a
difficult matter with hospital patients, who often change
their abode, and cease to present themselves for examina-
tion in spite of urgent requests to do so. While writing
this paper I have posted cards to the last known addresses
of all the patients in the list whose condition has not been
recently examined or heard of, and have embodied the
results in the appended tables.
From these it appears that the results of thirteen
operations cannot be ascertained at all, as the eleven patients
on whom they were done cannot bo traced since leaving
hospital.
In eight the hernia returned, and in four of these a
second operation was done with complete success so far as
I
280 OPERATION FOR THE RADICAL CURE
is known. In one of tlie cases of recurrence kangaroo
tendon was the material used in tlie first operation, for the
rings, but it dissolved so rapidly that the rupture came
down almost before the patient left hospital. In another,
chromic gut was employed for the first operation. In the
remaining two, silk was the material for suture. In the
four other cases of recurrence no second operation has yet
been undertaken. Two of them were umbilical herniae,
two inguinal.
In the remaining thirty there has been no recurrence
when last seen or heard from : five were well and without
hernia at between forty and fifty months after operation ;
seven between thirty and forty months ; six between twenty
and thirty months ; six between ten and twenty months ;
and six between two and ten months.
In many of these cases the sutured part had, as I have
already said, been subjected to severe strain, almost imme-
diately after leaving bed. " Plate-laying " and " quarry-
ing " have been undertaken in this way without bringing
back the hernia, and '' whooping-cough " and bronchitis
have been passed through soon after operation without
ill effect on the sutured area.
Except in the cases of umbilical hernise all these patients
have been told not to wear trusses on leaving bed, and
only in two cases has this rule been departed from, for
special reasons. In one or two of the other cases I should
have recommended a truss had I known that the ruptures
were returning under severe strain.
In not one of all my own cases have I ever seen or
heard of anj'^ ill effects upon the contents of the scrotum.
In every case here set down the operation was only
done when all the other usual means of controlling hernias
had been tried and failed for one reason or another; and
this is likely to remain my own guiding rule for the pre-
sent. There may be exceptions to it, but I think we
must be careful about admitting them. If I had operated
in all cases in which I have been requested to do so my
list would have been much longer.
OF NON-STRANGULATED HERNI.K. 281
If I liave learned anything from tliis study I tliink it
may be summed up as follows :
1. That tlie operation, if great care and attention to
detail is observed, may be performed with very little risk
of any kind.
2. That the spray ought to be dispensed with as very
chilling, and not giving more security against sepsis than
can be provided in less troublesome ways.
3. That drainage ought as a rule to be rendered un-
necessary by careful handling of the tissues during dissec-
tion, so as not to bruise them and leave shreds likely to
necrose, and also by arrest of all oozing before final closure
of the wound, which should be dried out at the very last
moment.
4. That trusses are not needed in the great majority
of cases after operation, but should be ordered for those
who have evidently very weak abdominal walls, and who
are obliged to return to very heavy work, if there be the
slightest sign of recurrence of the hernia.
282
OPERA'IIOX FOR THK RADICAL CURE
No.
Name.
Age.
Nature.
Date
of operation.
Operation.
i
1
R. Foster
44
Right
April 2nd,
Sac opened; omentum removed; pil-
oblique
1884;
lars sutured, strong catgut; drain-
inguinal for discharged
tube; spray; gauze dressing
10 years
April 24th
j
2
Emily
42
Umbili(!al,
April l>t.
Abraded skin included in two curved
Huntingford
5 years ;
1885;
incisions and removed ; ring size of
pain, sick-
discharged
forefinger; omentum and sac cut
ness
May 6th
away ; ring doubly sutured with
eiglit silk sutures; drain-tube; iodo-
form and salicylic wool dressing
3
James Swanson
U
Right
June 17th,
1
A. E. B.'s operation; silk sutures; gut
oblique
1885;
drain; salicylic wool dressing j
inguinal.
discharged
acquired
July Ist
when 2
montlisold
4
Anne Marshall
70
Left
July 8th,
Sac opened; omentum cut away and,
femoral for
1885;
gut reduced ; neck of sac tied with
40 years
discharged
Aug. 3rd
catgut; femoral ring closed with two
strong catgut sutures ; skin stitched
with gut; gut drain; Lister's gauze
dressing
5
Charles H.
3^
Right
July 11th,
Sac isolated with some difficulty ; } .
lliOS.
oblique
1885;
divided between two chromic gut '
inguinal,
discharged
sutures, but lower part not removed; :
acquired
July 18th
one stitch was put into tlie pillars' '
3 weeks
to draw them together (? material .'
after birth
of suture) ; spray all the time ; sali- '
cylic wool dressing; gut drain !
6
Maria Tuck
46
Umbilical
Sept. 2nd,
Same operation as No. 2; catgut drain;
spray; skin sewed with chromic gut
irreducible
1885;
(or 10 years
discharged
Oct. 21st
K
I
le
k
I
If
it
to
OP NON-S'l'RANnilLATKD IIEIiNIiT-;.
283
iVomid healed without accident.
only touched 100° on 10th day
Temp
Lst dressing' 3rd day, hloody serum only.
2iid dressing 6th day, only serum, feels
very well. 3rd dressing, drain reinoved,
alsii skin stitches. 4th dressing 15th day,
brown serum. 5th dressing 16th day, no
discharge. 6th dressing 19th day, one
deep stitch came away at lower angle of
wound. Left U. C. H. well on May 6th
Temp, only exceeded 100° on 3rd day, and
fell on escape of serum from 101'2°; did
not touch 100° afterwards. Convalescence
free from anxiety
st dressing 3rd day, no discharge, drain
removed; quite well in every way. Temp.
only touched 100"8° on 3rd day; after
this was usually below 100°
st dressing 7th day, wound healing by
tirst intention. 2nd dressing 11th day,
wound quite healed. Convalescence uu
interrupted. Temp, did not once touch
100°
it dressing 3rd day under spray ; all well
except soreness of skin of buttocks from
carbolic acid; temp. 102'6°; next day
temp. 98'i°, child quite well. 2nd dress-
ing 5th day, wound healed up to gut
drain, which was removed. 3rd dressing
7th day, wound perfectly healed. 8ti
day left hospital quite well
ttack of jaundice and gouty swellings
commenced 4th day, with temp. 101'4°.
Edge of dressing raised on 8th day; some
serum escaped from drain opening; not
further disturbed. Hypostatic pneu-
monia on 13th day, lasting a few days.
Wound dressed daily, quite free from all
inflammatory reaction. By Oct. 7tli
' wound healed, except drain opening.
, Patient well
Xot such a fat patient
as is common in cases
of umbilical hernia
Could not be traced
after leaving U. C. H. ;
house at address given
pulled down.
Examined March 24th,
1887 ; no trace of her-
nia. Wears abdominal
belt.
A very fat patient of in-
temperate habits ; was
very difficult tonianage
during convalescence.
Although wound did
not close at once there
was no suppuration,!
but a drain of serum,
evidently from clots of
blood contracting and!
organising in wound 1
Examined March 19th,
1887 ; no trace of her
nia ; no atrophy of
testicle; child quite
well.
Could not be traced
though written to.
The father of patient,
who is a medical man,
says there is no trace
of return of hernia,
i. e. in Dec, 1889.
For some months no re-
turn of hernia. I think
I heard casually from
a friend of patient
that it has since coine
back. Patienthassince
had gouty attacks like
that described. (Note
since writing. — Pa-
tient heard of lately ;
is quite well.)
284
OPERATION FOR THE RADICAL CURE
No.
10
11
12
13
14
Fred. Ashworth
F. Ashworth.
Re-operation
John White
Walter White
John Foale
(double)
John Foale
10
mos
Nature.
Walter Hunt
Richard
Greenfield
Left
inguinal,
oblique,
acquired
6 years
Same
hernia
5
mos
Right
inguinal,
oblique,
acquired at
Gwks.ofage
Right
oblique
inguinal,
congenital
Right
inguinal,
acquired
3 weeks
after birth
Left
inguinal,
acquired
3 weeks
after birtli
Right
inguinal,
congenital,
noticed
when 6
weeks old
Left
oblique
inguinal,
congenital
Date
of operation.
Operation.
Oct. 13th, Sac not down; pillars sutured with
1885; I silk, skin with chromic gut; salicylic
discharged
Nov. 4th
Jan. 8th,
1886;
discharged
Feb. 1st
Oct. 21st,
1885;
discharged
Nov. 13th
Nov. 13th,
1885;
discharged
Dec. 1st
May 7th,
1885;
discharged
May 22nd
Dec. 11th,
1885;
discharged
Dec. 25th
wool dressing ; spray
Sac divided between two silk liga-
tures; stump reduced within ring,
which was then sutured with silk.
During dissection one or two of the
former ligatures were found; no
trace of irritation about them. Cat-
gut drain
Sac divided between two silk liga-i
tures; pillars sutured with three!
silk ligatures; catgut drain ]
Sac opened, then ligatured in two
places, and divided between ; stump
reduced; pillars sutured with two
catgut stitches; drain-tube and silk
sutures in skin ; spray j gauzej
dressing
Sac divided between two silk ligatures;
pillars closed with three silk sutures;
skin sewn with catgut ; catgut
drain; spray; salicylic wool
Jan. 8th, Sac divided between two silk ligatures;] ,
1886 ; I stump reduced ; rings closed with
discharged silk sutures; catgut drain
Jan. 20th
Feb. 5th,
1886;
discharged
Feb. 24th
. E. B.'s operation; sac divided be-
tween two silk sutures, the uppei
of which was then used to draw th(
stump within the inner ring and
close the latter; then three othei
silk sutures in walls of inguina.
canal; spray; salicylic wool
OF NON-STRANGULATED HERNIA.
285
Healing process.
Ist dressinof 8th day, seemed to have healed
by first intention. 2nd dressing 11th
day, slight moisture, boracic lint. 3rd
dressing 16th day, no moisture. Temp.
never touched 100° from beginning to end
Ist salicylic wool dressing removed on 12th
day, wound healing by first intention.
2nd dressing 14th day, still healing. 3rd
dressing 19th day, drain removed. 4th
and last dressing 23rd day, wound quite
healed. Temp, rose to 101° on operation
day, and next night to 100-6° ; the next
to 100°, remaining below this until dis-
charged
Ist dressing on 2nd day. 3rd on 6th
Temp, about 100° until 7th day, when it
rose to 101°; cause undiscovered; again
on 15th. Child remained well through
oat
Ist dressing 5th day, drain removed. 2nd
dressing on 7th day, stitches in skin re
movedj edges of wound "a little sloughy,'
(?) testicle swollen. 3rd dressing 12th
day ; the wound has healed up except
where drain-tube lay. 4th dressing,
wound healed except at lower angle. Not
dressed again
Ist dressing 5th day, hardly any moisture,
drain removed. 2nd dressing 7th day,
wound nearly healed. 3rd dressing 8th
day, stitches in skin removed. Temp.
rose to 103'4° on evening of operation,
and next night to 102'4°. After this
went down, and uninterrupted convales-
cence ensued
1st dressing 5th day, wound healing. 2nd
dressing 11th day, stitches in skin re-
moved, a small moist spot remains where
drain lay ; dressed with boric lint, moist.
Temp. 101° on night of operation and
next night, then normal until discharged
Ist dres.sing, wound healed by first inten-
tion. 2nd dressing changed for wool and
collodion. Stitches in skin removed on
12th day. Discharged on 18th day quite
healed. Temp, rose on 2nd night to
101-2°, on 3rd to 100°, then remained
below 100° until discharged, except on
15th day, when it was 100-4° and 101-6°
Remarks.
On 2nd day temp
reached 103°, on 3rd
102-6", but afterwards
was below 100° until
patient was discharged
Hernia returned almost
immediately owing to
bad cougrh.
No return of hernia on
March 26th, 1886,
when patient was last
seen. Could not be
traced after this; let-
ters in Jan., 1890, re-
turned.
Patient could not
traced ; letters
turned 1888.
Patient could not
traced ; letters
turned 1888.
be
No return in Nov
1885, in spite of bad
bronchitis. Cannot
be traced; letters re
turned Jan., 1890.
No trace of recurrence
of hernia on Nov. 16th,
1888.
On March 9th a deep No trace of return of
stitch came away; hernia on Nov. 12th,
spot of moisture soon 1888. Cannot be
healed traced ; letter, Jan.,
1890, returned.
No truss was worn at No trace of return of
any time after opera- hernia when examined
tion on Dec. 24th, 1888, in
spite of recent bad
whooping-cough.
Quite well when exa-
mined Feb. 26th, 1890.
286
OPERATIOX FOR THE RADICAL CURE
No.
Name.
Age.
Nature. , ^^te
of nperauon.
Operatiiin. |
i
15
William Self
20
Left
Feb. 27th,
■ 1
A. E. B.'s operation ; three sutures in 1
inguinal.
_ 1886 ;
ring. T. vaginalis also opened ;
acquired
discharged
stitched up. Varicocele operated
2 years ago April 4th
on at same time; excision of portion
between ligatures; no spray j Hyd.
Bichlor. to wash wound; drain-tube
j
16
Harry Cooper
5
Right
March 3rd,
A. E. B.'s operation ; lower part of !
inguinal, ! 1886;
sac in this case removed, as it was
oblique, discharged
small and had come out of scrotum;
acquired
March 15th
five sutures in rings ; catgut drain j
4 years ago
spray; c. gauze
17
William Pride
n
Right March 16th,
A. E. B.'s operation ; four silk sutures
(double)
inguinal,
1886;
in rings. Just after tying sac and
congenital ;
discharged
dividing it, patient struggled, and
large with
the ligature slipped, a couple of'
wide ring
feet of bowel protruding between'
the thighs ; reduced easily, no fur-!
ther trouble ; catgut drain ; sprayl
broke down in middle of operation
18
William Pride
H
Left
March
Same operation ; four silk stitches in
inguinal, 26th, 1886
pillars; catgut drain
acquired six
months ago
19
George Pairvell
u
Right May 28th,
inguinal, 1886;
acquired discharged
June 14th
A. E. B.'s operation ; sac removed ; no
drain; spray
20
Mary A. Shay
1
Right Dec. 15th,
inguinal, 1886;
congenital discharged
1 Dec. 30th
A. E. B.'s operation; sac removed
21
William
7
Right September
A. E. B.'s operation; 5 stitches in 1
Whitbread
inguinal, 2nd, 1886 ;
congenital ; discharged
large ring September
rings; spray
1
1
18th, 1886
i
OF NON-STRANQDLATED HERNIJ^.
287
1st dressing on 2nd day, coverings having
slipped ; tube shortened. 2nd dressing
5th day. 3rd dressing 6th day, the lastj
having slipped; tube removed for good.
4th dressing 8tb day, stitches in skin
removed, healing by first intention ; somei
swelling and redness remains. 10th day,
a little pus can be squeezed out of chink
of upper angle. 13th day, two ligatures
came away from pillars. April 4th, per-
fectly healed; discharged
Lst dressing 7th day, wound dry, drain re-
moved. 2nd dressing 13th day, wound
healed per primam everywhere
.st dressing 5th day, wound healthy. 2nd
dressing, wound healed ; stitches in skin
removed, and most of catgut drain. April
2nd, circumcised
st dressing 12th day ; 2nd, 13th, on ac-
count of wetting with urine which has
produced eczema over abdomen. Dis-
charged 17th day, wound being perfectly
healed
The 2nd day patient de-
veloped pneumonia of
right base, with temp,
ranging from 103° to
98*4°. Attack over in
9 days, and normal
temp, from this on. At
no time was patient's
condition at all critical.
He might have left,
U. C. H. sooner, but
had to await turn for
convalescent home
Temp, only rose to
100-2° on 2nd day, and
on 4th to 100°, after-
wards normal
Temp, first night 101-4°.
2nd, 100-6°, after-
wards from 98-6° to
1006°. Child's con-
valescence uninter-
rupted. The protru-
sion of the bowels did
not seem to produce
any ill effect
Temp. 101° evening of
operation; normal on
and after 4th day. No
untoward symptoms
after operation
st dressing 5th day, wound almost dry. Convalescence uninter- March 19tb, 1887. — No
June 7th, 1886.— No
return of hernia. Has
been at work. There
is still a tiny track
leading to a ligature
which has still to come
away. Cannot be
traced; letter returned
Jan., 1890.
March 18th, 1887.— No
return of hernia on
coughing or straining;
health excellent. Can-
not be traced; letter
returned Jan., 1890.
Nov. 16th, 1888.— No
return of hernia. Died
of diphtheria at begin-
ning of 1889 at home.
Nov. 16th, 1888.— No
return of hernia.
Stitches in skin removed. Wool and
collodion. 2nd dressing 8th day, wool
and collodion. 3rd dressing 11th day,
wool and collodion. 4th dressing 14th
day, healed by first intention
st dressing 6th day, healed per primam.
Wool and collodion
rupted. Temp, on 4th return of hernia ; no
day 101-4°, which was
the highest recorded
atrophy of testicle.
Cannot be traced ;
letters returned Jan.,
1890.
Temp. 101° on 2nd day March 18th, 1887.— No
return of hernia;
health excellent. Can-
not be traced j no ad-
dress left.
st dressing 14th day, healing. 2nd dress- Convalescence uninter-
sing I7th day, healed ^er/)rma?». Dis- rupted. Temp. 101°,
charged to-day highest recorded
August, 1888.— No re-
turn of hernia. Child
quite well.
288
OPERATION FOR THE RADICAL CUKE
No.
22
Name.
Age.
Nature.
Date
of operation.
Operation.
Fred. Hammond
2
Left
August
Sac opened ; ligatured with silk in two
inguinal.
26th, 1885 ;
places, divided between ; Stump re-
congenital
discharged
September
2nd, 1886
duced ; rings closed with 2 chromic
gut stitches ; no drain
23
Fred. Hammond.
2
Left
August
A. E. B.'s operation ; silk used every-
Re-operation
inguinal;
20th, 1886 ;
where this time ; one suture for sac,
recurrence
discharged
September
2nd, 1886
two for rings ; catgut drain
24
Chas. Andrews
4i
Right
October
Sac tied at neck and divided ; stump
(double)
inguinal,
congenital
22nd, 1886
reduced; rings closed with 3 silk
sutures ; no drain ; spray
25
Arthur Westley
3
Right
September
Sac divided between two fine silk
mos.
inguinal,
15th, 1886;
sutures ; stump reduced ; rings drawn
congenital
discharged
together with one kangaroo tendon
in 1st week
October 6th
suture; spray
26
Arthur Westley.
7
Left
January
A. E. B.'s operation ; three silk sutures;
Re-operation,
mos.
inguinal,
congenital
in 1st week;
rings wide
4th, 1887 ;
discharged
January
29th, 1887
spray; no drain
27
Arthur Westley
10
Right
April 22nd,
A. E. B.'s operation ; four silk sutures ;
mos.
inguinal ;
recurred
1887
no drainage ; spray
28
Mary L. Beach
41
Umbilical }
Jan. 5th,
Sac, skin, and omentum cut away;
acquired
1887
ring closed with five stout silk
9 months
sutures
ago
OF NON-STRANGULATED HERNIA.
289
Healing process.
1st dressing Gth day, healed per primam.
2nd dressing 8th day, stitches in skin ro-
moved. Child sent home
iUnion per primam
1st dressing 5th day, everything quite dry.
2nd dressing 8th day, stitches in skin
removed. Healing per primam. Wool
and collodion
Remarks.
Result.
'remp.l00'2°,onlyonce; Reappeared April,1886
convalescence uninter '
rupted
Convalescence uninter-
rupted
ist dressing 2nd day, free serous discharge
2nd dressing 4th day, wound doing well
3rd dressing 5th day, some pus (?) came
out of wound. 4tli dressing 6th day, no
pus. 5th dressing 7th day, no pus. 6tl)
dressing 8th day, wool and collodion.
Discharged with wound healed on 19th
day
-st dressing 10th day, wound healthy. 2nd
dressing, wound healthy, some orchitis.
Wound had to be dressed daily on account
of wetting with urine. Stitches in skin
removed on 14th da}'. Discharged well
21st day
st dressing 2nd day on account of soaking
I with urine; wound looked quite well;
no serous discharge. 2nd dressing 7th
I day on account of urine ; wound dry. 3rd
! and 4th dressings on 9th and 11th days
for the same reason. Two stitches in
skin removed on 15th, the remaining
ones on 18th. Wound soundly healed
st dressing 7th day, wound healed per
primam without trace of pus. Stitches
removed 14th day, all quite dry. Di
charged quite well on 23rd day
VOL. LXXIII.
Highest temp. 100-4^
October 24th, 1888.
No return of hernia in
spite of whooping-
cough, which has pro
duced a rupture oi
opposite side.
Novemberl2th, 1888.—
No return of hernia
but is getting a rup
tui'e on the opposite
side, which was ope-
rated on by Mr. Wood at King's College Hos
pital. There is also almost complete atrophy
of the testicle on this side. No return of
hernia when seen Feb. 23rd, 1890; opposite
testicle atrophied, other quite normal
remp. 2nd day, 102-4°,
and remained over 103"
all night. On 3rd day
temp. 100°
Temp, reached 103-4'
on 12th day, but con-
valescence was good
Temp, rose to 103° on
2nd day. Dressings
soaked with urine.
Convalescence unin-
terrupted without sup-
puration in spite of
urine. Stitches re-
moved by 18th day;
wound soundly healed
Hernia size of large
orange, 3 inches by 4.
Vomited first two days.
Patient very fat.
Temp, did not touch
100° during convales
cence
Returned after June,
1887; see below, No
27.
No return of
hernia, June
1887.
either
14th,
Patient became enor-
mously stout. Hernia
returned by October,
1887, but not large in
October, 1888. Cannot
be traced; letters re-
turned, 1890.
19
290
OPEKATION FOR THE RADICAL CURE
No.
Name.
Age.
29
Alfred Cooke
Beach
30 Fred. McGregor
31
Samuel
Craker
32 Sidney Hudson
33 Sidney Hudson,
I Re-operation
23
34
Alfred Johnson
35
Frederick
Newman
21
25
Nature.
Right
inguinal,
acquired
when two
years old
Left
inguinal,
acquired ;
large ring
Right
oblique
inguinal,
acquired
9 years ago
Right
oblique
inguinal,
since birth
Right
oblique
inguinal
Right
inguinal,
congenital
Right
oblique
I inguinal,
I acquired
l'6 weeks ago
Date.
Operation,
Jan. 5tb, A. E. B.'s operation ; spray
1887; I
discharged '
Jan. 23rd
Feb. 2nd, Pillars stitched at once with thret
1887 ; silk sutures, as sac had gone back ;
discharged ] no drain
March 1st '
April 6th, Mace wen's operation, using silk in-
1887
April 26th,
1887 ;
discharged
May 10th
stead of gut ; spray
A. E. B.'s operation ; four silk sutures
catgut drain ; spray
Oct. 28th, A. E. B.'s operation, as before; spray
1887; and drain-tube
discharged I
April 27th,'Operation as usual, except that sac was
_ 1887 ;
discharged
May 28th
not divided below the point tied
(? correct notes)
June 23rd, A. E. B.'s operation ; four silk sutures;
1887 ; spray
discharged
OF N0N-STEAN6ULATED HERNIA.
291
Healiug process.
Ist dressing 13th day, wound doing well;
stitches removed. Wool and collodion.
Discharged well 19th day. Wound
healed per prlmam
Ist dressing 7th day, wound healed per
primam ; stitches in skin removed. 2nd
dressing 10th day, wound not so well, as
boy is very wild and pulls dressings off.
3rd dressing 11th day, the edges have
been burst open by romping. 13th day,
wound granulating; boy tied down in
bed. 18th day, wound healing. March
1st, discharged well
1st dressing 2nd day ; all quiet ; 2ud dress-
ing 13th day. Union per primam com-
plete. Stitches in skin removed
(Dressings changed on 2nd, 4th, 5th, and
10th day. Union per primam every
where
detailed notes mislaid
st dressing 9th day, wound healed per
primam ; all but two stitches in skin
removed. 2nd dressing 13th day, the
two remaining stitches had cut a little
3rd dressing 15th day, wound dry and
healed; 21st day out of bed
^t dressing 15th day, wound healed per-
fectly per primam. Stitches in skin
removed
Remarks.
Temp, rose to 101° on
2nd day, then fell to
normal
Except for rise of temp,
to 103-4^ on 12th day,
probably due to iodo-
form, there is nothing
to note about conva-
lescence
Convalescence abso-
lutely free from any
abnormal symptom
Patient had been ope-
rated on for strangu
lated hernia two years
ago
Convalescence free from
any abnormal syiii
ptom
Temp, did not rise
above 100-4° all the
Convalescence perfectly
free from any abnor-
mal symptom ; 5 mos
later one of the silk
ligatures worked its
way to the surface ;
all of the others re-
mained quiescent
Nov. 12th, 1888.— No
trace of return ofl
hernia on right. On]
the left, operated onl
by Mr. Wood three'
years ago, the testiclei
is quite atrophied.l
Quite well when seen!
on Feb, 23rd. No
trace of hernia, 1890.
Wound soundly healed.
No return of hernia
when seen on Feb.
27th, 1890.
Bupture bulging to
some small extent
owing to heavy work.
Worked without
truss always since ope-
ration. Truss ordered.
Slight bulging when
seen Feb. 23rd, 1890.
Truss worn.
Rupture returned
about 4 months (no
truss was worn). Can
not be traced ; letters,
Jan., 1890, returned.
Cannot be traced since
operation. Letter,
Jan., 1890, returned.
Returned for examina-
tion Feb. 23rd, 1890.
Says hernia came
down soon alter leav-j
ing hospital. Has worn'
no truss since. Very
large hernia. Very
weak abdominal wall, i
April loth, 1889.— No|
return of hernia. |
Wears a truss, as hisi
work as a " plate- 1
layer " is heavy. Let-'
ter, Jan., 1890, not|
replied to. j
292
OPERATION FOR THE RADICAL CURE
No.
36
37
38
39
40
41
42
43
44
Name,
Ellen Barker
James Stephens
Fred. Keeble
(double)
Fred. Keeble
J. W. H— ,
naval engineer.
Private case
Sarah Parmer
Harry Gibson
William White
W. F. Pearce
22
33
39
45
Nature.
Right
oblique
inguinal
Oblique
inguinal,
acquired
Date.
July 1st,
1887
Aug. 10th,
1887;
discharged
Aug. 29th
Right July 19th,
inguinal, 1887 ;
congenital ; discharged
rings large August 3rd
Left
inguinal,
congenital ;
ring large
Right
inguinal,
congenital
Right
femoral,
acquired
7 years ago
Right
oblique
inguinal,
acquired at
birth
Aug. 27th,
1887;
discharged
Sept. 27th
Sept. 3rd,
1887;
discharged
Sept. 21st
Sept., 1887
Nov. 15th,
1887;
discharged
Dec. 3rd
Left Nov. 11th,
inguinal, 1887;
acquired discharged
when Dec. 6th
6 weeks old
Right I Mar. 29th,
inguinal, j 1888 ;
acquired discharged
16 years April 20th
ago I
Operation.
No sac found ; rings closed in usual
manner with three silk sutures ;
spray ; no drain
A. E. B.'s operation ; spray
A. E. B.'s operation in usual way
A. E. B.'s operation ; five silk sutures
in rings ; lower part of sac left in
scrotum ; a few coils of gut were
coughed out before sac was closed ;
easily reduced ; no drain
A. E. B.'s operation; two strong silk
stitches in ring ; much omentum
cut away after ligature in seven or
eight places ; no spray ; lower part
of sac closed by stitches to form
tunica vaginalis ; drain-tube
A. E. B.'s operation; omentum adhe-
rent ; removed with sac
A. E. B.'s operation ; five silk sutures!
in lings; silk drain
A. E. B.'s operation ; four silk suturesl
in rings ; silk drain
A. E. B.'s operation ; sac removed
spray ; no drain
OP NON-STRANGULATED HERNIiE.
293
Healing process.
1st dressing 7th day; wound healed per-
fectly per primam; stitches in skin re-
moved ; same dressing applied
Wound he&led per primam
Wound healed per primam
Ist dressing same evening ; lower angle of
wound opened to allow escape of serum.
2nd dressing 2nd day ; lower stitche-
removed to permit free drainage. No
old tenderness. 3rd dressing 3rd day.
4th dressing 5th day; wound not look-
ing at all well ; discharge of pus free ;
all stitches in skin removed ; fomenta-
tions. After this did well
Wound healed per primam under 3 dress-
ing's
Healed per primam under two dressings
Ist dressing 11th day, wound quite healed
Dressings 2nd, 3rd, 5th, 9th day, when
I suppuration took place. By the 20th
I diiy all suppuration had ceased. On
26th day went home quite well
1st dressing 9th day ; wound looked well.
2nd dressing 16th day ; wound healed
I per primam. Stitches in skin removed.
I Truss applied. Sent home on 23rd day
Remarks.
Convalescence perfectly
" — from any ahnor-
symptom
free
mal
Temp. 100° same night;
normal next day ;
reached 100° on 3rd,
4th, and 5 th day ;
after this below 100^
Temp. 103° on evening
of operation, and next
day 104-6°, then 102°
3rd day. On 24th day
wound was granulat-
ing well, and all bad
symptoms were gone.
On 31st day wound
quite superficial. Weni
home
Temp, rose two degrees
day after operation ;
was subsequently nor-
mal. Convalescence
free from any bad
symptom
No abnormal symptoms
of any kind. This had
been a very trouble-
some rupture before
operation
Highest temp. 101° on
4th day. Convales-
cence free from abnor-
mal symptoms
remp. 101-4°
Highest temp. 1002°.
No abnormal sym-
ptoms
Nov. 19th, 1888.— No
return of hernia and
no other trouble.
Cannot be traced ; left
no address in hospital.
No reply to letter,
Jan., 1890.
Cannot be traced; left
no address. No reply
to letter, Jan., 1890.
Ditto.
Nov. 2nd, 1888.— No
return of hernia. Is
back at duty. Is much
pleased with result.
Nov. 12th, 1880.— No
trace of hernia in spite
of chronic cough. No
reply to letter, Jan.,
1890.
Cannot be traced. Let-
ter, Jan., 1890, not
replied to.
Father writes, Feb.
23rd, 1890 :— " No re-
turn of hernia ; boy
quite well."
Writes, February 23rd,
1890:— "Has no re
turn of hernia in spite
of very heavy work.
Wears no truss."
294
OPERATION FOR THE RADICAL CORE
No.
45
Name.
W. Beasley
Age.
Nature.
Date.
Operation.
40
_ Right
Sept. 7th,
A. E. B.'s operation ; omentum adhe-
inguinal,
1888;
rent to sac and removed with latter ;
acquired
discharged
no spray ; silk drain
10 years
Sept. 25th
ago; rings
large
40
Agatha
20
Right
Sept. 19th,
A. E. B.'s operation ; four silk sutiurcB
Minuiford
oblique
inguinal,
acquired
5 years ago
1888;
discharged
Oct. 3rd
in ring ; silk drain
47
George Hardy
9
Right
Nov. 2nd,
A. E. B.'s operation ; six silk liga-
mos.
inguinal,
congenital ;
ring very
large
1888;
discharged
Nov. 24th
tures in rings ; silk drain ; no spray
48
William
25
Right
Jan. 16th,
A. E. B.'s operation ; seven silk sutui'es
Fulcher
oblique
inguinal,
acquired
7 mouths
ago
1889;
discharged
Feb. Gth
in rings; no spray; no drain
4!)
William Coates
10
Right
Feb. 2Gth,
A. E. B.'s operation ; body of sac re-
inguinal.
1889;
moved in this case ; five silk sutures
acquired
discharged
March 8th,
in rings; silk drain
0.)
John Thomas
21
Right
March 1st,
A. E. B.'s operation ; very large ring;
inguinal.
1889;
si.K silk sutures to close them; ncj
acquired
discharged
spray ; no drain !
4 years ago
March 26th
1
1
OF NON-STKANGULATED HKRNI^.
295
Healing process.
1st dressing 4tli da}' ; drain removed, very
little serum. 2nd dressing 8th day ;
accidental wetting with urine; wound
doing well. 3rd dressing 11th day ;
wound quite healed per primam. Stitches
in skin removed. Sent home 14th day
1st dressing 9th day; wound dry; silk
drain removed. 2nd dressing 13th day ;
wound perfectly healed per primam.
Went home on 17th day quite well
Dressed 2Kd, 3rd, 4th days on account of
wetting himself. 5th day drain came
away quite dry ; wound quite healed.
Gtli day measles developed and ran usual
course. Slight impulse on coughing
1st dressing 3rd day, wound looks well,
quite dry. 2nd dressing 9th day, wound
hcvAeA per primam ; one stitch had cut a
little. All stitches in skin removed.
Dressings left off on 18th day ; quite
healed
1st dressing 6th day, wound healed and
dry. Silk drain removed. 2nd dressing
8th day, two stitches in skin removed.
3rd dressing 11th day, remaining stitches
removed
1st dressing 8th day, union per primam.
9th day, stitches in skin removed.
Healed soundly
Remarks.
femp. (
101-6° ;
normal
day after
afterwards
Highest temp. 100-4°.
No trace of any ab-
normal symptom
Highest temp. 100-6°
26 hours after opera
tion ; after this it was
normal.
remp. rose to 1006°,
26 hours after opera-
tion, then fell for good
remp. 101-6° 8 hours
after operation, then
below 100° to end of
case. At end of 1889
a stitch worked its way
to surface
Cannot be traced ; let-
ters returned Jan..
1890.
Writes, Feb. 25th,1890:
— " No return of her-
nia. Some deep su-
tures came away some
weeks after leavin
U. C. H. Now quite
well. Wears truss by
another surgeon's ad-
vice."
Cannot be traced;
letter, Jan., 1890,
not replied to.
E.xamined Feb. 23rd,
1890. Hernia has i-e-
turned under very
heavy work witliout
truss. Seme stitches
are working out during
last fortnight.
Cannot be traced ;
lettei-, Jan., 1890, not
replied to.
Seen January, 1890
Hernia is returning ;
stitches are working
out.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 94.)
SALICIN COMPARED WITH SALICYLATE
OF SODA
A3 TO EFFECT ON THE
EXCRETION OF URIC ACID, AND VALUE IN THE
TREATMENT OF ACUTE RHEUMATISM;
WITH SOME DEDUCTIONS AS TO THE CAUSATION
OF THE DISEASE.
BT
A. HAIG, M.A., M.D.OxoN.
Received March 10th— ReHd April 22nd, 1890.
It seems to be a pretty general opinion that salicin is
not nearly so useful in acute rheumatism as salicylic acid
or salicylate of soda.
Dr. T. J. Maclagan has noticed this general impression
(^Lancet/ i, 79, p. 875), and sought to explain it by sug-
gesting that the specimens of salicin used were not pure,
and more recently ('Lancet,' i, 1890) he has maintained
that the dose of salicin in general use is not large enough.
Dr. Bruuton (' Pharmacology and Therapeutics,' p. 939)
says of salicin, '' Its action is less powerful than that of
salicylic acid, and its depressing effect on the circulation
less marked."
I have myself also noticed apparently great differences
in the effects of salicin and salicylic acid both in health
298
SALICIN COMPARED WITH SALICYLATE OP SODA
and disease. In consequence of these observations I was
led to make comparative experiments to test tlie effects
of these drugs on the excretion of uric acid, and I pro-
pose in this paper to bring forward some of my results.
Fig. 1 shows the excretion of uric acid under salicylate
of soda taken to the extent of 45 grs. in the twenty-
FlG. 1.
No No Sodii Salicyl., No
drugs. dnisrs. gr. xv, ter. drugs.
13 429 60
ACIDITY
363 40^
9 297 20
7 231 0
URIC ACID
Uric acid excretion by salicylate of soda.
four hours. It is the ordinary curve of excretion ob-
tained with this salt or with salicylic acid, and corre-
m THE TREATMENT OF ACUTE RHEUMATISM.
299
spends very well Avitli the figure on p. 136 of my paper on
salicylic acid and its salts in vol. Ixxi of the Society's
' Transactions.'
Fig. 2 is on the same scale as Fig. 1, and shows the ex-
cretion of uric acid on a day when 100 grs. of salicin were
Fig. 2.
Salicin,
gr. 100 in
5 (loses.
9 297 2 0
URIC ACID
UREA
7 231 0 1——
Showing that 45 grs. of the sodinm salt has six times the excre-
tive power of 100 grs. of Falicin, or weight for weight thirteen
times the powei-.
taken in the twenty-four hours. I have several times
before got similar results, showing the greatl}' inferior ex-
cretive power of salicin as compared with a salicylate.
And there is this further point of difference as regards the
action of the two substances : the urine on da}- 3 of Fig. 1
gave with perchloride of iron a purple colour so dark that no
light would pass through it in a test-tube ; while on day 2
of Fig. 2 the reaction Avas much less marked, and light
passed easily through it. It happened fortuuately that the
amount of urine on these days was the same within 20 c.c,
so that there could be no error on the score of dilution ;
and I have noticed the same thing several times before,
viz. that salicin has much less effect on uric acid and gives
100
SALICIN COMPARED WITH SALICYLATE OP SODA
a much slighter perchloride reaction in the urine than an
equal weight of a salicylate.
Fig. 3 is given to show the comparative effect of a dose
of salol, 25 grs. being taken on day 2 and 50 grs. on day
3. From this it seems as if 50 grs. of salol had nearly as
much effect as 100 of salicin, but far less effect than 45 of
salicylate of soda.
Fig. 3.
Salol, gr. XXV,
in 2 doses,
taken
after 3 p.m.
No
druo'S.
Salol, ^
gr. 1, in]
3 doses.
No
drugs.
Uric acid excretion by salol.
It may be objected that after the salicylate had swept
out all the uric acid as shown in Fig. 1, there might be
little left for the salicin to do, and hence the compara-
tively small effect in Fig. 2 ; but unfortunately for this
objection, Fig. 1 is really consecutive to Fig. 2, day 3 in
Fig. 2 being the same as day 1 in Fig. 1. I purposely
gave the weaker drug first to avoid this ver}^ objection.
These figures show that, speaking roughly, salicylate of
soda has about thirteen times the excretive power of
salicin, weight for weight ; and that salol is intermediate,
much weaker than a salicylate, but stronger than salicin.
I now propose to go at some length into the action of
these compounds in disease, and see how far this corre-
sponds with their action on the excretion of uric acid.
IN THE TREATMENT OF ACUTE KHEUMATISM. 301
We see that salicin has beeu generally found to have
less effect in acute rheumatism than a salicylate, and salol
the same ; and in the ' Brit. Med. Journ./ ii, 1887, p. 1438,
it is stated that some people consider the carbolic ele-
ment in salol an actual drawback, and cases are recorded in
which when salol has failed to cure acute rheumatism sali-
cylate of soda has been successful. x\gain, in the ' Lancet,'
vol. i, 1888, p. 1073, it is stated that salol acts in rheumatic
fever like a small dose of salicylate ; and we see from
Fig. 3 that its action on the excretion of uric acid is
only one third of that produced by an equal weight of a
salicylate.
With regard to Dr. Maclagan's objections previously
mentioned, the impurity of the salicin in the market might
have been a good reason for some failure of action at the
time it was introduced and when the supply was small ;
but now it is cheap and easily obtainable, and a careful
examination of the specimen I made use of showed that it
was quite free from impurity.
We have only, therefore, now to deal with Dr. Maclagan's
second objection, that the doses given are not large enough,
and this I quite admit ; for if, as I have now shown,
salicin has only one thirteenth of the effect on uric acid
excretion that salicylate of soda has, by giving thirteen
times the dose of salicin you may make up for part of
its defects. But Dr. Maclagan himself admits that salicin
Avill cause some toxic symptoms such as singing in the ears
when given in the large doses he recommends (3ss omn. hor.
till 3j has been taken), and in my experience many cases
of rheumatic fever can be quickly and certainly cured by
salicylate of soda gr. xv 4tis horis without producing even
those slight symptoms. Where, then, is the advantage of
using salicin ?
Prof. Senator, of Berlin,^ has suggested that salicin is
partly converted into salicylic acid in the organism, and
owes its activity to this conversion ; and some such partial
conversion might perhaps explain the slight reaction with
1 ' Laucet,' ii, 1879, p. 79.
o02 SALICIN COMPARED WITH SALICYLATE OF SODA
perchloride of iron in the urine after salicin as compared
witli an equal weight of a salicylate.
A most interesting series of cases from the Leeds General
Infirmary showing the inferiority of salicin as compared
with salicylic acid in acute rheumatism is published in the
'Lancet/ vol. ii, 1876, p. 254.
The late Dr. Hilton Fagge ('Lancet/ ii, 1881, p. 1031)
drew up some valuable tables on the comparative treat-
ment of rheumatic fever by mint water, alkalies, and sali-
cyl compounds ; these show that with mint water patients
got well on the seventh to the eleventh day, with alkalies
on the fourth to the ninth day, and with salicylates on the
second to the sixth day, and I think the experience of
others will now fully bear out his conclusions in favour
of the salicylates.
In my paper on salicylic acid in the ' Transactions '
of the Society previously referred to (vol. Ixxi, p. 137) I
have said that the important point in the action of salicy-
lates is that they appear to be able to render the excretion
of uric acid independent of acidity, a point in which, so
far as I know, they stand alone amongst drugs ; and in my
thesis for the degree of M.D. (' Brit. Med. Journ,' July
7th, 1888) I have said that their curative action in rheu-
matism seems to me a strong point in favour of the uric
acid causation of this disease. It now seems to me that
the fact I have just been pointing out, viz. that salicyl
compounds are active in the cure of acute rheumatism
exactly in proportion to their power over the excretion of
uric acid, is another and by no means a weak argument in
the same direction.
I propose now to examine shortly some of the best
known and attested facts with regard to the action of drugs
and diet in acute rheumatism, and see how far they will
bear out the supposition of uric acid causation.
To begin with diet : is there any fact better known
and more completely attested than that a lowly nitrogen-
ous or non-nitrogenous diet is of the greatest importance
in acute rheumatism ? and is there any adequate explana-
IN THK TREATMENT OF ACUTE RHEUMATISM. 303
tion to be given of its effects^ except its influence on the
formation and excretion of uric acid ?
Among other authors Bouchard ('Le9ons sur les mahidies
par ralentissemeut de \•^^, nutrition/ pp. 241—2) narrates in a
most interesting passage that children fed much on meat,
meat juice, and jelly suifer from gastro-intestinal derange-
ments, constant affections of the skiu, and early migraine ;
and he goes on to say, "Le rhumatisme avec ses manifesta-
tions diverses est precoce et grave."
With regard to mig-raine I have the best of all reasons
(viz. personal experience) for endorsing this opinion,
and I believe that meat produces rheumatism by pro-
ducing and accumulating uric acid just as it produces
migraine.
Look again at the effects of beer, of excessive mus-
cular exertion or exposure to cold and damp,^ and do they
not all affect uric acid, and affect it in just tbe same way
both in rheumatism and gout ?
As to treatment, look at alkalies ; do they not represent
next to salicylates by far the most successful treatment of
rheumatic fever ? And what is their action on uric acid ?
just like salicylates, they cause a plus excretion of uric
acid both in health and disease, — only in the latter, having
first to overcome the acids present, their action is slower
and less powerful than that of salicylates. And in accord-
ance with this we see from Dr. Fagge's table that a large
number of patients get well on the second day or sooner
with salicylates, but not till the fourth day or later with
alkalies.
Some interesting points in this connection have been
brought out by those who have used acids or substances
which raise the acidity in the treatment of acute rheu-
matism.
In the ' Lancet,' i, 1874, p. 231, is recorded a case in
which Dr. Wilks gave dilute nitro-hydrochloric acid n^ xv,
quartis horis, with milk, bread, and beef-tea as a diet. I will
only note two points in the histoi-y of the case : first, that
^ " Collective Investigation Report," ' Brit. Med. Journ.,' i, 88, p. 387.
304 SALICIN COMPARED WITH SALICYLATE OF SODA
on the ninth day of treatment the patient was observed to
be perspiring freely, but the temperature was still as high
as 101"2°; second, that five days later (14tli day) the
swelling of the joints had gone and the urine was alka-
line.
I would also refer to some interesting remarks by Dr.
Fuller in the ' Lancet/ ii, 1862, p. 669, where he points out
that ammonia does not act as an alkali, and does not relieve
rheumatic fever, and that under its use the urine remains
acid and the pains bad ; but when potash is substituted
for it within two days the urine becomes alkaline, and the
pains are much relieved.
The action of ammonia in this matter, and the fact that
it acts as an acid and. not as an alkali, is now well known ;
and anyone who is interested in the point avIII find the
facts well stated in Dr. Mitchell Bruce's book on ' Materia
Medica and Therapeutics,' 4th ed., p. 48.
This no doubt explains the value of a dose of Sp. Amm.
Aromat. in the uric acid headache, which has been pointed
out by myself and others ; that is to say, it acts like an
acid, and it raises the acidity of the urine very decidedly,
as I have plenty of curves to show.
It will not be supposed that nitro-hydrochloric acid
made the urine alkaline (though I do not deny that in-
directly by causing dyspepsia it might do so) ; how then
did Dr. Wilks' patient get well even on the fourteenth day ?
From Dr. Fagge's table we see that most of the mint
water patients got well on the seventh to the eleventh day,
and if miut water had no action at all nitro-hydrochloric
acid must have had a bad or adverse action.
The explanation is, I think, that rheumatic fever is a
self-curing disease, and with favorable circumstances,
rest in bed and low diet, tends to recovery.
To illustrate this point a little let us suppose that some
one, who is estimating his urinary excreta from day to
day, goes to bed and puts himself on milk diet ; what will
be the result on the excretion ? His urea will fall, say from
500 grs. to about 300 grs. ; his uric acid, which was pre-
IN THE TREATMENT OF ACDTE RHEUMATISM. 305
viously slightly below its natural amount in proportion to
urea, having a relation of 1 to 35 or 1 to 38, will tend to
rise above it, having a relation of 1 to 28 or 1 to 26 {i. e.
a pkis excretion of uric acid) ; and the acidity o£ the urine,
pi'Gviously equal to say 60 grs. of oxalic acid, will fall to
about 40 — 45 grs. If in addition he puts on plenty of
blankets so as to keep the skin moist, there will be a
fui'ther fall of acidity, and a further tendency on the part
of the uric acid to rise and be excreted in excess of the
urea : we have here, in fact, a natural plus excretion of
uric acid under the influence of alkali, i. e. of the lowered
acidity of the urine and increased alkalinity of the blood
and tissue fluids.
And if we get these results in a natural physiological
condition, how much more shall we get them in a condition
of disease such as acute rheumatism ! The patient is in bed,
and the limbs so painful that he cannot move a muscle ;
he has little or no appetite, and what food he does take is
imperfectly digested owing to the effect of the fever on
the digestive organs ; it is little wonder, then, that his urea
and acidity run rapidly down and soon become very low
indeed, and though the fever no doubt keeps them up for
a time, it soon has insufficient supplies to work upon, and
begins to lose its power.
This action of the skin in lowering acidity is clearly
seen in Dr. Wilks^ case mentioned above, where it is noted
that the patient perspires freely, and five days later the
note says that his urine is alkaline and his pains are gone.
I have no doubt that the alkalinity of the urine was
due to the causes I have attempted to outline above, and
that when Nature took the matter in hand she acted so
thoroughly that a small dose of acid had very little effect ;
and I know from experience that when a patient is run
down by exhausting disease it is not easy to raise the acidity
of the urine very much by giving acids.
While speaking of skin activit}^ and its effect on the
acidity of the urine I should like to quote what Sir A.
Garrod has said on this subject, as I believe it to be a point
VOL. LXXIII. 20
306 SALICIN COMPARED WITH SALICYLATE OF SODA
the importance of whicli has not as yet been thoroughly
realised. Thus^ in his work on ' Gout and Eheumatic
Gout,' 3rd ed.^ p. 258, he says, " Suppressed perspiration
is immediately followed by an increase of urinary acidity ;"
and I can not only amply confirm this assertion, but can
show also that the converse is true, and that increased per-
spiration lowers the acidity of the urine.
Let us look for a moment at what is said by some re-
cognised authorities on the question of the skin excretion,
especially the perspiration; thus Besnier {' Dictionnaire des
Sciences Medicales,' p. 496) says, " Dans le rhumatisme
articulaire aigu comme dans toutesles affections sudorales
la sueur examinee au moment de sa production sur un sur-
face de la peau convenablement debarrasse par le lavage
des enduits sebaces et des produits de decomposition de
Tepithelium et des corps gras, la sueur est a peu pres neutre
dans le plus grand nombre de cas, aussitot qu'il s'est etabli
une veritable diaphorese, plus nettement acide quand elle
est peu abondante ou qu'elle commence a couler, excep-
tionellement alcaline."
Sir A. Garrod (Reynolds' ' System,' vol. i, p. 896) says,
" The perspiration is generally considered to be intensely
acid in acute rheumatism ; in several cases I have found
it less acid than in healthy subjects ; but it must be
remembered that the amount of perspiration is excessive."
Prof. M. Foster {' Physiology,' 5th ed., part ii, p. 695)
says, " When sweat is scanty the reaction is generally
acid, but when abundant it is alkaline, and when a portion
of the skin is well washed the sweat which is collected
immediately afterwards is usually alkaline."
With regard to the above quotations my friend Dr. A. E.
Garrod tells me that he has himself seen several cases of
acute rheumatism where even in the early stages of the
disease the perspiration collected after the surface of the
skin has undergone careful cleansing has been neutral or
even alkaline, so that he is quite prepared to endorse
Besnier's observations just quoted.
With regard to this point I would remark, firstly, that
IN THE TREATMENT OP ACUTE RHEUMATISM. 307
the perspiration must be moderately copious if it is to be
collected at all in this way — a fact, it will be observed,
very properly pointed out by Sir A. Garrod in the above
quotation from Reynolds' ' System ;' and secondly, that it
does not follow that a very large amount of acid is not
got rid of by the skin in the twenty -four hours because
the excretion is neutral or even alkaline for a short
time, and when very copious. The urine is often alkaline
for a few hours in the morning, but yet the acid excreted
in the whole day may be considerable ; and again, when
the urine is very copious the acidity may appear very low
till we come to multiply the acidity by the quantity
excreted.
But the fact of most consequence, and which to my
mind absolutely deprives the above line of argument of
all force as regards the effect of the skin excretion on the
reaction of the blood and tissue fluids, is the one above
mentioned as pointed out by Sir A. Garrod, viz. that
suppression of perspiration is immediately followed by a
rise of urinary acidity ; and the further fact which I can
vouch for, and which it is easy to demonstrate, that
increased skin action and perspiration are followed by a
fall in urinary acidity. I take it, therefore, that in spite
of the above observations on the reactions of the perspi-
ration a very considerable amount of acid is got rid of in
the excretions of the skin both in health and disease, and
that this is often enough to depress very considerably the
acidity of the urine, and raise to a corresponding extent
the alkalinity of the blood and tissue fluids.
It seems, then, that all the methods of treating acute
rheumatism that are of any value have one effect in
common, the causation of a 'plus excretion or elimination
of uric acid.
And further, that as regards salicin and compounds of
salicylic acid, their utility in the disease is directly propor-
tional to their power of eliminating ui'ic acid.
May we then go further, and say that acute rheumatism
is due to uric acid ? I for one should be inclined to say
308 SALICIN COMPAKED WITH SALICYLATE OF SODA
that the joint pains of this disease are undoubtedly due
to uric acid ; but there remains still the question, what
drives the uric acid into the joints ?
To this I would reply, high and rising acidity of the
urine and concomitant decreased alkalinity of blood and
tissue fluids, acting on uric acid in this disease just as it
does in gout. But why then is rheumatic fever so differ-
ent in many ways from gout ?
I do not know that I can completely answer this ques-
tion, but I have a very strong impression that it may be
due to a difference in the amount of uric acid present, and
to a difference in the activity of metabolism of young sub-
jects in whom rheumatic fever occurs, as compared with
that of older subjects in whom gout is met with. The
chief difference is a greater activity in the metabolic pro-
cesses of the young, for while an adult forms and excretes
some three or four grains of urea per pound of body-
weight, a child of three or four years may excrete as
much as nine or ten grains per pound, as I can show from
my own investigations ; and with this larger formation of
urea in a child there is a greater formation of uric acid,
and, what is perhaps more important, a greater formation
of acids. It thus appears evident tbat a child might soon
have much more uric acid in its blood than an adult could
easily get, and any little febrile disturbance might raise the
acidity very greatly and precipitate the uric acid into
the joints.
Of course it is quite possible that an essential factor in
acute rheumatism is the formation of an acid in large
quantities by some fermentation process, or, as has been
suggested, by a bacterium ('Brit. Med. Journ.,' i, 1887,
p. 1381). I cannot express any opinion on these points,
but I do believe very strongly that the essential feature
of acute rheumatism is the retention of uric acid in the
joints and tissues of the body by a high and rising acidity,
and that this, and this only, will enable us to explain com-
pletely the results obtained with drugs and diet in the
treatment of this disease.
IN THE TREATMENT OF ACUTE RHEUMA.TISM. 309
Sir A. Garrod has recorded the fact^ that he has
repeatedly examined the blood in acute rheumatism, and
has never been able to find any uric acid there ; he says,
" The absence of uric acid or urate of soda is important,
as it at once shows an essential difference between gout and
rheumatism.'^ But this is exactly what I should expect,
for it is not likely that the uric acid can be in two places
at once ; and if, as I am supposing, a high and rising
acidity has driven it all into the joints, it is not likely
that any will be found in the blood. And some of Sir A.
Garrod's own observations lend, I think, strong support
to this explanation, for he has pointed out {' Gout and
Rheumatic Gout,' pp. 187 and 274) that there is no uric
acid in the fluid of a blister, or in blood drawn directly
over the inflamed joint in gout ; and he proceeds to argue
from these facts that inflammation destroys uric acid.
It has, however, been shown that fever^ lowers the
alkalinity of the blood and raises the acidity of the urine.
This would, as I have shown {' Journal of Physiology,'
vol. viii), cause a diminished excretion of uric acid in the
urine, and, as I have argued, diminish also the amount of
it in the blood ; and there can be very little doubt that a
local inflammation will have the same effect, viz. to
diminish the alkalinity of the blood and tissue fluids, and
drive the uric acid they contain out of solution. So that
while I think that Sir A. Garrod's facts are perfectly
correct, I believe that the result he notices is due to a
precipitation of uric acid, and not to a destruction of it.
This explanation affords us also an insight into the
causation of one of the differences between gout and
rheumatism ; for I believe I am correct in saying that the
temperature in acute rheumatism is generally considerably
higher than in gout, and therefore the effect on the alka-
linity of the blood and the precipitation of urates from
solution will be more complete in the former than in the
latter disease.
' Eeynolds' ' System of Medicine,' vol. i, p. 897.
2 Dr. Peiper, ' Virchow's Arch.,' June, 1889, p. 337.
310 SALICIN COMPARED WITH SALICYLATE OP SODA
There has been recently published {' Brit. Med. Journ./
i^ 1890, p. 472) a paper by Dr. B. N. Dalton on the
" Etiology of Rheumatic Fever," in which he urges that
this disease may be " caused by breathing air con-
taminated by the emanations from sewers and drains/'
and gives many interesting facts and cases in support of
his argument.
From my point of view such a mode of causation is
extremely probable, for if the sewer emanations give rise
to fever (as there is no difficulty in believing that they
may do), they will, as we have seen, raise the acidity of
the urine, and diminish the alkalinity of the blood and
tissue fluids ; and under certain conditions of metabolism
which are often present in young subjects they may cause
the precipitation of a large amount of uric acid in the
fluids and tissues of the joints, thus producing what is
known as rheumatic fever.
The way in which the uric acid is precipitated on the
fluids and tissues of joints I have pointed out in previous
papers (see 'Brit. Med. Journ.,^ ii, 1888, p. 12).
I have also pointed out that Sir A. Garrod has shown
that the tissues and fluids of the joints are less alkaline
than the tissues and fluids of the body generally ; in this
respect they resemble the spleen, in which uric acid is
constantly found, so that the precipitation in the spleen
and in the joints stands on the same ground, and is sup-
ported by the same facts and argument.
In a paper in Wood's ' Medical and Surgical Mono-
graphs,' New York, February, 1890, I have suggested
that some fevers may act on uric acid in exactly the same
way, and thus produce rheumatic fever; and also that
tonsillitis and even some local inflammations, as an alveolar
abscess, of which a case is narrated, may by raising the
temperature, and so the acidity, produce the same result.
Though I speak here mostly of the effects of fever I do
not wish to lose sight of the fact that several other causes
may raise the acidity, as, for instance, suppression of per-
spiration, as pointed out by Sir A. Garrod ; and a severe
IN THE TREATMENT OF ACUTE RHEUMATISM. 311
chill is a commouly accredited cause of rheumatic fever.
Another is the iugestiou of acids and acid-forming foods ;
and in this way I believe it is possible to produce " rheu-
matic " (uric acid) pains in almost anyone. Indeed, I
have often produced such pains in patients, the subjects
of high arterial tension, when giving them acids, opium,
and other drugs to reduce their tension.
Again, acids may be formed in the stomach to a very
considerable extent, as pointed out by Bouchard, and I
am sure from my own experiences that gastro-intestinal
troubles have a most important connection with some
cases of rheumatism.
Moreover, as previously mentioned, it has been sug-
gested that some fermentation pi'ocesses, with or without
the agency of a bacterium, may produce considerable
quantities of acid.
The excretion of uric acid in rheumatic fever is enor-
mous, and only to mention one case I found upwards of
26 grs. in the urine of a man with this disease on the
first day of taking salicylate of soda, having a relation to
urea of 1 : 1 7, the normal relation being 1 : 33. There
was here double the ordinary quantity of uric acid per
grain of urea ; and if the additional 13 grs. of uric acid
were all in the joints, it would, I think, account for most
of the trouble they gave. For I can cause very distinct
symptoms in my own joints by precipitating only 2 or
3 grs. into them.
Again, when salicylate is left off after a rheumatic attack
there is often very marked high arterial tension to be ob-
served for some days, thus pointing, I believe (see paper
on " Uric Acid and Arterial Tension," ' Brit. Med. Journ.,'
i, 1889, p. 288), to excess of uric acid combined with
alkali in the blood ; and if at this time fever, dyspepsia,
or excess of nitrogenous food causes a sharp rise in acidity,
a relapse is the common and easily explained result.
It would lead me too far to go minutely into the action
of all these causes here, but in conclusion I will merely
suggest —
312 SALICIN COMPARED WITH SALICYLATE OP SODA.
1. That tlie essential feature of rheumatic fever (viz.
the joint symptoms) is the result of a precipitation or con-
centration of all, or nearly all, the uric acid in the body,
in the tissues and fluids of the joints.
2. That this concentration is due, as in gout, to high and
rising acidity or greatly reduced alkalinity of the tissue
fluids, of which the high acidity of the urine may be taken
as an index, or the reaction of the blood may be taken as
more direct evidence.
3. That the completeness of this precipitation accounts
for the absence of uric acid from the blood in rheumatic
fever, as noticed by Sir A. Garrod.
4. That such a process of causation enables us to ex-
plain completely the action both of drugs and diet in rheu-
matic fever ; and, lastly —
5. That, as it has been the object of this paper to point
out, the compounds of salicin and salicylic acid have a
curative power in rheumatic fever which is precisely pro-
portional to their powers of eliminating uric acid, and that
they cure the disease by effecting such elimination.
(For report of the discussion on ttis paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 105.)
ON THE CONDITION OF THE EEFLEXES
IN CASES OF
INJUEY TO THE SPINAL COUD;
WITH SPECIAL REFEEENCE TO THE INDICATIONS
FOR OPERATIVE INTERFERENCE.
ANTHONY A. BOWLBY, F.R.C.S.Eng.,
SUBGICAI, EEGISTEAE AND DEMONSTRATOR OF PEACTICAL AND OPERATIVE
SUEGEEY, AND OF SUEGICAL PATHOLOGY AT ST. BARTHOLOMEW'S
HOSPITAL; ASSISTANT SURGEON TO THE METROPOLITAN
HOSPITAL ; SrRGEON TO THE ALEXANDRA
HOSPITAL FOR HIP DISEASE.
Received March 23th— Read May 13th, 1890.
On February 25th of the present year a paper was read
before this Society by Dr. Charlton Bastian on the " Sym-
ptomatology of Total Transverse Lesions of the Spinal
Cord, with special reference to the Condition of the
various Reflexes/^ The author pointed out that, contrary
to the generally accepted teaching, the deep reflexes were
abolished in such cases ; and he supported his contention
by cases observed by himself, and by reference to the ob-
servations of others.
In the discussion which ensued I ventured to speak of my
own experience of injuries of the spinal cord, and stated
314 ON THE CONDITION OF THE REFLEXES IN
that in tweuty-two cases observed during the past six years
at St. Bartholomew's Hospital the reflexes were never
exaggerated when the spinal cord was completely crushed.
Since speaking on this subject it has seemed to me that,
considering the importance of the issues raised, it would
be advisable to record somewhat more in detail the cases
I have observed, and I am encouraged to do so by the fact
that in but few published examples of injury to the spinal
cord is there any definite statement of the conditions of
the reflexes.
I am aware that the opinions expressed in this paper
are at variance with the accepted doctrines of physiology
and with the results of experiments, but the facts I record
can be supported by the testimony of various independent
observers who have seen the patients with me, and I have
in all the cases demonstrated the conditions of the reflexes
to the students dressing in the surgical wards of St. Bar-
tholomew's Hospital. Microscopical preparations of the
spinal cords were made in most cases, and for several of
them I am indebted to my friend Dr. Howard Tooth.
For the purposes of this paper I have taken twenty-one
cases of complete crushing of the spinal cord, in all but
one of which this condition was confii^med by post-mortem
examination. In ten cases, however, the patients survived
but a few hours, and I have not therefore thought it
advisable to make use of them in considering the state of
the reflexes, although I have alluded to the conditions
found at the autopsies in considering the question of
operative interference. I may state, however, that in no
single case were any reflexes or rigidity of muscles shown,
although, on the other hand, in the more rapidly fatal
cases they were not examined for by those who treated
them, and such patients were not seen by myself.
In the eleven other cases, notes of which are appended,
the various reflexes were especially observed by myself as
well as by others, and records were made at the time.
I have also given brief notes of cases of injury of the
spinal cord when from the symptoms it was evident that
CASES OF INJURY TO THE SPINAL CORD. 315
there had not been complete solution of continuity, and
have pointed out that in these the reflexes are increased.
I may further add in explanation of the term " fracture
dislocation " which is frequently employed, that by it is
implied a partial dislocation of the body of one vertebra
from that of another, combined with fracture of the body
or processes of the displaced bones.
Cases of Complete Transverse Lesions of the Spinal Cord.
Case 1. — T. B — , aet. 45, fell through a window on to
his head on August 7th, 1888. On admission under Mr.
Willett he complained of pain in his neck and of loss of
power and of sensation in the trunk and limbs. He was
found to be completely paralysed in the lower extremities
and the trunk. There was anaesthesia of the abdomen,
and of the thorax below the nipples. Respiration was
almost entirely diaphragmatic. There was incontinence
of faeces and retention of urine. The arms were not
paralysed.
9th. — Priapism was marked.
loth. — Reflexes examined. The legs and thighs are
flaccid ; there is no clonus or rigidity ; the knee-jerks are
absent on each side ; there is no reflex on tickling the feet.
The patient developed cystitis and bronchitis, and died
on September 23rd, the reflexes not having returned.
Post-mortem examination showed a fracture dislocation
at the second and third dorsal vertebrae. There was no
pressure on the cord, and the membranes were uninjured.
The spinal cord itself appeared natural until it was cut
open ; its structure then appeared blurred and homogene-
ous, and a microscopic examination showed below the seat
of fracture the usual typical descending degenerations.
Case 2. — John H — , aet. 58, fell from a height on to
his head on July 17th, 1887, and was at once paralysed.
He was admitted into Colston Ward under Mr. Langton,
316 ON THE CONDITION OP THE REFLEXES IN
and on July 23rd there was found to be complete anaes-
thesia of the lower extremities, of the abdomen, and of
the thorax below the second intercostal space. The respi-
ration was diaphragmatic. The sphincter of the rectum
was paralysed. The urine was retained. The extensors
of the forearms were paralysed, but the elbow, fingers, and
wrists could be flexed. There was no rigidity, no ankle-
clonus, and no knee-jerks. There was slight sole reflex
on each side, but no cremasteric reflex.
Three days later the patient died.
A post-mortem examination showed a fracture disloca-
tion of the fifth and sixth cervical vertebrae, the frag-
ments being in good position and not compressing the
cord. The membranes were untorn, but the cord was
completely crushed to a pulp.
Case 3. — A man, set. 42, fell on the back of his head on
October 17th, 1887, and at once lost power in his lower
extremities. He was admitted into Colston Ward under
Mr. Langton. The day after the injury his lower extre-
mities were found to be completely paralysed, the abdo-
minal and thoracic muscles were paralysed, and sensation
was lost below the third rib in front. There was incon-
tinence of faeces and retention of urine. There was but
little anaesthesia of the arms, but the extensors of the
forearms, wrists, and fingers were paralysed. There was
slight priapism.
On October 21st the reflexes were examined. Both
deep and superficial reflexes were completely lost in the
lower extremities. There was no rigidity.
November 7th. — On tickling the soles there was decided
movement of the toes. No clonus or rigidity.
The patient died a week later, and a post-mortem exa-
mination showed a fracture dislocation of the sixth and
seventh cervical vertebrae, without any displacement. The
spinal cord was quite pulped.
Case 4. — A lad, get. 18, fell down a lift on June 17th,
1887, and was admitted into Rahere Ward, under the care
CASES OP INJURY TO THE SPINAL CORD. 317
of Mr. Baker. The same day he was found to have com-
plete paraplegia with retention of urine and incontinence
of faeces. Respiration was diaphragmatic^ and sensation
was lost below the nipple. The extensors of the forearms
and wrists were paralysed.
On June 20th there was found to be some further loss
of sensation, so that now anaesthesia was complete below
the second rib. Priapism was marked, and was increased
by catheterisation.
29th. — Examined for reflexes. There was no rigidity
of the lower extremities, and both superficial and deep
reflexes were absent.
November 1st. — Still no reflex in lower extremities.
December 1st (twenty-four weeks after the accident). —
Distinct return of the sole reflexes, the toes being moved
when the foot is tickled. No patellar reflex ; no clonus ;
no pectoral reflex. The patient says that he has a tin-
gling and pricking sensation over the chest when a catheter
is passed, and after its passage there is profuse perspira-
tion over the head, face, and neck, and the development
of a bright red rash which persists for fifteen or twenty
minutes.
31st. — No change in the reflexes.
January 26th, 1888. — The patient died.
A post-mortem examination showed a fracture disloca-
tion at the junction of the seventh cervical and first dorsal
vertebrae. There was no displacement at the time of death.
The membranes were intact, but the spinal cord was
crushed to a pulp.
Case 5. — H. W — , aet. 54, fell from a height of sixteen
feet on to a wall, striking his back. He at once felt as
though he had lost his legs.
He was admitted under the care of Mr. Morrant Baker
into Harley Ward, where two days later, i. e. on September
11th, 1884, his breathing was found to be chiefly diaphrag-
matic, and his abdominal muscles and lower extremities
to be completely paralysed. His urine was retained, and
318 ON THE CONDITION OF THE REFLEXES IN
motions were passed involuntarily. His legs and thighs
were quite limp and flaccid, and there were no knee-jerks
or ankle-clonus on either side. The cremasteric, sole,
and epigastric reflexes were also absent.
The patient gradually sank, and died on January 30th,
1885, from suppurative nephritis, having survived the
accident nearly six months.
A post-mortem examination showed that the bodies of
the fifth and sixth dorsal vertebras had been fractured.
The fracture had united, but there was no compression of
the cord. The dura mater was a little thickened, but was
not torn open.
The spinal cord looked as though it had been pinched
opposite to the seat of fracture, and was here quite
difiluent. Microscopical examination showed that it was
completely disorganised.^
Case 6. — Mary C — , set, 54, fell downstairs on November
17th, 1886, and was found lying on her back in a helpless
condition.
She was brought to St. Bartholomew's Hospital, and
was admitted into President Ward under the care of Mr.
Willett. She had severe pain in the neck ; the legs,
thighs, abdomen, and thorax were anaesthetic ; the respira-
tion was diaphragmatic ; there was complete loss of power
in all the muscles of the lower extremities ; the sphincter
ani was paralysed, and the urine was retained. The upper
extremities were partially paralysed, the pectorals, deltoids,
and biceps alone acting. The hands and forearms were
nearly quite anaesthetic. The lower extremities were
flaccid, and the knee-jerks and the sole reflexes were absent.
The patient died on November 20th, three days after the
injury, without there having been any alteration in the
symptoms. A post-mortem examination showed a fi^acture
of the fifth and sixth cervical vertebras with complete
crushing of the cord. The cord was not compressed by
displacement of the fractured vertebrae.
^ See report by Dr. Tooth in ' St. Bartholomew's Hospital Reports,'
vol. xxi, p. 141.
CASES OP INJURY TO THE SPINAL COED. 319
Case 7. — Florence S — , set. 31, fell on her head on July
11th, 1885, and was at once paralysed. She was admitted
into Lawrence Ward under the care of Mr. Smith. There
was complete paraplegia with incontinence of faeces and
diaphragmatic breathing. Sensation was lost on the inner
side of the arms, and the extensors of the forearms and
wrists were paralysed. There was no rigidity, and the
reflexes of the lower extremities were lost. The patient
died in four days, and a post-mortem examination showed
a fracture dislocation of the fourth and fifth cervical verte-
bras with complete crushing of the spinal cord. There
was no pressure on the cord by displaced fragments, and
the dura mater was not torn.
Case 8. — Henry S — , set. 41, fell from a height of twelve
feet on to his head, and was admitted into hospital under
Mr. Baker in an unconscious condition on March 14th,
1889. He soon regained consciousness, and then com-
plained of great pain in the neck, and was found to be
completely paraplegic. A more complete examination
next day showed that there was complete anaesthesia below
the level of the second rib, and paralysis of the muscles
of the chest, abdomen, and lower extremities. Urine was
retained and faeces were passed involuntarily. In the upper
extremities there was numbness in the distribution of the
ulnar and internal cutaneous nerves. The lower extremi-
ties were quite flaccid, and the sole reflex and the knee-
jerk were absent on each side. There was no clonus.
The patient survived a week, but the reflexes did not
return. A post-mortem examination showed a fracture
dislocation of the sixth and seventh cervical vertebrae
without any material displacement of fragments. The
dura mater was intact, but the spinal cord was completely
crushed.
Case 9. — A man, aet. 63, fell from a scaffolding on to
some rails on December 6th, 1884, and was at once para-
lysed. On admission into St. Bartholomew's Hospital
under Mr. Baker he was found to have complete loss of
320 ON THE CONDITION OF THE REFLEXES IN
sensation and of motion below the second rib, with paresis
of the left arm. The epigastric and sole reflexes were
absent, as were also the knee-jerks. The limbs were
flaccid. The patient died the day after the accident, and
a post-mortem examination showed a fracture dislocation
of the fifth and sixth cervical vertebrse with laceration of
the spinal cord.
Case 10. — A man, get. 43, fell off a ladder on April 12th,
1888. On admission into Henry Ward under Mr. Smith
he was found to have complete loss of sensation and motion
in the lower extremities, with loss of sensation below the
level of the fifth rib, and paralysis of the muscles of the
abdominal wall as well as of the lower intercostals. He
complained of great pain in the back. The urine was re-
tained, but there was marked priapism ; there was also
incontinence of fasces. Further examination showed that
the lower extremities were quite flaccid, and that the sole,
epigastric, and patellar tendon-reflexes were all absent.
There was no clonus. As there was no change in the
condition of the patient he was sent to an infirmary ten
days later.
Case 11. — W. G — , a man set. 52, was admitted into
Colston Ward under the care of Mr. Langton on March
12th, 1890. He had fallen from a scaffold, and was picked
up unconscious. The day after admission, when he had
recovered consciousness, I found him quite paraplegic,
with absolute anassthesia and loss of power below the third
rib. There was marked priapism. The hands and arms
were feeble, but there was no definite paralysis or loss of
sensation. Breathing was difficult. An examination of
the reflexes showed complete loss of patellar tendon-
reflex with absence of clonus and rigidity. The cremas-
teric reflexes were absent, but touching the skin of the
penis caused increased priapism. There were no sole
reflexes.
The following day I examined him again with Dr.
Ormerod. The right sole reflex had returned, but the
CASES OP INJUKY TO THE SPINAL CORD. 321
deep reflexes were unaltered. The contraction of all the
muscles of the lower extremities to a direct blow was much
increased. The supinator reflex on the right forearm was
increased.
On March 15th the left sole reflex had returned, and
the area of anaesthesia had extended as high as the second
rib.
On March 17th the patient died of congestive pneu-
monia without further alteration in the reflexes.
A post mortem examination showed a fracture disloca-
tion of the first and second dorsal vertebras. The dura
mater was untorn, but the spinal cord was completely
crushed, and was quite difiiuent.
Cases of Partial Lesion of the Spinal Cord.
Case 1. — J. R — , aet. 16, was admitted into Harley
Ward under Mr. Morrant Baker on June 6th, 1889,
having fallen from a height of six feet on to the back of
his head.
On admission he was found to be conscious, but could
not nod his head or rotate it on account of pain in his
neck. No deformity could be seen. The patient com-
plained of " numbness all over," but was not completely
paralysed, although unable to stand. Both legs could be
moved, but the left leg was very feeble, and neither limb
could be raised from off the bed. Both knee-jerks were
increased. The next day he was more carefully examined,
and it was found that he could move the right leg feebly,
although the left was quite paralysed. The intercostal
muscles acted feebly. Urine was retained, but the
sphincter ani was not relaxed. The hands and forearms
were not paralysed, but were very weak.
June 8th. — Can move both legs a little, and has passed
his water naturally.
11th. — Has gradually gone back again, and has reten-
tion of urine and fuither loss of power in the left leg.
VOL. LXXIIJ. 21
822 ON THE CONDITION OF THE REFLEXES IN
The left knee-jerk is absent, but the right knee-jerk is
increased.
13th. — Better again. Both knee-jerks are increased.
He has more power in the legs and in the arms. Passes
urine normally.
20th. — Some rigidity of both lower extremities with
exaggerated knee-jerks and clonus. The left arm and
leg are very weak, and can scarcely be moved. The right
arm is fairly strong, but the right leg is very feeble.
Micturates naturally,
July 25th. — Has slowly improved in every way, but has
a good deal of pain in the neck.
August 29th. — Continues to improve. Sensation has
returned considerably in both upper and lower extremities,
and there is definite increase of power in the left arm
and leg.
October 3rd. — Going on well. Patellar reflexes still
exaggerated, and some tremor in quadriceps extensors.
Ankle-clonus well marked. Sole reflex increased. Lower
extremities still a little rigid. Power of movement much
improved.
24th. — Knee-jerks not so much exaggerated. Is much
better in every way, and gets out of bed in the evening.
November 21st. — Can walk with the aid of a stick.
29th. — Discharged. Left leg and arm weak. Reflexes
of lower extremities still exaggerated.
February 20th, 1890. — Almost quite well, but complains
of some remaining weakness with left arm, although this
is rapidly improving. Knee-jerks are still exaggerated,
although but slightly.
Cash 2.— T. L— , set. 39, fell off a van on April 19th,
1884, and injured his back. He was admitted into Col-
ston Ward under Mr. Langton. His legs felt numb and
powerless directly after the injury, and on examination at
St. Bartholomew's he was found to be almost quite para-
plegic.
Next day his reflexes were examined. The lower ex-
CASES OF INJURY TO THE SPINAL CORD. 823
tremities were rigid, the patellar reflexes were increased,
and tickling- the soles caused spasmodic twitching of the
muscles of the thigh and leg.
The patient quickly improved, and in three days' time
he was again able to move the legs and thighs. A week
later he could get out of bed and walk with the aid of
crutches.
Numbness, rigidity, and increased reflexes continued
for some months.
Case 3. — A man, get. 28, fell and struck his spine, and
at once felt a loss of power and numbness in his lower
extremities. He was admitted into Abernethy Ward under
the care of Mr. Savory, and was found to have partial
paralysis of the legs and thighs, but no incontinence of
faeces or retention of urine. He could lift the legs off
the bed whilst lying down.
Next day further examination showed increase of knee-
jerks on both sides, muscular tremor and spasm on tickling
the soles, and ankle-clonus. He rapidly improved, and
made a complete recovery in fourteen days.
I have purposely abstained from entering into any
lengthy details as to the course and complications of the
cases here recorded, as the object of this paper is to direct
attention to a few definite observations. The first and
chief fact which is demonstrated is that in cases where
the spinal cord is completely crushed in the cervical or
dorsal regions the deep reflexes are at once lost and do
not return. I am aware that it has been formerly sug-
gested as an explanation of this that the cause of their
disappearance is shock, but this theory has never been
supported by anything in the shape of proof. On the
other hand, it is clearly shown by the cases here described
that after the lapse of a time much more than sufficient
to allow of recovery from shock the deep reflexes are
absent. Thus one patient survived a month, another
six weeks, a third five months, and a fourth ten months.
324 ON THE CONDITION OF THE REFLEXES IN
Tlie superficial reflexes are also generally lost imme-
diately after tlie accident, although this is not invariably
the case, and they, unlike the deep reflexes, may in time
return. In Case 2 the superficial reflexes were never
lost. In Case 3 they returned on the eighteenth day,
but in Case 4 not until the twenty- second week. In
Case 5, when the patient survived five months, they were
not noticed to return, and this also happened in all the
other patients who survived for periods varying from one
day to six weeks, with the exception of Case 11, in which
the sole reflexes returned on the second and third days
following the injury.
On the other hand, when the cord has been injured,
and when it is compressed, but when also its continuity
has not been entirely interrupted, the reflexes are not only
preserved, but may be, and generally are exaggerated.
The bearing of these facts on the question of operation
is obvious. If the limbs are flaccid and reflexes are
absent the diagnosis is that the cord is completely severed ;
and, as it is known that in the human subject such a
lesion is never repaired, operative interference is useless,
and should not be undertaken. If, however, in spite of
paralysis more or less complete tliei-e is rigidity and
increase of reflexes, then the diagnosis is that there is but
partial severance of the cord, and if there be any indica-
tions for operation, such as apparent compression by dis-
placed bone, there is justification for such a measure.
It must, however, be pointed out that operative inter-
ference can but seldom be of avail, and that in the vast
majority of cases of fracture dislocation of the spinal
column no good whatever can arise from it. This is
made abundantly clear by a consideration of the condi-
tions found on post-mortem examination. Among the
ten fatal cases I have recorded where the spinal cord was
found, post mortem, to have been completely crushed,
there was no pressure by displaced bone in any one. In
addition to these I have made post-mortem examinations
of nine other examples of fracture dislocation, and of one
CASES OF INJURY TO THE SPINAL CORD. 325
of simple dislocatiou without fracture, and in not one of
them was there found auy compression of the cord by dis-
placed bone. From a consideration of the conditions
found on post-mortem examination of these twenty cases I
think it may be concluded that the cord is injured by a
forward dislocation of the body of the upper of the two
vertebras involved in the injury, and that the spinal cord
is suddenly and violently stretched and crushed across
the upper and posterior margin of the body of the vertebra
below. As soon as the force which has caused the injury
is withdrawn the displaced vertebra is restored partially
or entirely to its natural position by the elasticity of the
ligaments and the contraction of the muscles. Unfortu-
natel}'^, however, the mischief is already done, and the
cord is injured beyond repair. In most of the cases I
examined I found the dura mater uninjured, and in many
of them the cord within it at first appeared natural. It
was often only on section that the amount of injury
inflicted could be estimated.
In conclusion I would point out that although I con-
sider there is suflScient proof that in all cases of total
transverse lesion of the spinal cord the deep reflexes are
abolished, and that in cases of partial lesion the reflexes
are increased, I am not prepared to assert definitely that
in all cases of partial lesion there is necessarily such in-
crease. It may be that in some severe cases of this
class the reflexes are also abolished for a time, and I am
acquainted with a case, which I did not myself observe,
in which in a patient with undoubted partial lesion the
reflexes were said to be abolished.
This is a matter which may easily be determined by
future careful examination.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. n4.j
SENILE HYPEETEOPHY AND SENILE
ATEOPIIY OE THE SKULL.
GEOEGE MURRAY HUMPHRY, M.D., F.R.S.,
PBOFESSOR OF SUEGEEY IN THE UNIVEBSITT OF CAMBEIDGE.
Received May 12th— Read May 27tli, 1890.
I AM desirous of directing the attention of the Society,
in a more especial manner than has hitherto been done,
to two changes of opposite natui'e which are not very in-
frequent in the skulls of elderly persons, affecting chiefly
the vault of the skull, both of which, so far as I know,
are peculiar to this part of the skeleton, and for neither of
which is it easy to offer a thoroughly satisfactory explana-
tion. One of these consists in an increase of bony material
and weight — a hypertrophy ; the other in a diminution of
bony material and weight — an atrophy.
It is well known that shrinkage of the brain-substance,
associated with old age, general wasting or prolonged al-
coholism, is commonly attended with an increase of fluid
in the meshes of the pia mater or a thickening of the cal-
varial part of the skull or with both these conditions.
Both conditions, we may judge, proceed from the same
cause, viz. a lessening of the pressure in the cranial cavity
resulting from the brain-shrinkage, a consequent dilatation
of vessels and a slowing of circulation in them which leads
to an increased filtration of their contents, serous and cellu-
328 SENILE HYPERTROPHY AND
lar, and a dropsy of the pia mater or a hypertrophy of the
calvaria or both. The condition is comparable with that of
a part under a bell-glar.s (or cupping-glass) or other ex-
hausted receiver ; and the results are similar to those
which take place in chronic oedema, viz. an increase not
only of the fluid or serous components of the blood but
of the cell-constituents also, and an increase of tissue-deve-
lopment. The latter, indeed, is not an uncommon sequence
of prolonged dropsical condition from whatever cause it
arises. Thus prolonged oedema of the lower limbs is
often attended with thickening of the connective tissues,
as illustrated in elephantiasis arabum, where the hyper-
plasia may extend to the bones causing thickening of them
with nodular outgrowths ; and thickening and sclerosis of
bones readily follows upon congestion of blood-vessels in-
duced by various causes, that is to say, the greater or
less nutrition of these tissues, of bone in particular, — their
hypertrophy or atrophy — is dependent, partly, upon their
own nutritive energies, partly, upon the greater or less
supply of nutritive material and tissue-forming elements,
and, partly, upon the more or less true balance between
these two. And it may be, or rather must be, a feature
of proper and properly regulated nutritive force to appro-
priate the required nutritive material and no more — not
merely to turn to account, but to control and keep within
bounds, the energies of the leucocytes with which they are
supplied. The paradox may thus come about that in the
connective tissues, more particularly bone and fat, under
certain circumstances, a decrease of nutritive force may
lead to an increase of nutrition or hypertrophy ; and it
may be that the same failure of nutrition which in the
aged person causes wasting or atrophy of the highly or-
ganised brain-tissue may cause thickening or hypertrophy
of the more lowly organised brain- case, first, by inducing
an increased afflux of blood there, and, secondly, by dis-
abling the osseous tissue of the skull from controlling the
ossifying tendencies of the blood-elements effused into it.
Whatever may be the view of the precise pathology of
SEXILE ATROPHY OF TEIE SKULL. 329
the condition, it seems to iiave its analogue in the enlarge-
ment of the prostate and the thickening of the arteries so
common in old people.
The coloured drawings (PL III, and PL IV, figs. 1 and 2)
show the congested state of the diploe and of the inner
tables of the skull-vault from an alcoholic man, aged 50,
who died in Addeubrooke's Hospital of apoplexy in the
early part of this year. The skull-wall is somewhat thick-
ened by boue deposit on the interior, and is slightly denser
than natural. I have lately seen a similar, though not
so marked, congestive condition in the skull of a man
aged 73 ; and the large size of the vascular canals often
seen on the interior of the senile skull renders it pi'ob-
able that a state of congestion is not uncommon in the
vessels of this part in those who are advanced in life.
The thickening of the skull-wall in old people takes
place chiefly, if not exclusively, on the interior, and is
commonly first and most marked beneath the domes of
the frontal bone, on the two sides of the median line, over
the part, that is, of the frontal lobes where brain-shrinkage
is first and most marked. It alters the inner contour of
these domes, flattening them, or even causing them to
bulge, on the interior. After a time it affects the whole
of the frontal bones and the rest of the vault, and may
reach the base, thus extending over all the interior of
the skull. In some cases the frontal and parietal bones
thus thickened are cancellous, the diploe being increased
and advancing upon the receding inner table, and there
may be little or no increase of weight. In other cases, and
more frequently, the inner table is thickened and bony
deposit takes place in the diploe, which is thereby con-
densed ; and the skull-wall is not only thickened but
rendered throughout denser and heavier. In some the
condensation or obliteration of the diploe has taken place
without much thickening of the skull-wall. It is the
increase at the expense of the cranial cavity which dis-
tinguishes the thickening of the skull in old age and in
other cases of brain-shrinkage from the thickening that
330 SENILE HYPERTROPHY AND
takes place in osteitis deformans and some other low in-
flammatory affections, for in these the increase is caused
by addition to the exterior.
The following specimens in the Cambridge Pathological
Museum illustrate these points : — 1. A nearly edentulous
skull with great thickening of the wall and increase of the
diploe except at the base, the thickening being at the ex-
pense of the cranial cavity. In this case there is not
much increase of weight. 2. An edentulous skull with-
out lower jaw and with atrophied superior maxillary and
facial bones, but with thick dense skull-wall, weighs 34 oz.
3. The edentulous skull of an aged female with much
wasted maxillary and facial bones, weighs 24| oz. The
bones of the cranium are not thick but rather dense, and
the ridges in the interior are somewhat pronounced. 4,
5, 6. Three skulls without lower maxillae, edentulous, and
with the usual thinning of the superior maxillary and facial
bones, weigh respectively 28| oz., 28 oz., and 26^ oz.
7. The skull of a man reputed to have died at 104 from
which the lower jaw and all the back part (about a
quarter of the whole cranium) has been removed, and
which is edentulous and with wasted facial bones, weighs
17 oz. 8. The lower part of an edentulous and evidently
very aged skull from which the upper part has been re-
moved a little above the orbits, weighs 15 oz. 9. A
thick dense piece of the upper part of the skull from a
woman aged 80. In all of them, except No. 1, the bones
are dense and more or less thickened ; there has been
addition of osseous matter interstitially as well as upon
the inner surface ; and the contrast between the thick,
heavy, dense cranium and the thin light facial bones is
marked in all these instances. I have long been in the habit
of illustrating this as well as the contrast with the other
bones of the skeleton by showing the skull and thigh-bone
which I took from a woman reputed to have died at 103,
and which are in the same museum. Although only one
tooth remains, the alveolary processes are nearly gone, and
though the maxillary and other facial bones are thin and
SENILE ATROPHY OF THE SKULL. 331
liglit., yet the skull weighs 28^ oz., which is above the
ordinary weight of the adult skull in which the teeth re-
main. The increase of weight is due to the thickness
and density of the cranial bones, the tables being thick
and the diploe dense. The encroachment upon the cranial
cavity is, as usual, most marked under the frontal domes,
but there has been some deposit upon the whole of the
interior. The thigh-bone of this person, though large and
well formed, weighs only 5 oz. ; the reduction of weight
being caused by absorption of the cancelli and thinning
of the bone-wall from the interior. The other bones of
the skeleton were in a similar atrophied condition ; and
the want of correspondence between the thick, heavy skull
and its fragile supporters was very striking. It should
be said that the old woman had latterly been bedridden.
The problem of the cause of the ill-assorted condition
of these bones — the dense heavy skull and the light porous
fragile thigh-bones in the same person — is not very easy
to solve. The increase and density of weight in old
people is, so far as I know, quite peculiar to the skull-
wall. All the other bones, as age advances, become lighter
and undergo absorption, which commences and proceeds
most rapidly in the cancellous or most vascular parts. This,
it is true, is often accompanied by some addition to the
exterior in the form of bony outgrowths into the perios-
teal and tendinous surroundings ; but these are slight and
by no means compensate for the absorption within and the
loss of weight attendant thereon. It is this absorption
and thinning of the cancelli, upon the strength as well as
the perfection of arrangement of which the upper part of
the thigh-bone is much dependent, that renders fracture
in that situation so liable to occur in elderly persons. I
can only suppose that fatty growth dominates in the
skeleton generally more than it does in the skull, and that
the same failure of nutritive force which leads in some
cases to hone-formation in the latter, leads to hone-ahsorp-
tion and fatty degeneration in the former.
The other change incidental to age which is also pecu-
332 SENILE HYPERTROPHY AND
liar to tlie skull is atrophy taking place from the exterior,
whereby the bones are rendered thinner and the cranium
proportionately smaller. This is common to all the bones
of the skull, affecting the maxillary bones in an especial
degree, and the other facial bones more or less, all these
becoming reduced in calibre as well as in thickness of
their walls, and the face becoming proportionately smaller.
In the calvarial parts the change is usually more marked
than in the rest of the skull-wall. The outer table re-
cedes, encroaching upon the diploe, and approaching or
coalescing with the inner table, so that the bone may be
composed of only one thin brittle table. It is a curious
process by which this change takes place, for the absorp-
tion of the outer table is not attended with any roughen-
ing of the exterior. Absorption and deposition go on
together, almost at the same spot. While the outer hard
laminge are being removed by the former, the subjacent
laminae are becoming condensed by the latter, and when
these again become the subjects of absorption the layers
next beneath them become the seat of deposition. Similar
changes are observed in the bones of the skull and of
other parts when absorption is caused by pressure, as by
tumours and sometimes by aneurysms, the lowered or de-
pressed surface being usually smoothed by a fiUing-in of
the cancelli accompanying or preceding the removal of
the exterior, and accordingly the part looks as if it had
been pi-essed or beaten in, and so differs from the rough,
ragged, gnawed condition caused by cancer or ulceration.
In some instances this absorption takes place uniformly,
the several parts of the skull-wall becoming equally
thinned, and the entire skull being reduced in size and
still more in weight, as shown by the following examples
in the Cambridge Museum : An edentulous skull with
lower jaw weighs only 15 oz., and the greatest circum-
ference is 19J inches. It is very thin, yet the diploe is
in fair proportion. There is some recent bone-deposit in
the interior, and the meningeal grooves are large. Another,
without the lower jaw, and with a circumference of
SENILE ATROPHY OP 'IHE SKULL. 333
19| inches, weighs 11| oz. A third, from a very aged
female, with the lower jaw, weighs 14 oz., the greatest
circumference being 20| inches. The entire skeleton of
this person weighs only 88 oz., though it is evidently that
of a fine person, inasmuch as it measures 5 feet 8 inches,
the thigh-bones measuring 18j inches and the angles of
the neck with the shaft being 130°.
What are the causes which determine the incidence of
one or the other of these very opposite changes — increase
of thickness, with commonly increase of density and weight,
on the one hand, and decrease of thickness, with decrease
of weight, on the other hand — I cannot tell.
Though commonly, as I have said, the atrophic thinning
and removal of the outer table, affects the whole of the
calvarial part of the skull in an equal, or nearly equal,
manner, yet in some instances it does so very unequally.
It has an especial tendency to attack symmetrically the
parietal bones between their sagittal or mesial parts and
the parietal protuberances, causing those remarkable de-
pressions of which specimens are to be found in most mu-
seums, and of which there are nine in the museum at
Cambridge and four in the College of Surgeons, one of the
latter being a well-formed edentulous Egyptian and one a
Wallachian gipsy woman, aged 82, from the Barnard-Davis
Collection.^ They present, on the whole, much simi-
larity, being usually ovoid, measuring three or four inches
from before backwards and two or three transversely.
At the deepest or middle part the inner layer of the bone
may be exposed, reduced to extreme thinness or even quite
removed, but it is never, so far as I have seen, indented —
that is to say, the inner contour of the skull- wall is not
altered. This is shown in PI. IV, figs. 3 and 4. The
surface is smooth, though in a few instances it is slightly
rough and marked by vascular foramina ; and in the speci-
men from which PI. IV, fig. 4, is taken it is traversed by
^ These were doscribt'd by Mr. Eve at the Pathological Society (' Litncet,'
February 22nd, 1890, p. 404). One of the Cambridge specimens is an edentu-
lous ancient Egyptian skull.
334 SENILE HYPPUITROPHY AND
grooves foi- the meningeal vessels which emerge from the
sides and have come to appear on the exterior of the skull.
The circumference rises, or shelves, rather suddenly. This
is least marked in front and behind, and most marked at
the outer border, which often reaches, but does not exceed,
the temporal ridge ; and the outer border is nearly straight,
whereas the inner one is more convex.
These depressions are met with in every stage from a
slight, scarcely perceptible, alteration of the normal level
to a thinning down to, or through, the inner wall. I am
not aware that they are attended with any symptoms or
productive of any ill result, though they may render the
effects of a blow serious or even fatal. This was shown
by a case under the care of Mr. Wherry. A lady, aged 90,
fell upon the back of her head, was taken up insensible,
and soon died. The parietal depressions, as seen in PI. IV,
fig. 4, are unusually large and extensive, and numerous frac-
tures had taken place through them and into the surround-
ing bones. They are of irregular shape, and there are
islands in which the bone has been less removed than in
other parts. In a few instances they are accompanied by
similar depressions in other parts of the skull, occasionally
in the frontal bone but more commonly in the hinder
sagittal parts of the parietals (see PI. IV, figs. 2 and 3).
Some of these latter are more circular, resembling the
depressions in the so-called pewter-pot fracture, but with-
out any inflection of the inner table or any fissure ; and
I have never seen these depressions in other parts so deep
as those on the sides of the parietals. In a specimen at
Munich the depressions in the usual situation of the
parietals are circular in outline ; and in one, at Vienna,
they are further back than usual, being near the back of
the parietals. The depressions look as if the outer layers
of the skull had been filed or planed away ; but the surfaces
are commonly smooth, showing that the process of bone-
formation was coincident with that of bone-absorption.
In most instances the skulls thus affected are thin and
light, the thinning having taken place from the exterior, so
SENILE ATROPHY OP THE SKULL. 835
that the canals for the meningeal vessels are nearer the ex-
ternal surface than is normal ; and these canals are often
deepened internally by some bony deposit which extends
more or less over the whole of the interior of the skull ; and^
in the specimen represented in PI. lY, fig. 4, as already
noticed, they have, by virtue of the absorption on their
exterior and deposition on their interior, come to be on the
outer surface of the thin layer which remains at the bottom
of the depressions ; and they are seen passing on it to the
thicker edges at the margins of the depressions, where
they disappear. These canals are quite as large and
abundant as usual, or more so ; there is therefore no evi-
dence of diminution of vascularity at the parts affected or
elsewhere.
It is further to be observed that the absorption or atrophy
which produces these depressions may be associated in the
same skull with the opposite, viz., thickening and conden-
sation or hypertrophy. One of the specimens in the Cam-
bridge Museum, a calvaria which I took from a woman,
aged 73, who died of apoplexy, is very thick, half an inch
in the frontal part, also dense and heavy, weighing 18 oz.
The thickening is evidently due to bone-formation on the
interior which, especially in the frontal region, is remark-
ably uneven, knotty, and craggy. The parietal depressions,
which occupy the usual position and present the usual
features, have not reached the internal table because it
has receded from them ; and the skull-wall at their deep-
est part has about the normal thickness and more than the
usual density. In the specimen from the woman, aged 90
(PI. IV, fig. 4), where the depressions are so large, the
frontal bone is denser than usual and is thickened with hard
knots or tubercles on the interior ; and there is similar de-
posit in the vicinity of the depressions, though the depres-
sions themselves are free from it.
I have been much puzzled to account for these remark-
able and symmetrical parietal depressions — these freaks, as
it were, of senile process. That they are the result, not,
as I once thought possible, of some congenital defect, but
3oG SENILE HYPERTROPHY, ETC., OF THE SKULL.
of senile and pi'obably atrophic process, I can no longer
doubt, for all the complete skulls in which I have seen them
are edentulous, and give other evidence of senile change.
That the excesses in the atrophic process ai-e not alto-
gether confined to this particular situation is shown by the
occasional occurrence of similar depressions in other parts,
more particularly in or near the sagittal suture. But there
must be some special cause for this part of the parietal
bones being so liable to it and for its advancing here so
much more than elsewhere. The cause does not seem to
be related to anything in the development, the growth,
the texture, the blood-supply or the nutrition of the part;
nor to its being subject to the gi-eat variation of level,
observed by comparing the ill-filled skull of the negro with
the well-expanded oval dome of the European and with
the squeezed-out parietals in the flattened heads of South
American tribes. It cannot be said, as suggested by Mr.
Eve, to be the part last ossified or to be in the situation of
the parietal foramen. It is indeed the part into which
ossification early spreads as it advances from the central
parietal protuberance towards the middle line.
In default of other cause, it seems to me that the
pressure of the occipito-frontalis tendon, stretched upon
and playing over this the most prominent part of the
vertex, deserves consideration. The appearance of the
depressions is suggestive of pressure ; and their shelving
front and hinder edges are suggestive of pressure from
this source ; while their outer margins, which are nearly
straight, are limited to the range of the tendon of the oc-
cipito-frontalis, and do not ever exceed it. Some counte-
nance is given to this view by the observation in some senile
skulls of deep depressions, though I believe these are to
some extent inbendings, in the fore part of the temporal
fossas, which are obviously due to the pressure of the thick
anterior portions of the temporal muscles.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chirurgical Society,' Third Series, vol. ii,
p. 122.)
I
DESCRIPTION OF PLATE III.
Senile Hypertrophy and Senile Atropby of the Skull (George
Murray Humphry, M.D., F.R.S.)-
Calvarial part of skull of an alcoholic man, set. 60, who died of
apoplexy, showing congestion of the inner table, which, at parts,
was very marked. At all these parts the interior of the skull was
thickened by bony deposit causing elevations of the inner lobe.
VOL. LXVIII, 22
DESCRIPTION OF PLATE IV.
Senile Hypertrophy and Senile Atrophy of the Skull (Geoege
Murray Humphry, M.D., F.R.S.)-
Fig. 1.— Section of Plate III.
Fig. 2. — Skull, showing depressions on parietal bones between
sagittal parts and tubera parietalia, also one in middle line.
Fig. 3. — Section of the same through the median and lateral
depressions.
Fig. 4. — Effects of extensive absorption taking place somewhat
irregularly on parietal bones. The patient, a woman set. 90, died
from fractures through the thinned bones caused by a fall.
The view is from behind, and the forepart is much foreshortened.
i?*?Sf-
A CONTEIBUTION
TO
THE CHEMISTEY OE GOUT.
BY
SIR WILLIAM EGBERTS, M.D., F.R.S.
Received June 2nd— Eead June lOtli, 1890.
The chemistry of gout centres round the properties of
uric acid and the urates. It has long been known that
gouty concretions are composed of sodium biurate ; and
in 1848-54 Sir Alfred Garrod demonstrated the important
fact that the blood and morbid effusions of gouty persons
are abnormally impi-egnated with uric acid. No substan-
tial addition to our knowledge of the chemistry of gout
has since been made.
In a paper recently read before this Society I gave an
account of the combinations which uric acid forms with
bases. ^ It was there shown that uric acid forms three
distinct orders of salts, namely, neutral urates, biurates,
and quadrurates. The neutral urates are not known to exist
in the body. They can only be produced (artificially) in
the presence of the caustic alkalies, free from carbonates,
and as such conditions never occur in the living economy,
' " On the History of Uric Acid in the Urine," &c., comrauiiicated March
25tb, 1890. It 18 assumed throuorhout the present paper that the reader is
acquainted with the second section of my previous paper dealing with the
composition and reactions of the quadrurates.
340 THE CHEMISTRY OF GOUT.
the neutral urates caunot, with our present knowledge, be
assumed to take any part in the nratic phenomena of gout.^
The biurates, although existing pathologically in gouty
concretions, are not known with certainty to exist in the
healthy or physiological state. The quadrurates, on the
other hand, appear to be in a special sense the physiolo-
gical salts of uric acid. They constitute exclusively the
combination in which uric acid exists in normal urine ;
and, in animals which eliminate their nitrogen as uric acid,
like birds and serpents, the urinary excretion is composed
entirely of quadrurates. It is, moreover, susceptible of
proof that uric acid in liquids containing alkaline carbo-
nates and phosphates, such as are the serum of the blood
and its derivatives, enters into solution in the first instance
as a quadrurate. From these considerations it may be
inferred that in the normal state uric acid is primarily
taken up in the body as quadrurate, that it circulates in
the blood as quadrurate, and that it is finally voided with
the urine as quadrurate ; and that when uric acid makes
its appearance in any other guise, whether as crystalline
biurate in gouty deposits or as free uric acid in gravel,
this event is due to secondary and abnormal changes in
the quadrurate.
In the paper referred to I traced the changes undergone
by the quadrurate in the urine which lead up to the sepa-
ration of uric acid in the free state as gravel and urinary
sediments. In the present paper I propose to trace the
converse changes which the quadrurate undergoes in the
blood, and which lead up to the formation and deposition
of sodium biurate in the tissues of the body. These latter
changes are, I think, intimately connected with the pro-
perty possessed by the quadrurates of slowly taking up,
in the presence of the alkaline carbonates and phosphates,
an additional atom of base, and of being thereby converted
into biurates. A knowledge of this property permits a
coherent view to be presented of the succession of events
^ For this reason the notion of W. Ebstein that the neutral urates are
Cijncenied in the formation of gouty deposits appears to be untenable.
THE CHEMISTRY OF GOUT. 341
wliicli culminate iu the gouty paroxysm, and whioli may be
expressed in the following terms.
In the normal state the uric acid, which circulates in
the blood as quadrurate, is removed unchanged by the
kidneys, and is removed with sufficient speed and com-
pleteness to prevent any undue detention or any accumu-
lation of it in the blood. But in the gouty state — either
from insufficient kidney action, or from increased introduc-
tion of urates into the circulation, or from some altered
quality of the blood itself — the quadrurate lingers unduly
in the blood and accumulates therein. The detained quad-
rurate, circulating in a medium which is rich in sodium
carbonate, gradually takes up an additional atom of base,
and is thereby transformed into sodium biurate. This
transformation alters the physiological problem. The uric
acid, or rather a portion of it, circulates no longer as the
highly soluble and pre^sumably easily secreted quadrurate,
but as biurate, which, as we shall see, is almost insoluble
in blood-serum, and is, moreover, probably, and for that
reason, difficult of removal by the kidneys. Under these
new conditions sodium biurate accumulates more and more
in the blood, and when the accumulation has reached a
certain point it is precipitated in the crystalline form in
the joints and elsewhere, thereby determining the occur-
rence of a " fit of the gout."
The evidence on which this view is based was obtained
from a study of the behaviour of uric acid and the urates
under various conditions in different media.
It is obvious that the reactions of uric acid and the
urates which concern us in gout are not their reactions
with simple water, but their reactions with the alkaline
and saline media in which they exist and circulate in the
body, namely, in the blood and lymph ; and herein lies a
radical distinction, inasmuch as the reactions in question
are wholly different according as the medium is water on
the one hand, or blood and lymph on the other.
The serum of the blood and its cognates, the lymph,
synovia, and interstitial juices, are closely allied in chemical
342 THE CHEMISTRY OF GOUT.
composition. Besides albuminoid matters, blood-serum
contains certain saline ingredients, on wbicL. its behaviour
with uric acid and the urates essentially depends. The
sodium salts are present in proportion of about 0*7 per
cent., the potassium salts in the proportion of about 0*06
per cent., and the calcium and magnesium salts together
in the proportion of about 005 per cent. It is thus seen
that the sodium salts exceed all the other salts put together
in the proportion of about seven to one. And practically,
for our present purpose, we may consider the saline basis
of the blood-serum as consisting essentially of sodium
salts, so greatly do these preponderate over the sum of
all the other salts put together. The most abundant of
the sodium salts is the chloride, which is present in a very
constant proportion of 0*5 per cent. The next most abun-
dant salt is the sodium carbonate, probably, chiefly at least,
in the condition of bicarbonate. This latter is present
in the proportion of about 0*2 per cent. The third sodium
salt is the phosphate, which, however, is only present in
the proportion of about 0*03 per cent. The serum has
always a sharply alkaline reaction, which is due to the
large proportion of sodium carbonate contained in it.
From these particulars it may be gathered that a watery
solution containing 0'5 per cent, of sodium chloride and
02 per cent, of sodium bicarbonate would be a fairly
exact imitation of the blood-serum in so far as its saline
ingredients are concerned. And it was found experiment-
ally that such a solution behaved in regard to uric acid
and the urates in the same manner as blood-serum itself,
and in the same manner as a solution composed of all the
salines of the serum in their due proportion, as ascertained
by the best analyses. A solution was therefore prepared
in distilled water, containing 0'5 per cent, of sodium chlo-
ride and 0*2 per cent, of sodium bicarbonate. This was
called the "standard" solution or solvent. The beha-
viour of uric acid and the urates with this solution was
studied in detail, under varying conditions of temperature
and time, and with varying modifications of its coniposi-
THE CHEMISTRY OF GODT. 343
tion. The results thus obtained were then collated with
those obtained with blood-serum in similar circumstances,
and with parallel modifications of its composition.
By this method of investigation a considei"able amount
of information was acquired, bearing on the chemistry of
the gouty state, and on the genesis of the uratic pheno-
mena of the complaint. The results of the inquiry are
considered in the following order. First, the behaviour
of the material of gouty concretions, namely, the biurate
of sodium, with the standard solvent and with blood- serum
is examined. Second, the strongly contrasted behaviour
of uric acid and the quadrurates with the same media is
followed out. Lastly, some of the conditions which hasten
or retard the precipitation of sodium biurate are inves-
tigated.
I. Behaviour of Sodium Biurate with the Standard
Solvent and its Modifications, and with Blood-serum.
When sodium biurate^ is digested, at blood heat, with
pure water it enters pretty freely into solution. Such a
solution acidulated with hydrochloric acid throws down a
copious precipitate of uric acid. Careful experiments indi-
cated that the solubility of sodium biurate in distilled water,
at 100° F., fully amounts to 1 part in 1100. But when
sodium biurate was digested at the same temperature
with the standard solvent very little went into solution —
so little that 100 c.c. of the filtered product, after treat-
ment with hydrochloric acid, only yielded a few scattered
crystals of uric acid — a quantity too small to be weighed.
' Sodium biurate was prepared by boiling 4 grams of uric acid in 400
cubic centimetres of a 1 per cent, solution of sodium bicarbonate. This was
filtered hot and then allowed to stand for twenty -four hours. A copious
precipitate of crystalline stars and needles was thus obtained. This was
thrown on a filter and washed with cold distilled water, and then dried at
100° F. In experimenting with the urates the investigator should always
prepare his own materials. Specimens of the urates supplied to me by
dealers proved to be mere crude mixtures of uric acid with the bases, and
were wholly unfit for exact experiments.
344 THE CHEMISTRY OF GOUT.
I estimated that the solubility of sodium biurate iu the
standard solvent at 100 F. could certainly not exceed 1
part in 10,000. It was, moreover, found that no addition
to the solvent of any salts — vi^hether of potassium, lithium,
or magnesium — whether as carbonates, chlorides, phos-
phates, salicylates, iodides, or bromides — made any
appreciable difference.^ On the other hand, if the standard
solution was modified in the opposite direction — iu the
direction of subtraction — its solvent power progressively
increased. In other words, the nearer the solution
approached to pure water the higher became its power of
dissolving sodium biurate ; and, on the contrary, the
richer it was in sodium salts the more was its solvent
capacity reduced.
The solvent power of the solution seemed to be deter-
mined exclusively by the sum of sodium salts contained
therein ; it mattered little, so long as the quantity of base
was constant, what the combination was. The degree of
alkalescence had not the slightest influence, and a solu-
tion of sodium chloride or sulphate was absolutely on a
par with a solution of sodium carbonate containing the
same amount of base.
Solutions of the salts of potassium, lithium, and mag-
nesium, containing from O'l to 0*5 per cent., dissolved
sodium biurate about as freely as distilled water, and
consequently very much more freely than equivalent solu-
tions of the sodium salts. These advantages as solvents
were, however, completely nullified when the potassium,
lithium, and magnesium salts were used not alone, but
as additions to the standard menstruum — that is to say, in
presence of 0*7 per cent, of sodium salts. Comparison
of the chloride with the carbonate of potassium showed
that the carbonate had not the least advantage over the
chloride.
Salts of calcium and ammonium were found to act, in
regard to the point under consideration, in the same way
and in about the same degree as salts of sodium — that is
' The additions made rariud from O'l to 0"5 per cent.
THE CHEMISTRY OF GOUT. 345
to say, tliey lessened the solveut power of water on sodium
biurate iu proportion to the strength of their solutions.
The behaviour of sodium biurate with the scrum of
the blood was next examined. In blood-serum sodium
biurate was found to be even less soluble than in the
standard solution, as the following observations indicate.
Experiment 1. — Sodium biurate in excess was digested
with serum of pig's blood, at 100° F., for twenty-four
hours, with frequent agitation. The serum was then
twice filtered through a threefold filter.^ Of this product
50 c.c. were acidulated with strong acetic acid and set
aside. After standing forty-eight hours no crystals of
uric acid were found to be deposited. A second portion
was carefully tested by Sir Alfred Garrod's uric acid thread
experiment. Only a few crystals were found sprinkled on
the thread. A third portion was simply evaporated, at
100° F.,to the consistence of a thick syrup. In this needles
of biurate Avere easily detected under the microscope.
These observations showed that sodium biurate, although
very sparingly soluble, is not absolutely insoluble in
healthy serum.
Experiment 2. — Three metatarsal bones^ from the body
of a gouty man, which were encrusted on their articulat-
ing surfaces with uratic deposits, were treated as follows :
— The first (a) was suspended in six ounces of distilled
water, the second (b) was suspended in a similar quantity
of the standard solution, and the third (c) in the same
volume of blood-serum. The phials in which the speci-
mens were contained were tightly corked, and their con-
tents preserved from putrefactive changes by the inclusion
of thirty or forty drops of chloroform. They were placed
in the Avarm chamber for a fortnight, and after that were
kept at the temperature of the room. In four days the
1 Tbe crystalline needles of sodium biurate are so niiuute and delicate
that a portion passes through the filter unless extraordinary precautious are
taken.
* Kindly presented to me by Dr. Norman Moore. The deposits were
tested and found to be composed of urates.
31:6 THE CHEMISTRY OF GOUT.
deposit was entirely dissolved out from the first specimen
(a). The second specimen (b) showed distinct signs of
solution in fourteen dajs^ and at the end of six weeks the
deposit had entirely vanished. The third specimen (c),
suspended in serum, still remains, at the end of eight
months, apparently unaltered ; the limits of the encrusted
spots are as sharply defined, and the quantity of the
deposit appears as great, as when the preparation was
first put up.
It was found that the addition to blood-serum of small
quantities (0*1 to 0"5 per cent.) of the carbonates, chlorides,
or phosphates of potassium, sodium, or lithium did not in
the least degree enhance the solvent power of the serum
on sodium biurate.
II. Behaviour of Uric Acid with the Standard Solvent,
AND with Blood-serum and Synovia.
Observations on the Standard Solvent and Blood-serum.
The reactions of uric acid with the standard solvent
and with blood-serum stand in the strongest contrast with
those of sodium biurate in the same media.
When uric acid is digested with the standard solvent or
with blood-serum it passes freely into solution in com-
bination with a base. The compound thus formed is, in
the first instance, undoubtedly a quadrurate.^ But the
process does not stop here. The quadrurate gradually
takes up an additional quantity of base, and is thereby
converted into biurate, and the biurate thus formed is,
after some delay, eventually precipitated in the crystalline
state. In studying this process it is desirable to distin-
guish two, if not three stages, namely, first, the taking up
the uric acid as quadrurate, or solution ; second, the trans-
formation of quadrurate into biurate, or maturation. This
' The experimental evidence on which this conclusion is based is given in
my previous paper published in the present volume.
THE CHEMISTRY OF GOUT. 347
latter stage culminates in the precipitation and deposition
of the biurate in the cystalline form, and this should per-
haps be considered as a third stage, or precipitation.
The following experiments may be taken as illustrations
of the method of experimentation pursued and of the re-
sults obtained.
Experiment 1. — A gram of uric acid was introduced
into a flask with 200 c.c. of the standard solvent. The
flask was tightly corked and placed in the warm chamber,
where the temperature was continuously maintained at
100° F. A considerable amount of uric acid went into
solution, but a portion remained undissolved at the bottom
of the flask, leaving a clear supernatant liquor. Things
remained apparently unchanged until the evening of the
second day, when a few stars of biurate were detected
amid the undissolved sediment of uric acid. On the
third day, however, a rapid change was observed to be
taking place, consisting in an abundant precipitation of
stars and tufts and detached needles of biurate. On the
fourth day the precipitation appeared to be nearly com-
plete, for the supernatant liquor now showed only small
traces of uric acid when it was treated with hydrochloric
acid.
Experiment 2. — A parallel experiment was made with
blood-serum. Fresh serum of pig^s blood was treated
with uric acid in excess in a 4-oz. phial, tightly corked
and chloroformed to prevent decomposition. The phial
was gently turned upside down a few times at first, and
was not subsequently disturbed. It was then placed in
the warm chamber at 100° F. The serum soon cleared,
the surplus uric acid fell to the bottom, and the super-
natant serum became transparent. For about twenty-four
hours no change occurred, but in the course of the second
day stars of biurate were detected amid the deposit, and
during the third day an abundant precipitation of stars,
tufts, and needles of biurate took place, exactly resem-
bling those found in gouty concretions. On the fourth
day the process of precipitation was nearly complete, and
348 THE CHEMISTRY OP GODT.
tlie siiperuataiit serum was found to be comparatively free
from uric acid.
In order to isolate the stage of maturation from that of
solution the experiments were modifled in the following
manner :
Experiment 3. — Uric acid in excess was digested Avith
frequent agitation with the standard solvent, at 100 F.,
for twenty minutes. The excess of uric acid was then
filtered off, and the clear solution was placed in a corked
phial in the warm chamber. It remained unaltered for
two days. On the third day it began to precipitate, and
on the fourth day a copious deposition of crystalline bi-
urate took place. On the fifth day the process was com-
pleted, and the supernatant liquor was found on acidulation
to contain only traces of uric acid.
Experiment 4. — Blood-serum of the horse was digested,
at 100° F., with excess of uric acid for fifteen minutes
with constant agitation. It was then filtered and placed
in a corked phial in the warm chamber. In about twelve
hours the serum, previously clear, began to lose trans-
parency, and fine needles of biurate were detected in it
with the microscope. On the next day copious precipi-
tation took place. On the fourth day the process seemed
to be completed, and the supernatant serum was found to
be comparatively free from uric acid.
It was impossible not to be struck with a certain rough
resemblance between the results observed in these experi-
ments and the phenomena of the gouty paroxysm. In
the gouty subject it is assumed that the blood becomes
more and more impregnated with uric acid until, after a
certain period of incubation has been accomplished, sudden
precipitation of sodium biurate takes place in and about
the joints, and the " fit of the gout " is declared. Then
follows a process of recovery, with restoration of the blood
to a purer state — that is, with a lessened impregnation
with uric acid. In the artificial counterfeit we observe a
similar succession of events : firstly, impregnation of the
medium with sodium quadrurate ; secondly, a period of in-
THE CHEMISTKY OP GOUT. 349
cubation or maturation, duriug which the quadrurate
passes into biurate ; thirdly, somewhat sudden precipitation
of sodium biurate in the crystalline form ; and lastly,
restoration of the medium to comparative purity.
In the above-recorded experiments the quantity of uric
acid in solution was not accurately gauged, but in the
light of subsequent experiments I judge it to have been
about 1 part in 1500. The speed of maturation (the
lengtli of time intervening between solution and pre-
cipitation) was found to be greatly influenced by tlie per-
centage of uric acid in solution. The richer the medium
was in uric acid, the more quickly was maturation con-
summated, and the earlier was the occurrence of precipi-
tation. In the case of blood-serum, when tbe impregna-
tion with uric acid amounted to 1 in 800 or 1 in 1000, the
first beginnings of precipitation were observed in four to
six hours, and copious critical precipitation took place in
twelve to fourteen hours. On tlie otber hand, when the
proportion of uric acid in solution was only 1 in 4000 or
1 in 5000, precipitation was delayed for six to twelve days,
and was even tlien so slight in amount as to be only de-
tectable by microscopic examination. It was further noted,
in these feebler solutions, that tlie deposition of crystals
w^as throughout gradual, and that there did not occur any
sudden or critical fall of crystals, such as was observed to
take place in the middle periods of maturation in the
stronger solutions. Some of these points will be again
adverted to in treating of the circumstances which hasten
or retard maturation.
Observations on Synovia.
It is a marked peculiarity of the uratic phenomena of
gout that the deposits occur most commonly in and about
the joints; and it was a matter of interest in the present
inquiry to ascertain how the synovial fluids which bathe
these parts behave when impregnated with uric acid, and
especially whether these fluids, as compared with blood-
350 THE CHEMrSTRY OF GOUT.
serum, and when impregnated to an equal degree, had the
property of promoting or hastening the precipitation of
biurate. This part of the investigation is beset with diffi-
culties, and my information thereupon is very scanty. The
synovial pouches are shut sacs, entirely detached from one
another, and it is conceivable that slight differences in the
composition and the percentage of their saline constituents
may exist between them, and that such differences may
account for the preferential order in which the joints are
attacked in the gouty paroxysm. The quantity of synovia
obtainable from the smaller joints is very scanty, even in
the case of the large quadrupeds which are dealt with in
our slaughter-houses. I have so far only been able to make
satisfactory experiments with synovial fluid drawn from the
hip of the ox. From this source about a couple of ounces
may be obtained from the two joints. Butchers tell me
that the synovia from the hip is thinner as well as more
abundant, than that obtained from the other joints.
On two occasions I was able to examine and compare
the synovial fluid of the hip-joint with the blood-serum of
the same ox. The behaviour of the two fluids with uric
acid was substantially the same, but in both instances I
found that, when impregnated with uric acid in an equal
degree, precipitation of biurate began distinctly a little
earlier in the synovia than in the serum. And my
impression is, but it is only an impression, that with the
thicker and more concentrated synovia of the smaller
joints this difference would be more pronounced. Whether
there is in this distinction between serum and synovia a
key to the preference of uratic deposition for the joints
is a question well worthy of further inquiry. It is at any
rate conceivable, supposing the blood and its derivative
fluids to be equably impregnated with uric acid, and sup-
posing the synovial fluids to be more largely charged than
their congeners with salts, and especially with sodium and
calcium salts, that precipitation of biurate would take place
earlier, and by preference, in and about the joints than
elsewhere.
THE CHEMISTRY OF GOUT. 351
Behaviour of the Quadrurates loith Blood-serum.
The quadrurates behave with the standard solvent and
with blood-serum substantially in the same way as uric
acid. This might have been expected from the fact that
these media take up uric acid in the first instance as a
quadrurate. There is, however, this difference, that the
quadrurates pass into solution much more rapidly than
uric acid, and, consequently, the period of precipitation
of biurate has its advent considerably accelerated.
III. The Conditions which Acceleeate or Retard the
Processes which culminate in the Precipitation op
Sodium Biurate.
Assuming a real analogy to exist between the processes
which go on in serum artificially impregnated with uric
acid, and the processes which go on in the blood of a
gouty patient, and which culminate in the deposition of
uratic concretions, it is a matter of interest, as bearing on
the pathology and treatment of gout, to investigate the
conditions which, in the artificial parallel, accelerate or
retard these processes. In pursuing this study from our
chemical standpoint the three stages or phases in the
development of the gouty paroxysm should be kept dis-
tinct in the mind, namely, the stages of solution, matura-
tion, and precipitation. The juvantia and obstantia of
these three stages are necessarily different and require
separate consideration.
The gouty man may be regarded as living on the brink
of a critical outbreak. His uric acid function is in a state
of unstable equilibrium, and it is conceivable that a little
quickening or favouring circumstance in any of the three
stages might determine the occurrence of a paroxysm
which would not otherwise have taken place. In the
gouty state it is probable, as Dr. Haig suggests, that there
may be stores of uric acid (or quadrurates) lodged in
certain organs, as the spleen or liver, or diffused more
generally through the tissues of the body. An elevation
352 THE CHKMISTRY OF GOUT.
of the dissolving powei' of tlie lymph or blood, acting ou
these stores, might lead to a sudden irruption of urates
into the blood, transcending the capacity (perhaps already
impaired) of the kidneys for their elimination, and so lead
to an outbreak. In like manner some new conditions in
the blood, some variation in its chemical or physical
propei'ties, might hasten or retard the other stages of
maturation and precipitation, and thereby determine the
occurrence or non -occurrence of a gouty paroxysm.
The rising and falling activity of the kidneys, in the
matter of separating the urates floating in the blood, does
not come within the scope of the present inquii-y, though
doubtless a potent, if not the most potent, factor in the gene-
sis of gouty explosions and of gouty phenomena generally.
Conditions affecting the Stage of Solution.
It may be stated generally that the more alkaline the
medium is, the more rapidly and freely does it dissolve
uric acid and quadrurates. This is certainly the case
with solutions of the alkaline carbonates and phosphates,
ranging from 0*5 to 5 per cent. The neutral carbonate
is a better solvent of uric acid than the bicarbonate. It
is believed that sodium carbonate circulates in the blood
partly as neutral and partly as acid carbonate, and that
the proportion varies. If this be so a rising proportion
of neutral carbonate would promote, and a rising propor-
tion of bicarbonate would retard, the solution of uric acid
stored in the tissues.
The solvent power of the blood on uric acid depends
exclusively on the alkaline carbonates and phosphates
contained in it. The neutral salts — chlorides and sul-
phates— were not found to have the least influence either
way on the act of solution.
The quadrurates are taken up more rapidly by blood-
serum than free uric acid. The following experiment
illustrates this point. Half a gram of uric acid and the
same quantity of serpent's urine (which is composed of
THE CHEMISTRY OF GOUT. 353
almost pure quadrurates), were separately digested in
200 c.c. of blood-serum^ without agitation^ at 100° F. In
the latter case all went soon into solution, and abundant
precipitation of biurate took place in twenty-four hours.
In the former case solution was much slower ; and pre-
cipitation did not begin until the third day, and was not
abundant until the fourth day.
Conditions affecting the Stages of Maturatiun and
Precipitation.
The investigation embi'aced a study of the effects of
temperature, percentage of uric acid in solution, and the
addition of various saline substances to the maturating
medium.
(a) Temperature. — It was found invariably that the
stage of maturation was more quickly accomplished in the
warm chamber at 100° F. than at the temperature of the
room, ranging from 60° to 70° F. ; but the ultimate result
was exactly the same in both cases. For example, serum
charged with 1 part of uric acid in 600 began to pre-
cipitate in the warm chamber in four hours, and precipi-
tated copiously in six hours. A duplicate specimen kept
at the temperature of the room (65° F.) began to pre-
cipitate in eight hours, and did not precipitate copiously
for sixteen hours. Another sample of serum, impregnated
with 1 part of uric acid in 1000, began to precipitate in
the warm chamber in six hours, and deposited copiously
in fourteen hours ; while a duplicate kept at the tempera-
ture of the room (60° to 70° F.) only began to precipitate
in thirty hours, and copious precipitation did not take
place for forty-eight hours.
The absolute constancy of these results led to the idea
that maturation would go on more rapidly at a febrile
temperature (104° to 105° F.) than at the normal tempe-
rature of the body, and that herein might be found an
explanation of the circumstance that gouty outbreaks
VOL. LXXIII. 23
354 THE CHEMISTRY OF GOUT.
sometimes follow immediately on the heels of an injury.
When, however, this notion was tested experimentally no
support was found for it.
It was also conceived that although maturation itself
was favoured by warmth, the terminal act of the process,
namely, the act of precipitation, might, on the contrary
(seeing that sodium biurate is more soluble at higher than
at lower temperatures), be favoured by cold, and that this
might account for the fact that gouty concretions tend to
be deposited in the cooler and more exposed parts of the
body, in the joints and subcutaneous tissues, rather than
in the warmer interior regions. I failed, however, to
obtain any direct experimental evidence in favour of this
conception.
(b) Quantity of uric acid in solution. — It was found
that no condition exei'cised so great and decisive an
influence on the speed of maturation and the advent of
precipitation as the proportion of uric acid in solution.
The amount or copiousness of the precipitation was like-
wise, of course, affected in the same way. The following
experiment with blood-serum, the results of which are
arranged in a tabular form, illustrates these points in a
striking manner. The phials containing the serum were
placed in the warm chamber for fourteen days, and were
afterwards kept at the temperature of the room. Chloro-
form was added to prevent putrefactive changes.
Table showing the influe^ice of percentage of uric acid in
solution on the speed of maturation, and the time of
advent of precipitation.
Quantity of uric acid Time of precipitation of
contained in '.lie serum. sodium biurate.
1 ill 1000 . . Precipitation began in 6 hours. Copious
precipitation in 14 hours.
1 iu 2000 . . Precipitation began in 33 hours. Copious
precipitation iu 3 days.
1 in 3000 . . Slight precipitation began in 3 days, which
became a little more copious in 12 days.
THE CHEMISTRY OP GOUT. 355
Quantity of uric acid Time of precipitation of
contained in tlie serum. sodium l)iurate.
1 ill 4000 . . A few iieeilles of biurate were detected on
the 6th day ; more needles and a few
tufts in 12 days.
1 in 5000 . . A few short needles were detected on the
13th day. In 30 days the needles were
somewhat more numerous,
1 in 6000 . . No needles were discoverable in 14 days;
a few were detected iu 40 days.
1 in 8000 . , No needles could be detected after the
lapse of 40 days.
Assuming that the inflammatory arthritic attacks in
gout are directly due to copious and sudden precipitation
of crystalline stars and needles of sodic biurate in the
cartilages and fibrous structures of tlie joints, the evidence
before me indicates that sucli copious sudden precipita-
tion can only take place Avhen the fluids bathing these
structures are impregnated ^\Tith uric acid in, at least, the
proportion of 1 part in 2500. Below this point the pre-
cipitation occurs slowly and scantily, and only in the form
of short scattered needles. When the proportion of uric
acid in the serum was only 1 part in 5000 the deposited
needles were mostly about as long as the diameter of a red
blood-disc, some were twice this length, and a few three
times this length, and all were of extreme tenuity. It is
quite conceivable that this slighter precipitation in the
tissues, of short scattered needles, might account for certain
irritations in the various organs, such as characterise irre-
gular or larval gout ; but it could scarcely engender down-
right inflammatory attacks. It is further conceivable that
the presence in the blood of such scattered needles might
constitute foci, around which clotting might take place ;
and that the thrombosis not unfrequently observed in
gouty cases might thus be accounted for.
The impregnation of the blood in gouty persons with
uric acid to the extent of these lesser degrees is within
the range of observed actualities. Sir Alfred Garrod ob-
tained, by quantitative analysis, from the blood-serum of
856 THE CHEMISTRY OF GOUT.
cue of his patients uric acid to the amount of 1 part in
5714 ; and he remarks that the quantities thus recover-
able from the blood are probably much under the actual
amounts, as considerable loss is liable to occur from un-
avoidable causes.
These considerations lead to the suggestion that a micro-
scopical examination of the blood in gouty persons might
sometimes reveal the existence of needles of biurate in
that fluid. I tested this point in ten cases of chronic
gout, by examining a drop of blood drawn from the finger,
but I failed to obtain positive results.
Addition of Various Saline Substances.
Our ideas on the therapeutics of gout are largely
coloured by chemical considerations. It is supposed that
the efficacy of mineral springs, which are so much resorted
to by gouty patients, depends on the saline ingredients
which they contain. The results of the present inquiry
throw great doubt on the validity of this notion. The
springs in repute, and in equal repute, are of the most
varied character. Some are charged with bicarbonate of
sodium, others with chloride and sulphate of sodium, others
again with salts of lime and magnesia, and a few contain
traces of lithia. These salts are supposed, when intro-
duced into the circulation, to have the property of render-
ing the uric acid floating in the blood more soluble, and
of thus promoting its elimination by the kidneys. Under
the influence of the same ideas the alkaline carbonates are
largely prescribed to gouty patients. It has already been
shown that these views, so far as they concern the solu-
bility of the material of gouty concretions, are based on
an erroneous assumption. The addition to serum of any
of these salts did not in the least degree enhance its sol-
vent power over sodium biurate ; and with regard to the
salts of soda and lime, their effect was, in this respect, dis-
tinctly adverse.
THE CHEMISTRY OF GODT. 857
A very cousiderable series of experiments Avere made
with the purpose of ascertainiug whether the addition of
saline substances to serum impregnated with uric acid
exercised any influence on the progress of maturation
and the advent of precipitation. The additions made
varied from 0"1 to 0"4 per cent.^ and the experiments were
carried out in the warm chamber at 100° F. The salts
tried were the carbonate^ chloride, sulphate, phosphate,
and salicylate of sodium ; the carbonate, chloride, and phos-
phate of potassium.; the carbonate of lithium ; the chloride
and sulphate of magnesium ; and the chloride of calcium.
The salts of soda and lime were found to accelerate the
process, and to hasten the advent of precipitation. The
carbonate and phosphate of potassium, the carbonate
of lithium, and the sulphate and chloride of magnesium
were indifferent. The addition of O'l per cent, of the
chloride of potassium appeared to sensibly postpone the
advent of precipitation. I obtained no evidence in sup-
port of the assumption that increasing- the alkalescence of
the blood lessened the tendency to the deposition of uratic
concretions.
The impression produced by the inquiry in regard to
the use of mineral waters in gout was to the effect that
their virtues depended a good deal more on the water
they contained than on their saline constitutents, and
that the springs which were most likely to be of service
were those which approached nearest to pure water.
(For report of the discussion on this paper, see ' Proceedings of
the Royal Medical and Chiriirgical Society,' Third Series, vol. ii,
p. 132.)
ON
FOUR HUNDRED CASES OF AMPUTATION
PERFORMED AT ST. GEORGE'S HOSPITAL,
FROM OCTOBER, 1874, TO JUNE, 1888;
WITH ESPECIAL REFERENCE TO THE DIMINISHED
RATE OP MORTALITY.
C. T. DENT, F.R.C.S.,
ASSISTANT SUEGEON TO THE HOSPITAL;
AND
W. C. BULL, M.B., F.R.C.S.,
LATE SURGICAL EEGISTEAE TO THE HOSPITAL.
Received May 13th— Read June lOtli, 1890.
To vol. i of the ' St. George^s Hospital Reports,' pub-
lished in 1866, Mr. Holmes contributed a paper dealing
with 300 cases of amputation. The statistics were ob-
tained from the " Amputation Book," in which are re-
corded particulars of all amputations performed since the
year 1852. Partial amputations of the hand and foot,
which are usually performed by the house surgeons, are
not included, but complete operations, such as Lisfranc's
or Chopart's, find a place. Vol. viii of the same
'Reports,' published in 1878, contained a second paper
also by Mr. Holmes on a further series of cases, 200 in
number. In this second paper Mr. Holmes made some
remarks on the antiseptic treatment of cases of amputation.
360 FOUK HUNDRED CASES OF AMPUTATION.
We propose now to consider a third series of 400 cases,
dealing witli the amputations performed between October,
1874, and June, 1888, following the lines that were laid
down by Mr. Holmes in order to facilitate comparison of
results. We have endeavoured to set forth the statistics
in the plainest possible manner, and to let the figures, as
far as may be, speak for themselves. The record is a con-
tinuous one. The three series, in fact, comprise a total
of 900 consecutive amputations performed by twelve sur-
geons at one hospital during a period of thirty-sis years.
It follows, therefore, that to a limited extent only can the
fig-ures be taken to show the difference between the results
obtained, before and those subsequent to the general adop-
tion of the antiseptic system. Our cases date from Octo-
ber, 1874. Previously to 1880 the records only occasion-
ally note the employment of antiseptic treatment on the
Listerian method. In 1876, for instance, silken ligatures
were very commonly employed. Usually one end was
cut off short, and the long ends, gathered together in a
bundle, were brought out at the corner of the wound,
providing in this way to some extent for drainage, though
the importance of this principle was not perhaps so fully
recognised as it is now. Layers of lint soaked in carbolic
acid solution were usually laid over the "wound and covered
by oiled silk. At the conclusion of an amputation the
wound was frequently syringed out with cold water or
with iced carbolic solution. This latter detail was by no
means the invariable practice, but it was certainly in 1876
one very frequently employed as far as amputations were
concerned. Due attention was paid, to cleanliness, but no
attempt was made, by soaking in antiseptic fluids, to render
the instruments or ligatures or the hands of the surgeon
aseptic. Cases of other kinds were often treated on the
Listerian method. The system had indeed been employed,
as in other hospitals, for some years. ^ In 1877 catgut
ligatures came into general use.
During the period 1877-9 the methods were constantly
• St. George's Hospital Reports,' vol. iii (18G8), p. 241.
FOUR HUNDRED CASES OF AMPUTATION. 361
changing. Taking a few cases almost at random from
our records for 1878 and 1879, we find, for example, the
follow'ing notes on the methods and dressings employed :
— '^ Antiseptic method throughout ; catgut ligatures ;
drainage." The next : — " Carbolic dressings ; drainage-
tube ; silk ligatures. '^ In some cases dry dressings were
used, and in a very few irrigation of the open wound was
practised.
In 1880 minute attention was paid to all detail which
might be considered to affect injuriously the asepticity
of an amputation wound. At this period and for some
years subsequently the carbolic spray was generally used
for amputations. Of late years it has almost entirely been
abandoned, with great advantage. It may be noted here,
parenthetically, that since the adoption of catgut ligatures
the occurrence of secondary hasmorrhage has been very
rare. Two such cases are recorded under Table VI, d.
In one of these gangrene had followed fracture of the
surgical neck of the humerus in a man aged 71, and the
arm was amputated. Secondary haemorrhage took place
on the sixth day, and the patient died on the seventh day.
Post mortem the vessels were found to be atheromatous.
The other occurred in a patient whose leg was amputated
through the knee-joint for a malignant tumour of the leg.
Consecutive htemorrhage happened once in a way when
some vessel that did not bleed at the time of operation
was overlooked, but the formidable hasmorrhage due to
the ulceration of a large vessel seems to have been almost
entirely done away with. Yet this used occasionally to
occur with the silken ligatures. When the vessels are
diseased and atheromatous, catgut or tendon seems beyond
question the safest material at present available.
These 400 amputations, then, comprise a large propor-
tion of cases treated strictly (according to the present
state of our knowledge) on the antiseptic system, but also
a considerable number in Avhich other, or what would now
be called imperfectly antiseptic methods were employed.
It is often supposed that the practice of a general hospital
362 POUR HUNDRED CASES OP AMPUTATION.
is greatly bound by traditions. To imagine this to be
the case is to presuppose a very limited capacity for im-
provement. The methods in vogue are in reality in a
constant state of modification with the view of further
improvement. That which might be accepted as nearly
perfect to-day may be, almost surely will be, considered
worse than antiquated a few years hence. The practice
as regards amputations at St. George's Hospital is the
same as obtains in all general hospitals. The patient is
considered before the amputation book. The possibility
— however remote — of saving life or relieving suffering,
even if only for a short time, is held paramount. The
statistician may employ the figures and tabulate the results,
but he has absolutely no influence on the practice.
It is worthy of remai'k that more amputations were
performed during the second than during the first half
of the period covered by these statistics. For the six
years 1876 to 1881 (inclusive) 146 cases are tabulated,
and for the six years from 1882 to 1887 (inclusive), 203.
Taking into account the increasing reluctance of surgeons
to submit their patients to amputation it is at least
probable that these 203 included an even larger number
of unpromising cases than the 146. On the whole, how-
ever, it is better to assume that the class of cases did
not greatly differ from those previously tabulated, though
if any advantage could be shown to exist it would pro-
bably be found in the earlier series. The hospital was
re-floored in 1886-7, hard wood (teak) being substi-
tuted for the deal that had stood the wear and tear and
scrubbing of many years, but otherwise no substantial
alteration was made in the building, and the same number
of beds was available. The conditions then under which
the present series of amputations was performed were
much the same as in former years. Save for the intro-
duction and elaboration of the antiseptic method no potent
factor can be held accountable for any alteration in the
rate of mortality. That rate, Mr. Holmes concluded,^
1 Vol. i, p. 320.
FOUR HUNDRED CASES OF AMPUTATION.
363
varies, ceteris paribus, with the prevalence of pyaemia.
Our investigation clearly proves the truth of this remark,
as will be seen later on.
The two main points to which Mr. Holmes directed
attention in his first paper were^ —
1. The influence of advancing age on the results of
amputation.
2. The proportion of cases dying from the effects of
previous injury and disease to those dying from the se-
quelae of the operation.
With regard to the first of these subjects of inquiry
we need say little. The following tables furnish at a
glance an interesting comparison.
Table I.
First
series.
Feb., 1852,
to
Feb., 1866.
Second
series.
Third
series.
To
Deaths
per cent.
to
Oct., 187i.
Oct., 1874,
to
Oct., 1888.
tal. '-"
1st
ser.
2nd
ser.
25-0
3rd
ser.
12-5
Total,
3 ser.,
900
amp.
14-3
Kg. Died.
No. 1 Died.
No. 1 Died. No.
Died.
Under 5 years
1 0
4 1
16 2 21; 3 —
Above 5 and under 10
14 1
6 1 !30 1
50; 3 7-1
16-6
3-3
6-0
„ 10
15
21 1
16 3 28 4
65' 8 4-7
18-7
14-2
12-3
, 15
20
47 8
21 7
44 8
112
23 17-0
33-3
18-1
20-5
, 20
30
74 14
46 16
95 14
215
44 18-9
34-7
14-7
20-4
, 30
40
53 21
42 17
63
9
158
47 39-6
40-4
L4-2
29-7
, 40
50
41 15
34 14
58
12
133| 41 36-5
41-1
20-7
30-8
, 50
60
34 17
17 9
40
18
91| 44 50-0
52-9
45-0
48-3
, 60
70
13 5
10 6
20
11
43i 22 38-4
60-0
550
51-1
, 70 .
2 1
4 1
4
3
10' 5 50-0
25-0
75-0
5-0
Adults of unkn
own age
— —
— —
2
2
2 2-
—
—
100-0
300 83
200 75 koO
( i
84
900 242 27-6
37-5
21-0
26-8
The most noticeable contrast will be observed in the
third series of amputations, between the ages of twenty and
fifty. The mortality between the ages of twenty and thirty,
which in the first series amounted to 18"9 per cent., and in
the second series to 34' 7 per cent., in the third has fallen to
14;7 per cent. Between the ages of thirty and forty the
' Ibid., p. 292.
364
FOUR HUNDRED CASES OP AMPUTATION.
figures are still more striking, for the mortality as shown in
Table I, which in the first series was 39 "6 per cent., and
in the second 40*4 per cent., has in the third series fallen
to 14*2 per cent. Between the ages of forty and fifty much
the same results will be observed. The improvement
shown in the third series is chiefly due to the diminished
mortality in these three divisions.
Of the gross total (900) of amputations tabulated, 506
were performed on persons between twenty and fifty years
of age. The third series illustrates in a very emphatic
manner the influence of age, for with a greatly diminished
gross rate of mortality this influence is as convincingly
demonstrated as in the former tables.
The youngest case tabulated was that of a child aged
1|, whose thigh was amputated for gangrene following
a simple fracture of the femur. This patient died of
pygemia (Table VI, A, No. 5). The condition may have
been due to fat embolism, but there was a wound also of
the other foot. The oldest was a woman aged 77, whose
forearm was amputated for epithelioma attacking a burn
of the hand of sixty-eight years' standing. This patient
made an uninterrupted and quick recovery.
The following table (II) shows the ages of the patieuts
in our series of cases :
Table II.
No. of cases.
Deaths.
Per cent.
Under 5 years
16
2
12-5
Above 5 and under 10
30
1
3-3
„ 10 „ 15
28
4
14-2
„ 15 „ 20
44
8
18-1
„ 20 „ 30
95
14
14-7
„ 30 „ 40
63
9
14-2
„ 40 „ 50
58
12
20-7
„ 50 „ 60
40
18
45-0
„ 60 „ 70
20
11
55-0
„ 70 .
4
3
75-0
Adults of unknown age
2
2
1000
400
84
!
21-0
FOUR HUNDRED CASES OF AMPUTATION. 865
Assuming, for convenience' sake, that of the two adults
mentioned in the last line one was under and one over
thirty, we have, out of 463 amputations under the age of
thirty, 81 deaths ; and out of 437 amputations over the
age of thirty, 161 deaths, or almost exactly double. This
is precisely the result at which Mr. Holmes arrived.' The
diminished rate of mortality is a general diminution. We
shall endeavour to show subsequently that it is chiefly due
to the rare occurrence in recent years of pyemia after
amputations, and shall ascribe this to the more perfect
employment of the antiseptic system. Nevertheless the
influence of age remains the same, and this fact should be
noted in questions of prognosis. Three hundred and
thirty-nine of the cases in the third series were under fifty
years of age, and of these 50 died. Sixty-one were over
fifty, and of these 34 died. The contrast is astonishing.
Yet these older people had every advantage and security
which the most modern and improved methods could give.
For all that they died. Whatever the methods employed
amputation is about four times as dangerous after the age
of fifty as it is before. No doubt the disorders for which
amputation is necessary in later life are, on the whole,
much graver than in those less than fifty years of age.
Chronic diseases of the joints, if the operation be not too
long deferred, are eminently favorable for amputation.
Such cases are rarely met with in old people, while they
constitute the great bulk of the " Pathological " amputa-
tions in the young. Gangrene, again, and the like grave
disorders swell the mortality in the old. Loss of blood
is less well withstood, and the general recuperative power
is feebler. A much larger percentage in the old really
die from the eifects of previous disease than from the
operation or its sequelas. This point will, however, be
dealt with later on. It sufiices now to note that the
concentration of attention on the condition of the ampu-
tation wound is not in itself likely to lead to a diminu-
tion of mortality in the old after amputation. The older
^ ' St. George's Hospital Reports,' vol. viii, p. 283.
S66 FOUR HUNDRED CASES OF AMPUTATION.
the patient, the more must he be considered apart from
his wound.
The second point to which we desire to draw attention
is the proportion of cases dying from the effects of pre-
vious injury and disease to those dying from the sequelae
of the operation.
It is, of course, obvious that no improved system of
wound treatment is likely to affect this proportion to any
very great extent. Indeed, if any influence at all could
be expressed, it is possible that it might not be in the
direction of improvement as regards the mere figures. A
method which aims at and almost invariably succeeds in
obviating traumatic fever may lead the surgeon to ampu-
tate in extremely unfavorable cases, as, for example, in
advanced phthisis. On this second point there is no
satisfactory way of illustrating by figures any contrast
between our series and those previously tabulated. Yet
it can hardly be doubted that some such improvement
exists and affects the general diminution of mortality.
Improved after-treatment, greater efficiency and skill in
nursing, increased watchfulness of detail, must have much
to do with the better results, for after all the antiseptic
system is directed to the operation wound primarily, and
not so much to the patient who has been operated on.
The antiseptic system is a most powerful weapon of
defence, but it is not a whole armament, and if the figures
work out to much the same totals the explanation is pro-
bably to be found in the greater severity of the cases ope-
rated on. Some support is lent to such an inference by
the increased number of amputations shown by our tables
to have been performed during the last few years. An
appreciable number of these cases would possibly have
been considered too hopeless for operation in former years.
For instance, the presence of albumen in the urine was at
one time held almost sufficient of itself to contra-indicate
operation, even amputation. Yet there are many cases in
our series, especially those of patients suffering from in-
veterate bone disease or joint affections of long standing,
FOUR HUNDRED CASES OF AMPUTATION. 367
who at the time of operation had mai'ked albuminuria,
which after opei'ation either entirely disappeared or gradu-
ally diminished to a mere trace. Slowly progressing
sclerosis of bone attended by much pain is particularly
associated with this albuminuria, and the presence of the
symptom frequently indicates the necessity for rather than
vetoes the amputation.
The results of the various amputations performed may
now be analysed to some extent. Attention may again be
drawn to the rule which has guided us throughout in esti-
mating the mortality. If a patient who has been the sub-
ject of an amputation dies while still on the books of St.
George's Hospital the case is reckoned as one of death
after amputation, whatever the proximate cause may have
been. Clearly, as will be seen by the remarks made
below, many cases tabulated as deaths after amputation
ought strictly never to have been so entered. Yet it
seemed better not to depart in any degree from the plan
hitherto adopted, nor to seek to arrange the results so as
to give the most favorable impression. A certain number
of patients who are entered as " recovered " may have died
shortly after leaving the hospital, and thus form a set-off.
As an example, a patient with, say, a diseased knee and
pulmonary tuberculosis undergoes amputation of the thigh.
The stump heals, and the patient dies of phthisis some
weeks or months later than would have been the case if
he had been dragged down by the pain of the diseased
joint. Yet such a case would be, and is in our tables
reckoned as, a death after amputation. Again, a similar
patient has his arm removed for diseased elbow. The
flaps break down, the bone protrudes, the pulmonary trouble
if anything is made worse. The patient leaves the hos-
pital wishing " to die at home," and probably does so
shortly. The case is entered as a '^recovery." Truth to
tell, the mortality of a given hospital forms but the coarsest
guide to the success of its practice, but no other test can
well be applied.
In order to furnish, as far as possible, material for
368
FOUR HUNDRED CASES OF AMPUTATION.
compai'ison, the different varieties of aniputatious com-
prised in our 400 cases have been set forth in the following
tables :
Amptifation at HiiJ-joint for Disease.
No. of
cases.
Died.
From 5 to 10
From 10 to 15
From 15 to 20
From 20 to 30
From 30 to 40
From 40 to 50
2
2
1
3
1
1
1
1
1
2
1
Hip disease. Death from shock iu 2 hours.
Periostitis of femur and disorganisation of
hip-joint. Died from exhaustion and vomit-
ing in 21 days.
Similar case to above. Death from shock in
20 minutes.
1. Broncho-pneumonia; lardaceous liver, kid-
neys, and spleen. 2. Exhaustion ; patient
in a very weak state at time of operation, to
which he had refused consent.
Old hip disease. Death from exhaustion in
12 hours.
10 6
Mortality GO per cent.
The number of cases is too small to justify us in drawing
any conclusions. From the nature of the cases the large
mortality is not surprising^ for the operation was in all
undertaken more with the object of prolonging or making
life more endurable than of actually saving it.
FOUR HUNDRED CASES OF AMPUTATION.
369
Primary and Secondary Amputations of the Thigh,
including Double Amputation.
No. of
cases.
Died.
Under 2 years
From 5 to 10
1
1
1
1
years
From 10 to 15
3
2
years
From 15 to 20
1
0
years
From 20 to 30
3
1
years
From 30 to 40
8
4
years
From 40 to 50
8
5
years
From 50 to 60
8
6
years
From 60 to 70
1
1
years
From pyaemia (Table VI, A, No. 5).
From shock.
1 from shock and other injuries.
From shock and haemorrhage from accident.
1 from exhaustion, the other leg having been
amputated at knee; 1 collapse, loss of blood
at time of accident ; 1 exhaustion (case of
suicide); 1 collapse on operating table.
1 on table (both thighs) ; 1 from shock,
haemorrhage before operation ; 1 from pyae-
mia (?) before operation (Table VI, A, No. 6) j
1 from diabetes; 1 from pyaemia following
simple fracture into the knee-joint (haemar
throsis and suppuration) (pyaemia probably
preceded operation) (Table VI, A, No. 7).
1 from exhaustion; 1 from haemorrhage at
time of accident ; 1 visceral disease ; 3 from
shock, of which 1 died on table.
1 from shock.
One man, age unknown, died from shock in a few hours.
I 1
35
22
Mortality 62 per cent.
VOL. LXXIIl.
24
370
FODK HUNDRED CASKS OF AMI'UTA'l'ION.
Amputation of Thigh for Disease.
No. of
cases.
Died.
Under 5 years
From 5 to 10
years
From 10 to 15
years
Prom 15 to 20
years
From 20 to 30
years
From 30 to 40
years
From 40 to 50
years
From 50 to 60
years
From 60 to 70
years
Above 70 years
6
17
11
17
32
21
20
6
5
1
0
0
1
6
4
1
4
3
3
1
From tuberculosis.
From phthisis and exhaustion 1 ; from pyaemia
before operation 2; from exhaustion and
prolonged suppuration before operation 2;
from shock and haemorrhage in previous
sequestrotomy 1.
From shock 1 ; hsemorrhage 2 ; from pyaemia
1 (Table VI, A, No. 3); from phthisis "l.
From exhaustion and erysipelas before opera-
tion.
From erysipelas 1 ; from exhaustion 2 ; from
diabetes 1.
From exhaustion in case of senile gangrene 1 ;
from tetanus 1 ; from exhaustion and chronic
suppuration 1.
From recurrent haemorrhage and exhaustion
1 ; from exhaustion and gangrene 1 ; from
exhaustion due to gangrenous cellulitis 1.
From gangrene of flaps.
136
23
Mortality 16'9 per cent.
These tables call for no special comment, save that they
illustrate well the influence of age, which has ah'eady been
considered.
Amputation through Knee-joint for Disease.
No. of cases.
Died
Above 15 years of age and
under 20
1
0
„ 20 and under 30
.
7
1
„ 30 „ 40
5
0
„ 40 „ 50
.
4
0
» 60 „ 70
,
3
3
Mortality 20 per cent.
20
FOUR HUNDRED CASES OF AMPUTATION. 371
Primary and Secondary Amputations through the Knee-
joint, including Multiple Amputations.
Six cases. Four deaths.
lu three of these fatal cases the amputation was double.
Amputation through Knee-joint.
Deaths.
1. Lisfranc on other foot at same time ; primary amputation ; traumatic
delirium day after operation. Died of exhaustion after 10 days.
2. Malignant tumour of leg; secondary haemorrhage.
3. Primary; right thigh amputated above condyles; left through knee.
Died of exhaustion after 14 days.
4. Double amputation ; primary; right through knee ; left leg about middle.
Died of exhaustion after 23 days.
5. For old ulcer of leg ; recurrent haemorrhage from stump ; sloughing of
flap. Died of exhaustion after 40 days.
6. Primary ; case of compound fracture ; much collapse on admission. Died
after 3 days.
7. For senile gangrene, to relieve intense pain ; commencing gangrene of
flaps. Died of asthenia after 6 days. Pain ceased after operation.
8. Man, set. 61. Chronic abscess of head of tibia; flaps retracted. Died of
pyaemia (Table VI, A, No. 8).
Most of these amputations were performed in the man-
ner advocated by Mr. Stephen Smith. The healing was
often slow but the resulting stumps left nothing to be
desired.
372
FODR HUNDRED CASES OP AMPUTATION.
Amputation of Leg for Disease.
No. of
cases.
Died.
Under 5 years of age
Above 5 and under 10
„ 10 „ 15
„ 15 „ 20
„ 20 „ 30
» 30 „ 40
„ 40 „ 50
„ 50 „ 60
» 60 „ 70
1
6
7
8
8
8
9
9
2
1
1
2
2
From septicaemia, which existed pre-
vious to amputation.
From pyaemia (Table VI, A, No. 1).
1 from sloughing and gangrene; 1
from erysipelas.
1 from gangrene; 1 from exhaus-
tion.
58
6
Mortality 10"3 per cent.
Primary Amputation of Leg, including Double and
Multiple Amputations.
Age.
No. of
cases.
Deaths.
Under 5 years
1
2
6
3
4
5
2
1
1
0
0
1
1
0
4
2
1
1
From shock ; both forearms also am-
putated.
Exhaustion and gangrene after com-
pound fracture.
2 from shock; 1 from other injuries,
and 1 from pyaemia which existed
previous to amputation.
1 from delirium and exhaustion, and
1 from other injuries.
Secondary after compound fracture ;
sloughing and exhaustion.
Shock.
Above 10 and under 20
., 20 „ 30
„ 30 „ 40
„ 40 „ 50
„ 50 „ 60
„ 60 „ 70
» 70
Age unknown
25
10
Mortality 40 per cent.
rODB HUNDRED CASES OF AMPUTATION.
873
Syvie's Amputation.
Age.
Cases.
Recovered
Under 5
years
. 4
4
Above 5
and under 10 .
. 4
3
„ 10
„
85 .
. 3
3
„ 15
„
20 .
. 6
5
„ 20
,,
30 .
. 14
12
„ 30
„
40 .
. 3
3
„ 40
„
50 .
. 4
3
., 50
„
60 .
. 3
3
» 60
"
70 .
. 3
44
3
39
Mortality
11-3 per
cent.
1. Pyaemia. Died after 20 days. Suppuration of ankle (Table VI, A,
No. 2).
2. Carbolic acid poisoning; sloughing of heel flap. No post-mortem exa-
mination (Table VI, A, No. 4).
3. Died after 71 days ; stump not healed ; haemorrhage from rectum and
dysenteric diarrhoea. No post-mortem.
4. Died of phthisis, bedsores, and exhaustion; sloughing of heel flap. No
post-mortem.
5. Flap sloughed ; urine became albuminous ; diarrhoea, ascites, and vomit-
ing. Died in 50 days of lardaceous disease.
Amputation through Shoulder-joint.
Friina/ry for Accident.
No.
^t. 20 .... 1
For Disease.
Died.
0
Age.
No. of
cases.
Died.
Prom 15 to 20 years
„ 20 to 30 „
„ 30 to 40 „
„ 40 to 50 ,.
„ 50 to 60 „
1
3
3
1
1
1
1
Death from shock in 7 hours.
Death from exhaustion in 5 days.
9
2
Mortality 22 per cent.
374
FOUR HUNDRED CASES OF AMPUTATION.
Amputation of Arm fur Accident.
Age.
No. of
cases.
Died.
Under 5 years
From 5 to 10 years
„ 10 to 15 „
„ 15 to 20 „
„ 20 to 30 „
„ 30 to 40 „
„ 40 to 50 „
„ 50 to 60 „
„ 60 to 70 „
Above 70
1
1
4
3
3
1
1
1
0
0
0
1
0
0
1
1
From penetrating wound of chest.
From shock.
Gangrene and exhaustion.
15
3
Mortality 20 per cent.
Amputation of Arm for Disease
Age. Cases.
Above 15 and under 20 . . • 4"i
» 20 „ 30 ... 3
» 30 „ 40 ... 1
.,50 „ 60 , . ,2
10
All recovered.
Amputation of Forearm for Disease.
Age. Cases.
Died
tween 20 and 30 .... 8 ...
1
„ 30 and 40 .... 7 ...
0
„ 40 and 50 . . . . 4
0
50 and 60 .... 5 ...
1
60 and 70 . . . . 3
0
„ 70 and 80 . . . . 1
0
28
Primary Amputation of Forearm.
Age. Cases.
between 10 and 20 . . . . 3
20 and 30 . . . . 4
„ 30 and 40 .... 1
Died.
0
2
0
8
2
FOUK HUNDRED CASES OF AMPUTATION. O/O
1. Both fore;irms and leg ; primary. Died in 10 hours.
2. Deformity from old burn seemed doing well when severe vomiting came
on on 117th day and could not be stopped. No post-mortem. ? Died
of operation.
3. Stump healed. Died in 49 days. Post-mortem, advanced phthisis.
■1. Many other injuries; fracture right femur and left clavicle, scalp wound,
and wound of right foot, from which pyajmia developed, of which he
died in 7 days. Primary amputation.
AYe have tliouglit it as well to tabulate these cases,
though practically amputation of the forearm jper se is an
operation of infinitesimal risk. In the 'Pathological ' series,
as will be seen, two deaths occurred. These can only be
included in our tables by the necessity for rigid obser-
vance of the rule laid down at the commencement of this
paper. In one case the patient, who was fifty-five years
of age, died from circumstances wholly unconnected either
with the operation or the disease that had rendered it
necessary. In the other the object of the operation was
fully attained, and the patient was relieved of a painful
local disease, but died of advanced phthisis.
We may now briefly consider the deaths after operation,
and their causes.
Table III furnishes the results of —
(a) Amputation for disease.
(b) Amputation for injury, chiefly primary.
(c) Double or multiple amputations for injury.
In the first section (a) we have 314 cases and 48 deaths,
showing a mortality of 15'2 per cent. In the second section
(b) 79 cases with 29 deaths, a mortality of 36'6 per cent.
In the third section (c) 7 cases and 7 deaths, a mortality
of 100 per cent. In some of the cases tabulated under
(c) the injuries were not limited to the limbs amputated,
and the operations were undertaken with little more hope
than that of enabling the sufferers to pass moie peacefully
out of the world.
376
FOUR HUNDRED CASES OF AMPUTATION.
Table III.
(a) Ainputation for Disease.
Nature of amputation.
Thigh
Thigh at hip-joint
Leg
Leg at knee-joint .
Syme
Arm
Arm at shoulder-joint
Forearm .
No. of cases.
136
10
58
19
44
10
9
28
314
/. e. 15"2 per cent.
Deaths
23
6
6
4
5
2
2
48
(b) Primary Amputations.
Nature of amputation.
Thigh
Leg
Leg at knee
Arm
Forearm .
No. of cases.
. 32
. 21
3
. 15
8
79
Deaths.
18
6
1
3
1
29
I. e. 36*6 per cent.
(c) Primary Double and Multiple Amputations.
Nature of amputatioii.
Thighs, hoth
Thigh and other leg at knee-joint
Leg
Legs, both .
Legs at knee-joint and Lisfrane
Leg and both forearms
No. of cases.
2
1
1
1
1
1
Deaths.
2
I. e. 100 per cent.
Summary.
For disease .
Primary
„ double or multiple
314 cases, of which 48 died.
79 „ „ 29 „
7 „ „ 7 ..
400
84
FOUR HUNDRED CASES OF AMPUTATION.
377
Table IV.
From causes unconnected with the operation ; death
inevitable.
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
1
Leg, secondary
508
37
Limb removed for gangrene following
compound fracture. Death in 3 days.
2
Legs, primary
509
50
Railway accident; both legs amputated;
never rallied from shock of injury.
Death on 3rd day.
3
Thighs, primary
510
13
Both thighs amputated ; also compound
fracture of arm. Death in a few hours.
4
Leg at knee,
primary
513
68
Railway accident; delirium came on one
hour after injury; Lisfranc's amputa-
tion on other foot. Death in 10 days.
5
Leg, primary
517
28
Railway accident; extreme collapse;
both forearms also removed. Death
in 10 hours.
6
Thighs, primary
523
44
Both thighs removed. Death on ope-
rating table.
7
L9g, secondary
527
57
For suppuration and necrosis in case
of compound fracture into ankle-joint
5 weeks previously; pyaemia existing
prior to amputation. Death in 7 days.
8
Leg, primary
528
56
Died in 2 days without recovering from
original shock.
9
Arm, primary
562
31
Gunshot wound, causing great collapse.
Death in 2 days.
10
Thigh, primary
564
38
Other leg removed through knee-joint;
railway accident. Death in 14 days.
11
Do.
577
?
Other injuries. Death in 5 hours.
12
Forearm
583
55
Removed for extensive ulceration from
burns. Died vomiting on 117th day.
No post-mortem. (This case ought
probably to be classed as a recovery
from amputation.)
13
Thigh, primary
612
13
Also compound fracture of arm. Death
in 8 hours.
14
Do.
613
32
Severe loss of blood prior to operation.
Death in 48 hours.
15
Do.
619
33
Suicidal injuries. Death in 2 days.
16
Do.
633
35
Railway accident. Death on operating
table.
17
Forearm, primary
650
23
Many other injuries, from which pyaemia
was developed. P.M. — Multiplepyaemic
abscesses. Death in 7 days.
18
Leg, primary
665
?
Both legs crushed. Death in 20 minutes.
19
Thigh, primary
666
3
Collapse from accident. Death in 3
hours.
20
Leg at knee,
primary
671
62
Collapse from accident. Death in 3
days. i
378
FOUR HUNDRED CASES OF AMPUTATION.
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
21
Thigh, primary
715
51
Loss of blood prior to amputation. Death
in 36 hours.
22
Leg, caries of
tarsus
717
31
Died exhausted in 3 days. P.M. — Tuber-
cles in lungs.
23
Thigh, primary
758
55
Other injuries. Death on operating
table.
24
25
Leg, primary
Thigli, for disease
776
841
53
61
Other injuries. Death in 2 hours.
Extensive gangrenous cellulitis of leg.
Death in 6 hours.
26
Do.
855
50
Extreme exhaustion following suppura-
tion of knee. Death in 8 hours.
27
28
Thigh, primary
Do.
870
876
58
44
Railway accident. Death in 8 liours.
Other injuries. Diabetes. Died coma-
29
Leg, primary
882
68
tose in 6 days.
Fracture of base of skull; also compound
fracture of other leg. Death in 2 days.
30
At hip-joint, for
disease
886
17
Extreme exhaustion in case of periostitis
and necrosis of femur. Patient almost
moribund from prolonged suppuration.
Haemorrhage at operation from cede-
matous tissues. Death in 20 minutes.
Table V.
From other causes coinciding with the operation, the other
causes having a main share in 'producing death.
Class A. — Death due mainly to previous visceral or local
disease.
Leg, for senile
gangrene
Thigh, for diseased
knee
Do.
Thigh, for failure
of excision of knee
At hip-joint
Thigh, for pulpy
disease of knee
Do.
j Forearm, for dis-
I eased wrist
507
70
533
16
1
534
13
1
545
15;
568
25
574
22
575
46
604
28
Gangrene attacked the flaps, and death
occurred on 5th day. P.M. — Athero-
matous vessels.
Tubercular child ; very feeble from pro-
longed suppuration. Death on 4th
day.
Suppuration of knee. Death in 11
days. P.M. — Tubercles in lungs.
Died in 26 days, worn out by pain and
suppuration following the excision.
Operation previously declined ; ex-
hausted at time of amputation. Sank
in 6 days.
Died of phthisis in 82 days.
I
Diabetes. Died in 12 days.
Died in 49 days. P.M. — Advanced
phthisis. '
FOUR HUNDEKD CASES OF AMI'UJ'ATION.
379
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Syme, for disease
of ankle
Sjme, for disease
of tarsus
Thigh, for sarcoma
of tibia
Thigh, for suppu'
ration of knee
Do.
Leg, for sloughing
At hiji-joint
rhigh, for diseased
knee
Leg and knee, for
gangrene
Thigh, for gan-
grene
At hip-joint
Syme, for disease
of tarsus
At hip-joint, for
disease of joint
Leg, for senile
gangrene
Thigh, for senile
gangrene
644
648
651
693
699
702
726
732
773
799
802
829
830
857
899
34
19
36
16
18
54
13
15
66
67
48
9
23
64
54
Wound not quite healed when man died
on 71st day from haemorrhage from
rectum and dysenteric diarrhoea. No
P.M.
Phthisis. Heel flap sloughed. Death
in 9 days from exhaustion and bed
sores. No P.M.
Myeloid sarcoma of tibia gouged out,
followed by erysipelas and suppuration
of the knee-joint. Death on operating
table.
Phthisical patient. Acute periostitis of
tibia, followed by destruction of knee-
joint. Death in a few days. No P.M
Suppurative arthritis of knee. Pyaemia
before amputation. Death in 10 days.
Excision of os calcis was followed by
sloughing of soft tissues of opposite
heel. Diseased arteries. Death
21 days.
Periostitis of femur and suppuration of
joint. Death in 21 days from ex-
haustion. P.M. — No morbid change
found in internal organs.
Pyaemia and disorganisation of knee
followed aspiration of joint for syno-
vitis. Death in 41 days. P.M. —
General tuberculosis.
Operation to relieve pain in case of senile
gangrene. Death on 6th day. P.M
Embolism of mid-cerebral artery ;
atheroma.
Death in 10 days. P.M. — Arterial
degeneration and chronic interstitial
nephritis.
Prolonged suppuration of hip; bed-
sores. Death in 12 hours.
Death in 50 days from lardaceous de
generation of viscera.
Death in 27 days from broncho-pneu
monia and lardaceous disease.
Amputated for severe pain. Gangrene
attacked the flaps, and extended to the
groin. Death in 11 days.
Senile gangrene; thrombus in femoral
artery at site of amputation. Death
in 7 days. P.M.— Thrombosis of left
pulmonary artery and external iliac
artery.
380
FOUR HUNDRED CASES OP AMPUTATION.
Class B. — Death due mainly to the consequences of previous
injury.
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
1
2
3
4
5
6
7
8
9
10
Leg, secondary
Thigh, secondary
Thigh, for ruptured
popliteal artery
Thigh, secondary
Do.
Leg, secondary
Thigh, secondary
Thigh, primary
Thigh, ruptured
posterior tibial
artery
Arm, secondary
611
632
641
667
688
757
787
823
854
874
28
55
58
57
41
70
50
28
66
68
Railway accident. Right leg removed
through the knee, and the left below
the knee; sloughing of flaps and ex-
haustion. Death in 21 days. No P.M.
For gangrene following primary exci-
sion of ankle-joint for compound dis-
location. Drayman, in a low state.
Death in 24 hours.
Severe haemorrhage at operation ; great
extravasation into soft tissues of limb.
Death in 3 days.
For sloughing after compound fracture.
Died suddenly on 3rd day. P.M. —
Fatty degeneration of cardiac muscles
and granular kidneys.
After compound fracture; a piece of
necrosed bone ulcerated into the popli-
teal artery; severe haemorrhage and
collapse. Death in 2 hours.
Compound fracture; flaps sloughed.
Phlebitis and delirium. Death in 9
days. No P.M.
Secondary to compound fracture ; septi-
caemia. Death in 25 days. P.M. — No
pyaemic deposits.
Severe haemorrhage before admission.
Death in 10 hours. (Possibly ought
to be in Table I.)
Enormous extravasation of blood into
leg. Death in 30 hours.
Commencing gangrene after compound
fracture opening the elbow-joint.
Death in 5 days.
FODR HDNDEED CASES OF AMPUTATION.
381
Table VI.
Deaths from amputation, i. e. due mainly to the
consequences of the operation itself.
Class A. — From Pysemia.
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
1
Leg
526
44
R. A. had caused dislocation of the
ankle and rendered the limb useless.
Rigors on 5th day after amputation,
and death from pyaemia followed on
the 22nd day.
2
Syme, for disease
of foot
536
41
Death from pyaemia in 20 days. Pyaemia
began on the 17th day.
3
Thigh, for disease
of knee
550
23
Death from pyaemia in 9 days. No
P.M. examination.
4
Syme, for disease
of tarsus
635
25
A delicate man with cardiac disease.
Carboluria followed amputation. Sep-
ticaemia and sloughing of heel flap.
Death in 10 days.
5
Thigh, secondary
716
li
For gangrene following a simple frac-
ture of thigh. Death from pyaemia in
17 days. There was also a wound of
the other foot. (Pyaemia probably
preceded the amputation.)
6
Do.
723
43
For compound fracture. Death from
pyaemia in 12 days. (Pyaemia almost
certainly preceded operation.)
7
Do.
833
49
Secondary for suppuration of knee fol-
lowing haemarthrosis in case of frac-
ture of femur into joint. Septicaemia.
Death in 9 days. (Pyaemia probably
preceded operation.)
8
Leg at knee, for
disease of tibia
834
61
For chronic osteo-myelitis of tibia.
Rigors and pyaemia, and death in 10
days. P.M. — Abscess in spleen and
thrombosis of femoral vein.
Class B, — Sloughing {in Mr. Holmes's papers this class
included also Fhagedsena).
1
Thigh, for ulcer
of leg
652
68
Recurrent haemorrhage ; sloughing of
flaps; bedsores; exhaustion. Death
in 40 days.
2
Thigh, for diseased
knee
751
50
Sloughing and gangrene of flaps ; osteo-
myelitis; tetanus. Death in 19 days.
382 FOUR HUNDRED CASES OF AMPUTATION.
Class C. — From Erysipelas.
No.
Nature of amputation.
Amp.
book No.
Age.
Remarks.
1
2
Thigh, for anky-
losed knee
Leg
504
682
46
55
Died in 62 days from erysipelas, ex-
haustion, and bedsores.
Amputated for old injury to foot. Ery-
sipelas attacked the wound within 24
hours of the operation. Sloughing of
fliips and bedsores. Death in 12 days.
Class D.-
-From Secondary Haemorrhage.
1
Arm, secondary
516
71
For gangrene following fracture of sur-
gical neck of humerus. Secondary
haemorrhage on 6th day. Vessels very
atheromatous. Death on 7th day.
2
Leg and knee for
malignant tumour
of leg
555
22
Profuse secondary haemorrhage. Death
in 17 days.
Class E, — Shock at Operation ; hsemorrhage.
Thigh
Do.
Arm at shoulder
Thigh
Arm at shoulder
Thigh
Do.
521
27
640
43
741
25
760
40
761
58
821
17
826
29
Thigh removed for myeloid sarcoma at
lower end of femur. Death in 18
hours from shock.
Ununited fracture of femur. Death
from shock of operation on 3rd day.
P.M. — Vessels atheromatous ; heart
fatty; emphysema of lungs; fibroid
and fatty changes in liver.
For sarcoma of humerus. Profuse haemor-
rhage and shock. Death in 7 hours.
Amputated for secondary haemorrhage
after ligature of femoral artery for
wound. Shock. Death in 2 days.
For sarcoma of humerus. Severe hae-
morrhage at operation. Death in 5
days.
For periostitis and necrosis of tibia. An
attempt was made to remove the shaft
of the tibia; this was followed by pro
fuse haemorrhage, and the limb was at
once removed. Shock. Death in 3
days.
Sarcoma of muscles of lower third of
thigh. Profuse hx uorrhage ; large
muscular thigh. Shock. Death in
40 hours.
FOUR HUNDKED CASES OF AMPUTATION. 383
Still following Mr. Holmes' method of arranging tlie
cases, we have drawn up a complete list of all the deaths.
These Tables IV, V, and VI speak for themselves. The
interest chiefly centres in the last two. It will be under-
stood that our main object has been to afford a ready com-
parison with the previously published statistics drawn from
the same source. Exception may be taken to the headings
under which particular cases have been entered, but it has
been our aim to secure uniformity even though some sacri-
fice should be involved in other respects. No branch of
medical literature has been more fiercely criticised than
the statistical. Undoubtedly the material is somewhat
plastic, but much of the distrust excited by any statistical
paper is due to two causes : one, the want of uniformity
in statistics furnished from different quarters ; the other,
that advertisement so often unfortunately adopts the
statistical guise. At the least we will endeavour to
avoid the former of these two drawbacks. It is often
said that '' anything may be proved by statistics," and
the statement is intended to imply distrust. It may be so ;
it is also difficult to prove anything in any other way.
Table IV comprises the deaths occurring from causes
unconnected with the operation, and in which death was
really inevitable. Thirty cases are included, twenty-six
of these being primary or secondary amputations for in-
jury. One of the deaths occurred in a patient whose
forearm was amputated for extensive ulceration the result
of a burn. This patient was attacked with severe vomit-
ing and died on the 117th day after operation; no post-
mortem examination was allowed. As regards the opera-
tion she had really recovered, but for reasons assigned
already the case is entered here as a death after amputa-
tion.
Table V includes the deaths occurring from other causes
coinciding with the operation, the other causes having a
main share in producing death. These cases are divided
into two classes.
Class A. Death due mainly to previous visceral or local
384 FOUR HUNDRED CASES OF AMTUTATION.
disease. — In this class we have twenty-three cases. In
seven of these death was due mainly to phthisis. Four
were cases of senile gangrene. Two died of pyaemia
which existed markedly before operation. One man aged
thirty-four^ on whom a Syme's amputation had been per-
formedj died on the seventy-first day from haemorrhage
from the rectum and dysenteric diarrhoea. No post-mortem
examination was allowed. The wound had not quite
healed.
Class B. Cases due mainly to the consequences of pre-
vious injury. — Ten cases, all primary or secondary. In
one case septicaemia developed after compound fracture,
and the limb was amputated. Death in twenty-five days.
Post mortem no evidence of pyaemia was found. Some
of these cases might perhaps more properly be transferred
to Table IV.
Table YI includes the cases in which death may really
be ascribed to the effects of the operation, or, if the term
be preferred, from surgical calamities. Altogether twenty-
one deaths are tabulated. Two patients died from sloughing
(one of these from tetanus) : in Mr. Holmes' 500 cases seven
are recorded from similar causes. Two died from secondary
haemorrhage : in the previous tables four are entered. Seven
died from shock and loss of blood at the amputation. Two
died from erysipelas : in the previous tables five.
Finally, from pyaemia our tables (Table VI, A) show
eight cases in 400 amputations ; though, as will be men-
tioned directly, the number might more properly be re-
duced to four. For the purposes of this table we draw
no distinction between septicaemia and pyaemia.
The previous tables show seventy-five deaths from
pyaemia in 500 amputations. The contrast is in itself so
striking that it needs but little comment. Cases in which
pyaemia unquestionably had set in before amputation are
not included. In two of our eight cases (5 and 6) pyaemia
almost certainly preceded operation, and in one other (7) it
probably did so. Yet it has been thought better to
tabulate these cases under the pyaemia heading. In the
FOUR HUNDRED CASES OP AMPUTATION. 385
case of one patient (4), on whom a Syme's amputation had
been performed, the heel flap sloughed. This man, who
was the subject of cardiac disease, suifered also from car-
boluria. German surgeons would have set down the
death probably not to septicaemia, but to carbolic poisoning.
In Cases 1, 2, 3, and 8 pyaemia seems undoubtedly to
have resulted from the amputation. It is noteworthy
that two cases occurred in 1876, one in 1877, one in 1880,
two in 1883, and finally two in 1886, in patients who were
submitted to amputation within three days of each other —
a significant fact. At the least this occasional occurrence
of pyaemia shows that the battle was not being waged
against any imaginary foe. The conditions, whatever
they be, tending to the production of pyaemia were there,
and were only kept at bay by adequate precautionary
measures. To our minds there is absolutely no question
that the whole of the improvement as regards the pyeemia
is due to the careful carrying out of the antiseptic system.
It is a preventable disease, and, as the figures show, has
almost entirely been prevented.
Amputations have been taken as a convenient example
only of major operations. Statistics of other operations
would show the same results. All the details necessary
for the thoroughly efficient carrying out of the antiseptic
system of surgery can be best practised in hospitals, and
it is not, perhaps, too much to assume that, considering the
extremely minute risk shown to be run in a well-managed
London general hospital, the old spectre of ''hospitalism'^
may be said to be laid.
At the outset of this paper it was pointed out that
from 1874 to 1879 inclusive the methods were constantly
undergoing slight changes, and that in our tables, unfor-
tunately for purposes of comparison, we are not ableto define
strictly what may be termed an antiseptic period. Yet it
is very significant that the percentage of mortality from
1874 to 1879 inclusive was 26*3 for all cases, while from
1880 to 1888 it fell to 18-8.
If we exclude the cases of death already tabulated as
VOL. LXXIII. 25
386 FOUR HUNDRED CASES OP AMPUTATION.
not really due to amputation, we are left with twenty-one
deaths in 341 cases, or a mortality of about 6 per cent.
We believe that some such figure represents the real risk
of the occurrence of a surgical calamity in an average
amputation.
To sum up, then, amputation is practically an operation
almost devoid of risk in a selected case, and a person
under fifty years of age. After that period of life the
danger is greatly increased, though not to the extent
shown in the tables^ for the gi'avity of diseases in the old
requiring the performance of an amputation chiefly con-
tributes to the increased mortality. Still the risk is un-
deniably very much greater, even though the dangers
arising from degenerated blood-vessels are sensibly dimin-
ished by the modern forms of ligatures.
In conclusion we have to thank the members of the sur-
gical staff of the hospital for the ready permission
accorded to make use of their cases.
(For report of the discussion on this paper, see ' Proceedings
of the Royal Medical and Ohirurgical Society,' Thu'd Series, voL ii,
p. 136.)
INDEX.
The 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' They are inserted, as soon as printed, in the Library
copy, lohere the entire Index to the current date may always be consulted.
ADDEESS of Sir Edward H. Sievekiog, M.D., LL.D., F.E.C.P.,
President, at the Annual Meeting, March 1st, 1890 1
AMPUTATION : On four hundred cases o£ (C. T. Dent and
W. C. Bull) . . .359
ANGEIOMATA and ANGEIOSAECOMATA of boke (Ed-
mund Eoughton) . . . .69
Annual Meeting, March 1st, 1890, address of Sir Edward H.
Sieveking, M.D., LL.D., F.E.C.P., President . 1
BABKEB, Arthur E., F.R.G.8.
A study of fifty consecutive cases of operation for the
radical cure of non-strangulated hernise . . 273
BASTIAN, R. Charlton, M.A., 3I.D., F.B.S.
On the symptomatology of total transverse lesions of the
spinal cord ; with special reference to the condition of
the various reflexes .... 151
BENNETT, William R.
A case of hernia of the caecum entirely wanting in a peri-
toneal sac, in which strangulation at the internal abdo-
minal ring co-existed with an intussusception through
the ileo-csecal valve .... 129
BEENEES STEEET, last meeting at . . xcii
BLOOD TUMOUES (axgeiomata and angeiosakcomata) of
BONE (Edmund Eoughton) , . .69
BONE : On BLOOB tumoues (angeiomata and angeiosaeco-
mata) of (Edmund Eoughton) . . .69
388 INDEX.
Boatock, J. A., C.B. (Treasurer) . . .31
BOWLBY, Anthony A., F.B.G.S.
Ou the condition of the reflexes in cases of injury to the
spinal cord, with special reference to the indications for
operative interference . . . 313
BULL, W. 0., M.B., F.B.C.S., see Dent, C. T. . 359
C^CUM : A case of heknia of the (William H. Bennett) 129
GAGNEY, James, M.A., M.D.
The mechanism of suspension in the treatment of locomotor
ataxy ..... 101
CALCULUS in the bladder, analysis of 964 cases of operation
for (Sir Henry Thompson) . . . 219
Chambers, Thomas King, M.D., obituary of . .11
GHABTEBIS, Matthew, M. D.
Rheumatism, its treatment past and present ; with special
reference to recent experimental research on salicylic
acids and their salts .... 141
GHAVASSE, Thomas F., li.D., G.M.
Successful removal of the entire upper extremity for osteo-
chondroma . . . .81
Cheadle, W.B., M.D., Building Gommittee . . xcvii
CHEMISTEY of gout (Sir William Roberts) . . 339
CHOLECYSTENTEROSTOMY : A case of (A. W. Mayo
Robson) . . . . .61
Coulson, Walter John, obituary of . . .14
Cumberbatch, Laurence Trent, M.D., obituary of . 18
Currey, John Edmund, M.D., obituary of . .28
BENT, G. T., F.B.G.S., and W. G. BULL, M.B., F.B.G.S.
On four hundred cases of amputation performed at St.
George's Hospital from October, 1874, to June, 1888 :
with especial reference to the diminished rate of mortality
359
— Building Gommittee .... ciii
Bonders, Eranz Cornelius, obituary of . .6
Elam, Charles, M.D.Lond., obituary of . . 16
INDEX. 389
ELECTRIC LIGHT, installation of . . cvii
ENDOWMENT FUND : Donations from Dr. Quainaud
Mr. Hussey . . . . cix
FALLOPIAN TUBE : Pregnancy of, with euptuee (J. Bland
Sutton) . . . . .55
Fish, John Crockett, M,D., obituary of . .27
Floekhart, William, Architect to the Society . . xcvii
Gee, S. J., M.D. (Hon. Librarian), Buildirif/ Committee xcvii, 31
GOUT: A contribution to the chemistet of (SirW.Eoberts) 339
Gull, Sir William, Bart., M.D., obituary of , .25
Habershou, Samuel Osborne, M.D , obituary of . . 14
KAIG, A., M.A., M.D.
Salicin compared with salicylate of soda as to effect on the
excretion of uric acid, and value in the treatment of acute
rheumatism, with some deductions as to the causation of
the disease ..... 297
Hare, Dr. C. J. {Treasurer) , Building Committee xcvii, 31
Haward, Warrington J. {Son. Secretary), Building Com-
mittee .... xcvii, 31
HEENIA : EADTCAL CUEE of NON-STEANGULATED (Arthur E.
Barker) .... 273
HERNIA of the cjecum, a case of, entirely wanting in a peri-
toneal eac, in which strangulation at the internal abdo-
minal ring co-existed with an intussusception through
the ileo-csecal valve (William H. Bennett) . 129
Holmes, Timothy, Chairman of Building Committee, xcvii, 31 ;
Installation as President, cxix
HOUSE — THE Society's new — See Sir Edward Sieveking's
Addresses, p. Ixxxvii and p. i ; also Proceedings at
Annual Meeting, p. xcix.
Hulke, J. W., F.R.S., {Hon. Librarian) . . 31
HTJMFHBT, Professor George Murray, M.D., F.R.S.
Senile hypertrophy and senile atrophy of the skull . 327
INTUSSUSCEPTION through the ileo-cjecal valve : A case
of hernia of the caecum (William H. Bennett) . 129
LEAD-POISONING in its acute manifestations, an analy-
tical and clinical examination of (Thomas Oliver) . 33
390 INDEX.
LITHOTOMY and LITHOTRITY : Analysis of 964 cases
of operation for calculus in the bladder (Sir Henry
Thompson) . . . .219
LOCOMOTOR ATAXY : The mechanism of suspension in the
treatment of (James Cagney) . . . 101
MacAlister, J. Y. W., {Resident Librarian) xcvii, cxii, cxiv
M'Donnell, Robert, F.R.S., M.D., obituary of . .27
Obituary Notices of deceased Fellows of the Society, 1889-90.
Chambers, Thomas King, M.D.
Coulson, Walter John, F.R.C.S.
Cumberbatcb, Laurence Trent,
M.D.
Currey, John Edmund, M.D.
Danders, Franz Cornelius.
Elam, Charles, M.D., F.R.C.P.
Fish, John Crockett, M.D.
Gull, Sir William, Bart., M.D.
Habershon, Samuel Osborne,
M.D., F.R.C.P.
M'Donnell, Robert, F.R.S., M.D.
Radclifee, Charles Bland, M.D.
Sankev, William Henry Octavius,
M.D.
Shaw, Alexander, F.R.C.S.
Volkmann, Professor, Richard von.
Walton, Henry. Haynes, F.R.C.S.
Williams, Charles James Blasius,
M.D., F.R.S.
Wise, Thomas Alexander, M.D.
1—28
OLIVER, Thomas, M.A., M.D.
An analytical and clinical examination of lead-poisoning in
its acute manifestations . . .33
OSTEOCHONDROMA : Successful removal of the entire upper
extremity for (Thomas F. Chavasse) . . 81
Owen, Isambard, M.D., Building Committee . . xcvii
Parker, R. W., Building/ Committee . . . xcvii
PREGNANCY : A case of tubal, with remarks on the cause of
early rujjture (J. Bland Sutton) . . 55
Radcliffe, Charles Bland, M.D.,, obituary of . .9
RHEUMATISM, treatment of acute, by salicin and salicylate
of soda (A. Haig) .... 297
RHEUMATISM: Its treatment past and present ; with special
reference to recent experimental research on salicylic
acids and their salts (Matthew Charteris) . 141
ROBERTS, Sir William, M.D., F.R.S.
A contribution to the chemistry of gout . . 339
— On the history of uric acid in the urine, wath reference
to the formation of uric acid concretions and deposits
245
INDEX. 39 1
BOBSON; a. W. Mayo.
A case of cholecystenterostomy . . . Gl
BOUQHTOX, Edmund, B.S.
On blood tumours (angeiomata and angeiosarcomata) of
bone . . . . ,09
EOYAL MEDICAL and CHIRUEGICAL SOCIETY,
ORIGIN and PHOGBESS of, — CHAUTER of tlie (see Sieve-
king, Sir Edward).
SALICIN compared with salicylate of soda (A. Haig) . 297
SALICYLATE of soda compared with salictk (A. Haig) 297
SALICYLIC ACIDS and their salts in rheumatism (Matthew
Charteris) ..... 141
Sankey, William Henry Octavius, M.D., obituary of . 2
SENILE HYPERTEOPHY and ATEOPHY of the skull
(G. M. Humphry) .... 327
Shaw, Alexander, obituary of . . . 23
SIEVEKING, Sir Edward R., M.B., LL.D., F.B.C.P.,
Address of, at the Annual Meeting, March \st, 1890 1
— Address on the occasion of the first meeting in the
new bouse (giving a history of tbe origin and deve-
lopment of the Society) . . Ixxxvii
— Presentation of a president's badge . . exix
SKULL : Senile hypertrophy and senile atrophy of the (Cx. M.
Humphry) . . . . .327
SPINAL COED: on condition of reflexes in injury to (A. A.
Bowlby) . . . . .313
— On the symptomatology of total transverse lesions of
the (H. Charlton Bastian) . .151
SUTTON, J. Bland.
A case of tubal pregnancy, with remarks on the cause of
early rupture . . . .55
SUSPENSION : The mechanism of, in the treatment of loco-
motor ataxy (James Cagney) . . • 101
Taylor, Frederick M.D., {Hon. Secretary) . . 31
392 INDEX.
THOMPSON, Sir Henry, F.B.G.S., M.B.
Analysis of 964 cases of operation for calculus in the
bladder by lithotomy and lithotrity, with remarks 219
TUBAL PREGNANCY : A case of, with remarks on the cause
of early rupture (J. Bland Sutton) . . 55
UEIC ACID : Effect of salicin and salicylate of soda on the
excretion of (A. Haig) . . . 297
— In gout (Sir W. Roberts) . . .339
— In the urine. On the history of, with reference to the
formation of uric acid concretions and deposits (Sir
William Roberts) . . . .245
URINE : On the history of uric acid in the (Sir William
Roberts) . . .
Volkmann, Professor, Richard von, obituary of
Walton, Henry Haynes, obituary of .
Willett, Alfred, Building Committee .
Williams, Charles James Blasius, M.D,,E.R.S., obituary of 3
Wise, Thomas Alexander, M.D., obituary of . .28
245
21
18
xcvii
PBINTED BY ADLARD AND SON, BAETHOLOMEW CLOSE.
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