Full text of "Reports"
ST. THOMAS'S HOSPITAL
REPORTS.
VOL. II.
LOJSTDON:
J. & A. CHURCHILL, NEW BTJELINaTON STREET.
MDCCCLXXI.
^\.
^%
SAINT
THOMAS'S HOSPITAL
KEPOETS.
^eto ^txm.
EDITED BY
Dit. BRISTOWE, Dii. STONE, and Mk. CROFT.
VOL. II.
LONDON :
J. AND A. CHUECHILL, NEW BURLINGTON STUEET.
MDCCCLXXI.
%
6
CONTENTS.
PAGE
I. An Account of some Experiments relating to the
Influence exercised by Colloids upon the Forms
of Inorganic Matter. By William M.Obd, M.B.
Lond., M.E.C.P. . . . . .1
II. On the Period of Incubation of Typhus, Eelapsing
Fever, and Enteric Fever. By Charles Mue-
CHisoN, M.D. Edin., LL.D., F.E.S., F.E.C.R . 23
III. Some Remarks on Gunshot Wounds of the Lower Ex-
tremity. By William Mac Coemao, F.R.C.S. 43
IV. On the Existence of Continued Currents in Fluids.
Sequel to a Paper in the last Volume of these
Eeports. By GrEOEaE Rainet, M.R.C.S. . 57
V. On Paracentesis Thoracis. A Thesis read for the De-
gree of M.D. Cantab. By G. H. Eyaxs, M.D.,
M.RC.P. . . . .69
VI. On the Therapeutical Importance of Recent Views of
the Nature and Structure of Cancer. By Henet
Arnott, F.R.C.S. . . .103
VII. On the Action and Use of the Opium Alkaloids Cryp-
topia and Thebaia. By John Haelet, M.D. .
Lond., F.R.C.P. . . . .123
VIII. Description of a Case of Unreduced Dislocation of the
Left Femur, in which Death occurred Eight Days
after the Receipt of the Injury. By William
Mac Coemac, F.R.C.S. . .143
IX. Remarks on the Healthy and Morbid Anatomy of the
Perivascular System of the Brain. By W. W.
Wagstaffe, F.R.C.S. . . 149
iv Contents.
PAGE
X. Remarks ou the Theory and Practice of Epidermic
Grafting. By William Andeeson, F.R.C.S. . 1G5
XI. Cases of Stricture of the (Esophagus. By E. Clapton,
M.D., E.R.C.P. . .177
XII. On .Egophouy. By William H. Stoke, M.B.,
F.R.C.P.' \ . . . .187
XIII. Cases of Inversion of the Bladder. By John Ceoft,
F.R.C.S. . . . .195
XIV. On Impairment or Loss of Power of Articulate Speech,
By John S. Beistowe, M.D., F.R.C.P. . . 203
XY. Ou the Prognosis of Valvular Diseases of the Heart,
By Thomas B. Peacock, M.D., F.E.C.P. . 233
XVI, On a New Method of Extraction of Cataract. By E.
LiEBSEicn, M.E.C.S. . . . .259
XVII. On Cleft Palate. By Francis Mason, F.E.C.S. . 271
XVIII. On Hypertrophic Polypus of the Os Uteri, and its
Eelation to Hypertrophy of the Cervix Uteri.
By EoBEET Baenes, M.D., F.E.C.P. . . 275
XIX. Contribution towards the Surgical Treatment of Dis-
eased Joints. By Sydney Jones, M.B., F.E.C.S. 283
XX. Eeport of the Obstetrical Department of St. Thomas's
Hospital. By Heney Geeyis, M.D. Lond.,
M.E.C.P. . . .297
XXI. Medical and Surgical Statistical Tables . . 313
XXII. The Old Students' Gift . . .375
XXIII. Calendar for 1871 . . . .383
LIST OF SUBSCRIBERS.
Adams, Edward, J., St, Matthew's Workhouse, Bethnal Green
Adams, William, 5, Henrietta Street, Cavendish Square
Addy, B., St. Thomas's Hospital
Air, Alexander C, 88, Kennington Park Road, S.E.
AUingham, William, 3G, Finsbury Square, E.G.
AUiott, A. J., St. Thomas's Hospital, S.E.
Amyot, Thomas E., Diss, Norfolk
Anderson, Henry B., 78, East India Road, Poplar
Anderson, William, St. Thomas's Hospital, S.E.
Arminson, John, 7, Lune Street, Preston, Lancashire, for Preston Med.
Soc.
Armstrong, John C, 19G, Parrock Street, Gravesend
Atkinson, F. P., Heath Villa, Bushy Heath, Herts ; and 30, Bess-
borough Gardens, S.W.
Aubin, Thomas J., Great Eccleston, Garstang, Lancashire
Avehng, C. T., Portland Place, Clapton
Arnott, H., (j, Nottingham Place, W.
Ball, John Woodhouse, Little Sutton, Eastham, Cheshire
Barker, T. A., M.D., 27, Wimpole Street, W.
Barnes, Robert, 31, Grosvenor Street, W.
Baron, Thomas, Welch Row, Nantwicb, Cheshire
Barrett, John J., 75, Biackfriars Road, S.E.
Barwell, Richard, 32, George Street, Hanover Square
Bean, William M., 93, Camberwell Grove, S.E.
Beardsley, Amos, Grange, Oversands, Lancashire
Bell, William, Eastgate, Rochester, Kent
Banham, H. S., St. Thomas's Hospital, S.E.
Bennett, J. Risdon, M.D., 15, Finsbury Square, E.G.
Bernays, Albert, J. Ph. D., St. Thomas's Hospital
Bicknell, Edward, 33, Union Street, Coventry
Bird, P. Hinckes, I, Norfolk Square, W.
Blackett, William C, 1, South Street, Durham
Booth, Edward J. H., Infirmary, Huddersfield
Boulger, J., St. Thomas's Hospital, S.E.
Bowen, Essex, 33, Grange Mount, Birkenhead.
Brand, Samuel E., 33, Cornhill, E.G.
Bringloe, John, 3, Champion Place, Cold Harbour Lane, Camberwell
Bristowe, John Syer, INI.l)., 11, Old Burlington Street, W.
Britton, Thomas, Driffield, Yorkshire
Browne, EJgar A., 86, Bedford Street, Abercrombie Square, Liverpool
VOL. II. b
vi List of Subscribers .
Brown, Fred. Gorrlon, 16, Finsbury Circus, E.G.
Browu, G. D., Uxbridge Road, Ealing
Brown, G. G., Mitton Grange, Stourport, Worcestershire
BuUen, H. Si. J., 89, Upper Kennington Lane, S.E.
Bunny, Joseph, Northbrook Sireet, Newbury, Berkshire
Carless, John, London Road, Stroud, Gloucestershire
Carpenter, A., M.D., High Street, Croydon
Carpenter, Edward, 149, Walworth Road, S.E.
Carter, William, 09, Elizabeth Street, Liverpool
Caudle, A. W. W., Henfield, Sussex
Ceely, Robert, Aylesbury
Chabot, Frederick, 24.5, Catnberwell Road
Chaffers, Edward, North Street, Keighley, Yorkshire
Chaldecott, Charles W., Dorking, Surrey
Chaldecott, 'V. A., Beamond, Chertsey
Chater, Sydney, 18, St. Helen's Place, E.G.
Churchill, Frederick, 19 a. Great George Street, Westminster
Clapton, Edward, M.D., St. Thomas's Street, S.E.
Clapton, William, 42, Bloomsbury Square
Clark, Arthur, Stock, near lugatestone, Essex
Clark, Fred Le Gros, St. Thomas's Street, S.E.
Clark, J. Lockhart, F.R.S., tiO, Warwick Street, Belgravia
Cleaver, Henry A., Croydon, Surrey, for Book Soc.
Coghlan, Wni. Boyle, 325, Oxford Road, Brighton Place, Manchester.
Colby, AVm. Taylor, New Malton, Yorkshire
Coppock, Charles, 31, Cornhili, B.C.
Corbin, ]\1. A. Bazille, St. Thomas's Hospital
Cowen, Philip, Res. i\led. Off. Hifirmary, Islington Workhouse, Upper
Holloway
Corney, Bolton G., St. Thomas's Hospital
Crisp, Edwards, 29, Beaufort Street, Chelsea
Croft, John, 01, Brook Street, Grosvenor Scjuare
Crofts, W^illiam, Carrick, Church Greslev, Burton-on-Trent
Crosby, T. B., 21, Gordon Square, W.C.'
Croucher, Henry, West Hill, Dartford, Kent
Cruise, F. Iv., 3, Merrion Square, Dublin
Curtis, James, 29, Norfolk Square, Brighton
Dalby, W. T., J. P., 109, Kennington Park Road, S.E.
Darke, James, Great Malvern
Denne, T. V. dc, Arlesey, Baldock, Herts
Denton, Sam. B., Ivy Lodge, Hornsea, Hull
Dewsnap, Mark, 0), King Street West, Hammersnuth
Dixon, Edward L., 94, Fishergate, Preston, Lancashire
Dobson, Nelson C, 7, Tottenham Place, Clifton
])onkin, H. B., St. Thomas's Hospital
Drake, Arthur J., Stratford, Essex, E.
Drake, C. H., Brixton Hill, S.W.
Drake, Thomas, Stratford, Essex, E.
Li.4 of Subscribers.
Dukes, Clement, Horton Crescent, Rugby
Durham, Arthur E., 82, Brook Street, Grosvenor Square, W.
Edmonds, Spencer, Appleby, Atherston, Leicestershire
Edwards, Vertue, Hospital for Consumption, Brompton
Elliott, J. W., 4, Finsbury Square, E.G.
Elwin, Charles J., 6, City Road, E.C.
Emson, Alfred, Dorchester
Etheridge, Charles, Little Goddesden, Hemel Hempstead
Evans, George H., M.D., St. Thomas's Hospital
Eve, R. W., 427, New Cross Road, S.E.
Farrant, Samuel, North Street House, Taunton
Fouracre, Robert P., 1, Alpha Villas, Hornsey Road, N.
Fowler, James, 13, South Parade, Wakefield
Franklin, G. C.
Freeman, \V. H., 29, Spring Gardens, S.W.
Garnham, D. J., St, Swithin Square, Lincoln
Garton, \Vm.
George, Charles F., Kirton-iu-Lindsey, Lincolnshire
Gervis, Frederick H., 1, Fellows Road, Haverstock Hill
Gervis, Henry, M.D., St. Thomas's Street, S.E.
Gervis, F. S., Tiverton, Devonshire
Gibson, John R., 10, Russell Square, W.C.
Gimblett, John, Sydney, Gloucestershire
Goddard, Eugene, 27, Fentonville Road, N.
Good, Joseph, Wilton, Wiltshire
Goolden, R. H., M.D., 1, Sussex Gardens, \V.
Graham, George T., St. Peter's Square, Stockport
Greaves, Charles A., Stafford Street, Derby
Guest, Ellis H., 251, Oxford Street, Manchester
Hague, Samuel, 65, Peckham Grove, Camberwell
Hainworth, John, 138, Camden Road, N.W.
Hammond, Jos. H., Wiiicklej Square, Preston, Lancasliire
Hardyman, Charles E., Worcester General Lifirmary
Harper, Robert, Holbeacli, Lincolnshire
Harris, Henry, Trengmeath Place, Redruth
Harvey, Thomas, 297, High Street, Poplar
Haslam, Jos., 141, Finborough Road, West Brompton
Hearnden, William Alex., Down House, Sutton, Surrey
Heygate, William N., Kibworth, Leicestershire
Hicks, J. Wale, M.D., Sidney Sussex College, Cambridge
Hitchcock, ii. K., 9, Torrington Villas, Lee, S.E.
Holland, Edward Charles, 15, Catherine Place, Bath
Howard, R. P., 9, Beaver Hall Hill, Montreal, Canada
Howell, Thomas S,, 14, High Street, Wandsworth
Hullah, Robert, Earlswood Asylum, Redhill
Hume, Frederick H., 21, St. Peter's Street, Islington
Hurman, Henry B., Eastover, Bridgewater
yiii List of Subscribers.
Harley, John, M.D., 78, Upper Berkeley Street, W.
Ideson, Joseph J., Colne, Lancashire
lies, Daniel, Fairforde, Gloucestershire
Inglis, Walter W,, Devon House, South Penge Park, S.E.
Jackson, T. Carr, 3, Weymouth Street, Portland Place
Jardine, J. Lee, Capel, Dorkinp;, Surrey
Jefferson, Thomas J., Market Weighton, Brough, Yorkshire
Jephcott, Samuel T., 87, Foregate Street, Chester
Jones, Evan, Aberdare, Glamorganshire
Jones, H. W., St. Thomas's Hospital
Jones, John, Tirbach, near Llanelly
Jones, Sydney, St. Thomas's Street, S.E.
Jones, Thomas, Church Street, Ross, Herefordshire
Johnson, Arthur Jukes
Kemp, George, Barnstaple, Devon
Kernot, G. C, Chrisp Street, Poplar, E.
Keyworth, John, Sutton Street, Aston, Birmingham
Kilner, W. J.
King, Robert, Hinton Villas, Uxbridge
King, W. Warwick, 23, Railway Api)roach, London Bridge
Knowles, Henry, 295, Regent Road, Salford, Manchester
Laver, A. H., St. Thomas's Hospital
Leeds Medical Society
Lees, Joseph, M.D., 112, Walworth Road
Littlejohn, J. E., Central London District School, Hanwell
Llewellyn, Wm. P. J., 71, Blackman Street, S.E.
Liebreich, R., 15a, Clifford Street, W.
MacCormac, William, 13, Harley Street, W.
Maconchy, John K., Lifirmary House, Downpatrick, co. Down
Male, H. D., General Dispensary, Lincoln
Mann, John, 3, Warltersville Road, Hornsey Hise
March, H. CoUey, 2, West Street, Rochdale
Marsack, Blackall, Howard Lodge, Tunbridge Wells
Mavor, W., 14, Liverness Terrace, Bayswater
Maybury, H. M., Cedar Lodge, Frimley, Surrey
Maynard, John C. M., 13, Northbrink, Wisbeach, Cambridgeshire
M'Lean, XWen, Caistor, Lincolnshire
Measures, J. W
Meymott, Henry, Ludlow, Salop
Miller, Benjamin, 4, Denmark Hill, S.E.
Miller, Frederick M., Claremont Villas, Stoke Newington Road
Miller, William, High Street, Poole, Dorset
Milne, Charles W., 138, AVandsworth Road, S.W.
Misken, G. A., 1G2, York Road, Lambeth
Mitchell, Joseph, 72, Charrington Street, N.W,
Mitchell, Robert, Manor House, New Crosa Road, Deptford
Monro, C. E
List of Subscribers. ix
Moore, Daniel, Hastings Lodge, Victoria Lodge, Upper Norwood, S,
Moore, J. W.
Moreton, James E., Tarvin, Cheshire
Morgan, John "W., C, Somerset Place, Oysterraouth, Swansea
Morton, John, Eastgate House, Guildford
Murchison, Charles, M.D., 79, Wimpole Street, W.
Mason, Francis, 10, Conduit Street
Napper, Albert, Cranleigh, Guildford
Newby, C. H., St. Thomas's Hospital
Newth, Alfred, Hayward's Heath, Sussex
Nichol, Robert, Denmark Hill, S.E.
North, H., Belmont House, Portwood, Southampton
Northey, G. W
Nowell, Arthur H., 28, Cornwall Road, W.
Orange, W., Broadmoor, Berkshire
Ord, George Rice, Brixton Hill, S.W.
Ord, William M., M.D., 11, Brook Street, Hanover Square, W.
Osborne, S., St. Thomas's Hospital
Owen, Charles W., Brigadier Hill, Enfield
Parker, T. D., 59, High Street, Deptford
Palmer, A., St. Thomas's Hospital
Parrott, — , St. Thomas's Hospital
Parson, Henry
Payne, Jas. Frank, M.D., 50, Green Street, Grosvenor Square
Peacock, T. B., M.D., 20, Finsbury Circus, E.G.
Pearson, D. T.
Penhall, John T., 5, Eversfield Place, St. Leonard's-on-Sea
Pern, Alfred, Botley, Southampton
Pilcher, W. J., 43, West Street, Boston, Lincolnshire
Pinchard, Benjamin, Cottenham, Cambridge
Plowman, R., 8, Bishop Street, Coventry
Pollard, Frederick, St. Thomas's Hospital
Prichard, Thomas, Baschurch, Shi'ewsbury
Pughe, John, J. P., Bryn, Awel, Aberdovey, North Wales
Purnell, J. J., Woodlands, Streatham Hill
Purvis, John P., Royal Hill, Greenwich
Rainey, George, St. Thomas's Hospital
Radford, Thomas, Moor Field, Higher Broughton, Manchester
Rayner, H., Bethlem Hospital
Ridge, John J., 30, Grafton Square, Clapham, S.E,
Richmond, Thomas G., Prestbury, Macclesfield, Cheshire
Robathan, C. B., The Grove, Risca, Monmouthshire
Roberts, Lloyd, 25, St. John Street, Manchester
Roots, William Sudlow, Kingston-on-Thames
Rosser, Walter
Sankey, AVilliam, Sutton-Valence, Staplehurst, Kent
Sams, John Sutton, Eltham Road, Lee, S.E.
X List of Subscribers.
Saunders, Charles E., Sutherland House, Hayward's Heath, Sussex
Saunders, Edwin, 13a, George Street, Hanover Square
Saunders, H. W., General Hospital, Bristol
Seaton, E
Sedgwick, James, Borouglibridge, Yorkshire
Sedgwick, L., 2, Gloucester Terrace, Hyde Park, W.
Shifman, Robert, Grantham
Siranionds, H. M., 66, Camberwell Road, S.E.
Simon, John, F.K.S., 40, Kensington Square, \V
Slater, J. P., St. Thomas's Hospital
Slaughter, J., Farningham, Kent
Slaughter, W. B., Farningham, Kent
Smith, Samuel, Ivy House, Weaverham, Northvvich, Chesliire
Snaith, Francis, Boston, Lincolnshire
Sparke, G. Whitefield, Mansfield, Notts
Staddon, John H., Friar's Road, Ipswich
Statham, Hugh W., 50, Woburn Place, W.C
Stocks, Frederick, County Lunatic Asylutn, Rainhill, Lancashire
Stewart, Charles, Albert Square, Clapham Road
Stone, W. H., M.D., 13, Vigo Street, W.
Strange, W. Heath, 13, Belsize Avenue, Hampstead, N.W.
Sturton, Hubert \V. S., 29, Burney Street, Greenwich
Surnmerhayes, AYilliam, Upper St. Giles, Norwich
Sutcliffe, John, Denmark Hill, Camberwell, S.E.
SutclifFe, J. H., Ripley, Surrey
Smith, Charles J., 36, Albany Villas, Cliftonville, Brighton
Smith, Heckstall, 4, Victoria Terrace, Cliftonville, Brighton
Snow, James, Atherstone Place, Lincoln
Timothy, P. Vincent, 72, Worship Street, E.G.
Tindale, Edward, Ashwell Baldock, Herts
Tomlinson, James, Lendal, York
Toovey, T. F.
Towne, A., 3.54, Kingsland Road, N.E.
Treves, W. Knight, 8, Cecil Square, ^Margate
Trend, Henry G., 191, Southgate Road, N.
Treves, E., Rest Villa, Loughborough Road, Brixton
Turner, Kichard, Lewes, Sussex
Tyrrell, Walter, Beresford House, Great Malvern
A^ardy, Joshua L., 74, Commercial Road, Soutiisea, Portsmouth
Vesey, T. A., West View, Itosstrevor, co. Duvvn
"Wadd, Frederick J., Beaconsfield, Bucks
Wagstalle, W. W., St. Thomas's Hospital
Walker, R., Budleigh Salterton, Devon
Waller, Arthur, Islington Dispensary
Ward, Charles Parker, 104, Buckingham Palace Road
Ward, Fred. Henry, County Asylum, Tooting, S.E.
Waterworth, E. A., Quay Street, Newport, Isle of Wight
Welch, James Kemp, Christchurch, Hants
List of Subscribers x
Wells, T. Spencer, 3, Upper Grosvenor Street, W.
West, James F., Broad Street, Birmingham
West, R. H.
Whitfield, R. G., St. Thomas's Hospital
Whittingham, George, Holloway Dispensary, 434, Liverpool Road, N.
Wilkinson, T. M., Wanstead
Wilks, Sam., M.D., F.R.S,, 77, Grosvenor Street, \V.
Williams, A. H., St. Thomas's Hospital
Williams, Henry, St. Thomas's Hospital
WiUiams, Rhys', M.D., Bethlem Hospital
Williams, John, Swiuton, Manchester
Williams, P. M. G., Tyllwyd, Trevine, Pembroke
Winstanley, Clement, Hatfield, Herts
Woakes, Edward, Luton, Bedfordshire
"Worthington, G. F. J., The Parade, West Worthing
Wrench, Edward M., Park Lodge, Baslow, Derbyshire
Wright, Alfred, Romford, Essex
Wright, F. J.
AVyman, W. S., Westlands, Upper Richmond Road, Putney
In Exchange.
St. Bartholomew's Hospital Reports
St. George's Hospital Reports
Guy's Hospital Reports
The Manchester Hospital Reports
The Obstetric Society's Transactions
AN
ACCOUNT OF SOME EXPEEIMENTS
EELATIXO TO THE
INPLUENCE EXEUCISED BY COLLOIDS
UPON THE
FORMS OF INORGANIC MATTER.
By WILLIAM M. ORD, M.B. Lond, M.R.C.P.
In the histology of the future the relations between matter
and form in living bodies will doubtless occupy much attention.
Certain forms being found in living bodies as characteristically
associated with life as the crystal is characteristic of matter
without life, wherever Ave may agree to fix the limit of what
can be demonstrated or estimated, and pass into the region of
the mysterious, it must be felt that, short of such limit, there is
room for inqu.iry as to how far matter determines form. When
the great chemical complexity and extreme molecular instability
belonging to the matter composing a vegetable cell or a piece
of germinal matter is borne in mind, it seems advisable to begin
by watching the behaviour of less complex and changeable sub-
stances belonging clearly to the inorganic world -when brought
under the influence of matter belonging to the organic world.
In this sense I put forward the following account of some
investigations carried on by me during the last few years with
much unavoidable interruption.
In December, 1868, while examining some urine I met with
dumb-bells of a kind quite new to me; and consulting Dr.
Beale's work on ' Urinary Deposits^ (3rd ed.), I found that he had
made drawings of dumb-bells of oxalate of lime contained in
VOL. II. 1
2 Experiments relating to the Infiuence of
transparent casts of renal tubes, accompanied by octobedra
floating- in tbe surronnding- fluid. In bis remarks upon tbcse
forms I found arguments adduced — 1st, to prove tbat tbe dumb-
bells were, in fact, composed of oxalate of lime ; 2nd, to explain
tbe assumption of tbe dumb-bell form in sucb cases by con-
siderations founded upon tbe investigations of Mr. Rainey,
wliicb show that the presence of viscid organic matter prevents
crystalline substances from assuming their usual form, and causes
the crystalline matter to be deposited in spherical or dumb-bell
shape. The investigations here quoted, too little noticed by
tbe scientific world, had long appeared to me to be the com-
mencement of a new and accurate method of studying tissue
facture. I resolved to apply a modification of Mr. Rainey's
plan of experiment to the determination of some of tbe con-
ditions under which dumb-bells might be formed ; to fix with
more certainty the relations between the octobedron and the
dumb-bell of oxalate of lime ; to try, in fact, to turn the one
into the other, and set at rest any remaining doubt as to their
identity. The first exjicriments were made in tbe following
way.
Some perfectly clear jelly prepared from isinglass was melted
in a flat-bottomed jar, in quantity enough to form a layer about
three quarters of an inch deep. In this, while still liquid, a
number of glass tubes, each about four inches long, half an
inch in diameter, and open at both ends, Avere placed upright,
so that each tube Avas immersed to the depth of nearly three
quarters of an inch. After cooling, the tubes Avere removed,
and each Avas found plugged with firm clear jelly, so as to be
thoroughly Avater-tigbt. Six of these tubes Avcre next filled Avith
a slightly alkaline solution of potassium oxalate, and placed with
their plugged ends in a Aveak solution (about 6 grs. to 1 oz.)
of chloride of calcium, the level of the solution in tbe tubes
being much higher than the level of tbe calcium solution. Tbe
plug of jelly was thus interposed betAveen the two solutions, in
tlie hope that, difl"usion slowly occurring, tbe results of the
mutual decomposition of tbe oxalate and calcium salt might be
found after a time in the jelly, a fair representative as fiir as
consistence was concerned, of tbe casts of tbe kidney tubes.
This experiment Avas performed in a room of the average tempe-
rature of 57° Fahr.
Colloids upon Forms of Inorganic Matter. 3
On the second day the plugs were clouded with white deposit,
and fragments removed from them were found to contain a
large number of crystalline and rounded forms, including both
octohedra and dumb-bells.
The process was then allowed to go on for three months, till
on the 12th March, 1869, an entire and uninjured plug was
removed and submitted to careful examination. The oxalic
solution was still clear; the calcium solution was thickened
with deposit of calcium oxalate, but the relative levels of the
solutions were unaltered. The ping was found free from decom-
position, and opaque with earthy deposit. The deposit was not
uniform, but somewhat stratified, forming a layer of greatest
density near the calcium solution, a layer of less density, with
some opalescence near the oxalic solution, and several inter-
mediate layers of still less density, with alternate spaces of
extreme scantiness of deposit.
Transverse sections of the plug were made at thirteen points ;
the sections were transferred to glass slides, melted with the
gentlest possible heat, and examined under the microscope with
the half-inch objective. For preservation they were afterwards
slightly dried at a gentle heat, and mounted in solution of
Canada balsam in chloroform. In this course of preparation it was
found that, although a great variety of forms were present in the
several sections, one only, the octohedron, was altered ; the rest
remained for many weeks unchanged, a point which was
easily determined by comparison with fine sections of sub-
sequently prepared plugs placed on slides without use of heat or
balsam.
To sum up the results of the examination of the thirteen
sections, it was found that the forms existing on the side of the
oxalate were very diff'erent from those on the side of the calcium
salt, and that a remarkable series of gradations led easily from
the one set of forms to the other. At the calcic end two forms
were most abundant — perfect octohedra, and large tabular
crystals of oblong outline with rounded angles. The tablets,
when seen lying flat, were colourless, marked with diagonal
lines and faint concentric shadings ; when tilted up on one side,
were yellowish in colour, highly refractile, longitudinally
laminated, and again marked Avith diagonal lines ; their thick-
ness was about one third of their breadth. They might be
4 Experiments relating to the Injluence of
described as consisting' of a number of fine oblong plates
bound togetber lace to face, tbe outermost larger in all dimen-
sions, tbe innermost shorter by one twelfth and narrower in
proportion (PL I, fig. 1, a,b, c). At this point also were found
in smaller numbers forms transitional between crystals and co-
alescence bodies (non-crystalline, rounded, calculous) ; two jjaths
being taken. By one the dumb-bell form was reached without
loss of outline of the crystals, the molecules undergoing rear-
rangement within, so that a large flattened dumb-bell, with
sharjDly cut edges, was found enclosed in the outline of a tablet
(PL I, fig. 2) ; by another much more frequented path the dumb-
bell was reached through entire disintegration. In this second case
smaller tablets -were found to lose their sharpness of outline and
to become granular, at the same time that they became marked
by a line of slight continuoiis constriction round the middle of
their long axis, the result being the formation of a small, not
very perfect dumb-bell, and beyond this of complicated masses
built up by the coalescence of a number of the smaller ones,
and taking sometimes the form of double, sometimes of single,
simple, or tuberculated spheres — mulberry calculi on a small scale
(PL I, fig. 3). The large dumb-bells were, as is already remarked,
very perfect, their outline sharp and running in a bold unbroken
sweep ; their substance nearly homogeneous — though there were
often indications of a tendency to radiating fibrillation — and
very refractile; they usually presented in each half a large
cavity joined to its fellow by a canal running through the
isthmus. As successive sections were examined, the tablets
and the octohedra steadily diminished in size to the junction of
the lower and middle third of the plug, and mixed with them
were found small spherical molecules increasing in si/c as the
others grew less, until they were moulded into large bodies in
which the rhomboidal and spherical forms were engaged in a
well-balanced struggle for superiority. They were at first
sisrht oval, but were, in fact, rhomboidal Avith much rounded
angles. Each had a tiny central cavity like that of a starch-
grain, and at tlie lev(>l of this a line corresponding to the plane
Avhich Avould join the obtuse angles divided the crystal into
halves. Internally, the structure was ajjiiarently fibrous ; it was,
in fact, laminai, the laminit^ being curiously bent and twisted in
a spiral way, the little central cavity nuirking the axis of torsion
Colloids upon Forms of Inorganic Matter. . 5
(PI. I, fig. 4). Above tlie middle of the plug tliese bodies, having
attained their full development, were suddenly lost.
Tablets, in some respects resembling the first, next appeared
(PI. I, fig. 5). They were, however, much longer, and much
thicker in proportion to their breadth. These, as they grew,
were also modified. They became longer and expanded at their
extremities, the middle transverse line being unaffected. At first
each half was split, as it were, into two crystals, firmly bound
together at the middle, slightly divergent at the end ; then, by
the continuation of the same process, each half became broken up
into a number of flat rods bound together at the middle, so that
the whole mass had a great resemblance to a wheatsheaf. Further
subdivision, with curving and flattening of the rods, turned the
wheatsheaf into a crystalline dumb-bell ; still further, as the
oxalic surface was approached, the forms rapidly fell in size,
acquired a sharper outline, thicker waist, and, to all appear-
ance, a central cavity. In some cases, by extreme arching over
of the points, the two halves of the dumb-bell met round the
middle and so a sort of sphere was formed. Here also the
octohedra which liad been present throughout, and had followed
the variations in the size of the associated bodies, underwent a
change of form. They were flattened in the direction of one
diagonal, and expanded in other directions. They next exhibited
indentations midway between the angles, with corresponding
outgrowth of the angles until they became distinctly cruciform.
The rays of the cross presently lost their sharpness, and by
transverse splitting (which never reached the axis of any ray)
became feathered. In the central mass of the crystal the octo-
hedral form could still be made out (PI. I, fig. 6). The prin-
cipal forms altogether observed were five, viz. — 1, octohedra ; 2,
tablets ; 3, ovoid rhombohedra ; 4, calculous (coalescing) dumb-
bells ; 5, wheatsheaves, and crystalline dumb-bells. The coa-
lescent forms were characteristic of the calcic end, the crystalline
of the oxalic end of the plug. It was further evident tliat
certain kinds of tablet were in distinct constructive relation
Avith the two kinds of dumb-bell and the ovoid bodies respec-
tively. It was evident also that the object originally proposed
had been attained; in the presence of such a colloid as gelatin
oxalate of calcium did assume the form of the dumb-bell and of
allied calculi ; and, further, a comparison of the bodies now
6 Eocperiments relating to the I/ifliieuce of
obtained with figures given by Dr. Beale and others left no
doubt that many, at least, of the dumb-bells found in urine by
different observers were composed of oxalate of lime.
But more than this was to be learnt. The meaning of the
great variety of the crystals, the conditions determining the for-
mation of each, and the relations held by them each to each,
must be sought for.
To begin, similar experiments were instituted with solutions
of calcic chloride and sodic bicarbonate, with a view of repro-
ducing the beautiful spheres originally figured by Mr. E,ainey.
It was here noticed that when the sodic carbonate was in con-
siderable excess only a few spheres were formed in the neigh-
bourhood of the calcium solution, the middle of the plug being
filled with large ovoid rhombohedra closely resembling the
bodies in PI. I, fig. 4. The suspicion then arose that some
alkaline carbonate might have been present in the oxalic solu-
tion in the first experiments, and that calcic carbonate might
have been formed and modified the results. The remarkable
facility with which this salt was brought into spherical form by
colloids made it possible that the form of the oxalate might
have been aflfected by the presence of the carbonate. The
solution of oxalate of potassium had, in fact, been rendered
alkaline by a little liquor potass?e, aiul here was a very probable
source of error.
A new series of experiments was accordingly instituted.
1. Acetic acid was added in considerable excess to the solu-
tion of oxalate of potash and all the carbonic acid expelled.
The solutions being now used as before, the plug was found at
the end of five day^s white and opaque with deposit in its lower
fourth, adjoining the calcium solution. Above this it was almost
clear, th(; acetic acid having, apparently in virtue of its greater
diffusibility, driven back, as it Avere — outstripped (?) — the calcium
salt. The deposit corresponded in the main to the oxalic end of
the first plug (PI. II, fig. 1). At the calcic end were " wheatsheaves"
and the crystalline kind of dumb-bell, mixed with long, narrow-
pointed, and very regular tablets ; the octohcdra Avcre few and
small. In the clear part of the plug were smaller oval tablets, and
small, beautifully rounded, thick-waisted dumb-bells of nearly
transparent substance enclosing a dumb-bell-shaped cavity.
These forms dwindled down at the oxalic end to tiny granules,
Colloids upon Forms of Inorganic Matter. 7
still resolved by the one-eighth-inch objective into dumb-bells,
and then found surrounded with still more tiny granules, possibly
demonstrable as dumb-bells by a higher magnifying power.
2. Solutions of pure oxalic acid were placed in the tubes.
(«) Oxalic acid was used in large excess of the chloride of
calcium. The plug was examined at the end of two days,
experience having now shown, in the case, at least, of oxalate
of calcium, such an interval to be suificient.
Three several lines of forms Avere here observed (Fl. II,
figs. 2, 3). _
(1) Beginning at the oxalic end, small spicules of no very
definite form were followed through many stages of aggrega-
tion to, first, the perfect and, next, the feathered octohedron.
(2) Beginning also at the oxalic end, small rounded but irre-
gular masses were shaped into thick-waisted, clear coloured,
homogeneous dumb-bells, which became thinner waisted and
more characteristic at the point where the perfect octohedra
were found ; underwent sudden enlargement and radial crystal-
lization where the octohedron became feathered, and finally
assumed the " wheatsheaf " condition.
(3) At the point where the foregoing series were completed, tiny
crystalline bodies appeared, soon seen as they grew to be octohedra,
much split up into planes parallel with the basial plane (which was
oblong), and partly divided by a superficial incision jDcrpendicular
to the long axis of the oblong plane (PI. II, fig. 4). The full
development of this series is seen in PL II, fig. 4, in the shape of
very large ovoid much facetted and laminated crystals not unlike
the large tablets of PI. I, fig. 1. We seemed to have here before
us the changes leading from the octohedron to the tablet. Here
also the " wheatsheaves " had become compressed into spheres
with radiating texture and with rough spiked surface.
Just at this point the density of the deposit was so great as
to draw a perfectly opaque white line across the middle of the
plug, with a comparatively clear stratum below. In most of
the plugs such a line existed, and appeared to indicate the
point at which the two solutions balanced one another. I
shall call it the line of greatest deposit. In this line only crys-
talline forms occurred, viz. small rhombohedra, large ovoid
tablets, and large perfect octohedra. Below the line all the
forms rapidly decreased in size ; the ovoid crystals thinned away.
8 Experiments relating to the Influence of
as it were, by casting off their outer laminse, till they were re-
duced to delicate hexagonal plates or lozenges, very transparent
and symmetrical ; a further simplification of outline by growth
of certain sides at the expense of others j^roduced the rhombic
form ; and finally, at the calcic extremity, the only crystals left
were three-sided prisms with shallow pyramidic ends (PI. II,
fig. 5). The series constructive of the large octohedra requires
some special description.
The little sjjicules before mentioned as having no very
definite shape were first gathered into radiating tufts; the tufts
became cruciform, with very irregularly outlined arms ; then
six-rayed, with arrangement of rays corresponding to the angle-
joining lines of an octohedron ; by the filling up of the inter-
radial spaces, and simultaneous smoothing of surfaces and
pointing of angles, the perfect crystal was obtained.
It was constantly to be observed that the cruciform bodies
Avere joined in pairs face to face by a bar, so as to resemble the
amphidisci of Spongilla ; the two halves then corresponded to
the two pyramids into which an octohedron can be divided,
and the bar joining them to the line joining the apices of the
pyramids, or third axis of the octohedron.
(b). Chloride of calcium was used in large excess of the
oxalic acid.
The line of greatest deposit was here removed to the vipper
end of the plug. The constituents of the de2)osit were the same
as in the preceding experiments, but above it very few of the
forms seen in the corresponding part of the plug in the preced-
ing experiment had been deposited ; there were no octohedra,
their place being taken by little rhombs. It was found that all
the oxalic acid had been withdrawn from the solution, and the
pr^'dominance of the calcic solution seems to have driven away
all the forms characteristic of the oxalic side.
3. Solutions of ammonium oxalate carefully purified by
repeated crystallizations, and of chloride of calcium of known
strength, were prepared.
The formula of ammonium oxalate is given in jNIiller's ' Ele-
ments of Chemistry' as follows :
(IT,N),CA, H.,0 = 142;
of calcic chloride in the fusible form as follows :
CaCl,,6H,.0 =219;
Colloids upon Forms of Inorganic Matter.
from which it can be calcidated that 100 parts of calcic chloride
Avill be decomposed by 65 parts of ammonium oxalate. The
solutions were therefore made to contain respectively 100
grains of calcic chloride and 65 grains of ammonium oxalate in
four ounces of distilled water.
Experiments were noAv carried on with more exactness :
1st, Avith equivalents of the two salts;
2nd, with 4 equivalents of oxalate to 1 of chloride ;
3rd, with 1 equivalent of oxalate to 4 of chloride.
The plugs, removed simultaneously at the end of six days,
were found very differently charged with deposit. In all, the
precipitate was confined to the upper (oxalic) half of the plug,
leaving the lower (calcic) half quite clear.
Ox.
Ox.
Ox.
Ca.
In No. 1 the deposit was divided into two strata ; the lower, a
little less than half, denser ; the upper, rather more than half,
more scanty.
In No. 2 a narrow line of excessive density ran along the lowest
part of the deposit, leaving the portion above rather less dense
than the upper part of No. 1.
In No. 3 a very dense deposit filled the upper half of the plug,
except at a very thin line in contact Avith the oxalic solution.
In all three cases the denser tract of the plug contained coal-
escence forms with octohedra. On the side of the oxalate were
laro-e wheatsheaves, bundles of crystalline plates looking like
packets of docketed letters tied tightly round the middle, and
octohedra of moderate size Avith much-broken angles (Pl.II,fig.6).
On the calcic side the wheatsheaves were replaced by smaller,
rounded, homogeneous dumb-bells of great beauty ; the octo-
hedra were much larger, flattened in the direction of their per-
pendicular axes, and much drawn out at their angles, their
10 Experiments relating to the Influence of
internal structure being at the same time disturbed. The upper
scantier hiyer of deposit contained in all three cases the same
forms — a series running from granular aggregations of crystal-
line matter to tolerably perfect octohedra, without any associated
coalescence forms. In the lower half of the plug, just below the
dense line, was a shallow layer of exquisitely perfect small octo-
hedra, with their three axes nearly equal. Below this layer the
plug contained nothing. Comparing the plugs in other respects,
it was noted that the coalescence forms Avere most abundant in
the broad tract of No. 3, most perfect in the thin dense line of
No. %, where the wheatsheaves were so luxuriant as to form
spheres of radiant crystal, and the dumb-bells were compacted
into lustrous spherical beads.
4. Lime water and oxalic acid were now used in the beaker
and tubes respectively. But the oxalic acid was evidently much
more diffusible than the lime, and the plugs were filled with a
slight deposit, corresponding in the main to the upper scantier
deposit of the foregoing experiments, and contained only a few
tables and bundles of plates at the very lowest point. When
equivalents were used, all the forms were small, and the tablets
were little oval-pointed lozenges. When two equivalents of
oxalic acid and one of lime were used, the tablets were rounded
at the ends, thicker, often laminated and compressed or con-
stricted in the middle, indicating the early stages of wheatsheaf
formation.
Reviewing the whole group of experiments, it is evident —
1. That when deposited in gelatin, calcium oxalate assumes
many forms, including, besides the characteristic octohedron,
dumb-bells of two kinds, crystalline and homogeneous, tablets
and prisms of several kinds, and variously shaped calculi.
2. That the octohedra, tablets, wheatsheaves, and crystalline
dumb-bells appear to stand in direct serial relation to one
another ; the granules, calculi, and homogeneous dumb-b( lis
having among themselves a similar relation. Crystals, however,
may be resolved into homogeneous dumb-bells in two ways —
either by a formation of dumb-bell within the outline of the
crystal, or by total disintegration of the crystal, which is con-
verted in mass into a non-crystalline dumb-bell.
3. That there is usually observed in the plugs a "line of
greatest deposit," corresponding, apparently, to the point at
Colloids vpon Forms of Inorganic Matter. 11
which the diffusive force of the two solutions is balanced. On the
calcic side of this line homogeneous or "coalescence" forms, on
the oxalic crystalline forms, predominate. Excess of oxalic or
oxalates is favorable to the size and perfection of the form
generally ; with excess of calcic salt, the coalescence forms are
immensely increased in numbers, but decreased in size.
Where the oxalic acid predominates, crystals are mostly
broken up at their angles and laminated ; where calcic salt pre-
dominates, they are flattened, drawn out at their angles, feathered,
or are small, perfect, and extremely symmetrical. The causes
which may produce these differences may be, and are probably,
of several kinds, namely :
a. The formation of basic, neutral, or acid salts, according as
the solutions balance or in turn prevail.
b. The formation of double salts.
c. Alterations in the firmness or chemical constitution of the
gelatin. It was generally noticed, in reference to this,
that the chloride of calcium tended to soften the gelatin,
the oxalic acid and oxalates to harden it.
d. The presence of undecomposed salts of different solubilities,
and containing bases of different solubilities, would pro-
bably, in each case, tend to modify the form in wliich
deposit occurred.
4. That in the first experiment the presence of calcium car-
bonate rendered the results different from those observed when
the presence of cai-bonic anhydride was avoided. And here new
questions arose : — Why should carbonate and oxalate of calcium,
when they had once ceased to be crystalline, assume different
coalescence forms ? This might be due to the fact that, their
crystalline form being different, their molecules still tended to
repulsions or attractions among themselves in certain directions,
and so modified the sphere-forming force ; or their different
degrees of hydration or of solubility might have influence. The
lines of weakening of the cohesion of crystals must evidently
be carefully noted.
Before complicating the evidence by using solutions of other
salts than those mentioned, it became desirable to determine
whether the action of the colloid upon the oxalate and carbonate
of calcium could be modified by the influence of the various
13 Experiments relating to the Influence of
physical forces. The curious viscosity of magnetism — first, I
believe, demonstrated by Faraday, and clearly described by
Prof. Tyndall in his work on lieat — here suggested itself as not
unlikely to intensify the viscosity of the colloid.
Common horseshoe magnets of moderate power were at first
used. In some experiments, the jjhigged tubes being arranged
as in the first experiment, the magnets were so placed that the
line of greatest deposit would run between their poles, in other
cases so that the length of the plug would be parallel to the
line joining the poles. In other experiments little jars were partly
filled with gelatin imbued with chloride of calcium, the poles
thrust into the gelatin while Avarm, and the jars, on cooling, filled
up with solution of oxalate of ammonia. The general result was
that there was an extraordinary increase in the size of all the
forms, crystalline and non-crystalline, where the plug or gelatin
was subjected to the action of magnetism, but that there was
no production of new forms or greater tendency to sphericity
(PL II, fig. T).
Similar experiments were made with an electro -magnet
capable, with the means at hand, of sustaining a weight of thirty
pounds. Some of the crystals in several cases appeared to have
their axes slightly twisted ; it would be very interesting to know
if this and the direction of the axis generally bore any relation
to the direction of the interpolar line, a point to which I iutcnd
to recur at some future period.
The influence of electric currents was next to be investigated.
A battery of four small cells, each containing a plate of
platinised silver, a little amalgamated zinc, with excess of
mercury, and about two drachms of weak sulphuric acid, was
constructed, and found to produce a weak current lasting for
several weeks.
Copper wires, carefully coated with shellac except at their
extreme ends, were taken from tlu; poles of the battery into a
plug, and their points ])lacc(l at opposite sides of the line of
greatest deposit. The solutions were used as usual, and the
plujy removed at the end of five days.
The plug, when cut across, was found divided into two un-
equal portions by a thin, curved, bluish line, the smaller portion
enclosed within the concavity of the line corresponding to the
negative pole. The appearance and consistence of the two parts
Colloids upon Forms of Inorganic Matter.
13
were very dissimilar. The larger was softer than the plug
before experimeutj more particularly in the neighbourhood of
/■- SOLAMM:OX
■^SL -PLUG
SOL:CAL-CHL0R
the wire (positive), and was of a purplish colour, darkest near
the line of separation, shading off towards the wire.
The line of separation was a firm transparent elastic mem-
brane, of a brilliant emerald-green colour when removed
and viewed by transmitted light, well defined and easily se-
parable from the surrounding gelatin, especially on its convex
side.
The smaller portion of the section was exceedingly firm and
elastic, required a great deal more heat to melt it than the
original gelatin, and was of a light green colour. Under the
microscope the differences were equally marked. On the positive
side the forms were chiefly crystalline, on the negative side all
were spherical, the membrane constituting an abriipt line of
demarcation like the so-called basement membrane in skin and
mncous membrane.
The crystals were chiefly depressed octohedra, with a few
sharp-ended tablets; the spherical bodies were opaque, greenish
in colour, perfectly circular from all aspects, of sharp and per-
fectly unbroken outline, and marked internally by a radiating
striation.
In the membrane at the level of the points of the wires bodies
of the same appearance and flattened spheres with fimbriated
margin were found giving to the structure under the microscope
much of the appearance to be seen in the shells of some Cyprids,
Lower down all forms disaj^peared from the membrane and from
14 E,rperiments relating to the Influence of
the negative side of the line, the crystals on the positive side
remaining abundant.
The nnex])ectcd conditions here met with were in great part
due to electrolytic action. It was found, in some comparative
observations, that oxalate of copper deposited in gelatin took a
form exactly like that of the beautiful green spheres (PI. II, fig.
8); and when carbonate of copper was formed by placing sulphate
of copper and bicarbonate of sodium on opposite sides of a gelatin
plug, no deposit occurred, but the middle of the i^lug assumed a
brilliant emerald-green colour, and became excessively firm and
resilient ; the sodic side of the plug was softened and purplish
in colour, the C02:)per side not altered. In subsequent experi-
ments, where platinum and silver wire were used and the
solution of the copper avoided, it appeared that the influence of
electricity was to favour the production of small, very perfect
crystals, chiefly octohedra. But these experiments Avere open
to the objection that the occurrence of electrolysis was certain,
and the advice of some able experimenter in electricity can alone
help one to more satisfactory results.
Effects of Temperature. — In some plugs prepared during the
second week of February, 1870, when very firm and strong
gelatin was rendered still firmer by the prevailing cold, hardly
anything except octohedra and their immediate derivatives
(macles, &c.) were found. It was then remembered that
coalescence forms had been abundant and well formed in the
softened plugs of the summer experiments ; and although expe-
rience had shown that, other things being equal, a denser plug
was favorable to the perfection of the coalescence forms, it was
now evident that the vibrations of heat, and possibly of light,
must be looked to as likely to aid the production of spherical
forms by disturbing the lines of crystallization and throwing the
molecules into the power of the colloid. Five dift'ercnt positions
were secured for strong plugs placed between equivalent solu-
tions of oxalate and chloride.
1. Kitchen, mantel-piece, temperature 55°- — 65° Falir., in
bad light.
2. Study, near window, temp. 35° — 5()°, good light.
3. Study, cupboard.
4. Garden, good light, temp. 27°— 45°.
5. Garden, dark shed.
Colloids upon Forms of Inorganic Matter. 15
It was intended to take into consideration here the effect of
light as well as of heat, but no decisive results were obtained
with regard to the former force. On the other hand, the influence
of temperature was made beautifully evident. In the kitchen
specimen the coalescence forms Avere three or four times as
numerous as the crystalline. In the garden specimen this con-
dition was more than reversed. The crystals were at least ten
times as numerous as the coalescence forms, and were, on the
average, more than twice the diameter of the crystals in the
warmer specimens. It will be noticed that the crystalline form
here remains perfect as long as the crystal does not exceed a
certain size. In the small crystals the force of crystallization
is strong enough to resist the surrounding forces of disturbance.
AVhen the length of the axes is extended, and the relations
between the more widely separated molecules become weaker,
the line is broken and disintegration of more or less completeness
follows ; just as liquids in small quantities will form drops,
but only drops of a certain limit of size for each kind of
liquid.
The next step was to institute comparisons with other salts.
Triple phosphate was first experimented on, the plug being
interposed between a solution of hydrodisodic phosphate (phos-
phate of soda) and chloride of ammonium on the one hand, and
of sulphate of magnesium on the other.
In the neighbourhood of the magnesic solution were found
small, not very perfect, crystals of the '' house-top " form. In
the middle of the plug were large scattered masses, plainly
visible to the eye, often more than a line in diameter, and con-
sisting each of a central spherical body with many radiating
stalactitic arms, composed of aggregated and overlapping jirisms.
The edges and angles were sharp on the magnesic side, rounded,
in conjunction with greatly diminished size of the masses at the
phosphatic end. Near the phosphatic end were subspherical,
or crescentic, or unsymmetrically sheaf-like tufts of fine radiat-
ing needles or raphides, easily broken up by pressure. All these
forms depolarized light, the larger with brilliant j^lay of colour,
the smaller with alternations of light and darkness. Phosphate
of calcium showed an equal power of resisting the influence of
the colloid. In INIr. Rainey's experiments it had been noticed
that the addition of phosphate to carbonate of calcium had up
16 Experiments relaiing io the Influence of
to a point been attended Avith the production of larger and more
perfect spheres ; but the spheres were unstable, and easily re-
verted to a crystalline condition, and Avhen a certain excess of
phosphate Avas attained spheres could no longer be produced.
But it was certain that the phosphates entered largely into the
constitution of the hard bony structures of animal bodies, and
that the form in which they were therein deposited partook
rather of the " coalescence " than of the crystalline type. Now,
in the human body at least, the conditions existing, particularly
during the period of most active groAvth, included the presence
of albumen, and a temperature much higher than had been
used in any of the foregoing experiments. Albumen, too, after
coagulation, could be used at temperatures which would destroy
the consistence of the gelatin plugs.
Tubes were therefore plugged with albumen on the same
principle as the tubes had before been plugged with gelatin.
Beakers were filled to the depth of three quarters of an inch
with fresh white of egg, the tubes were introduced, and heat
gradually applied by means of a water bath till the albumen w^as
thoroughly coagulated. When this was carefully carried out,
with a temperature not exceeding 200- Fahr., the plugs Avcre firm,
homogeneous, and water-tight, no leakage occurring after the
tubes had been filled with water and left for twenty-four hours.
Oxalate of calcium, deposited in these plugs at a temperature
of from 50° — 60°, took almost entirely the coalescence form.
When a plug was carefully examined, it was found firm and
bluish in colour at the oxalic end, soft and yellowish at the
calcic. In the third next the oxalate, no forms whatever of
crystalline or coalescence order existed, but the albumen
w^as remarkably fibrillated.^ Below this appeared, in small
numbers, large, perfect, homogeneous spheres, isolated, refract-
ing light energetically, and polarizing with one very perfect
cross. Low^er down these had decreased in size, increased in
number, and begun to coalesce with each other, forming here
and there very perfect dumb-bells ; and, further on, large con-
fused calculi, of which the line of greatest deposit was in chief
part composed. As to crystalline forms, only one was present —
the feathered octohedron, much dcpresseu and much drawn out
at angles, large enough to fill, when seen flat, the field of a haU-
' Query. — Did this indicate combination ? '
Colloids upon Forms of Inorganic Matter. 17
inch, of considerable angle of aperture; composed, when seen
sideways, of two plates joined face to face, with a boss or en-
largement at the middle, where generally a small coalescence
sphere could be seen. Albumen was evidently much more
active than gelatin in controlling crystallizing force.
Triple phosphate being used, the stalactitic crystals were
found turned into rounded rods, bulging at many points into
beads, and variously bent twisted and interwoven, so as to bear
some resemblance to the form in which earthy matter is deposited
in the skeletons of some of the Echinodermata. In the month
of April oxalate of calcium, triple phosphate, and phosphate of
calcium were severally deposited in albumen at temperatures of
75° — 85° Fahr. The oxalate was obtained in perfect spheres,
having radiant but no concentric markings, and greatly exceed-
ing in size any regular forms hitherto obtained.
The phosphates were found in irregular, elongated, curved,
and branching masses, which were neither decidedly crystalline
nor decidedly calculous in their internal constitution, but were
composed of subcubical fragments, mostly of small size, but by
no means uniform, agglomerated in an irregular Avay.
At this point the scope of the investigation widened consider-
ably. The light thrown upon the nature of the physical con-
ditions under which earthy matter was deposited in animal
bodies was sufficient to indicate the great importance of the
colloid bed and of the temperature. At once the difference of
texture of bony matter in warm- and cold-blooded animals was
remembered, and the curious connection between the tempera-
ture of the body of animals and the persistence or abolition of
sutures, long ago recognised by comparative anatomists, seemed
capable of explanation by the facts and the reasonings here
founded on them. Bones of the fish are seen interdigitating in
the most complicated way without losing their identity. In the
reptile they are gathered up into more compact though still
isolated masses, the long persistence of lines of suture being
very characteristic of the class. In the mammal sutures are
compacted for the most part in adolescence ; but in the short-
lived bird, wHth its high temperature, sutures are lost in a few
months, and a compaction of bone-tissue hardly seen elsewhere
is obtained. It is fair, I think, to attribute this earl)' and
complete compaction to the activity and extent of the vibrations
VOL. II, 2
18 Experiments rdating to the Influence of
of molecules produced by higher temperature. The linear for-
mations of crystallization are here most thoroughly disconcerted.
Stated broadly, the three most important or, at least, most
abundant constituents of these several forms of bony tissue are
on the one side a form of animal matter yielding gelatin, and on
the other phosphate and carbonate of lime. In a series of ex-
periments albumen was taken as the animal basis, in Avhich
carbonate and phosphate of calcium were first deposited sepa-
rately at different temperatures, and afterwards deposited
together in the proportions which they would bear to each
other in bone.
A table, to be found at page 20 in vol. i of Owen's 'Anatomy
of Vertebrates,' being taken as a guide, solutions were arranged
to give by mutual decomposition the following proportions :
64'4 phosphate, 7"03 carbonate of calcium, as in hawk.
59-6 „ 7-3 „ „ „ man.
52-6 „ 12-53 „ „ „ tortoise.
57-3 „ 4-9 „ „ „ cod.
The first two were placed in hot beds of different tempera-
tures, the hawk quantities in the warmer ; the others were left
in a cool room, so that the temperatures of about 85°, 75°, and
60° Fahr., Avere severally obtained. It followed that, in Avarmth
or in cold, phosj:>hate of lime was evenly distributed through
the albumen in definite strata, not forming crystals or spheres,
but cementing the albumen to great hardness, particularly at
the line of greatest density. Carbonate of lime, on the other
hand, never failed to form spheres at the highest temperatures
used. At the lower temperatures, however, it took very
remarkable forms. In certain strata were found spheres of very
regular size, having a much smaller diameter than the spheres
formed at ordinary temperatures, and these spheres were closely
beset with transparent often cnrved and pointed spines, so that
the Avhole strncturc came to resemble the spiny spores of some
of the Desmidiae. These spines were evidently attempts at
crystallization, which, as before noted, is f\ivoured by cold, and
Avhich would be able to assert itself when the spheres had
attained a certain bulk and radial attraction, and liad thereby been
sufficiently enfccl)led. Indeed, in some cases they were so
arranged as to form a sketch of rhombohedron investing the
central sphere.
Colloids upon Forms of Inorganic Matter. 19
In the bone-salt experiments a nearly uniform result was
obtained throughout. The carbonate of lime Avas subdued, so
to speak, by the phosphate, and even subcrystalline but con-
tinuous deposit was produced. With transmitted or reflected
light no spheres could be seen, but with polarized light indica-
tions of their existence were in some parts manifested by crosses
of faint white and black. The use of a phosphate as a cement
and manipulator of the less tractable carbonate is well indicated
in these experiments.
The strength of the carbonate seems necessary in all hard
tissues that have to be tough. But the carbonate alone does not
appear to be fitted to form tissue destined to be the seat of
active interstitial change. With the bird's high temperature
and great vital activity, therefore, we see associated a great pre-
dominance of phosphate. In the tortoise, with its low tempera-
ture and sluggish processes, a great decrease of phosphate and
increase of carbonate ; and in the shells of the invertebrata,
where interstitial change does not prevail, the carbonate alone,
or with little phosphate, suffices. In the case of the cod this
line of reasoning does not at first proceed so clearly. There is
far more phosphate and far less carbonate than in the tortoise.
The explanation is probably to be found in the nature of the
animal matter with which the salts are associated. Through-
out the tissues of the ordinary bony fish there is less compact-
ness and tenacity than in the tissues of the higher vertebrata.
Any one who has dissected fishes knows how much care is
required to avoid laceration of the parts that may be handled
freely in a rabbit or a bird, and the very diff"erence exhibited
in the matter of firmness by the cooked flesh of birds and the
higher animals is to the same effect. At present I have no
distinct information on this point, but I feel justified in sug-
gesting that the remarkable difference in the proportion of the
earthy salts is determined by association with a less powerful
and characteristic colloid, the greatly diminished carbonate
still requiring a large excess of phosphate to reduce it to
docility.
Reverting next to the repeatedly noticed fact that different
salts take different forms in the presence of the colloid, the most
readily suggested cause was the influence of natural crystalline
form in each several salt. It became important to learn if.
20 Experiments relating to the Influence of
taking the six systems into which crystals are ordinarily divided,
there Avere any coalescence forms corresponding to each, and, if
so, whether any one system Avas more prone to or more aA^erse
from assuming the spherical or calculous form than the rest.
As far as the investigation has as yet been carried, no clear
ansAver has been obtained to these questions. Comparative in-
solubility, hoAvever, Avas CAndently an important element,
coalescence being favoured Avhen small molecules are sloAvly
deposited, crystalhzation AAdiere deposit is'* rapid. I submit
some illustrations of the experiments made in reference to this
aspect of the inquiry.
In the first place, alum Avas taken as a representative of the
first or cubic system. Hot jelly Avas supersaturated Avith alum,
taking up a much larger quantity than Avould be taken up
by the same amount of Avater. On cooling, the alum Avas de-
posited in large masses of radiating feathered crystals AAdthout
octohedra.
Sodic nitrate was used for the third system. The jelly Avas
with difficulty saturated AA-hen hot ; it did not set on cooling,
and the nitrate Avas deposited in subcubical crystals.
Borax (fifth group) Avas deposited in i-adiating feathered
crystals.
Cupric sulphate (sixth group) Avas freely taken up and
partly deposited in an irregular crystalline form. But the
gelatin, as examined under the microscope, Avas strangely modi-
fied ; semi-opaque to the eye, it was noAv resolved into an
aggregate of delicate spherical vesicles, resembling rapidly
formed cells Avithout nuclei, of a size ranging from ■^-}^ inch
diameter doAvuAvards.
Calcium sulphate was obtained in three Avays — by sulpliuric
acid, magnesic sulphate, and sodic sidj)hate, respectively decom-
posing calcic chloride. With the acid large masses of radiating
spicules, subspherical in shape, perfectly free and distinct from
each other, Avere formed. With the sulphuric salts very beautiful
coalescence-forms, varying in size from ^.'^ inch downwards,
were obtained. They were each composed of a number of seg-
ments of spheres united into a botryoidal mass, with a regular
internal radiation corresponding to each segment, and Avith a
smooth unbroken outline to the segments.
Magnesic carbonate formed, Avith strong solutions, large sub-
Colloids upon Forms of Inorganic Matter. 21
spherical knobbed masses, not nnlike those of calcic sulphate,
but less regular, and easily broken up into irregular spicular
crystals. With weak solutions very perfect small spheres were
obtained at the end of twenty-four hours, but at the end of two
days disappeared spontaneously, reminding one of the instability
of the crystalline form of the same substance.
Baric sulphate; — Solutions of baric nitrate were decomposed
by sodic sulphate. Where the solutions balanced or barium w'as
in excess, very perfect small si^heres, with concentric lamination
and very faint radial lines, were the only forms produced. With
excess of sulphate similar spheres were formed upon the basic
side, but on the side of the sulpbate were half-crystalline bodies,
some rhombohedral, some octohedral with rhombic base, but all
with much rounded angles and curved faces.
It is evident, here and elsewhere, that the inquiry is as yet
but tentative and partially carried out. But I have ventured to
put forward such results as I have already obtained, with the
intention of further prosecuting this line of research at a future
time. One may hope, among other things, to arrive, by modi-
fications of the method adopted, at some knowledge of the cir-
cumstances under which silica is deposited in living tissues,
and, perhaps, through collateral experiments such as those with
the carbonate and sulphate of copper, to arrive at the mode of
action of some mineral remedies upon particular tissues.
DESCRIPTION OF PLATES,
Illustrating Dr. Ord's Account of some Experiments Relating
to the Influence Exercised by Colloids upon the Forms of
Inorganic Matter,
PLATE I.
Forms observed in tbirteen sections of the gelatin plug used in the first
exjieriment.
Fig. 1. First slide, from calcic end.
a. Large tables of oxalate of calcium seen sidewise ; b, the same,
flat ; c, smaller tablets ; d, compound tablets.
„ 2. a. Homogeneous dumb-bell formed within large tablet; b, c, d, e, dumb-
bells and allied spheroidal homogeneous bodies.
„ 3. A^arious forms of coalescence-bodies, showing their relation to tablets.
(Slide 2).
„ 4. Tablets and spherules of a new series j the spherules (a, b, and c) gi'owing
to large rounded, fibrous rhombohedra, composed of calcic carbonate ;
the tablets growing, further on, to " whcatsheaves." (Slides 3 to 7),
„ 5. Formation of " wheatsheaves " from the thick tablets. (Slides 8 — 13).
„ 6. Flattening and feathering of octohedra. (Slide 13).
PLATE II.
„ 1. Forms assumed by calcic oxalate in gelatin, acetic acid being present in
excess.
„ 2. Oxalic acid in excess of calcium salt. Series constructive of flattened
octohedron.
„ 3. Oxalic acid in excess. Series of dumb-bells from calcic end, where they are
homogeneous and rounded, to oxalic end, where they are crystalline
(" wheatsheaves ").
„ 4. Oxalic acid in excess. Octohedra passing into much facetted tablets.
„ 5. Thinning of tablets on calcic side of plug.
„ 6. Oxalate of ammonium and calcic chloride. Form of "wheatsheaf"
observed in oxalic region of plug. Note, that I have, since this was
drawn, observed similar forms twice in urine.
„ 7. Comparison of forms observed in magnetised plug with those formed at
tlie same time, all other conditions being perfectly equal, in non-
magnetised plug. The large tablet-sliaped bodies were formed in the
magnetic arc.
„ 8. Oxalate of copper, as deposited in gelatin.
W M . D E L. ;
FIG. I
A
FIO. II
^-9
no. Ill
:■ 8 OS goo
I
FIG. IV
r/c7. yi
ON THE
PEEIOD OF INCUBATION
TYPHUS, EELAPSING PEYEE, AND
ENTEEIC EEVEE.
By CHAELES MFRCHISON, M.D., LL.D., F.E.S.
The period of incubation of contagious diseases, or the
period that elapses between the entrance of the contagium into
the system and the first manifestation of its presence there by
symptoms, is not merely a matter of scientific interest, but has
many practical bearings, and lies at the bottom of many of the
most important sanitary questions. The subject has, never-
theless, not received that attention -which it deserves, and prac-
tically little is known about it. Authoritative statements based
on meagre and unsatisfactory data have been copied by one
writer from another, but with regard to most of the contagious
diseases there is a want of carefully recorded facts bearing upon
the latent period. Even with regard to smallpox, the latent
period of which has been most accurately and most frequently
observed, a collection of reliable facts is still a desideratum.
The subject is, no doubt, beset with many difficulties, and it
is only on very rare occasions that illustrations of the period of
incubation of diseases, free from fallacies of all sorts, are met
with. Cases throwing light on the latent period of a disease
are of a threefold nature :
1. Those in which there has been a single limited exposure
to the contagium.
2. Those in which there has been a protracted exposure,
both limits of which are known.
24 Period of Incnhation of Typhus,
3. Those in -wliicli there has been a protracted exposure, of
which only one limit is known. Either the exposure has per-
sisted from the commencement up to the date of the patient's
seizure, in which case it can only be said that the period of in-
cubation has not exceeded the duration of exposure ; or an in-
terval of time has elapsed between the cessation of a protracted
exposure and the commencement of symptoms, and then it can
only be said that the period of incubation has not been less
than that interval.
The first class of cases are, no doubt, the best, but the other
two classes, to one or other of which most of the recorded
instances of latent period of diseases belong, are not without
value.
The present communication is intended as a contribution to
our knowledge of the period of incubation of the so-called
continued fevers of Great Britain, a class of diseases which for
many years I had an opportunity of studying on a large scale
in the London Fever Hospital. Throughout my active connec-
tion with that hospital I was on the constant look-out for cases
calculated to throw light upon the subject of this memoir, and
I now place on record all such cases as I have encountered out
of upwards of ten thousand patients suffering from the continued
fevers who have been under my immediate care.
A. Typhus Fever.
{Typhus cxanthematicus.)
The following thirty-one observations have reference to the
period of incubation of typhus fever.
Case i. — Mary H — , aet. 21, was admitted into the London Fever Hospital on
April 14th, 1869, having been ill since the morning of the 11th with febrile symp-
toms. On April IGth the eruption of typhus appeared, and the disease ran its
usual course. She was brought to the hospital from 1, Narrow Street, Stepney.
The only cases of fever which had occurred in that street for many months before
had been four cases also in No. 1. All four patients, however, had recovered up-
wards of two months before ; all four had been young children, and there was
evidence that their fever was not true typhus. But on the night of Good Friday,
March 26th, Mary H — had set up all night with her brother, who, with his family,
was laid up with typhus, and who lived at a considerable distance from Narrow
Street. This was the only occasion on which Mary H — had visited her brother's
family during their illness ; but a sister who resided witii her, and who subsequently
Relapsing Fever, and Enteric Fever. 25
contracted typhus, for which she was admitted into the London Fever Hospital, had
been repeatedly backwards and forwards between the two houses both before and
subsequently to March 2Gth.
Here the latent period would appear to have been as long as fifteen days. The
only fallacy lay in the possibility of the sister having been the vehicle of the poison
before she had any symptoms of the disease.
Case 2. — Dr. B — visited the Fever Hospital in London, and went round the
wards with Dr. Buchanan on a certain Saturday. He had not been there before,
and he went the same afternoon to Nottingham, where true typhus was not known
to prevail. He remained well till the following Thursday week, when he shivered
and fell ill with typhus, the diagnosis being verified by Dr. Buchanan.
The latent period in this case was exactly twelve days.
Case 3. — Emma B — , set. 60, resided at the " Surrey Arras," Kennington. There
had been no cases of illness in the house, and no typhus in the immediate neigh-
bourhood, and she was in comfortable circumstances. On March 7th, 1869, she
visited her daughter-in-law, who resided in Walnut Tree Walk, Kennington, and
who, with her family, was ill with fever. This was the only occasion on which she
visited them during their illness. On Ma\ch 11th the daughter-in-law and two of
her children were brought to the Fever Hospital, ill with typhus. On March 19th
Emma B — was taken ill, and on the 22nd she was brought to the hospital, also
sulFering from typhus with the characteristic symptoms. Tlie disease ran the usual
course and terminated favorably.
Here, again, the latent period was exactly twelve days.
Case 4. — Catherine L — , aet. 15, was admitted into the Fever Hospital, suffering
from typhus fever, on March 22nd, 1860. She was a servant in a gentleman's
family residing in Tavistock Square. No other person was ill in this house, while
cases of typhus originating in families of the better class are almost unknown in the
practice of the Fever Hospital. But the girl's own family, living in a distant part of
London, had been suflfering from typhus, though after this became known to her
master she was not permitted to visit them. The last occasion on which she had
been to see them was on March 5th, but on the 9th her uncle, who had been to visit
her father's family, and who was himself in good health, called and spoke to her in
the hall of the house in Tavistock Square. On March 17th Catherine L — became
feverish, and when brought to the hospital, five days later, she had the eruption of
typhus well out.
As it is not probable that the poison was conveyed by the girl's uncle, the period
of incubation in this case must also have been exactly twelve days.
Case 5. — Maria W — , set. 25, was a nurse in the Middlesex Hospital. She was
exposed at intervals to the poison of typhus from cases in the wards during the
months of October, November, and early part of December, 1866, but on no
occasion was the exposure so intimate and protracted as during the night of the 7th
and the morning of the 8th of December, when she leant for many hours over a
female typhus patient who miscarried. On December 10th Maria W — was removed
to another ward, and after this she was free from all exposure to contagion. On
the forenoon of December 20th she had a rigor and became ill, and on the 24th the
eruption of typhus appeared.
26 Period of Inciibat'ion of Typhus,
If, as there seemed good reason for suspecting, Maria W — contracted the fever
during the night of the 7th of December, the latent period in this case also was
twelve days.
Case 6. — William — , aet. 31, a porter in a solicitor's house in Bedford Row,
was admitted into the Fever Hospital on December 24th, 1866, with a medical
certificate that he was suffering from typhus. His complaint was acute lichen, not
typhus. On December 27th he was discharged from the hospital free from all
febrile symptoms. He went home at once to the country to a locality where typhus
was not known to prevail, and on January 6th, 1867, he had rigors ushering in an
attack of typhus, which lasted a fortnight. When seen by me on January 21st, at
his residence in Bedford Row, to which he had been removed, the eruption of typhus
was well marked.
Here there could be no doubt that the typhus was contracted in the Fever Hos-
pital, and the period of incubation must, therefore, have been somewhere between
ten and thirteen days.
Case 7. — David W — , ret. 48, was admitted into the Fever Hospital on January
8th, 1868, certified to be suffering from typhus. He remained for two nights in the
typhus ward, and was then transferred to another ward, in which there were no
cases of an infectious nature, as he had no fever (pulse 72 and temperature
normal), and his complaint appeared to be a slight attack of articular rheumatism.
On the 21st he had severe shiverings, lasting for two or three hours, and followed
by heat of skin, loss of appetite, and other febrile symptoms, and on January 28th
by a distinct typhus rash. On February 4th he died.
The period of incubation in this case was somewhere between eleven and thirteen
days.
Case 8. — Mary T — , ajt. 19, was admitted as an inmate of the Magdalen Hos-
pital, Blackfriars Road, on March 2nd, 1865. For four nights previously she had
slept at " Carter's Refuge," Southwark Bridge Road, whence cases of typhus were
brought at the time to the Fever Hospital. There were no cases of illness in the
Magdalen Hospital, but eleven days after MaryT — entered it, March 13th, she first
felt ill. She became chilly, lost her appetite, and could not sleep, and ten days
later, on March 23rd, she was brought to the Fever Hospital with well-marked
typhus, from which on March 28th she was convalescent.
In this case, the period of incubation was between eleven and fifteen days.
Case 9. — Charlotte L — , aet. 20, was admitted into the London Fever Hospital on
December 16th, 1864. The nature of her case being at first doubtful, she was
placed at first in the typhus ward, where she remained for six days. Her illness,
however, turned out to be, not typhus, but erysipelas of the face. After removal to
another ward on December 22nd she had no further communication with typhus
patients, and she was quite convalescent, when on January 3rd she was again attacked
with pyrexia, which proved to be the comniencemeut of an ordinary attack of
typhus.
, Here the latent ])eriod was not less than twelve days, and might have been as
lon^T as eighteen days.
Ca.sk 10.^ — Mary T — , at. 28, was admitted into the Fever Hospital on December
18th, 1>?03, and discharged on January 7th, 1801. From the notes of her case it is
Relapsing Fever, and Enteric Fever. 27
clear that her attack was a mild one of enteric fever, but through some mistake she
was permitted to convalesce in the typhus convalescent ward for seven days prior to
her discharge. On January I'Zth she was again taken ill, and on January 20th she
was readmitted with a typical attack of typhus including the eruption.
In this case the period of incubation could not have been less than five, and might
have been as long as twelve days.
Case 11. — Elizabeth B — , set. 20, was a patient in the Fever Hospital with what
was noted as " febricula," from December 26th, 1866, to January 7th, 1867. No
other person was ill with fever in the house from which she came. There were
some doubts at first as to whether her illness was not a mild attack of typhus, and
she remained in the typhus ward all the time she was in the hospital. She was free
from fever and quite well when she left on January 7th, but next day she was again
taken ill, and on January 20th she was readmitted with maculated typhus.
The latent period in this case might have been only one day, and could not have
exceeded thirteen days.
Case 12. — Frederick H — , set. 7, was admitted into the Fever Hospital on March
16th, 1869, suffering from enteric fever. He came from a school at Edmonton,
whence eight other children were admitted with enteric fever in the same month.
On March 25th he was, in my absence, inadvertently transferred to the typhus ward,
where he remained till April 11th, when he was seen by me for tlie first time and
ordered back to the enteric fever ward. He was then quite convalescent, but next
day (April 12th) he again fell ill with fever, and on April 17th he had a copious
typhus eruption.
In this case the latent period must have been somewhere between one and seven-
teen days.
Case 13. — Fanny D — , ast. 19, was admitted into the Fever Hospital on November
27th, 1867, and remained in a typhus ward till December 6th, on which day, her
ailment having been only febricula and hysterical epilepsy, slie was removed to the
general ward. On December 15th she was again seized with febrile symptoms,
which this time proved to be the commencement of typhus, of which she died.
Here the period of incubation must have been somewhere between nine and
eighteen days.
Case 14. — .\nn N — , set. 18, was admitted into the Fever Hospital from the
Camberwell Workhouse on January 6th, 1864. She was then in good health,
but came as nurse to an infant suffering from typhus. She continued in good
health until January 18th, when she was seized with headache, loss of appetite,
and other febrile symptoms, and on January 23rd the eruption of typhus appeared.
It ought to be stated that for some time previously cases of typhus had been
occurring in the Camberwell workhouse, but Ann N — had not been directly exposed
to them, and it is more than probable that she did not contract the disease until she
came to the typhus ward of the Fever Hospital, and nursed in her arms an infant
typhus patient.
On this view of the case the period of incubation could not have exceeded twelve
days. It may have been shorter, but there are no means of determining this, as the
exposure to the poison continued up to the date of attack.
28 Period of Incubatioyi of Typhus,
Case 15. — Mary D — , tct. 13, was arlmitted into the Fever Hospital on February
2rtli, 1864, on the sixth day of an attack of typhus, the eruption being well out.
Her mother and two sisters had been previously, on February 4th and 9th, ad-
mitted with typlius. They had resided at 6, Model Houses,Lambeth ; but Mary D —
had left her home in good health on February 11th to go into service in a family
residing at 27, Princes Street, Lambeth, none of whom were ill, and she did not
revisit her home before falling ill on February 22nd.
In this case the period of incubation could uot have been shorter than eleven
days.
Case 16. — In the autumn of 1868 Joseph C — , aet. 16, was a patient for four
weeks in the London Fever Hospital with a mild and somewhat doubtful attack of
enteric fever. He was discharged on September 18tb, having been up and going
about for a week before. There was no evidence of any exposure to contagion after
his leaving the hospital, but on September 25th he had an attack of shivering, fol-
lowed by febrile symptoms and cough, and on October 5th be was readmitted into
hospital in a state of high fever, with general bronchitis and the eruption of typhus
on his trunk and limbs.
Here the period of incubation was not less than seven days, and, as the fever was
probably contracted during the week that the patient was going about the hospital,
it probably did not exceed fourteen days.
Case 17. — Elizabeth K — , set. 21, came as a nurse to the Fever Hospital on
January 24th, 1865. She had not previously been exposed in any way to the poison
of typhus fever. She remained well till February 3rd, when she felt chilly and
lost her appetite, while the pulse and temperature became elevated. On February
8th the eruption of typhus appeared .
Here the period of incubation could not have exceeded ten days.
Case 18. — Mary R — , at. 30, became a nurse in the typhus ward of the Fever
Hospital on September 15th, 1866. There was no reason to think that she had
been previously exposed in any way to the poison of typhus. She remained well till
September 25th, when she was seized with typhus, which ran the usual course.
In this case also the period of incubation could not have exceeded ten days.
Case" 19. — Sarah M — , aet. 30, was admitted into the Fever Hospital on April 12th,
1865, ill three days with typhus, which ran the usual course. On April 3rd, and
again on April 9th, she had visited her sister-in-law, who was then a patient with
typhus in the Fever Hospital. She had not seen her sister-in-law during her illness
except on these two occasions, and she was not aware of having been exposed in
any other way to the poison of typhus. She felt quite well when she came to the
hospital on the afternoon of the 9th, but after going iiome she felt sick and vomited,
and when brought to the hospital, three days afterwards, she had higli fever and the
eruption of typhus was appearing.
In this case the period of incubation could not have exceeded six days, and may,
as in Cases 23 and 24, have been only a few hours.
Case 20. — On the afternoon of Sunday, February 1st, 1857, I was seized rather
suddenly with my second attack of typhus fever. My fust attack had occurred in
Relaps'my Fever, and Enteric Fever. 29
Edinburgh in 1847. Both attacks were very severe, and in both the eruption was
copious and characteristic. On Tuesday afternoon, January 27th, I had visited the
London Fever Hospital to see Dr. Tweedie's patients. There were very few cases of
typhus in the hospital at the time, but one of these patients, who had congestion of the
lungs, I auscultated by putting my ear to his back without the intervention of a
stethoscope. I had not visited the Fever Hospital for several months before, nor did
I go there again before I was taken ill, and I was not in any other way exposed to
the poison of typhus, which at the time was far from being a prevalent disease in
London.
The period of incubation in this case was exactly five days.
Case 21. — Jane M — , aet. 26, was brought to the Fever Hospital, suffering from
typhus, on ^larch 23rd, 1805, at the same time and from the same house as Mary
T — (Case 8). She had been an inmate of the Magdalen Hospital for seven weeks,
during which time she had not been without the walls. She occupied the bed next
to that of Mary T — before the latter was taken ill, and she waited on her from the
day she was taken ill (March 13th) till March 17th, when she herself was seized
with faintness, chilliness, loss of appetite and fever. No other cases of typhus
occurred in the Magdalen Hospital.
In the case of Jane M — the latent period could not have exceeded four days.
Case 22. —In November, 18G3, a family named Harman, consisting of mother,
daughter, and six sons, was admitted into the London Fever Hospital, suffering from
typhus. The father, who had been taken ill first, had been treated at home. Their
house was 70, Granby Street, Waterloo Road, but one of the sons, Thomas, at. 26,
resided at 12, King Street, Lambeth Walk, a locality where, at the time, typhus was
not prevailing. He had visited his family at 70, Granby Street, after his father had
been taken ill, on two occasions only, viz. on November 8th and 11th. On Novem-
ber 12th he was seized with rigors and sickness, and on November 17th he was
admitted into the Fever Hospital with fever and a distinct typhus rash.
The period of incubation in this case could not have exceeded four days, and
might have been only one day.
Case 23. — Samuel H — , a sailor, aet. 26, arrived in the Thames from Quebec on
December 27th, 1863. The voyage had occupied twenty-one days, and there had
been no illness on board the vessel. On the afternoon of the ship's arrival Samuel
H — went to visit bis brother, residing at 12, Clarence Street, Rotherhithe, a locality
where typhus was at the time very prevalent, and from which many cases had been
brought to the Fever Hospital. This was the only occasion on which he had left
the ship before taking ill. On the second day after visiting his brother he was
seized with headache and pain in the limbs, loss of appetite, and thirst, and, when
admitted into the Fever Hospital on January 5th, 1864, his body was covered with a
copious typhus eruption.
The period of incubation in this case was exactly two days.
Ca»e 24. — Ann H — , aet. 49, was admitted as an inmate of the Lambeth work-
house on February 22nrl, 1865. She had been badly off, but was in good health at
the time, and remained so until two days afterwards, the 24th, when she went into
30 Period of Incubation of Typhus,
the sick ward, in which lay several jiatients with typhus, and assisted a nurse in
lifting a woman sick with that disease out of had. She was sensible at the time of
an offensive, overpowering smell from the patient, and on the same day, witliin a
few hours, she was seized with chilliness and sickness. Three days afterwards she
was brought to the hospital suffering from typhus, with a distinct eruption. ,
In this case the attack appears to have commenced almost immediately on exposure
to the poison, or the latent period did not exceed a few hours.
Case 25. — Mary C — , set. 17, a dressmaker, from 67, Newman Street, Oxford
Street, was admitted into the Fever Hospital on November 4th, 1867, with typhus
fever, the eruption being copious, and tiie attack altogether a typical one. There
had been no other case of fever in the house from which she came, and typhus at the
time was not known to be prevailing in the part of London in whicli Newman Street
is situated. The sanitary arrangements of the house were good, and Mary C — had
been in comfortable circumstances. Moreover, for several weeks she had not gone
any distance from her house, excepting on one occasion, October 30th, when she
went to see some friends in Wapping, and spent the day there. There was no evi-
dence that the friends whom she visited were suffering from fever, and so far the
case is unsatisfactory; but typhus fever was at the time extremely prevalent in
Wapping, whereas it did not exist in the locality where Mary C — resided. On the
evening of the same day, after returning to Newman Street, she shivered and became
feverish, and she continued ill until the time of her admission into hospital.
This case is not a conclusive one, but if the disease was contracted during the
visit to Wapping, as there are grounds for lielieving, the period of incubation did nut
exceed a few hours.
In addition to these twenty-four cases, which have for the
most part come under my observation at the London Fever
Hospital, a few others have been communicated to me.
Dr. T. J. Macla<^an, Medical Superintendciit of the Dundee
Royal Infirmary during a great epidemic of typhus, writes to
me that the only fiict observed by liim which bears with any-
thing hke accuracy on the period oi" incubation of typhus is the
following.
Case 20. — A male, ast. 21, was admitted into the Dundee Infirmary on the even-
ing of the 13th January, 18G5, with the usual symptoms of the early days of typhus.
As this fever was prevalent at the time, he was put into a typhus ward. But on the
night of the 14th, and the fourth day of his illness, he perspired freely, and on the
morning of the 15th the febrile symptoms were gone. He was accordingly trans-
ferred at once to a general medical ward, and on the 18th he was discharged from
the liospital.
On January 26th he again had rigors, followed by febrile symptoms, for which he
was readmitted into hospital, where he went through a well-marked attack of typhus.
There was no reason to doubt that this man bad contracted typhus on the first occa-
sion when he was in the hosjjital, for though typhus was prevalent at the time, he
Relapsing Fever, and Enteric Fever. 31
had not been near any one suffering from it, except during the two days when he
was located in the typhus ward for his attack of febricula.
In this case the period of incubation was not more than thirteen, and not less than
eleven, days.
The following cases have been communicated to me by Dr.
J. B. Russell, Physician and Superintendent of the City of
Glasgow Fever Hospital.
Case 27. — John G — , set. 19, was admitted with typhus into the City of Glasgow
Parochial Hospital from the North Prison. He had previously lodged in the New
Vennel, which was then full of fever, and the pyrexial symptoms set in three w eeks
after imprisonment.'
Case 28. — Mary M — , set. 26, entered the Glasgow Lock Hospital on October
10th, 1868. She had severe shivering on the 24th, and was subsequently admitted
into the Fever Hospital with well-marked typhus.
The latent period in this case was not less than fourteen days.
Case 29.— On October 11th, 1864, Mrs. \V — was sent to the Fever Ward, City
Parochial Poorhouse, with well-marked typhus. Her children, who were in good
health, were removed on the same day from the infected house to the Poorhouse,
where they were kept in quarantine. Of these, Sarah, act. 9, was seized with
pyrexial symptoms on October 24tb, and had a well-marked attack of typhus.
The period of incubation was in this case not less than thirteen days.
•
Case 30. — Jane, set. 12, another daughter of Mrs. W — , referred to in the last
case, was taken ill with typhus on October 22nd.
Here the latent period was not less than eleven days.
Case 31. — A boy, John Y — , was discharged from the City of Glasgow Fever
Hospital, after an attack of typlms, on January 7ih, 1865. He went straight to the
house of a companion, Robert M — , in Parliamentary Road, where typhus is rarely
seen, and was not then known. He slept in the same bed with his companion on
the next four nights, the last being that of January lOtb. On the 13tb, at 12.50
p.m., Robert M — shivered, and had severe fever, which proved to be the commence-
ment of an attack of tvphus.
In this case the period of incubation could not have exceeded five and a half days,
and might have been little more than two days.
The period of incubation of typhus fever has been variously
fixed by different writers as follows :
^ See also ' Glasg. Med. Journ.,' xii, 144.
32 Period of
Haygarth (1801 )i
Hildeubrand (1810)-
Bancroft (181 1)^
Sir W. Burnett^
Barker and Cheyne (1821
Sir Henry Marsli (1827)6
Dr. Gregory (1832)'
Dr. Perry (i836)«
Dr. Alison (1^44)^
Dr. Coplandio
Hussii
Dr. Peacock (1856)12
Do. (1862)'3
Jacquot (1858)1^
Barrallier (1861/5
Incubation of Typhus,
made it 5 days to 2 months.
,, 3 to 7 days.
„ 1 day to 5 or six months.
„ 7 to 18 days.
y ,, a few minutes to 6 weeks,
a few hours to as many
weeks or months.
10 days.
never less than 8 days,
very various.
3 to 14 days.
1 to 10 days.
10 to 14 days.
14 to 21 days.
9 to lo days.
12 to 15 days.
Many of these statements are based upon one or two ob-
servations, which in some instances are not detailed, and in
others are not quite to the point.
1 Haygarth, ' On the Prevention of Infectious Fevers,' London, 1801.
2 Hildenbrand, ' Ueber den Ansteckenden Typhus,' Wien, 1810. Frencli TransL,
1811.
^ Bancroft, ' Essay on Yellow Fever, with Observations concerning Febrile Conta-
gion, Typhus Fever, &c.,' London, 1811.
■* G. Gregory, "Observations on the Incubation of Morbific Germs," ' Lond. Med.
Gaz.,' vol. ix, 1832.
^ Barker and Cheyne, 'Account of the Fever lately Epidemical in Ireland,' London,
1821.
*• Marsh, " Observations on the Origin and Latent Period of Fever," 'Dub. IIosp.
Rep.,' vol. iv, 1827.
' Gregory, see note ''.
8 Perry, " Observations on Continued Fever in the Glasgow Hospitals," ' Ed. Med.
and Surg. Journ.,' vol. xlv, 183.
" Alison, 'Outlines of Pathology and Practice of Medicine,' 1844, p. 426.
^° Copland, * Med. Dictionary.'
" Huss, ' Stalistique et Traitement du Typhus,' Paris, 1855.
1- Peacock, " On the Varieties of Continued Fever and their Discrimination,"
'Med. Times and Gaz.,' xiii, 1856.
'^ Peacock, " On the Recent Epidemic of Fever," ' Lancet,' 1862, ii, 5.
" Jacquot, ' Du Typhus de rArmce d'Orient,' Paris, 1858.
'■'' Barrallier, ' Du Typlius cpideraique a Toulon,' Paris, 1861.
Relapsing Fever, and Enteric Pever
33
Of the 31 cases now recorded:
The period of incubation was exactly determined (Cases
1,2,3,4,5,20,23,24,25)
It occurred during a period of which both limits were
known (Cases 6, 7, 8, 9, 10, 11, 12, 13, 26, 31) .
It occurred during a period of which only one limit was
known —
a. Highest limit known (Cases 14, 17, 18, 19,
21,22) . . . . .
b. Lowest limit known (Cases 15, 16, 27, 28,
29, 30)
m
in 10
m
in 6
Total
31
The period of incubation in the 31 cases was as follows :
No. of Cases.
Not less than 21 days (Case 27) . . .1
Exactly 15 days (Case 1) . . . .1
Not less than 14 days (Case 28) ... 1
13 „ (Case 29) . . . 1
Exactly 12 days (Cases 2, 3, 4, 5) . . . 4
A 'period of which both limits known, and 12 days
within these limits (Cases 6, 7, 8, 9, 10, 11, 12,
13,26) 9
Not more than 12 days (Case 14) . . . 1
Not less than 11 days (Cases 15, 30) . . .2
„ 7 „ (Case 16) ... 1
Not more than 10 „ (Cases 17, 18) ... 2
6 „ (Case 19) . . .1
Exactly 5 days (Case 20) . . . .1
Between 5^ and 2 days (Case 31) . , . ' 1
Not more than 4 „ (Cases 21, 22) . .2
„ 2 „ (Case 23) . . . 1
None, or only a few hours (Cases 24, 25) . . 2
Total
31
From the cases now recorded it would seem that the usual
period of incubation is about twelve days. Of the nine cases
VOL. II. 3
34 Period of Incubation of Typhus,
in wliich it was exactly determined, in four it was twelve days ;
and in thirteen more of the thirty-one cases it might have been
twelve days. In other words, out of the thirty-one cases, in
seventeen the period of incubation was either twelve days or
this duration was within the known limits. It may be added
that Jacquot, who calculated the latent period from the date of
embarcation of healthy French troops on board vessels infected
with typhus, found in a considerable number of cases that it
varied from nine to thirteen days, the average being somewhat
less than twelve days.^
But occasionally the period of incubation exceeds twelve
days. It did so with certainty in four only of the thirty-one
cases now recorded. In one only of the cases was there reason
to think that it was as long as twenty-one days. Theurkauf
records two cases, in one of which it was eighteen days and in
the other between fourteen and nineteen days." Peacock also
relates the case of a man who, in 1863, nineteen days after
his admission into a surgical Avard of St. Thomas's Hospital,
was attacked with typhus to which it is believed that he could
only have been exposed prior to his admission.^ I know no
reliable facts, however, showing that the latent period of typhus
can exceed three weeks, and statements to the effect that it can
extend over several months require confirmation. Few, at all
events, will admit, on the evidence adduced by Bancroft,^ that
an interval of five or six months may elapse between exposure
to the jDoison and the commencement of the disease, an opinion
to which he was forced by his determined opposition to the pos-
sibility of an independent origin of the fever.
On the other hand, in not a few cases of typhus the period of
incubation is less than twelve days. It was so in ten, at least, of
the thirty-one cases now recorded. Davies records the cases of
' Jacquot, op. cit., 119.
2 Theurkauf, " Ueber Typhus exanthematicus," ' Virchow's Avchiv f. Path. Anat.
und f. klin. Med.,' Bd. xliii, 18G8, s. 40,
^ Peacock, " On the Recent Epidemic of Tever," ' Lancet,' 18G2, vol. ii, p. 5. In
reference to this case it may be mentioned that there appears to have been patients
suffering from typhus in the medical wards at the time, and that under similar cir-
cumstances I liave known patients in the surgical wards of the Middlesex Hospital
attacked with typhus many months after admission, although they were confined to
bed, and no communication with the typhus patients could be traced.
' Bancroft, op. cit.
Relapsing Fever, and Enteric Fever. 35
four Norwegian sailors, who on tlie night of their ship's arrival
in Bristol fioni Onega, visited some typhus-fever nests, and
all four sickened with typhus eight days after.^ In my own
second attack the latent period was exactly five days (Case 20).
There are also authentic instances of an extremely short latent
period, or where there has been scarcely any latent period at
all. The late Sir Henry Marsh collected nineteen cases in
which the disease maaiifested itself almost instantaneously after
exposure to the poison. In most of the cases the persons com-
plained of an offensive odour proceeding from the beds or
bodies of the sick, and immediately suffered from headache,
great prostration, nausea, or rigors, followed by the usual
symptoms of typhus.^ Similar cases were mentioned by
Haygarth ; ^ others were observed by Gerhard at Philadelphia
in 1836 ; "^ and in two of the thirty-one cases now recorded
(Cases 24 and 25) there were reasons for believing that the
symptoms commenced immediately after the first exposure. In
some of these cases it might be difficult to exclude the pos-
sibility of previous exposure to the poison, but in others there
were no grounds for such suspicion, and in all, the patients
appeared to be conscious of the moment at which the poison
entered the system. It would seem that the poison of typhus
may be so concentrated, or that the system may be so suscep-
tible of its action, that its effect may be almost instantaneous.
From the above facts the following conclusions may be
drawn :
1. The period of incubation of typhus varies in duration in
different cases.
2. In a large proportion of cases it is about twelve days.
3. In exceptional cases it is longer than twelve days, but it
rarely, if ever, exceeds three weeks.
4. In many cases (one third or more) it is less than twelve
days, and occasionally there is scarcely any latent period, the
1 Davies, " The late Epidemic of Typhus in Bristol," ' Med. Times and Gaz./
Oct. 19th, 1867.
• Marsh, op. cit.
3 Haygarth, op. cit., p. 65.
"• Gerhard and Pennock, " On the Typhus Fever which occurred at Philadelphia
in 1836, showing the Distinctions hetweenitand Dothinenteritis," ^American Journs
of Med. Science/ 1837, vol. xix, p. 299.
36 Period of Incubation of T'ypJms,
symptoms commencing almost at tlie instant of exposure to tlic
poison.
B. Relapsing Fever.
The following six cases are all that I am able to add to those
already on record illustrating the period of incubation of
relaj^sing fever. Only three of the six cases came under my
own observation.
Cases 1 and 2. — On October 27tli, 1870, a lad, ret. 17, who resided in a locality
of Glasgow in which relapsing fever was prevalent, had rigors, and in the evening of
October 31st he came to his mother's house in Dundee. On the 2nd of November,
at mid-day, he was admitted into the iiifirmarj', where his case was diagnosed as a
characteristic one of relapsing fever.
On November 16th his two sisters, act. 14 and 16, shivered within a few hours of
each other while at v^'ork. Both were sent to hospital, where they went through a
similar attack to that of their brother's. They had not visited their brother in the
infirmary, and there were no other cases of relapsing fever in Dundee at the time.
Dr. T. J. Maclagan, of Dundee, to whom I am indebted for these particulars, ob-
serves that as these girls went to work at six in the morning, and as they did not see
their brother till between six and seven in the evening of October 31st, it follows
that the disease was contracted by them between 6 p.m. of October 31st and 6 a.m.
of November 2nd.
The period of incubation in these two cases could not have been as long as sixteen
days, and must have been at least a few hours longer than fourteen days.
Case 3. — In June, 1869, a Prussian physician, Dr. Goltdammer, related to me the
following circumstances of his own attack. Some months previously he had been in
daily attendance on cases of relapsing fever in the Charite Hospital in Berlin. lie
then travelled 200 English miles into the country to a place where relapsing fever
was unknown. Six days afterwards, his appetite and general health having been
perfectly good in tlie interval, he was suddenly seized with vomiting and fever,
and this was the commencement of a well-marked attack of relapsing fever with
jaundice.
Here the period of incubation could not have been less than six days.
Case 4. — Ann A — , set. 46, was admitted into the London Fever Hospital on
January 21st, 1870, on the seventh day of an attack of relapsing fever. The first
crisis had taken place, and the skin was then cool, thougli slightly jaundiced. But
on the 28th slie had again rigors, followed by severe pyrexia, which, after four days,
subsided suddenly with copious perspiration. This patient had been a nurse in the
relapsing fever ward of the Fever Hospital from January 3rd to 12th, and on the
latter day she went as a nurse to St. Mark's Hospital for Fistula. She remained
well there for three days, but on January 15th she was suddenly seized with shiver-
ing, vomiting, and high fever, and was obliged to take to bed.
In this case the period of incubation must liavc been somewhere between three
and twelve days.
Relapsing Fever, and Enteric Fever. 37
By this patient relapsing fever was communicated to a number of persons in St
Mark's Hospital. In two instances the period of incubation seemed to be exactly
two days and seven days, and in five others not longer than ten, nine, eight, five ,
and four days. The details of these cases have been published by Dr. Leared in the
' Lancet."
Cases 5 and 6. — Two men, set. 27 and 42, were admitted into the Fever Hos-
pital, one on December 6th, 1869, and the other on March 10th, 1871, with relaps
ing, fever. They had both arrived in London in good health from the country, one
from Portsmouth, and the other from Croydon. They had both slept during the
night after their arrival in the Camberwell workhouse, from which many cases of
relapsing fever were being sent to the Fever Hospital, and both on the following
morning had been attacked with symptoms of the fever.
In both of these cases the period of incubation appeared not to have exceeded
a few hours.
The period of incubation of relapsing fever has been variously
estimated, but there are few facts for determining it accurately.
Cases have been recorded to show that the effects of the poison
may be instantaneous ; while, on the other hand, the physicians
of Silesia in 1847 made the latent period vary from fourteen to
twenty-one days. ^ According to Lcbert's observations in the
recent ejDidemic at Breslau, it varies from three to seven days,
but was oftener over than under five days, and sometimes
extended into the second week. ^ During the recent epidemic
of relapsing fever several important observations on its latent
period have been recorded — in this country by Leared '^ and
Muirhead, ^ in Germany by Zuelzer ^ and Wyss and Bock, ''
and in America by Dr. A. Clark. ^ These, Avith the six obser-
vations now recorded, and one made by Cormack in 1843, ^ make
in all twenty-five cases, which may be classified as follows :
1 June 11th, 1870.
2 Virchow, " Mittheiiungen iiber die in Oberschlesien herrschende Typhus-
epidemie," 'Arch. fiirPath. Anat.,' 1849, p. 262.
2 H. Lebert, " Aetiologie und Statistik des Riickfallstyphus und des Flecktyphus
in Breslau," 'Deutsch. Arch. f. Klin. Med.,' 1870, p. 469.
•* Leared, 'Lancet,' June 11th, 1870.
s C. Muirhead, "Relapsing Fever in Edinburgh," 'Ed. Med. Journ.,' July, 1870.
6 W. Zuelzer, " Der recurrirende Typhus in St. Peteisburgh." Being an appendix
to his German translation of ' Murchison on the Continued Fevers of Great Britain,'
1867, p. 657.
7 Wyss and Bock, ' Studien iiber Febris recurrens,' Berlin, 1869, p. 65.
8 A. Clark, 'New York Med. Record,' March 15th, 1870, p. 28.
9 Cormack, ' Natural History, Pathology, and Treatment of the Epidemic Fever
at present prevailing in Edinburgh,' 1843, p. 117.
.
6
1 case.
2 cases.
, ,
13
10 „
3 „
38 Period of Incubation of Typhus,
I. Period exactly fixed 9 cases.
9, 7, 5, 5, 4, 2 days ; attack immediate on ex-
posure, 3 cases.
II. Both limits of period fixed
Between 3 and 12 days
,, 14 „ IQ „ .
III. One limit only of period fixed .
a. Maximum . . • .
2, 3, 4, 4, 5, 6, 8, 9, 9, 10 days.
b. Minimum .
6, 6, 9 days. Total, 25 „
These facts, so far as they go, point to the following con-
clusions :
1. The period of incubation of relapsing fever is not a fixed
period, and is even more variable than that of typhus.
2. It is, on the whole, shorter than that of typhus. In not
one of the nine cases in which it was accurately determined did
it exceed nine days ; in none of the twenty-five was there
reason to believe that it exceeded sixteen days ; in only two did
it certainly exceed twelve days, and in only three others was
it possible for this period to have been exceeded ; while in
fourteen of the twenty-five cases, or in more than one half, it
did not exceed five days.
3. Occasionally, as in typhus, there is scarcely any latent
period at all, the symptoms commencing almost immediately
after the first exposure to the poison.
c. Enteric Fever.
(Typhoid or Pythogenic Fever.)
Reliable facts bearing on the period of incubation of enteric
fever are even more difficult to obtain than illustrations of the
latent period of typhus or relapsing fever. In my own prac-
tice I can call to mind only two cases throwing light upon the
question, and in these all that could be said was that the period
of incubation was not longer, in one case than tAventy-one days,
and in the other than fourteen days. Medical men of much
experience in fever, and among others Dr. J. B. Hussell,
Superintendent of the City of Glasgow Fever Hospital, and
Dr. T. J. Maclagan, formerly Superintendent of the Dundee
Relapsing Fever, and Enteric Fever. 39
Infirmary, have also informed me that they have met with no
cases showing the latent period of enteric fever. Several cir-
cumstances contribute to make it very difficult to obtain satis-
factory evidence on the point as regards enteric fever : — 1.
The difficulty in many cases in deciding when an attack of
enteric fever really commences. 2. The circumstance that nurses
and patients in fever hospitals rarely take enteric fever. 3. The
fact that in private practice, when the disease has been im-
ported into a healthy locality, according to my experience it
rarely spreads. 4. The difficulty often in determining, when
a person is seized with enteric fever soon after changing his
residence, whether he has brought the disease with him, or
whether he has been predisposed to the disease by recent arrival
in an infected locality. In the absence of original observa-
tions it may be well to refer briefly to some of the more
important recorded facts and opinions on the matter, which are
but little known.
Lothholz, a pupil of Gerhardt's, analysed a number of
cases observed in villages around Jena, with the following
results :
28 days 1 case.
26 „ 2 cases.
23 ,, . . . . . . . . 2 ,,
22 5 „
21 )> . . • • • • . o ,,
20 „ 5 „
18 ,, 1 case.
Total . . . .19
These cases he picked out of three epidemics as " ganz exact
zu bestimmenden Fallen," and he also gives some probable cal-
culations in nine other cases less certain, but in all of which
the latent period was about three weeks. He saw no instances
in which it was only a few days, and he concludes that the
period of incubation of enteric fever is longer than that of other
acute diseases, and is, on an average, about three weeks.^
Seidel determined the period of incubation in one case,
brought from a distance, to be at least twelve days."
Zehnder, from observations made at Zurich, concludes that
• ' Beitrag zur Aetiologie des Ileotyphus,' Jena, 1866.
' ' Jenaische Zeitschr, f. Med.,' iv, 480,
40 Period of Incubation of Typhus,
the period of incubation is usually between ten and twenty days,
but that when there is a strong predisposition it may not be
longer than twenty-four or forty-eight hours.^
De la Harpe has recorded twenty-one observations on the
latent period of enteric fever. In none of his cases Avas the
period exactly determined ; eight cases showed the minimum
duration^ and thirteen the maximum. Of the former, in seven
cases the minimum duration varied from five to twenty-three
days, and in the eighth it was between five and six weeks ; of
the latter, the maximum duration varied from six days to eleven
weeks.2
Dr. W. Budd states that a large number of cases have led
him to the conclusion that the latent period of enteric fever
ranges from ten to fourteen days.^
In July, 1826, an outbreak of enteric fever occurred in the
Military School of La Fleche, in France ; 109 boys were attacked.
The school was broken up, and the boys who Avere not ill Avere
sent to their homes in distant parts of France. T-sventy-nine of
these boys Avere taken ill Avith enteric fever some time during
the second Aveek after their reaching home.^
The folio Aving case is remarkable in other Avays than as an
illustration of the period of incubation of enteric fcA'cr. On the
evening of May 2nd, 1869, a soldier in the garrison of liom-
burgfell into the dung-pit of the latrine of the military barrack,
and Avas covered aa ith filth, Avhich also entered his mouth, nose,
and ears. Eight days after this he felt malaise and lost his
aj)petite, and on the fourteenth day diarrhoea set in. Careful
records were made of the pulse and temperature, Avhich left no
doubt that the illness was enteric fever. This disease Avas not
epidemic in Homburg at the time ; no case of it had occurred in
the barracks for upAvards of a year before, and none occurred
after Avards.^
1 Pamphlet published in 18G6. I have been unable to see the original, and am
indebted for the reference to it and to the observations of Lothholz and Seidel, to
Dr. Clifford AUbutt, of Leeds.
2 De la Harpe, ' Recherches sur les divers modes de propagation de la Ficvre
typhoide,' Lausanne, 18G7.
^ W. Budd, "Intestinal Fever, its Mode of Propagation," 'Lancet,' 1856, ii,
G18.
■^ Bretonncau, " Notice sur la contagion de la Dothiencnterie," ' Archiv Gen. d
Mud.,' ser. i, torn. xxi.
'•> Knocvci;agel, ' Berliner Klin. Woclieu^thr.,' 8th Nov., 18G9,
Bekqisiny Fever, and Enteric Fever. 41
Dr. Clifford Allbutt has put on record a case in which the
period of incubation was exactly four days. A nurse came to
her master's house in the early stage of enteric fever. On the
night of her arrival, and on that night only, she slept with a
little girl of the family. On the next morning the nurse was
isolated, but her little bed-fellow fell iU on the fifth day, and
had a very severe attack of enteric fever. No other person in
the house Avas attacked, and the house was in all sanitary con-
ditions irreproachable.^
There are well-authenticated facts, which prove the correct-
ness of Lehnder's opinion, that the period of incubation of
enteric fever may be even less than in the case last referred to.
In August, 1829, a drain was opened in a school house at
Clapham ; it was cleaned out, and its contents spread over a
garden adjoining the boys' play-ground. Within four days
tAventy out of twenty-tAVO boys at the school Avere attacked Avith
enteric fever in a scA'^ere form. The disease Avas proved to be
enteric fever by post-mortem examination of the fatal cases,
Avhile the opening of the drain Avas admitted to be the cause of
the outbreak by Drs. Latham and Chambers, and others who
investigated the matter.^
Lastly, Professor Griesinger gives the particulars of three
cases, one of them his OAvn, in AA^hich the illness commenced on
the day folloAving exposure to the infection. The following is
a translation of the passage in his Avork referred to :
" Few trustworthy observations have been made on the period
of incubation of enteric fever. This much appears to me
certain, that it may be very short. I myself fell rapidly ill on
the day following the one on which I thought I had caught the
infection. I had felt somewhat miAvell at the bedside of a female
patient suffering from a severe attack of enteric fever, at whose
chest I had listened for a long time. A patient in my clinique
went to nurse another patient ill Avith enteric fever, and slept
the first night in the patient's room. On the folloAving day she
began to sicken Avith the fever. A man remained for a quarter
of an hour in a house where enteric fever was, and in him also
the illness commenced next day."^
1 ' Brit. Med. Journ.,' May 7th, 1870, p. 480.
' "Account of the Disease in Mr. Day's School at Clapham, in August, 1829,"
' Lancet,' 1829, xvi, 696 ; ' Med. Gaz.,' vol. iv, 375, 410, 448.
3 ' Infectiouskrankheiten,' 2ad ed., 1804, p. 149.
42 Period of Incubation of Typhus, ^-c.
From the facts before us the following conclusions may be
drawn :
1. The period of incubation of enteric fever is most com-
monly about two weeks.
2. Instances of a longer duration appear to be more common
than in typhus or relapsing fever.^
3. The period of incubation is often less than two weeks, and,
as in typhus and relapsing fever, it may not exceed one or two
days.
It would be an interesting inquiry how far the period of
incubation varies according as the poison is introduced by the
alimentary canal or by the lungs.
1 With regard to the cases in which the latent period has been reported to extend
over many weeks or mouths, it may be doubted if the disease has not had an inde-
pendent origin.
SOME REMARKS
ON
GUNSHOT WOUNDS OF THE LOWEH
EXTREMITY.
BY
WILLIAM MAC CORMAC.
Reading recently some of the older writers on military
surgery, I was impressed by the similarity of the conditions
they describe as obtaining during the wars of the early part of
this century, to those which I myself observed during the
gigantic struggle which has but just terminated.
History, it has been said, repeats itself, and certainly in more
respects than one might this repetition be alleged to occur in
military surgery. Since the time of the great Napoleon but little
material change has taken place in the character of gimshot
injuries. Much, however, has altered in the method of treating
them, and much, though not sufficient improvement, has ensued
in the circumstances in which the wounded are afterwards
placed, and on which success so very much, if not entirely,
depends. The exigencies of the situation will always more or
less prevent a medical relief organization, no matter hoAv perfect
otherwise, from efficiently exercising its powers for good. How-
ever willing to assist may be the national volunteer aid societies,
it must always prove difficult for them to discover beforehand
where their services may most be needed, in order that they shall
there concentrate both surgeons and medical stores. The actual
scene of a great battle in these days of rapid marching is often
placed in some very unexpected quarter. It may be un-
known even to the general in command, and is never likely.
44 Sojne Remarks on Gunshot Wounds
under any pretext -whatever, to be coimnunicatedto a comparative
outsider.
One cannot doubt^ after tlie experience of the Franco-German
war, that the benevolent assistance of volunteer aid societies
Avill be freely accepted in any future campaign. Those defi-
ciencies which have been discovered in their working will in the
interval be made good, and should another war break out
the Red Cross will be ready with fresh zeal and a more perfect
organization.
In the writings of the old Peninsular surgeons we find many
a graphic account of the difficulties which may beset an army
surgeon. A civilian who has not experienced them fails to
realise it. The admissions to a general hospital in some large
town generally give the surgeon of the week enough to do,
surrounded though he be by a stafi" of assistants, skilled nurses,
handsome wards, and a perfect commissariat.
" But suppose," says Guthrie, " that instead of thirty patients
he had three hundred suddenly thrown upon him, without the
means of procuring further assistance, without bedding, and
partly without food, he could not do even half the necessary
operations, and, obliged to give a partial attention to all, few could
receive all that they absolutely required."
It was in circumstances to which Guthrie's sketch almost
exactly applies that I found myself last year present at the
memorable battle of Sedan, but with this important difference,
that more than thrice the number of wounded men fell to my
charge. The Anglo-American ambulance, of which I was Sur-
geon-in-chief, had been sent from Paris with orders to join
MacMahon's army. We got as far as Sedan, which we reached
the clay before the French army in full retreat arrived there,
and, unable to proceed any further, we perforce awaited in that
town the tide of events.
To show how little a great battle was expected near Sedan,
there were but one surgeon and two young assistant-surgeons in
the place, engaged in the performance of the routine work of the
military hos2:)ital. Yet hardly were we installed in the large
empty barrack which was assigned to us than the fighting com-
menced, and in some four and twenty hours nearly one thousand
wounded men were poured in upon us. The constant din of
cannon, mitrailleuses, and musketry outside, and the aspect of
of the Loiver Extremity. 45
the passages and beds crowded with woimded men arriving every
moment, often dripping with, fresh blood, produced an impression
such as no descriptive power which I possess can adequately
convey. As our position was as nearly as may be about the
centre of the battle-field, we received many wounded men very-
soon after they fell, and large numbers also came to us on foot.
The distress caused to oui'selves by reason of such a ghastly
crowd of human sufferers was mitigated by the necessity for
great bodily and mental exertion. But, -work as we might, we
felt there was much during that first dreadful day and night
which had to be left undone.
Of all the circumstances which conduce, not only to the com-
fort of the wounded at the time, but to their subsequent safety,
none is of greater importance than the mode and the length of
transport. Carriage by hand on stretchers surpasses any other
mode of conveyance. No ambulance waggon, however cun-
ningly contrived, will answer the purpose half so well. Of
course, if the distance be very far, carriage by hand ceases to be
Ijracticable, and this forms an additional reason, if any be needed,
for selecting the nearest available places to the scene of action
in order, in the first instance, to receive and treat the wounded.
A comj)lete " evacuation" system after the German example must
be added as the complement of this plan. By its means I have
no doubt much human life and suffering was spared, even though
it inflicted in some cases individual hardship. The neighbour-
hood of every great battle-field was speedily cleared by this plan
of all but those whom it was impossible to move. I am sure that
the practice of erecting rude wooden huts, built of any rough
boards that may be at hand, or even making a lean-to against a
garden wall, is a good one. The Germans employ their engineer
corps in such tasks after a battle^ and they very soon create
these impromptu hospitals, in which there is shelter, but at the
same time plenty of fresh air and no overcrowding. To collect
great masses of wounded men into huge buildings, such as bar-
racks or hospitals, is but to sign a death warrant for the large
majority of them. A field hospital should contain from ten to
twenty beds, with fresh air on all sides of it, plenty of pure W'ater,
and the most minute attention must be paid to the removal of
everything which may pollute the entourage of the patients. One
of the great reasons for transporting the wounded to a distance
46 Some Remarks on Gunshot Wounds
is now removed. Neither they nor any of those in attendance
upon them are any longer liable, thanks to the Geneva Con-
vention, to capture and its many attendant hardships.
No one has spoken more strongly than Larrey of the advan-
tages of the speedy evacuation of the -svounded from the neigh-
bourhood of the battle-field. He describes the fatal accidents
which surely supervene if they be not removed, and mentions
numerous striking examples of recovery after removal under
circumstances which some surgeons were pleased to style an act
of barbarism.
In no class of wounds is rough and distant transport more
harmful than in gmishot fractures of the loAver extremity, and
of the femur in particular. As Stromeyer says, "The avoidance
of this is, indeed, of essential importance, in order to diminish
amputations, and to increase the number of those cured by con-
servative means." The wounded treated by him in Floing^ had
received their injuries while fighting in the village itself and in
its immediate neighbourhood. This was the extreme left of the
German lines. At the other end of the lines the Balan division
of our ambulance received the wounded, as they were shot down,
at the door of the Mairie in which the ambulance was installed.
The troops approached very closely at these two points, en-
countering each other almost hand to hand. In the centre
opposite the town the battle was conducted by the artillery sta-
tioned on the opposing heights.
It was thus that Stromeyer was able to realise at Floing,
during his sixth and last campaign, what he so earnestly
wished for after his first. " Above all things/' he says, " it
appears to me to be requisite that cases of wound complicated
with gunshot fracture of the thigh should have no long trans-
port to endure, but should be brought on a stretcher to the
nearest house, and the treatment carried out on the ground
itself, even at the risk of allowing the wounded to be taken
into captivity." ~ In Floing this advantage was accidental, but
such chances, he urges, should always be taken advantage of.
Doubtless the frequently protracted transport the wounded
suffered in former wars was a chief reason why some of the
1 Floing is a village one mile north of Sedan, where there was hot fighting. Stro-
meyer's ambulance was placed there.
" 'Handbuch der Chirurgic,' vol. i, 1850.
of the Loiver Extremity. 47
older writers on military surgery have pronounced so emphati-
cally on the utter hopelessness of the conservative treatment of
gunshot fractures of the femur. I am much indebted to jMr.
Carr Jackson for an opportunity of reading some interesting
lectures delivered many years ago by Sir Rutherford Alcock,
surgeon to the expeditionary force in Spain. In these lectures he
remarks, " From the numerous cases I have seen myself, added
to all on the records of military surgery, under no ordinary
circumstances can I consider it justifiable to reserve a gunshot
comminuted fracture of the femur for treatment with a view to
save it. Out of thirteen cases which, fi-om unavoidable circum-
stances, were thus reserved, but one survived without secondary
amputation, and he at the end of two years was bedridden with
a useless limb. Larrey and Guthrie advocate similar views.
The latter gives a painful account of his experience of the treat-
ment of gunshot fracture of the femur in the following words : —
" Upon a review of the many cases I have seen I do not believe
that more than one sixth recovered with a useful limb, two
thirds died with and without amputation, and the sixth remain-
ing possessed limbs, not only nearly useless, but the cause of
much uneasiness to them for the remainder of their lives." ^
After the battle of Toulouse an attempt was made to save
forty-three of the best cases of thigh fracture, which had been
carried off the field of battle but a very short distance, and were
well accommodated in hospital, where they received great care
and surgical attention. Guthrie mentions that thirteen of these
died. On twelve, secondary amputation was performed with
seven deaths, while eighteen retained their limbs. Three months
after the battle only five of these could be considered well.
In two the result was doubtful, while in eleven, if recovery
eventually takes place, which he says is uncertain, it will be
with distorted and unserviceable limbs. In the five successful
cases the fracture was in the lower third, and in thirteen
others the injury was not above the middle third. From all
his experience Guthrie advises the more frequent amputa-
tion of the thigh, saying it is better to amputate even in
doubtful cases, and he excepts those only in which the lower
part of the femur is injured without implicating the knee-joint.
1 « A Treatise on Gunshot Wounds,' 2nd edit., 1820.
48 Some Ranarks on GunsJiot IVounds
Larrey says, ^ " Mon experience m'a appris que toutes Ics
plaies avec fracture clc la cuisse sont tres facheuses, et exigent
toutes en general ramputation." "While Professor Longmore,
the latest as well as the first authority on military surgery,
when speaking of these injuries in the Crimea,- remarks that
the hoj)es of avoiding amputation by conservative treatment
were not realised. " Of 174 cases of compound fracture
amongst the men, but fourteen recovered without amputation."
And in another place he remarks, " Excepting in special cases,
in fractures above the knee from rifle balls amputation is held
by most military surgeons to be a necessary measure." Of the
vast number of persons thus injured during the American war,
the results were definitively ascertained in 822 cases in which
amputation was performed, and in 1117 treated conservatively.
The mortality amongst the former was 65 per cent., in the
latter 6o per cent. But another important conclusion may be
drawn from the statistics given in the ' Surgeon-Generals'
Circular,' No. 6, 1865, namely that the comparative danger of
amputation and conservation of the limb vary inversely accord-
ing to the position in the limb in which the fracture is situated,
or nearly so.
Excluding fractures involving the hip- and knee-joints, the
table ofivcs of —
Mortality after
amputation in
detcrmiucd
cases.
75-00
Slortality after
conservative treat-
ment in determined
cases.
71-81
54-83
.
55-40
4G-09
57-79
Gunshot fractures of tlie upper third of the femur
„ „ middle „ „
,, „ lower „ „
In the Anglo-American ambulance we treated in all forty-seven
cases of gunshot fracture of the femur. Twenty-one of these
cases were submitted to amputation, sixteen terminated fatally.
A frightful mortality, but it must be remembered that the
circumstances under which these operations Avere performed
could not well have been worse. Besides, in three instances
a fatal issue followed the almost uniformly mortal ojieration
of disarticulation at the hip-joint. In eleven cases ampu-
tation was performed in the upper and middle third with five
deaths, while^ eight amputations in the lower third, terminated
1 ' Memoires de Chirurgic Militaire/ vol. ii, Larrey, 1812.
- ' Holmes's System of Surgery,' 2nd edit., vol. ii.
of the Lower Extremity . 49
in deatli. Supposing we exclude the disarticulations at the
hip, we have a rate of mortality of 72"22 per cent. Twenty-
six cases were treated without amputation, many of them being in
so hopeless a condition that no operation could be performed at
all. Of these one half perished, almost all pysemic. But even
this compai'ison affords a decided advantage in favour of conser-
vative treatment, so far as immediate safety to life is concerned.
We must not, however, lose sight of the protracted convales-
cence, the exfoliation of bone, delayed union, and in some
instances the deformed and useless limbs that finally result.
The experience of Stromeyer at Floing, where he was able to
trace the results of sixty-eight cases of gunshot fracture of the
lower extremity up till the 10th November, a period of more
than nine weeks, is as remarkable as it is encouraging. There
the patients were placed in most admirable hygienic conditions,
which with the fact that all had received their wounds close to
the place of treatment, must have largely contributed to the
unusually successful results. Thirty-five of these cases were
gunshot fractures of the femur, of which twenty-three were
'' evacuated " with the prospect of complete cure, four were in
a doubtful state at the time of the report, while only eight
died.
This experience has hitherto been a very exceptional one.
Stromeyer himself admits it to be so. But it is on that account
none the less noteworthy, and must tend, I conceive, to modify
our views as to the almost indispensable necessity of thigh
amputation for gunshot fracture. Most of the cases ^ of recovery
that I have seen took place after fracture in the ujiper third, and
it is in this part of the limb that amputation presents so large a
death rate. Lower down, amjoutation seems relatively or often
indeed absolutely less dangerous than conservation of the limb.
The treatment of gunshot fracture of the femur, owing to the
comminution of the fragments, is always difficult. No distiu'b-
ance of the limb by frequent readjustment or by digital exami-
nations of the wound is admissible.
The first examination should be the only one, and must
^ Three of my patients recovered satisfactorily after fracture in the upper third,
excellent union taking place in one of the cases without the slightest deformity,
while in a fourth case union was delayed. I have not learnt the ultimate fate of
all the patients.
VOL. II. 4
50 Some Remarks on Gunshot Wounds
determine whether an attempt shall be made to preserve the
extremity. After that, the less handling or interference of any
kind the better.
Stromeyer urges that our first care should be to endeavour
to save the life of the patient with fracture of the thigh^ and after-
wards, if possible, to rectify the deformity. '' The attempt,"
he says, '' to look after both at the same time often costs life,
and does not guarantee the absence of deformity. It is for me a
matter of surprise when I hear an experienced surgeon affirm
that for the preservation of the length and form of the limb the
surgeon is responsible. In the hands of such persons a patient
with gunshot fracture of the femur is generally lost."
If this be taken as a protest, and a tolerably energetic one,
against meddlesome surgery in gunshot fracture of the femur,
too much importance cannot well be attached to it, backed as
it is by such a record of the successful application of principles
to practice as no military surgeon has been able to show before.
There can be little doubt that violent continuous extension of a
bullet-smashed femur, combined with frequent handling and
readjustment, must prove injurious in the extreme. Stromeyer
has almost completely abandoned forcible extension and counter-
extension, and j)refers simply to lay the limb on the side, in the
position advocated by Pott. In my own practice I employed
long splints sometimes, sometimes sandbags, Avith a small weight
merely to steady the limb attached to the foot. In two in-
stances that I know of, subsequent deformity was successfully
relieved by refracturing the bone. This was performed once by
Dr. Wilms, in Berlin, six weeks after the injury, and once by
Dr. Duplessy, in Sedan, in one of my own cases, about two
months after the date of the wound.
When amputation is considered necessary in these cases, let
it be done at once, during the first twenty-four hours. Larrey,
Guthrie, and Stromeyer have all insisted on this, and cited
proof upon proof of Avhat they formulate. I may quote one
example : — Stromeyer, after the battle of Kirchhcilungen, in
1S66, performed, within tAvclve hours, nine amputations of the
tliigh. But one only proved fatal. Were any further illustration
needed of the excessive mortality after delayed amputations, my
own unfortunate experience would furnish it, when with hardly
an exception, although from causes beyond my control, the am-
of the Lower Extremity . 51
putations were secondary. A very interesting question is raised
by Stromeyer in respect of amputations, namely, that one need not
amputate clear of the diseased or injured soft tissues in ordinary
cases, but may divide the bone, unless split up and inflamed, just
at the seat of fracture. The track of a ball or a sinus may safely
be left in the flap, and the high division of the bone, which so
largely increases the risk, is thus obviated. For, as Dieffenbach
pithily expresses it, Zollweise stiegt die Gefahr.
The rule laid down by Guthrie, that for uncomplicated gun-
shot fracture of the leg amputation is not indicated, Stromeyer
would extend to all gunshot fractures of the diaphyses as well.
In our ambulance we received altogether fifty-seven cases of
fracture of the leg, usually of both bones, followed by twenty-
three deaths. Twenty-five were treated conservatively, with
eight deaths, or 32 per cent., while thirty-two required amputa-
tion. Of these last thirteen died, or 40'6 per cent.
Of the operation cases, sixteen consisted of primary amputa-
tions of the leg, with but five deaths, while sixteen were
secondary amj)utations, with eight deaths, another example of the
greater proportionate mortality after secondary operations.
Amongst the fatal cases in which no operation was performed was
an officer, the upper part of whose leg had been shattered by a shell.
He would not submit to have anything done, and he died next day
from shock. In a second, both legs had been badly fractured,
one ankle-joint opened, and a severe flesh-wound inflicted on the
thigh. Others had likewise received additional injuries. On
the whole, therefore, the conclusion appears to be distinctly in
favour of non-interference when possible.
At Floing the results were as remarkable as those obtained
after fractured femur. Of thirty- three cases, twenty involving
both the bones, twenty-four healed well, four remained doubtful,
and five died. Of eleven amputations of the leg, but two, both
secondary, proved fatal.
It now only remains to consider injuries of the three chief
joints of the lower extremity. I need not specially advert to
formal resections of the shafts of the bones immediately after
injury. When this appears necessary, amputation, a much less
dangerous measure, should be practised instead.
Gunshot injuries involving the hip-joint are of extreme
gravity. Primary coxo-femoral amputation is hardly feasible.
52 Some Remarks on Gunshot Wounds
secondary amputations are less uniformly fatal, while reamputa-
tions at this joint have proved least unsuccessful. The consi-
deration of hip-joint injuries and their treatment, in the
Surgeon-General's Circular, No. 2, 1869, is most interesting
and exhaustive, but I can do little more than refer to it here.
The uniform experience of American surgeons Avould seem to
be, that to abandon a patient Avhose hip-joint is implicated by a
gunshot fracture to the resources of nature is to send him in-
evitably to death, that amputation, more especially primary, is
but little better, and that it is to resection that we must look,
as affording the best, and often the only chance, not merely of
the preservation of the limb, but of life itself.
When the joint is not involved by a fracture near to it, ex-
pectant treatment furnishes the most favorable results, not be-
cause the expectant j^lan proves so successful, but because
amputation high up is so fatal. It is interesting to find that,
after a review in this Circular of all the modes of performing
resection of the hip, the one recommended for adojition is that
originally proposed by Charles White in 1769, when he first
formally suggested the operation. The. simple straight incision
in the axis of the shaft, a little behind the prominence of the
trochanter, was the plan adopted in forty out of the total number
of eighty -five authenticated cases on record, and was tlie mode
employed in six of the successful cases.
In three instances, under my own care, of secondary amputa-
tion at the hip-joint, two rapidly died, while one survived six
days. Prior to the w^ar in America excision of the hip for gun-
shot injury had been practised twelve times, once only success-
fully. During that war, in sixty-three instances the upper end
of the femur Avas excised. In fifty-eight cases death shortly
followed. In one of the surviving cases no result is recorded ;
in another the limb, though preserved, was useless. In three
only of the total number is a perfectly successful issue tabulated.
Stromeyer witnessed one case of resection of this joint at Ver-
sailles, which proved rapidly fatal, but he gives an account of
a second Avhich terminated otherwise, and of which some par-
ticulars may here prove interesting. The operator was Dr.
Hupedcn, of Hanover.
An infantry soldier named John was wouiuled at Spichcren, and two months later
came under the care of Dr. Ilupeden in a hospital of the Reserve. The operation
of the Lower Extremity. 53
was commenced with a view merely to remove a loose piece of bone. This proved
to belong to the edge of the acetabulum. On exploring the wound further, the
head of the bone was found to be in a carious condition and partially absorbed, while
the acetabulum was also enlarged and carious. The head and trochanters were then
sawn oflf. Ninety days after the operation the patient was able to leave his bed, and
in May, 1871, his healtli was completely re-established, the wound was thoroughly
healed, and a considerable amount of movement existed in the new joint.
As for the knee-joint, althongli it has been excised with
advantage after gunshot injury in civil hospitals, this is, in my
opinion, an operation wholly inadmissible in time of war. The
absolutely needful after-care on "nhich success depends is un-
attainable. When the conditions obtaining in war time assimi-
late themselves to the perfect means of treatment and hygiene
we enjoy in civil hospitals, then, and then only, will resection
of the knee-joint become a justifiable operation. To excise
knee-joints as was somewhat extensively done during the late
war, and afterwards to leave the patients to take care of them-
selves, often without even a splint applied to the limb, is but
to court disaster, to use no stronger phrase.
I was once only tempted to excise the knee-joint myself. A
bullet had passed transversely through the articulation, after
carrying away the outer border of the patella. The parts
removed are interesting, since they demonstrate that a bullet
may sometimes pass through this articulation, under certain
conditions, as has indeed been alleged by Professor Simon, with-
out injuring either the femur or the tibia.
The French surgeons in the Crimea frequently performed
amputation through the knee-joint, but with unfavorable results.
Nevertheless, I think that in injuries of this articulation Garden's
or Baudens' operation leaving untouched, if possible, the condy-
loid end of the femur, is the proper procedure to adopt, unless
indeed the bone be too extensively injured.
During the American war there were eighteen cases recorded
of partial or complete excision of the ankle-joint. On analysing
the list it appears that eight only were complete resections, and
of these six proved fatal, all of them being secondary operations.
Langenbeck and Neudorfer advocate immobilisation of the
injured joint and subsequent subperiosteal resection. Remark-
able success, including the preservation of joint movement,
is said to have attended their practice. But, as Professor
54 Some Remarks on Gunshot Wounds.
Lucke observes, this cannot per se furnish an argument for the
performance of the operation, because the power of motion in
the ankle-joint is not necessary for progression, and he cites eight
cases, seven of them successful, after simple expectant treat-
ment.' ^
At Versailles Stromeyer saw two fatal cases of resection of
the ankle-joint, in one of which he says the operation seemed
to him unnecessary, and the other was pyaemic at the time.
His own cases healed by simple means and the cautious
extraction of loose fragments.
Under my own care were seven cases. Three of these subjects
died after secondary amputation. The other four did well. In
one of the latter I had decided to resect the joint, but fortunately
for the patient delayed the execution of my plan until it became
no longer needful to interfere.
I scarcely think with our present experience we can admit
that Professor Langenbeck is justified in placing resection of the
shoulder and ankle-joints in the same category, and advising
that the one shoidd be as frequently and readily performed as
the other.
The indications for the necessity of amputation, apart from
injury to the great vessels and nerves wliich is comparatively
rare, chiefly rest on the amount of damage done to the bone by
the projectile. Few injuries of the soft parts are so extensive
as to entail the loss of the limb.
The importance, therefore, of a thorough examination of the
wound at the earliest possible period is of the utmost moment.
Elsewhere, I have insisted upon this, and I should like to quote
an interesting paragraph from Alcock's lectures to the same effect.
" In the examination of wounds," he writes, " never trust to
any future moment for making it more carefully and maturely.
The first is the best and often the only one. The future com-
fort and safety of the patient often depend on the officer who
first dresses him satisfying himself completely as to the nature of
the wound. When possible the finger is the best pi'obe to be
used. It is less likely to do mischief, and is much more certain
to convey correct information."
Sedillot affirms, as the results of his observations at Hagenau
' ' Kriegs Chirurglsc4ie Fragcn uiKJliemerkuiig en,' Bern, 1871.
of the Lower Extremity. 55
on nearly 2000 wounded accruing from th^ battle of Reiclis-
hoffen, that in any case of gunshot fracture of a limb admitting
of doubt amputation should not be performed ; and he states,
further,' " La conservation de la cuisse fracturee par une balle
donne, d'une maniere generale, plus de succes que I'amputation
quelle que soit I'epoque ou cette derniere est pratiquee."
The considerations detailed in this paper appear to me to
afford grounds for concluding against the universal application
of amputation in regard of gunshot fractures of the shaft of the
femur. Sound, though it may be delayed, union will often
follow conservative treatment. I think for general guidance we
may for the present declare that, in fractures of the lower half
of the femur, the rule should be when in doubt to amputate,
while in those of the upper half of the bone the converse should
apply, namely, when in doubt to try to preserve the limb. A
very large margin must in all cases be allowed for the ex-
tremely variable conditions under which wounds in war are
received, and have to be treated. The antecedent hardships of
the campaign, and above all the hygienic surroundings of the
locale itself, ought never to be lost sight of.
The interest taken in everything pertaining to military sur-
gery has ahvays been engrossing. Its pursuit affords the
greatest opportunities for investigation, pathological as well as
surgical, if only we shall be able to avail ourselves of them.
Perhaps in no other school can a surgeon better develop his
presence of mind, readiness of resource, skill or tact, than in
those great and necessarily unforeseen emergencies which may
in war at any time beset him. Unfortunately, too, we cannot
hope that wars have ceased. At no period have great wars
more unexpectedly arisen than now, and never possibly before
was there after the conclusion of a great war less sanguine ex-
pectation of prolonged peace.
' 'Fractures des Membres par Armes a Feu/ Strasbourg, 1871.
DESCRIPTION OF PLATES
Illustrating Mr. Mac Cormac's remarks on Gunshot Injuries of
the Lower Extremity .
PLATE I.
Fig. 1. Eight tibia of a Prussian infantry soldier smashed by a shell. There was
a very small wound in the soft parts. The fibula was intact, and the
fracture of the tibia had apparently not been recognised, as he had
been sent by train a journey of several days without any appliance on
the limb. Amputation of the thigh had to be performed one mouth
after the injiiry, but death soon occm-red from pyaemia.
„ 2. Lower extremity of right femur with a Chassepot bullet impacted in the
internal condyle. The subject was a young Bavarian soldier. Ampu-
tation, performed sixteen days after the wound, proved successful.
„ 3. Left femur of a Prussian infantry soldier, set. 19. The bullet first cai-ried
away the external border of the patella, and caused a stellate fracture
of that bone. It then lodged deeply in the extremity of the femur.
The subject of this injury was sent from the neighbourhood of Orleans
to Eperuay, being three days on the road. Only a small round wound
was observed on the outer side of the patella. The deeper lesions
were soon made out. Amputation, ten days subsequent to the injury,
was followed by death from pya;mia. The nature of the wovmd had
evidently not been discovered by those who first examined the man.
PLATE IL
„ 4. The right femur belonging to a French marine. He was shot through
the trochanters from behind forwards. The ball entered just external
to the tuber ischii, and was afterwards cut out at the apex of Scarpa's
triangle, where it was found lying just in front of the vessels. This
man was wounded at Balan on September 1st, and the next day he
walked into the hospital without assistance. The extent of injury
was not at first indicated by any external symptoms. But on the sixth
day sudden shortening to the extent of two and a half inches appeared.
Extensive suppuration, sloughing bed-sores, and pyaemia, carried him
off on October 10th. There was at no time an opportunity for opeia-
tive interference. It is very remarkable that any one could walk
after the receipt of so serious an injury.
„ 5. Right femur from a French artillery man. The bone is extensively split
by a bullet, which has lodged. At the end of September he was
brought to Balan from the German Ambulance at Lamoncelle, where
he had been treated for a simple flesh wound. He was then pya^mic,
and died forty-eight hours after admission.
ON THE
EXISTENCE OE CONTINUED CUUEENTS
IN ELUIDS.
SEQUEL TO A PAPER IX THE LAST VOLUME OF THESE
REPORTS.
By GEORGE KAINEY, M.R.C.S.,
LECTTJEEE ON MICBOSCOPICAL AXATOITT, AND DEMONSTRATOR ON SUEGICAI
ANATOMY AT ST. THOMAS'S HOSPITAL.
Since my previous paper " on the existence of continued
currents in fluids" was put into the hands of the editors of * St.
Thomas's Hospital Reports,' I have been able to simplify the
apparatus by which some of the earliest experiments were per-
formed ; I have^ therefore, drawn up a short appendix, explain-
ing the construction and manner of using it. I consider it to
be of essential importance that all facts resting v;pon experi-
mental evidence should admit of being verified with the least
amount of trouble, and with the least liability to failure ; or, in
case of failure occurring, that its cause may be so clearly un-
derstood, that the experimenter shall have it in his power at
once to rectify it. If he clearly comprehends the sources of
error as well as the laws which lead to the exhibition of current
motion, he will be able to produce normal or abnormal results,
as he may think proper. I have also in this appendix given an
account of some facts corroborative of the views before expressed,
but which are not mentioned in the original paper.
One of the improvements consists in the substitution of two
flattened bulbs of different sizes, joined by a very short passage
or strait, for the two-cell apparatus described at page 90.
58
On the Exist eyice of
This apparatus being made out of one jjiece of glass tube, left
open at one end only, admits of being hermetically sealed ; thus,
no cement being required in its constrviction, evaporation of the
fluid contained within it is impossible.
The accompanying diagram shows the form and size of the
apparatus I have found to be most convenient, and in all cases
to answer. The depth, Avhich cannot be shoAvn by diagram, I
may state to be between the eighth and the fourth of an inch.
The interior is to be filled with such mixtures of fluid and solid
particles as Avere employed in the two-cell apparatus, and they
may be examined in the manner directed at page 92. The class
of experiments described at page 95 are particularly well
suited to show the advantage of this form. I may add that
if, in this apparatus as well as in that in which the bulbs are
globular, a portion of the tube from which they were blown be
left connected with the side of the large bulb opposite to the
strait, and its interior be filled with the same fluid as that in
the bulbs, currents can be seen in the fluid of this tube after it
Continued Currents in Fluids. 59
has been hermetically closed, similar to those in the strait, the
upper currents passing from the tube towards the bulb and the
lower ones in an opposite direction ; that is, as in the other cases
described as normal, the upper currents being from the small
into the larger quantity of fluid, and the lower ones from the
large into the small quantity. I may notice that in tubes such
as the above, as also in the tubular form of the strait, the calibre
must be of the same size throughout.
The only disadvantage of the tubular form is the unnatural
shape of the moving particles, as seen by the microscope, owing
to the rotundity of the media through which they are viewed.
The upper stratum of moving particles when seen at the longest
focal distance at which they are distinctly visible will have the
form of fine lines placed transversely in respect to the axis
of the tube. These particles, this distance being gradually
shortened, will pass through a variety of intermediate forms,
still appearing as fine lines, but moving parallel with the axis of
the tube. These changes of form do not, however, interfere
with the distinctness of their movements. The particles in the
lower stratum of the fluid appear also as transverse lines con-
siderably magnified, but less defined than those of the upper
stratum ; the fact of their reverse movement is, however, suf-
ficiently obvious.
In these observations an eye-piece with cross wires and a lens
of one inch focal distance were employed.
If thought proper to make any deviation from this form, it
should not be in making the strait longer than has been named,
or in making the bulbs more nearly of the same size, for in pro-
portion as the strait is lengthened, and the bulbs are made more
nearly equal, will be the difficulty of securing what I have
termed normal results.
In the employment of the two-cell apparatus, as at first con-
structed, the principal difficulty of obtaining uniform results
arose from irregularities in the form of the strait, either in con-
sequence of the unevenness of its edges, or from imperfect con-
tact of the cover with the perforated slide, more especially with
that part of it which is in the vicinity of the strait. In this
situation spaces were left in which fluid became lodged and
secondary currents formed.
Another cause of abnormal results is to be found in imperfect
60 On the Existence of
adhesion of the cover ; for there may, consequently, be some
communication between the fluid in the cells and the external
air ; evaporation may occur, the fluid may be diluted by the
water of the atmosphere, as Avhen calcium nitrate or calcium
chloride are employed, and unequal density of the fluid may
be produced in difi'erent parts, and secondary currents by such
means established. It will be obvious that the arrangement
now described has not the first defects, namely, those occasioned
by irregularities in the strait, and hence the occurrence of ab-
normalities in the directions of the currents from such a cause
will in this case be entirely prevented ; in fact, abnormality
can now only be due to unequal density of the fluid in the
bulbs.
To ascertain the effect of this mode of experimenting upon
larger quantities of fluid, and thus to generalise the principle
upon which it depends, as far as these experiments will permit,
I employed an apparatus having two bulbs of similar relative
sizes as the above, but capable of containing upwards of a pint
of fluid ; the result was precisely tlie same as before described.
It has, however, two advantages : the experiments can be made
more easily and their results determined without the necessity
of a microscope.
By means of this and the other instrument of the latest con-
struction the cause of abnormality arising from difference of
density Avas carefully investigated, and the following facts
determined : — 1st. If the fluid in which the solid particles are
suspended be in all parts the same, or exactly of the same
specific gravity, the currents will be normal. 2nd. If the fluid
in the small cell be lighter than that in the large one, the
currents will still be normal, but rather accelerated ; and ord.
If the fluid in the small cell is heavier than that in the large,
the currents will be abnormal.
To prove the first fact, after the bulbs of an apparatus of the
kind last described had been filled with a mixture of fluid
and solid jiarticles, and so completely mixed that one part of
the mixture could not be denser than the other, it was placed
in the vertical position with the large bulb dowuAvards, and
so retained until no solid particles could be distinguished
individually in the fluid of the small bulb. It was then
removed from this position, and placed horizontally in a situa-
Continued Currents in Fluids. 61
tion as little as jDossible exposed to changes of temperature
or currents of air.
After the lapse of a few days I found that a considerable
part of the solid matter had jDassed over from the large into
the small cell, and become collected in the lowest part of the
latter.
Now, to render it certain that these particles, which had
become deposited in the most dependent part of the small bulb,
were not merely those which had remained in a state of sus-
jDcnsion in the fluid of this bulb before the position of the
apparatus had been changed from the vertical to the hori-
zontal, it was again replaced in the vertical position, and so
retained until all the solid particles deposited in the small cell
had passed through the fluid of the strait into the lower part
of the large cell. After this the apparatus was restored, as
before, to the horizontal position, and after remaining thus
for some weeks an accumulation of solid particles was found to
have taken place in the small bulb, just as in the first
experiment.
The same was again repeated with a like result, until the
fact that the w^iole or the greater part of the deposit which had
become collected in the lower part of the small bulb whilst in
the horizontal position had come from tliat Avhich before had
been accumulated in the lower part of the large one whilst
in the vertical position was rendered certain. Now, as in this
and similar experiments the dispersion of solid particles takes
place in a fluid of uniform density, it cannot be attributed to
the so-called law of diff'usion. The conditions necessary for the
operation of this law being absent, it seems more probable that
the phenomenon called diff'usion of fluids is due rather to the
operation of fluid currents.
I now proceed to consider the second fact, namely, that if the
fluid in the small bulb be lighter than that in the large one,
the currents will still be normal, but rather quicker than Avhen
both bulbs or cells are filled with the same fluid. For this
purpose it is necessary only to introduce into the small bulb of
the same apparatus water, and into the large one a filtered
mixture of gamboge and water. The apparatus is to be placed
horizontally as before, when these fluids will be seen to become
mixed in the strait, which will have the appearance of being
62
On the Existence of
divided diagonally into two parts, the upper one containing
cliiefly the water, and the lower one the mixture of water and
solid matter. After a few days the small cell will become filled
Fig. 1.— Cells of the same size filled with the same fluid.
„ 2. — Normal currents.
„ 3. — Abnormal currents from greater density in small cells.
„ 4. — Abnormal currents from changes of temperature.
with a mixture of the two fluids ; now minute particles of gam-
boge will be seen at the most dependent part of the small cell
where they will go on gradually increasing for an indefinite
period {see page 95), or until the deposit in the large cell has
become so dense and compact that the current force is not suffi-
cient to detach it from the solid mass, and thus to bring it into
a state of mixture with the fluid. The largest two-bulb appa-
ratus is the best for this class of experiments ; however, the tAvo
flattened bulbs are more convenient where it is required to make
Continued Currents in Fluids. 63
these experiments on a small scale. They answer exceedingly
well if placed in the horizontal position with their margins one
directly above the other, and consequently their surfaces one
anterior and the other posterior.
To show the third fact it is only necessary to reverse the con-
ditions of the second by introducing the mixture of gamboge
and water into the small cell, and water only into the large one ;
after which closing hermetically the open end of the apparatus,
as must be done in all other cases where it is employed. Then,
as might have been expected, it will be seen on examination
that the direction of the upper current along the strait is from
the larger into the small bulb, and the lower current in the
opposite direction ; so the directions of the currents will con-
tinue until the fluid in the two cells is brought to the same
density, when their directions in relation to their positions in
the strait will be the same as in the first and second experi-
ments, that is, normal.
A like effect is produced by a partial change of temperature
of the fluid contained in the cells of the apparatus. If heat, as
for instance that produced by the application of the finger, be
applied to the small bulb, the position of the current in the strait
will not be altered, but the movement of the floating particles
will be accelerated ; whilst, on the contrary, if cold be applied
to this bulb, a reversal, or Avhat has been termed an abnormal
movement of the fluid, will take place.
If cold be applied to the large bulb the directions of the cur-
rents will not be altered, but their movement will be slightly
accelerated, whilst on the contrary heat applied to this bidb Avill
cause a reversal of the currents.
A small piece of paper wetted witli alcohol when placed upon
the small bulb will change the directions of the currents, but if
placed upon the large one will accelerate them. Thus it is
obvious that the currents are affected by changes of temperature
exactly in the same way as by difference of density.
It may be further noticed that after the application of these
means to the different parts of the aj^paratus, with a view to
affect the temperature of the fluid in each part, have been with-
drawn, the currents will gradually return to their normal state.
Now, from what has been stated, the changes in the fluid
currents produced by changes of temperature are only second-
64 On the Existence of
ary results ; the explanation of the manner in Avhich changes
of density produce corresponding changes in fluid currents of
the strait ought first to be considered. The mere fact of the
effect of the partial application of heat in reversing the fluid cur-
rents is noticed at page 110 of the paper on this subject in the
first volume of these reports, but no attempt is there made to
explain how this effect was produced.
To render intelligible the explanation I am about to give it
will be necessary to refer to the original essay, pages 102, 106,
lOrandllS.
In diagram 3, page 100, the superficial currents are repre-
sented as passing from the circumference towards the centre of
the cell, around and near to Avhich, after descending a little,
their directions become reversed, being now from the centre to
the circumference, Avhere the two currents become again con-
tinuous {not represented in the diagram), that which was the
lower current being continued into the upper one. During
these movements of the fluid, the solid particles, being only
temjDorarily suspended, will keep falling towards the lower part
of the cell, assuming different forms as they pass through dif-
ferent strata of fluid currents as described at pages 106 and 107.
The currents themselves continue after all the heavier particles
have reached the bottom of the cell, as shown by the experi-
ments described at pages 102 and 113.
To render the facts and explanation above referred to more
easy of application in the case of the two-cell apparatus, first let
it be supposed that the two cells are exactly of the same size, and
that their contents also are the same.
Then it will be obvious that, as the fluid in the strait is
attracted equally on both sides of its centre, the peripheral por-
tions of the fluid currents of both cells will extend equally into
the fluid of the strait ; and thus if the strait is short, the con-
vexities of these currents will at or about the middle of the strait
come nearly or completely into contact, but without blending.
If, on the contrary, the strait is so long that the portion of fluid
occupying the part about its centre is out of the sphere of
attraction of the fluid in the cells, then this fluid, by the mutual
attractions of its owa particles, Avill be brought into secondary
currents, producing appearances such as are described at page
106 (see also diagram 14, at page 102.) If, on the contrary.
Continued Currents in Fluids. 65
the cell on one side of the strait is much larger than that on the
other side, then a larger quantity of the fluid of the side commu-
nicating directly with the larger cell will come under the
influence of the attraction of the fluid in this cell, and the peri-
pheral currents of this fluid will extend further on this side into
the strait than on the other side. If the strait should be very
short, these currents will extend even beyond the strait into the
fluid of the small cell. Now in this case {vide vol. i, page 100,
diagram o) the upper currents will jaass from the strait into the
large cell, and the lower ones back again from the large cell
along the lower part of the strait into the small one. The posi-
tions and directions of these currents being constant, are called
normal in contra-distinction to those having a reverse movement,
which are called abnormal.
Such are the directions taken by the fluid currents under the
conditions above named ; and, so long as these conditions are
strictly maintained, these directions will remain unaltered.
But it has been demonstrated experimentally that, just as
these conditions have been made to vary, so also will the direc-
tions vary. It seems to me that a brief explanation of the
manner in which the variation in the directions of the currents
are produced by the changes made in the conditions under
which they occur, will render this part of the subject more clear,
hence it will be necessary to prolong my paper by giving them.
To understand in what way a reversal of currents is jiroduced
in the case where the density of the fluid in the small bulb was
greater than that in the large one, let it be supposed, first, that
the eflect of the increased attraction of the fluid in the small
cell occasioned by the addition made to its density is such as to
render its attractive power exactly equal to that exerted by the
fluid in the large bulb, then, as before shown, it will be obvious
that the fluid in the strait being equally attracted on each side,
the quantity of fluid in the strait which is brought mider the
influence of the attraction of the fluid in the bulbs will be equal
on both sides of its centre, and hence the convexities of the
peripheral currents extending from both bulbs into the strait
will come nearly into contact at the middle. Thus, if it were
examined by the microscope, the currents would be seen to be
normal at the end of the strait next to the large cell, and abnor-
mal at the other end, as in the case where the two bulbs were
VOL, II. 5
66 On the Existence of
supposed to be exactly of the same size and filled with the same
fluid.
Next let it be supposed that a further addition be made to
the quantity of matter in the small bulb^ or in other words, that
its density be increased whilst that of the fluid in the large bulb
remains the same ; then it is obvious that if the increase of
density has been suflicient, the upper currents commencing from
the large bulb will be continued all along the upper part of the
strait into the small bulb, and from thence back again along the
lower region of the strait into the large one, and the currents in
the strait will be altogether abnormal.
Nov/, applying this mode of explanation to the other cases
named in the experimental evidence as given above, it will be
obvious that the deductions are so simple and self-evident as
not to render a,ny further explanation necessary.
The experiments next detailed relative to the causes of
abnormality in the currents of the fluid in the strait of the tv\^o-
bulb apparatus are those occasioned by change of temperature of
the fluid in one bulb, whilst the temperature of the fluid in the
other bulb remains unaltered.
Now, as it has been demonstrated that reversals of the currents
in the fluid of the strait produced by a partial change of density
exactly agree with those produced by change of temperature ; as
it is obvious that change of temperature is attended with a
corresponding change of density; as, moreover, it has been
shown that the change of temperature which causes abnormality
of current motion increases the density of the fluid in the small
cell, whilst that temperature which lessens the density of the
fluid in this cell favours normal motion ; hence it appears that
these changes can be produced v/ithout altering the temperature,
but not without altering the density. From these considerations
it seems certain that temperature has only a secondary influence
in altering the dii-ections of the currents, and consequently
cannot be considered as the immediate cause.
If, however, this conclusion is not admitted, and caloric is
considered to be the sole agent in the production of these phe-
nomena, then the attraction of matter both as it acts at insensible
and sensible distances must have been in these cases either anni-
hilated or rendered inoperative.
Continued Currents in Fluids. 07
Resume.
From all that lias been stated in my former paper and
in this appendix the following conclusions seem to me to be
arrived at :
1st. That the particles of all fluids, irrespective of quantity or
form, are always in motion.
2nd. That this motion is produced by the combined ope-
ration of two forms of attraction, namely, that acting at apparent
contact, and that acting at all sensible distances.
3rd. That the movements of the particles in these instances,
though modified by temperature, are not caused by it.
4th. That the rate of movement of these particles, besides
being affected by certain physical properties of the fluid, such
as that of density, of tenacity, &c., is influenced also by the
form in w-hich they are aggregated ; as for instance, if the form
be that of a sphere, all the particles being directed towards one
centre, will move more rapidly than if the same particles are
extended over a large space, and consequently be directed to
several centres at the same time. Hence in the different appa-
ratus which have been employed in the experiments above
described, the movements of the fluid particles will be very
different, as well as in different parts of the same apparatus.
For instance, in the passage between the two cells, especially
if its length be considerable, the particles will move more slowly
than in other parts of it.
5th. That the hypothesis relative to the cause of the different
altitudes of the currents m a single cell, and in the strait of the
two-cell apparatus, is so confirmed by later experiments, re-
corded in this appendix, as to me seems suflicient to justify its
admission here as a fact.
Now, considering the extreme delicacy of the conditions by
which these currents are maintained in what has been termed
their normal state, shown in the experimental process; apparent
deviations from this rule, in applying it to natural physical pro-
cesses, may be expected, the precise conditions of M'hich can
neither be known with certainty, nor, if known, controlled.
It has been shown by the above experiments that these currents
are not confined to small portions of fluid between larger ones,
but that they exist also in isolated masses, irrespective of their
form or quantity.
ON
PAEACENTESIS THOEACIS.
A THESIS READ FOR THE DEGREE OF M.D. CANTAB.
By G. H. EVANS, M.D., M.E.C.P,
The operation of paracentesis thoracis appears to have met
with rather hard treatment. It has been known and its value
to some extent recognised from the earliest times of which we
have any medical records ; but the beneficial results obtained
from its performance have been limited by insufficient appre-
ciation of the good to be effected by it, and of the danger to be
apprehended from leaving it undone, and by too much import-
ance being attached to objections which I hope to show are to a
great extent unfounded.
The operation is mentioned by Hippocrates, who describes the
symptoms which in his opinion indicate the necessity for its per-
formance ; but owing to the imperfect means of diagnosis of
physical signs possessed in his time, the symptoms as described by
him point to affections of very different kinds, comprising hsemor-
rhagic and purulent effusions, and in particular hydropnemno-
thorax, the experiment of succussion being given as an absolute
criterion. The mode of operating in his time was in one of two
ways, either by opening into an intercostal space, or by per-
forating a rib ; the intercostal space might be oj)ened either by
cautery or bistoury. These ajjpear to have been the only
methods proposed for making openings into the chest for many
centuries. Opinions varied from time to time as to the danger
of admitting air during the operation, some holding that the
70 Paracentesis Tlioracis,
wound ought to be closed as soon as possible^ some that it ought
to be left open till the whole of the fluid had been evacuated ;
and tlie more that attention Avas directed to the question of
admission of air, the more was the manner of operating modi-
fied. The fluid was evacuated by aspiration and suction.^ In
the middle of the seventeenth century it was proposed by
Drouin to use a trocar instead of the time-honoured bistoury ;
this idea was again taken up by Lurde in 1765, but was not
well received , owing to fears entertained of wounding the lung
with the point of the instrument.^ In 1808, Audouard pro-
posed evacuating the fluid as far as possible at once, in oppo-
sition to the rule till then laid down, that it ought only to be
allov/ed to flow little by little, it being supposed that if it
escaped suddenly the result Avould be a vacuum in the chest,
causing the death of the patient. In 1843, Trousseau pub-
lished his first work on the subject, his attention having been
first drawn to the expediency of performing the ojjeration earl}^,
by his having met v/ith instances of sudden death in cases of
large efi"usion ; one in 1833 and tAvo in 1843 ; besides which he
had found recorded betAveen fifteen and tAventy sudden deaths
in like circumstances. He considered that the performance of
paracentesis Avas indicated rather by the quantity of fluid eff'iised
than by the amount of functional disturbance caused by the
eff'usion."' From that time forAvard he consistently recommended
and practised the operation Avith very good results.
In our own country, in 1834, Dr. Thomas DaAdcs in a lecture
on pleurisy,^' recommended the operation to be performed Avhen
bleeding, mercury, purgatiA'cs, and diuretics had failed to remove
the efliision. His plan Avas, first, to introduce an exploratory
needle, to ascertain the nature of the fluid ; if it Avere serum,
he Avould let out tAvo or three pints Avith a small hydrocele
trocar ; if it Avere pus, he Avould let out a less quantity Avith a
large trocar, and then draAv off some fluid daily for two or three
weeks through a gum elastic catheter, leaving a fistulous open-
ing for some time. He did not object to the admission of air,
and had never seen it set up inflammation. He mentions six-
teen cases of empyema (including under that name serous as
1 Trousseau, ' Clin. Med,' Translated by New Syd. Society, vol. iii, p, 20G.
2 Trousseau, op. cit., p. 207. ^ ' Med. Times,' 1856.
■» ' Med. Gazette,' 1831.
Paracentesis Thoracis. 71
mtII as purulent effusions), in which he had performed the
operation, in twelve of %yliich the patients recovered.
In 1835,^ Dr. Hamilton Roe, in a clinical lecture, recom-
mended the early performance of paracentesis, with a view of
avoiding adhesion of the lung to the spine. He stated that he
believed that the presence of air in the pleura did no harm
whatever.
The operation does not appear at this time to have been looked
on with very general favour, for in 1838 Dr. Marshall Hall,
speaking of pleuritic effusions, said," " if all other remedies shall
have failed it may be a question whether paracentesis should
be performed ;" and in 1841, a paper Avas published in the
' Dublin Medical Press' on chronic pleurisy with effusion,
partly written by Dr. Hope, and partly from notes dictated by
him just before his death, in which he argued from thirty-five
cases of his own, and twenty of Dr. Stokes's, which had been
cured by treatment, that all really curable cases are curable
without paracentesis. His cases were treated with mercury and
opium to salivation, blisters, diuretics, and if these means failed,
with hydragogue piu-gatives. In 1843, Dr. Henry Bennett
wrote as foUov/s •? '' In the very great majority of the in-
stances in which it (paracentesis) has been resorted to, it has
proved fatal ; or at least, the patients have died, either from the
disease itself or from the results of the operation. The suc-
cessful cases on record are few compared to the number of
those on whom the operation has been performed." He then
mentions a few isolated successful cases, and proceeds : " The
celebrated French siu'geon, Boyer, often performed the opera-
tion, but never saved a patient. Dupuytren only knew it to
succeed twice out of fifty operations which he performed or
saw performed. Sir Astley Cooper Avas only acquainted with
one successful case. M, Gendrin has himself performed em-
pyema on twenty- six patients, not one of whom has survived.
I have myself witnessed three unsuccessful cases." He argues
that after the removal of the fluid " the disease of the pleura
has not been cured, there is still inflammation, still effusion,
and, generally speaking, the effusion soon regains its former
volume, producing the same symptoms, to be relieved by the
same means. It is, therefore, evident that mere puncture of
1 'Lancet,' Nov., 1835. ^ Ibid., May, 1838. 3 Ibid., Dec, 1843.
72 Paracentesis Thoracis.
the thorax is only a palliative and not a curative remedy. In
all cases, hoAvever, it momentarily relieves a distressing and
dangerous symptom, and may, by allowing time for the economy
to recover itself, or for other remedies to be used, lead to a
definite cure."
However, in the same year, at the Westminster Medical
Society, Dr. F. Bird stated^ that he had operated twenty times,
on each of which occasion, air had been admitted, in many cases
to a large extent, but it generally got absorbed in a few hours,
and he had never seen even uneasiness caused by its admission^
And, in 1844, in ' Guy's Hospital Reports,^ and in 1846, in
the ' Medical Gazette,' Dr. H. M. Hughes and Mr. Cock pub-
lished thirty cases in which the operation had been performed,
and recommended its performance — (1) early in serous effusion
to prevent the continual compression, and the coating of
the lung with a layer of lymph, so as to interfere with its
future expansion ; (2) to afford temporary relief in cases com-
plicated with other diseases, where no permanent benefit could
be expected ; and (3) in empyema or chronic pleuritic effusion,
in order by the occasional abstraction of a small quantity of
fluid to assist the action of other remedies, and thus to facilitate
and expedite the cure. Mr. Cock used a small trocar and
canula (one twelfth inch diameter) ; he considered the admis-
sion of air into the pleura as highly injurious, and thought it
caused subsequent effusion to be purulent.
In April, 1844, Dr. Hamilton Roe, a former advocate of the
operation, read a paper on the subject before the Medico-
Chirurgical Society, in which he gave a table of thirty-nine
cases between 1812 and 1832, and of tAventy-four cases under
his OAvn knoAvledge from 1833 to 1844 inclusiA'e, and shoAved
from them that the operation is as free from danger as any
other Avhich is performed on the human body ; that most of the
evil consequences supposed to attend it are more ajiparent than
real ; that it is generally successful Avhen employed at an early
stage of the disease, and that the chief cause of its failure is its
being postponed until too late a period. In none of his cases
did the abstraction of several pints at a time cause even a
tendency to syncope. He did not recommend tapping until
after the inflammation had been subdued by other means. lie
1 ' Lancet/ April, 1843.
Paracentesis Thoracis. 73
thought the admission of air did not matter, " as the experi-
ments of Speiss have fully proved that air introduced into the
pleura is invariably removed in a few days/' He gave two
instances of the extent of mischief sometimes done to the lungs
of patients said to be cured of effusions into the chest by
absorption. He stated that if a large quantity of fluid remain
for more than a certain time in the pleura, the lung becomes
carnified and incapable of expanding; the pleura gets
thickened and sometimes cartilaginous, incapable of resuming
its healthy action, and must continue to secrete fluid.
In 1851, Dr. Budd^ gave a clinical lecture on pleurisy, and
the results of tapping, in which he stated that " practitioners
are generally very averse to tapping the chest, because the
operation has often excited fresh inflammation of the pleura,
leading to the formation of pus ; so that while it has had the
immediate effect of relieving the breath by giving issue to some
of the fluid, it has set up fresh constitutional disturbance, and
rendered the liquid within the chest purulent instead of serous."
He thought the admission of air likely to do harm, and there-
fore avoided it by only withdrawing apart of the fluid at a time.
In 1854, at a meeting of the London Medical Society,^ Dr. J.
Risdon Bennett read a paper, inculcating the importance in
cases of inflammatory hydrothorax of not hastily resorting to
the operation of paracentesis. He founded his objection to this
proceeding in the early stage of the disease, both on the non-
necessity of the measure on account of the amenability of the
disease to general treatment, and on the mischief which was
likely to arise from puncturing the cavity of the chest. He
instanced a case in which paracentesis was performed twice, the
fluid being serum the first time, but purulent on the second
occasion three weeks later.
In the ' Lancet,'' of November 17, 1855, Dr. Addison was
stated to be decidedly against the operation of paracentesis
thoracis ; he feared that the chief danger lay in the first opera-
tion : he believed that it was one of the worst and most
deceiving operations in general practice. A serous cavity, he
thought, was almost invariably changed into a cavity pouring
out purulent matter by the first operation ; and the thick,
leather-like false membranes lining the pleura soon made the
1 'Med. Times,' 1851. - 'Lancet,' 1854,
74 Paracentesis Thoracis.
operation one of very great difficulty and danger. " Even
ha?morrliage into tlie pleura from the operation, when not
suspected, may do serious and fatal mischief — the dangers of
the operation are to be considered of such a serious nature that
they are by all means to be avoided.''
In spite, however, or indeed, perhaps, partly in consequence
of this opposition, the champions of paracentesis were not long
in again putting in an appearance. In 1854, in a paper read
before the Huntcrian Society,^ Dr. H. M. Hughes urged
strongly the expediency of tapping as soon as it was evident
that remedies were not causing the absorption of the effused
fluid, and, if possible, before the effusion had been converted
from serum into pus ; he considered it desirable to prevent the
admission of air, and stated that in at least 100 cases, in which
he had been concerned, the operation had not, in any one case,
been followed by any mischance, or even by any inconvenience
of considerable duration.
In a paper read before the York Medical Society, in 1855,^
Dr. Tuke gave a collection of 246 cases (which are included in
my tables), and discussed the question as to how long a lung
may remain compressed by fluid, and yet subsequently be able to
expand ; coming to the conclusion that probably between the
second and third month such extreme changes take place in the
texture of the lung and pleura, that we cannot expect the rc-
cxpansion of the former if there have been any quantity of fluid
in the pleura for such a period. He did not go quite so far as
Dr. Hamilton Roe, in thinking that the fluid should not be left
unremoved beyond the third week. In one case the lung was
stated to have expanded after the pleura had contained a large
quantity of fluid for four months. He said that in none of the
cases collected by him did the operation cause flvtal results.
About this time the opinions of Dr. Bowditch, of Boston, on
this subject were making themselves known in this coiuitry.
He was quoted in the ' Dublin Medical Press,' of 1857, to this
effect : " The perfect simplicity of the operation to one satisfied
with the correctness of his diagnosis, allies it to venesection or
vaccination. First, it is, as a general rule, less painful than a
blister ; second (if I may judge from my cases), it never does
harm; third, when fluid is obtained, it always gives relief,
1 ' Association Journal,' 1855. - Ibid., 1855.
Paracentesis Thoracis. 75
either temporary or permanent ; fourth, very often it is the
chief, if not the sole means capable of relieving severe symptoms,
and even of saving life.
On the other side, in 1859, Dr. Gairdner ^ argued that the
operation was hardly ever necessary to save life in acute
pleurisy ; and suggested that the disastrous effects observed in
so many cases had resulted from the absurd and dangerous
attempt to empty the chest completely.
In 1860, speaking of the operation, M. Aran" said that the
only contra-indication was gangrene of the lung or pleura. He
urged its importance in cases of large, rapidly increasing, or
persistent effusions, especially in children, to avoid deformity,
and in old people on account of the want of energy in their
absorbing system. He stated that he had operated in 250
cases without any disaster.
In 1868, Professor Ziemssen^ advocated its performance in
cases of hydrothorax, not dependent on inflammatory processes.
In the same year. Dr. Bartels, of Kiel,* recommended para-
centesis in case of inflammatory exudation into the pleural sac,
on the grounds (1) that abundant exudation might cause sudden
death by the mere mechanical obstruction of the circulation or
respiration ; (2) that changes were liable to take place in the
compressed lung, preventing its re-expansion; and (3) that
there is a tendency to chronic inflammatory processes in the
compressed lung, and also in the lung of the other side.
In 1869, Dr. Dupre '' gave an account of seventy-six cases of
so-called sero-plastic and rheumatic exudation, in which he
performed paracentesis thoracis. These effusions, he says, com-
mence sometimes with rigors and thoracic pains; sometimes
they directly follow articular pains or sciatica; the effusion
takes place Avithout pain, distress, cough, dyspnoea, or fever.
Medical treatment is useless, and the trocar should be resorted
to as promptly as possible.
In 1870, Mr. Berkeley Hill read a paper before the Clinical
Society, on three cases in which paracentesis thoracis had been
performed. He argued (1) that the operation need hardly ever
cause much danger or suffering ; (2) that when the effusion is
1 'Edin. Med. Journ.,' 1859. ' 'Med. Times and Gaz,,' 1860.
3 Ibid., 1868. ■* Ibid.
■' ' Bull, de I'Acad, de Med.,' xxxiv, 205.
76 Paracentesis Thoracis.
cojiioiis, it is prudent to "withdraw it to relieve dyspnoea, and to
"vrard off sudden death ; (3) that it is best to tap when the
condition of the patient is stationary, and the py-rexia has
abated, to enable the lung to expand before it has lost the
power of doing so ; (4) that after tapping serous effusions, the
wound should be closed at once, and the admission of air
scrupulously avoided ; (5) that in cases of purulent effusion
the admission of air does not matter, and that it is as well to
secure free drainage for the pus, and occasionally wash out the
cavity with Avarni water. At the same meeting. Dr. Douglas
Powell advocated repeated tapping, and the injection of iodine
in chronic empyema ; he deprecated the admission of air in cases
of serous effusion, as tending to set up suppurative inflammation,
and as rendering expansion impossible during its presence.
In a paper on pleuritic effusion,^ Dr. Sutton makes some
remarks to the following effect : (1) that pleuritic effusion of
recent origin may disappear when treated by absolute rest,
without tapping ; (2) that tapping is urgently^ demanded when
the effusion consists of pus; (3) that the difficult and frequent
respiration by which the presence of pus is accompanied, and
not the quantity of the fluid, is the best guide for tapping;
(4) that there is strong evidence that the pleura may^ be tapped
and air admitted without any ill effects following.
Having brought the history of the operation as far as I have
been able to collect it down to the present time, I will now
give short notes of three cases which have lately come under
my observation. The first is that of a young Avoman, set. 23,
who Avas admitted into Victoria Park Hospital, under Dr. J.
Risdon Bennett, on December 23rd, 1870, with signs of large
pleuritic effusion occupying the whole of the right side of the
chest. The date of effusion was uncertain, but she had been
short of breath for two years, and on three occasions had
had attacks of pain in the side, with increase of the dys-
pnoea. The question of paracentesis was entertained, but as the
dyspnoea was not very urgent except on movement, it was de-
termined to wait for a few days to see Avhat perfect rest might
effect in causing the absorption of the fluid. She continued
in much the same condition, Avitli the exception of one or two
attacks of increased dyspnoea ajiparently due to some recent
' ' Brit. Med. Jouni.,' 1870.
Paracentesis Thoracis. 77
pleurisy on the left side, until the morning of January 4th,
1871, when without any warning she suddenly sat up in bed,
coughed once in a strange, loud, and violent manner, and fell
back immediately, pallid.,with extreme dyspnoea. When seen
a few minutes afterwards, the dyspnoea was not marked, the
surface of the skin was bluish white, and there was no appear-
ance of distress, she being evidently in her last gasp. A trocar
was introduced at once, and from one to two pints of fluid
were let out, but without relief, death taking place in a few
minutes after one or two feeble inspiratory gasps, during which
air Avas sucked in through the canula. After death the right
pleural sac was found to be completely full of serous fluid, the
lung being collapsed and pressed inwards and backwards against
the spine. The lung was shi'unken and very small, looking
blue and airless ; in it were three masses, one in the upper and
two in the lower lobe, the largest of about the size of a pigeon's
e^^, described as being circumscribed, abrujDtly defined, solid,
not granular, easily broken, not so dark as most pulmonary
apoplexy, but darker than red hepatization. The pulmonary
artery at the root of the lung was completely j)lugged ; it was
filled with a grayish-yellow clot, partially decolorised in the
centre, and of a pink colour on the outside, which was adherent
to the lining membrane of the inilmonary artery, and extended
from the main trunk into the minute branches of the artery.
The left lung and the other thoracic and abdominal viscera were
normal. The brain was not examined.
The second case is that of a young man, set. 18, who was ad-
mitted into Victoria Park Hospital, under ])r. "Ward, on January
17th, 1871, with symptoms of large pleuritic effusion on the
left side, his illness having apparently commenced with a dis-
tinct rigor and pain in the side on January 8th. He had con-
siderable dyspnoea, and the heart was displaced, its impulse
being visible under the right nipple. He was kept in bed, and
poultices were applied to the side. On the third day after ad-
mission the effusion had evidently increased, his face was livid,
the heart was farther displaced, and his urine was almost sup-
pressed ; on that evening he was tapped, and seventy-two ounces
of clear serum were withdrawn through a fine canula with
immediate relief. He slept well that night, and during the
twenty-four hours following the operation passed nearly two
78 Paracentesis Thoracis.
gallons of Avater. From that time he steadily progressed to
recovery, with the exception of a slight relapse, Avhen the effu-
sion returned, and his temperature rose two or three degrees for
a day or two. When he was discharged from hospital on
March 2Tth, tactile fremitus was present, and fairly healthy re-
spiration could he heard all over the affected side, though there
was still dulness on percussion, most marked at the base ; the
heart had returned to its normal position ; and he stated
that his breath was as good as it ever had been.
The third case is that of a boy, set. S, who was admitted
into Victoria Park Hospital under Dr. Peacock, on February
1st, 1871, with very large pleuritic effusion on the left side.
The effusion probably dated from at least five or six weeks back,
at which time it was observed that his heart Avas palpitating
violently on the right side, giving rise to suspicion of heart
disease. He was considerably emaciated, and had a bedsore
over the left trochanter. He was tapped at once, and fifty-tAvo
ounces of clear serum Avere AvithdraAvn through a fine canula,
Avith considerable relief, the heart AAdiich had been beating to
the right of the right nipple, returned someAvhat toAvards its
normal position. He did not progress A^ry favorably, and in a
fortnight it Avas evident that there Avas again a large quantity
of fluid in the chest, and he was tapped again ; this time about
thirty-six ounces of clear serum Avere removed. He noAv began
steadily to imprOA'e, both as regards the local disease and his
general condition. The side contracted, and the heart returned
tOAvards the middle line ; in a fcAv Aveeks he Avas apparently
Avell; but at the present time there is still some contraction
of the side, and the heart has not regained its normal position.
I think these three cases may be regarded as typical, each
having its oavu points of interest ; the first illustrates one of the
dangers to Avhich persons are exposed Avith a large quantity
of fluid in one side of the chest; the second shoAvs the good
results to be obtained from the early performance of paracen-
tesis ; and the third proves that great relief and fairly good
recovery may folloAV, even Avdien the operation has been too long
delayed. MoreoA'cr, it affords an argument against the theory
that the operation has a tendency to set up suppurative inflam-
mation of the pleura.
On making an analjsis of the appended tables of cases, it
Paracentesis Thoracis. 79
will be seen that out of 232 cases in Table I, 156 recovered,
more or less completely, 69 died, and of 7 the result is not
stated. Selecting from Table II those cases of which the result
is stated, 217 recovered and 84 died; or out ^of a total of 533
cases, 373 recovered, 153 died, and of 7 the result is doubtful.
This makes the rate of mortality 29 per cent. Of the deaths,
only 2 (Nos. 143 and 218) are attributed to the operation, while
from Table I, in 39 eases either death Avas caused by s:)me disease
not apparently due to the operation, or the operation was per-
formed merely as a last resource, giving temporary relief and
prolonging life. Taking those in M'hicli the effused fluid Avas
serum, there are in Table I, 101 cases, of which 54 recovered,
32 died, 5 Avere progressing favorably Avhen reported, 6 partially
recovered (i. e. with some contraction of the side) , in I case (of
old effusion. No. 158), absorption was going on very sloAvly ; in
2 the result was not stated, and in 1 it was doubtful. In Table
II there are 207 cases of serous effusion, of which 165 reco-
vered and 42 died. Thus, out of a total of 308 cases, 74 died,
making the rate of mortality 24 to 26 per cent. In 24
cases of serous effusion Avhere the operation was performed not
later than the end of the fourth Aveek, 21 recovered and 3
died ; in one of the three fatal cases there Avas disease of the
liver, and in the other tAvo the operation was performed
as a last resource, merely Avith the view of prolonging life.
In 17 cases Avliere the operation was performed after the first
month but not after the second, 13 recovered and 4 died ; one of
these latter died tAvo years afterwards from phthisis. In 10
cases Avhere it Avas after the second month and not after the
fourth, 5 recovered and 5 died. In 8 cases AA^here the effusion
Avas of more than four months' standing, 3 recovered and 5 died.
I will noAv endeavour to prove with the assistance of the facts
and the figures that I haA-e brought forward, the expediency of
removing the fluid from the chest as early as possible in cases
of pleuritic effusion.
Firstly, pleuritic effusion may of itself cause fatal results,
which would be prevented by the early remoA^al of the effused
fluid. This is proved by numerous recorded cases, of Avhich I
Avill mention some. Trousseau, in 1841, knew of from fifteen
to twenty recorded instances of sudden, unexplained death in
cases of large pleuritic effusion. In his own practice, in 1832,
80 Paracentesis Thoracis.
one occurred on the sixth clay of the iUness.^ In 1843, a case of
death on the twelfth day, and a month later a case on the twentieth
day.- In 1847/a man died from pleuritic effusion of six weeks'
standing.^ In Paris, in 1864, M. Archambault related a case
of sudden death in acute pleurisy with effusion, in which there
AA^ere no very urgent symptoms, where after death the right
lung was found compressed against the spine by from three to
four pints of fluid, the left lung and all the other organs being
normal.'* In 1862, M. Blachez related a case^ in which a patient
with chronic pleuritic effusion died suddenly ; and stated that M.
Chomel had met with several cases, M. Cruveilhier two, M.
Oulmont two, M. Thibierge one, and M. Aran one. One I have
seen myself, being the case related above. This may, I think,
be considered as quite sufficient evidence that pleuritic effusion
may directly or indirectly cause sudden death. As regards the
mode of the sudden death in these cases, several theories have
been started, but the matter seems still to be involved in con-
siderable uncertainty. At all events, there can be no doubt on
the principal point, which is, that in whatever Avay these deaths
take place, the effusion in the chest is the cause of them.
Secondly. It has been often alleged, and I think with reason,
that the continued compression of a lung by pleuritic effusion
is likely to predispose to disease, tubercular or otherwise, of the
lung on the other side. I think it is pretty obvious that an
overworked lung, like an overworked man, is j)laced in an
unfavorable condition for resisting any noxious influences to
Avhich it may be exposed. Should there be any hereditary or
other constitutional tendency to disease, such as the so-called
tubercular diathesis, I hold that it is more likely to be developed
in a lung which has extra work to do in consequence of its felloAV
being incapacitated. Moreover, should a portion of the breath-
ing apparatus be rendered useless as a consequence of being
compressed by fluid, in the case of disease attacking any other
portion, there will be less spare lung, so to speak, to carry on
the Avork of respiration, and the patient Avill be exposed to all
the more danger.
Thirdly. The necessarily slow process of the absorption of tlic
' 'Clin. Med.,' translated by New Syd. Soc, iii, 198.
^ Op. cit., pp. 199 and 201. '' Op. cit., p. 218.
^ ' Med. Times and Gaz.,' 1864. * < ])„i,_ n^^^ Press/ 1862,
Paracentesis Thoracis. 81
effusion gives time for various changes to take place within the
chest, hindering or preventing the re-expansion of the whole or
part of the lung; in all probability there would not be time for
these changes to take place if the fluid were let out early. The
mischief done by these various changes is sufficiently shown by
the numerous cases in which *' recovery," so-called, from
pleuritic eifusion, has been accompanied with contraction of
the affected side from non-expansion of the lower lobe of the
lung; and by the fact that in nearly all the cases in which
after death fluid, or the evidence of former effusion, is found
in the pleura, part or the whole of the Jung on the affected side
is found collapsed, shrunken, and airless, and often bound down to
the spine by firm adhesions. I can instance forty-two cases which
I have collected from hospital post-mortem records, eleven in Dr.
Boyd's vital statistics from the Marylebone Infirmary for the
years 1840, 1841, and 1842,^ and fifteen from my table of cases.
A reference to the analysis of cases will show that the results
of the operation were favorable in direct proportion to the
shortness of the time during which the fluid had been suffered to
remain in the pleura. Here I think we have strong evidence
from facts in favour of the proposition that if you tap at all, the
earlier you tap the better the results will be.
Among the changes that occur to prevent the re-expansion of
the lungs are, the formation of firm adhesions between the
pulmonary and costal layers of pleura, and the thickening of
the pulmonary pleura by the deposition on it of lymph, some-
times forming a layer more than half an inch thick ; but
besides and independent of these changes going on outside the
lung, there must be some change frequently taking place with-
in the lung, preventing its expansion, as these collapsed and
shrunken lungs are frequently met with where there is no
mechanically-acting external cause operating against them ; and
I believe that the intrinsic change in the lung, by virtue of
which it is so often met with in a " carnified ^' condition, is due
in many, if not in all cases to stagnation and coagulation of the
blood in the pulmonary artery, .a tendency to which I believe
to exist in cases of compression of lung by pleuritic effusion.
It will be remembered that in the post-mortem examination of
the body of the young woman whose case I have related above,
I ' Edinburgh Med. aud Surg. Journ.,' 1843.
VOL. II. 6
82 Paracentesis I'horacis.
a clot, apparently several days old, was found occupying the
pulmonary artery of the affected lung. In 1862, M. Blachcz ^
gave a long and interesting account of a case in which sudden
death took place during chronic, not very marked, pleuritic
effusion, where, after death, a clot was found coiled up in the
right ventricle of the heart, which aj^peared as if it had been
formed in the pulmonary artery of the lung on the affected side,
which, in fact, it partially occupied when examined. He
suggested the possibility of the obliteration of the pulmonary
artery by coagulation being the cause of the sudden death. He
further said, " We must remark that the examination of the
pulmonary artery has been generally omitted." In this last
observation I am inclined to agree with him ; as the only other
notice of this condition that I can find is in some remarks
of M. Marrotte, quoted in the ' British Medical Journal ' for
ISCi, who says, '' In other cases death has really resulted from
the presence of coagula in the heart or pulmonary artery ; the
presence of these clots cannot be ascribed to the amount of the
effusion, for they have been met with when there has been
but little." In M. Marrotte's oj^inion, abundant effusion
predisposes to the formation of clots only through the
impediment offered to respiration and circulation. '^Slow
asphyxia," he says, " much more insidious than rapid asphyxia,
produces in the blood a relatively increased proportion of
fibrine, which recent observations have shown to be favorable
to the formation of clots." Now, 1 contend that the tendency
to coagulation is produced in the following way : Ave have in
pleuritic effusion, steadily increasing pressure on the surface of
the lung, tending to diminish its capacity ; in all probability
the first effect of this is to squeeze together the w^alls of the air-
vesicles, and prevent the admission of air into them ; for a time
the small branches and capillaries of the pulmonary artery will
probably not be mechanically occluded, but the blood circu-
lating through them will be insufficiently aerated, owing to the
diminished air-receiving capacity of the lungs, and its circulation
will be retarded and eventually stopped, as it appears to be the
case that blood charged with carbonic acid cannot pass freely
through the pulmonary capillaries.^
Although I cannot quite see my way to agreeing with MM.
' ' Dub. Med. Press,' 18G2. - ' Carpenter's Physiology,' 6tli cd., p. 255.
Paracentesis Thoracis. 83
Blachez and Marrotte, as to this condition (obliteration of the
l^uhnonary artery) being the cause of sudden death in pleuritic
effusion, yet I cannot but think that coagula thus formed in the
pulmonary artery^ or in some branch or branches of it, are much
more frequently than is supposed the cause of the imperfect
recoveries which are the rule rather than the exception in cases
of eifusion of long standing. In the fifteen fatal cases in
Table 1, previously referred to, it is mentioned that the whole
or part of a lung was compressed or collapsed ; in none is there
any mention made of the condition of tlie pidmonary artery.
Out of the forty-two cases that I have collected from the post-
mortem records of two hospitals, in which fluid was found in
the pleura, and one or both lungs partially or entirely collapsed,
in five more or less extensive patches of pulmonary apoplexy
were observed ; and in two of these latter, and in one of the
cases of collapsed lower lobe, clots were found in the branches
of the pulmonary artery leading to the affected portions ; in the
other cases the condition of the pulmonary artery was not
mentioned. In the case of which I have given the notes
above, I think that probably the three masses of pulmonary
apoplexy might date from three attacks of aggravated dyspnoea
mentioned in the history of the case, on each of which occasions
a branch of the pulmonary artery was suddenly occluded by
clot. Now, if my inferences be correct, surely we have here a
very strong argument in favour of the early removal of pleuritic
effusions, whatever be the nature of the effused fluid, an
argument which appears to have been entirely overlooked by
the opponents of paracentesis thoracis, and of which little or no
advantage has liitherto been taken by its advocates.
Having, I think, satisfactorily proved that it is urgently
necessary to get rid of the fluid fi'om the chest as soon as
possible, the next question is. Is paracentesis the best method
of doing this ? I hold that it is. Various objections have been
urged against it. Some have appeared to object simply on the
general ground of preferring medical treatment to operative
interference ; but most have founded their opposition on the
fear of (a) the danger of death from syncope during or imme-
diately after the operation ; {b) the operation itself setting up
suppurative inflammation ; (c) the probability of the admission
of air, and consequent suppurative inflammation -, {d) the possi-
84 Paracentesis Thoracis.
bility of haemorrhage from the operation. I shall endeavour to
show that these objections are, to a great extent, unfounded.
First. As regards the possibility of fatal consequences of the
operation (for instance,, sudden death from syncope, &c.). Let
us see what our cases say upon this point : out of a total number
of 820 cases, in only two is it recorded that death was in any
way the result of the operation ; in one of these (No. 143)
death was caused by hsemorrhage from wounding small arteries
by the puncture; in the other (No. 218), death took place the
next day, and Avas attributed to the shock of the operation. In
none is there any mention made of the fatal syncope which has
been supposed to be likely to ensue from the sudden emptying
of the chest previously full of fluid. I do not think that, judg-
ing from these facts, any one can bring forward its immediate
effects as any argument against the operation. Certainly,
" disastrous results " and " serious consequences "" have been
alluded to by some of the opponents of the operation, but I have
flxiled to find much evidence of them during a long and careful
search through the recorded cases. The only statement that I
can find bearing on this part of the subject is the gloomy list
of bad results given by Dr. Henry Bennett, Avho had also seen
three unsuccessful cases himself. I prefer drawing my in-
ferences from the numerous recorded cases Avhich I have quite
impartially collected from various sources extending over many
years. Undoubtedly, the proportion of perfect recoveries is but
small, but this is not surprising when Ave reflect that in a very
large majority of the cases, especially among the earlier ones,
the operation was only performed either Avhen the remedies of
the pharmacopoeia had been exhausted in A'ain attempts to pro-
mote absorption, the patient's strength being considerably
reduced by bleeding, blistering, and salivation, or, as a last
resource, Avhen it Avas too late or the case was too complicated
to alloAV of even a hope of a good recovery.
But it has been urged that the operation itself is likely
to cause fresh inflammation of the pleura and the formation of pus,
especially if air be admitted. Noav, Dr. Davies, Avitli consider-
able experience of the operation, has never seen the admission
of air set up inflammation. Dr. Hamilton Roc believed that
the presence of air in the pleura did no harm Avliatever. Dr.
F. Bird stated that on the tAventy occasions on Avliich he had
Paracentesis Thoracis. 85
operated, air had been admitted, in many cases to a large
extent, and that he had never seen even uneasiness caused by
its admission. Surely this bears out Dr. Sutton's conclusion
that there is strong evidence that the pleura may be tapped and
air admitted without any ill effects following. Still, I do not
mind conceding this point : granted that the admission of air
be injurious in cases of serous effusion ; yet this is no reason
why the operation should not be performed, since, by the use
of the most simple precautions, air can be effectually ex-
cluded.
In twenty-eight cases in Table I the operation was performed
more than once in cases of serous effusion ; in twenty-four of
these the fluid drawn off Avas serum each time, in the remaining
four cases it was purulent on one or more of the subsequent
tappings. These facts undoubtedly prove that the operation
itself does not necessarily induce suppurative inflammation in
the j^leura ; and the comparatively small number of cases
in which it is required to be repeated is a strong argument
against the probability of the operation inducing a tendency to
recurrence of the effusion.
The probability of haemorrhage from the operation, alluded
to by Dr. Addison, is best combated by a reference to the case
mentioned above, as being the only one in 820 in which it
occurred, and then it was said to be due to an abnormal
arrangement of small anastomosing vessels.
Having thus, I hope successfully, answered the objections
which I have been able to find alleged against the operation, I
will now say a few words in its favour. It is undovibtedly the
shortest and simplest method of getting rid of the fluid, and I
think I have proved that it is almost absolutely harmless. It
at once relieves the patient from distress and dyspnoea ; it frees
him from the imminent danger of sudden death, a danger all
the greater in that we do not know for certain in what way that
death is likely to take place — we only knoAv that it does not
iinfrequently happen ; and it places him at once in a more
favorable condition for the absorption of the remaining fluid,
or of any subsequent accumulation. I quite agree with Dr.
Sutton's conclusion that pleuritic eff'usion of recent origin may
disappear when treated by absolute rest, without tapping ; but
how are we to ascertain the time during which a lung may
86 Paracentesis Thoracis.
remain compressed by fluid without its future expansion being
prevented by the formation of coagula in the puhnonary artery,
or of adhesions preventing its movement ? Is it not better to
tap at once and evacuate the fluid as soon as it is present in
sufficient quantity to make one of these consequences possible,
namely, as soon as we find that the lung or its lower lobe is
compressed and receiving little or no air ? As to the energetic
treatment which has been until quite lately so much in vogue
in cases of pleuritic effusion, no doubt the engorgement of the
venous system may be temporarily relieved by bleeding; but
this engorgement is the consequence, not the cause, of the
effusion, and Avill be liable to recur as long as the effusion
■which has caused it continues to exist. After a course of
mercury, pushed to salivation^ many pleuritic effusions have un-
doubtedly been absoi'bed, it may have been in consequence of the
mercurial treatment; but even this much-valued remedy has
never been credited Avith the power of at once removing the
fluid ; and I think there can hardly be a question as to which
plan is the safer and the more comfortable for the patient,
— to undergo a course of mercury, bleeding, and blistering
for some weeks, with all the disagreeables of salivation, the
constant danger of sudden death, and the improbability of per-
fect recovery ; or to be at once relieved, and, in all probability,
rapidly cured, by the simple process of puncturing the chest and
letting out the fluid. As to the effect of diuretics in causing
the absorption of serous effusions, I cannot sec that they are
indicated in these cases, even where a very small quantity of
urine is being passed ; the deficient secretion from the kidneys
is not necessarily due to any fault in those organs, but more
probably to the fact that very little blood gets to them, oAving
to the small proportion of blood in the arterial system, the
aerating surface of the lungs being diminished directly by com-
pression of one lung, and indirectly by engorgement, and possibly
oedema, of the other lung ; as was seen in the case of the young
man of Avhich I have given the notes above, Avhere the urine,
which had been almost suppressed before the operation, floAved
in very large quantity directly the pressure on the lungs Avas
removed. The best diuretic in these cases seems to be para-
centesis thoracis.
Assuming, as I think I may assume, that the operation is
Paracentesis Thoracis. 87
free from danger in itself, and, if properly performed, is very
unlikely to lead to bad results, Ave get rid of the only objections
to its performance in numerous cases where we can only hope
to palliate and not to cure ; where there is hydrothorax depend-
ing on and secondary to some other disease ; where the primary
disease is sure to prove fatal, sooner or later, but where a good
deal of the distress of the patient is due to the accumulation of
fluid in the pleura : in these cases the fluid is almost sure
to reaccumulate ; but you can give great relief for the time,
and the operation being, as I hold, quite free from danger, can
be repeated as often as is necessary. In these cases it generally
prolongs life, and, at all events, it diminishes the discomfort of
the patient during the last weeks or months of his existence.
It is by cases such as these that the percentage of deaths after
the operation is largely increased, while, in reality, they testify
strongly in favour of its usefulness.
The essentially inflammatory conditions, characterised by a
good deal of constitutional disturbance, do not seem often to
lead to much efl"usion, and what there is is rapidly formed and
often as rapidly absorbed, when the patient is placed under
favorable conditions ; when they are accompanied by large effu-
sion, or the fluid does not become rapidly absorbed, I should
consider paracentesis indicated.
But it appears to me that the operation is of greatest value
in those pleurisies which have been called latent or insidious,
which are probably identical with Dupre's sero-plastic and
rheumatic exudations, where without very marked constitutional
disturbance, so that it is not always easy to fix the exact date
of the commencement of the illness, a large serous efl'usion is
poured out, eiddenced not so much by marked dyspnoea or
distress (though beyond a certain point these symptoms become
very apparent) as by the physical signs. These are the cases
in which I believe the largest proportion of sudden deaths to
take place ; and it is in these cases above all that I think (with
Dupre) that medicinal treatment is useless, that the trocar is
the one remedy, and that it should be applied at once.
Before concluding, it may, perhaps, be as well to say a few
words on the subject of the diagnosis of the presence of fluid
in the chest, as mistakes are occasionally made and have been
known to lead to fatal consequences.
88 Paracentesis Thoracis.
If one side of the chest be full or nearly full of fluids there
will be the following physical signs :
1. Increased size of the affected side determined by measure-
ment, with effacement of the intercostal spaces.
2. Diminished respiratory movement of the affected side.
3. If the left side be affected, the heart's impulse (if visible)
will probably be seen to the right of its normal position ; if the
right side be affected, and the effusion be in large quantity, the
hearths impulse may be seen to the left of its normal position ;
and the liver will be pushed down below the ribs, so that gene-
rally the fingers can be passed over its convex surface.
4. Tactile fremitus will be absent or diminished on the affected
side, especially at the base of the lung.
5. If the effusion be in large quantity, fluctuation may be
felt in some of the intercostal spaces.
6. There will be dulness on percussion of the affected side,
probably absolute at the base, the extent of dulness being
in proportion to the amount of effusion, and being less marked
at the apex than at the base of the lung. In cases of largo
effusion the dulness may extend beyond the middle line, or even
beyond the further edge of the sternum.
7. Respiratory murmur will be absent at the base, and more
or less deficient over the whole of the affected side ; probably
some tubular breathing may be heard towards the sternal end
of the subclavicular region, in the supra-spinous fossa, and near
the spine at its upper and middle part.
8. Vocal resonance will be absent or very deficient over the
greater part of the affected side ; there may be bronchophony
at the parts where tubular breathing is heard, and possibly
scgophony near the spine.
9. On the unaffected side the heart may be found in an
abnormal situation, and respiratory sounds will be probably
exaggerated.
The above signs in the aggregate arc, I think, conclusive of
the presence of fluid in the pleura. An extensive malignant
growth involving the lung and pleura might simulate many of
them, but the history of the case and the aspect of the patient
would probably settle tliat question. Tlie presence of fluctua-
tion in an intercostal space I believe to be very rare in serous
effusions, but when present it would be almost conclusive.
Paracentesis Thoracis. 89
As to the operation itself, various methods have been pro-
posed, and various instruments more or less elaborate have been
invented, most of them having for their object the exclusion of
air from the pleura, and some being arranged so as to pump the
fluid out, all coming generally under two heads, either consist-
ing of a syringe or a long flexible tube conducted under water,
attached to a canula. I am speaking now rather of serous
effusions, as where there is pus in the pleura I think the ad-
mission of air does not matter, and that a drainage tube passing
through two openings and giving free egress to the pus as
long as it continues to be formed is, perhaps, the best arrange-
ment. In the case of serous effusions, though it is probable
that the admission of a small quantity of air does no harm, it
is best to avoid it, especially as this can be done by the use of
a very simple apparatus. The plan to which I refer is one in-
vented, I believe, by Reybarb and adopted by Trousseau; it
consists in tying a flap of moistened gold-beater's skin round
the mouth of the canula, so as to form a valve or curtain which
admits of the fluid passing freely out, but prevents air from
making its way in. I should make a puncture (a preliminary in-
cision I believe to be unnecessary) in the fifth or sixth interspace
in the axillary line, and when the fluid ceases to flow during
inspiration, remove the canula and close the wound. An ordi-
nary hydrocele trocar is generally the best instrument; the
canula is large enough to alloAV the passage of serum, and the
w'ound is small and quickly heals.
In conclusion, I hope that the facts I have mentioned and
the arguments I have brought forward tend to this conclusion,
that when Ave have ascertained the j)resence of fluid in the
pleura, it is our duty to get rid of it as soon as possible, in order
to avoid the various bad consequences which may result from
its remaining there, and the simplest, the safest, the shortest, and
the best method for getting rid of the fluid is paracentesis thoracis.
Table I.
' Medico- Chirurgical Transactions^ 1844. Cases collected by
Dr. Hamilton Roe.
1. New Med. and Physi.Journ., 1812. Dr. Fretan. iEl. 9. lop. Contents,
pus. Duration, 3 weeks. Recovery.
90 Paracentesis Thoracis.
2. New Med. and Phys.Journ., 1812. Dr. Frefan. iEt. 28. lop. Contents,
hydatids. Recovery.
3. New Med. and Phys. Jonrn., 1S14. M. Toiirtuel. J£{. 22. 1 op. Con-
tents, pus, 14 plates. Duration, 16 days. Recovery.
4. New Med. and Pb3s. Journ., 1814. Mr. Robertson. 1 op. Contents, pus,
4 to 6 oz. daily. Duration, 9 weeks. Recovery.
5. Lond. Med. and Phys. Journ., 1815. Mr. James. Mt.i'i. lop. Con-
tents, serum, 1 pint. Duration, 3 months. Recover}-.
6. Lond. Med. and Phys. Journ., 1819. Dr. Archer, ^t. 41. lop. Con-
tents, serum, 11 pints. Duration, 3 years. Recovery.
7. Edin. Med. Journ., 1820. Mr. Anderson. JEi. 32. 3 op. Contents,
sero-purulent, 4 pints; ditto, 8 pints; ditto, o pints. Duration, 16
weeks. Death.
8. Med. and Phys. Journ., 1820. Dr. Hastings, ^t. 45. lop. Contents,
pus, 2 pint. Recovery.
9. Med. Repository, 1820. Dr. Novarra. J&\. .33. 1 op. Contents, pus, 12
pints. Duration, 4 months. Recovery.
10. Med. Repository, 1823. M. Auguet. ^Et. 30. 2 op. Contents, serum,
9 pints; 58 pints in 9 weeks. Duration, 5 weeks. Recovery.
11. Med. Repository, 1823. Mr. Betty. MX. 25. 2 op. Contents, pus, 5
pints ; ditto, 1 pint. Recovery.
12. Med.-Chir. Rev., 1823. M. Dupuylren. .Et. .33. lop. Contents, serum,
3 pints. Duration, 9 months. Death.
13. Med.-Chir. Rev., 1825. M. Moran. ^Et. 22. 2 op. Contents, 5 pints;
1 pint. Recovery.
14. Med.-Chir. Rev., 1825. Dr.Jackson. lop. Contents, serum, 4 pints. Deatli.
15. Med.-Chir. Rev., 1825. M. Martinet. Several operations. Jxecovery.
10. Journ. of Med. Science, 1820, Mr. Donaldson. 2 op. Contents, pus, 8
soup-plates; ditto, 5 soup-plates. Duration, 6 weeks. Recovery.
17. Med.-Chir. Rev., 1826. Dr. Hastings. /Et. 23. 1 op. Contents, pus, 7
pints. Death.
18. Med.-Chir. Rev., 1826. Dr. Hastings, ^t. 17. 1 op. Contents, sero-
purulent, 2 quarts. Duration, 16 weeks. Death.
19. Med.-Chir. Rev., 1826. Dr. Hasting.--. /Et. 25. 1 op. Contents, sero-
purulent, 1^ pint. Duration, 5 weeks. Recovery.
20. Med.-Chir. Rev., 1826. Dr. Hastings. 1 op. Contents, sero-purulent, 4
pints. Recovery.
21. Home's Archives, 1826. 2 op. Recovery. An interval of 22 years be-
tween the two operations.
22. IMed.-Chir. Rev., 1826. Mr. Stevenson. Contents, 6^ pints. Recovery.
23. Med.-Chir. Rev., 1826. Mr. Jowett. .Et. 9^. 1 op. Contents, pus, 3
pints. Duration, 4 weeks. Recovery.
24. Med.-Chir. Rev., 1827. Dr. Pitcairn. ^t. ll.}. 4 op. Contents, pus, 3
pints; ditto, 18 oz. ; ditto, 3^ pints; ditto, 3.^ pints. Duration, 6 months.
Recovery; chest contracted.
25. Med.-Chir. Rev., 1827. 1 op. Contents, pus, 200 oz. in 16 days. Dura-
tion, long time. Death.
20. Med.-Chir. Rev., 1827. Mr. Huggins. ^t. 27. 1 op. Contents, sero-
purulent. 7 pints. Duration, 3| months. Recover}-.
Pai'acentesis Thoracis. 91
27. Med.-Chir. Rev., 1828. Baron Larrey. ML 29. ] oi). Contents, sero-
sanguinolent, 15 pints. Duration, 3 months. Death.
28. Med.-Chir. Rev., 1828. Dr. Guerard. 1 op. Contents, large quantit}-.
Duration, some days. Recovery.
29. Lancet, 1828. ]\I. Roux. /Et. 28. 1 op. Contents, pus, 12 oz. Dura-
tion, 23 days. Death.
30. Gias. Med. Journ., 1S29. Mr. Cowan. ^Et. 43. lop. Contents, pus, 7
lbs. Duration, 9 months. Death. Post-mortem, lung reduced to the
size of two fists.
31. Med.-Chir. Rev., 1829. yEt. 23. lop. Contents, hydatids. Duration, 8
months. Recovery.
32. Med.-Chir. Rev., 1829. Dr. Hewett. lop. Contents, pus, 4 oz. Dura-
tion, 4 weeks. Death.
33. North Amer. Med. and Surg. Journ., 1829. Dr. Merewether. ^Et. 22,
1 op. Contents, pus, 2 galls. Recovery.
34. North Amer. Med. and Surg. Journ., 1830. Dr. Jaclison. ^t. 62. lop.
Contents, pus and bloody serum, 3^ pints. Duration, 28 days. Recovery.
35. Glas. Med. Journ., 1830. Dr. Auciiinloss. ^t. 18. 1 op. Contents,
pus, 6 pints. Duration, 3 months. Death. Post-mortem, lung com-
pressed.
36. Lon. Med. and Phys. Journ., 1831. Mr. Mayo. MX. 15. 1 op. Contents,
pus, 18 oz. Duralion, 3 weeks. Recovery.
37. Edin. Med. Journ., 1831. iEt.23. 1 op. Contents, pus, 1 pint, and 2 oz.
dailj'. Duration, 7 years. Recovery.
38. Edin. Med. Journ., 1631. Mr. Cleland. Mtl. lop. Contents, pus, 8
oz. Duration, 7 weeks. Recovery, with contraction.
39. Med. Gazette, 1832. -lEt, 22. lop. Contents, pus, 8 pints. Duration,
4 months. Recovery.
' Medico- Chinirgical Transactions j' 1844. Cases observed by
Dr. Hamilton Itoe from 1833 to 1844 inclusive.
40. Mi. 5^. 2 op. Contents, pus, 43 oz.; ditto, 38 oz. Duration, 98 days.
Recovery.
41. iEt. 20. lop. Contents, serum, 6 pints. Duration, 42 days. Recovery,
Died next year in St. George's Hospital, having been tapped on the other
side.
42. ML 50. 1 op. Contents, serum, 60 oz. Duration, 70 days. Relief,
Death. He worked for 5 months after the operation, and died of general
dropsy. He was phthisical when admitted.
43. Mi. 48. 1 op. Contents, pus, 28 oz. Duration, 455 days. Death from
phthisis.
44. Mi. 10. 1 op. Contents, pus, 8 oz. Duration, 32 days. Recovery.
45. ^t. 19. 1 op. Contents, pus, 4 pints. Duration, long time. Recovery,
w'ith contraction.
46. Mi. 1\. 1 op. Contents, pus, 5 oz. Duration, doubtful. Recovery,
with contraction.
92 Paracentesis Thoracis,
47. ^t. 2(3. 1 op. Contents, pus, 50 oz. Duration, 87 days. Recovery.
He died long after the operation.
48. Mi. 28. 1 op. Contents, pus, 10 oz. Duration, 2.3 days. Recovery.
49. M\.. 9. 1 op. Contents, pus, 8 oz. Duration, doubtful. Recovery, with
very slight contraction.
50. IE\. 62. 3 op. Contents, serum, 64 oz. ; uncertain; uncertain. Dura-
tion, doubtful. Relief. Death. The operation was performed to give
relief, but without a hope of saving him.
51. .^t. 53. 3 op. Contents, serum, 62 oz. ; ditto, 56 oz.; ditto, 41 oz.
Duration, doubtful. Death. A hopeless case from the first.
52. Mi. 43. 2 op. Contents, serum, 120 oz. ; ditto, 73 oz. Duration,
doubtful. Death.
53. Mi.^\. lop. Contents, sero-purulent, 4 oz. Duration, doubtful. Re-
covery, with contraction.
54. jEt. 28. lop. Contents, serum, 5^ pints. Duration, 212 days. Death.
55. Mi. 55. 1 op. Contents, serum, 105 oz. Duration, 106 days. Recovery.
56. ^t. 38. 1 op. Contents, serum, 4 pints. Duration, 38 days. Recovery.
57. Mi. 40. 1 op. Contents, serum, 4§ pints. Duration, 42 days. Recovery.
58. jEt. 21. 2 op. Contents, serum, 6 oz. ; ditto, 8 oz. Duration, 18 da3s.
Recovery.
59. ./Et. 28. Sop. Contents, serum, 30 oz. ; ditto, 25 oz. Duration, 42 da5s.
Recovery.
60. ^t. 34. 1 op. Contents, serum, 3^ pints. Duration, 21 da3s. Recovery.
61. Mi. 58. 1 op. Contents, pus, 90 oz. Duration, 21 days. Recovery.
62. ^t. 17. 3 op. Contents, serum, 3 pints; ditto, 3 pints; ditto, 5 pints.
Duration, 42 days. Recovery.
63. Mi, 38, 2 op. Contents, sero-purulent, 56 oz.; ditto, 8 oz. Duration,
49 days. Death. Pneumothorax. He was phthisical on admission.
64. Lancet, Sept., 1835, and Aug., 1837. Mr. Worthington. ^Et. 40. 3 op.
Contents, sero-purulent, 4 pints ; ditto, 9i pints ; serum, 7 pints. Dura-
tion, 9 months. Relief. Fairly good health,
G5. Lancet, 1836. Mr. Macnee. Mi. 16. 1 op. Contents, pus, 4 quarts
(and ait). Duration, 12 months. Great relief. Death. This was a
case of pyopneumothorax ; he died one month after operation. Post-
mortem, lung bound down by adhesions ; cavities in the other lung.
66. Lancet, 1837. Mr. Hale Thomson. Mi. 40. 3 op. Contents, serum,
2 pints; ditto, 46 oz.; ditto, 36 oz. Duration, 6 weeks. Relief. Re-
covery, with contraction.
67. Lancet, 1841. Dr. Bell Fletcher. ^Et. 20. lop. Contents, serum, 2
quarts. Duration, 6 weeks. Relief. Perfect recovery.
68. Edin. Med. and Surg. Journ., 1843. 2 op. Contents, serum. Relief. Death,
Post-mortem, pus in pleural sac ; lung collapsed, quarter inch thick,
bound down to spine, airless.
69. Prov. Med. and Surg. Journ., 1842. Dr. Cargill. Mi. '2i. lop. Con-
tents, serum, 1^ pint. Duration, 6 weeks. Relief. Death 8 days
after operation. Post-mortem, 6 quarts of serum in right pleural sac ;
)ung compressed, not diseased.
Paracentesis Thoracis. 93
'Guy's Hosj). Reports," 1844, and ' 3fed, Gaz.; 1846. Cases
rejjorted by Dr. Hughes and Mr. Cock.
70. /Et. 22. 4 op. Contents, serum, 50 oz. ; ditto, 30 oz. ; ditto, 40 oz. ; ditto,
to oz. Great relief. Partial recovery. Tbis case was complicated by
enlarged liver and ascites.
71. M\. 27. 2 op. Contents, serum, 6 oz. ; ditto, 13 oz. Great relief.
Recovery.
72. Mi. .58. 1 op. Contents, pus (none came out). No immediate effect.
Deatb. Fractured ribs and pulmonic abscess.
73. Mi. 9. 1 op. Contents, serum, small quantity. No immediate eflect.
Recovery.
74. iEt. 23. 2 op. Contents, serum, 7 oz. ; ditto, 15 oz. Relief. Partial
recovery. Tbis patient was suffering I'rom ascites, diarrhoea, and
pbtbisis.
75. iEt. 40. lop. Contents, serum, 1^ oz. No immediate effect. Deatb.
Phtbisis.
76. ML 38. 2 op. Contents, muddy serum, ^ pint; ditto, I pint. Great re-
lief. Death. Phthisis.
77. .iEt. 42. lop. Contents, pus, 1^ pint. Great relief. Recovery. He had
a tumour of the abdomen and an hydatid cyst.
78. jEt. 19. 2 op. Contents, serum, 36 oz. ; ditto. Approaching suffocation.
Death. Phthisis.
79. Mi. 25. 2 op. Contents, serum, 10 oz. ; ditto, 18 oz. Great relief.
Death. Phthisis.
80. Mi.25. ] op. Contents, serum, 10 oz. Relief. Progressing favorably.
Still under treatment when reported.
81. Mi. 25. 1 op. Slight relief. Death. He had pneumonia and pericar-
ditis, and was sinking when the operation was performed.
82. Mi. 45. 1 op. Contents, serum, 4 pints. Great relief. Recovery.
83. MX. 19. 1 op. Contents, pus, drawn off daily for 2 weeks. Relief.
Recovery.
84. ^t. 9. lop. Contents, pus, drawn otF daily for 2 weeks. Relief. Re-
covery.
85. ^t. 8. lop. Contents, pus, drawn off daily for 2 weeks. Relief. Re-
covery.
86. ^t. 48. Contents, serum. Relief. Partial recovery. He died in 3
months of general dropsy,
87. iEt. 45. Relief. Death. He died in 2 months of phthisis.
88. ^t. 30. Relief. Death, of phthisis.
89. Mi, 50. lop. Contents, serum. Slight relief. Death. Hydrothorax on
the other side.
90. Mi. 7. Contents, pus. Great relief. Recovery.
91. Mi.\9. 2 op. Contents, pus. Great relief. Partial recovery.
92. .iEt. 44. 2 op. Contents, serum, 30 oz.; ditto, 12 oz. Relief. Recovery,
with consolidation of lung.
93. Mi. 34. 3 op. Contents, serum, 24 Joz. ; ditto, 36 oz. ; ditto, 12 oz.
Relief. Progressing favorably. Some consolidation of the other lung.
91< Paracentesis Ihoracis.
!>-l. ^t. Ift. 1 op. Conlenls, sernm, llg oz. Reliel'. llecoveiy.
95. 2S.\.. 30. 2 op. Relief fust time. Death, of phthisis, 15 months after
operation.
96. iEt. 16. Contents, pus. No immediate eilect. Recovery, with slight con-
traction.
97. ^t. 23. Contents, pus. No immetliate effect. Death, of phthisis and
pneumothorax.
98. jEt. 30. lop. Contents, serum. Great relief. Recovery in 12 dajs.
99. ^t. 40. 2 op. Contents, serum, many oz. ; ditto, few oz. Great relief
first time. Death, of malignant disease.
100. /Et. 42. 1 op. Contents, serum, 32 oz. Great relief. Recovery.
101. yEt. 26. 2 op. Contents, serum, 3 pints; ditto, 1.^ pint. Great relief.
Death, of bronchitis, 3 months alterwards.
102. /Et. 45. 2 op. Contents, serum, 2(i oz. ; ditto 40 oz. Relief. Death, of
capillary bronchitis.
103. jEt. 26. 4 op. Contents, serum, first and second times; pus, third and
fourth times. Great relief. Death. He had pneumonia before the
third operation ; he had double tubercular pleuritis.
104. iEt. 26. 2 op. Great relief. Fairly good recovery. This was a case of
pneumothorax after injury.
105. yEt. 23. 1 op. Contents, pus. (ireat relief. Fairly good recovery.
There was pneumothorax in this case also.
106. jEt. 37. 2 op. Contents, pus. Relief. Deatb,[of bronchitis on the other side.
107. iEt. 24. 2 op. Contents, serum, 40 oz. ; ditto, 30 oz. No effect at once,
but great relief next day. Recovery.
108. Lancet, 1844. Dr. Theoph. Thompson. yEt. G—i). 4 op. Contents,
pus, 14 oz. ; ditto, 1 pint ; ditto, 1 pint ; ditto, 22 oz. Duration, 2
months. Relief. Recovery, with contraction. The wound was open
and discharging for several months.
100. Lancet, 1844. M. Trousseau. yEt. 33. lop. Contents, serum, 4 pints.
Duration, 12 days. Great relief. Rapid recovery.
110. Lancet, 1844. M. Trousseau. M\..25. 3 op. Contents, sero-purulent,
3 pints; ditto, 4 pints; ditto, 4 pints. Duration 12 days. Relief.
Death. This patient had puerperal fever and peritonitis.
111. Med. Times and Gaz., 1S45. 2 op. Contents, pus. Recovery.
112. Med. Times and Gaz., 1845. JM. Trousseau. 1 op. Contents, serum, 50
oz. Duration, 4 weeks. Recovery.
113. Med. Times and Gaz., 1845. M. Trousseau. 2 op. Contents, serum, 60
oz. ; ditto, 60 oz. Duration, 11 weeks. Death. This patient had cancer
of the breast ; died of erysipelas.
114. Med. Times and Gaz., 1845. Dr. OUifl'e and M. Trousseau, ^t. 10.
1 op. Contents, serum, 80 oz. Acute. Great relief. Recovery.
115. Med. Times and Gaz., 1845. M. Beau. ^t. 29. 1 op. Contents, 14
pints. " Favorable results."
116. Med. Times and Gaz,, 1845. Dr. Faure. Adult. 1 op. Contents,
serum, 7 pints. Great relief. Perfect recovery.
117. Med. Times and Gazette, 1846. Dr. Iluglies. Adult. Contents, serum,
72 oz. Relief. Death, I'roni pleuro-pneumouia of the other lung ; left
lung was compressed, but capable of being inflated.
Paracentesis Thoracis. 95
118. Med. Times and Gazette, 1840. Dr. IIn.<?hes. Recovery.
119. Med. Times and Gaz., 181(3. Adult. 3 oj). Contents, sero-purulent each
time. Relief. Great benefit. After injury.
120. Med. Times and Gaz., 1846. Dr. Grayling. JEL o. 2 op. Contents, pus,
36 oz. ; aqueous fluid, Ij dr. Relief. Recovery, after blistering, bleed-
ing and salivation with no effect.
121. Prov. Med. and Surg. Journ., 1840. Dr. Fletcher. M\.. 29. 1 op. Con-
tents, serum, 3 quarts. Duration, .3 — 4 weeks. Recovery, with slight
contraction of tiie lower lobe.
122. Lancet, 1847. Dr. Carson. Adult. 2 op. Contents, serum, 22 oz. ;
ditto, 16 oz. Duration, 9 djiys. Relief. Death. Cirrhosis of liver;
affected lung contracted, blue, airles.s ; much fluid in pleural sac ; the
other lung congested.
123. Med. Times and Gaz., 1847. Dr. Husson. ^t. 43. 2 op. Contents,
puriform, 170 oz. ; ditto, 35 oz. Acute. Favorable progress. Under
treatment when reported.
124. Lancet, 1848. Dr. Fletcher. 1 op. Contents, serum, 4 quarts. Dura-
tion, 4 months. Great relief. Death, 3 months later, from diarrhoea.
Tubercular deposits in pleura, peritoneum, and kidney.
125. Lancet, 1849. Mr. Fereday. ^^t. 10 months. 1 op. Contents, pus,
3 oz. Duration, 1 month. Relief. Death. Lung bound down by
adhesions, shrunken, and airless; wound open and discharging for some
days.
126. Lancet, 1849. Mr. Fereday. Mi. 10 months. 1 op. Contents, pus, 1
pint. Duration, 3 weeks. Recovery.
127. Dub. Med. Press, IS.-JO. Dr. Stewart, ^t. 30. lop. Contents, sero-
sanguineous, 4 quarts. Duration, 82 days. Relief. Recovery, with
contraction of lower lobe.
128. Med. Times and Gaz., 1S51. Dr. Budd. JEi. 21. 2 op. Contents,
serum each time. Duration, 6 weeks. Favorable progress. Under
treatment M'ben reported.
129. Med. Times and Gaz., 1852. Mr. Stedman. ^t. 19. 2 op. Contents,
serum each time. Duration, 4 months. Great relief. Favorable
results.
130. New York Journ. of Med., 1854. Dr. Tracy. 1 op. Contents, serum,
1 quart. Duration, 14 weeks. Perfect recovery.
131. Association Journ., 1854. Mr. Windsor. jEt. 45. 3 op. Contents, sero-
purulent, 52 oz. ; ditto, 30 oz. ; rather less puriform, 40 oz. Duration,
9 months. Relief. Recovery.
132. Lancet, 1854. Dr. J. R. Bennett. Sop. Contents, serum ; pus.
133. Med. Times and Gaz., 1854. Dr. Bentley. ^t. 26. lop. Contents,
serum, 3 drs. Duration, 6 weeks. Result, doubtful. The lung -was
punctured ; pus formed, and made an opening for itself externally ; sinus
still open 9 months later.
134. Med. Times and Gaz., 1854. Dr. Chambers. jEt. 18. 2 op. Contents,
senim, 18 oz. ; ditto, 1 pint. Duration, 3 weeks. Great relief. Death.
The operation was performed as a last resource ; he died suddenly 4 days
after the second operation ; lower lobe compressed.
135. Med. Times and Gaz., 1854. Mr. Paget. &{.5. lop. Contents, thin
96 Paracentesis Thoracis.
pus, huge qiKiiUity. Fuvorahle progress. In this case there was a sub-
cutaneous abscess, which was openetl ; sinus discharged for some
weeks.
136. MeJ. Times and Gnz., 1854. Dr. H. Roe. yEt.32. lop. Contents, pus,
90 oz. Duration, some months. Great relief. Death, 2 months later,
from tubercula] meningitis; the pleural cavity communicated with the
left lung.
137. Med. Times and Gaz., 18.54. Dr. Tuke. M\. A. 2 op. Contents, pus
each time. Duration, 4 weeks. Great relief. Good recover}-. The
sinus remained open for 6 months.
138. Med. Times and Gaz., 1854. Dr. Bennett. ML 6. 3 op. Contents,
pus, 4 pints; ditto, 2 pints; ditto, 5 — 6 pints. Duration, !> months.
Great relief. Favorable progress. The sinus remained open for several
months.
139. Med. Times and Gaz., 1854. Dr. Bennett. /Et. 40, 4 op. Contents,
serum, 4 quarts ; muddy ditto, 5 quarts ; pus, 200 oz. ; ditto, 4 pints.
Duration, over 6 months. Great relief after first operation. Death, 6
weeks afler the last operation, with abdominal symptoms. Post-mortem,
lung about the size of a fist; air and pus in pleura; large hepatic
abscess.
)40. Med. Times and Gaz., 1854. Dr. Chambers. yEt. 13. 2 op. Contents,
pus and air; fetid pus. Duration, 3 months. Great relief. Death.
The wound discharged till death. Post-mortem, right lung collapsed,
pus and air in pleura ; lung tuberculous.
141. Med. Times and Gaz., 1854. Dr. Seth Thompson. yEt. 38. lop. Con-
tents, sero-purulent, many pints. Duration, 9 weeks. Relief. Death.
Free communication between bronchial tulies and pleural cavity ; lung
collapsed.
142. Lancet, 1855. M. Barthez. ^Et. 6. 2 op. Contents, pus, 2 pints; ditto,
1 pint. Recovery.
J 13. Lancet, 1855. Dr. Addison. Adult. 3 or 4 op. Contents, 6 pints.
Death, from haemorrhage, from wounding anastomosing branches of
intercostal with internal mammary artery.
141. Association Journ., 1855. Dr. Hughes. ML 20. 1 op. Contents,
serum, 12 oz. Duration, 2 weeks. Relief. Perfect recovery.
145. Association Journ., 1855. Dr. Hughes. ^Et. 46. 3 op. Contents,
serum, 04 oz. ; ditto, 75 oz. ; ditto, 6 oz. Duration, some months.
Great relief after first and second operations. Death 3 days after the
third operation. Malignant disease of lungs and mediastinal glands.
146. Association Journ., 1855. Dr. Hughes. M{. 19. 1 op. Contents,
serum, 1 pint. Duration, some months. Relief. Death, 3 da3s after
the operatiou, from malignant disease of lung and pleura.
147. Association Journ., 1855. Dr. Walker. Adult. 1 op. Contents, serum,
10 pints. Duration, 4 months. Recovery.
148. Med. Times and (iaz., 1855. Dr. Burrows. ^:t. 24. 1 op. Contents,
pus, 12 oz. Favorable i)rogress. Under treatment when reiiorted.
149. Med. Times and Gaz., 1855. Dr. F^irre. Mi. 3. 2 op. Contents, pus,
34 oz. ; ditto, 8 oz. Duration, some weeks. Relief. Death. Pneu-
monia of right lung ; air and a little fluid in left pleural sac.
Paracentesis Thoracis. 07
150. Metl. Times and Gaz., 1855. Dr. Sib.-on. /Et. 18. 1 op. Content-s
serum, 30 oz. Duration, acute. Great relief. Recovery.
Cases reported by Dr. Tuke iji ' Association Joiirn.^ 1855.
151. Dr. Paley. 1 op. Content.**, pus. Deatb.
152. Dr. Paley. 1 op. Contents, serum. Recovery.
153. Dr. Paley. 1 op. Contents, serum. Recovery.
154. Dr. Theoph. Thompson. Contents, pus. Recovery.
155. Dr. Hey. Contents, pus. Recovery.
156. Dr. Williams. Contents, pus. Deatb.
157. Edin. Med. Joiirn., lS5t). Dr. Gairdner. jEt. 27. 2 op. Contents, sero-
purulent, 70 oz. ; sero-purulent, 72 oz. Duration, some months. Great
relief. Fair recovery.
158. Med. Times and Gaz., 1857. Dr. Jeaft'reson. ^Et. 55. lop. Contents,
serum, 40 oz. Duration, 85 months. Very slow absorption of re-
maining effusion.
159. Med. Times and Gaz., 1857. M. Trousseau. iEt. 26. 1 op. Contents,
serum, 70 oz. Duration, 2 — 3 months. Relief. Death, from
phthisis, 6 weeks after the operation.
160. Association Journ., 1858. Dr. Rogers. jEt. 30. 1 op. Contents, pus,
16 oz. Duration, uncertain. Relief. Death. Pneumothorax, from
vomica opening into pleural sac ; operation performed as a last
resource.
161. Med. Times and Gaz., 1858. Dr. H. Roe. 1 op. Contents, serum, 6
pints. Recovery.
162. Med. Times and Gaz., 1858. Dr. H. Roe. yEt. 10. 2 op. Contents,
serum, 6 pints ; ditto, large quantitj-. Duration, 2 — 3 months. Fairly
good recovery.
163. Med. Times and Gaz., 1858. Dr. H. Roe. .Et. 14. 3 or 4 op. Con-
tents, turbid serum, some pints. Duration, some time. Recovery.
164. Med Times and Gaz., 1858. Dr. H. Roe. iEt. 28. 1 op. Contents,
serum, 3 quarts. Duration, 14 days. Rapid recovery.
165. Med. Times and Gaz., 1858. Dr. H. Roe. ^t. 50. 2 op. Contents,
30 oz. ; 68 oz. Duration, 3 months. Perfect recovery.
166. Med. Times and Gaz., 1858. Dr. H. Roe. SA. 18. 2 op. Contents,
serum, £2 oz. ; ditto, 90 oz. Duration, long time. Fairly good
recovery.
167. Med. Times and Gaz., 1858. Dr. IJ. Roe. iEt. 27. lop. Contents,
serum, 2^ pints. Duration, 1 month. Relief. Rapid recoveiy.
168. Med. Times and Gaz., 1858. Dr. H. Roe. ^Et. 28. 1 op. Contents,
serum, 30 oz. Duration, a few days. Relief. Rapid recovery.
169. Lancet, 1859. Dr. Farre. iEt. 25. 1 op. Contents, pus, 2^ pints.
Duration, 3 weeks. Relief. Favorable progress. Under treatment
when reported.
170. Edin. Med. Journ., 1859. Dr. Gairdner. FEA. 24. 1 op. Contents, pus,
20 oz. Duration, 22 days. Favorable progress. Under treatment when
reported.
VOL. II. 7
98 Paracentesis Thoracis.
171. Brit. Meil. Joiirn., 18(30. Dr. 11. Roe, yEt. 12. 1 op. Contents, pus, i
pint. Relief. Perfect recovery.
172. Brit. Med. Jom-u., 1861. Dr. Waters. jEt. 19. 2 op. Contents, pus, 3
pints; ditto, 2 pints. Duration, some months. Relief after first operation.
Deatb. Post-morteni, left lung verj- small, carnified ; heart entirely to
right of middle line ; pericardial adhesions.
173. Brit. Med. Jonrn., 1861. Dr. Woodfall. yEt. 17. 1 op. Contents,
.serum, 11 pints. Duration, uncertain. Great relief. Fair recovery.
174. Dub. Med. Press, ISOl. Sir H. Marsh. iEt. 21. 2 op. Contents, pus,
3 pints ; ditto, 3 — -I pints. Duration, 5 weeks. Great relief.
Recovery. ,
175.- Dub. Quart. Journ., 1862. Dr. Thorp, lop. Contents, fetid pus, large
quantity. Duration, uncertain. Recovery.
176. Dub. Quart. Journ., 1862. Dr. Thorp. 1 op. Contents, serum, large
quantity. Duration, some weeks. Great relief. Death some months
afterwards. Bronchitis, general dropsy, and enlargement of liver.
177. Brit. Med. Journ., 1863. Dr. P. Martyn. ^Et. 6. 2 op. Contents, pus,
teacupful; ditto, 12 oz. Relief. Death.
178. Med. Times and Gaz., 1863. Mr. Hine. iEt. 7. 4 op. Contents, pus,
16 oz.; ditto; ditto, 13 oz. ; ditto, 8 oz. Duration, 6 weeks. Great
relief. Deatb, from phthisis, 2 years afterwards.
179. Med. Times and Gaz., 1863. Mr. Hine. ^Et. 6. lop. Contents, pus,
20 oz. Duration, 4 weeks. Relief. Recovery.
180. Med. Times and Gaz., 1863. Mr. Him-. .Et, 16. lop. Contents, pus,
26 oz. Duratiou, 4 weeks. Relief. Dealli, ten days later, Iroui pneu-
monia from exposure.
181. Med. Times and Gaz., 1863. Dr. Peacock. yEt. 38. lop. Contents,
serum, 2 pints. Duration, 9 weeks. Relief. Death one montli after
operation. Post-mortem, pus and air in pleura; lung compressed and
carnified.
182. Lancet, 1S64. Dr. G. Johnson. yEt. 49. 1 op. Contents, serum, 70
oz. Duration, 2 weeks. Relief. Death 2 days later. Post-mortem,
no pus in pleural sac.
183. Lcuicet, 1865. Dr. Fincham. iEt. 36. 1 op. Contents, fetid pus, 3
pints. Duration, 3 — 4 weeks. Relief. Death. Lower lobe of lung
carnified.
184. Lancet, 1866. Dr. H. Roe. ^Et. 24. 3 op. Contents, sero- purulent,
170 oz. ; ditto, 150 oz. ; pus, 60 oz. Duration, over 12 months, Reliel',
Recovery.
185. Lancet, 1866. Dr. Basham, yEt. 22. 1 op. Contents, sero-purulent, 2
pints. Duration, 11 days. Relief. Favorable progress.
186. Brit. Med. Journ., 1866. Dr. Guinier. jEt. 15 months. 1 op. Dura-
tion, 3 — 4 weeks. Perfect recovery.
187. Brit. Med. Journ,, 1867. Dr. Hillier. yEt, 6, 1 op. Contents, serum,
3 oz. Duration, 3 weeks, JUipid recovery.
188. Brit, Med. Journ., 1867. Dr. Hillier. ^Et. 5. 4 op. Contents, pus, 4
oz. ; ditto, 10 oz. ; ditto, 4 oz. ; ditto, 3 oz. Duration, 4 weeks. Good
recovery. Canula left in for some time after fourth operation.
Paracentesis Thoracis, 99
180. Brit. Med. Joiirn., 1867. Dr. Hillier. lEi. \^. lop. Contents, pus, 3
oz. Duration, 7 weeks. Recovery.
190. Brit. Med. Journ., 1867. Dr. Hillier. MX. 5. 4 op. Contents, pus
eiicli time. Duration, 3 months. Perfect recovery.
191. Brit. Med. Journ., 1867. Dr. Hillier. Mt. 4. 2 op. Contents, pus
each time. Duration, 3 weeks. Fair recovery. Double pneumonia,
nephritis, and scarlatinal dropsy.
102. Brit. Med. Journ., 1867. Dr. Bishop. JEU 42. lop. Contents, pus, 7
pints. Duration, 11 weeks. Great relief. Perfect recovery.
193. Med. Times and Gaz., 1868. Dr. H. Browne. JEt.35. lop. Contents,
pus, 208 oz. Duration, 12 months. Relief. Death.
194. Brit. Med. Journ., 1869. Dr. Spencer, ^t. 9. 2 op. Contents, pus
each time. Good recovery.
19J. Lancet, 1869. Dr. Fox. lop. Contents, pus, 1 pint. Great relief.
196. Lancet, 1869. Dr. Handtield Jones. 2 op. Contents, serum, 1| pint;
ditto, 2 pints. Great relief.
197. Lancet, 1869. Dr. Sibson. Favorable results.
198. Lancet, 1870. Dr. Murchison. Mt. 7. 1 op. Contents, serum, 24 oz.
Duration, 12 days. Favorable progress. Under treatment when
reported.
199. Med. Times and Gaz., 1870. Sir H. Thompson. Mi. 22. 1 op. Con-
tents, serum, 80 oz. Acute. Great relief. Recovery.
200. Med. Times and Gaz., 1870. Dr. Handfield Jones. Mt. 19. 1 op.
Contents, serum, 86 oz. Duration, a few days. Rapid recovery.
201. Brit. Med. Journ., 1869. Dr. Peter. 1 op. Contents, serum, 5 quarts.
Duration, 2 months. Rapid recovery.
202. Brit. Med. Journ., 1869. Dr. Peter. Relief. Death. Cardiac disease.
Life prolonged by the operation.
203. Brit. Med. Journ., 1869. Dr. Peter. Relief. Death, 5 months later,
from phthisis, existing at time of operation.
204. Brit. Med. Journ., 1869. Dr. Peter. Chronic. Recovery.
205. Brit. Med. Journ., 1869. Dr. Peter. Acute. Recovery.
206. Brit. Med. Journ., 1869. Dr. Peter. Acute. Recovery.
207. Brit. Med. Journ., 1869. Dr, Peter. Contents, pus. Amelioration.
Scarlatinous empyema, pericarditis, and pulmonary tuberculosis.
208. Brit. Med. Journ., 1869. Dr. Peter. Acute. Recovery.
209. Brit. Med. Journ., 1869. Dr. Peter. Acute. Recovery.
210. Brit. Med. Journ., 1869. Dr. Peter. Recovery.
211. Med. Times and Gaz., 1870. Dr. Berkeley Hill. Contents, pus. Favor-
able results.
212. Med. Times and Gaz., 1870. Dr. Berkeley Hill. Contents, pus. Chronic.
Favorable results.
213. Med. Times and Gaz., 1870. Dr. Berkeley Hill. Contents, serum.
Recovery.
214. Brit. Med. Journ., 1870. Dr. Paley. Mt. lOi. 2 op. Contents, pus
each time. Relief. Good recovery.
215. Brit. Med. Journ., 1870. Dr. Paley. .Et. lOi. 3 op. Contents, pus
each time. Relief. Good recovery.
216. Victoria Park Hosp., 1871. Dr. Peacock. Mt 8. 2 op. Contents,
100 Paracentesis Thoracis.
serum, 52 oz. ; ditto, 36 oz. Duration, 5 weeks. Relief. Recovery,
with contraction of side.
217. Victoria Park Hosp., 1871. Dr. Ward. ^t. 18. 1 op. Contents,
serum, 72 oz. Duration, 12 days. Great relief. Perfect recovery.
218. Watson's Princ. of Physic. Dr. Watson, lop. Contents, serum. Death
on next day, probably from shock.
219. Watson's Princ. of Physic. Dr. Watson. 1 op. Contents, serum. Per-
fect recover}'.
220. Watson's Princ. of Piiyslc. Dr. Watson, lop. Contents, serum. Per-
fect recovery,
22i. Watson's Princ. of Physic. Dr. Watson. 1 op. Contents, serum. Per-
fect recovery.
222. Watson's Princ. of Physic. Dr. Watson. 1 op. Contents, serum. Re-
lief. Death, Post-mortem, oflensive pus found in cavity.
223. Watson's Princ, of Physic, Dr. Watson, lop. Contents, serum. Re-
lief. Death. Post-mortem, offensive pus found in cavity.
221. Watson's Princ. of Physic. Dr. Watson, lop. Contents, pus. Dura-
tion, some months. Death. The wound did not lieal.
225. Watson's Princ. of Pliysic. Dr. VVatson. 1 op. Contents, pus. Re-
covery. The wound remained open some time, then healed.
226. Trousseau's Clin. Med., vol. iii. Prof, Trousseau. Mi, 16. 1 op.
Contents, serum, 2S oz. Duration, 9 days. Great relief. Perlect re-
covery.
227. Trousseau's Clin. Med., vol. iii. Prof. Trousseau. 1 op. Contents,
serum, 70 oz. Duration, 14 days. Great relief. Recovery.
228. Trousseau's Clin. Med., vol. iii. Prof, Trousseau. ML 30. 1 op.
Contents, serum, 70 oz. Duration, 'J months. Great relief. Re-
covery.
229. Trousseau's Clin, Med., vol, iii. Prof. Trousseau. 1 op. Contents)
serum, 88 oz. Recovery.
230. Trousseau's Clin. Med., vol. iii. Prof. Trousseau, ^t. 36. 1 op.
Contents, serum, 88 oz. Duration, 3 — 4 weeks. Great relief. Re-
covery.
231. Trousseau's Clin. Med., vol. iii. Prof. Trousseau, /Et. 54. 1 op.
Contents, serum, 54 oz. Duration, 7 days. Great relief. Rapid and
complete recovery.
232. Trousseau's Clin. Med-, vol. iii. Prof. Trousseau. ^t. 23. 1 op.
Contents, serum, 27 oz. Duration, 26 days. Great relief. Perfect
recovery.
paracentesis Thoracis.
101
Table II.
Reference to
cases.
-1
i
1
Cases of
serous
effusion.
i
o
1
Cases of
piurulent
effusion.
i
1
11
1
Q
(S
P
A
P
Dr. T. Davies
16
12
4
(' Med. Gaz.,'
1834)
Dr. Phillips
122
88
34
91
62
29
31
26
5
(see ' Med.
Gaz.,' 1844)
.M. Aran (' Bi-
250
...
"Without any
ennial Retro-
disaster."
spect,' 18G1)
Dr. Bowditch
75
29
26
26
21
5
24
8
7 And 9 (purulent)
(Amer. Jour.
were much re-
of Med. Sci.,'
lieved.
1863)
Cases seen by
10
In none of these
Dr. Bowditch
any bad results
M. Guinier
31
from tapping.
Recoveries being
('Edin. Med.
to failures as 6
Journ.,' 1865)
tol. The ope-
ration never
seemed to do
Prof.Kussmaul
18
6
12
any harm.
('Med. Times
and Gazette/
18G7)
M. Dupre (do.,
76
68
8
76
68
8
47 were in the
1869)
second week;
46 recovered.
M. Besnier
14
14
14
14
('Amer. Journ
of Med.
Science,' 1870)
612
217
84
207
165
42
55
34
12
ON THE
THERAPEUTICAL IMPORTANCE
OP
EECENT VIEWS OF THE NATURE AND
STEUCTUEE OF CANCEE.
By HENEY ARNOTT, F.R.C.S.
Few points of abstract surgical pathology have been more
keenly discussed of late than the theory of the nature of cancer ;
and perhaps few practical subjects have been more frequently
and hotly canvassed during the same period than the treatment
of cancer, more especially with regard to the propriety or other-
wise of ablation of cancerous tumours with the knife.
And yet the result of all these discussions seems to be, that
upon the first point, the theory of the disease, opinions still
widely differ ; and that upon the second, whilst both schools
of theorists agree in the admission that we have failed as yet to
discover any cure for cancer, opinions are about equally divided
upon the subject of its relief or aggravation by any of the
measures at present in common use.
Nor is the gravity of the situation rendered less painfully
manifest by the reflection that so greatly does personal prejudice
ajDpear to influence the judgment in this matter, that the majority
of operating surgeons are strongly in favour of the knife, whilst
the majority of physicians and surgeons, little used to operations,
declaim against this remedy. It is to be further noted that
statistics are quoted by both sides, and that the difference of
104 On the Therapeutical Importance of Recent Vieios
opinion is guided by such subtle influences that many surgeons
are knoAvn to have held opposite views on the subject at different
periods of life.
Now, it is clear that Avitli diametrically opposed opinions on a
subject of so vast importance as the treatment of cancer, there
must be some fallacy underlying the statistics which are quoted
alike by both sides, or, perchance, some scepticism or miscon-
ception of the facts comingunder the ken of the pathologist, which
a little careful and dispassionate consideration of the matter,
from an anatomical point of view, may serve to clear up. The
time, indeed, seems to have come when we may well pause and
endeavour to ascertain how far and in what respects the recent
modifications of our views of the nature and origin of cancer
should affect our treatment of the disease.
It will be the object of this article, therefore, briefly to review
our present position in this regard, and to endeavour to ascertain
Avhether we may not fairly deduce from the pathological facts
already recorded, some definite principles of treatment which
may approve themselves alike to the practical surgeon and the
theorist.
It is obvious, however, that in such a paper as the present
we must be content to use the term ' cancer ' in its broadest
sense, as synonymous with the word ' malignant,' by which is
imj)lied a property of certain morbid growths to flourish at the
expense of the tissues in which they appear, to return more or
less speedily after removal, to infect the neighbouring lymphatic
glands, and finally to be accompanied by similar ncAV growths
in various and remote portions of the body. These terrible
qualities being common to many different forms of new growth
— although perchance in varying degrees of severity — it is
obviously inconvenient to apply any of the arguments to be
here set forth to any one form of neo])lasm, as e.g. carcinoma
proper as met with in the scirrhous breast.
Taking, then, the word cancer to mean malignancy, let us
proceed to consider the theories of its nature.
[But whilst thus disregarding for the moment the peculiar
anatomical formation of the several varieties of malignant
tumours, I am anxious to guard myself against the imputa-
tion of not believing sufficiently in their real importance.
of the Nature and Structure of Cancer. ] 05
It has been said that it is puerile to pay very much attention to
the minute structural elements of a morbid growth ; that the
form of the component cells teaches one little or nothing of the
attributes of the tumour exhibiting them ; that similar cells are
to be found in the most diverse growths, and that one might as
well expect to be able to sketch out the future dog or horse
from an inspection of the cells constituting the early embryo, as
to predicate the course and symptoms of a morbid growth
by observation of its cellular elements. It may be that we are
perhaps laying too great stress upon the minute structure of
tumours at the present day, but we are certainly making great
advances in diagnosis thereby, and we may not unreasonably
hope to make corresponding advances in therapeutics. For it
is to be observed that although the particular shape and size of
each cell may be unimportant, yet the general appearance and
arrangement of these vary Avith great regularity in the several
classes of ncAV growth. And the minute structure of a tiny
tumour differs from that of an immature ovum in the important
circumstance that the neoplasm very early takes on the structure
whicli is to constitute without any further development the
great bulk of the possibly enormous and fatal tumour. It
is true that in the " granulation stage ^' of certain of the more
malignant new formations very little can be predicated — the
clustered round corpuscles may be the first indications of an
inflammatory process or of the most deadly cancer; but as a
matter of fact surgeons never meet ■with tumours in this stage
without having close by a structure more pronounced if not as
fully differentiated as it is destined to become. And hence, if
we are ever to discriminate fairly between the several forms of
tumours, we must not neglect the careful inspection of their
minute structure ; for it will be only from the time that such
accurate distinctions are constantly made that statistics Avill be
of any real value in advancing our knowledge of the clinical
history of new growths.]
There are two leading views of the nature of cancer which
may be briefly characterised as that which regards it as an
affection purely constitutional , and that which ascribes to it
^, purely local character. Of these two views the latter is by far
the move recent ; but although it has been warmly adopted by
106 On the Therapeutical Importance of Recent Vieivs
some fc^y English surgeons, notably by Mr. De Morgan,^ and
by the late C H. Moore,^ it cannot be said to be generally wel-
comed on this side of the channel^ though long held by some of
the leading pathologists of Germany."
Without attempting to consider all the minor differences of
detail in the opinions which may be held by individuals in
cither of these schools, we may sum up the doctrine of the
first class of writers thus : — that cancer is as essentially a consti-
tutional or blood disease as gout or syphilis, and with analogous
local manifestations ; and the corollary usually ap2>ended implies
that one might as well hope to eradicate gout or syphilis by
amputating the inflamed toe or cutting out tlie indurated
chancre, as to stem the course of cancer by cutting off the
tumour.
Of course the physical proofs of the existence of a consti-
tutional disease cannot be furnished, but the chain of other
evidence adduced in its support is at first sight very striking.
We have presented to us (1) a disease unquestionably here-
ditary in many instances ; (2) an inveterate resistance to any
attempt at removal, as shown by a return of the growth in sitfi,
sometimes even after a lapse of years ; (3) a tendency to the
production of secondary growths in certain parts of the body,
which is apparently inexplicable by any other theory ; and (4)
a cachexia, which of itself is said to be sufficient to kill the
patient, irrespective of the local malady.
1 " On the Origin of Cancer;" a series of Papers by Campbell Dc Morgan, F.R.S.,
in the ' Lancet,' July, 1871.
2 "The Antecedents of Cancer." By Charles 11. Moore, F.R.C.S., 18G5.
" Cancer." Article by C. H. Moore, in 2nd Edit, of ' Holmes's System of Sur-
gery,' 1870.
^ Since writing the above sentence it has been gratifying to note the thorough
adhesion of the learned President of the Clinical Society to this doctrine. At a
meeting of this society, held October 13tli, 1871, at which the subject of the local
nature of cancer was discussed. Dr. Gull, in a remarkable speech, derided the notion
of cancer being a " constitutional" disease, and expressed his own conviction that
cancer is at first an absolutely local growth, which, by diffusion of its minute ele-
ments, subsequently affects the body in numerous places. Sir Thomas Watson also,
in the last edition of his ' Lectures on the Principles and Practice of Physic,'
seems to favour this view more distinctly than in former years. The importance of
the point being thus augmented by the support of so high authorities, it is the
more necessary that the doctrine itself should receive general and critical atten-
tion.
of the Nature and Structure of Cancer. 107
On the other hand, those who are opposed to this view main-
tain that cancer is, in the first instance, as purely a local
disorder as the most innocent tumour ; but that, owing to cer-
tain peculiarities of structure, its elements may become diffused
throughout the body, chiefly by means of the lymph or blood
streams, and so give rise to other or secondary growths in distant
parts, and that if the first tumour be only sufliciently removed
before this wide dispersion be effected, cancer is as eradicable as
any fatty or bony growth. To use a homely illustration, accord-
ing to this theory, a cancer in the human body may be compared
to a thistle in a cornfield. If this weed be allowed to remain until
the flower-head has passed to its stage of ripe, feathery seeds,
these are wafted hither and thither, and, taking root, become so
intimately and largely mingled with the corn that the complete
removal of the nuisance is impossible without greatly endanger-
ing the whole croj). But if the original plant be removed
at once all this danger is avoided. And the illustration may
further serve to show what is meant by complete extirjmtion of
the cancerous tumour, and its bearing upon the theory of the
nature of cancer. For if the thistle be merely cut down it will
surely sooner or later again flourish and scatter its seeds far and
wide ; and even if small portions of its root, or rhizome, be
suffered to remain, these may be the source of a return of all
the mischief, though after a longer period.
In like manner it is argued that manifestly incomplete re-
moval of a cancerous groAvth can never be of any permanent
service ; that injudicious tampering with it may be as the shaking
of the thistle down and the dispersion of the fatal seeds ; and that
even very careful removal may too often fail to extirpate all the
tiny offshoots which if left behind will, after a longer or shorter
interval, develop a fresh and virulent cancer.
Such are the two theories of the nature of the disease com-
monly received, and since the local theory is gaining ground
rapidly with the younger pathologists of the day, it may be well
to examine from their point of view the arguments of the older
school seriatim.
That cancer is undoubtedly hereditary in many cases proves
nothing either way, although it is a very favourite argument of
those who contend for the constitutional aspect of the question.
When we reflect that such absolutely local blemishes as a sixth
108 On the Therapeutical Importance of Recent Views
toe, a clubfoot, an early disposition to gray hair, and tlie like, are
oftcntinies clearly hereditary, there is no difficulty in understand-
ing that an hereditary cancerous tumour may be quite as local
in its nature ; and, indeed, it has been pointed out by Mr.
De Morgan^ that Avarts and even atheromatous tumours are
occasionally distinctly to be traced in families. Cases of here-
ditary tendency to the formation of fatty tumours have been
also recorded.
The great proneness to return in the neighbourhood of the
scar left by the operation for the removal of the first growth
is also capable of abundant explanation in these days of micro-
scopic research, "without the necessity of presupposing any
general taint of the system. Indeed, when we reflect upon
the way in Avhicli many of these malignant tumours are
built up of exceedingly minute cells, bound together in the
loosest manner^ or even (as in scirrhous carcinomaj floating
freely in a thin fluid, each cell possessing independent and inde-
finite powers of reproduction, and even as it Avould seem being
capable of inducing a like morbid development in the j)hysio-
logical tissues amongst which it is implanted, it seems more easy
to explain the frequent recurrence of such growths than their
occasional complete removal. The recent experiments on skin
grafting for superficial ulcers must have brought this point
forcibly home to the surgeons who have practised the method.
The occurrence of secondary growths is a much stronger fact
in supjDort of the theory of the constitutional nature of cancer,
although much light has been thrown upon this point also by the
pathological observations of the last few years. The contami-
nation of the nearest chain of lymphatic glands is, of course,
readily intelligible, but the more remote growths as in the brain
or distant limb are not capable of so facile an interpretation.
No doubt the doctrine of embolism as set forth by Dr. Kirkes
and amplified by many subsequent observers has gone far to
remove from the difl'usion of cancer the mystery which formerly
enshrouded it, and the great majority of secondary growths may
be explained by a transference of cells or fluid from the primary
tumour by cither the lymph- or blood-channels. These modes
of extension of the disease have been already too abundantly
illustrated to need any further confirmation here. Perhaps the
' 'Lancet,' vol. ii, 1871, p. 154,
of the Nature and Structure of Cancer. ' 109
most perfect and convincing examjile of transference of tumour
elements by the blood is furnished by Sir James Paget's striking
case of primary cancer of the liver in which the growths
were stained bright yellow by bile, and in which numerous
secondary growths of the same structure and peculiar colour
were found scattered through the lungs and blocking the branches
of the pulmonary artery.^ But some exceptional instances are
not so obviously capable of such a solution, and it is these cases
which are mainly relied upon by those who hold to the consti-
tutional essence of the disease.
It has been argued by those seeking to establish the local
origin of cancer, on the other hand, that the disease in its secon-
dary form never, or extremely rarely, attacks any of the common
seats of its primary manifestation.
My own observations, however, have hitherto not coincided with
those of Mr. Sibley- in this respect. In 109 cases of cancer of
the breast recorded by me in the annual statistical tables of
the cancer department of the Middlesex Hospital, the other
breast was affected in twelve instances, i. e. in the proportion of
11 per cent., whilst I have once seen a patient with cancer of
the uterus and both breasts at the same time. In these same
109 cases the lungs were the seat of secondary deposit eight
times, and the liver fourteen, so that even making alloAvance
for imperfect examinations in which the other breast might be
noted when the luugs or liver could not be examined, the
occurrence of secondary disease in the opposite breast is too
common an event to permit of any useful deduction being drawn
as to the local origin of cancer, from tlie fact of common pri-
mary seats of cancer being rarely selected for secondary manifes-
tations.
A heavy blow seems to be aimed at the theory of the local
origin of cancer in the recent researches of Cohnheim and
Kecklinghausen upon the nature and properties of the -wan-
dering cells or white corpuscles of the blood. Without follow-
ing up too closely the tangled web of inferences which may be
and have been drawn from the observations on this subject, it may
be at least stated that it is held by many as extremely probable
that the tiny clusters of roundish granular corpuscles, which
1 ' Lectures on Surgical Pathology,' 2nd Edit., 1863, p. 803.
» • Med.-Chir. Trans.,' vol. xlii.
110 Oil the IVierapeutical Importance of Recent Views
under tlie names of '' indifferent''' and '^ granulation^' tissue, have
long been recognised as the first indications of a developing
cancer, are really neither more nor less than white blood-cor-
puscles which, in obedience to some impulse not clearly under-
stood, have passed through the vessel walls into the tissue
beyond. To those who had adopted after much consideration
the views of Virchow as to the almost exclusive part played in
all these changes by the ubiquitous connective-tissue corpus-
cles the more recent observations on the subject have come with
such startling novelty, that we are hardly yet in a position to
give in an unreserved adhesion to either doctrine. The appear-
ance of multiplying connective tissue nuclei, and even of the
nuclei of striped muscle, in the neighbourhood of a growing
cancer seems too real to be readily distrusted. Meantime it is
clear that if these first elements of a cancerous tumour are really
W'hitc corpuscles, which have issued from the blood-vessels in
the vicinity, cancer may be a blood disease in a more absolute
sense of the term than has been yet conceived, although
its local manifestations may be extremely limited.
Such an admission would give enormous weight to the vievr of
a special dyscrasia against which we must hopelessly strive to
fight. Might we not, then, argue, on the other hand, that as the
same corpuscles play an equally prominent part in any trifling-
inflammatory or reparative action — as the healing of a lancet
i:)rick, or the formation of a boil — the force Avhich determines
their special development when once outside the vessel, must
depend solely upon some local change or aptitude or force in the
tissues amongst which they are extravasated .''^ Siich a sugges-
• Thus, Sir James Paget, writing long before the share talicn by the white blood-
corpuscles in the development of tumours was recognised, insisted strongly upon the
necessity for the coexistence of two things in the formation of any cancer, " namely,
a certain morbid material in the blood, and some part appropriate to be the seat of
a growth incorporating that material, some place in which the morbid material may
assume or enter into organic structure." Op. cit., p. 767.
The necessity for assuming the coexistence of these two conditions, neither of
which is capable of distinct manifestation, in order to explain the appearance of a
given malignant growth, seems (o be one of the greatest diflicullics in the path of
the ' constitutionalist,' for it is not easy to conceive that witli a specific poison
circulating in the blood an appropriate habitat can only be found in a single minute
portion of one breast or one tiny region of connective tissue. It is as though the
poison of variola were to be limited in its manifestation for a long time to a single
of the Nature and Structure of Cancer. Ill
tion would be^ at least, more consistent with the facts of the
case, for we have never — so far as we can accurately observe —
the phenomenon presented to us of more than one cancerous
tumour appearing at the same time as primary evidence of the
disease.
A strong argument in behalf of the local theory of cancer is
furnished by the consideration of the several varieties of malignant
growths, and their respective malignant properties. It is for
this reason that it is so unwise to limit such an inquiry as that
in which Ave are now engaged to carcinoma anatomically defined,
since such a limitation deprives the question of more than one
important aspect. If, for instance, we attempt to range the
different tumours in the order of their malignancy, we shall find
that, in spite of the great difficulties in the way of an absolute
adjustment of the conflicting claims before us, just those forms
of growth are most liable to general diffusion which from their
physical structure might be so predicated, any apparently
opposing facts being explained by the seat of the growth. This
is a statement so important to the point at issue that it may be
well to dwell upon it more in detail. The merely recurrent
growths have been already referred to as readily explicable by
the microscopic evidence of a diffusion of their minute elements
amongst the neighbouring tissues far greater than is at all
obvious to the unaided senses, and they need not be included
here. Of the growths exhibiting more particidarly the higher
degrees of malignancy, the most important are hard and soft
carcinoma, sarcoma, epithelioma, lymphoma, and (rarely) glioma.
Of these, lymphatic gland contamination is observed especially
in carcinoma and epithelioma. (Lymphoma, as probably a
growth exclusively of lymph-gland origin, may be excluded.)
The researches of MM. Cornil and Ranvier have shown that
into the spaces filled with loose cells, characteristic of carcinoma,
the mouths of lymphatic vessels open straight.^ Hence the
inoculation of the nearest glands with the cells or juices of a
carcinoma may be considered as an almost unpreventible and
clearly intelligible process. It is not so clear in regard of
pustule. For the development of a new growth it is more easy to believe that the
local change is the only really essential condition.
1 ' Manuel d'Histologie Pathologique,' par V. Cornil et L. Ranvier, Paris, 1869,
p. 175.
112 On the Therapeutical Importance of Recent Views
epithelioma, nor is the gland infection nearly so frequent in
this case. But where it does occur, especially in the lips,
tongue, the genital organs, and, perhaps, the rectum, it is to he
noted that the epithelioma is situate on a part much subjected
to constant movement, and so naturally moist as to render the
growth softer and more infiltrating than it is apt to be in other
localities as the cheek, or the edge of an ulcer on the shin.^
The effect of locality in influencing the malignancy of new
growths is perhaps hardly sufficiently considered by surgeons.
We see an ulcer with elements of epithelioma in its edge and
base, situated upon the temple or cheek, and we marvel at its
slow and insidious progress, a progress] often so slow that many
years may elapse before much of the face is consumed in the
advancing havoc ; whilst in these cases it is the rare exception
to find any contamination of the neighbouring lymphatic glands
or remote viscera. But let the same epitheliomatous ulceration
attack the lip or the tongue, and at once we have to deal with a
rapidly progressive disease, liable, in a proportion of about fifty
per cent, of cases, to infect the glands in the vicinity, if not
raoi'e remote parts also.
In support of this statement reference may be made to the
following analysis of seventy-three cases of epithelioma, of
which careful notes were made by myself, and which are
included in the annual statistical tables of the cancer practice
of the Middlesex Hospital before referred to. Cases of uterine
cancer are not included in this table on account of the un-
certainty often attending the microscopic diagnosis of cancer in
this organ.
' A striking illustration of the truth of this suggestion is furnished hy the fol-
lowing example from my out-patient room at St. Thomas's Hospital. A draper's
assistant, ahout 60 years of age, noticed, in August, 1871, a small sore place on the
fra;num of the tongue. Within one month the glands helow the jaw enlarged, and he
then consulted a surgeon; but being told that the swelling would soon subside, he
paid little attention to it until the increasing pain and tenderness drove him for fur-
ther advice elsewhere. I saw him within three months of the time at which he had
first noted the sore, and already the ulcer had assumed well-marked characters of
epithelioma, three or four glands below the jaw were diseased and inflamed, and
there was induration and fixation of the glands above the clavicle. In fact, the dis-
ease had already extended beyond the reach of surgical interference, although the
man was still in excellent general health, and most unwilling to accept the grave
prognosis which it was right to put before him.
of the Nature and Structure of Cancer.
113
Locality of tlie epithelioma
(including four cases
of so-called
"rodent cancer").
Number of cases in
wliicli neigliliouriiig
lymphatic glands
were implicated.
Number of cases in
which more remote
parts were also
diseased.
Clieek or face .
23
5
2
Lip
8
4
1
Tongue
19
11
1
Scrotum
4
Vulva
3
2
Penis
3
2
Rectum
3
1
Leg
3
Hand
2
2
1
Foot
BlaiMer
Heel
1
1
Clitoris
1
...
Groin
1
73 30 6
It will be remarked in tliis table tbat the cases showing con-
tamination of the glands and other parts, are precisely those
in which the growth is subjected to the greatest amount of
movement. Thus, in the lip, tongue, genitals, groin, hand,
and heel, the glands Avere affected in from 50 to 100 per cent,
of the whole number of cases, whilst the disease attacking the
less movable parts of the face spread to the glands in a propor-
tion of only 21*7 cases; and in the leg and scrotum remained
absolutely local. I have selected epithelioma for this com-
parison because it is a form of new growth, whose malignancy
seems to me to depend almost entirely upon the circumstances
of its locality, and partly also because its genuine malignancy
under untoward conditions, has been generally so little re-
cognised, that a late eminent writer upon cancer^ altogether
refuses the name to this neoplasm.
In illustration of the comparative malignancy of cancer,
sarcoma, and epithelioma, when an extremely movable and
moist part is invaded by them, I would refer to some recent
observations upon uterine cancer, in which I have made special
reference to this point."
Sarcoma, excepting those singular instances of largely diffused
melanosis, hardly ever infects the lymphatic glands.
1 The late Maurice H. Collis, of Dublin.
* "Cases illustrating certain points in the Pathology of Cancer of the Uterus,"
' Pathological Transactions,' vol. xxi, 1870.
VOL. II, » 8
llJj On the Therajjeutical Importance of Recent Views
For the more fatal property of Avicle diffusion to distant parts,
the structure of carcinoma with its freely floating cells in tiny
reservoirs of thin fluid is eminently adapted. For the rest it
will be seen that the softest, most quickly growing, and infil-
trating growths, are at the same time, and apparently in direct
pro2:)ortion to the existence of these qualities in any given spe-
cimens, most liable to general spreading of the disease. This
is true also of the more rarely malignant growths as soft en-
chondroma and myxoma. A capsule to the growth (much more
rare in sarcoma than is often taught), Avhether furnished by
condensed connective tissue around it, or by the accidental
envelopment by tough fibrous structures (as in the case of a
growth springing up within a joint or limited by tough fascia?),
is almost equally a protective against the occurrence of remote
growths in all these varieties of neoplasm.
That we occasionally meet with instances of secondary
tumours so far removed from all apparent anatomical communi-
cation with the primary growth, should only stimulate us to
observe with the greater scrutiny the means whereby the phe-
nomenon is brought about — although, of course, we can always
take refuge, as respects these excejitional cases, in the assumjition
that the two growths are absolutely independent of one another,
and have appeared just as a couple of sebaceous or fatty tumours
occasionally develop at widely separated parts.
Turning now to the fourth argument, the cachexia which is
of itself sufficient to slay, even without the local manifestation, it
might be sufficient to reply that the existence of such a cachexia,
save as a general deterioration of health due to a grave local
malady, is a pure assumption, which the considerations just
put forward tend to contradict.^ But it has been contended
' " It (cancerous cachexia) has therefore no necessary connection with the malady,
but is only a result of the effect of the malady upon the constitution." — Prof. Hum-
phry, on " Cancer of the Testicle," ' Holmes's System of Surgery,' vol. v, p. 143.
" Nothing can be more erroneous than the belief entertained by those who have
not had much experience of the disease that there is a cachectic condition in the
early stages of cancer." — C. De IMorgan, 'Lancet,' vol. ii, 1871, p. 41.
" I look upon cachexia as an evidence of disease interfering with some of the
principal viscera, and preventing the due renewal or purification of the blood, which
is their function ; if the disease be cancer, the cachexia will be evidence of it ; but
it will not per se enable us to distinguish between cancer and other internal or
bidden morbid actions." — 'On Cancer and tlie Tumours analogous to it,' by Maurice
H. Collis, M.B.,F.R.C.S.I., 1864, p. 141.
of the Nature and Structure of Cancer. 115
not only that patients have died of this dyscrasia irrespective
of the local ailment, but also that the local growth forms, as it
Avere, a loophole for the escape of the poison from the
system — an excreting gland without whose aid the patient
would speedily succumb to the virus circulating through his
frame.
This view, however, requires a corresponding belief in the
beneficial effect upon the patient of the development of the
tumour itself, and in the immediate ill effects of its removal by-
operation which the attentive examination of the majority of
ordinary cases of cancer precludes us from recognising.
The appearances which we are accustomed to associate with
the existence of the cancerous dyscrasia, may often be seen in
very different complaints, as chronic hip disease, chronic pyaemia,
certain uterine disorders, and other ailments attended by fre-
quent losses of blood or prostration of strength, and these ap-
pearances when they do present themselves in cancer, seem to
prove only that the sufierer is beginning to languish terribly
under the scourge with which he is attacked.
A calm survey of the two opposite views of the nature of
cancer, and of the facts which are adduced in support of them,
seems to leave us in about this position : — that while it is
impossible absolutely to deny the existence of a special dys-
crasia as the cause of the appearance of malignant tumours,
the evidence in its favour will not bear careful scrutiny, although
it may be admitted that certain individuals and even families
exhibit a remarkable predisposition to the occurrence of these
growths, just as a similar predisposition may be shown to the
appearance of fatty growths, warts, or other such local defects
of nutrition : that owing to appreciable physical causes — as
the special arrangement of structural elements, the part of
the body attacked, &c. — certain tumours are more prone to
malignancy than others : that whether the original growth be
absolutely local or depending on general changes in the system,
a stage may be at length reached in which there may be, in-
deed, an ineradicable and necessarily fatal blood contamination :
and finally, that as all the I'eal evidence before us goes to
prove that it is in any case the local tumours or ulcers which kill,
— either by invasion of vital organs, or by the breaking-up of
health caused by excessive hsemorrhages, pain, and exhausting
116 On the Therapeutical Importance of Recent Vieivs
and foetid discharge from the primary seat of the disease —
these shoukl be completely removed when possible.
Of course the zeal and hopefulness with which the surgeon
sets about this task will depend in a great measure upon the
particular theory which he may hold, but it seems illogical to
contend that because a man believes that profound constitutional
changes have caused the appearance of a terrible local mischief,
therefore he need not trouble to attempt the removal of the dire
result of a cause which is beyond his control. Even if he feels
confident of the system of his patient being saturated with the
poison, he Avill yet endeavour to obviate the more tangible
manifestations, whenever this can be done without incurring a
yet greater risk.
If, on the other hand, the surgeon be persuaded that all the
formerly mysterious phenomena of cancer are now explicable by
local changes readily appreciable to his senses, and to a great
extent under his control, he will arduously seek for some
means by which to eradicate the malady in its more harmless
stage.
In the endeavours to establish a sound therapeutical applica-
tion of these modern doctrines of the pathology of cancer, one
most coinforting assurance is at once presented to us. It is
this : We have seen that malignancy is by no means the exclu-
sive property of one form of new growth, but it is shared to
some extent by nearly all the tumours with which we are
acquainted. We have further seen that the degi-ee of malig-
nancy appears mainly to depend upon such physical conditions
as the minute structure of the tumour, its consistence, and the
amount of moisture and movement of the affected locality.
Clearly, then, we need not isolate cancers from the other new
growths in the selection of our remedial measures. There is no
apparent reason why a remedy, Avhich Avill remove an innocent
tumour, will not be equally efficacious, as regards its action ujDon
local overgrowth, when applied tea malignant one ; any circum-
stances (as extensive local infiltration, or early gland contamina-
tionj likely to interfere with the successful issue, maybe readily
taken into consideration, and the treatment and prognosis varied
accordingly.
Hence there is nothing specific distijiguishing cancerous
from other tumours Avhich should prevent us from applying
of the Nature and Structure of Cancer. 117
other methods of treatment to such cases as for any reason
happen to be ill-suited for operation. To speak of the knife,
as some distinguished surgeons have done, as the only trust-
worthy resource for the cancerous patient — and tliis, too, in the
face of the unsatisfactory results hitherto achieved by this
means — and to rank with quacks those who earnestly seek for
better remedies, is calculated to advance neither our knowledge
of disease, nor our faith in therapeutics.
Lastly, there is no reason in the world why we should refuse
to admit that a cancer has been cured or permanently removed.
It has become quite common to hear surgeons say of a tumour
which has not returned after extirpation some years previously,
*' I suppose it was not really cancer, as it has not come back,
but it had certainly all the ordinary characters of cancer." In
like manner it is frequently said of reputed cures of cancer by
pressure, or caustic, or by other means, that the tumours could
not have been cancerous simply because they disappeared under
the treatment. It is surely time that we give up these notions
of the specific and inevitably mortal [character of malignant
tumours, for such doctrines are not only to be deprecated on
account of the insufficiency of pathological facts to be urged in
their support, but for the far more serious reason that they
stand in the way of any advance in rational therapeutics.
Nevertheless, when we come to consider the question of
treatment more carefully, complete removal of the tumour with
the knife is the first and obvious expedient of the surgeon, and
indeed, where it can be safely and effiectually accomplished, this
seems to be the distinct indication. But it is unfortunately the
fact that complete removal is only certainly possible in a very
early stage of the disease.
Partial removal is clearly inutile — if not absolutely hurtful —
from any point of view, save under very exceptional circum-
stances.
But since patients seldom seek advice until the earliest stage
has already passed, what is noAv indicated ?
Still, as it would seem, complete removal if possible; but now
a large amount of apparently healthy tissue must be taken
away with the tumour and any infected glands must be extir-
pated at tlie same time.
This is the operation which is most frequently called for, and
118 On the Therapeutical Importance of Recent Views
the defective performauce of which is to be blamed for much of
the opprobrium attaching to surgical interference in cancer.
It is, however, very important to bear in mind that this opera-
tion, if effectually done, is often necessarily hazardous to life.
How hazardous we have no statistics to show, for its danger
has been misrepresented by the invariable custom of grouping
together in the same statistical statements these larger with the
com j)aratively trifling incisions of less permanent value, or which
are sufficient in an earlier stage of the disease.
This point has been always overlooked in quoting the
mortality from the operation of amputation of the scirrhous
breast, and the consequence has been that a variety of useless
operations have been added to a few effective ones Avitli the
result of lowering the rate of mortality of the Avhole.
But this grave error, which has deceived surgeons by per-
mitting them to under-estiniate the risks to life of these opera-
tions, is not the only evil Avhich has resulted from this custom.
The profession being thus guided by the results of operations
clearly inadequate for the removal of the complaint (as when
enlarged glands are left in the axilla, or portions of the breast or
thickened skin are left behind, not to speak here of the strange
practice of intentionally removing most of a tumour only, and
leaving the nijiple or hardened muscle to spread the disease
again), a great and unjust prejudice has been excited against
the use of the knife at all, the erroneous impression of the
small risk to life being overweighed by the almost constant
return of the disease after a longer or shorter interval.
It is difficult to over-estimate the importance of these con-
siderations, for they strike at the root of all our present practice
for the relief or cure of" the most terrible disease with which the
surgeon has to grapple. Taking the most favorable view of
the nature of cancer — that it is an absolutely local change, but
extending far beyond its obvious limits, and very prone to dis-
seminate itself widely unless removed at an early period — it is
yet evident that we have to combat a malady Avhich will yield
to no half measures. The knife which is to cure it must cut
widely and deeply to effect its purpose. There must be no
piepe-meal removal which may scatter the seeds of the disease
in the wound ; nor must any the least suspicious bit be left
behind. The practice of sponging into the fresh operation
of the Nature and Structure of Cancer. 119
wound a solution of chloride of zinc, as first suggested by Mr.
De Morgan, seems also to be strongly indicated, unless the
surgeon prefers to use carbolic acid, or any other of the
numerous substitutes which, under the title of " disinfectants,"
have been zealously advocated since chloride of zinc was first
used in this way at the Middlesex Hospital. It will do no
good to shut our eyes to the gravity of such an operation.^
Let its increased risks be set against its greatly increased
efficacy, and if the risks are found to outweigh the benefits,
then let other means less dangerous be sought.
It is probable that in a large proportion of the cases coming
under the surgeon's care, some less immediately dangerous
therapeutical measure might be profitably substituted.
Caustics have seemed to some to meet this end to a great
extent, and their employment is certainly attended with in-
finitely less risk to life than extensive cutting operations.-^ The
intolerable and enduring pain attending their use has hitherto
contributed mainly to their neglect by English surgeons. From
some reason not easy to comprehend the practice of congealing
the part before the application of the caustic, although found to
be completely efiectual in the instances in which it has been
tried,^ has not yet been sufficiently widely tested to permit this
combination to be ranked amongst the reliable measures for the
relief of cancer ; but much remains to be done in this direction,
more particularly in those cases where the disease is con-
veniently located for such an application, and where the patient
has an unconquerable dread of the knife.
No doubt any remedy which affects the system generally
I " Since the operation has been done in more advanced disease, and the risk in-
creased by more freely opening the axilla, worse cases have enjoyed an extension of
health over three and four years, but the mortality has doubled. In one year the
deaths amounted to three in twelve." — " Cancer," by the late C. H. Moore,
Holmes's ' System of Surgery,' 2nd edit. vol. i, p. 599.
* " So far as our observation goes, this proceeding by caustics is altogether free
from risk to life, and from liability to blood disease." — ' Report of the Surgical Staff
of the Middlesex Hospital, On the Treatment of Cancer (by Chloride of Zinc
Paste),' 1857, p. 44.
3 " Congelation may be employed with great advantage in conjunction with
caustic, of which it diminishes the pain, without interfering with its action." —
" Cancer," by the late C. H. Moore, ' Holmes's System of Surgery,' 2nd edit., vol. i,
p. 609.
120 On the Therapeutical Importance of Recent Views
must, to some extent, affect any local ailment ■which, may be
present, and in this sense general remedies may be of some
service in cancer. But it does not seem likely that we shall
readily succeed in finding a drug Avhose action shall be so con-
centrated upon a given limited portion of the body as to arrest
in that part the excessive and ill-directed cell proliferation which
is so vigorously going on. It seems to be a peculiarity of all
morbid growths (as distinct from mere inflammatory tissue
changes), that they flourish quite independently of the general
nutrition of the body, and at the expense of the normal tissues
from Avhich the necessary pabulum is diverted.
Failing, then, general remedies, we should seek such a mea-
sure as will aim at correcting the local growth, by supplying
such condition or combination of conditions as arc found to
retard physiological growth and develoi^ment.
The present despairing custom of anointing the surface of
the swelling or ulcer with soothing unguents, or of fomenting,
or of the application of the various bland lotions or liniments
in common use must be regarded as mere placebo treatment —
useful, indeed, in its way for the alleviation of some of the
aches and pains of the growth, and for the calming of the
minds of the suflferers, but unworthy the serious consideration
of pathologists who, holding either of the theories of the nature of
the disease, yet hopefully seek some rational means of removing
the local mischief.
For we may again remind ourselves that the mystery of the
nature of cancer has almost entirely passed awav. That we
still know nothing of the proximate cause of the appearance of
a malignant growth is an admission we may fearlessly make,
since we know so little of the proximate cause of most of the
morbid changes whose results are now so minutely studied by
the morbid anatomist. But we no longer vex ourselves with
the fruitless search for a specific cell-form or chemical test which
shall distinguish cancers from other tumours.^ If our micro-
^ " The anatomical elenicnts of cancer and tubercle are now known to have no
special and peculiar characteristics, and they are believed to be as easily derivable
from pre-existing tissues as are oilier non-specific morbid growths. A mere local
change in the mode and intensity of pre-exisiting tissue-changes suffices to engender
them." — " Epidemic and Specific Contagions Diseases," Introductory Address by
Prof. Bastian, F.R.S., ' British Med. Journal,' Oct. 7th, 1871, p. 401.
of the Nature and Structure of Cancer. 121
scopic researches have taught us nothing more, at least they
have taught us this, — that the most mahgnant tiimours differ
from the most innocent and benign only in certain physical
conditions of structure or position which vary greatly in different
specimens, and which by their variations seem to explain with
sufficient clearness the corresponding varieties of malignant
projierties.
More than twenty years have passed since Dr. J. Hughes
Bennett published his work on Cancer, with its able and (con-
sidering the period at which it was written) heretical chapter
on " rational treatment," and to-day we may still learn many
a valuable lesson from its perusal. The operation which that
distinguished physician on purely pathological grounds, so
w'armly advocated, we on the like ground, and strengthened by
greatly extended histological researches, still contend for as the
most certain means of eradication of the disease where it can
be sufficiently boldly performed. Ablation by means of caustic
has been vastly imjDroved since then, and now forms one of the
recognised modes of treatment of certain cancers. In the " pre-
vention of the disease" we have made no ^^I'ogress, and if we
have to admit the same w4th regard to " means of retardation
and resolution," it is probably because surgeons have not suffi-
ciently considered the suggestions there referred to. The in-
fluence of " cold, dryness, pressure, and locality," have been
suffered to pass comparatively unnoticed, whilst all the heat of
debate and profusion of conflicting experiences have been
centred upon the operation and its results. Noav that we are
no longer baffled at the outset by a conviction of the constitu-
tional and hopeless character of cancer, and are no longer
walling to admit its '^ specific" nature, we may return with re-
newed ardour to the perusal of such encouraging works as those
of Young, Travers, Recamier, Bayle, Arnott, Walshe, and Collis,
prepared to weigh their evidence with the more favour and
candour now that we can class cancers with all other new growths
as far as any inherent and inveterate malignancy is concerned.
The practical application of the principles of treatment here
advocated cannot be considered in the present essay. That they
are not novel, and those who have employed them — in however
limited an experience — have not been dissatisfied with the
results, are facts greatly in favour of their being systematically
122 Receyit Vieivs on the Nature and Structure of Cancer.
and thoroughly ^.'orkecl out by surgeons generally, instead of
our being content to admit the virulence of the disease M^nch
combats all remedies, or to choose between an insufficient use
ot the knife, or an indiscriminate employment of bland and
inoperative topical applications.
ON THE
ACTION AND USE
OF THE
OPIUM ALKALOIDS CEYPTOPIA AND
THEBAIA.
By JOHN HAELET, M.D. Lond.
Cryptopia.
The only observations on the j)hysiological action of this
alkaloid are those made hy myself three or four years ago, and
recorded in my work on ' The Old Vegetable Neurotics.'
A very Umited supply of the substance prevented me at that
time from extending my observations as far as I Avished, but the
renewed kindness and liberality of Messrs. T. and H. Smith, of
Edinburgh, the discoverers of the alkaloid, have enabled me to
advance them a step or two further.
The chemical characters of the alkaloid used in the followins:
observations are those of the pure substance described at p. 165
of my work. It is there stated, on the authority of Messrs.
Smith, that it exists in opium in the proportion of about one
ounce to a ton ; but these gentlemen have since informed me
that they have succeeded in isolating it in double this proportion,
and that there are grounds for inferring that a ton of opium
contains at least four ounces of cryptopia, the percentage being
probably equal to that of meconine, viz. 0*026. In the follow-
ing observations, a solution of the alkaloid in water containing a
slight excess of acetic acid was employed : 100 minims of the
solution containing five grains of the pure alkaloid.
Physiological action. — This has been studied afresh on the
dog, the cat, the rabbit, and on man.
124 On the Action and Uses of the Opium Alkaloids.
OxthkDog. — The effects of cryptopia on the dog vary like
those of morphia, hut not to the same extent, for they are always
eminently characteristic. In one class of this animal — that in
which morphia causes persistent nausea, faintness, and restless-
ness — cryptopia produces a most remarkable excitement of the
voluntary movements, followed by somnolency. In the other
class, that in which the hypnotic effect of morphia is readily
induced to the exclusion of any notable derangement of the
vagus, cryptopia still manifests its peculiar action, but the
hypnotic and convellent effects are more equally balanced, and
in some animals the former effect exceeds the latter and partially
effaces it. Tims :
Obs. 1. — Injected beneath the skin of a young dog weighing
twenty-one pounds, and in whom the subcutaneous use of half a
grain of morjihia induced complete narcotism for eight hours,
one and a half grain of cryptopia. The operation frightened
the dog, and after ten minutes he was dull and slobbered very
much, clear glairy mucus dropping occasionally from his closed
mouth. After thirty minutes, the first stage of excitement, the
seemingly prying motions of the head were observable, but
these soon subsided, and he lay down at my feet and remained
very quiet during the next hour. Pulse 120 and regular, the
pupils dilated, and clear miicus dropping continually from the
mouth. He seemed in a dozy, dreamy condition. When
disturbed at the end of the second hour, he followed me down
stairs ; ate food as usual at the third hour, and then lay down
and slept tranquilly for several hours.
The effects of the same dose on a dog of the other class
mainly consist in extraordinary vivacity of mind and body,
marked by an interesting play of voluntary and involuntary
movements. This condition is fully described in my work, and
it is well illustrated in the following observations on the cat and
rabbit, whence it will appear that the action of cryptopia on
the dog, cat, and rabbit, and so flir on carnivora and hcrbivora,
is remarkably uniform.
On the Cat. — Obs. 2. — Injected half a grain of cryptopia be-
neath the skin of a young cat. A, weighing two pounds. After
eighteen minutes she began to look about intently in front of the
nose. After twenty minutes, pupils dilated ; mouth and throat
Cryptopia on the Cat. 1.25
uncomfortable, evidenced by licking the lips, and efforts of
swallowing ; walked slowly and naturally, looking pryingly about
her. After thirty-five minutes, champing and swallowing, slob-
bering of tenacious mucus. After forty -five minutes, advanced
very slowly, apparently impelled forwards, and yet holding back
and moving with hesitating advance of the fore paw and
frightened looks, only a step in a minute, as if she were walking
on dangerous ground. This continued until the end of the
second hour, when the pulse was 240, the pupils still dilated.
Apparently about to advance, the body was swayed backwards
and forwards, as she looked with a scared aspect from side
to side, as if under the influence of some illusion ; and thus
she succeeded about once in ten minutes in advancing a pace
forwards. At the fourth hour the slobbering had ceased, and
she mewed in recognition of my call. Pulse 200 ; pupils con-
tracting a little at the light. Half an hour afterwards she
had quite recovered.
The experiment was repeated with another cat of the same
age and family with exactly the same results, viz. slobbering of
tenacious mucus ; forward impulsive movements ; dilated pupils.
Heart beats from 260 to 280 ; respiration accelerated 80.
Obs. 3. — Injected three quarters of a grain cryptopia beneath
the skin of a young cat w-eighing about three pounds. After five
minutes, she suddenly started across the room in an awkward
frightened manner, and began to lick the lips, and then became
quiet. After fifteen minutes, characteristic cfiects came on and
continued for the next three quarters of an hour ; the fore legs
were advanced, a little outspread and firmly set, and the head
retracted and afiected with rapid jerking movements backwards
and forwards and from side to side. Now and then a fore paw
was raised from the ground and twisted or shaken with spasm,
and then the body while rigidly oscillating, as it seemed, between
a forward and backward impulse, w^as thrown forAvards in a
nervous scramble. After a succession of such movements the
animal got into a corner, and there continued to jerk the head
about as if constantly avoiding a prick of the nose. ^\Tien
approached, she manifested first great nervousness, then anger,
putting back her head and hissing at me, but after a little caress-
ing she became more composed and seemed comforted; the
choreic movements of the head and fore paws continued ; tlie
126 On the Action and Uses of the Ojnum Alkaloids.
respiratory movements were increased, and the pnpils dilated to
twice their initial size. Brought again into the centre of the
room, she got hack into the corner hy a succession of the hesitating
scrambling movements, the body being arrested as soon as the
rush was made, by the rigid forward set of the fore legs. These
spasmodic movements gradually declined, and ceased about an
hour and a half after the injection, and the animal remained in
the same corner during the next ten hours sleeping comfortably.
At the end of this time she had taken neither food nor water, nor
passed any excretions. Next day she was quite well and lively.
Obs. 4. — Injected one grain cryptopia beneath the skin of a
young cat of the same family, age, and weight as A. She con-
tinued quiet, but, after ten minutes, strings of frothy tenacious
mucus were hanging from the mouth, and she began looking
attentively from side to side. After fifteen minutes, these
symptoms continuing, the tail was extended, and curved up-
Avards near the root ; the body rigid and tremulous, apparently
impelled forwards, and the impulse resisted or balanced by a
rigid advance and set of the forelegs. While in this attitude
a fore paw was occasionally raised slowly and supinated, and
then advanced as if striking at a mouse. When the animal had
maintained this constrained attitude for two minutes, she was
suddenly hurled forwards, and rolled over and over in an opis-
thotonous convulsion, which lasted half a minute. As soon as
the animal regained her legs she Avas impelled forAvards in a
succession of little convulsive leaps, first to the right and then
to the left, the tail and ears erect, and the head raj^idly jerked
from side to side, the pupils dilated and the eyes staring. As,
however, she constantly regained her legs, she seemed to be
wildly scampering after a mouse. After tAventy-tAvo minutes
she crept sloAvly and quietly along, Avith a stiff, awkAvard timid
gait — the extended tail and erect ears being occasionally strongly
tAvitched ; meAving and ansAvering Avhen spoken to — and couched.
While in this position, all the muscles Avere affected with inter-
mittent spasm; noAvahipAvas suddenly raised, nearly throwing
the animal on her side ; now the muscles along the back of the
neck were violently Avorked ; and noAv a fore arm was raised, the
claws extended, and the limb shaken with spasm ; one or other
ear meauAvhilc Avas in a state of vibration. This continued to
increase until the thirtieth minute, Avhen she Avas throAvn forAvards
Cryptopia on the Cat. 127
a second time, in a most violent tetanic spasm. It lasted but a
second, and as the cat lay on the side the suspended respira-
tion was re-established with slow and laboured inspirations,
until they increased to seventy, and became regular ; then the
animal was for a few minutes free from spasm, and continued
lying on her side looking about intelligently. At the fortieth
minute the twitchings came on again, and the cat, having raised
herself on the slightly-sprawling and floor-clutching legs, was
alternately swayed backwards and forwards until the forty-
seventh minute, when she was again thrown violently forwards
in a third convulsion, in which all four legs were aifected with
most rapid movements. The attack lasted about fifteen seconds,
and the breathing was recovered as before. The cat now seemed
recovered, but exhausted, and she moved a length now and
then when disturbed. At the fifty-second minute the spasm
returned, in a milder degree ; and at the fifty-fifth minute the
body was raised on the haunches, the head and chest being
curved forwards, and the fore paws incurved, and shaken for a
few seconds with the most violent and rigid spasm. This over,
the cat fell exhausted on her side, relaxed and apparently dead;
the breathing, however, was restored by one or two laboured
inspirations. At the sixtieth and sixty-second minutes, she had
a fourth and fifth convulsion, the former lasting twenty seconds;
in the interim the respirations were twenty, snatching and
irregular. After the last attack she lay on her side breathing
freely and deeply ; but shortly afterwards she regained the
couching position, Avith her fore legs a little sprawling, and,
while in this position, and from this time up to the end of the
fourth hour, the body was affected with constant choreic move-
ments. These were at first so severe that the animal could not
stand, and, as she lay along on the belly, the writhings of the
muscles of the trunk moved the body half a circle from left to
right in the course of half an hour. The abdominal muscles
were strongly worked, and the head was extended and twisted
in a wriggling manner by the spasm of the cervical muscles.
The pupils were widely dilated throughout. During the earlier
part of the choreic stage the respiration was twenty, irregular;
the inspiration labored, and the expiration short and explosive ;
the heart's action weak and raj^id. Towards the decline of
the chorea the respiration increased to eighty, but continued
128 On the Action and Uses of the Opium Alkaloids.
irregular ; heart heats 260 and regular. The intelligence was
apparently unimpaired throughout. From the fourth to the eighth
hour the animal remained in a quiet dozy state, but passed no
excretions from first to last. Next day she had quite recovered.
The effects of morphia on this animal in doses varying from
T^jths to \ grain,, were delirium and restlessness with increased
cardiac action and temperature, and complete and fixed dilata-
tion of the pupils. Effects in fact precisely similar to those which
follow the use of morphia in the horse.
On the Rabbit. — Obs. 5. — Injected two grains of cryptopia
beneath the skin of an adult male rabbit, A. Immediately after-
wards the respiration was 160 and panting, apparently from the
excitement caused by the act of injection. He continued to hop
and pry about the room actively and naturally until the seventh
minute, Avhen he erected an ear, and began to pant, and to hop
round at short intervals. During the next few minutes the
excitement increased; and, as he hopjjed sideways in a circle,
the head was constantly advanced, and the nose rapidly worked
Avith a sniffing motion, as if the animal was busy upon
some object before its face. A fore paw was occasionally
advanced as a preliminary to the hopping movement; the chest
was contracted, and in vibration from rapid panting. After
fifteen minutes, he began to slip forwards a little on the legs,
the fore limbs being extended forwards, and seemingly exerted
to prevent the advance. After half an hour, having con-
tinued in the same state, the head was now raised, and
jerked backwards and forwards, the lips being separated each
time the head Avas jerked backwards, and the animal was sud-
denly advanced a pace, as often the apparently voluntary resis-
tance gave way to the involuntary impulse forwards ; pupils
widely dilated ; respiration still a fine pant. After three
quarters of an hour, the hind legs seemed weak, and the for-
ward movement was more clumsily restrained. After one hour,
heart beats 160 ; respiration still shallow and panting ; pupils
still dilated ; restlessness decreased. From this time the
symptoms slowly subsided, and after five hours from the injec-
tion, the animal leisurely ate a little green stuft'. After six and
a half hours he Avas in his usual condition, but as yet liad not
passed any excreta.
CrijiHopia on the Rabbit. 129
Obs. 6. — Injected, by four punctures, three and a quarter
grains of cryptopia beneath the skin of another adult male
rabbit, B. After fifteen minutes he was in the state of rabbit A
(Obs. 5), at the same time. After twenty minutes the hind legs
gave way, and the animal lay on the chest and belly, the head
being rapidly jerked backwards and forwards, and from side to
side. Occasionally the head was bent downwards, and the nose
frequently tapped on the floor. After twenty-five minutes,
lost the use of the fore legs ; occasional spasm in the hind legs,
slightly advancing the body ; increased restlessness of the head ;
respiration 80, short, snatching, and somewhat irregular]
pupils a little dilated. After thirty minutes, the jerkings and
writhings of the head and neck increased, with very strong
retractile action of the muscles of the neck, while the facial
muscles, and especially those of the lips and vibrissa?, were
powerfully convulsed. Five minutes later the muscles of the
lower jaw were similarly implicated, the mouth being alter-
nately opened and closed, with strong grinding of the teeth.
The tongue was also convulsed. The animal now lay on the
side, incapable of voluntary movement, the hind legs and hips
flaccid, and the muscles of the face, head (excepting the orbicu-
laris and muscles of the eyeball), chest, shoulders, and fore legs
in a constant state of regularly intermittent spasm, the twitch-
ings numbering fifty in the minute, and being synchronous with
the inspirations. Heart's action meanwhile quite regular, and
140. The parts unaffected by spasm were not paralysed, for the
hind leg was drawn up when touched, and the eyelids closed on
attempting to approach the cornea. After one hour, the eyelids
and hind legs were affected with spasmodic twitchings. Pupils
of their initial dimension. The animal continued in this state
until the end of the second hour, when the twitchings began to
intermit, and give place to intervals of quiet of a few seconds
duration. It had lately been impossible to coimt two successive
inspirations, or even to distinguish the respiratory movements
from the general twitchings of the muscles, but now five or
six panting inspirations coukl be counted continuously. There
was no apparent change in the circulation, and the body
continued very warm. After two and a quarter hours the animal
struggled to get on the belly, but was unable to retain this
position until seven minutes later on, when he had just power
VOL. II. 9
130 On the Action and Uses of the Opium Alkaloids.
enough to maintain the couching posture. Heart heats 160 ;
respiration 144, irregular, heing sometimes accelerated to a
quicker pant. The head alone was restless now.
From this time the symptoms rapidly passed off, and at the
fifth hour the animal seemed to have quite recovered. Up to
the seventh hour no excretions Avere passed.
Obs. 7. — Injected three and a half grains of cryptopia into
the subcutaneous tissue of rabbit A. After forty minutes, one
grain more, and one hour later another grain, making in all
five and a half grains. Up to the forty -fifth minute the effects
were precisely the same as those described in Obs. 5, the head
being constantly twitched, the hind legs weakened and still, and
the body slowly moved round in a circle from right to left by
the spasmus of the anterior part; the chest contracted, and
the resi)iration reduced to a fine, rigid, irregular panting,
numbering 160 a minute. During the second hour the symp-
toms were the same as those in Obs. 6, at that period of the
oj^eration of the drug ; there was the same powerful grinding of
the teeth and writhing of the tongue. The muscles of the
eyeball and the orbicularis muscle escaped throughout, and
the latter exhibited reflex movement up to the time of death.
Half an hour after the third injection, the muscles of the face,
neck, shoulders, and upper part of the chest were still affected
with incessant twitchings, but the spasms were growing weaker,
and the rest of the body was flaccid, and losing heat. Four
hours after the first injection the spasmodic movements had
become very weak, but not less frequent, and being now
confined to the shoulders, neck, and head, the respirations
could be counted ; they were 50, and very faint; the heart beats
96, and feeble ; the pupils dilated. The spasmodic movements
became gradually weaker, until at last they were almost im-
perceptible, and then the animal was dead ; this occurred four
hours and twenty minutes after the first injection. At the moment
of death the pupils contracted to their initial size, and the tem-
perature of the rectum Avas 94° Fahr.
The body was opened ten minutes after death; the diaphragm
was drawn up into the chest; the lungs collapsed, pale, and
crepitant ; the large veins at the roots full of dark blood. Both
auricles were contracting synchronously and regularly 70.
Shortly after the pericardium was opened, the ventricles began
C)'yj)ioj)ia on Man. 131
to contract, and continued to do so regularly sixty times a
minute.
The ventricular contractions chiefly affected the apex of the
heart, the left side of the organ being twisted forwards to the
right, and the apex at the same time drawn upwards towards
the base, and flattened. These movements continued for fifteen
minutes after opening the pericardium, and were independent
of the withdrawal of blood from the heart. All four cavities of
the heart, the pulmonary veins, and their branches in the lungs,
as well as the venee cavse, were distended Avith dark venous
blood, and it was clotted in the ventricles. The urinary
bladder was full, and the stomach and intestines were filled
with food and faeces.
On Man. — The main conclusions which, from a limited
number of observations, I formed three years ago as to the action
of cryptopia on man, were as follows: — 1. The hypnotic effect
is both considerable and protracted in those Avho are readily
calmed by morphia, and that. in this respect it is one fourth as
powerful as morphia. 2. Although no unpleasant effects have
followed its use in man, furtlier experience is required to show
that, as a hypnotic, it possesses any advantage over morphia.
Subsequent experience has confirmed me in the former of
these conclusions, and with regard to the latter I am able to
say that, as a gentle hypnotic, used subcutaneously, it does
possess considerable advantages over morphia. In only one
case has the subcutaneous use of the drug been attended by any
unpleasant consequences, but even this does not properly form
an exception. I give the case with the patient's statement, in
order that my readers may form their own opinion. The other
cases will serve to illustrate the general and particular eff*ects of
the drug.
OI)S. 8. — James B — , act. 55, a feeble, anrcmic man, afflicted
with general rheumatic neuralgia. Pulse 90, regular, of fair
volume and power. Right pupil one eighth, left one ninth. In-
jected Dlxxiiss of solution of acetate=l^ grain of cryptopia,
beneath the skin of the arm. After seventeen minutes, pulse 76,
pupils unchanged; somnolency, but felt faint. After twenty-seven
minutes, continued feeling of faintness, cold and pale; pulse 60,
weak, regular. Gave him 5J Spir. Amnion, co. in a draught of
132 On the Action and Uses of the Opium Alkaloids.
water. Still sat quietly in the chair, and moaned occasionally
Avhen left alone. The faint feeling gradually passed off. After
three quarters of an hour, pulse 60, weak and regular; respiration
30, regular ; pupils unchanged ; tongue natural ; surface cold.
After two hours, quite comfortable and dozing ; pulse 58, regu-
lar, of initial volume and power ; respiration 20 ; pupils un-
changed ; continued to doze comfortably for another hour and
then walked home. I attributed the fi\intness to the action of the
medicine, but the patient assured me it had nothing to do Avith
it as he was liable to frequent attacks of the kind, and that they
were occasionally of greater severity than the one I had witnessed.
A week after, he reported himself as being free from pain.
Ohs. 9. — Thomas W — , ret. 31, a strong man affected Avith
right facial neuralgia. Pulse 88, tongue moist ; pupils, the right
-fth, the left ',th.^ Injected into the subcutaneous tissue of
the arm iH.xxiiss of solution of acetate = 1 \ grain cryptopia. After
twenty minutes, decided dilatation of the pupils, and somnolency.
After thirty minutes, pulse 84, tongue unchanged; pupils, right
one sixth, left one fifth ; considerable somnolency. Went home
and slept soundly for some hours. After a week he reported
that the tic passed off under the influence of the cryptopia, and
had not reappeared. This was five weeks ago, and as he has
not reappeared amongst my out-patients I conclude that the
relief has been thus far permanent.
Ohs. 10. — Charles H — , ret. 18. Insomnia, fifth day of typhus.
Pulse 100 ; respiration 24; pupils one seventh ; tongue clean,
dry, and glazed. Injected solution of acetate = to 1^ grain cryp-
topia, into the subcutaneous tissue of the arm. After twenty
minutes, pulse 96 ; respiration 26 ; pupils and tongue unchanged;
inclined for sleep. After one hour and a half, had slept com-
fortably since last seen. Pulse 96, increased in volume and power ;
respiration, sleeping 36, Avaking 30. Pupils dilated as he slept,
on waking, one fourth ; felt quite comfortable. After two hours,
was still sleeping ; pulse 96 ; respiration, sleeping 40, awake
36. After three hours, still sleeping ; respiration 40 sleeping,
awake 36 ; pulse 100. Five hours after the injection, passed f,5xvj
of dark brownish acid urine like maltwort, sp. gr. 1027-2; on
standing it deposited a quarter of its volume of stone-coloured fluffy
amor})hous deposit, soluble in ammonia. The clear urine had
' See Obs. 1 5^ et scq.
Cryptopia on Mom. 133
a peculiar glaucous-brown colour; it contained a large excess of
lithic acid.
After an interval of three days the injection of 1^ grain cryp-
topia was repeated, the pulse being 100, respiration 36, and the
pupils one seventh. After thirty-five minutes, pulse 98, respi-
ration ^Q, pupils one sixth ; a troublesome cough had prevented
sleep. After one hour, pulse 100, respiration 40 ; sweating mo-
derately, and was comfortable and inclined for sleep. After two and
a quarter hours, slept since last seen ; pulse 100, respiration
40, pupils one sixth. Five hours after the injection, passed f Jvij
of normally acid urine, sp. gr. 1022, of the same peculiarly yellow-
ish- or greenish-brown colour, quite bright and free from deposits.
Ohs. 11. — Injected solution of the acetate in doses varying
from 1 to 1^ grains, beneath the skin of a weakly man of middle
age who had suffered long and severely from sciatica. The
anodyne effect of the drug was immediate, marked, and en-
during. As a hypnotic the result of its action was most satis-
factory. Somnolency came on about ten minutes after the in-
jection and continued for five or six hours ; the sleep was tran-
quil and undisturbed by dreams. Dilatation of the pupil was
a marked effect in this case.
Eltminatiox. — The urine excreted after the action of cryp-
topia, in the cases in which I have had an opportunity of
examining it, has possessed a peculiar yellowish- or greenish-
brown tinge by transmitted light. This was the condition in
Obs. 7 and 10. On opening the bladder of the rabbit I found the
urine crowded with white pyriform bodies, about half the size
of a graiu of Avheat, and of faint outline and gelatinous appear-
ance, but quite distinct and of equal size. Searching as I was
for Bilharzia (having fed the animal on the eggs of the parasite),
my first thought was that they might be a brood of minute
flukes. This idea, however, was not long tenable, and my
second conjecture, remembering the remarkable way in which
narceine is separated from the blood in the kidney, wa's that the
bodies were jelly-like masses of cryptopia, as they had been
dropped from the orifices of the tubules into the calyces of the
kidney. This led me to examine the urine for cryptopia. I
collected a portion of the jelly-like bodies on a filter, and washed
them free from urine, and, having dried the filter, boiled it in
absolute alcohol to abstract any cryptopia. The hot alcohol
134 On the Action and Uses of the Opium Alkaloids.
filtrate was allowed to evaporate spontaneously in a watch-
glass. A stain remained, composed at tlio margin of a few
minute scattered prisms. On causing sulphuric acid to flow
over the stain, a rich violet colour was developed, and on heat-
ing the fluid it became slate coloured, thick, and opaque. The
other portion of urine was treated, first with acetic acid, which
dissolved tlie gelatinous bodies, and then Avith ammonia to neu-
tralization. The deposit thus obtained, composed chiefly of
phosphates, was washed and exhausted with alcohol. The stain
left by evaporation also gave a violet colour. Hence I think it
may be inferred that a minute quantity of cryptopia was present
in the urine; but the jelly-like masses could scarcely have been
wholly composed of this substance, for in this case the quantity
obtained would have been greater ; probably they were formed
by the deposit of phosphates, in the most delicate gelatinous
film of cryptopia. I examined the urines obtained in Obs. 10
in a similar way, and, by means of hot chloroform, obtained from
the deposit of washed phosphates a filmy residue ; but this
developed only a reddish-brown colour with sulphuric acid, be-
coming darker on the application of heat.
Co^XL^SIONS. — Taking now a general review of the action
of cryptopia, we cannot ftiil to see that in its effects on the
nervous system it stands exactly midway between morphia
and thebaia, sharing equally in the qualities of both. We
have applied the test of diff'erent nervous systems to the sub-
stance, and found that those of the mouse, of some dogs, and
of man, give sleep, while those of other dogs, of the cat, and
of the rabbit, give convulsion. A grand physiological truth
lies here, for surely these experiments teach us that sleep and
convulsion are but one, mutually and readily interchange-
able, the variation being determined by certain peculiarities
resulting from mechanical or molecular variations of the nervous
system ; in a word, the one test gives us white light, the other
a coloured spectrum.
He must be a dull observer of disease Avho has failed to recog-
nise the close relationship of sleep and convulsion. How many
an epileptic patient, for example, is distressed with the thought
that, on laying himself down to rest for the night, sleep and
convulsion will struggle for the possession of his nervous
system, or that, on rising in the morning, and before he has
Cryptopia and Thebaia compared. 135
completely shaken off the influence of sleep, convulsion may
assert its relationship !
After witnessing the extreme susceptibility of the mouse to
the tetanizing action of thebaia and codeia, and seeing a power-
ful dog thrown over and over in the convulsions produced by
cryptopia, nothing has surprised me more than to see the former
little animal sleeping soundly for many hours under the influence
of a moderate dose of cryptopia, and passing, under the action
of a larger, from the state of narcotism to that of death, without
the slightest movement.
What is the explanation of this apparent anomaly ? Are the
nervous systems of the different physiological classes of animals
like different musical chords ? and do the constituents of opium
correspond to variations of a particular note, one of which is in
unison with this particular chord, another Avith that, while all
the rest are more or less at variance with both ?
But, to return to facts, we have yet to discriminate a difference
in the hypnotic action of cryptopia and morphia on the one hand,
and a difference of excitant action between cryptopia and thebaia
on the other. First as to the excitant action, the broad distinc-
tion between the two alkaloids is this — that the convulsion of
thebaia is a persistent spasm, and that of cryptopia an intermit-
tent one. Thebaia holds the muscles with the most inflexible rigor,
and the stiffened and motionless body may be held straight out by
one of the extended hind legs. Cryptopia throws the whole of
the voluntary muscular system into rapid and violent vibration.
Thebaia descends upon the muscles like a stroke of lightning ;
one minute the animal is tranquil in mind and body, the next
he is thrown over, extended and stiffened, and, at the same time,
suffocated by a prolonged iron-like grip of the chest. Cryptopia
diffuses its influence gradually; at first there is but a restless
vivacity of the ordinary movements, a mere impulse to greater
muscular activity ; after a while the impulse becomes stronger,
but the animal is not yet deprived of control over his actions ;
and now follows a remarkable struggle between voluntary
and involuntary movement. As the influence of cryptopia in-
creases, the former slowly gives way to the latter ; the battle,
however, is severe, and the bodily and mental excitement intense,
until the cryptopia obtains complete mastery, and then the help-
less animal is thrown over on its side, vibrating with a violent.
136 On the Action and Uses of the Ophnn Alkaloids.
intermittent spasm. The aeration of the blood, however, is not
completely suspended, for the chest may still be said to pant
under the influence of the spasm. The fit over, the animal is
completely conquered and exhausted, and as the action of the
alkaloid declines, and he slowly regains power over his movements,
he now submits unresistingly to the influence of the cryptopia,
and his body is affected Avith every variety of choreic movement.
Thus, from first to last, cryptopia follows, so to speak, in the
track of the ordinary movements, and ultimately excites them
beyond the power of control ; the primary chorea culminates in
epilepsy, and the epileptic fits cease when the choreic move-
ments deline in intensity.
Such is the main distinction between the convcUent actions
of thebaia and cryptopia on animals generally ; but I must again
go back to the mouse to shoAV how this distinction is eff'aced.
Thus, Avhile cryptopia has no convellent action whatever on this
animal, thebaia induces the vibratile spasm of cryptopia. Thebaia
is to the mouse Avhat cryptopia is to the dog, cat, or rabbit.
It now remains for us to consider the difl'erence between the
hypnotic and general effects of morphia and cryptopia. The
sleep of cryptopia is as prolonged as that of morphia, but it is
lighter and consequently more refreshing, and, as far as I have
been able to ascertain, it is quite free from the illusions Avhich
so often attend sleep induced by morphia. But this is not the
only advantage which cryptopia possesses over morphia. Cryp-
topia exercises no deranging influence over the vagus. The
subcutaneous use of morphia in man is often followed by dis-
tressing sickness, and occasionally by alarming, not to say fatal,
faintncss ; while in the dog, vomiting is the first and hwariahlG
consequence of its use. Such effects never, as far as I have
seen, follow the use of cryptopia in any animal, whatever the
dose may be. After the explanation given, and the want of
similarity to the distressing effects of morphia, I cannot consider
Obs. 8 as an exception to this statement. Cryptopia is therefore
in many cases a pleasanter, and in all a safer, remedy than
morphia given subcutaneously. As an anodyne I have reason to
be well satisfied with cryptopia. I have employed it with a
success equal to that obtainable by morphia, in several cases of
severe neuralgia. jNIessrs. Smith prepare a soluble sulphate of
the alkaloid, of which half a grain may be considered a medium
Thebaia on the Rabbit. 137
(lose for a woman and one grain for a man, nscd snbcutaneously,
I prefer the acetate, however, as it is more sohible.
Thebaia.
I know of no observation on the action of this alkaloid on
man. It is assumed to have a simple tetanizing effect. I
discovered in my earlier experiments that this Avas an imperfect
view of its action, and that like all the other active constituents
of opium, thebaia induces the two apparently opposite states of
hypnosis and tetanus. In the lower animals the tetanizing action
so greatly exceeds and disturbs the hypnotic effect, that the latter
is overlooked. But even in these animals a marked degree of
somnolency may he observed under the influence of moderate
doses of the alkaloid. In man, however, and in medicinal
doses, hypnosis, with contraction of the pupil, is the only effect
to be observed. In nearly all of the following observations I
have sat by the side of the patient during the action of the
drug with the view of catching the first indications of convul-
sive action, but I have uniformly failed to witness the slightest
tendency thereto. The largest dose given by the subcutaneous
tissue was one and a half grain = six grains by the alimentary
canal. The thebaia employed is identical in chemical and
physical characters with that used in my former observations
(op. cit., p. 1T9). The solution used was formed by dissolving
thebaia in water by the aid of acetic acid, iH.xv = one grain of
the pure alkaloid. I have studied its action alone, and in com-
bination Avith atropia, and in order to bring out its action upon
man into stronger contrast, I shall preface my observations upon
him by an illustration of the effects of a poisonous dose on the
rabbit.
On the Rabbit. — Ohs. 12. — Injected nixxx of the solution
= gr. ii thebaia, by two punctures beneath the skin of a
healthy full growai rabbit, b. At the seventh minute the animal
was aroused from a state of quietude by a few preliminary
convulsive starts, and then thrown upon the side in strong
opisthotonous spasms, the head being strongly retracted, and the
fore legs stretched forwards and shaken with a fine rigid spasm.
This continued Avith momentary interruptions, Avhen the chest
Avas released, and the respirations (84 and regular) could be
138 On the Action and Uses of the Opium Alkaloids.
counted for a few seconds, until the twelfth minute, when the
hind legs were thrown out in rigid spasm, and semen was
ejected. The spasm only relaxed with death, at the seventeenth
minute. The chest was opened six minutes afterwards. The
lungs were of a salmon colour, and completely collapsed above
and behind the heart. The great veins at the roots of the lungs,
the cavae, and the right heart, were enormously distended with
venous blood. The right ventricle was motionless, the right
auricle pulsating faintly but regularly 72. The left heart Avas
contracted and motionless. On relieving the distension of the
right auricle by dividing some small branches of veins converg-
ing to it, the contractions of this cavity became stronger, and
were increased to 200 a minute. On puncturing the inferior
cava just above the liver, a minute later, a stream of black
blood spouted forth, and the right ventricle at first became
flaccid, then, having contracted, began to beat regularly 8J: times
a minute, the auricular contractions under the influence of the
free depletion being at the same time reduced to 70. These
contractions of the right heart continued until the eighteenth
minute after the death of the animal (the thirty-fifth after the
injection of the poison), the pericardium lying open the whole
of the time. The urinary and gall bladders were full ; the urine
was thick from amorphous deposit, and of a primrose-yellow
colour.
Death was the direct result of simple cramp of the muscles
of respiration sufficiently prolonged to exhaust the arterial
blood of its oxygen.
On Man.— 0^*5. 13.— Samuel M— , »t. 50. Pulse 84, pupils
one eighth, respiration 19-20. Accustomed to the subcutaneous
use of the active principles of opium, occasionally given for the
relief of severe facial neuralgia (see " Old Veg. Neur," Obs. 60).
I'lv of the solution = one third grain of thebaia were injected
into the subcutaneous tissue of the arm. After fifteen minutes,
somnolency. After thirty minutes continued somnolency ; pulse
78, unchanged in volume and power ; pupils one ninth ; re-
spiration 20-21, regular. After one hour, continued somnolency ;
pulse 78, a little fuller ; pupils one ninth ; respiration 20. After
two and a half hours, somnolency had continued, and he had
slept a quarter of an hour ; but the effect Avas now passing off.
Thebaia on Man. 139
Pulse 78, decidedly fuller and stronger, and quite regular ; pupils
dilated to their initial size ; mouth a little clammy ; felt quite
comfortable during the action and continued to do so. Now
walked home and went to bed, and slept soundly all night.
Ohs. 14. — After an interval of four months, pulse 76; pupils
one ninth, at a given distance from a gas light ; respiration 20.
Injected nix of the solution = two thirds of a grain. After thirty-
five minutes, considerable somnolency, " very heavy for sleep ;"
pulse 76, decidedly fuller ; pupils one tenth. After one hour
and ten minutes, continued somnolency ; pulse 76, of increased
volume and power ; pupils one tenth. After two hours, somno-
lency passed of; pulse 68 of initial volume and power. Pupils
nearly attained their initial dimension ; respiration 20. Now
walked home, went to bed, slept soundly all night, and ex-
perienced decided somnolency next day.
Ohs. 15. — After an interval of a week, the pulse being 72, small
and Aveak, with an occasional intermission, right pupil one ninth,
left one sixth,i injected ni.xv = one grain. After thirty minutes,
pulse 72, unchanged ; pupils one tenth ; respiration 20, regular ;
great somnolency. After one hour, pulse 78 without inter-
mission; both pupils one tenth; respiration 21. Had slept
quarter of an hour, and was still very sleepy. After two hours,
pulse 72, regular ; pupils returned to initial size ; respiration
18-19. Had been sleeping most of the time comfortably.
Ohs. 16. — After an interval of six months, injected nixix of
the solution = one and a quarter grain, and he immediately
walked home a distance of two miles, and went to bed. Som-
nolency came on ten minutes after the injection, and, after
reaching home, he slept soundly through the remaining ten
hours of the day, and the following night.
Ohs. 17. — After an interval of five days, the pulse being 84
and small, the pupils one sixth, and the respiration 20, injected
iil.xxiiss= one and a half grain of thebaia. After twenty minutes,
pulse 76, unchanged in volume and power ; pupils one eighth ;
respiration 21-22; great somnolency. After one hour and twenty
minutes, pulse 76, unchanged ; pupils one eighth ; respiration
' The intermission of one or two heats a minute, and the inequality of the
pupils, were symptoms which commonly attended a paroxysm of neuralgia.
This was confined to the right side of the face, and caused slohhering from the
angle of the mouth, and hypersesthesia of the affected part.
140 On the Action and Uses of the Opium Alkaloids.
19-20. Somnolency continued, but a paroxysm of tic prevented
sleep. Went home, slept soundly until next morninii-.
Ohs. 18. — Mrs. T — , a:t. 3(S,a weakly woman with impaired in-
nervation of the lower extremities. Pulse 80 ; pupils one eii>hth ;
injected v.\s. of the solution = two thirds of a grain thehaia into
the subcutaneous tissue of the arm. After five minutes, began
to feel a little giddy and stupid. After forty minutes, continued
to feel stupid and a little sickish and faint, and could not walk
without the support of the wall or furniture, having great
difficulty in getting the weaker leg from the ground. Pulse
and pupils unchanged. After one hour pulse, 78 and fuller ;
pupils not appreciably smaller. The effects were now passing off,
and she w-as sitting in a chair talking to a friend. Shortly after
she lay down and dozed comfortably for the rest of the afternoon.
Ohs. 19. — Frederick T — , Kt. 22, rather lame from sciatica of
eleven weeks' duration. Injected, on four separate occasions,
:, 1, 1}, and \\ grains of thebaia into the subcutaneous tissue
of the thigh. A pleasant hypnotic effect followed each dose
within ten minutes, increasing in intensity for the next hour,
and then, as an irresistible influence, passing off; but, left quiet,
the patient slept tranquilly for several hours afterwards. During
sleep, or at the moment of awaking, the pupils Avere dilated,
but on looking intently at a distant object they Avere decidedly
contracted. The anodyne effect AA-as such that the pain Avas
relieved by the first injection, removed by the second, and has
not returned since.
Ohs. 20. — George H — , a?t 20, a delicate youth, took two
grains of thebaia by the mouth every third day, six times. It
caused a slight and transient giddiness, coming on after half an
hour, and lasting about thirty minutes. After one dose there
Avas a little somnolency, but this Avas attributed to over-eating.
CoNCLL'SiONS. — I have finished my previous observations on
the action of the active principles of opium Avith these Avords : —
" Since cryptopia throAvs one animal into convulsions, and acts
as a pure hypnotic to another, it is not unreasonable to suppose
that there may be nervous systems Avhich are able, in like man-
ner, to convert a large portion, if not all, of the impressions
excited by thebaia into soporific effects."' The foregoing obser-
vations on man realize this supposition, and form a proper sup-
1 Op. fit., p. 103,
Cryptopia and Thebaia Combined. I4l
plement to what I have said respecting the connection between
sleep and convulsion. The hypnotic action of thebaia on man
is, as for as I have observed, free from all unpleasant effects
(the symptoms mentioned in Obs. 18 would not have been expe-
rienced had the patient been recumbent and at rest). As a
soporific 1^ grain is about equal to ^ of a grain of a salt of
morphia.
The contracting effect on the pupil is, in most cases, much
weaker than that of morphia ; but it possesses an equally stimu-
lating effect upon the pulse. The influence upon the respira-
tory movements, however, is the reverse of that of morphia,
viz. stimulant. During the action of a quarter or half grain of
acetate of morphia, the respirations in Samuel M — , usually
decreased to 16 or 15 a minute.
Thebaia and Atropia Combined.
The following observations were made upon Samuel ^I — -,
the subject of Obs. 13 to 17. The solution of thebaia was
that used in the previous Observations. The solution of atropia
contained two grains of the sulphate in one ounce of water.
Obs. 21. — Pulse 72; pupils one eighth. Injected one sixth
of a grain of thebaia and one forty-eighth of a grain of atropia
sulphate by one puncture. Somnolency came on within four
minutes. After one hour, pulse 102, fuller; pupils unchanged.
Conjunctiva slightly injected ; mouth and throat dry; continued
very sleepy and comfortable. After two hours, had dozed since
last date ; mouth still dry ; pulse 100 ; of good volume and
power ; pupils one seventh and one sixth, right and left respec-
tively. The effect was now passing off.
Obs. 22. — Pulse 72; pupils one eighth. Injected one fourth
of a grain of thebaia and one forty-eighth of a grain of atropia
sulphate by one puncture. After twenty minutes, pulse 100,
slight somnolency, and a little dryness of the mouth. After one
hour, continued very dozy and comfortable. Pulse 100 ; pupils
unchanged; mouth and throat very dry; respiration 20, regular.
After two hours and twenty minutes, pulse 88, contracted,
regular; respiration 20, regular; right pupil one seventh, the
left a trifle larger. Throat and mouth very dry ; was still
sleepy, but the effect was now passing off.
142 On the Action and Uses of the Opium Alkaloids.
Ohs. 23. — Pulse 74; pupils one eighth; respiration 20.
Injected one third of a grain of thebaia and one forty-eighth of a
grain of atropia sulphate by one puncture. After twenty minutes,
pulse 120, of good volume and power; pupils unchanged;
respiration 23 ; dryness of throat, and somnolency. After one
hour, pulse 120, contracted, but of ftiir pov/er; pupils still un-
changed ; respiration 20, regular ; had been dozing. After two
hours, had continued very sleepy; pulse 110, contracted and
regular; pupils one seventh and one sixth; respiration 20.
Went home and slept comfortably all night, and experienced
somnolency the next day.
Ohs. 24. — Pulse 72; pupils one eighth; respiration 21. In-
jected half a grain of thebaia and one fortieth of a grain of atropia
sulphate by one puncture. After fifty minutes, pulse 120 ; pupils
unchanged ; throat and mouth quite dry ; great somnolency
since five minutes after the injection. After two hours, pulse
98, soft, and of good volume ; pupils one seventh and one
sixth ; respiration 19 ; mouth still dry ; had slept comfortably
for some time.
Ohs. 25. — Pulse 80 ; pupils one eighth and one seventh
respectively. Injected one grain of thebaia and one forty-eighth
of a grain of atropia sulphate by one puncture. After one hour,
pulse 120; pupils unchanged; mouth and throat very dry;
great somnolency, and had slept for quarter of an hour. After
two hours pulse 98; pupils one seventh and one sixth; con-
tinued somnolency, but the effect Avas nov/ passing off. Went
home and slept soundly all night.
From a comparison of these observations with those on
thebaia alone, it will appear that atropia increases and pro-
longs the hypnotic action of thebaia. I have previously shown
that it does not diminish its convellent action (op. cit., p. 298).
The counteracting effect of atropia upon the pupils, under the
influence of thebaia and morphia, is about equal for equivalent
doses. The stimulant effect of thebaia upon the respiratory
movements is preserved under the combined action.
DESCRIPTION OF 2V CASE
OF
UNEEDUCED DISLOCATION OE THE
LEET EEMUR,
IN wnicii
DEATH OCCURRED EIGHT DAYS AFTER THE RECEIPT
OP THE INJURY.
EX
WILLIAM MAC COIIMAC.
Specimens of the dissected hip-joiut after recent luxation of
the head of the femur are comparatively rare^ since persons
suffering from this form of injury do not often die^ unless at
the same time they have incurred some other serious hurt.
The London Museums furnish but few examples. Not one is
to be found in the College of Surgeons nor in the Museum of
St. Thomas's Hospital. In St. George's there is a good dry
preparation.
In Bartholomew's there are four specimens^ but only one of
them^ that described by Mr. M^ormald, is of much value. In the
London Hospital I saw two, but they only showed the rent in the
capsular ligament. I am not aware of any others in London.
In vol. XX of the ' Path. Trans.' Mr. Adams describes a case
of dislocation backwards. The head of the bone passed under-
neath the tendon of the obturator internus.
In Mr. Birkett's interesting case, described in the ' Medico-
Chirurgical Trans./ vol. Hi, the head of the femur was dislocated
directly backward between the pyriformis and the obturator
internus muscles, and a portion of the head of the femur was
l44 Description of a Case of
split off. Tlie edge of the fracture is like a clean cut, and
corresponds to tlie margin of the acetabulum, when the femur
is flexed to a right angle. The limb was doubtless in this
position when the violence was applied, but, as Professor R. W.
Smith suggests, the retentive power of the ligamentum teres
may have assisted in causing the fracture. The nature of the
injury in this instance affords a possible explanation of the
difficulty of retaining the head of the femur in situ after reduc-
tion, which heretofore has been accounted for by a supposed
fracture of the rim of the acetabulum, the interposition of a
portion of the capsular ligament, or other causes.
In the case I am about to describe, no novel feature is, per-
haps, presented ; but it will serve at least to confirm some of the
pathological characters of an injury which, though sufficiently
common, is rarely the subject o^ post-mortem examination.
Stephen Houston, a hale-looking man, nearly seventy years
of age, was admitted to the Belfast Hospital Nov. 9th, 1870.
"Whilst at his ordinary work in an iron foundry a metal
casting, ten hundredweight, fell upon him. It was at the time
partially suspended in a crane, one end resting upon the
ground, and when the tackle gave way the man was thrown
violently over on his knees upon a wooden block, between which
and the metal the abdomen was forcibly compressed. Houston,
who was an intelligent man, described how the casting first
struck his hip, and that he subsequently felt himself twisted
round towards the prone position during the act of crushing.
The first effect of the blow Avas to dislocate the left hip back-
wards, and then the forcible compression of the abdomen drove
the contents of an old inguinal rupture through the scrotal wall.
I saw the patient shortly after the injury, and found he had
partially rallied from the prostration consequent on the accident.
On examination a broad ecchymoscd bend was observed stretch-
ing across the abdomen. Between the man's legs, reaching
nearly to the knees, lay a quantity of both the large and small
intestines. A foot of the former and about three feet of the
latter had been extruded through a somewhat irregular rent, four
inches in length, extending obliquely from the bottom of the left
side of the scrotum towards the external abdominal ring.
The caput coli, with the vermiform appendix, Averc readily
distinguishable.
Unreduced Dislocation of the Left Femur. 145
On inquiry I found that he had been long the subject of
double scrotal hernia, larger on the right than on the left side,
and, having forgotten to apply his truss that morning, both hernise
were prolapsed at the time of the accident.
To all appearance the intestine protruded belonged to the rup-
ture of the left side, and it was not until an effort to return the
gut in that direction failed, and a further careful examination
had been made that I discovered the left rupture was uninjured,
and that it was the intestine from the right side which, having
first forced its way through the septum scroti, had afterwards
ruptured the left scrotal wall. To facilitate the reduction of so
large a protrusion, I slightly enlarged the abdominal ring, and
also the rent in the scrotal septum.
The intestine appeared nowhere damaged, but by the time it
was replaced, the patient being under the influence of chloroform,
his condition became so alarming that I did not consider myself
justified in proceeding further, and the dislocated hip was con-
sequently left unreduced.
The symptoms of the dislocation were inversion of the limb,
the thigh was flexed and rigid, the amount of shortening was
difficult to make out. As the patient lay in bed the knee rested
above the patella of the sound thigh. The head of the bone
could with difficulty be discovered, lying near the sciatic notch.
The trochanter was in a place somewhat posterior to the normal
situation.
As indeed had been anticipated, no further attempt to reduce
the dislocated femur was practicable. After an interval of four
and twenty hours symptoms of general peritonitis in an acute
form manifested themselves. Large doses of opium were ad-
ministered without effect, and death took place on Nov. 17th,
eight days after the receipt of injury. The poor man com-
plained of severe pains in the hip, stretching down the limb,
doubtless from pressure on or straining of the sciatic nerve.
His friends absolutely interdicted any species of autopsy, but
an examination was, nevertheless, hastily made at five o'clock
the following morning, and, under circumstances unusually diffi-
cult, the parts were removed.
The head of the femur was found to have been displaced
almost directly backwards. It rested behind the acetabular
ridge, opposite the middle and upper part of the great ischi-
VOL. II. 10
146
Description of a Case of
atic foramen^ behind the posterior border of the glutseus
mediuSj and only covered by the glutseus maximus and integu-
ments. Neither the femur nor any portion of the pelvis had
sustained fracture. In removing the specimen the pubic ramus
■svas accidentally broken.
The accompanying sketch admirably shows the posterior rela-
tions of the different parts concerned. It was accurately and
beautifully drawn by Mr. Charles Stewart, the Curator of our
Museum.
Disloc.ition backwards of the Lt?ad of the femur.
The engraving shows the head of the bone, just behind the acetabulum,
the pyriformis and glutteus minimus muscles lying over it, the obturator
internus, with the torn gemellus muscles, immediately below.
The only difference between this and the original is that the
iliac bone is represented perfect, whereas it was sawn through
to facilitate removal at the place indicated by the dotted line.
An examination of the specimen shows that the rent is
merely in the back part of the capsule, and that the neck of
the bone is as it were locked over the acetabular ridge. The
strong anterior part of the capsule is tightly stretched between
its attachment below the inferior iliac spine and the inter-
trochanteric ridge, but it is not separable, as described by Bigelow,
into two distinct branches. It is this strong ligament, however,
which mainly prevents the head of the femur rising over the edge
Unreduced Dislocation of the Left Femur. 147
of the acetabulum, and even in its present relaxed condition the
obturator internus muscle similarly opposes the return of the
bone to its socket. In order to reduce the dislocation, exten-
sion of the limb at right angles to the trunk with rotation
inwards to relax the capsule, would seem to be the direction
most efl&ciently to apply the force. As soon as the head of the
bone had been thus drawn to the edge of the socket, abduction
with rotation outwards would immediately prize the head of the
bone into its place.
The case under consideration confirms some of Professor
Bigelow^s views as to the nature of hip dislocations.^ He classes all
dorsal dislocations in two categories, according as they are above
or below the tendon of the obturator internus muscle, and says
that they pass gradually one into the other, or may be converted
one into the other. He ascribes to the anterior part of the
capsule, which, from the form of its strongest portions, he
terms the Y ligament, the determination of the character of
the deformity. To the muscles he attributes but little import-
ance either in producing the kind of deformity or in impeding
reduction.
The position on the dorsum assumed by the head of the boue
would seem to depend on the amount of flexion of the thigh at the
time the violence was applied, and further observation confirms
Malgaigne's belief that the head of the bone is to be found in
most instances close to the acetabulum. Bigelow considers the
dislocation between the obturator internus and pyriformis as
rare. His directions for reducing this form of dislocation,
namely, on the dorsum ilii, are so clear, and have been prac-
tised by himself with such marked success that it will be in-
teresting if I quote from them here.
" The patient being supine, the knee and thigh should be
flexed to a right angle, then abduction and rotation inwards
should be made to disengage the head of the boue from behind
the edge of the acetabulum. If the thigh can now be abducted
beyond the perpendicular the capsule and other tissues have
been sufficiently lacerated to permit of easy reduction. The
limb need only be forcibly jerked or lifted towards the ceiling
with a little circumduction and rotation outwards for the bone
to slip into its place. Counter-extension should be made on
' ' The Mechanism of Dislocation and Fracture of the Hip,' Pliiladelphia, 18G9.
148 Case of Unreduced Dislocation of the Left Femur.
the spine of the ilium or on the pubis^ while the surgeon^ with
his left arm under the knee and his right hand grasping the
foot, executes the manoeuvre/''
" If on trial the flexed thigh cannot be abducted beyond the
perpendicular, the head has either escaped by a small opening
in the capsule, or has perhaps also passed above the obturator
tendon or pyriformis muscle, and is suspended just behind the
socket by the capsule. In the former condition reduction may
be obtained by flexion, abduction, and outward rotation. In the
latter it is possible but not easy to disengage the head of the
bone by traction across the symphysis. If these attempts do
not succeed, the obturator muscle and capsule may be ruptured
by outward circumduction of the flexed limb.^' In direct luxa-
tion backwards Bigelow further adds, " the capsule is but little
torn and the limb firmly locked, giving the idea of the head
being in the sciatic notch.''
A careful examination of my own specimen confirms in a
remarkable manner most of these statements. After dissection
the deformity was persistent and identical with that existing
during life. The dislocating force had been applied when the thigh
was flexed at right angles, and the bone was driven directly back-
ward between the pyriformis and obturator internus muscles.
The locking or rigid condition of the limb was very evident,
while the rent in the capsule was limited to its posterior part.
Manipulation after the manner described by Bigelow appeared
in the dissected specimen to be the way in which the head of
the bone might most readily be returned to the socket.
REMARKS
HEALTHY AND MORBID ANATOMY
PEEIVASCULAE SYSTEM OE THE BEAIN.
By W. W. WAGSTAFFE, F.E.C.S.
Since the discovery of the perivascular system by Robin iu
1855 {' Comptes Rend, de la Soc. de Biolog./ Paris), very few
observers have added to our knowledge of it until recently, when
Professor His, of Basle, published a monograph upon the subject
in the ' Zeitschrift f. "Wissenschaftl. Zoologie,^ vol. xv, 1866. In
this country Dr. Bastian has translated Professor His's paper,
and appended his own observations upon it in the ' Journal of
Anatomy and Physiology,' 1867, and it is only since that date
that the perivascular canals have been looked upon as other than
the result of pathological changes occurring around vessels. On
the Continent, however, more attention has been paid to these
structures, and Rindfleisch described in 1866 ('Lehrbuch der
Patholog. Gewebelehre ') some points in the anatomical relation
of meningeal tubercle to this system, and Virchow even earlier
('Die Krankhaften Geschwillste,' 1864-5). The pathology of
acute tuberculosis has been examined with great care in this
country by Dr. Bastian {' Path. Transactions,'' vol. xviii, and
'Edin. Med. Journal,' April 1867), but so little notice has been
taken generally of the subject, that I am glad the occurrence of
three peculiarly interesting cases gives me the opportunity of
offering the following remarks upon what must be considered
a most important physiological structure.
150 Remarks on the Healthy and Morbid Anatomy
Healthy Anatomy.
The perivascular canals are seen with the greatest ease in the
fresh brain. They are sometimes visible even with the naked eye.
Remove a small vessel from the substance of the brain by meaus
of a fine pair of forceps, aud it will be seen upon examining it
under the microscope, that ensheathing the wall of the vessel
is a very transparent membrane, broader in some parts than in
others, and distinguished from the vessel by its almost stucture-
less character, and by the absence of the ordinary contents of
vessels. In some places the membrane lies close to the vessel-
wall, so that it is with difficulty detected ; in other places a
large space exists between them ; and, as a general rule, it may
be stated that the size of the perivascular space increases with
the size of the vessel.
That this membrane forms a complete canal around the vessel
is certain, from the result of examination microscopically, and
also from the result of injection. The space is so well defined,
and the membrane limiting it so distinct, and its occurrence is
so constant when ordinary care is used in the examination, that
it would be useless to question its existence. Moreover, Professor
His has been able to inject the system, and has shown that
everywhere these canals surround the blood-vessels, aud that
they are quite sharply defined externally.
The structure of the sheath is peculiar, and the description
of it given by His, and Robin, and Bastian, differing as they do
from one another, cannot be considered altogether correct.
Robin and Bastian describe it as a delicate hyaline membrane
in its normal condition, but His states that it is composed of a
striped basis-substance very similar to the walls of the splenic
veins, Bastian allows that it frequently undergoes a fibroid
change, but he apparently considers this the result of some
morbid process, and not its constant and normal condition in
any part.
It may be easily shown, however, that the structure of the
sheath differs very consideraljly in different parts, and that a
description of a sheath surrounding a small vessel will not at all
apply to that enclosing a large one. If a small vessel be ex-
amined after removal from the human brain ten or twelve hours
after death, the wall of the sheath appears to be structureless
of the Perivascular System of the Brain. 151
(PI. I, fig. 1), or only faintly granular, when a one sixteenth
object-glass is used, and no epithelial lining is visible. But, if
such a vessel be examined immediately after death, the ap-
pearances are different (PI. I, fig. 2). The transparent mem-
brane is lined by a very definite layer of epithelium, composed
of cells of very unequal sizes packed together closely, and con-
taining nuclei which occupy nearly the whole of the cells. Both
the cell outline and the nucleus are extremely faint, and no
space appears to be left between this epithelium and the wall
of the vessels ; where the cells are large, the perivascular canals
are bulging, and where they are small they project but slightly.
The transparent membranous wall too gives indication of a
transverse and longitudinal striation.
When a rather larger vessel is taken, evidences are then ob-
tained of a somewhat different structure. Examined from the
human brain some hours after death, the sheath is seen to be
marked by faint lines branching and anastomosing, starting here
and there from more definite fibres, and now and then there
appears a faint nuclear corpuscle embedded in the wall (PI. I,
fig. 3) and connected with the fibre-markings on every side.
The intermediate wall appears still almost structureless, but
I have noticed both in the fresh preparations and in those which
have been treated with nitrate of silver, that there is a tendency
to a transverse striation sometimes very marked, but usually
difficult to trace. I have been unable to detect any connection
between the fibres of the wall and the exterior of the vessel
within, and Professor His states positively that " no connection
exists between the wall of the vessel and the wall of the peri-
vascular canal.''^
A similar vessel being examined next from a dog immediately
after death, it was found that the perivascular canal presented
the appearance seen in PL I, fig. 4. The walls were composed of
an outer set of longitudinal wavy fibres, inside which was a
circular set of delicate but distinct branching fibres. Inside this
again was a quantity of corpuscular material of which I was
unable to trace the anatomical relations.
Lastly, when a large vessel is examined, the structure of the
perivascular wall is again different. It is composed of bun-
dles of wavy fibres, similar to if not identical wdth those of
white fibrous tissue, and no trace of the structureless membrane
152 Remarks on the Healthy and Morbid Anatomy
remains within this fibrous longitudinal layer. Indications
still exist of the transverse markings, but they are much
more obscure than in the smaller vessels, and they are
only at all readily traceable in the perfectly fresh brain. The
examination of the larger sheaths is difficult, and it is not easy
to determine the existence or absence of epithelial lining, or of
the connection between the wall and the exterior of the con-
tained vessel, although such connection appears to me highly
probable.
The appearance of the large sheaths in the perfectly fresh
brain coincided with what has just been described, with this
exception, that the transverse markings were readily traced as
forming part of a second layer, and there was a slight indication
of a third layer with longitudinal markings distinct from the
proper coat of the artery contained within the sheath.
The contents of these sheaths are obscured by the fibrous
character of the walls, but these appear to be of the same nature
as the corpuscles described as occurring in the other parts of the
system. In the human subject some hours after death they
are distinct as free nuclear bodies, closely resembling lymph-
corpuscles, but there can be little or no doubt that they are
the result of post-mortem changes in the epithelium of the
tubes. For this epithelium is very delicate in character, and
evidently will be easily aff'ected by the changes which go on
after death in the tissues. A proof of its proneness to change
may be seen in the difficulties with which it can be made out,
and in this as in its general features it is closely related to the
epithelium of the arachnoid.
It will be observed that I have in the description of the
appearances of the sheaths been careful to make a difference
between those found in the brain some time after death and
those found immediately after killing an animal. The difference
appears to be rather marked, and it is of considerable import-
ance ; for in cases of disease in the human being it is only
possible to examine the organ about twelve to twenty-four hours
after death, and, consequently, one is bound rather to compare
the appearances seen in pathological conditions with those
usually seen in a healthy subject twelve to twenty-four hours
after death, rather than with those seen during the life of the
part.
of the Perivascula?' System of the Brain. 153
Perivascular canals exist without question throughout the
whole of the brain. They may be traced, as I have said before,
upon any vessel pulled from the substance of the brain.
But it is not so easy to follow them in the membranes, and
there is reason for it. The structure of the membranes is
sufficient usually to obscure so delicate an arrangement, and
with regard to the larger vessels it is only to be expected that
the wavy fibrous tissue of the membrane should communicate
freely with the similar structure of the sheath, and it would
be only by injections artificial or natural that their existence
could be shown. Now, the artificial injections have been made
by Professor His, and an example of the natural ones is shown
in the accompanying cases of tubercular meningitis.
But without doubt it is not only in the brain and spinal cord
that this perivascular system exists, although it is in these nerve-
tissues that it can be most readily demonstrated. In the cornea
it has been described as occurring, by Dr. Lightbody (' Journal
of Anatomy and Physiology,' vol. i), and Professor Strieker in
' Robin's Journal,' 1867, confirms the existence of it in con-
nection with other capillaries. I have been able to trace what
1 believe to be evidence of it in preparation of muscular tissues,
and more clearly in fibrous tissues. Around the blood-vessels
of lymph-glands, I have seen a similar arrangement, and in
injected preparations of the ovary, I have observed unequi-
vocal evidence of its existence. I hope at some future time to
be able to demonstrate these more fully, but as they are beyond
the immediate object of this paper I merely refer to them now.
With regard to the connection of this system with the lym-
phatic system generally, it may be stated that little doubt exists
that these canals open ultimately into some of the larger
lymph spaces. The brain is separated from the pia mater by a
wide system of lacunse which were described by His and have since
been demonstrated by Axel Key and Gustav Retzius, as forming an
intermediate band of connection between the perivascular canals
of the substance of the brain and those of the pia mater, and
these are invariably distended in the most carefully prepared
injection either of the perivascular system of the pia mater, or
of the brain substance. Further than this, it is exceedingly
probable that the serous space of the arachnoid must be looked
upon as a large lymph space, and that, in fact, all the large serous
154 Remarks on the Healthy and Morbid Anatomy
cavities must be placed in the same category. Receut observers
(Recklinghausen, Ludwig, Dybkowski, and Schweigger-Seidel)
claim to have discovered open communication between these cavities
and the lymph-vessels in the shape of minute pores between the
epithelium cells on the free surface of the serous membranes.
In the brain, then, we have evidence of a direct connection
between the perivascular canals in the substance of the organ
and the subarachnoid spaces, and of the latter with the peri-
vascular system and lymph spaces of the membranes. That
the latter are part of the lymphatic system appears beyond
doubt from comparisons of the results of injections from the
two ends, perivascular and lymphatic. Those prepared by His
from the perivascular end have been compared with those in-
jected after the manner of Arnold from the lymphatic trunks,
and the two sets of preparations agree. We have, then, strong
evidence of the immediate communication of the two sets of
vessels; and if Professor Ilis's observations can be relied
upon, there can be little doubt that the perivascular is only an
offset of the lymphatic system in the brain.
I may finish these introductory remarks by alluding to the
probable function of these canals, and in doing so it will be
necessary to bear in mind the fact that, althougli so distinct in
the central nervous organs, they are extremely difficult to trace
in the majority of tissues, and that in many textures their
existence is at the most only a matter of conjecture. Where
they are most easily seen, as in the brain substance, there is no
surrounding connective tissue, whereas in the structure in which
they are either absent or their existence is doubtful, loose con-
nective tissue surrounds the vessels. It seems, therefore,
probable that the fluid which exudes from the blood for the
purposes of nutrition, particularly in tissues undergoing rapid
nutritive changes, such as nerve substance, and, possibly,
muscular and gland tissues, is held in these canals ready for
immediate use, wdiercas in other structures the fluid which
exudes is held in the abundant spongy connective tissue which is
so evident in these situations. Add to this that in the case of
the central nerve organs we have in the perivascular canals a
means of reducing to a minimum the mechanical eff'ects of alter-
nate dilatation and contraction of the vessels, and of protecting
the delicate nerve substance from the more gradual alterations in
of the Perivascular System of the Brain. 155
pressure which might otherwise result from the sudden, exten-
sive, or permanent alteration in the blood supply. A further
function might be suggested in their influence upon the vessels
themselves. In principle these are floating within the perivascular
sheaths, and the chances of rupture or other injury from con-
cussion are thereby materially diminished. The physiological
function of the contents of these canals is, therefore, probably
identical with that of the cerebro-spinal fluid with which it is in
direct communication. It may be looked upon, in fact, as both
protective and compensatory.
Morbid Anatomy.
Case 1. — The first case which I have to mention is that of a
child who died at the age of a year and a half of tubercular menin-
gitis in November, 1869. There was a family history of phthisis.
The mother had sufi'ered from phthisical symptoms before and at
the time of the child's birth, and had died of this disease when the
child was a few months old. Since the child's death an elder
sister has also died of phthisis. He had the usual symptoms of
cerebral meningitis, and died at the end of rather more than
three weeks after the first appearance of the symptoms.
The 2J0sf -mortem appearances coincided with what was sus-
pected before death. Tubercular deposits were scattered freely
over the surface of the brain, and a large mass of similar structure
was found occupying the fissure of Sylvius on the right side.
The tubercle was always related to the vessels definitely ; on the
upper surface of the hemispheres clusters of miliary deposits
were arranged along the sides of the larger vessels : in some
eases the naked eye could trace small vessels running into single
deposits : in the large mass in the Sylvian fissure the carotid
and the middle cerebral arteries were surrounded by the new
growth ; and it is worthy of notice that both carotid arteries
were very markedly thickened before they entered the brain.
On slicing the brain it was found to be congested, as were the
membranes outside, and there were small points of extravasa-
tion in the ventricles, as there also were rather frequently in
the membranes. Everywhere the brain substance was rather
soft, but the distinction between the white and gray matter
was well defined ; the softening was, if anything, rather more
marked on the right side.
156 Remarks on the Healthy and Morbid Anatomy
The relation of the deposits to the vessels has just been referred
to above ; but when they were examined microscopically a much
more beautiful and exact relationship could be traced. To ex-
plain this I will premise by saying that both the large and the
small deposits were composed of nucleated corpuscles — of nuclei,
in fact, surrounded by an irregular amount of plasma, the nuclei
being of pretty uniform size. In some places they were mixed
with a large quantity of granular and oily matter ; sometimes
with the so-called compound granule cells — these additions being,
of course, only the evidences of degenerative changes. Now,
when a portion of the membrane was examined, which was but
little obscured by the large masses of deposit, but in which it
was still easy to see the small miliary tubercles standing distinct,
the first point which attracted attention was the marked disten-
sion of the perivascular canals. These, which are often difficult to
demonstrate in the meninges in health, were now very distinct,
and distinct from being distended with abnormal contents.
They contained corpuscles exactly similar to those found in the
masses of tubercle. Sometimes there were many particles of
oily and granular matter, and other evidences of degeneration,
and such appearances were usually more marked in the neigh-
bourhood of the larger masses of deposit. But, besides the dif-
fusion of the elements of tubercle in these perivascular canals,
and their great abundance near the masses of the deposit, fur-
ther evidence was obtained of the relation between them. One
of the very small miliary deposits was examined, and showed
that it was situated entirely within the perivascular sheath
(PL I, fig, 5). The sheath was bulged considerably by it; and
although the large amount of molecular and oily matter pre-
vented the artery itself being seen, yet it may be fairly inferred
from the evident accumulation of tubercle corpuscles between
the vessel and the sheath in other parts, that such miliary
deposit was here situated in the same position — that is to say,
simply in the perivascular space.
This specimen was taken from the pia mater, and affords, it
seems to me, conclusive evidence of the existence of the peri-
vascular system liere. The same is shown by the result of the
examination of a portion of the membrane in the neighbourhood
of one of these deposits (PL II, figs, G and 7).
Case 2. — The second case which bears upon the pathology of
of the Perivascular System of the Brain. 157
this system was one of acute tubercle of the lungs^ with miliary
deposits in the kidneys. The man was an adult^ about thirty
years of age, and no symptoms of tubercle had been observed
until about three days before his death. There was nothing very
remarkable in the history of his case as bearing upon the ques-
tion of this paper. There were no cerebral symptoms. The
only symptoms of tuberculous mischief that had been observed
were some chest symptoms, which had apparently occurred
suddenly during the treatment by pressure of a large popliteal
aneurism. Immediately upon the cessation of pulsation in the
sac of the aneurism the symptoms of tubercle in the lungs
appeared.
At the post-mortem examination, besides finding extensive
miliary deposits in the lungs, there were scattered tubercles in
the kidney. There were no other deposits visible to the naked
eye in the other organs of the body, but these were generally
congested. The brain was congested, but not extremely so.
The vessels of the meninges were in the same condition, but
there was nothing to indicate the presence of tubercle either in
the form of miliary deposits or larger masses, and there was no
abnormal adhesion of membranes to one auother or to the
skull.
In order, however, to compare the state of the perivascular
canals with that in the case narrated above, they were carefully
examined with the following results : — the perivascular spaces
were filled with corpuscles apparently similar to those described
in the first case. In fact, it would be impossible to distinguish
a preparation of these vessels from one taken from the neigh-
bourhood of the miliary deposits in the former case. There
were, however, no accumulations of corpuscles into masses, and
there was likewise far less evidence of degeneration than was
generally visible in the more decided and advanced case of
tubercular meningitis (see PI. II, fig. 8) . No marked changes
appeared in the walls of the perivascular canals either in the
form of degeneration or in the greater abundance of the pale
nuclei which sparingly show themselves as part of its structui'e,
or in an alteration of their appearance. The corpuscles which
occupied the canals floated freely and, like those in Case 1, were
not distinguishable from ordinary leucocytes. Examined as
these preparations must be in a state inconsistent with the
158 Remarks on the Healthy and Morbid Anatomy
continuance of natural processes, the origin of the corpuscles
must be a matter of conjecture and not readily capable of proof,
and I was unable to trace any direct relation between them and
the elements of previously existing structures.
These two cases bear in a very interesting manner upon the
pathology of the perivascular system, and also upon the pathology
of acute tuberculosis, and a contrast must be made between
the appearances found in them with those noticed in the earlier
part of this paper as commonly seen upon careful examination
of the human brain twelve to twenty-four hours after death.
It is evident that in each case the morbid appearances in the
brain were related definitely to the peculiar canals which sur-
round the vessels, and that the immense multiplication of
corpuscles had taken place primarily at all events in those
canals, and in them alone. In the second case the disease had
reached apparently only its early stages in the brain. Time
had not been given for the accumulation of the tubercular
products in sufficient quantity to form the so-called granula-
tions ; but in other tissues and organs, as the lungs in parti-
cular, the disease had been so acute as to destroy the life of the
patient. We find, however, that the perivascular canals in the
brain were full of corpuscles apparently identical in character
with those in the more advanced case recorded in the first, and
we are justified, I think, in considering this to represent the
early stage of the disease (PI. II, fig. 8).
A further stage is represented in PI. I, fig. 5, where the tubercle-
corpuscles have accumulated within the sheath of the artery to
such an extent as to form a bulging mass, and a still further
advance is seen in the degeneration which has occurred in the
constituents of the mass from pressure, and possibly from
interference with the requisite blood supply.
When the growth has increased to such an extent as to pro-
duce a mass of large size, like that in the fissure of Sylvius in
the first case, there still remains the marked relation to the
position of vessels, although tissues and structures cannot be
followed out so closely as in the earlier stages. The centre of
the mass degenerates, and in this case the degeneration was
not only fatty but also calcareous, for the brain knife in making
a section was checked by the hard cretaceous character of the
interior of the deposit ; and this, again, is indication of the age
of the Perivascular System of the Brain. 159
of the deposit, for such changes could not possibly have occurred
simply in the three weeks during which the child had been
seriously ill. The circumference of the mass was composed of
newer deposit, for the corpuscles were less granular and degene-
rated, and the vessels of the neighbourhood showed that their
sheaths were choked with the tubercle-corpuscles.
There is one feature which may have attracted observation,
and to which reference has not yet been made. It is, that in
the membrane, between the vessels of the pia mater, corpuscles
were scattered very abundantly ; and it may be asked how these
will bear upon what has been observed as to the distribution of
the deposit in other parts of the brain. In other parts the morbid
process takes place primarily, if not altogether, in the sheaths of
the vessels ; but in this situation the corpuscles cover and occupy
the intervening membrane. It may be that these appearances
are the result of a secondary inflammation in the membrane, and
that, consequently, these corpuscles, which are not distinguishable
from lymph-corpuscles, or, as one may term them more gene-
rally, " leucocytes,'' may have had their origin from the vessels (as
Cohnheim and Recklinghausen have demonstrated unequivocally
to occur in inflammation), or from the corpuscles of the tissues, as
has been shown to occur in the cornea by Strieker, in cartilage
by Redfern, or in tendon by Guterbock. This view of the
nature of the appearances in the membranes, and the consequent
presumption that the neighbourhood of the tubercular deposit
is occupied by simple inflammatory products, find their parallel
in what evidently occurs in the lungs and other organs, where a
miliary tubercle can commonly be traced as having around it an
area occupied with the products of inflammation.
It may be assumed that the absence of similar appearances
beyond the vessels in the substance of the brain is due to struc-
tural peculiarities : the membranes are more vascular, the tubercle
granulations more frequent in the membranes than in the brain
itself, and consequently the foci of irritation are more numerous
in the meninges. But the eff'ects of inflammation are certainly
seen in the brain substance, and in direct relation, moreover, to
the tubercular deposits. For instance, in Case 1 the large mass
surrounded the vessels of the base of the brain anteriorly,
the interior of the ventricles was occupied by serous fluid, and
the walls of the descending cornea were softened and completely
160 Remarks on the Healthy and Morbid Anatomy
disorganised^ and contained the compound granular cells which
are commonly associated with inflammatory results in the brain.
Here^ then, we have two effects of considerable pathological
importance — effusion of fluid and disorganisation of nerve tissue,
and both common results of tubercular disease in the brain.
Having referred to the seat and process of the disease, as ex-
emplified in the above cases, it may be well to ask, What is
the nature of the deposit, and whence it is derived ? and to see
whether the cases here narrated throw any light upon these points.
The character of the deposit in the well-marked case No. 1 was
cellular, and the cells consisted of a small amount of plastic
matter surrounding a single nucleus. The appearance of these
nuclear bodies was similar in the sheaths of the vessels beyond ;
and here they could be examined more clearly, and they were
not modified in character by packing, or pressure, or degenera-
tion. They then bore a close resemblance to lymph-corpuscles
and to the bodies usually found in small number in the peri-
vascular canals ; but there appeared to be no resemblance to the
faint corpuscles which occasionally show themselves as imbedded
in the substance of the walls, and connected with the delicate
fibres of that structure.
Yulpian, who was one of the first to notice the frequency with
which tubercle granulations were related to the walls of vessels
and surrounded them, looked upon the growth as the result of
proliferation of the connective tissue elements of the outer coats
of the vessels. The deficiencies, however, of connective tissue
elements in the deposits makes such an explanation unsatisfac-
tory, and an examination of specimens of the early part of the
disease shows no peculiar relation of the corpuscles to the out-
sides of the vessels.
In M. Robin's paper ('Brown-Sequard's Journal,' 1859) the
suggestion is made that the corpuscles found within the sheath
in tubercular meningitis may be lymph-corpuscles. Let us,
therefore, see how far such an hypothesis is supported by the
appearances found in these cases. We have, in the first place,
the fact that the tubercle-corpuscles seen within the sheaths
resembled closely lymph-corpuscles. We have also the fact
that similar corpuscles are seen usually in these situations when
examined some hours after death. So far, then, as can be
determined by these cases, it is quite possible that the corpuscles
of the Perivascular System of the Brain. 161
accumulated iu tubercular meningitis may be lympb-corpuscles
from whatever source they may be derived.
Moreover^ this view would recive support from the fact that
the disease in the brain affects almost peculiarly a system
which is merely part of the general lymphatic system, if we
may believe the testimony of careful observers. Recent obser-
vations upon the pathological anatomy of tubercle appear to
me to point towards the same conclusion, inasmuch as they
associate the origin of tubercle with pre-existing lymph-cor-
puscles. Dr. Burdou Sanderson (10th and 11th Reports of the
Medical Officers of the Privy Council) has added more than any
other observer to our knowledge of this subject. He has shown
that tubercular deposits occur in all organs and tissues in
peculiar positions, which are determined by the previous ex-
istence of what he terms adenoid tissue, normal collection, that
is to say, of lymph-corpuscles. In the spleen he follows this out
carefully, in the skin he shows that aggregations of adenoid
tissue normally exist, and these are hypertrophied in the tuber-
cular state, in the lungs and in the liver he traces the deposits
of tubercle to the situations of normal adenoid.
Moreover, there appears to be another point of some import-
ance shown by his researches. He could in no case trace the
development of tubercle from the well-formed sinuously outlined
epithelial scales of lymphatic spaces and capillaries, but always
found it in connection with the corpuscular adenoid tissue.
Now the peculiar epitheliara of the delicate sheaths of the cere-
bral vessels very closely resembled this tissue in its spheroidal
character, in its irregularity in size, and in the plastic character
of the cell-substance.
Now, the fact of this close and constant relation of tubercle in
other organs to the aggregations of lymph-corpuscles which
normally exist, and the apparent identity of the constituents of
tubercle granulations in the brain with lymph-corpuscles, and
the proved connection between the lymphatic and perivascular
systems, seems to me to afford the strongest presumptive
evidence of the origin of this morbid product in previously
existing corpuscles, identical with or closely allied to lymph-
corpuscles, and these we have in the bodies seen occupying
the perivascular spaces.
I am inclined, then, to trace the source of these tubercle-
VOL. II. 11
162 Remarks on the Healthy and Morbid Anatomy
corpuscles to the cells occupying the sheath normally as an
epithelium which is intermediate between the spheroidal and
tesselated varieties, and would look upon, the disease as one of
excessive multiplication. Although the elements of ordinary
inflammation consist in the main of cells whose appearance is
identical with these lymph elements, we are not justified, I think,
in looking upon the tuberculous disease as simple inflammation,
or as His suggests, inflammation of the perivascular sheath, for
we do not find an alteration in the fibrous part of the sheath-wall,
or the presence of fibre-cells until later in the disease, when the
primary deposit has probably acted as a focus of- inflammation.
MoreoA'er, the peculiarity of the miliary character of the deposits
distinguishes tuberculous from ordinary inflammation.
These two cases show the progress of the tuberculous disease
in the brain, and one of them (the second) shows the condition
of the perivascular system under circumstances which have not
been previously noticed, that is to say, during the stage imme-
diately preceding the deposit of the morbid product in so-called
granulations, or during the conditions associated with general
tuberculosis of other organs.
Case 3. — The third case difl'ers considerably from the preceding
two, but is one of much interest with reference to the morbid
anatomy of this system. An examination was made by me of
the brain of a patient who had died with symptoms of cerebral
haemorrhage, and evidences were obtained of the haemorrhage
being in connection with a new growth, which sprang from
the sheath of the vessels, and extended into the brain.
The notes taken at the time give the following descriptions :
the left hemisphere was greatly enlarged, its convolutions flat-
tened and increased in breadth, and a feeling of fluctuation was
conveyed to the fingers on pressing it. At the base a portion of
the convolutions had been pushed within the circle of AVillis on
the left side, and this protrusion was about equal in size to the
ungual phalanx of the little finger. The left optic tract had
been apparently much pressed upon. In texture, colour, and
vascularity the surface of the brain appeared healthy, one or
two of the smaller arteries at the base being atheromatous.
The upper part of the brain on section appeared healthy, but
here and there a small vessel projected beyond the surface of
the section, owing apparently to the atheromatous condition of
of the Perivascular Sijstem of the Brain. 163
its walls. The ventricles were dilated and the right more es-
pecially so ; their walls were very much softened, and in the
right ventricle there was a considerable effusion of serum, which
had raised the lining membrane of these cavities in places. In
the right M'as a quantity of blood-coloured serum, and in the
left was some flocculeut decolorised fibrin lying on the choroid
plexus.
On further examination it was found that the base of the left
middle lobe was occupied by a quantity of extravasated blood,
scattered and collected, and the neighbouring brain tissue was
extremely softened. A large mass of what appeared at first
sight to be decolorised fibrin projected towards the left lateral
ventricle, and in this mass were numerous points of extravasa-
tion. This mass was about equal in size to a walnut, and it
had evidently displaced by pressure the convolutions found in
the circle of Willis. Elsewhere in the crus cerebri and in the
pons varolii on the left side were small and large patches of
extravasation, and the brain tissue around these spots was
softened. The vessels were carefully searched for aneurisms,
but none were detected.
When examined microscopically it was found that the perivas-
cular sheaths were apparently thickened (PI. II, fig. 9), and from
their outer surface started an abundant cellular growth. This
growth extended outwards into the brain substance, which was
broken up, and contained a large quantity of compound granule-
cells, molecular matter, and other evidences of acute degeneration.
The elements of the growth consisted of caudate nucleated cells
of pretty uniform character, together with an abundance of
free nuclei. The nuclei was sharply defined, large, uniform in
size, and contained usually a good deal of granular matter,
which prevented any nucleoli being distinguished. The vessels
of the healthy regions were examined, and showed no appear-
ances similar to those just described; except in the walls being
unusually atheromatous, they did not differ from healthy speci-
mens.
The large mass of growth occupying the base of the left
middle lobe, and which has been referred to as somewhat resem-
bling decolorised clot, Avas found to consist of a cell growth,
similar in character to that described in connection with the
walls of the perivascular canals, and interspersed in its meshes
164 Anatomy of the Perivascular System of the Brain.
were tlie remains of degenerated nerve tissue. The flocculent
fibrin in tlie ventricle of this side was somewhat corpuscular,
but its structure was indistinct. It was probably only true
fibrin undergoing ordinary corpuscular changes.
The examination of the rest of the body did not throw any
light upon the nature of the growth in the brain.
In this case we have an instance of another form of disease af-
fecting the perivascular system, but in a manner entirely different
from tubercular disease. There was a new growth of the sarcoma
tvpe, and here as usual it appeared to have its origin in a tissue
closely related histologically with fibrous tissue. It would be
interesting to examine more carefully into the condition of the
vessels and perivascular canals in all cases of similar or allied
tumours of the brain, but I am not aAvare of attention having
been given to this point. Doubtless the origin of such growths
may, and perhaps does, usually occur in connection with fibrous
structures of a pronounced character, as, for instance, the mem-
branes of the exterior or of the interior of the brain ; but the
suggestion arises that a disease, starting in the first place from
the connective tissue elements of a membrane or tissue, which
is in direct connection with a semifibrous tissue, such as that
composing the larger sheaths, may be developed rapidly along
the course of these structures.
EXPLANATION OF PLATES I AND 11,
Illustrating Mr. Wagstajfe' s Remarks on the Healthy and Morbid
Anatomy of the Perivascular System of the Brain.
Fig. 1. Small arttry of the braiu, showing perivascular canal, containing a few
nuclear bodies floating freely. The wall of the sheath should be repre-
sented as structureless. From the human subject, about eighteen
hours after death.
Examiued by ^'g object-glass.
Fig. 2. Small artery of the braiu of a dog, examined immediately after death.
One of the vessels shows the perivascular sheath with a layer of epithe-
lium inside it, but more closely related to the exterior of the artei*y.
The other shows the epithelium regularly arranged outside the vessel,
but the sheath does not distinctly appear.
Examined by { objective.
Fig. 3. Larger artery from the human brain, about eighteen hours after death.
Scattered and branching fibres are seen lining the sheath.
Examined by -j^ objective.
Fig. 4. Larger artery from the braiu of a dog, examined immediately after death.
An outer layer of longitudinal fibres is seen, and inside this a layer of
transverse fibres, and inside this, again, an indication of another
longitudinal set.
Examined by ^ objective.
Fig. 5. Sheath of artery from Case 1, examined twenty-four hours after death.
The sheath is seen to be full of nucleated corpuscles, which are aggre-
gated in the circular white area into a mass of miliary tubercle. The
constituents of this mass are represented separately in this figure.
Examined by /g objective.
F'igs. 6 and 7. Also from Case 1, showing the aggregation of corpuscles within the
perivascular sheath, both in the brain substance and in the meninges.
The character of the corpuscles, when detached, is also represented.
Examined by ■f'j objective.
Fig. 8. Small arid large artery, from Case 2, showing similar increase of corpus-
cular elements in the sheaths, as is seen in Figs. 6 and 7. The
character of these corpuscles was similar to that of the corpuscles
noticed in Case 1.
Fjxamined liy \ objective.
Fig. 'J. Small and large artery, from Case 3, showing outgrowth of spindle
cells, from the exterior (apparently) of the perivascular sheath
Numerous free nuclei were observed in the growth.
Examined by { objective.
(The drawings were kindly made by Mr. W. Andeeson.)
REMARKS
ON THE
THEOEY AND PEACTICE OP EPIDEEMIC
GEAPTING.
By WILLIAM ANDEESON, F.R.C.S.
The operation of "skin grafting/^ or transplantation, was
first brought into general notice in this country by Mr. Pollock.
M. Reverdin's original experiments, although opening a wide and
interesting field for practical and scientific research, attracted
only limited attention, quite disproportionate to the importance
of the discovery. The report of his success brought by Dr. Guy on
before the Societe Imperiale de Chirurgie, and published in the
' Gazette des Hupitaux ' for January 11th, 1870, entirely escaped
the comment of our medical press. In May, 1870, an account
of the process reached England, and its worth was at once put
to the test by Mr. Pollock in a case of extensive destruction of
skin resulting from a burn. His success was made known on
the following July, and, after this stimulus, several interesting
discussions upon the subject took place at the Clinical Society,
and valuable papers were contributed to the medical periodicals
by Mr. Dobson and Dr. Steele, of Bristol, Dr. Page, of Edin-
burgh, and others. During the present year the matter has
been allowed to languish, and notwithstanding the undoubted
advantages of the practice it is now but rarely brought under
observation, nor have any additions of moment been recently
made to our experience. It is probable that the happy results
of the treatment in a few cases prominently laid before the
166 Remai'ks on the Theory and
profession at the outset encouraged too sanguine conclusions as
to the simplicity of the process, and the certainty of attaining
the desired end. Numerous subsequent failures having damped
the ardour of followers in the footsteps of Rcverdin and
Pollock, the practice has been threatened with neglect, or at
any rate with reduction to a humble position quite beneath the
place it is entitled to hold in the therapeutics of surgery. This
can, perhaps, be traced to two sources ; in the first place too
much may have been expected from the plan, and, secondly,
some experiments may have been conducted without the care
and attention to minutiae absolutely necessary to secure a good
average of success.
In our estimation of the results to be obtained from the pro-
cess, we cannot institute any close comparison with the older
plastic operations, in which we cover in a freshly exposed surface
with a portion of integument in its entire thickness, usually
commensurate in size with the area prepared for its reception,
and retaining a connection with adjacent parts by means of a
vascular isthmus. Such a covering possesses, of course, all the
natural advantages with the minute structure of true skin, but
the material employed for filling up the one gap has been gained
by making another, and it has been necessary, until lately, to
allow a process of ordinary cicatrization to close as much of the
space left by the abstraction of the reparative texture as cannot
be obliterated by suture or other means. On the other hand,
epidermic grafting, after the manner of M. Reverdin, has the
recommendation that the amount of tissue required for the
process is small, the operation simple and without risk, and,
more particularly, that a failure is in no degree serious; but it
must be borne in mind that the best result attainable is the
production of a sound cicatrix, often, it is true, stronger and more
pliant than the ordinary cicatrix of a large slowly healing sore,
but still possessing the main imperfections of such a texture.
The title of " skin grafting," it need hardly be said, is not
strictly accurate, and may have led at first to deceptive views
both as to the pathology and results of the process.
The objects with which the operation has been adopted
may be briefly enumerated. Firstly, to procure the cicatriza-
tion of a granulating surface where the natural processes of repair
appear to bo insufilcicnt, or more or less exhausted. Every
Practice of Epidermic Grafting. 167
surgeon has seen distressing cases, generally a sequel of burns
and scalds, in which a large granulating superficies after a time
appears to have lost its power of marginal repair, and remains
as a source of crippling and exhaustion until the part, if a limb,
has been removed by amputation, or the sufferer by death.
Secondly, to hasten the healing of an indolent ulcer, and,
particularly, to shorten the tedious progress which so often
defies, week by week, the completion of cicatrization of a sore
which had, perhaps, up to a certain point made satisfactory
advance, but appearing to gradually tire as nearing the end of
its course sadly tests the patience of those anxious to see the
closure of the breach.
Thirdly, in the case of any active and healthy granulating
surface, merely with a view to increase the natural rapidity of
cure, and abbreviate the usual period of treatment as much as
possible.
Fourthly, to diminish cicatricial contraction and consequent
deformity, the presence of a number of islands of repair tend-
ing to lessen the traction upon the adjacent healthy skin. A
modification of M. Reverdin^s operation may be adopted with
great advantage where a granulating surface exists upon the
face or any exposed part, either as a result of ulcerative destruc-
tion, burn, or plastic operation.
The processes to which the name of skin grafting has been
applied have a rather wide range ; large portions of the entire
thickness of the skin have been successfully transplanted, and
new centres of growth have been initiated from almost invisible
segments of integument, from mere scrapings of epiderm, and
even from free epithelial cells contained in the serum of a
blister; the smaller portions have been engrafted by simple
superposition, by being forcibly thrust into the granulations,
and by implantation into incisions made for their reception.
The site chosen for the operation has hitherto been an area of
granulations, but there is little doubt that the grafts could be
made to take root on a freshly exposed surface.
The grafts may be taken from the patient himself or from
another person. A recently amputated limb, too, has been
found to yield serviceable material, and we may hence assume
that skin removed from a body within a certain period of death
would be available. Where it is determined, however, to obtain
168 Remarks on the Theory and
the required portion of integument from a foreign source, it
will be well to bear in mind the possibility, alluded to by Dr.
Gull^ that certain morbid conditions may thus be inoculated.
As physiological experiments, portions of mucous membranes
bearing different varieties " of epithelium may be transplanted,
and the skin of various animals may be laid under contribution.
I have very recently attempted to graft portions of the hairy
skin of a dog and pieces of pigmented mucous membrane from
the gums of the same animal, but the results of the operation
are not yet sufficiently manifest for publication. The grafts
have usually been removed from any convenient portion of
integument, but as the patliology of symmetrical diseases indi-
cates the striking identity in composition of parts placed in
corresponding situations upon opposite sides of the body, this
point may, perhaps, as suggested in one of the discussions on
the subject, be turned to practical advantage in our selection.
The uncertainty in the results of the treatment is greater
than can well be accounted for by individual differences in the
constitution and age of the patient, and in the character and
condition of the granulating surface under notice. In order to
ascertain how far the issue is influenced by external circum-
stances, I have made a series of experiments which have led me
to believe that ill success, in a considerable number of instances,
depends almost entirely upon the method of operation adopted,
and the subsequent dressing. Ulcers of large size were selected,
and upon each were grafted portions of skin in definite sitviations
and order, an accurate tracing showing the outline of the
margin of the sore ; the position of the transplantations was
then taken, and daily observations of progress could be made
with the greatest exactitude. The grafts were, in certain parts,
merely laid upon the granulations, in other situations forcibly
imbedded, and in others inserted into small incisions about one
sixth of an inch in depth. In other cases the grafts consisted
of portions of the horny layer of the epidermis, separated by
vesication or by scraping ; portions involving part of the rete
raucosum, but not containing any of the papillary structure ;
portions including the papillae, but not the entire thickness of
the cutis vera ; and, lastly, segments of the skin in the whole
depth. In other instances, and in like manner, were tried
pieces of different sizes, ranging from the dimensions of a small
Practice of Epidermic Grafting. 1C9
pin's head to those of a split pea; lastly, comparisons were
instituted between the activity of grafts taken from the subject
of operation and those from strangers. The first dressings, in
some instances, consisted of strips of ordinary strapping applied
to keep the grafts in position, and covered with lint ; in others
of strips of linen dipped into water, evaporation being prevented
by the use of oiled silk.
Instead of transcribing the lengthy details of the individual
experiments, I propose to convey as briefly as possible the prac-
tical deductions I have drawn from the results obtained. Since
making my observations upon cases under my own care, I have
had frequent opportunities of confirming my conclusions by
watching the progress of ulcers subjected to the same treatment
by others, and I may here remark, that some similar investi-
gations by Mr. WagstafFe have in almost every particular led
to the same issue as my own.
Istly. As to the mode of applying the grafts. In a few
cases all the plans succeeded, and here it was noticeable that the
surface grafts usually showed signs of extension some days in
advance of those implanted, often as early as the third day, and
maintained the advantage thus gained throughout; but on
the average more than one half of the superposed segments
failed to take root, and in some cases all were displaced by pus
formation. The majority of those forced into the granulations
became surrounded with little areae of suppuration and were
destroyed. On the other hand nearly all of the pieces inserted
into incisions became adherent. In these cases unmistakeable
signs of vitality were generally visible on about the seventh or
eighth day, but sometimes much later ; on one occasion no
evidence of existence being manifested until the end of the third
week after transplantation. In this instance the sore, which
was situated upon a varicose and greatly enlarged limb, took
on unhealthy action upon the day following the operation ; all the
surface grafts were swept away, and it was supposed that the
implanted pieces had shared the same fate, but at the period
mentioned the granulations in the mean time having reassumed a
healthy aspect, areas of cicatrisations unexpectedly appeared in
the situations of five out of the eight buried grafts. A similar
peculiarity has been observed in two cases now in the Hospital.
2ndly. As to the depth of integument required. More than
170 Remarks on the Theory and
one half of the o-rafts which included the whole thickness of
the skin, acted well when imbedded in incisions, hut those
laid upon the surface were much less successful; where the
segment consisted of the cuticle and papillae, failure was the
exception, but here too the advantage was on the side of those
imbedded in incisions. Only a small proportion of the purely
cuticular sections became centres of growth, and action from
these points was almost always feeble and slow. In no instance
did the epidermic scrapings or fragments of blister-skins prove
of service, but Dr. Fiddes and others have been more fortunate
Avith this plan. Where the entire depth of integument was
fixed upon the surface of the sore, it remained as a nodular
elevation, distinguishable for months after complete cicatri-
sation, in other cases the level of the scar was uniform.
The greater success of those grafts which included the
papillse, as compared with the more superficial kinds, I attribute,
not to the presence of the papillse, but to the pi'eservation of
the deepest and youngest cells of the Malpighian layer of the
epiderm lying between the bases of the papillary elevations.
3rdly. As to the size of the grafts. The results of my expe-
riments did not appear to be greatly infiuenced by the extent
of tissue transplanted, the most minute grafts were more fre-
quently lost than those of somewhat larger size; but it is
probable that some of them did not include any of the younger
epidermic cells. I have since seen portions of skin as large as
a shilling readily made to adhere when fixed upon the granu-
lations. The possibility of grafting very small segments is of
importance, as we are thus enabled to start numerous centres
of cicatrisation by means of an inconsiderable outlay of integu-
ment ; on the other hand, larger pieces of skin in its whole
depth are especially adapted for the lessening of deformity and
cicatricial contraction. The operation has thus been successfully
applied by Mr. Francis Mason to fill up the frontal gap left
after the operation of rhinoplasty. A respectable antiquity was
lately conferred upon this latter method by an hostler, himself
the subject of transplantation, under the care of Mr. Le Gros
Clark ; he informed us with apparent truthfulness that he had
made use of the same plan twenty years ago for the purpose of
concealing losses of skin and hair in horses which had denuded
their knees by falling down. The principle of transplantation
Practice of Epidermic Grafting. 171
of large portions of skin to a granulating surface appears also
to have been known and practised in America as early as 1854.
I have been unable as yet to detect any difference in the
results following the use of grafts from the patient, and those
observable when the material is derived from strangers. The
constitutional condition of the person operated upon is a matter
of some importance in prognosis, as debility, especially that
induced by intemperance, will as a rule greatly retard and im-
peril the success, but old age per se appears to exercise very
little influence over initiation of new growth, or over the rapidity
and completeness of the process of cure ; in fact some of the most
striking examples of the benefits of the treatment that have
come under my notice have been supplied by patients long past
the meridian of life.
A healthy sore with a minimum of discharge will of course
yield the best results after transplantation, but undue pus for-
mation will not necessarily prevent, although it must endanger
success; this fact was exemplified in M. Reverdin's first case,
in which free suppuration occurred on the day after operation,
but happily did not prevent adhesion ; had it been otherwise, a
failure at the outset might have prevented further efforts, and
the birth of skin grafting would have been indefinitely deferred.
It is possible even to succeed to a certain extent in iilcers which
manifest no tendency to assume a condition of healthy granu-
lation ; in such cases, surface transplantation, I believe, always
fails, but by imbedding the grafts in incisions made into the
most promising parts of the sore, I have in several instances
attained the desired end ; the appearance of the new centres did
not, however, take place until the third week, and growth was
slow.
M. Reverdin placed the shreds of epidermis upon the sore, their
deep surface applied to the granulations, and fixed them with
strips of diachylon. Others have followed this plan, and in many
instances have found that the contact of the plaster induces, as
in M. Reverdin's case, free suppuration, and thus many of the
grafts become washed away. The same result has occurred in
several of my cases, and I have since limited my applications to
strips of liuen soaked in water, warmth and moisture being pre-
served by the use of oiled silk ; daily renewal of the dressing
without disturbance of the grafts may be readily effected. As
172 Remarks on the Theory and
soon as extension of cicatricial tissue from the transplantation
is well established, medicated dressings, varying with the con-
dition of the granulations, may be safely substituted.
From my own observations I feel convinced that, with careful
attential to detail, failure will be very exceptional, but disap-
pointment will occasionally occur after repeated efforts however
caiitiously conducted. In some instances the grafts will adhere,
although the granulating surface is apparently healthy ; in
others, adhesion and growth progress to a certain point, when
suddenly our thriving plantation is reduced to a desert, as
though some poisoned blast had swept over it. Tins catastrophe
is probably connected with unhealthy atmospheric influence,
and is seen in cases which have long been under treatment in
hospital wards, but is not necessarily attended with any inflam-
matory or erysipelatous condition of the sore. A little girl
under the care of Mr. Croft during the present year was to
a limited extent the subject of a misfortune of this kind. In
yet other cases we find that the grafts will '' strike root,"" and
that extension will occur ; but growth does not pass a very
narrow limit, each area, perhaps, never exceeding in diameter a
third of an inch. The indication here is to compensate for the
smallness of the arese by a close approximation of the centres.
By this means I have succeeded in healing a large, unhealthy,
and hitherto intractable ulcer of fourteen years^ duration.
The phenomena observable after the operation have been re-
peatedly detailed, and need be only briefly recapitulated. The
first well-marked sign of change is generally an unwonted re-
parative activity in those parts of the margin of the sore which
are nearest to the implanted tissue. The graft in a few days is
found to be adherent to the granulations, and shortly afterwards
loses its superficial epithelium, and either exchanges its white-
ness and opacity for a bluish filmy aspect, or, where the whole
depth of the skin has been used as a surface transplantation,
appears as a reddish nodule, which maintains its prominence
for a considerable period ; from the centre thus formed a delicate
layer of epidermis extends on all sides, and rapidly becomes
strengthened by the addition of a basement of connective tissue
into ordinary cicatricial substance, the covering thus produced
occasionally, as in a case treated by Mr. Le Gros Clark, be-
coming so thick and pliant as to assume a close resemblance to
Practice of Epidermic Grafting.
173
true skin. The extent of new material to be obtained from a
single graft is probably indeterminate ; it usually, however,
happens that after a time the progress of circumferential exten-
sion becomes very slow and the texture developed is compara-
tively weak and thin. This apparent loss of formative energy
as the cicatrizing margin recedes from the nuclear point is also
instanced, in the transplantation of coloured skin, by the non-
appearance after a time of pigmentary contents in the new
cells.
The closing in of the sore from its margins after the per-
formance of the operation is an almost constant occurrence,
and I have generally observed that it is manifested, as already
mentioned, before any other evidence of change is visible. In
October, 1870, I was enabled to illustrate this peculiarity in a
striking manner. A patient was then under treatment for an
indolent ulcer of long duration. It was distinctly marginated
and almost perfectly oval in outline, and measured about two
inches and three quarters in its long diameter, one inch and three
quarters transversely. At the junction of the middle and lower
Gra/l
OriginalJiarffin .
^f'^day.
thirds of the surface, in the axis of the long diameter, I im^
planted a small graft ; at the end of two days this had under-
174 Remarks on the Theory and
gone no perceptible change, but the adjacent margin of the
sore showed a decided tendency to extend inwards towards the
implanted skin. On the fourth day the whole ulcer was smaller,
and, as a result of the greater rapidity of cicatrization in the
more immediate neighbourhood of the graft, had assumed a
pear shape ; the graft itself had in the mean time become semi-
transparent, and was evidently adherent. On the tenth day the
graft had reached the size of a pea, and the approximation of
the margins at its level had nearly bisected the ulcer. Further
progress was very slow, but at the expiration of a inonth the
o-ranulatins: surface was divided into two by a cicatricial band
formed by the meeting of the adjacent edges of the central
and marginal growths ; the part then had the appearance shown
in the sketch, a larger sore remaining above the graft, and a
small one below. A complete cure was subsequently effected
by an additional transplantation.
The product of the process is precisely the same as that of
ordinary marginal cicatrization, and the pathology of both
actions is undoubtedly identical. Microscopical examination of
the fully formed texture radiating from the graft shows the usual
elements of scar-material, namely, a layer of striated connec-
tive tissue supporting a cellular epidermis, divisible into horny
and ]\Ialpighian strata. jNI. Reverdin and Mr. Pollock believe
the extension of the graft to be dependent upon multiplication
of the living cells of the transplanted cuticle, and experiments
already quoted prove that such cells are sufficient to start new
centres, but their precise share in the process is yet open to
investigation. Professor Arnold, of Heidelberg, referring to
ordinary cicatrization, maintains that the epidermic elements
are formed by the division of a protoplasm, at first entirely
amorphous, in the immediate vicinity of the existing border of
epidermis, and that there is no segmentation of adjacent pre-
existent cells or direct conversion of granulation-tissue.
The formation of the subjacent connective tissue of a scar has
been supposed to result from the direct metamorphosis of granu-
lation-cells, but Billroth more recently has asserted that the
texture has another origin. The granulation-cells are said to
disappear by disintegration and absorption, the formation of new
cells cease, and the gelatinous intercellular material, by the loss
of its water, which is carried off by vessels and evaporated from
Practice of Epidermic Oirafting. 175
the surface^ gradually consolidates to striated connective tissue,
any remaining cells at once assuming the shape of the ordinary
connective tissue-corpuscles.
Whatever view be adopted as to the intimate nature of scar
formation, there appears to be a natural law that granulations
are quite unable to produce or undergo conversion into scar-
tissue, except at a line of contact with preformed epithelial
cells. The very exceptional instances in which islets of cica-
trization appear de novo are probably explained by the preser-
vation of minute portions of the rete mucosum in the midst of
the original devastation by burns or otherwise, or by accidental
transplantation of epidermic cells. We see daily more or less
extensive areas of healthy gi'anulations, and these, except at the
margins, undergo little change, but continue to yield more or less
waste product in the form of pus-cells and debris, showing no
tendency towards independent production of reparative material.
In the operation of skin-grafting we transfer marginal elements
to the centre of the sore, and in contact with these the healing:
process is instituted, and results in an extension of cicatrization
similar to that in progress at the general circumference. The
cuticular layer appears to be formed in advance of the deeper
stratum, and is generally visible beyond the more opaque line of
scar-texture, as a narrow film or glazing, under cover of which
the development of strengthening connective tissue is to be
accomplished. It would seem that the generation of new
epiderm is essentially dependent upon the direct influence of
contiguous epithelial cells, while the production of underlying
fibrous tissue can only be effected in connexion with cuticular
growth.
Much ingenuity appears to have been wasted upon the elabo-
ration of abstruse theories to account for the renewal of mar-
ginal activity in the ulcer after transplantation. These views
are mostly either set aside by the fact that the effect to be ex-
plained nearly always precedes the operation of the alleged
cause, or are upheld only by the insubstantial framework of
speculation, and one is fain to seek an elucidation of the
mystery by a more commonplace light. In this we are assisted by
noting the possibility of producing a precisely similar pheno-
menon by the application of an ordinary stimulant; thus, I
have seen the formation of new cuticle from the adjacent portion
176 Theory and Practice of Epidermic Grafting.
of the periphery of an indolent sore set up by the temporary
fixture of a small piece of sheet lead upon the centre of the
granulations, and after a gentle use of caustics, and again by
the grafting of portions of dead cuticle, which have afterwards
separated without having given any indication of vitality.
Several instances, too, have been mentioned by others, in which,
after an unsuccessful attempt at transplantation with shreds of
epidermis, the circumference of the sore has shown an unusual
reparative vigour, notwithstanding the complete absence of new
central growths, but the special significance of this fact has
been passed over. These considerations lead to the inference
that the action is simply an effect of the stimulus of the grafting
as a process ; aud without venturing into the question of the
intimate philosophy of stimulation we may, I think, assume that
the contact of the graft in the first instance induces a local
determination, as might a foreign body or ordinary stimulant,
but with the difference that the action induced by the piece of
living and reproductive tissue has no tendency to pass the
boundary line of healthy stimulation and encroach upon the
dangerous ground of irritation. The vital activity, instead of
setting up a process for the expulsion of the piece of transplanted
integument, incorporates the allied elements with the contiguous
structure, and the increased textural vigour affecting the parts
within a more or less extended radius leads to reparative changes
which would obviously affect most markedly the nearest portions
of tissue (i.e. a cicatrizing margin) most capable of manifesting
the effects of repair.
In concluding these remarks I must express my thanks to
the surgeons of the Derbyshire Infirmary, JNIessrs. Wright
Baker, Dolman, and Curgenven, for many opportunities of
testing the plan of treatment in cases under their charge.
CASES
STEICTUEE OP THE GESOPHAGUS.
By E. CLAPTON, M.D.
We do not meet with many cases of stricture of the oeso-
phagus in hospital practice, and those which do occur are usually
seen in the out-patients' rooms. Dysphagia of a more or less
obscure character, or as a symptom in connection with a variety
of affections, is tolerably common, such affections being hys-
teria, hypochondriasis, general debility, rheumatism, neuralgia,
and some forms of dyspepsia. The difficulty of swallowing may
be from actual pain or spasm, or it may be a mere nervous
sensation ; more rarely it is induced by a relaxed condition of
some part of the gullet, or by paralysis.
There may be pressure from without, as by aneurism, bron-
chocele, and various tumours, or impaction of some foreign body
within ; but actual or permanent stricture of the oesophagus,
in the great majority of cases, depends on either fibrovis thick-
ening or cancerous infiltration, the latter being by far the more
common of the two. There has been only one case of stricture
of the CESophagus in St. Thomas's Hospital during the present
year, and there was one only in 1870 from malignant disease.
There were none in 1869 or 1868 ; one in 1867, a young man,
who remained in the hospital nineteen days, and was presented
relieved. In 1866 there, were two, one spasmodic and one ma-
lignant. The latter, a fatal case, was one in which marked
symptoms of obstruction had existed for three months, and at
VOL. II. 12
178 Cases of Stricture of the (Esojjhayus.
the time of admission had become very urgent. Gastrotoniy
was performed, and lie was progressing favorably, but was
attacked by a low form of pneumonia, and died eleven days
after operation. At the post-mortem the ossophagus was found
totally obstructed by a malignant growth mainly epithelial in
character.
I do not observe any mention of stricture of the oesophagus
as a cause of death in the last annual report of the Registrar-
General ; but perhaps this disease is included under the general
head "Stricture of Intestines/' or " CEsophagitis.'''
The patient vv'ho was in St. Thomas's last year was John
Q — , let. 51; admitted 2.2nd July; had been suffering four
months from constant dyspliagia and frequent dyspnoea. The
difficulty of swallowing gradually increased, so that latterly,
notwithstanding his appetite was good, he was only able to
swallow a little liquid at a time ; had gradually lost flesh and
strength. On admission he was found very thin, pale, and
feeble. Voice weak and husky ; had been so, he said, from the
commencement of his illness. There was considerable pain on
deglutition, especially when he endeavoured to swallow solids.
Chest resonant; heart-sounds and breath-sounds healthy, though
feeble ; slight hacking cough ; saliva constantly flovv'iug from
his mouth. There was fulness in the lower part of the neck,
on the right side, but no evidence of aneurism. Nothing par-
ticular observed by means of laryngoscope ; skin cool and moist ;
tongue white and clammy ; urine normal. He gradually got
worse, both as to difficulty in swallovring and general weakness,
so that it was deemed necessary that he should be fed by means
of a stomach-pump. This was passed without much difficulty,
though there was an obstruction opposite the upper margin of
the sternum. In this way a large quantity of strong fluid nour-
ishment was given him tw^o or three times daily, and at first
with marked benefit, but the improvement did not last long.
He brought up from time to time some excessively fetid glairy
mucus, and at last, just before his death, a large quantity of
blood.
For the last three weeks of his life the stomach-pump Avas
never removed, and his stomach retained well all food which
was thus administered. He died on Uitli October. Tor the
first week or two after admission, and again for about the same
Cases of stricture of the (Esophagus. 179
period before death, lie was under the charge of my colleague.
Dr. Bristowe, but intermediately was under my care.
At the post-mortem examination very extensive destruction
of the oesophagus was found, commencing on a level with the
lower border of the thyroid body, terminating below at the
arch of the aorta, occupying about two inches of the length of
the oesophagus, and involving the whole of its circumference,
excepting only a narrow band at the back and towards the left
side. There existed, in fact, in this situation, interrupting the
course of the oesophagus, an irregular excavation, capable, pro-
bably, of holding a hen's egg, the margins of which were, for
the most part, shreddy and gangrenous. The destruction of
tissue had taken place chiefly to the front and towards the left
side, and had involved the posterior and left half of the circum-
ference of the trachea for about one inch of its length (so that
the oesophagus and trachea, in this situation, formed a common
cavity), and had led to perforation of the left common carotid
artery by a minute aperture of about an inch and a half from
its origin. There was a small pharyngeal ulcer at the back of the
cricoid cartilage, partly exposing the cartilage, and there were
several greatly enlarged lymphatic glands above and to the right
of the oesophageal ulcer, and lying between the common carotid
and subclavian. These had been recognised during life. The
lungs were small and crepitant, and the bronchial tubes con-
tained blood, but there was no disease in them. All other
organs throughout the body were fairly healthy. On micro-
scopical examination both the lymphatic glands and the parietes
of the oesophageal ulcer were found cancerous. The greater
part of the parietes of this ulcer was, however, slough of other-
Avise healthy tissue. The ulcer over the cricoid was free from
cancer.
The patient who is under my care at St. Thomas's Hospital
at the present time is John Stephen C — , set. 55, a greengrocer,
residing at Walworth. He was admitted 8th September, 1871.
Is a short man, with a dark complexion, not indicating cancer-
ous cachexia. Family history very good, with the exception
that his mother was gouty. He has for many years been
exposed to wet and draughts, especially early and late in the
day, but always enjoyed good health until nine months before
admission. Never had sypliilis, gout, rheumatism, or enlarge-
180 Cases of Stricliwe of the (Esophagus.
ment of glands of neck. Never swallowed any hurtful foreign
body or corrosive fluid. Was always very temperate. Three
weeks before Christmas last he first suffered from stoppage of
the food at the lower part of the gullet, about three times a
week ; could scarcely get his breath until the food was brought
up. Felt as though it was prevented from passing by '' wind-
balls" rising from the stomach. Three days before Christmas
he had a more distressing attack than usual, and then the food
stopped after every meal. He pointed to the ensiform cartilage
as the part where it appeared to lodge. It felt as a heavy
weight, and caused great distress vnitil it Avas ejected, generally
in about three minutes, but sometimes as long as half an hour.
Occasionally it did slip down into the stomach, and he was
then easy at once. Would sometimes partially overcome the
stoppage by bolting as much solid food as he could, the greater
portion being quickly regurgitated. From being very stout he
rapidly got thin ; had suftered from a constant aching pain
between the shoulders for a week or two before Christmas, but
not subsequently. After a time milk and all fluids stopped, as
well as solids. For several months he lived upon a little
milk, beef tea, and raw eggs. Every now and then he would
swallow a little better for a few days, but the obstruction and
uneasiness were sure soon to return with increased severity.
When not taking food he suff'ered no pain or spasm, and the
only thing he complained of, besides great general weakness, was
a feeling of numbness and " pins and needles" in the head and
extremities. He had been under several medical men, and
attended as an out-patient at two or three hospitals, but coukl
never keep down whatever medicine was prescribed. No in-
strument had l)een passed. AVas decidedly Avorse since July, and
he asserted that there had been complete incapability of swal-
lowing food, even liquids, for several days. On admission he
was found excessively emaciated and prostrate. The abdomen
was so shrunken that the umbilicus seemed almost to touch the
spine. He complained of intense uneasiness and some pain
about the ensiform cartilage, as though a large marble were fixed
in the lower part of the gullet.
On drinking about a Avineglassful of milk he was observed to
eject it in about one or two minutes, Avithout pain or dilliculty.
There had been no action of the boAvcls since Jth September
Cases of Stricture of the (Esophayus. 181
(four days before admission). Tongue furred^ dry, and brown.
Pulse 88, thready ; same at both wrists. Hearths action very
weak ; no murmur. Slight irritable cough. Skin cold and
dry. Urine thick, Avith cream-like sediment, consisting of
phosphates, urates, and mucus. Sp. gr. 1026. No albumen or
sugar.
Was ordered a bismuth and glycerine mixture, and strong
nutrient enemata, consisting of beef tea, brandy, arrowroot, &c.,
at first with some slight benefit, but very soon the rectum
became exceedingly irritable, and the injections could not be
retained, so that he rapidly became weaker and to all appear-
ances dying; was unable to swallow anything whatever. A
No. 9 prostatic catheter was now passed through the nostril
down the oesophagus, towards the lower part of which there was
evidently a considerable pouch, and the end of the instrument
was then felt to be tightly grasped just above the cardiac orifice,
but by gradual and continued pressure it was passed through
the constricted part without much difficulty into the stomach.
Strong nutrient liquids were then injected through the tube,
and in this way the patient was fed for some days. On the
18th (ten days after admission) he could swallow a little with-
out the tube. After three or four days, however, the food again
refused to pass into the stomach, and he was obliged to have
the catheter reinserted, but after two days he could again
swallow fairly well without it. Thus he went on until October
9th, when a No. 10 catheter was passed. This was removed
from time to time, but if symptoms of obstruction again re-
turned the patient would himself at once pass the instrument
down to the strictured part and press against it, without passing
it through into the stomach ; he could thus dilate it sufl[iciently
to allow him to take his meals very well, occasionally even con-
sisting of some finely minced meat. On October 10th he was
ordered Potassii lodidi gr. iiss^ Infusi Calumboe jss, bis die.
Also plenty of strongly nutrient liquid food, wine_, oysters, and
any kind of fish, &c. October 20th, a No. 11 prostatic catheter
was passed and kept in four days, after which he was able to
eat well. The day after its introduction he brought up about a
table-spoonful of blood, but there has been no repetition of
tliis.
October 27th. — No. 12 passed, and retained two days. After
182 Cases of Stricture of the Oesophagus.
tins lie was able to take all his meals remarkably wcll^ but it
was deemed advisable to keep in the catheter every nighty re-
moving it for the day.
November 1st. — A No. 14 (Esophagus tube was found too
largCj so that No. 12 was passed instead,, and kept in for the
night only. Was ordered Syrupi Ferri lodidi ^ss, Glyccrini ^j,
Aqua3 5Jj ^Jis die.
11th. — Is quite well, and will be shortly discharged.
The chief point in this case is the nature of the disease which
induced the constriction. Geiierally, such is found to be can-
cerousj especially when seated near the cardiac orifice of the
stomach (simple fibrous indurations, as a rule, affecting that
part of the oesophagus which is opposite the cricoid cartilage) ;
but there are here none of the elements of malignant disease,
at least its absence may be assumed by — (1) The non-existence
of cancerous cachexia. (2) The long time which elapsed with-
out more decided occlusion taking place, and the rapidity with
which it was cured by mechanical means. (3) The absence of
lancinating or burning pain in the part affected. (1) The fact
that when he brought up a little blood (doubtless caused by the
friction of the instrument) he was even better afterwards,
whereas if it v.'cre scirrhus any lesion of mucous membrane
would be quickly followed by increasing carcinomatous growth
and worse symptoms of constriction, and perhaps also by the
discharge of dark grumous fluid. Then, again, the whole course
of the case, and the evident grasping of the elastic tube when
pressed through the constricted part, together with the locality
of the latter, put aside any question of tumours, &c., from with-
out. In the latter case, too, the dysphagia would not be nearly
so urgent nor so constant as Avhen the morbid changes affect
the parietes of the oesophagus directly. Lastly, the constriction
could hardly be from mechanical or chemical injury, for there
would necessarily be a distinct history of such hurtful sub-
stances being swallowed. I remember a fatal case at the old
St. Thomas's Hospital which was very similar to the one now
described in all its bearings, only that in that instance there
was clear history of the man having, two years previously,
swallowed a quantity of Burnett's disinfecting fluid out of a
bottle, in mistake for gin. He was for some time after this
accident severely ill, a^id suffered great pain about the pit of the
Cases of Stricture of the (Esophagus, 1 83
stomach, but he gradually got Ijetter, and seemed to have
completely recovered. It was long after the accident that the
stricture formed, or, at least, was perceived by the patient.
Probably, in the case now under consideration, as in all such
where there is organic stricture, whether idiopathic or not, the
disease existed a long- time before it was sufficiently advanced
to be perceived and give serious uneasiness.
In the case now under my care my belief is that there is a
simple organic stricture at the cardiac end of the oesophagus,
due to thickening of the mucous membrane and submucous
fibrous deposit. There are several instances on record of such
an affection occurring idiopathically, and leading to trans-
formation of a portion of the parietes into a fibrous or fibro-
cartilaginous substance, independently of precedent ulceration
of inflammation. What the diathetic condition which led to
it in this man may be it is difficult to determine; probably
gouty, as his mother suffered much from gout.
There is no doubt that a considerable pouch or dilatation
existed just above the stricture, for whenever the catheter
reached that part any fluid he may have previously taken at
once gushed up through the catheter. It was observed that
for some days after admission, whenever the man drank, the
fluid passed down readily enough, and remained for a minute
or two without pain or uneasiness ; it was then brought up
without any action of the diaphragm and without any effort,
seemingly as though by the exercise of wdll. In diseases of
the stomach, on the contrary, however near the cardiac orifice
they may exist, the food induces great uneasiness and nausea,
is rejected almost immediately with spasmodic action of the
diaphragm, and, of course, to the test-paper is found excessively
acid.
The chief characteristics of spasmodic stricture are, of course,
wanting in this case. As long as spasmodic closure con-
tinues, I know of no way by which it may be distinguished from
organic stricture, but it is paroxysmal rather than permanent,
and it does not usually attack such patients as this man.
Liquids, too, in the present case were more easily swallowed
than solids, which would not be the case were it spasmodic.
The patient had certainly remissions from time to time, espe-
cially in the earlier period of his disease, but in permanent
184 Cases of Stricture of the (Esophagus.
strictures that is often the case. There can be no difficulty,
however^ in distinguishing between the long-continued attacks
of the one and the short paroxysmal seizures of the other. The
stricture in this patient cannot be a result of ulceration; for
that is always attended with great pain, and is generally the
result of either syphilis or of chronic inflammation, both of
which Avere here absent. Paralysis of the oesophagus, also, is
out of the question, as the constricted part could be so easily
felt on passing the instrument, and in the event of paralysis
solids are always more easily swallowed than liquids, and larger
quantities more readily than small. This affection, too, is
generally associated with paralysis elsewhere, or occurs in con-
nection with low fever. I may here mention that I have met
with several cases of typhoid within the last month or two, in
Avhich favorable progress was being made until the third or
fourth week, when paralysis of the oesophagus occurred, and
proved rapidly fatal. As a rule, the prognosis in cases of
stricture of the oesophagus, from whatever cause it may arise,
is most unfavorable, although a fatal issue may sometimes be
long delayed. I see no reason, however, wh}^, in this particular
case, the favorable issue already arrived at may not be per-
manent by an occasional careful use of bougies when necessary,
in the same way that similar cures are attained in stricture of
the urethra or of the rectum. There is, indeed, a striking
analogy between these three forms of permanent stricture, not
having a malignant character, and they require much the same
local treatment as to bougies, &c., for the purpose of dilating
the diseased part. But, in addition to this, elastic tubes are
absolutely essential in stricture of the oesophagus for the purpose
of administering food. By this means life may be protracted
for a considerable time. It doubtless was so in the case de-
scribed as occurring last year. Without the introduction of the
stomach-pump the patient must have died much earlier, not-
withstanding that, in all probability, it was the cause of the ulcer
at the lower part of the pharynx, as described, Avhich led even-
tually to perforation of the left common carotid artery. There
must always be a risk of such evils whenever the clastic tube is
necessarily retained for any length of time, and especially when
there is infiltration of cancerous deposit in the parietcs of the
oesophagus. Another reason why, in the present case, a per-
Cases of Stricture of the (Esophagus. 185
manent cure will most likely be effected by the occasional
judicious use of elastic instruments is that the stricture evi-
dently occupies very little extent of the gullet at its lower part.
The patient can now pass the tube himself very readily. Some-
times, he says, a little spasmodic action seems to impede its
course, but a little pressure alone is quite sufficient to allow
him to swallow food fairly well afterwards, in the same way
that mere pressure by a catheter against a similar stricture of
the urethra is sufficient to give relief. I do not see any danger
in his using the instrument himself, although at first he em-
ployed it without permission, especially as he will shortly leave
the hospital, and it will be advisable to keep up its occasional
use for some time.
Of course, whenever there is suspicion of ulcer or of aneurism
pressing against the oesophagus, or malignant disease affecting
its walls, the passing of such instruments should be undertaken
reluctantly and with the greatest possible care, being not un-
attended with danger.
I do not know whether medicines can assist in promoting ab-
sorption of the fibrous infiltration in the submucous cellular
tissue, but I am treating him with iodine mixture, and shall
also try means to apply the iodine locally.
With regard to nutrient enemata, with which I treated this
patient in the first instance, I confess I have little faith in them
from all that 1 have hitherto observed myself. I have read and heard
of patients being entirely supported for several weeks in this way.
It may be so in dysphagia, however severe, for life may be long
preserved if only a very little food is swallowed and retained in
the stomach, especially if supplemented by not too frequent
nutritious enemata ; but in complete acataposis, whether from
paralysis or stricture or any other cause, I have never seen a
patient survive longer than four days by being fed entirely upon
nourishments injected intra anum, and in most of the cases
which I have observed there was no evidence that life was really
thus preserved for a single day.
ON iEGOPHONY.
By WILLIAM H. STONE, F.E.C.P., &c.
No one auscultatory sigu has been the subject of so much
debate as segophony. Every shade of opinion has been ex-
pressed concerning it, from that of Skoda, which declares it to
be diagnostically worthless, up to the original view of Laennec,
its discoverer, Avhich held it to be pathognomonic of pleurisy.
It has, therefore, in a sense, stood apart from the other acknow-
ledged jihysical signs, and has been estimated at a variable and
uncertain valuation.
No person, however, who has practised auscultation to any
extent can doubt of its striking character as a physical pheno-
menon. Every now and then, in the examination of a case, it
suddenly rings out with such force and clearness as to be abso-
lutely startling. For this very reason, perhaps, it has been less
closely studied than it would have been otherwise, the observer
contenting himself with substantiating the fact and passing on
to other indications.
It has long occurred to me that this, as well as many other of
our auscultatory phenomena, required re-examination in the light
of modern researches, specially those of Helmholtz, on acoustics.
I have endeavoured, on his method, first to analyse the sonorous
elements into their constituents, and then to reconstitute the
whole results by a synthetical process of a mechanical nature.
It was just in this fashion that the distinguished physicist in
question attained to his great discovery of the formation of
vowel- sounds during articulate speech; first, by applying a
series of " resonators" to decompose the compound sound ; and
then, having isolated its harmonic elements, recompounding
lS8 On jEgophony.
these in such manner as to reproduce the original effect. This
method has the greatest attainable accuracy, and all but equals
mathematical demonstration.
It is now some years since I made the first step in this direc-
tion by testing the transmission of musical sounds through
healthy and diseased lung. The observations Avere published
in a medical periodical. I there showed that we were at
once able to separate two very distinct phenomena, which
are of necessity combined in auscultating the voice, namely,
vocal fremitus and vocal resonance. The former of these is
vibration of a coarse and violent kind, transmitted from the
vibrating larynx through the tissues, and sensible to the hand
placed over the pectoral region. The fact of its transmis-
sion through solid tissue, and not by the air-passages, is shown
by its being distinctly felt all over the head of the person
speaking, and by the curious observation which I have since
noticed, and have now to record, that it is very distinct all over
the head during the utterance of a " falsetto" note in what has
always been appropriately called " the head voice," a note
which entirely fails to produce any vocal fremitus over the
thorax. Vocal resonance, on the other hand, is admitted to
depend mainly, if not wholly, on the column of air in the trachea
and bronchial tubes vibrating after the fashion of an organ-pipe.
The mechanism of its transmission through healthy or solid
lung has been the subject of much discussion, especially by
Skoda, and will be adverted to farther on.
The method adopted for filtering off, as I may say, the coarser
fremitus from the finer musical sounds consisted in the use of a
pitchpipe placed between the lips, and made to utter its note
by drawing a deep insjiiration. The column of air was thus
inspired in a vibratory state, which, by the way, is quite sensi-
ble to the delicate nervous apparatus of the tongue. However
loud the note thus sounded, and however distinctly transmitted
to the ear, it fails to produce any thoracic fremitus. The metal
tube of the pitchpipe can be felt to vibrate, and the vibration
extends to the soft tissues of the lips for a short distance, but is
soon extinguished, and is only slightly felt over the head. Even
this slight conveyance of fremitus can be obviated by inserting
the pitchpipe into a piece of vulcanized india-rubber tubing
and inspiring through the other extremity.
On /Egopho)nj. 189
in the pajier referred to above I j)oiiited out that the esta-
blishment of what may be called an artificial larynx might
prove of value in auscultation, where the natural organ Avas
injured by disease; and also by enabling us to produce the
same note in every case without being obliged to allow for the
great discrepancies of bass and treble, male and female, infantile
and adult voices.
I have since found that it leads on to an observation which
is, to my mind, of considerable interest, not only in a jihysical
point of view, but also as bringing into harmony the disagree-
ment which has long existed respecting the diagnostic import-
ance of segophony. There are, indeed, many other applications
of the method, which I do not propose to enter into on the pre-
sent occasion,- some still being under examination, others too
bulky for my allotted space in this volume. The discussion of
a?gophony so far stands alone that it can without violence be
dissociated from kindred phenomena.
For the better investigation of musical sounds I obtained
what is called a chromatic pitchpipe, on Eardley's patent, by
means of which the pitch can be altered more than an octave,
from F in the bass stave, a note on which many male voices
speak, up to F of the treble stave, Avhich is within the compass
of most or all female voices. The experiments Avcre made witli
every note of this register, so as to avoid the fallacy Avliich
might arise from the transmission of one note, and the non-
transmission of another.
I was early surprised to find how little the musical sound was
conveyed. Even over a lung solid from pneumonia there was
hardly any transmission, usually none whatever. This fact at
once disposed of the old and before refuted fallacy that con-
solidated pulmonary tissue conveys sound better than the same
tissue in a healthy state. I have long satisfied myself that
Skodas' absolute negative to this eff'ect is perfectly true, and can
only feel astonishment at the vitality of the error. No doubt
bronchophony as a crude fact exists, but the very simplest ex-
periments will prove to any one who thinks it worth while to
try them, that either Skodas' doctrine of consonance or some
other must be found, competent to its explanation. With a
pure musical note, such as that of a pitchpij^e, from which
vocal fremitus has been cut off, bronchophony only exists in the
190 On j^yophony.
neiglibourlioocl of the large bronchi, even where the king is
extensively pneumonic. In phthisical cases there is more
transmission, though the complications with cavernous and
cavernulous sounds render the subject too long for the present
moment, and, indeed, require further investigation. I may,
however, state provisionally that every now and thou a cavity,
if empty, and communicating freely with the bronchi, seems to
possess the same key-note as that sounded, and reinforces it
poAverfully, while it is quite silent to other notes. This rein-
forcement can often bo brought about by varying the note, and
in some degree affords a measure of the size and condition of
the vomica.
At first I felt somewhat disappointed at these negative
results, and more so at linding that the pitchpipe produced no
evidence of regophony, even where it was marked Avith the
speaking voice, and the other signs of pleurisy were distinct.
But it occurred to me to reduce the voice to the same con-
ditions as the pitchpipe, by making the patient sing or intone
a note. Here there were great difficulties in my way ; most of
the lovrcr classes from Avhom hospital patients are recruited
being uneducated, and profoundly unmusical. Many of them,
therefore, resented what seemed an ill-timed jocularity on my
part ; some were shy, and others, with the best will in the
world, produced a groan or screech which lacked every possible
musical character, and was open to all the inflections and com-
plications of the speaking voice. With patience I succeeded in
obtaining from a patient with chronic pleurisy a good intoned
bass note, about A or G. Then I found that this, like the
pitchpipe, produced no cegophony, although the phenomenon
was jDcrfectly disthict whenever he spoke in his ordinary con-
versational tone. I was thus led to notice that the a?gopliony
did not occur with every sound, even of the speaking voice, but
came and went, and again returned, according to the syllable
pronounced. I then tried the converse experiment ; having
made him sound a note without vocalising, I asked him to
whisjier loudly. The segophony was immediately distinct, and
almost painful in its clearness. Now, whispering is vocalisa-
tion pure and simple ; it is articulate speech made entirely in
the mouth and fauces without any laryngeal ground-note ; to
this, cegophony, absent from the musical sound, seems to belong.
On JRgophony. 191
AVhatevcr may be tlie ^ s of my coming explanation,
I can honestly affirm the facts to be mere matter of
observation. In this case, ti. Joseph Hardwick, of which
I propose to give my notes fart, r on, and in another, that of
George French^ now under my cure, I have demonstrated the
condition described several times to a large class of students,
and Joseph Hardwick went with me by appointment to the
house of my colleague, Dr. Bristowe, for examination. Dr.
Bristowe was able to confirm, in every respect, the presence of
the sounds as given above, and of some which shall be presently
mentioned.
Having obtained this clue to the mechanism of segophony, the
next step was to test the explanation by reproducing the sound
artificially. A piece of india-rubber tubing was obtained, some-
what over a yard in length, and nearly an inch in bore. Over
this was placed a bladder or a small india-rubber bag containing
Avater. A moutli-piecc like that of an ordinary speaking-pipe
was adapted to the end of the tube, and by its instrumentality
notes of various kinds Avere transmitted into it. The ear, or, still
better, the stethoscope, was steadily applied to the upper surface
of the Avater-bag, and the efifects noted. As in the lung, a pure
musical note, Avhether of the A'oice or of a pitchpipe, Avas hardly
at all transmitted ; I say hardly, because from the elasticity of
the india-rubber it Avas impossible to prevent some transmission
of vibration through the solid containing wall. This was easily
distinguished from that passing through the water, after a little
practice. When, hoAVCA'er, spoken Avords containing vocalised
voAvel sounds Avere used, the eegophonic twang reappeared in
startling force and distinctness ; indeed, combinations of words
could be formed expressly calculated to develop the phenomenon.
If the india-rubber tube Avas flattened by pressure, or naturally
took an oblate form, the segophony became more distinct, the
flat side of the tube apparently acting as a vibrating mem-
brane.
On analyzing the sound transmitted, the principal point to be
noted Avas the raising of its pitch. This Avas usually to the ex-
tent of a minor third above the note heard by the open ear ; but
it seemed also to be accompanied by a squeaking or bleating
sound, due to the presence of notes some octaves higher, and
too remote for their exact pitch to be ascertained. The same
19.2 On jEgophony.
observation was very clearly made in some of the pleuritic cases
examined; of Avliicli I proceed to give a few notes.
Case 1. — Joseph Hardwick, ret. 2G, engineer. Had been under my care in Feb-
rnarv, 1871, for chronic pleurisy, for which I had ordered his admission into tlie
hospital. He remained some months under the care of Dr. Clapton, and left on
May 10th not materially relieved. The general symptoms were not very urgent, and
he was a ruddy, healthy-looking young man.
The left side of the chest was evidently distended and fuller than the right. It
was universally dull on percussion. Breath sounds of a feeble though fairly healthy
character were audible down to the base, apparently the lung being tied down by old
adhesions, and, therefore, not forced upwards by the fluid.
With his ordinary speaking voice there was distinct regophony. On making him
sound apitchpipe by inspiration no sound whatever was transmitted. After some
little trouble I taught him to sing a note in unison with me. Directly the tone
became musically pure, and what a singer would call a good note, the OEgophony disap-
peared, returning more or less when his voice failed and the tone became uncertain.
On June 7th, I took this patient to the house of my colleague Dr. Bristowe with a
view to more careful observation. Dr. Bristowe confirmed the physical condition,
which was, moreover, testified to by Dr. Clapton's notes during his stay in hospital.
Besides tlie facts above stated we elicited the following facts :
With the broad a or rather ah used by singers, there was hardly
any a?gophony. With the sharp a, (as in the word " April" or
" Apron") it immediately became distinct. AVitli the sharp
e also (as in " easy") it was more marked. With the u, or
00, as in " use^' or " ooze," it was the most remarkable of any ;
because apparently the notes on which these closed vowels arc
spoken lie much lower than those of ii or e. When at Dr.
Bristowe's suggestion I made him whisper, the conveyance of
a high pitched sound was singularly clear and striking.
This patient continued for a month or two more under my
care. Vocal fremitus, at first absent on the affected side, became
slightly perceptible, but otherwise he altered little.
Cask 2. — James Levens, iut. 25, horsckeeper, came to the hospital on October lOtl;,
1871, with symptoms of albuminuria. The face, legs, and scrotum, were very cedc-
matous ; the breath was short, the urine abundant, containing much albumen.
On his first visit there was dulness and pneumonic crepitus at the base of both
lungs, most marked on the left side.
On the 2Gth the dulness was marked over the lower third of the left huig;
there was no crepitus beyond slight creaking at the end of a deep inspiration. Vocal
fremitus was abolished in the same space. With the speaking voice there was a com-
bination of bronchophony and acgophonic twang, the result being that the note
heard through the stethoscope was of a distinctly higher pitch than the ordinary
On JElyopliony . 193
voice, and of a difterent character. On making him sound a pitchpipe no sound
whatever was transmitted.
Case 3. — George French, a^t. 28, brewer's servant, made out-patient on October
26th, 1871, with signs of pleurisy.
He suffered from cough, pain on the right side, short breath, with rapid emacia-
tion and profuse night sweats. No haemoptysis. The apices of both lungs were
normal. On the right side there was complete dulness over the lower two thirds,
no vocal fremitus, and high shrill aegophony. On measuring the musical interval
between the transmitted and the natural note, it was found to be a minor third
higher.
There was no transference whatever of the vibrations from the pitchpipe, though
vigorous and continued inspiratory efforts were made.
This patient only attended twice, with some improvement. The sounds were easily
demonstrated to a large class of students, and it is probable that he objected to the
examination.
I am anxious as much as possible to separate this first part of
my paper from any explanation which I now proceed to offer.
The facts as hitherto stated are simple and easily demonstrated ;
utterly independent of views or theories, and perhaps suscep-
tible of other solutions than mine. But on considering the
curious, and, I believe, new observation, that a pure musical
vibration within the limits of the ordinary speaking voice is
not transmitted at all, either through consolidated lung or
through a layer of pleuritic fluid; but that the same note,
when vocalised and modified by the addition of vowel sounds,
immediately passes through the obstructing media at a changed
pitch, I cannot avoid connecting the phenomena "svith Helm-
holtz's discoveries as to the mechanism of vocalisation. I need
not recapitulate his views more than to remind my readers that
he finds all vowel-sounds surrounded with numerous remote
harmonics. Many of these vowels he has succeeded in repro-
ducing from a series of tuning-forks kept in steady vibration by
electrical agency. He specially states that he experienced a
difficulty in obtaining the E and I sounds, until he reinforced
the extreme high harmonics at the expense of the fundamental
notes. Now, these are exactly the sounds on Avhich aego-
phony is most distinct, w'hether in a living lung or in an arti-
ficial india-rubber substitute. I am, therefore, led to the
impression that ajgophony has the same, or rather the converse,
modus operandi; that the layer of fluid, while it stops the
larger and coarser vibrations of the ground-tone, lets pass the
finer and closer undulations of the high harmonics. We thus
VOL. II. 13
194 On jEgophony.
have plienomena in what we may call an ascending scale ;
beginning with the rough vibration of vocal fremitus, wliicli,
like some forms of loud cardiac murmur, is actually sensible to
the tactile papillre of the finger, but which is easily intercepted,
through the phenomena of vocal resonance which are more
penetrating, up to a?gophony, which is thus explained to be
vocal resonance divested of its lower fundamental tones by the
deadening effect of a layer of more or less inelastic fluid.
Therefore, I was led early in the paper to name it a filtration.
It is thus not dissimilar in kind from that which in a transparent
medium, like glass, obstructs the undulations of sound and heat,
but gives free passage to the finer and more subtle pulsations of
light.
CASES OF
INYEESION OF THE BLADDEE.
By JOHN CHOET, F.E.C.S.
Ur to the present time only three cases of this affection have
been recorded. It may be supposed, therefore, to be of very
unusual occurrence. Probably cases may have been met with
but not published. In the one recorded by the late Mr.
Crosse of Norwich, but for the caution of that gentleman a
ligature Avould have been applied, under the impression that the
inverted vise as was a vascular tumour. Had that plan of treat-
ment been carried into effect perhaps we might never have heard
of that case.
The following case presents features of interest common to the
others, and has, in addition, a complication Avhich gives extra
importance to it.
On going to my out-patient room at St. Thomas's on May the
20th, 1870, 1 Avas hurried to see an infant in a sad plight. I
was informed that a tumour from the vagina had burst, and was
bleeding. The little sufferer, who was only fourteen months old,
was crying and struggling. On examination I found a red vas-
cular, pear-shaped projection between the labia, about the size
of an ordinary walnut. The mother stated that this had been
down for four hours. It became evident, on careful scrutiny
and handling, that this was not of the nature of a polypus, or
solid tumour, but the surface seemed to be formed by a mucous
membrane, probably by that of the bladder. It was tense with
fluid. On turning this tumour from side to side and about, the
vaginal orifice and hymen were distinguished posteriorly, but
196 Cases of Inversion of tJic Bladder.
the lateral attachments were difficult to uncover. I was in the
act of inserting a little finger through the anus, when a violent
struggle was made and the tumour burst upon its prominent
front aspect at a tiny spot, and a fountain of clear straw-coloured
fluid played for a few seconds, and then the tumour partly col-
lapsed. A very small clot of blood formed at the seat of rupture.
The mucous character of the surface was noAv apparent, I did
not see the orifices of the ureters, but I should say that I did not
pull down the sac for the purpose of exposing them. Whilst
trying further to examine the case, the collapsed sac partly re-
filled, and the cryinii- and strurjslin": of the infant caused more
of the fluid to be ejected, and more than once. Mr. Stewart,
the curator of the museum, was present at this time, and took
some of the fluid to test and examine microscopically. Mean-
while chloroform was administered. Under the influence of this,
defalcation and violent strainings occurred. In order to prevent
mischief from these efforts, I kept my thumb and finger pressed
against the now collapsing sac, and found it gradually reducing
in volume and receding ; as insensibility became complete
the little finger easily returned the remainder of the tumour
through the meatus urinarius and urethra. I did not pass the
finger through this passage, as I might have done, to explore,
but inserted a director, which moved freely, as though in a
bladder. I felt no doubt from that time the case was one of
bladder turned inside out through the meatus.
To my inquiries the mother stated that the tumour had been
down for four hours, and that it had been noticed more than
once before. Three days back it had been down for half an
hour, and went up during sleep. She had observed a difficulty
in urination, and dribbling during about two months. The
mother said the infant's bowels had been habitually costive.
After reduction, the case was admitted into the hospital
to be Avatched, on the supposition that during the state of in-
version the bladder had ruptured, and that mischief might
radiate from the seat of lesion. Mr. Stewart's examination of
the fluicl tended to support me in the opinion that the bladder
had ruptured. He informed me that when he had evaporated
some of the fluid on a glass slide to within a little of dryness, it
turned yellowish (like a serous fluid), but there was not any
crystalline ajipearance ; that on the addition of nitric acid no
Cases of Inversion of the Bladder. ~ 197
change took place, and tliere was not any indication of uric
acid, that when this had been a little farther evaporated,
ammonia was added, but no change Avas observed, no colour
developed, there was no sign of murexide.
After admission, however, no bad symptoms ensued. The
urine flowed away so freely that it was not even necessary to
keep a catheter in the bladder. On the third day, as the child
seemed pretty well, the mother was allowed to take her out.
The water continued to dribble away, and to be expelled on
coughing, &c., for a few days, but soon almost complete control
was regained over the urethra and meatus. I may here add
that in July, 1871, the mother reported that there had not been
any relapse of the inversion, but that occasionally dribbling
occurred, and sometimes dvu-ing coughing or sneezing a gush of
urine took place.
For the sake of comparison, and for future reference, I here
insert abstracts of the three cases to which I have already
referred. These constitute, at present, our stock of facts on
this subject.
Case 1. — Dr. Murphy^ s Case, reported in the ' Liverpool Medical
Gazette,' and quoted in the 'London Medical Gazette,' 1833,
p. 525.
Jane R — , set. 4 years, admitted July 9th, 1829, into the Meath Infirmary.
Presented the following appearances on admission ; a pyriform tumour, the size
of a small hen's egg, depending from between the upper portion of the labia
pudenda, of the colour of dark mahogany, the base below, apex above ; the little
finger in rectum communicated no motion to tumour, nor could anything unnatural be
detected. On raising the tumour towards the pubis, the vagina was seen, but the
meatus urinarius could not be traced. The orifices of the ureters were not discovered
until a very slight traction of the tumour downwards rendered the inversion com-
plete. A small silver probe passed up each orifice, on being withdrawn, was fol-
lowed by urine almost devoid of either smell or colour.
Replacement. — The neck of the bladder was steadied by the thumb and forefinger
of the left hand, and the fundus having been pushed upwards by the end of a gum-
elastic catheter, its reinversion was easily affected.
The catheter was retained there for a few hours by an assistant.
Some tenderness of the pubic region followed, attended by vomiting ; leeches,
warm baths, and castor oil were prescribed. Those symptoms quickly yielded.
Discharged cured, July 17th (eight days).
198 Cases of Inversion of ilie Bladder.
Case 2. — Mr. Crosse's Case, reported in the '■ Transactions of
the Provincial Medical and Surgical Association,' N.S.,
1846, p. 185. Mr. J. Green Crosse was Senior Surgeon to
the Norfolk and Nortvich Hospital.
In the year 1829 a highly respected coUeagne of mine, since deceased, received
under his care a healthy looking female child aged between two and tlirec years, on
account of a tumour about the size and shape of a walnut, projecting visibly at the
external labia pudenda. It was of a florid red colour, and somewhat granulated on
its surface, so as to resemble a large strawberry ; and the surgeon entertained a
notion that it was a vascular tumour, which might be removed by ligature, on which
account he requested me to inspect it. After a slight examination, I expressed my
doubts as to its being a vascular tumour, and dissuaded him from the hasty applica-
tion of a ligature. Towards the posterior part of the tumour, and on its sacral
aspect, there was an aperture, which was conjectured to be the entrance into the
displaced urethra. A very small female catheter easily entered this aperture, and
passed along a channel a little to the left side of the median line. Urine distilled in
drops through the catheter, but there was not a gush, although the instrument had
entered so far that we concluded it must have reached the cavity of the bladder.
Besides what thus oozed through the catheter, slightly tinged with blood, there was
an oozing of urine from another source, which was not explained until a second and
more strict examination, instituted a few days afterwards, on my casually coming to
the patient's bedside, just as the surgeon was prepared to apply a ligature round the
neck of the tumour. I now found concealed in a fold of the tumour, and near the
posterior junction of the labia, two orifices not far asunder, from which the urine
ooz^d, and which were evidently the vesical terminations of the ureters.
On pressing the tumour firmly, as if to reduce it like a hernia, I found it yield,
and pass gradually behind the symphisis pubis, and within the labia; and under a
continuance of the taxis it all retired, leaving the external parts in their proper shape
and position. A passage remained through which the tumour on retiring had taken
its course, which was actually the dilated urethra, into which I could and did in-
troduce my little finger, until it fairly entered the cavity of the replaced bladder.
Historp. — It was stated that the tumour had existed for a considerable time, and
had been always attended by stillicidium urina; ; also, that it had been once replaced,
but had descended again shortly before it came under my observation. During the
time it was under notice no relapse took place. After an interval of sixteen years
no relapse had occurred, but she was constantly troubled with incontinence.
I accomplished reduction liy returning first that part of the bladder which is next
the urethra, and, lastly, the fundus.
Case 3. — Dr. Lowe's Case, reported in the 'Lancet' of March
the 8th, 1862.
M. A. H — , at. 2i years, fine healthy child, but very irritable. Admitted in
West Norfolk and Lynn Hospital, under Dr. John Lowe, November lOtli, 1859.
On examination, a vascular looking tumour, about the size of a large walnut, was
Cases of Inversion of the Bladder. 199
found projecting through the external labia. When the little patient cried, the
tumour became more injected, and increased considerably in size; at the same time
a gush of urine took place. On closer inspection the mass was found to be seated at
the orifice of the urethra. On making a little gentle pressure the tumour receded
under the finger, and presently disappeared altogether within the urethra, and the
forefinger could readily be passed into the bladder. I had, therefore, no difficulty in
diagnosing an inversion of the bladder.
From the statement of the mother, it appeared that the child had been subject to
nconiinence of urine from its birth, and that from the time it was two or three
days old a small substance had been observed to protrude during a fit of crying or
straining.
Each effort of this kind was followed by a flow of urine, and the child's condition
from this cause was truly pitiable. The thighs and labia were much excoriated, and
the latter, as well as being swollen and indurated, were covered with numerous
pustules. Until the age of two years, the tumour had receded as soon as the fit of
straining was over, but latterly it constantly protruded more or less.
Treatment by actual cautery. She was eleven months under treatment. Result
no relapse, but some degree of incontinence.
I have stated that my case differs from the others in the
serious complication which occurred, viz., the rupture of the
bladder. Dr. Lowe reports that when his patient cried " the
tumour became more injected, and increased considerably in
size." At the same time a gush of urine took place. He has
kindly replied to an inquiry on this point, and written me that
he is sure the fluid was urinous, and that it escaped from the
ureter. I cannot think the fluid which I h.a.\e described as
escaping in little Lewis's case was ejected in a fountain from
either of the ureters. 1st, because during the projection and
tension of the bladder those orifices must have been tightly
closed ; 2nd, because the spot at which the fluid leapt out bled
at the time, and became clotted immediately after; 3rd, the
rupture was situated above and in front, whereas the orifices of
the ureters must have been behind and below. Now, Dr. Lowe
states in his letter that he watched '' the escape from the
ureters, which wei'e distinctly visible." If it did not come ffom
either of the ureters, whence did it escape ? It could not have
come from the bladder, for that was already turned inside
out.
With regard to the nature of the fluid ; had it bean whious,
I think Mr. Stewart would not have failed to find evidence of
its being so, either chemically or microscopically. I thought
at the time, and I see no reason to change my opinion, that the
200 Cases of Inversion of the Bladder.
fluid was serous, and came from the peritoneal cax'\t\i. I think
the bladder^ in becoming inverted through the urethra and
meatus, carried its partial peritoneal coat with it. That being
the case a hernia of the peritonevnn was formed, a hernia
through the urethra and meatus. I think this sac became con-
stricted by the meatus, just as an inguinal hernia suffers con-
striction by the internal abdominal ring ; the peritoneum, under
these circumstances, poured out, as it would do in an inguinal
hernia, serous fluid, and that fluid gradually distended the
pouch. Violent expulsive efforts of the abdominal muscles at
last caused the rupture which I witnessed.
The after absence of peritonitis, to my mind, is no contra-
indication to the occurrence of the rupture of the bladder, nor
does it invalidate the theory that the peritoneum had been
herniated and the fluid serous. That rupture of the bladder
per se is recoverable we know for a fact. AVhen death has
followed upon this accident, the fatal result has' been due to the
invasion of the peritoneal cavity by urine, and its disastrous
consequences. It is obvious that no such contamination took
place in little Lewis's case ; the urine flowed away unobstructed
through the natural, though for the time paralysed, channel.
The lesion, too, was small. Under such circumstances it is not
surprising that the recovery was very rapid.
Such an accident may happen again, though cases of this
nature seem rare ; it is, therefore, all the more important that
the nature of the affection should be recognised early, and
the inversion treated promptly.
A small pyriforra, red, vascular, elastic tumour, situated
between the labia, below the clitoris, and in front of the vaginal
orifice; the urethra not distinguishable; the ureters, exposed,
and perhaps distilling urine ; a history of more or less inconti-
nence previous to the appearance of the tumour : these symp-
toms should lead one to recognise an inversio vesica, and to
distinguish such an affection from a solid polypoid growth.
Mr. Holmes has described a vaginal hernia in his work on
' Diseases of Children.' In that malady the urethra can be
defined in front of the tumour, which has not the red vascular
appearance of an inverted vesical mucous membrane.
The best mode of reduction seems to be by taxis, and the thumb
and forefinger are the best compressors; they should be used
Cases of Inversion of the Bladder, 201
gently. If the child struggle much it would be better to employ
chloroform. Dr. ^Nlurphy used a gum-elastic catheter to push up
the fundus ; but that plan seems dangerous^ and is quite unneces-
sary. In the event of much incontinence resulting, the treat-
ment adopted by Dr. Lowe, of Lynn, seems calculated to be
very beneficial ; but I think if I had such a case to deal with, I
should first employ Faradization. I conjecture that, in these
cases, the vesical sphinctral fibres and the muscles of the
urethra are congenitally weak, but not absolutely deficient; and
that constipation and violent efibrts at defalcation combine to
effect the inversion. For this state of things Faradization
seems to offer a reasonable prospect of improvement or cure.
ON
IMPAIRMENT OE LOSS OE POWER OE
ARTICULATE SPEECH.
By JOHN S. BRISTOWE, M.D., ]?.R.G.P.
The object of the following paper is to put on record a series
of interesting cases illustrative of various forms of impairment or
loss of speech, which have come under my observation during
the last year or two, and some of which have been investigated
by me with considerable care.
It would be foreign to my purpose and impossible within the
limits of space at my disposal to go into the literature of the
subject, and to discuss the view^s wdiich have been advanced by
the many distinguished men who have contributed to it ; among
whom must be especially enumerated the Messrs. Dax (father
and son), Broca, and Trousseau, in France, and Drs. Hughlings
Jackson, W. Ogle, Sanders, Bateman, Maudsley, Bastian, and
Moxon, in our own country. I propose, however, to make some
observations on my cases, to discuss some of the principal
points which they illustrate, and to state the view^s which I
incline to hold in reference to aphasia.
I am dis]Dosed to divide paralytic affections of sj)eech into
four classes : 1st, that in which the motor nerves of the organs
of speech are paralysed in a greater or less degree, and where,
therefore, the defect of speech is simply the result of inability to
use these organs : 2nd, the class in which the co-ordinating
centre of the movements of articulation is affected, and where
the patient, having complete control over the movements of his
lips and tongue for all other purposes, is yet unable to utter articu-
201 On Impairment or Loss of
late sounds : ord, the class in which the impairment of speech
is central, Avhere there is loss of memory of Avords or amnesia,
and other losses of mental attributes — a class which includes all
cases of pure amnesic aphasia, and many of so-called " ataxic '^
aphasia ; and, 4tli, a complex class^ to include all those cases
in which the conditions characteristic of the second and third
classes are combined.
The first class comprises a well-defined and generally well-
recognised, but rather wide, range of cases, among which may be
enumerated motor hemiplegia (right or left), general paralysis
(of the insane), general paralysis (spinal), locomotor ataxy,
chorea, glosso-laryngeal paralysis, and lesion of one or more of
the motor nerves of the organs of speech. In most cases of
motor hemiplegia there is some degree of thickness of speech
or other imperfection of articulation, due to partial paralysis of
the portio-dura and hypoglossal of the affected side. Of this
common condition Case 7 furnishes a good example. In the
general paralysis of the insane the first symptom to attract atten-
tion is visually an indistinctness or thickness of utterance, which
is dependent upon impaired innervation of the lips and tongue,
and consequent imperfect controul over their movements. The
tongue and lips are slow to act, and their movements are preceded
and accompanied by tremulous vibration of the muscular fibres.
A disease which presents many points in common with general
paralysis is that to which, for the sake of distinction, Duchenne
has given the name of " general spinal paralysis." Cases 4 and
5 I take to be good examples of this affection. Both patients
I believe to be perfectly intelligent. The first of them (a young
man) says that he had a similar attack a year or two ago, from
which he recovered in the course of a few weeks, and that his
present attack came on gradually a few weeks before the notes
of his case were taken. He had general and jiretty equal para-
lysis of his arms and legs, so that though he could move them
all pretty freely he was unable to Avalk, or to use his hands for
any delicate operation. He complained of a little numbness in his
lips and tongue, which were tremulous when in use ; and his
speech was consequently slow and hesitating, and indistinct.
The second patient (a middle-aged woman) had been ill for
about four years. The affection had begun on the right side,
and luul gradually involved the rightlcg, both arms, and the lips
Poivcr of Articulate Speech. 20 S
and toHgue. Her general loss of power was less than that of
the man, and she could walk well ; but the use of the organs of
sj^eech was more impaired, and she comj^lained alf^o that there
was a tendency in her jaw to " hang," and for saliva to dribble
from her lips. Case G belongs, probably, to the same category,
but there are some points in the history which render it more
complicated than the other two. The man was a painter ; he
had had acute rheumatism and kidney disease, and there was,
I believe, associated with the motor palsy some actual forgetful-
ness of words. On admission he was suffering from weakness
and tremulousness of the right arm and leg, manifested chiefly
during exertion, and similar affection of the right half of the
lips and tongue. The disease progressed, and before he left the
hospital the left arm also was distinctly involved. In Case 3,
again, there was general paralysis, but the onset of the affection
here was sudden, and the symptoms seemed to point to some
effusion of blood into the medulla oblongata as their cause. There
was jjaralysis of arms, legs, and sphincters, and paralysis of the
muscles of the tongue and face, so that, although he could swallow
whatever reached the back of his tongue, he could not chew
or retain fluids in his mouth, or execute any articulate
sound. He was given to a kind of hysterical laughter, which
showed itself most as he began to get better ; but his intelligence,
so far as I could ascertain, remained perfect from first to- last.
Presenting, in some of their features, a close resemblance to the
case just narrated, are typical forms of the disease which Trous-
seau terms glosso-laryngeal palsy, in which the symptoms appear
to be due to some chronic atrophic condition, involving the
roots of the hypoglossal nerves and of some of the other motor
nerves springing from the medulla oblongata and upper jiart of
the spinal cord. Case 1 is the only case of the kind which I have
had the opportunity of observing throughout its Avhole course.
This, as usual, was fatal, but I was, unfortunately, not able
to make a post-mortem examination. There was progressive
paralysis in the lips, tongue, and fauces, so that, gradually, her
lips became almost motionless and pendulous, and saliva dribbled
from them constantly ; her tongue became large and incapable
of executing almost any degree of movement, so that by degrees
she lost almost completely her power of chewing and of articu-
lating ;^aHjwassM deglutition became difficult, and in attempt-
206 On Impairment or Loss of
ing the act food "would constantly slip into the larynx. She "was
entirely sensible to the last. In tabes dorsalis or progressive
locomotor ataxy the po"v\xr of articulation is sometimes im-
paired. The second of my cases, I think, illustrates this fact.
The patient had been suffering from the disease in a "well-
marked form for six years, during the last three of "which his
utterance, previously good, had become draAvling and imperfect.
JN'o'w, in all the examples "s\-hich I have quoted, and in other
cases of the same class, there is more or less loss of controul over
the muscles concerned in articulation, "which depends either on
simple paralysis (glosso-laryngeal paralysis) or feebleness in the
nerve centres, indicated by passive tremors (general paralysis
and general spinal paralysis), and by active tremors (chorea),
or an impairment of the general power of co-ordination (loco-
motor ataxy) ; and the morbid condition on "wdiich the loss of
power depends exists either in the nerve trunks, in their nuclei
of origin, or between these latter and some subordinate co-
ordinating centre.
The second class corresponds to the group of cases to Vnicli
Dr. Bastian endeavours to limit the use of the "word " aphemia,"
adopting the "word from Broca,"who has, however, employed it in
a diiferent and far "wider sense. Typical cases of this kind are
confessedly very rare. Indeed, the only two with which I am
acquainted are one published by Trousseau (' Clin. Med.,' Syd.
Soc. Trans., vol i, page 261), and one by myself in the third
volume of the ' Transactions of the Clinical Society.' In both
of these cases the patients, on recovering from an attack of un-
consciousness, were found to be entirely speechless, and remained
speechless — in the former case for a fcAv weeks, in tbe latter case
for some months notwithstanding that they had regained the use
of every other faculty which might be supposed to have any,
the remotest, connection with speech, that is to say, notwithstand-
ing that they could hear, understand everything that was said to
them, read, converse by means of writing, and use the lips and
tongue with the utmost precision for every purpose excepting
speech. I quote Trousseau's case in preference to my own,
because it is so much shorter.
" I received one day, in my constdting room, a carrier of the
Paris Halles, very young, and having the appearance of a man
enjoying excellent health. He made signs that he could not
Poiver of Articulate Speech. 207
speak, and handed to me a note, in which the history of his
ilhiess was detailed. He had written the note himself with a
very steady hand, and had worded it well. A few days
previously he had suddenly lost his senses, and had been un-
conscious for nearly an hour. When he came round he ex-
hibited no symptoms of paralysis, but could not articulate a
single word. He moved his tongue perfectly, he swallowed
with ease, but, however much he tried, he could not utter a
word He completely recovered his speech five or six
weeks after the invasion of the complaint. It is very remark-
able, however, that during the whole- course of this singular
affection he could manage all his affairs, continue them even, in
a certain measure by substituting writing for speech."
Now, in such cases as this it is obvious that the patient
retains, as in the first class of cases, all his mental faculties,
that he thinks, as is probably usual, with the aid of words,
which he still retains the power of expressing by means of
writing, but which he cannot utter, not because, as in the first
class, he has lost the use of his muscles of articulation, but
because the wish to speak does not invoke the automatic move-
ments on which speech depends. In ordinary conversation
the words which express our thoughts flow automatically from
our lips ; the complicated combinations of movements on which
their utterance depends are executed momentarily and with the
utmost precision, without any attention whatever being, as a rule,
bestowed upon the movements themselves. And looking to the
extreme complexity of these movements it seems certain that that
part of the brain in which words are transformed into ideas, and
are revived in thought, acts, in the process of transforming
them again into articulate speech, upon the centres of origin of
the various nerves of speech, through the intermediate agency
of a special co-ordinating centre. This centre is situated, pro-
bably, somewhere within or below the corpus striatum, and
within it, on the receipt of the message from above, the
various telegraphic communications Vf'iih. the nerve-origins below
are automatically so manipulated as to cause, through these
latter, the organs of speech to execute the necessary combined
movements.
Words may be regarded as being practically innumerable.
If I recollect right it has been calculated that Shakespeare
208 On Lnpairment or Loss of
uses no less than 16^000 ; and a man like Cardinal Mezzofanti,
Avlio knew upwards of 100 languages and dialects, must have
had at his command a far larger vocabulary. The articulate
sounds, however, which by their combinations produce articulate
language are probably less than fifty in number, and this com-
paratively small number, therefore, also represents all the
groups of combined movement which the tongue and lips can
be called upon to execute. It seems to me, partly on these
grounds, partly from the consideration that language (apart from
the mere mechanism by which it is uttered) is a mental func-
tion, and partly from the belief that the function of a co-ordi-
nating motor centre can only be to regulate or combine groups
of movements, that the duty of the assumed co-ordinating centre
of speech must simply be to preside over that essential but
comparatively subordinate department of speech which consists
in the production of the elementary articulate sounds.
If this view be correct, it is easy to understand how some lesion
involving this co-ordinathig centre, or cutting off either the
direct communication between this and the intellectual centre
of language above, or between it and the nerve-nuclei below,
might result in dumbness, while at the same time the command
of language in all other respects might be perfectly retained,
and the power of executing the most delicate movements with the
lips and tongue might remain intact. It is easy also to under-
stand how in such cases as this (considering that all articulate
sounds are merely the result of certain mechanical arrangements
of the speech-organs) the patient who has lost the power of
speech might be taught to copy these mechanical arrangements,
and thus again to speak, exactly as deaf mutes are taught.
In my own case, alluded to above, the patient, who had been
perfectly inarticulate for nearly twelve months, was thus
taught to speak in the course of a month or six weeks.
In the third class of cases there is amnesia, or loss of memory.
In typical examples of this kind the patient, with perfect power
of utterance, is yet incapable, for want of words, of joining in
conversation, with perfect vision he is unable to read, even to
himself, and with (it may be) entire command over his arm and
hand he cannot make himself understood by writing, or even write.
But it must be added that in all these cases there is not merely
forgetfulncss of words, but there is more or less inability to
Power in Articulate Speech. 209
recall facts, to concentrate the thoughts, and to pursue any
train of reasoning. I will make a fe\y remarks on each of
these heads.
An amnesic patient, when he attempts to speak, commences,
perhaps, with one or two words correctly uttered, then hesi-
tates for a word, probably uses a wrong one, notices that he is
Avrong, tries to correct himself, perhaps repeats the words that
he first uttered, stumbles a little, and then, with a look or
gesture of annoyance, comes to a stop. If his attempts to speak
be carefully observed, it will generally be noticed that his vo-
cabulary is limited to a very few words, and that he tends to
rejDcat certain of these, and especially to repeat sj^ecial combina-
tions of them ; and, indeed, he often seems to recall phrases more
readily than words. If asked to name even the most common
things, he fails in very large proportion, and fails probably to
remember w'ords which he has been taught to utter only a
minute or two previously. Yet he seems to understand every-
thing that is said to him, he at once distinguishes the right
name from the wrong when submitted to the test, and he can
articulate readily every word which is dictated to him. It is
very interesting to note that uttered words entering by the ear are
by a voluntary effort at once and j)erfectly reproduced by the
organs of speech, and at the same time recall for the moment to his
mind the ideas which pt^operly attach to them.
Such a patient may often be seen with a newspaper or book,
over Avhich he pores as if he derived the greatest interest from
its perusal; but on asking him to read aloud he will probably
express his inability to do so, and not even make the attempt ;
or possibly he may pick out a word here and there Avliich he
recognises, and which he pronounces with more or less approach
to accuracy. It might be supposed that, although he cannot
translate the Avritten into vocalised words, yet that the written
words convey to his mind, through the eye, their proper
meaning, and that hence he really understands what he
reads. This, however, is not the case, for if he be examined by
leading questions he fails to show that he has any knoAvledge of
what he seems to have been reading about. He will, however,
not infrequently point out here and there words, or even
phrases, w^hich he recognises, and, perhaps, utters. He seems,
indeed, much in the condition of a child poring over the pages
VOL. II. 1^
210 On Impairment or Loss of
of a book written in a foreign language wliich he has only begun
to learn. If now asked to name the letters, he fails probably to
do this just as much as he previously failed Avith words ; and,
again, if asked to point out letters as they are named to him, his
failure is equally marked. In fact, just as he has forgotten the
names of things he has forgotten the names of letters, and, con-
sequently, their value ; and he fails, partly on this account and
partly in consequence of the complexity of the mental process
which it involves, to attach any sound or any meaning to the
various combinations of letters which stand for -words. When
he recognises Avritten words, it is, I believe, as a Avhole that he
generally recognises them ; thus, he will sometimes point out his
own name, though nnable to point to or to designate a single
letter that it contains.
A similar difficulty exists in regard to Avriting. If his hand
and arm be not paralysed, or only very slightly thus affected, he
can execute all his accustomed delicate movements Avitli them,
and, indeed, can employ the hand as a mere machine just as
well, probably, as ever he did. If he could draw, he can pro-
bably still draAA'^, and he can copy the forms of geometrical
figures, and, therefore, the forms of letters. He can write and
print from a copy. If, however, he tries to write (and he is not
infrequently fond of Avriting), he either makes a series of un-
meaning up and down strokes, manifesting even here a dim
recollection of the art of Avriting ; or he begins a word, perhaps
his OAvn name, correctly, and after Avriting a letter or two
repeats them and then stops, or passes on into unmeaning
strokes. If words are dictated to him, he Avrites them even
more incorrectly than those which he Avrites voluntarily, and
probably he AviU Avrite letter-characters Avhich are dictated to
him very^ nearly, if not quite, as faultily as Avords. Yet not in-
frequently, if he be set to copy from a printed page, he Avill
translate the printed words (letter for letter) into their Avritten
equivalents as well and as quickly as if he Avcre in perfect
mental health, and this without being able to name or to
understand the printed Avords and letters, or those Avliich he
himself forms. // is curioiis to observe here the correspondence
that exists between the eye and the hand ; the patient sees the
printed word, and by an effort of the will reproduces it auto-
matically in written characters, yet neither the word he sees nor its
Power in Articulate Speech. 211
written equivalent, nor the act of writing it, brings to his mind
even for an instant any glimpse of its meaning.
An amnesic patient Avho is unable to write to dictation will
often put down figures to dictation, and, further, will perform
simple arithmetical sums upon a slate with tolerable correctness.
He may even perform sums in addition of money, and, very
curiously, he will sometimes, while adding up, miscall the figures
which he is writing down correctly.
Now, the degree in Avhich any one or all of the above pecu-
liarities may be present in any case varies, of course, within very
wide limits, and so also does the degree in which the patient's
memory of facts and powers of concentrating his thoughts and
of reasoning are retained. But I do not at all believe that the
deficiency of the mental powers is to be measin-ed by the degree
of loss of the memory of words. Many of these patients take
such a lively interest in all that is going on around them, play
at simple games of skill so cleverly, are so quick in their
movements and in the use of their senses, and display such
ready intelligence, that we are apt to give them credit for much
more intelligence than they really possess. But it seems to me
here that, in proportion to their inability to recall facts and
words by a voluntary effort, they live more and more, as it
were, in the objects which present themselves to their senses,
and in the evanescent ideas which they evoke.
I will not here discuss the many curious cases of aphasia or
amnesia which various authors have put on record, but I will
venture to remark on two or three points to which more or less
importance has been attached. 1st, it seems to me that when
patients use two or three words or two or three phrases only,
pronouncing the words correctly, and yet at the end of months,
or even weeks, have failed to enlarge their vocabulary, they are
suffering, not from a mere want of co-ordination, but from
amnesia in a very marked degree, and that this is the case still
more obviously when they habitually use expressions or words
wrongly without recognising the error which they are commit-
ting. I admit, however, that when such a patient, having no
paralysis of the organs of speech, cannot repeat articulate sounds
which are dictated to him, there is, doubtless, also some affec-
tion involving the co-ordinating centre. 2nd. I cannot conceive
how the ordinary form of agraphia can be looked upon as an
212 On Impairment or Loss of
ataxic defect; to me it seems one of the strongest proofs of
amnesia. The patient cannot speak because he has forgotten
words, he cannot read because he has forgotten the precise
meanings of letters and of their combinations, and he cannot
■write because he cannot recall to his mind the complex com-
binations of strokes -which represent words. It is not really
a question here of the involvement of a co-ordinating centre
of writing which governs the movements of the hand; for, in
the first place, the use of the hand is only a matter of con-
venience, for writing may be effected by means of the foot or
nose, or any other part of the body which admits of pretty
free movement, or, as in skating, by the movement of tlie en-
tire body ; and, in tlie second place, there is no reason wliy
the agraphic patient who is free from paralysis of the riglit
hand and arm should be unable to copy simple geometrical
figures, and if he can coi)y these he can surely copy letters,
and can therefore perform the manual operation of writing. I
acknowledge, of course, that there may be ataxic conditions
interfering with writing; thus, as in loco-motor ataxy we find
Avant of co-ordinating power over the lower limbs interfering
with locomotion, and Avant of co-ordinating power over the lips
and tongue causing stammering and drawling articulation, so
we very frequently find such patients with imperfect control over
the arms. They cannot write, but do not suffer from agraphia.
And again, just as an aphemic patient is unable to repeat arti-
cviiate sounds which have been dictated to him, it is probable
that in many cases of agraphia the patient might fail to trans-
late automatically printed into written characters. Such a
failure may possibly be an ataxic condition, but then it does
not happen to be the essential part of the condition known as
agraphia.
It is this third group of cases, together with the fourth group,
which I shall presently consider, to which the investigations of
ls\. Broca and others chiefly relate. Concurrent testimony
proves beyond all doubt that amnesia almost invariably attends
right hemiplegia, and therefore disease on the left side of the
cerebrum — roughly, the district which the left middle cerebral
artery supplies, namely, the corpus striatum and the wedge of
nervous substance extending outwards towards and including
in its base the island of Reil and some neishbourinix convolu-
Power in Articulate Speech. 213
tions — more precisely (according to M. Broca), the posterior
third of the third frontal convolution. It is the district, too, in
Avhich the effects of cerebral embolism are most frequent. My
own experience during the last few years supports this view.
In only one case of right hemiplegia has there been no amnesia
whatever (Case 13). In one case of well-marked amnesia there
was no hemiplegia (Case 10), but the man had been thrown out
of a cart, had injured the right side of the head, and, therefore,
presumably the left side of the surface of the cerebrum by
contre-coup, and as the immediate result of the injury he had
been insensible and had a series of convulsive attacks. In all the
remaining cases of amnesia there Avas or had been right hemi-
plegia. It may be w^orth while to remark, as bearing on Dr.
Moxon's theory of the cause of amnesia in association with right
hemiplegia — namely, that the left side of the brain only is edu-
cated for speech, and the suggestion that this may be connected
w'ith a similar education of the nervous system in reference to
manipulative processes (right-handedness) — that one of my am-
nesic patients with right hemiplegia was left-handed (Case 7),
and that the non-amnesic patient with the same form of para-
lysis was right-handed (Case 13).
The fourth group of cases, to whicn allusion has been already
made, includes all those in which amnesia is associated with
aphemia, or with both aphemia and paralysis of the organs of
speech. These cases are very numerous, and present great
varieties of sy 
