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SAINT 

BARTHOLOMEW'S    HOSPITAL 

REPORTS. 


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BALLANTYNE,    HANSON   AND  CO. 
EDINBURGH   /IND   LONDON 


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SAINT 

BARTHOLOMEW'S    HOSPITAL 

REPORTS. 


EDITED    BY 


W.   S.  CHURCH,  M.D. 

a:n'd 

JOHN  LANGTOX,   F.R.C.S. 


VOL.    XXI 


LONDON: 
SMITH,  ELDER,  &  CO.,   15  WATERLOO  PLACE. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/saintbartholomew21stba 


IX  EXCHANGE. 

Guy's  Hospital  Eeports. 

St.  Thomas's  Hospital  Reports. 

Westminster  Hospital  Eeports. 

Pharmaceutical  Society's  Journal  and  Transactions. 

American  Journal  of  Medical  Science. 

Madras  Medical  Journal. 

Society  des  Sciences  medicales  de  Lyons. 

Surgeon-General's    Office,    War    Department,     U.S.A.,    per    Mr. 

Wesley,  8i  Fleet  Street,  E.G. 
Revue    des    Sciences     m6dicales,     M.     le    Docteur     G.     Hayem, 

Redacteur  du  Journal,   aux  soins  de  M.  Masson,   17   Place  de 

I'Ecole  de  M^decine,  Paris. 
Le  Progres  Medical. 
Annales    de   Dermatologie   et    de   Syphilographie,    Dr.    A.   Doyon, 

Ueiage,  near  Grenoble,  France. 
The  Chicago  Medical  Journal  and  Examiner,  Dr.  Byford  (Messrs. 

Keen,  Cook,  &  Co.,  Chicago,  Illinois). 
The    Transactions    of    the    American    Medical    Association,    Dr. 

William  Lee,   21 11  Pennsylvaniau  Avenue,   Washington,  D.C., 

per  Smithsonian  Institution. 
Centralblatt    fiir    Chirurgie,    lierausgegeben     von    F,    Kcinig,     E. 

Ricbter,  R.  Volkmann  (Messrs.  Breitkopf  &  Hartel,  Leipzig). 
Transactions   of  the  American   Gynecological   Society,   Dr.    James 

R.  Chadwick,  Clarendon  Road,  Boston,  Mass.,  U.S.A. 
Transactions  of  the  New  York  Academy  of  Medicine. 
Memoires  de  la  Soci^te  de  Medecine  et  de  Chirurgie  de  Bordeaux. 

Dr.  A.  Demons,  45  Cours  de  Tourny,  Bordeaux. 
The  Journal  of  Nervous  and  Mental  Disease,  edited  by  William 

J.    Morton,   M.D.,  New   York  (Messrs.    G.   P.    Putnam's  Sons, 

18  Henrietta  Street,  Covent  Garden). 
The    Liverpool    Medico-Chirurgical    Journal.    Liverpool    Medical 

Institution,  Hope  Street,  Liverpool. 


CONTENTS. 


PAGE 

List  of  Subscribers xi 

In  Memoriam — Francis  Harris,  M.D xxxiii 

The  Book  of  the  Foundation  of  St.  Bartholomew's, 

WITH  AN  Introduction  by  Norman  Moore,  M.D.      .  xxxix 


Akt. 
I.  On  the  Amount  of  Destructive  Impulses  in  the  In- 
sane.    By  T.  Claye  Shaw,  M.D i 

II.  Cases  Resembling  General  Paralysis  of  the  Insane. 

By  J.  A.  Ormerod,  M.D 23 

III.  Note  on  Tuberculous  Tumours  of  the  Larynx.     By 

Percy  Kidd,  M.D 37 

IV.  On  the  Presence  of  the   Tubercle  Bacillus   in   Old 

Specimens   of    Diseased   Lung.      By   Vincent   D. 

Harris,  M.D 45 

V.  Profuse    Non-Fatal    Pulmonary    Hsemoptysis.      By 

Samuel  West,  M.D 51 

VI.  Five   Cases  of  Functional   Nervous   Disorder.      By 

Samuel  West,  M.D 59 

VII.  Cases  from   Mr.   Willett's   Wards.      By  W.   T.   H. 

Spicer  and  Owen  Lankester   .         .         .         .         '65 
VIII.  Notes  of  Three  Cases  of  Coal-Gas  Poisoning.     With 
Remarks  on  the  Symptoms  as  illustrated  by  these 
and  other  Cases.     By  Charles  A.  Morton       .         .       73 
IX.  The  After-Treatment  of  Tracheotomy.    By  S.  Herbert 

Habershon,  M.B 79 

X.  Two   Cases   of  Parasitic  Hsematuria.      By  Norman 

Moore,  M.D 89 

XI.  Some  Cases  of  Sclerosis  of  the  Spinal  Cord.      By 

Archibald  E.  Garrod,  M.B 93 


viii  Contents. 

Art.  pa  ok 

XII.   Oil  the  Nature  and  Origin  of  Rodent  Ulcer.    By  G.  B. 

Ferguson,  M.D.     .         .         .         .         .         .         .101 

XIII.  Clinical    Contributions   to    Practical  Medicine.      By 

Dyce  Duckworth,  M.D. 105 

XIV.  Two    Contributions   to  Renal    Surgery.     By  W.  J. 

Walsliam       .         .         .         .         .         .         .         .121 

XV.  Variola  as  seen  in  tlie  Casualty  Department.     By  A. 

Ilaig,  M.B 131 

XVI.  A  Contribution  to  the  Topographical  Anatomy  of  the 

Spinal  Cord.     By  H.  H.  Tooth,  M.B.     .         .         .137 

XVII.  From  the  Department  for  Diseases  of  the  Larynx.    By 

Henry  T.  Butlin    .         .  .         .         .         .         .145 

XVIII.  Cases  of  Mental  Disturbance  after  Operations.     By 

W.  P.  Herringham,  M.B 165 

XIX.  A  Case  of  Lead-Poisoning  with  Bosses  on  the  Meta- 
carpal Bones.     By  W.  P.  Herringham,  M.B.  .     169 
XX.  Parametritis  and  Abscess  of  the  Liver.      By  E.  "W. 

Houghton,  M.D.    .         .         .         .         .         .         -173 

XXI.  The  Formation  of  Abnormal  Synovial  Cysts  in  Con- 
nection with  the  Joints.     By  W.  Morrant  Baker    .      177 
XXII.  On  the  Breath  Sounds  in  Health  and  Disease.     By 

J.  F.  Bullar,  M.B 191 

XXIII.  Cases  from  Dr.  Church's  Wards.     By  T    G.   Styan, 

M.B 211 

XXIV.  Note  on  the  Six  Gifts  of  Theophilus  Philanthropos, 

or  Robert  Poole ;  an  Appendix  to  "  Our  Hospital 

Pharmacopoeia    and   Apothecary's  Shop,"  vol.  xx. 

p.   279.     By  W.  S.  Church,  M.D.  .         .         .231 

XXV.  Proceedings  of  the  Abernethian  Society  for  Winter 

Session  1884-85    .         .         .         .         .         .         -237 

Descriptive  List  of  Specimens  added  to  the  Museum        .         .     263 
List  of  Prizemen   .........     300 

Hospital  Staff        .........     302 


Index 305 


LIST  OF  ILLUSTEATIONS. 


PAGE 

Sections  of  the  Medulla  Oblongata  and  Spinal  Cord 

{to  face)     142 

Diagram  Illustrating  the  Production  of  the  Eespira- 

TORY  Sounds 192 

Illustration  of  an  Apparatus  for  Producing  Ex- 
pansion AND  Contraction  of  the  Lungs  without 
THE  Admission  of  Fresh  Air 194 

Diagrams  Illustrating  the  Production  of  Unnatural 

Respiratory  Sounds   .        .        .        .        ,        .     199,  202 

Diagram  Illustrating  the  Movement  of  the  Air  in 

the  Lungs  and  Trachea 204 

Illustration  of  the  Artificial  Thorax         .        .        .207 

Illustration   of  a  Sliding  Frame  for  the  Artificial 

Thorax        . 208 

Illustration  of  a  Sliding  Frame  for  the  Artificial 

Thorax  with  Lung  in  Situ 208 

Diagrams  Illustrating  Mr.    Womack's  Paper  on  the 

Temperature  after  Death 255 


NOTICE    TO    SUBSCEIBEES. 


It  is  particularly  requested  that  Subscriptions  be  remitted 
without  delay,  as  an  acknowledgment  of  the  receipt  of  the 
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the  volume  will  be  cliarged  as  a  Non-Subscriber's  cop3^ 

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Office  to  Mr.  P.  Francis  Madden,  the  Library,  Saint  Bartho- 
lomew's Hospital. 

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Eight  Shillings  and  Sixpence. 

An  Index  to  the  first  twenty  volumes  was  published  last  year, 
and  can  be  obtained  of  Mr.  P.  Francis  Madden,  or  through 
the  Publishers,  Messrs.  Smith,  Elder,  &  Co.,  15  Waterloo 
Place.  Price  to  Subscribers,  Three  Shillings  and  Sixpence  ;  to 
Non-Subscribers,  Five  Shillings. 

December  31,  1885. 


LIST    OF    SUBSCEIBEKS. 


Abercrombie,  Dr.  J.,  23  Upper  Wimpole  Street,  W. 

Adams,  Dr.,  Ashburtou,  Devon 

Adams,  Dr.,  Boston 

Adams,  Dr.  James,  Barnes,  Surrey 

Adams,  John,  184  Alder sgate  Street,  E.G. 

Adams,  Dr.  J.  0.,  Brooke  House,  Upper  Clapton,  E. 

Aldous,  G,  F.,  Library,  St.  Bartholomew's  Hospital 

Allen,  Dr.  Henry  Marcus,  20  Eegency  Square,  Brighton 

Anderson,  A.  R,  General  Hospital,  Nottingham 

Andrew,  Dr.,  22  Harley  Street,  W.,  three  copies 

Andrews,  A.,  136  Fenchurch  Street,  E.G. 

Andrews,  S.,  Basingstoke 

Archer,  John,  Carpenter  Road,  Edgbaston,  Birmingham 

Armitage,  J.,  Emu  Bay,  Tasmania 

Armstrong,  Dr.  J.,  Green  Street  Green,  Dartford 

Atkinson,  T.  R,  47  Earl's  Court  Road,  W. 

Back,  H.  H.,  Acle,  Norfolk 

Badcock,  S.  H.,  26  Granville  Square,  W.C. 

Bailey,  F.  C,  53  Bethel  Street,  Norwich 

Baines,  John,  7  Sumner  Hill,  Birmingham 

Baker,  Alfred,  3  Waterloo  Street,  Birmingham 

Baker,  S.  I.,  Abingdon,  Berks 

Baker,  W.  Morrant,  26  Wimpole  Street,  W. 

Balgarnie,  W.,  21  Westbourne  Park  Crescent,  W. 

Banks,  Dr.  W.  A.,  Rockland,  Maine,  United  States,  America 

Barber,  F.  S.,  Library,  St.  Bartholomew's  Hospital 


xii  List  of  Subscribers. 

Barker,  Edgar,  21  Hyde  Park  Street,  W. 

Barrow,  B.,  Ryde,  Isle  of  Wight 

Barton,  J.  K.,  2  Courtfield  Road,  Gloucester  Road,  S.W. 

Bateman,  a.,  13  Cauonbury  Lane,  N. 

Bateman,  F.,  Whitchurch,  near  Reading 

Bateman,  H.  E.,  York  Dispensary,  York 

Bathe,  A.  J.,  The  Infirmary,  Gloucester 

Batten,  R.  D.,  15  Airlie  Gardens,  Campdeu  Hill,  W. 

Bazeley,  W.,  4  Princes  Square,  Plymouth 

Beattie,  H.,  37  Albert  Square,  Stepney,  E. 

Beckett,  F.  M.,  St.  Audrey's,  Ely,  Cambridge 

Benfield,  T.  W.,  Friar  Lane,  Leicester 

Benton,  Samuel,  2  Bennett  Street,  St.  James',  S.W. 

Berry,  James,  27  Upper  Bedford  Place,  Russell  Square,  W.C. 

BiNDLOtS,  E.  F.,  Library,  St.  Bartholomew's  Hospital 

Bird,  Ashley,  The  Dispensary,  Kilburn,  N.W. 

Birmingham  Medical  Institute,  per  W.  G.  Archer,  4  Waterloo 

Street,  Birmingham 
Biss,  Dr.  C.  Y.,  65  Harley  Street,  W. 
Blakeney,  H.  T.  W.,  73  High  Street,  Dorking 
Blaker,  N.  p.,  29  Old  Steyne,  Brighton 
Bland,  Dr.  G.,  Park  Green,  Macclesfield 
Bloxam,  John  A.,  8  George  Street,  Hanover  Square,  W. 
Blue,  Wm.  A.  S.,  Strathalbyn,  South  Australia 
Bolton,  J.  W.,  Moreton  House,  Shrewsbury 
Bossy,  A.  H.,  118  Stoke  Newington  Road,  N. 
BosTOCK,  E.  Ingram,  Horsham,  Sussex 
Bostock,  R.  a.,  Library,  St.  Bartholomew's  Hospital 
BoswELL,  Dr.  A.,  Ashbourne,  Derbyshire 
BoTT,  H.,  Brentford,  Middlesex 
Boulter,  H.  B.,  Barnard  House,  Richmond,  Surrey 
BousFiELD,  E.  C,  363  Old  Kent  Road,  S.E. 
BoWLBY,  A.  A.,  75  Warrington  Crescent,  W. 


List  of  Suhscribers.  xiii 

Brewer,  The  Messrs.,  45  Stow  Hill,  ISTewport,  Monmouthshire 

Bridger,  John,  CottenhLam,  Cambridgeshire 

Brinton,  E.  D.,  Prince  Alfred  Hospital,  Sydney,  Australia. 

Bristol  Royal  Infirmary,  per  Messrs.  James  Fawn  &  Sou, 
Bristol 

Broadbent,  F.,  South  Collingham,  near  Newark,  Notts 

Brodribb,  Francis  B.,  Colne,  Lancashire 

Brook,  Charles,  Minster  Yard,  Lincoln 

Brown,  George  J.,  132  Bath  Row,  Birmingham 

Browne,  Dr.  Oswald,  30a  George  Street,  Hanover  Square, 
W. 

Bruce-Clarke,  W.,  46  Harley  Street,  Cavendish  Square,  AV. 

Brunton,  Dr.  T.  Lauder,  F.R.S.,  60  Welbeck  Street,  W. 

BucHAN,  Dr.,  The  Green,  Stratford,  E. 

Bullock,  C,  Library,  St.  Bartholomew's  Hospital 

BuRD,  Dr.,  9  Gray's  Inn  Square,  W.C. 

Burn,  Dr.,  Ecclesbourne,  Bedford  Hill  Road,  Balham,  S.W. 

BuRNiE,  W.  Gilchrist,  Houghton  House,  Bradford,  York- 
shire 

Burrows,  Sir  George,  Bart.,  F.R.S.,  18  Cavendish 
Square,  W. 

Butler,  T.  M.,  Guildford 

. Butler- Smythe,  A.  A.,  35  Brook  Street,  W.  . 

BuTLiN,  H.  T.,  47  Queen  Anne  Street,  W. 

Carter,  F.  H.,  7  Bellevue  Road,  Upper  Tooting,  S.W. 
Cattltn,  William,  1  Highbury  Place,  Islington,  N. 
Cave,  E.  T.,  Royal  United  Hospital,  Bath 
Chambers,  H.  W.,  Yoke-fleet  House,  Cottingham,  near  Hull. 
Champnets,  Dr.  Francis  H.,  60  Great  Cumberland  Place,  W. 
Chapman,  H.  F.,  Old  Friars,  Richmond,  Surrey 
Chapple,  a.  D.,  Library,  St.  Bartholomew's  Hospital 
Cheese,  James,  31  East  Southernhay,  Exeter 


xiv  List  of  Subscribers. 

Chipperfield,  T.  J.  B.  P.,  Bloxham,  Banbury,  Oxon 

Chittenden,  T.  H.,  St.  Mark's  Hospital,  London,  E.G. 

Cholmelet,  Dr.,  63  Grosvenor  Street,  W. 

Chkistopherson,   Cecil,   Grove   House,   Kidbrooke,   Black- 
heath,  S.E. 

Church,  Dr.,  130  Harley  Street,  W. 

Clark,  Alfred,  Twickenham,  Middlesex 

Clarke,  Ernest,  21  Lee  Terrace,  Blackheath 

Clarke,  W.  M.,  2  York  Buildings,  Clifton,  Bristol 

Clifton  Medical  Reading  Society,  per  James  Fawn  &  Son, 
Bristol 

Close,  T.  J.,  Library,  St.  Bartholomew's  Hospital 

Clubbe,  W.  H.,  London  Eoad,  Lowestoft 

Coalbank,  I.,  Teddington 

CoATES,  Dr.  Gr.,  30  Brechin  Place,  South  Kensington,  S.W. 

CoBBOLD,  Dr.  C,  Earlswood  Asylum,  Redhill,  Surrey 

Cocker,  W.  Henry,  Blackpool 

Cockey,  Edmund,  Frome,  Somerset 

Coleman,  Alfred,  The  Wood,  Nelson,  New  Zealand. 

CoLLiNGRiDGE,    Dr.    W.,    65   TressiUiau   Road,    St.    John's, 
S.E. 

Collins,  W.  C.  G.,  Library,  St.  Bartholomew's  Hospital 

Collins,   Dr.   W.  Job,    1    Albert    Terrace,   Regent's    Park, 
N.W. 

CoLLYNS,  G.  Nelson,  Moreton-Hampstead,  Devon 

CoLLYNS,  J.  B.,  Dulverton,  Somerset 

Cooke,  Alfred  S.,  Badbrook  House,  Stroud,  Gloucestershire 

CooKSON,  R.  A.,  Beulah  Hill,  Upper  Norwood,  S.E. 

Combes,  Reginald  H.,  3  Argyle  Square,  King's  Cross,  W. C. 

Coombs,  Dr.,  Bedford 

Cooper,  A.,  9  Henrietta  Street,  Cavendish  Square,  W. 

Cope,  Ricardo,  Bellevue,  West  Tarring,  Worthing 
Cornwall,  John,  Manor  House,  Meare,  near  Glastonbury 


List  of  Subscribers.  xv 

CoRRiE,  Alfred,  Surgeon,  E.N.,  Library,  St.  Bartholomew's 

Hospital 
CovENEY,  James  H.,  Thorndjke,  Prestwich,  Mancliester 
CowiE,  Dr.  A.  J.,  Halifax,  Nova  Scotia 
CowLET,  J.  S.,  Upton-on-Severn,  "Worcestersliire 
Cozens,  C.  H.,  7  Melbury  Road,  Kensington,  TV". 
Craven,  R.  M.,  14  Albion  Street,  Hull 
Cressey,  Gr.  H.,  Library,  St.  Bartholomew's  Hospital 
Cripps,  E.  C,  Cirencester 
Cripps,  AV.  H.,  2  Stratford  Place,  W. 
Croft,  John,  48  Brook  Street,  Grosvenor  Square,  W. 
Crompton,  Dr.  S.,  Cranleigh,  Surrey 
Cronk,  H.  G.,  Repton,  near  Burton-on-Trent 
Crosse,  J.  W.,  22  St.  Giles  Street,  Norwich 
Crowfoot,  Dr.  W.  M.,  Beccles,  Suffolk 
CuMBERBATCH,  A.  E.,  17  Quceu  Anne  Street,  TV. 
CuMMiNGS,  H.  C,  Brackley  Villa,  Thurlow  Park  Road,  West 

Dulwich,  S.E. 
CuTHBERT,  C.  F.,  Mendlesham,  Suffolk 

Daniel,  William  J.,  Beaminster,  Dorset 

Darbishire,  Dr.  S.  D.,  60  High  Street,  Oxford 

Davey,  Dr.  Alexander  G.,  9  Belvidere  Street,  Ryde,  Isle 

of  Wight 
Davey,  Dr.  Staines,  Hill  House,  Walmer,  Kent 
Davies,  Arthur,  23  Finsbury  Square,  E.C. 
Davis,  Dr.  Sydney,  The  Sanatorium,  Cairo 
Davis,  Theodore,  Devon  House,  Caterham  Valley,  Surrey 
Davis,  Dr.  T.,  Beech  croft,  Clevedon 
Davison,  Dr.  R.  T.,  Langton  House,  Battle,  Sussex 
Dawson,  Dr.  W.  H.,  St.  Helen's,  Great  Malvern 
Day,  Donald  D.,  Surrey  Street,  Norwich 
Dayman,  Henry,  Millbrook,  Southampton 

vol.  XXI.  b 


xvi  List  of  Subscribers. 

Devon  and    Exeter   Hospital    Library,  per  J.    Baulcait,    19 

Soutlieruhay,  Exeter 
Dingle,  W.  A.,  61  Buuliill  Row,  Fiusbury,  E.G. 
DiNGLEY,  Allen,  7  Argyle  Square,  King's  Cross,  "W.C, 
DoiiAN,  Alban  H.  G.,  51  Seymour  Street,  Portman  Square,  W. 
Dove,  A.  C,  12  Trebovir  Road,  South  Kensington,  S.W. 
DowsoN,  Dr.  ^Y.,  Infirmary,  Bristol 
Drage,  Dr.,  Hatfield,  Herts 

Duckworth,  Dr.,  11  Grafton  Street,  Piccadilly,  W. 
DuDFiELD,  R.,  8  Upper  Pliillimore  Place,  Kensington,  W. 
Duncan,    Dr.    J.    Matthews,    F.R.S.,    71    Brook     Street, 

Grosvenor  Square,  W. 
Dunn,  George,  Stevenage,  Herts 

Dunn,  H.  P.,  3  St.  Stephen's  Road,  Westbourue  Park,  W. 
Durham,  Arthur  E.,  82  Brook  Street,  W. 

Eccles,  George  H.,  Bedford  Villa,  Bedford  Terrace,  Plymouth 
EccLES,  W.  SoLTAU,  Church  Road,  Upper  Norwood,  S.E. 
Edwards,  C.  R.,  St.  John's,  Antigua,  West  Indies 
Edwards,  F.  S.,  93  Wimpole  Street,  W. 
Edwards,  H.  Nelson,  Mureton  House,  Shrewsbury 
Elkington,  Thomas,  Feuny-Compton,  Leamington 
Elliott,  J.,  Library,  St.  Bartholomew's  Hospital 
Ellis,  Dr.  J.  W.,  Swavesey,  Cambridgeshire 
Ellis,  W.  G.,  Middlesex  Couuty  Lunatic  Asylum,  Banstead 

Downs,  Sutton,  Surrey 
Ellis,  W.  H.,  Shipley,  Leeds 
Ellison,  Dr.  J.,  14  High  Street,  Windsor 
Ellison,  Samuel  Kitchlng,  Adelaide,  per  Messrs.  Meadows 

&  Co.,  14  King  William  Street,  E.C. 
Evans,  Ernest,  Hertford 

Evans,  Herbert  N.,  3  Thurlow  Road,  Hampstead,  N.W. 
Evans,  Dr.  J.  Tasker,  Jud.,  Hertford 


List  of  Subscribers.  xvii 

Evans,  Dr.  Nicholl,  Clieshunt,  Herts 

Evans,  Frederick  H,,  10  Crocliherbtown,  Cardiff. 

Eve,  F.  S.,  15  Finsbury  Circus,  E.C. 

EvERSHED,  Arthur,  10  Mansfield  Villas,  Hampstead,  N.W. 

Failes,  F.  G.,  Library,  St.  Bartbolomew's  Hospital 

Fairbank,  W.,  Windsor 

Falwasser,  Francis,  Surgeon- Major,  Senior  Medical  Officer, 

Cyprus 
Farmer,  W.  H.  F.,  4  Seymour  Villas,  Anerley,  S.B. 
Favell,  W.  F.,  Brunswick  House,  Glossop  Eoad,  Sheffield 
Fenton,  Henry,  Shrewsbury 

Ferguson,  Dr.  G.  B.,  Altidore  Villa,  Pittville,  Cheltenham 
Fetherstonhaugh,  R.  T.,  The  Library,  St.   Bartholomew's 

Hospital 
Finch,  J.  E.   M.,  Borough  Lunatic  Asylum,  Humberstoue, 

near  Leicester 
Firth,  Dr.  C,  196  Parrock  Street,  Gravesend 
Fish,  Dr.  J.  C,  92  Wimpole  Street,  W. 
Fitzgerald,  Dr.  Charles  E.,  Folkestone 
Fletcher,  A.  C,  12a  Charterhouse  Square,  E.C. 
Flint,  Arthur,  Westgate  Lodge,  Westgate-on-Sea 
Fox,  Herbert,  Brambletye,  Park  Hill,  Croydon 
Francis,  H.  A.,  53  Lincoln's  Inn  Fields,  W.C. 
FuRNER,  Willoughby,  2  Brunswick  Place,  Brighton 

Gabb,  C.  B.,  3  Castle  Place,  Hastings 

Gardner,  W.  H.,  Library,  St.  Bartholomew's  Hospital 

Gardner,  W.  T.,  Haddon  House,  Hampstead,  N.W. 

Gay,  John,  51  Belsize  Park,  Hampstead,  KW. 

Gayton,   Dr.   F.   C,   Surrey   County   Asylum,  Brookwood, 

Woking 
Gee,  Dr.,  54  Wimpole  Street,  W. 


xviii  List  of  Stihsci'ibers. 

Gell,  II.  W.,  St.  Bartholomew's  Hospital 

GiBBES,  Heneage,  94  Gower  Street,  W.C. 

GiFFARD,  D.  ^y.,  5  Pavilion  Parade,  Old  Steyne,  Brighton 

GiFFARD,  H.  E.,  Denham  House,  Egham,  Surrey 

GiLBERTSON,  Dr.  J.  B.,  2  Starkie  Street,  Winckley  Square, 

Preston 
GiLBERTSON,  J.  H.,  MangrovB  House,  Hertford 
GiLLAM,  T.  H.,  Bromyard,  Worcester 
GiMSON,  Dr.  ^Y.  G.,  Witham,  Essex 
GiPPS,  A.  G.  P.,  Royal  Naval  Hospital,  Haslar,  Gosport 
GiRDLESTONE,  W.  T.,  Rhyl,  North  Wales 
GiRViN,  J.,  Library,  St.  Bartholomew's  Hospital 
Gledden,  a.  M.,  Helenslea,  Hornsey  Lane,  N. 
Glynn,  Dr.  Thomas  R.,  62  Rodney  Street,  Liverpool 
Godson,  Dr.  Clement,  9  Grosvenor  Street,  W. 
Godwin,  Dr.  A.,  28  Brompton  Crescent,  S.W. 
Good,  F.  T.,  St.  Neot's,  Hunts 
Goods  ALL,  D.  H.,  17  Devonshire  Place,  W. 
GoRHAM,  R.  Y.,  Sans-Souci,  Yoxford,  Sufiblk 
Graham,  Dr.  A.  R.,  Holmwood,  Weybridge 
Grayling,  Dr.,  Sitting-bourne,  Kent 
Green,  F.  K.,  3  Gay  Street,  Bath 
Grellet,  Charles  S.,  Hitchin,  Herts 
Griffith,  Dr.  Walter,  114  Harley  Street,  W. 
Griggs,  W.  A.,  Easton  Lodge,  11   Tressillian  Crescent,  St. 

John's,  S.E. 
Grime,  Henry  A.,  22  Water  Street,  Blackburn 
Gripper,    Dr.    Walter,    Featherstone    Villa,    Walliugton, 

Surrey^ 
Groves,  J.  W.,  90  Holland  Road,  Kensington,  W. 
Guterbock,  Dr.  Paul,  Berlin,  per  Messrs.,  Lessor  &  Co.,  13 

Bridgefield,  Manchester 


List  of  Suhscrihers.  x  i  x- 

Habershon,  S,  H.,  70  Brook  Street,  Grosvenor  Square,  W. 

Haig,  Dr.  Alexander,  30  Welbeck  Street,  Cavendish 
Square,  W. 

Hall,  Dr.  B.,  Middlesex  County  Lunatic  Asylum,  BansteaJ 
Downs,  Sutton,  Surrey 

Hall,  Dr.  db  Havilland,  46  Queen  Anne  Street,  W. 

Hall,  F.  A.,  4  Albion  Street,  Lewes 

Hallo  WES,  F.  B.,  Eedhill,  Eeigate 

Hames,  G.  H.,  2  Queensborough  Terrace,  Hyde  Park,  "VY. 

Harding,  C.  O'B.,  Library,  St.  Bartholomew's  Hospital 

Harle,  Ezra,  Eagle  Villa,  Darnley  Koad,  Hackney,  E. 

Harris,  J.  D.,  45  Southernhay,  Exeter 

Harris,  Samuel,  Qaorndon,  Leicestershire 

Harris,  Dr.  V.  D.,  39  Wimpole  Street,  W. 

Harris,  W.  J.,  26  Marine  Parade,  Worthing 

Harrison,  Dr.  A.  J.,  Guthrie  Koad,  Clifton,  Bristol 

Harrison,  Dr.  Charles,  30  Newland,  Lincoln 

Harrison,  Keginald,  38  Rodney  Street,  Liverpool 

Hatfield,  W.  H.,  Stanstead  Road,  Forest  Hill,  S.E. 

Hawkins,  Clement  J.,  Wellington  Place,  Cheltenham 

Haydon,  Dr.  N.  J.,  Bampton  Street,  Tiverton 

Haynes,  Dr.  F.  H.,  23  The  Parade,  Leamington 

Head,  R.  T.,  Balsham,  Cambridge 

Heard,  C.  G.,  Hunmanby,  Yorkshire 

Heath,  W.  L.,  88a  Gloucester  Road,  S.W. 

Hemborough,  J.  W.,  Waltham,  Grimsby 

Hensley,  Dr.  Philip,  4  Henrietta  Street,  Cavendish 
Square,  W. 

Herringham,  W.  p.,  22  Bedford  Square,  W.C. 

Hewer,  John  H.,  Sandford  House,  33  Highbury  New  Park,  N. 

Hewett,  Augustus,  1  Cambridge  Park  Gardens,  Twicken- 
ham, Middlesex 

Hill,  Alexander,  Botolph  House,  Cambridge 


XX  Liftl  of  Suhso'ihers. 

HiLLABY,  A.,  Garton  House,  Poutefract 

HiLLiER,  James  T.,4  Chapel  Place,  Eamsgate 

Hind,  A.  E,,  Library,  St.  Bartholomew's  Hospital 

Hind,  Henry,  3  Whitehall  Place,  Stockton-on-Tees 

Hitchcock,  Dr.  Charles,  Market-Lavington,  Wilts 

Hogg,  A.  J.,  Westhourne  Villa,  Ealing 

HoLCROFT,  Henry,  Seven  oaks,  Kent 

HoLDEN,  Luther,  Pinetoft,  Rnshmere,  Ipswich 

HoLLis,  Dr.,  8  Cambridge  Road,  Brighton 

Holmes,  T.,  18  Great  Cumberland  Place,  Hyde  Park,  W. 

Howard,  H.,  6  The  Terrace,  Mount  Pleasant,  Cambridge 

HoYLAND,  S.  S.,  Tower  House,  Ipswich 

Hughes,  D.  A,,  Coed-y-Bachan,  Dyffryn,  Merionethshire 

Hughes,  D.  Watkins,  AVymondham,  Norfolk 

Hughes,  J.  B.,  Roe  Street  House,  Macclesfield,  Cheshire 

Humphry,  C.  H.,  Lower  Camden,  Chislehurst,  Kent 

Humphry,  F.  A.,  25  Marine  Parade,  Brighton 

Humphry,  L.,  3  Trinity  Street,  Cambridge 

Hunt,  B,,  Library,  St.  Bartholomew's  Hospital 

Hunter,  R.  H.,  Isleworth,  W. 

Husband,  W.  E.,  56  Bury  New  Road,  Manchester 

HussEY,  E.  L.,  8  St.  Aldate's,  Oxford 

Hutchinson,  J.,  15  Cavendish  Square,  W. 

HuTTON,  E.  R.,  18  West  Green  Road,  Tottenham 

Iliffe,  W.,  41  Osmaston  Street,  Derby 

Ilott,  Edward,  26  Tweedie  Road,  Bromley,  Kent 

Ilott,  Dr.  Herbert  J.,  56  High  Street,  Bromley,  Kent 

Jackman,  T.  S.  H.,  11  Stoke  Newington  Road,  N. 
Jackson,  Arthur,  17  Wilkinson  Street,  Sheffield 
Jackson,     H.     F.    V.,     141     Westbourne    Terrace,     Hyde 
Park,  W. 


List  of  Subscribers.  xxi 

Jacob,  A.  H.,  9  Dalhousie  Square,  Calcutta 

JallanDj  E.,  Horncastle 

James,  Edwin  M.,  Library,  St.  Barfholomew's  Hospital 

Jenkins,  Dr.  E.  J.,  Douglas  Park,   Sydney,  Australia,  per 

H.  K.  Lewis,  136  Gower  Street 
Jessop,  W.  H.,  73  Harley  Street,  W. 
John,  D.,  Hafod  Villa,  Swansea 
Johnson,  J.  G.,  108  Lansdowne  Eoad,  Clapham,  S.W. 
Johnson,  M.,  County  Hospital,  Lincoln 
Jolliffe,  W.  J.,  Yofford  House,  Isle  ofWiglit 
Jones,  H.  Lewis,  St.  Bartholomew's  Hospital,  Chatham 
Jones,  Mokkis,  Aberystwyth,  Cardiganshire 
Jones,  Dr.  E.,  Colney  Hatch  Asylum,  N. 
Jones,  E.  Owen,  Bala,  Merionethshire 
Jowees,  Feedekick  W.,  27  Old  Steyne,  Brighton 

Kay,  "W.,  Bentley  Cottage,  Bentley,  near  Farnham,  Hants 
Keetlet,  C.  E.  B.,  10  George  Street,  Hanover  Square,  "W. 
Kendall,  T.  M.,  per  Messrs.  Johnson  &  Archer,  147  Fen- 
church  Street,  E.C. 
Kesteven,  Dr.,  401  Holloway  Eoad,  N. 
KiDD,  Dr.  P.,  60  Brook  Street,  W. 
KiNGDON,  J.  A.,  2  Bank  Buildings,  E.C. 
KiNNEiE,  F.  W.  E,,  Horsham,  Sussex 
KiNSET,  E.  H.,  2  Harpur  Place,  Bedford 
Knight,  H.  J.,  Brooklands,  Eotherham,  Yorkshire 

Lanceraux,  Dr.,  19  Eue  de  la  Paix,  Paris 

Langdon,  Thomas  C,  Northgate  House,  Winchester 

Langton,  John,  2  Harley  Street,  W. 

Latham,  Dr.  P.  W.,  17  Trumpington  Street,  Cambridge 

Laueie,  C.  E.,  6  Eaton  Villas,  Loughton,  Essex 

Laweence,  H.  Ceipps,  49  Oxford  Terrace,  Hyde  Park,  W. 


X  X I  i  List  of  Subscribers. 

Lawrence,  L.  A.,  37  Belsize  Avenue,  N.W. 

Lee,  John,  Ashbourne,  Derbyshire 

Leeds  School  of  Medicine,  per  Thomas  Scattergood,  41  Park 

Square,  Leeds 
Lediaed,  Dr.  H.  A.,  78  Lowther  Street,  Carlisle 
Legg,  Dr.  WiCKHAM,  47  Green  Street,  Park  Lane,  W, 
Leppington,  H.  M.,  Great  Grimsby,  Lincolnshire 
Leveeton,  H.  Spey,  Truro,  Cornwall 
Lewis,  H.   K.,  Medical   Library,  136    Gower  Street,   W.C., 

seven  copies 
Library  of  St.  Bartholomew's  Hospital 
Little,  T.  S.,  106  London  Street,  Keading 
LocKWOOD,  C.  B.,  8  Serjeant's  Inn,  Fleet  Street,  E.C. 
LoNGHURST,  Dr.  Aethue  E.  T.,  22  Wilton  Street,  S.W. 
Low,    C.    W.,   Powis    Lodge,    Vicarage   Park,    Plumstead, 

S.E. 
Lowe,  Geoege,  Burton-on-Treut 

LowNE,  B.  T.,  65  Cambridge  Gardens,  Netting  Hill,  W. 
LuPTON,  Haeey,  The  Old  Vicarage,  Stratford-on -Avon 

MacDougall,  Dr.  J.  A.,  4  Portland  Square,  Carlisle 

Mackenzie,  Dr.  J.,  lugleby,  Hillmorton  Road,  Rugby 

Mackenzie,  Dr.  Moeell,  19  Harley  Street,  W. 

Mackinder,  Dr.,  Gainsborough 

Maconcht,  Dr.  John  K.,  Infirmary,  Downpatrick 

Maceeady,  J.,  51  Queen  Anne  Street,  W. 

Mahee,  C.  H.,  College  Street,  Sydney,  K  S.  Wales 

Malden,  F.  J.,  Infirmary,  Huddersfield 

Manchester  Royal  Infirmary,  the  Secretary,  Manchester 

Manning,  Joseph,  Wye,  Ashford,  Kent 

Maek,   Leonaed   p.,   Halidon,   Upper  Beulah  Hill,  Upper 

Norwood,  S.E. 
Marsh,  Howard,  36  Bruton  Street,  Berkeley  Square,  W. 


List  of  Suhscribers.  xxiii 

Maesh,  Dr.  N.  P.,  Hospital  for  Sick  Children,  Pendlebury, 

Manchester 
Martin,  Dr.,  51  Queen  Anne  Street,  W. 
Martdst,  p.,  Abingdon,  Berks 
Mason,  J.,  Windermere 

Matthews,  F.  E.,  Library,  St.  Bartholomew's  Hospital 
Maude,  A.,  5  Bishopwood  Eoad,  Highgate,  N. 
May,  Dr.  E.  Hooper,  Tottenham  High  Cross,  Middlesex 
McKay,  Dr.  W.  W.,  Bois  City,  United  States  of  America 
M'Lean,  W.,  Library,  St.  Bartholomew's  Hospital 
Meade,  R  H.,  Bradford,  Yorkshire 
Menzies,  J.  L.,  1  Gwendwr  Road,  West  Kensington,  W. 
Metcalfe,  E.,  55  Clifton  Gardens,  Maida  Vale,  W. 
Mills,  J.,  15  Henrietta  Street,  Cavendish  Square,  W. 
Milner,  E.,  32  New  Cavendish  Street,  Portland  Place,  W. 
Milsome,  Dr.  J.  P.,  Addlestone,  Chertsey 
Mitchinson,  Dr.,  Lindum  Holme,  Lincoln 
Moore,  E.,  Lifford  House,  Dartford 

Moore,  Dr.  Norman,  The  College,  St.  Bartholomew's  Hospital 
Moore,  Thomas,  6  Lee  Terrace,  Blackheath,  S.E. 
Morrice,  G.  G.,  Library,  St.  Bartholomew's  Hospital 
Morris,   C.  A.,  Royal  Infirmary,  Liverpool 
Morris,  Edward,  7  Windsor  Place,  Plymouth 
MouLLiN,  C.  W.  M.,  69  Wimpole  Street,  W. 
MuDGE,  T.  H.  T.,  Blagdon,  Paignton,  Devon 
Muriel,  C.  J.,  Willow  Lane,  Norwich 
MuRRELL,  W.  H.  J.,  Sefton  House,  Kent  Road,  Southsea 

Nall,  S.,  Disley,  near  Stockport,  Cheshire 

Nance,  H.  Chester,  Norfolk  and  Norwich  Hospital,  Norwich 

Neatby,  Dr.  T.,  29  Thurlow  Road,  Hampstead,  N.W. 

Nettle,  W.,  Liskeard,  Cornwall 

Newman,  Dr.  A.,  70  Macklin  Street,  Derby 


xxiv  List  of  Subscribers. 

Newman,  Dr.  W.,  Baru  Hill  House,  Stamford 

Newstead,  J.,  9  York  Place,  Clifton,  Bristol 

Newton,  C.  J.,  Oriel  Lodge,  Chelteuliam 

Newton,  Edward,  85  Gloucester  Terrace,  Hyde  Park,  W. 

Newton,  Lancelot,  Alconbury  Hill,  Hunts 

NiMMO,  J.  C,  14  King  William  Street,  Strand,  W.C. 

NuNN,  p.  W.  Gr.,  Bournemouth 

Odell,  Thomas,  Hertford 

Odling,  T.  F.,  per  Hickey  &  Borman,  14  Waterloo  Place, 
S.W. 

O'Grady,  E.  S.,  33  Merrion  Square  North,  Dublin 

Oldman,  John,  Huntingdon 

Oldfield,  F.,  174a  Boy  son  Eoad,  Camberwell  Gate,  S.E. 

Ormerod,  Dr.,  25  Upper  Wimpole  Street,  W. 

Orton,  G.  H.,  30  Lower  Phillimore  Place,  Kensington,  W. 

Outhwaite,  Dr.  W.,  Hebert  House,  Denmark  Hill,  S.E. 

Owen,  Sir  Kichard,  K.C.B.,  F.RS.,  Sheen  Lodge,  Rich- 
mond Park 

Paget,  Sir  George  E.,  K.C.B.,  F.RS.,  Cambridge 

Paget,  Sir  James,  Bart.,  F.R.S.,  1  Hare  wood  Place,  Hanover 

Square,  W. 
Pardington,  Dr.  G.  L.,  The  Spa,  Tunbridge  Wells 
Parke,  J.  Latimer,  Tideswell,  Derby 
Parker,  C.  A.,  Library,  St.  Bartholomew's  Hospital 
Parker,  G.  R.,  11  King  Street,  Lancaster 
Parker,  R.  W.,  8  Old  Cavendish  Street,  W. 
Parnell,    G.     C,    St.    Norman's,    London    Road,    Forest 

Hill,  S.E. 
Peacey,  William,  214  Lewisham  High  Road,  S.E. 
Pearse,  William,  St.  Tudye,  Bodmin 
Penfold,  H.,  7  Brunswick  Place,  Brighton 


List  of  Suhscribers.  xxv 

Penny,  Dr.  G.  T.,  Stanley  House,  Oakfield  Boad,  Upper 
Tollington  Park 

Pettifer,  E.  H.,  60  Southgate  Road,  N. 

Pollard,  William,  Torquay 

Portman  Book  Club,  per  Edmund  Owen,  49  Seymour  Street, 
Portman  Square,  W. 

PowDEELL,  John,  160  Euston  Road,  N.W. 

Power,  Henry,  37a  Great  Cumberland  Place,  W. 

Pratt,  F.  T.,  Marine  Parade,  Appledore,  North  Devon 

Prentis,  Charles,  11  Upper  Phillimore  Place,  Kensing- 
ton, W. 

Preston,  A.  Chevalier,  Swaffham  Prior,  Cambridgeshire 

Preston,  F.  H.,  11  Amp  ton  Street,  Gray's  Inn  Road,  W.C. 

Prichard,  Augustin,  4  Chesterfield  Place,  Clifton 

Peickett,  Dr.  Marmaduke,  12  Devonport  Street,  Gloucester 
Square,  W. 

Prideaux,  T.  E.  p.,  Sutherland  House,  Wellington,  Somer- 
set 

Pryce,  E.  W.,  Pontefract,  Yorkshire 

Pugh,  J.  L.  P.,  Bonegate  Road,  Brighouse,  Yorkshire 

PuLLiN,  B.  G.,  Sidmouth,  Devon 

Pye,  W.,  4  Sackville  Street,  Piccadilly,  W. 

Pyne,  Richard,  Royston,  Cambridgeshire 

Quennell,  John  C,  Brentwood,  Essex 
Quick,  James  R.,  96  East  Street,  Penzance 

Radford,  The  Library,  St.  Mary's  Hospital,  Manchester,  per 

Librarian 
Ranking,  Dr.  J.  E.,  18  Mount  Ephraim  Road,  Tunbridge 

Wells 
Raven,  Thomas  Francis,  Barfield  House,  Broadstairs 
Rayner,  Dr.  Henry,  Library,  St.  Bartholomew's  Hospital 


X  X  V  i  List  of  Subscribers. 

Read,  H.  G.,  30  Finsbury  Square,  E.C. 

Read,  Mabyn,  M.B.,  13  Clapliam  Common  Gardens,  New 

Wandsworth,  S.W. 
Reece,  R.  J.,  1  Edwards  Place,  Kensington  Road,  W. 
Rees,  Albert  B.,  75  High  Street,  Swansea 
Reid,  James,  12  Lower  Bridge  Street,  Canterbury,  two  copies 
Reynolds,  Dr.  Russell,  F.R.S.,  38  Grosvenor  Street,  W. 
Rice,  Dr.  Edward,  RadclifFe  Infirmary,  Oxford 
Richards,  Dr.  Owen,  Vrouheulog,  Corwen,  Merionethshire 
Richmond   Hospital    Library,   per    Dr.    Gordon,    13    Hume 

Street,  Dublin 
Richmond,    W.    Stephenson,    Library,    St.   Bartholomew's 

Hospital,  E.C. 
RiGDEN,  G.  C,  Lewes 
RiGGE,  J.  A.  M.,  Grays,  Essex 
Risk,  E.  J.,  St.  Andrew's  Chapelry,  Plymouth 
Rivers,  W.  H.  R.,  Library,  St.  Bartholomew's  Hospital 
Roberts,  Sidney  M.  P.,  Sheffield 
Roberts,  Arthur,  Keighley,  Yorkshire 
Robinson,  Haynes,  St.  Giles'  Place,  Norwich 
Robinson,  G.,  Harpnr  Place,  Bedford 
Rogers,  T.  L.,  Rainhill,  Prescott 
Rogers,  Tom  Stannard,  16  Hanover  Square,  W. 
Rolleston,  H.  D.,  St.  John's  College,  Cambridge 
Roughton,  Dr.  E.  W.,  Brook  Green,  W. 
RoYDS,  W.  A.  S.,  32  London  Street,  Reading 
Rumbold,  0.  F.,  Lowborue  House,  Melksham,  Wilts 
RuNDLE,  H.,  Warflete,  11  Clarence  Parade,  Southsea 
Rushworth,  Norman,  Beechfield,  Walton-on-Tliames 
Rust,  H.  R.  G.,  Wethersfield,  Braintree 

Salmon,  Dr.  A.  G.,  Bodmin,  Cornwall 
Sargent,  D.  W.,  364  Brixton  Road,  S.E. 


List  of  Subscribers.  xxvii 

Saul,  Dr.  W.  Wingate,  Lancaster 

Saundeks,  E.  D.,  Tenterden,  Kent 

Savoey,  Dr.  0.  T.,  1  Douglas  Koad,  Canonbury,  N. 

Savory,  W.  S.,  F.E.S.,  66  Brook  Street,  W. 

Sayer,  C.  W.,  Enville  House,  White  Ladies'  Road,  Clifton, 

Gloucestershire 
ScHOLLiCK,  T.  J.,  13  Haydon  Place,  Guildford 
Scott,  J.,  Library,  St.  Bartholomew's  Hospital 
Shad  WELL,  H.  W.,  167  The  Grove,  Hammersmith,  W. 
Sharman,  Malin,  18  Newhall  Street,  Birmingham 
Sharpif,  E.  C,  Bedford 

Shaw,  Josephus,  24  Plough  Road,  Rotherhithe 
Shaw,  Dr.  T.   Claye,  Middlesex  County   Lunatic  Asylum, 

Banstead  Downs,  Sutton 
Shaw,  Dr.  William,  13  Tonbridge  Road,  Maidstone 
Shears,  C,  H.  B,,  1  St.  James  Road,  Rodney  Street,  Liverpool 
Sheehy,  Dr.,  4  Claremont  Square,  N. 
Shelly,  Dr.  C.  E.,  Hertford 
Shepard,  W.  L.,  15  Euston  Road,  N.W. 
Shoolbred,  W.  a.,  The  Castle  House,  Chepstow 
Shore,  Dr.  T.  W.,  Library,  St.  Bartholomew's  Hospital 
Simmons,  H.  C,  79  Carleton  Road,  Tufnell  Park,  N. 
Simpson,  S.  H.,  Romsey,  Hants 
Skeate,  Edwin,  16  The  Paragon,  Bath 
Skelding,  H.,  Library,  St.  Bartholomew's  Hospital 
Slater,  Dr.  D.  J.,  Library,  St.  Bartholomew's  Hospital 
Smith,  H.  L.,  80  Tollington  Park,  N. 
Smith,  Dr.  T.  Gilbart,  68  Harley  Street,  W. 
Smith,  Thomas,  6  Stratford  Place,  Oxford  Street,  W. 
Soame,  C.  B.  H.,  Dawley,  Salop 

SouTER,  J.,  20  Wellington  Terrace,  Beverley  Road,  Hull 
South  London  Medical   Reading    Society,   per    H.    Taylor, 

180  Kennington  Park  Road,  S.E, 


XX V  i  i I  List  of  Subscribers. 

SouTHECOMBE,  A.  G.,  Library,  St.  Bartholomew's  Hospital 

SouTHEY,  Dr.,  32  Grosvenor  Road,  Westminster,  S.W. 

Spaceman,  H.  R.,  Penn  Fields,  Wolverhampton 

Spicer,  W.  T.  H.,  Library,  St.  Bartholomew's  Hospital 

Square,  W.  J.,  22  Portland  Square,  Plymouth 

Stagey,  W.   H.    W.,    The   Limes,    Grimstow,   near   Lynn, 

Norfolk 
Stamford  Infirmary,  Medical  Book  Society,  Stamford 
St.  Bartholomew's  Hospital,  The  Governors  of,  thirty  copies 
Steayenson,   Dr.    W.    E.,    39   Welbeck    Street,    Cavendish 

Square,  y\\ 
Steedmak,    J.   F.,    High   Ercall   Hall,   Wellington,    Shrop- 
shire 
Steele,  H.  F.,  Stoke  Ferry,  Brandon,  Norfolk 
Steer,  A.  W.  T.,  Library,  St.  Bartholomew's  Hospital 
Stephen,  Guy  N.,  Library,  St.  Bartholomew's  Hospital 
Stevens,  Dr.  A.  Felix,  13  High  Street,  Stoke  Newington,  N. 
Stevenson,  N.,  51  Wimpole  Street,  W. 
Stoney,  p.  Butler,  Holborn  Hill,  Cumberland 
Storrs,  Robert,  Hallgate,  Doncaster 
Stowers,  Dr.  Ja^ies  H.,  23  Fiosbury  Circus,  E.C. 
Stretton,  Samuel,  Kidderminster 
Stretton,   Dr.   W.   H.,    8    Suffolk   Place,   Pall- Mall   East, 

S.W. 
Strugnell,  F.  W.,  45  Highgate  Road,  N. 
Strugnell,  W.  T.,  Library,  St.  Bartholomew's  Hospital 
Stubbs,  p.  B.  T.,  Library,  St.  Bartholomew's  Hospital 
Styan,  T.  G.,  Library,  St.  Bartholomew's  Hospital 
Suffolk   Medical  Book  Society,   care  of  Messrs,   Pawsey  & 

Hayes,  Ipswich,  per  Hayden 
Swales,  Peter,  Alexandra  Terrace,  Sheerness 
Sye:es,  M.  Carrington,  Beckett  Hospital,  Barnsley 
Sylvester,  K.  F.,  Trowbridge,  Wilts 


List  of  Suhscribers.  xxix 

Sympson,  Thomas,  3  James  Street,  Lincoln 

Tait,  E.  S.,  54  Highbury  Park,  N. 

Tait,  H.  B.,  The  Bank,  Crouch  Hill,  N. 

Tayler,  a.  C,  Trowbridge,  Wilts 

Taylor,  Thomas,  Sutton  Coldfield,  Warwickshire 

Terry,  George,  Mells,  Frome 

Thomas,  W.  Duncan,  Llanelly,  Carmarthen 

Thompson,  Charles  R.,  Westerham,  Kent 

Thorne,  Dr.  R.  Thorne,  45  Inverness  Terrace,  Kensington 

Gardens,  W. 
Thurland,  F.  E,,  1  Wilmington  Square,  W.C. 
ToBiN,  George,  22  Halliwell  Street,  Chorley 
Tooth,  Dr.  H.  H.,  34  Harley  Street,  W. 
TowNSEND,  K.,  168  Lewisham  High  Road,  S.E. 
Trevan,  F.   a..    Surgeon   R.A.,    care   of  Messrs.   Banton, 
Mackrell,  &  Co.,  26  Budge  Row,  Cannon  Street,  E.C. 
Trinder,  a.  p.,  Librarj^,  St.  Bartholomew's  Hospital 
Trollope,  Dr.,  9  Maze  Hill,  St.  Leonards-on-Sea 
TucKWELL,  Dr.,  64  High  Street,  Oxford 
Turnbull,  G.  L.,  Library,  St.  Bartholomew's  Hospital. 
Turner,  Professor,  Edinburgh 

Turner,  F.  H.,  High  Street,  High  Wycombe,  Bucks 
Twining,  A.  H.,  The  Knoll,  Kingsbridge,  South  Devon 
Tylecote,  Dr.  E.  T.,  Great  Haywood,  Staffordshire 
Tyrer,  Robert,  Rainhill,  Lancashire 

Upton,  A.,  Rio  Lodge,  Brighton 

Upton,  H.  C,  28  Medina  Villas,  Hove,  Brighton 

Yalpy,  C.  E.,  48  Regent's  Park  Road,  N.W. 
Yaughan,  William  E.  W.,  Crewe  Cottage,  Crewe 
Yernon,  Bowater  J.,  14  Clarges  Street,  Piccadilly,  W. 


XXX  List  of  Suhsa'lbers. 

Yerralt.,  T.  J.,  95  Western  Road,  Brighton 
Vos,  G.  H.,  The  Hospital,  Tottenham,  N. 

"Walker,  E.  G.  A.,  Church  Street,  Reigate,  Surrey 

Walker,  Dr.  J.  West,  Spilsby,  Lincolnshire 

Wallis,  F,  C,  Library,  St.  Bartholomew's  Hospital 

Wallis,  G.,  Corpus  Buildings,  Cambridge 

Walsham,  Hugh,  426  Camden  Road,  N. 

Walsham,  W.  J.,  27  Weymouth  Street,  Portland  Place,  W. 

Watlex,  George,  Longcroft  House,  Devizes 

Wayman-,  C.  p.  S.,  Foulsham,  East  Dereham,  Norfolk 

Webb,  H.  S.,  Welwyn,  Herts 

Webber,  E.  S.,  Library,  St.  Bartholomew's  Hospital,  E.G. 

Weiss,  H.  F.,  30a  George  Street,  Hanover  Square,  W. 

West,  Dr.  Samtel,  15  Wimpole  Street,  W. 

West,  Dr.  W.  C,  Tarnton  Lodge,  Great  Malvern 

Wharrt,  Dr.  R.,  6  Gordon  Square,  W.C. 

White,  W.  H.,  Carolgate,  Retford,  Notts 

Whitehead,  H.  E.,  Library,   St.  Bartholomew's  Hospital, 

two  copies 
Whitlis'G,  He^t.y  T,  ,  High  Street,  Croydon 
Whitmore,  W.  Tickle,  7  Arlington  Street,  S.W. 
WiLKixs,  H.  G.  G.,  The  Green,  Ealing 
Wilks,  Dr,  George,  Ashford,  Kent 
Wellett,  a.,  36  Wimpole  Street,  W. 
WiLLETT,  C.  v.,  11  Edith  Road,  West  Kensington 
Willett,  E.  W.,  Arnold  House,  Brighton 
William,  Dr.  J.,  Bryumeurig,  Bethesda,  Bangor 
Williams,  Charles,  Sebonig  Dyffryn,  Merioneth 
WiLLLkMS,  Dr.  Edward,  Holt  Street  House,  Wrexham 
Williams,  E.  R.,  Infii-mary,  Macclesfield 
Williams,  J.  T.,  Rossall  House,  Barrow-in-Furness,  Lanca- 
shire 


List  of  Suhscribers.  sxxi 

"Williams,  Dr.  "Wynx,  1  Montague  Square,  "W. 
"WiNKFiELD,  Alfeed,  26  Beaumont  Street,  Oxford 
"WoMACK,   F.,   11   Kingdon  Eoad,   Dennington  Park,  "West 

Hampstead,  IST.W. 
"U'ooD,  FredePwICe:,  12  Lewes  Crescent,  Brigliton 
Woods,  G.  A.,  57  Houghton  Street,  Sonthport,  Lancashire 
WoESHiP,  J.  L.,  Eirerhead,  Sevenoaks 
Wright,  F.  M.,  Bottesford,  iNotts 
Weight,  Thomas  G-.,  Stilton,  Hunts 
"Wtee,  Dr.  Otho,  The  Avenue  Road,  Leamington 

Yareov,  Dr.  G.  E.,  87  Old  Street,  E.G. 
York  Medical    Book  Society,  per  Fred,  Shann,   69    Peter- 
gate,  York 
Young,  Adam,  14  High  Street,  Sevenoaks,  Kent 


The  Subscription  List  in  each  year  luill  he  closed  on  the 
Fh'st  of  October. 


vol.  XXI. 


FKANCIS   HAEEIS,    M.D. 

BY 

SAMUEL  GEE,  M.D. 


Feancis  Haeeis  was  born  on  December  i,  1829,  at  Winchester 
Place,  in  the  ancient  "  Manor  of  the  Bishop  of  Winchester  known 
as  the  Manor  or  Liberty  of  the  Clink,"  in  Southwark.^  His 
father,  who  represented  the  borough  in  Parliament  for  some  time, 
died  whilst  his  son  was  a  very  young  child,  and  was  buried  in  St. 
Saviour's  Church.  In  the  same  church  Prancis  Harris  had  been 
christened  only  a  few  months  before.  After  his  earliest  schooling, 
and  some  later  studies  at  King's  College,  London,  he  entered  at 
Caius  College,  Cambridge.  What  led  him  to  choose  medicine  for 
a  profession  I  do  not  know,  unless  it  were  a  natural  bent  towards 
the  physical  sciences,  which  was  fostered  by  an  uncle  who  was 
somewhat  of  an  amateur  chemist.  He  graduated  B.A.  in  1852 
For  many  details  concerning  his  life  from  this  time  forward,  I  am 
much  indebted  to  some  memoranda  which  have  been  kindly  fur- 
nished by  Dr.  Chance.  "  The  chief  thing  that  I  remember  about 
him  at  that  time  (1852),"  says  Dr.  Chance,  "  is  that  his  hair  was 
even  then  (he  was  only  twenty-two)  marked  by  grey.  He  told 
me  afterwards  that  his  hair  had  begun  to  get  grey  as  early  as 
sixteen.  It  may  possibly  have  resulted  from  a  very  serious  illness 
which  he  had  when  about  that  age.  He  suffered,  namely,  from 
very  severe  haemorrhage  from  the  lungs,  was  nearly  dyiag,  and 
was  said  by  the  medical  man  who  attended  him,  and  who  probably 
did  not  know  much  about  the  stethoscope,  to  have  lost  the  greater 
part  of  one  lung."  When  he  was  at  the  worst,  a  consultation  was 
held  (Dr.  Chance  is  not  responsible  for  this  story).    Young  Harris 

^  "  The  south  outwork  of  the  City,  and  hence  our  name  of  Suthweorce,  which 
some  modern  folk  affect  to  call  Stitherk." — Old  Southward  and  its  People, 
by  William  Rendle,  F.R.C.S.,  1878,  page  5.  See  also  "  Southwark  in  the  Time 
of  Shakspere,"  by  the  same  author,  1878. 


xxxiv  Memoir  of  Dr.  Harris. 

insisted  upon  going  down  to  a  house  ■which  his  mother  had  at 
Brenchley,  and  the  doctors  agreed  that,  inasmuch  as  he  was  dying, 
it  mattered  not  where  the  end  came.  To  Brenchley  he  went,  pro- 
vided with  bottles  of  physic  for  inward  and  outward  use.  Next 
morning,  looking  from  his  bedroom  window,  he  saw  a  rose-tree, 
sickly,  faded,  and  pining  away  like  himself.  Forthwith  he  chari- 
tably bestowed  his  remedies  upon  the  tree,  with  this  result — 
the  rose  soon  died,  whilst  he  almost  as  quickly  recovered.  There 
is  little  doubt  that  his  disease  was  pleurisy.  Dr.  Chance  con- 
tinues :  "  The  Cambridge  school  of  medicine  was  then,  I  may  say, 
superficial,  altogether  dijBFerent  from  what  it  is  now.  There  were 
certainly  not  more  than  from  eight  to  ten  students.  But  even 
then  there  were  unusual  advantages  for  students.  There  being 
so  few  of  them,  they  could  visit  the  cases  in  the  wards  when  they 
liked,  and  were  on  much  more  intimate  terms  with  their  teachers 
than  they  could  be  in  a  larger  medical  school.  They  were  even 
allowed  to  make  the  post-mortems  themselves.  I  certainly 
learned  more  there  in  two  years  than  I  did  at  St.  Bartholomew's 
in  the  same  space  of  time,  and  I  have  no  doubt  Dr.  Harris  would 
say  the  same."  I  may  add,  that  he  used  to  tell  me  that  nothing 
struck  him  more,  when  he  first  came  up  to  St.  Bartholomew's, 
than  the  btisiness-like  character  of  the  lectures  and  instruction 
generally,  compared  with  what  he  had  been  accustomed  to  at  Cam- 
bridge. Indeed,  Dr.  Chance  says  that  the  University  school  was 
at  that  time  superficial.  In  1854  Dr.  Harris  took  the  degree  of 
M.B.  From  November  1856  to  August  1857  he  was  House- 
Surgeon  at  the  Hospital  for  Sick  Children  in  London.  In  1857  he 
was  admitted  M.E.C.P.,  London.  In  this  year,  Dr.  Chance  "  went 
to  Paris  to  see  what  was  going  on  there.  One  day  soon  after  I 
arrived,  I  met  Dr.  Harris  accidentally  in  the  street.  He  was  then 
living  in  the  Kue  de  la  Harpe  (now  Boulevard  St.  Michel),  and  he 
soon  persuaded  me  to  go  and  live  at  the  same  house  with  him  (it 
was  quite  in  the  medical  quarter).  In  the  spring  of  1858  we  met 
again  in  Berlin,  though  we  did  not  go  there  together.  He  first 
lived  with  a  Professor  Kannegiesser,  for  the  sake  of  studying  the 
language ;  but  ultimately  he  came  to  the  house  in  the  Leipziger 
Strasse,  in  which  I  was  living.  Here  we  were  more  together,  for 
we  both  attended  Professor  Virchow's  lectures  and  courses,  and 
but  little  else,  for  these  occupied  several  hours  each  day.     In  the 


Memoir  of  Dr.  Harris.  xxxv 

summer,  he  and  I,  accompanied  by  an  Alsatian  of  the  name  of 
Koechlin  and  a  South  American  Spaniard  of  the  name  of  Lima, 
went  a  tour  of  four  or  five  weeks  and  visited  Saxon  Switzer- 
land, Dresden,  Prague,  and  Vienna.  Our  object  was  to  visit  the 
hospitals  in  Prague  and  Vienna,  and  it  was  in  those  towns  that 
we  principally  spent  our  time.  We  were  six  months  together  in 
Germany,  and  I  should  say  Dr.  Harris  was  about  the  same  time 
in  Prance."  Eeturning  to  England,  he  was  elected  Obstetric  Phy- 
sician to  St.  George's  and  St.  James's  Dispensary,  and  Assistant- 
Physician  to  the  Hospital  for  Sick  Children  in  May  1859.  The 
same  year  he  took  his  degree  of  M.D.,  and  chose  for  his  aca- 
demical disputation  "The  Nature  of  the  Substance  found  in  the 
Amyloid  Degeneration  of  Various  Organs  of  the  Human  Body." 
In  this  essay,  which  was  printed  in  i860,  he  maintains  "  that  the 
reactions  of  these  substances  (corpora  amylacea  and  amyloid 
degenerations)  with  iodine  and  sulphuric  acid  indicate  their 
analogy,  not  their  perfect  identity,  with  the  substances  of  the 
amylaceous  group."  This  was  his  only  published  work.  "He  had 
not  been  used  to  writing  for  the  press,"  says  Dr.  Chance,  "  and 
when  he  wrote  letters,  he  commonly  made  but  little  use  of  stops, 
and  substituted  dashes.  When,  therefore,  he  came  to  write  the 
thesis  for  his  M.D.  degree  (a  thesis  which  attracted  a  good  deal 
of  attention  at  the  time),  he  also  used  dashes  to  a  great  extent 
instead  of  stops.  The  printers  contented  themselves  with  copying 
what  they  had  before  them,  and  I  well  remember  Dr.  Harris's 
horror  when  the  proof-sheets  arrived  studded  with  innumerable 
dashes." 

The  Dispensary  he  soon  gave  up,  together  with  any  intention 
he  may  have  had  of  applying  himself  to  obstetrics.  It  was  Dr. 
Baly's  accidental  death  in  1861  which  brought  about  this  change  of 
plans.  There  was  an  opening  for  a  physician  at  St.  Bartholomew's; 
Dr.  Harris  took  advantage  of  it,  and  was  elected  Assistant-Physician 
to  the  Hospital.  About  the  same  time  he  was  appointed  Lecturer 
on  Botany,  a  science  in  which  he  took  much  interest  to  the  end  of 
his  life,  as  will  be  shown  hereafter.  In  August  of  this  year  he 
was  married  to  a  lady  who  was  his  second  cousin,  and  who,  with  a 
son  and  two  daughters,  survives  him. 

In  1865  he  resigned  the  Children's  Hospital  and  the  Lecture- 
ship, and  bought  an  estate  in  that  part  of  Kent  which  had  been 


XXX vi  Memoir  of  Dr.  Harris. 

well  known  to  him  from  childhood.  His  love  of  a  country  life 
drew  him  away  more  and  more  from  London  and  the  pursuit  of 
his  profession.  His  friend  says  :  "  I  was  not  only  not  surprised  to 
hear  he  had  retired  from  practice;  I  was  surprised  that  he  ever  went 
in  for  it,  and  continued  to  practise  so  long.  That  he  might  have 
made  a  large  practice  is  undoubted.  His  presence  was  good,  and 
calculated  to  inspire  confidence.  He  was  calm  and  self-possessed, 
and  therefore  likely  to  make  the  best  use  of  his  unusually  sound 
judgment.  All  that  he  wanted  was  energy,  ambition,  and  lack  of 
money.  If  he  had  no  money,  I  believe  he  would  have  made  it ;  but 
even  then  he  would  have  stopped  when  he  thought  he  had  suflBcient. 
His  chief  aim  was — so  it  seems  to  me — to  enjoy  life  in  a  reasonably 
comfortable  manner,  and  anything  that  interfered  with  his  enjoy- 
ment he  would  get  rid  of  if  he  could.  One  of  the  last  things  he 
ever  told  me  was  that  he  was  getting  into  practice  fast  [about 
1864],  much  too  fast  for  him  ;  and  he  confessed,  with  a  smile, 
that  he  sometimes  told  his  servant  to  say  that  he  was  not  at  home, 
in  order  that  he  might  not  be  bothered  with  patients."  Dr. 
Chance  adds :  "  I  used  to  go  to  him,  not  only  for  the  sake  of  his 
conversation,  but  to  ask  him  for  advice,  as  I  considered  his  judg- 
ment to  be  very  sound." 

I  purposely  omitted  saying  that  on  Di'.  Harris's  return  from 
Germany  he  was  appointed  Demonstrator  of  Morbid  Anatomy  at 
St.  Bartholomew's.  The  reader  will  now  be  glad  to  peruse  a  letter 
which  Dr.  Andrew  has  sent  me,  and  which  refers  to  this  period  of 
his  life  : — 

"  I  am  much  obliged  to  you  for  having  given  me  this  oppor- 
tunity of  recording  the  obligation  which  many  other  old  students 
of  the  Hospital  not  less  than  myself  must  feel  towards  our  late 
colleague,  Dr.  Harris. 

"When  appointed  Demonstrator  of  Morbid  Anatomy  at  St. 
Bartholomew's,  he  was  fresh  from  Virchow's  pathological  theatre 
at  Berlin,  and  full  of  enthusiasm  and  delight  in  his  work.  I  well 
remember  crossing  the  Hospital  square  with  him  one  afternoon, 
and  meeting  a  member  of  the  surgical  staff,  who,  struck  by  the 
expression  of  satisfaction  on  his  face,  asked  what  good  fortune  had 
befallen  him.  'Just  examined  a  case  of  amyloid  degeneration/ 
was  Harris's  reply.  The  case  was,  I  believe,  the  first  one  fully 
described  in  English,  and  "supplied  him  with  the  subject  of  his 


Memoir  of  Dr.  Harris.  xxxvii 

thesis  for  the  M.D.  degree  at  Cambridge.  As  a  teacher,  he  was 
clear  and  accurate  in  statement,  cautious  and  shrewd  in  his  reason- 
ing, always  ready  to  help  his  pupils,  and  sparing  no  pains  in  doing 
so.  Very  many  of  my  evenings  were  spent  at  his  rooms  in  New 
Cavendish  Street  watching  his  microscopical  examination  of  mor- 
bid specimens  ;  and  I  still  recall  with  admiration  his  mastery 
of  the  means  of  investigation  then  in  use,  his  deft  fingers,  the 
extent  of  his  reading,  and  the  soundness  of  his  knowledge.  On 
such  occasions,  too,  the  severity  of  our  studies  was  always  relieved 
by  his  ready  wit  and  sense  of  humour.  All  these  powers  and 
acquirements  were  unreservedly  placed  at  the  service  of  the 
Hospital  and  School." 

In  1868  he  was  elected  Physician  to  St.  Bartholomew's,  and  from 
this  time  forth  I  myself  was  closely  associated  with  him,  and  may 
therefore  undertake  to  speak  of  him  as  I  knew  him  during  the 
last  eighteen  years  of  his  life.  He  had  now  (1868)  retired  from 
all  medical  work  excepting  at  the  Hospital.  He  lived  as  much  as 
possible  on  his  estate,  which  was  situated  partly  in  Lamberhurst 
and  partly  in  Brenchley  parish,  in  the  Weald  of  Kent,  the  Andreds 
weald  of  our  forefathers — 

"  Saepe  hunc  Anderida,  sub  caelo  Octobris,  ab  urbe 
Venatum  in  silv^  ruris  agebat  amor." — K.  Bridges. 

His  house,  called  the  Grange,  was  close  to  the  thirty-ninth  mile- 
stone upon  the  highway  from  London  to  Hastings.  Prom  his 
garden  there  was  a  remarkable  prospect,  reaching  half  round  a 
distant  horizon  to  Best  Beech  Hill  and  Coursley  Wood  in  Wad- 
hurst,  Ticehurst,  Bedgbury  Park,  Goudhurst,  Horsemonden, 
"high  Brenchley's  hill,"  Sutton  Valence,  and  the  hills  east  of 
Maidstone.  In  the  foreground  was  the  valley  of  the  Teise,  one  of 
the  "  pretty  handmaids  "  of  the  Medway  celebrated  by  Spenser. 
The  soil  of  the  Weald  is  ill-suited  for  agriculture,  and  hence  the 
country  is  charming  in  respect  of  scenery.  Much  of  the  old 
forest  remains  ;  the  clearings  are  devoted  to  little  else  than  pasture 
hops,  and  gardens.  I  cannot  write  this  about  my  friend  and  not 
recall  to  mind  the  many  happy  days  I  have  spent  beneath  his 
roof.  Por  he  was  a  perfect  host,  wishing  to  oblige  to  the  utmost 
of  his  power,  yet  making  no  show,  pressing  nothing  upon  you,  and 
leaving  you  to  do  as  you  pleased.    The  verses  of  Phineas  Fletcher, 


xxxviii  Memoir  of  Dr.  Harris. 

born  twelve  miles  off,  at  Cranbrook,  might  have  been  most  fitly 
applied  to  Dr.  Harris  and  bis  guests — 

"  Then  do  not  marvel  Kentish  strong  delights, 
Stealing  the  time,  do  here  so  long  detain  me." 

He  took  especial  pleasure  in  his  garden,  his  orchard-house,  his 
vinery,  and  latterly  in  his  orchid-houses.  Here  he  turned  his 
botanical  knowledge  to  good  account,  and  made  numerous  experi- 
ments in  crossing  orchids.  Since  his  death  many  of  his  seedling 
hybrids  have  come  into  bloom,  whereof  two  have  been  named 
after  him.  The  first,  Dendrohium  Harrisii,  from  a  cross  between 
D.  nobile  and  D.  hetcrocarpum,  a  flower  more  than  three  inches 
across,  almost  pure  white,  with  a  large  lip  and  a  large  dark  purple 
eye.  The  next,  Calanilie  Harrisii,  from  0.  Veitchii  and  G.  vestita 
lutea.  Doctor  Eeichenbach  of  Hamburg,  who  is  great  in  orchid 
lore,  awards  a  high  meed  of  praise  to  the  Calanthe,  which  bears 
an  inflorescence  of  twenty  or  thirty  flowers,  each  more  than  two 
inches  across,  and  pure  white. 

Other  seedlings  which  have  not  yet  bloomed,  or  have  not  yet 
been  named,  are  Dendrobiums,  Calanthes,  Cypripediums,  and 
Cattleyas. 

In  1874  he  resigned  his  Hospital  duties  on  account  of  ill-health. 
Two  or  three  years  before  this  time  he  began  to  suffer  from  pro- 
gressive emphysema  of  the  lungs  and  pulmonary  catarrh,  connected 
with  a  disposition  to  gout ;  and  those  infirmities  gained  upon  him 
somewhat  quickly.  During  the  last  three  or  four  years  of  his  life 
dyspnoea  was  almost  continual,  and  sometimes  very  severe.  In 
June  1882  he  passed  through  an  attack  of  pneumonia.  A  recur- 
rence of  this  disease  put  an  end  to  his  life  on  September  3,  1885. 
He  died  in  London,  and  was  buried  at  Brenchley  by  the  side  of  his 
mother.  His  death  was  felt  to  be  a  great  loss  by  many  friends 
both  in  town  and  country,  to  whom  his  kind  and  hospitable  spirit 
had  made  him  dear. 

Heu  ubi  et  Harrisius  1  nee  tantum  Musa  gemebat 
Absentem,  quantum  viribus  orba  domus.^ 

^  Carmen   elegiacum    Robert!    Bridges   de   nosocomio  Sti  Bartolomaei  Lon- 
dinensi,  v.  369. 


The  Book  of  the  Fotmdatioii  of 
St.  Bartholomews. 


All  the  accounts  of  the  foundation  of  St.  Bartholomew's 
Hospital  and  of  the  Priory  of  St.  Bartholomew  which  have 
hitherto  been  published,  with  almost  everything  which  has 
been  written  about  the  founder,  are  based  directly  or  indirectly 
upon  a  manuscript  called  Lihcr  fundacionis  ecdesie  Sancti 
Bartholomei  Londoniarum.  The  manuscript  measures  io|-  in. 
by  7^  in.,  and  is  written  on  vellum,  containing  eighty-six 
leaves  of  vellum,  and  encased  in  a  modern  binding.  It  is 
preserved  in  the  British  Museum,  and  is  numbered  "  Vespasian 
B  IX."  This  title  is  taken  from  the  bust  which  surmounted 
the  bookcase  which  contained  the  manuscript  in  the  Cottonian 
collection.  It  was  a  fortunate  chance  for  us  that  the  book 
stood  beneath  the  tenth  Ceesar,  for  the  fire  which  in  1731 
destroyed  a  part  of  that  splendid  collection  began  at  the  oppo- 
site end  of  the  room,  and  injured  many  of  the  contents  of  the 
cases  surmounted  by  the  earlier  emperors.  "With  the  Cottonian 
collection  the  manuscripts  came  to  the  British  Museum.  Ee- 
cords  of  four  of  its  former  owners  are  to  be  found  on  its 
leaves.  On  the  first  page  is  written,  "  Thomas  Cotton."  He 
was  son  of  Sir  Eobert  Cotton,  who  died  163 1,  and  was  no 
doubt  the  last  of  the  private  owners  of  the  manuscript  whose 
names  are  recorded  on  its  pages.  On  a  vacant  page  at  the 
end  an  earlier  owner  has  written,  "  Iste  liber  jpertinet  ad  Thomam 
Otioell  de  London;"  ^  and  below  the  title  is  the  autograph  of  a 
third  owner,  probably  intermediate  between  Otwell  and  Cotton, 
"  Ei.  St.  Geo.  iSTorroy,  King  at  Arms."  Sir  Eichard  St.  George 
was  Norroy  King  at  Arms  from  1603  to  1623.  On  the  same 
page  as  his  name,  and  continuous  with  the  title,  is  the  record 
of  the  original  ownership  of  the  manuscript,  "pertiuens  pri- 

^  Lower  down  on  the  same  page  is  written,  "  Thomas  Powell  of  London,  sta- 
cioner  ; "  and  on  leaf  83b,  which  is  otherwise  blank,  "Mistress  Otwell  I  bid  yon 
farewell  for  you  do  well  and  in  bewtie  beareth  the  Bell." 

d 


xl  FoimdatioJi  of  St.  Bartholomews. 

oratui  ejusdem  in  \Yestesmythfelde."  This,  with  the  title,  is 
in  the  same  character  as  the  MS.  itself,  while  the  other  entries 
are  in  several  modern  hands.  It  proves  that  the  manuscript 
belonged  to  the  Priory  of  St.  Bartliolomew  in  Smithfield. 
"When  that  foundation  was  broken  up  at  the  general  dissolution 
of  the  monasteries,  this  book  left  the  library  of  the  Augustiniau 
canons,  and  was  turned  out  into  the  world  like  its  masters. 
A  careful  search  in  the  libraries  descended  from  those  formed 
in  London  in  the  sixteenth  century  will  probably  discover 
some  of  its  shelf  companions,  but  at  present  it  is  the  only 
sur\dving  relic  of  the  library^  of  the  priory.  The  manuscript 
contains  two  versions  of  the  same  work ;  the  first,  of  forty 
leaves,  in  Latin ;  the  second,  of  thirty-eight  leaves,  in  English. 
The  Latin  is  in  a  straight  Gothic  character,  with  large  letters  : 
the  English  is  in  a  less  vertical  and  differently  shaped :  a 
manuscript,  of  about  the  year  1400,  in  the  Cambridge  Uni- 
A'ersity  Library,  exhibits,  as  Mr.  Henry  Bradshaw  pointed  out 
to  me,  a  similar  distinction  between  the  character  in  which 
Latin  and  that  in  which  English  is  written.  There  is  no 
colophon  stating  the  name  of  the  composer  or  of  the  scribe, 
or  the  date  of  the  composition,  or  of  the  writing,  but  there 
is  internal  evidence  which  makes  it  possible  to  determine 
both.  The  author  states  that  he  belonged  to  the  Priory  of 
St.  Bartholomew,  and  to  the  Augustiniau  Order.  He  was 
one  of  the  thirty-five  canons  who  formed  the  community  in 
his  time.  IMany  details  throughout  the  work  confirm  the 
truth  of  this  statement,  while  his  use  without  special  note 
of  quotation  of  the  words  of  a  charter  of  Henry  L,  which 
was  the  most  precious  muniment  of  the  priory,  is  strong  con- 
firmatory evidence.  Several  statements  of  the  author  show 
that  he  was  li^^.ng,  and  probably  wrote,  in  the  latter  part  of 
the  reign  of  King  Henry  11.     He  mentions  no  later  king.     He 

^  In  a  deed  which,  by  the  kindness  of  the  Dean  and  Chapter,  I  have  examined 
at  St.  Paul's,  three  other  volumes  of  this  librarj-  are  mentioned — a  psalter  and 
gloss  in  two  volumes,  and  the  Epistles  of  St.  Paul.  The  deed,  of  which  some  parts 
are  a  little  faded,  is  of  the  year  1250,  and  states  that  Richard  of  Wendover  gave 
these  books  to  the  Prior  and  Convent  of  St.  Bartholomew,  and  that  they  received 
him  into  their  fraternity.  The  Antiphonarium,  mentioned  in  Rahere's  life,  makes 
a  fourth  volume  of  this  library.  A  finely-illuminated  MS.  in  the  British  Museum, 
said  to  belong  to  the  Priory,  contains  evidence  that  it  was  the  property  of  the 
hospital,  which  had  a  library  of  its  own. 


Foundation  of  St.  Bartholome'uJs.  xli 

says  that  he  had  talked  with  those  who  remembered  Eahere, 
who  died  September  27,  1143,  and  that  he  himself  had  been 
a  canon  during  the  priorate  of  Thomas,  Eahere's  successor, 
who  died  January  18,  11 74.  He  speaks  of  ecclesiastical 
privileges  obtained  from  several  popes,  from  Anastasius  IV., 
who  reigned  1 1  5  3-1 1  54,  from  Adrian  IV.  (i  i  54-1 1  59),  and 
from  Alexander  III.,  Adrian's  successor,  who  died  August  30, 
1 181.  Evidence  exists  that  later  popes  also  favoured  the 
priory,  and  these  would  certainly  have  been  mentioned  had 
the  writer  lived  to  hear  of  their  grants. 

More  general  evidence  is  his  mention  of  the  castle  of 
Munfychet  in  the  city  as  still  standing,  for  it  is  known  to 
have  been  finally  demolished  in  the  reign  of  Henry  III. 
These  circumstances  demonstrate  the  place,  the  time,  and  the 
author  of  the  work.  It  was  composed  in  the  Priory  of  St. 
Bartholomew  in  West  Smithfield,  between  the  death  of  Prior 
Thomas  and  that  of  King  Henry  II.,  that  is,  between  the  years 
1 1 74  and  1 1 89,  and  its  author  was  an  Augustinian  canon  of 
the  Priory.  He  wore  a  white  rochet  with  a  great  black  cloak 
and  hood  like  those  upon  the  effigy  on  Eahere's  tomb,  and 
he  kept  the  canonical  hours  in  the  beautiful  Norman  church 
which  is  all  that  is  now  left  of  his  beloved  Priory.  He  was 
as  familiar  with  our  hospital  as  we  are,  and  the  first  reports 
of  cases  admitted  into  it  are  contained  in  his  pages.  Adwyne 
was  the  name  of  the  first  of  these  reported  patients,  and  he 
seems  to  have  suffered  from  long-continued  muscular  debQity, 
such  as  is  sometimes  seen  in  patients  after  a  long-continued 
acute  illness.  The  canon  wrote  in  Latin,  in  a  good  twelfth- 
century  style.  He  had  read  but  little  of  the  poets,  but  had 
St.  Jerome's  version  of  the  Bible  at  his  finger  ends.  He 
uses  its  phrases  on  every  possible  occasion,  and  seems  as  much 
at  home  in  the  Minor  Prophets  as  in  the  Psalms. 

It  is  only  the  Latin  life  which  can  have  been  composed  in 
the  reign  of  Henry  11.  The  English  version,  which  contains 
•a  few  amplifications,  is  proved  by  its  language  to  be  of  later 
date,  and  since  the  existing  Latin  manuscript  and  the  English 
were  clearly  written  on  parchment  at  the  same  period,  the 
date  of  the  English  version  fixes  that  of  the  manuscript  as  it 
stands.     The  language  is  Middle  English,  and  the  character 


xlii  Foundation  of  St.  Bartholomews. 

that  of  about  the  year  1400.  The  scribe  has  supplied  by  a 
slip  of  his  pen  an  important  indication  of  his  period.  In  the 
middle  of  the  translation  where  the  original  Latin  has  "Henry 
II.,"  he  has  given  "  Eichard  II."  as  the  king's  name.  The 
Latin  version  was  written  before  any  Eichard  had  reigned  in 
England,  and  nothing  is  more  likely  than  that  a  scribe,  who  had 
lived  with  Eichard  II.  on  the  throne,  should  inadvertently  put 
the  name  of  the  reigning  king  for  that  of  a  past  sovereign  of 
the  same  number  but  of  a  different  name. 

To  sum  up  the  facts  :  the  manuscript  in  the  British  Museum 
was  written  about  the  year  1400,  and  the  English  transla- 
tion was  composed  at  that  period.  The  Latin  manuscript, 
also  transcribed  then  and  rubricated  in  the  same  style,  was 
originally  composed  about  the  year  1 180. 

Besides  its  interest  to  us  in  St.  Bartholomew's,  the  manu- 
script well  deserves  a  careful  perusal  for  the  glimpses  which 
it  gives  of  life  in  London  in  the  reign  of  Henry  II.  Space 
compels  me  to  leave  it  to  speak  for  itself,  only  adding  that 
the  reader  must  bear  in  mind  that  the  Augustinian  canon's 
object  was  to  write  the  spiritual  history  of  our  founder  and 
liis  foundation,  and  not  to  compose  a  detailed  historical  work. 
This  life  of  Eahere  is  now  published  in  full  for  the  first  time. 
I  have  chosen  the  English  version  because  it  has  an  interest 
as  an  example  of  our  prose  literature  soon  after  the  time  of 
Chaucer.  In  the  text  I  have  expanded  the  contractions,  which  are 
very  few  and  so  often  repeated  as  to  present  no  difficulties  ;  and 
I  have  otherwise  printed  the  words  exactly  as  they  are  in  the 
manuscript,  adding  a  few  notes  solely  with  a  view  to  making 
the  perusal  easy  to  a  general  reader.  There  are  very  few  words 
which  are  not  easily  intelligible  when  sound  and  not  spelling 
is  regarded.  The  precise  evidence  as  to  the  date  of  the 
foundation  of  St.  Bartholomew's  Hospital  given  in  the  manu- 
script, and  many  other  facts  elucidated  by  it,  deserve  con- 
sideration, but  would  add  too  much  to  the  length  of  this 
introduction.  I  hope  on  a  future  occasion  to  set  forth  in 
detail  the  whole  life  of  our  Founder. 

NOEMAN  MOOEE. 

Septsmber  20,  1S85. 


LIBER   1/ 


For  asmooche,^  that  the  meritory  ^  and  notable  operacyons,  of 
famose  goode  and  devoute  faders*  yn  God,  sholde  be  remembred 
for  instrucion  of  aftyr  cummers^  to  theyr  consolacion  and 
encres  ®  of  devocion  thys  Abbrevyat  Tretesse/  shal  com- 
pendiously expresse  and  declare,  the  wondreful  and  of  celestial 
concel^  gracious  fundacion^  of  oure  hoely^*^  placys  callyd  the 
Priory  of  seynt  Bartholomew  yn  Smythfyld,  and  of  the  hospital 
by  olde  tyme  longyng^^  to  the  same,  with  other  notabiliteis 
expediently  to  be  knowyn.  And  most  specially  the  gloriouse 
and  excellent  myraclys  wroghte-'^  with  yn  them,  by  the  inter- 
cessions suffragys  and  meritys,  of  the  forsayd,  benygne  feythfuU 
and  blessid  of  God  apostyl  sanct  Bartholomy,  yn  to  the  laude 
of  almyghty  God  and  agnicion  of  his  infinite  powere. 

FFYRST  SHAL  BE  SHEWYD  WHO  WAS  FFUNDER^^  OF  OWERE  ^* 
HOELY  PLACES,  AND  HOWH  ^^  BY  GRACE,  HE  WAS  FFYRST 
PRYOR  OF  OWR  PRIORY;  AND  BY  HOWH  LONGE  TYME 
THAT  HE  CONTYNUED  YN  THE  SAME. 

Thys  chirche  yn  the  honoure  of  most  blessid   Bartholomew 
apostle,   fundid    Rayer,  of  goode   remembraunce    and  theryn 

^  The  MS.  begins  as  above,  with-  *  fader s,  fathers, 

out  any  heading  of  Book  or  Chap-  ^  cummers,  comers, 

ter,  and  tlie  first  sixteen  lines  form  ^  encres,  increase. 

a  sort  of  preface  which  is  not  in  the  '  tretesse,  treatise. 

Latin.     Then  follows  in  red  the  title  ^  cancel,  counsel. 

of  the  first  chapter,  and  then  the  text  ^  fundacion,  foundation. 

begins  with  a  large  and  beautifully  ^^  hoely,  holy, 

illuminated  T.     The  heading  of  each  ^^  longyiig,  belonging, 

subsequent  chapter  is  in  red,  with  a  ^^  ivroghte,  wrought, 

red  number  in  the  margin.  ^^  ffunder,  founder. 

^  asniooche,  as  much.  ^^  aivere,  our. 

'  tneritory,  meritorious.  ^^  howh,  how. 


xliv  Foundation  of  St.  Bartholojnew's. 

to  serve  God,  aftir  the  rewle^*'  of  the  moo?t  holy  fader 
Austyn,  aggregat  to  gidir^^  religiouse  men  and  to  them  was 
})relate  xxii  vera,  usynge  the  office  and  dignite  of  a  prlore : 
not  havynge  cunnynge^^  of  liberal  science,  but  that  that  is 
more  emynente  than  all  cunnvnge,  ffor  he  was  richid  yn 
puryte  of  conscience ;  ayenste  ^'^  God  by  devocyon,  ayenste  his 
brethryn  by  humylite,  ayenste  his  enemyes  with  a  beny- 
volence.  And  thus  hym  self  he  excercised  them  paciently 
sufferynge,  whoose  provyd  puryte-*^  of  soule,  bryght  maners  with 
honeste  probyte,^^  experte  diligence  yn  dy  vyne^^  servyce,  prudent 
besynes-^  yn  temperalle  mynystracyun,^*  in  hym  were  gretely  to 
prayse  and  commendable.  In  festis-^  he  was  sobir/^  and  namely 
the  folowere  of  hospitalite,  tribulacions  of  wretchis,  and  neces- 
siteys  of  the  pouer  peple  oportunyly  admvttyng,  paciently  sup- 
portyngj  competently  spedynge.  In  prosperite  nat  ynprided  ;2^ 
in  adversite  paciente ;  and  what  sumevere  unfortune  ranne 
agevn  hvm,  he  restvd  hymself  undir  the  schadowe  of  his 
patron,  that  he  worshippid,-^  whom  he  clippid-^  to  hym,  with 
yn  the  bowell  of  his  soule.  In  whose  helpe  for  all  perelles^  he 
was  sekyr^^  and  preservyd.  Thus  he  subjett  to  the  kyng  of 
blisse  with  alle  mekenesse,  prevydyd  with  alle  dilegence,  that 
were  necessarie  to  his  subiectys/-  and  so  provydynge  he  en- 
cresid  dayly  to  hymself,  before  God  and  man  grace,  to  the 
place  reverence,  to  his  frendes  gladnesse,  to  his  enemyes  peyne,^ 
to  his  aftircummers  joye.  And  suche  certeyn  was  the  lyef^*  of 
hvm  aftir  his  conversyon  bettyr  than  hit  was  beforn,^^  in 
goodnes  ever  more  encresid.  And  yn  what  ordir  he  sette  the 
fundament  of  this  temple,  yn  fewe  wordys  lette  us  shewe,  as 
they  testified  to  us  that  sey^^  hym,  herd  hym,  and  were  pre- 

'®  reivU,  rule.  *^  ynprided,  elated. 
1'  aggregat    to   gidir,    aggregated  ^  that  he   'worshippid,   quem   ven  era- 
together,  batur. 

^^  cnnnynge,  cunning  (knowledge)  -^  clippid,  embraced, 

^'  ayenste,  towards  (erga).  ^"^  perelles,  perils. 

^  puryte,  purity.  ^^  sekyr,  safe. 

^^  probyte,  probity.  ^-  siibuctys,  subjects  {suhdito  gregt). 

^^  dyvyne,  divine.  ^  peyiu,  pain. 

^  bcsynes,  business  [sollicitudd).  '^  lyef,  life. 

^^  mynystracyun,  ministration.  ^^  befarn,  before. 

*^  festis,  feasts.  '^  sey,  saw. 

^  sobir,  sober. 


Foimdation  of  St.  Bartholomew's. 


xlv 


sente  yn  his  werkys  and  dedis/'^  of  the  whiche  summe  have  take 
ther  slepe  yn  Cryiste^  and  summe  of  them  be  5itte^^  a  lyve 
and  wytnesseth  of  that  that  we  schall  aftir  say. 


CAPITULUM  IT. 

WHAT    LYEF    HE    LEDDE    A    FORN  ^    HIS    CONVERSION. 

Thys  mann  sprongyng^  or  boryn  of  lowe  lynage/  whan 
he  attayned  the  floure  of  yougthj  he  began  to  haunte  the 
housholdys'^  of  noble  men  and  the  palices^  of  prynces^  where 
undir  every  elbowe  of  them,  he  sprede  her  ^  coshynys  '^  with 
japys  ^  and  flatterynges,  delectably  anoyngtyng  her  eerys/  by 
this  maner  to  drawe  to  hym  ther  frendschippis.  And  3itte  he 
was  nat  content  with  this^  but  ofte  hawntid  ^°  the  kynges 
palice,  and  amonge  the  noysefull  prese  of  that  tumultuous 
courte  inforsid  ^^  hymself  with  jolite^^  and  carnale  suavyte^^^by 
the  whiche  he  myght  drawe  to  hym  the  hertvs  ^*  of  many  oone/^ 
ther  yn  spectaclis,  yn  metys^  ^^  yn  playes,  ^^  and  othir  courtly 
mokkys  ^^  and  trifyllys^^  intendyng,  he  ledeforth  the  besynesse 
of  alle  the  day.  ^^  And  nowe  to  kynges  attendens,  now  fol- 
lowyng  the  entente  of  grete  men  presid  yn  -^  proferynge 
servyce  that  myght  piece  ^^  them,  besily  -^  so  occupied  hys 
tyme  that  he  myghte  opteyne  ^^  the  rathir  the  peticions  that 
he  wolde  desire  of  them.  Thiswyse  to  kyng  and  grete  men 
gentylls  and  courtyours  y  knowen,  famylier  and  felowly  -^  he 


^''  dedis,  deeds. 
^^  T^itte,  yet. 

^  aforn,  before. 

^  sprongyng,     springing    {oriun- 
dus). 

^  lynage,  lineage  (prosapia). 

*  hotisholdys,  households. 

^  palices,  palaces. 

®  her,  their. 

^  coshynys,  cushions  {pulvillos). 

^  japys,  jokes. 

9  eerys,  ears. 
^"  hawntid,  haunted. 
^^  inforsid,  enforced, 
^*  jolite,  jollity. 


•'^  suavyte,  suavity. 
■■*  hertys,  hearts. 
^^  many  oone,  many-one. 
^^  metys,  banquets  {epulis). 
^^  playes,  pastimes  {jocis). 
^^  mokkys,  nonsense  {rmgis). 
^  trifyllys,  trifles, 
^°  iota     die     intenden     negocium 
ducebat. 

^^  presid  yn,  pressed  in. 
^  piece,  please. 
^  besily,  busily. 
^^  opteyne,  obtain. 
^felowly,  socius. 


xlvi  Foundation  of  St.  Bartholofnew's. 

was.  This  rnanere  of  levynge^  he  chose  yn  his  begynnyng,  and 
yn  this  exercisid  his  yougth ;  but  the  inwarde  seer^  and 
mercyfull  God  of  all,  the  whiche  oute  of  Mary  Magdalene  cast 
oute  vii  feendvSj^  the  whiche  to  the  ffysshere  ^  jave  the  keyes 
of  hevyn  ^  mercyfuUv  convertid  this  man  fro  the  erroure  of 
hys  way,  and  addid  to  hym  so  converted  many  3iftys  of  vertu, 
for  why :  they  that  are  fonnysche  ^^  and  febill  ^-  in  the  worldys 
reputacion,  oure  Lorde  chesith,^  to  confounde  the  myghte  of 
the  worlde. 


CAPITL'LL'M    III. 

HERE    FOLOWETH    HOWE    CONVERTID    HE    WEXTE    TO    ROME. 

This  man  therfore  by  the  grace  of  God,  of  hys  synnes 
sumtyme  ^  penvtent  a  parposyng  to  halfe  -  his  dayes,  that  he 
mvghte  obtevne  ^  parfite  and  plenere  pardon  and  indulgence 
of  his  synnes :  to  that  entente  *  he  decreid  yn  hym  self  to  go  to 
the  courte  of  Rome,  covetynge  yn  so  grete  a  laboure  to  do  the 
worthy  fruytes  of  penaunce.  The  whiche  habite  of  hevynly 
inspirid  soule  and  purpos  he  wolde  nat  with  a  slowthfull 
mvnde  be  deferrid  yn  to  tymes  and  yeres,  but  the  conceyved 
goode  dede  by  feithfull  desire  constawntly  executynge,  he  toke 
his  wav,  ^  oure  lord  God  directyng  his  pace,  and  hole  and 
sownde®  whydir'^  he  purposid  came,  where  at  the  martirdomes^ 
of  the  blessid  Apostles  Petir  and  Poule,  he  wepynge  hys  dedis 
and  reducyng  to  mynde^  the  scapis^^  of  hys  yougth  and  igno- 
raunces,  prayd  to  oure  Lorde  for  remyssion  of  them,  behestynge^^ 
furthermore,  noon  like  to  do,  but  thyes^-  utterly  to  forsake,  ever 


^  Uvyttgi,\Wvag.  *  entente,  intent. 

-"  iftivarJe  seer  {^ms^cXox).  *  domiiio  greszus  ejus  dirigente 

**  feendys,  fiends.  '  hole  and  sozunde,  incolumis. 

^  ffyssfure,  fisher.  ^  whydir,  whither. 

*•  /tayn,  heaveiu  ^  martirdomes,  places  of  mar:jT- 

''  fonnysche,  foolish.  dom  {martiria). 

•*  febill,  feeble.  ®  reducyng  to  mynde,  ad  memoriara 

^  f .^^jiV/ij  chooseth.  reducens. 

^  sumtyme,  somelime.  '*  scapis,  delicta, 

*  halfe  (dimidiare).  "  behestyngi,  promising. 

'  obteyne,  ob'^in.  "  t^yes,  these. 


FoMndation  of  St.  Bartholomew  s.  xlvii 

devoutly  his  will  promyttyng  to  obeye.  These  ii  clere  lightys 
of  hevyn,  ii  men  of  mercy,  Petir  and  Poule,  he  ordeyned 
mediatOLires  betwyn  hym  and  the  lorde  of  all  erthe,^^  promysynge 
that  he  wolde  be  ware,  of  all  passid  unhabilnesse,  ^*  and  yeve 
aifectualy  his  diligence  and  laboure,  to  that  he  hatha  promysyd, 
and  whyle  he  taryed  ^^  ther,  in  that  meene  whyle,  he  began  to 
be  vexed  with  grevous  sykenesse,  and  his  doloures,  litill  and 
litill,  takynge  ther  encrese,  he  drewe  to  the  extremyte  of  lyf,  ^® 
the  whiche  dredynge  ^"^  with  yn  hymself,  that  he  nat  3itte  for  his 
synnys^^  hadde  satisfied  to  God^  and  therfore  he  supposid  that 
God  toke  vengeawnce  of  hym  for  his  sinnys  a  monges  owte 
landisshe^^  peple,  and  demyd^*'  the  last  oure  of  oure^^of  his  deith^'^ 
drewe  hym  nygh.  Thys  remembrynge  inwardly,  he  schedde  ^^ 
owte  as  water  his  herte  in  the  syght  of  God,  and  albrake  owte 
in  terys,  2*  than  ^^  he  avowyd  yf  helthe  God  hym  wolde  grawnte, 
that  he  myght  lefully  returne  to  his  contray,  ^^  he  wolde  make 
and  hospitale  yn  recreacion  of  poure  ^^  men,  and  to  them  so  there 
i  gaderid,  ^^  necessaries  mynystir,  ^^  aftir  his  power.  And  nat 
long  aftir,  the  benigne  and  mercyfull  lord,  that  byhelde  the 
terys  of  E3echie,  the  kynge,  the  importune  prayer  of  the 
woman  of  Chananee  rewardid  with  the  benefeit  of  his  pite,^^ 
thus  lykewyse  mercyfully  he  behelde  this  wepyng  man,  and 
gaf  ^^  hym  his  helth,  approvyd  his  avowe,^^  so  of  his  sykenes 
recoveryd  he  was,  and  in  short  tyme  hole  y  maade,  ^^  began 
homwarde  to  come,  his  vowe  to  fulfille  that  he  hadde  made. 


^*  erthe,  earth.  -^  than,  then. 

1*  tmhabilnesse,  folly  (ineptiis).  ^  ad patriam  suam  reciire  licdrei, 

15  taryed,  tarried.  '^  poure,  poor. 

■'^  lyf,  life.  ^  i  gaderid,  gathered, 

^^  dredynge,  dreading.  ^  mynystir,  minister. 

^'  sinnys,  sins.  '"  pile,  pity. 

^^  owtelandisshe,  foreign.  ^^  gaf,  gave  ("gif-gaf  makes  good 

^^  dimyd,  deemed.  friends  "  is   a  well-known  saying  iu 

'^  oure,  hour.  Antrim). 

^^  deithy  death.  ^^  avowe,  vow. 

^^  schedde,  shed.  ^  hole y  maade,  made  whole. 


24 


terys,  tears. 


xlviii  Foundation  of  Si.  Diirtholome'uus, 

CAPITULUM  IV. 

OF    THE    VISION    THAT    HE    SAVVE    IN    THE    WAY^    AND    OF    THE 
COMMAUNDEMENT    OF    SEYNT  BARTHOLOMEW   THE    APOSTLE. 

Whan  he  wolde  perfete  his  way  that  he  hadde  begon,  in  a 
certayne  nyght  he  sawe  a  vision  full  of  drede  ^  and  of  swetnesse, 
whan  aftir  the  labourous  and  swetyng  that  he  had  by  dayes, 
his  body  with  reste  he  wolde  refresshe.  It  semyd^  hym  to  be 
bore  up  an  hye,^  of  a  certeyn  beiste*  havynge  viii  feete  and  ii 
wyngges^  and  sette  hym  yn  an  hye  place,  and  whan  he  from 
so  grete  an  highnesse  wolde  inflecte  and  bowe  down  his  yie^ 
to  the  lower  party  '^  donward,  he  behelde  an  horrible  pytte  * 
whose  horryble  beholdyng  ynpressid  in  hym  the  beholder  grete  ^ 
drede  and  horroure,  ffor  the  depnesse  of  the  same  pytte  was 
depper  than  eny  man  myghte  atteyne  to  see.  Therfore  he, 
secrete  knowere  of  his  defautes,  demyd  hym  self  to  slyde  in  to 
that  cruell  a  downcast,  and  therfore  as  hym  semyd  ynwardly 
he  fremyshid,^^  and  for  drede  tremelyd,^^  and  grete  cryes  of  his 
moweth  ^^  procedyd.  To  wham  dredyng  and  for  drede  criynge 
apperid  a  certeyn  man  pretendynge  in  chere^^  the  majeste  of  a 
kynge  of  grete  bewte/*  and  imperiall  auctorite,'^^  and  his  yie  on 
hym  fastynd,  he  seyd  goode  wordes,  wordes  of  consolacion  bryng- 
ynge^^  goode  tydynges^'^  as  he  schulde  sey  in  this  yn  this  wyse, 
'^  O  man/'  he  seyd,  "What  and  howe  muche  servyce  shuldes^^ 
thou  yeve  to  hym,  that  yn  so  grete  a  perele  hath  brought  helpe  to 
the  :^'  annone  he  answerde  to  this  seyynge,  "  whatsumever  myght 
be  of  hert^^  and  of  myghtys,^®  diligently  shulde  I  yeve,  in  recom- 
pence  to  my  delyverer."  And  than  saide  he,  "  I  am  Bartholomew 
the  Apostle  of  Ihu  Crist  that  come  to  socoure^^  the,  yn  thvn 

^  drede,  dread  (terrore).  ^^  tremdyd,  trembled. 

^  semyd,  seemed.  ^^  moweth,  mouth. 

3  hye,  high.  i3  chere,  mien  (vultu). 

*  beiste,  beast.  .                   "  bewte,  beauty. 

5  wyngges,  wings.  ^'  mictorite,  authority. 

®  yie,  eye.  '^  bryngynge,  bringing. 

^  to  the  lower  party,  ad  ima.  i''  tydynges,  tidings. 

^  pytte,  pit,  18  shuldes,  shouldest. 

^  grete,  great.  ^9  ^^^/^  heart, 

^^  fremyshid,      shuddered  (inhor-               ^'^  myghtys,  powers, 

ruit).  ^^  socoure,  succour. 


Foundation  of  St.  Baj^t/wlotnezvs.  xlix 

angwysshe/^  and  to  opyn  ^^  to  the  the  secrete  mysterves  of 
hevyn,  knowe  me  trewly^  by  the  will  and  commanndemente 
of  the  hye  Trinite^  and  the  comyn  ^^  favoure  of  the  celestiall 
courte  and  consell  to  have  chosyn  a  place  yn  the  Subbarbis^° 
of  London  at  Smythfeld  wher  yn  myn  name  thou  shake 
founde  a  chirche  and  it  shall  be  the  house  of  God  :  ther  shalbe 
the  tabernacle  of  the  lambe,  the  temple  of  the  Holy  Gost.  This 
spirituall  howse  almyghty  God  shalle  ynhabite  and  halowe  yt 
and  glorifie  yt  and  his  yen^^  shall  be  opvn  and  his  eerys^'^ 
yntendyng  on  this  howse  nyght  and  day  that  the  asker  yn 
hit  schall  resceyve^  the  seker  shall  fynde  and  the  rynger  or 
knokker  shall  entre.  Trewely  every  soule  convertid  penytent 
of  his  synne  and  in  this  place  pravng,  yn  hevyn  graciously 
schall  be  herde  :  the  seekere  with  perfite  hertefor  whatsumevyer 
tribulacion  withowte  dowte  he  schalle  fynde  helpe  :  to  them 
that  with  feithfull  desire  knoke  at  the  doyr^^  of  the  spowse, 
assistent  angelys  shalle  opyn  the  gatis  ^^  of  hevyn,  recey vyng 
and  oiFeryng  to  God  the  prayers  and  vowys  of  feithfull  peple. 
Wherforet  hyn  handys  be  there  confortid  in  God,  havyng  in 
hym  truste,  do  thou  manly  ^"^  nethir  of  the  costis  of  this  bildynge 
dowte  the  nowght,  onely  yeve  thy  diligence,  and  my  parte  schal- 
be  to  provyde  necessaries,  directe,  bilde  and  ende  this  werke, 
and  this  place,  to  me  accepte,  with  evydent  tokenys  and  signys 
protecte  and  defende  contynually  hyt.  Undyr  the  schadowe  ^^ 
of  my  wyngys,  and  therfore  of  this  werke  knowe  me  the  maister 
and  thy  self  onely  the  mynyster :  use,  diligently  thy  servyce, 
and  I  shall  schewe  my  lordeschippe."  In  these  wordes  the  vision 
disparyschydde.^^ 


^"^  angwysshe,  anguish.  ^^  doyr,  door. 

23  opyn,  open.  ^^  gcid^,  gates. 

24  comyn,  common.  3"  do  thoti  manly,  viriliter  age. 

25  subbarbis,  suburbs.  ^^  schadowe,  shadow. 

26  yen,  eyes.  ^2  disparyschydde,  disappeared  (dis- 

27  eerys,  ears.  paruit). 


1  Foundation  of  St.  Bartholotnew  s. 

CAPITULUM  V. 

WHAT    HE    YX    HVMSKLF  TRETID  ^    OF    THVS    VISYN.^ 

He  awakid  began  to  revolve  wysly  in  his  mynde  that  he  hadde 
seyn.  In  that  nieene  while,  to  his  flittvng  soule^  was  mewyd'* 
to  have  a  dowtable  sentence,^  whethir  it  schulde  be  hadde,  and 
take  for  a  fantastykke  illiisyon,  that  ofte  happyth  ^  to  men  yn 
ther  slepe,  or  for  an  hevynly  warnyng  or  answere,  the  whiche 
he  demyd  himself  nat  worthy  to  have.  Thus  stryvyd  togedyr'^ 
in  his  herte,  feithfull  mekenesse  and  drede  and  uncertayn  he 
was,  to  whom  more  credence  schulde  be  gowyn,  and  as  a 
meke  man  he  wolde  them  have  hvdde  and  nat  presume  hier 
thynges  above  hym  self,  than  he  undrestode.  Also  tymorosely 
he  dred  to  laches^  the  preceptis  of  the  apostle,  and  so  lachesynge,^ 
nat  meke,  but  prowte,^*'  to  be  bownde,  with  the  streite^^  examina- 
cion  of  the  hiejuge.  Therfore,  with  worthier  sentences  and 
better  allegacion  whan  he  was  informyd,  drede  of  God  and  the 
apostle  optenyd  the  victorye,  to  whom  grace  was  felowschippe, 
and  blessedly  areysed  up  the  meke  man,  confortid  the  faynt- 
hertid,  the  suatperynge  man^- stedfastid.  The  goode  forseyd 
dede  in  stabill  degre  with  his  welsumme  and  happy  purpose  to 
performe.  He  therfore,  techynge^^  hym  inwardly,  as  we  beleve, 
by  his  unccion  that  beforne  hadde  instructe  hvm  by  nvghtly 
vision,  ordaynyd  to  make  perfite  that  was  commawnded,  namely, 
whyle  he  was  commawnded  oonly  and  grettely  to  yeve  dile- 
gence  and  laboure.  And  soethly  the  overplues  shulde  be  as 
the  commawnder  wolde  ordeyne.  Trewly  by  dremys^^many 
secretis  of  Goddis  wille  hath  come  to  the  knowleche  of  men.  In 
the  seryous^^  scripture  of  the  olde  and  newe  testamentis,  as 
nat^^  onys^^  but  oftyn  we  have  redde,  wherof  oone  wittnesse  of 

1  tretid,  thought  on.  ^  lachesynge  (negligeiido). 

^  visyn,  vision.  ^*'  prowte,  proud. 

8_/?;//y«^j^«/£',  fluctuanti  animo.  ^^  streite,  strict. 

*  mew^'d,  moved.  i^  suatperynge  vian  (initantem). 
®  dowtable  sentettce,    dubiam   sen-  ^*  teckyttge,  teaching. 

tenciam.  ^^  dreviys,  dreams. 

*  happyth,  happeneth.  ^^  seryous  (serie). 
^  togedyr,  together.  ^®  ttat,  not. 

^  to    laches,     to    diiregard    (negli-  ^^  onys,  once. 

gere). 


Foundation  of  St.  Bartholomew  s.  li 

them  bothe  sufficith  us  to  bryngforth.  Holy  Danyel  in  his 
dreme  lernyd  the  dreine  of  the  kynge^  and  the  interpretacionn 
of  the  same,  oure  Lorde  revelynge  he  knewe.  Rightwus  Joseph 
yn  his  slepe  was  warnyd  nat  to  drede  to  take  Marye  his  wyf, 
and  stondynge  the  article  of  persecucion  to  flee  with  her  in  to 
Egipte.  And  whan  Herode  the  autoure  of  persecucion  was 
deed,  by  the  angle  he  was  commannded  to  returne  a3en  in  to 
Jurye.  Visions  in  nyght  tymes  i  made  pretende  nat  alway 
cause  of  deseit  but  sumtyme  pregnant  and  frutefull  sentences 
of  hevenly  mystery,  worthy  to  be  trowid^^  with  feith^^  and  admi- 
racion.  With  theys  and  many  moo  auctorites  ^*^  of  scripture,  we 
ben  taght^^  of  the  whiche  to  have  perfite  discrecion.  I  trowe^ 
yt  nat  of  mannys  witte,  but  of  a  godly  gyfte  and  therfore 
after  the  lawe  the  residue  of  the  lambe  lat  us  leve  yt  to  the 
fyre  that  ys  the  Hoely  Gooste. 


CAPITULUM  Vl.i 

EXPOSICION    OF    THIS    VISION. 

Forthermore  what  yf  it  be  inquerid  what  pretendith  the 
vision  of  the  federyd  beiste,  what  the  horrible  pitte,  what  settyng'"^ 
of  the  man  an  bye  what  I  feill  of  this  in  fewe  wordis  I  schalle 
expresse.  I  derae^  the  beiste  to  signifie  the  devyl,  the  which 
in  E3echiel  mysterially  ys  callid  the  grete  egle.*  Nowe  for  the 
dignite  of  hevenly  nature.  Nowe  for  magnitude  of  spirituall 
wykkednes,  the  whiche  bothe  there  yn  E3echiel,  and  also  in 
this  vision,  the  beyste  semyd  grete  wynges  to  have,  by  that  ys 
understonde  he  swollyn  with  pride  of  elacion  purposid  in  will 
to  be  like  almyghty  God,  and  to  the  same  elacyon  man  with 
deceyvable  promysse  proudly  he  arysyd  ^  a3enste  his  creator,  with 
the  whyche  synne  never  cesith  he  to  attaste®  alle  the  kynde  of 

^8  irowid,  believed.  translator  has  here  added  a  gloss  of 

^*  feith,  faith.  his  own. 

*"  auctorites,  authorities,  ^  settyng,  setting. 

*^  iaght,  aught.  '  deme,  deem. 

*2  trowe^  think  (reoi).  *  egle,  eagle. 

^  Chapter  V.  in    the  Latin  ends  '  proudly  he  arysyd,  snperbe  erex- 

with    the    words    "ideo    secundum  erit. 

legem ;  relinquamas  igni,"  so  that  the  ®  attasfe,  attemptare. 


Hi  Foundation  of  St.  Bartholomew's. 

men,  many  to  ynfoldeyn/  and  many  with  hym  to  adde,  to 
everlastving  fyre,  no  houre  ne  tyme  cessith  not,  hys  iv  feete 
ben  iiii  wyndys  of  the  which  is  spoken  yn  3acharie:  or 
els  iiii  gendrys^  of  temptacion,  the  which  anumbrith^  the 
psalmyst,  or  els  iiii  vices  of  whiche  spekith  the  prophete 
Joel,  seivng :  the  residue  of  the  Eruce  etyth  the  buttyrflye, 
and  the  residue  of  the  butty rflie  etyth  brucus,  and  the  residue 
of  bruce  etvth  rubigo,  undirstondyng  lecherie  by  Eruca,  by 
the  buttyrfllie  vaynglorie,  by  brucus  glutteny,  by  rubygo  ire 
signifying  and  wrath.  Note  well  that  Eruca  ys  a  worme/*^  that 
growith  of  the  worttys,  Locusta  that  fleith  frome  floure  to  floure, 
brucus  is  the  issue  of  the  buttyrflie,  or^^  he  have  wynges. 
Of  iiii  wyndys  remembrith  3acharie^-  seiyng  I  lyfte  up  my 
eiyn  and  sawhe,  and  to  me  was  seyed  beholde  iiii  hornnys, 
and  I  seied  to  the  angle,  that  spake  in  me,  what  ben  theys,^^ 
and  he  seide  to  me,  these  ben  the  hornnys  that  shall  blowe 
and  ventilatte,^*  Ji-ide,  Israel  and  Jerusalem.  By  the  which  iiii 
wyndys  he  signified  iiii  passions  of  the  soule  that  ys  to  seye, 
dredcj  and  hevynesse,  love  and  gladnesse,^^  that  dissipate 
alweyes  the  quyete^*^  of  mynde,  and  no  soule  ther  is  bownde 
with  bridyll  where  theys  regne.  Of  iiii  gendres  of  temptacion 
seide  David  of  the  rightwes  man,  thus,^''  Thou  schalt  nat  drede 
for  the  nyghte  drede,  ne  for  the  arrowfleynge  in  the  day,  ne 
for  the  besynes^^  walkynge  in  derknesse,  ne  for  the  yncourse^^ 
and  mydday  devyl.     The  fyrst  temptacion  is  lighte  and  hydde, 

^  ynfoldeyn,  infold.  scattered  Judah,  Israel,  and  Jerusalem. 

*  gefidrys,  kinds.  — Zcch.  i.  i8,  19. 

*  anunibrith,  enumerates.  ^^  'ujhat  ben  theys,  what  are  these. 
^"  That   which  the    palmer  worm  ^■*  veniilaite,  veniilaverunt. 

hath  left  hath  the  locust  eaten :  and  ^^  Timor  et  tristicia, 

that  which  the  locust  hath  left  hath  Amor  et  leticia. 

the     cankerworm    eaten,    and    that  '^  guy^^^t  quiet. 

which     the     cankerworm    hath    left  ^^  Thou  shalt  not  be  afraid  for  the 

hath  the  caterpillar  eaten. — ^Joel  i.  4.  teiror  by  night ;  nor  for  the  arrow  that 

The  sentence  beginning  Note  well,  is  flieth  by  day  ;   nor  for  the   pestilence 

an  addition  of  the  translator.  that  walketh  in  darkness  ;  nor  for  the 

^^  or,  before.  destruction  that  wasteth  at   noonday. 

1-  Then  I  lifted  up  mine  eyes,  and  — Psalm  xci. 

saw,  and  behold  four  horns.     And  I  ^^  besynes  represents   the   negocio   of 

said  unto  the  angel  that  talked  with  the  Vulgate,  and 

me.  What  be  these?  And  he  answered  ^^  yncoutse,  the  incursu. 
me,  These  are  the  horns  which  have 


Foundation  of  St.  Bartholomew  s.  lill 

the  secunde  lighte  and  opyn,  the  thirdde  grevous  and  hydde, 
the  iiiith  grevous  and  opyn.  With  these  and  be  forseyd  maners 
as  be  his  feete,  this  singuler  ennemy  of  mankynde  compressith 
us  to  the  erthe  and  so  to  hym  he  throwythe  dowyn  men, 
and  them  so  prostrate  with  horrible  clays  of  malice  violently 
constrayneth.  And  furthermore,  men  adherent  wilfully  to 
hym,  he  drawith  from  vice  in  to  vice,  from  evillys  to  wors, 
compelleth  them  to  breke  owte  of  rewle  tyl  his  synnys  ben 
complete,  and  as  he  were  lyfte  up  yn  to  the  hye  towre  of  all 
wikkidnesse,  where  God  vengynge  they  falle  downe  in  to  the 
lowest  of  the  pytte,  that  ys,  into  the  moost  profunde  helle, 
ordeyned  for  wrecchis,  and  of  all  wrecchis  moost  wrecchidde. 

By  this  vision  I  trowe  be  signified  to  man,  that  he  shulde 
attende  and  considre,  the  manyfolde  snarys^*^  of  oure  sotelP^ 
enemy  prudently,  and  aware  them  holsumly,^^  leyste  that  by 
a  cruell  downecastynge  suppid  up  ^^  wrecchidly  he  shulde 
perysche.  But  sithen  it  is  not  yn  manys  wytte,  his  way, 
nothir  in  his  kunnynge  to  directe  his  jornay,  there  ys  addid  to 
hym  consolacion  of  hevynly  mercy,  and  nat  a  litill  but 
mochyll  occasion  to  optene  vertue.  And  by  that  moere 
spedily  to  deserve  godly  helpe,  by  the  whyche  besily  he  myght 
fulfille  the  comawndemente  of  the  apostle.  I  esteeme  hym 
a  wysman  that  canne  undirstande  by  theys  thynges  that  arne 
shewid  to  hym ;  and  not  i  hidde  from  hym,  but  schewed  yn 
dede  and  worde  what  ys  to  be  doyn. 


CAPITULUM  VII. 

HOWE    THE    KYNGES    FAVORE    Y    HADDE,    THE    PRECEPTE 
AND    HIS  VOWE  HE  FULFILLID. 

Therefore  i  passid  that  remaynyd  of  his  way,  he  came  to 
London,  and  of  his  knowleche^  and  frendes  with  gretejoye  was 
receyved,  with  whiche  also  w^ith  the  Barons  ^  of  London  he 
spake  famyliary  of  these  thynges,  that  were  turnyd  and  sterid  ^ 

2"  snarys,  snares.  ^^  suppid  up,  absortus. 

^^  sotell,  subtle.  ^  of  his  knowleche,  a  notis. 

2^  aware   them   holsumly,  salubriter  "  barons,  men,  citizens, 

caverunt.  *  sterid,  stirred. 


liv  Foundation  of  St.  BartJiolomews. 

in  his  hcrtc,  and  of  that  was  done  about  hym,  in  tlie  way 
he  tellid  it  owte.  And  what  schulde  ben  done  of  this,  he 
cowncellid.  Of  them  toke  he  this  answere,  that  noone  of 
these  myght  be  perfityd  ;  but  the  kynge  were  first  i  cowncelled. 
Namely  sith  the  place  godly  *  to  hym  y  schewid  was  conteyned 
withyn  the  kynges  market  of  the  whyche  it  was  not  levefuU 
to  prynces  or  other  lordys  of  there  propyr  auctoritate  eny 
thyng  to  mynuysse,^  nethyr  3itte  to  so  solempne  an  obseqiiy 
depute.  Therfore  usyng  thcys  mennys  cowncell  in  oportune 
tyme  he  dressed  hym  to  the  kynge,  and  before  hym  and  the 
Bisshoppe  Richarde^  beynge  presente,  the  whiche  he  hadde 
made  to  hym  favorable  byforne,  effectually  expressid  his 
besynes,  and  that  he  myght  levefully  brynge  his  purpose  to 
effectej  mekely  besought.  And  nyh  hym  was  he  in  whoes 
hande  it  was,  to  \\  hat  he  wolle,  the  kynges  hert  ynclyne,  and 
yneffectualle  these  prayers  myght  nat  be  whoes  auctor  ys  the 
apostle,  whois  gracvous  herer ''  was  God,  his  worde  therfore  was 
plesaunte  and  acceptable  in  the  kynges  yie.  And  whan  he 
hadde  peysyd^  the  goode  wille  of  the  man  prudently,  as  he  was 
wytty  graunted  to  the  peticioner  his  kyngly  favore,  benyngly 
vevynge  auctorite  to  execute  his  purpos.  And  he  havynge  the 
title  of  desired  possession  of  the  kynges  majeste  was  right  gladde. 
Than  nothynge  he  omyttynge  of  cure  and  diligence  ii  werkys 
of  pyte  began  to  make :  oone  for  the  vowe  that  he  hadde 
made,  an  othyr  as  to  hym  by  precepte  was  injoynyde.  Ther- 
fore as  the  case  prosperously  succedid,  and  aftvr  the  apostles 
word,  all  necessaryes  flowid  unto  the  hande.  The  chirche  he 
made  of  cumly  stoonewerke  tabylwyse,  and  was  an  hospitall 
howse  a  litill  Icnger  of,  from  the  chirche  by  hymself  he  began 
to  edifie. 

The  chirche  was  fowndid  as  we  have  take  of  oure  eld  res  ^  in 
the  moneth  of  Marche  in  the  name  of  oure  lorde  Ihu  Crist  in 
memorie  of  moost  blesside  Bartholomewe  apostle,  the  yere  from 
the  Incarnacion  of  the  same  lorde  oure  Savyoure,  M.C.xxiii. : 
thanne  haldyng,  and  rewlyng,  the   holy  see  of  Rome  mooste 

*  godly,  divinitus,  of  London  May  24,  i  loS  ;  died  Jan, 
^  mynuysse,  diminish,  16,  1 128. 

*  Richard  de  Bilmeis,  elected  Bishop       ^  kerer,  exauditor. 

'  t^y^y<i)  perpendens.      ®  eldres,  elders 


Foundation  of  St.  Barthohmews.  Iv 

holy  fadir  Pope  Calixte^"  the  secunde;  presidente  in  the  churche 
of  Inglond,  William/^  Archebisshoppe  of  Cawntirbury,  and 
Richarde,^^  Bysshoppe  of  London,  the  whiche  of  due  lawe  and 
right  halowid  that  place  yn  the  eiste  party  of  the  forsayde 
felde  and  bysshoply  auctoryte  dedicate  the  same,  that  tyme 
fulbreve  and  shorte^^  as  a  cymytory.  Regnyng  the  yonger  son 
of  William  Nothy,  first  kynge  of  Englischemen  yn  the  North 
Herry  the  firste^*  xxx'^-  yere,  and  a  sidehalfe  the  thirde  yere 
of  his  reigne  to  the  laude  and  glorie  of  the  hye  and  indyvyduall 
Trynyte  to  hym  blessynge  thank ynge  honoure  and  empyer 
worlde  with  owtyn  ende.     Amen. 


CAPITULUM  VIII. 

WHAT    WAS    YN    REVELACYON    SHEWYD    TO    KYNGE    EDWARDE 
OF    THIS    PLACE. 

Heir  we  may  nat  silence  kepe  but  evydently  expresse  that  by 
relacion  of  oure  senyoures  we  have  fownde  dyvynly  schewid, 
this  to  be  a  place  of  prayer,  longe  beforne  tyme,  to  the  glorious 
kynge  Edwarde  the  confessoure,  the  son  of  Etheldrede  the 
kynge,  brothir  of  Seynt  Edwarde  the  martir,  of  whom  many 
goode  thynges  they  seye  they  hadde  herde  in  ther  tymes  nowe 
to  be  declarid.  Thys  blessid  kyng,  whan  he  was  in  the  Chirche 
of  God,   replete  with  manyfolde  bewte  of  vertu,  as  the  boke 

^f'  Calixtus  II.,  elected  February   i,  Henry  I.  was  crowned  August  5,  iioo, 

1 1 19;  died  December  12,  1 124.  so  that  the  thirty-third  year  of  his  reign 

^1  William  de  Curbuil,  elected  arch-  was  from  August  5,  1132,  to  August  4, 

bishop  February  4,    1123;  died   Nov-  USS-     The   twenty-third   year   of    his 

ember  26,  11 36.  reign  extended  from  August  5,  1122,  to 

•^2  Richard  de  Belmeis,  elected  May  August   4,    1123.     The   dates    of    the 

24,  I108;  died  January  16,   1128,  but  ecclesiastics  named  are  :  Pope  Calixtus, 

he  was  disabled  from  public  affairs  by  1119-1124;  Archbishop  William,  1123- 

an  attack  of  hemiplegia  in  the  latter  1136;     Bishop     Richard,    1108-1128. 

half  of  1 123.  They  prove  that  the  xxx.  of  the  trans- 

'^  breve  tunc  admodium  cimiterium.  lation  and  of  the  Latin  are  errors  of 

■'^  The  Latin  MS.  reads  :   "  Regnante  transcription    for  xx.      An   important 

juniore   filio   willi   nothi    primi    regis  charter  was  granted  to  the  Priory  in 

anglorum   ,ex     aquilonaribus    henrico  1133,  and  with  this  in  his  mind  the 

primo  anno  xxx.  mo  et  circiter  tercium  scribe  might  the  more  easily  err.     The 

regni    ejus    ad    laudem    et    gloriam "  MS.  has  Herry. 

e 


Ivi  Foundation  of  St.  Bartholomew's. 

of  Gestys  declarith,  as  a  religious  and  full  of  the  spirite  of 
prophlcie  he  schoone  bright  beholdyng  thynges  ferof/  as  they 
were  presente^  and  thynges  to  cumme  as  they  were  nowe  ex- 
istente  with  the  yis  of  his  soule  by  the  Holy  Goste  for  he 
was  illumyned.  The  whiche  in  a  certayn  nyght  whan  he 
was  bodely  slepyng,  his  herte  to  God  wakyng,  he  was  warnyd 
of  thys  place  with  an  hevynly  dreme  made  to  hym  that  Gode 
this  place  hadde  chosyn  his  name  ther  yn  to  be  putte  and  sette : 
and  holy  and  worschipfull  it  schulde  be  schewyd  to  cristyn 
peple.  Wherupon  this  holy  kynge,  erly  arisyng,  come  to 
this  place  that  God  had  shewid  hym  and  to  them  that  abowte 
hym  stoid  expressid  the  vision,  that  nyght  made  to  hym,  seyde 
before  all  the  peple^  prophecied  this  place  to  be  gret  before 
God  whoes  cleyr  prophecyes  howh  they  be  supportyd  grettly 
with  the  myghte  of  treweth :  experience  hath  approvyd  yt, 
and  every  feithfulman  may  cleirly^beholde  the  same. 


CAPITULUM  IX. 

WHAT  III  MEN  OF  GREYCE  SEYED  BEFORNE  OF  THYS  PLACE. 

It  was  seyed  that  iii  men  of  greyke  y  sprongyn  of  noble  lynage 
goynge  owte  frome  ther  countre  and  kynrede,  takyng  on  them 
for  God  the  holy  laboure  of  pilgirmage,  and  whan  with 
devoute  soule  they  sowght  the  helpe  of  seyntes  in  many  places, 
from  the  grete  see,  they  hadde  enteryd  Inglande,  desiryng  to 
visite  the  bodies  of  seyntes  theyre  restynge,  and  by  ther  merytes 
in  the  laste  examinacion  to  be  succurrid  and  defendid  whan 
they  came  to  London,  they  wente  to  thys  place,  and  ther 
prostrate  honoured  and  worschippid  God,  and  aforn  them, 
that  ther  was  presente,  and  behelde  them,  as  symple  ydiottys,^ 
they  began  wondirfull  thynges  to  seye,  and  prophecye  of  this 
place  seyynge,  "Wondir  nat  36,  vs  here  to  worschipp  God, 
where  a  fulle  acceptable  temple  to  hym,  shall  be  bylid,  ffor  the 
high  maker  of  all  thyng  wyll  that  it  be  bylded  and  the  fame 
of  this  place  schall  attayn  from  the  spryng  of  the  sunne  to  the 
goynge  downe." 

^  f^"/)  ^^^  off'  *  tanquam  simplices  et  idiotas. 


Foundation  of  St.  Bartkolo7news.  Ivii 

CAPITULUM  X. 

OF  THE  CLENSYNGE  OF  THYS  PLACE. 

Truly  thys  place  afoni  his  clensynge  pretendid  noone  hope 
of  goodnesse,  right  uncleene  it  was,  and  as  a  maryce  dunge 
and  fenny  with  water  almost  everytyme  habowndynge.^  And 
that  that  was  emynente  a  hove  the  water  drye^  was  deputid 
and  ordeyned  to  the  Jubeit  or  galowys  of  thevys^  and  to  the 
tormente  of  othir  that  were  dampnyd  by  judicialle  auctoryte. 
Truly  whan  Rayer  hadde  applied  his  study  to  the  purgacion  of 
this  place^  and  decreid  to  put  his  hande  to  that  holy  bilyng, 
he  was  nat  ignoraunte  of  Sathanas  wyles,  for  he  made  and 
feyned  hym  self  unwyse,  for  he  was  so  coattid,  and  outward 
pretendid  the  cheyr^  of  an  ydiotte,  and  began  a  litill  while^  to 
hyde  the  secretnesse  of  his  soule,  and  the  moore  secretely  he 
wroght,  the  moore  wysely  he  dyd  his  werke.  Truly  yn  playnge 
wise,  and  maner  he  drewe  to  hym  the  felischip  of  children  and 
servantes,  assemblynge  hym  self  as  one  of  them,  and  with  ther 
use  and  helpe  stonys  and  othir  thynges  profitable  to  the 
bylynge,  lightly  he  gaderyd  to  gedyr,  he  played  with  them 
and  from  day  to  day  made  hym  self  moore  vile  in  his  own 
yen,  in  so  mykill  that  he  plesid  the  apostle  of  Cryiste, 
to  whome  he  hadde  provyd  hym  self.  Thorowgh  who  is 
grace  and  helpe  whan  all  thynge  was  redy  that  semyd  necessarie 
he  reysid  uppe  a  grete  frame.  And  nowe  he  was  provyd  nat 
unwyse,  as  he  was  trowid,  but  verry  wyse :  and  that,  that  was 
hydde  and  secrete  opynly  began  to  be  made  to  all  men.  Thus 
yn  merveles  wyse  he  comforttid  in  the  Holy  Gooste,  and 
instructe  with  cunnynge  of  trweth,  seide  the  worde  of  God 
feithfully  by  dy verse  chirches;  and  the  multitude  bothe  of 
clerkys  and  of  the  laife,^  constauntly  was  exhortid  to  folowe 
and  fulfyll  those  thynges  that  were  of  charite  and  almesdede. 
And  yn  this  wyse  he  cumpasid  his  sermon,  that  nowe  he  sterid 
his  audience  to  gladnesse  that  all  the  peple  applaudid  him, 
and  in  contynent  anoon  he  proferred  sadnesse  and  sorow  of 
ther  synnys,  that  all  the  peple  were  compellid  yn  to  syghyng 

^  habowndynge,  abounding.  ^  cheyr,  mien  {Skeat). 

^  of  the  laife,  laicorum. 


Iviii  Foundation  of  St.  Bartholomew's. 

and  wepyng,  but  he  trewly  yn  the  same  cheir  and  soule  ever- 
more perseveraunte  expressyd  holsumme  doctrine  and  aftir 
God,  and  feithfull  sermon  prechyd,  and  yn  his  techynge 
unreprevyd  was  fownde,  those  thynges  techynge  that  the  Holy 
Gost  by  the  apostles^  and  appostolyke  expositoures  have  yeve 
to  the  chirche  unmovcably  and  stedfastly  to  beholde  fForther- 
more  hys  lyfe  acorded  to  his  tonge  and  his  dede  approved  well 
hys  sermon,  and  so  yn  the  sacrifice  of  God  the  moueth  and  bylle 
of  the  turtyll  was  returnyd  to  his  armepittes,  and  recleyned 
unto  the  wyngvs  leisse  that  he  prechyng  to  othir  schulde  be 
fownde  reprovable  yn  hym  self.  Of  this  almen  grettly  were 
astonvd,*  boeth  of  the  novelte  of  the  areysid  frame,  and  of  the 
fownder  of  this  newe  werke.  Who  woldetrovve  this  place  with 
so  sodavn  a  clensyng  to  be  purgid,  and  ther  to  be  sette  up  the 
tokenvs  of  crosse:^  and  God  there  to  be  worshippid  where 
sumtvme  stoid  the  horrible  hangynge  of  thevys,  who  shulde 
nat  be  astonyid,  ther  to  se,  constructe  and  bylyd  thonorable 
byldynge  of  pite,  that  schulde  be  a  sekir  ^  seyntwary  to  them, 
that  fledde  ther  to,  wher  sumtyme  was  a  comyn  officyne  ^  of 
dampnyd  peple,  and  a  general,  ordeynyd  for  payn  of  wrecchys 
who  schulde  nat  mervel  ther  to  be  haunttid  the  mysterie  of 
Oure  Lordys  body  and  precious  blode,  where  was  sumtyme 
schewid  owte  the  blode  of  gentyly  and  hethyn  peple.  Whois 
hert  lightly  schulde  take  or  admytte  suche  a  man  nat  producte 
of  gentyl  bloode,  nat  gretly  yndewid  with  litterature  of 
mannvs,^  or  of  dyvyne  kunnynge,  so  worschipfull,  and  so  grete 
a  worke  prudently  to  begynne,  and  hyt  begunne  to  so  happy 
a  progresse,  fro  day  in  to  day  to  perfecte  and  partorme  ?  This 
ys  the  change  of  the  right  hande  of  God  :  O  Chryst  these  ben 
thy  workys,  that  of  thyn  excellent  vertu  and  synguler  pyte 
makyst  of  unclene,  clene  ;  and  chesist^  the  feble  of  the  worlde  to 
confownde  the  mvghty,  and  calHst  them  that  be  nat,  as  yt  were 
they  that  been  :  ^°  the  whiche  Golgotha  the  place  of  opyn 
abhominacion  madist  a  seyntwary  of  prayer,  and  a  solempne 
tokyn  or  sygne  of  devocion. 

*  asfonyd,  astonished.  ®  litterature  ofmatuiys,  humanarum 

s  tokenys  ofcrosse,  ciucis  insignia.  literarum. 

8  sekcr,  sure.  ®  chesist,  choo>est. 

''  offuyne,  officina.  ■"'  et  vocas  ea  que  non  sunt  tanquara 

ea  que  sunt. 


Foundation  of  St.  Bartholomews.  Itx 

CAPITULUM  XI. 

OF    THE    RIOTTYS    AND    ASSEMYLYNGES    OP    THE    ADVERSARIE 
PARTYS,    AND    OF    THE    PRYVYLEGYS    OF    THE    CHIRCHE. 

Thus  procedynge  the  tyme,  clerkis  to  leve  undir  reguler  ynsti- 
tucion,  ill  the  same  place  in  breif  tyme  were  vuyd  to  gidir : 
Rayer  optenynge  cure  and  office  of  the  priorhede,  and  myny- 
strynge  to  them  necessaries  nat  of  certeyn  rentys  but  plente- 
ously  of  oblacions  of  feithfull  peple;  and  nat  longe  aftyr  that 
drede  that  he  drade  come  to  hym,  and  that  he  dredyd  happid 
hym.  He  was  to  summe  the  odur  of  lyif  yn  to  lyif,  to  othir 
the  odur  of  deith  yn  to  deith.  Summe  seid  he  was  a  deseyver, 
for  cause  that  yn  the  nette  of  the  grete  fFyscher  evil  fischis  were 
medillid^  with  goode  aforne  the  houre  of  the  laste  dissever- 
awnce,  his  howseholde  peple  were  made  hys  enemyes,  and  so 
roys  a3enste  hym  wyckid  men,  and  wykydnes  lyid  to  hym  self.^ 
Therfore  with  prikkyng  envye  many  privatlv,  many  also  opynly, 
ajenste  the  servant  of  God  cesid  nat  to  gruge,  and  in  derogacion 
to  the  place  and  prelate  of  the  same  browghtyn  many  sclawnders 
with  thretnynges,  the  goodes  that  they  myght  they  withdrewe 
and  toke  a  wey  :  constreyned  hym  with  wykkidnes,  made  wery  ^ 
hym  with  injuries,  provoked  hym  with  despitis^  bygilid  hym 
with  symulate  frendschippis ;  and  summe  of  them  brake  owte 
in  to  so  bolde  a  wodnesse/  that  they  drewe  among  them  self 
a  contracte  of  wikkid  consperacion,  what  day  i  sette  and 
place  the  servant  of  God  they  myght  thorowgh  wylys  and 
sutilte  draw  to  ther  cowncell  wyth  a  deceyte,  and  hym  so  ther 
present  to  plukke  from  the  stappis^  of  his  lyif;  and  so  his 
remembraunce  they  wolde  had  doyn  awey  from  this  worlde. 
But  ther  is  no  wysdom,  ther  is  no  kunnyng,  ther  is  no  cowncell, 
a3enste  God,  in  whom  he  cast  his  thowght,  and  with  the 
apostle  put  his  strengith.  He  therfore  that  was  his  hoope  was 
his  myght,  and  for  hym  he  discunfyit  his  ennemyes,  therfore 
whan  the  day  abydde  comme,  whiche  was  deputed  to  the  inno- 
centis  deith,  oone  of  them  partner  of  so  grete  a  wykkidnesse, 
secrete  to  hym  self  abhorryng  so  grete  a  synne,  aforyn  the  houre 

^  medillid,  admixti.  ^  wery,  weary. 

2  et  insurrexerunt  contra  eutn  viri  iniqui        *  luodnesse,  madness, 
sed  mentita  est  iniquitas  sibi.  ^  stappis,  steps  {vestigia). 


Ix  Foundation  of  St.  Bartholomew  s. 

of  this  perell  drawyng  neir,  shewide  by  ordir  to  the  servante 
of  God,  the  summe  of  al  ther  cownccll.  He  for  this,  to  God  and 
to  his  patrone  3af  thankys,  that  the  secretes  of  his  ennemyes 
were  nat  hydde  fram  hym,  and  that  by  the  benefete,  of  Oure 
Lordes  pyte,  he  hath  skapid  the  deith  to  hym  arayed^  for  thys 
and  lyke  causys  apperynge.  A5en  he  wente  to  the  kyng  with  a 
lamentable  querell,-  expressvnge  howe  with  untrew  despitys,  he 
was  deformyd,  and  whate  fastidious  owtbrekynges  hadde  temptid 
hym,  besekyng  his  royall  munyficence,  that  his  persone  and 
the  place  that  he  hadde  grauntid  hym,  he  wolde  defende.  Also 
yn  his  suggestion  to  the  kynge,  he  made  this  reson  :  he  bidith 
no  rewarde  of  God,  that  hath  begunne  a  goode  werke,  and  so 
bygunne,  with  a  dew  ende  hath  nat  fynyshid  the  same,  wher- 
fore  for  the  ynward  bowelles  of  the  mercy  of  Cryst,  that  he 
trustid  yn,  for  the  dignvte  that  he  schoone  with,  and  for  the 
power  of  his  emynence,  he  wolde  opyn  the  bosumme  of  his  pite 
to  them  that  were  desolate  and  honoure  God  yn  his  servantes, 
and  restreyn  the  berkyng  wodnesse^  of  unfeithfull  peple,  so  that 
to  the  goode  bygynnynges  he  now  joynyng  bettir  yssuys,^  and 
largeor  exsecucions,  myghte  byle  to  hym  self  eternal  howse  yn 
hevyn  whyle  that  he  worschippith  and  defendith  the  howse 
of  God,  yn  erthe.  Thus  the  kynge  mervellyng  the  prudence  and 
constaunce  of  this  man,  answerd,  that  he  wolde  applie  hym  to 
his  just  and  nessessarie  peticions,  and  that  fFurthermore  he 
behestid  hym  self  to  be  a  tutur  ^  and  defensur  of  hym  and  of 
hys,  therfore  he  made  this  chirche  with  all  his  pertynences  with 
the  sam  fredommys  that  his  crowne  ys  liberttid  with,^  or  ony 
othir  chirch  yn  all  Inglonde,  that  is  most  y  freid  and  relesid  hit 
all  customys  and  decreid  for  to  be  free  from  all  erthly  servyce, 
power,  and  subjecion,  and  3ave  sharpe  sentence  a3enste  contrary 
malyngnorsj  This  and  many  othir  insignys  that  ys  to  sey 
dignyteys  of  liberte,  he  grauntid  to  the  prior  and  to  them 
undirneith  hym  servynge,  and  to  the  forsayd  chirche,  and  with 
his  chartur   and    seel  confirmyd^    hyt,  adjurynge    also  all  his 

'  to  hym  arayd,  sibi  paratam.  extant.    It  was,  however,  produced  in  a 

2  querell,  complaint.  court  of  law  by  the  prior  and  convent 

'  berkyng   'tuodtiesse,    latrantem     in-  in  the  reign  of  Henry  VI.,  and  there  is 

*  yssuysy  issues.  [saniam.  in  the  Hospital  a  copy  made  in  the  same 

'  tulur,  tntoT.  •  A.D.  1 133.  reign.     Another  copy,  not  I  think  the 

'  maly7ignors,  malignantes.  original  enrolment,  was  preserved  in  the 

'  The  original  of  this  charter  is  not  Tower,  and  is  now  in  the  Record  Office. 


Foundation  of  St.  Bartholomew's.  Ixi 

heyris  and  successoures  yn  name  of  the  Holy  Trinite,  that  this 
place  with  royall  auctorite,  they  upholde  and  defende  and  the 
libertees  of  hym  i  grauntid  they  schulde  graunte  and  conferme. 
With  suche  privelegge,  thus  whan  he  was  streyngethyd  and 
confortably  defendyd^  glad  he  went  owte  from  the  face  of  the 
kynge.  And  whan  he  was  cummyn  home  to  his,  what  he  had 
obteynyd  of  the  royall  maieste  expressid  to  othir,  that  they 
schulde  joy  with  hym,  and  to  othir  that  ther  schulde  be 
affrayed.  Also  this  worschipfull  man  proposid  for  to  depose 
the  quarell  of  his  calamyteys  afore  the  see  of  Rome/  Goddis 
grace  hym  helpynge,  and  of  the  same  see  writynges  to  brynge 
to  hym,  and  to  his  aftyr  cummers  profitable;  but  dyverse  undir- 
growynge  impedymentys,  and  at  the  last  lettyng  the  article 
of  deith,  that  he  wold  had  fulfillid,  he  myght  nat :  and  so  only 
the  reward  of  good  wylle  he  deservyd.  Aftir  his  decese  iii  men 
of  the  same  congregacion  whoys  memory  be  blessid  in  blisse, 
sondirly^  wente  to  sondirly^  byschoppis^  of  the  see  of  Rome, 
And  three  privlegies  of  three  bysshoppys  *  obteynyd,  that  is  to 
seye  of  seyntes^  Anastace,  Adrian,  and  Alexander,  this  chirche 
with  three  doweryes,  as  it  were  with  an  unpenytrable  scochyn^ 
wardid  and  defendyd  a3enst  ympetuous  hostylyte.  Now  be- 
holde  that  prophesye  of  the  blessid  kynge  and  confessoure 
seynt  Edward  that  beforn  tyme  hadde  profysyed  and  seyn  by 
revelacion  of  this  place,  of  grete  party  is  seyn  and  fufillid. 
Beholde  trewly  that  this  holy  chirche  and  chosyn  to  God, 
schyneth  with  manyfolde  bewte,  ffowndyd  and  endewid  with 
hevenly  answer,  i  sublymate  with  many  privylegies  of  notable 
men,  and  to  a  summe  of  laude  and  glorie  rychessid  with  many 
relikys  of  seyntes,  and  bewtyfied  with  hawntid  "^  and  usuall 
tokenys  of  celestiall  vertu.  This  nat  unprofitably  byfore  tastid, 
lette  us  draw  nere  to  the  narracion  of  myracles. 

^  From  this  it  seems  probable  that  the  Alexander  III.  reigned  September  7, 

newly-introduced    Augustinian  canons  1 159- August  30,  1181. 

had  their  difficulties  with  the  secular  ®  scochyn,  shield. 

clergy.  The  king  had  settled  all  the  civil  ^  hawntidy     frequentissimis.        The 

difficulties,  the  ecclesiastical  remained,  words  of  the  charter  here  referred  to 

2  sondirly  sondirly , 'sm^xiX\  singulos.  are  "hanc  autem  ecclesiam  cum  omni- 

^  byschoppis,  presules.  bus  que  ad  eam  pertinent  sciatis  me 

*  bysshoppys,  pontificum.  velle  manutenere  et  defendere  et  liberam 

^  Anastasius    IV.    reigned    July    9,  esse  sicut  coronam  meam  et  accepisse 

1 1  S3 -December  2,  11 54.     '  in  manu  mea  et  in  defensione  contra 

Adrian   IV.    reigned    December   3,  omues  homines." 
1154-August  30,  1 1 59. 


Ixii  F oujidation  of  St.  Bartholomew  s. 


CAPITULUM  XII. 

OF    LIGHT    HEVENLY    SENT    OWTE. 

Whan  therfore  in  the  forsaid  place,  at  the  bygynnyng  was  made 
an  oratorye  in  honoure  of  the  blessid  apostle,  many  and  innu- 
merable were  schewid  tokynnys  of  myracles,  but  what  for  the 
grete  plenty  of  them,  and  necligence  of  writyng  of  the  same, 
they  be  almoyste  unremembred,  wherfore  of  these  a  fewe,  spe- 
cially of  these  that  lattir  dayes  were  knowe  to  us  more  by 
sight,  than  by  heryng,  as  they  cam  to  oure  mynde,  feithfully 
we  shall  tell.  In  the  begynnynge  of  this  areysed  frame  oure 
senyores  tellid  us,  that  on  a  day  at  evensong  tyme,  whan 
derkenys  drew  upon,  ther  was  seyn  a  light  from  hevyn  sent 
schynynge  on  this  chirche,  abidynge  there  uppon  the  space 
of  an  howre,  that  they  sawe  them  self,  and  many  othir  men 
also,  the  whiche  lyght  aftir  returnyd  up  an  hye,  and  to  no  man 
aftirwarde  aperid,  and  that  yn  a  moment  was  take  a  wey  from 
the  yis  of  the  beholders.  Howe  grete  a  tokyn  this  was  of  pite 
and  grace  hevynly,  opynly  aftirward  was  schewid,  by  multitude 
of  toknys  yn  the  same  place. 


CAPITULUM  XIII. 

OF    WOLMER    CONTRACT    AND    THERE    I    CURID. 

There  was  an  sykeman  Wolmer  be  name  with  grevous  and 
longe  langoure  depressid,  and  wrecchid  to  almen  that  hym 
behylde  apperyd,  his  feit  destitute  of  naturall  myght  hyng  down 
hys  legges  clevyd  to  his  thyis,  part  of  his  fyngerys  returnyd 
to  the  hande,  restynge  alwey  uppon  two  lytyll  stolys,i  the 
quantite^  of  his  body,  to  hym  onerous,  he  drew  aftir  hym,  and 
to  the  encrese  of  his  wrecchidnesse  was  addyd  grete  poverte, 
yn  more  affliccion  to  hym  than  his  langoure  :  sith  to  a  man  that 
nethir  myght  labur,  ne  goo,  were  withdrawe  necessaries  of  his 

^  slolys,  stools.  ^  quautite,  molem. 


Foundation  of  St.  Bartholomew's.  Ixili 

lyvelode,  this  wrecchidnes  was  so  mykill  to  hym  the  more 
grevous,  that  it  was  longe  abidynge,  trewly  almost  xxx  wynteres 
with  this  so  grete  a  sykenes  was  he  deteynyd  :  and  he  thus 
othir^  with  crepynge,  othir^  with  the  helpe  of  othir^  i  born  sate 
at  London  yn  the  Chirche  of  PouHs,^  askynge  almes  of  them 
that  enterid  yn.  This  i  don  nowe  come  the  tyme  acceptable,  the 
yere  of  benygnyte,  in  the  whiche  Rayer  hadde  sette  the  fown- 
dementys  of  his  holy  temple,  and  the  fame  of  the  newe  werke, 
as  it  were  a  full  swete  odur  dyfFusyd  by  the  mowthis  of  all  the 
peple,  it  myght  nat  be  hydde  from  hym,  the  whiche  by  the  mercy 
of  Oure  Lorde  conceyvyd  a  swete  desire  and  feithfull,  that  he 
myght  be  borne  to  that  place,  ther  to  beeseke  God  of  his  helpe. 
And  he  of  his  frendes  thiddir  thus  borne  yn  a  basket  felle 
down  a  forne  the  awter,*  porrectynge  his  meke  prayers  to 
hevyn,  and  to  the  hye  and  glorious  meritys  of  the  blessid 
apostle,  alleggyng  them  to  the  hye  and  dredfull  juge,  that  by 
them  he  myght  obteyne  forgevenesse  of  synne  and  his  bodyly 
helth.  And  with  owte  tariynge,  that  welle  of  pyte,  that  was  and 
is  opyn  to  the  menstruat  woman  and  synful  man,  was  present 
at  his  callyng,  and  a  streem  and  ryver  of  helth  and  grace  of 
hym  self  made  welowte  :  and  by  and  by  every  crokidnes  of 
his  body  a  litill  and  litill  losid,^  he  strecchid  un  to  grownde  his 
membris  and  so  anoon  avawntynge  hym  self  up  warde,  all  his 
membris  yn  naturale  ordir  was  disposid.  As  it  were  a  newe 
man  he  was  seyn  to  procede  forth,  than^  howe  grete  a  crye  of 
them,  that  were  present  was  lyfte  up  to  hevyn  :  what  terys 
i  schede  owte  for  joye :  what  praysyng  to  God,  uppon  soe 
mervelous  and  wondrefull  myracle  were  yeve  and  payed  to 
God,  yt  may  bettyr  be  conceyved,  with  a  devoute  soule,  than 
expressid  by  worde.  This  dede  anoon  was  dyvulgate  by  all  the 
cyte,  and  with  a  grete  fame  gretely  accendid  the  peple  of 
boith  ordres,  the  clergie  and  the  laife.  And  from  that  tyme, 
the  noble  matrones  of  the  cite  kepte  ther  nyght  wacchis,  the 
clergie  and  laife  by  companyes  fyllyn  with  grete  devocyon  of 
soule,  and  herte  gladdenes,''  hawntyng  this  place  and  with  ofte 
visitacon  solempne  laude  yeldid  to  God,  with  the  fowndatore. 

^  othir-othir,  vel-vel.  ^  awfer,  altar. 

^  Cf.  otkir,  aliorum.  ^  losid,  dissoluta. 

^  Chirche  of  Foulis,  in  ecdesia  lun-  ®  than,  then. 

doniensi  beati  pauli  apostoli,  St,  Paul's  ''  herte  gladdenes,  cordis  allacritate. 
Cathedral. 


Ixiv  Fowidatioii  of  St.  Bartholovieiv^s. 

CAPITULUM    XIV. 

OF   THE    ANTHYPHONER. 

A  certeyn  man  toke  a  way  a  boke  from  this  place,  that  we 
calUth  an  antiphonere,  the  whiche  was  necessarie  to  them  that 
schulde  synge  ynne  the  chirche,  in  that  specialy  that  ther 
was  nat  at  that  tyme  grete  plente  of  bokys,  in  the  place.  Whan 
it  was  sowghte  besily  and  not  i  fownde,  it  was  tellid  to 
Rayer  the  priour  what  was  done  of  thee  boke  and  he  toke 
this  harme  with  a  softe  herte^  paciently.  At  nyghtys  tyme, 
whan  as  he  was  ynne  his  chambre  to  take  his  reste  the  glorious 
apostle  of  God,  Bartholomew  spake  to  hym  and  seyid,  "sey 
Rayer,  what  is  that,  of  whoeys  loste,-  me  presente,  thus  ye 
playne."  And  he  seied  "syr  thy  clerkis  hadde  a  profitable  boke 
to  them,  in  the  whiche  to  the  honoure  of  God  and  of  the,^  in 
the  holy  temple  of  thy  glorie  they  were  wownte  to  synge;  and 
now  yf  it  be  hidde  yn  ony  place,  or  stolyn  a  way,  they  know 
nat."  "In*  the  mornnynge  eerly  commaunde  thyn  hors  to  be 
redy,  and  hastly  entre  the  cite  and  whan  thou  cummyste  yn  to 
the  Jewes  strete,^  spare  thy  sporys,^  lose  thy  brydyll  lette  thyn 
hors  to  my  governaunce,  and  yn  to  what  howse  thy  hors  wilfully 
putte  yn  his  fote,  know  welle  of  me,  ther  thy  boke  schall  be 
fownde.  Dowte  no  thyng,  prudently  and  constawntly  inquyre." 
No  more  this  i  seid  yn  a  moment  he  disparisshid.  Rayer  yn 
the  mornynge  slyd  owte  of  his  bedde,  and  diligently  all  that 
was  commaunde  hym  he  executid,  and  with  the  enemyes  of 
pees  he  spake  pesibly ;  and  the  boke  that  he  sowghte  he  fownde, 
and  toke  hit  and  broo;ht  hit  hoome. 


CAPITULUM  XV. 

OF    A    WOMAN    1    HELYD. 

The  tonge  of  a  woman  so  gretly  was  swolle  that  she  myght 
nat  shete  here  moweth ;  and  so,  opynly  grevvyng  that  sche 
myght  nat  hidde  the   swellynge  thys  woman  of  her  freendes 

^  softe  herte,  placida  mente.  *  In  the  Latin  the  apostle's  second 

2  ivhoeys  loste,  cujus  amissione.  remark  is  indicated  by  inquit. 

3  the,  thee.  »  Old  Jewry.  «  sp7ys,  spurs. 


Foundation  of  St.  Bartholomew's.  Ixv 

was  broght  to  this  chirch  and  ofFerid  to  Raver  the  pryor, 
whiche  havynge  compassion  of  her,  as  he  was  a  man  of  mercy 
and  grete  benygnyte,  ofTeryd  to  God  and  to  his  patron  prayer 
for  her.  And  he  revolvynge  his  relikys  that  he  hadde  of  the 
Crosse,  he  depid  ^  them  yn  water  and  wysshe  the  tonge  of  the 
pacient  ther  with,  and  with  the  tree  of  lyif,  that  ys  with  the 
same  signe  of  the  crosse  paynted  the  tokyn  of  the  crosse  upon 
the  same  tonge.  And  yn  the  same  howre  all  the  swellynge 
wente  his  way,  and  the  woman  gladde  and  hole  went  home  to 
here  owne. 


CAPITULUM    XVI. 

OF    A    RICHE    MAN. 

Hit  ys  tolde  of  a  richeman  uplond  dwellyng,  that  come  to 
this  chirche,  and  he  so  delitid  with  the  gladnes  of  this  place, 
and  with  the  servyce  of  God  ther  contynualy  and  devoutly  y 
doyn,  he  seid  to  the  priour  '^  syr  many  goodnes  of  this  vertuoiis 
place  by  opyn  fame  I  have  knowe,  and  moo  with  myn  yene 
I  have  seyn,  wherfore  T  purpose  in  my  soule  from  this  day 
forwarde  I  shall  coramytte  me  and  all  myn  to  seynt  Bar- 
thilmewe  advocatte  of  this  place,  and  to  his  servyce  I  shall  me 
subdew,  everywher  calle  hym  and  preche  hym  my  lorde,  and 
with  my  substawnce  as  he  wolle  inspire  me,  his  clerkys  honoure. 
Then  seiede  Rayer;  "Wele  thou  hast  purposid,  and  dowtles 
a  wyse  keper  of  thy  goodes  thou  hast  chosyn,  whom  yf  thou 
serve  as  thou  with  feithfull  mynde  hast  promysid,  without 
dowte  by  him  thou  shalt  optene  the  blysse  of  God."  After  these 
wordes  the  man  went  his  way.  A  wondyr  thyng  and  a  worthy 
to  be  remembrid :  nat  longe  aftir  it  happid  hym  sittynge  at 
his  table,  oone  of  his  servantes  tolde  hym  that  his  kechyn  ^ 
was  a  fyre  sodenly,  and  likly  to  perish  with  woodenes  of  fyre,^ 
he  was  prayd  therfore  hastly  to  come,  and  delay  nat  helpe 
to  brynge  to  the  howse  nowe  peryshynge  and  nowe  fallynge. 
And  to  the  serventes  so  yn  soule  he  stunyid  *  and  with  grete 

^  depid,  dipped.  ^  woodenes  of  fyre,  furente  incendio. 

*  kechyn,  kitchen.  *  stunyid,  consternatus. 


Ixvi  Foiuidation  of  St.  Bartholoinew  s. 

feer  affrayed,  the  same  howscholde  fadir^  answerde;  *' Have 
nat  I  late  me  and  myne  commyttid  to  blessid  Barthilmew 
the  apostle,  and  him  I  have  made  and  deputid  keper  of  my 
hede-  and  of  all  thyng  that  perteyneth  to  me.  Yf  therfore  it 
plesith  hym  his  to  kepe  to  hym  self,  he  shall  nat  nede 
oure  helpe,  but  also  all  hole  and  saf,  not  niynnschyd  to  the 
solace  of  his  servantes  yf  he  be  wyllyng  hys  myght  I  know 
wel  ys  sufficient :  forsouth  yf  it  be  the  respecte  of  the  ire  of 
God  from  above,  that  sendith  to  us  worthy  paynys  for  oure 
demerites,  what  or  how  moche,  yn  withstandynge  may  oure 
besy  purpos  prevayle,  as  who  seyth  lityll.  Suffir  therfore 
noon  of  us  put  to  his  hande,  lette  us  abyde  yn  sylence,  and  yn 
hope  the  sanacyon  of  God  and^  the  myght  of  oure  tutoure."  And 
yete  as  the  word  was  yn  the  moweth  of  the  speker,  and  at  the 
nomynacion  of  the  glorious  apostle,  the  same  fyre  semyd  to 
suffre  violence,  for  the  fflamys  naturaly  ascendyng  upward, 
defavvtid  of  ther  power,  and  undir  certyn  lymytys  were  re- 
streynyd.  And  whan  this  was  broght  to  the  howsholdfadir, 
beholde  what  he  seid,  "  Howh  mykil  avayleth  the  feith,  and 
howh  emynently  apperith  the  vertu  of  the  apostle,  whan 
schulde  the  unpetuous  flame  yeve  way  to  oure  myghtis  the 
whiche  yn  a  momente  by  the  apostle  of  God  ys  qwenchid, 
thankys  of  us  therfore  be  to  hym,  that  as  nowe  and  also  frohens 
forwarde  wolde  wouchesafe  thus  to  kepe  us. 


CAPITULUM  XVII. 

OF    THE    SHIPPEMEN    YN    PERYLL. 

Certeyn  men  of  the  kyngis  cyte  of  London  went  owte  to  fer 
cowntrees,'^  and  certeyn  tyme  made  them  redy  to  come 
home  agayn  with  all  thers.  And  whan  they  trustid  them  to 
the  wavvys  of  the  see,  than  blowynge  of  the  syde  the  westryii 
wynde  y  callid  jephirus,  with  a  swifte  curse  ^  they  tendid  to 
the  desirid  havyn,  and  they  behelde  aferre,  as  it  were  the  space 
of  II  furlonges,  the  high  scharpe  hedis  ^  owte  warde  aperynge  of 
rochis  of  stoyn  by  the  whiche  they  most''  nedysly  passe,  yf  it 

^  howseholde  fadir,  paterfamilias.  *  cowntrees,  countries. 

"  hede,  head,  ^  curse,  course, 

^  In  the  MS,  ad,  but  in  the  Latin  et :  *  scharpe  hedis,  cliffs. 

a  stroke  representing  n  was  omitted  by  ''  mosl,  must. 

the  scribe  over  the  a. 


Foundation  of  St.  Bartholomew  s,  Ixvli 

plesid  them  to  go  further  by  that  wey.  And  the  malster  of  the 
schippe  seynge  beforne  grete  perell  to  hym  cummynge^  yn  that 
the  schippe  with  the  rochis  schulde  be  gobettemele  be  mynusid 
and  brokyn,  her  merchauntdise  schulde  peryssh,  with  the  men, 
and  noon  hope  ther  was  of  scapynge.  Nevertheles  he  exhortid 
them  to  truste  yn  the  pyte  of  Oure  Lorde,  and  mekely  to 
porrecte^  to  hym  ther  prayers,  to  whom  nothynge  ys  unpos- 
sible,  no  thynge  to  harde.  And  to  this,  seide  the  Londoners, 
"What  seide  they  drede  we,  men  of  letill  feith,  the  which  have 
blessid  Barthilmewe,  the  doer  of  so  grete  merveles  at  London, 
And  we  have  hym  at  home  anyhe  by  us  glorified,  therfore  lette 
us  prostrate  oure  self  yn  prayer  to  hym,  and  to  hym  with  all 
confidence  offir  oure  avowys,  and  he  that  so  grete  and  so 
shynyge  bencfetys.  sheweth  to  strangers,  he  schall  nat  hyde  the 
bowelles  of  his  mercy  to  his  concytyseyns."  ^  And  whan  so 
prostrate  they  hadde  so  prayed  to  gedir  they  areysed  up  from 
ther  prayer  and  lokid  abowte  them,  this  way  and  that  way. 
Ther  they  sey  them  self  by  grete  space  y  put  of  wher  before 
ther  prayer  they  semyd  that  they  drewe  full  nye  the  peryl, 
therfore  they  were  gladde  and  a  noon  as  they  came  to  lande, 
they  dressid  ^  them  to  the  chirche  of  the  gloriouse  apostle, 
and  II  tapers  of  grete  quantyte  offerid  for  ther  vowe. 


CAPITULUM  XVIIL 

OF    AN    YONGE    GROWYNGE    MAN. 

Ther  was  a  yonge  man  Osberne  by  name  whoes  right  hande 
clevyd  to  his  lyfte  schuldyr,  his  hede  compressid  down  to  the 
hande  laye  unmevable,  and  nethir  the  hande  from  the 
shuldyr,  ne  the  hede  from  the  hande  myghte  be  departed,  this 
man  cummynge  a  forne  the  auter  of  the  blessid  apostle  Bar- 
tholomewe  with  sighynge  terys  his  mercy  mekely  besought. 
And  he  deservyd  graciousy  to  be  herde.  And  therfore  whan 
the  fredome  of  his  lymys  were  y  hadde,  God  that  is  mervelous 
in  his  seyntes,  he  with  alle  them  that  wer  present,  with  worthy 
preysyng  magnyfied. 

^  porrede,  porrigere.  ^  they  dressid,  contulerunt. 

^  concytyseyns,  concivibus.  .     .  . 


Ixviii  Foundation  of  St.  Bartholomew  s. 


CAPITULUM  XIX. 

OF    A    WOMMAN    CONTRACTE.^ 

A  certeyn  woman  in  seynte  Jonys^  parissh  at  London  with 
longe  sykenes  febelid  contynuelly  kepte  her  bedde  and^  helth 
dispeyrid,  she  abided  only  the  last  houre  of  thys  lyfe^  whan  she 
herde  of  her  neyghbores  how  many  and  howe  grete  thynges  by 
the  virtu  of  God  were  don  yn  the  chirche  of  the  holy  apostle, 
by  the  virtu  in  her  conceyvyd  of  unskunfitid^  feith  with  goode 
hope  she  askid  herself  thider  to  be  borne.  And  thidir  whan 
she  was  i  browght,  that  she  hadde  herde,  by  experience  she 
provid,  felynge  the  profit  and  consecutyng  the  effecte,  of  her 
peticion,  grauntyng  that,  Oure  Lorde  Ihu  Cryste  the  auctore 
of  oure  feith  which  helith  contrite  in  herte  and  byndith  up 
the  contriciones  of  them. 


CAPITULUM  XX. 

OF    A    CHILDE    BLYNDE    FROM    HIS    BIRTH. 

A  childe  blynde  from  his  birth^  oon  ledynge  hym,  fadyr  and 
modyr  folowyng,  was  browght  to  the  solempnyte  of  the  glorious 
apostle,  and  as  he  enteryd  the  chirche  he  fill  down  to  the 
erthe  and  ther  a  whyle  turnyd  hymself,  now  this  way,  nowe 
that  way :  and  with  tariyng  restid  undir  the  hande  of  the 
hevenly  leche*  that  lightyth  every  man  cummynge  in  to  this 
worlde,  in  whoes  light  all  we  see  light.  And  a  noon  the 
inward  born  blyndenesse  fledde  a  way,  and  the  blode  from 
the  yen  by  the  chekis  down  rennynge,  light  and  sight  to  the 
syke  was  restoryde,  nat  that  he  hadde  beforn,  but  than  first 
it  was  yeve  to  the  childe.  And  than  he  knew  his  parentys 
with  opyn  yen,  that  never  he  sawe  beforne,  and  sundry  thynges 
by  ther  propyr  namys  distynctly  he  callide. 

^  contrade,  crippled,     cf.  Porta  Con-  as  St.  Agnes  and   St.  Anne  with  St. 

tractorum,  Cripplegate,  John  Zachary. 

^  The  nearest  ancient  parish  of  St.  ^  unskimfitid,  invicte. 

John  is  that  in  Aldersgate,  now  united  *  leche,  physician. 


Fou7idation  of  St.  Bartholomews.  Ixix 

CAPITULUM  XXI. 

OF   WYMUNDE    THAT    WAS    DUM. 

A  yonge  man  Wymund  by  name  yn  the  courte'of  Eustase 
De  Brooke,  nat  a  litill  while  y  nurysshed.  Dumme  he  was, 
know  to  all  men  that  hadde  knowleche  of  hym,  this  man 
berynge  hevyly  the  detrimente  of  his  tonge,  presumyng  of 
mercy  of  God  and  on  the  meritys  of  the  apostle,  he  drewe 
hym  to  his  chirche  and  ther  contynually  kepte  devoute  wacche 
And  feithfully  that  he  askid  he  deservyd  to  obteyne,  upon  a 
day  aftir  cumplyn^  the  bonde  of  his  tonge  was  losyd  and  with 
a  grete  voice  he  praysid  the  virtu  of  the  apostle  thankynge 
and  blessynge  the  myght  and  the  wysdome  of  God,  the  whiche 
openyth  the  dumme  moweth,  and  the  tongis  of  infantis  maketh 
opyn  and  diserte. 


CAPITULUM  XXII. 

OF    GODRYKE    THE    BOCHER. 

Whan  trewly  the  plantacion  that  the  hye  faydr  hadde  plantyd, 
that  is  to  seye,  the  forseid  chirche,  whan  it  a  roose  hyer  and 
the  fame  of  the  apostolike  vertu  everywhere  to  neyghbores 
perfitly  sownyd,  and  was  knowen;  Rayer  joynyd  to  hym  a 
certeyn  olde  man  Alfun  byname,  to  whome  was  sadde  age 
and  sadnes  of  age  with  experience  of  longe  tyme.  This  same 
olde  man  not  longe  beforne  hadde  bilid  the  chirche  of  seynt 
Gylys  at  the  gate  of  the  citye,  that  ynne  englissh  tonge  is 
callid  Cripilgate.  And  that  goode  worke  happely  he  hadde 
endyd.  Demynge  Rayer  this  man  profitable  to  hym,  he  deputyd 
him  as  his  compayr;  and  with  his  counsell  and  helpe,  that  was 
for  to  be  don,  disposid  and  parformyd.  It  was  manner  and 
custome  to  this  Alfunne,  with  mynystris  of  the  chirche,  to 
cumpasse  and  go  abowte  the  nye  placys  of  the  chirche  besily 
to  seke  and  provyde  necessaries  to  the  nede  of  the  poer  men, 
that  lay  in  the  hospitall,  and  to  them  that  were  hyryd  to  the 

^  cumplyn,  compline.j 


Ixx  Foiuidation  of  St.  Bai'tholomew  s. 

iTiakynge  up  of  ther  chirche;  and  that,  that  was  commyttid  to 
hym,  trewlv  to  brvnge  home  and  to  sundry  men  as  it  was 
nede  for  to  devvde.  And  ther  was  a  certeya  bocheyr  Goderyke 
byname  a  man  of  grete  sharpnesse,  more  than  semyd  hym,  he 
was  a  streyt  man,  the  whiche  nat  oonly  to  the  asker  wolde  nat 
veve,  but  was  woonte  with  scorn yng  wordes  to  ynsawt  them. 
It  ill  upon  a  dav  that  while  this  forsaid  Alfunyne  wente  abowte 
the  bochers,  man  bv  man,  and  aftir  othur  whan  he  cam  to 
this  Godrvke  and  mevid  hym  aftir  the  apostle  with  goode  and 
honeste  wordes  oportunely  and  importunely  by  cause  he  was 
nat  willvnge  to  yeve,  he  perseveryd  stedfastly  and  he  wolde 
not  go  from  hvm  vovde,  and  whan  the  olde  man  beheld  that, 
nat  for  drede,  nether  for  love  of  God,  ne  also  for  mannys 
shame  he  mvirht  not  tempyr  the  hardnes  of  that  yndurat 
herte,  from  his  rvgoure  he  brake  owte  yn  these  wordes,  '*  O 
thou  unhappy,  O  thou  ungentle  and  unkynde  man,  to  the 
vever  of  all  goodys,  that  for  the  geifte  of  hevenly  goodnes 
will  nat  comvn  with  the  poremen  of  Cryist,  I  beseche  the 
wrecche,  put  a  way  a  litill  and  swage  the  hardnes  of  that 
unfeithfull  soule,  and  take  in  experience  the  vertu  of  the 
glorious  apostle,  vn  whom  yf  thou  truste,  I  promytte  the  that 
every  piece  of  thy,  that  thou  yevest  me  aporcion  of,  shall  the 
sonner  be  solde  to  othir,  and  no  thynge  to  the  mynyssynge  or 
lessynge  of  the  pryce,  and  what  more."  He  was  mevyd  nat  wdth 
the  vnstvncte  or  ynward  sterynge  of  charite  but  overcummyn 
with  importunyte  of  asker,  he  drewe  owte  a  peis  of  vilest  and 
castyd  vt  yn  to  his  vessell  call)Tige  them  trewantes,  and  bade 
them  lightlv  go  from  hvm;  to  whom  Alfunyne  answerd  "I 
shall  not  go  fro  the,  tyll  my  worde  and  promysse  be  fulfilled.'' 
And  with  owte  tarynge,  there  was  a  cyteseyn  covetynge  to 
bye  flevssh,  for  hym  and  his  housholde,  and  of  that  heip  of 
the  whiche  Alfunyne  spake  before  he  boughte  atte  the  wille 
of  the  seller,  and  bare  hit  with  hym.  And  whan  this  was 
dvvuleate  by  all  the  bocherie,  for  a  wurthy  mvracle,  as  it 
^vas  fittvnge,  it  was  take.  And  from  that  tyme,  they  began 
to  be  more  prompte  to  yeve  ther  almes,  and  also  fervent 
in  devocion.  And  stryvyd  who  myght  prevent  anothir  yn 
yevynge,  namely,  he  whoes  hardnes  of  unfeithfull  soule,  the 
virtu  of  Crpst,  hadde  undirnymyd,  the  whiche  lorde  promysid 


Fotmdation  of  St.  Bartholomew's.  Ixxi 

to  the  3ever  of  a  dyschfull  of  coolde  water  to  hym  that  cum- 
myth  yn  the  name  of  a  disciple  nat  to  lake  his  meide.^ 


CAPITULUM  XXIII. 

OF  EDEN  THE  WYFFE  OF  EDRED. 

An  nothir  tyme  the  same  Alfunyne  those  thynges  that  nedid 
to  the  makyng  of  ale  he  went  a  bowte  to  matronys  howsis  in 
cumpasse  and  askid,  and  whan  he  came  yn  to  the  parissh  of 
Seynt  Giles  of  London,  for  this  same  gaderynge,  he  cam  yn  to 
a  devoute  matron,  Eden  by  name,  the  wyf  of  Edred  the  whiche 
with  mervellus  devocion  lovynge  Cryistis  apostle,  her  almes 
to  his  chirche,  or  els  she  broughte,  or  els  was  wonte  to  sende 
yt :  to  whom  cummynge  Alfunyne  he  prayed  her  of  her  blessyng, 
that  sumwhat  sche  wolde  departe  with  hym,  for  the  love  of 
God.  And  sche  answerd  that  she  hadde  but  oonly  vii  ceves  ^  ful 
of  make;  and  she  shulde  take  a  wey  ony  thyng  of  these,  she 
myghte  nat  than,  parforme  the  brethen,^  that  she  hadde 
begunne,  ^'' Never  the  lees,"  she  saide,  ^''albe  that  I  be  certeyn 
to  have  damage  or  harme,  yete  hadde  I  lever  to  suffir  harme  of 
myn  ale,  than  yow  to  go  voyde  with  owte  frute  of  myn  almes," 
thus  seyynge,  she  mesurid  one  cevefull  and  yave  it  to  the 
mynystris,  the  whiche  passynge  forthe  and  i  go,  she  began  to 
mesure  that  remaynyd,  and  wondir  to  seye,  vii  mesures  she 
fownde,  the  whiche  her  self  trowynge  to  have  errid  in  num- 
berynge,  began  to  telle  ageyn  :  and  than  she  fownde  viii :  the 
thirde  tyme  she  numberid  and  fownde  ix  :  and  than  at  the  foureth 
metynge  fownde  x,  Beholde  that  she  that  studied  to  fulfill  the 
plenytude  of  the  lawe,  that  is  charite,  of  the  rightwys  rewarder, 
for  her  mede  fownde  x.  The  which  woman,  that,  that,  remanyd 
so  habowndynge,  commawndid  to  be  born  to  the  same  chirche 
anoyn,  and  tolde  everywhere,  the  mervelous  encresse,  bles- 
synge  God  that  by  his  seyntes  workith  tokenys  and  virtues  to 
whom  whan  he  wolle  myghte  is  redy. 

^  lake  his  meide,  lack  his  reward.  '  brethen,  beer  (cervisiam). 

^  Ceves,  sieves. 

/ 


Ixxii  Fowidatioii  of  St.  Bartholomew  s. 

CAPITULUxM  XXIV. 

DE    GODEXA    CONTRACTA.^ 

A  certyn  woman  Godene  bv  name,  hadde  her  leggis  returnyd 
to  her  thyys  that  never  mvght  stonde  upright,  but  with  con- 
tynuall  use  of  sittynge  ledde  a  tedious  Ij-fe,  yn  sorowe  and 
wepynge  she  on  a  tyme  was  born  to  the  chirche  of  the  blessid 
apostle,  and  askid  the  yifte  of  parfit  helth,  and  obteynyd  it 
grauntynge  that  oure  lord  Ihu  Criste  the  whiche  losith  stokkid  ^ 
men,  reysith  up  down  pressid,  and  directith  the  rightwys. 


CAPITULUM  XXV. 

OF    A    MAN    THAT    MYGHT    XOT    SLEPE. 

A  certvn  man  at  Norwiche  opynly  i  know/  while  on  a  tyme 
he  wolde  be  lette  blode  and  of  hym  self  toke  noon  hede,  as  it 
was  expedient,  hadde  lost  the  rest  of  slepe,  the  whiche  how 
good,  and  how  necessarie  it  is  to  man,  for  to  expowne  it  is  nat 
now  necessarie,  this  reste  longe  and  dayly  sweites  and  labores 
allightith,  and  aftyr  labur  repayrith  man  a5eyn  to  labour,  and 
this  reste  nat  onely  of  men  but  of  bestis  conservyth  the  nature 
sownde  and  hole.  The  sayed  wrecchid  man  lackynge  this 
rest  ledde  on  nvghtvs  withowte  slepe  almost  vii  yere.  And  by 
and  by  his  senowys  were  contracte  pale  and  lene,  and  ryvelyd 
abowte  the  moweth  all  discolouryd,  and  all  his  bonys  to  be 
numbrvd,  apperid  to  the  sight  of  them  that  byhelde  hym  : 
and  to  the  heip'^  and  encrece  of  his  greve  and  febylnes  was 
putte  to  nedynesse,  so  moche  that  the  man  beforn  was  riche 
yn  frendes  and  money,  and  nowe  of  bothe  destitute  he  was 
applied  to  vdelnes  fFor  nethir  to  hym  self,  nethir  to  his,  myght 
he  onv  thvncre  provyde.  In  vii  3eire  of  his  unfortune,  whan  the 
relikys  of  the  same  chirche  of  seynt  Batholomewe,  were  browght 
and  put  yn,  to  the  oratorye  of  sente  Nicholas^  at  ^ermoweth. 


^  coniracta,  the  cripple.  ^  to  the  help,  ad  cumulum. 

2  stokkid,  in  the  stocks.  ^  The  parish  church  of  Yarmouth 

3  opynly  i  kurw,  notissimus.  is  dedicated  to  St.  Nicholas. 


Foundation  of  St.  Bartholomew  s.  Ixxiii 

this  man  drewe  to  the  same  relikys  devoutly,  and  mekely 
prostratte  hymself,  askyng  and  sekynge  remedy.  And  he 
fownde  that  he  sowght,  he  range  at  the  doyr,  and  oure  porter 
opynde  to  hym,  and  shewid  to  hym  magnyfycently  the  bowelles 
of  his  mercy,  and  grovelynge  to  the  grownde  he  multiplied  his 
prayers  and  began  to  slepe  :  and  whan  he  hadde  slepte  a  grete 
while  he  roys  up  hole,  and  wente  to  his  owne,  yeldynge 
thankynges  to  God,  that  mortifieth  and  revyvyth,  smytyth  and 
helyth. 


CAPITULUM    XXVr. 

OF   A  DUM    CHILDE. 


Also  a  chllde  that  longe  tyme  was  dumme,  to  the  laude  of 
the  glorious  apostle,  the  vertu  of  God  opynde  both  tonge  and 
moweth  and  right  wesly  he  spake. 


CAPITULUM  XXVII. 

OF    AN    OTHUR    CALLID    NYCHALAS. 

A  childe  faire  of  forme,  Nicholas  by  name,  so  had  he  his 
legge  so  strecchid  forth,  to  the  upper  parties  of  his  thyy, 
that  he  myght  nat  putte  yt  forward  ne  drawe  yt  bakewarde, 
yn  asmoche  that  the  synowys  were  dryed  up  and  alwevs 
lackid  bowablenesse,  he  therfore  lenyng  on  a  stafFe  usid  that 
yn  stede  of  his  fote.  This  childe  cummynge  to  the  chirche  of 
the  blessid  apostle  Bartholomew  was  expert  that  Oure  Lorde  is 
full  sweytt  to  al  men  and  his  mercy  ys  abovyn  all  his  workvs, 
by  the  merites  of  the  most  glorious  apostle,  hete  of  lyf  was 
ynfowndid  to  seyr  and  drye  membrys  and  anoon  folowid  full 
helth,  the  whiche  chylde  abided  ther  a  while  and  servyd  the 
chanons  ther,  yn  ther  kychyn,  and  for  the  yifte  of  his  helth, 
he  yave  the  servyce  of  his  body. 


Ixxlv  Foundatio7t  of  St.  Bartholomew  s. 


CAPITULUiM  XXVIII. 


OF    ADWYN'E    THE    CARPENTER. 


An  nothir  man  Alfunyne  bvname  in  the  towne  of  Dunwych^ 
that  dwellid  on  the  see  svde,  so  was  contracte  that  he  myghte 
nat  use  the  free  office,  nethir  of  hande^  ne  of  fote,  his  legges 
were  clevynge  to  the  hynder  parte  of  his  thyes,  that  he  myghte 
nat  goo,  and  his  handis  turnvd  bakewarde,  no  thynge  with 
them  myght  be  do,  ne  worke:  the  extremyteis  of  his  fvngers 
were  so  rigorisly  contracte  in  the  svnowys,  that  he  myght 
unneith  put  mete  to  his  moweth.^  In  this  grevous  sykenes  he 
passid  his  yonge  age.  And  whan  he  attayned  to  mannys  age 
and  not  yette  hadde  he  power  of  his  Ivmmvs,  yette  sith  the 
fame  of  tokenys  and  myracles  of  the  blessid  apostle  come  to 
hym  by  relacion  of  othir  men,  he  began  to  ley-fte  up  his  sorow- 
full  soule  in  to  abetter  hope.  And  thow  helth  were  yn  that 
tyme  dilaid,  it  was  promvsed  to  come.  Therfore,  for  that  he 
was  ferre  from  that  chirche,  he  yave  shipmen  for  hyr  hyyr 
and  bv  shippe  he  was  browght  to  the  chirche,  and  put  yn  the 
hospital!  of  pore  men.  And  ther  a  while  of  the  almes  of  the 
same  chirche  y  sustenvd.  And  he  began  yn  the  meyn  while, 
bv  the  vertu  of  the  apostle  to  take  breith  unto  hym,  and  he 
desirid  helth,^  by  certeyn  incrementys  began  to  come  ageyn  ; 
ffirst  with  handys  thow  they  were  crokyd,  he  dyd  make  smale 
workvs  as  disstafes,  and  antell,'*  and  othir  wommenys  instru- 
mentvs,  and  forthermore  by  succession,  whan  othir  membrys 
usvd  ther  naturall  myghte  he  followid  yn  greter  workys,  hewerrys 
of  wode  with  axe,^  and  squarerys  of  tymbyr  with  chippynge 
axe,^  and  nat  longe  aftir,  the  crafte  of  carpentrye,  yn  the  same 
chirche,  and  va  the  cite  of  London  he  excercisid,  as  it  hadde 
be  taught  hvm  from  his  childehode,  blessynge  God,  whoes  yen, 
be  oon  them,  that  dredith  hym,  and  uppon  them  that  hope 
on  his  mercv. 


1  In  Suffolk. 

2  vix  ori  escas  porrigebat. 

3  et  optata  sanitas. 

*  antell,  pensa,  weights. 


5  fiewerrys  of  wode  with  axe,  cesores 
lignorum  securi. 

®  el  dolabra  magnis  operibus  imi- 
tabatur. 


Fotmdation  of  St.  Bartholomew  s.  Ixxv 

CAPITULUM    XXIX. 

OF    A    DROPYK    MAN. 

A  certeyn  dropik  man  that  bare  his  surname  of  the  happe^ 
of  this  siknes,  myght  nat  hyde  away  his  ynwarde  greyf,  but  to 
the  sight  of  uttir  beholders^  he  shewyd  owte  his  greyf  and 
wracchidnys  soithly  an  humor  reynnynge  undir  the  skyn  made 
a  bolluyng  inflacion  and  the  wombe'^  swellyng  owte,  shewid 
owtwarde,  what  pestilence  was  hydde  ynward.  this  man  was 
browght  to  the  chirche  of  seynt  Bartholomew,  but  for  the 
gretnes  of  his  doloure,  he  was  turmentid,  and  in  to  dyvers 
parties  he  walowid  hymself  yn  the  pament :  ^  and  at  the  last 
yn  the  sight  of  all  men  he  cast  owte  wondir  venym,  and  his 
ynwardes  were  purgid  from  this  dedly  fylthe  and  all  hole 
returnyd  to  his  awne  howse. 

HERE    ENDITH    THE    FIRSTE    BOKE. 


^  happe,  eventu.  English  MS.  capitals  are  chiefly  used 

^  wonibe,  belly.  as  a  part  of  the  punctuation,  sometimes 

3  The  Latin  MS.  has  a  capital  at  the  to  proper  names  and  sometimes  not. 

beginning  of  each  sentence,  a  full  stop  In  this  text  I  have  used  the  capitals 

at  the  end,  and  marks  divisions  of  sen-  as   indications  of  clauses,  marked   by 

tences  by  one   stop    only  : .     It  gives  commas  or  other  stops,  and  for  the  rest 

capital  initials  to  most  proper  names,  as  have   followed    their   practical   use   of 

Raherus,  but  always  has  deiis.     In  the  marking  the  sense  to  the  eye.^ 


Ixxvi  Foundation  of  St.  Bartholomews. 


LIBER  11. 

AND    HERE    BEGYNNETH    THE    PROLOG    OF    THE    SECUNDE. 

To  US  confessynge  to  God,  and  bigynnynge  to  telle  his 
mervels,  we  truste  feithfuUy  he  shall  yeve  a  goode  endynge, 
the  whiche  hath  yeve  a  goode  begynnynge.  Nowe  ren- 
nyth  to  oure  mynde  one  solempne  thynge,  to  be  seled  for 
many,  and  whan  this  hath  be  movyd,  both  by  opyn  resunne^ 
and  unyversall  wytnes,  more  licencyous  we  may  passe  yn  to 
othir,  y  don  by  like  vertu,  and  evyn  power.  Hedirto  we  have 
writyn  examplys  of  myracles,  the  whiche  were  don,  in  the 
dayes  of  goode  remembrawnce  of  Rayer  priore  and  foundatore 
of  this  place  to  the  laude  of  God,  and  excitament  of  holynes; 
and  nowe  it  is  for  to  do  and  procede  of  these  thynges  that  we 
han  seyn  and  herde  don  in  the  dayes  and  tymes  of  the  succes- 
sores  of  the  forsaide  priore.  The  grete  solempne  thynge  ys 
thys,  ffirst  whan  the  rememberid  priour  was  3it  a  lyve,  the 
whiche  ediffed  the  frame  of  this  precious  worke  upon  the 
fowndament  of  appostles  and  prohetys,  ffor  as  moche  as  the 
bygynnynges  of  grete  thyynges,  nedith  gretter  helpe,  thanne 
most  was  prompte  and  presente  haunttid  plenty  of  mynystryd 
grace  from  God,  ffurthermore  those  than  aftir  to  the  avowers, 
that  the  celestiall  fadir  drewe  yn  to  the  odur  of  his  oynnementys  ^ 
renuydde  a  newe  solempnyte,  of  them,  than  ranne  to  religion 
with  an  ynwarde  newydde  devocyon.  Also  a  newe  solempnyte 
was  for  obvencyouns  and  3iftes ;  in  money,  in  howseholde, 
in  come,  and  in  meveable  goodis,  grete  nowmbyr.  And  than 
aftir  a  jocondefeiste,  bisy  in  this  place  was  hadde  of  recoverynge 
men  yn  to  helthe,  of  them  that  langwsshid;  of  drye  men,  of  con- 
tracte  men,^  of  blynde  men,  dome*  men,  and  deif  men,  fFor  these 
causys  whan  the  day  of  his  natyvyte  in  to  hevyn  was  knowyn 

^  resunne,  reason.  ^  of  contracte  men,  not  in  the  Latin 

2  oynnementys,  ointments.  MS.  *  dome,  dumb. 


Foundation  of  St.  Bartholomew  s.         Ixxvii 

it  was  solempnyzed  and  honourid  with  grete  myrth  and  dawn- 
synge  yn  erth.     And  menne  presydde  hydder  thykly  for  vari- 
awnte  causys,  and  shuldrid  to  gider,  and  as  languyshynge  men 
were  there  abidynge  the  mevynge  of  the  water  of  grace,  that  yn 
a  certeyn  place,  as  this  same,  and  yn  certeyn  tyme  they  shold 
presume,  and  truste  well  the  wonte  grace,  to  be  3even  to  them, 
as  was  beforn  to  othyr,  as  the  dayly  relikys  of  them,  preche 
and  schew  to  us,  and  this  is,  that,  that  we  seide  beforn,  oone 
solempne  for  many,  or  els  many  to  make  one  solempne  feiste. 
Ffor  as  the  blesside  kyngdome  of  Israel,  all  was,  as  it  hadde  be 
one  proficye  of  Cryste  and  of  his  chirche,  so  al  these  thynges 
that  ben  seide  or  shall  be  seide,  they  beholde  the  ende  and  con- 
summacion  of  this  document,  ffor  trewly  God  is  yn  this  place, 
and  though  there  be  non  place  with   owte  hym,  the  whiche 
God  yn  place  ys  not  comprehended,  nothir  mesurid,  nat  for  the 
place  these  be  doon  oonly,  but  for  man,  ffor  the  whiche  bothe 
man  and  place  is  reverencid.     Neverthelese  there  is  no  so  privy 
man  of  Crystes  secretys,  that  may  contempne  the  reverence  of 
holy  place,  whiche  deputat  ys  only  to  dyvyne  use,  and  consecrate 
ys  to  the  remedye  of  soulys,  where  oure  holy  thynges  be  put,  wher 
is  the  distribucion  of  the  sacramentis,  and  wher  that  is,  that  is 
most  beste,  the  presence  of  Crystes  body,  nat  w^ithoute  experience 
of  his  vertuys  with  grete  office  of  angely  mynystracion,  and 
with  solempne  worschip  of  devocyon  of  all  seyntes,  dredefull 
therfore  is  this  place  to  the  understander,  ther  is  no  thyng  her 
els,  but  the  howse  of  God  and  the  gate  of  hevyn,  to  the  belever. 
Trewly  they  that  byleve  nat  ne  undirstonde  not  by  charite  yn 
belevynge  of  these  mysteryes,  but  scornyth  oure  Sabatte  dayes, 
and  poluteth  oure  halowys  that  clensyn  othir  men,  we  schall 
take  them  as  men  transfiguryng  them  self,  yn  to  an  angell  of 
lighte  thowgh    they   be    darke    bodyes :    demynge   pyte  to   be 
feynyd  for  lucre,  and  so  they  sholde  be  takyn  till  the  consumma- 
cion  of  synne,  antecryste,  shall  come  \vhan  the  erthe  shall  be 
take  unto  wykkid  men,  and  halow^ys  yn  to  conculcacion,  that 
they  may  be  opyn  than,  that  now  be  hydde  yn  the  denne  of 
theyfes.    Spirituall  sothly  seyntwary,  that  heir  ys  bilid  of  qwyke 
stonys :   abilydnge  certeynly  styddefastly  here    permanent  un- 
spottid  shall  be  translatid  yn  to  the  kyngdome  everlastynge  ; 
and  as  yn  the  erthly  empyr  unfittynge  it  is,  and  suspecte  any 
man  excepte  only  oone  persone,  to  schewe  knyghthode  yn  his 


Ixxviii        Foundation  of  St.  Bartholomew  s. 

propre  name,  we  have  oone  of  these  tliat  Oure  Lorde  hathe 
ordeynyd  prvnces  uppon  erthe,  we  have  as  I  seye,  the  doer 
of  mervels  oure  patrone,  and  duke/  seynt  Bartholomew,  whom 
by  the  grace  that  he  hath  plentwesly  reccyvyd  of  Cryste,  we 
beseke  hym,  that  with  his  mvghty  auctorite,  that  connnendeth 
the  vertu  of  his  mavster,  us  aftir  hym  nat  oonly  he  wolde  lede, 
but  also  that  he  drawe  and  heigge-  oure  waves,  with  thornys, 
that  we  go  nat  aftir  the  desires  of  oure  fleshe.  And  with  fadirly 
chastvng;e  compelle  us  to  entre  the  soper^  of  the  lambe,  and 
the  everlastvng  mariage  of  hym,  that  takith  awey  the  synnys 
of  the  worlde,  the  whiche  peticion  he  vouychesafe  to  5eve  us, 
the  which  lyvyth  and  reigneth  God  per  all  worldes  with  owtyn 
ende.  Amen.  ' 


ALSO  AXOTHIR.* 
Also  as  we  be  lernvd  of  worldly  kunnynge,  as  it  were  by  the 
spoylvs  of  egipcyanys,^  the  office  of  a  necligent  man  is,  nat  to 
know  the  besrynnynges  of  his  werkys,  nethir  to  charge  the 
endynges,  gretly  yn  us  it  semyth  reproveable,  that  ar  lernyd 
men,  nat  to  know  the  grownde  and  the  reson  of  them,  that  we 
worschippe :  Movses  sothly,  that  fyrst  taught  us,  to  spoyle  the 
esfipcians  he  taught  us,  how  we  shulde  answere  to  oure  aftir 
cummers,  askvng  upon  oure  sacramentis  what  they  wolde  meyn, 
seyng  thus,  for  to  signyfie  to  them,  the  religion  of  the  same. 
Therfore  aftir  the  3erys  of  his  prelacie  xxii^  and  vi  monthes,  the 
.xx*^.  day  of  September  the  vii  moneth,  the  cley  howse  of  thys 
worlde  he  forsoke,  and  the  howse  everlastynge  he  enterid,  that 
fowndid  this  howse  in  to  the  laude  and  honoure  of  the  name  of 
Crvst,  that  vn  the  howse  of  his  fadir  he  myght  be  crownyd  yn 
his  mvildnes,  and  yn  his  mercyes.  And  in  asmykil,"  as  of  no 
workys  with  owtecharitecummyth  forth  profeite  with  owte  whiche 
charite,  othir  goodys  may  not  prevayle,  the  whiche  also  charite 

1  duki,  ducem.  September  20,  1144,  as  the  day  of  his 

-  heigge,  sepiat,  hedge.  death.     The  Latin  reads  "  Igitur  post 

'  soper,  supper.  annos  prepositure   xxir.  os  et  menses 

^  Also  another,  Item  aliud.  sex   vigesimo   die    sept'    septi    mensis 

!  egipcyanys,  Egj'ptians.  relicta  domo  lutea."     As  Easter  day  in 

*  XXII.     This  would  make  Rahere  1144  was  on  March  26,  September  was 

begin  his  priorate,  March  1123,  as  the  the  seventh  month  in  that  year. 

manuscript    implies,    and   would   give  ^  asmykil,  as  much. 


Foundation  of  St.  Bartholomew  s.  Ixxix 

iliay  nat  be  hadde  with  owte  other  goodys^  by  the  whiche  man  is 
made  goode  :  rightly  so  we  of  hym  have  this  hope  that  no  thynge 
hath  he  omysid  by  hym  that  tochith  grace,  of  that,  that  we  seke 
here  in  thys  passyng  lyfe,  as  is  the  communyon  of  Crystis  feith, 
and  communycacion  of  his  sacramentis  and  namly  insignys  of 
a  contrite  herte  by  penaunce,  fFor  why,  amonge  these  we  trust 
that  be  passid,  and  yn  thys  we  trust  as  we  hope  in  the  meritorie 
helpe  of  oure  myghty  patrone,  to  whom  the  Htil  flokke  of  xiii 
chanonns  as  a  few  sheippe  he  hath  lefte  with  litil  lande,  and 
right  fewe  rentys^  neverthelese  with  copious  obvencyons  of  the 
awter  and  helpynge  of  the  nygh  parties  of  the  populous  cyte 
they  were  holpyn.  Sothly  they  florysch  now,  with  lesse  fruite 
than  that  tyme,  whan  the  forsayd  solempnyties  of  myracles 
were  excercysyd  by  a  lykewyse,  as  it  were  a  plante  whan  yt  is 
wele  y  rotyd,  the  ofte  wateryng  of  hym  cesith.  The  tyme  of  a 
3ere  turnyd  abowte,  succedid  to  the  prepositure  and  the  dignyte 
of  the  priore  of  this  new  plantacion  admyttid  by  the  bysshope 
of  London  lorde  Robert/  Thomas  ^  oone  of  the  chanonns  of  the 
chirche  of  seynt  Osyth,^  the  3ere  of  oure  Lorde  M°.  and  C™°.  and 
xliiij'*.  the  sevyn  indiction/  reignynge  Stephyn,  the  sone  of 
Stevyn,  Erie  Blesence/  the  whiche  promovyd.  Theobalde^ 
Beccence,  in  to  the  archebisshope  of  Cawntirbery.  This 
Thomas  as  we  have  provyd  in  comyn,  was  a  man  of  jocunde 
companye,  and  felowly  jocundite,  of  grete  eloquence,  and  of 
grete  cunnynge,  instruct  in  philosophy,  and  dyvyne  bokys 
exercisid  and  he  hadde  yt  in  prompte,  what  sumever  he 
wolde  uttir,  to  speke  yt  metyrly,  and  he  hadde  in  use 
every  solempne  day,  whan  the  case  requyrid,  to  dispense 
the  worde  of  God,  and  flowynge  to  hym  the  prees  of  peple, 
he  3ave  and  so  addid  to  hym  glorie  utward,  that  ynward  hadde 
■^eve  hym  this  grace.  He  was  prelate  to  us  mekly  almost  xxx  3ere, 
and  in  age  an  hundrid  wyntir  almost,  with  hole  wyttis, 
with  all  crystyn  solempnyte,  tochynge  Crystes  grace  he  decessid 

^  Robert      de      Sigillo,     Bishop    of  meis,  Bishop  of  London,  the  friend  of 

London,  I141-1151.  Rahere. 

'  Thomas     was     therefore     elected  *  The  seventh  indiction  is  A.D.  1 144. 

Prior  about  September  1141.  ^  Blesence,  of  Blois. 

3  St.  Osyth  in  Essex  :  a  house,  like  ®  Theobald,  Abbot  of  Bee,  in  Nor- 

St.     Bartholomew's,     of     Auguslinian  mandy,   elected  Archbishop,  Dec.   13, 

canons,  founded  by  Richard  de   Bel-  1138.     He  died  April  1 8,  1 161. 


Ixxx  Foundation  of  St.  Bartholo^news, 

and  was  put  to  his  fadres,  the  3ere  of  Oure  Lorde.  M.C.lxxiiij, 
of  the  papassie  of  blesside  Alcxawndir  the  third,  xv,  3ere/  of 
the  coronacioii  of  the  most  unskunfitid  kynge  of  Englonde 
Henry  the  secunde  xx."  3ere/  the  xvij  day  of  the  moneth  of 
JanvLier,  yn  the  same  3ere  of  the  election  of  lorde  Richard^ 
Archbysshop  of  Cawntirbery,  aforne  whom  oure  brethren 
were  put,  and  sette  of  his  goode  grace  hym  praynge,  whom  the 
grace  of  God  from  the  forsayid  paucyte,  encresid  yn  to  xxxv.*° 
Encresyng  with  them  temporall  goodes  evynly,  the  whiche  the 
3ever  of  all  goodys,  promysid  to  be  cast  to  them,  that  sekith 
the  kyngdome  of  God,  yn  this  manys  tyme  grewe  the  plante  of 
this  appostolike  branche  yn  glorie,  and  grace  before  God,  and 
man,  and  with  moor  ampliat  bylyng,  were  the  skynnys  of 
oure  tabernaculys  dylatid,  to  the  laude  and  glorie  of  oure  lorde 
Ihu  Criste  to  whom^  be  honoure,  and  glory,  worlde  with  owtyn 
ende.     Amen. 


CAPITULUM  I.     SECUNDI  LIBRI. 

OF   A    DEYF    MAYDE    DUM    BLYNDE    AND    CONTRACTE. 

The  3ere  from  the  incarnacion  of  Oure  Lorde  M.C.xlviij.  aftir 
the  obite  of  Harry  the  first,  kynge  of  Englonde,^  the  xij  yere, 
whan  the  goldyn  path  of  the  son,  reducid  to  us  the  desirid 
joyes  of  festfull  celebrite,  than  with  a  newe  solempnyte,  of  the 
blessid  apostle  was  yllumynyd  with  newe  myracles  this  holy 
place.  Langwissyng  men  grevyd  with  variant  sorys,  soiftly  lay 
yn  the  chirche  with  schynynge  lightys,  prostrate,  besekynge 
the  mercy  of  God,  and  the  presence  of  seynt  Bartholomew. 
And  certyn  the  longe  mercy  of  God,  was  not  fer  fro  them  the 
whiche  alway  is  present  to  the  vowis  of  feithfull  besekers. 
Summan,  joyed  with  voyce  of  jubilacion,  that  he  hadde 
receyvyd  remedie  of  his  akynge  hede,  an  nothir  for  reparacion 
of  his  goyng,  that  he  lackyd,  an  nothir  from  ryngyng  of  his 
erys.     This   man  was  free  from   corrupcion  of   lymmys,   this 

1  i.e.  1 1 74.  Aprils,  11 74.      The  year  11 74  began 

-   The  XX.  of  He7iry  II.,  1173-74.  March  24,  and  ended  April  12. 

^  Richard,  prior  of  Dover,  was  con-  *  Henry  I.  died  December  i,  1135. 

secrated    Archbishop    of    Canterbuiy       So  that  these  events  took  place  in  the 

year  1147. 


Foundation  of  St.  Bartholomew  s.  Ixxxi 

man  putte  a  syde  bleriednes  of  yen/  and  joyid  the  clerenes 
of  sharp  sight  recevyd,  many  other  men  joyid  to  be  swagid 
from  the  vexacion  of  feverys^  3evynge  thanke  to  the  honoure 
of  the  appostle.  Certeyn  whyle  everywhere,  for  suche  thynges 
was  3eve  applause  and  gladenes  of  all  the  peple,  in  the  lyfte 
corner  of  the  chirche,  of  summen  was  herde  wepyng  and 
waylyng  where  lay  a  certeyn  damsell  deyf  and  dum  lackyng 
sight,  of  boeth  yen,  and  with  returnyd  leggis  contract  whoes 
parentys  waylynge  lay  grovelynge  to  the  pavyment,  and  cesid 
not  from  prayer,  tyl  all  thyng  was  fynyschid  of  the  clergy,  that 
was  expedient  to  so  grete  a  feste.  It  plesid  therfore  the  goodnes 
of  God  to  condescende  to  ther  peticionns,  and  not  furthermore 
his  creature  of  the  malicious  power  to  be  vexid,  but  from  every 
bownde  of  syknes  fully  and  perfitly  to  be  delyveryd,  therfore 
whan  the  chanonns  sange  the  seconde  evyn  songe,  the  mayde 
began  grevously  to  be  turmentyd  and  sorer  than  she  was 
woonnte  to  be  vexid,  frotyng  at  the  moweth,  smytynge  her 
breste  and  betynd  her  hede  a  3enste  the  grownde,  trewly  whan 
they  come  to  the  ympne  of  oure  blessid  lady,  that  the  altarys 
shulde  be  yncensid,  the  forsaid  mayde  began  with  a  sharpe 
voyce  to  crye,  and  her  membrys  with  a  grete  myght  she 
strecchid  owt,  anoon  joyfull  skippyng  forth  here  yen  now 
iiewe,  and  now  clere,  with  the  lynnyn  clothe,  that  she  was 
clothid  yn,  wypyd  them,  and  dryed  them,  and  thus  with  sted- 
fast  stondyng  whan  she  was  repayrid  of  heryng,  and  of  the 
acceptable  light  of  seying  so  gracyously  receyvyd,  she  ran  to 
the  table  of  the  holy  awter,  spredyng  owte  bothe  handys  to 
hevyn  and  so  she  that  a  litill  beforne  was  dum  now  joyng  in 
Jaude  of  God  perfitly  sowndyd  her  wordes,  and  to  her  parentys 
ther  for  joye  wepynge  plenteously  affirmyd  her  self  free  from 
all  maner  of  syknes. 


CAPITULUM  11. 

OF   A    CHILDE    DELYVERYD    OWTE    OF    BONDYS. 

Hit  happid  on  a  tyme,  that  a  pore  man  for  to  bye  his  vitayles,^ 
cam  to  London,  also  his  wyfe  to  sustene  ther  pore  lyfe,  was 

^  bleriednes  of  yen,  occuloram  lippitudine.  ^  vitayles,  victuals. 


Ixxxii         Foundation  of  St.  DartJiolomews. 

wonnt  also  from  the  contray  cuine  to  the  cite,  to  receyve  her 
wagys,  for  that  she  haclde  spoiine/  this  pore  man  with  his  wyf 
hadde  yn  custome  every  3ere  to  visite  the  place  of  Scynt  Bar- 
tholomew with  his  offerynge,  and  mekly  commend  hym  self 
to  the  holy  relikys  of  the  same  chirch.  The  olde  serpent 
enemy  to  all  mankynde,  the  whiche  ever  is  besv,  to  devoure,  or 
els  to  troble,  the  pees  of  feithfull  men,  enviynge  the  tranquyllite 
of  these  man  and  woman^  and  the  honest  poverte,  he  suggestid 
to  a  certeyn  bayly  of  his  byssynne  that  he  shulde  pretende,  to 
the  forseide  pore  man  leynge  awayte  and  a  spyes,  he  roos  ther- 
fore  erly,  yn  the  mornnynge^  this  gylfull^  man  namyd  Alureid, 
the  bedyl  or  forcryer,  and  leyid  wacche,  as  a  rampawnde  lyon, 
a3enst  the  pore  man,  ther  was  no  taryng,  bat  the  ynnocent 
and  the  theyf  meitt,  and  whan  this  gallowus  man  toke  hym  by 
the  skyrtis,  of  his  palle  or  mantyl,  he  cryed  uppon  hym  hor- 
riblely,  undir  nymdid  hym,  and  reprevid  hym  of  thefte,  and 
smytte  hym  wykkidly  with  his  fyste,  seiynge  "  VVher  be  thy 
mersmentes,  that  thou  by  theifte  hast  take  away,  deceyvyng  the 
mynystrys  of  the  shereve^  with  drawyngtol  a  thowsand  tymes/' 
And  whan  the  pore  man  arayed  hym  to  answere,  ther  come 
rennynge  to  hym,  many  of  the  same  gylefull  felschip, 
accusynge  the  ynnocent,  they  smytte  hym,  they  trode  hym 
undir  fote,  they  bownde  hym,  and  yn  captyvyte  led  hym  to 
pryson,  and  whan  they  come  to  the  howse  of  this  forcryer  or 
bedyl,  or  y  may  say  of  that  robber,  they  bownde  hym  with 
fetterys,  beit  hym  with  scorgys,  askyng  of  hym,  that  he  hadde 
nat,  that  is  to  say  gret  quantyte  of  money.  At  the  last  wery 
of  betyng,  they  put  abowte  his  necke  a  coller  of  iren,  of  grete 
weighte  and  a  grete  chayne  on  othir  parte  of  the  inner  towre, 
rennyng  thorow  the  myddyl  of  the  wallys  that  they  myghte 
kepe  hym  more  surly,  and  fastnyd  the  ende  of  the  cheyne,  with 
a  staake,  thus  this  wrecche,  withowt  remedye,  withowt  mercy,  yn 
wepynge  and  sighynge,  in  colde,  and  brosynge,*  drayf  forth 
many  dayes.  Upon  a  day  whan  of  custome  the  chanons  of 
the  chirche  of  seynt  Bartholomewes  a  fore  the  mornynge,  the 
matens  endid,  and  began  to  synge,  Te  deum  laudamus,  and 
the  peyll  of  bell  was  roonge,  the  forsayed  pore  man  the  whiche 

^  spotme,  spun.  ^  shereve,  sheriff. 

*  gyifull,  guileful!.  ^  brosynge,  bruizing. 


Foundation  of  St.  Bartholomew  s.        Ixxxiii 

was  artid  in  bondys,  herynge  the  sownde  of  the  bellis,  and  the 
melodye  of  ympnys/  the  howse  sothly  that  he  was  cnicyat  yn 
was  nygh  by  to  the  chirche,  and  he  began  with  devout  soule 
and  lamentable  voice  to  crye,  and  as  he  cowde  or  myght  to  calle 
upon  seynt  Bartholomewe  whan  he  hadde  so  don  intently  and 
ofte,  he  deservyd  to  have  the  affecte  of  his  feithfull  peticion, 
and  felt  now,  nat  as  beforn  hym  self  so  chargid  with  ferra- 
mentes  and  iryns,  wherfore  leftynge  up  handys  and  armys  he 
fownde  hym  self  y  losid,  and  skippynge  forth  with  all  iryn 
machynamentis^  he  came  to  the  doer,  and  fownde  yt  opyn, 
and  whan  the  grete  cheyne  and  coller  of  iryn  and  of  the 
fetterys  grete  payse^that  he  bare  made  so  grete  anoyse,  the 
forsaide  Alurede  sodaynly,  awakid,  skippid  owte  of  his  bedde, 
and  with  a  swyft  paase  folowid.  Anoon  as  he  was  owte,  and 
his  fngityve  by  the  mone  light  sawh,  he  wolde  a  folowid 
hym,  and  he  wolde  a  cried,  but  thorow  the  wylle  of  God, 
nethir  he  myght  meve  his  fote,  nethir  breke  owt  with  his 
voyce.  So  the  pore  man  skapyng  by  seynt  Barthilmew  help, 
and  with  a  grete  joye  enterynge  his  chirch,  prostrayt  hym  self 
afore  the  holy  auter  of  the  apostle  makyng  knowlegge  that  by 
his  helpe  he  was  delyvered,  yeldyng  to  God,  and  hym  thank- 
ynges,  and  tolde  to  them,  that  stoid  abowte,  the  ordir  of  the 
benefeit  i  3even  to  hym. 


CAPITULUM  III. 

OF    SHIPPEMEN    YN    GRETE    PERYLL, 

Certeyn  marchawntes  havyng  ther  shippis  stuffid  with  nesses- 
saries  to  howseholde,  with  hope  of  lucur  commytted  them  self  to 
the  meveable  wyndis,  and  uncerteyn  see,  purposyng  to  London 
to  eschange  with  encreys  of  the  marchawndise,  sothly  whan 
they  were  mevyd  from  the  porte  of  Flawndrys,  and  with  swifte 
course  bygan  to  passe  thorow  the  see,  the  light  of  the  son  was 
closid  yn  derke  clowdys,  and  the  eyr  was  changid  and  began 
to  be  fulle   of  stormys   and   thonderygne   horrible.      All   the 

^  ympnys,  hymns.  ^  payse,  weight. 


Ixxxlv       Foundation  of  St.  BartJiolomeTjjs. 

elementys  portendid  to  the  wrecchld  shipmen  deith  of  nature. 
And  whan  a  litil  a  forn  xi  schippis  fro  the  havyn  of  the  peseble 
porta,  with  joye  ther  shulde  be  losid,  a  mervelous  happe  and 
a  lamentable  caase,  in  a  breyf  space,  with  the  wodnes  of 
wynde,  everv  of  them  were  cast  from  othir,  ther  was  amonge 
othir,  one  grete  schippe  amonge  them,  that  were  yn  peryll, 
with  so  grete  a  violence  of  contrary  wynde  so  smyt  and  festnyd 
yn  the  derke  sandys,  that  as  mykil  as  it  was  yn  mannys  know- 
lege,  stode  to  the  myddis  yn  the  sande :  neverthelese  ther  was 
oone  a  monge  the  wepers,  and  waylers  and  mystrustres  ripyr 
and  sadder  of  age  whiche  with  a  meke  and  contryte  herte, 
offerynge  sacrifice  to  God  seid,  ''  I  warne  yowe,  overcumme  in 
labour,  and  now  here  felowis  of  peryll,  unto  this  tyme,  that 
the  goodnys  of  God  hath  be  mercyfull  to  us,  lette  not  us  be 
unkvnde  to  the  precedent  meritis  of  oure  former:  lette  us 
prayse  oure  maker  for  the  perceyvyd  3iftis  of  affluent  grace, 
and  also  for  this  evylles  that  we  sufFre,  justly  oure  demerytys 
requvrynge,  lette  us  take  hit  with  a  pacient  soule.  Now  now 
as  ye  se,  stondith  yn  to  us,  the  day  of  oure  jugement:  now, 
wil  we,  nul  we,  we  become  for  oure  synnys  to  the  butte  and 
terme  or  marke  of  universall  kynde  of  man.  Nevertheles,  O 
vou  men  trust  ve,  3it  remaynyth  hope,  and  3it  here  ther  is 
place  of  foryevdnesse,  and  God  may  delyver  us  from  our  peryll : 
noo  cownsell  artyth  hym,  noo  thyng  excludith  he  from  them 
that  callith  upon  hym  yn  trewith  and  yn  tyme  of  angwyssh, 
whoes  dyvyn  will,  eternally  precedith  every  creature,  his 
dignyte  transcendith  and  his  power  disposith,  lette  us  confesse 
to  hym  oure  synnys,  lette  us  shewe  to  hym  the  nakidnes  of 
oure  synfull  nature,  lette  us  now  or  never,  begyn  to  be  ashamyd 
of  the  wykkidnes  of  oure  shamefull  conversacion,  lette  us  calle 
to  us  the  citycens  of  the  hevenly  courte,  and  beseke  the  helpe 
of  the  blessid  modir  of  God  Marye,  that  she  peys  to  us  the 
kvnge  of  eternall  glorie.  And  5it  ther  is  a  litill  space,  I  beseke 
you  with  oo  sowyl  to  here:  and  3e  here  me  paciently  now, 
now,  it  shall  be  opyn  to  you  the  way  of  helth,  the  porte  of 
jocundite,  the  gate  of  youre  dilyverawnce,  1  have  herde 
specialy  of  oo  seynt,  an  hevynly  cityseyn,  I  have  herde  of 
seynt  Barthilmewe  that  a  monge  the  knyghtis  of  the  hevynly 
kynge  ys  worthy  to  be  callid  uppon  whiche  plesawntly  con. 


Foundatioji  of  St.  Bartholomew  s.         Ixxxv 

descendith  to  the  prayers  of  devoute  askers,  therfor  lette  us 
offer  oure  vowys  to  so  grete  a  patrone  that  it  may  plese  hym, 
by  hys  prayers  to  dehTer  us,  and  oure  shippe  with  marchawn- 
dyse.  Lette  us  therfore  lyfte  up  oure  handis  to  hevyn.  and 
avowe  with  clere  devocion^  that  whan  we  cum  whidir  we 
purpose  to  Lundon^  we  shall  here  thedir,  in  the  hououre  of 
seynt  Barthilmewe  a  shippe  of  sylver,  aftir  the  forme  of  oure 
shippe,  made  on  oure  costys  and  collecte  or  gaderyng  maade 
amongse  us^  offerynge  yt  to  that  chirche  yn  mynde  of  oure 
delyverance."  Unneith  he  cesid  of  speche,  that  al  men  ther 
togidir  helde  up  an  highe  ther  handys,  and  made  ther  vowys, 
callyng  on  seynt  Barthilmewe,  and  nat  yn  ydle.  Al  men  trewly 
by  holdyng  and  the  houre  of  the  nyghe  deith  abidynge : 
presente  was  seynt  Barthilmewe  mercyfully^.  and  with  his  holy 
hande  drewe  forth  the  shippe  by  the  for  ende  the  which 
goynge  forth  with  his  wonnte  pase,  in  the  over  partv^  of  the 
see  come  in  to  the  streym,  and  was  delyvered  from  the  sandys, 
than  at  the  laste  all  were  gladde,  and  blowynge  a  goode  wvnde 
they  come  to  the  porte  of  the  desired  c^te.  And  so  thev  govngfe 
owt  of  the  shippe^  that  litill  shippe  forgyd  and  made  of  silwr 
joyfully  they  bare,  to  the  chirche  of  the  holv  apostle,  and  to 
the  prior  i  callid  with  summe  of  his  chanonns  thev  tellid  the 
processe  of  all  this  storie,  yeldynge  thankvs  to  almvghty  God, 
and  to  the  glorious  apostle  and  martir  seynt  Barthilmewe. 


CAPITULU.M   IV. 

OF  THE  ORATORY  OF  OURE  LADY. 

In  the  eeste  parte  of  the  same  chirche  ys  an  oratorv,  and  vn 
that,  an  awter  yn  the  honoure  of  the  most  blessid,  and  per- 
petuall  vergyne^Iaryy  consecrate.  Ther  was  in  the  conereo^acion 
of  those  brethren  a  certeyn  man  Hubert  byname,  cumme  of  srrete 
kyn,  informyd  yn  liberall  science,  of  goode  age  and  of  wondir- 
full  myldenes,  that  yn  his  all  thyng  worldiv  hadde  forsake  for 
the  love  of  Criste,  nakidly  askapynge  the  wrake  of  this  worlde. 
And  the  habite  that  he  did  on  of  holy  religion,  with  feithfnll 
maners  worshipfully  he  bewtified,  whan  he  was  admyttid  in  to 

^  over pariy,  superficie.  traces  remain  under  the   late   Fringe 

'  This  is  ihe  Lady  chapel  of  which      Factory. 


Ixxxvl         Foundation  of  St.  BartJiolo77te'u/s. 

the  feleship  of  brethren  he  turnyd  all  his  study  to  love  God,  and 
to  prayer,  and  redynge  bysyly  toke  hede,  and  many  that  were 
his  elders  he  passid  yn  rightwysnes,  and  trewth.  This  man  yn 
the  forsayd  oratorye,  afore  the  holy  awter  ofte  prostrate  hym 
self,  and  offerid  hym  self,  a  lovcable  and  qwyke  hooste  in  to 
odure  of  swetnesse  to  God,  and  to  his  blessid  modir.  To  this 
man  a  monge  praynge  yn  the  same  place,  sunityme  apperid  the 
modvrof  mercy,seiyngwith  a  honvand  swete  moweth  "Chanons, 
she  sayed,"  of  this  chirche  thy  bretheryn,  my  derlynges,  yn  this 
place  consecrate  to  my  name,  sumtyme  payid  to  me  solempne 
office  of  massys,  and  devoute  servyce  of  feithfull  reverence  3eif 
to  me,  and  now  hath  undircrept  them  necligence,  charite 
chyillith,  that  nethir  heir  the  holy  mysterys  of  my  son  be 
hawntid,  nethir  to  me  wonnte  praysyng  of  them  be  3evyn,  ther- 
fore  from  the  highe  descense  of  hevynnes  by  the  consent  of  my 
son  hedir  I  descende,  for  the  3evyn  obsequy  of  honoure  to 
3eve  thankys,  and  for  the  necligence  to  undirnym  and  reprove, 
and  for  to  vvarne  my  derlvncres.  Heer  sothly  prayers  and  vowys 
of  them  I  shall  receyve  and  mercy  and  blisse  I  shall  yeve  to 
them  everlastyng,"  thus  she  seyed,  and  from  the  sight  of  hym 
sodanly  dysperyshid.  He  that  these  wordys  herde,  opynly 
expressid  them  to  hys  bretheryn.  And  yn  to  the  servyce 
of  the  modir  of  God  made  them  moore  prompte  and  fervent. 
O  wyth  what  reverence,  with  what  feithfull  and  swete  affeccion, 
ys  that  place  worthy  to  be  worshippid,  whiche  ys  so  holy,  wher 
the  shynynge  queya  of  hevyn,  the  lady  of  the  worlde,  the 
modir  and  most  cleene  spowse  of  the  eternall  kynge  hath 
vouchesayf  to  shew  her  propre  presence,  and  to  the  puttyng 
forth  and  praysyng  of  her  name,  mercyfully  hath  excited  with 
plesaunte  exhortacion,  repellynge  the  sleweth  of  her  servantys. 


CAPITULUM  V. 

OF    A    CERTEYN    CLERKE. 


It  happid  yn  a  towne  that  ys  callid  Enfelde,^  beestis  to  dye, 
with  harde  and  sodayne  pestlence,  the  whiche  pestlence  was 

^  Enfelde,  Enfield, 


Foundation  of  St.  Bartholomew  s.       Ixxxvli 

causid,  of  the  corrupcion  of  the  ayre,  or  els  as  we  bettir  trow, 
for  to  noye  man  to  his  amendment,  5even  of  God  from  above. 
Hit  did  grete  harme  yn  townys  neir  adjacent,  also  ther  was  a  mong 
them  a  certeyn  clerk  a  lover  of  treweth,  and  equyte,  that  lyk 
unfortune,  lyke  harm  had  sufFerid,  ix  of  his  oxys  with  this  pesti- 
lence weere  slavn ;  and  a  yonge  hefker^  alone  levvng,  lay 
yn  thryssheholde  lyke  deithe  as  the  othur  abidynge.  The  seied 
clerk  thes  thinges  consideryng  seied  thes  wordes  "  Lo  our  synnes 
askyng  theunmercyof  oureLordys ire,howgh  yt  commyth  uppon 
us,  and  the  bestys  that  ben  ordeynyd,  to  the  use  of  man,  by  and 
by  dyen,  this  is  expedient  us  for  to  do,  that  be  tweyn  oure 
squorgyng,^  ^eve  we  thankynges  to  God,  in  that  God  3evyth, 
and  God  takyth,  and  as  it  plesith  God,  so  it  is  don,  blessid  be 
the  name  of  God.  In  that,  this  clensyng  scourge,  may  be  with- 
drawe  from  us,  and  this  pestlence  furthermore  attayn  nat,  to 
oure  bowndys,  this  hefker,  that  is  oonly  leyfte  to  me,  3yf  it 
leva,  I  a  vowe  yt  to  be  sent  to  the  chirche  of  most  blessid 
Barthylmewe  the  apostle,  that  by  his  glorious  prayers,  may  be 
turnyd  from  us,  the  respect  of  Goddis  yndignacion,  and  3yf 
this  beist  dye,  whan  the  skyn  shall  be  takyn  from  the  fleshe 
and  I  have  solde  hit  I  shall  make  the  pryse  to  be  sent,  to  the 
same  chirche."  In  the  meyn  whyle  a  marchaunte  was  att  hande, 
with  whom  the  clerke  began  to  treit  of  sale  of  this  beisi, 
demynge  it  shulde  not  escape  the  peryll  of  deith  and  whyle 
they  alterid  to  gidir  the  hefker  airisupp  hole,  and  sownde, 
and  began  to  ete  of  the  hey  that  was  by,  and  the  clerke  this 
beholdyng,  anoon  payed  his  vowe  and  sent  this  hefker  to  this 
forsayd  chirche,  with  goode  hope  made  full  gladde  that  Oure 
Lorde  by  the  merytis  of  the  glorious  apostle,  hadde  accepte  his 
vowe  and  his  prayer. 


CAPITULUM  VI. 

OF  A  CALF  HEVENLY  Y  MARKFD  YN"  BOTHE  ERYS. 

A  certeyn  woman  dwellynge  beside  the  castell  of  Munfychet  ^ 
ledyd  an  holy  lyif  and  thow  she  stode  yn  the  bonde  of  mariage, 

^  hefker,  heifer.  ^  Castle  of  Mountfichet,  finally  de- 

'  squorgyng,  scourging.  stroyed  1276,  was  near  Blackfriars. 

g 


Ixxxviii      Fo7Uidation  of  St.  BariJioloinews. 

as  it  was  us  seyid,  she  3ave  her  soule  to  contynence  and  with 
pravers  and  abstvnence  did  her  devir  ^  God  to  plese.  She  hadde 
a  cowe  with  calfe  the  whiche  by  tokenys  outwarde  drewe 
neir  to  calvyng,  and  stondyng  neyr  the  tyme  that  the  fruyt 
shulde  be  proferid  forth,  the  cowe  began  inwardly  with  throwys 
to  be  torinentid  hugely,  that  it  was  trowid  to  suffir  deith, 
that  beholdvng  this  devoute  woman  sevid  to  her  servauntys, 
"Yf  the  glorious  apostle  Barthilmewe  of  his  wonnt  pite  wyll 
restore  to  us  oure  cowe  hole,  the  calfe  that  she  bryngeth 
forth,  we  shall  marke  yt  on  the  ere,  and  diligently  norysche 
hit,  and  whan  it  is  wenvd  I  shall  sende  yt  to  his  chirche." 
And  with  owt  taryng  whan  all  therto  was  assentynge,  the 
doloure  was  swagid,  the  fruyt  was  forth  brought,  and  a 
mervelous  thyng,  and  a  novelte  wondirfuU  there  nowe  hap- 
pid,  the  calfe  that  newly  was  browght  forth  yn  to  the  light 
from  his  modir  is  worn  be,  hadde  boith  endes  of  his  erys  kyt 
of.  And  the  same  tokyn  and  marke  that  the  woman  seied 
beforn  she  wolde  make  yn  one  ere,  apperid  y  made  yn 
boith.  And  havvnge  no  tokvn  of  the  wonde  newe,  but  as  a 
thvnge  hadde  be  kut  of,  and  helid  a5evn,  so  vestige  apperid, 
who  was  the  doer,  or  with  what  instrument  thei  were  kut,  we 
commvt  that  to  hvm,  that  serchid  the  deyp  secretes  of  man  to 
whom  is  no  thvnge  harde,  no  thynge  ympossible,  they  wondrid 
all,  that  wer  presente,  and  with  a  grete  astonyynge,  all  hertys 
were  smvten,  this  woman  acceptable  to  God  norvsshyd  forth 
this  calf  berynge  yn  hymselfe  opyn  toknys  of  the  hevenly 
marks,  and  yn  due  tyme  browght  with  her,  the  calf  to  the 
chirche  of  the  apostle  and  fulfillid  her  vowe,  blessynge  God, 
that  makith  grete  and  unsercheable  thynges  with  owte 
numbre,  whoes  grete  vertu  and  wysdome  is  with  owte  numbre. 


CAPITULUM  VIT. 

A  GRETE  MYRACLE  OF  A  FRAGMENT  OF  EREDE. 

Certvn  shypmen    at    Sandwyche-  glad  and   mery,  with    a 
prosperous    cowrse    forowid    the    dowtable    see.^      And    them 

^  drc-ir,  duty.  ^  foroivid    the    dowtable    see,   dubia 

"  Sandwyche,  Sandwich.  sulcabant  equora. 


Foundation  of  St.  Bartholomew  s.         Ixxxix 

askyng  the  depth  of  the  see,  that,  that  was  beforn   y  pesid, 
now  was  excitid  by  the  rage  of  wyndys  and  the  forwarners  of 
variannte  tempeste  to  come,  the  clowdys  yn  hevyn   ranne  a 
bowte  the  swellynge,   yn  his  fervor  with  the  hepys  growyng 
of  wavvys,  leift  up  hym  self,  and  cast  the  shippe  nowe  hydyr, 
now  thydyr.    The  governer  wyste  never  whydyr  to  come,  whydyr 
he  shulde  turne  hym,  yn  that,  that  the  gretenes  of  peryll  hadde 
stonyid  ther  mynde,  berefte  them  discrecyon  of  ther  crafte, 
the  wavvys  smyte  upon  them  and  more  myghtly  caste  them  in 
to  the  wavvys,  than  bare  them  up,  and  the  unhappy  shypmen 
thus  owte  of  the  wey  y  cafte.     At  the  laste  they  were  drownd, 
oone  of  them  oonly  clevyd  to  the  flyttynge  maste,  and  with  all 
his  myghtys,  ascendid  on  the  tree,  and  saate  a  bove.     Whiche 
ther  sittynge  and  sumwhat  commynge  to  hymself,  to  the  erys 
of  Godis,  he  sesid  nat  to  crye  and  askid  the  blessid  apostle  of 
Cryist,  seynt  Barthilmew  to  be  nygh  hym,  that  sumwyse  he 
myghtthis  peryll  askape,  and  whan  he  longe  hadde  y  multiplied 
his  prayer,  and  no  remedye  sawe  commynge  neir,  he  seid,  "O 
glorious  apostle  of  Criste,  Barthilmewe,  how  ofte  have  I  callid 
the,  in  the  article  of  so  grete  nede,  and   I  have  not  deservyd 
to  be  graciously  i  herde,  therfore  ther  is  no  thynge  els  nowe 
to  me  but  deithe,  I  beseke  the,  at  the  mercy  of  God,  be  meyn 
for  my  synnys,  that  I,  that  have  not  deservyd  to  be  delyvered 
from  these    perellys,  lette  nat   me   be  deputid   to   everlastyng 
flammys,   that  whatsumever  yn  this  presente  lyf  be  denayid 
me    of  mercy,  may  be   fulfillid  yn  tyme    to    come,  by  thyn 
intervencion   and   merytys."     To   hym   thus   seyynge  beholde 
anoon  was   present  the   glorious   apostle  of  God,  with   glad- 
sum  face   and    plesaunte   chere,  and  at  his  beke  or  wyll  the 
ire   of  wyndys   were   restreynyd,   the    fervor  of   the   swellyng 
see  was  i  sesid,  clerenes  to  hevyn,  tranquyllite  to  the  see  was  i 
3even,  he  beyng  nvgh  to  the  criynge  man  seyed,  "Thy  wepyng 
sighys  of  thyn  contrite   herte  sownyd  yn  to  myn  erys,  ne  I 
denayid  nat  to  3eve  the  helpe,  but  delayd  hit,  nowe  therfore 
come   I  to  the,  a  messanger  of  good  tydynges,  to  3eve  the  a 
3eifte  of  desirid  helth,  for  why  the  mercyful  lorde  hath  perdonyd 
thy  lyif.     And  loo  a  shippe  of  Dovyr^  shall  come  to  the,  and 

^  Dovyr,  Dover. 


xc  Foundation  of  St.  BartJiolomews. 

receyve  the,  and  glad  and  hole  restore  the  to  thy  frendys."  He 
thus  seyynge  porrectid  to  him  a  pece  of  breid,  and  yn  a 
moment  vanysshid  away,  from  his  sight.  An  anoon  a  shipp 
of  Dovyr  was  presente,  yn  the  whiche  he  was  recevuyd 
aftir  the  worde  of  apostle,  hole  and  glad  come  home  to  his, 
and  than  tho  thyngys  the  whiche  the  pite  of  glorious  apostle 
anenst  hym  magnyficently  hadde  i  shewid,  with  feithfull 
relacyon  he  made  opyn,  and  to  the  confirmacion  of  the 
hevenly  benefeit,  the  part  of  breid  that  the  apostle  3ave  hym  he 
shewid,  magnifiynge  God  whiche  puttyth  a  terme  to  the  see, 
whiche  all  thynge,  whatsumever  he  will  he  doith. 


CAPITULUM  Vlir. 

ALSO    A    MYRACLE    Y    DONNE    YN    THE    SEE. 

An  nothir  tyme  befell  a  nothir  myracle,marchauntys  of  Fiawn- 
drys  with  chargid  vessellys,  with  raarchaundise  havynge  wynde 
and  wedir,  enterid  the  see  dredyng  noon  adversyte,  and  faveryng 
the  see,  purposid  to  Lundon.  And  whan  thev  were  passyng  by 
the  myddys  of  the  see,  loo  here  gladnes  was  turnyd  yn  to 
waylyng,  and  joye  in  to  sorowe,  lyif  yn  to  deith,  unwarys  brake 
up  an  violent  tempest,  and  swellyng  the  wavvvs  of  the  see, 
with  unhappy  fortune  the  last  happe  of  unfortune  was  trowid 
nygh  to  them.  What  shall  I  drawe  my  sermon  a  longe,  the 
wyndis  contynually  wexynge  woyde,  boith  shipp  and  shipmen 
were  cast  in  to  the  depthe  of  the  see,  and  both  the  shipp  of 
her  marchauntyse  and  they  of  ther  lyif  ar  privatid,  oone  of  them 
only  lenyng  to  the  maste  yn  the  same  ii  dayes  myghtly  clevynge 
gret  peyne  suiferyd  and  yn  meyn  while  he  usyng  the  benefeit 
of  his  voice,  he  prayid  the  undefawtyng  mercy  of  Criyst,  by 
the  meritys  of  seynt  Barthilmewe  myght  be  neir  hym,  yn  that 
highest  angwyse,  to  whom  whan  for  defaw^tynge  of  his  hert 
the  utteryng  of  his  voice  began  to  breke,  beholde  aforne  the 
weylyng  man  seynt  Barthilmewe  stoid  cherefully  confortynge 
hym,  puttyng  forth  his  hande,  and  drewe  hym  owte  of  the 
wavvys,  and  with  drye  stappys,  sette  hym  at  Dykysmuth  porte, 
and  so  disparisshid.  And  he  fre  from  all  peryll  was  not  unkende 
to  the  vertu  and    grace  of  the  apostle  but  what   he   hadde 


Foundatio7i  of  St.  Bartholo77zews.  xci 

sufferid  of  greyf,  what  of  mercy  he  hadde  optenyd^  by  the  holy 
apostle,  with  trewe  worde  he  inade  hit  opyn,  3evynge  thankys 
to  Godj  in  whom  who  that  trustith,  ys  nat  confowndid,  and 
who  that  callith  hvm  in  to  hymself  is  not  cotempnyed. 


CAPITULUM  IX. 

OF    A    YONGE    MAN    ROBERT    BY    NAME. 

A  certeyn  vonge  cumly  of  person,  Robert  by  name,  from  his 
yonge  age  norvsshid  yn  courte,  from  Northampton  ■■■  purposid 
to  London.  And  it  happid  hym,  thorow  a  thyke  woode  to 
make  his  passage,  where  he  wery  of  his  jorney,  toke  his  reste, 
on  the  grownd  and  a  while  wath  a  litill  slepe  recreate  hym^ 
that  his  way  begon,  the  swyfterly  he  myght  parforme ;  but  loo 
whyle  he  sowghte  reest,  he  fownde  labur,  and  whan  he  wolde 
with  a  litill  reest  his  wery  lymys  refresshe  he  was  yntanglyd 
with  the  snarys  of  his  ennemy.  In  his  slepe  he  was  raveshid 
from  his  resonable  wyttys,  in  his  slepe  his  olde  ennemy  apperid 
to  hym,  yn  the  forme  of  a  right  fair  woman,  the  whiche  with 
flateryng  chere  it  semyd  to  have  sitte  at  his  hede,  and  whan 
with  flaterynge  blandysh,  a  goodwhyle  she  hadde  flateryd 
hym,  and  smothid  hym,  she  put  a  litill  bird  in  to  his  moweth, 
and  so  apperid  no  more.  The  man  awakid,  was  afrayed  of  this 
unwonnt  vision,  and  the  same  houre  he  lost  his  wytte  and 
reson  and  of  all  myght  was  private,-  and  what  was  to  be  don, 
or  lefte  he  knew  nat,  ledynge  hym  woidenes,^  nowe  this  way, 
now  that  way,  he  wanderid  rennynge,  unknowynge  what  he 
did,  hastyly  he  went  whedyr  the  impetuosnes  of  the  malicious 
woodenes  ympellid  hym.  At  the  last  he  was  takyn  at  Lundon 
and  browght  to  the  chirche  of  seynt  Barthilmewes,  and  ther 
yn  shorte  space  his  witte  was  recoveryd  where  a  litill  tyme  he 
taried,  blessyng  God  that  to  his  apostles  hath  vouchesaf  to 
commytte  his  excellent  power,  to  hele  syke,  to  dense  lepers,  and 
to  caste  owte  feendys. 

^  It  is  curious  that  the  passport  in  ^  private,  deprived, 

the  Rules  and  Orders  is  made  out  for  ^  woidenes,  madness. 

a  native  of  Northampton. 


xcii  Foundation  of  St.  BartJwlomew  s. 

CAPITULUM  X. 

OF    A    CERTEYX    KNVGIIT    RADULPII  ^    BY    NAME. 

A  certeyn  knvght  Rayf  bv  name,  of  the  howseholde  of 
William  Demunfychet,-  whan  he  made  his  wey  by  Essex  to 
London,  by  the  dome  of  God/  he  was  ravashid  of  a  feende,  and 
made  woid,'*  and  yn  to  a  reprovable  witte  be  taken,  and  he 
so  woid  i  made,  slyde  down  from  his  hors  ant  rent  his  clothis, 
the  money  tliat  he  bar  he  skaterid  a  brode,  and  thrywh  stonys 
to  them,  that  he  mette  with,  and  now  erryng  yn  wodis,  nowe 
yn  billys,  and  now  a  monge  he  medyliyd  hym  self.  Amonge 
the  preysse  of  peple  and  them  that  came  a3enst  hym  he  cast 
them  yn  peryll,  or  yn  drede.  Thys  man  on  a  tyme,  thowh 
gretely  he  withstode,  was  take,  and  browght  to  the  same 
chirche,  and  whan  he  hadde  taryed  ther  ii  nyghtys  he  come 
to  his  mvnde  asfavn. 


CAPITULUM  XL 

OF    A    CERTEYX    MANNYS    SOXE. 

Ther  was  also  in  the  towne  of  Berwyk  ^  a  certeyn  man,  Spyl- 
inan  by  name,  thst  usid  the  plowe,  and  solde  woode,  and  with 
woode  to  sylle,  he  come  to  London.  Y  know  to  many  men  he 
hadde  a  childe  that  was  grevously  syke,  with  the  fallynge  evill. 
The  fallynge  evill  aftir  phisiciens  is  a  syknes,  that  compressith 
the  ventriclis  and  the  weys  of  the  brayn,  lettyng  the  operacion 
of  the  wyttis,  as  sight,  heryng  and  othir  bodyly  wyttys  takith 
a  way,  and  werith  all  the  body  with  an  harde  passion.     This 

•*  The   title  of  this   chapter   in  the  in  1135,  and  was  not  livinij  in  Henry 

Latin  life  is  "De  milite  quodam  Wil-  II. 's  reign;  the  second,  his   nephew, 

lelmo  nomine,"  but  it  goes  on  "Miles  is  a  witness  of  the  charter  of  founda- 

quidam   Radulphus  nomine  de  familia  tion  of  that  abbey,  and  is  probably  the 

Willelmi  de  Munfichet."  lord  whose  retainer  Rayf  was. 

-  The  family  of  Montfichet  flourished  ^  dome  of  God,  judicio  Dei. 

in  England  from  1066  to  1258,  and  the  *  woid,  mad. 

name    is   still    preserved   at    Stansted  *  The  Latin  MS.  gives  the  true  name 

Mountfitchet,  in  Essex.      There  were  of  this  town  Bef7tech,  Barnack,  in  Nor- 

two  Williams  of  the  name.     The  first  thamptonshire. 
founded  the  abbey  of  Stratford  Langton, 


Foundation  of  St.  Bartholomew  s.  xciii 

childe  laborvnge  yn  this  sykenes,  was  browght  to  the  forsaid 
chirche,  yn  the  solempnyte  of  the  glorious  apostle,  and  whan 
the  iiij  lesson  of  his  passion  was  redde,  the  helth  receyvyd  of 
all  his  membris  he  come  to  kvsse  the  auctur,  and  than  nat  a 
Htil!  he  accendid  yn  to  devocion,  all  that  wer  ther  presente  to 
the  laude  of  God,  and  the  blessid  apostle,  and  nat  oonly  of  the 
comyn  pepyll,  but  also  of  the  clergye,  thankynges  were  3eve 
to  God,  for  why  he  ys  good,  and  forvvhy  in  to  the  worlde.  his 
mercy  is. 


CAPITULUM  XII. 

OF    THE    DOUGHTVR    OF    WYMUNDE    THE    PREYST. 

A  preiste  Wymunnde  bv  name,  that  governyd  the  chirche  of 
seynt  Martvn,i  that  is  situate  yn  the  corner  of  the  wey,  that 
ledith  to  Westmynster,  many  yeres  he  had  receyvyd  on  hym 
by  the  institucyon  of  the  bysshoppe  of  London,  the  deynrye 
of  nygh  chirches  for  maters  ecclesiasticall  to  discusse.  This 
man  by3onde  equyte  3even  to  voluptuous  lyif,  and  his  in- 
continence, was  ever  redy  to  slyde  to  the  worse,  nat  refrevn- 
ynge,  with  the  bridill  of  clennes  and  chastite,  purchasid  hym  a 
lemman,  and  of  her  unlefully  begait  a  doughtir,  whom  he 
lovynge  with  fadirly  afFeccion  yn  yonge  age  put  her  to  lern- 
ynge,  and  whan  she  came  to  age  of  mariage,  put  her  to  a 
matrone,  the  whiche  yn  a  wommannys  breyste  hadde  a  mannys 
herte,  and  refreynyd  her  from  that  vice  that  folowyth  that 
age^  and  with  wholsumme  doctryne  studied  to  enforme  her.  The 
mayde  therfore  was  kepte  attendawntly  and  with  chaaste  dis- 
cipline informyd,  and  she  began  to  be  wyser  than  her  techer, 
and  for  to  shewe  the  forme  and  example  of  virgynal  puryte, 
to  all  them  that  lyved  abowt  her.  Certeyn  whan  of  many 
wowers,  this  virgyn  was  desirid,  she  myght  nat  by  noon 
cautelys  or  suttyll  suggesstion  be  deceyvyd,  for  n eider  wolde 

^  St.  Martins  in  the  Fields.     Triis  is  date  is  unknown,  but  it  was  between 

probably  the  Wymund,  "dean  of  Lin-  I103  and   1162,   and   may  have  been 

coin,"  recorded  as  having  held  the  stall  near  the  latter  year,  so  that  his  daughter 

of  Neasdon  in  St.   Paul's    Cathedral.  might  easily  be  grown  up  in  1 1 74,  the 

(Le  Neve  :  Fasti.  II.  414.)     His  exact  year  of  these  wonders. 


xciv  Foundation  of  St.  BartJioloinew  s. 

not  she  admytte  the  flatterynge  speche  of  bawdys  or  lechorys, 
but  the  carnal  drawghtes  of  voluptuosite  she  tamynge  myghtly 
troid  them  undir  foit,  unspottid  evermore  abidyng.  Thys 
clennes  envied  the  ennemye  of  man  kynde,  wyllynge  to  sub- 
verte  yn  her  the  purpos  of  clennes.  And  new  suttelteys  of 
noyyng  he  consellid  and  sowghte,  and  unherde  deceytys 
ordeynyd  and  fownde,  a3enst  the  virgvne,  the  whiche  sufFerynge 
the  rightwysnes  of  God  not  oonly  we  merveyle  but  also  drede, 
ffor  thowh  God  ynwardly  beholdynge  howh  it  myght  be  don, 
we  be  demynge  to  us  this  a  monstruous  thynge.  Therfore  this 
suttell  serpent  transformyng  hym  self,  yn  to  the  lyknes  of  a 
fair  yonge  man,  as  he  hadde  be  a  gentill  man  of  the  kynges 
blode,  more  vylyfycat  with  precyous  ornamentis,  than  y  bewti- 
fied  for  shynyng  of  his  bewte,  thus  sodenly  slyde  yn  to  the 
chambyr,  where  sole  this  mayde  sate,  the  whiche  y  seyn,  with 
a  sodayn  fray  she  was  smytte,  and  whens  he  came,  and  howe 
he  entrid  she  was  astonyed  and  raervellid,  and  behelde  the 
bewty,  and  the  shynynge  of  his  chere  with  a  sympyl  but  nat 
with  a  prudent  ye.  The  ennemy  felt  the  drede,  of  the  light 
wommanhedcj  wherfore  he  drewe  nyghyr  and  sate  down  by  her 
syde,  and  owte  of  mortall  and  dedly  breste  he  cast  owte  harde 
venym.  Ffirst  trewly  with  swete  venemvs  wordis  comfortid  the 
dredfull  and  than  prayers  and  promyssis  medillid,  yn  that  she 
wolde  grawnte  her  assent  to  fowylle  use,  and  yn  the  meyn 
while  he  knytte  his  engynnvs,  of  sotell  deseyt.  The  mayde  a 
litill  withdrewe  her  drede  and  toke  an  hardynes  of  speche, 
and  thus  she  answerd,  "  It  is  no  prudent  mannys  dede,  that  usith 
reson  suche  a  conseyvyd  desire  yn  herte,  so  unshamfully  to 
uttyr,  ne  so  unsemely  will  to  do,  ffirste,  it  were  fittyng  the 
nobiley  of  thy  birthe  to  shewe  to  my  parentys,  and  than  with 
consent  of  us  both  the  lawe  of  matrymony  to  make,  and  that 
i  contracte  and  streghthyd  with  solempne  auctorite  of  the 
chirche  halowynge,  and  so  to  pay  the  dette  of  body  eche  of  us 
to  othyr  nat  for  bernynge  luste,  but  oonly  by  cause  of  genera- 
cion.  Thou  purposist  alweyes  the  contrary  way,  thou  makyst 
no  mencion  of  God,  nethir  of  man,  but  oonly  purposist  the 
fury  and  wodenys  of  thyn  voluptuous  soule,  and  so  the  shame 
of  God  and  man  y  putte  behynde,  thou  prayst  me  to  consent 
to  thyn  maligne  voluptuosyte,  fiyrst  forsothe  telle  me  who  and 


Foundation  of  St.  Bartholomew  s.  xcv 

what  thou  art,  and  by  whom  a  wyttnes  thou  art  hydder 
admyttyd,  and  of  other  thynges  heeraftyr  use  thou  bettyr 
concell  and  be  bettyr  avisid.  To  this  the  ennemy  answerid, 
what  sekist  thou  heyr  the  ordir  of  reson,  wher  only  we  talke 
to  gidre  for  oure  wylle,  heyr  pite  is  wynnyng,  religion  is  super- 
sticion,  where  oure  dede  and  purpos  ys  of  the  wracke  of  chastite, 
no  lawe,  no  custome  is  to  be  consellyd,  but  oonly  the  rewarde 
of  unclennesse  is  to  be  attendid  vvherfore  to  aske  this,  who  I 
am  and  howh  I  cam  hidyr  it  is  but  voyde  to  enquere,  oonly 
to  my  peticion  joyne  thyn  afFeccion,  and  aftir  promysse 
swiftly  an  hastly  shall  folowe  effecte/^  Aftir  theys  and  moo 
yn  this  wyse  whan  they  hadde  to  gider  said,  the  noryssh  ^ 
of  the  virgyn  cummynge  uppon  mervellid  with  whom  she 
spake,  she  herde  a  voyce  of  oone  that  spake,  but  she  sawh 
no  man,  but  the  mayden.  At  whois  cummyng,  the  ennemy 
disparysshid  a  wey,  but  3eit  he  was  nat  for3eitfull  of  the 
unshamefaste  boldnes,  wher  that  ever  the  mayd  he  sawh  aloyn, 
in  the  manner  of  a  wantan  joly  yonge  man,  yn  like  ordyr  he 
callid  on  the  mayde:  she  trewly  with  prayer,  and  tokyn  of  the 
crosse,  her  self  wardyng,  so  defendyd,  that  for  all  his  engynnvs 
and  waytys  she  skapid  untowchid.  On  a  day  whan  the  mayde 
was  sole  yn  her  chambre,  this  malignynge  theyf  was  presente 
tayryr  than  he  was  wont,  with  shyiiynge  chere,  and  first  he 
yave  prayers,  and  aftir  promysse,  and  whan  with  this  nothyng 
he  profitid,  he  arayed  to  brynge  yn  violence,  whois  boldes  the 
virgyne  felynge  beforn,  with  grete  cryes  she  fulfillid  the  bowse. 
In  the  meyn  whyle,  whan  the  servauntes  raan  to  the  noyse,  the 
malignyng  ennemy  went  his  way,  and  smytte  the  virgyne 
seyyng,  "Why  wolt  nat  thou  consente,  and  receyve  of  my  3yftis, 
sumwhat  now  thou  shalt  feil,  what  may  the  hande  doo  of  myn 
enmyte."  And  an  noon  yn  the  goynge  a  way  of  the  ennemy, 
the  virgyne  fyll  down  yn  to  erth,  owte  of  her  wytte,  and  with 
a  grete  passion,  yn  her  body  was  tormentid  and  wallowynge 
ofte,  and  a3en  turnyng  with  ynordynate  gesture  of  her  lymmys, 
the  sorow  wytnesyd  deith.^  To  whom  rennyng  the  servauntes 
fownde  her  halfe  a  lyve  and  with  a  compleynynge  noyse 
fulfillid  the  howses.     The  neyghborys  were  gaderyd  all  abowte 

^  noryssh,  XM^xit.  internum  testatur  dolorem.    Latin  MS., 

'  De  inordinata^  gestu   membrorum       32  A.  col.  I,  line  1-3. 


xcvi  Fo7indation  of  St.  Bariholomew's. 

and  grete  confluence  of  peple,  for  the  novelte  of  suche  a  dede, 
and  all  the  peple  were  turnyd,  yn  to  a  stonyynge,  and  an 
horror,  and  whan  the  virgyne  was  thus  longe  y  tormentid, 
at  the  laste  fomynge  at  the  moweth,  aftyr  many  sighynges,  a 
litill  she  toke  breith,  and  tolde  was  don  abowte  here  how  the 
spirite  of  malice,  hadde  aperid,  and  with  what  promysse,  he 
hadde  atemptid,  to  drawe  here  to  consente  of  unclennesse, 
and  howe  confusid  goyng  away,  he  smytte  her,  and  aftir  the 
stroke  so  grevous  ynfermyte  folowid,  and  uneith  she  hadde  endid 
her  wordys,  and  loo  a5een  the  same  wyse  as  be  forne  she  began 
to  be  tormentid.  Therefore  whan,  twyes,  or  thryes  every  day 
and  sumwhyle  moer  oftynner  she  was  so  i  tormentid,  by  the 
peticion  of  the  same  virgvne  and  consell  of  her  parentys,  she 
was  browghte  to  the  chirche  of  seynt  Barthilmewe,  and  she 
was  born  forth  on  a  carpete^  and  passid  forth  aforn  the 
hospitall  of  the  same,  the  forsaid  ennemy  was  present,  seyvnge 
to  the  virgyne,  ^' Whidir  art  thou  born,  trowyst  thou,  that  the 
apostle  shall  delyver  the  from  myn  handys  yf  thou  graunte  nat 
and  consent  to  me,  with  lenger  and  harder  dvsesys  thou  vexid 
and  made  wery  shall  dve."  Aien  also  whan  she  was  put  down 
from  the  carpent  for  to  be  born  yn  to  the  chirche  he  apperid 
to  her  sevvng  "  Stonde  mayde  stonde  and  forbydde  to  be  born 
yn  to  the  chirche,  for  I  shall  5eve  the  helth,  and  all  that  is 
desirable  to  helth  at  thyn  wylle  I  shall  make  3evyn  to  flowe  to 
thyn  hande,"  and  to  this,  the  mayde  answerde  no  thvnge,  but 
trustid  yn  God,  and  her  handys  lyfte  up  yn  to  hevyn  she 
besowghte  the  mercv  of  God.  Therfore  this  wykkid  ennemy 
sevnge  hvmself  thus  deluded,  and  scorned  with  sharper  prik- 
kvnges  wexid  woide  a5enste  the  virgyne,  and  with  a  moore 
grevous  passion,  than  he  was  wonnt  smyt  her.  The  channons 
of  the  chirche  was  ther  present,  seyng  this,  and  with  devout 
prayers  besowght  the  apostle,  that  with  his  woonnte  pyte  he 
wolde  succur  this  laborynge  virgyne.  Our  'Lorde  graciously 
herde  his  pravnge  servauntes,  askynge  that  was  right  and  by  the 
merytys  of  the  holy  apostle,  delyverid  the  virgyn  from  the 
feende,  and  so  delyverd,  restorid  her  fully  to  her  helth.  The 
mavde  than  was  betake  to  her  parentys,  the  whiche  all  vn  God  ^ 

^  carpet,  a  mistake  for  carpent,  car-  -  Latin  MS.,  in  domino. 

pen  to  in  the  Latin  MS.,  a  litter. 


Foundation  of  St.  Brn'tholomew's.  xcvii 

joyynge,  prechid  everywhere^  the  vertu  of  the  apostle,  preysvng 
and  blessyng  God,  the  whiche  hatyth  no  thynge  that  he  hath 
made,  whois  domys^  ben  manyfolde  depe  derkenesse. 


CAPITULUM  XIII. 

OF    A    FEVERUS    MAN    THAT    LACKID    HIS    YE  ^    SIGHT. 

A  certeyn  man  of  the  castell  of  Chillam/  take  with  grete 
syknes,  in  sorowe  and  byttyrnes  of  herte,  lede  his  unhappy  lyfe. 
Atte  the  laste  sorowe  grewe,  uppon  sorowe,  for  his  axses*  encres- 
ynge  he  lost  the  light  of  boith  yen,  therfor  he  graspid  abowte, 
trustynge  to  othir  mennys  paysse,  and  sayynge^  his  way  with 
his  stayff,  and  so  a  certyn  tyme  he  sate  yn  derknes.  Now  the 
ix*'  monyth  was  passid,  whan  the  wrecch  cessid  nat  of  his 
contynuall  syknes,  ever  cryynge  and  askyng  and  askyng  and 
criynge,  till  the  mercy  of  God  wolde  here  hym. 

Whan  he  come  trewly  to  the  chirche  of  seynt  Barthylmewe 
the  holy  apostle,  he  receyvyd  light  of  boith  yen,  and  for  the 
gyfte  opteynyd,  he  3yldynge  thankys  to  God,  boith  to  lerned 
and  othir  that  stoide  abowte  witnessid  feithfully  the  vertu 
of  Cryistes  apostle. 


CAPITULUM  XIV. 

OF    A    CERTEYN    YONGE    MAN    Y    BOWNDE. 

A  certeyn  yonge  man  takyn  of  his  ennemyes  y  bownde,  was 
born  yn  a  carte,  for  to  be  commyttyd,  to  a  streyter  warde.  And 
whan  the  passage  was  made  by  the  same  chirche,  yn  goynge, 
he  callid  uppon  the  name  of  the  holy  apostle,  and  sodenly  he 
fownde  hym  self  i  losid,  and  an  noon  he  skippid  owte  of  the 
carte  and  enteryd  the  chirche.  And  yn  this  wyse  he  skapid, 
the  handis  of  his  ennemyes. 

^  douiys,  dooms,  judicia.  man  keep  which  was  standing  in  the 

^  y^t  eye.  time  of  this  man. 

^  Chilham    castle,    six    miles  from  ^  axses,  access  of  fever,  febre. 

Canterbury,  includes  parts  of  a  Nor-  ^  sayynge,  trying. 


xcviii  Foundation  of  St.  Bai'tholomews, 

CAPITULUM  XV. 

OF    A    CERTEVN    YONGE    MAN    DUM. 

A  certeyn  yonge  man,  while  haply  he  lay  grovelynge  on  the 
grownde,  desirynge  awhile  to  rest  hym  self,  by  the  malice 
of  the  olde  ennemye,  he  wexed  dumme,  and  so  lakkynge  his 
speche  of  a  certeyn  yonge  woman  cosyn  to  hym,  was  leid  and 
browght  to  the  same  chirche.  And  boith  of  them  knelid  down, 
a  fore  the  holy  awter,  and  with  waylyng  hertys  besowghte 
the  helpe  of  seynt  Barthilmewe,  and  the  same  day,  was  restorid 
to  hym,  the  office  of  his  tonge. 


CAPITULUM     XVI. 

OF    A    MARCHAUNT. 

Ther  cam  on  a  day  to  the  sayd  chirche  a  certeyn  man,  and 
askid  to  speke  with  the  bretheryn,  and  what  that  happid  to 
hym,  he  wolde  expresse.  He  was  browghte  yn  to  the  chapter 
howse,  and  the  chanonns  beyng  prcsente,  thus  he  began  to 
speke  "That  ye  may  knowe  how  pituous  and  howe  glorious 
a  patron  ye  have,  her  my  lordis,  what  late  happid  to  me, 
and  to  my  felshippe,  and  consider  that  he  that  ye  worship 
yn  erthe,  yn  hevyn  and  yn  the  see,  is  of  grete  mercy,  and 
of  grete  vertu.  We  were  yn  a  shippe,  many  of  us  to  gidir, 
and  arysynge  up  a  sodayn  tempest,  we  began  to  perysshe, 
yn  so  mykill,  that  mystrustynge  to  leve,  oonly  we  abyded 
the  last  houre  of  oure  perill :  in  the  meyn  whyle,  we  cessid 
nat  to  wayle  for  oure  synnys,  to  knocke  oure  brystys,  to 
calle  yn  to  us  many  helpys  of  seyntes,  and  trewly  yn  the 
hyndyr  part  of  the  shippe,  with  tremulynge  lippys,  and 
sorowfull  herte  y  besowghte  the  mercy  of  God,  where  I  herde 
a  voice  seyyng,  "what  crye  3e  upon  so  many  namys  of  seyntes, 
and  youre  patron  by  specyal  prevylege,  grawntid  of  God,  to 
yow,  3e  lacches  to  calle:  "^  to  whom  I  seyed,  "who  is  that 
my  lord,"  and  he  seid,  "most  blessid  Barthilmew  calle  yeyn  to 

^  le  lacches  to  calle,  invocare  negligitis. 


Foundation  of  St.  Bdrtholoinews.  xcix 

you,  and  hym  56  shall  feill  most  prompte  helper  in  this  present 
perill,"  and  forthwith^  I  cam  to  my  felshippe,  and  tellid  what 
I  herde,  and  that  they  shulde  yeve  feith,  ther  to,  yn  all  wyse 
I  monyschid  them,  and  than  to  gidyr  with  one  soule,  and 
inwarde  afFeccion  of  hert,  with  grete  clamoure  of  voice,  we 
callid  yn  the  holy  apostle  to  3eve  his  helpe,  to  wrecchis 
perysshynge,  and  to  grannte  us  port  salfe  seyynge,  "Lord,  Lord, 
save  us,  we  perysch,  oure  helth  ys  yn  thyn  hande,  lette  thy 
mercy  loke  uppon  us,  and  securly  we  shall  serve  the."  O  mervel- 
lous  is  to  sey,  to  the  a3eyn  criynge,  of  that  holy  name  the 
elementys  yeve  way  to  us,  and  servyd  oure  wille,  the  sky  that 
beforn  was  derke  clothid  hym  yn  hys  light,  the  see  cesid  from 
his  fervor,  the  trowblys  tempestuous  wyndis  uttirly  rested  them. 
And  so  forth  than  aftyr  brethynge  of  softe  plesaunte  wynde, 
that  ys  callid  3ephirus  we  saylid  and  optenyd  a  port,  and 
nowe  we  came  to  the  chirche  of  oure  delyverer,  and  for  the 
benefeit  y  govyn  to  us  of  so  grete  a  pite  both  to  hym  and  to 
you  the  servantys  and  frendys  of  hym,  we  3eve  thaukynge  and 
to  God,  O  ye  happy  and  weylsum  36,  and  most  weylsum 
religious  men,  that  joye  her  undyr  so  clere  a  duke,  so  myghty 
a  prince,  and  so  mercyfull  a  fadir.  Of  us  ye  may  considre, 
ho  we  rauche  3e  may  trust  and  hope  of  hym,  of  consolacion 
and  of  grace  for  whyle  he  was  so  mercyfull  to  us,  so  strange 
from  his  his  servyce,  what  benygnyte  and  howmuche  reservyth 
he,  to  his  most  belovyd  servantys."  Thus  he  seyid,  and  commend- 
ynge  hym  self  to  the  prayers  of  the  bretheryn,  he  offerid  his 
oblacion,  and  joynge  from  joyfulmen,  he  toke  his  way. 


CAPITULUM  XVIIT. 

OF    A    CERTEYN    MARCHAUNTE. 

In  that  tyme  that  the  secunde  kynge  ^  of  Englond  besegid 
Walys,  wuth  strange  hande/  it  happid  a  notable  myracle,  and 
worthy  to  be  tolde.  Ther  was  a  man  of  Colchester,  havyng 
oportunyte  to  execute  that  he  had  decreid,  yn  his  mynde,  that 

^  The  Latin  reads  :  Henricus  secundus  ^   With  strange  hande,  represents  cum 

rex  anglie.    Henry  II.  invaded  Wales  in       valida  manu  of  the  Latin  MS. 
1 1 57.  Matthew  Paris,  Rolls  ed.,  II.,  214. 


c  Foiindation  of  St.  DartJiolovieiv  s. 

were  nedefull  to  the  hoyste  lyynge  at  the  seygge.  Of  his 
goodis  he  studied  to  brvng  thidir,  and  that  he  wolde  be  solde, 
he  sette  yt  at  a  price  as  he  wolde,  and  with  yn  shorte  tynie 
wan  muche  money.  And  whan  he  hadde  layid  it  uppe  dili- 
gently, in  certeyn  the  seyid  man  had  sum  penyes  the  whichc 
of  a  vowe,  were  dettefull  to  the  chirche  of  seynt  Barthylmewe, 
nevertheles  he  reteynyd  these,  that  these  with  othir  of  his 
owne,  by  ofte  eschangynge  he  wolde  had  multiplied,  and 
yii  oportune  tyme  bothe  his  vowe,  and  whatsumever  encressid 
a  bove  of  his  vowe,  he  wolde  brynge  hyt  to  the  forsaid  chirche, 
Therfore  whan  he  disposid  hym  self  to  turne  home  to  his,  and 
be  watyr  he  was  coartid  ^  to  make  his  passage,  the  shippe  with 
othir  no  thynge  demynge  of  evyl,  he  enterid,  and  whan  they 
saylid  forth,  he  slepyd,  his  money  layid,  undir  his  hede,  in  the 
meyn  whyle,  oone  that  wente  with  hym,  conceyvyd  hit,  And  he 
overcumme  with  desire  of  that  money,  theyfly  withdrew  hyt, 
and  whan  they  cam  to  the  port,  undyr  a  certeyn  stone,  nat 
fer  from  the  port,  he  hidde  hit,  the  man  awakid  sowghte  his 
money  and  fownde  it  nat,  inquyryd  of  hys  felship,  yf  ony 
man  yn  game  or  ernest  had  take  hyt,  they  for  his  demawndynge 
3eif  hym  rebukys,  havynge  scorne  that  he  shulde  rejirove  them 
of  thevft,  the  whiche  feithfull  felship  he  hadde,  Therfore  wher 
he  sawh  that  mannys  helpe  was  uttirly  denayd  hym,  with  all 
his  soLile  he  convertid  hym  self  to  God  and  with  an  ynvvard 
waylynge,  shedynge  owte  for  sorowe  terys,  cessid  nat  to  calle 
on  the  mercy  of  the  blessid  apostle  Barthylmewe,  and  loo  in 
the  sylence  of  the  derke  nyghte,  to  hym  slepynge  apperid  yn 
a  vision  the  glorious  apostle  of  God,  and  in  thys  maner 
many  thynges  with  hym  he  talkid,  '' O,"  he  said,  "man,  what 
cryiste  thou  soo  oncessantly  and  with  importune  crves  cessist 
nat  to  unreste  me,"  and  he  sayd,  '^  thou  knowist  and  well  knowist 
syr,  the  cause  of  my  crye,  and  it  is  no  nede  to  opyn  to  the,  the 
maner  of  my  wrecchidnesse,  the  whiche  so  many  sighyngys  yn 
wepynge  and  waylyng  I  have  opynd  a  forne  thy  face,  and 
ageyn  reherssid  hyt,  no  it  is  not  hidde  from  thy  pite,  from  how 
grete  joye,  in  to  how  grete  waylyng,  from  how  grete  ricches, 
with  sodeyn  case,  I  am  come  yn  nedynes,  and  of  so  grete  an 

^  Et  per  aquam  tiansire  necessitas  itinerii  cogeiet. 


Foundation  of  St.  BartJiolomews.  ci 

hurte,  ther  is  to  me  no  remedy,  ne  no  cownsell  3evyn,  ther- 
fore  the  allone  I  trustid,  that  my  solace  shulde  come,  thou 
therefore,  that  thou  mayist  3oe  and  for  thou  mayste,  helpe  me, 
havyng  mercy  of  me."  To  whom  answered  the  seynt,  "This 
money  for  whoes  lost,  thus  thou  lamentyst,  unrightwysly  thou 
hast  gotyn,  and  whyle  with  myn  helpe  thou  askyst  to  be 
of  that  restorid,  so  thou  askist  that  thou  woldyst  make  me 
partyner  of  thyn  synne,  the  whiche  of  the  rightwys  dome  of 
God,  thou  hast  lost  and  for  cause  yn  rycchynge  of  thy  self, 
othir  men  thou  spoylid,  undredfully,  now  thou  begynnyst  to 
nede,  and  othir  have  and  consume  thy  rycches :  3e  forsothe 
marchauntis,  men  of  untrew  soule,  forsakers  of  trewth  and 
equite,  nat  dredynge  God,  ne  havynge  compassion  of  youre 
evyn  crysten,^  with  gyle  and  othys  al  men  bygilynge,  ye 
presente  God  and  his  seyntes,  wytnes  to  youre  wyckednes, 
consumynge  othir  mennys  poochys  to  fulfill  your  pursys,  who 
therfore  shulde  have  mercy  on  yowe,  who  shulde  norysshe 
suche  wreechis,  nat  mercyable  yn  so  grete  a  malice."  "  Lord," 
he  seyide,  "yf  I  have  unrightwysly  gete  my  money,  3it  sum  of 
that  I  have  decreid,  to  converte  yn  to  goode  werkys  and  with 
them  to  visite  thy  chirche,  and  purpose  to  rewarde  thy  servauntys 
ther."  ''O,"  seid  he,  "  this  is  yur  woodnes,  that  whan  with  many 
wylysj  36  have  spoylyd  pore  men,  that  of  the  raveyn  of  pore 
men,  sumwhat  to  the  worship  of  God  ye  depart,  that  more 
securly  ye  may  abyde  yn  youre  synne,  and  yn  thys  wvse 
36  trowe  to  pees^  God,  but  God  hatyth  raveyn  3even  yn  to 
sacryfyce,  and  no  more  the  3iftis  of  suche  men  plesith 
hym,  than  the  wagis  of  strompethode,  or  the  sacrifice  of 
an  hownde,  or  as  he  that  wolde  sacrifice  the  childe  to  the 
fadyr.  Nevertheles  wher  of  joyest  thou  telle  rae,  and  whan 
thou  visitid  my  chirch."  "I  wolde,"  he  seyid,  "and  purposid, 
but  with  dyvers  bysynes,  i  lette  I  myght  nat  come  thidyr." 
And  than  the  seynt  answerid,  "Whan  all  thyng  habowndid 
with  the,  thou  haddist  no  tyme,  to  come  to  my  chirche,  to 
prayse  God  to  redeme  thy  synnys,  now  y  sped  and  delyveryd 
of  all,  thou  hast  noon  impediment,  ne  no  perill  of  drede,  surelv 
whidir  that  ever  thou  wolt,  thou  mayst  goo."     And  he  seyid, 

^  ne  havynge  compassion  of  youre  ezyn  ^  fi^-s,  appease. 

crysten,  nee  proximis  compacientes. 


cii  Foundation  of  St.  Bartholomew  s. 

''  Lord^  how  inav  I  presume  thv  glorious  temple  to  aske  or  desire, 
and  voyde  from  sacrifice,  in  the  sight  of  God  and  of  the  to 
appere."    "  Nay,"  sapd  he,  "  I  nede  nat  thy  5iftis,  it  is  sufficient 
to  me  y  nowh  the  grace  of  God,  for  to  provyde  for  the  nede  of 
my  clerkes  ne  I  am  nat  unmyghty  to  5eve  fode  to  them,  that 
servyth  me."     "That  ys  trowth,"  seyid  the  merchawnt,  "ther- 
fore  my  goode  lorde,  leste  hapley  my  wykydnes  be  more  than 
thy  copyous  goodnys,  loo  heyr  before  the,  of    my  trespace  I 
repente,  behestyng  amendes,  that  the  raony  whiche  summtyme 
I  promysid,  to  thy  chirche,  and  more   I   avowe  me  thedir  to 
brynge."  To  this  the  apostle  answeryd,  "And  I,"  seyid  he,"undir 
this  condicion,  trewly  shall  not  dyscover  the  gilty  by  name, 
but  to  hvm  of  whom  thy  money  shulde  dewly  be  asked  ageyn, 
I  shall  gyf  cownsell,  to  seye,  that  he  of  thy  felship  late  skun- 
fitid  in  batayll,  prively  toke  a  way  thy  money,  and  yn  to  thys 
tyme  hath  kepte   hyt   hole,  and   I  of  this   nat  unknowynge, 
iiave  not  y  sufferid  hym  to  lessen  hit,  in  that  I  knewe  beforne, 
that  thou  calledist  upon  me,  that  by  me,  thou  myghtstid  thy 
loosse  recove."     At  thevs  wordys  speche  and  vision  made  an 
ende.    The  man  awakid,  that  he  sawh  and  herde  besyly  revolvyd 
yn  his  mvnde,  discussynge  diligently,  the  life  and  dede  of  his 
felshipp,  and  by  hym  self  no  thyng  certeyn  myght  comprehende. 
At  the   laste  he  5ave  way  to   a  flittyng   and   a  tempestuous 
varyaunte  soule,  and   began   to   aske  and  cownsell  a  preyst  i 
lernyd  by  scripture  yn  suche  visions,  what  were  goode  yn  thys 
to  be  done.     And  the  preyste  cownsellid,  dowtys  layid  a  parte, 
and  commawndid  hym  to  3eve  feith,  to  that  he  herde,  seynge 
hit  were  impossible,  to  be  othir  wyse,  than  the  apostle  hadde 
sayde.    It  plesid  therfore,  them  bothe  to  calle  oone  of  the  kynges 
mynystris  for  that  to  such  men  dyvers  thynges  ben  knowe  that 
be  doyn  in  many  placys,  the  which  ofte  ben  present  yn  pleys 
in  quarellys  in  sclaundrys,  in  jugementes;  therfor  thei  went  to 
gidir  to  the  provost  of  that  place  and  with  promyssys  prayed  him 
to  be  favorable  to  the  be  forsaid,  and  so  they  declarid  to  him  al 
the  processe  of  this  mater.    And  by  the  dylygence  of  this  man, 
the  man  was  sowght  and  fownde,  and  browght  yn  to  a  secrete 
place,  and  only  presente  the  provost  and  the  doer  of  the  tres- 
pace, he  was  callid  yn  of  the  preyste  and  opposid,  and  the 
preyste  prayed  hym,  and  exhortid  hym^  that  he  wolde  restore 


Foundatio7i  of  St.  Bartholomew's.  ciii 

the  money,  that  he  toke  a  way,  undyr  the  mannys  hede,  whan 
he  slepid,  and  this  he  seyed  I  was  shewid  and  ynformyd  veryly 
with  so  trew  a  wytnesse,  the  whiche  by  commyn  estymacion 
myght  nat  lye,  therfore  yf  he  wolde  ynclyne,  to  ther  cown- 
sellys  he  may  go  unhurte,  yf  he  wolle  denay  hit,  the  kynges 
officer,  hym  as  a  theyf  may  holde,  and  sesyn,  and  for  to  be 
condempnyd,  betake  hym  to  the  jugys.  He  anoon  full  of  drede, 
drewe  the  preist  a  parte,  and  his  gilt  confessid,  restorid  to  hym 
the  money  yn  hole  summe,  and  no  harme  sufFerynge  frely  went 
his  way.  By  this  maner  the  forsaid  man  by  seynt  Barthylmewe 
receyvyd,  that  was  take  from  hym,  and  aftirward  comyng  to 
his  chirche,  ofFerid  that  he  vowid,  and  to  the  bretheryn  of  the 
place,  all  thyng  that  was  donne  abowte  hym  opvnly  declaryd. 


CAPITULUM  XIX. 

OF    A    CERTEYN    YONGE    WOMAX. 

A  certeyn  yonge  woman  was  yn  the  cyte  of  London  i  know 
to  many  men,  and  as  an  hyryd  servaunt,  wonnte  to  serve 
many  men ;  the  more  was  knowe,  thys  woman  on  a  day,  by  a 
bawde  bigilid,  from  the  profite  of  her  just  laboure,-to  voluptu- 
ousnes  of  uncleyne  synne  and  by  the  robber  of  her  clennesse 
wylfully  admyttynge  she  was  robbid  of  vncomperable  tresure. 
Ne  it  was  nat  longe,  but  loo  the  reward  of  syn  folowid,  and 
where  her  hole  body  and  fleyssh  she  made  sugget  to  svnne, 
uttirly  she  lost  her  hole  mynde,  and  that  membris  that  were 
armore  of  wykkidnes,  be  turnyd  yn  to  armur  of  woodnesse. 
The  hert  that  is  pryncipall  of  man  with  oppresion  of  the  feende, 
the  whiche  was  onyd  ^  to  hym  was  derkid,  and  that  which  yn 
syn,  God  wolde  nat  drede,  yn  peyne,  nethir  God,  ne  hym  self 
undirstode,  the  yen  now  left  up  an  hye,  now  dredfully  rollid 
abowte,  her  clothis  be  rente  with  her  handys,  the  tonge  was  un- 
bridillid  to  blasfemy,  and  rybawdy,  and  encresynge  her  woode- 
nes,  y  streyned  she  was  yn  streyghte  bondys,  these  bondys  with 
her  woodnys  myght,  lightly  y  broke,  othir  were  addid,  ther  to, 

^  onyd,  united. 


civ  Foundatio7i  of  St.  Bartholomew's. 

thus  she  was  browght  to  the  hospitale  of  the  seyid  chirche,  and 
yn  short  tvmc  folowid  contraxion  of  all  membris,  that  yn  no 
wyse  inyght  she  use  them  frely,  and  yn  so  grcte  a  vvrecchidnes, 
was  presente  the  mercy  of  the  blessid  apostle,  the  whiche  the 
madde  woman  losld  of  her  woodnes  mercyfully,  and  erectid 
the  contracted  myghtly,  and  fulhole  went  home  to  her  owne. 


CAPITULUM  XX. 

OF    A    WOMAN    Y    TAKE    WITH    THE    PALSY. 

An  nothir  woman  dyssolvyd  with  the  palsy,  and  growyngc 
ynwardly,  the  grevous  syknes  sufFerid  throwys  of  all  her 
membrys.  She  dwellid  uppon  Temse,^  and  to  the  same 
howse  she  was  browght,  and  the  same  woman  with  the 
vertu  of  the  apostle,  aftir  a  litill  tyme  was  curid  of  her 
syknes  and  joynge  wente  home  to  her  howse,  toke  an  hows- 
bond  and  browcfht  forth  childryn. 


CAPITULUM  XXI. 

A    MYRACLE    OF    A    MAYDE. 

A  certeyn  mayde  and  servaunt  of  a  cytyseyn  of  London  was 
browghte  to  the  forsaid  hospitalle,  the  whiche  myght  nat 
strecche  forth  ony  fote  that  she  hadde,  or  for  longe  syknes  y 
vexid,  she  hadde  kepte  her  bedde  longe,  or  by  cause  her 
synewys  of  hammys  were  contract.  The  blessid  apostle  on  a 
nyght  apperid  to  her  yn  her  slepe,  and  commaundid  her  to 
strecche  owte  her  feite,  and  she  at  the  commawndment  of  the 
apostle,  lightly  her  foit  did  owte  strecche,  and  yn  the  mornyng 
risynge  up  she  hadde  helth  of  the  toone,  and  at  evensong  tyme 
she  hadde  fre  use  of  both,  they  mervelid  that  were  presente, 
and  askid  her  what  betidid  her  that  nyght,  and  she  tolde, 
■what  she  sawh,  and  confessid  the  auctor  of  her  helth,  praysynge 
the  apostle  of  Cryist  and  3evyng  thankynges  to  God. 

^  the  contracte,  cripple.  ^   Teritse,  Thames. 


Foundation  of  St.  Bartholomew's.      ,         cv 
CAPITULUM  XXII. 

ALSO    A  MYRACLE    OF    A    CERTEYN    WOMAN. 

The  yeir  of  incarnation  of  Oure  Lord  MC  ^  and  L'^  and  nyne, 
of  the  reigne  of  kynge  Richard  the  secunde,  the  sixtene_,  yn 
the  solempnyte  of  the  apostle  seynt  Barthilmewe,  many 
tokynnes  of  vertu  were  shewid  yn  his  holy  chirche.  A  certeyn 
womman  laborynge  yni  grevous  skyenes,  that  was  born  yn  an 
horslytter  to  that  holy  temple ;  and  beholde  yn  the  vigill  of 
the  same  apostle,  abowte  the  hoare  of  complyn^  she  began 
bettir  to  have,  and  a  litill  her  myghtys  that  she  hadde  lost 
she  resumyd,  and  forthermore  anoon  aftir  ful  helth  optenyd_, 
ffor  why  joynge  and  hole  she  rooys  oute  of  her  lyttyr,  and 
come  to  kys  the  hy^e  auter,  offerynge  her  self  yn  to  an  ac- 
ceptable hoist  to  God,  with  grace  and  thankes  yeldynge. 
Anooyn  the  godly  myracle  was  made  opyn  and  of  the  convent  of 
that  chirche,  and  mykil  peple  praysyng  and  thanke  was  5eve 
to  God,  devoutly,  and  to  his  blessid  apostle. 


CAPITULUM  XXIII.2 

OF    A    CHILDE    THAT    RECEYVYD    HIS    SYGHT. 

In  the  same  solempnyte  a  certeyn  childe,  that  hadde  lost  hys 
sight,  by  the  meyn  of  the  holy  apostle  receyvyd  hit  ageyn, 
and  he  seynge  with  othir  seers  the  mercy  of  God,  and  the 
vertu  of  the  blessid  apostle  seynt  Barthymewe,  with  the 
shewyng  of  the  hevenly  tokyn  gretly  he  magnyfied  and  prechid. 

^  The  Latin  reads :  Millesimo  cetitesi-  fifteenth  and  not  in  the  sixteenth  year 

mo  quinquagesimo  nono  regni  Henrici  of  Henry  II. 

secundi  regis  sexto  decimo.     Qimiqiia-  •  The   number   of    each   chapter   is 

gesimo  is  an  error  for  sexagesimo.     The  written  in  the  margin  of  the  manuscript 

sixteenth  of  Henry  II.,  who  is  the  king  in  red.      In  this  place,  and  in  most, 

meant,  was  1169-70  ;  but  it  is  clear  that  Cap"^.    23"^;    in    one    place,     Caplm. 

the  writer  was  not  very  exact  in  the  use  Arabic   numerals    are    used,    and   the 

of  the  regnal  year,  for  Stephen  died  Roman  numerals  of  this  text  are  to  be 

October    25,    1 154,    and    Henry    was  taken  as  representing  the  Latin  word 

crowned  December  19,  11 54,  so  that  by  indicated  by  the  Arabic  numeral  and 

calculating  from  either  the  feast  of  St.  the  contraction  above  it.      The  Latin 

Bartholomew  (August  24)  1 169  is  in  the  version  has  no  numbers  to  the  chapters. 


cvi  Fo7indatio7i  of  St.  Bartholomew's. 

CAPITL'LUM  XXIV. 

OF    A    WOMMAN    THAT    HADDE    LOST    HER    GONE    SYDE. 

In  the  same  chirche  yn  the  forsaid  solempnyte  a  certevn 
woman  was  browght,  the  whiche  on  a  tyme  slepynge  on  the 
toone  syde,  was  smyte  with  a  palsy,  and  lost  that  side,^  and  yn 
that  destitucvon  of  her  lymmys,  duryd  nat  a  litill  tvme.  This 
woman  vn  the  nyght  of  the  holy  solempnyte  was  helid,  and  with 
jove  hole  went  home  to  her  owne. 


CAPITULUM  XXV. 

OF    A    LITILL    CHILDE    THAT    WAS    MADDE. 

Aftir  the  utas-  of  the  same  feiste,  a  certeyn  litill  childe  was 
browght  of  his  modyr  to  that  chirche,  the  whiche  from  the 
feist  of  seynt  Lawrence  the  martyr,  hadde  lost  all  felynge 
of  reson,  and  for  his  woodnes  laborid  sore,  grevous  and  intol- 
lerable  to  the  modir  he  was,  and  as  she  seid,  he  was  bore  by 
many  placys  of  seyntis  a  forn  that  tyme,  but  never  optenyd 
remedy,  and  whan  his  mod\T  hadde  browght  hym  to  the 
forsayd  place,  and  ther  hadde  falfillid  holy  wacche  and  prayer, 
she  deservyd  of  the  most  mekest  Crystis  apostle,  the  efFecte 
of  her  peticion,  and  so  optenyd  to  her  self  gladnes,  and  to 
the  childe  helth,  and  every  Sonday  followyng  shewid  hym  to 
all  the  peple. 

CAPITULUM  XXVI. 

OF    A    CERTEYN    WOMMAN". 

A  certeyn  woman  of  Wyndesover,^  havynge  many  bevstys 
sufferid  a  grete  harme  and  losse  of  them  by  sodeyn  deith,  onely 
oo  cow,  she  hadde  a  lyve  remaynyng  of  that  pestilence.     And 

^  Que  quadam  tempore  donniens  uno  -  Octave.     The   Latin  reads  :   post 

latere  paralisi  percussa  est :  unum  latus       octavas  ejusdem  festivitatis. 
amiserat.  ^  Wyttdesover,  Windsor :  in  the  Latin, 

de  Windlesores. 


Foundation  of  St.  Bartholomew  s.  cvii 

she  lackynge  foode^  almost  was  browght  to  the  deth,  her 
neyghborys  abowte  her  havynge  compassion  of  her,  and  of  her 
sorowys,  5ave  her  cownsell,  that  she  shulde  beseke  the  mercy 
of  the  blessid  apostle  for  this  harmys,  and  make  to  hym  sum 
promysse  that  he  wolde  restore  her  cow  by  hys  myghty  power, 
that  began  to  dye,  she  yevynge  grete  credence  to  holsome 
cownsell,  anoon  began  to  mesure  her  cowe,  that  she  myght 
have  the  mesure,  for  a  light  to  ben  offeryd,  of  that  lengith, 
and  so  here  vow  to  be  parformyd,  and  a  mervelous  thynge;  an 
noon  the  cowe  revyved,  and  began  to  ete,  as  noone  harme  hadde 
happid  her.  In  dew  tyme  the  womman  came  to  the  forsayid 
chirche  to  3elde  thankynges  to  God,  and  to  his  glorious  apostle, 
and  oiferid  the  light  that  she  avowid,  and  expressid  the  benefite 
of  pite,  that  so  mercyfully  she  hadde  receyvyd. 


CAPITULUM  XXVII. 

OF    THE    REPERCION    AND    FYNDYNGE    OF    AN    HORS. 

A  certeyn  preist  of  Kente  commynge  neyr  the  gladnesse  of  the 
feist  glorious  purposid  to  come  to  of  the  oftesayid  ^  chirche, 
sittynge  on  a  goode  hors,  the  whiche  was  deyr  to  hym,  with 
othir  men,  that  intendid  to  the  same  place,  and  whan  the 
Sonne  went  almost  to  rest,  and  nyght  derke  sprede  on  the  erthe, 
nede  compellid  them  to  take  ther  yn,^  and  whan  they  lokid 
abowte  on  every  side,  and  sye  noon  hostrye,  whydyr  they 
myghte  drawe,  it  plesid  them  to  late  ther  hors  to  pasture,  and 
they  kepte  wacche  yn  kepynge  of  ther  horssys  yn  the  same 
place.  This  y  don,  the  prestis  hors  brake  further,  noone  of  them 
considerynge,  nethir  the  preyst  fast  a  slepe  wyttynge,  but 
what  myghte  falle,  to  them  of  adversite,  that  hastid  with  a 
desire,  to  that  place  of  unwastid  pite^  as  who  seith  noon  evyn 
by  the  slepynge  preiste,  a  certeyn  man  apperid,  havyng  a 
shynynge  chere,  and  shooke  the  vestment  that  he  weyr  softly 
and  seyid,  '^  A  rise  why  art  thou  so  longe  oppressid  with  slum- 
mrynge  ? "  and  he  with  a  litill  noyse  awakid  risid  up  and  lokid 

'^  ad  sepedictam  tendebat  ecclesiam.  ^  yn,  inn. 


SAINT  BMTHOLOIEW'S  HOSPITAL 
REPORTS. 


OX 

THE  FORECAST  OF  DESTRUCTIVE  BiPULSES 
IN  THE  INSANE. 

BY 

T.  CLAYE  SHAW,  M.D. 


One  of  the  most  anxious  questions  that  beset  the  treatment 
of  mental  diseases  is  the  probability  of  suicidal  or  homicidal 
attempts  during  the  progress  of  the  attack.  I  confess  that  at 
present  the  prognosis  is  uncertain,  and  that  casualties  occur  when 
least  expected.  That  out  of  the  enormous  number  of  suicidal  or 
homicidal  patients  collected  in  asylums  so  few  accidents  hap- 
pen is  due  perhaps  to  the  fact  that,  special  warning  having  been 
already  given,  in  the  shape  of  a  previous  attempt  or  an  uttered 
threat,  extra  precautions  are  used.  It  is  also  noteworthy  that 
the  persons  least  suspected  are  those  who  mostly  act  in  this 
destructive  manner,  although  one  finds  occasionally,  upon  in- 
quiring closely  into  the  matter,  that  the  previously  unsuspected 
person  had  exhibited  for  a  longer  or  shorter  period  before  an 
amount  of  excitement  or  a  change  of^symptoms,  which  appeared 
to  the  attendant  slight,  but  which  really  denoted  an  advance  in 
the  history  of  the  disease.  It  may  be  said  that  if  the  change 
of  symptoms  had  been  reported,  precautions  would  have  been 
adopted  to  prevent  a  probable  act ;  but  even  allowing  that  such 
precautions  might  have  been  ordered,  1  can  call  to  mind  several 
instances  where,  whilst  perfectly  cognisant  of  a  change  in  the 

VOL.  XXI.  A 


2  Forecast  of  Destructive  Impulses  in  the  Insane. 

condition  of  the  patient,  it  was  not  deemed  necessary  to  order 
special  precautions,  and  yet  destructive  attempts  followed  ;  on 
the  other  hand,  an  extra  watch  has  occasionally  heeu  ordered, 
wliich  has  proved  unnecessary. 

Two  persons  sliall  be  taken  for  comparison,  who,  in  so  far  as 
one  mind  in  disease  can  resemble  another,  are  alike  and  suffer- 
ing from  the  same  form  of  disease.  They  shall  have  delusions 
of  the  same  depressed  type,  shall  equally  declare  themselves 
tired  of  life,  and  yet  the  one  we  might  safely  put  in  a  general 
ward  without  special  supervision,  and  the  other  would  be  an 
unceasing  source  of  anxietv  and  special  care. 

It  may  be  said  that  both  should  be  under  special  protection, 
and  that  it  is  merely  an  accidental  circumstance  that  the  un- 
suspected person  does  not  commit  some  act  to  show  the  falsity 
of  the  diagnosis;  but  be  this  as  it  may,  it  is  perfectly  well 
known  to  specialists  in  mental  disease  that  there  are  some  cases 
that  may  be  trusted,  whilst  others,  apparently  the  same  in  kind 
and  degree,  always  must  be  under  supervision. 

It  almost  makes  one  think  that  the  suicidal  or  homicidal  act 
lies  for  its  prompting  in  a  special  part  of  the  brain  which  must 
be  involved  before  the  attempt  is  made.  But  yet  such  a  theory 
cannot  be  accepted  in  the  face  of  suicidal  attempts  done  under 
the  influence  of  drink,  delirium,  kc,  where  true  consciousness  is 
really  abolished,  and  the  brain  has  been  reduced  to  the  level  of 
a  simple  reflex  machine — for  if  the  upper  centres  are  masked 
in  their  action,  all  notion  of  purpose  must  be  set  aside.  Most 
of  these  persons,  if  they  commit  suicide,  do  it  accidentally,  a 
deliberate  intention  being  rendered  impossible  by  the  absence 
of  true  consciousness,  and  so  they  scarcely  come  under  the  class 
of  cases  we  are  considering.  Care  must  be  taken  to  eliminate 
those  people  (chiefly  women,  but  not  necessarily  so)  who  are 
always  feigning  suicide,  that  is,  who  attempt  suicidal  acts  for 
the  purpose  of  frightening  those  who  have  tlie  care  of  them,  no 
real  intention  of  destroying  themselves  existing.  Such  persons 
sometimes  succeed  by  accident — they  carry  out  their  deception 
too  well.  I  remember  well  the  case  of  a  young  woman  who 
nearly  killed  herself — much  against  her  inclination — by  getting 
a  piece  of  her  dress  tightly  twisted  round  her  neck.  Siie  was 
not  really  suicidal,  but  always  made  her  attempts  when  some 
one  was  near.  I  had  also  a  male  patient  who,  after  being 
discharged,  was  repeatedly  brought  before  the  magistrates  for 
feigned  suicidal  attempts.  Such  persons  cause  more  trouble 
than  really  suicidal  patients,  because  there  is  no  knowing  what 
turn  their  tricks  may  take,  nor  when  they  may  be  tried  on, 
whereas  really  suicidal  persons  are   more  consistent  in   their 


Forecast  of  Destructive  Impulses  in  the  Insane.  3 

attempts,  and  tliey  either  remain  so,  or  the  time  comes  when 
they  recover,  and  we  feel  that  we  can  trust  them. 

One  great  preventive  of  suicide  is  the  presence  of  an  attendant, 
not  merely  owing  to  that  person's  actual  presence  as  a  resource 
in  case  of  an  attempt,  but  from  the  feeling  of  safety  engendered 
by  the  company  of  a  friend.  A  state  of  dementia  is  no  safeguard 
against  a  suicidal  act.  One  of  the  most  suicidal  patients  under 
my  care  is  an  okl  woman  who  never  shows  any  excitement,  but 
who  at  times  ties  anything  she  can  get  hold  of  tightly  round  her 
neck.  I  think  that  here  the  tendency  to  suicide  is  a  real  one, 
and  will  last  until  she  becomes  still  more  demented.  At  present 
she  suffers  from  partial  cerebral  anaemia,  but  retains  sense  suffi- 
cient to  know  that  she  can  do  away  with  herself  by  acting  in  a 
certain  manner,  and  not  having  any  further  useful  purpose  in 
life,  she  obeys  the  impulses  of  what  has  become  the  educated 
part  of  her  brain. 

A  person  in  health  never  thinks  of  himself  as  liable  to  sudden 
inaptitude  to  perform  an  act  to  which  he  is  accustomed ;  but 
after  an  illness  of  an  exhausting  kind  he  loses  his  self-confidence, 
lie  fears  a  paralysis  that  never  comes,  he  is  afraid  of  walking  or 
of  travelling  alone  lest  he  should  be  taken  ill,  he  will  not  cross  a 
road  lest  he  should  stick  in  the  middle  of  it  and  be  run  over. 
Such  persons— and  I  have  seen  many — are  not  suicidal.  Why  ? 
Because  they  are  not  affected  with  permanent  organic  disease. 
At  times  their  nervous  system  is  braced  up  and  acts  harmoni- 
ously. Then  all  their  fears  disappear,  and  they  are  ready  to 
undertake  anything,  and  if  so,  can  generally  carry  it  out  success- 
fully; but  by-and-by  the  old  feeling  returns,  and  though  they 
talk  despondingly,  still  they  live  on  without  any  suicidal  act, 
because  the  brain  not  being  organically  diseased,  they  are  able 
to  remember  and  to  reason  that  they  are  in  a  temporary  state 
of  discomfort  from  which  they  will  soon  emerge. 

Take  again  the  class  of  epileptics.  They  are  at  times  the 
most  really  suicidal  of  all  classes  of  insane  persons  ;  but  at  other 
times  they  could  be  trusted  with  any  form  of  lethal  weapon  with 
impunity.  When  suffering  from  the  epileptic  attack,  or  soon 
after  it,  there  is  a  functional  affection  of  so  intense  a  kind  as  to 
amount  practically  to  an  organic  one,  which  renders  them  incap- 
able of  forming  the  judgment  that  it  is  better  to  endure  the  ills 
they  have  than  fly  to  others  that  they  know  not  of ;  but  when 
the  attack  is  over,  and  the  circulation  in  the  brain  going  ou 
normally,  they  repudiate  the  idea  of  either  a  suicidal  or  homi- 
cidal attack.  Are  we  then  to  make  the  existence  of  organic 
brain  disease  the  factor  of  suicidal  and  homicidal  attempts  ?  I 
think  that  we  must  do  so,  and  I  would  say  that  for  any  destruc- 


4  Forecast  of  Destructive  Impulses  in  the  Insane. 

live  attempt  tliere  must  be  a  temporary  impairment  of  harmoni- 
ous brain  action.  How  is  this  to  be  reconciled  with  the  idea  of 
deliberate  homicide  or  suicide  in  persons  wlio  are  said  to  have 
shown  no  sign  of  insanity,  and  to  have  acted  with  deliberation 
on  arriving  at  the  conclusion  that  it  is  better  to  die  than  to  live  ? 
I  do  not  believe  that  these  are  ever  found  to  happen  unless  the 
brain  is  for  the  time  being  unhinged.  There  are  many  suicides 
and  homicides  brought  to  light  where  the  perpetrators  are  at 
the  time  of  inquiry  perfectly  sound  in  their  minds,  but  they 
have  passed  throngh  tlie  period  of  aberration,  and  must  pay  for 
the  results  of  it  if  it  was  caused  ))y  their  own  indiscretion  ;  and 
often  they  have  to  do  so  if  by  misfortune  they  have  inherited  the 
evil  legacy  of  a  proneness  to  excitability  or  temporary  disorder. 

One  class  of  cases  in  Avhich  suicidal  or  homicidal  attacks  occur 
where  they  might  least  have  been  expected  is  in  that  of  imbeciles. 
I  often  receive  patients  from  the  "  imbecile  "  asylums  who  are 
transferred  because  of  exhibitions  of  this  kind.  And  very 
troublesome  they  are  from  the  suddenness  and  unexpected 
nature  of  their  attacks.  They  are  of  all  classes  particularly 
prone  to  passion  and  anger,  conditions  which  represent  a  most 
powerful  upset  of  mental  equilibrium,  and  in  which  for  the  time 
there  is  more  loss  of  self-control  than  in  any  other  form  of  mental 
affection.  I  consider  them  the  most  dangerous  class  of  all  of 
patients,  and  as  their  sense  of  responsibility  can  never  be  pro- 
perly educated,  they  remain  dangerous  persons  to  the  end  of 
their  lives.  As  long  as  any  reasoning  power  is  left  I  am 
inclined  to  place  confidence  in  the  assurances  of  melancholy 
persons  that  they  are  to  be  trusted,  but  this  certainty  of  the  fact 
that  such  power  does  remain  must  be  well  grounded,  for  other- 
wise it  is  but  a  snare,  and  w^ould  lead  us  to  give  the  patient  the 
wished-for  opportunity.  Persons  undoubtedly  insane  can  argue 
very  well  on  many  subjects  at  times,  but  they  are  all  more  or 
less  liable  to  periodical  exacerbations,  when  they  become  quite 
unreliable,  and  if  at  any  time  they  have  exhibited  destructive 
propensities,  it  is  just  at  these  times  that  such  are  apt  to  recur. 
Of  the  utmost  consequence  is  it  to  prevent  a  first  display  of 
explosive  destructiveness,  for  it  would  seem  as  if,  when  once 
attempted,  it  is  apt  to  recur  again  under  favouring  conditions. 
The  impression  left  on  the  mind  of  a  person  who  has  once 
attempted  a  suicidal  or  homicidal  act  seems  to  be  very  pro- 
found. It  amounts  to  this,  that  an  experience  has  been  gained 
by  the  brain  as  an  actual  entity  which  before  had  no  existence. 
There  is  a  newly-developed  idea  which  can  never  again  disappear, 
just  as  a  new  sensation  or  a  new  experience  of  a  striking  char- 
acter modifies  the  composition  of  the  individual's  character,  and 


Forecast  of  Destructive  Impulses  in  the  Insane.  5 

from  that  moment  the  person  is  changed.  A  man  is  suddenly 
placed  in  a  great  danger  of  his  life,  or  in  conditions  that  place 
his  social  position  in  jeopardy,  and  from  these  positions  he 
escapes  hy  some  means  or  other.  He  perhaps  has  never  been 
so  placed  before,  and  thus  an  impression  of  a  kind  never  before 
experienced  is  thrust  upon  him,  and  his  store  of  real  knowledge 
is  added  to  in  a  way  that  affects  him  permanently.  He  be- 
comes what  is  called  a  "  changed  man "  after  it ;  that  is  to 
say,  his  mind  is  different  from  what  it  was  before,  and  can 
never  return  to  its  original  freedom  from  the  now  dominant 
idea.  This  explains  why  people  who  suffer  from  "nervous 
exhaustion,"  who  have  experienced  the  sensations  known  as 
"  agoraphobia,"  never,  or  rarely  ever,  in  my  experience,  recover 
throughout  their  lives  their  original  mental  stability.  It  would 
be  indeed  contrary  to  what  we  know  of  the  growth  of  the  faculties 
if  they  ever  did.  When  a  man  has  once  experienced  tlie  feeling 
that  he  may  have  fainting  attacks  at  any  moment,  that  if  he  goes 
to  a  certain  place  he  will  have  peculiar  sensations  come  over 
him,  &c.,  I  do  not  think  that  he  ever  entirely  loses  them  ;  they  may 
become  less  prominent,  and  if  he  again  arrives  at  robust  bodily 
health  they  may  for  the  time  disappear,  but  tbe  slightest  ailment 
causing  an  impairment  in  the  nutritive  conditions  of  the  brain 
will  bring  them  on  again.  And  so  it  is,  I  think,  with  the  suicidal 
or  homicidal  feeling — when  once  either  has  been  established,  it 
is,  in  my  experience,  sure  to  recur  if  any  cerebral  aneemia  or 
other  lesion  is  present.  One  reason,  then,  why  we  can  trust 
some  persons  who  are  melancholy  and  have  delusions  is  that 
they  have  never  attempted  destructive  acts.  For  some  reason 
or  other  tlie  instinct  of  self-preservation,  and  the  respect  for 
life  in  others,  have  never  been  affected,  and  so  they  go  on  in 
their  own  miserable  manner  for  years,  but  they  are  quite  safe 
as  regards  themselves  or  others.  But  it  may  be  fairly  asked — 
how  long  w^ill  this  immunity  from  the  upset  of  a  natural  instinct 
continue  ?  Can  we  guarantee  that  the  depressed  state  and  the 
melancholy  delusions  will  continue  harmless  ?  Certainly  not ; 
and  the  more  extensive  the  affection  of  the  brain  is,  the  more 
likely  is  the  self-protective  instinct  to  become  affected ;  and 
therefore  all  persons  suffering  from  brain-disease  are  liable  to 
become  destructively  affected ;  but  statistics  teach  us  that  of  all 
who  do  become  insane  only  about  22  per  cent,  become  destruc- 
tively so.  Experience  of  criminals,  i.e.  offenders  against  nature 
and  education,  shows  that  when  once  the  nucleus  of  the  first 
fault  is  formed  there  is  an  insatiable  craving,  i.e.  a  morbid  and 
imrestrainable  impulse,  to  repeat  it.  If  brain-disease  remained 
fixed  in  its  extent,  we  might  make  ourselves  easy  as  to  the 


6  Forecast  of  Destructive  Impulses  in  the  Insane. 

lesults,  but  it  does  not.  Nothing  is  more  extraordinary  than 
the  way  in  whicli  mental  phenomena  change  in  the  insane,  and 
no  matter  how  "clironic"  the  case  may  he,  it  never  ceases  to  ho 
interesting  from  its  versatilit3^  Tliis  cuts  both  ways  :  it  some- 
times renders  a  person  self-deslructive  or  homicidal,  but  it  also 
in  time  reduces  the  most  des{)erate  characters  to  a  state  of  harm- 
less dementia.  I  have  a  patient  here  wlio  was  one  of  the  most 
violent  patients  at  one  time  in  the  asylum  from  whicli  he 
came.  There  he  was  the  terror  of  the  place,  but  now  lie  is  a 
harmless  dement,  without  any  true  consciousness  and  destitute 
of  reasoning  power.  The  sudden  and  unexpected  appearance 
of  destructive  symptoms  in  a  previously  quiet  patient  is  no  more 
to  be  wondered  at  than  the  sudden  development  of  them  in  a 
hitherto  supposed  sane  person.  Both  are  signs  of  a  new  depar- 
ture in  the  mental  processes,  and  just  as  the  suicidal  or  homicidal 
act  may  be  the  first  prominent  sign  of  insanity  in  a  person,  so  is 
it  the  first  sign  of  a  new  implication  in  a  person  already  insane. 
No  state  of  imbecility  is  too  profound  for  the  impulse  to  appear, 
because  persons  of  this  class  are  liable  to  irritative  conditions 
of  the  brain  in  which  it  may  be  set  up,  and  no  person  is  so 
demented  but  that  some  excitement  of  a  temporary  nature  may 
occur  and  cause  an  attempt. 

Let  us  consider  for  a  moment  the  motives  of  suicide.  We  see 
persons  go  through  the  most  frightful  tortures  and  inconvenience 
from  bodily  disease,  and  yet  the  idea  of  suicide  would  be  most 
repugnant  to  them,  and  with  every  opportunity  they  never  do  it, 
because  their  intellect  is  unimpaired.  We  see  others  suffering 
from  bodily  pain  and  incapacity  for  the  exertion  necessary  to 
get  their  own  living,  and  these  at  last  kill  themselves,  because 
their  ailments,  being  caused  by  perhaps  some  fault  of  their  own, 
the  mind  is  affected  by  the  same  cause  (disease),  and  the  in- 
stinct of  self-preservation,  which  is  a  faculty  of  the  mind,  is 
weakened  just  as  the  other  functions  are.  We  see  another 
person  who  has  suffered  some  great  mental  shock,  or  is  in  danger 
of  social  degradation,  and  yet  he  is  able  to  weather  the  storm, 
and  will  undergo  a  sentence  of  penal  servitude  without  much 
concern.  Why  ?  Because  in  him  the  shock  has  been  success- 
fully resisted,  his  feelings  are  too  blunt  to  be  affected,  and  his 
mind  remains  sound,  i.e.  his  faculty  of  self-preservation  is  intact. 
Self-preservation  is,  then,  a  faculty  of  mind,  and  is  as  constituent, 
a  part  of  it  as  is  memory,  or  as  the  natural  feeling  of  love  of 
offspring,  or  of  normal  sexual  desire — and  loss  of  this  instinct 
is  a  sign  of  disease,  just  as  the  non-secretion  of  urine  is  a  sign 
of  disease  of  the  kidney,  or  sudden  death  is  a  sign  of  disease 
of  the  heart.     If  a  child  is  persistently  cruel,  we  view  the  obliquity 


Forecast  of  Besiructive  Impulses  in  the  Insane.  7 

as  a  defect  in  tlie  moral  nature,  and  inasmuch  as  tliis  cruelty  is 
seen  to  come  on  after  an  attack  of  acute  disease,  or  of  convulsions, 
or  is  noted  in  connection  with  other  signs  of  imbecility,  we  view 
it  as  a  result  of  disease  of  the  brain,  which  it  undoubtedly  is. 
When  we  see  how  lunatics  can  hide  their  delusions,  retaining 
sufficient  control  to  enable  them  to  suppress  what  they  actually 
believe,  and  even  dangerous  lunatics  will  conceal  successfully  for 
a  time  their  murderous  thoughts  until  an  opportunity  offers  for 
carrying  them  out,  we  can  understand  how  a  person  may  be 
very  insane  and  yet  not  commit  a  suicidal  or  homicidal  act ; 
but  we  can  also  see  that  the  same  person  may  become  irre- 
sistibly destructive,  because,  in  the  presence  of  a  disease  which 
lias  already  affected  some  of  the  intellectual  power,  there  is  no 
knowing  when  it  may  not  also  affect  the  mental  attribute  of 
self-preservation. 

Suicide  and  homicide  are  by  no  means  the  special  attributes  of 
melancholy.  There  is  a  female  patient  here  who  is  a  cheerful 
and  pleasant-looking  woman,  yet  withal  very  insane,  and  she 
threw  herself  into  the  river  because  she  was  told  to  do  so ;  not 
because  she  was  depressed  and  wished  to  lose  her  life,  but  because 
she  was  "told"  to  do  so.  She  acted  in  the  same  way  as  a  child 
would  do,  who,  having  no  experience  of  a  danger,  would  go  into 
it  when  told  by  a  person  of  superior  authority  to  do  so.  There 
can  be  little  doubt  that  cases  of  recurrent  insanity,  where  the 
destructive  propensity  becomes  manifest  only  in  the  accessions, 
point  directly  to  the  fact  that  such  is  a  diseased  idea.  People 
under  these  circumstances  repeat  the  attack  with  such  exactness 
that  every  phase  may  be  distinctly  forecast.  If,  then,  a  delusion 
of  a  definite  kind,  or  an  act  of  a  specific  nature,  comes  round 
invariably  as  a  symptom,  why  should  not  the  destructive  act  be 
also  as  much  a  symptom  ?  It  is  so  indeed,  and  by  being  so 
proves  that  it,  as  a  symptom,  is  directly  due  to  disease.  Here 
then  we  have  suicide  or  homicide  proved  specially  to  be  as  much 
a  sign  of  disease  as  is  a  delusion.  Now  some  of  these  recurrent 
states  are  attended  with  consciousness  afterwards,  others  are  not, 
but  whether  they  are  so  or  not  seems  to  make  little  difference  as 
regards  the  act  of  destructiveness  if  it  has  once  become  impressed 
on  the  brain.  We  see  epileptics  in  the  condition  of  mental  auto- 
matism attempt  suicidal  acts  when,  so  far  as  we  can  judge  from 
what  they  say  afterwards,  there  is  absolutely  no  real  conscious- 
ness of  what  they  are  doing.  In  this  state  the  controlling  power 
of  the  will  being  in  abeyance,  and  certain  parts  of  the  brain 
being  under  uncontrolled  excitement,  there  is  nothing  to  pre- 
vent an  act  which  may  or  may  not  be  suicidal,  but  which  is 
sometimes  the  one  and  sometimes  the  other,  and  the  manifesta- 


8  Forecast  of  Destructive  Impulses  in  the  Insane. 

tion  of  which  ceases  as  soon  as  the  brain  recovers,  i.e.  wlieii  the 
temporary  disease  has  subsided. 

I  have  spoken  of  this  instinct  of  preservation  as  an  "instinct." 
Is  it  really  one  ?  Would  a  child,  if  left  to  its  own  resources, 
avoid  the  sharp  edfj^e  of  a  knife  or  the  stepping  into  deep  water 
as  naturally  as  a  bird  takes  to  flying?  Probably  not  until  it 
had  learnt  by  experience  the  danger,  but  having  once  learned 
that  such  and  such  things  are  dangerous  to  life,  it  avoids  them 
to  its  utmost  extent.  A  fully  grown  person,  with  every  desire 
to  preserve  his  life,  might  think  it  no  harm  to  touch  a  highly- 
charged  Leydeu  jar,  but  his  ignorance  would  not  show  that  he 
did  not  possess  the  in.slinct  of  self-preservation.  This  instinct 
of  self-preservation  and  the  love  of  life  would  appear  not  to 
be  directly  connected,  and  they  are  certainly  very  differently 
developed  in  different  individuals.  A  man  may  valne  his  life 
highly  (and  would  sell  it  very  dearly  if  in  danger  of  losing  it), 
and  yet  he  will  perform  acts  which  his  instinct  of  self-preserva- 
tion would  counsel  him  to  avoid ;  and  a  man  may  be  intensely 
suicidal,  but  he  would  resent  strongly  any  attempt  of  others  to 
injure  him.  As  growth  and  development  progress,  this  idea 
of  self-preservation  grows  stronger,  and  it  is  especially  so  in 
people  who  have  many  claims  to  society  to  fulfil  ;  now  as  these 
are  just  the  people  who  at  times,  to  our  great  surprise,  attempt 
an  act  of  the  nature  we  are  considering,  it  becomes  necessary  to 
find  out  if  there  are  other  signs  of  insanity  in  them.  I  think 
that  if  looked  for  they  will  always  be  found.  It  very  often 
happens  that  a  sudden  and  unexpected  suicidal  act  terminates 
fatally,  and  we  have  no  opportunity  of  judging  of  the  presence 
of  other  aflfection  of  mind ;  but  in  the  cases  I  have  seen,  when 
such  an  act  has  been  attempted  and  has  failed,  I  have  had  no 
difiiculty  in  tracing  other  affection  of  the  brain,  and  therefore 
in  noting  the  attempt  at  injury  as  one,  among  others,  of  the 
symptoms.  A  woman  was  admitted  here  a  short  time  ago  who 
had  thrown  herself  into  the  Thames,  in  consequence,  as  she 
alleged,  of  her  husband's  ill-treatment.  Her  story  was  very 
circumstantial  and  was  clearly  told,  and  it  was  only  on  evidence 
of  a  very  positive  character,  and  the  development  in  her  of  hal- 
lucinations of  sighf^  that  it  was  evident  that  she  was  really  affected 
with  delusions.  Though  she  now  denies  any  destructive  feelings, 
I  refuse  to  believe  her,  as  she  is  still  affected  mentally,  and  I 
believe  that  the  destructive  impulse  might  occur  at  any  moment. 
This  woman's  story  was  so  well  given  at  first  that  it  was  only 
after  repeated  examinations  that  the  symptoms  of  brain-disease 
were  found.  It  is  impossible  for  a  person  in  health  to  realise 
the  sensations  he  had  when  suffering  from  a  disease,  and  so  a 


Forecast  of  Destructive  Impulses  in  the  Insane.  g 

person  who  has  recovered  from  a  suicidal  attack  of  insanity 
cannot  realise  the  impulse  that  made  him  attempt  his  life,  and 
lie  is  "  truly  sorry  "  for  what  he  did  ;  but  in  his  insane  state  he 
equally  forgets  how  he  felt  when  in  health,  and  it  becomes  as 
necessary  for  him  to  act  according  to  his  then  (insane)  condition 
of  brain,  and  to  maintain  the  rectitude  of  his  conduct,  as  to 
do  the  opposite  was  his  natural  healthy  state. 

What  we  call  a  diseased  state  is  one  which  has  a  life  of  its 
own,  and  from  tlie  mental  standpoint  has  its  own  ideas,  acts,  and 
feelings;  in  a  world  of  madmen  these  would  be  the  correct 
expressions  of  tlie  mind  of  the  day,  and  a  sane  person  would 
appear  to  be  the  incoherent  unreasonable  person  that  madmen 
now  often  take  him  to  be.  I  have  often  spoken  with  lunatics 
about  the  cases  of  other  patients  in  the  same  ward  with  them, 
and  have  often  got  the  reply  that  they  "  were  only  shamming," 
or  that  they  "  were  not  insane,"  as  they  happened  to  have  the 
same  or  different  delusions  from  the  person  speaking.  The 
suicidal  impulse  may  last  a  long  time,  and  if  so,  the  group  of 
mental  symptoms  remains  the  same  too,  but  in  many  cases  the 
attempt  is  one  of  the  earliest  symptoms  of  the  disease,  and  being 
of  such  a  prominent  and  startling  nature,  it  causes  the  person  to 
be  brought  at  a  very  early  stage  under  curative  treatment.  Thus 
it  is  that  so  many  recover,  and  are  indeed  on  the  fair  road  to 
recovery  when  brought  to  the  asylum.  In  a  person  who  has 
been  long  living  quietly  in  an  asylum  the  attack  may  come  on 
suddenly,  showing  an  extension  or  alteration  in  the  seat  of  the 
disease,  and  if  he  is  a  patient  who  has  been  allowed  a  certain 
amount  of  liberty  the  attempt  is  often  successful.  I  used  to 
think  that  general  paralytics  were  never  suicidal,  because  of  the 
generally  happy  nature  of  their  delusions  and  feelings,  and 
because  I  was  too  apt  to  associate  a  suicidal  or  homicidal  act 
with  a  condition  of  melancholia;  but  I  have  recently  had  under 
care  an  undoubted  general  paralytic  who  was  intensely  suicidal 
by  strangulation,  and  there  are  now  two  here  who  persistently 
refuse  food,  and  have  to  be  fed  artificially,  who  would,  indeed, 
if  they  were  allowed,  die  from  starvation,  and  yet  there  is  no 
sign  of  melanclioly  delusion  (though  there  are  numerous  other 
delusions  present);  and  I  can  recall  a  homicidal  case  in  that  of 
a  man  who  was  of  a  mild  and  amiable  nature,  but  very  insane, 
who  committed  a  very  foul  deed  because  of  his  diseased  brain. 
We  must  look  upon  these  acts  as  constituent  parts  of  the 
disease,  as  factors  without  which  indeed  the  disorder  would  not 
be  complete,  and  as  of  necessity  being  as  much  the  result  of  a 
certain  condition  of  brain  as  are  the  acts  of  a  reasonable  being 
the  results  of  the  working  of  a  healthy  mind. 


10  Forecast  of  Deslruciue  Impulses  in  the  Insane. 

Tlie  education  in  a  certain  channel  of  a  liealtliy  brain  will,  if 
ilie  education  be  a  vicious  one,  produce  a  pliysiological  criminal, 
and  so  a  man  becomes  a  murderer  or  a  thief,  but  his  brain  is 
not  diseased,  and  lie  may  never  show  any  sign  of  insanity.  What 
would  be  the  effect  of  an  attack  of  insanity  on  him?  It  might 
make  him  worse,  but  not  necessarily  so,  though  it  probably 
would,  because  the  good  side  of  life  never  having  been  presented 
to  him,  there  is  no  favourable  nucleus  which  disease  might  act 
upon  and  develop,  whilst  the  man  who  has  always  been  brought 
up  to  respect  virtue  and  abhor  vice  has  seen  both  sides  of  the 
shield,  and  probably  the  vicious  side  very  strongly,  in  order  to 
induce  respect  for  the  good,  so  that  there  is  here  a  condition  of 
tilings  whicli  may  be  acted  upon  by  disease.  In  other  words,  a 
good  man  becoming  insane  may  become  destructive,  but  a  bad 
man  becoming  insane  is  likely  to  become  uncontrollably  worse. 

There  is  in  nature  an  evident  tendency  to  the  abscission  of 
the  weakest  members,  and  inasmuch  as  melancholia  and  all  its 
accompanying  horrors  tend  to  unfit  the  individual  for  fulfilling 
his  place  in  life,  it  would  seem  that  the  culminating  act  of  suicide 
is  simply  the  natural  evolution  of  a  condition  in  which  the  in- 
dividual is  of  no  use  to  the  community,  which  is  better  rid  of 
him.  There  is  one  condition  of  things  under  which  life  goes  on 
prosperously,  and  this  is  generally  formulated  by  the  term  health, 
and  one  prominent  factor  of  this  state  is  the  desire  of  self- 
preservation.  There  is  another  state  the  converse  of  this,  where 
life  becomes  literally  insupportable,  the  individual  is  too  im- 
paired to  be  able  to  find  the  means  for  his  own  living  or  enjoy- 
ment, and  the  formula  that  expresses  this  is  the  term  disease. 
AVhen  this  state  is  established  the  desire  of  self-preservation  is 
affected,  and  self-destruction  becomes  the  exponent  of  the  new 
state  of  mind.  We  cannot  approach  the  subject  more  inti- 
mately than  this  of  viewing  the  destructive  as  a  condition  superin- 
duced by  disease.  If  a  person  has  a  valvular  disease  of  the  heart 
nothing  will  cure  (though  remedies  may  for  the  time  alleviate) 
the  pressure-signs  and  physical  results  of  obstruction  that 
ultimately  end  in  death.  A  man  does  not  really  commit 
suicide ;  it  is  the  disease  that  is  sim))ly  working  out  its  own 
symptoms.  A  person  affected  witli  renal  disease  is  able  for  a 
time,  just  as  is  a  man  with  brain  disease,  to  go  about  and 
complete  his  functions,  but  with  the  progress  of  the  disease 
there  is  a  limit  to  his  potentiality  of  energy  and  usefulness, 
and  he  finally  dies  from  coma  produced  by  albuminuria.  It 
looks  !  s  if  to  every  disease  there  is  a  final  cidminating  symptom 
of  a  very  acute  and  powerful  nature  which  gives  the  coup  de 
grace  to  the  long  but  slow  process  which  has  been  substituting 


Forecast  of  Destructive  Impulses  in  the  Insane.  1 1 

itself  for  the  natural  one  of  health.  Thus,  the  person  who  dies 
from  enteric  fever  frequently  does  so  from  rupture  of  the  bowel, 
than  which  no  surer  mode  of  procuring  death  could  be  devised  ; 
he  who  dies  from  acute  rheumatism,  as  a  rule,  does  so  from 
implication  of  the  heart  or  lungs,  a  very  sure  mode  of  death, 
inasmuch  as  it  attacks  tlie  source  of  power  and  heat.  A  man 
who  suffers  long  from  kidney  or  liver  disease  finally  dies  poisoned. 
And  so  a  person  labouring  under  brain  disease  dies  by  a  process 
akin  to  the  rupture  of  the  bowel :  he  commits  suicide.  How  else 
is  his  end  to  be  brought  about?  He  is  just  as  responsible  for 
his  melancholia  or  his  delusion  as  for  his  suicidal  act.  He  can 
no  more  prevent  the  aneurysm  in  his  aorta  than  he  can  its  rup- 
ture. Organs  often  act  for  their  destruction  through  the  agencies 
they  employ  for  fulfilling  their  functions  in  health.  A  fatty 
heart  acts  for  its  destruction  through  the  weak  muscular  wall 
by  which  it  contracts.  The  diseased  kidney  kills  by  throwing 
into  the  circulation  the  poison  that  it  is  its  duty  to  eliminate. 
And  so  the  diseased  brain  kills  by  impressing  with  its  prompt- 
ings the  only  agents  it  has  at  command,  which  are  just  the  same 
as  those  by  which  the  sound  brain  acts.  The  homicidal  pro- 
pensity is,  equally  with  the  suicidal,  the  result  of  a  morbid 
action.  The  epileptic  who  in  a  fit  of  excitement  takes  up  a 
chair  to  defend  himself  against  a  person  who  he  imagines  is 
going  to  suffocate  him,  and  who  kills  his  supposed  antagonist, 
is  no  more  a  murderer  than  is  he  who  in  his  sound  mind  kills 
another  who  attacks  him,  e.g.  a  soldier.  The  state  of  his  brain 
for  the  time  being  renders  such  an  act  the  necessary  consequence 
of  the  train  of  thought  then  going  on,  and  the  sequence  of  thought 
would  be  as  incomplete  without  the  final  act  as  would  be  the 
moral  necessity  of  a  man  on  the  bank  of  a  river  to  save  another 
who  was  drowning  without  the  final  act  of  plunging  into  the 
water. 

It  is  often  said  that  in  the  insane  the  judgment  is  at  fault, 
but  I  think  this  an  error.  With  a  certain  state  of  mind  destruc- 
tive results  are  the  proper  and  natural  ones.  No  one  expects 
from  a  serpent  the  withdrawal  from  the  fatal  dart  of  the  fang, 
nor  from  a  lion  that  it  should  hesitate  and  desist  from  the  final 
stun  of  the  paw,  for  every  phase  of  nature  is  complete  in  its 
course.  The  readiness  with  which  civilised  man  reverts  to  the 
savage  type  shows  simply  that  the  original  ferocity  is  only  tamed, 
not  changed.  It  would  probably  take  many  generations  of  care- 
ful breeding,  training,  and  cultivating,  before  the  "animal" 
nature  was  taken  out  of  him,  and  as  long  as  competition  exists, 
it  probably  never  will  be,  for  the  quiet  and  peaceful  condition 
brought  about  by  the  absence  of  necessity  for  exertion  in  order  to 


12  Forecast  of  Destructive  Impulses  in  the  Insane. 

live  will  never  cease.  Patients  come  under  our  hands— women — 
whose  hinguage  and  acts  are  sodifFerent  from  what  their  friends  are 
accnstomed  to,  that  they  are  supposed  to  be  under  a  demoniacal 
possession.  This  sim[)ly  sliows  that  a  brain  in  one  state  has 
one  group  of  symptoms,  and  in  another  state  has  a  diametrically 
opposite  one,  and  we  can  imagine  nothing  more  {)otent  in  pro- 
moting such  a  derangement  than  anosmia.  For  integrity  6f  brain 
action  there  must  be  a  normal  reaction  of  one  part  on  the  olher. 

What  can  be  imngined  more  likely  to  disturb  this  reaction  than 
an?emia,  or  what  is  practically  the  same  thing,  the  sudden  in- 
jection of  a  poison  like  alcohol?  Why  an  anaemic  brain  should 
.so  prominently  show  the  features  of  the  savage  type  cannot  be 
explained  any  more  than  why  the  symptoms  are  not  those  of  a 
simple  dementia  ;  but  so  it  is,  and  in  no  form  of  disease  is  the 
destructive  impulse  so  great  as  in  insanity  caused  by  anaemia. 
Lactational  insanity  is  one  of  the  most  destructive  forms,  and 
the  signs  are  those  of  extreme  exhaustion. 

Heart-disease  is  a  frequent  accompaniment  or  cause  of  destruc- 
tive tendencies,  and  I  have  frequently  noted  most  dangerous 
symptoms  connected  with  a  slow  irregular  pulse.  There  is  a 
boy  here,  epileptic,  with  a  diastolic  aortic  murmur,  and  he  is 
liable  to  most  passionate  outbreaks,  in  which  he  is  both  suici- 
dal and  homicidal,  whilst  in  the  intervals  between  the  attacks 
he  is  quiet  and  trustworthy,  and  disclaims  any  knowledge  of 
what  he  has  gone  through  or  been  the  cause  of.  Again,  the  most 
violent  patient  we  have  here  is  an  epileptic  whose  pulse  is  normal 
and  good  between  his  paroxysms,  but  when  passing  through 
an  "attack"  his  pulse  is  irregular,  very  compressible  and  feeble 
and  slow,  pointing  to  great  want  of  nourishment  of  the  brain, 
and  he  is  indeed  unconscious  of  what  really  occurs.  So  that 
destructive  propensities  and  the  absence  of  true  consciousness  are 
often  associated.  Another  very  suicidal  patient  here  has  a  very 
feeble,  slow,  and  irregular  pulse  when  the  morbid  feelings  are 
uppermost,  but  ordinarily  he  is  very  civil  and  well  conducted,  and 
is  able  to  work  actively.  This  irregularity  of  the  heart's  action 
is  worth  noting  in  all  cases  of  destructive  propensity,  and  where 
a  patient  with  incurable  disease  of  the  heart  has  once  shown 
these  impulses,  he  is  not,  in  my  opinion,  fit  to  be  ever  again 
trusted.  Old  people  are  very  dangerous  in  this  way,  and  no 
doubt  the  fatty  state  of  their  hearts  has  a  great  deal  to  do  with 
the  sudden  attacks  to  which  they  are  liable.  All  know  how 
liable  to  sudden  and  unexpected,  faintness  people  with  fatty 
hearts  are,  and  the  occurrence  of  this  condition,  together  with  an 
atheromatous  state  of  the  arteries,  in  comparatively  j'oung  per- 
sons has  no  doubt  much  to  do  with  the  development  of  the 


Forecast  of  Destructive  Im;pulses  in  the  Insane.  1 3 

destructive  state  in  them.  I  would  not  go  so  far  as  to  state  that 
the  condition  of  the  heart  is  to  be  the  criterion  of  responsibih'ty 
as  regards  destructive  habits  in  the  insane,  but  it  undoubtedly 
has  a  great  deal  to  do  with  many  of  the  cases,  and  the  great 
part  that  it  plays  should  never  be  lost  sight  of.  Gouty  persons, 
and  those  who  sutfer  from  the  hereditary  gouty  temperament,  are 
notably  liable  to  these  destructive  feelings,  and  I  could  quote 
many  cases  of  people  with  the  gouty  neurosis  who  are  at  times 
subject  to  unaccountable  languor  and  depression  of  spirits,  and 
are  at  times  suicidal  and  dangerous.  These  depressing  feelings 
are  most  common  in  the  mornings,  and  whenever  they  occur  are 
most  easily  relieved  by  a  stimulant.  There  is  here  a  woman, 
formerly  in  good  position,  whose  habits  of  temperance  have  not 
been  such  as  to  bear  inspection,  who  is  at  times,  when  her  circula- 
tion is  good,  of  a  most  cheefy  nature  and  an  excellent  com- 
panion, laughing  at  any  idea  of  suicide,  yet  this  woman  is  one  of 
the  most  dangerous  and  destructive  in  the  place,  for  she  suffers 
from  a  fatty  heart,  and  when  at  times — as  is  the  case  with  this 
pathological  condition — her  heart's  action  fails  and  becomes 
irregular,  she  becomes  almost  unmanageable.  The  wonder  is 
that  such  people  do  not  meet  with  sudden  death  oftener  than 
they  do.  When  she  is  in  this  state  I  find  the  best  remedy  to 
be  a  dose  of  brandy,  and  whenever  I  now  find  her  depressed  and 
her  pulse  irregular,  I  always  order  a  stimulant,  and  the  results 
are  most  satisfactory.  People  who  have  been  large  drinkers — 
whether  young  or  old — suffer  much  from  this  irregular  action  of 
the  heart,  and  one  of  the  most  painful  feelings  that  the  re- 
generate drunkard  has  to  contend  with  is  the  feeling  of  de- 
pression that  comes  over  him  from  the  irregularity  and  feebleness 
of  the  action  of  the  heart  set  up  by  the  withdrawal  of  his  accus- 
tomed food.  The  same  thing  may  be  witnessed,  although  the 
cause  is  different,  in  persons  who  become  melancholy  and  de- 
pressed when  placed  in  positions  different  socially  from  those  they 
before  occupied.  To  a  man  habituated  to  society  in  a  large 
town  nothing  is  so  distasteful  as  to  be  relegated  to  some  spot 
where  he  misses  the  stimulus  to  his  brain  to  which  he  has  been 
accustomed.  His  spirits  droop,  he  loses  his  appetite,  his  circula- 
tion becomes  languid,  and  unless  he  has  a  change  or  becomes 
interested  in  some  other  mode  of  life,  he  stands  a  great  chance 
of  becoming  destructively  insane.  Soldiers  who  are  suddenly 
placed  in  a  condition  of  idleness,  especially  if  it  be  accompanied 
with  some  degree  of  privation,  after  going  through  the  excitement 
of  a  campaign,  become  most  depressed  and  easily  succumb.  The 
condition  of  nostalgia  which  affects  frequently  large  bodies  of 
men,  and  especially  those  of  an  emotional  cast,  is  always  accom- 


14  Forecast  of  Destructive  Impulses  in  tJie  Insane. 

panied,  if  not  due  to,  cardiac  symptoms.  There  was  a  patient 
here  whose  pulse  was,  when  she  was  quiet  and  well-behaved,  of 
a  good  tone,  but  at  times  it  became  very  irregular  and  inter- 
mittent, and  then  she  was  one  of  the  most  destructive  women  I 
ever  saw.  She  herself  described  her  state  as  a  sudden  feeling 
of  pain  and  faintness  in  the  cardiac  region  with  a  violent  and 
irregular  thumpiug  of  the  heart — after  this  a  red  colour  seemed 
to  appear  and  she  felt  an  irresistible  inclination  to  smash  furniture 
and  glass  and  to  destroy  herself,  and  being  a  powerful  woman  she 
generally  succeeded  in  doing  a  great  deal  of  damage.  I  think 
that  here,  as  in  the  other  cases,  the  heart  affection  was  the 
primary  one,  not  that  the  irregularity  of  its  action  was  the  result 
of  a  sudden  discharge  of  energy  from  the  brain.  I  do  not  think 
that  I  should  err  in  stating  that  there  is  not  a  single  suicidal  or 
homicidal  patient  who  does  not  suffer  from  a  disturbed  circula- 
tion in  consequence  of  a  disabled  heart,  though  there  are  some 
here  with  various  forms  of  heart-disease  who  have  not  yet  deve- 
loped the  destructive  impulse.  There  are  at  least  four  patients 
here  who  are  suffering  from  "rheumatic  insanity,"  and  they  have 
all  valvular  heart-disease  and  destructive  symptoms.  In  dys- 
pepsia, especially  if  of  gouty  origin,  irregular  action  of  the  heart 
and  depression  are  very  common,  and  the  destructive  feelings 
often  met  with  in  this  ailment  are  due  to  the  irregular  brain- 
circulation.  Perhaps  the  most  impulsive  and  destructive  classes 
in  asylums  are  to  be  found  in  the  masturbators.  An  exceed- 
ingly dangerous  person  here  is  one  who  is  greatly  addicted  to 
this  habit,  and  its  effect  on  his  circulation  causes  great  irrita- 
bility of  the  heart,  the  beats  being  most  irregular  after  he  has 
been  practising  his  bad  habit.  The  effect  of  sexual  drain  upon 
the  action  of  the  heart  is  recognised,  and  when  once  the  rhyth- 
mic action  of  the  ganglia  of  the  heart  has  been  interfered  with,  it 
is  with  difficulty  restored;  hence,  persons  who  become  what  is 
generally  called  "  nervous,"  or  who  suffer  from  "nervous  exhaus- 
tion," experience  feelings  of  faintness,  want  of  confidence,  &c., 
for  a  long  time,  and  I  have  no  doubt  that  their  momentary  feel- 
ings of  giddiness  or  loss  of  power  in  one  of  the  extremities  are 
due  to  sudden  irregularity  in  the  heart's  action,  and  if  the  pulse 
be  felt  at  this  time,  it  will  be  found  to  be  intermittent  or  altered 
from  its  normal  rate.  Many  of  the  feelings  of  nervousness  and 
melancholia  are  ascribed  to  indigestion,  and  the  recurrence  of 
a  foul  state  of  the  tongue,  constipation,  and  loss  of  appetite  are 
often  as  regular  concomitants  of  an  attack  of  epileptic  destruc- 
tiveness  as  are  most  of  the  other  special  symptoms.  There  is  a 
patient  here,  in  whom  this  disordered  state  of  the  viscera  occurs 
regularly  before  a  severe  homicidal  attack,  and  if  we  can  man- 


Forecast  of  Destructive  Impulses  in  the  Insane.  1 5 

age  to  procure  an  alvine  evacuation  early,  the  attack  is  often 
prevented  altogether,  and  so  are  the  cardiac  symptoms  that,  in 
my  opinion,  follow  the  prolonged  visceral  disorder,  and  cause 
the  destructive  symptoms. 

The  gastric  crises  that  occur,  not  only  in  locomotor  ataxia  but 
in  many  other  nervous  affections,  are,  as  a  rule,  accompanied 
with  great  depression ;  and  there  was  recently  a  striking  instance 
of  this  in  the  person  of  a  male  patient  (who  was  for  a  time  an 
in-patient  of  St.  Bartholomew's)  whose  attacks  of  vomiting  and 
irregularity  of  action  of  the  heart,  occurring  at  intervals  of  three 
or  four  weeks,  were  of  a  very  severe  character,  and  accompanied 
by  pains  in  the  shins,  which  were  of  the  nature  recently  described 
as  "  alcoholic."  This  man  had  been  many  years  in  various  asy- 
lums, and  was  at  times  extremely  suicidal.  Usually  he  was  in- 
dustrious, and  being  a  muscular  man,  was  able  to  take  a  large 
amount  of  exercise.  There  was  no  sign  of  ataxia  about  him, 
nor  had  he  any  delusions,  but  with  the  recurrence  of  the  vomit- 
ing and  shin  pains  he  became  intensely  irritable  and  depressed, 
and  was  cai-efully  watched.  He  never  attempted  suicide  here, 
but  I  was  for  a  long  time  apprehensive  of  it.  He  had  been 
rather  a  large  drinker,  but  judging  from  his  lively  and  intelli- 
gent demeanour  between  the  attacks,  there  was  not  actually  an 
organic  disease  of  the  brain.  I  became  more  confident  about 
him,  and  in  these  intervals,  when  his  circulation  was  regular 
and  fair,  he  was  allowed  to  go  about  without  any  special  super- 
vision. "  Dyspepsia  "  is  the  cause  of  misery  to  many  people,  but 
it  is  not,  as  a  rule,  attended  with  destructiveness,  and  I  think 
that  it  only  becomes  dangerous  when  associated  with  heart-disease. 

In  terror  and  great  excitement  the  heart's  action  is  changed, 
no  doubt  with  regard  to  preserving  the  balance  of  the  circulation 
in  the  brain,  and  if,  as  so  often  is  found  in  the  insane,  the  heart 
is  itself  fatty,  there  is  an  additional  reason  for  the  violence  of 
their  actions  if  I  am  right  in  assuming  that  the  heart  is  so  pro- 
minent a  factor  in  these  destructive  conditions.  There  are  some 
physiological  conditions  that  indicate  the  effect  of  the  heart's 
action  upon  the  conduct  of  people ;  for  instance,  sudden  anger 
in  one  man  will  cause  a  fluttering  action  of  the  heart,  and  faint- 
ness  with  impulsive  tendencies  (such  as  smashing,  suicide,  &c.) ; 
in  another,  "  whose  pulse  doth  temperately  keep  time,"  there  are 
no  signs  of  excitement ;  a  third  is  quite  another  individual  for 
the  time  being,  and  the  change  is  shown  by  general  excited  con- 
duct. As  the  heart's  action  becomes  quieter,  so  the  mental 
symptoms  subside,  and  the  well-known  effect  of  tobacco  as.  a 
sedative  to  excitement  doubtless  acts  through  its  influence  on 
the  heart.     I  do  not  mean  to  imply  that  heart-disease  by  itself. 


1 6  Forecast  of  Destructice  Impulses  in  the  Insane. 

without  any  affection  of  tlie  brain,  will  cause  destructive  ten- 
dencies, for  the  action  of  digitalis  proves  that  we  can  materially 
alter  the  pulse,  and  yet  not  affect  the  mental  symptoms  at  all. 

The  following  are  the  conclusions  which  I  arrive  at: — That 
the  destructive  state  is  one  result  of  a  certain  condition  of  brain, 
and  may  exist  in  its  greatest  intensity  without  consciousness. 
That  it  is  especially  frequent  in  those  forms  of  brain-disease 
attended  with  weak  or  irregular  action  of  the  heart.  That  epi- 
lepsy, the  insanity  of  old  age,  puerperal  insanity,  masturbatioiial 
insanity,  and  imbecility,  are  very  liable  to  exhibit  it.  That,  in- 
asmuch as  brain-disease  is  rarely  stationary  in  its  extent,  and 
often  proceeds  insidiously,  it  is  impossible  to  deny  that  any  in- 
sane person  may  develop  the  destructive  factdty;  but,  at  the 
same  time,  we  do  see  persons  who,  though  insane,  still  retain 
sufl&cient  controlling  power  over  themselves  to  warrant  oin*  con- 
fidence. That  patients  may  be  of  the  reverse  of  a  melancholy 
disposition,  and  yet  most  suicidal ;  that,  in  fact,  the  nature  of  the 
delusion  has  no  necessary  connection  with  destructive  habits, 
and  that  therefore  such  habit  is  not  a  consequence  of  a  train  of 
thought  in  the  same  way  as  in  the  sound  mind  a  certain  conclu- 
sion results  fioiu  certain  premisses,  but  that  it  is  as  much  a  sign 
of  disease  as  a  delusion  is.  I  believe,  indeed,  that  the  destrnc- 
tive  faculty  may  be  the  only  sign  to  be  found  of  insanity  at  a 
particular  time,  and  I  view  it  as  a  particular  form  of  brain- 
disease,  just  as  I  see  that  other  forms  of  insanity  may  occur  in 
association  with  it  or  without  it,  Some  insane  persons  we  see 
go  on  for  years  without  showing  any  destructive  impulse  ;  if  they 
become  glass-smashers  or  destructive  of  clothing,  do  we  view  the 
access  of  this  symptom  in  the  same  light  as  we  should  do  one  of 
the  suicidal  or  homicidal  kind  ?  I  think  that  we  ought  to  do. 
At  present  it  seems  to  us  accidental,  whether  a  chronic  insane 
person  becomes  dangei'ous  to  himself  and  others,  or  simply  be- 
comes destructive  of  clothing ;  why  the  progress  of  the  disease 
should  be  at  times  in  the  one  direction  or  the  other  is  a  mystery. 
If  patients  take  to  pulling  their  clothes  to  pieces  and  eating 
them,  it  is  certainly  not  always  due  to  delnsion:  it  is  in  itself  as 
much  a  symptom  as  is  a  delusion  or  incoherence  or  dirty  habits, 
or  anything  else  that  we  choose  to  name. 

Shock,  bad  news,  lovers'  quarrels,  jealousy,  passion,  lead  to 
destructive  acts  more  frequently  than  any  other  causes.  Why  is 
this  ?  I  can  only  account  for  it  by  supposing  that  a  great  effect 
is  suddenly  produced  in  the  supply  of  blood  to  the  brain  by 
interference  with  the  heart's  action,  and  that  the  action  of  the 
brain  is  rapidly  placed  in  a  negative  state  to  what  it  is  in  health, 
and  hence  any  act  that  is  the  pole  of  a  healthy  one  may  be 


Forecast  of  Destructive  Impulses  in  tlie  Insane.  17 

expected.  The  medico-legal  bearing  of  this  view  of  the  question 
is  significant.  If  destructive  impulses  may  be  the  first  sign  of  a 
diseased  brain — perhaps  for  a  time  more  or  less  long  continued 
the  only  one — the  difiiculty  of  deciding  how  far  a  person  is 
responsible  becomes  very  great,  but  it  does  not  alter  the  fact ; 
and  although  many  persons  have  been  deliberate  homicides  or 
suicides,  yet  many  more  have  been  convicted  and  suffered  the 
extreme  penalty  because  either  time  has  not  been  allowed  for 
the  other  symptoms  to  develop,  or  they  have  suffered  from  a 
temporary  insanity^  and  have  been  cured  before  trial. 

It  is  often  asked  if  suicidal  and  homicidal  tendencies  are 
generally  connected  in  the  insane.  They  may  be,  and  probably 
jilways  are,  in  some  form  or  other.  As  forms  of  destructiveness 
they  would  probably  be  more  likely  to  be  connected  than  would 
either  of  them  separately  with  another  symptom,  but  there  is  no 
necessary  clinical  connection  between  the  two.  We  see  homi- 
cidal patients  who  take  the  greatest  possible  care  of  themselves, 
and,  again,  there  are  suicidal  patients  who  would  not  hurt  a 
worm  ;  there  are  others  who  are  destructive  to  glass  and  furniture 
(and  who  feel  great  relief  in  doing  such  acts),  who  are  quite 
harmless  in  every  other  way ;  but  in  all  of  them  there  is  the  same 
answer  to  inquiries  as  to  why  they  have  so  acted — they  "  cannot 
tell  you."  They  cannot  reproduce  the  train  of  reasoning  by 
Avhich  they  arrived  at  their  act,  because  there  is  no  such  train  ; 
no  more  can  they  do  it  than  an  incoherent  man  in  a  state  of 
acute  mania  could  go  through  his  jargon  again,  or  a  pauper  give 
you  a  reason  for  his  assertion  that  he  is  as  rich  as  a  Kothschild. 
It  is  not  always  possible  for  a  sane  man  to  repeat  the  mental 
])rocess  by  which  he  arrived  at  a  certain  conclusion.  If,  then, 
this  is  60  with  a  healthy  mind,  how  can  we  expect  that  the  insane 
person  can  give  again  his  processes  of  arriving  at  a  conclusion  ? 
In  the  insane  there  is  no  direct  process  of  a  kind  subject  to 
explanation,  and  a  dreamer  is  just  as  irresponsible  and  as  unable 
to  control  his  movements  as  is  an  insane  man.  This  very  day  I 
watched  a  general  paralytic  tearing  his  clothes  for  the  first  time 
during  his  illness.  He  was  a  very  quiet,  harmless  man  by  nature, 
and  was  always  very  neat  in  his  person  ;  but  when  I  asked  him 
why  he  tore  his  clothes,  he  simply  replied  that  he  was  "not  tearing 
them  ;  he  was  mending  them."  He  had  lost  the  very  meaning 
of  terms,  and  his  mind,  as  regarded  the  act  of  "  tearing,"  had 
lost  its  significance;  and  this  I  believe  to  be  the  condition  of  the 
insane  generally,  that  acts  lose  their  significance.  What  would 
be  murder  or  suicide  in  the  case  of  a  sound  man  is  not  so  to  the 
lunatic,  but  is  purely  an  act  that  he  follows  out  as  unthinkingly 
as  a  sane  man  does  many  of  the  reflex  acts  which  go  on  co- 

VOL.  XXI.  B 


iS  Forecast  of  Destructive  Impulses  in  the  Insane. 

ordinately  in  him,  but  of  wliicli  lie  i.s  onl}'  partially,  if  at  all, 
conscious.  I  doubt  if  the  lunatic  has  really  a  true  perception  of 
his  ideas;  for  though  professing  to  be  a  king,  he  sits  down  con- 
tentedly with  the  beggar;  although  possessing  millions,  he  is 
happy  in  a  pauper's  clothes,  and  never  tliiidis  of  insisting  on  the 
luxuries  and  position  to  which  his  riches  would  entitle  him. 
The  madman's  mind  is  another  existence  this  side  of  the  grave, 
and  is  as  incapable  of  intimate  research  as  is  the  life  on  the 
other  side.  If  we  knew  (which  we  do  not)  that  each  brain-cell 
was  moved  in  a  definite  vibratory  manner  for  each  word  uttered, 
or  that  for  every  insane  delusion  there  was  a  recognised  affection 
of  a  cell  or  defined  group  of  cells,  we  might  be  able  to  say,  in 
this  case  or  that,  that  the  individual  would  of  necessity  do  certain 
things,  that  he  would  not  be  suicidal  or  homicidal,  and  so  on  ;  but 
the  most  recent  expositions  of  the  connection  between  brain 
action  and  vibratory  motion  teach  us  nothing  of  this  particu- 
larity, and  all  we  do  know  is  that  such  and  such  results  may  be 
expected  to  follow,  but  that  we  cannot  surely  tell  that  they  will. 
We  are  like  the  philosophers  of  old,  who  knew  that  a  comet 
would  return,  but  could  not  say  when,  because  they  were  not 
acquainted  with  Kepler's  kw.  How  easily  is  a  prognosis  upset, 
not  only  in  mental,  but  in  both  general  medical  and  surgical 
cases,  because  of  the  difficulty  of  gauging  the  bounds  of  the 
lesion  I  Seeing  how  surprised  one  oft  en  is  at  the  cure  of  a  reputed 
hopeless  case  of  long  duration,  or  at  the  recoveiy  of  an  unpromis- 
ing acute  case,  there  can  be  little  wonder  if  we  are  unable  to 
predict  the  vagaries  that  occur  in  the  course  of  a  madman's 
career.  The  change  from  depression  to  exaltation  is,  it  is  true, 
often  accompanied  by  the  loss  of  destructive  tendencies ;  and  a 
notable  instance  of  this  occurred  here  recently  in  a  woman,  who, 
up  to  the  time  of  a  severe  uterine  haemorrhage,  was  most  melan- 
choly and  suicidal,  whereas  now  she  has  completely  changed  in 
temperament,  and  is  one  of  the  most  cheerful  patients  here,  but 
she  is  much  more  deluded  and  insane  than  when  she  was  in 
the  melancholic  state,  though  not  now  destructive.  Conversely, 
there  is  a  woman  here  who,  though  formerly  of  a  very  depressed 
nature,  yet  not  suicidal,  is  now  in  a  state  of  exaltation,  but  withal 
extremely  destructive. 

An  attack  of  insanity  is  a  first  experience  of  a  new  condition, 
and  the  individual  then  belongs  to  a  community  that  knows  no 
laws  except  those  not  of  its  own  making.  There  is  no  difference 
between  the  insanity  of  the  peer  and  that  of  the  ploughman, 
except  perhaps  in  the  range  of  the  delusions,  and  it  is  only  after 
an  attack  of  insanity  that  the  latent  traits  of  mind  come  out. 
Disease  will  not  produce  symptoms  unless  the  germs  of   the 


Forecast  of  Destructive  Impulses  in  the  Insane.  19 

symptoms  are  there.  There  would  not  be  any  destriictiye 
tendencies  shown  in  the  course  of  a  disease  unless  the  idea 
was  there  already.  We  cannot  conceive  an  individual  develop- 
ing a  new  brain  factor  under  the  influence  of  insanity,  any  more 
than  that  a  disease  of  the  liver  should  produce  more  gland 
structure ;  for  the  essence  of  a  disease  is  to  produce  a  structure 
that  interferes  with  the  true  one  and  usurps  or  alters  its  function. 
However  superexcellent  in  its  display  of  function  an  organ  may 
be  in  health,  there  is  no  difference  in  its  abasement  in  disease. 
The  high  moralist,  the  exemplary  man  of  business,  the  brilliant 
debater,  all  come  to  the  same  level  as  the  destructive  dement 
who  scarcely  ever  showed  any  sign  that  he  was  at  one  time  of  the 
intelligent  class,  and  the  levelling  tendency  of  disease  reaches  the 
universal  platform  in  death. 

The  sexual  feeling  rises  to  a  beiglit  that  is  only  extinguished 
by  its  gratification,  the  feeling  of  hunger  in  the  same  way,  and 
so  is  the  necessity  of  respiration.  This  in  health ;  but  in  disease 
there  is  no  satiety,  and  the  effect  of  this  is  to  urge  to  extraordi- 
nary acts  for  the  relief  of  the  feelings.  These  acts,  which  are  the 
efforts  of  nature  for  the  preservation  of  the  individual,  may  be  of 
so  ultimate  a  nature  that  they  entail  injury  to  others,  and  the 
law  under  the  circumstances  excuses  the  deed,  though  it  may 
not  justify  it.  Just  the  same  process  occurs  in  disease  of  the 
brain  itself :  to  an  unsound  brain  there  is  no  satiety.  It  is  suffi- 
cient for  the  sane  man  who,  being  in  danger  of  losing  his  social 
position,  has  the  idea  of  destroying  himself  presented  to  him,  to 
discuss  the  idea  with  the  presentiment  of  it ;  but  in  disease  there 
is  no  cessation  of  the  idea ;  it  is  always  there,  as  is  the  feeling  of 
hunger  to  the  man  who  can  get  nothing  to  eat ;  and  eventually 
it  leads  to  the  final  accomplishment,  or  the  effort  for  it,  which 
must  follow,  unless  the  central  irritation  stops.  It  is  as  bound 
to  continue  as  is  a  railway  engine  to  go  on  as  long  as  the  valves 
are  open  and  the  steam  lasts.  People  not  acquainted  with  the 
insane  are  often  surprised  at  the  coherence  and  intelligence  of  the 
letters  they  write ;  but  it  often  happens  that  a  very  deluded  and 
dangerous  man  will  write  a  coherent  and  apparently  sensible 
letter  on  subjects  not  connected  with  his  delusion,  whilst,  on  the 
other  hand,  a  harmless  patient  will  write  the  most  incoherent  and 
dangerous-sounding  nonsense.  There  is  not  really  the  incon- 
gruity here  that  apparently  exists ;  in  the  former  case,  the  man, 
if  he  expressed  the  delusions  which  really  exist  in  him,  and  which 
in  his  destructive  practices  he  exposes,  would  appear  just  as 
insane  as  the  latter.  There  are  here  two  men  who  exactly 
carry  out  the  above-named  conditions;  one  writes  coherently, 
but  is  really  deluded  with  suspicions  of  poisoning,  and  the  other 


20  Forecast  of  Destructive  Impulses  in  the  Insane. 

is  most  threatening  and  deluded  according  to  liis  writing,  but 
is,  as  far  as  we  see,  quite  harmless.  The  insanity  of  the  latter 
is  apparent  to  any  one,  and  an  untrained  jury  would  have  no 
difficulty  in  finding  him  insane  ;  the  former  man's  insanity  is 
more  subtle,  and  might  not  be  recognised  by  an  outsider ;  but 
all  the  same  it  is  there ;  and  whilst  the  latter  might  be  taken 
home  by  his  friends  if  they  would  have  him,  the  former  must 
be  kept  under  strict  supervision  as  a  dangerous  lunatic.  Now, 
what  is  it  that  makes  these  men  so  different  ?  Not  extent  of 
disease,  for  the  harmless  one  is  insane  to  the  very  tips  of  his 
fingers,  whilst  the  other  can  converse  rationally,  if  he  likes,  at 
any  rate  for  a  time ;  not  the  nature  of  the  delusions,  for  both 
have  delusions  of  suspicion  ;  not  presence  of  motives  of  revenge, 
for  both  have  been  equally  kindly  treated  by  people  absolute 
strangers  to  them ;  but  the  dangerous  man  has  a  bad  crimi- 
nal history,  has  always  lived  in  an  atmosphere  of  low  morality, 
and  has  a  very  irritable  heart,  whilst  the  former  has  had  a  very 
diff'erent  training,  and  has  a  good  circulation. 

The  cataleptic  state  is  common  in  women  who  are  epileptic, 
or  who  have  been  indulging  in  sexual  excess,  as  also  it  is  seen, 
but  more  rarely,  in  men  under  the  same  conditions.  What  is 
known  as  the  condition  of  anergic  stupor  has  this  cataleptic 
symptom  for  its  chief  feature,  and  the  vaso-motor  affection  that 
is  intimately  associated  with  the  condition  is  shown  by  the  readi- 
ness with  which  red  streaks  appear  on  the  skin  in  the  tracks  of 
lines  drawn  there  by  any  blunt  object.  Now  the  suicidal  im- 
pulse is  very  strong  in  persons  who  exhibit  this  symptom,  and 
as  long  as  the  condition  lasts,  I  consider  the  patients  very  un- 
trustworthy. The  heart  may  not  be  actually  diseased  in  these 
persons,  but,  at  any  rate,  its  power  is  much  affected,  and  the  im- 
pairment of  the  circulation  is  shown  by  the  cold  and  blue  extre- 
mities, greasy  skin,  and  congested  capillary  appearance,  all  symp- 
toms pointing  to  an  ansemic  state  of  the  brain.  There  is  now  a 
female  patient  here  who  is  markedly  cataleptic  and  insensible  to 
the  prick  of  a  needle  or  to  the  touch  of  the  finger  placed  on  the 
cornea,  yet  she  is  very  suicidal,  and  has  to  be  most  carefully 
watched,  and  will  have  to  be  so  whilst  the  attack  continues; 
indeed,  her  vaso-motor  system  has  become  so  affected  that  I 
doubt  if  it  will  ever  regain  its  normal  condition,  and  so  her 
destructive  state  will  be  always  a  source  of  anxiety.  Another 
female  patient  here  is  in  much  the  same  state  as  the  one  just 
described,  but  though  she  has  not  as  yet  made  a  destructive 
attempt,  I  am  prepared  for  its  demonstration  at  any  moment, 
and  have  given  instructions  accordingly. 


Forecast  of  Destructive  Impulses  in  the  Insane.  21 

However  great  our  experience  may  then  be,  we  are  occasion- 
ally deceived  by  the  exhibition  of  dangerous  and  destructive  acts 
where  they  were  not  expected ;  but  if  we  keep  prominently  before 
us  the  condition  of  the  heart  and  the  vaso-motor  system,  with 
especial  reference  to  their  causation  of  a  sudden  ansemic  state  of 
the  brain,  we  have,  in  my  opinion,  a  trustworthy  warning  which 
will  justify  us  in  taking  steps  which  we  shall  find  afterwards  no 
reason  to  regret. 


CASES  RESEMBLING  GENERAL  PARALYSLS 
OF   THE   INSANE. 

BY 

J.  A.  OEMEROD,  M.D. 


It  is  scarcely  necessary  to  insist  upon  the  interest  possessed  by 
general  paralysis  of  the  insane,  as  the  most  striking  instance  of 
a  disease  which  affects  both  the  mental  and  material  functions  of 
the  nervous  system,  and  in  which  mental  symptoms  are  associated 
with  definite  pathological  changes  post-mortem ;  nor  is  it  neces- 
sary to  describe  an  affection  which  figures  in  every  text-book  of 
lunacy,  and  in  some  text-books  of  general  medicine.  Most  of  the 
cases,  brief  notes  of  which  I  append,  belong,  I  believe,  to  that 
subordinate  type  of  the  disease  in  which  the  paralytic  symptoms 
predominate  throughout  over  the  mental.  This  type  has  been 
recognised  and  described  both  by  alienists  and  general  physi- 
cians.^ But  so  impressive  are  the  extravagant  ideas  and  conduct 
of  a  typical  general  paralytic,  that  it  is  difficult  in  one's  imagi- 
nation to  make  room  beside  him  for  less  obtrusive  cases.  For 
instance,  Dr.  Claye  Shaw  lately  showed  us  at  the  Banstead 
Asylum,  as  a  typical  case  of  the  disease,  a  man  who  declared  he 

was  the  Duke  of  S ,  the  husband  of  the  Virgin  Mary,  willing 

to  draw  us  cheques  for  thousands,  able  to  cure  all  the  other 
inmates,  only  they  were  not  worth  his  attention,  and  who,  so  far 
from  being  paralysed  in  the  ordinary  sense  of  the  term,  was 
violent  and  had  to  be  kept  by  himself.  By  the  side  of  such  a 
patient  I  should  hardly  like  to  classify  such  tame  cases  as  my 
own,  were  it  not  for  the  recognition  by  good  authorities  of  the 
non-delusional  variety,  and  the  fact  that  in  both  classes  the 
ultimate  progress  towards  bodily  and  mental  decay  appears  to 
be  the  same.  But  assuming  the  existence  of  such  a  variety,  it  is 
perhaps  safest  to  say  only  of  the  present  cases  that  they  resemble 

^  See,  amongst  others,  Gower's  "  Diseases  of  the  Brain,"  p.  233 ;  Clouston, 
"Mental  Disease,"  p.  365  ;  Savage,  "  Insanity  and  Allied  Xeuroses,"  p.  277, 


24  Cases  Besembling  Paralysis  of  the  Insane. 

general  paralysis,  since  the  sphere  of  observation  was  limited  lo 
the  out-patient  room,  and  since  even  typical  general  paralysis 
may  be  simulated  by  other  coudilious. 


Case  I. 

Affection  of  sjyeech ;  tottering  gait ;  extravagant  ideas ; 
exaggeration  of  tendon-reactions. 

William  R.,  ret.  50,  railway  porter.  In  this  case  tiiere  was  a 
history  of  extravagant  ideas ;  the  patient  thought  he  had  money, 
plenty  of  good  clothes,  &:c. ;  he  was  also  irritable  and  spiteful  lo 
his  wife.  His  speech  had  become  indi.stinct  gradually  during 
the  last  twelve  months;  his  gait  had  become  tottering  for  the 
last  nine  luonths  ;  and  for  nine  months  he  had  been  forgetful. 
He  had  had  a  kind  of  fit  nine  days  before  coming  to  the  hos- 
pital ;  he  clutched  the  mantelpiece  near  which  he  was  standing, 
and  could  not  move,  nor  could  his  friends  move  him  ;  he  did  not 
lose  consciousness. 

His  speech  is  now  slurring  and  indistinct,  his  gait  unsteady 
(ataxic) ;  he  sways  about  when  his  eyes  are  shut ;  yet  the  patellar 
tendon-reactions  are  exaggerated,  and  the  pupils  act  to  light. 
The  tongue  and  lips  were  quite  steady  when  I  first  saw  him ; 
later  a  very  slight  tremor  of  the  tongue  was  noticed.  There  was 
no  history  of  excess  of  any  kind,  nor  of  overwork  or  anxiety. 
In  a  few  weeks  more  he  had  another  fit,  and  got  so  feeble  that 
he  could  come  no  more. 

Case  II. 

Attacks  of  fai iitness ;  severe  pain  in  the  head;  deafness;  affec- 
tion of  speech  ;  tremor  of  tongue,  lips,  and  limbs;  progres- 
sive lueahness;  some  delusions. 

Thomas  B.,  fet.  36,  gasfitter  (August  1881  to  December  1882). 
In  November  1880  had  an  attack  in  which  he  felt  suddenly  faint, 
though  without  actual  loss  of  consciousness.  Has  been  subject 
to  these  attacks  since.  Had  been  noticed  to  stutter  even  before 
the  first  attack.  During  the  last  three  months  has  been  losing 
[)Ower  in  the  limbs,  lie  now  complains  chiefly  of  sudden  violent 
pain  in  the  head,  lasting  about  a  quarter  of  an  houi". 

He  is  very  deaf :  with  the  right  (the  best)  ear,  he  can  only  just 
hear  a  loud  tuning-fork,  whether  held  at  the  meatus  or  on  the 
bone.  Speech  thick  ;  tremor  of  lips  and  tongue  when  he  begins 
to  speak.  Tendon-reactions  much  exaggerated  in  all  the  limbs  ; 
ankle-clonus  on  both  sides.     Pupils  act  normally ;  optic  discs 


Cases  Resembling  Paralysis  of  tlie  Insane.  25 

normal.  Tlie  patient  could  not  be  questioned  on  account  of  his 
deafness ;  liis  wife  said  he  liad  no  delusions,  though  he  had  been 
discharged  from  one  hospital  as  unmanageable  ;  she  had  had  by 
him  one  healthy  child,  and  had  miscarried  three  times. 

He  became  weaker  and  more  tremulous,  anxious-looking,  and 
excitable,  and  in  April  1882  could  only  walk  by  holding  on  to 
the  fm'niture. 

In  August  1882  he  reappeared,  seeming  much  better,  though 
some  difficulty  of  swallowing  had  developed.  But  the  improve- 
ment did  not  last.  He  became  spiteful  to  his  wife ;  thought  "  there 
was  a  green  monster  after  him."  His  mother  said  he  was  anxious 
to  give  guineas  to  various  societies,  though  certainly  he  had  no 
money  to  spare.     He  finally  went  to  an  infirmary. 


Case  III. 

Transient  attacks  of  rigid  hemiplegia;  affection  of  speech;  ataxia 
of  legs,  absence  of  tendon-reactions ;  tendency  to  extravagance, 
and,  later,  doivmnght  insanity. 

William  W.,  set.  48,  corndealer  TApril  15  to  August  1884). 

April  15,  1884. — He  says  that  from  October  to  Christmas  of 
last  year  he  used  to  have,  each  month,  an  attack  in  which  he 
lost  speech  and  the  power  in  his  right  arm  and  leg.  It  would 
last  from  half-an-hour  to  an  hour.  He  was  not  convulsed  and 
did  not  lose  consciousness. 

The  right  side  of  his  face  looks  rather  flattened.  He  speaks 
slowly,  sometimes  stammers,  and  has  difficulty  in  getting  his 
words  out.  He  walks  in  an  uncertain  fashion;  the  right  leg 
looks  rather  stiff;  the  left  leg  sometimes  gets  crossed  in  front  of 
it.  Is  unsteady  when  he  stands  with  his  feet  together  and  eyes 
shut.  Tendon-reactions  quite  absent.  Pupils  of  moderate  size 
and  acting  normally ;  optic  disc  (right)  rather  white.  (Says  that 
for  seven  weeks  last  spring  he  lost  his  sight,  but  recovered  from 
this.)  He  seems  at  times  vacant,  and  as  if  he  did  not  under- 
stand what  was  said  to  him ;  at  times  his  manner  is  rather 
theatrical. 

His  wife  came  next  week,  and  said  she  had  noticed  a  stam- 
mering speech  and  an  irritability  of  manner  three  or  four  years 
ago ;  he  had  sometimes  thought  he  was  going  to  die,  and  said  he 
must  kill  himself  or  her ;  there  was  only  this  much  indication  of 
extravagance,  that  he  says  he  means  to  write  a  large  and  valuable 
book,  for  which  he  collects  newspaper  cuttings  about  all  sorts  of 
trivial  things.  The  first  symptoms  had  followed  heavy  business 
troubles,  and  were  ascribed  to  them  as  cause. 


26  Cases  Resenibling  Paralysis  of  the  Insane. 

During  his  attendance  he  had  several  more  attacks  of  transient 
right  hemiplegia  and  aphasia;  his  speech  became  more  indistinct, 
liesitating,  and  drawling;  he  used  to  screw  up  liis  face  and 
wrinkle  his  occipito-frontalis  as  he  spoke;  his  tongue  and  lips 
became  tienuilous ;  he  stumbled  as  he  walked ;  he  became 
childish.  Finally  (August  19),  his  wife  told  me  he  had  had  an 
attack  in  which  he  slept  all  day  and  night  for  a  week ;  on 
waking,  he  was  quite  insane,  wanted  to  go  out  naked,  Sec.  He 
got  better  again,  but  had  lo  be  taken  later  to  the  Three  Counties 
Asylum,  Arlesey. 

Case  IY. 

Insanity  requiring  confinement  for  three  months;  subsequently 
attacJcs  0/ right  hemiplegia;  much  tremor  and  hesitation 
of  speech ;  increased  tendoii-reactions  ;  finally,  paraplegia, 
bed-sores.  (i:c. 

Benjamin  I.,  set  21.  This  patient  was  sent  to  the  hospital 
by  Dr.  Fiankisli  in  March  18S4,  and  I  again  saw  him  by  the 
kind  permission  of  Dr.  Frankish  in  September  1885.  His 
symptoms  came  on  rather  suddenly  in  July  1883.  He  came 
home  in  a  stupid  condition,  saying  he  had  been  struck  by  light- 
ning. In  two  or  three  weeks  he  became  insane ;  bought  some 
flowers ;  said  he  was  going  to  leave  home,  &c.  He  was  put  in 
Hanwell  Asylum  for  three  mouths.  So  far  as  I  could  make  out 
from  his  mother,  he  had  no  marked  grandiose  ideas.  In  Novem- 
ber 1883,  and  several  times  since,  he  had  a  transient  attack  of 
right  hemiplegia  and  aphasia.  Twice  in  the  present  year  (1884) 
he  has  had  right-sided  convulsions.  Kow  (March  1884)  his 
tongue,  lips,  and  limbs  are  remarkably  tremulous  ;  his  speech  is 
slurring  and  hesitating;  he  can  stand  steadil}'^  with  his  eyes 
shut;  the  tendon-reactions  at  the  knees  are  exaggerated;  the 
pupils  are  of  medium  size  and  equal,  do  not  act  to  light,  and  act 
very  little  to  accommodation. 

September  19,  1885. — He  is  now  completely  paraplegic,  and 
unable  to  sit  up  in  bed ;  he  still  retains  some  power  in  arms  and 
hands,  though  not  enough  to  feed  himself.  (The  loss  of  power 
in  the  legs  appears  to  have  come  on  rather  suddenly  five  months 
ago,  after  some  kind  of  fit.)  There  has  been  incontinence  of 
urine  for  two  weeks,  and  lately  of  faeces  also.  A  bed-sore  has 
developed  on  each  buttock.  There  is  contracture  of  the  lower 
limbs,^  and  the  patellar  tendon-reactions  are  marked.  Face 
expressionless ;  still  some  tremor  about  lips ;  appears  unable  at 
present  to  protrude  tongue  or  to  speak.     His  mother  says  he 

^  Contracture  of  the  arms  has  since  set  in,  as  Dr.  Frankish  tells  me  (Xov.  19,  i835)' 


Cases  Besemhling  Paralysis  of  the  Insane.  27 

recognises  liis  friends.    He  can  only  swallow  fluids.    At  one  time 
his  appetite  was  very  lai-ge. 

The  youth  of  the  patient  in  this  case  is  remarkable.  As  no 
one  witnessed  the  lightning  stroke,  it  is  quite  possible  that  it  may 
have  been  an  apoplectic  attack.  He  had  always  lived  at  home, 
and  been  exceedingly  steady  and  well-behaved.  His  father  died 
of  heart-disease ;  his  mother  was  healthy  ;  he  had  five  healthy 
brothers  and  sisters. 

Case  Y. 

Tremor  0/ hands  and  tongue ;  absence  of  tendon-reactions ; 
inability  to  stand  luith  eyes  slmt. 

Henry  F.,  «t.  29,  bootmaker  (February  to  October  1884).  Had 
been  ill  eighteen  months ;  no  sufficient  cause  could  be  assigned 
for  his  illness.  His  family,  though  none  of  them  were  insane, 
seem  to  have  been  excitable  people.  His  tongue  and  hands  were 
very  tremulous.  His  pupils  reacted  slightly  and  sluggishly  I0 
light.  The  patellar  tendon-reactions  were  absent,  and  he  could 
not  stand  wiih  his  eyes  shut.  His  articulation  was  slow  and 
confused.  He  once  had  the  delusion  that  the  room  was  a  ship, 
and  that  he  could  make  it  sail  wherever  he  liked. 

During  his  attendance  he  once  complained  of  shooting  pains 
in  the  back  and  in  the  head.  He  appeared  to  improve  on  the 
whole,  and  finally  went  away  to  Leicester. 

Case  VI. 

Paresis  of  left  side  ;  tremor  of  tongue  and  of  limbs  ( +  L.) ; 
affection  of  speech;  attach  of  left  hemianopia. 

Thomas  Frederic  B.,  set.  45  (January  8,  1884).  Complains  of 
some  loss  of  power  in  the  left  side,  and  of  pain  in  the  head  and 
chest.  Onset  gradual  during  the  last  four  or  five  years;  worse 
during  last  fortnight.  His  manner  is  excitable,  but  his  state- 
ments seem  coherent.  Speech  is  thick  and  somewhat  stammer- 
ing, tongue  shaky  ;  there  is  a  general  tremulousness,  worst  on  the 
left  side,  and  startings  and  tremor,  even  as  he  sits  quietly  in  a 
chair.  Tendon-reactions  normal ;  no  unsteadiness  on  standing 
with  eyes  shut.  Fundus  of  eyes  normal ;  right  pupil  acts  little, 
if  at  all,  to  light ;  left  acts  readily  to  light;  both  act  during  ac- 
commodation.    No  physical  signs  in  chest. 

January  15. — As  he  came  to  the  hospital  to-day  "something 
took  him  in  the  head,"  and  he  became  unable  to  see  things  to 
the  left  of  him ;  he  kept  hitting  people  with  his  left  hand  as  he 


28  Cases  riesemhllng  Paralysis  of  the  Insane. 

passed  tliem ;  finally,  got  among  the  veliicles,  and  had  to  be 
bronglit  here.     Tliere  appears  to  l)e  some  left  hemianopia  now. 

He  became  an  in-patient  at  St.  Bartholomew's  under  Dr.  Gee^ 
on  January  19  till  February  1884,  and  afterwards  at  various  in- 
firmaries. 

He  came  once  more  to  me  in  April  1884;  he  walked  into  the 
room  as  if  he  did  not  know  where  he  was  going  or  what  he  was 
doing ;  yet  he  answered  questions,  &c.,  rationally.  A  woman 
who  brings  him  says  he  has  had  another  attack  on  the  way  here 
like  the  last  one.  She  also  says  he  once  had  delusions  that  men 
were  in  the  room  with  him,  pulling  his  bed  about,  &c. 

Three  cases  of  hemianopia  occurring  in  the  course  of  general 
paralysis  are  given  by  Zacher,  "  Archiv.  fiir  Psychiatrie,"  &c.,  vol. 
xiv.  Charcot  relates  a  case  ("  Lemons,"  vol.  iii.  p.  78)  where  "  oph- 
thalmic migraine  "  occurred  in  an  early  stage  of  general  paralysis. 

Case  VII. 

Deafness;  hesitation  of  speech ;  tongue  ty^emor ;  general  tremor 
and  tveakness  {especially  left  side),  folloiving  an  attack  of 
partial  left  hemiplegia ;  ahsence  of  tendon-reactions ;  men- 
tal depression. 

Matthew  P.,  £et.  34,  bootfinisher  (March  to  June  1885).  This 
man  was  very  deaf;  he  could  scarcely  be  got  to  hear  conversa- 
tion at  all ;  but  he  could  hear  a  tuning-fork  placed  on  his  head. 
His  speech  is  hesitating;  his  tongue  and  lips  very  shaky;  his 
limbs  shaky,  especially  the  left  hand.  He  stated  that  in  Decem- 
ber 1884  he  had  a  sudden  attack  of  weakness  in  the  left  side. 
Before  that  he  had  felt  nervous,  and  used  to  fall  down  sometimes. 
His  wife  stated  (on  the  occasion  of  his  next  visit)  that  as  regards 
the  above-mentioned  fit  he  came  back  one  morning  from  the 
yard  saying  he  had  lost  power  down  his  left  side ;  he  then  seemed 
to  become  insane,  and  attacked  her,  but  did  not  use  his  left  hand ; 
in  three-quarters  of  an  hour  he  became  quiet  and  went  to  sleep. 
Ever  since  this  the  left  hand  has  been  weak.  Before  the  fit  he 
was  irritable  and  used  to  cry,  but  she  noticed  no  tremor  nor 
affection  of  speech  till  afterwards.  He  will  wander  about  as  if 
looking  for  something,  and  says  he  will  hang  himself  if  he  does 
not  improve.     Has  headache  at  times  ;   coughs  much.     Pupils 

^  On  referring  to  the  Ward  Books,  I  find  that  the  history  given  by  him  and  his 
physical  condition  were  the  same  as  in  my  notes,  with  the  addition  that  some 
deafness  was  noted.  With  regard  to  mental  symptoms,  a  note  of  January  25  says, 
"  He  sees  things  rushing  by  him  at  night,  and  people  outside  the  ward  windows." 
January  28 — "  Manner  strange  ;  forgets  his  bed  ;  walks  out  of  ward  door,"  &c. 


Cases  Resemblwg  Paralysis  of  the  Insane.  29 

equal ;  very  slight  action  to  light ;  normal  action  to  accommoda- 
tion. Patellar  tendon-reactions  absent ;  yet  he  stands  steadily 
with  his  e3^es  shut.  He  got  no  better,  and  in  July  1885  went 
into  the  Poplar  and  Stepney  Sick  Asylum. 

Case  VIII. 

History  0/ hemiplegia  eleven  years  ago;  epileptiform  attack ; 
progressive  loeakness  of  limbs  aiid  mental  enfeeUement; 
hesitation  of  speech ;  tremor  of  tongue  and  lips ;  lively 
tendon-reactions. 

Ellen  D.,  get.  32  (October  to  July  1884).  Eleven  years 
ago  she  had  an  attack  of  left  hemiplegia,  affecting  chiefly  the 
face  and  arm ;  from  this  she  recovered.  Six  or  seven  months 
ago  had  an  attack,  in  which  she  fell,  and  lost  the  use  of  all  her 
limbs  and  power  of  speech  for  an  hour.  Since  that  she  has  fre- 
quently fallen,  but  apparently  more  through  stumbling  than 
through  any  loss  of  consciousness.  She  also  drops  things  from 
her  hands. 

She  complains  now  of  pain  in  the  head  and  eyes,  and  of  pain 
all  over  her.  Speech  hesitating ;  tongue  and  lips  slightly  shaky. 
Tendon-reactions  lively  in  all  the  limbs.  Pupils  act  normally 
to  light.  As  regards  her  mind,  the  friend  in  attendance  told  me 
that  two  or  three  years  ago  she  used  to  be  very  jealous.  Some- 
times she  would  write  her  letters  outside  the  envelopes. 

In  six  weeks'  time  she  became  worse  ;  speech  worse  ;  heavy 
stupid  look  ;  memory  very  bad ;  constantly  falling  about.  She 
was  then  given  iodide  of  potassium  grs.x.  to  grs.xx.  three  times 
a  day.  She  seemed  to  improve  both  in  mind  and  body  till  April 
1884,  but  about  this  date  the  headache  and  pains  in  the  limbs 
began  again;  the  tongue  and  lips  got  more  and  more  unsteady, 
and  she  became  childish. 

In  September  1884  she  was  taken  to  the  Surrey  County 
Asylum,  Wandsworth  ;  the  diagnosis  (her  husband  told  me)  was 
general  paralysis,  and  the  prognosis  altogether  unfavourable. 

General  paralysis,  like  tabes  dorsalis,  is  rarer  in  women  than 
in  men.  Dr.  Clouston  says  that  the  disease  when  it  occurs  in 
women  is  likely  to  be  of  the  non-expansive  form  so  far  as  the 
mental  symptoms  are  concerned.^  Dr.  Savage,  speaking  of  the 
spinal  symptoms,  says  he  has  never  seen  a  female  general  paralytic 
who  was  also  markedly  ataxic.^  This  case  illustrates  both  these 
remarks ;  the  mental  condition  was  simply  childish ;  the  motor 

\  Mental  Disease,  p.  366.  ^  Insanity  and  Allied  Neuroses,  p.  319. 


30  Cases  Bessmhling  Paralysis  of  the  Insane. 

iifFection  was  parelic  in  character ;  ilie  tendon-reactions  lively, 
suul  the  action  of  the  pupils  normal. 

Case  IX. 

Weakness,  affecting  first  and  principally  the  rigid  side;  luasting 
of  left  half  of  tongue ;  drawling  speech;  increase  of  tendon- 
reactions  ;  inactive  pupils.  Later,  increase  of  ivecdcness ; 
tongue-tremor ;  epileptiform  attacks ;  progressive  loeahiess 
of  mind,  with  some  delusions.     Deccth  in  statu  epileptico. 

Alexander  MK,  ret.  50  (February  to  April  1883,  and  April 
1S84  to  January  1885). 

February  28,  1883. — Weakness  of  right  leg  began  four  or 
five  years  ago,  followed  in  a  year's  time  by  weakness  of  right 
hand.  On  one  occasion  patient  had  had  a  difficulty  in  speak- 
ing, but  this  was  slight  and  transient.  Now  the  loss  of  power 
in  the  right  hand  seems  to  be  chiefly  in  the  way  of  exten- 
sion of  the  fingers  ;  the  muscles  of  that  thumb  and  fore-arm 
are  smaller  than  on  the  left  side,  but  not  distinctly  atrophica), 
and  they  act  to  faradism.  He  seems  nervous  and  tremulous 
while  being  examined  in  this  way.  The  tendon-reactions  are 
exaggerated  everywhere,  but  remarkably  so  on  the  right  side, 
and  on  this  side  there  is  a  short  ankle-clonus.  Pupils  un- 
equal, left  the  largest;  neither  of  them  contract  at  all  to  light, 
and  they  contract  very  little  during  accommodation.  Ophthal- 
moscopic examination  negative.  His  speech  is  drawling,  but 
not  more  tlian  might  be  due  to  his  native  Scotch.  Tongue 
steady,  but  there  is  distinct  wasting  of  the  left  side  of  it.  His 
manner  in  the  out-patient  room  was  a  little  odd,  and  he  laughed 
occasionally  in  a  meaningless  way.  He  had  no  pain  nor  head- 
ache; nor,  according  to  liis  wife,  any  mental  symptoms,  except 
that  his  memory  was  not  good,  and  she  thought  him  "rather 
dtdl."  He  had  always  been  sober.  There  was  a  history  of 
syphilis  many  years  ago. 

The  diagnosis  evidently  lay  between  some  diffuse  affection, 
such  as  general  paralysis,  or  a  localised  lesion  affecting  princi- 
pally the  right  motor  tract  and  the  left  hypoglossal. 

He  was  ordered  01.  morrh.  syr.  ferri  iod.  a.a  3j.  bis.  and  Pot. 
iod.  gr.v.  ter. 

He  seemed  to  improve  very  much,  though  he  had  one  attack 
in  which  he  could  not  speak,  because  "  he  could  not  get  the 
word."     After  two  months  I  lost  sight  of  him. 

In  April  18S4  he  again  came  imder  my  care,  ray  colleague, 
Dr.  Ferrier  (under  whom  he  had  renewed  his  letterj,  having 
kindly  handed  him  over  to  me.     In  the  preceding  year  he  had 


Gases  Resembling  Paralysis  of  the  Insane.  31 

left  home  to  take  a  post  as  time-keeper  under  the  Thames  Con- 
servancy, but  this  he  had  to  give  up,  and  came  home  mucli 
worse.  The  speecli  is  now  nasal,  and  much  more  indistinct, 
being  indeed  almost  unintelligible ;  the  tongue  is  tremulous 
(wasted  on  left  side,  as  before)  ;  the  limbs  weaker  than  before, 
the  right  side  still  the  weakest.  There  is  some  deafness,  not 
noticeable  for  conversation,  but  for  the  watch  the  hearing  dis- 
1ance  =  /g-  K.  side,  -^%  L.  He  laughs  uncontrollably  for  no 
reason.  Tendon-reactions,  pupils,  &c.,  as  before.  His  wife  says 
he  has  no  delusion,  but  is  childish ;  he  once  stole  an  egg ;  he 
thinks  chance  peo})le  in  the  street  take  much  interest  in  him. 
He  was  given  iron  and  iodide  of  potassium,  the  latter  in  con- 
siderable doses. 

Dining  the  summer  he  had  slight  convulsive  attacks;  and 
sometimes  while  asleep  the  respiration  became  embarrassed. 

In  September  he  had  (by  day)  fits  of  "helplessness,"  with 
tremors  affecting  specially  the  right  hand.  He  lay  awake  at 
night,  because  he  thought  "men  were  coming  for  him." 

In  October  he  had  very  severe  ophthalmia  of  the  right  eye, 
with  extensive  chemosis,  and  discharge  partly  purulent,  partly 
sauious.  For  this  he  was  an  in-patient  at  Moorfields  under  the 
care  of  Mr.  Hulke ;  the  eye  was  completely  cured  there.  No 
cause  could  be  assigned  for  the  attack,  and  whether  or  not  it 
was  neuro-paralytic  in  origin  I  could  not  determine. 

At  the  end  of  December  he  was  admitted  to  Queen  Square 
imder  the  care  of  Dr.  Buzzard.  Dr.  Buzzard  had  no  doubt  that 
he  was  suffering  from  general  paralysis.  The  man  had  now  a 
half-frightened,  half-wild  look;  he  mistook  the  ward  attendant 
for  a  policeman,  and  finally  assaulted  him,  and  tried  to  get  out 
of  window.  Examination  of  his  chest  showed  that  the  action 
of  the  heart  was  irregular,  and  there  was  a  loud  blowing  systolic 
apex  murnuu". 

He  had  to  be  discharged,  and  his  wife,  who  could  not  be  per- 
suaded to  take  him  to  an  asylum,  kept  him  at  home.  On 
January  21,  1885,  he  had  a  fit  in  the  night.  From  this  he 
partially  recovered,  but  a  series  of  fresh  fits  followed,  in  which 
he  died.     She  told  me  this  a  week  afterwards. 

The  hemi-atrophy  of  the  tongue  may  be  compared  (as  Dr. 
Buzzard  pointed  out  to  me)  to  that  which  is  sometimes  found  in 
tabes  dorsal  is.  It  is  said  by  good  authorities  to  occur  as  an  early 
symptom  of  tabes.  Ballet  says  it  occurs  in  no  other  disease ;  but 
this  is  going  too  far.  In  most  of  the  cases  given  by  him^  there 
was  irregularly  distributed  muscular  atrophy  elsewhere.     Eay- 

^  Archives  de  IS'eurologie,  vol.  vii.  p.  191. 


32  Cases  Resembling  Paralysis  of  the  Insane. 

mond  and  ArtaiKP  have  sbowii  that  iu  such  cases  it  is  due  (as 
we  might  expect)  to  atrophy  of  the  hypoglossal  nucleus  of  one 
side.  Dr.  Dudley  -  gives  a  case  of  general  paralysis  where  there 
were  symptoms  of  posterior  sclerosis,  and  also  herai-atrophy  of 
the  tongue.  In  my  case  the  symptoms  (if  we  except  the  fixed 
pupils)  pointed  to  lateral  rather  than  posterior  sclerosis. 

Case  X. 

Attacks  of  pain  in  rigid  side  of  head,  with  noises  in  head  and 
right-sided  convidsions ;  right  hemi-paresis ;  some  deafness ; 
transient  paraplegia  ;  symptoms  of  general  paralysis  three 
years  later. 

William  R,  get.  43  (August  18S0  to  May  1882). 

August  18,  1880. — Ten  weeks  ago  he  was  brought  home  from 
his  work ;  his  right  arm  and  leg  were  shaking,  and  he  could  not 
speak.  The  attack  began  suddenly ;  he  did  not  fall  nor  lose 
consciousness  (at  least  at  the  beginning  of  it).  Previously  he 
had  been  quite  well,  except  for  sleepless  nights. 

He  now  complains  chiefly  of  a  "booming"  noise  in  the  head, 
and  of  severe  burning  pain  in  the  head,  coming  on  every  half- 
hour.  There  is  twitching  of  the  facial  muscles,  especially  on  the 
right  side ;  but  this  seems  to  be  caused  by  the  pain.  A  severe 
momentary  attack  of  pain  occurred  in  the  consulting-room ;  it 
was  followed  by  twitching  of  the  right  arm.  With  this  excep- 
tion, there  is  no  twitching  of  the  right  limbs,  but  they  are  still 
weak.  He  is  said  scarcely  to  have  recovered  his  sjieech  yet, 
and  he  seems  barely  to  understand  when  spoken  to.  The  head- 
ache seems  to  preoccupy  and  confuse  him.  Pupils  very  small, 
reaction  unfortunately  not  noticed ;  fundus  oculi  (right  side 
examined  under  atropine)  normal.  Some  deafness  on  right 
side;  thus  hearing  distance  of  left  ear  (for  watch)  =  ||,  for  right 
ear  -j| ;  tuning-fork,  whether  through  air  or  bone,  heard  best 
with  left  ear.  Doubtful  exaggeration  of  tendon-reactions  in  right 
limbs. 

He  improved  much  under  the  free  use  of  iodide  of  potassium 
(grs.x.  to  grs.xx.  three  times  a  day) ;  his  powers  of  speech  improved ; 
he  seemed  perfectly  intelligent ;  and  between  August  and  Septem- 
ber 1880  he  had  only  two  attacks  of  noises  and  pain  in  the  head. 
On  December  28  he  had  a  more  severe  fit,  loss  of  consciousness, 
shaking  of  right  arm  and  leg,  and  afterwards  sensation  of  pins 

^  Archives  de  Physiologic,  April  i,  1885. 

^  Brain,  Ko.  30.  In  the  same  number  abstracts  of  the  two  French  papers  just 
quoted  will  be  found. 


Cases  Resembling  Paralysis  of  the  Insane.  33 

and  needles  in  right  arm  and  leg.  Bromide  of  potassium  was 
given  in  addition  to  the  iodide ;  yet  he  continued  to  have  slight 
fits. 

On  March  9,  1881,  lie  was  wheeled  into  the  consulting-room  ; 
he  had  a  sallow  earthy  look  ahout  his  face,  was  unahle  to  walk, 
and  suffered  severe  pain  whenever  the  legs  were  moved.  This 
paraplegic  attack  had  come  on  suddenly  nine  days  before.  He 
again  improved,  and  in  a  fortnight  could  walk ;  and  he  now 
seemed  to  have  got  rid  of  the  fits  and  of  tlie  pain  in  the  head. 
The  patellar  tendon-reactions  after  the  attack  got  gradually 
weaker,  till  the  right  is  noted  as  "slight,"  the  left  "almost 
absent." 

In  September  1881  he  said  he  was  quite  well,  and  ceased  to 
attend. 

In  November  1881  a  recurrence  of  the  fits  brought  him  back 
to  me  again.  Once  more  the  iodide  treatment  seemed  to  stop 
Ihem ;  but  during  the  spring  of  1882  increasing  weakness  of  the 
right  side  was  noted.     I  then  lost  sight  of  him. 

Looking  to  the  headache,  the  attacks  of  right-sided  convulsions 
followed  by  right-sided  paresis,  the  transitory  paraplegia,  the 
seeming  improvement  under  iodide  of  potassium,  I  thought  that 
the  patient  had  some  localised  intracranial  lesion,  and  also  some 
spinal  meningitis,  probably  syphilitic  in  nature,  although  I  could 
obtain  no  direct  syphilitic  history. 

However,  in  May  1885  I  heard  by  chance  that  he  was  in  the 
Caterhara  Lunatic  Asylum;  and  the  superintendent,  Dr.  Elliott, 
in  reply  to  my  inquiries,  very  kindly  wrote  me  an  account  of 
him,  stating,  that  although  the  patient  had  no  grandiose  delusions, 
he  was  doubtless  in  the  first  stage  of  general  paralysis. 

The  general  similarity  of  these  cases  is  obvious  enough.  Their 
connection  with  the  delusional  type  of  general  paralysis  may  be 
])ut  thus : — In  Case  I.  there  had  been  distinct  grandiose  ideas ;  in 
Cases  II.,  III.,  lY.,  V.  (?)  there  was  just  enough  history  of  ex- 
travagance to  indicate  their  clinical  affinity  that  way ;  in  the 
rest  there  was  no  extravagance,  but  only  (in  those  watched  long 
enough)  progressive  mental  decay.  The  mental  symptoms  were, 
to  say  the  least,  unobtrusive;  and  inquiries  made  as  to  the  exist- 
ence of  typical  grand  delusions  were  usually  received  by  the 
patient's  friends  with  unfeigned  surprise. 

With  respect  to  bodily  symptoms,  the  well-known  affection  of 
speech,  the  tremor  of  the  tongue  and  lips,  the  tremulousness  and 
weakness  of  the  limbs,  may  be  passed  over  without  remark,  except 
to  say  that  the  diagnosis  mainly  rested  on  them.     Certain  other 

VOL.  XXI.  c 


34  Cases  Resembling  Pandysis  of  the  Insane. 

points  may  be  noticed  which  liave  aitracted  the  attention  of 
recent  authors.^  First  tlie  state  of  tlie  tendon-reactions.  'Jhese 
were  almost  always  abnormal,  and  that  in  the  opposite  directions 
of  excess  and  of  absence.  It  is  tempting  to  conclnde  at  once  that 
we  have  to  do  in  such  cases  with  lateial  and  posterior  sclerosis, 
respectively.  And  thongh  clinical  evidence  alone  may  be  insnflfi- 
cient  to  warrant  this  conclnsion, — for  we  know  that  tendon- 
phenomena  may  be  affected  by  cerebral  conditions  apart  from 
organic  spinal  disease  (thns  they  may  be  exaggerated  in  hysteria 
temporarily  exaggerated  or  diminished  after  epileptic  fits,  or  even 
permanently  annnlled  in  cases  of  cerebellar  tnmonr), — yet  anato- 
mical proof  has  been  afforded-  both  of  the  existence  of  spinal 
sclerosis  in  general  paralysis,  and  of  its  relation  to  variations  in 
the  tendon-renctions. 

What  connection  exists  between  the  spinal  and  the  cerebral 
disease  is  still  a  matter  of  discnssion.  As  to  the  lateral  sclerosis, 
the  suggestion  is  obvious  that  it  is  a  secondary  degeneration  pro- 
pagated downwards  from  the  diseased  coilex  cerebri.  This,  how- 
ever, is  by  no  means  certain,  and  eminent  authorities  deny  that 
it  is  so.  For  the  posterior  sclerosis  such  a  relation  cannot  hold  ; 
but  that  some  connection  exists  here  also  between  the  spinal  and 
the  cerebral  disease  is  probable,  both  from  the  fiequence  of  their 
coincidence  in  general  paralysis,  and  from  the  fact  that  cases  of 
long-established  tabes  dorsalis  sometimes  terminate  in  general 
paralysis.  It  seems  not  unlikely  tliat  in  general  paralysis  with 
spinal  disease  the  degeneration  may  attack  the  nervous  system 
simultaneously  at  more  points  than  one,  a  fact  that  may  be  seen 
sometimes  in  cases  of  pure  and  simple  spinal  disease.^ 

Certain  ocular  symptoms  form  another  bond  of  union  between 
this  disease  and  tabes.'*  One  of  these  is  optic  atrophy.  This 
was  not  noted  in  any  of  the  above  cases,  though  a  patient  at 
present  under  observation  exhibits  it.  The  second  consists  of 
abnormality  in  the  contraction  of  the  pupils.  Either  the  pupils 
do  not  contract  under  light,  yet  contract  during  accommodation 
(reflex  irido-plegia,  Argyll-Kobertson  phenomenon,  as  in  Case 
VII.),  or  there  is  failure  to   contract  under  either   condition 

^  Mickle  :  "  The  Knee-jerk  in  General  Paralysis,"  Journal  of  Mental  Science, 
xxviii.  342.  Beutley  :  "A  Study  of  the  Deep  Kefleses  in  General  Paralysis," 
Brain,  No.  29. 

*  Savage:  "Cases  of  General  Paralysis,  with  Lateral  Sclerosis  of  the  Spinal 
Cord,"  Journal  of  Mental  Science,  xxx.  57.  Zacher  :  "  Ueber  den  sogenannten 
spastischen  Symptomen  complex,  bei  der  progressiven  Paralyse,"  Arch,  fiir 
Paychiatrie,  &c.,  xv.  359. 

'  See  Brain,  No.  29,  "  Combined  Lateral  and  Posterior  Sclerosis." 

*  Brain,  Nos.  25  and  26,  "The  Condition  of  the  Fundus  Oculi  in  Insane  In- 
dividuals,"  by  Drs.  Wiglesworth  and  Bickerton  ;  and  Transactions  of  Ophthal- 
mological  Society,  1883,  Papers  by  Drs.  Gowers,  Bevan  Lewis,  and  Lawford. 


Cases  Besemhling  Paralysis  of  the  Insane.  35 

(Cases  IV.  and  IX.)  In  Case  VI.  there  was  reflex  iriJo-plegia 
in  one  eye  only.  In  only  one  instance  (Case  IX.)  were  the 
pupils  unequal. 

Turning  from  the  eye  to  the  ear/  there  was  extreme  deafue.'^s 
twice  (Cases  II.  and  VII.),  and  less  marked  deafness  twice  (Cases 
IX.  and  X.)  Sometimes  it  was  due  probably  to  middle  ear 
disease  (Case  VII.) ;  once  at  least  it  was  probably  of  central 
origin  (Case  X.) ;  for  the  patient  had  epileptiform  fits  associated 
with  noise  in  the  head  on  the  side  of  the  deafness,  and  the  hear- 
ing power  through  the  bone  as  well  as  through  the  meatus  was 
diminished.  In  this,  as  in  one  of  the  extremely  deaf  cases  (Case 
II.),  there  was  severe  pain  in  the  head. 

It  is  important  to  notice  the  occurrence  of  certain  transient 
cerebral  disorders.  Thus  one  patient  (Case  III.)  came  com- 
})laining  that  regularly  every  month  he  had  a  mild  attack  of 
right  hemiplegia  with  aphasia.  Another  (Case  X.)  had  epilepti- 
form fits  several  years  before  he  had  to  go  to  an  asylum.  In 
almost  all  the  cases  there  were  attacks  of  some  kind,  paralytic 
or  epileptiform.  Such  incidents  are  well  known  to  occur,  both 
in  general  paralysis  (of  which,  indeed,  a  '"'congestive  form"  has 
been  described),  and  in  other  chronic  nervous  diseases,  such  as 
insular  sclerosis.  To  the  importance  of  these,  and  of  other  early 
symptoms.  Dr.  Sutherland  has  recently  drawn  attention,^  and  he 
ai)tly  compares  them,  from  the  prognostic  point  of  view,  to  the 
rigor  of  an  acute  disease;  we  know  thereby  that  mischief  is 
afloat,  but  for  positive  diagnosis  we  must  wait  upon  events. 
Only  in  the  case  of  the  disease  we  are  considering,  the  interval 
of  waiting  may  be  long,  and  may  possibly  be  precious  for  pre- 
ventive treatment.  For  while  the  hesitation  of  speech  and  the 
tremor  of  the  lips  and  tongue  are  usually  the  first  diagnostic 
sign  of  general  paralysis,  they  are  also  said  to  be  a  sign  of  fatal 
omen.  Might  we  not  discover,  among  earlier  and  less  definite 
symptoms,  something  which  may  yet  be  sufficient  to  give  us 
more  timely  warning  ? 

^  Dr.  Clouston  mentions  (ileutal  Diseases,  p.  365)  a  case  in  wliich  lie  thinks 
the  disease  was  propagated  upwards  from  the  internal  ear. 
^  Lancet,  August  22,  1885,  "  Ou  the  True  First  Stage  of  General  Paralysis." 


^OTE 


TPBERCDLOUS  TDMOURS  OF  THE  LAMM. 


PEECY  KIDD,  M.D. 


In  vol.  xvii.  of  the  Clinical  Society's  Transactions  I  gave  an 
account  of  a  case  of  tuberculous  tumours  of  the  larynx. 

I  then  stated  my  belief  that  only  one  other  case  of  this  disease 
had  been  recorded,  viz.,  by  Professor  Schnitzler  in  the  Wiener 
medicinische  Presse,  8th  April  1883. 

Since  my  paper  was  written,  Dr.  John  N.  Mackenzie  of  Balti- 
more has  conclusively  proved,  to  my  mind  at  least,  that  he  was 
the  first  to  describe  tuberculous  tumours  of  the  air-passages.  It 
is  true,  as  Professor  Schnitzler  says,  that  Dr.  Mackenzie  made 
his  diagnosis  on  the  dead  subject  only,  but  that  does  not  alter 
the  fact  that  Dr.  Mackenzie  was  the  first  to  draw  attention  to 
this  rare  form  of  laryngeal  tuberculosis. 

Professor  Schnitzler  may  justly  claim  priority  in  the  diagnosis 
of  these  tumours  during  life. 

I  may  remark  in  passing,  that  when  my  first  case  came  before 
me,  I  was  quite  unaware  of  the  existence  of  such  a  form  of 
tumour,  and  I  failed  to  make  a  correct  diagnosis  during  the  life 
of  the  patient.  Before  I  proceed  to  give  a  description  of  three 
more  instances  of  this  disease  that  I  have  met  with,  it  may  be 
well,  considering  the  rarity  of  the  affection,  to  give  a  brief 
abstract  of  the  cases  that  have  been  hitherto  published. 


38  Nole  on  Tuberculous  Tumours  of  the  Larynx. 

I. — By  Dr.  Jolin  N.  Mackenzie,  Archives  of  3Iedicine,  vol.  viii. 
]).  109.  Post-morlem  examination  by  Dr.  Hans  Chiari, 
Budolf  Hospital,  Vienna,  on  a  male  loho  died  of  carcinoma 
of  the  stomach,  luith  secondary  nodules  in  liver,  kidneys, 
spleen,  and  other  organs. 

Lungs  contained  tubercnlar  cavities.  Pharynx,  larynx,  and 
trachea  free  from  inflammation  or  ulceration.  Bronchial  glands 
caseous. 

In  the  trachea,  i^  cm.  above  the  bifurcation,  a  circumscribed, 
smooth,  hard  tumour,  of  the  size  of  a  bean,  was  seen  springing 
from  the  membranous  or  posterior  wall. 

The  tumour  was  covered  by  mucous  membrane.  A  similar 
nodule  in  the  pericardium. 

The  specimens  were  handed  over  to  Dr.  Mackenzie  for  micro- 
scopical examination. 

AH  the  growths  were  carcinomatous  witb  the  exception  of  those 
in  the  trachea  and  pericardium.  These  proved  to  be  composed 
of  aggregations  of  miliary  tubercles  in  various  stages. 

II. — By  Dr.  John  N.  Mackenzie,  Archives  of  Medicine,  vol.  viii. 
]).  116.  Post-mortem  examination  by  Dr.  Hans  Chiari, 
Budolf  Hospital,  Vienna,  on  a  fcitient  who  died  outside  the 
hospitcd,  of  pidmonary  phthisis. 

The  whole  upper  compartment  of  the  hirynx,  including  the 
epiglottis,  aryepiglottic  iblds,  and  ventricular  bands,  presented  a 
remarkable  granular  appearance,  due  to  the  presence  of  small, 
uniformly  smooth,  firm,  nodular  growths,  which  lay  beneath  the 
mucous  membrane. 

The  nodules  were  about  the  size  of  a  split  pea,  each  merging 
into  its  neighbours,  so  as  to  form  one  continuous  growth. 

This  process  ceased  abruptly  at  the  free  border  of  the  ventri- 
cular band.  No  trace  of  ulceration  in  pharynx,  larynx,  or  trachea. 
There  was  also  ])ulmonary  phthisis,  tubercular  ulceration  of  the 
intestine,  and  tubercular  meningitis.  The  laryngeal  growth  was 
examined  microscopically,  and  found  to  consist  of  closely  aggre- 
gated miliary  tubercles,  resembling  the  growth  on  the  trachea 
of  the  previous  case. 

III. — By  Professor  Schnilzler,  Wiener  medicinische  Presse, 
8th  Ap)ril  1883  {preliminary  account),  and  ibid.,  Nos.  44 
and  46. 

A  young  man  consulted  him  suffering  from  cough,  hoarseness, 
and  ui'gent  dyspnoea. 


Note  on  Tuberculoiis  Tumours  of  tlie  Larynx.  39 

The  patient,  who  was  the  subject  of  pulmonary  phthisis,  pre- 
sented the  following  condition  of  larynx: — Multiple  tumours,  in 
size  from  a  bean  to  a  hazel-nut,  were  seen  projecting  into  the 
cavity  of  the  larynx,  and  springing  from  the  ventricles  of  3Ior- 
gagni.  After  a  preliminary  tracheotomy,  Schnitzler  removed  all 
the  growths  with  tlie  guillotine.  The  tumours  proved  to  be  con- 
glomerations of  miliary  tubercles,  which  confirmed  Schnitzler's 
original  diagnosis  of"  the  tuberculous  nature  of  the  growths. 

The  patient  was  greatly  relieved  by  the  operation,  but  the 
tracheotomy  tube  was  not  removed  for  three  months, 

Recurrence  of  the  growth  took  place  three  months  later. 
Again  tracheotomy  was  performed,  and  the  larynx  was  cathe- 
terised. 

The  canula  was  removed  a  year  later.  AYhen  last  seen,  the 
patient  had  greatly  improved ;  he  could  breathe  freely,  and 
spoke  in  a  thick  but  audible  voice. 


lY. — By  the  Writer,  Clinical  Society's  Transactions, 

vol.  xvii.  p.  154. 

A  male,  aged  50,  with  this  history : — TVinter  cough  for  two 
years.  The  last  eight  mouths,  increase  of  cough,  hoarseness,  and 
shortness  of  breath. 

Physical  signs  of  consolidation  of  the  upper  lobe  of  the  left 
lung.  In  the  larynx  a  pea-sized,  smooth,  rounded  tumour  in  the 
position  of  the  left  "  processus  vocalis,"  but  no  ulceration  or  other 
disease.  Gradual  appearance  of  a  symmetrical  tumour  on  the 
right  side,  and  development  of  marked  signs  of  pulmonary 
phthisis.  The  tumours  persisted  without  undergoing  any 
ulceration  till  death,  which  occurred  about  eight  months  after 
the  patient  was  first  seen. 

Post-mortem  examination  revealed  pulmonary  phthisis,  tuber- 
cular ulceration  of  larynx,  trachea,  and  intestine;  arterio-sclero- 
sis  ;  granular  kidney ;  fatty  liver. 

Larynx. — Epiglottis  and  aryepiglottic  folds  pale  and  swollen, 
but  not  ulcerated. 

Extensive  ulceration  of  posterior  wall,  extending  into  subglottic 
region.  Yocal  cords  not  ulcerated,  but  in  the  position  of  the 
"processus  vocalis,"  on  either  side,  a  firm  spherical  tumour  the 
size  of  a  pea;  surface  not  ulcerated. 

The  tumours  were  apparently  attached  to  the  cords,  but  really 
only  lay  upon  them,  their  point  of  origin  being  the  angles  be- 
tween the  arytenoid  cartilages  and  the  interarytenoid  fold. 
Microscopical  examination  showed  that   the  tumours  consisted 


40  Note  on  Tuberculous  Tumours  of  the  Larynx. 

of   agf^regations   of    miliary   tubercles,   covered   by   laminated 
epithelium. 

Tubercle  bacilli  were  present  in  great  abundance  in  tlie 
tubercles. 

V. — Bii  Frofessor  Schni/zler,  Wiener  medidnische  Fresse, 
Nos.  44  and  46. 

A  medical  man,  aged  40,  suffering  from  pulmonary  pbtliisia. 
Sclinitzler  found  the  larynx  healthy,  but  in  the  upper  part  of 
llie  trachea  there  was  a  greyish-white  tumour  the  size  of  a  hazel- 
nut springing  from  the  posterior  wall.  Tracheotomy  was  per- 
formed, but  the  patient  sank.     No  autopsy  mentioned. 

yi. — Bi/  Frofessor  SchnUzler,  Wiener  medidnische  Fresse, 
Nos.  44  and  46. 

An  out-patient  suffering  from  advanced  pulmonary  phthisis. 
In  the  larynx  there  were  several  tumours,  varying  in  size  from  a 
bean  to  a  hazel-nut,  springing  from  the  ventricles  of  Morgagni, 
with  numerous  miliary  nodules  around,  but  no  ulceration.  No 
further  details  given. 

I  wish  now  to  describe  three  other  cases  of  this  rare  affection 
which  have  come  under  my  observation.  I  beg  to  thank  Dr. 
Symes  Thompson  and  Dr.  Keginald  Thompson  for  their  per- 
mission to  make  use  of  their  cases. 

XDase  I. 

John  E.,  fet.  37,  a  groom,  admitted  into  the  Brompton  Hos- 
pital under  Dr.  Symes  Thompson,  12th  December  1883.  Family 
history  unimportant.  At  the  age  of  17  the  patient  had  gonor- 
rhoea and  a  venereal  sore,  but  never  suffered  from  any  secondary 
symptoms  of  syphilis.  Nine  years  ago  he  had  stricture  of  the 
urethra,  for  which  he  was  treated  with  bougies.  The  present 
illness  began  rather  more  than  a  year  ago  with  cough  and  ex- 
pectoration. 

A  few  months  later  hoarseness  and  dysphagia  developed,  and 
these  symptoms  have  persisted  ever  since. 

On  admission  he  was  completely  aphonic,  and  complained  of 
severe  dysphagia  (worse  for  solids  than  liquids),  cough,  and  ex- 
pectoration. 

There  were  physical  signs  of  phthisis  in  both  lungs,  most 
marked  at  the  right  apex,  where  there  was  evidence  of  excava- 


Nole  on  Tuberculous  Tumours  of  lite  Larynx.  41 

tion.  I  was  asked  by  Dr.  Thompson  to  examine  Ins  throat,  and 
found  the  following  condition : — On  the  posterior  wall  of  the 
phar3^nx,  just  to  the  right  of  the  middle  line,  there  was  a  circu- 
lar nicer  as  big  as  a  sixpenny-piece,  with  slightly  raised  edges 
and  yellowish  base,  and  also  a  small  lenticular  ulcer  on  the  right 
posterior  pillar  of  the  fauces. 

On  laryngoscopic  examination,  I  found  partial  destruction  of 
the  tip  of  the  epiglottis,  with  ulceration  of  its  edges.  Both  glosso- 
epiglottic  folds  were  superficially  ulcerated,  and  there  was  swell- 
ing and  ulceration  of  the  left  ventricular  band  and  interarytenoid 
fold.  The  aryepiglottic  folds  were  slightly  swollen,  and,  like  the 
rest  of  the  larynx,  were  rather  pale. 

On  the  upper  surface  of  the  middle  of  the  right  aryepiglottic 
fold  there  was  a  distinct  tumour,  of  the  size  and  shape  of  a  small 
cherry.  The  tumour  was  sessile,  its  surface  was  smooth,  of  a 
yellowish-white  colour,  and  was  studded  with  numerous  bright 
red  points. 

The  vocal  cords  were  not  ulcerated. 

From  my  previous  experience,  I  had  no  doubt  that  this 
tumour  was  tuberculous,  and  that  the  ulceration  of  the  larynx 
and  pharynx  was  of  a  similar  nature. 

In  sufflations  of  morphia  and  iodoform  were  ordered,  and 
greatly  relieved  the  patient's  dysphagia. 

A  fortnight  after  my  first  examination,  I  found  that  the  laryn- 
geal tumour  had  undergone  slight  crumbling  ulceration  at  various 
points,  and  presented  a  worm-eaten  appearance.  Unfortunately 
the  patient  now  left  the  hospital,  and  I  was  unable  to  watch  the 
course  of  events  any  farther.  I  heard,  however,  that  he  died  at 
his  home  in  the  country  soon  afterwards.  I  think  there  can  be 
little  doubt  as  to  the  tuberculous  nature  of  the  tumour,  from  the 
general  character  of  the  laryngeal  and  pharyngeal  disease,  the 
appearance  of  the  tumour  itself,  and  the  slow  ulcerative  changes 
which  it  underwent. 


Case  II. 

Frederick  J.,  eet.  32,  clerk,  admitted  under  the  care  of  Dr. 
Keginald  Thompson  into  the  Brompton  Hospital,  5th  November 
1883. 

No  family  history  of  any  special  disease.  The  patient  had  a 
venereal  sore  and  a  urethral  discharge  five  years  ago,  and  about 
the  same  time  he  had  a  slight  sore  throat.  No  other  secondary 
symptoms. 

Present  illness  began  fourteen  months  ago  with  cough,  expec- 
toration, and  hoarseness.     A  month  before  admission  he  lost  his 


42  No'.e  on  Tuberculous  Tumours  of  the  Larynx. 

voice.  Physical  examination  revealed  signs  of  phthisis  on  both 
bides,  witli  excavation  at  both  apices. 

Liver  much  eidarged. 

Pharynx. — A  hirge,  circular,  rather  shallow  ulcer,  with  only 
slightly  raised  edges  on  the  po^sterior  wall,  and  a  small  patch  of 
irregular  ulcei-atiou  at  the  base  of  the  tongue. 

Larynx. — Ulceration  at  the  posterior  extremities  of  both  vocal 
cords. 

It  was  thought  that  the  phaiyngeal  idceration  might  be  of  a 
syphilitic  character,  and  he  was  treated  accordingly,  but  with  no 
good  result.  Dr.  Keginald  Thompson  asked  me  to  examine  the 
])atient,  which  I  did  some  weeks  alter  he  was  admitted.  I  found 
the  pharynx  and  larynx  in  the  condition  described  above,  which 
seemed  to  me  to  be  tuberculous  in  both  instances.  I  examined 
the  patient  on  several  occasions  subsequently.  The  ulceration 
of  the  pharynx  made  scarcely  any  progress,  but  the  laryngeal 
disease  slowly  advanced,  and  ultimately  invaded  the  greater  part 
of  the  larynx. 

The  last  time  I  examined  him  laryngoscopically,  about  four 
or  five  weeks  before  death,  there  was  no  appearance  of  anything 
like  a  tumour.  Troublesome  diarrhoea  set  in,  and  he  gradually 
sank  and  died,  ist  March  1884. 

For  some  time  he  did  not  appear  to  suffer  as  much  pain  in 
swallowing  as  might  have  been  expected,  but  during  the  latter 
part  of  his  days  the  pain  became  so  severe  that  he  took  very 
little  food.  Applications  of  morpliia  and  iodoform  to  the 
pharynx  relieved  him  a  little. 

At  the  autop.sy  the  jiharyux  presented  a  lai'ge  circular  ulcer  as 
big  as  a  florin  on  its  posterior  wall.  The  edges  of  the  ulcer  were 
slightly  thickened,  aud  in  its  base  was  some  scai-tissue.  Near 
it  were  two  other  smaller  ulcers  of  a  similar  character,  one  of 
them  on  the  left  tonsil.  There  were  also  numerous  small  nodules 
in  the  mucous  membrane,  many  of  which  showed  a  minute 
central  point  of  ulceration.  There  was  also  some  slight  super- 
ficial ulceration  of  the  root  of  the  tongue. 

The  epiglottis  was  unaffected. 

Both  aryepiglottic  folds  were  extensively  ulcerated.  The  in- 
terarytenoid  fold  was  much  thickened  and  ulcerated,  the  cricoid 
cartilage  being  exposed  and  bare  in  one  spot. 

The  ulceration  had  destroyed  both  vocal  cords  and  ventricular 
bands,  and  no  trace  of  the  arytenoid  cartilages  remained. 

At  the  outer  aspect  of  the  posterior  wall,  on  the  left  side,  there 
was  a  small  greyish-pink  rounded  tumour,  as  big  as  a  small  pea, 
springing  from  the  interarytenoid  fold. 

Trachea  and  bronchi  reddened,  but  free  from  ulceration. 


Note  on  Ttiherculous  Tumours  of  the  Larynx.  43 

Both  lungs  contained  small  puckered  apex-cavities,  and  in 
places  were  emphysematous  and  studded  with  miliary  tuhercles. 

The  liver,  spleen,  and  kidnej's  were  amyloid,  and  there  was 
tubercular  ulceration  of  the  intestine. 

Microscopical  examination  of  the  pharyngeal  ulcers  and  of  the 
tumour  of  the  larynx. — The  ulcers  proved  to  be  of  a  well-marked 
tuberculous  nature,  with  miliary  tubercles  in  their  edges  and 
base.  Most  of  the  tubercles  were  rather  old  and  fibro-caseoua. 
The  earlier  ones  contained  a  fair  number  of  "tubercle  bacilli." 
In  the  older  ones  no  bacilli  were  found. 

The  laryngeal  tumour  consisted  of  groups  of  miliary  tubercles, 
in  which  were  numerous  tubercle  bacilli.  The  tumour  was 
covered  by  laminated  epithelium  in  some  places,  while  other 
parts  of  the  surface  presented  a  finely  granular  necrotic  appear- 
ance. 

Tiiis  tumour  would  seem  to  have  developed  during  the  last 
few  weeks  of  the  patient's  life. 

Case  III. 

Kichard  L.,  set.  23,  a  clerk,  with  a  strong  family  history  of 
phthisis,  hail  suffered  from  pulmonary  phthisis  for  two  years. 
ilTo  details  as  to  the  condition  of  his  throat  were  obtained  beyond 
the  fact  that  he  had  complained  of  aphonea  and  dysphagia  for 
some  months  before  his  death. 

Autopsy. — Pulmonary  ])lithisis  with  cavities  in  both  lungs. 
Tubercular  ulceration  of  the  intestine.     Fatty  liver. 

The  larynx  presented  the  following  appearance  : — There  was 
considerable  destruction  of  the  epiglottis,  its  edges  and  base 
being  ulcerated,  and  the  cartilage  exposed  in  places. 

The  lateral  and  posterior  walls  were  also  ulcerated.  The 
vocal  cords  were  replaced  by  reddish  ridges  running  forwards 
and  downwards  from  the  arytenoid  cartilages  to  a  point  in  the 
anterior  angle  of  the  thyroid  cartilage  situated  below  the  normal 
insertion  of  the  cords. 

The  ventricles,  which  in  consequence  appeared  abnormally 
large,  presented  a  granular  ulcerated  surface  with  traces  of 
scar-formation. 

The  ventricular  bands  were  comparatively  little  ulcerated. 

In  the  anterior  extremity  of  the  ventricles  on  either  side  there 
was  a  tumour  of  the  size  and  shape  of  a  small  bean,  springing 
from  the  under  surface  of  the  ventricular  band  and  lying  with 
its  long  axis  parallel  to  it.  The  surface  of  the  tumours  was 
smooth. 

Trachea  and  bronchi  infected,  but  free  from  ulceration. 


44  Note  on  Tuberculous  Tumours  0/ the  Larynx. 

One  of  tlie  tiiinonrs  was  exaniiiiod  microscopically,  and  found 
to  consist  of  a  tuberculous  growth  iti  the  mucous  membrane, 
extending  from  the  surface  down  to  the  mucous  glands. 

The  main  features  of  the  growth  were  a  small-celled  infil- 
tration, through  which  were  scattered  numerous  microscopical 
tubercles  containing  giant  cells,  and  irregular  tracts  of  large 
epithelioid  cells. 

In  most  ])laces  the  surface  presented  a  gramilar  necrotic 
appearance,  but  towards  its  edges  tlie  tumour  was  covered  by 
normal  laminated  epithelium. 

Tubercle  bacilli  were  found  in  considerable  numbers  in  the 
giant  cells  and  among  the  epithelioid  cells. 

A  review  of  the  nine  cases  of  tuberculous  tumours  of  the  air- 
passages  that  have  now  been  recorded  yields  these  facts: — 

In  three  cases  there  was  a  single  tumour;  in  two  cases  there 
were  two  tumours ;  in  the  remaining  three  cases  they  were 
described  as  numerous.  In  every  case  their  surface  was  smooth 
and  their  shape  rounded.  Their  size  varied  from  a  pea  to  a 
hazel-nut  or  a  small  cherry.  In  five  cases  they  were  unac- 
companied by  ulceration ;  in  one  case  the  development  of  the 
tumours  was  followed  by  ulceration  after  some  time,  and  in 
three  instances  they  were  associated  witli  ulceriiti(.)n  when  first 
observed. 

Their  situation  was  as  follows: — Ventricles  in  three  cases; 
whole  upper  part  of  larynx  in  one  case;  inlerarytenoid  fold  in 
two  cases;  aryepiglottic  fold  in  one  case;  membranous  part  of 
trachea  in  two  cases.  Probably  they  may  originate  in  any  part 
of  the  larynx  or  trachea. 

As  to  the  advisability  of  removing  such  tumours,  if  the 
growths  are  huge,  or  their  situation  is  such  as  to  interfere  with 
respiration,  a!i  attempt  should  be  made  to  remove  them,  either 
wholly  or  in  part ;  otherwise  it  would  probably  be  well  to  leave 
them  alone. 


ox  THE 

PRESENCE  OF  THE  TUBERCLE  BACILLUS  IN 
OLD  SPECIMENS  OF  DISEASED  LUNG. 

BY 

VINCENT  D.  HAERIS,  M.D. 


The  very  close  relationship  which  exists  between  tlie  tubercle 
bacillus  of  Koch  and  tlie  production  of  lung-disease  is  becoming 
day  by  day  more  apparent.  The  influence  which  Koch's  re- 
searches have  already  had  upon  the  pathology  of  lung-diseases 
has  been  undeniably  very  great.  Not  a  few  believe  that  tbe 
influence  will  be  farther  exerted  at  some  future  time,  not 
only  upon  the  pathology,  but  also  upon  the  treatment  of  the 
various  tubercular  processes  in  the  lungs.  The  question  as  to 
whether  the  presence  of  a  specific  micro-organism  in  the  lesions 
of  phthisis,  as  w^ell  as  in  the  sputum  and  breath  of  phthisical 
patients,  gives  any  support  to  the  belief  so  generally  held  by  tbe 
laity  of  the  contagiousness  of  consumption  is  at  present  open ; 
but  I  cannot  help  thinking  that  the  possibility  of  propagating 
phthisis  by  contagion  is  admitted  by  a  larger  number  of  physi- 
cians than  was  formerly  the  case.  In  the  discussion  at  one  of 
the  Societies  last  winter.^  it  appeared  to  be  the  opinion  of  nearly 
all  the  speakers  that  Koch's  bacillus  was  to  be  found  in  the 
lesions  of  tuberculosis  as  a  general  rule.  This  discussion  repre- 
sented fairly  well  the  views  upon  the  matter  held  in  this  country 
at  that  time.  I  have  myself  examined  microscopically  specimens 
from  a  considerable  number  of  cases  of  various  kinds  of  lung- 
disease,  and  have  almost  invariably  found  the  bacilli ;  but  to  this, 

^  Royal  Medical  and  Chirurgical,  on  Dr.  Percy  Kidd's  paper.  British  Medical 
Journal,  toI.  ii.  (1884),  p.  193. 


46  Tuherclc  Bacilhis  in  Diseased  Lung. 

as  it  is  unnecessary  to  hriiif]^  forward  nny  fintlier  proofs  of  tlie 
general  presence  of  the  bacilli  in  plitliisical  sputum,  pathological 
secretions,  pus  from  cavities,  and  in  the  phthisical  organs  exa- 
mined within  a  few  weeks  or  days  after  death,  I  will  turn  to  the 
object  of  this  memorandum,  which  I  think  supplies  some  definite 
information  upon  a  point  not  hitherto  touched  upon,  viz.,  the 
presence  of  the  bacilli  in  specimens  of  diseased  lung  which  have 
been  put  up  in  spirit  for  many  years. 

I  was  induced  to  direct  my  attention  to  this  point  from  the 
fact  that  one  day  coming  across  a  specimen  of  tubercular  disease 
of  the  lung  which  I  had  put  up  some  time  before  at  the  Vic- 
toria Park  Hospital,  it  struck  me  that  it  would  be  an  interest- 
ing point  to  ascertain  whether  the  diseased  tissue  exhibited  the 
bacillus  of  Koch.  Having  discovered  in  the  specimen  examined 
large  numbers  of  bacilli,  I  determined  to  examine,  if  possible, 
museum  specimens  with  the  same  object  in  view.  Permission 
to  go  over  all  the  specimens  of  diseased  lung  in  the  Museum  of 
St.  Bartholomew's  Hospital  was  courteously  given  me  by  the 
curator,  Mr.  D'Arcy  Power,  with  all  the  more  willingness  be- 
cause many  of  them  required  remounting,  and  I  proceeded  to 
examine  about  a  dozen  of  the  oldest  and  most  typical  specimens. 
The  exact  date  at  which  these  specimens  were  added  to  our 
Museum  cannot  beaccurately  given ;  nearly  all  of  those  I  examined 
were  contributed  to  the  Museum  previous  to  the  year  1846,  and 
several  of  them  were  presented  by  Dr.  Farre,  sen.,  who  was,  I 
am  told,  engaged  in  the  work  of  putting  them  up  about  the 
year  18 12.  Nearly  all  the  specimens  examined,  therefore,  were 
about  forty  j'ears  old,  several  in  all  piobability  no  less  than 
seventy.  My  seaicli  for  the  bacilli  in  these  specimens  was  in 
almost  all  cases  successful;  but  I  will  give  a  short  description 
of  each  specimen,  and  will  add  any  remarks  about  it  as  I  go  on. 
(Tbe  description  of  the  specimens  is  partly  derived  from  the 
last  edition  of  the  Catalogue.) 

Specimen  I. — A  case  in  which  the  lung  was  generally  indu- 
rated, cutting  with  a  cartilaginous  section,  with  thick  streaks  of 
fibrous  tissue  interlacing,  visible  to  the  naked  eye,  and  very  plain 
with  a  low  power  of  the  microscope.  On  section,  the  tissue  showed 
small  masses  of  caseous  material,  more  or  less  rounded,  sur- 
i-ounded  by  excessive  fibrous  tissue  (about  fourteen  or  fifteen  to 
the  twelve  mm.  square).  The  lung-tissue  was  nowhere  to  be 
seen  unaffected  in  the  part  examined.     This  must  have  been  an 

1  References  to  tbe  numerous  researches  in  proof  will  be  found  in  MM.  Cornil 
and  Babes'  work,  "  Les  Bacteries,"  Paris,  1885  ;  also  in  Drs.  Woodhead  and  Hare's 
"Practical  Mycology,"  toI.  i.  p.  161  ei  seq^.,  p.  577  et  seq. 


Tubercle  Bacillus  in  Diseased  Lung.  47 

excessively  clironic  auJ  fibroid  phthisis,  but  with  little  pigmenta- 
tion. In  all  of  these  sections  there  were  a  very  large  number 
of  bacilli,  which  appeared  generally  in  clum{)R  or  clusters,  arranged 
ranch  like  the  bacilli  of  bovine  tuberculosis  {Perlsucht),  which 
seem  to  be,  as  Klein  ^  has  pointed  out,  smaller  and  with  a  most 
definite  relation  to  the  cells  (especially  to  the  giant  cells)  than 
is  the  case  with  human  tuberculosis.  The  bacilli  in  this  speci- 
men were  nearly  all  small. 

Specimen  II. — This  was  a  section  of  lung  in  which  there  were 
large  irregular  masses  of  tubercular  matter  infiltrated  in  its  tissue. 
The  whole  specimen  was  solid,  and  the  pleura  very  thick  through- 
out. The  lung  substance  remained  only  here  and  there,  the  alveoli 
being  quite  filled  with  debris.  The  tubercular  masses,  caseous. 
The  whole  tissue  was  very  extensively  infiltrated  with  bacilli, 
which  here  were  in  long  zooglear  masses  in  many  places.  This 
might  be  taken  as  an  example  of  lobulated  tubercular  caseation. 

Specimen  III. — From  a  section  of  lung  the  tissue  of  which 
was  quite  solid,  heavy,  and  of  a  pale  yellowish-white  colour  from 
uniform  infiltration  of  tubercular  matter.  The  pleural  surface 
was  covered  by  a  thin  layer  of  tough  false  membrane  with  small 
tubercles  scattered  in  it.  On  microscopical  examination  the  sec- 
tions-taken  showed  a  very  large  number  of  bacilli  everywhere, 
both  in  clumps  here  and  there,  and  also  distributed  throughout 
its  tissue.  Very  little  of  the  lung  substance  remaining.  The 
caseous  masses  were  surrounded,  i.e.,  encapsuled,  by  fibrous  tissue. 
The  thickened  pleura  presented  a  considerable  number  of  bacilli. 
This  was  another  case  of  lobulated  tubercular  caseation.  No 
isolated  tubercles  in  the  tissue  or  giant  cells. 

Specimen  IV. — From  a  more  recent  specimen.  It  was  from  a 
case  of  acute  tuberculosis.  The  very  small  tubercles  were  as  a 
rule  isolated.  The  bacilli  occurred  here  and  there  in  clumps  in 
the  breaking  down  caseous  debris  of  some  of  the  tubercles. 

Specimen  V. — From  a  portion  of  a  lung  exhibiting  an  exten- 
sive destruction  of  its  substance  consequent  on  the  formation 
and  progress  of  tubercle.  The  walls  of  the  large  cavity,  which 
occupied  more  than  half  the  lung,  wei-e  composed  of  pulmonary 
tissue,  indurated  and  infiltrated  with  tubercular  matter,  and 
rendered  very  irregular  by  the  projection  of  numerous  large 
branches  of  the  blood-vessels,  which  weie  not  involved  in  the 
destruction  of  the  adjacent  parts.    The  pleura  was  thickened,  and 

^  Micro-O.ganisms  and  Disease,  p.  125. 


48  Tuhercle  Bacillus  in  Diseased  Lung. 

lias  a  soft  false  membrane  ou  its  surface.  The  tissue  was  rotten 
ami  very  difficult  lo  cut,  but  in  the  i)ieces  of  sections  a  very  large 
number  of  bacilli  were  discovered.  The  lung-tissue  in  places  was 
but  little  affected,  but  even  in  the  alveoli  epithelial  debi-is  and 
.many  bacilli  were  found.  Evidently  a  very  chronic  case,  and 
fibroid. 

Specimkn'  YI. — Lung  in  the  upper  part  of  which  are  nume- 
rous miliary  tubercles,  arranged  for  the  most  part  in  groups,  and 
in  the  lower  part  are  several  irregular  cavities  surrounded  by 
similar  tubercles  and  by  tubercular  matter.  On  section  the 
material  proved  to  be  exceedingly  rotten  and  difficult  to  cut, 
especially  in  the  neighbourhood  of  the  cavities.  In  spite  of  this, 
in  carefully  stained  specimens  bacilli  were  copiously  found,  chiefly 
in  the  fibrous  tissue  surrounding  the  cavities. 

Specimex  YII. — From  a  portion  of  lung  with  small  tubercles 
scattered  through  its  substance.  The  lung  had  been  minutely 
injected,  but  the  injection  had  not  penetrated  the  tubercles.  A 
small  but  distinct  number  ot"  bacilli  ;  but  the  specimens  were 
necessarily  much  spoiled  in  consequence  of  the  opaque  injection 
used. 

Specimex  VIII. — A  specimen  of  acute  tuberculosis,  very 
similar  to  Specimen  IV.,  but  the  bacilli  much  less  numerous. 
This  was  a  more  recent  addition  to  the  Museum. 

Specimex  IX. — A  very  old  specimen  of  Dr.  J.  E.  Farre's. 
The  lungs  injected.  Their  tissues  and  subpleural  surfaces 
covered  with  tubercles,  and  the  bronchial  gland  enlarged  and 
indurated.  I  could  not  satisfy  myself  that  there  were  any  bacilli 
})resent  in  the  lungs  which  were  affected  with  isolated  tubercles, 
but  in  the  corresponding  enlarged  bronchial  glands  in  the 
superficial  lymph  path  were  a  number  of  bacilli  closely  resem- 
bling the  tubercle  bacilli  of  Koch. 

Specimen  X. — From  a  portion  of  lung  with  small  masses  of 
tubercular  matter  very  thickly  deposited  in  its  substance.  They 
have  an  opaque  yellowish  colour,  and  many  of  them  showing 
minute  cavities  at  their  centre.  On  examination,  the  specimen 
showed  a  considerable  number  of  bacilli,  but  in  addition  to  the 
large  bacilli  are  zooglear  masses  of  much  smaller  bacilli  or 
micrococci. 

The  above  description  applies  to  fen  of  the  specimens  exa- 
mined.     In  two  others,  also  derived  from  the  same  source,  I 


Tubercle  Bacillus  in  Diseased  Lung.  49 

liave  not  yet  been  able  to  find  satisfactory  proof  of  the  presence 
of  any  micro-organisms,  but  further  examination  may  yet  afford 
it.-  In  several  cases  it  was  only  after  repeated  attempts  that  it 
was  possible  to  stain  the  bacilli  and  so  render  them  evident ; 
many  methods  had  therefore  to  be  tried  before  success  was 
attained.  In  these  specimens  there  is  no  doubt  but  that  the 
])acilli  resisted  the  ordinary  metliods  of  staining,  probably  from 
their  long-continued  immersion  in  spirit ;  and  not  only  was  this 
the  case,  but  also  the  staining  was  much  less  permanent  than 
in  recent  sections  of  diseased  lung. 

The  staining  which  was  found  to  be  most  successful  was  the 
Ehrlich-Wergert  method.  Thin  sections  were  placed,  about 
half-a-dozen  at  a  time,  in  a  slightly  diluted  solution  of  fuchsine, 
made  according  to  a  slight  modification  of  Ehrlich's  formula,  and 
kept  in  small  glass  jars  protected  from  the  air  by  greased  covers 
for  from  two  to  three  days.  They  were  afterwards  washed  for 
about  a  minute  in  diluted  nitric  acid  (i  in  3)  and  then  in  water. 
After  this  they  were  ready  for  the  contrast  stain  of  methylen 
blue  (or  vesuvin),  dehydrated  quickly,  transferred  to  cedarwood 
oil  to  clear,  and  mounted  in  Canada  balsam  dissolved  in  cedar 
oil.  (This  answers  quite  as  well  as  turpentine.)  In  the  examina- 
tion of  the  tissues,  1  have  found  Leitz  one-twelfth  oil  immersion 
of  great  service,  and  quite  sufficient  for  the  purpose. 

It  will  be  seen  that  the  bacilli  were  observed  in  tliree  of  the 
chief  forms  of  wasting  lung-diaease,  viz. : — (i.)  In  isolated  or 
miliary  tubercles.  (2.)  In  caseous  masses.  (3.)  In  fi.broid 
thickenings  as  well  as  in  thickened  pleurae.  The  finding  of  the 
bacilli  in  a  single  case  of  sufficiently  old  diseased  lung  would  be 
enough,  one  would  suppose,  to  render  it  very  probable  that  the 
relationship  between  the  bacilli  and  the  diseased  processes  of 
tubercle  is  no  new  one,  or,  in  other  words,  that  baciUar  phthisis 
is  no  new  disease. 

The  foregoing  account  must  be  considered  only  as  a  pi-e- 
liminary  communication  upon  the  subject,  and  as  concerniug 
chiefly  our  Museum  specimens.  I  have,  however,  in  hand  other 
specimens,  some  of  which,  by  the  great  courtesy  of  Profe-ssor 
Stewart  and  Mr.  Eve,  I  have  obtained  from  the  Hunteriaii 
Museum.     Of  these  I  propose  to  publish  u  further  account. 


Vol    XXI. 


PHOFUSE   NON-FATAL    PULMONARY 
HEMOPTYSIS. 


SAMUEL  WEST,  M.D. 


Haemoptysis  may  be  due  to  lesions  in  the  trachea,  bronchi,  or 
lung  tissue,  and  may  be  accordingly  spoken  of  as  tracheal, 
bronchial,  and  pulmonary.  Profuse  haemorrhage  from  the 
trachea  or  larger  bronchi  is,  with  but  few  exceptions,  the  result 
of  disease  external  to  them,  such  as  aneurysm  of  one  of  the  main 
arteries.  Pulmonary  hasmoptysis  is  the  result  of  pathological 
change  in  the  lung  tissue  and  the  pulmonary  vessels.  The 
rare  cases  in  which  an  aneurysm  of  some  vessel  other  than  the 
pulmonary  bursts  through  the  lung  is,  by  ordinary  usage,  not 
included  under  this  term.  The  pathology  of  fatal  pulmonary 
haemoptysis  is,  I  think,  now  well  established.  The  lesion  is 
found  to  be  a  ruptured  aneurysm  or  ulceration  of  a  branch  of 
the  pulmonary  artery.  I  propose  to  consider  in  this  paper 
whether  there  be  not  good  ground  for  believing  that  profuse 
non-fatal  pulmonary  haemoptysis  has  the  same  pathology.^ 

The  facts  established  about  fatal  pulmonary  haemoptysis  are 
briefly  these  :— 

I.  It  may  occur  at  any  age.  There  is  no  period  of  life  which 
is  specially  liable,  nor  any  which  is  exempt. 

^  The  analogy  of  the  stomach  renders  it  conceivable  that  haemorrhage 
severe  enough  to  be  called  profuse  might  take  place  from  the  bronchi  without 
any  lesion  in  them  gross  enough  to  be  detected  post-mortem ;  for  there  are  cases 
of  fatal  hsematemesis  in.  which  the  source  of  the  hffimorrhage  is  not  to  be  dis- 
coTered.  But  if  this  ever  occurs,  it  must  be  very  rare,  and  need  hardly  be  more 
than  mentioned. 


52  Profuse  Non- Fatal  rvlmonary  Haemoptysis. 

2.  Moil  suffer  more  fVequeiiUy  lliau  women,  in  the  proportion 
of  about  3  to  I.  Possibly  the  greater  frequency  of  chronic 
phthisis  in  men  may  account  in  part  for  this. 

3.  Ciuonic  phthisis  is  tlie  predisposing  condition  of  the  bmg. 

4.  Ruplure  of  an  aneurysm  or  ulcerated  vessel  is  the  imme- 
diate cause. 

5.  There  is,  I  believe,  no  case  of  fatal  luTemoptysis  recorded 
in  which  the  post-mortem  examination  disclosed  the  lesions  of 
acute  phthisis. 

6.  Diligent  search  will  rarely  fail  to  discover  the  source  of 
the  haemorrhage,  and,  considering  the  difficulties,  occasional  fail- 
ure is  hardly  matter  for  surprise. 

7.  In  the  great  majority  of  cases  the  haemorrhage  is  due  to 
the  rupture  of  the  sac  of  an  aneurysm  of  tlie  pulmonary  artery. 
In  the  small  minority  it  is  traced  to  ulceration  of  a  branch  of 
the  pulmonary  artery,  or  possibly,  in  some  very  rare  cases,  of 
the  pulmonary  vein. 

8.  Oi  'pulmonary  aneurysms  the  facts  known  are  these: — 

a.  They  are  of  small  size,  rarely  larger  than  a  Morella  cherry, 
often  much  smaller. 

h.  They  always  occur  in  chronic  cavities,  which  they  may 
sometimes  completely,  but  more  often  only  partially  fill. 

c.  They  spring  either  from  a  prominent  trabecula  situated 
upon  the  walls  of  the  cavity  or  as  it  crosses  it,  or  else  directly 
from  the  walls  of  the  cavity  itself. 

d.  They  are,  as  a  rule,  globular  in  shape,  but  not  unfrequently 
irregularly  pouched  and  attached  to  the  vessel  by  a  broad  base. 

A  distinction  has  been  made  between  aneurysms  and  ectasias 
or  partial  dilatations,  but  the  difference  is  only  one  of  degree. 

e.  They  are  often  surrounded  by  laminated  clot,  so  that  their 
size  becomes  deceptive. 

/  Frequently  also  they  contain  laminated  clot,  though  this 
has  been  denied. 

g.  The  vessel  from  which  they  arise  is  generally  of  moderate 
size,  2  to  3  lines  in  diameter.  They  are,  however,  often  situated 
close  to  the  origin  of  this  vessel  from  one  of  the  main  branches 
of  the  artery. 

h.  The  rupture  varies  much  in  size  ;  sometimes  it  is  a  linear 
slit,  more  often  an  irregular  rent,  and  sometimes  nearly  the 
whole  sac  of  the  aneurysm  is  torn  off;  so  that  the  difficulties  of 
diagnosis  from  an  ulcerated  vessel  become  veiy  great. 

i.  They  are  frequently  single,  but  many  cases  are  recorded 
in  which  more  than  one  existed,  and  in  a  few  cases  they  have 
been  numerous. 

j.  The  cause  of  aneurysm  is  to  be  referred  in  the  first  place 


Profuse  Non-Fatal  Pulmonary  Hcemoptysis.  5  3 

to  chronic  changes  set  np  in  the  walls  of  the  vessel  by  extension 
from  the  walls  of  the  cavity,  and  secondarily  to  want  of  support 
on  the  side  towards  the  cavity,  as  well  as  to  partial  obliteration 
of  the  distal  portion  of  the  vessel. 

Tc.  The  cavities  in  which  aneurysms  are  found  are  always 
chronic,  with  fibroid  and  usually  trabeculated  walls. 

They  may  be  of  any  size  and  occupy  any  position  in  the  lung, 
but  they  are  more  frequently  small,  and  their  favourite  position 
is  in  the  mid-lateral  region  peripherally. 

They  are  sometimes  completely,  but  more  commonly  only 
partially,  filled  with  the  aneurysmal  sac ;  and  frequently  contain 
clot,  which  may  be  decolourised  and  laminated. 

They  may  sometimes  be  so  small,  and  the  pulmonary  disease 
so  limited,  that  diagnosis  of  the  lesion  during  life  may  be  from 
physical  signs  alone  almost  impossible. 

9.  Ulceration  or  erosion  of  vessels  is  a  much  less  common  cause 
of  fatal  haemoptysis  than  aneurysm. 

It  occurs,  however,  under  similar  conditions.  Usually  it  is 
the  pulmonary  artery  which  is  affected,  but  on  one  occasion  I 
have  found  the  rupture  in  a  branch  of  the  pulmonary  vein. 

It  is  conceivable  that  ulceration  might  lead  lo  fatal  heemor- 
rhage  in  acute  phthisis,  but  I  do  not  know  of  any  post-mortem  of 
this  kind  recorded ;  for  the  vessels,  though  of  course  early  and 
considerably  involved  in  the  disease,  become  quickly  plugged  and 
impervious. 

in  order  to  establish  the  identity  of  pathology  in  the  fatal 
and  non-fatal  forms  it  will  be  necessary  to  show  : — 

1.  That,-  except  in  respect  of  the  result,  there  is  no  clinical 
difference  between  the  two  sets  of  cases ;  and 

2.  That  aneurysm  and  ulceration  of  the  pulmonary  vessels, 
whether  after  rupture  or  not,  may  heal. 

Of  the  fatal  cases  there  are  two  groups.  In  the  first,  death  is 
sudden,  and  to  this  the  name  of  Suffocative  Hcemoptysis  has 
been  well  given,  for  the  patients  die  after  a  few  minutes,  suffo- 
cated by  the  blood  poured  into  their  air-tubes.  In  the  second, 
the  hsemorrhage  occurs  again  and  again,  and  death  is  the  result 
of  exhaustion  from  loss  of  blood  ;  but  even  in  this  group  death 
may  be  sudden  at  the  last,  though  it  is  then  due  not  so  often  to 
suffocation  as  to  cardiac  syncope.  To  this  second  group  the 
name  of  Remittent  Hcemoptysis  has  been  given — an  appropriate 
name  if  used,  in  the  sense  in  which  it  is  applied  to  fevers,  to 
mean  a  hsemorrhage  which  recurs  before  the  previous  one  has 
completely  ceased.  But  all  remittent  haemoptysis  is  not  fatal, 
and  from  this  group  of  non-fatal  remittent  haemoptysis  we 
pass  to  another  class,  which  may  on  the  same  analogy  receive 


54  Profuse  Non-Fatal  Pulmonary  Ha:moptysis. 

the  name  of  Intermittent  HcBmoptysis,  but  which  differs  from 
the  previous  group  only  in  the  longer  intervals  between  the 
attacks  and  in  the  complete  recovery  meanwhile,  so  that  we 
may  trace  clinically  every  gradation,  from  a  single  non-fatal 
profuse  attack  through  a  non-fatal  intermittent  and  a  uon-fatal 
remittent  to  the  fatal  remittent,  and  finally  to  the  single  suffo- 
cative li  rem  0  ply  sis. 

I  omit  entirely  for  the  present  the  consideration  of  hfemopt)'si8 
which  does  not  deserve  the  name  of  ])i-ofuse.  For  here  we  have 
to  deal  with  a  more  obscure  and  difficult  pathology,  though  I 
cannot  help  thinking  that  the  process  and  the  lesions  are  in 
all  probability  the  same. 

I  now  proceed  to  bring  forward  the  clinical  series  of  cases, 
which  will,  I  think,  establish  the  first  of  my  propositions,  viz., 
that  the  cases  of  profuse  haemoptysis,  whether  fatal  or  not,  all 
belong  to  the  same  clinical  family. 

Case  I. 

Remittent  licemoptysls — Short  duration — Death  from  suffoca- 
tion— liuptured  aneurysm. 

John  E.,  aged  38,  ill  two  years,  admitted  with  very  extensive 
excavation  of  the  left  lung.  After  he  had  been  in  the  hospital 
for  five  weeks,  he  was  seized  with  profuse  ha?mo]itysis,  and  spat 
daily  for  six  days  about  a  pint  of  blood.  On  the  seventh  day 
he  died  suddenly  in  a  more  profuse  attack  than  usual. 

The  post-mortem  showed  that  the  left  lung  was  completely 
excavated,  a  few  coarse  ridges  only  remaining  at  the  root  over 
the  course  of  the  great  vessels  and  bronchi.  Upon  one  of  them 
was  a  ruptured  aneurysm  as  lai-ge  as  a  cherry.^ 

Case  II. 

Eemittent  hcemopfysis — Lovg  duration — Death  from  suffoca- 
tion— Large  ruptured  aneurysm. 

George  C,  aged  21,  a  labourer,  was  admitted  for  htemoptysis.^ 
He  had  had  a  cough  for  about  fifteen  months,  and  had  occasion- 
ally spat  up  a  little  blood,  but  never  much.  A  few  days  before 
admission,  haemoptysis  began  again,  and  rapidly  became  severe. 
The  patient  was  in  the  hospital  forty-five  days,  and  spat  up  on  the 
average  half  a  pint  of  blood  dailj',  at  first  regularly  every  da}', 
but  towards  the  last,  two  or  three  days  at  a  time  passed  without 

^  Pathological  Society's  Transactions,  vol.  iii.  p.  25. 
^  Ibid.,  vol.  XXXV.  p.  94. 


Profuse  Non-Fatal  Pulmonary  Hcemojptysis.  55 

lisemoptysis.     In  the  last  attack  lie  brought  up  ■^y  ounces,  and 
■died  of  suffocation. 

The  post-mortem  examination  disclosed  hut  little  change  iu 
the  left  lung,  hut  the  right  was  adherent,  except  the  lower 
part,  where  there  was  a  localised  empyema,  containing  about  one 
pint  of  pus.  The  upper  wall  of  this  cavity  was  formed  by  the 
•collapsed  lower  lobe  of  the  lung,  in  the  mid-lateral  region  of 
which  was  an  irregular  cavity  about  two  inches  in  diameter, 
filled  for  the  most  part  with  laminated  clot.  Occupying  the 
upper  part  of  the  cavity  was  an  aneiu-ysm,  oval  in  shape,  and 
measuring  i^"  by  f".  The  rupture  was  a  small  linear  slit,  one 
-eighth  of  an  inch  long. 

Case  III. 

Remittent  hcemoptysis — Death  from  exhaustion — Aneurysm — 
Limited  hmg  lesion. 

A  man  aged  45,  had  been  in  good  health  and  in  active  work 
imtil  fourteen  days  before  admission,  when,  after  running  some 
<listance,  he  was  seized  with  haemoptysis,  which  since  that  time 
had  returned  on  the  slightest  exertion.  In  the  hospital  he  had 
several  attacks  of  profuse  and  obstinate  haemoptysis,  and  finally 
died  of  exhaustion. 

Both  the  lungs  were  emphysematous,  and  in  other  respects 
healthy,  except  that  in  the  left,  in  the  upper  part  of  the  lower 
lobe,  two  small  old  cavities  with  fibroid  walls  were  found,  and  in 
one  of  these  a  ruptured  aneurysm  the  size  of  a  cherry. 

This  case  is  important,  as  showing  how  very  limited  the 
disease  may  be,  and  how  difficult,  and  perhaps  impossible,  it 
may  sometimes  be  to  diagnose  it. 

The  next  case  illustrates  these  facts  again. 

Case  IV. 

Remittent  hcemoptysis — Death  from  suffocation — Limited 
lung  lesion. 

A  woman  aged  46  was  brought  in  dead,  having  been  found 
lying  in  a  pool  of  blood. 1  Slie  had  been,  it  transpired,  an  out- 
patient for  a  few  days  for  slight  hasnioptysis,  but  until  this 
attack  she  had  been,  though  never  strong,  in  her  usual  health. 
She  was  the  mother  of  twelve  children. 

Both  lungs  were  healthy  except  in  two  places.  At  the  apex 
of  the  right  lung  was  a  small  wedge-shaped  patch  of  fibroid  indu- 
ration, containing   several   small   bronchi-ectatic  cavities  with 

^  Pathological  Society's  Transaction.'?,  1878,  p.  41, 


56  Profuse  Non-Fatal  rulmonary  Ha'mopt/jsis. 

dense  fibroid  pigmented  walls.  In  the  base  of  the  lung  was 
;i  second  patch  of  similar  indnraiion  with  ir>imilar  cavities,  and 
in  the  largest  of  these,  the  size  of  a  walnut,  was  the  aneurysm 
which  had  ruptured. 

I  desire  to  draw  especial  attention  to  these  cases,  as  showing 
how  limited  the  lung-disease  may  be. 

The  last  case  especially  suffered  from  oidy  slight  hemoptysis, 
such  as  would  ordinarily  give  no  anxiety,  until  the  sudden  fatal 
hgemorrhage  occurred.  This  is  very  suggestive  as  to  the  patho- 
logy even  of  slight  hasmoptysis. 

The  cases  wdiich  belong  to  the  third  group,  that  of  remittent 
liEemoptysis  with  recovery,  are  common,  and  I  need  only  select 
one  or  two  as  illustrations. 

Case  V. 

Bemittent  hccmoptysis — Long  duration — Recovery. . 

Maurice  N".,  aged  32,  with  no  family  history  of  phthisis,  had 
slight  pleurisy  at  20,  and  since  then  had  suffered  occasionally 
from  cough.  He  spnt  blood  for  the  first  time  four  years  before 
admission,  in  slight  amount  only.  In  the  second  attack,  one  and 
a  half  years  later,  he  brought  up  a  pint  of  blood  on  one  day,  and 
small  quantities  for  about  a  week.  The  third  attack  came  on 
three  months  before  admission.  It  was  very  profuse,  and  he  was 
laid  up  for  a  month.  On  December  21  he  had  another  attack, 
and] expectorated  a  pint  of  blood.  On  the  24tli  and  25th  he 
drank  a  good  deal,  and  spat  blood  every  day  since  in  varying 
amount.  After  his  admission  the  bleeding  rapidly  subsided,  and 
after  a  fortnight  he  was  discharged.  A  week  later  he  wa& 
readmitted  with  haemoptysis.  On  the  14th  of  January  he  spat 
about  6  ounces;  on  the  15th  about  10  ounces;  on  the  i6th,  6 
ounces;  on  the  17th,  13  ounces.  A  little  only  on  each  succeed- 
ing day  until  the  21st,  when  he  again  brought  up  10  ounces. 
The  bleeding  then  gradually  subsided,  and  he  was  free  until 
February  4,  when  a  few  ounces  more  were  brought  up,  and  a 
little  spat  for  a  few  days  longer.  On  February  14  the  patient 
had  another  slight  attack,  lasting  also  a  few  days,  and  on  March 
20  he  was  discharged. 

The  physical  signs  were  very  indefinite,  but  there  was  some 
crepitation  in  the  region  of  the  right  nipple. 

The  fourth  and  last  group  consists  of  cases  of  intermittent 
haemoptysis. 

It  is  quite  unnecessary  to  bring  forward  cases  of  intermittent 


Profuse  Non-Fatal  Pulmonary  Hcemojofysis.  57 

haemoptysis  -wliich  did  not  die  of  hjemonhage.  All  the  cases 
last  referred  to  would  serve  as  illustrations  prior  to  the  last  fatal 
attack. 

The  series  of  cases  of  profuse  haemoptysis  is  as  follows: — 

1.  Cases  of  single  suffocative  haemoptysis. 

2.  Cases  of  remittent  hseraoptysis  which  were  fatal — 

(a)  From  suffocation. 
(/S)  From  exhaustion. 

3.  Cases  of  remittent  haemoptysis  which  recovered. 

4.  Cases  of  intermittent  hfemoptysis  which,  after  several 

attacks,  ended  at  last  fatally  from  haemoptysis. 

5.  Similar  cases  to  the  last,  which  recovered. 

In  all  the  fatal  cases  above  referred  to  the  same  pathological 
lesion  was  discovered  post-mortem. 

I  turn  now  to  the  second  proposition. 

If  the  pathology  of  the  fatal  and  non-fatal  forms  of  haemoptysis 
be  the  same,  we  require  evidence  that  aneurysm  and  ulcerated 
vessels,  to  the  rupture  of  which  the  haemorrhage  is  in  both  cases 
attributed,  may  heal. 

I  will  take  the  question  of  aneurysms  first.  Several  of  the 
cases  described  show  the  presence  in  the  aneurysm  of  laminated 
clot,  and  disprove  therefore  the  assertion  of  Rasmussen  that 
laminated  clot  is  never  found  in  pulmonary  aneurysms. 

In  two  cases  the  aneurysm  was  embedded  in  laminated  clot. 

Partial  adhesions  also  often  form  between  the  sac  of  the 
aneurysm  and  the  walls  of  the  cavity.  When  the  cavity  is 
small  and  the  aneurysm  completely  fills  it,  as  it  often  does, 
complete  adhesion  may  take  place,  and  in  this  way  the  sac  may 
obtain  adventitious  strength.  In  one  case  of  this  kind  rupture 
took  place  in  the  only  unprotected  part,  viz.,  at  the  mouth  of  a 
bronchus. 

It  may  be  objected,  however,  that  if  pulmonary  aneurysms  did 
heal  in  this  way,  they  ought  to  be  frequently  found  post-mortem. 
It  is  quite  true  that  not  many  cases  of  this  kind  are  described, 
but  the  explanation  is,  I  think,  simple  ;  for,  in  the  first  place,  they 
are  hardly  ever  looked  for,  except  when  haemoptysis  has  been  a 
leading  recent  symptom,  and  the  difficulties  of  finding  them  are 
much  increased  when  there  is  no  blood-clot  to  guide  the  search. 

Dr.  Percy  Kidd  has  recently  published  a  remarkable  case  in 
which  many  aneurysms  were  found  in  each  lung,  each  in  a  little 
cavity  of  .its  own,  and  each  lined  with  tough  laminated  clot. 
Death  was  due  to  haemorrhage  from  one  of  them. 

Many  of  the  "fibroid  masses,"  so  frequently  described  in 
phthisis  as  existing  on  or  in  the  walls  of  cavities,  and  of  which 


58  Profuse  Non-Fatal  Fulmonarij  Hccmoptysis. 

no  satisfactory  pathological  explanation  is  often  given,  will,  I  be- 
lieve, prove  to  be,  on  carclnl  examination,  obliterated  aneurysms. 
On  tliis  point  further  evidence  may  be  confidently  awaited. 

The  cure  of  ulcerated  vessels  admits  of  clearer  proof.  Though 
rarely  a  cause  of  fatal  hreraoptysis,  ulceration  is,  I  believe, a  very 
common  cause  of  profuse  ha2moptysis.  From  the  very  earliest 
commencement  of  excavation  in  the  lung  there  is  an  active  de- 
struction of  vessels.  That  hemoptysis  is  not  constant  in  every 
case  alike,  and  that  profuse  h;i3moptysis  is  not  more  common, 
depends  upon  the  obliteration  of  vessels,  which  is  almost  part  of 
the  disease. 

As  with  vessels  in  other  parts  of  the  body,  the  more  acute  the 
disease  in  their  neighbourhood,  the  more  certain,  if  they  become 
involved  in  the  process,  is  their  rapid  obliteration.  It  is  only  in 
connection  with  the  more  chronic  processes  that  they  are  likely 
to  remain  pervious,  and  so  lead  to  hremorrhage.  The  most  cur- 
sory examination  of  phthisical  cavities  establishes  the  applica- 
bility of  these  facts  to  the  pathology  of  the  lungs. 

Though  possible,  it  is  extremely  improbable  that  profuse 
hfemorrhage  should  occur  in  acute  phthisis.  Many  of  the  cases 
of  phthisis  ab  hccmoptoe,  if  not  of  all,  where  profuse  haemoptysis 
is  the  first  symptom  of  a  disease  which  afterwards  runs  an  acute 
course,  are,  I  believe,  not  cases  of  new  disease,  but  of  old  disease 
starting  afresh.  Instances  of  severe  bleeding  into  the  lungs  is  so 
common  from  various  causes  with  complete  lecovery  as  to  prove 
beyond  question  that  it  is  not  the  blood  which  produces  the 
disease,  but  something,  it  may  be,  which  the  blood  brings  with 
it.  This  something  will  be,  according  to  modern  views,  the 
infective  tubercle  bacillus,  and  the  ])resent  germ  theory  of 
phthisis  is  in  some  degree  evidence  against  the  existence  of  such 
a  variety  of  the  disease  as  the  classical  heemoptoic  ])hthisis. 

From  these  considerations  we  should  a  ijriori  expect  that 
profuse  hsemorrhage,  in  tubercular  phthisis  at  any  rate,  could  only 
occur  in  chronic  disease ;  for  aneurysms  take  some  time  to  grow, 
and  ulceration,  if  acute,  leads  at  once  to  thrombosis ;  and  further, 
that  aneurysm  will  be  a  far  commoner  lesion  than  erosion.  Each 
of  these  expectations  is  abundantly  confirmed  by  post-mortem 
examination. 

The  evidence  brought  forward  is  sufificient,  I  think,  to  esta- 
blish the  required  proposition,  viz.,  that  the  causes  of  profuse 
hfemoptysis  are  the  same,  whether  the  case  be  fatal  or  not,  viz., 
aneurysm  or  erosion  of  a  vessel ;  and  further,  that  in  both  cases 
alike  cure  is  possible,  and  of  not  uncommon  occurrence.  The 
bearing  of  these  conclusions  upon  the  treatment  of  hasmoptysis  is 
obvious,  but  this  subject  I  propose  to  discuss  on  another  occasion. 


PIVE  CASES  OF  FUNCTIONAL  NERVOUS 
DISORDER. 

BY 

SAMUEL  WEST,  M.D. 


1.  Hysterical  stupor  with  external  strabismus. 

2.  Hysterical  tremors. 

^,4.  Paraplegia  after  shock,  loith  "jumping  movements"  of 

body,  in  two  hoys  of  10  and  12  years. 
'$.'  Somnambulism  after  shock  in  girl  0/13. 


I.  Stupor  ahnost  amounting  to  coma,  luith  inequality  of  pupils 
and  external  strabismus. 

Alice  B.  was  brought  into  the  hospital  on  January  31st  in 
a  condition  of  semi-coma,  with  the  history  that  she  had  been 
in  her  usual  health  until  January  29th,  when  she  complained  of 
pains  in  her  back  and  head.  The  catamenia  were  due,  but  did 
not  appear.  On  the  30th  she  was  worse  and  went  to  bed,  and 
the  next  day  she  was  in  the  condition  described.  Headaches 
and  pains  in  the  back  she  had  suffered  from  from  time  to  time 
previously,  especially  for  the  last  few  months,  during  which  period 
«he  had  become  paler. 

On  admission  she  appeared  unconscious,  but  could  be  roused 
tind  made  to  answer  her  name  with  difficult}'.  Other  questions 
she  answered  incorrectly.  She  was  irritable  when  disturbed, 
and  relapsed  at  once  into  the  same  condition  of  stupor.  There 
was  no  paralysis  of  extremities,  nor  any  rigidity,  though  it  was 
stated  that  the  legs  had  been  stiff  when  she  was  first  attacked. 

The  sole-ieflexes  were  feeble  and  the  patellar  tendon-reflexes 
absent.  Ordinary  sensibility  was  retained  and  the  response  to 
the  prick  of  a  pin  was  ready.  The  patient  lay  as  if  deeply 
asleep.      The  cornese  were  sensitive,  but  the  right  pupil  was 


6o  Five  Gases  of  Functiunal  Nervous  Disorder. 

persistently  lar^^er  than  tlie  left,  and  there  was  marked  external 
strahisimis,  which  varied  considerably  in  amount  from  time  to 
time.  It  was  difficult  to  decide  which  muscle  was  at  fault,  but 
the  squint  appeared  to  be  due  to  over-action  (spasm)  of  the  right 
external  rectus. 

The  motions  were  passed  in  bed,  apparently  unconsciously,  on 
the  nif^ht  after  admission. 

During  the  night  she  lay  in  the  same  condition,  never  rousing 
up,  but  taking  food  when  offered  her.  The  next  day  (February 
1st),  the  catamenia  commenced,  one  week  behind  their  time. 
On  February  2d  she  was  less  heavy,  and  answered  questions 
more  readily,  at  first  inarticulately,  and  then  by  an  efibrt  arti- 
culately and  correctly.  In  the  middle  of  the  night  she  suddenly 
sat  up,  asked  the  time,  drank  a  lai'ge  draught  of  milk,  said  she 
felt  no  pain,  and  then  immediately  afterwards  sank  down  into 
her  previous  condition. 

On  February  3d  there  was  steady  and  gradual  improvement. 
On  the  4th  she  took  notice  of  all  that  was  going  on  round  her, 
but  when  observed,  relapsed  into  her  previous  condition.  The 
pupils  were  equal  and  the  squint  had  disappeared,  but  now  and 
then  the  right  pupil  became  larger  than  the  left  for  a  time.  The 
fundus  oculi  was  frequently  examined  and  no  change  found. 

The  improvement  contimied,  and  in  a  week's  time  the  patient 
was  well  and  was  discharged. 

During  this  time  she  was  difficult  to  manage,  refusing  food 
when  it  was  offered  her  by  the  nurse,  and  taking  it  herself 
directly  the  nurse's  back  was  turned.  Once  or  twice  she  relapsed 
into  a  state  of  apparent  stupor,  but  finding  no  notice  was  taken 
of  it,  came  to  herself  and  behaved  rationally. 

She  states  herself  that  a  year  or  two  ago  she  had  a  similar 
but  less  severe  attack,  also  at  the  catamenial  period  ;  but  there  is 
no  confirmation  given  of  this  by  her  mother. 

The  pulse,  respiration,  urine,  and  temperature  were  normal 
throughout. 

The  case  was,  I  think,  clearly  one  of  hysteria.  It  presented 
great  clinical  difficulties  at  first,  on  account  of  the  deepness  of 
the  stupor,  and  especially  on  account  of  the  condition  of  the 
eyes,  viz.,  the  difference  in  the  pupils  and  the  strabismus  ;  but  the 
rapid  disappearance  of  all  these  symptoms  and  the  absence  of 
evidence  of  other  nerve  disease  established  the  nature  of  the 
case.  The  attack  could  be  attributed  to  no  cause,  unless  it 
is  correct  to  refer  it  to  the  delay  in  the  appearance  of  the  cata- 
menia. The  patient  was  not,  so  far  as  could  be  learnt,  at  other 
times  especially  emotional. 


Five  Cases  of  Functional  Nervous  Disorder.  6i 

2.  Tremors  of  legs  and  ayms,  like  those  of  paralysis  agitans, 
luith  so-called  fits. 

Jane  F.,  aged  26,  a  cook,  was  admitted  with  tremblings  of 
the  legs  and  arms,  resembling  most  the  movements  of  paralysis 
agitans.  It  appeared  that  she  had  been  subject  to  fits  of  some 
kind,  possibly  of  an  epileptic  character,  since  childhood.  The 
last  fit  occurred  two  years  ago;  and  during  this  period  she  has 
at  times  had  pain  and  numbness  in  both  arms.  Her  health  has 
been  good  and  her  functions  regular. 

In  November  she  felt  pain  on  the  inner  side  of  the  left  knee, 
and  the  thigh  is  stated  to  have  swelled.  She  was  treated  for 
rheumatism,  and  kept  her  legs  up  at  rest  until  the  commence- 
ment of  January,  when  the  left  leg  began  to  take  on  the  peculiar 
movements  observed  now.  They  gradually  became  worse  until 
January  28th,  when  she  fainted,  and  on  regaining  consciousness 
the  movements  affected  both  arms  as  well  as  the  right  leg. 
With,  the  exception  of  frontal  headache  she  has  not  felt  pain. 

The  patient  is  fat  and  well  nourished ;  expression  weak  and 
emotional. 

The  peculiar  movements  resembled  those  of  paralysis  agitans ; 
they  were  rhythmic,  constant  while  awake,  ceasing  on  sleep ;  not 
large  in  extent,  and  not  interfering  with  the  action  of  the  limbs; 
walking  stopped  the  tremors  in  the  legs  at  once,  though  they 
returned  on  standing  still.  They  varied  in  intensity  a  great  deal 
at  various  times,  being  always  most  marked  when  the  patient 
was  under  observation.     The  electrical  reaction  was  normal. 

There  was  considerable  bilateral  atisesthesia,  which  varied 
greatly  in  extent  and  amount  from  time  to  time,  and  was  often 
patchy.  The  legs  were  ischeemic;  the  skin  bleeding  but  little  on 
})uncture  with  needles.  The  reflexes  were  diminished.  Once 
on  approaching  the  patient  when  asleep,  she  was  found  to  bo 
quite  still ;  then  a  blush  suffused  her  cheek,  the  movement  at 
once  recommenced,  and  she  woke  up. 

The  patient  gradually  improved,  so  that  the  movements  were 
absent  sometimes  for  hours  together  while  she  was  up  ;  but  even 
then  they  were  easily  produced  by  observation  and  excitement. 

She  had  frequent  complaint  of  vague  pains  in  different  parts 
of  her  body;  but  their  existence  was  doubtful.  On  February 
1 8th  marked  ankle-clonus  was  observed,  which  had  not  been 
present  before,  and  did  not  last  for  more  than  a  day  or  two. 
On  February  25th  she  had  what  was  called  a  fainting  fit,  and 
fell  out  of  bed,  but  she  did  herself  no  injury.  After  this  she 
had  frequent  fits ;  on  one  day  as  many  as  nine  in  the  twenty- 
four  hours.     The  nurse  was  told  to  touch  the  cornea,  to  see  if 


62  Five  Cases  of  Functional  Nervous  Disorder. 

it  was  sensitive  during  the  fits;  and  on  doing  so,  on  the  first 
opportnnity,  the  fit  at  once  ceased  and  tlie  patient  came  ronnd ; 
and  afterwards  this  was  a  certain  way  of  cliecking  them  when 
they  commenced.  These  attacks  also  suhsided,  and  for  a  week 
before  lier  dischai-ge,  on  April  3d,  she  had  had  neither  fits  nor 
movements,  and  she  left  apparently  recovered. 

No  cause  to  which  these  attacks  could  be  referred  was  ascer- 
tained. 

3,  4.  Tivo  hrothers  affected  with  loss  ofiwwer  in  legs,  and  pecidiar 
juin2nng  spasms,  attributed  to  the  shock  of  their  mother's 
death. 

John  Brown,  aged  10,  was  admitted  on  March  3d  for  spas- 
modic movements  and  loss  of  power  in  his  legs.  The  following 
history  was  given  by  the  friends  : — 

This  was  the  youngest  living  child,  and  ho  had  been  fairly 
strong  until  the  death  of  his  mother,  five  weeks  ])reviously.  It 
was  to  this  shock  that  his  present  illness  is  attributed. 

On  February  22d  the  child  was  struck,  it  is  said,  by  bis 
teacher  upon  the  back  with  a  ruler.  On  February  25th,  he  com- 
plained of  "pins  and  needles"  in  his  feet  and  pains  in  his  back, 
and  the  next  day  the  movements  appeared,  and  have  continued 
since.  The  child  is  stated  to  have  been  "light  headed"  for  the 
last  week. 

The  patient  was  a  poorly  nourished  pale  child.  The  expres- 
sion was  somewhat  vacant.  He  was  generally  found  sitting  up 
in  bed  with  his  back  held  unusually  straight.  When  the  patient 
is  under  observation,  frequently  repeated  rapid  spasmodic  jerk- 
ing movements,  chiefly  of  the  extremities,  aie  marked.  They 
are  more  violent  on  the  right  side,  but  are  well  marked  on  both. 
They  appear  to  be  due  to  contraction  of  the  muscle  comiecting 
the  trunk  with  the  legs  rather  than  to  contraction  of  the  leg 
muscles  themselves.  The  effect  is  to  make  the  body  jump,  as  it 
were.  If  the  attention  be  diverted,  the  movements  do  not  occur, 
and  they  are  absent  during  sleep.  The  reflexes  are  fairly  good. 
There  is  no  ankle-clonus,  no  impairment  of  sensation,  and  no 
loss  of  power.  There  is  a  tender  spot  over  one  of  the  lower 
dorsal  vertebras,  where  the  child  says  he  was  struck,  and  here 
there  is  a  slight  bruise. 

When  placed  upon  his  feet,  his  legs  double  up  under  him,  and 
he  falls  down  in  a  heap;  and  he  falls  similarly  if  placed  upon  his 
knees.  He  complains  of  pain  in  the  soles  of  his  feet,  but  there 
is  nothing  there  to  be  seen.  The  eyes  were  normal,  and  the 
other  organs  healthy. 


Five  Cases  of  Functional  Nervous  Disorder.  63 

Tlie  patient  made  a  rapid  recoveiy.  On  March  8tli  he  could 
stand  steadily  without  assistance.  On  the  nth  the  movements 
occurred  rarelj^  and  then  only  when  under  observation.  By  the 
1 5  til  he  was  well. 

The  brother,  Fred,  aged  12,  was  admitted  two  days  later,  and 
suffering  in  the  same  way.  One  week  after  his  mother's  death, 
he  too  felt  "  pins  and  needles  "  in  his  feet  and  pains  in  his  back, 
and  was  attacked  with  movements  like  those  described  in  the 
first  case,  and  he  was  quite  unable  to  walk  from  the  commence- 
ment. The  attack  commenced  one  week  before  that  of  the  first 
case  described  here. 

He  too  was  a  weakly  pale  child.  He  too  doubled  up  when 
set  upon  his  feet,  and  complained  of  pain  in  the  soles  of  his  feet  \ 
but  no  movements  similar  to  those  described  were  observed  in 
his  brother  after  admission,  though  they  had  been  present  up 
to  that  time. 

Three  days  after  admission  he  too  was  able  to  walk  a  little, 
and  by  the  nth  had  regained  his  power  completely,  and  the 
two  brothers  left  the  hospital  at  the  same  time  perfectly  well. 

5.  Condition  of  somnambulism  after  friglit. 

The  patient,  a  girl  of  13,  was  brought  to  the  Koyal  Free 
Hospital.  She  was  a  general  servant,  and  had  been  in  her 
usual  health  until  two  days  before  admission,  when  she  was 
greatly  frightened  by  some  clothes  catching  fire  in  the  kitchen. 
She  seems  to  have  given  no  assistance  towards  putting  out  the 
fire,  and  when  it  was  over  was  found  in  her  present  condition. 
As  she  did  not  improve,  the  next  day  she  was  brought  to  the 
hospital.  She  was  a  slightly-built  but  fairly  well-nourished 
girl,  with  no  evidence  of  diisease  of  any  kind.  When  first  seen, 
she  was  in  bed,  lying  with  her  eyes  wide  open,  apparently  taking 
little  or  no  notice  of  what  was  going  on  around  her.  She  sat 
up  slowly  in  bed  when  told  to  do  so,  and  performed  certain 
simple  acts  as  directed.  She  was  able  to  walk  about  without 
stumbling  over  objects  in  her  way,  but  did  everything  in  a  list- 
less way,  without  any  apparent  understanding  of  what  she  was 
about.  Her  functions  were  all  normally  performed,  and  food 
was  taken  when  given  to  her  without  any  expression  of  desire 
for  it.  She  seemed  as  if  she  was  dreaming  with  the  eyes  open 
or  in  a  condition  of  somnambulism.  At  night  she  slept,  but  occa- 
sionally would  rise  and  wander  objectless  through  the  w^ard,  and 
frightened  some  of  the  patients  by  standing  without  a  sound  at 
their  bedside  looking  at  them.     She  suffered  herself  placidly  to 


64  Five  Cases  of  Functional  Nercoics  Disorder. 

be  led  back  to  her  bed,  and  she  never  at  any  time  had  any  fits 
of  violence. 

For  about  a  week  she  remained  in  the  same  condition,  and 
then  began  gradually  to  pay  attention  a  little  to  what  was  going 
on  around  her.  In  another  week  she  was  able  to  be  interested 
in  little  occupations  for  a  short  period  of  time,  and  to  make 
herself  a  little  useful  in  the  ward,  and  then  began  rapidly  to 
improve,  and  in  thi-ee  weeks'  time  left  the  hospital  well. 

Though  a  biddable  child,  she  seemed  never  to  have  been  either 
lively  or  intelligent.  The  fire  had,  as  it  seemed,  literally  fright- 
ened her  out  of  her  wits,  and  nothing  more. 


CASES  FROM  MR.  WILLETT'S  WARDS. 

BT 

W.  T.  H.  SPICEE  AND  OWEN  LANKESTEE. 


OSTEOTOMY  OF  THE  FEMUR. 


W.  T.  H.  SPICEE. 


Osteotomy  of  the  Femur  for  Mal-union  of  the  Femur  after 
Fracture. 

William  S.,  set.  26,  admitted  to  Pitcairn  Ward,  St.  Bartholo- 
mew's Hospital,  on  January  21,  1885,  suffering  from  the  results 
of  an  old  fracture  of  the  femur,  with  union  in  bad  position. 

The  patient  is  a  cachectic,  half-starved  man,  a  bricklayer's 
labourer  and  militiaman.  He  states  that  while  with  his  regi- 
ment at  Aldershot  on  June  29,  1884,  trying  in  a  hurdle-race  to 
take  one  of  the  flights  of  hurdles,  he  got  his  right  leg  twisted 
under  his  left,  and  fell,  breaking  his  right  thigh-bone.  He  was 
taken  to  the  South  Camp  Hospital,  and  lay  there  ten  weeks ;  he 
states  that  there  he  was  treated  with  a  long  iron  side  splint  for 
six  weeks,  then  by  starched  bandages  for  four  weeks.  After  this 
he  was  sent  to  the  Fulham  Infirmary,  and  remained  seven  or 
eight  weeks;  he  has  only  been  able  to  use  the  limb  without 
support  for  a  month. 

On  examination,  the  right  femur  is  found  to  be  curved,  witli 
the  convexity  outwards ;  nearly  the  whole  of  the  antero-external 

VOL.  XXT.  E 


66  Cases  from  Mr.  Willett's  Wards. 

aspect  of  the  middle  third  of  the  bone  is  occupied  by  a  hard 
globular  mass,  presumabl}'  callus ;  the  ends  of  the  bones  appear 
to  have  overlapped.  Measured  along  the  whole  length  of  the 
limb  there  is  a  shortening,  as  compared  with  the  other  side,  of 
three  inches;  measured  directly  from  the  anterior  superior  spine 
of  the  ilium  to  the  internal  malleolus,  the  shortening  amounts  to 
nearly  four  inches;  the  extensor  muscle  is  much  wasted.  The 
patient  says  it  gives  him  pain  to  stand  much  upon  the  limb;  he 
walks  with  much  limping;  when  he  stands  upright  there  is  con- 
siderable obliquity  of  the  pelvis  and  lateral  curvature  of  the  spine 
in  consequence  of  the  unequal  length  of  the  two  limbs.  He  is 
unable  to  obtain  work  on  account  of  his  condition  ;  he  states 
that  he  has  been  to  several  London  hospitals,  but  has  always  been 
told  that  nothing  can  be  done. 

Pulse  72  ;  respiration  quiet ;  thoracic  organs  healthy.  Urine 
acid,  sp.  gr.  1025;  abundance  of  urates;  no  albumin  nor  sugar. 
At  a  consultation  it  was  decided  to  attempt  re-fracture  of  the 
femur,  and  that  failing,  to  perform  osteotomy. 

Fobrunry  17. — Thepatient  was  taken  to  the  theatre  and  placed 
under  the  influence  of  ether.  Several  powerful  and  determined 
attempts  were  made  to  fracture  the  femur  at  the  mass  of  callus 
by  bending  it  across  the  knee  of  the  operator;  these  were  unavail- 
ing. Mr.  Willett  then  made  an  incision  at  the  outer  border  of 
the  rectus  femoris  muscle  about  two  inches  in  length,  dividing 
all  the  tissued  down  to  the  bone ;  the  two  ends  of  the  bone  were 
found  to  be  overlapping  and  ensheathed  in  a  great  amount  of 
callus.  A  chisel  was  introduced  into  the  groove  between  the 
fragments  where  they  overlapped,  and  with  some  difficulty  the 
greater  part  of  the  very  hard  callus  was  cut  through;  the  un- 
divided portion  was  then  broken  ensily. 

The  operation  was  done  under  the  spray.  Lister's  dressings 
were  applied  and  the  limb  was  put  up  on  a  Liston's  long  side 
splint,  a  weight  of  10  lbs.  being  attached  to  it. 

Feb.  18. — Was  kept  awake  last  night  by  slight  pain  in  limb; 
there  was  some  oozing  through  the  dressings  ;  more  of  the  gauze 
was  applied  with  a  fiim  bandage. 

Feb.  21. — No  more  discharge  through  the  dressings.  Measure- 
ment on  right  side  from  anterior  superior  spine  of  the  ilium  to 
the  internal  malleolus  is  29!  inches ;  on  left  side  between  same 
points,  31^  inches;  2I  inches  diffeience. 

Feb.  23. — General  condition  satisfactory ;  the  weight  was 
increased  to  14  lbs.  this  morning. 

Feb.  24. — 18  lbs.  weight  applied  to-day;  measurement  of 
limb  shows  i|  inches  of  shortening. 


Cases  from  Mr.  Willett's  Wards.  67 

Feb.  26. — Weight  increased  to  22  lbs. ;  complains  of  its 
dragging  on  the  skin  of  the  leg. 

March  4. — No  pain ;  eats  and  sleeps  well.  Measurement 
shows  ^  inch  difference  between  the  lengths  of  the  two  limbs. 
Weight  increased  to  26  lbs. 

March  12. — The  splint  was  taken  off  and  the  dressings  changed 
under  the  spray ;  the  wound  was  quite  superficial  and  had 
almost  healed ;  the  gauze  dressings  were  discontinued  and 
salicylic  cream  applied.  A  Thomas's  hip-joint  splint  was  put 
on  with  a  weight  of  15  lbs. ;  while  the  weight  is  on  there  is  no 
difference  in  length  between  the  limbs.  There  was  some  ex- 
coriation of  the  skin  of  the  leg  from  the  pressure  of  the  strapping 
to  which  the  weight  was  attached. 

March  18. — The  splint  is  comfortable;  the  weight  fell  off 
last  night ;  there  is  only  about  \  inch  of  difference  in  the  length 
of  the  two  limbs. 

March  21. — Splint  and  dressings  removed;  wound  healed. 
The  splint  was  reapplied  and  kept  in  position  by  plaster  of 
Paris  bandages,  the  weight  being  left  off". 

March  25. — As  the  shortening  had  increased,  the  plaster  of 
Paris  was  reapplied  and  a  weight  of  15  lbs.  put  on  again. 

April  8. — The  right  leg  is  about  f  inch  shorter  than  the  left ; 
the  weight  was  removed  entirely. 

April  1 5. — Plaster  of  Paris  removed.  The  right  leg  measured 
30  inches,  the  left  31^  inches,  about  i\  inches  of  shortening 
being  present.  Much  of  the  callus  has  been  absorbed ;  the 
limb  is  quite  straight,  and  in  excellent  position. 

March  24. — Patient  sent  to  Swanley  Convalescent  Home. 

On  his  return  from  Swanley  he  was  ordered  a  thick  sole  to 
his  right  boot ;  with  this  he  could  walk  without  any  difficulty 
or  lameness.  He  had  been  examined  by  the  Militia  authorities 
and  declared  fit  for  duty. 


68  Chses  from  Mr.  WiUetCs  ^YarJs. 


RE-FRACTURE  OF  THE  FEMUR, 

FOR  THE  RELIEF  OF  SHORTENING  AND  DEFORMITY, 
THE  RESULT  OF  A  FRACTLTIE. 

BY 

OWEN  LANKESTEE. 


William  H.,  seaman,  aged  46,  adinittcd  to  Pitcairn  Ward  on 
June  29,  1885,  under  the  charge  of  Mr.  Willett,  suffering  from 
deformity  of  the  right  femur  and  shortening  of  the  right  lower 
extremity,  due  to  a  fracture  sustained  on  board  ship  in  March 
1885. 

History  of  accident. — During  a  storm  off  Cape  Horn  on  March 
15,  1885,  the  patient,  whilst  engaged  in  his  work  as  an  ordinary 
seaman,  was  washed  heavily  against  the  pump,  striking  his  right 
thigh  just  above  the  knee.  He  was  immediately  unable  to  rise 
or  to  move  his  leg.  There  being  no  medical  man  on  board,  he 
was  seen  by  the  captain  of  the  vessel,  who  did  not  think  that  the 
thigh  was  fractured  ;  consequently  no  active  treatment  was  em- 
])loyed,  and  no  splints  were  applied,  but  he  simply  lay  in  his 
berth  resting ;  there  was  a  good  deal  of  bruising  and  swelling 
about  the  leg,  which  gradually  subsided.  For  six  weeks  he  lay 
in  bed  unable  to  move  his  leg;  at  the  end  of  this  time  he  got 
about  on  crutches,  and  has  since  walked  with  a  marked  limp, 
and  only  with  crutches ;  he  has  no  pain  in  the  affected  leg, 
except  occasional  aching  at  night,  and  he  cannot  lie  comfortably 
on  his  right  side. 

Condition  on  cidmission. — Right  leg,  from  ant.  sup.  spine  of 
ilium  to  int.  malleolus,  measures  30  inches.  Same  measure- 
ment on  left  leg=22^  inches,  thus  making  2^  inches  shortening 
of  right  leg,  which  is  inverted  to  a  slight  extent.  The  knee- 
joint  is  quite  sound,  and  its  movements  quite  free.  There  is 
marked  outward  bowing  of  the  thigh.  Two  inches  above  the 
knee-joint  a  considerable  mass  of  callus  can  be  felt;   on  the 


Cases  from  3Ir.  Willeth  Wards.  6g 

outer  side  there  is  a  prominence  wliicli  appears  to  correspond 
with  the  upper  end  of  the  lower  fragment,  and  on  the  posterior 
sm'face  there  is  another,  which  is  probahly  the  lower  end  of  tlio 
upper  fragment.  No  movement  of  the  fragments  on  one  another 
can  be  obtained.  The  girth  of  the  right  thigh  at  the  seat  of 
fracture  is  two  inches  greater  than  the  girth  of  the  left  thigh  at 
a  corresponding  point.  Sixteen  weeks  have  intervened  since  the 
accident. 

There  is  some  oedema  of  the  right  foot  and  leg,  which  has 
been  considerably  worse  than  at  present. 

General  health  is  good  at  present,  although  he  has  had 
syphilis. 

July  6th. — Patient  being  put  under  the  influence  of  ether, 
the  right  thigh  was  re-fractured  in  the  following  manner: — 

The  patient  being  laid  on  his  left  side,  with  his  left  leg  well 
drawn  up  and  out  of  the  way,  the  right  leg  was  brought  straight 
down  so  as  to  rest  on  the  bed ;  the  operator,  standing  by  the 
side,  placed  one  knee  over  the  site  of  the  fracture,  and  then 
proceeded  to  draw  the  leg,  kept  in  an  extended  position,  up  from 
the  bed  towards  himself,  using  it  as  a  lever ;  the  union  of  the 
fracture  was  so  firm  that  the  manoeuvre  had  to  be  repeated 
several  times  before  re-fracture  was  accomplished.  The  frag- 
ments being  satisfactorily  separated,  an  extension  apparatus, 
with  a  weight  of  12  lbs.,  was  applied,  and  the  leg  put  up  on  a 
Listen's  long  outside  splint.  The  inversion  of  the  leg  and  the 
prominences  on  the  outer  and  posterior  surfaces  of  the  thigli 
were  corrected  in  the  new  position  of  the  limb. 

July  7th. — Complains  only  of  inconvenience  of  lying  on  his 
back.     Leg  quite  comfortable. 

July  8th. — Weight  increased  to  15  lbs. 

Eight  leg  only  i^  inches  shorter  than  left. 

July  loth. — Difference  in  measurement  i^  inches. 

July  I2tli. — Weight  increased  to  17  lbs. 

July  15  th. — Eight  leg  shortening  |  inch. 

July  23d. — Listen's  splint  discontinued.  Thomas's  hip-joint 
splint  applied. 

Weight  17  lbs.  continued. 

July  29th. — Owing  to  tendency  of  the  leg  to  become  everted, 
it  has  been  put  up  in  a  plaster  of  Paris  case  over  the  splint. 

Weight  continued  as  before. 

Leg  remains  in  excellent  position. 

A  considerable  amount  of  new  callus  is  thrown  out. 

August  14th. — A  patten  having  been  fitted  to  the  boot  of  left 
foot,  the  patient  now  gets  about  on  crutches,  the  extension 
apparatus  having  been  removed. 


70  Cases  from  Mr.  Willett's  Wards. 

August  igi\\. — Splint  and  plaster  removed. 

Riglit  leg  just  ij  inch  shorter  tlinn  left. 

Right  leg  is  in  good  position  ;  deformity  quite  corrected. 

August  26ih. — Has  lain  in  bed  for  one  week  with  no  apparatus 
on  leg;  can  lift  right  log;  knee  rather  slifF. 

September  2d. — Gets  up  witli  crutches  and  patten  on  left 
foot. 

September  17th. — Patten  discontinued.  Gets  about  well  with 
a  stick;  expresses  himself  much  pleased  with  result. 

Leg  quite  straight.     Shortening  of  right  leg  still  |  inch. 

September  30th. — To  go  to  Convalescent  Home. 

On  his  return  he  will  have  a  boot  for  right  foot  with  a  high 
sole,  when,  it  is  hoped,  he  wuU  walk  quite  satisfactorily. 


REMARKS  OX  THE  PREVIOUS  CASES. 

BY 

Me.  WILLETT. 

These  two  cases  illustrate  the  good  results  that  are  obtain- 
able by  re-fracturing,  eitlier  by  manipulation  or  by  osteotomy, 
bones  that  have  united  in  bad  position  with  great  deformity 
and  serious  impairment  in  the  utility  of  the  limbs. 

In  the  first  case,  as  seven  months  had  elapsed  since  the  acci- 
dent, there  could  be  but  little  hope  of  re-fracturing  the  femur 
simply ;  yet  it  seems  strange  that  this  man  should,  as  he  says, 
have  wandered  from  hospital  to  hospital,  and  until  he  applied  at 
St.  Bartholomew's  have  been  told  at  each  that  nothing  could  be 
done  for  him.  It  is  the  more  remarkable  that  this  could  occur 
in  the  present  day,  when  osteotomy  has  achieved  a  recognised 
position  as  a  safe  and  effectual  means  of  correcting  most  of  the 
bony  deformities  of  the  extremities. 

In  planning  the  operation,  it  was  necessary  to  take  into  account 
the  fact  that  a  simple  transverse  division  of  the  bone,  or  even  a 
haphazard  section  at  the  site  of  the  old  fracture,  would  not  help 
materially  in  restoring  the  length  of  the  limb,  but  that  to  effect 
this  object  it  was  essential  to  chisel  almost  longitudinally  through 
the  callus  ensheathing  the  overlapping  fractured  ends,  and  of 
course  between  them,  in  this  manner  restoring  the  conditions  of 
the  orio^inal  fi-acture. 


Cases  from  Mr.  Willett's  Wards.  yi 

Careful  examination  had  assured  me  exactly  of  the  altered  re- 
lations of  the  parts,  and  had  disclosed  the  fact  that  the  lower 
fragment  was  in  front  of  the  upper ;  that  this  was  so  was  borne 
out  when  the  femur  was  reached  in  the  course  of  the  operation. 
No  attempt  was  made  to  perform  the  operation  subcutaneously. 
No  difficulty  was  experienced  in  its  performance  greater  than 
was  due  to  the  density  of  the  callus. 

His  after  progress  was  most  satisfactory ;  not  the  slightest 
unfavourable  symptom  followed  the  operation.  It  is  noteworthy 
how  well  the  patient,  who  was  a  very  plucky  fellow,  and  took 
the  keenest  interest  in  his  case  and  was  most  sanguine  of  the 
result,  bore  the  great  strain  of  26  lbs.  extension  weight.  He  has 
been  seen  lately,  and  is  as  active  and  strong  on  his  leg  as  ever 
he  was,  with  scarcely  any  perceptible  lameness. 

The  second  case,  where  re-fracture  was  effected  after  sixteen 
'weeks,  does  not  call  for  much  comment.  It  taxed  the  strength 
of  a  very  powerful  man,  the  House  Surgeon  (Mr.  Owen  Lankester), 
to  eflfect  it,  although  very  effectual  leverage  was  obtained.  The 
result  in  this  case  promises  to  be  as  satisfactory  as  in  the 
other. 


NOTES 


THREE  CASES  OF  COAL-CIAS  POISONEN^G. 

WITH  REMARKS  ON  THE  SYMPTOMS  AS  ILLUSTRATED 
BY  THESE  AND  OTHER  CASES. 


BT 

CHARLES  A.  MOETOK 


Three  persons  were  brought  to  St.  Bartholomew's  Hospital  on 
November  i,  1883,  suffering  from  coal-gas  poisoning. 

The  escape  of  gas  was  due  to  a  leak  in  the  main  pipe  under 
the  house.  The  gas  ascended  into  the  house,  reaching  as  high 
as  the  first  floor,  where  the  three  persons  who  were  poisoned  by 
it  were  sleeping.  The  room  contained  a  fireplace  ;  the  fire  was 
not  lighted,  but  as  it  was  laid  ready  for  lighting  in  the  morning, 
no  doubt  the  chimney  was  open.  The  gas  was  not  burning 
when  they  went  to  bed.  The  grandmother  and  grandfather 
slept  on  a  bed,  and  the  grand- daughter  on  a  sofa-mattress  on  the 
floor  at  the  foot  of  the  bed,  so  that  she  would  be  the  first  affected 
by  the  gas  in  its  ascent.  They  all  went  to  bed  at  the  same 
time.  There  were  no  means  of  finding  out  the  exact  hour 
when  the  gas  began  to  enter  the  room.  At  3  a.m.  the  grand- 
father was  awakened  by  hearing  the  girl  vomiting  and  groaning. 
He  got  some  of  his  clothes  on,  lighted  the  gas  in  the  room,  and 
then  fell  down  insensible.  He  smelt  something  peculiar  but  did 
not  recognise  it  as  coal-gas.  The  gas-jet  came  down  in  the 
centre  of  the  room  so  low  that  a  man  of  moderate  height  could 
not  pass  under.     No  explosion  followed  the  lighting  of  the  gas. 

At  8  A.M.  they  were  all  found  insensible.  The  grandfather 
was  brought  to  the  hospital  at  11  a.m.  He  was  heavy  and 
stupid,  with  congested  conjunctivse.     The  pupils  were  natural. 


74  Three  Cases  of  Coal-Gas  Poisoning. 

There  was  no  smell  of  coal-gas  in  liis  breath.  He  {gradually 
recovered,  and  in  the  evening  was  able  to  go  home.  The  grand- 
mother, seen  an  hour  later,  was  quite  unconscious,  but  not  livid. 
The  breathing  was  quiet  and  not  distressed,  and  her  pulse  was 
fairly  good.  The  pupils  were  natural.  There  was  no  marked 
smell  of  coal-gas  about  her.  She  gradually  regained  conscious- 
ness, and  in  the  afternoon  swallowed  food,  but  remained  drowsy 
all  the  evening.  She  had  no  relapse.  Next  morning  she  was 
very  weak,  but  otherwise  well.  The  grandfather  and  grand- 
mother were  quite  old  people. 

The  girl,  aged  about  i8,  when  admitted  with  the  grandmother 
at  noon,  was  also  quite  unconscious,  and  was  somewhat  livid,  with 
very  feeble  pulse.  There  was  no  smell  of  coal-gas  in  her  breath. 
The  pupils  were  natural  in  size.  She  very  quickly  became 
worse,  got  very  livid,  and  the  pulse  became  very  feeble  indeed. 
The  conjunctivre  were  not  congested.  There  were  no  convulsive 
movements  of  the  e3'eballs.  The  respirations  were  rapid  and 
ishallow,  and  the  temperature  97°, 

Artificial  respiration  was  ])er formed  at  short  intervals,  and 
the  temperature  kept  up  with  artificial  warmth.  She  slowly 
inhaled  a  large  quantity  of  oxygen  gas,  not  unmixed  with  air, 
but  through  a  tube  passed  into  the  mouth,  the  gas  passing 
along  the  tube  under  pressure  from  the  gasometer.  She  was 
})laced  in  a  current  of  fresh  air  between  the  open  window  and 
fireplace. 

A  few  hours  after  beginning  the  treatment  she  had  not  im- 
proved at  all,  but  seemed  rather  to  get  worse,  and  the  trachea 
was  obstructed  by  mucus.  At  times  she  seemed  to  improve  a 
little  and  then  became  very  livid  again.  At  2.30  p.m.  she  seemed 
in  a  hopeless  condition  ;  the  pulse  was  almost  imperceptible,  and 
«he  could  not  retain  enemata  of  brandy.  Artificial  respiration 
was  still  performed  to  supplement  the  natural  res2)iratory  move- 
ments, but  the  failure  of  respiration  was  not  so  marked  as  the 
cardiac  depression.  Later  in  the  afternoon  she  began  to  revive 
again,  and  at  4  p,m.  retained  an  enema  of  brandy.  The  pulse 
then  improved  and  the  lividity  diminished,  but  she  remained 
quite  unconscious.  About  10  p.m.  the  lividity  again  increased. 
Ten  ounces  of  blood  were  removed  from  the  back  by  cupping, 
as  it  did  not  flow  readily  from  the  arm.  It  was  very  dark  in 
€olour,  and  the  red  corpuscles  were  markedly  crenated.  During 
the  evening  she  was  fed  twice  through  a  soft  catheter  passed 
down  the  oesophagus  from  the  nose,  with  brandy,  egg,  and 
essence  of  beef  (a  hospital  preparation).  Her  temperature  went 
up  as  high  as  104°  in  the  axilla.  The  urine  was  10 18,  natural 
in  colour,  and  did  not  contain  albumin.     Whether  she  was  any 


Three  Cases  of  Coal-Gas  Poisonmcf.  75 

better  for  the  inhalation  of  oxygen  or  the  removal  of  blood, 
there  does  not  seem  to  be  sufficient  evidence  to  show  ;  she  varied 
much  without  alteration  in  treatment. 

During  the  night  she  remained  in  the  same  state,  quite  un- 
conscious, and  became  rather  livid  at  times.  The  pulse  re- 
mained feeble  and  rapid,  and  tbe  respiration  quick  and  shallow. 
Artificial  respiration  was  not  continued.  Her  pupils  varied 
much  ;  sometimes  they  were  natural,  at  other  times  dilated,  and 
occasionally  almost  as  contracted  as  those  of  opium-poisoning. 
At  5.30  A.M.  she  had  another  slight  relapse.  The  respirations 
became  more  laboured,  but  she  quickly  recovered  with  artificial 
respiration  and  the  sudden  application  of  cold  to  the  chest. 

Next  day,  November  2,  she  was  still  unconscious,  but  her  colour 
was  fairly  good.  Pulse  160,  very  weak;  respiration  40,  rather 
shallow.  In  the  evening  the  face  was  very  much  flushed,  and 
on  examination  of  the  chest  small  rales  were  discovered  at  both 
bases  behind  with  some  dulness  at  the  right,  and  larger  rales 
over  the  front  of  the  chest.  She  could  move,  and  evidently  felt 
the  passage  of  the  catheter  through  which  she  was  fed,  but  was 
not  fully  conscious.  Daring  the  night  she  remained  much  in 
same  condition. 

November  3. — She  was  more  conscious,  taking  notice  of  those 
about  her,  able  to  swallow  and  do  what  she  was  asked,  but  did 
not  speak.  Her  colour  was  good  and  pulse  stronger.  The  pul- 
monary catarrh  continued. 

November  4. — She  could  talk,  but  did  not  understand  where 
she  was.  The  breathing  was  rather  distressed  from  the  bron- 
chitis ;  otherwise  she  was  doing  well. 

November  5. — Quite  rational.  Bi'onchitis  better.  After  the 
5th  she  rapidly  improved,  and  soon  left  the  hospital. 

The  proportion  of  coal-gas  in  the  air  of  the  room  must  have 
been  below  10  per  cent.,  for  in  this  proportion  the  mixture  is 
explosive,  and  had  there  been  10  per  cent,  an  explosion  would 
have  occurred  when  the  grandfather  lighted  the  gas.  That  less 
than  10  per  cent,  is  most  poisonous  is  further  shown  by  a  case 
recorded  by  Dr.  Chaumont  (in  the  Lancet  for  October  25, 
1873),  i'l  which  two  women  were  poisoned  by  coal-gas  in  a  room 
where  a  benzoline  lamp  was  burning.  But  Dr.  Taylor's  investi- 
gations show  that  much  less  than  10  per  cent,  may  be  fatal.  In 
a  case  recorded  by  him,  death  occurred  after  sleeping  in  a  room 
with  3  per  cent.  only. 

These  three  cases  well  illustrate  the  fact  that  persons  exposed 
to  the  gas  are  poisoned  by  it  without  awakening  from  sleep,  or 
becoming  conscious  of  its  presence  if  awake.     When  the  gas 


^6  Three  Cases  of  Coal-Gas  Poisoning. 

entered  the  room,  they  must  either  have  been  asleep  or  have 
failed  to  recognise  the  smell,  and  so  been  slowly  narcotised  by 
the  gas;  for  had  any  of  them  smelt  it  they  would  certainly  have 
taken  means  to  discover  where  it  came  fiom,  and  to  stop  the 
escape.  That  at  least  one  out  of  the  three  did  wake  and  smell 
the  gas,  and  fiiil  to  recognise  it  as  coal-gas,  we  know. 

Dr.  von  Pettenkofer  has  lately  recorded  cases  showing  that 
persons  may  be  very  seriously  affected  by  coal-gas,  and  yet  quite 
fail  to  recognise  its  presence.  In  these  cases  the  gas  has  passed 
through  the  ground  in  its  ascent.  In  the  Lancet  for  May  24, 
1884,  is  the  following  account  of  one  ca^^e  related  by  him  : — 

"At  Roveredo  two  sisters  who  slept  in  the  basement  of  a 
house  awoke  on  three  successive  mornings  suffering  from  violent 
headache  and  a  general  feeling  of  illness.  This  circumstance 
was  attributed  to  the  effects  of  an  ii'on  stove  with  which  the 
apartment  was  heated,  which  was  removed  before  the  fourth 
night,  when  the  mother  shared  the  room.  The  night  was 
extremely  cold  and  the  roadway  fi-ozen.  On  the  following 
morning,  none  of  the  inmates  making  their  appearance,  the 
door  was  broken  open,  and  the  three  women  were  found  motion- 
less, the  daughters  being  dead,  and  the  mother  so  affected  by 
gas-poisoning  that  she  only  survived  a  few  days."  He  also 
relates  the  case  of  a  man  who  died  from  coal-gas  poisoning,  in 
which  the  cause  of  death  was  not  discovered  until  his  sons  were 
affected  by  the  gas  after  sleeping  in  the  same  room.  In  these 
cases  the  gas  had  entered  the  houses  from  an  escape  in  an  under- 
ground pipe.  From  Dr.  von  Pettenkofer's  experiments  with 
coal-gas  he  has  been  led  to  believe  that  it  loses  its  smell  to  a 
considerable  extent  in  passing  through  a  layer  of  earth. 

That  the  girl  was  so  much  more  affected  by  the  gas  than  the 
grandfather  or  grandmother  may  be  explained  by  the  fact  that 
she  slept  on  the  floor,  and  so  would  be  the  first  to  breathe  the 
gas  in  its  ascent ;  but  it  could  not  have  taken  long  to  reach  the 
bed  where  her  grandparents  were  sleeping.  In  the  case  already 
referred  to,  recorded  by  Dr.  Chaumont,  the  younger  members  of 
the  family  were  the  least  affected,  and  there  seems  to  be  no  reason 
why  the  young  should  suffer  more  severely  than  the  old.  It  may 
be  that  there  was  some  slight  current  of  air  passing  over  the  bed 
situated  between  two  windows,  diluting  the  poisoned  air  in  the 
room,  which  did  not  pass  along  the  floor.  The  bed  was  not 
directly  between  two  windows,  but  only  a  little  out  of  the  direct 
line  between  them. 

The  length  of  coma  was  remarkable  in  the  case  of  the  girl. 
She  was  unconscious  for  forty-eight  hours,  only  showing  signs  of 
feeling  the  passage  of  the  catheter  through  which  she  was  fed 


Three  Cases  of  Coal-Gas  Poisoning.  77 

after  the  first  twenty-four  hours  ;  but  she  could  not  speak  on  the 
third  day,  and  on  the  fourth,  although  she  could  speak  very  well, 
her  understanding  was  still  very  deficient.  In  some  cases  re- 
corded as  poisoning  from  coal-gas,  one  person  remained  uncon- 
scious for  eight  days,  and  died  on  the  twelfth  day,  and  another 
was  comatose  for  twenty-four  hours,  but  recovered.  They  were 
due  to  sleeping  in  a  room  heated  by  a  stove  burning  Dantzic 
coal.  Dr.  Wyn  Williams,  at  the  Medico-Chirurgical  Society  in 
1862,  related  a  case  in  which  an  old  woman,  after  sleeping  in  a 
room  into  which  coal  gas  was  escaping,  was  comatose  for  forty- 
eight  hours,  and  then  partially  sensible,  but  in  three  or  four 
days  again  comatose.     The  case  ended  fatally. 

Another  point  of  interest  in  the  case  of  the  girl  is  that  she 
so  often  relapsed  after  improving.  In  Dr.  Williams's  case  the 
relapse  was  into  a  state  of  coma  after  an  interval  of  several  days, 
but  in  this  case  she  got  less  livid,  and  the  heart  and  lungs  began 
to  work  better,  and  then  cardiac  and  respiratory  failure  with 
lividity  returned,  although  there  was  no  change  in  the  condition 
of  deep  coma. 

The  pupils  were  natural  in  all  these  cases  on  admission,  but 
in  the  case  of  the  girl  there  was  considerable  variation  in  their 
size  after  admission,  and  at  one  time  very  marked  contraction. 
The  condition  of  the  pupils  seems  to  vary  in  coal-gas  poisoning. 
In  the  few  recorded  cases  of  coal-gas  poisoning  in  which  there 
is  a  note  as  to  the  condition  of  the  pupils  that  I  can  find,  they 
were  natural  in  one  case,  contracted  in  one  case,  and  dilated  in 
two  cases. 

These  cases  are  not  without  interest  from  a  medico-legal 
aspect.  In  a  case  where  a  person  was  found  dead  in  a  room 
into  which  coal-gas  was  found  escaping  (the  Chantrelle  case),  \\, 
was  important  to  decide  whether  death  was  due  to  the  gas  or  to 
a  narcotic  poison,  the  idea  being  that  after  a  narcotic  poison 
had  been  given  the  gas  had  been  allowed  to  enter  the  room,  to 
lead  to  the  supposition  that  she  had  been  poisoned  by  it.  It 
was  considered  in  favour  of  poisoning  from  a  narcotic  that  there 
was  no  smell  of  coal-gas  in  the  breath.  But  in  two  of  these 
three  cases,  the  breath  certainly  did  not  smell  of  coal-gas,  and 
my  note  about  the  third  is,  "  there  was  no  marked  smell  of  coal- 
gas  about  her." 

The  absence  of  all  convulsive  movements  in  this  case  is  of 
interest.  In  a  case  recorded  by  Mr.  Jessop  of  Leeds,  after  ex- 
posure to  gas  undiluted  with  air  in  a  main  pipe  for  twenty 
minutes,  a  man  was  found  completely  comatose,  and  in  half  au 
hour  violent  convulsions  came  on.  These  convulsions  were 
especially  marked  in  the  muscles  of  the  face,  neck,  and  body. 


yS  Three  Cases  of  Coal-Gas  Poisoning. 

The  man  recovered  in  less  tlian  twenty-four  hours.  la  two 
oilier  reconled  oases  convulsions  were  present:  they  were  fatal. 
These  convulsions  may  he  very  violent  intleotl.  In  Mr.  Jessop's 
case  the  patient  required  chloroform  to  stop  them.  In  a  case 
recorded  by  Dr.  Gilbart-Smith,  a  young  man  aged  17,  poisoned 
by  coal-gas,  suffered  from  marked  muscular  rigidity,  with  slight 
convulsive  movements. 

Only  in  two  cases  of  coal-gas  poisoning  can  I  find  a  note  as  to 
the  temperature.  In  Mr.  Jessop's  case  (above  alluded  to)  it  was 
99° ;  in  Dr.  Gilbart-Smith's  case  it  reached  103^  and  this  was  at 
the  time  the  patient  began  to  improve.  In  the  case  of  the  girl, 
the  temperature  was  104°  at  one  time,  but  there  was  no  marked 
improvement  at  the  time  it  was  taken.  The  temperature  of  the 
grandparents  was  not  taken. 

The  condition  of  the  blood  taken  from  the  girl  is  of  interest, 
the  colour  differing  so  much  from  the  bright  red  blood  of  pure 
carbonic-oxide  poisoning.  Mr.  Bloxam  records  a  case  in  which 
post-mortem  the  blood  was  everywhere  black.  The  inhalation 
of  pure  oxygen  is  sometimes  extremely  beneficial  in  carbonic- 
oxide  poisoning.  In  a  case  in  which  pure  carbonic  oxide  was 
inhaled  as  an  experiment,  leading  to  coma  and  cardiac  failure, 
the  inhalation  of  oxygen  had  a  very  rapidly  beneficial  effect, 
after  other  methods  of  treatment  had  failed.  In  this  case  of 
coal-gas  poisoning,  howevei',  other  jwisonous  gases  as  well  as 
carbonic  oxide  were  doubtless  present,  and  so  the  inhalation  of 
oxygen  had  no  very  marked  effect.  The  condition  of  the  blood 
shows  us  that  carljonic  oxide  had  not  produced  its  usual  effects 
on  the  blood ;  therefore  probably  it  alone  was  not  the  cause  of 
such  prolonged  coma  with  cardiac  and  respiratory  failure.  In  a 
case  recorded  by  Dr.  Barnes  at  the  Medico-Chirurgical  Society, 
the  patient  was  of  a  "  dark,  livid,  leaden  colour.'"' 


THE  AFTER-TREATMENT  OF  TRACHEOTOMY. 


S.  HEKBEET  HABERSHON,  M.B. 


My  object  in  discussing  tliis  subject  is  not  to  encroach  on  the 
domain  of  the  surgeon,  but  to  ilhistrale  by  a  few  successful  cases 
in  Dr.  Andrew's  wards  (which  he  kindly  allows  me  to  make 
known)  a  form  of  treatment  initiated  by  a  previous  House  Phy- 
sician (Dr.  Bullar),  the  value  of  which  is  fully  borne  out  by 
the  cases  I  shall  relate,  as  well  as  by  the  cases  referred  to  in  a 
pamphlet  recently  published  by  liim  on  the  subject. 

Seven  cases  of  membranous  laryngitis  have  occurred  in  Dr. 
Andrew's  wards  during  the  past  nine  months,  in  which  the 
laryngeal  symptoms  were  sufficiently  urgent  to  necessitate  trache- 
otomy. 

Of  these,  five  have  recovered.  Of  the  two  that  ended  fatally, 
one  was  a  case  of  slow  malignant  diphtheria  in  a  child  aged  three 
and  a  half.  The  child  died  on  the  eighth  day  of  the  disease,  and 
the  second  day  after  the  operation  was  performed.  The  symptoms 
were  severe.  There  was  extreme  foetor  of  the  discharge  from  the 
nose  and  larynx,  a  large  amount  of  albumen  in  the  urine,  great 
ansemia,  protracted  and  uncontrollable  vomiting,  and  a  tempera- 
ture high  throughout,  and  rising  to  io6°  before  death. 

The  second  fatal  case  was  that  of  an  infant  aged  seven  months. 
The  lungs  were  affected  on  admission,  but  the  urgency  and  pre- 
dominance of  laryngeal  symptoms  rendered  tracheotomy  advis- 
able. The  child  died  from  asphyxia  twenty-six  hours  after  the 
operation  from  extension  of  the  disease  in  the  lungs. 

The  other  five  cases  present  a  brighter  record.  Before  relating 
them,  I  shall  mention  the  form  of  treatment  adop^-d,  and  after- 
wards illustrate  it  by  reference  to  the  cases. 

In  all  cases  of  diphtheria,  provided  the  disease  is  not  of  a  suffi- 
ciently malignant  type  to  kill  by  the  virulence  of  the  poison,  the 


8o  The  After- Treatment  of  Tracheotomy. 

great  difficulty  in  treatment  seems  to  be  to  persuade  the  patient 
to  take  sufficient  nourishment. 

If  the  strength  can  be  maintained  for  a  period  long  enough  to 
allow  the  disease  to  be  tided  over,  and  the  extension  of  the  mem- 
branous process  sta3'ed,  it  appears  to  be  possible  to  combat  the 
anaemia  and  the  debility,  which  form  such  prominent  features  of 
the  disease,  by  proper  and  sufficient  nourishing  food. 

In  the  earlier  days  of  tracheotomy  it  seems  not  to  have  been 
thought  remarkable  that  milk  or  other  liquid  food  given  by 
the  mouth  should  find  its  way  out  through  the  tracheotomy 
tube.  To  this  passage  of  food  into  the  trachea  the  occurrence 
of  local  pneumonias  is  probably  due,  to  which  the  term  deglu- 
tition imeumonia  has  been  applied. 

Undoubtedly  the  presence  of  a  tube  in  the  trachea  favours  the 
passage  of  food  into  the  windi)ipe,  probably  by  dimiuisiiing  the 
sensibility  of  the  epiglottis  and  by  removing  the  safeguard  against 
such  an  occurrence  during  health,  or  from  the  fact  that  too  little 
air  passes  into  the  larynx  above  the  tube  to  enable  fluid  to  be 
expelled.  A  third  and  not  unimportant  factor  is  also  present. 
In  the  action  of  deglutition  the  closure  of  the  aperture  of  the 
larynx  by  the  cushion  at  the  base  of  the  epiglottis  is  assisted  by 
the  raising  of  the  thyroid  cartilage  behind  the  liyoid  bone  by 
means  of  the  laryngeal  muscles.  This  movement  of  the  thyroid 
is  in  some  measure  prevented  by  the  presence  of  a  tube  in  the 
trachea. 

Again,  the  difficulty  is  great  of  giving  nourishment  in  sufficient 
quantity  (especially  in  the  case  of  a  child)  without  disturbing 
the  patient's  rest.  A  child  will  not  take  a  large  amount  of  fluid 
at  once  on  account  of  the  pain  caused  by  the  act  of  swallowing, 
and  the  consequence  is  that  it  has  to  be  fed  at  frequent  intervals, 
night  and  day,  either  with  a  teaspoon  or  in  small  sips.  Thus 
the  natural  physiological  functions  of  the  stomach  are  interfered 
with,  and  in  addition  the  sleep  of  the  patient  is  disturbed.  The 
child  has  to  be  awaked  every  quarter  or  half  an  hour,  and  if  this 
is  not  done,  enough  food  catmot  be  given. 

The  plan  Dr.  Bullar  suggested,  which  Dr.  Andrew  has  allowed 
to  be  adopted  in  all  his  cases  since  March,  is  to  feed  the  patient 
by  a  soft  catheter  or  elastic  tube  passed  directly  into  the  stomach 
through  the  nose.  In  a  child  a  No.  4  to  No.  6  soft  rubber  catheter 
is  used.  A  small  piece  of  glass  tubing  is  fixed  in  the  outer  end  of 
the  tube,  or  an  ordinary  glass  pipette,  and  the  fluid  food  is  placed 
warm  in  a  brass  syringe  of  4  to  6  ounces  capacity,  and  slowly  forced 
into  the  stomach.  The  end  of  the  brass  syringe  is  kept  wedged 
in  the  glass  tube  by  placing  a  short  piece  of  gutta-percha  tubing 
round  the  conical  nozzle  of  the  syringe,  of  calibre  sufficient  to 


The  After-Treatment  of  Tracheotomy.  8r 

enable  it  to  pass  into  the  end  of  the  glass  pipette.  The  first 
time  or  two  that  the  tube  is  passed  the  child  struggles  a 
little,  but  it  is  usually  easy  after  the  first  attempt,  and  I  have 
occasionally  seen  the  child  close  its  eyes,  and  even  sleep  during 
the  process.  On  one  occasion  a  patient  was  fed  during  sleep 
without  being  awaked,  so  free  is  it  from  discomfort. 

It  will  be  found  to  simplify  the  passage  of  the  tube  if  it  be 
held  as  a  pen  with  the  finger  and  thumb  of  the  right  hand, 
whilst  the  tip  of  the  nose  is  pressed  upwards  with  the  thumb 
of  the  left  hand,  the  fingers  of  the  same  being  placed  on  the 
bridge  of  the  nose  or  on  the  forehead  of  the  patient ;  in  short, 
exactly  as  in  the  passage  of  the  Eustachian  catheter. 

It  is  almost  impossible  to  get  the  tube  into  the  larynx.  If  so, 
only  a  few  inches  will  pass,  and  the  irritation  produced  is  certain 
to  afford  a  sure  index  of  the  mistake. 

A  difficulty  that  sometimes  occurs  is  that  the  retching  and 
the  efforts  at  regurgitation  bring  back  the  end  of  the  tube  into 
the  mouth,  where  it  can  be  seen  coiled  up.  This  can  usually  be 
overcome  by  a  second  or  several  trials.  If  there  is  any  doubt 
whether  the  tube  be  in  the  stomach  from  gurgling  of  clear  fluid 
in  the  glass  pipette,  the  reaction  of  the  fluid  will  often  serve  to 
distinguish  gastric  secretion  from  laryngeal  mucus.  The  re- 
action is  of  course  acid  if  it  be  gastric  juice,  provided  that  lime- 
water  has  not  been  previously  given.  Food  should  be  given  at 
least  every  four  hours,  the  quantity  varying  from  two  to  six 
ounces  or  more,  according  to  the  age.  Not  more  than  four 
ounces  should  be  given  at  the  first  feeding,  and  if  this  be  kept 
down  without  regurgitation  or  vomiting,  the  child  should  be  fed 
every  four  hours.  In  one  of  the  cases  -reported,  a  child  twO' 
and  a  half  years  old,  it  was  observed  that  just  before  tbe 
feeding  time  the  patient  was  subject  to  fits  of  dyspnoea  and 
coughing,  apparently  from  exhaustion.  When  food  was  given 
at  shorter  intervals  (every  three  hours),  it  was  remarked  that 
these  attacks  did  not  occur.  In  the  same  patient  ihe  food  was 
gradually  increased  to  six  ounces  every  four  hours.  The  indication 
that  too  much  food  has  been  given  is  usually  that  regurgitation 
or  vomiting  occurs  after  feeding,  or  the  patient  becomes  dyspeptic. 

The  following  cases  are  of  interest  as  illustrating  the  success 
of  the  above  treatment,  for  I  believe  their  recovery  has  been  in 
great  measure  due  to  it. 

Case  1} 

J.  A.  C,  aged  2^,  admitted  to  Mark  Ward,  February  i8, 
1885. 

^  Extracted  from  Dr.  Bullar's  notes. 
VOL.  XXT.  F 


82  The  Aftcr-Treatment  of  Tracheotomy. 

The  child  had  been  apparently  well  on  the  previous  day,  but 
in  the  evening  its  breathing  became  difficult,  and  it  was  brought 
to  the  surgery  at  8  A.M.  in  a  state  of  urgent  dyspnoea  with  great 
recession  at  the  lower  end  of  the  sternum.  Tracheotomy  was 
performed  at  once  by  Mr,  Lewis  with  great  relief ;  no  membrane 
was  seen. 

The  child  took  food  well  until  the  22d.  It  then  began  to  take 
badly,  and  nutritive  enemata  were  given  and  retained.  On  the 
26th  the  food  was  noticed  to  come  back  through  the  tracheotomy 
tube.  All  feeding  by  the  mouth  was  given  up  at  once,  and  the 
child  was  fed  entirely  by  a  soft  catheter  passed  through  the  nose. 
Haifa  pint  of  milk,  half  an  egor^  and  two  teaspoonfuls  of  brandy 
were  given  every  six  hours.  There  was  no  difficulty  in  passing 
a  No.  4  india-rubber  catheter,  and  the  Sister  was  able  to  feed  the 
child  so  easily  that  he  scarcely  awoke,  and  always  fell  asleep  as 
soon  as  his  stomach  was  full. 

On  March  lOtli  the  tracheotomy  tube  was  removed  and  the 
wound  was  closed ;  but  it  was  found  on  trial  that  liquids  still 
passed  into  the  trachea  when  he  was  allowed  to  drink.  The 
nasal  feeding  was  therefore  continued  until  March  I2lh,  when 
he  was  able  to  eat  and  drink  properly.  Ho  left  the  hospital 
well,  but  has  since  been  admitted  with  pulmonary  tuberculosis, 
and  died  in  the  hospital  of  tubercular  meningitis. 

Case  IT. 

S.  H.,  aged  15  months,  was  admitted  by  Dr.  Bullar  on  March 
15th  with  symptoms  of  croup,  which  commenced  on  the  previous 
(lay.  Two  other  children  were  ill  in  the  same  house  with  sore 
throat. 

On  admission,  patches  of  membiane  were  visible  on  both 
tonsils.  The  increasing  dyspna-a,  evidenced  by  the  lividity  and 
extreme  recession,  rendered  tracheotomy  necessary  a  few  hours 
after  admission.  Mr.  Lewis  performed  the  operation,  and  a  small 
piece  of  membrane  was  coughed  up  after  the  trachea  was  opened. 

The  child  went  on  well  for  some  days,  and  was  fed  at  first 
entirely  by  a  tube  through  the  nose,  and  at  the  end  of  a  week 
partly  by  the  tube  and  fctrthj  hy  the  viouth.  On  the  29th  the 
tracheotomy  tube  was  left  out  for  twenty-four  hours,  and  on  this 
day  impairment  of  resonance,  with  bronchial  breathing  and  bron- 
chophony, was  observed  at  the  base  of  the  left  lung  behind.  The 
wound  rapidly  closed,  and  food  was  again  given  by  the  mouth 
only,  the  child  improving  rapidly.  On  the  9th  of  April  some 
difficulty  in  swallowing  occurred,  and  on  the  12th  fresh  physical 
.signs  of  consolidation  appeared,  this  time  at  the  right  base  and 


Tlie  After-Treatment  of  Tracheotomy.  83 

in  the  right  axilla  anteriorly.  Feeding  by  the  tube  was  again 
resorted  to.  The  pneumonia  ran  a  typical  course,  the  tempera- 
ture, which  had  risen  on  the  12th,  falling  at  the  crisis  on  the 
20th  inst.  Since  no  difficulty  in  swallowing  remained,  food  was 
again  given  by  the  mouth,  and  the  child  continued  to  improve 
uninterruptedly  until  its  discharge  on  May  5th. 

There  is  very  little  doubt  that  the  pneumonia  on  each  occasion 
was  due  to  the  passage  of  a  small  quantity  of  liquid  food  into 
the  trachea  and  thence  into  the  lungs.  Food  was  given  partly 
by  the  mouth  during  the  time  that  efforts  were  being  made  to 
remove  the  tracheotomy  tube,  and  the  signs  of  consolidation  were 
easy  to  explain  on  the  supposition  that  some  food  had  gone 
the  wrong  way.  On  the  second  occasion,  when  a  similar  acci- 
dent occurred,  it  is  possible  that  there  was  slight  diphtheritic 
paralysis. 

Case  III. 

C.  L.,  aged  6J  years,  admitted  on  June  9tli  with  a  history 
of  cough  since  June  6th;  becoming  brassy  and  with  stridulous 
breathing  on  the  7  th. 

On  admission,  a  large  patch  of  greyish  membrane  covered  the 
fauces,  uvula  and  pharynx.  There  was  great  bilateral  recession 
of  the  lower  ribs  and  infraclavicular  regions,  with  a  frequent 
pulse,  intermitting  with  inspiration.  The  patient  was  ansemic 
and  slightly  livid.  Occasional  paroxysms  of  dyspnoea  with  in- 
creased lividity  and  recession  occurred.  A  severe  spasm  on  the 
morning  of  the  loth  caused  him  to  cease  breathing  after  a  few 
gasps.  The  child  was  moribund,  and  I  had  to  perform  a  hasty 
operation.  The  trachea  was  opened,  and  a  hair-pin  used  as  a 
dilator  to  keep  the  edges  of  the  wound  apart.  On  cutting  into 
the  trachea,  a  long  membranous  cast  about  2  inches  in  length, 
and  forming  a  perfect  tube,  was  coughed  through  the  opening, 
and  a  few  more  pieces  of  membrane  were  subsequently  coughed 
up.  He  was  fed  by  a  tube  through  the  nose  shortly  after  the 
operation,  and  at  intervals  of  six  hours,  with  eight  ounces  of 
milk,  two  of  lime-water,  two  teaspoonfuls  of  brandy,  and  one 
Qgg  in  the  twenty-four  hours.  Large  pieces  of  membrane  were 
coughed  up  until  the  evening  of  the  day  after  the  operation. 
The  tracheotomy  tube  was  removed  for  six  hours  on  the  fourth 
day,  the  wound  having  healed  by  first  intention  everywhere  but 
at  the  opening  for  the  tube.  It  was  replaced  for  the  night,  but 
on  the  fifth  day  the  child  was  able  to  do  without  it,  and  could 
breathe  freely  through  the  mouth.  The  feeding  by  the  tube  was 
continued  until  the  17th,  two  days  after  the  closure  of  the  wound. 
By  this  time  the  child  could  drink  water  without  coughing,  and 


84  The  After-Treatment  of  Tracheotomy. 

llie  woiiiid  had  completely  lieuled.    Oq  the  26tli  he  had  recovered 
his  voice  completely,  and  was  discharged  on  the  31st. 

The  two  last  cases  I  shall  mention  illustrate  not  only  the 
success  of  the  above  form  of  treatment,  but  a  method  of  meeting 
an  emergency  that  sometimes  occurs  in  cases  where  membrane 
extends  below  tlie  tracheotomy  tube. 

Cases  of  diphtlieria  will  be  familiar  to  all,  in  which,  either 
immediately  after,  or  at  a  variable  period  after  the  operation  for 
tracheotomy  has  been  performed,  a  sudden  obstruction  occurs 
below  the  tube  in  the  trachea  or  large  bronchi.  Violent  ex- 
piratory efforts  are  made  to  cough  up  the  obstruction,  but  in 
vain,  and  in  spite  of  attempts  to  clear  the  trachea  and  to  excite 
still  further  expiratoiy  efforts  by  passing  a  feather  down,  the 
child  rapidly  becomes  asphyxiated,  and  if  relief  is  not  afforded 
ceases  breathing. 

Sometimes  the  obstruction  is  caused  by  the  loosening  of  a 
large  piece  of  membrane,  frequently  a  complete  cast  of  the 
trachea  or  large  bronchi.  Partly  loosened  and  partly  adherent, 
it  cannot  be  coughed  up  by  the  most  violent  efforts  the  child 
can  make.  At  other  times,  when  the  raw  surface  of  the  trachea 
denuded  of  membrane  is  healing,  it  is  a  hard  dried  pellet  of 
mucus  that  forms  the  obstruction,  and  in  all  cases  recovering 
from  diphtheria  these  mucous  pellets  cause  more  or  less  frequent 
attacks  of  dyspnoea  and  no  little  anxiety  to  the  attendant. 

It  is  certain  that  means  to  excite  expiratory  efforts,  such  as 
passing  a  feather  through  the  tracheotomy  tube  or  irritation 
with  ammonia,  are  of  no  avail  in  some  cases.  I  am  convinced 
that  the  best  means  of  meeting  the  emergency  is  by  suction 
applied  in  one  form  or  another.  The  more  sudden  and  powerful 
the  suction  the  better,  provided  it  can  be  applied  locally.  General 
suction  at  the  end  of  the  tracheotomy  tube  is  more  likely  to  pro- 
duce collapse  of  the  lung  than  to  remove  an  obstruction.  Applied 
by  the  mouth,  it  is  not  as  sudden  or  as  powerful  as  applied  by 
other  methods,  and  is  scarcely  justifiable, 

I  have  used  a  simple  means,  always  at  hand  in  a  hospital 
ward,  previously  in  use  by  one  or  two  House  Physicians,  but  dis- 
carded because  it  has  been  said  only  to  act  like  the  feather  in 
producing  expiratory  efforts.     I  have  found  it  otherwise. 

A  small  soft  rubber  catheter,  Nos.  2  to  6  in  a  child,  the 
largest  that  will  pass  easily  down  the  trachea,  is  fitted  to  the  end 
of  a  small  brass  syringe.  The  end  containing  the  eye  is  snipped 
off.  It  is  passed  rapidly  through  the  tracheotomy  tube  down 
the  trachea  as  far  as  possible,  regardless  of  the  patient's  increased 
dyspnoea,  and  firmly  nipped  with  the  finger  and  thumb  just 


The  After -Treatment  of  Tracheotomy.  85 

outside  the  opening  into  the  trachea.  The  nurse  holding  the 
brass  syringe  is  then  requested  to  rapidly  exhaust  it  by  drawing 
up  the  handle  sharply.  When  this  is  done  the  finger  and 
thumb  are  suddenly  let  go,  and  the  whole  force  of  suction  is 
transferred  at  once  from  the  nipped  portion  to  the  end  of  the 
catheter  in  the  trachea.  Pieces  of  membrane  are  not  unfre- 
queutly  drawn  thus  into  the  tube,  and,  as  it  is  slowly  removed, 
mucus  or  membrane  usually  enters  the  tube  with  a  loud  sucking 
noise.  On  one  occasion  I  was  fortunate  enough  to  draw  up  a 
piece  of  membrane  forming  a  cast  of  part  of  a  large  bronchus,  too 
large  to  be  sucked  into  the  tube,  but  kept  adherent  to  the  open 
end  by  the  suction  force  in  the  catheter.  This  operation  may  be 
repeated  any  number  of  times  without  exhausting  the  child  as 
much  as  its  own  violent  and  fruitless  attempts  at  expiration. 

Case  IV. 

G.  B.,  aged  3,  admitted  to  Hope  Ward  on  June  25,  1885. 
Three  weeks  previously  he  had  contracted  measles,  and  for  the 
last  few  days  had  been  attending  the  ophthalmic  department 
with  purulent  ophthalmia.  Shortly  after  leaving  the  hospital 
on  June  24th  his  breathing  became  difficult,  and  towards  night 
the  voice  and  cough  were  croupy.  On  the  25th  he  was  admitted 
suffering  from  urgent  dyspnoea  with  hurried  stridulous  breathing 
and  a  metallic  cough.  The  face  and  lips  were  livid,  and  the  reces- 
sion of  the  sternum  so  great  that  at  each  inspiration  a  concave 
funnel-like  depression  was  produced.  The  pulse  was  120,  and 
was  slightly  quickened  during  expiration  and  retarded  during 
inspiration. 

The  fauces  were  congested.  No  sign  of  membrane  was  visible. 
Some  relief  was  afforded  by  a  hot  bath  and  the  use  of  the  steam- 
kettle,  but  it  proved  only  temporary.  The  breathing  became  more 
embarrassed,  and  at  6.30  p.m.  Mr.  Hind  performed  tracheotomy. 
The  patient  was  faint  after  the  operation,  but  rallied  quickly  after 
food  and  brandy  had  been  given.  He  was  led  by  a  tube  through 
the  nose  with  three  ounces  of  milk,  one  of  lime-water,  and  two 
teaspoonfuls  of  brandy  at  intervals  of  four  hours. 

The  child  improved  slowly ;  a  few  pieces  of  membrane  were 
coughed  up  and  the  dyspncea  decreased.  The  wound,  however, 
was  unhealthy,  and  on  the  29th  became  covered  with  a  diphthe- 
ritic slough.  The  child  continued  to  hold  its  ground,  and  took 
its  food  by  the  tube  without  vomiting.  On  the  30th  several 
attacks  of  dyspnoea  occurred,  chiefly  on  account  of  the  difficulty 
in  coughing  up  mucus,  which  continually  clogged  the  tube.  On 
July  2d  the  wound  presented  the  appearance  of  a  large  ragged 


86  The  Afler-Tveafment  of  Tracheotomy. 

ulcer  witli  unlicalthy  granulalions  covered  with  a  slough.  The 
ulcer  was  deep,  almost  laying  bare  the  cricoid  cartilage. 

The  child  breathed  for  several  hours  without  the  tube,  but 
was  unable  to  do  so  through  the  inoutli  when  the  o})ening  in 
the  trachea  was  closed.  With  the  tube  out  all  went  on  well  until 
evening,  but  at  5.30  p.m.  a  sudden  attack  of  dyspnoea  occurred, 
Ihe  wound  appearing  to  close  up  suddenly  and  spasmodically. 
The  tube  (Baker's)  was  ])ut  back,  and  the  dyspnoea  increasing, 
a  silver  one  was  substituted.  A  feather  passed  into  the  trachea 
did  not  clear  it  of  nuicus, and  the  cliild  ceased  bieathing.  Arti- 
ficial respiration  was  resorted  to,  and  meanwhile  a  soft  elastic 
lube  with  a  brass  syringe  attached  was  prepared  and  introduced 
into  the  trachea.  Powerful  suction  was  applied  by  exhaust- 
ing the  syringe  with  the  tube  pinched  between  the  thumb 
and  forefinger,  and  then  suddenly  let  go  and  drawn  out  slowly. 
By  this  means  a  large  amount  of  mucus  was  extracted  from  the 
trachea.  The  child  gave  one  gasp  after  the  tube  was  removed, 
and  artificial  respiration  was  continued.  A  second  application 
of  suction  by  similar  means  was  moi-e  successful,  and  the  child 
gave  another  breath  and  soon  rallied.  The  exhaustion  con- 
sequent on  this  attack  passed  off  by  the  following  day.  The 
wound  improved  and  gradually  closed  in.  On  the  5th  a  similar 
attack  of  dyspncea  occurred  suddenly  while  the  tube  was  out, 
but  it  was  replnced  before  breathing  ceased,  and  the  child 
recovered  more  rapidly. 

On  the  loth  the  urine  for  the  first  time  yielded  a  cloud 
of  albumen.  The  wound  externally  looked  more  healthy,  but 
granulations  could  be  distinctly  seen,  almost  clossing  the  opening 
into  the  larnyx  from  below.  These  granulations  were  cauterised 
every  few  days  with  chromic  acid  fused  on  the  end  of  a  probe, 
but  still  the  child  was  unable  to  breathe  for  more  than  a  short 
time  without  the  tracheotomy  tube.  The  health  of  the  patient 
improved  greatly;  its  eyes  became  completely  well,  and  by  the 
beginning  of  August  the  only  difficulty  thnt  remained  was  the 
inability  to  remove  the  tracheotomy  tube.  The  patient  having 
been  nearly  six  weeks  without  food  given  by  the  mouth,  and  being 
able  to  swallow  without  difficulty,  was  now  fed  partially  with 
semi-solid  food,  and  gradually  the  feeding  by  the  tube  was  dis- 
continued. After  the  i8th  inst.  he  took  food,  both  solid  and  liquid, 
naturally  by  the  mouth,  and  was  allowed  to  run  about  the  ward. 

The  removal  of  the  tube  is  still  impossible  (November).  There 
is  some  obstruction  due  to  granulations  which  partially  close  the 
opening  into  the  larynx  from  below,  but  since  the  beginning  of 
September  there  has  been  some  voice  and  a  noisy  cough  when 
the  tube  is  withdrawn  and  the  opening  closed.     The  child,  how- 


The  After-Treatment  of  Tracheotomy.  87 

ever,  is  so  frightened  that  it  does  not  try  to  breathe  without  the 
tube,  and  the  edges  of  the  opening  are  at  once  spasmodically 
closed  a  few  seconds  after  its  removal.  This  has  been  overcome, 
during  November  by  gradually  shortening  the  soft  india-rubbe.u 
tracheotomy  tube  (Baker's). 

The  child  can  now  breathe  better  without  the  tube,  but  not 
for  any  length  of  time.  More  voice  has  been  heard  during  the 
last  few  days  when  the  opening  is  closed.  He  has  been  in  good 
health  and  has  taken  food  well  since  the  early  part  of  August, 
but  cannot  be  discharged  on  account  of  the  difficulty  with  the 
tracheotomy  tube. 

Case  V. 

C.  M.,  aged  2  years  7  months,  was  brought  to  the  surgery 
ou  October  29th  with  a  croupy  cough  and  very  slight  dyspnoea. 
There  was  no  membrane  visible,  and  no  congestion  of  the  fauces 
or  pharynx,  nor  was  there  any  enlai-gement  of  the  cervical  glands-. 
The  temperature  was  slightly  raised,  being  somewhat  above  99°; 
The  lower  ribs  were  slightly  drawn  in  during  inspiration.  Over 
the  whole  chest  were  abundant  moist  sounds  and  rhonchus,  but 
there  was  no  dulness  on  percussion,  and  no  bronchial  breathing. 
The  patient  living  close  to  the  hospital,  the  mother  was  told  to 
bring  it  back  if  it  became  worse. 

The  child  was  admitted  on  the  evening  of  October  30th  with 
great  dyspnoea,  accompanied  by  extreme  bilateral  recession  of 
the  chest,  with  "pulsus  paradoxus,"  a  complete  intermission  of 
one  or  two  beats  occurring  with  each  recession.  The  voice  and 
cough  were  croupy,  the  breathing  stridulous,  and  the  face  livid. 
The  dyspnoea  and  recession  increasing,  tracheotomy  was  per- 
formed at  9  P.M.  The  child  ceased  breathing  before  the  trachea 
was  opened,  but  when  the  tube  was  put  in  it  recovered  after 
artificial  respiration.  Feeding  by  a  tube  through  the  nose  was 
commenced  shortly  after  the  operation,  and  continued  every 
four  hours  subsequently.  Five  ounces  were  given  at  a  time 
with  a  teaspoonful  of  brandy  and  its  medicine  (five  minims  of 
the  tincture  of  perchloride  of  iron). 

The  child  was  fairly  comfortable  during  the  night  and  the 
whole  of  the  following  day  except  for  occasional  attacks  of 
coughing.  On  November  ist  a  cast  of  a  small  bronchus  was 
coughed  up.  No  difficulty  occurred  with  feeding,  the  child 
almost  sleeping  during  the  process. 

On  the  evening  of  November  ist  a  fit  of  dyspnoea  came  on, 
the  patient  becoming  livid,  with  much  recession  of  the  chest. 
Feathering  the  trachea  gave  no  relief,  but  by  means  of  a  sofi. 
rubber  catheter  at  the  end  of  a  brass  syringe  suction  was  apT 


88  The  After- Treatment  of  Tracheotomy. 

plied.  Several  large  pieces  of  membrane  and  a  good  deal  of 
mucus  were  drawn  up,  and  one  cast  of  a  large  bronchial  tube 
about  an  inch  and  a  half  in  length.  The  patient  improved 
after  this,  but  the  pulse  was  very  feeble  and  the  respiration* 
still  hurried  (sixty-four  to  the  minute).  A  few  hours  later  the 
dyspnoea  returned,  and  the  same  process  was  again  successfully 
repeated.  Some  obstruction,  howevei",  remained,  and  a  larger 
silver  tracheotomy  tube  w<is  therefore  inserted.  After  another 
application  of  the  soft  calheter  the  child  was  left  breathing 
quietly  and  easily.  At  5  A..M.  on  the  following  morning,  Nov- 
ember 2d,  the  same  alarming  symptoms  returned,  but  were 
relieved  by  suction  with  the  tube  in  the  same  fashion. 

On  the  3d  and  4th  occasional  slighter  attiicks  occurred  every 
few  hours.  Small  lumps  of  mucus  were  expelled,  and  no  mem- 
brane. On  the  5th  it  was  noticed  that  the  dyspnoea  was  greatest 
immediately  before  the  hour  for  feeding.  Food  w^as  therefore 
given  by  the  tube  at  inteivals  of  three  instead.of  four  hours,  with 
distinct  improvement.  On  the  same  day  the  urine  contained  a 
trace  of  albumen.  The  child  now  improved  rapidly,  the  wound, 
which  had  previously  looked  luihealthy  and  inclined  to  slough, 
began  to  contract.  The  granulations  were,  however,  exuberant, 
.and  protruded  into  the  trachea.  On  the  i  ith  inst.  some  voice  was 
heard,  but  the  child  was  unable  to  breathe  without  the  tracheo- 
tomy tube  altogether.  Since  the  attacks  of  dyspnoea  on  the  5th 
a  Baker's  tube  was  substituted  for  the  silver  one.  By  November 
17th  the  wound  had  healed,  except  at  the  opening  for  the  tracheo- 
tomy tube.  The  child  can  now  cry  loudly  if  the  opening  is  closed 
with  the  finger  after  removing  the  tube,  but  cannot  breathe 
through  the  mouth  for  more  than  a  few  minutes. 

On  tlie  20th  the  tracheal  opening  was  closed  with  a  pad  for 
several  hoins  at  intervals,  the  tracheotomy  tube  having  to  be  put 
back  occasionally  for  a  few  minutes.  The  Baker's  tube  has  now 
been  shortened  to  about  half  an  inch  in  length,  and  is  put  in 
during  the  night,  and  when  necessary  during  the  day.  It  is  still 
not  safe  to  allow  the  opening  in  the  trachea  to  close,  but  it  is  hoped 
that  the  difficulty  will  be  overcome  in  the  course  of  a  few  days. 

Feeding  by  the  catheter  is  still  employed.  The  child  has  taken 
no  food  by  the  mouth  since  the  operation  was  performed. 

The  cases  that  I  have  thus  detailed  will,  I  think,  demonstrate',, 
firstly,  the  value  of  the  nasal  feeding,  especially  in  young  sub- 
jects, not  as  a  substitute  for  other  modes  of  treatment,  but  as  an 
important  addition;  and,  secondly,  the  superiority  of  the  use 
of  an  exhausting  syringe  over  other  methods  for  the  removal 
of  obstruction  below  the  opening  in  the  trachea  when  simpler 
means  fail. 


TWO  CASES  OF  PARASITIC  HiEMATURIA. 


NOEMAN  MOOEE,  M.D. 


On  July  i8,  1885,  Denis  M.,  aged  61  years,  a  teacher  of 
music,  came  to  the  casualty  department  of  St.  Bartholomew's 
Hospital  suffering  from  hsematuria.  He  related  that  he  had 
had  hsematuria  for  eighteen  months,  and  that  it  had  heea 
absolutely  continuous,  except  for  three  days  in  the  middle  of 
this  period.  He  had  never  had  hsematuria  before,  but  eight 
years  ago  had  passed  three  small  calculi,  which  he  brought 
with  him.  He  looked  pale,  and  said  that  he  was  exhausted, 
but  had  no  pain.  He  also  complained  of  indigestion.  During 
the  period  of  his  haBmaturia  he  had  never  passed  a  calculus, 
jind  when  he  passed  the  three  calculi  he  brought  he  had  no 
hsematuria.  He  had  never  suffered  from  renal  colic.  The 
quantity  of  blood  in  the  urine  was  large.  He  stated  that  he 
had  been  bandmaster  in  the  90th  regiment,  and  that  he  had 
served  in  Canada  from  1852  to  1858,  in  the  West  Indies  in 
1861,  and  in  South  Africa,  including  Natal,  from  1864  to  1868. 
In  1868  he  was  at  Pietermaritzburg,  thence  came  home,  and 
had  never  been  abroad  since.  He  had  never  had  ague,  and 
never  dysentery,  and  had  generally  enjoyed  good  health.  I 
examined  his  urine,  and  found  many  red  blood  corpuscles  and 
some  blood  casts,  but  nothing  more,  and  on  July  20  admitted 
him  into  John  Ward.  On  examining  him  in  bed,  his  chest 
and  abdomen  were  found  to  give  none  but  normal  physical 
signs.  The  calculi  consisted  chiefly  of  uric  acid.  Mr.  S.  K. 
Alcock  was  so  good  as  to  prepare  a  microscopic  section  of  one 
for  me,  but  in  rubbing  it  down,  the  nucleus,  whatever  it  was, 
dropped  out.  In  the  ward  the  urine  invariably  presented  the 
characters  at  first  observed.  It  was  of  a  bright  red  colour,  and 
contained  great  numbers  of  red  blood  corpuscles,  with  many 
j)lood  casts  and  some  gianular  casts.     Now  and  then  it  was 


90  Tivo  Cases  of  Parasitic  Hematuria. 

slightly  paler,  but  was  always  red.  It  also  contained  almost 
every  time  it  was  examined  numerous  ova  and  embryo  cases 
of  Bilharzia,  These  presented  all  the  usual  forms,  but  were 
for  the  most  part  embryo-shells,  though  many  active  embryos 
were  at  times  also  to  be  seen.  After  a  dose  of  ten  grains  of 
santonin  night  and  morning,  two  days  later  reduced  to  five 
grains,  the  urine  became  much  paler,  but  on  continuing  the 
santonin  the  change  for  the  better  did  not  continue;  and  as 
it  caused  dimness  of  vision,  vomiting,  and  general  disturbance 
of  digestion,  I  did  not  continue  to  administer  it.  During  the 
Ihirty-five  days  that  he  was  in  the  hospital,  bis  evening  tem- 
perature was  on  twenty-eight  days  from  one-third  of  a  degree 
to  a  degree  above  the  normal  temperature.  He  had  no  diarrhoea. 
His  daily  quantity  of  urine  was  on  an  average  a  little  over  three 
pints.  When  he  left,  on  August  24,  1885,  his  urine  was  still 
bright  red,  and  contained  abundant  embryos.  His  digestion 
had  improved  slightly,  but  otherwise  he  was  in  the  same  con- 
dition as  on  admission. 

The  second  case  was  also  that  of  an  old  soldier,  Kichard  H., 
aged  55  years,  who  since  he  had  left  the  army  had  been  a  labourer. 
When  he  came  to  the  casualty  department  on  August  27,  1885, 
he  was  suffering  from  hpematuria,  which  he  had  had  for  seven 
months.  He  said  that  at  first  the  blood  only  came  on  at  the 
end  of  micturition,  but  that  after  a  short  time  it  persisted 
throughout  micturition.  He  had  had  no  renal  colic,  no  rigors, 
and  no  vomiting,  and  had  never  had  haematuria  before.  He 
had  been  in  the  Royal  Artillery,  and  in  1854  was  sent  to  Bengal, 
and  served  in  the  Indian  mutiny  with  the  Malwa  field-force. 
While  in  India  he  had  ague.  In  i860  he  served  at  Gibraltar, 
and  had  remittent  fever  there.  From  1864  to  1869  he  was  in 
Mauritius,  and  there  had  ten  attacks  of  fever.  In  1869  he 
was  at  the  Cape,  and  came  home  thence  in  1872,  and  had 
had  good  health  from  1872  till  seven  months  before  coming 
to  St.  Bartholomew's.  He  was  sure  that  he  had  never  had 
lijematuria  while  abroad.  He  said  that  in  India  he  had  drank 
freely,  but  had  never  been  so  drunk  during  the  mutiny  as  to 
be  unable  to  go  into  action.  1  admitted  him  to  John  Ward, 
August  28,  1885.  He  had  well-marked  aortic  obstruction, 
but  except  the  systolic  basic  murmur,  physical  examination 
showed  nothing  abnormal  in  his  chest  or  abdomen.  His  urine 
was  of  a  dark-red  coloin-,  and  at  the  time  of  passing  contained 
numerous  blood-clots.  Microscopic  examination  showed  abim- 
dant  red  corpuscles  and  a  few  separate,  apparently  epithelial, 
<;ells.     On  September  2d  one  hyaline  cast  was  found.      On  the 


Tloo  Gases  of  Parasitic  Hcematuria.  91 

next  day  I  found  several  granular  casts  and  a  single  bod}'  shaped 
like  Paramecium  bursaria,  but  with  a  small  terminal  process 
and  granular  contents.  When  first  passed,  the  urine  was  of 
a  very  bright  red  colour.  On  September  4tli  I  found  three 
well-marked  ova  of  Bilharzia  hsematobia  in  the  urine.  The 
quantity  of  urine  was  usually  about  i  to  i|^  pints  a  day,  and  his 
temperature  was  not  raised.  A  dose  of  five  grains  of  santonin 
given  three  times  a  day  was  followed  by  a  slight  increase  in  the 
quantity  of  urine,  but  by  no  other  change,  and  no  diminution 
of  blood.  On  September  loth  ova  of  Bilharzia  were  very  abun- 
dant, and  were  again  so  on  the  12th.  On  the  i6tli  he  went  out  of 
the  hospital,  still  passing  a  large  quantity  of  blood  daily. 

Since  the  discovery  of  the  parasite  which  causes  the  endemic 
!i£ematuria  of  several  hot  countries  by  Bilharz  in  185 1  (pub- 
lished in  "  Zeitschrift  fiir  Wissenschaftliche  Zoologie,"  1853), 
gradual  additions  have  been  made  to  our  knowledge  of  the 
clinical  features  of  the  disease,  and  these  two  cases  seem  to  add 
one  important  fact  to  those  already  known.  They  show  that 
the  parasite  may  live  in  the  patient's  body  for  a  longer  time  than 
has  hitherto  been  supposed.  Dr.  Harley  and  Dr.  Eoberts  mention 
several  months  as  elapsing  between  infection  and  the  first  attack 
of  heematuria.  Dr.  Guillemard  speaks  of  nine  months ;  while  in 
the  interesting  case  described  by  Dr.  Arthur  Davies  in  the  St. 
Bartholomew's  Hospital  Keports  for  1884,  it  is  possible,  though 
not  certain,  that  the  first  attack  of  hcematuria  took  place  three 
years  after  infection. 

In  the  two  cases  described  in  this  paper  the  interval  between 
infection  and  the  first  attack  of  hsematuria  was  much  longer. 
Denis  M.  could  not  have  acquired  the  parasite  later  than  1868, 
while  his  first  attack  of  hsematuria  was  in  1884.  Eichard  H.  may 
have  received  the  parasite  in  1869  in  Mauritius,  or  before  leaving 
the  Cape  in  1872,  while  his  first  attack  of  hsematuria  was  in 
1885.  Thus  in  the  first  case  the  interval  between  the  infection 
by  Bilharzia  and  the  onset  of  heematuria  was  at  least  fifteen 
years,  while  in  the  second  case  it  was  at  least  twelve  years.  Both 
patients  were  men  of  good  intelligence,  whose  accounts  might 
fairly  be  trusted. 

Dr.  Zancarol  of  Alexandria  states  that  it  is  common  to  find 
vesical  calculi  in  Egyptians  who  have  died  with  parasitic 
haamaturia,  and  in  whose  bladder  walls  the  ova  of  Bilharzia  are 
to  be  found  post-mortem.  The  case  of  Denis  M.  illustrates  the 
fact  that  these  calculi  may  be  formed  before  any  liEematuria  has 
taken  place.  I  consider  their  occurrence  as  strong  confirmatory 
evidence  of  the  supposition  that  the  patient  had  abundance  of 


92  Ttuo  Cases  of  Pavasitic  Hcematuria. 

ova  ia  bis  body  many  years  before  tlie  onset  of  ba^maturia. 
Tbere  seems  every  reason  to  believe,  wiLb  Dr.  Cobbold,  that  tbe 
parasite  finds  its  way  into  tbe  body  thronj^b  tbe  aUmentary 
canal.  That  its  ova  live  very  well  in  almost  any  tissue,  I 
feel  sure  from  an  examination  of  more  tban  a  bundred  micro- 
scopic sections  of  some  pieces  of  abdominal  tissues  kindly  sent 
to  me  by  \)y.  Zancarol.  These  were  pieces  of  small  intestine, 
mesentery,  bladder,  ureters,  and  kidney.  In  all  tbe  ova 
were  abundant.  The  walls  of  tbe  bladder  in  some  sections 
sbowed  abumlant  ova  close  to  tbe  peritoneal  surface,  and 
actually  in  tbe  peritoneum.  Tbe  same  was  the  case  witb  tbe 
ureters.  In  the  small  intestine  the  ova  were  often  abundant 
in  all  parts  of  tbe  intestinal  wall  except  tbe  epithelium  of  the 
mucous  membrane.  They  were  often  to  be  seen  in  tbe  sub- 
stance of  the  villi  and  between  Lieberkiihn's  crypts.  Tbey 
seemed  sometimes  to  have  pushed  up  the  epithelial  cells  from 
tbe  crypt  wall.  In  a  very  few  instances  I  saw  them  in  or  between 
epithelial  cells.  These  specimens  illustrated  tbe  fact  tbat  tbe 
ova  of  Bilharzia  may  stay  for  a  long  time  in  other  tissues 
before  reaching  tbe  kidney,  and  this  is,  I  believe,  the  explanation 
of  tbe  long  interval  between  the  time  of  infection  and  tbe  onset 
of  bsematuria  in  my  two  cases.  The  bearing  of  this  fact  on 
treatment  is  obvious.  No  one  who  had  looked  at  many  sucli 
microscopic  sections  would  think  of  treating  parasitic  hcematuria 
by  injections  into  tbe  bladder.  How  can  the  injection  reacb  the 
peritoneal  surface  of  the  bladder,  the  mesentery,  or  tbe  muscular 
coat  of  the  small  intestine  ?  Yet  these  parts  are  quite  as  likely  to 
be  studded  witb  ova  as  the  mucous  membrane  of  the  bladder. 

Santonin  has  sucb  a  general  effect  on  the  system  that  tbere 
seemed  some  liope  tbat  it  might  act  as  a  paraciticide  on  the 
Bilharzia,  in  whatever  tissue  living,  but  the  result  in  these  two 
cases  was  not  encouraging.  In  October  1885  I  asked  Dr.  Guille- 
mard  tbe  event  of  the  case  so  clearly  described  by  him  in  bis  admir- 
able tbesis  "  On  tbe  Endemic  Hematuria  of  Hot  Climates,"  and 
he  informed  me  that  the  patient,  who  bad  acquired  the  parasite 
in  1878,  is  still  living  in  fair  health,  and  that  he  occasionally 
passes  embryos  of  Bilharzia  in  his  urine.  This  case  has  there- 
fore lasted  seven  years,  while  the  two  described  in  this  paper 
have  lasted  respectively  fifteen  and  thirteen  years,  thus  proving 
that  while  the  specific  treatment  of  endemic  ha3maturia  has  yet 
to  be  discovered,  the  prognosis  of  the  disease  for  patients  who 
come  to  live  in  a  temperate  climate  is  not  bad  as  regards  the 
continuance  of  life,  and  that  while  the  presence  of  the  parasite 
certainly  impairs  the  patient's  strength,  he  may  witb  moderate 
care  be  able  to  work  for  bis  livinfi:. 


SOME   CASES 


SCLEROSIS    OF    THE    SPINAL    CORD. 


AECHIBALD  E.  GAKROD,  M.B. 


I  am  indebted  to  Dr.  Duckworth  and  Dr.  Norman  Moore  for 
permission  to  publish  the  following  cases. 

During  the  present  year  a  considerable  number  of  interesting 
cases  of  diseases  dependent  upon  sclerotic  changes  in  the  spinal 
cord  have  been  treated  in  John  Ward,  and  amongst  them  no 
less  than  four  of  disseminated  cerebro-spinal  sclerosis.  These 
have  all  a  common  point  of  interest,  viz.,  that  the  tremors  were 
either  entirely  confined  to  one  side  of  the  body,  or  affected  one 
side  much  more  than  the  other.  In  no  one  of  the  cases  was 
there  any  nystagmus,  a  symptom  which  appears  to  be  absent 
in  a  much  greater  number  of  cases  of  this  disease  than  is  usually 
supposed. 

Tlie  first  case  is  that  of  T.  P.,  a  stone-mason,  who  was  admitted 
to  John  Ward,  under  the  care  of  Dr.  Norman  Moore,  in  June 
1885. 

The  earliest  symptom  which  he  had  noticed  was  pain  in  the  left 
arm  and  leg,  from  which  he  began  to  suffer  some  twelve  months 
before  admission.  A  month  later  he  noticed  that  he  could  not 
chisel  so  well  as  before  on  account  of  a  tremulousness  of  his  left 
arm,  and  when  in  bed  he  suffered,  from  spastic  contractions  of 
the  corresponding  leg.  Three  months  later  he  had  a  sudden 
attack  of  twitching  in  the  limbs  of  the  left  side,  with  spasm  of 
the  fingers,  which  grasped  the  stone  upon  which  he  was  working 
so  forcibly  that  he  was  obliged  to  release  it  with  his  right  hand ; 
moreover,  on  attempting  to  walk  he  staggered.  The  attack 
lasted  some  ten  minutes,  and  then  passed  off. 

Since  then  he  has  had  several  such  attacks,  always  preceded  by 
a  kind  of  aura,  a  sensation  of  '•'  pins  and  needles,"  beginning  in  the 


94  Scl€7'0sis  of  the  Spinal  Cord. 

left  foot  and  extendiug  upwards  as  far  as  the  left  side  of  the 
face.  After  the  first  attack  he  noticed  that  his  speech  was 
afiected,  and  it  has  remained  so  ever  since.  His  mental  facul- 
ties were  somewhat  impaired,  and  he  was  very  irritable. 

On  admission  the  knee-jerks  were  found  to  be  greatly  exag- 
gerated, and  ankle-clonus  was  elicited  on  the  left  side. 

The  tremors  affected  all  the  limbs,  but  were  far  more  marked 
in  those  of  the  left  side.  Any  attempt  at  use  of  the  limbs 
increased  the  tremors  enormously.  The  left  side  of  the  face 
twitched  constantly,  and  the  tongue  was  very  tremulous  when 
protruded.  Both  eyelids  were  similarly  ad'ected,  and  action  of 
the  orbicularis  greatly  increased  the  movements. 

There  was  no  nystagmus,  the  oi)hthalmoscope  showed  nothing 
abnormal,  and  the  pupils  reacted  naturall3^ 

His  gait  was  tremulous  and  uncertain,  but  improved  after  the 
first  few  steps. 

Tiie  speech  had  the  peculiar  scanning  character  characteristic 
of  his  disease. 

His  irritable  temper  made  him  very  difficult  to  manage,  and 
in  a  few  days  he  discharged  himself  from  the  hospital. 

At  the  end  of  September  he  was  again  admitted  under  the 
care  of  Dr.  Duckworth,  when  the  tremors  were  found  to  have 
increased  in  severity  and  range,  so  that  he  was  no  longer  able 
to  feed  himself.  Ankle-clonus  was  then  obtained  on  both  sides, 
being  still  more  marked  on  the  left. 

Nystagmus  was  still  absent,  and  the  optic  discs  were  natural. 
He  remained  in  hospital  about  a  fortnight,  and  was  then  dis- 
charged at  his  own  request.  During  his  stay  the  temperature 
was  usually  slightly  raised,  100.2°  being  the  highest  record. 
His  urine  contained  a  trace  of  albumen. 

As  there  was  a  history  of  syphilis^  he  was  at  first  treated  with 
potassium  iodide.  On  readmission  he  was  given  hyoscyamus, 
taking  nine  grains  of  the  extract  daily,  but  his  stay  was  too 
short  to  give  a  fair  trial  to  the  drug. 

In  the  three  following  cases  the  tremors  were  entirely  confined 
to  the  right  side  of  the  body  : — 

G.  E.,^  a  groom,  aged  21,  was  admitted  to  John  Ward  under 
the  care  of  Dr.  Duckworth  in  February  1885.  Nine  months 
previously  tremors  had  commenced  in  the  right  arm,  and  three 
months  later  the  leg  had  been  similarly  affected. 

He  was  a  healthy-looking  well-nourished  man.  The  speech 
was  natural,  and  the  face  and  tongue  were  free  from  all  tremor. 
The  right  arm  and  leg  remained  quite  still  when  at  rest,  but  on 

^  This  case  was  the  subject  of  a  clinical  lecture  by  Dr.  Duckworth,  whicli  may 
be  found  in  the  Lancet  (May  1885). 


Sclerosis  of  the  Spinal  Cord.  95 

any  attempt  to  use  them  they  performed  a  variety  of  irregular  and 
incoordinate  movements.  The  gait  was  rigid,  the  right  leg 
moving  in  an  ataxic  manner,  and  dragging  as  he  walked.  The 
knee-jerks  were  increased,  especially  on  the  right,  but  there  was 
no  ankle-clonus.  There  was  no  history  of  syphilis  nor  of  injury 
to  the  head.  Here  again  there  was  no  trace  of  nystagmus,  nor 
were  there  any  ophthalmoscopic  changes. 

An  electrical  examination  made  by  Dr.  Steavenson  showed  that 
the  muscles  of  the  right  arm  and  leg  reacted  naturally  both  to 
the  continuous  and  interrupted  currents,  and  that  electric  sensi- 
bility was  unimpaired. 

Any  attempt  to  write  with  the  right  hand  resulted  in  a  con- 
fused mesh  work  of  erratic  scratches,  but  he  had  trained  himself 
to  write  legibly  with  his  left.  He  remained  in  the  hospital 
three  months,  and  was  treated  with  faradisation,  with  conium 
in  large  doses,  and  with  physostigma  (taking  at  one  time  as 
much  as  a  grain  of  the  extract  daily).  The  pupils  responded 
very  slightly  to  these  drugs,  even  when  he  was  taking  the  largest 
doses,  and  he  left  with  very  little  alteration  in  his  condition. 

J.  K.,  a  quarryman,  aged  25,  who,  like  the  last  patient,  came 
from  a  rural  district  of  Wiltshire,  was  admitted  to  John  Ward, 
under  the  care  of  Dr.  Duckworth,  in  October  1885.  Like  the 
last  patient,  he  had  tremors  of  the  right  arm  and  leg  only. 

The  tremors  began  in  December  1882,  after  he  had  been 
pulling  at  a  crane,  and  he  was  treated  at  that  time  in  the  Bath 
Hospital  with  considerable  benefit.  In  the  following  June  the 
tremors  became  aggravated,  and  he  was  a  second  time  obliged  to 
give  up  work  for  a  time,  but  in  ten  days  the  attack  had  subsided, 
only  to  return  again  in  June  1885  after  some  heavy  lifting. 

The  right  eye  was  constantly  opened  and  closed  by  a  twitching 
movement,  and  there  were  slight  uncertain  movements  of  the 
eyeballs,  which  did  not,  however,  amount  to  nystagmus.  The 
speech  was  unaffected,  and  the  tongue  was  quiet  when  protruded. 
The  ophthalmoscope  showed  nothing  abnormal.  The  tremors  of 
the  right  arm  and  leg  w^ere  much  exaggerated  on  exertion; 
sensation  in  the  limbs  was  unimpaired,  and  there  was  no  mus- 
cular wasting.  The  urine  deposited  crystals  of  calcium  oxalate. 
By  resting  upon  his  right  elbow  the  movements  of  the  right  arm 
were  so  much  controlled  that  the  patient  was  able  to  write  a 
fairly  good  hand. 

During  his  stay  of  one  month  in  the  hospital  this  patient  was 
treated  with  belladonna  in  gradually  increasing  doses,  which 
reached  at  the  time  of  his  discharge  a  grain  of  the  extract  three 
times  a  day.  His  condition  had  greatly  improved,  for  whilst 
the  dynamometer  showed  increased  power  in  his  hands,  the 


g6  Sclerosis  of  the  Spinal  Cord. 

exaggeration  of  tlie  knee-jerks  had  disappeared,  and  the  tremors 
were  much  reduced. 

The  last  case  resembles  closely  the  last  two,  but  is  that  of  a 
considerably  older  man. 

E.  H.,  a  shipwright,  aged  49,  was  admitted  to  John  Ward, 
under  the  care  of  Dr.  Norman  Moore,  in  August  1885. 

Three  months  before  admission  the  patient  noticed  tremors  in 
the  right  hand  on  exertion,  and  two  months  later  they  began  to 
aflfect  the  right  leg  also,  the  left  side  of  the  body  remaining 
unaffected,  with  the  exception  of  slight  tremulousness  of  the 
left  arm.  The  pupils  reacted  naturally ;  there  was  no  nystag- 
mus, and  the  ophthalmoscope  showed  nothing  abnormal. 

The  tendon-reflexes  were  not  increased,  and  there  was  no 
ankle-clomis ;  nor  was  there  any  change  in  the  electrical  reac- 
tions, nor  muscular  wasting. 

The  speech  was  natural,  and,  with  the  exception  of  slight 
tremor  of  the  tongue,  the  head  and  neck  were  unaffected. 

The  temperature  remained  normal  and  subnormal. 

This  patient  remained  in  the  Hospital  about  a  month  without 
any  improvement,  and  at  the  ])resent  time  there  is  very  little 
alteration  in  his  condition  to  be  observed. 

In  July  1885,  a  patient  was  admitted,  under  Dr.  Duckworth, 
suffering  from  lateral  spinal  sclerosis,  who  had  the  characteristic 
symptoms  of  this  disease  developed  in  a  remarkable  degree.  He 
was  a  labourer,  aged  29,  who  had  suffered  from  occasional  dorsal 
and  lumbar  pains  for  three  or  four  years.  Latterly  he  had  been 
free  from  pain,  but  for  five  months  previous  to  his  admission  had 
noticed  failure  of  power  in  his  legs,  and  for  a  week  he  had  noticed 
tremors  in  the  hands  on  making  an  effort. 

There  was  no  nystagmus,  and  the  discs  were  natural. 

There  was  some  tremor  of  the  tongue. 

Fibrillary  twitchings  of  the  muscles  were  observed;  all  his 
tendon-reflexes  were  much  exaggerated,  and  on  tapping  the 
patellar  tendon,  violent  knee-clonus,  which  lasted  for  a  consider- 
able time,  was  induced.  A  similar  result  was  obtained  with  the 
trice])s  muscles  of  both  arms. 

Ankle-clonus  was  well  marked. 

The  gait  was  in  the  highest  degree  spastic,  the  legs  being 
separated  only  to  a  minimum  extent,  whilst  the  patient  could 
only  get  up  on  a  chair  with  the  greatest  effort. 

An  electrical  examination  of  the  muscles  was  made  by  Dr. 
Steavenson,  who  reported  that  all  the  limbs  reacted  normally  to 
the  continuous  current,  and  that  there  was  no  increase  of  irrita- 
bility. 

Strong   currents   produced    violent   tremors  in  one  or  other 


Sclerosis  of  the  Spinal  Cord.  97 

of  the  limbs,  not  necessarily  that  which  was  being  tested  at 
the  time.  Faradic  contractility  and  electro-sensibility  were 
natural. 

Although  no  history  of  syphilis  was  obtained,  some  scars  on 
the  legs  led^  to  the  adoption  of  anti-syphilitic  treatment,  and 
during  his  stay  in  the  hospital  he  improved  considerably  upon 
the  iodides  of  potassium  and  sodium. 

Two  cases  of  locomotor  ataxia  which  presented  abnormal 
features  will  form  a  fitting  appendix  to  the  above  cases.  Of 
these,  one  is  remarkable  from  the  supervention  of  paraplegia 
shortly  before  the  death  of  the  patient,  whilst  in  the  second  we 
had  an  opportunity  of  witnessing  a  series  of  attacks  which  may 
be  described  as  ataxic  storms  of  a  transient  character,  during 
which  all  the  symptoms  were  greatly  exaggerated. 

A.  T.,  a  cabinetmaker,  aged  30,  had  been  in  Raliere  Ward, 
under  Mr.  Morrant  Baker,  in  February  1885,  for  a  perforating 
ulcer  of  the  left  great  toe.  At  that  time  the  knee-jerks  were 
abolished,  and  he  suffered  from  lightning  pains. 

On  April  20th  he  had  an  attack  of  vomiting,  with  lightning 
pains  in  the  legs,  and  girdle  pain.  On  the  22d  he  lost  power 
in  both  legs,  but  there  was  no  loss  of  sensation.  On  the  24th 
the  paralysed  limbs  "jumped  "  a  good  deal,  and  three  days  later 
bedsores  began  to  form. 

On  May  ist  he  was  admitted  to  John  "Ward  with  complete 
loss  of  power  in  both  lower  limbs,  with  no  loss  of  sensation,  and 
exaggeration,  if  anything,  of  the  superficial  reflexes. 

The  knee-jerks  were  entirely  absent.  The  pupils  reacted  to 
accommodation,  but  not  to  light.  There  was  a  prsesystolic  apex 
murmur  and  a  thrill.  A  large  bedsore  covered  the  sacral  region 
and  extended  to  the  buttocks,  and  there  was  a  second,  smallei', 
on  the  right  hip. 

The  sphincters  were  paralysed. 

The  temperature  was  104.2°  on  admission,  and  the  pulse  118 
to  the  minute,  small,  soft,  and  regular. 

The  bedsores  were  carefully  treated,  and  began  to  improve 
slightly  soon  after  admission. 

On  May  5th  he  had  a  rigor,  during  which  his  temperature, 
which  had  been  raised  since  admission,  rose  to  103°,  and  these 
rigors  recurred  frequently  during  the  remainder  of  his  life. 

A  few  days  later  there  was  some  haemorrhage  from  a  vessel 
laid  open  by  the  detachment  of  slough  from  the  large  bedsore, 
but  it  was  soon  checked  with  ice. 

On.  the  17th  vomiting  commenced,  and  as  this  continued,  he 
was  fed  with  nutrient  suppositories, 

VOL.  XXL  G 


98  Sclcros's  of  the  Spinal  Cord. 

On  tlie  23(1  tliore  was  some  more  liremoirhage  from  the  bed- 
sore, wliich  was  discharging  freely. 

From  this  lime  he  rapidly  sank,  and  eventnally  died  on  Jnne 
I4tli.     Unfortnnately  there  was  no  post-mortem  examination. 

W.  H.,  bookkeeper,  aged  42,  was  bronght  to  the  surgery  by  a 
policeman  on  the  evening  of  July  i,  1885.  He  had  not  been 
feeling  well  during  the  afternoon,  and  whilst  making  his  way  to 
ihe  office-door  on  leaving  work  had  had  two  or  three  fits,  in 
which  he  fell  down  and  lost  consciousness.  He  eventually 
succeeded  in  reaching  the  door,  and  locked  it  behind  him,  but 
fell  in  the  passage  in  another  fit.  On  admission,  he  seemed  to 
1)6  in  an  exhausted  condition,  and  on  attem])ting  to  walk 
with  help,  was  seized  w^itli  a  sort  of  exaggerated  "petit  mal," 
losing  con.-ciousness  for  a  time  and  falling.  He  gave  no  cry, 
but  the  fit  was  preceded  by  an  ill-defined  aura,  and  during  the 
period  of  unconsciousness  tlie  arms  made  a  few  clonic  move- 
ments. The  radial  pulse  could  not  be  felt  during  the  fit.  On 
one  occasion  he  vomited. 

In  the  intervals  his  gait  was  markedly  ataxic,  and  he  com- 
plained much  of  darting  pains  in  all  his  limbs,  wliich  caused 
violent  muscular  twitchings.  The  pupils  were  extremely  con- 
tracted. 

The  patient  had  rheumatic  fever  twelve  years  previously,  and 
had  three  fits  then,  and  had  since  had  five  or  six  at  long  intervals, 
besides  many  attacks  of  vertigo  which  did  not  cause  him  to  fall. 
On  no  occasion  had  he  bitten  his  tongue. 

For  four  or  five  years  he  had  had  difficulty  in  walking  in  the 
dark. 

On  admission  to  John  Ward,  under  Dr.  Duckworth,  the  pupils 
were  found  to  react  perfectly  both  to  light  and  to  accommo- 
dation. The  tendon-reflexes  were  abolished.  The  right  great 
toe  was  red  and  swollen,  but  not  tender.  It  grated  on  move- 
ment and  presented  the  characters  of  a  Charcot's  joint. 

His  gait  was  then  not  markedly  ataxic,  but  he  could  not 
stand  with  his  eyes  shut  and  his  feet  together.  The  ophthalmo- 
scopic examination  showed  nothing  abnormal.  The  temperature 
was  subnormal.     The  urine  yielded  a  faint  cloud  of  albumen. 

On  the  night  of  July  2d  the  temperature  rose  to  102.6'',  but 
returned  to  subnormal  on  the  morning  of  the  4th.  On  the  6ih 
he  had  some  pain  in  the  right  knee,  wliich  felt  cold,  and  on  the 
following  morning  it  was  found  to  be  the  hotter  of  the  two  by 
5°  of  the  surface  thermometer.  On  the  8th  the  Argyll  Robertson 
phenomenon,  which  had  been  carefully  looked  for  in  vain  a  week 
earlier,  was  found  to  be  well  marked. 

On  the  evening  of  the  loth  he  was  allowed  to  sit  up  for  2J 


Sclerosis  of  the  Spinal  Cord.  59 

hours,  and  felt  no  worse  for  it,  but  on  returning  to  bed  he  had 
a  rigor,  and  the  lightning  pains  returned  with  great  intensity, 
causing  violent  twitchings  of  the  limbs.  The  pains  seemed  lo 
affect  the  arms  and  legs  equally. 

Meanwhile  the  temperature,  which  at  8  p.m.  had  been  99°, 
rapidly  rose,  reaching  104.8°  at  eleven  o'clock,  and  fell  gradually 
from  that  time,  reaching  the  normal  again  at  4  p.m.  on  the  fol- 
lowing day. 

On  the  15th  he  again  sat  up,  and  the  temperature  rose  to 
100.6°,  but  there  were  no  lightning  pains.  This  happened 
after  sitting  up  on  a  series  of  evenings.  His  progress  was  some- 
what retarded  by  an  abscess  in  the  cheek,  but  he  gradually  im- 
proved, and  eventually  left  the  hospital  on  August  28Lh. 

When  last  seen,  he  was  feeling  better  than  he  had  felt  for 
some  time,  and  the  Argyll  Kobertson  phenomenon  had  disa})- 
peared.  Daring  his  stay  he  was  treated  with  silver  nitrate,  and 
for  the  last  fortnight  with  mercury  and  potassium  iodide. 


ox  THE 

NATURE  AXD  ORIGIX  OF  RODEXT  ULCER 

BY      ■ 

G.  B.  FEEaUSON,  M.D. 


As  to  the  precise  tissue  iu  which  rodent  ulcer  originates,  there 
€xists,  and  will  probably  continue  for  some  time  to  come,  con- 
siderable uncertainty.  According  to  the  view  originally  pro- 
pounded in  Thiersch's  work  "On  Epithelial  Cancer"  (1865), 
rodent  ulcer  is  a  superficial  or  flattened  epithelioma,  and  derives 
its  origin  from  the  sebaceous  glands.  Dr.  Warren  of  Boston 
(1872)  also  argues  for  its  epithelial  nature,  though  he  considers 
its  origin  to  be  primarily  leucocylal.  Dr.  Thin  would  pronounce 
it  to  be  an  adenoma  of  the  sweat  glands ;  while  Drs.  Tilbury 
and  Colcott  Fox  considered  that  it  originated  in  the  outer  sheath 
of  the  hair  follicles. 

Kather  more  than  a  year  ago,  a  woman,  aged  50,  applied  to 
me  with  a  rodent  ulcer  involving  the  outer  fourth  of  either  lid  of 
the  right  eye.  I  freely  excised  the  affected  parts,  and  she  made 
a  good  recovery,  retaining  at  the  same  time  a  useful  degree  of 
vision,  notwithstanding  the  narrowed  resulting  chink  of  the  eye- 
lids. The  microscopic  examination  of  the  growth  was  decisive 
and  characteristic,  though  it  threw  no  light  on  the  question  of 
its  origin. 

But  this  same  patient  presenting  herself  again  after  the  lapse 
of  a  year,  I  noted  the  caruncula  of  the  affected  side  to  be  slightly 
indurated,  as  also,  though  hardly  perceptibly,  the  contiguous 
portion  of  the  lower  lid.  There  was  no  ulceration,  or  anything 
approaching  to  it,  and  the  entire  change  of  tissue  had  originated 
at  about  half  an  inch  of  distance  from  the  operation  scar.  She 
gladly  assented  to  my  anticipating  a  return  of  the  ulceration  by 
excision  of  the  suspected  site,  and  the  specimen  thus  secured 


102  Nature  and  Origin  of  Eodent  Ulcer. 

was  found  to  present  the  pomewliat  unui^ual  cliaracter  of  a  rodent 
growth  in  its  earliest  iucipiency.  Very  numerous  sections  were 
cut,  and  Iwcnty-three  of  the  tliinnest  mounted.  Tliese  were 
slained  Ity  the  iron  process  of  the  Drs.  Hoggan,  in  my  expeiience 
tlie  best  of  all  the  histological  processes  for  many  departments 
of  pathological  woik ;  certainly  no  other  one  known  to  me  so 
clearly  evidences  the  tinest  granules  and  fibrilke. 

The  microscopic  characters  of  rodent  growth  are  highly  distinc- 
tive, and  tqually  so  whether  the  powers  employed  be  low  or  high. 
With  the  low  ones  there  is  a  peculiar  streakiness  (like  the  veins 
of  some  marbles),  produced  by  the  deeply-stained  interlacing 
circles  and  cylinders  of  the  cellular  growth,  pcimeating,  as  they 
do,  a  special  variety  of  fibi'ous  tissue.  AVith  the  higher  powers 
this  streakiness  is  seen  to  depend  on  a  very  special  arrangement — 
one  obscured  in  the  older,  but  veiy  evident  in  the  more  incipient 
specimens — an  arrangement  of  wedges,  hollow  circles,  and  hollow 
cylinders  of  fairly  uniform  multi-nucleated  cells  (possibly  more 
truly  described  as  grauuled  nuclei).  Such  represents  the  highest 
degree  of  simplicity.  The  same,  with  more  massing  of  cells  and 
more  entanglement,  will  represent  the  most  complex ;  whilst  the 
oldest  parts  present  a  medium  degree  of  complexity,  and  are 
arranged  in  massive  alternating  veins  of  cells  and  fibres.  I 
would,  in  fact,  prouotmce  this  latter  appearance  to  be  the  one 
most  usually  characteristic  of  rodent  growth.  The  cells  are  of 
very  uniform  size  (that  of  the  nuclei  of  the  mucous  layer  of  the 
epidermis,  i.e.,  about  the  47/0  ^th  of  an  inch  in  their  long  diameter), 
and  the  angular  and  irregular  nuclei  of  the  fibrous  part  are  of  not 
far  different  size.  These  irregular  and  comparatively  faintly- 
stained  nuclei,  and  the  fibres  to  which  they  can  be  seen  to  give 
oiigin,  make  up  the  entirety  of  the  peculiar  fibrous  tissue  above 
referred  to. 

Then  as  to  the  origination  of  the  growth.  At  first  I  quite 
thought,  with  Thiersch,  that  this  must  be  from  the  sebaceous 
glands,  and  I  possess  specimens  which  would  apparently  favour 
this  view.  Such  present  the  aspect  of  a  group  of  normal  glands 
on  one  side  of  a  hair  and  rodent  tissue  on  the  other  side,  as 
though  a  direct  metamorphosis  had  there  occurred.  In  fact,  the 
appearance  is  highly  suggestive  of  the  actual  production  of  the 
growth  from  the  nuclei  of  the  sebaceous  glands.  Attentive 
examination,  however,  more  especially  with  a  y^^th  inch  immer- 
sion objective,  negatives  this  view,  and  discloses  the  case  as  one, 
not  of  nuclear  proliferation,  but  of  actual  invasion  of  the  glands 
and  their  destruction  by  the  neoplasm.  There  are,  besides,  two 
good  reasons  for  taking  this  view :  firstly,  that  the  rodent  cells 
are  decidedly  smaller  than   the  sebaceous  nticlei   (the   former 


Nature  and  Origin  of  Rodent  Ulcer.  103 

about  ToVotli,  the  latter  Wiroth  of  an  inch  in  diameter),  and, 
secondly,  that  they  are  much  more  deeply  stained.  The  latter 
facts  would,  indeed,  seem  to  remove  all  question  of  genetic 
affinity  between  the  sebaceous  glands  and  rodent  growth. 

In  respect,  next,  to  Dr.  Thin's  suggestion  of  the  genesis  of 
rodent  growth  from  the  sweat  glands,  I  can  only  state  that  my 
specimens  showed  no  sweat  glands  at  all,  even  in  the  healthy 
marginal  portions  of  the  skin ;  from  which  the  inference  that 
the  growth  could  not  have  originated  from  a  tissue  non-occurrent 
at  its  site  or  in  its  proximity. 

Whilst  writing  thus,  I  would  add  that  it  is  with  much  hesita- 
tion that  I  venture  to  differ  from  so  competent  an  observer  and 
so  close  a  reasoner  as  Dr.  Thin  (and  undoubtedly  the  resem- 
blance, one  extending  to  micrometric  measurements,  between  a 
cylinder  of  sweat  gland  and  one  of  early  rodent  growth  is  very 
striking),  but,  commenting  on  the  specimens  before  me,  my  con- 
clusions should  be  from  them  alone. 

In  regard  to  the  view  of  Drs.  Tilbury  and  Colcott  Fox,  that 
the  origin  is  from  the  outer  root  sheath  of  the  hair  follicles,  we 
are  here,  I  believe,  approaching  closely  to  the  truth.  In  fact, 
in  one  specimen  I  find  a  small  isolated  rodent  growth  distinctly 
sprouting  from  the  outer  coating  of  an  imperfect  hair;  one  un- 
attended, and  not  even  bordered  by  sebaceous  glands.  Still, 
whilst  feeling  sure  that  rodent  growth  has  this  origin  some- 
times, such  did  not  appear  to  me  to  be  its  usual  mode  of  com- 
mencement. But  what,  in  truth,  is  the  outer  root  sheath  other 
than  an  extension  of  tlie^ Malpighian  layer  of  the  epidermis? 
And  it  is  from  this  latter  that  I  most  decidedly  consider  the 
rodent  growth  (in  my  specimen,  at  any  rate)  to  have  originated. 

This,  I  believe  for  many  reasons :  because  of  the  similarity  in 
size  between  the  rodent  cells  and  the  Malpighian  nuclei ;  because 
the  growth  can  be  here  and  there  seen  actually  originating  at 
the  distal  extremity  of  the  Malpighian  fingers ;  because  the 
gradual  passage  of  these  fingers  into  rodent-growth  masses  can 
be  traced  in  places;  because  the  proximal  and  younger  portions 
of  the  growth  are  liker  to  nothing  else  than  to  ramified  Mal- 
pighian processes ;  because  the  incipient  nodules  can  be  seen 
in  fortunate  sections  to  be  covered  with  the  corneous  cuticular 
layer  alone,  and  to  occupy  the  exact  position  of  the  Malpighian 
layer. 

Whence  the  conclusion,  which  I  again  submit  to  be  the  true 
one,  that  the  growth  in  question  originates  simply^  in  a  meta- 
morphosis of  the  stratum  Malpighii;  in  a  nuclear  as  distinguished 
from  a  cellular  proliferation. 

Eodent  ulcer  is,  therefore  (as  Thiersch  suggested),  distinctly 


104  Nature  and  Origin  of  Rodent  Ulcer. 

au  epitlielioma  ;  and  my  study  of  many  cases  of  epithelioma 
would  lead  me  to  conclude  that  we  may  recognise  three 
varieties — (i.)  where  tlie  growth  is  mainly  of  the  corneous 
layer  (common  nest-forming  epitheliomata) ;  (2.)  mainly  from 
the  mucous  laj'er  (less  common  cohminar  ei)itheliomata);  and 
(3.)  from  the  nuclei  of  the  mucous  layer  (rodent  ulcer). 


CLINICAL  CONTRIBUTIONS  TO  PRACTICAL 
MEDICES[E. 

BY 

DYCE  DUCKWOETH,  M.D. 


PAET  III. 


I  propose  to  make  brief  commentaries  on  tlie  following 
subjects : — 

1.  Enteric  fever  with  beematuria. 

2.  Enteric  fever  with  loss  of  speech  for  more  than  a  month. 

3.  Periostitis  following  enteric  fever. 

4.  Enteric  fever  fatal    by  bfemorrbage  —  Passage  of  many 

lumbrici. 

5.  On  the  occurrence  of  green  stools  in  enteric  fever. 

6.  On  a  case  of  enteric  fever  with  spinal  symptoms. 

7.  Enteric  fever  with  parotid  bubo. 

8.  Enteric  fever  followed  by  bacillary  pulmonary  phthisis. 

9.  On  the  use  of   alum-whey  and  malt-extract  in  enteric 

fever. 

10.  Free  fat  in  the  urine. 

1 1 .  Symmetrical  herpes  zoster. 

12.  Boro-glyceride  as  a  remedy  in  pruritus,  &c. 

13.  On  the  necessity  of  urging  expectoration  in  certain  cases 

of  lung-disease. 

I.  Hcematuria  in  Enteric  Fever. 

I  have  twice  known  cases  to  die  where  hasmaturia  occurred 
during  enteric  fever.  In  both  it  was  apparently  of  renal  origin, 
and  was  present  at  the  end  of  the  illness.  In  one  case  of  a  man, 
set.  25  to  30,  in  which  death  occurred  from  perforation,  beyond 

^  For  Part  II,  vide  vol,  xv.  p.  16,  1879. 


io6  Clinical  Contrihulious  to  Pro  diced  Medicine. 

redness  of  the  cortex  of  the  kidneys  nothuig  was  found  to  cx- 
[)hiiii  the  hasiuorrhage,  no  ulceiutioa  being  met  with  on  the 
urinary  tract.  lu  the  other  tliere  was  a  prostatic  abscess,  and 
cMuboh'c  masses  probably  reached  the  kidneys  before  death  and 
led  to  the  hasmorrhago. 

I  have  seen  several  other  cases  in  which  the  symptom  has 
passed  away  and  led  to  no  subsequent  trouble.  One  of  the 
severest  cases  was  the  following : — 

F.  D.,  a  nurse,  ^t.  20,  admitted  May  4,  18S5,  to  Elizabeth 
Ward.  She  had  never  had  serious  illness  till  about  six  weeks 
before,  when  she  had  nausea  and  anorexia,  felt  ill,  left  her  situa- 
tion, and  had  to  keep  her  bed  after  the  29th  of  April. 

The  temperature  fell  the  first  night,  but  rose  the  next  to  103°, 
and  on  the  6th  May  reached  103.4°,  its  highest  point.  From 
that  time  gradual  fall  to  normal.  Pulse  about  130.  The  bowels 
were  confined.  The  urine  was  bloody ;  sp.  gr.  loio,  in  agree- 
ment with  pulse;  albumin  jV ;  crystals  of  uric  acid.  The 
patient  was  very  weak  and  pallid  on  admission.  She  said  the 
urine  had  been  red  at  the  beginning  of  her  illness,  and  black 
the  first  few  days.  No  history  of  scarlet  fever.  Thinks  she 
caught  cold  since  she  began  to  be  ill  from  sleeping  near  an 
open  window.  There  was  a  good  deal  of  hectic  flush  on  the 
cheeks  and  sweating  during  the  last  days  of  the  pyrexia.  On 
May  8th,  during  defervescence,  sudamina  appeared  in  large 
numbers.  Granular  tube-casts  were  also  found  in  the  urine 
on  this  day.  The  history  of  the  case  and  the  temperature  chart 
led  me  to  believe  that  the  illness  had  been  enteric  fever.  The 
family  history  was  very  bad  in  respect  of  tuberculosis,  and  I  was 
at  first  fearful  lest  I  had  to  deal  with  acute  tuberculosis  in  this 
case.  The  urine  was  no  longer  red  on  the  20tli  May,  and  was 
free  from  albumin  on  the  25th.  The  quantity  passed  was  from 
three  to  four  pints  on  admission,  gradually  falling  to  two  and 
one  and  a  half.  There  was  never  any  oedema  of  the  feet  or  face. 
There  was  an  excellent  recovery,  and  the  patient  was  discharged 
to  the  Convalescent  Hospital,  where  she  further  improved. 

Quinine  and  digitalis  were  used  while  the  heematuria  lasted, 
and  quinine  and  iron  given  subsequently. 


2.  A  Severe  Case  of  Enteric  Fever  in  luliicli  Sjpeech  was  Lost 
for  more  than  a  Month. 

L.  W.,  girl,  £et,  10  years,  admitted  February  12.  Ailing  since 
2d,  laid  up  on  5th,  delirious  since  7th.  Two  or  three  loose  stools 
daily.     Mother  died  of  enteric  fever  two  weeks  previously,  and 


Clinical  Gontrilutions  to  Practical  Medicine.  107 

an  elder  brother  had  same  disease  and  recovered  sis  weeks 
ago.  Very  ill  on  admission  ;  complexion  dusky,  tongue  crusted, 
dicrotic  pulse ;  temperature  104°,  and  105°  on  following  day 
(highest  point  reached).  Spleen  large  ;  much  papular  rash  ; 
bronchitis.  Diarrlicea  and  high  temperature  maintained.  Pulse 
irregular  on  I5tli  day,  and  urine  half  albumin.  No  cedema 
of  legs.  On  17th  day  albumin  gone.  Had  to  be  fed  by  nares 
with  soft  tube  and  syringe.  Temperature  fell  to  99°  on  morning 
of  1 8th  day,  but  rose  to  103.6°  the  same  evening.  Had  seven 
minims  of  laudanum  each  night  with  marked  benefit.  On  the 
2ist  day  the  temperature  rose  at  night  to  101.2°,  having  fallen 
to  96.4°  Ihe  same  morning.  No  more  pyrexia.  The  girl  was 
very  dull,  and  noticed  nothing  for  many  days.  Though  quite 
conscious  when  admitted,  she  did  not  speak,  and  had  not  uttered 
a  word  for  two  days.  When  the  stupor  of  her  feverish  state 
liad  passed  away,  recognition  of  her  family  and  those  about 
her  being  obviously  perfect,  she  could  not  be  made  to  speak. 
On  the  12th  of  March  she  spoke  a  little  for  the  first  time,  having 
been  absolutely  silent  for  thirty-five  clays}  There  was  extreme 
muscular  wasting  in  this  case.  On  March  ist  the  arms  could 
not  be  placed  under  the  bed-clothes  if  they  were  left  uncovered. 
Faradisation  was  employed,  and  perfect  recovery  took  place. 
Discharged  April  7th.  Mellin's  food  was  used  at  one  period, 
and  four  ounces  of  brandy  were  taken  daily  during  the  first 
week.  The  child  was  a  very  bright  and  lively  one,  and  her 
sisters  seemed  healthy  and  vigorous.  Faradisation  was  of 
marked  benefit  during  the  convalescence  of  another  patient  from 
a  severe  attack  of  enteric  fever.  It  had  distinct  tonic  and 
bracing  action,  and  roused  the  patient  from  a  very  languid  con- 
dition. 


3.  Periostitis  following  Enteric  Fever. 

The  occasional  occurrence  of  periostitis  as  a  sequel  of  enteric 
fever  is  now  well-recognised.^  Sometimes  this  trouble  is  slight 
and  unimportant.  In  some  cases  it  is  veiy  tedious  and  in- 
tractable. I  have  had  four  or  five  examples  within  two  or  three 
years  imder  observation  in  the  wards.  A  case  seen  privately 
was  one  of  periostitis  and  perichondritis  affecting  one  of  the  left 
ribs.    The  man  was  aged  thirty-six,  and  had  always  been  healthy 

1  Vide  case  of  boy,  set.  9,  recorded  by  Dr.  Churcli  in  "Observations  on  Typhoid 
Fever,"  St.  Bartholomew's  Hospital  Keports,  vol.  xvii.  p.  103  (1881),  in  which 
speech  was  absent  for  fifty-four  days. 

2  Vide  Sir  J.  Paget's  paper  on  this  subject.  St.  Bartholomew's  Hospital  Re- 
ports, vol.  xii.  p.  2,  1S76. 


io8  CHnical  Contributions  to  Practical  Medicine. 

till  an  att-ack  of  euteiic  fever  occurred  three  months  previonsl}'. 
A  swelling  came  over  the  sternum  and  hroke,  and  it  continued 
to  discharge  matter  fur  twelve  months  before  healing.  The 
health  was  impaired  by  so  mucli  discharge,  but  perfect  recovery 
was  made,  and  is  maintained  up  to  the  present  time. 

In  another  case,  that  of  a  young  woman,  periostitis  appeared 
over  one  of  the  tibi?e  before  convalescence  was  complete.  The 
pain  was  relieved  by  lead  and  opium  lotion,  and  in  a  short  time 
complete  recovery  occurred.  The  two  following  cases  were  more 
severe  and  obstinate: — 

Case  I. — C.  B.,  £et.  27,  married  eight  years,  has  three  healthy 
children.  Xo  miscarriages.  No  history  of  sypliilis.  A  pale  woman 
with  dark  bair.  On  i6th  August  18S4  was  confined  of  her  fourth 
child,  which  died  in  convulsions  on  the  second  day.  Puerperal 
fever  and  mania  were  said  to  have  supervened.  Two  chiklren 
in  the  house  had  enteric  fever,  and  this  patient  developed  the 
disease,  and  was  laid  up  for  five  weeks.  Di-.  Slater  wrote  to  me 
about  the  case,  and  as.sured  me  of  his  diagnosis,  reporting  the 
occurrence  of  rose  spots. 

On  October  21st  there  was  pain  in  the  right  instep  and  shin. 
In  a  few  days  the  left  shin  became  painful,  and  several  nodes 
appeared  on  both  shins. 

Patient  soon  afterwards  admitted  to  hospital.  She  was  ob- 
viously in  poor  health.  There  was  evidence  of  mitral  stenosis. 
The  urine  was  natural.  Xo  febrile  movement.  In  November 
another  node  appeared  on  left  tibia,  and  all  these  swellings  grew 
slowly  larger.  They  were  never  very  painful,  and  never  ached 
more  at  night.     Veiy  little  change  took  place  in  them. 

Iodide  of  potassium  was  given  in  small  and  in  very  large 
doses — up  to  three  drachms  daily — without  any  benefit  whatever. 
Iron  was  of  some  value.  Some  of  the  nodes  softened  in  parts, 
leaving  the  integument  over  them  soft  and  allowing  fluctuation, 
but  there  was  no  threatening  of  rupture.  In  January  this  patient 
returned  home.  In  a  few  weeks  she  was  readmitted,  the  nodes 
having  grown  larger  and  become  more  painful.  Rest  in  bed 
was  useful,  and  syrup  of  phosphate  of  iron  was  given.  Good 
diet  and  wine  were  taken  with  appetite.  The  patient  again 
went  out.  August  1885. — Much  in  the  same  condition.  Lately 
had  a  miscarriage  with  much  flooding.  Iodine  liniment  relieves 
the  pain  to  some  extent.  Lead  and  opium  lotions  were  also 
soothing  at  one  time.  At  the  end  of  August,  the  skin  broke  in 
two  places  over  a  large  node  on  the  right  tibia.  A  little  glairy 
discharge  came  from  the>e.  They  were  dried  and  painted  over 
with  collodion.     In  October  there  was  marked  improvement  in 


Clinical  Contributions  to  Practical  Medicine.  109 

both  sliins,  and  the  general  healtli  Tvas  also  Letter.     Iron  and 
cod-liver  oil  vrere  continued  regularly. 

Case  II. — A.  J.,  set.  16,  a  rather  frail-looking  girl,  came  into 
Ehzabeth  "Ward  in  September  18S4  with  enteric  fever.  Had  a 
rather  severe  attack.  During  her  convalescence  she  had  nodes  on 
both  tibias,  larger  on  the  right  leg.  This  case  very  closely  resem- 
bled the  one  previously  described.  The  nodes  were  painful,  but 
not  to  the  same  extent  commonly  experienced  in  syphilitic  cases. 
They  were  not  worse  at  night.  Similar  treatment  to  that  prac- 
tised in  the  former  case  was  employed.  In  June  1SS5  there  was 
little  change  for  the  belter.  The  general  health  was  very  fair. 
The  legs  ached  a  good  deal  at  times.  In  August  hardly  any 
improvement.  In  one  or  two  places  slight  softening  and  fluctua- 
tion felt.  However  tempting  such  cases  might  be  for  surgical 
interference,  I  took  care  to  have  the  fluctuant  spots  protected  and 
let  alone.  I  imagine  if  the  skin  was  to  break  there  would  be  a 
troublesome  sore,  and  exfoliation  of  a  lamina  of  bone  might  occui-. 
These  cases  are  very  tedious,  and  seem  little  influenced  by  any  line 
of  treatment,  at  any  rate  in  patients  in  a  humble  sphere  of  life, 
who  cannot  secure  rest  or  bracing  climate.  Tonics,  iron,  and  good 
food,  with  all  the  rest  possible,  seem  to  be  best  for  them.  The 
condition  possibly  depends  upon  some  special  predisposition  to 
periosteal  disease,  some  inherited  weakness  which  manifests 
itself  during  the  exhaustion  and  low  state  of  health  induced  by 
the  fever. 

4.  Fatal  Case  of  Enteric  Fever — Hcemorrliage  from  tlie 
Bowels — Passage  of  ma  ay  Lumbrici. 

This  case  was  under  Dr.  Andrew's  care,  and  he  kindly  allo\vs 
me  to  record  the  main  features  of  it  here. 

G.  M.,  a  young  Italian,  fet.  18,  not  long  resident  in  London, 
was  admitted  to  Mark  Ward  on  December  26,  1882.  He  bad 
been  ill  for  a  fortnight.  Had  good  health  previously.  He  had 
marked  symptoms  of  enteric  fever,  with  tender  and  enlarged 
spleen.  On  the  30th  vomited  six  times.  On  the  31st  he  passed 
four  round  worms  with  his  motions.  Occasional  vomiting.  On 
January  2d  vomited  one  worm,  and  in  the  evening  passed  another 
by  the  bowel,  some  blood  being  also  present.  Pulse  soft  and 
running.  Objected  to  take  nourishment,  and  very  wakeful. 
Opium  was  freely  employed  in  various  forms.  The  urine  was 
free  from  albumin.  On  the  3d  January  had  pain  in  abdomen, 
and  passed  three  worms  with  some  more  blood.  Refused  nou- 
rishment, and  died  on  following  day.     The  temperature  rose  to 


1 10  CUnicai  Contributions  to  Practical  Medicine. 

104.6°  on  Jannaiy  I  si,  and  j^nidually  fell  from  the  morning  of 
Jammry  2d  to  the  time  of  death.  Santonine  was  prescribed  on 
January  4th.     Death  occnrred  the  same  day. 

Murchi.-^jon  quotes  the  opinion  of  Louis  to  tlie  effect  that  lum- 
biici  are  often  passed  in  enteric  fever,  and  that  he  had  on  many 
occasions  found  them  in  the  small  intestine  after  death.  In 
Murchison's  experience  their  presence  was  exceptional,  and  I 
should  be  quite  disposed  to  agree  with  him.  He  further  re- 
marks upon  the  ftict  that  enteric  fever  was  attributed  to  lum- 
brici  by  Lancisi  in  the  seventeenth  century,  also  by  many 
writers  in  the  eighteentli  century,  and  hence  called  worm- 
fever.^ 

5.  Oil  the  Occurrence  of  Green  Stools  in  Enteric  Fever. 

I  have  now  seen  several  cases  of  enteric  fever  in  which  the 
patients  passed  at  some  time  green  stools.  Some  of  these  oc- 
curred in  Dr.  Andrew's  wards.  Green  stools  were  likewise 
passed  in  two  remarkable  cases  of  his  in  which  there  was 
severe  ulceration  of  the  large  intestine,  which  led  to  hepatic 
abscess  in  each  instance,  the  ulceration  being  quite  peculiar 
and  unlike  that  of  ordinary  dysenter}'.  This  autumn  I  have 
met  with  gi-een  shreds  and  particles  in  the  ordinary  (ochrey) 
stools  of  two  patients  suffering  from  enteric  fever.  These 
small  masses  closely  resembled  in  one  case  particles  of  boiled 
green  peas,  and  in  the  other  shreds  of  mucous  membrane 
deeply  bile-stained.  Microscopically  their  structure  was  evi- 
dently that  of  sloughs  of  the  mucosa.  Chlorophyll  was  not 
detected  in  one  of  them  by  the  spectroj^cope  at  the  hands  of  my 
house-physician,  Dr.  Garrod. 

In  another  case  of  well-marked  enteric  fever  with  eruption 
and  enlarged  spleen,  the  patient,  a  male,  ffit.  24,  passed  soon 
after  admission,  about  the  end  of  the  second  week,  a  bright 
green  motion.  On  standing,  this  sei)arated  into  two  layers. 
The  upper  one  was  a  turbid  green  Huid,  the  lower  one  re- 
sembled a  thin  paste  of  vivid  emerald  green  colour,  consist- 
ing of  finely  granular  masses  like  mashed  pistachio  nuts. 

The  next  stool  was  much  darker  in  colour,  separated  into  two 
layers,  the  lower  one  being  of  olive-green  or  boiled-cabbage 
colour.  The  third  stool  was  of  the  ordinary  ochrey  character. 
At  the  end  of  the  third  week  some  patches  of  blood  were  passed 
in  the  stools.  Tlie.se  usually  fall  to  the  bottom  of  the  vessel,  and 
must  be  sought  there.  0[)ium  was  freely  used  in  small  enemala. 
This  controlled  the  bowel-aclions,  and  was  generally  of  ranch 

^  Treatise  on  tlie  Continued  Fevers  of  Great  Britain,  edit,  i.,  pp.  390,  539,  1862. 


Clinical  Contributions  to  Fractical  Medicine.  1 1 1 

avail.  In  a  day  or  two  later  some  small  clots  of  blood  were 
again  passed,  the  temperature  having  fallen  below  normal,  and 
the  pulse  become  dicrotous,  1 12-140.  Dark-green  stools  were 
again  passed  from  time  to  time,  alternating  with  ochrey  ones. 
Some  of  these  masses  sank  to  the  top  of  the  lower  layer  in  the 
vessel,  and  had  shreds  of  sloughed  mucous  membrane  and  blood 
mixed  up  with  them.     A  relapse  subsequently  took  place. 

It  is  difficult  to  account  for  stools  of  this  character.  Dr. 
Andrew,  from  his  experience,  is  disposed  to  connect  their  occur- 
rence with  the  existence  of  ulceration  as  well  in  the  large  as  in 
the  small  intestine.  It  is  noteworthy  that  a  stool  presenting 
this  peculiarity  should  be  followed  not  long  afterwards  by  one  of 
■ordinary  enteric  fever  character,  having  no  apparent  relation  to 
the  former  in  respect  of  colouring  matter.  Nothing  in  the  diet 
or  medicinal  treatment  will  account  for  this  peculiarity.  In  the 
above  case  there  was  no  doubt  of  the  presence  of  deep  ulcera- 
tion. 

6.  On  a  Case  of  Enteric  Fever  ivith  Spinal  Symptoms. 

This  was  the  case  of  a  young  married  woman,  A.  H.,  aet.  21, 
who  was  admitted  into  Elizabeth  Ward  on  12th  November  1885. 
She  had  been  suckling  for  four  months.  For  several  weeks  be- 
fore admission  she  had  been  ailing,  had  kept  her  bed  for  a  week, 
and  suffered  from  diarrhoea.  Tlie  temperature  was  103°  and 
the  pulse  144,  small  and  soft.  There  was  a  good  deal  of 
bronchitis  and  troublesome  cough.  There  were  a  few  spots,  and 
the  spleen  was  tumid.  The  urine  had  to  be  drawn  off  soon 
after  she  came  in,  and  contained  one-eighth  of  albumin.  The 
fever  continued  high  and  there  was  nuich  prostration.  The  face 
was  much  flushed.  In  a  few  days  subsultus  occurred,  and  there 
was  coma  vigil.  On  the  iStli  the  pulse  was  152  and  running. 
Stimulants  were  required,  and  by  this  time  she  was  taking  ten 
ounces  of  brandy  in  each  twenty-four  hours.  Opium  w^as  given 
from  the  14th,  in  a  n\_v.  dose  at  first,  then  in  an  enema  with 
TT]_xv.  of  laudanum  one  night.  This  was  twice  repeated  to  keep 
the  diarrhoea  in  check  and  to  induce  sleep.  On  the  19th  there 
was  much  stiffness  of  the  neck  and  limbs,  and  later  in  the  day 
there  was  an  obvious  degree  of  opisthotonos,  the  feet  being  in 
equino- varus  positions.  It  had  become  difficult  to  feed  her,  and 
swallowing  was  imperfect.  Opium  was  now  given  in  pills  of  a 
grain  broken  up  in  food,  and  nourishment  was  very  successfully 
introduced  by  a  soft  india-rubber  catheter  along  the  nares.  She 
rallied  considerably  under  0])ium  and  fuller  support.  There 
was  now  much  meteorism.  Three  grains  of  opium  were  given 
as  above,  and  the  pupils  became  smaller,  and  some  sleep  was 


1 1 2  Clinical  Contributions  to  Practical  Medicine. 

.secured.  Next  clay  the  opisthotonos  was  less  marked  and  the 
tympanites  diminished.  She  was  more  intelligent,  and  swallowed 
a  little.  A  grain  of  opium  was  given  four  times  daily,  and  each 
liour  she  had  half  an  ounce  of  brandy  day  and  night.  Decubitus 
generally  dorsal,  with  all  the  limbs  fully  extended.  Abundant 
Kudamina  and  much  sweating.  On  the  22(1  the  pulse  was  128, 
improved  in  character.  Neck  still  rigid.  ]\Iuch  moaning.  The 
urine  was  passed  under  her  plentifully,  1020,  acid,  and  contain- 
ing a  cloud  of  albumin.  Turned  on  her  side  of  her  own  accord. 
23d. — Had  sleep.  Restlessness  and  muttering  delirium.  Pulse 
140,  feebler.  Arms  still  rather  stiff,  neck  less  so,  body  extended 
full}'.  Much  sweating.  The  bowels  had  been  unmoved  for 
several  days  till  to-d;iy,  when  some  semi-solid  masses  were  passed 
with  powdery  matter.  Tympanites  still  present.  Was  very 
prostrate  early  in  the  morning,  and  revived  by  a  musk  and  ether 
draught.  Opium  still  continued  in  half-grain  doses  four  times 
daily.  The  spasmodic  symptoms  gradually  passed  off  and  im- 
provement set  in,  but  the  temperature  remained  high  for  three 
weeks. 

Spinal  symptoms  are  very  rarely  met  with  in  enteric  fever. 
Dr.  John  W.  Ogle  reported  some  instances  twenty  years  ago.^ 
They  all  occurred  in  young  women.  The  head  was  retracted, 
and  the  muscles  of  the  neck  were  very  rigid,  interfering  with 
swallowing.  There  was  hypereesthesia.  In  this  case  the  latter 
symptom  was  not  met  with.  Dr.  Ogle  quoted  in  his  paper  some 
cases  reported  by  Fritz  -  wdiere  tetanic  symptoms  prevailed  in 
cases  of  enteric  fever  in  young  women  about  the  middle  or  end 
of  the  first  week. 

In  the  experience  of  both  these  writers  the  cases  ended  fatally. 
No  autopsies  w-ere  made.  The  complication  is  most  grave. 
Feeding  by  the  nasal  catheter  is  a  measure  of  great  vaUie  in 
such  cases,  and  may  be  employed  in  many  conditions  when 
nourishment  is  badly  taken,  as  recommended  in  an  admirable 
paper  by  Dr.  Bulhir."' 

7.  Enteric  Fever  luith  Parotid  Bulo. 

W.  C.  0.,  ftt.  28,  a  potman,  was  admitted  into  John  Ward 
under  my  care  on  April  3,  1885.     He  was  a  sparely-nourished 

^  Medical  Times  and  Gazette,  January  1865. 

2  Etude  cliiiique  sur  les  divers  symptomes  spinaux  observfe  dans  la  Fievre 
Typboide.     Paris,  1864. 

2  On  the  Treatment  of  Cases  of  Imperfect  and  Painful  SwalLjwing,  by  J.  F. 
Bullar,  M.B.  Practitioner,  London,  October  1SS5.  Vide  Church  (loc.  jam  cit.), 
p.  102. 


Clinical  Contributions  to  Practical  Iledicine.  113 

man.  On  25th  March  lie  begau  to  feel  ill  and  vouiited  ;  on 
26tli  he  was  at  work,  but  had  to  take  to  bed  on  27th.  Was 
at  work  again  for  two  days,  and  was  finally  laid  up  on  31st. 
Diarrhoea  began  on  26th.  On  admission  he  had  rose  spots,  and 
his  uriue  contained  one-fourth  of  albumin.  His  temperature 
reached  105°  on  4th  April.  This  was  reduced  by  sponging,  a 
cradle  placed  under  the  bedclothes,  and  several  five-grain  doses 
of  quinine.  Pulse  ^d>,  dicrotous.  Motions  were  characterisiic. 
Some  impaired  resonance  over  left  back,  and  friction  heard  in 
the  axilla. 

On  the  7th  April  eruption  copious ;  seven  motions. 

9th. — Diarrhoea  continued;  eruption  abundant;  pulse  96, 
dicrotous.  Tongue  thickly  coated.  Urine  1035  ;  one-fourth 
albumin. 

iith. — Four  motions  in  last  twenty-four  hours  ;  temperature 
under  104°.  Some  tenderness  and  swellitig  under  left  ear. 
Fresh  spots  appearing. 

.  13th. — Swelling  under  the  ear  increasing;  no  fluctuation  de- 
tectible. 

14th. — Increase  of  swelling.     Pulse  112,  soft. 

15th. — Some  pulfiness  in  the  right  parotid  region. 

iStli. — Much  delirium  on  previous  night;  trying  to  get  out  of 
bed.  Abscess  was  opened  yesterday  afternoon  below  the  ear, 
and  two  drachms  of  pus  were  evacuated.  Drainage  tissue 
inserted  and  a  poultice  applied.  Is  wasting  rapidly.  Swelling 
on  right  side  is  subsiding.  Diarrhcea  continues.  Taking  uitro- 
hydrochloric  acid  draught  and  opium  each  night.  Quinine 
causes  sickness. 

19th. — Swelling  going  down;  free  discharge  into  poultices. 
Delirium.     Pulse  100,  firmer. 

2ist. —  Sweating  a  great  deal.  Bad  night,  with  delirium. 
Temperature  fell  to  99.2'  to-day.  Four  motions.  Tongue 
thickly  furred  in  centre. 

23d. — Temperature  subnormal  after  profuse  sweating.  De- 
lirious,    Semi-solid  motion  passed.     Pulse  6S,  firmer. 

25th. — Much  in  same  condition.  Urine  now  free  from  albu- 
min. The  abscess  cavity  was  explored  under  chloroform  by 
Mr,  Murray,  the  house-surgeon,  and  two  fresh  counter-openings 
made. 

26th. — Very  faint  in  the  evening,  and  required  more  brandy. 
He  took  usually  from  six  to  eight  pints  of  milk  (much  of  this 
used  as  whey),  ten  ounces  of  beef-essence,  and  from  four  to 
eight  ounces  of  brandy  daily. 

27th. — Temperature  normal ;  tongue  cleaner. 

VOL.  XX  r.  H 


1 14  Clinical  Contributions  to  Practical  Medicine. 

29tl). — Becoming  rational.  Pulse  100,  dicrotous.  Motions 
semi-solid. 

May  61I1. — Abscess  healing.     Taking  fisli. 

7tli. — Considerable  bleeding  from  the  absce.=s  cavity  on  pre- 
vions  evening ;  stopped  by  a  compress  and  bandage.  Some 
nightly  rise  of  temperature.     No  motion  for  eight  days. 

9th. — Bowels  relieved  by  an  olive  oil  enema.  Pulse  io3, 
firmer. 

14th. — Sweats  freely.     Wound  'healing  well. 

i/tli. — Sat  up  for  an  hour.  Appelite  very  good.  Discharged 
to  Swanley  Convalescent  Hospital.  June  5th. 

The  temperature  fell  on  the  twenty-eighth  and  thirtieth  days 
of  the  fever  after  profuse  sweatings.  The  abscess  began  on  the 
eighteenth  day. 

Parotid  abscess  is  not  a  common  complication  in  enteric  fever. 
It  is  more  frequently  met  with  in  typhus  fever.  It  is  always 
associated  with  severe  cases,  and  the  result  is  very  often  fatal. 
Suppurative  parotitis  occurred  16  times  in  1600  cases  of  enteric 
fever  at  Basle,  7  of  these  proving  fatal.  Hoffmann,  who  affords 
these  statistics.,  believes  that  the  close  and  tough  texture  of  the 
fascia  enclosing  the  parotid  leads  to  greater  pressure  and  severer 
inflammation  in  it  than  occurs  in  other  salivary  glands  and  the 
jancreas,  which  are  all  affected  by  parenchymatous  changes  in 
enteric  fever.^  Its  occurrence  would  seem  to  point  to  a  strong 
impregnation  with  the  specific  poison  of  the  fever.  There  was 
clearly  an  abortive  effort  at  suppuration  on  the  right  side  in  this 
case.  Unwearied  attention  on  the  part  of  the  nursing  staff 
had  much  to  do  with  saving  this  man's  life.  A  case  occurred  last 
year  in  Faith  Ward  under  Dr.  Church's  care  in  which  double 
}>arotid  bubo  was  present.  B}^  his  permission  I  record  the  main 
features  of  it.  A  little  girl,  aet.  three  years,  had  well-marked 
but  rather  mild  enteric  fever  with  eruption.  On  the  thirteenth 
day  the  left  parotid  gland  began  to  swell,  and  the  temperature 
rose  from  normal  to  103.2°.  Shortly  afterwards  the  right  gland 
swelled.  On  the  sixteenth  day  the  swelling  was  much  increased, 
nnd  the  following  day  first  the  left,  and  a  little  later  the  right 
bubo  burst  into  the  adjacent  external  auditory  meatus.  The 
temperature  fell  forthwith.  Counter-openings  were  made  on  each 
side  to  secure  drainage  of  pus.  The  child  remained  very  ill  for 
three  weeks,  but  made  subsequently  an  excellent  recovery.  In 
1883,  in  146  cnses  of  enteric  fever  in  the  hospital,  two  had  paro- 
tid bubo,  one  ending  in  abscess.  In  1884,  in  126  cases  one  ended 
fatally  with  parotid  bubo. 

^  Zieinsseu's  Cyclopaedia,  art,  "  Typhoid  Fever." 


Climcal  Contributions  to  Practical  Iledicine.  1 15 

8.  Enteric  Fever  folloiued  hy  Bacillary  Pulmonary  Phthisis. 

M.  W.,  housewife,  set.  35,  living  in  Peabody's  Buildings, 
Clerkenwell  Eoad,  was  admitted  under  my  care  to  Elizabeth 
Ward  on  March  7,  1885,  suffering  from  well-marked  enteric 
fever.  Had  never  been  robust,  but  had  no  serious  illnesses 
previously.  Her  son,  a  boy  of  13  years,  was  admitted  at  tlie 
«ame  time  with  the  same  illness  into  John  Ward,  also  under 
my  care.  They  lived  on  the  ground-floor,  and  the  sanitary 
arrangements  of  the  building  were  believed  to  be  beyond  sus- 
picion. 

M.  W.  had  a  rigor  on  28tli  February;  took  to  bed  on  2d 
March,  and  diarrhoea  began  on  3d.  A  well-nourished  woman, 
with  much  integumentary  and  omental  fat.  Some  rose  spots  oa 
abdomen.  Spleen  impalpable.  Motions  characteristic.  The 
temperature  reached  105°  on  the  tenth  and  eleventh  days; 
105.4°  on  the  twelfth  day  (the  liighest  recorded),  and  re- 
mained high  till  the  end  of  the  fifth  week,  when  the  morn- 
ing fall  reached  the  normal  line.  The  case  was  very  severe. 
Oopious  eruption  appeared,  as  was  also  the  case  in  the  sou. 
The  urine  contained  a  trace  of  albumin.  There  was  some 
bronchitis  at  the  bases  of  the  lungs.  Towards  the  end  of 
the  third  week  much  delirium  and  subsiiltus  tendinum ; 
■cedema  of  the  ankles.  Some  general  cedema  noticed  on  twenty- 
third  day,  and  very  feeble  pulse.  Cough  was  troublesome. 
Mucous  rales  heard  at  base  of  left  lung.  Respirations  48; 
pulse  140.  Left  leg  more  swollen  thau  right.  A  high  tem- 
perature was  maintained,  with  nightly  rise,  till  the  105th  day 
of  the  illness.  The  albumin  disappeared  from  the  urine. 
There  was  threatening  of  bed-sore  over  right  trochanter.  An 
-jibscess  began  to  form  under  this,  and  tea  ounces  of  pus  were 
let  out  on  the  forty-ninth  day,  a  drainage  tube  being  put  in 
the  cavity.  At  this  date  the  motions,  which  had  been  semi- 
solid and  formed  for  more  than  a  fortnight,  became  again 
powdery.  No  distinct  relapse  of  fever  could  be  made  out. 
The  chart  of  temperature  showed  a  continuous  nightly  rise  to 
About  102°  at  this  period,  with  a  morning  remission  to  99°  or 
normal.  The  abscess  cavity  was  washed  out  with  antiseptics 
-daily,  and  began  to  contract  and  discharge  less  freely.  _A 
portion  of  fascia  lata  came  away  as  a  slough  before  the  cavity 
closed.  On  the  sixty-third  day  a  threatening  of  another  abscess 
in  the  right  hip.  Some  pain  in  the  lefc  chest,  with  slight  pleural 
friction  on  sixty-ninth  day.  This  passed  away  in  a  few  days- 
On  seventy-seventh  day  a  trace  of  albumin  again  in  the  urine. 
This  had  disappeared  oa  the  ninety-first  day.     The  pyrexia  w;is 


1  i6  Clinical  Conlrihnlions  to  Practical  Medicine. 

less  marked  about  the  lOOth  day.  There  was  no  sweatiug.  Some 
dry  cough.  On  tlie  105th  day  examination  of  the  chest  revealed 
that  there  was  impaired  peicussion  note  at  both  ai)ices,  extending 
lower  on  right  than  on  left  side;  bronchial  breathing  at  both 
apices ;  most  marked  on  right  side.  Pulse  88.  Sputa  scanty. 
Bacilli  detected.  Fluctuation  in  swelling  over  left  hip.  A 
grooved  needle  was  passed  into  this,  and  some  clear  tenacious 
yellow  fluid  was  withdrawn,  sp.  gr.  1020,  alkaline,  containing 
oil  globules,  and  becoming  solid  on  boiling.  On  the  126th  day 
j)hysical  signs  in  chest  much  the  same,  more  mischief  being 
detected  on  right  side.  Able  to  sit  up  in  the  ward,  and  carried 
down  into  the  hospital  square.  After  the  lootli  day  the  morn- 
ing remissions  of  temperature  were  often  subnormal.  The  cough 
was  of  very  little  moment.  A  good  deal  of  discharge  came  from 
the  abscess-cavity  in  the  left  thigh.  The  temperature  did  not, 
become  fairly  natural  till  the  150th  day  of  the  illness.  For  many 
weeks  previously  the  ap{)etite  was  very  good,  and  a  liberal  dietary 
with  malt  liquor  was  fully  enjoyed. 

The  patient  was  sent  to  the  Convalescent  Hospital  at  Swanley 
on  August  7,  and  left  on  the  /tli  September.  Her  weight  was 
ten  stones  on  leaving  London.  She  gained  six  pounds  at  Swan- 
ley,  and  on  g\h.  October  weighed  eleven  stones  four  pounds. 
Can  walk  a  mile  with  a  stick.  Lately  spat  about  a  teaspoonful 
of  blood.  Temperature  normal.  Pulse  no,  snail,  after  some 
exertion.  Physical  signs  in  chest  indicate  deposits  in  each  aj)ex, 
with  softening,  most  advanced  on  the  right  side.  Some  flatten- 
ing is  in  progress  under  each  clavicle,  and  the  finger-ends  are 
becoming  aduncated.  There  was  no  family  history  of  phthisis 
to  be  obtained.  The  boy  made  a  good  recovery  in  due  course 
without  any  noteworthy  sequela3. 

Tuberculosis  was  probably  the  cause  of  the  prolonged  pyrexia 
in  this  case.  Emaciation  was  considerable.  Murchison  observed 
tuberculosis  to  arise  not  uncommonly  as  a  complication  or  a 
sequel  in  enteric  fever, and  certaitdy  with  greater  frequency  than 
in  the  case  of  typhus  fever.  Dr.  Walshe  mentions  that  he  has 
occasionally  observed  moht  )-emarkable  disappearance  of  local 
and  geneial  symptoms — practically  comj)lele  recovery — in  cases 
of  this  kind,  and  thinks  the  deposits  can  hardly  have  been 
genuine  tubercle.^ 

Dr.  Douglas  Powell  tells  me  that  in  his  experience  at  the 
Middlesex  and  at  Brompton  Hospitals  he  has  not  observed 
enteric  fever  to  be  at  all  a  common  antecedent  of  tubercular 
ca.se8,  Liebermeister  found  phthisis  "a  tolerably  frequent 
sequel"  of  enteric  fever  during  six  years' observation  at  Basle, 

^  Diseases  of  the  Lunar?. 


Clinical  Contributions  to  Practical  Medicine. 


117 


and  quotes  Mettenlieimer's  experience  of  thirteen  cases  of  phthisis 
in  thirty-eight  fatal  instances  of  enteric  fever  amongst  French 
prisoners  in  Schwerin  during  the  war  1870-71  ;  also  Hoffmann's 
report  of  250  post-mortem  examinations,  in  which  four  cases  of 
general  miliar)'  tuberculosis  were  met  with.^  My  experience 
leads  me  to  affirm  that  cases  of  enteric  fever,  as  commonly  seen 
in  hospital  practice,  \e\-j  rarely  develop  signs  of  phthisis  so 
long  as  they  remain  under  observation,  and  the  records  of  tlie 
dead-house  indicate  precisely  the  same  thing  at  this  hospital. 

Last  year  one  patient,  a  male,  £et.  36,  developed  phthisis  in  tlie 
hospital  after  enteric  fever. 

9.  On  the  Use  of  Alum- Whey  and  Malt-Exlract  in 
Enteric  Fever. 

I  have  found  this  form  of  nutriment  of  use  in  cases  marked  by 
troublesome  diarrhoea,  especially  in  the  later  stages.  When  it 
is  desirable  to  prevent  milk-cnrds  from  irritating  deep  ulcers 
and  adding  to  the  general  mucous  catarrh,  and  when  hsemor- 
rliage  is  at  the  same  time  threatened  or  actually  present,  alum- 
whey  seems  specially  indicated. 

The  suggestion  is  due  to  the  late  Dr.  Murchison.^  The  alum 
is  added  to  hot  milk  in  the  proportion  of  a  drachm  to  a  pint; 
tiiis  is  then  boiled  and  set  aside  for  an  hour  or  two,  and  the  curd 
separated  by  passing  the  whey  through  muslin.  It  is  not  un- 
pleasant. Whey  made  in  the  ordinary  manner  with  rennet  is  like- 
wise very  useful  when  milk  becomes  distasteful  in  a  protracted 
case.  All  sick-nurses  should  be  instructed  in  making  it.  In 
cases  of  deep  ulceration  in  enteric  fever,  extract  of  malt  is  useful 
as  an  unirritating  form  of  nourishment.  It  may  be  given  with 
milk  and  lime-water,  or  alone  with  water  in  the  form  of  Mellin's 
food,  or  of  any  of  the  well-prepared  extracts  now  readily  pro- 
curable. 

10.  Free  Fat  in  the  Urine. 

Instances  in  which  fat  is  found  in  the  urine  are  so  rare  that  I 
am  induced  to  record  the  following  case,  which  illustrates  a  mode 
of  entry  of  fatty  matter  into  the  urinary  tract  not  commonly 
recognised. 

J.  H.,  set.  41,  a  plumber,  was  admitted  under  my  care  in  John 
Ward  on  May  16,  1885.  A  pale,  anxious-looking  man.  Parents 
living  and  family  healthy.  His  history  was  of  severe  pain  for 
six  months  past,  shooting  through  to  front  of  belly,  across  the 

1  Ziemssen's  Cyclopgedia,  art.  "  Typhoid  Fever." 

"  Treatise  on  Coutiuued  Fevers,  edit.  i.  p.  574:  1862.    \ 


1 1 8  Clinical  Contributions  to  Practiced  Medicine. 

loins,  weakness  in  the  back,  increasing  pallor  and  wasting.  Nine 
weeks  before  admission  laid  np  with  pains  in  chest  and  right 
BlionUIer,  In  liis  chest  Ihere  was  found  some  impairment  of 
resonance  under  the  clavicles  with  harsh  respiration;  dulness  at 
the  base  of  right  lung  behind,  with  defective  breath  sounds,  some 
friction,  and  increased  vocal  resonance.  Heart — reduplicated 
second  sound  at  base.  Pulse  over  ico.  Abdominal  viscera 
apparently  natural  to  palpation  ;  some  increased  aortic  pulsation. 
Urine  1020,  acid;  no  albumin  or  glucose;  crystals  of  uric  acid, 
and  large  and  small  sized  granular  casts.  Nothing  seemingly 
wrong  with  spinal  column,  although  percussion  over  the  lower 
dorsal  region  increased  the  pain.  There  was  a  tender  spot  in  the 
right  lumbar  region,  but  nothing  definitely  wrong  could  be  felt 
tliere.  No  marked  change  for  some  days;  pain  persisting,  and 
gradually  progiessive  autenu'a  and  weakness.  IJric  acid  con- 
stantly present  in  the  urine.  Knee-jerk  found  increased  on  right 
side  and  aidde-clonus;  later  on,  both  knee-jerks  increased. 

May  20. — Some  albumin  in  the  urine  and  some  blood-streaks 
in  sputa.  Tempeiature  rose  to  100°  each  night.  Abdomen  exa- 
mined under  chloroform  on  26th  May.  No  more  than  a  ful- 
ness felt  in  the  region  of  the  pancreas,  Avitli  undue  aortic  pul- 
sation. Blood  examined,  and  red  globules  found  diminished  to 
nearly  one-half  the  normal  number;  leucocytes  i  to  180.  In- 
creasing pain  and  tenderness  in  left  and  right  hypochondria. 

June  I. — Some  small  granular  casts  in  mine.  Losing  weight ; 
is  now  two  stones  eight  pounds  lighter  than  when  in  health. 

June  6. — Pulse  108,  full  and  soft.  Same  signs  at  base  of 
right  lung. 

June  9. — Urine  1025,  acid  ;  trace  of  albumin,  and  large  num- 
ber of  fat  glohides,  also  casts  large  and  small. 

June  13. — Losing  appetite.  Crepitation  at  base  of  left  lung. 
Much  pain.  Fat  found  on  several  occasions  in  the  urine,  great 
caie  being  taken  with  all  vessels  containing  the  secretion. 

July  I. — Increasing  pallor  and  cachexia;  agonising  pain  only 
relieved  by  fi-cquent  and  full  doses  of  morpliia.  Numerous  en- 
larged glands  felt  through  abdominal  walls.  Temperature  falling. 
Hard  masses  now  felt  in  right  anterior  lund)ar  region  and  over 
the  spinal  coluum  deep  down.     Death  on  July  2, 

The  diagnosis  here  was  at  first  very  obscure.  One  thought 
of  Addison's  disease,  of  pernicious  anfemia,  of  lymph-adenoma, 
of  renal  calculus,  and  latteily  of  malignant  disease.  In  a 
clinical  lecture  on  the  case,  1  ventured  on  the  diagnosis  of  osteo- 
sarcoma, beginning  in  the  spinal  column  and  involving  the  lum- 
bar glands,  and  possibly  the  kidneys  and  bases  of  the  lungs.  I 
surmised  that  the  fiee  fat  came  perchance  from  the  detritus  of 


Clinical  Contributions  to  Practical  Medicine,  1 19 

masses  in  the  kidneys,  wliich  were  shed  gradually  into  tlie 
urinary  tract.  The  uric  acid,  so  constantly  present,  was  com- 
mon in  cases  of  cancer. 

At  the  autopsy  this  diagnosis  was  partly  verified.  The  im- 
portant changes  found  were — Costal  cartilages  partly  calcified. 
Lungs  both  adherent  over  much  of  surface,  with  many  very 
small  whitish  nodules  on  surface  and  in  substance.  Heart — 
several  whitish  masses  of  new  growth  ;  same  on  the  diaphragm 
on  its  lower  surface.  No  general  difi'iised  new  growths  in  peri- 
toneum. Liver  normal ;  intestines  and  pancreas  likewise.  Spleen 
enlarged.  Adrenals  natural.  Kidneys — pelves  dilated ;  many 
small  masses  of  new  growth  in  each,  some  breaking  down  ; 
obviously  the  source  of  the  oily  matter  shed  into  the  urine.  A 
large  mass  of  new  growth  involved  the  deep  lumbar  glands  and 
spread  up  the  pillars  of  the  diaphragm,  attacking  the  pleurae. 
Microscopical  examination  of  it  led  Dr.  IS!"orman  Moore  to  the 
opinion  that  it  was  a  sarcoma. 

1 1.  Symmetrical  Herpes  Zoster. 

L.  L.,  eet.  19,  a  fairly  well-nourished  lad,  came  to  the  hospital 
on  November  5,  1881.  He  stated  that  he  noticed  a  rash  on  his 
body  on  the  3d  instant.  It  came  out  without  any  pain.  An 
eruption  of  herpes  was  found  crossing  both  shoulders,  with  more 
symmetry  in  front  than  behind.  It  occurred  in  the  distribution 
of  the  acromial  and  clavicular  superficial  cervical  nerves.  There 
were  distinct  vesicles  on  brilliantly  red  bases,  many  of  them  be- 
ginning to  dry  up.  No  local  irritant  appeared  to  have  induced 
the  attack,  and  there  was  no  sign  of  recent  catarrhal  disturbance- 
The  lad  seemed  to  be  in  very  fair  health.^ 

12.  Boro-glyceride  as  a  Bemedy  in  Pruritus,  d:c. 

I  have  found  boro-glyceride  a  successful  remedy  in  several 
cases  of  troublesome  pruritus.  In  anal  and  pudendal  itching, 
common  in  gouty  and  diabetic  patients,  it  has  afforded  relief 
when  other  means  have  failed.  It  may  be  used  diluted  with 
water,  one  to  three  or  four,  or  in  severe  cases  pure. 

It  is  not  commonly  known  that  borax  preparations  are  much 
more  soothing  and  sedative  to  tender  and  abraded  mucous  sur- 
faces than  chlorate  of  potassium,  which  is,  locally,  somewhat  of 
an  irritant.     Glycerine  is  itself  a  penetrating  and  sometimes  an 

1  Vide  cases  reported  by  Mr.  Bryant,  Medical  Times  and  Gazette,  1865,  vol. 
i-  P-  335  ;  a-°<i  by  M:r.  B.  Squire  in  same  journal,  1873,  vol.  i.  p.  495.  (Referred 
to  in  Medical  Digest.) 


1 20  Clinical  Con&ibtttions  to  Practical  Medicine. 

iiTitatin«^  application.  The  clieraical  compound  boro-glyceiide 
seems  to  be  free  from  this  objection,  \Yhich  is  not  the  case  with 
glycerinnm  boracis. 

In  a  case  of  sore  tongue  occurring  in  association  witli  severe 
chronic  pemphigns, glycerine  of  borax  was  fonndtemporarily  the 
more  grateful  of  the  two,  keeping  the  mouth  more  moist  than 
dicl  equal  parts  of  the  boro-glyceride  and  water,  but  the  latter 
seemed  to  have  more  healing  elToct.  Honey  of  borax  seems  less 
irritating  than  the  glycerine  preparation.  A  lotion  of  boro- 
glyceride,  two  per  cent,  strength,  was  fonud  of  much  value  in  a 
very  obstinate  case  of  cystitis,  which  yielded  to  no  kind  of  treat- 
ment by  diet  and  commonly  approved  drugs.  IMy  colleagne, 
Mr.  jNIarsh,  at  my  reqnest,  began  local  treatment  by  washing ont 
the  bladder.  There  was  great  sensitiveness,  and  only  two  drachms 
of  flnid  could  at  first  be  tolerated  in  the  viscus.  This  was  gra- 
dually overcome  by  the  preliminary  use  of  a  four  per  cent, 
solution  of  cocaine,  and  thns  the  bladder  was  regularly  washed 
out,  at  first  every  two  days,  then  daily,  and  then  twice  daily. 
Great  improvement  resulted  in  about  six  weeks.  This  is  pro- 
bably the  best  method  of  treatment  for  sucli  cases  of  cystitis  as 
do  not  soon  yield  to  ordinary  means. 

13.   On  the  Necessity  of  urging  Expectoration  in  certain  Cases 
of  Lung- Disease. 

In  many  cases  of  pulmonary  disease  patients  are  apt  to  state 
that  they  have  no  expectoration.  On  examining  the  chest, 
evidence  is  foiuid  indicating  abimdant  secretion  into  and  from 
the  bronchial  tubes.  There  may  be  much  cough,  and  yet  the 
spittoon  is  I'egularly  found  empty.  It  is  well  known  that  chil- 
dren commonly  swallow  their  sputa  in  lung-disease.  Adnlts 
often  do  likewise.  The  habit  is  in  every  way  bad,  and  may  be 
pernicious.  In  cases  where  there  is  evidence  that  expectoration 
should  be  forthcoming,  I  am  in  the  habit  of  ordering  the  patient 
to  eject  everything  he  coughs  up,  and  it  is  surprising  how  much 
can  be  thns  produced  for  inspection.  Habit,  false  delicacy,  and 
ignorance  lead  patients  to  swallow  their  expectoration.  Tiie 
sputa,  being  thus  added  to  the  contents  of  the  alimentary  canal, 
interfere  with  digestion,  and  in  the  cases  of  bacillary  phthisis, 
fcetid  bronchitis,  and  empj'ema  with  bronchial  fistula,  may  add 
mischievous  products  for  inoculation  or  sei)tic  impregnation. 
And,  in  any  case,  a  prominent  sign  of  the  morbid  process  is 
Avilldield  from  onr  view.  This  may  seem  a  trivial  matter,  but 
I  deem  it  a  very  important  one,  and  commend  the  practice  I 
have  here  inculcated  for  systematic  adoption  when  necessar}'. 


TWO  CONTRIBUTIONS  TO  RENAL  SURGERY. 


W.  J.   WALSHAM. 


Although  great  strides  have  of  recent  years  been  made'  in 
renal  surgery,  this  branch  of  practice  may  figuratively  be  said  to 
be  still  in  its  infancy.  The  two  following  cases,  therefore,  which 
have  been  under  my  care  during  the  current  year,  will,  I  trust, 
be  considered  of  sufficient  interest  for  a  place  in  the  forthcoming 
volume  of  our  Eeports.  For  the  notes  of  the  cases  I  am  indebted 
to  Mr.  Edward  Jessop,  the  then  junior  house-surgeon,  to  whose 
unremitting  zeal  and  attention,  combined  with  the  watchful  care 
of  that  most  excellent  of  nurses,  Sister  Stanley,  I  cannot  but 
feel  that  the  success  attending  the  first  of  these  cases  was  in  great 
measure  due. 

Case  I. 

Calculous  Pyelitis — Nej^lirectomy — Becovery. 
(Notes  by  Mr.  Edward  Jessop.) 

M.  A.  B.,  41  years  of  age,  and  a  married  woman,  was  ad- 
mitted into  Mary  Ward,  under  the  care  of  Dr.  Wickham  Legg, 
on  March  5,  1885,  suffering  from  a  tumour  in  the  right  flank. 

The  patient  first  noticed  the  tumour  seven  months  previous  to 
her  admission  ;  she  has  had  no  severe  attacks  of  pain,  only  a 
constant  aching  in  the  lumbar  region,  intensified  on  sitting  up  or 
walking  about.  Her  urine  she  characterises  as  thick  and  creamy, 
but  the  act  of  micturition  has  been  natural.  Catamenia  have 
always  been  regular.  Confined  of  fifteenth  child  twenty-one 
months  ago. 

The  patient  is  well  nourished.     No  dropsy.     Heart  and  lungs 


122  Two  Contributions  to  Renal  Surgery. 

norninl.  Liver  not  below  ribs.  Spleen  can  be  felt  on  deep 
palpation.  Lying  close  beneatii  the  ribs  and  deep  in  the  right 
hypochondrinc  and  npper  part  of  riglit  Innibar  region  is  a  hard 
and  somewhat  nodular  tumour  about  the  size  of  a  large  orange, 
dull  to  percussion,  not  movable  from  tlie  right  loin,  and  not 
very  tender  on  pressin-e. 

Urine — passes  about  three  pints  in  twenty-four  hours;  sp.  gr, 
1025  ;  acid  ;  large  amount  of  pus  ;  one-third  albumen  (after  filter- 
ing);  276.15  grains  of  urea  in  twenty-four  hours  (Russell  and 
"West's  test).  Temperature  normal.  Pidse  natural.  Mother 
died  of  phthisis.     No  other  family  history  of  importance. 

March  20. — The  patient  was  tiansferred  to  Stanley  Ward 
under  Mr.  Walsham's  care. 

Her  condition  was  carefully  watched  for  a  fortnight,  when 
Mr.  "Walsham,  with  the  concurrence  of  other  members  of  the 
surgical  staff,  determined  to  expose  the  kidney,  and  deal  with  the 
tumour  as  circumstances  indicated. 

April  8. — The  patient  being  under  ?ether,  Mr.  Walsham, 
assisted  by  Mr.  Cripps,  made  an  incision  from  the  tip  of  last  rib 
to  about  an  inch  behind  the  anterior  superior  spine  of  the  ilium  ; 
and  having  divided  the  several  layers  of  mu.scles,  exposed  the 
tumour.  The  peritoneum,  which  had  been  carried  forward  by 
the  tumour,  was  not  seen  during  the  ojieration.  An  aspirator 
needle  was  now  introduced  into  tlie  tumour,  which  felt  tense  and 
fluctuating,  and  about  a  pint  of  clear  yellow  fluid  drawn  off.  A 
calculus  could  not  be  felt  by  the  needle,  but  on  enlarging  the 
puncture  and  inserting  the  index-finger,  a  large  branched  cal- 
culus was  found  to  occupy  the  pelvis  of  the  kidney.  Attempts 
were  made  to  extract  it  with  various-shaped  forceps  ;  and  in  this 
way  several  small  pieces  were  removed.  It  was  felt,  however, 
by  Mr.  Walsham  that  the  whole  stone  could  not  be  got  away 
without  using  great  force,  and  it  was  decided,  with  the  approval 
of  those  of  his  colleagues  who  were  present,  that  the  excision  of 
the  whole  kidney  would  be  attended  with  less  risk.  The  capsule 
was  therefore  freely  opened,  and  the  kidney  shelled  out  from 
it  with  the  finger.  The  ureter  was  then  freed  and  ligatured 
with  China  silk,  and  the  kidney  severed  from  it.  Two  straight 
ovariotomy  clamps  were  next  fixed  on  the  pedicle,  which  was  tied 
in  two  places  with  silk  ligatures,  the  ends  being  left  long,  and  the 
kidney  with  the  stone  was  brought  out  of  the  wound.  A  diainage 
tube  was  inserted,  and  the  edges  of  the  wound  were  brought  to- 
gether with  silver  sutures.  The  carbolic  spray  was  used  through- 
out the  operation,  and  carbolic  gauze  dressings  were  applied. 
The  patient  was  a  good  deal  collapsed,  and  late  the  same  evening 
the  dressings  had  to  be  changed  as  the  discharo:e  had  come 


Two  Contributions  to  Renal  Surgery.  125 

through.  She  was  given  a  draught  of  potass,  bromidi  grs.x. 
tr.  hyoscyami3ss., opium  being  thought  unadvisable.  She  vomited 
repeatedly  until  the  following  evening,  and  consequently  was 
fed  Avith  peptonised  enemata  and  Slinger's  suppositories.  She 
passed  32  oz.  of  urine,  with  a  specific  gravity  of  1026,  containing 
a  trace  of  albumen  and  126  grains  of  urea,  according  to  Eussell 
and  West's  test.  The  quantity  and  condition  of  the  urine  before 
and  after  the  0])eration  is  given  in  the  nccompanying  chart. 

April  14. — The  enemata  and  suppositories  were  left  off,  and 
the  patient  fed  entirely  on  slops  by  the  mouth  ;  40  oz.  of  urine 
were  passed,  with  a  specific  gravity  of  1025, in  twenty-four  hours, 
containing  180  grains  of  urea,  urates,  but  no  albumen  and  no 
pus.  Her  temperature  rose  to  102°  on  the  day  after  the  opera- 
tion, but  gradually  fell,  and  this  morning  was  subnormal. 

April  16. — Solids  are  now  allowed  to  be  taken.  The  wound 
has  been  dressed  every  day  and  looks  extremely  well,  the  spray 
(i  in  100)  and  carbolic  lotion  (i  in  100)  being  used. 

April  29. — The  patient  progressing  extremely  favourably.  ISIo 
pain,  sleeps  well,  appetite  good ;  temperature  never  rises  above 
100°;  the  wound  is  almost  healed,  a  siiuis  leading  downwards 
and  forwards  into  a  cavity  only  remaining.  Urine — 40  oz.,  quite 
clear,  sp.  gr.  1020;  acid;  174  grains  of  urea. 

April  30.— Temperature  102°.  She  has  been  sick  twice,  and 
there  is  a  slight  redness  round  the  wound. 

As  the  spray  and  carbolic  lotion  were  still  being  used,  it  was 
thought  the  redness  might  be  due  to  carbolic  irritation ;  the 
woimd  was  consequently  syringed  out  with  a  solution  of  iodine 
and  the  spray  left  off.  The  sickness  continued,  the  temperature 
rose  still  higher,  and  the  blush  spread,  leaving  no  doubt  that 
erysipelas  had  set  in. 

May  7. — The  patient  has  been  removed  to  Ooborn,  the  erysi- 
pelas having  spread  to  the  back  and  over  the  abdomen. 

She  seemed  to  derive  benefit  from  the  change  of  wards,  for  the 
temperature  gradually  fell  and  the  blush  diminished,  so  that 
within  a  week  all  signs  of  erysipelas  had  disappeared.  The 
ligature  was  found  loose  in  the  wound,  and  was  removed. 

May  27. — A  small  stone,  apparently  phosphatic,  came  away 
from  the  wound. 

May  29. — Patient  got  up.  The  external  wound  had  closed, 
but  a  small  collection  of  pus  having  formed,  it  had  to  be  re- 
opened. 

Her  convalescence  from  this  time  became  complete,  though  a 
sinus  still  remained. 

-July  I. — The  patient  was  sent  to  Swanley  Convalescent  Home. 
She  was  able  to  walk  about,  and  her  general  health  was  perfectly 


124 


Two  Contributions  to  Eenal  Surgery. 


good.  She  was  passing  a  normal  amount  of  liealtliy  urine.  Hor 
temperature  was  normal.  On  returning  from  Swanley  she  ex- 
])ressecl  herself  as  being  quite  well ;  but  the  sinus  had  not  healed. 
About  three  weeks  after  her  return  a  small  stone  about  the  size 
of  a  lentil  came  away  from  the  wound,  but  without  pain. 

In  the  second  week  of  October  the  ])atieut  brought  to  the 
hospital  a  silk  ligature,  which  she  said  had  come  from  the 
wound.  After  (his  the  sinus  rapidly  closed,  and  the  wound 
remains  firmly  healed.  When  last  seen  (November  i8,  1885), 
she  had  gained  flesh,  her  urine  was  healthy,  and  she  expressed 
herself  as  feeling  in  perfect  health. 

The  kidney  removed  was  reduced  to  little  more  than  a  series 
of  thin-walled  cysts.  Tlie  stone  contained  in  it  consisted  chiefly 
of  phosphates. 

UmNE  Ghaut. 

The  amount  of  urea  %oas  tested  hij  Russell  and  IFest's  apparatus. 


Date. 

Quantity. 

Sp.  Gr.     Reactiou. 

Albumen. 

Urea  in  grains 
in  24  hours. 

April    6 

60  oz. 

IO15   1      Acid 

Large  quantity. 

261 

.,       7 

40    „ 

...     : 

Do. 

174       ! 

„       8 

45   .. 

... 

200 

.,       9 

Operatiou. 

,.   '10 

32    „ 

1026 

Trace. 

126 

„     II 

32    „ 

1026 

140    ' 

.-.     12 

36   „ 

1028 

Slight  trace. 

80.184 

„     13 

34  ,. 

1026 

74.500 

:,        14 

40  „ 

1025 

Xoue. 

1S0.5 

„        15 

46  „ 

1016 

157-6 

„        16 

42   „ 

1019 

145 

,.        17 

46   „ 

1020  1 

,, 

„        18 

66  „ 

... 

212 

..       20 

60  „ 

...     i 

184 

,.       23 

40  „ 

1 

174 

„       24 

25   >. 

no 

»       25 

45   » 

164 

„       26 

30  „ 

132 

,,       27 

30  „ 

260 

„       2S 

31       M 

- .'. 

340 

■,       29 

40  „ 

»»  . 

May      2 

36  „ 

1015 

210 

,.       4 

25   „ 

1025 

175 

„      9 

30  „ 

1020 

Trace. 

... 

,>     11 

22  „ 

..     13 

26  „ 

... 

None. 

June    I 

50  » 

1020 

210 

»       8 

50  „ 

300 

„     19 

1 

45    ;, 

1016 

200 

Two  Contributions  to  Renal  Surgery.  125 


Case  II. 

Calculous  Pyelitis — Nepliro-Litliotomy — Trismus — Death — 
Einthelioma  of  Pelvis  of  Kidney. 

(Notes  by  Mr.  Edward  Jessop.) 

C.  B.,  aged  63,  married,  was  admitted  into  President  Ward, 
April  8,  1885,  under  Mr.  Walsham's  care,  \Yitli  a  tumour  in 
the  left  lumbar  region.  Patient's  attention  was  first  called  to 
the  swelling  about  five  months  ago,  on  account  of  the  pain  she 
suffered  in  that  region.  She  is  quite  unable  to  say  whether  it 
has  increased  in  size.  The  pain  has  got  much  worse  lately,  and 
she  can  now  only  obtain  ease  by  lying  on  her  back  with  the  left 
leg  drawn  up;  lying  on  either  side  inci-eases  the  pain.  The 
tumour  extends  an  inch  beyond  the  middle  line  in  front,  occupy- 
ing the  left  half  of  the  umbilical  and  the  left  lumbar  region. 
Its  margins  are  moderately  well  defined,  and  it  is  dull  all  over 
to  percussion.  It  is  tender  on  handling,  and  most  so  in  the 
lumbar  region,  and  distinct  fluctuation  can  be  felt.  During  the 
last  year  the  patient  has  been  troubled  with  frequent  micturi- 
tion, but  the  quantity  of  urine  passed  is  small,  not  more,  she 
says,  than  half  a  pint  per  diem.  She  has  never  had  to  get  up 
more  than  once  during  the  night  to  micturate,  and  the  act  is 
not  attended  with  any  pain.  She  has  only  noticed  blood  in  her 
urine  once,  about  four  years  ago,  though  she  says  the  urine  is 
always  thick  and  dark  brown  in  colour. 

With  the  exception  of  rheumatic  fever  the  patient  has  had  no 
severe  illness,  and  there  is  nothing  remarkable  in  her  family 
history. 

Urine — passes  ij  pints  per  diem;  alkaline;  sp.  gr.  1017. 
Contains  pus,  mucus,  phosphates,  and  blood. 

April  15. — Patient  has  suffered  continuous  pain  in  the  left 
side,  much  aggravated  on  movement.  It  has  been  necessary  to 
give  her  morphia  at  night  to  relieve  the  pain.  To-day  Mr. 
Walsham  aspirated  the  tumour  in  the  lumbar  region,  and  drew 
off  6  oz.  of  pus  mixed  with  a  little  blood.  A  microscopical 
examination  showed  nothing  but  pus  and  blood. 

April  21. — Since  the  time  of  the  aspiration  she  has  had  no 
return  of  the  pain  until  yesterday,  but  she  complains  of  feeling 
weaker. 

Urine — passes  i|- pints;  sp.  gr.  1020;  pus  and  blood;  157.8 
grains  of  urea  in  twenty-four  hours. 

April  29. — The  pain  in  the  left  side  has  rather  increased  than 
diminished.     The  urine  presents  the  same  characteristics,  but  is 


126  Two  ContrihuUons  to  Rend  Surgerrj. 

free  from  blood.  She  has  evidently  lost  flesh  since  being  in  the 
hospital,  and  complains  of  getting  mnch  weaker.  After  con- 
sultation with  Drs.  Duncan  and  Legg  and  several  of  the  surgical 
staff,  it  was  decided  to  explore  the  kidney  for  stone. 

May  I. — Yesterday  the  patient  was  taken  into  the  theatre, 
and  Mr.  \Yalsham,  assisted  by  Mr.  Cripps,  operated.  A  longi- 
tudinal incision  was  made  from  the  tip  of  the  last  rib  to  near  the 
crest  of  the  ilium,  and  the  several  layers  of  muscles  having  been 
cut  through,  an  abscess  cavity  was  opened,  from  which  sevei'al 
ounces  of  blood  and  pus  escaped.  The  parts  were  found  to  be 
much  matted  together  by  previous  inflammation.  Mr.  Walsham 
made  an  examination  of  the  wound  with  his  finger,  and  deep 
down  came  upon  a  large  branched  calculus  in  the  pelvis  of  the 
kidney.  This  was  removed  by  means  of  forceps  bit  by  bit,  one 
piece  measuring  as  much  as  i^  by  i^  inches,  and  another  f  inch 
by  'h  inch.  It  consisted  of  uric  acid  encrusted  with  phosphates. 
The  peritoneum  was  not  seen  during  the  operation,  it  having 
been  carried  forward  by  the  tumour.  The  spray  was  used 
throughout,  the  wound  well  washed  with  carbolic  lotion,  two 
drain  tubes  were  inserted,  the  edges  brought  together  with  wire 
sutures,  and  gauze  dressings  applied. 

May  2. — The  patient  slept  fairly  well,  but  complains  of  a 
sinking  feeling  and  great  thirst.  She  has  vomited  several  times. 
Her  temperature  is  subnormal ;  pulse  natural.  She  has  passed 
one  pint  of  urine,  sp.  gr.  1020;  no  albumen,  no  blood,  but  still 
some  pus;  158.14  grains  of  urea  in  the  twenty-four  hours.  As 
the  discharge  had  come  through  the  dressings,  these  were  changed 
under  the  carbolic  sjjray. 

May  8. — The  patient  does  not  recover  her  strength,  thongli 
she  takes  her  food  fairly  well.  The  wound  looks  healthy,  but 
there  is  a  smell  as  of  decomposing  urine  about  it.  A  distinct 
hardness  can  be  felt  in  the  region  of  the  kidney.  It  is  now 
syringed  out  with  a  weak  iodine  lotion  (3ij  to  oj),  and  iodoform 
afterwards  dusted  in.  Tiie  urine  has  a  specific  gravity  of  loio, 
and  is  very  alkaline ;  it  contains  no  albumen,  no  blood,  but  some 
pus.  About  two  pints  are  pas:<ed  in  the  twenty-four  hours,  and 
yield  220  grains  of  urea. 

On  waking  this  morning  and  trying  to  eat  some  bread  and 
butter,  the  patient  found  she  was  unable  to  open  the  mouth  suf- 
ficiently wide  to  bile.  She  has  been  unable  to  eat  anything  solid 
since,  and  is  in  a  highly  nervous  condition  for  fear  of  the  jaws 
closing  completely.  The  masseters  ar«  hard,  and  the  steruo- 
mastoids  somewhat  harder  than  natural,  but  the  abdominal 
muscles  and  the  muscles  of  the  extremities  are  not  contracted. 

May  9. — The  condition  of  the  muscles  remains  the  same,  but 


Two  Contributions  to  Benal  Surgery, 


127 


llie  patient  is  getting  weaker.  Slie  is  still  able  to  swallow  liquids, 
and  there  is  no  contraction  of  the  abdominal  muscles  or  of  the 
muscles  of  the  extremities. 

May  9,  1 1  P.M. — Patient  has  not  passed  any  urine  since  8  a.m., 
and  only  an  ounce  at  that  time.  She  has  been  sinking  fast  all 
day,  and  is  unable  to  take  liquid,  as  she  is  seized  with  violent 
coughing  whenever  any  fluid  is  poured  between  the  teeth.  She 
was  dry  cupped,  but  without  any  beneficial  effect.  She  died 
before  midnight. 

Fost-mortem. — Left  kidney — upper  end  adherent  to  the  pan- 
creas, its  substance  being  converted  in  part  into  a  multilocu- 
]ar  abscess  cavity.  The  upper  half  of  the  kidney  presented 
the  appearance  of  a  new  growth,  which  under  the  microscope 
proved  to  be  an  epithelioma.  The  ureter  could  not  be  traced  to 
the  kidney. 

Eight  kidney — twice  the  normal  size  and  fatty.  The  ureter 
was  dilated  and  pervious,  and  contained  urine. 

No  stone  was  found  in  the  right  kidney,  but  some  small  pieces 
were  found  in  the  left. 

The  friends  would  not  allow  a  further  examination  of  the  body 
to  be  made. 


Urine   Chart. 


Date. 

Quantity. 

Sp.  Gr. 

Reaction. 

Albumen. 

Blood. 

Sediment. 

Urea  In 
24  hours. 

April  23. 

i^  pints. 

A  trace. 

None. 

Pus.          157.9  grs.| 

„     24. 

I 

1020 

Alkaline. 

,, 

„ 

)  J 

96.6    „ 

»     25. 

if      ,) 

IO18 

Slightly 
alkaline. 

j> 

» 

157.3    » 

,.     27. 

li       u 

1022 

Very    do. 

,, 

,, 

I) 

79.06  „ 

„     28. 

2          „ 

I02I 

Very    do. 

>! 

,, 

!J 

140.56  „ 

„     30. 

I^        „ 

IOI9 

Alkaline. 

,, 

„ 

144.96,, 

May  I. 

Alkaline. 

Slight. 

,, 

Not'so  much. 

... 

„      2. 

I^'"„ 

I02I 

Acid. 

,, 

Tua. 

158.14,, 

„    4- 

2           ,, 

ICI5 

Slightly 
alkaline. 

" 

" 

210.86  „ 

,,     7- 

2          ,, 

IOI8 

Very    do. 

,, 

,, 

)> 

„    S. 

li       ., 

IO18 

Alkaline. 

" 

j; 

!> 

Bemarhs. — Tlie  symptoms  in  both  these  cases  pointed  clearly 
to  a  calculus  in  the  kidney,  and  the  presence  of  the  swelling  in 
the  abdomen  and  the  condition  of  the  urine  made  the  diagnosis 
almost  certain.  The  first  patient  was  admitted  under  the  care 
of  Dr.  Legg,  who,  after  some  weeks'  observation  of  her  in  the 
hospital,  had  come  to  the  conclusion  that  surgical  interference 
was  not  only  justifiable,  but  imperatively  called  for  on  account  of 


128  Two  Contrihutions  to  Renal  Surgery. 

the  pain  wliicli  she  declared,  tliough  not  excessively  severe,  ren- 
deicd  her  totally  unlit  for  her  household  duties.  She  was  quite 
willin<^,  uKMcover,  to  undergo  the  risk  of  a  serious  operation  if 
any  prospect  C(Mdd  be  held  out  to  her  of  relief.  After  consulta- 
tion with  several  of  my  colleagues  on  the  surgical  staff,  it  was 
agreed  that  an  exploration  of  the  kidney  ought  to  be  undertaken, 
and  a  calculus,  if  found,  extracted,  or  failing  to  be  able  to  do  this, 
the  whole  kidney  extirpated. 

One  of  the  chief  points  of  interest  in  connection  with  the 
case  is  the  incision  which  was  adopted.  Much  discussion  of 
late  has  arisen  at  the  various  Societies  and  in  the  Medical 
periodicals  on  the  comparative  advantages  of  the  lumbar  versus 
the  intraperitoneal  section.  The  one  adopted,  T  think,  com- 
bines many  of  the  advantages  of  both,  while  it  avoids  what 
to  my  mind,  whatever  may  be  said  to  the  contrary,  is  a  pro- 
ceeding increasing  the  danger  of  the  operation,  viz ,  opening  the 
peritoneal  cavity.  The  room  that  can  be  obtained  in  the  lumbar 
incision  is  necessarily  limited,  and  ere  now  operations  undertaken 
in  this  way  for  the  removal  of  the  kidney  have  had  to  be  aban- 
doned. It  is  true  that  where  the  kidney  has  been  found  too 
large  to  be  got  out  through  the  lumbar  incision,  this  has  been 
finally  accomplished  by  cutting  it  into  two  or  more  pieces.  Such 
a  proceeding,  however,  greatly  prolongs  the  operation,  and  is 
attended  wntli  considerable  liasmorrhage  and  increased  risk. 
Moreover,  the  wound  is  not  only  limited  but  often  deep,  and 
considerable  difficulty  in  consequence  may  attend  the  ligature  of 
the  pedicle.  In  the  lateral  incision  adopted  in  both  these  cases 
there  was  abundance  of  room,  and  more  could  have  been  obtained 
if  required  by  prolonging  the  incision  downwards.  The  pei'i- 
toneum  was  not  seen,  and  the  pedicle  was  readily  secured  from 
the  front,  instead  of  having  to  be  sought  from  behind  at  the 
bottom  of  a  deep  and  limited  wound.  A  few  days  before  the 
first  0[)eration  was  undertaken,  I  had  the  benefit  of  helping  Mr. 
Willett  to  remove  a  kidney  for  a  similar  condition,  and  1  was 
impressed  by  the  striking  advantages  of  the  lateral  incision 
which  he  then  made,  and  which,  as  far  as  I  know,  originated 
wiih  him.  He  had  previously  suggested  it  to  me  in  a  conversa- 
tion with  reference  to  my  own  case,  and  I  had,  acting  on  this 
suggestion,  piactised  it  on  the  dead  body,  in  which  I  found  that 
the  normal  kidney  could  be  removed  in  this  way  without  opening 
the  peritoneum.  With  a  kidney  of  natural  size,  however,  greater 
care  is  required  to  avoid  wounding  the  peritoneum  than  in  cases 
such  as  the  above,  where  the  peritoneum  is  carried  well  forward 
by  the  enlarged  organ.  There  is  something  to  be  said  both  for 
and  against  shelling  out  of  the  kidney  from  its  capsule  in  place 


Tloo  Contributions  to  Eenal  Surgery.  129 

■of  enucleating  the  kidney  willi  the  capsule  from  the  perirenal  fat. 
The  arguments  in  favour  of  it  are,  that  all  danger  of  injurino- 
the  peritoneum  is  avoided ;  the  suppuration  is  limited  by  the 
oapsule ;  and  where  there  is  much  inflannnatory  adhesion  be- 
tween the  capsule  and  the  perirenal  tissue,  the  kidney  is  more 
easily  got  away.  On  the  other  hand,  it  may  be  said  tliat  if  the 
■capsule  is  adherent,  a  longer  time  is  required  to  shell  out  the 
kidney,  and  that  the  condensed  capsule  which  is  left  behind  may 
form  a  cavity  apt  to  degenerate  into  a  suppurating  sinus.  On  the 
whole,  however,  I  think  the  advantages  of  leaving  the  capsule 
are  greater  than  the  disadvantages.  With  regard  to  Case  II., 
for  which  I  was  indebted  to  Mr.  Chick-Lucas,  the  symptoms 
were  very  similar  to  those  of  Case  I.  ;  and  after  the  aspiration 
and  the  removal  of  the  purulent  fluid,  appeared  almost  identical. 
The  epithelioma  was  not  discovered  at  the  operation,  or  I  should, 
as  in  Case  I.,  have  attempted  the  removal  of  the  organ.  As  the 
stone,  however,  came  away  fairly  easily,  I  followed  what  would  ap- 
pear now  to  be,  or  likely  to  become,  an  established  rule  in  surgery, 
viz.,  that  where  any  of  the  secreting  structure  remains,  the  kidney 
should  not  be  removed,  as  one  kidney  plus  a  piece  of  another  is 
better  than  only  one ;  and  that  should  the  removal  of  what  is 
left  of  the  kidney  ultimately  become  necessary  on  account  of  the 
wound  remaining  as  a  suppurating  sinus,  there  would  be  less 
risk  of  removing  such  a  shrunken  mass  than  the  enlarged  cystic 
organ.  In  Case  I.  the  stone  was  so  firmly  impacted,  sending 
branches  as  it  did  in  all  directions,  that  its  forcible  removal 
could  only  have  been  accomplished  with  a  great  deal  of  lacera- 
tion and  heemorrhage,  and  hence,  it  was  felt,  with  greater  risk 
than  that  which  would  attend  the  extirpation  of  the  whole  organ. 
The  two  small  stones  which  esca])ed  from  the  wound  during  con- 
valescence I  imagine  might  be  due  to  deposit  from  some  urine 
which  had  regurgitated  up  the  ureter  from  the  bladder,  or  they 
might  have  existed  at  the  time  of  the  operation  in  the  ureter 
below  the  spot  where  the  ligature  had  been  applied,  in  either 
case  effecting  their  escape  by  causing  ulceration  of  the  walls  of 
the  ureter.  I  am  not  aware  that  this  phenomenon  has  before 
been  observed.  The  epitheliomatous  growth  which  was  found 
at  the  post-mortem  examination  was  probably,  as  may  be  inferred 
from  the  history  of  the  case  and  the  size  of  the  stone,  the  result 
of  the  irritation  of  the  impacted  calculus.  A  somewhat  similar 
condition,  viz,  an  epitheliomatous  growth  in  the  gall-bladder, 
apparently  depending  upon  the  irritation  of  biliary  calculi,  may 
be  seen  in  a  specimen  recently  added  to  the  Museum. 


VOL.  XXI. 


VARIOLA  AS   SEEN   IN  THE    CASUALTY 
DEPARTMENT. 


A.  HAIG,  M.  B. 


As  in  the  nine  months  preceding-  July  18S5  upwards  of  100 
cnses  of  variohi  have  been  certified  and  sent  off  from  the  hospi- 
tal, while  in  eighteen  months  before  that  the  number  of  cases 
hardly  amounted  to  30,^  I  think  that  a  few  notes  on  some  of 
these  recent  cases  and  the  points  in  diagnosis  they  raise  or  ilhis- 
trate  may  be  of  interest. 

I  propose  to  give  a  short  account  of  two  cases  which  led  to 
errors  in  diagnosis,  and  then  to  say  a  few  words  on  the  general 
ty[)e  of  cases  seen,  as  well  as  on  some  cases  of  other  diseases 
which  raised  the  question  of  variola. 

The  first  case  is  that  of  S.  S.,  fet.  45,  a  large  and  powerful  man, 
by  trade  a  waste-paper  dealer,  who  came  into  my  room  on  Nov- 
ember 7,  1884,  saying  that  he  was  subject  to  bilious  attacks,  but 
had  had  a  much  more  severe  attack  than  usual  during  the  last 
five  days. 

He  had  had  pain  between  the  shoulders  and  been  sick.  This 
morning  he  noticed  a  rash  all  over  him,  which  on  examination 
was  seen  to  consist  of  thickly  scattered  petechise,  in  some  places, 
especially  at  the  back  and  sides  of  the  neck,  inclined  to  be  raised 
and  papular;  in  other  parts  among  the  petechia  were  small  flat 
circular  htemorrhages  ("ink  spots"). 

The  rash  was  very  thick  between  the  scapuke  behind,  and  on 
the  legs  the  "ink  spots"  were  more  numerous  than  elsewhere. 

He  said  he  felt  better  now  than  he  had  done  during  the  last 
few  days. 

He  passed  some  water,  and  it  was  seen  to  be  almost  pure 

^  I  am  indebted  for  this  information  to  a  record  kept  by  Mr.  Waymaik  of  all 
cases  certified. 


13-2  Variola  as  Seen  in  the  Casually  Department. 

blood  ;  lliis  was  the  first  time  he  had  noliced  it  to  be  so.  Under 
the  microscope  it  showed  nothing  but  blood,  no  casts  of  any 
description.     Tiie  temperature  was  raised  a  little  over  ioo°. 

My  first  impression  was  that  it  was  a  case  of  hfemorrhagic 
variola,  from  the  symptoms  and  the  somewhat,  to  my  mind, 
])apular  tendencies  of  the  rash  on  the  neck.  I  was,  however, 
rather  put  out  by  the  hajmatnria;  and  as  there  were  other 
opinions  in  the  field,  I  unfortunately  did  not  hold  to  my  opinion 
very  strongly. 

The  patient  was  taken  into  Luke  Ward,  where,  bowever,  he 
was  treated  with  some  susj)icion,  isolated  as  much  as  possible, 
and  carefully  watched. 

While  in  the  ward,  during  the  afternoon  and  evening  of  the 
7th  and  the  morning  of  the  8th  November,  before  being  trans- 
ferred to  Homerton,  the  following  notes,  which  Dr.  Gee  has 
kindly  allowed  me  to  see,  were  taken  : — 
Nov.  3  and  4. — Felt  seedy. 

Nov.  5. — Vomiting  almost  conlinuous;  no  shivering ;  general 
pain  not  more  marked  in  loins.  (He  had  told  me  that  it  was  most 
maiked  between  the  scapulae.) 

Nov.  7. — Rnsli  on  right  arm,  then  left,  and  very  soon  became 
general.     Urine  noticed  bloody. 

Nov.  7,  evening. — Flushed,  febrile.  Tongue  fine  white  fur  over 
the  whole  dorsum.  A  few  papules  on  face  round  mouth  and  nose. 
General  highly-marked  purpura  over  body,  arms,  and  legs,  chiefly 
in  the  groins  and  on  chest  and  abdomen,  also  on  wrists.  A 
few  papules  on  wrists  and  chest.  No  vesicles.  Urine  1018  ; 
obviously  contains  blood. 

Nov.  8. — Sore  throat.  Last  night  slept  a  little;  no  delirium. 
Haamorrhage  under  conjunctivae  ;  also  into  soft  palate  and  fauces. 
Vesicles  about  face,  wrists,  and  other  parts. 

Temperature. —  November  7,  on  admission,  101.8°;  later, 
102°.     November  8,  it  fell  to  100°. 

The  diagnosis  of  h£emorrhagic  variola  having  been  made,  lie 
was  sent  to  Homerton  Hospital,  and  it  was  afterwards  ascertained 
that  he  died  within  twelve  hours  of  admission  there. 

I  may  say  that  when  first  seen  on  the  7th,  and  then  only 
about  thirty-six  hours  before  death,  he  had  by  no  means  the  a])- 
pearance  of  a  patient  suffering  from  severe  disease ;  he  took  his 
turn  on  the  forms  with  the  rest  of  the  patients,  walked  strongly 
and  steadily,  and  spoke  somewhat  cheerfully  about  his  bilious 
attacks. 

The  other  interesting  case  is  that  of  H.  C,  aged  11  months, 
who  was  brought  by  his  mother  to  the  Casualty  Department  on 
February  2,  1885.     The  history  she  gave  was  that  he  had  been 


Varioht  as  Seen  in  the  Gasiialtij  Lejxirtment.  133 

ill  since  the  31st  Jaiinaiy,  and  on  the  night  of  1st  February  a 
rash  had  come  out.  The  child  had  been  very  sick  all  night  and 
could  take  no  food.  She  said  that  about  a  month  ago  a  man  had 
iiad  small-pox  in  the  house  in  which  she  lives,  but  in  different 
rooms. 

Present  condition. — The  rash  was  confined  to  the  arms,  legs, 
and  face  ;  none  on  the  body.  On  the  face  it  was  most  round 
the  mouth  and  on  the  cheeks ;  very  little  on  the  forehead. 

The  condition  of  the  arms  was  as  follows  : — 

There  was  a  general  erythema  over  the  whole  arm,  most 
on  the  upper  part ;  thickly  scattered  through  this  were  slight 
circular  wheal-like  elevations,  giving  the  feel  of  very  thin  discs  of 
gelatine  under  the  skin,  and  in  the  centre  of  each  was  a  minute 
dark  red  spot ;  so  that  the  whole  somewhat  resembled  the  wheals 
caused  in  some  skins  by  tiie  bite  of  a  flea.  Other  wheals  were 
more  or  less  covered  with  pin-head  petechise,  apparently  spread- 
ing from  the  central  spot,  blending,  and  becoming  irregular. 
On  other  parts,  especially  on  the  back  of  the  hands,  were  larger 
ecchymoses  and  vibices. 

The  child  had  been  vaccinated  at  four  months  old,  and  on 
the  upper  part  of  the  left  arm  were  four  laige  scars  from  the 
operation.  As  no  satisfoctory  diagnosis  could  be  arrived  at,  the 
case  was  isolated,  and  I  saw  it  again  in  two  hours'  time,  when  I 
had  seen  all  the  other  patients. 

In  these  two  hours  the  rash  had  altered  considerably.  The 
hsemorrhage  had  much  increased,  and  all  the  wheals  were  now 
nearly  completely  covered  with  irregular  groups  of  petechise. 
There  was  much  increase  of  haemorrhage  in  the  spots  on  the 
face ;  still  no  spots  or  petechife  on  the  body.  There  were  plenty 
of  spots  and  petechiee  on  the  legs.  As  the  prevailing  opinion 
was  in  favour  of  its  being  a  case  of  hsemorrhagic  variola,  I  wrote 
a  certificate  to  that  effect,  and  the  child  was  removed  to  the 
Homerton  Hospital.  The  mother  said  that  the  urine  was 
natural.  I  regret  that  the  temperature  was  not  taken ;  but  I 
think  that,  with  so  much  illness  as  the  child  had  had  the  night 
before,  it  would  very  probably  have  been  raised,  even  if  the 
disease  were  only  purpura ;  while,  on  the  other  hand,  the  tem- 
perature may  be  nearly  or  quite  normal  in  hsemorrhagic  variola. 
(See  Dr.  Collie's  article  on  "  Small-pox  "  in  Qiiain's  Dictionary.) 

But  for  the  marks  of  recent  and  successful  vaccination,  I 
should  have  been  ready  to  believe  that  it  was  some  form  of 
hsemorrhagic  variola,  of  which  I  had  only  seen  one  case  ;  but,  on 
account  of  the  vaccination,  I  wrote  to  Homerton  to  ascertain,  if 
possible,  the  further  history  of  the  case,  and  received  in  reply  an 
invitation  from  the  medical  officers  to  come  and  see  the  child,  as 


1 34  Variola  as  Seen  in  the  Casualty  Department. 

they  considered  it  to  be  a  case  of  purpura  simplex,  and  be  was 
now  convaleschig. 

I  tberefore  went  to  Homerton  on  February  6th,  and  saw  the 
child,  and  was  able  to  identify  some  of  the  spots  I  have  de- 
scribed. The  wlioal-like  ones  had  a  pigmented  line  at  their 
margin,  and  an  irregular  patch  of  fading  pigment  in  their 
centre.  The  petechia  and  vibiccs  were  undergoing  similar 
changes. 

The  chikl  seemed  pretty  lively,  slept  and  took  well.  The  rasli 
had  been  confined  to  the  lace,  arms,  and  legs,  with  the  exce])tion 
of  a  few  petecln'je  on  the  upper  part  of  the  cliest  down  to  the  level 
of  the  third  rib. 

There  was  a  small  patch  of  hn?morrhage  on  the  ujiper  gums, 
and  the  notes  said  that  the  motions  had  been  black,  and  that 
one  distinctly  contained  blood. 

The  fact  that  the  chikl  recovered  is  pretty  strong  proof  that 
it  was  not  variola  ;  though  Dr.  Collie  admitted  that  at  first  there 
was  a  good  deal  to  be  said  for  the  diagnosis  of  haimorrhagic 
variola.  It  was  probably  purpura,  and  the  rash  that  I  have 
attempted  to  describe  seems  to  correspond  pretty  closely  with 
that  spoken  of  in  text-books  as  ])urpura  urticans.^ 

Note. — I  saw  this  child  again  in  September  1885,  when  he 
came  to  the  Casualty  Department  with  a  cough  and  some  ble- 
pharitis, but  seemed  otherwise  fairly  healthy  and  well  nourished. 

With  regard  to  diagnosis  of  the  cases  generally,  by  far  the 
greater  number  were  of  the  discrete  type,  and  where  the  rash 
was  fairly  well  out,  and  had  been  preceded  by  some  of  the 
characteristic  symptoms,  as  ])ain  in  the  back,  vomiting,  headache, 
&c.,  did  not  present  much  difficulty.  A  large  number  of  patients 
remarked,  or  readily  admitted  when  asked,  that  they  felt  consider- 
ably better  since  the  rasli  had  come  out. 

The  condition  of  the  tongue  varied  considerably,  and  also 
the  temperature,  being  so  often  normal  when  the  rash  was  out, 
that  after  a  time  I  gave  up  taking  it. 

Cases  with  small  discrete  papules  and  a  well-maiked  erythema 
may  make  one  think  of  scarlatina,  especially  if  they  complain 
of  sore  throat,  as  in  the  case  of  a  giil  of  16,  a  patient  of  Dr. 
Herriugham.  She  had  erytliema  of  breasts,  lower  chest,  and 
upper  abdomen,  not  elsewhere,  and  complained  of  sore  throat, 
though  there  was  nothing  to  be  seen  there.  She  had  some 
scattered  papules  on  the  face  and  arms,  and  a  temperature  of 
100.2°. 

^  See  "A  Treatise  ou  the  Theory  and  Practice  of  iledicine,"  by  J.  S.  Bristowe, 
ed.  iv.,  p.  29S. 


Variola  as  Seen  in  the  Casualty  Department.  135 

I  went  to  this  patient's  liome  in  the  afternoon,  and  found  her 
brother,  aged  14,  in  ahnost  precisely  the  same  condition,  except 
that  in  him  the  erythema  was  on  the  lower  abdomen  and  upper 
part  of  the  thighs — its  most  common  position,  according  to  I)r, 
Collie.  I  have  since  seen  one  case  where  there  was  apparently 
a  universal  erythema  along  with  early  papules ;  but  if  this  case 
had  been  seen  before  there  were  any  papules,  and  if  there  were 
also,  as  in  the  above  cases,  high  temperature  and  sore  throat,  I 
do  not  see  how  the  diagnosis  from  scarlatina  could  have  been 
made,  for  of  the  premonitory  symptoms,  headache  and  vomiting 
might  belong  to  either  disease,  and  in  either  the  rash  might 
appear  on  the  second  da}',  while  pain  in  the  back  might  not  be 
})resent. 

With  regard  to  pain  in  the  back  as  a  diagnostic  symptom  of 
the  invasion  of  variola,  the  following  case  will  show  that  it  must 
be  weighed  with  some  caution,  even  when  it  is  well  marked  and 
severe. 

J.  H,,  aged  22,  by  trade  a  blacksmith's  assistant,  and  a  tall 
and  powerful  man,  says  that  yesterday  afternoon  he  felt  ill,  and 
in  the  night  he  was  awoke  by  a  violent  pain  in  the  back,  which 
has  continued. 

He  looks  pale  and  ill,  and  is  evidently  in  considerable  pain. 

Temperature  101°.  Tongue  slight  fur.  Feels  sick,  and  has 
taken  nothing  since  last  night.     Says  he  has  been  shivering. 

Urine  clear,  acid,  no  albumen. 

No  rash  anywhere. 

One  rather  indistinct  vaccination  mark  on  the  left  shoulder, 
dating  from  infancy. 

I  considered  that  variola  was  probal)le,  and  certified  accordingly. 
I,  however,  wrote  to  the  medical  officer  of  the  hospital  ship  to 
which  he  was  sent  to  inquire  about  him,  and  nine  days  later  I 
heard  from  the  medical  officer  that  no  eruption  had  developed, 
and  that  revaccination  was  successful ;  and  he  adds,  "  We  were 
unable  to  trace  a  cause  of  the  fever,  and  diagnosed  febricula." 

Where  the  rash  of  variola  is  confluent  on  the  face  and  the 
papules  are  somewhat  flattened,  it  may  resemble  a  papular 
syphilide,  but  the  history  will  generally  prevent  mistakes. 

On  the  body  also  syphilitic  papules  may  resemble  those  of 
variola  at  first  sight,  though  if  the  rash  is  examined  all  over  the 
body,  the  resemblance  generally  disappears;  and  I  remember  one 
case,  that  of  a  patient  under  Mr.  Bruce  Clarke,  wdiere  the  rash 
in  one  part  of  the  body  had  the  characters  of  the  papules  of 
syphilis,  in  another  part  presented  umbilicated  vesicles  almost 
indistinguishable  from  those  of  variola.  And  I  am  indebted  to 
Mr.  Bruce  Clarke  for  the  information  that  this  case  was  kept 


136  Variola  as  Seen  in  the  Casualty  Department. 

under  observation  and  developed  110  oilier  symptoms  of  variola  ;, 
and  furllier,  lliat  this  so-called  variola-form  sypliilide  is  described 
by  several  writers  on  syphilis.  Of  course  the  fact  above  men- 
tioned, that  the  rash  was  in  quite  different  stages  in  different 
parts  of  the  body,  was  greatly  against  variola  ;  but  in  other  cases 
the  history  might  require  to  be  taken  into  account,  the  chief 
point  in  it  being  the  slow  development  of  the  syphilitic  as  com- 
pared with  the  variolous  eruption. 

The  papular  form  of  copaiba  rash  may  now  and  then  bear  :t 
superficial  resemblance  to  that  of  variola,  but  in  a  case  of  this 
kind  of  which  I  have  notes,  the  rash  on  the  face  was  not  shotty, 
and  rather  resembled  measles  in  colour  and  arrangement,  though 
a  normal  temperature  helped  to  exclude  this;  the  breath  smelt 
strongly  of  copaiba,  and  the  urine  contained  it.  Two  days  later 
the  rash  had  completely  disappeared  from  the  face,  and  there 
was  no  trace  of  the  resin  in  the  urine. 

In  varicella  the  eruption  is  not  all  in  one  stage ;  while  there 
are  papules  in  some  parts,  there  are  vesicles  in  others.  There  will 
probably  be  more  spots  on  the  back  than  elsewhere,  and  gener- 
ally on  the  upper  part  of  the  back,  or  about  the  shoulders  or 
axillce,  there  may  be  found  several  pure  crystal  vesicles,  globular, 
not  umbilicated,  and  with  little  or  no  areola.  As  to  general 
symptoms,  I  have  seen  one  or  two  cases  that  I  took  to  be  vari- 
cella accompanied  by  considerable  constitutional  disturbance; 
and  Dr.  Collie  says  that  the  eruption  of  varicella  is  followed  by 
a  rise  of  temperature,  that  of  variola  by  a  fall. 

Where  the  characters  of  the  rash  are  doubtful,  the  presence  of 
good  primary  vaccination  marks  in  a  child  under  10  or  1 1  years 
of  age  should,  I  think,  throw  a  doubt  on  the  diagnosis  of  variola  ; 
but  above  this  age  it  should  not  count  for  so  much,  and  varicella 
also  is  much  less  common  after  this  age  than  before  it. 

One  case  (probably  rheumatic)  with  a  very  peculiar  eruption, 
in  some  parts  reminding  one  of  erythema  nodosum,  and  in  others 
formed  of  papules  either  scattered  or  grouped,  was  thought  by 
some  who  saw  it  at  first  to  be  perhaps  some  form  of  variola ; 
but  there  were  pretty  distinct  joint  symptoms.  The  tempera- 
ture was  raised,  and  the  history  was  certainly  not  characteristic 
of  variola.  The  case  was  taken  into  the  wards,  and  was  there 
treated  with  salicylate  of  soda,  and  in  a  week  was  convalescing 
and  the  rashes  fading.  "With  regard  to  this  case,  Dr.  Collie 
mentions  acute  rheumatism  with  a  pustular  eruption  as  one  of 
the  things  which  may  be  mistaken  for  variola;  but  I  don't  know 
whether  the  papules  in  this  case  ever  became  pustules. 


A  CONTRIBUTION  TO  THE  TOPOGRAPHICAL 
ANATOMY  OF  THE  SPINAL  CORD. 


HOWAED  H.  TOOTH,  M.B. 


Although  considerable  advances  have  been  made  of  late  years 
in  the  anatomy  of  the  central  nervous  system,  yet  it  appears  that 
the  topographical  anatomy  of  the  spinal  cord  is  still  far  from 
complete. 

The  methods  by  which  our  present  knowledge  has  been  ob- 
tained are  pathological,  physiological  (Waller's  method),  and 
embryological.  Of  these  methods,  the  former  has  yielded  by  far 
the  most  important  results.  The  study  of  the  development  of 
the  various  tracts  is  highly  interesting  and  important,  but  has 
so  far  done  little  more  than  confirm  the  facts  already  established 
by  pathology.  The  methods  used  by  Waller  to  demonstrate 
the  course  of  the  fibres  in  nerves  has  not  been  applied  with 
very  great  success  to  the  cord  at  present,  owing  to  the  surgical 
difficulties  attending  operations  on  so  delicate  an  organ.  But 
the  facts  established  by  Waller  ^  can  be  applied  to  the  bundles 
of  nerve-fibres  composing  the  white  matter  of  the  spinal  cord, 
and  it  is  on  these  facts  that  is  based  our  knowledge  of  ascending 
and  descending  lesions. 

Cruveilhier^  was  the  first  to  notice  that  in  lesions  of  the 
motor  tract  degeneration  of  a  certain  part  in  the  cord  followed. 
But  Tiirck^  in  1851  was  the  first  to  treat  systematically  of 
descending  lesions  in  the  lateral  and  anterior  columns ;  and  in  a 
further  research  in  1853  he  discussed  the  ascending  degeneration 
in  eight  cases  of  compression  of  the  cord  from  Pott's  disease, 
tumours,  &c.     Of  the  ascending  changes,  he  describes  in  six  cases 

^  Waller,  Comptes  Rendus,  November  23,  1851. 

^  Cruveilhier,  Anafc.  pathologique,  vol.  xxxii.  p.  15. 

3  Tiirck,  Sitzungsberichte  der  Akad.  der  Wissenschaf t  in  "VVien,  1851  and  1853. 


138  Topographical  Anatomy  of  the  Spinal  Cord. 

degeneration  of  the  tract  known  as  the  posterior  median,  or 
postero-internal  column,  and  lie  also  recognises  a  narrow  Land 
situated  outside  the  pyramidal  tract  in  the  lateral  column,  which 
has  been  since  traced  by  Flochsig  to  the  cerebellum,  and  is 
now  known  as  the  direct  cerebellar  tract.  Thus  it  will  appear 
that  it  is  to  Tiirck  that  we  are  indebted  for  a  great  deal  of  our 
knowledge  of  these  tracts,  and  that  we  have  not  made  any  very 
great  progress  in  the  pathology  of  them  since  his  time. 

At  present  there  are  recognised  two  definite  tracts  of  descend- 
ing or  motor  fibres,  namely,  the  direct  i^yramidal  tract  in  the 
anterior  column,  and  the  crossed  pyramidal  tractm  the  posterior 
segment  of  the  lateral  column.  There  are  also  two  definite 
bundles  of  ascending  or  sensory  fibres,  the  posterior  median 
column,  and  the  direct  cerebellar  tract. 

There  are  still,  however,  two  considerable  areas  to  be  accounted 
for — first,  alai'ge  wedge  of  white  matter  included  between  the 
posterior  median  column  and  the  posterior  root,  called  the 
postero-external  column,  the  piosterior  radicidar  zone,  or  the 
fasciculus  cuneatus  ;  second,  a  large  area  in  the  lateral  column, 
bounded  anteriorly  and  internally  by  the  anterior  horn  of  the 
grey  matter,  posteriorly  by  the  crossed  pyramidal  and  direct 
cerebellar  tracts  combined,  and  externally  by  the  pia  mater  ;  this 
tract  has  been  called  by  Flechsig  the  "  mixed  tract." 

The  posterior  radicular  zone  certainly  contains  ascending  fibres, 
for  in  compression  of  the  cord,  if  the  section  be  taken  close 
above  the  constricted  spot,  the  whole  of  the  posterior  coUunns 
may  be  found  degenerated.  Tliis  is  shown  very  well  in  the 
figures  illustrating  Bouchard's  paper  ^  on  secondary  degenera- 
tions ;  also,  though  to  a  less  degree,  in  figs.  7  and  8  of  this 
article.  But  a  very  little  way  above  the  lesion  the  degeneration 
is  found  to  be  confined  to  the  posterior  median  columns  only. 
It  is  more  than  probable  that  large  numbers  of  the  posterior  root- 
fibres  pass  straight  into  this  column,  instead  of  passing  into  the 
grey  matter,  and  so  into  the  posterior  median  column  to  the 
brain.  This  afi'ords  an  explanation  of  the  pains,  anassthesia,  and 
loss  of  knee-jerk  in  sclerosis  of  this  posterior  radicular  zone. 

It  is,  however,  to  the  comparatively  unexplored  "  mixed  tract " 
that  I  wish  to  draw  particular  attention.  In  his  work  on  the 
Diagnosis  of  diseases  of  the  spinal  cord,  Dr.  Gowers  mentions  a 
case  of  fracture  of  the  vertebrce  low  down  in  the  spinal  column, 
with  crushing  of  the  cord  at  that  spot.  Six  months  after  the 
accident  the  patient  died,  and  well-marked  ascending  change  of 
the  posterior  median  cobmin  was  found.  But  there  was  also 
noted  and  figured  by  him  a  small  patch  of  sclerosis  occupying  a 

^  Bouchird,  Arch.  Gen.  de  Med.,  1 866,  t.  vii.  viii. 


Topogra-pliical  Anatomy  of  the  Spinal  Cord.  139 

wedge-sliaj)ed  area  in  the  mixed  tract.  The  interest  of  Dr. 
Gowers'  case  is  greatly  enhanced  by  the  fact  that  the  direct 
cerebellar  tract  was  not  affected  owing  to  the  injury  being  so  low 
down  in  tlie  cord.  The  cerebellar  tract  is  supposed  to  receive 
fibres  all  the  way  up  from  the  ganglion  cells  of  the  vesicular 
column  (of  Clarke),  and  therefore  the  lower  down  the  injury,  the 
fewer  of  these  fibres  will  be  degenerated.  Now,  the  tract  de- 
scribed by  Dr.'Gowers  has  been  figured  by  several  observers.  Dr. 
Bastian  ^  in  1867  describes  a  case  of  injury  to  the  cervical  cord, 
with  resulting  secondary  lesions,  and  in  one  of  his  figures  this 
ti-act  is  undoubtedly  affected,  but  it  is  in  direct  continuity  with 
the  cerebellar  tract, 

WestphaP  again  in  1879,  in  a  case  of  combined  lateral  and 
posterior  sclerosis  of  the  dorsal  region,  figures  in  one  of  the  cervical 
sections  a  distinct  wedge-shaped  area  in  the  mixed  tract,  in 
addition  to  the  direct  cerebellar  tract.  Another  striking  case  is 
given  by  Westphal^  in  1880  of  compression  of  the  cord  by 
tumour;  here  in  some  of  the  sections  this  same  degeneration  is 
very  evident.  Among  other  observers  may  be  mentioned  Kahler 
and  Pick,*  Sliiimpell,^  and  Leyden.*^  None  of  these  writers, 
however,  have  drawn  particular  attention  to  this  tract,  but  have 
apparently  considered  it  as  part  of  the  cerebellar  tract.  In  no 
case  was  the  cerebellar  tract  free  from  degeneration,  as  in  Dr. 
Gowers'  case.'^ 

A  veiy  important  observation  has  been  made  by  Becliterew^ 
in  connection  with  the  development  of  this  tract.  He  describes 
a  bundle  corresponding  in  situation  to  the  one  in  question  as 
developing  at  an  earlier  period  than  the  jiyramidal  tract,  and 
later  than  the  rest  of  the  lateral  column.  Bechterew  considers 
that  the  fibres  of  this  bundle  are  sensory  and  give  passage  to 
})ain  sensations.  He  does  not  appear  to  have  known  of  Dr. 
Gowers'  observation. 

The  case  about  to  be  narrated  will,  I  hope,  help  to  substantiate 

^  Bastian,  Med.  Chi.  Trans.,  1S67,  p.  499. 

^  Westphal,  Archiv  fiir  Psychiatrie,  1879,  p.  413. 

^  Westphal,  Ibid.,  1880,  p.  788. 

■*  Kahler  and  Pick,  Ibid.,  1880,  p.  179. 

5  Striimpell,  Ibid.,  1880,  p.  676. 

^  Leyden,  Zeitschrift  fiirkliu.  Med.,  1880. 

^  Dr.  Byrom  Bramwell  in  his  "Diseases  of  the  Spinal  Cord"  shows  a  drawing 
of  a  case  of  ascending  degeneration  in  the  naixed  tract  on  one  side,  secondary  to 
Pott's  disease.  The  posterior  median  columns  are  sclerosed,  but  not  the  cere- 
bellar tract.     He  makes  very  little  comment  upon  it. 

Dr.  Hadden,  Pathological  Transactions,  1881,  describes  a  case  of  symmetrical 
patches  of  sclerosis  in  the  same  tract,  but  there  is  no  change  in  the  posterior 
median  column,  neither  is  there  any  history  attaching  to  the  case. 

^  Bechterew,  St.  Petersburg  Psycbiatrische  Gesellschaft,  December  1S84. 
Abstract  in  Neurolog.  Centralblatt,  1885,  p.  155. 


140  Topographical  Anatomy  of  the  Spiiml  Cord. 

the  claim  this  little  tract  has  to  he  considered  one  of  the  ascend- 
ing hnndles  of  fihres  of  the  lateral  cohimn. 

As  to  the  destination  of  the  tract  in  question,  all  that  can  be 
said  at  present  is  that  the  degenerated  fibres  marking  its  course, 
in  the  case  about  to  be  described,  cease  as  a  separate  lesion  by 
nbout  the  level  of  the  first  cervical  nerve-roots.  It  is  possible 
that  the  fibres  take  the  same  course  as  the  cerebellar  tract. 

There  is  great  probability  that  the  function  of  this  tract  is  to 
conduct  pain  sensations.  This  is  Bechterew's  opinion,  and  it  is 
borne  out  by  a  case  reported  by  Dr.  Gowers  ^  of  gunshot  injury 
involving  the  anterior  part  of  the  lateral  column  between  the 
first  and  second  cervical  nerves.  Here  there  was  distinct  loss  of" 
sensation  to  pain,  but  not  to  touch. 

I  am  indebted  to  Mr.  Morrant  Baker  for  permission  to  report 
the  following  case,  and  to  Mr.  Bowlby,  who  made  the  post- 
mortem, for  the  spinal  cord. 

Fracture  -  dislocation  of  fifth  and  sixth  dorsal  vertehrce  — 
Corresponding  transverse  crushing  of  the  cord — Hcemor- 
rhage  into  7-ight  half  of  cord  between  first  and  second  dorsal 
roots — Total  paraplegia  and  parancesthesia  heloio  level  of 
sixth  ribs — Sacral  decubitus — Secondary  degeneration  of 
certain  tracts  of  co7'd  above  and  beloio  the  lesion.    {See  plate. ) 

The  main  facts  of  the  case  as  gathered  from  the  ward  notes 
are  as  follows : — 

H.  W.,  £et.  54,  a  scafFolder,  was  admitted  into  Harley  Waid 
on  September  9,  1884.  He  had  fallen  from  a  scaffold  16  feet 
high,  on  his  back,  across  a  wall.  He  w^as  sensible  on  admission, 
but  had  total  loss  of  sensation  and  power  in  the  lower  extremi- 
ties, and  in  the  trunk  to  the  level  of  the  sixth  ribs. 

Breathing  was  quite  diaphragmatic.  Great  pain  in  the  upper 
part  of  back  and  chest.  No  knee-jerk,  ankle-clonus,  cremas- 
teric, or  abdominal  reflex  could  be  elicited  on  admission,  but  the 
epigastric  reflex  was  present  on  the  right  side.  Two  months 
atter  admission  it  was  noted  that  on  pinching  the  lower  part  of 
the  thigh  the  ham-string  muscles  contracted ;  but  there  was  no 
sole  reflex.  The  state  of  the  deep  reflexes  was  unfortunately 
not  noted  at  this  time.  There  was  complete  atony  of  bladder 
and  rectum.  Six  weeks  after  admission  extensive  bedsores  ap- 
peared, which,  however,  w^ere  rapidly  healing  before  death. 

The  patient  developed  hectic  temperature,  sank,  and  died 
January  30,  1885.  He  had  lived  twenty  weeks  and  four  days 
after  the  injury. 

1  Gowers,  Clin.  Soc.  Trans.,  vol.  xi.,  1S77. 


Topographical  Anatomy  of  the  Spinal  Cord.  141 

Post-mortem. — Brain,  thoracic,  and  abdominal  viscera  natural, 
except  the  kidneys,  of  which  the  pelves  were  dilated  with  puru- 
lent urine  ;  numerous  small  abscesses  were  scattered  throughout 
the  cortex  and  ])yramids.  Through  the  middle  of  the  bodies  of 
the  fifth  and  sixth  dorsal  vertebrae  had  been  fractures  now  firmly 
united.  There  was  some  deviation  of  the  column  at  this  point, 
the  fractured  bodies  being  twisted  on  their  long  axes.  The 
spinous  processes  had  been  driven  inwards  and  formed  an  ano-le, 
narrowing  the  canal,  but  not  to  such  an  extent  as  to  compress 
the  cord  closely.  The  spines  were  fixed  by  callus,  and  there 
was  some  thickening  of  the  dura  mater.  The  membranes  were 
not  torn. 

Condition  of  the  cord. — Opposite  the  fifth  dorsal  vertebra  the 
cord  was  markedly  constricted ;  in  fact,  it  had  the  appearance 
of  having  been  cut  across  without  injury  to  the  membranes,  in 
the  same  way  as  the  middle  coat  of  an  artery  is  cut  by  the  liga- 
ture. This  must  have  been  done  by  the  dislocation  of  one  of  the 
fragments  of  the  fractured  vertebrae,  the  dislocation  probably 
being  reduced  by  the  moving  of  the  patient.  In  the  region  of 
the  injury,  above  and  below,  the  cord  is  very  soft,  probably  owing 
to  myelitis  spreading  from  the  lesion.  No  ascending  or  descend- 
ing changes  could  be  seen  by  the  naked  eye. 

Microscopical  examination. — The  cord  was  hardened  m 
Miiller's  fluid  for  about  fourteen  days  in  the  incubator.  Sections 
were  cut  in  parafiin  principally,  but  in  the  softened  regions 
celloidin  was  found  necessary,  as  recommended  by  Scliief- 
ferdecker.^  The  staining  method  which  gave  the  best  results 
was  the  haematoxyliu  method  instituted  by  Professor  Weigert 
of  Leipzig.^  By  this  means  the  medullated  nerve-fibres 
only  are  stained  a  deep  purple,  the  grey  matter  and  areas  of 
degeneration  being  left  yellow.  The  result  is  au  almost 
diagrammatic  representation  of  the  degenerated  areas.  Picro- 
carmine  was  not  so  successful  in  mapping  out  the  affected 
tract,  because  there  was  not  much  increase  of  connective  tissue. 
In  the  immediate  neighbourhood  of  the  constriction  the  cord 
was  com])letely  disorganised.  The  grey  matter  was  indistin- 
guishable from  the  white  in  the  general  destruction  of  tissue. 
Axis  cylinders  were  few.  There  was  little  increase  of  connec- 
tive tissue,  but  a  large  number  of  inflammatory  nuclei  in  the 
meshes  of  the  neuroglia,  and  also  in  the  subarachnoid  spaces. 
This  description  applies  to  a  region  extending  from  the  level  of 

^  Journal  Royal  Microscopical  Society,  1884. 
^  Weigert,  Fortschritt  fiir  Medicin,  18S4,  p.  190. 

I  am  indebted  also  to  Dr.  Beevor,  who  has  used  this  method  with   great 
success,  for  several  valuable  hints. 


14-  Topographical  Analomy  of  the  Spinal  Cord. 

the  fifth  to  tliat  of  the  seventh  dorsal  vertebrae,  the  point  of 
constriction  h'ing  midway  between. 

Dorsal  between  third  and  fourth  roots  (fig.  8)  (above  the  con- 
striction).— Here  are  signs  of  general  iuflainiuatory  piocesses 
spreading  from  the  injury.  The  lesions  are  not  very  distinct. 
The  posterior  median  columns  are,  however,  quite  devoid  of 
nerve-fibres,  and  show  also  a  large  number  of  inflammatory 
corpuscles  and  so-called  "  amyloid  bodies. '"  The  posterior  root- 
zone  is  very  small,  little  more  than  a  narrow  strip  of  nervous 
tissue  next  the  posterior  roots.  In  the  Inleral  columns  there 
is  a  general  and  indefinite  destruction  of  the  white  matter,  pro- 
bably inflammatory.  The  form  of  the  grey  matter  remains,  but 
there  are  veiy  few  ganglion  cells,  and  they  have  an  abnormally 
granular  appearance. 

Dorsal  heticeen  second  ami  third  roots  (fig.  7). — Here  the 
signs  of  inflammation  are  less  distinct.  The  nerve-fibre  destruc- 
tion in  the  lateral  columns  tends  to  become  more  circumscribed, 
occupying  the  posterior  part  of  the  mixed  tract.  The  cerebellar 
tract  is  not  represented  here  in  its  usual  position,  a  circumstance 
I  am  unable  to  explain. 

Dorsal  between  first  and  second  roots  (fig.  6). — There  was  in 
the  position  of  the  right  anterior  horn  a  cavity  as  large  as  a  pea. 
This  was  probably  the  focus  of  a  haemorrhage  occurring  at  the 
time  of  the  accident.  The  section  was  taken  at  the  lowest  level 
of  the  cavity,  not  at  its  broadest  part  (fig.  6,  d).  The  posterior 
median  columns  are  much  sclerosed.  There  is  general  destruc- 
tion of  the  right  half,  but  the  left  has  plenty  of  nerve-fibres  in 
it,  except  in  the  small  area  marked  b  ou  the  left  side.  This  is 
the  first  appearance  of  this  tract.  This  lesion  of  tlie  cord  will 
account  for  the  paralysis  of  the  intercostal  muscles  and  the 
diaphragmatic  breathing. 

Cervical  leticeen  the  seventJi  and  eighth  roots  (fig.  5). — In  this 
section  it  will  be  seen  that  the  degeneration  of  the  posterior 
median  columns,  though  not  so  extensive  as  in  figs.  7  and  8,  yet 
is  more  so  than  in  the  superior  cervical  sections.  There  is  some 
atroi)hy  of  the  left  half  of  the  cord  in  this  region.  The  degenera- 
tion of  the  direct  cerebellar  tract,  (o),  is  well  marked,  and  extends 
from  the  posterior  root  round  the  margin  of  the  section,  to 
become  expanded  apparently  into  the  wedge-shaped  area  (b),  well 
shown  on  the  left  side.  This  is  the  condition  which  has  been 
so  often  figured,  and  evidently  mistaken  for  the  anterior  con- 
tinuation of  the  cerebellar  tract.  The  grey  matter  here  and  in 
the  succeeding  sections  is  normal. 

Cervical  between  third  and  fourth  roots  ^fig.  4). — This  descrip- 
tion will  apply  also  to  fig.  3,  which  is  taken  between  the  second 


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Topographical  Anatomy  of  the  Spinal  Cord.  143 

and  third  cervical  roots.  Here  the  degeneration  of  the  posterior 
median  columns  is  complete,  but  the  area  is  smaller  than  in  the 
preceding  sections.  This  degeneration  is  marked  by  complete 
absence  of  nerve-fibres,  but  very  little  increase  of  connective 
tissue ;  in  fact,  it  cannot  be  called  a  sclerosis.  In  these  sections 
the  degenerated  area  (&)  in  the  mixed  tract  is  seen  to  be  quite 
distinct  from  the  direct  cerebellar  tract  (a) ;  they  are  separ- 
ated from  one  another  by  a  neck  of  healthy  white  mattei-. 

Cervical  at  the  level  of  the  first  roots  (fig,  2). — The  posterior 
median  degeneration  is  here  very  small.  The  cerebellar  tract  is 
well  represented,  but  the  little  area  above  described  has  dis- 
appeared; possibly  its  fibres  may  have  merged  into  those  of  the 
cerebellar  tract,  and  so  passed  up  to  the  cerebellum. 

Medulla  through  loiuer  third  of  olivary  body  (fig.  i). — A 
little  way  behind  the  grey  matter  of  the  olivary  body  may  be 
seen  a  wedge-shaped  patch  of  degeneration  (a),  which  is  the 
upward  continuation  of  the  direct  cerebellar  tract. 

Below  the  constriction  the  cord  shows  the  ordinary  descending 
lesion  in  the  crossed  pyramidal  tract  (figs.  9  and  10),  taken 
between  the  seventh  and  eighth,  the  eighth  and  ninth  dorsal 
roots  respectively.  There  is  no  degeneration  of  the  anterior 
columns,  a  fact  which  confirms  the  observation  made  by  Bouchard 
that  the  direct  pyramidal  tracts  do  not  reach  lower  down  than 
the  middle  of  the  dorsal  region. 

In  conclusion,  a  curious  and  hitherto  unexplained  point  in  the 
symptomatology  is  the  complete  abolition  of  all  reflexes  super- 
ficial and  deep  below  the  lesion  shortly  after  the  injury.  It  is 
unfortunate  that  the  condition  of  the  reflexes  was  not  noted 
when  the  shock  had  completely  passed  off,  and  the  secondary 
changes  had  begun  to  be  established.  This  state  of  the  reflexes 
is  not  unprecedented,  for  a  case  has  been  recorded  by  Kahler 
and  Pick,  in  an  article  quoted  above,  of  fracture  of  one  of  the 
cervical  vertebrae,  in  which  all  reflexes  were  abolished  up  to  the 
time  of  death,  seventeen  dnys  after  the  accident. 


FROM  THE  DEPARTMENT  FOR  DISEASES  OF 
THE  LARYNX. 

BY 

H  E  N  K  Y    T.    B  U  T  L  I  K 


Article  III.  —  Teacheal    Papilloma  —  Malignant    Nasal 
TuMOUKS — Adenoid  Vegetations  of  the  ISTaso-Pharynx. 

In  my  two  previous  articles  on  this  department  (see  Vols. 
XVIII.  and  XIX.),  the  general  working  of  the  department  was 
described,  and  its  gradual  growth  and  increasing  importance 
were  alluded  to.  Again  I  have  to  announce  that  its  sphere  of 
activity  has  been  enlarged.  From  six  lamps  we  have  increased 
to  eight.  Instead  of  two  dressers,  there  are  six  every  three 
months,  in  addition  to  one  senior  dresser,  who  has  already  dressed 
for  three  months  in  the  department.  The  appointment  of  a 
senior  dresser  is  a  great  advantage,  not  only  to  the  man  who 
holds  the  office,  but  to  the  other  dressers  ;  for  he  knows  the 
manner  in  which  the  work  is  carried  on;  he  allots  the  new  cases; 
assists  me  in  instructing  the  other  dressers  in  the  use  of  the 
laryngoscope;  shows  them  how  to  apply  solutions  and  powders 
to  the  larynx,  and  takes  charge  of  some  of  the  most  important 
of  the  cases.  The  extra  three  months  which  he  devotes  to  the 
study  of  the  laryngoscope  is  rendered  far  more  valuable  to  him 
because  it  is  not  a  mere  desultory  or  dilettante  study,  but  is  a 
real  labour,  obliging  him  to  know  his  work  thoroughly  in  order 
to  impart  it  to  the  others.  The  senior  dresser  is  almost  always 
a  qualified  man,  and  the  responsibility  of  carrying  on  the  work 
is  intrusted  to  him  during  my  absence.  Tlie  number  of  pa- 
tients is  also  increasing.  Daring  the  past  year  there  have  been 
475  new  patients,  which  gives  an  average  of  a  little  over  nine 
new  patients  on  every  Friday  afternoon,  compared  with  rather 
less  than  seven  in  a  previous  report.     Each  dresser  takjs,  tlijre- 

vol.  XXI.  K 


14^       From  the  Depart  men  I  for  Diseases  of  the  Lari/)ix. 

lore,  about  lliiee  new  cases  in  two  afternoons, — at  first  si«^lit 
apparently  a  very  small  ninnber,  until  it  is  i emembered  that 
the  cases  are  not  so  strictly  the  property  of  the  dresser  who  takes 
them  as  they  are  in  the  out-patient  room,  but  that  each  dresser 
is  encouraged  to  examine  all  the  patients,  provided  they  are  not 
seriously  ill,  and  consequently  unlit  to  bear  prolonged  examina- 
tion. 

In  spite  of  the  improvements  which  have  been  made,  the 
number  of  ap[)lications  for  dressershi{)s  is  still  in  excess  of  the 
supply,  and  we  are  obliged  to  encoui'age  men  whom  we  can- 
not receive  as  dressers  to  come  on  Friday  afternoon,  bringing 
with  them  their  laryngoscopes,  to  learn  to  use  them.  Even  the 
most  industrious  dresser  is  not  seated  at  his  lamp  during  the 
whole  afternoon,  but  is  writing  prescriptions  or  taking  fresh 
notes  of  his  cases ;  and  this  gives  an  opportunity  to  the  un- 
atl ached  student  of  examining  many  cases.  In  the  same  way 
former  dressers  frequently  attend,  if  only  for  half  an  hour  at  a 
time,  and  keep  up  their  knowledge  of  the  art  of  laryngoscopy. 

The  number  of  laryngoscopes  in  the  wards  and  in  the  hands 
of  students  may  be  taken  as  an  indication  of  the  increased  im- 
])ortance  which  the  students  attach  to  a  knowledge  of  the  use  of 
the  laryngoscope.  AVhereas  iive  years  ago  there  were  only  two 
or  three  of  these  instruments  within  the  walls  of  the  hospital, 
I  am  probably  far  within  the  mark  when  I  estimate  that  there 
are  more  than  fil'ty  of  them  at  the  present  time.  And,  what  is 
of  far  more  importance,  they  are  frequently  used  in  the  wards 
by  the  house-physicians  and  clinical  cleiks.  Owing  to  what 
may  be  described  as  the  establishment  of  "  friendly  relations," 
I  am  asked  to  see  laiyngeal  cases  of  interest  in  the  medical 
wards,  and  consequently  see  many  instances  of  disease  which 
would  not  naturally  come  under  my  caie  in  the  Throat  Depart- 
ment. I  attach  great  importance  to  this,  not  only  because  it 
gives  me  the  opportunity  of  seeing  rare  cases,  but  because  it 
tends  to  increase  the  interest  which  is  already  exhibited  iu 
laryngology  throughout  the  hospital.  In  order  to  meet  a  want 
which  has  been  frequently  expressed  by  students,  I  am  glad  to 
be  able  to  announce  that  one  of  my  former  senior  dressers,  Dr. 
A.  Garrod,  who  has  spent  several  months  at  work  in  the  throat 
clinics  in  Vienna,  is  about  to  publish  a  small  woik  on  the  use 
of  the  laryngoscope.  The  opportunity  he  has  afforded  me  of 
looking  through  the  manuscript  enables  me  to  say  beforehand 
that  I  shall  be  able  strongly  to  recommend  it  to  all  students  who 
Avish  to  learn  not  only  the  manner  of  using  their  laryngoscopes, 
but  also  the  reasons  for  the  different  manceuvres,  together  with 
such  general  knowledge  of  the  anatomy  and  physiology  of  the 


From  the  Department  for  Diseases  of  the  Larynx.       147 

larynx  as  is  necessary  for  the  perfect  comprehension  of  the  pic- 
tures in  the  mirror. 

Tkacheal  Papilloma. 

lu  the  article  on  Diseases  and  Injuries  of  the  Air-Passages 
in  Ashhurst's  "  Encyclopjedia  of  Surgery,"  Dr.  Solis-Cohen  has 
given  a  very  complete  account  of  papilloma  of  the  trachea, 
together  with  a  table  containing  a  large  number  of  cases.  The 
first  case  in  his  table  is  that  which  I  described  in  the  i8th  and 
19th  volumes  of  our  Eeports.  In  the  last  note  which  was 
given  in  Yol.  XIX.,  the  development  of  a  small  papilloma  was 
described  as  it  occurred  on  the  left  vocal  cord,  quite  unconnected 
with  the  original  papilloma  of  the  trachea.  This  was  in  Xov- 
ember  1883.  During  the  course  of  the  following  summer  she 
appeared  to  have  some  symptoms  of  returning  tracheal  obstruc- 
tion, and  I  began  to  fear  that  the  papilloma  was  growing 
again.  About  this  time  she  ceased  to  attend  the  hospital.  A 
few  months  ago  I  was  asked  by  my  friend  Dr.  Semon  to  review  the 
articles  relating  to  diseases  of  the  throat  in  "  Ashhui-st's  Surgery" 
for  the  "  Centralblatt  fiir  Laryngologie,"  and  finding  that  Dr. 
Solis-Cohen  had  described  my  case  of  tracheal  papilloma  as 
cured  by  the  operation,  I  mentioned  the  occurrence  of  symptoms 
indicative  of  return  of  the  disease.  But  shortly  afler  the  review 
was  completed,  the  woman  came,  in  reply  to  a  letter  sent  her 
from  the  hospital,  to  show  herself.  The  small  papilloma  of  the 
left  cord  had  increased  in  size,  but  gave  her  no  inconvenience, 
and  there  were  no  symptoms  or  appearance  of  return  of  the 
tracheal  growth.  I  am  therefore  pleased  to  be  able  to  report, 
that  although  three  years  have  elapsed  since  the  operation,  she 
is  quite  free  from  recurrence.  This  is  the  more  remarkable, 
because  the  original  growth  was'sessile,  and  occupied  a  tolerably 
large  area  of  the  surface  of  the  interior  of  the  tube. 

TUMOUES   OF  THE   IXTEEIOE   OF  THE   XOSE. 

I.  Osseous  Oiitcjrowtli. — 2.  Sarcomatous  Polypi. — 3.  Papilloma 
of  Septum. — 4.  Ppithelioma  of  Ala. 

I.  Osseous  Outgrowth. — This  case  is  an  illustration  of  a  disease 
which  is  not  at  all  common,  but  of  which  nearly  every  patholo- 
gical museum  furnishes  at  least  one  example.  The  patient  was 
a  servant,  18  years  of  age,  who  for  eighteen  months  had  suffered 
from  gradually  increasing  obstruction  of  the  left  nostril,  with 
which  there  had  lately  been  associated  lachrymation  of  the  left 
eye.     There  was  neither  pain  nor  dischaige,  whether  of  blood  or 


14S       From  the  Deparlment  for  Diseases  of  the  Larynx. 

matter,  nor  was  there  any  iiiij>airment  of  the  general  health. 
The  face,  close  to  the  ala  of  the  nostril,  was  fuller  on  the  affected 
side,  and  an  exannnation  of  the  interior  of  the  nostril  discovered 
a  diffused  swelling  of  the  onier  wall,  corresponding  to  the  hor- 
der  and  nasal  process  of  the  superior  maxilla,  rounded,  sraoolb, 
covered  with  unbroken  mucous  membrane,  and  very  hard  be- 
neath the  membrane.  The  consistence  was  that  of  ordinary 
bone.  The  nostril  was  almost  completely  blocked  by  the  growth, 
which  appeared  to  be  limited  to  the  front  part  of  the  bone,  for 
nothing  could  be  seen  or  felt  of  it  behind. 

On  account  of  the  diffused  character  of  the  growth  and  the 
slowne.ss  with  which  it  was  progressing,  it  was  decided  to  watch 
it  and  not  to  operate,  for  the  time  at  least.  She  first  came 
to  the  hospital  in  January  of  this  year  (1885),  and  after  one 
month  ceased  to  attend  the  throat  department. 

The  only  other  case  of  the  kind  which  has  been  seen  in  the 
department,  or  of  which  I  have  any  recollection,  was  that  of  a 
young  woman  who  was  sent  down  from  one  of  Mr.  Willett's 
wards  for  examination.  She  ^was  suffering  from  a  precisely 
similar  outgrowth,  but  of  both  sides,  and  very  symmetrical  in 
character  as  well  as  in  position.  In  her  case,  too,  no  operation 
was  performed. 

"What  the  ultimate  fjite  of  these  patients  may  be  is  diflScult 
to  foretell.  It  is  not  improbable  that  the  tumours  may  cease  to 
grow,  or  may  grow  so  slowly  that  many  years  may  elapse  before 
they  produce  any  more  serious  mischief  than  they  caused  at  the 
time  the  patients  last  were  seen.  On  the  other  hand,  there  is 
no  probability  of  spontaneous  improvement,  and  the  disease 
may  attack  other  of  the  facial  bones,  or  other  parts  of  the 
superior  maxilla,  producing  horrible  deformity,  against  which 
surgery  may  be  defenceless.  In  the  case  which  was  under  my 
own  care,  the  question  of  operation  was  considered,  but  it  w:is 
concluded  that  more  deformity  might  be  caused  by  the  opera- 
tion than  by  the  disease,  and  that  it  would  be  certainly  more 
prudent  to  watch  its  progress  for  a  few  weeks  than  to  attack  it 
at  once. 

2.  Sarcomatous  Polypi. — On  the  2d  of  October  a  very  upright 
and  sturdy  old  lady,  y^)  years  old,  came  to  us  with  considerable 
disease  of  the  right  nostril.  She  said  she  had  been  quite  well 
imtil  two  years  previously,  when,  about  Christmas  time,  lier 
nose  began  to  bleed  violently  at  intervals  of  about  three  weeks. 
But  it  was  not  until  twelve  months  later  that  the  nose  began  to 
swell,  and  shortly  afterwards  a  polypus  came  away  when  she 
was  blowing  her  nose,  after  which  there  was  copious  hieniorrhage. 


From  the  Deparlment  for  Diseases  of  the  Larynx.       i^g 

About  tliis  time  she  noticed  a  clear  watery  discliai-ge,  and 
experienced  difficulty  in  breathing  through  the  nostrils.  The 
lisemorrhage  occurred  at  short  intervals,  and  in  June  a  polypns 
was  removed  at  St.  Thomas's  Hospital.  During  the  last  four 
months  the  swelling  of  the  nose  had  increased  very  much,  and 
the  obstruction  had  become'complete ;  besides  which,  tears  had 
been  overflowing  from  the  right  eye. 

In  spite  of  her  repeated  losses  of  blood,  she  presented  the 
aspect  of  a  remarkably  strong  old  person.  She  walked  well,  and 
was  active  in  mind  as  well  as  body.  The  bridge  of  the  nose  was 
very  much  broader  than  natural,  and  the  whole  of  the  nose 
appeared  to  be  enlarged.  The  swelling  was  very  elastic,  so  that 
there  was  a  sensation  of  fluctuation  where  the  nasal  bones  ought 
naturally  to  have  stood.  Examination  with  the  speculum  dis- 
covered a  very  large  mass,  looking  like  an  ordinary  but  exceed- 
ingly large  mucous  polypus,  in  the  right  nostril,  where  it  almost 
reached  the  orifice.  It  was  very  juicy,  and  rather  firmer  than  a 
simple  mucous  polypus.  Its  attachment  could  not  be  perceived. 
The  left  nosti-il  appeared  to  be  free  from  new  growth,  but  the 
septum  was  thrust  over  so  far  towards  the  left  side  that  the 
nostril  was  almost  wholly  blocked.  With  the  rhinoscope  the 
tumour  could  be  only  just  perceived.  With  the  exception  that 
the  lachrymal  duct  was  obstructed,  and  the  tears  consequently 
overflowed  the  right  eye,  there  was  no  sign  of  invasion  of  any  of 
the  parts  bordering  on  the  nostril,  and  the  antrum  and  spheno- 
palatine fossa  appeared  to  be  free  from  the  disease.  On  the  other 
hand,  it  had  extended  up  through  the  nasal  bones,  which  were 
almost  completely  destroyed,  and  had  probably  made  its  way 
into  the  frontal  sinus,  although  the  sinus  was  not  distended.  In 
addition  to  the  distress  of  the  nasal  obstruction,  she  complained 
exceedingly  of  neuralgia  of  the  frontal  region  and  of  the  root  of 
the  nose,  and  of  the  annoyance  due  to  the  abundant  watery  dis- 
charge. 

She  was  treated  with  insufflations  of  tannic  acid  (one  grain  to 
one  drachm  of  borax),  and  with  croton  chloral,  and  the  ])ain  and 
discharge  wei'e  somewhat  lessened.  But  the  disease  made  steady 
progress ;  the  bridge  of  the  nose  became  more  swollen,  and  soon 
an  opening  formed  on  the  right  side  of  the  bridge  and  discharged 
thin  fluid  abundantly.  In  the  course  of  a  week  or  two  a  second 
opening  formed  on  the  opposite  side,  and  discharged  in  like 
manner.  She  complained  so  much  of  the  obstiuction  of  the 
nostril,  and  said  that  she  had  been  so  much  relieved  by  the 
removal  of  the  growth  some  time  previously,  that  I  acceded  to 
her  request,  and  removed  with  the  galvano-cautery  loop  a  large 
piece  of  the  polypus  which  lay  lowest  in  the  nostril.     In  spite  of 


150      From  the  Department  for  Diseases  of  the  Laryna^ 

llie  hot  wire  the  hleediuj;  was  profuse,  and  I  began  to  wish  that 
I  had  not  meddled  wilh  it ;  but  a  tampon  of  cotton  wool  arrested 
tlie  hemorrhage,  and  she  went  home  as  usual  to  Brixton.  She 
has  been  only  once  since  then,  when  she  was  none  the  worse  for 
the  loss  of  blood,  and  indeed  apparently  little  the  worse  for  the 
rapidly  progressing  disease. 

3.  Papilloma  of  Septum. — Papilloma  of  the  interior  of  the 
nostrils  is  not  by  any  means  a  common  disease,  so  far  as  our 
experience  in  this  country  goes.  The  only  case  I  have  seen  of 
it  during  the  ]iast  year  was  towards  the  end  of  Mai-ch  in  the 
right  nostril  of  a  girl,  13  years  of  age,  who  had  suffered  for 
six  months  previously  from  frequent  lia3morrhages  and  obstruc- 
tion, but  no  other  symptoms.-  Examination  with  the  speculum 
showed  a  warty  growth  depending  from  the  upper  part  of  the 
front  of  the  nostril  and  almost  completely  blocking  the  passage. 
I  put  a  galvano-cautery  loop  around  it  as  high  as  I  could,  and 
cut  the  tumour  through.  Free  bleeding  followed,  but  was  very 
easily  arrested  by  a  plug  of  cotton-wool.  On  the  following  Fri- 
day the  loop  was  passed  up  around  the  remains  of  the  growth  to 
its  constricted  base,  which  was  attached  to  the  septum,  and  it 
was  easily  removed. 

The  tumour  was  a  well-marked  specimen  of  vascular  papil- 
loma, a  species  of  growth  which  is  not  veiy  common  in  the 
interior  of  the  nose,  and  regarding  which  there  has  been  much 
discussion.  Hopmann  of  Cologne  has  observed  many  cases  com- 
pared with  the  total  number  of  cases  of  intra-nasal  tumours 
which  have  been  observed  by  him.  He  has  found  them  always 
on  the  inferior  turbinated  bone.  Zuckerkandl  has  only  seen  a 
single  instance,  and  in  his  case  the  tumour  grew  from  the  inferior 
turbinated  bone.  Morell  Mackenzie,  on  the  other  hand,  has  only 
seen  a  few  cases,  but  in  neither  of  them  was  the  growth  situated 
on  the  turbinated  bone.  It  was  attached  to  the  septum  or  to 
"  the  inner  plate  of  the  alar  cartilage,  where  it  joins  its  fellow  in 
the  middle  line  close  to  the  tip  of  the  nose."  Tiie  present  ob- 
servation confirms  the  experience  of  Mackenzie ;  and,  in  the  only 
other  instance  I  have  seen,  the  tumour  was  seated  at  the  point 
which  he  has  indicated,  near  the  tip  of  the  nose.  It  is  not  im- 
probable, as  Mackenzie  has  suggested,  that  Hopmann  has  dis- 
covered by  microscopical  examination  a  papillary  structure  in 
many  polypi  which  look  like  ordinary  mucous  polypi,  and  this 
has  given  rise  to  the  curious  character  of  his  experience.  On  the 
other  hand,  I  have  examined  a  large  number  of  mucous  polypi 
taken  from  different  individuals,  and  have  not  discovered  such  a 
.  structure  as  would  ever  lead  me  to  classify  them  as  jDapillomata. 


From  the  Dzpartment  for  Diseases  of  tlie  Larynx.       151 

So  far  as  the  diagnosis  and  treatment  of  this  disease  is  con- 
cerned, the  former  is  easy,  for  the  warty  character  of  the  tnmoiir 
is  distinctly  visible  as  it  lies  in  the  interior  of  the  nostril.  It 
may  of  course  be  mistaken  for  a  warty  epithelioma,  a  disease 
even  more  rare.  The  difference  between  the  two  tumonrs  will 
be  better  perceived  by  a  comparison  of  this  case  with  the  next. 
No  method  of  treatment  could  be  more  satisfactory  than  that 
which  was  adopted  in  the  present  case — removal  with  the  gal  van- 
cautery  loop  ;  but  in  the  absence  of  the  galvano-cautery,  there 
is  no  reason  why  the  tumour  should  not  be  snared  with  a  cold 
wire  loop  or  torn  away  with  polypus  forceps. 

4.  Squamoiis-celled  Carcinoma  {Epitlielioma)  of  the  Inner 
Aspect  of  the  Ala. — At  the  beginning  of  October  (1885),  Mr. 
Humphry,  Mr.  Smith's  house-surgeon,  brought  to  the  Throat 
Department  an  Italian  asphalte-layer,  44  years  old,  who  com- 
plained of  obstruction  of  the  left  nostril.  He  was  quite  sure 
that  there  had  not  been  anything  the  matter  with  his  nose  until 
about  two  months  previously,  when  the  obstruction  had  gradually 
formed,  until  at  length  it  had  become  complete,  and  had  entirely 
stopped  the  left  nostril.  There  had  not  been  any  pain  or  dis- 
charge or  hsemorrhage,  and  the  health  of  the  man  was  as  good  as 
it  had  ever  been.     No  cause  was  known  for  the  disease. 

The  patient  was  a  very  rough-looking  man,  in  whose  left 
nostril  a  warty  growth  could  easily  be  seen  without  the  aid  of  a 
speculum.  It  appeared  to  be  about  the  size  and  shape  of  half  a 
nut,  had  a  distinctly  warty  surface,  was  very  firm  to  the  touch, 
and  was  clearly  attached  to  the  inner  aspect  of  the  ala  about 
two-thirds  of  an  inch  from  its  free  border.  The  outer  surface 
of  the  ala  corresponding  to  the  growth  was  very  firm,  rather 
stiff  than  hard,  and  the  stiffness  extended  beyond  the  apparent 
attachment  of  the  tumour.  I  put  a  galvano-cautery  looj)  around 
it,  and  cut  through  its  slightly  constricted  base  flush  with  the 
inner  surface  of  the  nostril.  There  was  scarcely  any  bleeding, 
and  the  man  went  home. 

The  tumour  was  very  firm,  with  a  cauliflower  surface.  Its 
firm  consistence  and  the  stiffening  of  the  ala  made  me  very 
suspicious  of  its  nature,  and  the  suspicion  was  confirmed  by  the 
microscopical  examination  made  by  Mr.  Bowlby,  who  found  that 
it  was  a  typical  epithelioma,  squamous-celled,  and  containing 
numerous  nests. 

Three  weeks  later  to  the  very  day,  the  man  came  again  to 
the  Throat  Department  with  a  recurrence  of  the  tumour,  which 
was  quite  as  large  as  when  it  was  removed.  Seeing  that  the 
complete  removal   of  the  ala  was  necessary,  he  was  admitted 


152       From  the  Department  for  Diseases  of  the  Larynx. 

under  Mr.  Sniitli,  whom  I  assisled  at  the  operation  at  tlie 
beginning  of  November.     The  man  is  still  in  the  hospital. 

Carcinoma  of  the  interior  of  the  nose  is  always  a  rare  disea.se, 
and  tlie  carcinomatous  tumours  which  do  grow  there  are  still 
more  rarely  pquamous-celled.  "With  this  and  one  other  ex- 
ception, those  I  have  examined  have  been  cylindrical-celled, 
such  as  are  found  in  the  rectum  and  the  uterus,  or  spheroidal- 
celled  ;  and  this  ex^^erience  accords  with  that  of  most  other  ob- 
servers. Again,  the  situation  of  the  growth  is  so  unusual,  that  I 
am  not  aware  of  any  other  instance  of  epithelioma  in  that  situa- 
tion. In  the  other  case  I  have  alluded  to,  which  will,  I  hope,  be 
published  by  my  friend  Dr.  Felix  Seraon,  the  disease  appeared 
to  have  commenced  in  the  lower  and  front  part  of  the  septum, 
or  even  in  the  floor  of  the  nose  close  to  the  septum. 

In  spite  of  the  very  free  removal  of  the  ala,  the  prognosis  in 
this  case  cannot  be  other  than  bad,  for  the  original  tumour  had 
grown  very  rapidly,  and  the  recurrence  was  immediate,  while  the 
infiltration  of  the  ala  for  some  distance  beyond  the  actual  seat  of 
attachment  of  the  tumour  augured  ill  for  the  patient's  future. 
He  is  at  present  well,  and  there  is  no  glandular  eulai-gement. 

Adenoid  Vegetations  :   their  Importance,  Diagnoses,  and 

Treatment. 

Although  at  least  twelve  years  have  elapsed  since  Dr.  Meyer 
of  Copenhagen  published  an  account  of  the  adenoid  vegetations 
in  the  Tiansactions  of  the  Medico-Chh-ui-gical  Society  of  London, 
the  disease,  with  its  important  associations,  has  not  even  yet 
attracted  nearly  so  much  attention  as  it  deserves  to  do.  Nut 
that  it  has  been  unknown  to  or  neglected  by  some  of  the  chief 
specialists  in  diseases  of  the  throat  and  ear  in  London  and  some 
of  the  principal  towns  in  the  United  Kingdom,  or  that  pnpei's 
have  not  been  written  describing  the  vegetations,  their  situation, 
dingnosis,  and  treatment ;  but  that  it  is  not  generally  recognised 
by  practitioners,  either  in  town  or  country.  Very  little  appears 
to  have  been  known  of  these  adenoid  vegetations  in  England, 
even  by  specialists,  until  the  year  of  the  International  Congress 
( 1 88 1  J,  when  papers  were  read  in  the  section  devoted  to  diseases 
of  the  throat  by  Dr.  Meyer  himself,  by  Dr.  Loewenberg  of  Paris, 
and  by  Dr.  Woakes  of  London.  Since  the  Congress,  other 
papers  have  been  published  by  English  medical  men,  and  the 
disease  is  described  in  some  of  the  general  works  on  diseases  of 
the  throat  and  nose.  Nevertheless  adenoid  vegetations  are  not 
generally  recognised  by  practitioners,  whether  in  town  or  country. 
Nor  can  this  be  wondered  at  when  it  is  possible  to  point  to  more 


From  the  Department  for  Diseases  of  the  Larynx.       153 

than  one  specialist  wlio  little  more  than  a  year  ago  was  almost 
absolutely  ignorant  of  even  the  existence  of  the  disease,  much 
more  of  the  methods  of  treating  it. 

Yet  this  adenoid  disease  is  an  exceedingly  important  disease, 
producing  very  serious  consequences,  and  well  worthy  of  study. 
And  it  is  by  no  means  uncommon,  occuiring  in  children  both  of 
the  upper  and  the  lower  classes  of  society. 

The  Throat  Department,  working  in  conjunction  with  the 
Aural  Department,  over  which  my  friend  and  colleague  Mr. 
Cumberbatch  presides  so  ably,  furnishes  me  with  a  considerable 
number  of  cases  in  the  course  of  every  year.  On  these  cases, 
and  on  those  which  have  occurred  in  my  private  practice,  the 
following  remarks  are  founded.  I  shall  probably  not  furnish 
any  matter  which  is  not  well  known  to  specialists,  nor  shall  I 
tell  a  very  different  story  to  that  which  has  appeared  in  some  of 
the  papers  which  have  been  published  in  Transactions,  Keports, 
and  Journals.  But  this  paper  is  not  intended  for  specialists,  but 
for  men  who  practise  general  medicine  and  sui'gery,  and  these 
Reports  will  probably  be  read  by  men  who  have  not  seen  the 
Transactions  of  our  principal  societies  or  the  Reports  of  other 
hospitals,  or  even  the  Transactions  of  the  Congiess  of  188 1.  I 
intend,  too,  to  describe  the  treatment  and  after-treatment  of  the 
disease  more  in  detail  than  is  usually  done,  and  particularly  to 
impress  the  necessity  for  great  care  of  the  patients  after  the 
operation. 

Take  a  typical  case  of  the  disease,  and  the  symptoms  are  as 
follows  : — A  child,  perhaps  eight  years  old,  and  either  male  or 
female,  is  remarkable  by  the  vacant  expression  of  its  countenance, 
which  amounts  almost  to  an  air  of  stupidity.  While  you  are 
talking  to  the  parent  or  friend  who  brings  it,  you  notice  that 
its  mouth  is  kept  almost  constantly  open,  and  that  it  breathes 
with  a  peculiar  snoring  sound.  The  nose  is  generally  narrow 
from  side  to  side;  the  eyes  are  heavy;  the  face  is  lacking  in 
expression.  In  rejdy  to  a  question,  it  speaks  in  a  "dead"  voice, 
dull  and  nasal.  The  appearance  of  the  child  and  the  character 
of  the  voice  suggest  enlargement  of  the  tonsils,  and  an  examina- 
tion of  the  throat  frequently  confirms  this  impression;  for  enlarge- 
ment of  the  tonsils  and  granulations  on  the  pharynx  are  often 
associated  with  adenoid  vegetations.  Or  you  may  learn  that  the 
tonsils  have  already  been  removed,  and  that  the  improvement 
which  was  expected  to  follow  the  operation  has  either  not  been 
gained  or  has  been  only  partial.  Closer  examination  discovers 
semi-purulent  discharge  running  down  the  back  wall  of  the 
pharynx  from  the  naso-pharynx,  and  in  many  instances  the  soft 
palate  is  more  forward  and  more  fixed  than  usual.     The  patient 


154      From  the  Deparhnent  for  Diseases  of  the  Larynx. 

is  usually  deaf;  indeed,  deafness  is  one  of  the  chief  reasons  for 
which  the  child  is  brought.  Inquire  into  the  liistory  of  the 
case,  wlien  it  will  probably  appear  that  the  symptoms  have  been 
noticed  in  a  varying  degree  for  many  months  or  several  years, 
perhaps  even  from  the  earliest  infancy.  The  dnll  expression, 
the  mnffled  voice,  and  the  discharge  at  the  back  of  the  throat 
have  been  present  continuously  from  the  first;  but  the  deafness 
lias  been  intermittent,  or  has  been  nuich  worse  at  one  time  than 
another.  There  has  occasionally  been  discharge  from  one  or 
both  ears,  sometimes  associated  with  pain  and  with  all  the 
symptoms  of  middle-ear  catarrh.  Occasionally,  too,  the  dis- 
charge in  the  throat  has  been  tinged  with  blood.  The  child 
lias  snored  at  night  ever  since  the  commencement  of  the  symp- 
toms. All  the  symptoms  have  been  slowly  growing  worse,  and 
have  always  been  rendered  more  intense  by  a  cold,  to  ■which  the 
patient  is  usually  very  subject. 

The  symptoms  and  the  history  point  to  some  affection  of  the 
throat  and  naso- pharynx.  A  rhinoscopic  examination  is  made  ; 
the  patient  is  told  to  breathe  through  the  nose,  first  with  the 
mouth  closed,  then  with  it  open,  and  while  the  mouth  is  open 
and  the  breathing  is  carried  on  through  the  nose,  the  rliino- 
scopic  mirror  is  introduced  ;  for  now  the  ]>alate  lies  well  forward, 
and  there  is  ample  space  between  it  and  the  back  wall  of  the 
pharynx.  Although  the  breathing  is  not  easily  carried  on 
through  the  nose  on  account  of  the  disease,  it  can  usually  be 
managed  for  a  minute  or  two.  But  the  majority  of  patients, 
whether  young  or  old,  require  training  before  they  will  permit 
a  thorough  rhino?copic  examination  :  the  nasal  breathing,  which 
is  maintained  with  very  little  effort  so  long  as  the  tongue  is 
unrestrained  in  the  mouth,  becomes  exceedingly  diflicult  when 
the  tongue  is  depressed.  The  tongue  and  palate  are  until 
that  moment  in  apposition,  and  the  entrance  of  air  through  the 
mouth  is  barred,  but  the  depression  of  the  tongue  opens  a  wide 
aperture  through  which  air  can  pass  by  the  mouth.  It  is,  how- 
ever, surjirising  how  even  very  sensitive  and  intolerant  patients 
can  be  trained  in  the  course  of  a  few  days  to  the  necessary 
docility.  Several  of  my  dressers  in  the  Throat  Department, 
whose  business  it  has  been  to  train  children  for  rhinoscopic 
examination,  will  bear  me  out  in  this.  The  mirror  shows  first 
that  the  posterior  wall  of  the  naso-  pharynx  is  rough,  and  more  or 
less  closely  covered  with  sessile  lumps,  of  the  same  colour  as  the 
natural  mucous  membrane,  or  redder.  The  sides  of  the  cavity 
are  afiected  in  the  same  manner,  and  the  smooth  Roman  arches, 
which  are  naturally  formed  by  the  roof  of  each  nostril  with  the 
septum,  are  broken  and  lowered  by  similar  red  masses.    In  some 


From  the  Departme7it  for  Diseases  of  tlie  Larynx. 


155 


instances  the  chief  seat  of  the  vegetations  is  immediately  behind 
the  posterior  orifices  of  the  nostrils,  in  the  roof  of  the  naso- 
pharynx, in  the  situation  of  Luschka's  tonsils.    In  other  instances, 


Fig.  I. — Yiew^of  posteiior  nares,  showing  adenoid  vegetations,  numerous  and  small. 

the  cavity  of  the  naso-pharynx  is  so  filled  by  vegetations  that 
scarcely  any  of  the  natural  structures  can  'be  distinguished. 
The  Eustachian  jirominences  and  the  orifices  of  the  tubes  often 


Fig.  2. — View  of  posterior  nares,  showing  larger  masses  of  vegetations. 

appear  quite  free  from  vegetations,  even  in  patients  whose  most 
serious  symptom  is  deafness  or  middle-ear  catarrh.  In  addition 
to  the  examination  with  the  mirror,  and  in  those  cases  in  which 
rhinoscopic  examination  cannot  be  accomplished,  the  finger 
should  be  passed  up  behind  the  soft  palate,  when  the  larger 
masses  can  easily  be  distinguished  and  the  smaller  vegetations 
produce  the  impression  of  a  velvety  substance  or  the  surface  of 
a  velvet-pile  carpet.  The  roof  of  the  cavity  on  each  side  must 
be  especially  examined,  for  here  lies  in  most  cases  some  of  the 
disease — in  many  cases  the  bulk  of  it.  When  the  finger  is 
withdrawn,  it  will  be  found  to  be  smeared  with  blood,  for  the 
vegetations  bleed  much  more  readily  than  the  walls  of  the 
normal  naso-pharynx. 

Such  are  the   symptoms,  appearance,  and   feel   of   adenoid 


156       From  the  Department  for  Diseases  of  the  Larynx. 

vegetations,  and  when  they  can  be  seen  as  well  as  felt,  there  is 
no  fear  of  making  an  error  of  diagnosis.  They  occnr  very  far 
more  frequently  in  children  than  in  adults :  indeed,  it  is  very 
rare  to  meet  with  them  in  persons  more  than  twenty  years  of 
age,  allhongh  there  is  at  the  present  time  a  male  patient  in  the 
Throat  Department  more  than  thirty  years  of  age,  from  whom 
I  have  removed  several  large  masses.  They  aie,  in  my  exi)e- 
rience,  more  frequently  met  with  in  girls  than  boys;  but  other 
surgeons  have  found  them  more  commonly  in  boys,  so  that 
probably  the  two  sexes  are  equally  subject  to  them.  The 
youngest  patient  on  whom  I  have  operated  was  three  years  old, 
but  the  symptoms  often  date  from  a  much  earlier  age  than  this. 
They  occur  in  children  of  the  rich  as  well  as  of  the  poorer  classes. 
Now  ivhat  are  these  adenoid  vegetations,  Q.ni\.  to  what  do  theyowo 
their  origin  and  growth  ?  They  are  outgrowths  of  the  adenoid 
tissue  of  the  mucous  membrane,  and  present  a  structure  similar 
to  that  of  an  enlarged  tonsil  or  of  the  granulations  of  granular 
pharyngitis.  They  aie  covered  by  a  layer  of  epithelium,  either 
cylindrical  or  squamous  according  to  the  part  of  the  cavity  from 
which  they  spring,  and  the  adenoid  tissue  lies  almost  immediately 
beneath  the  epithelium.  Their  polypoid  or  warty  aspect  when  they 
are  present  in  great  numbers  has  led  to  the  opinion  that  they 
are  papillary  growths,  but  this  opinion  is  not  justified  by  their 
structure,  or  indeed,  in  all  instances,  by  their  gross  characters. 
With  regard  to  their  nature,  I  believe  they  belong,  more  or  less 
closely,  to  the  class  of  sci-ofulous  affections.  They  are  much 
more  frequent  in  delicate  than  in  healthy  children  ;  they  are 
commonly  associated  with  enlarged  tonsils  and  with  some  en- 
largement of  the  glands  behind  the  angle  of  the  jaw;  and  they 
consist  of  overgrowths  of  the  tissue,  which,  above  all  others,  is 
subject  to  morbid  growth  in  scrofulous  persons.  They  occur, 
too,  much  more  frequently  in  children  than  in  adults,  and  I 
have  found  them  associated  with  lymphatic  glands  which  were 
not  only  enlarged,  but  actually  suppurating.  In  studying  their 
natural  history  and  course,  the  circumstance  that  they  are  very 
rarely  found  in  adults  must  be  particularly  borne  in  mind. 
When  a  disease  which  is  common  in  children  is  comparatively 
rarely  observed  in  adults,  several  explanations  of  the  circumstance 
may  be  offered.  The  disease  may  have  been  cured  by  opera- 
tion during  childhood  ;  it  may  have  undergone  resolution,  or  it 
may  cease  from  troubling.  The  first  of  these  three  explanations 
can  scarcely  apply  to  adenoid  vegetations,  for  the  operation  for 
their  removal  has  only  been  practised  a  few  years  in  any  country ; 
in  this  country  not  much  more  than  five  years  by  any  surgeon, 
whether  special  or  general,  and  only  so  long  as  this  by  two  or 


From  the  Department  for  Diseases  of  the  Larynx.       157 

tliree  surgeons.  The  experience  of  tliese  men  is  that  tlie  disease 
is  a  disease  of  childhood  and  seldom  occurs  in  adults.  Meyer 
himself,  one  of  the  first  surgeons  to  discover  and  treat  the 
disease  by  operation,  tells  the  same  story.  Nor  do  I  think  the 
third  of  the  three  ex|)lanations  I  have  offered  is  the  correct 
explanation  ;  for  although  masses  of  vegetations  must  neces- 
sarily produce  much  more  discomfort  or  serious  trouble  in  the 
small  naso-pharyngeal  cavity  of  a  child  than  in  the  large  cavity 
of  an  adult,  even  the  comparative  obstruction,  the  deafness,  and 
the  discharge  could  not  fail  to  be  noticed.  Nor  is  there  any 
reason  to  assume  that  the  vegetations,  if  they  persist,  remain 
stationary  in  size.  The  contrary  is  more  probably  the  case  ;  for 
where  I  have  met  with  them  in  adults,  they  have  generally  been 
of  large  size  and  have  occupied  a  large  space  in  the  naso-pha- 
ryngeal cavity.  The  second  is  the  explanation  which  appears 
the  most  probable  :  that  with  advancing  age  the  vegetations 
gradually  disappear  in  the  large  majority  of  patients,  perhaps 
not  by  simple  resolution  and  subsidence,  but  by  contraction 
following  the  organisation  of  inflammatory  products  and  by  sup- 
puration, whence  comes  some  of  the  discharge  which  runs  down 
from  the  naso-pliarynx. 

Unfortunately,  before  they  disappear  spontaneously,  the  vege- 
tations not  only  produce  threatening  of  mischief,  but  in  not  a 
few  instances  are  the  cause  of  serious  and  permanent  trouble.  The 
mere  cii'cnmstance  that  the  patients  are  forced  continually  to 
breathe  with  the  open  mouth  is  in  itself  a  source  of  peril.  Sore 
throats  are  frequent,  and  attacks  of  bronchitis  and  broncho- 
pneumonia are  not  rare  in  some  of  the  children.  The  ailments 
of  infancy  and  childhood  are  more  severe  in  these  children  than 
in  other  healthy  children.  The  semi-])urulent  discharge  which 
runs  down  into  the  stomach  or  on  to  the  larynx  affects  the  ap- 
petite and  induces  chronic  laryngitis.  The  natural  delicacy  of 
the  child  is  increased  by  the  disease,  which  was  perhaps,  in  the 
first  instance,  the  result  of  delicacy  of  constitution.  But  an  evil 
scarcely  less  dreaded  than  the  impairment  of  general  health 
threatens  a  large  number  of  these  patients,  that  of  deafness, 
more  or  less  intense  and  permanent.  At  first  it  is  probable  that 
the  deafness  is  due  to  temporary  obstruction  of  the  mouths  of 
the  Eustachian  tubes  by  swelling  of  the  vegetations  during  the 
occurrence  of  catarrh.  But  by  and  by  catarrh  of  the  middle 
ear  is  produced,  either  by  extension  of  inflammation  from  the 
naso-pharynx  along  the  tubes,  or  secondary  to  the  long-con- 
tinued obstruction  at  their  orifices.  The  patients  are  subject 
to  repeated  attacks  of  pain  in  one  or  other  of  the  ears,  and  some- 
times the  pain  is  followed  by  discharge.     Usually  in  the  course 


158       From  tlie  Department  for  Diseases  0/  the  Laryiix. 

of  a  few  (lays  the  discharge  ceases,  at  least  hi  the  eailier  attacks, 
but  the  deafness  becomes  more  intense  and  permanent. 

In  addition  to  these  evils,  the  chest  is  said  not  to  be  normally 
develo[)ed  in  patients  with  adenoid  vegetations ;  and  a  modifica- 
tion of  the  form  of  the  upper  jaw  has  been  pointed  out  to  me  by 
my  friend  Mr.  Mackrell  as  due  to  the  presence  of  the  adenoid 
growths  and  the  constant  breathing  through  the  open  mouth. 
With  i-egard  to  the  ill-develoi)ment  of  the  chest,  it  appears  more 
probable  that  it  is  due  to  associated  enlargement  of  the  tonsils 
and  consequent  obstruction  to  the  free  entrance  of  air.  It  can 
matter  little  to  the  development  of  the  chest  whether  the  air 
enters  in  through  the  mouth  or  nose,  provided  there  is  no 
obstruction  to  the  free  entrance.  The  prominence  of  the  incisor 
teeth  and  narrowing  laterally  of  the  alveolar  arch  is  said  by 
Morell-Mackenzie  not  to  have  any  direct  connection  with  the 
vegetations,  but  to  be  due  to  an  irregular  mode  of  development 
of  the  palatine  arch  which  occurs  in  many  persons  who  are 
not  the  subjects  of  post-nasal  affections,  and  he  quotes  Oakley 
Coles  in  support  of  his  statement. 

From  what  has  been  said  of  the  effects  produced  by  adenoid 
vegetations,  it  is  quite  evident  that  the  spontaneous  cure  which 
they  may  be  expected  to  undergo  in  the  course  of  years  cannot 
with  safety  be  awaited,  Althougli  I  believe  that  a  scrofulous 
constitution  lies  at  the  bottom  of  many  of  the  cases,  I  am  not 
aware  of  any  facts  which  show  that  the  disease  is  capable  of  cure 
by  constitutional  treatment,  by  the  administration  of  cod-liver 
oil  and  iron,  and  the  phosphates  and  hypophosphites,  or  by  sea 
air  and  the  various  measui'es  which  are  employed  against  scrofula. 
Nor  will  this  appear  singular  to  those  who  know  how  obstinately 
enlarged  glands  and  chronic  enlargement  of  the  tonsils  resist 
constitutional  treatment.  The  opinion  of  almost  all,  if  not  of  all 
surgeons,  special  and  general,  is  that  the  groiutJis  must  he  removed 
or  destroyed,  and  that  constitutional  measures  are  only  of  value 
in  association  with  or  after  operation.  But  althougli  there  is 
such  harmony  with  regard  to  the  necessity  for  operative  treat- 
ment, there  are  great  differences  in  the  methods  which  are 
employed,  and  great  weight  is  laid  on  the  relative  advantages 
and  dangers  of  different  methods.  I  shall  not  enter  into  a 
description  of  all  the  instruments  which  have  been  invented  for 
the  removal  of  the  growths,  or  of  all  the  possible  or  commonly 
employed  methods  of  removal,  but  shall  limit  myself  to  a  detailed 
description  of  the  method  which  I  have  been  in  the  habit  of 
pursuing  for  the  last  three  years,  and  shall  give  the  reasons  why 
I  prefer  it  to  any  other. 

The  patient  having  been  prepared  for  the  oiieration  in  the 


From  tlie  Be'parlment  for  Diseases  of  tie  Larynx.       159 

usual  manner,  is  laid  on  a  table  willi  the  head  raised  and  towards 
the  light.  Chloroform  is  administered,  and  is  maintained  durini^ 
the  operation  b}^  means  of  Mr.  Mills's  tube  and  air-ball.  A 
strong  gag  is  placed  between  the  teeth  on  the  opposite  side 
to  that  on  which  I  stand.  If  there  are  vegetations  in  close 
proximity  to  the  Eustachian  orifices  (which  has  probably  been 
already  determined,  but  which  may  now  be  clearly  ascertained 
by  examination  with  the  innger,  for  the  Eustachian  prominence 
and  orifice  can  easily  be  felt),  or  if  there  is  merely  thickening  of 
the  mucous  membrane,  I  keep  the  forefinger  of  one  hand  on  the 
orifice  of  the  tube,  and  with  the  other  hand  pass  Meyer's  ring- 
knife  throngh  the  corresponding  nostril,  and,  guiding  the  knife 
with  the  finger  behind  the  palate,  scrape  the  prominence  care- 
fully from  above  downwards  until  the  abnormal  tissue  is  removed. 


Fig.  3. — Meyer's  ring-knife,  used  through  the  nostrU. 

The  same  manoeuvre  is  repeated  on  the  opposite  side.  This  is 
done  first  in  order  that  the  small  growths  at  these  important 
points  may  not  be  overlooked  or  obscured,  as  they  very  well  may 
be  wdien  the  uaso-pharynx  is  full  of  soft  blood-clot.  In  many 
cases,  however,  nothing  requiring  treatment  will  be  discovered 
in  the  immediate  vicinity  of  the  Eustachian  orifices,  even  in 
those  cases  in  which  deafness  is  a  prominent  symptom.  K'ext, 
the  exact  situation  of  the  largest  growths  having  been  ascertained 
by  examination,  they  are  removed  piece  by  piece  with  Loewen- 
berg's  forceps,  which  may  require  to  be  introduced  many  times. 


Fig.  4. — Loe-^enberg's  forceps,  used  behind  the  soft  palate.  ^ 

Between  the  re-iutioductions  the  naso-pharyux  is  frequently 
examined  with  the  forefinger,  and  in  large  cavities  the  finger 
and  the  forceps  can  be  employed  simultaneously.  The  back  of 
the  mouth  is  sponged  out  at  frequent  intervals,  for,  in  addition 
to  abundant  salivary  and  mucous  discharge,  the  bleeding  is  free, 


i6o       From  the  Dcimrtment  for  Diseases  of  the  Larynx. 

Foraelimes  even  })rofuse,  owing  to  the  vascularity  of  the  vegela- 
tions.  The  free  bleeding  may  well  alarm  persons  wlio  are  not 
accustomed  to  the  larger  operations  in  the  interior  of  the  mouth, 
such  as  the  removal  of  the  tongue  or  upper  jaw.  It  is  impossible 
to  describe  all  the  manipulations  with  the  forceps,  the  blades  of 
which  require  to  be  pressed  in  turn  against  the  back  wall  of  the 
pharynx,  its  sides  aud  upper  wall,  where  the  largest  masses  are 
often  found.  Care  must  be  taken  not  to  seize  the  Eustachian 
])iominences  or  the  septum  nasi.  The  Ibiceps  at  first  appear 
very  clumsy,  but  a  little  practice,  especially  if  they  ai-e  first 
employed  on  the  dead  body,  will  enable  them  to  be  used  with 
safety,  if  not  indeed  with  ease  and  freedom.  It  is  particularly 
in  regard  to  the  use  of  these  forceps  that  I  always  take  care  that 
the  ])atient's  mouth  is  opposite  as  good  a  light  as  can  be  obtained. 
The  uvula,  and  even  the  free  border  of  the  soft  palate,  is  apt  to 
be  thrust  into  the  naso-pharynx  by  the  finger  or  the  forceps,  and 
may  be  seized  aud  torn.  To  avoid  this  unfortunate  error,  the 
uvula  and  soft  palate  should  be  seen  in  front  of  the  forceps  as 
the  blades  lie  in  the  naso-pharynx.  When  the  projecting 
masses  which  can  be  removed  with  the  forceps  have  been  taken 
fiway,  the  entire  cavity  is  examined  with  the  forefinger,  first  on 
one,  then  on  the  other  side,  and  every  irregularity  or  flattened 
])romiuence  is  scraped  away  with  the  finger-nail,  which  should 
be  rather  long  for  the  purpose.  I  generally  use  the  forceps  from 
the  right  side  of  the  patient,  on  account  of  the  greater  facility 
with  which  it  is  managed  with  the  right  hand,  but  it  is  often 
necessary  to  introduce  it  from  the  left  side,  in  order  more 
readily  to  grasp  a  vegetation  which  cannot  thoroughly  be  reached 
from  the  right  side.  The  mani[)ulations  with  the  ring-knife 
and  with  the  finger-nail  are  performed  first  on  the  one,  tlien  on 
the  other  side.  Dtu-ing  the  whole  of  the  operation  the  bleeding 
is  very  free;  the  pharynx  requires  to  be  constantly  sponged  out, 
and  the  child  may  need  to  be  turned  over  on  its  side  to  allow 
the  fluids  to  escape.  At  a  recent  operation  I  completed  the 
removal  of  the  vegetations  while  the  child  was  still  lying  on  its 
side,  and  probably  this  may  be  eS'ected  in  many  cases  witii  great 
advantage  to  the  patient,  both  on  account  of  the  freedom  of 
breathing  at  the  time,  and  of  the  far  less  quantity  of  blood  which 
runs  down  into  the  stomach,  and  perhaps  the  lungs.  When  the 
o])eration  is  completed,  it  is  surprising  how  quickly  the  bleeding 
ceases. 

The  after-treatment,  although  it  may  be  said  to  consist  in 
doing  nothing,  is  even  more  important  than  the  manner  of  operat- 
ing. The  child  is  put  to  bed  and  kept  there  for  at  least  a  week. 
If  the  weather  is  in  the  least  degree  cold,  a  fire  is  ordered  to  be 


From  the  Department  for  Diseases  of  the  Larynx,       i6i 

kept  up  day  and  night,  so  as  to  maintain  the  temperature  of  the 
room  at  about  65°.  These  precautions  are  the  more  difficult  to 
carry  out  because  the  patients,  after  the  second  day,  usually  feel 
well  and  desire  to  get  up.  They  are  the  more  difficult  to  carry 
out  because  there  is  absolutely  no  other  treatment  in  twenty-nine 
cases  out  of  thirty.  There  is  no  syringing,  or  insufflation  of 
powder,  or  gargling ;  and,  as  a  rule,  no  medicine  is  needed.  But 
when  the  child  is  delicate  and  has  lost  much  blood  at  the  time  of 
operation,  it  is  well  to  administer  a  dose  of  iron  twice  a  day  after 
the  third  or  fourth  day,  and  with  the  iron,  in  some  instances,  a 
small  quantity  of  cod-liver  oil.  At  the  end  of  a  week  the  patient 
is  allowed  to  get  up,  but  is  not  usually  allowed  to  go  out  until 
ten  days  have  elapsed  since  the  operation.  The  necessity  for 
great  caution  after  the  operation  will  be  admitted  by  all  surgeons 
who  have  been  accustomed  to  treat  adenoid  vegetations.  To 
begin  with,  many  of  the  patients  are  naturally  delicate,  and  there- 
fore require  special  care  :  the  loss  of  blood  at  the  time  of  the 
operation  is  never  inconsiderable,  and  is  often  large  for  young 
children,  so  that  they  are  weakened  by  it,  and  more  liable  in 
consequence  to  cold  and  pulmonary  inflammations;  and  one 
great  danger  in  all  cases  is  of  inflammation  of  the  middle  ear, 
set  up  by  the  inflammation  which  almost  of  necessity  follows 
wounds  of  the  naso-pharynx.  The  object  of  the  extreme  caution 
in  after-treatment  is  to  reduce  as  far  as  possible  the  liability  to. 
these  dangers.  The  only  instances  in  which  I  have  seen  trouble 
ensue  upon  the  operation  have  been  those  in  which  these  precau- 
tions have  been  neglected.  Among  the  earliest  cases  which  came 
under  my  care  was  a  young  man  on  whom  I  operated  at  the 
house  of  one  of  his  relatives  Jn  London.  The  weather  was  very 
cold  and  damp,  and  there  was  no  fire  in  his  room  during  the  first 
days  after  the  operation.  He  suffered  from  a  slight  attack  of 
pulmonary  inflammation,  which  weakened  him  exceedingly,  and 
delayed  his  recovery,  although  it  did  not  impair  it.  A  boy  from 
Wales,  on  whom  I  operated  in  the  hospital  last  summer,  was  so 
well  on  the  fourth  day  that  the  house-surgeon  permitted  him  to 
get  up.  On  the  day  following  he  complained  of  pain  in  both 
ears,  and  I  fully  expected  the  pain  would  be  followed  by  suppura- 
tion. He  was,  however,  saved  by  being  immediately  sent  to  bed 
and  kept  quiet  for  several  days.  Eecovery  from  the  operation  is 
in  the  majority  of  patients  very  rapid,  so  that  those  who  come  from 
the  country  are  able  to  return  there  in  less  than  a  fortnight.  No 
after-treatment  such  as  is  described  by  some  authors  is  needful. 

The  above  treatment  and  after-treatment  differ  so  widely  from 
that  which  is  employed  by  some  of  those  who  treat  adenoid 
vegetations,  that  it  would  not  be  right  to  pass  over  without  notice 

VOL.  XXI.  L 


1 62      From  the  Department  for  Diseases  of  the  Larynx. 

the  objections  which  have  been  made  to  it.  Tlie  use  of  an  anaes- 
thetic of  wliatever  kind  is  very  strongly  opposed  by  more  than 
one  author,  probably  by  the  majority  of  those  who  have  written 
on  the  subject :  it  is  said  to  add  much  to  the  danger  of  the  opera- 
tion. Unquestionably  the  use  of  an  anaesthetic  implies  danger, 
whatever  it  may  be  used  for.  But  chihhen  are  in  so  much  less 
danger  from  this  cause  than  adults  that  the  danger  is  reduced 
to  a  minimum.  The  anaesthetic  has  been  administered  for  me 
by  Mr.  Mills,  Mr.  Gill,  and  Mr.  Colville  at  St.  Bartholomew's 
Hospital,  and  I  have  particularly  asked  the  opinion  of  Mr.  Mills 
whether  he  thinks  there  is  any  objection  to  the  use  of  an  anaes- 
thetic in  these  operations,  or  whether  he  has  ever  seen  one  of 
these  patients  in  serious  danger  dining  the  operation.  His 
reply  is  decidedly  in  the  negative  on  both  points. 

The  second  objection  is  that  there  is  far  greater  danger  of 
inflammation  of  the  middle  ear  after  complete  removal  of  the 
vegetations  than  when  they  are  removed  at  several  or  many 
sittings.  To  this  I  answer,  that  there  is  danger  of  middle-ear 
catarrh  in  either  case,  and  that  the  danger  comes  rather  from 
neglect  of  precautions  after  the  operation  than  from  the  amount 
of  tissue  which  has  been  removed.  Many  of  the  patients  have 
already  suffered  from  catarrh  of  the  middle  ear,  and  it  is  there- 
fore not  surprising  that  they  should  be  a! tacked  by  it  after  an 
operation  in  the  close  proximity  of  the  Eustachian  orifice.  One 
or  two  of  my  hospital  out-patients  have  suffered  frotu  it  after 
operation,  but  not  a  single  one  among  my  in-patients  or  private 
patients,  from  which  I  infer  that  the  latter  have  been  preserved 
by  the  better  conditions  in  which  they  are  placed  after  the 
operation,  and  by  the  care  with  which  they  are  kept  warm 
and  quiet.  On  the  other  hand,  I  know  that  patients  who  have 
been  treated  without  an  aucesthetic  at  several  sittings  have  been 
attacked  during  the  course  of  the  treatment  by  middle-ear  catarrh. 
My  firm  belief  is,  that  in  those  cases  in  which  it  is  possible  to  carry 
out  the  after-treatment  rigidly,  there  is  less  danger  of  middle- 
ear  catarrh  after  the  complete  operation  than  after  the  piece- 
meal removal,  for  the  caution  which  ought  to  be  exercised  after 
each  sitting  in  the  latter  is  observed  absohitely  in  the  former. 

The  advantages  of  what  may  be  termed  the  single-sitting 
treatment  are  that  no  previous  training  is  required,  and  that  it 
does  not  matter  how  intractable  the  patient  is.  The  operation 
is  so  thorough  that  no  after-treatment  with  the  galvano-cautery 
or  nitrate  of  silver  is  needed.  The  length  of  time  necessary  for 
the  entire  treatment  is  reduced  from  several  weeks — sometimes 
as  many  as  ten  or  twelve — to  ten  days  or  a  fortnight,  a  matter 
of  great  importance  to  patients  not  residing  in  London. 


From  the  Department  for  Diseases  of  the  Larynx.       163 

So  far  as  the  out-patients  on  whom  I  operate  in  the  Throat 
Department  on  Friday  afternoon  are  concerned,  I  am  quite 
ready  to  admit  tliat  they  run  far  greater  chance  of  mischief  after 
the  operation  on  account  of  the  impossibility  in  most  instances 
of  enforcing  the  requisite  after-treatment.  But  on  mature  con- 
sideration, I  have  been  forced  to  the  conckision  that  the  occasional 
mishap  of  middle-ear  catarrh  or  slight  bronchitis  (than  which 
I  have  seen  nothing  worse)  is  more  than  compensated  by  the 
gain  to  the  greater  number  of  them  of  complete  removal  of 
their  disease  without  the  necessity  of  previous  training  and  very 
numerous  attendances,  which  so  deter  them,  that  many  of  them 
cease  to  attend  long  before  the  growths  have  been  removed. 

Before  finishing  this  paper  it  is  necessary  to  refer  to  questions 
which  are  often  asked  with  regard  to  the  prognosis  after  opera- 
tion :  first,  with  regard  to  the  likelihood  of  recurrence  of  the 
vegetations  ;  second,  as  to  whether  the  patient  will  be  completely 
cured  of  all  the  troubles  which  arose  from  the  presence  of  the 
growths.  The  answer  to  the  first  question  is,  that  if  the  vege- 
tations have  been  completely  removed,  there  is  very  little  pro- 
bability of  a  recurrence.  Even  when  fragments  have  been  left 
behind,  I  have  not  seen  them  enlarge  and  form  important  masses, 
as  they  have  been  reported  to  do.  Nevertheless  it  is  quite  con- 
ceivable that  the  same  conditions  which  led  to  their  formation 
in  the  first  instance  may  lead  to  their  recurrence,  especially  if 
portions  of  the  original  growths  are  left  behind.  The  reply  to 
the  second  question  must  depend  on  the  amount  of  injury  which 
has  been  inflicted  by  the  presence  of  the  growths  before  their 
removal.  It  may  be  s^ifely  afiirmed  that  the  patient  will  be 
able  to  breathe  through  the  nose  and  will  lose  the  vacant  expres- 
sion which  was  due  to  the  post-nasal  obstruction.  And  here  one 
word  of  caution  is  needful.  Associated  with  the  vegetations, 
perhaps  depending  partly  on  their  presence,  there  may  be  very 
considerable  enlargement  of  the  inferior  turbinated  bones,  and 
this  may  be  so  considerable  that  the  passage  of  air  through  the 
nostrils  may  be  seriously  hindered.  It  should  always  be  looked 
for,  and  if  it  is  of  very  long  standing,  and  feels  firm,  and  is 
therefore  likely  to  be  permanent,  the  bone  should  be  removed  at 
the  time  of  removal  of  the  vegetations,  or  the  thickened  tissue 
should  be  destroyed  at  a  later  period  by  caustics  or  the  galvano- 
cautery.  Attention  to  this  complication  and  the  mere  mention 
of  it  before  the  vegetations  are  removed  will  often  spare  both  the 
operator  and  the  friends  of  the  patient  great  disappoiutment. 
My  experience  is  that  this  condition,  when  present,  almost  in- 
variably requires  active  treatment,  and  the  earlier  it  is  treated 
the  better  for  the  perfect  result  of  the  operation. 


164       From  the  Department  for  Diseases  of  the  Larynx. 

So  far  as  the  recovery  of  hearing  is  concerned,  it  is,  in  tlie 
majority  of  instances,  complete.  In  the  course  of  a  week  or 
tea  days  after  the  operation,  tliere  is  usually  a  marked  im- 
provement, and  the  improvement  advances  until  the  hearing  is 
perfectly  re-estahlished.  But  the  prognosis  naturally  is  not 
nearly  so  good  when  the  middle  ear  has  been  the  seat  of  frequent 
attacks  of  inflammation  and  perhaps  of  suppuration.  The  im- 
provement, however,  in  cases  in  which  the  membrana  tympani  is 
perforated,  or  in  which  it  is  distinctly  thickened,  is  distinct,  and 
often  considerable,  and  future  attacks  of  inflammation  are  pre- 
vented, so  that  the  progress  of  the  mischief  from  bad  to  worse  is 
arrested. 


CASES 

OF 

MENTAL  DISTURBANCE  AFTER  OPERATIONS. 

BY 

W.  p.  HEEKINGHAM,  M.B. 


Between  October  1881  and  1882,  when  I  was  Mr.  Smith's 
liouse-surgeon,  two  cases  occurred  which  were  both  unusual  and 
interesting. 

An  employ^  on  the  Underground  Railway,  aged  44,  was  brought 
in  on  December  7,  1881.  He  had  been  knocked  down  by  a 
train,  which  had  crushed  his  left  hand,  nearly  tearing  off  the 
thumb,  and  breaking  the  second  metacarpal  bone.  Under  gas 
and  selher  I  disarticulated  the  first  metacarpal  bone  and  sewed 
up  the  wound.  He  had  also  a  cut  over  the  right  eyebrow,  and 
a  cut  on  the  right  thigh.  He  was  never  fully,  though  almost, 
conscious. 

The  accident  happened  at  two  in  the  morning,  and  that  after- 
noon he  became  wildly  delirious,  so  that  I  had  to  strap  his  right 
arm  to  the  bed  ;  but  being  dosed  with  pot.  brom.  and  chlor.  hydr., 
became  quiet  and  slept  well.  The  next  day  he  became  gradually 
sensible,  and  slept  well  the  following  night.  From  this  time  his 
hand  healed  up  well. 

On  December  17  a  slough  formed  over  the  sacrum,  which 
with  poulticing  recovered. 

On  January  9  an  abscess  had  formed  up  the  left  thigh  among 
the  muscles.  It  was  opened,  but  refilled,  and  had  to  be  opened 
again  on  January  17.  A  few  hours  after  this  operation  it  had 
filled  with  blood,  but  when  laid  freely  open  no  artery  could  be 
found  spouting,  nor  any  other  source  for  the  blood  but  general 
oozing. 

From  this  time  he  recovered  well  of  his  bodily  ailments. 


1 66  Cases  of  Menial  JDisiurhance  after  Operations. 

From  liaving  been  conscious  and  rational  on  December  8  and  9, 
he  began  on  December  10  to  wander  sliglitly,  and  from  that  day 
until  January  15  was  continuously  out  of  his  mind. 

He  was  not  raving  nor  violent,  but  wandered  in  his  speech,  talk- 
ing aimlessly  to  himself,  and  answering  wrongly,  having  delusions, 
not  recognising  his  friends,  and  unable  to  feed  himself. 

His  temperature  varied,  occasionally  rising  to  101°  or  102°, 
but  generally  near  the  normal,  and  often  below  it.  The  pulse 
was  at  first  very  soft,  but  gradually  became  firmer.  The  urine 
was  not  albuminous. 

He  recovered  his  mind  slowly,  and  on  January  16  he  showed 
no  symptoms  of  insanity.  He  was  discharged  cured  on  February 
23,  1882,  and  often  now  puts  me  into  my  train. 

When  the  mania  first  began  it  was  violent  in  character,  and  I 
supposed  that  he  had  an  attack  of  delirium  tremens.  His  wife, 
liowever,  the  safest  of  all  witnesses  against  a  man,  and  he  himself 
when  he  recovered,  have  continually  assured  me  that  he  was 
never  in  the  least  degree  intemperate,  and  his  position  on  the 
railwaj'^,  which  is  one  of  considerable  trust,  points  in  the  same 
direction.  The  mania  was,  moreover,  after  the  first  violence, 
not  in  the  least  like  delirium  tremens.  There  was  no  history  of 
insanity  in  his  family.  He  had,  however,  an  accident  two  years 
before,  in  which  he  was  knocked  down  by  an  open  door,  and 
bruised  his  left  leg  and  thigh.  After  this  also  he  was  delirious 
for  four  days  and  nights. 

Mrs.  H.,  aged  42,  married,  but  deserted  by  her  husband,  wns 
admitted  on  August  24,  1882,  for  femoral  hernia,  and  was 
operated  upon  the  same  night.  In  the  middle  of  the  night  she 
began  to  bleed.  I  opened  the  wound,  but  found  no  artery; 
plugged  it,  and  laid  ice  upon  it.  Slie  went  on  well  until  the 
evening  of  August  28,  when  she  informed  the  nurse  that  she 
would  shortly  die.  Nurse  turned  a  deaf  ear  to  this  warning, 
so  that  I  never  heard  of  it  till  afterwards;  but  at  4.30  a.m.  on 
the  morning  of  the  29th  I  was  called  to  the  ward,  as  she  could 
not  be  roused  and  was  apparently  sinking. 

She  was  then  looking  very  bad ;  her  head  thrown  back,  her 
mouth  open,  her  lips  blanched,  her  eyes  half  opened,  her  eyeballs 
turned  back,  nose  pinched  "  like  a  lawyer's  pen,"  and  cheeks 
sunken.  Her  breath  smelt  foul,  and  her  body  had  an  odour 
like  that  of  a  corpse.  There  was  very  slight  corneal  reflex,  and 
slow  slight  movements  of  the  eyeballs.  There  was,  besides,  that 
quivering  of  the  eyelids  which  I  have  since  seen  in  a  case  of 
trance,  and  have  never  seen  except  in  hysteria. 

The  severest  pinching  produced  no  sign  ;    the  arms  stayed 


Gases  of  Mental  Disturbance  after  Operations.  167 

rigidly  for  some  time  where  they  were  placed,  and  then  dropped 
heavily  on  to  the  bed. 

Meanwhile  her  pulse  was  good,  her  chest  sounds  and  move- 
ments were  natural,  the  abdomen  soft  and  full,  and  the  wound 
discharging  healthily. 

Nothing  was  done  to  her,  except  that  fluids  were  inserted  by 
the  nose  and  withdrawn  by  the  catheter,  until  August  31,  when, 
at  9  A.M.  she  awoke  and  said  to  the  nurse,  "I  have  been  dead." 
She  went  off  again,  however,  and  continued  entranced  off  and  on 
until  September  3,  on  which  night  she  became  very  noisy,  and 
had  to  be  taken  to  Casualty  Ward.  The  next  day  she  asserted, 
when  the  nurse  wished  to  feed  her,  that  she  had  no  tongue  or 
stomach.  She  was  restless  and  violent  in  the  night,  and  then 
went  again  into  a  trance.  At  this  time  she  passed  everything 
under  her,  unless  regularly  put  upon  the  bedpan.  On  September  7 
she  again  came  to  herself,  and  showed,  by  mentioning  her  friends 
and  our  conversation,  that  she  had  been  at  any  rate  to  some  ex- 
tent conscious.  On  September  9  she  came  round  for  good,  and 
was  discharged  at  the  end  of  the  month.  The  wound  always 
did  well,  and  was  in  no  way  influenced  by  the  state  of  her  mind. 

We  found  afterwards  that  she  had  had  hysterical  convulsions 
before,  and  she  was  by  profession  a  pew-opener. 

In  March  last  Mr.  Barwell  detailed  a  case,  and  mentioned 
others,  of  mania  after  ovariotomy.  So  many  sins  are  laid  at  the 
door  of  these  viscera,  that  it  seems  important  to  show  that  an 
allied  change  may  take  place  where  they  have  not  been  touched, 
and  mania  itself  after  an  operation  upon  a  person  who  does  not 
possess  any.^ 

^  British  Medical  Journal,  1885,  vol.  i.,  p.  695,  for  another  case  in  a  male. 


A  CASE  OF  LEAD-POISONING  WITH  BOSSES 
ON  THE  METACARPAL  BONES. 

BY 

W.  p.  HERKINGHAM,  M.B. 


Henry  F.,  a  tall  strong  man  of  30,  came  to  me  in  the  Casualty 
Department  on  November  21,  1883.  He  had  complete  wrist- 
drop on  both  sides,  but  could  supinate  both  arms. 

His  history  was,  that  one  day  last  Christmas,  in  Australia,  he 
had  an  attack  of  severe  colic  ;  that  his  hands  gradually  got 
weak  from  that  time,  and  that  in  March  a  blue  line  was  noticed 
on  the  gums  both  by  the  doctor  attending  him  and  by  himself. 

He  was  at  the  time  drinking  beer  which  came  through  leaden 
pipes — this  was  inquired  into  at  the  time — and  often  had  a  glass 
before  breakfast,  when  the  beer  had  probably  been  standing  in 
the  pipe  for  some  hours.  Since  his  paralysis  did  not  improve, 
he  came  to  England  for  treatment. 

When  I  saw  him,  his  general  health  was  good,  his  digestive 
functions  and  his  heart  natural,  and  his  urine  contained  no 
albumen.  The  extensor  muscles  at  the  back  of  the  fore-arm 
were  much  wasted,  though  not  entirely  gone. 

So  far  the  case  was  one  of  ordinary  lead-poisoning,  but  he  pos- 
sessed an  unusual  symptom  in  a  large  bony  boss  projecting  on  the 
dorsum  of  each  hand.  These  lumps,  which  I  examined  carefully, 
lay  beneath  the  extensor  tendons,  which  worked  freely  over  them 
and  had  no  connection  with  them.  They  were  situated  over, 
and  apparently  were  enlargements  of,  the  carpal  ends  of  the  third 
metacarpal  bone  of  each  side,  resembling  very  much  the  swellings 
produced  by  rheumatoid  arthritis.  They  were  not  tender,  and 
caused  no  inconvenience  to  the  patient.  They  measured  nearly 
an  inch  across  the  bases,  and  projected  about  three-eighths  of  an 
inch  above  the  general  surface. 


I/O     Lead- Poisoning  with  Bosses  on  the  Metacarpal  Bones. 

There  was  neither  liistory  nor  sign  of  either  sj^pliilis  or  rheu- 
matism ahout  the  man,  who  did  not  seem  inclined  to  conceal 
any  such  fact  if  it  had  existed.  The  hiinps  had  appeared  since 
the  paralysis. 

I  gave  him  pot.  iod.  gr.v.  three  times  a  day  and  sent  him  for 
electrical  treatment  to  Dr.  Steavenson,  who  kindly  allows  me  to 
confirm  my  notes  hy  his  own. 

The  lumps  decreased  under  the  treatment,  and  hy  the  end  of 
his  attendance  (April  7)  were  almost  impei'ceptihle. 

Besides  rheumatism  and  syphilis,  I  know  of  no  other  disease 
likely  to  produce  such  bony  bosses  as  these,  and  upon  the 
strictest  investigation  I  could  discover  no  trace  of  either.  But 
although  they  must  be  exceedingly  rare,  tumours  like  these 
have  been  before  now  noticed  in  cases  of  lead-poisoning.  Ernst 
Kemak  writes  that  his  father,  Robert,  noticed  them,  and  refers 
to  three  papers  by  him  mentioning  the  subject.  I  have  only 
been  able  to  see  one  of  these,  in  which  I  cannot  find  the  point 
noted.  I  suppose,  therefore,  that  this  paper,  which  touches  upon 
a  kindred  subject,  joint  affection  in  progressive  muscular  atrophy, 
lias  been  given  by  mistake.  Eosenthal  in  his  "  Klinik  der  Nerven- 
krankheiten  "  mentions  a  case  of  the  sort,  though  without  any 
full  description.^ 

This  affection  is  quite  different  from  the  uratic  deposit  which 
accompanies  renal  disease  in  cases  of  lead-poisoning,  upon  which 
Lancereaux  has  written.  This  is  apparently  nothing  but  gout, 
and  according  to  Lancereaux  is  always  complicated  with  renal 
disease.  The  bosses  in  this  man's  hand  were  in  their  hardness, 
their  painlessness  from  the  first,  and  their  regularity,  different 
from  any  gouty  deposits  that  I  have  seen.  I  have  never  noticed 
gouty  deposit  in  the  carpal  end  of  the  metacarpal  bones  alone. 
There  were  no  otlier  signs  of  gout,  and  the  urine  was  natural. 

I  conclude,  therefore,  that  they  were  connected  with  the  lead- 
poisoning  itself. 

Besides  the  mere  rarity  of  their  occurrence,  these  tumours  are 
of  great  interest  as  being  possibly  another  instance  of  nervous 
disease  affecting  the  articular  end  of  bones.  They  are  so  con- 
strued by  Eosenthal,  and  according  to  Ernst  Eemak  were  be- 
lieved to  be  of  this  nature  by  his  father.  The  joint-disease  in 
locomotor  ataxia  is  referred  by  Charcot  to  disease  of  the  spinal 
cord.  Cases  of  progressive  muscular  atrophy  have  been  noted 
which  had  enlargement  of  the  articular  end  of  the  metacarpal 
bones,  and  rheumatoid  arthritis  itself  has  been  from  many  of 
its  symptoms  referred  to  some  central  nervous  affection. 

The  seat  of  the  lesion  which  produces  wrist-drop  in  lead- 

1  Edition  1875,  p.  800. 


Lead-Poisoning  loith  Bosses  on  the  Metacarpal  Bones.     171 

poisoning  has  not  been  establislied.  Some  have  found  chano-es, 
others  have  denied  them,  in  the  spinal  cord,  the  nerves,  and  the 
affected  muscles.  Supposing,  as  seems  most  probable,  that  the 
disease  is  nervous,  and  that  the  lead  affects  either  the  peripheral 
nerves  or  the  nervous  centres,  the  fact  that  the  posterior  inter- 
osseous nerve  supplies  both  the  affected  muscles  and  the  carpal 
joints  renders  it  at  least  possible  that  in  this  case  also  some 
similar  cause  to  that  observed  or  supposed  for  the  diseases  above 
mentioned  may  have  been  active  in  producing  the  articular  en- 
largement here  described. 


PAEA^IETRITIS  AND  ABSCESS  OF  THE  LITER. 


E.  W.  EOUaHTON,  M.D. 


The  causes  of  abscess  of  the  liver  are  very  numerous  and 
varied,  and  are  fully  stated  in  text-books,  but  I  am  unable  to 
find  any  record  of  cases  of  abscess  of  the  liver  secondary  to 
parametritis.  It  is  for  that  reason  that  I  am  induced  to  publish 
the  notes  of  the  following  case. 

M.  A.  W.  was  admitted  to  "  Faith,"  under  the  care  of  Dr. 
Church,  on  May  i6,  1885  :  she  was  subsequently  under  the 
care  of  Dr.  Matthews  Duncan  and  Mr.  Langton.  To  the  kind- 
ness of  these  gentlemen  I  am  indebted  for  permission  to  publish 
the  notes. 

She  was  a  well-made  woman,  25  years  old,  and,  with  the 
exception  of  an  attack  of  typhoid  fever  in  August  1884,  had 
always  enjoyed  good  health.  She  had  been  married  one  year, 
but  had  never  been  pregnant.  The  catamenia  first  appeared  at 
the  age  of  15,  and  had  always  been  natural.  On  May  14th 
she  was  taken  ill  somewhat  suddenly,  with  pain  in  the  lower 
abdomen  and  back,  accompanied  by  vomiting  and  pain  in  pass- 
ing water. 

She  was  transferred  to  "  Martha"  on  May  25th,  complaining 
of  the  above-mentioned  symptoms.  Her  temperature  varied 
from  100°  to  103°,  and  she  presented  the  usual  symptoms  of 
pyrexia.  The  urine  was  of  sp.  gr.  1027,  acid,  and  free  from 
albumen. 

The  abdomen  was  not  distended  or  generally  tender,  but 
there  was  fulness  in  the  left  iliac  and  adjacent  portion  of  the 
hypogastric  regions,  and  some  hardness  and  dulness  to  percus- 
sion over  the  horizontal  ramus  of  the  left  pubic  bone. 

On  vaginal  examination,  the  cervix  was  found  to  be  far  back 
in  the  pelvis,  and  in  front  of  it  a  dense  mass  of  tender  indura- 


174  Paramelrilis  and  Abscess  of  the  Liver. 

tion,  felt  bimannally  to  be  only  slightly  displaceable.     She  was 
ordered  a  milk  diet,  saline  laxatives,  opiates,  and  poultices. 

No  particular  change  took  place  for  some  days  ;  the  tempera- 
ture remained  high,  reaching  102°  to  103°  at  night,  and  falling 
to  near  the  normal  in  the  morning  ;  the  swelling  in  the  lower 
abdomen  gradually  increased,  and  the  urine  became  slightly 
albuminous,  and  showed  a  few  pus  cells  under  the  microscope. 

On  June  9th  the  urine  contained  about  three-fourths  albumen, 
but  no  pus;  the  swelling  had  become  more  prominent  immediately 
over  Poupart's  ligament,  and  seemed  as  if  about  to  point  in  that 
situation. 

On  June  20th  she  complained  of  cough  and  pains  in  the  lower 
part  of  the  right  side  of  the  chest.  On  auscultation  it  was  found 
that  the  breath  sounds  were  weak,  and  that  there  was  slight 
pleuritic  friction  and  increase  of  vocal  resonance  over  the  painful 
area ;  there  was  no  expectoration.  The  hypogastric  swelling  had 
become  less  tender  and  decidedly  smaller,  but  no  discharge  of 
pus  was  discovered,  althongh  the  urine  and  feeces  were  carefully 
examined.  The  temperature  continued  to  fluctuate,  and  she 
became  weaker  day  by  day. 

On  July  1st  some  fulness  and  tenderness  was  first  noticed  in 
the  hepatic  region,  and  an  abscess  of  the  liver  was  suspected. 

On  July  7th  the  liver  could  be  felt  one  inch  below  the  costal 
margin  in  the  nip{)le  line;  there  was  great  tenderness,  but  no 
jaundice,  and  her  general  condition  remained  about  the  same. 

On  July  nth  the  fulness  was  nuich  more  marked,  especially 
in  the  epigastric  region  ;  an  aspirator  was  passed  into  the 
swelling  just  below  the  ribs,  and  ten  ounces  of  pus  removed. 

As  no  improvement  followed  the  tapi)ing,  on  July  I5tli  she 
was  put  under  the  influence  of  jether,  and  Mr.  Langton  made  a 
free  incision  into  the  abscess  and  evaciuited  four  or  five  ounces 
of  pus.  After  the  anresthetic  had  been  stopped  for  about  five 
minutes,  and  whilst  the  dressings  were  being  adjusted,  she 
suddeidy  ceased  breathing,  and  although  artificial  respiration 
was  vigorously  performed,  she  did  not  lally. 

The  post-mortem  examination  was  made  twenty-four  hours 
after  death. 

The  uterus  was  quite  natural.  Surrounding  it,  but  chiefly  in 
front  and  on  the  left  side,  was  a  dense  inflammatory  mass  com- 
posed partly  of  cellular  phlegmon  and  partly  of  small  collec- 
tions of  serous  fluid  enclosed  by  peritoneal  adhesions.  The  right 
ovary  contained  about  two  drachms  of  pus.  The  liver  was  much 
enlarged,  and  contained  three  enormous  abscesses,  only  the 
most  superficial  one  of  which  had  been  opened.  The  base  of 
the  light  lung  was  collapsed  and  its  pleura  slightly  roughened. 


ParametrUis  and  Abscess  of  the  Liver.  175 

The  intestines  were  quite  lieallhy,  and  showed  no  signs  of  ulcera- 
tion, past  or  present.  There  were  no  abscesses  elsewhere,  and 
all  the  other  viscera  were  quite  normal. 

The  first  point  of  interest  about  this  case  is  that  the  pelvic 
inflammation  developed  without  any  apparent  cause.  She  had 
never  been  pregnant,  had  never  sustained  any  injury,  never  had 
any  operation  performed  on  the  uterus,  and  had  never  suffered 
from  any  menstrual  irregularity.  I  do  not  think  that  it  could 
have  been  a  sequel  of  the  attack  of  typhoid  fever  nine  months 
jtreviously. 

The  common  situation  of  parametritis  is  in  the  cellular  tissue 
of  the  broad  ligament,  but  in  this  case  a  large  portion  of  the 
phlegmon  occurred  in  front  of  the  womb.  It  has  only  recently 
been  recognised  that  there  is  an  appreciable  amount  of  cellular 
tissue  between  the  uterus  and  bhidder,  all  inflammatory  lumps 
in  front  of  the  uterus  having  previously  been  considered  peri- 
metric. This  was  a  typical  and  undoubted  case  of  "  anterior  " 
parametritis. 

The  gradual  increase  of  the  swelling  made  one  think  than  an 
abscess  had  formed,  and  was  about  to  point  just  above  Poupart's 
ligament ;  and  on  one  occasion  it  was  almost  decided  to  insert  an 
aspirator.  Had  we  done  so,  we  should  certainly  have  withdrawn 
nothing  except  perhaps  a  few  drops  of  serum.  This  indicates  a 
point  of  some  practical  importance  in  the  treatment  of  pelvic 
inflammations,  viz.,  that  they  should  not  be  incised  until  it  is 
absolutely  certain  that  they  will,  if  left  alone,  burst  externally. 
Fluctuation  (as  understood  by  surgeons)  is  but  a  very  uncertain 
sign  of  the  presence  of  fluid.  One  frequently  sees  inflamed  parts 
which  present  this  sign  incised,  and  no  fluid  except  blood  evacu- 
ated. The  only  certain  sign  of  the  presence  of  fluid,  short  of 
actual  tapj)ing,  is  fluctuation  in  its  proper  sense,  ie.,  the  feeling 
of  a  distinct  thrill  or  wave  communicated  from  side  to  side  of 
the  tumoin-,  but  this  sign  is,  of  course,  rarely  available  in  an 
ordinary  abscess. 

But  the  most  interesting  point  to  consider  is  the  relation  in 
which  the  pelvic  inilammation  and  the  hepatic  abscess  stood  to 
one  another.  They  might  have  been  simply  coincident  and  not 
causally  related,  or  they  might  both  have  been  due  to  the  same 
cause,  or  the  parametritis  might  have  been  the  cause  of  the 
abscess  in  the  liver. 

It  is  of  coui-se  quite  possible  that  these  two  conditions  might 
have  been  quite  independent  of  each  other,  but  in  the  absence 
of  any  other  discoverable  cause  which  could  have  produced  the 
hepatic  abscess,  one  naturally  associates  them  as  cause  and  effect, 
although   by  so  doing  one  may  be   falling  into   a  'post  ergo 


176  Parametritis  and  Abscess  of  the  Liver. 

propter  fallacy;  yet  it  is  impossible  to  avgne  with  anything 
like  logical  certainty  on  a  single  case.  It  is  well  known  that 
dysentery  and  he{)atic  abscess  are  frequently  associated,  and  the 
theory  of  Dr.  Budd,  that  the  abscess  is  the  result  of  a  portal 
pyaemia,  is  the  most  generally  received  explanation.  Arguing 
from  analogy,  I  think  that  the  present  case  may  admit  of  a 
similar  explanation.  Many  of  the  pelvic  veins  involved  in  the 
inflammatory  mass  must  have  been  thrombosed,  and  it  is  quite 
possible  that  an  embolus  might  have  been  detached  from  one  of 
them  and  found  its  way  to  the  liver,  there  setting  up  inflam- 
matory action. 

I  have  seen  one  ot.her  case  of  abscess  of  the  liver  following 
parametritis.  The  liver  was  aspirated,  and  fifteen  ounces  of 
pus  evacuated  :  the  patient  recovered. 

I  have  put  this  case  on  record  as  one  of  parametritis  associated 
with  abscess  of  the  liver,  but  it  must  be  left  to  subsequent  ex- 
perience to  determine  whether  or  not  hepatic  abscess  may  be 
included  under  the  occasional  results  of  parametritis. 


THE 

FORMATION  OF  ABNORMAL  SYNOVIAL  CYSTS 
IN  CONNECTION  WITH  THE  JOINTS, 

{Second  Communication,) 

BT 

W.  MOKEANT  BAKER 


In  the  13th  volume  of  the  St.  BarLholomew's  Hospital  Reports 
I  drew  attention  to  the  formation  of  synovial  cysts  in  the  leg  as  a 
consequence  of  disease,  especially  osteo-arthritis,  of  the  knee-joint ; 
and  I  ventured  to  deduce  from  an  examination  of  the  cases  there 
related  the  following  conclusions  : — 

1.  That  in  cases  of  effusion  into  the  knee-joint,  and  especially 
in  those  in  which  the  primary  disease  is  osteo-arthritis,  the  fluid 
secreted  may  find  its  way  out  of  the  joint,  and  form  by  distension 
of  neighbouring  parts  a  synovial  cyst  of  large  or  small  size. 

2.  That  the  synovial  cyst  so  produced  may  occupy  (a)  the 
popliteal  space  and  upper  part  of  the  calf  of  the  leg,  or  may  (h) 
be  evident  in  the  calf  of  the  leg  only,  projecting  most,  as  a  rule, 
on  the  inner  aspect  of  the  leg  as  a  small  defined  swelling,  not 
approaching  within  three  or  four  inches  of  any  part  of  the  knee- 
joint. 

3.  That  however  large  the  synovial  cyst  may  be,  fluctuation 
may  not  be  communicable  from  it  to  the  interior  of  the  knee- 
joint;  but  the  absence  of  such  fluctuation  must  not  be  taken  to 
contra-indicate  the  existence  of  a  connection  between  the  joint 
and  the  cyst. 

4.  That  the  synovial  cyst  may  be  expected  to  disappear  after 
a  longei-  or  shorter  period,  without  leaving  traces  of  its  existence, 
even  on  dissection  of  the  limb. 

5.  That  the  cyst  should  not  be  punctured  or  otherwise  sub- 

VOL.  XXI,  M 


178  Synovial  Cysts  in  Connection  ivitli  the  Joints. 

jectecl  to  operation,  unless  there  appear  strotig  reasons  for  so 
doing,  inasmuch  as  interference  may  lead  to  acute  inflamma- 
tion and  suppuration  of  the  knee-joint. 

6.  That  most  often  the  disease  in  the  knee-joint  will  be  found 
to  have  begun  some  time  before  the  appearance  of  the  secondary 
synovial  cyst ;  but  sometimes  the  patient's  attention  may  be 
first  drawn  to  the  latter,  or  the  cyst  may  seem  for  a  long  period 
the  more  important  part  of  the  disease. 

In  the  course  of  the  eight  years  which  have  elapsed  since  the 
publication  of  n)y  paper,  I  have  met  with  many  oilier  cases  of 
these  synovial  cysts  in  connection  with  the  knee,  and  have  found 
the  preceding  conclusions  amply  confirmed  by  further  experience. 

With  reference  to  the  route  taken  by  the  synovial  fluid  when 
escaping  from  the  interior  of  the  joint,  I  suggested  in  my  former 
communication  that  it  is  probably  one  determined  in  many  cases 
by  definite  anatomical  conditions,  especially  those  connected 
with  the  tendons  respectively  of  the  semi-membranosus  and  the 
popliteus  muscles,  although  in  others  the  starting-point  may 
be  a  "hernia"  of  the  synovial  membrane  in  some  other  situa- 
tion. 

The  following  account  of  two  dissections,  since  made  by  Mr. 
D'Arcy  Power,  appears  to  show  that  the  suggestions  then  offered 
were  correct : — 

The  first  case  was  that  of  a  man  (under  the  care  of  Mr. 
Thomas  Smith),  set.  44,  who  had  suffered  from  pain  in  the 
left  knee-joint  for  a  period  of  two  )'ears  before  its  amputation. 
"At  some  time  between  March  and  October  1884  a  swelling 
appeared  in  the  calf  of  the  leg,  behind  and  below  the  head  of  the 
fibula.  In  October  the  swelling  was  ])unctured  and  a  few  drops 
of  blood  with  some  glairy  fluid  were  removed,  but  there  was  no 
pus.  He  stated  that  many  years  before  he  had  rheumatism  in 
his  shoulder.  On  admission  into  St.  Bartholomew's  Hospital 
his  symptoms  were  recorded  by  Mr.  Buwlby  as  follows : — '  The 
knee  is  stiff,  and,  as  the  patient  lies,  the  leg  is  at  right  angles 
with  the  thigh.  The  head  of  the  tibia  is  enlarged  and  the 
patella  is  displaced  outwards.  A  fluctuating  swelling  about 
the  size  of  half  an  orange  is  situated  behind  and  below  the  head 
of  the  fibula,  extending  into  the  popliteal  space.  A  sinus  in 
the  middle  of  this  swelling  constantly  discharges  jjus.  The  skin 
over  it  is  red  and  inflamed.' 

"  On  opening  the  knee-joint  after  amputation  of  the  leg,  about 
half  an  ounce  of  pus  escaped. 

"The  cartilage  covei'ing  the  external  condyle  of  the  femur 
is  ulcerated  in  patches."    .     .     . 


Synovial  Cysts  in  Connection  with  the  Joints.  I'jg 

"  The  synovial  membrane  is  much  thickened,  and  in  parts  has 
grown  over  the  upper  portion  of  the  femoral  condyles.  It  is 
slightly  pedunculated,  the  tufts  of  synovial  membrane  being 
well  defined.  The  crucial  ligaments  are  destroyed.  There  is 
no  lipping  or  eburnation  of  the  bones  in  any  part,  and  the  car- 
tilage, upon  microscopic  examination,  does  not  appear  to  be 
fibrillated. 

"On  the  outer  side  of  the  spine  of  the  tibia  is  a  passage 
through  which  a  probe  can  be  passed  downwards,  backwards, 
and  slightly  inwards,  through  the  posterior  ligament,  into  a  sac 
containing  about  four  ounces  of  a  thick  curdy  pus."     .     .     . 

"  The  cyst  lies  beneath  the  gastrocnemius  muscle  in  the  situa- 
tion of  the  popliteus.  It  is,  I  believe,  the  popliteus  muscle, 
which  itself  has  been  gradually  distended  until  all  traces  of 
muscular  substance  have  disappeared."     .     .     . 

"  Near  the  outer  edge  of  the  plantaris,  at  the  back  of  the  joint, 
is  a  well-marked  hernia  or  pouch  of  the  synovial  membrane, 
which  has  protruded  between  the  fibres  of  the  ligamentum 
posticuni." 

Mr.  Power  comes  to  the  conclusion  tliat  in  this  case  the  for- 
mation of  the  cyst  in  the  leg  was  preceded  by  that  of  a  hernia 
of  the  synovial  membrane  of  the  knee-joint,  and  that  "  as  the 
swelling  increased  in  size  its  course  was  directed  by  the  popliteus 
muscle." 

In  the  second  case,  that  of  a  girl,  set.  22  (under  the  care  of 
Mr.  Langton),  "  On  the  inner  side  of  the  leg,  commencing  at  a 
point  two  inches  below  the  inner  condyle  and  extending  down- 
wards for  about  six  inches,  was  a  fluctuating  swelling.  This 
swelling,  the  patient  said,  had  existed  for  about  six  weeks,  and 
was  getting  larger.  The  skin  over  it  was  normal.  No  com- 
munication could  be  detected  between  the  swelling  and  the 
knee-joint.  The  swelling  was  punctu<-ed,  and  three  ounces  of 
puriforra  viscid  fluid  were  drawn  off.  Three  weeks  later  the 
swelling  was  agnln  punctured,  and  an  ounce  of  very  viscid  fluid 
was  with  difficulty  removed." 

(The  preceding  note  was  made  by  Mr.  J.  L.  Hewer.) 
"  The  leg  was    amputated.      Subsequent   dissection    showed 
that,  as   in  the   previous  case,  the  joint  was  completely  dis- 
organised."    .     .     . 

"The  bones  showed  no  signs  of  rheumatoid  change,  and  no 
history  of  rheumatoid  or  other  affection  could  be  obtained  from 
the  patient. 

"  On  the  posterior  surface  of  the  joint  two  openings  are 
visible.  The  one  situated  at  the  back  of  the  internal  condyle, 
immediately  above  the  inner  head  of  the  gastrocnemius,  is  large 


i8o  Synovial  Cysls  in  Connection  ivith  the  Joints. 

euourr]^  to  admit  a  lead  pencil.  The  opening  is  part  of  a  canal 
wiiicii  led  from  a  cyst  into  the  connective  tissue  surrounding  the 
muscles  at  the  back  of  the  thigh."     .     .     . 

"  The  second  aperture  is  situated  in  the  tendon  of  the  inner  head 
of  the  gastrocnemius  ;  it  is  somewhat  below  and  a  little  to  the 
inner  side  of  the  preceding,  and  is  in  communication  with  the 
cyst.  By  an  opening  in  communication  with  this  channel  a  con- 
nection is  formed  between  the  cyst  and  the  knee-joitit,  through 
whicii  a  probe  can  be  passed  beneath  ihe  internal  condyle  of  the 
femur."     .     . 

"  Tiie  cyst  measures  4  hy  3  inche.=!.  It  appears  to  have  been 
formed  by  an  enlargement  of  the  bursa  which  naturally  exists 
beneath  the  semi-membranosus  muscle,  and  in  this  instance 
may  have  commtmicated  wilii  ihe  knee-joint.  Theenhargement 
has  taken  place  in  the  connective  tissue  on  the  inner  side  of  the 
gastrocnemius  muscle,  and  some  of  the  fibres  of  this  muscle  form 
its  inner  and  posterior  wall."^ 

My  object  in  the  {)reseut  paper  is  to  direct  attention  to  the 
fact  that  abnormal  synovial  cysts  are  formed  in  connection  with 
other  joints  than  the  knee;  that,  like  those  met  with  in  connec- 
tion with  the  latter  joint,  they  may  present  many  difficulties  in 
diagnosis  ;  and  that  these  difficulties  may  lead  a  surgeon  astray 
as  to  both  prognosis  and  treatment. 

At  the  time  of  my  previous  contribution  on  this  subject  to  the 
Hospital  Reports,  I  had  not  noticed  the  disease  except  in  the 
neighbourhood  of  the  knee.  Since  that  period,  I  have  seen  it 
in  connection  with  the  shoulder,  the  elbow,  and  the  hip  joints. 
Eegarding  the  wrist-joint  and  the  ankle,  I  am  not  so  sure.  In 
connection  with  the  former  I  can  recall  one  case  at  least,  which 
was  probably  identical  in  nature;  but  it  occurred  many  years 
ago,  and  I  have  not  preserved  any  detailed  record  of  it. 

Case  L 

Disease,  probably  Osfeo- Arthritis,  of  the  Right  Shoulder- Joint, 
with  Consecutive  Synovial  Cyst  in  the  Upper  Arm. 

A  healthy-looking  man  (E.  S.),  aet.  24,  was  admitted,  under 
my  care,  into  St.  Bartholomew's  Hospital  on  September  26,  1883, 
on  account  of  a  fluctuating  swelling,  supposed  to  be  an  abscess, 
in  the  upper  arm.  He  had  applied  at  the  surgery  on  the  previous 
day,  complainitig  of  the  swelling  in  the  arm,  and  stating  that 
three  months  ago  he  first  noticed  pain,  which  struck  upwards  to 
the  shoulder.     Soon  afterwards  he  noticed  the  lump,  of  about 

^  Trans.  Path.  Soc.  of  London,  vol.  xxxvi.,  1885. 


Synovial  Cysts  in  Connection  with  iJie  Joints.  1 8 1 

the  size,  at  tliat  time,  of  a  hen's  egs^,  and  this  has  gradually  in- 
creased in  size.  The  swelling,  which  at  the  time  of  his  admis- 
sion measured  ahout  4  inches  in  length  by  3  in  breadth,  was 
situated  at  about  the  middle  of  the  upper  arm  in  front,  immedi- 
ately over  the  biceps  muscle,  to  which  it  seemed  to  be  adherent. 
It  fluctuated  readily,  and  was  formed  obviously  by  a  sac  of 
some  kind  containing  fluid.  It  had  been  punctured  on  the 
j)revious  day  in  the  surgery  by  a  grooved  needle,  and  a  small 
quantity  of  thin  straw-coloured  fluid  had  escaped.  There  was 
sh'ght  redness  of  the  skin  over  the  swelling,  but  it  nowhere 
"  pointed  "  like  nn  abscess.  At  this  time  no  complaint  was  made 
regarding  the  shoulder-joint,  and  nothing  regarding  its  condition 
was  recorded  in  the  noles. 

[Three  years  previously  the  patient  had  undergone  amputation 
of  the  thigh  on  account  of  "white  swelling  "  of  the  knee-joint. 
Beyond  this  there  was  nothing  apparently  worth  noting  in  his 
previous  history,  unless  that  he  had  had  an  abscess  in  each  groin 
about  lour  years  ago,  and  that  he  had  had  small-pox.] 

From  the  general  character  of  the  swelling,  and  the  absence 
of  complaint  on  the  part  of  the  patient  of  any  symptom  which 
might  have  guided  one  to  a  different  diagnosis,  I  came  to  the 
conclusion  that  the  tumour  must  be  either  a  simple  cyst  or  a 
chronic  abscess,  and  gave  directions  that  it  should  be  again 
l)unctured.  The  house-surgeon  accordingly  punctured  it  with 
a  tenotomy  knife.  About  two  ounces  of  straw-coloured  fluid 
escaped  first;  then  the  fluid  became  blood-stained,  and  this  was 
followed  by  the  escape  of  about  a  dessert-spoonful  of  curdy  lymph 
or  pus. 

On  examination  the  fluid  was  found  faintly  alkaline,  and 
became  solid  on  boiling.  Mixed  with  liq.  potassae  it  became 
slightly  gelatinous.  The  pus  (?)  was  slightly  soluble  in  cold  liq. 
potassse,  and  completely  so  on  boiling. 

[The  urine  was  normal.     Sp.  gr.  1025.] 

Oct.  2,  1883. — To  this  date  (four  days  after  the  puncture),  the 
])atient  had  had  no  pain  in  the  arm  ;  a  good  deal  of  clear  fluid 
had  escaped  from  the  site  of  the  puncture. 

On  the  following  day  the  patient  complained  of  headache,  and 
his  temperature  rose  to  102°  F.  Pulse  100.  In  the  evening 
the  temperature  was  104°  F.  A  good  deal  of  purulent  fluid 
escaped  from  the  wound. 

Oct.  6. — The  temperature  was  at  this  date  102°  F.  There 
l)ad  been  less  discharge  from  the  wound. 

At  about  this  time  the  patient  first  complained  of  pain  in  the 
shoulder,  and  I  began  to  suspect  the  true  nature  of  the  swelling 
of  the  arm.     But  unless  I  had  previously  known  that  a  synovial 


1 82  Synovial  Cysts  in  Connection  with  the  Joints. 

cyst  in  connection  willi  the  knee  miglit  appear  in  tlie  middle  of 
the  calf  of  the  leg,  it  is  quite  likely  that  even  at  this  time  the 
direct  connection  between  the  abscess  and  the  shoulder-joint 
would  not  have  been  discovered.  For,  as  before  mentioned,  the 
cyst  or  abscess  was  abont  half  way  between  the  shonlder  and  the 
elhow,  and  my  attention  had  not  been  previously  drawn  to  any 
affection  of  the  former. 

On  questioning  the  patient,  we  found  now  that  he  had  suffered 
from  pain  and  stiffness  abont  the  shonlder-joiut  for  many  weeks, 
although  the  relation  in  time  between  the  appearance  of  these 
symptoms  and  that  of  the  cyst  in  the  arm  could  not  be  clearly 
made  out. 

Oct.  13. — The  discharge  had  now  ceased,  but  there  was  in- 
creased pain  in  the  shoulder-joint,  and  a  slight  grating  was  per- 
ceptible on  rotating  the  head  of  the  humerus. 

Oct.  22. — At  this  date  it  is  noted  that  there  is  again  discharge 
from  the  wound  in  the  arm,  and  that  the  patient  suffers  from 
pain  in  the  shoulder-joint^  especially  in  the  evening.  He  gets 
up  in  the  afternoon. 

Nov.  5. — The  patient  is  now  much  better.  The  pain  in  the 
shonlder  is  less,  and  he  can  move  the  arm  much  better. 

Nov.  II. — There  is  now  no  pain  in  the  shonlder.  The  patient 
can  raise  his  arm.     The  wound  still  discharges. 

Nov.  26. — There  is  still  discharge  of  pus  from  the  woimd,  and 
there  is  occasionally  a  good  deal  of  pain  in  the  shoulder-joint., 
which  of  late  has  been  swollen  and  tendiM-. 

Dec.  10. — At  this  date  the  discharge  from  the  arm  had  almost 
ceased,  and  there  was  little  or  no  pain  or  swelling  about  the 
shoulder  ;  but  during  the  last  few  days  the  patient  has  suffered 
from  pain  in  the  head  and  sleeplessness.  He  has  also  frequently 
vomited.     The  temperature  has  varied  from  99.8°  to  101.6°  F. 

Dec.  II. — The  patient  was  delirious  this  morning,  and  on  the 
following  day  he  became  unconscious,  taking  no  food,  and  pass- 
ing his  urine  and  faeces  involuntarily. 

On  December  14  the  patient  was  better,  perspiring  freely,  and 
quite  conscious;  but  no  real  improvement  was  maintained,  and 
lie  died  December  16. 

(For  the  details  of  the  preceding  notes  I  am  indebted  to  Mr. 
Aldous,  surgical  dresser.) 

Post-mortem  Examination. — Nothing  abnormal  was  discovered 
in  the  brain,  or  in  the  thoracic,  or  abdominal  viscera. 

The  cartilage  had  disappeared  from  the  head  of  the  right 
humerus  and  from  the  glenoid  cavity,  and  pus  was  found  track- 
ing from  the  joint  for  some  distance  backwards  beneath  the 
latissimus  dorsi  muscle. 


Synovial  Cysts  in  Connection  ivith  the  Joints.  183 

I  regret  tliat  by  some  accident  no  account  has  been  given  in 
the  surgical  registrar's  notes  of  any  careful  dissection  of  the 
specimen ;  but  there  can  be  no  doubt  (there  was  none  at  the 
time)  that  synovial  fluid  had  found  its  way  from  the  shoulder- 
joint  to  the  middle  of  the  upper  arm  by  tracking  along  the 
course  of  the  long  tendon  of  the  biceps  muscle. 


Case  II. 

Synovial  Cyst  in  connection  with  the  Shoulder- Joint — Puncture — 
Subsequent  Suppuration — Amputation  at  the  Shoulder-Joint 
— Becovery. 

In  August  1884  I  was  asked  by  Dr.  Fred.  F.  Andrews  to  see, 
in  consultation  with  him,  a  patient  (F.  H.  P.),  set.  54,  with 
abscess  and  several  sinuses  in  the  upper  arm  and  about  the 
shoulder-joint.  He  had  suffered  from  aching  pains,  apparently 
rheumatic,  in  the  shoulder  since  November  1883,  and  in  February 
1884  there  was  a  large  prominent  fluctuating  swelling  at  the 
upper  part  of  the  chest,  at  about  the  level  of  the  shoulder,  but 
which  did  not  seem  to  have  any  connection  with  the  shoulder- 
joint  (although  at  this  time  the  latter  was  somewhat  stiff  and 
painful),  but  rather,  from  its  position,  to  be  connected  with  the 
anterior  and  upper  part  of  the  thorax.  In  June  1884  the 
swelling,  which  was  veiy  tense  and  fluctuated  readily,  was 
punctured,  when  there  escaped  a  quantity  of  thick  yellowish 
fluid  like  serum  or  synovia.  At  the  time  it  was  considered 
possible  that  the  fluid,  if  not  cystic,  might  have  come  from  the 
thorax;  there  were  no  symptoms  attracting  attention  to  any 
definite  connection  with  the  shoulder-joint.  Soon  afterwards, 
however,  suppuration  occurred  in  and  about  the  site  of  the 
original  swelling,  and  in  the  neighbourhood  of  the  shoulder- 
joint.  Various  abscesses  "  formed,"  and  were  either  punctured  or 
burst  spontaneously — one  above  the  clavicle,  and  one  or  more 
in  the  upper  arm. 

The  patient,  notwithstanding  the  abscesses  and  the  increasing 
stifi^ness  of  the  shoulder-joint,  was  able  to  get  about,  and  for  a 
time  to  return  to  his  business.  Suppuration,  however,  never 
entirely  ceased,  and  indications  of  disease  of  the  shoulder-joint 
became  more  and  more  marked. 

When  I  first  saw  the  patient,  he  was  in  the  condition  just 
mentioned ;  able  to  get  about,  but  with  several  sinuses  leading 
for  long  distances  beneath  the  skin  and  towards  the  shoulder- 
joint,  with  pus  escaping  rather  profusely  from  some  of  them. 


184  Synovial  Cysts  in  Connection  v:ith  the  Joints. 

The  joint  was  stiff,  but  at  tliis  time  no  symptoms  of  acute 
disease  were  present. 

Some  few  months  afterwards,  in  December  1S84,  the  symptoms, 
both  ^^eneral  and  local,  became  much  more  serious.  There 
could  be  no  doubt  that  the  shoulder  was  undergoing  a  process  of 
acute  inflammation  and  disorganisation  ;  abscesses  were  extend- 
ing from  it  in  various  directions,  with  profuse  discharge  from 
sinuses  above  the  clavicle  and  in  front  of  the  shoulder  and  in  the 
tipper  arm.  The  patient's  health  was  much  broken  ;  he  had  a 
led,  glazed,  and  aphthous  tongue,  and  a  hectic  temperature,  and 
was  fast  losing  flesh  and  strength. 

I  performed  amputation  at  the  shoulder-joint  in  December 
1884;  the  patient  afterwards  making  a  rapid  and  complete 
recovery. 

The  specimen,  which  was  kindly  dissected  for  me  by  Mr. 
D'Arcy  Power,  curator  of  the  ]\Iuseum  at  St.  Bartholomew's 
Hospital,  is  figured  in  the  36th  volume  of  the  Path.  Sue.  Trans., 
plate  xii.,  p.  336.  It  shows  the  effects  of  acute  inflammation  of 
the  head  of  the  humerus,  with  ulceration  and  destruction  of 
the  cartilage.  In  connection  with  it  are  the  remains  of  a  cyst, 
which  was  probably  in  connection  with  the  bursa  beneath  the 
6ub.scapularis  muscle. 

Case  III. 
Synovial  Cyst  in  connection  with  the  Elboio-Joint. 

A  post-office  porter  (W.  H.),  £et.  32,  was  admitteil  into  St. 
Bartholomew's  Hospital,  under  my  care,  in  August  1884,  on  ac- 
count of  a  swelling  in  the  neighbourhood  of  the  left  elbow-joint. 

The  swelling,  which  had  an  oval  outline,  was  about  the  size 
of  a  hen's  e^^g,  and  was  situated  immediately  above  the  internal 
condyle. 

The  skin  over  it  was  quite  normal,  and  was  not  adherent  to  the 
tumour.  There  was  slight  fulness  on  each  side  of  the  triceps 
tendon,  just  above  the  olecranon,  as  if  from  the  pi'esence  of  fluid 
in  the  elbow-joint.  The  movements  at  the  elbow-joint  were  pain- 
less, but  the  forearm  could  not  he  quite  completely  flexed  or  ex- 
tended. The  swelling  was  not  tender,  but  a  little  pain  was  pro- 
duced by  free  movements  at  the  joint. 

The  swelling  was  first  noticed  two  years  and  a  half  ago,  when 
it  was  about  the  size  of  a  small  nut.  It  grew  slowly,  but  for 
the  last  three  or  four  weeks  has  rather  rapidly  increased. 

A  few  days  after  the  patient's  admission  into  the  hospital,  the 
swelling  was  tapped,  when  some  brownish  viscid  synovial  fluid 
containing  granular  matter  escaped. 


Synovial  Cysts  in  Connection  with  the  Joints.  185 

The  tumour  almost  entirely  disappeared  after  the  tapping, 
but  rapidly  re-filled ;  and  the  patient  left  the  hospital  in  almost 
exactly  the  same  condition  as  on  admission. 

I  have  seen  the  patient  at  intervals  of  a  few  weeks  to  the 
present  time  (November  1885). 

But  little  alteration  has  occurred  in  the  swelling,  but  gradually, 
under  gentle  pressure  with  a  flannel  bandage,  the  size  has  some- 
what diminished,  and  the  patient  has  been  able  to  do  his  work; 
the  pain  and  tenderness  gradually  becoming  less,  and  the  move- 
ments of  the  arm  less  restricted. 


Case  IV. 
Synovial  Cyst  in  connection  luith  the  Elhoio- Joint. 

(For  permission  to  publish  this  case  I  am  indebted  to  Mr. 
Savory,  and  for  the  notes  to  his  house-surgeon,  Mr.  Lawrence.) 

A  man  (H.  D.),  ^t.  40,  was  admitted  into  St.  Bartholomew's 
Hospital,  November  25,  1884,  under  the  care  of  Mr.  Savory,  on 
account  of  a  swelling  in  the  arm.  The  swelling  is  situated 
on  the  inner  side  of  the  left  elbow,  about  an  inch  above  the 
internal  condyle,  being  somewhat  larger  than  a  pigeon's  Qgg, 
fixed  to  the  deeper  textures,  but,  like  the  skin  over  it,  freely 
moveable.  There  is  fluctuation.  The  arm  cannot  be  extended 
beyond  an  angle  of  120°,  and  cannot  be  completely  flexed. 

The  swelling  was  first  noticed  in  the  beginning  of  May  last, 
and  increased  so  rapidly  that  the  patient  came  to  the  hospital 
as  an  out-patient  about  a  week  afterwards.  At  that  time  the 
swelling  extended  in  front  from  the  internal  to  the  external 
condyle  ;  full  extension  being  impossible. 

An  angular  splint  was  applied,  with  lotio  plumbi  dressing. 

After  about  six  weeks  the  arm  had  so  much  improved  that  in 
July  the  patient  recommenced  work  ;  but  about  a  week  before 
his  admission  he  again  suffered  from  pain  and  swelling  and 
inability  to  fully  extend  the  arm. 

A  few  days  after  his  admission  into  the  hospital  the  tumour 
was  punctured  with  a  grooved  needle,  and  about  three  drachms  of 
thin  glairy  and  curdy,  apparently  synovial,  fluid  escaped.  A 
pad  and  bandage  were  applied  and  the  arm  placed  in  a  sling. 

As  a  result  of  the  treatment  the  swelling  almost  disappeared; 
but  in  a  few  days  it  "  re-formed,"  though  it  did  not  become  so 
large  or  tense. 

January  10,  1885. — Another  small  incision  into  the  tumour 
was  made  to-day,  when  some  clear  yellow  glairy  fluid  escaped, 
with  a  small  piece   of   what  looked  like   thickened   synovial 


1 86  Synovial  Cysts  in  Connection  loith  the  Joints. 

membrane.     A  pad  was  applied;  and  a  few  days  afterwards  the 
patient  left  the  hospital  wearing  a  i)laster  of  Paris  bandnge. 

I  have  seen  one  other  case  very  like  the  two  which  have  been 
just  recorded. 

Case  V. 
Synovial  Cys',  in  connection  luith  the  Hip-Joint. 

[I  am  indebted  to  Mr.  Thomas  Smitli  for  an  opportunity  of 
seeing  on  several  occasions  the  patient  to  whom  the  following 
nccount  belongs,  which  has  been  published  by  Mr.  Stephen 
Paget  in  the  36th  volume  of  the  Trans.  Path.  Soc.  of  London, 

P-  342.] 

'•  William  B.,  house-decorator,  set.  34.  Father  rheumatic ; 
himself  healthy,  except  for  rheumatism.  Four  children,  all 
very  healthy  ;  has  lost  none. 

The  history  of  his  case  is  as  follows  : — 

In  1874  he  began  to  feel  pain  in  the  left  hip  and  knee. 

In  1876  these  pains  interfered  with  his  work.  He  was  in  St. 
George's  Hospital  fur  four  months,  and  then  in  the  Koyal  Free 
Hospital. 

In  1877  he  was  in  St.  Bartholomew's  Hospital  under  Mr. 
Thomas  Smith.  The  left  hip  was  immoveable;  the  left  knee 
was  stiff;  there  was  slight  fulness  below  Poupart's  ligament; 
and  the  note  taken  at  this  time  puts  "deep-seated  fluctua- 
tion (?)."  He  was  treated  by  extension  of  the  limb  with  a 
weight  of  10  lbs.,  and  was  sent  out  on  crutches. 

In  1883  he  was  again  admitted,  having  managed  to  get  about 
and  do  his  work  for  the  last  six  years.  The  movement  of  the 
left  knee  was  now  much  impaired,  and  of  the  left  hip  still 
more.  There  was  pain  only  after  exertion.  The  limb  was  everted 
and  three-quarters  of  an  inch  shortened.  The  trochanter  was 
thickened.  The  whole  of  Scai-pa's  triangle,  from  Poupart's 
ligament  to  the  middle  of  the  thigh,  and  inwaid  as  far  as  the 
edge  of  the  adductor  longus,  was  occupied  by  a  large  hemi- 
spherical cyst,  fluctuating  throughout,  measuring  7|  inches  ver- 
tically by  7  across.  It  was  tapped,  and  42  oz.  of  yellow  alkaline 
fluid  drawn  off,  of  specific  gravity  1028,  containing  much  fat 
and  cholesterine.     Next  month  it  was  again  tapped. 

In  1884  it  was  again  tapped,  and  40  oz.  of  fluid,  evidently 
synovial,  were  drawn  off. 

In  1885  (March)  he  can  get  about  well  enough  to  do  his  work, 
and  can  walk  two  miles.  He  has  lately  suffered  from  more  pain. 
There  are  pain  and  creaking  noises  in  both  shoulders.    He  com- 


Synovial  Cysts  in  Connection  luith  tJie  Joints.  187 

plains  of  pain  at  tlie  back  of  the  head  and  at  the  epigastrium. 
Pupils  normal ;  patellar  reflex  normal.  The  cyst  is  filling  again. 
The  veins  of  the  limb  are  varicose.  Theie  is  no  oedema  of  the 
scrotum,  such  as  folloAved  the  first  tapping  in  1883." 

The  following  case  of  disease  of  the  ankle-joint  appears  to  be 
one  of  like  nature  to  those  previously  recorded.  But  I  do  not 
remember  seeing  the  case,  and  lighted  upon  it  only  by  accident 
in  the  Hospital  Records. 


Case  VI. 
Synovial  Cyst  over  and  heloiv  the  External  Malleolus. 

"  E.  B.,  £et.  13,  was  admitted  into  Darker  Ward,  March  22, 
1879,  under  the  care  of  Mr.  Callender. 

No  history  of  injury. 

In  the  last  three  years  patient  has  noticed  a  swelling  in  the 
neighbourhood  of  the  left  ankle-joint,  which  has  varied  in  size, 
nearly  disappearing  after  prolonged  rest,  and  getting  much 
larger  during  exertion.  It  gives  him  no  pain,  but  he  states  that 
the  joint  is  weak,  and  inclined  to  yield  under  him. 

24th. — At  present  there  is  a  small,  smooth,  fluctuating  swell- 
ing stretching  along  the  anterior  edge  of  the  external  malleolus, 
generally  rounded  in  shape,  and  evidently  containing  fluid.  The 
skin  over  it  is  natural,  with  the  exception  of  having  been  dis- 
coloured by  the  application  of  some  iodine.  The  top  of  the 
swelling  slightly  overlaps  the  surface  of  the  malleolus,  but  does 
not  extend  either  below  its  apex  or  under  the  anterior  tendons. 
No  alteration  in  size  is  noticed  after  short  pressure  upon  it.  The 
hollow  behind  the  malleolus,  between  it  and  the  tendo-Achillis, 
is  not  so  well  marked  as  it  should  be.  The  anterior  tendons  are 
rather  more  lifted  up  from  their  bed  than  those  of  the  opposite 
side.  There  is  no  thickening  of  the  bones  round  the  joint,  nor 
is  there  any  pain  on  movement  or  pressure  anywhere.  Mobility 
(passive)  of  the  joint  appears,  if  anything,  to  be  increased. 

25th. — Trocar  and  cannula  inserted  into  swelling,  with  the 
result  of  evacuating  a  clear,  gelatinous,  synovial  fluid. 

April  4. — The  swelling  has  again  increased. 

9. — Swelling  tapped,  and  lead  foil  strapped  over  the  part 
where  the  fluid  had  been  evacuated. 

29. — Swelling  much  smaller  than  formerly',  but  still  it  gives  a 
sense  of  fluctuation. 

May  23. — Swelling  nearly  gone. 


1 88  Synovial  Cysts  in  Conneclioii  loilh  the  Joints. 

Discliaiged. 

Bead  mi  I  ted  into  Abeiuetliy  Ward  under  the  care  of  Mr.  Savory, 
January  i,  1880. 

In  the  hist  five  months  he  has  been  in  Bow  Infirmary,  and 
unable  to  walk. 

He  cannot  now  bear  his  weight  upon  liis  left  foot.  The  foot 
he  keeps  extended,  and  cannot  flex  it  more  tlian  to  a  right  angle. 
The  leg  and  thigh  have  wasted,  and  are  cons[)icuously  smaller 
than  the  right.  Tliere  is  uniform  swelling  round  the  ankle- 
joint.     It  is  soft  and  tender  on  pressure. 

The  surface  of  the  joint  is  hot,  and  when  the  foot  is  moved 
or  ihe  heel  pressed  n]>wards  he  complains  of  pain. 

Back  splint,  swing  cradle,  lotio  plumbi. 

Jan.  8. — 01.  morrhuse,  syi-.  ferri  phos.  oi.  ter  s. 

1 8. — Less  tenderness. 

26. — Gum  and  chalk  bandage. 

Discharged. 

I  have  seen  a  case  some  few  3'ears  since  of  an  apparently 
bursal  multilocular  cyst  on  the  back  of  the  fore-arm  and  carpus, 
which  I  have  no  doubt  was  identical  in  its  pathology  with  that 
of  the  synovial  cysts  here  described.  Unfortunately  I  cannot 
find  any  written  notes  of  the  case.  The  patient  was  a  man  about 
30  to  40  years  of  age,  a  butcher  from  Smitlifield  jl\Iarket,  who 
attended  as  an  out-})atient  for  many  months  on  account  of  a  large 
fluctuating  irregular  swelling  on  the  back  of  the  hand  and 
extending  up  the  fore-arm  for  some  little  distance  ;  the  swelling 
being  deep-seated  and  involving  the  region  of  the  sheaths  of  the 
tendons,  but  without  any  indications  of  being  produced  by  a 
regular  thecal  distension.  On  the  contrary,  the  swelling  was 
irregular  in  outline,  as  if  more  or  less  multilocular,  with  a 
general  thickening  of  all  the  tissues  in  the  neighbourhood  of  the 
wrist-joint,  and  I  believe  (although  I  cannot  now  speak  positively 
on  this  point)  with  restricted  movement  of  the  latter. 

With  the  help  of  elastic  support  to  the  wrist  the  patient  was 
able  to  continue  his  work;  and  although  the  question  of  opera- 
tion was  often  considered,  I  never  felt  justified  in  recommend- 
ing any.  After  many  mouths  I  lost  sight  of  the  case  ;  but  the 
last  memory  I  have  of  it  is  distinctly  that  of  a  more  or  less 
thickened  and  crippled  wrist-joint,  and  not  that  of  thecal  disease 
only. 

In  the  British  Medical  Journal,  vol.  ii.  1884,  p.  413,  Mr. 
Arthur  T.  Norton  describes  cases  of  what  he  terms  "gangliar 
disease  of  joints,"  which  seem  to  me  identical  with  the  case  just  de- 
scribed, and  which,  like  it,  are  probably  identical  in  their  pathology 


Synovial  Cysts  in  Connection  with  iJie  Joints.  t  89 

with  many  of  the  cases  which  I  have  related  in  connection  with 
other  joints. 

"  In  one  case  a  woman,  set.  40,  fancied  she  had  sprained  her 
wrist  five  years  ago,  but  did  not  recollect  the  occasion.  For  four 
years  there  had  been  some  swelling  and  pain,  but  she  had  not 
been  prevented  from  continuing  her  employment  as  a  domestic 
servant.  For  the  last  three  months  before  admission  to  the 
hospital  there  was  a  so-called  ganglion  about  four  inches  in 
length,  extending  upwards  from  the  wrist-joint  in  the  centre  of 
the  fore-arm.  The  ligaments  of  the  wrist-joint  were  sufficiently 
loose  to  allow  lateral  gliding  movement.  The  aninilar  ligament 
was  pushed  forward  by  ganglionic  enlargement,  and  there  wns 
evidently  fluid  within  the  wrist-joint.  The  hand  hung  down, 
and  there  was  no  power  to  raise  it.  The  hand  was  quite  useless, 
and  the  disease  was  increasing  and  had  continued  so  to  do  for 
more  than  five  years,  regardless  of  treatment." 

From  a  past  experience  of  similar  cases  Mr.  Norton  concluded 
that  the  only  treatment  was  amputation,  which  he  accordingly 
performed.  On  examination  of  the  hand  after  removal,  he  found 
the  ganglion  already  mentioned  filled  with  the  usual  jelly-like 
material,  which  on  pressure  separated  into  plates  or  melon-seed 
shapes.  This  ganglion  extended  into  the  wrist-joint.  The 
wrist-joint  contained  a  small  quantity  of  fluid;  the  synovial 
membrane  was  villous ;  the  ligaments  were  distended  and 
allowed  lateral  gliding  movement  of  the  joint ;  and  all  the 
bones  of  the  carpus  were  rarefied  or  softened,  so  that  a  pin  or 
a  knife  could  be  easily  pushed  through  their  substance.  Though 
there  was  no  caries,  the  articular  cartilages  were  thinned. 

Mr.  Norton  relates  other  similar  cases. 

From  the  foregoing  cases  the  following  conclusions  may  be 
drawn  : — • 

1.  That  abnormal  synovial  cysts  may  be  formed  in  connection, 
not  only  with  the  knee,  but  in  connection  with  the  shoulder,  the 
elbow,  the  wrist,  the  hip,  and  the  ankle  joints. 

2.  That  the  manner  of  formation  of  these  synovial  cysts  pro- 
bably resembles  that  which  has  been  proved  to  occur  in  connec- 
tion with  the  knee-joint,  namely,  that  the  synovial  fluid  on  reach- 
ing a  certain  amount  of  tension  by  accumulation  within  the 
joint,  finds  its  way  out  in  the  direction  of  least  resistance,  either 
by  the  chaimel  by  which  some  normal  bursa  communicates 
with  the  joint,  or,  in  the  absence  of  any  such  channel,  by  form- 
ing first  a  hernia  of  the  synovial  membrane.  In  both  cases, 
should  the  tension  continue  or  increase,  the  fluid  at  length  escapes 
from  the  sac,  and  its  boundaries  are  then  formed  only  by  the 


190  Synovial  Cysls  in  Connection  with  the  Joints. 

muscles  and  other  tissues  between  and  amongst  which  it  accu- 
midates. 

3.  That  in  the  case  of  the  shouUler-joint  the  abnormal  s3'no- 
vial  cyst  may  be  found  either  in  front  a  little  below  the  clavicle, 
or  in  the  upper  arm  in  the  region  of  the  biceps  muscle. 

4.  That  in  connection  witli  the  elbow-joint  the  cyst  is  usually 
placed  on  the  inner  side,  a  little  above  the  internal  condyle  of 
the  humerus. 

5.  That  in  the  case  of  the  wrist-joint  the  synovial  cyst  may 
be  either  in  front  or  behind. 

6.  In  the  only  case  in  connection  with  the  hip  of  which  a  note 
has  been  preserved,  the  swelling  was  in  the  upper  part  of  Scarpa's 
triangle. 

7.  In  the  one  case  in  connection  with  the  ankle-joint  the 
synovial  cyst  was  in  front  and  to  the  outer  side. 

8.  That  the  apparent  want  of  direct  communication  between 
the  joint  and  the  abnormal  synovial  cyst  is  frequently  deceptive, 
and  should  not  leail  to  the  inference  that  no  such  communication 
exists. 

9.  That  the  caution  given  in  the  previous  communication,  not 
to  interfere  by  operation  with  these  synovial  sacs  without  good 
reason,  has  been  justified  by  increased  experience. 

Hitherto  I  have  not  discovered  any  relationship  between  the 
form  of  osteo-arthritis  with  which  some  of  these  synovial  cysts 
are  associated  and  locomotor  ataxy,  but  I  suspect  that  in  some 
of  them  a  relationship  will  be  found  to  exist. 


ON  THE 

BREATH  SOUNDS  OF  HEALTH  AND  DISEASE. 

BY 

J.  R  BULLAE,  M.B. 


The  present  paper  is  an  extension  of  an  account  of  an  artificial 
thorax,  and  of  some  experiments  performed  with  it,  in  illustration 
of  the  production  of  the  respiratory  sounds,  which  appeared  last 
autumn  in  the  Proceedings  of  the  Eoyal  Society  (No,  234). 

The  experiments  to  be  described  demonstrate  that  the  vesicular 
murmur  is  produced  in  the  lungs,  and  not  only  dispose  of  the 
theories  based  upon  the  assumed  glottic  origin  of  this  sound,  but 
explain  satisfactorily  all  the  peculiarities  of  the  resjDiratory  sounds 
in  health.  The  experiments  further  illustrate  the  effects  upon  the 
respiratory  sounds  of  the  various  physical  changes  in  the  lungs, 
and  enable  us  to  understand  how,  in  different  conditions  of  the 
parts,  the  morbid  sounds  are  due  either  to  changes  in  the  sound- 
conducting  power  of  the  parts  ausculted,  to  suppression  of  the 
sounds  produced  in  health,  or  to  the  addition  of  new  sounds  hav- 
ing no  existence  in  the  healthy  state. 

The  artificial  thorax  (a  description  of  which  is  given  at  the  end 
of  the  paper)  was  made  in  the  hope  of  illustrating  the  manner  of 
production  of  bronchial  breathing  in  cases  of  consolidation,  but 
after  a  few  preliminary  trials  it  became  evident  that  the  first  thing 
to  do  was  to  determine  in  what  parts  of  the  respiratory  tract  and 
in  what  manner  the  breathing  sounds  of  health  are  produced.  It 
is  surprising  that  the  cause,  and  even  the  place  of  production 
of  these  sounds  should  still  be  a  matter  of  dispute;  but  such  is 
the  case.  There  is  no  generally  accepted  theory  of  the  respiratory 
sounds  in  health ;  almost  every  author  of  a  text-book  upholds  a 
particular  view,  and  builds  upon  it  a  theory  of  the  morbid  sounds, 
with  the  result  that  the  literature  of  the  subject  is  a  mass  of  con- 
fusion. 


192  On  the  Breath  Sounds  of  HcaWi  and  Disease. 

The  point  in  dispute  is  the  place  of  origin  of  the  vesicuhir  mur- 
mur. If  this  could  be  demonstrated,  the  resi)iratory  sounds  of 
liealth  would  be  sufficiently  understood,  and  the  foundation  of  a 
true  theory  of  morbid  sounds  would  be  laid,  for  the  sounds  which 
are  known  to  be  glottic  and  oral  in  origin  present  no  difficulty. 

An  account  of  the  various  explanations  of  the  breathing  sounds 
may  be  found  in  Dr.  Paul  Niemeyer's  "  Handbuch  der  Percussion 
und  Auscultation"  (Erlangen,  1870),  of  which  the  following  is  a 
short  abstract. 

The  various  theories,  though  differing  more  or  less  in  detail, 
may  be  arranged  under  three  principal  heads. 

According  to  the  first,  the  sounds  are  produced  all  along  the 
respiratory  tract  by  the  friction  of  the  air  against  its  walls. 

According  to  the  second,  the  sounds  are  produced  at  the  glottis 
alone  ;  the  difference  in  the  sounds  heard  over  the  trachea  and 
lungs,  and  the  modifications  they  undergo  in  disease,  are  attri- 
buted to  the  greater  or  less  conducting  power  of  the  structures 
through  which  they  are  heard  at  each  spot. 

According  to  the  third,  the  sounds  are  produced  at  those  parts 
of  the  respiratory  tract  where  the  air  passes  from  a  narrower  to  a 
wider  space.  Thus  during  inspiration  one  sound  is  produced  at 
the  glottis  and  another  at  the  points  where  the  smallest  bronchioles 
open  into  the  vesicles.  During  expiration  a  sound  is  produced  at 
the  glottis  alone. 

The  sites   of  the  production  of   the   sounds   are    represented 


Sy 


{         ' 


in  the  figure  by  arrows  which  show  the  direction  of  the  air-current 
by  which  a  sound  is  produced  at  each  spot. 

I  shall  describe  first  an  experiment  which  demonstrates  that  the 
vesicular  murmur  is  produced  in  the  lungs. 


On  the  Breath  Sounds  of  Health  and  Disease.  193 

In  the  rest  of  the  paper  I  shall  consider  the  origin  of  the  vesi- 
cular murmur  as  proved,  and  my  arguments  are  of  no  value  if  I 
am  wrong  on  this  point. 

The  experiment  was  performed  in  the  following  way  :  ^ — 

A  pair  of  sheep's  lungs  with  the  trachea  attached  was  arranged 
so  that  the  left  lung  was  within  the  artificial  thorax,  while  the 
right  lay  outside  upon  the  roof  of  the  chamber.  The  chamber  was 
filled  with  water,  and  by  moving  the  handle  of  the  bellows  the  left 
lung  could  be  made  to  breathe  without  affecting  the  right  lung, 
which  lay  collapsed  outside  the  chamber.  By  fixing  the  handle  of 
the  bellows  in  different  positions,  diff'erent  degrees  of  distension  of 
the  left  lung  could  be  maintained.  An  india-rubber  air-bag  was 
now  attached  to  the  trachea.  Pressure  on  this  bag  tended  to 
drive  air  into  both  the  lungs,  but,  owing  to  the  incompressibility 
of  the  water  in  the  chamber,  it  had  no  effect  upon  the  lung  within 
it  as  long  as  the  handle  of  the  bellows  was  kept  still,  but  caused 
only  the  outer  lung  to  breathe. 

If  now  the  handle  of  the  bellows  was  fixed  in  the  raised  posi- 
tion so  as  to  keep  the  inner  lung  collapsed,  while  tlie  outer  lung- 
was  made  to  breathe  by  pressure  on  the  bag,  the  sounds  heard 
over  the  two  lungs  were  very  different.  In  the  outer  breathing  lung 
the  sound  was  vesicular,  inspiration  soft  and  rustling,  expiration 
much  more  faint.  In  the  inner  lung  both  inspiration  and  expira- 
tion were  loud  and  blowing,  the  sound  bronchial.  Over  the 
trachea  the  sounds  were  loud,  and  resembled  those  in  the  collapsed 
lung  in  character.  If  the  inner  lung  was  kept  in  a  state  of  expan- 
sion while  the  outer  lung  breathed,  the  sounds  heard  over  it  had 
the  same  bronchial  character  as  before,  but  were  vety  faint.  The 
sounds  heard  over  the  distended  and  motionless  lung  were  not 
more  vesicular  in  character  than  those  heaid  over  tiie  lung  when 
collapsed — they  were  the  same  sounds  but  fainter.  The  more  the 
motionless  lung  was  expanded  the  fainter  were  the  sounds  heard 
through  it ;  the  more  it  was  collapsed  the  louder  were  the  sounds 
— they  never  acquired  the  character  of  the  sound  heard  over  the 
breathing  lung. 

If  now,  while  the  inner  lung  was  expanded  and  the  outer  lung 
was  breathing,  the  handle  of  the  bellows  was  allowed  to  move,  both 
the  lungs  breathed  at  once,  and  at  each  inspiration  the  rushing 
vesicular  murmur  could  be  loudly  heard  over  the  inner  lung. 

The  only  explanation  of  these  facts  is  that  the  vesicular  mur- 
mur is  produced  in  the  lung  itself,  for  the  experiment  proves  that 
the  sounds  elsewhere  produced  are  heard  but  faintly  through  a 
distended  and  motionless  lung,  and  that  they  have  the  bronchial 
character ;  it  further  proves  that  the  vesicular  murmur  is  developed 
in  the  distended  lung  by  the  entrance  into  it  of  a  current  of  air, 
■^  For  a  figure  of  the  apparatus  see  Appeudix,  p.  207. 

VOL.  XXI.  N 


194  On  the  Breath  Sounds  of  Health  and  Disease. 

that  is,  by  a  cause  which,  while  it  may  produce  a  sound  in  the  lung 
itself,  must  diminish  its  power  of  conducting  sounds  produced 
outside  it ;  for  we  have  seen  that  increase  of  distension  lessens  the 
conducting  power  of  the  lung. 

The  above  experiment  proves  simply  that  the  vesicular  murmur 
is  produced  in  tlie  lung  during  its  expansion ;  it  does  not  indicate 
the  way  in  which  the  sound  is  produced. 

The  following  experiment  was  devised  to  determine  the  manner 
of  production  of  the  vesicular  murmur,  and  though  it  had  a  negative 
result,  it  is  of  interest  as  showing  that  the  murmur  is  not  produced 
by  the  movement  of  the  tissues  of  the  lunsf,  as  has  been  suggested.''- 


I  thought  tliat,  as  the  vesicular  murmur  is  produced  in  the 
lung,  it  might  be  possible  to  obtain  it  without  allowing  any  air 
to  enter  the  bronchi.  Witli  this  view  I  made  an  apparatus  in 
which  a  lung  with  its  bronchus  tied  could  be  at  will  relieved  from 
or  subjected  to  the  atmospheric  pressure,  jind  thus  made  to  expand 
and  contract.  I  supposed  that,  the  bronchial  tubes  being  incapable 
of  much  distension,  a  current  of  air  would  be  set  up  from  them 
to  tlie  vesicles,  and  that  thus  a  murmur  might  be  produced. 

The  apparatus  used  is  shown  in  fig.  4.  From  the  bottom  of 
^  Bristowe,  Theory  and  Practice  of  Medicine,  2d  edit.,  p.  380. 


On  tlve  Breath  Sounds  of  Health  and  Disease.  195 

the  glass  vessel  A  an  .india-rubber  tube  C  leads  to  the  vessel  B. 
The  junction  of  the  tube  and  glass  vessel  is  surrounded  by  the 
india-rubber  funnel  D  filled  with  gelatine  jelly  to  ensure  the  joint 
being  air-tight.  The  neck  of  the  glass  vessel  is  ground  to  fit  an 
india-rubber  stopper,  and  the  edge  of  the  glass  expands  and  pro- 
jects above  the  stopper  so  that  it  can  be  covered  with  water.  A 
solid  stethoscope  passes  through  the  stopper. 

In  order  to  use  the  instrument,  the  vessel  B  is  raised  and 
mercury  poured  into  the  tube  C  till  it  rises  into  the  lower  part 
of  the  glass  vessel.  The  rest  of  the  glass  is  then  filled  up  with 
water.  A  cat's  lung  or  the  small  lobe  of  a  sheep's  lung,  with  the 
bronchus  securely  tied,  is  placed  in  the  water,  the  cork  and 
stethoscope  adjusted,  and  the  cork  covered  with  water.  On 
lowering  the  vessel  B  and  the  tube  C  connected  with  it,  the 
lung  expands,  and  on  raising  it  again  contracts.  This  expansion 
and  contraction  is,  of  course,  caused  by  the  expansion  and  con- 
traction of  the  air  contained  in  the  bronchial  tubes  and  vesicles 
of  the  lung ;  but  as  the  bronchial  tubes  are  far  less  extensible  than 
the  vesicles,  the  expansion  is  accompanied  by  a  passage  of  air  from 
the  bronchi  to  the  vesicles,  and  the  contraction  by  a  passage  of 
air  from  the  vesicles  to  the  bronchi.  The  less  the  amount  of  air 
contained  in  the  vesicles,  or,  in  other  words,  the  more  the  lung  is 
collapsed  when  the  bronchus  is  tied,  the  greater  will  be  the  relative 
amount  of  air  contained  in  the  bronchi,  and  hence  the  greater 
will  be  the  current  from  bronchi  to  vesicles  and  from  vesicles  to 
bronchi  during  expansion  and  contraction.  Although  the  lung 
expanded  and  contracted  freely,  no  breathing  sounds  could  be 
satisfactorily  heard  through  the  stethoscope.  This  was  not  the 
fault  of  the  stethoscope  or  stopper  around  it,  for  the  breathing  of  a 
living  cat  could  be  heard  quite  plainly  with  it. 

I  thought  that  after  pressing  as  much  air  as  possible  out  of  a 
part  of  the  lung,  and  placing  the  stethoscope  over  this  part,  the 
first  expansion  was  accompanied  by  a  faint  sound,  but  of  this  it 
was  difficult  to  be  certain.  The  current  of  air  set  up  in  this  way 
was  probably  very  feeble,  the  greater  part  of  the  expansion  of  the 
vesicles  being  caused  by  that  of  the  air  already  contained  in  them. 
For  this  reason  the  result  of  the  experiment  is  no  evidence  that 
the  vesicular  murmur  is  not  produced  in  the  lungs  under  natural 
conditions,  but  simply  shows  that,  for  the  production  of  this  as  of 
all  similarly  developed  sounds,  a  certain  minimum  force  of  air- 
current  is  essential.  The  experiment  shows  that  the  vesicular 
murmur  is  not  caused  by  the  movements  of  the  tissues  of  the 
lung,  since  these  were  as  great  as  in  ordinary  breathing. 

The  results  of  the  above  experiments,  proving  as  they  do  that 
the  vesicular  murmur  is  produced  in  the  lungs,  dispose  altogether 
of  the  glottic  theory  of  the  production  of  the  vesicular  sounds. 


1 96  On  the  Breath  Sounds  of  Health  and  Disease. 

There  remain  for  our  acceptance  the  first  and  last  theories  quoteil 
at  the  beginning  of  this  paper.  The  first  of  these,  the  theory  of 
the  production  of  sound  all  along  tlie  respiratory  tract  by  friction 
of  air  against  its  walls,  is  unsatisfactory,  for  it  is  easily  demon- 
strable that  a  current  of  air  passing  through  a  uniform  tube  is 
unproductive  of  sound,  and  that  sound  is  produced  by  making  a 
constriction  in  the  tube.  It  is  true  tliat  the  trachea  and  bronchi 
are  not  absolutely  uniform  tubes,  and  that  some  sound  may  be 
produced  in  them  at  different  parts,  but  that  the  vesicular  murmur 
is  produced  by  "friction"  against  their  walls  is  negatived  by  the 
fact  that  the  sound  is  much  louder  during  inspiration  than  during 
expiration,  a  difference  which  cannot  be  accounted  for  by  any 
difference  in  the  friction  between  the  air  and  air-passages  in  the 
acts  of  inspiration  and  expiration.  "We  shall  be  safe  in  assuming, 
therefore,  that  any  sounds  produced  in  liealth  at  parts  other  than 
those  indicated  in  the  diagram  (p.  192)  are  almost  certainly  too 
feeble  to  have  any  practical  importance. 

The  theory  of  the  healtliy  respiratory  sounds  which  I  adopt, 
therefore,  is  the  third,  which  may  be  re-stated  as  follows  : — 

During  both  inspiration  and  expiration  sounds  are  produced 
in  the  nose,  mouth,  and  glottis — sounds  which  vary  with  the  vary- 
ing conditions  of  the  parts.  In  the  trachea  and  bronchi,  which 
are  in  the  natural  condition  nearly  uniform  tubes,  little  or  no 
sound  is  produced.  The  "vesicular  murmur"  is  produced  in  the 
lungs  during  inspiration,  and  though  the  exact  place  of  its  pro- 
duction has  not  been  demonstrated,  it  is  probably  at  tlie  junction 
of  the  narrower  bronchioles  with  the  wider  vesicles.  The  healthy 
sounds  of  respiration  then  are  nasal,  oral,  glottic,  and  pulmonary. 
The  nasal,  oral,  and  glottic  sounds  may,  for  purposes  of  descrip- 
tion, be  all  included  together,  and  when  in  future  I  speak  of  tlie 
glottic  sounds,  I  am  to  be  understood  to  refer  to  all  sounds  pro- 
duced in  the  glottis  or  above  it. 

In  order  to  make  our  ideas  of  the  healthy  respiratory  sounds 
clear,  it  is  necessary  to  consider  not  only  the  sounds  themselves 
and  the  places  of  their  production,  but  also  the  conducting  power 
of  the  parts  through  which  they  are  heard,  and  the  consequent 
differences  in  the  sounds  at  different  parts  of  the  living  body. 

If  the  respiratory  organs  and  the  structures  covering  them 
were  good  conductors  of  sound,  the  sounds  produced  at  any  one 
part  would  be  heard  at  all  other  parts,  and  wherever  we  listened 
on  the  surface  of  the  chest  or  throat,  we  should  hear  the  combina- 
tion of  all  the  sounds  produced  at  the  time.  The  distance  between 
the  most  remote  parts  of  the  respiratory  tract  is  so  small  that  none 
but  feeble  sounds  would  be  entirely  lost  on  that  account,  even  if 
it  were  not  the  case  that  in  a  great  part  of  this  short  distance  the 
sound  is  conducted  through  tubes  (trachea  and  larger  bronchi),  by 


On  the  Breath  Sounds  of  Health  and  Disease.  197 

which  the  effect  of  distance  is  diminished.  Of  course  each  sound 
would  bear  a  somewhat  greater  or  less  proportion  to  the  whole 
combination  as  the  point  auscultated  was  nearer  to  or  farther  from 
the  place  of  its  production,  and  thus  there  would  be  a  difference 
of  character  in  the  resultant  or  combination  sound  at  different 
parts.  It  would,  however,  everywhere  be  a  combination  of  the 
sounds  produced  at  the  different  parts  of  the  respiratory  tract. 
The  rate  of  the  air  currents  is  so  slow  as  to  have  no  influence  on 
the  conduction  of  sound. 

Distended  lung,  as  the  first  experiment  proves,  is  a  bad  con- 
ductor of  sound  ;  collapsed  lung  a  fairly  good  conductor;  and  the 
conducting  power  diminishes  as  the  collapse  gives  place  to  dis- 
tension; the  greater  the  distension  the  less  the  conduction  of 
sound  through  the  lung. 

The  whole  of  the  phenomena  of  the  healthy  respiratory  and 
voice  sounds  become  explicable,  indeed  almost  self-evident,  on  the 
recognition  of  the  following  facts  : — 

The  production  of  a  glottic  sound  during  inspiration  and  ex- 
piration. 

The  production  of  a  pulmonary  sound  during  inspiration. 

The  feeble  conducting  power  of  distended  lung. 

The  glottic  sounds,  including  the  voice,  are  heard  loudly  over 
the  trachea  and  in  the  neighbourhood  of  the  large  bronchi.  They 
are  heard  indistinctly  over  distended  lung.  In  the  first  experi- 
ment the  glottic  sounds  were  clearly  heard  over  the  trachea  and 
tlie  collapsed  lung ;  as  the  lung  was  distended  they  became  fainter 
and  fainter  over  the  lung,  but  were  still  audible  during  full  dis- 
tension. When  the  lung  was  allowed  to  breathe,  the  vesicular  or 
"  pulmonary  "  sound  was  added  to  the  glottic  inspiratory  sound,  and 
the  combination  produced  the  sound  of  healthy  inspiration.  Dur- 
ing expiration  the  sound  did  not  appear  to  be  much  louder  than 
when  the  lung  was  at  rest ;  probably  therefore  the  expiratory  part 
of  the  so-called  vesicular  murmur  consists  of  conducted  glottic 
sounds  alone.  Just  as  the  sounds  heard  over  the  lung  consist,  in 
part,  of  sounds  conducted  from  the  glottis,  so  the  sounds  heard 
over  the  trachea  consist,  in  part,  of  sounds  conducted  from  the 
lungs.  This  point  will  be  discussed  more  fully  when  I  come  to 
deal  with  the  morbid  respiratory  sounds. 

Alterations  of  the  healthy  sounds  may  be  brought  about  in 
three  ways.  By  suppj^ession  of  a  healthy  sound,  by  altera- 
tions in  conducting  poioer  0/ the  parts  through  which  the  sounds 
are  heard,  and  by  the  production  of  sounds  having  no  existence 
in  health.  These  causes  of  alteration  do  not,  as  a  rule,  come  into 
existence  separately.  As  we  shall  see  hereafter,  the  same  physical 
condition  of  the  lung  may  both  suppress  a  healthy  sound,  alter 
the  conducting  power  of  the  lung,  and  be  the  cause  of  production 
of  a  sound  having  no  existence  in  health. 


198  On  the  Breath  Sounds  of  Health  and  Disease. 

In  the  experiment^  in  wliich  one  lung  is  distended  and  motion- 
less while  the  other  breathes,  we  have  an  example  of  the  sup- 
pression of  the  pulmonary  sound  in  the  distended  lung  without 
alteration  of  its  conducting  power.  In  the  experiment  in  which 
one  lung  is  collapsed  while  the  other  breathes,  we  have  an 
example  of  suppression  of  the  pulmonary  sound  in  the  collapsed 
lung  with  accompanying  increase  in  its  conducting  power.  In 
each  case  the  breathing  heard  over  the  motionless  lung  is  bronchial, 
but  in  the  first  the  sounds  are  feeble,  in  the  second  loud. 

The  question  whether  in  these  experiments  there  is  or  is  not  a 
production  of  sound  which  does  not  exist  in  health  remains  to  be 
solved. 

In  order  to  answer  this  question  I  shall  show  that  in  these 
experiments  the  conditions  for  the  production  of  a  new  sound 
are  present,  and  that  these  conditions  are  of  such  a  nature  as 
to  explain  the  various  kinds  of  bronchial  breathing  met  with  in 
practice,  and  shall  describe  an  experiment  intended  to  demonstrate 
the  production  of  new  sound. 

First,  then,  it  is  well  known  that  a  current  of  air  passing  over, 
but  not  entering,  the  mouth  of  a  tube,  produces  a  sound  which, 
under  certain  conditions  of  the  length  of  the  tube,  &c.,  may  be- 
come a  musical  note,  and  that  in  cases  where  the  sound  is  a  noise 
rather  than  a  note,  that  by  listening  carefully  a  note  may  be 
detected  through  the  rushing  noise.  What  I  mean  may  be  easily 
illustrated  by  blowing  across  the  mouth  of  a  test-tube.  By  blowing 
more  or  less  hard  one  may  produce  either  a  clear  note  or  a  rushing 
lioise  characterised  by  a  certain  pitch,  or,  in  other  words,  a  noise 
and  an  accompanying  note.  Now,  in  the  experiments  the  bronchus 
leading  to  the  non-breathing  lung  is  in  the  position  of  the  test- 
tube.  Air  does  not  enter  it,  but  blows  across  it  on  its  way  from  the 
trachea  to  the  breathing  lung.  Tlie  condition  for  the  formation 
of  a  neio  sound  is  therefore  present  ichenevcr  there  is  stasis  of  air 
in  a  hronchus,  from  ivhatever  cause  this  may  arise. 

Secondly,  if  we  first  blow  across  the  mouth  of  an  empty  test-tube, 
and  then  gradually  fill  it  with  water,  blowing  across  it  again  after  each 
addition  of  fluid,  we  shall  notice  that  the  pitch  of  the  note  produced 
rises  in  proportion  as  the  air-space  in  the  tube  becomes  shorter. 

Clinically  the  bronchial  breathing  in  different  cases  is  charac- 
terised by  differences  in  pitch.  In  some  the  pitch  is  low,  like  that 
of  the  sound  heard  over  the  trachea  in  health  ;  in  others  high  and 
the  sound  whiffing. 

The  production  of  unnatural  sounds  was  demonstrated  in  the 
following  way  : — A  gutta-percha  tube  of  about  an  inch  in  internal 
diameter  was  moulded  at  one  end  so  as  to  form  a  bifurcation  into 
two  smaller  tubes,  each  having  an  internal  diameter  of  somewhat 

1  Page  193. 


On  the  Breath  Sounds  of  Health  and  Disease.  rpg 

more  than  half  an  inch,  and  to  each  of  these  was  fitted  an  india- 
rubber  tube  of  the  same  diameter  and  about  six  inches  in  length. 
The  inside  of  the  whole  apparatus  was  smooth. 

To  the  lower  free  ends  of  the  india-rubber  tubes  equal-sized 
bacs  of  india-rubber  tissue  were  attached,  as  shown  in  the  figure. 


The  artificial  thorax  being  filled  with  air,  the  tubes,  with  the 
bags  attached,  were  let  through  its  roof  as  far  as  the  dotted  line 
in  the  figure.  By  working  the  handle  of  the  bellows  air  was 
drawn  in  and  out  of  the  bags.  During  the  inspiration  and  expi- 
ration thus  caused  a  gentle  murmur  was  produced,  probably  at 
the  open  ends  of  the  tubes.  The  loudness  of  the  murmur  de- 
pended upon  the  force  with  which  the  respirations  were  performed, 
and  by  working  with  a  proper  force  the  sound  could  be  made  very 
faint  indeed.  If,  when  this  was  the  case,  one  of  the  smaller  tubes 
was  nipped,  so  as  to  prevent  any  air  passing  through  it,  the  sounds 
became  much  louder.  The  expiratory  sound  was  increased  more 
than  the  inspiratory.  The  character  of  the  sound  also  changed ; 
a  note  could  be  detected  in  it  whose  pitch  varied  with  the  part  of 
the  tube  pinched — tiie  shorter  the  length  of  tube  between  the 
bifurcation  and  obstruction  the  higher  was  the  note. 

The  sounds  could  be  heaid  either  at  the  mouth  of  the  large  tube 
(trachea)  or  with  the  stethoscope  in  the  obstructed  and  unob- 
structed tubes  (bronchi). 

The  same  result  was  obtained  with  the  lungs  of  a  calf.  Both 
lungs  were  placed  in  the  artificial  thorax  with  the  trachea  and 
main  bronchi  above  the  cover.     On  compressing  either  of  the 


200  On  the  Breath  Sounds  of  Health  and  Disease. 

bronchi  a  maiked  increase  of  sound  was  lieard  over  the  trachea, 
the  increase  in  the  expiratory  sound  being,  as  before,  the  greatest. 
Tlie  siiortness  of  tlie  broncld  made  it  impossible  to  elicit  different 
notes  by  comjties.sing  them  at  different  p(nnts. 

Tliese  experiments  show  that,  witli  a  given  rate  of  respiratory 
movement,  more  sound  is  produced  when  there  is  stasis  of  air  in 
a  bronchus  than  when  all  parts  of  the  lungs  breathe  at  once  ;  they 
further  show  that  a  change  in  the  character  of  the  sound  accom- 
panies this  increase,  and  that  the  quality  of  the  change  depends 
upon  the  length  of  tube  in  which  there  is  stasis  of  air. 

Consolidation  of  the  lung,  therefore,  acts  in  three  ways  in  alter- 
ing the  sounds  of  respiration  : — 

J^'irst,  the  pulmonary  sound  is  abolislied  in  the  consolidated  part. 

Second,  the  conducting  power  of  the  consolidated  part  is  in- 
creased, so  that  we  hear  the  sounds  produced  elsewhere  more 
})lainly  through  it. 

Third,  a  new  sound,  having  no  existence  in  health,  is  produced 
at  the  mouth  of  the  tube  or  tubes  leading  to  the  consolidated  part, 
and  this  new  sound  is  characterised  by  some  particular  note,  whose 
pitch  depends  upon  the  size  of  the  tubes  in  which  there  is  stasis 
of  air. 

In  different  cases  of  consolidation  the  result  of  the  combination 
of  the  three  causes  of  ciiange  will  be  different.  In  cases  of  small 
masses  of  consolidation  the  amount  of  healtliy  sound  suppressed 
and  of  morbid  sound  produced  will  be  insignificant,  and  the  con- 
solidation w^ill  be  effective  simply  by  its  increased  conducting  power; 
it  will  act  as  a  continuation  of  the  stethoscope  through  the  vesicu- 
lar structure  to  the  bronchus  on  which  it  rests,  and  will  enable  us 
to  hear  tiie  sounds  normally  present  in  the  bronchi. 

Tiiat  this  is  the  case  may  be  shown  in  the  following  way : — A 
lung  is  made  to  breathe  by  attaching  it  to  the  air-bag  and  pressing 
intermittently  on  the  bag.  Tlie  stethoscope  is  first  placed  lightly 
on  the  lung,  so  as  not  to  interfere  with  its  movements,  and  the 
vesicular  murmur  is  iieard.  The  stethoscope  is  then  pressed  more 
firmly,  so  as  to  compress  and  consolidate  the  lung  beneath  it;  the 
breathing  sounds  then  become  bronchial. 

In  a  large  consolidation,  on  the  other  hand,  the  suppression  of 
pulmonary  sound  will  be  great,  and  the  production  of  new  sound 
may  also  be  considerable,  giving  rise  to  bronchial  breathing  of 
high  or  low  pitch  according  to  the  size  of  the  tubes  in  which 
there  is  stasis  of  air. 

It  is  needless  to  give  more  examples  of  the  various  proportions 
in  which  suppression,  altered  conduction,  and  new  formation  of 
sound  may  occur.  All  that  is  necessary  is  to  remember  that  in  every 
case  of  unnatural  breathing-sounds  due  to  consolidation,  the  change 
is  produced  by  one  or  more  of  these  three  causes. 


On  the  Breath  Sounds  of  Health  and  Disease.  201 

I  shall  next  consider  the  clianges  produced  by  cavities,  so  as  to 
be  able  to  compare  their  effects  with  those  of  consolidation,  and 
then  discuss  separately  some  further  points  of  interest  which  can- 
not be  introduced  here  without  confusion. 

,  In  a  cavity,  as  in  a  consolidated  portion  of  lung,  the  natural 
pulmonary  sound  is  abolished. 

The  conducting  power  of  air  is  greater  than  that  of  healthy 
lung ;  therefore,  if  the  cavity  contain  air,  the  conduction  through 
it  is  increased  just  as  it  is  in  consolidation. 

•  A  cavity  may  also  be  the  cause  of  the  production  of  new  sounds. 
These  sounds  may  be  produced  in  various  ways,  which  I  shall  dis- 
cuss immediately,  but  before  doing  so  I  wish  to  point  out  a  fact  which 
is  not  always  sufficiently  insisted  upon.  It  is  that  unless  the  new 
sound  produced  by  the  cavity  has  some  special  character  by  which 
it  may  be  distinguished,  the  auscultatory  signs  of  cavity  and  con- 
solidation are  the  same.  Suppression  of  pulmonary  sound  and 
increased  conduction  of  sounds  produced  elsewhere  are  common  to 
both  consolidation  and  cavity,  and  the  characters  of  the  new 
sounds  produced  are  seldom  sufficiently  distinct  to  enable  us  to 
say,  by  the  auscultatory  signs,  whether  the  case  before  us  is  one  of 
consolidation  or  cavity.  Cavities  are  always  accompanied  by  more 
or  less  consolidation,  and  it  is  not  uncommon  to  find  post-mortem 
that  auscultatory  signs  which  during  life  were  attributed  to  a  large 
cavity  were  really  due  to  extensive  consolidation  surrounding 
only  small  excavations.  The  signs  then  of  consolidation  and 
cavity  may  he,  and  frequently  are,  ideiitical. 

The  new  production  of  sound  in  cases  of  cavity  may  be  due,  as 
in  consolidation,  to  stasis  of  air.  A  cavity  with  rigid  walls  can- 
not expand  appreciably  during  respiration,  and  if  it  is  in  com- 
munication with  a  bronchial  tube,  the  air  in  the  cavity  and  tube 
will  be  motionless,  and  the  conditions  for  the  production  of  a 
sound  at  the  origin  of  the  bronchus  leading  to  the  cavity  will  be 
the  same  as  in  a  case  of  consolidation.  Supposing  the  communica- 
tion between  the  bronchus  and  the  cavity  to  be  free,  the  cavity 
will  have  some  influence  by  resonance  on  the  character  of  the  sound 
produced,  but  this  may  be  too  slight  to  distinguish  it  clinically  from 
consolidation. 

In  cases  in  which  the  air  passes  through  the  cavity,  as  in  a  dilated 
bronchus,  a  sound  will  be  produced  in  the  cavity  both  during 
inspiration  and  expiration ;  but  again  these  sounds  may  have  no 
special  characters  by  which  they  can  be  distinguished  from  the 
sounds  due  to  consolidation,  and  though  produced  by  movement 
of  air  in  the  cavity,  may  resemble  the  sounds  due  to  stasis. 

A  very  low-pitched  note  in  the  bronchial  breathing,  or,  as  it  is 
called,  cavernous  breathing,  may  be  indicative  of  the  resonance 
of  a  large  cavity.     If  the  pitch  is  not  lower  than  that  of  the 


202  On  the  Breath  Sounds  of  Health  and  Disease. 

normal  traclieal  sounds,  it  is  not  an  indication  of  cavity,  since  the 
tracheal  sounds  may  be  heard  by  conduction  through  a  solid  lung. 
An  important  point  to  remember,  and  one  which  is  made  evident 
by  the  experiments  I  have  described  is  that  breathing  sounds, 
other  than  the  vesicular  murmur,  heard  over  parts  of  tiie  lungs 
in  ■which  the  vesicular  murmur  is  naturally  present,  are  no  indica- 
tion that  air  is  entering  those  parts.  We  hear  loud  bronchial 
breathing  over  parts  of  the  lung  that  are  completely  consolidated 
by  pneumonia,  and  they  only  cease  to  be  heard  if  the  bronchial 
tubes  become  jilngged  by  mucus.  In  tlie  same  way  we  may  hear 
loud  breathing  sounds  over  an  empty  cavity,  but  we  cannot  there- 
fore infer  that  air  enters  tlie  cavity  during  inspiration.  The 
entrance  of  air  into  a  cavity  may  be  inferred  from  the  sound  of 
splashing  or  of  large  bubbles,  but  not  from  the  breathing  sounds 
alone. 

1  shall  now  discuss  a  point  which  was  mentioned  in  the  descrip- 
tion of  the  previous  experiments,  but  which  has  not  yet  been  fully 
considered. 

In  the  experiments  demonstrating  that  a  new  sound  is  produced 
when  there  is  stasis  of  air  in  a  bronchus,  it  appeared  that  the  expira- 
tory sound  was  more  increased  than  in  the  inspiratory.  (See  p.  199.) 
The  explanation  of  this  appears  to  be  that  the  trachea  is  a  larger  tube 
than  a  bronchus,  and  that  hence  when  there  is  stasis  of  air  in  one 
lung,  as  shown  by  the  shading  in  the  diagram,  the  conditions 
for  the  production  of  sound  are  different  during  inspiration  and 
expiration.  In  both  cases  the  air-current, 
as  shown  by  the  arrows,  passes  over  the 
mouth  of  the  shaded  bronchus  in  which 
til  ere  is  stasis  of  air,  and  gives  rise  to  a 
sound  in  the  way  described  above.  During 
inspiration  this  is  the  only  new  sound  pro- 
duced, but  during  expiration  the  air  passes 
from  the  smaller  bronchus  into  the  larger 
trachea,  and  the  passage  of  air  from  a 
smaller  to  a  larger  tube  produces  sound, 

A  sound  produced  at  the  mouth  of  a  bron- 
chial tube  is  conducted  upwards  as  well 
as  downwards.  In  the  experiments  the 
tracheal  sounds  were  changed  as  well  as  the  sounds  in  the  ob- 
structed and  unobstructed  bronchi.  In  the  living  body  sounds 
produced  in  the  bronchi  and  lungs,  rales,  clicks,  and  even  crepi- 
tation, may  often  be  heard  over  the  trachea.  It  is  to  be  expected, 
therefore,  that  in  cases  of  high-pitched  bronchial  breathing,  in 
which  well-characterised  sounds  are  produced  in  the  bronchial 
tubes,  there  should  be  a  change  in  the  sounds  heard  over  the  trachea. 
The  natural  sounds  heard  in  the  trachea  are  formed  in  the  glottis 


On  the  Breath  Sounds  of  Health  and  Disease.  203 

and  in  the  lungs.  The  addition  to  these  sounds  of  a  new  sound 
formed  in  the  bronchial  tubes,  unless  it  were  of  a  different  character 
from  them,  would  not  be  recognisable  ;  it  would  simply  increase 
the  loudness  of  tiie  tracheal  sounds  ;  and  as  the  trachea  is  a  single 
organ,  and  we  have  nothing  with  which  to  compare  it  directly, 
the  change  would  not  be  detected.  Cases,  however,  occur  in  which, 
as  the  bronchial  breathing  disappears  from  the  lungs,  a  change 
may  be  detected  in  the  tracheal  sounds.  Dr.  Andrew  has  liad 
the  kindness  to  examine  several  cases  of  pneumonia  and  phthisis 
in  his  wards  with  regard  to  this  point,  and  he  has  in  several  in- 
stances observed  a  distinct  cliange  in  the  character  of  the  tracheal 
sounds  to  occur  simultaneously  with  changes  in  the  character  of  tlie 
breathing  sounds  heard  over  the  lungs.  The  changes  in  the  tracheal 
sounds  are  not  likely  to  be  of  any  clinical  importance,  but  are 
interesting  in  connection  with  the  theory  of  bronchial  breathing. 

In  cases  in  which  a  considerable  portion  of  lung  ceases  to 
breathe,  as  in  pneumonia,  phthisis,  pleurisy  with  effusion,  &c., 
the  sounds  heard  over  the  unaffected  parts  of  the  lungs  are  often 
louder  than  natural  and  are  called  puerile.  Thus  Dr.  Gee  (Aus- 
cultation and  Percussion,  second  edition,  p.  257),  in  speaking  of  the 
signs  of  pulmonary  phthisis,  says :  "  The  loudness  of  the  puerile 
breathing  sometimes  leads  the  inexpert  to  predicate  disease  just 
in  that  solitary  part  where  the  lung  remains  healthy."  And  in 
discussing  the  physical  conditions  of  the  respiratory  sounds  (p. 
131)  he  says:  "Puerile  breathing  implies  louder  sounds  than 
usual,  produced  in  the  glottis,  and  a  very  open  state  of  lung." 
The  implication  is  a  necessary  one  if  the  theory  of  the  glottic 
origin  of  the  vesicular  murmur  adopted  by  Dr.  Gee  is  true.  It 
will  be  interesting  therefore  to  inquire  whether  the  destruction  of 
lung  tissue  affects  the  production  of  sound  in  the  glottis,  and 
whether  the  occurrence  of  puerile  breathing  can  be  explained,  if, 
as  I  believe,  the  vesicular  murmur  is  produced  in  the  lungs. 

In  order  to  understand  the  changes  in  the  movements  of  air 
consequent  upon  parts  of  the  lungs  ceasing  to  breathe,  it  is  neces- 
sary first  of  all  to  picture  to  ourselves  the  movements  of  air  which 
take  place  in  the  healthy  respiratory  tract. 

The  glottis  is  the  narrowest  part  of  the  tract;  from  this  point 
the  cross  section  of  the  tract  increases  and  is  largest  in  the  vesicles. 
Just  as  the  blood  current  is  quickest  in  the  narrower  aorta,  and 
slowest  in  the  wider  capillaries,  so  the  air  current  is  quickest  in 
the  glottis  and  slowest  in  the  vesicles.  During  inspiration  the 
movement  of  the  air  from  the  glottis  towards  the  vesicles  becomes 
progressively  slower,  and  during  expiration  the  movement  of  the 
air  from  the  vesicles  towards  tlie  glottis  becomes  progressively 
quicker.  The  absolute  rate  of  the  air  current  at  any  part  of 
the  respiratory  tract  depends  upon,  the  energy  of  the  respiratory 


204  On  the  Breath  Sounds  oj  Health  and  Disease. 

movements,  but  the  relative  rates  at  different  parts  of  the  tract 
depend  upon  the  areas  of  tlie  cross  sections  at  those  parts.  The 
following  diagram  will  make  what  I  mean  clear : — 


The  outline  to  the  left  of  the  vertical  line  A  A  represents  a 
longitudinal  section  of  the  respiratory  tract ;  the  narrowest  part  is 
at  the  glottis  G ;  this  is  followed  by  the  uniform  trachea  T,  after 
which  the  cross  section  represented  by  the  truncated  cone  L 
rapidly  increases  to  the  line  A  A,  which  is  supposed  to  pass 
through  the  vesicles  or  widest  part  of  the  tract.  During  inspira- 
tion a  stream  of  air  may  be  supposed  to  flow  from  G  to  A  A. 
The  dotted  outline  to  the  right  of  A  A  represents  the  same  parts 
as  the  outline  on  the  left,  and  during  expiration  a  stream  of  air 
may  be  supposed  to  flow  from  A  A  to  G\  Thus  inspiration  and 
expiration  may  be  represented  diagrammatically  by  a  stream  flow- 
ing through  the  whole  scheme  in  the  direction  of  the  arrow  from 
G^toG. 

The  rate  at  which  the  air  passes  any  point  of  the  scheme,  G,  C, 
B,  or  A,  will  depend  upon  the  force  with  which  the  respiratory 
movements  are  performed ;  but,  whatever  the  absolute  rate  may 
be,  there  will  be  a  certain  proportion  between  the  rates  at  the 
different  parts  of  the  scheme.  Supposing  the  current  at  G  to  be 
ten  times  quicker  than  at  C,  and  a  hundred  times  quicker  tlian  at 
A,  this  relation  will  hold  good  whatever  the  rate  may  actually  be 
at  G,  since  the  differences  in  rate  at  G,  C,  and  A  depend  solely  on 
the  differences  in  the  cross  sections  of  the  scheme  at  those  points. 
Now,  consolidation  of  the  lung  would  be  represented  in  the  figure 
by  a  narrowing  of  the  scheme  at  A  A,  and  the  efiect  of  it  would 
be  to  upset  the  ratio  previously  existing  between  the  rates  of  the 
current  at  A  and  G.  In  proportion  as  the  cross  section  at  A  was 
diminished,  the  rate  of  the  current  at  A  would  be  increased ;  but 
there  would  be  no  cause  of  increase  in  the  rate  of  the  current  at 


On  the  Breath  Sounds  of  Health  and  Disease.  205 

Gr.  As  the  intensity  of  a  sound  depends  upon  the  rate  of  the 
current  producing  it,  the  consolidation  of  one  lung  would  increase 
the  sound  produced  in  the  other,  but  would  have  no  effect  upon 
the  production  of  sound  in  the  glottis. 

We  thus  see  that  the  destruction  by  compression,  consolidation, 
or  otherwise,  of  a  part  of  the  lung  implies  greater  rapidity  of  air 
currents  in  the  healthy  parts  of  the  lungs,  and,  therefore,  if  sound 
be  produced  in  them,  greater  production  of  this  sound. 

We  further  see  that  consolidation  does  not  imply  greater 
rapidity  of  air  current,  and  therefore  of  production  of  sound  in 
the  glottis.  If  consolidation  leads  to  an  increase  in  the  glottic 
sounds,  it  must  do  so  indirectly,  either  by  narrowing  the  glottis  or 
by  increasing  the  force  of  the  respiratory  movements. 

So  far  as  I  know,  there  is  no  reason  to  suppose  that  the  rinia 
glottidis  is  narrowed  in  cases  of  consolidation. 

With  regard  to  increased  force  of  respiration,  it  must  be  remem- 
bered that  increased  frequency  and  increased  force  are  quite  dis- 
tinct. Suppose  a  man  with  healthy  lungs  to  be  breathing  fifteen 
times  a  minute,  and  that  during  each  inspiration  thirty  cubic 
inches  of  air  pass  through  his  glottis,  say  in  two  seconds. 
Suppose  now  that,  while  he  continues  to  breathe  at  exactly 
the  same  rate,  one  of  his  lungs  becomes  suddenly  consolidated. 
(We  may  assume  for  the  sake  of  argument  that  the  capacity 
of  each  lung  is  the  same.)  Each  inspiration  will  now  occupy 
one  instead  of  two  seconds,  during  which  time  fifteen  cubic 
inches  of  air  will  pass  through  his  glottis ;  the  time  occupied  in 
expiration  will  be  equally  diminished,  and  he  will  be  able  to 
perform  thirty  respirations  a  minute  in  place  of  fifteen  without 
any  increase  in  the  rate  of  the  air  current  in  the  glottis  or  of  the 
sound  produced  in  it.  If,  therefore,  the  capacity  of  the  chest 
is  diminished  by  half,  the  rate  of  respiration  must  be  more  than 
doubled  before  any  increase  in  the  production  of  the  glottic  sound 
is  produced. 

I  think  it  will  be  admitted  that  the  facts  of  puerile  breathing  re- 
ceive a  better  explanation  from  the  theory  of  the  pulmonary  origin  of 
the  vesicular  murumr  than  they  do  from  the  glottic  theory,  and  that 
they  are,  therefore,  an  additional  proof  of  the  truth  of  the  former. 

I  have  one  more  experiment  to  describe,  which  may  help  to 
explain  the  cause  of  jerking  or  intermittent  breathing.  While  I 
was  working  at  the  respiratory  sounds  I  saw  a  very  marked  case  of 
this  kind,  in  which,  after  the  general  expiratory  sound  had  ceased, 
there  came  a  distinct  pufi",  quite  audible  to  the  patient  himself, 
and  at  a  little  distance  from  him.  In  this  case  there  was  certainly 
a  considerable  cavity,  for  periodically  an  ounce  or  more  of  purulent 
sputum  was  thrown  up,  and  the  sign  was  only  present  shortly  after 
this  had  occurred. 


206  On  the  Breath  Sounds  of  Health  and  Disease. 

It  struck  me  that  the  sound  might  depend  upon  altered  elas- 
ticity of  the  different  parts  of  the  lung  giving  rise  to  a  differ- 
ence in  the  periods  of  inspiration  and  expiration  at  which  they 
would  expand  and  contract,  I  therefore  modified  the  apparatus 
described  on  p.  198  by  replacing  one  of  the  gutta-percha  bags  by 
a  thin  elastic  india-rubber  balloon.  During  inspiration  the  in- 
elastic bag  became  filled  first,  and  not  until  it  was  full  did  the 
elastic  bag  become  distended.  During  expiration  the  elastic 
bag  contracted  and  emptied  itself  before  the  inelastic  one  began 
to  expire.  It  seems  probable  that  the  same  cause  may  give  rise 
in  the  lungs  to  the  same  irregularity  in  the  filling  and  emptying 
of  different  parts  :  and  if  it  does  so,  it  would  have  the  effect  not 
only  of  producing  an  irregularity  in  tlie  vesicular  sound  during 
inspiration,  but,  by  causina:  a  temporary  stasis  of  air  in  various 
bronchial  tubes,  would  produce  the  conditions  for  the  development 
of  new  sounds  at  the  mouths  of  these  tubes,  and  thus,  under  con- 
ditions favourable  to  the  conducrion  of  sound,  give  rise  to  jerking 
expiration. 

I  have  not  made  any  experiments  on  the  proiluction  of  the 
various  accessory  sounds,  rales,  crepitation  and  friction,  since  there 
does  not  appear  to  be  any  great  difficulty  about  them,  A  rale 
pro  inced  in  the  lungs  may  be  heard  over  the  tracliea,  and  a  rale 
produced  in  the  mouth  may  be  heard  at  the  base  of  the  lungs. 
This  may  be  easily  shown  by  sucking  air  through  a  pij^ette  con- 
taining a  drop  of  water  ;  the  rale  in  the  pipette  is  easily  heard  at 
the  base  of  the  lungs  behind.  A  rale  heard  over  a  patch  of  con- 
solidation may  simply  be  heard  there  on  account  of  the  increased 
conducting  power,  and  may  be  produced  elsewhere. 

Stoppage  of  the  bronchial  tubes  by  plugging  with  mucus  or  by 
pressure  prevents  the  conduction  of  breathing  sounds  through  the 
lung  to  which  they  lead. 

In  conclusion,  I  may  ssy  that  tlie  results  of  my  experiments  on 
the  vesicular  murnmr  confirm  those  of  Chaveau,  Bondet,  and 
Bergeon  performed  on  horses,  and  quoted  in  Dr.  Paul  Xiemeyer's 
work,  and  that  the  demonstration  of  the  production  of  a  new  sound 
when  there  is  stasis  of  air  in  the  bronchi,  &c.,  I  have  not  seen 
elsewhere. 

I  have  to  thank  Dr.  Andrew  for  his  kindness  in  giving  me 
nmch  help  an  i  many  suggestions  with  regard  to  the  experiments, 
and  also  Dr.  Buller  for  manv  valuable  criticisms. 


On  the  Breath  Sounds  of  Health  and  Disease.         207 


APPENDIX. 


DESCRIPTION  OF  THE  APPARATUS. 

DESCBIPTION  OF  FIG.  I. 

A.  Chamber  with  glass  sides. 

EC.  Chamber  with  india-rubber  sides  (like  the  body  of  a  pair  of  bellows),  com- 
municating with  A  through  the  hole  K. 

D.  Handle  for  working  bellows. 

E.  Hinge  on  which  handle  D  turns. 

F.  Tap  for  emptying  bellows. 
H.  Hole  in  roof  of  chamber  A.  . 

I.  Tap  leading  through  roof  into  chamber  A . 
K.  Communication  between  the  two  chambers. 
LL.  Stethoscope  with  india-rubber  tube. 


Tig.  I. 


2o8  On  the  Breath  Sounds  of  Health  and  Disease. 

The  artificial  thorax  with  which  most  of  tlie  experiments  were 
made  is  represented  in  tig.  i.  The  glass-sided  chamber  A,  fixed 
upon  a  firm  wooden  bench,  communicated  through  the  smooth 
liole  K  with  a  second  chamber  C.  Tlie  sides  of  the  chamber  C 
were  made  of  flexible  india-rubber  cloth,  like  the  sides  of  a  pair 
of  bellows.  The  top  of  the  bellows  was  fixed  air-tight  to  tlie 
bench  round  the  hole  leading  into  the  upper  chamber  A,  and  the 
bottom  of  the  bellows  was  attached  to  the  handle  D,  moving  on  a 
iiinge  at  E  ;  at  the  bottom  of  the  bellows  was  a  tap  F.     The  hole 


Fig.  3- 

H  in  the  roof  of  the  chamber  A  was  intended  to  admit  the 
collapsed  lung  of  a  calf  or  sheep.  The  tube  of  the  flexible  stetho- 
scope L  and  the  tap  I  also  passed  through  the  roof.  The  inner 
end  of  the  stethoscope  was  covered  with  a  piece  of  bladder  to  pre- 
vent the  escape  of  air  or  water  from  the  chamber. 

In  order  to  place  a  lung,  or  pair  of  lungs,  in  the  chamber  for 
experiment,  the  bronchus  or  trachea  was  passed  between  the  two 
parts  of  the  sliding  frame,  flg.  2,  and  the  parts  brought  together 
so  that  the  bronchus  lay  without  pressure  in  the  hole  formed  by 
the  two  notches  in  the  frame  at  N.     A  lung  placed  in  the  frame 


On  the  Breath  Sounds  of  Health  and  Disease.  209 

is  represented  in  fig.  3.  The  interval  between  the  bronchus  and 
the  sides  of  the  hole  N  was  stopped  uj)  by  wrapping  some  tow 
dipped  in  a  strong  solution  of  gelatine  around  the  bronchus.  The 
gelatine,  when  solidified,  adhered  firmly  to  the  frame  and  bronchus, 
and  made  a  perfectly  air-tight  joint.  The  two  parts  of  the  frame 
shut  upon  a  piece  of  india-rubber,  so  that  the  frame  with  the  lung 
fixed  in  it  formed  an  air-tight  lid  which  could  be  screwed  down 
air-tight  upon  a  ring  of  india-rubber  surrounding  the  hole  H  in  the 
top  of  the  chamber  A.  The  inner  end  of  the  stethoscope  L  was 
attached  to  the  lung  by  tying  it  to  the  fold  of  pleura  known  as 
the  ligamentum  latum  pulmonis. 

"When  the  lung  was  suspended  in  the  air-tight  cavity  formed 
by  the  continuous  chambers  A  and  C,  it  could  be  made  to  breathe 
by  raising  and  lowering  the  handle  D,  just  as  in  the  natural  chest 
the  lung  is  made  to  breathe  by  the  ascent  and  descent  of  the 
diaphragm. 

By  means  of  the  taps  I  and  F  the  cavity  of  the  artificial  chest 
could  be  filled  either  with  air  or  water,  and  the  quantity  of  its 
contents  regulated. 

The  motion  of  the  machine  itself,  and  of  the  air  or  water  con- 
tained in  it,  produced  no  sound. 


VOL.  XXI. 


CASES   FROM  DR.    CHURCH'S   WARDS. 


T.  a.  STYAN,  M.B. 


Cases  of  Aortic  Aneurysm. 

By  the  kindness  of  Dr.  Church  I  am  enabled  to  publish  an 
account  of  three  cases  of  aortic  aneurysm  which  have  lately  been 
treated  in  his  wards.  They  possess  one  point  of  interest  in  com- 
mon, namely,  that  they  all  ended  fatally  by  a  sudden  rupture 
into  the  left  pleural  cavity.  They  present,  in  addition,  individual 
features  which  render  them  worthy  of  record.  The  first  two 
illustrate  the  great  difficulty  that  may  be  experienced  in  formino- 
a  correct  diagnosis  or  prognosis  of  such  cases ;  the  former  was 
rendered  difficult  by  the  indefinite  nature  of  the  symptoms,  and  the 
latter  was  at  fault  because  the  patient  had  been  actually  improv- 
ing for  some  time  before  death  came  unexpectedly.  The  third 
case  was  an  ordinary  one,  but  possesses  interest  as  exhibiting  the 
results  of  Tufnell's  diet  maintained  for  many  weeks. 

For  the  notes  of  the  post-mortem  examinations  I  am  indebted 
to  Dr.  Norman  Moore. 

Case  T. 

E.  H.,  a  woman  aged  55,  came  to  the  surgery  on  the  evening 
of  October  25,  1885. 

She  walked  there,  alone,  a  distance  of  more  than  a  mile. 
She  stated  that  she  had  been  in  good  health  up  to  that  after- 
noon ;  at  about  5  P.M.  she  had  been  seized  with  sudden  and  severe 
pain  in  the  epigastrium  and  had  vomited  several  times.  She 
attributed  her  illness  to  "  stomach-ache,"  and  considered  that  it 
had  been  caused  by  her  taking  a  rather  heavy  meal  of  bacon  in 
the  middle  of  the  day.  The  contents  of  her  stomach  had  been 
ejected,  but  retching  still  continued. 


212  Cases  from  Dr.  Church's  IJ^'ards. 

"VTlien  seen,  slie  was  evidently  in  great  pain,  being  unable  to 
keep  still  for  a  minute  at  a  time,  with  beads  of  perspiration 
standing  out  on  her  forehead. 

Her  pulse  was  84,  regular  and  full,  rather  hard.  Respiration 
20,  easy.     Temperature  99°. 

She  kept  retching  at  intervals,  but  brought  nothing  up.  Her 
bowels  had  acted  in  the  morning,  and  had  been  previously  regular. 

Being  questioned  closely  as  to  any  previous  history  of  gastric 
pains  or  vomiting,  she  denied  having  experienced  either,  but  ulti- 
mately said  she  had  noticed  a  slight  sensation  of  pain  in  the  lefc 
side  of  her  chest  at  times  during  the  last  month.  It  was,  how- 
ever, of  a  trivial  character,  and  she  had  not  i)aid  much  attention 
to  it. 

After  further  examination,  as  the  pains  appeared  to  be  due  to 
colic,  an  opiate  draught  was  administered  internally,  and  a  mus- 
tard and  linseed  poultice  applied  to  the  seat  of  the  jiaiu.  She  was 
directed  to  lie  down  on  the  couch  in  the  surgery  and  visited  at 
intervals. 

Paroxysmal  attacks  of  pain  continued  in  the  epigastrium  and 
as  low  down  as  the  umbilicus,  but  the  retching  became  alleviated. 

Later  on  a  subcutaneous  injection  of  morphia,  gv.  ^,  was  given, 
and  the  pain  disappeared  in  the  course  of  the  next  hour. 

There  was  no  vacant  bed  in  the  hospital,  so  she  was  sent  home 
in  a  cab,  with  orders  to  return  in  t'le  morning  if  she  still  felt 
unwell.  At  9  A.m.  the  fodouing  day  she  walked  back,  saying 
that  the  pains  had  begun  to  return  about  6  A.M.,  and  were  now 
getting  worse.  She  had  also  vomited  twice  during  the  night,  each 
time  innuediately  after  drinking  some  tea,  and  had  had  very  little 
sleep. 

She  was  then  admitted. 

Condition  on  admission. — A  well-nourished  woman,  with  a  some- 
what congested  face.  Had  an  anxious  expression  of  countenance, 
as  if  in  momentary  exi^ectation  of  pain.  She  preferred  to  lie  on  her 
back,  that  position  being  the  least  painful. 

Pulse  90,  full,  regular.     Eespirations  26,  easy,  but  not  deep. 

She  complained  of  great  pain  of  a  shooting  character,  which 
started  from  the  upper  part  of  the  epigastrium  and  travelled 
through  the  left  hypochoudrium  round  to  the  back.  She  kept 
retching  at  intervals,  but  brought  nothing  up,  her  stomach  being 
probably  empty.  There  were  no  signs  of  collapse  ;  her  extremities 
vrere  warm.     Temperature  was  99.2°. 

A  careful  examination  was  made  of  her  chest,  and  nothing  could 
be  discovered  there  to  account  for  the  pain.  The  lungs  were  both 
emphysematous,  but  the  breathing  was  easy,  and  no  moist  rales 
were  present ;  there  was  no  dulness  at  any  part  of  them. 


Cases  from  Dr.  Churclis  Wards.  213 

The  heart  was  displaced  a  little  downward  by  the  empliysema- 
tous  lungs  ;  its  action  was  normal,  the  sounds  clear  and  distinct. 

The  cause  of  the  pain  thus  appeared  to  be  not  in  the  thoracic 
cavity. 

The  abdomen  was  natural  in  appearance  and  not  distended. 
The  liver  was  somewhat  lower  than  normal,  its  edge  being  quite 
an  inch  below  the  ribs  in  the  right  hypochondrium.  This  could 
be  accounted  for  by  the  condition  of  the  hmgs.  Its  surface  was 
smooth. 

Spleen  could  not  be  felt. 

The  stomach  seemed  normal. 

There  were  no  signs  of  any  tumour,  and  no  pulsation  nor  bruit 
could  be  detected  either  in  front  or  behind. 

There  was  no  jaundice. 

Urine,  sp.  gr.  1022,  acid,  clear;  no  albumen;  no  blood. 

She  was  given  some  ice  to  suck  at  intervals.  A  linseed  poultice 
was  applied  over  the  epigastrium,  and  a  subcutaneous  injection  of 
morphia,  gr.  \,  was  given,  with  the  result  that  the  pain  became 
easier.  Three  times  in  the  course  of  the  day  about  two  ounces  of 
milk  were  administered  by  the  mouth,  and  the  effect  noted  ;  they 
were  on  each  occasion  rejected  within  a  quarter  of  an  hour,  but  it 
was  noticed  that  they  did  not  in  any  way  increase  the  pain. 

In  the  afternoon,  as  she  had  retained  no  nourishment  in  the 
stomach  for  eighteen  hours,  it  was  decided  to  feed  her  by  the 
rectum.  Accordingly  an  ordinary  warm-water  enema  was  first 
given,  in  order  to  clear  out  the  bowel.  A  copious  evacuation  took 
place,  the  fgeces  being  quite  natural  in  appearance.  After  this, 
nutrient  enemata,  each  containing  four  ounces  of  milk  and  two 
drachms  of  brandy,  were  given  every  other  hour,  and  were  all 
retained.  At  8  P.M.  the  subcutaneous  injection  of  morphia  was 
repeated  and  the  patient  passed  a  very  fair  night,  only  waking 
three  times. 

On  the  morning  of  the  26th  at  9  A.M.  a  severe  paroxysm  of  pain 
in  the  epigastrium  and  left  hypochondrium  came  on  suddenly. 
The  pain  was  evidently  intense  ;  she  crouched  in  a  sitting  posture 
in  the  bed,  rocking  herself  to  and  fro,  groaning,  and  at  times 
screariiing  out  loud.  Pulse  was  104,  regular.  She  vomited  up 
some  green  bile-stained  mucus.  A  morphia  injection  eased  the 
pain  for  the  rest  of  the  day,  and  the  nutrient  enemata  were 
continued. 

Her  symptoms  were  in  many  ways  similar  to  those  of  an  attack 
of  biliary  or  renal  colic,  but  there  was  no  jaundice,  and  the  urine 
was  natural ;  sp.  gr.  1030,  acid,  and  containing  no  blood  nor 
albumen. 


214  Cases  from  Dr.  Church's  Wards. 

During  the  night  of  the  26th  slie  again  had  two  sudden 
and  sharp  attacks  of  pain,  which  necessitated  the  further  use 
of  morphia  injection.  She  then  had  some  hours'  sleep,  and 
awoke  in  tlie  morning  feeling  better  and  complained  of  hunger. 
During  the  day  she  took  half  a  pint  of  milk  by  the  mouth  and 
retained  it.  The  bowels  acted  once,  the  motion  being  solid  and 
quite  natural.  The  jiulse  was  100.  On  the  whole,  she  was  de- 
cidedly better  and  more  comfortable.  The  temperature  was 
98.8°. 

On  the  28th,  after  a  good  night's  rest,  she  had  a  pain  in  the 
epigastrium,  no  longer  paroxysmal,  but  persistent  and  dull  in 
character.  The  retching  had  quite  ceased,  and  she  was  taking 
all  her  nourishment  by  the  mouth.  The  pain  gradually  lessened 
during  the  day,  and  she  slept  well  the  following  night.  An  acute 
paroxysm  of  pain  came  on  at  7  A.M.  on  the  29th,  but  it  only  lasted 
a  few  minutes,  and  afterwards  she  had  a  comfortable  day.  The 
pulse  was  96,  and  regular. 

The  note  taken  on  the  3,0th  was,  "  Better ;  has  no  more  pain,  and 
the  retching  and  vomiting  have  quite  ceased.  Is  taking  plenty  of 
liquid  food  by  the  mouth  without  any  discomfort.     Pulse  90." 

On  the  31st,  about  noon,  the  note  was,  "  She  has  passed  an 
easy  and  comfortable  night,  with  some  good  sleep.  Has  been  quite 
free  from  pain  for  two  days  and  nights  now.  It  threatened  to 
return  in  the  epigastrium  early  this  morning,  but  soon  passed 
away,  and  she  is  quite  easy  now.  Pulse  84,  regular  and  full. 
Tongue  clean  " 

Half  an  hour  after  this  note  was  taken  she  vomited  some  milk, 
and  continued  to  retch  for  some  minutes.  An  action  of  the  bowels 
followed,  and  almost  immediately  after  the  bed-pan  had  been 
removed  she  gave  a  piercing  shriek  and  fell  back  dead  on  the 
pillow,  becoming  suddenly  blanched. 

Post-mortem  examination. — Body  fat.  No  anasarca.  Cranial 
bones  very  thick.  Dura  mater  and  sinuses  thick.  Arachnoid  and 
pi  a  mater  opaque  on  the  vertex.  Cranial  arteries  atheromatous. 
Chest  pigeon-breasted.  Both  lungs  emphysematous  ;  the  left  one 
altogether  collapsed  by  an  effusion  of  blood  in  the  left  pleural 
cavity.  At  the  end  of  the  arch  of  the  aorta,  at  its  junction  with 
the  descending  portion,  was  a  small  calcareous  patch,  about  the 
size  of  a  threepenny-bit,  one  third  of  an  inch  long,  situated  in  the 
jjosterior  wall  of  the  vessel.  This  was  cracked  across,  a  trans- 
verse linear  fissure  letting  blood  escape  between  the  middle  and 
outer  coats  of  the  artery.  The  escaped  blood  extended  about  one- 
third  round  the  aorta,  and  had  tracked  down  the  whole  length  of 
the  vessel,  and  had  made  its  way  between  the  coats  of  the  two 
iliac  arteries.     On  the  left  side  it  had  burst   into  the   pleural 


Cases  from  Dr.  Church's  Wai'ds.  215 

cavity,  which  was  full  of  freshly  clotted  blood.  The  aorta  was 
calcareous  at  the  spot  where  the  rupture  occurred,  and  very  con- 
siderably so  near  the  bifurcation. 

The  valves  of  the  heart  healthy  ;  some  hypertrophy  of  the  left 
ventricle.     Kidneys  granular  and  small,  with  the  capsules  adherent. 

The  diagnosis  of  this  case  was  difficult.  When  first  seen,  her 
symptoms  in  many  respects  resembled  those  of  three  patients 
lately  admitted  with  a  perforating  ulcer  of  the  stomach.  But  this 
was  negatived  by  the  absence  of  any  previous  gastric  symptoms, 
in  conjunction  with  the  fact  that  she  was  not  at  all  collapsed.  The 
case,  therefore,  seemed  to  be  one  of  intestinal  colic,  and  was  treated 
as  such.  Later  on,  the  sudden  and  paroxysmal  nature  of  the  pain, 
together  with  vomiting  and  retching,  seemed  to  point  to  biliary 
or  renal  colic.  The  absence  of  any  jaundice  and  the  natural  con- 
dition of  the  urine  militated  against  this  view. 

The  question  of  aneurysm  arose  several  times,  but  not  the 
slightest  evidence  of  it  could  be  detected.  The  tumour  caused  by 
the  blood  was  too  deeply  seated,  and  not  sufficiently  circumscribed 
to  allow  of  any  pulsation  being  felt,  even  if  any  was  present,  and 
no  bruit  could  be  heard  anywhere. 

Dui-ing  the  last  two  days  of  her  life,  the  symptoms  were  so 
greatly  alleviated  that  she  appeared  quite  convalescent,  and  no 
suspicion  was  aroused  of  the  nearness  of  the  end.  It  was  not 
until  the  actual  moment  of  death,  which  was  so  characteristic  of 
a  copious  and  sudden  internal  hsemorrhage,  that  any  real  light 
was  thrown  upon  the  nature  of  her  disease. 

This  case,  though  falling  under  the  head  of  dissecting  aneurysms, 
was  in  truth  not  an  aneurysm  at  all.  There  was  no  dilatation  of  the 
aorta  itself,  and  no  circumscribed  pouch  in  the  vicinity  of  the 
crack.  In  immediate  connection  with  the  crack  in  the  aorta  there 
was  a  considerable  quantity  of  laminated  clot,  which  appeared  of 
older  date  than  the  remainder.  It  seems  probable  that  the  leak 
through  the  crack  in  the  aorta  was  at  first  slight,  and  that  for  a 
time  but  a  limited  portion  of  the  outer  coat  of  the  vessel  was 
separated  from  the  middle,  and  that  the  blood  thus  slowly  extra- 
vasated  formed  the  older  and  more  thoroughly  laminated  portion 
of  the  clot.  This  may  have  taken  place  without  causing  severe 
symptoms,  and  may  thus  explain  the  trivial  pain  she  told  us  had 
been  present  from  time  to  time  in  the  left  side  of  the  chest.  When 
the  crack  in  the  small  atheromatous  patch  widened,  more  and 
more  blood  would  be  pumped  through  it ;  the  cohesion  between 
the  laminse  of  the  middle  coat  was  not  sufficient  to  withstand  the 
pressure,  and  the  effused  blood  made  its  way  right  down  the  aorta 


2i6  Cases  from  Dr.  CJiurch's  Wards. 

and  along  the  iliac  arteries.  This  was  contemporaneous  with  the 
occurrence  of  the  severe  symptoms.  Then  came  a  time  when  the 
patient  had  almost  complete  relief  from  her  symptoms ;  this  may 
possibly  have  been  due  to  a  lessening  of  the  pressure  on  the  parts 
around  the  aorta  and  iliac  arteries,  when  the  extravasated  blood 
began  to  make  its  way  through  the  mediastinal  tissues  towards 
the  left  pleura,  into  which  it  eventually  burst. 

The  late  Dr.  Peacock  took  much  interest  in  these  cases  of 
dissecting  aneurysms,  and  in  the  14  th  volume  of  the  Pathological 
Society's  Transactions  collected  together  numerous  instances  of 
this  lesion.  The  present  case  is  interesting  as  belonging  to  the 
rarer  form  of  this  lesion.  lu  only  eight  out  of  seventy-three  cases 
collected  by  Dr.  Peacock  did  rupture  of  the  vessel  occur  iti  the 
descending  portion ;  in  all  the  rest,  the  wall  had  given  way  in  the 
ascending  portion  or  in  the  arch  of  the  aorta.  Another  point  of 
unusual  interest  in  this  case  was  the  general  freedom  from  disease 
of  the  coats  of  the  aorta  at  the  place  where  the  rupture  took  place ; 
with  the  exception  of  the  small  calcified  patch  which  had  cracked, 
there  was  little  or  no  atheroma  at  that  portion,  although  there  was 
a  good  deal  near  the  bifurcation  of  the  aorta.  The  very  small  size 
of  the  crack  as  compared  with  the  size  of  the  ruptures  of  the  wall 
usually  found  is  also  noteworthy,  the  diseased  patch  not  exceeding 
a  threepenny  bit  in  size.  The  separation  of  the  coats  of  the  aorta 
took  place  in  this  instance,  as  it  commonly  does,  through  the 
laminae  of  the  middle  coat.  Mr.  D'Arcy  Power's  report  of  the 
specimen  is  as  follows : — "  The  calcareous  plate  in  the  aorta  is 
situated  a  quarter  of  an  inch  below  the  level  of  the  bifurcation  of 
the  trachea,  or  an  inch  and  a  half  lower  down  than  the  origin  of 
the  left  subclavian  artery.  The  blood  appears  to  have  separated 
the  layers  of  the  middle  coat,  for  I  have  made  sections  of  the 
artery,  and  I  find  that  the  inner  portion  consists  of  elastic  and 
fibrous  tissue  with  a  small  proportion  of  muscular  tissue.  The 
outer  portion  of  the  artery,  when  examined  with  the  microscope, 
consists  of  loose  areolar  tissue,  which  has  undergone  some  small 
amount  of  cell  infiltration  as  the  result  of  inflammation,  and  to- 
wards its  deeper  layers  some  elastic  and  muscular  fibres  are  visible  ; 
so  that  I  believe  it  to  be  the  outer  and  a  portion  of  the  middle 
coat  of  the  vessel." 

Case  II. 

J.  Pi.,  a  man  aged  41,  was  admitted  to  MatthcAV  on  October 
2,  1885.  He  stated  that  he  had  always  enjoyed  good  health, 
and  had  been  quite  well  till  the  present  illness,  which  com- 
menced three  months  previously.     The  first  symptom  he  noticed 


Cases  from  Dr.  Church's  Wards.  '     217 

was  pain  in  the  right  lumbar  region,  worse  at  night.  It  was  at 
first  intermittent  in  character,  but  had  gradually  become  more  fre- 
quent and  also  more  severe.  He  had  worked  for  many  years  as  a 
porter  in  the  meat-market,  but  in  consequence  of  this  pain  he  was 
obliged  to  stop  work,  and  attended  for  some  weeks  as  an  out- 
patient of  Guy's  Hospital.  For  the  last  three  weeks  he  had  been 
confined  to  bed  at  home  by  his  great  weakness.  His  illness  had 
been  marked  by  rapidly  progressing  debility  and  loss  of  flesh. 
He  formerly  weighed  12  stones,  but  now  only  9  st.  3  lbs.  His 
bowels  had  become  costive,  so  that  four  or  five  days  usually  passed 
without  a  motion;  the  faeces  were  small  and  hard,  "like  bullets." 
He  was  not  aware  of  any  melsena ;  he  had  been  much  troubled 
with  flatus.     There  had  been  no  vomiting. 

There  was  no  pain  during  defcecation,  but  a  little  in  the  abdomen 
after  the  act. 

He  had  noticed  nothing  unusual  in  his  urine. 

Condition  on  admission. — Very  pallid  and  weak,  with  the 
appearance  -of  a  man  who  had  lost  much  flesh.  Temperature 
normal.  Pulse  84,  and  regular.  Eespirations  20.  Bowels  have  not 
acted  for  five  days.  His  chest  was  somewhat  hyper-resonant  on 
both  sides,  chiefly  at  the  bases.  Expiration  prolonged  ;  no  moist 
rales;  there  was  no  cough.  Heart  natural,  in  normal  position; 
area  of  cardiac  dulness  diminished. 

He  complained  of  a  dull  pain  in  the  right  side  of  the  abdomen, 
on  a  level  with  the  umbilicus,  both  in  front  and  beliind.  There 
was  no  dulness  at  this  spot,  and  no  tumour  could  be  felt  on  deep 
pressure.     The  pain  was  not  increased  by  the  pressure. 

There  was  no  enlargement  of  the  liver  or  spleen.  The  whole 
abdomen  was  natural  in  appearance,  and  nothing  abnormal  could 
be  discovered  in  it.  The  urine,  sp.  gr.  10 12,  acid,  clear,  with  no 
deposit,  and  contained  no  albumen. 

He  was  ordered  to  have  half  an  ounce  of  castor-oil  with  ten 
minims  of  laudanum,  to  get  his  bowels  oj)en.  It  had  no  eflect 
on  him. 

He  slept  well  the  two  following  nights,  but  had  pain  at  times, 
always  in  the  same  place,  catching  him  chiefly  when  he  moved  in 
bed. 

On  October  5tli,  as  there  had  been  no  action  of  the  bowels  foi- 
a  week,  an  enema  was  given.  The  result  was  a  copious  evacua- 
tion, containing  a  large  quantity  of  small,  hard  feecal  pellets. 

On  the  6th  and  7th  he  complained  of  pain  over  the  lower  part 
of  the  abdomen,  especially  on  the  left  side.  On  the  9th  he  passed 
a  small  motion  after  a  dose  of  castor-oil ;  the  motion  consisted  of 
a  very  small  quantity  of  loose  feecal  matter,  and  about  four  ounces 
of  bright  blood  with  it. 


2i8  Cases  from  Dr.  Cliunlis  Wards. 

A  rectal  examination  was  at  once  made,  and  neither  haemor- 
rhoids nor  any  malignant  growth  could  be  felt.  He  felt  so  much 
pain  in  the  left  iliac  fossa  that  it  was  necessary  to  give  him 
laudanum  during  the  day. 

During  the  week  he  had  now  spent  in  the  hospital  he  had  lost 
4  lbs.  in  weight,  and  was  weaker  than  he  had  been.  This  fact, 
taken  in  conjunction  with  his  constipation,  the  small  size  of  his 
feeces,  the  abdominal  pain,  and  the  passage  of  blood  by  the  bowels, 
seemed  to  point  to  some  constriction  of  the  intestines,  probably 
due  to  malignant  disease,  though  at  what  part  it  was  impossible 
to  say. 

During  the  next  month  he  continued  to  lose  flesh,  till  he 
weighed  only  8  st.  6  lbs. ;  he  also  lost  strength.  His  bowels 
continued  constipated,  and  were  only  relieved  about  twice  a  week, 
chiefly  by  the  use  of  enemata.  Various  purgatives,  such  as  castor- 
oil,  sulphate  of  magnesia,  senna,  jalap,  and  cascara  sagrada,  had 
little  or  no  influence  on  them. 

On  three  occasions  dm-ing  this  month  he  passed  blood  with  the 
motions.  The  pain  shifted  about,  sometimes  being  altogether 
absent  for  a  day,  and  then  returning  once  more.  When  present,  it 
was  always  either  in  the  right  lumbar  or  the  left  iliac  region. 

His  pulse  varied  between  8o  and  lOO,  being  always  regular  and 
fairly  strong.  He  slept  well  at  night  without  the  aid  of  morphia. 
He  continued  very  pale  and  weak,  feeling  faint  if  he  got  out  of 
bed  for  any  purpose.  On  one  occasion  he  did  actually  faint  for  a 
few  seconds.  He  complained  of  no  syn^ptoms  referable  to  the 
thorax ;  and  although  several  examinations  were  made,  no  abnormal 
sound  or  bruit  was  heard.  His  appetite  continued  good,  and  he 
had  no  pain  after  a  meal. 

About  jSTovember  5th  he  began  to  improve;  the  pain  lessened, 
though  still  present  at  times  in  both  sides  of  the  abdomen.  He 
began  to  gradually  regain  weight ;  in  one  week  he  increased  by 
4  lbs. ;  his  strength  gradually  improved  also.  His  bowels  re- 
mained constipated  ;  the  ftecal  masses  were  of  small  calibre,  but 
only  once  was  there  any  trace  of  blood  in  the  motions.  The 
temperature  was  quite  normal ;  the  pulse  continued  between  80 
and  90. 

He  became  quite  cheerful,  and  several  times  requested  leave  to 
sit  up  in  the  evening. 

On  the  evening  of  the  25th  his  temperature  reached  as  high  as 
100°  for  the  first  time. 

The  following  night  it  was  again  100°,  and  his  pulse  was  118. 
His  heart's  action  was  quite  regular,  but  the  first  sound  was  no 
longer  distinct,  having  a  faint  and  prolonged  character.  He  felt 
quite  comfortable  and  slept  well. 


Cases  from  Dr.  ChurcJis  Wards.  219 

On  the  28th  his  temperature  was  100°  in  the  morning;  the 
pulse  was  120,  regular,  but  weaker.  He  felt  some  pain  at  the 
heart,  and  the  first  sound  at  the  apex  was  indistinct.  During  the 
day  he  became  quite  free  from  any  uneasiness,  and  in  the  evening 
wanted  to  sit  up,  but  was  not  allowed  to.  He  went  to  sleep  at 
9  P.M.,  and  about  two  hours  later  suddenly  shouted  out  twice  for 
help.     When  the  nurse  reached  his  bedside  he  was  dead. 

Post-mortem  examination. — The  body  was  lean.  The  lungs 
were  highly  emphysematous  ;  the  right  one  weighing  21 J  oz.,  but 
the  left  one,  which  had  been  greatly  compressed  at  the  moment  of 
death,  only  1 1  oz.  The  left  lung  was  collapsed  by  an  efiusion  of 
blood  into  the  pleural  cavity,  so  great  that  the  diaphragm  was 
depressed.  The  heart  weighed  lojoz. ;  the  valves  were  healthy, 
and  both  the  endocardium  and  pericardium  quite  natural.  The 
cardiac  tissue  was  brownish  and  soft.  From  the  end  of  the  first 
three  inches  of  the  straight  part  of  the  aorta  to  the  diaphragm 
was  a  largish  aneurysm  with  a  complete  anterior  wall,  but  behind 
only  bounded  by  the  eroded  vertebrae.  The  sac  extended  about 
equally  to  the  right  and  left,  and  had  burst  into  the  left  pleural 
cavity  by  a  large  rent.  The  liver  and  spleen  were  natural;  there 
was  no  abnormal  condition  noticed  in  the  gastro-intestinal  tract. 
There  were  no  haemorrhoids. 

Here  again  the  diiignosis  was  far  from  simple.  The  usual  signs 
of  thoracic  aneurysm,  such  as  pain  in  the  chest,  dysphagia, 
dyspnoea,  loss  of  voice,  &c.,  were  entirely  absent.  Instead  of  them, 
the  leading  symptoms  were  abdominal  pain,  obstinate  constipation, 
with  fseces  of  small  calibre,  and  passage  of  blood  with  the  motions. 
These,  taken  in  conjunction  with  the  rapid  loss  of  flesh  and 
strength,  were  suggestive  of  ulceration  of  the  intestines,  probably 
of  a  malignant  nature. 

The  absence  of  any  audible  bruit  is  easily  accounted  for.  The 
aneurysm  Avas  situated  immediately  behind  the  left  side  of  the 
heart,  and,  in  addition,  the  lungs,  being  highly  emphysematous, 
were  unduly  distended  in  front  of  it.  The  breath  sounds  and  the 
cardiac  sounds  together  were  quite  sufficient  to  drown  any  bruit 
that  might  exist. 

But  it  is  not  so  easy  to  account  for  the  absence  of  pain  or 
pressure  symptoms  in  the  thorax  during  his  illness.  It  was  only 
four  days  before  his  death  when  signs  of  pressure  were  first  exhi- 
bited in  the  increased  rapidity  and  weakness  of  the  pulse,  showing 
embarrassment  of  the  action  of  the  heart.  Thoracic  pain  was  first 
felt  at  the  same  time,  and  the  systolic  cardiac  sound,  previously 
clear  and  distinct,  became  prolonged  and  indistinct.  The  probable 
explanation  is  that  the  aneurysm  increased  slowly  at  first  and  did 


220  Cases  from  Dr.  Churclis  Wards. 

not  exert  any  pressure  on  the  surrounding  organs.  During  the 
last  \Yeek  of  his  life,  however,  the  walls  of  the  sac  yielded  rapidly, 
and  embarrassed  the  action  of  the  heart  and  caused  pain. 

Case  III. 

T.  J.,  aged  45,  was  aduiitted  to  Matthew  on  April  28,  1884. 
He  was  a  muscular,  well-built  man ;  a  boatswain  on  a  large  cargo 
steamer.  He  had  been  in  India  for  nineteen  years,  but  always 
enjoyed  good  health,  and  had  never  had  syphilis.  For  the  last 
few  years  he  had  been  at  sea,  but  had  little  physical  work  to  do. 
Eighteen  months  ago,  whilst  superintending  the  loading  of  the 
vessel,  he  had  been  knocked  down  and  doubled  up  by  some  bales 
of  goods.  At  the  time  he  did  not  feel  much  hurt,  but  some  weeks 
later  he  began  to  experience  pain  in  the  epigastrium,  and  soon 
afterwards  felt  pulsation  and  swelling  just  below  the  sternum. 
He  continued  his  duties  till  three  mouths  ago.  Since  then,  he 
had  been  very  ill  with  severe  epigastric  pain,  which  extended  from 
there  to  his  left  shoulder  and  through  the  abdomen  down  both 
thighs.  During  these  three  months  he  had  lost  flesh  and  strength, 
and  had  suffered  much  from  vomiting  and  dysphagia.  Tiie  food 
appeared  to  lodge  about  the  level  of  the  ensiform  cartilage. 

On  his  admission,  there  was  visible  in  the  epigastrium  and  left 
hypochondrium  a  large  pulsating  tumour,  about  seven  inches 
across.  It  was  not  distinctly  expansile,  but  a  faint  bruit  was 
audible  in  front.  No  bruit  could  be  heard  behind.  The  lungs 
were  emphysematous  ;  the  heart  sounds  were  natural. 

The  legs  were  slightly  cedematous.  The  urine  contained  no 
albumen. 

From  the  day  of  admission  till  May  8th  he  remained  much  the 
same,  except  that  the  vomiting  became  less.  The  pain  remained 
unchanued,  and  kept  shooting  at  intervals  from  the  epigastrium. 

On  ]\Iay  12th  he  was  put  on  Tufnell's  diet. 

During  the  next  fortnight  the  pain  was  very  severe  at  times, 
and  had  to  be  relieved  by  injections  of  morphia.  He  stood  the 
restricted  diet  well  and  his  pulse  continued  steady  at  72. 

After  this  the  complete  rest  and  the  diet  seemed  to  benefit  him. 
On  June  5th  the  note  says  that  the  pain  was  decidedly  less  than 
on  admission,  so  that  he  was  able  to  sleep  well  without  the  aid  of 
morphia.  A  week  later,  when  he  had  completed  the  first  month 
of  Tufnell's  treatment,  the  pain  had  ceased  entirely.  He  had  not 
apparently  lost  flesh.  The  pulse  was  only  51,  but  quite  regular. 
The  temperature  was  generally  somewhat  subnormal. 

He  remained  on  the  same  diet  till  August  ist,  by  which  time 
he  had  completed  twelve  w^eeks  of  it.     During  this  period  the  pain 


Cases  from  Dr.  Church's  Wards.  221 

was  very  seldom  felt,  aiul  was  not  severe  on  the  few  occasions 
when  it  did  occur.  Tiie  pulsation  gradually  and  sensibly 
diminished,  and  he  felt  stronger  and  more  comfortable  in  every 
way.  An  opinion  was  formed  that  the  marked  improvement  in 
his  coudition  was  most  likely  due  to  the  formation  of  a  fibrinated 
clot  in  the  sac. 

During  the  month  of  August  his  diet  was  gradually  increased. 

On  September  4tli  he  had  been  in  bed  for  four  months  and  a 
half,  and  he  was  then  allowed  to  sit  up  for  a  short  time  in  tlie 
eveniug.  This  immediately  caused  a  fit  of  shivering,  and  his 
temperature  rose  to  I0I°  that  night ;  the  next  day  it  had  risen  as 
high  as  104.4°,  ^^^  ^^0  abnormal  physical  signs  were  detected 
which  could  account  for  it.  It  tlien  began  to  descend,  and  on  the 
7th  was  again  normal,  and  he  was  feehng  well  and  comfortable  ; 
he  had  no  pain  of  any  sort. 

He  continued  to  get  up  for  longer  periods  each  day  until 
October  i6th,  when  he  left  the  hospital.  He  was  then  feeling- 
strong  and  was  free  from  pain. 

A  few  daj's  after  leaving  the  hospital  he  returned  to  his  old 
occupation,  and  superintended  the  loading  of  the  vessel  in  prej)ara- 
tion  for  a  voyage  to  India. 

On  November  13th,  the  day  before  she  was  to  start,  the  pain 
returned  in  the  epigastrium.  The  next  day  it  was  so  severe  that 
he  wisely  decided  not  to  go  to  sea. 

On  November  17th  he  came  back  to  the  hospital  and  was  re- 
admitted. The  tumour  was  then  pulsating  over  a  wider  area  than 
before,  and  the  pain  was  so  severe  that  he  had  repeated  injections 
of  morphia  given  to  him. 

On  November  27th  he  was  again  put  on  Tufnell's  diet,  having 
ten  ounces  of  solid  food  and  ten  of  fluid  in  the  day.  This  was 
rigorously  continued  till  February  7th,  a  period  of  exactly  ten 
weeks.  In  addition  to  this  he  was  kept  on  fifteen-grain  doses  of 
iodide  of  potassium  taken  three  times  a  day.  No  appreciable 
effect  was  produced  by  the  treatment.  The  pain  came  and  went 
at  intervals.  On  the  whole,  his  condition  did  not  materially  alter 
during  the  winter. 

After  February  7th  his  diet  was  gradually  increased,  as  he  had 
lost  a  good  deal  of  flesh  and  no  effect  seemed  to  have  been  pro- 
duced on  the  tumour.  His  pulse  remained  fairly  constant  between 
70  and  80,  and  the  temperature  was  always  about  normal. 

On  April  15  th  the  bruit  of  the  aneurysm  could  be  heard  for  the 
first  time  m  the  back,  close  to  the  spine,  at  the  level  of  the  last 
dorsal  and  upper  lumbar  vertebrae.  This  grew  gradually  more 
distinct,  till,  on  May  14th,  pulsation  conld  also  be  felt  there. 

On  May  21st  he  was  comfortable  in  the  morning,  but  soon  after 


222  Cases  from  Dr.  Church's  Wards. 

noon,  wliilst  talking  quietly,  he  sudJeiily  gave  a  shout  for  the 
nurse  and  died. 

Post-mortem  examination. — A  well-nourished,  muscular  man. 
The  head  was  not  examined.  The  costal  cartilages  were  calcified. 
The  lungs  were  highly  emphysematous,  but  the  left  one  was  much 
compressed  by  an  effusion  of  blood  into  the  pleural  cavity ;  the 
clot  of  effused  blood  weighed  3  lbs.  14  oz.  The  heart  weighed  9 
oz.  The  pericardium  and  endocardium  were  natural.  The  liver 
and  kidneys  were  both  natural 

The  aneurysm  extended  both  above  and  below  the  diaphragm, 
more  below  than  above ;  and  when  the  abdomen  was  opened,  it 
appeared  at  the  upper  edge  of  the  stomach  as  a  large  projecting 
tumour  the  size  of  a  large  orange.  The  opening  of  the  aneurysm 
towards  the  aorta  was  the  size  of  a  florin,  and  the  orifice  of  the 
cffilic  axis  was  near  it,  and  was  much  thickened  and  corrugated. 

The  sac  was  6  inches  long  by  3  inches  broad.  Its  lower  wall, 
which  was  the  strongest  portion,  was  a  quarter  of  an  inch  thick  ; 
elsewhere  it  was  thinner,  especially  at  the  upper  jiart.  It  con- 
tained no  coagulum  or  clotted  fibrin.  There  was  a  large  rent  in 
its  upper  surface,  by  which  it  had  opened  into  the  left  pleural 
cavity.  The  rent  was  2  inches  long  by  ij  inches  across,  and 
had  thin  edges. 

The  clinical  interest  of  this  case  lies  in  the  results  obtained  by  a 
prolonged  trial  of  Tufnell's  diet.  The  patient  was  an  intelligent 
man,  who  put  up  bravely  with  the  discomfort  of  this  treatment  for 
a  period  altogether  of  twenty-two  weeks,  more  than  half  of  which 
was  during  a  hot  summer,  when  it  must  have  been  particularly 
irksome. 

The  treatment  at  its  first  trial  seemed  to  be  decidedly  beneficial 
to  him;  the  pain  was  much  relieved  and  the  pulsation  diminished, 
so  that  reasonable  hopes  were  entertained  that  a  firm  coagulum 
had  formed  in  the  sac.  At  its  second  trial  it  appeared  to  have  no 
beneficial  effect,  and  was  not  persevered  with. 

From  an  examination  of  the  aneurysm  and  adjoining  parts  after 
death,  taken  in  consideration  with  the  clinical  symptoms,  it  is 
probable  that  the  marked  relief  from  pain  and  the  lessening  of 
pulsation  observed  after  the  patient  had  been  for  some  time 
under  treatment  on  Mr.  Tufnell's  plan,  was  due  to  the  aneurysm 
undergoing  a  partial  cure,  but  in  a  very  different  manner  to  that 
we  usually  see.  The  density  and  thickness  of  the  anterior  lower 
portion  of  the  aneurysmal  sac  was  remarkable,  being  much  more 
than  could  be  accounted  for  by  the  wall  of  the  vessel  and  the 
tissues  it  had  pushed  before  it,  and  appeared  due  to  the  organisa- 
tion of  inflammatory  exudation  in  immediate  connection  with  the 


Cases  from  Br.  Churclis  Wards.  223 

fibrous  coat  of  the  aorta.  The  original  dilatation  probably  ceased 
to  increase  when  the  man  was  subjected  to  the  first  course  of 
Tufnell's  treatment,  and  during  this  time  the  dilated  wall  gained 
so  much  strength  from  the  contraction  and  condensation  of  the 
new  fibrous  tissue  that  for  a  time  (whilst  he  was  able  to  resume 
his  ordinary  life)  it  was  strong  enough  to  withstand  the  blood- 
pressure.  The  second  sudden  advent  of  pain  on  November  13th 
marks  the  time  at  which  a  fresh  portion  of  the  wall  of  the  vessel 
suddenly  bulged,  and  from  that  time  tlie  aneurysm  appears  slowly 
but  steadily  to  have  increased  in  size. 

The  case  is  valuable  as  showing  how  careful  one  should  be  in 
drawing  conclusions  from  incomplete  cases.  Had  this  man  not 
returned  to  St.  Bartholomew's,  but  been  taken  to  another  hospital 
or  treated  privately,  his  case  would  probably  have  been  considered 
one  of  abdominal  aneurysm  successfully  treated  on  Mr.  Tufnell's 
plan.i 

Cases  of  Optic  Neuritis  from  Intra- Cranial  Disease. 

Dr.  Church  has  had  three  patients  under  his  care  during  the 
last  few  months  in  whom  symptoms  of  cerebral  irritation  were 
followed  by  acute  inflammation  and  atrophy  of  the  optic  nerves. 
The  first  two  cases  present  similar  features,  and  both  of  the 
patients  after  a  long  illness  eventually  recovered  excellent  health, 
but  remained  totally  blind.  The  last  case  varied  in  many  respects 
from  the  others,  and  ended  fatally.  Dr.  Norman  Moore  has 
kindly  given  me  the  notes  of  the  post-mortem  examination. 

Case  I. 

J.  W.,  a  policeman,  aged  31,  was  admitted  to  Matthew  on 
February  23,  1885.  His  family  history  was  good,  and  he  had 
always  enjoyed  good  health  himself  till  the  present  illness  com- 
menced. Some  months  before  admission  he  began  to  complain  of 
pain  in  the  b;ick  of  the  neck  and  head,  which  he  attributed  to  a 
fall  that  he  had  lately  had  whilst  on  duty.  He  continued  at  work 
till  December  1884,  when  the  pain  became  greatly  aggravated. 
He  also  felt  pain  now  at  the  back  of  the  eyes,  and  his  vision  be- 
came impaired.  Vomiting  and  retching  commenced  at  the  same 
time.  He  was  taken  off  duty,  and  for  the  last  eight  weeks  had 
been  laid  up  at  home  suffering  with  headache  and  vomiting. 
According  to  his  wife,  he  had  been  frequently  delirious. 

^  Note  hy  Dr.  Church. — Though  unsuccessful  in  this  instance,  I  have  great  con- 
fidence in  the  value  of  Mr.  Tufnell's  plan  of  treating  aneurysms,  and  have  had 
several  most  favourable  results  in  thoracic,  though  not  as  yet  in  any  case  of 
abdominal  aneurysm. 


224  Cases  from  Dr.  Chuck's  Wards. 

He  was  a  strongly-built  man,  and  appeared  to  have  lost  flesh. 
Ilis  pulse  was  60  and  regular.  Tlie  tongue  was  very  foul  on  the 
dorsum,  the  tip  and  edges  being  cleaner;  the  breath  was  offensive. 
He  was  in  a  lethargic,  heavy  condition,  taking  no  notice  of  any- 
thing, but  could  be  aroused  by  speaking  to  him  loudly.  He 
answered  questions  in  a  slow  and  deliberate  manner.  The  eyes 
were  bloodsliot,  the  pupils  being  equal,  but  rather  dilated.  His 
movements,  like  his  speech,  were  slow  and  deliberate,  but  gave  no 
signs  of  paralysis.  There  was  no  strabismus.  His  thoracic  and 
abdominal  organs  all  appeared  natural. 

The  urine  was  natural  and  contained  no  albumen.  He  denied 
having  had  syphilis,  and  there  were  no  signs  of  it  about  him. 

His  bowels  had  not  acted  for  a  few  days.  The  temperature 
was  98°. 

For  the  first  three  days  after  admission  he  remained  in  the 
same  condition.  Very  free  action  of  the  bowels  was  obtained  by 
castor-oil  and  enemata,  and  his  breath  became  less  offensive.  He 
was  then  put  upon  ten-grain  doses  of  iodide  of  potassium  with 
twenty  minims  of  sp.  ammon.  aromat.  three  times  a  day,  and  this 
treatment  was  continued  witliout  intermission  till  the  day  of  his 
discharge. 

On  February  27th,  Dr.  Eoughton,  the  ophthalmic  house- 
surgeon,  examined  his  eyes,  and  reported  that  both  discs  were 
blurred  and  swollen,  the  veins  swollen  and  tortuous,  and  in  places 
hidden  by  effusion.  There  were  numerous  white  patches  of 
effusion  surrounding  the  discs,  and  also  many  flame-shaped 
haemorrhages. 

These  appearances  were  consistent  with  the  presence  of  albu- 
minuric neuro-retiuitis ;  so  the  urine  was  again  examined,  and 
found  to  be  sp.  gr.  1018,  acid,  and  to  contain  no  trace  of 
albumen.  Only  a  natm-al  quantity  was  passed  in  the  twenty- 
four  hours. 

On  March  ist  he  became  much  more  drowsy,  and  could  only 
be  roused  with  the  greatest  difficulty  ;  he  complained  of  much 
occipital  paim  The  urine  was  passed  in  bed.  For  three  days  he 
lay  in  a  nearly  comatose  condition,  passing  both  urine  and  motions 
into  the  bed,  and  taking  very  little  nourishment.  The  pulse  was 
regular,  about  64.  The  respirations  were  a  little  noisy,  but  not 
stertorous,  and  were  about  26  a  minute. 

On  March  4th  he  became  more  sensible,  and  was  able  to  answer 
questions,  speaking  in  a  slow  drawling  manner.  His  eyesight,  he 
said,  had  become  worse;  he  could  see  bystanders  round  his  bed, 
but  could  not  distinguish  between  them.  He  had  a  good  deal  of 
frontal  headache  now. 

ITie  following  day  he  was  again  nearly  comatose,  frequently 


Cases  from  Dr.  Churclis  ^¥ards.  225 

putting  his  hand  to  his  head  as  if  in  pain.  He  passed  urine  in 
the  bed  and  vomited  several  times. 

Another  fortnight  passed  without  material  alteration  in  his 
symptoms ;  he  would  be  nearly  unconscious  for  a  day  or  two  at  a 
stretch,  with  intervals  in  which  he  seemed  much  better. 

On  March  i8th,  Mr.  Vernon  examined  his  eyes  with  the 
ophthalmoscope,  and  reported  that  there  was  no  material  change 
in  the  fundus  since  Dr.  Eoughton's  examination  ;  but  that  the 
retinal  effusion  had  increased,  so  that  the  details  could  not  be 
made  out  so  clearly  then. 

He  continued  to  vomit  at  intervals  and  to  pass  urine  and 
motions  under  him  occasionally  till  the  end  of  the  month.  The 
pupils  were  dilated  but  equal.  The  pulse  was  always  between  60 
and  70,  and  quite  regular.  The  temperature  varied  between  97° 
and  99°.  The  bowels  were  somewhat  constipated,  bat  acted  after 
occasional  doses  of  medicine.  On  the  26th  the  vision  was  suddenly 
and  markedly  worse,  so  that  he  could  not  see  bystanders. 

After  the  first  week  in  April  a  gradual  im23rovement  began  ; 
the  headache  and  vomiting  ceased  first,  and  he  became  more  con- 
scious and  intelligent.  His  appetite  improved,  and  the  involun- 
tary escape  of  urine  stopped. 

The  blindness,  however,  remained  so  complete  that  he  could  at 
last  distinguish  light  only  with  difficulty.  Mr.  Vernon  made  a 
further  examination  on  April  25th,  and  found  some  atrophy  of 
the  right  disc. 

At  the  end  of  April  his  general  health  was  so  far  improved 
that  he  was  allowed  to  sit  up  in  the  evening.  At  first  he  walked 
with  a  staggering  gait  and  required  assistance  ;  but  there  was  no 
paralysis.     It  was  due  to  general  debility  and  the  blindness. 

During  the  month  of  May  he  progressed  rapidly,  becoming 
stout  and  strong,  and  feeling  well. 

On  May  22d  he  went  to  Swanley,  and  since  then  he  has  twice 
returned  to  Matthew  to  show  himself.  When  last  seen,  in  August, 
he  was  in  excellent  health  but  quite  blind,  and  had  been  pen- 
sioned out  of  the  police  force. 

Case  II. 

M.  P.,  aged  19,  a  general  servant,  was  admitted  to  Faith  on 
April  I,  1885.  Her  family  history  was  good,  but  she  herself 
had  never  been  strong  as  a  child,  and  her  tibise  were  slightly 
rickety.  She  had  been  able,  however,  to  do  very  hard  work  as  a 
general  servant  in  a  school  until  the  present  illness  began.  This 
had  set  in  three  months  previously  with  headache  and  vomiting, 
and  for  the  last  seven  weeks  she  had  been  in  bed. 

VOL.  xxr.  p 


226  Cases/rom  Dr.  Church's  Wards. 

The  vomiting  at  firs.t  used  to  be  about  once  a  day  in  the  early 
morning ;  it  had  latterly  increased  to  about  a  dozen  times  a  day. 
The  headache  had  become  gradually  more  severe.  Her  bowels  dur- 
ing this  time  had  been  constipated,  nine  days  sometimes  elapsing 
witliout  a  motion.  The  vomit  was  usually  greenish  and  contained 
no  blood. 

On  admission,  she  was  a  thin,  wasted  girl,  with  a  pinched  and 
anxious  expression  ;  her  skin  was  very  dry  and  rough,  almost 
ichthyotic.  The  pupils  were  widely  dilated  but  equal,  and  acted 
but  slightly  to  light.  The  pulse  was  84,  and  regular.  The  res- 
pirations were  24,  and  easy.  Her  temperature  was  98.4°.  The 
urine  was  sp.  gr.  10 18,  neutral,  and  contained  no  albumen.  Her 
bowels  had  not  acted  for  five  days.  The  heart  and  lungs  were 
natural. 

Her  abdomen  was  sunken  and  the  walls  thin  and  wasted ; 
scybala  could  be  felt  in  the  descending  colon ;  there  was  no 
tenderness  over  the  stomach.  She  complained  only  of  severe 
pains  shooting  through  both  the  frontal  and  occipital  regions  and 
constant  vomitiug.  She  vomited  nine  times  during  the  day,  the 
vomit  consisting  of  curdled  milk  and  bile. 

She  was  given  a  simple  enema,  which  brought  away  a  large 
quantity  of  hard  black  scybalous  masses.  She  had  some  ice  to 
suck,  and  an  effervescing  draught  of  citrate  of  potash  every  four 
hours.  Her  symptoms  became  relieved  towards  evening  and  she 
slept  well. 

The  next  day  another  enema  was  administered,  and  a  further 
quantity  of  hard  fieces  removed.  At  the  end  of  the  first  week 
she  was  decidedly  improved  ;  she  both  felt  and  looked  better. 
The  headache  had  almost  gone,  and  she  only  vomited  once  daily. 
The  pulse  was  steady  at  about  84,  and  the  temperature  normal. 
The  tongue  was  clean.     She  slept  well. 

She  began  to  complain,  however,  that  her  vision  was  failing  her. 

Mr.  Spicei",  the  ophthalmic  house-surgeon,  accordingly  examined 
lier  eyes,  and  found  that  both  optic  discs  were  large  and  swollen, 
with  their  margins  obliterated.  The  veins  were  congested  and 
obliterated  in  places,  and  there  was  one  point  of  retinal  haemor- 
rhage in  the  right  eye. 

On  April  14th  her  eyesight  was  more  misty,  and  on  the  29th 
had  become  decidedly  worse,  so  that  she  could  not  count  fingers 
nor  distinguish  the  surrounding  beds;  she  could  only  just  make 
out  the  position  of  the  window  in  front  of  her  bed.  During  this 
time  the  headache  and  vomitiug  had  returned  with  their  former 
severity. 

Her  history  for  the  next  six  weeks  was  of  a  similar  character. 
There  was  more  or  less  vomiting  nearly  every  day  in  spite  of 


Cases  from  Dr.  ChurcJis  Wards.  227 

various  remedies  which  were  tried.  It  was  so  excessive  at  the 
end  of  May  that  for  two  days  she  was  fed  by  the  rectum. 
Obstinate  constipation  continued,  and  was  relieved  by  enemata 
and  purgatives. 

Her  headache  was  the  most  troublesome  symptom  to  combat. 
It  varied  in  severity  from  time  to  time,  but  was  always  present  in 
some  degree. 

Her  head  was  shaved  and  ice-bags  applied  to  it,  blisters  were 
raised  in  the  temporal  regions,  leeches  were  applied  behind  each 
ear,  and  mustard  poultices  to  the  back  of  her  neck,  with  only 
partial  relief.  Ultimately  thirty-grain  doses  of  bromide  of  potas- 
sium given  every  six  hours  were  found  to  have  the  best  effect.  The 
pulse  remained  regular,  between  60  and  80.  Her  vision  became 
worse,  until  complete  blindness  supervened. 

The  pupils  varied  in  size  from  day  to  day,  but  were  always  equal 
and  usually  dilated. 

There  was  no  paralysis  anywhere. 

At  the  end  of  May  the  pain  had  extended  from  the  head  to  the 
back  of  the  neck,  causing  rigidity,  and  continued  for  quite  a  month 
there. 

No  signs  of  cervical  caries  could  be  discovered,  and  there  was  no 
impairment  of  either  motion  or  sensation  in  any  part  of  the  body. 

She  became  much  weaker  and  thinner,  and  twice  during  June 
she  had  shivering  fits,  and  her  temperature  rose  over  101°  for  a 
few  hours. 

At  the  end  of  June  there  seemed  a  strong  probability  of  her 
death.  She  was  too  weak  to  sit  up  in  bed  for  a  minute ;  she  passed 
her  urine  and  motions  under  her  in  bed  for  more  than  a  week,  and 
was  in  a  semi-unconscious  condition,  talking  nonsense,  and  taking 
no  notice  when  spoken  to. 

In  July  an  improvement  set  in  gradually  but  surely ;  the  head- 
aches became  less  frequent,  though  still  severe  at  times ;  the  vomit- 
ing was  diminished,  and  her  consciousness  and  reason  returned. 
On  the  nth  of  the  month  she  was  sitting  up  in  bed;  the  bromide 
of  potassium  was  discontinued  and  a  tonic  of  liquor  strychnise  and 
syrup  of  phosphate  of  iron  substituted  for  it. 

On  the  15th  Mr.  Vernon  examined  her  eyes  and  reported: 
"  There  are  the  remains  of  extensive  optic  neuritis  in  both  eyes, 
i.e.,  both  discs  are  ill-defined,  irregular,  and  surrounded  by  cede- 
matous  retina  ;  there  is  considerable  tortuosity  of  the  veins ;  there 
are  no  definite  patches  of  effusion  nor  any  haemorrhages  in  the 
retina ;  in  some  places  there  is  much  disturbance  of  the  choroidal 
epithelium  (?  from  commencing  choroidal  atrophy). 

"  This  description  applies  to  both  eyes,  which  are  remarkably 
alike." 


228  Cases  from  Dr.  Church! s  Wards. 

From  this  time,  with  some  sliglit  intermissions,  there  was  a 
steady  improvement  in  her  ojeneral  health. 

On  August  I  St  she  sat  up  in  a  chair,  but  was  still  too  weak  to 
stand  alone. 

On  the  15th  she  was  up  nearly  all  day,  and  could  walk  feebly 
with  assistance. 

On  September  2d  she  was  sent  to  Swanley,  and  was  then  able  to 
walk  well  by  herself. 

When  last  seen,  early  in  October,  she  had  increased  greatly  in 
weight  and  strength,  and  was  in  good  health,  though  completely 
blind.  The  vomiting  and  headache  had  quite  gone  away.  Her 
optic  discs  were  then  showing  signs  of  atrophy,  and  she  could  not 
distinguish  light  from  darkness. 

In  both  these  cases  the  inflammation  of  the  optic  nerves  came 
on  a  long  time  after  the  establishment  of  other  leading  symptoms 
of  disease,  and  was  clearly  secondary.  "What  was  the  nature  of 
the  primary  affection  ?  Two  main  facts  can  be  relied  upon  in 
solving  this  question :  the  disease  was  a  chronic  one,  and  was 
curable.  It  was,  therefore,  probably  either  a  chronic  form  of 
inflammation  or  some  syphilitic  growth ;  no  other  form  of  intra- 
cranial new  growth  being,  so  far  as  I  am  aware,  curable. 

Now,  there  was  no  evidence  of  syphilis  in  either  of  the  patients, 
and  no  history  of  it  was  obtained. 

The  balance  of  evidence,  then,  seems  to  be  in  favour  of  a  chronic 
inflammation,  most  probably  in  the  form  of  chronic  meningitis. 


Case  III. 

M.  A.  R,  aged  20,  whilst  dancing  in  the  street  in  the  latter  half 
of  July,  fell  down  and  struck  Ler  head  against  the  pavement.  It 
hurt  her  a  good  deal  at  the  time,  but  she  kept  the  accident  a  secret 
from  her  friends.  A  few  days  later  she  was  troubled  by  constant 
vomiting  and  pains  in  the  vertex  of  her  head.  These  became  so 
severe  that  she  was  obliged  to  stop  her  work  as  a  machinist,  and 
was  laid  up  at  home  for  six  weeks.  During  this  period  the  head- 
ache and  vomiting  continued,  and  a  fortnight  before  her  admission 
the  eyesight  had  become  impaired.  Lately  she  had  become  childish 
in  her  manner  at  times. 

She  was  admitted  to  Faith  on  September  5,  1885.  She  was 
a  sallow,  fairly-nourished  girl,  and  complained  of  pain  in  the 
vertex  of  her  head.  She  was  unable  to  localise  the  seat  of  the 
pain,  but  tapping  hurt  her  more  on  the  right  side  than  on  the  left. 
The  pulse  was  64,  regular,  and  of  good  volume.     The  respirations 


Cases  from  Br.  Churclis  Wards.  229 

were  20,  and  natural.  The  temperature  was  97°.  Her  tongue 
was  coated  with  a  thin  brown  fur  on  the  dorsum. 

There  was  slight  ptosis  of  the  right  upper  ej'elid,  and  the  right 
pupil  was  greatly  dilated  and  larger  than  the  left.  There  was  no 
.strabismus. 

The  thoracic  and  abdominal  organs  all  seemed  healthy.  The 
urine,  sp.  gr.  1030,  acid,  and  contained  no  albumen.  Her  bowels 
had  not  acted  for  two  days.  There  was  no  paralysis  of  her  limbs; 
she  spoke  with  ease,  and  answered  questions  readily. 

During  the  night  after  admission  she  vomited  twice,  the  vomit 
consisting  of  curdled  milk  and  bile.  Her  bowels  were  freely 
moved  after  an  enema. 

On  September  7th  the  ptosis  of  the  right  side  had  increased. 

On  the  9th,  Mr.  Spicer  examined  her  eyes,  and  found  there  was 
in  each  disc  a  large  amount  of  effusion,  the  whole  disc  being  very 
much  swollen  and  the  margins  entirely  obliterated;  there  were 
white  patches  of  lymph  in  great  amount  both  there  and  in  the 
neighbouring  parts  of  the  retina.  The  veins  were  somewhat 
engorged,  tortuous,  and  entirely  obliterated  in  places. 

The  headache  seemed  to  be  constantly  present,  but  never  very 
severe.  She  vomited  more  or  less  daily,  but  kept  down  sufficient 
nourishment.     Her  pulse  and  temperature  remained  about  normal. 

On  the  14th  she  was  delirious  all  day.  Both  pupils  reacted 
to  light ;  the  right  one  was  now  smaller  than  the  left.  Her  vision 
had  become  worse,  but  she  could  count  fingers.  Three  leeches 
were  applied  to  her  right  temple,  and  relieved  both  the  headache 
and  delirium. 

No  material  change  in  her  condition  took  place  till  the  26th, 
when  she  first  complained  of  stiffness  and  pain  at  the  back  of  the 
neck.  She  soon  became  more  drowsy  than  she  had  been,  sleep- 
ing all  night  and  a  great  part  of  the  day,  but  could  be  roused  to 
answer  questions.  When  aroused  her  manner  was  childish  and 
silly.  The  cervical  pain  continued,  but  no  evidence  of  caries 
could  be  discovered. 

On  October  4tli  the  drowsiness  had  increased  so  that  she  took 
no  notice  of  anything  going  on  in  the  ward  and  would  not  feed 
herself.  The  pulse  was  84,  regular.  She  could  no  longer  count 
fingers  correctly.  During  the  following  week  she  was  very  childish, 
constantly  singing  and  talking  nonsense  out  loud.  When  spoken 
to,  however,  she  appeared  rational  and  answered  questions  properly. 

On  October  8th  she  began  to  pass  urine  in  bed,  and  occasionally 
her  motions  also.  The  ptosis  increased,  so  that  the  right  eye  was 
half  hidden.  The  right  pupil  remained  always  larger  than  the 
left.     There  was  no  strabismus. 

On  October  14th  about  midday  she  became  very  drowsy,  and  in 


230  Cases  from  Dr.  CJmrch's  JVards. 

the  course  of  an  hour  comatose.  The  respirations  became  irregular, 
varying  from  5  to  9  a  minute.  Eight  hemiplegia  came  on,  fol- 
lowed later  on  by  left  hemiplegia  as  well.  In  the  middle  of  the 
afternoon  she  died. 

During  her  whole  illness  the  temperature  had  varied  between 
97°  and  99°,  and  the  pulse  between  65  and  90. 

Post-mortem  examination. — Well-nourished  body.  The  skull- 
cap was  internally  rough  and  with  deepened  vascular  grooves. 
There  was  no  local  thickening  of  the  dura  mater  or  broken 
sinuses. 

There  was  much  effusion  into  the  sub- arachnoid  space.  The 
cerebral  arteries  showed  no  signs  of  disease. 

From  the  back  of  the  rioht  ascendino-  frontal  convolution  of  the 
brain  to  the  level  of  the  posterior  coruu  of  the  lateral  ventricle 
there  was  a  shallow  depression  in  the  cei'ebral  hemisphere  filled 
with  very  soft,  broken-down  grey  matter  and  some  pus.  At  the 
middle  of  this  was  a  small  haemorrhage  the  size  of  a  large  pea, 
and  here  the  broken-down  part  had  a  very  thin  limiting  membrane 
on  its  inner  side.  There  was  a  very  large,  clear  effusion  into  both 
lateral  ventricles. 

This  case  differed  from  the  preceding  ones  in  being  acute.  The 
sequence  of  events  was  probably  a  localised  meningitis  at  the 
seat  of  injury  consequent  on  the  rupture  of  a  small  vessel  from 
shock  caused  by  the  fall  in  the  street.  This  spread  quickly,  and 
within  a  month  after  the  accident  both  the  optic  nerves  were  in- 
flamed. A  limited  portion  of  the  superficial  brain  substance  also 
became  inflamed,  and  at  the  time  of  death  had  begun  to  break 
down  and  form  an  abscess.  The  amaurosis  was  not  so  complete 
as  in  the  preceding  cases,  because  the  disease  had  not  existed  for 
so  long.  The  immediate  cause  of  death  was  the  large  effusion  into 
the  lateral  ventricles. 


NOTE 


SIX  GIFTS  OF  THEOPHILUS  PHILAXTHROPOS, 


PiOBERT  POOLE. 

AN  APPENDIX  TO  "OUR  HOSPITAL  PHAR]MACOP(EIA 
AND  APOTHECARY'S  SHOP,"  Vol.  xx.  p.  279. 


W.  S.  CHUECH,  M.D. 


In  a  note  on  page  287  in  tlie  last  volume  of  Eeports,  vrriting  of 
Theophilus  Philanthropos's  "Physical  Vade  IMecinn,"  or  fifth  Gift, 
I  say,  "  I  have  been  unable  to  discover  Tvhy  he  calls  this  work  a 
fifth  Gift,  and  go  on  to  say  that  I  could  find  no  other  anonymous 
publication  attributed  to  Eobert  Poole  in  the  r)ritish  Museum 
Catalogue,  except  the  work  known  as  the  '  Benificent  Bee,'  pub- 
lished in  1753." 

This,  I  regret  to  say,  was  due  to  my  carelessness,  as  I  find  that 
the  British  Museum  Library  contains  copies  of  all  Theophilus  s 
works. 

The  first  four  Gifts  are  all  theological,  or,  more  correctly, 
"revivalist"  in  character;  the  fifth  is  the  "Physical  Vade  Mecum;" 
the  sixth  is  of  the  same  character  as  the  first  four.  As  Poole's 
works  are  rare  and  somewhat  curious,  a  brief  description  of  them 
may  interest  some  of  those  who  read  my  last  year's  article. 

The  first  work  is  entitled  "  A  Friendly  Caution  ;  or  Pirst  Gift  of 
Theophilus  Philanthropes,  Student  in  Physick."  The  copy  in  the 
British  Museum  is  dated  1740.  I  think  it  must  be  a  reprint,  for  the 
copies  of  the  second,  third,  and  fourth  Gifts  were  also  printed  in 
1740,  and  are  entitled  "Second  editions  with  large  additions." 
The  sixth  Gift, printed  also  in  1740,  is  the  fourth  edition;  so  that 
I  think  it  is  evident  that  these  works  of  Poole  must  have  been 


232  The  Six  Gifts  of  Theopliilus  Fliilanthropos. 

printed  before  1740,  and  that  in  that  )'ear  he  reprinted  all  of 
them.  It  is  certain  that  the  third  Gift  mnst  have  been  published 
prior  to  April  21,  1739,  on  which  day  it  was  publicly  burnt  in 
Anne's  Ward  in  St.  Thomas  Hospital,  as  we  learn  from  Poole 
himself  in  the  dedication  to  the  second  edition  of  the  third 
Gift. 

Opposite  the  title-page  of  the  "Friendly  Caution"  or  first  Gift  is  a 
very  well-engraved  plate  containing  the  ten  commandments,  the 
Belief,  and  the  Lord's  Prayer,  resembling  in  its  arrangement  and 
ornamentation  the  tablets  so  commonly  found  in  churches  of  that 
period.  On  the  title-page,  immediately  below  Philanthropos's 
name,  come  a  series  of  texts,  and  at  the  bottom,  "  Printed  for  the 
good  of  the  Publick,  Anno  Dom.  1740,  and  to  be  had  at  Mr. 
Duncomb's  in  Duck  Lane,  Little  Britain." 

The  dedication  is  addressed  to  "  my  pious,  most  learned,  in- 
genious, and  worthy  friend  Prof.  Eames,  P.S.T.,  P.R.S."  The 
preftice  is  long,  and  is  printed,  as  is  also  the  rest  of  the  book, 
in  double  columns. 

It  is  almost  impossible  to  give,  without  trespassing  too  far  on 
the  patience  of  my  readers,  an  abstract  of  the  contents.  The 
"  Friendly  Caution,"  as  well  as  the  other  Gifts,  resemble  in  many 
points  the  revivalist  literature  of  the  present  day.  A  great  part 
of  the  work  is  taken  up  by  "Examples  of  Children  who  have 
gained  Salvation,"  taken  from  the  "Token  for  Children"  of  James 
Janeway,  minister  of  the  gospel. 

[James  Janeway  was  a  somewhat  celebrated  Nonconformist 
divine;  he  was  born  in  the  year  1636,  being  a  son  of  the  Rev. 
William  Janeway,  who  at  one  time  held  the  living  of  Kellshall 
in  Hertfordshire.  James  was  the  third  of  five  brothers,  several 
of  whom  became  celebrated  for  their  abilities  and  strong  religious 
views.  James  Janeway  was  ejected  in  1655  from  his  studentship 
at  Christ  Church  for  nonconformity ;  he  subsequently  set  up  a 
meeting-house  in  Eotherhithe,  and  gained  great  popularity  as  a 
preacher.  During  the  Plague  he  remained  at  his  post  when  most 
other  ministers  had  deserted  their  pulpits.  Many  of  his  sermons 
are  printed,  and  he  jDublished  several  religious  works,  the  best 
known  being  his  "  Token  for  Children."  He  wrote  also  the  Life 
of  his  elder  brother  John,  who  seems  to  have  been  a  young  man 
of  very  great  learning  and  ability.    James  Janeway  died  in  1674.] 

The  British  INIuseum  has  two  copies  of  the  "  Christian  Muse,"  or 
second  Gift.  One  is  a  separate  volume,  the  other  is  bound  up 
with  the  copies  of  the  third,  fourth,  and  sixth  Gifts. 

The  second  has  the  same  frontispiece  as  the  first  Gift,  and  the 
title-page  is  also  very  similar.  After  the  texts  are  the  two  follow- 
ing lines : — 


Tlie  Six  Gifts  of  TJieopJiilus  Pliilanihropos.  233 

"  A  verse  may  find  him  who  a  sermon  flies, 
And  turn  delight  into  a  sacrifice." 

— Herbert. 

On  the  title-page  of  the  separate  copy  is  printed  "  Second  edition 
with  large  additions ;  "  on  the  title-page  of  that  bound  up  with  other 
Gifts  is  "  Second  edition  greatly  enlarged."  The  contents  are  pre- 
cisely the  same  in  the  two  copies,  and  consist  of  disquisitions  in  verse, 
on  the  Sabbath  ;  on  the  fear  of  want ;  on  wandering  thoughts  ;  on 
marriage ;  on  youth ;  on  the  deceitfulness  of  the  heart ;  on  afflic- 
tion ;  on  envy,  malice,  and  slander  ;  on  covetousness  ;  on  censure ; 
on  profane  swearing ;  a  morning  hymn  in  praise  of  the  Creator ; 
on  death  ;  on  the  last  day  ;  on  hell ;  on  heaven. 

The  dedication  of  the  second  Gift  is  addressed  "To  my  much 
esteemed  friend  the  Eev,  Mr.  Eeading,  M.A.,  Keeper  of  the  Library 
of  Sion  College." 

In  the  preface  Theophilus  relates  a  vision  or  dream  by  which 
his  faith  was  strengthened.  He  thought  that  he  was  in  a  guest- 
chamber  with  our  Lord  and  was  afterwards  crucified,  and  on 
awakening  heard  a  voice  saying,  '^  Arise,  proclaim  thy  Master's 
honour."  On  falling  asleej)  again  the  dream  was  repeated  a  second 
time. 

The  third  Gift  is  called  the  "  Christian  Convert ;  or  the  Third 
Gift  of  Theophilus  Philanthropos,  Student  of  Physick."  The  title- 
page  is  very  similar  to  that  of  the  preceding  Gifts.  "  Dominus 
exaltatio  mea  et  illuminatio  est  "  is  placed  immediately  above  the 
texts.  The  British  Museum  copy  is  the  second  edition  greatly 
enlarged. 

The  dedication  is  addressed  to  the  Honourable  Samuel  Lessing- 
ham,  treasurer  to  St.  Thomas's  Hospital,  and  commences  by  thank- 
ing him  "  for  his  interposition  in  preserving  this  little  book  in  its 
infancy."  A  copy  (of  the  first  edition,  I  presume)  having  been 
publicly  burnt  in  Anne's  Ward,  April  21,  1739,  the  treasurer 
appears  to  have  interposed  his  authority  and  prevented  copies  in 
the  other  wards  receiving  similar  treatment.  The  preface  and  the 
rest  of  the  work  is  printed,  like  the  first  Gift,  in  double  columns. 

The  preface  is  long,  and  in  it  Theophilus  takes  a  very  gloomy 
view  of  the  state  of  society.  The  "  Christian  Convert "  itself  is  in 
the  shape  of  a  conversation  between  Philathletes  and  Philanthropos, 
who  are  joined  by  Theologos. 

The  frontispiece  is  curious.  On  the  left  the  author,  kneehng 
on  one  knee  with  a  Bible  in  the  left  hand,  and  under  the  figure 
"Effigies  authoris."  On  the  right  the  open  jaws  of  a  monstrous 
beast,  representing  hell.  Flames  are  leaping  up  from  the  throat  of 
the  monster,  and  the  mouth  contains  figures  of  two  men  being 
tormented  by  devils.     In  the  upper  part  of  the  plate,  in  the  centre 


234  Tlie  Sic  Gifts  of  Thcoplulus  Fhilanthrojws. 

is  a  representation  of  the  Crucifixion;  on  the  left  an  angel  and  a 
personage  dressed  in  a  square-cut  coat  are  going  up  to  heaven ; 
on  the  right  the  devil  is  taking  a  man  similarly  diessed  off  to 
hell.  Ciierubs  flit  round  the  word  0eo9  in  the  right  hand  top 
corner,  and  texts  lead  from  our  author's  mouth  towards  the 
Crucifixiou  and  the  word  0eo?. 

The  fourth  Gift,  or  "  Token  of  Christian  Love,"  is  adorned  with 
a  very  similar  frontispiece.  The  figin-e  of  the  author  is  the  same  ; 
there  is  the  same  monstrous  beast  with  his  open  jaws  and  flaming 
tliroat.  The  Crucifixion  is  absent  and  the  landscape  altered.  The 
same  cherubs  appear,  but  not  the  word  0eo9.  The  words  "  Effigies 
authoris  "  are  printed  at  the  bottom  of  the  page,  instead  of  imme- 
diately below  the  kneeling  figure  in  the  plate. 

The  title-page  resembles  those  already  described.  "Vive  hodie 
et  nosce  te  ipsum  "  is  printed  immediately  above  the  texts. 

The  dedication  is  addressed  to  Sir  John  Gonson,  Hon.  Chair- 
man to  the  General  Quarter  Sessions  of  the  Peace,  held  for  the 
Liberty  of  Westminster. 

At  the  end  of  the  preface  Theophilus  signs  himself  as  Philo- 
math es. 

The  fifth  Gift,  or  "Physical  Vade  Mecnm,"  is  the  book  to  which 
such  frequent  reference  was  made  in  my  paper  last  year.  Its  title- 
page  indicates  its  contents  "  A  Physical  Vade  Mecum  ;  or  Fifth  Gift 
of  Theophilus  Philanthropos.  Wherein  is  contained  the  Dispen- 
satory of  St.  Thomas's  Hospital,  with  a  Catalogue  of  the  Diseases 
and  the  Method  of  their  Cure  prescribed  in  the  said  Hospital.  To 
which  is  also  added  the  Dispensatory  of  St.  Bartholomew's  and 
Guy's  Hospitals."  Then,  as  on  all  his  title-pages,  come  texts,  and 
at  the  bottom,  "London  :  Printed  for  and  sold  by  E.  Duncomb,  in 
Duck  Lane,  Little  Britain,  1741."  Tliis  date,  as  I  shall  show  here- 
after, is  difficult  to  reconcile  with  the  date  of  the  sixth  Gift. 

The  "  Physical  Vade  Mecum  "  has  a  very  long  dedication  addressed 
to  "  The  Eight  Honourable,  the  Honourable  and  Worthy  the  Presi- 
dent, Treasurer,  and  Governors  of  St.  Thomas's  Hospital." 

The  preface  contains  a  most  minute  account  of  St.  Thomas's 
Hospital,  with  lists  of  the  governors  and  benefactors,  and  the  rules 
and  regulations  for  its  governance ;  also  estimates  of  the  expenses, 
and  a  list  of  the  numbers  of  in  and  out  patients  under  the  care  of 
each  of  the  physicians  of  the  Hospital. 

The  preface  is  of  very  great  interest  to  those  who  wish  to  form 
an  idea  of  the  condition  of  the  Eoyal  Hospitals  150  years  ago,  as 
the  account  of  St.  Thomas's  Hospital  is  most  minute  and  complete. 

The  sixth  Gift  is  entitled  "  Seraphic  Love  tendered  to  the 
Immortal  Soul."  The  British  Museum  copy  is  the  fourth  edition, 
corrected  and  enlarged. 


Tlie  Six  Gifts  of  Theopliilus  PMlantJiropos.  235 

The  frontispiece  is  the  same  as  that  in  the  fourth  Gift;  preceding 
the  texts  are  the  following  lines  : — 

"  Object  not  (reader)  against  the  title-page  ; 
Turn  over  tlie  leaves,  if  you  be  sage  : 

From  vrhence  you  may  find, 

If  you  have  a  mind. 
True  love  tendered  to  our  immortal  soul, 
Which  from  the  gifts  of  sin  will  make  you  whole  ; 

And  from  the  vale  of  woe  and  misery 

Safely  convey  you  to  eternity." 

Following  the  texts  comes  "  Deo  initium,  progressum  et  exitium 
refer."  The  work  is  dated  1740.  The  dedication  is  addressed  to 
the  "  Honourable  Society  for  the  Eeformation  of  Manners,"  who 
are  addressed  as  "Christian  monitors,"  and  is  signed  by  Philomathes 
Philathletes.  There  is  no  preface,  but  in  the  place  of  it  a  prayer. 
At  the  end  of  the  work  comes  an  appendix,  particularly  addressed 
to  the  minors  of  the  age.  It  is  printed,  like  the  others,  in  double 
columns,  and,  notwithstanding  that  the  title  and  subject  might 
have  stimulated  Theophilus's  muse,  is  in  prose. 

It  will  be  seen  from  the  above  descriptions  of  Theophilus' 
works  that  the  dates  are  somewhat  puzzling.  The  first  Gift  is 
dated  1740,  and  there  is  no  intimation  that  it  is  a  second  edition 
or  a  reprint ;  the  second,  third,  and  fourth  are  also  dated  1740, 
and  are  stated  to  be  second  editions.  And  the  second  edition 
appears  to  have  been  printed  twice  in  174O;  as  the  title-pages  of 
the  two  copies  (see  page  233)  do  not  agree.  The  sixth  Gift,  which 
from  its  title  must  have  come  after  the  fifth,  was  also  printed  in 
1740,  and  is  stated  to  be  a  fourth  edition  ;  and  yet  the  "Physical 
Vade  Mecum"or  fifth  Gift  is  dated  1741.  I  have  seen  three 
copies  of  the  "Physical  Vade  Mecum;"  they  are  all  dated  1741, 
and  in  none  is  it  stated  that  they  are  reprints  or  second  editions. 
It  is  possible,  if  not  probable,  that  Theophilus  named  his  works 
according  to  the  order  in  which  he  composed  them,  rather  than  as 
he  gave  them  to  the  world  in  print. 

One  other  anonymous  work  attributed  to  Eobert  Poole,  the 
"  Benificent  Bee ;  or  Traveller's  Companion,"  &c.,  was  not  pub- 
lished until  1753,  and  doubts  have  been  expressed  by  some 
whether  it  was  the  work  of  the  same  E.  Poole  as  the  Gifts.  I 
think  that  any  one  who  will  take  the  trouble  to  read  some  of  the 
"  Benificent  Bee,"  and  compare  it  with  Poole's  writings  in  the 
Gifts,  will  be  satisfied  that  the  authorship  is  rightly  attributed 
to  him.  I  have  as  yet  failed  in  discovering  any  further  particu- 
lars of  Poole's  life. 

On  page  291  I  give  my  reasons  for  estimating  the  number  of 


236  The  Six  Gifts  of  Theopliilus  Fliilanthropos. 

patients  in  our  hospital  at  the  time  of  Dr.  E.  Browne's  appoint- 
ment, 16S2,  and  drew  tlie  conclusion  that  they  were  about  300 
in  number.  I  found  in  the  British  Museum  a  broadsheet  dated 
in  MS.  April  24th,  1644.  The  sheet  is  headed  "A  True  Report 
of  the  Great  Costs  and  Charges  of  the  foure  hospitals  in  the  City 
of  London,  in  the  maintenance  of  this  great  number  of  poore  the 
present  year  1644,  as  followeth. 

"  There  hath  been  cured  this  yeare  lust  past  at  the  charge  of 
St.  Bartholomew's  Hospitall  of  niaymid  souldiers  and  other  dis- 
eased persons  to  the  number  of  1 122,  all  which  have  been  relieved 
with  money  and  other  necessaries  at  their  departure. 

"Buried  after  muche  charge  in  their  sicknesse  152. 

"Remaining  under  care  this  present  at  the  charge  of  the 
Hospitall  249." 

These  numbers  in  1644,  and  the  returns  given  in  the  early  part 
of  the  eighteenth  century  in  Strype's  edition  of  '"'  Stowe,"  make  it 
probable  that  I  am  not  far  wronsj  in  thinking  that  the  hospital 
contained  about  300  beds  in  16S2,  the  year  of  Browne's  ap- 
pointment. 


PROCEEDINGS 


OF 


THE    ABEMETHIAN   SOCIETY 

DURING  THE  WINTER  SESSION  1884-85. 


October  9. 

Eirst  general  meeting.     Election  of  members. 

Dr.  Legg  read  the  Introductory  Address. 

He  began  by  pointing  out  that  in  all  education  there  were  two 
kinds  of  knowledge  to  be  imparted,  first,  the  mere  storing  of  facts; 
secondly,  the  digestion  and  assimilation  of  facts  ;  the  first,  a  mere 
exercise  of  the  memory;  the  second,  the  exercise  of  the  higher  facul- 
ties of  the  mind.  Eor  the  first  there  were  the  lectures,  demonstra- 
tions, class  examinations,  medals,  and  academical  rewards,  while 
for  the  second  there  was  at  St.  Bartholomew's  the  Abernethian 
Society,  in  which  the  student  who  had  learnt  his  facts  was  taught 
to  ponder  over  and  reflect  upon  the  ideas  that  he  had  gained. 
The  Abernethian  Society  being,  in  fact,  an  intellectual  gymnasium, 
in  which  the  mind  was  trained  and  exercised,  just  as  it  was  in  the 
disputations  and  exercises  of  the  mediseval  universities. 

In  conclusion,  Dr.  Legg  pointed  to  the  decay  of  real  university 
training  and  to  the  superficial  smattering  encouraged  by  what  he 
called  dissipation  of  mind,  not  progress  in  knowledge,  that  had  fol- 
lowed of  necessity  in  the  wake  of  the  examination  system,  the 
introduction  of  which  into  England  was  one  of  the  many  evils  for 
which  the  University  of  London  would  have  to  be  responsible. 

October  16. 

Election  of  members. 

Dr.  Collins  showed  a  specimen  of  a  new  drug,  'cocaine,'  which 
has  the  property  of  causing  insensibility  of  the  cornea  and  con- 


238  Proceedings  of  the  A  hcrnetliian  Society. 

junctiva.     It  dilates  the  pupil,  but  docs  not  affect  accommodation. 
It  also  causes  retraction  of  the  upper  lid. 

Mr.  R.  J.  Collyns  then  read  a  paper  on  '  Optic  Neuritis.' 
He  began  by  describing  the  blood  supply  of  the  optic  disc,  and 
explained  that  the  blood  supply  may  be  seriously  altered  without 
any  appreciable  change  in  the  retinal  vessels  with  which  it  seems 
to  be  so  intimately  connected.  He  then  explained  that  the  tint  of 
the  physiological  cup  and  the  definition  of  the  outline  of  the  disc 
are  the  two  points  to  be  observed  in  congestion  of  the  optic  disc. 
He  described  the  development  of  optic  neuritis,  and  showed  how 
it  was  that  vision  was  absent  in  some  cases  and  present  in  others. 
Mr.  Collyns  then  discussed  the  relation  of  the  optic  nerve  to 
encephalic  disease,  and  considered  the  question,  What  is  the  value 
of  optic  neuritis  as  a  diagnostic  sign  ?  and  decided  that  in  the 
majority  of  cases  it  is  worth  very  little,  and  certainly  that  it  is 
impossible  to  determine  the  size,  form,  position,  or  nature  of  a 
cerebral  tumour  from  its  consideration.  Still  he  allowed  that,  as 
a  confirmation  of  a  diagnosis  formed  on  other  symptoms,  it  is  very 
useful.  In  passing  on  to  the  treatment  of  optic  neuritis,  Mr. 
Collyns  said  that  the  eyes  must  be  rested,  and  then  the  treatment 
must  be  that  of  the  causes  ;  and  since  syphilis  is  very  often  the 
cause,  iodide  of  potassium  is  indicated. 

October  23. 

Election  of  members. 

Mr.  Moberly  showed  a  child  suffering  from  paralysis  of  the 
deltoid  and  biceps. 

Dr.  Collins  showed  an  eye  with  a  bony  tumour  of  the 
choroid. 

Mr.  T.  W.  Shore  then  read  his  paper  on  '  Hemiplegia.' 

Mr.  Shore  began  by  dividing  the  subject  of  hemiplegia  into 
two  parts — functional  and  organic.  In  discussing  functional 
hemiplegia  he  distinguished  (i)  hysterical  hemiplegia  ;  (ii)  epi- 
leptic hemiplegia  ;  (iii)  uremic  hemiplegia,  and  (iv)  toxic  hemi- 
plegia. Of  these  varieties  he  gave  full  descriptions  in  relation  to 
illustrative  cases  which  he  had  had  under  his  care  and  observa- 
tion. He  then  entered  at  some  length  into  the  j)rinciples  of 
diagnosis  between  these  conditions. 

He  then  passed  on  to  the  consideration  of  organic  hemiplegia, 
and  divided  the  cases  into  those  of  sudden  and  gradual  hemi- 
plegia, confining  his  remarks  to  the  cases  in  which  the  paraly- 
sis was  sudden.  Of  these  cases  he  distinguished  three  clinical 
varieties: — i.  Those  in  which  there  was  sudden  coma  associated 
with  hemiplegia ;  2.  Those  in  which  the   loss  of  consciousness 


Proceedings  of  the  Ahe^'nethian  Society.  239 

was  gradual ;  and  3.  Those  in  which  there  was  no  loss  of  con- 
sciousness. He  then  detailed  several  cases  and  discussed  the  value 
of  the  more  unusual  symptoms  in  the  diagnosis  of  the  seat  of  the 
lesion. 

He  touched  upon  early  rigidity,  equal  contraction  of  both  pupils, 
and  dwelt  fully  on  the  symptoms  of  conjugate  deviation  of  the  eyes, 
contending  that  when  this  symptom  occurs  the  lesion  must  be 
in  the  cerebrum  above  the  corpora  quadrigemina. 

He  considered  conjugate  deviation  of  the  eyes  to  depend  on 
co-ordination  of  the  fibres  in  relation  to  the  nerves  of  the  eyeball 
in  tlie  corpora  quadrigemina,  and  brought  forward  three  cases,  in 
two  of  which  a  post-mortem  examination  had  showed  the  exist- 
ence of  a  lesion  which  would  agree  with  his  theory. 

He  then  mentioned  the  results  which  he  had  seen  follow  hemi- 
plegia. 

He  concludeil  by  saying  that  in  discussing  his  subject  he  had 
not  gone  out  of  the  range  of  his  own  experience. 

October  30. 

Election  of  members. 

Mr.  Lyndon  exhibited  a  supernumerary  toe,  which  had  been 
removed  in  the  surgery,  possessing  three  articular  facets. 

Mr.  F.  Andrewes  then  read  a  paper  on  '  Glycogen.' 

He  first  drew  attention  to  the  fact  that  while  nutrition  is  a 
constant  process,  alimentation  is  an  intermittent  one,  and  that 
hence  arose  a  necessity  for  the  storage  of  reserves.  Comparative 
physiology  sheds  much  light  on  the  problem  of  reserves,  and 
especially  those  of  carbo-hydrate  food.  In  the  vegetable  kingdom 
the  potato  and  beetroot  are  familiar  examples  of  such  reserves. 
In  the  animal  kingdom  carbo-hydrates  are  almost  invariably  stored 
up  as  glycogen,  and  the  consideration  of  this  body  falls  into  two 
stages — that  of  its  synthesis  and  that  of  its  utilisation.  Amongst 
many  of  the  lower  animals  these  stages  are  successive  instead  of 
contemporaneous,  and  can  be  studied  apart.  But  as  the  liver 
becomes  specialised  in  ascending  the  animal  scale,  the  glycogenic 
function,  at  first  generalised  in  the  tissues,  becomes  localised  in  it ; 
and  the  same  is  true  in  the  evolution  of  the  individual  in  higher 
vertebrates.  The  placenta  and  foetal  membranes  are  the  earliest 
seat  of  glycogenesis  in  the  mammal ;  the  fcetal  tissues  next  take 
up  the  task;  and  finally  the  function  becomes  localised  in  the  liver. 

Normally  carbo-hydrates  in  the  liver  are  the  main  source  of 
glycogen,  .while  proteids  seem  to  play  a  secondary  part.  In  all 
cases  Kving  protoplasm  is  the  essential  factor  in  its  synthesis.  The 
main  agent  in  the  downward  phases  of  its  history  is  an  unorganised 


240  Proceedings  of  the  Ahernetliian  Society. 

ferment,  '  diastase/  which  converts  it  into  grape-sugar.  Her- 
mann's '  mogen '  theory  of  muscular  activity  furnishes  the  most 
satisfactoi-y  explanation  of  the  role  which  sugar  plays  in  the  nutri- 
tion of  muscles,  namely,  as  fuel  for  their  energy,  the  nitrogenous 
element  being  not  excreted,  but  retained  to  enter  into  new  com- 
binations with  carbo-hydrate  material. 

Any  phase  in  the  history  of  sugar  in  the  organism  may  be 
interfered  with  by  pathological  changes.  The  only  way  in  which 
it  has  hitherto  been  shown  that  nervous  lesions  can  cause  diabetes 
or  glycosuria  is  through  the  vaso-motor  system.  Many  cases  of 
these  affections  are  not,  however,  explained  by  reference  to  the 
nervous  system. 

Noveniber  6. 

Election  of  members. 

Mr.  Murray  showed  a  curious  round-celled  sarcoma  situated  on 
the  left  side  of  the  neck  of  a  young  woman. 

Mr.  Shore  showed  the  cast  of  a  hand  of  a  woman  with  Heber- 
den's  nodes  well  marked.  The  bones  of  the  hand  of  same  woman 
were  also  shown. 

Mr.C.  B.Lockwood  opened  the  surgical  discussion  upon  'Syphilis' 
by  calling  attention  to  the  points  involved  in  a  correct  diagnosis. 
The  period  of  incubation  never  being  less  than  three  weeks,  helped 
to  discriminate  syphilitic  from  soft  or  filth  sores ;  the  later,  re- 
sembling ordinary  poisoned  wounds,  had  a  short  period  of  incuba- 
tion, and  ran  a  course  characterised  by  the  usual  complications  of 
poisoned  wounds,  such  as  inflamed  lymphatic  vessels  and  inflamed 
lymphatic  glands.  The  possibility  of  the  abrasion  which  had 
admitted  the  filth  which  caused  the  soft  sore  having  also  admitted 
syphilitic  poison  was  referred  to.  If  a  patient  presented  himself 
v.ith  a  sore  which  had  appeared  immediately  after  exposure,  it  was 
possible  to  say  that,  at  the  time  of  the  examination,  the  sore  did 
not  appear  syphilitic,  but  it  was  impossible  to  say  that  it  would 
not  become  syphilitic.  Next  the  question  of  tlie  induration  of  the 
sore  was  discussed.  Cases  were  mentioned  to  show  that  this 
feature  was  exceedingly  unreliable.  The  worst  case  of  syphilis 
the  speaker  ever  saw  followed  a  sore  devoid  of  any  induration. 
Sores  typically  indurated  had  not  been  followed  by  symptoms  of 
the  disease  in  question  even  after  the  lapse  of  two  years.  It  was 
pointed  out  that  when  a  person  had  had  syphilis,  induration  might 
recnr  at  the  seat  of  the  sore.  The  history  of  the  case  would  help 
to  eliminate  this  source  of  error.  The  induration  of  the  lymphatic 
glands  was  next  considered,  and  it  was  said  that  unless  it  was 
present  in  other  glands  besides  the  inguinal,  and  unless  it  was 


Proceedings  of  the  Ahernethian  Society.  241 

accompanied  by  general  eruption,  it  could  not  be  accepted  as  an 
indubitable  sign.     The  fact  that  there  seemed  to  be  an  impression 
that  syphilitic  sores  were  always  single  was   commented   upon. 
Although  this  was   often,  the  case,  it  was  not  very  rare  to  see 
patients  with  a  number  of  sores  in  various  places.     It  was  pointed 
out  that  these  must  all  have  been  produced  at  the  same  moment ; 
in  fact,  that  syphilitic  sores  were  comparable  to  vaccine  vesicles, 
and  might  be  produced  in  any  number,  provided  that  no  interval 
elapsed  between  the  inoculations.     If  the  characters  of  the  sore 
and  of  the  lymphatic  glands  were  fallacious,  it  was  necessary  to 
state  what  constituted  satisfactory  evidence  of  the  acquirement  of 
syphilis.     This  was  said  to  be  the  presence  of  a  sore,  indurated 
gland,  general  eruption,  or  lesions  in  the  throat.     The  delay  in 
commencing  active  treatment  caused  by  the  surgeon  waiting  for 
the  appearance  of  the  skin  eruption  did  not  conduce  to  a  real  pro- 
longation of  the  disease  or  make  it  less  amenable  to  treatment. 
When  it  was  certain  that  a  giveii  patient  had  acquired  syphilis,  it 
was  necessary  to  impress  him  with  the  fact  that  he  would  have  to 
be  under  treatment  at  least  a  year.     Supposing  that  a  case  was 
being  treated  with  mercury,  after  it  had  been  diagnosed  on  the 
strength  of  an  indurated  sore  and  indurated  lymphatic   glands, 
if  at  the  end  of  four  months  no  eruption  had  appeared,  the  question 
would  arise  whether  the  treatment  had  been  efficacious  in  arresting 
the  disease,  or  whether  it  never  had  been  syphilis  at  all,  and  had 
got  well  in  spite  of  the  treatment  1     The  speaker  said  that,  owing 
to  the  fact  that  mercury  kept  the  disease  in  abeyance,  he  had  found 
that  unless  patients  had  seen  the  eruption  it  was  exceedingly  diffi- 
cult to  prevail  upon  them  to  submit  to  treatment  a  sufficient  time 
to  ensure  a  permanent  cure. 

The  division  of  syphilitic  eruptions  into  suppurative  and  non- 
suppurative was  mentioned,  because  their  discrimination  was  im- 
portant for  purposes  of  treatment.  The  former  did  best  under 
the  influence  of  mercury,  the  latter  under  iodide  of  potash.  The 
curability  of  gummata  by  means  of  iodine  was  referred  to,  and  was 
said  to  lend  hope  to  those  who  might  anticipate  that  other  tumours 
might  be  capable  of  removal  by  internal  medication. 

In  conclusion,  treatment  by  tonic  doses  of  mercury  was  advo- 
cated ;  a  grain  of  blue  piU  thrice  daily  being  enough  to  produce 
satisfactory  results. 

November  13. 

Election  of  members. 

Mr.  Davis  showed  a  girl  suffering  from  lead  colic,  with  an  ulcer 
on  the  tongue  of  a  marked  blue  colour. 

Mr.  Paget  showed   a  boy  with   a   salivary  fistula.     He   also 
VOL.  XXI.  '  ^ 


242  Proceedings  of  Ike  Ahernelhian  Sociefi/. 

showed,  in  connection  with  bis  paper,  a  man  with  a  large  abdo- 
minal abscess. 

^Ir.  Lyndon  exhibited  two  microscopic  specimens  —  one  a 
melanotic  alveolar  sarcoma  of  the  skin,  the  other  lympho- 
sarcoma of  liver. 

Mr.  0.  Lankester  then  read  a  short  paper  on  '  Infantile 
Diarrhcea.' 

^Ir.  Lankester's  paper  treated  of  simple  diarrhcea  unconnected 
with  organic  diseases  of  the  intestines.  He  divided  the  subject 
into  the  four  varieties  of  non-inflammatory  diarrhcea,  inflamma- 
tory diarrhoea,  choleraic  diairhoea,  and  dysentery.  Of  these  four 
he  considered  only  the  two  first  varieties.  He  mentioned  cold, 
bad  feeding,  dentition,  and  worms  as  the  chief  causes,  and  sketched 
out  the  diet  of  infants.  He  mentioned  the  complications  of 
diarrhcea,  as  blood  in  the  stools,  prolapse  of  rectum,  and  spoke  of 
the  use  of  opium  in  connection  with  the  latter,  Mr.  Lancaster 
next  alluded  to  the  uncertainty  of  diagnosis  in  cases  of  diarrhoea 
caused  by  dentition.  "With  i-egard  to  the  inflammatory  diarrhcea, 
the  causes  may  be  the  same  as  those  of  simple  ;  also  bad  smells. 
In  considering  the  question  of  diet,  he  spoke  of  the  necessity  of 
avoiding  the  use  of  milk,  and  advised  the  substitution  of  broth, 
also  white  wine  in  cases  where  collapse  is  present.  He  alluded  to 
the  use  of  mustard  baths  and  brandy,  and,  in  antiseptic  treatment, 
washing  out  the  stomach,  and  small  doses  of  soda  benzoates  fre- 
quently. In  cases  of  chronic  forms  of  inflammatory  diarrhoea,  the 
utmost  attention  should  be  paid  to  diet,  and  pepsin  and  raw  meat 
are  very  useful. 

Subsequently  Mr.  Stephen  Paget  contributed  a  paper  on  '  Ab- 
dominal Abscesses.' 

He  divided  the  subject  according  to  the  causes,  i.  Injury  or 
disease  of  the  wall  itself,  (ci)  Contusion  ;  (b)  Tracking  of  dis- 
charge from  a  non-penetrating  wound ;  (c)  Injury  or  disease  of 
bones  or  muscles ;  (rf)  Inflammation  of  the  connective  tissues 
between  the  muscles.  2.  Inflammation  of  the  subperitoneal  con- 
nective tissue.  3.  Injury  or  disease  of  internal  organs.  4.  Deep- 
seated  cancer.  Mr.  Paget  mentioned  some  extraordinary  cases 
which  have  from  time  to  time  been  recorded,  and  also  the  frequency 
of  abscesses  following  necrosis  of  a  rib  from  scrofula  or  ty])hoid 
fever.  He  next  discussed  the  nature  and  appearance  of  phleg- 
monous inflammation  of  the  connective  tissue,  and  cases  were 
produced  showing  its  causes  and  also  its  course  under  treatment. 
He  brought  forward  three  cases  of  pelvic  abscesses  in  young 
women,  treated  by  puncture  or  incision  through  the  abdominal 
wall,  and  also  three  cases  of  deep-seated  abscesses  of  the  subperi- 
toneal connective   tissue   incised  above  the  pubes  and  drained. 


Proceedings  of  the  A  hernelMan  Society.  243 

Lastly,  six  cases  were  given  of  abscesses  of  the  abdominal  wall 
due  to  deep-seated  cancer.  Mr.  Paget,  in  conclusion,  urged  the 
necessity  of  treating  all  acute  abscesses  of  the  abdominal  wall  as 
soon  as  possible,  and  by  incision  rather  than  by  puncture,  and 
impressed  upon  his  hearers  the  fact  that  in  elderly  people  the 
cause  is  fi-equently  cancer. 


Novemher  20. 

Mr.  E.  W.  Eoughton  showed  a  well-marked  case  of  intra- 
ocular haemorrhage, 

Mr.  Brinton  then  read  his  paper  on  '  Blood-Letting.' 
He  began  by  sketching  shortly  the  history  of  blood-letting. 
The  first-mentioned  case  was  one  which  occurred  at  the  close  of 
the  Trojan  war,  and  the  origin  of  the  process  was  attributed  by 
Pliny  to  the  hippopotamus.  The  change  of  practice  which  has 
recently  taken  place  was  shown  to  be  due  to : — 

1.  The  discovery  of  chloroform,  which  in  very  urgent  cases 
does  that  which  before  could  be  only  accomplished  by  copious 
depletion. 

2.  By  watching  the  natural  history  of  those  diseases  which 
previously  had  been  treated  by  bleeding. 

The  author  disclaimed  any  such  excuse  for  its  discontinuance  as 
that  occasionally  brought  forward,  viz.,  change  of  type  of  disease 
as  well  as  of  mankind.  He  went  on  to  say  that  he  would  discuss 
blood-letting  chiefly  in  respect  to  the  treatment  of  mania,  puer- 
peral and  epileptic  convulsions,  apoplexy,  bronchitis,  dilatation  of 
the  right  heart  from  valvular  disease,  pneumonia,  and  thoracic 
aneurysm. 

The  utility  of  its  practice  in  these  diseases  was  illustrated  by  cases. 
In  apoplexy  it  might  be  called  for  during  the  period  of  reaction — 
never  before.  Allowing  that  in  apoplexy  there  was  cerebral 
anaemia,  the  only  effect  which  rapidly-increasing  effusion  of  blood 
would  have  must  be  increasing  strangulation  of  the  circulation  of 
the  parts  near  it,  and  limiting  the  effusion  would  tend  to  prevent 
increase  of  strangulation.  In  valvular  disease  of  the  heart,  leading 
to  a  dilated  right  ventricle,  general  bleeding,  when  other  remedies 
failed,  was  of  signal  service. 

In  severe  cases  of  pneumonia,  when,  about  the  time  of  the  crisis, 
there  were  signs  of  failing  heart,  blood-letting  should  be  cautiously 
tried.  Bleeding  in  bronchitis,  with  the  object  of  relieving  the 
right  side  of  the  heart,  was  often  necessary,  and  should  be  done 
without  regard  to  the  irregular  action  of  the  heart,  as  this  was  due 
to  other  causes. 


244  Proceedings  of  the  Ahernethian  Society. 

With  regard  to  its  use  in  thoracic  aneui-ysin,  Mr.  Brinton  men- 
tioned a  case  in  which  the  man  had  a  swelling  in  the  front  of  the 
chest  absorbing  the  costal  cartilages  and  ribs  for  fifteen  years.  He 
died  at  the  age  of  65,  having  been  bled  over  160  times.  Local 
blood-letting  loy  leeches  he  considered  to  be  indicated  when  pain 
was  present,  as  in  dry  pleurisy. 


November  27. 

Dr.  W.  J.  Collins  read  a  paper  entitled  'Physiognomy  and 
Phrenology — What  are  they  worth  ? ' 

Physiognomy,  the  author  said,  was  the  science  which  seeks  to 
read  the  mind  by  the  body.  It  therefore  includes  phrenology  as 
the  whole  or  part.  As  a  psychological  method,  it  is  opposed  to 
introspection  ;  it  implies  a  looking-out,  not  a  looking-in.  It 
necessitates  powers  of  emission  on  the  part  of  the  observed,  and 
implies  sensorial  and  mental  power  in  the  observer.  Pliysiognomy 
is  thus  far  older  than  man,  and  had  its  birth  when  first  a  living 
consciousness  became  aware  of  another's  consciousness.  Indeed, 
the  spirit  which  it  embodied  is  applicable  to  all  existence,  whether 
animate  or  not ;  and  the  power  to  compreliend  the  invisible  by 
the  things  that  are  made  is  but  the  loftiest  evolution  of  the  science. 
He  who  is  able  to  read  the  mind  of  man  aright  is  also  best  qualified 
to  interpret  the  face  of  Nature. 

Dr.  Collins  then  sketched  the  growth  of  modern  pliysiognomy, 
from  Delia  Porta  to  Lavater  and  down  to  Sir  C.  Bell  and  Darwin, 
dwelling  at  length  upon  the  works  of  Lavater,  and  proving  that 
many  of  his  physiognomical  rules  had  a  strictly  scientific  founda- 
tion. The  invention  of  phrenology  was  then  touched  upon,  and  the 
author  concluded  from  a  long  array  of  arguments  tliat  this,  as 
vulgarly  understood,  had  been  from  the  first  an  impudent  im- 
posture. 

From  evidence  drawn  from  cranial  measurements,  weights  of 
brains,  size  of  hats,  &c.,  the  conclusion  was  drawn,  that  inasraucli 
as  convolution  and  surface  of  brain  varied  with  size,  while  specific 
gravity  was  constant,  the  size  of  the  brain  could  be  ascertained 
with  tolerable  accuracy  by  the  size  of  the  head,  or  even  the  size  of 
the  hat. 

Much  evidence  was  then  adduced  to  show  that  the  greater  the 
brain  the  greater  was  the  capability  of  the  mind.  Statistics  of 
various  head-measurements  were  given.  Thus  the  average  cir- 
cumference of  the  adult  male  head  is  22  inches  ;  the  average  of 
twenty-two  imbecile  heads  was  21  inches;  of  twenty-five  medical 
men  22^.     As  regards  nationality,  it  is  quite  true  the  Scotch 


Proceedings  of  the  Ahernetliian  Society.  245 

have  large  heads ;  Germans,  according  to  the  hatter's  figures,  have 
round  heads ;  Portuguese  are  small ;  Spaniards  slightly  larger ; 
Malays  very  small ;  Japanese  exceed  the  English  average.  As 
regards  occupation,  it  is  asserted  that  grooms  and  government 
clerks,  before  competitive  examinations  were  introduced,  came 
lowest  in  the  scale. 

As  to  the  growth  of  the  brain,  it  is  probable  that  this  continues 
until  much  later  than  is  usually  supposed.  Its  maximum  weight  is 
reached  between  20  and  40.  Probably  growth  of  the  brain  and 
the  cranium  take  place,  as  it  were,  by  common  consent. 

As  to  the  physiognomy  of  action,  the  mind,  by  the  law  of 
association,  brinsfs  toorether  such  features  and  gestures  as  it  has 
learnt  by  past  experience  to  associate  with  mental  power,  and  by 
observing  the  presence  or  absence  or  amount  of  these  in  a  given 
face  forms  a  notion  of  the  mental  power  of  its  possessor.  Now 
those  features  will  be  most  indicative  of  mind  which  are  the 
distinctive  property  of  man,  as  opposed  to  those  of  the  anthropoid 
apes,  which  most  nearly  approach  him.  These  are  :  well  developed 
and  broad  nose  and  chin,  the  breadth  of  the  interorbital  span, 
parallelism  of  the  inner  walls  of  the  orbits,  &c.  These  translated 
into  the  transcendental  language  of  Lavater  are  practically  the 
same  as  some  of  his  physiognomical  rules. 

In  conclusion,  Dr.  Collins  held  that  the  science  of  physiognomy, 
that  of  '  finding  the  mind's  construction  in  the  face,'  was  a  perfect 
induction,  backed  up  by  innumerable  facts  and  corroborated  by 
common  sense. 

Decemher  4. 

The  house-physicians  introduced  the  discussion  on  'Pneu- 
monia.' 

Decemher  11. 

Mr,  Montagu  Smith  read  a  paper  on  '  Ethics  of  Vivisec- 
tion.' 

January  8. 

Mr.  Lyndon  showed  a  man  suffering  from  myxoedema. 
Mr.  C.  Percival  Crouch  then  read  a  paper  on  '  Mesmerism.' 
He  began  by  shortly  sketching  the  history  of  mesmerism,  refer- 
ring to  its  probable  origin  in  the  East,  where  it  was  practised  by 
the  Magi,  who  combined  the  qualification  of  priest  ami  physician  ; 
while  at  Delphi  it  was  interesting  to  read  that  the  oracle  uttered 


246  Proceedwgs  of  the  Ahernelhlan  Sucieii/. 

her  responses  while  in  the  mesmeric  trance.  In  the  temples  of 
^sculapius  mesmerism  was  very  largely  employed  in  the  treatment 
of  disease.  He  then  referred  to  Mesmer's  practice  in  Paris,  which 
became  so  notorious  that  the  Government  appointed  a  committee 
of  inquiry,  who,  however,  did  not  return  a  report  satisfactory  to 
Mesmer,  and  he  was  from  that  time  generally  looked  upon  as  an 
ignorant  impostor.  The  various  methods  of  inducing  sleep 
were  then  discussed,  and  the  reader  impressed  upon  his  hearers 
the  fact  that  it  was  by  no  means  an  easy  matter  to  put  any  one 
into  the  sleep,  but  often  many  attempts  were  necessary  before 
success  was  attained.  He  then  passed  on  to  discuss  the  various 
stages  of  the  sleep.  In  the  first,  or  '  alert '  stage,  certain  pheno- 
mena of  an  active  sort  were  to  be  obtained,  remembrance  of  which 
was  retained  when  the  subject  returned  to  the  normal  waking  state ; 
that  he  was,  in  fact,  in  the  condition  of  a  will-less  though  con- 
scious automaton.  In  the  '  deep '  stage  phenomena  were  also  to 
be  obtained,  but  the  subject  had  no  remembrance  of  what  had 
taken  place  when  he  returned  to  his  waking  state.  He  next  spoke 
of  the  anaesthetic  stage,  and  reminded  his  readers  that  Esdaile 
practised  painless  surgery  many  years  before  the  introduction  of 
ether  and  chloroform,  and  some  of  his  operations  were  quoted. 
With  regard  to  the  various  theories  put  forward  from  time  to  time 
to  explain  the  trance,  Heidenhain's  was  chiefly  dwelt  upon  as  being 
the  most  scientific  ;  but  the  reader  impressed  upon  his  audience 
that  it  would  require  veiy  considerable  modification  before  it 
would  explain  all  the  phenomena  met  with.  In  conclusion,  the 
more  unusual  phenomena  were  shortly  considered,  as  transference 
of  tastes  and  pains,  &c. 

January  15. 

Dr.  Eoughton  showed  a  case  of  wounded  cornea  followed  by 
sympathetic  ophthalmia. 

Mr.  Steedman  then  read  his  paper  on  '  Gangrene.' 

He  began  by  briefly  discussing  the  causes  of  gangrene. 

(l)  Deficiency  in  the  supply  of  arterial  blood  by  occlusion  of 
arteries — (a)  By  ligature  ;  (/3)  By  embolism  ;  (7)  By  thrombosis. 

(ii.)  Deficiency  in  amount  of  blood,  due  to  hemorrhage,  to 
pressure  of  new  growths,  to  cold,  to  ergotism. 

(iii.)  Complete  arrest  of  the  circulation,  by  strangulation,  by 
acute  inflammation,  by  pressure  (as  in  bedsores),  by  traumatic 
injury,  by  specific  poisons  (as  in  the  various  forms  of  local  gan- 
grene, such  as  hospital  gangrene,  noma,  charbon,  &c.) 


Proceedings  of  the  Ahernethian  Society.  247 

(iv.)  Specific  fevers,  e.g.,  sloughing  of  the  tonsils  in  some 
virulent  forms  of  scarlet  fever, 

(v.)  Neuroses. 

(vi.)  Abnormal  conditions  of  the  blood,  e.g.,  relation  of  car- 
buncle to  diabetes. 

The  author  then  proceeded  to  discuss  the  following  forms  of 
gangrene : — 

1.  Gangrene  of  penis  and  scrotum,  following  acute  inflamma- 
tion, 

2.  Symmetrical  gangrene  of  Raynaud. 

3.  Pbagedcena, 

4.  Senile  gangrene, 

5.  Diabetic  gangrene. 

6.  Traumatic  spreading  or  septic  gangrene. 

He  laid  great  stress  on  the  treatment  of  gangrene  of  penis  and 
scrotum,  which  he  said  should  be  of  two  kinds — (a)  Constitu- 
tional; (/S)  Local;  the  constitutional  consisting  in  giving  the 
patient  nourishing  and  non-stimulating  diet  and  exhibiting  opium 
in  the  form  of  half  a  grain  of  the  extract  twice  a  day ;  the  local, 
in  giving  warm  baths  for  three  hours  or  more  at  a  time  at 
least  twice  a  day,  and  in  the  application  of  charcoal  poultices. 
The  gonorrhoea  should  be  treated  in  the  usual  way. 

In  speaking  of  diabetic  gangrene,  he  stated  that  he  did  not 
believe  that  gangrene  due  to  diabetes  per  se  existed,  but  that 
where  such  cases  were  said  to  exist,  they  were  really  cases  of  gan- 
grene (embolic,  senile,  &c.)  complicated  by  diabetes.  The  reasons 
for  this  conclusion  were  as  follows  : — Diabetes  is  most  virulent  and 
of  the  worst  type  when  occurring  in  young  people  ;  therefore  it  is 
in  these  cases  that  one  would  expect  to  find  diabetic  gangrene  ;  but 
we  find  nothing  of  the  sort.  How  much  less,  therefore,  would  one 
expect  to  find  it  causing  gangrene  in  old  people  ? 

Symmetrical  gangrene  was  treated  of  at  some  length,  and  the 
belief  expressed  that  there  are  two  distinct  classes,  as  shown  by 
the  following  cases  : — 

Case  i. — Case  of  dry  gangrene  in  a  child,  slowly  spreading  and 
involving  the  extremities — great  debility — recovery. 

Mr.  Steedman  took  this  to  be  a  case  of  gangrene  due  to  defi- 
ciency in  the  amount  of  arterial  blood-supply  to  the  parts,  the 
result  of  mal-nutrition  and  an  enfeebled  circulation. 

Case  2. — Moist  gangrene  in  a  child,  very  rapidly  spreading,  and 
involving  not  the  extremities,  but  beginning  at  the  calves  of  the 
legs,  then  spreading  above  the  knees,  and  finally  to  the  buttocks. 
Death  in  two  days. 

He  did  not  feel  certain  what  explanation  should  be  given  of  this 


248  Proceedings  of  the  Ahernethkm  Society. 

case,  but  suggested  a  peripheral  nerve  lesion  or  vascular  spasm 
as  possible  causes. 


Januarij  15. 

Dr.  Roughton  showed  a  case  in  wliich  a  wound  of  the  ciliary 
region  had  been  followed  by  syiupatlietic  ophthalmia. 

Mr.  Reginald  Combes  read  a  paper  entitled,  'Quacks  and 
Quackeries.'  He  began  by  defining  a  quack  as  '  one  who, 
without  a  diploma  granted  by  some  recognised  licensing  body, 
practises  medicine.' 

Of  medical  quacks  he  recognised  two  sorts — first,  the  man 
with  no  dijDioma ;  secondly,  the  man  who,  holding  a  license  of 
some  sort,  uses  it  only  as  a  source  of  gain  to  himself,  caring 
nothing  for  the  anxieties  and  sufferings  of  his  patients  as  long  as 
his  fee  be  forthcoming. 

Mr.  Combes  then  pointed  out  how  easy  it  was  under  the 
existing  laws  to  practise  without  a  diploma,  since  the  medical 
register  and  the  college  lists  were  the  only  means  by  which  it  was 
jDOSsible  to  ascertain  the  nature  of  a  man's  qualifications. 

He  then  went  on  to  consider  the  various  kinds  of  quacks,  and 
in  speaking  of  the  'bone  setters/  was  of  opinion  that  the  term 
'adhesion  breakers  '  was  a  more  suitable  term,  for  the  occasional 
successful  cures  were  generally  to  be  accounted  for  by  the  fact 
that  many  sprained  joints,  from  being  kept  in  one  position  for  a 
length  of  time,  became  stiffened  by  the  formation  of  adhesions, 
which  were  broken  down  by  the  wrench  of  the  bone-setter. 

In  asking  the  question,  '  Are  they  justified  in  their  work  since 
they  occasionally  have  good  results?'  he  emphatically  replied  in 
the  negative,  since  in  cases  where  chronic  inflammation  was  pre- 
sent the  most  disastrous  results  would  be  obtained. 

Venereal  quacks  were  then  fully  dealt  with,  and  Mr.  Combes 
showed  that  their  patients  included  chiefly  those  suffering  from 
'  venereal  diseases  '  and  those  from  '  sexual  hypochondriasis,'  and 
mentioned  how  not  uncommonly  suicide,  and  even  murder,  fol- 
lowed after  prolonged  and  unavailing  treatment  by  these  men. 

He  then  lightly  touched  upon  the  qualified  quack,  who  by  his 
meanness  and  cruelty  reflected  discredit  on  the  profession.  The 
subject  of  homoeopathy  was  then  briefly  discussed,  and  Mr. 
Combes  went  on  to  consider  the  cure  for  quackery. 

He  showed  how  nothing  but  a  stern  unflinching  exposure  of 
the  impostors  would  eradicate  this  deeply-rooted  evil,  and  thought 
that  through  the  medium  of  medical  papers,  eg.,  '  Lancet,' '  British 
Medical   Journal,'    was    this    to    be    chiefly   effected.     That   no 


Proceedings  oftJie  Ahernethian  Society.  249 

faltering  references  must  be  made  to  unknown  practitioners,  but 
a  clear  and  unhesitating  publication  of  his  name  and  deeds  be 
given  to  the  profession  and  lay  public. 

In  conclusion,  he  pointed  out  the  urgent  necessity  for  addi- 
tional legislation  with  regard  to  medical  registration. 

January  29. 

Mr.  W.  T.  H.  Spicer  read  a  paper  on  'Temperature  in  Health 
and  Disease.' 

Feh'uary  5. 

Mr.  Hind  showed  a  case  of  congenital  syphilis  in  a  boy. 

Mr.  Steedman  showed  a  boy  who  had  suffered  from  a  com- 
pound, comminuted,  depressed  fracture  of  the  frontal  bone. 

Mr.  Lyndon  exhibited  three  microscopic  specimens  :  the  first 
was  a  melanotic  glioma  of  the  cerebellum  ;  the  second  a  mela- 
notic alveolar  sarcoma  of  skin  ;  the  third  a  melanotic  alveolar 
sarcoma  of  gland  (from  same  case  as  No.  2).  He  also  showed  a 
case  of  multiple  diverticula  of  the  duodenum. 

Dr.  Eoughton  then  opened  the  medical  discussion  on  '  Coma.' 

He  began  by  discussing  the^  various  current  definitions  of  coma, 
and  showed  how  vague  and  inaccurate  they  were.  He  thought 
that  the  term  coma  should  be  limited  to  loss  of  consciousness 
brouglit  about  directly  by  some  altered  condition  of  the  higher 
nerve-centres.  He  then  brought  forward  a  classification  of  the 
causes  of  coma,  which  he  had  found  to  be  of  practical  value,  and 
stated  his  views  as  to  their  mode  of  action.  Of  the  organic  causes 
of  coma  he  mentioned  cerebral  haemorrhage,  softening,  meningitis, 
tumour,  and  injury.  He  believed  that  cerebral  hjemorrhage  gave 
rise  to  coma  by  the  disturbance  of  cerebral  circulation  which  it 
brought  about,  more  than  by  the  amount  of  actual  damage  done 
to  the  brain  substance.  He  spoke  of  the  somewhat  rare  condition 
known  as  urticaria  of  the  brain.  In  alluding  to  the  pathology  of 
concussion,  he  discussed  the  chief  views  held,  and  expressed  his 
opinion  that  although  some  definite  lesion  is  always  discoverable 
in  fatal  cases,  yet  in  many  slighter  cases  there  is  no  lesion  other 
than  a  molecular  one.  He  considered  coma  due  to  various  dis- 
turbances of  the  circulation,  such  as  cerebral  ansemia,  hypertemia, 
syncope,  &c.,  and  also  mentioned  that  coma  may  be  produced  by 
various  toxic  conditions  of  the  blood.  He  spoke  of  the  current 
views  on  the  pathology  of  ursemia,  dividing  the  various  theories 
into  the  mechanical  and  chemical.  The  relation  of  acetonEemia 
to  diabetic  coma  was  alluded  to,  also  the  coma  of  choljemia,  which 
he  believed  to  be  due  to  the  presence  of  leucin  and  tyrosiu  in  the 


250  Proceedings  of  the  Ahcrnelkian  Sockiy. 

blood.  The  coma  of  alcoholic,  narcotic,  and  other  poisons  was 
slightly  touched  ufioii.  He  then  passed  on  to  the  two  varieties  of 
coma  occurring  in  the  acute  specific  fevers,  viz.,  that  occurring 
early  in  malignant  cases  and  the  typhoid  condition.  In  treating 
of  diagnosis  Dr.  Roughtou  laid  chief  stress  upon  the  following 
points  : — The  history,  mode  of  onset  of  the  coma,  injury,  evidence 
of  poisoning,  age,  previous  symptoms  of  renal  disease,  history  of 
drink,  degree  of  coma,  pulse,  jmpils,  examinations  of  chest  and 
urine,  squint,  hemiplegic  rigidity,  examination  of  any  matter 
vomited.  With  regard  to  treatment  he  said  but  little,  pointing 
out  that  it  depended  so  much  upon  diagnosis,  and  he  recommended 
the  establishment  of  a  casual  ward  in  connection  with  all  large 
hospitals  which  could  be  used  by  the  house-surgeons  for  cases  of 
coma  in  which  the  diagnosis  between  drunkenness  and  disease 
could  not  at  once  be  nuide. 

In  the  discussion  that  followed,  Mr.  Shore  agreed  with  Dr. 
Eoughton's  definition  of  coma,  but  differed  from  him  in  his  classi- 
fication of  the  causes,  contending  that  all  causes  may  be  arranged 
under  the  heads — Disturbances  of  blood-sup})ly,  toxic  conditions 
of  blood,  and  direct  nutritive  changes.  He  believed  tliat  cerebral 
haemorrhage  and  cerebral  tumour  caused  coma,  not  so  much  by 
pressure  as  by  disturbance  of  blood-supply.  He  alluded  to  a  case 
of  transition  coma,  probably  due  to  a  form  of  meningitis  allied  to 
urticaria.  Mr.  Shore  believed  that  cholsemia  was  due  to  the  over- 
flow of  peptones,  leucin,  and  tyrosin  produced  during  digestion 
into  the  blood,  owing  to  the  failure  of  the  liver,  through  disease, 
to  act  chemically  on  the  bodies,  as  occurs  in  the  healthy  subject. 
He  had  seen  cases  of  epilepsy  in  which  every  symptom  was  present 
except  loss  of  consciousness,  and  did  not  consider  that  this  nega- 
tived the  diagnosis. 

Dr.  Collins  next  spoke,  and  said  that  doubtless  much  of  the 
indisposition  of  medical  men  and  students  to  discuss  subjects  like 
coma  bearing  on  the  mental  side  of  medicine  was  due  to  the  fact 
that  no  knowledge  of  psychology  was  required  of  them,  and  a 
course  of  psychological  medicine  was  only  voluntary.  It  was  as 
absurd  to  expect  acquaintance  with  mental  disorders  without  a 
prior  study  of  psychology  as  to  look  for  pathological  knowledge 
without  physiological  training.  It  was  impossible  to  say  that  in 
coma  there  was  unconsciousness ;  we  could  only  say  there  was  an 
abolition  of  manifestation  of  consciousness.  The  same  occurred 
naturally  in  sleep,  yet  there  were  facts  to  show  the  sleeper's  mind 
was  consciously  active.  The  physical  antecedents  of  coma  were 
structural  change,  or  blood  supply  abnormal  in  quantity  or  quality, 
of  the  brain. 

Messrs.  Lyndon,  Steedmau,  Hiude,  and  Crouch  also  spoke. 


Proceedings  of  the  Ahernethian  Society.  251 

February  12. 

Election  of  members. 

Mr.  Hoyle  showed  the  joints  from  a  case  of  rheumatoid 
arthritis. 

Mr.  Wallis  then  read  his  paper  on  'Injuries  in  and  about  the 
Knee-joint." 

Speaking  of  inflamed  '  bursa  patellae,'  he  advocated  early  and 
free  incisions,  suggesting  that  better  results  were  obtained  thus 
than  by  waiting  until  fluctuation  could  be  felt ;  also  that  it  was 
better  to  make  two  lateral  incisions,  one  at  the  extreme  limit 
on  either  side  of  the  cavity,  as  well  as  one  down  the  centre,  better 
drainage  and  better  results  generally  being  thus  obtained. 

In  chronically  enlarged  bursse  he  gave  his  experience  of  having 
successfully  tapped  with  an  ordinary  trochar  those  bursse  in  which 
the  fluid  predominated. 

Concerning  synovial  effusions,  Mr.  Wallis  said  that  they  could 
be  diagnosed  from  blood  efi"usions  by  the  rapid  appearance  of  those 
latter  ;  effusions  of  synovia  taking  much  longer. 

In  cases  of  original  injuries  which  had  become  chronic,  he 
related  cases  which  had  derived  great  benefit  by  wearing  a  Thomas 
knee-joint  splint  for  some  time,  thus  giving  the  joint  almost  per- 
fect rest. 

He  then  passed  on  to  speak  of  fractures  of  the  lower  end  of  the 
femur  and  into  the  joint.  Here  again  cases  were  related  where  at 
first  absolute  rest  with  cooling  lotions  were  used  for  some  days 
until  the  effusion  had  somewhat  subsided  ;  they  were  then  put  up, 
in  some  cases  on  a  double  inclined  plane,  in  others  the  American 
anterior  splint  was  used  with  great  advantage. 

The  various  methods  of  operating  on  loose  cartilages  in  the 
knee-joint  were  then  discussed,  and  a  case  related  in  which  an 
undoubted  loose  cartilage  had  been  absorbed  after  the  limb  had 
been  kept  at  rest  for  some  time. 

finally,  the  various  methods  of  treating  fractured  patellae  were 
explained. 

References  were  made  to  various  papers,  statistics,  and  discus- 
sions concerning  the  operation  of  wiring  the  patellse,  and  drawing 
conclusions  from  these,  Mr.  Wallis  gave  his  opinion  that  the  means 
did  not  justify  the  end. 

February  19. 

Mr.  Castle  showed  some  microscopical  specimens : — 
(i.)  Of  a  fungating  growth  from  the  breast  of  a  woman.     This 
growth  in  parts  exhibited  a  sarcomatous  structure   with    well- 
marked  myeloid  cells,  while  in  other  parts  it  showed  the  structure 
of  carcinoma. 


252  Proceedings  of  the  Ahernethian  Society. 

(2.)  A  malignant  tumour  from  tlie  lip  showing  sarcomatous 
and  carcinomatous  structures. 

Mr.  Lyndon  showed  the  knee-joints  from  a  case  of  Charcot's 
joint-disease. 

Mr.  ^y.  H.  Jessop  then  gave  a  demonstration  on  '  Germiculture,' 
and  illustrated  his  lecture  by  a  large  number  of  apparatus  brought 
from  the  laboratory  of  the  Health  Exhibition,  and  also  by  micro- 
scopical specimens, 

February  26. 

Mr.  Womack  read  a  paper  on  the  '  Rate  of  Cooling  of  the  Body- 
after  Death.' 

The  object  of  the  paper  was  to  ap})ly  exact  physical  laws  to  the 
subject,  and  tlius  to  supplement  the  experiments  performed  by 
Drs.  Taylor  and  Wilks  in  1863  at  Guy's  Hospital.  The  experi- 
ments of  the  two  last-named  observers  extended  over  several 
months,  umier  very  varying  conditions  as  regards  external  tem- 
})erature  of  medium,  and  cause  of  death,  and  consisted  princi- 
pally of  observations  of  the  body  temperature  taken  at  irregular 
intervals  after  death.  The  results  were  consequently  very  varied, 
and  from  the  seventy  cases  which  were  finally  available  for  investi- 
gation the  following  general  conclusion  could  alone  be  drawn: — 
That  in  the  first  period,  from  two  to  three  hours  after  death,  the 
average  temperature  was  25°  C.  (yy°  F.)  ;  in  the  second  period, 
from  four  to  six  hours  after  death,  the  average  temperature  was  23.3° 
C.  (74°  F.) ;  in  the  third  period,  from  six  to  eight  hours  after  death, 
the  average  temperature  was  21.1°  C.  (70°  F.) ;  and  in  the  fourth 
jieiiod,  from  eight  to  twelve  hours  after  death,  the  average  tempera- 
ture was  20.5°  C.  (69°  F.)  Hence  the  body  cooled  more  rapidly 
at  first  than  later,  and  fell  on  an  average  about  1°  F.  per  hour. 

Now  it  is  obvious  at  once  that  it  is  useless  to  attempt  to  draw 
means  from  experiments  extending  over  several  months  unless  a 
correction  is  inserted  for  the  varied  conditions  under  which  the 
experiments  were  performed,  especially  those  relating  to  tempera- 
ture of  the  surrounding  atmosphere,  and  also  bearing  in  mind 
that  in  each  of  the  arbitrary  periods  of  time  chosen  by  Drs.  Taylor 
and  Wilks  the  temperature  ranged  over  10°  F.,  and  during  the 
first  period  over  as  much  as  17°  F. 

The  author  decided,  therefore,  to  investigate  the  subject  experi- 
mentally, to  determine  how  nearly  a  well-known  physical  law 
applied  to  the  given  problem.  He  had  constructed  a  set  of  special 
thermometers,  the  bulbs  of  which  were  of  large  capacity,  flattened, 
and  of  very  thin  glass,  and  which  gave  readings  to  ^V^'^i  of  a  degree 
centigrade.  In  all  cases  where  practicable,  the  temperatures  were 
taken  on  the  surface  of  the  abdomen.     At  first  a  series  of  observa- 


Fi'oceedings  of  the  Ahernetliian  Society.  253 

tions  was  taken  to  determine  the  average  temperature  of  the  ab- 
domen during  life,  the  thermometers  being  strapped  down  to  the 
abdominal  surface  by  adhesive  plaster,  and  no  reading  taken  until 
after  the  lapse  of  fifteen  minutes.  By  this  means  efficient  contact 
with  the  surface  is  ensured,  the  heated  air  around  the  thermometer 
does  not  escape  by  convection,  and  the  back  of  the  plaster  being 
white,  a  feebly  radiating  surface  is  substituted  for  the  considerable 
radiating  power  of  glass  and  mercury.  From  a  considerable 
number  of  observations  so  taken  the  mean  value  of  the  tempera- 
ture of  the  abdomen  was  found  to  be  36.2°  C.  (93.1°  F.) — a  value 
considerably  higher  than  that  which  has  been  hitherto  adopted. 

It  is  well  known  that  a  body  at  a  higher  temperature  than  the 
surrounding  medium  cools  at  a  rate  which  is  almost  directly  pro- 
portional to  the  actual  excess  of  temperature  at  the  instant  of  time 
considered.  Strictly  speaking,  this  law,  known  as  Newton's  law  of 
cooling,  is  applicable  only  to  liquids  in  which  passage  of  heat  from 
the  hottest  central  portion  to  the  coldest  superficial  portion  takes 
place  through  the  medium  of  convection  currents.  Now  in  the 
case  of  the  body,  although  we  are  not  dealing  with  a  liquid,  we  are 
nevertheless  dealing  with  a  substance  the  tissues  of  which  are 
bathed  in  liquid,  and  one  in  which  the  excess  of  temperature  over 
that  of  the  surrounding  medium  is  small.  The  greatest  excess 
with  which  we  ever  have  to  deal  may  be  put  at  about  35°  C,  and 
Newton's  law  holds  almost  absolutely  throughout  this  excess.  It 
is  on  this  account  that  Dulong  and  Petit's  more  exact  law  was  not 
applied,  according  to  which  the  rate  of  cooling  is  a  function  not 
only  of  the  difference  of  temperature  of  the  body  and  that  of  the 
surrounding  medium,  but  also  of  the  absolute  temperatures  of  the 
body  and  of  the  surface  to  which  it  cools. 

The  problem  may  be  thus  expressed : — 

Let  S  =  area  of  the  body  surface  in  square  centimetres. 
E  =  thermal  emissivity  of  the  surface. 

Then  ^aS'  =  heat  lost  per  second  from  the  whole  surface  if  the 
surface  is  i °  hotter  than  the  surroundino:  medium. 

Let  6  =:  excess  of  temperature. 
Then  in  an  infinitely  short  time,  denoted  by  dx, 

heat  lost  =  USddx 
Denote  by  Jf  and  G  the  mass  and  specific  heat  of  the  body,  and 
by  —  dO  the  infinitely  small  fall  in  temperature  of  the  surface 
accompanying  the  infinitely  suiaR  loss  of  heat.     Then  we  have — 

-  dOMO  =  usedx 
-de  _ES  ■, 

In  any  experimental  case  it  would  be  an  almost  impossible  pro- 
blem to  determine  separately  the  values  of  E,  0,  M,  and  aS^,  varying 


2  54  Proceedings  of  the  Aheniethian  Society. 

so  largely  as  they  do  from  one  body  to  another,  but  we  may  write 

__  =  k  a.  quantity  which  is  readily  determinable  for  any  one 

MC 

body  ;  hence  we  should  have  on  integration — 

k  1  dx 


M' 


—  log^  6  =  kx 
In  other  words,  if  a  curve  is  drawn  the  ordinates  of  which,  Aa, 
Bh,  denote  excesses  of  temperature,  and  the  abscissoe,  ab,  5c,  denote 

times,  the  lengths  of  successive 
ordinates  equally  distant  apart 
will  represent  the  successive  terms 
of  a  diminishing  geometrical  pro- 
gression. Hence,  assuming  for 
the  moment  the  simple  case  of  an 
unchanging  temperature  of  ex- 
ternal medium,  it  will  be  possible 
to  construct  the  curve  represent- 
ing the  post-mortem  fall  of  tem- 
perature, and  hence  to  calculate 
how  long  it  is  since  the  moment 
of  death  corresponding  to  a  known  excess  of  temperature  of  the 
body  surface.  Or  if  two  careful  observations  of  temperature  are 
made  at  a  few  minutes  apart,  it  is  possible  by  means  of  a  mathe- 
matical formula  or  by  a  geometrical  construction  to  determine 
within  a  small  error  the  moment  at  which  the  person  died,  pro- 
vided only  that  the  body  has  not  yet  reached  the  temperature  of 
the  surrounding  medium. 

The  cases  in  which  the  investigation  might  be  of  special  value 
■would  be  those  medico-legal  cases  of  sudden  death  where  the 
question  of  murder,  homicide,  or  suicide  might  have  to  be 
decided. 

The  next  questions  dealt  with  in  the  paper  were  the  methods  of 
calculating  the  effect  produced  by  certain  complicating  conditions, 
viz.,  (i )  a  varying  temperature  of  the  external  medium  ;  (ii.)  the 
unknown  temperature  of  body  surface  at  death  ;  (iii.)  the  develop- 
ment of  rigor  mortis;  (iv.)  the  varying  locality  in  wliich  the  body 
may  have  been  placed ;  (v.)  tlie  varying  condition  as  to  covering 
of  the  body.  It  was  shown  that  if  tl)is  last  condition  occurred  in 
any  medico-legal  case  it  would  cause  difficulties  of  calculation 
well-nigh  insuperable.  The  cases  which  were  investigated  by  the 
author  were  mostly  complicated  by  this  condition,  but  owing  to 
the  fact  that  the  times  at  which  the  changes  occurred  were  known 
the  calculation  was  not  interfered  with.     Thus  a  patient  dying  in 


Proceedivgs  of  the  Abernethian  Society.  255 

a  ward  lies  for  a  certain  length  of  time  covered  by  clothing  whicli 
very  effectually  prevents  radiation  of  heat.  The  body  is  then  per- 
haps washed,  then  removed  to  the  dead-house,  where  the  tempera- 
ture is  very  different,  and  is  then  covered  by  only  a  sheet,  so  that 
radiation  proceeds  rapidly.  These  changing  conditions,  however, 
are  very  easily  taken  into  account,  and  the  reliability  of  the 
method  is  by  them  only  the  more  certainly  tested.  One  case 
investigated  was  as  follows  : — 

Male,  age  and  name  unknown,  admitted  unconscious  February 
24th,  Remained  unconscious  up  to  death,  with  stertorous  breath- 
ing. Right  hemiplegia,  vomiting,  and  bleeding  from  the  nostrils. 
Probable  cause  of  death,  haemorrhage  on  to  brain. 

The  body,  examined  on  February  25th,  gave  the  following 
temperatures  : — 

At  2.3  p.m.  temperature    =  22.5°  C. 
„    2.18  „  „  =  22.05°  C. 

„   2.33  „  „  =  21.55°  c. 

„    2.48  „  „  =  21.05°  0. 

»   3-3     >,  »  =  20.675°  c; 

The  value  of  the  constant  h  mentioned  above  has  first  to  be 
determined.     It  will  be  admitted  that  during  a  short   interval, 
such  as  a  quarter  of  an  hour,  the  temperature  would  fall  uniformly  ; 
hence,  taking  only  the  first  two  observations. 
Average  excess  of  tempera-  loo 

ture  between   2.3    p.m.  >■ —?^J_^h^^l- _  8.9°=:  13.375° 
and  2.18  p.m.  j  2 

Fall  of  temperature  in  fifteen  minutes  =  .45° 

7  dd  .45 

k=  —  7^^—= =t2 =  .002242 

ddx      13-375  X  15 
The  problem  has  to  be  worked  in  two  parts.     It  was  ascertained 
that  the  body  was  moved  to  the  mortuary  at  9  a.m,  that  is,  practi- 


Temperature  of 
mortuary  =  8.9°  C. 


256  Proceedings  of  the  Ahernelhian  Society. 

cally  300  minutes  before  tlie  first  observation  of  temperature.  The 
integral  of  the  equation  above  gives : — 

I       7      9o 

300  =     loCfe   .- 

.002242         6^ 
%e  J  =  .6726 
Hence  7        do 

^og.oQ-  =.2921 

^=1-9593 

But  6^  =.  13-375°  C,  therefore  60  =z  26.2°,  and  the  temperatuie  of 
the  bod}^  at  the  time  of  transfer  to  the  mortuary  would  therefore 
be  by  estimation  26.2°  +  8.9°,  that  is,  35.1°.  Now,  when  trans- 
ferred from  the  ward,  the  temperature  of  the  latter  was  15.5°  C.  ; 
hence  the  body  temperature  was  then  higher  than  that  of  the 
ward  by  19.6°  C.  Proceeding  in  the  same  way,  we  find,  when  the 
body  temperature  was  higher  than  that  of  the  ward  by  27° — 

I  7        27 

.002242  190 

I 

= X  .32027 

.002242  -^         ' 

=  143  minutes. 
Hence  this  man  could  not  have  died  later  than  half-past  six  at 
most,  even  upon  the  assumption  that  the  cooling  had  been  as  rapid 
in  the  ward  as  in  the  dead-house,  which  was  certainly  not  the 
case,  seeeing  that  the  body  was  more  covered  in  the  ward.  To 
avoid  this  uncertainty, a  separate  experiment  was  made,  covering  the 
body  with  several  layers  of  sheeting,  and  under  these  circumstances 
of  altered  radiating  power  the  temperatures  were  at 

P.M. 

3.12  temperature  =  20.5°  C.  1      Temperature  of 

3.42  „  =  20.2°  C.  J  mortuary  =  8.9°  C. 

Hence  similaiiy  k  =  .000873,  and  the  time  of  death  previous  to 

^2027 

Q  o'clock  =  ~ '—  =  xGl  minutes. 

^  .000873       ^  ' 

Hence  the  latest  time  at  which  death  could  have  occurred  is 

about  a  quarter  to  three.     The  actual  figures  were — 

Feb.  24>dmitted  1 1    a.m.  temp.  =  35°  C.    )    Temnerature  of 

6  p.m.      „     =Z9AyX^''^ZtZ      ' 

12  p.m.  „        =40.3     C.   r  jr    r°   0 

Feb.  25,  f^m^A       1.30  a.m.     „     =42.5°C. ;  ■'■■' 


Proceedings  of  the  Ahernethian  Society.  257 

This  case  shows  the  accord  of  the  calculation  with  the  known 
times,  especially  coupled  with  the  observation  that  the  tempera- 
ture rose  just  before  death^  and  probably  continued  to  do  so  for 
some  time  after. 

Other  cases  were  similarly  referred  to  in  the  paper,  in  some  of 
which  the  result  of  calculation  was  strikingly  in  accord  with  the 
known  time  of  dea:li,  the  problems  being  less  complicated  by  a 
high  temperature  at  death.  In  others,  the  result  of  calculation 
could  not  be  depeuded  on,  owing  in  part  to  insufficient  data  as  to 
temperature  of  ward,  and  as  to  varying  conditions  of  covering. 
One  case  was  also  given  where  the  problem  was  not  complicated 
by  pathological  temperatures — the  sort  of  case  that  would  be  met 
with  in  medico-legal  investigation.  In  this  case  a  lad  was  brought 
into  the  hospital  dead,  with  fractured  skull,  at  a  quarter  past  nine. 
The  temperatures  were  taken  at  two  o'clock,  about  five  hours  sub- 
sequently. A  calculation  precisely  similar  to  that  given  above 
led  to  the  conclusion  that  the  time  of  death  was  312  minutes 
antecedent  to  2.20  P.M.  This  would  make  the  time  of  death  eight 
minutes  past  9  A.M.  The  conditions  in  this  case  were  favourable 
to  a  successful  calculation,  as  the  body  had  been  removed  at  once 
to  the  mortuary,  where  the  temperature  of  the  air  was  almost 
constant. 

Altogether  fifteen  cases  had  been  examined  similarly,  with  a 
result  which  was  sufficiently  encouraging  to  lead  to  further  obser- 
vation, so  as  to  thoroughly  test  whether  the  method  of  determina- 
tion was  reliable. 

Allusion  was  made  in  the  paper  to  the  stated  conditions  under 
which  the  rate  of  body  cooling  was  affected.  Thus  a  child  ex- 
poses for  a  given  volume  of  body  a  proportionately  larger  body 
surface  than  an  adult,  and  would  therefore  cool  the  faster,  just  as 
the  smaller  planets  of  the  solar  system  have  cooled  more  rapidly 
than  the  larger.  So,  too,  it  is  stated  that  the  body  cools  more 
rapidly  after  death  from  asphyxia,  and  more  slowly  after  death 
from  accident,  apoplexy,  or  acute  disease.  With  regard  to 
apoplexy  (and  other  nervous  causes),  the  explanation  may  be  that 
there  is  often  a  marked  rise  of  temperature  after  death,  and  this 
may  appear  to  delay  the  cooling. 

March  5. 

Mr.  Lyndon  showed  three  intestinal  calculi  of  large  size,  and  in 
appearance  like  polished  marble,  removed  from  the  stomach  ojp  a 
horse. 

Dr.  Collins  showed  a  new  form  of  eye-irrigator. 

VOL.  XXI.  R 


258  Proceedings  of  ilie  Aherncililan  Society. 

Tlie  house-surgeons  then  introduced  a  discussion  on  '  Injuries 
and  Diseases  of  the  Spinal  Cohinin.' 

Mr.  Lewis  dealt  with  tlie  subject  of  caries  of  the  spine.  In 
speaking  of  the  treatment  of  caries,  he  drew  attention  to  the  fact 
that  Pott  treated  all  his  cases  by  rest  in  bed.  He  objected  very 
much  to  the  use  of  instruments.  He  says  :  '  These  pieces  of 
mechanism  are  calculated  to  obviate  and  remove  what  does  not 
exist;  they  are  founded  on  a  supposition  of  actual  dislocation, 
which  is  never  the  case.'  Mr.  Lewis  objected  to  prolonged  rest 
in  bed,  because  it  deprives  the  patient  of  fresh  air  and  exercise, 
and  the  debility  so  induced  militates  strongly  against  repair,  and 
also  the  abscesses  track  backward  among  the  muscles  of  the  back, 
instead  of  tracking  along  the  natural  drainage  tube  formed  by 
the  sheath  of  the  psoas  magnus  muscle.  He  advocated  plaster 
of  Paris  jackets  combined  with  fresh  air  and  exercise  wherever 
possible. 

Mr.  Tayler  continued  the  discussion,  taking  the  subject  of  con- 
genital malformations  of  the  spinal  column.  Stating  briefly  that 
the  tails  of  tailed  children  usually  consisted  of  fat,  but  that  cases 
vrere  on  record  where  the  tail  was  formed  by  an  increase  of  the 
actual  number  of  the  vertebrae,  he  passed  on  to  consider  spina 
bifida,  which,  he  said,  was  the  most  important  congenital  malfor- 
mation, as  it  could  be  benefited  by  surgical  interference.  Having 
described  a  spina  bifida,  he  spoke  of  the  various  kinds  of  treat- 
ment, recommending  the  partial  evacuation  of  the  cyst  and  the 
injection  of  about  half  a  drachm  of  Morton's  fluid. 

Mr.  W.  T.  H.  Spicer  dealt  with  lateral  curvature  of  the  spine, 
and  directed  his  remarks  mainly  to  the  subject  of  treatment. 
After  pointing  out  the  general  relation  which  the  nutrition  of  the 
muscles  bears  to  that  of  the  bones  and  ligaments,  both  in  hyper- 
trophy and  atrophy,  he  illustrated  this  by  what  takes  place  in  the 
spinal  column,  the  wasting  of  the  muscles  in  scoliosis  going  on 
pari  passu  with  a  weakening  and  relaxation  of  the  ligaments. 
Next  the  conditions  which  bring  about  this  wasting,  the  class  of 
person,  and  the  age  at  which  it  occurs,  were  commented  on.  These 
considerations  led  to  the  treatment,  the  first  part  of  which,  pro- 
phylaxis, was  most  strongly  emphasised  ;  the  hygiene  of  youth, 
the  proper  physical  training  of  young  girls,  the  avoidance  of  all 
errors  in  diet,  dress,  and  occupation,  were  insisted  on  at  length. 
After  condemning  as  a  means  of  efiecting  a  cure  of  scoliosis  all 
rigid  instruments,  supports,  or  jackets,  the  fault  of  which  was  to 
impede  respiration,  and  only  further  induce  wasting  of  the  muscles 
which  support  the  spine,  the  treatment  which  in  the  writer's 
opinion  was  most  satisfactory  was  indicated.     The  removal  of  any 


Proceedings  of  the  Abernetliian  Society.  259 

obvious  cause,  an  inquiry  into  the  kind  of  clothing  worn,  should 
first  be  niade ;  then  the  careful  practice  of  certain  exercises,  the 
nature  of  which  was  explained,  calculated  to  improve  the  nutrition 
of  the  muscles  of  the  body  generally  and  of  the  spine  in  particular, 
was  advised.  Several  mechanical  aids,  the  use  of  the  sloping  seat 
and  the  wearing  of  elastic  spinal  bandages,  were  spoken  of.  The 
combination  of  these  methods  with  a  sufficient  amount  of  rest 
were  relied  on  as  a  main  basis  for  the  treatment  of  the  deformity. 
Mr.  Steedman  then  discussed  '  Concussion  of  the  Spine,'  includ- 
ing under  this  heading  all  injuries  to  the  spine  short  of  fracture 
and  dislocation,  accompanied  by  signs  and  symptoms  of  affection 
of  the  spinal  marrow,  such  injuries  being  due  to  direct  or  indirect 
violence.  He  said  that  the  cord  may  be  aflfected  in  three  ways, 
viz. — I.  By  concussion,  causing  anaemia  or  a  suspension  of  its 
functions,  just  as  in  concussion  of  the  brain ;  2.  By  compression, 
the  result  of  effused  blood  or  inflammatory  products  in  the  spinal 
canal,  either  outside  the  membranes,  between  the  membranes,  or 
in  the  cord  ;  3.  By  inflammation,  acute  or  chronic,  beginning 
primarily  in  the  cord  or  secondarily  to  a  spinal  meningitis,  the 
latter  being  the  more  common  cause.  He  then  illustrated  the 
signs  and  symptoms  of  concussion  and  compression  by  a  case  then 
under  treatment  in  his  wards,  and  spoke  at  some  length  on  the 
course  of  those  cases  where  symptoms  come  on  weeks  or  months 
after  the  accident. 

Mr.  Vogan  discussed  '  Fractures  of  the  Spinal  Column.' 
He  said  they  derive  their  chief  importance  from  accompanying 
injury  to  the  spinal  cord.  The  position  of  the  spinal  canal  being  that 
of  least  movement  on  bending  of  the  column,  the  cord  is  advanta- 
geously placed.  There  are  two  great  classes  of  fracture,  direct 
and  indirect.  Direct  injury  usually  causes  fracture  of  processes; 
indirect,  as  a  bend  of  column,  crushes  the  bodies,  and  is  the  more 
serious.  Fracture  through  the  laminae  is  serious,  as  the  spinal 
canal  is  opened.  Fractures  through  the  bodies  in  the  cervical 
region  are  most  serious,  and  in  them  there  is  more  likelihood  of 
the  cord  being  injured  on  account  of  the  small  size  of  the  bodies, 
which  are  easily  crushed.  In  the  lumbar  region  the  cauda  equina 
can  be  pushed  aside  or  strands  separated  without  being  crushed. 
Diagnosis  of  the  seat  of  injury  may  be  made  by  the  line  of  hyperass- 
thesia  between  the  wound  and  paralysed  parts  and  by  the  exag- 
gerated reflexes  below  the  injury.  Breathing  may  be  impeded 
when  the  fracture  is  quite  in  the  lower  dorsal  region  by  paralysis 
of  abdominal  muscles,  the  intestines  becoming  inflated  and  pressing 
up  the  diaphragm.  The  kidneys  are  sometimes  injured  in  fractures 
in  the  lumbar  region ;  early  alkaline  urine,  due  to  trophic  kidney 
changes,  is  then  met  with. 


26o  Proceedings  of  the  Aheiiiethian  Society. 

March  12. 
Dr.  Klein,  r.Pt.S.,  read  a  paper  on  the  '  -Etiology  of  Cholera.' 

March  19. 

Annual  general  meeting. 

The  accounts  of  the  Society  were  audited. 

Messrs.  Arnold  and  Humphry  were  appointed  scrutineers  of 
the  ballot.  The  election  of  members  of  the  committee  for  the  fol- 
lowing yt-ar  then  took  place  : — Treasurer,  Mr.  Savory;  Presidents, 
Dr.  E.  AV.  Koughton,  ^Ir.  AT.  T.  H.  Spicer ;  Vice-Presidents,  Mr. 
C.  P.  Crouch,  A.  Lyndon  ;  Hon.  Secretaries,  Mr.  F.  W.  Andrewes, 
Mr.  "W.  G.  Gardiner;  Additional  CovLmittee-rnen,  Mr.  G.  Colby, 
Mr.  R.  Farrar. 


DESCRIPTIVE    LIST 


OF 


SPECIMENS  ADDED  TO  THE  MUSEIM 

DURING  THE  YEAR  1885. 


SPECIMENS  ADDED  TO  THE  MUSEUM 

During  the  Year  ending  October  i,  1885. 


BY 

D'AECY  POWEE. 

SEEIES  L 
DISEASES  OF  BONE. 

96a.  Lower  portions  of  the  Radius  and  Ulna,  showing  the  effects  of  an 
injury  to  the  wrist  many  years  before  death, 

119c.  Section  of  the  lower  portion  of  a  Femur  which  has  undergone  a 
process  of  rarefying  osteitis  owing  to  the  long-continued  presence  of  a 
sequestrum.  The  outer  and  posterior  portion  of  the  bone  has  undergone 
partial  absorption,  due  to  the  invasion  of  an  epitheliomatous  ulcer  which 
commenced  at  the  opening  of  the  sinus  leading  to  the  sequestrum. 

M.  set.  43.  The  sequestrum  appeared  to  have  existed  29  years.  See  Male  Surgical 
Register,  vol.  iii.  (1884),  No.  2713. 

132a.  Section  through  the  lower  part  of  the  left  Tibia  and  Ankle, 
showing  an  abscess  in  the  bone,  with  some  inflammation  of  the  tibio- 
astragaloid  joint. 

From  a  man  aged  47,  who  had  injured  his  ankle  thirty  years  previously,  and  who  for 
ten  or  twelve  years  subsequently  had  sinuses  about  the  part,  from  which  pieces  of  dead 
bone  came  away  at  different  times.  Seven  years  before  the  amputation  the  patient 
suffered  from  a  "gathered  ankle,"  and  was  laid  up  for  five  weeks  ;  the  "gathering  burst," 
but  no  dead  bone  was  discharged.  In  March  1884  he  had  rheumatic  pains  in  his  ankle, 
which  swelled.  On  admission  to  the  Bristol  Infirmary,  the  joint  was  stiff,  but  not 
uniformly  enlarged.  The  skin  was  adherent,  glazed,  and  pigmented.  There  was  a  good 
deal  of  hard  swelling  over  the  tendo-Achillis.  No  tenderness  anywhere  above  the  joint. 
The  abscess  may  have  been  secondary  to  the  joint-disease,  or  else  it  may  have  super- 
vened on  the  long-standing  osteitis  of  the  tibia. 

Presented  by  "W.  Dowson,  Esq.,  M.B. 
NECROSIS. 

198a.     A  Sequestrum  removed  from  the  thigh  four  years  after  a  compound 
fracture. 

M.  set.  20.  The  sequestrum  had  given  no  trouble  during  the  four  years  until  about  a 
week  before  its  removal. 

See  Male  Surgical  Register,  vol.  iii.  {18S5),  No.  2027. 


264  specimens  added  to  the  Museum 

226a.     Portion  of  the  Temporal  and  Occipital  Bones,  showing  the  results 
of  necrosis  of  the  mastoid  process.    The  temporal  was  trephined  shortly 
before  death.     (In  Case  F.) 
See  Male  Surgical  Register,  vol.  iii.  (1885),  No.  482. 

271a.  Portions  of  two  Ribs,  with  their  costal  curtilages,  showing  the 
"  beading  "  characteristic  of  rickets. 

296a.     A  Calvarium  Avhich  has  undergone  much  thickening.     The  inner 
surface  is  not  corrugated.     (In  Case  F.) 
For  further  details  see  Post-Morlem  Book,  vol.  xi.  p.  174. 

296b.  Calvarium  much  thickened,  apparently  as  a  result  of  syphilis 
(In  Case  F.) 

340a.  Calvarium  showing  a  Node  upon  its  outer  surface.  On  the  inner 
side  of  the  right  parietal  bone  is  a  bare  patch,  corresponding  to  which 
there  was  a  dense  local  thickening  of  the  dura  mater,  which  appeared 
to  be  a  partially  degenerated  gumma.     (In  Case  F.) 

From  a  woman  aged  46,  the  subject  of  visceral  s}'philis.  See  Transactions  of  the 
Pathological  Society,  vol.  xxxv.  (1884),  p.  233.  The  iutestines  are  preserved  in  Series 
xviii.  No.  2007a. 

340b.  Calvarium  thickened  and  ulcerated  as  a  result  of  long-standing 
syphilis.     (In  Case  F.) 

357a.  Calvarium  which  has  undergone  much  ulceration.  The  outer 
table  is  ulcerated  over  its  whole  extent,  and  several  pieces  of  dead  bone 
have  fallen  away  and  lie  at  the  bottom  of  the  bottle.  The  inner  table 
is  also  ulcerated,  but  not  to  so  great  an  extent.  The  bone  is  so  soft 
that  it  can  easily  be  cut  with  a  knife. 

M.  set.  42,  who  denied  having  had  syphilis,  and  in  whose  body  no  evidence  of  the 
disease  could  be  found  after  death.  The  scalp  was  entire,  but  for  many  months  had  felt 
pufFy  over  an  extensive  area.  When  it  was  raised,  a  quantity  of  pus  was  found  beneath 
it.  The  dura  mater  was  entire,  but  there  was  a  superficial  abscess  in  the  posterior  parij. 
of  the  right  cerebral  hemisphere.  The  case  was  shown  at  the  Pathological  Society,  See 
Pathological  Societijs  Transactions,  vol.  xxxiv.  (1883),  p.  209. 

437a.     Sarcomatous  growth  involving  the  skull  and  dura  mater. 

F.  set.  60.  Sarcoma  of  breast  of  two  years'  duration.  See  Lucas  Ward  Boole,  vol.  ix. 
p.  48. 

441a.     Sarcoma  of  Forearm,  from  a  child  aged  nine  months. 

A  drawing  is  preserved  in  Series  Ivii.  No.  31a.  A  microscopical  section  is  preserved  in 
Series  Iv.  No.  14a. 

Presented  by  C.  L.  Lockwood,  Esq. 

554a.  Lower  Jaw  of  a  man  presenting  an  osseous  tumour  on  its  right  half. 
Tlie  tumour  has  grown  from  the  interior  of  the  ramus,  immediately 
above  the  mental  foramen.  Its  upper  surface  is  indented  apparently 
by  the  action  of  the  teeth  in  the  upper  jaw.     (In  Case  G.) 

Presented  by  G.  F.  Aldous,  Esq. 


during  the  Year  ending  October  i,  1885.  265 

SERIES  II. 
DISEASES  OF  JOINTS. 

650a.     Synarthrosis  of  the  Hip-Joint.     (In  Case  G.) 

From  a  case  of  morbus  coxeb  of  28  years'  duration.  See  Medical  Post-Mortem  Book, 
vol.  xi.  p.  174,  and  Male  Surgical  Register,  vol.  iv.  (1885),  No.  535. 

650b.     Synostosis  of  Hip-Joint. 

See  Male  Surgical  Register,  vol.  iv.  (1885),  No.  535. 

673c.     Head  of  a  Radius  apparently  affected  with  chronic  osteo-arthritis. 
The  papillated  condition  of  the  synovial  fringes  is  well  seen. 

From  a  man  aged  26. 

Presented  by  "W.  Bruce  Clarke,  Esq. 

690a.     A  Patella  showing  the  changes  which  take  place  in  the  cartilage  at 
an  early  period  of  chronic  osteo-arthritis. 

The  cartilage  Las  become  in  part  eroded  and  is  fibrillated. 

CHANGES  DUE  TO  OSTEO-ARTHIIITIS. 

691b.     A  Right  Knee-Joint  affected  with  osteo-arthritis,  from  a  patient 
who  had  locomotor  ataxy. 

The  joint  is  very  much  enlarged.  The  enlargement  is  due  to  a  thickening  and  develop- 
ment of  the  various  folds  and  processes  of  the  synovial  membrane,  and  to  an  alteration 
in  the  shape  of  the  bones.  When  first  opened,  the  joint  contained  a  considerable  quantity 
of  thin  pus. 

The  lower  end  of  the  femur  and  the  head  of  the  tibia  have  undergone  remarkable 
alterations  in  shape.  The  external  condyle  of  the  femur  has  almost  disappeared,  its 
place  being  apparently  taken  by  two  irregular  nodules  of  bone,  together  about  the  size  of 
a  horse-chestnut,  lying  in  the  thickened  synovial  membrane.  The  internal  condyle  is 
remarkably  enlarged,  being  much  flattened  from  side  to  side.  Near  its  inner  and  upper 
surface  is  a  marked  projection  caused  by  the  growing  out  of  the  bone,  and  immediately 
beneath  it  is  a  groove  formed  by  the  friction  of  the  opposed  surface  of  the  head  of  the 
tibia.  The  shape  of  the  lower  end  of  the  femur  resembles  an  enormously  enlarged 
external  malleolus.  At  the  posterior  surface  of  the  internal  condyle  is  a  large  nodular 
outgrowth  of  bone.  This  latter  outgrowth  fits  into  a  corresjionding  cup-shaped  surface, 
formed  by  an  outgrowth  from  the  posterior  surface  of  the  tibia. 

The  tibia  has  undergone  a  compensatory  alteration.  The  inner  part  of  the  head  seems 
to  have  been  rubbed  away  by  the  inner  surface  of  the  condyle,  whilst  the  outer  side  of 
the  head  takes  the  place  of  the  wasted  external  condyle  of  the  femur.  To  such  an 
extent  has  this  occurred,  that  the  plane  of  the  tibio-femoral  articulation,  instead  of  being 
horizontal,  is  almost  vertical ;  whilst  the  only  part  01  the  bones  which  would  serve  as 
a  support  in  standing  is  the  ridge  on  the  femur  and  the  surface  on  the  tibia  which 
corresponded  with  it. 

The  patella  has  undergone  less  alteration  than  the  other  bones,  but  is  irregular  in  out- 
line. Its  articular  surface  is  covered  with  cartUage  in  an  advanced  stage  of  degenera- 
tion, whilst  the  bone  on  this  aspect  is  irregular  and  pitted. 

The  cartilage  has  almost  completely  disappeared  from  the  articular  surfaces  of  the 
tibia  and  femur,  though  patches  remain  on  both  bones.  The  portions  of  cartilage  thus 
left  have  undergone  fibrous  degeneration. 

The  bone  covering  the  articular  surfaces  of  the  tibia  and  femur  is  smooth  and  hard  : 
it  forms  a  continuous  layer,  but  it  has  disappeared  in  other  parts,  and  the  bone  is  also 
pitted  and  irregular,  the  cancellous  tissue  being  exposed  as  in  caries. 

The  development  of  osteophytes  in  the  soft  tissues  surrounding  the  joint  has  taken 
place  to  a  remarkable  extent. 

The  osteophytes  are  infiltrated  in  the  tissues  around  the  ligamentum  patella  and  in 
various  parts  of  the  synovial  membrane  ;  they  are  especially  well  marked  in  the  portion 
which  covers  in  and  protects  the  lower  edge  of  the  elongated  condyle.  The  edge  of  the 
head  of  the  tibia  is  covered  by  the  overhanging  and  irregular  ridges  of  bone  which  are  so 
common  in  museum  specimens  of  osteo-arthritis. 


266  Specimens  added  to  the  Museum 

The  inner  surface  of  the  synovial  membrane  has  developed  villous  outgrowths,  some 
of  whicli  are  calcareous,  whilst  others  are  still  soft,  of  the  kind  ordinarily  found  in  case* 
of  "rheumatoid  arthritis." 

The  shaft  of  the  femur  four  inches  above  the  condyles,  and  the  tibia  at  about  the  same 
distance  below  its  head,  appear  to  be  in  all  respects  normal.  See  Male  Surgical  Register, 
vol.  V.  (1884),  No.  2319.  See  Transactions  of  the  Clinical  Societi/,  vol.  xviii.  (1885),  p,  50, 
and  plates  iv.  and  v. 

Casts  of  the  knee  are  preserved  in  Series  Ivi.  No.  20c,  and  drawings  in  Series  Ivii. 
Nos.  45g — i.     A  section  of  the  cartilage  is  preserved  in  Series  Iv.  No.  53h. 

696a.  A  Patella  and  Knee  (right)  affected  with  rheumatoid  arthritis.  Tlie 
patella  is  small ;  it  has  been  thinned  by  rubbing  to  about  one-third  of 
its  normal  thickness,  and  it  is  eburnated.  Around  it,  especially  beneath 
the  vastus  externus  muscle,  are  osteophytes  of  all  sizes  ;  one  is  as  large 
as  the  patella ;  some  of  the  smaller  outgrowths  are  pedunculated.  On  the 
external  condyle  of  the  femur  is  an  eburnated  surface  corresponding  to 
that  on  the  patella.  An  osteophyte  is  growing  in  a  fringe  of  the  synovial 
membrane  on  the  head  of  the  tibia. 

The  specimen  came  from  the  dissecting-room.  It  was  presented  and  prepared  by 
John  Gay,  Esq. 

712c.  Loose  bodies  removed  from  the  Knee-Joint.    The  bodies  are  synovial 
fringes  thickened  with  caseating  inflammatory  material. 
See  Male  Surgical  Register,  vol.  iii.  (1885),  No.  3544. 


SERIES  III. 

INJUEIES  OF  BONE. 

761b.     Calvarium  showing  gunshot  wound.     (In  Case  H.) 

Patient  survived  ten  days  after  injury  :  a  hernia  cerebri  formed.  See  Male  Surgical 
Register,  vol.  iii.  (1885),  No.  1163. 

796a.  Portion  of  a  Tibia  which  has  undergone  a  comminuted  fracture. 
The  fracture  has  been  partially  repaired,  and  during  the  process  the 
posterior  tibial  vessels  and  nerve  have  become  involved. 

From  the  dissecting-rooms. 

Presented  by  F.  Swinford  Edwards,  Esq. 

807a.  The  Left  Knee-Joint  seventeen  months  after  the  performance  of 
Ogston's  operation  of  chiselling  through  the  internal  condyle  of  the 
femur  for  the  relief  of  genu  valgum. 

The  scar  of  the  operation  was  visible  in  the  skin  and  muscles  at  a  point  about  2^  inches 
above  the  articular  border  of  the  internal  condyle.  The  tibio-femoral  articulation  is 
more  posterior  than  in  a  normal  limb.  The  patella  has  only  a  single  facet  upon  its 
under  surface  ;  it  lies  wholly  upon  the  external  condyle  of  the  femur,  and  is  loosely  con- 
nected by  a  few  inflammatory  adhesions  with  the  upper  part  of  the  external  condyle. 
The  adhesions  do  not  interfere  with  the  movements  of  the  joint. 

The  superior  articular  surface  of  the  tibia  lies  in  a  horizontal  line,  whilst  its  shaft 
is  curved  to  such  an  extent  as  to  render  its  convex  surface  internal.  There  are  two  well- 
marked  ridges  of  bone  along  its  inner  border.  On  raising  the  patella,  the  external  con- 
dyle is  alone  seen  so  long  as  the  leg  remains  extended.  The  outer  margin  of  the  external 
condyle  is  lipped  as  in  chronic  osteo-arthritis,  and  the  cartilage  covering  it  is  pitted  in 
such  a  manner  as  to  resemble  the  pearly  concretions  seen  in  oyster-shells. 

On  flexing  the  leg  and  raising  the  patella,  the  joint  moves  through  an  angle  of  45°. 
Its  further  flexion  is  restrained  by  fibrous  material  in  the  neighbourhood  of  the  crucial 


during  the  Tear  ending  October  i,  1885.  267 

ligaments,  resulting  from  the  matting  together  of  the  ligamenta  mucosa  et  alaria.  The 
internal  condyle  then  comes  into  view.  Its  articular  surface  is  very  much  smaller  than 
that  of  the  external  condyle,  since  the  latter  measures  3I  inches  in  length,  -whilst  the 
articular  surface  of  the  internal  condyle  is  only  i^  inches.  In  no  part  does  the  internal 
condyle  articulate  with  the  patella  ;  it  is  covered  with  smooth  articular  cartilage.  Al- 
though the  articular  surface  is  small,  the  condyle  is  itself  hypertrophied.  It  is  united 
to  the  shaft  of  the  femur  hy  callus,  and  at  its  point  of  union  with  this  bone  there  is 
an  abrupt  raised  line,  as  if  its  base  had  been  pushed  upwards  on  to  the  femur. 

The  condyles  lie  almost  on  the  same  plane,  the  external  being,  if  anything,  rather  the 
lower  of  the  two.  The  inter-condyloid  notch  is  very  wide,  the  increased  width  being 
apparently  due  to  a  new  formation  of  bone,  which  has  filled  up  a  gap  formed  by  a 
forcible  separation  of  the  condyles  as  a  result  of  the  operation.  The  inter-condyloid 
notch  is  occupied  by  synovial  membrane. 

After  reflecting  the  quadriceps  extensor  tendon,  the  subcrureus  muscle  is  seen  to  be 
inserted  upon  the  external  surface  of  the  femur  in  correspondence  with  the  lateral 
deviation  of  the  patella.  The  shaft  of  the  femur  is  bent  antero-posteriorly  with  such  a 
twist  that  its  axis  is  almost  spiral. 

The  femur  of  the  other  leg  exhibited  the  well-marked  and  typical  antero-posterior 
curve  of  rickets.  The  lower  extremity  appears  to  have  undergone  the  same  changes  as 
in  the  preceding  specimen.  The  inner  condyle  is  very  small,  and  there  is  a  well-marked 
line  of  union  showing  where  it  was  separated  at  the  operation.  The  inter-condyloid 
notch  is  unusually  large,  and  the  external  condyle  appears  by  comparison  to  be  of  a 
large  size.     The  patella  articulated  solely  with  the  outer  condyle. 

The  patient,  a  girl  of  21,  died  of  puerperal  mania  in  December  1884.  In  June  1883  she 
was  admitted  to  the  Hospital  under  the  care  of  Mr.  Willett.  At  this  time,  the  knees 
being  placed  together,  there  was  an  interval  of  19I  inches  between  the  two  internal 
malleoli.  On  July  12,  1883,  the  left  inner  condyle  was  separated  from  the  bone  with 
a  chisel ;  during  the  following  month  the  same  operation  was  performed  upon  the  right 
leg.  On  September  7th,  the  malleoli  were  only  separated,  with  the  knees  now  together, 
by  a  space  of  3-4  inches,  and  a  few  weeks  before  death,  eighteen  months  afterwards,  the 
limbs  were  practically  parallel. 

For  further  details  see  a  paper  by  Mr.  "Willett  in  the  St.  Bartholomew's  Hospital 
Reports,  vol.  xx  (1884),  p.  69 ;  and  an  account  of  the  joint  by  Mr.  D'Arcy  Power  in  the 
Transactions  of  the  Pathological  Society,  vol.  xxxvi.  (1885),  p.  345. 
Presented  by  C.  Gross,  Esq. 

879a.     Left  Parietal  Bone  showing  comminuted  depressed  fracture  through 
both  tables.     A  clot  of  blood  was  found  between  the  dura  mater  and 
the  bone. 
From  a  man  who  was  found  unconscious  on  a  railway. 

Presented  by  C.  J.  Heath,  Esq. 

881a.     Skull  of  a  child  showing  a  large   gap  in  the  bones  forming  the 
vault.     The  bones  of  the  skull  are  much  thinned. 

From  a  child  aged  8  months,  who  fell  from  a  window  and  fractured  its  skull.  During 
life  there  was  an  oval  swelling  with  fluid  contents  occupying  the  site  of  the  gap  in  the 
skull.  It  appears  probable  that  the  cavity  of  the  tumour  communicated  with  the  sac  of 
the  arachnoid. 

For  further  details  of  this  case  see  a  paper  by  Mr.  Thomas  Smith  upon  "Traumatic  Ce- 
phalhydrocele  "  in  the  St.  Bartholomew' s  Hospital  Reports  for  1884,  vol.  xx.  p.  233,  Case  I. 

A  drawing  of  the  skull  is  preserved  in  Series  Ivii.  No.  34b. 

892a.     Portion  of  the  Orbit  of  a  child  showing  a  small  punctured  fracture 
of  the  orbital  plate  of  the  frontal.     (In  Case  H.) 

M.  set.  3.  Is  said  to  have  fallen  on  the  pavement  and  injured  his  eye  about  a  month 
before  death.  He  was  admitted  with  symptoms  of  paralysis,  and  died  with  a  cerebral 
abscess.     See  Male  Surgical  Register,  vol.  v.  (1884),  No.  1844. 

898a.     An  incomplete  transverse  Fracture  of  the  Sternum,  through  the 

gladiolus  immediately  below  its  junction  with  the  second  costal  cartilages. 

Patient  fell  from  a  second-floor  window.    See  Surgical  Register,  vol.  v.  (1884),  No.  1849, 


268  Specimens  added  lo  the  diuseiim 

900b,  The  Lung  and  a  portion  of  the  Chest  Wall  of  a  child.  The  heads 
of  the  third,  fourth,  fifth,  and  sixtli  ribs  have  been  separated  from 
their  tubercles.     The  luug  shows  two  large  rents  in  its  posterior  lobe. 

903a.  Apparent  fracture  through  the  acromion  process.  The  fracture  is 
united  by  bone.     (In  Case  H.) 

Presented  by  J.  C.  Hoyle,  Esq, 

930a,     Hand  and  part  of  the  bones  of  the  Forearm,  showing  the  condition 

of  parts  many  years  after  a  Colles'  fracture.     The  upper  end  of  the 

radius  has  been  impacted  into  the  lower  fragment.     The  impaction, 

however,  has  not  been  quite  even,  since  the  outer  edge  of  the  radius 

has  been  driven  farther  upwards  than  the  inner,  i.e.,  that  next  to  the 

ulna.     This  obliquity  of  the  radius  has  rendered  the  ulna  unusually 

])rominent.     The  cuneiform  and  pisiform  bones  are  situated  below  the 

articular  surface  of  the  radius. 

For  a  further  account  of  this  specimen  see  Pathological  Society's  Transactions,  vol. 
XXXV,  p.  272. 

Presented  by  C,  B,  Lockwood,  Esq, 

999a,  The  lower  portion  of  the  Tibia  and  Fibula  with  a  part  of  the 
Astragalus,  showing  the  results  of  a  badly  set  Pott's  fracture  Avhich  had 
occurred  many  years  before  death.  The  articular  surface  of  the  astra- 
galus is  firmly  cemented  by  bone  to  the  tibia.     (In  Case  H.) 

From  the  dissecting-rooms.     Presented  by  J,  Berry,  Esq, 


SERIES  V, 
DISEASES  OF  THE  SPINE. 

1089a,     Vertebrse  from  a  case  of  chronic  osteo-arthritis.     The  two  ver- 
tebrae are  united  by  processes  of  new  bone  which  have  interlocked  upon 
their  left  lateral  aspect.     (In  Case  H.) 
See  Female  Surgical  Register,  vol,  iv.  (1884),  No,  2319. 

1136a.     Fracture  of  the  odontoid  process  of  the  axis. 

From  a  groom  aged  35,  who  had  been  exercising  a  horse,  and  was  found  dead  in  the 
road  without  any  visible  injury  except  a  slight  extravasation  on  the  back  of  the  head. 
Post-mortem  examination  showed  that  the  odontoid  process  had  been  fractured.  The 
lower  part  of  the  medulla  was  destroyed  by  the  pressure,  and  there  was  an  extravasation 
of  blood  into  the  cord. 

Presented  by  H,  Holdrich  Fisher,  Esq, 

SERIES  VI. 
DISEASES  OF  MUSCLES  AND  BURStE. 

TUMOUR. 

1174a,     A  Tumour  of  the  Biceps, 

From  a  woman  aged  62.  The  tumour  was  of  nine  months'  duration.  It  was  pyriform 
and  obtuse  in  shape,  situated  subcutaneously  and  growing  rapidly.     It  was  of  slightly 


during  the  Year  ending  October  i,  1885.  269 

lobulated  and  semifluctuating  and  sarcomatous  nature.     Sctions  are  preserved  in  Series 
Iv.  No.  57c. 

Presented  by  Dr.  George  Wilks. 

1174b.     A  Tumour  of  tlie  Biceps  muscle. 

INTERMUSCULAR  SYNOVIAL  CYSTS. 

1205a.  The  Left  Knee- Joint  and  Calf,  showing  an  intermuscular  cyst 
connected  with  the  joint.  The  knee-joint  has  been  recently  inflamed. 
On  the  outer  side  of  the  spine  of  the  tibia  is  a  passage  along  which 
a  rod  has  been  passed  through  the  ligamentum  posticum  into  a  cyst. 
The  cyst  lies  beneath  the  outer  head  of  the  gastrocnemius  ;  it  is 
pyriform  in  shape,  and  is  possessed  of  a  distinct  cyst -wall.  Its 
upper  border  is  fused  with  the  tendon  of  origin  of  the  outer  head  of 
the  gastrocnemius.  The  plantaris  blends  with  the  inner  wall  of  the 
cyst.  Some  fibres  of  the  gastrocnemius  are  spread  out  over  its  super- 
ficial surface.  The  cyst  is  bounded  below  by  the  tendinous  arch  of  the 
soleus.  On  the  outer  side  of  the  leg  the  cyst  has  burrowed  for  some 
distance,  dissecting  out  the  peroneal  nerve  at  the  point  where  it  turns 
round  the  head  of  the  fibula.  At  this  point  the  skin  had  sloughed, 
and  the  cyst  communicated  by  a  sinus  with  the  exterior.  Near  the 
plantaris,  at  the  back  of  the  joint,  is  a  well-marked  hernia  or  pouch  of 
the  synovial  membrane  of  the  knee. 

From  a  man  aged  44,  a  hawker,  who  had  suffered  from  pain  in  his  joint  for  two  years 
before  his  leg  was  amputated. 
See  Male  Surgical  Register,  vol.  ii.  (1885),  No.  460,  and  (1884)  No.  3643. 

1205b.  The  Left  Knee-Joint  and  Calf,  showing  an  intermuscular  synovial 
cyst.  The  joint  is  completely  disorganised,  the  synovial  membrane  is 
thickened  and  pulpy,  and  has  grown  over  the  articular  surfaces  of  the 
bones.  The  cartilages  are  eroded,  and  their  bones  are  bare  in  places. 
At  the  posterior  surface  of  the  joint  two  openings  are  seen.  The  one 
situated  at  the  back  of  the  internal  condyle  of  the  femur  immediately 
above  the  inner  head  of  the  gastrocnemius  has  received  a  piece  of  brown 
catheter,  which  passes  directly  intO'  the  cavity  of  the  cyst.  It  is  part 
of  a  channel  which  led  from  the  cyst  into  the  connective  tissue  sur- 
rounding the  muscles  at  the  back  of  the  thigh,  and  it  was  cut  across 
during  amputation.  The  second  aperture  is  situated  in  the  tendinous 
inner  head  of  the  gastrocnemius,  and  a  black  catheter  is  passed  through 
it ;  it  puts  the  cyst  into  communication  with  the  posterior  aspect  of 
the  knee-joint.  The  cyst  itself  measures  4"  x  3".  It  appears  to  have 
taken  the  place  of  the  popliteus  muscle. 

From  a  female  aged  22,  who  had  suffered  four  years  from  trouble  with  her  knee. 
For  further  history  and  remarks  on  the  two  preceding  cases  see  Transactions  of  the 
Pathological  Society,  vol.  xxxvi.  (1885),  p.  337,  where  No.  1205a  is  figured  in  plate  xii.(a). 
Presented  by  J.  Langton  Hewer,  Esq. 

1205c.  The  head  of  a  Humerus  which  is  inflamed  owing  to  the  suppura- 
tion of  an  intermuscular  cyst  which  was  situated  beneath  the  teres  minor. 
The  remains  of  the  inflamed  cyst  are  seen  as  a  mass  of  tissue  upon  the 
left  side  of  the  specimen. 


270  specimens  added  to  the  diuseum 

From  a  male  aged  55.  The  specimen  is  described  and  figured  in  Transactions  0/  the 
Pathological  Sociclii,  vol.  xxxvi.  (1885),  p.  337,  and  plate  xii.  fig.  b.  Drawings  are  pre- 
served in  Series  Ivii,  Nos.  45b,  c,  d. 

Presented  by  "William  Morranfc  Baker,  Esq. 


SERIES  VIT. 
DISEASES  OF  THE  HEART. 

1219a.  Heart  and  Lungs  with  part  of  the  Chest  Wall,  from  a  case  of 
pericarditis  following  upon  pysemia.  The  parietal  pericardium  is  much 
thickened  in  part,  and  is  adherent  to  the  left  pleura.  The  heart  is 
covered  with  tlakes  of  recent  lymph.  The  left  lung  is  collapsed,  and 
is  separated  from  the  lower  part  of  the  pleural  cavity  by  firm  bands 
of  adhesion. 

From  a  boy  aged  9,  who  fell  from  a  swing  and  sustained  an  injury  to  his  shoulder. 
For  further  history  and  notes  of  the  case  see  St.  Bartholomew'' s  Hospital  Reports,  vol.  xix. 
p.  271,  "Notes  on  a  Case  of  JPysemia  with  Suppurative  Pericarditis,"  by  Dr.  R.  D. 
JJrinton  and  R.  J.  Collyns,  Esq.,  and  by  Dr.  Samuel  West  in  the  Transactions  of  the 
Pathological  Society,  vol.  xxxv.  p.  104. 

1359a.  A  Heart  with  commencing  aneurysm  of  the  aortic  valves.  The 
left  ventricle  is  much  liypertrophied  and  dilated.  There  is  a  circular 
eroded  patch  about  two  lines  in  diameter  upon  the  anterior  cusp  of  the 
left  auriculo-venticular  valve.  This  patch  is  surrounded  by  granulations. 
There  is  a  commencing  aneurysm  of  this  valve.  The  aortic  valves  are 
quite  incompetent ;  they  are  thickened  and  adherent  at  their  edges  and 
bases.  The  edges  are  jagged. 
For  further  details  see  Post-Mortem  Book,  vol.  x.  p.  97. 

1359b.  First  part  of  the  Arch  of  the  Aorta,  showing  a  commencing 
aneurysm  in  the  sinus  of  Valsalva.  The  arterial  wall  has  undergone 
atheromatous  changes  at  some  distance  above  the  sigmoid  valves. 


SERIES  VIII. 

DISEASES  OF  ARTERIES. 


1512a.  Heart  and  large  vessels,  with  Tongue,  Larynx,  and  Trachea.  The 
right  subclavian  artery  is  dilated  into  two  aneurysmal  pouches.  The 
proximal  is  the  larger  of  the  two,  and  is  almost  filled  with  laminated 
clot.  The  posterior  inferior  wall,  however,  has  given  way,  allowing  it 
to  become  diffuse.  It  presses  upon  the  right  common  carotid  artery, 
and  during  life  simulated  an  aneurysm  of  that  artery.  The  trachea  is 
considerably  flattened,  as  a  result  of  the  pressure  excited  by  the  aneu- 
rysm. The  distal  aneurysm  is  smaller,  and  is  situated  on  the  posterior 
wall  of  the  subclavian;  it  has  been  nearly  obliterated  owing  to  the 
pressure  exerted  by  the  larger  aneurysm. 

See  Female  Surgical  Register,  vol.  iv.  (1884),  No.  650. 

F.  agt.  62.     Suffered  pain  in  right  arm  and  shoulder  for  seven  mouths  previous  to 
death.    A  modified  Tufnell's  treatment  was  adopted. 


during  tlie  Year  ending  October  i,  1885.  271 

1551a.  Iliac  and  Femoral  Arteries,  from  a  case  in  which  the  femoral 
artery  had  been  ligatured  in  its  continuity  in  Scarpa's  triangle.  The 
operation  was  performed  six  years  and  nine  months  before  death,  and 
effected  the  cure  of  a  popliteal  aneurysm.  The  site  of  the  ligature  is 
apparent  just  above  the  second  black  bristle,  and  from  this  point  to  the 
first  bristle  is  a  clot  which  is  decolourised.  Immediately  above  the 
aneurysm  is  another  clot  which  has  not  yet  become  discolourised.  The 
aneurysm  itself  has  become  converted  into  dense  fibrous  tissue.  The 
vessel  is  throughout  calcareous.  It  is  patent  between  the  seat  of  liga- 
ture and  the  cured  aneurysm. 

A  railway  porter.  Aneurysm  of  ten  months'  duration.  It  was  very  large,  filling  the 
■whole  popliteal  space  so  as  to  bulge  out  upon  the  inner  side  of  the  thigh.  The  leg  was 
cedematous,  the  veins  being  varicose.  Esmarch's  bandage  and  digital  pressure  having 
failed  to  effect  a  cure,  the  superficial  femoral  artery  was  tied  with  a  carbolised  silk 
ligature.     Death  resulted  from  pneumonia. 

See  Henry  Ward  Book,  vol.  vi.  p.  396,  and  Medical  Post-Mortem  Book,  vol.  xi.  p.  17. 

1551b.  Iliac,  Femoral,  and  Popliteal  Arteries,  from  a  patient  whose  super- 
ficial femoral  was  ligatured  for  the  cure  of  popliteal  aneurysm  six  years 
before  his  death.  At  the  seat  of  the  ligature  the  vessel  has  become 
converted  for  a  short  distance  into  a  fibrous  cord.  Between  the  point 
of  ligature  and  the  origin  of  the  anastomotica  magna,  however,  the 
femoral  artery  is  pervious  and  apparently  healthy.  It  gives  off  several 
small  branches.  The  aneurysm  is  converted  into  dense  fibrous  tissue. 
Below  the  aneurysm  the  popliteal  is  patent. 

Cf.  No.  1407. 

A  labourer,  aged  49,  who  had  syphilis  eighteen  years  previously.  The  aneurysm  was 
noticed  three  weeks  prior  to  admission,  although  he  had  suffered  pain  in  his  knee  for 
two  years.  An  Esmarch's  bandage  affording  no  relief,  the  artery  was  tied  in  two  places 
with  a  catgut  ligature,  and  divided.  Pulsation  returned  five  months  later,  and  the 
aneurysm  was  cured  by  flexion.  Death  resulted  from  rupture  of  an  intra-pericardial 
aortic  aneurysm. 

See  Henry  Ward  Book,  vol.  vii.  p.  67,  a.nd  Surgical  Post-Mortem  Book  for  1885,  p.  loi. 

1559b.  Portion  of  the  Frontal  Lobes,  showing  plugged  anterior  and 
middle  cerebral  arteries  on  the  left  side. 

The  patient,  a  woman  aged  55,  had  stenosis  of  the  aortic  valvea.  Her  leg  was 
amputated  for  gangrene,  when  the  main  artery  was  found  to  be  plugged.  The  kidneys 
and  spleen  both  contained  infarcts. 

For  further  details  see  Mary  Ward  Book  for  1885  (s.  v.  Mary  Crabh),  and  Surgical 
Post-Mortem  Book  for  1885,  p.  12. 

1571c.  The  Aorta  and  main  Arteries  of  the  left  upper  extremity.  It  will 
be  seen  that  the  artery  is  plugged  from  the  commencement  of  the  sub- 
clavian to  the  termination  of  the  radial  at  the  wrist. 

F.  set.  48.     No  history  of  injury  or  other  cause.     111  three  months. 
See  Female  Surgical  Register,  vol.  ii.  {1884),  No.  742. 


2/2  Specimens  added  to  the  Blasenm 

SERIES  IX. 
INJURIES  OF  A^EINS. 

1608a.  The  Left  Kidney  and  a  portion  of  the  Left  Lobe  of  the  Liver, 
from  a  case  in  wliich  the  riglit  kidney  had  been  removed.  A  Ugature 
has  been  passed  round  the  right  renal  vessels  at  the  point  where  the 
right  renal  vein  opens  into  the  inferior  vena  cava.  A  portion  of  the 
inferior  vena  cava  has  been  included  in  the  ligature.  A  thrombus 
fills  the  entire  vena  cava. 


SERIES  X. 

INJURIES  OF  THE  LARYNX. 

1663a.     Tongue  and  Larynx,  showing  the  common  situation  in  which  the 
throat  is  cut. 

From  an  old  woman  who  cut  her  throat  with  a  razor ;  the  wound  did  not  at  first 
extend  into  the  pharynx,  though  it  did  so  in  the  course  of  a  week  by  a  process  of  ulcera- 
tion.    Death  resulted  from  dysphagia. 

Presented  by  H.  Lewis  Jones,  Esq.,  M.B. 


SERIES  XL 
DISEASES  OF  THE  LUNGS. 

1724a.  Right  Lung  of  a  girl  aged  ii  months.  There  is  a  large  cavity 
in  the  uppermost  lobe.  The  cavity  is  lined  by  a  membrane  and  is 
crossed  by  the  remains  of  a  vessel. 

The  right  lung  contained  several  smaller  cavities.  The  left  was  filled  with  tubercle. 
The  child  had  suffered  from  a  cough  for  more  than  a  month  before  its  death.  It  sud- 
denly developed  symptoms  of  acute  tuberculosis,  and  died  with  meningitis.  The 
peritoneum,  liver,  spleen,  and  kidneys  contained  masses  of  tubercle. 

Exhibited  by  Dr.  Norman  Moore  at  the  Pathological  Society.  See  Transactions  of  the 
Pathological  Society,  vol.  xxxvi.  (1885),  p.  108. 

1724b.     Lung  showing  tubercular  cavities  in  its  upper  lobe. 

See  Male  Surgical  Register,  vol.  iv.  (1884),  No.  647. 

1746a.  Portions  of  the  walls  of  an  Hydatid  Cyst  which  were  coughed  up 
from  the  lungs  of  a  young  woman  who  was  supposed  to  be  phthisical. 

After  expectorating  the  hydatid  membrane  she  made  a  good  recovery. 
Presented  by  S.  J.  Gee,  Esq.,  M.D. 


SERIES  XIL 
DISEASES  OF  THE  TONGUE. 

1788c.     Epithelioma  of  Tongue. 

From  a  woman  aged  35. 

Presented  by  "W.  S.  Savory,  Esq.,  F.Pv.S. 


during  the  Tear  ending  October  i,  1885.  273 

1788d.     Tongue   and   Larynx.      The  tongue   is   excavated   by   a   large 
epitheliomatous  ulcer. 


SERIES  XIII. 
DISEASES  OF  THE  TEETH. 

ISllg.  A  left  upper  Wisdom  Tooth  of  curious  shape,  much  destroyed  by 
caries. 

1811h.  Aright  upper  Wisdom  Tooth  of  remarkably  small  size.  Extracted 
previous  to  the  insertion  of  artificial  teeth. 

TRANSPLANTATION  OF  TEETH. 

18111.  Three  Teeth ;  two  of  them,  the  right  upper  canine  and  left 
upper  second  bicuspid,  had  been  replanted  about  six  or  seven  years  ago, 
and  when  extracted  were  quite  loose  in  their  sockets.    The  third  Tooth  ; 

I  the  left  upper  first  bicuspid,  extracted  at  the  time  of  the  same  opera 
tion  on  account  of  caries,  is  included  in  the  preparation  to  show  tlie 
amount  of  absorption  the  fangs  of  the  first  two  have  undergone. 

Presented  by  William  M.  Gabriel,  Esq. 

1820a,  A  Wisdom  Tooth  on  each  side  of  which  is  an  enamel  nodule. 
The  tooth  has  been  sawn  in  half,  and  in  its  interior,  nearly  opposite  to 
the  smaller  nodule,  is  a  dentinal  nodule,  the  tip  of  which  has  been  un- 
fortunately taken  off  in  preparing  the  section.  The  tooth  was  extracted 
for  pain  of  a  neuralgic  character,  which  had  existed  for  three  or  four 
years. 

Presented  by  "William  M.  Gabriel,  Esq. 


SERIES  XVII. 
DISEASES  OF  THE  STOMACH. 

1919a.    A  piece  of  the  mucous  and  muscular  coats  of  the  Stomach,  showing 
a  small  sessile  polypus. 


SERIES  XVIII. 

DISEASES  OF  THE  SMALL  INTESTINES. 

2007a.  Portions  of  small  Intestines,  showing  the  cicatrices  resulting  from 
syphilitic  ulceration.  The  patches  are  numerous  and  thickened  ;  some 
are  ulcerated  ;  some  show  scar  tissue  and  contraction,  and  some  consist 
of  fresh  connective  tissue. 

An  account  of  the  case  will  be  found  in  the  Pathological  Society's  Transactions,  vol. 
XXXV.  (1884),  p.  233.     The  skull-cap  is  preserved  iu  Series  i.  No.  340U. 

-      YOL.  XXI.  S 


274  Specimens  added  to  the  Museum 

2020a.  A  piece  of  Jejunum,  about  one  foot  from  the  duodenum,  having 
a  mass  of  cancerous  material  situated  opposite  the  attachment  of  the 
mesentery. 

From  a  man  who  had  cancer  of  the  pancreas.     For  further  details  see  Medical  Post- 
Mortem  Book,  vol.  x.  p.  93. 

2032a.     A  Pin  surrounded  by  a  mass  of  hard  faecal  matter,  which  becom- 
ing impacted  in  the  vermiform  appendix,  caused  typhlitis,  perforation 
of  the  intestine,  peritonitis,  and  death. 
For  further  details  see  Male  Surgical  Register,  vol.  v.  (1885),  No.  1311. 


SERIES  XIX. 
DISEASES  OF  THE  LARGE  INTESTINE  AND  ANUS. 

2046a.  Large  Intestine  and  Rectum.  The  whole  extent  of  the  gut  is 
superficially  ulcerated,  the  ulceration  terminating  abruptly  by  a  trans- 
verse line  at  the  lower  part  of  the  specimen. 

From  a  woman  who  had  no  syphilitic  or  tubercular  history,  but  who  had  suffered  from 
symptoms  of  stricture  of  rectum  for  2^  years  before  her  death.  See  Sitwell  Ward  Book 
vol.  viii.  p.  176. 


SERIES    XX. 
HERNIA. 


2099a.  A  piece  of  Intestine  removed  from  a  hernia.  The  intestine  pre- 
sents a  well-marked  stricture,  which  was  situated  at  a  point  3  inches 
from  the  ileo-caecal  valve.  The  mesentery  is  greatly  thickened  as  a 
result  of  chronic  inflammation. 

From  a  case  of  strangulated  hernia,  in  which  reduction  had  been  effected  by  taxis. 
The  patient  subsequently  died  from  a  rupture  of  the  bowel. 

2109a.  A  "  spur  "  of  small  Intestine,  removed  by  an  enterotome  from  a 
case  of  strangulated  femoral  hernia,  which  could  not  be  returned  at  the 
time  of  the  operation  owing  to  the  adhesions  which  the  gut  had  con- 
tracted. 

From  a  woman  aged  55,  who  had  been  ruptured  twenty  years.  The  bowel  was  laid 
open  April  29.  The  enterotome  was  inserted  upon  September  6.  The  enterotome, 
with  the  piece  of  intestine  in  its  blades,  was  removed  on  October  8.  The  patient  was 
discharged,  faeces  passing  per  anum,  on  January  20,  See  Female  Surgical  Register,  vol. 
iv.  (1884),  No.  453. 

2140b.  The  Sac  of  an  Inguinal  Hernia.  The  funicular  portion  of  the 
peritoneum  is  closed  at  the  level  of  the  internal  ring,  but  for  the  rest 
of  its  extent  remains  as  an  open  tube,  into  which  a  black  rod  has  been 
passed.  A  hernia  descending  through  the  internal  ring  has  made  its 
Avay  behind  the  unclosed  funicular  portion.  The  position  of  the  hernial 
sac  (which  has  been  opened  in  front)  is  indicated  by  a  white  glass  rod. 
A  drawing  is  preserved  in  Series  Ivii.  No.  260c, 


during  the  Year  ending  October  i,  1885.  275 

2140c.  An  Inguinal  Hernia  constituting  an  example  of  the  form  described 
by  Hey  as  "encysted."  The  funicular  portion  of  the  peritoneum  is  un- 
closed, except  at  its  upper  extremity.  A  hernial  sac  has  been  formed 
by  the  gradual  invagination  of  the  closed  upper  extremity  into  the 
unobliterated  portion  of  the  funicular  process  of  the  tunica  vaginalis. 

2140d.  An  Inguinal  Hernia  in  many  respects  similar  to  the  foregoing, 
but  differing  in  the  fact  that  the  sac  is  lobulated,  or  divided  by  a  parti- 
tion into  two  separate  portions. 

The   preceding    specimens   were    exhibited  before    the    Pathological    Society.      See 
Transactions  of  the  Pathological  Society,  vol.  xxxvi.  (1885),  p.  216. 

INTUSSUSCEPTION  OF  THE  RECTUM  IN  AN  ADULT. 
2188a.  The  Large  Intestine  is  invaginated  for  about  three  inches ;  it  is 
firmly  bound  down  by  a  contracted  mesenteric  attachment;  the  intus- 
suscepted  portion  cannot  be  drawn  out ;  it  therefore  appears  to  have  been 
of  long  standing.  Above  the  intussuscepted  portion  is  a  small  projec- 
tion which  appears  to  be  the  root  of  a  small  polypus. 

M.  ast.  37.  Labourer,  always  in  good  health.  He  had  an  attack  of  diarrhcea  and 
tenesmus,  but  subsequently  he  was  found  to  be  suffering  from  an  intussusception, 
the  invaginated  portion  being  within  easy  reach  of  the  finger  after  the  hand  had  been 
introduced  into  the  rectum.  On  the  ninth  day  vomiting  and  hiccough  commenced  ;  the 
abdomen  was  tympanitic.  Lumbar  colotomy  was  performed,  but  the  patient  died. 
Presented  by  Dr.  Lanchester. 


SERIES  XXL 
DISEASES  OF  THE  LIVER. 

2198a.     A  Liver  showing  the  effects  of  cirrhosis. 

2217a.  A  Liver  affected  with  diffuse  lympho-sarcoma.  The  gland  is 
uniformly  enlarged,  and  is  nearly  white.  Its  surface  is  smooth.  It 
weighs  40  ounces.     There  were  no  isolated  growths. 

F.  set.  5.  In  perfect  health  until  six  months  before  death.  Tubercle  in  both  lungs. 
Microscopic  examination  showed  the  liver  to  be  infi.ltrated  with  small  round  cells.  The 
glandular  destruction  was  not  so  great  towards  the  centre  as  towards  the  surface,  and 
there  was  a  considerable  amount  of  fibrous  tissue  in  the  central  part. 

A  section  is  preserved  in  Series  Iv.  No.  90I.  See  Transactions  of  the  Pathological 
Society,  vol.  xxxvi.  (1885),  p.  236, 

2237a.     Numerous  small  Hydatid  Cysts  passed  per  anum  by  a  woman. 

223713.  Portions  of  the  wall  of  an  Hydatid  Cyst  with  some  of  the 
intracystic  gro-wths  passed  per  anum  by  a  lad  aged  8  years. 

The  liver  was  enlarged  to  within  i  inch  of  Poupart's  ligament,  and  the  spleen  to  within 
2  inches  of  the  crest  of  the  ilium.  The  patient  suffered  from  jaundice  and  genenil 
wasting.     He  recovered. 

2239a.    Section  of  a  human  Liver  from  a  case  of  actinomycosis. 

Sea  Transactions  of  the  Pathological  Society,  vol.  xxxvi.  (1885),  p.  254. 
Presented  by  S.  G.  Shattock,  Esq. 


276  Specimens  added  to  the  Museum 

SERIES  XXVI. 
DISEASES  OF  THE  THYEOID  GLAND. 

2311a.     Tongue  and  Larynx.     The  thyroid  gland  is  hypertrophied. 

Sections  are  preserved  in  Series  Iv.  No.  90m. 

2314a.  Tongue,  Larynx,  Trachea,  and  Lungs  of  a  child.  A  large  cystic 
growth  of  about  the  size  of  half  an  orange  extends  along  the  left  side  of 
the  larynx.  Tracheotomy  has  been  performed.  The  inner  surface  of 
the  trachea  is  ulcerated.  The  lungs  are  studded  with  several  small 
patches  of  consolidated  tissue. 

From  a  child  .iged  2  years,  in  whom  the  swelling  had  been  noticed  for  twenty-two 
months.  One  week  before  death  Morton's  fluid  was  injected.  The  child  died  of 
br.iiicho-pneumonia.  During  life  the  tumour  extended  backwards  as  far  as  the  pharynx 
and  si>ine,  and  it  was  closely  adherent  to  the  lower  jaw  and  trachea. 

For  further  details  see  Female  Surgical  Register,  vol.  ii.  (1884),  No.  594. 

2314b.  Larynx  and  Trachea.  The  trachea  is  flattened  from  before  back- 
wards by  the  pressure  of  a  large  cystic  tumour  which  was  in  connection 
with  the  isthmus  of  the  thyroid.  The  cyst  is  lined  with  the  remains  of 
a  partially  organised  blood-clot.  Its  walls  are  composed  of  encephaloid 
cancer,  which  is  undergoing  colloid  degeneration. 

From  a  woman  aged  46,  who  died  suddenly  of  asphyxia.  In  the  few  minates  pre- 
ceding death,  the  tumour  was  said  to  have  increased  from  the  size  of  a  walnut  to  that  of 
an  orange.  After  death  it  contained  about  two  ounces  of  recent  blood.  For  further 
details  see  The  British  Medical  Journal,  vol.  ii.  (1884),  p.  20.  A  section  is  iireserved, 
Series  Iv.  No.  90!. 

Presented  by  J.  S.  Hunt,  Esq. 


SERIES  XXYIII. 
DISEASES  OF  THE  KIDNEYS. 

2338a.  Kidney  enlarged  and  in  an  advanced  condition  of  pyonephrosis. 
The  cavities  were  filled  with  inspissated  pus  of  the  consistency  of 
cream-cheese. 

See  Martha  Ward  Book,  1884,  No.  329. 
NEPHROPHTHISIS  IN  ANIMALS. 

2342a.  Portions  of  the  Kidney  of  an  ox  affected  with  tubercular  disease. 
The  kidney  substance  is  completely  changed  into  a  tuberculous  mass, 
whilst  numerous  white  nodules  are  seen  upon  its  surface.  In  some 
parts  of  the  lower  specimen  are  zones  of  more  or  less  completely  calcified 
material.     The  kidneys  were  greatly  enlarged. 

Upon  microscopic  examination,  abundant  groups  of  bacilli  were  found.  The  bacilli 
agreed  in  form,  method  of  staining,  and  size  with  the  bacilli  of  tubercle  in  man.  The 
morbid  changes  correspond  with  the  descriptions  of  Perlsucht. 

This  specimen  was  exhibited  before  the  Pathological  Society, 

Sections  are  preserved  in  Series  Iv.  No.  93c. 


dw'ing  the  Year  ending  October'  i,  1885.  277 

2373a.  Kidneys,  Bladder,  and  portion  of  the  Eectum  of  a  child.  The 
pelvis  and  calyces  of  the  right  kidney  are  dilated,  and  considerable 
absorption  of  the  glandular  substance  has  taken  place.  The  left  kidney 
is  less  altered.  The  ureters  are  dilated  and  pervious.  The  bladder  does 
not  appear  to  be  thickened. 

From  an  infant  aged  14  days,  who  had  an  imperforate  anus.  At  the  autopsy  the 
sigmoid  flexure  was  found  to  be  much  distended :  it  turned  aci'oss  the  sacrum  to  the 
right  side,  and  ended  in  a  blind  dilated  rectum.  The  bladder  contained  a  drachm  of 
healthy  urine.  The  dilated  condition  of  the  kidneys  may  have  been  due  to  the  dis- 
tended and  abnormal  sigmoid  flexure  impeding  the  flow  of  urine  along  the  ureters. 

See  Female  Surgical  Register,  vol.  i.  (1885),  No,  3993. 


SERIES  XXIX. 
DISEASES  OF  THE  URINAEY  BLADDER. 

2404a.     A  dilated  Bladder  with  a  large  number  of  small  saccules,  into 
which  black  bristles  have  been  passed. 
See  Male  Surgical  Register,  vol.  ii.  (1884),  No.  3054. 

2410a.  A  Bladder  which  presents  a  well-marked  pouch.  The  viscus  is 
heart-shaped;  the  left  side  is  thicker  and  smaller  than  the  right;  it  is 
the  true  bladder.  Glass  rods  have  been  passed  through  the  prostatic 
urethra  and  through  each  ureter.  Between  and  below  the  openings 
of  the  ureters  is  a  deep  cul-de-sac,  large  enough  to  admit  the  tip  of  the 
little  finger.  The  right  portion  of  the  bladder  is  the  larger;  it  is  sepa- 
rated from  the  left  by  a  strong  fibrous  band.  The  mucous  membrane 
of  the  whole  organ  is  inflamed,  and  is  in  some  places  ulcerated. 

From  a  man  aged  54,  who  had  suffered  from  bladder  trouble  all  his  life.  Catheters 
were  habitually  employed.  Two  or  three  seconds  after  his  bladder  appeared  to  have 
been  emptied,  an  ounce  or  two  of  pui-ulent  urine  with  a  little  blood  was  expelled  violently 
through  the  catheter.     He  had  no  stone. 

His  bladder  was  shown  at  the  Pathological  Society.  See  Transactions  of  the  Patho- 
logical Society,  vol.  xxxvi.  {1885),  p.  283. 

Presented  by  D.  Mackinder,  Esq.,  M.D. 

2433a.  The  Urinary  Organs  of  a  patient  who  had  numerous  calculi.  The 
left  kidney  contains  a  branched  phosphatic  calculus  in  its  pelvis.  The 
bladder  is  pouched,  a  glass  rod  being  passed  through  the  aperture 
of  communication.  The  portion  which  is  in  direct  connection  with  the 
urethra  contains  a  uric  acid  calculus,  whilst  the  pouch  contains  two 
smaller  stones  of  the  same  nature.  The  prostatic  urethra  is  blocked  by 
a  long  round  calculus,  which  appears  to  be  moulded  to  its  shape,  con- 
sisting chiefly  of  urates  and  phosphates. 

M.  set.  24.  DiflBculty  in  passing  water  for  five  years  ;  catheter  first  passed  two  years 
since  ;  admitted  with  retention  of  urine ;  a  No.  7  silver  catheter  was  passed.  Death 
from  ansemia. 

See  Surgical  Register,  vol.  iv.  (1884),  No.  loio. 


278  Specimens  added  to  the  Blusenm 

SERIES  XXX. 
DISEASES  OF  THE  BRAIN. 

2468a.  A  Tumour  of  the  Cerebellum  involving  the  median  portion  of  its 
under  surface.  It  measured  3^  inches  in  length,  and  widely  separates 
the  two  lateral  lobes.  Anteriorly  it  extends  as  far  as  the  pons,  whilst 
behind  it  reaches  almost  to  the  free  margin  of  the  cerebellum.  Its 
upper  surface  lies  on  the  under  aspect  of  the  median  lobe,  which  it  much 
compressed  and  flattened.  It  grew  from  the  pia  mater.  Examined  by 
the  microscope,  it  was  found  to  be  a  round-cell  sarcoma. 

F.  set.  9.  Suffered  from  violent  attacks  of  vomiting  a  year  before  death.  Double 
optic  neuritis,  partial  blindness,  and  slight  incoordination  of  muscles  in  walking  occurred 
in  August  1884.  In  January  1885  complete  blindness,  but  the  optic  neuritis  has  not 
I)assed  into  atrophy;  vomits  once  a  week;  severe  frontal  headache.  Death  February 
1885. 

On  opening  the  skull,  the  inner  table  in  the  region  of  the  occipital  protuberance  was 
rough,  as  if  from  chronic  osteitis,  but  with  no  adhesion  of  the  dura  mater  ;  on  removing 
I  the  brain,  a  large  quantity  of  cerebro-spinal  fluid  escaped.  The  floor  of  the  third  ventricle 
was  translucent  and  much  expanded  owing  to  the  quantity  of  fluid.  Lateral  ventricles 
enormously  dilated.  Foramina  of  Monro  large  enough  to  admit  the  end  of  the  little 
finger.  Third  and  fourth  ventricles  and  aqueduct  of  Sylvius  enlarged  ;  the  optic  thalami 
about  i;|  inches  apart.  Foramen  of  Magendie  undiscoverable.  The  venae  Galeni  were 
not  pressed  upon  l)y  the  tumour. 

A  section  is  preserved  in  Series  Iv.  No.  103(a). 

Presented  by  J.  L.  Hewer,  Esq. 

2530a.  Sections  through  the  Cerebral  Hemispheres  from  a  case  of  aphasia, 
in  which  the  chief  lesions  were  seated  in  the  supramarginal  and  angu- 
lar gyri,  Broca's  convolution  being  unaffected.  On  the  left  side  of  the 
brain,  corresponding  with  the  whole  extent  of  the  supramarginal 
and  angular  convolutions,  is  a  large  area  of  softening,  which  in  the 
recent  condition  was  considerably  depressed  below  the  level  of  the  rest 
of  the  cortex.  The  colour  was  pale  yellow,  and  the  surface  was  speckled 
with  small  patches  of  white  and  yellow  (fatty  change). 

The  softening  appears  to  have  been  due  to  embolism  of  the  peripheral 
branch  of  the  Sylvian  artery. 

For  further  details  and  history  of  the  case  see  the  British  Medical  Journal,  vol.  i. 
(1885),  p.  1242,  and  the  Medical  Society  s\Proceedings,  vol.  viii.  Photographs  of  the  case  are 
preserved  in  Series  Ivii.  Nos.  3S3(a),  (b),  and  (c). 

Presented  by  S.  West,  Esq.,  M.D. 


SERIES  XXXVI. 
DISEASES  OF  THE  TESTICLE  AND  ITS  COVERINGS. 

2745a.  Hsematocele  of  the  left  Tunica  Vaginalis.  The  testicle  appears 
to  be  healthy.  The  tunica  vaginalis  is  greatly  thickened.  There  is  a 
small  cyst  just  above  the  testis  under  the  tunica  vaginalis. 

M.  set.  60.     The  swelling  had  existed  many  years,  and  had  been  thrice  tapped.     After 
the  second  tapping  there  was  much  pain  ;  after  the  third  tapping  blood  was  drawn  off. 
Presented  by  Stephen  Paget,  Esq. 


during  the  Year  ending  October  i,  1885.  279 

2772a.  A  Testis  which  contains  a  degenerating  gumma  in  its  substance. 
On  the  left  side  is  a  small  testicular  hydrocele. 

Sections  preserved  in  Series  Iv.  No.  119c. 

Presented  by  C.  B.  Lockwood,  Esq. 

2796a.     Sarcoma  of  Testis  with  Hsematocele. 

M.  set.  39.  Patient  received  a  blow  from  a  cricket-ball  upon  his  testis  4I  years  before 
his  death.  The  testis  swelled,  but  subsequently  appeared  to  get  well.  Six  months  later 
the  organ  again  swelled  and  slowly  increased  in  size,  but  without  pain  or  any  impairment 
of  the  general  health.  Three  and  a  half  years  after  the  injury  the  testis  began  to  grow 
rapidly.  It  was  tapped,  and  some  chocolate-coloured  blood  was  removed,  leaving  behind 
a  solid  mass.  Four  years  after  the  injury  castration  was  performed;  at  the  time  of  the 
operation  the  glands  did  not  appear  to  be  infiltrated  and  the  cord  was  not  thickened. 
Two  months  later  the  left  leg  swelled  and  the  iliac  glands  became  enlarged.  A  mass 
subsequently  formed  in  the  pelvis,  and  after  exhibiting  signs  of  intestinal  obstruction 
for  ten  days,  the  patient  died.  Sections  preserved  in  Series  Iv.  No.  121b. 
Presented  by  W.  Harrison  Cripps,  Esq. 

2797c.  A  Testis  infiltrated  with  a  round- celled  sarcomatous  growth.  Iti 
many  parts  the  sarcoma  has  undergone  cystic  degeneration.  It  has 
been  partially  injected. 


SERIES  XLI. 

DISEASES  OF  THE  OVARIES. 

2804c.     An  Ovary  showing  commencing  cystic  degeneration. 


SERIES  XLIIL 
DISEASES  OF  THE  UTERUS. 

2945a.  Anterior  Perimetritis.  A  large  abscess  cavity  is  situated  behind 
and  above  the  bladder  in  front  of  the  uterus  and  right  broad  ligament. 
It  extends  above  the  right  half  of  the  fundus  uteri ;  below  it  passes 
between  the  bladder  and  vagina  to  within  two  inches  of  the  orifice  of 
the  urethra,  and  two  inches  below  the  external  os.  It  is  bounded 
above  by  a  pyogenic  membrane  and  by  the  right  ovary,  which  is  seen  to 
be  much  enlarged.  It  was  suppurating.  The  peritoneum,  which  normally 
lines  these  parts,  has  disappeared  entirely,  and  has  been  replaced  by  a 
pyogenic  membrane.  Some  of  the  structures  of  the  broad  ligament  are 
thereby  exposed,  to  wit,  the  round  ligament  and  a  Fallopian  tube,  which 
form  a  band  crossing  the  upper  part  of  the  cavity.  The  abscess  cavity 
measures  5|-  by  4  inches.  It  has  no  external  openings,  its  walls  being 
everywhere  thick.  The  left  ovary  is  cystic ;  it  is  situated  above  and 
posterior  to  the  left  cornu  of  the  uterus. 

Patient  had  been  ill  since  birth  of  last  child,  20  months  previously.  At  the  examination 
after  death  the  patient  was  found  to  have  general  peritonitis,  lardaceous  spleen,  and  au 
early  stage  of  suppuration  of  bhe  left  kidney,  in  addition  to  the  condition  of  the  genera- 
tive organs  above  described.  For  further  details  see  Martha  Ward  Book,  vol.  vi.  Case 
172,  and  President  Ward  Book,  vol,  s.  p.  118. 


2 So  Specimens  added  to  the  Museum 

2951b.  Retroversion  of  the  Gravid  Uterus.  The  uterus  is  lined  Ly  tho 
decidua  vera. 

From  .a  woman  aged  41,  married  19  j'ears,  in  tlic  eleventh  week  of  pregiinncy.  During 
life  tlie  retroversion  was  reduced  by  the  liand  in  the  vagina  ;  but  tlie  patient  bad  retention 
of  urine.     She  aborted  three  days  before  death. 

2974b.     Calcified  Fibroid  of  the  Uterus. 

Obtained  from  the  dissecting-room.  The  greater  part  of  the  skeleton  of  the  same 
patient  is  preserved  as  a  specimen  of  osteomalacia. 

2976b.  Uterus,  showing  the  site  of  a  fibroid  which  had  been  removed 
two  months  previously. 

See  Martha  Ward  Book,  March  1884  {s.v.  J.  Millard). 

3015a.  A  Myosarcoma  of  the  Uterus.  The  upper  part  of  the  body  of 
the  uterus  is  much  enlarged  by  a  red  vascular,  softened,  and  dilfuse 
growth. 

F.  set.  23.  Married  four  years  ;  one  child  seven  months  before  her  death.  Menor- 
rhagia, followed  liy  dyspnoea  and  haemoptysis,  until  the  patient  became  very  anaemic. 
She  died  suddenly.  At  the  autopsy  the  lumbar  glands  and  lungs  were  found  to  be 
studded  with  new  growths.  A  small  sarcomatous  growth  was  attached  to  the  anterior 
w.ill  of  tlie  vagina,  immediately  behind  the  orifice  of  the  urethra. 

For  further  details  see  Martha  Ward  Book,  November  21,  1883  [s.v.  M.  Church). 

3015b.  Uterus  with  the  placenta  in  sihi,  removed  by  the  utero-ovarian 
Caesarian  operation  of  Porro.  The  placenta  is  adherent  to  the  posterior 
wall  of  the  uterus.  The  rugae  of  the  contractions  of  the  peritoneum 
over  the  contracted  uterus  are  plainly  visible. 

F.,  dwarf,  set.  24,  whose  pelvis  had  been  smashed  when  she  was  four  years  of  age. 
The  conjugata  vera  measured  about  i|  inches.  Mother  and  child  survived.  Nine 
months  after  tbe  operation  the  motlier  appeared  to  be  in  peifect  health.  She  had  not 
menstruated.  The  case  is  published  by  Dr.  C.  Godson  in  tlie  British  Medical  Journal, 
vol.  i.  (1884),  p.  142. 


SERIES  XLVI. 


DISEASES  AND  INJURIES  INCIDENTAL  TO 
GESTATION  AND  PARTURITION. 

3072b.  Uterus  and  Ovaries,  showing  an  early  tubal  pregnancy.  The 
right  Fallopian  tube  is  seen  to  be  dilated  at  a  point  near  to  the  uterus. 
The  sac  measures  f  inch  in  length ;  it  is  thinner  at  its  upper  and  an- 
terior surface,  thicker  posteriorly.  On  its  posterior  surface  is  a  small 
aperture  marking  the  seat  of  rupture.  The  sac  contains  a  little  shreddy 
debris,  which  may  be  the  remains  of  the  chorionic  villi.  The  uterus 
measures  3 J  inches  externally  and  2|  inches  internally.  There  is  a 
decidua  vera,  and  the  cervix  is  plugged  with  mucus.  No  obstructicn 
was  found  in  the  Fallopian  tubes. 

F.  »t.  28,  who  had  missed  one  menstrual  period.     She   was  suddenly  seized  with 
great  abdominal  pain.     When  seen,  she  was  pallid  but  conscious  ;    the  abdomen  was 
slightly  distended  and  tender  ;  the  vagina  was  inverted  round  the  cervix.     The  jiatient 
died  from  hsemon-hage  into  the  abdomen  fifteen  hours  after  the  first  symptoms. 
Presented  by  F.  W.  Strugnell,  Esq. 


during  the  Year  ending  October  i,  1885.  281 

3102b.     The  Parietal  Bones  of  a  child  aged  2^  years,  showing  a  well- 
marked  depression  of  the  outer  table  of  the  left  parietal. 

The  child  was  deliTered  by  forceps,  and  it  is  supposed  that  the  indentation  was  caused 
by  this  means. 
See  Ma7-y  Ward  Book  (1885),  p.  468,  and  Post-Mortem  Booh,  vol.  xi.  p.  355. 


SERIES  XL VII. 
DEFOEMITY  OF  THE  PELVIS. 

3129a.  A  slightly  oblique,  flattened,  rachitic  Pelvis,  from  a  woman  upon 
whom  Porro's  operation  was  performed.  Diameters — Conjugate,  2 
inches ;  transverse,  5  inches ;  right  oblique,  4^  inches ;  left  oblique,  4^ 
inches ;  antero-posterior  of  outlet,  4^  inches ;  transverse  of  outlet,  4 
inches;  posterior  spines,  2  inches;  crests,  9^  inches;  spines,  10  inches. 
Angle,  100°. 


SERIES  XLVIII. 
DISEASES  OF  THE  MAMMARY  GLAND. 

3159a.  An  Adenoma  of  the  Breast.  The  tumour  measures  3x2 
inches.  It  is  a  fine  specimen  of  a  true  adenoma.  It  is  completely 
encapsuled.  Its  anterior  surface  is  roughly  divided  by  a  constriction 
into  two  lobes.  The  larger  of  these  lobes  is  studded  with  nodules  as 
in  a  case  of  "hobnail  liver,"  whilst  the  smaller  is  smooth.  On  making 
a  section  of  the  tumour  whilst  fresh,  it  appeared  pearly  white  like  a 
normal  mammary  gland.     It  did  not  contain  any  cysts. 

The  tumour  was  removed  from  the  pectoral  border  of  the  mammary  gland  of  a  lady 
who  was  four  months  pregnant.  It  had  been  noticed  for  five  months.  Three  months 
before  excision  it  was  so  soft  that  it  appeared  to  be  cystic;  it  was  punctured,  but  no 
fluid  was  withdrawn.  The  father  and  father's  mother  died  of  cancer.  Sections  are  pre- 
served in  Series  Iv.  No.  142a.  See  Transactions  of  the  Pathological  Society,  vol.  xsxvi. 
(1885),  p.  411. 

Presented  by  A.  "Willett,  Esq. 

3181f.  Scirrhus  of  the  Breast,  removed  as  a  slough  after  treatment  by 
caustics. 

The  skin  was  first  destroyed  by  concentrated  nitric  acid,  and  a  paste  of  zinc  chloride 
was  applied  daily  to  the  cancerous  mass.  The  furrows  in  the  slough  are  the  result  of 
incisions  made  to  facilitate  the  action  of  the  chloride  of  zinc.  The  slough  came  away 
five  weeks  after  the  first  application  of  the  nitric  acid. 

Presented  by  Howard  Marsh,  Esq. 

3185c.     Portion  of  a  Breast  aff"ected  with  colloid  cancer. 

F.  eet.   35.     Growth   first  noticed  four  years   previously.     For  further  details   see 
I     Female  Surgical  Register,  vol.  i.  (1884),  No.  1648.     A  section  is  presei-ved  in  Series  Iv. 
No.  153d. 


282  Specimens  added  io  the  Museum 

SERIES  XLIX. 

ATROPHY  OF  THE  BOXE  OF  A  STUMP  AFTER 
AMPUTATION. 

3194a.     The  Head  of  a  Humerus  showing  an  extreme  degree  of  rarefying 
osteitis. 

From  a  man  aged  34,  whose  arm  had  been  amputated  sixteen  months  previously  on 
account  of  gangrene.  The  gangrene  followed  a  CoUes'  fracture.  It  was  found  after 
amputation  that  the  radial  artery  had  been  obliterated  owing  to  a  stab  received  ten 
years  previously. 

See  Surgical  Eegistrar's  Report  (1883),  Appendix,  p.  73. 


.SERIES  L. 
GENERAL  PATHOLOGY. 

3235d.  A  Hand  affected  with  moist  gangrene,  resulting  from  embolism 
of  the  arteries. 

See  Male  Surgical  Register,  voL  i.  (1884),  Xo.  3637, 

3264a.  A  Tumour  removed  from  the  scalp  over  the  left  parietal  bone  by 
a  series  of  ligatures.  The  operation  of  removal  occupied  over  four 
months.     After  removal  it  weighed  2^  lbs. 

The  tumour  consists  of  fibrous  tissue.  It  is  verj'  vascular.  A  section  is  preserved  in 
Series  Iv.  Xo.  ii6b. 

Presented  by  F.  F.  Andrews,  Esq.,  M.D. 

3284a.     A  large  Fibrous  Tumour. 

3294a.  A  Sarcoma  of  somewhat  unusual  shape,  which  grew  beneath  the 
skin  of  the  left  side  of  the  neck. 

F.  aet.  36.  First  noticed  six  months  previously.  Recurrence  took  place  before  the 
wound  healed.  A  drawing  is  preserved  in  Series  Ivii.  No.  556a,  and  a  cast  in  Series  Ivi. 
No.  212(a). 

For  further  details  see  Female  Surgical  Register,  vol.  iv.  (1885),  No.  2362. 

3375h.  A  multilocular  cystic  Tumour  of  Finger.  It  consists  of  soft 
fibrous  tissue  containing  one  or  two  small  cysts. 

J.  "W.,  set.  7.  The  tumour  extended  over  the  first  phalanx  and  over  half  the  second 
phalanx  of  the  left  ring-finger  on  its  dorsal  aspect.  It  measured  an  inch  in  length  by 
half  an  inch  across.  It  rose  about  three-quarters  of  an  inch  above  the  finger.  It  pre- 
sented an  ill-marked  sense  of  fluctuation.  It  was  painless,  and  had  been  noticed  from 
birth. 

Presented  by  Stephen  Paget,  Esq. 


SERIES  LI. 
INSTRUMENTS  PRODUCING  INJURIES. 

3385a.  Stick  which  was  driven  through  the  left  orbit,  fracturing  the 
right  lesser  wing  of  the  sphenoid  and  passing  into  the  right  lateral 
ventricle  of  the  brain. 

See  also  Surgical  Registrar's  Report  for  1883,  Appendix,  p.  78. 


during  the  Year  ending  October  i,  1S85.  283 

3386a.     A  Halfpenny  which  was  passed  per  anum  after  being  swallowed. 

J.  S.,  set.  9,  swallowed  the  coin  at  5.30  p.m.  on  July  27th,  passed  it  at  9  p.m.  oa 
July  29th  ;  he  was  fed  on  figs  and  porridge. 

Presented  by  W.  T.  Strugnell,  Esq. 


SERIES  LIII. 

CALCULI  AND  OTHER  CONCRETIONS  FORMED  IN 
THE  DIGESTIVE  ORGANS. 

274a.  Biliary  Calculi.  The  larger  of  the  two  is  1^  inches  long  and  i 
inch  in  thickness ;  it  is  cylindrical,  and  is  facetted  at  both  ends.  The 
smaller  one  is  broken ;  its  rounded  extremity  fits  into  the  facet  in  the 
previous  one. 

These  calculi  were  passed  per  anum  by  a  woman  who  had  suffered  for  ten  days  previ- 
ously from  constipation.  A.  year  before  passing  these  stones  the  patient  had  an  attack 
of  "congestion  of  the  liver"  with  intense  jaundice,  but  in  the  interval  she  had  been  free 
from  hepatic  trouble.     Weight  3  drachms  and  28  gr;iins. 

Presented  by  G.  H.  Fosbroke,  Esq.,  and  Montague  Smith,  Esq. 

285a.  A  Cast  in  hair  of  the  Stomach  of  a  patient  suffering  from  melan- 
cholia. The  tape  had  passed  through  the  pyloric  orifice,  and  lay  in  the 
duodenum  with  the  calcareous  nodule  at  its  end.  The  entire  mass 
weighs  i2|-  ounces. 

The  specimen  was  found  post-mortem  ;  it  was  not  known  that  the  patient  swallowed 
her  hair. 

Presented  by  M.  Johnston,  Esq. 


SERIES  LV. 
PATHOLOGICAL  MICROSCOPICAL  PREPARATIONS. 

la.  Transverse  Sections  of  the  Rib  of  a  lunatic,  showing  the  dislocation 
of  the  osseous  laminae. 

Illustrating  a  paper  "  Upon  a  Peculiar  Condition  of  the  Bones  of  two  Insane  Patients 
who  had  Fractured  Ribs,"  by  E.  L.  Ormerod,  M.D.,  in  the  St.  Bartholomew's  Hospital 
Jieports,  vol.  vi.  (1870),  p.  65. 

2a.  Chronic  inflammation  of  Hyaline  Cartilage.  The  section  was  pre- 
pared from  the  ulcerated  articular  cartilage  of  a  knee  affected  with 
white  swelling. 

2b.     A  Section  of  Carious  Bone. 

31).     Bone  Cells  from  an  ulcerated  surface. 

Prepared  by  E.  L.  Ormerod,  Esq.,  M.D. 

5b.  Sections  of  the  Femur,  showing  the  repair  which  takes  place  in 
rickets. 

5  c.     Transverse  Section  of  a  decalcified  Rib. 


284  specimens  added  to  the  Museum 

5d.     Transverse  Section  of  a  thickened  Femur. 

Prepared  by  E.  L.  Ormerod,  Esq.,  M.D. 

14a.     Sections  of  a  Periosteal  Sarcoma  of  the  forearm. 

See  Series  i.  No.  441a. 
14b.     Sections  of  an  oval-celled  Sarcoma  of  the  humerus. 

53c.  Sections  of  an  Osteophyte,  from  a  case  of  osteo-arthritis,  Tho 
cartilage  is  becoming  fibrillated. 

53I1.  Sections  of  the  Cartilage  covering  the  lower  articular  surface  of  the 
femur,  from  a  case  of  osteo-arthritis  in  a  patient  who  had  symptoms  ol 
locomotor  ataxv.     The  cartilaginous  matrix  is  fibrillated. 

See  Series  ii.  No.  691b. 

55a.     Muscle  infested  with  trichina  spiralis. 
See  Series  vi.  No.  1176b. 

57d.     Myeloid  Sarcoma  of  the  diaphragm. 

57e.     ^luscle  undergoing  fatty  infiltration. 

64b.  A  portion  of  the  Acromio-Thoracic  Axis,  showing  an  infiltration 
of  the  external  and  middle  coats,  with  a  round-celled  sarcoma. 

A  portion  of  the  axillary  artery  is  preserved  in  Series  viii. 

69a.  A  Section  of  a  Lung  affected  with  croupous  pneumonia. 

71a.  A  Lung  secondarily  affected  with  scirrhous  cancer. 

72a.  Section  of  a  small  Labial  Glandular  Tumour. 

72b.  Section  of  a  Rodent  Ulcer  of  the  nose. 

73h.  A  Xasal  Polypus,  consisting  chiefly  of  connective  tissue,  and  con- 
taining many  blood-vessels;  it  is  covered  by  a  layer  of  columnar 
epithelium. 

78b.  A  Kse'v'us  of  the  tongue.  The  enlarged  vessels  appear  to  be 
situated  in  the  muscular  tissue  immediately  beneath  the  papillae. 

79a.     Sections  of  a  scirrhous  Cancer  of  the  oesophagus. 

See  Series  xv.  No.  1846b. 

DISEASE  OF  THE  PANCREAS. 

83b.     Carcinoma  of  the  pancreas. 

84a.     Myeloid  Sarcoma  of  the  stomach. 

84b.  Cancer  affecting  the  stomach  secondarily.  The  primary  growth  com- 
menced in  the  pancreas. 

Presented  by  H.  L.  Jones,  Esq. 

86a.  Section  through  a  Typhoid  Ulcer  of  the  lower  part  of  the  ileum  at 
tlie  commencement  of  cicatrisation. 

86b.     Portion  of  Intestine  invaded  by  a  growth  of  encephaloid  cancer. 
See  Series  xviii.  No.  2018a. 


during  the  Tear  ending  October  i,  1885.  285 

86d.      Intestine  infested  with  the  ova  of  Bilharzia  hsematobia. 

86e.  Section  through  a  portion  of  Intestine  aflfected  with  syphilitic 
ulceration. 

86f.  Section  through  a  portion  of  Intestine  affected  with  tubercular 
ulceration. 

87f.     Epithelioma  of  the  Rectum. 

90k.     Cirrhosis  of  the  Liver  in  a  patient  who  suffered  from  syphilis. 

901.     Lympho-sarcoma  of  the  liver. 
See  Series  xxi.  No.  2217a. 

90m.     Section  of  Hypertrophied  Thyroid  from  a  case  of  goitre. 
See  Series  xxvi.  No.  2311a. 

90n.     Liver  from  a  case  of  acute  phosphorus  poisoning. 
90o.     Carcinoma  of  the  liver. 

See  Medical  Post-Mortem  Book,  vol.  xi.  p.  42. 

90p.     Endothelioma  of  the  Adrenal. 

9la.     Amyloid  disease  of  the  Kidney. 

92a.     Section  of  a  Kidney  affected  with  interstitial  nephritis. 

93c.     Kidney  of  an  ox  affected  with  bovine  tuberculosis.     The  tubercle 
bacilli  are  well  seen. 
See  Series  xxviii.  No.  2342a. 

100a.     Section  of  a  pigmented  Gliosarcoma  of  the  cerebellum. 

Presented  by  A.  Lyndon,  Esq. 

103a.     A  Eound- celled  Sarcoma  of  the  cerebellum. 
See  Series  xxx.  No.  2468a. 

104d.     Sections  of  the  Medulla  showing  sclerosis. 

From  a  case  of  crossed  paralysis  diagnosed  as  tumour  of  the  pons :  the  patient  Lad 
excessive  reflex  excitability  with  scanning  speech.  Post-mortem  no  gross  lesion  was 
found  in  the  nervous  tract. 

107c.  Section  through  the  Spinal  Cord  in  the  lumbar  region,  from  a 
patient  who  had  osteo-arthritis  associated  with  locomotor  ataxy.  The 
postero-median  columns  have  undergone  a  process  of  degeneration. 

See  Series  ii.  No.  691b. 

lOTd.  Sections  taken  through  the  cervical  portion  of  the  same  spinal 
cord. 

110a.     Tubercle  of  the  Choroid  and  Sclerotic. 

112c,     Portion  of  a  Glioma  from  the  eye  of  a  child. 

The  eye  is  preserved  in  Series  xxxiii. ,  and  a  drawing  in  Series  Ivii. 

112d.  Sections  of  an  Aural  Polypus  :  it  consists  chiefly  of  connective  tissue 
with  a  large  number  of  cells  ;  it  proved,  however,  to  be  malignant. 

113g.     A  Melanotic  Sarcoma  growing  in  the  region  of  the  umbilicus. 


286  Specimens  added  to  the  Museum 

115a.     Epithelioma  of  tiie  forehead  of  a  man. 

116b.     Sections  of  a  diffuse  Fibroma  of  the  scalp. 

See  Series  1.  No.  3264.1. 
119b.     Sections  from  a  Testis  affected  with  tubercle. 

119c.     Sections  of  a  Testis  affected  with  tertiary  syphilis  (gumma). 

See  Series  xxxvi.  No.  2772a. 
121b.     Sarcoma  of  the  Testis. 

See  Series  xxxvi.  No.  2796a. 

123a.  Sections  through  the  skin  of  a  prepuce  affected  with  elephantiasis. 

123b.  Sections  through  a  papilloma  of  the  penis. 

124a.  Carcinoma  of  the  prostate. 

ISOli.  Epithelioma  of  the  cervix  uteri. 

ISOj.  A  Sarcoma  of  the  uterus. 

See  Series  xliii.  No.  30isa. 

142a.  Sections  of  a  true  Adenoma  of  the  breast.  The  tumour  is  com- 
posed of  acini  scattered  irregularly  in  a  matrix  of  delicate  areolar  tissue. 
The  acini  are  separated  by  a  very  small  quantity  of  fibrous  tissue.  In 
the  central  portions  of  the  tumour  the  acini  are  very  numerous,  and  the 
amount  of  areolar  tissue  is  small,  whilst  towards  the  periphery  the  acini 
are  more  widely  separated.  Each  acinus  consists  of  a  tube  with  short 
lateral  diverticula.  The  tubes  are  lined  by  low  columnar  epithelium, 
their  lumina  being  occupied  by  polygonal  cells.  The  lining  epithelium 
has  not  undergone  any  degenerative  change. 

The  tumour  is  preserved  in  Series  xlviii.  No.  3159a. 

142b.     Sections  of  a  Fibroadenoma  of  the  breast. 

142c.     Sections  from  the  central  portion  of  an  Enchondroma  of  the  female 

breast. 
142d.     Section  of  an  Enchondroma  occurring  in  the  breast  of  a  bitcli. 

146g.  Section  of  a  Sero-cystic  Tumour  of  the  breast.  The  epithelium 
lining  the  cysts  is  well  seen.  The  chief  structure  of  the  tumour  is 
connective  tissue  with  numerous  cells,  some  of  which  are  probably 
sarcomatous. 

146h..     Sections  of  a  Chondro-sarcoma  of  the  breast.     It  consists  of  round 
and  oval  connective  tissue  cells  with  some  hyaline  and  fibro  cartilage. 
Drawings  of  the  microscopic  appearances  are  preserved  in  Series  Ivii.  No.  525,  a,  b,  c. 

149b.  Sciirhus  of  the  breast.  There  is  an  unusually  large  quantity  of 
condensed  fibrous  tissue  ;  it  is  an  example  of  the  "  hard  scirrhus  "  of 
Paget. 

153cL     Section  of  a  Colloid  Cancer  of  the  breast. 

See  Series  Iviii.  No.  3185c. 
154b.     A   Section    through    a    Nipple    affected    with    eczema   (Paget's 
disease). 


during  the  Year  ending  October  i,  1885.  287 

156a.     Section  through  scar  tissue  sho"v\-ing  the  process  of  repair  by  first 
intention  (third  day). 

166b.  An  alveolar  Melanotic  Sarcoma. 

171b.  A  Eodent  Ulcer  of  the  nose. 

171c.  A  Rodent  Ulcer  of  the  eyelid. 

176d.  A  Rodent  Ulcer  from  the  pinna  of  the  ear. 


SERIES  LVI. 

CASTS  OF  DISEASED  OR  INJURED  PARTS. 

2d.  Pelvis  and  Lower  Extremities  of  a  girl,  showing  the  deformities  re- 
sulting from  rickets. 

See  Female  Surgical  Register,  voL  ii.  (1885),  No.  1292. 
2e.     The  Leg  and  Foot,  showing  the  effects  of  rickets. 

See  Male  Surgical  Eegi&ter,  vol.  iii.  {1885),  No.  1967a. 

13d.  Casts  of  Fronts  of  Right  and  Left  Legs  of  a  case  of  periostitis  follow- 
ing typhoid  fever.  The  nodes  appeared  on  recovery  from  the  fever,  five 
weeks  before  admission  ;  they  were  accompanied  by  shooting  pain  in 
the  legs.  Rest  and  diet  reduced  them  somewhat  in  three  weeks,  and 
the  patient  was  discharged.  A  week  of  poor  diet  brought  the  nodes  back 
almost  larger  than  before,  and  these  casts  were  taken  on  readmission. 
There  was  no  history  of  syphilis.  Large  doses  of  iodide  of  potassium 
had  no  effect  on  the  tumours. 

20c.  Cast  of  Knee  from  a  case  of  osteo-arthritis  in  a  patient  who  had 
tabetic  symptoms  (Charcot's  disease). 

The  knee  itself  is  preserved  in  Series  ii.  No.  691b. 

20e.     Cast  of  Knee  from  a  case  of  Charcot's  disease. 

The  knee  itself  is  preserved  in  Series  ii.  No.  691c. 

20f.     Cast  of  Knee  affected  with  Charcot's  disease. 

See  Female  Surgical  Register,  vol.  ii.  (1885),  No.  1823. 

20g.     Cast  of  the  Knee  of  a  patient  suffering  from  chronic  osteo-arthritis. 
See  Male  Surgical  Register,  vol.  v,  (1885),  No.  1004. 

23c.     Cast  of  Right  Hand  of  a  patient  affected  with  gout. 

23d.     Cast  of  the  Hands  of  a  patient  affected  with  gout. 

31a.  Right  Foot  and  Leg.  The  seat  of  an  old  Pott's  fracture.  The 
tendo-Achillis  was  divided,  and  osteotomy  of  the  external  malleolus  was 
performed.  The  astragalus  was  also  excised,  and  the  internal  malleolus 
was  separated. 

See  Male  Surgical  Register,  vol.  iii.  (1885),  No.  1044. 

45a.  Cast  of  the  Wrist  of  a  patient  whose  ulna  was  dislocated,  and 
whose  radius  was  fractured  an  inch  above  its  carpal  extremity. 


288  Specimens  added  to  the  Museum 

47a.     Cast  of  the  Pelvis  from  a  patient  with  double  congenital  dislocation 
of  the  hip. 

M.  set.  24.     The  cast  was  taken  whilst  the  patient  was  in  a  recumbent  posture. 

68c.     The  Two  Hands  of  a  woman  who  liad  a  collection  of  fluid  in  the 
sheaths  of  the  flexor  and  extensor  tendons. 
See  Female  Surgical  Register,  vol.  i.  (1885),  No.  849. 

69a.     Cast  of  a  Leg  from  a  man  who  had  a  large  intermuscular  cyst  in 
the  calf  connected  with  the  knee-joint. 

See  Male  Surgical  Register,  vol.  iv.  (1884),  No.  2247,  and  Transactions  of  the  Patlwlogical 
Society,  vol.  xxxvi.  (1885),  p.  340. 

70a.     Cast  of  a  Knee  showing  a  greatly  enlarged  bursa  patellar. 

75a.     Cast  of  a  Foot  with  talipes  calcaneus. 

See  Female  Surgical  Register,  vol.  iii.  (1884),  No.  1811. 

85d.     Cast  of  a  Case  of  Talipes  Equino-varus.     A  portion  of  the  tarsal 
arch  was  subsequently  removed. 

94a.     Foot  of  a  patient  affected  with  Talipes  cavus. 

See  Male  Surgical  Register,  vol.  iii.  (1885),  No.  3739. 

97b.     Casts  of  the  Feet  of  a  patient  with  Talipes  calcaneus  before  and 
after  section  and  suturing  of  the  tendo-Achillis. 

98a.     Cast  of  a  case  of  Aortic  Aneurysm  pointing  through  the  thoracic 
wall. 

The  aneurysm  is  preserved  in  Series  viii.     A  drawing  in  Series  Ivii.  No.  105a. 

102c.     Cast  of  the  Face  of  a  man  showing  a  lateral  deviation  of  the 
septum  of  the  nose. 

144a.     Cast  of  Hand  from  a  patient,  the  fingers  of  whose  right  hand  were 
contracted  after  inflammation.     An  old  wound  of  the  median  nerve 
had  been  followed  by  partial  anchylosis  of  the  phalangeal  joints,  with 
trophic  changes  in  the  skin  of  the  nails  and  muscle.s. 
See  3fale  Surgical  Register,  vol.  i.  (1884),  No.  3336. 

144b.     Cast  of  Hand  from  a  patient  whose  ulnar  nerve  had  been  divided 
eight  months  previously. 
See  Male  Surgical  Register,  vol.  iii.  (1884),  No.  570. 
172d.     Cast  of  the  Hands  of  a  patient  suffering  from  chronic  rheumatism. 

187a.     Cast  of  the  Abdomen  of  a  woman  Mdio  suffered  from  an  ovarian 
cyst.     At  the  level  of  the  umbilicus  the  girth  was  sixty-two  inches. 

Sixty-four  pints  of  dense  ovarian  fluid  were  drawn  off  :  the  cyst  refilled,  and  forty-five 
pints  were  withdrawn  ;  at  a  third  tapping  fifty  pints  were  removed.     Death  resulted 
,,  from  suppuration  of  the  sac. 

212a.      Painted   Cast   of  a   Eound-cell   Sarcoma   growing   immediately 
below  the  lobule  of  the  ear  in  a  young  woman. 

The  sarcoma  is  preserved  in  Series  1.  No.  3294a.    A  drawing  is  preserved  in  Series  Ivii. 
No.  S56a. 


during  the  Year  ending  October  i,  1885.  289 

SERIES  LVII. 
DRAAVINGS  AND  PHOTOGRAPHS. 

31a.     Sarcoma  of  the  Forearm  in  a  child  aged  9  months. 
The  specimen  is  preserved  in  Series  i.  No.  441a. 

34b.     The  Calvarium  of  a  child  aged  8  months,   showing   a  traumatic 
cephalhydrocele. 
The  specimen  is  preserved  in  Series  iii.  No.  88ia. 

39a.  A  Knee-Joint  in  a  state  of  acute  inflammation,  from  a  puerperal 
woman. 

See  Female  Surgical  Register,  vol.  iii.  (1884),  No.  2226. 

39b.     A  Knee-Joint  showing  the  results  of  acute  suppuration. 

40a.     Pulpy  degeneration  of  the  Knee-Joint. 

45b.     The  Poj^liteal  Space,  showing  an  intermuscular  synovial  cyst, 

45c.  The  Posterior  Aspect  of  the  Leg,  showing  an  intermuscular  synovial 
cyst. 

45d.  The  Head  and  Part  of  the  Shaft  of  the  Humerus  from  a  case  of 
arthritis  resulting  from  the  suppuration  of  an  intermuscular  synovial 
cyst. 

The  three  preceding  drawings  illustrate  a  paper  in  the  Pathological  Society's  Transac- 
tions, vol.  xxxvi.  (1885),  p.  335. 
The  specimens  are  preserved  in  Series  vi.  No.  1205a,  b,  and  c. 

45e.     The  Elbow  of  a  patient  showing  an  intermuscular  synovial  cyst. 

45f.  Arm  showing  the  deformity  produced  by  osteo-arthritis  in  a  patient 
with  tabes  dorsalis. 

45g.  Right  Knee-Joint  from  a  patient  aged  50,  the  subject  of  marked 
locomotor  ataxy. 

45h.  The  same  Joint  laid  open  to  show  the  changes  which  have  taken 
place  in  the  bones. 

45i.     Another  view  of  the  same  Joint  laid  open. 

45k.     A  side  view  of  the  same  Joint  laid  open. 

The  preceding  specimen  was  shown  at  the  Clinical  Society.     See  Transactions  of  the 
Clinical  Society,  vol.  xviii.  (1885),  p.  50,  iv.  and  v.  pi. 
The  specimen  is  preserved  in  Series  ii.  No.  691b. 

451.  The  Right  Knee-Joint  of  a  patient  who  suffered  from  osteo-arthritis, 
and  who  had  well-marked  symptoms  of  locomotor  ataxy. 

45m.     The  Left  Knee-Joint  of  the  same  patient. 

The  two  preceding  joints  are  preserved  in  Series  ii.  Nos.  691c  and  d. 

45n,  0.     Drawing  of  various  Joints  with  deposits  of  urate  of  soda." 
VOL.  XXI.  T 


290  Specimens  added  to  the  Museum 

45p,  q,  r.     Knee  and  Ankle  Joints  from  a  case  of  liaemophilia. 

The  joints  are  preserved  in  Series  ii.  Nos.  740b,  c.  d. 

68a.     Back  of  a  Girl  showing  well-marked  lateral  curvature. 

105a.     Aneurysm  of  the  Arch  of  the  Aorta  which  has  ruptured  externally. 

The  specimen  is  preserved  in  Series  viii. ,  and  a  cast  in  Series  Ivi.  No.  98a. 

112b.     An  unusual  form  of  Nsevns. 

172g.     The  Gums  and  Tongue  from  a  case  of  lead-poisoning. 
See  Hope  Ward  Book,  1884. 

175b.  Hypertrophy  of  the  Gums. 

178b.  Cancer  of  the  Tongue. 

187a.  Dyspeptic  Ulcers  of  the  Tongue. 

221a.  Stomach  from  a  case  of  poisoning  by  corrosive  sublimate. 

244b.  A  Photograph  of  Dysenteric  Ulceration  of  the  Intestine. 

260b.     A  Case  of  Strangulated  Hernia  into  the  fossa  intersigmoidea. 

See  British  MedicalJoumal,  vol.  i.  (1885),  p.  1195. 
230c.     A  Case  of  Obturator  Hernia. 

260d.     A  second  Obturator  Hernia  occurring  in  the  same  case. 
See  Transactions  of  the  Pathological  Society,  vol.  xxxiv.  (1883),  p.  109. 

260e.     A  Case  of  Encysted  Hernia,  showing  the  sac  invaginated  into  the 
imperfectly  obliterated  funicular  portion  of  the  tunica  vaginalis. 

See  Transactions  of  the  Pathological  Societj/,  vol.  xxxvi.  (1885),  p.  216.     The  specimen 
is  preserved  in  Series  xx.  No.  2140c. 

260f.     An  Ovary  laid  open.     It  was  found  in  an  inguinal  hernia  in  a 
woman  aged  25. 

260g.  Diaphragmatic  Hernia.     The  greater  part  of  the  transverse  colon 
lay  in  the  thorax. 

2601i.  Ulceration  of  the  Vermiform  Appendix. 
See  Male  Surgical  Register,  vol.  iv.  (1885),  G.  Beale. 

263b.     Condylomata  round  the  anus  of  a  child. 

288a.     Lymphangectasis  in  the  Abdomen  of  a  woman  who  had  a  large 

ovarian  tumour. 
292a.     Photograph  of  a  recent  Splenic  Infarct. 

305g.     The  Face  of  a  Girl  who  had  Addison's  disease. 

324a.     A  Kidney  showing  a  condition  of  acute  pyonephrosis.     The  ureter 
is  blocked  by  a  calculus,  and  several  calculi  are  seen  lying  in  the  sacculi. 
The  specimen  is  presei'ved  in  Series  xxviii. 


during  the  Year  ending  Ocfoher  i,  1885.  291 

329b.  Four  Drawings  of  the  Urine  from  a  case  of  nitric  acid  poisoninc'. 
The  urine  (i)  was  passed  about  20  hours  after  the  nitric  acid  had  been 
swallowed. 

M.,  set.  29,  died  in  loo  hours  after  drinking  ^iof  strong  nitric  acid. 
See  Transactions  of  the  Clinical  Society,  1886. 

335b.     Acute  inflammation  of  the  brain  substance. 

339a.  An  unusual  form  of  Cerebral  Hgemorrhage.  The  bleeding  has 
taken  place  into  the  right  corpus  striatum.  The  straight  sinus  and  the 
left  vena  Galeni  are  plugged. 

From  a  woman  aged  25,  who  was  brought  to  the  Great  Nortliern  Hospital  in  a  coma- 
tose condition,  and  so  continued  until  her  death  five  days  afterwards.  There  was  no 
history  of  injury. 

353a,  b,  c.  Photographs  of  the  Cerebral  Hemispheres  from  a  case  of 
aphasia,  in  which  the  chief  lesions  were  seated  in  the  supramarginal 
and  angular  gyri ;  Broca's  convolution  being  unaffected. 

The  brain  is  preserved  in  Series  xxx.  No.  2530a. 

370a.     A  Section  through  the  Cerebral  Hemispheres  to  show  the  position 
of  the  tumours  in  a  case  of  multiple  sarcoma  of  the  brain. 
See  Transactions  of  the  Pathological  Society,  vol.  xxxvi.  (1885),  p.  120. 

388c.  The  Hands  of  a  patient  whose  left  median  nerve  had  been  divided 
nine  months  previously.  There  are  well-marked  trophic  changes  in 
the  left  hand.     The  right  is  normal. 

392a.  A  Melanotic  Tumour  growing  from  the  left  eye  of  a  child  aged 
2  years, 

395c.  Horizontal  section  of  an  Eye  to  show  a  glioma  springing  from  the 
optic  nerve. 

395d.     A  Melanotic  Sarcoma  growing  from  the  sclerotic. 
See  Eye  Wards'  Register,  1884,  Case  No.  1286. 

402b.  Acne  Keloid  in  a  man  aged  47.  The  disease  had  existed  about 
four  years. 

415b.     Erythema  Multiforme  on  the  arm  of  a  child. 

No.  95  in  Register  of  Skin  Cases  (1880). 

423a,  b.  Two  Photographs  of  a  case  of  Herpes  Zoster  affecting  the  flank. 
The  numbers  refer  to  the  ribs. 

438a.  A  Syphilitic  Ulcer  of  twenty  years'  duration,  occurring  on  the 
radial  side  of  the  carpus. 

The  arm  is  preserved  in  Series  xxxv. 

441a.  The  Arm  of  a  Man  who  was  supposed  to  have  been  vaccinated 
with  lymph  taken  from  a  syphilitic  child. 

441b.    Drawing  of  an  Eruption  which  appeared  in  a  child  after  vaccination. 

465c.     Lupus  Lymphaticus  occurring  in  the  axilla  of  a  young  woman. 


292  Specimens  added  to  the  Museum 

465d.     An  unusual  form  of  Lupus  occurring  on  the  chin  of  a  child. 

See  Female  Surgical  Megister,  vol.  iii.  (1884),  No.  2150. 
470b.     Epithelioma  affecting  the  nose  of  a  man. 

See  Male  Surgical  Register,  vol.  i.  (1885),  [s.v.  F.  Finn). 
470c.     Rodent  Ulcer  affecting  the  nose. 

M.,  »t.  70.     The  ulcer  was  of  25  years'  duration.     See  Male  Suraical  Register,  vol.  ii. 
(1885),  [s.v.  T.  Parsons). 

504a.     Hypertroi)hio  elongation  of  the  Cervix  Uteri  protruding  from  the 
vagina. 

516b.     The  Bladder  and  Uterus  from  a  case  of  serous  perimetritis. 

The  specimen  is  preserved  in  Series  xliii.  No.  2951a. 

517a.     Prolapse  of  vagina. 

See  Female  Surgical  Register,  vol.  iii.  (1885.) 

525a,  b,  c.      Di-awings  of  the  histological  appearances   presented   by   a 
case  of  chondro-sarcoma  of  the  breast. 
A  section  is  preserved  in  Series  Iv.  No.  i46h. 

531c.     Ecze:iia  of  the  left  nipple. 

538d.     A  Moist  Gangrene  of  the  hand. 

See  Male  Surgical  Register,  vol.  i.  (1884),  No.  3637. 

556a.     An  unusual  form  of  Round-celled  Sarcoma,  occurring  at  the  angle 
of  the  jaw  in  a  young  woman. 

A  painted  cast  is  preserved  in  Series  Ivi.  No.  212a.    The  specimen  itself  in  Series  1. 
No.  3294a. 

605a,  b.     Photographs  of  a  Girl  aged  15,  who  had  recovered  from  hip- 
joint  disease,  the  hip  being  anchlyosed  in  a  faulty  position. 

606.  Photograph   of  a  Boy  who  suffered  from  the  effects  of  infantile 
paralysis. 

607.  Photograph  of  a  young  Man  whose  left  shoulder  and  forearm  were 
wasted  as  a  result  of  infantile  paralysis. 


TERATOLOaiOAL  CATALOGUE. 
SERIES  L— ABNORMAL  CONDITIONS  OF  AXIS. 
CLASS  IL— DUPLICITY. 
POSTERIOR  DICHOTOMY. 

3408a.  A  Monstrous  Pig.  The  head  and  neck  and  the  thoracic  organs  are 
single.  Two  forelegs  are  normally  situated,  the  other  two  project 
upwards  from  the  scapular  region.  The  abdominal  organs  are  double, 
and  there  are  two  backbones.     The  hind-quarters  are  distinct. 

Pi-esented  by  Crawford  Duncan,  Esq. 


during  the  Year  ending  October  i,  1885.  293 

SUB-CLASS  II. 
HOMOLOGOUS  UNION. 

3412a.     Portions  of  an  "  attached  foetus." 

The  mass  was  attached  to  the  child,  so  that  it  lay  with  its  long  axis  in  the  same  direc- 
tion as  that  of  the  child.  It  contains  plenty  of  cartilage  and  bone,  which  apps^ir  to  have 
gi'own  from  the  spinous  processes  of  two  of  the  lumbar  vertebrae  of  the  child. 

When  the  specimen  was  fresh,  it  presented  a  rounded  mass  of  skin,  which  appeared 
to  be  a  head.  On  each  border  of  this  rounded  mass  was  a  row  of  tubercles  arranged 
longitudinally,  one  set  appearing  to  represent  the  face,  whilst  a  mass  of  tissue  below  the 
neck  might  be  the  lungs. 

Presented  by  J.  Mason,  Esq.,  M.B. 


TERATOLOGY. 
SEEIES    I.    AND    II. 

ABNORMAL  CONDITIONS  OF  THE  AXIS  AND  LIMBS. 

SPINA  BIFIDA  AND  CONGENITAL  TALIPES. 

3480a.  Tlie  lower  half  of  the  body  of  a  foetus  at  full  term,  with  a 
sloughing  spina  bifida  in  the  lumbo-sacral  region  and  extreme  varus  of 
both  feet.  The  astragalus  of  the  right  foot  has  been  exposed  in  such  a 
manner  as  to  show  that  its  articulating  surfaces  have  become  con- 
siderably modified. 

The  dissection  was  made  by  S.  G-.  Shattock,  Esq.,  who  has  described  the  specimen  in 
the  Transactions  of  the  Pathological  Society,  1884,  Case  6,  vol.  xxxv.  p.  423. 

3488a.  An  adult  Sacrum  in  which  the  spinal  canal  is  unclosed  in  its 
whole  extent. 

Presented  by  E.  V.  Hugo,  Esq. 


SEKIES  II. 
ABNORMAL  CONDITIONS  OF  THE  LIMBS. 

3499a.  A  Supernumerary  Fifth  Toe.  The  base  presents  three  articular 
facets  each  covered  with  cartilage. 

Presented  by  A.  Lyndon,  Esq. 

CLASS  I.— VARIATION. 

(c.)  In  the  Pelvic  Girdle. 

3500a.  The  Os  innominatum.  No  round  ligament  existed  in  either  hip- 
joint  ;  and  in  place  of  the  usual  attachment  of  the  ligament  to  the  head 
of  the  femur  an  elevation  of  bone  existed  :  in  all  other  respects  the 
bones  appear  natural.  It  is  believed  that  the  absence  of  the  ligaments 
was  congenital.     (Case  in  top  gallery.)  A.  155. 


294  SiJecimejis  added  to  /he  Museum 

3508a.  Leg  and  Foot.  The  tibia  is  congenitally  absent.  The  fibula 
articulates  with  the  outer  and  anterior  aspect  ol:"  the  external  condyle 
of  the  femur,  its  head  being  received  into  a  depression  lined  by  articular 
cartilage  and  provided  with  a  distinct  synovial  cavity  which  was  con- 
tinuous with  that  extending  between  the  condyles  beneath  the  patella. 
Both  the  external  and  internal  semilunar  cartilages  were  present,  and 
were  invested  with  synovial  membrane.  Tlie  foot  is  in  a  condition  of 
extreme  equino-valgus. 

See  Darker  Ward  Book,  vol.  ix.  (1883),  p.  108. 


SERIES  III. 

ABNORMAL  CONDITIONS  OF  THE  OSSEOUS  AND 
MUSCULAR  SYSTEMS. 

3522a.     Skull  of  an  adult  European.       The  right  half  of  the  atlas  is 
firmly  ossified  to  the  occipital  condyle.     (Case  in  top  gallery.) 

Presented  by  E.  J.  Woodward,  Esq.,  per  Dr.  Duckworth. 

3524a.     Bony  nodules  in  the  lineae  transversse.     The  small  nodules  appear 
to  represent  rudimentary  abdominal  ribs. 

For  further  details  see  a  paper  by  C.  B.  Lockwood,  Esq.  in  the  Transactions  of  the 
Pathological  ,iccietif,  vol.  xxxvi.  (1885),  p.  359. 


SEEIES  IV. 
ABNORMAL  CONDITIONS  OF  THE  HEART. 

CLASS  v.— ARREST  OF  DEVELOPMENT. 

3601a.  Heart  of  a  Child  aged  3  years.  The  right  ventricle  is  greatly 
hypertrophied,  the  left  being  of  normal  size.  The  tricuspid  and  mitral 
valves  are  natural.  The  pulmonary  artery  is  given  off  normally.  At  its 
root  the  external  measurement  is  barely  a  quarter  of  an  inch.  Internally 
the  valves  are  represented  by  a  small  cone  projecting  into  the  artery, 
with  a  perforation  at  its  apex  no  larger  than  a  medium-sized  pin.  The 
aorta  is  larger  than  natural,  and  measures  three-quarters  of  an  inch  across 
at  its  origin.  The  valves  are  normal.  The  orifice  of  the  aorta  communi- 
cates freely  with  both  ventricles  ;  it  is  exactly  over  a  circular  orifice  at 
the  top  of  the  ventricular  septum,  about  three-quarters  of  an  inch  in 
diameter.     The  foramen  ovale  is  widely  open. 

From  a  child  who  during  life  was  deeply  cyanosed,  with  general  dilatation  of  the 
superficial  veins.  When  the  heart's  action  was  irregular  no  murmur  could  be  heard, 
but  when  it  was  beating  quietly  a  systolic  murmur  was  audible,  which  was  most  distinct 
between  the  left  nipple  and  the  sternum.  The  child  died  with  necrosis  of  all  the  tissues 
of  the  right  cheek,  including  a  small  piece  of  the  superior  maxilla.  The  fingers  and  toes 
were  clubbed. 

A  drawing  is  preserved  in  Series  Ivii.  No.  loia,  showing  the  rash  of  measles  modified 
by  cyanosis. 

See  Transactions  of  the  Pathological  Society/,  vol.  xxxvi.  (1885),  p.  176. 


during  the  Year  ending  October  \,  1885.  295 


SERIES  VI. 

ABNOEMAL  CONDITIONS  OF  THE  DIGESTIVE 

ORGANS. 

CLASS  v.— ARREST  OF  DEVELOPMENT. 

3638b.  Diverticulum  in  small  intestine  about  three  feet  from  the  ileo- 
csecal  valve.  The  diverticulum  is  of  unusual  size,  measuring  nearly  two 
inches  in  length. 


SERIES  VIL 

ABNOEMAL  CONDITIONS  OF  THE  UEINAEY 
OEGANS. 

CLASS  L— VARIATION. 

3651a.     A  Horse-shoe  Kidney. 

3660a.  A  Malformed  Kidney  resulting  from  the  fusion  of  the  two 
organs.     The  arterial  supply  remains  distinct,  and  there  are  two  ureters. 

3660b.  A  single  Kidney,  situated  lower  than  the  usual  position,  as  it 
lies  between  the  two  common  iliac  arteries.  The  kidney  possesses  two 
ureters.  It  derives  its  arterial  supply  from  a  branch  of  the  arteria  sacra 
media.     The  aorta  is  extensively  diseased. 


SERIES  VIII 

ABNOEMAL  CONDITIONS  OF  THE  GENEEATIVE 

OEGANS. 

CLASS  v.— ARREST  OF  DEVELOPMENT. 
3673a.     A  Uterus  Bicorporeus  with  single  cervix 

From  a  patient  aged  40,  mother  of  ten  children. 

Further  details  and  plate  -will  be  found  in  the  Obstetrical  Society's  Transactions,  vol. 
xxvi.  (1884),  p.  i84. 

Presented  by  J.  Matthews  Duncan,  F.R.S. 

3673a.     Deciduous  fleshy  substance,  whole  at  the  time  of  expulsion,  which 
took  place  thirty  hours  after  delivery  of  the  patient,  whose  uterus  is 
preserved  in  the  preceding  specimen. 
A  similar  substance  had  been  voided  at  each  of  the  eight  previous  labours. 


296  Speclinois  added  to  the  Museum 

ANATOMICAL  AND  PHYSIOLOGICAL  CATALOGUE. 

SERIES  VII. 

THE  TEETH. 
135a.     The  Skull  of  a  young  Calf,  to  show  tlie  deciduous  dentition. 

Presented  by  Norman  Moore,  Esq.,  RLD. 

SERIES  VIII. 
(A.)  HUMAN  OSTEOLOGY. 
204a.     Dried  Skull  of  a  Ne\y  Zealand  chief,  tatooed. 

Presented  by  George  Dunn,  Esq. 
(B.)  OSTEOLOGY  OF  ANIMALS. 
331a.     Disarticulated  Skull  of  a  Cod  (Gadus  morrhua).     (In  Comparative 
Osteology  Case,  first  gallery.) 

Presented  by  the  Rev.  E.  C.  Russell,  M.A. 

355a.     Half  the  Skeleton  of  a  Pigeon.     (In  Comparative  Osteology  Case, 
first  gallery.) 

Presented  by  the  Rev.  E.  C.  Russell,  M.A. 
397a.     The  Os  Penis  of  a  Walrus.  xxviii.  173. 

397b.     Sections  of  the  Os  Penis  of  a  Walrus  (Trichecus  Rosmarus). 

xxviii.  174. 
534a.     Transverse  Sections  through  the  Skull  of  a  Rabbit. 
Presented  by  the  Rev.  E.  C.  Russell,  M.A. 


SERIES  XXXI. 

UNIMPEEGNATED  FEMALE  OEGANS  OF 
GENERATION. 

1165a.     Uterus   and   Ovaries   with   the   broad   ligaments   to  show  the 
parovaria,  which  are  stained  with  carmine. 


SERIES  XXXII. 
1251a.     Umbilical  Cord  with  an  unusually  complex  knot  or  series  of  knots. 

Presented  by  C.  B.  Gabb,  Esq. 


SERIES  XXXIV. 

DISSECTIONS  OF  VARIOUS  REGIONS  OF  THE 

HUMAN  BODY. 

1334a.     Four  Frozen  Sections  made  through  the  orbit. 

A.  Suspensory  ligament  of  the  eye  seen  from  above.     The  red  rod  is 

placed  in  the  lachrymal  duct.     The  section  was  made  a  little  below  the 

level  of  the  canthi. 


during  the  Yea7'  ending  October  i,  1885.  297 

B.  Vertical  section  made  through  the  centre  of  the  cornea  and  the  optic 
foramen.  The  wedge-shaped  process,  which  consists  of  the  upper  part 
of  the  sheath  of  the  rectus  and  underneath  part  of  the  sheath  of  the 
levator  palpebrse,  is  indicated  by  a  blue  rod  placed  between  its  layers. 
A  red  rod  is  placed  inside  the  capsule  of  Tenon  just  above  the  suspensory 
ligament.  The  process  which  the  inferior  rectus  sends  to  the  inferior 
oblique  is  pinned  down. 

C.  Horizontal  section  a  little  above  the  level  of  the  canthi.  The  globe 
is  pulled  forward  to  show  the  interior  of  the  capsule  of  Tenon,  and  the 
loose  areolar  tissue,  "  tunica  adventitia,"  has  been  left.  The  blue  rods 
are  placed  beneath  the  check  ligaments  of  the  internal  and  external 
recti. 

D.  A  vertical  section  through  the  centre  of  the  cornea  and  apex  of  the 
orbit.  The  eye  has  been  pulled  out  of  the  capsule  of  Tenon.  The 
"  tunica  adventitia "  has  been  removed  to  show  the  band  of  fibres, 
"intracapsular  ligament,"  which  holds  the  rectus  to  the  wall  of  the 
orbit ;  the  muscle,  owing  to  the  displacement  of  the  sclerotic,  is  bent  as 
it  passes  over  the  ligament.  A  blue  rod  has  been  placed  beneath  the 
slip  which  the  inferior  rectus  sends  to  the  inferior  oblique  muscle. 

1334b.     Two  Specimens  in  long  bottle. 

Upper. — Part  of  a  frozen  section  of  the  orbit.  The  blue  rod  is  placed 
beneath  the  tendinous  origin  of  the  external,  superior,  and  internal 
rectus. 

Lower. — Part  of  an  orbit.  The  red  rod  is  placed  beneath  the  tendon 
of  Zinn. 

These  specimens  illustrate  a  paper  by  C.  B.  Lockwood,  Esq.,  upon  "The  Anatomy  of 
the  Orbit  "  in  the  Journal  of  Anatomy  and  Physiology,  vol.  xx.  (1885),  p.  i. 

Presented  and  prepared  by  C.  B.  Lockwood,  Esq. 


SERIES  XXXVI. 
CATALOGUE  OF  INVERTEBRATA. 

CLASS  11— SCOLECIDA. 

1479a.  Head  and  Proximal  Segments  of  Bothriocephalus  latus.  The 
head  has  a  chink-like  aperture  on  either  side ;  there  are  no  hooks  or 
suckers. 

1483a.  Acephalocyst  hydatids,  rolled  up  and  compressed  in  the  cyst 
which  was  formed  around  them.  Between  their  membranes  are  half- 
dried  portions  of  the  secretions  of  the  walls  of  the  cyst.  The  changes 
here  shown  are  such  as  are  commonly  observed  in  connection  with 
inflammation  of  the  adventitious  cysts  formed  around  hydatids  in  the 
liver  and  other  organs.  B.  4  A. 


298  Speci)ne)is  added  to  (he  Mueum 

SUB-KINGDOM  IV. 
ANNULOSA. 

1524d.     Disarticulated   Lobster   (Homarus  vulgaris).     (In  Comparative 
Anatomy  Case  on  ground  floor.) 

Presented  by  the  Rev.  E.  C.  Russell,  M.  A. 

1524e.     The  ChelsB  of  a  Lobster,  prepared  to  show  the  cliitinised  tendons 
of  the  muscles. 

Presented  by  the  Rev.  E.  C.  Russell,  M.  A. 


SERIES  XXXVIL 

CASTS  AND  MODELS  OF  NOKMAL  STRUCTURES 
AND  CONGENITAL  MALFORMATIONS. 

42a.  A  Painted  Plaster  Cast  showing  the  histological  appearance  of  the 
healthy  skin, 

70a.  Left  Hand  of  a  "Woman  who  had  congenital  absence  of  the  entire 
little  finger  with  an  ill-developed  thumb. 

78a.  Cast  of  the  Hand  of  a  patient  showing  a  supernumerary  little 
linger. 

78b.  Cast  of  the  Foot  of  the  same  patient  showing  a  well  developed 
sixth  toe. 

98.  Cast  of  Hand  and  Forearm  showing  a  congenital  malformation  of 
the  humerus  with  absence  of  the  radius.  The  thumb  is  undeveloped 
and  the  carpal  bones  appeared  to  be  absent  with  the  exception  of  the 
unciform  process. 

See  Female  Surgical  Register,  vol.  iv.  (1884),  No.  2365. 

99.  Cast  of  a  Forearm  in  which  there  was  a  congenital  shortening  of  the 
radius. 

100.  Foot  of  a  Cretin. 

100a.     Hand  of  a  Cretin. 

See  Luke  Ward  Book,  1885,  No.  823. 

101.  A  Cast  of  a  specimen  of  well-marked  hare-lip,  involving  the  upper 
jaw,  showing  a  precanine  incisor  on  the  left  side  of  the  cleft  and  an 
extra  incisor  above  the  first  left  incisor  on  the  right  of  the  cleft. 

From  a  native  of  India  who  died  during  a  famine. 

Presented  by  C.  W.  Cathcart,  Esq. 

102.  Cast  of  Foetal  Head,  showing  the  result  of  passing  through  a  de- 
formed pelvis. 

See  Series  xlvii.  No.  3129(a). 


dui'ing  the  Year  ending  October  i,  1885.  299 

SERIES  XXXVIII 

DRAWINGS  AND  PHOTOGRAPHS  OF  CONGENITAL 
MALFORMATIONS  AND  NORMAL  STRUCTURES. 

29,  A  Virgin  Uterus  at  the  period  of  menstruation. 

30,  30a.     Front  and  Back  Views  of  a  man  who  had  a  remarkable  cartil- 
aginous development  in  his  true  skin. 

See  Male  Surgical  Register,  vol.  iii.  (1885). 

31,  31a,  31b.     Photographs  of  Cretinous  Foetuses. 

The  specimens  are  preserved  in  the  Teratological  Series,  vol.  ii.  Nos.  3492a,  b,  and  c. 


ADDENDA  TO  BOTANICAL  COLLECTIONS,   1885. 

Rosacese. 

POTENTILLA  TORMENTILLA  (TormentU). — Rhizomes,  formerly  used  for 
their  astringent  properties. 

Myristicacese. 

Myristica  officinalis. — The  fruit,  showing  seed  (nutmeg)  and  mace 
(aril). 

Liliacese. 

LiLiUM  auratum. — Aerial  bulbs  on  the  stem,  similar  to  those  usually 
borne  by  Lilium  hulhiferum. 

Graminese. 

Flour. — White  Hungarian  flour  contains  a  large  percentage  of  starch 
with  but  little  gluten,  and  is  the  least  nutritious.  Granular  wheat-meal — 
or  whole  meal  as  ground  by  Dr.  Morfit's  process — contains  the  entire 
ingredients  of  the  grain,  excepting  the  outermost  (fibrous)  skin,  being 
made  from  decorticated  wheat.  This  is  the  most  nutritious  form  of 
wheat-meal. 


APPENDIX. 

Tulip  with  a  pistilloid  perianth. 

Clematis,  fl.  pi.,  with  petals  foliaceous. 

EosE,  with  foliaceous  calyx  and  proliferous,  bearing  a  central  flower- 
bud  in  place  of  the  pistil. 

Pears. — Proliferous    axes  (internodes)  only,    without   a   trace  of    an 
ovary. 

Horse-chestnut,  root  with  embedded  stones. 

PiCEA  LASIOCAEPA  giafied  on  Pkea  pectinata  (Silver  Fir). 


300 


List  of  Prizemen. 
EXAMINATIONS,  1883-84. 


Lawrence  Scholarship  and  Gold  Medal-^ 
S.  H.  Habershon. 
Brackenhury  Medical  Scholarship — 
„     <  A.  H.  Garrod. 
^1-  I  G.  U   Murray. 

Brackenhi?-!/  Surgical  Scholarshij^ — 

W.  T.  H.  Spiceh. 

Senior  Scholarship  in  Anatomy,  Phi/siolor/i/,  and  Chemistri/- 

„      {  W.  G.  Spencer. 

^1-  I  F.  W.  Andrewes. 

Open  Scholarships  in  Science — 
„      I  F.  M.  BROWti. 
^^-  \  J.  G.  C.  Colby. 


JSq. 


H.  G.  Adamson. 
S.  Blackmore. 


Frelimbmry  Scientific  Exhibition — 

2C,        I  J.   WiLKIE. 

^1-     H.  Symonds. 


Jeaffreson  Exhibition— 

S.  WiLKIE. 

Kirkes  Gold  Medal — 

S.  H.  Habershon. 

Bent  ley  Prize — 
A.  G.  Francis. 

Hichens  Prize — 

H.  D.  ROLLESTON. 

JVix  Prize — 

F.  W.  Andrewes. 

Harvey  Prize — 

I. 

2. 
J- 

F. 
W 
C. 

\V.  Eridge-Green. 
.  H.  Hamer. 
H.  Hands. 

4- 
5- 
6. 

W. 
W. 
R. 

H.  R.  Rivers. 
W.  L.  M'Lean. 
Balgarnie. 

PRACTICAL  ANATOMY. 

Senior. 

Junior. 

Foster  P 

•ize- 

2. 

3- 

4- 

5- 

7- 
8. 

9- 

— F.  W.  Eridge-Green. 

M.    C.  MoXHAM. 

0.  C.  P.  Evans. 

M.  Laing. 
j  W.  H.  Hamer, 
1  J.  R.  Mackenzie. 

H.  Deacon. 

F.    He  ASM  AN. 

F.  Englebach. 

Treasure) 

'sf 

^rize 

2. 

3- 

4- 
5- 
6. 

7- 
8. 

lO. 

II. 

— T.  J.  Dabell. 
H.  Huxley. 

T.  J.    LiSSAMAN. 

J.  J.  G.  Colby. 

A.  LncAS. 
A.  G.  Hendley. 
H.  B.  Cardew. 
W.  G.  Williams 

E.  L.  Haynes. 

F.  S.  J.  Lulham 

R.    BlKD. 

List  of  Frizemen. 


301 


EXAMINATIONS,  1884-85. 


Lawrence  Scholarship  and  Gold  Medal — 

W.  G.  Spencer. 

Brackenhury  Medical  Scholarship — 

W.  J.  Gow. 

Brackenhury  Surgical  Scholarship— 

L.  M.  Gabriel. 

Senior  Scholarship  in  Anatomy,  Physiologi/,  and  Chemistry — 

J.   WiLKIE. 

Open  Scholars/lips  in  Science — 
B.  Pierce. 
m     J  E.  P1CKA.RD. 
^^-  \  E.  N.  Reichaedt. 
Preliminary  Scientific  Exhibition — 
R.  G.  Elliott. 
Jeaffreson  Exhibition — 
^^    (H.  G.  Cook. 
^^-  \W.  A.  Murray. 

Kirkes  Gold  Medal— 

W.  J.  Gow. 

Prox.  accessit — W.  G.  Spencer. 

Bentley  Prize — 
A.  M.  Gledden. 
Hichens  Prize — 
E.  H.Hankin. 
Wix  Prize — 
*M.  0.  Mason. 
Harvey  Prize — 


1.  E.  H.  Hankin. 

2.  W.  G.  Williams. 

3.  G.  Heaton. 

4.  J.  G,  E.  Colby. 


Blackman. 
j.  bokenham. 


R.  Bird. 


PRACTICAL  ANATOMY. 

Senior.  Junior. 

Treasurer's  Prize — C.  H.  Roberts. 

2.  H.  G.  Cook. 

3.  D.  T.  Belding. 
(T.  J.  P.  Jenkins. 

^'  tw.  G.  Willoughbt. 

6.  Hansbt  Maund. 

7.  J.  G.  Ogle. 

8.  H.  A.  Sylvester. 
W.  F.  Cholmeley. 
C.  E.  R.  Eendle. 

fC.   PI  HUTT. 

(J.  J.  Macgregor. 
Junior  Scholarships — 

1.  B.  Pierce. 

2.  C.  H.  Roberts. 

3.  R.  Pickard. 


Foster  Prize- 

-C.  S.  Edwards. 

2. 

A.  Lucas. 

3- 

J.  Rust. 

;  W.  N.  Evans. 

4- 

j  T.  J.  LiSSAMAN. 

6. 

W.  B.  Lane. 

\  F.  M.  Brown. 

7- 

1  H.  Symonds. 

9- 

H.  Huxley. 

\  G.  Heaton. 

10. 

I  J.  E.  Spencer. 

9. 

10. 
II. 


ST.  BARTHOLOMEW'S  HOSPITAL  &  COLLEGE. 


THE  MEDICAL  AND  SUKGICAL  STAFF. 

Consulting  Physicians — Sir  G.  Burrows,  Bart.,  D.C.L.,  F.RS., 

Dr.  Farre,  Dr.  Martin. 
Consulting    Surgeons  —  Sir    J.    Paget,    Bart.,    D.C.L.,    LL.D., 

F.E.S.,  Mr.  Luther  Holden. 
Physicians — Dr.  Andrew,  Dr.  Church,  Dr.  Gee,  Dr.  Duckworth. 
Surgeons— Mr.  Savory,  F.Pt.S.,  Mr.  Thomas  Smith,  Mr.  Willett, 

Mr.  Langton,  Mr.  Morrant  Baker. 
Assistant-Physicians — Dr.  Hensley,  Dr.  Brunton,  F.E.S.,    Dr. 

Wickham  Legg,  Dr.  Norman  Moore. 
Assistant- Surgeons — Mr.  Marsh,    Mr.    Butlin,   Mr.   Walsham, 

Mr.  Cripps,  Mr.  Bruce  Clarke. 
Physician-Accoucheur — Dr.  J.  Matthews  Duncan,  F.RS. 
Assistant-Physician- Accoucheur — Dr.  Godson. 
Ophthalmic  Surgeons — Mr.  Power,  Mr.  Vernon. 
Dental  Surgeons — Mr.  Ewbank,  Mr.  Paterson. 
Assistant-Dental  Surgeons — Mr.  Ackery,  Mr.  Mackrell. 
Aural  Surgeon — Mr.  Cumberbatch. 
Administrator  of  Chloroform — Mr.  Mills. 
Casualty  Physicians — Dr.  Haig,  Dr.  Davies,  Dr.  Nias. 
Medical  Registrar — Dr.  S.  West. 
Surgical  Registrar — Mr.  Bowlby. 
Electrician — Dr.  Steavenson. 


Hospital  Staff.  303 


LECTUEES. 

Medicine — Dr.  Andrew,  Dr.  Gee. 

Clinical    Medicine — Dr.  Andrew,  Dr.   Church,  Dr.    Gee,    Dr. 

Duckworth. 
Surgery — Mr.  Savory,  E.E.S. 
Clinical    Surgery — Mr.    Savory,    E.E.S.,   Mr.    Thomas    Smith, 

Mr.  Willett,  Mr.  Langton,  Mr.  Baker. 
Descriptive     and     Surgical     Anatomy  —  Mr.    Langton,     ]\Ir. 

Marsh. 
General  Anatomy  and  Physiology — Dr.  Klein,  E.E.S. 
Histology — Dr.  Klein,  F.E.S. 

Chemistry  and  Practical  Chemistry — Dr.  Eussell,  F.E.S. 
Materia  Medica — Dr.  Brunton,  F.E.S. 
Forensic  Medicine — Dr.  Hensley. 
Public  Health — Dr.  Thorne  Thorne. 
Midwifery  and    the  Diseases  of  Women    and  Children — Dr. 

Matthews  Duncan,  F.E.S. 
Botany — Eev.  George  Henslow. 
Pathological  Anatomy — Dr.  Wickham  Legg. 
Comparative  Anatomy — Dr.  Moore. 
Ophthalmic  Medicine  and  Surgery — Mr.  Power. 
Mental  Diseases — Dr.  Claye  Shaw. 


304  Hospital  Staff. 

DEMONSTKATIOXS. 

MorLid  Anatomy — Dr.  Moore. 

Diseases  of  tlie  Skin — Mr.  Harrison  Cripps. 

Diseases  of  the  Ear — Mr.  Cumberbatch. 

Diseases  of  tlie  Ej^e — Mr.  Vernon. 

Diseases  of  the  Larynx — Mr.  But! in. 

Orthopaedic  Surgery — Mr.  Walsham. 

Practical  Surgery — Mr.  Butlin,  IVIr.  Walsham. 

Practical  Anatomy  and  Operative  Surgery — Mr.  Bruce  Clarke, 

Mr.  C.  B.  Lockwood,  Mr.  Jessop. 
Assistant-Demonstrators — Dr.    Herringham,  Dr.  Collins,   Mr. 

Berry. 
Mechanical  and  Xatural  Philosophy — Mr.  F.  Womack. 
Practical  Physiology — Dr.  V.  D.  Harris. 
Assistant-Demonstrators — Dr.  Tooth,  Mr.  Shore. 
Chemistry — Dr.  Armstrong,  E.E.S. 
Medical  Tutor — Dr.  S.  West. 
Assistant-Medical- Tutor — Dr.  Ormerod. 
Tutor  in  Midwifery — Mr.  W.  S.  A.  Griffith. 
Curator  of  the  Museum — Mr,  D'Arcy  Power. 

COLLEGIATE  ESTABLISHMENT. 
Warden — Dr.  Noeman  Moore. 

Students  can  reside  within  the  Hospital  walls,  subject  to 
the  College  regulations. 

Ten  Scholarships,  varjmig  in  value  from  £20  to  .^130,  are 
awarded  annually. 

Fm'ther  information  respecting  Scholarships,  Pujjils'  Ap- 
pointments, and  other  details,  may  be  obtained  from  Dr. 
Xorman  Moore,  and  at  the  Museum  or  Library. 


ST.  BARTHOLOMEW'S  HOSPITAL  REPORTS. 

YOLUME  XXL 


INDEX. 

Abscess,  cerebral,  from  a  fall,  witli  optic  neuritis,  228. 
„         in  thigh,  after  typhoid  fever,  115. 
,,         of  liver,  with  parametritis,  173. 
„         parotid  in  typhoid  fever,  112,  114. 
Abscesses,  abdominal,  242. 
Agoraphobia,  its  cause,  5. 
Alum-whey  in  typhoid  fever,  117. 
Anaemia  of  the  brain  in  the  insane,  12. 
Anatomy,  topographical,  of  the  spinal  cord,  137. 
Andrewes,  Mr.,  on  glycogen,  239. 
Aneurysm  of  aorta,  abdominal,  220. 

„  „     _    dissecting,  215. 

„         thoracic,  219. 

,,  „        treated  on  Tufnell's  system,  220,  222. 

„         pulmonary,  52,  54,  55,  57. 

„  „  cure  of,  57. 

,,  ,,         facts  connected  with,  52. 

Ankle-joint,  synovial  cyst  in  communication  with,  187. 
Aorta,  aneurysm  of.      See  Aneurysm. 
Aortic  obstruction,  case  of,  90. 
Ataxia,  locomotor,  with  abnormal  symptoms,  97. 

Bacillus  of  tubercle  in  tumours  of  the  larnyx,  40,  43,  44. 

„  ,,        present  in  old  specimens  of  lung  disease,  45. 

Baker,  Mr.,  on  abnormal  synovial  cysts  in  connection  with  joints,  177. 
Bilharzia,  length  of  life  in  man,  91. 

„  ova  and  embryo,  cases  of,  90. 

,,         situations  of  the  ova,  92. 

,,         use  of  santonin  in  the  treatment  of,  92. 

„         vesical  calculi  due  to,  91. 
Blindness  following  optic  neuritis,  225,  228.  .     . 

VOL.  XXI.  U 


306  Index  to  Vol.  XXL 

Blood,  condition  of,  in  coal-gas  poisoning,  78. 

Blood-letting,  its  utility  in  various  diseases,  243. 

Body,  rate  of  cooling  of,  after  death,  252. 

Bones,  metacarpal,  with  bosses  in  lead-poisoning,  169. 

Boro-glyceride  as  a  remedy  in  pruritus,  119. 

Bosses  on  the  metacarpal  bones  in  lead-poisoning,  69. 

Breath  sounds  in  health  and  disease,  191. 

Brinton,  Mr.,  on  blood-letting,  243. 

Bubo,  parotid,  in  typhoid  fever,  112. 

Bullar,  Dr.,  on  the  breath  sounds  in  health  and  disease,  191. 

Butlin,  Mr.,  on  some  diseases  of  the  larynx,  145. 

Calculi  in  cases  of  bilharzia,  89,  91. 

,,      of  uric  acid,  89. 
Calculus,  renal,  122,  126. 
Casualty  department,  variola  in,  131, 
Catalepsy  in  the  insane,  20. 

Cavities  in  the  lung,  effect  on  the  respiratory  sounds,  201. 
Church,  Dr.,  cases  from  his  wards,  211. 

,,  note  on  the  Six  Gifts  of  Theophilus  Philauthropos,  231. 

Coal-gas  poisoning,  artificial  respiration  in,  74. 

,,  „         coma  in,  76. 

,,  ,,         condition  of  the  blood  in,  78, 

pupils  in,  77 

„  ,,         inhalation  of  oxygen  in,  74,  78. 

,,  ,,         percentage  of,  in  air  to  produce  symptoms,  75. 

,,  „         three  cases  of,  73. 

Cocaine,  its  action  on  the  eye,  237. 
Collins,  Dr.,  on  cocaine,  237. 

„  physiognomy  and  phrenology — what  are  they  worth  1 

244. 
Collyns,  Mr.,  on  optic  neuritis,  238. 
Coma  in  coal-gas  .poisoning,  76. 

„      its  definition,  causes,  &c.,  249. 
Combes,  Mr.,  on  quacks  and  quackery,  248. 

Consolidation  of  the  lung,  its  effect  on  the  respiratory  sounds,  200. 
Copaiba  rash  simulating  variola,  136. 
Crouch,  Mr.,  on  mesmerism,  245. 
Cysts,  abnormal  synovial,  in  connection  with  joints,  177. 

Death,  rate  of  cooling  of  body  after,  252. 

Decubitus,  sacral,  140. 

Diarrhoea,  infantile,  242. 

Diphtheria,  method  of  removing  membrane  from  trachea  in,  84. 

Duckworth,  Dr.,  clinical  contributions  to  practical  medicine,  105. 

Elbow-joint,  synovial  cyst  in  connection  with,  184,  185. 
Enteric  fever.     See  Fever,  typhoid. 


Index  to  Vol.  XXI.  307 

Epileptics,  suicide  in,  3,  7. 
Epithelioma  of  ala  of  nose,  151. 

J,  pelvis  of  kidney,  127,  129. 

Expectoration,  its  desirability  in  lung  disease,  120. 

Faradisation  in  typhoid  fever,  107. 
Fat,  free,  in  urine,  117. 
Femur,  osteotomy  of,  65. 

„       re-fracture  of,  68. 
Ferguson,  Dr.,  on  the  nature  and  origin  of  rodent  ulcer,  loi. 
Fever,  enteric.     See  typhoid. 

„     typhoid,  abscesses  in  thigh  after,  115. 

,,  ,,        faradisation  in,  107. 

,,  ,,        followed  by  bacillary  phthisis,  115. 

,,  ,,        hsematuria  in,  105. 

,,  .,        haemorrhage  in,  109. 

,,  .,        loss  of  speech  in,  106. 

.,  ,,        parotid  abscess  in,  112,  114. 

,,  ,,  ,,       bubo  in,  112. 

,,  „        passage  of  lumbrici  in,  109. 

,,  ,,        periostitis,  following,  107. 

,,  .,        use  of  alum-whey  in,  115. 

,,  .,  „     malt  extract  in,  117. 

,,  ,,        with  special  symptoms,  iii. 

,,  ,,        stools,  green,  in,  no. 

Fright  followed  by  somnambulism,  63. 

Gangrene,  its  causes,  246. 

Garrod,  Dr.,  some  cases  of  sclerosis  of  the  spinal  cord,  93. 
Gee,  Dr.,  memoir  of  Francis  Harris,  M.D.,  xxxiii. 
Glycogen,  its  synthesis  and  its  utilisation,  239. 

Habershon,  Dr.,  the  after-treatment  of  tracheotomy,  79, 
Hsematuria  in  enteric  fever,  105. 

,,  two  cases  of  parasitic,  89. 

Haemoptysis,  due  to  pulmonary  aneurysm,  52. 

„  „       ulceration  of  the  walls  of  the  pulmonary  vessels, 

53- 
,,  intermittent,  54,  56,  57. 

„  pathology  of,  51. 

,,  profuse  non-fatal,  51. 

,,  relative  frequency  of,  in  the  different  sexes,  52. 

remittent,  53,  54,  55,  56,  57. 
suffocative,  53,  54,  55,  57. 
Haemorrhage  in  typhoid  fever,  109. 
,,  into  spinal  cord,  140. 

Haig,  Dr.,  variola  as  seen  in  the  casualty  department,  131. 


3o8  Index  to  Vol.  XXL 

Harris,  Dr.,  on  the  presence  of  the  tubercle  bacillus  in  old  specimens 
of  diseased  lung,  45. 

Heart,  weak  or  irregular  action  of,  in  the  insane,  16. 

Hemiplegia  from  cerebral  abscess,  230. 
„  functional  and  organic,  238. 

Herpes  zoster,  symmetrical,  119. 

Herringham,  Dr.,  a  case  of  mental  disturbance  after  operation,  165. 

„  a  case  of  lead-poisoning  with  bosses   on  the  meta- 

carpal bones,  169. 

Hip-joint,  synovial  cyst  in  connection  with,  186. 

Homicide  in  imbeciles,  4. 
„        in  the  insane,  2. 
,j  J,    melancholic,  7. 

Imbeciles,  homicide  among,  4. 

,,  suicide  among,  4. 

Impulses,  destructive,  on  the  forecast  of,  in  the  insane,  i. 
Injuries  and  diseases  of  the  spinal  column,  258. 
Insane,  catalepsy  in,  20. 

„        general  paralysis  of,  cases  resembling,  23. 

„         heart  disease  in,  12. 

„        the  destructive  impulses  in  the,  i,  16. 
Intracranial  disease  with  optic  neuritis,  223. 

Jessop,  Mr.,  on  germiculture,  252. 

Joints,  abnormal  synovial  cysts  in  connection  with  the,  177. 
„       injuries  in  and  about,  251. 

KiDD,  Dr.,  note  on  tuberculous  tumours  of  the  larynx,  37. 
Kidney,  epithelioma  of  pelvis  of,  125,  127. 

„       removal  of,  121. 

„  „  stone  from,  126. 

Klein,  Dr.,  on  the  aetiology  of  cholera,  260. 

Lankesteb,  Mr.,  on  infantile  diarrhoea,  242. 

„  ,,  re-fracture  of  the  femur,  68 

Larynx,  department  for  diseases  of  the,  145. 

,,       tuberculous  tumours  of,  37. 
Lead-poisoning  with  bosses  on  the  metacarpal  bones,  169. 
Legg,  Dr.,  introductory  address  to  the  Abernethian  Society,  237. 
Liver,  abscess  of,  with  parametritis,  173. 
Lockwood,  Mr.,  on  syphilis,  240. 
Locomotor  ataxia.     See  Ataxia. 
Lumbrici,  passage  of  many,  in  typhoid  fever,  109. 
Lung  disease,  desirability  of  expectoration  in  certain  forms  of ,  120. 
„  old  specimens  of,  containing  tubercle  bacUli,  45. 


Index  to  Vol.  XXI.  309 

Malleolus,  external,  ganglionic  swelling  over,  187. 

Malt  extract,  use  of,  in  typhoid  fever,  117. 

Mania  after  injury  to  the  hand,  166. 

Medicine,  clinical  contributions  to  practical,  105. 

Melancholia,  suicide  and  homicide  in,  7, 

Meningitis,  chronic,  with  optic  neuritis,  223,  225,  228. 

Mental  disturbance  after  operations,  165. 

Mesmerism,  245. 

Moore,  Dr.,  The  Book  of  the  Foundation  of  St.  Bartholomew's,  xxxix. 

„  two  cases  of  parasitic  haematuria,  89. 

Morton,  Mr.,  notes  of  three  cases  of  coal-gas  poisoning,  with  remarks 

on  the  symptoms,  as  illustrated  by  these  and  other  cases,  73. 
Muscles,  electrical  condition  of,  in  sclerosis,  95,  96. 

ISTares,  sarcomatous  polypi  of,  148.  ' 
Naso-pharynx,  adenoid  vegetations  in,  152. 
Nephrectomy  for  calculous  pyelitis,  121. 
ISTephro-lithotomy  in  calculous  pyelitis,  125. 
Nervous  disorder,  five  cases  of,  59. 
Neuritis,  optic,  cases  of,  223,  238. 

„  „     followed  by  total  blindness,  225,  228. 

„  „     with  cerebral  abscess,  228. 

„  „     with  chronic  meningitis,  225,  228. 

Nose,  epithelioma  of  ala  of,  151. 
Nose,  feeding  through,  in  tracheotomy,  81. 

,,       papilloma  of  septum  of,  150. 
Nostril,  osseous  outgrowth  of,  147. 

Opeeations,  mental  disturbance  after,  165, 

Optic  neuritis.     See  Neuritis. 

Ormerod,  Dr.,  cases  resembling  general  paralysis  of  the  insane,  23. 

Osteotomy  for  mal-union  of  the  femur,  65. 

Outgrowths,  osseous,  of  the  nostril,  147. 

Oxygen,  inhalation  of,  in  coal-gas  poisoning,  74,  78. 

Paget,  Mr.,  on  abdominal  abscesses,  242. 
Papilloma  of  the  septum  of  the  nose,  150. 

,,  „       trachea,  147. 

Paralysis  agitans,  tremors  of  legs  and  arms  resembling,  61. 

„        cases  resembling  general  paralysis  of  the  insane,  23. 
Parametritis  with  abscess  of  the  liver,  173. 
Paraplegia  and  paraneesthesia,  140. 

„         sacral  decubitus  in,  140. 

„         with  jumping  movements  after  shock,  62. 
Parotid  abscess,  114. 

„       bubo  in  typhoid  fever,  112. 
Periostitis  following  typhoid  fever,  107. 


3 1  o  Index  to  Vol.  XXI. 

Philantbropos,  TbcopLilus,  his  Six  Gifts,  231. 

Phrenology  and  physiognomy — what  are  they  worth  1  244. 

Phthisis,  baciHary,  after  typhoid  fever,  115. 

Pliysiognoniy  and  plirenology — what  are  they  worth  ?  244. 

Pneumonia,  local,  in  tracheotomy,  80. 

Poisoning  by  c<ial-gas,  three  cases  of,  73. 

Polj-pi,  sarct)matous,  of  nose,  148. 

Pruritus,  boro-glyceride  in,  119. 

Pulsus  paradoxus,  87. 

Pupils  in  coal-gas  poisoning,  77. 

„      irregularity  of,  with  external  strabismus  and  hysterical  stupor, 

59- 
Pyelitis,  calculous,  nephrectomy  for,  121. 

„  ,,  nephro-Iithotomy  in  a  case  of,  125. 

Quacks  and  quackery,  248. 

Re-feacture  of  the  femur,  68. 

Renal  surgery,  two  contributions  to,  121. 

Ptodent  ulcer,  its  nature  and  origin,  10 1. 

,,  ,,       microscopical  characters  of,  102. 

Eoughton,  Dr.,  parametritis  and  abscess  of  the  liver,  173. 
,,  ,,     on  coma,  249, 

Saceal  decubitus  in  paraplegia,  140. 
Santonin,  its  uses  in  cases  of  bilharzia,  92. 
Sclerosis  of  spinal  cord,  93. 

,,        with  unilateral  tremors,  94. 
Shaw,  Dr.  Claye,  on  the  forecast  of  destructive  impulses  in  the  insane,  i. 
Shock  followed  by  paraplegia  and  jumping  movements,  62. 
Shore,  Mr.,  on  hemiplegia,  238. 

Shoulder-joint,  .synovial  cyst  in  connection  with,  180,  183. 
Somnambulism  following  fright,  63. 
Sounds,  respiratory,  the  place  of  their  origin,  192. 
Speech,  loss  of,  in  typhoid  fever,  106. 
Spicer,  Mr.,  osteotomy  of  the  femur,  65. 
Spinal  column,  injury  and  disease  of,  258, 
Spinal  cord,  cases  of  sclerosis  of,  93. 

,,  ,,     crushing  of,  140. 

,,  ,,     htemorrhage  into,  140. 

.,  ,,     method  of  microscopical  examination  of,  141. 

,,         ,,     mixed  tract  of,  138, 

,,  ,,     topographical  anatomy  of,  137. 

,,  symptoms  in  typhoid  fever,  iii. 

Spine,  concussion  of,  259. 

„      fracture  of,  259. 

„  „         with  dislocation,  140. 


Index  to  Vol.  XXI.  3 1 1 


Strabismus,  external,  with  hysterical  stupor,  59. 

Steedman,  Mr.,  on  gangrene,  246. 

Stupor,  hysterical,  with  external  strabismus,  59. 

Stools,  green,  in  typhoid  fever,  no. 

Styan,  Dr.,  cases  from  Dr.  Church's  wards,  211. 

Suicide  among  epileptics,  3,  7. 

„       in  imbeciles,  4. 

„       „  melancholia,  7. 

„       ,,  the  insane,  2. 
Surgery,  renal,  two  contributions  to,  121. 
Synovial  cysts  in  connection  with  joints,  177. 


Theophilus  Philanthropos,  his  Six  Gifts,  231. 

Theory  of  the  respiratory  sounds,  196. 

Thorax,  the  artificial,  191,  207. 

Tooth,  Dr.,  a  contribution  to  the  topographical  anatomy  of  the  spinal 

cord,  137. 
Trachea,  method  of  removing  membrane  or  mucus  from,  84. 

„        papilloma  of,  147. 
Tracheotomy,  cases  illustrating  the  after-treatment  of,  81-87. 
„  cause  of  local  pneumonia  in,  80. 

„  feeding  through  the  nose  in,  81. 

„  the  after-treatment  of,  79. 

Trance,  condition  of,  after  an  operation  for  hernia,  166. 
Tremors,  hysterical,  61. 

„         of  the  legs  and  arms  resembling  paralysis  agitans,  61. 
„         unilateral,  in  sclerosis,  94. 
Trismus  after  nephro-lithotomy,  125. 
Tubercle  bacillus.     See  Bacillus. 
Tumours,  tuberculous,  of  larynx,  37. 
Typhoid  fever.     See  Fever,  typhoid. 


Ulcer,  rodent,  microscopical  characters  of,  102. 

,,  nature  and  origin,  loi. 

Ulceration  of  the  pulmonary  vessels,  53,  58. 
Uric  acid  calculi,  89. 

Urine,  charts  of  the,  in  calculous  pyelitis,  124,  127. 
„       free  fat  in,  117. 


Varicella,  distinction  of  the  rash  from  variola,  136. 
Variola  as  seen  in  the  casualty  department,  131. 
Vegetations,  adenoid,  of  naso-pharynx,  152, 
Vertebrae,  dorsal,  fracture  and  dislocation  of,  140. 
„         eroded  by  aneurysm  of  aorta,  219. 


312  Index  to  Vol  XXI. 

Wallis,  Mr.,  on  injuries  in  and  about  joints,  251. 
Walsbam,  Mr.,  two  contributions  to  renal  surgery,  121. 
West,  Dr.,  profuse  non-fatal  hemoptysis,  51. 

,,         five  cases  of  functional  nervous  disorder,  59. 
Willett,  Mr.,  cases  from  his  wards,  65. 
Womack,  Mr.,  on  the  rate  of  cooling  of  the  body  after  death,  252. 


THE   END. 


PRINTED  BY  BALLANTYNE,   HANSON  AND  CO. 
EDINBURGH  AND  LONDON. 


STATISTICAL    TABLES 


fati^nts   under   Sfqatnuiit 


IS   THE   AVAKD3   OP 


ST.  BARTHOLOMEW'S  HOSPITAL 


THE     MEDICAL     EEGISTEAE, 

SAMUEL  WEST,  M.D.  (Oxox.)— F.E.C.P.  ; 

AST) 

THE     SURGICAL     EEGISTEAE, 

AisTHOXY  A.  BOWLBY,  F.E.C.S. 


PRINTED     BY    JAS.     TRUSCOTT    AND     SON, 

SUFFOLK  LAXE,  CITY. 


PEEFACE. 


The  Classification  of  Diseases  in  the  Medical  Tables 
is  that  adopted  by  the  College  of  Physicians  in  their 
Nomenclature  of  Diseases. 


A  2 


CONTENTS. 


PAGE 

Peefacb iii 

Number  of  Beds vii 

General  Statement  of  the  Patients  under  Treatment  during  the  Year .        .  vii 

Patients  brought  in  Dead vii 

Number  of  Post-mortem  Examinations          .......  vii 

Occupations  of  the  Male  Patients viii 

Occupations  of  the  Female  Patients x 

MEDICAL  report- 
Table  I. — Showing  the  Total  Number  of  Cases  of  each  Disease  under 

Treatment  during  the  Year  1884,  with  the  Results  .        .        .        .  12 

Abstract  of  Table  1 28 

Appendix  to  Table  I.       .... 30 


vi  CONTENTS  {continued). 

SUKGICAL  REPORT— 

PAGE 

Table   I. — Showing  the  Total  Number  of  Cases  under  Ticatmcnt 
during  the  Year    188-1,   with    the    comparative    frequency  and 

mortality  of  each  Disease  at  different  ages 40 

Abstract  of  Table  1 72 

Appendix  to  Table  1 73 

Table  showing  the  Surgical  Operations  performed 83 

Statistics  of  Ansesthetics 94 

Appendix  to  Table  of  Surgical  Operations  performed    ....  95 

Sub-Table,  showing  the  Number  of  Cases  of  Erysipelas,  Pyemia,  &c.  .  100 

Appendix  to  the  Sub-Table  of  Erysipelas,  Pyaemia,  kc 101 

Table  of  Amputations,  with  the  Percentage  of  Deaths  during  the  Ten 

Years  from  1875  to  1884  inclusive 102 


ST.  BAETHOLOMEW'S  HOSPITAL. 


1884. 


Number  of  Beds  in  Medical  Wards  (including  14  for  Diseases  of  Women)        236 

Q       .    ,  j  including  6  for  Diseases  of  Women  )  „q~ 

„        „        „      bUTgical    „      I        ^^^  26  for  Ophthalmic  Cases        f         "^^"^ 

„        „        „      TJnassigned 41 

672 


(Radcliffe  Ward  was  closed  for  the  last  six  months  of  the  year.) 


GENERAL   STATEMENT   OF  THE    PATIENTS   UNDER   TREATMENT 
DURING   THE   YEAR   1884. 


Patients  remaining  in  January  1st,  1884  : — 

Medical 

Surgical 

Admitted  during  the  year  1884  : — 

Medical 

Surgical 


Discharged  :— 


Died  :— 


Medical     . . . 
Surgical    . . . 


Medical 
Surgical 


Remaining  in  January  1st,  1885  : — 

Medical     

Surgical 


Patients  brought  in  Dead         

Number  of  Post-mortem  Ejcaminations 
or  about  4  out  of  5. 


5711 


221  \ 
350/    •• 


}...    7,640 


2,389  ) 
3,957/  • 

..6,346  n 

519  1 
237  f  • 

..  756 

•...  7,640 

201) 
337/  • 

..  538. 

..   27 
..  445 

OCCUPATIOXS    OF    MALE    PATIENTS. 


Attendants 

.       3 

Cloth  worker  ... 

.       1 

Gardeners 

.     15 

Accountants    ... 

4 

Coach  makers... 

.     10 

Gasfitters 

.     13 

Actor 

..       1 

Coachmen 

.     14 

General  dealers 

.     11 

Agents 

0 

Coal  heavers   ... 

.       8 

Gilders 

.       2 

Artists 

.       3 

Charcoal  worker 

.       1 

Glass  cutters    ... 

3 

Auctioneer 

..       1 

Collar  makers... 

.       3 

Glass  fitters     ... 

.       2 

Asphalte  worker 

..       1 

Colourmen 

.       2 

Glass  workers  ... 

5 

Commercial  travellers 

15 

Gravedigger     ... 

.        1 

BailifE 

1 

Commission  agents    . 

.       3 

Greengrocers   ... 

.       7 

Bakers 

Banker... 
Bargemen 
Barmen 

.     li 

.       1 

.       4 

14 

Compositors     ... 
Confectioners  ... 

..     18 
.       4 

Grocers 

Grooms... 

7 
.       8 

Cooks    ... 

.       8 

Gunsmiths 

.       2 

Coopers 

.       4 

Gutta-percha  makers. 

.       2 

Basket  makers 

'.       3 

Custom-house  officers 

2 

Bath  chairman 
Bill  posters 
Billiard  marker 

1 

.       3 

1 

Cutlers 

Cork  cutter      ... 
Cricketer 

2 

.       1 
1 

Hairdressers    ... 

Hatters 

Hawkers 

.       7 
.       4 
.     42 

Blacksmiths    ... 
Blind  makers  ... 
Boat  makers    ... 
Boatmen 

.     11 

.       2 

.     23 

4 

Decorators 
Distiller 

.       2 
.        1 

Horse  keepers... 
Horse-hair  dressers    . 
Housekeepers  ... 

.       9 
.       3 
.     16 

Boilermakers... 

Drapers 

.     17 

Bonnet-shape  makers 
Bookbinders    ... 
Boot  finishers  ... 
Boot-last  makers 
Boot  makers    ... 

3 
.     22 
.     17 
.       2 
.     25 

Draymen 

Drovers 

Dustmen 

Dyer 

5 

5 

.       2 

.       1 

Ink  maker 

Instrument  makers    . 
Iron  workei-s   ... 
Ivory  turner    ... 

1 
.       2 
.     10 

1 

Box  makers 

18 

Brass  finishers... 
Brewers 
Bricklayers 
Brick  maker    ... 
Brush  makers  ... 
Butchers 

7 

.     10 

.     40 

.       1 

5 

13 

Electro  plater... 
Engine  drivers 
Engineers 
Engine  fitters... 
Errand  boys    ... 
Engravers 

.       1 
.      14 
.     31 
.      11 
.     31 
.       2 

Jam  maker 

Japanners 

Jewellers 

Joiners 

Jockey  

.       1 
.       2 
.       8 
.       3 
.       1 

Builders 

5 

Envelope  makers 

.       3 

Butler 

.       1 

Knife  grinders 

.       2 

Bottle  makers... 

6 

Button  makers 

3 

Factory  hands... 

.       7 

Farmers 

.       8 

Lawyers 

.       6 

Cabinet  makers 

Cabmen 

Cardboard  makers 

Card  maker     ... 

Carmen 

Carpenters 

Carpet  workers 

Carriers 

Carvers... 

Cellarmen 

Chair  makers  ... 

.     19 
.     42 
.       2 
.       1 
.  136 
.     50 
.       4 
.       6 
.       3 
.       9 
5 

Farriers 

Firemen 
Fishermen 
Fishmongers    ... 

Fitters 

Florists 

Footmen 

Foremen 

French  polishers 

Fruiterers 

Furniture  makers 

Furriers 

.     12 
.       3 
.       3 
.     11 
.       3 
.       2 

7 
.       6 
.       4 

5 
.       2 

5 

Law  writers     ... 
Labourers 
Lamplighters  ... 
Last  makers     ... 
Lath  renders   ... 
Leather  cutters 
Leather  dresser 
Lightermen 
Lithographers... 
Locksmith 
Looking-glass  makers 

.       3 
.  391 
.       2 
.       2 
.       2 
.       3 

1 
.       6 
.       6 
.       1 

4 

Chemists 

5 

Clerks  

Clock  makers  ... 

.     72 
.       9 

Gamekeepers  ... 

.       3 

Machiidsts       

Machine  rulers 

.       3 

.       8 

OCCUPATIONS    OE   MALE   PATIENTS    {continued). 


Maltsters 

..       2 

Publicans        11 

Stokers 

..       9 

Masons... 

..     15 

Pupil  teachers 2 

Students 

..     12 

Mechanics 

..       8 

Postmen           ...         ...       5 

Surgeons 

.       6 

Messengers 

..     17 

Poulterer         1 

Sweeps 

..       8 

Milkmen 

..       4 

Miller 

1 

Musicians 

..       7 

Kagmen           ...         ...       3 

Tailors 

..     25 

Matchmakers... 

2 

Eailvray  porters          ...     13 

Tent  maker 

..       1 

Kope  maker     1 

Telegraph  clerks 
Timekeeper 

4 
..       1 

News  vendors  . . . 

5 

Tin-plate  workers 

5 

Night  watchmen 

..       3 

Sadlers 

.       6 

Tobacconists    ... 

..       3 

Sail  makers 

.       2 

Trimming  makers 

..       3 

Sailors  ... 

.     31 

Turners 

..     10 

Oilmen 

..     22 

Salesmen 

.       2 

Typefounders  ... 

..       3 

Omnibus  conductors 

5 

Sawyers 

.       3 

Ostlers 

..     11 

Scavengers 

.       7 

Schoolboys 

.  401 

Umbrella  makers 

..       3 

Schoolmasters 

.       2 

Undertaker 

..       1 

Packers 

..     11 

Servants 

.     42 

Upholsterers    ... 

..       2 

Packing-case  makers 

..       4 

Sewermen 

.       8 

Painters 

..     50 

Shepherds 

.       2 

Paper  hangers... 

..       2 

Shu-t  maker 

1 

Van  boys 

..     18 

Paper  folders  ... 

..       3 

Shoeblacks 

.       4 

Paper  stainers... 

..       7 

Shopboys 

.       8 

Park  keeper     . . . 

1 

Shopmen 

.     27 

Waiters 

..     18 

Pensioners 

..       8 

Showman 

.       1 

Warehousemen 

..     15 

Photographers... 

..       3 

Signalmen 

.       3 

Washermen     ... 

..       3 

Pianoforte  makers 

..       3 

Slaters  ... 

.       3 

Watch  makers ... 

..       6 

Picture-frame  maker. 

5              2 

Smiths  ... 

.       5 

Watchmen 

..       2 

Plasterers 

..       7 

Soldiers 

.       5 

Waterproof er  ... 

..       1 

Platelayers 

..       5 

Solicitors 

.       2 

Weavers 

5 

Plumbers 

..       8 

Sorters  ... 

3 

Wheelwrights... 

..       4 

Policemen 

..     21 

Stationers 

.       3 

Whip  makers  ... 

..       3 

Polishers 

5 

Station  masters 

.       4 

Writers 

..       7 

Porters... 

..   105 

Steel-rail  maker 

1 

Potmen 

..       9 

Stereotypers    ... 

.       3 

Printers 

..     63 

Stevedores 

.     10 

Zinc  workers  ... 

2 

Printers'  boys  . . . 

..       8 

Stick  makers  ... 

5 

OCCUPATIONS   OF   EEMALE   PATIENTS. 


Attendants 

...       2 

Fish  curers 

.       2 

Needlewomen ... 

..       3 

Artificial-flower 

makers     15 

FloTver  makers 

.       2 

Nurses  (hospital) 

..      16 

Flower  sellers... 

3 

„       (monthly) 

..       6 

French  polishers 

.       2 

Nursemaids     ... 

5 

Bag  makers     .. 

...       2 

Furriers 

.       2 

Barmaids 

9 

Fur  sewer 

1 

Bible  readers  .. 

...       2 

Paper  sorter    ... 

..       1 

Bookbinders    . . 

...       3 

Packers 

..       2 

Bookfolders      .. 

...     12 

Governesses     ... 

.       fi 

Bookkeepers    . . 

5 

Glove  makers  ... 

.       2 

Boot  makers    .. 

...       4 

Bag  sorters 

..       4 

Bottlers 

...       3 

Rug  maker 

..       1 

Box  makers      .. 

...     12 

Harlots 

.     91 

Broom  makers.. 

...       2 

Hawkers 

.       9 

Brush  drawers.. 

...       2 

Housekeepers  ... 

.       9 

School  girls 

..  248 

Housemaids 

..       8 

Sempstresses    ... 

..     17 

Hairdressers    ... 

.       2 

Servants 

..  317 

Cabinet  maker 

...       1 

Shirt  makers    ... 

2 

Cap  makers     .. 

2 

Shopwomen     ... 

'.'.     14 

Char-women     . . 

'..'.     22 

Ironers 

5 

Cigar  makers  .. 

...       3 

Collar  makers.. 

...        5 

Tailoresses 

9 

Cooks    

...     19 

Lace  maker     ... 

.        1 

Teachers 

..       8 

Corset  makers.. 

...       3 

Lauudi-esses     ... 

.     29 

Telegraphist    ... 

..       1 

Clerks 

...       4 

Ladies'  maids  ... 

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Tie  makers 

..       4 

Letter  sorter   ... 

.       1 

Trimming  makers 

..       2 

Dressmakers    . . 

...     24 

Machinists 

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Umbrella  makers 

..       4 

Mantle  makers 

4 

Upholstresses  ... 

..       3 

Envelope  folder 

3        ...       4 

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Waitresses 

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Factory  girls  .. 

...       8 

Milliners 

7 

Ward  maids     ... 

..       4 

Feather  makers 

...       3 

Musicians 

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White-lead  workers   . 

.       2 

MEDICAL    REPORT. 


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DISEASES    OF    THE 
RESPIRATORY  SYSTEM. 

Laryngitis 

Group  Qice  Surgical  Tables) 

Tumour  of  Larynx 

Paralysis  of  Vocal  Chords. . . 
Whooping  Cough    ... 

Bronchitis  (3")         

Emphysema            

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DISEASE. 

DISEASES  SOP  THE 
DIGESTIVE  SYSTEM. 

Stomatitis  C^")         

Glossitis 

Epistaxia 

OzEena       

Tonsillitis 

Pharyngitis 

Stricture  of  CEsoi)ha!4'us    . . 

Dyspepsia 

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APPENDIX   TO   TABLE    I. 


1.  Diphtheria. — A  student,  aged  25,  had  a  severe  attack,  and  suffered  in  the  4th 
week  from  slight  paralysis  of  the  palate,  and  of  the  muscles  of  accommodation. 
He  was  apparently  going  on  well,  when  he  was  seized  suddenly  with  convulsions, 
became  cyanosed,  and  died.     No  post-mortem. 

A  second  case,  M  46,  died  of  cellulitis  of  the  neck. 

2.  Typhoid  Fever.-— (1)  JI  35  :  Developed  phthisis.  (1)  F  31  :  Attack  com- 
menced like  rheumatic  fever  %vith  joint  pains.  (1)  F  3  :  Had  double  parotid  bubo, 
bursting  into  external  auditory  meatus.  (4)  F  17,  F  50,  M  20,  M  19  :  Had  throm- 
bosis of  femoral  vein.  (1)  F  17  :  Had  periostitis  of  both  tibia.  In  6  post-mortems 
perforation  was  found  6/20.  (1)  F  21  :  The  larynx  was  ulcerated.  (1)  F  11  :  Had 
phagedenic  ulceration  of  labium,  but  died  of  perforation. 


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Average  age  of  males  =  21'()  years. 

„           „         females  =  20     „ 
53/90  =  59  per  cent,  had  some  permanent  heart 
mischief  ;  the  proportion  being  equal  in  the 
two  sexes. 
'  One  F.  14,  had  chorea  one  week  later. 
'■^  M.  21,  had  pleuritic  effusion  which  was  tapped. 
^  F.  19,  had  pericarditis  as  well. 

*  1  M.  and  1  F.  had  pericarditis  too. 

*  1  F.  had  pericarditis  too. 

40/52  =  79  per  cent,  had  permanent  heart  mis- 
chief ;  percentage  being  higher  in  females. 

a 
.a 

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& 

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to  tM 

11:3 

50_« 

Of  all  cases  of  rheumatic  fever,  122/191  had 

morbus  cordis  =  64  per  cent. 
Of  all  cases  of  rheumatism  only,  4/81 = 5  per  cent. 
Of  the  3  fatal  cases,  2  had  pericarditis  and  1 

delirium  tremens. 

5 

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33 

4.  Purpura. — (1)  M  19  :  Was  in  Hospital  witli  mild  attack,  and  one  week  after 
discharge  came  back  much  worse  with  epistasis  and  melsena,  and  bleeding  from 
glims.  (2)  M  47  :  With  simple  purpura  had  wrist-drop  on  both  sides  ;  no  history 
of  lead  poisoning.  (3)  Two  cases  (M  ?,  F  26)  had  swelling  and  pain  in  joints. 
(4)  F  19  :  Came  on  7  weeks  after  confinement.  (5)  M  21  :  Had  "rheumatic"  pains. 
Died  with  hsemorrhage  into  peritoneum.  (6)  F  22  :  Came  in  for  haemorrhage  from 
stomach,  and  developed  purpura  later.     Died.     No  post-mortem. 

5.  Hsemophilia. — Was  in  twice  in  year.  In  second  time  for  bleeding  from  nose 
and  bowels,  and  purpura  spots. 

6.  Addison's  Disease. — (1)  F  15  :  Deep  colour  12  months  ;  languor  and  palpita- 
tion 6  months;  loss  of  appetite  and  flesh  3  months.  Another  child  in  family,  3  years 
old,  pigmented.  (2)  F  26  :  Losing  strength  13  months,  but  pigmentation  noticed 
only  for  2  months.  (3)  F  29:  In  December,  1883,  had  giddiness  and  pain  in  vertex; 
in  January,  1884,  discoloration  of  skin,  with  dyspepsia  and  sickness  ;  legs  pigmented 
soon  after.  On  admission  short  systolic  apex  murmur  and  enlarged  gland  under  jaw; 
temperature  varied  from  normal  to  102°  and  103°;  patient  died  of  gradual  exhaus- 
tion. Post-mortem  both  suprarenal  capsules  reduced  to  fibrous  masses  ;  the  left 
formed  a  cyst.     (^Cf.  Lancet,  June  5th,  1885.) 

7.  Myxcedema. — F  47  :  This  case  was  described  in  Clin.  Soc.  Trans.,  vol.  1880. 
(2)  M  53  :  Noticed  for  4  years.     Thyroid  gland  not  felt. 

8.  Lymphadenoma. — (1)  M50:  In  neck  2  years;  dyspnoea  and  dysphagia  lately. 
(2)  M  49  :  Had  pleuritic  effusion,  which  was  tapped. 

9.  Leucocytiiasmia. — (1)  F  40:  "Splenica";  white  corpuscles  equal  red  in 
number  ;  spleen  reached  to  pubes. 

10.  Adenitis. — M  7  :  General  adenitis  ;  was  attributed  to  drains. 

11.  Hydrocephalus — (1)  M  6  months:  Chronic  hydrocephalus  with  spina  bifida. 
Spina  bifida  tapped — i.  3iv ;  ii.  Jxxii ;  iii.  5xlix — with  relief.  (2)  M  4  :  Acute  hydro- 
cephalus, but  no  tubercles  or  meningitis  found  post-mortem ;  some  superficial  hfemor- 
rhage  in  posterior  part  of  left  lobe  of  cerebellum. 

12.  Apoplexy. — (1)  M  49:  Had  hjemorrhage  into  pons  and  left  crus.  (2)  M  39  : 
Had  granular  kidney,  and  died  fi'om  rupture  of  a  vessel  and  heemorrhage  on  surface 
of  brain, 

13.  Hemiplegia. — (1)  (2)  Two  cases  (M  52,  F  49):  Had  hemianesthesia  ;  both 
left-sided  paralysis.  (3)  M  24 :  Had  right  hemiplegia,  aphasia,  and  hemianesthesia, 
with  optic  neuritis,  probably  syphilitic.  (4)  F  62  :  Left;  great  rigidity.  (5)  M  35  : 
Excessive  reflexes  after  hemiplegia  4^  years  before.  (6)  M  62  :  Associated  vrtth 
glycosuria.  (7)  M  44 :  Coming  on  gradually  after  blow  4  years  before;  optic  neuritis. 
(8)  M  9  :  Spastic  right-sided  hemiplegia  since  birth  ;  delivered  by  forceps. 

14.  Cerebral  Tumour. — (1)  F  32  :  Small  tumour  (pea)  in  posterior  part  of  left 
corpus  striatum;  cyst  filled  with  serum  in  left  side  of  cerebellum.  (2)  F  ?:  Glioma 
in  right  opt.  mal.  (3)  M  27:  Vomiting,  giddiness,  and  pain  in  back  of  head;  double 
optic  neuritis ;  tumour  in  left  side  of  cerebellum. 

15.  Epilepsy.— (V)  M  6  months  :  Died  after  having  136  fits  in  8  days.  (2)  M 
54  :  Died  in  fit,  and  was  found  to  have  a  ruptured  bladder. 

16.  Chorea. — 19/44  had  morbus  cordis  (16  F,  3  M)=43-2  per  cent.;  all  systolic  apex 
murmur  except  2,  who  had  pericarditis  only;  one  other  had  both  mitral  disease  and 
pericarditis.  In  2  cases  the  chorea  commenced  3  weeks  after  rheumatic  fever,  and 
in  2  more  3  months  after.  Of  these  cases,  in  3  the  attack  was  the  second,  in  4 
the  third,  in  1  the  fourth,  and  in  1  the  seventh  ;  one  had  urticaria  just  before  the 
attack;  one,  F  12,  had  choraic  movements  for  3  years,  and  had  melasma;  one,  F 
10,  had  sugar  in  urine,  which  had  not  quite  disappeared  on  leaving. 

Hemiplegic  chorea  (M  42) :  14  years  before  had  injury  to  back  of  head  and  neck  ; 
was  "unconscious  6  months"  ;  the  movements  began  in  the  right  arm  7  years 
afterwards. 

o 


84 

17.  Sunstroke. — F  6  months:  Had  cervical  opisthotonus,  and  died  a  few  days 
after  being  removed  from  Hospital. 

18.  Hysteria. — (1)  F  19  :  Spasmodic  contraction  of  both  legs  and  of  jaw.  (2) 
F  22  :  Spasmodic  contraction  of  right  hand  and  arm.  (3)  F  11  :  Paraplegia  after 
a  fall  7  weeks  previously.  (4)  F  22  :  Excessive  patella  reflexes ;  no  ansesthesia. 
(5)  F  23  :  Vomiting.     (6)  F  23  and  F  20  :  Hystero-epilepsy. 

19.  Paraplegia. — (1)  M  36:  Spastic  paraplegia,  secondary  to  transverse  myelitis 
after  exposure  to  cold.  (2)  M  56  :  After  fall  and  blow  on  neck.  Later  developed 
rigidity  in  right  arm  and  leg. 

20.  Locomotor  Ataxy. — (1)  M  -10  :  Had  perforating  ulcers  on  both  feet,  and 
arthritis  both  left  great  toe  joints.  (2)  M  45  :  Dislocation  of  shoulder  and  many 
other  joints ;  admitted  for  examination  and  report  to  Clinical  Society. 

21.  Myelitis. — M  32  :  On  post-mortem  had  also  hydatid  of  liver. 

22.  Pseudohypertrophic  Paralysis. — (1)  M  10  :  12  months  difficulty  in  going  up 
stairs  ;  calves,  thighs,  pectoralis  major,  biceps  and  triceps,  trapezius,  aliected;  8  sons 
in  family  ;  1,  5,  6,  7,  well ;  2,  3,  tt  affected  with  pseudohypertrophic  paralysis ;  8 
died  infant.  (2)  M  8  :  Only  boy  ;  2  sisters  well.  In  1882  in  Luke,  and  could  walk 
then  ;  calves  very  large  ;  infraspinatus  large,  but  arms  not  affected.  Now,  legs 
flabby  and  soft ;  pectorals  and  biceps  atrophied,  and  some  of  muscles  of  left  palm. 
(3)  Mil:  Only  noticed  for  3  years,  e.g.,  since  8  years  of  age. 

23.  Diphtheritic  Paralysis.— (_!)  M  7  :  Of  palate.  (2)  F  26  :  Of  legs,  arms,  and 
hands.  (3)  M  31:  Diphtheria  7  weeks  before  ;  paralysis  of  legs,  of  accommodation, 
and  palate.  (4)  M  28  :  Diphtheria  3  months  before  ;  paralysis  of  fauces  4  weeks 
after,  and  some  dyspnoea,  and  defective  vision  ;  legs  and  hands  weak  ;  during  last 
month  sensation  impaired  in  both  ;  constipation. 

24.  Sciatica. — M  43  :  Nerve  stretched  three  times  by  forciljle  flexion. 

25.  Hemiidrosis — M  43:  Unilateral  left  facial  sweating,  said  to  be  congenital. 

26.  Pericarditis. — (1)  F  34:  Aortic  with  albuminuria,  probably  gi-anular  kidney. 
(2)  M  15  :  Exploratory  incision  made  in  fourth  space  near  sternum.  Death  on 
table. 

27.  Morbus  Cordis.— 

Congenital. — M  3  :   Pulmonary  stenosis  and  patent  septum  ;  gangrene  of 
fiigers  and  toes. 

Aortic  Stenosis. — Three  cases — M  20,  18,  and  62  :  The  last  died  with  dropsy, 
and  had  cirrhosis  of  liver ;  one  suffered  with  angina. 

Mitral  Disease . — 

(a)  Stenosis. — 12  M,  5  of  whom  died;  16  F,  2  of  whom  died. 

(;8)  Stenosis  (with  regurgitation). — 6  M,  1  of  whom  died ;  9  F,  with  no 
deaths. 

Mitral  Stenosis.— loi&l  28— discharged,  7  M,  14  F ;  died,  5  M,  2  F.  Under 
15 — discharged,  1  M  ;  died,  1  M.  Under  20 — discharged,  1  M,  2  F. 
Under  30 — discharged,  2  M,  6  F ;  died,  3  M.  Under  40 — discharged, 
3  M,  3  F.  Under  50— discharged,  1  F  ;  died,  2  F.  Under  60— died,  1  M. 
Over  60— discharged,  2  F. 

Mitral  Stenosis  (with  regurgitation) — 

(1)  F  29  :  Mitral  stenosis  ;  had  triscupid  constriction  as  well.  (2)  M 
12  :  Post-mortem  had  also  adherent  pericardium.  (3)  M  28  :  Ditto; 
post-mortem  had   also   phthisis,     (4)  M  26  :   Ditto  ;   post-mortem 


85 

had  embolisms  in  lungs,  spleen,  and  kidneys  ;  during  life  irregular 
temperature  and  rigors.  (5)  M  17:  Ditto;  developed  left  hemiplegia 
at  Highgate.  (6)  F  36  :  Ditto  ;  had  hemiplegia  May,  1883  ;  and  at 
present  time  rigidity  of  paralysed  side.  (7)  F  46 :  Ditto  ;  was 
admitted  for  inflamed  fibroid  ;  had  effusion  in  pleura,  pericardium, 
and  peritoneum.  (8)  F  10  :  Double  apex  murmur  ;  had  had  chorea 
on  and  off  for  4  years.  (9)  M  24  :  post-mortem  had  vegetations  on 
tricuspid,  mitral,  and  aortic,  with  adherent  pericardium ;  only  mitral 
murmur  heard  during  life.  (10)  M  49  :  Mitral  regurgitation  ;  had  a 
fit  in  Hospital ;  developed  purpura  ;  had  pleurisy  and  wrist-drop  (not 
lead)  ;  readmitted  with  delirium  and  fresh  purpura,  and  died.  (11) 
M  30  :  Had  stenosis  of  mitral,  tricuspid,  and  aortic  orifices.  (12)  F  65: 
With  aortic  and  mitral  disease  had  also  cirrhosis  of  liver  post- 
mortem, (13)  F  9:  With  mitral  regurgitation  developed  small-pox  ; 
and  another  (F  8)  developed  typhoid  fever ;  both  recovered.  (14) 
Two  cases  developed  pneumonia.  F  29  :  Of  both  bases  with  aortic 
regurgitation.  M  21  :  Of  right  base  with  mitral  regurgitation  ;  both 
recovered.  (15)  F  47  :  Died  with  embolism  of  pulmonary  artery. 
(16)  F  27  :  Had  deep  jaundice,  thought  to  be  due  to  gall-stones.  (17) 
F  20  :  Mitral  regiirgitation  ;  had  gangrene  of  end  of  right  great  toe. 

28.  Aneurism. — Of  4  cases  treated  on  Tuffnell's  plan,  one,  M  40,  could  not  stand 
treatment,  and  left ;  of  the  other  three,  M  45,  M  45,  F  40,  two  were  gi-eatly  relieved. 
M  50  :  Died  of  oedema  of  glottis.  M  38  :  Suffered  from  angina-like  attacks,  and 
died  in  one. 

29.  Exophthalmio  Goitre. — (1)  F  26  :  Had  double  aortic  and  systolic  mitral 
murmur.  (2)  F  50:  Had  had  palpitation  10  years,  exophthalmos  6  years,  but  thyroid 
was  not  enlarged.  (3)  F  24  :  After  fit  2  years  previously  eye  became  prominent  ; 
has  systolic  apex  murmur,  aphonia  ;  catamenia  absent  2  years  ;  bronzed  skin.  (4) 
F  24:  Fits  for  2  years  ;  throat  swelled  7  months  ;  eye  prominent  and  palpitation 
for  6  months  ;  pulse  very  rapid.  Patient  died  suddenly  ;  pulse  running  up  to  20'J 
before  death.    No  post-mortem, 

30.  Broncf]itis. — F  45:  Much  oedema;  legs  punctured  ;  gangrene  of  punctures, 
and  death. 

31.  Pneumonia. — 

Might  Apex. — 5  M,  3  F;  no  deaths.  Ages  of  males,  6,  9,  and  3  at  14  ;  one  had 
temperature  of  106°  ;  ages  of  females,  2  at  6,  1  at  14. 

Left  Apex. — 4  M;  ages  2^,  6,  2  at  7  ;  no  death,  2  F,  aged  7  and  28  ;  one 
death  ;  2  (M  6,  M  7)  developed  empyema,  which  was  aspirated,  and 
recovered. 

Right  Base.— 22  M,  with  5  deaths  ;  10  F,  with  2  deaths.  1  F  8  developed 
afterwards  necrosis  of  inguinal  phalanx  of  left  thumb  ;  1  M  33  had 
double  pleuritic  effusion. 

Left  Base. — 29  M,  with  6  deaths  ;  1  M  17  had  double  pleurisy  and  peri- 
carditis,    8  F,  no  deaths  ;  1  F  5,  had  empyema ;  tapped  and  recovered. 

Boulle. — 5  M,  with  2  deaths,  all  double  base,  7  F,  with  2  deaths  (4  double 
base,  2  died ;  the  remaining  3  crossed,  none  died  ;  all  left  base  and 
right  apex.) 

Unspecified, — 1 1 . 

32.  Phthisis.— (X)  M  35  :  Died  with  gangrene  of  right  apex.  (2)  M  34:  Had 
epileptiform  convulsion,  and  became  comatose, 

33.  Pneumothorax. — (1)  M  22  :  In  and  ou !;  of  hospital  several  times ;  at  first  hydro 
later  pyo-pnuemothorax  ;  tapped  but  not  of  ened,  with  relief.  (2)  M  24  :  Of  latent 
origin;  patient  noticed  gurgling  in  chest ;  no  hectic  or  constitutional  symptoms  for  2 }. 
months,  then  temperature  began  to  rise  ;  phthisis  developed  at  opposite  apex,  and 

c  2 


30 

advanced  rapidly.  (3)  F  26  :  In  Hospital  4  months  before  with  typhoid  fever ; 
3  weeks  afterwards  arm  became  weak  ;  extensors  and  supinators  of  both  forearms 
atrophied  ;  later  patient  became  hemiplegic  ;  pneumothorax  developed,  and  patient 
died  next  day. 

34.  Pleurisy, — Paracentesis  in  8  cases  ;  in  6  cases  only  once,  32,  38,  51, 63, 136  oz. 
of  serum  ;  once,  twice  70  and  56  oz.  ;  once,  three  times  50,  4,  1  ;  all  recovered  ; 
one  had  pericai'ditis  ;  one  had  adherent  pericardium,  and  fluid  removed  was  haemor- 
rhagic  (no  new  growth). 

35.  Empyema. — 

A.  Recovered. 

(rt)  Aspirated  only.  (1)  F  2|  :  Developed  after  whooping-cough  ;  10  oz. 
removed  ;  recovery.  (2)  M  6  :  Tapped  once  ;  recovery.  (3)  F  24 : 
Spat  through  lung  ;  recovery. 

(V)  Free  Incision. — (4)  F  24  :  tapped  once  previously  ;  recovery  ;  tapped 
twice  previously.  (5)  F  3  :  Left  with  incision  quite  closed.  M  5  : 
Left  with  a  little  discharge.  M  40  :  Left  still  discharging  ;  had  also 
pus  in  urine.  M  4^  :  Tapped  3  times  previously  ;  left  with  slight 
discharge.  M  23  :  Tapped  many  times  previously ;  left  with  slight 
discharge.     M  8  :  Old  case  ;  had'  fistula  18  months. 

B.  Died. 

F5:  Twice  tapped;  incision.  M  13  :  Had  peritonitis.  F  20  :  Twice 
tapped ;  last  time  pus  fetid.  M  33  :  Pleuritic  effusion  (serum)  after 
rheumatic  fever  ;  one  month  later  purulent ;  incision  ;  died  3  months 
later.  M  42  :  Died  with  amyloid  disease.  M  47:  Dry  tapping;  burst 
suddenly  into  lung,  and  suffocated  patient. 

36.  Stomatitis. — M  7^  :  Gangrenous;  recovered.  M  54  :  Gangrenous,  in  a  case 
of  granular  kidney  and  morbus  cordis  ;  death  sudden. 

37.  Hsematemesis. — (1)  F  49  :  Had  mitral  regurgitation  and  gastric  ulcer.  (2) 
F  49  :  Had  mitral  regurgitation,  and  developed  hemiplegia  in  Hospital ;  granular 
kidiiey  and  cirrhotic  liver  found  post-mortem. 

38.  Cancer  of  Duodenum. — M  44  :  Died  of  thrombosis  of  pulmonary  artery. 

39.  Cancer  of  Stomacii. — M  45  :  Had  been  under  treatment  as  a  case  of  per- 
nicious anaemia,  and  was  transfused  without  permanent  benefit ;  on  death  cancer  of 
stomach  found,  which  was  not  suspected  during  life. 

40.  Intestinal  Obstruction.— (1}  M  28  :  From  band.  (2)  M  48  :  Volvulus  and 
band.     (3)  F  43  :  Carcinoma  uteri. 

41.  Jaundice. — F  22:  Due  to  cancer  of  liver,  with  cancer  of  peritoneum  and 
glands  and  mediastinum  ;  had  perforated  spinal  cord  at  fij-st  lumbar  vertebra. 

42.  Cancer  of  Liver. — M  61  :  Started  from  gall-bladder. 

43.  Peritonitis.— 

Tubercular. — (1)  F  16  :  Ascites  12  months  before  ;  cured.  Second  attack 
8  months  later  :  legs  swelled,  and  abdomen  later,  3  weeks  before  ad- 
mission.    Post-mortem,  tubercular,  pleurisy  and  peritonitis. 

Perforation. — (1)  F  62:  Simple  stricture  of  large  intestine  (sigmoid  flexure), 
vagina  just  above.  (2)  M  26:  Cancerous  stricture  of  large  intestine. 
(3)  M  17,  (4)  M  17  :  From  ulcer  of  vermiform  appendix.  (5)  M  64  : 
After  perityphlitis.     Qcf.  Typhoid  Fever.) 

44.  Ascarides. — F  4  :  Patient  admitted  with  head  retracted  :  when  worms  cured 
retraction  passed  off. 


37 

45.  Hydatid  of  Liver. — Three  cured  by  single  tapping ;  in  one  fluid  was  bile- 
staiued ;  one  required  to  be  tapped  twice,  and  one  was  freely  opened  and  cured. 

46.  Acute  Nephritis. — 5  M,  with  one  death  ;  5  F,  with  two  deaths,  after  scarlet 
fever.  M  6  :  Died  with  double  pleuritic  effusion.  F  1|  :  Died  with  meningitis. 
(1)  M  11 :  Acute  nephritis  associated  with  purpura.  (2)  F  14  :  Has  also  umbilical 
abscess. 

47.  Ciironio  Nepfiritis. — One  case  after  an  acute  attack  4  years  ago,  from  which 
patient  never  recovered  completely  ;  had  also  mitral  constriction  ;  died  with  peri- 
carditis. 4  M  and  1  F  had  urtemia  before  death  ;  one  of  these,  M  46,  had  cancer  of 
stomach  also. 

48.  Granular  Kidney. — (1)  F  37  :  Had  pericarditis  shortly  before  death.  (2)  F 
50 :  Subject  of  gout ;  found  post-mortem  to  have  also  hydatid  of  hver.  (3)  F  30 : 
Had  leadline;  convulsions  before  death.  (4)  M  49  :  Had  pericarditis,  and  died  with 
uremia  ;  found  post-mortem  to  have  also  malignant  disease  of  urinary  bladder. 

49.  Hydronephrosis. — M  67  :  Bight  kidney  was  a  sac  containing  muddy  fluid 
with  abundant  cholesterin  crystals  ;  the  left  contained  a  small  cyst  also. 

50.  Hematuria. — M  48  :  Came  on  after  taking  turpentine. 

51.  Diabetes  Mellitus. — Two  cases,  F  62,  F  69,  had  also  eczema  valva.  M  31: 
3  years  history  ;  oxalate  of  lime  calculus  removed  12  months  before  with  recovery  ; 
wasting  for  6  months.  Died  comatose.  M  37  :  Symptoms  noticed  12  months,  but 
carbuncle  2  years  before.  M  26  :  Died  with  phthisical  albuminuria,  and  oedema 
of  feet.     F  43  :  Daxsero  myxoedema  and  lupus  vulvte. 

52.  Biiharzia. — M  25  :  Says  he  caught  it  by  drinking  water  fouled  by  cattle 
suffering  from  the  disease  called  "  red  water"  ;  those  which  recover  from  it  fetch 
three  or  four  times  then-  value,  and  are  called  "salted"  ;  fii'st  discovered  in  August, 
1882,  in  Transvaal  Gold  Fields. 

53.  Parametritis.— F  26,  F  39  :  Psoas  abscess.  F  21,  F  27  :  Burst  into  bladder 
and  rectum.     F  22,  F  24  :  Burst  into  bowel.     F  35  :  Burst  into  bladder. 

54.  Fibroid.— F  49,  F  50:  Weighed  1  lb.  1  oz.  F  42  :  2^  lb.  removed  ;  death 
from  peritonitis.  F  62  :  Many  times  in  Hospital ;  supposed  fibro-cystic  disease  ; 
much  removed  from  time  to  time  by  uterus. 

55.  Premature  Birth. — F  6  weeks  :  A  seven  months'  child,  and  weighed  only 
2  lb.  10  oz.  in  clothes. 

56.  Retroversion.— F  30  :  Replaced.    F  34  :  Produced  severe  cystitis. 

57.  Extra-uterine  Foetation,  Tubal.— F  27  :  Incised  per  vaginam ;  foetus  removed. 

58.  Abortion. — F  34  :  Had  hydatid  in  peritoneum  tapped. 

59.  Puerperal  Septicsemia.-F  24  :  Peritonitis.  F  20  :  From  peritonitis.  F 
35  :  From  retained  placenta. 

60.  Placenta  Praevia. — F  22  :  Flooding  ;  died  under  chloroform. 

61.  Lead.  —  F.  25  :  Had,  as  well  as  wrist-drop,  paralysis  of  peronasi  and  ex- 
tensors. 

62.  Phosphorus.— M.  35  :  November  11,  eat  bread  and  butter  spread  with  phos- 
phorus paste  ;  1  hour  later  felt  drowsy  and  giddy  ;  November  12,  vomiting  and 
pain  in  epigastrium  ;  November  15,  vomiting  every  day,  drowsy,  slight  jaundice  ; 
eructation  with  phosphorous  taste,  epigastrium  tender,  liver  and  spleen  not  palpable. 
Died  on  November  20th,  collapsed,  the  jaundice  and  drowsiness  having  increased 
during  the  preceding  days.  Temperature,  15th,  99°  ;  16th,  100^  ;  17th,  102-2°  ; 
18th,  99-8°.  Post-mortem,  small  haemorrhage  into  nearly  all  organs ;  liver  about 
normal  size.     No  microscopical  examination. 


38 

63.  Belladonna. — (1)  Took  liniment.  (2)  F  IJ  :  Eat  ntropia  ointment,  "as 
mucli  as  wou'l  cover  a  sixpence  ; "  2  hours  later  vomited  ;  lips  swollen  and  dry,  and 
fingers  swollen  ;  pupils  widely  dilated.  Pulse  =  128°  ;  delirium  at  night.  Ee- 
covercd  next  day. 

64.  Opium. — F.  24  :  10.30,  found  by  police  ;  11.45,  stomach  washed  out  in 
surgery;  atrojiia  injected;  1.30,  gave  name  and  address,  and  sat  up;  3.0,  suddenly 
became  comatose,  and  died  in  about  three-quarters  of  an  hour,  in  spite  of  artificial 
respiration. 

63.  Delirium  Tremens. — The  one  case  that  died  had  albuminuria. 


SURGICAL    REPORT. 


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disease. 

Diseases  op  the  Nervous  System 
(continued'). 

Spinal  Meningitis        

Epilepsy 

Lunacy  

Diseases  of  the  Eye. 

A.  Ophthalmia — Conjunctiva 

Catarrhal      

Eheumatic    ... 
Phlyctenular 
Purulent       

B.  Cornea — 

Keratitis 

Interstitial  Keratitis       

Ulcers         

Opacities 

Staphyloma           ...         

Fistula       

C.  Iris — 

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D.  Lens — 

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DISEASE. 

Diseases  of  the  Eye  (amtmued). 

D.  Lens  (continued') — 

Cataract,  Zonular           

„          Traumatic       

Dislocation  of  Lens 

Aphakia      

Opaque  Capsule 

E.  Ectina,  Optic  Nerve,  and  Vitreous 
Humour — 

Optic  Neuritis       

„      Atrophy       

Hffimorrhajje         

Detached  Retina 

F.  Diseases  of  the  Choroid,  &c. — 

Choroiditis...         

Melanotic  Sarcoma 

G.  General  Affections  of  the  Eye — 

Glaucoma 

Panophthalmitis 

Sympathetic  Ophthalmia 

0[)tlialmopIcgia  Interna 

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DISEASE. 

Diseases  of  the  Eye  {ctintlnued'). 
H.  Strabismus — 

Internal      

External 

I.  Errors  of  Refraction — 

Asti<jfmatism          

Hypermetropia     

Myopia 

Ametropia 

Asthenojiia            

J.  Diseases  of  Lachi-ymal  Apparatus — 

Lachrymal  Obstruction 

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Lachrymal  Fistula           

K.  Diseases  of  the  Eyelids — 

Granular  Lids       

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Naavus        ...         ...         

Sebaceous  Cyst     

Dermoid  Cyst        

Papilloma  ...         

Tumours  of  Doubtful  Nature     ... 
Blepharitis...         

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DISEASE. 

Diseases  of  the  Digestive  System 

Mouth,  Tongue,  and  Pharynx  (ro/ifd.') — 

Tonsils  Enlarged        ...         

Ulcerated  Throat        

Canerum  Oris 

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Tongue — 

Chronic  Superficial  Glossitis 

Tubercular  Ulceration           

Pharyngeal  Fistula 

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Dysphagia        ...         ...         

Ulcer  of  Pharynx  opening  Internal 
Carotid  Artery        

Diseases  of  the  Intestines. 

Intussusception  ...     • 

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72 


I 


ABSTRACT    OE    TABLE    L, 

With  Average  Duration  of  Surgical  Patients  in  the  Hospital. 


Discharged.  Cured  or  Relieved 


Died 


Eemaininfr  in  at  the  end  of  year  1884" 


M.  —  2,514 
F.  —  1,433 

M.  —      158 
F.   —        79 


|M.  —     218 
""(f.   —     119 


Average  stay  of  Men  |  25-07  days. 

„  Women ]  28-34      „ 

Average  stay  in  Hospital  of  all  Surgical  Patients  —  2G-70  days. 
*  These  cases  are  not  included  in  Table  I. 


73 


APPENDIX  TO  TABLE  1. 


GENERAL  DISEASES. 

Trichinosis. 

A  showman,  aged  29,  recently  returned  from  America,  was  admitted  suffering 
from  acute  phlegmonous  inflammation  of  the  arm  and  forearm,  with  muscular 
pains  and  high  temperature.  He  died  7  days  after  admission.  A  post-mortem 
showed  a  general  infiltration  of  all  the  voluntary  muscles  with  trichina. 

Varicella  Gangrenosa. 

Case  1. — A  male  infant,  of  10  months,  had  varicella  li  days  before  admis- 
sion. On  examination  six  gangrenous  patches  were  found — one  in  front  of 
the  right  ear,  one  behind  the  left,  three  on  the  scalp,  and  one  on  the  neck. 
The  cranial  bones  were  rough  and  bare.  Temperature  99°  to  102°.  Con- 
valescence was  rapid,  and  the  child  was  discharged  in  good  health  13  days 
after  admission.  Fourteen  hours  after  discharge  it  died  in  a  convulsion.  No 
post-mortem  allowed. 

Case  2. — Female,  aged  8  months,  a  vesicular  eruption  10  weeks  before  admis- 
sion. Six  weeks  later  a  fresh  crop  of  vesicles.  One  month  later  another  fresh 
crop.  Some  of  the  vesicles  on  the  head  pustulated  and  left  ulcers.  On  admission 
had  a  vesicular  and  pustular  eruption  with  two  ulcers  exposing  the  cranial 
bones.  Whilst  in  Hospital  fresh  vesicles  appeared,  but  quickly  healed,  and 
the  child  was  discharged  well  in  a  fortnight.     Seen  a  month  later  quite  well. 

Case  3. — Female,  aged  13  months.  Three  weeks  ago  had  chicken-pox.  Mother 
noticed  that  some  of  the  spots  did  not  get  better  like  the  rest,  but  became  red 
and  painful.  On  admission  child  pale  and  ill.  Temperature  98'5°  to  100'5°. 
Three  small,  circular,  punched  out  ulcers  with  gangrenous  edges  and  base  on 
back.     Convalescence  rapid.     Discharged  well  in  a  fortnight. 

Tetanus. 

A  boy,  aged  14  years,  received  a  lacerated  flap  wound  of  right  buttock  on 
August  6th.  The  flap  sloughed.  Erysipelas  set  in  on  August  10th.  Tetanus 
supervened  August  16th.  He  died  August  21st.  A  post-mortem  examination 
showed  much  sloughing  and  a  good  deal  of  retained  and  very  foul  pus.  The 
spinal  cord  and  the  nerves  were  natural. 

Hydrophobia. 

Case  1. — Male,  aged  27.  Two  months  before  admission  bitten  in  the  thumb  by 
a  mad  dog.  Two  days  before  admission  he  noticed  a  sudden  catch  in  his  breath, 
shortly  followed  by  inabihty  to  swallow,  and  spasm.  On  admission  he  was  in 
a  very  excited  state,  but  talking  was  interrupted  by  frequent  spasms.  He  was 
treated  with  morphia,  pilocarpin,  and  chloroform,  but  died  in  10  hours. 

Case  2. — Male,  aged  37.  Bitten  by  a  mad  dog  6  weeks  before  admission. 
Admitted  to  Hospital  August  25th.  He  had  been  quite  well  until  12  hours 
before  admission,  and  then  was  seized  quite  suddenly  with  pharyngeal  spasm 
whilst  drinking.  He  was  treated  with  morphia  and  chloroform,  but  convul- 
sions supervened,  and  he  died  8  hours  after  admission.  No  post-mortem 
allowed. 

Case  3, — Male,  aged  21,     Bitten   by  a  cat   6  weeks  before  admission  on 


74 

March  31st.  Well  two  days  before  lie  came  to  Hospital.  On  March  29th  felt 
sick.  March  30th  could  not  swallow.  On  admission  ^'cat  dread  of  being 
made  to  swallow.  Occasional  convulsions.  Treated  with  morphia  and  pilo- 
carpin,  and,  as  respiration  suddenly  stopped  after  a  spasm,  tracheotomy  was 
performed,  though  without  beneficial  results.  Pie  died  24  hours  after  ad- 
mission. 

Gangrene. 

(1)  IdiojmtJiic. — An  infant,  aged  3  weeks,  vaccinated  6  days  after  birth, 
was  attacked  by  gangrenous  inflammation  of  the  neck  and  back,  which  proved 
fatal  12  days  after  admission. 

(2)  Dry  Gangrene  of  Hand  and  Arm. — An  anfemic  woman,  aged  48,  was 
admitted  with  dry  gangTcneof  the  left  hand  and  forearm.  No  pulse  in  any  of 
the  arteries  of  the  afEected  extremity.  8he  gi-adually  sank  and  died  a  fortnight 
after  admission.  A  post-mortem  examination  showed  that  the  left  subclavian, 
axillary,  brachial,  and  radial  and  ulnar  arteries  were  filled  with  clot.  There 
was  no  evidence  of  arteritis  or  of  embolism. 

A  man,  aged  63,  with  morbus  cordis  was  admitted  with  dry  gangrene  of  the 
hand,  aird  absence  of  pulsation  in  the  vessels  of  the  whole  extremity.  He 
died  4  weeks  after  admission.  A  post-mortem  examination  showed  embolism  of 
the  axillary,  brachial,  radial,  and  ulnar  arteries,  and  advanced  morbus  cordis. 

(3)  Spreading  Traumatic  Gangrene. 

Case  1. — A  very  stout,  unhealthy-looking  man,  aged  31,  suffered  a  compound 
fracture  of  the  left  radius  with  a  good  deal  of  laceration  of  the  soft  tissues.  His 
urine  was  loaded  with  sugar.  Three  days  after  the  accident  moist  gangrene 
commenced  at  the  edges  of  the  wound,  extended  rapidly  over  the  whole  arm, 
then  to  the  shoulder  and  thorax,  and  caused  death  6  days  later. 

Case  2. — A  healthy  man,  aged  49,  sustained  a  compound  comminuted  fracture 
of  the  left  radius  and  ulna  with  much  damage  to  the  soft  tissues.  Two  days 
after  the  accident  the  temperature  rose  to  103°,  and  the  arm  became  painful 
and  swollen.  On  the  next  day  diffuse  gangrene  set  in  and  rapidly  extended. 
Amputation  was  then  performed  immediately  below  the  shoulder  joint,  and 
the  patient  made  a  rapid  recovery. 

Case  3. — A  child,  aged  6  years,  sustained  a  large  lacerated  and  contused 
wound  of  the  leg,  with  much  bruising  of  the  tissues,  through  being  run  over  by 
a  cart.  Thirty-six  hours  later  gangrene  supervened  and  rapidly  extended. 
Amputation  through  the  lower  third  of  the  thigh  was  at  once  performed,  and 
the  patient  made  a  good  recovery. 

TUMOURS. 
Colloid  Carcinoma. 

Three  cases  of  colloid  carcinoma  of  the  breast  in  women  aged  respectively 
35,  45,  and  35. 

Sarcoma. 

Of  the  sarcomata  of  the  breast,  one  was  a  solid  round-celled  recurrent 
growth  in  a  man  aged  22,  six  were  instances  of  fibro-sarcoma  of  the  female 
breast  with  cysts,  and  two  were  specimens  of  alveolar  sarcoma. 

A  myeloid  sarcoma  of  the  head  of  the  tibia  was  treated  by  local  gouging  in 
a  girl,  aged  17.  Suppuration  in  the  knee  joint  ensued  and  the  patient  very 
nearly  lost  her  life,  amputation  being  refused.  She  recovered  -ttith  a  stiff  limb. 
The  growth  recurred  some  months  later. 

Arterial  Naevus. 

In  a  girl,  aged  12,  the  tumour  was  situated  on  the  scalp  and  left  temporal 
region.    It  was  successfully  l-emoved  by  the  knife. 

In  a  man,  aged  30,  the  tumour  was  situated  on  the  thigh.  It  was  improved 
but  not  cured  by  galvano-puncture. 

A  man,  aged  22,  died  of  haemorrhage,  resulting  from  an  attempt  to  remove  a 
naevoid  growth  behind  the  superior  maxilla  (.v^-f-  Table  II.  page  96), 


75 

SYPHILIS. 

A  man,  aged  24,  who  had  contracted  syphilis  3  years  previously  was  admitted 
to  the  Hospital  June  26th.  He  had  gummata  in  the  lips  and  face  and  chest, 
periostitis  of  the  superior  maxillary  bone,  albuminuria,  and  disease  of  the  right 
knee  joint.  He  died  6  weeks  after  his  admission.  A  post-mortem  showed 
numerous  gummatous  deposits  in  the  viscera,  and  extensive  syphilitic  affection 
of  the  knee  joint.  The  synovial  membrane  was  infiltrated  with  gummy 
products,  as  was  also  the  periosteum  of  the  femur.  The  shaft  of  the  femur 
was  the  seat  of  periostitis. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 
Neuralgia. 

A  man,  aged  73,  was  admitted  suffering  from  epileptiform  neuralgia  of  10 
years  duration.  Four  previous  operations  had  failed  to  give  permanent  relief. 
The  inferior  dental  nerve  was  stretched,  and  the  patient  left  the  Hospital 
12  days  later.     At  the  time  of  his  discharge  the  pain  had  not  recurred. 

A  blacksmith,  aged  55,  apphed  for  relief  for  severe  epileptiform  neuralgia 
of  i  years  duration  ;  various  operations  had  previously  been  performed.  The 
inferior  dental  nerve  was  stretched,  with  the  result  that,  so  long  as  the  patient 
remained  in  the  Hospital,  he  was  free  from  pain.  A  fortnight  later  the  pain 
had  returned  in  the  lower  jaw. 

A  man,  aged  52,  was  admitted  for  epileptiform  neuralgia.  The  inferior 
dental  nerve  was  stretched.  The  patient  suffered  no  more  pain  during  his 
stay  in  the  Hospital. 

A  woman,  aged  53,  had  epileptiform  neuralgia,  accompanied  by  lacrymation 
and  abnormal  dryness  of  the  nasal  mucous  membrane.  The  mucous  membrane 
over  the  turbinate  bones  was  cauterised,  but  the  patient  did  not  receive  material 
benefit. 

A  man,  aged  49,  who  had  suffered  much  pain  in  connection  with  cancer  of 
the  tongue,  and  who  was  not  much  benefited  in  this  respect  by  excision, 
underwent  the  operation  of  stretching  of  the  gustatory  nerve,  and  expressed 
himself  as  much  relieved. 

Neuritis. 

A  man,  aged  44,  whose  shoulder  joint  had  previously  been  excised  on  account 
of  great  pain  and  immobility,  returned  to  the  Hospital  with  radiating  pain 
over  the  whole  upper  extremity.  The  brachial  plexus  was  stretched  in  the 
axilla,  but  without  relief  to  the  patient. 

DISEASES  OF  THE  CIECULATOEY  SYSTEM. 
ANEURISM. 
Of  Sterno-mastoid  Artery. 

A  man,  aged  33,  a  drunkard,  was  admitted  with  a  small  aneurism  of  an 
artery  which  entered  the  sterno-mastoid  muscle  about  its  centre.  The  patient 
discharged  himself  before  any  treatment  was  adopted. 

Popliteal. 

(1)  A  man,  aged  28,  of  healthy  appearance,  a  fireman  in  an  aerated  water 
business,  and  accustomed  to  much  standing,  was  admitted  with  an  aneurism  of 
the  left  popliteal  artery.  He  had  suffere'^d  from  syphilis  9  years  previously. 
The  superficial  femoral  was  tied  in  two  places  with  a  kangaroo  tendon  ligature, 
and  the  vessel  divided  between.     The  patient  made  a  good  recovery. 

(2)  A  woman,  aged  36,  had  noticed  a  swelling  in  the  right  ham  for  5  weeks. 
She  had  a  well-marked  aneurism  -nith  a  very  thin  sac.  After  rest  in  bed  an 
Esmarch's  bandage  was  applied  and  retained  for  one  hour  ;  pressure!  by  a  tour- 
niquet was  then  maintained  for  two  hours,  but  without  causing  any  improve- 
ment ;  digital  pressure  was  then  applied  for  several  days,  but  without  success. 
The  superficial  femoral  was  then  ligatured  in  Scarpa's  triangle.  The  vessel 
was  tied  in  two  places  with  catgut,  and  divided  between  the  ligatures.  Eecovery 
was  rapid. 


7G 

Subclavian. 

A  woman,  risked  62,  was  admitted  with  a  pulsatiri!?  swclliniiT  on  the  ri^ht  side  of 
the  neck,  in  tlie  course  of  tlie  carotid  arlwy.  'J'lic  swelling  extended  downwards 
l)cyond  the  sterno-clavicular  articulation,  and  its  Lnver  margin  could  not  be 
felt.  The  pulse  in  the  temporal  and  facial  arteries  was  diminished,  and  a 
s]ihygmographic  tracing  showed  that  the  blood  current  in  them  was  very  feeble. 
The  radial  pulse  also  was  feeble  and  not  synchronous  with  that  of  the  opposite 
arm.  The  patient  had  occasional  attacks  of  aphonia  and  giddiness.  The 
swelling  had  been  noticed  for  3  months.  Pain  was  referred  to  the  arm  and 
head.  The  case  was  thought  to  be  one  of  carotid  and  innominate  aneurism, 
but  no  operation  was  deemed  advisable.  The  aneurism  progressed  with  gi-eat 
rapidity,  the  trachea  was  compressed,  and  the  patient  died  o  weeks  after 
admission.  A  post-mortem  examination  showed  that  the  aneurism  was  situated 
in  the  first  part  of  the  subclavian,  and  that  it  had  extended  beneath  the 
sterno-mastoid  muscle,  and  compressed  the  carotid.  The  latter  vessel  and  the 
innominate  were  quite  healthy.  On  the  thiixl  part  of  the  subclavian  was 
another  aneurism  the  size  of  a  large  walnut,  evidently  of  long  standing,  and 
completely  consolidated. 

Recurrent  Pulsation  in  Aneurism. 

A  messenger,  aged  37,  whose  external  iliac  had  been  ligatured  in  1878  for 
aneurism  of  that  vessel,  and  who  had  been  in  the  Hospital  in  August,  1883,  with 
recurrent  pulsation  in  the  sac,  was  readmitted  with  marked  pulsation  at  the 
site  of  the  previous  aneurism.  He  had  led  a  very  active  life  since  the  operation. 
After  a  few  days  rest  in  bed  pulsation  entirely  ceased. 

A  hawker,  aged  38,  whose  femoral  had  been  ligatured  in  January,  1883,  for 
popliteal  aneurism,  and  who  had  returned  to  the  Hospital  with  recurrent 
pulsation  in  October  of  the  same  year,  was  readmitted  in  February,  1884,  with 
pain  and  distinct  pulsation  which  had  supervened  after  a  20-mile  walk.  Under 
treatment  by  careful  bandaging  the  pulsation  much  diminished,  but  had  not 
quite  ceased  when  the  patient  left  the  Hospital. 

Traumatic  Aneurism. — («)  Radial. 

A  clerk,  aged  21,  cut  his  wi'ist  3  weeks  before  admission  to  Hospital;  hajmor- 
rhage,  which  was  slight,  was  arrested  by  pressure.  A  swelling  soon  appeared, 
and  proved  to  be  a  small  circumscribed  aneurism.  Pressure  resulted  in  a 
rapid  cure. 

(h)  External  Iliac. 
A  carman,  aged  45,  of  healthy  appearance,  suffered  from  a  very  severe  wrench 
of  his  leg  on  December  11th.  The  next  day  he  noticed  a  swelling  in  the  right 
gi'oin,  and  felt  a  dull  aching  pain  in  the  same  situation.  He  continued  at 
work  until  December  28th,  not  suffering  much  pain,  but  the  swelling  gradually 
increasing  in  size.  On  the  29th  he  came  to  the  Hospital.  He  was  then  found 
to  have  a  large,  oval,  pulsating  swelling  in  the  right  iliac  fossa,  extending 
from  Poupart's  ligament  below  up  to  the  level  of  the  anterior  superior  spine 
of  the  ilium.  The  right  leg  and  foot  were  oedcmatous  ;  there  was  pulsation  in 
the  femoral  and  posterior  tibial  arteries.  The  circumference  of  the  right  thigh 
measured  G  inches  more  than  that  of  the  left ;  urine  showed  a  trace  of 
albumin.  On  December  29th  the  external  iliac  was  secured  above  the  site  of 
the  aneurism  with  a  kangaroo  tendon  ligature,  under  antiseptic  precautions  ;  the 
wound  did  not  heal  by  first  intention,  but  the  sac  diminished  in  size  and  ceased  to 
pulsate.  The  wound  gxanulated  healthily,  and  all  went  well  until,  on  February 
14th,  slight  oozing  occurred  from  a  sinus  at  one  end  of  the  wound.  On 
February  21st  sudden  and  copious  hcemorrhage  occurred  from  the  same  situa- 
tion. The  v,'ound  was  at  once  opened  up,  the  peritoneal  cavity  also  being  freely 
exposed,  but  the  tissues  were  so  matted  by  the  inflammation  that  it  was  not 
possible  to  recognise  the  exact  seat  of  the  hemorrhage.  Two  ligatures  were, 
however,  successfully  placed  upon  the  external  iliac.  Hfemorrhage  however 
continued,  and  was  finally  arrested  by  clamp  forceps  placed  on  what  appeared 
to  be  the  bleeding  point,  and  by  plugging  with  lint  steeped  in  perchloride 
of  u'on.     The   patient  lost  a  considerable  quantity  of  blood ;  for  a  time  he 


77 

rallied,  but  then  again  became  weaker  ;  lie  had  copious  expectoration  and 
troublesome  cough  ;  the  pulse  became  small,  rapid,  and  running,  but  the  tem- 
perature rose  to  10r5°.  He  died  at  9.30  in  the  everdng  of  February  23rd, 
without  any  further  recurrence  of  the  hemorrhage.  A  post-mortem  examination 
showed  commencing  peritonitis.  The  tissues  were  so  matted  and  discoloured 
by  perchloride  of  iron  that  it  was  not  possible  to  ascertain  accurately  their 
condition.  The  original  ligature  was  not  found  ;  the  sac  of  the  aneurism  was 
almost  obliterated,  as  was  also  the  external  iliac  on  its  distal  side.  The  sac 
was  situated  about  half  an  inch  below  the  bifurcation  of  the  common  iliac, 
but  that  part  of  the  external  iliac  on  which  the  ligature  had  originally  been 
placed  was  completely  destroyed,  and  an  irregular  aperture  closed  by  a  pair  of 
forceps  communicated  with  the  termination  of  the  common  Hiac. 

LYMPHATIC  SYSTEM. 
Lymphangiectasis. 

This  condition  was  found  in  a  boy,  aged  16,  who  applied  to  the  Hospital  on 
account  of  a  warty  growth  on  the  buttock,  which  was  said  to  be  congenital. 
On  remoYal,  the  growth  was  found  to  be  composed  of  numerous  distended 
lymphatics. 

DIGESTIVE  SYSTEM. 

(1)  TONGUE. 

Chronic  Superficial  Glossitis. 

This  occurred  in  a  woman,  aged  30,  and  liad  existed  4  years  in  spite  of  treat- 
ment.   No  cause  could  be  assigned 

Tubercular  Ulceration. 

In  a  woman,  aged  44,  who  died  of  phthisis  after  being  transferred  to  a 
medical  ward. 

(2)  Si\JIALL  INTESTINES. 
Intussusception. 

A  female  child,  aged  one  year  and  nine  months,  was  admitted  with  well- 
marked  symptoms  of  intussusception.  After  the  failure  of  taxis  and  injection 
of  the  rectum,  abdominal  section  was  performed,  and  the  invaginated  gut 
reduced  without  much  difficulty.  The  child  at  the  time  of  operation  was  in 
a  condition  of  severe  collapse,  and  died  of  shock  within  a  few  hours.  There 
was  no  peritonitis. 

In  a  child,  aged  one  year  and  a  half,  an  intussusception  of  considerable  size 
was  reduced  by  injection  vdth.  warm  milk.  It  again  descended  the  next  day, 
and  was  again  returned  by  similar  treatment.    The  child  made  a  good  recovery. 

An  infant,  aged  4  months,  admitted  with  a  very  large  intussusception,  and  in 
an  almost  moribund  condition,  died  after  attempts  at  reduction  by  injection  of 
warm  water.  A  post-mortem  examination  showed  a  rupture  of  the  descending 
colon,  and  a  large  intussusception  commencing  at  the  ileo-coecal  valve. 

An  infant,  aged  7  months,  died  a  few  hours  after  admission  to  the  Hospital. 
It  had  suffered  from  an  intussusception  for  8  days.  Eeduction  apparently 
followed  injection  of  warm  milk,  but  the  patient  did  not  rally.  A  post-mortem 
examination  was  not  permitted. 

Ulcer  of  Intestine  followed  by  Perforative  Peritonitis. 

A  porter,  aged  43,  was  admitted  with  a  view  to  amputation  of  a  diseased 
finger  with  necrosed  bone.  He  was  found  to  have  albuminuria,  and  operation 
was  postponed.  Eight  days  later  he  had  symptoms  of  peritonitis ;  sickness 
supervened,  and  he  died  on  the  fourth  day  after  the  symptoms  commenced. 
A  post-mortem  examination  showed  a  small  ulcer  of  the  small  intestine  12 
inches  from  the  cscum,  about  the  si2e  and  shape  of  a  date-stone,  lying  trans- 
versely to  the  long  axis  of  the  bowel,  with  no  thickening  or  induration  of 
either  base  or  edges,  and  opening  into  the  peritoneal  cavity  by  a  longitudinal 
slit.     Remainder  of  intestines  quite  healthy.     General  peritonitis. 


78 

Hernia. 

(1)  Traumatic. — In  a  man,  aged  22,  a  scrotal  hernia  resulted  from  an  assault, 
during  which  a  man  jumped  forcibly  on  his  belly. 

Strangulated  Inguinal. — Of  22  cases  taxis  was  successful  in  11  ;  all  the 
patients  were  males.  In  one  case  the  sac  was  cut  away  at  the  time  of  opera- 
tion.    Three  patients  died  after  herniotomy. 

A  tram-driver,  aged  42,  was  admitted  on  January  28th  with  strangulated 
right  inguinal  hernia  of  2-1  hours'  duration.  After  taxis  he  was  relieved  and 
the  symptoms  subsided.  Until  the  third  day  after  this  he  had  no  sickness 
whatever,  and  no  sign  of  peritonitis.  He  took  liquid  food  well,  but  his  belly 
became  gradually  gi'catly  swollen.  On  January  31st  he  became  suddeidy  worse, 
had  great  pain  with  sickness  and  collapse.  Herniotomy  was  performed,  and 
several  inches  of  almost  gangrenous  gut  were  found  in  the  inguinal  canal ;  the 
small  intestines  above  were  distended  almost  to  bursting,  and  in  many  places 
the  peritoneal  coat  had  split.  He  died  a  few  hours  after  the  operation.  A  post- 
mortem examination  showed  that  he  had  been  the  subject  of  an  '•  encysted  " 
hernia  on  the  right  side,  and  of  an  ''  infantile  "  one  on  the  left ;  the  sac  of  the 
latter  was  empty. 

A  Jew,  aged  41,  was  admitted  -nnth  a  strangulated  inguinal  hernia  which  had 
been  irreducible  for  72  hours.  Reduction  was  effected  without  the  aid  of 
anesthetics,  but  without  affording  any  relief  to  the  symptoms  ;  12  hours  later 
an  exploratory  operation  in  the  inguinal  region  was  undertaken,  but  nothing 
abnormal  was  discovered.  Vomiting  continued,  and  the  patient  died  exhausted. 
No  post-mortem  examination  was  permitted. 

An  imbecile,  aged  52,  was  admitted  with  a  large  irreducible  scrotal  hernia. 
There  were  no  local  signs  of  strangulation,  but  vomiting  was  continuous, 
and  there  was  no  passage  of  wind  or  feces.  The  operation  of  herniotomy  was 
performed,  but  no  strangulation  was  discovered.  The  patient  died  the  following 
day.  A  post-mortem  examination  showed  a  distinct  volvulus  with  constriction 
of  the  gut  and  general  peritonitis. 

Strangulated  Femoral. — All  the  patients  were  women  ;  out  of  19  cases  taxis 
was  successful  in  only  2;  of  17  cases  operated  upon,  6  died.  In  .3  of  the  6  who 
died,  the  sac  was  excised  at  the  time  of  operation,  as  well  as  in  7  of  those  who 
recovered. 

One  patient,  aged  44,  died  the  same  day  she  was  admitted,  6  houi's  after 
operation.  A  post-mortem  showed  general  peritonitis  with  perforation  of  the 
gut  at  the  seat  of  stricture,  and  foecal  extravasation. 

A  feeble  old  woman  of  59  died  6  weeks  after  herniotomy  with  bed-sores  and 
gangrene  of  the  great  toe. 

A  woman  of  72  died  with  general  peritonitis  48  hours  after  operation.  The 
gut  at  the  site  of  strangulation  was  simply  congested. 

A  woman  of  52  died  with  general  peritonitis  48  hours  after  operation.  The 
gut  was  congested. 

A  woman  of  65  who  had  suffered  from  symptoms  of  strangulation  for  4  days, 
and  whose  intestine  at  the  time  of  operation  was  almost  gangrenous,  died  with 
general  peritonitis  36  hours  after  operation. 

A  woman  of  65  died  apparently  of  collapse  on  the  second  day  after  hernio- 
tomy.    There  was  no  peritonitis  ;  the  kidneys  were  granular. 

Strangulated  Umhilieal. — A  married  woman,  aged  40,  was  admitted  with  an 
iimbilical  hernia  strangulated  for  48  hours.  Herniotomy  was  successfully 
performed,  and  a  large  mass  of  omentum  removed. 

A  woman,  aged  45,  died  with  general  peritonitis  about  14  hours  after 
herniotomy  had  been  perfoi-med.  The  post-mortem  examination  showed  that 
the  gut  was  ulcerated  through  at  the  seat  of  stricture.  Strangulation  had 
existed  5  days. 

A  woman,  aged  64,  made  a  good  recovery  after  operation  for  a  hernia  which 
had  been  strangulated  some  days. 

A  woman,  aged  61,  made  a  good  recovery  after  herniotomy  and  removal  of  a 
large  mass  of  omentum  ;  the  sac  also  was  cut  away  and  its  neck  stitched  up. 


79 

Strangulatecl  Ventral. — A  -vroman,  aged  46,  -n^lio  had  undergone  the  operation 
of  ovariotomy  5  years  previoiisly,  and  who  had  suffered  from  a  hernia  at  the 
site  of  the  wound  ever  since  the  latter  had  closed,  was  admitted  with  symptoms 
of  strangulation.  She  was  extremely  stout ;  reduction  was  comparatively  easily 
effected  by  taxis,  but  the  patient  died  3  hours  later.  A  post-mortem  "exami- 
nation showed  general  peritonitis,  with  very  extensive  adhesions  of  the  coats 
of  intestines  to  one  another,  as  well  as  to  the  cicatrix  ;  part  of  the  gut  was 
gangrenous,  and  faeces  had  escaped  into  the  abdominal  cavity. 

(3)  RECTUM.  \ 

Fibrous  Stricture.  '*''^' 

Eleven  cases  of  fibrous  stricture  were  treated  ;  all  the  patients  were  women. 
In  3  cases  proctotomy  was  performed. 

Cancer. 

Colotomy  was  performed  upon  a  woman,  aged  35,  for  obstruction  ;  she  made 
a  satisfactory  recovery. 

A  woman,  aged  39,  was  admitted  with  a  foecal  abscess  in  the  abdominal 
wall,  and  cancer  of  the  rectum  and  uterus  ;  she  died  12  days  after  admission. 
A  post-mortem  showed  that  there  were  ulcerated  apertures  in  the  small  intes- 
tines and  in  the  colon. 

An  emaciated  woman  of  43  died  2  days  after  admission  \nth.  symptoms  of 
peritonitis.  A  post-mortem  examination  showed  extensive  cancerous  ulcera- 
tion of  the  rectum,  and  an  abscess  situated  between  the  rectum  and  anus, 
which  had  burst  into  the  peritoneal  cavity. 

In  a  man,  aged  29,  too  far  advanced  for  operation. 

A  man,  aged  37,  who  had  previously  been  a  patient  in  the  Hospital,  returned 
in  September.  In  March,  1882,  colotomy  had  been  performed  on  account  of 
intestinal  obstruction,  the  cause  of  which  was  not  at  the  time  ascertainable. 
On  readmission  he  was  found  to  have  extensive  cancerous  growth  in  the 
sigmoid  flexure  and  rectum. 

Excision  of  the  rectum  was  performed  twice.  In  the  first  case  on  a  man, 
aged  62,  for  a  cancerous  growth  of  the  nature  of  cylindrical-celled  epithelioma. 
The  patient  died  on  the  thii-d  day  with  symptoms  of  collapse.  Post-mortem, 
no  peritonitis,  kidneys  granular,  lungs  oedematous. 

In  the  second  case  the  operation  was  undertaken  for  a  soft  gi-owth.  partly 
pedunculated,  about  2^  inches  in  diameter,  which  on  removal  was  found  to  be 
fibrous.     The  patient  died  of  peritonitis. 

DISEASES  OF  THE  URINARY  SYSTEM. 
Removal  of  Enlarged  Prostate. 

A  man,  aged  65,  who  had  previously  been  operated  on  for  calculus  vesicte,  was 
admitted  with  fresh  symptoms  of  calculus.  Median  lithotomy  was  performed; 
the  prostate  was  found  to  be  very  gi-eatly  enlarged,  and  was  therefore  removed. 
The  patient  made  a  good  recovery.  A  year  later  he  died  after  another  opera- 
tion for  removal  of  a  calculus.  A  small  cavity  marked  the  site  of  the  excision, 
a  thin  capsule  of  prostatic  tissue  alone  remaining. 

Lithotrity. 

In  a  woman,  aged  21,  for  a  uric  acid  stone,  weighing  1  ounce. 
In  a  lad,  aged  15,  for  a  uric  acid  stone,  measuring  f-inch  in  its  greatest 
diameter. 

In  a  man,  aged  71,  for  a  phosphatic  stone,  averaging  1  inch  in  diameter. 
In  a  man,  aged  59,  for  a  small  uric  acid  stone. 

In  a  man,  aged  64,  for  a  small  phosphatic  stone.  This  patient  had  a  bad 
stricture  of  the  urethra. 

All  these  operations  were  done  at  a  single  sitting. 

Lithotomy. 

Nine  operations  ;  7  by  the  lateral,  and  2  by  the  median  incision.  All  the 
patients  recovered. 


80 

DISEASES  OF  THE  ORGANS  OF  LOCOMOTION. 

Bones. 

Acute  Periostitis  of  the  tibia  proved  fatal  in  a  girl  aged  8  a  fortnight  after 
admission  ;  death  resulted  from  pyasmia.  A  post-mortem  examination  showed 
purulent  periostitis  and  multiple  abscesses. 

A  lad,  aged  12,  died,  6  weeks  after  admission,  of  pytemia  following  acute 
periostitis  of  the  femur.     No  post-mortem  was  allowed. 

Joints. 

Syphilitic  Disease  (see  also  "  Syphilis"). 

A  woman,  aged  27,  the  subject  of  inherited  syphilis,  had  suffered  pain  in  the 
knee  for  H  months.  On  admission  the  left  knee  was  found  swollen  and  partly 
flexed  ;  there  was  an  excess  of  fluid  in  the  synovial  cavity,  and  thickening  of 
the  synovial  membrane;  nodes  on  tibia  and  radius;  ulcer  on  foot ;  iritis.  Under 
treatment  by  pot.  iod.  and  mercury  the  thickening  and  efEusion  subsided. 

Charcot's  Disease. 

In  a  man,  aged  42,  well-marked  symptoms  of  tabes.  Knee-joint  affected  for  5 
years  ;  has  had  perforating  ulcers  of  the  foot. 

A  man,  aged  50,  died  of  blood-poisoning  after  amputation  of  the  great  toe 
for  perforating  ulcer.     He  had  disease  of  the  knee-joint  and  tabes  dorsalis. 

A  man,  aged  46,  had  well-marked  disease  in  the  right  knee  and  commencing 
trouble  in  the  left ;  he  had  also  tabes  dorsalis. 

In  a  woman,  aged  51,  for  25  years  the  subject  of  tabes  dorsalis,  the  knee- 
joint  had  become  completely  disorganised  during  the  12  months  previous  to 
her  admission  to  the  Hospital. 

[For  further  accounts  of  these  cases,  see  the  discussion  at  the  Meetings  of 
the  Clinical  Society  in  November  and  December,  1884,  and  in  January,  1885.] 

Suppurative  Arthritis  of  the  Knee  after  Puerperal  Fever. 

Two  cases,  each  in  women  aged  36.  Both  patients  were  in  a  very  bad  state 
on  admission,  and  both  died  a  few  days  after  amputation  had  been  performed. 
In  neither  was  there  any  evidence  of  pyaemia  or  other  form  of  blood-poisoning 
following  the  operation.  In  each  patient  the  kidneys  were  found  enlarged 
and  fatty. 

DISEASES  OF  SKIN. 
li/lalignant  Pustule. 

In  a  man,  aged  42,  who  had  been  employed  in  currying  hides.  He  had 
noticed  a  swelling  on  the  neck  for  about  a  fortnight ;  on  admission  he  was 
found  to  have  a  typical  malignant  pustule  below  the  right  car  ;  after  complete 
excision  he  made  a  rapid  recovery. 

INJURIES. 

Head—Punctured  Fracture  of  Skull. 

In  a  child,  aged  3.  On  June  11th  fell  on  the  pavement  and  bruised  his  right 
eye  ;  on  June  13th  had  convulsions.  Admitted  June  14th  with  paresis  of 
left  half  of  body  and  limbs,  and  muscular  twitchings ;  semi-comatose.  Cheyne- 
Stokes'  respiration  ;  pupils  equal ;  no  strabismus.  After  ice-bag  to  head,  and 
calomel,  gr.  ij,  the  paresis  and  twitching  passed  off,  and  the  child  became 
sensible.  June  17th,  chemosis  of  conjunctiva  ;  19th,  rigor  ;  20th,  abscess 
pointing  in  upper  eyelid  opened.  Temperature  ranged  from  102°  to  105°. 
From  this  time  forwards  convulsions  were  frequent ;  much  pus  was  discharged 
from  the  abscess  above-mentioned.  Temperature  remained  high  until  the  child 
died  on  July  7th.  A  post-mortem  examination  revealed  a  small  scar  of  a 
punctured  wound  at  the  upper  reflexion  of  the  conjunctiva.  Corresponding  to 
this  a  punctured  fracture  of  the  roof  of  the  orbit,  and  an  orbital  abscess  com- 
municating with  a  large  collection  of  pus  in  the  frontal  convolutions. 


81 

Neck — Fracture  of  Cervical  Spine. 

In  a  man,  aged  63,  who  died  the  day  after  admission.  The  injury  was  caused 
by  a  fall  from  a  height  of  12  feet.  There  was  a  fracture-dislocation  at  the  level 
of  the  5th  and  6th  cervical  vertebra  ;  the  spinal  cord  was  torn.  The  2nd  and 
3rd  ribs  on  the  right  side,  and  the  Brd  and  4th  on  the  left  were  fractured. 

A  similar  accident  proved  fatal  in  a  man,  aged  52.  Injuries  of  a  similar 
character  were  found  post-mortem,  and,  in  addition,  the  sternum  was  fractured. 

Hsemorrfiage  into  Spinal  Cord. 

A  strongly  built  man,  aged  29,  plunged  into  a  swimming-bath  containing 
4  feet  of  water  from  a  height  of  4  feet.  He  struck  his  head  against  the  bottom 
and  was  immediately  paralysed  ;  he  had  complete  paraplegia,  and  died  2  days 
after  admission.  There  was  no  displacement  of  the  vertebrEe  nor  laceration  of 
the  spinal  meninges,  but  a  copious  haemorrhage  had  taken  place  into  the 
cord  itself  opposite  the  oth  cervical  vertebra,  the  tip  of  whose  spinous  process 
had  been  torn  off.     There  was  a  fissured  fracture  of  the  skull. 

Injuries  of  Tfiorax. 

A  man,  aged  24,  was  admitted  shortly  after  receiving  a  punctured  wound  in 
the  side  with  a  dinner-knife.  The  wound  was  situated  in  the  6th  interspace, 
just  outside  the  nipple  line  ;  there  was  much  haemorrhage,  but  no  evidence  of 
wound  either  of  the  lung  or  the  heart.  Two  days  later  his  breathing  became 
difficult,  and  his  temperature  raised  ;  the  following  day  he  developed  symptoms 
of  pericarditis,  and  a  day  later  had  effusion  in  each  pleura.  Temperature 
continued  high,  and  in  spite  of  tapping  of  the  pleuritic  effusion  the  patient 
died  12  days  after  the  receipt  of  the  injury.  A  post-mortem  showed  that  the 
knife-blade  had  glanced  forwards,  missing  both  the  pleura  and  the  pericardium, 
and  entering  the  anterior  mediastinum  ;  diffuse  suppuration  had  ensued  in 
the  mediastinal  cellular  tissue,  and  had  extended  to  both  the  pleura  and  peri- 
cardium. 

Injuries  of  ttie  Abdomen — Punctured  Wound. 

A  woman,  aged  36,  made  an  uninterruptedly  good  recovery  after  a  stab  with 
a  chisel  just  outside  and  below  the  level  of  the  umbilicus. 

Gunshot  Wounds. 

A  police  constable,  aged  34,  was  shot  by  a  burglar.  The  weapon  was  a 
revolver.  The  bullet  entered  1^  inches  above  the  pubic  spine  to  the  right  of 
the  tinea  alba,  and  tracked  downwards  and  outwards  towards  the  great  tro- 
chanter.    The  bullet  was  not  discovered,  but  the  man  made  a  good  recovery. 

A  police  constable,  aged  32,  was  shot  by  a  burglar  in  the  abdomen.  The 
weapon  in  this  case  also  was  a  revolver.  The  bullet  entered  just  below  the 
cartilages  in  a  line  drawn  from  the  right  nipple  to  the  umbilicus,  and  passed 
out  opposite  the  3rd  lumbar  vertebra  on  the  outer  edge  of  the  erector  spinse. 
There  were  no  symptoms  of  injury  to  any  important  viscus,  and  the  patient 
made  a  good  recovery. 

Injuries  of  Pelvis. 

A  woman,  aged  36,  died  of  pyaemia  2  months  after  a  compound  fracture  of 
the  pelvic  bone,  with  laceration  of  the  vagina.  There  was  extensive  necrosis 
of  the  fractured  bone. 

A  woman,  aged  32,  fractured  her  coccyx  5  months  before  admission  to  the 
Hospital.  Four  months  later  she  was  confined.  For  a  fortnight  before  admis- 
sion had  had  rigors  ;  she  was  in  a  very  weak  state  ;  temperature  was  high,  and 
during  a  rigor  rose  to  105°  and  106°  ;  she  had  an  abscess  in  the  coccygeal 
region.  She  died  9  days  after  admission,  having  had  numerous  rigors.  A  post- 
mortem examination  showed  fracture  of  the  coccyx  with  necrosis  of  the  sepa- 
rated portion  ;  the  broken  fragment  lay  in  a  sloughy  cavity.  Numerous 
abscesses  in  the  lungs  ;  purulent  pericarditis. 

F 


82 

Injuries  of  Upper  Extremity. 

In  two  cases  of  compound  fracture  of  the  bones  of  the  forearm,  spreading 
gangrene  supervened.     (See  "  Gangrene.'") 

A  dislocation  of  the  metacarpo-phalangeal  joint  of  a  fortnight's  duration 
was  found  to  be  quite  irreducible,  in  spite  of  free  subcutaneous  incision  of 
the  structures  which  appeared  tense.  The  patient  had  been  under  treatment 
at  another  hospital  immediately  after  the  accident,  and  all  attempts  at  reduction 
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Salivary  Fistula 
Rhinoplasty... 

Webbed  Fingers      

Contracted  Cicatrices 

Penile  Fistula         

Urethro- Vaginal  Fistuhi    ... 
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Extroverted  Bladder 

Excision   of   Bones   and 

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Wrist 

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Os  calcis        

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(b)  Neck  of    Femur  foi 
Anchylosis 

(c)  Tibia  for  Curvature 
(fZ)  Tarsus  for  Talipes  . . . 

Refracture  of  Femur 

Wiring — 

(a)  Old  Fractured  Patella 

(h)  Humerus       

(fi)  Fractured  Jaw 

Linear  Osteotomy 

Trephining — 

(a)  Femur           

(h)  Tibia 

Perfoi-ation  of  Antrum 
Removal  of  Carious  Bone... 

Removal  of  Sequestra — • 
(a)  Jaw  Bones    ... 
(h)  Humerus       

(c)  Carpus 

(d)  Metacarpal  Bones  and 
Phalanges     

(e)  Pubic  Bones 

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(q)  Tibia' 

(li)  Bones  of  Foot 

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OPERATIONS. 

Operations  on  Genito-Uei- 
NARY  Organs  (_co)dd.). 
Lithotomy — 
(«)  Lateral 
(i)  Median          

.15    : 
,2 

3 

Urethrotomy — 
(rt)  External 
(b)  Liternal        

Removal  of — 

(a)  Urethral  Calculus  ... 

(i)  Vascular  Caruncle  of 

Urethra       

Radical  Cure  of  Hydrocele 
HiBmatocele  Incised 

Castration 

For  Varicocele        

Rectal  Operations. 
Removal  of — 

(rt)  Ulcer  of  Rectum     ... 

(Z*)  Condylomata 
For  Fissure  of  Anus 

For  Fistula  in  Auo 

For    Fistula    opening    into 

Rectum  and  Urethra     ... 

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94 


STATISTICS   OF  ANiESTHETICS. 


During  the  year  1884  AnEesthetics  were  administered  3,404  times. 


Chloroform  was  administered        

...     1,244  tunes 

Nitrous  Oxide  Gas  (alone) 

...        437      „ 

Ether  (alone) 

...     1,016      „ 

Ether,  preceded  by  Nitrous  Oxide  Gas 

...        704      „ 

Methylene      i         

3      „ 

3.404 


No  Death. 


95 


APPENDIX   TO   TABLE   II. 


PLASTIC  OPEEATIONS. 

Ehinoplasty  was  performed  on  a  girl,  aged  11,  whose  nose  had  been  destroyed 
by  a  ferret  some  years  previously.  The  flap,  which  was  taken  from  the  arm, 
on  account  of  the  destruction  of  the  skin  of  the  forehead,  did  not  unite. 

In  one  case  for  extroverted  bladder  with  a  very  satisfactory  result. 

EXCISIONS. 

Of  the  shoulder,  in  the  case  of  a  man  whose  arm  had  been  amputated  at  the 
juncture  of  the  middle  and  upper  thii-d,  and  who  had  neuralgia  of  the  stump. 

Of  the  elbow  in  two  cases  for  strumous  disease. 

Of  the  wrist  in  two  cases  for  strumous  disease. 

Of  eight  cases  of  excision  of  the  hip,  five  patients  recovered.  In  two  of 
these  amputation  was  also  performed,  after  failure  to  obtain  a  good  result  by 
excision.     Of  the  three  patients  who  died  one  also  underwent  amputation. 

Excision  of  the  knee  was  successfully  performed  on  three  occasions.  In  one 
case  the  limb  was  the  seat  of  infantile  paralysis. 

Re-excision  was  performed  with  satisfactory  result  in  a  child,  aged  11,  whose 
limb  had  become  distorted  after  a  previous  operation. 

The  astragalus  was  twice  excised,  once  for  caries  and  once  for  necrosis  following 
upon  dislocation  of  the  bone  forwards. 

The  superior  maxillary  bone  was  twice  removed,  once  for  epithelioma  and 
once  for  sarcoma.     Both  patients  recovered. 

One  lateral  half  of  the  inferior  maxilla  was  excised  for  periosteal  sarcoma. 

The  body  of  the  lower  jaw  was  excised  in  another  case  for  a  similar  disease. 

OSTEOTOMT. 

In  eleven  cases  of  genu  valgum,  double  osteotomy  after  McEwen's  method 
was  performed  on  four  occasions,  in  each  with  good  result.  In  two  cases  one 
leg  alone  was  operated  on  by  the  same  method.  In  one  of  these,  suppuration 
of  the  wound  and  of  the  knee  joint  ensued,  but  the  patient  after  a  prolonged 
illness  recovered  with  a  stiff  articulation.  In  one  case  McEwen's  operation 
was  performed  with  good  results  on  a  limb  which  had  on  a  previous  occasion 
been  operated  on  after  Ogston's  method.  In  one  case  Ogston's  operation  was 
performed  on  one  side  only ;  in  another  case  on  both  sides.  In  a  patient,  aged 
16,  Ogston's  operation  was  performed  for  genu  valgum  on  the  right  side,  and 
osteotomy  of  the  femur  was  attempted  for  genu  varum  of  the  left  extremity. 
This  operation,  however,  was  not  completed  on  account  of  the  extreme  laxity 
of  the  ligaments  allowing  the  leg  to  be  brought  into  good  position  without 
division  of  the  bone. 

WIRING  OF  BADLY  UNITED  FEACTUEE  OF  THE  PATELLA. 

This  was  undertaken  in  one  case.  Much  difficulty  was  experienced  in  brine- 
ing  the  fragments  into  good  opposition,  and  suppuration  of  the  joint  ensued. 
The  patient  recovered  with  a  stiff  articulation. 


96 

OSTEOPLASTIC  SECTION  OF  SUPE2I0R  MAXILLA. 

This  operation  was  undertaken  on  account  of  a  tumour  in  connection  with 
the  nasal  cavities,  accompanied  by  frequent  and  copious  hsemorrhage.  The 
superior  maxillary  and  malar  bones  were  pushed  forward,  but  not  apparently 
infiltrated  by  the  growth.  No  difficulty  was  experienced  in  wrenching  the 
superior  maxilla  aside  after  the  usual  incision  had  been  made.  The  removal 
of  the  tumour,  however,  was  not  feasible.  There  was  no  definite  tumour,  but 
the  whole  of  the  mucous  membrane  and  periosteum  covering  the  palate  bones, 
lining  the  left  nostril,  the  anterior  fossa  of  the  base  of  the  skull,  and  the 
sphenoidal  and  ethmoidal  sinuses  was  the  seat  of  a  nsevoid  growth  (which  on 
microscopic  examination  showed  an  almost  erectile  structure)  from  which  the 
haemorrhage  was  exceedingly  profuse.  A  considerable  mass  of  the  tumour  was 
removed,  and  the  haemorrhage  arrested  by  pressure.  The  patient  died  half  an 
hour  after  getting  back  to  bed,  never  having  rallied  from  the  time  of  the  first 
gush  of  blood. 

AMPUTATIONS. 

Primary. 

Thigh. — In  one  case  amputation  in  the  upper  third  proved  fatal  from  shock. 
The  operation  was  undertaken  for  a  compound  fracture  of  the  femur  opening 
the  knee  joint  with  much  laceration  of  the  muscles.  The  other  femur  was  also 
fractured.    Xo  post-mortem  examination  was  permitted. 

An  old  woman,  aged  72.  died  of  shock  29  hours  after  amputation  of  the  thigh, 
performed  for  a  compound  fracture  of  the  tibia  and  fibula. 

Secondary. 

Arm. — For  spreading  gangrene.     QSee  •■  Gangrene,"  page  74.) 

For  diffuse  cellulitis  following  crushed  fingers  in  an  old  man  of  72.  Ampu- 
tation was  performed  10  weeks  after  the  injury,  the  hvimerus  being  found 
necrosed  in  parts.  Eleven  days  later  rigors  with  high  temperature  supervened, 
and  the  patient  died  exhausted  18  days  after  operation.  No  post-mortem 
allowed. 

Thigh. — For  gangrene.    (^See  ••  Gangrene,"  page  74.) 

AMPUTATIONS  FOE  DISEASE. 

Shoulder  Joint. — In  one  case  for  periosteal  sarcoma  of  humerus.  In  another 
for  subclavian  aneurism.  (For  details  of  latter  case,  see  Surgical  Report  for 
1883.) 

Forearm. — In  three  cases  for  strumous  disease  of  wrist.  In  one  case  for 
epithelioma  of  the  back  of  the  hand. 

Hip  Joint. — In  three  cases  after  the  failure  of  excision.  Two  patients 
recovered,  one  died. 

Thigh — Upper  Tliird. — In  one  case  for  sarcoma  of  the  femur  with  good 
result.  In  another  for  epithelioma  occurring  in  the  site  of  an  old  sinus  leading 
down  to  dead  bone.  In  this  case  a  large  portion  of  the  flap  sloughed,  and  the 
patient  gradually  became  very  weak.  The  evening  before  his  death,  which 
occurred  very  suddenly,  he  had  a  rigor.  A  post-mortem  examination  showed 
large  fatty  kidneys,  but  no  evidence  of  blood  poisoning. 

Middle  Tliird. — In  a  man,  aged  27,  on  account  of  suppurative  arthritis 
following  an  operation  for  the  removal  of  a  bursal  cyst,  which  was  within  the 
capsule  of  the  joint.  In  three  cases  for  joint  disease.  In  one  for  syphilitic 
ulcer  of  the  leg. 

In  two  cases  for  suppurative  arthritis  following  puerperal  fever.  QSee 
"  Joints  "  page  80.)     Both  patients  died. 

In  one  case  for  periosteal  scarcoma  of  femur.  In  the  latter  case  the  patient, 
a  lad  of  20.  died  with  double  pleurisy  12  days  after  operation.  The  viscera 
generally  were  found  healthy,  and  there  was  no  other  evidence  of  blood 
poisoning. 


97 

Lower  Third. — In  thirteen  cases  for  diseased  knee  joint.  T-welve  patients 
recovered,  one  died.  In  the  latter  case  the  patient  was  a  wonian,  aged  53. 
Pj-resia  set  in  the  day  after  operation  ;  the  patient  died  18  days  later.  A 
post-mortem  showed  numerous  abscesses  in  the  lungs  and  advanced  kidney 
disease. 

In  a  girl,  aged  11,  for  fibro-sarcoma  of  the  popliteal  space. 

In  a  girl,  aged  17,  for  diseased  ankle  and  infantile  paralysis. 

In  a  girl,  aged  11,  for  diseased  ankle  with  necrosis  of  tibia. 

In  one  case  for  myeloid  sarcoma  of  tibia.  The  patient,  a  man.  aged  25,  had 
previously  undergone  another  operation  for  the  local  removal  of  the  tumour, 
during  which  it  was  found  necessary  to  open  the  knee  joint. 

In  a  man,  aged  26,  for  periosteal  sarcoma  of  the  femur. 

Knee  Joint. — A  man,  aged  57,  died  after  a  sharp  attack  of  secondary  hfemor- 
rhage  ensuing  on  the  7th  day  after  operation,  and  treated  by  ligature  of  the 
femoral  in  Hunter's  canal.  A  post-mortem  showed  the  popliteal  artery  to  be 
widely  open  at  the  seat  of  section,  and  extensively  atheromatous. 

Leg. — In  a  lad,  aged  20,  for  a  large  ulcer  on  the  leg,  with  caries  of  the  tibia, 
resulting  from  a  burn. 

In  a  woman,  aged  56,  for  disease  of  ankle  joint.  At  the  time  of  operation 
the  patient  was  in  an  unsatisfactory  condition,  the  limb  being  much  inflamed 
as  the  result  of  an  operation  undertaken  a  week  previously  for  the  removal  of 
some  dead  bone  fTom  the  astragalus  and  internal  malleolus.  The  amputation 
was  performed  because  the  patient  appeared  to  be  rapidly  going  down  hill  on 
account  of  the  constant  pain  and  profuse  suppuration.  No  material  benefit 
resulted ;  the  patient  became  weaker,  and  diarrhoea  with  inability  to  retain 
any  food  followed.  The  patient  left  the  hospital  against  advice,  and  died  3 
days  later. 

A  woman,  aged  29,  was  admitted  with  much  swelling  of  the  leg,  and  pain 
about  the  ankle  joint.  The  case  was  found  to  be  one  of  necrosis  of  the  shaft 
of  the  fibula.  The  course  of  the  case  was  by  no  means  acute,  but  rather  sub- 
acute. The  patient  was  in  a  very  weak  and  anaemic  condition,  and  after  pro- 
longed attempts  to  save  the  limb,  amputation  in  the  upper  third  of  the  leg  was 
performed.     The  patient  died  of  exhaustion  2  days  later. 

Syme's. — ^In  four  cases  for  disease  of  the  ankle  joint. 
In  three  cases  for  disease  of  the  tarsus. 
All  the  patients  recovered. 

Breast. — Of  thirty-four  cases,  thii-ty-two  recovered  and  two  died.  One 
woman,  aged  50,  of  erysipelas  contracted  5  days  after  removal  ;  the  other  of 
pleurisy  and  congestion  of  the  lungs,  found  after  death  to  be  due  to  secondary 
deposits  in  the  lungs  and  pleura. 

A  woman  of  51:  died  3  months  after  removal  of  a  recurrent  gi'owth,  from 
exhaustion  due  to  secondary  growths  in  the  viscera  and  from  recurrence  in  the 
wound. 

REMOVAL  OF  TUMOUES, 

Tongue. — The  whole  tongnie  was  twice  removed  by  scissors ;  fi\'e  times  by  the 
whijicord  ecraseur ;  once  by  Kocher's  submental  operation ;  and  once,  together 
mth  the  body  of  the  lower  jaw,  by  scissors  and  the  ecraseur.  Of  these  cases 
two  died.  One  patient,  whose  tongue  had  been  excised  with  scissors,  died  of 
septic  pneumonia ;  and  the  patient  on  whom  Kocher's  operation  had  been 
performed  died  5  days  later  with  inflammation  extending  from  the  larynx  to 
the  smaller  bronchi ,  the  lungs  being  much  congested. 

The  lateral  half  of  the  tongue  was  thi-ee  times  excised  with  scissors ;  twice 
with  a  whipcord  ecraseur.  In  one  case  a  small  epitheliomatous  growth  was 
cut  out  with  scissors.  All  these  patients  recovered.  One  patient,  half  of  whose 
tongue  was  excised,  was  a  woman,  aged  32.  The  disease  recurred  shortly  after 
she  left  the  hospital. 

o 


98 

EEMOVAL  OF  CARCINOMA  OF  PROSTATE. 

The  operation  of  perineal  section  was  done  on  a  man,  aged  51,  and  a  portion 
of  a  carcinous  gro\\-th  was  removed  from  the  region  of  the  prostate.  The 
patient  died  of  an  extension  of  the  gro^rth  some  months  later. 

NERVE  SUTURE. 

In  one  case  primary  suture  was  done  for  a  recently  divided  ulnar  nerve. 

In  three  cases  the  divided  ends  of  the  ulnar  nerve  were  resected  and  secon- 
dary suture  was  performed.  In  one  case  a  similar  operation  was  performed 
on  the  median  nerve.  In  one  on  both  the  median  and  ulnar,  and  in  one  on  the 
peroneal.  (Although  some  of  the  patients  were  improved  by  operation,  in 
none  had  the  nerve  cntu'ely  united  at  the  time  of  the  patient  leaving  the 
Hospital.) 

NERVE  STRETCHING.     {See  also  "  Neuralgia,"  page  75.) 

An  engineer,  aged  31,  was  shot  in  the  leg  in  1875.  In  October,  1880,  he  was 
operated  on  by  Mr.  Holdeu  on  account  of  epileptiform  fits,  which  had  super- 
vened since  the  injury,  i  inches  of  the  posterior  saphenous  nerve  being  excised, 
with  the  result  that  the  patient  had  no  return  of  the  fits  until  March,  1884. 
He  came  to  the  Hospital  on  April  17th.  There  were  several  shots  near  the 
surface  of  the  leg  on  its  outer  side,  and  there  was  pain  and  tenderness  along 
the  peroneal  nerve.  The  shots  were  excised  and  the  patient  improved.  After 
discharge  the  fits  again  recurred,  and  on  July  9th  the  sciatic  nerve  was 
stretched.  The  patient  had  no  more  fits,  and  was  discharged  well  on 
September  12th.  The  operation  was  followed  by  much  suppuration  in  the 
course  of  the  sciatic  nerve. 

EXCISION  OF  MECKEL'S  GANGLION. 

This  operation  was  performed  on  a  man,  aged  59,  for  the  relief  of  epilepti- 
form neuralgia,  which  had  resisted  other  operation  procediu'es.  While  in  the 
Hospital  the  patient  had  no  return  of  the  pain. 

OPERATIONS  ON  TENDONS. 

In  two  cases  the  tendo  achillis,  and  in  one  the  peronei  tendons  were 
resected  with  the  object  of  diminishing  their  length.  In  the  former  cases  for 
talipes  calcaneus,  in  the  latter  for  talipes  valgus. 

In  four  cases  tendons  which  had  been  previously  divided  were  resected  and 
sutured. 

URINARY  ORGANS.     (See  also  "  Lithotomy  and  Lithotrity,"  page  79.) 

In  two  cases  the  bladder  was  explored  for  tumours.  In  each  case  a  sar- 
comatous gro'VNi:h  was  found. 

Ne2)lirotomy. — In  a  girl,  aged  21,  for  suppurating  kidney.  It  was  doubtful 
whether  the  case  was  one  of  a  renal  calculus  or  of  tubercular  disease. 
After  being  in  the  Hospital  many  months  the  patient  went  out  in  a  very 
emaciated  condition. 

Kejjhrectomy. — In  a  gu-1,  aged  2.3,  by  median  abdominal  incision  for  a  large 
kidney  distended  with  thick  inspissated  pus  of  the  consistence  of  mortar.  The 
patient  died  the  day  following  the  operation.  At  the  post-mortem  examina- 
tion the  other  kidney  was  foimd  to  be  the  seat  of  tubercular  abscesses,  and 
grey  tubercles  were  scattered  over  the  bladder. 

SUPRA-PUBIC  ASPIRATION  OF  BLADDER. 

The  operation  was  performed  on  a  man,  aged  33,  for  retention  resulting 
from  stricture  of  the  urethi-a.  Some  urine  was  evacuated  but  the  bladder  was 
not  emptied,  and  puncture  per  rectum  was  resorted  to,  with  the  result  that 
10  ozs.  more  were  evacuated.  Three  days  after  operation  there  was  pain  and 
tenderness  in  hypogastric  region,  followed  shortly  by  oedema  and  later  on  by 
suppuration.  Soon  after  pus  was  discharged  foecal  matter  made  its  escape. 
The  patient  died  1  month  after  admission,  despite  some  relief  afforded  by 


99 

external  urethrotomy.  A  post-mortem  examination  revealed  a  small  ulcerated 
aperture  in  the  cscum,  which  had  apparently  been  caused  at  the  time  of 
aspiration. 

ABDOMINAL  SECTION. 

In  one  case,  in  a  man,  aged  23,  for  symptoms  of  abdominal  obstruction  due 
to  enteritis.  In  one  case  for  intussusception.  QSee  page  77.)  In  one  case  for 
an  abdominal  tumour,  which  proved  to  be  an  irremovable  uterine  fibroid.  In 
one  case  for  an  abdominal  swelling,  which  proved  to  be  a  retroperitoneal 
abscess.  In  one  for  f cecal  fistula  due  to  the  opening  of  a  perimetric  abscess 
into  the  intestines. 

COLOTOMY. 

In  one  case  for  intestinal  obstruction  of  doubtful  nature.  In  three  cases 
for  cancer  of  the  rectum  with  obstruction. 

EXCISION  OF  RECTUM.    (/See  page  79.) 

TEACHEOTOMT. 

In  29  cases  for  croup  and  diphtheria.  In  one  case  for  cancer  of  the  larynx. 
In  one  case  for  syphilitic  laryngitis.  In  two  cases  for  scald  of  the  pharynx 
and  glottis.  In  a  case  of  hydrophobia.  In  a  case  of  lipoma  of  the  neck  in 
which  dyspnoea  followed  upon  suppuration  produced  by  injection  of  Morton's 
fluid. 

LIGATUEE  OF  AETEEIES  IN  CONTINUITY.     {See  also  pages  75  and  76.) 
External  Iliac. — For  traumatic  aneurysm. 

Superficial  Femoral. — In  two  cases  for  aneurysm.  In  one  for  a  punctured 
wound.     In  one  for  secondary  hemorrhage. 

Brachial. — For  punctured  wound  in  one  case. 


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101 


APPENDIX  TO  SUB-TABLE  OF  CASES  OF  ERYSIPELAS,  &c. 


ERYSIPELAS. 

All  Cases,  both  Medical  and  Surgical,  are  included  in  the  Table. 

Admissions. 

The  apparent  discrepancy  between  the  number  of  cases  in  this  and  in  the 
first  Table  is  due  to  the  fact  that  some  cases  were  admitted  with  erysipelas, 
complicating  some  other  disease  or  some  injury,  and  that  such  cases  have  been 
entered  in  the  first  Table  under  the  heading  of  the  primary  disorder. 

Occurring  in  Hospital. 

Male. — In  one  case  complicating  advanced  disease  of  knee  joint  with  much 
exhaustion  and  suppuration  ;  in  one  case  of  ischio-rectal  abscess  ;  both  these 
patients  died.  In  one  case  of  carbuncle,  one  of  wound  of  scalp,  one  epithelioma 
of  cheek  treated  with  caustics,  two  of  simple  abscesses. 

Female. — In  one  case  of  scalp  wound,  three  of  simple  abscesses,  one  diffuse 
inflammation  of  hand,  and  one  of  lupus  of  the  face. 

After  Operations. 

Male. — In  two  cases  after  sequestrotomy.  In  two  after  incision  of  an  anal 
fistula.  In  one  after  removal  of  epitheliomatous  glands.  In  one  after  removal 
of  rodent  ulcer.     In  one  after  removal  of  sebaceous  cyst  from  the  head. 

Female. — In  two  cases  after  amputation  of  the  thigh  for  ulcerated  leg  and 
diseased  knee  joint  respectively.  In  three  cases  after  amputation  of  the  breast. 
In  one  after  local  removal  of  a  mammary  tumour.  In  two  after  removal  of 
sebaceous  cysts.  In  one  after  removal  of  strumous  glands.  In  one  after 
removal  of  enlarged  bursa  patellse.  In  one  after  removal  of  a  fatty  tumour 
from  the  arm.     In  one  after  proctotomy. 

PTJIMIA  AND  SEPTICiEMIA  OCCURRING  IN  HOSPITAL. 

Male. — In  two  cases  of  necrosis,  one  resulting  from  injury,  one  from  perios- 
titis and  osteitis. 

Female. — In  two  cases  of  fracture  of  portions  of  the  pelvic  bones,  followed 
by  necrosis.     In  one  case  of  disease  of  the  ankle  joint. 

TYEMIA  AND  SEPTICAEMIA  AFTER  OPERATIONS. 

Male. — In  one  case  of  amputation  of  the  thigh  for  sarcoma.     In  one  of 
amputation  of  the  toe  for  perforating  ulcer. 
Female, — In  one  case  of  amputation  of  the  thigh  for  diseased  knee  joint. 

TETANUS  OCCURRING  IN  HOSPITAL. 

See  Appendix  to  Table  I,,  page  73. 


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PL, 

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LONDO.V: 

ymSTCD  nv  JlS.  TllUSfOTT  AND  S0», 

tuafjlk  Liiue,  City. 


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