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TRANSACTIONS 



OF 



THE CLINICAL SOCIETY. 



VOL. xvm. 



s 



TEANSACTI0N8 



THE CLINICAL SOCIETY 



LONDON. 



TOLCME THE EiaETBENTH. 




LONDON; 

LONQMANS, GEBEN, AND 00. 

1886. 



NOTICE. 



-•o*- 



The present Volume comprises the Proceedings of the 
Society during its Eighteenth Session, October, 1884, 
to May, 1885. 

The Council think it proper to state that the authors 
of the several communications are alone responsible 
for the statements, reasonings, and opinions contained 
in their respective papers. 



68, BxBVSBS Stbbbt, Oxpobd Stbebt; 
October, 1886. 



^J 



CONTENTS. 



■ 01 



Notice i^om the Council v 

List op Illustbatioits xiii 

List of Oefioebs ajstd Membebs of the Goitncil DUBora 
1885 XV 

List of Pbesidents of the Society fbom its Pobmatiok xvi 

List of Hoifl^OBABT Membebs of the Society . . xvii-xviii 

List of Membebs of the Society xix 

BSPOBT OF THE COJTSOIL xlix 

BaiiAitce Sheet Hi 

Addbess by the Pbesibent liii 

COMHUinOATIOS^S : — 

I. Ok Cebtaut Nebye Symptoms in Eheitmatic 

Affections. By W. B. Hadden, M.D. 1 

n. Cases of PBEPUTiAi Calculi. By John Cboft 8 

m. A Case of IJbticabia Pigmentosa, ob Xan- 

THELASMOIDEA. By H. BaDCLIFFE CbOCEEB, 

. M.D 12 

rV. A Case of Pebpobation of the Yebmifobm 
Appendix with Pebitoneal Abscesses. 
Death afteb a long intebtal fbom Pyemia. 
By David W. Pinlay, M.D. ... 16 



228187 



tLOX 

V. A Case of HTxavnu. B7 Jaxbs Asmaaow, 

MJ) 21 

TI. A Cask op Pakalttic DiSLOCATton op -rHs 

Patkll^ By C. Hiltoh Ch}u>nie-BiKD, H.B. 25 

TIL A Casi op Skik BBrpnoir ditk to Bboiobm. 

Bj B. B. Cakritgtok, M-D 28 

YUI. A Cabb of TmoiTB op the Riobt Exdbet or 

AIT IltPAKT SirCCISSnrLLT KOCOTXD BT AIT 

Abdomisal Iscibion. Bzcitkkbiio. Dsath. 
Bj Bicemab J. Godles, H.8. ... 31 
IX. Ob thk Tbkatmkbt op Chbohic Dtskbtebt 
BT ToLtnoBOirs Bkkhata op Nitrate op 
811.TKS. Bj SrspHXir Macekkxik, M.D. . 87 
X. Thxxb Casks op Jonrt Disbacs m costtscrmv 
wiTB Locomotob Ataxt. Bj W. Mobbast 
Bakkb a, 

DiSCFSSIOK OS THB ABOTX FaIKB .58 

XI. Ok LisiOKS OP thb Prohtal Lobb. By W. 

Haib HVhim. M.D 186 

XII. Oh a Casx op Bsctbbxzit Ksmatbicxsu ihth 

Vbticabia. By J. J. PBiBeu, M.B. . . 148 
XIU. Cabb op Huoakjsthbsia pboh Cosobkitai 

Bbais Disbabx. Bj Jvutb Ai.TEAue, H.D. ISl 
SIT. A Cabb or Maxiokakt Stbictube op ths 

CSSOPSASVB ILLVmBATIHa THX rSB OP A KIW 

POBM OP (Ebophaokal Cathbibb. Bj Cbab- 

TBBS J. Sthobbb, M3 IM 

ST, A Cass op MTCODntA. •wmi a PoBT-MOKmr 

BXAMiSATios- Bjr v.- Halk Whitb, MI). . 159 
XVI. Two Caas9 Of PHLKttjtosora PuABrj 
K. £. CABSCidTO^i. M.D. 
uoktbm BT W. Hali Whii 




Oonienia. ix 

PAOB 

XVII. A Case of Locomotob Ataxy, withoitt Dis- 
ease OF THE FOBTEBIOB COLTTBIirS OF THE 

SpinaIi Gobd. By A. Hvohes BEinrETT, M.D. 168 

Xyni. A Case of Abbested BiomsTS. By Seyhoub 

Tatlob, M.D 177 

XIX. A Case of Nephbo-Lithotoky. By Chabtebs 

J. SYMOin)S, M.S 180 

XX. A Case of Nephbo-Lithotomy. By Heitby 

MoBBis 185 

XXI. Case of Nephbo-Lithotohy. TJitdeb the cabe 

OF W. HoWSHIP DiCKDTSOlf, M.D., AJTD J. 
B0I7SE. COMKXmiCATED BY Db. DlCEDTSOir . 189 

XXII. A Case of Thbombosis of the Basilab Abteby, 

WITH PBOFOUITD COMA, EXTBEME LOWEBIKG OF 
BECTAL TEMPEBATUBE, AJBfD DEATH IK FIYE AlTD 

A HALF HOXJBS. By H. Chabltok Bastiak, 
M.D., F.E.S 193 

XXni. UinjsuAL Sequela OF Otabiotomy, ByBiCHABD 

Babwell 199 

XXIV. Ok Thbee Cases of Colotomy with Delayed 
Opening of the Iktesthte. By J. N. C. 
Dayies-Colley . . . . . . 204 

XXV. A Sebies of Cases of Spina Bifida tbeated 
BY Plastic Opebation. By A. "W. Mayo- 
Bobson 210 

XXVI. A Case of Chobeifobm Moybhentb stjpeb- 
TEzmra iir Infakcy, aitd pbobably of Cok- 
OEHiTAL Obigik. By W. B. Haddek, M.D. 221 

XXVII. Calculus abtd Tumotjb of the Bladdeb (Cab- 
cnroMA P) ; Lithotomy ; Death on the "sistb. 
DAY. By JoHH B. Lttkn .... 225 



t Gontents. 

XXVni. Thbee Cases of Bullet Wottscd. By Bichabd 

Babwbll 228 

XXIX. AlCPTTTATIOirS AT THE Htp-JOUTT by ElTRirEAUX 

JoBDAir's Method. By Lewis W. Marshall, 
M.D 234 

XXX. Ok AHPTJTATioir at the Ftp ii!r oebtadt des- 
perate CASES 07 Disease or the Joint ob 
BoiTE. By Jonathan Hittchinsok, r.B.S. . 240 

XXXI. On Pittbiasis ciBcnrf (Hoband) and Pttt- 

BIASIB CIBOIN^ ET MABGIN^ (YxDAL). By T. 

CoLOOTT Pox, M.B 244 

XXXII. A Case of Sporadic Gbetinism. By Sidney 

Phillips, M.D 248 

XXXIII. A Case of iNauiNAL Anevbism. Ligattjbe 

OF THE External Iliac Abteby with two 
Eangaboo-tail Tendon Ligattjbes and Divi- 
sion OF the Abteby between them. Sup- 

PTJBATION OF THE SAO. ULTIMATE BECOYEBY. 

By W. J. Walsham 254 

XXXIY. A Case of Obstbxjction of Abtebies and 
Veins extending oyer many yeabs. By 
W. B. Hadden, M.D 268 

XXXY. FoTTB Cases of Osteitis Defobmans. By 

John E. Lxjnn 272 

XXXVI. A Case of Hjemoptysis tbeatbd by the In- 
duction OF PNEUMOTHOBAX 80 AS TO COL- 
LAPSE THE Lung. By W. Caylby, M.D. . 278 

XXXVII. A Case in which (at the sttogkstion of the 

late Db. Mahomed) a Calculus was be- 

MOTBD FBOM the VbBMIFOBM APPENDIX FOB 
THE BELIEF OF BbCUBBBNT TyPHUTIS. By 
ChABTBBS J. SYMONDSy M.S. . 285 



Contents. xi 

PA0B 

XXXym. (Ebophagotomt fob the Bemotal of a Flats 

WITH THBEE AbTIFICIAL TeETH WHICH HAD 
BEEN AOOIBENTALLY SWALLOWED, AlH) WAS 
IMPACTED IS THE (EsOPHAGXJS. Bj GeOBGE 

Lawson 292 

XTTTT A Case op OEsophagotomt. By H. A. Lediabd 297 

XL. On Two Gases op Eatnattd's Disease. By 

T. CoLOOTT Fox, M.B 300 

XLI. Seqttel to papeb ok Thbee Cases op Bay- 
wattd's Disease, •Cltn'. Tbai^s.,' tol. xn, 
p. 179. By Thomas Baelow, M.D. . 307 

XLII. A Case op Papilloma op the Bladdeb sitc- 

CESSPI7LLY BEMOTED BY OPEBATIOB". By WlL- 

LiAM Akdebsoit 313 

XLin. A Case op Ttjmoub op the Bladdeb; Be- 
motal; Cube. By Bebkabd Pitts • . 320 

Limra Specimens — Dbscbibed by Cabd: 

I. PlGMEKTATIOW OP THE ToNOTJE (P AdDISOK'S 

Disease). By J. K. Powlbb . . 323 

n. AsEBBAirr PoBM OP PsoBiASis. By W. Hale 

White, M.D 324 

in. A Case op Hypbbtbophy op the Sttbctttaitbous 
Tissues op the Pace, Hands, and Peet. 
By Chables A. Ballance and W. B. Haddbn, 
M.D 326 

lY. Malignant Disease op the Phabynx, Tonsil, 

ETC. ; Gastbostomy. By C. Stonham . . 327 

V. Two Cases of "Wibing Ununited Pbactubbs. 

By C. Macnamaba 328 



sli Oontentt. 

VI. A Oi.ix or TTvniriTED Fbactvbc or Sight 

OLIOBiJIOV WlBED AVTISEmCiXLT. Cl,OHE 
"Ukioit. By BraHTOK Pjjbkbe, B.S. . 829 

Til. FiuiTiii Of TBI Lett Fitth Nxbte. By 

F. W. STBueimi. 880 

VIII. SrooMarro Thtbotomt fob PAfULOKA. with 

PBlsBSTi.Tioii OF TOiOB. By B. W. Pabeeb 830 

IZ, A OiiB OF OaixtTiB DiFOBiuiia. By ^tessss 

MiouitBiK, M.I> 831 

X. EsBiDiTiBT MiTLTULB TuicorBS. By Stepkbit 

MlOKKKaiX, M.D 831 

XI. Two Oasbb of Mtzocdxiu.. By J. Hofxhtb . 832 

Xtl. CXBTICA.L Rib. By W. Abbutrnot Lake, M.S., 

AND W. Hub Whitb, M.D. .834 

XIII. FucTirBB or LutTHz. By W. ABBtrtmror 

Lake, M.S. 835 

XIV. A Cabs op Batvavd's Dibkabb. By A. T. 

Mtem, M.D 336 

R&POM OH SpDtA BtnOA ADO ITS TBBATVBn 
BX THB IXJBCTIOH OP DK. UoBIOH's IoDO- 
OfcXCSBOtB SOLVTIOir 839 

WOBX 419 



LIST OF ILLUSTRATIONS. 



■•o*- 



PLATES. 

PAGB 
I. CHBOMO-LlTHOaBAPH. VbTICASIA PieKEHTOSA. 

H. Eadcliffe Cbocksb, M.D 12 

n. Chbomo-Lithogbaph. Bbomtdb Bash. B. E. 

Cassingtof, M.D 28 

in. LiTHOGBAPH. ChABCOT'S JoOTT DiBEASE. TwO 

EiGUBES. Fig. 1. BLBOw-joiisrT. Fio. 2. Ekeb- 
jonrr. W. Mobbakte Bajlbb .... 46 
IT. LiTHOGBAPH. Chaboot's Joint Disbase. Two 

FiGiJBES. W. MoBBAirr Bakeb ... 51 
y. Chbomo-Lithogbaph. Chaboot's Jonrr Dis- 
ease. Two EiGTJBBs. !FiG. 1. Bight Kbeb- 
jonrr. Eig. 2, Lbpt KiraE-Jonrr. W. Mob- 
BAirr Babeb 54 

YI. LiTHOGBAPH. ChaBCOT's JoINT DISEASE. FoUB 

Figubbs. Fig. 1. Seotiof op Postebiob 
Tibial Nbbye. Fig. 2. Ikcbease op Eiitdo- 
inBiTBiTjM. Fig. 3. Disappeabaitce op smal- 

LEB (SEliTSOBT OB TbOPHIC) FiBBILS. HeITBT 

MoBBis. Fig. 4. Tuhottb op Blasbeb. Mb. 
William Aitdebsok 94 

YII. LiTHOGBAPH. LOCOMOTOB AtAXT WITHOUT DlB- 
BASE OP THE FOSTEBIOB GOLUMKS. FOUB FlGUBES. 

Fig. 1. SECTioiiT op Mobbid G-bowth. Fig. 2. 
Sabcomatotjs Tijmotjbs is Fia Mateb. Fig. 8. 
Sabcomatotts G-bowth ABOinirD Ceittbal Caital 
OP GoBD. Fig. 4. Sbctioit op Medulla in- 

TOLYED BT SaBCOMATOUS GbOWTH. A. HuGHES 

BEin^TETT, M.D 170 



xiy List of Illustrations. 



PAGE 



Vin. LiTHOGBAPH. LOCOMOTOB AtAXT WITHOUT DIS- 
ease of the postebiob coltjmks. two ^flgttbes. 
Fig. 1. Section oe Cobb is Dobsal Begioit 
SHOWING Postebiob Boots tsyojjTed ts Sabco- 
MATOus Q-bowth. Fig. 2. Section of Cobd in 
Ltthbab Begion, showing Postebiob and An- 
TEBioB Boots intolyed in Sabcomatotjb 
Q-BOWTH. A. Hughes Bennett, M.D. . 172 

IX. Chbomo-Lithogbaph. Fotib Figubes. Fig. 1. 
Benal Calculus bemoyed by Opebation (be- 

FEBBED to AT P. 188). HeNBY MoBBIS. FiG. 

2. Pbeputial Calculi. Fig. 3. Benal Cal- 
culus, BEMOYED by OpEBATION (bEFEBBED TO AT 

p. 184). Chabtebs Symonds. Fig. 4. Cal- 
culus BEMOYED FBOM YeBMIFOBM APPENDIX 

(befebbed to at p. 288). Chabtebs Symonds . 188 

X. LiTHOGBAPH. TeMPEBATUBE ChABT OF CaSE OF 

Benal Calculus. W. Howship Dickinson, 

M.D 190 

XI. LiTHOGBAPH. Cases of . Osteitis Defobmans. 

Thbee Figubes. John B. Lunn . . . 272 
XII. Chbomo-Lithogbaph. Pigmentation of Tongue. 

J. K. FowLEB, M.D 323 

XIII — XX. Lithogbaphs. Spina Bifida Bepobt . 339 — 418 



WOODCITTS. 

OESOPHAGEAL Catheteb FOB Stbictube in sitii. Chab- 
tebs J. Symonds 156 

Abbested Bickets. Seymoub Taylob, M.D. . . . 178 

Calculi bemoyed by Opebation fbom Kidney, W. How- 
ship Dickenson, M.D 191 

Opebation fob Spina Bifida. Thbee Figubes. A. W. 

Mayo Bobbon 217 

Dental Plate bemoyed by CBsophagotomy. Geobge 

Lawson 293 

Papilloma of Bladdbb. W. Andebson .... 314 

Spina Bifida Bepobt. Figs. 1—12 . 345—370 



CLINICAL SOCIETY OF LONDON. 



OFFIOEBS AND COUNCIL 

BLBCTJED AT 

THE GENERAL MEETING, JANUARY 9, 1885. 



PEESEDENT. 

THOMAS BRYANT. 



VICE-PKESTDENTS. 



JOHN WILLIAM OGLE, M.D. 
JAMES ANDREW, MJ). 
WILLIAM CAYLEY, M.D. 



ARTHUR EDWARD DURHAM. 
WILLIAM MORRANT BAKER. 
THOMAS PICEJSRING PICE. 



TEEASTTBES. 

CHRISTOPHER HEATH. 



COTJNCrL. 



HENRY RADCLIFFE CROCKER, 

M.D. 
SIDNEY COUPLAND, M.D. 
ARTHUR W. EDIS, M.D. 
WILLIAM EWART, M.D. 
DAVID W. FINLAY, M.D. 
F. DE HAYILLAND HALL, M.D. 
DAVID B. LEES, MJ). 
FELIX SEMON, M.D. 
T. GILBART SMITH, M.D. 
JOHN WILLIAMS, M.D. 



ARTHUR £. J. BARKER. 
HENRY HUGH CLUTTON. 
J. N. C. DAVIES-COLLEY. 
CLINTON T. DENT. 
A. PEARCE GOULD. 
J. WARRINGTON HAWARD. 
R. CLEMENT LUCAS. 
JOHN HAMMOND MORGAN. 
HENRY MORRIS. 
GIFFORD RANSFORD. 



HONORABY SEGSETABIES. 

STEPHEN MACKENZIE, M.D. RICKMAN JOHN GODLEE, MJS. 

TSXJSTEES. 

E. HEADLAM GREENHOW, M.D., F.R.S. 
J. BURDON SANDERSON, M.D., F.R.S. 
CHRISTOPHER HEATH. 



PRESIDENTS OP THE SOCIETY 

{From its Formation), 

BLBOTBD 

1867 Sip Thomas Watsoit, Bart., M.D., D.C.L., LL.D., P.E.S. 

1869 Sip Jambs Paget, Bart., D.C.L., LL.D., F.E.S. 

1871 Sip William Withet Gfll, Bapt., M.D., D.C.L., P.E.S. 

1873 Sip PsEsooTT G-ABDNEB Hewett, Bapt., P.B.S. 

1875 Sip William Jeiwee, Bapt., M.D., K.C.B., D.C,L.,P.E.S. 

1877 G-eobge William GALLEin)EB, F.E.S. 

1879 Edwabd Headlam Gbeenhow, M.D., F.E.S. 

1881 Sip Joseph Listeb, Bapt., D.C.L., LL.D., P.E.S. 

1883 Sip Akdbew Clabe, Bapt., M.D., LL.D., P.E.S. 

1885 Thomas Bbyaitt. 



HONORAET MEMBERS. 

1885 Bttbbows, Sib GEOBaE, Bart., M.D., D.C.L,, L.L.D., P.B.S., 
Physician in Ordinary to H.M. the Queen; Consulting 
Physician to St. Bartholomew's Hospit^ ; Member of the 
Senate of the IJniyersity of London ; 18, Cavendish Square, 
W. 

1881 Paget, Snt James, Bart., D.C.L., LL.D., F.B.S., Sergeant- 
Surgeon to H.M. the Queen ; Surgeon-in-Ordinary to 
H.E.H. the Prince of Wales ; Consulting Surgeon to St. 
Bartholomew's Hospital; Vice- Chancellor of the Tlni- 
yersity of London ; 1, Harewood Place, Hanover Square, 
W. (V.-P. 1867-8.) (P. 1869-70.) • 

1885 SiMOK, JoHK, C.B., D.C.L., LL.D., F.R.S., Consulting 
Surgeon to St. Thomas's Hospital ; 40, Kensis^on Square, 
S.W. 

1875 Williams, Chables James Blasitjs, M.D., P.E.S., Physi- 
cian Extraordinary to H.M. the Queen; Consulting 
Physician to the Hospital for Consumption and Diseases 
of the Chest ; 47, Upper Brook Street, W. 



VOL. TfUl. 



POEEIGN HONORARY MEMBERS. 

1881 BiGELOWy Heitby J., M.D., Professor of Surgery, Harvard 
irniyeraitj ; Surgeon to the Massachusetts General Hos- 
pital. 

1881 BniLiKOS, John S., M.D., Breyet Liea.-Col. and Surgeon, 
U.S. Army; Librarian, Surgeon-General's Office, Wash- 
ington. 

1874 BiLLBOTH, Theodob, M.D., Professor of Surgery in the 
University of Vienna. 

1874 Chabcot, J. M., M.D., Physician to the "Hdpital de la 
Salp^tri^re." 

1881 EsMABCH, Fbiedbich, M.D., Professor of Surgery and 
Director of the Surgical Glinique in the University of 
Kiel; Surgeon to the University Hospital, Kiel, and 
Surgeon- General to the Prussian Army. 

1874 FLnrT, AusTiiir, M.D., Senr., Professor of Medicine in the 
Bellevue Hospital, Medical College, New York. 

1874 Lanoekbeck, BEBifTHABD TOiT, M.D., Profcssor of Surgery 
in the University of Berlin. 

1881 Mazzoni, CosTAirzo, Professor of Surgery at the Boyal 
University of Bome, and Surgeon to the Hospital of San 
Giacomo at Bome. 

1881 Ollieb, Leopoli), Honorary Surgeon to the Hotel Dieu of 
Lyons. 

1881 Pasteitb, L., Member of the Institute (Academy of Sciences) 
of Paris. 

1874 BicoBi), Philippe, M.D., £z-Surgeon-in-Chief of the 
H6pital du Midi, and late President of the Academy of 
Medicine, Paris. 

1881 Vebitefil, Abistide, Professor of Clinical Surgery at the 

Paculty of Medicine, Paris. 

1882 YoLEicANiir, Pbopessob Bichabd, Medical Privy Councillor, 

Director of the Surgical Clinique, University of Halle. 

1874 ZiEMSSEK, H. YON. M.D., Professor of Clinical Medicine at 
Erlangen. 



^«* Members are requested to inform the Secretaries of any 

Oorreotions when necessary. 



LIST OF MEMBEES. 



(P.) President. (T.) Treasurer. 

(V.P.) Vice-President, (S.) Secretary. 

(C.) Member of Council. 

Members who have compounded for their Subscriptions are marked 

thus (•). 

Non'Bendent Members who have paid the Composition Fee 
for the Transactions are marked thus (t). 

The figures sncceedins the word Trans, show the number of 
Papers contributed to the * Transactions ' by the Member to 
whose name they are annexed : C.S, refers to the specimens 
exhibited by card. 

Elbotbd 

1879 Abebcbombie, John, M.D., Assistant Physician to, 
and Lecturer on Porensic Medicine at, Charing 
Cross Hospital ; 23, Upper Wimpole Street, Caven- 
dish Square, W. 

Grig. Memb. Aclakd, Sir Hekby Wbntwobth, M.D., K.C.B., 

LL.D., E.B.S., Honorary Physician to H.RH. the 
Prince of Wales, and Eegius Professor of Medicine 
in the University of Oxford ; Broad Street, Oxford. 
(V.P. 1868-70.) 

1879 Adams, James Edwabd, Grately, Andover, Hants. 
Trans. 1. 

1879 Adams, William, Tower Lodge, Begent's Park 
Eoad, N.W. 

1883 Adams, William Coodb, M.B., Tower Lodge, 

Begent's Park Bead, N.W. 

1884 Adeitey, Edwot LsoiirABD, M.D., 3, Sion Terrace, 

Mount Sion, Tunbridge Wells. 

1870 tAjiLBUTT, Thomas Clutobd, M.D., F.B.S., Phy- 
sician to the Leeds General Infirmary ; 35, Park 
Square, Leeds. ISrans. 3. 



List of Members. 

EliEOTED 

1883 Allchtn, "William Heitbt, M.B., Physician to, 
Lecturer on Medicine at, the Westminster Hos- 
pital ; 5, Chandos Street, Cavendish Square W. 

1885 Allikgham, Hebbebt William, 25, Grosvenor 
Street, *W. 

1871 Althafs, Jttlifs, M.D., Phjsician to the Hospital 
for Epilepsy and Paralysis, Eegent's Park ; 48, 
Harley Street, Cavendish Square, W. (C. 1879- 
81.) Trans. 5. 

1883 Andebson, James, M.D., CM., Assistant Physician 
to the City of London Hospital for Diseases of the 
Chest ; 84, Wimpole Street, Cavendish Square, W. 
Trans, 1. 

1868 Ain)EBSOir, John Fobd, M.D., 28, Buckland Crescent, 
Belsize Park, N.W. 

1883 Andebson, William, Assistant Surgeon and Joint 
Lecturer on Anatomy, St. Thomas's Hospital ; 13, 
Welheck Street, Cavendish Square, W. Trans, 2. 

Orig. Memb. Andbew, James, M.D. (V.P.), Physician to, and 

Lecturer on Medicine at, St. Bartholomew's Hos- 
pital; 22, Harley Street, Cavendish Square, W. 
(C. 1872-4, V.P. 1885.) Trans, 1. 

Orig. Memb. Aenott, Henbt. (C. 1871-5.) Trans, 3. 

1880 *Bakeb, Henbt Pbancis, 15, Hanover Square, W. 

Orig, Memb, Baeeb, W. Mobeant (V.P.), Surgeon to St. Bartho- 
lomew's Hospital ; Consulting Surgeon to the 
Evelina Hospital for Sick Children ; 26, Wimpole 
Street, Cavendish Square, W. (C. 1873, V.P. 
1884-5.) Trans, 5. 

1880 Ball, B., M.D., Professor to the Faculty of Medi- 
cine of Paris ; 3, Faubourg St. Honore, Paris. 

1878 Ball, James Babet, M.D., 29, Belgrave Eoad, 
S.W. 

1883 Ballai^ce, Chaeles Alebed, M.B., Assistant Sur- 
geon, West London Hospital; Demonstrator of 
Anatomy, St. Thomas's Hospital ; 56, Harley Street, 
Cavendish Square, W. 0,S, 1. 

1868 Bantock, GEOBaE Q-banville, M.D., Surgeon to the 
Samaritan Free Hospital; 12 Granville Place, 
Portman Square,]W. 



List of Members. 

Elbotbd 

1876 Babkeb, Abthub E. J. (C), Surgeon to IJniversity 
College Hospital; 87, Harley Street, Cavendish 
Square, W. (C. 1883-6.) Trans, 5, C.8. 3. 

1882 Babsieb, Ebedebick Chables,M.D., Surgeon-Major, 
Bombay Medical Service, India [care of Abthub 
Bab£EB, Esq., 87, Harley Street]. 

1875 Bablow, Thomas, M.D., Physician to University 
College Hospital, to the Hospital for Sick Chil- 
dren, Great Ormond Street, and to the London 
Eever Hospital; 10, Montague Street, Eussell 
Square, W.C. (C. 1880-82.) Trans, 8, O.S. 1. 

Orig, Memh. Babwbll, Eichabd, Surgeon to, and Lecturer on 

Surgery at, the Charing Cross Hospital ; 55, Wim- 
pole Street, Cavendish Square, W. (C. 1872-5, 
V.P. 1877-9.) Trans. 16. 

Orig. MenA. Bastian, Henbt Chablton, M.D., E.E.S., Physi- 
cian to University College Hospital, and Assistant 
Physician to the National Hospital for the Para- 
lysed and Epileptic, and Professor of Pathological 
Anatomy at University College ; 20, Queen Anne 
Street, W. (C. 1876-8.) Trans. 4i. 

1882 BATEMAif, Alfbed Q-., M.B., 13, Canonbury Lane, 

Islington, N., and 64, Longridge Boad, South 
Kensington, S.W. 

1868 Bat^mleb, Chbistiak Q-. H., M.D., Professor of 
Materia Medica in the University of Erlangen. 
Trans. 4. 

1875 Beok, Mabcxis, M.S., Professor of Surgerjr, Uni- 
versity College, London, and Surgeon to University 
College Hospital ; 30, Wimpole Street, Cavendish 
Square, W. (C. 1880-81.) l^ans. 1. 

1880 •Bebvob, Chables Edwabd, M.D., Assistant Phy- 
sician to the National Hospital for Paralysed and 
Epileptic ; 33, Harley Street, Cavendish Square, W. 

1875 Bellamy, Edwabd, Surgeon to Charing Cross Hos- 
pital ; Lecturer on Artistic Anatomy in the Science 
and Art Department, South Kensington ; 17, Wim- 
pole Street, Cavendish Square, W. (C. 1879-80.) 
Trans, 8. 

1884 BEimAM, Ebakcis, M.D., 93, Elizabeth Street, Eaton 
Square, S.W. 

1883 Benham, Bobebt Eitzbot, Abercom House, Baron's 

Court, S.W. 



xxii List of Members. 

Elected 

1885 Bennett, A. Httghes, M.D., Assistant Physician to 
the Westminster Hospital ; 38, Queen Anne Street, 
Cavendish Square, W. Trans. 1. 

1878 Bennett, Stobeb, Dental Surgeon to, and Lecturer on 

Dental Surgery at, the Middlesex Hospital ; Dental 
Surgeon to the Dental Hospital of London ; 17, 
Gteorge Street, Hanover Square, W. 

1874 Bbnntstt, William Henbt, Assistant Surgeon to 
St. G-eorge's Hospital ; Surgeon to the Belgrave 
Hospital for Children ; 1, Chesterfield Street, May- 
fair, W. Trans. I. 

1882 Bebby, Fbedebiok Hayobaet, M.B. , Watford, Herts. 

1885 Bebbt, James, 27, Tipper Bedford Place, W.C. 

1882 BiNDLBY, Philip Hekby, M.B., Boccabruna, Brank- 

some Wood Boad, Bournemouth. 

1879 BiNDON^, William John Vebezeb, M.D., 18, St. 

Ann's Street, Manchester. 

1883 Biss, Cecil Yates, M.D., Assistant Physician to the 

Middlesex Hospital, and to the Hospital for Con- 
sumption, Brompton ; 65, BLarley Street, Cavendish 
Square, W. 
1881 Black, James, Lecturer on Anatomy, Westminster 
Hospital, 16, Wimpole Street, Cavendish Square, W. 

1883 BowLBY, Akthony A., Curator of the Museum, St. 
Bartholomew's Hospital ; 75, Warrington Crescent, 
Maida Vale, W. 

1883 tBowLES, Bobebt Lbamon, M.D., 8, West Terrace, 
Polkestone. 

1868 Bbace, William H., M.D., 7, Queen's Ghtte Terrace, 
Kensington, W. (C. 1876-7.) 

1883 Bbadshaw, James Dixok, M.B., 30, Gheorge Street, 
Hanover Square, W. 

1878 Bbtdges, Eobebt, M.B., M.A„ The Manor House, 
Yattendon, Berkshire. Trans. 1. 

1868 Bbiqht, Geobge Chables, M.B., 29, Luttichen 
Strasse, Dresden. 

1868 Bbioht, John Meabubn, M.D., Forest Hill, S.E. 

Orfy. Memh. Bbistowe, Johf S., M.D., F.E.S., Physician to, and 

Lecturer on Medicine at, St. Thomas's Hospital ; 
Medical Officer of Health for Camberwell ; 11, Old 
Burlington Street, W. (C 1869-70, V.P. 1879- 
80.) Trans. 2. 



List of Members. xxiii 

Eleotid 

Ori^. Memb, BfiOADBEiirr, William Henby, M.D., Physician to, 

and Lecturer on Medicine at, St. Mary's Hospital ; 
Physician to the London Fever Hospital ; 34, Sey- 
mour Street, Portman Square, W. (C. 1871-^, 
V.P. 1881-3.) Trans. 17. 

Ori^. Memh, BBODHtiBST, Bebitabd Edwabd, Surgeon to the 

Eoyal Orthopaedic Hospital ; 20, Grosyenor Street, 
W. OOrans. 2. 
1876 Bbowitb, Geobob Bfckstoit, 80, Wimpole Street, 
Cavendish Square, W. 

1883 Bbttoe, John Mitohell, M.D., Physician to, and 

Lecturer on Materia Medica at, the Charing Cross 
Hospital ; Assistant Physician to the Hospital for 
Consumption, Brompton ; 70, Harley Street, W. 

Orig, Memh, Bbtaitt, Thomas (President) , Surgeon to, and 

Lecturer on Surgery at, Guy's Hospital ; 53, tipper 
Brook Street, Grosvenor Square, "W. (C. 1872, 
V.P. 1876-7, P. 1885.) Trans, 7. 

Oriff, Memb, Bfohakait, Geobqe, M.D., P.B.S., Medical 0£Glcer 

of the Local Government Board ; 24, Nottingham 
Place, W. (C. 1877.) 

1884 Buck, William Elgab, M.D., 6, Welford Eoad, 

Leicester. 
1881 Bubnet, Eobebt "William, M.D., 94, Wimpole 
Street, Cavendish Square, W. 

1868 tBuBTON, John M., Lee Park, Blackheath, S.E. 

1879 BuBTON, William Edwabd, 24, Wimpole Street, 

Cavendish Square, W. 

1881 BuTLLNr, Henbt Tbentham, Assistant Surgeon to, 
and Demonstrator of Practical Surgery and Dis- 
eases of the Larynx at, St. Bartholomew's Hospital ; 
47, Queen Anne Street, Cavendish Square, W. 
Trans, 2. 

1871 Butt, William P., 48, Park Street, Park Lane, W. 

1884 BxjiTOir, Dudley Wilmot, M.D., B.S., 82, Mortimer 
Streel^ Cavendish Square, W. 
Orig, Memh, Buzzabd, Thomas, M.D., Physician to the National 

Hospital for the Paralysed and Epileptic; 56, 
Grosvenor Street, W. (S. 1870-2, C. 1873-6, 
V.P. 1880-1.) Trans, 14, C,S, 1. 

1880 Cabbington, Bobebt Edmuitd, M.D., Assistant 

Physician to, and Demonstrator of Pathology at, 
Guy's Hospital ; Visiting Physician, Seamen's 
Hospital, Greenwich ; 15, St. Thomas's Street, 
Southwark, S.E. Trans, 4. 



List of Members. 

Elboted 

1888 Cabteb, Fbedebiok Healbb, Eaton Villa, Belleyue 
Boadi Upper Tooting, S.W. 

1869 Cabtbb, Bobebt Bbudekbll, Ophthalmic Surgeon 
to, and Lecturer on Ophthalmology at, St. George's 
Hospital ; Surgeon to the Boyal South London Oph- 
thalmic Hospital ; 27, Queen Anne Street, Gaven^sh 
Square, W- (0. 1873-6, V.P, 1879-81.) 2h'ans.7. 

1868 Cayabt, Johit, M.D., Physician to St. George's 
Hospital ; 2, Upper Berkeley Street, Portman 
Square, W. (C. 1881-83.) ^ans. 4. 

Oriff. Memb. Catlet, William, M.D. (V.P.), Physician to, and 

Lecturer on the Principles and Practice of Medi- 
cine at, the Middlesex Hospital; Physician to the 
London Fever Hospital, and to the iforth-Eastem 
Hospital for Children ; 27, Wimpole Street, W. 
(C. 1874-5, S. 1876-8, 0. 1879-80, V.P. 1885.) 
Trans. 7, O.S. 1. 

1885 Chalmebs, Johit, M.D., 29, Keppel Street, Bussell 
Square, W.C. 

1884 Chapmaet, Paul M., M.D., 26, Gordon Square, W.C. 

1873 Chisholm, Edwht, M.D., Abergeldie, Ashfield, near 
Sydney, New South Wales. 

1868 Cholmeley, William, M.D„ Physician to the G-reat 
Northern Hospital, and Margaret Street Infirmary 
for Consumption; 63, Grosvenor Street, W. (C. 
1871-3.) Trans. 2. 

Ori^. Memb, Chubch, William Selby, M.D., Physician to, and 

Lecturer on Clinical Medicine at, St. Bartholo- 
mew's Hospital ; 130, Harley Street, Cavendish 
Square, W. (C. 1874-6.) 

1873 CnuBToiir, Thomas, 35, Clarendon Boad, Leeds. 

Trans. 1. 

1882 Clafham, Edwabd, M.D., 29, Lingfield Boad, 
Wimbledon. 

Orig. Menib. Claptok, Ebwabd, M.D., 10a, St. Thomas's Street, 

Southwark, S.E. (C. 1872-4.) Trans. 1. 

Orijf. Memb. Clabk, Sib Ahdbew, Bart.^ M.D., LL.D., F.B.S., 

Physician to, and Lecturer on Clinical Medicine 
at, the London Hospital; 16, Cavendish Square^ 
W. (C. 1876-8, V.P. 1880-82, P. 1883-84.) 
Trans. 1. 

1874 Clabk, Akdbew;, Assistant Surgeon to, and Lecturer 

on Practical Surgery at, the Middlesex Hospital; 
19, Cavendish Place, Cavendish Square, W. 



List of Members. 

Elbotbd 

1877 tCLAT, BoBEBT HoGABTH, M.D., 4, WindsoF Villas, 
Plymouth. 

1877 *Cltittok, Henbt Hugh, M.A. (C), AflsiBtant Sup- 

geon to St. Thomas's Hospital ; 2, Portland Place, 
W. (0. 1885.) l^ans. 5. 

1878 Collie, Alexandeb, M.D., Fever Hospital (Metro- 

politan Asylum District), The Grove, Homerton, E. 

1882 CoLLiEB, Hebbbbt, M.D., Marine Villa, GK>rleston, 
G-reat Yarmouth, Norfolk. 

1878 Collins, W. Maunsell, M.D., M.O., 10, Cadogan 

Place, S.W. 

1882 CoLQUHOUK, Daniel, M.D., Dunedin, New Zealand. 

1872 CooKB, Thomas, Assistant Surgeon to the West- 
minster Hospital ; 40, Brunswick Square, W.C. 

1868 Coopeb, Yrajsk W., Leytonstone, Essex. 

1880 Cottle, Wtsdkam, M.D., Senior Assistant Surgeon 

to the Hospital for Diseases of the Skin, Black- 
friars ; 3, Savile Bow, W. 

Orig. Memh, Coupeb, Johk, Surgeon to the London Hospital and 

to the Boyal London Ophthalmic Hospital; 
80, Grosvenor Street, W. (0. 1874.) 

1875 CouPLAiTD, Sidney, M.D. (C), Physician to, and 
Lecturer on Practical Medicine at, the Middlesex 
Hospital; 14, Weymouth Street, Portland Place, 
W. (S. 1883-4, C. 1885.) l^ans. 3. 

1882 CoxwELL, C. P., M.B., 14, Pinsbury Circus, E.C. 
Trans. 2. 

1881 Cbeiohtoit, Chables, M.D., 11, New Cavendish 

Street. 

1879 Cbipps, William Habbisok, Assistant Surgeon to 

St. Bartholomew's Hospital; 2, Stratford Place, 
Oxford Street, W. Trans. 3. 

1872 Cbitchstt, Aetdebsoit, Ophthalmic Surgeon to St. 
Mary's Hospital and to the Boyal Pree HospitiU ; 
21, Harley Street, W. 

1877 Cboceeb, Heioiy Badcliffe, M.D; (C), Physician to 
the Skin Department, University College Hospital ; 
Assistant Physician and Pathologist to the East 
London Hospital for Children ; 28, Welbeck 
Street, Cavendish Square, W. (C. 1884-4.) Titans. 
14. 



xxvi List of Members. 

Elbotbd 

Ori^. Menib, Cboft, Johk, Surgeon to St. Thomas's Hospital ; 

48, Brook Street, Grosvenor Square, W. (C. 
1870-2, V.P. 1882-4.) Trans. 10. 

1872 Dalbt, "Willulm Baetlbtt, M.B., Aural Surgeon 
to St. George's Hospital ; 18, Savile Eow, W. 
(C. 1879-81.) Trans. 4t. 

1882 Dallawat, J. W, DENiins, Langham Hotel, W. 

1879 Davies-Collet, J. Neville C, M.B., M.C. (C), 
Surgeon to G-uy's Hospital ; 36, Harley Street, 
Cavendish Square, W. (C. 1886.) Trans. 5. 

1879 tI>AVT, Henbt, M.D., 34, Southemhay, Exeter. 

1868 Day, "Willloi Henet, M.D., Physician to the 
Samaritan Free Hospital for Women and Children ; 
10, Manchester Square, W. Trans. 6. 

1872 Ds Castbo, James Cato, M.B., Fau, France. 

1879 tDBiwis, Fbbdebio S., M.D., 21, East 2l8t Street, 
New York, U.S. 

1875 Dent, Clinton T. (C), Assistant Surgeon to St. 
George's Hospital; 61, Brook Street, W. (C. 
1884-6.) Tram. 1. 

Orig. Menib. Dickinson, "William Howship, M.D., Physician 

to, and Lecturer on Medicine at, St. George's 
Hospital; Physician to the Hospital for Sick 
Children ; 9, ChesterjBeld Street, May&ir, W. 
(C. 1874-6.) Trans. 1. 

1871 Diyeb, Ebenezeb, M.D., Kenley, Caterham Yalley, 
Surrey. 

Orig. Memb. Down, John Langdon H., M.D., Physician to, and 

Lecturer on Clinical Medicine at, the London 
Hospital; 81, Harley Street, W. (C. 1870-2.) 
l}rans. 1. 

1874 Dowse, Thomas Stbbtch, M.D., 14, Welbeck Street, 
Cavendish Square, W. Trans. 6. 

1868 Dbage, Chables, M.D., Hatfield, Herts. 

1879 Dbewitt, F. G. Dawtbet, M.D., Assistant Physician 
to the West London Hospital, and to the Victoria 
Hospital for Children ; 62, Brook Street, Grosvenor 
Square, "W. Trans. 1. 

Orig. Memb. Dfckwobth, Dtcb, M.D., Physician to, and Lecturer 

on Clinical Medicine at, St. Bartholomew's Hos- 
pital ; 11, Grafton Street, Bond Street, W. (C 
1876-7.) Tram. 12, O.S. 2. 



List of Members. xxvii 

Elbotbd 

Ori^. Memh, Dui*7iK, Alfbsd B., M.D., Physician to King's 

College Hospital, and Professor of Pathological 
Anatomy in Eang's College, London ; 18, Devonshire 
Street, Portland Place, W. (C. 1872-4.) Trans. 6. 

1884 DuEE, EnaAB, Locksley, Freshwater, Isle of Wight. 

1869 Duke, Olliyeb Thomas, M.B., Surgeon, Bengal 
Army, India. 

Orig. Memh. Dubham, Abthxjb Edwaed (V.P.), Surgeon to, and 

Lecturer on Surgery at, Guy's Hospital ; 82, Brook 
Street, W. (C. 1867-9, V.P. 1884-^5.) T^ans. 6. 

Orig. Memh, Enis, Abthtjb W., M.D. (C), Obstetric Physician 

to, and Lecturer on Midwifery at, the MLddlesez 
Hospital ; 22, Wimpole Street, Cavendish Square, 
W. (C. 1884-6.) Th-ma. 1. 

1884 EDMtmns, Walteb, M.C, 79, Lambeth Palace Boad, 

S.E. 

1882 Emond, Emile, M.D., Mont Dore, Auvergne, and 
113, Boulevard Beaumarchais, Paris. 

1881 EiraLisH, Thomas Johnstok, M.D., 128, Fulham 
Eoad, S.W. 

Orig. Memh. Ebichsen, Johk E., LL.D., E.B.S., Surgeon Extra- 

ordinary to H.M. the Queen ; Emeritus Professor 
of Surgery at University College, and Consulting 
Surgeon to University College Hospital ; 6, Caven- 
dish Place, Cavendish Square, W. (V.P. 1869^71.) 

1868 Evans, Jtjlian-, M.B., Physician to the Victoria 
Hospital for Children; 123, Einborough Boad, 
Eeddyffe Square, S.W. 

1877 EwABT, William, M.D. (C), Assistant Physician to, 

and Lecturer on Physiology at, St. George's 
Hospital; 33, Curzon Street, Mayfair, W. (C. 
1884-5.) 

1868 Eaibbake:, Fbedebick Eoyston, M.D., 46, Hall 
Gkte, Doncaster. Th'ons. 1. 

1872 Eeitwicb:, J. C. J., M.B., 16, Old Elvet, Durham. 

1878 Field, Geobge P., Aural Surgeon to St. Mary's Hospi- 

tal ; 31, Lower Seymour Street, Portnuin Square, W. 

1876 FiHLAT, David White, M.D. (C), Physician to, 
and Lecturer on Forensic Medicine at, the Middle- 
sex Hospital, and Physician to the Boyal Hospital 
for Diseases of the Chest ; 9, Lower Berkeley Street, 
Portman Square, W. (C. 1885.) Trans. 4. 



xxviii List of M&mberg. 

Elxoted 

1868 Fish, John Cbookett, M.D., 92, Wimpole Street, 
CavendiBh Square, W. (C. 1869-70.) 

1885 FiTZPATBiCK, Thomas, M.D., Physician to the 
WeBtem G-eneral Dispensary, 80, Sussex Gturdens, 
Hyde Park, W. 

1878 *FoNMAKTiK, Henbt de, M.D., Parkhurst, Isle of 
Wight. 

1881 EowLEB, James Kingston, M.D., Assistant Physi- 

cian to, and Lecturer on Pathological Anatomy 
at, the Middlesex Hospital, and Assistant Physi- 
cian to the Hospital for Consumption, Brompton ; 
85, Clarges Street, Piccadilly, W. Trans. 3, 

as. 3. 

1878 Fox, Thomas Coloott, M.B., B.A., Physician to the 

Skin Department, Westminster Hospital, and to 
the Paddington Qreen Hospital, and Assistant 
Physician to the Victoria Hospital for Children ; 
14, Harley Street, Cavendish Square, W. Trans, 5. 

Ori^, Memh, Fox, Wilson, M.D., F.R.S., Physician Extraordinary 

to H.M. the Queen ; Holme Professor of Clinical 
Medicine in University College, and Physician to 
University College Hospital ; 67, Grosvenor Street, 
W. (C. 1873, V P. 1878-9.) 

1868 G-ANT, Fbedebick James, Surgeon to the Eoyal 
Free Hospital; 16, Connaught Square, W. (C. 
1877-9.) Trans. 3. 

1879 Gabstang, Thomas Walteb Habbopp, Dobcross, 

near Oldham. 

1885 Gibbons, Bobebt Alexandeb, M.D., Physician to 
the GroBvenor Hospital for Women and Children ; 
32, Cadogan Place, S.W. 

1868 Gloveb, James Gbet, M.D., Hon. Surgeon to the 
HoUoway and North Islington Dispensary; 25, 
Highbury Place, N. (C. 1878-80.) Trans. 2. 

1882 GoDDABD, Eugene, M.D., 106, Highbury New Park, 

N. 

1875 GoDLBE, EiCE3£AN JoHN, M.S., M.B. {Son. Secretary) y 
Surgeon to University College Hospital ; Teacher 
of Operative Surgery, University College, London ; 
Surgeon to the North-Eastem Hospital for 
Children, and to the Hospital for Consumption, 
Brompton ; 81, Wimpole Street, Cavendish Square^ 
W. (C. 1882-3, S. 1884-6.) Trans. %. 



List of Members, xxiz 

Elected 
1882 GoLDiE, BoBEBT WiLLiAM, Medical Superintendent, 
Poplar and Stepney Sick Asylum ; Deyons Boad, 
Bromley. 

1878 GoLDiKG-BiBB, C. H., M.B., Assistant Surgeon to, 
and Lecturer on Physiology at, G-uy's Hospital ; 
13, St. Thomas's Street, Southwark, S.E. ^B'ans. 9. 

1875 G-ooDHABT, James Ebedsbio, M.D., Assistant 
Physician to, and Curator of the Museum at, Guy's 
Hospital; 25, "Weymouth Street, Portland Place, 
W. (C. 1880-2.) Trans. 9, O.S. 1. 

1869 GooDBrDGE, Henby Pbedebiok AuGusTrs, M.D., 
Physician to the Bath Boyal United Hospital; 
10, Brock Street, Bath. 

1882 GooDSALL, D. H., 17, Devonshire Place, Upper 
"Wimpole Street, W. 

1881 GoBDON, Hugh Alex., M.D., HoUoway Prison, 
Camden Boad, N.W. 

1877 QoTTLB, A. Peabce, M.S. (C), Assistant Surgeon to 
the Middlesex Hospital ; 16, Queen Anne Street, 
Cavendish Square, W. (C. 1885.) Trans. 6. 

1871 Goveb, Bobebt M., M.B., 12, Hereford Gardens, W. 

1875 Gowebs, William Bicbabd, M.D., Physician to 
University College Hospital; 50, Queen Anne 
Street, Cavendish Square, W. (C, 1881-2.) 
Trans. 4. 

1868 Gbeen, T. Hettby, M.D., Physician to, and Lecturer 
on Pathology at, the Charing Cross Hospital ; 
Assistant Physician to the Hospital for Consump- 
tion, Brompton; 74, Wimpole Street, W. (C. 
1877-9.) Trans. 2, 0.8. 1. 

1875 tGnEBinriELD, William Smith, M.D., Professor of 
General Pathology in the University of Edin- 
burgh; 7, Heriot Bow, Edmburgh. (C. 1881.) 
Trans. 8. 

Oriff. Memh. Gbeenhow, Edwabd Headlam, M.D., F.B.S., Con- 
sulting Physician to the Middlesex Hospital; 
Castle Lodge, Beigate. (T. 1867-78, P. 1879-80.) 
Trans. 24. 

1888 Gboss, Chables, Medical Superintendent, St. 
Saviour's Infirmary, Westmoreland Boad, Wal- 
worth, S.E. 



List of Members. 

Elbctbd 

1868 tO-rENBAr be MrssY, Hekbi, M.D., 15, Bue da 

Cirque, Paris. 

Oriff. Memb. Gtjll, Sir "William "Withet, Bart., M.D., D.C.L., 

E.B.S., Physician Extraordinary to the Queen; 
Consulting Physician, G-uy's Hospital ; 74, Brook 
Street, W. (V.P. 1868-70, P. 1871-2.) Trans. 6. 

Orig. Memb. ELabebshon, Samuel Osbobne, M.D., 70, Brook 

Street, W. (C. 1873, V.P. 1878-9.) Trans. 6. 

1882 Haddeit, Walteb Baugh, M.D., Demonstrator of 
Morbid Anatomy at St. Thomas's Hospital; 21, 
Welbeck Street, Cayendish Square, W. Trans. 5, 
0,8. 1. 

1875 Hale, C. D. B., 8, Sussex Gardens, Hyde Park, W. 

1878 Hall, E. de Hayillaetd, M.D. (C), Assistant Physi- 

cian to the Westminster Hospital ; 46, Queen Anne 
Street, Cavendish Square, W. (C. 1885.) Trans. 4. 

Orig. Memb. Hablet, Johbt, M.D., F.L.S., Physician to, and 

Lecturer on General Anatomy and Physiology at, 
St. Thomas's Hospital; 39, Brook Slareet, Gros- 
venor Square, W. (C. 1875.) Trans. 1. 

1872 Habbis, Henbt, M.D., Trengweath, Bedruth, Corn- 
wall. 

1881 Habbisoit, Chables Edwabd, M.B., Grenadier 

Guards Hospital, Bochester Bow, S.W. 

Orig. Memb. Habt, Ebitest, 38, Wimpole Street, Cavendish 

Square, W. (C. 1867-8.) 

1869 Hawabd, J. Wabbingtok (C), Surgeon to St. 

George's Hospital; 16, Savile Bow, Burlington 
Gardens, W. (C. 1876-8, 1884-6, S. 1881-3.) 
Trans. 11. 

Orig. Memb, Heath, Chbistofheb {Treasurer)^ Surgeon to Uni- 
versity College Hospital, and Holme Professor of 
Clinical Surgery in University College ; 36, Caven- 
dish Square, W. (C. 1867-71, V.P. 1876-8, 
T. 1879-85.) l}rans. 18. 

1879 Hekdebson, GsoBaB Coxibtekay, M.D., Kingston, 

Jamaica, West Indies. 

1885 Hbntt, Stdnet H., 308, Camden Boad, N. 

1882 Hebon, Geobge Allan, M.D., Assistant Physician 

to the City of London Hospital for Diseases of the 
Chest, Victoria Park ; Assistant Physician to the 
West London Hospital for the Paralysed and Epi- 
leptic ; 57, Harley Street, Cavendish Square, W. 



List of Members. 

Elmcted 

1884 Hbbbikgham, Wilmot Pabkeb, M.B., 22, Bedford 
Sqnare, W.C. 

Oriff. Memb. Hewett, Sib Pbbboott G-abdkxb, Bart., F.B.S., 

Surgeon-Extraordinary to H.M. the Queen ; Con- 
sulting Surgeon to St. George's Hospital ; Ghesnut 
Lodge, Horsham, Sussex. (V.P. 1869-71, P. 
1878-4.) Trans. 3. 

Orig. Memb. Hewitt, Gbaily, M.D., Professor of Midwifery in 

University College, and Obstetric Physician to 
TJniyersily College Hospital ; 36, Berkeley Square, 
W. (C. 1878-9.) 7h^am.l. 

Orig. Memb. Hioks, J. Bbaxtok, M.D., E.B.S., F.LkS., Consulting 

Physician Accoucheur to Guy's fiospital ; 24, 
George Street, Hanover Square, W. (C. 1876-7.) 

1868 Hill, Bebkeley, M.B., Professor of Clinical Sur- 
gery in University College, London, Surgeon to 
University College Hospital, and Surgeon to the 
Lock Hospital; 66, Wimpole Street, W. (C. 
1870-1.) 5V«««. 7, O.S. 1. 

1874 HoLDEBirEss, William Bbowit, 15, Park Street, 
Windsor. 

1868 fHoLMAir, CoKSTANTnns, M.D., Beigate, Surrey. 

1868 HoLMAN, William Henbt, M.B., 68, Adelaide 
Bead, South Hampstead, N.W. 

Orig. Memb. Holmes, Timothy, Surgeon to, and Lecturer on 

Surgery at, St. George's Hospital; 18, Great 
Cumberland Place, Hyde Park, W. (C. 1867-9, 
V.P. 1873-6.) Trans. 13. 

Orig. Mevnb. Holt, Babkabd Wight, Consulting Surgeon to, and 

Lecturer on Clinical Surgery at, the Westminster 
Hospital; Medical Officer of Health for West- 
minster ; 14, Savile £ow, W. Trans. 1. 

Orig. Memb. Holthouse, Cabsteit. (C. 1870-2.) Trans. 8. 

1878 Hood, Donald William Chables, M.D., Assistant 
Physician to the West London Hospital; 43, 
* Green Street, Park Lane, W. Trans. 1. 

1873 Hope, William, M.D., Senior Physician to Queen 
Charlotte's Lying-in Hospital ; 56, Gurzon Street, 
May&ir, W. 

1883 HoPKiifs, John, Medical Superintendent, Central 
London Sick Asylum; Cleveland Street, W 
0.8. 1. 



List of Members. 

Elbctxb 

1884 HoBBLEY, ViCTOB, M.B., Assistant Surgeon, Uni- 
versity College Hospital; Assistant Professor of 
Pathological Anatomy, University College, London; 
Superintendent of tne Brown Institution, Wands- 
worth Bead ; 80, Park Street, Orosvenor Square, W. 

1878 HoxraHTON, Waltbe B., M.D., late Assistant Phy^si- 

cian to Charing Cross Hospital; Church Villa, 
Warrior Square, St. Leonard's-on-Sea. 

1880 HovELL, T. Mabk, Junior Aural Surgeon to the 
London Hospital.; 3, Mansfield Street, Portland 
Place, W. 

1876 HowsE, Hbnbt Gbbenwat, M.S. Surgeon to, 

and Lecturer on Anatomy at, Quy*s Hospital; 
Surgeon to the Evelina Hospital for Sick Chil- 
dren ; 10, St. Thomas's Street, S.E. (C. 1881-3.) 
Trans, 3. 

Oriff. Memh, Htjlke, John Whitakbb, F.E.S., Surgeon to the 

Middlesex Hospital, and Surgeon to the Boyal 
London Ophthalmic Hospital ; 10, Old Burlington 
Street, W. (C. 1867-9, V.P. 1878-80.) l}rans, 13. 

Orig. Memh, Humphbt, Qeobge Mubbat, M.D., E.E.S., Pro- 
fessor of Surgery in the University of Cambridge, 
and Surgeon to Addenbrooke's Hospital, Cam- 
bridge. (V.P. 1867-70.) 

Orig, Memh, HTJTCHnrsow, Jonathan, E.E.S., Consulting Sur- 
geon to the London Hospital; Surgeon to the 
Hospital for Diseases of the Skin, Blackfriars, 
and Surgeon to the Boyal London Ophthalmic 
Hospital ; 15, Cavendish Square, W. (C. 1867-8, 
V.P. 1875-6.) Trans, 9. 

1879 Ineson, James, M.D., Surgeon-Major, Army Medical 

Department. 

1883 Jackson, G-eobge Hekbt, Lansdowne House, Totten- 
ham. 

Orig, Memh, Jaokson, J. HuGHLiKas, M.D., E.B.S., Physician to 

the London Hospital; Physician to the National 
Hospital for the Paralysed and Epileptic ; 3, Man- 
chester Square, W. (C. 1872-3.) Trans. 1, 

1877 JAOOBsoir, Walteb HAMixToif AoLAin), M.B., 

Assistant Surgeon to Gf^uy's Hospital ; 41, Einsbury 
Square, E.C. 



List of Members. xxxiii 

Elbotbd 

Oriff, Memb. Jeniteb, Sir William, Bart., M.D., K.C.B., D.O.L., 

LL.D., P.E.S., Physician-in-Ordinary to H.M. the 
Queen and to n.B.H. the Prince of Wales ; Con- 
sulting Physician to TJniyersity College Hospital ; 
63, Brook Street, W. (V.P. 1867-70, P. 1876-6.) 
Trans. 2. 

1875 Jessett, Ebebebick Bowbbmait, Surgeon to the 

Eoyal General Dispensary; 16, Upper Wimpole 
Street, W. 

Orijf. Memh, Johkbok, &EOBaE, M.D., E.E.S., Physician to King's 

College Hospital; 11, Savile Row, W. (V.P. 
1874t-6.) Trans. 5. 

1878 JoHKSTON, William, M.D., M.C., 16, Lonsdale 
Terrace, Upper Kent Street, Leicester. 

Orig. Memh. Joites, Sydney, M.B., Surgeon to, and Lecturer on 

Surgery at, St. Thomas's Hospital; 16, George 
Street, Hanover Square, W. (C. 1867-8.) 
Trans. 1. 

1872 Jones, Thomas Eidge, M.D., Physician to the 

Victoria Hospital for Children ; 4, Chesham Place, 
Belgrave Square, S.W. 

1876 JoBDAN, Ftjbnbaux, Surgeon to the Queen's Hos- 

pital, Birmingham ; 22, Colmore Bow, Birmingham. 
Th'ons. 1. 

1878 Kbetlby, Chables Bobebt Bell, Assistant Sur- 
geon to the West London Hospital; 10, G-eorge 
Street, Hanover Square, W. Trans. 2. 

Orig. Memb. Kelly, Chables, M.D., Medical Officer of Health 

for the West Sussex District ; Worthing, Sussex. 

1882 Kesteyen, William Hsnby, 401, Holloway Bead, 

N. Trans. 1. 

1883 Ktdd, Pebcy, M.D., Assistant Physician to the 

Hospital for Consumption, Brompton ; 60, Brook 
Street, Grosvenor Square, W. Trans. 1. 

1878 Lacey, Thomas Wabiosb, 196, Burrage Bead, Plum- 
stead, S.E. 

1873 Lacy, C. db Lacy, M.B., 31, Grosvenor Street, W. 
1883 Laitb, William ABBriHifOT, M.B., M.S., Assistant 

Surgeon to the Hospital for Sick Children ; 14, St. 
Thomas's Street, Southwark. Trans. 1, O.S. 2. 
Orig. Memb. LANeroK, Johk, Surgeon to, and Lecturer on Ana- 
tomy at, St. Bartholomew's Hospital, and Surgeon 
to the City of London Truss Society ; 2, Harley 
Street, W. (C. 1878-80.) Trans. 2. 

VOL. XVIII. C 



xxxiv List of Members, 

Elboted 

1885 Labdeb, Hebbsbt, St. Marylebone Infirmary, Net- 
ting HiU, W. 

1883 Lawbekce, Hekbt Cbipps, 49, Oxford Terrace, 
Hyde Park, W. 

Oriff. Memh. Lawson, Geobge, Surgeon to the Middlesex Hos- 
pital, and Surgeon to the Eoyal London Ophthal- 
mic Hospital ; 12, Harley Street, W. (S. 1871-8, 
C. 1874-6, V.P. 1881-3.) Trans. 16. 

1877 Lediabd, Henbt Ambbose, M.D., Surgeon to the 
Cumberland Infirmary; 41, Lowther Street, Car- 
lisle. Trans. 4. 

Orig, Memh, Lee, Henby, Consulting Surgeon to St. Oeorge's 

Hospital; 9, Savile Eow, W. (V.P. 1870-2.) 
Trans, 7. 

1882 Leeds, Thomas, "Wanderers' Club, 9, Pall Mall, 
S.W. 

1877 Lees, Dattd B., M.D. (C), Physician (with charge 

of out-patients) to, and Lecturer on Materia 
Medica at, St. Mary's Hospital, and Assistant 
Physician to the Hospital for Sick Children; 2, 
Thurloe Houses, Thurloe Square, S.W. (C. 1885.) 
Trans, 2. 

1879 LiCHTEXTBEBa, Geobge, M.D., 47, Einsbury Square, 
E.C. 

1878 LisTEB, Sir Joseph, Bart., D.C.L., L.L.D, r.E.S., 

Professor of Clinical Surgery at King's College, 
and Surgeon to King's College Hospital ; 12, Park 
Crescent, Eegent's Park, W. (P. 1881-2.) 2h'ans,S. 

1868 Little, Louis Stbometeb, China. 

1875 LiYEore, Edwabd, M.D., 52, Queen Anne Street, 

Cavendish Square, W. 

1872 LrvEiNG, Eobebt, M.D., Lecturer on Dermato- 
logy, and Physician to the Skin Department at the 
Middlesex Hospital ; 11, Manchester Square, W. 
(C. 1883-4.) Trans, 2. 

1878 Lloyd, Eobebt Honasiirs, M.D., Medical Superin- 
tendent Lambeth Infirmary, Brook Street, Kenniog- 
ton Eoad, S.E. Trans. 1, 

1876 Loii^aHTJBST, Abthub Edwik Temple, M.D., 22, 

Wilton Street, Grosvenor Place, S.W. 

1881 Ltjbbocs:, MoNTAaxr, M.D., Assistant Physician to 
Charing Cross Hospital ; 19, G-rosyenor Street, W. 



r 



Liai of Members. xxxv 

Elected 

1876 LrcAs, B. Clement, M.B., B.S. (C), Senior Assistant 
Surgeon to, and Demonstrator of Operative and 
Practical Surgery at, Guy's Hospital ; 18,!Finsbury 
Square, E.C. (C. 1883-6.) Ttom. 6. 

1879 LuNTT, John Bettben, Besident Medical Officer, New 
Marylebone Infirmary, Backham Street ; Ladbroke 
Grove Boad, Netting Hill, W. Traru, 3, O.S. 2. 

1871 MacGobmao, Sib William, Surgeon to, and Lecturer 
on Surgery at, St. Thomas's Hospital ; 13, H^ley 
Street, W. (0. 1877-9.) Trans, 6. 

1883 fMACPABLAiTE, Alexandbb William, M.D., Con- 

sulting Physician to the Kilmarnock Fever Hos- 
pital and Infirmary ; "Walmer, Kilmarnock, N.B. 

1884 McGiLL, Abthitb EEBaussoK, Professor of Anatomy, 

Yorkshire College ; Surgeon to the Leeds General 
Infirmary ; 23, Park Square, Leeds. 

1881 McHabdy, Malcolm Maodonald, Ophthalmic Sur- 

geon to King's College Hospital ; 5, Savile Bow, 
W. Trans, 1, 

1882 Mackenzie, Fbedebio Mobell ; 10, Hans Place, 

S.W. 

Oriff. Memh, MACKEisrziE, Mobell, M.D., Physician to the Hospital 

for Diseases of the Throat; 19, Harley Street, 
Cavendish Square, "W. Trans, 4. 

1879 Mackenzie, Stephen, M.D. {Hon, Secretary), Phy- 
sician to, and Lecturer on Medicine at, the London 
Hospital; 26, Finsbury Square, B.C. (C. 1884, 
S. 1886.) Trans. 6, CS. 6. 

1884 Maceebn, John, M.B., Assistant Physician, Chelsea 

Hospital for Women ; 30, Cambridge Street, Hyde 
Park, W. 

1879 Maclagan, Thomas John, M.D., 9, Cadogan Place, 
Belgrave Square, S.W, 

1875 Macnamaba, Chables, Surgeon to the Westminster 
Hospital, and to the Boyal Westminster Ophthal- 
mic Hospital ; 13, Grosvenor Street, W. (C. 1879- 

81.) aa, 1. 

1879 Magill, James, M.D., M.C., Surgeon, Coldstream 
Guards ; Coldstream Guards Hospital, Vincent 
Square, Westminster, S.W. 

1885 Magtjibe, Bobebt, M.D., Assistant Phvsician to St. 

Mary's Hospital ; St. Mary's Hospital College, 33, 
Westbourne Terrace, W. 



xxxvi List of Members. 

Elbotbd 

1881 Makins, Geobge Hekbt, St. Thomas's Hospital, 

Albert Embankment, S.E. 

Oriff, Memb. Mabost, William, M.D., r.B.S., 39, Grosvenor 

Street, W. (0. 1867-9.) Trans. 1. 

1868 Mabsh, E. Howabd, Assistant Surgeon and Lecturer 
on Anatomy to St. Bartholomew's Hospital, and 
Surgeon to the Hospital for Sick Children ; 36, 
Bruton Street, Berkeley Square, W. (C. 1876-7, 
1881-83, S. 1878-80.) Trans. 9, 0.8. 2. 

1875 Mabshall, E. J., Besident Medical Officer, St. 

George's Hospital, "W. 

1884 Matjdslby, Heitbt, M.D., Besident Medical Officer, 
University College Hospital, G^wer Street, "W.C. 

1868 tMAT, EnwABD Hoopeb, M.D., High Cross, Totten- 
ham, Middlesex, N. 

1868 Meadows, Alfbed, M.D., Physician-Accoucheur to, 
and Lecturer on Midwifery at, St. Maiy's Hospital ; 
27, George Street, Hanover Square, W . (C. 1871- 
4.) Trans. 1. 

1876 Melladew, H. F. L., M.D., Surgeon-Major, Boyal 

Horse Guards ; Begent's Park Barracks, N."W. 

1878 Mebedith, William Appleton, M.B., CM., Sur- 
geon to the Samaritan Eree Hospital for Women 
and Children ; 6, Queen Anne Street, Cavendish 
Square, W. 

1873 Mickle, William Julius, M.D., Physician Superin- 

tendent, Grove Hall Asylum, Bow, E. 

1877 *MiLN£B, EnwABD, Surgeon to the Lock Hospital ; 

32, New Cavendish Street, Portland Place, W. 

1882 Moi^EY, AiroEL, M.D., Assistant Physician to the 

City of London Hospital for Diseases of the Chest, 
Victoria Park, and to the Hospital for Sick Chil- 
dren, Great Ormond Street ; 24, Harley Street, 
Cavendish Square, W. Trans. 1. 

1874 MoBGAN, John Hammgih) (C), Assistant Surgeon to 

the Charing Cross Hospital, and to the Hospital for 
Sick Children ; 68, Grosvenor Street, W. (C. 
1883-5.) Trans. 1, C.S. 2. 

1877 » MoBBis, Henbt, M.B. (C), Surgeon to, and Lecturer 
on Surgery at, the Middlesex Hospital ; 2, Mans- 
field Street, Portland Place, W. (C. 1884-5.) 
Trans. 6. 



List of Members. xxxvii 

Elboted 

1877 MoBBiB, Malcolm Alex., Lecturer on Skin Diseases 

at St. Mary's Hospital ; 63^ Montagu Square, W. 
3}^an8. 1. 

1885 MoTT, Fbedebick Walkeb, M.B., CM., 55, Torring- 
ton Square, "W.O. 

1879 MouLLiN, Chables W. Maksell, Assistant Surgeon 
to the London Hospital ; 69, Wimpole Street, 
Cavendish Square, W, Trans. 1. 

Ori^, Memh. MoxoN, Walteb, M.D., F.L.S., Physician to, and 

Lecturer on Medicine at, Guy's Hospital; 6, 
Finsbury Circus, E.G. (C. 1874-6.) Trans. 2. 

1878 Mtjib, J. C. Pollock, 44, Cornwall Eoad, Westboume 

Park, W. 

1875 MiTBPHr, Shiblbt P., 158, Camden Boad, N.W. 

1885 MuBBAY, Alexaio)eb Dalton, M.B., Eickmans- 
worth, Herts. 

1883 MuBBAY, Htjbebt Montaoue, M.B., Assistant Phy- 
sician to Charing Cross Hospital; 27, Sayile 
Eow, W. 

1868 Mtebs, Abthfb Bowen Bichabds, Surgeon to Ist 
Battalion of the Coldstream Guards ; Vincent 
Square, Westminster, S.W. (C. 1877-9.) Trans. 1. 

1882 Myebs, a. T., M.D., 24, Clarges Street, Piccadilly, 
W. O.S.I. 

1873 Mybtlb, Akdbew S., M.D., 8, Park Parade, Harro- 

gate. 

1874 Nakkivell, Abthub Wolcot, Besident Surgeon, 

St. Bartholomew's Hospital, Chatham. 

1875 Nbttlbship, Edwabd, Ophthalmic Surgeon to, 

and Lecturer on Ophthalmology at, St. Thomas's 
Hospital ; 5, Wimpole Street, Cavendish Square, 
W. (C. 1881-82.) Trans. 2. 

Orig. Memh. Nobton, Abthtjb Tbehebit, Surgeon to, and Lecturer 

on Siffgery at, St. Mary's Hospital ; 6, Wimpole 
Street, W. (C. 1874-6.) Trans. 6. 

Orig. Memh. Nttkit, Thomas Willla^, Consulting Surgeon to the 

Middlesex Hospital; 8, Stratford Place, Oxford 
Street, W. (C. 1873-74.) Trans. 5. 

1880 O'CoNNOB, Bebnabd, M.D., Physician to the North 
London Hospital for Consumption, and Physician 
to the Westminster General Dispensary ; 17, St, 
James^ Place, S.W. Trans. 1. 



xxxviii List of Members, 

Elected 

Orig. Memb. Ogle, John William, M.D. (V.P.)> ConBultmg 

FhTsician to St. Qeorge's Hospital ; 80, CavendiBQ 
Square, W. (C. 1867-8, V.P. 1884^.5.) Trans. 6. 

1868 tOoLE, William, M.D., Physician to the Derbyshire 
General Infirmary ; 98, Priar Gate, Derby. 

1883 Oliyeb, Geoboe, M.D., West End Park, Harrogate. 

1868 Oppebt, Ebanz, M.D. ; 128, Leipzigerstrasse, Ger- 
many. Trans. 1. 

1877 Obd, William Milleb, M.D,, Physician to, and 
Lecturer on Medicine at, St. Thomas's Hospital ; 
7, Brook Street, Hanover Square, W. (0. 1882-4.) 
Trans. 5. 

1884 Obmsby, Lambebt Hepenstal, M.D., Lecturer on 

Clinical and Operative Surgery at, and Surgeon to, 
the Meath Hospital and County Dublin Linrmary ; 
Surgeon to the Children's Hospital, Dublin; 4, 
Merrion Square West, Dublin. 

1883 Obton, Geoboe Hunt, M.B., 1, Campden Hill Bead, 

Kensington, W. 

1877 Owen, Isambabd, M.D., Assistant Physician to St. 
George's Hospital; 5, Hertford Street, Mayfair, 
W. Trans. 1. 

1875 Paoe, Hebbebt W., M.C, M.B., Surgeon to, and 
Joint-Lecturer on Surgery at, St. Mary's Hospital ; 
146, Harley Street, W. (C. 1882-4.) Trans. 1. 

1884 Paqet, Stephen, 5, Wimpole Street, Cavendish 

Square, W. 

1873 Pabkeb, Bobbbt William, Surgeon to the East 
Loudon Hospital for Children ; 8, Old Cavendish 
Street, W. (C. 1882-4.) Tram. 4, C.S. 4. 

1881 Pabkeb, Bushton, M.B., Professor of Surgery in 
University College, Liverpool, and Assistant Sur- 
geon Liverpool Boyal Infirmary ; 59, Bodney 
Street, Liverpool. Trans. 1, 0.8. 1. 

1881 Pastbtjb, William, M.D., Medical Begistrar to 
the Middlesex Hospital ; Physician to the North- 
Eastem Hospital for Children ; 19, Queen Street, 
May Pair, W. 

1883 Paul, Johk LisTOir, M.D., 43, Queensborough Ter- 
race, W. 

Orig. Memb. Pavt, Pbbdbbiob: William, M.D., F.B.S., Physi- 
cian to G-uy's Hospital; 35, Grosvenor Street, 
W. (C. 1869-71, V.P. 1882-4.) Trans. 3. 



List of Members. xxxix 

Elected 

1879 Feel, Eobebt, 130, Collins Street East, Melbourne, 
Victoria. 

1882 Peppee, Atjgfstus Joseph, M.S., M.B., Surgeon to 

St. Mary's Hospital; 122, Gower Street, W.C. 
Trans, 1. 
1874 Phillips, Chaeles Dotjglas F., M.D., 10, Henrietta 
Street, Cayendish Square, W. 

1884 Phillips, Sidney Philip, M.D., Physician to St. 

Mary's Hospital ; 12, Eadnor Place, Hyde Park,W. 
Trans, 1. 

Orig, Memb, Pick, Thomas Piczeeikg (V.P.), Surgeon to, and 

Lecturer on Surgery at, St. George's Hospital; 
Surgeon to the Belgrave Hospital for Children; 
18, Portman Street, Portman Square, "W. (S. 
1874-7, C. 1878-80, V.P. 1886.) Trans. 3. 

1885 Pitt, Geobge ^NTewton, M.D., Assistant Physician 

to the East London Hospital for Children; 34, 
Ashbum Place, South Kensington. 

1883 Pitts, Bebnabd, M.A., M.C., Assistant Surgeon, St. 

Thomas's Hospital ; 31, Harley Street, W. Trans. 1. 

1871 fVhATS^, Alpeed, M.B., Maidenhead. 

1884 Poland, John, Demonstrator of Anatomy, Guy's 

Hospital ; 16, St. Thomas's Street, South wark, S.E. 

1884 PoLLAED, Bilton, Surgical Registrar to University 
College Hospital ; 60, Torrington Square, W. 

1868 Pollock, James Edwaed,M.D., Consulting Physician 
to the Hospital for Consumption and Diseases of the 
Chest ; 52, Upper Brook Street, Grosvenor Square, 
W. (C. 1878-80.) 

1871 PooEE, Geoege Vivian, M.D., Professor of Medical 
Jurisprudence in University College, and Assistant 
Physician to University College Hospital ; 30, 
Wimpole Street, W. (C. 1879-81.) Trans. 2. 

1873 Poet, Helneich, M.D., Physician to the German 
Hospital ; 48, Einsbury Square, E.'C. 

1881 Powell, H. A., M.A., Elm Cottage, Beckenham, 
Kent. 

Orig, Memh. Powell, E. Douglas, M.D., Physician to, and Lec- 
turer on Practical Medicine at, the Middlesex Hos- 
pital ; Physician to the Hospital for Consumption 
and Diseases o£ the Chest, Brompton ; 62, Wimpole 
Street, Cavendish Square,W. (C.1874-76.) Trans. 4i. 

1868 Peentis, Chaeles, Surgeon-Major, Bengal Medical 
Service; India. 



d List of Members. 

Elbotbd 

1884 Pbingle, John Jakes, M.B., Assistant Physiciiui to 
the Middlesex Hospital aod to the Boyal Hospital 
for Diseases of the Chest ; 35, Bmton Street, Ber- 
keley Square, "W. S^rans. 1. 

1884 Pte-Smith, Philip Henby, M.D., Physician to, and 
•Lecturer on Medicine at, Guy's Hospital; Ex- 
aminer in Physiology at the University of London ; 
64, Harley Street, Cavendish Square, W. 

Orig. Memh, Quain, Eichabd, M.D.,E.B.S., Consulting Physician 

to the Hospital for Consumption and Diseases of 
the Chest ; 67, Harley Street, W. (C. 1867-9.) 

Orig, Memh, Bamskill, J. Spence, M.D., Consulting Physician to 

the London Hospital; Senior Physician to the 
National Hospital for the Paralysed and Epileptic ; 
5, St. Helen's Place, Bishopsgate Street, E.C. 

1873 Eanspoed, Gippoed, M.D. (C.), 27, Gloucester Place, 

Hyde Park, W. (C. 1884-6.) 

1868 Easch, Adolphtjs A., M.D., Physician for Diseases 
of Women to the German Hospital; 7, South 
Street, Einsbury Square, E.C. 

1877 Eayneb, Heitbt, M.D., Lecturer on Mental Diseases 
at St. Thomas's Hospital ; Middlesex County 
Lunatic Asylum, Hanwell, W. 

1888 Bead, Thomas Laitbekce, 11, Petersham Terrace, 
Queen's Gate, "W. 

1874 Bee, Ebedesick G., Boyal India Asylum, EaUng, W. 

Orig, Memh. Bees, Gsobgs Owen, M.D., E.B.S., Consulting 

Physician to Guy's Hospital; 26, Albemarle Street, 
PiccadiUy, W. (V.P. 1871-a.) 

1868 Beeves, H^amx A., Assistant Surgeon to the London 
Hospital ; 78, Grosvenor Street, W. Ihms. 2. 

Orig. Memb, BEXifOLns, John Bt7Ssell, M.D., F.B.S., Consulting 

Physician to TJniversily College Hospital; 38, 
Grosvenor Street, W. (C. 1867-8.) 

1868 Bice, Michael W., M.D. (C. 1876-8.) 

1883 Btetg, EDMTJin) Cuthbeet, Salisbury Club, 10, St. 
James' Square, S.W. 

Orig. Mmh. BnroES, Stditsy, M.D., Professor of the Principles 

and Practice of Medicine in Umversity College, 
and Physician to University College Uosmtid ; 15, 
Cavendish Place, W. (C, 1871-2.) 

1877 BrvureroN, Waltsb, M,&, M.B., Surgeon to» and 
Lecturer on Surgery at, the London IIo»pilid i 
22, Finsbury Square, KC. Jhn^ 9. 



List of Members, xli 

Elbotbd 

1873 tRoBEETS, David Lloyd, M.D., PhyBician to St. 

Mary's Hospital, Manchester ; 28, St. John Street, 
Manchester. 

1883 EoBBETS, Feedbeiok Thomas, M.D., Professor of 
Materia Medica and Therapeutics in TJniyersity 
College, London, and Physician to University Col- 
lege Hospital ; Physician to the Hospital for Con- 
sumption, Brompton ; Examiner in Materia Medica 
in the University of London; 63, Harley Street, 
Cavendish Square, W. 

1885 EoBSON, A. W. Mato, Surgeon to the Leeds Gheneral 
Infirmary, Hillary Place, Leeds. Trans. 1. 

1876 BoGEBS, William Eichabd, M.D., 56, Bemers 

Street, Oxford Street, W. 

1877 EoTH, Bebnaed M. S., 48, Wimpole Street, W., and 

Eossmore, Preston Eoad, Brighton. 2?rans. 1, 0,8. 2. 

Oriff. Memb. Eouse, James, Surgeon to St. G-eorge's Hospital, and 

to the Eoyal Ophthalmic Hospital, Charing Cross ; 
2, Wilton Street, Grosvenor Place, S.W. (C. 
1875-7.) Trans. 2. 

1874 BowLAio), Edwaed E. 

1882 Sahtsbtibt, HAEEnrGTON, M.D., 27, Gk)wer Street, 
W.C. 

1868 Sandeeson, Hugh James, M.D., 26, Upper Berkeley 

Street, W. 

Orig. Memb. Sakdbesok, John Buedon, M.D., LL.D., F.E.S., 

Waynflete Professor of Physiology in the University 
of Oxford ; 60, Banbury Eoad, Oxford. (S. 1867-9, 
C. 1870, V.P. 1871-3.) l}rans. 3. 

1878 Sangstee, Alfeed, M.B., Physician to the Skin 

Department and Lecturer on Skin Diseases at the 
Charing Cross Hospital; 6,SavileEow,W. l^ransA. 

1873 Savage, Geoege Heney, M.D., Bethlem Eoyal Hos- 
pital, St. G-eorge's Eoad, S.E. (C. 1882-3.) 

1885 Sawtell, Tom Henet, M.B., 14, Stapleton Hall 
Eoad, Stroud Green, N. 

1877 Seatow, Edwaed, M.D., 35, George Street, Hanover 
Square, W. 

1869 Sedgwick, Leokaed William, M.D., 2, Gloucester 

Terrace, Hyde Park, W. (C. 1879-81.) 



xlii List of Members, 

Elbotbd 

1878 Semov, Eeux, M.D. (C.)^ AsBistant Physician for 

Diseases of the Throat to St. Thomas's Hospital ; 
59, Welbeck Street, Cavendish Square, W. (C. 
1885.) Trans. 4. 

1884 Shabkey, Seymottb J., M.B., Assistant Physician and 
Lecturer on Pathology to St. Thomas's Hospital ; 
2, Portland Place, W. 

1875 Shebwood, Abthtjb Paul, 8, Seaside Boad, East- 
bourne. 

Oriff. Memh, Sibley, Septimus William, 7, Harley Street, 

Cavendish Square, W. (C. 1871-4.) 

1879 SsEBBiTT, Edwabd Mabksam, M.D., Physician to 

the Bristol General Hospital, Lecturer on Medicine 
at the Bristol Medical School ; Coburg Villa, Bich- 
mond Hill, Clifton, Bristol. Trans, 2. 

1877 SxiiiWEB, William A., 45, Lower Belgrave Street, 
Eaton Square, S.W. 

1872 Slight, aEOBGE, M.D., 8, Clifford Street, Bond 

Street, W. 

1882 Smith, E. Noble, Senior Surgeon, and Surgeon to 
the Orthopssdic Department, of the Farringdon 
Dispensary ; 24, Queen Anne Street, Cavendish 
Square, W. Trans. 1. 

1868 Smith, Heywood, M.D., Physician to the Hospital 
for Women, and Physician to the British Lying-in 
Hospital ; 18, Harley Street, Cavendish Square, W. 

1868 Smith, Pbotheboe, M.D., Physician to the Hospital 
for Women ; 42, Park Street, Grosvenor Square, W. 

1884 Smith, E. Pebcy, M.D., Assistant Medical Officer, 
Bethlem Eoyal Hospital^ S.E. 
Ori^. Memh. Smith, Thomas, Surgeon to, and Lecturer on 

Clinical Surgery at, St. Bartholomew's Hospital, 
and Surgeon to the Hospital for Sick Children ; 5, 
Stratford Place, Oxford Street, W. (C. 1869-71, 
y.P. 1880-82.) Trans. 13. 

1875 Smith, T. Gilb abt, M. A., M.D. (C.) > Assistant Physi- 
cian to the London Hospital ; Physician to the Boyal 
Hospital for Diseases of the Chest, City Boad ; 68, 
Harley Street, Cavendish Square, W. (C. 1883-6.) 

1873 Smith, William Johitson, Surgeon to the Seamen's 

Hospital, Greenwich, S.E. 

1873 Smith, William Wilbebfobce, M.D., 14, Stratford 
Place, Oxford Street, W. 



List of Members. xliii 

Elected 

1883 Smith, Whtckwobth Tonge, M.D., 129, Ladbroke 

arore, W. 

1B68 Sirow, William Y., M.D., Bichmond Gardens, 
Bournemouth. 

Ori^, Memh, Southey, Eegikald, M.D., CommiBsioner in Lunacj, 

32, Grosvenor Eoad, Pimlico, W. (C. 1867-70, 
1876-8, S. 1873-5, V.P. 1883-4.) Trms. 16. 

1885 Spiceb, Ebedebice:, M.B., Boyal Free Hospital, 
Gray's Inn Eoad, W.C. 

1882 Spooiteb, Ebedebick Henbt, M.D., Howard House, 
Clapton, E. 

1876 Sqtjibe, a. Balman^o, M.B., 24, Weymouth Street, 
Portland Place, W. 0[}rcms, 6. 

1879 Staples, Pbancis Patbick, late Assistant Professor of 
Military Surgery, Netley ; Army Medical Depart- 
ment, Boyal Victoria HoB|)ital, Netley, and Junior 
Army and Navy Club, Eang Street, St. James', 
S.W. [Station Hospital, Gibraltar]. 

1871 Stewabt, William Edwabd, 16, Harley Street, 

Cavendish Square, W. 

1874 tSTiBLiNG, Edwabd C, M.D., late Assistant Sur- 
geon to, and Lecturer on Physiology at, St. 
George's Hospital; Adelaide, South Australia, 
[care of T. Gemmell, Esq., 11, Essex Street, Strand, 
W.C] 

1881 Stoees, Henby Ebaseb, 2, Highbury Crescent, N. 

1878 Stokes, William, M.D., Professor of Surgery, 
Eoyal College of Surgeons, Ireland ; Surgeon to 
the Eichmond Surgical Hospital ; 5, Merrion 
Square North, Dublin. Trans, 2. 

1884 Stoitham, Chables, Curator of the Anatomical 

Museum at University College ; Assistant Surgeon 
to the Cancer Hospital, Brompton; 109, Gower 
Street, W.C. C,S. 2. 

1878 Stbugkell, Ebedebice: William, 45, Highgate Eoad, 
Highgate, N. C.S. 1. 

1878 tSTUBGE, William Allen, M.D., late Assistant Phy- 
sician to the Eoyal Free Hospital ; 9, Eue Long- 
champ, Nice, Alpes Maritimes, France. Trans, 4. 

1872 •SuTHEBLAiTD, Henbt, M.D., Lccturer on Insanity, 

Westminster Hospital; 6, Eichmond Terrace, 
WhitehaU, S.W. Trans, 1. 

1868 Stjtbo, Sigismtjnd, M.D., Senior Physician to the 
German Hospital ; 37a, Finsbury Square, E.C^ 



xliv List of Members, 

Eleotbd 

Oriff. Memh, Sutton, Henbt Qawew, M.B., Physician to, and 

Lecturer%on Pathology at, the London Hospital ; 
9, Finsbury Square, E.G. (C. 1878.) Trans, 2. 

1882 STM0in)s, Chabtebs James, M.S., Assistant Sur- 
geon to Guy's Hospital; 26, Weymouth Street, 
Portland Place, W. Trans. 4, 0,8. 1. 

1876 Stmoitos, Hobatio Pebct, Surgeon to the Badcliffe 
Infirmary, Oxford ; 36, Beaumont Street, Oxford. 

1868 Tatham, John, M.D., Physician to the Hospital for 
Consumption and Diseases of the Chest ; 12, George 
Street, Hanover Square, W. 

1878 Tayleb, Ebajtcis Thomas, B.A., M.B., 224, Lewis- 
ham High Boad, S.E. 

1875 Tatlob, Ebedebick, M.D., Physician to, and Lec- 
turer on Materia Medica at, Guy's Hospital ; Phy- 
sician to the Evelina Hospital for Sick Children ; 
11, St. Thomas's Street, Southwark, S.E. (S. 1879- 
81, C. 1882-4.) Trans. 9. 0.8. 1. 

1882 Tatlob, Seymovb, M.D., Physician to the North 
London Hospital for Consumption ; 22, Taviton 
Street, Gordon Square, W.C. Trans. 1. 

1886 fTATLOB, W. 0. Eveblet, 34, Queen Street, Scar- 
borough. 

Griff. Memh. Tbevan, William F., Mostyn Villa, Brockman 

Road, Folkestone, Kent. (C. 1880-2.) Trans. 8. 

1882 Tnnr, Geobgb, M.D., 22, Queen Anne Street, Caven- 
dish Square, W. Trans. 1. 

Oriy. Memh. TnoMFSOiir, Edmukd Stmes, M.D., Physician to 

the Hospital for Consumption and Diseases of the 
Chest ; Gresham Professor of Medicine ; 33, 
Cavendish Square. W. (C. 1880-82.) Trans, 1. 

Orig, Memh, Thompson, Sir HsinEty, Knt., Surgeon-Extraordinary 

to H.M. the King of the Belgians; Emeritus 
Professor of Clinical Surgery in University Col- 
lege ; 35, Wimpole Street, W. (C. 1867-8.) 
Trans. 1, 

Orig. Memh, Thompson, Hebtbt, M.D., Fellow of St. John's 

College, Cambridge; Consulting Physician to the 
Middlesex Hospital ; 53, Queen Anne Street, W. 
(V.P. 1875-7.) Trans. 4. 

1872 Thobnton, William Pugin, Canterbury. Trans. 6. 



List of Members,. Iv 

Eleotbd 

1876 Thbtjpf, James G-oditbey, Fern House, Heston 

HoudbIow. 

1885 Thtjbsfieli), Thomas William, M.D.y 26, The 
Parade, Leamington. 

1877 Ttbbits, E!ebbbbtj 68, Wimpole Street, Carendish 

Square, W. 

1874 Tbatebs, William, M.D., 2, Phillimore Gardens, 

Kensington, W. 

1884 Tbeybs, Ebebebick, Surgeon to, and Lecturer on 

Anatomy at, the London Hospital; 18, G-ordon 
Square, W.C. 

1882 TiTBinsB, Fbaetcis Chablewood, M.A., M.D., Physi- 
cian to the London Hospital, and to the North- 
Eastem Hospital for Children; 15, Finsbury 
Square, E.G. 

1882 TuBVEB, Geobge Bobebtsok, Visiting Surgeon, Sea- 
men's Hospital, Greenwich; Joint Lecturer on 
Practical Surgery, St. George's Hospital ; 49, 
Green Street, Park Lane, W. Trans. 8. 

1877 Tweedy, John, Professor of Ophthalmic Medicine 

and Surgery at TJniyersity College, and Assistant 
Ophthalmic Surgeon to tTniversity College Hos- 
pital ; Assistant Surgeon to the Boyal London 
Ophthalmic Hospital ; 100, Harley Street, Caven- 
dish Square, W. 

1878 Ttsok, William Joseph, M.D., 10, Langhome 

Gtirdens, Folkestone. Trans. 4. 

1881 Uhthofp, John Caldwell, M.D., 46, Western 
Eoad, Hove, Brighton. 

1868 VENimsro, Edgcombe, 30, Cadogan Place, S.W. (C. 
1876-8.) Trans. 2. 

1868 Wagstappe, William Wabwick, Purleigh, St. 
John's Hill, Sevenoaks. (C. 1878.) 

1885 Wakley, Thomas, Jun., 96, Bedcliffe Gardens, S.W. 

1875 Walsham, William J., Assistant Surgeon to, and 

Demonstrator of Practical and OrthopsBdic Sur- 
gery at, St. Bartholomew's Hospital; Surgeon to 
the Metropolitan Eree Hospital and to the Boyal 
Hospital for Diseases of the Chest ; 27, Wey- 
mouth Street, Portland Place, W. (C. 1882-4.) 
Trans. 8. 

1876 Watebs, John H., M.D., 101, Jermyn Street, St. 

James's, S.W. 



xlvi List of Members. 

EiaOTBD 

1868 Watkins, Edwiit T., M.D., 61, Guilford Street, W.C. 
(C. 1881-83.) 

Oriff, Memh, Watson, William Sfeitceb, M.B., Surgeon to 

the Great Northern Hospital; Surgeon to the 
Boyal South London Ophthalmic Hospital ; 7, 
Henrietta Street, Cayendish Square, W. (C. 1880 
-82.) Trans. 10. 

1879 Wattetille, Abmakd de, M.A., M.D., B.Sc, Medical 
Electrician to St Mary's Hospital; 80, Welbeck 
Street, W. ' 

Orig, Memh, Webeb, HEBMATsnr, M.D., Physician to the German 

Hospital ; 10, Grosvenor Street, W. (C. 1867-71, 
V.P. 1873-5.) Trms, 9. 

1876 Weib, Abchibald, M.D., St. Mungho's, Great 
Malvern. 

1868 Wells, Sib Thomas SpEifCEB, Bart., Surgeon in 
Ordinary to H.M.'s Household; Surgeon to the 
Samaritan !Free Hospital; 3, Upper Grosvenor 
Street, W. (C. 1873.) 

1882 West, Samuel, M.D., Physician to the City of 
London Hospital for Diseases of the Chest, Vic- 
toria Park ; Physician to the Boyal Free Hospital ; 
Medical Eegistrar and Medical Tutor at St. Bar- 
tholomew's Hospital ; 15, Wimpole Street, Caven- 
dish Square, W. Trans. 2, C.S. 1. 

1874 Wheelhottsb, Claudius Galen, Senior Surgeon to 
the Leeds General Infirmary, and Lecturer on 
Surgery, Leeds Medical School ; Hilary Place, 
Leeds. Trans. 1. 

1868 Whipham, Thomas Tillteb, M.B., Physician to, 
and Lecturer on Clinical Medicine at, St. George's 
Hospital ; 11, Grosvenor Street, Grosvenor Square, 
W. (C. 1878-80.) Trans. 10. 

1874 Whistleb, W. M., M.D., 28, Wimpole Street 
Cavendish Square, W. 

1882 White, Edwht Pbaitcis, St. Thomas's Hospital, and 

7, Dealtry Eoad, Putney. 

1883 White, William Hale, M.D., Assistant Physician 

to Guy's Hospital ; 4, St. Thomas's Street, South- 
wark. Trans. 3, S.C. 2. 

1883 White, William Henbt, M.D., Assistant Physician 
to the Boyal Hospital for Diseases of the Chest ; 
43, Weymouth Street, W. 



List of Members. xlvii 

Elbotbd 

1882 Whittle, Edwabd GEoseE, M.D., 66, Dyke Boad, 

Brighton. 

1871 Wight, Geoboe, M.B., CM. ; 428, Liverpool Eoad, N. 

1879 WrLCoi, Hekbt, M.B., Dorchester House, Herbert 

Boad, Woolwich. 

Ori^. Memh. Wilks, Samuel, M.D., F.B.S., Consulting Physician 

to Guy's Hospital; 72, Grosvenor Street, W. (C. 
1871-2.) Trans, 1. 

1884 WiLLCocEs, Fbedebice, M.D., Assistant Physician to 
the Charing Cross Biospital ; Physician in charge of 
Out-patients at the Evelina Hospital for Children ; 
14, MandeviUe Place, W. C.S, 1. 

Oriff. Memh, Willett, Alfbed, Surgeon to St. Bartholomew's 

Hospital ; 36, Wimpole Street, W. (C. 1872-6.) 
C,S. 1, 

Orig, Memh, Williams, Chables Theodobe, M.D., Physician to 

the Hospital for Consumption and Diseases of the 
Chest ; 47, Upper Brook Street, Grosvenor Square, 
W. (C. 1877-9.) Trans. 8. 

1881 Williams, Johpt, M.D. (C), Obstetric Physician to 
University College Hospital; 11, Queen Anne 
Street, Cavendish Square, W. (C. 1885.) 

1870 Williams, William Bhts, M.D., Commissioner in 
Lunacy ; 19, WhitehaU Place, S.W. 

1876 WiLLiAMSGU, James Mann, M.D. ; Ventnor, Isle of 
Wight. 

Orig, Memh, Willis, Fbancis, M.D., Braceborough, Stamford. 

1868 Wiltshiee, Alebed, M.D., Joint Lecturer on Ob- 
stetrics, and Assistant Physician-Accoucheur, St. 
Mary's Hospital ; Torridon, Somers Boad, Beigate. 
(C. 1880-82.) Trans, 1. 

1880 Wood, John, r.B.S., Professor of Clinical Surgery 

in King's College, London, and Senior Surgeon to 
King's College Hospital ; 61, Wimpole Street, 
Cavendish Square, W. 

1883 Woodcock, John Bostbon, Hagley Boad, Birming- 

ham. 

1879 WooDWABD, Geobge p. M., M.D., Deputy Surgeon- 
General ; Sydney, New South Wales. 

1884 WoBTS, Edwin, 6, Trinity Street, Colchester. 

1872 Teo, I. Bttbnet, M.D., Physician to King's College 

Hospital ; 44, Hertford Street, May&ir, W. (C. 
1881-3.) Trans. 5. 



BEP QET 

OF THB 

COUNCIL OF THE CLINICAL SOCIETY. 

Deoehbbb, 1884. 



■•o*- 



IN making tlie customary Annual Statement the Council is 
gratified to assure tlie members tliat during tlie past year 
tlie Society has continued to maintain its position and to justify 
its existence. The number and character of the communica- 
tions^ the quality of the debates^ and the large attendances at 
the meetings have been evidence to its growth in importance 
and estimation. 

The roll of members steadily increases ; it comprises now 
288 resident and 94 non-resident members. Thirty-one new 
members have been elected during the past year. Two have 
resigned membership, and three resident members have become 
non-resident. 

Since the last Annual Meeting the Society has had to 
deplore the loss of three of its members by death, viz. Dr. Gt* 
Hall Davis and Dr. A. W. Barclay, who were both original 
members of the Society, and Dr. F. A. Mahomed, who at the 
time of his death was a member of the Council and was 
serving upon two of your Committees. By the death of Mr, 
Oaesar Hawkins the Society loses an honorary member, and in 
Professor S. Gross a foreign honorary member. The death 
in January last of Mr. B. R. Wheatley, the much-esteemed 
Librarian of the Royal Medical and Chirurgical Society, 
deprived the Secretaries of one whose assistance had always 
been highly valued. The Council marked its sense of Mr. 
Wheatley's long-continued and ungrudging service by voting 

VOL. 2VIII. d 



1 Report of the Council 

the sum of £25 to the Testimonial Fund raised on behalf of 
his sister and niece. 

The balance-sheet presented herewith shows that financially 
the Society is in a most satisfactory condition. Grants of 
money have been made in aid of Committees; and the 
Society's balance at the bankers amounts to £112 11«. 2d,, 
exclusive of £600 invested in Consols. 

The exhibition of living specimens at th,e meetings has been 
continued during the past session on an increasing scale ; and 
it is felt that in the development of this practice the value 
of the Society is much enhanced. The records of cases so 
exhibited now form a distinctive feature of the Transactions, 
and the current volume contains illustrations of such cases. 
Arrangements have been recently made to facilitate this 
exhibition. 

At the close of last year a large and influential Committee 
was nominated to investigate the remarkable affection known 
as myxoedema, in records of which the Society's Transactions 
are rich, including the earliest published cases. The Com- 
mittee is actively pursuing its labours, and will, in due course, 
present a report, which cannot fail to throw much light 
upon the clinical history and pathology of the disease. In 
connection with this inquiry some important experimental 
researches were commenced on behalf of the Committee by 
Mr. Godlee, in conjunction with Professor Horsley, at the 
Brown Institution, and have been pursued by the latter 
gentleman, who dealt with the results so far obtained, in his 
course of lectures delivered at the University of London in 
December. 

The Committee on spina bifida and its treatment by iodo- 
glycerine injection has nearly completed its inquiry ; and the 
report, which will comprise a very thorough investigation of 
the subject, will shortly be presented. 

The Council cannot conclude this report without alluding 
with satisfaction to the recent valuable and exhaustive debate 
upon Charcot's disease of joints, which arose out of a paper 
by Mr. Morrant Baker, one of the Vice-Presidents. So large 
a number of illustrative living specimens and of morbid pre- 
parations, the latter including a valuable series kindly lent by 
Professor Charcot, has never hitherto been brought together 
in this country ; and the thanks of the Society are due to all 
those gentlemen who thus contributed to the success of the 
meetings. The effect of this prolonged debate will be to 
;t^nlighten the profession upon the nature and relations of the 



Report of the Councils li 

artliropatliy. In view of the interest it excited the Council 
has made arrangements to secure a verbatim report for 
publication in the Transactions^ and has also nominated a 
Committee to report upon the cases brought forward. 

The seventeenth volume of the Society's Transactions^ 
recently published^ exhibits a few slight but desirable improve- 
ments in style. It contains forty-eight communications, twenty 
recordB of living specimens^ and twelve lithographic plates. 



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1 



PRESIDENTIAL ADDRESS 

DILITBBBD AT THB 

CLINICAL SOCIETY OE LONDON 

ON FEBRUABY 13th, 1886, 

By THOMAS BRYANT, F.R.C.S., 

PBBSIDBNT. 



GENTLEMEN, — ^Inclination, no less than a sense of duty, 
urges me to thank you warmly for the distingpiished 
honour you have conferred upon me by placing me in this chair. 
I know of no higher compliment than the one you have bestowed 
upon me which the working members of a Society such as this 
can pay to a working brother. I value it accordingly, and will 
do my best to justify your choice. Should I fail, however, I 
must throw some of the responsibility upon your shoulders, 
since it has been by your kind interpretation of my fitness for 
the position that I am placed here. 

The work that the Society has already done has been very 
good, but it is yet allowable to hope that that achieved in the 
future may be still better. Our predecessors have laboured 
productively for our advantage in various ways. Let us 
endeavour to improve upon their work, aud so add to the sum 
total of attained results that the next generation may be able 
to say like things of us. Let us continue to walk — as they 
have walked — ^in the paths of patient observation, and be precise 
about our facts ; upon these facts and observations let us think 
closely and consistently, and then without fear or hesitation 
carry our reasoning to its legitimate conclusions. Let us, 
however, in our facts beware.of accepting the false for the true, 
and so escape false reasoning; and let us be sure that the 
words we use convey clear thoughts. Let us, moreover, in our 
anxiety to be discoverers, guard against announcing as a 



liv Address by the President, 

novelty some thoaglit or observation whicli, thongH new to us, 
may not be so fresh to others ; remembering in the pursuit of 
knowledge that our own observations are so mixed up with 
those of others, that our thoughts are so often merely the 
outcome of others' thoughts ; our ideas are so constantly no 
more than the assimilation of the thoughts and observations of 
other men, that to be original is almost impossible. With 
respect to the use of terms, for instance, can we say that, 
under all circumstances, we are as careful as we should 
be, and that we never deceive ourselves or others by using 
phrases which, from our not being clear as to their mean- 
ing, tend in reality either to confusion or perhaps to some- 
thing worse ? To illustrate my meaning, may I ask what is 
meant by " strumous '' disease when that term is applied to a 
joint, bone, or other local affection ? Do we all agree as to its 
meaning ? When we apply it, do we feel that we are conveying 
any accurate idea of the case under discussion to our pupils or 
hearers ? As a teacher I unhesitatingly say that by the term 
" strumous disease " applied to any local affection, whether of 
joint, bone, or gland, we do not convey any clear thought. 
Indeed, I may say that we do the reverse ; we confuse instead 
of clearing ideas. 

Let me ask the members of this learned Society what they 
understand by the terms "strumous disease of a joint," 
" strumous glands," &c. It would be interesting to have in 
writing the definitions of these phrases from the individual 
members. Would they all agree? Would they even be at all con- 
sistent ? The answers to these questions would, I fear, be in the 
negative. With such an admission, can we therefore possibly say 
that this very common term is an intelligible one, or that it 
ought to be retained ? If we mean, when we use the term, to 
convey the idea that the enlargement of the affected tissue is a 
specisd one caused by struma, may I ask what is struma ? and 
how does it cause the local disease ? Or, do we mean that it is an 
inflammatory affection of some form, in which the inflammatory 
process is modified by a condition of body which may or may 
not be associated with the deposition of tubercla ? If the latter 
be the correct view, as I take it to be, why should we not say 
so, and why should we not call the local affection a chronic 
inflammation in a strumous subject, or a chronic strumous 
inflammation either of the bone, of the synovial membrane, or 
of both, the inflammatory process being modified by the consti- 
tutional tendency of the individual, in the same way as a 
ehronic inflammation in a gouty or syphilitic subject may be 



Add/re88 by the President. Iv 

modified ? It need hardly be pointed out tliat by this cHange 
of expression mncli good would accrne^ since tbe alteration 
would tend to clear botb the pathological and the clinical 
aspects of the case^ and help our pupils instead of confusing 
them. At the present time, we hear of strumous, scrofulous, 
and tubercular disease of a joint or of bone, as if inflammation 
had nothing to do with the changes met with, and as if any 
one of the terms carried with it a precise thought. 

Again, may I ask — and I do so with some amount of trepi- 
dation — what are we now to understand, when discussing the 
treatment of wounds, by the term *' antiseptic precautions ? " 
How, with the diversities of practice encountered, is the expres- 
sion to be interpreted ? Has it, indeed, at the present day any 
special significance ? One surgeon, when asked the question 
as to its meaning, will answer. It means, of course, the spray 
and gauze system in one or other of its modes of application. 
A second, with equal decision, will apply it to one of the many 
forms of antiseptic irrigation, in which the antiseptic in solu- 
tion is employed either during or after an operation, and some 
antiseptic gauze or other dressing later on. A third surgeon will 
use the term as applied to some antiseptic dry or moist dressing. 
Each one, at any rate, will apply it to his own system, and not 
to another, the former being in his own sight orthodox and all 
others heterodox. Is this confusion of meanings right, or even 
necessary ? Is it not confusing to the seniors of the profession ? 
And if so to them, how much more confusing it must be to our 
pupils. Why should we not, therefore, when we mean it, say 
the ^^ aseptic '* or ^'antiseptic spray and gauze system,^' or 
^' antiseptic irrigation/' or '^ antiseptic dry or other dressing V* 
Such terms would be perfectly intelligible to all, and would 
leave the special antiseptic drug employed as detail to be intro- 
duced in the description or not, as wished, and at the same time 
allow the term " antiseptic precautions '' to lapse into a general 
expression as denoting the well-established and recognised 
principles of antiseptic surgery. At the present day, the 
phrase "antiseptic precautions," as applied to any single case, 
is absolutely unintelligible as indicative of any special form of 
practice. 

Again, have we not in past times too generally mixed 
together cases of intestinal strangulation with those of intes- 
tinal obstruction ? — having been led to do so by the fact that 
bowel obstruction is a common symptom of both classes of 
cases. And have we not, by so doing, obscured and rendered 
difficult of understanding cases concerning which it is very 



Ivi Address hy the President, 

requisite that we should entertain clear views ? In past^ pre- 
pathological ages this confusion of terms was possibly excus- 
able^ but with our present exact pathological and clinical 
knowledge are we not obliged to adinit that strangulation of 
the bowel is one thing and obstruction another ? — that in the 
former class of cases the symptoms are all due to the strangu* 
lation of the intestine^ and but little^ if at all to the obstruction? 
— whereas, in cases of the latter class, all the symptoms are in a 
general sense due to the obstruction and to the changes brought 
about by it ! — these changes being experienced either at the 
seat of obstruction, or, when the obstruction is in the rectum 
or sigmoid flexure, fouud in the csdcum or ascending colon. 
Are we not therefore impelled, for the sake of a clear under- 
standing of these two large subjects, to separate the cases and 
give to each its own proper place ? Shall we not by so doing, 
gain clearer thoughts upon each, and thus be able, as teachers, 
to impart them to others ? 

Again, is it not most important that we should have very 
clear views on such general and elementary subjects as repair 
and inflammation ? And yet, may I ask, are our thoughts upon 
the relations of these two pregnant processes sufficiently clear ? 
Do we, or do we not, in our teaching, mix them up inextricably, 
and, by so doing, encourage, if not impart, erroneous views ? 
Experience leads me, as an examiner of students, to believe 
that this confusion of thought is too general, and that ^^the 
healing of wounds is still supposed by some to be essentially 
an inflammatory process,^' and that even an anchylosis of a 
joint, the result of disorganising inflammatory changes, is " a 
formative termination of the inflammatory process itself/' As 
if, indeed, repair and inflammation, from their both presenting 
in their respective courses certain histological changes which 
are allied, are on that account to be deemed identical; and 
as if the union of the articular ends of the bones following a 
disorganisation of a joint, the result of an acute or chronic 
inflammation, can be brought about by an inflammation, or by 
any other process than a reparative one, which does not begin 
until all inflammation has ceased, which is continued only so 
long as the inflammatory process is kept in abeyance, and 
which ends in the desirable result of anchylosis because the 
reparative process is allowed to go on undisturbed, without 
either the aid or hindrance of inflammatory action. 

In the treatment of a wound is it not the surgeon^s chief 
object to prevent inflammation, and is not this object, based 
upon the knowledge that when a wound is undergoing quick 



Address by the President. Ivii 

repair by primary union^ and becomes the seat of inflammation^ 
the repair at once stops^ and what may have taken place in the 
way of repair becomes disrepair — the exposed sur&ice of the 
wound^ if the inflammatory process continues^ becoming the seat 
either of ulceration or of other destrnctive changes ? When 
ulceration follows a local inflammation it continues so long as 
the inflammatory process lasts ; when this stops repair begins 
by what is called granulation^ and this formative reparative 
process continues and ends in cicatrisation^ so long as no 
inflammation reappears to interfere with its progress. 

When a granulating wound becomes the seat of inflam- 
mation the reparative process at once ceases^ and what had 
been a granulating soon becomes an ulcerating surface. With 
these clinical facts before us^ which are fanuliar enough to 
practical surgeons, there should be no difficulty in demon- 
strating that repair and inflammation are not only not identical, 
but that whilst the one is wholly formative the other is mostly, 
if not always, destructive ; the one is physiological, the other 
pathological. Is it not therefore absolutely necessary that 
the teachers of students should have clear views upon these 
points, and not by such terms as " the formative termination 
of the inflammatory process,'^ and other allied mixed expres- 
sions, put into students^ miuds a cloud of words to cover their 
own uncertain views ? Is it not incumbent upon all teachers 
to enunciate that repair and inflammation are not only not 
identical but that they are incompatible ? — that repair only 
begins in a tissue that has been inflamed when the process 
called inflammation has left it, and continues to complete its 
work as long as the inflammatory action is kept away ? — ^that 
when inflammation attacks a wound in which repair is progress- 
ing the process is at once arrested ; and that what was repair 
then becomes disrepair, if not ulceration ? I think I can hear 
you — ^the members of this Society — say ^^ yes " to my questions, 
and may calculate upon your working in the lines I have laid 
before you. 

With these suggestions, which I trust you will not consider 
out of place, as they are truly clinical, allow me for a few 
minutes to call your attention to some practical points which 
require looking into, since it seems that in our general advance 
in medicine and surgery we sometimes in special subjects 
recede to the practice of our ancestors. This may be said to 
be true in the application of ligatures to arteries in their 
continuity ; for some of our surgical brethren now prefer to 
tie in two places, and divide between the ligatures, an artery 
VOL. XVI 11. e 



Iviii Address by the President. 

that has to be occluded for any caase^ thus following the 
practice of last century rather than that of more recent times. 
It is not my intention here to criticise this practice^ which I 
look upon with favour, but it would be interesting if we could 
obtain during the present session full particulars of the results 
of this revised method, and thus be able to estimate from a 
practical point of view the relative advantages of the different 
methods employed. 

Again, may I ask, is there any truth in the accusation, 
which in recent times has been raised against surgeons, that 
the great successes which they have all round achieved in sur- 
gical operations have to a degree encouraged them not only to 
do, and to do rightly, what they would never have thought of 
doing a few years ago, but also to undertake operative measures 
which may with some justice be looked upon as speculative, if 
not rash ? Have our successes engendered an over-estimation 
of our own powers, and led us to attempt and perform 
operations which past experience has not supported, and which 
seem to be less founded on scientific probabilities of success 
than on the sanguine hopes of their performers ? Are opera- 
tions upon the pylorus, or stomach, for cancer to be placed in 
this last category ? Are there other operations which should 
be so classed 7 I have no wish to answer definitely these 
questions, but I do feel that it is very necessary that the 
principles which have hitherto regulated operative surgery, 
and which have tended to suppress all experimental work, 
unless based on a scientific probability of success, should be 
carefully observed, and that we should avoid even the sem- 
blance of an experimental operation. 

And here let me express for surgeons generally the satis- 
faction with which in our best new surgical work we greet the 
kind aid we are receiving from physicians. We are now work- 
ing, more than we have ever before worked, hand in hand with 
them to make the diagnosis of disease of the brain, kidney, 
bladder, and abdomen more certain. And we are thus, with a 
clearer diagnosis, mutually helping to bring within the domain 
of scientific surgery large classes of disease which have hitherto 
been deemed to lie outside its pale, and have consequently 
been either allowed to drift or to pass into the surgeon^s hands 
only when the time for effective action has passed or almost 
passed, and when operative measures can at the best be carried 
out for purposes of relief, but not of cure. 

May I now ask for even more help in this direction, and 
urge our medical friends to seek surgical conference early, at 



Address by the President. lix 

least in all abdominal cases in which symptoms of intestinal 
strangulation exist^ as well as in all cases in which intestinal 
obstruction is present, in order that operative interference, in 
both classes of cases, may not be delayed longer than the 
scientific diagnosis of the case requires ; and that the subjects 
of these troubles may have a chance of relief from operative 
measures whilst there is still a reasonable hope of obtaming it. 
Let us remember that exploratory operations undertaken for 
diagnostic purposes, but which may be used for curative ends, 
when the exploratory proceeding shall have cleared up or estab- 
lished a diagnosis (which could not have been made by other 
means), are as scientific as any other operations, and often 
more satisfactory. 

Let us therefore encourage our medical brethren to con- 
sider closely with us surgical problems, in order that we may 
have their efficient help in diagnostic questions as well as their 
valuable support when action, by way of operation, is called 
for ; and let us employ the opportunity to convince them of the 
expediency of expediting action as soon as the necessity for 
action has arrived, and at the same time to demonstrate the 
evil effects of postponing operative interference when such is 
demanded for either diagnostic or curative ends. In surgery, 
as in so many conditions of life, action, to be effective, must 
be decisive and not dilatory; it should ever follow closely 
upon decision. • 

These remarks which I have thus brought before you I 
have been tempted to make under an impression that they will 
be generously received, and under the conviction that they have 
reference to subjects of grave clinical importance. Some of 
the subjects to which I have alluded are important in them- 
selves; others are important on account of the principles 
embodied in them. 

Should my observations appear to some too critical, let me 
say that they have not been made in any captious spirit, but 
with the feeling that it is always better for us to criticise our 
own work than to leave such criticism to others ; that as your 
President, it is as much my duty to point out what I believe to 
be defects in our work or in our mode of work, as it is to 
indicate the direction in which we should travel; and in the 
hope that, by so doing, I am likely to receive the full support 
of the members of this Society in what I believe to be the 
best for the '' cultivation and promotion of practical medicine 
and surgery," objects for which this Society was formed, and 
which we all have so much at heart. 



COMMUNICATIONS. 



■*o^ 



I. — On Certain Nerve Symptoms in Rheumatic Affec- 
tions. By W. B. Haddbn, M.D. Read October 10, 
1884. 

I WISH to bring before the Society a few cases illustrating 
certain nerve symptoms which are apt to supervene in the 
course of acute and chronic articular affections. One of these 
conditions^ the wasting of muscles in relation to diseased 
joints^ has been pointed out by several observers, some of 
whom have ascribed it to simple disuse of the part, whilst 
others have argued in favour of its central origin. 

In the following cases it will be seen that not only muscular 
atrophy, but ansdsthesia, rigidity, and cutaneous trophic lesions 
sometimes make their appearance. 

Case 1. — The first case I shall mention is one of glossy 
skin, following on an acute joint affection. 

The patient, who was a woman 89t. 35, was admitted into 
St. Thomas's Hospital under Dr. Bristowe. A year before 
admission she had been laid up for six months with an attack 
of acute rheumatism, which affected the knees, left ankle, and 
hands, especially the right. She was jaundiced for six weeks 
after the attacK. A month before admission she had rheu- 
matic pains in the knees, back, and hands, and for the last fort- 
night had suffered from sickness, pain between the shoulders, 
and dyspnoea. 

State on admission. — She complains of rheumatic pains in 
both shoulders and arms, but the joints are not swollen or 
tender. All the fingers of the right hand are extended. The 
fore and middle fingers are wasted, and sensation is a little 
impaired. She can only flex them very slightly. The ring 
and little fingers are more readily bent. She cannot separate 
the fingers of the right hand so well as those of the left. 
VOL. xviii. 1 



2 Dr. Hadden On Nerve Symptoms in Rheumatic Affections. 

The fingers and tliamb of the right hand^ and more especially 
the two distal joints of each finger^ and the distal joint of the 
thumbs are wasted^ smooth^ and shiny. The nails are mnch 
longer and more filbert-shaped than those of the other hand. 

The muscles of the npper forearm, especially on the outer 
side, are more full and plump on the left than on the right 
side. The antero-posterior thickness above the wrist seems 
also greater on the left side. The thenar and hypothenar 
eminences are also less full on the right side. All the muscles 
of the arm, forearm, and hand may be made to act by using 
twenty-five cells ; the muscles on the ulnar side respond more 
rapidly and vigorously than those on the radial side. 

The continuous current was used daily with great benefit. 
A week after admission she could bend the fingers of the right 
hand fairly well, and had a pretty good grasp. The skin on 
the back of the hand was much less tense, and the wrinkles 
-reappeared over the joints. She was discharged in about five 
weeks, nearly cured. 

In this case we find the co-existence of a well-marked 
cutaneous lesion, i. e, glossy skin, with slight anaesthesia, 
enfeeblement of muscular power, and muscular wasting. 

In connection with this case I will mention briefly another 
instance of what appears to me to be a trophic lesion of the 
skin. 

Case 2. — A young married woman, ast. 26, came to me as 
an out-patient. For a week or so before, her finger-joints and 
knees had become swollen and painful, particularly at night. 
The right fingers were most affected. She complained chiefly, 
however, of two small rounded superficial sores, one on the 
extensor surface of the second joint of the right little finger, 
the other on the extensor surface of the left middle finger, near 
the base of the nail. They appeared as little red specks about 
the time the joints became affected. They were very tender, 
and itched a good deal. On examination I did not find any 
marked tenderness or swelling of joints. 

The patellar tendon reflex was normal. The catamenia, 
which had been previously regular, every four weeks, bad for 
the last six months appeared at intervals of seven or eight 
weeks. They were preceded by leucorrhoea, but there was no 
dysmenorrhoea. I mention this fact because it seems to 
support the idea, put forward by Dr. Ord, that there is a rela- 
tion between menstrual disorders and articular affections. I 
prescribed Liq. Arsenicalis v\ iij t. d. s« In ten days the ulcers 



Dr. Hadden On Nerve Symptoms in RheumaUe Affections. 3 

were qaite healed and the joints were only a little painfol af 
night. She subsequently recovered perfectly. 

1 must add that I sent the patient to Dr. Ord^ who agreed 
with me that the sores were probably trophic. 

The next case is one which I venture to give somewhat in 
detail^ because the patient exhibited quite a series of nerve 
disorders^ including muscular atrophy^ anaesthesia^ rigidity of 
limbSj and increased tendon reflexes. 

Case 3. — A man^ est, 57^ came under my care as an out- 
patient^ complaining of severe articular pains. In the course 
of examination I discovered the various nerve symptoms 
above mentioned^ so I sent him to Dr. Ord^ who kindly took 
him into his wards at St. Thomas's Hospital^ and investigated 
his condition with great care. 

The only point to note in his family history is that a Bister 
suffered severely from gout. 

As regards his personal history it must be mentioned that 
he had never had acute rheumatism or anything like an attack 
of gout. The man had been a soldier^ and had passed 
fourteen years in foreign service. He ascribed his rheumatic 
affection to the exposure he underwent in the Crimea. 

According to his account^ he was perfectly well until nine 
months ago^ when he was seized one day with a fit of giddi- 
ness and fell down. He did not lose consciousness^ and got 
up again immediately without help, feeling perfectly well and 
afterwards doing a hard day's work. Soon afterwards he felt 
he was losing power in his left side. Six months before admis- 
sion he began to lose power in his right arm and leg. 

I do not think that the attacks he described were of a 
hemiplegic nature. The loss of power he mentioned seemed 
rather to depend on his joint affection. 

For many years he has suffered from cramps in the legs, 
and seven months ago became an out-patient at the Middlesex 
Hospital. At that time he was passing a large quantity of 
urine, and his legs were much swollen. Possibly this attack 
was renal, but during his stay in St. Thomas's Hospital no 
indications of kidney mischief were discovered. 

For the eight months preceding admission he had been 
subject to sudden pains in the hips, knees, shoulders, elbows, 
and wrists, accompanied by sudden flexion of these joints. 

State on admission, — On examination the patient was 
found to be a spare man with a fixed expressionless face, 
holding himself stiffly, and with a marked forward inclina- 



4 Dr. Hadden On Nerve Symptoms in Rheumatic Affections. 

tion. HIb appearance indeed^ when first I saw liim^ suggested 
paralysis agitans. He complained of articular pains. 

The sban over both hands is shiny and smooth^ especially 
over the phalangeal joints^ where the usual wrinkles of the 
skin are wanting. 

The metacarpo-phalangeal joints of the first two fingers of 
right hand are very large, the enlargement affecting more 
especially the head of the metaicarpal bones. The corre- 
sponding joints of the ring and little fingers are not involyed. 
The bases of the first phalanges of the &st and second fingers 
are partially dislocated into the palm, and there is a similar 
partial dislocation of the second phalanges of the first three 
fingers, so that each of the first three fingers appears concave 
on the dorsum and convex on the palm. The ungual phalanx 
of the little finger is dislocated slightly in the direction of the 
ring finger. There is a distinct collar of bone at the terminal 
joints of all the four fingers. There is slight grating in the 
joint between the first and second phalanges of the index 
finger, but not elsewhere. 

The condition of the fingers of left hand is very similar to 
that on the opposite side. The left thumb, however, is more 
affected than the right, having a distinct collar of bone at the 
end of the first phalanx. 

The fingers generally are fixed in an extended position and 
have a nodulated appearance, due to the thickening of the 
ends of the bones. The interossei are much wasted. In both 
hands there is power of flexion and extension at the meta- 
carpo-phalangeal articulations, but the patient cannot move 
any of the other joints. The right thumb, however, can be 
flexed and extended at both joints. 

There is crackling of the right shoulder- joint, none of the 
left. There is some thickening of the tissues about the left 
knee-joint. The hips and right knee seem unaffected, except 
that movement is difficult on account of pain. 

The toes are not involved. The prick of a pin is not felt 
over the back of the left hand, except over the terminal 
phalanges of the second and ring fingers. There is also loss 
of sensation over the ball of the thumb, the radial part of 
forearm behind, the whole anterior surface of forearm and all 
the upper arm, except near the elbow-joint. On the right side 
sensation is much impaired over the front and back of thumb, 
absolutely lost over the radial half of the front of forearm, and 
all around the shoulder-joint. Sensation is a little impaired 
about the left temporal region. There is no loss of feeling on 



Dr. Hadden On Nerve Symptoms in Rheumatic Affections, 5 

the trank. The prick of a pin is not felt over the front and 
back of the left leg and dorsum of left foot^ but elsewhere in 
the lower limbs there is no loss of sensation. 

The muscles on the front and back of both legs can be 
seen vibrating through the skin. 

In addition to the atrophy of the interossei mentioned 
above^ there is evident wasting of the muscles on the bax^ks of 
the forearms. All the muscles on the right side respond well 
to the interrupted current except the palmar interossei^ which 
do not act quite readily. On the left side the extensors do not 
act so freely as on the right side. The extensor communis 
digitorum does not respond at all. 

All the cutaneous reflexes are readily obtained^ the plantar 
being especially brisk^ particularly on the right side. The 
abdominal reflexes^ on the other hand^ are more marked on 
the left side. The tendon reflexes in the upper and lower 
limbs are exaggerated^ and there is ankle clonus on both sides, 
but this is sometimes difficult to elicit on account of the 
rigidity. 

The mouth seems a little drawn to the left^ but there is no 
other sign of facial paralysis. The tongue is protruded 
straight and the ocular muscles are natural. 

There is a myopic crescent in the right eye and some 
impairment of hearing on the left side. The special senses 
are otherwise natural. The gait of the patient is decidedly 
spastic^ the knees being flexed little during progression. 

There are two tender spots on the spine, one over the third 
dorsal vertebra, the other over the second lumbar. 

The thoracic and abdominal organs appear healthy. The 
temperature was generally subnormal, the lowest being 96*4°. 
Usually it was between 97° and 98°. 

What is the explanation of the various nerve disorders in 
this case? Is there an extension of the inflammation from, 
the joints to the nerves ? This assumption might account for 
the anaesthesia and muscular atrophy of the upper limbs, the 
small joints of which were profoundly affected. But the 
anaBsthesia of the left leg and the rigidity of the lower 
extremities cannot be so explained. The knees and hip-joints 
were very slightly affected, and the small joints of the feet 
and toes not at all. 

It seems to me probable that in this case there was a 
rheumatic neuritis as well as a rheumatic arthritis, and that 
the nerve disorders were neither concerned with the causation 
of the joint affection, nor dependent on it. 



6 Dr. Hadden On Nerve Symptoms in Rheumatic Affections, 

In the first two cases wliicli I narrated^ the trophic dis- 
orders occurred daring the subsidence of the articular rheu- 
matism^ and might really be looked upon as a relapse 
affecting the nerves. Bather more than three years ago a 
female patient who had just recovered from an attack of acute 
rheumatism^ chiefly involving the finger-joints, complained to 
me of numbness. On examination I found absolute ansds- 
thesia strictly limited to the course of the ulnar nerve. This 
condition lasted only a day or two. 

So far as I know, anaesthesia has not been previously 
noticed in connection with rheumatism, although its occur- 
rence in chorea is far from uncommon. 

The muscular atrophy in Case 1 was undoubtedly of nerve 

origin. In Case 3 the wasting seemed to me greater than 

could be accounted for by simple disuse, and, moreover, the 

extensors were much more affected tha^ the flexors. This 

seems to be a law in all joint affections, whether rheumatic or 

not. We see examples in the wasting of the deltoid in 

shoulder-joint disease and of the gluteal muscles in hip disease. 

It has been urged that this depends on some selective action 

exerted by the spinal cord. But in lead palsy and alcoholic 

paralysis the lesion is essentially one of the peripheral nerves, 

and in these affections the paralysis of the extensors is the 

most prominent feature. In Case 3 the wasted extensors, with 

one exception, responded to the interrupted current, though 

less actively than normally. This is exax^tly the experience of 

Professor Charcot. The change in the electrical reactions is 

quantitative. It is interesting to note, however, that the left 

extensor communis digitorum had the reaction of degeneration 

—a qualitative alteration. 

I have seen rigidity of the lower limbs and ankle clonus 
twice before in chronic articular rheumatism. One case was 
under my own care and the other was shown me by Professor 
Charcot. Such a condition is probably due to structural 
change in the spinal cord. Nevertheless, I have occasionally 
found ankle clonus in cases of pressure upon the lumbar 

I)lexus by new growth, and in one such instance there was no 
esion of the spinal cord when examined microscopically. It 
is quite possible, therefore, that the rigidity and ankle clonus 
occasionally observed in these cases may depend on lesion of 
the peripheral nerves. 

The occurrence of these nerve disorders in rheumatic 
idleotions cannot be referred either to the duration or intensity 
ojf the joint affection. From time to time I have examined in 



I 
I 

I 
I 



Dr. Hadden On Nerve Symptoms in Eheumatie Affections, 7 

our infirmaries cases of chronic rheumatoid artliritis of ten^ 
fifteen^ and twenty years' standings but have found nothing 
which could be looked upon as a trophic disorder. 

The cases which I have given neither support nor disprove 
the theory of the neurotic origin of articular rheumatism^ so 
ably advocated recently by Dr. Ord and Dr. Dyce Duckworth. 
They merely show^ I thinks that certain symptoms^ referable 
to the nerves and possibly in part to the spinal cord^ occur in 
rheumatic subjects* 

I beg to express my thanks to Dr. Ord, who not only first 
directed my attention to this subject, but who has also assisted 
me in obtaining the material which has illustrated the paper. 



EBBATUM. 



TO 4,^ TV fiff 3 on page 9. is the largest of 
The stone referred to as Plate IX, hg. i, on pag 

those marked fig. 2 in Plate IX. 



-..^w* ^«ai\/tfX« 



October 10, 1 884. 

THE specimens which I have the pleasure of exhibiting 
were given me by my friend, Mr. B. Comey, who is an 
emigration medical officer in Fiji. He met with these instances 
of preputial calculi in the course of his duties as an inspector 
of coolies, as his following notes will show. 

'' Casb 1. — ^In September, 1881, R., set. about 17, a native of 
the Bubiana group, in the Solomon Islands, came before me at 
Sura (Fiji) for physical examination before being allotted to his 
employer for field labour. 

On taking hold of his penis I felt a curious grating sen- 
sation between my finger and thumb as of a bag of pebbles ; 
I also heard the sound produced by their grating. He had 
phymosis of congenital origin, but of course no history of the 
pebbles could be extracted from R., there being no one present 
who understood his language. I thought at first that he had 
introduced them himself, and ordered him into hospital that I 
might remove them. This I did one by one with a very fine 
pair of bullet forceps, after which I decided to circumcise 
the boy to prevent a recurrence of the annoyance. It is easy 
to understand how the retention of some of the smegma pre- 
putii may afford nuclei for the beginning of these calculi when 
the degree of phymosis is so great that some urine gets left in 
the preputial folds each time of micturition. There were 
twenty-two stones in all. (Plate IX, fig. 2.) 

Case 2. — B., set. about 18, a native of Guadalcanar, one of 
the Solomon Islands, was brought to Sura (Fiji) in September, 
1882, under an indenture to work for three years on a sugar 
estate. He came before me at the immigration depot for 
physical examination, prior to being allotted by the Government 
to his employer. My eye was attracted by what appeared to 
be an enormous glans penis. On taking hold of it, however, it 
felt too hard for that, and on closer examination I found an 
excessive degree of phymosis without infiammation. I was 
able with just a little difficulty to introduce the bulbous end 



Mr. Croft's Oases of Preputial Calculi. 9 

of an ordinary probe within the prepuce. Upon arriving there 
it struck a hard stony body, and having previously met with a 
similar case I readily perceived that this was a case of sub- 
preputial calculus. 

The orifice of the prepuce was of so much less calibre than 
the urethra and meatus urinarius that during micturition the 
prepuce became distended like a bladder, and a small stream 
of urine spurted out from it in an odd jerky manner like water 
under pressure from a leak in an india-rubber tube. 

This effect was the cause of much mirth amongst B.'s com- 
patriots. I ordered him into hospital, and next morning sUt 
up the prepuce on a director, when the stone rolled out. The 
director stretched the orifice of the prepuce to its utmost. 
The stone when removed, being wet, weighed 1 oz. 110 gr. 
(Plate IX, fig. 3.) The edges healed in a fortnight. 

Nearly all the natives of the Solomon Islands have con- 
genital phymosis. About 1} per cent, of them have the orifice 
no larger than a pin^s head. Only a few tribes remedy this 
condition by art. Instead of circumcising they slit it up 
generally with a sharp shell. 

In the New Hebrides the foreskins are not usually so long, 
though phymosis is exceedingly common. 

In the island of Malakula all the natives, except one tribe 
at the north-east comer, slit up the prepuce, and very neatly 
and effectually. This, too, is the only island where com- 
pression of the skull is practised (during infancy, as with 
some aborigines of North America), and the north-east 
tribe which does not slit the prepuce does not compress the 
skull. 

As a result of this congenital phymosis, balanitis, which I 
believe to be of a non-specific nature, and to originate merely 
from want of cleanliness and consequent irritation, is very 
common amongst these simple people, whose prejudices and 
customs restrain them from universally adopting so simple and 
safe a precaution as that which is necessary. 

The Fijians, who are a much superior race, all circumcise 
orsUt." 

Dr. Bemays, of St. Thomas's Hospital, was so kind as to 
examine these calculi, and he reported that they consisted of 
the triple phosphate and traces of urates. 

In South's ' Chelius,' under heading of " Urinary Stones 
external to the Urinary Passage,*' p. 632, vol. ii, we find : — " In 
the College (Boyal College of Surgeons) collection there is also a 



10 Mr. Croft's Oases of Preputial Calculi. 

very curious case of Vincent's (of St. Bartholomew's), numerous 
small calculi wluch, with about 200 others, were removed from 
between the prepuce and glans penis of a very old man. The 
patient had congenital phymosis, the orifice of the urethra 
scarcely admitting the introduction of a common probe. From 
the pressure of the calculi the prepuce was distended to the 
size of a large pullet's egg, and retention of urine was finally 
produced. On dividing the prepuce one of the calculi was 
found completely blocking up the orifice of the urethra. The 
glans penis was in a state of ulceration, and a large portion of 
its substance had been absorbed. The patient had during 
many years occasionally experienced great pain and diffi- 
culty in making water, and latterly he had a constant stil- 
lici^um. 

The calculi are composed principally of the fusible com- 
pound. Most of them have a small nucleus of uric acid ; their 
external surface is varnished over with urate of ammonia. 
From the composition of the nucleus there can be no doubt 
but that the greater number of these calculi had passed &om 
the urethra into the sac of the prepuce, and their irregular 
form and close adaptation to each other proves that in this 
situation they had increased considerably in size by the depo- 
sition of the earthy phosphates." 

These calculi are of some interest beyond their extreme 
rarity in this country. They show how little the form of the 
bladder is concerned in modelling the concretions. Condi- 
tions similar to those which determine concretions in the. 
bladder determine concretions in the phymotic prepuce. This 
condition is a sac which possesses a relatively small inlet and 
still smaller outlet. 

Although it does not appear to be a matter of any import- 
ance to decide whether the nuclei of these concretions were 
formed in the bladder or within the phymotic prepuce, this is 
a subject of interest as it bears upon the mode and seat of 
commencement of urinary calculi generally. It appears to be 
most probable that the nuclei of these concretions, large and 
small, were ejected from the bladder and urethra under the 
influence of the compensatory strengthening of their walls, 
but failed to escape through the minute orifice of the prepuce, 
and, having become lodged there, increased in bulk by mole- 
culajr coalescence in the ordinary manner of vesical calculi. 
AU the calculi of which sections were made present central 
cavities lined by crystals, but examination of these fails to 
discover any obvious nuclei of organic matter. 



Mr. Croft's Caises of Preputial Oalculi, 11 

I tLink I am justified in pointing to tlie facts mentioned in 
Mr. Come/s notes and remarks as emphasising tlie propriety 
of early operations for congenital phymosis. On this account^ 
and becanse of the clinical and ethnological interest^ and 
on account of the great rarity of such calculi^ I have yen* 
tured to place these specimens before the Society. 



■ ■-Miijfti 



12 Dr. Crocker's Oase of Urticaria Pigmentosa. 



III. — A Case of Urticaria Pigmentosa, or XanthelaS" 
moidea. By H. Radoltffb Orookbb, M.D. Bead 
October 10, 1884. 

LAVINIA N., a9t. 4i months, came to XJniversity College 
Hospital on September 22, 1883, with the following 
history : 

A day or two after birth, a blister was noticed in one groin, 
and two or three days later some came in the axilla and on 
the neck. The mother saw no more for two or three weeks, when 
the present eruption began, first on the neck, and then all over 
the body. 

It commences as tubercles, singly, or more often in groups 
of three or four, about the size of a small split pea, distinctly 
raised above the level of the skin, of a yellowish-red colour 
with a narrow pink areola (Plate I) ; on some of the tubercles a 
vesicle about a quarter of an inch or more in diameter forms with 
clear contents which get absorbed in a few days, the tubercle 
still remaining, but covered with a thin crust of dried epider- 
mis. Many of the tubercles increase in size subsequently, 
perhaps by coalescence where there was a group, and as they 
get older become of a distinctly yellowish colour, and thus there 
are lesions varying in size from a hempseed to a good-sized 
bean, and in colour from a brownish red to a pale fawn, but 
most of them are of the yeflow shade. They are somewhat 
firmer than the normal skin, and at first did not itch, but 
latterly their evolution has been attended with some irritation, 
but there is none after they are fully formed ; the eruption is 
still coming out at intervals of a few days, but there are never 
any transitory wheals of the ordinary kind. 

The tubercles are all over the head and face except the 
vertex, very thick on the neck, not so numerous on the 
arms, but are on both backs and palms of the hands. There 
were not many about the genitals, and the anus and its imme- 
diate neighbourhood were quite free for some time, but now 
all these parts are pretty thickly covered, as well as the loins 
and backs of the thighs. There are a few on the soles, but they 
are less abundant, on the whole, below the knee. 

The child was a fine baby at birth, but has lost flesh to 
some extent, but is still fairly nourished for a London baby. 



^ 



r 



< 



*-\.. 



■* ■*" 



> ^ 



Miiiter-r Bro.*? CKrcrtiO 



D^ Croc'^ei'r C&oe of L'rti cax^iai Pigmentosa 



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w • 



Dr. Crocker's Oase of Urticaria Pigmentosa. 13 

but rather pale. SHe is suckled entirely^ and seems well on 
the whole^ and tke eruption does not trouble her in any way 
except at the period of evolution. There is no evidence^ either 
in herself or in the other children^ of congenital syphilis. 
Three of the children had rickets^ but are now well^ and the 
&ther and mother are apparently healthy. In deference to 
the opinion of others^ who thought the eruption must be 
syphilitic^ hydrarg. cum creta gr. j three times a day^ alter- 
nating with mercurial inunctions^ was given for two months^ 
but without any efEect upon the eruption. The child has now 
been under observation for six months^ during which period 
fresh lesions have appeared at irregular intervals of a few days, 
and others have undergone partial involution^ getting wrinkled 
and less prominent^ bufc very few have completely disappeared^ 
leaving only pigmented patches on their former site. Rubbing 
does not appear to produce exacerbations of the older wheal- 
like tubercles^ but on the other hand fresh vesicles have some- 
times formed on the old tubercles. Factitious urticaria could 
never be produced. 

This is the twentieth published case of this rare affection^ 
which was first described by Mr. Nettleship in the British 
Medical Journal for September 8, 1869, but which did not 
attract attention until Mr. Morrant Baker and Dr Tilbury Fox 
showed cases to this Society, which are published in vol. viii 
of the Transa^^tions, From these twenty cases the following 
general account may be given. 

In nineteen cases the sex is mentioned, and there were 
fourteen boys to five girls. It begins in the first six months 
of life, the earliest age being three days. This very early 
commencement points to a congenital defect as the primary 
cause of the affection. The first lesion is usually a wheal-like 
tubercle of rapid evolution but great persistence, often coming 
out in the night, about the size of a pea, yellowish white at the 
apex, with a red areola; less frequently vesicles have appeared, 
though probably, as in my case, they were preceded by erythe- 
matous, if not urticarial, elevations. In many cases where the 
mothers speak of blisters, no doubt wheals are intended, as 
that is a common expression for them. 

No part of the body is exempt from the eruption, though 
the lesions are most abundant on the trunk and neck, next 
on the limbs, and only occasionally on the palms and soles. 
The palatal and buccal mucous membranes were affected in 
two cases. Itching is generaUy present during the evolution 
of the tubercles, but it may be sUght or quite absent ; when this 



14 Dr. Crocker's Case of Urtica/ria "^Pigmentosa. 

symptom is prominent^ ordinary nrticarial wheals usnally make 
their appearance from time to time^ and factitioas urticaria is 
often easily producible. 

The disease is little if at all influenced by treatment^ but 
tends to get well of itself. After some years fresh lesions 
cease to appear, and the old tubercles are gradually absorbed 
by the time puberty is reached. This is only an approach to 
the truth, for in Lewinski's case fresh lesions were still mfiking 
their appearance at eighteen years of age. 

Microscopical examination of the tubercles has been made 
by Dr. Thin from a case of Mr. Morrant Baker's, by Pick, of 
Prague, and by Dr. Colcott Pox from Dr. Tilbury Fox's most 
severe case. Thin came to the conclusion that the structure 
was indistinguishable from that of lupus. Pick found hasmor- 
rhages surrounded by small-celled infiltration, while Colcott 
Fox described the structure as that of a typical wheal plus 
some cell infiltration and small haemorrhages. These observa- 
tions are probably less conflicting than they appear at first, 
and seem to me to represent a lesion affecting the upper part 
of the corium, the result of hyperasmia, oedema, small haemor- 
rhages and a variable amount of cell infiltration, the last very 
great in Dr. Thin's observation, slight in the other two. This 
might well represent a wheal made permanent by cell and 
blood exudation. That the disease is in any way related to 
lupus no one who has observed its clinical aspect and course 
could believe. 

"With regard to the urticarial nature of it, were they all 
like Dr. Tilbury Fox's first case and my own, the difficulty of 
regarding the disease as a modified urticaria would be consider- 
able, as, except in the shape of the tubercle and the sudden 
evolution of the initial lesion, they have no other feature in 
common. With no itching, persistent lesions, buUas, and 
great pigmentation, no wonder Tilbury Fox could not recog- 
nise urticaria in this condition, espeicially as many of the inter- 
mediate links had not then been demonstrated. Our diffi- 
culties diminish, however, when we consider the gradations 
produced by other cases and also certain occasional features 
of ordinary urticaria. Thus there are cases of recognised 
urticaria where bullae are a pronounced feature ; pigmentation 
sometimes follows ordinary wheals, as in a case of Dr. 
Liveing's shown at the Congress in 1881 ; persistence of the 
wheals occurs in urticaria perstans ; cell exudation is present 
in the papules following the wheals in the urticaria of children, 
and haemorrhage into wheals is not unknown. The peculiarity 



Dr. Crocker's Com of Urticairia Pigmentosa. 15 

of tliis disease is tliai all these f eafeures, wliich individnally are 
rather rare in the course of ordinary urticaria^ are combined 
in these cases of urticaria pigmentosa^ a name suggested by 
Dr. Sangster^ which^ though not altogether satisfactory, hais 
met with general acceptance, displacing the uncouth xanthe- 
lasmoidea of Dr. Tilbury Fox, which was only applicable to 
the most aberrant cases, such as his first and worst, and 
perhaps to some extent to the one of which the drawing is 
shown to-night. 

I have not discussed some of the points so fully as I might 
have done, as Dr. Colcott Fox has recently given an elaborate 
resume of the subject in the last volume of the Medico-Ohirur* 
gical Transactions, with an abstract of all the cases published 
up to that time, and I should therefore only have traversed 
recently trodden ground. 

Since this paper was sent in, last session, the child has 
unfortunately died of whooping-cough and bronchitis on May 
6, but I did not hear of the death until some days afterwards. 
I saw the child a few weeks before its end and the skin had 
improved considerably ; some of the tubercles had undergone 
partial involution so that the skin over them was wrinkled, 
while others had completely flattened down, leaving only pur- 
plish brown stains. 

I am not aware that any other cases have been published 
recently, but Dr. Wallace Beatty, of Dublin, has brought 
forward two cases, an abstract of which is given in the 
British Medical Journal of April 26, which he thought de- 
served the name of urticaria pigmentosa, but the cases were 
so unlike in many important respects that unless connecting 
links are discovered it would not be justifiable to include 
them in the same category as the cases that we have just 
been considering. 



16 Dr. Finlay's Oase of Perforation of the Vermiform Appendix. 



IV. — A Case of Perforation of the Vermiform Appendix 
with Peritoneal Abscesses. Death after a long 
interval from Pycemia. By David W. Finlay, M.D. 
Bead October 10, 1884. 

JOHN L., 83t. 24, a baker, came under my care in the Middle- 
sex Hospital on January 4, 1884. 

On admission he was described as a spare, dark-complex- 
ioned man of muscular development, complaining of severe 
pain over the whole of the abdomen. His pulse was 96, com- 
pressible; temperature 99*6°; respirations 24, and entirely 
thoracic. The tongue was dry and coated with a brownish 
strip down the centre ; the cheeks were flushed, and the lips 
dry and cracked The abdomen was moderately distended, 
everywhere tender, and apparently tympanitic, palpation or 
percussion, however, causing him so much pain that they had 
to be sparingly employed. The skin of the abdomen was very 
red from the previous application of mustard poultices, and 
the tenderness was no doubt partly due to this cause. The 
areas of liver and splenic dulness were normal. 

In the chest the percussion resonance over both fronts was 
fair and equal. The breath-sounds were also fair, although 
accompanied sometimes by a faint sibilant sound. Over the 
backs the resonance was not very good, but breath- and voice- 
sounds were nearly normal. 

The hearths maximum impulse was seen and felt in the fifth 
interspace a little outside of the nipple line, and its sounds were 
normal. 

The urine was turbid with lithates, very acid, of a specific 
gravity of 1034, and free from albumen or sugar. 

The patient stated that his illness had commenced sud- 
denly a week before admission, namely, on the evening of 
Saturday, December 29, 1883, with pain of a griping character 
across the lower part of the belly. This pain continued all 
night, and on Sunday morning he began to vomit, and con- 
tinued to do so at intervals of one and a half or two hours all day. 
The vomiting had continued more or less every day up to the 
date of admission. He had also suffered from headache at first, 
and had had some diarrhoea on the Tuesday, Wednesday, and 
Thursday. 



Dr. Pinlay's Oase of Pevf oration of the Vermiform Appends. 17 

He had had a similar attack three years previonsly which 
consisted of abdominal pain with siclmess and feyerishness. 
With this exception his health had been generally good. There 
was nothing suggestive in his family history. 

As regards treatment^ he was ordered a snbcntaneoas 
injection of one fourth of a graiu of morphia at once^ to be 
followed by half a grain of extract of opium in pill every four 
hours^ a lead and opium lotion to the abdomen^ and a diet 
consisting of milk and beef tea. 

Next morning (January 5) he was sick and vomited^ 
bringing up about two ounces of clear yellowish fluid. There 
was still marked abdominal distension and tympanitic reso- 
nance^ but less tenderness ; no spots were observed. He said 
that he felt much better although he had slept badly. His 
morning temperature was 99*8°, that of the evening 1()0°. 

On the following day (January 6) his tongue was cleaner^ 
and he was rather better. The morning temperature was 
100*2°, evening temperature 100°. 

On January 7 the note states that he expressed himself as 
feeling better. During the night, however, he had vomited 
five or six times and had been much troubled with hiccough. 
The tongue was very dry and brownish in the centre but not 
much coated ; the bowels not open ; respirations still thoracic ; 
pulse 92. He complained of no pain, and the general abdo- 
minal tenderness had disappeared, but there was a spot midway 
between the costal margin and iliac crest in the left flank 
where tenderness remained, and where the percussion note was 
dull. The evening temperature was 100^. 

On the evening of the 8th he was suddenly attacked by 
pain in both parotid regions ; and during the night his bowels 
were opened three times, the motions bei^g loose, and light in 
colour. 

On the morning of the 9th the tongue was cleaner and less 
dry. There was marked swelling and tenderness of both 
parotids with inability to open the mouth to any extent. 
During the day the bowels acted four times. The following 
night he was restless, and slept badly. 

Next day (January 10) the parotid swelling had increased, 
and he was found to be sweating profusely. His pains were 
relieved by poppy-head fomentations. The urine was acid, 
sp. gr. 1032, free from albumen. 

His condition did not vary for a couple of days^ but on 
January 14 a sense of fluctuation was. detected in the parotid 
swelling on the left side accompanied by a slight discharge 

VOL. XVIII. 2 



18 Dr. Finlay's Case of Peff oration of the Vermiform Appendix. 

from tlie ear^ and at my reqnest Mr. Lawson saw lum and 
made an opening into it^ evacaating about two drachms of 
pus. 

Daring the following night he was restless and delirious. 
There was a profuse discharge of pus from the opening in the 
parotid to which poultices had been applied. Eggs were now 
added to his diet^ and he was ordered ammonia and bark with 
brandy. 

On the morning of January 16 his temp, was 101*2°. 
Pulse 128, weak, but regular, resp. 44. Tongue dry and 
glazed. He had slept fairly well and had no pain. He 
looked apathetic and was somewhat emaciated. A purpuric 
eruption of small reddish-purple spots, not completely fading 
on pressure, was noticed over a space about the size of the 
palm of the hand on the surface of the abdomen above the 
umbilicus, and another patch over the prascordia. A smaller 
area in the right mammary region was also occupied by a 
similar crop ; there was none elsewhere. 

No adventitious sounds were heard over the chest, but the 
breath and voice sounds were feeble. 

The swelling in both parotid regions had diminished, but 
there was some discharge from the right ear, and accordingly 
about 3 P.M. Mr. Lawson incised the right parotid swelling, but 
no pus appeared. At half-past 5 o'clock I saw him again, and 
found that he had been sweating profusely for the last half 
hour; and now the pplse was feeble and irregular both in 
force and rhythm. The temperature was 103 , and he was 
delirious and trying to tear ofE his bandage. At 6.30 his 
temperature rose to 104"8°,r and in two hours he was dead. 

At the post-mortem examination, which was made by Dr. 
Fowler eighteen hours after death, the great omentum was 
found spread out upon i^e. surface of the intestines, and 
firmly adherent to thd plarifetal peritoneum in each iliac 
region. In the adhesions hei-e formed there were abscess 
cavities, each about the size of a walnut, containing creamy 
yellow pus. Their position was about the internal inguinal ring. 

A very large sac was found in the right lumbar region 
which contained about a pint of brownish pus. It was 
bounded above by the under surface of the liver and the gall- 
bladder, below by the caecum, in front by some coils of small 
intestine; on its outer side by ascending colon and small 
intestine, and behind by the abdominal wall covered by peri- 
toneum. The cavity was lined by a thick pyogenic membrane 
which was pigmented and of a yellowish-brown colour. 



Dr. Pmlay's Case of Perforation of the Vermiform Appendix. 19 

On the left side of the abdomen another similar but 
smaller cavity appeared enclosed by firm peritoneal and 
omental adhesions^ This was boonded above by the spleen, 
behind by i}he kidney and descending colon^ and elsewhere by 
c-oils of small intestine. It contained about eighteen onnces 
of pas; its lining membrane was rough and deeply pig- 
mented. 

In the pelvis there was a third abscess cavity, formed by 
the pelvic walls, roofed in by peritoneal adhesions, full of 
brownish coloured pus. • 

There was also a small sac, containing thick yellow pus, 
in the mesentery of a coil of bowel lying in the right iliac 
region. 

Over the whole peritoneal surface there were old fibrous 
bands and greasy-looking flakes uniting the coils of intestine 
together, and also some recent injection, but no recent lymph. 

On examiniug the intestines after removal, the vermiform 
appendix was seen to be ulcerated through about halfway from 
its attachment, the opening communicating with the sac of the 
pelvic abscess. A small mass of fascal matter plugged the 
interior of the appendix on the caBcal side of the perforation. 

The liver, kidneys, and heart were normal, the spleen con- 
gested, the lungs cedematous. The left pleural sac contained 
a quantity of clear serous fluid, the right was obliterated by 
adhesions. 

Since these notes were written I have ascertained that the 
man was employed at a large hotel, and had been there for a 
year and eight months, during which he had shown no sign of 
illness until the last, and had always been fit for his work. I 
have also learned from his previous medical attendant that he 
formerly suffered from attacks of obstinate constipation, and 
that on the occasion referred to by the man himself, three 
years before I saw him, his temperature rose to over 103° : also 
that he always appeared to recover perfectly from his attacks. 

The case seems to me interesting as suggesting how long 
serious disease may remain latent without showing any imme- 
diate tendency towards death. I would explain it by suppos- 
ing that the attack of abdominal pain and vomiting &om 
which the man suffered three years before coming under my 
notice, was due to the perforation then of his vermiform 
appendix, adhesions being formed which prevented for the 
time a fatal result ; and although this may seem to do violence 
to probability, such a supposition has its analogy in other 
varieties of disease. For instance, a small empyema or its 



20 Dr. Finlay's Case of Perforation of the Vermiform Appendix. 

caseoo^ remains may exist for years before it becomes the 
immediate focus which determines an outbreak of tuberculosis 
in the lungs or the meninges of the brain. It is impossible, 
at all events^ that th^ condition found post mortem should 
date, only from the time when his last illness commenced^ and 
if so we must suppose one of two things^ either that the per- 
foration of the appendix took place without giving rise to any 
symptom at all^ or that many months at least elapsed between 
its occurrence and death. Another alternative may perhaps 
occur to some^ viz. that the abscess around the oascum was 
first in point of time and helped in some way towards the per- 
foration^ which may then be supposed to have taken place 
just before I saw him ; but in that case it is all the more 
difficult to account for the presence of the abscess. 

In any case it is certain that the abscess-sacs were of 
.very considerable age, and it is a striking fact that the man 
should have been able to go about his daily work, apparently 
in good health, with such a condition of his abdominal cavity. 



Dr. Anderson's Oaae of Myxoedenu^* 21 



V. — A Case of Myxoedema. By Jahbs Anderson, M.D, 

Read October 24, 1884. 

THE patient^ Jessie A.^ an unmarried woman^ sat. 40, came 
to Moorfields Eye Hospital in Febmary of tliis year as an 
out-patient nnder the care of Mr. Gnnn^ to whom I am in- 
debted for permission to bring the case before this Society. 
She complained of swelling of her eyelids^ especially the 
npper^ which she had noticed for the past nine years in 
gradually increasing amount. 

The patient is one of a family of nine, none of whom 
have shown any symptoms resembling hers^ her four sisters, 
all older than herself, being in perfect health, one of them 
who was seen contrasting markedly with the patient. Her 
iather died at seventy-four of ^ulceration of the bowels," 
having previously been a very healthy man. Her mother 
died at the age of fifty-seven from ''hsemorrhage," having 
had '' coffee-ground vomiting " and oozing of blood from the 
-mouth. Of her grandparents she knows nothing. There is 
no history of gout or haemophilia either in near or distant 
relatives, so far as the patient is aware. 

Up to the age of twenty the patient lived at home in 
-Liverpool. Thereafter she was for twelve years nurse and 
maid in a frmily in Liverpool, and for the last eight years she 
has held a similar position in a family living in Kendal. She 
has always had a good home, with plenty of fresh air and 
exercise^ and freedom from anxiety or exposure. For the 
first twenty-three years of her life she enjoyed excellent 
health, when, seventeen years ago, she had two teeth 
extracted, the bleeding from which lasted twenty-four hours 
and was very copious. She says she has never been well 
since, and to this she attributes sJl her trouble. She believes 
that when she pricks or cuts herself she loses more blood than 
others, but of this she did not complain spontaneously. Her 
gums are extremely vascular and hypertrophied. They bleed 
freely, and she sometimes awakes in the morning with her 
.mouth full of blood. She began to menstruate at the age of 
fourteen and has menstruated regularly since. The amount 
has always been copious, but sometimes after the discharge 



22 Dr. Anderson's Case of Myxc&Aema. 

has ceased it commences again^ and may last for three weeks^ 
leaving her very exhausted. She has never suffered from 
epistaxis or haemorrhoids, has had no swellings of the joints 
or dark coloured urine. I may state here that in June of this 
year, after leaving London, she was under the care of Dr. 
Symington, of Wolverton, for severe monorrhagia. 

The patient presents the characteristic fades of myzce- 
dema as described by Dr. Ord, the defined scarlet flush of 
cheek and nose contrasting markedly with the waxy pallor 
round eyes and mouth. I need hardly describe her loose, 
baggy, almost translucent lids, dry, brawny cheeks, and thick 
blue lips, her swollen, red, " expressionless '^ hands, with their 
stunted fingers, and her characteristically deliberate speech 
and action. Her sister says she noticed the difference in her 
twelve years ago, and that it has become steadily more and 
more marked. The patient is a woman of considerable intelli- 
gence. She says she always spoke slowly and deliberately, 
but she is conscious of sometimes feeling heavy and listless, 
at others bright and active. 

Her digestive system is somewhat defective, but her appe- 
tite is fairly good except for breakfast. Her front teeth are 
good, but the molars have crumbled away bit by bit, and she 
has the unhealthy condition of gums noted above. The 
heart's impulse is in the usual position and the sounds normal. 
The pulse in the peripheral arteries is regular, but very 
feeble. She is occasionally troubled with palpitation and 
dyspnoea on exertion. The lungs are normal. The liver, 
spleen, and other abdominal organs are apparently healthy. 
Her urine varies much in quantity, from scanty to copious ; 
but scanty or copious, the total amount of urea excreted daily 
is invariably deficient, only rising to half the normal amount, 
and frequently being as low as one fourth. The specific 
gravity varies from 1015 to 1025, and neither sugar nor albu- 
men has on any occasion been detected. There is no pitting 
on pressure in any part of her body, but the whole body is 
tolerably uniformly affected with the solid oedema peculiar to 
these cases. The mucous membrane of the mouth is tumid 
and dirty grey in colour. All her skin is dry and scaly, and 
she never perspires even on exertion. Her extremities are 
always cold, and her axillary temperature always subnormal. 
She has a small mole on her right cheek. The supra- 
clavicular regions are full and elastic to touch; there is no 
definite tumour. It is difficult to make out the precise condi- 
tion of the thyroid gland* It is certainly not hypertrophied. 



Dr. Anderson's Oase of Myxoedema. 23 

it may be atropliied. She gives a Idstory of fnlness of the 
throat with thickness of speech^ and a ^'choking feelings" 
when she had the severe hasmorrhage seventeen years ago. 

On the side of the nervous system she has the charac- 
teristic slowness of speech and action, from which we perhaps 
too hastily infer a corresponding slowness of sensation, 
thought, and volition. United ¥rith this apparent hebetude is 
the constant recurrence of a nervous restlessness which she 
terms '^ fidgets,'^ so marked and troublesome that she some- 
times dreads night coming on as she cannot lie still. The 
motor system is intact, and sensation as regards touch, pain, 
and temperature is normal and not appreciably delayed. The 
knee-jerks are present. Taste, smell, and hearing are up to 
the usual acuteness. She is slightly hypermetropic, but with 
the correcting lenses has perfect vision. Ocular movements, 
pupils, and colour vision are normal. Under atropine there is 
seen to be slight peripheral opacity of the left lens, otherwise 
the media are normal. In neither eye, however, according to 
the observation of Mr. Gunn and Mr. Nettleship, is the retina 
of normal transparency, a haze surrounding the vessels, espe- 
cially in the neighbourhood of the disc. The appearances 
differ entirely from those of a past neuritis or retinitis, and, as 
has been said, do not interfere with perfect vision. 

As regards treatment the usual tonics seemed to have no 
effect whatever. Dr. Stephen Mackenzie kindly admitted her 
under his care at the London Hospital, and to him I am 
indebted for detailed observation daring her stay there. A 
fortnight after her admission she was pat upon half-drachm 
doses of Tinct. Jaborandi, which she continued till she left the 
hospital three weeks later. Of objective improvement there 
was none or almost none, but she expressed herself as feeling 
greatly better within a few days after commencing the 
jaborandi. This subjective improvement was greatest when 
the skin was somewhat moist, and was accompanied by a 
steady and marked increase in the daily amount of urea 
excreted, which doubled itself during the period, and was at 
its maximum on her discharge from the hospital. Fallacy 
from variation in diet was guarded against as carefully as pos- 
sible. Since leaving London she has been under the care of 
Dr. Symington, of Wolverton, who has kindly written me 
regarding her. She appears to remain in very much the same 
condition. 

The points of interest in the case seem to be — (1) the history 
of commencement from a severe haemorrhage combined ynth. the 



24 Pr. Anderson's Case of Myxoedema, 

presiBnt hasmorrliagic tendency of tlie patient ; (2) the occasional 
state of nervons restlessness so apparently incompatible with the 
general character of the disease; (3) the retinal condition^ 
which is peculiar^ whether characteristic of the disease or not ; 
and lastly^ (4) the efEect of jaborandi on the subjective condi- 
tion of the patient, and on the amount of urea excreted 
by her. 



Mr. Golding-Bird's Oase of Dialocatum of the Patella, 25 



VI. — A Case of Paralytic Dislocation of the Patella. 
By C. Hilton Golding-Bied, M.B. Bead October 
24, 1884. 

EMILY M., set. 11, came to the out-patient department Guy's 
Hospital on July 17, 1883, with this history : 

Six months ago, whilst running, her left knee gave way 
under her and she {eU; in getting up again she felt it click. 
There was no bruising, pain, or swellings and she went about 
as usual, 

A week later, and at inten^ls during the next si^ months, 
the same circumstance recurred, but at last, the knee getting 
painful, she came for advice. 

The note then made was, '' Capsule of left knee very lax ; 
on flexion, the patella rides on to the external condyle but 
returns to the middle line with a click on extension ; this causes 
no pain. The patella is very moveable laterally when the knee 
is bent to a right angle j there is a slight tendency to genu 
valgum.^' 

From July to November the knee was encased in plaster 
of Paris. On its removal this note was made : " The patella on 
flexion still rides on to the external condyle, and goes back to 
the intercondyloid notch on straightening, with an audible 
click. This occurs both with active and passive movement. 
The patient now walks with the knee stiff er than on the former 
visit.'' 

Nothing more was done for her till February, 1884, when 
she was adjmitted as in-patient. 

The same conditions were noticed except that on flexion 
the patella now lay completely on the outer side of the external 
condyle. 

The following facts were now observed in addition. Both 
lower extremities were of the same length, and from the knees 
downwards equally developed, but the thighs were of unequal 
girth. The posterior half circumference of the thighs 
was the same at aU levels, but the anterior half circumference 
of the left thigh was everywhere three quarters to one inch 
smaUer than on the right side, due to wasting of the quadri- 
ceps extensor. Palpation showed the left extensors to be 
markedly wasted, though they were with the right extensors 



26 Mr. Grolding-Bird's Oase of Dislocation of the Patella. 

equally irritable to the interrupted constant electric cnrrent. 
When lying flat in bed the patient could lift both legs up, but 
the loss of power on the left side was very evident. 

When, during flexion, the patella was on the outer side of 
the external condyle, the ligamentum patellsB as a rigid cord 
was seen passing obliquely from the tip of the patelkk to its 
tibial attachments. 

The displacement being clearly due — as will be directly 
mentioned — ^to structural shortening of the extensors, I divided 
the ligamentum patellsB subcutaneously, and replacing the 
patella in the middle line and strapping it down, put the knee 
in a splint in a semiflexed position. 

When examined a week later it was found that whilst on 
flexion, active or passive, the patella still rode over the external 
condyle, yet that by slight pressure with the finger this could 
be prevented. No amount of pressure prevented the displace- 
ment on flexion prior to the operation. 

The child was sent out ten days after operation wearing a 
plaster-of-Paris splint, which was removed four weeks later. 
The note on its removal (in May, 1884) was, " The only per- 
ceptible difference now is that whilst the patella can be dis- 
placed outwards as before, yet that when it returns to the 
middle line it does so by a gliding movement and without the 
' click.' The child walks as when first seen, {.e. with the knee 
rather stiff and the foot somewhat everted. There is no 
pain or loss of power.^' 

Bemarka. — The wasting of the extensors seems to have 
been due to infantile paralysis although its existence was not 
known before. The growth of these muscles not keeping pace 
with that of the femur, a time came when, in the flexed position, 
it was a shorter route for the tendon and muscle from origin 
to insertion to pass first over and then outside the external 
condyle. I do not think that this displacement occurred 
suddenly at the time of the fall ; but that it was the first time 
the '^ cUck '' was noticed and hence attention was drawn to the 
deformity. 

The operation performed was founded upon the explanation 
given, in the hope that by adding to the length of the tendon 
the dislocation might be cured. Though this did not result, 
yet the absence of the click proved that some tension had been 
removed. 

The condition described and the explanation of the case 
given are in accord with the statements of Hueter, though it 
seems to me that the name '' paralytic '' dislocation of the patella 



Mr. GoldiBg-Bird's Oase of Dislocation of the Patella. 27 

better expresses the real state of affairs than '' congenital '' dis- 
location. The reason that I attempted operative measures for 
a condition in which it is known patients get along very com- 
fortably through Uf e^ and in which this case certainly will have 
to remain^ was^ that pain was complained of^ though in a less 
degree than the annoyance of the '' click/' The former was 
early relieved by the plaster splint^ the latter by operation. 



28 Dr. Carrington^s Oa»e o/^ /S/pin ^Bmpfiow Avs to Bromism. 



VII. — A Case of Skin Eruption due to Bromism. By 
R. E. Oarrtngton, M.D. Bead October 24^ 1884. 

I AM able to bring tbe case before tbe Society by tbe 
kindness of Dr. Boyd, of Victoria Park, nnder whose care 
the patient came for the skin affection. The sabject of the sketch 
is a male child, aged one yeaf. There is phthisis in the father's 
family, but none in the mother^s. Both the parents are healthy 
and well. The mother has not lost any children, nor had any mis- 
carriages. She has another child, a female aged three years, who 
has never been ill in any way except from an attack of impetigo 
capitis, from which she completely recovered by the use of tar 
ointment. This child is now plump, healthy, and rosy. I j&rst 
saw the child, the subject oi the present communication, on 
March 8, 1884, and received the following history. The boy 
was quite healthy when bom, and remained so for nine months, 
except that after vaccination, when three months old, he was 
affected by a red rash, according to the mother's description 
resembling measles. This remained out for a week and then 
subsided. He never suffered from '* snuffles," or any other 
evidence of congenital syphilis. 

Three months before I saw the patient the mother noticed 
that the child was unable to hold up his head, which fell 
backwards when unsupported. At this time he was able to say 
a few words and to walk a little with assistance, but he has 
been unable to do either since the present illness. Six weeks 
before I saw him the child became convulsed and unconscious, 
and medical advice was sought. Dr. Bothamley, of South 
Hackney, under whose care the patient came, has been so kind 
as to furnish me with the following note of the case at that 
time. He wrote to me as follows : ^' It was a case apparently 
of cerebro-spinal meningitis with very severe convulsions, the 
movements being constant for hours at a stretch. I started 
with one scruple of bromide of potassium in an ounce and a 
half mixture of which one drachm was administered every four 
hours. I pushed it for a time to one drachm eveiy three hours, 
afterwards diminishing it again to the four hours. He went 
on without change, to as nearly as I can remember seven weeks. 
For a time I substituted the ammonium for the potassium salt. 
The rash came out very gradually, and as soon as I saw the 






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Veil XVi:: Pla-..e II. 



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I. 






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N'ii\t,»»rr. l^ros . C^trv/rr.i^ iil n. 



•y \\M'fi:\^ior\s Case of rV.^onwde. V^K-;tv 



JDr, Garrington's Oase of 8Jcm Erupiian due to Bromism, 29 

papules I stopped the bromide^ but in spite of that they 
increased until they arrived at the severe looking eruption you 
saw." 

Under this treatment the child^ after a months recovered 
from the unconsciousness to a considerable degree^ but was 
still liable to convulsions from time to time^ and indeed 
had been so affected on the day I saw him ; there had been 
progressive loss of flesh since the onset of the illness. Four 
weeks previously to my first visit the child had had a discharge 
from the eyes and nose which had got quite well in a week 
and was but slight at any time. The eruption had first appeared 
three weeks before I saw the patient. The mother, who is an 
intelligent, observant woman, said that it came out in the form 
of minute red spots, which in the course of three days increased 
to the size of split peas, and that then in a few hoars many of 
them enlarged to the size of penny pieces. At first each spot 
was surrounded by a narrow deep red halo. They first appeared 
on the right side of the body, and three days elapsed before 
any were seen on the left. The child always lay on the left 
side. Fresh spots appeared from time to time, and some became 
smaller, none, however, had disappeared up to the time I saw 
him. At my first visit, on March 8, the boy was lying on the 
left side, for the most part quiet, but crying when disturbed. 
He was unobservant, more or less unconscious. There was con- 
siderable wasting but it was not extreme. There were no signs 
of rickets nor of congenital syphilis. Only the two upper and 
the two lower central incisor teeth- were cut. The anterior f on* 
taneUe was rather widely open, but not depressed then, though 
the mother had noticed that it became so from time to time. 

The parts affected by the eruption were the buttocks, legs, 
and thighs ; there, were a few spots on the scalp and face, the 
front of the abdomen, one on the chest, one or two on the left 
arm, none on the right. The back of the trunk and the hands 
and feet were free. There appeared to be no itching, the 
child lying quiet unless disturbed ; this conclusion was also 
confirmed by the mother. The spots varied greatly in size 
from that of a pin^s head to that of a penny piece. They were 
for the most part discrete, but here and there two or three had 
run together. They had never been moist from the beginning. 
The small spots at first were of a bright crimson colour, subse- 
quently they b(3came of the dull brownish hue most of them 
presented at the time I saw him. In only one spot did I see a 
halo present, and in this case it was bright red and about one 
eighth of an inch in diameter. The small spots were hemi- 



80 Dr. Camngton's Case of Skin Eruption dvs to Bromism, 

spherical and smootli^ the larger ones were flattened^ circnlar^ 
or elliptical in shape^ with an elevated^ sharply defined edge at 
least one eighth of an inch in thickness (Plate II). Their 
surfaces were corrugated and wrinkled. A thin film could be 
removed by means of a lancet^ without pain^ and the masses 
appeared porous and spongy^ without the least trace of serum or 
of pus in the interior. The chest, with the exceptions I have 
indicated, appeared healthy, and I could discover no physical 
signs of visceral disease. Dr. Boyd had been treating the 
child with half a grain of iodide of potassium and one minim 
of Fowler's solution three times a day, and this was maintained 
throughout. 

I again saw the child on March 22. There was now very 
great improvement in every respect. He was now quite 
conscious and observant. The nutrition was also greatly 
improved and his colour was good. He had had some convul- 
sions during the preceding two days, but save these none 
since I last saw him. All the spots now were much altered. 
Some of these, formerly of the largest dimensions, were repre- 
sented only by a pinkish discoloration, others were of a dark 
coppery red, much shrunken and nearly level with the skin, 
and evidently in process of disappearance. There had never 
been any moisture, and no new spots had appeared since my 
previous visit. All the spots that had disappeared had 
been on the right side, none had completely gone from the left ; 
so that those which came out first disappeared first. Several 
of the small spots had died away without any increase in size. 
The child was still being suckled by the mother. 

I have little further to add, for the child made an uninter- 
rupted recovery from all his troubles. I saw him again on 
May 20. He was then plump and healthy looking. Dr. Boyd's 
medicine had been discontinued for six weeks. All the spots 
were gone except one or two on the scalp and one on the face, 
and these appeared as dry scabs. No new ones had come out 
since I last saw him. It seems worthy of note that though the 
eruption was apparently due, without doubt, to bromism, it 
subsided completely during the continuous administration of 
iodide of potassium. 



Mr. Godlee's Oase of Tumour of the Bight Kidney, 81 



VIII. — A Case of Tumour of the Bight Kidney in an 
Infant successfully removed by an Abdominal Inci- 
sion. Recurrence. Death. By Biceman J. Gk)DLifiB, 
M.S., M.B. Bead October 24, 1884. 

I TTA VM ventured to submit an isolated case of removal of 
the kidney to the attention of the Society, becanse it is, 
I hope, a not nnimportant one in connection with the treatment 
of a disease of children not very uncommon, which if left 
alone is necessarily fatal, but which, if diagnosed tolerably 
early, it will be seen can be dealt with easily and safely by 
the surgeon ; and even though this child did not prove to be 
permanently cured^ I think the result of the operation should 
encourage us to endeavour to make a diagnosis and to interfere 
surgically at a much earlier period. Tlus is I am aware more 
easily said than done, because it is well known that such 
tumours of the kidney very commonly cause no symptoms, 
and thus the existence of a tumour is most likely not suspected 
by the mother until it has reached a very considerable size. 

J. I. K,, set. 1 year 10 months, was admitted under my 
care at the North-Eastem Hospital for Children^ on August 3, 
1883, on account of a very obvious swelling in the right 
lumbar region. It was brought to the out-patient room some 
weeks previously, but it was impossible to admit it at that 
time because it had suffered from measles in the early part 
of July^ as a result of which, it was when first seen pale and 
sickly looking. The mother first noticed that the child^s 
abdomen was swelled in the month of June^ and when I saw 
it there was a very distinct tumour, very easily to be felt, and 
which it was scarcely possible to mistake for anything but an 
enlarged kidney. It was of a rounded or ovoidal shape, the 
long axis being vertical or nearly so, smooth on the surface 
or but sUghtly irregular, very elastic but without giving a 
sense of fluctuation. The upper end of the mass reached the 
middle line about two inches above the umbilicus ; the lower 
end was situated further backwards. No bowel passed over 
the surface of the tumour, though some was present over the 
lower extremity. It reached upwards towards the liver but 
obviously was not continuous with it; downwards it did not 
extend much below the level of the umbilicus, and behind it 



34 Mr. Godlee^s Case of 'tumour of the Bight Kidniey. 

so that it was out of the question to attempt any operation for 
the removal of the recurrence. The persistence of the chest 
symptoms^ moreover, and the irregularity of their course, made 
me suspect the presence of secondary deposits in the thorax, 
though there were not at any time definite physical signs 
pointing to such a condition. After some weeks, while the 
general condition became worse, the tumour extended with 
great rapidity, filling up the iliac fossa, and extending down- 
wards through the inguinal canal along the scrotum, where it 
formed a hard pyriform swelling. It was last seen about the 
end of February, after which it was not brought to the 
hospital, but I am informed by Mr. Ritchie Norton, of Totten- 
ham, who afterwards attended the case, that it died in the 
course of a few weeks, and that he was unable to obtain 
permission to examine the body. 

The tumour, which, I am sorry to say, was accidentally de- 
stroyed a few weeks ago, weighed about a pound ; it was of a 
pretty uniform ovoidal shape, but somewhat knobby on the 
surface ; it was completely enclosed in a very definite and quite 
firm oapsule, and when cut into was found to be excessively soft, 
haying a whitish, brain-Kke appearance. The growth appeared 
to involve the whole of the kidney, as no normal kidney substance 
was to be discovered, and the ureter simply passed out of the 
lower part of the mass. I am not able to say whether the supra- 
renal capsule was involved, but I imagine that it was not, and 
that it was not interfered with by the operation. I have placed 
some microscopical preparations upon the table which will 
show that its structure is that of a sarcoma, the cells being of 
moderate size. The nuclei are for the most part irregularly 
round or oval, but a considerable number are oat-shaped, 
corresponding to strands of spindle cells which traverse the 
tumour, dividing the rounder cells in parts into larger or 
smaller irregularly shaped masses. The tumour is excessively 
vascular, the vessels being thin walled and of moderate size. 
No trace of the proper kidney substance was seen in any of 
the sections examined, nor were any striped muscular fibres 
discovered. 

A certain number of cases of removal of the kidney for 
tumour in infants have been published, and there are no doubt 
several others which have not been recorded. 

Mr. Jessop removed a kidney affected with " encephaloid " 
disease, in 1877, from a boy sat. 2^, by means of the lumbar 
incision; and although there was considerable haemorrhage 
and the operation was not performed antisepticaUy, the child 



Mr. Godlee^s Case of !tumour of the ttight Kidney, 35 

made a good recovery, but died eight months afterwards of a 
recurrence {Lancet, 1877, vol. i). 

Kocher, of Bern, had a similar case, " adenosarcoma,*' which 
he removed from a boy aet. 2^, in 1878, by the abdominal 
incision. Here again there was considerable hasmorrhage, and 
the child died of septic peritonitis {Deutsche Zeitschrift fiir 
Ohirurgie, Bd. xix, 1878). 

Czerny has the youngest case on record, a girl eet. 11 
months. The tumour, which affected the left kidney, was 
removed through a median abdominal incision. There was 
but little bleeding, but the child died three days after the 
operation of septic peritonitis {Deutschs Med, Wochenshrift, 
1881). 

Hiiter operated on a girl of 4 years by an abdominal inci- 
sion over the tumour in 1876, but death occurred during the 
operation from hemorrhage. 

These are the four cases mentioned in Czerny's table 
appended to the paper read by him at the Medical Congress in 
London in 1881. 

Hicquet records a case which perhaps hardly comes under 
the present category. The patient was a girl aet. 6 years, and 
the tumour which when first observed in February, 1880, 
was no larger than a hen's egg, by August had filled the 
greater part of the abdominal cavity. It was removed, how- 
ever, apparently without much difficulty, by the median abdo- 
minal incision. A drainage-tube was employed, and the child 
made a good recovery in thirty-six days. In five months no 
recurrence had taken place, but we have no late note of the 
case. 

There is also a case, the only other on record of which I 
have been able to find, by Bokai, junr., of Orvosi. The age is 
not given; the tumour, which was on the left side, was a 
medullary sarcoma weighing 4 kg., about a quarter of the 
weight of the child. It was removed by an abdominal incision. 
The child died on the third day of septic peritonitis. There 
were no secondary deposits. 

I can add, however, another not yet recorded, which was 
under the care of Mr. Heath at University College Hospital. 
It was in a little girl and the tumour was of large size. 
I helped Mr. Heath with the operation, which was one of great 
difficulty ; in fact it was not possible to remove the whole of 
the growth which had involved the surrounding parts exten* 
sively. The child died. 

It may be said that these are not very encouraging statistics 



86 Mr. €k)dlee*s Oase of Tumour of the Bight Kidney. 

on which to argue in f avonr of snrgical interference in these 
cases. Eight children in all^ five of whom died of the imme- 
diate effects of the operation^ two who recovered and remained 
well for some months and then died of a recnrrence^ and one 
who recovered and was well when last heard of. But^ on the 
other hand^ it is a condition which^ if left alone^ is so absolutely 
hopeless and leads to a result so miserable^ both for the child 
and its parents^ that I think we are justified in recommending 
an operation^ at all events until a certain number of small 
tumours — I mean smaller than mine — ^have been dealt with. 
If after the removal of such small tumours^ recurrence after a 
certain number of months should be shown to be the invariable 
result, the question would have to be reconsidered. 

I am far from advocating the attempted removal of those 
enormous masses of growth that we not infrequently meet with. 
The mere size of the tumour I beUeve materially increases the 
shock of the operation, and although, as was said above, it is 
not invariably the case, there is very great probability that 
secondary deposits or the infiltration of surrounding structures 
may have taken place ; under which circumstances the chance 
of cure is of course absolutely nil, while the surgeon will very 
likely have to endure the painful reflection that he has 
performed a useless operation which has been immediately 
followed by a fatal result. 

As to the minute structure of these growths, there is not a 
very large amount of evidence forthcoming. Some of them 
are described as cancers, but when an accurate description of 
them is given it has usually proved to be (as far as my inves- 
tigations have gone) some form of sarcoma, as it was in the 
present case. 

There is a very interesting class of cases, some of which 
were brought to the Pathological Society in 1882 by Mr. Eve 
and Dr. Dawson Williams, in which a large part of the growth 
was composed of striped muscular fibre. These tumours are 
thought to be congenital; they may reach an enormous size, 
and have in more than one instance affected both kidneys. 
This last peculiarity would obviously make them, if diagnos- 
able, particularly unsuitable for surgical interference. 



Dr. Mackenzie On the Treatment of Chronic Dysentery. 87 



IX. — On the Treatment of Chronic Dysentery by Vohi' 
mvnous Enemata of Nitrate of Silver. By Stephen 
Mackenzie, M.D. Bead November 14, 1884. 

IN 1882 I bronglit before aD other Society* a series of cases 
of chronic dysentery^ or dysenteric diarrhcea^ treated by 
Yolnminoos enemata of nitrate of silver. This plan of treat- 
ment of an admittedly most rebellions disease had yielded^ in 
my hands^ most satisfactory results. Further experience has 
starengthened my belief in its efficacy^ and 1 now feel that we 
have in it a safe and sure remedy that will arrest the disease in 
most cases. The mode of procedure I adopt is as f ollo¥ra : The 
quantity of nitrate of silver to be used is dissolved in three 
pints of tepid water in a Leiter's irrigating funnel. This is 
connected oy india-rubber tubing with an oesophageal tube 
with lateral opening or openings. A stopcock in the india- 
rubber tubing renders the apparatus more managable but is 
not essential. The patient is brought to the edge of the bed^ 
and made to lie on his left side with his hips well raised by a 
hard pillow. The terminal tube of the apparatus being well 
oiled is then gently passed eight or ten inches along the 
rectum^ and the Loiters funnel raised^ or if previously raised 
to a suitable height^ the stopcock turned, when the solution of 
nitrate of silver gradually, but irresistibly, forces its way along 
the colon until the whole is injected. Sometimes no pain or 
discomfort is experienced, but occasionally the injection gives 
rise to some pain, rarely of any severity. The bulk of the 
enema causing contact with the whole or nearly the whole of 
the colon usually promptly excites peristaltic contraction of the 
bowel and causes the prompt evacuation of the injected fluid. 
Usually it is not retained for more than five minutes, often 
less, occasionally it is retained for a quarter of an hour or 
longer. It has been thought advisable in the latter case to 
inject a solution of chloride of sodium for fear of absorption of 
the silver salt. The injection of the latter has given rise to 
more discomfort than the enema of nitrate of silver, but it is 
perhaps advisable when the fluid, as occasionally but rarely 
nappens, is long retained. TJsuaJly little difficulty is expe- 
rienced in injecting the whole of the three pints. I have tried 

• Medical Society, March 20, 1882. Lancet, 1882, vol. i, p. 640. 



38 Dr. Mackenzie On the Treatment of Chronic Dysentery. 

various strengths of the nitrate of silver, from tlurty to ninety 
grains to the three pints, according to the severity of the case 
and the vigour of the patient. One drachm of nitrate of 
silver to three pints of water has been the most usual strength 
employed. 

The treatment is based on the view that whatever the 
nature of dysentery, whether constitutional or local in the first 
instance, its later effects, when chronic, are due to ulceration 
or chronic inflammation of the colon, and that this local dis- 
ease of the bowel is best treated, as ulceration or chronic 
inflammation elsewhere, by topical applications. The large 
bulk of the enema insures probably the whole of the colon 
being bathed with the medicament employed. I have once 
or twice tried perchloride of iron instead of the silver salt, but 
the results have not been so satisfactory. 

The immediate effect of the enema has been in some cases 
to temporarily increase the looseness of the bowels, but only 
for a day or so. In the majority of cases a marked but rather 
gradual recession of the diarrhoea takes place, and in several 
the injection has required to be repeated before the case was 
cured. In one case I have published, as many as twelve injec- 
tions were used, and in another seven injections. In no oflier 
cases have more than two injections been required. In some 
cases a single injection immediately arrests the flux, and the 
stools become solid. 

In some of the cases all other treatment has been suspended 
when the injections were employed; in some the Dover^s 
powder, which the patient had been previously taking without 
restraining the looseness of the bowels, has been continued ; 
and in some, small doses of perchloride of iron have been con- 
tinued or subsequently administered. 

In the earlier cases various plans of treatment were pre- 
viously employed, audit was only when these were found wanting 
that the large injections were had recourse to. In this way 
the fallacy that other recognised plans of treatment would 
have been equally successful was avoided. During the period 
over which these cases have been distributed I have successfully 
treated many other slighter cases of chronic dysentery or 
dysenteric diarrhoea without injections. But I have become so 
convinced of the saving of time and suffering to the patient in 
severe cases by the large enemata of nitrate of silver, that in the 
last two cases I did not waste time by preliminary treatment. 

The plan of treatment has no claim of novelty. Enemata 
of nitrate of silver have been recommended and used ; volu- 



Dr. Mackenzie On the Treatment of Chronic Dysentery. 89 

minous enemata of different kinds have been nsed for years by 
some physicians; and volnminous enemata of nitrate of silver 
have been employed by a few. But it is a fact that large 
enemata of nitrate of silver are not in general use, and are not 
in use by those who have ample opportunity of treating the 
disease, as I showed in my former communication. 

In no case in which I have employed this treatment has it 
failed, and I now bring forward six additional cases, comprising 
all I have treated in this manner since my former series. All 
the cases have been under my care in the London Hospital, and 
the following brief abstracts of them have been made for me by 
my house physician, Mr. Alfred Peskett. 

Case 1. — H. P., ast. 38, a painter, was admitted into the 
London Hospital on January 1, 1881. Twelve years ago, when 
at Mauritius, he had an attack of dysentery which lasted five 
weeks. Six months after this, when on his way to England, 
he was attacked again ; this time it lasted a few days. He 
then enjoyed good health for two or three years, when he was 
again attacked, and each year since then he has suffered from 
diarrhoea, the attack every year becoming more severe, the 
present illness being a continuation of one of these attacks. 

On admission, — He was wasted and ansBmic ; he complained 
of sleeplessness, a feeling of fulness after food, and diarrhoea, 
the bowels acting five or six times a day. He was treated 
with compound ipecacuanha powder in gr. x doses and rest in 
bed; this was continued till the 15th January with no benefit, 
80 on the evening of that day an enema of one drachm of 
nitrate of silver to three pints of tepid water was given. All 
other treatment was suspended. 

January 16. — ^Bowels acted four times. January 1 7. — Five 
times. January 18. — ^Four times. January 19. — Injection 
repeated as before. January 20. — Pour times. January 21. — 
Three times. 

From this date till February 8 his bowels were opened 
from twice to three times a day, but the motions have been 
formed, and have been passed without tenesmus or any trace 
of blood. 

February 18. — Passed two loose motions during last twenty- 
four hours. Has been on fish diet for two days ; compound 
ipecacuanha powder ordered, in gr. v. doses, three times a day. 

February 28. — Motions again well formed ; and from this 
time until his discharge on March 22, his bowels generally 
acted once, and occasionally twice a day. 



40 Dr. Mackenzie On the Treatment of Ohrondc Dysentery. 

Case 2. — H. S.^ ast. 25 years, a sailor, a native of Bombay, 
was admitted on December 13, 1881. 

He bas bad dysentery once before, and assigned tbe present 
attack to tbe cold weatber. 

On admisaion. — He was well nourisbed. He complained of 
great pain in bis abdomen and burning pain in bis rectum, 
witb diarrboea; tbe bowels acting ten times in twenty-four 
bours, T. 98°. He was treated witb Pulv. Ipecac. Co. gr. v, 
4tis boris, and an enema of starcb and opium {v\ xxv of tinc- 
ture). 

He rapidly improved under tbis treatment until on tbe 
18tb December be passed only one motion during tbe twenty- 
four bours. He continued to improve till tbe 26tb December, 
wben bis bowels again became relaxed and were opened four 
times ; be gradually got worse, so on 6tb January, 1882, an 
enema of one dracbm of nitrate of silver to tbree pints of tepid 
water was given. Tbe injection returned in a quarter of an 
bour. 

January 7. — Bowels acted four times, temp. 104*5.® Janu- 
ary 8. — Tbree times, temp. 101*8.® January 9. — ^Five times, 
temp. 99'5.° January 10. — ^Twice, temp, normal. January 
11. — Five times. 

Tbe motions were fluid, of a yellowisb-brown colour, witb 
no blood or mucus. Enema repeated. 

From tbat time till 28tb January, tbe bowels acted, on an 
average, tbree times. January 29. — Enema repeated. 

February 10. — ^Very little improvement since last note. 
Enema repeated. 

February 11. — One motion. From tbis date till May 20tb, 
wben be was discbarged, be passed only one formed motion a 
day. 

Case 3. — F. F., set. 52, a sailor, was admitted on October 
27, 1882. Two months before, wben on sbipboard in tbe 
Indian Ocean, be was attacked witb diarrboea, wbicb was 
somewbat relieved by treatment, but just before arriving bome 
be became worse and passed a little blood. 

On admission. — He was a well-nourisbedman witb a sallow 
complexion. He complained of pain in bis stomacb and diar- 
rhoea, tbe bowels acting eight times in tbe day. Temperature 
normal. 

October 28. — ^Bowels acted six times. October 29. — Five 
times. 

October 30. — He passed eight motions, so an enema of 



Dr. Mackenzie On the Treatment of Chrome Dysentery. 41 

forty grains of nitrate of silver to three pints of tepid water was 
given. 

October 31. — Bowels acted six times. November 1. — ^Five 
times. Injection repeated. November 2. — Three times. No- 
vember 3. — Once. November 4. — Twice, motions formed, with 
a slight streak of blood in them. 

From that date till November 24 his motions remained 
formed, with occasionally a streak of blood in them. Dis- 
charged cured on that date. 

Case 4. — ^W. P., ast.' 61, a labourer, was admitted on 
December 19, 1883. At the age of 21 when in India he had 
a severe attack of dysentery which lasted eighteen months, 
but from that time until five years ago he had always enjoyed 
good health, when he was again suddenly attacked, the onset 
being ushered in by severe abdominal pain and diarrhoea, and 
passing of blood and mucus in his motions ; ever since then the 
symptoms have persisted, varying in degree from time to 
time. 

On admission. — He was fairly well nourished, but stated he 
had lately got much thinner, and complained of flatulence and 
diarrhoea, the bowels acting from six to eight times a day ; the 
motions consisted of yellow slimy blood-steined fluid. He was 
treated with compound ipecacuanha powder in gr. v doses 
three times a day and rest in bed ; this was continued for a 
month with no benefit, the bowels acting from nine to five 
times a day, so on February 4, an enema of one drachm of 
nitrate of silver to three pints of tepid water was given. 

February 2. — Bowels acted twice. February 3. — Once. 

From this date till February 27, when he was discharged, 
he averaged two motions a day, which were semi-solid, of a 
dark colour, but no blood was passed. 

During his stay in hospital he gained 131bs. in weight. 

Case 5. — ^W. R., set. 51, ship smith, admitted January 1, 
1884. Enjoyed exceptionally good health until four years 
ago, when he had rheumatic fever, which left his health much 
impaired, and he was unable to resume his employment for 
two years. Eighteen months ago was attacked with looseness 
of the bowels, which has continued up to admission. For the 
last six weeks this has been unusually severe, the bowels acting 
as many as sixteen times in the twenty-four hours on some 
occasions, the motions being generallv of a pale yellow colour 
and containing mucus and si^aks ox blood. He lost control 



32 Mr. Godlee^s Case of Tumour of the Right Kidney. 

seemed to extend about as far as the mid-axillaiy line. It was 
freely moveable when grasped between the hands, and manipu- 
lation caused tl^e child no inconvenience, nor did it give rise 
to the appearance pf l^loqd in the u^ne. The long axis of the 
tumour was about f pur inches, the short axis about two inches. 

The child wa^ naturally fair, but was somewhat paler 
^nd thinner than was consiistent with good health; it was 
slightly rickety Oiui. suffered from cough |ast winter. It never 
had any iirinary symptoms ; the water, I regret to say, was not 
examined as the child passed it usually into a napkin. 

No facts of importance were elicited frpm inquiring into 
the family history. The mother had had five pjiildren, the 
eldest of which died with convulsions. 

I had been on the look-out for a caa© of this kin^ for some 
time, because from the appearances observed ^t a certain 
number of post-mortem examinations on capes presumably of 
a similar nature, I had been struck with the fact that even 
after these sarcomas of the kidney have obtained tlie enormous 
size which is frequently observed in children, they often in- 
filtrate or involve surrounding structures, comparp-tively speak- 
ing, to a slight extent. It seemed, therefore, nqt improbable 
that,. while the tumour was small, it would be found tolerably 
free from adhesions and its removal would be easy. The event 
proved that this was the case. 

On August 10, while the child was under the influence of 
chloroform, an incision was made for six inches near the outer 
edge of the rectus over the most prominent part of the tumour. 
The rectus was unexpectedly wide, and the sheath had to be dis- 
sected off for some little distance before the edge of the muscle 
became visible. When this was reached the peritoneal cavity 
was opened and the smooth surface of the tumour was at once 
seen, covered by peritoneum, with the caecum and ascending 
colon at the lower and inner part. The peritoneum was divided 
over the outer part of the tumour and stripped forwards, so as 
to separate the mass from the colon, which was then covered 
with a sponge placed in the lower angle of the wound and was 
not again seen during the operation. A very little separation 
with the finger served to free the posterior part of the tumour, 
and a little traction then drew the mass out of the wound on 
to the surface of the abdomen, the cellular tissue round it 
being quite soft and the growth perfectly circumscribed. At 
this stage the second part of the duodenum was seen, and 
separated carefully from the front of the mass. A large vein 
-which followed a curved course across the hilus was then tied 



Mr. Godlee^s Case of Tumour of the Right Kidney, 88 

in two places with catgut (sulphurous acid and chromic acid), 
and then the pedicle was isolated and transfixed with a blunt 
aneurysm needle armed with a stouter piece of the same catgut 
and firmly tied, the ends being cut as short as possible. The 
pedicle was then cut well beyond the tumour. No other vessels 
required ligature. No haemorrhage of any consequence 
occurred during the operation. The sutures were applied 
as in a case of ovariotomy, and the wound was dressed with 
carbolic-acid gauze secured by a roller. The child was pro- 
tected by a sheet of thin mackintosh during the operation 
from the spray, which was purposely made as fine as seemed 
consistent with its efficiency. The operation was completed 
in about half an hour and caused very little shock. 

There is really nothing to say about the progress of the 
case, because the child did not su£er from a symptom of any 
kind. The temperature reached 99° the day after the opera- 
tion and then kept always at, or a little below, normal. It 
was given three drachms of brandy during the first twenty- 
four hours and none afterwards. It did not pass water till 
the next morning, and then, and always afterwards, in good 
quantity and without trouble. It took its food well from the 
first, and instead of being a very fretful child it became at 
once quiet and happy. The dressing was changed on the third 
day because it had become soaked with urine ; it was changed 
again a week after the operation and the stitches were all 
removed, the wound being completely cicatrised. Another 
dressing was applied and kept on for another week. The child 
was sent home on August 26, siicteen days after the opera- 
tion. 

I saw the child frequently after its discharge; it grew very 
fast and looked rather pale and delicate ; it also had a little 
internal strabismus which I had not noticed before, but my 
attention was not directed to its presence or absence. It 
became cross and fidgety when it was cutting its teeth, but 
at other times seemed well and happy. 

I examined the abdomen carefully many times but failed 
to detect any return of the tumour for several months. At last, 
however, in January, 1884, while the child was suffering from 
a severe cough, which had apparently originated in an attack 
of whooping-cough, it was clear that there was a tumour in the 
right iliac fossa considerably below the position of the original 
mass. 

At this time the child was very ill from the effects of its 
cough, and it developed well-marked symptoms of pneumonia, 

VOL. XVIII* 8 



42 Dr. Mackenzie On the Treatment of Oh/ronic Dysentery, 

over the sphincter ani. With these symptoms he has had 
much abdominal pain and at times cramps in the lower ex- 
tremities. Nine months before admission he experienced great 
thirst and frequent micturition, and his clothes were spotted 
with a sort of powder where the urine fell on them. He lost 
about four stones in weight in nine months. 

On admission, — The patient was wasted and worn; his 
tongue was red. There were no abnormal signs in the 
chest. He passed about 3500 to 4000 cc. of urine with 
about 5 per cent, of sugar and *9 per cent, of urea. On 
the first two days the bowels acted five and six times respec- 
tively. Feeling that with this double drain upon him it 
was imperative that the diarrhoea should be promptly ar- 
rested, I ordered an enema of forty grains of nitrate of 
silver to three pints of water. It was retained for a consi- 
derable time and caused slight pain. He improved greatly 
with this, the motions becoming nearly solid, and from two 
to three in the twenty-four hours. On January 8 a second 
enema of one drachm of nitrate of silver to three pints of water 
was ordered. The motions after this were formed and free 
from blood, he regained power over the sphincter, and his 
general condition improved, the diabetes continuing. The 
patient remained in the hospital until April 23, under treat- 
ment for the diabetes, which was greatly lessened but was not 
cured. During this time he passed large, bulky, solid, pale 
motions, generally two, sometimes three and occasionally four 
in the twenty-four hours. The motions were never fluid, 
and they never contained blood or mucus. He gained one 
stone in weight during his stay in the hospital. 

Case 6. — W. B., aet. 17, a ship^s steward, admitted August 
6, 1884. Fourteen months before admission, when at Hankow, 
he was attacked with diarrhoea, which in three weeks became 
dysenteric and continued up to the present time. 

On admission, — Fairly nourished, tongue dry, red, and 
furred at back. Sleep disturbed by action of bowels. Motions 
liquid, of a dark-green colour, with some scybala, very ofEen- 
sive. Temperature 100° F. He was at first treated with the 
following mixture : Ex. Catechu 5SS, Sp. Chloroform, ir^xv, 
Ext. BelsB liquid. 53, Aquam ad 5], ter die sumenda. 

On August 9 he had passed three motions in the night and 
two in the day. There were four motions the night before. 
He was ordered an enema of forty-five grains of nitrate of 
silver to three pints of water. It was retained about four 



Dr. Mackenzie On the Treatment of Chronic Dysentery. 43 

minutes. He passed a very liquid motion with a trace of 
blood tlie same evening after the injection. 

August 10. — ^Two motions, liquid, with a trace of blood. 

August 11. — One motion, liquid. 

August 12. — One liquid motion. 

August 15. — One motion, with scybalous masses and a few 
streaks of blood. 

August 16. — One motion more formed, no blood. 

August 20. — ^Two motions, liquid, with a trace of blood. 

August 27. — ^Temperature rose to 101*4°, only one motion. 

September 5. — ^Four motions yesterday, of dark colour, 
and partly formed. No blood. Temperature normal. 

September 8. — ^Passed a perfectly formed motion, but yes- 
terday there was a trace of blood. 

September 11. — ^Motions perfectly formed and contained 
no blood. 

September 13. — Stools well formed, with a little mucus 
and blood. The bowels act regularly once a day. Has been 
up two days and is on a fish diet. 

September 16. — Stools well formed. Bowels act every 
other day. Allowed to go into garden. 

October 1. — Discharged cured. The patient gained 1 st. 
1 lb. whilst in the hospital. 

To summarise these cases : 

Duration of disease preyions No. of injections Duration of 
Case. to treatment. employed. treatment. Besnlt. 

1 . Several years on and . 2 .6 weeks . Cure. 

off 



2 . Uncertain ; 2nd attack 

3 . 2 months 

4 . 5 years 

5 . 18 months 

6 . 14 „ 



4 
2 
1 
2 
1 



5 „ 
Si „ 
3 ^, 

7 weeks 



I hope the narration of these cases will lead any members 
who have employed this plan of treatment to contribute their 
experience, and that it may induce others who have not tried 
it to test it in suitable cases. 



44 Mr. Baker's Oaaea of Joint Disease with Locomotor Ataay, 



X. — Three Oases of Joint Disease in connection with 
Locomotor Ataxy. By W. Moebant Baeee. Bead 
November 14, 1884. 

CASE 1. — (For the following notes I am indebted to Mr. 
Francis and Mr. Aldous^ surgical dressers.) A woman^ 
E. M.^ 8Bt. 54^ was admitted into St. Bartholomew's Hospital 
nnder the care of Mr. Morrant Baker, October 18, 1883, 
suffering from disease of the right elbow-joint and of both 
hip- joints, and with symptoms of advanced locomotor ataxy. 

biatory. — She had always been in somewhat delicate 
health. Was married at twenty-nine years of age, and has had 
two children who are alive and well. She has suffered from 
rheumatic fever, bnt has never had chorea or heart disease. 
Her father and mother are still alive and well. A brother and 
sister died of " consumption.'' 

The present illness began about twenty years ago, when 
she had lightning pains for the first time. They were prin- 
cipally lancinating and confined at first to the legs. These 
have persisted to the present time, and are now more constant 
and more severe. 

Soon afterwards bormg pains commenced, as if a ''red-hot 
skewer were being thrust into the flesh." At first these were 
confined to the neighbourhood of the hip- and knee-joints, but 
now extend all over the legs, arms, and occasioni^y on the 
body, and are very severe. 

At about the same time she began to have a sensation as 
if " the skin were very tightly stretched all round her waist." 
She had had similar constrictive sensations in the legs and 
thighs, at first only occasional, but now almost constant. 

Many years ago she began to suffer from diplopia, and of 
late her vision has been very defective and glasses do not help 
her. She has been especially troubled with mv^csB, and 
objects always appear very misty. 

Ataxic symptoms began about eighteen years ago. Her 
feet felt as if " wrapped up in something soft." The move- 
ments were tremulous and rapidly became worse, so that she 
could only with difficulty walk across the road or any such 
short distance, and the legs in walking felt " hardly separated 



•i • 









Clm Soc . Trans . Vol XVIIL Plate I 



t Baker's cases of Charcot's joirtL disease 



Mr. Baker's Oases of Joint Disease with Locomotor Ataay. 45 

from one another if she did not look at them/' She was nn- 
able to stand or walk in the dark. At present she cannot lie 
down unless a light is burning in the room. 

Seventeen years ago she was admitted to Guy's Hospital^ 
and was there off and on for more than a year^ nnder the care 
of Dr. Wilks and Dr. Habershon^ and was said to be suffering 
from paraplegia. She had loss of power and of sensation in both 
limbs. She has partially recovered from this^ but for eight 
years could not use her legs in the least. Before she was 
admitted^ and while at Guy's Hospital^ she was troubled with 
severe vomitings but with no violent pain in the abdomen. 

Present condition. — The patient is anaemic^ thin^ and debili- 
tated. The pupils are dilated and do not respond to lights but 
contract on looking at near objects. There is no colour 
blindness. There is no affection of the facial muscles. She 
speaks fluently and without fatigue. There is no ear affection. 
At times she suffers from violent headaches and '' neuralgic " 
pains shooting to the lower jaw and temporal region. 

Her skin is smooth and glossy^ and appears thin as if from 
atrophy. This, she says, was remarked when she was at Guy's 
Hospil^l. She suffers continually from pain in the epigastric 
region, occasionally becoming extremely acute and at times 
with vomiting, the '^ crisis " lasting several days. She suffers 
also from boring and lancinating and constrictive pains in the 
abdomen. 

She has scarcely any power of movement in the lower 
extremities. The muscles are much wasted. Tactile sensa- 
tion is much impaired. Two pin-points, seven inches apart, 
are felt in the leg as one. As she lies in bed she can raise the 
thighs to about an angle of 45^, but cannot lift the feet. 

There is no patellar tendon reflex or ankle clonus percep- 
tible. 

Sometimes she suffers from involuntary micturition. Some- 
times she has difficulty in expelling the contents of the bladder 
and rectum. During micturition there are generally pains in 
the region of the sacrum, and occasionaJ^ tibere are bearing- 
down pains in the bladder and rectum. Tlie bowels are seldom 
moved without the aid of medicine. 

Joints, — ^The right elbow-joint is much enlarged (Plate III, 
fig. 1), measuring twelve inches in circumference against eight 
and a half in the opposite limb, and has a roughly globular out- 
line. It is tense and in parts elastic, this condition seeming on 
examination more due to gelatinous synovial membrane than to 
the presence of fluid. On flexing the arm there is much grating 



46 Mr. fiaker^s Gases of Joint Dtsease with Locomotor Ataacy^ 

perceptible^ and the arm admits of abnormal movement in a 
lateral as well as antero-posterior direction. Hard nodtdes 
can be felt forming part of the enlargement^ especially on the 
inner aspect. The joint seems as if scarcely held together at 
all by ligaments^ bat the patient is able to bend and extend 
it almost perfectly^ although with creaking and grating. Now 
and then there is a hitch for a moment^ and then suddenly the 
joint sur&tces again slip. The superficial veins are enlarged. 

Sensation is defective in the little fins^er and on the lilnar 
side of the ring-finger. The disease of the elbow- joint began 
about a twelvemonth ago^ after a slight injury produced by 
falling off a sofa. 

On examination of the hip-joints they are found to present 
the same loose and flail-like condition that has been mentioned 
with respect to the right elbow-joint. The trochanters are 
about one inch and a half above the level of the anterior supe- 
rior spines of the ilium^ but they can be brought down to their 
proper level by making traction on the legs^ the abnormal 
position being again assumed when the traction is discon- 
tinued. On flexing and extending the thighs there is some 
creaking at the hip-joints^ and on flexing and adducting the 
limb in such a way as to throw out the great trochanters the 
head of the femur cannot be recognised. It seems as if the 
trochanter formed the upper end of the bone with no head or 
neck attached to it. There is no feeling as of gelatinous 
synovial membrane or of nodular deposits of bone. 

The hip-joints have been affected for many years. It is 
difficult to assign an accurate date for the commencement^ on 
account of the disablement caused by the paralysis. 

Metatarso-phalcmgeal joi/nt, great toe {right). — The great 
toe of the right foot is shorter by an inch than that of the left. 
The metatarso-phalangeal joint is freely movable^ and there 
is well-marked grating when the articular surfaces are rubbed 
together. There is no evidence of nodular bony deposits; 
there appears to be some fluid in the joint. On the base of 
the first phalanx three scars are visible^ one on .the dorsum, 
one on the plantar surface, and one in the cleft between it and 
the second toe. These, the patient states, are the scars of three 
"perforating ulcers'^ which healed two years ago under 
stmiulating ointment, after they had existed for many months 
as little sinuses discharging matter. She knew of no exciting 
cause of these ; they did not begin in the site of corns. 

No material change in her condition occurred during her 
stay in the hospital, and she was discharged on December 8th* 



Mr. fiaker's Gases ofJomt Disease with Locomotor Ataay. 47 

Mr. Francis was so good as to find out lier condition as it 
was three months afterwards, and reports that she has been 
getting worse. She has had four severe gastric crises. The 
lightning pains have been more severe and the sight has been 
worse. At times the left elbow-joint is very painful and 
enlarged, resembling the condition of the right when it first 
became affected. She has not injured it. The right elbow- 

{'oint is in about the same condition as when she was in the 
Lospital. There is no apparent change in the condition of 
the hips. The knees swell nearly every night, but with little 
pain; they become smaller towards the morning. There is 
no oedema of the legs. The great toe-joint (right) is in about 
the same condition as before described. No other joints are 
affected. The patient complains of being very cold, in spite 
of abundance of fire *and blankets. She is living, and has 
lived, for several years in a very damp and draughty cottage, 
built in a damp garden, without any foundations. 

At the present time (October, 1884) she is reported by Dr. 
Deeping, of Southend, to be in about the same condition, " but 
the gastric crises recur at longer intervals. The joint condi- 
tion does not grow materiaUy worse." 

Case 2. — (For the details of the following notes I am 
indebted to Mr. R. Cross, surgical dresser.) A man, W. E., 
set. 56, a driver, was admitted into St. Bartholomew's Hospital 
under the care of Mr. Morrant Baker in July, 1884, on account 
of disease of the right knee-joint. 

History. — The patient is said to have enjoyed excellent 
health all his life until about two and a half years ago, when, 
in helping to carry a heavy piece of furniture, he gave his 
knee a severe twist. He heard it crack distinctly, but he did 
not fall. The joint at once began to swell and he walked 
with great difficulty. After keeping his bed for three weeks 
the knee remained swollen, but he could walk and bend the 
knee without much pain. Three months after the accident he 
went to a bone-setter and was under his treatment for five 
months. The knee was moved and painted with iodine about 
once a fortnight. He next became an out-patient at the 
London Hospital, where rest was advised and an india-rubber 
bandage applied. For some little time he wore a splint, which 
gave him much support. About five months ago a horse trod 
on his right foot, and for this injury he has been a patient at 
the German Hospital to within the last month. Possibly as 
the result of tms injury the middle toe is contracted and 



48 Mr. Baker's Cases of Joint Disease with Locomotor Ataxy. 

drawn up above the level of the rest. Corresponding to it on 
the plantar surface is a scar about an inch and a half long. 
He has never suffered from syphilis and has not been specially 
exposed to cold or damp. He has never suffered from any 
gastric troubles. 

Present condition. — Theright knee-joint is much swollen and 
distorted (Plate III, fig. 2), measuring in circumference at the 
level of the patella three inches and a half more than the left. 
The internal condyle of the femur, although preserving its 
normal shape, gives the idea on examination of being enlarged 
and of projecting downwards and inwards, not resting at all on 
the inner half of the head of the tibia, which has apparently 
been absorbed. The external condyle has almost disappeared, 
and in its place can be felt a semi-detached, rounded nodule of 
bone, freely movable, of about the size of a walnut. 

The outer half of the head of the tibia seems to take the 
place of the wasted external condyle of the femur, projecting 
as it does on a higher level, by about four inches, than the 
lower surface of the internal condyle of the femur. 

The joint is very loose and flail-like, allowing hyper- 
extension of the tibia on the femur. The leg can be also 
readily bent outwards and inwards as well as in an antero- 
posterior direction. On grasping the knee the bones can be 
felt grating against each other when the patient bends and 
extends the limb. The leg cannot be flexed beyond a right 
angle. The superficial veins over the joint are somewhat 
dilated. The patient suffers no pain in the joint. On the 
plantar aspect of the great toe of the same foot is a small 
perforating ulcer. A probe enters it for about an inch in a 
direction towards the sole of the foot. The skin of the toe 
is swoUen and somewhat inflamed. There is slight oadema of 
the ankle. 

In both legs sensation is impaired. There has been 
a feeling of numbness in the right leg ever since the acci- 
dent, but in the left leg only during the last six weeks. 
There is no patellar tendon reflex and no ankle clonus. At 
times the patient has suffered from what he terms lightning- 
pains in all parts of his body. There is loss of sexual desire. 
Micturition is normal. 

The pupils are much contracted and do not react to light. 
They contract during accommodation for near objects. There 
is no colour blindness. The feet are said to be always damp 
from sweat. 

About ten days after the patient's admission into the 



1 



Mr. Baker^s Oases of Joint Disease with, Locomotor Ataxy, 49 

hospital^ a small abscess which had formed on the right great 
toe was punctured ; but no communication between it and the 
perforating ulcer could be found. Dead bone was felt on 
probing the latter. The patient complained of a good deal of 
pain extending up the calf of the leg^ and of aching pain 
in the stomach and hypogastric region. 

On the 23rd August one of my junior colleagues^ under 
whose care the patient was during my absence from town, 
judged it best to amputate the great toe, which seemed to 
be the source of most of his trouble. The second joint 
was found much diseased, the phalanx being necrosed through- 
out. 

On the following day the wound looked well, but on the day 
afterwards there was a good deal of unhealthy discharge from 
it. On the 27th of August the patient had a severe rigor 
lasting for half an hour. 

On the 29th August the temperature was normal in the 
morning, but the patient was suffering from abdominal pain, 
with vomiting and diarrhoea. The motions came away involun- 
tarily. On the 30th the diarrhoea had ceased and there was 
less vomiting ; and from this date to the 1st September there 
was some slight improvement in the symptoms, although the 
patient seemed to steadily get weaker. The temperature 
varied from about 100° to 103°; the urine was of sp. gr. 1013 
with a trace of albumen. 

On September 3rd the diarrhoea returned, and on the 
following day the patient died. 

The right thigh and leg had assumed during the last two 
days a yellowish colour, as-if from incipient decomposition, a 
large bulla forming on the inner side of the right knee. The 
odour of the limb was very offensive. 

Prom the symptoms, which need not be further detailed, it 
may be concluded that the patient died from acute septicaemia. 

Post-mortem examination. — Head. — Permission could not 
be obtained to examine the head. 

Thorax. — Old adhesions in pleurae. Pibroid and cretaceous 
nodules at apices of both lungs. 

Abdomen. — Liver normal ; spleen soft and engorged. Kid- 
neys slightly granular. 

The spinal cord and posterior tibial nerve were removed 
for future examination. Mr. Bowlby has since examined them 
and has kindly given me the following account : 

*' Transverse sections of the spinal cord were made on its 
removal from the body. To the naked eye the posterior 
VOL. xviu. 4 



50 Mr. Baker's Oases of Joint Disease with Locomotor Ataooy. 

median columns presented a more greyish hue tlian the re- 
mainder of the white matter. (Portions of the cord were then 
preserved in Miiller's fluid for several weeks, and after being 
kept a short time in spirit were cut with a freezing microtome 
and stained in picro-carmine and in osmic acid.) 

'^ Microscopically examined, the columns of Goll were found 
to be degenerated through the entire length of the cord. 
There was in them an excess of connective tissue, a marked 
disappearance of the nerve-fibres, and a good deal of granular 
debris. In some parts of the field but few normal fibres were 
to be seen. 

'* In the ddrsal and lumbar regions that part of the postero- 
lateral tract which was contiguous to the columns of GoU 
presented similar degenerative changes. The blood-vessels 
also were unusually large and numerous in this region, and in * 
places their walls appeared to be thickened. 

'' Microscopic examination of the posterior tibial nerve did 
not show any definite lesion. It could not be certainly stated 
that there was any atrophy of the nerve-fibres." 

Bight fenee-^om^.— The right knee-joint, which was found 
distended with thin and foul purulent matter, was removed 
and is exhibited this evening to the Society. (No pus was 
found in any other joint.) 

On examination the joint was found much enlarged ; the 
enlargement being due to thickening and development of the 
various folds and processes of the synovial membrane and to 
alterations in the shape of the bones. The lower end of the 
femur and upper end of the tibia have undergone remarkable 
alterations in shape (Plate IV). 

The external condyle of the femur has almost disappeared, 
its place having been taken by two irregular nodules of bone, 
together of about the size of a horse chestnut, which lie 
embedded in the thickened synovial membrane. The internal 
condyle appears remarkably enlarged bv contrast, but the 
appearance is deceptive, and is produced partly by the almost 
complete absence of the fellow condyle, and partly by a com- 
pensatory alteration in the shape of the tibia to be imme- 
diately noticed. The internal condyle seems much flattened 
from side to side, and near its inner and upper surface is a 
marked projection or ridge which overhangs a groove pro- 
duced by friction on the opposed surface of the head of the 
tibia. The shape of the lower end of the femur, indeed, 
resembles that of an enormously enlarged external malleolus. 
At the back of the internal condyle is a large nodulated mass 



I 

■ 



* 



90*' 



T * 



-«— .%^^ ., fl 



TlD • 



v.. im*" . . ., 



, .•^.>!^ ' ■'■ 



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'Tl,- 



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^ air ■ 

^ m ~ 

Jilt 

* *' -♦ 



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r Ataxy. 58 

not at any 
nlargement 
dng of the 
place being 
v'hicli seems 
an be felt, 
•3 ligaments 
I. The leg 
is suddenly 
t admits of 

I movement 
•1 communi- 

moves the 
• somewhat 

left knee is 

ilgomj and 

re irregular 

;rane seems 

grating on 

h the semi- 

ower of the 

that he has 

no tingling 

II the soles 
e sensitive 

lot react to 
ts. There 
lour blind- 

1 continence 
. arily. He 
Oj when he 

te normal. 
r the most 

1 occurred 
as applied 
•nsiderable 
November, 




& 



Mr. Baker's Oases of Joint Disetue with Locomotor Ataxy » 51 

of bone^ wliich fits into a corresponding cup-shaped depression 
on the posterior surface of the tibia. 

The articular surface of the head of the tibia has under- 
gone a compensatory alteration. The inner part seems to 
have been completely worn away by the internal condyle of 
the femur^ while the outer side^ on the other hand^ takes the 
place of the absent external condyle. To such an extent has 
this alteration occurred that the line of the tibio-femoral 
articulation, instead of being horizontal, is almost vertical ; 
while the only part of the bones which could serve as a sup- 
port in standing or walking is the narrow ridge on the femur 
just referred to, and the corresponding narrow sur&ce of the 
head of the tibia (Plate IV, %. 1). 

The bone which covers the articulating surfaces of the 
femur and tibia is smooth and hard, and f omi3 a continuous 
layer, but in other parts this smooth lamella has disappeared 
and the cancellous tissue is exposed as in superficial caries, 
the bone being pitted and irregular. The cartilage has almost 
entirely disappeared, but here and there a patch has escaped 
the grinding process. These patches have undergone advanced 
fibrous degeneration. (Mr. lyArcy Power has kindly pre- 
pared sections of the cartilage and exhibits them this evening 
to the Society.) 

The patella has undergone less alteration than the other 
bones, but it seems thickened and irregular. Its articular 
surface is covered by cartilage in an advanced stage of dege- 
neration, and the bone is on this aspect irregular and pitted. 

The inner surface of the synovial membrane has developed 
in many parts villous outgrowths, some of which contain 
calcareous matter, while others are still soft. 

The development of osteophytes or of calcareous matter in 
the soft tissues which surround the joint has taken place to a 
remarkable extent. Nodules are, so to speak, infiltrated in 
the tissues around the Ugamentum patellse, and in various parts 
of the synovial membrane. They are especially well marked 
in the tissues which cover and protect the lower edge of the 
internal condyle. The edge of tiie head of the tibia is covered 
by overhanging and irregular ridges of bone, exactly resembling 
those seen in museum specimens of osteo-arthritis. The shaft 
of the femur, four inches above the condyles, and that of the 
tibia at about the same distance below its head, appear to be 
in all respects normal. 

Case 3. — (For the details of the following notes I am 



52 Mr. Baker's Oases ofJomt Disease with Locomotor AtaoBy. 

indebted to Mr. J. Close.) A man^ J. G., set. 46, a French 
polisher, was admitted under the care of Mr. Morrant Baker 
into St. BartholomeVs Hospital September 22nd, 1884, on 
acconnt of disease of the right knee-joint. 

History, — For about two years the patient has suffered 
occasionally from shooting pains in the right leg, which he 
thought rheumatic, as he had been often exposed to cold and 
wet. He had been quite well in health, however, and was not 
at all lame until about the end of December of last year (1883), 
when, in going upstairs he fell, and then found on getting up 
that the right knee was very painful and that he could only 
with difficulty walk across the room. He believes there was no 
swelling of the knee ; and in two or three days he was able 
to go about his work as usual, only occasionally limping a 
little. 

Three months or thereabouts before his admission into the 
hospital while walking he heard and felt his knee crack, and 
immediately found that he could scarcely get along, not on 
account of pain but because he felt he had lost nearly all power 
in the limb. He managed, however, to get home, but found 
it quite useless to attempt to get about, and the knee began 
to gradually increase in size. From that time to the present 
he has been quite unable to walk without support. He has 
had no shooting pains since the knee became swollen until the 
night before his admission into the hospital, when they were 
very severe for about two hours. 

When a young man he was somewhat intemperate and 
dissolute. He suffered from gonorrhoea but never had syphilis. 
He has had smallpox. Twelve years ago he hurt his back in 
a fallfrom a cart and two abscesses formedin the lumbar region. 
He was laid up at this time for two months, but, so far as he 
knew, quite recovered from all effects of the accident. 

His father and mother both lived to a good old age and were 
always healthy. There is no history of epilepsy, insanity, or 
phthisis in the family. He has never suffered from special 
gastric troubles, nor from headache or neuralgia. 

Present condition. — The right leg (measuring from the 
anterior-superior spine of the ihum to the internal malleolus) 
is about two inches shorter than the left, obviously on account 
of disease of the knee-joint, which is much deformed and 
enlarged, measuring in circumference about two and a half 
inches more than the left. 

On examination of the affected joint, it seems as if the 
external condyle were enlarged and projecting downwards and 



Mr. daker^s Oases of Joint Disease with Locomotor Ataocy. ht 

backwards, oyerlapping the head of the tibia and not at any 
point resting on its npper surface. The apparent enlargement 
is probably illusory, and is produced by the wasting of the 
internal condyle, the latter having disappeared, its place being 
taken by the internal part of the head of the tibia, which seems 
to extend upwards and backwards. The patella can be felt, 
but seems higher up the thigh than nonniaJ. The ligaments 
of the joint seem much weakened or even destroyed. The leg 
can be flexed to an angle of about 135^ and then is suddenly 
stopped. It can be hyper-extended, and the joint admits of 
a very abnormal amount of rotation and of lateral movement 
both inwards and outwards. There is no sensation communi- 
cated to the hand as of grating when the patient moves the 
joint. The superficial veins over the joint are somewhat 
enlarged, and the skin is slightly glossy. 

The patient suffers no pain in the joint. The left knee is 
also somewhat abnormal. There is slight genu valgum ; and 
the articular ends of both the femur and the tibia are irregular 
at their edges and nodulated. The synovial membrane seems 
lax but thickened ; and there is much crackKng or grating on 
flexing and extending the limb. The bursa beneath the semi- 
membranosus tendon is enlarged. The muscular power of the 
legs seems not much impaired, and the patient says that he has 
never noticed any defect of sensation. He has had no tingling 
or numbness in the feet, or any other part. When the soles 
of the feet are tickled, however, the left seems more sensitive 
than the right. 

The pupils are moderately contracted, they do not react to 
light, but contract on accommodation for near objects. There 
is no diplopia, amblyopia, or strabismus ; and no colour blind- 
ness. 

The patient sufEers occasionally from nocturnal incontinence 
of urine, and the faeces occasionally pass involuntarily. He 
dates the latter from his accident twelve years ago, when he 
fell from a cart. He has not lost sexual desire. 

The urine is slightly acid and apparently quite normal. 
The body temperature is rather variable, being for the most 
part subnormal. 

Little or no change in the patient's condition occurred 
during his stay in the hospital. A leather splint was applied 
to the right knee-joint, and from this he obtained considerable 
relief. He left the hospital at the beginning of November, 
1884. 

He is exhibited this evening to the Society. 



64 Mr. Baker's Gases ofJomt Disease with Locomotor Ataxy. 

Postscript, June, 1885. — ^This patient died at his home 
within a few months after exhibition to the Society. I am 
indebted to my late house surgeons, Mr. J. N. Vogan and Mr. 
Alfred Hind, for the considerable trouble they took in obtain- 
ing the knee-joints which are now in the Museum of St. 
Bartholomew's Hospital. 

On examination of the right knee-joint, the synovial 
membrane was found everywhere thickened and pulpy, and in 
some parts papillated. The cartilage of the condyles was 
ulcerated, the ulceration being best marked on the inner side. 
On the bones are small pearly concretions like sago-grains. 
The articular surface of the patella is completely covered by 
thickened synovial membrane. 

The whole of the posterior surface of the upper end of the 
tibia, for a depth of three inches, is worn away in such a 
manner as to allow of the dislocation of the bone forwards upon 
the femur, and a new articulating surface has been formed 
on the eroded surface (Plate V, fig. 1), partly by a moulding 
of this surface, and partly by osteophytic processes. A 
portion of the lower surface of this new articulating cavity is 
formed by the posterior part of the original articulating surface 
of the head of the tibia, which, having been apparently under- 
mined, seems to have slipped down bodily, letting the femur 
fall, so to speak, and carrying with it a part of the external 
semilunar cartilage. This part of the original joint surface, 
however, assumes now a nearly vertical instead of a horizontal 
direction. 

The posterior crucial ligament, with a portion of the 
external semilunar cartilage, remains attached to the femur. 

The anterior crucial ligament retains its normal attachment 
to the tibia, but it has lost its attachment to the femur, and is 
connected above with the thickened tissue surrounding the 
patella. 

The margins of the articulating surfaces of the femur and 
tibia are "lipped'' by slightly projecting outgrowths. 

The synovial membrane of the left knee-joint (Plate V, fig. 
2) was found vascular and papillated, the portion below the 
patella being pulpy. The cartilage covering the internal 
condyle is ulcerated at one spot. It is thickened, and clearly 
undergoing fibrous degeneration over its whole extent, although 
it still retains its polished surface. 

The cartilage covering the external condyle is thickened, 
except at one spot where it is worn away, leaving dense 
eburnated bone. 












k 
k 



Mr. Baker's Octses of Joint Diaease with Locomotor AtaoDy, 55 

The edges of the articulating snrfEU^s of the condyles are 
''Kpped/' 

The semilnnar cartilages are intact. 

The anterior crucial ligament is pulpy and in part eroded; 
the posterior is also softened. The^patella is "lipped;" it is 
covered by cartilage undergoing pnlpy degeneration. It is 
not overgrown by thickened synovial membrane. The articu- 
lating sur&ces of the head of the tibia are bare of cartilage. 
The external surface is undergoing erosion at the point at 
which it is opposed by the eroded sur&ce of the external 
condyle of the femur. All the soft tissues are more or less 
thickened^ P^P7^ ^^^ degenerated. 

Rema/rTc8. — ^If one tries to formulate the conditions found 
on examination of this remarkable disease of the joints^ one 
might say that the &ult lies not so much in active destructive 
processes as in incapoMlity of repair. There is decay without 
re-construction ; or the attempts at repair are inefficient and 
disorderly. Patients are able^ however^ in a wonderful manner 
to use joints which appear completely and hopelessly spoiled. 
They can bend and extend an arm^ or bear considerable weight 
on a leg ; in the latter case causing^ one might say^ some alarm 
to one who watches the movement at the knee^ when this 
joint is affected^ lest the limb should break in two. But the 
effect of usinfif the Umb is to wear out the joint, as if it 
were a me^mechanical lunged apparatus, ^4 of bad 
materials^ with no more power of repair in the bone-sur&ces 
than if they were bad mill-stones. The osteophytes^ if not 
remnants of the old bone which have escaped the grinding 
process^ are only examples of degeneration^ not of true 
development; and the surface of the bones presents the 
appearance not of active destruction or breaking down by 
some pathological process within^ but rather that of having 
been merely rubbed down as by a grindstone. The tissues are 
equally incapable of resenting injuries and of repairing them. 

Is not this " incapability of repair '* expressed by the patho- 
logical changes of other parts in tabes f We see it at a glance 
in the bones^ because in the performance of their mechanical 
functions they are worn away. But in tissues not subject^ 
like the bones^ to mechanical attrition^ the diseased condition 
may be perhaps equally well expressed as depending on 
incapability of the physiological reconstruction which, for 
health, must always accompany physiological decay. 

It is clearly impossible withm the time at my disposal to 



66 Mr. Baker's Oases of Joint Diseases with Locomotor Aiadsy. 

do more tban refer to the difiFerent theories which may be 
adopted with regard to the causation of Charcot's disease of 
the joints, but I would venture to suggest for discussion the 
following questions. 

(1) Is this disease of the joints a new disease, or is it one 
long known, but which seems new on account of its connection 
with other diseased conditions only lately recognised ? For 
myself, I cannot resist the belief that the disease is only, in 
an exaggerated form, what has been long familiar to us under 
the names chronic rheumatic arthritis or osteo-arthritis. Apart 
from the a priori improbability of the sudden evolution of a 
new disease, I think we must come to this conclusion on 
comparing the pathological appearances with those presented 
by the specimens of chronic rheumatic arthritis preserved in 
our museums. One is struck by the apparent identity in the 
two cases. There is the same kind of deformity of joint 
surfaces, the same overgrowth or apparent overgrowth at one 
point with erosion at another, the same ebumation, the same 
thickening of tissues with infiltration of bony or calcareous 
deposits, the same dendritic outgrowths of synovial membrane, 
the same fibrous degeneration of cartilage. 

(2) If the two diseases are identical, the next question is 
" Wliat is the connection between the arthritic disease and 
locomotor ataxy ? Is the connection a mere coincidence or, in 
other words, a mere accidental occurrence of rheumatic arthritis 
in a patient the subject of tabes ? This question I am disposed 
to answer in the negative. Since attention has been drawn to 
the subject, one has been in the habit of looking for symptoms 
of locomotor ataxy in all severe cases of joint disease similar 
to those which have been related, and in almost all the cases 
which have come under my notice, it has been possible to 
guess and to guess rightly that the patient was the subject also 
of tabes dorsalis. And although one may allow that exactly 
similar conditions may exist without the usual signs of tabes, 
the concurrence of these pathological conditions is too frequent 
to permit the notion that their relationship is a coincidence only. 

(3) But if this be so — ^if this form of rheumatoid arthritis 
be closely connected pathologically with tabes — ^how can we 
explain the fact that rheumatoid arthritis is not always accom- 
panied by symptoms of tabes dorsalis ? 

(a)' One way out of the difficulty is to assume that all 
cases of osteo-arthritis, whether accompanied by signs of tabes 
or not, have a neurotic origin, and that their frequent associ- 
ation with tabes indicates to us their pathological origin in 



Mr. Baker's Oases ofjomt Disease with Locomotor Ataofy, 57 

cases in which the usual signs of tabes do not co-exist. In 
other words, if a certain group of symptoms are unquestionably 
the result, in some cases, of a nerve-lesion, it is fair to assume 
as probable, to say the least, that the same group of symptoms 
in other cases have a direct relationship to a nerve-lesion, even 
when the signs of the latter are, for some reason or other, 
undiscoverable. If, for example, that peculiar condition of 
glossy fingers, of deformed nails, of low vitality of all the tissues 
with tendency to ulceration or even gangrene, with which all 
surgeons are familiar, be undoubtedly the result, in many cases, 
of injury to one or more nerves of the forearm, it would be a 
fair inference, if a case presented itself with exactly similar 
symptoms, but with no history of injury, that there was a 
lesion somewhere in the corresponding nerves or nerve-centres, 
even if the effects only of such a lesion were, at the time; 
discoverable. So with the disease of the joints which has been 
long termed osteo-arthritis. Does not its frequent associa- 
tion with locomotor ataxy form a strong reason for believing 
that its alliance with disease of the nervous system is a close 
one, even when the symptoms of the latter are not sufficiently 
pronounced to be demonstrable ? 

(6) Another theory, however, may be adopted which seems 
to me to explain matters equally well or better. Even if we 
assume the pathological relationship between locomotor ataxy 
and osteo-arfchritis to be a close one, we are not compelled to 
assume that the two diseases stand in the relationship, one to 
another, of cause and effect j nor indeed that osteo-arthritis 
has an immediate neurotic origin. It seems to me conceivable 
that the ataxy and the joint disease may be due to some pre- 
existing depraved condition common to both of them, of which 
the effects are seen most clearly, sometimes in disease of the 
nervous system, with its direct consequences — ^paralysis, &c. — 
sometimes in diseased conditions of the joints, sometimes in 
both. That one organ or tissue should be the chief point of 
attack in one case of a given disease, and that another organ 
or tissue should chiefly suffer in another case of the same 
disease, is only what happens unquestionably in many affec- 
tions of known origin. Syphilis and tuberculosis may be 
quoted as examples. Why should not tabes dorsalis and 
chronic rheumatic arthritis be examples of the same general 
law ? Does not the Protean character of tabes (to which Dr. 
Wilks has referred so acutely of late) suggest that, as at 
present described, it is not a distinct pathological entity, but 
only a small bit of a large disease, of which we see the effects, 



56 toiscussion on foint Disease in 

sometimes in one organ^ sometimes in another; a disease of 
which we cannot understand the true size and proportions 
until we become better acquainted with its effects on other 
organs than those of the nervous system. 



Mr. Barker referred to a case now exhibited to the Society. 
It was of a porter aet. 38, who came first under his notice in 
1881 for treatment of some urinary affection attended with 
difficult micturition. Some years previously the patient 
suffered from dyspepsia and vomiting, with nausea, distension 
of the stomach, &c. He complained of numbness in his feet, 
shooting pains in the lower limbs, and a sore place on one foot. 
Later, he became an in-patient, and was examined by Dr. 
Gowers, who could find in him none of the ordinary symptoms 
of locomotor ataxy. He left the hospital, but subsequently 
returned with a second ulcer of the foot, which healed under 
treatment ; but last year he once more returned, the sores 
having broken out afresh. The gastric disturbance was worse 
also. Dr. Barlow then examined him in vain for the usual 
ataxic symptoms. The patient improved, but the ulcers later 
on were a source of trouble, and in January, 1884, Mr. Barker 
had him for the fourth time under observation. The pains, 
weakness, and gastric disturbance were all aggravated, the left 
thigh being the seat of shooting pains. On the day preceding 
the meeting of the Society the same man presented himself yet 
again, and this time with complete disorganisation of the left 
knee-joint. This was increased in size, but could be moved 
without pain ; it was partially dislocated inwards and back- 
wards. He had had no evidence of structural change in this 
knee until the previous July, when without any assignable cause 
it suddenly swelled up, and, so far as the patient^s power of 
observation went, at once assumed its present condition, which 
has not since varied. His pupils are now normal. The knee 
jerk is still present on both sides j the erect position is easily 
maintained when both eyes are closed ; the gastric trouble and 
pain are both less in amount. SwelHng of the foot has 
recurred, and a red papular rash lately erupted during the 
patient's residence in the hospital. 

Dr. Dycb Duckworth congratulated Mr. Baker on being one 
of the few surgeons who had formed the opinion that there was 
something more to be studied in cases of so-called Charcot's 
disease than the characters of ordinary chronic rheumatic 



connection with Locomotor Ataxy. 59 

arthritis. He thought it was a ifttting task for the Clinical 
Society to undertake to clear the ground for a comprehensive 
discussion of the whole subject involved in Mr. Baker's 
communication. Although M. Charcot's position was now 
completely accepted in France, and perhaps in Germany, 
there remained sceptics in this country who refused to see any- 
thing specific and very remarkable about these cases of joint 
disease. It seemed at the outset very unlikely that M. Charcot, 
who had himself so well and minutely studied the features 
of chronic rheumatic arthritis, and taught the profession so 
lucidly on the subject twenty years since, should be mistaken in 
adopting a different view of the malady now under considera- 
tion. His exceptional opportunities at the Salp6tri&re afford 
him the largest scope for a study of the whole matter. First, 
with respect to the specimens brought forward, it was un- 
doubtedly true that many of them were quite indistinguishable 
from joints affected with chronic rheumatic arthritis. But it 
was also true that certain characters pertained to the bones, to 
the form and degree of the arthritis in these cases, which were 
never met with in the rheumatic disease. Now, it was to the 
existence of these peculiarities and the clinical features asso- 
ciated with them that heed must be paid in discussing this 
question. The essential point of difference in the morbid 
specimens was the extreme wasting and wearing away of the 
bones. Attempts at repair andbony outgrowths were met with, 
but in many cases the atrophic changes predominated. Putting 
aside this feature, it was difficult, if not impossible,^af ter death 
to tell what form of arthritis had led up to the appearances, 
because both rheumatism and gout will disturb both cartilagin- 
ous and bony nutrition. The clinical features related especially 
to somewhat sudden and riotous inflammatory action, more 
injury being suffered in a joLut in a period of three weeks than 
would accrue in thirty years of chronic rheumatism. Surely 
there was something specific and very significant in this. It 
was difficult to believe that the disorder was a new one. He 
believed that many museums contained specimens of so-called 
Charcot's disease labelled as those of ordinary chronic 
rheumatic arthritis. Still it was remarkable that no museums 
had hitherto contained specimens of the wasted, porous, and 
worn-down bones which were so characteristic and were now 
being everywhere collected. He had hitherto believed in the 
special features of this disease, and accepted M. Charcot's 
teaching as to its neurotrophic origin. We were now bidden 
to regard all these joint affections as dependent on one common 



60 Discussion on Joint Disease in 

or general cause. If such should be the opinion ultimately 
arrived at^ he^ for one^ should feel gratified^ since he had come 
to believe that not only the disorder under consideration^ but 
also rheumatic and gouty arthritis^ were largely the result of 
neurosis. Let it be remembered^ however^ that M. Charcot 
had distinctly declared that in cases of locomotor ataxia^ 
chronic rheumatic arthritis may supervene and present none 
but its ordinary characters. 

Dr. Hale White said he thought the hypothesis that 
Charcot^s disease was an arthropathy peculiar to locomotor 
ataxy was hardly tenable, for many English observers of large 
experience had no knowledge of the train of symptoms described 
by Charcot j thus whilst he (Charcot) found them in five out of 
fifty patients examined. Dr. Moxon had never seen them in 
thirty cases he observed. It was pointed out that there was 
not a single symptom in Charcot^s description of his arthro- 
pathy that was not also a symptom of ordinary arthritis. Dr. 
Hale White had seen six cases of joint lesion in locomotor 
ataxy, all of which were considered to be examples of Charcot^s 
disease by some one or another who had seen them, but not 
one of them was universally allowed to be an example of the 
disease : on the other hand, he had never seen a case which was 
universally allowed to be rheumatoid arthritis in an ataxic 
patient. He also believed that an examination of the speci- 
mens after death would show that there were no real points of 
distinction between Charcot^s disease and other forms of 
arthritis ; certainly this seemed true of the specimens existing 
in England. Thus there is one in the College of Surgeons^ 
Museum which is said in the catalogue to present just the fea- 
tures of Charcot^s joint disease, but still to remain oneof general 
rheumatism. There was the possibility that some of the cases 
of Charcot^s disease might be due to nervous lesion, but then 
they would belong to the same class as those diseases of joints 
sometimes produced after lesions of nerves, diseases of the cord 
and hemiplegia, and would not be peculiar to locomotor ataxy ; 
probably, however, the majority of cases of Charcot^s disease 
were examples of rheumatoid arthritis occurring in patients 
with locomotor ataxy; or in those patients in whom the 
arthritis came on late in the course of the ataxy it might be 
due to injury from flinging the legs about or due to the pro- 
longed inactivity of the Umbs in bed. Putting these two causes 
aside, however, the connecting links, both clinically and patho- 
logically, between rheumatoid arthritis and Charcot^s disease 



cormection with Locomotor Ataayy. 61 

are so numerous that in the present state of our knowledge it 
seems rash to think that the latter disease is a distinct one 
peculiar to locomotor ataxy. Even if there be found cases 
which cannot be included either in rheumatoid arthritis^ the 
traumatic^ or the prolonged rest group, it is probable that they 
belong to the same group as other nervous arthropathies. 

Dr. BuzzABD concurred in the remarks made by Dr. Duck- 
worth, and was strongly of opinion, with the latter, that Char- 
cot's joint disease was noj} a new disease, but that our recog- 
nition of it was new, and arose out of the refinements intro- 
duced into methods of examination during the last few years. 
No absolute proof of this could be adduced, but at least there 
was evidence that tabes itself was not a new disease. He had 
found in Dr. Graves's classical work on clinical medicine an 
account of a patient afPected with typical gastric crises dating 
from the year 1823. The case was evidently one of tabes. It 
ought to be remembered also that, as compared with the state 
of things existing at the time named, the profession of to-day 
enjoyed multifold opportunities of observation. Not only had 
an enormous increase of population occurred, but until within 
the past fifty years or less there was no system of seeing out- 
patients at our hospitals, so that it was not strange that we 
should come across many more cases in proportion than would 
have been met with many years ago. It should be remembered 
that the disease under ^cussion is a disease of bone. The 
question of the connection of joint disease with tabes was 
introduced by Charcot in 1868, and five years later he brought 
forward the case of a woman with several joints typically 
affected and some of her long bones spontaneously fractured. 
Charcot deduced from that and similar examples that the 
osseous tissue was primordially involved in these cases, the 
joint disease being a secondary affection. Lionville investi- 
gated the subject by comparing a case of arthropathy, asso- 
ciated with tabes dorsalis, with a case of spontaneous fracture 
of the bones occurring in another patient in the same disease. 
He found that the same changes obtained in each instance. 
There was enormous dilatation of the Haversian canals, the 
osseous substance being thinned and eroded, a condition of 
what was called rarefying osteitis. Blancard found that the 
lesion started by a disappearance of calcareous salts, the erosion 
of the Haversian system being a secondary feature. Chemical 
analysis, according to Begnard, shows that in the osseous 
affection of tabes we have to do with a true trophic lesion of 



62 Discussion on Joint Disease i/n 

bone, a fatty degeneration with disappearance of the mineral 
substance. The phosphates he found, in a certain case, reduced 
from 48 parts to 11 in the 100, and the proportion of fat had 
risen from 5 to 37 parts in 100. In these circumstances Dr. 
Buzzard suggested that surgeons, when the opportunity 
occurred, should measure the specific gravity of the bones 
entering into the composition of the joints affected both in 
tabes and in rheumatoid arthritis, when probably a consider- 
able contrast would be observed.* In Dr. Adamses classical 
work on rheumatoid arthritis he found no mention made of 
such a chemical alteration of bone fts that described, nor did 
he find any record of spontaneous fracture of a long bone in 
any of the cases detailed in that work. It was to the surgeons 
that cases of joint disease naturally went, and that was the 
reason why although he (Dr. Buzzard) had probably seen two 
or three hundred cases of tabes yet he could count upon 
the fingers of his two hands the number of patients with joint 
disease who had consulted him amongst the sufferers from 
tabes. Referring to Dr. Hale Whitens diflSlculty as regards 
the contrasted experience of Dr. Moxon and Dr. Charcot, he 
reminded that gentleman that Dr. Charcot^s opportunities at 
the Salp6tri&re were very different from those of a physician 
to a London hospital. His field was a vast one, and included 
patients such as are found in our workhouse infirmaries, and 
who remained for years under observation. On the other hand, 
in our hospitals a process of sifting took place ere admission 
to the wards, and patients presenting such visible lesions as 
would be suggested by enlargement of a joint would be natu- 
rally referred to a surgical member of the staff. A large 
number of persons — all sensible people, in fact — would be 
anxious to consult his friend. Dr. Moxon, on account of almost 
any departure from health, but probably the last thing about 
which they would think of seeking his opinion would be the 
sudden occurrence of an enormous and painless swelling of a 
joint ! Having had to do for many years with numerous cases 
of nervous disease in the out-patients as well as in the in- 
patients of a hospital devoted to diseases of the nervous system, 
it was not surprising that he (Dr. Buzzard) should have met 
with several examples of associated joint disease, yet in every 
instance in which the joint affection presented the peculiar 
characters of that which was under discussion, the disease was 
invariably tabes dorsalis. He had never seen it in association 
with cases of hemiplegia, paraplegia, epilepsy, lateral or dissemi- 

* It will be necesBary to compare fresh wet preparations. 



connection with Locomotor Atcmj. 63 

nated sclerosis, or other of the numerous forms presented by dis- 
ease of the nervous system. This was surely a sufficient answer 
to those who thought that there was but a fortuitous connection 
between tabes and the joint affection, and who looked upon it 
as the accidental occurrence of rheumatoid arthritis in a patient 
affected with tabes. On the other hand, cases of typical 
rheumatoid arthritis might be watched for years and no deve- 
lopment of symptoms of tabes would be seen to occur. At 
least, he had never seen or heard of such a case, although 
this subject had engaged his attention for the last eleven 
years. Now, if we had to do here with a simple alliance of 
rheumatoid arthritis with tabes this particular chronological 
sequence would surely not always obtain. We should at least 
sometimes find the symptoms of rheumatoid arthritis occurring 
antecedently to those of tabes. He had investigated a large 
number of typical cases of rheumatoid arthritis in our work- 
house infirmaries, and except where the mechanical conditions 
interfered with the test he had found the knee phenomenon 
always present, the pupillary condition normal, and an utter 
absence of other symptoms pointing to tabes. Charcot^s joint 
disease contrasted strongly in its clinical aspects with rheu- 
matoid arthritis. Without going further into detail he believed 
the disease to be due to a trophic change in the osseous tissues 
incident upon a lesion in the medulla oblongata. Further 
observation had tended to confirm this view, which he had 
submitted to the Pathological Society in February, 1880. He 
thought that in the bulb there was something in the nature of 
a centre concerned in the nutrition of the osseous skeleton. 

Mr. Baewbll felt himself unable to follow Mr. Baker in his 
excellent paper concerning the neuropathy, the neural origin, 
of joint disease. It was a question of which but little was 
known, and, as all the members were well aware, many of the 
multiarticular forms of joint disease had been ascribed to 
neuropathy, such as acute rheumatism, and many forms of 
chronic rheumatism, some even of gonorrhoeal rheumatism, 
&c. Mr. Barwell felt that he could not agree with Mr. Baker 
in this further than to say that there was great evidence to 
show that arthritis deformans originated in some nervous 
pathological injury or lesion. But was it, therefore, neces- 
sary to suppose that this nervous injury should be the same as 
the nervous injury in locomotor ataxy ? He ventured to think 
that, though these two joint diseases, which he believed to be 
separate, might both be due to neuropathy, they nevertheless 



64 Discussion on Joint Disease in 

were not tlie same^ and were not due to tlie same nenropathic 
affection. The subject might well be diyided into two, 
namely^ the anatomical appearances and the clinical pheno- 
mena. The anatomical appearances were really more different 
than appeared at first sight. Taking an elbow-joint (ataxic), 
in which the form of the elbow was pretty well lost, it was 
seen that one bone, the radius, had its head and its neck 
almost entirely worn away. Very much the same thing was 
seen with regard to the ulna, and to the internal condyle of 
the humerus. The repair which had taken place was merely 
by a very slight ossification of one of the ligaments, and was 
not the same sort of thing as was found constantly in such 
specimens of chronic rheumatic arthritis as the speaker had 
brought for exhibition. If, again, this same joint were 
examined, it looked very unlike a joint affected with chronic 
rheumatic arthritis. The bone was affected almost half way 
down its length, and large pieces thrown out; it reminded Mr. 
Barwell very much of a case which Dr. Buzzard described 
some time ago, but occurring in the hip. On close inspection 
there would be seen none of the porcellanous deposit charac- 
teristic of arthritis deformans, as described some years ago by 
Mr. Quekett, an absolute deposit into the material of the 
bone, like the wax with which a French polisher filled up 
porous wood before giving it the final polish. On yet closer 
inspection, a great many of these tabetic bones were found to 
be filled up by an almost tufa-like growth, which was not such 
as in rheumatic arthritis. Mr. Barwell showed that in 
typical arthritis deformans, hyperplasia, especially marginal 
hyperplasia, very much exceeded any wearing away. The 
bone was evidently much more solid and much denser than in 
any such specimens of tabetic disease as were exhibited that 
evening. In arthritis, there were polished surfaces of a very 
considerable extent raised above the level of the other parts of 
the joint, while the marginal hyperplasia had gone on to such 
an extent as to embed and almost involve the whole of the 
neck j the wearing away being, on the contrary, very slightly 
marked indeed, such as had never been found in ^he same 
condition in the tabetic joint disease. Mr. Barwell showed a 
cast which was another example of marginal hyperplasia, 
nearly always so strongly marked in chronic rheumatic 
arthritis. The enlargement of the head of that radius was 
unlike what was seen in locomotor ataxy. Enlargements of 
bone were almost constant in that disease, but such conditions 
of hyperplasia were never seen as in this cast. Then, in these 



connection with Locomotor Ataxy. 65 

specimens (rheumatic arthritis), the bone was perforated^ like 
a wormeaten piece of mahogany^ by large holes, evidently the 
wearing away of the Haversian systems ; what he ventured to 
call interstitial atrophy, in contradistinction to the marginal 
hyperplasia which was also found in the arthritic specimens 
which he exhibited. Mr. Barwell was not aware that porcel- 
lanous deposits and very highly poHshed surfaces ever occurred 
in locomotor ataxy; but rough surfaces were of common 
occurrence. Then, again, in locomotor ataxy, false bodies 
were not common. In arthritis deformans, false bodies were 
not only common but the rule, and they occurred in very large 
numbers. Mr. Barwell did not think that the filling of a joint 
with dendritic synovial outgrowths ever took place in loco- 
motor ataxy. He was rather surprised to hear Mr. Baker 
speak of fibrous degeneration of cartilages occurring in loco- 
motor ataxy. The fibrous change of cartilage in rheumatic 
arthritis was very peculiar; and Mr. Barwell had never seen 
it in any other disease. It might possibly occur in locomotor 
ataxy, but must be proved to do so by a careful microscopic 
examination. Mr. Barwell thought that the clinical differ- 
ences were very great indeed. As a role, the arthritic 
troubles of ataxy commenced in a perfectly painless manner. 
The whole limb one morning was found swollen ; and after a 
little time, a day or two, this swelling subsided, leaving only 
a loosened joint. Arthritis deformans never commenced thus, 
but by pain, followed by gradual hydrarthrotic swelling of the 

{'oint, not of the whole limb. In locomotor ataxy, this 
lydrarthrosis frequently returned and remained very long. 
In a number of the patients then present, the joints were full 
of fluid, and there were various forms of displacement of bone ; 
but in arthritis deformans the hydrarthrosis was a compara- 
tively short and painful stage; then, when the fluid was 
absorbed, the grating and the immobility appeared again. In 
all the cases of ataxy which Mr. Barwell had seen, excessive 
normal and false movement in the joint predominated greatly 
over the limitation of movement. It was precisely the con- 
trary in arthritis deformans ; there might be some false move- 
ment, but that was generally pretty limited, and the natural 
movement was very limited. Then, in ataxy, as he had said, 
the first attack, as well as the rest of the malady, was usually 
painless, even when deformity was extreme. In arthritis 
deformans, pain was usually the commencement, and was con- 
tinuous. After the patient had taken exercise, on getting up 
in the morning, the pain might diminish, or perhaps dis- 

VOL. XTXU. 5 



66 DisciASsion on Joint Disease in 

appear; bnt^ tliroughont the disease^ tlie first movements of 
the joints, after rest, were always painful, especially certain 
movements, as of rotation of the thigh outwards, or abduction. 
That appeared never to be the case in the ataxic disease. 
Tabetic conditions never appeared to afFect small joints, 
but always large ones, like the knee. Mr. Barwell hardly 
thought he could find it in a smaller joint than the elbow ; but 
arthritis deformans was especially liable to affect small joints, 
such as the fingers, as well as large ones. Whenever several 
large joints are affected by arthritis, the small ones never 
remain unaffected. Even though not nodose, the fingers are 
peculiarly adducted in a manner never seen in ataxy ; they 
exhibit that peculiar slope towards the ulnar side which was 
always found in multiarticular arthritis deformans. Even 
though the patient himself might be unconscious of any 
trouble about the hands, the phalanges would be seen to slope 
away towards the ulnar side, and the toes towards the fibular 
side; they sloped considerably at the metacarpo-phalangeal 
joints. 

. Sir James Paget was disposed to say that he agreed with 
Mr, Baker very nearly, though not perfectly, on almost all the 
points upon which he had spoken. He would avail himself of 
Mr. Baker^s suggestions of points for discussion. The first 
was, whether Charcot's disease might be regarded as a new 
malady. In speaking of a new disease the great difficulty lay 
in the fact that one had to establish, not a positive conclusion, 
but a negative one ; for, when proving that a thing was new, 
the real thing to prove was that it was not old, and to do that 
was a much greater difficulty in regard to most diseases than 
at first sight appeared. Sir James Paget knew that enormous 
tracts of knowledge had, in past times, been overlooked. 
A man could not study his own career, or observe, as science 
made progress, the number of things that had been constantly 
within his sight, of which he remained totally unconscious, 
without feeling sure that many minds must have been in some- 
what the same condition, and that it was hardly possible to 
reckon the full extent of the facts which were overlooked. 
Yet it seemed nearly sure that the older observers of cases, of 
diseases of bones and joints had really not seen such conditions 
as had now become &miliar in the changes of joints in loco- 
motor ataxy. It had been said that these were cases that 
presented themselves chiefly in the out-patient room and to 
surgeons at workhouses. But John Hunter collected specimens 



connection with Locomotor Ataasy. 6? 

by the limidred in workhouses. That great collector of speci- 
mens, George Langstaff, was a Poor-Law medical officer, and 
the greater part of his practice was in workhouses. Cruveil- 
hier^s great pathological work was in the Salp^triSre, and 
among exactly the same class of patients; and, to speak of but 
one more, closely within Sir James Paget^s own knowledge, there 
was scarcely a workhouse in London which did not once supply 
Mr. Stanley with every specimen of diseased bone of any 
apparent value that could be found in them. Now, this extent 
of work began more than a century ago, and ended about 
forty years ago. But these sixty or eighty years of work in 
coUecting diseased bones had, he beUeved; left nothing in any 
book or museum to show that any of these watchers ever 
found such a specimen as was now a well-known thing in all 
museums. If any one of the poorhouse patients, who were 
now in the next room, had existed in a workhouse in London 
during any part of the thirty or forty years in question, they 
would certainly have been dissected, and their bones preserved. 
Thus, considering the fact that, in the collections of those 
great collectors, there did not now remain a single specimen 
characteristic of Charcot's disease, there was as nearly as 
possible sufficient evidence of the negative that the disease 
did not exist, at least in anything approaching its present 
frequency. Sir James Pa&fet had not only had much experience 
hii^elf in museums, but lad sought information from others; 
yet he could not find a specimen of old date in London. So, 
then, Mr. Baker's first question might be answered : Yes. In 
general terms this was a new disease ; in more especial terms 
it was a new compound of diseases. In this belief the chief 
direction of inquiry must be followed. In all the discussions 
that Sir James Paget had heard the question had been asked : 
'' Is this a neurosis ? Is it rheumatic arthritis ? Is it this or 
that?'' He thought that it was neither this nor that, but 
rather some of these or some of those — a disease made up of 
several different constituents, and appearing, therefore, only 
at a time when, we knew not by what external conditions, all 
these constituents of disease met in the same person. Sir James 
Paget was conscious that in speaking of this he was referring 
to subjects which were altogether obscure, and very uncertain ; 
but if an apology were needed, he would say that we were 
talking of " Charcot's " disease, and he thought it would be'in 
the observation of all that, so long as a disease was called by 
the name of any person, or any nation, it might be concluded 
that its pathology was very imperfectly ascertained. The old 



68 Disdbssion on Joint Disease in 

terms morbus Anglicus and morbus Grallicus had been left off^ 
now that somethmg was known about rickets and syphilis. 
The term Bright's disease was fast vanishing as the pathology 
of the disease was better known. Thus, the very name of the 
disease under consideration implied that its pathology was 
altogether obscure, and he held that it was really to be studied 
not by endeavouring exactly to define what was its type, or 
whether it was to be called by this name or by that, but by 
trying to ascertain of what diseases, and in what proportion of 
each, it was compounded. And there was a fair illustration 
of such compound diseases in what surgeons had consented, 
apparently, to call chronic rheumatic arthritis. There was no 
much better practical name for it than rheumatic gout, and, 
speaking generaUy, there might feirly be an impression that 
there was in one person more or less of gout, and in another 
more or less of rheumatism, and that in some way or other 
there came to be a compound of these two things. Thus 
whether ''Charcot^s " disease should be called rheumatic gout, 
or be regarded as an example of rheumatic arthritis, might 
be answered by holding that it was a method of rheumatic 
arthritis, altered from its ordinary fashion by the intervention 
of the locomotor ataxy. What Mr. Baker had said of the 
general characteristics of locomotor ataxy was quite enough to 
explain the contrasts between the ordinary typical cases of 
rheumatic arthritis, such as Mr. Barwell introduced, and the 
mere wasting of a part, such as would follow deficient nervous 
nutrition. Mr. Baker was doubtless right in saying that the 
character of the disease, as distinguished from rheumatic 
arthritis, was, that it was wasting without repair. The 
characteristic of those specimens which Mr. Barwell had pro- 
duced was, that they showed disease with wasting, but with 
coincident attempts at the reparative process. But though 
rheumatic arthritis and the joint-disease of locomotor ataxy 
could be broadly distinguished from one another, it was not 
fair to assume that there was in locomotor ataxy no measure 
whatever of rheumatic arthritis. It might well be a rheumatic 
arthritis modified by its coincidence with a disease of the spinal 
marrow, which hindered the ordinary, however ill directed, 
processes of repair found in the ordinary rheumatic arthritis. 
The general feature of the most marked cases of locomotor 
ataxy was wasting ; but all the cases of partial wasting, with 
some new production of bone about the articular borders, 
brought it so near to the characteristics of some of the cases of 
rheumatic arthritis, that one could not doubt that there was a 



connection with Locomotor Ataxy. 69 

certam relation between the two. And when it was said that 
the ordinary course of the diseases was very different^ it coold 
be answered that this belief was founded only on having 
observed the characters of each in typical examples. Sir 
James Paget would agree with what Mr. Barwell had said^ as 
to the general progress of an ordinary case of rheumatic 
arthritis ; but it was no very rare thing to see a person with 
his knee-joint distended^ and the tibia displaced and worn away 
and gone altogether from its natural holdings in that which 
might be fairly called rheumatic arthritis^ although there were 
no locomotor ataxy connected with it. If one took^ on the one 
side, the whole range of joint-affections in locomotor ataxy^ 
and^ on the other^ the whole range of joint-affections in rheu- 
matic arthritis^ it was impossible not to see that cases could 
be found in which it would be hard to say^ when one looked at 
the pathological specimens^ to which class of cases each 
belonged. And^ as they thus ran into the border, and became 
confused by the extreme cases on each side, it might justly be 
suspected that the diseased joints in locomotor ati^ were 
really examples of chronic rheumatic arthritis so-caUed, occur- 
ring in persons with a special tendency to disease of the spinal 
marrow. Another element, syphilis, might be suspected in 
many cases ; but Sir James Paget had not found a distinct 
reference to an examination on this point in many of the cases 
which had been published. If the existence of three such 
diseases together could be assumed, a very wide range of 
characteristics might no doubt be explained. Syphilis was just 
one of those diseases in which one could most distinctly discern 
the various complications into which it might enter. In 
ordinary practice, at least, it could be clearly seen that syphilis 
implanted in a person with distinctly gouty inheritance was, 
to all external appearance in its tertiary state, a very different 
thing from syphuis implanted in a person of tubercular or 
scrofulous tendency. It pursued two courses, which were as 
unlike as almost any two so-called typical diseases could pro- 
duce. There was here no difficulty in studying the combination 
of diseases j it was only by a fair extension of the same method 
of inquiry that it might justly be believed that three or four 
or more things might enter together into the composition of 
such a disease as was in locomotor ataxy. It seemed vain to 
hope that any of these diseases should ever be reduced to one 
typical form, so that one should be able to say it was this or 
tt^t. The younger men whom Sir James Paget saw round 
him had rather to study their pathology after the manner, if 



70 Discussion on Joint Disease in 

possible^ of minute analysis^ to determine the several con- 
stitaents of eacli case and tlie proportion of eacli constituent 
in the general composition of each. Instead of trying to reduce 
pathology into a system similar to that of natural history^ in 
which one could use Latin and Greek words to express exactly 
what one meant, one should rather study it after the fashion 
of organic chemistry, and find, if possible, what were the 
constituents of which each disease was composed, and even 
in what proportion each disease, or each morbid condition, 
entered into the composition of that of which the whole was 
seen. 

Dr. OsD had seen cases of the disease under the care of 
other physicians ; he had never had a case of his own under 
constant observation, and so, with regard to the relation of the 
joint afEection now being dealt with to tabes dorsalis, or loco- 
motor ataxy, he would say very Kttle. Of course, he had had 
many opportunities of seeing the preparations of the bones 
and joints ; and when he considered Mr. Baker^s statement 
that there was a general agreement between the morbid 
anatomy of Charcot^s disease of joints and chronic rheumatoid 
arthritis, although he agreed with him in his general conclu- 
sions very thoroughly, he was compelled to recognise more 
than Mr. Baker had recognised in the matter of waste. 
Looking at the various specimens exhibited that night, and 
looking, before this, with greater leisure at others, in some of 
the specimens exhibited. Dr. Ord recognised what Dr. Buzzard 
had pointed out, the actual wasting of the bone substance, 
generally quite independently of its wearing down at the points 
of weakness. And, on the other hand, it did not seem accurate 
to state that there was no attempt at repair. In very few, if 
any, cases were the outgrowths that Mr. Barwell had very 
eloquently described totally absent j and, in some cases, cer- 
tainly, he had seen something like eburnation ; in many cases, 
he had found an excessive development of osteophytes. There 
was a specimen in the other room, exhibited by Professor 
Humphry, which presented these in an excessive degree. Dr. 
Ord, after many years^ deliberation, was inclined to pkice this 
among the conditions which were included under the head of 
what Sir James Paget had been speaking of, chronic rheumatic 
arthritis. Sir James Paget's first remarks on this subject im- 
plied that this disease, as being called rheumatic gout, included 
both rheumatism and gout ; and this was, to a certain extent, 
true. His later remarks brought out what was the real 



eomieetion with Locomotor Ataay, 71 

oatcome of such a consideration as engaged the Society to- 
night ; that was^ the absolute necessity of analysing fully and 
completely all the individual cases that might be included 
under presumably common heads ; not to deal here^ as in com- 
parative anatomy^ with typical cases^ but to qualify^ as one 
had to deal with individual men^ the idea of the typical case 
by its application to the particular person^ to the particular 
exponent with whom one was dealing. In the case of rheumatic 
arthritis — ^a term which Dr. Ord did not think a very good 
one^ the more neutral term^ osteo-arthritis^ appearing prefer- 
able^ as it fettered the mind less if one considered the whole 
question of osteo-arthritis — one could recognise lesions having 
the same essential details^ or at all events what appeared to 
be the same essential details, as those which were being dis- 
cussed. Lesions consisting in waste of cartilage, waste of 
bone, and, at the same time, in outgrowth around the articula- 
tion, were to be seen in relation to gout, were to be seen in 
relation to chronic rheumatism, and, again^ were to be seen in 
a number of cases in which the presence neither of gout nor 
of rheumatism^ as it was at present understood, could be 
recognised. In those cases one sometimes called in the ex- 
planation of blood-poisoning, and in others a neurotic explana- 
tion. Dr. Ord then described three cases (women) under his 
care, at St. Thomases Hospital, the general lesions of which 
were, to all appearances, those of chronic osteo-arthritis. In 
the first, a young married woman, of 34, there were irregular 
lesions of the joints of the fingers, with well-marked wasting, 
and outgrowths of many joints, but complete ankylosis of both 
wrists, and of one elbow, and partial ankylosis of one hip. 
There was no trace of gout that one could make out. In 
another case, with much less marked joint lesions, and with no 
trace of nervous disorder at all, the woman had a very well- 
marked nodosity of the joints, an afFection chiefly of the wrists 
and hands, without any ankylosis, some looseness of the joints 
and that well-marked deviation of the digits to the ulnar side 
to which Mr. Barwell had very properly directed attention. 
In this case the woman, having no nervous affection, gave a 
history of nine attacks of acute rheumatism, in each of which 
the joints were affected. That the disease had been probably 
acute rheumatism was evident, from her having had a slight 
attack since she had been under Dr. Ord's observation, and 
from her having extensive affection of the valves of the heart. 
In the third case the woman had, in its typical form, such a 
lesion as Mr. Barwell had described, enormous thickening of 



72 Discussion on Joint Disease in 

the joints^ looseness of the joints, deviation to the nhiar side 
of the fingers, in fact, all- that belonged to a subluxation. 
With this, although the woman was generally in her whole 
body well nourished, there were great wasting of the skin of 
the fingers, a glossy or satiny condition of the skin, particu- 
larly towards the ends of the digits, wasting of the nails, 
wasting of the muscles, quite in excess, as far as one could see, 
of the disease; and with this the presence of those interesting 
phenomena, subcutaneous nodules. These were three very 
different cases, and yet they were all such as would be included 
roughly under the head of osteo-arthritis, or rheumatic arthritis. 
For some years Dr. Ord had urged the necessity of analysing 
this very difficult and obscure change in joints ; he was very 
grateful to Mr. Baker that he should have brought the question 
forward in a way which enabled him once more to emphasise 
these observations. He did not wish to push forward the idea 
of a neurotic process as being necessarily present in all cases 
of rheumatoid arthritis ; but he did recognise that, in the cases 
before the meeting, and in many others, there was strong evi- 
dence of a neurotic influence, direct or reflex, being the main, 
if not the actual, agent. At the same time Dr. Ord did not 
forget the many other causes that might give rise to chronic 
osteo-arthritis more or less related to that which was under 
discussion. 

Professor Humphry agreed with the remarks which fell 
from Sir James Paget, that this was a disease with which sur- 
geons were not familiar in olden time. Till lately he had 
never seen such rockings of joints and such deformities of arti- 
cular surfaces taking place with the rapidity now observed, 
and we did not formerly find these specimens so marked in 
museums as we now do. He also quite agreed with Sir James 
Paget in the view of its being a compound affection between 
the disease called rheumatic arthritis and tabes dorsalis; 
that it was a combination of the wearing away with the ner- 
vous affection. In the old affections, however, it was rather 
a wearing away, a rubbing and wearing away, proceeding 
altogether from the articular sur&ces, and a resultant, as it 
always appeared to him, of a low inflammatory affection occur- 
ring in the synovial membrane, altering the synovial fluid and 
causing a slow change in the articular cartilages, and a subse- 
quent slow change in the osseous surfaces, associated with a 
certain amount of osteophytic growth from the marginal parts, 
as described by Mr. Barwell. In this present affection there 



connection with Locomotor Ataxy. 73 

was a rapid decay^ as it were^ a rapid wasting^ a rapid 
removal of the bone ; and in the specimen which had been 
alluded to by Dr. Ord, which Professor Humphry had brought 
from Cambridge^ this was most marked. In this specimen^ in 
which tabes dorsalis in a woman had been going on only 
about three months^ the whole of the head of the tibia was abso- 
lutely gone^ and the rough upper end of the shaft was exposed 
and lying in contact with the articular surface of the femur. 
And not only so^ but the cartilaginous surfaces of the tibia 
were in part preserved, and had been broken away from their 
sarroan^ngsf and one of them was applied quite against the 
outer surface of the femur ; so that there had not here been 
that usual wearing away commencing with the articular sur- 
face, but a decaying of the bone beneath the articular surfaces, 
the bone giving way and allowing the articular surfaces to be 
applied against the side of the femur, in this respect differing 
considerably from the familiar disease called rheumatic 
arthritis. Professor Humphry did not quite agree with Sir 
James Paget and Mr. Baker in the view that there was an 
entire absence of reparative process. In some instances, as in 
the specimen he produced, there was a very marked and large 
amount of what was called reparative process, that is to say, a 
very large amount of osteophytic growth — ^a very large amount 
of new bone-formation taking place in the immediate neigh- 
bourhood of very large bone-destruction. This was very 
curious, and very remarkable. The only thing which he could 
at all compare with it in that respect was the intracapsular 
fracture of the neck of the thigh-bone, where there was, in 
many instances, rapid removal of the neck of the femur 
between the fracture and the trochanters, associated with very 
considerable outgrowth at the base of the trochanters. In 
that instance, too, rapid bone-absorption was associated with 
rapid bone-formation. The speaker had recently made a 
good many observations about old people, and had published, 
not long ago, a short paper on the quick repair of bones in old 
persons ; and he remarked here that although bone-absorption 
from atrophic condition was taking place throughout the 
skeleton, yet the work of bone-repair was capable of being 
rapidly called into existence. These examples of the associsb- 
tion of atrophic bone-absorption with abundant new bone- 
formation, and others of a like kind might be adduced, were 
of interest in connection with the specimen he showed, in 
which the effects of the two processes were so marked. 



74 Discussion on Joint Disease in 

Mr. Hutchinson said that he had taken much interest in 
this subject from the time that Professor Charcot first published 
his yiews^ and had made several visits to Paris to see his cases. 
In a course of lectures on the connection between the nervous 
system and lesions of nutrition delivered at the College of 
Surgeons about seven years ago, although we were indebted to 
Dr. Buzzard for the first cases observed in England^ he had^ he 
believed, been himself the first to discuss the subject in detail 
and to illustrate it by producing a collection of specimens. 
The views which he should express to-night were much the 
same as those which he brought forward in the lectures referred 
to. In the first instance he had been so struck with the pecu- 
liarities of some well-marked cases that he had been inclined 
to accept Charcot's view that the conditions were almost sui 
generis and were in essential connection with ataxy. He had 
at the same time been inclined to admit that their occurrence 
did illustrate and prove the direct trophic influence of the 
nervous system. The more, however, he worked at the subject 
the further he had got from this opinion, and the conclusions 
which he finally expressed in his lectures were by no means 
exactly those with which he had commenced their preparation. 
He had come to believe that many causes might contribute 
to the production of the peculiar condition in question, such, for 
instance, as injuries, rheumatism, and gout, but above all the 
senile state, whether general or local. The changes of ataxy 
might in some sense be said to produce a sort of tumultuous 
and irregular senility in which some parts of the body got old 
before the others. The loss of normal reflexes was a condition 
common both to old age and the ataxic state, and on this dis- 
turbance of reflex sensibility and partial abolition of the sense 
of pain, many peculiarities in modes of nutrition and disease 
might be held indirectly to depend. It was a noteworthy fact 
that if ever we found the conditions of the ataxic joint simu- 
lated in a patient not the subject of ataxia it was almost always 
in association with senile rheumatism. In this relation he had 
been much interested in the observations just made by Prof. 
Humphry. The contracted pupils, the weak bladder, the 
sluggish bowels and dulness of general sensation, but especially 
of pain, were all features in which the ataxic and the senile 
state approach each other. In both there was the liability at 
once to almost painless inflammatory changes, resulting in 
atrophy and outgrowth at the same time. It would not be 
asserted that senile rheumatism, as seen in the morbus coxsd 
senilis, was always painless, but all must have been struck by 



catmeddon with Locomotor Ataxy. 75 

the observation with what extensive local changes, such as 
absorption of the head of the bone, and g^wth of osteophytes, 
tolerably free nse of the limb was stiU compatible. In no 
other diseased states did persons continue to nse their joints 
freely after the cartilages had been removed than in senile 
rheumatism or locomotor ataxy. His impression was that the 
question might be much simplified by bearing rather strongly 
upon the line of argument which he had just suggested. In 
the ataxic patient many of the special sensations were dull, 
extremely dull, and hence the attacks of painless retention of 
urine wluch were so characteristic of the disease. The bladder 
might be distended until it reached the umbilicus, and the 
patient yet avow that, excepting a little feeling of fulness, he 
had no discomfort. The distress which attends retention of 
urine in the healthy is wholly absent in the ataxic. Then 
again we have the perforating ulcer of the foot with its very 
remarkable features, all of them, he believed, due to the 
obtunded sensation in the sole of the foot. This ulcer, 
common to ataxy and to leprosy, is in both diseases a 
'' pressure sore.^^ The patient, unable to feel well in the skin 
of his sole, is apt to stand too long, and to make injurious 
pressure on one particular part. The success which attends 
treatment by appliances which exempt the sole from pressure 
fully prove this assertion. There is no need whatever for 
assuming any trophic influence of the nervous system in this 
instance, although very probably the loss of perfect reflex 
functions may by its influence on dilatation and contraction of 
blood-vessels much modify the process of inflammation set 
going by undue pressure. In applying this suggestion to the 
explanation of the phenomena of the joint changes in ataxia, 
he would fully admit that no abrupt line of demarcation could 
be drawn between them and those met with in some cases of 
rheumatic arthritis ; especially in the early stages of the two 
diseases it was impossible to say whether the changes were 
likely to advance in the special directions of the ataxic joint 
or not. Admitting, however, that there were many cases which 
it was impossible definitely to diagnose, he still joined with 
what Mr. Barwell had just asserted, and with the original 
proposition of Charcot, that there were many cases in which 
the final results were characteristic. Certainly he had never 
witnessed in connection with rheumatic arthritis any approach 
to the extreme cases which he had now seen in ataxy, — cases 
in which a patient might have one, two, or more joints so 
much disorganised that their bones might be pushed out of place 



76 Distyussion on Joint Disease in 

and pulled back again almost at will^ and without giving the 
patient much pain or inconvenience. The changes in rheumatic 
arthritis^ however greats were usually of a nature to prevent 
dislocation^ whilst in ataxy they often favoured it. In no 
other disease than in ataxy had he ever seen any approach to 
what is witnessed in the typical examples of joint disorganiza- 
tion in that malady. Mr. Baker had suggested^ and Sir 
James Paget had seemed to support the suggestion, that the 
ataxic joint was an example of rheumatoid, arthritis assuming 
peculiarities from the fact that it occurred in an ataxic patient. 
To some extent, and in some cases, he (Mr. Hutchinson) was 
quite inclined to agree with them, but if the proposition were 
made universal then he must with diffidence say that he could 
not accept it. He was not at all prepared to admit that all 
those that became the subjects of ataxic arthropathy were also 
the subjects of the rheumatic-gout diathesis, whether from 
inheritsmce or otherwise. The cUnical evidence on this point 
would, he felt sure, fail in a certain proportion of cases. So 
deficient, indeed, would it appear to have been found by some 
observers that the assertion has gained credence that the 
subjects of ataxic changes are never the subjects of rheumatism. 
Charcot himself, and other observers, have described rheuma- 
toid arthritis occurring in ataxic subjects and still keeping its 
own features. He (Mr. Hutchinson) well rememberea a case 
in which a patient who had for some time been known to be 
the subject of ataxy, came under his care with effusion into 
one knee-joint. He was put to bed in the hospital and 
treated as if for rheumatism, and his joint got perfectly well 
in a comparatively short time. Such a fact did not, to his 
mind, prove that ataxic arthritis and rheumatoid arthritis were 
wholly different, but that ai*thritis in an ataxic subject, if 
treated by rest, might pass away. It affirmed the proposition 
for which he had been contending, that the peculiarities of the 
affection in advanced cases were due to the fact that the 
patient did not experience pain from motion, and consequently 
did not rest. In some cases of ataxia it was quite true that 
the joint disorganization advanced even after the patient had 
been confined to bed ; these were, however, exceptions, and they 
were so rare that he had himseK no personal experience of 
them. As a rule it appeared certainly to be the fact that, in 
both rheumatoid and ataxic arthritis, it was the patients who 
used their joints most who got the most peculiar changes. 
The less the pain, the more the use, and tiie more the dis- 
organization. Such, he said, was the general statement of his 



connection with Locomotor Ataxy. 77 

creed. In rheumatic arthritis if a patient took to his bed 
joint changes of a certain kind woold^ it was quite true^ occur. 
Ankylosis might happen^ extensive erosion of cartilage might 
occur^ but the tendency to osteophytes^ loose bodies^ alterations 
in the shape of the bone^ and ebumation of the articular sur- 
faces were very rarely seen except in those who continued to 
walk about. Thus then he would submit that after all^ neither 
in rheumatism nor in ataxy did the state of the nervous system 
take a direct share in the production of the arthritis. In each 
it was probably true that the peculiarities assumed were due 
to nerve changes; that the share taken was passive or 
permissive rather than active or initiative. He found more 
difficulty, he must admits in explaining brittle bones and 
spontaneous fracture in al^xy. But these after all were rare^ 
much more rare than the joint affectioDS. And they had their 
parallels in other cases in which the nutrition of the osseous 
system generally, and possibly of other tissues as well, became 
disturbed in connection with nerve disorder. It was not 
unlikely that the general failure in nerve power might exert 
some influence on assimilation and nutrition. Thus even for 
the brittle bones he was indisposed to call in aid so large an 
hypothesis as trophic nerves and of special centres. Before 
resorting to such speculations he preferred to see how far more 
simple explanations would go, and amongst these he felt sure 
that the obtunded sensation of the ataxic limb was one of the 
most important elements in causing peculiarities when its joints 
became inflamed. 

The Pbesident observed that Sir James Paget said that he 
considered this Charcot's affection somewhat in the light of an 
arthritis associated with a definite disease of the spinal cord. 
It would be important for us to know whether by the expres- 
sion ^' definite '' he meant the pathological changes associated 
with tabes, as obviously Mr. Hutchinson meant, or whether he 
meant other pathological changes akin to them, or whether he 
meant, in the last place, pathological changes quite indepen- 
dent of these with which he associated tabes or any like 
affection. 

Sir James Paget replied that he was not disposed to say 
that the changes that took place in the arthritic diseases of 
locomotor ataxy were dependent merely on what Mr. Hutchin- 
son referred to as the passive condition of the nervous system, 
nor merely that they were such changes as would take place 



78 Discussion on Joint Disease in 

in any person who had lost sensibility. He thought rather 
that the nervous system had in itself, by whatever morbid 
conditions might be found in it, a power of actually deter- 
mining disease ; not merely of permitting disease to go on un- 
checked when such disease arose from other causes, but that 
it had in itself a definite power of producing disease in this 
part or that. For example, taking a most typical instance of 
it, the nervous system showed a power of producing disease 
in what was called herpes zoster; there, after attacks of 
definite, and often exceedingly acute, neuralgia, an eruption 
occurred along the lines of the diseased nerve, and that neu- 
ralgia often continued, as was well known, after the eruption 
had ceased. But he would not refer the changes either in 
locomotor ataxy, or in any other disease to which a neurotic 
origin might be assigned, wholly to the condition of the 
nervous system. He thought that nervous disturbance could 
determine the occurrence of disease, but he did not believe 
that the method of a disease and its morbid changes could be 
determined by any condition of the nervous system alone. In 
the case of the herpes zoster, a disease was produced by an 
error of nervous force ; but surely it could not be held that 
the nervous system had a determining power to make that 
disease a vesicular eruption, and not a scaly one, or not an 
ulcerative one. He would hold that there was in none of these 
instances a simple disease, or a morbid process determined 
solely by an error or deflection of nervous force, but in each 
case a £sease determined by disorder of the nervous system, 
and having its method or manner of external appearance 
determined by other conditions. And so in cases of loco- 
motor ataxy there were, he believed, many morbid conditions, 
rheumatic gout, syphilis, gout, rheumatism, scrofula — or any 
of these combined ; but the occurrence of that disease was 
determined by the nervous system. 

Mr. HuLEE felt quite unable to agree with those who 
looked upon Charcot's affection of the jo\nt as a distinct and 
separate thing from that affection which had been known for 
a very great number of years past either as malum senile or 
arthritis, rheumatoid arthritis, or arthritis deformans. In 
using the term rheumatoid arthritis, he did not wish to tie 
himself down to be understood to mean that he thought it was 
necessarily the expression of rheumatic diathesis. He simply 
used it to label, to describe, a particular joint affection more 
or less familiar to all. In considering the essential distinc- 



connection with Locomotor AtaoBy. 79 

tions or identity of these two affections^ neither in their 
morbid anatomy nor in their clinical history^ taking a large 
number of cases^ could Mr. Hulke see any essential difference ; 
and he might point, perhaps, to one of the specimens which 
Mr. Barwell first of all exhibited — ^the bones of the arm. 
The humerus was excessively wasted, as could be seen in a 
large nmnber of instances wliicli might be considered typical of 
Charcot^s joint disease. Most persons would agree that this was 
not at all a bad specimen of Charcot^s joint disease. There was 
considerable wasting of the articular end of that bone, consider- 
able bony new growth in relation to the ligaments and the syno« 
vial structures. But Mr. Hulke showed the knee of the same 
individual. There was no great wasting of the ends of the 
bones; on the contrary, there were those expansions, those sorts 
of stalactitic masses and outgrowths round the margins of the 
articular surfaces which many would consider to be eminently 
typical of chronic rheumatic artihritis, so that in the same 
individual there was in the upper limb, as was alluded to at 
the former meeting, a condition which would be agreed to by 
most to be typical of the morbid anatomy of Charcot^ s 
malady, and here in the lower limb was another specimen 
typical of chronic rheumatic arthritis. Now, either it must be 
supposed that they were essentially the same disease with 
rather different expressions in the upper and lower limbs, 
from different circumstances to which he might presently 
allude, or that there were concurrent in the same individual 
two essentially distinct disorders. Mr. Barwell also stated 
that in Charcot's joint disease there was no eburnation. Now, 
here was a thigh-bone, or what remained of the thigh- 
bone, and a portion of the pelvis of the same indivi- 
dual that yielded this knee and the elbow- joint. There 
was certainly no neck of the femur. All that had gone, and a 
good piece of the upper portion of the inner surface of the 
shaft had gone. This man had the extreme misfortune to 
have fracture of the neck of the thigh-bone some time before 
his death. There was here an instance in which one would 
be puzzled to distinguish between the ebumated surfaces and 
this condition. It looked exceedingly like eburnation; so 
that there were in the same individual these specimens, some 
essentially those of Charcot's malady, some essentially those 
of chronic rheumatoid arthritis. Therefore Mr. Hulke was 
quite unable, not merely from the examination of these two, 
but from the examination of a large number of specimens, to 
satisfy himself that there was an essential difference in their 



80 Discission on Joint Disease in 

morbid anatomy. His own strong fooling was in favoar of their 
being essentially the same j the morbid anatomy of the two 
seemed to present no essential difierences. It had been said 
by Mr. Barwell that in Charcot's malady the lesser joints 
were not affected. There was a specimen sent by ProfesBOr 
Charcot himself, where almost every joint of the tarens and 
of the phalanges and of the metatarsns was affected with this 
malady. Many looking at it would say that it was a typical 
example of rheumatoid arthritis. Not long since, he had, in 
the Middlesex Hospital, a Frenchwoman who had been an 
actress and a dancer in a theatre. She had had for a long 
time darting pains in her lower limbs, and darting pains in her 
back, and aao had been unable to follow her occupation for 
some months in conseqnence of a gradual failure of her knees. 
She had considerable enlargement of all the joints of both the 
lower limbs, and particnlarry of the left, bnt with a stick she 
had been able to hobble about until a few days before coming 
into the hospital; then, while she was walking, she was 
suddenly seized (to use her own words) with excruciating 
pains in her left knee, immediately followed by swelling. 
She came into the hospital with as typical an attack of syno- 
vitis as one could wish to see. Thus, every now and then 
in Charcot's disease, cases occurred which were not perfectly 
sluggish, nor perfectly painless, so far as these clinirad mani- 
festations were concerned. There conld not be a shadow of 
a doubt that a considerable number of tabetic cases occurred 
without any articular affections whatever. Again, in a large 
number of articular affections there was no tabes whatever. 
Then there was a third class where the two were concurrent ; in 
such, he thought there would not be any difference in the morbid 
anatomy, nor did he believe that it would be found that there 
were in the clinical circumstances essential differences. He 
therefore looked upon the joint affections of Charcot's disease 
as a chronic rheumatoid arthritis. But then the nature of the 
association had to be considered. Mr. Baker asked, was this 
an accidental, or was it a causative connection, or did they 
both stand in relation to some third as a cause T Mr. Hnlke's 
impression was in &70ur of the hitter; he was particularly 
plea^eJ \vit)i Sir James Paget's suggestion of syphilis, 
because thai hud been a loug timki pfissing through his mind. 
There could be no doubt that a very considerable proportion 
of tabetic patients were males who had had syphilis. He 
'^"uld,^(.wi^ (0 state positively that he was convinced that 
- 'i^fMiKi-bottom of both ; it might be, or it might 



eonneetion with Locomotor Ataxy. 81 

not; bat he thought this was a hint which it would be well 
for all to follow np^ and endeavour to elucidate as &r as 
possible. 

Dr. Dtcb Duckwobth read abstracts of two letters he had 
received from Professor Charcot. M. Charcot regrets that his 
winter coarse of lectures prevents his coming to London at 
this time to take part in this debate. He desires to take part^ 
however^ indirectly, by sending some of his preparations and 
casts illustrating the disease in question. One of the most 
important of these is the preparation of a foot illustrating his 
Jirst case of pied taheUmie, and of which Mr. Page showed an 
example in a patient during the London Congress in 1881. 
Models illustrating this affection accompany the specimen. 
He sends also a pelvis from an ataxic patient with the upper 
extremities of the femora — specimens indicating very plainly^ 
he thinks, that the disorder is not ordinary rheumatic arthritis, 
but a veiy different thing. The femora show the wearing 
away to be of mechanical nature. M. Charcot cares little 
what term is applied to the disease, or whether it be con- 
sidered rheumatic arthritis, so long as it is acknowledged to he 
truly a spinal one, both clinically and nosographics^y. He 
believes that the disease is not met with, nor anything at all 
comparable to it, apart from cases of locomotor ataxia. He 
thinks that rheumatic arthritis may certainly supervene in the 
subjects of ataxia, but that is a different matter. The condi- 
tion of the hones is as remarkable as that of the joints in cases 
of arthropathy. The disease affecting the diaphysis as well as 
the epiphysis has nothing in common with that met with in rheu- 
matic curthritis. (The porosity and fragility are here referred 
to. — ^D. D.) He avows his surprise that in London the pro- 
fession should still be in doubt about a question that in France 
is considered definitely resolved by anatomists, by surgeons, 
and by pathologists. He is very pleased, however, that the 
Clinical Society should again discuss the whole matter, not 
only for illustration of the pathology of tabes, but for the 
benefits that will accrue both to clinical surgery and the whole 
field of pathology. 

The Pbbsident said that Professor Charcot had contributed 
in a very large degree to the interest of the debate, and he sug- 
gested that someone should propose that the thanks of the 
Society be given to him. Although they were so deeply indebted 
to him, they were also indebted to Dr. Duckworth, who had put 
VOL. xvin. 6 



82 Discussion on Joint Disease in 

himself immediately in commmiication with Professor Charcot, 
and nsed his influence with him to indnce him to send his speci- 
mens, and to write the important letters which had been read. 

Dr. MoxoN proposed a vote of thanks to Professor Charcot, 
f br whose powers of imagination and observation he expressed 
great admiration. It might be accepted as certain that a great 
&rct had been put before the Society, evidently a very sugges- 
tive &ct. But when he asked what it was that this fact sug- 
gested, he felt an uncomfortably indefinite state of mind. At 
the last meeting, the President had asked Sir James Paget to 
make more clear what it was that he meant. He (Dr. Moxon) 
felt a certain degree of disappointment at the answer which 
Sir James Paget gave. He was particularly sorry to find that 
he dragged in herpes zoster. He would be veiy thankful to any 
member who would explain in what possible way herpes zoster 
threw any light on this so-called Charcot's dLsease. Physi- 
cians know a little about herpes zoster. Only last week an old 
lady, capable of much suffering, b6th in mind and body, 
the wife of a clergyman, obtained his services with reference 
to a disorder which, she told him, had been diagnosed three 
days before, by her very competent medical man, as a combi- 
nation of gout, neuralgia, and rheumatism ; and she said that, 
after three days of agony, pimples appeared in the place where 
the pain had tormented her. Dr. Moxon did not know whether 
there had been any gout, or neuralgia, or rheumatism ; but 
unquestionably the lady had herpes zoster of the neck when 
he saw her. He was able to promise her that her disease 
would run a definite course ; that it might end, perhaps, in 
some painful after-effects; but that, even supposing ulcers 
should occur, there would be sound healing ; and that it would 
never come again. He took it that those were the characters 
of herpes zoster, and he would like any member of the Society 
to show him what a disorder so characterised had to do with 
so-called Charcot's disease ; for Charcot's disease ^commenced 
in a condition extremely like common chronic rheumatic inflam- 
mation of the joint affected, only that there was no pain in 
the joint, nor any nervous symptoms. Very little indeed that 
was definite had been put before the Society about this so- 
called new disease ; but a good deal of what was definite came 
from Mr. Hulke, who showed that in the initial stages of this 
so-called peculiar disease of the joint there was nothing pecu- 
liar at all. It was only after at first simple rheumatism (or 
whatever it might be) had domiciled itself in the particular 



connection with Locomotor AtcuBy. 83 

joint that it began to show those pectdiarities which made up 
Charcot's disease. He would ask everybody who believed in 
Charcot's disease to show him any parallel between herpes 
zoster^ which was definite in its origin^ exact in its course, 
complete in its termination, and this other disorder, which 
at first showed no definiteness at all, which was absolutely^ 
hopelessly indefinite in its course, and which was peculiar 
amongst rheomatisms in having no nervons phenomeJI at aU. 
whereas herpes zoster was full of nerve from the beginning. 
Such things failed absolutely to fit. In one line only did they 
touch each other — ^the line of indefiniteness — the line in which 
nothingwasknown about them. If, only on the line whereignor- 
ance was, these coincided, might it not be through ignorance 
that they coincided or appeared to coincide at all ? Having so 
&r spoken negatively, he would advance a positive contribu- 
tion. Locomotor ataxy had branches ; and it had a branch 
which was scarcely a giufted branch, yet which seemed natural- 
ised in another quite distinct affection. Seven or eight years 
ago. Professor Westphal showed that, in what was odled 
general paralysis of the insane, the conditions of locomotor 
ataxy were present to a large extent. That statement inter- 
ested him much, and he visited St. Luke's Hospital, taking 
with him a galvanic battery, and several Guy's men. By the 
kindness of the resident physician he was able to make a 
careful examination of the general paralytics there; and he 
came to the conclusion that about one third of all those unhappy 
sufferers had the physical conditions objectively characteristic 
of locomotor ataxy. Dr. Savage had told him that, in his 
experience, about one-third of all general paralytics in Bethlem 
showed locomotor ataxy; but he had never met with an 
example of Charcot's disease in the hospital. If, in truth, 
the conditions of ataxy were present in a paralysing disorder, 
and if this peculiar joint disease, supposed to belong to ataxy, 
did not appear in the ataxy that accompanied paralysis, then 
might not one look for some traceable effect of paralysis to 
explain the absence of the joint affection ? Sir James Paget 
had very well expressed the peculiarities of Charcot's joint 
disease, as summed up in the presence of the destructive effects 
of inflammation and the absence of repair. Now, if that com- 
bination never occurred in certain ataxics, who, if ataxic, were 
also paralysed, had the paralysis anything to do with the 
absence of it f Was it not a fair suggestion that if a man were 
paralysed, and therefore did not go about upon his ataxic joint, 
and therefore did not keep up a continual irritation, this might 



84 Disetusion on Joint Diaetue in 

be the reason why he did not make an originally chronic simple 
rheumatism into an aggravated, nnrepairing, i^tative, severe, 
therefore strange and peculiar disease of the joint ? He had 
a specimen from Guy^s Museum — ^the shoulder-joint of a cab- 
man who was thrown from his cab and hurt his shoulder a 
year before his death ; but^ in order to support his wife and 
family^ he continued driving his cab. A year's cab-driving 
with an injured shoulder-joint would not be very far different 
from a yeaor's unsteady stumbling about on a knee-joint. Now^ 
this cabman's shoulder-joint was a Charcot's jomt^ or some- 
thing nearly approaching it. Dr. Moxon had also had a 
normal humerus brought with it for comparison. In the cab- 
man's shoulder-joint^ half the head of the humerus was 
entirely gone, and yet there was no production of new bone 
about it. Those were, he considered, the most striking 
characters of the so-called Charcot's disease, as defined and 
summarised by Sir James Paget; so that a half Charcot's 
joint would be made by the irritation connected with the un- 
guarded and continued use of a joint suffering rheumatically 
or from any injury. He would ask whether, if due allowance 
were made for those conditions of joint which arose from the 
disablement that could be traced to ataxy, all the phenomena 
of Charcot's disease must not be expected to supervene upon 
any form of rheumatism casually occurring. When he was 
demonstrating anatomy at Gruy's Hospital, he always tried to 
show his class some reason why that which was evident should 
be expected to exist. Amongst the most interesting general 
facts of anatomy first observed, and to the larger extent, by 
Mr. Hilton, was this : Mr. Hilton said that whenever a nerve 
supplied a muscle, it supplied the skin over that muscle. 
That was not entirely true, nor was it so suggestive as it 
should be. The proposition which observation taught Dr. 
Moxon to lay down was this : whenever a nerve supplied a 
muscle, it supplied the skin of the part moved on the side 
towards which motion was effected, and it likewise supplied 
the joint which that muscle moved, and generally on the side 
towards which motion took place. If that were true, and he 
believed it to be so largely true as to be a general principle, 
there must be some meaning in it. It could not be accident, 
and the meaning lay easily to hand. The meaning must be 
that there was some underlying necessity that the part moved 
should be sensitive to the effect of motion ; given that any- 
thing harmful was occurring through a movement, the moving 
agency might be immediately and duly checked. If that were 



connection with Locomotor Ataxy. 85 

a reqnisite of joint-life— and it was probably necessary— -take 
away the sensibility of a joints make the muscles spasmodic, 
and ask what ill-result might afterwards be traceable. Must 
there not be found some standard to show what the probable 
result of it all must be, before saying that, when a joint, 
deprived of its sensibility and subjected to spasm, showed 
serious signs of chronic inflammation, there must be some- 
thing mystical and marvellous in the nervous system to explain 
it f But this so-called Charcot's disease began as a common 
rheumatism, as Mr. Hulke showed, and ended in extensive 
disorganisation, only after long experience of spasmodic irre- 
gularity of action in the presence of a wholly broken-down 
condition of the protective system. Given the cabman's 
shoulder, and added thereto an insensitive state of his joint, 
pltis a spasmodic state of his muscles, and Dr. Moxon would 
advance the proposition that the half -Charcot joint of the cab- 
man would be a whole Charcot joint. To what extent was 
security in disease really due to those protective efforts of 
muscle to which he was now alluding ? He had in his mind 
a most painful example. He was in the clinical ward when 
a man, 8Bt. 19, came in for perityphlitis. This man had the 
usual condition of board-like hardness of the muscles in the 
lower and right part of the abdomen, and this hardness 
appeared to be, and was proved to be, protective of an inflam- 
matory condition beneath. Dr. Moxon had him put under 
chloroform, so that he might examine the condition of the 
intestines apart from the spasm. He was profoundly anaes- 
thetised, and Dr. Moxon himself, and two or three members 
of his class, certainly not coarsely nor carelessly, examined 
the part whilst the muscular protective spasm was thus taken 
ofi. The unfortunate youth came out of his chloroform nar- 
cosis in intense agony, and died of peritonitis from rupture of 
the intestines within nineteen hours. Painful as that was, it 
taught him a lesson. It made him ever since very respectful 
to, very recognitive of, the value of the sense of pain in 
mechanical disturbance of inflamed parts calling upon the 
protective agency of the muscles to prevent injurious move- 
ments. Something parallel undoubtedly existed in the pro- 
tection of the inflamed joints of healthy persons, by the pain 
which they would otherwise suffer in the severe and coarse 
action which a large joint had to undergo. He asked the 
Society, before deciding upon anything obscure in the matter, 
to make it clear to what extent it was probable that the later 
stages of a joint inflammation would be aggravated by insensi- 



66 Diacuasian on Joint Disease vn 

bility and spasm^ even when iihat inflammation commenced as 
common rheumatism. Woold it not become an exaggerated, 
irritative, severe, perhaps strange-looking disorder ? It was 
no new thing in the history of the medical profession, that a 
mysterious origin should be claimed for a local manifestation. 
About fifteen or twenty, or more years ago, strong attention 
was drawn to the occurrence in lunatic asylums of a remark- 
able condition of the external ear, in which it swelled up, and, 
indeed, became full of blood, so that the disease went by the 
name of hsematoma auris or auricular hematoma, and papers 
were written to show how it was that the strange condition of 
the nervous system which was peculiar to highly maniacal 
lunatics should so govern the nutrition of the external ear, 
that, under certain conditions remarkably limited to asylums, 
the external ear should grow into a bleb of blood. Those who 
were not content to ignore a conclusion so improbable were 
compelled to put up with it until recently, when a parallel was 
instituted. The present secretary of the Football Association 
had a hematoma auris. One of the most distinguished foot- 
ball players in GruVs Hospital admitted, almost with pride, 
that> the very height o^ a scrimmag^ he was disl^ctly 
maniacid. Those whose imagination in scientific subjects was 
equal to such a scope, might think that there was in a football 
scrimmage an instantaneous discharge into the ear of the 
peculiar kind formerly supposed to belong only to inmates of 
lunatic asylums, and which was thought to produce hematoma ; 
but Dr. Savage had told him that a gentleman, going round 
Bethlem Hospital with him, being shown one of those hadma- 
tomata on one of the patients, said that in his travels he had 
seen a statue of a Greek boxer, upon whose sculptured ear 
was represented a shrunken hsematoma auris. He trusted 
that the Society would not think that there was anything 
frivolous or trivial in the parallel he had endeavoured to draw. 
The general proposition common to both positions was this : 
that in the absence of proven direct causes, there was a ten- 
dency in the profession to appeal to the nervous system. 
There used, once, to be some degree of moderation in that 
invocation, until what was called the trophic nervous system 
was invented, which had charge of the special supplies of the 
several textures, such as the bones and the joints, having its 
seat in the medulla oblongata, and being, in fact, a sort of 
secretary of state for the joint department. He thought he had 
a right to ask of those who supposed that there was a special 
nervous provision for the nutrition of the joints, why it was 



timnectwn with Locomotor Ataxy. 87 

that one joint especially should become a victim of some fright- 
ful, tenacious, unsparing catastrophe 7 He would admit that 
there was some physical sense in it, and not mere metaphysical 
nonsense, if those who believed that the knee-joint in Gnarcof s 
disease was affected by the nerves would show that the nerves 
themselves were affected. Sanielssen and Boeck showed that, 
in anBdsliietic leprosy, the ansBsthesia was due to a disease of 
the nerves ; but they shoWed that the nerves were diseased. 
Who had shown that, when any special joints were attacked 
with Charcot's disease, which we were asked to attribute to 
the nerves, the nerves were in fault ? Was there an exostosis 
pressing on the nerves ? Was there any particular degenera- 
tion, any structural disease, anything that would induce that 
which was assumed to be a consequence of a thing, the 
existence of which was neither shown nor attempted to be 
shown? 

The Pebsidbnt believed that two of Professor Charcot's 
pupils had demonstrated the existence of nervous disease in 
the neighbourhood of the joint. 

Dr. MoxoN would stop the rest of his remarks until he had 
read the contributions of those gentlemen. Nevertheless there 
yms a veiy large opening here for further contributions, and it 
was not enough to show that the nerve was pink, or yellowish, 
or of any colour whatever, or a little swollen. He had exa- 
mined nerves — ^for instance, cervical ganglia — to try to find 
out something exact in their pathology. When a little pink- 
ness, or a little yellowness, or a little swelling, or a little 
shrinking, or a little excess of fibre, was observed, one was 
often tempted to find pathology where there really was not any ; 
and, unless M. Charcot's pupils made plain, not only a diseased 
condition of the nerves, but one which was itself both destruc- 
tive and irritative, he must still hold that the nervous condi- 
tion which gave rise to a tenacious, continuous, and absolutely 
destructive influence on a joint ought not to be set down to 
some mere change of colour, or mere alteration of fibre. Not 
merely hsBmatoma auris, but a certain very fragile state of the 
bones had been asserted to characterise some inmates of 
lunatic asyl^uns. The theory was, that the bones of the insane 
were softer and more fragile than other people's bones. But 
a part of his demonstation at Guy's Hospital, in morbid 
anatomy, was to tskke the ribs of a somewhat elderly person, 
and to show the students that, with two fingers of either hand, 
he could easily fracture the ribs without any conspicuous or 



88 Dismission on Joint Disease in 

evident effort. In fact^ fragility of bone was a tiling whicli 
existed to an extent that became startling only when the con- 
ditions were mystic. Tbere was a tendency to bring in the 
vague and the general, and to avoid measuring the forces of 
the direct and measurable causations; and this was a ten- 
dency which, he thought, ought to be severely repressed. 
M. Charcot had brought forward, as evidence of some veiy 
mysterious influence of the trophic nerves, the very strikingly 
significant occurrence of one-sided bedsore in persons para- 
lysed on one side only; and Dr. Moxon was very much im- 
pressed by the picture in Charcot's book, so clean on the one 
side, and with a hideous patch on the other. He had seen 
similar cases. He saw a lady with profound hemiplegia, and, 
within a fortnight, he was astounded at the degree in which 
the buttock sloughed on the paralysed side. A large part of 
it mortified and proceeded to separate, so that the chasm 
looked almost as if a spade had been thrust in and a spadeful 
turned out. But he was not ready to admit that it was neces- 
sary to herp suppose any vague provision of trophic nerves to 
explain such an occurrence. There were two points which he 
could advance with reference to the hemiplegic bedsore. He 
had observed that, whenever a person was severely hemi- 
plegically paralysed,the tendency always was for the body to 
roll round and Ue upon the paralysed side. That seemed to be 
due to the continued action of the still active limbs of the 
sound side, and especially of the muscles of accessory respira- 
tion. This happened in a way that could easily be conceived, 
and even watched ; the activity of the limbs that were still 
active tended to drag under and roll round the paralysed side. 
There was another point which was a little more abstract. 
When he was demonstrator of anatomy he used to point this 
out to the students. Whenever an artery was passing by a 
bone to enter a muscle, it ran under a tunnel of tendinous 
fibre, and this tunnelof tendinous fibre had muscularfibre arising 
from the outside of the arch of the tunnel, in such a way that 
the contraction of the muscle held the tunnel open, and so 
kept free the course of the artery from pressure by the mass of 
contracting muscle. The meaning was obvious. In fact, it 
evidently was the duty of the muscle, in acting, to pull open 
the channels of its own arterial supply. A contrivance of the 
kind could not be traced further into the muscle, though he 
believed that,if it were necessary to prevent an artery from being 
compressed against a bone by the muscle swollen in contraction 
it must be equally necessary to prevent the arteries from being 



con/necti'On with Locomotor Ataay. 89 

compressed within tlie muscle itself. If this were true, then an 
absolutely paralysed muscle was deprived of a system whereby 
it was able to secure its own nourishing supplies. If the tone 
were taken away from a muscle by a total paralysis which 
reduced its previously vital mass to the condition of inanimate 
clay, and if it were then heavily compressed, its nutrition was 
prejudiced, so that mortification was likely to occur, not only 
of the muscle, but of any texture which received its blood- 
supply by arteries sent through the muscle. The skin* of the 
buttock was fed by arteries coming through the gluteus maxi- 
mus ; and with the whole weight of the body, through the roll 
of the patient, resting on the gluteal mass of the one buttock, 
unprotected by the tone of the muscle, what was the wonder 
that the muscle and the textures over it should perish exactly 
in proportion to the pressure f In drawing towards a con- 
clusion, he must remember that, indeed, in point of form, he 
was not speaking as to Professor Charcot^s joint disease at 
all. but only proposinfif a vote of thanks to him, which he did 
in the highist aLin^ion of the great services which he had 
rendered to medicine. But this was not, if he remembered 
correctly, the first occasion on which a somewhat mystic light 
had been thrown by Professor Charcot on an obscure subject. 
About eight or ten years ago. Professor Charcot was very 
prominently before the profession throughout Europe in asso- 
ciation with the marvellous. Some years ago, when he was 
in the clinical ward, a young professional Mend of his, who 
wafi now caUed a gynecologist, came home from Paris, and 
his advent threw the ward into a veiy singular condition, 
which to this day he (Dr. Moxon) had never quite grasped. 
He remembered that this gentleman had a splendid case of 
what people called '' hysteria.'^ In short, he had as patient 
in one of the beds a young woman who was extremely anes- 
thetic on one side. She could not feel anything whatever on 
one half of her &ce, arm, leg, side, &c., yet she was quick 
enough on the other. Well, this gynaecological colleague 
was hard at work with sovereigns and shilHngs, and he said 
ic was all according to Charcot ; he was putting a sovereign 
on one arm, or leg, or side, and a shilling on the other, and 
he did not know what happened, but it was something very 
mystical. There was a transfer of total want of sense from 
place to place, from time to time, and a pricking went on. 
Shortly afterwards. Dr. Moxon and others, who were not 
gynecologists, did the same thing with circular bits of potato- 
parings, and all happened as if under gold and silver. At 



90 DiaciMsion on Joint Disease in 

the same time^ there was no doubt that^ on that occasion^ the 
marveUons was brought upon the ordinary in a very saffgestive 
manner. And now^ thanking Professor Charcot profoundly^ 
he asked the meeting to pass him a vote of thanks. 

Mr. MoBBANT Baeeb seconded the vote of thanks to Pro- 
fessor Charcot^ which was carried by acclamation. 

Mr. Henby Mobbis related the histories of two cases. 

Case 1. So-called Charcots disease of the left knee-joint. 
Becurrent rodent ulcer. — On March 20, 1877, Robt. M., 8Bt. 
53, a collier^ was admitted into the Middlesex Hospital with 
what had been supposed to be recurrent cancer of the face, 
and malignant disease of his left knee-joint. It was expected 
that amputation of the thigh would be required. Five opera- 
tions had been performed at different times upon his right 
upper lip and cheek. On admission a rounded, flattened, hard 
mass occupied the scar and extended upwards and outwards 
upon the malar bone. I removed the diseased tissues, which 
under the microscope proved to be rodent ulcer. He recovered 
quickly from this operation. The knee-joint affection was looked 
upon by us at the hospital as '^ chronic rheumatic arthritis,^^ 
but of most exceptionally severe form. The leg was like a flail. 
The knee was considerably enlarged, the enlargement being 
very unsymmetrical and most madded on the inner side of the 
joint. The measurement around the left knee was nineteen 
inches; around the right fourteen inches. The tibia was 
bowed inwards from the knee, so that when he attempted to 
stand the femur formed an angle with the tibia, the convexity 
of which was on the outer side of the knee. The synovial 
membrane was distended unequally with fluid. There was more 
bulging on the inner than on the outer side. The Ugaments 
were aU relaxed, and there was considerable lateral movement 
of the leg upon the thigh. In the internal lateral ligament, 
concealing the tuberosity of the tibia, was a thin plate of 
bone. The head of the flbula was not enlarged, and no out- 
growths from the femur could be felt. Voluntary and passive 
movements were equally painless. Flexion was only possible 
as far as a right angle^ but extension was complete. The 
tibia slipped backwards and forwards on the femur with a 
most distinct creak. The man could stand and walk in spite of 
the flail-like condition of the leg and the outward bowing at the 
knee. The disease of the knee began three years (or six 
years ?) before his admission, after he had been working in 
water in a mine^ and it set in with^ as he called it, '' rheumatic 



eormecUon with Locomotor Ataay. dl 

pain/' The pain was variable^ according to the dtate of the 
weather^ and after it had continued twelve months the joint 
began to swell. The swelling was first noticed on the inner 
side^ bnt it gradually increased until there was bulging on 
each side of the quadriceps tendon. Then followed thickening 
and enlargement and lateral increase of the head of the tibia. 
He had noticed the joint give under him and bow outwards 
for twelve months^ and during this period the swelling 
of the knee and the occasional pains had increased. No 
other joint was affected. He was fitted up in a Thomas's 
knee-spUnt and discharged from the hospital. Twelve months 
later he was heard of as being in good health and following 
his usual occupation. On November 26^ 1884^ I heard from 
Mr. Court, of Staveley, to this effect : — ^^ Robert M., died one 
and a half years since, 2b\ 60. Six years before death you 
removed a cancer from his face, and applied a splint for the 
joint disease. He wore the splint and worked regularly up to 
eight weeks before his death. The joint got smaller, so that 
at the time of his death the size was not much greater than 
that of the other knee. He could move it in every direction. 
His last illness began eight weeks before death with hoarse- 
ness and complete loss of voice, but no pain anywhere. 
Oradually the weakness increased until he could not sit up, 
and he kept his bed for six weeks before death. He could 
not bear tiie least draught of air upon his face, and therefore 
kept his face, head, and mouth closely muffled up. He lost 
strength and appetite, gradually. Night sweats were profuse. 
Two days before death a quantity of blood came from his 
mouth, and he bled a^ain the next day. The blood seemed to 
come from his throat » No post-mortem ezamiBation was 
obtained. 

Case 2. Old-standing y painless deformity of ankU-joint 
{Charcots disease) and elephantioMS of the leg and foot of the 
sams side. Death from intestinal obstruction drie to volvulus. — 
Thomas C, sat. 53, formerly a drapeir, but for the last fifteen 
years a clerk in a large tea warehouse, was sent into the Middle^ 
sex Hospital at 8 a.h. on Friday, March 14, 1884. The patient 
had a large irreducible inguino-scrotal hernia on the right side, 
and when admitted was suffering from stercoraceous vomiting 
and other symptoms of intestinal obstruction. His abdomen 
was much distended, very tense and hard, encroaching on the 
thorax and causing dyspnoea. He had been ruptured for many 
years, but had not worn a truss. Under ether an oblique 
incision over the neck of the tumour was made and the sao 



92 Diseu88i<m on Joint Disease in 

opened. The intestine was greatly distended with flatns; 
deeply congested^ and of a dark greenish purple colour. It 
was large intestine^ and was contained in a distinct hernial 
sac from which a quantity of blood-stained serum having a 
fsBcal odour escaped. No obstruction existed at the inguinal 
rings or neck of the sac^ yet the bowel could not be returned 
on account of its enormous size and distension. An aspiratory 
needle was introduced^ and some gas escaped^ but reduction 
being still impossible the bowel was opened and stitched 
to the skin. About two pints of blood-stained fluid fasces 
flowed away. The patient^ however, died at 12.30 p.m. When 
on the operating-table it was observed that his right lower 
limb from his knee downwards was greatly deformed. It 
looked like an immense elephantiasis ; but, in addition, the 
angle of this foot to the leg was very unnatural, the foot 
being displaced externally and having a very loose connection 
with the leg. It could be moved and rotated freely and 
painlessly, bat with a peculiar scranching noise. Move- 
ment outwards around the antero-posterior axis of the foot 
was specially free, and the patient walked upon the inner 
edge of the foot. There were scars and sinuses on either 
side of his ankle. The toes did not share in the elephan- 
tiasis. The great toe was shorter than usual, in proportion 
to the second toe. There was also a perforating ulcer of 
the great toe of the left foot. I ascertained the following 
facts from his wife : — He was of a quiet, cheerful disposi- 
tion and very active, and had continued so till his last 
illness. He had always been very thin, bat had gained in 
flesh slightly during the last three years. His eyesight was 
good, and though for the last two years he had worn glasses, 
his wife was quite sure there was ^^ nothing unusual about 
his sight.'^ He only used his glasses while reading, not for 
office work. He did not suffer from headache, pains in his 
head, nor had he any twitchings. Of late he had been subject to 
great coldness in his hands, which often ^^ went quite pallid. '^ 
Before his marriage, twenty-five years ago, and throughout 
his subsequent life, he used occasionally to suffer most acute 
pains in his ^' stomach.'^ These came on chiefly after meals 
and did not last long, but they had been more severe daring 
the last year or two of life. He had all the " virile " power 
natural to a man of his age. There was no loss of muscular 

Eower in any part of him except in his right leg; and on the 
aturday before his death he had spent the afternoon (after 
leaving his regular work) in fitting up a window-garden. 



eormeetion with Locomotor Attjuoy. 93 

When remonstrated with by his wife for carrying both arms 
full of flower-pots across the street and up to the second floor 
of his hoQse^ he answered^ '^ Why not ? It does me no harm^ 
and if I had but a rod to steady my f oot^ I could walk without 
the least inconvenience." " W ater " used to pour oflE his leg at 
night j in f act^ the night perspiration of the limb became so 
bad that his wife provided mackintosh for his Umb to rest upon. 

Twenty-one years ago he had a bunion on the toe of 
the right foot and pieces of bone had worked out and been 
taken away from time to time from this toe. For more than 
fifteen years he had had a sore on the great toe of the left 
foot. Ten years ago at least the right ankle began '^ to swell 
and in other ways to be deformed^ but it was a matter of 
surprise to him that with such a bad foot there was no pain." 
Up till about seven years ago he used to cut his right boot in 
one way and another so as to make it fit ; but for the last 
seven years at least he has never bought a pair of boots^ as 
the right one always required to be specially made and not 
always in the same way. The deformity of the ankle and the 
great increase in size of the foot and leg had been increasing 
more rapidly during the last three or four years. Pour years 
ago a box fell on the right f oot^ but did not hurt him suffi- 
ciently to cause him to lay up. Since then offensive pus had 
been discharged from the sinuses which had formed first on 
one side and then on the other of the ankle. Still he continued " 
his occupation uninterruptedly, carrying with him a second 
sock and pieces of Unen to apply during the business hours of 
the day, to keep himself free of the smell. The patient was 
the father of six children, one of whom, the eldest (daughter), 
died from peritonitis and obstruction of the bowels after eating 
a quantity of unripe fruit when three and a half years old. 
His own &ther died from cause unknown when about fifty-five 
years, his mother lived to be seventy-eight, and was always 
very healthy and died of old age. One brother died of ^^ con- 
sumption of the throaf when forty-three years old; another 
at fifty-five still lives ; his only two sisters are also living, aged 
sixty and fifty-six. The third brother died suddenly a few 
days after patient's funeral from haemorrhage from a cancer 
of the stomach. 

The right leg was amputated after death, and on dissec- 
tion Mr. Sutton found the posterior tibial nerve enormously 
enlarged. It is seen in the specimen * to be the size of the 

* Tbe specimen is in the Mufleam of the Middlesex Hospital. Catalogue, No. 
7, under ** Elephantiasis." 



94 



Discussion on Joint Diaease m 



little finger or larger. Both tibia and fibula were eltere< 
shape, and the edge and angles of the bones were irregi 
and unduly prominent. The fibnla was mach enlarged, : 
at the lower end it had been fractured obliquely ; the fi 
menta had united and were overlapping. The outer t 
leolua is represented by a large ovkI articular sarface, so 
what resembling one of the condyles of the femur; ■■ 
fitted into a large, shallow, irregular, saucer-shaped sari 
on the upper aspect of the 08 calcis. The upper eur&cf 
the astragalus is roughened and eroded in places, and 
also is the head of this bone, which moves freely from side 
side on the ob scaphoides. New bone has been formed at 
margins of the articular surfaces, and the ligaments of 
ankle bad been in great part destroyed. There waa a j 
forating ulcer of the great toe of the left foot, and the 

Sisterior tibial nerve was somewhat enlarged. Mr. Leot 
udaon has made carefnl preparations of parts of w 
nerves, and gives the following account of their microscop 
appearances: 

"I, Moriiiontalaectionqf upper third of right posterior ti 
nerve. — (a) There is very great increase in the epinenral c 
nective tissue, and this increase is more marked in the cet 
than at the periphery (Plate VI, fig. 1). Large w. 
bundles of white fibrous tissue, taking principally a vertica 
oblique direction, are everywhere found separating the ne 
fasciculi. This tissue is fully developed, contains few nnt 
and is abundantly supplied with vessels, a considerable amo 
of adipose tissue surrounding the latter in many places. B 
and there are groups of axis cylinders, devoid of moduli 
sheath and tightly bound together with fibrous tisf 
evidently the atrophied remains of nerve fasciculi, (b) '. 
perineurium is not abnormally developed nor is there i 
appreciable change in its intimate structure, (c) Within 
fasciculi the endoneurium is seen to be very considera 
increased in amount, its constituent fibres running vertioi 
and appearing in section as minute red points closely sorrou 
ing the ultimate nerve-fibres (Fig. 2) . The nerve-fibres th( 
selves ajre greatly diminished in number, in manyplaces, inde 
being only sparsely scattered through the fasciculus. Tl 
are seen to consist almost entirely of (or^e nerve-tubes, and 
are found to preponderate in purely motor nerves (Fig. 
The smaller fibrils which are now held to be sensory or tropl 
and which are relatively abundant in normal post-tibial nen 
have almost completely disappeared, their place being tal 



DESCBIPnON OP PLATE VI. 

Pios. 1, 2, 3. — ^To illiistmte Mr. Mottis'b case of Chaicof s Joint 

P. 94. 



Pio. 1. — Patt of upper third of right posterior tibial nerre. ( x 16.) 

a a a. Dilated yeins of epineariimi. 

6. Yasciilar adipose tissne (to the left of h, lying in the epi- 
nenrium, are the remains of an atrophied fasciculus). 

Fio. 2. — A single fasdcnlos sorrotinded by its perineurinm. ( x 65.) 

a a. Corpora amylacea. 

h h. Nuclei of endonenrinm. 

Fia. 3. — ^Part of preceding fascicnlns. (x 260.) 

a. Yertical. 

b. Horizontal fibres of perineurium. 

e. Intra-fascicnlar lymph-space (the endonenrium has some- 
what shrunken in hardening). 

d. Greatly hypertrophied endoneurium. 

e, large white nerve-tubes. 

Fio. 4. — To illustrate Mr. Anderson's case of Papilloma of the 

Bladder. P. 315. 

▲. General view under a low power. 
B. One of the papillae highly magnified. 



Clin.SrJrinj.Vol.XVl;: 





cormeetion with Locomotor Ataay. 95 

by the hypertrophied endoneural tissue. This intrafascicnlar 
change is most marked near the periphery of the nerve-trunk. 
Nnmeroos small ^ corpora amylacea ' are found in those &sciculi 
in which the degenerative change is most advanced.'' 

^' II. Horizontal section of middle of left posterior tibial nerve. 
— (a) There is some overgrowth of the epineurium^ but to far 
less a degree than on the opposite side, (b) The perineurium 
is normal, (c) Changes precisely similar in kind^ but less in 
extent^ to those of the right side are seen withm the nerve 
fasciculi. Almost complete absence of the smaller fibrils with 
corresponding increase of endoneurium. The fibrous tissue in 
this nerve stains more deeply and appears to be of more recent 
growth.'' 

At the post-mortem inspection there was found by Dr. Fow- 
ler to be an enormous volvulus of the lower five feet six inches 
of the small intestine^ C89cum^ and part of the ascending colon. 
These parts of the large bowel had each a very large mesentery, 
and thus a portion of the ileum which was twisted on its own 
mesentery had become folded beneath the caecum and ascending 
colon in the right iliac fossa. The enormously dilated csBCum 
and colon were flaccid and contained very little f 8Bcal matter^but 
there were three linear rents in their peritoneal coat, the effects 
of over-distension. The csBcum was attached to the wound in 
the right groin. At the hepatic flexure of the colon, at a 
point corresponding to the lower end of the volvulus, the 
great omentum had been gathered up into the form of a purse 
eight inches long, with a narrow neck. It had evidently lain 
for some time in the sac of the hernia. The mesentery of the 
C83cum and colon was scarred and ribbed with raised ridges, 
evidence of old chronic peritonitis, the probable result of 
stretching, dragging, and twisting. The mucous membrane 
of the dark portions of the csBcum and colon was intensely 
congested but not gangrenous. The transverse and descend- 
ing parts of the colon were contracted. The post-mortem 
examination thus afforded ample explanation of the acute 
abdominal pains so often felt during life. 

Bemarhs. — ^The flrst case presents the changes in a sisygle 
joint which are typical of those described by Charcot. GNie 
points noticeable about it, are : (1) the long duration of the 
joint affection without any ataxic symptoms supervening; 
(2) the disappearance of the swelling in the joint, under 
the condition of rest provided by the splint; (3) the co- 
existence of malignant disease of the face and mouth from 
a recurrence of which, in all probability, his death is to be 



96 Diaousaion on Joint Disease in 

attributed. The last point was worth noting^ especially in 
connection with the family history of Case 2, one of the 
brothers of whom died of cancer^ because it may possibly be 
that malignant disease is one of the constituent elements 
which go to make up the composition of this joint affection^ 
and more extended observations will show what proportion^ if 
any^ it bears to the whole number of constituent conditions 
which lead to it. Cancer^ as is well known^ leads to marked 
changes in bones^ softening their structure and predisposing 
them to spontaneous fractures^ which fractures^ however^ 
readily unite. It has sometimes been associated with osteitis 
deformans ; possibly it may be found to have some determin- 
ing influence on joint changes. The improvement which 
occurred under the rest secured by a Thomases splint (not- 
withstanding that the man kept at his work during the time 
he wore the splint) lends support to the view of Mr. Hutchin- 
son and others^ who regard the changes in the joints as being 
due to the rubbing and pressure effects from continued use of 
the joints and that these changes would cease if rest be main- 
tained. The commencement of the affection after long expo- 
sure to wet^ and the rheumatic pains which so long preceaed 
the structural changes in the joints go to support the view of 
Mr. Hulke and others^ who regard the affection as rheumatic 
arthritis. The noticeable points of the second case are (1) 
the perforating ulcers which had existed for from fifteen to 
twenty-one years; (2) the painlessness^ the necrosis^ the 
profuse perspiration of the foot and leg^ and the pathological 
changes in the nerves of the leg which are characteristic 
of perforating ulcer; (3) the enormous hypertrophy of the 
cellular tissue of the limb which resembled the ordinary 
Barbadoes leg^ (4) the changes in the ankle-joint^ which in 
respect of the wearing away of bony surfaces^ and the great 
laxity and swelling of the misshapen joint are seen in the 
joint affection described by Charcot ; (5) the great thickening 
and irregularity of the bones of the leg^ such as have been 
described as occurring to a less degree in some cases of per- 
forating ulcer; and lastly^ complete absence of ataxic sym- 
Stoms. Whether this is to be regarded as primarily a nerve 
isease or not^ the case shows me occasional association of 
perforating ulcer of the foot with an affection of the ankle^ 
uke that of so-called Charcot's disease ; and at the same time 
with a condition of the soft tissues like that of elephantiasis 
Arabum. 



connection with Locomotor Ataxy. 97 

Mr. Herbert Page called attention to a case of tabes dorsalis 
brought by him before the Society early in last year. It was 
the case of a man who for some years had been the subject of 
gastric crises^ attacks of vomiting to an extreme degree^ and 
who also had lightning pain of great severity. The man 
came under observation for an affection of the tarsal bones of 
one f oot^ and^ while he was under treatment^ there arose the 
same sorfc of condition in the other foot. The tarsal bones of 
both feet underwent a change which obviously consisted in 
extensive destruction ; but^ under the influence of rest^ anky- 
losis ultimately took place^ leaving the feet '^ extremely mis- 
shapen.^' So far^ the history of the case^ it might be said^ was 
nothing but rheumatoid arthritis attacking the bones of the 
feet^ possibly promoted by certain nerve-changes. The later 
history of the case made the appearance of things somewhat 
different. All the various symptoms subsided. The man was 
able to go about his business as he had done before. There were 
few or none of the symptoms of ataxy in the case. He was 
at work^ in what was to him perfect healthy till about the end 
of August^ when he again came into St. Mary^s Hospital^ with 
a recurrence of the attack in one foot. He had lately been in 
the hospital^ and most extensive changes had taken place in 
one ankle and one series of tarsal bones ; but the other foot 
had been wholly unaffected. It seemed to Mr. Page incon- 
ceivable that^ if this condition of bone-changes were due to 
rheumatoid arthritis^ and this attack were an exacerbation of 
the rheumatic affection^ it should not have at the same time 
attacked both feet^ as on the first occasion. The fsuct that it 
only attacked one foot also seemed to point to some other 
cause than a general condition such as rheumatoid arthritis. 
In the debate^ speakers had referred to pathological changes^ 
and very little indeed had been said of the clinical features of 
the disease. Various speakers had referred to the gradual 
wearing away of ends of bone in this condition ; and doubtless 
one did meet with^ in the course of months^ a change induced 
by the gradual wearing away^ which very much simulated the 
ordinary appearance in specimens which unquestionably were 
only met with in tabes dorsalis. But that was not the ordinary 
condition which the clinical history of these cases showed; 
here the wearing away was extremely rapid^ and he thought 
there must be some other cause than the rheumatoid change^ 
or the friction of bones one against another, to account for that 
condition. Charcot himself had pointed out numbers of cases 
in which a rapid wearing away had taken place in association 
VOL. xviii. 7 . 



98 Discussion on Joint Disease in 

with exacerbation of other symptoms of the disease^ gastric 
crises^ and other phenomena of the same kind. There was no 
reason to believe^ in a case such as that which he (Mr. Page) 
had related^ that friction of the bone could have given rise to 
the condition ; because^ in the later stage^ only one joint had 
been affected^ both being subjected to precisely the same in- 
fluence. Then^ putting aside this rheumatoid arthritic change^ 
might not the nervous system itself have some share in the pro- 
duction of this rapid destruction of bone? Certain irritative 
lesions of nerve-trunks did give rise to certain definite effects. 
In a nerve which had been divided, and in which the distal 
end was irritated by inflammation, or by being bound down 
in cicatricial tissue, if the distal end of the nerve were released 
by operation from the cicatrix, the changes due thereto ceased, 
but the condition of nerve-inactivity remained for some time 
till the nerve-functions had been restored by the union of the 
nerve. They might or might not be trophic changes, but 
they were essentially due to some effect upon the nerve-trunk 
at the part where the division had taken place. If such a 
change should take place there, the same sort of change 
might be due to lesions in more central parts of the nervous 
system. But recent observations had shown that nerve-trunks 
themselves underwent very extensive and serious changes in 
this disease, which were degenerative changes of the nerves 
going to the limbs and to the various parts affected ; and even 
in the case of bedsores, observation had shown quite recently 
that extensive changes were found in the nerve-trunks them- 
selves going to the seat of the acute bedsores. And it was 
quite possible that that might really be the thing underlying 
this condition, determined by the central lesion in the spinal 
cord. Mr. Page had also had a case, which he published 
in Brain, very like that which Mr. Morris had related, where 
there had been a history of perforating ulcer with ansasthesia, 
and so on, and where after some years, when the perforating 
ulcer had healed up, there came changes in the joints, and 
doubtless in that case changes in the nerve, because there was 
considerable anaesthesia combined with the change in the joint. 
Dr. Moxon had referred to the bedsores met with in hemi- 
plegia; and Mr. Page believed that in some of the cases 
described by Professor Charcot, where paralysis was induced 
by injury, not only was bedsore met with on the opposite side 
where there was anaesthesia, but actual changes were met with 
also in the joints on the same side as the lesion, where there 
was motor paralysis. Hence possibly, if the conditions on one 



connection with Locomotor Ataxy. 99 

side were dne to changes in the nerve^ the same cause might 
exist on the other side also. He believed that the disease 
under consideration was a distinctive disease of joints, induced 
by some change in the nervous system, and that Professor 
Charcot himself was not far wrong when he originally decided 
that it was a distinctive disease having special clinical charac- 
teristics of its own. The various matters mooted in the course 
of the debate with reference to rheumatic arthritis and so on 
had all been considered by Professor Charcot in his various 
papers ; and, with his numerous opportunities of observation, 
he still adhered to the view he originally put forward. 

Dr. MoxoN asked Mr. Page whether his patient with this 
tarsal disease, as he described it, had or had not locomotor 
ataxy definitely; and, secondly, whether Mr. Page would say 
in what way locomotor ataxy was a less general disease of both 
feet than rheumatoid arthritis. 

• 

Mr. Page said there was certainly no ataxy in the ordinary 
sense of the word. There was no ataxy in locomotion, and 
there was no flinging about of the limbs, such as to cause 
unusual rubbing of the bones against each other. The man 
walked perfectly well, even with his eyes shut. Then, with 
reference to the second question, in the course of this year, 
the patient had no changes whatever in one foot, although 
he had extensive changes in the other; and that seemed to 
him a strong point against the existence of rheumatoid arthritis 
being the cause of the condition, because he could hardly 
conceive of rheumatoid arthritis being absolutely quiescent in 
one limb, previously affected to so extreme a degree, and yet 
active in the other. 

Dr. Ptb-Smith said the first point brought before the 
Society by Sir James Paget was whether Charcot^s disease 
was a new disease. His opinion was that there was no evi- 
dence of any really new disease, certainly not of this. Cholera, 
diphtheria, and cerebro-spinal insular sclerosis, had all been 
only lately recognised ; but none believed that these diseases 
did not exist previously. The second point was the relation 
of so-called Charcot^s disease to osteo-arthritis ; and, on the 
whole, it seemed to him that there was no adequate evidence 
for separating them. No doubt, in somewhat extreme cases of 
the two affections, there was a great excess of fresh bone in 
osteo-arthritis, and there was a great diminution in Charcot^s 



100 Discussion on Joint Disease in 

joints. But, in almost every joint with osteo-arthritis, one 
could discern, along with the osteophytes and hypertrophy, 
much wasting, and loosening, and shrinking of tissue, not only 
of the cartilages and soft tissues, but also of the bone itself. 
And, as had been well pointed out by Mr. Hulke, in most cases 
of Charcot^s disease one could, where there were several joints 
to look at, discern in some [of them an attempt, more or 
less successful, to produce new bone. The difierence also, 
which no doubt was a real one, between the one affection 
being chiefly confined to a joint, and the other affecting the 
shafts of the bones, was, he thought, not absolute, and was 
affected by conditions of age and duration of disease. If one 
admitted it as belonging to the somewhat large group of osteo- 
arthritis, one must see, also, that even in that well-recognised 
group of affections, certain varieties could be distinguished. 
There was apparently but little similarity between the early 
stage of osteo-arthritis, as it affected the girl and the young 
woman — where it affected very symmetrically the small joints 
in the fingers, with considerable pain, and a little febrile 
reaction perhaps, and a very little distortion — and a disease 
affecting one hip-joint of an old man, with, perhaps, hardly 
another joint in the body, very slow, very local, very traumatic, 
very little constitutional. Therefore, he did not think that the 
mere fact of a well-marked typical case of Charcot's disease 
di£Eermg from an ordinary ca^ of osteo-arthritis, would lead 
one entirely to separate them. Moreover, he would suggest 
that, beside the anatomical changes in the joints, the clinical 
characters of the disease must also be considered; and he 
thought all would agree that it was quite possible for any long- 
continued chronic infiammation of the joint, not suppurative, 
not of an irritative character, to produce some of the changes 
which were recognised in osteo-arthritis. He had seen a joint 
with all the clinical features of gout, in which the edges of 
bone round the articular surfaces presented characters which 
if one dissolved away the urate of soda, would have left the 
joint very much in the condition of osteo-arthritis. This had 
been also observed by Professor Virchow; but no one would 
say that gout and osteo-arthritis were the same disease. Acute 
rheumatism he believed most thoroughly to be an absolutely 
distinct disease, entirely separate from osteo-arthritis, or the 
affections included under '' chronic rheumatism," *' rheu- 
matic gout,'* or other vague terms. At the same time, 
deformity and some changes occasionally resulted from acute 
rheumatism, which were far more frequently seen in osteo- 



connection with Locomotor Ataxy. 101 

artHritis. Two cases Had lately come under His care. One 
was tHat of a young man witH acute rHeumatism and valvular 
disease, witH tHe deformity of tHe wrist and knuckles wHicH 
was quite cHaracteristic. AnotHer was tHe case of a young 
lad wHo Had also been subject to acute rHeumatism several 
times, witH valvular disease. He Had a decided beginning of 
tHickening of tHe pHalangeal joints. All must Have seen, like 
cases occasionally, and no doubt, after tHe deatH of sucH 
patients, cHauges were found in tHe joints not unlike tHose of 
osteo-artHritis. Thirdly, Had tHis osteo-artHritis or CHarcot^s 
disease, taking tHe two togetHer, any definite relation to 
rHeumatism, to gout, to tropHic disease, to nervous disease, or 
to tabes ? WitH regard to tropHic nerves. He could not agree 
witH Dr. Moxon. THe existence of tropHic nerves Had been 
placed beyond tHe possibility of reasonable doubt ; and wHen 
once tHat Had been done, tHen tHe many clinical and pHysio- 
logical &ct8 wHicli before one had endeaTOtired to exp Ju upon 
otHer HypotHeses, witHout calling in tHese obscure ti'opHio 
nerves, became not only clear, but added mucHweigHt to wHat 
one knew before. He tHerefore admitted tHe existence of 
tropHic nerves, but He could not admit tHat tHey were proved 
to Have mucH to do witH CHarcot^s disease ; because, in tHe 
first place, tHere was no reason to suppose tHat tropHic nerves 
Had any connection witH tHe posterior columns of tHe spinal 
cord, and tHere was reason to believe tHat tHe tropHic nerves 
passed out tHrougH tHe anterior roots, wHicH, so far as was 
known, were unaffected in tabes. THen, witH respect to gout, 
was tHere tHe sligHtest connection witH gout of any sort ? 
THere was an entire absence of urate of soda from tHe true 
cases. Again, tHe distribution was different. Whence was 
it tHat most in tHe early History of osteo-artHritis Had been 
learned ? It was to tHe IrisH surgeons tHat we owed most of 
our knowledge respecting it, and yet in Ireland gout was 
almost unknown. Again, osteo-artHritis was extremely common 
in tHe dead-Houses, not only in Paris, but also in Vienna, 
wHere gout was so uncommon tHat He once found a joint witH 
urate of soda, and tHe assistants of one of tHe professors were 
quite ignorant of wHat it was. Bokitansky recognised it, but He 
said He Had never seen anotHer sucH case. THe extreme rarity 
of gout in certain parts of tHe world, and tHe extremely 
common diffusion of tHe otHer disease^ was surely enougH to 
sHow tHat tHere was no connection between tHem. Again, tHe 
same disease was common among animals. He Had brougHt a 
specimen of tHe fetlock of a Horse, wHicH sHowed a good 



102 Discussion on Joint Disease in 

example of osteo-arthritis. Mr. Busk once exUbited at tHe 
Pathological Society some bones of bears from a bone-cave at 
Gibraltar^ whicH^ in the glacial period^ had been affected by 
something which would now be called osteo-arthritis. In the 
Zoological Society last year. Professor Flower showed some 
cervical vertebrae of a porpoise exhibiting exquisite examples 
of osteo-arthritis. But no one certainly had traced gout in 
horses^ nor in prehistoric bears nor in porpoises. Had syphilis 
anything in the world to do with either of the afEections ? 
Surely the distinctions between syphiUtic and gouty disease 
were as broad and essential as could be. Finally j with regard 
to the connection of Charcot^s disease with tabes^ he felt in 
some difficulty^ because he had never seen a- case of joint 
affection supervening in the course of this disease. No doubt 
the explanation was that which Dr. Buzzard gave — that 
physicians generally did not^ in medical practice^ see these 
cases. They knew them from the ataxic side, and the igno- 
ranee which physicians consequently had on this subject stood 
in striking contrast to the extensive and accurate familiarity 
of surgeons with rheumatism and gout. His knowledge of the 
connection of these two forms of disease was almost or entirely 
derived from the cases of medical and surgical friends which 
he had had the opportunity of seeing, from museum specimens, 
and descriptions. But with regard to the connection between 
tabes and Charcot^s disease, tabes itself was not at aU such an 
absolutely fixed and definite entity that one could hang a still 
more doubtful disease on it. He thought it had suffered very 
much from want of accurate definition ; there had been too 
much tendency to include under the wide category of tabes a 
number of cases which were wanting in many of its essential 
features ; and, to gain better knowledge, it was not philo- 
sophical views as to its origin and connection with other forms 
of disease that were wanted, but more well-observed cases of 
joint affection in persons with locomotor ataxy, and more well- 
prepared sections of spinal cords in persons who had had that 
disease. In studying Charcot^s disease or any allied questions, 
it was not by generalisations or theories, or by referring to 
occult causes, or by invoking dyscrasiae, diatheses, blood- 
diseases, neuroses, and such vague and undetermined causes 
that any further knowledge of them would be gained. The 
very desire for explanation — ^for finding a cause — seemed to 
have retarded the progress of medicine. 

The President said from some remarks made in a previous 



connection with Locomotor Ataxy, 103 

part of the discassion he suspected that the exact position of 
the illustrious French physician to this question was not fully- 
understood; and he thought that in one^ or at most^ two^ 
sentences^ he could put the matter with sufficient clearness 
and accuracy to prevent any further mistake. Charcot dis- 
tinctly admitted that arthropathies might occur independently 
of any special influence from any special nervous disorder; 
nay^ he even went further than that^ he said that an ordinary 
osteo-arthritis might occar in the course of tabes dorsalis^ and 
have no specific characters ; but he contended that there were 
injuries and diseases^ acute and chronic^ of the nerves of the 
spinal cord and of the brain, which produced arthropathies of ^ 
various kinds; and he furthermore contended that, amongst 
this class of arthropathies, there was one which, by its ana- 
tomical characters, and by the assemblage and progression of 
its clinical symptoms, possessed such an individuality as to 
deserve, and, indeed, demand, a specific name; and it was this 
form of joint disease occurring in tabes, and, as he alleged, 
peculiar to it, which the Society had been discussing. 

Mr. Macnamaba said it seemed hardly possible that those 
who had cases of Charcot^s disease under their care, or who 
had taken the trouble to examine the remarkable series of 
patients brought before the Society, could have any doubts as 
to the existence of the afEection. As a proof that the disease 
was not so rare as some people supposed, it was a fact that, 
through the kindness of Mr. Lunn and Dr. Larder, there had 
been no fewer than five typical cases of this affection brought 
to the rooms of the Society from the wards of a London 
Infirmary. The essential point of the suggestive questions 
put by Mr. Morrant Baker was, not as to the existence of 
Charcot^s disease, but whether it depended upon lesions of the 
nervous system. He thou&rht that joints should be regarded 
as interruptions in the continuity of bones. Bmbi^^logy 
taught that such was their origin; histology enforced the 
same lesson, demonstrating the fact that the synovial mem- 
brane, like the periosteum, contained numerous osteoblasts, 
especially where it was reflected from the bone. Disease 
confirmed this idea; for in non-suppurative chronic affections 
of joints, osteophytes were built up from osteoblasts in the 
synovial membrane, in the same way as they were formed 
from the periosteum round the extremities of an ununited 
fracture, and in various forms of disease. Consequently, 
he failed to appreciate Mr. Hulke^'s argument that, because 



104 Discussion on Joint Disease in 

osteophytes were a prominent feature in cases of rheu- 
matic arthritis^ and were also found in Charcot^s disease^ 
therefore^ these affections were identical. The dried bones 
were very unreliable landmarks at the best of times^ but 
utterly unsafe guides as indicating the nature of the abnormal 
action which during life had caused osteophytes to form on 
their surface. Moreover, as Dr. Buzzard remarked eleven 
years ago, there could be no reason why a patient suffering 
from Charcot^s disease of the joints should not be affected by 
rheumatic arthritis, synovitis, or any of the other maladies to 
which human beings were liable. If one turned from the 
pathological to the clinical side of this question, we could not 
have a better illustration of the disease than that presented 
by the patient whom Mr. Barker had brought to the rooms of 
the Society. This man had for some years been suffering from 
symptoms indicating lesions of the nervous system, among 
others, perforating ulcers on the right foot. One morning, 
about two years ago, he went to his work as usual, but at 
breakfast-time, finding his right foot hot and uncomfortable, 
he took his boot off, and then discovered that the foot was so 
much swollen that he could not put his boot on again; by 
dinner-time the right leg and thigh were greatly swollen, but 
there was no pain in the limb. The patient was, however, 
obliged to return home in consequence of severe retching, 
lightning-pains, and in truth, a violent nerve-cyclone, out of 
which he emerged at the expiration of three days. His leg, 
however, remained swollen for two months, when it gradually 
resumed its normal size, and at present the limb, and its joint, 
were quite sound. In July last, this man was suddenly seized 
with rapid painless swelling of his left thigh and leg. This 
had not passed off as yet, and now his left knee was totally 
disorganised ; the leg hung like a flail on the thigh and could 
be moved in any direction without pain. This patient had 
never had any symptom of rheumatism, gout, or syphilis. In 
Charcot^s disease, therefore, there were invariably well-marked 
antecedent symptoms of lesions of the nervous system ; there 
was sudden serous effusion into the affected limb, as well as 
into the joint; the joints were rapidly disorganised, without 
* pain; the bones were easily fractured; there was seldom any 
fever; ankylosis did not occur; recovery was not unfrequent; 
the affected bones underwent a rapid rarefying osteitis. In 
cases of rheumatoid arthritis there is always some amount of 
fever, with marked synovitis, and long-continued rheumatic 
pains, and a progress from bad to worse, ending in stiffness 



connection with Locomotor Ataxy. 105 

and often in ankylosis of the affected joints. The lesions and 
the symptoms of Charcot^s disease and of rheumatoid arthritis 
were, therefore, dissimilar. Bhenmatoid arthritis was charac- 
terised by well-marked symptoms and lesions, and it was fair 
to infer that a disease having entirely different characters was 
not induced by rheumatism. And, further, as Charcot^ s disease 
was never met with unless among persons suffering from a 
remarkable train of symptoms referable to disorders of the 
nervous system, he would not pretend to say if the neurosis 
was due to changes in the spinal cord, or, as Dr. Buzzard had 
suggested, to disorder of a nerve-centre controlling the nutri- 
tion of the diseased structures. 

The President asked if he understood Mr. Macnamara 
aright, that there was always pain in chronic rheumatic 
arthritis, and that there was never condensation or ebumation 
in Charcot^s disease ? 

Mr. Macnamaba replied that, in chronic rheumatic arthritis, 
there was always rheumatic pain, and pain in the affected 
joint, tendons, and bursse. In Charcot^s disease, the patho- 
logical changes were destruction of the epiphyses of the affected 
bones, and sometimes the shaft of a bone by means of a rarefy- 
ing osteitis, with osteophites round joints and along tendons, 
if long-continued motion of the joint had existed after the 
disease had set in. The osteophites, as in rheumatoid arthritis, 
were due to the irritation and pressure of the diseased ends 
of the bones against one another; the same condition was 
found in chronic traumatic synovitis as in the case referred 
to by Dr. Moxon, and was seen to perfection in ununited 
fractures. 

Dr. BsoADBBiirr remarked that there was nothing in the 
extent of his experience, and nothing in any new views 
that he had to present to the Society, which justified him in 
taking part in this discussion earUer, but the protraction of the 
debate might perhaps leave time for the few remarks he should 
make. It seemed to him that one of the most important points 
which had come out in the discussion was the conclusion by 
Sir James Paget that the disease in question, the articular 
affection arising from tabes, as described by Charcot, was a 
new disease. He scarcely thought that the effect and bearing 
of that conclusion had been rightly appreciated, because it 
seemed to leave absolutely no room for any identification of 



106 Discussion on Joint Disease in 

this disease with chronic rheamatic arthritis. While Sir 
James Paget's authority was accepted as very great on any 
subject on which he spoke, on this subject his authority he 
(Dr. Broadbent) supposed was unrivalled. It was evident, 
from the place which chronic rheumatic arthritis took in Sir 
James Paget^s work on 8v/rgical Pathology, that it occupied 
his attention early, and it was certain from his late declarations 
that he had continued to interest himself in that and like sub- 
jects, so that his conclusion might be taken as one of special 
value ; it seemed to Dr. Broadbent to reduce to a level of mere 
cavil the attempts which had been made to connect the two 
diseases by intermediate links, especially when those links were 
based on dried specimens of bones. But even were the inter- 
pretation of morbid specimens by Sir James Paget less 
equivocal, he agreed with Mr. Macnamara, Mr. Barwell, and 
others, that the clinical features of the two diseases established 
a complete distinction between them. In the history of disease, 
vital processes were of greater importance than morbid 
anatomy, and the life-history must be allowed a determining 
influence in the opinion to be formed as to the nature of any 
disease. He thought that at least four different modes could 
be traced in which joints became deformed in a way which 
gave results similar to those described as belonging to osteo- 
arthritis, or chronic rheumatic arthritis. For example, two 
distinct diseases were included under that term, the early 
disease of which examples were seen in young females, and the 
late disease of morbus coxsb senilis; those seemed to him, 
although included under the same name, to be really two 
distinct clinical diseases. Then, besides chronic rheumatic 
arthritis, there were the effects of tabes to be considered; and 
he thought there were very similar results merely from 
neglected chronic synovitis, of which an illustration was quoted 
by Mr. Morris. But, as he had said, he thought the clinical 
history, which had been minutely described by Mr. Barwell 
and Mr. Macnamara, and had been referred to by Mr. Page, 
of itself established this great distinction. There was then a 
new disease, and the important point in this inquiry was what 
was the new morbid factor. Sir James Paget, in one part of 
his remarks, he thought had coincided very much with 
Professor Charcot's conclusion ; but in other parts he had sent 
them to search for the causation of this particular result as a 
sort of a resultant of possible different morbid processes, and 
had left them to determine between rheumatism, gout, 
rheumatic arthritis, and syphilis, as the dominating influence 



connection with Locomotor Ataxy. 107 

which gave rise to this particular condition. It seemed to him 
that research in this direction would bring results of no value. 
With regard to syphilis, indeed, if they admitted (as he 
certainly would) the relation between tabetic arthropathy and 
tabes; and if they admitted (as he thought they must) the 
extraordinary predominance which syphUis had among the 
antecedents of tabes, then there seemed some sort of remote 
connection between syphilis and this particular disease, and 
perhaps between the greater frequency of tabes, and the 
greater frequency, as he thought, which there had been of late 
years of syphilitic disease of the brain and the spinal cord. 
He thought all these might be, to some extent, traceable to 
the sHpshod treatment of syphilis which prevailed for a great 
many years when antimercurial ideas exercised considerable 
influence, and led to ne&rlect of radical treatment of early 
sypliilis. At any rate, in his own experience, both in regard 
to tabes and to syphilitic diseases of the nervous system, it 
was comparatively rarely that he found that a patient had 
undergone anything like adequate treatment for the primary 
syphilis. This was a mere parenthesis. It seemed to him 
that no result of any particular value would be reached, if it 
were determined that it was through a rheumatic arthritis, or 
through gout, or through any other tendency, that tabetic 
disease acted in the production of this joint disease. But it 
seemed to him that it would be quite another thing if, for 
example, Charcot's disease were regarded not as chronic 
rheumatic arthritis intensified by nerve-disorder, but if the re- 
lation between chronic rheumatic arthritis and Charcot^s 
disease were looked on as a relation established by like causa- 
tion, that both were efEects of the derangement of nutrition 
through the influence of the nervous system. In one, in 
chronic rheumatic arthritis, it was reflex ; in the other, it was 
the effect of the persistent irritative lesion in the spinal cord. 
If that were the relation established, a like causation in this 
way, then it seemed to him that an important step had been 
gained; but it would be an explanation of ordinary chronic 
rheumatic arthritis through tabes, and not an explanation of 
the tabetic disease through chronic arthritis. This was very 
much the position which had been taken up by Dr. Ord, and 
argued for some considerable time. It would, perhaps, be 
premature to say that that view was established, but certainly 
the weight of evidence tended strongly in that direction. 
There seemed to him to be no explanation possible of this 
joint disease, except a disturbing influence through nervous 



108 Btscttssion on Joint BUease in 

agency. Dr. Moxon had found fault with the illnistration of 
herpes zoster^ and^ of course^ there was a contrast between the 
definite duration and spontaneous cure of herpes zoster as 
compared with lesions that came in the course of tabes. But 
Dr. Moxon had left out of sight the fact that herpes zoster left 
cicatrices ; that herpes attacking the region of the fifth nerve 
would damage an eye permanently ; that^ from time to time^ 
cases occurred in which the entire area of skin supplied by the 
fifth nerve became atrophied^ and thinned^ and shiny after an 
attack of herpes ophthalmicus. He thought that^ with certain 
qualifications^ the comparison held good^ and was a fair illus- 
tration. Mr. Hutchinson had suggested that the explanation 
of these tabetic lesions might be the use of a diseased joints 
which was permitted by the loss of sensation^ or the loss of 
sensibility to pain^ and Dr. Moxon had maintained the same 
view. But surely a view of this kind admitted of illustration 
by facts. Was it in accord with experience that those cases 
were the ones to suffer from this disease^ in which there was 
the most exaggerated flinging about of thelimbs^ and in which 
there existed the most stnking anaBsthesia f He thought that 
the reverse was the case ; and while it was not in every case 
that there were the gastric crises^ to the association of which 
with this disease Dr. Buzzard had called attention ; while that 
association had not been^ in his own experience^ absolute^ yet 
that was the rule ; and those were cases in which the violence 
of the movements and the degree of ansBsthesia were not par- 
ticularly marked. Cases were going about with impunity in 
which these exaggerated movements were carried to their 
greatest extreme ; and there were others in which the ataxy 
had actually to be discovered after the occurrence of these 
tabetic phenomena. He therefore had no doubt whatever in 
admitting the accuracy^ the exactness^ of Professor Charcot's 
views^ as stated by the President at the commencement of the 
meeting. In conclusion^ he thought he might be permitted to 
express before the Society his regret that^ in the vote of 
thanks to Professor Charcot for sending his specimens^ which 
had been moved by Dr. Moxon^ there was a tone of sarcasm. 
Whilst all would be sorry to miss Dr. Moxon from their meet- 
ings and from the periodicals^ while he thought that the loss 
of his criticism would be a loss to medical science^ yet he did 
think that^ on this occasion^ it would have been better omitted. 
Of course^ if he had been speaking otherwise than as moving 
this vote of thanks^ it would not^ so to speak^ have committed 
the Society^ but it had^ in a way^ almost compromised the 



connection with Locomotor Ataxy. 109 

Society that this tone should have been employed in moving 
this vote of thanks. He further deprecated the bringing in of 
an allusion to the cases of hysterical hemi-an89sthesia — ^in order 
to throw discredit on M. Charcot's work in connection with this 
particular disease— burlesqued as they were in the amusing 
scene which Dr. Moxon related with regard to his gynascologi- 
cal pupil or colleague. He thought it only fair that there 
should be some statement made in this Society of the part 
which Professor Charcot took in relation to the subject. It 
was the honour of the Society which had moved him to make 
these remarks ; and he would only further say that Professor 
Charcot's attitude was throughout that of a scientific observer^ 
who was as far from partaking in any extravagances which 
might have attached to this idea as Dr. Moxon himself. He 
was quite sure that Dr. Moxon^ seeing^ as probably he would 
after what had been said^ that the occasion was of a special 
kind^ would be the first to regret that his remarks should be 
understood as a slight upon Professor Charcot. 

The President said that^ in Dr. Broadbent's reference to 
the speech of Sir James Paget bearing upon the antecedent 
causation of arthropathy and tabes^ he thought Dr. Broadbent 
had omitted to mention that Sir James spoke not only of ante- 
cedent processes^ but most particularly and specially of the 
combinations of antecedent processes^ such as the combination 
of gout and syphilis. 

Mr. Clement Lucas thought that many would regret^ 
especially those who, like himself, held the more advanced 
views concerning this disease, that the weight of authority in 
the discussion had been thrown almost wholly on the side of 
conservatism. He attributed this in great measure to the lead 
given by Sir James Paget in his brilliant address at a former 
meeting. When he (Mr. Lucas) listened to that oration he 
felt himself fairly carried away by its eloquence, but when 
he reflected on what had been said, he found himself scarcely 
able to agree with any of Sir James's conclusions. He quite 
wished that someone would rise at once and overthrow what 
he believed to be the erroneous doctrines of that speech. But 
the distinguished surgeons who followed — Mr. Hutchinson, 
Professor Humphry, and Mr. Hulke— seemed to be under the 
same influence. They used very similar arguments and 
arrived at very similar conclusions. Mr. Hutchinson and 
Professor Humphry, it was true, saw very great distinctions 



110 Discussion on Joint Disease in 

between the pathological results characteristic of Charcot's 
joint disease and those characteristic of osteo-arthritis, but 
they could not disentangle themselves from the idea of osteo- 
arthritis — ^that this disease must be osteo-arthritis modified by 
some other disease added to it. Mr. Hulke seemed to take 
firmer ground; and he used an argument which at first sight 
appeared to be a powerful one^ for he said : " I take here a 
joint which is from the upper extremity of one who is ataxic^ 
and it shows atrophy, wearing away, characteristic of Charcot's 
joint disease j and I take here another joint from the lower 
extremity of the very same patient, and here are outgrowths 
of bone similar to what you have in osteo-arthritis ; therefore, 
these are one and the same disease.'' But these joints were 
in different stages of inflammation, and he would ask. Was it 
not true that all groups of diseases were very much alike at 
their commencement? Was it not true, for instance, that 
fevers at their commencement were undistinguishable until 
the rashes became developed ? Inasmuch as there were only 
certain anatomical structures in the joint which could undergo 
inflammation, must not joint diseases of necessity have certain 
similarities, and, a fortiori, he would say. Was it not certainly 
true that osteo-arthritis and Charcot's joint disease, being both 
of them chronic joint diseases, must therefore, of necessity, 
present certain similarities ? To his miud, it would be very 
extraordinary if it were not so. If any further argument were 
required in opposition to what Mr. Hulke had said, he would 
take it from the speech of Dr. Moxon. It was well known 
that Dr. Moxon disagreed with everything Professor Charcot 
had described. He did not believe that this was a distinct 
disease ; and to disprove it he brought a joint which was from 
a case of traumatic arthritis. He said, ^^Look at my case of 
traumatic arthritis, and see the wearing away of the humerus, 
similar to what you get in Charcot's joint disease." But those 
who examined that specimen further would have seen that, 
arising from the scapula, were outgrowths of bone and pieces 
of bone attached by fibrous tissue, not unlike the outgrowths 
in osteo-arthritis. Here, then, was shown a connection between 
three diseases, viz. : traumatic arthritis, Charcot's joint disease, 
and osteo-arthritis. Why ? Simply because they were all chronic 
joint diseases. The question had been asked. Was this a new 
disease? Sir James Paget gave a double answer; he said, 
^^ Yes, in a general sense it is a new disease, but in an especial 
sense it is the result of a combination of diseases." To Mr. 
Lucas's mind that was a combination of errors. In one sense 



connection with Locomotor Ataxy. Ill 

Sir James declared this as a new disease. Why? Beoanse no 
old specimen could be found in any of the museums. He 
thought that was a very fallacious argument^ for collectors of 
specimens collected what they believed to be typical specimens ; 
and this disease had hitherto been confused with osteo-arthritis. 
All the museums in the world would not hold the specimens of 
osteo-arthritis which might be collected; therefore only typical 
cases were preserved. These cases of Charcot^s joint disease 
were not typical of osteo-arthritis ; they were different, yet 
similar, and so rejected. Moreover, curators of museums 
annually or periodically visited their shelves, and threw away 
the specimens which they did not consider typical, or not good 
for teaching purposes, or not complete as to their histories. 
He perfectly remembered that when Dr. Moxon was curator 
of the Guy's Hospital Museum he threw away a great many 
specimens that he considered useless. How, then, was it 
known that he did not throw away all the cases of Charcot's 
joint disease? In his present state of scepticism he might 
still be inclined to throw away these specimens. As to Sir 
James Paget's second conclusion, that this was a result of a 
combination of diseases, that, he thought, was a most erroneous 
doctrine. Sir James said that there might be three or four or 
or more diseases acting to cause this disease. If one had to 
search for three, or four, or a dozen diseases before deter- 
mining what was the matter with a patient, he would be dead 
and buried before one knew what was the matter with him. 
Sir James Paget had said that syphilis ran a different course 
in a gouty person and in a strumous person. That was true 
enough; but did not all diseases run different courses in 
different persons? Yet syphilis was syphilis all the world 
over. It gave rise to a number of secondary and tertiary 
lesions, but it was the same disease all through, and to those 
who knew all the different lesions, and knew them well, they 
were each and every one of them characteristic ; therefore he 
thought Sir James Paget's illustration most unfortunate. 
Then, if the pathological specimens were not sufficient to dis- 
tinguish one disease from the other, there were the clinical 
signs, and he thought it was unfortunate for the Society that 
more attention had not been paid to the clinical distinctions. 
He was happy to hear Mr. Macnamara referring to the clinical 
signs, and he thought sufficient credit had not been given to 
Mr. Harwell for what he said about them. These were chiefly 
the sudden onset, great swelling, the rapid disorganisation 
which often took place^ the peculiar joints affected, and the 



112 Discussion on Joint Disease in 

very pecnliar painlessness of those joints. He should like to 
refer, in illustration^ to the case he had brought before the 
Society last year^ when they first had Dr. Moxon's experience 
of the disease^ which was to the effect that after seeing many 
cases of locomotor ataxy^ Dr. Moxon had never seen a single 
case of Charcot's joint disease. That case was of interest in 
this respect^ that the symptoms of ataxy were so little deve- 
loped that they had not attracted the attention either of the 
patient or of his medical advisers. He had come among Mr. 
Lucas's out-patients suffering from an inflamed foot. The 
speaker had studied this disease with great care, and for some 
years had worked at the cases which he had seen under Dr. 
Buzzard and Dr. Hughlings Jackson, as well as others which 
were brought to the Hunterian Society. These were all cases 
in advanced stages, and with the disease in this form he was 
familiar; but when this case came to him among his out- 
patients he saw something that was new. Here was a man 
with a great swollen foot, red, puffy, but not oedematous, 
extending from the malleoli up to the bases of the metacarpal 
bones. Was it gout ? No ; it was not intensely painful like 
gout. The great toe had never been affected; there was no 
enlargement of the veins such as accompanied gout. Was it 
osteo-arthritis ? He did not recognise osteo-arthritis suddenly 
coming on as this had done in the tarsal joints, the others 
being unaffected. Here the foot suddenly inflamed, and the 
man was laid up for three or four days ; and then he came 
walking about upon it. He asked, '^ Was there any other 
joint affected ?'' The man said, '' I have something the matter 
with my elbow, but it does not trouble me very much." Upon 
his arm being stripped, there was seen a most extraordinary 
elbow-joint, a great bossy swollen joint, with which one would 
have said it was impossible for a man to work, and yet he had 
been working for two years with it. When it first became 
inflamed he came amongst the out-patients at Guy's Hospital, 
and the joint had been strapped. Then he ceased to attend 
and had worked with it for two years. Now, neither this joint 
nor foot, in the speaker's opinion, coxdd be classified under 
either osteo-arthritis or gout. He was pressed by the students 
for a diagnosis but could not give one. He had Charcot's joint 
disease in his mind and looked at the man's pupils, but found 
they were not contracted. He asked if there were lightning- 
or girdle-pains, but the man denied them. He then let the 
man go, and wrote on his letter, '' Inflamed foot and disease 
of the elbow," because he could not give a better diagnosis ; 



J 



connection with Locomotor Ataxy, 113 

and he claimed some credit for recognising that the case was 
not one of ordinary osteo-arthritis, gout^ or rheumatism. On 
the man^s next attendance he went more thoroughly into his 
case. When he was told to shut his eyes he was found to be 
unsteady ; he had the Argyll-Robertson pupils j and his knee- 
jerks were quite absent, yet he was himself unconscious of 
anything being the matter except these joint affections. In 
the speaker^s opinion this was a newly recognised disease — 
one that had been unravelled from a confusion of diseases — 
and he believed a few years would settle it absolutely^ and 
that people would look back to this discussion and wonder 
that those great men who had spoken in doubt had made such 
great mistakes. Here was a new disease^ let there be but the 
courage to recognise it ; here was a new field for more exact 
clinical inquiry, let it be pursued without prejudice; and, 
lastly, let there be but common honesty to give the credit of 
the discovery to that great man to whom the credit wias due. 

Dr. Maclagan desired to make a few remarks from a 
physician's point of view. He would simply condense all 
that he would say on the relation which it was possible that 
Charcot's disease bore to rheumatism, and gout, and rheumatoid 
arthritis, by saying that he would entirely homologate all 
that Dr. Pye-Smith had said. He thought the disease was 
perfectly distinct from all three. But, dismissing that point, 
he would proceed to discuss the pathogenesis of Charcot's 
disease. He did not see how this disease could be divorced 
from tabes dorsalis ; there was no evidence that it had ever 
been found unassociated with that disease ; though it occurred 
in only a very small percentage of cases in tabes dorsalis that 
did not show that there was no causal relationship between the 
two. It was not said, for instance, when a parturient woman 
had a white leg, that it had no connection with her recent 
confinement, simply because t^e immense majority of parturient 
women had no white leg ; nor because only one leg was affected 
was it said that the local condition of the limb had nothing to 
do with the general condition. In the same way with Charcot's 
disease, simply because it was an occasional thing, and did not 
affect all the joints and all the limbs, it could not be said that 
it had no connection with tabes. The question was. What was 
that connection ? The general characteristics of a tabetic 
limb were, that its general vitality was lowered, there was a 
loss of sensibility, and a tendency to spontaneous fracture. 
That was an important element in the pathogenesis of the 

VOL. xviii. 8 



114 Discussion on Joint Disease in 

disease^ whicli had been lost sigHt of in tHe discussion. But 
all these characteristics it had only in conunon with other forms 
of paralysis — ^general paralysis^ for instance^ as Dr. Moxon 
showed. The special peculiarity of a tabetic limb was the loss 
of the power of co-ordinate movement. Attention must not 
be concentrated solely on the posterior spinal cord, or on the 
muscles. The posterior columns of the cord were no doubt the 
seat of disease ; the muscles must have lost their co-ordinating 
power ; the bones were also affected, as were the ligaments — 
the fibrous, ligamentous, and tendinous parts of the joints. 
He would confine his observations to the knee-joint, though 
his remarks applied to all the others. The absence of patellar 
reflex was looked on as a characteristic sign of the disease. 
He would simply direct special attention to this phenomenon as 
evidence of the loss of sensibility and diminishea vitality of the 
ligamentum patellfls; and what was known to occur in the 
ligamentum patellsd might reasonably be assumed to occur also 
in other tendinous and ligamentous attachments of the knee- 
joints. Ligaments were absolutely as essential as the muscles 
to co-ordinate movement; the muscles could not produce 
co-ordinate movement unless the ligaments bound the -bones 
together. This he thought had a most important bearing 
on the pathogenesis of Charcot^s disease ; for one could not 
read the accounts of the early stages of that disease as given 
by Professor Charcot, Dr. Buzzard, and others — one could not 
look on the casts of limbs in the next room, without seeing 
that it was the ligaments that had given way ; the heads of 
the tibia and fibula had lost their relationship to each other 
and to the patella ; the swelling of the limb which had taken 
place was not an ordinary oedema, but it was such a swelling 
as he presumed would result in a limb with diminished vitality 
and in which all the soft parts were being strained by the 
absence of ordinary ligamentous support, such ligamentous 
support being absent at a time when the muscles retained a 
great deal of the power of movement, and were not in the con- 
dition of a paralysed limb at all. That seemed to be the con- 
dition that obtained in the early part of Charcot^s disease. 
The ligaments gave way first, just as in later stages the bones 
gave way by spontaneous fracture, and they gave way without 
pain simply because of the loss of sensibility. In the same 
way, if the ligaments gave way, by-and-by, in the more 
advanced stages, the bones would be rubbing against one 
another, and with the diminished vitality the bones would 
waste and wear away, and in time there would be produced 



eonneetian with Locomotor Ataxy. 115 

the pathological change which was characteristic of the 
advanced stage^ of Charcot's disease. The limb^ in shorty of 
such a man sofiering from tabes was^ so far as vitality was 
concerned^ the limb of a middle aged man. In connection 
with that^ he would point out that Charcot said that this con- 
dition always occurred at first in the lower limbs, and when it 
occurred later and in the upper extremities it was a very 
advanced disease. It must be borne in mind that Charcot's 
observations were all made in the Salp6triSre ; and the people 
there were in the habit of walking and pottering about on 
their legs but never using their arms ; and naturally enough, 
their legs went wrong. There was a case to which Mr. Lucas 
referred, which had been exhibited there by Dr. Duckworth 
at the last meeting, in which the elbows were affected. But 
that man was a cooper, and used his arms a good deal more 
than his legs. That was a point to which he wished to direct 
attention, that they were apt to lose sight of among the 
attendant phenomena. The fibrous tissues of the joint affected 
were absolutely essential to co-ordinate movement, and there 
was a good deal of evidence to show that they primarily 
suffered in Charcot's disease. With regard to Professor 
Charcot, he entirely homologated all that Dr. Broadbent had 
said ; his regret was that Dr. Moxon did not go a little 
further back in Professor Charcot's career. Seventeen or 
eighteen years ago, Charcot had first pointed out the existence 
of the minute aneurysms which were now associated with 
cerebral haemorrhage; he threw more light than any other 
man on that subject, and had done excellent work in connec- 
tion with it. 

The Pebsidbnt asked the speaker if he adopted Dr. Pye- 
Smith's assertion that a new disease was impossible. 

Dr. Maclagan said that Charcot's joint disease had no 
connection, clinically or pathologically, with rheumatism, gout, 
or rheumatoid arthritis. 

The Pbesidekt said that that was not exactly the question. 
It was stated, in reply to Sir James Paget, that a new disease 
could not arise, that a new disease was impossible. That 
statement was made by Dr. Pye- Smith; did Dr. Maclagan 
adopt it ? 

Dr. Maclagan did not say that a new disease was impos- 
sible, but there was not sufficient evidence that this was one. 



116 Discussion on Joint Disease vn 

Dr. Bastian said that his own experience of this particular 
joint affection was extremely limited. He had seen several 
well marked cases in the practice of others ; bnt^ though he 
had been on the look-out for the disease since 1868^ when 
Charcot's description first appeared^ he hadneveryethadasingle 
marked case under his care^ although he had seen a large number 
of cases of locomotor ataxy. He was compelled to belieye^ 
therefore^ that this joint disease was not a necessary appanage 
of the ordinary lesions of locomotor ataxy, and that, he believed, 
was precisely M. Charcot's own position — that this joint affec- 
tion, when it occurred, was to be looked on as the result of 
some altogether unusual extension or incidence of the ordinary 
pathological processes. M. Charcot's first view, afc all events, 
was that it was the result of an extension of a pathological 
process, from the posterior nerve-roots and posterior columns 
into the grey matter of the anterior comua. Whether that 
was the right view to adopt, at present, would seem perhaps 
open to doubt. He thought it necessary to call attention to 
this point, because, in the remarks both of Dr Moxon and of 
Dr Pye-Smith, it seemed to have been lost sight of ; they 
argued as if the affection were assumed to be a result of the 
ordinary lesions of locomotor ataxy in the posterior columns. 
Then, again, it seemed to him that, if locomotor ataxy were 
such a very common thing as it was known to be, compara- 
tively speaking, and this joint affection were so rare, these 
facts of themselves must tend to throw a considerable shadow 
of doubt across the views of some speakers, who had laid stress 
upon the fact of the loss of sensibility in this disease, combined 
with exaggerated movements, being of themselves adequate 
to produce Charcot's joint affection of this kind. A further 
reason in the same direction tending to discredit that view 
was to be found, as it seemed to him, in the fact that, in a great 
number of these cases the joint affection in question was said 
to manifest itself at quite early stages of locomotor ataxy. In 
several of the recorded cases it had manifested itself quite 
early, and in others at irregular periods of the disease. It 
seemed to him that in inquiring into the connection of this 
disease with neural disturbances the question ought to be 
looked at in the light thrown upon it by other simpler joint 
affections, which were more clearlv related to certain disturbed 
neural conditions. He would reier specially to two sets of 
such cases. First, there was the fact that, in certain cases of 
hemiplegia, there were joint affections in the form of a simple 
arthritis, occurring in the paralysed limbs only, not on the 



connection vdth Locomotor Ataxy. 117 

opposite side^ and that in those cases there was often the 
coexistence of tenderness over the nerve-trunks and sometimes 
atrophy of the paralysed muscles. He believed that, in nearly 
all such caseSj there was evidence of a sclerosis in the lateral 
columns of the cord^ and he knew that in some of these cases 
it had been actually ascertained by M. Charcot himself^ that 
there was an extension from the sclerotic region in the lateral 
column of the cord into the contiguous anterior comu ; so that^ 
in this case^ there might be a relation between the joint affec- 
tion and changes in the grey matter^ or the coincident changes 
in the nerves of the limb. There was another set of cases in 
which there was the association of simple arthritic inflamma- 
tions with the onset of nerve affections. He alluded especially 
to progressive muscular atrophy. This had been observed 
not un&equently of late years^ especially since attention had 
been called to it. About two years ago he had seen a very 
remarkable case, in which the progressive muscular atrophy 
was of unusually rapid onset, and in which the joint affection, 
pain, tenderness, and inflammation about the joint was so 
marked as to have caused this disease to be regarded, at first, 
by the practitioner under whose care the patient came, as one 
of rheumatic fever. There could be no doubt that, in a certain 
proportion of these progressive muscular atrophy cases, a simple 
joint affection declares itself. Here, again, there was disease 
in the anterior comua of the spinal cord, and, possibly, changes 
in the nerves in connection with those anterior cornua. It 
seemed to be impossible to define more closely the patho- 
genic relation between these simple arthritic affections and the 
two nervous diseases with which they are associated. In 
regard to Charcot's disease there might be extensions of the 
morbid process from the posterior columns into the grey matter, 
and, also, there was a reasonable probability that there might 
be implication of the peripheral nerves in relation with the 
affected joints. He thought it very important not to lose 
sight of the fact that, during the last two years there had 
been cases of locomotor ataxy of an ordinary kind, so far as 
their clinical characters were concerned, but in which post- 
mortem examination had shown not central changes in the 
spinal cord, but peripheral lesions only in the nerves. Several 
of these cases had been recorded. Of course, further informa- 
tion about them was wanted ; but it seemed to him quite pos- 
sible that, if symptoms of locomotor ataxy could be produced 
in this way by diseases of peripheral nerves, it was also pos- 
sible that, in the ordinary cases of locomotor ataxy, cases in 



118 Discussion on Joint Disease in 

which there were centric changes, there might also be some 
changes in the peripheral nerves, and that some of the changes 
might be specially related to the production of Charcot's joint 
affection. This was a subject which future investigators would 
have to decide. Then, even if it were supposed that there was 
a causal connection between the occurrence of these joint 
affections and these lesions in the nerves, it did not seem to 
him at all necessary that the existence of special trophic nerves 
should, therefore, be postulated. Some of the best marked 
trophic lesions seem to occur from the cutting off of ordinary 
nerve impressions from parts which were accustomed habit- 
ually to receive such impressions. He would mention, under 
this head, the secondary degenerations that occurred in the 
brain, those in the spinal cord, and also the degenerations that 
occurred when a motor nerve was cut across, and, again, the 
extremely well-marked atrophies that occurred in muscle under 
those conditions. Here, when there was a cutting across of 
a motor path in any of these situations, there was, as a result, 
a disturbance of nutrition below; and the part so affected 
either underwent fatty degeneration or a process of atrophy. 
At least half of the trophic lesions seemed to be of that land ; 
so that it seemed to him as if the mere cutting off of the neural 
excitations which were accustomed to pass along motor tracks 
might of itself produce one important set of these trophic 
changes in physiologically related tissues. He believed that 
at least a large proportion of the remaining known trophic 
lesions might be produced by unnatural influences passing 
along sensory nerves, on account of pathological changes of 
an irritative nature occurring either in their track or in the 
nuclei of the spinal cord and medulla at the root of such 
sensory nerves. In this way the trophic changes occurring in 
the skin might be explained likewise, that was to say, the 
various eruptions of the skin that occurred, some in the course 
of herpes zoster, some in the course of locomotor ataxy itself, 
over the course of painful nerves ; the trophic ulcerations that 
occurred in the skin, and the ulcerations of the cornea, which 
had always attracted much attention ; as well as those peculiar 
atrophies of the skin to which attention was first called by Sir 
James Paget, the so-called glossy skin, which he showed to be 
due to nerve-irritation. Although, as a rule, sensory nerves 
transmit impressions towards the centre, still, if the nerve 
were irritated in its course, or if its nucleus were irritated, 
there seemed no reason why impressions might not be sent 
to the periphery from which these nerves came. It had 



connection with Locomotor Ataxy. 119 

been shown by physiologists that a nerve might transmit 
impressions in both directions. It seemed to him to be qnite 
possible that this occurred^ and that^ therefore^ if there were 
an irritating lesion in the conrse of a sensory nerve^ or an 
irritation affecting the nerve-cells at the nuclei of one of these 
nerves^ there might arise^ in that way, a constant flow of 
unnatural nerve influences going to the tissues which might 
suffice to disturb and upset the balance of their nutrition. It 
seemed to him possible that, just as the skin affections were 
produced in this way, so the joint affections might also be the 
results of lesions occurring in the sensory nerves or the sensory 
nuclei rather than in the motor nerves or their nuclei. He 
threw that out merely as a suggestion, because he thought at 
present the point was one which could not be proved, and it must 
rather remain for future investigation to decide the question 
as to the exact pathogenesis of these joint changes. Whilst 
he thought it quite possible, therefore, that some one or other 
of the changes occasionally met with in locomotor ataxy, 
either some of the changes in the grey matter or some of the 
changes in the peripheral nerves, might act in this way as irri- 
tants and set up an inflammatory or perverted nutritive condi- 
tion in the joint such as is met with in Charcot's disease, it 
was impossible to go further, and to say precisely how the 
morbid condition in the joint is produced. It seemed to him 
that if the disease were initiated in some such way as he had 
indicated, it might progress to a certain extent, and that then 
there might also come into play those causes whose influence 
had been insisted upon by many, that is to say, the continued 
use and movement of the ansesthetic joint which might tend 
greatly to aggravate the previous condition. With regard to 
the notion that a causative connection exists between the pro- 
cesses that may occur as part of the phenomena of locomotor 
ataxy and this particular joint affection, he thought there was at 
present good evidence for believing that that was so, and 
therefore that M. Charcot's position generally was one which 
must be fully conceded; but that, when one came to the 
details, and to ask exactly what was the precise pathogenesis, 

{resent knowledge would not enable an opinion to be given, 
n reference to the question whether this was a new disease 
or not, he said that it seemed to him that those who contended 
that this was a new disease drew a conclusion which was 
diametrically opposed to the conclusions of M. Charcot. He 
would submit that our nervous systems had always been sub- 
mitted to much the same kind and range of influences during 



120 Discussion on Joint Disease in 

periods of civilisation at all events ; and it would be extremely 
difficult, therefore, to understand how, if this disease were one 
really due to the disturbing influences of certain not infre- 
quently recurring pathological conditions of the nervous system, 
it should be new. On the other hand, it was quite possible to 
explain in ways which had been already hinted at, how it was 
that the joint conditions in question had not previously been 
recognised as an occasional appanage of locomotor ataxy. He 
thought that a distinct relation between this disease and loco- 
motor ataxy should be admitted, although the exact patho- 
genesis could not be precisely defined. 

Mr. Howard Mabsh referred to the interest which Sir 
James Paget had introduced into the debate by his remark on 
the subject of the evolution of disease. From the fact that no 
specimen of Charcot's disease was to be found in the collections 
either of Hunter, Langstaff, and Stanley, Sir James believed 
that the affection did not exist, at least in anything like its 
present frequency, in their day. Had it existed it seemed 
nearly impossible that they could all have failed to preserve 
some examples of it. He therefore held that the disease was 
new, and that it had arisen out of the mingling of various 
constitutional affections, the chief among which we might 
justly suspect had been syphilis, rheumatic gout, and a special 
tendency to disease of the spinal cord. While recognising, in 
common with all those who were competent judges. Sir James 
Paget's great authority on such a subject he knew that Sir 
James would be the first to wish that his views should be 
freely discussed. Stanley worked at diseases of the bones 
down to about 1850. So that by Sir James's argument, the 
disease had become prevalent only within the last thirty or 
forty years. But, though Sir James had passed himself over, 
we could not forget what his labours in surgical pathology 
had been, nor that they extended down at least to 1865. So 
that if it were safe to conclude that the disease did not exist, 
or was very rare, down to 1850, because Hunter and Stanley 
had not recorded it, we, holding that it was fully as unlikely 
that Paget could have failed to notice it or that Stanley had 
done so, must believe that it had been developed since 1865, 
a conclusion which it was difficult to accept. Even since 1865, 
though probably no one would expect his claim to an equality 
with Hunter, a very large number of able pathologists and 
clinical observers had been at work, yet they had failed, till 
within the last few years — ^that is, for some ten years after 



connection with Locomotor Ataay, 121 

Charcot had described the disease in 1868 — to bring forward 
any considerable number of examples^ thongh it could not be 
doubted that numerous instances of it were in existence. Now, 
he thought that if in these more recent periods in which 
pathology and clinical observation had made such rapid 
advances, these cases had been so generally overlooked they 
might also have passed unrecorded by Stanley, and by 
Hunter, who, it must be remembered, was a student not so 
much of pathology as of biology and natural history. Three 
difficulties seemed to present themselves in respect to the view 
that this disease had been the product of evolution within the 
period named by Sir James Paget. In the first place, it did 
not appear out of what new elements or combinations it could 
have arisen, for syphilis and osteo-arthritis had been mingled 
with each other, and, as we must believe, with diseases of the 
nervous system long before even the time of Hunter. Secondly 
though all must own the strong probability that many diseases 
must undergo some modification by admixture with other forms, 
as time went on, these changes seemed to be very slowly 
effected, and the thirty or forty years assigned by Sir James 
Paget, and which did not cover the natural period even of a 
single life, or include even two generations, appeared too short 
for the evolution of a new disease presenting such remarkable 
features as those observed in the affection under discussion. 
Thirdly, in any process of evolution the original form gradually 
faded out, and the new form took its place ; but, so far as we 
knew, syphilis, for example, except that it had assumed a 
milder type, was very much the same now as it was a hundred 
years ago. In endeavouring, therefore, to estimate the pro- 
babilities of the case, Mr. Marsh was inclined to believe not 
that the affection now termed Charcot^s disease was really 
new, but that it had been till recently overlooked. The rela- 
tionship of Charcot's disease to osteo-arthritis he believed was 
a more difficult question to solve than many appeared to think. 
Without venturing to assert their full identity, he must con- 
fess that he was unable to see any proof that the two affections 
were absolutely distinct from each other. In his opinion, the 
points of resemblance outweighed those of clear difference. 
Dr. Duckworth had allowed, and Mr. Hulke had conclusively 
shown, that in its morbid anatomy Charcot's disease was often 
not to be distinguished from osteo-arthritis, and the same 
must be said of its clinical features. No doubt by taking 
extreme cases very marked difference, both pathological and 
clinical, could be observed ; but this was equally true of other 






122 Discuaaion on Joint Disease in 

diseasesj for instaiicej o£ syphiliB ; but these diSerencea became 
far less obvious when intamiediate examples were taken ioto 
account. He waa aware that the argmneut that because two 
diseases could be connected by a number of intermediate links 
there was no essential difference between them, must not be 
carried too far j for this was a form of argument by which it 
was easy to show that there was no difference between a saint 
and a sinner, or between black and white. Still, it was 
entitled to considerable weight when the cases that lay 
between the two affections were carefully selected. He had 
himself recently seen a case in which an affection of the hip 
which begun ten years ago as a well-marked and apparently 
ordinary example of osteo-arthritis, had very gradually acquired 
the characters of a typical Charcot's joint ; the limb had 
become three inches short, and completely everted ; the head of 
the femur was gone, and the upper end of the bone could be 
made to slide upwards on the pelvis ; large heaps of loose 
bone could be felt around the joint, and there was a large col- 
lection of fluid in Scarpa's triangle. The patient had no pain 
and could walk long distances on the limb. But although 
this joint now presented features which many asserted were 
never met with except in association with tabes, the patient 
showed no indication whatever of disease of the nervous 
system. But if, faihng to discover any crucial differences 
between these affections in regard either to their pathological 
anatomy or their clinical history, we turned to the question 
of their essential nature, we were at once met with the diffi- 
culty that we were ignorant of the true nature of osteo- 
artlmtis. Until we knew what osteo-arthritis really was, 
whether a disease, as many held, of nervous origin, or as 
others suspected, himself among the number, a common name 
for several distinct affections not yet distinguished from 
each other, we were not in a position to say how, if at all, 
Charcot's disease was related to it. It seemed wiser at present 
rather to continue our studies of these diseases than to venture 
upon the expression of strong opinions respecting them. 
Looking merely at the morbid anatoniy of Charcot's disease, 
the aSection seemed, as Dr. Buzzard has remarked, to be 
located primarily in the bones, and there was evidence to show 
that the condition was no mere failure of repair, but an active 
And destructive disease. Kobones that were suffering merely 
&om deficient repair would present the features observed in 
these cases, but whether this change was due to the direct 
action of the uervous system or not, it seemed impossible at 



connection with Locomotor Ataxy. 123 

present to determine. Sir James Paget had observed that the 
nervous system had a power of actually producing disease^ as, 
for example, in the case of herpes zoster. Some might 
remember that a few years ago Mr. Hutchinson had 
shown a skull and lower jaw in which, corresponding to the 
distribution of the fifth nerve, on one side, the several bones 
were intensely hard, greatly thickened, and deformed by irre- 
gular nodular swellings. In this case, the only thing common 
to the affected bones was their nerve-supply. Such examples 
were both rare and obscure, but, as far as we could read them, 
they seemed to point to some abnormal influence of the ner- 
vous system. As far as mere naked-eye appearances went, 
the change in the bone in Charcot's disease somewhat 
resembled that observed in some cases of mollities ossium, in 
which the bones became rarified and so brittle and soft that 
they bent, and broke very easily. A change somewhat 
sinular in its effect was also observed in cases of fragilitas 
ossium, some of which were of a very remarkable kind. The 
origin and true nature of these affections of bone, however, 
were, at present, altogether obscure, and the same might be 
said of the disease which Sir James Paget had lately so fully 
described under the name osteitis deformans. It was by care- 
fully studying this whole group, and taking not a narrow view 
of Charcot's disease, but by tracing out all its general and 
local characters, and its association with other affections, that 
we should at length ascertain its true position in pathology 
and clinical medicine. 

Dr. Bae,low said that, so far as he had followed the dis- 
cussion, those who had been opposed to the specific origin of 
Charcot's disease had maintained that it was indistinguishable 
from rheumatoid arthritis. He should Uke to ask whether 
rheumatoid arthritis was itseU so definite a clinical entity that 
this really added anything to the knowledge of the subject. 
The anatomical outcome of rheumatoid arthritis, thanks to the 
labours of Adams and others, was perfectly well known ; but 
members should consider the very many different ways in 
which rheumatoid arthritis might begin. How would any 
pathologist, who had examined the bones of old people, dis- 
tinguish many cases of senile degeneration of cartilage and 
bone from slight cases of rheumatoid arthritis ? He differed 
from Mr. Macnamara with respect to the question of pain. It 
seemed to him that, in many cases, old people might have 
most extensive changes at the ends of the bone without any 



124 Discussion on Joint Disease in 

pain at all. There was another pointy to which Dr. Pye- 
omith referred. Although he agreed that acute rheamatism 
was sharply defined from Adams's disease, rheumatic gout, yet 
there were unquestionably cases of young subjects who had 
begun with attacks of acute rheumatism, which had relapsed, 
and which had ultimately developed rheumatoid arthritis. 
Again, there was the relation of gout. There were cases like 
that to which Dr. Pye-Smith had referred typical cases of 
rheumatoid arthritis during life, in which, nevertheless, post- 
mortem deposits of urate of soda were found in connection 
with outgrowths of bone. A number of other cases had also 
been seen ; so that it was clear, whatever the relation might 
be, that one did find outgrowths of bone, and so forth, in con- 
nection with unquestionable gouty deposits. Further, rheuma- 
toid arthritis, as he had himself seen, might supervene upon 
acute specific disease. He remembered seeing an old lady, about 
eighty, who had typical malum coxae senile, with the knee- 
disorder, and characteristic affection of the joints of the 
fingers, in whom the disease commenced with a virulent attack 
of scarlatina. During this attack, the knee and hip were 
affected; that was the starting-point of her rheumatoid 
arthritis. He could also quote a case of measles in a child, 
which led to a typical attack of rheumatoid arthritis super- 
vening immediately upon it. Then there was the moot point 
of gonorrhoeal rheumatism. Mr. Hutchinson and others, 
whose authority was undisputed, admitted that gonorrhoeal 
rheumatism could not be distinguished anatomically from 
rheumatoid arthritis. He remembered two cases of spondy- 
litis deformans, both in men aged about forty. In one case 
it had begun with an attack of acute rheumatism, and in 
the other with an attack of gonorrhoea; the latter not 
only had spondylitis deformans, but he had the shoulder and 
elbows and one knee affected, and the characteristic deformity 
of fingers. In every respect, it was a typical example of rheu- 
matoid arthritis. Lastly, there were cases, to which Dr. Ord 
had drawn attention, where rheumatoid arthritis began in con- 
nection with dysmenorrhoea ; as the dysmenorrhoea diminished, 
the rheumatic manifestations subsided. The outcome of what 
he had to say was, that rheumatoid arthritis was merely an 
anatomical term ; it was a description of a morbid anatomical 
product, which could be brought about by many different pro- 
cesses. Was it reasonable to say that all these processes were 
identically the same, because the anatomical result was the 
same? !l^ven granting that some of the cases of Charcot's 



cormection with Locomotor Ataay. 125 

disease were indistinguisliable anatomically from rheumatoid 
arthritis^ he submitted that this added nothing whatever to 
knowledge in that category ; it was the life-history which must 
come into consideration. He would refer, on the other hand, 
to the affection of the joints, and structures round joints, in 
connection with disease of the spinal cord. There were not 
only the hemiplegic cases, and cases of muscular atrophy, of 
which he had seen one notable example, exactly like what Dr. 
Bastian had described, but also that very common disease, in- 
fantile paralysis. If anyone would examine a case of old 
infantile parsdysis he would find a very remarkable condition 
of joint. He alluded especially to the hip-joint. In some 
respects, the hip-joint in old cases was not very unlike a 
joint in locomotor ataxy. The mobility of the joint was 
remarkable, and also the looseness of the ligaments. Further- 
more, the upper end of the femur was quite atrophied; 
all the bony prominences were bevelled down; and altogether 
there was an extremely atrophic condition. But if exception 
were taken to this, he would refer to a condition sometimes 
found during the acute stage of infantile paralysis, so that it 
was distinctly related to the acute onset of the disease. He 
had seen two cases in children, and one in an adult, similar to 
the case to which Dr. Stephen Mackenzie alluded a few weeks 
ago, wherein there was a condition of swelling around the joint- 
structures, redness, extreme tenderness, and some slight heat 
of skin, lasting a week or ten days, or more, within the first 
two or three weeks of an attack of infantile paralysis. That 
condition was more like the appearance of gouty swelling than 
anything to which he could compare it. But, of course, it 
would be absurd to suppose that in a child a few months old, 
within the circle of the febrile disturbance at the onset of in- 
fantile paralysis, such a condition as gout should be set up. 
He had had, also, under his observation for more than a year, 
a case of myelitis in a young lady whose initial symptoms 
suggested spinal apoplexy. There was complete paralysis of 
sensation and of movement of the lower Umbs, the sphincters 
also being paralysed ; and he had seen in her, no fewer than 
three times, a swelling coming on in the knee-joint, with pain- 
less effusion, without any obvious cause, lasting a time and 
then subsiding. As to how this was brought about he could 
not offer an opinion, but it was clear that affections of joints 
did occur in connection with disease of the spinal cord; and 
that being so, with the fact that rheumatoid arthritis was a 
mere anatomical name for conditions brought about by many 



126 Diecussion on Joint Disease in, 

different processes^ it seemed to him by no means absnrd to 
suppose tnat these curious joint diseases in locomotor ataxy 
had a real association with the nerve condition. 

Dr. B. (y GoNNOB said that the impression left on his mind^ 
as the result of the discussion on so-called Charcot^s disease, 
was, that some speakers seemed to think the disease was not 
this, and some thought it might be that ; and he believed there 
were some who regarded the disease as non-existent. It would 
be interesting to bear in mind that the views of Dr. Buzzard, 
Sir James Paget, Professor Humphry, and Mr. Jonathan 
Hutchinson, to a certain extent agreed. They were very 
similar on many points, notwithstanding the fact that it was 
believed, and very often stated, that patients advanced in life, 
presenting the symptoms of chronic rheumatic arthritis, were 
particularly and singularly free from ataxic symptoms. Pro- 
fessor Charcot himself, with reference to his typical cases at 
the London Congress, had referred to the ataxic symptoms ; 
and, if he recollected rightly, the only thing which he said of 
a definite character respecting the joint affections was, that no 
ordinary pathological condition was found which would coincide 
with dry arthritis. B.egarding it for a moment as an affection 
other than rheumatoid arthritis, the question was, what was 
the disease ? It had been said by several speakers that there 
were symptoms in locomotor ataxy which came on very sud- 
denly, which lasted for a time, which might remain permanently, 
or which might disappear. There were certain conditions 
which had been referred to by M. Charcot himself, affecting 
certain joints, which remained permanently; and he took it that 
those permanent elastic oedematous swellings which occurred 
in joints in cases of ataxy were the cases to which some persons 
now-a-days referred as Charcot's disease ; but he could not say 
on what good grounds this was done. He could imagine an 
author writing an elaborate treatise on some of the permanent 
nerve paralyses in cases of ataxy, and another writmg a book 
on amaurosis, and another saying that some ataxic patients were 
unable to walk backwards ; but he failed to see grounds upon 
which one would say that they were dealing with three new 
diseases. At the Richmond Hospital in Dublin, fifteen or 
sixteen years ago, he certainly haid seen a great number of 
joints and bones indistinguishable, at all events by himself, 
from many of those specimens which had been here regarded 
as very unusual, if not unique. With respect to the probable 
origin of it, it seemed to him that an hypothesis might readily 



eonneetian with Locomotor Aiaxy. 187 

be put forward; and^ after all^ it seemed to him that many 
were working on an hypothesis^ which was this — ^that a certain 
nerve lesion existed^ and this nerve lesion, whatever it might 
be, showed itself in certain ways. On the one hand, there 
might be cases with symptoms of rheumatic arthritis ; and, on 
the other hand, with ataxic symptoms ; and these ataxic cases 
might themselves be divisible into two classes — those without 
and those with permanent joint trouble. 

Dr. Hadden thought there was very little doubt that 
Charcot's was a distinct disease, and the arguments he should 
have used, if they had not already been put forward, were 
chiefly drawn from clinical and pathological facts. Still, as 
to Sir James Paget's question, W as this a new disease ? he 
remembered that, in the 8t, Bartholomew's Hospital Reports, 
three years ago, Mr. Eve called attention to a case of Mr. 
Stanley's which, he should think, was clearly a case of Charcot's 
disease. He gave the clinical symptoms — impairment of vision, 
incontinence of urine, and anaesthesia ; and Mr. Stanley went 
on to remark that, tmless the patient saw his legs, he could 
not tell their direction; but, on looking at them so as to know 
their position, he could readily move them. Then the condi- 
tion of the joints was described, and he thought they were 
singularly typical of Charcot's joint disease. As far as he had 
understood Dr. Bastian, he intimated that Charcot's idea that 
the disease really lay in a lesion of the motor cells was a hypo- 
thesis. But, as a matter of fact, Charcot figured the condition 
of the anterior horns in two cases— one, a case of diseased 
shoulder- joint, in which there was atrophy of the anterior horns 
in the cervical region. The other was the case of a knee-joint, 
with atrophy just above the lumbar region. 

Dr. Bastian said he was aware of that. The only question 
was whether that was the change which related to the joint 
disease. 

Dr. Hadden said that possibly it might be a coincidence ; 
at any rate, it was highly suggestive. It had also been noted, 
in cases of arthropathy, that there was a rapid atrophy of 
muscles in the neighbourhood of the joint. He should think 
the lesion was an anterior poliomyelitis affecting certain multi- 
polar cells. 

Mr. Hopkins said it appeared to him that there was a 



128 DisctLSsian on Joint Disease in 

traumatic element in the case of these joints, which wonid 
account for the manner in which they were affected asym- 
metrically. There were in tabes anaesthesia of the skin, 
delayed sensation, perverted sensation and anaesthesia of the 
ligaments ; this condition of limb, it seemed to him, was suffi- 
cient to account for the joint affection. A limb in that condi- 
tion might be readily injured. A very slight strain was suffi- 
cient to cause considerable injury when the ligaments were 
soft. A patient might have no knowledge of the accident, 
though effusion had resulted. He would briefly allude to a 
case that came under his care. A man the subject of tabes, 
whilst turning in bed, fractured the shaft of his femur ; there 
followed a considerable effusion into the thigh, which extended 
from the iliac crest to the knee; there was also abundant 
effusion into the knee-joint. The force was not wholly ex- 
pended upon the fracture of the femur; it was also sufficient 
to lacerate the ligaments of the knee-joint and cause effusion 
into it. It might be said that the fluid in the joint was due 
to the fracture. In that case injury to a limb at a distance 
from a joint could cause effusion into the joint. In any case, 
it showed how readily one might have effusion into a joint, 
from injury in an ataxic subject, and the effusion might be the 
starting point of the disease under discussion. 

The President thought that the Society was greatly to be 
congratulated on having initiated, continued, and, so &r as it 
was possible in the present state of knowledge, completed, an 
interesting and important discussion. The occasion had given 
the opportunity of bringing together more distinguished 
speakers on a subject of this kind than it was their privilege 
commonly to hear now-a-days. In the next place, it had 
afforded a pronouncement of English opinion, which had been 
much desired and needed, upon this question, which had 
received much attention abroad, and little public attention in 
England. In the third place, it would be the means of com- 
municating that which was much needed — accurate, extensive, 
and important information — ^to the great body of the profession 
upon this subject. Lastly, certainly not least, it had given 
an opportunity of doing justice to the distinguished foreign 
physician, to whom was due a very great advancement in our 
common knowledge. It might have been considered interest- 
ing, even instructive, to have summed up the opinions which 
had been expressed concerning this subject in the course of 
the discussion ; but it had already been done so well in one 



connectio7i with Locomotor Ataxy, 129 

of the journals, that, even if there had been time (which there 
was not), it had been rendered unnecessary. It would have 
been almost equally interesting, and perhaps a little more 
instructive, to have summed ap, not the speeches which had 
been delivered, but the ideas which had been evolved in the 
course of the discussion; but, as he saw that Mr. Morrant Baker 
had been taking very close notes, he had no doubt he would 
himself unfold and deal with those ideas with the same lucidity 
and ability with which he had started the discussion. 

Mr. MoBRANT Bakeb, in reply, expressed his gratitude to 
the Society for the very kind and altogether unexpected 
manner in which they had dealt with his paper. He would 
not attempt to enter into every detail that had been raised ; 
for, if he dealt with each speaker in succession, he should be 
repeating many things that had been said before, and he feared, 
that if he did that at any length, he should at that late hour 
carry out that process which was known as emptying the church 
down to the sexton. He thought he had been a little mis- 
understood as to his views ; and, although he had no preten- 
sions to be an authority on the matter, he should be glad, as 
he had read the paper, to state briefly what his view was with 
regard to Charcot's disease. He believed that the disease was 
identical with what was known as rheumatoid arthritis. At 
the same time, one ought to be as clear as possible as to what 
waa meant by rheumatoid arthntis. He meant by it neither 
rheumatism nor gout, nor anything that could be fairly called 
either the one or the other. He had been taught and had 
taught others, that there was a disease called rheumatoid 
arthritis, which was neither rheumatism nor gout. That dis- 
ease might best be called arthritis deformans or osteo-arthritis. 
This arthritis deformans was a fairly definite disease ; it was 
characterised by the same anatomical and pathological lesions 
which were undoubtedly met with in Charcot's disease— ebur- 
nation, osteophytes, fibrous degeneration of cartilage, wearing 
away of bone, and so forth. It was not fair to take an out-of- 
the-way case, which could hardly be called osteo-arthritis, and 
to say that it was unlike Charcot's disease. To be fair, one 
must take a typical case of each ; and, if that were done, it 
seemed to him that it must be acknowledged that, from the 
pathological point of view, it was impossible to find any real 
distinction. In reading carefully one at least of Professor 
Charcot's descriptions of the disease, it seemed to him that he 
had &iled to find any pathological difference, as to which it 
VOL. xviii. 9 



180 Disiyussum on Joint Disease in 

conld be said : '' This constitutes a radical distinction between 
the one disease and the other/' Yet^ at the same time^ the 
association with locomotor ataxy was not an accidental com- 
bination of two different diseases. He believed there was a 
most close pathological alliance between this form of arthritis 
deformans and locomotor ataxy ; and the only point on which 
he differed from Dr. Duckworth and Dr. Buzzard was this, 
that, instead of looking upon the two diseases as being cause 
and effect, he should be inclined, from present evidence, to 
look upon them as dependent upon some common cause— that 
is to say, a disease which in one case fell especially on the 
nervous system, in another case on the joints, and in another 
on both. And supposing a case to exist in which the disease 
fell upon joint and upon the spinal cord, it could readily be 
imagined that the concurrence of the two things would make 
the disease different ; in other words, if the patient had tabes 
and disease of the joints, one could not expect the symptoms 
in the joint disease to be exactly like those in a patient who 
had disease of the joint, but was not troubled by any disease 
of the nervous system. The difficulty in his mind in believing 
that it was merely a case of cause and effect was that he had 
seen cases which, as far as he could tell, clinically and patho- 
logically, were identical with Charcot's disease, but in which 
there were no*symptoms of tabes. There was a case that he 
had seen only a few days ago, under the care of Mr. Thomas 
Smith, of St. Bartholomew's Hospital, which he hoped Mr. 
Smith would bring before the Society. It was a case of a 
man, the condition of whose hip-joint seemed absolutely indis- 
tinguishable from Charcot's aisease, as shown in the speci- 
mens ; yet he was able to continue his work as a plasterer, 
and he had no symptoms whatsoever of locomotor ataxy. The 
man declared that he never had stomach-ache, so that he could 
not be accused of gastric crises. So long as cases of that kind 
occurred, it was difficult to say that this disease was due to, 
and always associated with, tabes ; therefore they should with- 
hold their opinion for a time, and try to obtain more &cts. 
There was one other thing to which he would refer. In build- 
ing up the knowledge of arthritis deformans, and saying that 
this disease was identical with it, they had been learning from 
cases that occurred during the years in which no questions 
were asked regarding the presence of locomotor ataxy, and 
they did not know, therefore, how many of these cases were 
really associated with tabes. He had seen these cases crop- 
ping up occasionally during the last few years, but only 



cormection with Locomotor Ataxy. 181 

witliin the last year or two had he asked a patient whether 
he had any symptoms of tabes. Therefore^ in saying that 
this disease was identical with arthritis deformans^ he was 
willing to allow that he might, in some cases, be merely saying 
that Charcot's disease was identical with Charcot's disease. 
He felt sure that there were many cases that wonld have 
shown symptoms of tabes also ; bat, so long as there were 
cases in which there were no snch symptoms, there was a 
difficulty in believing that locomotor ataxy must always be 
expected when this joint disease was found. With regard to 
what Dr Buzzard said about the specific gravity of bones, he 
did not think there would be any radical distinction in the 
two cases, but it would be well worth observing. Dr. White 
had anticipated him in what he should have said with regard 
to the apparent difference of opinion between Professor 
Charcot and Dr. Moxon. It was obviously, he thought, that 
they had been working in a different field of observation. 
Dr. Andrew, Dr. Ord, and Dr. Bastian, had each said, '' I 
have never had under my own care a case of Charcot's dis- 
ease." He would quote Professor Charcot, who, if he were 
not mistaken, said that his proportion of cases was six out of 
fifty. If he might compare small things with great, his own 
experience as a surgeon was this, that out of the cases of 
locomotor ataxy he had had under his own care within the 
last year, 100 per cent, had also disease of the joints ; so that 
one might look upon it that the explanation given by Dr. 
Buzzard was correct, that these cases naturally came to the 
surgeon. Since the debate began, he had been consulted 
about a case which he was told was a disease of the knee- 
joint. He had looked at the joint, and found it was a typical 
case of Charcot's disease. Mr. Barwell had had a very large 
experience in diseases of the joints, but he differed from him 
in thinking that one could set up a clear pathological dis- 
tinction between osteo-arthritis and Charcot's disease. He 
thought that there was ebumation in both cases, that there 
was fibrous degeneration, and he would refer to the micro- 
scopic specimens put up for him by Mr. D'Arcy Power, at 
two or three of the meetings, showing apparently the fibrous 
degeneration in Charcot's disease had been long known in 
association with osteo-arthritis. He believed that the small 
joints were affected; indeed, in three out of four cases of 
Charcot's disease that had been under his care, some small 
joint or other had been affected as well as the larger ones ; 
and with regard to clinical symptoms, at present he had not 



132 Diaeussi&n on Joint Disease %n 

been able to find any snch groap of symptoms as would make 
one say that they separated Charcot's disease from arthritis 
deformans. In the last case of this affection he had seen^ the 
joint had been painless ; but the patient said that his sensa- 
tion was defective in the whole limb. The swelling had been 
gradual^ and so had the symptoms. There was not that 
sadden onset of all the symptoms which occurred in a typical 
case. He could not agree with Sir James Paget with regard 
to what he said about this being a new disease. Sir James 
Paget had said that this must be a new disease^ because there 
were no specimens in the museums ; and^ if it had a separate 
existence^ how was it that it had been overlooked? With 
regard to the first pointy he thought that he had brought 
specimens from the museum of St. Bartholomew's Hospital 
which were not to be distinguished from specimens acknow- 
ledged by all to be those of Charcot's disease; and he 
thought^ if these bones could be clothed again with fleshy and 
live^ and if there could be the opportunity of asking questions 
as to this^ that^ and the other^ it would be found that many of 
those old bones had been taken from cases of locomotor 
ataxy. Of course, that could be only told from their present 
appearance ; but he should imagine that that was the case. 
He had seen other bones besides those which he had brought, 
which appeared to be old specimens ; and he should gather 
that some of these, at all events, were cases that had been 
enshrined in museums on account of something observed at 
the time as worthy of being recorded. They were, of course, 
labelled as osteo-arthritis, or chronic rheumatic arthritis. But 
he did not think with Sir James Paget that the differences 
between typical cases were so startling as he beUeved. He had 
referred to the case that he had seen with Mr. Thomas Smith, 
where apparently the symptoms were indistinguishable. With 
regard to the question, *^How had the disease been over- 
looked ?" he ventured to say, because it was so common. His 
(Mr. Baker's) argument would be this; that, as a rule, a 
museum was built up by carefully preserving anything which 
was out of the common. He believed that the reason why 
these specimens were not more numerous, was because they 
were looked upon as being common, and were not distin- 
guished from other severe cases of osteo-arthritis. He also 
agreed with what Mr. Marsh had said. These cases were 
being overlooked five or ten years ago ; and if they were over- 
looked then, why should they not have been overlooked fifty 
years ago 7 He had been much struck by a remark made to 



connection with Locomotor AtcLxy, 133 

him by a surgeon of a large infirmary in London after the first 
meeting. He had asked Mr. Baker whether he would like^ 
not to see one case of Charcot's disease in his infirmary, but 
to see a waggon-load. It was not to be supposed that this 
large number of cases had occurred in an infirmary within the 
last few months. Some of them must have been there for 
years^ and if this large number within five or ten years had 
been overlooked, did it not seem almost certain that cases for 
many years had been overlooked, because they had not been 
dissociated from cases of osteo-arthritis ? Therefore, until 
Professor Charcot threw light upon them by showing the con- 
nection between them and tabes, specimens had not been 
accumulated in museums. Again, with the greatest deference 
to Sir James Paget's authority, he thought it unfortunate that 
the term rheumatic arthritis should find a strong friend, as it 
had, in Sir James Paget, and he wished all could agree to 
discard it altogether, and only use the term osteo-arthritis or 
arthritis deformans. "With reference to the remarks of Dr. 
Ord, he had rather accused the speaker of saying that there 
was no attempt at repair. He (Mr. Baker) had hardly said 
that. He said, *^ either no attempt, or that it was inefficient 
and disorderly.^' He had not meant to imply that there was 
no attempt ; that there was waste without repair at all ; that 
would be, of course, rather a definition of death than of 
disease. He had meant to imply that the great characteristic 
of the disease was a wearing away, it might be at a natural 
rate, and that the repair was not at a natural rate, and was 
deficient, and that the tendency of the repair was disorderly. 
He was glad that Dr. Ord was on his side in preferring 
the term osteo-arthritis or arthritis deformans to that of 
rheumatic arthritis; and also that he had supported him 
in believing that there was a close pathological connection 
between osteo-arthritis and the nervous system. He was a 
little doubtful whether he might look upon Mr. Hutchinson 
as a friend or as an opponent. He agreed with him in what 
he said about premature senility. He thought that would 
express fairly in some respects the condition which there was 
in the joints, and he had attempted to express that, by saying 
that he thought the great feature of the disease was waste 
without repair. He would not suggest any term to express 
this, because words, which we intended, when we coined them, 
to be our servants, often became our masters; but still he 
hoped that someone with a greater knowledge of etymology 
wonld^ in time to come, invent a word which would express 



134 Discussion on Joint Disease m 

tliat idea. Ab to the theory about standing and walkings and 
that being the cause of this wearing away of the joints, he 
would quote the case of an old woman with Charcot's disease 
of the joint^s who had been paralysed for seyenteen years, in 
which both the hip-joints had almost disappeared as joints ; 
that is, the heads of the femora had disappeared. The upper 
end of the f emm* was drawn up above the level of the anterior 
superior spine of the ilium. That old woman could not pos- 
sibly have been the subject of much friction of the joint-sur- 
faces by walking, because she was more or less paralysed for 
the whole of the time. It would not be difficult to find facts 
that would oppose a theory like that of Mr. Hutchinson's on 
the subject ; and there was no doubt about the diagnosis of 
the case of this old woman, because she happened to be in 
Guy's Hospital^ under the care of Dr. Habershon and Dr. 
Wilks, at the beginning of her illness, and her case was dia- 
gnosed there as one of paraplegia. He agreed with what Mr. 
Hulke had said with one exception, namely, with regard to the 
connection of Charcot's disease with syphilis. He could not 
think that syphilis had anything to do with it. So &r as his 
own observation went, he could not trace any connection of 
syphiKs with locomotor ataxy, or with osteo-arthritis, or with 
this ioint disease. He could not think that Charcot's disease 
was indefinite in the sense in which Dr. Moxon put it, and he 
felt sure that, if the latter had a case presented to him, as it 
had been presented to himself on several occasions, he would 
be converted. When one saw a case, and one was only told it 
was a diseased knee-joint, and upon looking at the joint and 
examining it for two or three seconds, one could say that the 
joint was almost certain to be associated in the patient with 
symptoms of locomotor ataxy, and then, upon asking a few 
questions^ one found that it was so — when that happened over 
and over again, one could not help feeling absolutely certain 
that it could not be a mere coincidence. Therefore, he hoped, 
when Dr. Moxon had the opportunity of seeing more of these 
cases^ he would think differently on that point. With regard 
to the ex-cabman to whom Dr. Moxon had referred, he must 
doubt the appositeness of the illustration. He could not 
think that Dr. Moxon could seriously wish the members to 
believe that when a man had damaged his shoulder-joint, any 
amount of movement could wear down the head of the bone 
when the joint was more or less disabled from the injury. If 
that were the case with this unfortunate cabman^ the move- 
ment must have been of a very forcible description. The cases 



tonnection with Locomotor Ataxy. 135 

brought forward by Mr. Barker and by Mr. Henry Morris 
were cases of mach interest^ but be would not deal with them 
in detail^ nor with those of Mr. Herbert Page. With regard 
to the remarks made^ so many of them were in answer to pre- 
vious speakers that^ if he dealt with each in detail^ he should 
be going over very much the same ground. Mr. Hopkins said 
that many of these cases might be determined by traumatic 
causes. He was inclined to agree with him. Certainly that 
would explain the want of symmetry in many. In more tlmn one 
of his own cases the disease had apparently been started by an 
injury; inthecaseof one man by the wrenching of the knee; in 
the case of an old woman by falling off the sofa on her elbow. 
He thought it would be founds on closely examining into the 
history of many of these cases that, whatever their origin, what- 
ever the connection with tabes, yet some slight injury started 
the disease. He had no wish to dogmatise with regard to this 
question ; he had no authority to dogmatise on the subject. 
His anxiety had been to bring forward certain facts. He was 
anxious to add to the facts, and in raising the discussion he 
ventured to state, as clearly as possible, what theories might 
be adopted on the subject ; but he felt that one could not be, 
at the present moment, sure as to the right one. He had his 
opinion. He thought Charcot's disease was identical with a 
disease long known ; that the two diseases, tabes dorsalis and 
this form of osteo-arthritis, were not in the relation of cause 
and efiect, but were due to one and the same cause ; the disease 
of the spinal cord reacting unfavorably on the joint disease, 
when both were present ; but, should fresh facts arise to show 
that one could put on one side cases of Charcot's disease with 
certain symptoms, and fail to find those symptoms in osteo- 
arthritis, he would be glad to acknowledge that such was the 
fact. But he felt that, in order to get these new facts and 
opinions from others, he could not do better than bring his 
cases before the Clinical Society, and he felt especially happy 
in bringing them forward during the presidency of Sir Andrew 
Clark. 



1S6 Dr. Hale White On Lesions of the Frontal Lobe. 



XI. — On Lesions of the Frontal Lobe. By W. Hale 
White, M.D. Bead January 9, 1885. 

ALICE H.^ »t. 26^ was admitted nnder the care of Dr. Wilks^ 
Jane 14, 1884, for severe pain in the forehead and vertex. 
Family history of consumption. She never had any illness be- 
fore the present, and had not been liable to headache or loss of 
sight. Eight years ago she fell down, striking her head on the 
left side, and was unconscious for some time. She has been ill a 
month with severe pain over both eyes, shooting up into the top 
of the head. She has also become very near-sighted ; frequently 
when walking about she has lost the power of sight altogether 
for a few seconds without loss of consciousness. She is sometimes 
giddy when eating and has been sick twice since the beginning 
of the illness, but not severely. After her death I went to see 
her brother, with whom she lived, and questioned him closely 
but could obtain no further history from lum ; none of her friends 
thought her very ill, and they expected her to be well shortly. 
The doctor who saw her does not seem to have thought the case 
serious. The only mental symptom noticed was that she was 
a little " mysterious.^^ She would often use the phrase " I am 
thinking,'^ and when her brother suggested that she should 
tell what she was thinking about she declined to do so. He 
does not think that her memory, reasoning, or emotional 
faculties were at all impaired. She was engaged to be mar- 
ried and would take long walks with her fiance, remaining 
constant to him till the end. 

On admission, — ^No paralysis or ansBsthesia ; in short, the 
only sign to be detected was marked double optic neuritis. 
She complained of nothing but intense pain over the eyes. 

June 22. — ^Was up for a short time to-day. Went to bed 
early because of the pain in the head. She had one sixth of 
a grain of morphia subcutaneously ; a little while after this 
she vomited and then became quiet. 

At 2 a.m., on June 23, she was found dead in bed. 

Post-mortem examination. — Brain : Membranes and vessels 
healthy. The convolutions were flattened, especially those of 
the left frontal lobe^ which was much more prominent than the 
ri^ht, projecting forwards beyond it considerably. In the 
left &ontal lobe a hardness could be felt. On making hori- 



Dr. Hale White On Lesions of the Frontal Lobe. 137 

zontal sections it was found to contain a very Kght-coloured 
greyish new formation, which at the front and outer part con- 
tained a cyst full of fluid which might possibly haye been old 
blood. It was difficult to say whether this new formation was 
inflammatory or gliomatous, probably the latter. The lateral 
ventricle, caudate, and lenticular nuclei, internal and external 
capsules, and claustrum were none of them implicated. The 
island of Beil and ascending frontal convolutions were also 
free, but the new formation extended into the front part of 
the gyrus fomicatus, the marginal convolution, the first, second, 
and third frontal convolutions, and the orbital convolutions, 
but there was no bulging on the orbital surface of the frontal 
lobe. The lateral ventricles were dilated. The rest of the 
brain was absolutely healthy; no descending degeneration. 
Intense optic neuritis in both eyes, the discs being swollen 
and blurred. Every other structure in the body was quite 
healthy. Microscopic examination showed the tumour to be a 
glioma. 

Case 2. — ^Alice A., set. 31, was admitted into Guy's Hospital 
June 20, 1884. No illness before the present one, which she 
first noticed twelve months before admission. No history of 
scarlet fever, rheumatic fever, or fits. Work light. Occa- 
sional difficulty of late in her breathing. First consulted the 
doctor a month ago for stiffness confined to the right leg ; this, 
together with swelling of the leg, has troubled her on and off 
till admission, five days before which she noticed in the morn- 
ing a stupid feeling in her head and she could not speak 
plainly nor use her left hand efficiently ; by the next day her 
left leg was similarly affected, and on the day after that she 
was unable to rise without assistance ; her foot subsequently 
turned cold and she lost sensation from the mammary line to 
the foot. 

On admission. — Healthy looking; lies in bed without any 
distress ; complains of vertical and occipital headache ; left arm 
and leg fall lifeless when lifted, and she does not appear able 
to move them. On tickling the sole of the left foot there is 
more movement than in right. Complains of a strange sensa- 
tion running all down the left side and leading to twitching 
movements. Says she has had similar symptoms for some 
years. Finger ends much clubbed and bulbous. Cardiac impulse 
visible over whole of left mammary region and also in neck. 
Loud whiffing systolic bruit audible at apex and carried round 
to the back. To and fro basic murmur carried up the vessels 



138 Dr. Hale White On Lesions of the Frontal Lobe, 

in the neck and also down the sternum. Pulse 84^ water- 
hammer. Sphygmographic tracing shows it to be a charac- 
teristically splashing pulse. Lungs normal. Liver dulness an 
inch below the ribs. Spleen not to be felt. Urine normal. 

The power in the leg began to improve directly after 
admission. Thus on the second day of her stay the nurse 
complained of the patient because she kicked off the bed- 
clothes^ and after she had been in five weeks she was walking 
about daily and using the left arm to work. 

On August 18 she was heard to fall whilst in the water- 
closet ; she was found in epileptiform convulsions, cyanosed, 
frothing at the mouth, insensible, and with Cheyne-Stokes 
respiration. On coming to, she vomited excessively, her pulse 
was found to be 150, and she was very collapsed. This con- 
dition of prostration lasted a few days, diminishing in inten- 
sity each day, till soon she returned to her former condition. 

On September 7 she had an attack of inability to speak 
which lasted a quarter of an hour and was accompanied by 
sweating and a feeling of coldness. 

Towards the end of October her breathing became worse ; 
she gradually sank and died November 15. 

Post-mortem exaimnation. — Heart 22 ^ oz. All the cavities 
dilated considerably; thickness of muscle normal in all parts. 
No pericarditis ; muscular tissue had undergone some fatty 
change. The segment of the aortic valve that has no coronary 
artery behind it was covered with a large irregular mass of 
vegetations with much fibrin on them ; this mass had come into 
contact with the ventricular surface of the anterior division of 
the mitral valve and had here given rise to a mass of vegetations 
about the size of small sago grains; these had caused a rough- 
ness on the other surface of the valve, which rough part coming 
into contact with the posterior surface of the auricle above the 
posterior valve had there caused some vegetations to appear. 
All the orifices were dilated. Lungs : Some oedema at bases ; 
white patch, probably small infarct, in right, at anterior edge. 
Liver fatty and nutmeg. Kidneys fatty ; several small pucker- 
ings on the surface due to minute infarcts. Spleen contained 
three infarcts, one very large. 8tonuich congested. Brain : 
Vessels and membranes healthy. The posterior part of the 
right frontal lobe seemed perhaps slightly distended, and felt a 
little softer than the corresponding part of the opposite side. 
On slicing through the brain at the level of the corpus cal- 
losum one came on a brick-colom*ed clot about the size of a 
filbert nut, situated in the white matter of the brain in the 



Dr. Hale White On Lesions of the Frontal Lohe. 139 

right frontal lobe, encroaching slightly npon the gyms f omi- 
catus just where it bends round the corpus callosum. This 
clqt lay on the roof of the anterior comu of the right lateral 
ventricle, but was separated from it by a layer of healthy brain 
substance, about a quarter of an inch thick. The clot was 
triangular, with the apex directed downwards, and, passing in 
front of the anterior comu, it terminated at about the leyel 
of the floor of the comu. The brain substance around the 
comu was unaffected. The rest of the brain and spinal cord 
were absolutely healthy. 

I have ventured to bring these cases before the notice of 
the members of this Society because of the many points of 
interest attached to them. Although, as is well known, 
tumours of the brain, especially those of the frontal lobe, may 
produce no symptoms in the earlier stage, it is ra.re for none to 
occur during the final stages of the illness. In the first case 
for a whole month absolutely the only symptom was headache, 
and although at the end of the illness this symptom became of 
the character indicative of cerebral mischief, yet earlier not any 
of the friends or the doctor thought it of any importance ; the 
vomiting was very infrequent and very slight, the alteration 
in sight was unimportant, a history of it only being elicited 
when particularly asked for. After her death I questioned 
her brother, who was very intelligent, most carefully, and all I 
could find out from him was that the girl had had a headache, 
but that nobody thought anything of it, and that she went about 
her occupations as usual. On her admission the only thing 
discovered beyond this was optic neuritis. She was well enough 
to be about the ward twelve hours before she was found dead 
in bed. 

In addition to the interest which the fewness of symptoms 
gives to the case, and the consequent liability, except for the 
optic neuritis, to confound it with a case of gastric derange- 
ment, we have also the peculiar mode of death, which can 
hardly be attributed to do small a dose of morphia as one sixth 
of a grain. Why did she die ? Surely it is strange that she 
should do so when well enough to be up and about the ward 
a few hours beforehand, more especially as the growth was 
not situated in a part of the brain concerned with vital func- 
tions, nor was it likely that it affected other parts by pressure, 
because a few hours before death there was no evidence of 
such pressure. Tumours of the brain no doubt have fre- 
quently a sudden termination, but generally there are at the 



140 Dr. Hale White On Lesions of the Frontal Lobe. 

same time some important symptoms such as coma^ &c.^ 
present. 

Then, again^ in addition to the clinical interest which the 
case derives from the fewness of symptoms and the sudden- 
ness of deaths it possesses great interest to the physiological 
psychologist owing to the large destruction of brain substance 
without either loss of motion^ sensation^ or intellectual 
faculties. 

The second case is also very instructive. Dealing only 
with the nervous symptoms we may, I think, dismiss the phe- 
nomena of loss of motion in the left leg and arm as not due to 
any coarse lesion in the brain ; for not only was there an entire 
absence of such lesion at the post-mortem examination, but the 
facts that the loss of power occurred first in the right then in 
the left, that it was so gradual in its onset, that it was accom- 
panied by '' queer sensations,^' and recovery was so rapid, are all 
against the supposition that it was due to embolism ; probably 
it was functional ; anyhow it could not have been the result of 
the haemorrhage discovered post mortem. The only sym- 
ptoms one can connect this vntii are those of the attack which 
came on in the water-closet, all of which, except perhaps the 
convulsion, are easily explicable by it. But the reason why 
this case is brought forward is that we have here a large 
destruction of the frontal lobe without any destruction of 
motor or sensory faculties or impairment of intellectual power. 
Cases of damage to the frontal lobe without any very marked 
symptoms are to be found scattered through medical litera- 
ture ; still they are sufficiently rare for it to be veiy unusual to 
meet with two in such a short space of time. It is pretty 
generally allowed that the front part of the frontal lobes have 
to do with the intellectual functions, for it is a matter of 
common observation that races of low intellectual calibre have 
receding foreheads. How is it then that there is in cases of 
injury of the frontal lobe such slight, if any, intellectual impair- 
ment ? The reason is, I think, because the intellectual powers 
are the latest acquisitions both in the life of the individual and 
also in the animal series. Early formed functions, such as 
movements of the arms and legs, have fixed centres, whilst the 
later formed movements, such as those of the &ice, are not so 
well fixed. This is well seen in gestures; all the lower 
animals and children can move their arms and legs, but it is 
not till the child has advanced some way in life that it 
acquires the power of such gesticulation as elevating the eye- 
brows in surprise, contracting them in anger, &c. Now, 



Dr. Hale White On Lesions of the Frontal Lobe, 141 

stimulation of one face centre causes movement of both sides^ 
and the face is the least affected and the first to recover in 
hemiple&Hla. Both these facts bear out the hypothesis that 
impressions arriving^t or proceeding from the f ice centre are 
not so definitely impressed as those from the movements of 
the arms and legs^ and that the centre of the opposite side^ on 
the Broadbent hypothesis^ is quickly capable of taking up the 
work of the damaged one^ just as Broca's right convolution is 
capable of quickly taking up the function of the destroyed left 
one, because here also the power of connecting objects with 
definite sounds is acquired late both in the life of the indivi- 
dual and in the history of the animal series. Expressed in the 
terms of the view of Mr. Horsley we should say that, in the later 
formed functions, the second of the bilateral associated centres 
is more quickly brought into play than in the earlier formed 
functions. Now, on this law, that the recently acquired func- 
tions are the less firmly fixed to one particular part of the 
brain, and that the rapidity with which they are capable of 
being taken up by some uninjured part either on the same 
side or the opposite is in proportion to the lateness, in the 
animal series, of their acquisition, it is not difficult to under- 
stand how, in cases of disease of the frontal lobe, which 
presides over the very latest formed powers, the uninjured 
should be capable of very quickly taking on the function of 
the diseased parts. It matters not on this hypothesis whether 
we generally in our intellectual operations use only one side or 
both, because in the latter case it would only be necessary to 
suppose the uninjured side capable of quickly taking on 
double work. In generations to come, what are now recently 
acquired intellectual functions, will become so fixed that when 
they are lost by injury of one frontal lobe, no other part will 
be able to take them up, whilst the still higher functions, as 
yet unimaginable, will be rapidly taken up by the sound side. 
In those cases in which, after injury to the frontal lobe, there 
has been intellectual impairment, it is because the lesion is so 
extensive, and so many intellectual functions are impaired, that 
the remaining parts of the brain can only take up some of 
them. 

Without entering into the respective merits of the Broad- 
bent hypothesis and that recently urged by Mr. Horsley, of 
bilaterally acting cortical centres to account for recovery of 
motion after cerebral lesion, I would point out that the great 
extent of the damage in my first case, with complete absence 
of any symptoms, drives one to the conclusion that in the case 



142 Dr. Hale WUte On Lesions of the Frontal Lobe, 

of intellectnal facilities the sonnd side of the brain is capable 
of taking on the work of the diseased side. I snspect that any 
newly acquired capability is at first represented on both sides 
of the brain^ both thus acquiring a new but similar function ; 
after a loug time of transmission through many generations^ 
ond of these gets gradually more used than the other, until, if 
such a capability has existed for a multitude of generations, 
as the power of connecting ideas with certain movements of 
vocalization, it takes some months to educate the usually 
unused side, whilst if the functions belonging to the injured 
part be recently formed, the uninjured side can take them on 
at once. Of course if both frontal lobes are destroyed this is 
impossible; hence the idiocy of children without the front part 
of the frontal lobes. 



Dr. Pringle^B Ockse of Becurrent HsBmatemesis. 148 



XII, — On a Case of Recv/rrent Hamatemesis with Urti- 
caria. By J. J. Pbingle, M.B. Bead January 9, 
1885. 

THE subject of the cnrions affection I am about to describe 
is a gentleman, 8Bt. 51, retired from the army with the 
rank of lieutenant-colonel, with a history of no illness previous 
to the present, except one slight attack of dysentery and one 
or two mild agues during a seven years^ stay in India, from 
1858 to 1865. He had always been most abstemious as regards 
alcohol, and is a tall, muscular, and robust-looking man, of 
active mental and bodily habits. 

There is no family history of gout, haemophilia, or of any 
decided diathetic tendency to throw light upon the present 
case, unless the facts that his father died oi diabetes at the 
age of seventy, that a brother is subject to curiously capricious 
asthmatic attacks, and that several members of his family are 
liable to '^ biliousness,^' may be considered to do so. The 
elder of patient's two sons, set. 3, is peculiarly subject 
to copious and troublesome nettlerash. None of his five 
daughters are so affected. 

The history of the present ailment may be dated from 1872, 
when the patient had two severe attacks of ordinary nettle- 
rash, attributed to indiscretions of diet. He remained in 
Eerfect health till September, 1878, when he began to suffer 
*om repeated attacks of nettlerash with an unusual amount 
of prostration and malaise. During 1879 the nettlerash 
recurred with increasing frequency and severity, the tongue 
and mucous membrane of the mouth and fauces being involved 
in the more severe attacks. In the latter part of the same 
year vomiting of clear watery or glaiiy fluid with intense retch- 
ing, and subsequently of altered blood in the shape of ^^ coffee- 
ground matter " first showed itself. During 1880 the patient 
may be said never to have been entirely free from nettlerash, 
which appeared on the most trivial exposure to cold, or from 
such subjective symptoms as " itching, " twingings,'' "irrita- 
bility," " heats and chills " of the skm. At intervals of about 
two months occurred attacks of great severity, during which 
vomiting often lasted for twenty-four hours at a time, and large 
quantities of pure red blood were ejected in addition to altered 



144 Dr. Pringle^s Oase of Recurrent Hoematemesis. 

blood. In 1881 the attacks were less frequent^ an immunity 
for eight months being enjoyed, but those which did occur 
were of an even more alarming nature than the previous year. 
In 1882 he had one mild attack in May with vomiting only of 
altered blood, and in November occurred the most severe 
attack he has ever had. It was attributed to exposure to cold 
whilst fishing; the initial skin rash was very abundant, the 
affection of the mouth and fauces intense, and the hasmatemesis 
so copious that the patient^s wife says " the blood poured out 
like water from a jug, filling two handbasins and saturating the 
bed." The condition was so critical that for forty-eight hours 
the patient could not be undressed, and his medical attendant — 
Mr. Hill, of Crickhowel — writes me, that "he could not allow his 
friends to entertain any hope of his recovery." I had the oppor- 
tunity of witnessing the end of his next attack on April 15, 1883, 
kindly accompanied by Dr. Wilks, who was acquainted with 
the history of the case, and by Dr. Hurd- Wood of Leatherhead, 
who had watched it from its earUest commencement. The 
attack was a severe one, the first warning being a copious 
eruption of nettlerash over the whole body forty-eight hours 
before our visit, followed in due course by swellmg of the 
touffue and fauces, and by vomitin&r of blood which filled a 
large handbasiu. Bright pink urti<irial wheals, showing in 
places a crescentic arrangement, were studded over the trunk 
and extremities ; nowhere were they purpuric. The interven- 
ing body surface was of statuesque pallor, the face and ears, 
however, flushed; the temperature not raised; the skin 
moist ; the pulse soft, beating 80 to the minute ; the stomach 
apparently somewhat dilated to light percussion ; the spleen 
not swollen ; the voice a mere whisper ; the pupils contracted ; 
and the patient in such a condition as may be inferred from 
the amount of blood lost and the free use of morphia subcu- 
taneously, which had been found the only remedy e£Scacious 
in allaying vomiting. A relapse of all the main symptoms 
occurred two days later without obvious cause, after which 
recovery was, as usual, rapid and apparently complete. 

The treatment of the attacks had hitherto comprised all the 
various measures generally resorted to in cases of gastric 
hsemorrhage, with free purgation by salines on the earliest 
appearance of symptoms, and feeding exclusively by the bowel 
during and for some days after an attack. Hypodermic injec- 
tions of morphia and ergotin and rectal injections of Battley's 
liquid extract of ergot had been employed, but only after haema- 
temesis had already set in. Shortly affcer the above I suggested 



Dr. Pringle's Oase of Recurrent Hsematemesit. 145 

that as soon as nettlerash appeared and nansea was complained 
of, hypodermic injections of ergotin (one third of a grain) and 
morphia (one sixth of a grain) should be at once administered 
with a view to controlling haemorrhage on the one hand and 
vomiting on the other. An opportunity for employing this 
method of treatment presented itself four months later, ^. e, in 
August, 1883, when the patient was resident in Bournemouth, 
under the observation of Mr. Scott, but during this interval 
an interesting and important new feature of the case presented 
itself in the form of two unequivocal attacks of acute gout, the 
first affecting the right foot, the second the left hand. In 
August the early symptoms of an attack set in with severity and 
vomiting of " bilious " matter ensued, but not of blood. After 
two injections vomiting ceased, and the attack was apparently 
arrested although the patient felt ill and was unable to get 
about for three days, at the end of which he passed a copious, 
dark, tarry motion, with complete relief to all his symptoms. 
On only one previous occasion early in the history of the case 
had anything in the motions suggestive of blood been observed. 
For nearly a year perfect health was enjoyed, but in July, 1884, 
he had a fresh attack with no new feature except persistent 
sneezing as an early symptom. A little altered blood was 
vomited before the injections were used, but after their employ- 
ment all vomiting ceased and there was no subsequent melsana 
although fresh crops of nettlerash continued to appear for three 
days. His last attack was in December last ; the earlier sym- 
ptoms were severe, and " bilious " vomiting set in, but after 
employing the remedies prescribed the attack passed off. In 
addition to the more striking features of the case it has been 
noticed that before many of the attacks the patient has been 
out of sorts, with impaired appetite, furred tongue, constipated 
bowels, headache, and a yellowish tint of conjunctiva, but these 
symptoms have by no means been constant or in any relation 
to the subsequent severity of the attack. Since 1878 the diet 
has been carefully regulated, and for the last two years the 
remedies usually employed for the restoration of suppressed or 
disordered hepatic function have been conscientiously taken, the 
patient himself expressing a decided preference for podophyllin. 
Exposure to cold, to which the patient was formerly very sus- 
ceptible, has in many instances been the undoubted immediate 
determining cause of an attack, the two last, for instance, having 
ensued upon a game of lawn tennis on a cold day, and upon 
attendance at a heated political meeting with subsequent 
exposure to chilly night air. The patient recuperates with 
VOL. xvm. 10 



146 Dr. Pringle's Oase of Becfwrrent Hssmatemeins. 

amazing rapidity after the attacks and in the intervals his 
digestive powers are in every respect excellent in so &r 
as they are put to the test; he is absolutely devoid of pain 
or uneasiness in connection with food and does not wince 
under forcible abdominal palpation. His liver is of normal 
size ; his spleen is not enlarged. I regret that I am unable 
to give details as to the state of the urine during the attacks ; 
it is certain^ however^ that it is of high colour and concentrated^ 
but that it has never contained blood-corpuscles or blood- 
pigment. The average amount of urine passed in twenty-four 
hours has, unfortunately, never been estimated, but for more 
than a year the patient has had to rise about 4 a.m. regularly to 
pass water. The specific gravity of the urine fluctuates 
between 1020 and 1025 ; it is of a pale sherry colour, sometimes 
with a deposit of pink urates, and all the specimens I have 
examined have been intensely acid and have deposited the 
various crystalline forms of uric acid in great abundance. I 
have had no opportunity of estimating the average amount of 
urea excreted. Neither albumen, sugar, nor casts have ever 
been present. 

The heart is not obviously hypertrophied, its impulse is 
weak, the sounds free from bruit, but the second over the 
aortic area is sharply accentuated and occasionally redupli- 
cated. The radial pulse is rather small, but hard and slow, 
sphygmographic tracings from it being flat topped with very 
gradual descent. The fundus in both eyes is normal, the 
arteries of fair size. 

The blood has never been examined during an attack ; in 
the intervals it has presented no abnormal microscopical 
characters and is of average corpuscular richness. Within 
the last six months, what I take to be minute tophi have made 
their appearance in the pinna of the right ear. 

Remarks. — ^The main point of interest being the occurrence 
of coincident attacks of urticaria and haamatemesis, I purpose 
to consider the relationship, if any such there be, between 
these two chief features of the case. The absence of symptoms 
of hepatic cirrhosis or other conditions producing portal con- 
gestion and of disordered blood states, such as scurvy or 
purpura, precludes the possibility of hadmatemesis from such 
causes. It is obviously impossible, in view of clinical and 
pathological experience, to deny the existence of a gastric 
ulcer, but on the other hand, there are none of the symptoms 
usuaUy associated with such a lesion, the patient's digestion 



Dr. Pringle's Oase of Recurrent Essmatemesis. 147 

beings as I have mentioned, unaccompanied by any subjective 
indication of gastric dyspepsia. Nor would me presence of a 
gastric ulcer account for any of the phenomena except the 
copious vomiting of blood. 

I am forced then to the conclusion that the hadmorrhage 
from the stomach m due to capillary rupture, occurring when 
the mucous coat of that organ is in a state analogous to the 
urticarial condition of the skin, and in support of this view, 
bizarre as it may appear, I would submit the following con- 
siderations : (1) that on no occasion has the patient suffered 
from gastric disturbance or hflematemesis without the previous 
occurrence of copious nettlerash upon the skin and in the 
mouth and fauces ; (2) that in less severe attacks, only vomit- 
ing of mucous or ^^ bilious'' matter has ensued, indicating a 
less marked or more transitory dilatation of the gastric capil- 
laries, whilst in attacks of intermediate severity the small 
quantities of altered blood vomited have indicated sKght and 
gradual capillary hadmorrhage ; (3) that the apparent success 
of the treatment in arresting the haemorrhage renders its 
dependence upon gastric ulcer, or any condition involving the 
erosion of large vessels, extremely improbable. 

Presuming then that such a condition is possible in the 
stomach, and bearing in mind that urticaria of the fauces shows 
itself as diffuse redness and swelling, not in the form of cir- 
cumscribed wheals, we have, I think, some indication of the con- 
dition which obtains in the mucous membrane of the stomach 
during these attacks. The fact that the capillaries of the 
gastric mucosa form an extremely fine and extensive network, 
supported and separated from the cavity of the organ only by 
a delicate basement membrane, and a single layer of caducous, 
columnar epithelial cells fully accounts for the occurrence 
of haemorrhage and for its amount in the more severe attacks 
described. 

I have been unable to find any account of similar cases. 
Those most nearly approaching it are found in Graves's Clinical 
Lectures. He narrates* the case of a gentleman of very gouty 
habit who, after labouring for some time under languor and 
weakness accompanied by spasms, pains, and sense of weight 
in the stomach developed swellings which became as large as a 
pigeon's egg, were accompanied by a sensation like the bite of 
a gnat, were generally about the face and sometimes inside the 
mouth and about the palate and uvula; their duration lasted 

• Clinical Leotures, 1848, vol. i, p. 462, et teq. 



148 Dr. Pringle's Oase of Recu/rrent HsBmatemesis. 

only a few hours. The patient was under the impression that 
sinular swellings affected his stomach also. 

Again, Graves* describes two cases which he calls ^' exan- 
thema haemorrhagicum/^ The first is that of a robust man 
89t. 29 admitted into hospital with febrile symptoms^ vomiting 
dark fluids passing blood in his urine and mingled with his 
faeces; subsequently blood oozed from his gums and mouth 
and he had haemoptysis. On the seventh day from the com- 
mencement of bleeding from the intestines an eruption of 
rather large elevated red spots appeared on the arms and 
thighs^ which never became haemorrhagic and completely 
faded after five days. There is no mention of subjective 
symptoms in connection with these spots. The patient died 
on the twenty-ninth day of his illness &om repeated bleedings, 
and at the autopsy no lesion beyond minute red spots dispersed 
over the surface of the mucous membranes was found. 

Graves's third case is that of a labourer^ aat. 34, robust, 
but with an alcoholic history and subject for years to bleed- 
ings from the nose^ preceded by malaise. Fourteen days 
before coming under observation he took some cold water 
whilst in a state of perspiration, and was immediately attacked 
by rigors, nausea, and lassitude, soon followed by bleedings 
from the nose, mouth, and bowels, which recurred at intervals 
till his admission te hospital, and which seem not te have been 
mitigated by treatment there. On the twentieth day of his 
illness an eruption, ushered in by a tingling sensation resem- 
bling the sting of nettles made its appearance over the surface 
of the body, the spots having the same characters as in the 
preceding case. Vomiting of " coffee-ground '* matter ensued 
and the patient died on the twenty-seventh day of his illness, 
the eruption having totally disappeared after existing for five 
days. There was no autopsy. 

Murchisont mentions the case of a boy, aet. 9, who suffered 
from urticaria tuberosa and purpura urticans with haemorrhage 
from the bowels, kidneys, and urinary passages, and with the 
discharge of much lithic acid in the urine. No further details 
are given regarding the case, which seems te have many 
points of resemblance te mine. 

Dr. Sievekingt records a case of haematemesis without 
obvious cause in a girl, immediately relieved on the appear- 
ance of an erythema nodosum. 

* Ihid.f vol. ii, p. 362, et seq, 
t Lancet, 1874^ vol. i, p. 581. 
t Ibid,, 1868, vol. i, p. 12. 



Dr. Pringle's Case of Recurrent HsBmatemesis. 149 

Mr. Milton* describes several cases of " giant urticaria " 
affecting the nostrils, fauces, glans penis, and probably the 
urethra, some of them in decidedly gouty subjects ; and Leubet 
mentions the occurrence of temporary albuminuria in connection 
with eruptions of nettlerash. 

The relation between urticaria and bronchial asthma, in 
many cases at least, is too well attested to need anything 
beyond mention here. 

It would also be beyond the object of the present paper to 
enter into any discussion upon the complex subject of the 
relationship between the gouty condition, hepatic derange- 
ments, and skin eruptions, all of which form component parts 
of this case. It is rather curious, however, to note that very 
many writers upon dermatology neglect to enumerate the 
gouty diathesis among the causes of urticaria, and that among 
writers upon gout it should be a French physician — Dr. 
Lecorche, of Paris — ^who should most strongly insist upon the 
association.]: 

Fanciful as it may appear to some, I cannot but think that 
the marked improvement which ha^ occurred in the case 
cannot entirely be attributed to the greater attention the 
patient has latterly paid to the rules laid down by his medical 
attendants, but, in some measure at least, is due to the frank 
development of his arthritic affection. 

Finally, I desire to express my thanks to Dr. Hurd-Wood 
of Leatherhead, Mr. Hill of Crickhowel, and Mr. T. B. Scott 
of Bournemouth, who have kindly supplied me with many of 
the facts of the case, and very especially to Dr. Talfourd 
Jones of Brecon, who first, in 1881, recognised its true nature, 
and with almost prophetic penetration laid down a line of 
treatment from which no tangible departure has yet had to 
be made. 

Since the preceding paper was read before the Society 
the patient has been totally free from urticaria, with one 
exception. 

In the last week of April he awoke one morning with 
the subjective warnings of an imminent attack. During the 
course of the day a copious crop of nettlerash developed and 
there was considerable retching and actual vomiting. At the 
same time the right wrist became much swollen, hot, and 

* Sdin, Med, Joum,, December, 1876. 
t EapoBi, HautkranJeheiten, 1880, p. 800. 
t TraUi de la Qoutte, 1884, p. 876. 



150 Dr. Pringle^B Oase of Recurrent SaBmatemesis, 

somewhat painful^ " as if it were sprained/^ but all symptoms 
disappeared in the course of twenty-four hours under the 
treatment already described. 

This rapid and evanescent effusion into a joint confirms 
the view of the truly gouty nature of the case^ and is explic- 
able only on the theory of a trophoneurosis. 

May 26^ 1885. 



Th, Altlians^s Octae ofHemicmsBsthesiafrom Brain Disease, 151 



XIII. — Case of HemiancBsthesia from Congenital Brain 
Disease. By JuLrcrs Althaus, M.D. Bead Jammry 
23, 1885. 

EB., a Kvely girl, set. 11, was admitted under my care 
• into the hospital on May 15th last with the following 
history: 

She is the eldest of four children, and the three others are 
quite well. There appears to be no neurotic tendency on the 
part of either of her parents, but she was delivered with 
lorceps. Immediately after birth she had a succession of 
convulsive attacks, and her left side appeared to be paralysed. 
Ever since, the left side has been different from the right, and 
the arm more useless than the leg, for while she can run about 
as well as other healthy children, she has great trouble in 
using her left hand, and can only just hold her fork at table. 
She began to walk and talk at about the same age as other 
children, but continued having slight fits at intervals all along. 
About two years ago she had a much more severe attack than 
she had ever had before, having been violently convulsed for 
nearly an hour ; and she has since then had one or two such 
strong attacks at long intervals, with continuous lesser 
seizures. Of the latter she has occasionally eight or ten in a 
single day, and then none for a week or ten days. With all 
this her general health is excellent ; she can run about and 
swing, play battledore and shuttlecock, knit, and do a little 
reading and writing when she is inclined to, not otherwise. 
She is, however, subject to ^' violent moods,*^ in which she 
kicks, bites, and smashes crockery j indeed, there is nothing 
teo bad te expect of her. At other times she is anxious to 
please everybody. Her perseverance is great, an instance of 
this being that she knitted twenty-three pairs of cuffs for 
children at the Jenny Lind Hospital in Norwich last winter, 
besides a great many others for other people. 

Present state. — ^The patient is a well-grown and muscularly 
well-developed child. Her physical health is good. There 
are no peculiarities in the formation of her skull. Her con- 
versation is impetuous and occasionally silly; she answers 
questions readily and impulsively. On examining the side 
said to to be paralysed I found that there was no paralysis of 



152 Dr. Althaus's Oase of HemiansBsthesia from Brain Disease. 

motion anywhere, but that she was subject to complete hemi- 
ansdsthesia of the entire left side of the body from the vertex 
down to the toes. On the right side of the body, on the con- 
trary, sensibility was unusually keen, and the line of demarca- 
tion between the sensitive and the anaesthetic zone was 
sharply defined. In order to show me that she felt nothing 
in the left hand she bit and scratched it, ran a pin right into 
the flesh of the hand and the forearm, and then expressed 
her astonishment that she should not feel anything of it ; she 
added that as long as she could remember she had never felt 
anything at all in the whole of that side. Indeed, neither 
contact, nor pricking, nor pinching, are perceived, and there 
is therefore not only hemianaesthesia but also hemianalgesia. 
The sense of temperature is likewise absent, as the girl 
cannot distinguish between two test-tubes, one of which con- 
tains hot and the other cold water. The same is the case 
with the sense of pressure, for she is unable to distinguish 
between the weight of a sixpenny-piece and half-a-crown. 
The anaesthesia affects not only the skin, but also the mucous 
membranes of the eyes, nose, and mouth. The superficial 
reflexes were everywhere lost, while the deep or tendon 
reflexes could be elicited. The left pupil was large, although 
not different in size from the right, and it did not respond to 
the influence of light, while the right pupil contracted visibly 
when a lighted match was held near it. 

In addition to all this there was anaesthesia of all the 
nerves of special sense. The patient saw nothing with the 
left eye. The ophthalmoscopic examination of the fundus of 
the eye, which was made by my colleague. Dr. Laidlaw Purves, 
showed "the left optic disc of pearly-white lustre, circular; 
calibre of vessels small." Smell was entirely lost. I tested 
the patient with camphor, assafoetida, eau de Cologne, and 
opoponax, none of which she perceived with the left, but all 
very keenly with the right nostril. She did not taste quinine, 
vinegar, tablesalt, and sugar on the left side of the tongue, 
but most plainly on the right side of it. Here also the line of 
demarcation between the sensitive and the anaesthetic zone 
was most sharply defined. The patient was deaf in the left 
ear, as she did not perceive the ticking of a watch which 
was pressed on that ear, while she heard the ticking quite 
plainly when the same watch was held at a distance of four 
inches from the right ear. Indeed, sensibility was everywhere 
on the unaffected side so unusually keen that the condition 
almost amounted to hyperaesthesia. 



Dr. Althaus^s Case of HemiansBsthesia from Brain Disease, 153 

The muscular force of the affected limbs, as measured by 
tbe dynamometer, appeared to be normal. The left hand, 
however, was clumsy and awkward in its movements. The 
patient could play on the piano a little with the right, but not 
with the left hand. This awkwardness of the hand, however, 
partook of the nature of ataxy, and not of paralysis, and was 
evidently owing to the loss of sensation. There was ischadmia 
in the left side, as punctures did not bleed. 

From these symptoms and the history of the case I drew the 
conclusion that the patient had, through the pressure of one 
of the blades of the forceps, during delivery, sidBFered from the 
effects of squeezing of the right hemisphere, and that this had 
probably led to rupture of a blood-vessel, and haemorrhage 
limited to that part which is generally designated as the pos- 
terior third of the posterior segment of the white internal cap- 
sule. Flechsig has shown that the internal capsule consists of 
three distinct portions, viz. Ist, the anterior segment, which 
is situated between the nucleus caudatus and the anterior 
extremity of the nucleus lenticularis ; 2ndly, a central segment, 
which he has called the knee of the capsule ; and Srdly, of the 
posterior segment, which is situated between the thalamus 
opticus and the posterior extremity of the nucleus lenticularis. 
This posterior segment has again to be divided into a larger 
anterior and a smaller posterior portion. The two anterior 
thirds of it contain the pyramidal strands, that is to say, the 
paths which conduct the power of motion that is generated 
in the central convolutions of Rolando and the corpus striatum, 
to the opposite side of the body ; and Charcot has shown that 
the posterior third of the same segment contains the paths for 
the conduction of all forms of sensation from one side of the 
body to the centres of sensation in the cortex of the brain. 
Indeed, we find in permanent hemiplegia with late muscular 
rigidity, destruction of the two anterior thirds of the posterior 
segment of the capsule ; while in hemianaasthesia of cerebral 
origin, the lesion has been discovered in the posterior third 
of that segment. As there was no trace of paralysis in the 
present case, it would appear that the clot had spared the 
anterior portion of the third segment of the capsule, but had 
compressed the posterior end of it, thus preventing the trans- 
mission of any form of sensation to the cineritious substance 
of the right hemisphere. That the affection must have been 
due to a definite lesion, either of the cortical centres of sensa- 
tion, or of the conducting paths in the capsule, could surely 
not be gainsaid from the preceding description. It would 



154 Br. Altliaus^B Case of BemiansBsthssiafrom Srain l)i8eas^. 

be an absnrdiiy to assnine the eziBtence of hysterical hemi- 
anadsthesia in a newly-born infant; nor conld the idea of 
a tumonr be entertained^ as the affection had never varied 
throughout lif e^ but had always been present in exactly the 
same degree. 

Electricity appeared to me under these circumstances the 
most appropriate remedy for the condition with which I had 
to deal; and amongst the various methods of application which 
presented themselves to my mind^ I selected that which is 
known as faradisation of the skin. I used Stohrer's double- 
celled induction coil^ and a large soft gilt-wire brush as the 
active electrode, while the circuit was closed by a moistened 
conductor applied to the nape of the neck. The brush was 
slowly passed over the back of the left forearm, and a current 
strength which generally produces a smart sensation in a 
healthy person, was not perceived. The first faint sensation 
of tingling was felt in the forearm with a current strength 
of 10°; on gradually adding five more degrees, a more decided 
feeling of pricking and heat was caused ; and this sensation 
gradually became much stronger during the further course of 
the application. This latter lasted altogether five minutes, 
and no part of the body except the left forearm was touched. 
The result was most astonisliing, as immediately after the 
application sensation was found to have been completely re- 
established in the entire left side of the body. 

The girl was kept under treatment at the hospital for some 
time longer for the epileptic seizures from which she suffered, 
and at her discharge some weeks afterwards sensation appeared 
to be quite equal in both sides of the body, the condition of 
hyper»sthesia on the right side having greatly abated. The 
surprisingly rapid effect of a single application of electricity, 
in restoring an important function which had been in complete 
abeyance during the patient's previous lifetime, may be ex- 
plained by assuming that the clot of blood, which was the 
primary cause of the affection, had been absorbed soon after 
birth, but that this lesion had left a condition of functional 
inertia or paralysis in the part originally affected. Pricking, 
pinching, biting and scratching, which the patient herself had 
abundantly applied to the suffering parts, had not been able 
to rouse the dormant energy ; but tlus was easily effected by 
the more suitable stimulus of electricity, which overcame 
without difficulty the impediment which had so long existed 
in the conduction of sensitive impressions to those cortical, 
centres by which they are appreciated. 




To illaitrote Mr. Ctuirben J. SymondE'e (GBophageal Tube in liii. 

A. Upper apertDre of larynx. 

B. (EBophagoBluid open, 

c. Silt thread by which the tnbe ie retained in pogitioti. 
D. Wide Dpper end of the tnbe above the stricture. 
B. Narrower lower port of tnbe below the stricture. 
P. Cardiac end of atomach. 



Mr. Symonds^s Oase of 8trictu/re of the (Esophagus. 155 



XIV. — A Gase of Malignant Stricture of the (Esophagus 
illustrating the use of a new form of (Esophageal 
Catheter. By Chaetbbs J. Stmonds, M.S. Bead 
January 23, 1885. 

JAMES M., 89t. 40, warehouseman, was admitted into Guy's 
Hospital under my care June 23, 1884. Seven weeks ago 
he began to have difficulty in swallowing ; this rapidly increased, 
so that when first seen on Monday, June 23, he assured me 
that he had not swallowed anything for two days, and that for 
some time previously he had been restricted to fluids. The 
man was much emaciated, having lost 2 st. 10 lbs. in the seven 
weeks. He was very weak and scarcely able to come up to 
the hospital. He complained of hunger and sleeplessness, and 
had all the symptoms of oesophageal obstruction. I immediately 
attempted to pass a bougie, but failed to introduce even the 
smallest size. The obstruction was met eleven inches from the 
teeth, and appeared to be about the bifurcation of the trachea. 
He was ordered, for that night, nutrient enemata every four 
hours, and to take by the mouth what beef tea and rnilV he 
could. On the 24th he was better, having swallowed a pint of 
beef tea and some milk. He continued to take fluids easily by 
the mouth, so the enemata were discontinued. By July 10 he 
had gained 8| lbs., and though swallowing well, it was 
impossible to pass a bougie. 

July 15. — ^I succeeded in introducing a long oesophageal 
catheter about No. 10 gauge. This was the kind of tube 
recommended by Mr. Durham at a meeting of the Society, and 
projected from the mouth. He retained this about thirty-six 
hours, and then coughed or pulled it out. In this particular 
case the tube produced great distress, partly owing to laryn- 
geal irritation, and partly to his being obliged to expectorate 
his saliva constantly during the night. Being anxious to avoid 
the operation of gastrostomy, it occurred to me that the incon- 
veniences of the tube would be removed, and all its advantages 
retained, by making it shorter and retaining it by means of a 
piece of silk. I had accordingly a piece of oesophageal tube 
about six inches long, connected by German silver to a box- 
wood funnel, with a strong silk thread passing through the 
wood. 



156 Mr. Symonds's Case of Stricture of the (Esophagus. 

July 22. — This tube was passed through the stricture by- 
means of an ordinary conical bougie fitted into the funnel. 
The bougie being withdrawn^ the funnel end was left resting 
on the upper &ce of the stricture. The silk passing from this 
point upwards out of the mouthy was looped over the ear and 
fastened by a piece of strapping behind. This tube was 
retained eight days^ and was easily withdrawn by the silk 
ligature. He swallowed fluids freely through it^ enjoying at 
the same time the taste of his food^ and was relieved of the 
constant expectoration caused by the other tube. No tube was 
worn during the next twelve days. 

August 12. — A tube with an ivory funnel was introduced, 
and retained ten days. During a week of this time the man 
returned home, and experienced no inconvenience whatever. 
Being alive to the possibility of ulceration of the oesophagus 
from the use of wood and ivory, Messrs. Down Bros, made me 
some tubes composed entirely of gum-elastic ; the earlier ones 
were lined with silver to afford a firmer attachment for the 
silk, but in the later ones this lining has been omitted, and no 
difficulty has been found in withdrawing the tubes. 

August 27. — ^A tube was passed. I was now leaving for 
my holiday and placed my patient in charge of my dresser, 
Mr. Campbell Gowan, to whom I am greatly indebted for 
successfuUy carrying out the treatment during my absence, 
and for suggesting a plan of introducing the tubes which has 
proved of great service. After ten days the tube was removed, 
cleaned, and reintroduced. Four days later (September 12) 
a fresh tube was inserted, and retained twelve days. The 
patient had, up to this date, gained 1 st. 9 lbs., and could, with 
the tube in, drink a pint of milk at a draught. He went daily 
into the grounds. 

October 9. — The tube removed after fifteen days, was still 
in good condition (this tube was reintroduced November 1). 
A fresh tube without the silver lining was now inserted. It 
was removed on the 23rd, cleaned, returned, and retained 
another week. It was thus, after three weeks' residence in the 
oesophagus, still strong and but little altered. An attempt to 
reintroduce it failed and the same result followed on the 31st. 

November 1. — The difficulty in swallowing is now increas- 
ing, and he has lost weight. The tube removed on October 9 
was introduced, after some difficulty, by directing it along the 
posterior wall of the oesophagus. It was tightlv grasped by 
the stricture. The man was at once able to swallow freely. 

About October 9^ the patient began to have cough with 



Mr. Symonds^s Case of Stricture of the (Eaophagua. 157 

foul expectoration^ and to complain of thoracic pain. These 
symptoms have not increased^ and at present (November 10) he 
is comparatively comfortable^ and is able to go out daily. 

Bema/rha. — ^The tube which I introduce has proved of the 
greatest service in the treatment of the patient whose case I 
have related^ and there is no evidence that any injurious effect 
has been produced upon the oesophagus. The funnel end 
engages the stricture, and has an outside measurement of one 
half to three quarters of an inch. The tube is six and a half 
inches long, has an ordinary catheter end and eye. It is 
prevented slipping down by the silk cord in addition to the 
funnel expansion, and by means of this cord it can be easily 
withdrawn. 

This form has many advanta&res over the loner tube which 
projects from the moudt ; it is ^ unsightly, it does not inter, 
fere with deglutition in any way, it produces no^irritation of 
the larynx, and retains to the patient the pleasures of taste. 

The largest tube introduced in the present case was a No. 
12 catheter gauge, but, if taken earlier, a much larger tube 
might be used. What is the largest that may be safely 
employed remains to be seen. So complete did the obstruction 
appear to be that I expected to be obliged to perform gastros- 
tomythe day after admission. This operation is often attended 
with so much distress from excoriation of the skin around the 
opening that I was glad to avoid it, and I cannot but think 
that so long as these tubes can be passed, the result will 
prove more satisfactory than the gastric fistula. In order to 
ensure the easy reintroduction of tubes, I propose to have 
some made with an open end, and before withdrawing, to run 
through the tube a guide over which it can be removed and a 
new one introduced. My main object, at present, is to bring 
the principle of the treatment before the Society, and to solicit 
opinions as to its value. 



Note. — ^The patient died on April 17. 

From January 23, the day on which he was exhibited at the 
Society he continued to wear the tubes till the time of his 
death. 

February 16. — It was found that the stricture had dilated 
so that the funnel easily passed through it. I therefore fitted 
a silver funnel into a larffe-sized india-rubber tube and inserted 
this. He was able to take minced meat through the tube, and 
the cough which accompanied swallowing with the smaller 



158 Mr. Symonds^B Case of Strictv/re of the (Esophagus. 

tnbes disappeared. This was removed in tliree weeks^ cleaned^ 
and returned for thirteen days. 

March 10. — He weighed 7 st. 13^ lb. and in the next week 
lost three pounds ; the expectoration abundant and very foul 
and the cough disturbs his rest. 

March 23. — ^There is dulness at left base with r&les and 
general signs of pnlmonary compUcations. 

March 25. — He could not swallow at all^ violent fits of 
coughing accompanying every attempt. This appeared due 
to the growth having extended beyond the limit of the tube. 
I therefore passed a long gum elastic tube of No. 14 gauge^ 
and appeared to traverse a second stricture. Through this he 
at once swallowed freely and the tube was worn till his deaths 
and is now preserved with the specimen. He died with sym- 
ptoms of gangrene of the lung^ and the inspection revealed 
this change in the left lower lobe. There was pus in the 
pleura^ and pneumonia of the right base. The growth in the 
oesophagus was four and a half inches in lengthy and began 
eleven inches from tip of tongue^ and four inches from cricoid 
and reached to within one inch of the cardiac orifice of the 
stomach. There was considerable narrowing at the upper end^ 
but in the rest there was great loss of substance from ulcera- 
tion^ the aorta being exposed at one pointy the pleura at 
another^ and the me£astinal glands at a third. The trachea 
was not involved. There was no evidence whatever of ulcera- 
tion above the stricture from the pressure of the tube^ which 
reached through the growth into the stomach. 

In reviewing the case it may be shortly added that the man 
was kept alive eight months in comparative comfort ; that he 
never experienced any inconvenience from the tubes ; that the 
stricture dilated considerably^ and that no injurious effect 
attributable to the tube was apparent at the post-mortem. 
During the later stages it was necessary to remove the tube 
more frequently^ as it became blocked by the sputum. As to 
the durability of the tube and silk it may be stated that one 
tube with its silk was in the oesophagus altogether for three 
months, and still remains sound and fit for use. 



Dr. Hale White's Oaae of Myxcedema. 159 



XV. A Oase of Myobcedema with a Postmortem Examu 
nation. Bj W. Hale White, M.D. Bead February 
leS, 1885. 

IN the first place I feel that I mnst explain the late appear- 
ance of this paper. The post-mortem examination was 
made last June. In the antnmn I prepared the microscopical 
sections and wrote an account of tiiem. My friend Dr. 
Mahomed was to have written the clinical part of the paper 
and to have prefaced my pathological account with it^ but 
his sad illness prevented this ever being accomplished^ 
and hence the imperfection of the following account of the 
patient's condition whilst alive^ for I have had only the clinical 
clerk's notes for the description of the symptoms. The same 
reason will also I am sure be accepted as sufficient excuse for 
the pathological results only appearing now^ although I had 
described them in October ; it will be noticed that Bfc. Victor 
Horsley's Brown Lectures delivered last December confirm 
them in every particular. 

At page 98 in volume xv of this Society's Transactions 
will be found recorded by the late Dr. Mahomed a case of 
myxoedema which seemed at first to improve under treatment 
by nitro-glycerine, but the patient soon relapsed into her 
former condition^ and was not permanently benefited by the 
treatment. The case was complicated by albuminuria. 

On June 12, 1884, the patient was admitted into Guy's 
Hospital for ascites. She had not been seen since July, 1884, 
but in that interval had enjoyed good health, and the myxce- 
dematous condition had diminished. A year before admission 
she first noticed the commencement of abdominal disten- 
sion which began two months after her being delivered of 
twins. The abdomen continued slowly to increase in size till 
admission, when it was noticed that the myxoedematous con- 
dition was less marked, although it could be seen in the 
face and hands, and the speech was slow. Three days before 
admission she had an epileptic fit. 

On June 17, paracentesis abdominis was performed and 5 
gallons 5 pints of fluid were withdrawn. Soon after this she 
had several epileptiform fits and she passed into a status 
epilepticus and died. 



160 Dr. Hale Whitens Case of Myxoedema, 

At the autopsy^ the brain was anaBmic^ the cerebral vessels 
decidedly thick^ and there was an old elongated brownish 
haBmorrhage into the outer division of the lenticular nucleus, 
at its posterior part, not involving the external capsule. The 
thyroid was very small and atrophic, it had lost its ordinary 
juicy red appearance and was pale and shrunken looking, the 
cervical glands were healthy. The heart and lungs were 
normal. There was much clu'onic peritonitis ; soft and deeply 
pigmented lymph lined the abdominal cavity and bound the 
intestines together. The walls of the stomach, intestines, and 
abdominal aorta were thick and juicy, but this was probably 
due to the ascites. Much perihepatitis, the capsule of the liver 
being uniformly thickened and white, the hepatic tissue itself 
was fatty; the capsule of the spleen was also thickened. 
Pancreas, mesenteric glands, suprarenal bodies and abdominal 
sympathetic all appeared normal. The kidneys might have 
been a little fatty, otherwise they were quite normal. The 
tongue seemed normal ; there was a distinct blue line on the 
gums as if from lead. The genital organs and bladder were 
all healthy. The chief muscles of the body were normal and 
there was no gout in the great toes. The right middle 
cervical ganglion was larger than the left, and had a well- 
marked blood-vessel ramifying down it. The pituitary body 
seemed large. 

Histological exa/mination of the organs. 

1. Lungs healthy. 

2. Kidmys. — ^The only abnormality to be detected is that 
there is a slight proliferation of nuclei in the intertubular con- 
nective tissue and also perhaps on the Malpighian bodies. 

3. Liver. — The only changes are a proliferation of nuclei 
in the intercellular connective tissue, as described by Ord, and 
a fatty change in the liver-cells. This is not extreme, but is 
peculiar from the fact that the fat is deposited around the 
intralobular vein rather than around the periphery of the 
lobule. 

4. Spleen healthy. 

5. Submaadllary gland. — Between the cells there is a 
slight proliferation of nuclei, but the chief change is seen in 
the larger masses of connective tissue such as ULOse around 
the blood-vessels and lobes of the gland. The connective 
tissue in these situations is, I think, best described as having 
a degenerate sodden appearance ; there seems to be more of it 
than natural^ and yet there is no multiplication of any of its 



Dr. Hale White's Case of Myxoedema, 161 

elements. Such an appearance might be produced byeffnsion 
into it. Very few naclei are visible, and in many parts the 
fibres themselves can hardly be distinguished ; it looks just as 
though they had degenerated into a clear material which did 
not stain with logwood. As these changes have taken place 
in connective tissue around blood-vessels it gives the appear- 
ance that the tunica adventitia of the vessels is much thickened 
because that, in common with other connective tissue, is altered 
and no distinct line of demarcation is observable between it 
and the surrounding tissue. 

6. Thyroid gland. — There is little or no proper thyroid 
structure left ; a few bodies, evidently the remains of vesicles, 
are to be seen, and in one or two instances just a trace of the 
epithelial lining still remains. These degenerate vesicles are 
filled with small epithelial cells which have been apparently 
produced by the multiplication of the proper epithelial lining. 
The connective tissue between the vesicles would for the most 
part be suited by the description of the connective tissue in the 
submaxillary gland, having a sodden, degenerate appearance, 
but, whilst nowhere is there any evidence of the formation of 
new connective tissue, yet here and there in patches there is 
considerable small cell proliferation, rendering the section 
quite dark. There are to be seen in places some white blood- 
cells which have evidently wandered out of the blood-vessels. 
The whole organ has undergone extreme simple degenera- 
tion. 

7. HeaH. — ^The muscle-cells are perfectly normal; in parts 
the connective tissue appears to have the same condition 
as has already been described, but the change is not so 
universal and might perhaps have been passed over had not it 
been already detected in other organs. 

8. Bight middle cervical ganglion. — ^The cells are abundant, 
very few pigmented; in many a distinct nucleus and nucleolus 
are visible. Considering how cells may vary in ganglia which 
we have no reason to thmk abnormal, these cells appear very 
healthy ; it is true that some are blurred and have no distinct 
nucleus, but this is not more so than is often the case. The con- 
nective tissue has the degenerate, ill-defined, sodden appearance 
already described ; the result of this is that it has pressed on the 
nerve-cells so as to reduce the size of the capsule, and in several 
instances the connective tissue is brought in such close contact 
with the cell that the line of demarcation is not very evident. 
Here and there this condition of the connective tissue obscures 
the nerve-fibres. There is no small cell proliferation. 

VOL, xviu. 11 



162 Dr. Hale Whitens Oase of Myzoadema. 

9. Right superior cervical ganglion. — Tlie description of the 
middle ganglion applies here^ except that the changes described 
in the connectiYe tissue are not so marked; hence as there is 
less degeneration a few more nnclei are to be seen; the altera- 
tion is most evident in some connective tissne around a vessel^ 
giving the appearance of great thickening of its adventitia. 
The nerve-cells are healthy. 

10. Right cervical sympathetic nerve. — ^In longitudinal 
section it is to be noted that the nerve-fibres and also a few 
nerve-cells which happen to be present are quite healthy ; the 
connective tissue around the nerve appears veiy abundant^ 
and has somewhat of the character already described. 

11. Left superior cervical ganglion. — ^The remarks made 
about the right cervical ganglion apply here also. The condi- 
tion of the connective tissue is to be noted^ and also the large 
quantity of it around the ganglion. 

12. Semilimar ganglion. — The cells are well formed and 
there are plenty of healthy nerve-fibres ; the connective tissue 
has not the same appearance as in the other gangUa^ but here 
and there are plenty of small cells^ if anything^ more than the 
normal number^ wluch can be seen in places distinctly develop- 
ing into fibrous interstitial tissue. 

13. Anterior crural nerve. — ^Normal. The connective tissue 
is abundant^ and has much the same appearance as in other 
parts. 

14. Supra/renal body perfectly healthy. 

15. Lymphatic gland quite healthy. 

16. Carotid artery perfectly healthy. 

17. Pituitary body normal. 

The histological examination of the organs fully bears out the 
position taken up by Dr. Semon that the atrophy of the thyroid 
is the cause of the whole disease^ because in this case it is the 
only discoverable pathological lesion^ excepting the myxcede- 
matous condition affecting various parts of the organism. 
The changes in the sympathetic ganglion and submaxillary gland 
are simply the results^ and not particularly important results^ 
of the atrophy of the thyroid. This view is fully borne out by 
the fact that in Kocher's patient^ in whom the thyroid was 
totally extirpated and no myxcedematous symptoms followed^ 
there was found an accessory thyroid body which underwent 
compensatory hypertrophy. Our case also shows that the view 
put forward by Dr. Hadden that the disease is due to a lesion 
of the cervical sympathetic is untenable^ for the specimens 
show that the essential parts^ such as nerve-cells and fibres^ are 



Dr. Hale White's Case of Myxoadema. 168 

quite healthy^ and also against the sympathetic theory I 
would urge that if the disease is due to a lesion of the cer- 
vical sympathetic^ evidences of this^ such as vasomotor and 
pupillary disturbances^ should be constant symptoms in myx- 
cedema as they are in all cases of tumours^ aneurysms^ and 
injuries of the neck in which the cervical sympathetic is injured. 
This is not so^ and^ further^ in none of the numerous physio- 
logical experiments on the cervical sympathetic have the sym- 
ptoms of myxoedema ever been observed. Lastly, on the hypo- 
thesis of disease of the sympathetic it is quite impossible to 
explain the case in which the whole thyroid was removed and no 
myxoadema supervened^ but the accessory thyroid hyper- 
trophied. In this case no inference can be drawn from the 
difference in size of the two middle cervical sympathetic gan- 
gUa, because normally the variations in size are so great. 

Since the above was written Mr. Victor Horsley has drawn 
attention to the tremors observable in monkeys after excision 
of the thyroid. This symptom has not been frequently 
observed in myxoadema ; hence it is interesting to note that the 
patient is described as having had epileptic fits. What they 
were like I cannot say; as I never saw them I can only quote 
the report of the case. 



164 Dr. Camngton's Ocmt^fi of Phlegmonotu Pharyngitis. 



XVI. — Two Gases of Phlegmonous Pharyngitis. By 
R. B. Oabbington, M.D. Notes of Post-mortem by 
W, Hale White, M.D. Bead Februa/ry 13, 1885. 

THE following cases are brought before the Society becanse 
they seem to be examples of a disease which hitherto 
has not been recognised clinically to any great extent. 
Patients labouring under the affection are admitted into 
hospital with symptoms of laryngeal dyspnoea^ and tracheo- 
tomy may or may not be performed. It appears^ however, 
always to be useless, and the patient dies of the general and 
not of the local condition. 

The disease is doubtless of considerable rarity as is 
evidenced by the fact that Birch-Hirschfeld {Lehrhuch de 
Pathologischen Anatomie) makes no mention of it, although he 
describes the state of the larynx in over six thousand autop- 
sies at the Berliner Charity. 

I may add that I know of at least two other undoubted 
cases, which, however, I am not able to publish. 

Case 1. — T. M., 89t. 46, was admitted on the early morning 
of May 28, 1884. He had been ill the previous seven days 
somewhat remittently, some days being passed in bed; on 
others he did his work. On his admission there was laryngeal 
stertor, bat no marked dyspncea. He was placed in a tent with 
a steam apparatus and watehed. In the course of a few hours, 
however, he died quite suddenly before the house surgeon 
could be called in again. 

The autopsy was made nine hours after death by Dr. 
Goodhart, by whose kindness I am able to publish the 
report. He was a fine, healthy-looking man, well nourished. 
There were no sores, scars, nor signs of injury. There 
was much subpleural ecchymosis on the right side. The 
lungs were somewhat airless and congested. All the soft 
tissues of the pharynx were oedematous, and on the right side 
from the tonsil downwards for two inches the mucous mem- 
brane was minutely injected and swollen with pumlent 
oedema. Yellow spots of pus pointed here and there, and on 
section there was a diffused purulent infiltration of the mucous 
membrane and submucous tissue. The same condition had 



J 



Dr. Oarrington^s Oases of Phlegmonous Pharyngitis. 165 

spread into the tissue of the epiglottis so that the cartilage 
was buried in a similar diffuse infiltration. On the left side 
the oedema was serous only. There was very little narrowing 
of the rima glottidis. 

With the exception that the spleen was rather large^ 
though not soft^ and that there were a few cysts in the 
kidneys, all the other viscera were healthy. 

Dr. Goodhart. suggested in his report that the man died 
of asthenia rather than asphyxia. 

Case 2. — The patient, a medical man, 8Bt. 49, was admitted 
into Guy's Hospital on November 10, 1884, under my care, 
when I was doing duty for Dr. Wilks. We could get little 
or no history from him, but he told us that three days before 
he began to suflfer from a severe '' cold,** and this had 
gradually become worse, so that he himself came up to the 
hospital urgently requesting tracheotomy to be performed. 
An old friend, an esteemed member of the profession, knew 
him well, and felt sure that he was by no means an intemperate 
man, but it was ascertained that probably for some little time 
before his illness he had been indulging a good deal in beer. 
He came up to the hospital at 2 p.m., and was at once placed 
in a tent before the fire, the air of which was moistened by a 
steam apparatus. He walked up to the ward, and though 
there was a good deal of laryngeal stridor, there was no " suck- 
ing in ** of any part of the chest, so that it was not thought 
advisable to perform tracheotomy before trying whether any 
relief would be obtained from palliative treatment. He was in 
a great state of apprehension and very restless, tossing his 
arms about, and still urgently desired the operation. At 4.30 
he was seen by Mr. Clement Lucas, and operation was decided 
upon. The patient vehemently shook his head when chloro- 
form was suggested. 

At 4.45 when desired to leave his bed to walk to the 
table, a distance of two or three yards, he was suddenly 
seized apparently with a spasm of the glottis, fell back 
and ceased to breathe. Tracheotomy was immediately per- 
formed and the tube inserted without delay. Artificial respi- 
ration by Silvester's method was at once resorted to, and was 
so far successful that in a few seconds he began to breathe spon- 
taneously although very feebly. Almost immediately he was 
seized ¥dth an epileptiform attack, his eyes were fixed, his 
face, at first pale, became blue, and the muscles twitched con- 
vulsively. Artificial respiration was still maintained^ subcuta- 



166 Dr. Carrington's Oases of Phlegmonotis Pharyngitis. 

neons injections of brandy were administered^ and Hot water 
applied to the prsacordial region. The result was that after 
some little time the patient began to breathe slowly and very 
feebly. A couple of capsules of nitrate of amyl were now admi- 
nistered. The heart's action had never ceased^ but the pulse 
had become very feeble^ and during the fit almost impercep- 
tible. The feeble^ slow respiration continued^ and he appeared 
to regain a certain amount of consciousness, looking now and 
then at those about him. He was also able to swallow a small 
quantity of brandy and milk. In fact he appeared to be pro- 
gressing &yorably. The bed was then moved to the tent, 
his head slightly raised on a pillow, the steam apparatus 
turned on, and arrangements were made to leave him under 
proper supervision. But he suddenly again became pale, 
his eyes turned upwards, and he ceased breathing. He then 
became cyanosed, and double internal strabismus ensued. 
The pulse again became almost imperceptible. Artificial respi- 
ration was at once resorted to, and I may here remark that it 
was respiration of a very effectual kind, viz. a combination of 
Silvester's and Howard's. The arms were raised above the 
head by one operator, whilst another knelt across the patient 
and compressed the chest in alternation. The amount of air 
passing in and out of the cannula by these means was very con- 
siderable. This was kept up for a full hour, until 6.20 p.m. 
Subcutaneous injections of brandy and ether were administered. 
The faradic battery was freely used, but all was of no avail, 
he never breathed again, and the heart-sounds became 
inaudible at least half an hour before efforts at resuscitation 
were discontinued. 

Dr. Hale White furnishes the following account of the 
autopsy. 

At the ppst-mortem examination the following condition 
was discovered : 

The larynx was congested and dark blue in colour, especially 
at its posterior part ; the epiglottis was reddened, thickened, 
but not ulcerated ; the rima glottidis appeared perhaps slightly 
smaller than natural; there was some oedema of tiie glosso- 
epiglottoidean folds. The right ary-epiglottoidean fold was 
reddened, and had in it an open abscess-cavity about .three 
quarters of an inch long and half an inch wide, the long axis 
corresponding with the long axis of the fold ; this cavity was 
shallow, and its floor was coated vdth pyogenic membrane. 
The left ary-epiglottoidean fold was thickened and congested, 
and on making an anterior posterior vertical section through the 



Dr. Carrmgton^s Oases of Phlegmonous Pharyngitis. 167 

soft parts oatside it^ the &t and cellnlar tissue were fonnd to 
be infiltrated with a greenish-yellow porulent material which 
had not anywhere formed a cavity. There was no ulceration 
within the larynx^ and except for perhaps slight thickening 
the vocal cords seemed healthy. No disease of the cartilages 
could be detected after prolonged and careful dissection. The 
two ala3 of the thyroid were much ossified. No membrane was 
present. The left crico-thyroid and thyro-arytenoid muscles 
were obviously inflamed but not suppurating. The active 
disease was^ it will be seen^ chiefly extra-laryngeal^ although 
there was some swelling of the folds and epiglottis. The 
tracheotomy wound had gone through the lower quarter of an 
inch of the crico-thyroid membrane^ through the cricoid carti- 
lage^ and just down to the isthmus of the thyroid. There 
was no impediment to the free entrance of air below it. The 
contiguous lymphatic glands were reddened^ the thyroid gland 
was healthy. There was no evidence that the vagus nerves 
were implicated. 
f The lungs were intensely congested and somewhat softened 

at the posterior parts ; no pus was found in the bronchial 
tubes^ but, together with the trachea, they were much con- 
gested. 

The heart was considerably fatty, and weighed eight 
ounces. There was no noteworthy change in any other 
organ. 



\ 



Dr. Bennett's Oaee of Locomotor Ataxy. 



XVII. — A Case of Locomotor Ataxy, without Disease of 
the Posterior Cohtmns of the Spinal Cord. By 
A. Hughes Bennett, M.D. Bead Februa/ry 27, 
1885. 

THE case to wtich I beg to direct tlie attention of the 
Society is specially interesting from the circumstance 
that, although the patient daring life presented all the promi- 
nent symptoms of so-called tabes dorsalis, the posterior colomns 
and comoa of the spinal cord were found after death to be 
nithont a trace of disease. This fact suggests certain im- 
portant considerations concerning the physiology and patho- 
logy of locomotor ataxy. 

The patient was a gamekeeper, aged 48, who stated that he 
had always been a healthy man, never having suffered from 
syphilis or other disorder. About fifteen years ago he com- 
plained of severe pains in his legs, which continued for three 
months, from which symptoms he completely recovered. He 
afterwards remained well till nine months before he came under 
observation. He then for the first time expei^nced gradual 
weakness of the legs, so that he was easily fatigued and was 
unable to do a full day's work. This slowly increased, without, 
however, actually incapacitating him from his duties. Some 
months afterwards he was attacked with severe shooting pains 
in his lower extremities, occurring in paroxysms, and shifting 
from place to place. With the advent of these the weakness 
of the legs augmented, and was accompanied with a sensation 
of numbness in the feet. He was therefore compelled to give 
np bis situation as a nobleman's gamekeeper. 

On examination the patient was fonnd in good general 
health. There was no evidence that his intelligence was 
abuormally affected, but he was an uneducated andstnpidman 
from whom it was difficult to obtain a satisfactory account of 
hia illness. There were no headaches or cerebral symptoms 
except occasional giddiness. Vision in both eyes was good, 
there was no paralysis of the ocular muscles, and the fundi 
of both eyes were normal. Voluntary movements of the eye- 
balls were accompanied with slight nystagmus. The pupils 



Dr. Bennett's Case of Locomotor AtaoDy. 169 

were of moderate size, the left Bomewhat smaller tlian the 
rights and both contracted well to light and accommodation. 
The muscles of the face and tongue were as in healthy and 
articulation^ mastication^ deglutition^ and all the special senses 
were normal. The movements of the upper extremities could 
be all performed^ but the grasp of the hands was weak^ and 
delicate actions of the fingers were unsteady and slightly 
inco-ordinated. The movements of the trunk seemed normal^ 
and the functions of the bladder^ rectum, and sexual organs 
appeared to be intact. The patient felt his lower extremities 
to be weak. He walked with a slow^ unsteady^ hesitating^ 
and markedly ataxic gait. Without assistance he staggered, 
had difficulty in turning or walking in a straight line. He 
could not stand on one leg, and all his motor difficulties were 
increased in the dark. When the eyes were closed the patient 
swayed and would have fallen if not supported. In bed the 
mo/ement8 of the lower limbs were villous and displayed 
considerable force, but they were accompanied by the typical 
phenomena of inco-ordination. The knee jerk on both sides 
was totally absent and the plantar reflexes were diminished. 
There was very slight rigidity of the large joints, which was 
easily overcome by passive movement. The sensibility of the 
skin to touch and pain appeared to be everywhere normal, 
except in the feet and legs, where it was both diminished and 
retarded. The patient complained of a constant dull aching 
in his back and lower limbs, and this was almost daily accom- 
panied by attacks of lancinating pains which shifted about from 
place to place, and which were sometimes very severe. The 
muscles throughout the body were thin and spare but nowhere 
specially atrophied ; their mechanical irritability and electrical 
reactions were unimpaired. The other organs and functions of 
the body were normal. 

The patient died after a residence of two and a half months 
in the hospital. From the beginning the weakness of the legs 
and insecurity of gait increased, so that in about six weeks he 
could not stand. The lancinating pains were very constant 
and severe. For many weeks there were attacks of uncon- 
trollable vomiting. Emaciation ensued and the general health 
broke up. During the last week the patient was feverish, 
restless, and prostrate ; he became semi-comatose, and finally, 
after a severe convulsive attack, died. Otherwise no new or 
special symptoms developed. 

Post-mortem examination (30 hours after death). — ^Permis- 
sion was given to examine the brain and spinal cord only. 



170 Dr, Bennett^s Oase of Locomotor Ataay. 

The entire body was thin and emaciated^ bat nowhere was 

there any special atrophy. On the right gluteal region there 

was a supe^cial bedsore abont three inches in diameter^ and 

there was commencing change in the skin on the corresponding 

left side and over the sacmm. On removing the calvarium 

the membranes of the brain were found deeply congested ; 

there were considerable oedema and sub-arachnoid effusion^ but 

no adhesions. The convolutions were somewhat flattened^ 

especially on the left side^ in the frontal and parietal regions^ 

otherwise they were normal. On removing the brain several 

ounces of cerebro-spinal fluid escaped. The vascular congestion 

was found id be universal ; in other respects the blood-vessels 

were healthy. On slicing through the hemispheres the cerebral 

substance was seen to be deeply injected^ the lateral ventricles 

each contained about half an ounce of clear yellow fluids and the 

choroid plexuses were oedematous. In the substance of each 

frontal lobe, involving the anterior comua of the lateral ven- 

tricle, was a circumscribed patch of softening, on the left side 

about the size of a hen's egg, on the right somewhat smaller. 

These extended inwards to the third ventricle and longitudinal 

fissure, downwards to the base of the brain, and upwards to 

within an inch of the cortical substance. The under and fore 

part of the corpus callosum, the lamina cinerea, and the tuber 

cinereum were involved in the softening ; but the fornix, the 

corpora albicantia, the corpora striata, and optic thalami were 

apparently normal. There was a similar patch of softening in 

the cerebellum about the size of a walnut, situated at the left 

side of the anterior free margin of those lobes forming the 

upper boundary of the great longitudinal fissure. The middle 

and inferior peduncles on the left side were softened, but the 

superior remained of normal consistency. To the naked eye 

the pons, medulla, corpora quadrigemina, cerebral peduncles; 

and other parts of the encephalen appeared healthy. 

Microscopical examination of the softened cerebral matter 
showed much granular detritus, broken-down cells, Grluge's cor- 
puscles, numerous oil-globules, and shrivelled blood-corpuscles. 
On opening the spinal canal the vessels of the membranes 
were seen to be deeply congested, especially in the lower dorsal 
region, where there were found small patches of superficial 
hsBmorrhage. There were no adhesions either to the bone or 
to the cord, and the latter was enucleated without difficulty. 
The pia mater was thickened, especially at its posterior aspect, 
most marked inf eriorly, and gradually diminishing from below 
upwards. Behind, the membrane was studded throughout 



was 

lere 

and 

ling 

inm 

ed; 

but 

ed, 

ns, 

ral 

ion 

els 

ral 

les 

he 

ch 

n- 

]e 

r. 

»I 

;o 

•e 

r 

e 

3 
I 



am, SocTians Vol XVIII, Plate VH 



r^: 






ri3i. 






D- H^a^hes Bennett's case ol Locomotor Atax)' 



DESCRIPTION OF PLATE VII, ILLUSTRATING DR. 
BENNETT'S CASE OF LOCOMOTOR ATAXY. 



Fio. 1. — Section of morbid growth, 200 diam., showing cellular struc- 
ture of sarcoma. 

Fia. 2. — Naked-eye appearance of the middle dorsal region of the 
spinal cord, showing multiple sarcomatous tumours scattered over the 
posterior aspect of the pia mater. 

Fio. 3. — Transverse section at the lower part of the medulla 
oblongata, showing the central canal surrounded by sarcomatous 
growth. 

Fig. 4. — ^Transverse section at the upper part of the medulla 
oblongata, showing the floor of the fourth ventricle involved by sarco- 
matous growth. 



n 



Dr. Bennett's Oaae of Locomotor Ataay. 171 

witli wliat to tlie naked eye appeared to be a number of isolated 
tumonrs. These were of a round or oval shape^ of firm Lard 
consistence^ of a wliite colour^ and they varied in size from a 
mustard seed to a pea. At the medullary end of the cord 
these were few in number^ but on proceeding downwards they 
gradually augmented^ so that in the middle dorsal region they 
were perhaps from six to eight to the square inch (PI. 8^ fig. 2) . 
Continuing to increase in number towards the lower portion of 
the cord^ they became in the lumbar region quite confluent so 
as to make the cord in that situation of abnormal thickness 
and rigidity. These growths were seen to be attached to and 
to surround the posterior roots. To the naked eye none of 
these tumours were seen on the anterior or lateral aspects of 
the cord. 

The medulla and cord were first hardened in Muller's fluid 
and strong methylated spirit. They were then immersed for 
several days in absolute alcohol^ and afterwards embedded in 
celloidin. Sections were made by Dr. Hebb^ Pathologist to 
the Westminster Hospital^ to whom I am indebted for the 
following description of the microscopical appearances. ^^ There 
was general thickening of the pia mater most marked at the 
anterior and posterior aspects. This diminished gradually 
from below upwards, and at any iriven level was much more 
marked beUnd than in front. In the lumbar region the 
neoplasm which constituted the thickening of the membranes 
closely embraced the posterior^ and to a slight extent the 
anterior roots; in the dorsal region the posterior only^ and in 
the cervical region the cell growth had greatly diminished in 
extent and did not involve any of the nerve-roots. In a 
limited portion of the lumbar region, one anterior comu was 
involved by the disease, the cells of the neoplasm having 
advanced along the lines of the comual rootlets and blood- 
vessels. This seemed to have invaded the normal structures 
without causing their destruction to any appreciable extent. 
With this exception the nervous tissues of the cord were 
normal (PL 7, figs. 1 and 2) . Some of the anterior spinal roots 
were involved in the growth, but only to a limited extent in 
the lower lumbar region. Ilieir structure on section seemed 
normal. Although the tumour closely surrounded the posterior 
roots on both sides throughout the dorsal and lumbar regions 
their histological condition appeared to have suffered little 
demonstrable change. Examined with a high power (one 
twelfth of an inch) the only peculiarity that could be detected 
was unusual swellmg of the white substance of Schwann. The 



172 Dr. Bennett's Oase of Locomotor Ataxy. 

state of the nerve-trunks of tbe body with their peripheral 
terminations in the muscles and skin^ were not examined. 

^^ The medulla oblongata^ which to the naked eye appeared 
normal^ after staining^ disclosed in its upper part a morbid mass 
measuring 0'5 x 0*7 cm., which extended from the floor of the 
fourth ventricle, into which it projected, to the centre of the 
bulb, towards the lower portion of which it diminished in size 
and was limited to its centre, surrounding the central canal, 
thus being of conical shape, the base upwards (PI. 8, figs. 3 and 
4). The morbid material here also seemed only to infiltrate 
the otherwise healthy tissues rather than destroy them. In 
addition to this fairly circumscribed mass there were a number 
of minute patches of similar nature scattered throughout the 
substance of the medulla. 

''The neoplasm was everywhere composed of round cells, 
and was sarcomatous in character (PI. 8, fig. 1).'^ 

Commentary. — In commenting on the facts of this case, 
special attention is directed to the pathological and clinical 
phenomena. 

1. Pathological. — ^The patches of softening in the frontal 
lobes, and in the cerebellum and its peduncles, were probably 
recent, and due to the general cerebral inflammation, which 
supervened shortly before death. 

The sarcomatous mass as seen by the microscope in the 
centre of the medulla, was in size and shape &irly defined. 
The morbid process' was not strictly limited to this area, but 
was dotted here and there all over the bulb. Such a patho- 
logical condition is extremely rare. The fact that the growth 
seemed to infiltrate and displace the normal tissues rather than 
destroy them, may explain the almost total absence of serious 
bulbar symptoms during life. 

Disease of the same nature involving the spinal membranes, 
appearing to the naked eye as a series of small multiple 
tumours confined to their posterior aspect, and surrounding 
the posterior roots, is also an interesting and almost unique 
pathological condition. Histologically the lesion was found 
to leave the cord itself absolutely intact, except at one anterior 
cornu, in a limited portion of the lumbar region, where the 
tissues, as in the case of the medulla, were displaced but not 
extensively destroyed. This also accounts for the absence of 
symptoms due to serious implication of that locality. The 
anterior roots were seen to be only slightly implicated, which 
harmonises with the fact that there was no paralysis, wasting 
of the muscles^ or abnormal electrical reactions during life. 



XJjsb::5i::F!njs or plate viif, 

UEJy-JS'ZTrS CASE OF LOC(^ 

Fxif.l' — TcaaaertjTBe hvcxy^n of tLe !<p:.. 
j!*^WL. ttiinFixi^ lit poBUfrior roots invuh- . 

Fxii £. — T?aaa»T.er«j bection of tLc spii; 
«^j«t- ©liVWiaa^ Tirtr posterior roots, and, jl 
ivirtifc aok^ ttJit: axteric^ oormi iuyolved in -, • 



• ■T" 



Dr. Bennett's Case of Locomotor Atcmf. 178 

Jly^ the posterior roots were extensively involved, and 
.ofh the anatomical changes in their stmctore were slight 
. indeed doubtful^ they were sufficient to induce marked 
' )rmalities in the functions of the sensory tracts. 
-. Clinical, — The points of clinical interest may be con- 
ned under two heads^ namely the phenomena connected 
L disease of the medulla^ and of the spinal cord. From 
])osition and extent of the growth in the former it might 
. u been supposed that important bulbar centres would have 
n involved and corresponding symptoms produced. Yet 
-t' during life were conspicuous by their absence. There 
< no \4sual disturbance and no facial paralysis or spasm; 
special senses were intact j articulation, vocalisationi 
uhitition^ respiration, and circulation were normal, and there 
• \'.< no optic neuritis or glycosuria. The only phenomena 
.in ributable to derangement of the medulla were giddiness, 
ii ght nystagmus, and during the last few weeks ot life per* 
T tnt vomiting. The explanation of this absence of symptoms 
^>i already been suggested. 

rhe clinical point illustrated by this case, to which it is the 

ect of this paper specially to direct attention, is the relation 

''A\ exists between the spinal symptoms and the lesion of 

posterior roots of the cord discovered after death. The 

.' nt had been examined by many physicians, all of whom 

td pronounced him to be suffering n*om tabes dorsalis, and 

.Is condition in most respects justified that diagnosis. There 

' ns inco-ordination in the movements of the limbs and chiefly 

. tlie lower extremities, with a typical ataxic gait, increased 

: the dark. There was at the same time no appreciable 

ilure in the gross power of the muscles, nor were these 

•iirophied. The Eomberg symptom was present, the patient 

\ aying and losing his balance when his eyes were dosed. 

iiere were paroxysms of characteristic lancinating pains, and 

H ficient and retarded sensibility in the skin of the lower limbs. 

1 lie plantar reflexes were diminished, and the knee-jerk phe- 

•inena totally abolished. This sequence of events, although 

t constituting a complete clinical picture of tabes, war- 

rted^ it must be admitted, the conclusion during life that 

'J patient was suffering from that disease. It is true that 

re was no affection of vision, or trace of optic atrophy. 

' I'.e pupils, though unequal in size, were not paralysed to 

i.t* stimulus of light or accommodation. There was no 

.!>iiurmality of the vesical or sexual organs, and the disease 

ul only been in existence for nine months. But clinical 



174 Dr. Bennett's Oase of Locomotor Atcuoy. 

experience has shown tliat none of these circumstances 
preclude the presence of those central changes which are 
usually associated with tabes dorsalis^'or that the absence of 
these symptoms is incompatible with a pronounced specimen 
of that affection as we now recognise it at the bedside. Now, 
it is universally assumed that the lesion which causes this train 
of phenomena is situated in the posterior columns of the spinal 
cord, and our standard text-book on nervous diseases thus 
expresses the general belief : — " Sclerosis of the posterior root 
zones for a considerable portion of their longitudinal extent, 
is the essential morbid alteration in locomotor ataxia.''* 

In the case before us there were all the prominent symptoms 
of that affection, withoat a trace of degen^ation of any portion 
of the posterior columns, the posterior comua, or the posterior 
roots within the circle of the spinal membranes. Evidence is 
thus adduced to show that, in the production of that group of 
symptoms comprised under the term tabes dorsalis, disease of 
the posterior columns of the cord is not an essential factor, and 
that this may be fully developed, that centre being in a 
perfectly normal condition. This fact had already been 
observed by M. Dejerine, who has placed at least two cases 
on record presenting features during life almost exactly the 
same as the case at present under consideration, in which after 
death the cord, spinal roots, and nerve-trunks were found 
healthy.f In these, however, he discovered that there was 
parenchymatous neuritis of the nerve-endings, in the skin, 
and, to a lesser degree, in the muscles of the limbs affected. 
He concluded from this that the ataxic symptoms were due to 
disease of the sentient nerves in the skin and muscles, produc- 
ing anaesthesia of the former, and loss of the so-called muscular 
sense in the latter. Afferent paths were thus interrupted at the 
periphery which alone was capable of producing the typical con- 
dition of ataxy without central change. This form of the disease 
he proposed to call ^^nervo-tabea peripherique" in contradistinc- 
tion to the classical tabes dorsalis. In tne present case it is a 
matter of regret that the cutaneous and muscular nerve-endings 
were not histologically examined ; at the same time facts show 
that the primary disease did not originate there, the post- 
mortem revelations proving the lesion to have begun in another 
portion of the nervous system. There can be no doubt that 

* A 2¥e<xtu€ on J>i»ease9 of the Niervous Sljfstem, by Jamee Boss, MJ)., 
second edition, vol. ii, p. 67. 

t " titades snr le Nervo-tabes pMpli6riqtie/' par J. Dejerine, Areh. de Fk^9%o* 
logie, 8me s^^ vol. iii, p. 281. 



Dr. Bennett's Oase of Locomotor. A taosy. 176 

locomotor atazy^ as generally met witli in practice^ is usually 
associated with degeneration of the posterior root zones. The 
observations of M. Dejerine demonstrate that symptoms indis- 
tingaishable from this may occur without any appreciable 
lesion of the cord^ and may be due to degeneration of the 
peripheral nerves only. This case makes it evident that pre- 
cisely similar results may follow interruption of the co-ordinat- 
ing paths in a third locality^ namely^ in the posterior nerve-roots. 
Yan Deen and Claud Bernard experimentally demonstrated 
that the section of these in animals induced total inability to 
steadily utilise and co-ordinate movement, without causing 
loss of motor power; in short, a condition of extreme and 
typical ataxia. We have here before us a repetition of this 
experiment, produced by disease, and followed by precisely 
the same physiological phenomena. The posterior roots 
throughout the dorsal and lumbar regions were embedded in 
a sarcomatous mass. Pressure on their fibres was the conse- 
quence, accompanied by the symptoms of tabes dorsalis. Thus 
may the anaesthesia, analgesia, and retardation of sensibility 
be explained. Irritation of the sensory filaments caused the 
neuralgia and attacks of lancinating pains. Interruption at 
this portion of the reflex arc accounts for the alteration of the 
tendon and other phenomena, as well as the production of 
ataxy and the Bomb^rg symptom. So far then this case 
supports the view that those elements which convey the 
impulses regulating co-ordinate movement, are situated in the 
afferent paths of the nervous system. The disease in this case 
being limited to the posterior roots, constitutes a more conclu- 
sive fact in favour of that theory even than those in which 
degeneration of the peripheral nerve-endings alone was demon- 
strated. 

It is admitted that in this observation there are two possible 
flaws against absolute proof of the preceding proposition, 
namely the existence of implication by disease of the medulla, 
and anterior* roots. Reasons, however, have already been 
given for the opinion that these complications, for practical 
purposes, need not militate against the argument. 

Whether Dejerine's lesion was primary or secondary to 
undemonstrable trophic influences in the nerve-centres, need 
not be here discussed. But, whatever theory be advanced to 
explain the physiology of locomotor ataxy, and the prominent 
symptoms of so-called tabes dorsalis, this case serves to show 
that the point at which, in the causation of the phenomena, 
the nervous path is interrupted^ need not of necessity, as is 



176 Dr. Bennett's Oase of Loc-omotor Ataxy. 

generaUy asserted, be primarily situated in the posterior root 
zones of the spinal cord. 

Reflection on this fact suggests that we have not yet 
&thonied the anatomical, substratum of that Protean disorder 
which we at present recognise under the term tabes dorsalis. 
This assemblage of symptoms probably consists of a com- 
bination of different pathologicsJ conditions, many of which 
are represented by pnenomena common to all. and each of 
which in time m/7^>e differentiated. It is possible that a 
case such as the present may be a link in the chain of dis- 
covery. 

Such considerations are of practical utility, as the tendency 
of the present day is to assume that certain isolated symptoms 
of necessity indicate the existence of serious and progressive 
central disease. In practice we see persons who happen to 
suffer from pains in their extremities, peculiarities of their 
pupils, alteration in their reflexes, or from other special 
nervous symptoms, often pronounced as the subjects of tabes 
dorsalis. These are either made the victims of prolonged and 
unnecessary treatment on that hypothesis, or doomed as hope- 
lessly incurable. The case under consideration, although it 
ultimately ended fatally, proves that our present conceptions 
of the pathology of locomotor ataxy must be modified, and that 
the generally believed classical lesion for its production is not 
without exception. It further suggests that there may be 
other more innocent or removable circumstances which may 
give rise to the same series of symptoms. 



Dr. Seymour Taylor's Case of Arreated Micketa, 177 



XVllI. — A Case of Arrested Bickeis. By Setmoue 
Tatloe, M.D. Bead February 27, 1885. 

ALEXANDER S., tet. 6, came under my notice at the oat- 
patient department of the NortH London Consumption 
Hospital in Jnne, 1884. 

The history of the caBe ia briefly as follows : — His mother 
has had sixteen children, of which the present child was the 
twelfth. He was bom at fnll term. His father and mother 
appear quite healthy people, and the former is a teetotaler. 
His mother has lost Ave of her children, — two from whoop- 
ing-cou^, one each from bronchitis, from smallpox, and from 
inflammation of the lungs. All the other children are perfectly 
healthy, except that two of his sisters, the sixth and seventh 
children respectirely, are knook-kneed. 

When 1^ years old the patient fell out of his cot, and his 
illness with subsequent bending of bones dates from this 
accident. He was subsequently treated by different practi- 
tioners, first on account of bronchitis and soon afterwards for 
" enlarged liver." At that time he used to scream terribly, 
especially if lying flat on his back, and he also suffered from 
profuse sweatings, especially about the head. I have ascer- 
tained that at this period he had a distinct attack of laryngiemus 
stridulus. At the time of his fall he was onable to walk ; he 
could not even push a chair in front of him as his limbs and 
muscles seemed peculiarly painful. He waa not restless at 
night. 

The child will be found on examination to have the typical 
pigeon-breast, with beading of the sternal ends of the ribs. 
He suffers from the chronic form of bronchitis usual in rickety 
children. The heart is depressed and pushed somewhat to the 
right side ; there is no cardiac murmur. He is stunted in 
growth, being 29^ inches in height only, the limbs are short- 
ened. The clavicles have their curves so pronounced, as to 
become almost V-shaped. The homeri are curved forwards, 
and are only five inches in length. The forearms are bent, and 
held in a position of extreme pronation. Supination is only 
possible as far as the supinator longus will allow. He is 
"pot-bellied." The liver proieotB one inch below the costal 
arch and is painful to the toned. The spleen cannot be made 
VOL. XTIII. 12 



178 Dr. Seymour Taylor's Oaae of Arrested Rickets. 

out to be enlarged. The Bpine is carved to the right, and the 
thorax hulgea to the right side posteriorly. 

The tibiee and fibulee are bowed forwards and he is flat- 
footed. When he first came under obserration the tibiie and 
other long bones were very soft and pliout, so much so that I 
was somewhat afraid to use mach force in manipnlstion. He 
has not been accustomed to creep on all fours, but has rather a 
tendency to shuffle along on his buttooks. 

The f ontanelles are closed, the os frontia is somewhat prow- 
shaped, and the girth of the skull at the level of the occipital 
protuberance is 20} inches. I have never found any evidence 
of increased urio acid in the urine. 




BeTnarhs. — In connection with the causation and associa- 
tions of rickets I may again revert to the child's parentage 
and early history. 

The child was born and reared in a bouse where the venti- 
lation and light were always good. He was well formed and 
healthy at birth. He was suckled twelve months, and was 
not given any starchy food till the ninth month. Tho father 
and mother are both healthy, and certainly neither show any 
signs of ever having suffered from rickets. There are no signs 
of tubercular disease in either parent, nor did the mother 



Dr. Seymour Taylor* s Oase of Arrested Rickets. 179 

suffer from any deprivation during her pregnancies. She was 
quite healthy when this child was bom. I may note, however, 
that she had children very fast, sixteen births in twenty-two 
years. I have carefully cross-examined both parents with a view 
to ascertain the possibility of a syphilitic taint, but have failed 
to obtain the slightest evidence thereof. The mother has had 
no miscarriages, no premature births, no stillborn children, nor 
have any of the infants suffered from snuffles or rash. 

There is no history of what Hilton Fagge called the pro- 
dromata of rickets, viz., drowsiness, vomiting, diarrhoea j 
although drowsiness is a symptom which has supervened upon 
the bending of the bones. The child has not had alcoholic 
stimulants given to it ; its father wears the blue ribbon. The 
children bom subsequent to this one are all healthy; two of 
the patient's brothers have enlisted into the army, and have 
been taken into corps which have picked men only. 

It will thus be seen that the evidence which I have brought 
before the Society as to the cause of rickets is mainly of a 
negative character. This case only tends to strengthen my 
belief in Sir William Jenner's opinion that rickets is a 
diathesis, and quite a distinct condition from syphilis. We 
have here samples of healthy parents, living with good 
hygienic surroundings, and producing healthy children with 
the exception of the one under our notice. 

But when we come to remember the rapid pregnancies of 
the mother I submit that it is not to be wondered at that one 
at least of her children should show signs of bodily weakness. 

In mental qualities my patient does not appear defective. 
He is intelligent for hi/s age, and in some directions he shows 
great aptitude for learning. I am informed by his father that 
he is especially quick at music, and that he sings, with his 
treble pipe, the bass parts which he has heard his father sing. 

Lastly, I may draw the attention of the Society to the 
opinion offered by the child's mother, viz. that his illness 
dates from, and is in consequence of, his fall from the bed. 
This traumatism of rickets as a starting-point is, I believe, 
one which has been before acknowledged, and is extremely 
interesting to me, and one on which I hope to make some 
further observations. 

I have ventured to call this a case of arrested rickets, as 
the child is improving under treatment. The pliancy of bones 
is less marked, and there can now be felt in the long bones, 
notably the tibisd, strengthening buttresses of bone on the 
concave surfaces of the arches. 



180 Mr. Symonds' Oase of Nephro-Lithotomy. 



XIX, — A Case of Nephro-Lithotomy. By Chabtebs J. 
Symonds, M.S. Bead Febniary 27, 1885. 

JC.^ set. 50^ a carpenter and joiner^ of a healthy family 
• and abstemious habits^ was admitted under the care of 
Dr. Mahomed^ into Guy's Hospital on June 11, 1883. He 
was a well-nourished, healthy man, and never had any severe 
injury or general disease. 

During the last twenty-four years he has been subject to 
attacks of pain commencing in the left loin, thence passing 
down into the groin and inner side of thigh. The frequency 
of the attacks varied, occurring from once to three or four 
times in a year. The attack lasted sometimes a day or less, at 
others it extended over a week with exacerbations and remis- 
sions. Sometimes he would be laid up for a month or even 
two months after an attack, from a feeling of general illness, 
what he calls ''liver,'' during which time he suffered from 
loss of appetite and general malaise. There was no diminution 
of urine during these attacks or during the after-period. 

The pain he describes as agonising, and he could obtain 
no relief until it spontaneously disappeared. This pain has 
left him for four years, and up to seven months ago he was 
comparatively well. At this date he had for a time increased 
frequency of micturition, being obliged to empty the bladder 
every two hours or less. So sudden was the desire to micturate 
and BO urgent the call that he was often unable to reach a 
convenient place. 

In February last, i.e. four months ago, he first observed 
blood in the urine. Usually clots were present, sometimes 
being one to one and a half inches in length, and occasionally 
interrupting the flow of urine by being caught in the urethra. 

On one occasion after a sharp walk he passed urine red from 
blood, but without clots. After a sharp walk or after work which 
entailed a good deal of stooping, some blood would pass with 
the first micturition, and afterwards clots. As the man said, 
''anything which worked the body," meaning movements 
requiring the use of the erector spinas muscles, produced 
haemorrhage ; especially he noticed it when gardening. He was 
unable to ride in a carriage on account of the pain and haemor- 
rhage. He found himself easiest while living on one floor. 



Mr. Symonds' Oase of Nephro^Lithotomy. 181 

and walking with a sliding motion of the feet j planting his 
foot firmly caused an increase of pain. 

For the last three or four months he has been resting and 
is better of the pain^ but feels languid and weak. He has a 
persistent dull aching pain in the left loin. He sleeps on the 
left side^ as resting on the right causes the lumbar pain. 
When admitted there was no pain on micturition nor increased 
frequency so long as he kept in bed. There was no fulness 
or tenderness in the loin. 

The wrine was pale, strongly alkaline, specific gravity 1015. 
It contained some albumen, and small clots were usually 
present. 

A few days later it is stated to contain pus in considerable 
amount and phosphatic crystals with mucus. 

He was placed upon a milk and farinaceous diet. 

I was asked to see the patient by Dr. Mahomed, and 
sounded the bladder, but found no evidence of stone, a 
result similar to that obtained on two former occasions by Mr. 
Bansford, his medical attendant in Bath. 

July 6 it is noted that he had improved, had gained flesh, 
and had a good appetite. He daily went into the grounds. 
The dull aching pain continued, and the urine had the same 
characters noticed on admission, the blood always increasing 
on exertion. 

There being little doubt as to the diagnosis in this case it 
was decided to cut down upon the kidney, to remove the 
calculus if possible, leaving the kidney, unless from suppura- 
tion its condition was sufficiently bad as to render its complete 
removal advisable. This was accordingly done on July 11. 

I made an incision parallel and close below the last rib. 
The lower end of the kidney was isolated, and the anterior 
surface of this part and the pelvis examined. At once a hard 
body was felt at the commencement of the ureter. The kidney 
was large, bulging in several places, and evidently distended 
with fluid. By means of a steel director the pelvis was 
scratched through over the stone, which was then seized with 
forceps. Being conical in shape, and the small end being 
seized, it was impossible to extract it through the small 
opening. On enlarging the hole by means of a raspatory, a 
large quantity of watery, odourless fluid gushed out, the 
ki£iey collapsed and the stone disappeared. The search to 
recover the calculus lasted a long time; we thought it had 
fatUen back into the dilated pelvis, or had escaped into the 
wound. Not finding it in the latter place an incision was made 



} 



182 Mr. Symonds' Oase of Nephro^Lithotomy. 

througli tlie cortex^ whicli proved to be but a quarter of an incb 
in tbickness. Througb tbis opening tbe finger was inserted^ 
bat careful exploration &iled to discover tbe stone. As tbere 
were many recesses, bowever, from tbe dilated calyces tbis was 
not surprising. Mr. Howse and Dr. Mabomed botb assisted 
me in tbis searcb. Having nearly completely isolated tbe 
kidney, tbe ureter was booked up into tbe wound so as 
to make tbe upper end of tbe kidney dependent. On examining 
now tbe calculus was found in tbe pelvis; it was brougbtupto 
tbe cortex, tbe latter incised, and tbe stone removed. 

Necessarily in sucb a prolonged manipulation a good deal 
of injury was inflicted. Tbree openings were made into tbe 
pelvis : one by scratcbing tbrougb it ; anotber by incising 
tbe cortex, tbrougb wbicb tbe finger was passed in searcb of 
tbe stone, tbus enlarging tbe aperture by tearing its margins ; 
and a tbird tbrougb wbicb tbe stone was finally removed. As 
stated before, tbe organ was so completely isolated tbat it would 
bave been easy to remove it. As no pus bad been found (and 
baving in view tbe greatly increased danger of nepbrectomy 
as compared witb nepbrotomy) we elected to leave tbe kidney 
and close tbe wound. Tbe operation lasted nearly two bours. 
Tbe wound was closed by silk sutures placed deeply tbrougb 
tbe muscles, and two large drainage-tubes were inserted, tbeir 
deeper ends being in contact witb, but not witbin, tbe kidney. 

Tbe carbolic spray was used and tbe usual antiseptic dress- 
ings applied. 

In five bours it was necessary to dress tbe case, as a copious 
tbin fluid bad soaked tbrougb; tbis was blood-stained, but 
witbout urinous odour. 

July 12. — ^At 9.30 a.m. second dressing, tubes removed, 
cleaned, and returned. 

July 13. — ^Tbird dressing 9 p.m. Skin united. One 
tube shortened. One suture cut, one loosened. 

July 15. — 9 A.M. fourtb dressing. Tbe same tbin fluid, 
no pus. One tube removed and one suture. Two otbers cut. 

July 16. — A simple enema given. 

July 18. — Two sutures removed and remaining tube. 
Eucalyptol dressings substituted on account of persistent 
carboluria. 

July 20. — Tbe wound was practically superficial, and on 
24tb tbe spray was discontinued, and boracic lint employed. 

In a few days be was up. Tbe pus persisting, together witb 
a little blood, tbe bladder was examined, but no stone 
detected. 



Mr. Symonds' Case of Neph/ro-Idthotomy. 188 

On Angnst 17 he was discharged. For some time he 
had been free from pain^ but as the urine still contained alba- 
men^ which on August 4 had increased from -nr ^ 7 (after 
sounding)^ he was kept in the hospital upon a low diet. On 
August 14 it was noted that there was slight oedema of the 
feet. When discharged there was some tenderness^ and, a 
feeling to him of fulness in the loin^ attributable probably to 
the incision. A pulse tracing at this time showed a slight 
increase of arterial tension. 



30 oz. 
14 oz. 
40 oz. 
1022 
1-5 



ConcUtion of Urine. 

For nmeteen days before operation. 

Average daily quantity 

Smallest 

Largest 

Average specific gravity 

Average per cent, of urea 
Beaction alkaline. Albumen about ^th. 
Deposit contained mucus^ pus and blood arranged in 
three strata. The two latter always in small amount; the 
blood forming a stratum about -j^th of an inch thick. 

Day of operation. 

14 oz. passed before operation showed the usual 

characters. 
8 oz. passed afterwards contained more blood than 

usual. 



43 oz. 

24 oz. 

60 oz. 
1022 
2-0 
2-5 



For nineteen da/ya after operaUon. 
Average daily quantity 
Smallest quantity 
Largest quantity 
Average specific gravity 
Average per cent, of urea 
And for the first five days 
Beaction generally alkaline^ often faintly so^ and some- 
times acid^ especially after the operation. 

The ^9^ day after operation 52 oz. were passed having a 
smoky appearance^ from diffused bloody and about 4th 
albumen. 

On the tJdrd day carbolic acid appeared in the urine 
six hours after the fourth dressings the urine remained dark 
for five hours. 

On the fifth day carbolic acid again appeared about six 



184 Mr. Symonds' Case of Neph/ro-Lithotomy. 

hours after the dressings remaining about the same time as 
before. 

The albumen dropped to -n^th^ but on August 4 rose to 
^rd. This was due probably to his being sounded on the 3rd, 
for the albumen in four days had again fallen to -nrth. 

The stone is conical^ its greatest length | inch^ greatest 
breadth -^y narrows to |^th. It is of a tawny colour, covered 
with fine rounded nodules, and in particidar lights shows 
bright, crystalline points. (Plate IX, fig. 3.) On section there 
is no lamination to be seen, but the larger end has in its centre 
a darker material. The stone is hard and dense, and weighs 
about 18 grains. 

An analysis of the stone carried out under the supervision 
of Dr. Stevenson, shows it to be composed entirely of 
phosphates. 

Bema/rka, — The method adopted in searching for the stone 
was that suggested by Mr. Howse in his paper in vol. xvi 
of the Transactional The lower end of the kidney was 
freed, and the pelvis just where it is becoming ureter was 
examined from the anterior sur&ce. Here a hard substance 
was at once detected and held by the fingers, while the pelvis 
was scratehed through with a blunt director. The opening 
was made in the infundibulum on the side next the kidney. 
The plan adopted for finding the stone seems a valuable one, 
for, as Mr. Howse has pointed out, exploration is greatly 
facilitated by the presence of a firm understratum of muscle. 

But little alteration took place in the urine after the opera- 
tion, and as the bladder appeared healthy, it is probable that 
the blood came from the other kidney. This is the more 
likely when the distended condition of the left kidney is 
remembered, for the calculus appeared to have completely 
obstructed the ureter. Though relieved of the stone, the man 
is by no means cured, for he writes in January, 1884 — six 
months after the operation — ^that he still suffered pain in his 
left side on steeping. The urine still contained blood at 
times, and the specimen sent up for examination contained 
some pus, albumen, and blood. The man said in his letter, 
that though able to work a little he did not consider his health 
good. 

November 10, 1884. — The patient writes that he is much 
better, is free from pain, except when he over-exerts himself. 
A specimen of urine which he forwarded showed abundance 
of pus-cells and some blood-discs. 



Mr. Morris's Case of Neph/rO'Lithotomy. 185 



XX. — A Case of Nephro-Lithotomy. By Henet Mobbis. 

Bead February 27, 1885. 

THIS case is recorded with the object of adding one more to 
the series of successful nephro-lithotomies which have 
been read before this Society since October, 1880. (See vol. 
xiv, pi 30.)* 

Edward Q-., set. 24, a jeweller, was admitted, under Dr. 
Powell, into the Middlesex Hospital on April 10, 1884, suffer- 
ing from symptoms of calculus in the left kidney. To Dr. 
Powell I am indebted for the opportunity of performing the 
operation, as well as for some of the earlier notes of the case. 

Since his schoolboy days Edward G-. had complained of 
pain in his loins, but in spite of this he had enjoyed fairly good 
health till two years ago, when he was attacked by a '' kidney 
complaint." This came on without any assignable cause, and 
was chiefly marked by pains in the left loin, shooting down, at 
times, to his left testicle. For three weeks before admission 
these pains had been too severe to permit of his working, and 
he attended during this period at the out-patient department. 
On admission he had pain in the left renal region, and tender- 
ness on deep pressure in the left loin. His urine was neutral, 
of sp. gr. 1010, and contained blood and triple phosphates. 
There was frequency of micturition, though the urine was 
stated to be somewhat deficient in quantity. Five days after 
admission, however, it was noted that the average daily 
quantity of urine voided had been 45 ounces. From April 18 
to 25 the pain was diminished and less constant, but there was 
still tenderness on deep pressure in the left lumbar region. 
When the pain occurred the left testis was retracted ; more- 

* I desire to take this opportanity of correcting an error which inadvertently 
crept into my first paper on Nephro-lithotomy in the process of correcting for 
press ; and to which my attention has since been directed. 

It is implied on p. 34 of the fourteenth volnme of the ' Transactions ' of the 
Society that Charles Bernard was not a medical man. In my MS., however, I 
wrote that the description of Marchetti's operation which has come down to ns 
" was written by one to whom it wcu narrated, hut not wUil ten yeare <tfter the 
event, by the patient who was not a medioal man." I never intended to state^ 
though in my printed paper it woold appear that I did — that Charles Bernard, 
F.B.O., was not a snrgeon. 

Apart from the fact that he was one of the snrgeons of St. Bartholomew's 
Hospital, his description of what is said to have been Marchetti's operation on 
the English Consul Hobson is in itself evidence that he was a medical mant 
(Vide Medieal Tmee, February 21st and ^th, 1886.) 



186 Mr. Morris's Oase of NepJirO'Lithotomy. 

over, tliis testis was discovered to be mucli atrophied. The 
urine at this time was acid^ sp. gr. 1024^ and contiuned a trace 
of albamen due to the presence of pus. After consultation 
with Dr. Powell it was decided that the patient should be 
transferred to a surgical ward for the purpose of undergoing 
nephro-lithotomy. 

The operation was performed on May 10, 1884. 

A calculus was felt, by the finger passed over the front 
surface of the kidney, near the inner border, and below the 
hilum. Digital examination of the posterior surface, and acu- 
puncture of the kidney had &iled to detect it. The sensation 
communicated to the finger by the calculus through the renal 
substance was simply that of increased induration, as com- 
pared with the resistance offered by the rest of the kidney. 
With my finger-nail |I scratched through the renal tissue 
covering the calculus, and thus verified the nature of the 
induration ; then with a bistoury I incised the inner edge of 
the kidney on its posterior surface ; and partly by pushing the 
calculus with my left index finger (which I kept all the while 
in front of the kidney), and partly by the aid of a narrow 
curette, the stone was dislodged and removed. There was no 
hsBmorrhage of any moment from first to last. A large 
drainage-tube was introduced into the wound, but not into 
the kidney ; the edges of the wound were held together by 
sutures ; and terebene oil on lint and a thick layer of absorbent 
cotton wool were retained over the wound by a Ught bandage. 

The operation was performed at 2 p.m. At 1 p.m. he had 
micturated for the last time before the operation, and no urine 
was passed after the operation by the penis, until 7.30 a.m. on 
May 11, when 15 ounces of lightly blood-stained urine were 
voided naturally. At 12 o^clock at noon on the same day 
(May 11) 9 ounces more were voided; so that 24 ounces were 
passed naturally in the first twenty-four hours after the opera- 
tion. The dressings were changed once in the evening of the 
day of operation, and three times on the following day ; but on 
May 12 there was so little discharge from the wound that this 
frequency of dressing was considered quite unnecessary, and 
was therefore discontinued. Urine had in fact ceased to pass 
by the wound. During the second period of twenty-four hours 
the urine was passed per urethram as follows : 

May 11. — 2.50 p.m., 4 ounces ; 5 p.m., 4 ounces; 10 p.m., 4 
ounces. May 12. — 12.15 a.m., 5 ounces ; 2 a.m., 4 ounces ; 5.15 
A.M., 6 ounces; 7.50 a.m., 10 ounces; 10.45 A.M., 6 ounces; 
1,21 p.M.^ 5 ounces. Making a total of 48 ounces, 



Mr, Morris's Oase of Neph/rO'Idthotomy. 187 

The urine continued to be blood-stained until May 14. On 
the 15th it was neither blood-stained, nor did it contain albu- 
men ; its sp. gr. was 1023, and there were 40 ounces voided in 
twenty-four hours. On the 16th the quantity of urea was 
estimated, and found to be 495 grains in 42 ounces of urine 
passed in the twenty-four hours. On May 17 the wound was 
in great part united^ and the stitches were removed. The 
patient had had no pain since the operation, and his only dis- 
comfort had been the enforced restriction to the recumbent 
position. The temperature rose on this day to over 101° 
(101-8° being the highest). On the foDowing day (the 18th) 
and on part of the 19th, the temperature remained just below 
100°. With these exceptions the temperature throughout 
never exceeded 99° Fahr. 

May 20. — The bowels had not acted since the operation, 
and so an enema was given. This had the desired effect, and 
the defsacation was unattended by pain; but on May 21, from 
the state of the dressings it was inferred that a little urine had 
again been discharged through the loin wound; 60 ounces of 
urine were passed per urethram, so that the chief part, if not 
the whole of the urine from the left, as weU as from the right 
kidney must have come the proper way. 

On the 23rd the bowels acted twice, and again a small 
quantity of urine was thought to have come subsequently 
throufi^h the wound : but the amount so escaping: was extremely 
sinaU It would seem as if the passage of the1»ces along thi 
descending colon caused some disturbance to the wound in 
the kidney, which, however, must have been nearly healed. 
This interference was the more probable owing to the situation 
of the wound in the kidney. Forty-six ounces of urine were 
passed the natural way; it was of good colour, sp. gr. 1027, 
acid, and contained no albumen. 

On May 28 the patient, who had been on ordinary diet 
since the 26th, was feeling quite well, and only the track of the 
drainage-tube remained unhealed. 

On June 3 this track had closed so that not even a fine 
probe could be introduced. On June 10 he got up for the 
first time, and on the 12th went into the garden, and there 
took walking exercise. He continued to gain strength daily, 
and was considered to be well, when on June 26, at 8 p.m., 
after taking a good deal of exercise out of doors during the 
day, he passed urine coloured deeply with blood. On June 
27, at 4*30 a.m., the urine was still more blood-stained 
than that passed at 8 o^clock the previous evening. At 9 a,m. 



188 Mr. Morris's Case of Neph/ro-Liihotorny. 

on June 27, the urine was much less mixed with blood; and 
on June 28, 51 ounces of urine were passed in twenty- 
four hours ; it was acid, and of sp. gr. 1020, and contained 
neither blood nor albumen. The bowels had been acting 
twice a day, so that the hsemorrhage could not have been due 
to pressure on the kidney by an overloaded colon. No pain, 
sense of discomfort, or feeling of illness of any sort attended 
this attack of hsBmaturia. 

For a few days he was kept in bed, but there was no 
return of the haematuria ; on July 8 he left the hospital quite 
well, and with the cicatrix in his loin perfectly firm through- 
out. On several occasions since this paper was read he has 
been seen at the hospital. There has been no return of the 
haematuria, he never suffers pain, has been at work regularly 
since leaving the hospital, and has never felt better in his life 
than since the operation. 

The calculus was divided (Plate IX, fig. 1), and Mr. 
Thomas Taylor has kindly given me the following account 
of its composition. " The half of the calculus which I herewith 
return consists of a small dark-coloured nucleus of oxalate of 
lime, upon which has been deposited urate of ammonia mixed 
with a small quantity of oxalate of lime ; this is surrounded by 
a layer of dark oxalate of lime, and the whole is coated by a 
thin layer of nearly white oxalate of lime, upon which are 
deposited, in parts, crystals of pure oxalate of lune. 

" 1. Nucleus, oxalate of lime. 

'' 2. Urate of ammonia. 

''3. Oxalate of lime.'' 



DEISCRIFTIOH OP PLATE IX. 

JT/zi, 1 -^r; Wlnititnie Mr. Morrit'f etme oi Hepbro-lithotoiiiy. P. 188. 
Vit^. ^.^nin illtiiirilio Mr. Orofi't ca«et of Preputial GalcoH. P. 8. 
tttit Ht^^o i]\w$irnie Mr. Sjmondt'f case of Kephro-lithotomy. 

Ft^i 4f.— To llltttirate Mr. Symondi'i case of Removal of Calcnlas 
ttfim tlio V<n*mlforiai Appendix. P. 288. 



GliaSccTTOTs'W.MlIl.PlalE IX 




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0(i8eof NephrO'IdthotomyyhjDr.l)iolsin&onBind'M.r, Boase. 189 



XXI. — Gdse of NephrO'Lithotomy. Under the care of 
W. HowsHXP Dickinson, M.D., and J. Rouse. Com- 
municated by Dr. Dickinson. Bead April 24, 1885. 

HENBY 8,, living at Leighton Bnzzard^ remembered to 
have occasionally passed dark-coloured, apparently 
bloody, urine since he was six or seven years old, and was 
told by his mother that he had done so earlier, '^ ever since 
he was a child." In the year 1877 he, then being twelve years 
old, came under my care in St. G-eorge^s Hospital with hsema- 
turia, which was attributed to stone in the kidney. 

On April 2, 1884, then having reached the age of nine- 
teen, he again became my patient in the same place with 
similar symptoms. I had on his discharge urged his parents 
to put him in some quiet way of life. They responded by 
apprenticing him to a blacksmith, at whose trade he worked 
until his admission. Up to this time he had had attacks of 
hsBmaturia with intervals which varied from a week to six 
months. These attacks were attended or preceded by sharp 
pain in the right lumbar region in the position of the kidney, 
passing thence to near the anterior superior spine of the ilium, 
not to the testicle or thigh. This pain was often present inde- 
pendently of the hsBmaturia, though the two were often, asso- 
ciated, the pain usually preceding the hsDmorrhage. 

Both were brought on by exertion, more particularly by 
lifting, and by jolting, as by riding in an omnibus, not by 
cold. Beer had been noticed by the patient to bring on both 
pain and bleeding, in consequence of which he was for some 
time a teetotaler. In the hospital two pints of porter were 
found to be effectual in these respects; pain came on two 
hours afterwards, hsDmaturia the next day. 

The urine was generally natural in appearance and of good 
specific gravity, 1016 to 1020. It was sometimes faintly acid, 
sometimes alkaline, and displayed under the microscope some- 
times oxalate, and sometimes phosphate of lime. No casts were 
at any time found, nor was there any albumen excepting when 
blood was present. This occurred while he was in the hospital 
on slight provocation and at frequent intervals, which varied 
from two to ten days. The urine then assumed a full blood 
colour; the blood, which was corpuscular^ fell on standing as 



190 Oase of Nephro-Lithotomy , by Dr. Dickinson and Mr. Bouse. 

a bulky red deposit^ leaving tbe supernatant fluid but slightly 
tinted. 

The character of the heemorrhagic discharge, its associa- 
tion with movement and exertion, the localised pain, and the 
history of the case were sufficiently indicative of stone in the 
kidney, and it may be added that the absence of pus, of 
albumen, save when blood was present, and of caste, were 
sufficient evidence that but for the stone the kidneys were 
practically healthy. The patient was in good general health, 
rather thin than fat, but not extremely so; beyond slight 
sallowness of complexion he showed little sign of having lost 
blood, and altogether the freedom from doubt with regard to 
the diagnosis, and the health of the patient, marked him as a 
promising subject for renal lithotomy. In these circumstances 
I suggested to my colleague Mr. Bouse that he should under- 
take the operation. 

After consultation with the other surgeons this was done 
on May 8, 1884. Under ether, and with antiseptic precau- 
tions, a transverse incision was made in the right loin, 
as in Amussat's operation; the kidney was readily exposed, 
and a lump which was thought to be a stone was readily felt 
with the finger through the renal substance. This was punc- 
tured with a needle and the grating of stone recognised. The 
glandular tissue was then incised, with some haamorrhage, and 
the stone felt and somewhat displaced with the finger. It 
appeared to lodge, or to be embedded, in one of the calyces. 
A second stone, apparently much smaller, was also felt. The 
larger stone was easily withdrawn by means of a pair of for- 
ceps. The second stone could not be readily grasped, and 
was left in its place in the hope that it would subsequently 
come out of the wound under the influence of movement and 
position. 

The stone which was extracted was almost exactly of the 
shape of a heart, the apex and separation of the ventricles 
being clearly distinguished. The notched base had evidently 
fitted into the calyces, the apex into the infundibulum. From 
base to apex the stone measured three quarters of an inch, 
the same from side to side. When dry it was found to weigh 
sixty-five grains. It was preserved uncut, but from its dark 
colour and finely nodulated surface, there could be no doubt 
that it consisted superficially and probably chiefly of oxalate 
of lime. The lesser stone came out of the wound on the fourth 
day after the operation. It was of about the size of a pea ; it 
had a polished and roundly faceted exterior, and weighed 



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Otweof JfepAro-iiiAofcMByjbyDr.DickmsoiiMidMr.BioaBe. 191 

two graiuB. The colour was suggestive of oxalate of lime 
rather than uric acid. 




The patient went on smoothly from May 8 until the 22nd, 
when he had a rigor and the temperature went up to 103'7°. 
Xext day there waa another rigor, with a temperature of 
104°, and much rusty Bputum such as belongs to pneumonia. 
The difficulty of moving the patient prevented any adequate 
examination of the chest. The rigors were repeated on the 
24th and 25th, and the temperature continued to ascend with 
evening exacerbations until on the 27th it reached 107°, which 
was the maximum attained during the illness. There was 
now much pain in the left elbow and wrist and the latter joint 
was red and swollen. There was some effusion in the left 
knee. The wound itself, in spite of the alarming constitutional 
disturbances, was going on well ; it looked healthy, was granu- 
lating steadily from the bottom, and the amount of urine dis- 
charged through it, which at first had been most profuse, was 
diminishing. Alcohol and quinine were given freely. 

On the 29th an attack of profuse diarrhoea occurred, the 
bowels acting twenty times in about the same number of hours. 
This was controlled by enemata of opium, and from this time 
there was some improvement in the aspect and temperature 
of the patient, which from this date never went above 105°, 
Between May 29 and June 11, the daily range was still very 
great, often over six degrees, the lowest temperature during 
this period being 97'6°, the highest 105°. {Plate X.} Mean- 
while the local condition of the joints was improving ; they 
were less swollen, less red, and less exquisitely tender, the 
diarrhcea was in abeyance, the patient took liquid nourishment 
and stimulants well and had not quite the look of hopeless 
prostration which commonly attends such a temperature in 
such circumstances. From June 12 the temperature steadily 
decUned, the general symptoms mitigated and the healing of 
the wound progressed. By the 20th very little urine passed 
through the wound, which was almost skinned over. The 
new surface was powdered with calomel to keep it dry ; the 



192 Case of Nephro-IAthotomy, by Dr. Dickinsoii and Mr. Bouse. 

crust so formed generally broke wben lie turned over^ allowing 
a few drops of urine to escape^ whicli was all that made its 
way otherwise than by the natural channels. 

On July 10 the wound was perfectly healed and the 
patient up. 

On the 29th he was sent to Wimbledon convalescent^ 
whence he passed to his own home^ where he resumed work as 
a blacksmith. 

On October 27 he came to the hospital to show himself; 
the urine was then natural^ he had no symptoms of calculus ; 
nothing remained of the disease but the two stones in my 
possession, and nothing of the operation but the scar. 

The case presented no difficulty in diagnosis. HaBmaturia 
is a better guide to stone than pyelitis ; the latter condition 
may depend on so many causes that it is of little value as a 
surgical indication. After the operation the most noteworthy 
occurrence was the alarming attack of what must be called 
septicsemia, for the recovery without suppuration was, I suppose, 
enough to show that the disturbance did not attain to pyaBmia, 
however much it resembled it. It may be observed that the 
antiseptic method of dressing was renlered impracticable bv 
the profuse discharge of uri^e from the wound. ^ 



Dr. Bastian^B Case of Thrombosis of the Basilar Artery. 193 



XXII. — A Case of Thrombosis of the Basilar Artery ^ 
with profound coma, extreme lowering of rectal tern- 
perature, and death in fwe and a half hours. By 
H. Chaelton Bastian, M.D., F.R.S. Bead March 
13, 1885. 

MICHAEL D.J 8Bt. 43, a watchman, was admitted into 
University College Hospital under my care in a comatose 
condition, at 6 p.m., on November 16, 1884. 

The following history of the patient was subsequently 
obtained : 

His health had been generally good, but three years ago 
he was in Middlesex Hospital on account of ulcers on his 
legs, just above the ankle-joint on each side. The wife says 
these ulcers existed when he married eleven years ago, and 
they continued up to the time of his death. The ulcer on the 
left leg was said to have followed a kick. No definite history 
of syphilis, though the patient's wife had had three mis- 
carriages (she could not say at what term) and no living 
children. Has lived in a good house, and has mostly had suf- 
ficient food ; has been rather intemperate, getting intoxicated 
occasionally. His occupation has been that of a night watch- 
man for the parish of St. Giles ; his duty being to look after 
the tools of workmen employed upon the roads. He has not 
had constant employment, having been out of work for two 
months preceding the week before his death. During this 
time he had very little either to eat or drink. Had suffered 
from a bad cough lately, and has complained of a severe pain 
in the left frontal region during the paroxysms of coughing. 

Had been at work again one week when the illness 
commenced. On the afternoon of the day on which it occurred 
he went to his work as usual, and appeared to be in good 
health. He was seen by a man at 4.30 p.m., and seemed quite 
well. One hour later the patient was again seen by this same 
man, who found him in a sitting position groaning, but unable 
to speak. He was soon put into a cab and sent to University 
College Hospital. 

The following careful notes of his condition were then taken 
by my late house physician, Mr. Henry Littlewood. 

In Casualty Boom, 6 p.m. — Patient profoundly comatose, 

VOL. XVIII. 13 



,94 Dr. Bastiaa^B Oaae of Th/romhoais of the Basilar Artery. 

not to be roused ; no distinct stertor, but breathing irregular 
and at times slightly stertorous ; no flapping of cheeks ; face 
pale^ cold, and clammy. All limbs flaccid, with the exception of 
some sKght rigidity of right arm. PupUs equal, somewhat con- 
tracted. No conjugate deviation of head and eyes ; eyes open. 
No want of symmetry about the face noted. No conjunctival 
reflex. No knee lerk: no ankle clonus. No involuntary 
evacuations. Urine drkwn ofE, acid, and containing a sma^ 
quantity of albumen. Temperature in rectum at 6.10 p.m. 98° ; 
at 6.20 97°. Heart-sounds healthy; its action tumultuous. 
A few moments later pupils became more dilated, and it was 
now noticed that they reacted sluggishly to light on both 
Bides, although any such reaction was doubtful when patient 

was first seen. 

The patient was transferred to Ward Vil, a mustard 
plaster being applied to the nape of the neck, and two drops 
of croton oil on butter administered. The following notes 
were subsequently taken. 

7 P.M., temperature in rectum 96*2° The thermometer does 
not rise in either axilla above 95°. Pulse 80, fairly full, 
regular in time, but irregular in force. Eespirations irre- 
gular — ^there are a few rapid inspirations, then a pause, 
followed by a long and deep expiration. 

7.50 P.M., patient remains in much the same condition. 
Temperature in rectum now below 95°. Pulse 84, compressible, 
rather irregular, 9, 5, and 7 in successive periods of five 
seconds. Respirations of character above noted, but hampered 
now by excessive secretion of mucus. Trachea and throat full 
of mucus of a glairy character. Pupils of medium size, do not 
react. 

8 P.M., rectal temperature below 95°. Pulse 64. 

8.45 P.M., rectal temperature below 95°. Pulse 100; re- 
spirations 17 per minute. All limbs now quite flaccid, the 
sUght rigidity of right arm, originaUy noted, having dis- 
appeared. 

10.15 P.M., rectal temperature still below 95°. Pulse can 
only be felt with difficulty; irregular, and at times (varying 
with respirations) imperceptible. Respirations unaltered. 
Pupils more contracted than at last note, unaffected by light. 
AJl Umbs flaccid. 

10.30 P.M., three spontaneous and momentary dilatations of 
pupils seen. Pulse cannot be felt at wrist. 

10.45 P.M., death occurred. (Fifteen minutes afterwards, 
the rectal temperature was found to be still below 95°.) 



l)r. Bastian's Oaae of Thrombosis of the Basilar Artery. 195 

The necropsy was made by myself fourteen hours after 
death. Calvaria and dura mater presented nothing un- 
natural. Longitudinal sinus almost empty^ containing only a 
small quantity of semi-fluid blood. On removing dura mater 
some flattening of the convolutions over the posterior two 
thirds of both hemispheres was seen, more marked on the 
right than on the left side. On examination of the large 
vessels at the base of the brain, the first part of the right 
middle cerebral was seen to be more opaque, and its walls 
thicker than natural. Other portions of the middle, anterior, 
and posterior cerebrals presented a fairly healthy appearance. 
The posterior half of the basilar [a/rtery was dilated to twice 
the diameter of the anterior portion. The length of this fusi- 
form aneurismal swelling was one third of an inch, and the 
walls of the vessel were here opaque and notably thickened. 
On opening the basilar artery the dilated portion was found 
to be perfectly occluded by a soft colourless clot, uniformly 
adherent to the aneurismal walls. Two or three small specks 
of dark blood were seen in the midst of this pale fibrinous 
clot. The middle cerebellar arteries were in connection with 
the aneurismal swelling and were also occluded. Both verte- 
bral arteries were healthy and patent, the right being much 
larger than the left. The left posterior communicating artery 
was unusually small, and the right rather large. All parts of 
the hemispheres were carefully examined without revealing 
anything unnatural. The lateral ventricles contained a distinct 
excess of serum, about one ounce in each ; and there was a 
general dilatation of veins over the walls of these ventricles. 
Sections through the corpora striata and thalami revealed 
nothing unnatural. Similar incisions made through cerebellum, 
pons, and medulla also showed no focal lesion of any kind, and 
nothing distinctly unnatural. No notable excess or diminution 
of blood could be said to exist in these parts, nor was there any 
appreciable diminution in the consistence of the pons. 

Heart of medium size, right cavities distended with fiuid 
blood, much blood-staining of lining membrane. Tricuspid 
and pulmonary valves healthy; mitral and aortic valves 
thicker and more opaque than natural. Boot and other parts 
of thoracic aorta show many patches of degeneration, yellowish 
white in colour and slightly raised above the general surface ; 
lining membrane generally smooth, no ulcerations. 

Lungs congested and oedematous, especially in lower lobes ; 
in that of the right side several small extravasations of blood 
were seen, whilst in the upper part of the left lower lobe a 



196 Dr. Bastiati's Case of Thrombosis of the Basilar Artery, 

large patch 1^" in diameter was found, in which blood had 
been recently extravasated into the lung substance. 

Liver, Spleen^ and Kidneys congested, notably tougher than 
natural; no other distinct change. Testicles healthy. 

Bema/rlcs. — This case is in many respects a remarkable one. 
It very rarely happens that a patient dies from occlusion of one 
of the cerebral vessels in less than twelve hours, and I have 
been unable to find any case on record in which it occurred 
so rapidly as in this instance. In none of the cases of throm- 
bosis of the basilar artery recorded by Hayem {Archiv. de 
Physiolog., 1868, p. 270) was the fatal progress of the case so 
swift, death having taken place in them in sixteen to twenty- 
one hours. The clinical record of the present case resembles 
in the closest manner what might be found in a case of very 
large cerebral haBmorrhage. This is seen especially by the 
extreme depression of the rectal temperature, which in about 
two hours and a half from the onset of the attack had sunk 
below 95°, and continued at this low point till the patient 
died, three hours later. Unfortunately, the thermometer not 
being graduated below 95°, the exact minimum was not 
ascertained. 

Last year I brought before the Society the record of a case 
of cerebral haemorrhage in which the rectal temperature sank 
as low as 94*5°, and where, as in this case, it continued thus 
depressed till death occurred three hours afterwards. 

The fact that the thrombosis in the present case occurred 
in the lower half of the basilar artery, and thus cut off or 
greatly diminished the supply of blood to the respiratory 
centres, doubtless accounted for the suddenness with which the 
fatal issue was brought about. The centres for the third 
nerves, which are situated in the floor of the fourth ventricle 
above the upper part of the pons varolii, seem to have been 
partially paralysed rather than stimulated ; thus at 7.50 the 
pupils were found to be of ^^ medium size and insensitive to 
light.^^ It is well known that in many cases of haemorrhage 
into the pons varolii the pupils are notably contracted, so as 
to simulate the condition met with in opium poisoning. 

The respirations, as in Hayem^s cases, were much dis- 
turbed, weak, and irregular, but never very frequent. Within 
an hour and a half of the patient's death they were only 17 
per minute ; yet in a remarkable case of thrombosis of the ver- 
tebral and basilar arteries recorded by Dr. Duffin {Med. Times 
and Oaz,y 1876, vol. ii, p. 622) the respirations are said to have 
been 105 per minute for about six hours previous to death ; 



Dr. Bastian^s Case of Thramhosis of the Basilar Artery, 197 

the pulse being at the same time about 156^ and the tem- 
perature 105°. 

The clinical picture presented by thrombosis of the basilar 
artery varies greatly in different cases, according as the upper 
or the lower half of the vessel becomes blocked, and also 
according to the rapidity or slowness with which complete 
occlusion occurs. In two or three of the cases recorded by 
Hayem, in which death was brought about rapidly, the patients 
were, as in this case, found in an apoplectic condition, so that 
unfortunately we are stiU in need of information as to the 
premonitory or initial symptoms. The clinical details of the 
actual attack given by my late excellent house physician, Mr. 
H. Littlewood, are more complete than in any of the cases 
which I have been able to find on record. 

The present case affords a further illustration of the ex- 
treme difficulty, or even impossibility in some cases, of making 
a diagnosis between cerebral haemorrhage and thrombotic 
occlusion of some cerebral artery. Still, in no other artery 
except the basilar would such occlusion be likely to reduce 
the temperature to such an extent as^ in this case. The tem- 
peratures recorded by Boumeville {Etudes Clin, et Thermom,^ 
1873) in cases of occlusion of one or more of the other cerebral 
vessels by embolism or thrombosis were rarely depressed below 
98' 6°, and never below 98°. Amongst cases of this type, that 
which has now been recorded is almost, if not quite, unique, 
^ both as regards the extent to which the temperature was 
depressed and the rapidity with which death was brought 
about. 

Lesions in the pons are altogether exceptional in regard to 
the remarkable amount of variation which they may cause in 
the general temperature of the body. Here we have an 
occlusion of the basilar artery {i, e. an incipient softening 
process) depressing the temperature below 95° for some hours ; 
on the other hand, some years ago, I saw the terminal stages 
of a less acute attack, in which softening of the pons was 
found, ending with a temperature of 110°. 

In regard to the cause of the thrombosis, in two of Hayem's 
cases it was due to arteritis. Here we had rather a simple 
aneurismal dilatation of the basilar with a thickened and 
degenerated vessel wall. The clot which filled the vessel was 
colourless, soft, and altogether resembled in appearance the 
clots which often form in the right side of the heart some 
hours before death. 

Microscopical sections kindly made for me by Mr. F. G. 



198 Dr. Bastian's Oase of Th/rombosia of the Basilar Artery. 

Penrose quite confirmed this view as to the nature of the 
change^ and the colourless thrombosis (wholly composed of 
fibrin and white blood-corpuscles) was seen to extend into 
each middle cerebellar artery. Other sections made through 
the hardened medulla oblongata revealed most typical speci- 
mens of endarteritis in some of the vessels on its anterior 
surface. As may be gathered from the clinical history^ there 
was only a possibility that the patient had suffered from 
ByphiUs. 

In the case recorded by Dr. Dnffin the lateral ventricles 
contained several ounces of serum^ and the veins of Gralen were 
distended; in the present case there was also a distinct excess 
of fluid in the ventricles^ and all the veins on their walls were 
notably gorged. This is scarcely to be wondered at, seeing 
that the posterior cerebral artenes supply the walls of the 
ventricles with blood, and also in part the choroid plexuses. 
The cutting off of the propulsive force with which the blood 
is usually driven through the basilar artery may go far to 
account for these effects, and also even for some evidence of 
oedema in the posterior part of the hemisphere, to which the 
.slight flattening of the convolutions was probably due in the 
case now recorded. 



Mr. Barwell's Case of Ovariotomy. 199 



XXni. — Unusual Sequela of Ovariotomy. By Riohaed 
Baewbll, Bead March 13, 1885. 

AT the latter end of last October (1884) I removed the 
left ovary of an unmarried woman, set. 29. The 
local results were as good as could be desired ; but certain 
mental sequelas followed such as have been hitherto un- 
recorded. 

Nevertheless, by questionings I traced the fact that this 
was not an isolated event, and especially I found, that to Dr. 
Keith, Mr. Knowsley Thomton> Mr. Dent, and others, cases 
very similar, if not quite identical, had occurred. 

Hence it appears that although rare as a sequela of 
ovariotomy such perturbation has arisen with sufficient fre- 
quency to render it a fact that should be known to the 
profession. 

Louisa H., 89t. 29, fair complexioned, flushing easily, and 
of somewhat excitable temperament, admitted into Victoria 
Chandos Ward under the care of Dr. Black, September 
5, 1884, suffering from large ovarian cyst. 

Save for the ovarian complaint the patient appeared in 
good health, the lungs, heart, and kidneys sound ; somewhat 
constipated. 

Owing to circumstances unconnected with the condition of 
the patient the operation had to be postponed ; a week or two 
afterwards the approach of a catamenial period interfered, so 
that it was not until October 28 that I was able to proceed. 

October 28. — Ovariotomy performed. The case was 
perfectly simple, the cyst unilocular without adhesion. There 
were drawn off by the trocar twenty-three pints of fluid some- 
what thinner than usual. The disease was on the left side ; 
the pedicle, tied with silk, first by transfixion, then by inclu- 
sion of the whole, was allowed to drop back into the abdomen. 
The other ovary being healthy, the section wound was closed 
by deep quiU sutures and by superficial ones of wire. 

October 29. — ^A considerable amount of blood in the urine, 
and probably, but with the deep blood*staining, it is difficult 
to judge, some carboluria. Highest temperature 99*2°. 

October 80. — ^Hffimaturia continues. Deep sutures removed, 



200 Mr. Barwell's Case of Ovariotomy. 

wound in good condition. Temperature (highest) 99*2°. She 
is menstruating.* 

November 1. — The haematuria almost ceased. Yesterday 
the temperature at 2 a.m:. was 100°, during the next four 
hours it rose, and at 6 a.m. stood at 102*4°, it then fell steadily 
again, and at 10 a.m. was at 99°. It will be unnecessary to 
refer again to temperature, as during aU the rest of the case it 
was normal. 

November 4. — The nurse's notes for the night of the 
2nd and 3rd state that she was hysterical, but on seeing 
her I had strong doubts as to the particular form of mental 
excitement and irritability. The wound had healed, there 
was no abdominal or pelvic tenderness. In fact the conditions 
locally were quite satisfactory. 

November 5. — Owing to circumstances connected with the 
service of the hospital and the exigencies of other patients 
she was moved from the private to a general ward. 

November 7. — On the first night of her removal she was 
fairly quiet ; she slept, however, but very little. On the night 
of this date she was very violent, mistook identity of persons 
about her, shrieked, struggled, and at last became so uncon- 
trollable that Mr. Dodson (my house surgeon) had to give a 
little chloroform in order to secure her, afterwards to inject 
four minims of the hypodermic solution of morphia. The 
bowels acted for the first time since the operation (eleventh 
day). 

November 8. — The morphia calmed her for about three 
hours; she did not sleep, and about 5 a.m. became violent 
again. The condition was not the least like the delirium of 
fever, nor like delirium tremens, it was unmistakably acute 
mania. She was again removed to the private ward. 

November 16. — There have been various phases of 
violence alternating with quieter intervals, during which she 
talked incessantly. She had but very little sleep — in very 
short snatches — ^making up altogether in the twenty- four 
about one and a half hours. Dr. Blandford was so kind as to 
see her with me; she happened then to be in one of the 
quieter phases just described. He gave a favorable pro- 
gnosis, advised that no opium should be given, but chloral 
and bromide of ammonium, and these only in small doses 
when absolutely necessary. 

November 20. — During the last five days and nights, the 

* She had only ceased normal menstraation on the 20fchy one week before the 
operation ; the return of the flow was very slight* 



Mr. BarwelPs Case of Ovariotomy, 201 

record says^ "Very restless, sleeping at short intervals so as to 
make up about two hours in the twenty-four. I detected to- 
day for the first time a little heat about the head ; ordered 
therefore an icebag. Out of the next twenty-four hours she 
slept about five." 

November 24. — She has been rather quieter during the 
last three days, sleeping still in short snatches about five 
hours. It appeared to me a sign of improvement that she 
volunteered the statement that she had been, and felt then, 
" mad." 

November 29. — Sleep has been gradually becoming longer 
and quieter. She is, with the exception of a few intervals, 
rational. 

December 6. — After this date she was quite restored to 
reason and was allowed to go out with a nurse, then with 
another patient. In spite of a good deal of jactitation and of 
some violent stuggling there was no sign of hernial protrusion 
at the wound. As soon as her belt was finished she left the 
hospital. 

Of a case like this several views may be taken, thus : 

1. That there may have been proneness or hereditary 
tendency to insanity. 

2. That insanity may follow any of the major operations, 
ovariotomy not more than any other. 

3. That it was the result of disturbance of the urinary 
organs (kidney). 

4. That it was the result of disturbance of the generative 
organs. 

5. That it was merely coincident. 

1. I took considerable pains to ascertain the history, in 
the matter of mental malady, of this patient's family. Her 
father died of cerebral apoplexy at the age of seventy-four ; 
beyond this there is absolutely no trace of brain trouble. The 
patient herself is of the temperament called " mobile^'' fiushing 
easily when spoken to, and evidently troubled with shyness ; 
but before the operation she was very docile, very amenable 
to regulations. 

2. If insanity be an occasional sequela of surgical opera- 
tion the matter is not known to me, except in a few cases 
where strong hereditary tendency existed or where the 
patient had been previously insane. 

3. The amount of blood lost by the kidney was not enough 



202 Mr« Barwell^B Caae of Ova/riotomy. 

to prodnce cerebral distnrbance. Indeed^ a certaiii amonnt of 
hsBinaturia not unfrequently follows intraperitoneal operations 
performed, as was this one, under the carbolic spray, but 
mania is not a usual sequela of such event, and I shaU have 
to refer to a case of mania after ovariotomy without any 
kidney disturbance. 

4. In disturbance of the generative organs seems to lie the 
most probable etiology of this condition, but insanity from 
such cause usually leads to words and actions which betray 
its origin. Now, Laura H. never let fall an obscene or a 
doubtful word ; her actions were none of them provocative or 
amatory. On November 6, when she was at her worst, she 
evinced some affection for my house surgeon, but she mistook 
him for her brother. 

5. There remains the question of coincidence, and such 
explanation might be accepted if this case stood alone, but I 
can point to several cases of operation, not on the ovaries 
alone, but also on the uterus, which have been followed by 
such result. Thus Dr. Keith writes of a patient whose uterus 
he had removed under carbolic spray : " There was blood in 
her urine the next day, the day after albumen, and then came 
an attack of acute mania from which she died.^'* I am not sure 
that I am right in my interpretation of a private letter he 
was so kind as to send me that another of his patients became 
maniacal. Mr. Knowsley Thornton informs me that one of 
his ovariotomies died insane, and that he has at the present 
time a case of partial removal of the uterus, which he thinks 
will recover from an attack of mania. 

Dr. Bantock kindly permits me to say that one of his 
patients was for some davs insane; he at that time looked on 
the case as one merely oi hysterical mania. 

One case operated on in St. Thomases Hospital died 
insane. 

Mr. Dent had a fatal case of acute mania after ovario- 
tomy. In this there was no hsBmaturia nor any hereditary 
procliviiy. 

Thus we must recur to the subject of disturbance of the 
generative organs, and I submit that I have educed evidence 
to show that this occurrence, though very rare, is too frequent 
to be classed as a mere coincidence, but that some disturb- 
ance of those organs acting on the cerebro-spinal system is 
capable of occasionally producing mania, which may, as in 



• Bnti$k MedtMl J0nmal, Jmrnsiy 81, 1885. 



Mr. BarwelVfl Ocue of Ovcmot&mf. 203 

most of tlie cases quoted^ be f atal^ may be very evanescent^ as 
in Dr. Bantocl^s case, or may, as in my own case, continue for 
a full month and then pass entirely away. 

Since this subject is not, so far as I know, mentioned in 
any work on ovariotomy or on other branches of gynascological 
surgery, it appeared to me desirable to bring the matter 
under the notice of this Society. 



204 Mr. Davies-CoUey's Gases of Golotomy, 



XXrV. — On Three Gases of Golotomy with Delayed 
Opening of the Intestine, By N. Davies-Colley. 
Bead March 13, 1885. 

IN the operation of colotomy as usually performed I consider 
that there are two great dangers. The first is that of 
peritonitis which may follow the wounding of the peritoneum, 
either during the search for the bowel or when it is being 
incised and stitched to the edges of the skin wound. The 
second is the suppuration of the deep planes of connective and 
adipose tissue in the vicinity of the colon. This is no doubt 
due to the admission of the external air, and frequently also 
of the gaseous and fltiid contents of the intestine to the tissues 
which have been lacerated in exposing and drawing to the 
surface the extraperitoneal portion of the bowel. On several 
occasions I have seen the operation followed by extensive 
cellulitis, and in some cases in which pneumonia and other 
visceral diseases have been the inmiediate cause of death, it 
has appeared to me that the fatal result was due primarily to 
blood-poisoning dependent upon the deep-seated suppuration. 
Many years ago, therefore, it occurred to me that it would 
be wise when possible to delay the opening of the intestine 
until, under antiseptic precautions, time has been allowed 
for the wounds of the peritoneum and the lacerations of the 
soft parts to be sealed up by reparative lymph. It was not, 
however, until very recently that I put this idea to the test of 
actual experiment. But meanwhile my colleague, Mr. Howse, 
who had derived such excellent results from a similar change 
in the operation of gastrostomy, had already applied the same 
principle to that of colotomy, and I believe that he has been 
very well satisfied with the success which has followed the 
adoption of this mode of procedure. In the last three cases 
in which I have had to perform colotomy I have used various 
means for attaching the intestine to the skin wound, and have 
then left it unopened, in the first case for one day, in the second 
for four, and in the third for as many as six days. I propose 
to read to you the reports of these cases, and you will easily 
gather from them that the operation has been attended with 
much less suppuration than often follows colotomy, and that 



Mr. Davies-Colley's Gases of Colotomy. 205 

the risks to whicli the patients have been subjected have been 
considerably diminished. 

Case 1. — Edward K., eet. 49, waiter at a public-house, was 
admitted into Guy^s Hospital under my care on November 13, 
1883. Nine months before he had suffered much from pain in 
the loins, and had had to keep his bed. In July, after some 
difficulty in micturition, he suddenly passed a large quantity 
of pus in his urine. Since that time he had suJBEered from 
frequent and painful micturition, together with bearing-down 
pains in the rectum.. On admission he was pale, thin, and 
anxious looking. He was passing his urine every ten minutes 
day and night. It contained pus, and occasionally flatus and 
f aBces. He was also troubled with a frequent desire to def aBcate 
and his stools were of a *^ slimy '^ character. On digital exami- 
nation a smooth, moderately firm rounded mass could be felt 
bulging into the anterior aspect of the rectum above the pros- 
tate, which was of normal size ; and about four inches from the 
anus some polypoid excrescences could be felt which were 
thought to be the fringe of an opening into the bladder. There 
was some swelling and tenderness also in the left iliac fossa. 
As rest and anodynes gave him but little relief it was decided 
to perform colotomy. 

This was done, under ether, upon December 7. A vertical 
incision was made in the left lumbar region ; the bowel was 
easily found, and then drawn out of the wound. Two harelip 
pins were passed through all its coats at right angles to each 
other, and a piece of drainage-tubing was wound around the 
small knuckle of the colon, which was thus isolated. The rest of 
the wound was then closed with sutures. The operation was 
performed under the spray, and carbolic gauze dressings were 
then applied. There was no escape of flatus or faBcal matter. 
Considerable abdominal pain accompanied by vomiting followed. 
The next day the rubber tubing was removed, but the needles 
were left in their places. On the second day a quantity of 
faecal matter was found in the dressings. He felt much better 
and the vomiting had not recurred after the removal of the 
tubing. Eight days after the operation the needles were taken 
out, and a small slough of intestine, which had been strangu- 
lated by the tubing, came away. All the faeces now escaped 
by the wound. The discharge from the rectum consisted only 
of mucus and a little urine. But little constitutional disturb- 
ance followed the operation. His temperature rose above 101° 
on the seventh and eighth days, but at other times it was 



206 Mr. DavieB-Golley^B Oases of Cototomy. 

about 100^ or lower. The upper part of the skin wound healed 
by primary union. In the lower part there was for a time 
some suppuration until a few small sloughs of connectiye tissue 
had been discharged. 

In January the patient was able to £pet about the ward, and 
mth short exceptioL he continued to lo so nntU April. His 
bladder symptoms then became more severe. He had to mic- 
turate frequently^ and occasionally he passed phosphatic 
crystals or small portions of fascal matter. 

Some relief was given him by perineal section on April 17, 
but he gradually sank and died on April 30. A cancerous 
mass was found between the upper part of the rectum and 
the bladder, communicating by large openings with each 
cavity. 

Case 2. — ^Anne Q., 8Bt. 47, a married woman, was admitted 
under my care into Gny^s Hospital on February 5, 1884. For 
many years she had had piles with occasional loss of blood. 
Of late the piles and bleeding had been more troublesome. 
For eleven months she had suffered from constipation, and for 
six weeks she also had from time to time severe lumbar pain 
during defsBcation. She was fairly well nourished, with a 
rather congested condition of the cheeks. At the margin of the 
anus there were some inflamed external piles, and four inches 
up the rectum an annular growth could be felt, like the cervix 
uteri in shape, with a central passage one quarter to three 
eighths of an inch in diameter. As the obstruction appeared 
to be increasing, and as she suffered from considerable pain in 
defsBcation, it was decided to perform colotomy. 

On February 8, ether was administered, and the descending 
colon was drawn out of the wound through a vertical incision. 
It was then fixed by a sort of clamp which held two points of the 
bowel wall by the rounded extremities of screws. Antiseptic 
precautions were used, and the extremities of the wound were 
brought into apposition by sutures. But little disturbance 
followed. The pulse was quick. There was vomiting for the 
first evening, and she complained afterwards of some abdominal 
pain. There was also some feeling of distension, with a desire 
to get rid of flatus and fsBces. The pressure of the screws 
was relaxed daily, but on February 12, four days after the 
operation, one of them was found to have penetrated the 
intestine. The clamp was therefore removed, and a vertical 
incision made into the bowel. 

On the 17th (nine days after the operation) I noted that 



Mr. Davies-Oolley's Oases of Oolotomy. 207 

the upper part of tlie wound was healed by primary union, 
but that below the artificial anus there was a small opening 
through which a few drops of healthy pus could be pressed. 
This soon healed, and m less than three weeks from the opera- 
tion she was able to get up. (In a week from the operation 
her temperature had fallen to normal, and it remained low all 
the rest of her stay in the hospital.) 

She went out on April 5, wearing a belt with an india- 
rubber plug for the artificial anus. At this time she was 
passing half of her motions by the wound and half by the anus. 
There was also a considerable tendency to contraction in the 
artificial anus. 

In October she came to see me, and I found that the 
colotomy wound had entirely closed up, the condition of the 
stricture having considerably improved. She was passing her 
motions regularly, and she stated that they were as thick as 
one or two of her fingers. She had lost a little flesh, but she 
was otherwise in good health, and she suffered less discomfort 
than before the operation. There was occasionally some 
haemorrhage from the bowel, but this could readily be checked 
by the use of tannic acid suppositories. The parietes bulged 
a little at the site of the colotomy wound, but the scar was 
smooth and inconspicuous. I saw her last in the beginning 
of February, and she was in much the same condition. 

Case 3. — James W., set. 39, a foreman on the railway, was 
admitted into Guy's Hospital under my care on March 13, 
1884. He had suffered from diarrhoea for twelve months. 
For four months he had been passing blood, and for three 
there had been bearing-down pains. He had been obliged to 
leave off work the previous September. On admission he was 
a tall, strongly-framed man, but rather wasted, having lost 
4 st. in weight during the last year. His appetite was 
very bad, and he was evidently suffering much pain. The 
anus was relaxed, and from one inch up, the rectum, as far as 
the finger could reach, was indurated, fixed, and tender, but 
without much contraction. Ovoid nodules could be felt in its 
walls about f inch in their longest diameter. He was passing 
loose motions eight or nine times a day, and there was some 
incontinence of the faeces. 

On March 14 colotomy was performed under ether. The 
bowel was found, and after it had been with some difficulty 
laid hold of and drawn out through the vertical incision, it was 
held in its place by the clamp which I now exhibit. This 



208 Mr. Davies-CoUey^s Cases of Colotomy. 

consists of two parallel steel bars, each furnished with two 
rounded ivory studs rather more than ^ inch apart. A screw 
head at either end approximates the bars and so brings the 
ivory studs close enough to hold the intestine firm at two 
points of its surface. The ends of the clamp were prevented 
from pressing upon the skin by the interposition of small pads 
of gauze, and the rest of the wound was brought together by 
wire sutures. The operation was performed under spray, and 
carbolic gauze dressings were applied. 

The next day he looked well, but he complained of repeated 
attacks of vomiting during the night, and his pulse was .120. 
The clamp was therefore removed, and the vomiting did not 
recur. On the 20th, six days after the operation, an incision 
i inch long was made into the knuckle of bowel, which 
had remained in situ since the removal of the clamp. A week 
later the wound was found to have almost completely healed 
by primary union. No deep suppuration occurred, and after 
the first week his temperature remained about normal. 
Although nearly all the faeces from that time escaped by the 
artificial anus, he still continued to pass mucus and blood with 
small quantities of faecal matter per anum, and there was but 
little relief of the pain wTiich he suffered. 

He is now (March, 1885) a good deal weaker, and there 
has latterly been some suppuration in the left ischio-rectal 
fossa. Nearly all the faeces still come away by the artificial 
opening. 

I have not brought these cases before the Society to illus- 
trate the advantage of performing colotomy for cancer of the 
rectum, but in order to point out the safety with which this 
operation may be performed by the method which, with various 
modifications, has been adopted in these and other cases by my 
colleagues and myself at Guy^s Hospital. 

The chief difficulty which I have had to contend with has 
been that of securing the intestine without causing symptoms of 
strangulation. If sutures are used they cannot be passed 
through the whole thickness of the intestine, for they would be 
sure to cause the escape of its gaseous or fluid contents into 
the wound. If, on the other hand, they are passed through 
the outer coats of the intestine, these are so thm that I should 
fear that any effort of the patient, such as the straining which 
accompanies vomiting, might cause them to cut their way out, 
and allow the bowel to retreat again into the abdominal cavity. 
Two of my colleagues at Guy^s Hospital, viz. our President, 



Mr. Davies-CoUey's Oases of Oolotomy. 209 

Mr. Bryant, and Mr. Howse, liave drawn out the knuckle and 
left it protruding from the wound without any sutures to secure 
it, but I have hesitated to do so for fear of the difficulties 
which might arise if the bowel should slip back into the wound. 
In my first case, as I have related, I used two needles to trans- 
fix the bowel, and a piece of rubber tubing to constrict the 
portion thus isolated in such a way as to prevent the escape of 
any of the contents of the intestine. This proved to be an 
objectionable plan on account of the symptoms of strangulation 
to which it gave rise. In the other two cases I used clamps 
by which the intestinal wall was pressed upon at only two 
points and so held in position. These can be gradually 
unscrewed so as to lessen the pressure, or they may be entirely 
removed at the first dressing, when the knuckle will probably 
have contracted sufficient adhesions to retain it in its new 
position. 

I need hardly add that there are many cases of colotomy in 
which the opening of the colon cannot be postponed. When 
the patient is suffering from complete obstruction of the lower 
bowel it will be necessary to open the colon at once. But in 
a large majority of the cases for which colotomy is performed 
for cancerous and ulcerative affections of the rectum, there is 
no immediate necessity for opening the colon, and in such 
cases I submit that some such plan as that which I have 
adopted in these, the only three cases in which I have yet 
applied the principle, will be found beneficial. 

It has also occurred to me that still further extensions of 
this method may be possible. For example, in the case of a 
tumour of the colon, it might be better to draw out the loop 
of intestine containing the growth with the investing peri- 
toneum and wait for a few days before excising the loop by the 
knife, the cautery, or some caustic agent. Again, in order to 
secure the absolute freedom of the lower bowel &om the passage 
of faeces, a small loop containing the whole calibre of the colon 
might be brought out of the external wound and after a few 
days removed. In this way we should be able to prevent all 
possibility of faecal matter passing on into the rectum, for the 
artificial anus thus formed would be the terminus, and not 
merely a lateral outlet, of the bowel. 



VOL. x?iu. 14 



210 Mr, Mayo-Robson's Oases of 8pma Bifida. 



XXV. — A Series of Gases of Spina Bifida treated by 
Plastic Operation. By A. W. Mayo-Robson. Bead 
March 27, 1885. 

IN 1881 tlie following paragraph attracted my attention in one 
of the leading text-books on surgery : — '' Viewing, then, 
the great danger of any effectual surgical treatment in cases 
of spina bifida, it seems better to watch the case carefully, 
and not to interfere unless the tumour is growing.'* This led 
me to carefully think over the subject with a view to carrying 
out some more definite lines of treatment than those hitherto 
adopted, which seemed to me very uncertain and very fre- 
quently fatal. 

It was not, however, till the end of 1882 that I had a 
chance of putting my ideas into practice, the result quite 
coming up to my anticipation. I have since that time operated 
on four cases; have seen the operation done by Professor 
Jessop and Mr. Atkinson, my colleagues at the Leeds Infir- 
mary ; and have also had a letter from Dr. Robert T. Hayes, 
of Rochester, U.S.A., telling me that he has operated success- 
fully by the same method. 

My first case was fully described in a paper in the Brit. 
Med. Journ. for March 24, 1883; hence I need only quote 
it briefly. 

Case 1. — A. S., a fairly well-nourished child, aet. 6 days, the 
subject of a spina bifida in the lumbar region the size of an 
orange, was operated on at such an early age, because the sac 
was excessively thin, had become infiamed at the fundus and 
threatened to burst. 

The operation done on October 26, 1882, was as follows : 
When the infant was fully under the influence of chloroform 
I made a vertical incision through the skin on each side of the 
tumour, about half an inch from its base, and then very care- 
fully dissected the integuments from the meninges, until I 
reached the laminae of the vertebrae; this required very 
careful dissection, as the membranes left were so thin as to be 
perfectly translucent ; the fluid was now let out by puncturing 
with fine scissors, which were also used to cut away the 
redundant membranes. The cauda equina was fully exposed, 



Mr. Mayo-Robson^s Oaaes of Spina Bifida, 211 

lying on the floor of the spinal canal. I now had two folds on 
each side, each fold being of a different widths the two inner 
meningeal folds three fourths and half an inch respectively, 
and the two skin-flaps of the same width; bat whilst the wider 
meningeal flap was on the right, the wider skin-flap was on 
the left. Thus, when satures were applied, the lines of union 
were not opposite. 

Acting on the same principle as is carried out in uniting 
the peritoneum, I brought together the serous surfaces of the 
arachnoid by several satures, so as to completely shut off the 
spinal canal. 

Mr. Mayo had, in the meantime, been dissecting (under the 
antiseptic spray) the periosteum from the femur and frontal 
bone of a rabbit, which he had just killed. This periosteum 
I now placed, with its osteogenic layer undermost, over the 
closed meninges, and carefully sutured it to the periosteum of 
the laminaa on each side, and to the bony margins above and 
below. After this the skin was sutured, a layer of protective 
applied, and a pad of salicylic wool placed over the wound. 

The whole operation, which occupied more than an hour, 
was performed under the eucalyptus air. Catgut ligatures 
were employed, and the instruments and sponges were well 
carbolised. On the second day, the nurse in applying the 
napkins displaced the dressing; but although the skin- 
wound slightly opened there was no formation of pus, and no 
slough came away; in facb, through the small opening I could 
see that granulations had covered the superficial surface of 
the interposed periosteum. The child recovered without a bad 
symptom, and when shown to the Leeds and West Biding 
Medico-Ohirurgical Society in December, 1882, two months 
after, the skin of the lumbar region was quite flat, and only 
presented a cicatrix where the tumour had been. 

A thin shield was worn in order to protect the tender part 
of the spine. Six months after, the child was perfectly well 
in every respect; but when nearly a year old it died from 
teething convulsions after a day's illness, and no autopsy 
could be obtained. The portion of sac removed I show you in 
the jar handed round. 

Case 2. — ^Mary A., 89t. 18 days, a puny, ill-developed child 
of weakly parents, with a questionable history of syphilis, but 
without any family history of deformity, was brought to me 
with a spina bifida in the lumbar region, the size of a large 
orange, the coverings being so thin and translucent quite up 



212 Mr. Mayo-Bobson's Oases of Spvtia Bifida. 

to the margin of tlie tumour that it was quite evident that no 
integumental cover could be obtained from the surface of the 
swellings and as the skin all round was inflamed and 
beginning to ulcerate the case was not of a promising nature^ 
but as it was quite evident the child must die shortly unless 
relieved I decided to operate. 

Operation December 5, 1882. — The translucent membrane 
was partly cut away, just sufficient being left to form the menin- 
geal cover, which was sutured with catgut over the opening into 
the spinal canal, that being three quarters of an inch wide and 
two inches and a quarter long ; the skin was then dissected up 
over the loins so as to allow two flaps to be slid towards the 
middle line, where they were joined together over the meninges 
by silver sutures. 

The whole operation was done strictly antiseptically. The 
after-progress locally was all that could be desired, the wound 
apparently healing by flrst intention without any signs of 
inflammation, but when the silver sutures were taken out on 
the third day the centre of the skin wound reopened a little, 
showing granulations springing from the meninges ; the wound 
was supported by strapping. 

The general condition was not altered, and although there 
was no elevation of temperature and no purulent discharge from 
the wound, the condition of marasmus present on admission 
continued, and the child died, apparently from asthenia, on the 
evening of December 8, 1882. 

Post-mortem report by Dr. Griffith, house physician. — " All 
the lumbar and the two upper sacral vertebras were found to 
be bifid ; the meningeal wound had healed and the skin wound 
almost. There was no evidence of meningitis, and no apparent 
increase or diminution in^ the amount of cerebro-spinal fluid.^^ 
The bifid spine which 1 pass round shows well the extensive 
deformity. 

Case 3. — Elizabeth J., set. 16, residing in Armley, was 
admitted on November 4, 1884, into the infirmary, suffering 
from spina bifida and talipes equino-varus. She said that she 
had no relations similarly affected. Up till the age of seven 
her feet were perfectly normal, after which time she commenced 
walking on her toes, the pedal deformity having from that 
time gradually increased. 

During the last month the spina bifida had slightly enlarged, 
but had given no pain except when handled, and she had been 
entirely free from all head symptoms. 



Mr. Mayo-Robson^s Cases of 8pma Bifida. 213 

She sought advice on account of the deformity of the feet, 
and was admitted as an in-patient to Leeds Greneral Infirmary 
in order to have tenotomy performed; but the day after 
admission the spina bifida, which was situated in the lumbar 
region, and was about the size of a large foetal head with 
somewhat thin covering, began to weep from several points at 
its fundus; a clear watery non-albuminous fluid transuding 
in such quantity that a thimbleful was easily collected for 
analysis. This continued for three days, during which time 
the tumour was dressed with salicylic wool changed from time 
to time. The tumour was now much increased in size, very 
tense and hot to the touch; and at the same time, as shown by 
the chart, the temperature in the axilla was raised. 

The patient now complained of headache, was restless, 
cross, and peevish ; answered sharply when spoken to, looked 
pinched and extremely ill ; the pupils were dilated, eyes blood- 
shot, skin was cold and clammy, pulse feeble and flickering, 
breathing rapid. Potassium bromide was ordered to be taken. 
Ice was applied to the tumour and hot bottles to the feet; 
these gave relief to a certain extent, but on November 13 the 
tumour was so tense and the headache and other nervous 
symptoms so severe that it was felt that unless relief could be 
given the patient must soon die. Aspiration was performed 
with full antiseptic precautions, 16 oz. of a clear transparent 
fluid (cerebro-spinal) being withdrawn ; the pupils immediately 
gained their normal conation although the pain in the head 
became very much increased, but after half an hour the patient 
slept comfortably, and the temperature fell from 102° to 
normal. When the sac was empty the opening into the spinal 
canal could be felt to admit three fingers. The relief was of 
short duration, all the symptoms returning by the 15th, when 
the patient was very restless and constantly moaning, refusing 
food and complaining of intense headache, the pupils being 
dilated and slu&rRish. 

November if -Aspiration was again performed, when 6 oz. 
of clear fluid were withdrawn, giving reKef as before ; on the 
19th aspiration became again necessary, and'14 oz. of fluid were 
removed. A general consultation was held with a view to 
further operative treatment, but it was decided that the patient 
would staiid the best chance by continuing the same treatment ; 
hence the aspirations were repeated, and on the 21st 8 oz., 
23rd 10 oz., 25th 10 oz., December 5th 12 oz., and 8th 
7 oz., of fluid were withdrawn. At the fifth aspiration the 
fluid was slightly cloudy, at the sixth, seventh and eighth, it 



214 Mr. Mayo-Bobson's Oases of Spina Bifida. 

was decidedly purulent but sweety strict antiseptic precautions 
having been observed throughout. 

On December 10^ as the patient was getting decidedly 
worse and the temperature was keeping high^ the headache 
and other nervous symptoms still continuing^ it was felt that 
unless something more decided was done the patient must 
shortly sink. 

On December 11^ the following operation was performed. 
A large crucial incision was made^ so as to raise four tri- 
angular flaps of skin^ with their bases outwards^ from the sur- 
face of the tumour^ the dissection being performed so as to 
separate skin from sac without puncturing the latter ; after 
the base of the tumour had been reached the thin fundus was 
opened^ when it was found that there were no nerves in its 
walls^ and as the sac was inflamed, and was lined with a thick 
layer of lymph, it was completely removed quite down to the 
base, which was in some parts nearly an inch thick. There 
being a good deal of haemorrhage, about twenty catgut liga- 
tures were applied to vessels. The base of the sac (as proved 
by passing a probe) communicated with the spinal canal, the 
opening being surrounded by lymph. The skin-flaps were 
accurately brought together by silver sutures and a large 
drainage-tube was inserted; the whole operation was done 
anti^eptically and the wound was dressed on the 13th, 16th, 
20th, when the drainage-tube was removed, and the 24th, when 
the wound was perfectly healed. From the time of the opera- 
tion the patient gradually gained strength, lost her nervous 
symptoms, and was discharged cured on January 5, twenty- 
four days after operation. The accompanying temperature 
chart very clearly shows the progress of the case. 

February. — ^At the present time the patient wears an oval 
vulcanite pad over the site of the tumour; she is perfectly 
well, and intends to come into the infirmary after a time to 
have her feet operated on. 

Patient exhibited to the Society. 

Temperatti/re Record. 





A.M. 


FJC. 


Not. 6 


9&-4^ .. 


99-4^ 


6 


98-4 .. 


100-0 


7 . 


98-2 


99*2 


8 


98-2 .. 


99-4 


9 


97-6 .. 


99-8 


10 


97-9 .. 


100-6 


11 


99-8 


101-8 



Mr. Mayo-Robson's Oases of Spina Bifida. 215 



Nov. 12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

80 

Dec. 1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

24 



.•* 
... 
... 

• • • 

• • . 
. •* 
••• 
•*. 
■ • • 



100-8° 

102-4 

980 

98-9 

100-9 

99*6 

1000 

100-6 

100-4 

99-8 

100-4 

99-6 

990 

102-8 

103-0 

98-2 

99-8 

99*8 

100-4 

100-0 

100-0 

100-4 

100-2 

100-4 

98-4 

99-0 

101-4 

99-2 

103-2 

101-6 

100-4 

99-4 

99-8 

98-2 

99-2 

98-2 



• • . 
... 
•* « 

• •• 
*• • 



• • • 
... 

••• 
... 



■ ■ • 
II. 
.*. 

• *. 

• • • 



• •. 
... 
... 



••• 



... 



P.M. 

101-2° 
102-0 

98-8 
100-9 

980 
lOOO 

99-8 

98-4 
101-2 
102-4 
100-2 
101-6 
100-2 
108-2 

99-6 
101-6 
100-4 
101-2 
100-8 
101-0 
101-0 
101-2 
101*2 
102-4 
100-2 

99-0 
100-8 
102-2 
102*8 

98-4 
100-4 
100-4 

99-4 
100-0 
100-8 

99-2 



Aspiration. 16 oz. Watery fluid. 



Aspiration. 6 oz. 



Aspiration. 14 oz. 



Aspiration. 8 oz. 
Aspiration. 10 oz. 

Aspiration. 12 oz. 



Aspiration. Pas 12 oz. 

Aspiration. Pus 7 oz. 

Operation of excision of sac at 8 p.m. 

Dressed. 



Dressed. 

After which a normal temperature. 

Dressed and found healed. 



Case 4. — ^Notes of tliis case were furnished me by my 
hoase surgeon^ Mr. A. Atkinson, to whose care and attention 
the successfol result of this and the last case are in a great 
measure due. 

Daniel C.^ set. 7 weeks^ the child of healthy parents^ was 
admitted into the Leeds Infirmary on January 31st^ 1885^ 
suffering from a large spina bifida in the lumbar region. The 
child was puny and badly nourished. It had a large head 
with open lon&nelles and dilated yeins^ the face was uiin and 
small^ but the eyes were not prominent. The tumour measured 
seven and a quarter inches in circumference and three and a 
half inches across, the coverings being very thin and ulcerated 
at the fundus. 



216 Mr. Mayo-Robson^s Cases of Spina Bifida. 

On February 5, Mr. Robson, operating under the eucalyptus 
air, made a vertical incision along the right of the tumour and 
tried to dissect the skin from the meninges, but, owing to the 
coverings being thin, the sac was perforated and cerebro- 
spinal fluid escaped ; the dissection being continued, a wider 
meningeal flap was taken from the left and made to bridge over 
the opening in the spinal canal, which was one inch long by haU 
an inch wide, being there united by a continuous catgut suture 
to a narrow meningeal fold on the right; the redundant 
integument having been excised, the slmi-flaps were united 
along the middle line by silver sutures. The nervous contents 
of the spinal canal were in no way interfered with. Before 
the operation was completed, the child became suddenly 
collapsed, apparently owing to the chloroform ; suspension by 
the feet and artificial respiration restored it, and the operation 
was completed. 

A drainage-tube was inserted between the skin and 
meninges, and the wound was dressed with a layer of gauze 
dipped in carbolic solution and covered with salicylic wool, 
this being well covered with adhesive plaster to prevent 
soiling of the dressings. 

February 7. — Drainage-tube and wire sutures removed, 
child looking well and wound apparently healed. 

February 8. — Temperature rose to 104'5,° but sodium 
salicylate gr. j, every hour reduced it to 99|^° in a few 
hours. 

The temperature fluctuated till the 12th, after which it was 
normal, but during the whole time the wound looked well and 
showed no sign of inflammation. 

On the 11th, i.e. six days after operation, the fontanelles 
were depressed as they appear in a child suffering from 
choleraic diarrhoea; this lasted two days, and the infant rolled 
its head from side to side as if uneasy, but it did not 
cry. 

On the 16th the fontanelles were well filled and the head 
looked large, but the mother said that it was no larger than 
before operation. Discharged from the infirmary on the 18th, 
thirteen days after operation, apparently well but weak. 

March 20. — The child was brought to the infirmary to have 
a pad adjusted. 

The site of the tumour presented a linear scar showing the 
old line of incision, and the skin was on a level with that over 
the loins and sacrum. 

Child exhibited to the Society, March 27, 1885. 



Mr. Mayo-!RolisoQ'B Oaaee of Spina Bifida, 

T&mperatvire Chart. 



- ■ 


. 988° 


Operation. Eicidon of sac and flntnring of 
■neuiag^ and ikin-flaps. 


100-0° . 


. 882 




101-0 . 


. 100-8 




103-0 . 


104-8 




104-8 . 


99-8 


Temp, rednced b; p. j Sod. SaUcjl. every hour 
for sii dosei. 


1020 . 


88-6 


Sod. SaUcfl. repeated. 


101-8 . 


. 89-4 




101-0 . 


. 99-4 




98-6 . 


. 99-6 




98-6 . 


. 99-0 




99-6 . 


. 99-6 




98-6 . 


. 98-8 




98-e . 


. 98-S 


Discharged cnred. 




Fro. 1.— The dotted lines (b) indicate t1 
meningeal mcision, the plain lines (a) 
the edges of the cnt skin. 




Fia. 2. — The dotted lines (a) in^cate 
the meningeal ind^n.the jilidn lines 
<a) the edge* of the cot skin. 



1 



218 Mr. Mayo-RobBon^B Ccutes of Spina Bifida. 

The points to whicli I would draw attention are : 

1. The principle of closing the meninges by bringing 
together two serous surfaces as in peritoneal surgery, and 
superimposing separate skin-flaps, the meningeal and skin 
Un^ of suture not being opposite^ ^ 

2. The great importance of observing strict antiseptic pre- 
cautions, as a septic condition would probably end in the same 
way as these cases usually do when they spontaneously ulce- 
rate, viss. by meningitis and convulsions. 

3. The success attending the plastic operation in cases 
which are absolutely not amenable to any other form of treat- 
ment, e.g. when the coverings are thin or the opening into the 
spinal cajial large. 

4. The possibility of transplanting periosteum and its 
capability ot surviving ; as in the case read first ; although in 
that example bone did not form, one may hope that the use of 
human periosteum {e.g. from a recently amputated limb) will 
give better results. 

5. The successful issue of Case 3, where, although the sac 
was acutely inflamed, its complete removal with efficient 
drainage effected a cure. This case presents several points of 
pathological importance, e.g. : 

(a) The increase of temperature without septicity, appa- 
rently due to tension of ^ or pressure on, the great nerve 
centres. 

(6) The gpreat relief given by aspiration. 

(c) Suppuration in the sac, possibly due to simple tension, 
probably not due to septicity, as the fluid was quite sweet 
on every occasion. 

(d) The entire absence of brain symptoms after operation, 
although the pressure on the cerebro-spinal centres must have 
been considerably interfered with during the time the wound 
was heaUn^. 

I would suggest the following as a practical classification 
of cases of spina bifida for purposes of treatment : 

1. Where no operation can or should be done. 

2. Where no operation need be done. 

3. Where an operation should be done. 
Class 1. — ^Where no operation should be done. 

{a) Where the deformity is very extensive, as in fissure of 
the whole or a considerable portion of the vertebral canal. 

{b) Where there is complete paraplegia, as in a case my 
friend. Dr. Libbey, of Horsf orth, asked me to see with him, 
where the sac was large and excessively thin quite to its 



Mr. Mayo-Robson^s Oases of Spina Bifida. 219 

margin^ and where the lower extremities hung absolutely 
powerless. 

(c) Where the sac is large, the fissure extensive, and the 
coverings excessively thin quite to the edge of the tumour, and 
no skin can be obtained to cover the meninges. But that 
such extreme examples may stand a chance of cure is proved 
by Case 2. 

Class 2. — ^Where nothing need be done. 

Where the sac is small, and the coverings are so dense and 
firm as to form a good pad over the opening in the spinal 
column, as in the case of a girl of fourteen, whose mother 
brought her to see me a few months ago, where I advised a 
thin silver shield to be worn over the swelling to protect it 
from injury and prevent further bulging. 

Class 3. — Where some operation should be done. 

(a) Where the sac only communicates with the spinal canal 
by means of a small opening; here it is a simple matter to dissect 
off the skin, expose the neck of the sac, ligature it by means 
of one circiQar ligature, and cut ofE the redundant meninges, 
bringing the skin over so as to have the line of skin sutures 
quite at the side away from the pedicle. Such an operation 
was performed by Mr. Edward Atkinson, one of my colleagues 
at the Leeds Infirmary. 

{b) Where the sac has a good skin cover and communicates 
with the spinal canal by a large opening it is quite easy to 
perform the operation described in Case 1, carefully closing 
the meninges, and if possible placing the line of skin sutures 
away from the meningeal line of union. Such cases have been 
operated on successfidly, not only by myself but by Professor 
Jessop, of Leeds, and by Dr. R. Hayes, of Eochester, U.S.A. 
Human periosteum might be placed between the meninges 
and skin, but I am not at all sure that a thin plate of bone 
if formed would be very serviceable, although I hoped to 
obtain it in the first of my cases. If the expanded neural 
arches be large, I think it might be advisable to bend them 
towards the central line, and by uniting them with thin silver 
wire to obtain a truly physiological closure of the spinal canal. 
I have not had a chance of trying this plan as yet. 

(c) Where the coverings are excessively thin quite to the 
margin of the tumour, as in Case 2, the operation is more diffi- 
cult and uncertain, as the skin can only be obtained by a pro- 
cess of sliding from the contiguous parts, and the tension 
necessarUy present is not conducive to healing. 

(d) Where the spinal cord or the nerves are blended with 



220 Mr. Mayo-Bobson^s Oases of 8pma Bifida. 

the sac^ a condition which, often cannot be diagnosed until the 
dissection of the skin from the meninges is made^ I should 
advise excision of portions of the redundant meninges between 
the nerves, replacing the nervous structures in the spinal 
canal and bringing over the skin cover, keeping up free drain- 
age between the membranes and integuments ; or, if this could 
not be done, the membranes might be punctured, the collapsed 
sac with the nervous structures intact be placed in the canal, 
and the skin cover made as before. 

It is important to remember that a silver or leather shield 
should be worn over the site of operation in order to protect 
the parts from injury and to prevent the cicatrix from 
stretching or giving way. 



Dr. Hadden's Case of Ohoreiform Movements. 221 



XXVI. — A Case of Ohoreiform Movements Supervening 
m Infancy 9 and probably of Congenital Origin. By 
W. B. Haddbn, M.D. Bead Ma/rch 27, 1885. 

AC, female, aet. 22, first came under my notice in December, 
• 1884, when she was an in-patient under the care of Dr. 
Stone, at St. Thomases Hospital. On January 12, 1885, she 
was admitted under me at the Royal Hospital for Children 
and Women. Her father and mother are alive and healthy. 
There are four other children in the family, all healthy. The 
eldest child, a girl, died from convulsive fits at the age of ten 
months. 

The mother has had no miscarriages. The patient is the 
second child. The mother is said to have suffered from albu- 
minuria for two months before her confinement. Labour 
occurred at fuU time and lasted twelve hours, no instruments 
being used. It was noticed soon after birth that the child's 
head used to fall back, and that she did not sit up like other 
children. She cut her teeth regularly and without trouble. 
She never had any fits, and there is no history of head injury. 
She never could walk better than she does now. Movements 
were first observed when the patient was seven months old, 
but it was not until the age of two that they attracted serious 
attention. They have persisted ever since without much 
alteration. She began to talk between the age of two and 
three. The catamenia appeared at fifteen, have always been 
scanty and accompanied by pain, but are regular every four 
weeks. 

The patient is a short, thick-set girl with large mammas. 
She seems quite intelligent. She reads fairly, but has never 
learnt to write, on account of the condition of her hands. 
Her head is rather large and flattened at the top. On measure- 
ment it is symmetrical in all diameters. The hard palate seems 
somewhat arched. There is no deformity of the spinal column. 

When lying down in bed the movements are very slight, 
and during sleep they are (pite absent. But if excited by 
being watched or on attemptmg movement they are at once 
noticeable. The condition affects almost entirely the face and 
upper extremities. 

On making an effort to speak the face becomes much con- 



1 



222 Dr. Haddeo's Case of Choreiform Movements. 

torted. Tlie angles of the mouth are retracted^ the upper lip 
and ake nasi raised^ the forehead wrinkled^ the eyelids partially 
closed. These grimaces give rise to various and rapidly suc- 
ceeding expressions. An appearance of gaiety is followed by 
a frowuj by a sniff of disdain, or by a momentarily lachrymose 
aspect. Her speech is interrupted by the violence of the 
spasm; the words are brought out explosively, and she is soon 
out of breath. With effort, however, she can pronounce pretty 
clearly. The muscles of the neck, especially the stemo- 
mastoids, are rigid, but those of the back and abdomen appear 
unaffected. There are slight movements of the tongue, but 
it is protruded straight and not atrophied. The fingers are 
flexed at the metacarpo-phalangeal joints and extended at the 
phalangeal. But this position is not fixed. The fingers are 
often separated, and there are simultaneous to and fro move- 
ments. The movements often strongly suggest athetosis, but 
they are more rapid and more various. 

The muscles of the forearms and arms are tense, the 
rigidity being especially marked in the flexors at the elbow- 
and shoulder-joints. She usually keeps the left hand, which 
is more affected than the right, behind her back or pressed 
firmly against the coverlet, possibly with a view to restraining 
its movements. All the muscles of the upper extremities are 
well developed and respond to a continuous current of mode- 
rate strength. Each hand measures seven inches across the 
palm. Her grasp is decidedly feeble. 

The legs are short, but well developed, and as she lies in 
bed she has very fair muscular power. She can neither stand 
nor walk without help. When supported on each side she 
shuffles along, the legs tending to overlap and the knees to 
rub together. At the same time the thighs are adducted and 
the len foot turned outwards nearly at a right angle to the 
leg. During progression the movements of the &ce and 
hands are well s^n. After a few steps she gets short-winded 
and has to rest. On making passive movement of the lower 
limbs much resistance is felt. Occasionally there are slight, 
barely appreciable, movements of the toes. The patellar tendon 
reflexes are very brisk, apparently exaggerated, and more 
marked on the right side than on the left. Now and then ankle 
clonus could be elicited. The muscles of the lower limbs 
respond to a continuous current of about twenty cells. Sensa- 
tion is perfect all over the body. There is no loss of control 
over bladder or rectum. Taste, smell, and hearing are good 
on each side. There is no colour-blindness, no nystagmus or 



Dr. Hadden's Oase of Ohoreiform Movements. 223 

squint^ and the fundus of each eye is quite healthy. Lastly^ 
there is no sign of any visceral disease. 

The case just described belongs to a group which, although 
having many striking points of difference, possesses one 
characteristic condition. I refer to the spasm of the lower 
limbs and the peculiar gait. 

Spastic paraplegia may exist alone, with or without affec 
tion of the upper extremities, constituting the disease known 
as spasmodic tabes dorsalis (Charcot) or infantile spas- 
modic paralysis. Very frequently, however, other symptoms 
are superadded. In Brain, October, 1883, I recorded two 
instances in which there were atrophic changes in the upper 
limb, but I do not know of any similar published cases. 

Including the present, I have seen three instances in which 
there were choreiform movements. Two of these are quite 
public characters. One, who sweeps the crossing at the comer 
of Bond Street and Grafton Street, has the characteristic gait 
and movements of the left hand. I examined him about a 
year ago and noted as follows. ^^ As he walks the thighs are 
adducted, and the knees rub and overlap, the feet scrape along 
the ground and the great toes are directed inwards. The 
fingers of the left hand are flexed at the metacarpo-phalangeal 
joints and extended at the phalangeal, and are moved con- 
stantly backwards and f orwards.^^ In addition his articulation 
was very indistinct, his speech being like that of a child learn- 
ing to talk. He told me that the condition of his limbs dated 
from birth and that he did not speak until he was thirteen. 

The other patient is half beggar, half vendor, who is usually 
to be seen outside the Mansion House Station. The upper 
limbs are in constant movement as he walks, and his grimaces 
are such that they attract the attention of passers-by. His 
gait also is characteristic. Although I have not had the 
opportunity of entering into his case I have no doubt that it 
belongs to the category of the one just mentioned. 

In connection with the spasmodic paraplegia of infants 
other symptoms are often found. Pits in early life, which may 
or may ilot persist later, are very common. In many intelli- 
gence is not impaired, but mental deficiency and even absolute 
idiotcy are not infrequent. I have also seen nystagmus, 
squint and inequality of pupils. In my experience the tendon 
reflexes are well marked, usually exasreerated, and ankle 
clonus is frequently present. Among c^asional symptoms 
are, deformity of chest, asymmetry of skull, arching of palate^ 
delayed dentition, and defects of speech. 



224 Dr. Hadden's Case of Choreiform Movements, 

But to revert to the first case I have described. Where, 
it may be asked, is the lesion, and what is its natnre ? I 
confess I am not prepared to discuss this question, but I think 
it probable that the affection is dependent on some congenital 
defect in the brain, or a porencephalous condition. I discovered 
that the patient had been under Dr. Hughlings Jackson's care 
at the London Hospital nine years ago. Dr. James Anderson 
was good enough to search for the case and found it noted as 
one of '^ Congenital Double Hemiplegia with Slow Choreiform 
Movements.*' 

I must mention that Dr. Boss describes a very similar case 
in Brainy Oct., 1882. Here the affection appeared to date from 
an injury in infancy. The writer thinks it probable that there 
was a lesion on each side involving the operculum or that part 
of the cortex which lies between the two limbs of the fissure 
of Sylvius and which forms the roof of the island of Beil. 

It has been suggested that those motor disorders in chil- 
dren known as infantile spasmodic paralysis and congenital 
athetosis are dependent on injury to the cranium or spinal 
column during birth. I have made careful inquiries on this 
point in about a dozen cases, and have found that there is 
no justification for this supposition. I could not satisfy myself 
in a single instance that violence during delivery, either by 
forceps, or by traction on the legs, had any influence. 

The case which I have described in many respects 
resembles athetosis, but I think it preferable to limit that 
term to the motor disorder occurring after a distinct hemiplegic 
attack. 

As regards treatment, I may say that drugs, galvanism, 
and ether spray to the back have been, as might be expected, 
without the least benefit. 



Mr. Lann's dise of Lithotomy. 225 



XXVn. — Galcuhis a/ad Tumour of the Bladder (Gar^ 
dnoma ?) ; Lithotomy ; death on the ninth day. By 
John R. Lunn. Bead March 27, 1886. 

JC.^ 88t. 35^ married^ by trade a stoker^ was admitted Sep- 
• tember 8^ 1884. He had rheumatic fever fifteen years 
ago^ but had not been laid up since with any serious illness. 
Four weeks before admission he noticed his water began to 
pass away involuntarily. He attended as an out-patient at 
the University College Hospital^ where he was sounded. Two 
weeks before admission into the infirmary he gave up work in 
consequence of the increasing incontinence of urine. The 
smell of his water was very offensive, but it never contained 
any blood. He thought he had lost fiesh lately. 

On (id/mission. — ^Patient was thin and ansBmic, had a care- 
worn expression of face. He complained of shooting pain in 
his perinsBum, some difficulty witli his bowels, and constant 
dribbling of urine. The meatus extemus urethras was 
swollen and excoriated. A No. 10 catheter was passed with- 
out difficulty, but caused a good deal of pain. The prostate 
was apparently enlarged and tender. The urine was loaded 
with p^and^albomel. The temperatore on admission was 
99° Pahr. Tongue very dry and furred. All the other organs 
appeared healthy. No enlarged glands were discovered. 
The bladder was ordered to be washed out daily. The appe- 
tite slightly improved during the next few days. On soundmg 
the bladder on September 17 a stone was struck. The next 
day lateral lithotomy was performed, and a large stone, 
weighing one ounce and a half (the size of a pewit^s egg) was 
extracted from the bladder without much difficulty or bleeding. 

In addition to the calculus a new growth was felt, which 
was too extensive to remove. On the evening of the operation 
the temperature was 100° Pahr., respiration 20, and pulse 92, 
and the patient expressed himself much relieved and free from 
pain. The wound and bladder were ordered to be washed 
out with boro-glyceride (1—40) twice a day. The second 
day after the operation acute orchitis set in which soon 
yielded to treatment. Yomiting occurred at intervals. The 
urine still contained pus and was the colour of claret wine. 
The pulse ranged between 92 and 124 a minute, and the day 

VOL. xvni. 15 



226 Mr. Lnnn^B Case of Lithotomy. 

before lie died the left kidney was noted to be enlarged (Sep- 
tember 26). 

Post-mortem notes (forty-eight honrs after death). — ^Body 
very emaciated ; rigor mortis passed off ; the wound in the 
pennffinm looked very unhealthy and showed no signs of heal- 
ing. The bladder weighed 8 oz. and was empty; almost the 
entire surface was occupied by a villous growth, the wall of 
the bladder being greatly thickened and apparently consisting 
of dense fibrous tissue. No enlarged glands were found any- 
where. The ureters both were distended to the size of one's 
little finger and full of pus. Both kidneys were completely 
disorganised and full of purulent matter. The right kidney 
weighed 8 oz., the left 14 oz. All the other viscera were 
healthy. 

The calculus has been tested chemically and is formed of 
phosphate and oxalate of calcium and a little uric acid. 

I am indebted to Mr. Eve for the following account of the 
bladder and description of the growth : 

'^ A urinary bladder opened by a horizontal incision from 
before backwards. Its walls were infiltrated with a soft can- 
cerous growth, which in the interior waU has attained an inch 
and a quarter in thickness. The growth projects from the 
inner surface of the bladder in irregular and papiUiform 
shreds. One of these, an inch in length, formed a tabular pro- 
longation from the origin of the right ureter as if a prolapse 
of, or a growth from, its mucous membrane had occurred. In 
microscopic structure the tumour had the character of a soft 
cancer. The cells were rather small, spheroidal, with large 
nuclei, and were in no part observed to be arranged in baUs 
or nests. In the softer parts of the tumour they were aggre- 
gated in large, diffuse, smaller, and rounder masses, in spaces 
formed by a scanty stroma, while in the finer parts the stroma 
was abundant and fibrous and the cells formed elongated rods 
and masses.'' 

BemarJes. — This case appears worthy of note: 1st. On 
account of the existence in the same individual of the two 
conditions, calculus and extensive new growth in the bladder. 

2nd (if the man's statement be taken as correct), on 
account of the short period during which symptoms were 
present. 

3rd. The growth in the bladder appears to be of a purely 
local character, no doubt caused by uie irritation set up by 
the calculus, and this again accounting for its very extensive 
and general disposition over the entire surface of the organ. 



Mr. Lnnn's Case of Lithotomy, 227 

In Sir Henry Thompson's latest woA on Tnmours of the 
Bladder, the new growths were aU limited in size and position. 
As regards the growth^ I have not been able to find any record 
of a similar case to the present one. 

4th. The fact that the patient had been sonnded for stone 
before and on admission^ but none detected^ his statement 
that there had been no haemorrhage^ and the short period 
during which any symptoms had appeared^ and the presence 
on rectal examination of a rounded fulness of an indefinite 
character at the anterior part of the base of the bladder, led 
one to suspect an abscess of the prostate spreading backwards. 

5th. The slight obstruction of the bowels and the incon- 
tinence and character of the urine would appear to agree with 
this condition. From the history and symptoms of the case 
there did not seem to be any distinct evidence of a tumour of 
the bladder. 

6th. On discovering the stone at a later examination it 
was determined to perform lateral lithotomy as giving the 
patient a chance of recovery, and as presenting also an oppor- 
tunity of further exploring the bladder. After removal of 
the stone, however, the growth was found to be so extensive 
and firmly fixed to the wall of the organ that it was not 
thought advisable to interfere with it. Although the patient 
ultimately sank he was greatly relieved by the operation and 
suffered little pain afterwards. On this account it would 
appear to have been perfectly justifiable. 

The bladder and calculus I have given to the Royal Col- 
lege of Surgeons (No. 3701a). 



228 Mr. BarwelVs Oases of Bullet Wov/nd. 



XXVni. — Three Gases of Bullet Wound. By Riohabd 
Babwbll. Bead March 27, 1885. 

CASE I. At about 11 o^clock of the night, November 14tli, 
1875, ayonng gentleman, after taking a copious dinner in 
apparently the highest spirits, shot himself with a Derringer.* 
Presumably he aimed at the heart, but went a little too low. 
He vomited immediately, and was soon after taken to the hos- 
pital. I found him greatly collapsed ; over the seventh costal 
cartilage was a small black wound from which oozed a drop or 
two of blood. No probe could be passed — ^nor could one Imve 
been unless force had been used — ^through the opening in the 
cartilage, which evidently had spUt to let the bullet pass, and 
had closed again. The patient survived twenty-two hours, 
dying of prolonged shock and of almost constant vomiting, 
which no remedy would control. 

After death there was found in the cartilage an opening 
formed by three Unes diverging at equal angles from a centre ; 
behind this was a scarcely perceptible rift in the diaphragm, 
without any ecchymosis, through which the bullet, leaving the 
chest, entered the abdomen. It then passed through the ante- 
rior and posterior walls of the stomach, and notching the upper 
inner edge of the kidney went between the first and second 
lumbar transverse process, and was found behind the former 
projection. The case interested me much as showing the 
power of such small weapons, and of projectiles driven only 
by the fulminate in the copper cap. 

Since the above date various cases of pistol-shot wound of 
limbs, or superficial ones of the head and trunk, have occurred 
in my practice. Most of these have not been very severe nor 
important; but two of a serious nature will, it is hoped, prove 
of interest to the Society. 

Case II. Thomas H. B., eat. 35, a gentleman against whom 
his partners in business had brought some charges (unfounded 
as was afterwards proved), shot himself in the Charing Cross 
Station with a Derringer, October 22, 1880. He was brought 

* The weapon originally bearing this name, the bore of which is ^ inch in 
diameter. 



Mr. BarwelPs Gases of Bidht Wound. 229 

at once to the hospital. I saw him very shortly after. He was 
much collapsed^ pulse 74, very weak, surface cold. On the 
right side of left nipple and within the circle of the areola was a 
bullet wound from which arterial blood flowed pretty freely. 
He coughed occasionally, not very violently, and this caused 
the blood to spurt forth, so that when he was sitting nearly 
upright at the head of the bed (for he could not lie down) the 
blood was driven out and fell to the floor two feet nine inches 
beyond the foot of the bed. There was also considerable 
hsBmoptysis. The wound was dressed with a single layer of 
lint dipped in carbolised oil very lightly applied, and sur- 
rounded by a ring pad. Strict silence and immobility 
enjoined, ice frequently given by the mouth. 

October 23. — Bleeding from wound gradually diminished 
and ceased a little after two this morning. Collapse at 2 p.m. 
nearly passed off. Much surgical emphysema round wound, 
also extensive pneumothorax, but prolonged examination un- 
advisable ; haemoptysis continues. Temp. 98*3° (evening) ; 
pulse 112; resp. 40. 

October 27. — Surgical emphysema occupies all the left side 
down to the eighth rib and half the front aspect of the chest. 
There is pneumo- and h»mo-thorax. A line (horizontal in his 
semi-recumbent position) almost coincident with the fourth rib 
separates the hyper-resonant from the dull portion of the chest ; 
in this latter part absence of respiratory murmur, but marked 
cegophony is present. I detected by palpation the bullet a little 
outside the angle of the scapula, just superficial to the ribs. 
I shall not at present interfere with it. HsBmoptysis continues, 
but the blood is no longer fresh,* save an occasional small 
quantity. 

November 4. — Has been going on well; the pneumo- 
and haamo-thorax diminishing, the temperature steady and 
normal. But at this date he was evidently weaker and last 
night had severe sweating. 

November 16. — The sweating has been diminished by sul- 
phuric acid, and the strength has improved. During the last 
ten days the hsBmoptysis has changed its character to dark 
and then to discoloured blood. Expectoration now slight and 
consists almost entirely of unstained mucus. The surgical 
emphysema has disappeared, also, except quite at the upper 
part of the chest, the pneumothorax ; round the lower portions 
there is still dnlness on gentle percussion, but more powerful 
taps elicit a clearer note. The respiratory murmur is a little 
distant. 



2301 Mr. Barwell's Gases of Bullet Wound. 

November 26. — ^Removed the bullet ; it wajs flattened on 
one side^ and had here embedded in it a fragment of bone 
which probably it rent from the back part of the rib as it passed 
out of the chest. 

December 3. — ^Nothing but gradual progress to record. The 
patient left to-day^ save for some slight weakness, perfectly 
well. The treatment had consisted in the administration of 
acetate of lead^ small repeated doses of opium^ sulphuric acid ; 
also as debility and pneumonia came on, of small doses of 
ipecacuanha and of brandy ; later still of quinine and iron. 

Case m. Carl Anel F.^ est. 31, shot himself with a small 
pistol ; he had for some years been suffering from the head, 
hearing voices, Ac. He hardly appeared to know how or why 
he unlocked the pistol and made such use of it ; after doing so 
at 2 A.M. on October 24 he lay on his bed for four hours, then 
woke his wife and told her. At 9 a.m. husband and wife 
walked together to the hospital. 

There were found two small wounds, one traversing the 
left side of the soft palate, the other three quarters of an inch 
down the right auditory meatus; &om this latter a little blood 
flowed. It may as well be said at once that the first-named 
wound gave no trouble. I once, by lifting the palate, caught 
sight of a corresponding wound at the back and side of the 
pharynx; this, as well as the one in the velum palati, healed 
quickly. The situation of the bullet is unknown ; it is surmised 
from the direction to be among the deep muscles at the back 
and left side of the spine. 

I examined the wound at the ear; the bullet had passed 
three quarters of an inch down the meatus without damaging 
the skin on either side ; then it left that channel very obliquely^ 
continuing its directly transverse course. On passing a probe 
I came upon a hard substance which gave to my hand the 
impression of being metallic. This substance was touched at 
a depth of just over two inches, not from the tragus or anti- 
tragus, but from the margin of the meatus. 

Now, the direction and depth of this tract being considered, 
it seemed to me that the bullet must lie in very dangerous 
proximity to the lateral sinus as it passes inside the mastoid 
bone ; it might even have wounded that vessel, and be acting 
like a cork to prevent hsamorrhage. It seemed to me the safe 
course to leave it alone. 

October 26. — ^The flow of blood almost ceased on the second 
day (25th). On the 26th this became mixed with a consider- 



Mr. Barwell^s Oases of Bultei Wound. 281 

able quantity of clear^ watery* fluids either cerebro-spinal or 
liquor Ootunnii; some was collected for testing, but was too 
mucli mixed with blood. On the 28th it was mingled with 
pus. 

November 1. — A spiculum of bone came away. The 
parotid and the parts behind the jaw swelled. 

November 14. — During the past fortnight the patient has 
been suffering from inflammation of parts overlying the 
ascending ma^ollary ramus, and I this day detected a softer 
spot with deep fluctuation near the angle of jaw. The tempera- 
ture has been high at night, 102 , on two occasions but 
down to 99° in the morning. He is singularly apathetic, and 
hardly takes notice of anything. 

November 23. — Some troublesome cough caused me to 
ask Dr. Murray to examine the chest. He had bronchitis and 
some emphysema ; phthisis doubtful. With a Nelaton's probe 
I obtained a clear mark of lead. 

December 4. — There is now a somewhat large abscess over 
the ramus of the jaw, and though temperature is not &r from 
normal the man is getting weaker and thinner ; it seemed to 
me time to endeavour to extract the bullet. To do this from 
the bottom of the narrow channel was evidently impossible ; no 
sufficiently powerful forceps could be introduced and opened. 
When, therefore, after a few failures a sufficiently character- 
istic lead mark on a N61aton^s probe had been obtained, I 
made a crmred incision immediately behind the ninna, turned 
the flaps backward and forward, and trephined the mastoid 
process to the depth of | of an inch. The cavity left by 
removal of the bone-plug was examined by touch and with 
Nelaton^s probe, without result., but I f ouna with my finger a 
narrow opening. The probe, passed along this, was again 
blackened, but at a great depth — over an inch from the floor 
of the trephine hole. This track was now very cautiously 
enlarged with a gouge, a pair of fine strong sinus forceps 
passed down till it seemed to me I got a touch as of metal ; 
they were opened, and I felt that I had hold of the bullet, 
which, loosening with a rocking movement, for it was tightly 
fixed, I now extracted. On the night of this operation the 
temperature rose to 100*8°. 

December 5. — Temperature fell last night after 12, and at 
10 A.M. to-day was normal; it rose afterwards, and was at 
100*4° from 2 to 6 p.m., and then began to &11 again ; patient 
has some pain. 

December 9. — ^At my request, Mr. Dodson, my house 



232 Mr. Barwell's Gases of Bullet Wound. 

surgeon^ to whose unremitting care I am mucli indebted^ 
opened the abscess over the jaW. 

After this I have nothing to report, the trephine opening 
filled quickly, the sinus contracted. He had no abnormal 
temperature, and was discharged on January 5 perfectly well. 
Indeed, he might have gone a week earlier, but for some police 
arrangements. 

On the two last cases much might be said did time permit. 
A few words are inevitable. Both men shot themselves ; the 
pistols, therefore, were very close, and in a medico-legal point 
of view, especially bearing on a recent case, it is important to 
observe tiikt although the muzzle was in this last case on the 
skin, no clothes intervening, there was neither scorching nor 
powder-tattoo, and this is, as tsar as my observation goes, the 
usual condition with projectiles driven only by the power of 
the fulminate. 

In the former case (the thoracic wound) the bullet passed 
through about seven inches of lung tissue, as near as 1 could 
measure, inflicting, therefore, very grave injury to a vital 
organ. In the latter case, although there is no positive proof, 
yet there is high probability that the projectile entered, though 
it did not pass entirely into, the cranial cavity. Yet both these 
men recovered. 

These results must be, I think, attributed to the shape of 
the projectiles. Conical bullets, though they split bones more 
widely than round ones, must bruise soft parts through which 
they pass less.* Still more may the result be due to the small 
size of the bullets — ^that extracted from the thorax of Thomas 
B. measures a little less than a quarter of an inch in diameter. 
That taken from the head of G. F., is No. 230 Ele/s gauge, 
which measures exactly a quarter of an inch. 

It must not be supposed that the projectile possesses but 
little force ; the bullet that went through T. B.'s lung is flat- 
tened on the side which struck the back part of the rib, and as 
it left the chest it ripped off a piece of bone, burying it in the 
lead. 

The bullet which I took out of Carl F.'shead is, as you see, 
flattened and twisted ; it is indeed very much misshapen by its 
passage for two inches through bone ; the drainage-tube passed 
and kept in after the operation measured &om the skin inward 

* As evidenced by the singnlar absence of eochymoeis in the first case of this 
series. Only the edge of the kidney wound, and that to a very small degree, 
■bowed signs of broinng. 



Mr. Barwell's Cases of Bullet Wound. 283 

two and an eighth inches. The weapon has^ indeed^ considerable 
power. Carl P.*s pistol — ^here it is — is a beautifully made rifle 
barrelled, seven chambered revolver (American). It looks 
like a toy, and can be hidden completely in the hand. At ten 
paces I fired at a beech-wood board exactly one inch thick ; 
the bullet went clean through the wood and flattened itself 
against the wall behind, out of which it raised a little cloud of 
brickdust. 

It is evident, however, that unless some immediately vital 
part be hit, such as the heart or certain parts of the brain and 
spinal cord, such small bullets have but little immediate effect. 
A man might have several such bullets in him, yet still be 
good for some little fighting, and may after all recover even 
though long and deep wounds like those described have been 
made. 



234 Dr. MarshalPs Cases of Amputation at the Sip^jomt^ 



XXIX. — Amputations at the Hip-joint by Furnea/ax 
Jordan^s Method. By Lewis W. Marshall, M.D. 
Bead April 10, 1885. 

ON October 27^ 1882^ a paper upon Amputation at the Hip- 
Joint by Pumeaux Jordan's Method was published by me 
in the British Medical Journal, having been previously read at 
a local meeting of the Midland Branch, on June 24^ 1880. 
Four cases formed the basis of this paper. Since tlmt time 
this operation has become much more widely known and 
generally adopted. A list of cases has been recorded by Dr. 
Maclaren^ of Carlisle, in a paper read by him in Edinburgh, and 
afterwards published in the British Medical Jov/mal of June 7, 
1884. 

I am permitted by your Society to lay before you those 
cases already published, and to add to them the amputations 
done by me since October, 1882. Before doing so, I will briefly 
describe this method of amputation. 

If excision of the hip has been previously practised, the 
existing incision is prolonged to about the middle of the thigh ; 
the femur enucleated, the soft parts cut through with a circular 
sweep of the knife, and the femoral tied. This is the first 
method suggested by Mr. Jordan, but he goes on to say, in his 
report of a case in the Lancet , March 23, 1879, that ^'the 
surgeon may if he choose, make the circular sweep before the 
shaft of the bone is turned out, if precautions against haemor- 
rhage have been complete.'' Of the two methods I have more 
often adopted the latter than the former for reasons to be 
given hereafter. 

Summarised my cases stand thus : — ten in number. Three 
after excision, and the remainder when this operation could 
not be practised on account of extensive implication of the 
femur or pelvis, or from the general condition of the patient 
being such that more conservative measures were likely to 
prove futile. In all, it may be briefly expressed, that the main 
object of the operation was to save a life which would other- 
wise have been sacrificed. Their ages were as follows :— two 
cases at eleven years, one case at ten years, two cases at eight 
years, two cases at seven years, one case at six years, one case 
at five years, one case at three years. 



t)r. Marshall's Oases of Amputation at the Sip-joint, 235 

In all but one the fingers were used to compress the 
femoral ; in two Esmarch's bandage was first applied^ the fingers 
being finally substituted^ because the bandage was insecure. 
Davy's lever has been used by me twice^ once in this operation^ 
and once in a double flap amputation. Of the bleeding 1 may say 
that although it is not excessive^ there is extreme variation in 
the quantity lost in eachcase^ because where large abscess 
cavities are present, much oozing is apt to occur from them ; 
the actual number of vessels requiring catgut ligature being 
usually not more than two, the femoral included. 

In this list, one death — the direct result of the operation, 
an amputation on- the right side in which Davy's lever was 
used — ^has to be placed. Death occurred in a few hours, the 
patient never rallying, the blood loss being excessive. With 
the exception of two other deaths, one of which took place 
three months after operation from visceral lesions, and the 
second, nine days after from the effects of the rupture of an 
abdominal abscess, all are, I believe, living and well. 

Drainage was secured by horsehair, and in addition, when 
an opening into the pelvic cavity existed, an india-rubber 
tube was used at the upper end of the incision. It is my 
custom to secure the flaps loosely together by wire sutures at 
three or four points only ; and as a dressing, a loose covering 
of carbolic oil and lint, with an outer layer of oakum has been 
most commonly chosen. The lint is kept soaked by repeated 
applications of carbolic oil. The earlier cases were done under 
the spray. In the later ones it was omitted. This gives a 
general outline of my success in this operation, and also, very 
briefly, of the details of after-treatment. I would supplement 
the remarks made in reference to the dressing, by a full 
statement of the means adopted by me for limiting the shock 
of operation and securing a comparative speedy reaction. To 
these details and to the care with which they have been 
carried out, I attach much importance, and consider that, to 
some extent, my success is due. Half an hour before opera- 
tion I order to be given a dose of opium in proportion to the 
age of the patient, the customary abstention from food usual 
before the giving of an anaesthetic being observed. The bed 
to be occupied by the patient after his removal from the table 
is kept thoroughly warm by hot-water bottles, and an enema 
of beef -tea and m^, containing aromatic spirits of ammonia, 
is at hand to be administered immediately. If the collapse is 
great, both brachials and the femoral are ordered to be held. 
I give a suppository of morphia within half an hour of the opera- 



236 Dr. Marshall's Cases of Amputation at the Si/p-jomt. 

tion. In my earlier cases — ^indeed in all — ^vomiting has come on 
at an early period and has given much trouble and distress. 
To meet this difficulty I am now, and have been in the last four 
or five cases, led to withhold all feeding by mouth, if small 
quantities of iced champagne be excepted. Nutrient enemata 
either with or without ammonia as the case appears to demand, 
are given every half hour until such time as it is found by a 
careful use of Brandos beef jelly, whey and cream, or a little 
milk, that the stomach is capable of doing its work. At the 
risk of being thought prolix, I have felt it necessary to insist 
on these details because, as I have before expressed, I feel so 
much is due to them. 

Mr. Jordan remarks upon his single case in support of 
his method that, '^ as compared with the ordinary operation of 
two flaps, the wound was less severe, the cut surfcices were 
less extensive, and in a manner further removed from the 
trunk ; it was followed by less shock, less haemorrhage, less 
opportunity of septic infection. The vessels cut were more 
easily dealt with. The thigh might be simply cut through 
with a circular sweep of a few sawing movements. The bone- 
less thigh should be firmly held and somewhat flattened if 
cut across. The muscles may be cut on the same level as the 
skin ; the bone being absent, they retract so strongly that the 
skin readily covers them ; its vitality is less endangered j and 
a large cellular plane is not opened. The bulk of the soft 
parts of the thigh, especially near the pelvis, lies at the inner 
side of the femur. Why put a knife through these parts ? It 
is better to enucleate the femur when it is covered, and cut 
across the limb where it is smaller and further removed from 
the trunk. In removing the thigh very low down, the area 
of the wound is no doubt increased j but even then it would 
be a much less dangerous wound in character and locality." 
He goes on to say that the operation is more suitable for those 
cases in which the soft parts can be freely left. He also calls 
attention to the value of the operation as giving safe access 
and free drainage for any length of time. 

I have given these quotations from Mr. Jordan^s paper 
because I feel that in his own words the advantages of the 
operation introduced by him are more likely to be conveyed 
accurately than by any words of my own. There are some 
points in connection with the carrying out of this method 
which I wish to mention. 

I stated in the earlier part of this paper that the second 
plan recommended by the writer has been most commonly 



Dr. Marshall's Oases of Amputation at the Hip-joint, ^37 

employed by me^ I mean the performance of the circular * 
sweep of the soft parts before the enucleation of the femur is 
attempted. My reason for doing this is that the increased 
length of leverage given by freeing the limb from the main 
attachment of the muscles enables the fingers and the knife 
to pare the muscles off from the bone with much less risk of 
wounding vessels unnecessarily. Also, when the hip-joint is 
arrived at, separation is rendered much easier and more rapid 
of the tough bands which in old-standing cases of hip disease 
held the trochanter and what exists of the neck of the femur so 
closely to the pelvis. The chief advantage gained by Purneaux 
Jordan^s operation is, that the gluteal vessels remain untouched, 
the wounding of these in the double flap operation and the con- 
sequent bleeding being the cause of much risk to the patient. In 
all discussions upon the subject of amputation at the hip-joint, 
that I have read or heard of, great stress has been laid on the 
anxiety to which the bleeding from these vessels has given rise. 
The value of abdominal tomiquets and Davy's lever for the 
compression of the aorta and common iliac artery has been 
freely discussed, and the conclusion arrived at was that Davy's 
lever was most to be preferred. I regret to say that my only 
death occurred after the use of this instrument in a boy ddt, 
11, and in better health than any other patient operated on by 
me, but with the disease requiring removal of the right 
leg. This last fact may probably account for its incomplete 
action, and my mind therefore may have been somewhat un- 
justly prejudiced against the lever. Whilst admitting this, I 
however see good cause for omitting its use. Handling per 
rectum does not appear to me to be desirable if not absolutely 
needed. Where — and we never know when it may not exist — 
intra-pelvic inflammation or suppuration is present, harm may 
result by the pressure and manipulation of the lever. The 
efficacy of nutrient enemata directly after operation might also 
be interfered with. 

In all my cases I have had the valuable help of Mr. Wright, 
senior surgeon to the General Hospital, Nottingham, by whom 
the common femoral has been controlled most satisfactorily. 
The presence of the hand in the groin has in no way been a 
hindrance to the operator. It must of course be remembered 
that my cases have been collected from children's work, and 
these remarks may not therefore apply with equal force to 
adult patients. The femoral artery has always been tied by 
me immediately on completion of the circular incision before 
enucleation of the femur is commenced. Although of secondary 



288 Dr. Marshall's Oases of Amputation at the Hip-JotnU 

importance^ amputation at the hip-joint being undertaken 
principally for the saving of life, I may state that the stump 
left by Jordan's method is in every way all we could wish for. 
I am aware of the late Mr. Shuter's case and his suggestion 
that the periosteum should be left. Whilst such a measure 
would probably add to the usefulness of the stump, the time 
occupied by the operation must be lengthened, and this is 
undesirable. One important matter I must refer to before 
concluding. It is that one of my cases, a girl, who h^ been 
in hospital nine months, and whose hip-joint had been pre- 
viously excised, was the subject of extensive lardaceous disease. 
Her liver reached well towards the umbilicus, and a heavy 
deposit of albumen was found in her urine, of which traces 
could be detected up to ten months after amputation. She 
was seen by Dr. G-oodhart amongst some other cases shown by 
me in June, 1880 (eleven months after removal of her limb), 
by whom her liver was then found to be enlarged, although at 
that time much reduced from its original size. This girl is now 
hale and hearty, and seen constantly by me, walking on her 
crutch and enjoying life thoroughly. Her liver is now to be 
felt just below her ribs. The albumen in her urine has not 
returned. In two other cases large deposits of albumen were 
present when amputation was done. 

In conclusion, I may say that by giving us this plan of 
operation Mr. Jordan has conferred a boon on the patients and 
a welcome addition to surgery. My object in placing my cases 
before the Society is to add to the previous record of cases as 
yet confined, I believe, to the publication of papers written by 
Mr. Jordan, Dr. Maclaren, of Carlisle, and myself. I have to 
thank my Mend Dr. Groodhart for his suggestion that I should 
read this paper here, and the president and members of this 
Society for permission to do so. 



Dr. MurshiJl'B Omm of Amputation at the Hip-jmt. 239 

"lip li 1 % 
i ii I I « 1^ 

1 M I H ' % 

m ii ill a i jM 

I III it' 'I lHH' 

III ■ ' ' -sitl '4 

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Jiliiiiiiijii' -^^ 

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240 Mr. HutchinBon On Amputation at the Hip. 



XXX. — On Amputation at the Hip in certain desperate 
cases of Disease of the Joint or Bone. By Jonathan 
Hutchinson, P.R.S. Bead April 10, 1885. 

MY object in the present paper is to elicit the opinion of the 
surgical members of the Society as to whether the ampu- 
tation of the entire limb in certain desperate cases of disease 
of the hip and femurs might not be advantageously per- 
formed more frequently than it is. Especially I think is this 
the case when things are going badly after excision of the 
hip-joint. I feel sure that in my own practice amputation has 
in several instances snatched the patient from an otherwise 
certain death, and I can look back on several others in which 
I much regret that it was not performed. It is astonishing 
how well, in cases of even extreme exhaustion, this formidable 
operation is borne, and how rapid and satis&ctory is the 
convalescence. I do not indeed recollect that I have ever 
lost a patient after amputation at the hip-joint for suppurative 
disease. The difference is very marked between this class of 
cases and those of amputation tor new growths. 

I shall not attempt to produce statistics either from my 
own practice or from the narratives published by other 
surgeons, since I have not the facts before me, but shall 
content myself with the brief recprd of three or four illustrative 
cases. 

The first of these is one which, having been already pub- 
lished, I shall allude to very briefly. 

It occurred many years ago, at a time when I had the good 
fortune to have the services of Mr. B. W. Parker as my house 
surgeon at the hospital. 

Our patient, a young woman of about twenty, was enfeebled 
and emaciated to the last degree by combined disease of the 
hip, knee, and femur. We had thought her too ill to bear any 
operation, and had been for some time expecting her death. 
It was finally determined to give her the chance. She was too 
weak, I well recollect, to be taken to the theatre, and I ampu- 
tated at the hip- joint on her bed. Thanks to Mr. Parker's 
assiduous care, she recovered, and is at the present time stout 
and healthy. 

My next case is one in proof that even advanced amyloid 



Mr. Hutchinson On Amputation at the Hip, 241 

disease of the viscera is no bar to the operation. In this 
instance the hip- joint itself was not involved, but there was 
necrosis of the femur up to the great trochanter. The patient 
was a boy set. 10. I had removed the sequestrum and then 
sent him to Margate. He returned after a stay of some months 
with profuse suppuration stiU going on, with his Uver enor- 
mously enlarged, and so bloodless that his face and lips were 
of waxy pallor. His feet were somewhat swollen, but there 
was a good point,— he had no albumen in the urine. 

I amputated at the hip-joint by Fumeaux Jordan's method, 
detaching the periosteum from the shell of new bone over con- 
siderable parts of its surface. He recovered easily from the 
operation, but the point of most interest was that his liver 
afterwards diminished to half its bulk, and that he regained to 
a very remarkable degree his strength and colour. There 
was some reproduction of bone at the stump. 

I had him under observation for about a year after the opera- 
tion, but have not seen him lately. Several of my friends have 
mentioned to me other cases in which, as in this, there was 
definite proof of diminution in size of an amyloid liver after 
removal of the diseased bone or joint which had caused it. I 
am bound, however, to admit that this is not invariably the case, 
for in another instance in which, after amputation at the hip- 
joint, the parts healed perfectly and the patient went to the 
seaside, I found some months later that the amyloid cacchexia 
was decidedly advancing and the liver getting larger. 

My third case is that of a young gentleman whom I attended 
with Mr. Benjamin Duke at Glapham Common. 

He was 89t. 15. I had excised the head of the femur one 
year before the amputation at the hip-joint on account of 
disease attended by a very large abscess. Most of the interval 
had been spent at the seaside, and at one time there had seemed 
good hopes that recovery would ensue. These, however, &uled 
away. He lost strength, became extremely thin, and had still 
profuse suppuration. He was as pale as he could possibly be, 
but there was no evidence of visceral enlargement and no 
albuminuria. On the day that Mr. Dukes and myself decided 
to recommend the amputation we did not think it at all likely 
that he would live another week. On the following day when 
we met for the performance of the operation, a most untoward 
complication presented itself, for we found the leg below the 
knee attacked by erysipelas. Peeling sure that this was our 
nly chance, we decided to go on with the intended operation. 

I again adopted F. Jordan's method, and although for a 

^OL. xvin. 16 



242 Mr. Hutchinson On Amputation at the Hip. 

few days after the operation onr patient remained in a very 
critical condition, he nltimately made a fair recovery and has 
since undertaken a voyage to Australia for his health. 
Although much improved, I believe that sinuses still exist. 

In this case, as m the first, the acetabulum was carious, but 
in neither of them were any conditions found at the amputation 
which could have been treated with benefit by any other 
measures. 

By the side of these very encouraging eases, permit me to 
place two others in which the operation was not done, and 
which are, I fear, fadrly illustrative of a considerable group. 

About four years ago I excised the head of the femur in the 
London Hospital for a young woman aged about twenty 
three, who had long suffered from suppurative disorganisation 
of the joint. After the excision she remained in the hospital 
about six months, with profuse suppuration all the time and 
steady deterioration of health. At tength, amputation being 
declined, she was taken home by her friends for the benefit of 
change of air^ and some time afterwards I heard that she had 
died. 

In another case I attended ten years ago with Mr. Benjamin 
Clark, of Clapton, a young gentleman 89t. 19, who was in a very 
advanced condition of exhaustion from suppurative disease of the 
hip-joint when I first saw him. He was too ill for us to think 
of excision, and I urged as strongly as I could that we ought 
at once to relieve him by the removal of the entire limb. His 
parents naturally thought this very serious advice, and it was 
decided that another opinion should be asked. I met in con- 
sultation a very distinguished surgeon, since deceased, who 
entered into the consideration of the case in a most careful and 
thorough manner. The result was, however, that although he 
agreed with me that the patient was too weak to bear 
excision he could not bring himself to recommend an amputa- 
tion. He reminded us that although patients often became 
very ill from hip-joint disease, that yet they but seldom died, 
and recommended that we should wait. Within a fortnight of 
our consultation, nothing having been done, the patient died. 

The conclusion which I would wish to submit for the con- 
sideration of the Society is this : — That amputation at the hip- 
joint, when done in the state of hectic produced by suppurative 
disease, is attended usually by but little shock to the system, 
and is often followed immediately by definite indications of 
relief, and in the sequel by perfect restoration to health. 

That it would be well if this operation were resorted to 



Mr. Hutchinson On Arn/putation at ths Hip. 248 

more frequently than it is^ and that it ought to be considered 
as distinctly indicated whenever in a patient otherwise free 
from disease death seems likely to occur from the joint 
miseliief. 

Thirdly, that the existence of even advanced amyloid 
disease of the viscera doe» not preclude the operation, sii^e it 
does not prevent the recovery of the patient nor prevent the 
restoration of the general healths 

in conclusion^ let me say that I am well aware that there is 
nothing novel in the recommendation of this operation in tlie 
class oi cases referred to. Indeed^ I quite hope that in the 
discussion which will follow, other surgeons will relate yet more 
satisfactory resillts than those which I have brought forward. 
My sole desire in introducing the subject to your notice is to 
recommend a practice which I feel sure is good, and to elicit 
the experience of others respecting it. 



244 Dr. Colcott Pox's Cases of Pityriasis drdne. 



XXXI. — On Pityriasis ci/rcine {Horand) and Pityriasis 
circine et margine (Vidal). By T. Ooloott Fox, 
M.B. Bead AprU 10, 1885. 

IN recent years attention has been directed to an affection 
of the skin^ interesting from a diagnostic point of view^ 
thongh otherwise of a comparatively trifling natnre^ which 
approaches somewhat in aspect the well-known roseola annnlata 
of Willan^ bnt^ nnlike it^ pursues a chronic coarse. It is not 
my intention on the present occasion to occupy the time of the 
Society with a recitfJ of the history of the disease^ varionsly 
described as pityriasis rosea, pityriasis maculata and circinata, 
&c., but I will refer those interested in the matter to the theses 
of Mettou (1877) and Nicolas (1880), and to the papers by 
Vidal ("Du Pityriasis/' Progres Med., 1877), by Dnhring {Amer. 
Joura. Med. 8ci., Oct., 1880), by Behrend {Be^'L Min. Woch,, 
1881-2), and by myself in the Laaicet for 1844. 

As I shall deal with the affection only as seen in children, 
I will take as my text the paper entitled '^ Notes pour servir 
a rhistoire du Pityriasis circrue,'^ by Horand, of Lyons, in 
vol. vii of the first series of the Arm. de Derm, et de 8yph. 

Horand there gives a detailed description of seven cases 
in children, whose ages ranged between eight and thirteen 
years, and accurately portrays an affection which seems to me 
a distinct morbid entity, and which I have several times 
recognised in this country. Horand says that the affection 
can have for its site the neck, the trunk, and the limbs, but 
it shows itself especially about the scapular, deltoid, and sub- 
clavicular regions. It is constituted by discrete or confluent 
patches, of which the dimensions vary ordinarily from a lentil 
to a two-franc piece. They exceed these dimensions only in 
rare cases. The patches are slightly raised, rounded, the 
smaller uniform in aspect, the others depressed in the centre 
with only the borders raised, which gives them a distructly 
circinate form. Their colour varies from a pale rose to a 
yellowish white, approaching to the tint of the surrounding 
skin, so that one can sometimes with difficulty distinguish them 
from the rest of the integument if the patient be not placed 
obliquely. Often the border alone is coloured. These macules 
are constantly dry, their sur&ce is more or less furfnraceous, 
and the tissues upon which they are set are supple, and not 
thickened or inflamed. The skin which separates them is 



Dr. Colcott Fox^s Oases of Pityriasis drdni. 246 

healthy. They are accompanied by a little pruritus sometimes^ 
and then under irritation they redden. They give rise to no 
other inflammatory phenomena during their evolution of 
which the duration cannot be determined precisely. The 
eruption can persist many months^ if not treated^ but in spite 
of chronicity the characters do not change^ the patches seem to 
preserve throughout the dimensions they first presented^ and 
on their disappearance the affection leaves no trace of their 
presence. The nature of the eruption is quite obscure^ but it 
seems to occur only in those who do not practise scrupulous 
cleanliness. The subjects of it are often apparently quite well^ 
though sometimes below the standard of health. It is not 
contagious and no fungus can be discovered. 

To this accurate descriptive summary I will add that it 
seems to commence nearly always on the trunk and thence to 
extend to the limbs^ as it pales away in the regions originally 
invaded. In its extension down the limbs the eruption first 
occupies the inner aspect of the upper arms and thighs. 
I have never traced it on the palms or soles^ nor in the buccal 
cavity. I must point out again the delicacy of the eruption^ 
for it is much less marked than even slight cases of psoriasis 
in children and even commencing macules of tinea circinata. 
The majority of the lesions indeed^ as Horand says^ can often 
be only detected in certain incidences of light, and the skin 
simply looks dirty from a faint roughening and yellowish 
pigmentation. After a bath, however, and when the circula- 
tion through the skin is stimulated, the original pale rosy 
aspect of the older macules is brought out and the eruption 
shows very plainly. As a rule the macules, which are more 
or less rounded or oval when freshly evolved, remain isolated 
and are very closely set, being separated by at least an equal 
area of healthy skin. As to its frequency Horand met with 
seven cases in seven years, and I have recognised as many in 
two or three years, so that whilst not very rare it cannot be 
very common. The youngest child affected in my experience 
was four years old. 

Without going into details I will ask the Society to accept 
from me the statement that it is not a roseolar or erythematous 
syphilide, though closely resembling it in aspect except for 
the rings, and it is not caused by any of the well-known fungi 
which attack the skin. Nor do I think it can be classed with 
the now clearly-defined group of the erythemata. It corre- 
sponds closely to what one would imagine a chronic roseola 
annulata (Willan) would be like, and as such I think it would 
be best to group it. 



246 Pr. Gploptft Fox^b Ofise^ of Pityriasis cirfme^ 

Ow of my objects in bringing po notice tlii^ piffection is to 
opntrast it with pother. In ifn\j, 1879. Yidal of t^ H6pital St. 
lionj^^ demonst^Q^ied to the Spciete qe Biplpgie a form of P. 
circin6 et margine whijD]i %q stated ^ t>e a pprf (9ctly dp^ed apd 
eaoly diagnose^ aSpcj^ion. In the J.rma^ d0 B^rm, et (2a ^yphn 
yol. iii^ 2nd 3er.^ ^882^ }^ further figured in jcpnnectipn wit^ 
snch capes a mpinte fapgRS calle4 by him the Microsporon 
anomaaon on dispar^ co|:^si8tpig of roqind ppo^s averaging one 
thpusandtl^ of a millipiet?'^ in ^^^ but particularly irjregular 
in YQlupie^ dispo^d v^ cprd^s romi^ tl^e epifiheli^l cells^ 9ji4 
arranged a}so in groups or 7)msB^s of spores irregularly dis- 
tributed on pr between t}ie cells qf t\^ superficial layer, and 
especially the middle lawyer of t^ha epidermis and about the 
orifice of the hair-f oUicles. Yi^ co^l4 never detect with any 
certainty any mycelium^ in this paxticular differing widely from 
the fungus ^sociq^ted wi|}h Erythrasma. This fungus WP^ &>nn4 
in patp^es on th^ face, beard, isfifxA. neck, ^d I dp not gather 
that any cases in cl^dren ^ere not^iced. The h^s were un- 
altered. Yidal distinguishes the eruption fropi tl^ maculate 
and circinate pityriasis of adults (!Pazin) by the &cts that the 
parasitic form is never symmetrica}, its distribution has t)ie 
c&pricipns irregularity of parp^sitic affections, an4 it pommei^ces 
on the Umbs or trunk, itp course is irregular and its duration 
is many months. He does not, however, contrpi^t it ^t}h 
Horand^s pityriasis drcin^. 

I have n^et with two cases lat)ely in children of four years 
and seven ye^s respectivpiy, closely corresponding to Horand^s 
affection, in whiph I haye f OI^ld a micro-orgaI^sm apparently 
identical with that described by Yidal. The only difference 
from Horand's disease is th^t th^ nngs seemed to attai|i a some- 
what larger size, some bpipg nearly on inch in diameter. I show 
a water-colour drawing of one case and will briefly describe it. 

Agnes S., apt. 7, a chil4 V\^^ reddish hair, very &ir com- 
plexion and deiipate ski^, deyeioped ^ pink-ringed maci^e the 
size of a shilliiig o^ the innpr side of the left knee in September, 
1 884. She was at the time apparently in her iisual good I^eelth. 
The macule was thought to be a ringworm and was treated as 
snch by two medical men, Tl^e eruption, however, gradually 
spread down and up the leg ^d appeared on the other limb, 
and then extended upwfkrds over t)ie trunk. The child was 
observed to scratch occasionally in the daytime and at night 
considerably. 

In October, 1884j I found the whole surface o| the body 
find Umbs stndde4 Plosely with Ifidpd rqsy macules from a split 
pea to a shilling in size, rounded or oval in outline, roughen^ 



Dr. Colcott Pox^s Cases of Pityriasis cvrdne. 247 

or &intly scaly^ and hardly at all raised. Here and there 
they were ringed^ and coalesced to form gyrate patterns. 
A few existed on the face and one in the scalp^ but the hair 
remained unaffected. There was an appearance of considerable 
symmetry. It was difficult to estimate the duration of all the 
maciiles^ which were first noticeable when the size of split peas^ 
as they appeared to slowly spread and intersect one another 
and remain in a semifaded condition for a long time. The 
bpdy eeemed i^ost clear at times except for some patchy 
roughness and tawny staining^ but after heating of the skin 
or a bath they showed up again quite brightly. I watched the 
qhild carefuUy until the middle of January^ 1885^ in the 
hospital^ and by thpit time most of the eruption had dis- 
appeared by constaut bathing and under arsenic, but since her 
fischarge many new macules have evolved irregularly, especi- 
ally about the loins. The child suffered from dyspepsia and 
ponstipation. None of the girl's brothers and sisters were 
affected. 

In both the cases I found a great quantity of a minute 
organism in every patch I examined, and not in the inter- 
vening healthy skin. It is a very minute organism, as I show 
Qnder the microscope, and occurred mostly in the dense 
aggregations of which here is a drawing. I have never been 
able to detect any mycelium, My friend and colleague Mr. 
Watson Oheyne was kind enough to undertake a cultivation, 
a specimen of which, permanently stained, I also show. It is 
presumably the same organism, but repeated attempts at 
inoculation have so far failed. 

I have no intention of jumping to the conclusion that this 
fungus is the cause of the eruption ; indeed, I am disposed to 
think otherwise, as I have already found a similar organism in 
two cases of psoriasis in children, and it is possible that it is 
commonly to be found amongst desquamating epithelial scales 
on children's skins. Very similar organisms have been met 
with by other observers in several affections of the skin, but 
I will not now detain the Society with a review of this subject, 
but content myself with the foregoing remarks in the hope 
that other members may investigate the matter as occasion 
arises^ 

August, 1885. — Since the foregoing remarks were con- 
tributed I have systematically sought this organism in the 
desquamating cuticle of psoriasis, ringworm, &c., in children, 
and can affirm that it is almost invariably present. It is 
probably, as Dr. Stephen Mackenzie has suggested, only a 
micrococcus flourishing in a shedding epithelium. 



248 Dr. Sidney Pliillips^s Oase of Sporadic Oretimam. 



XXXII. — A Case of Sporadic Cretinism. By Sidney 
Phillips, M.D. Bead April 24, 1886. 

NP.^ a female cliild^ 8dt. 10^^ first came ander my observa- 
• tion in the out-patient department of St. Mary's Hospital 
in February of this year. She was bom at Holloway, of 
healthy parents^ each 89t. 25 at the time of her birth, and 
between whom no blood-relationship existed. For the first 
four years of her life she lived at Holloway, since then at 
Ealing. 

There have been six other children of the marriage^ two 
older and four younger than the present patient; all these 
children^ except the youngest, who died of bronchitis, are living 
and healthy. 

The father was, previous to the birth of the child, occasion- 
ally intemperate in the use of alcohol. 

There is no evidence of rickets in any of the children and 
no indication of phthisis or syphilis can be traced. 

When seven months pregnant the mother was much 
frightened by a child felling into a weU, but pregnancy con- 
tinued the full term, and the child — ^the present patient — ^was 
born after a natural labour and without^ instrumental assist- 
ance. 

From the mother's account it appears that she was a fine 
child at birth, and progressed very well till about the age of 
nine months ; she was then observed to become quieter than 
heretofore and less active than other children of the same age. 
She also grew more slowly than natural and ceased to grow 
altogether at about 2^ to 3 years of age. 

Dentition was not difficult nor delayed, but she did not 
attempt to speak or to walk till six years old. 

Her habits which had previously been very dirty, improved 
about this time. Since then she has not altered in any way, 
either mentally or physically. She has never been able to 
learn even her letters, and attempts to teach her anything have 
been discontinued. 

She was admitted early in February into the hospital, and I 
am indebted to the kindness of my coUeague, Dr. Gheadle, for 
allowing her to remain under my care. 



Dr. Sidney Phillips'B Case of Sporadic Cretinism. 249 

She is now set. 10 J years, her height is 2 feet 7| inches 
(the average height of a child of 2^ to 3 years of age), her 
weight is 2 st. 7 lb. ; her head is large, measuring 20} 
inches round the forehead and occiput; the vertex is very 
flattened, and the anterior f ontanelle is still unclosed over the 
upper part of the head, the hair is very scanty, and the scalp 
is covered with thin dirty-looking scales. The eyebrows and 
eyelashes are well developed. 

The face is broad, with an absence of expression ; the cheeks 
large and flabby ; the bridge of the nose is broad and depressed 
and the nostrils expanded. 

No thyroid gland can be felt, and though it is often difficult 
of detection in children of this age, the circumference of the 
trachea can here be so nearly surrounded by the fingers 
that I think there can be no doubt of its absence in this 
case. 

The skin is everywhere very harsh and dry, and in some 
places scaly ; it feels, too, decidedly thickened. The mother 
says she never perspires, and a hot bath failed entirely to make 
her do so. 

Above the clavicle on each side of the neck is an elastic 
rounded mass fully the size of a large orange and on both 
sides to some extent moveable. 

The whole body presents a condition of firm oedema ; both 
upper and lower limbs, but especially the calves, are much 
enlarged, and, though fairly hard, will pit on using considerable 
pressure, but the pitting disappears again on removal of the 
pressure much more rapidly than in cases of ordinary dropsy. 
The hands are much thickened and may be fairly described as 
^'spade-like.** The feet also are very short, thick, square, 
and oedematous, and the skin of the sole is somewhat wrinkled. 
There is also oedema of the face and forehead, and a thick 
elastic roll in the submental region gives her the appearance 
known as " double chin." 

The tongue is large and cannot be fully protruded ; its 
substance is very hard and almost leathery. The voice is 
hoarse and croaking and her speech almost impossible to 
understand. There is very marked lordosis, and this with the 
enlargement of the limbs gives her somewhat the appearance 
of a child with pseudo-hypertrophic paralysis ; and after being 
laid on her back she protrudes the buttocks in the act of rising 
very much as do patients suffering from this disease, but she 
does not elevate the trunk by climbing up her own lower 
limbs in the characteristic way. 



250 Dr. Sidney PhiUips^B Case of Sporadic Cretinism. 

She can walk fairly well, but is weak on the legs and 
easily pnshed over. Hiere is some onrving of the tibisd which 
has only recently come on. She rarely moves about the ward, 
but sits in bed or by the fire all day in a state of perfect con- 
tentment, playing with toys, of which, unlike other children, 
she never tires. She rarely speaks, and never unless addressed, 
and only answers by a word or two such as " yes " or " no." 

She shows very little emotion of any sort. She appears 
to recognise her mother when she visits her in the ward, but 
stares stolidly at her and gives no evidence of satisfaction or 
the reverse. 

She seems somewhat insensitive to pain, presenting her 
finger for blood exandnation with apparent pleasure. 

She sometimes, but not always, passes the urine under her. 
The urine is clear, sp. gr. 1018, acid, free from albumen. 

When first admitted she was very ansemic, but during five 
weeks' stay in the hospital, under treatment with small doses 
of tincture of iron, the corpuscles increased from 61 to 78 per 
cent, of the normal. There is no increase in the white cor- 
puscles, and the red discs readily run into rouleaux. 

The circulation is feeble; the nose and extremities become 
blue in cold weather ; and on one occasion a soft systolic apex 
bruit was audible. The appetite and general health are fairly 
good j the fundus oculi normal. Temperature 98®. 

This case is an example of the condition of sporadic cretinism 
of which Mr. Curling in 1850, and the late Ih*. Hilton Fagge 
in 1871 recorded cases before the Boyal Medical and Ghirur- 

£ical Society. Similar cases have also been recorded by Dr. 
angdon Down,* Dr. Fletcher Beach,t and Dr. Routh.f In 
all ten cases, inclusive of the present one. have been com- 
municated to one or other of the Medical Societies of London 
since Mr. GurUng first commented on the disease. 

The symptoms have varied somewhat widely in degree and 
in mutual association. 

In one of Dr. Fagge's cases the disease is said to have 
been congenital, in others to have first shown itself during 
early childhood, but in none later than the age of seven or 
eight years. Eight of the ten cases have occurred in females, 
only two in males. In all there was defective intelligence, but 
in some the mental condition was that of complete idiocy with 
or without deaf mutism ; in others there was a fair degree of 
rutellectual power. Thus in one case Dr. Fagge says, " The 

t ^ Trans, of Path Soc., vol. xx. f Ibid., voL x^y, 

X Proceedingi of Medical Society ^ vol. vii. 



Dr. Sidney Phillips's Case of Sporadic Oretimsm. ?51 

mental faculties are very good and the patient is fond of read- 
ing all sorts of boo^3 and converses freely.'* 

In all the cases the thyroid app6ared to be absent^ though 
it sl^ould be mentioned that in ooa dase a post-mortem exami- 
nation Efubsequently revealed its presence, xhe supra-clavicular 
swellings were present in all the cases^ but in Dr Fletcher 
Beach^s case they gradually disappeared while the patient 
was under observation. 

The enlargement of the tongue^ the croaking voice and the 
scanty growth of hair were noticed in some cases but not in 
others. 

The exact symptoms then which are essential to the 
cretinoid state are roither difficult of definition. It differs 
from mere idiocy in not being always congenital^ and in other 
symptoms it differs from mere dwarfishness, for there is arrest 
of mental development in cretinism as well as stunting of 
bodily growth. The condition seems to consist in arrested 
bodily growth with degeneration of intellect, associated m 
most cases with absence of thyroid gland, croaking voice, 
scanty hair and supra-clavicular swellings. 

The present patient is, if I may so call it, a very complete 
example of the disease ; in her all the symptoms which have 
been distributed among the other recorded cases are strikingly 
mar]s:ed. But she presents in addition a condition closely allied 
to, if not identical with, the disease known as myxoedema. 

The hebetude of mind, the general firm oedema of limbs 
and face, the spade-like hands, the enlarged tongue and 
scanty hair, with the occasional flushings of the face, combine 
to form Q; strong resemblance to this condition. 

It is true that the mental state here is somewhat different 
from that i;sually observable in myxoedematous adults, but it 
must be remembered, as Dr. Ord has pointed out, that if the 
oedema should begin with early life, the nervous symptoms 
would naturally differ from cases where it was developed at a 
later period. In the case of the adult there is, as he says, '^ a 
sleep or torpor of a central nervous system abeady built up," 
but in the child this central nervous system is undeveloped 
from the beginning and remains, as he describes it, '^ shapeless.'^ 
The condition of myxoedema had not at the time when Dr 
Pagge's paper was read (1871) received the attention which 
has since been devoted to it, but there can, I think, be no doubt 
that it was present in three of Dr. Fagge's cases of cretinism. 

The engravings which accompany nis paper in the ' Tran- 
sactions,' of the Koyal Medical and Chirurgical Society, as 



252 Dr. Sidney Phillips's Case of Sporadic Cretinism, 

well as his description of the cases are sufficient evidence of 
this. Thus in one case he speaks of the ^^ hands being short 
and broad ;'' in another^ ^^ the limbs are short and thick as 
also are the feet and toes ;'' in a third case^ ^^ the skin of the 
hands and legs looks as if too large for him/' In one of Mr. 
Curling's cases " the body was thick and the limbs dispro- 
portionately large and the tongue swollen ;" in another case^ 
^^the tongfue was protruding. In Dr Bouth's case exhibited 
before the Medical Society last year the oedematous condition 
was well marked. 

It appears then that of the ten recorded cases of cretinism^ 
oedema was present to a greater or less extent in at least six 
of them ; and this result is quite in accordance with the state- 
ment of Foder6^ quoted by the Sardinian Commission^ that 
^^ cretinous infants mostly become oedematous." 

And in connection with this subject^ perhaps I may be 
allowed to point out the remarkable prescience with which Dr. 
Fagge almost foretold the disease now known as myxoedema. 
Reasoning from what he had observed in cases of sporadic 
cretinism he writes in the paper to which I have already 
alluded as follows. He says: ^^It may be interesting to 
speculate as to what characters would be present should the 
disease sporadic cretinism (if this be possible) arise still later 
in the course of adult life. The peculiarities in the form of 
the cranial and &tcial bones and in the bony framework gene- 
rally would then probably be absent^ the development of the 
skeleton being unalterable when once completed. And I think 
we must conclude the most marked features in such a case 
would be a coarseness and thickness of the soft parts of the 
face^ especially the lips^ and perhaps of the subcutaneous 
tissues of the hands and feet, besides the presence of supra- 
clavicular tumours and possibly a wasting of the thyroid body." 
Here the disease myxoedema is anticipated with a remarkable 
approach to accuracy. 

There is then good evidence both here and on the Conti- 
nent, that myxoedema is not an exceptional association with 
cretinism, but rather one of the usual symptoms of that con- 
dition, present at least as often as some of the other 
symptoms. 

And this clinical association of myxoedema and cretinism 
is quite in accordance with what we might be led to expect 
from the result of experimental investigation. It has been 
demonstrated by Kocher that ablation of the thyroid gland 
will produce a cretin condition in human beings. Mr. Victor 



Dr. Sidney Pliillips^s Case of Sporadic Oretinism, 253 

Horsley's experiments on monkeys have shown that in them 
at any rate myxoedema^ or something much allied to it^ follows 
the same operation. 

That the condition of myxoedema then should be associated 
with other cretin manifestations in the subjects of deficient 
thyroid is only what might be expected. 

Clinical evidence then accords with experimental observa- 
tion that myxoedema is one of the usual evidences of the cretin 
state^ and I have brought forward this case to-night^ not as 
an exceptional example of sporadic cretinism^ but rather as a 
typical case exhibiting prominently and strilangly the charac- 
teristic symptoms of the disease. 

As to the causes to which the absence of the thyroid gland 
may be referable I can ofier no suggestion ; the cause is as 
obscure here as in all the other recorded cases. I would only 
point out that this is the third among ten cases in which there 
has been a clear history of fright to the mother during preg- 
nancy^ and that the conditions which in this case at any rate 
are accountable for the deficiency of the thyroid must be in 
their nature rather transient and accidental than connected 
with the constitution of the parents or the locality inhabited, 
since there are six other children of the marriage all healthy 
and living under the same conditions as the present patient. 



254 Mr. Walsliam's Oaae of Ingumal Aneurism. 



XXXIII. — A Case qf Inguinal Anemism. Ligature of 
the External Iliac Artery with two Kangaroo-tail 
Tendon Idgatv/res and Division of the Artery between 
them. Suppv/ration of the sac. Ultimate recovery. 
By Wi J. Walsham. Bead April 24, 1885. 

WF.^ 8Bt. 33^ a strong and muscular man^ caiiie' uiid^' my 
• care on February 4, 1884, for an atieurism in the right 
groin. For twelve years lie had been in the ariny, but for 
the last six had worked as a dock labourer. He adlnitted 
having been a hard drinker, and having some years tireviously 
contracted syphilis. About two months ago he fell whilst 
carrying a sack o! coals aad hurt Ms ri^Kt groin, and innnedi- 
ately afterwards perceived a small lump in that situatioli the 
size of a walnut. This lump graduaUy grew larger, btit he 
followed his employment till a week before his admission^ when 
he had to give it up on account of the pain and sWelHng of 
his limb. On examination a prominent globular pulsating 
swelling the size of a small cocoa-nut was found in the right 
groin in the course of the main vessel. It measured five and 
a half inches in its longitudinal diameter, seven inches in its 
transverse, and projected two inches above the level of the 
thigh, while its upper margin extended about an inch above 
Poupart's ligament. Pulsation was visible over the whole 
swelling, and was of a forcible and expansile character, but 
could be stopped, although with some difficulty, by pressure 
upon the external iliac artery. A loud bruit could also be 
heard in all parts of the tumour. The right leg and the penis 
were very oedematous, the right calf measuring two inches 
more in circumference than the left, and pulsation in the tibials 
could not be felt. The heart, lungs, and kidneys, it may be 
added, were examined and found normal. The man was put 
to bed, the limb raised and bandaged, his diet restricted and 
potassium iodide in ten-grain doses given three times a day. 

On February 7 (three days later) the swelling and oedema 
of the limb had markedly diminished, but the aneurism itself 
had clearly increased in size while the pulsation was more 
forcible and could be felt as far outwards as the great trochanter. 
The following day (the 8th) I tied the external iliac artery, 
making my incision a little higher than usual, so as to avoid 



Mr. Walsham^s Oase of Ingmnal Aneurism. 255 

the sac of the aneurism whicli encroached upon the lower part 
of the vessel. Having exposed the artery and found it not 
perceptibly dilated^ I applied^ about one inch from the sac^ 
two strong kangaroo-tail tendon ligatures three eighths of an 
inch apart^ and divided the artery between them with blunt- 
pointed scissors. Pulsation entirely ceased on tightening the 
first ligature. The ligatures were then cut off shorty a 
drainage-tube was inserted^ and the wound closed by four 
stout catgut sutures and dressed with antiseptic gauze and 
absorbent cotton. Owing to an accident with the steam spray 
apparatus the carbolic spray failed in the middle of the opera- 
tion. 

The limb, which had been previously swathed in cotton wool 
and flannel bandages, was raised on a pillow. Thirty minims 
of tinctura opii were given immediately and five minims ordered 
to be taken every two hours while the patient was awake. 

The wound was dressed for the first time on the second day 
after the operation, and was found to have united by the first 
intention except at the situation of the drainage-tube. The 
temperature was 102°, but the patient's condition in all other 
respects was excellent. From this time he progressed favor- 
ably. The temperature rapidly fell to normal, the swelling of 
the limb disappeared, he slept and ate weU, and appeared in 
every way perfectly comfortable. But the aneurism still con- 
tinued soft and fluctuating, though slightly smaller in size, 
and the wound in the situation of the drainage-tube would 
not close, but remained as a sinus down which a probe could 
be passed for about two inches. The patient was therefore 
not allowed to get up, and in this state he continued tiU March 
27th (seven weeks), when his temperature rose from normal to 
101°, and the next day, the 28th, to 103°, whilst his pulse was 
found to have increased from 72 to 130. The wound was then 
dressed. It appeared healthy, and nothing fresh was noticed 
in the aneurism. On the evening of the 29th the temperature 
had fallen to 99*6° and the pulse to 120; but the patient com- 
plained that the bandage felt tight, and it was loosened by the 
nouse surgeon Mr. Power, who was sure that he had not 
applied it more tightly thaji usual at the last dressing. 

On the 30th the temperature was 99*4°, the pulse 120. 

On my visit on the morning of the 31st I found him with 
a temperature of 100*4°; a puke of 120, and a thickly furred 
tongue but otherwise comfortable. On removii^ the dressings 
the aneurism was evidently larger and the thigh swollen, dis- 
coloured, and scored by the bandage. 



256 Mr. W^ham's Case of Ingvinal ATievrism. 

Orer the most prominent part of the aneurism the cnticle 
was raised into a blister the size of a penny-piece hj flnid 
black blood which oozed np through a very minate pin-prick 
opening in the skin below. The sinus left in the sitaation of 
the operation wonnd looked healthy and was nearly healed. 
A pad of lint well soaked in collodion was applied over the 
small bole in the aneorism, the limb bandaged, the patient 
placed on low diet and ordered to be carefully watched. On 
April I the aneurism was smaller, bat the aperture in the 
sac bad increased to the size of half a crown and through it a 
black clot the size of a walnut was projecting. A probe 
dipped in a strong aolution of percMoride of iron was thrust 
into the clot in six or eight different places, and the aperture 
covered with a flat pellet of cotton wool soaked in coUodion, 
the aneurism being left exposed so that should any bleeding 
occur it might be at once detected by the nurse on guard. 

On April 2 there was a slight ooziug of brickdast red fluid 
from under the pellet of collodionised cotton wool, and a probe 
dipped in perchloride of iron was again thrust into the clot in 
different directions, and the pad reapplied. On April 3 the 
sac was evidently sloughing, and a linseed poultice was 
ordered. 

On the 1 0th the aneurism was level with the thigh and 
free^ snppnrating. 

On the 17th it was reduced to a healthy granulating sore. 

On May 5th it had contracted to a small sinus, and on May 
17tih the '^tient was discharged with both wounds soondly 
healed. The man's allowance of stimulants during his stay in 
the hospital had been one pint of ale daily, but on the night of 
bis disciiarge his friends got np a benefit for him and he was 
dmnk for uiree days or more. The debauch did not appear to 
do h 'f any physical harm, and when his benefit money was 
all spent and he had become sober he at once returned to the 
laborious occupation of a dock labourer, and when last heard 
of was still continoing that employment in good health. 

S/cmarks. — The aneurism nad formed so rapidly, had 
attainbd so large a size, its increase was so marked during 
the few days I had the patient under observation, and its sac 
was so thin, that I did not hesitate to tie the artery at once 
without maldng any attempts to cure it by pressure. There 
are some surgeons who hold that it is hardly jostifiable, as a 
frenera! rule, to tie the external iliac without previously trying 
a effects of pressure. Had the aneorism not presented the 
aracters given above I should probably have followed their 



Mr. Walsham's Oase of Ingumal Aneurism, 257 

teachings and subjected the patient to a course of pressure 
before l^turing the vessel. But since this case was under 
my care I have collected all the cases of aneurism of the groin 
that I could find published since 1870, in the Lancet, British 
MecUcal Jou/mal, Medical TimeSy Dublin Medical Joumaly and 
American Journal of Medical Sciences ; and from a review of 
them I am inclined to think that pressure should be the 
exception and ligature the rule. 

Of the fifty-eight cases thus collected thirty-seven were 
treated by pressure, or by pressure and subsequent ligature of the 
external iliac. But in only ten of these was the pressure success- 
ful. In two of the remainder pulsation ceased in the sac ; but 
one of these died nine days after leaving the hospital from the 
rupture of an aortic aneurism, which Mr. Glutton, under whose 
care the patient was, seems inclined to attribute to the increased 
blood-pressure thrown upon the aorta from the use of the 
Esmarch^s bandage. In the other, just as consolidation was 
thought to be taking place, death occurred from the rupture 
of an aneurism which had formed just above the spot where 
the abdominal aorta had been compressed. An Esmarch's 
bandage had here, also, been applied to the limb. In two 
others the pressure not only failed to stop the pulsation in the 
aneurism, but led to the death of the patient, one man dying 
nine days after the last attempt of pneumonia and exhaustion 
with the upper lobe of the lung infiltrated with pus, and lymph 
on the sigmoid flexure of the colon; and the other, seven days 
after the last compression, of exhaustion with suppuration in 
the sac and thrombosis of the femoral vein. Both were healthy 
and well nourished previous to the commencement of the 
treatment. In the rest (twenty-three) a ligature was applied, 
but not only in these twenty-three cases did the previous treat- 
ment fail to stop the pulsation in the aneurism, but it seems in 
many to have placed the patient in a worse condition for sub- 
sequent ligature, and in some to have been the direct cause of 
death after the artery was tied. Thus in three the parts were 
found so matted together that much difficulty was experienced 
in separating the fascia transversalis from the peritoneum, and 
the latter structure in two out of the three was in consequence 
wounded. In one the artery gave way at the seat of ligature 
and former pressure (Bellingham's), and the patient died of 
hasmorrhage. In one the parts were found greatly congested 
at the operation in consequence of the pressure, and the patient 
died of diffuse cellular inflammation extending upwards as high 
as the left kidney. In one the sac of the aneurism became 

VOL. XVIII. 17 



258 Mr. Walsham's Oase of Inguinal Aneuriam. 

very thin, and in another actnally bnret whilst ander the 
presaure treatment, (but in this latter case fibrin ferment had 
also been injected into the sac). In three extensive slonghing 
of the woimd took place. In one slouching of the skin occurred 
followed by cicatncial contraction of the parte, rendering the 
subsequent operation of tying very-tediona and difficult ; whilst 
in another the parts were found much swollen and congested 
at the operation, though the patient ultimately did well. In 
the remainder, beyond the delay and irritation to the patient 
from failure, no apparent harm from the pressure treatment 
ensued. 

To sum up : Of the whole thirty-seven cases subjected to 
pressure ten only were cored; fonr died apparently as the 
direct result of the treatment, and twenty-three bad to have 
the artery tied. And of these twenty-three, twelve were placed 
by the pressure treatment in a worse condition for the ligature, 
and two actually died, the fatal result being attributable 
entirely or in great part to the pressare. In iace of these 
fetcts it seems to me a question whether, as generally taught, 
pressare ought to be attempted before resorting to the ligatnre 
unless, other things being equal, pulsation through the aneurism 
is very easily controlled, and by very moderate pressure — cases, 
which would appear to be the exception in aneurism in the 
groin rather than the rule. 

With regard to the operation, as far as I know this is the 
first instance in which the method of securing an artery with 
two ligatures and dividing it between them has been applied 
to the external iliac since, at any rate, its revival in our own 
times. I have now tied five large arteries in this way without 
any mishap, and I have seen sixteen others similarly tied by 
my colleagues at St. Bartholomew's Hospital, all with like 
success. The advantages claimed for the method are, first, 
that it diminishes the risk of secondary htemorrhage by 
removing the longitudinal tension of the vessel, and ensuring 
that no part of the artery above the upper, and below the 
lower ligature is deprived of the nourishment it receives from 
its sheath ; and secondly, that the artery, being divided com- 
pletely ncrOBs, there can be no chance of its calibre being re- 
Ktoi-LHl through the slipping of the knot, the too rapid absorp- 
tion or giving way of the ligatnre, or the failure of division of 
the internal and middle coats. Such a restoration of the 
artery, as is well known, has now in several instances led to a 
return of pulsation in the aneurism and as a consequence in 
some tases to the giving way of the sac and fatal heemorrhage. 



Mr. Walsham's Case of Inguinal Aneurism. 259 

I find tliat of the thirty-three large arteries tied with one liga- 
ture at St. BartholomeVs Hospital since 1870, secondary 
hsemorrhage has occurred in no less than four cases, whilst of the 
twenty-one tied with two, with division of the artery, there 
has been no case of secondary hasmorrhage. 

The last point in the case to which I would refer was the 
suppuration and sloughing of the sac. This did not appear 
to depend in any way on the method of tying the artery. It 
occurred seven weeks after the operation, the operation wound 
being then practically healed. This complication appears to 
be not very uncommon after ligature of the external iliac for 
inguinal aneurism. Thus of 153 cases in Norris and Cutter's 
tables as quoted in Holmes* * System of Surgery,' three died of 
this accident which occurred in no less than thirteen instances. 
In the cases I have collected it also occurred three 
times. I did not adopt the method I believe generally 
recommended, of free incision and turning out the clots, as it 
seemed to me that in so doing there must be considerable risk 
of disturbing the clots sealing the vessels entering the sac. I 
find on looking up the published cases where this has been 
done that haemorrhage has in several instances ensued. I 
would therefore submit that it is better to be in no hurry to 
open the inflamed sac, and turn out the clots, but to promote 
suppuration and the breaking down of the clots and the 
formation of firm coagula in the vessels communicating with 
the sac by some such method as was adopted here, of course 
taking care that there should be a free exit for the pus when 
fully formed. 



260 Mr. Walsham's Oase of Inguinal Aneurism, 



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268 Dr. Hadden^s Case of Obstruction of Arteries y ^c. 



XXXIV. — A Case of Obstruction of Arteries and Veins 
extending over many years. By W. B. Hadden, M.D. 
Bead May 8, 1885. 

THE patient is a healthy-looking man^ aat. 51^ formerly a 
commercial traveller. He has been married many years 
and has had two children^ who are alive and healthy. His 
wife has had some premature confinements. His paternal 
grandfather and grandmother had gout. His father died at 
forty-two of heart disease ; and his mother at seventy, of bron- 
chitis ; a brother died of heart disease, and had varicose veins 
for many years. The patient denies syphilis and alcoholic 
excess. 

In 1862 he had his first illness since childhood. From 
his description it appears to have been renal colic, although he 
had no hsematuria. 

The disease from which he now suffers dates from 1868, 
when he was suddenly seized with a sharp pain in the left foot 
and heel. He was said at the time to be suffering from rheu- 
matic gout. Phlebitis of the same leg followed and mortifica- 
tion was feared. The left leg was swollen and tender up to 
the groin. He was laid up for about five months. 

In 1874 he injured his leg, and to this cause he ascribes 
the pigmented scars to be mentioned presently. 

In 1880 he came under the care of Dr. Mitchell Bruce at 
Charing Cross Hospital, and remained under his observation 
for three or four years. I have to thank Dr. Bruce for most 
of the details in the history of the patient before he came 
under my notice. 

When first seen by Dr. Bruce he had obstruction of the 
right brachial artery. The attack began suddenly with 
cramp in the fingers, weakness of the hand, and pain in the 
upper brachial region. To the patient the fingers appeared 
dead, numb, and useless, and the limb swollen, although it 
was visibly flabby and shrunken. The pulse at the radial 
artery was small. The heart was irregular. The man states 
that the nails became black at this time, but did not come 
away. 

During improvement the right radial and ulnar veins 



Dr. Hadden^s Case of Obstruction of Arteries, ^c. 269 

became painful^ converted into solid cords^ and evidently 
thrombosed. In August^ 1881^ that is^ about eighteen months 
after he was first seen by Dr. Bruce, he was returning home 
one day when he suddenly dropped a bag he was carrying in 
his left hand. He was confused^ but was not convulsed and 
did not &>11. 

The left leg was not afiEected, but the doctor who then saw 
him thought that the face was drawn. The patient says he 
had no pain in the arm at this time. He was put to bed at 
once and was unconscious for some days, not knowing anybody. 
A complete recovery seems to have followed. 

Between 1881 and 1884 he had attacks of arteritis or 
phlebitis, according to his medical^attendant, but of the details 
I am ignorant. Between June and November, 1884, he is 
stated to have had phlebitis of both femoral veins, and also 
of the veins of the right buttock and pubes. 

It was at this time the man first came under my notice, as 
an applicant for an out-patient letter at St. Thomas's Hospital. 
I then thought that his case resembled very closely one that 
I described before this Society last year as obliterative arteritis. 
I only made a casual examination as the man refused to come 
into the hospital and went away without treatment. I did not 
lose sight of him, however, and on February 2nd of this year 
he was admitted into St. Thomas's Hospital under Dr. Stone, 
who kindly allows me to use the case. 

He complained of pain in the right groin. On examination 
there was tenderness in this position and feeble pulsation of 
the right femoral artery. No beat could be felt in the right 
popliteal and posterior tibial arteries, but the dorsal artery 
of the foot was pulsating strongly. The right internal 
saphenous vein was thickened, cord-like, and evidently throm- 
bosed. There was very sUght cedema over the dorsum of the 
foot and some enlargement of the superficial veins. 

There was no pulsation whatever in the right brachial 
artery, which was thickened, but it was good in the third part 
of the subclavian. At the back of the arm, just above the 
external condyle, there was a strongly pulsating collateral 
branch. The pulse at the right radial was very feeble, and 
that at the ulnar could not be detected at all. There was no 
marked enlargement or thickening of the superficial veins. 
The right hand was cold and blue, and the grasp was not so 
good as that of the left hand. On the left side the femoral 
artery and vein were unafiected, but there was some dilatation 
of the superficial veins. 



270 Dr. Hadden's Case of Obstruction of Arteries^ 8fc. 

There was nothing abnormal in the vessels of the left upper 
extremity. 

Just above the pubes the superficial veins were slightly 
prominent. There was no enlargement of veins over the 
buttocks. On the front of both legs^ and on the inner 
and outer sides of both ankles^ there were pigmented scars^ 
some of which were large^ others small and outlying. Those 
on the right side he ascribed to injury when a boy, but he 
confessed to ulcers of the left leg ten years ago. He indig- 
nantly denied the imputation of acquired syphilis, stating that 
if he had had syphilis it must be hereditary. 

There was no hypertrophy of heart, and no bruit, but the 
rhythm was irregular. There was no sign of aneurism. The 
urine was free from albumen whenever examined. 

For about six weeks after admission the pain in the right 
groin continued, but no fresh obstruction in the course of 
either artery or vein was noticed. 

Three weeks after admission he was suddenly seized with a 
rigor, and his temperature, which had been previously normal, 
rose to 103' 8^. At this time he had headache and tenderness 
limited to the right frontal and parietal regions. He com- 
plained too of sorethroat and the tonsils were red and inflamed. 
On one occasion he was slightly delirious at night. The 
attack passed ofi without further mischief. About a fortnight 
later he had a recurrence of the headache, which was localised, 
as before, to the right side. Since his admission he has had 
occasional attacks of diarrhoea, the explanation of which was 
not altogether clear. 

The treatment adopted consisted mainly in the administra- 
tion of mercury and iodide of potassium, and of hot soda 
baths on alternate days. At the same time he was confined to 
bed. 

At the present moment he is free from pain and tenderness 
and says that he is better than he has been for two years. I 
am not prepared to say what share the anti-syphilitic treat- 
ment ha^ had in bringing about the improvement. 

As to the cause and nature of this affection I am much 
perplexed. 

Is it gouty ? His paternal grandparents were said to have 
suffered from this disease, but I am &r from satisfied that the 
sharp pain in the left foot which occurred in 1868, and which 
was clearly the beginning of his present affection, was really 
gout. It is quite possible, probable I think, that it was 
phlebitis. 



Dr. Hadden's Case of Obstruction of Arteries , 8fc, 271 

Tlie question arises whetlier the disease is syphilitic. In 
spite of the patient^ s emphatic denial the scars on his legs are 
highly suggestive. There is, however, no evidence of old 
disease in the throat, eyes, or testicles. Whatever may be the 
constitutional taint or state underlying this affection its 
pathological nature is by no means clear. 

The sudden obstruction in the right brachial artery 
suggests embolism, and this assumption is, to some extent, 
supported by the condition of his heart, which was irregular. 
But although irregular there was no hypertrophy and no bruit. 
In addition there was no history of arterial obstruction in the 
viscera, with the exception of a suspicion of a cerebral block 
giving rise to loss of power of the left arm. 

Two explanations may be put forward. 

First, there may be a twofold agency, embolism affecting 
the arteries, and phlebitis. Secondly, we may assume a 
common cause, an inflammatory condition involving the coats 
of both arteries and veins. This hypothesis has an a priori 
probability. In its favour may be urged the absence of a 
cardiac bruit, the relation in time, on one occasion, between 
the arterial and venous obstruction, and the prolonged tender- 
ness in the course of the right femoral vessels without corre- 
sponding obstruction. 



272 Mr. Lann's Oases of Osteitis Deformans, 



XXXV, — Four Gases of Osteitis Deformans. By John 

R. LuNN. Bead May 8, 1885. 

IN the 8t. Thomases Hospital Reports for 1883, vol. xiii, I 
have given a full account of a case of osteitis deformans 
which came under my care in the new St. Marylebone In- 
firmary. In that article I gave a description of the clinical 
features and physical changes during life and a report of the 
condition found after death, including the minute changes in 
the bone as seen under the microscope. 

Having four other cases under my care at the present time 
I thought it would be interesting to bring them to the notice 
of the Clinical Society. The four cases to be shown this 
evening, I think, illustrate very well the changes which take 
place during Hfe in the different stages of the disease. The 
admirable description of the disease by Sir James Paget in 
the sixty-fifth volume of the Medico-Chirurgical Trans- 
actions, so fully agrees with my own cases, that I need not 
weary the Society with the details of the clinical histories 
of the cases shown to-night. Since 1876, when Sir James 
Paget drew attention to the disease, numerous other cases 
have been recorded, and evidence goes to prove that the 
disease is more ancient and of more common occurrence than 
was at first supposed. The reason why it was so long un- 
noticed is the fact that the disease occurs late in life and 
rarely gives rise to symptoms requiring active medical trieat- 
ment, death usually being due to some intercurrent disease. 
The majority of cases recorded have either occurred in public 
institutions or been discovered accidentally. 

The chief symptoms noticed by the patient are pains of a 
rheumatic character in the affected limbs, loss of height, and 
in male patients increased size of the head, rendering the hat 
too small. 

The facts which strike the eye of the observer are the large 
size of the head, prominent eyebrows and chin, drooping 
position of the head, the chin resting on the sternum or 
approaching it, the curvature of the long bones of the lower 
limbs, and the curvature of the spinal column. I beUeve these 
conditions are due to the fact that at some previous time the 
bones of support have lost their normal strength or solidity. 



1 



t " 



Mr. Lunn's Oases of Osteitis Deformans. 273 

I have drawn my conclusions from an extended observation 
of the disease daring life^ the conditions found after deaths 
and the changes which are shown to have taken place on ex- 
amination of the bones by the microscope. If we look at the 
bones themselves to see how to account for the weakness and 
curvature, we find a definite change in their structure sufficient, 
I think, to explain this yielding, in fact a great part of the 
natural firm bone has disappeared, and in its place is a large 
quantity of porous and spongy bone. In my fatal cases the 
morbid process was nearly universal, but its chief stress seems 
to have fallen upon the bones about the main axis of the body, 
the cranial vault, spine, pelvis and long bones of the lower 
limbs being most damaged, the face, fingers, and feet least. 
The absorption and disappearance of the original bone seems 
to have been the primary event in the course of the disease, 
and this must have taken place not by any coarse process^ 
but by very delicate interstitial changes. The latter had 
affected not only the compact tissue of the shafts, but also 
the cancellous tissue of the extremities of the bones. 

The formation of the porous bone must be regarded as 
secondary, but its presence is difficult to explain. As to the 
nature of the morbid process which produces the anatomical 
alteration, the view advanced by Sir James Paget is that it 
is a kind of chronic osteitis, which I believe has been gene- 
rally accepted. But while fully admitting that chronic in- 
flammation may have some share in the process, I scarcely 
can think that it altogether accounts for the changes found after 
death. The conclusions I have arrived at are that osteitis 
deformans consists of : 

1. A constitutional disease producing atrophy and absorp- 
tion of a large part of the osseous systems. 

2. Consequent weakening of fche bones, so that they yield 
when exposed to strain. 

3. Compensatory strengthening by the growth of what 
may be looked upon as a variety of callus. 

4. The occasional formation of definite tumours. 

5. A fatal cachexia. 

Case 1 (male) . PI. XI, fig. 3. — C. S., sBt. 75, a coachman by 
trade, married twice, but has had no children. He was ad* 
mitted May 10, 1884. Father dead, cause unknown; mother 
was a lunatic in Glasgow Asylum for many years before she died; 
one brother, who was quite well when he was last seen. The 
patient had been in the workhouse for fourteen years. He 
VOL. xvin. 18 



274 Mr. Lqud's Oases of Osteitis Deformans. 

was in Hanwell Lanatic Aaylnm seven years ago, for four 
years. Never had any serious illness, bnt states he suffered a 
good deal with his brain. 

It is imposeible to get a tmstworthy history of him. 
He has had one or two attacks of gout wlulst a patient here. 
The patient is very quiet and reserved in his manner and slow 
in his movements. He has the typical aspect of a case of 
" osteitis deformans ;" he walks with his ohm almost touching 
his sternnm and has some difficulty in turning his head to 
either shoulder. His shoulders are raised and thrown forward, 
he stands with tegs apart, his fingers are nearly on the level with 
his knees, his head looks too heavy for his body ; his chest 
small and square-shaped and does not move well. On breath- 
ing the costo-stemal cartilages appear ossified and his posture 
is similar to the photographs in the sixtieth volume of the 
Royal Medical and Chirurgical Society's Trartsactions. 

The head measures twenty-three inches in circumference 
at the widest portion, appears enlarged and bossy, the supra- 
orbital arches look enlarged and stand ont boldly, the facial 
bones appear free from disease at present. Both femora 
enormously enlarged and massive at their lower half, curved 
outwards and forwards. Both tibise appear in the same condi- 
tion, but the right is more advanced than the leftj the right 
leg measures thirteen and a half inches in circumference, the 
left thirteen inches. No ankylosis of knee- and ankle-joints ; 
the bones of the feet appear free from disease at present. 
Both humeri more thickened than naturaJ, bnt not much 
curved. The left radius and ulna thickened and curved with 
the convexity on the dorsal aspect; hands free. Some anky- 
losis of both shoulder-joints, and inability to raise the arm 
above the head. 

Both clavicles appear enlarged and thickened, and some 
irregularity at the acromial end of the left one, viz. old fracture. 
The pelvis feels broader than natural and both crests massive 
jtud thickened. 

All the ribs feel thickened and larger than natural ; inter- 
costal spaces small. Viscera appear normal, urine contains 
Tio albumen ; a small fatty tumour on the back of the neck. 

Case 2 (male). PI. XI, fig. 1.— H. S., set. 68, married, a 

labourer, was admitted into the Marylebone Infirmary, July, 
1884, with an ulcer of leg. Father died at the age of seventy; 
mother died at ninety, causes unknown; one brother subject to 
lut, another said to have died of cancer in Paddington Infir- 



Mr. Lunn's Oases of Osteitis Deformans. 275 

mary^ fourteen years ago. (I am not able to find any notes of 
this case there.) 

The patient has always enjoyed good healthy with the excep- 
tion of a winter cough, and a bubo which he had thirty years 
ago (scars still in the left groin). He thinks his hat has got 
too small of late, suffers from pains of a rheumatic character 
in both legs, generally worse at nights. The last eighteen 
months he noticed his legs curving and thinks he is getting 
shorter ; his height at present is five feet five and a half inches. 
Enlarged glands in both groins. Superficial and deep reflexes 
normal. JNo ansBsthesia, walks with his head inclined forwards 
and downwards, his chest seems small and square shaped, his 
arms hang low. His shoulders are raised and the upper dorsal 
vertebrsB appear curved and rigid, giving him the appearance 
of having an angular curvature of his spine. Both femora 
curved forwards and outwards and thickened at the lower 
half. When he stands with his feet touching, the distance 
between the two internal condyles is three and a quarter 
inches. Both patellae normal. Both tibisB seem enlarged and 
their anterior borders rounded. The right measures fourteen 
and a quarter inches, the left fourteen inches. Feet quite free at 
present. No ankylosis of hip-, knee-, or ankle-joints. Neither 
arms nor forearms seem affected. The clavicles seem thicker 
and more massive than natural. The head appears enlarged at 
every part and measures at the widest circumference twenty- 
two inches. The orbital arches look larger than natural, bones 
of the face appear free from disease. No disease of viscera 
with the exception of bronchitis; urine normal. Ectropion 
of both lower lids. Since examining the above case I have 
seen his brother, James S — , aged 68, who tells me that he 
has noticed his own head getting larger and his hat seems too 
tight for his head. I find both femora enlarged in their lower 
halves, and the right clavicle is decidedly larger than the left. 
Now and then suffers from attacks of gout. 

Case 3 (female). — S. S., set. 53, a woman, married, ad- 
mitted into St. Marylebone Infirmary for rheumatism j father 
and mother both dead ; causes unknown ; has had four chil- 
dren, one daughter still living and quite well. No miscarriages 
or difficult confinements. No history of gout, consumption, 
syphilis, or cancer in the family. Always had excellent 
health until ten years ago, when she says she was frightened 
by the Regent^ s Park explosion, and was struck in the back 
by a Venetian blind ; she states that whilst in bed she has 



276 Mr. Lnnn's Oases of Osteitis Deformcms. 

grown shorter^ also her legs have gradnally become bent and 
thighs thicker. They have been crossed for four years, and 
she has been confined to bed for the last twelve months, and 
is rapidly becoming more helpless, bent, and in pain. 

The patient is just able to stand with her legs crossed, the 
left over the right ; her chin inclines towards her suprasternal 
notch, she is not able to rotate her head from side to side. 
Her trunk seems very short, there seems a good deal of ten- 
derness over the lower dorsal vertebrsB, and over the right 
arm, where pressure is made. She thinks her head is larger 
than it ought to be. Both femora are curved and thickened, 
ankylosis of both hip- and knee-joints (the latter only I 
think is due to being confined in bed) ; generally lies with 
her left foot out of bed. Both clavicles enlarged and thickened, 
the right seems larger than the left. The right humerus 
feels thickened and solid, curved on its posterior sur&ce (the 
patient generally rests on her right arm, the circumference of 
which is nine inches). The left humerus not so much affected. 
The right elbow-joint is stiff, and gives the patient a good 
deal of pain when moved ; both radii and ulnsB curved in their 
posterior surfaces. Bight hand and wrist stiff, and skin over 
hand and fingers very glossy and tense ; left hand seems free 
from disease. The head measures twenty-three inches in cir- 
cumference at the widest part and looks too heavy for her 
body, and feels bossy over the parietal regions. The chest is 
very square-shaped, and the last ribs seem nearly to touch the 
crest of the ilium. The ribs appear broadened and nearly 
touching each other, costal cartilages ossified ; the pelvis much 
wider than normal and both crests of the ilia appear thickened 
and massive. The patient weighs 7 st. 4 lb. Urine normal. 
Slight bronchitis, liver slightly displaced and other viscera 
normal. 

Case 4 (female). PI. XI, fig. 2. — M. W., sBt. 70, married, 
was admitted September 20th, 1884, into St. Marylebone In- 
firmary with bronchitis. Granular lids, and the right eye 
destroyed from old inflammation, commencing cataract in the 
left eye with some old choroiditis, i.e. senile. My attention was 
drawn to the condition of her legs by the nurse of the ward, as 
she seemed to resemble the patient (Case No. 8) in thenext bed, 
who was suffering from osteitis deformans. The patient has 
had four children, two sons and two daughters (one of whom 
has been a patient here with diphtheria, and who seemed rather 
weak-minded) ; no history of insanity, syphilis, or cancer. 



Mr. Luim's Oases of Osteitis DeformanSi 277 

The last two years she has noticed her legs becoming 
gradually bent and has suffered from shooting pains, which she 
attributed to rheumatism. Her attitude resembles the two male 
patients. Cases 1 and 2. Her chin inclines towards the sternum, 
and her head looks too large for her body ; shoulders are raised 
and thrown forwards; Ues in bed with her legs crossed, the right 
resting on the left. Her chest is square-shaped and moves a 
little on respiration ; the ribs seem larger and broader than 
natural. Both clavicles feel massive and enlarged ; the bones 
of the upper extremity are not much affected yet. No anky- 
losis of shoulder- or elbow-joints. Both femora are bent, but 
not so much thickened as Cases 1, 2, and 3. Head measures 
twenty-two inches in circumference ; both tibisB are bent and 
not much thickened, their anterior borders feel rounded, feet 
free from disease. Both patellse normal and movable; the 
pelvis seems thickened and rounded. Bones of the face appear 
normal at present; urine contains no albumen or sugar; 
bronchitis signs in chest. 

Case 5. — Since preparing my paper the brother of Case 
No. 2 has come under my care for gout, from which he has 
suffered a good deal at times. 

J. S., 8Bt. 65, married, no children, no history of syphilis. 
Has been always a hard worker, but lately he has noticed his 
hat getting too tight, but has never noticed his legs curving. 
The right femur (lower half) seems larger and more massive 
than natural. Both clavicles feel enormous : chest square- 
shaped and ribs appear broader than natural. His head looks 
large and his supra-orbital arches stand out prominently. He 
cannot move his head well from side to side. Feet and upper 
extremities appear free at present. 



278 Dr. Oayley^s Ctise of B-SsmopiAfsia, 



XXXVI. — A Case of Hamoptysis treated by the Ind/uc- 
tion of Pneimiothorax so as to Collapse the Limg. 
By W. Caylby, M.D. Bead May 8, 1885. 

FEEDERIOK W., aet. 21, a porter, was admitted into the 
Middlesex Hospital on February 9, 1885. 
Family history. — Father and other relatives suffer from 
rheumatism. A cousin on the father's side died of consump- 
tion. Mother dead, but he does not know from what disease. 
Has six sisters who are all alive and well. 

Previous history, — Had rheumatic fever at the age of 11, 
and has been liable to rheumatic pains ever since, but has 
otherwise been strong and healthy. Had another attack of 
rheumatic fever last winter, and was an in-patient in this 
hospital from December 18 to December 29. Nothing wrong 
was noticed with his lungs while in the hospital, and there was 
no cardiac complication. He has since suffered from a slight 
cough, but his general health has been good. 

Present attack, — On February 7 he was at work in his 
usual health. At nine in the evening he had an attack of 
hasmoptysis, which recurred the following noming, and again 
in the night of the 8th. He estimated the whole quantity 
which he brought up as about a pint. 

State on admission, — Patient was a pale-faced young man, 
well nourished and of good muscular development, pulse 96, 
resp. 18, temp. 100°. He was quite free from malaise, tongue 
clean, appetite good, breathing tranquil. The expansion of 
the left side of the chest was very deficient, and the breath- 
sounds in front were extremely feeble ; percussion was not 
attempted. Heart-sounds were normal. 

Shortly after his admission he coughed up about 2 oz. of 
florid blood. 

He was ordered to keep the recumbent posture, ice was 
applied to the left front, and he was ordered gr. x of gallic 
acid every three hours. 

At 11.30 P.M. he coughed up about 2 oz. of florid blood 
and some clots. He was given a grain of ergotine subcuta- 
neously. 



Dr. Oayley^s Case of Ssamopiysis. 279 

February 10. — Slept well, is free from malaise, has a slight 
cough and spits transparent bronchial mucus containing pellets 
of blood. Expansion of left side of chest extremely deficient, 
and breath-sounds very weak. Over the scapular region there 
is dulness on percussion and feeble bronchial breathing. 
These signs were attributed to the lung being clogged with 
blood. 

At 2.30 P.M. he coughed up 4 oz. of bright red blood, and 
at 9 P.M. 6 oz. more, and he continued to spit blood in small 
quantities during the night. Two hypodermic injections of 
ergotine were administered, and a sixth of a grain of morphia. 

February 11. — ^Pulse 84, resp. 18, tranquil, slept fairly, 
crepitant r&les, attributed to blood in the bronchial tubes, are 
audible all over the left back. At 1 p.m. he coughed up 8 oz. 
of florid blood. Ghr. j of ergotine was administered subcuta- 
neously. Ordered v\. x of 01. Terebinth, every four hours. 

February 12. — Has brought up no large quantity of blood 
since yesterday afternoon. Expectoration is viscid and blood- 
stained. Last night, and again this morning, had retention 
of urine necessitating the use of the catheter. Urine turbid 
with lithates, not albuminous, slept well, feels comfortable. 
Pulse 80. 

At 8 P.M. he brought up 8 oz. of blood, and at midnight 
6 oz. After each was given a hypodermic injection of 
ergotine. 

February 13. — ^Pulse 72, resp. 20, tranquil, slept fairly well, 
but required the catheter. Has brought up during the night 
about an ounce of viscid blood-stained mucus, has no malaise, 
but has become very ansBmic. During the day he coughed up 
16 oz. of florid blood. 

February 14. — ^At 5 a.m. he brought up 6 oz, of blood. 
Sputa still viscid and blood-stained. Pulse 84, dicrotic. 

Expansion of left side continues very deficient, breath- 
sounds very feeble, and accompanied, both back and front, with 
moist r&les, dulness, and feeble bronchial breathing over 
scapular region. 

Ordered gr. x of pot. iodide with rn.. x of 01. Terebinth., 
three times daily. 

At 3 P.M. brought up 8 oz. of blood. Ergotine gr. j was 
administered subcutaneously. 

February 15. — ^Pulse 112, dicrotic; resp. 20, tranquil; 
passes urine naturally. 

At 10.30 P.M. brought up 9 oz. of blood. 

February 16. — ^Pulse 100, weak and dicrotic; resp. 28, 



280 Dr. Cayley's Omb of Hsemopiyda. 

tranquil. Is mncli blanched^ complains of feeling oE weakness^ 
is tlursty and has a sensation of tightness across the stemnm. 
Gongh less troublesome^ sputa continue viscid and blood-stained. 
Urine turbid with Uthates^ sp. gr. 1030. 

Ordered infusion of digitalis^ 2 drachms^ three times daily ; 
ergotine to be discontinued. 

February 17. — ^Brought up 6 oz. of blood in the night. 
Pulse 104^ resp. 32. Condition much the same. 

February 18. — Has brought up 4 oz. of blood. 

February 19. — Had an attack of profuse haemoptysis in the 
night, bringing up 24 oz. of florid bl<x)d. Is much blanched 
and very weak. Pulse 108, dicrotic ; resp. 18, urine, sp. gr. 
1035, loaded with lithates. 

February 20. — Continues much in the same state, has had 
no haemoptysis, but the sputa continue blood-stained, of a some- 
what brownish colour. Ordered r\, xx of Liq. Ferri. Pemitrat. 
three times daily. 

Patient now had no return of the haemoptysis till the 26th, 
and during this time his general condition decidedly improved, 
though, as will be seen by the chart, he had slight evening 
febrile exacerbations. The anaemia became less marked, the 
pulse of better quality, he took his food well, and expressed 
himself as feeling much better, the expectoration continued 
blood-stained and the physical signs remained much the same. 

At 8 A.M., February 26, he had another attack of haemo- 
ptysis, bringing up 12 oz. of florid blood. There was no return 
till March 2, when, at 2.30 p.m., he again had a profuse attack, 
bringing up 32 oz. The blood came up in gushes, and he 
seemed in great danger of being suffocated. The blood was 
bright red and frothy, and rapidly coagulated. After this he 
was much exhausted and was again extremely blanched. 

March 3. — ^Pulse 112, dicrotic ; resp. 24, tranquil. Is in 
much the same condition. 

March 4. — ^Pulse 96, dicrotic; resp. 20. Expectoration 
more profuse ; it presents the same blood-stained character. 
Complains of pain in the second left intercostal space above 
the nipple. At 11 p.m. he brought up 12 oz. of blood. 

March 5. — ^Pulse 92. Pain in chest subsided after the 
haemoptysis. 

March 6. — Brought up 3 oz. of blood in the night. 

March 7. — No return of the haemoptysis. 

March 8. — ^No return of the haemoptysis, feels better. At 
4.30 P.M. brought up 10 oz. of blood. 

March 9. — At 9.30 a.m. brought up 8 oz. of blood, is very 



Dr. Caylej^s Oase of KamopiyBia. 281 

prostrate and ansBmic. Pulse 104^ small and dicrotic ; resp. 36^ 
laboured. Scarcely any expansion of left side of chesty coarse 
r&les heard all over left front and axillary region^ and now 
numerous moist r&les^ finer than on the left side^ are audible 
over the right front and axilla. It was not considered safe to 
raise him in order to examine the back. 

March 10. — ^Patient had another attack of haemoptysis 
this mornings bringing up 4 oz. His condition was now one 
of great prostration. He was much blanched^ pulse 96^ very 
small ; resp. 28^ temp. 98*6^^ and it was evident that he would 
soon succumb to repetition of the hsBmoptysis^ the source of 
which was considered to be in all probability either a pulmo- 
nary aneurysm or the ulceration of an artery of some size in the 
left lung. He had brought up^ since his admission^ a gallon 
of blood besides a large quantity of blood-stained sputum. 

The moist r&les which had become audible first over the 
left^ then over the right lung were attributed to the presence 
of blood in the bronchial tubes. Acute tuberculosis was 
considered as excluded by the absence of emaciation^ the 
slight amount of general constitutional disturbance^ the tranquil 
breathings and the very moderate degree of fever. 

It appeared to me that if the left lung could be collapsed^ 
the consequent great diminution of the circulation through it 
would afford a fair prospect of arresting the hsBmorrhage. It 
would^ moreover^ probably cheeky at any rate for a time^ the 
development of tubercle in this lung^ supposing such to be in 
progress. The extreme anaemia of the patient would^ I thought^ 
render this proceeding less dangerous^ as less oxygen would 
be required for the aeration of the bloody and he would there- 
fore be better able to support the collapse of the lung. 

Accordingly^ at 6 p.m. on the lOth^ chloroform was 
administered^ and Mr. Hulke made an incision over the sixth 
intercostal space^ an inch behind the anterior axillary f old^ and 
opened the pleural cavity^ and then introduced a double tube 
made by uniting two pieces of elastic catheter about 3 inches 
long by means of a shield; the opening was protected by a 
small cage lined with carboUc gauze^ and the whole covered 
by a carbolized gauze bandage. The operation was performed 
under the carboUc spray with all the usual antiseptic precau- 
tions. The air passed freely in and out of the tube and the 
apex of the heart became displaced to the mid-sternal region. 
The respirations at the same time became much accelerated. 

In the night following the operation he twice brought up 
blood, 4 oz. and 2 oz. 



282 Dr. Cayley's Case of Hsemopiyais. 

Marcli 11. — ^Has slept well after a hypodermic injection of 
morphia. Pulse 112^ resp. 48^ jerky in character. There is 
tympanitic resonance over the left front. 

March 12. — ^Pulse 128, resp. 44. Tympanitic note over 
left front less marked, and breath-sounds more audible. The 
tube was found to be completely blocked with fibrinous mate- 
rial ; it was accordingly removed and a silver tube, in form like 
a flattened tracheotomy tube, was introduced in its place. 
The air now passed in and out freely, the resonance became 
markedly tympanitic, and a bell-sound could be elicited. The 
breathing over the left front became inaudible. 

After the introduction of the silver tube he complaiued of 
much pain, which was relieved by a hypodermic injection of 
morphia. His temperature rose to 104'6°, and much serous 
fluid began to flow through the tube. 

March 13. — At 10 p.m. last night the silver tube was 
removed. Much serous fluid had flowed through the wound. 
He passed a good night, but is very prostrate this morning. 
Pulse 128, resp. 52. Sputa less abundant, continue to be 
glairy and blood-stained. Physical signs unaltered. 

March 14. — ^Pulse 120, resp. 40. Slept pretty well after 
morphia, but sweated a good deal. Serous fluid continues to 
ooze from the wound, but in smaller quantities. Physical signs 
unchanged. 

March 15. — Pulse 124, very feeble; resp. 44, irregular and 
jerky. This morning had a severe attack of dyspnoea which 
was relieved by a hypodermic injection of morphia. There is 
still tympanitic resonance and absence of breath-sounds over 
the left front. The apex-beat can be felt at the fourth inter- 
space, immediately to the right of the sternum. Abundant 
crepitation is present over the right front. Serous fluid con- 
tinues to ooze from the wound. At 3.45 p.m. he died quite 
suddenly, having previously seemed rather better. 

Post-mortem examination. — There were firm fibrous adhe- 
sions at the left apex which extended down the posterior 
border of the upper lobe to below the interlobular fissure. 
The anterior extremity of the lower lobe was also adherent to 
the parietal pleura. This had evidently prevented the com- 
plete collapse of the lower lobe towards the spine. The col- 
lapse extended over the greater part of the lower lobe and 
the lower part of the upper one. The pleural surfaces were 
in a state of inflammation and covered with recently effused 
lymph, but there were only two drachms of non-purulent 
fluia in the cavity. There was a free opening into the pleural 



Dr. Cayley^s Case of Hs&moptysia. 28t) 

sac^ wliich wonld admit the finger^ through the left sixth 
interspace. 

The left apper lobe was partially divided by a fissure into 
two lobes. In fche extreme apex was a small cavity with 
smooth walls round which the lung was puckered. The whole 
lung^ except quite at the base^ was thickly studded with grey 
miliary granules. 

In the lower part of the upper lobe^ two inches from its 
anterior extremity and abutting on the interlobular septum^ 
which was bulged downwards by it^ was a cavity the sise of a 
walnut^ filled^ except at its centre, bv concentric layers of 
tawny fibrin, so as closely to resemble an aneurysm. In 
the centre of this laminated clot was a small round cavity 
containing some loose black coagula, and this communicated 
with a considerable branch of the pulmonary arterv. A large 
bronchus opened into the cavity in the lang which contained 
the laminated clot, but there was no communication between 
the cavity in the centre of the clot and the bronchus, though 
at the upper part the clot was soft and had no doubt reoeutiy 
allowed a communication to take place. No trace of any 
aneurysmal sac could be detected, the cavity in the luuff had 
a smooth wall and showed but little trace of any chronic disease 
round it. 

The right lung showed no signs of old tubercular disease^ 
but was thickly studded with recent grey miliary granules. 
The other organs were normal. 

As the case turned out to be one of acute miliary tuber* 
culosis, it is evident that no treatment could have prevented 
a fatal termination, and the patient did not live long enouffh 
to enable any positive conclusions to be drawn as to the 
effects of the operation on the haemoptysis. He had two 
attacks in the night following the operation, but no subse- 
quent recurrence, and the post-mortem examination showed 
that the communication between the false aneurysm and the 
bronchus was closed, and not improbably, if the patient had 
lived, complete solidification of the aneurysm would have 
taken place. The lung round the aneurysm was quite 
collapsed. 

When we consider how largely the pulmonary circulation 
is influenced by the respiratory process, and the small amount 
of blood which circulates through a collapsed lung, I think 
such a mode of treatment affords a fair prospect of arresting 
otherwise uncontrollable haemorrhage. Extensive consolida- 
tion of the lung would no doubt, by preventing the collapse 



284 



Dr. Cayley^s Oase of Hwmoptysia. 



of the lung^ be a contra-indication^ and thus would restrict 
the applicability of the operation to a few cases. The proba- 
bility of exciting pleurisy is of course another objection. In 
this case^ notwithstanding antiseptic precautions^ pleurisy was 
set up^ but it was of a non-suppurative form^ and but for the 
tuberculosis would not^ I think^ have added much to the 
patient's danger. 

Temperature^ pulse, and respiration. 







Temp. 


False. 


Reap. 




Temp. 


Pulse. 


Aesp 


Feb. 










Feb. 








9.— M. 


• • • 


100-0** 


• • • cfO ... 


18 


26.— E. . . 


. 100-6° 






£. 


• •• 


100-6 






27. M. .. 


99-0 


... ffO . . ■ 


20 


10.— M. 


• •• 


99*2 






E. .. 


. 102-2 






£. 


• • • 


101-0 






28.— M. .. 


99*0 






11.— M. 


• • • 


98-4 


..• o4 ... 


18 


E. .. 


. 100-6 






E. 


• • • 


100-0 






March 








12.— M. 


• • • 


97-8 


... 80 




1.^— M. .. 


. 99*6 


... 80 




£. 


• • • 


98-8 






E. .. 


. 100*4 






13.— M. 


• • • 


98-2 


... 72 ... 


20 


2.— M. .. 


99-2 


... ItO ... 


18 


E. 


• • • 


101-8 






E. .. 


. 100-4 






14.— M. 


• • • 


98-6 


... 84 ... 


20 


8.— M. .. 


. 99-6 


... 112 ... 


24 


E. 


• • • 


100-6 






E. .. 


. 101*6 






15.— M. 


• •• 


102-8 


... 112 ... 


20 


4.— M. .. 


. 98-2 


... W} ... 


20 


E. 


• • • 


100-2 






E. .. 


. 101-6 






16.— M. 


• •• 


100-0 


... 100 ... 


28 


5. — M. . . 


. 98-6 


... 92 




£. 


• • • 


100-0 






E. .. 


. 101-6 






17.— M. 


• •• 


100-2 


... 104 ... 


82 


6. — M. .. 


98-2 


... 96 




E. 


• ft 


1020 






E. .. 


. 101-6 






18.— M. 


• • . 


990 






7.— M. .. 


99-2 


... 


36 


E. 


• • • 


101-2 






E. .. 


. 101-2 






19.— M. 


• • • 


101-0 


... 108 ... 


18 


8.— M. . , 


. 99*0 






E. 


• • • 


103-2 






E. .. 


. 101-6 






20.— M. 


• • • 


98*6 


... sK> ... 


20 


57.^^Jll. . . 


. 98-6 


... X v4 ... 


88 


E. 


• •• 


99-6 






E. .. 


. 102-0 






21.— M. 


• • • 


98-6 


... 92 ... 


24 


10.- M. .. 


98-6 


• . . (70 ... 


28 


E. 


■ • • 


100-0 






£. .. 


. 102-6 


. . . 128 


44 


22.— M. 


• • • 


97-8 


... 104 ... 


20 


ll.-M. .. 


. 100*4 


... 112 ... 


48 


£. 


• • • 


99*8 






£. .. 


. 102*4 






28.— M. 


• • • 


97-8 


... 76 ... 


20 


12.^M. ., 


. 101-2 


. 128 ... 


44 


E. 


• •• 


101-0 






E. .. 


. 108-8 






24.— M. 


• • • 


98-0 






13.— M. .. 


. 101*4 


... xmO ... 


52 


£. 


• •• 


101*0 






E. .. 


. 102-8 






26.— M. 


• •■ 


98*0 


... ov .•* 


18 


14.-M. .. 


99*6 


• . • Xwv ... 


40 


E. 


• • • 


101-8 






E. .. 


99*0 






26.— M. 


• • • 


99*4 






16.— M. .. 


. 100-0 


... xJni ... 


44 



Mr. Symonds's Oaae of Removal of Oalcuhis. 285 



XXXVII. — A Case in which (at the suggestion of the 
late Dr. Mahomed) a Calculus was removed from the 
Vermiform Appendix for the relief of Recurrent 
Typhlitis. By Charters J. Symonds, M.S. Read 
May 8, 18S5. 

CHAELES S.^ 8st. 23^ basket-maker^ was admitted into 
Philip Ward, Guy^s Hospital, under the care of Dr. 
Mahomed, July 16, 1883. The following history which he 
gave of himself, and all the early clinical notes, are com- 
piled from the careful report made by Mr. Vernon. 

Both parents were dead, the one from heart disease and 
the other from cancer of the uterus. Two sisters were living. 
Two years ago he had typhoid fever. Six months ago 
(January, 1883) he was seized during the night with pain in 
the right iliac region; this increased in severity and he 
became ill generally, and at the end of a week was uncon- 
scious, remaining in this state four days. The illness lasted 
seven weeks. During the first week he vomited everything, 
and his bowels were not opened for ten days, and the whole 
time there was great tenderness in the right iliac fossa. 
Daring the latter part of this illness he was in the Camber- 
berwell Infirmary, where he was told he had typhlitis. When 
he got up he observetd a hard lump in the right groin, about 
the size of a walnut ; sometimes this was tender^ but for the 
most part painless. Since this illness he has had repeated 
attacks of pain, which come on suddenly and last one or two 
days. At first these attacks recurred about once a month, 
but during the last five weeks he has had six, and they have 
been increasing in severity. Three days before admission 
(July 13) he was seized while at work with severe pain in 
the right iliac fossa, which he said ^' doubled him up." He 
felt sick but did not vomit, and was obliged to leave 
his work. He applied poultices with turpentine and obtained 
some relief, remaining in bed till the day of his admission 
(July 16). 

On admission there was to be felt in the right groin on 
deep pressure a smaU^ hard (slightly tender) lump, two inches 



286 Mr. Symonds's Case of Removal of Calculus, 

long, and parallel with Poapart's ligament, and three fourths 
of an inch wide. His bowels acted regularly, and all his 
organs appeared healthy. The man was placed on a fluid 
diet, was soon relieved of all pain, and by July 20 he was up. 
About this time I was asked by Dr. Carrington, who was tem- 
porarily in charge for Dr. Mahomed, to see the case with a 
view to some operative interference. We decided, however, 
that, as the case was recent, there was a fair probability of the 
com'plete disappearance of the swelling and so of the recurrent 
attacks of pain. 

On July 26 pain returned in the groin and continued up to 
the 30th, occasionally shooting over the abdomen. It was 
increased by resting on his left side. The abdominal walls 
became rigid and the swelling enlarged. He was again re- 
stricted to a milk diet, had opium internally and hot fomenta- 
tions over the abdomen. On the 30th he was much better, 
and the lump could again be felt, and by August 4 it had 
decreased to the size observed on admission. 

Dr. Mahomed, having returned^ considered fully the ques- 
tion of operation, to which the man had no objection whatever 
so long as there was a prospect of being relieved from the 
recurrence of pain, which prevented his continuing long at his 
work. Dr. Mahomed proposed that the appendix should be 
approached by an incision in the right iliac region, as he was 
strongly of opinion that there existed an abscess-cavity con- 
taining a concretion, and that the periodical occlusion of a 
communication with the C83cum determined the recurrence of 
pain and the symptoms of peritoneal irritation. This view 
was strengthened by the apparent enlargement of the swelling 
during the attack observed in the hospital, and by the fact 
that the sweUing remained dull on percussion. I was of 
opinion myself that while the small lump to be felt was pro- 
bably a concretion, that the recurrent attacks were due to 
some peritoneal adhesion or band constricting the last por- 
tion of the ileum. On account of urgent home affairs the 
man left the hospital on August 10, to return as soon as 
possible. 

On August 11, the day after his return home, he resumed 
work, and after two hours was seized with the old pain and 
obliged to go to bed. The next day (August 12) he was re- 
admitted, with extreme tenderness in the right iliac region, 
shooting nains across the abdomen, and a temperature of 
102*1®. He was placed on a milk diet with opium. On the 
18th the pain was less, but the tenderness remained, and there 



Mr. Symonds's Odse of Removal of Oalculus. 287 

was a visible swelling above Poupart's ligament too tender 
for manipulation. 

August 14. — The swelling was hard^ with a distinct upper 
edge^ about two inches and a quarter above Poupart's liga- 
ment^ with which structure it ran parallel for about three 
inches. 

August 16. — He was easy again^ and on the 18th the lump 
decreased to its smallest size. 

As everything now seemed quiescent we decided to explore 
the swelling through the iliac fossa. Dr. Mahomed planned 
the operation^ and it was on his recommendation that the 
incision adopted was selected. The lump was oval in shape^ 
could be distinctly felt, but could not be taken hold of ; it was 
well defined and only slightly tender. We concluded that we 
had to deal probably with a concretion, but whether it lay 
inside the appendix or rested in a cavity bounded by perito- 
neal adhesions and bowel it was impossible to say. We also 
thought that it might be a small abscess, with or without a 
concretion. Our plan was to approach the mass from behind, 
to remove a calculus if present, or to drain the cavity should 
we find pus. 

On August 24 chloroform was administered, and under the 
carbolic spray an incision was made, commencing two inches 
above and one internal to the iliac spine, curving downwards 
and forwards for about four inches, being much like that used 
in ligaturing the external iliac artery. It was so arranged 
that its centre corresponded with the position of the swelling. 
The various structures were divided and all recognised dis- 
tinctly, except the transversalis fascia. Being particularly 
anxious to avoid the peritoneum, the structures were at once 
raised out of the iliac fossa, when the lump was plainly felt 
as a hard rounded body. A hand pressed deeply from the 
front steadied the swelling and brought it further into the 
wound. A vertical incision was now made down on to the mass 
and a hard and calcareous body exposed. Before removing 
the calculus a fine silk suture was passed through the tissues 
just above the opening, lest when the body was extracted we 
should lose the entrance into the cavity. The opening was 
now enlarged and a calculus removed. No pus at all was 
seen, and the cavity from which the calculus was removed 
seemed smooth and free from deleterious material. The soft 
and purplish lining was evidently mucous membrane, and as 
moreover we could trace the tortuous and cord-like appendix 
upwards towards the caacumi there seemed no room to doubt 



288 Mr. Symonds's Oase of Removal of Calculus. 

that the appendix had been opened. Exploration of the 
cavity, which seemed only large enough to contain the cal- 
cnlns, failed to detect a channel leading towards the caBCum 
or in any other direction. There was no fsBcal or other un- 
pleasant odour. We therefore decided to close the aperture 
in the appendix, which was done by silk sutures introduced 
after Lembert's manner. Our object in doing this was to 
diminish the chance of a fascal fistula. At no time did we 
recognise the peritoneum, so that we presume the cavity lined 
by this membrane was not opened. It appeared that the 
appendix had become adherent to the parietal peritoneum, 
and that through the adhesions we had entered its canal. It 
was the probable existence of such an arrangement that led 
us to approach the concretion from behind. The wound was 
closed by deep silk sutures, a large drainage-tube inserted, 
and the usual gauze dressings applied. The calculus is oval 
and much like a small bird's egg. It measures three quarters of 
an inch by half an inch. It had a brownish-yellow colour well 
shown in the drawing (Plate IX, fig. 4). On section it shows 
a laminated capsule, enclosing an irregular mass of putty-like 
material which has partly shrunk away from the wall. This 
gave a slightly fadcal odour when sawn through. The calca- 
reous material is composed of phosphate of lime. 

August 26. — First dressing. Tube removed, freed from 
coagulum and reinserted. Some of the sutures were loosened. 

August 28. — Second dressing. Tube removed, as there 
was every sign of primary union ; no f fflcal odour from lower 
end of tube. 

August 29. — He had for two days been complaining of 
aching pain in the wound, which became severe on this day. 
The respirations were hurried and the abdomen hard, but 
there was no sickness and no fever. The opium he had been 
taking was renewed. 

September 1. — Some pus escaped from the wound, and 
he was relieved. A fresh tube was introduced and two sutures 
removed. The pus had no fsBcal odour. 

September 5. — He was nearly free from pain, the tube 
was shortened to an inch and a half, and the wound was 
healing. 

September 11. — He had pain again, probably due to the 
retention of a Uttle pus. 

September 14. — He was free from pain and was on full diet. 

September 20. — He got up, a small scab only remaining 
over the centre of the incision. 



Mr. Symonds's Case of Removal of Calculus. 289 

September 25. — After walking about the ward lie felt 
something escaping from the wound and had pain all that 
night; the next morning it was found that about two 
drachms of pus had escaped from the wound. The antiseptic 
dressings, which had for some time been discontinued, were 
reapplied, and as the pain was still severe the wound was 
reopened by a probe and a piece of small drainage-tube 
inserted. 

October 7. — He was discharged at his own request. There 
remained some induration to be felt on deep pressure, but the 
wound had apparently healed. 

During the whole of his stay the temperature never rose 
above 99"4° F. Fearing some further trouble might arise so 
long as any perceptible induration remained, and being alive 
to the possibility that the real cause of all his pain might still 
exist, he was directed to return at the first sign of a recur- 
rence of his former symptoms. 

The man resumed work in a fortnight, and suffered no 
inconvenience till November 3, when he had a return of the 
old pain in the iliac region; gradually it spread as before 
over the abdomen and became so severe that he was obliged 
to take to his bed. Two days later he observed a yellowish 
fluid escaping from the sinus. 

He was readmitted into Job Ward under my care on 
November 5th. There was a sinus (three inches deep) dis- 
charging a thin yellowish fluid, and the hard swelling still 
remained. By November 11 he had improved, and now we 
could feel the appendix passing upwards from the induration 
beneath the centre of the scar. The rounded swelling that 
had been observed before November 3, and which had varied 
in size, had now completely disappeared. On November 22 
he was discharged, the sinus having closed and the man being 
in good health. He soon after returned to his work, and when 
last seen some weeks later he had been able to follow his occu- 
pation without any pain. There was at this time scarcely any 
induration to be felt, no more than could be explained by a 
deep cicatrix. When last heard of, April 1885, though an 
inmate in the Barming Heath Lunatic Asylum, he was well 
as regards his old disease, and had never had any trouble since 
November, 1883. 

Remarks. — I believe I am correct in saying that this is the 
first case in which a concretion or calculus has been removed 
from the appendix vermiformis without, at the same time, the 

VOL. XVIII. 19 



290 Mr. Symonds^B Case of Removal of Calculus. 

opening of an abscess^ and the credit of whatever value rests 
in the procedure must be given to my late and lamented col- 
league^ Dr. Mahomed^ at whose suggestion the operation was 
undertaken^ and who further advised the inguinal incision^ in 
opposition to that in the linea semilunaris proposed by myself. 
It is a matter to me of great regret that I am deprived of the 
association of Dr. Mahomed on this occasion^ and his untimely 
death has lost to us much information upon disease of the 
appendix^ more especially with a view to operation, which I 
know he was collecting. That the operation in this case was 
justified I think few will deny, when it is remembered how 
frequently a concretion is found to be the cause of fatal 
typhlitis. This f secal concretion was present in eleven out of 
seventeen fatal cases, in all of which the disease originated in 
the appendix, either as a sloughing ulcer with a concretion, 
or a sloughing ulcer without a concretion. I mention this to 
exclude tubercular ulcers. I think this case so individual that 
it is not expedient to attempt to formulate conditions under 
which we should undertake similar operations. The guide 
throughout was the hard mass, and without this I scarcely 
think we would have undertaken the proceeding. In none of 
the eleven cases mentioned above was the concretion calca- 
reous, so that I imagine it is rare to find a calculus, and so it 
will not be often that the foreign body in the appendix will 
serve as a guide. We directed our dissection to the posterior 
Bur&ce of the caecum and appendix, not because we imagined 
that under normal circumstances we might avoid the perito- 
neum, but because here, if anywhere, we would probably meet 
with adhesions, and so possibly enter a cavity containing the 
appendix and concretion shut oB. from the general peritoneal 
cavity. Again, without such a guide as we had in this case 
there would be great uncertainty in reaching the appendix, 
when we remember how variable is its position. Though it is 
not my intention to enter to-night into the general subject of 
surgi(^ interference in typhlitis, I would, after the study of 
twenty-three fatal cases, and with a knowledge of how fre- 
quently large iliac swellings due to typhlitis disappear, sug- 
gest that some cases at least might be saved by earlier inci- 
sion, before, I mean, fluctuation is felt. Such cases are 
recorded, and success has followed the treatment. This 
treatment has been more especially advocated by American 
physicians, and applies chiefly to those cases where there is 
iliac fulness, and the low general condition resulting from the 
accumulation of pus, the case at the same time lasting longer 



Mr. Symonds's Oase of Removal of Calculus. 291 

than nsaal. The diflSculty very often in diagnosing the cause 
of sudden abdominal pain, and the number of cases of typhlitis 
that recover will, I imagine, long deter us from opening the 
abdomen and removing the appendix, and yet post-mortem 
inspection shows that if such a procedure could be undertaken 
a recovery might have been possible in some otherwise hope- 
less cases. 



292 Mr. Lawson^s Case of CEsaphagotomy, 



XXXVIII. — (Esophagotomy for the Bemoval of a Plate 
vnth three Artificial Teeth which had been acciden- 
tally swallowed^ and was impacted in the (Eso- 
phagus. By Geo&qe Lawson. Bead May 22, 
1885. 

MARY N., aet. 55, a milkwoman, was admitted under my 
care into Queen Ward, Middlesex Hospital, on January 
14, 1885, having about half an hour previously swallowed a 
plate with three false teeth. 

On examination externally something hard could be felt in 
the oesophagus, about the level of the cricoid cartilage, by 
deep pressure with the fingers on the left side of the neck. 
The patient was brought into the theatre, and I tried to catch 
the foreign body with a pair of long curved oesophagus 
forceps, but although I could just feel the plate, yet I could 
not grasp it, so I decided at once to open the oesophagus. 
The patient having been placed under chloroform, a long No. 
10 elastic catheter was passed into the oesophagus, so as to be 
used as a guide if necessary. The patient^s head being turned 
to the opposite side I made an incision about three inches in 
length along the lower prominent border of the stemo-mastoid 
and exposed the edge of that muscle and a portion of the omo- 
hyoid. The stemo-mastoid and the omo-hyoid with the 
carotid sheath were then drawn outwards, whilst my colleague 
Mr. Gould drew the trachea in the opposite direction, and with 
his fingers on the right side of the neck pressed the oeso- 
phagus towards the incision. The recurrent laryngeal nerve 
was then seen, and this was also pushed outwards. The oeso- 
phagus was now visible, and the plate could be easily felt with 
the fingers. I then made a vertical incision through the oeso- 
phagus on to the plate, and seized it with a pair of forceps, 
but it was so firmly fixed into the walls of the oesophagus, by 
the sharp clips which had held it to the neighbouring teeth, 
that I could not readily remove it through the incision. I 
therefore enlarged the opening upwards, and in doing so, 
divided a thyroid artery, probably the superior thyroid as the 
current of blood was from above, which bled sharply. This 
was at once arrested with pressure-forceps. As the plate was 
still firmly held, I divided it with a pair of bone-forceps and 



Mr. LawBon's Caae of (Esopkagotomy 

remored it in two portions, taking care to maintain a 
each portion with a pair of pre^are-forceps 




A ligatare was then placed on the thyroid artery and the 
lips of the woand hrought together with foar sutures, andinto 
the lower end of the wound a drainage-tube was inserted. No 
sutures were pat into the cnaophagus, as owing to the 
stretching caused in drawing out such an irregular body which 
was impacted across the cesophagus, I felt that there must 
necessarily have been some laceration of muscnlar tissne, and 
I thought that the parts would fall together better than I conld 
adjust them with sutures. 

As soon as the plate was felt with the fingers in the wound, 
the catheter was withdrawn from the oesophagus. The wound 
was covered with boracic lint cbarpie, and over this was placed 
carbolic gauze with oilsilk. The patient was then sent to 
bed and ordered to be fed with nntrient enemas, and with 
Slinger's nutrient meat anppositoriea. No food was to be 
taken by the month, but from time to time the lips and tongue 
were to be sponged with ioed water to allay thirst. 

The nutrient enemas were composed of peptonised beef tea 
and gruel ; a three-ounce enema to be given every four or six 
hours, and three of the meat suppositories in the twenty-four 
hours. 

January 15. — The patient wasveryrestless during the night 
and complained of great thirst. The dressing was changed j 
there was a very free discharge of saliva and mucus from the 
wound. The drainage-tobe waa removed and the wound 
covered with iodiform wool, into which the secretion from the 
wound could drain. To relieve the thirst the patient was 
allowed to suck a little ice. 

8 P.M, — Temperature 101-6°, pulse 110. She has retained 
the enemas, and the beef suppositories. 



294 Mr. LawBon's Case of CEsophdgotomy. 

January 16. — Patient passed a very restless night, and has 
a distressing and frequent cough. Before her admission into 
the hospital she was suffering from a chronic bronchitis, which 
had now become aggravated. 

Has had the enemas and suppositories regularly, and has 
retained them. 

A quantity of saliva and mucus continue to flow from the 
wound. Three sutures removed. Ordered to go on with the 
enemas and suppositories and to each alternate enema to add 
ten minims of Tinct. Opii. 

Temperature 1004^ pulse 120. 

January 17. — Has had a bad night, scarcely sleeping at 
all. A large quantity of saliva, mucus, and some pus flows 
from the wound. Has had a mustard poultice over the chest, 
which seemed to afford some relief. 

Temperature 99®, pulse 108. 

To continue enemas and suppositories, but as the pulse was 
a little flagging to add three drachms of brandy to each enema. 

January 18. — ^About the same ; still much secretion from 
the wound. As the patient was feeling ybtj weak, Brand's 
essence of beef to be given frequently by the mouth in tea- 
spoonfuls at a time. To continue the enemas, but omit the 
suppositories. 

January 19. — Passed a much better night. Not quite so 
much discharge, but it has a very off ensive, gangrenous smeU. 
Around the wound there is a blush of redness. Has taken 
two tins of Brand's essence in the twenty-four hours. To 
continue the enemas and Brand's essence. Temp. 101®^ 
pulse 108. 

January 20. — The redness around the wound has increased. 
The discharge has diminished in quantitv^ but is very offen- 
sive. Patient refused to take any more of the Brand's essence. 
Ordered milk to drink in small quantities at a time, and to 
continue the enemas with the brandy, but without the Tinct. 
Opii except when restless. The cough still continues trouble- 
some ; a mustard poultice is applied daily and seems to give 
great relief. Temp. 100-2®, pulse 100. 

January 21. — ^The redness around the wound is less, but 
the discharge continues from the wound and is very offensive. 
The patient had a good night. As a portion of all fluids 
taken by the mouth escaped out of the wound, I passed an 
OBSophagus-tube, such as is used in cases of stricture of the 
oesophagus, with a funnel-shaped extremity w;hich projected 
about six inches from the mouth, and allowed it just to enter 



Mr. Lawson^s Case of (Esophagotomy, 295 

the stomacli^ but not to press against its walls. This was 
to be kept in, and through it all food was to be introduced 
into the stomach. For about half an hour after its introduc- 
tion the patient had cough and some irritation, but the dis- 
comfort soon passed off and she was able to retain it without 
any apparent inconvenience. Three ounces of peptonised 
beef and an egg were then given by the tube, and fluid 
nourishment was regularly administered through it every four 
or six hours. Temp. 99*2°, pulse 100. 

January 22. — ^The cellulitis around the wound about the 
same as yesterday. The discharge still very offensive. The 
patient suffers no inconvenience from the oesophagfus-tube 
which has been kept in, and through which liquid food is 
passed into the stomach. During the twenty-four hours she 
had administered one and a half pints of peptonised beef tea 
and gruel, two eggs, four ounces of milk, and two ounces of 
brandy. Temp. 99*2°, pulse 88. 

January 23. — Passed a good night. There is still redness 
and some swelling around the wound. The nutrient enemas 
discontinued. Three pints of beef tea and gruel and two 
eggs were administered by the tube. Temp. 98*2^, pulse 96. 

January 24. — This morning an abscess was opened at the 
upper part of the cicatrix of the wound, and about half an 
ounce of pus escaped. Took two and a half pints of strong 
beef tea and gruel, two eggs, and two ounces of brandy. 
Temp. 98-4°, pulse 88. 

From this date the patient made a steady progress 
towards recovery. From the wound several small sloughs of 
cellular tissue escaped. The discharge ceased to be offensive 
and was healthy, and diminished daily in quantity. The 
wound gradually closed and by February 22 was completely 
healed. The oesophagus-tube was worn continuously until 
February 8. About every four or five days the tube was 
removed and a fresh one introduced. The wearing of the 
tube did not produce any real discomfort. The patient slept 
well and did not complain of annoyance from its presence. 
As the patient improved in health her appetite increased, and 
the quantity of food given by the tube was, on February 1, 
three pints of beef tea, one pint of milk, two pint^ of gruel, 
two eggs, and two ounces of brandy. This was administered 
in quantities of- one pint every four hours. On some days she 
would take only five pints through the tube in the twenty-four 
hours. 

On February 8 the opening in the oesophagus had appa- 



296 Mr. Lawson^s Case of CEsophagotomy, 

rently quite closed, as only a small quantity of pus escaped 
through a small sinus at the lower part of the wound. The 
tube was now removed, but it was ordered to be reintroduced 
for the administration of food. 

The patient from this date was fed by the tube five times 
during each twenty-four hours, and this was continued until 
February 22, when the wound was quite cicatrised. 

The patient has since been able to take her food without 
any discomfort. There is a deep puckered cicatrix in the site 
of the incision, and the parts are firm and healthy. 

BemarJcs. — ^Prom the experience of this case the questions 
of interest which arise are : Is it better to introduce sutures 
to close the wound in the oesophagus, or to leave the cut 
edges to fall together of themselves ? I certainly think that, 
when the body which has to be removed is an irregular and 
j^Sgod one, so as to necessitate some bruising or tearing of 
the tissues in its e:xtraction, it is better not to use sutures, 
but if the foreign body could be extracted through a clean 
cut wound, then sutures might be applied with advantage. 

One point which struck me in this case was the amount of 
saliva which was constantly fiowing through the wound, and 
which was no doubt the cause of the little cellulitis which 
followed. My impression is that this cellulitis might have 
been avoided if, immediately after the operation, I had intro- 
duced an oesophagus- tube and fed the patient through it. In 
this patient, the way in which an oesophagus-tube can be 
tolerated was weU shown. For three weeks she wore a tube 
continuously and without any real discomfort. The patient 
began to improve from the time that the tube was introduced, 
and this no doubt was due to two causes. 1st, the patient was 
better nourished, and 2nd, only saliva and mucus escaped 
through the opening in the oesophagus, as no food was given 
by the mouth. 

The successful termination was no doubt greatly due to 
the oesophagotomy having been performed soon after the 
false plate was swallowed, and before any ulceration or in- 
flammation had taken place at the locality in which it was 
impacted. 



Mr. Lediard^s Case of (Esophagotomy. 297 



■A Case of (Esophagotomy. By H. A. 
Lbdiabd. Bead May 22, 1885. 

WILLIAM W., a postman, aet. 49, living at Ambleside, was 
asleep on a sofa on the evening of March 22, 1885, 
when he was awakened by finding that the plate, bearing one 
artificial tooth, had slipped into his throat. He attempted to 
reach it with his finger, bnt failed, and shortly after he was 
seen by Dr. Redmayne, by whom he was pnt under chloroform 
whilst extraction was attempted, without success. He was 
sent to the Cumberland Infirmary, and was admitted on the 
evening following the accident. 

Patient was a healthy-looking man, of probably abstemious 
habits. It was found that he had great pain on any attempt 
to swallow, chiefly in the region of the thyroid cartilage, and 
emphysema of the neck was present, but there was no projec- 
tion felt in the neck to indicate the presence of a foreign 
body. 

Upon my seeing him I ascertained that before coming to 
the Infirmary emetics had been given, and that our house 
surgeon had made several efforts to extract the plate, which he 
had felt and grasped about the thyroid region ; a horsehair 
probang had been used unsuccessfully, and the patient was 
altogether in a very uneasy state, being anxious that no 
further attempts should be made through the mouth. On his 
removal to the theatre I endeavoured to find a guide to the 
point of impaction, but could feel nothing externally ; I passed 
an oesophageal bougie into the stomach (about the size of 
the little finger), and thought I felt the instrument scrape 
slightly as it was withdrawn. Finding that the patient was 
unable to swallow a mouthful of water, and that there was 
evidence of some injury to the pharynx from the emphysema, 
and blood on the forceps used, the patient was put under ether 
and oesophagotomy performed on the left side of the neck. 

After dividing the platysma muscle the knife was put aside 
and the cellular tissue separated with the fingers only until 
the spine was reached, the omo-hyoid muscle was pushed down- 
wards, and one small vessel only was tied. The gullet was 
next searched with a finger, behind and below the larynx, but 
nothing felt, and after passing a bougie through the mouth 



298 Mr. Lediard's Case of CEaophagotomy, 

into the oesophagus^ I cut into it behind the cricoid cartOage ; 
the finger was now used inside the gullet with the same 
result as in the examination from outside^ the bougie was 
next passed through the wound downwards into the stomachy 
and at or about the cardiac end of the stomach I believed that 
the plate was f elt^ but without giving to the hand the impression 
that the plate had been pushed into the stomach. 

The cut in the gullet was closed with two catgut sutures^ 
but the skin incision was left gaping slightly at the centre^ 
and a drainage-tube passed down to the bottom of the 
wound. 

Very little need be said as to the subsequent progress of 
the case as the recovery was steady and uninterrupted. 
Bectal alimentation only was allowed for the first three days 
and then fluids were given by mouthy a little milk or beef tea 
sometimes leaking through the wound^ and one day a little 
orange pulp he had been eating ; a wood-wool pad was kept 
on the neck and this served to absorb the discharge from the 
wound or leakage from the gullet. Enemata were occasion- 
ally given and a little purgation employed^ and after running a 
painless course the plate appeared at the anus on April llth^ 
i.e. nineteen days from the date of impaction. 

There was very little febrile reaction following the opera- 
tion ; the chief trouble seemed to be some coughing with dis- 
charge of mucus from the pharynx, but swallowing seemed 
fairly easy from the moment that liquids were first allowed. 

Patient left the hospital on April 20 feeling and lookrug 
well iu all respects. 

The plate will be seen to measure 1^ inches long by | 
inches broad, and was made to hold two incisors, one of which 
is wanting. The margins of the plate present numerous sharp 
points in addition to a formidable-looking hook at one end. 

The whole subject has been ably dealt with by Dr. Church 
in the nineteenth volume of the ISt, Bartholomew's Hospital 
Beports ; and two cases have been recently brought before the 
Society by Dr. McKeown in vol. xi and Mr. Butlin in vol. 
xvii. The present case bears out Dr. Church's conclusion 
from statistics, viz. " that there is very little risk in the opera- 
tion itself, and that a good result may be fairly expected if the 
operation is done shortly after the foreign body becomes 
impacted,'^* whilst the circumstances in which the plate became 
dislodged are similar to Dr. McKeown's and Mr. Butlin's 
cases. 

* 8i» BarikolomeK^s EotpUal Beports, yoL xiz, p. 67. 



Mr. Lediard's Case of CEsophagotomy. 299 

There is notliing to be said as to the operation, which 
seemed to be surprisingly simple and free from haemorrhage, 
whilst there was little or no difficulty in separating with the 
fingers the layers of cellular tissue lying between the carotid 
sheath and the windpipe. 

It may seem to have been an error to have operated in 
this instance^ because the plate was not found in the pharynx 
or oesophagus, and I am unable satisfactorily to explain by 
what means the plate became dislodged whilst the patient 
was on the table, or if the finger unconsciously disturbed the 
plate from its resting place. 

There is another point. Was it justifiable to open the gullet 
after the finger in the wound detected nothing ? I think it 
was, for the plate might have been lodging in the thoracic por- 
tion of the oesophagus and been extracted with ease. 

I have omitted to mention that there were no laryngeal 
symptoms from the first, yet there can be little doubt that the 
plate was lying behind the lower end of the larynx when 
grasped in the forceps, and from the fact that the mucous sur- 
face of the gullet about the cricoid cartilage presented several 
ecchymosed patches. 



300 Dr. Colcott Fox's Oases of Raynaud's Disease. 



XL. — On two Gases of Raynaud* s Disease. By T. 
Colcott Fox, M.B. Read May 22, 1885. 

IN 1862, Raynaud wrote as follows : '^ I propose to demon- 
strate that there exists a variety of dry gangrene, affect- 
ing the extremities, which it is impossible to explain by a 
vascular obliteration ; a variety characterized especially by a 
remarkable tendency to symmetry, as well as that it always 
affects similar parts, the two superior and inferior limbs, or the 
four together ; moreover, in certain cases, the nose and ears ; 
and I shall seek to prove that this species of gangrene has its 
origin in a vice of innervation of the capillary vessels, which 
it will remain with me to specify/' He believed it to be essen- 
tially a neurosis characterized by an exaggeration of the excito- 
motor power of the central parts of the cord presiding over the 
vascular innervation. The existence of such morbid condi- 
tions was established by Maurice Raynaud in his masterly 
These de Doctorat in 1862, under the title De F Asphyxia 
Locale et de la Oangrene Symmetrique des Extremites ; in the 
article " Gangrene " in the Nouveau Dictionnaire de Medecine, 
1874, and in Archives Oenerales de Medecine, 1874. But not- 
withstanding the papers by Dr. Southey in the 8t. Bartholo- 
mew's Hospital Reports, vol. xvi, and in the Clinical Society^s 
Transactions for 1883, and the record of three cases by Dr. 
Barlow in the same volume, the disease has as yet attracted so 
little attention in this country that I hope the exhibition of two 
cases, rather different from those already shown here, will be 
of interest to this Society. 

Case 1. — ^Mrs. S., aet. 41, was sent to me by my friend 
Mr. P. F. Gilbert. She states that as a girl she always had 
cold hands and perspirations, but not blue hands and chil- 
blains. Friends would frequently remark, " How cold your 
hands are !" or, when kissed, ^' How cold your nose is !" She 
was, however, little conscious, from her own sensations, of cold 
extremities. There is nothing otherwise of note in her early 
life. Her family history is good. Her father died of apoplexy 
aged 77, and her mother, though never robust, is still alive at 
the age of 78. All have good blood circulation and I have 



Pr. Colcott Pox's Oases of Raynaud's Disease. 301 

failed to bring to Ught any nenroses. She never had rheu- 
matic fever or any special iUness. 

At the age of 18 she came to London as a kitchenmaid^ 
and had frequently to wash the doorsteps. She was married 
at the age of 27^ and has had six children^ including twins at 
the last birth. Her functions have been generally in good 
order, and she has not had any miscarriages. 

Mrs. S. dates the commencement of her disease from June 
ten years ago^ on moving into a damp house. Her fingers 
then began to go at frequent intervals white and dead^ all of 
them simultaneously on both hands, "like wax" as she 
expresses it, and they pained her excessively. I think there 
is some doubt whether she did not suffer from " dead fingers " 
at a much earlier date, but her memory fails her a good deal. 
Such, however, is her own account, and, at any rate, the pain 
seems at that time to have specially attracted her attention to 
her hands. Gradually her feet also became involved, and up 
to the present time the recurrences have been getting more 
frequent, the local syncope has given place to local asphyxia, 
and the condition has become more pronounced as the ravages 
of the attacks accumulate. 

She is now a woman of spare habit and with an anxious 
face and intensely nervous temperament. She says she is a 
'* dreadful sleeper,^' especially after the slightest worry or 
excitement, and she has had several severe hysterical attacks 
on similar provocation, but I cannot connect these with any 
local attacks of asphyxia. Her heart and other organs are 
healthy. There is no diabetes. 

When I saw the patient in February, the condition of the 
fingers might easily have been mistaken, at first sight, for 
scleroderma. All the fingers were icy cold, of a slightly blue 
tinge, fusiform in shape ; the skin over them was shining and 
shrunken ; the nails were variously affected and some of the 
bones atrophied. The history, however, at once made the 
nature of the malady clear. On subsequent occasions I have 
seen all the fingers slightly swollen and of various shades of 
lividity up to the metacarpo-phalangeal joints, with the course 
of some of the veins traced out by blue lines. The colour is 
always deepest at the palmar surface of the ends of the fingers. 
The attacks of asphyxia are now so frequent as to be almost 
continuous. The fingers are always the seat of pains, which 
are intensified with each fresh spasm of the vessels and are 
often excruciating as the relaxation sets in. Then the 
patient is much distressed and will frequently burst into tears. 



302 Dp. Colcott Fox's Cases of Raynaud's Disease, 

Occasionally the asphyxiated condition of one of the fingers 
will lead to the formation of a blood blister^ the contents 
subsequently become purif orm, and on the rupture of the bullae 
an ulcerated surface is left which is very slow to heal. At 
the time of writings the left ring finger is ulcerated at the end 
and under the nail. 

These attacks^ so constantly repeated over ten years^'have 
led to striking deformity of the fingers. I have already 
alluded to their fusiform shape and the atrophied condition of 
the skin generally. On the right hand^ the distal phalanx of 
the thumb is shortened^ and the nail incurvated over the 
scarred and puckered end. The end phalanx of the ring 
finger is nearly atrophied away and the nail shrivelled up. 
The little finger is in a similar condition and has been much 
attacked. The riug and middle fingers are conical with the 
nails carved over their ends. On the left hand the state of 
things is closely similar, but perhaps the changes are hardly 
so pronounced. As I have already remarked, the end of the 
ring finger is ulcerated. All the fingers are now in a chronic 
state of asphyxia and lividity^ which is intensified with each 
attack. The joint movements are also very limited. 

In the toes the disease is less severely felt, but their ends 
are somewhat blue and cold. The tip of the nose is rather 
blue, with dilated venules. There are scars over the right 
external malleolus. 

The influence of cold is very marked. Her ears and nose 
go blue and cold directly she goes out of doors ; her hands and 
feet get intensely livid with an " agony of pain.'' She dare 
not take her very warm soc]|^ off even in the house, and she 
keeps her hands muffled in cotton wool and warm gloves. 

She also states that her extremities go blue ^'ina second" 
if she is startled by a sudden knock at her door or any 
unusual occurrence, and her heart ''feels as if in a vice." 
Her pulse is thready and compressible. There has been no 
haemoglobinuria, and her blood appears to be normal. 

The patient has now been for some weeks under observa- 
tion in the Westminster Hospital, and her excessively 
" nervous," hysterical, and emotional condition fully noticed. 
She has had many attacks of asphyxia of the fingers and toes, 
accompanied by excruciating pain, and for the most part 
ending in the formation of a crust at the end of the fingers 
beneath the nails. Some purpuric stains about the insteps at 
the present moment mark the site of symmetrical patches of 
congestion. The extremity of the nose is often involved, and 



Dr. Colcott Fox's Gases of Raynaud's Disease. 303 

in one attack became covered with a tliick crust. These 
attacks seem to occur without any regularity, but are mostly 
traceable to a colder change in the weather. 

I would call attention to the condition of the face where 
the skin seems more pigmented than natural, covered with 
dilated venous radicles, and thinned, giving a rather 
expressionless aspect, which reminds one of scleroderma. 

She has been treated according to Raynaud's method by 
descending constant currents to the spine, and with manifest 
improvement. 

Case 2. — Joseph A., 8Bt. 51, a man of most regular life, 
who had been for twenty-five years in the police force, con- 
sulted me in the Department for Diseases of the Skin at the 
Westminster Hospital in February, 1883. He is a stout, 
florid-complexioned man with a remarkably good physique, 
but yellowish conjunctivae, and he then and still complains of 
feeling weak and often very unweU. There is nothing of 
interest in his early history. He applied to me on account of 
two oval, symmetrical, gangrenous sores, superficial, about the 
size of a half crown, one at the junction of each middle 
and lower third of the shins. These sores were covered with 
an adherent black eschar, and they had originated suddenly 
in '' blood blisters." There were also a few pustules scattered 
around. His feet and hands were cold, and his pulse soft and 
weak, but with one exception I could find no other diseased 
condition. He was suffering from marked diabetes, but was 
not aware of it. I may here remark that a brother, 8Bt. 41, 
also has diabetes, and it is perhaps significant that his father 
died comparatively young of phthisis, although the family are 
not phthisically inclined. 

To continue the narrative, the sores were very obstinate to 
heal, and on March 28 another congestive patch appeared 
on the right shin which seemed to threaten gangrene, but 
eventually subsided. At the end of May the skin lesions were 
quite well. 

On January 2, 1884, he applied to me again for a renewed 
outbreak of blood blisters about the feet and shins, but at that 
time, not appreciating their' true significance, I did not make 
exact notes of them. His circulation at this time was very 
weak. The fact that he was suffering from Raynaud's disease 
was disclosed to me by the following occurrence. 

On the 5th January his left great toe became suddenly 
black and swollen and intensely painful. Redness, which 



304 Dr. Oolcott Fox's Cases of Raynaud^ s Disease, 

gradually changed to lividity, extended up the side of the foot 
and leg to the junction of the middle and lower thirds of the 
tibia. 

On the 9th a blister formed on the toe, and the pain and 
swelling subsided. The right foot was unaffected. On 
making further inquiries I now found that in the winter of 1883, 
before I saw him, he had suffered from a severe attack in his 
left foot which laid him up for five weeks. His doctor told 
him he had a severe frostbite, and that he was a lucky man 
not to lose his great toe. A month before Christmas of the 
same year four '^ black blisters " appeared beneath his toes. 
I gathered also that he has suffered for years from sudden 
blanching and numbness of the digits, in fact from '^ dead 
fingers," and occasionally from asphyxia of the fingers. The 
patient was a doorporter at some well-known stores and there- 
fore much exposed. Ee has given up his occupation, and 
during the past winter has clothed himself with great care and 
carefully protected his hands and feet. Moreover, he has not 
ventured out unless the weather was genial. Consequently he 
has been almost free from these attacks of cramp of the 
vessels ; indeed he has suffered from little else than the usual 
attacks of local syncope. 

Remarks, — I will detain the Society with but few comments 
on these cases, as I have little to add to the masterly elucida- 
tion of the disease by Raynaud. The case of the man illus- 
trates the advisability of denominating the affection Raynaud's 
disease rather than symmetrical gangrene of the extremities, 
a name which Raynaud fully recognised as not completely 
satisfactory. The conjunction of the disease with diabetes is 
of much interest. Raynaud only met with one such case 
in a woman, aged 31, who passed seventy-six grammes 
of sugar per litre of urine. The diabetes was completely 
cured and the gangrene arrested by an exclusively nitrogenous 
diet, the exhibition of alkalies internally, and a sojourn at 
Vichy three years running. The local asphyxia in her^ase 
preceded by eight years the first definite signs of diabetes, but 
the influence of the latter on the nutrition of the tissue was 
seen in the increased severity of the gangrenous process. I 
would call attention to the asymmetrical character of some of 
the man's attacks. Raynaud rightly insisted on the remark- 
able tendency to symmetry usually present, but that asymme- 
trical attacks also occar is certain and in such cases the nature of 
the malady may be far less obvious. In neither of my cases 



\r 



Dr. Colcott Fox^s Oases of Raynaud* s Disease. 305 

could I get any clue to the occurrence of liaBinoglobinuria^ 
although I have seen a remarkable case in a girl of thirteen 
years under the care of my friend Dr. Leslie Ogilvie in which 
such a coiQcidence existed. With her the patches occurred on 
the body and did not impHoate the digits. 

The case of the woman is very well marked and the con- 
dition typical of incessant^ long-continued^ and moderately 
severe attacks. I show for comparison a woman of the same 
age with extreme atrophy of the fingers and other parts of the 
body left by a long-standing generalised scleroderma. The 
histories of the two afEections are quite dissimilar and the 
appearances^ as seen to-night^ quite distinct to the careful 
observer. However, the diagnosis does not appear to be 
always so clear, as one may see from the interesting discussion 
on Prof. Ball^s case at the Soc. Med. des Hdpitaux. I find under 
the head Scleroderma several cases which read like Raynaud^ s 
disease. I may refer to the cases described under the name 
Sclerodermie in 1871 by Ball and Dufour and mentioned in the 
article '^Main^^ in the Nouveau Dictionnaire de Medecine, and 
those by Vemeuil, Ball and LiuviUe and Hallopeau collected 
in Beauregard^s thesis Des Deforrrdtes des Doigts, 1875, also by 
Hardy and by Vidal {Oaz. des Hop,, 1878), a very severe and 
interesting case by' Gr asset and Apolinario of Montpellier 
reported by BroohLa {Oaz. des Hop., 1878), in which brown 
taches and cicatricial patches simulate morphaea, and by L. 
Bapin under the term Sol6rodactylie {Bews des. 8ci. Med., 
1878). The polished, stretched, atrophied condition of the 
face is referred to in the latter case of undoubted Raynaud's 
disease. Yidal says that his case proves the ii^timate relation 
between scleroderma and Raynaud's disease, and Brochin 
points out that the symptoms of the two diseases can bejunited 
in the same patient. With reference to this point I may 
mention that in two unquestionable cases of generalised 
scleroderma under my observation in which the hands were 
involved both women had been long subject to '^ dead fingers," 
and one of them continued to have mild attacks of asphyxia 
of tJie fingers after the onset of the scleroderma. 

In conclusion, I may add to the references given by 
Raynaud and Southey the following : — 

Marroin (of Constantinople), '^Observation d'asphyxie 
locale des extremit^s" following intermittent fever, in the 
Archwes de Med. Nav., 1870, xxiii p. 341. 

Behier's Th^se de Paris on AsphyoBie locale, 1875. 

L. Yaillard ('' Contribution i, Fetiologie de I'asphyxie locale 

VOLV xviii. 20 



306 Dr. Colcott Fox's Oases of Raynaud^ s Disease. 

des extr6mit6s/' Recueil de Mem, de Med. et de Chdr. Mil. 1877, 
p. 585, from the Provence Med., 1877). 

Camilo Nielson {Ugeskr.f. Lager 1877 copied to Schmidfs 
Jahrb., 1878. 

I would also call attention to the following references : — 

'^ Ein Pall von Lepra maculosa mutilans/' by Kochler of 
Kosten {Berl.Klin. Wochen., 1877, p. 676.) 

Deux Cas de l^pre ansesth^tique mutilante, by Thaon, of 
Nice, Progres Med. 10 Nov., 1877. 



Dr. Barlow's Cases of Bayncmd's Disease. 807 



XLI. — Seqttel to paper on Three Cases of Raynaud* 8 
Disease^ * Clin. Troms.^ vol. xvi, p. 179. By 
Thomas Baelow, M.D. Bead Kay 22, 1885. 

I PROPOSE in tliis communication to give some brief notes 
of the further progress of the three cases of Raynaud's 
disease which I described in the 16th volume of the Transao 
tions, and to deal especially with the results of treatment. 

The first case, Elizabeth N., originally under the care 
of my colleague. Dr. Poore, came again under my obser- 
vation August 29, 1884. She was acCnitted into University 
College Hospital with the fingers of the right hand almost 
black, the dorsum of the hand of a dark purple, and the palm 
of a light purple colour. The forearm for the lower two thirds 
was blue, the colour gradually fading away. There was slight 
distension of superficial veins. 

The left upper limb was similar to the right, but the 
colouration was less intense. The limbs felt very cold. The 
radial pulse was almost imperceptible at the wrists. The feet 
were also of a purplish colour, which was most marked over the 
toes, but not so intense as the colour of the fingers. The coloura- 
tion extended upwards for at least an inch above the ankles. 
There was also a little distension of superficial veins, and the 
child complained of aching in both feet and arms. 

The &ice was sallow and pale. Temp, in axilla at 12 noon, 
98*8°. The heart-sounds were natural, the second being, 
perhaps, a little accentuated, 84 per minute. The urine 
passed at 2 p.m. was pale, acid, free horn, deposit of any kind, 
and contained no albumen. 

I cannot give the exact duration of this attack, but I 
believe it was not more than three hours. It is to be noted 
that August 29 was very chilly, succeeding a very hot 
day. 

Next day, August 30, between 6 and 7 A.M., body temp, 
wapi 100°, and at 9 a.m. 99*8° in the rectum. The urine passed 
in the night was of a dark amber colour, but there was no 
deposit of pigment. It was of slightly alkaline reaction, sp. 
gr. 1018, and free from albumen. There was no play of 
colours with nitric acid. 

The liEubs felt warm and the skin showed no pigmentary 
changes. The child was kept in bed until September 2, when 



808 Dr. Barlow's Cases of Raynmid^s Disease. 

slie was allowed to get up at 8.30 a.m. At 9.55 a.m. the hands 
and feet began to get bine and gradually became quite purple^ 
the colouration extending to 1 in. above the wrists and just 
above the ankles. The child cried out with paiu and nothing 
could quiet her. 

At 10.5 A.M. I placed the child's right hand in a large basin 
o{ hot salt and water^ the positive pole of a Leclanch6 constant 
current battery being applied to the inner side of the child's 
arm and the negative pole in the water. The current was 
rapidly made^ broken, and reversed by a commutator and the 
number of cells increased until a moderately vigorous contrac- 
tion of muscles occurred. At the end of thirty minutes the 
right hand was perfectly normal in colour, or rather, of a 
pale pink tint. The thumb and two radial fingers lost 
their lividity first, then the little finger, and finally the 
ring finger. The left hand was still as purple as before. 
The same treatment was then applied to it, and in about the 
same time recovery took place and in the same order. Nothing 
was done to the feet except that they were surrounded with 
cotton wool. The colouration had not been so intense as that 
of the hands, but it is noteworthy that it did not clear up 
entirely until 6 p.m. The urine passed at 12 noon was pale in 
colour, contained slight deposit of mucus, but no pigment and 
no blood corpuscles ; it was of sp. gr. 1016, and was free from 
albumen. The temp, was, at 7 a.m. 99*4°, 1 p.m. 99*2°, 3 p.m. 
100-4°, 8 P.M. 101-2°. 

Patient was kept in bed on September 3, but on Sep- 
tember 4 was allowed to get up. She was quite comfortable 
till 2 P.M., when she complained of slight pain in the right 
foot and said she felt an attack coming on. A sHght coloura- 
tion of the right sole was found. She was allowed to sit by 
the fire and in half an hour this attack passed off. It is noted 
that the temperature of the ward was higher that day than on 
the 2nd. 

September 5. — Patient was allowed to get up at 3 p.m. She 
was playing about in the ward until 5.15 p.m., when she com- 
plained of her feet. The soles were found bluish and the 
colouration rapidly extended over the dorsum up to the middle 
of the leg. The colouration was more intense on the left leg than 
on the right. The child complained of much pain. There was 
nothing abnormal about the hands. I was anxious to ascertain 
the effect of nitrite of amyl, and Mr. Fleming, the house 
physician, allowed the child shortly after the beginning of this 
attack to inhale three minims. For about ten minates the radial 



Dr. Barlow^s Cases of Raynaud's Disease, 309 

pulse became perceptibly fuller and the face became markedly 
flushed^ but no change whatever took place in the appearance 
of the lower limbs. The constant current was then applied to 
one leg^ but the child struggled so much that the application 
could not be persevered with. The feet were wrapped in cotton 
wool and the child was put in front of the fire. By 8 p.m. the 
feet were normal. 

September 7. — The child got up to-day at 2 p.m. She was 
comfortable until 4.30 p.m. and then complained of her feet. 
The distribution of the lividity was about the same as that of 
the last attack and the hands were quite normal. 

The feet were wrapped in wool and she was allowed to sit 
by the fire. The feet were normal by 6 p.m. Urine normal. 
The mother volunteers the statement that the feet are attacked 
about three times as often as the hands. 

From September 8 to September 15 she was allowed to 
be up and was free from attacks. She was then discharged 
from the hospital. I learnt that on October 9 and 10 she had 
attacks^ but she was not brought to the hospital. 

On November 3, she was brought to me in the out-patient 
room^ five minutes after the commencement of an attack. The 
left foot was cold and blue up to the ankle and the child was 
crying with pain. I placed the child^s foot in a galvanic bath 
as before described^ and in ten minutes the foot was quite right 
again. The second and third toes recovered first and the big 
toe last. 

I satisfied myself^ whilst the child was in hospital^ that in 
her case there was no initial paUor observed, and that when- 
ever she complained of pain at the onset ef an attack there 
was already some blueness which generally increased up to 
lividity. The freedom from paroxysms when in bed, as stated 
in the previous paper, was confirmed. 

The second case, Lillie C, recommenced her attacks on 
October 1, 1883. During the time she was under observation 
her attacks occurred as before, generally in the middle of the 
day. They were chiefly confined to the lower extremities. 
They lasted from half an hour to an hour and were repeatedly 
followed within an hour or two by the passage of a small 
quantity of dark urine. I had several opportunities of exa- 
mining such dark urine, and found as before no red blood-discs, 
but pigment and oxalates, marked reaction to the guaiacum 
test, and the characteristic spectrum of methaBmoglobin. 

The child living some distance from the hospital and the 
attacks on the whole being of shorter duration than the former 



310 Dr. BarloVs Oases of Rayncmd^s Disease. 

series^ there was no opportunity of trying the effect of gal- 
vanism on the shortening of an individual attack. She attended 
daily for galvanism for a fortnight or more, but I cannot say 
that the result was conclusive, because it was obvious that 
independently of any treatment the asphyxia of the limbs was 
less severe than formerly, and the child was able to go to 
school regularly, so that it seemed unnecessary to insist on her 
continuing the treatment. 

The third case, John P., came under my observation again 
in August, 1883, and I then determined to give galvanism a 
thorough trial. I first appUed the poles to the spine as 
Raynaud directs, but not obtaining any definite result, after a 
few days I applied them locally to the blue extremities them- 
selves, holding the two sponges a few inches apart and painting 
the limbs vigorously for about a quarter of an hour daily. 
Fifteen to twenty cells of a Leclanch6 constant current battery 
were employed and the plan was sometimes varied by the bath 
method before described. 

The patient very soon testified to the benefit of the treat- 
ment. He began to walk better ; he was comparatively free 
from the burning pains, which had rendered him miserable 
both by day and night, and he was soon able to go to his work, 
for which he had been quite incapacitated. The tonic effects 
on the peripheral circulation were obvious directly; the colour 
of the skin became much less blue, though months elapsed 
before it became a healthy colour. There was at first a degree 
of anaesthesia to the galvanic as well as to the f aradic current, 
but this gradually passed away and he became normally 
sensitive. There were no degenerative reactions, although 
there was a certain amount of wasting of the leg muscles as 
well as of the feet. Under the galvanic treatment and increased 
exercise the feet gradually became much better nourished. 

The man attended regularly six days a week from August, 
1883, to the end of January, 1884, and subsequently three or 
four times weekly until the end of May, and I have to thank 
my assistant, Mr. Roberts, for his systematic and regular applica- 
tion of the galvanism. There were three days of very cold 
weather in January, when it was certain that, according to his 
statement, in previous years he would have been exceedingly 
bad. He had a slight attack of blueness, tingling, and pain 
in his right foot, but it did not interfere with his work and it 
soon passed off. 

When he was allowed to attend less frequently for 
galvanism, viz. at the end of January, great pains were taken 



Dr. Barlow's Oases of Raynaud^ s Disease. 311 

to show his wife how to shampoo the f eet^ and this was done 
daily by either the patient or his wife till the end of May. He 
was then dismissed and told to show himself again in October^ 
1884. At the latter date he was free from pain and his feet^ 
though not plump, were moderately nourished, and were only 
a little colder and bluer than natursJ. He could walk well and 
do his work. 

To these cases I may add two others, perhaps allied, but I 
think not strictly coming under the category of Raynaud^s 
disease. The first was that of a little girl who had a deep 
cyanosis of both lower limbs extending nearly up to the knee. 
The affection was not paroxysmal and was not attended with 
pain. The child had always had a feeble circulation, but the 
condition had become greatly aggravated shortly before she 
came under my care. There was no morbus cordis to be made 
out and the only other noteworthy clinical feature was the 
occurrence of some ill-defined epileptoid attacks followed by 
some paresis of the lower limbs. It was for one of these 
attacks that the child was brought to the hospital. 

The daily use of the constant current, applied alternately 
by " painting ^* and by means of the bath, was followed by 
very marked benefit to the cyanotic condition of the limbs. 
The child's legs were also shampooed, but there could be no 
doubt about the benefit of the galvanism to the local condition 
and she expressed herself as more comfortable after every 
application and walked much better. 

The other case was that of a middle-aged woman who had 
severe tinglings and pains in both hands, and a condition some- 
thing like " dead fingers.'' The pains often kept her awake 
at night, and this and the numbness from which she suffered 
had seriously interfered with her work as a needlewoman. 
There was no actual lividity, but the fingers were of a pale 
leaden colour, also there were no definite paroxysmal attacks. 

My assistant, Mr. Roberts, galvanised her several times 
weekly for more than two months with very great benefit. 
She was taught to rub her fingers systematically at home and 
to use alternate hot and cold water douches, but she herself 
was emphatic as to the comfort that galvanism gave her. 

In her case as in some others the curious fact was noted 
that certain fingers (symmetrical on the two sides) were more 
affected than others and that in the healthy glow which 
followed any given application of galvanism certain fingers 
became pink sooner than the others. 

To sum up, although the observations which I have nar* 



812 Dr. Barlow's Gaaea of Raynaud^s Disease. 

rated are very imperfect, and the experiments themselves 
were not all of them sufficiently absolute for scientific pur- 
poses, I think they support the recommendation of systematic 
daily employment of galvanism for the condition of local 
asphyxia. 

I venture to think, with all deference to Raynaud's 
authority, that the local application is better than the method 
recommended by him of passing the current over the spine, 
or, as he would state it, " through the spinal cord." 

It seems hardly necessary to add that galvanism ought to 
be supplemented by the employment of every other method 
which can be devised of improving the peripheral circulation, 
whether locally, by shampooing, hot and cold douches, &c., or 
centrally, by the timely administration of food before any 
exposure to cold. 



Mr. Anderson's Onae of Papilloma of the Bladder, 313 



XLII. — A Case of Papilloma of the Bladder successfully 
removed by operation. By William Anderson. 
Bead May 22, 1885. 

JAMES 8., 8Bt. 53^ caretaker of a lecture-liall^ was admitted 
into St. Thomas's Hospital on August 9, 1884, with sym- 
ptoms of vesical tumour. 

The first indication of the presence of vesical disease was 
a spontaneous attack of hasmaturia in the summer of 1872, 
during convalescence from a railway accident. The haemor- 
rhage was unaccompanied by pain or marked constitutional 
disturbance, and subsided at the end of a few days, leaving 
the patient perfectly free from symptoms for a year, when a 
second and precisely similar paroxysm made its appearance. 
This also passed away speedily, but the succee<£ng inter- 
mission was abbreviated to six months, and subsequently 
recurrence took place at fairly regular intervals about four 
times yearly. 

In July, 1882, the man attended as an out-patient at St. 
Thomas's Hospital. He was then in the midst of an attack of 
haematuria, losing a considerable quantity of blood, usually 
fluid, and voided principally with the final contractions of the 
bladder, but sometimes also in the form of clots, which 
escaped at the commencement of the stream. There was 
neither pain nor increased frequency of micturition, the con- 
dition was not affected by ordinary exercise, and there were 
no indications of urethral obstruction. He was somewhat 
anaemic and debilitated, but was able to discharge the duties 
of his office. 

The introduction of a sound into the bladder revealed on 
the first and subsequent occasions a peculiarly acute sensi- 
bility localised to the region of the trigone (an area afterwards 
found to coincide with that of the tumour), but was otherwise 
negative in its results. Rectal and abdominal examination 
gave no indications of disease, and the urine was found to 
contain no abnormal elements except blood-discs. Neither in 
the first nor in later investigations were any fragments of 
vilU detected. The symptoms yielded at the end of ten days 
under the adminstration of perchloride of iron, and for a time 
the patient was restored to a fairly satisfactory state of health, 
but attacks of a similar character recurred again and again at 



314 Mr. Anderson'a Case of Papilloma of the Bladder, 

intervals of about three montha, always enbsiding readily 
nnder treatment and not indDcing any serioas loss of strength. 
In Jane, 1884, however, the disease assumed a new phase; 
during a paroxysm of more than usual eeTority symptoms of 
catar^ became superadded, and from this time the intermis- 
sions ceased. The haemorrhage became less profuse at the 
end of a few days, but never entirely disappeared, and the 
nrine continued to present a copious muco-purolent deposit. 
The patient was now tormented by hypogastric pain and 
irritability of the bladder, and his strength began to fail 
rapidly. He was advised to enter the hospital with a view to 
operation, but did not determine to do so until Angost. 

On admission the local examination and the investigation 
of the urine were carefnUy repeated without obtaining any 
new evidence, bat the symptoms were regarded as safficieotly 
indicative of vesical tumour to call for an exploratory opera- 
tion. This was accordingly undertaken on Augast 14. 

An incision being made throi^h the perinieum into the 
membranons portion of the nretbra, the finger was introduced 
into the bladder and at once impinged upon a soft flocenlent 
growth involving a considerable portion of the rectal wall of 
the viscna The mass extended from near the mtemal 
urinary meatus upwards for a distance of about an inch and a 
half, and laterally for about an inch on either side of the 
median line It appeared to consist of long villous processes 
springing from a broad and slightly elevated base, and during 




Diagrammatie view of the 



wall of tha bladder ihoiritig t^ptia 



Mr. Anderson's Case of Papilloma of the Bladder, 315 

tHe manipulation all doubt as to tHe nature of tHe disease was 
set at rest by the detachment and escape of two or three 
slender semitransparent fragments having the usual character 
of papillomatous fimbriae. 

The prostatic urethra dilated under steady pressure suffi- 
ciently to allow the introduction of a pair of forceps (with long 
naiTOW straight blades and a slight bulbous extremity) into 
the bladder by the side of the finger, and by careful manipu- 
lation of the instrument the root of the tumour was crushed, 
segment by segment, and the villi twisted away until the whole 
of the growths appeared to have been removed. The bleeding 
was severe but not dangerous, and ceased spontaneously after 
the expulsion of a mass of clot by a powerful reflex contraction 
of the bladder. A drainage-tube was passed through the 
wound and the patient was removed to bed. 

In the evening the temperature rose to 100*4° and a slight 
rigor occurred. The rigor returned twice on the following 
day, the temperature rising on the second occasion to 104°, but 
there was nothing alarming in the condition of the patient. 
Some bloody urine was passed by the urethra and a little 
oozing of blood took place from the wound. 

For a few days after the operation the urine contained an 
admixture of pus and blood, and the passage of the secretion 
by the normal channel induced an acute pain referred to the 
glans penis, but these symptoms gradually disappeared and 
the further progress of the case was complicated only by the 
development of a small perineal abscess at the end of the 
third week, associated with febrile disturbance and rather 
severe rigors. 

On September 10, twenty-seven days after the removal of 
the tumour, the patient was able to leave his bed, and on the 
21st was discharged from the hospital free from all trouble 
save a minute fistulous opening in the perinasum and a trace 
of blood in the urine. 

Histologically the growth was found to consist of a mass 
of closely aggregated processes of various lengths springing 
directly from the mucous membrane. Some of the fringes 
were long and slender, the longest reaching three quarters of 
an inch, others shorter and more solid, often branched, and 
containing a more or less considerable basis of loose connective 
tissue. The vessels were for the most part of large size and 
with thin walls. The tumour may be considered to represent a 
combination of the fimbriated and fibrous papillomata figured 
in Sir Henry Thompson's work. (See Plate VI, fig. 3.) 



318 Mr. Aaderson's Oase of Papilloma of the Bladder. 

mstances it has permitted the satisfactory removal of all the 
tumours it has brought within the surgeon^s reach^ and has 
given marked relief to pre-existing symptoms in a certain 
number of cases where it has &iled to reveal their cause. 

It is maintained by the advocates of the high operation that 
the suprapubic incision confers much greater advantages for 
the ablation of tumours^ but this has yet to be demonstrated 
by results, and is by no means proved even in theory. If it be 
borne in mind that nearly all vesical growths spring from the 
lower half of the viscus, and the great majority from the rectal 
wall, which is almost in a direct line with the asds of the pros- 
tatic urethra (Woodcut, p. 314), it will be seen that there are 
few cases that are not sufficiently accessible by the perineal 
route. There is, however, no doubt that it is less eligible 
for the removal of growths implicating a very extensive area^ 
and in those which spring from the anterior or upper walls, 
but the latter regions are not often primarily involved, and 
the timely employment of perineal exploration would reduce 
the number of widely diffused vesical neoplasms by facilitating 
their discovery in the earlier sta^e of their existence. 

The statistics of mortality are of Uttle value, as the result 
of operation is so frequently complicated by extreme anasmia, 
renal disease, and other grave constitutional conditions suffi- 
cient in themselves to account for a fatal termination to the 
case. Taking the figures for what they are worth, we find in 
twenty-seven cases six deaths which may have been caused or 
accelerated by the surgical intervention. On the other hand^ 
of eight suprapubic operations four ended fatally, one from 
extravasation of urine attributed to too rapid absorption of 
catgut ligatures of the vesical wall, the others from exhaus- 
tion within a few days of the removal of the tumour, and pro- 
bably due in great part, if not wholly, to the loss of blood 
preceding it. 

We are still to a great extent in the dark as to the ulti- 
mate results of the ablation of vesical tumours, as nearly all 
the more systematic operations are of very recent date, but it 
may be serviceable to analyse the published examples of non- 
malignant growth removed by surgical means, with a view to 
trace, firstly, the frequency of recurrence, and in cases of 
relapse, the duration of the interval between the operation and 
the reappearance of symptoms ; and secondly, the length of the 
period of immunity in cases in which no return has been noted. 
Theoretically it seems probable that a relapse would take 
place sooner or later in a rather large proportion of cases. 



.ri :2ia. 



^uViL * 






Mr. Anderson's Octae of Papilloma of the Bladder. 819 

considering the exceptional difficulty tliat must frequently 
arise in ensuring the removal of every portion of the tumour 
by any mode of operation yet devised. Bearing in mind also 
the very slow development of the primary growth in many 
instances — extending over a long term of years — ^it might be 
expected that the signs of recurrence would occasionally be 
deferred until a late period, long after the apprehensions of the 
patient had ceased, and after the surgeon had lost sight of his 
case. 

An examination of thirty-eight cases (male and female), in 
which the nature of the tumour was sufficiently indicated in 
the reports, shows four instances of undoubted and four of 
probable recurrence, all within a year of the operation ; com- 
plete relief in one case for five years up to the date of record ; 
in one for four years, in five for two years, and in four for 
periods ranging between fifteen and twelve months. In nine- 
teen other cases no signs of recurrence had appeared at the 
time of the report, but the observations had been limited to a 
term of less than twelve months. There are hence as yet only 
eleven oases out of thirty-eight in which we possess evidence 
of an immunity of one year and over, against eight cases in 
which relapse is noted as certain or probable. We may hope, 
however, that the operators will at some future time favour 
the profession with supplementary information upon those 
cases which can be followed after the pubhcation of the earlier 
details. 



320 Mr. Pitta's Oa$e of Tvmowr of the Bladder, 



XLni. — A Ca^e of Titmov/r of the Bladder ; Removal; 
Owe. By Bbrnaed Pitts. Bead May 22, 1886. 

WB.^ 8Bt. 43^ watchmaker^ was admitted on September 
• 10, 1884, to St. Thomas's Hospital. Patient had a 
very blanched appearance, and was evidently in a debilitated 
condition, having been losing flesh and strength for many 
months. He stated that for more than two years he had been 
passing blood with his urine, but that of late the quantity 
had much increased, and become alarming in amount. He 
had never had any pain beyond a tickling sensation in the 
penis at the end of micturition when passing clots. Of late 
his water had been very offensive, and there had been a con- 
stant desire to empty the bladder. For some mont^is he had 
been unable to follow his occupation. The urine was of sp. 
gr. 1020, alkaline, and very offensive, of a deep red colour, 
and always containing a quantity of clot. A microscopical 
examination showed possible traces of villous growth. Ex- 
amination by sound and by rectal exploration gave no indi- 
cations. 

On September 15 I made a perineal exploratory incision 
and on introducing the finger into the bladder, at once felt a 
tumour situated on the right side and just below the orifice 
of the ureter. The tumour seemed circumscribed and soft, 
and of about the size of an orange, but in reality was no 
doubt smaller, adherent clot giving one a false impression of 
size. With serrated forceps I was able to munch off por- 
tions of the growth, but no satisfactory progress was made, 
and a further examination revealed the presence of a very 
firm pedicle of the thickness of a finger. The pedicle was 
divided by means of a strong wire 6craseur. The bladder was 
then examined for any further evidence'of growth, and washed 
out, and a soft tube tied in. There was a good deal of bleed- 
ing during the early part of the manipulation, but none after 
the wire of the ecraseur was attached. The patient was fairly 
comfortable for the next two or three days, the urine contained 
no clot, but was very red, and became more offensive, and 
with considerable increase of the mucus. The tube was left 
out on the 19th, and on the 20th he had a rigor lasting ten 



Mr. Pitts^s Case of Tumour of the Bladder, 321 

minutes, with temp. 102*6°. The next day the temperature 
became normal, and continued so during the remainder of his 
convalescence. 

On October 7 he was passing his water entirely the right 
way and without pain. The urine was clear and free from 
any trace of blood. He rapidly put on flesh and regained a 
healthy appearance, and has remained perfectly well since. 
On no occasion has he had the slightest trace of any blood in 
his water. An examination of the tumour showed it to be 
what Sir H. Thompson calls a fimbriated papilloma. On 
floating the portions detached by the forceps in water, the 
delicate long flmbriated processes were very evident. Micro- 
scopical examination showed each of these processes to con- 
sist of a fine membrane covered by layers of columnar epithe- 
lium, with blood-vessels running up into the process and 
branching directly under the membrane. The diagnosis in 
this case was quite clear. One was confident from the amount 
of bleeding, and from the prominence of this symptom, that 
there must be a vascular tumour. The microscopical] exami- 
nation gave indications of imperfectly formed villi, but pre- 
vious to the operation I did not place great reliance on this 
evidence, for I was quite inexperienced as to the value of such 
evidence, and had made up my mind to explore on the con- 
sideration of the hasmorrhage alone. Following the directions 
given by Sir H. Thompson in his valuable book on Tumours 
of the Bladdery I was provided at the operation with a gorget 
director and a pair of serrated forceps. The gorget was of 
no use to me. I tried it, but found I could manage far better 
with an ordinary straight director as a guide for the finger. 
After finding the tumour, I spent a long time, and occasioned 
a good deal of unnecessary bleeding by tearing off portions of 
the growth with the forceps. Finding that the stalk was a 
substantial one, I pulled it as far as possible into the neck of 
the bladder, and then made use of an ecraseur, applying the 
wire quite close to the expanded portion of the growth, and 
as the portion of pedicle left was about an inch long, I again 
used the ecraseur and detached the remaining part as close 
as possible to the wall of the bladder. The lesson I learnt 
was that, however desirable crushing and biting with forceps 
may be, when the attachment of the growth is broad, that in 
a case like the one I met with, where there is a firm, strong 
pedicle, it would have been far better to use the wire in the 
first instance. The prognosis in this case is most favorable. 
If one had been contented with breaking off the softer parts 
VOL. xviii. 21 



322 Mr. Pitta's Case of TufMmr of the Bladder. 

from the stalk there would have been risk both of after- 
haemorrhage and of possible recnrrence of the growth. By a 
division of the pedicle close to its attachment there can 
hardly be any fear of a recurrence at that particular spot. 
The rest of the bladder snrface was smooth^ and there was no 
difficulty in examining every part of it with the finger. 



». 



C;ui.o:=r.Tr-Hii,s Vol XVllI Plate XII 



I I 




LIVING SPECIMENS 



DESCRIBED BY CARD * 



I. — Pigmentation of the Tongue (? Addison's Disease). 
By J. K. FowLEE. Exhibited October 24, 1884. 

WILLIAM C, aet. 42, a butcher, attended as an out-patient 
at the Middlesex Hospital, complaining of cough and 
tsemoptysis. 

The patient is a fairly-nourished man, of a sallow com- 
plexion. 

The tongue presents the following appearance (Plate XII) : 
The central part is covered with a moderately thick yellow fur 
extending from the circumvallate papilla© to within half an inch 
of the tip. The mucous membrane of the sides of the tongue is 
free from fur and the surface quite clean, but deeply pigmented 
of a bluish-black inky colour, along a strip from half to three 
quarters of an inch in breadth, narrowing toward the front 
of the tongue and not quite reaching to its tip. The dis- 
colouration is not uniform, pinkish spots being present here 
and there. 

There are also a few small patches of pigment in the 
central furred part. At the junction of the hard and soft 
palates there is a small brown spot in the middle line, and the 
buccal mucous membrane and that of the lips is slightly mottled 
with pigment. The only other part of the body presenting 
any unusual traces of pigment is the forehead, where there is 
a band of brown discolouration which the patient states has 
been present for many years. 

The areoIaB of the nipples are not pigmented. The dis- 

* Pablished in accordance with the Regulation relating to the exhibition of 
living specimens at the meetings of the Society, viz. that ** each case shall be 
accompanied by a card containing a brief description of the points it illustrates , 
such card to be retained by the Secretary for publication or not in the TrantaO' 
ticm at the discretion of the Council." 



324 Living Specimens. 

colouration of the tongae was first noticed six montHs ago ; it is 
thought to be of a rather lighter tint now than then. He has 
never had syphilis. He has not suffered from any of the con- 
stitutional symptoms of Addison^ s disease. 

Remarks. — It is unusual in Addison^s disease to find such 
an amount of pigmentation of the mucous membrane of the 
tongue as is present in this case without pigmentation of the 
areolae and of other parts usually affected. The absence of 
any constitutional symptoms of the disease is to be noted^ but 
a confident opinion cannot be formed on that point alone^ as 
the order of appearance of the local and general signs of the 
disease is very variable. 

I am disposed to regard the case rather as one of unusual 
pigmentation associated with tuberculosis than as one of 
Addison's disease. 

Postscript. — This patient remained under observation for 
six weeks after being shown to the Society, during which time 
the pulmonary disease progressed rather rapidly, but no change 
occurred in the degree or site of the pigmentation. He was 
reported to have died suddenly from syncope a fortnight later. 
No post-mortem examination was made. The mode of death 
makes it, on the whole, probable that the case was really one of 
Addison's disease. 



II. — Aberrant Form of Psoriasis. By W. Hale White, 
M.D. Exhibited November 29, 1884. 

CA., ddt. 32, presented himself to me at the out-patient 
• department of Guy's Hospital, with an eruption which 
he had had five years, and which had first appeared as a small 
pimple on the leg. Now it is situated chiefly on the extremities, 
but the knees and elbows are remarkably free. It is more on 
the extensor than on the flexor aspect and is remarkably 
symmetrical on the two extremities. This is best seen in the 
fold between the buttock and the back of the thigh. It is 
present on the back also. There the symmetry is so marked 
that it looks as though one side were an impression of the 
other, radiating as it does like the letter X from the centre of 
the back. There is a well-marked patch on the front of the 
body at the level of the xiphoid cartilage, extending round like 
a belt, most marked on the left side ; it is slightly to be seen at 
the back of the head at the margin of the hair^ slightly on the 



Living Specimens, 825 

face at the junction of the nose and orbit on the right side. 
It is absent on the scrotum^ the palms of the hands^ and soles 
of the feet. In many places it consists of circular rings with 
a margin one third to half an inch wide, with dark skin in 
the centre; the margin consists of a reddened base with 
several fine scales on it. Even where the circular arrangement 
is not evident the patches have the same characteristics. The 
dark skin in the middle shows that the disease spread from a 
centre in a circular manner ; this is seen on the back, where 
the X like arrangement is probably due to the coalescence of 
a circle on the upper part of the back with one on the lower 
part, for the skin is dark in both the upper and lower angles 
of the X. It is only irritable in cold weather ; it has got slowly 
worse during the last five years. There is absolutely no 
history of syphilis. The eruption was never moist. The 
treatment proposed to be adopted is tar ointment and large 
doses of arsenic. 



III. — A Case of Hypertrophy of the Subcutaneous 
Tissues of the Face^ Sandsy and Feet. By Charles 
A. Ballanoe and W. B. Haddbn, M.D. Exhibited 
January 23, 1885. 

THE patient was a married woman, aat. 35. She had had 
three children in ten years, but no miscarriages. There 
was nothing noteworthy in the family history. Up to two 
years and a half ago she had had no illness and was a strong 
hale woman. At that period scarlet fever broke out in the 
house and one of her children died. The patient herself had 
sorethroat and oedema of the feet, but no rash. She states 
that there was also dropsy of the hands at this time, but not 
of the face; but of this Mr. Dismorr, the practitioner in 
attendance, makes no mention in a letter which he was good 
enough to write us on the subject. 

The patient ascribes her present condition to the scarlet 
fever, although she admits she had tingling in the hands pre- 
viously. It must be mentioned also that the catamenia ceased 
a few months before the attack of scarlet fever, and have never 
reappeared. 

On examination we found the face large and puffy, 
and strikingly different from a photograph taken a few 



826 Living Specimens, 

montlis before the scarlatinal attack. Tlie nose was broad 
and the also nasi thickened. The lower lip was thick^ rose 
colonred^ and everted. The submaxillary glands were easily 
felt but not certainly enlarged. The neck was full, short, 
and the subcutaneous tissues seemed to be too abundant. 
The thyroid gland was normal in size. There was slight 
prominence above the clavicles. The clavicles themselves 
were much curved and distinctly larger and thicker than 
normal. The hands were remarkably large, the enlarge- 
ment being due to a thickening of the subcutaneous tissues, 
which was especially evident at the inner border of the hand. 
The skin was moist, and wrinkles were present on the backs 
of the fingers. The nails were large but otherwise appeared 
healthy. The phalanges and metacarpal bones were not 
enlarged. Each hand measured across the palm in circum- 
ference nine inches. Formerly she used to wear No. 7 gloves. 

The feet were more affected than the hands. The mea- 
surement around the foot about the centre was twelve inches. 
Before her present illness she used to wear large 4 boots, 
afterwards large 6, and now large 8. There was much sub- 
cutaneous thickening at the outer border of the foot, on the 
plantar surface, and below the internal malleolus, but very 
little over the dorsum. The thickened parts formed pads, 
which could readily be taken up by the finger and thumb. 
The hair on the scalp was soft and natural, and had no ten- 
dency to fall. The heart and lungs were healthy, and the 
urine was not albuminous. 

The speech was not slow, but was distinctly guttural. This 
was due to a very unusual enlargement of the tonsils, which 
interfered with speech, deglutition, and respiration. Indeed, 
it was for this affection that she came under the care of Mr. 
Ballance, who removed the tonsils. At the same time his 
attention ws,b called to the appearances above mentioned. 
The woman was active both in body and mind. The .skin of 
the body was natural and the perspiration free. There was 
no anaasthesia. 

The case in some respects resembled myxoedema, but 
many of the most striking characteristics of this disease were 
absent. The enlargement of the hands and feet was not like 
that we have seen in myxoedema. The skin was soft, moist, 
and supple, quite different from the dry scaly surface in 
myxoedema. 

Without pronouncing any definite opinion on the case, we 
consider that while it has some superficial resemblance to 



Living Specimens, 327 

myxoedema^ it probably does not depend upon the same patho- 
logical process, but is more nearly allied to those local fibro- 
ceUular pendulous hypertrophies which are seen occasionally 
affecting the buttock and elsewhere. 



IV — Maligna/nt Disease of the Pharynx^ Tonsil, Sfc. ; 
Gastrostomy . By 0. Stonham. Exhibited March 
13, 1885. 

RA., 89t. 37j came under notice in the beginning of 
• January. 

There was a history of '' ulcerated throat,'* dating twelve 
months. He was an in-patient at St. George's Hospital for 
fourteen days, but nothing was done locally. A doctor cauter- 
ised the throat three or four times. He had syphilis fourteen 
years ago, but the throat was not then affected. 

The growth extends down below the epiglottis, and involves 
the right side and the posterior wall of the pharynx, and also 
the right side of the posterior half of the tongue. The teeth 
have been removed on account of pain. 

February 5. — The growth is extending rapidly and the 
patient does not take any solid food, and only a very small 
amount of liquid, on account of the pain. 

February 17. — Gustrostomy performed. The stomach 
presented at once, and the lower part of the great curvature 
was attached to the peritoneum and skin by fourteen silk 
sutures. 

February 22. — Dressing (antiseptic) removed for the first 
time, and a small opening made in the stomach. A vulcanite 
female self -retaining catheter introduced. 

February 25. — ^All sutures removed. 

February 27. — Got up for the first time. 

Before the stomach was opened, patient was fed by means 
of nutrient enemata every two hours, only a little ice being 
given by the mouth on account of the dryness of the tongue. 
Since opening the stomach he has been fed by the fistula 
only. 

On an average he takes per diem, milk Oiss, beef tea Oiij, 
eggs iij, minced meat and biscuit powder once or twice daily, 
about yj I wine 5ii]. 



826 Living Specimens. 

montlis before the scarlatinal attack. Tlie nose was broad 
and tlie also nasi tkLckened. The lower lip was thick^ rose 
colonredj and everted. The submaxillary glands were easily 
felt bnt not certainly enlarged. The neck was full^ shorty 
and the subcutaneous tissues seemed to be too abundant. 
The thyroid gland was normal in size. There was slight 
prominence above the clavicles. The clavicles themselves 
were much curved and distinctly larger and thicker than 
normal. The hands were remarkably large, the enlarge- 
ment being due to a thickening of the subcutaneous tissues, 
which was especially evident at the inner border of the hand. 
The skin was moist, and wrinkles were present on the backs 
of the fingers. The nails were large but otherwise appeared 
healthy. The phalanges and metacarpal bones were not 
enlarged. Each hand measured across the palm in circum- 
ference nine inches. Formerly she used to wear No. 7 gloves. 

The feet were more affected than the hands. The mea- 
surement around the foot about the centre was twelve inches. 
Before her present illness she used to wear large 4 boots, 
afterwards large 6, and now large 8. There was much sub- 
cutaneous thickening at the outer border of the foot, on the 
plantar surface, and below the internal malleolus, but very 
little over the dorsum. The thickened parts formed pads, 
which could readily be taken up by the finger and thumb. 
The hair on the scalp was soft and natural, and had no ten- 
dency to fall. The heart and lungs were healthy, and the 
urine was not albuminous. 

The speech was not slow, but was distinctly guttural. This 
was due to a very unusual enlargement of the tonsils, which 
interfered with speech, deglutition, and respiration. Indeed, 
it was for this affection that she came under the care of Mr. 
Ballance, who removed the tonsils. At the same time his 
attention was called to the appearances above mentioned. 
The woman was active both in body and mind. The .skin of 
the body was natural and the perspiration free. There was 
no anaBsthesia. 

The case in some respects resembled myxoedema, but 
many of the most striking characteristics of this disease were 
absent. The enlargement of the hands and feet was not like 
that we have seen in myxoedema. The skin was soft, moist, 
and supple, quite different from the dry scaly surface in 
myxoedema. 

Without pronouncing any definite opinion on the case, we 
consider that while it has some superficial resemblance to 



Lwvng Specimens. 327 

myxoedema^ it probably does not depend upon the same patho- 
logical process, but is more nearly allied to those local fibro- 
cellular pendulous hypertrophies which are seen occasionally 
affecting the buttock and elsewhere. 



IV — Maligncmt Disease of the Pharynx^ Tonsil^ Sfc. ; 
Oastrostomy. By 0. Stonham. Exhibited March 
13, 1885. 

RA., 89t. 37, came under notice in the beginning of 
• January. 

There was a history of '' ulcerated throat,'* dating twelve 
months. He was an in-patient at St. George's Hospital for 
fourteen days, but nothing was done locally. A doctor cauter- 
ised the throat three or four times. He had syphilis fourteen 
years ago, but the throat was not then affected. 

The growth extends down below the epiglottis, and involves 
the right side and the posterior wall of the pharynx, and also 
the right side of the posterior half of the tongue. The teeth 
have been removed on account of pain. 

February 5. — The growth is extending rapidly and the 
patient does not take any solid food, and only a very small 
amount of liquid, on account of the pain. 

February 17. — Gastrostomy performed. The stomach 
presented at once, and the lower part of the great curvature 
was attached to the peritoneum and skin by fourteen silk 
sutures. 

February 22. — Dressing (antiseptic) removed for the first 
time, and a small opening made in the stomach. A vulcanite 
female self -retaining catheter introduced. 

February 25. — ^All sutures removed. 

February 27. — Got up for the first time. 

Before the stomach was opened, patient was fed by means 
of nutrient enemata every two hours, only a little ice being 
given by the mouth on account of the dryness of the tongue. 
Since opening the stomach he has been fed by the fistula 
only. 

On an average he takes per diem, milk Oiss, beef tea Oiij, 
eggs iij, minced meat and biscuit powder once or twice daily, 
about yj ; wine 5iii- 



Tkm mamt wwb Imnd 



fcih >tot ^u*^ i«ra«nihr «iittr9tB&. ISie uok w*b full, shoit, 

^nvirsr :trcts:i ,rtr^^ jasi isscanf^y jk^sit asui tkkiiHr than 
^TunC rW lifiivas^ ^r*n:^ :rjnntrrir:i>r lew*. Ae enSarge- 

^^hx^ ^«?». i^swrtuiirx i^^*?itf!ta S3 xitf imwr iwir&r ctf libe hand. 
rW $i%i: iiKiss^ »>n:^ jos£ '^rratii^ iwe?^ ppweBa cm the Incks 
vi ^!W -fcr^r^ Tisr lutik wt*f?^ JKW Vott ^njiiflninBe aj^peued 

im^i$i::c^ VjfcSk ^iiia}£ J isii c qjr jftc 3i5r,nK liir faulaa ia ciicinn- 

sMg^w w cti 4^^^it;2!^ xix* T,v« i»hv*tia li? .r^faic* ^wae Twelre indies. 

«c^^jrir«Tic%33i ij»r^ ?v. 4cr^ ivr^ iur« S^ !rb«* wms iEi«ii sab- 

^iiUi^aKr $ficr^Vv 4^ V Ccir ii<^ xLOfcrcniil aiaGtfccss^ but TCty 

^iv^ xVct^'i ryu»i.\^ W tifeibjin XT 'ix xb^ ii:£«r as>i ibamb. 
TW iij*ir ^nj: tij^ ^"uuT ^«T» :5ci?i ioji hooxaL 4t»i kad »o te»- 
^aettNTx tv*' t*Zl TW ^ls^«rt a3!C I ia5« ^nec^ iiwuxiiT, and the 

TW$y«<|^A^lr»lsN^$i;c^,>aa^•R» This 

mmsi ^S^- tw^ ;» Twr xxn^QsjiI ecLkr^?«iwitl ct lie icckslis*^ which 

M w*ji foe ti,55i *iSx'a:?ci3i xiir ^j^ -wacw^ xsjmt tie caure of itr. 
£jujftss>\ mW :t>riS3>^T^ t^ TCiitSL^ At t^ suae tme his 
%ttieei:^o^ w;ik$ Oju^';>^ ti^ t^ a?c^«m»c«is mK^T« meiLiz-csMd. 
Ti>^ wvcGKMi m:» ^c^tiT^ K^ti £x "io.^ 3cd3 atr»L Tie skin of 



T&e <iiksie iai SKMSfe^ T(etsl^^cits rosmiVJSed SLTxced^etia^ bat 

IT of tie s>ct5« sicniir^ ^i«rjfcrtrecK5x'T$ cf tiis disease wera 
mhseat^ Tie ecr.^air§yg2yc:i cf tie jn-Tvis arji feiet ^iras x>ot like 
that v^ haTe s^^eci un sjiTx^xcjecuk lie skrr vas isoft^ noist, 
acd saarrle* c^sdie dS^^ivsrt ircca tie drr sca^r ssacrface in 



Wixhcat pronooncis^ asT cefziie cc£:::>on on the case, we 
that while it has scoie SQfi{!iei6aal i^dsenfibbnce to 



LMmg Specimens. 327 

myxoedeina^ it probably does not depend upon the same patho- 
logical process, but is more nearly allied to those local fibro- 
cellular pendulous hypertrophies which are seen occasionally 
affecting the buttock and elsewhere. 



IV — Maligncmt Disease of the Pharynx^ Tonsil^ Sfc. ; 
Oastrostomy. By 0. Stonham. Exhibited March 
13, 1885. 

RA., 89t. 37, came under notice in the beginning of 
• January. 

There was a history of " ulcerated throat,'* dating twelve 
months. He was an in-patient at St. Greorge's Hospital for 
fourteen days, but nothing was done locally. A doctor cauter- 
ised the throat three or four times. He had syphilis fourteen 
years ago, but the throat was not then affected. 

The growth extends down below the epiglottis, and involves 
the right side and the posterior wall of the pharynx, and also 
the right side of the posterior half of the tongue. The teeth 
have been removed on account of pain. 

February 5. — ^The growth is extending rapidly and the 
patient does not take any solid food, and only a very small 
amount of liquid, on account of the pain. 

February 17. — Gastrostomy performed. The stomach 
presented at once, and the lower part of the great curvature 
was attached to the peritoneum and skin by fourteen silk 
sutures. 

February 22. — ^Dressing (antiseptic) removed for the first 
time, and a small opening made in the stomach. A vulcanite 
female self -retaining catheter introduced. 

February 25. — ^AU sutures removed. 

February 27. — Got up for the first time. 

Before the stomach was opened, patient was fed by means 
of nutrient enemata every two hours, only a little ice being 
given by the mouth on account of the dryness of the tongue. 
Since opening the stomach he has been fed by the fistula 
only. 

On an average he takes per diem, milk Oiss, beef tea Oiij, 
eggs iij, minced meat and biscuit powder once or twice daily, 
about 3i] ; wine ^j. 



826 Living Specimens, 

montlis before the scarlatinal attack. Tlie nose was broad 
and the also nasi thickened. The lower lip was thick^ rose 
colonred^ and everted. The submaxillary glands were easily 
felt but not certainly enlarged. The neck was fuU^ shorty 
and the snbcntaneons tissues seemed to be too abundant. 
The thyroid gland was normal in size. There was slight 
prominence above the clavicles. The clavicles themselves 
were much curved and distinctly larger and thicker than 
.normal. The hands were remarkably large, the enlarge- 
ment being due to a thickening of the subcutaneous tissues^ 
which was especially evident at the inner border of the hand. 
The skin was moist^ and wrinkles were present on the backs 
of the fingers. The nails were large but otherwise appeared 
healthy. The phalanges and metacarpal bones were not 
enlarged. Each hand measured across the palm in circum- 
ference nine inches. Formerly she used to wear No. 7 gloves. 

The feet were more affected than the hands. The mea- 
surement around the foot about the centre was twelve inches. 
Before her present illness she used to wear large 4 boots, 
afterwards large 6, and now large 8. There was much sub- 
cutaneous thickening at the outer border of the foot, on the 
plantar surface, and below the internal malleolus, but very 
little over the dorsum. The thickened parts formed pads, 
which could readily be taken up by the finger and thumb. 
The hair on the scalp was soft and natural, and had no ten- 
dency to fall. The heart and lungs were healthy, and the 
urine was not albuminous. 

The speech was not slow, but was distinctly guttural. This 
was due to a very unusual enlargement of the tonsils, which 
interfered with speech, deglutition, and respiration. Indeed, 
it was for this affection that she came under the care of Mr. 
Ballance, who removed the tonsils. At the same time his 
attention was called to the appearances above mentioned. 
The woman was active both in body and mind. The. skin of 
the body was natural and the perspiration free. There was 
no an89sthesia. 

The case in some respects resembled myxoedema, but 
many of the most striking characteristics of this disease were 
absent. The enlargement of the hands and feet was not like 
that we have seen in myxoedema. The skin was soft, moist, 
and supple, quite different from the dry scaly surface in 
myxoedema. 

Without pronouncing any definite opinion on the case, we 
consider that while it has some superficial resemblance to 



Living Specimens, 327 

myxoedema^ it probably does not depend npon the same patho- 
logical process^ but is more nearly allied to those local fibro- 
cellnlar pendulous hypertrophies which are seen occasionally 
affecting the buttock and elsewhere. 



IV — Maligncmt Disease of the Pharynx^ Tonsil^ Sfc. ; 
Gastrostomy, By 0. Stonham. Exhibited March 
13, 1885. 

RA.^ 89t. 37j came under notice in the beginning of 
• January. 

There was a history of '' ulcerated throat," dating twelve 
months. He was an in-patient at St. George's Hospital for 
fourteen days, but nothing was done locally. A doctor cauter- 
ised the throat three or four times. He had syphilis fourteen 
years ago, but the throat was not then affected. 

The growth extends down below the epiglottis, and involves 
the right side and the posterior wall of the pharynx, and also 
the right side of the posterior half of the tongue. The teeth 
have been removed on account of pain. 

February 5. — ^The growth is extending rapidly and the 
patient does not take any solid food, and only a very small 
amount of liquid, on account of the pain. 

February 17. — Gastrostomy performed. The stomach 
presented at once, and the lower part of the great curvature 
was attached to the peritoneum and skin by fourteen silk 
sutures. 

February 22. — ^Dressing (antiseptic) removed for the first 
time, and a small opening made in the stomach. A vulcanite 
female self -retaining catheter introduced. 

February 25. — ^All sutures removed. 

February 27. — Got up for the first time. 

Before the stomach was opened, patient was fed by means 
of nutrient enemata every two hours, only a little ice being 
given by the mouth on account of the dryness of the tongue. 
Since opening the stomach he has been fed by the fistula 
only. 

On an average he takes per diem, milk Oiss, beef tea Oiij, 
eggs iij, minced meat and biscuit powder once or twice daily, 
about 31] ; wine 5iii. 



826 Living Specimens, 

montlis before the scarlatinal attack. Tlie nose was broad 
and the alaa nasi thickened. The lower lip was thick^ rose 
oolonred^ and everted. The submaxillary glands were easily 
felt but not certainly enlarged. The neck was foll^ shorty 
and the subcntaneons tissues seemed to be too abundant. 
The thyroid gland was normal in size. There was slight 
prominence above the clavicles. The clavicles themselves 
were much curved and distinctly larger and thicker than 
.normal. The hands were remarkably large, the enlarge- 
ment being due to a thickening of the subcutaneous tissues^ 
which was especially evident at the inner border of the hand. 
The skin was moist^ and wrinkles were present on the backs 
of the fingers. The nails were large but otherwise appeared 
healthy. The phalanges and metacarpal bones were not 
enlarged. Each hand measured across the pahn in circum- 
ference nine inches. Formerly she used to wear No. 7 gloves. 
The feet were more affected than the hands. The mea- 
surement around the foot about the centre was twelve inches. 
Before her present illness she used to wear large 4 boots^ 
afterwards large 6, and now large 8. There was much sub- 
cutaneous thickening at the outer border of the foot^ on the 
Slantar surface^ and below the internal malleolus, but very 
ttle over the dorsum. The thickened parts formed pads^ 
which could readily be taken up by the finger and thumb. 
The hair on the scalp was soft and natural, and had no ten- 
dency to fall. The heart and lungs were healthy, and the 
urine was not albuminous. 

The speech was not slow, but was distinctly guttural. This 
was due to a very unusual enlargement of the tonsils, which 
interfered with speech, deglutition, and respiration. Indeed, 
it was for this affection that she came under the care of Mr. 
Ballancej who removed the tonsils. At the same time his 
attention was called to the appearances above mentioned. 
The woman was active both in body and mind. The. skin of 
the body was natural and the perspiration free. There was 
no an89sthesia. 

The case in some respects resembled myxoedema, but 
many of the most striking characteristics of this disease were 
absent. The enlargement of the hands and feet was not like 
that we have seen in myxoedema. The skin was soft, moist, 
and supple, quite different from the dry scaly surface in 
myxoedema. 

Without pronouncing any definite opinion on the case, we 
consider that while it has some supei^cial resemblance to 









s 



«T- ' . I. . — **■' * iiMii B r «-<>w*'flri; 'S^-.Ttr Tlfr*^^ 






• •••• ^ 



tbe T^gif «ai& ^lii "^^^^ w»srr/^ ^. * :**»- ,;i««r^ 
the TL^ sae: if roigr >5«Krr^ :Bi*i ^ ^^ ►^--s?:**'. 
bare utea. ^Bfflcr^ lit jesrmMf r 5ws- _ ^ ^ 






* >vt. »>• VUJ ^ '^•^^ 












* j^jt *. 



Before tift i««KKl» *a« «f«aed, prtieiit w«afcd by WW*^* 

of nntrieat earaisto erery tw^ft i«i«, <H>fy • li"i* *^^^ ^^^'^'^ 
siren br the mwli » aemimt of the diynees of t*^ «>;)W^^^j;^ 
Si!ce ^emng Ae rt««iact he has been fed by Uv* «*t«H 

*^dn aa arerage he takes per diem nulk Oi-. WvJ »>>V^v\^ 
eggaSj, nrincedlinea* and Wacuit powder ouoo vw» ♦VfW'^ v^^V^ v 
about ^ ; wine Jnj. 



826 Living Spedmens. 

montlis before the scarlatinal attack. Tlie nose was broad 
and the alaa nasi thickened. The lower lip was thick^ rose 
colonred^ and everted. The submaxillary glands were easily 
felt but not certainly enlarged. The neck was full^ shorty 
and the subcutaneous tissues seemed to be too abundant. 
The thyroid gland was normal in size. There was slight 
prominence aboye the clavicles. The clavicles themselves 
were much curved and distinctly larger and thicker than 
normal. The hands were remarkably large^ the enlarge- 
ment being due to a thickening of the subcutaneous tissues^ 
which was especially evident at the inner border of the hand. 
The skin was moist^ and wrinkles were present on the backs 
of the fingers. The nails were large but otherwise appeared 
healthy. The phalanges and metacarpal bones were not 
enlarged. Each hand measured across the palm in circum- 
ference nine inches. Formerly she used to wear No. 7 gloves. 

The feet were more affected than the hands. The mea- 
surement around the foot about the centre was twelve inches. 
Before her present illness she used to wear large 4 boots^ 
afterwards large 6, and now large 8. There was much sub- 
cutaneous thickening at the outer border of the foot^ on the 
plantar surface^ and below the internal malleolus, but very 
little over the dorsum. The thickened parts formed pads, 
which could readily be taken up by the finger and thumb. 
The hair on the scalp was soft and natural, and had no ten- 
dency to fall. The heart and lungs were healthy, and the 
nrine was not albuminous. 

The speech was not slow, but was distinctly guttural. This 
was due to a very unusual enlargement of the tonsils, which 
interfered with speech, deglutition, and respiration. Indeed, 
it was for this affection that she came under the care of Mr. 
Ballance, who removed the tonsils. At the same time his 
attention was called to the appearances above mentioned. 
The woman was active both in body and mind. The. skin of 
the body was natural and the perspiration free. There was 
no ansDsthesia. 

The case in some respects resembled myxoedema, but 
many of the most striking characteristics of this disease were 
absent. The enlargement of the hands and feet was not like 
that we have seen in myxoedema. The skin was soft, moist, 
and supple, quite different from the dry scaly surface in 
myxoedema. 

Without pronouncing any definite opinion on the case, we 
consider that while it has some supei^cial resemblance to 



Living Specimens. 327 

myxoedema^ it probably does not depend npon the same patho- 
logical process^ but is more nearly allied to those local fibro- 
ceUular pendulous hypertrophies which are seen occasionally 
affecting the buttock and elsewhere. 



IV — Maligncmt Disease of the Pharynx^ Tonsil^ Sfc. ; 
Oastrostomy. By 0. Stonham. Exhibited March 
13,1885. 

RA.^ 89t. 37j came under notice in the beginning of 
• January. 

There was a history of ''ulcerated throat,'* dating twelve 
months. He was an in-patient at St. G-eorge's Hospital for 
fourteen days, but nothing was done locally. A doctor cauter- 
ised the throat three or four times. He had syphilis fourteen 
years ago, but the throat was not then affected. 

The growth extends down below the epiglottis, and involves 
the right side and the posterior wall of the pharynx, and also 
the right side of the posterior half of the tongue. The teeth 
have been removed on account of pain. 

February 5. — ^The growth is extending rapidly and the 
patient does not take any solid food, and only a very small 
amount of liquid, on account of the pain. 

February 17. — Gastrostomy performed. The stomach 
presented at once, and the lower part of the great curvature 
was attached to the peritoneum and skin by fourteen silk 
sutures. 

February 22. — Dressing (antiseptic) removed for the first 
time, and a small opening made in the stomach. A vulcanite 
female self -retaining catheter introduced. 

February 25. — ^All sutures removed. 

February 27. — Got up for the first time. 

Before the stomach was opened, patient was fed by means 
of nutrient enemata every two hours, only a little ice being 
given by the mouth on account of the dryness of the tongue. 
Since opening the stomach he has been fed by the fistula 
only. 

On an average he takes per diem, milk Oiss, beef tea Oiij, 
eggs ii], minced meat and biscuit powder once or twice daily, 
about 31] ; wine 5iii- 



328 Living Specimens, 

The gastric jnice never escapes^ nor are the edges of the 
wound digested. 

Weight, March 4, 8st. 71b. ; 11, 8st. 51b. 

He feels satisfied with the amount of food given. 

The pain in the throat is less since the operation, and the 
patient looks much better. 

P.S. Patient lived five months after the operation, by which 
he was much benefited. 



V. Two Gases of Wiring Ununited Fractures. By 0. 
Macnamaba. Exhibited March 13, 1886. 

I AM anxious to bring these patients before the members of 
the Clinical Society, to demonstrate the advisability of 
employing early passive motion of the knee- and elbow-joints, 
after wiring an ununited patella or olecranon process. 

Case 1 is that of F. G., aet. 25, admitted into the West- 
minster Hospital, on October 22, 1884. This patient 
was a seaman in the Eoyal Navy ; he fell and fractured the 
patella of his left leg on the 9th of the previous March. After 
the accident F. G. was under treatment for nine weeks ; he then 
left the hospital still very lame, and he asserts he could pass 
his two fingers between the extremities of the ununited bone. 
On October 3 the patient slipped and inflicted further injury 
to the left leg. In these circumstances he was taken into the 
Westminster Hospital for operation. 

Case 2 is that of W. H., est. 32, a labourer, admitted 
into the Westminster Hospital on January 23, 1885. In 
the previous October he fell and fractured the olecranon 
process of his right ulna ; he was under treatment for some 
weeks, but when the splints had been removed it was found that 
union had not taken place between the ends of the broken 
bone. The patient attempted to resume his work, but the 
strength and use of his arm was so much impaired that at 
his own request an operation was undertaken on January 
28, in order to retain the fractured olecranon in contact 
with the ulna. I employed the Listerian system of dressing 
in both cases ; and, with the valuable aid of Mr. A. B. Barrow, 
removed a thin slice from the surface of the fractured bones. 
Holes were then bored through the ends of the ununited bone. 



Living Specimens^ 329 

and thick silver wire having been passed through the holes into 
the extremities of the ununited fracture, were securely brought 
together. I bored directly through the bones so that in both 
cases a loop of silver wire pressed into the joints. This enabled 
me to use considerable force in bringing the ends of the bones 
together, without the fear of the wire cutting through the bone 
from traction made upon it by the muscles. I found in the 
case of the patella, however, that the rectus exerted so much 
force in preventing the upper fragment from coming into 
apposition with the lower one, that I divided a considerable 
portion of the tendon at its insertion into the patella. The 
knee- and elbow-joints were laid open and exposed to the air 
and a certain unavoidable amount of rough treatment during 
the operation, but in neither case were there any subsequent 
local or constitutional symptoms. I may mention that in both 
cases at the time of the operation interrupted splints were 
secured to the limbs by means of gum and chalk bandages. 
These splints were not removed until three weeks after the 
operation, when passive motion of the knee and of the elbow- 
joint was commenced. I wish to lay stress on this method of 
treating these cases (not that the practice is anything new), 
but from my own experience their success depends largely on 
keeping the limb after the operation absolutely at rest ; and 
this can only be done by means of some such bandage as that 
to which I have referred. Passive motion also must as a rule 
be commenced from three weeks to a month after the opera- 
tion. The silver wire can be felt beneath the skin on the 
surface of the patella and of the olecranon in both these 
patients, but the fractured ends of the bones have united firmly 
and so completely that it is impossible to feel where the dis- 
union had occurred. The patient's limbs are as strong and as 
useful as they were before the bones were fractured. 



VI. — A Case of Ununited Fracture of Bight Olecranon 
Wired Antiseptically. Close Union. By Rushton 
Pabker, B.S. Exhibited April 24, 1885. 

MR. S., aet. 21, fell off a bicycle in Wales about the middle 
of June, 1884. Was skilfully treated by a medical man, 
but disturbed the fragments himself after a fortnight by 



830 Livmg Specimens. 

improper use of the limb. By the end of September, hopeless 
non-union was established. Antiseptic suture under Listerian 
carbolic acid arrangements, with copper bell-wire embedded 
and left in October 7, 1884. Uncomplicated recovery after a 
two or three days' simple traumatic fever; union chiefly 
primary, the rest by granulation, but with no suppuration, 
tension, or avoidable inflammation. Drainage-tube removed 
at the third dressing on the third day. The elbow treated at 
an angle throughout ; rather more than a right angle the first 
day, flexed up to rather less than a right angle on third day 
and kept at that. Wire remains in. 



YU.— Paralysis of the Left Fifth Nerve. By F. W. 
Steugnell. Exhibited April 10, 1885. 

ON February 18, the patient, a man 8Dt. 49, had violent pain 
of neuralgic character over left side of head with slight 
numbness of the part affected. 

February 19. — Complete loss of sensation of the left side 
of the face and parts supplied by the fifth nerve. Partial 
dilatation of the left pupil, which does not act. Earache on 
the left side ; severe catarrhal ophthalmia. Does not feel 
continuous current from thirty-cell battery. 

February 24. — Cornea of left eye has become hazy. 

March 17. — Pain of severe character in left arm and forearm, 
cornea sloughing. Thickening of zygoma on left side. 

March 27. — Small tumours noticed in different parts of the 
body. 

The patient has had syphilis. 

Treatment. — Large doses of potass, iodidi. 



VIII. — Successful Thyrotomy for Papilloma with pre- 
servation of voice. By R. W. Parkee. Exhibited 
April 24, 1885. 

MARTHA Gr., 86t. 5, was operated on seven months ago. 
At the time she was suffering from urgent dyspnoea due 
to papilloma of the vocal cords. The child had been ^^ gruff '* 



Living Specimens, • 831 

smce she began to talk^ and there had been increasing dyspnoea 
with exacerbations from time to time. The child has re- 
covered witlL preservation of the voice. 



IX. — A Case of Osteitis Deformans, By Stephen 
Mackenzie, M.D. Exhibited April 24, 1885. 

MC.^ a woman aet. 48. Aboat five and a half years ago the 
• leg bones were noticed to gradually become bent and 
bowed^ and at the same time she experienced in them aching 
pains. Four and a half years ago she broke both bones of the 
left leg by slightly knocking against a stool; she did not fall. 
Seven and a half years ago she had some internal illness^ 
which left her weak for a long time. 

There is no history of similar affection nor of carcinoma 
in fajnily. Her father died of phthisis. 

Both femurs, tibi89 and fibul89, bend outwards and forwards 
BO as to form a continuous curve, causing extreme bowing of 
the lower extremities. The heels and toes can be apposed, 
but the knees remain widely apart. The bones appear thick- 
ened. There is a forward stoop, and some stiffness of neck. 
No enlargement of the head. No affection of the upper 
extremities, with the exception of some thickening of the left 
clavicle. 

Aching pain is more or less constantly experienced in the 
affected bones. 



X. — Hereditary Multiple Tumours, By Stephen Mac- 
kenzie, M.D. Exhibited April 24, 1885. 

EG. B., set. 85. At the age of nineteen the patient acci- 
• dentally discovered a lump in the buttock, and subse- 
quently found numerous others in various parts. He has counted 
from fifty to a hundred. They have increased in number and size 
since he first observed them but not for some years. They appear 
to follow no regular order in distribution and have caused him 
no pain or inconvenience except when pressed upon. He has 



332 Living Specimens, 

had rheumatoid arthritis. A brother, aged thirty-seven, also 
has a number scattered about body ; they were first noticed 
when he was fourteen years of age. He thinks they have 
remained stationary in size and that no new ones have been 
developed for many years. He has no pain or inconvenience 
from them unless they are pressed upon. He has never had 
rheumatism in any form. An elder brother, now about fifty 
or fifty-two, has one tumour for certain and possibly more. 

Their mother, aged seventy-two, seen in 1881, when she 
had one tumour, about the size of a pea, on the inner side of 
the arm, and another on the extensor surface of one forearm. 
She stated she had one on the thigh, but it could not be dis- 
covered. They were all painless unless pinched. She has 
had more but they have disappeared. She had rheumatic 
fever when thirty, and attacks of subacute rheumatism subse- 
quently. 

The tumours in all cases have felt firm, somewhat lobulated, 
and subcutaneous. They appear to be lipomata or fibro- 
lipomata. The chief interest in the cases is their hereditary, 
and probably congenital origin. 



XI. — Two Gases of Myxcedema. By J. Hopkins. 

Exhibited May 8, 1885. 

CASE 1 kindly supplied by Dr. Suckling, of Birmingham 
(copied from Myxcedema Schedule issued by Clinical 
Committee). — ^Mrs. H., 8Dt. 57. Working class. Mother died 
of phthisis. Father of plumbism. Sister died of myxcedema. 
No syphilis or alcoholism. No mental disturbance. Consider- 
able trouble and worry. Catamenia, excessive at the last, 
ceased at forty-seven. Pregnant three times. Two children 
survive. Had one miscarriage. The children were born before 
the establishment of myxcedema. She lived in Birmingham 
fourteen years; previous to that sixteen years in Hammersmith. 
The symptoms were first noted when she was fifty-four years 
old; first in eyelids. The face is large and oedematous and 
the skin clear, translucent, with oedema of both eyelids, espe- 
cially the lower. 

She is a big woman. Skin of body dry and scurfy. Supra- 
clavicular regions fatty^ and great prominence of these regions. 



Living Specimens. 333 

Skin of extremities dry and does not perspire; hands not 
spade-like, nails normal. Hair scanty, has come off much 
lately. Thyroid body she says has been enlarged. At present 
it cannot be felt. Temperature in the mouth 99° P. No 
dropsy. Sensation normal; feels cold; no occipital headache; 
no paralysis ; retardation of motion. She had a bad fall at 
Christmas, 1883. No convulsions. Superficial reflexes dimi- 
nished; deep reflexes normal. Slowness of intellect. Bad 
memory for recent events. Placid disposition. (Here several 
negatives omitted.) Speech slow and when she talks she feels a 
difficulty, as if her tongue would not move. Byes, &c., normal. 
Heart normal; pulse 60. Respiratory and digestive system 
normal. No teeth at all for the last three years; gums 
atrophied; tongue large and pale; uvula and soft palate 
normal. Defaecation normal. Lymphatics normal. 

Urine clear, copious, about three pints daily. Sp. gr. 1024. 
(This was exceptional urine; this day being scanty.) Acid 
and no albumen. Colour pale yellow. Micturition two or 
three times during the night and frequently during the day. 
The lower lip is very thick, pendulous, and cyanotic. 
Notes by Exhibitor. — ^Mrs. H. has two daughters. The 
eldest, twenty-seven, has bad sick headaches; the other, twenty- 
one, has bad headaches, not accompanied by sickness. 

Mrs. H. already had a broad parting of the hair when a 
young woman. Urine at present time contains a little albumen. 
(For family history see accompanying case, Mrs. B.) 
Case 2. — Mrs. B., set. 47, myxoedema in two sisters. 
Present state. — Cheeks and lower part of face thick and 
pendulous. Eyelids oedematous ; nose broad ; speech thick ; 
teeth loose; gums retracted and atrophied; body fat, and 
abdomen large. 

Absence of lumps above clavicles, of waxy blue lips, of loss 
of hair, of patches of dilated capillaries in cheeks and of slow- 
ness of movements, &c. 

Symptoms. — Flushing and sweating of face, which some- 
times becomes the blue-red of ^' pickled cabbage." Slavers 
upon her pillow at night. Difficulty in swallowing small 
morsels, and food often sticks in the throat, producing choking. 
Sleep is light and troubled by worrying dreams. Awakes 
with distressing headache and heaviness of eyehds. Morning 
vomiting. *^Pins and needles " in hands and feet, and bouts 
of sudden involuntary movements of legs. Tinnitus aurium 
and musc8B voHtantes. Painful indigestion. 

History. — ^Was always very thin till of late years. Attacks 



834 Living Specimens. 

of headaclie whole life, often with sickness. Thyroid enlarged 
when a young woman. Menstruation irregular before 
marriage. One pregnancy. The patient has had a good deal 
of pain about sacrum since eighteen years old and tender 
spines of vertebrse. Has noticed fulness of lids and of lower 
part of face for some years. Has lost many teeth during the 
past two or three years; they have "turned to chalk" and 
come away whole. Her hair came out in great abundance 
during 1888. No history of syphilis or alcohol. 

Family history. — ^Father had lead-poisoning and is said to 
have died at sixty-three of abscess of liver. Mother died at 
thirty-five of phthisis. One brother phthisical and another 
had had rheumatic fever and neurosis of jaw. Two sisters 
older than patient. One, Mrs. H. (exhibited), has myxoedema ; 
the other, Mrs. K., died of it in 1884. (Case reported in 
Lancet, vol. ii, 1881). Mrs. K.^s eldest daughter has bad 
headaches, flushes and perspires much about the face, has an 
enormously large abdomen, severe pain about the sacrum, and 
tumbles about very much. The patient^s son siifiers from 
headaches. 

Rema/rks. — Many of the symptoms of myxoedema point to 
the sympathetic system. The history of this family does so 
more definitely. All except Mrs. H. siifier from headache or 
sick headache. Two flush and perspire abnormally. The two 
exhibited have had enlarged thyroids. 

Perhaps flushing, inordinate sweating, sacral pain and 
enlarged abdomen will be found to be, in some cases at least, 
the first symptoms of the disease to appear. 



4 
\ 



Xn, — Cervical Bib. By W. Aebuthnot Lane, M.S., 
and W. Hale White, M.D. Exhibited May 22, 

1885. 

THE man has a movable cervical rib on the left side. Its 
full length is about If inches. It appears to terminate in 
a pointed extremity from which a short tendinous band extends 
to the upper margin of the first thoracic rib. The scalenus 
medius is inserted into its whole length, and the scalenus 
anticus has a less defined lower origin than that on the right 
side. The scalene tubercle is very indistinct. There is no 
marked displacement of the subclavian artery. It seems to 



Living Specimens. 335 

cross tlie first rib at the inner limit of tlie attacliment of the 
fibroas prolongation from the cervical rib. The lower cords 
of the brachial plexus lie on the cervical rib and are in conse- 
quence much more easily felt than on the opposite side. The 
span of the first left thoracic rib is not markedly greater than 
that of the rights although its cartilage is distinctly thicker and 
larger j this causes the inner end of the clavicle to be more 
prominent than its fellow. The clavicles are of equal length. 
There is no indication of a cervical rib on the right side, nor 
any particular prominence of the transverse process of the 
seventh cervical vertebra. The right first thoracic rib is 
apparently normal. There is no disproportion in the size of 
the manubrium and gladiolus. Seven cartilages articulate 
symmetrically with the sternum. Twelve ribs are present on 
either side, the last is about 4 inches long. The cervical rib 
produces a distinct and characteristic prominence in the left 
side of the neck, which presents a striking contrast to the 
normal curve on the right side. This appearance is exag- 
gerated by the absence of subcutaneous fat. This case presents 
none of the more obvious modifications in the form of the ribs 
and sternum which have been shown to be characteristic of the 
presence of cervical ribs {" Cervical and Bicipital Ribs in Man," 
Ouy'a Hosp. Sep., vol. xlii) ; at the same time it must be 
remembered that the left rib is a small one and that there is 
only one present in this specimen. ^ 



XIII. — Fractwre of Larynx. By W. Abbuthnot Lane, 

M.S. Exhibited May 22, 1885. 

FA. — Eight months ago this man received a heavy blow 
• from a fist on the right side of his neck. This caused 
him very great pain, and a chokincf sensation in his throat 
with inability to speak. This lasted for a few minutes. For 
twenty-four hours he was only able to speak in a whisper, and 
it was not for three or four days that he was able to speak 
with his natural voice. For three days he suffered from pain 
in swallowins*, which he referred to the region of the larynx. 
After these few days all difficulty in swallowing and all feeling 
of discomfort passed away, and his throat felt as natural as it 
did before the injury. 



336 Living Specimens, 

The angle between the ake of the thyroid cartilage is 
somewhat increased. Both superior comua have been 
broken obliquely from the angles of the al89, which are seen 
to be rounded, as in those specimens I showed at the Patho- 
logical Society, and which are described in my paper, " Frac- 
tures of the Larynx and Hyoid Bone" {Trans, Path, Soc, 1884), 

The right great cornu of the hyoid presents a distinct 
irregularity at its centre, the posterior half passing obliquely 
inwards from the direction of the anterior. It is impossible to 
to say whether this irregularity is traumatic or not, owing to 
the thickness of the structures over it. 



XIV. — A Case of Raynaud^ s Disease. By A. T. 
Myees, M.D. Exhibited May 22, 1885. 

I HAVE been most kindly allowed by Dr. Cavafy to bring 
forward a case which is under his care, and before I 
attempt to describe it I ought to acknowledge my obligations 
to him and to Dr. H. T. Griffiths, the Medical Registrar of 
St. George's Hospital, to whom I owe many of the particulars. 

The patient, Tracy T., is a boy set. 12, rather pale, but 
otherwise healthy looking, who bears the scars of symmetrical 
gangrene of the ears, and is suffering at present from 
paroxysmal haemoglobinuria with some tendency to recurrence 
of the gangrene. The parents and the five brothers and 
sisters, whom I have seen, exhibit no similar symptoms. 
There is no syphilis in the family and no ague. They have 
lived since before this boy's birth in a suburb of Cheltenham 
in which no malaria is to be found after careful inquiry. 

About five years ago, when the boy was seven years old, 
and apparently soon after measles, the first attack of 
paroxysmal haemoglobinuria took place. About the same 
time, or soon after it, the ears were noticed to be very much 
cyanosed when the boy was chilly, and ached much as he got 
warm. A little later the physician in charge of him at the 
Cheltenham General Hospital, Dr. E. T. Wilson, despribes 
gangrene of both ears, with a mottled and pasty look, probably 
the tachetee of Raynaud. This gangrene recurred or recrudesced 
some eight or ten times between 1880 and 1883, always in the 
winter, and destroyed a small portion of the helix and concha 



Living Specimens, 337 

of each ear, very nearly but not absolutely symmetrically. 
For the last two years there has been no more actual gangrene, 
but extreme cyanosis on exposure. Meanwhile the attacks of 
paroxysmal haemoglobinuria have never been absent for very 
long during these last five years, though much more frequent 
in winter than in summer. There is an imperfect history of 
occasional red itching patches scattered over the skin which 
may possibly represent one of the skin manifestations of the 
asphyode locale. 

Since January 14, 1885, he has been under Dr. Cavafy's 
care in St. George's Hospital. The scars of the first symme- 
trical gangrene of the ears are plain, and almost any exposure 
to cold is followed by cyanosis, tenderness, and aching in them. 
During these four months in the hospital he has had twenty-two 
attacks of paroxysmal haemoglobinuria which have been similar 
in all their main points. The first symptoms have been what 
have been so often described as premonitory in this disease, viz. 
yawning and lazy stretching of the limbs with Uttle rigor or 
subsequent flush. With these the patient is very familiar as 
leading almost invariably to the passage, within an hour or so, of 
water of the colour of porter or old ale and as a rule tolerably 
clearly transparent. 

The abnormal colour is rarely observable for more than 
three or four hours ; the water is passed often, scalds him 
slightly, and changes back from the abnormal to the normal 
very rapidly, the albumen, which sometimes amounts on boiling 
to as much as one half in the paroxysmal attack, disappearing 
as completely and nearly as rapidly as the discolouration. The 
interparoxysmal urine has been perfectly normal. Repeated 
examination with the microscope has failed to show any com- 
plete blood-cells in the water; once or twice thin, almost 
colourless stromata of blood-cells have been noticed, from 
which probably the hsBmoglobin has been separated. There 
is also a considerable amount of granular detritus, varying in 
colour from tawny yellow to dusky red, and, with this, occa- 
sional renal casts containing pigmented granules. 

The blood also was examined several times during the 
attacks, taken from the ears when cyanosed and from the hand. 
The coloured corpuscles were fairly normal in outline, but 
sometimes had crenate edges ; there was always an abnormal 
disinclination to form rouleaux, as Boas and others have 
noticed ; and sometimes, but not always, blood-flakes, as they 
have been called, were found, varying in colour from a deep, 
reddish black to a thin transparent red, and in size from about 

VOL. zviu. 22 



338 Living Specimens. 

fonr to ten times as large aBanormal coloured corpuscle. On 
one occasion they seemed to be contained in a transparent 
envelope^ and to be themselves somewhat granular^ shading 
off into the colourless envelope. These were the chief sym- 
ptoms of the blood dissolution. 

On May 12^ after the boy had been free from any attack 
for six weeks, his left hand was put into a bowl of ice and 
water for ten minutes, and, though there were no immediate 
effects, yet next morning and on the mornings of the two 
following days he had a recurrence of the paroxysmal attacks 
with a feeling of numbness in the left hand, and the same 
symptoms of dissolution in the blood drawn from his left hand. 
In other cases where similar experiments have been made the 
results of artificial chill have been more rapid and the causal 
connection more indisputable. Still in this case it is worth 
notice that the only attacks during the last nine weeks were on 
those three days following the chiUing of the left hand. 

It is also worth recora that for five days (April 23 — 28) he 
had a sharp attack of pleurisy and pneumonia, following 
apparently on slight exposure; the lower half of the left lung 
was consolidated, the temperature reached 104*5^, and it ended 
favorably by crisis ; but during this sharp fever there was no 
haBmaturia of any kind nor even albuminuria. The paroxysmal 
attacks in some cases, but by no means in all, were accompanied 
by a slight rise of temperature to about 100^ F., for a few 
hours ; after the attacks there was slight but distinct icterus 
lasting as a rule about twenty-four hours. The spleen is very 
slightly enlarged, but no definite temporary enlargement 
during the paroxysms has been established. 



REPORT 

OP A 

COMMITTEE OF THE SOCIETY NOMINATED NOVEMBER 10, 1882, 

TO INVESTIGATE 

SPINA BIFIDA 

Ain> ITS 

TREATMENT BY THE INJECTION OF DR. MORTON'S 

lODO-GLTCERINE SOLUTION. 

Bead May 22, 1885. 



•««•• 



Befobb attempting to discuss tlie results of the treatment 
of spina bifida by Dr. Morton^s or other methods^ it has been 
thought of essential importance to determine more dearly than 
has hitherto been done the pathological conditions included 
under this term. 

With this object we have undertaken an examination of 
all the specimens contained in the London museums as well as 
those in Cambridge and Glasgow^ and sundry others which 
have been placed at our disposal by different contributors to 
this report. The importance of this inquiry may be judged 
from the fact that in England alone^ as may be seen from the 
Begistrar-Greneral's report^ no less than 647 deaths from spina 
bifida occurred in 1882^ of which 615 were in children under 
one year of age. 

Although the literature of spina bifida is large it is so 
unsatis&ctory and inexact that the Committee have decided to 
found their report on the examination of the specimens already 
alluded to, and on cases which have either been under their 
own immediate treatment or especially reported to them for 
the purpose of this investigation. 

The subject will therefore be considered in two parts : 1. 
Pathological. 2. Clinical. 



840 B^ort of the Oommittee on Spina Bifida, 

1. Pathological Anatomy. 

The term spina bifida, which, was first used by Nicolai 
Tulpius* about the early part of the seventeenth century, is 
employed to define certain congenital malformations of the 
vertebral canal with protrusion of some of its contents in the 
form of a fluid tumour. With very rare exceptions the mal- 
formation affects the neural arches of the vertebras, and the 
tumour projects posteriorly ; in rare cases, however, the mal- 
formation involves the bodies of the vertebras, the tumour in 
such cases protruding anteriorly into the thorax, abdomen, or 
pelvis between the lateral halves of the bodies affected. 

The main bulk of specimens may be classed under three 
chief divisions, of which the second is by far the most nume- 
rous : — 

1. Protrusion of the membranes only, spinal meningocele. 

2. Protrusion of the membranes together with the spinal 
cord and its appertaining nerves, meningo-myelocele. 

3. Protrusion of the membranes together with the spinal 
cord, the central canal of which is dilated so as to form the 
sac cavity, the inner lining being constituted by the expanded 
and atrophied substance of the cord, syringo-myelocele. 

The pathological anatomy of these lesions is strictly parallel 
with those occurring in the head, and known under the terms 
" meningocele " and '' encephalocele.^' The affection, indeed, 
may implicate both head and spine, as in the occipito-cervical 
cases, of which specimens exist in the museum of the Boyal 
College of Surgeons. The present report, however, has refer- 
ence to the spine only. The specimens are discussed under 
some of the following headings : 

1. Position of the tumour. 

2. Size and form of the tumour, whether pedunculated, 
sessile, or intermediate. Presence of an umbilicus, or of a 
longitudinal furrow or other subdivision. 

3. Coverings of the sac; the extent of the cutaneous 
investment, of the " membranous '' area, of '^ ulceration " (if 
any). 

4. Disposition of the meninges within the tumour. Seat 
of the fluid. Nature of the fluid. 

5. Size and configuration of the deficiency in the neural 
arches. 

* Observationes MedM€B, Liber 2, caput xxx, p. 281 ; " Spina dorsi bifida," 
Amstel., 1685. 



Beport of the Oommittee on Spi/na Bifida, 341 

6. Disposition of the cord and nerves. 

7. Unusual variations, (a) Subdivision of sac, complete or 
partial, by partitions, (b) The presence of bony outgrowths 
across the spinal canal in the neighbourhood of the tumour. 

8. The process of cure. 

9. Theoretical considerations, drawn from the anatomical 
facts. 

1. Spinal meningocele. — Of the 125 specimens of spina 
bifida which we have examined in the various museums before 
referred to, 10 were examples of meningocele. The deformity 
may occur in any region. So far as our examination of 
specimens allows us to generalise, the deficiency in the 
neural arches in these cases is usually limited to a 
small area; sometimes the protrusion occurs between the 
arches of two adjacent vertebrsB without their being in any 
way deficient. 

On the other hand, the neural arches may be deficient for 
a considerable extent, the neck of the sac being comparatively 
small, as in Specimen No. 1 of our List (R. C. S. Teratological 
Series, No. 271), p. 864, where the arches of the last lumbar and 
all the sacral vertebrae consist chiefly of membrane, and the neck 
of the sac does not exceed the size of a goose-quill. We have 
seen no specimen illustrating what we assume to be the typical 
form of spinal meningocele, that is to say, a sac composed of 
dura mater and arachnoid (the so-called visceral layer) com- 
municating with the general cavities of the spinal membranes, 
invested with normal skin, and tending to be pedunculated. 
In some probably rare cases the sac is double within, com- 
posed of distinct portions beneath a single cutaneous covering, 
the pedunculated communication with the general spinal 
cavities being also double, as in Specimen No. 2 (St. George's 
Hosp. Museum, No. 15h). In other cases the spinal cord 
opposite the opening becomes slightly prolapsed or displaced 
back BO as to lie in the neck of the sac and to more or less 
occlude it. This condition is represented in Plate XIII, from 
Specimen No. 3 (Glasgow Royal Infirmary Museum, No. 
145) ; the line of origin of the nerves from the spinal cord 
deviates but little, the nerves not beiiig in any way involved 
in the protrusion. A similar but less marked condition is 
shown in Plate XTV", fig. 1, Specimen No. 4, a cured meningo- 
cele (Glasgow Western Infirmary Museum, Series I, No. 2). 
Specimen No. 5 (St. Bartholomew's Hospital Museum, No. 
3486) is the greater portion of the sac of a meningocele, suc- 



c 



342 Meport of the Committee on Spina Bifida. 

cessfolly excised (and reported upon in Pathological Society^s 
TransactionSf vol. xiv^ p. 214^ 1863). In tliis specimen the 
sac is umformly thick except at its summit^ where there is a 
longitudinal depression^ unpigmented and smooth. There is 
no corresponding eminence on the opposite aspect of the sac^ 
that is to say^ the depression affects the proper substance of 
sac-wall. Microscopic examination shows this depressed por- 
tion to be devoid of hairs and glands^ in marked contrast to 
the adjoining healthy skin. This portion of the sac is composed 
of fibrous tissue continuous with that of the corium and having a 
similar arrangement except that there is no papillary structure. 
The deeper layer of the epidermis is continued over this surface^ 
the outer layers being lost through partial maceration^ and 
the same is true of the adjoining normal skin. Vessels in this 
depressed area are visible and appear proportional to the 
amount of fibrous tissue of which it is composed. 

Specimen No. 6 (St. Bartholomews Hospital Museum^ 
3483) represents the parts concerned in a sacro-coccygeal 
meningocele^ after destruction of the sac ; the terminal portion 
of the cord^ cauda equina and filum terminale can be seen lying 
at the bottom of the vertebral furrow in the normal position. 
We have under observation a child presenting a small tumour in 
this region, which it may be assumed is a simple meningocele ; 
the skin over it is perfectly normal. The tumour does not 
increase ; it measures at its base 1*5 cm. in diameter and it is 
elevated about *5 cm. at its centre. The child is healthy and 
free from all symptoms. 

From the scarcity of specimens of meningocele in museums 
it may be inferred that this form of lesion (which sometimes re- 
mains in statu quo^ and sometimes undergoes spontaneous cure) 
is much less &tal than the more ordinary form of spina bifida. 

2. Meningo-myelooele. — ^The pathological anatomy of this 
division offers more complex phenomena, but, though subject 
to minor variations, it is remarkably constant. Of 125 speci- 
mens examined the arrangement about to be described was 
found in seventy-six cases (63 ' 2 p er cent.). This arrange- 
ment is illustrated by Plate Xv from Specimen No. 7 
(E. 0. S., No. 273 b), taken from the body of a female 
child aged eighteen days ; the lower limbs were well formed 
but paralysed, as were also the bladder and rectum. Death took 
place from general marasmus, with retraction of the head due 
to meningitis. No treatment was adopted. The neural arches 
are unclosed from the fifth lumbar vertebra to the end of the 



Meport of the Oommittee on Spina Bifida. 843 

spinal column inclnsive. The bodies of the vertebrse are all 
well formed, and the spinal nerves normal. The wall of the 
protrusion is formed, except at its summit, of skin and dura 
mater, the latter being continued uninterruptedly from the 
theca surrounding the spinal cord within the intact part of the 
neural canal. The arachnoid membrane is continued over the 
interior of the sac, the cavity of which corresponds to the sub- 
arachnoid space. The spinal cord is traceable from the entire 
portion of the vertebral canal across the upper part of the sac 
to its posterior wall, with which it becomes inseparably incor- 
porated at a point a short distance above the middle. The 
last of the nerves (third lumbar) arising from the cord within 
the intact canal passes horizontally forwards to emerge by its 
proper intervertebral foramen. The fourth lumbar nerve 
arises from the spinal cord within the sac, and is applied to 
the side of the cord in its forward course to the succeeding 
intervertebral foramen. The nerves succeeding this arise in a 
double longitudinal series along the back of the sac. Of each 
nerve both roots are present, and at their origin are separated 
by a falciform fold of pia mater, an exaggerated continuation 
of the ligamentum denticulatum. The nerves pass forwards 
with slight convergence to their respective intervertebral 
foramina ,* their course through the bone has been displayed 
by the removal of the left lateral mass of the sacrum ; as they 
lie in the foramina the posterior roots present the usual 
ganglia, and the posterior primary division arises as usual. 
On the roots of some of the lowest nerves within the sac are 
some small additional ganglia {O* aberrantia) similar to those 
at times met with as a variation in normal anatomy. There 
is no coalescence of the sacral ganglia. 

It will be seen that the anterior and posterior nerve-roots 
of each nerve, arising along the back of the sac, are separated 
horizontally by a considerable interval (in which lies the falci- 
form process of pia mater described), and the same is true of 
the anterior roots of each pair of nerves. It is to be concluded, 
therefore, that the nervous tissue 'of the spinal cord, much 
thinned out, extends commensurately with the area so included, 
being limited on either side by the line of attachment of the 
posterior roots. The sac contained a considerable quantity of 
lymph which lined its interior, and ensheathed the nerves 
passing through it. During life the swelling presented ex- 
ternally a shallow median furrow, due probably to the resist- 
ance here offered by the nerve-roots passing through the 
middle of the sac to the intervertebral foramina. 



344 Report of the Oommittee on 8pma Bifida^ 

Aroand such a specimen almost all examples of meningo- 
myelocele may be grouped, the main exception being that in 
which the central canal is greatly distended and the expanded 
cord lines the interior of the sac (syringo-myelocele), a condi- 
tion which will next be noticed. 

3. Syringo-myelocele. — The cases in which the cavity 
of the sac is a dilatation of the central canal of the cord 
are very rare. Among the 125 specimens examined, we have 
only found two unequivocal examples. One is in University 
College Museum (Specimen No. 8), and was situated in the 
sacral region. The sac, collapsed and wrinkled, measures 1'5 
cm. in diameter ; its interior is lined with soft pulpy substance, 
and neither cord nor spinal nerves pass through its cavity ; 
the innermost lining of the sac is well defined and fibrous. 
On dissecting off this latter a series of nerves is displayed 
coursing round its outer surface and connected with it ; at the 
mouth of the sac the dura mater is distinct and lies superficial 
to the innermost membrane referred to. The other is in St. 
Bartholomew's Hospital Museum, No. 3481 (Specimen No. 9). 
It will be observed from the description that the spinal cord 
and nerves do not lie within the sac, from which it might be 
concluded that the specimen is one of meningocele simply. 
Dissection, however, shows that there exists an innermost 
well-defined membrane, on removing which the nerve-roots 
are exposed lying in loose connective (? subarachnoid) tissue 
between the first-mentioned membrane and the other com- 
ponent layers of the sac-wall. In this manner the nerve-roots 
pass round the sac towards the intervertebral foramina. A 
minute foramen leads from the sac into the substance of the 
cord, and presumably represents the central canal of the cord. 
Such a specimen iUustrates the difficulty of diagnosing, without 
dissection, between a simple meningocele and a dilatation of 
the central canal. The anatomy of the three other specimens 
referred to in the table is too doubtful to permit a fuller 
description. 

It is well known that the central canal of the cord above 
the protrusion is not infrequently dilated, but we would point 
out that this condition is not confined to spina bifida, and may 
sometimes exist to a very considerable degree, and even extend 
throughout the cord without being accompanied by deficiency 
in the neural arches (syringo-myelus). In Specimen No. 3 
(Glasgow Royal Infirmary Museum, No. 145) this condition is 
observed above the protrusion, at the seat of which, however, it 



Report of the Oommittee on Spina Bifida. 345 

abruptly terminates (Plate XIII}. Hence it must be conclnded 
that sacli a condition above the protrusion affords no criterion 
of the exact ajiatomy of the sac. 

From Specimen No. 10 (St. Thomas's Hospital Museum, 
No. LL 13^), a partially cured case (Fig. 1), it would appear 
as if a dilatation of the central canal might afFect the portion 
of cord lying within the sac, in cases where otherwise the 
anatomy is that described under the preceding heading of 
meningo-myelocele, and shown in Plate XV. 




We may next proceed to notice the anatomy in more detail 
under the headings already alluded to (p. 840). 

(1) Position of the tv^nour. 

An analysis of the 125 specimens examined shows the 
various regions of the spine to have been afCacted as follows : 
The whole spine in 1 case, '8 per cent. 
The dorsal region in 9 cases, 72 per cent. 
The lombar region in 9 cases, 7'2 per cent. 



346 Report of the Oommittee on Spina Bifida, 

The dorsi-lumbar region in 3 cases^ 2*4 per cent. 
The lumbo-sacral region in 68 cases, 54*4 per cent. 
The sacral region in 21 cases^ 16*8 per cent. 
The dorsi-lumbo-sacral region in 7 cases, 5*6 per cent. 
The sacro-coccygeal region in 1 case, '8 per cent. 
Not determinable in 6 specimens. 

(2) Form and size of the sac. 

In the great majority of cases, at the time of birth, the 
size of the sac rarely exceeds that of a Tangerine orange, i.e. 
from 3 — 5 cm. in diameter. As a tumour of exceptional size 
at birth may be noted Specimen No. 10, in which the sac 
measured 8 cm. across, 8*5 cm. longitudinally, and 7 cm. from 
before backwards ; the child was bom dead. In some cases 
the size does not exceed that of half a walnut. In a few cases, 
where the patients reach adult life, the tumour may assume 
very large proportions, as in a case shown to the Society on 
November 22, 1884, sent from Portland by Dr. McLean. 
The tumour, which was situated in the lumbo-sacral region, 
measured round its base, where it was somewhat constricted, 
22i inches (57 cm.) In King's College Museum there, is a 
cast (No. 1744) of a spina bifida, which measures 27 inches (69 
cm.) around its base. 

In form sessile, somewhat constricted at the base, circular, 
ovoid or cordiform in outline, these tumours occasionally 
present a slight median longitudinal furrow, or sometimes a 
more localised depression at or near the summit — the so-called 
umbilicus. The latter indicates the spot at which the spinal 
cord meets and becomes incorporated with the posterior wall 
of the sac ; but whilst its presence indicates that the tumour is 
a meningo-myelocele, its absence cannot be held to show the 
contrary. The same is true of a median furrow ; this corre- 
sponds to the attachment of the cord and series of nerve- 
roots (Plate XY). By no means constant, these depressions 
depend much on the distension of the sac, the free parts 
yielding to the pressure within more readily than those which 
are tied down to the vertebral column by the cord and 
nerves. The presence of furrows, however, in the sac "is of 
importance not only as evidence that the spinal cord and 
nerves are incorporated with its walls, but as showing the 
possible existence of internal partitions. A median furrow 
may indicate a median partition of the sac, while a bilateral 
longitudinal furrow may indicate the presence of a double 
partition or the subdivision of the sac into a central and two 



Report of the Committee on 8pvna Bifida. 347 

or more lateral portions j to these points fuller reference will 
be made further on. 

Still more rarely the aurface of the protrusion presents not 
an " Timbilicua," bnt a more clearly defined and deeper depres- 
sion, an excellent example of which is represented in Plate XVI, 
from Specimen No. 13 (Middlesex Hospital Museum, No. 725). 
A dissection of this specimen has shown that the depression 
corresponds precisely to the point at which the cord meets the 
sac, and a probe passed through it leads into the mid-sub- 
stance of the cord, from which it may be inferred that this 
foramen represents the opening of the central caoal of the 
cord upon the surface of the tumour, as shown in outline in 
Fig. 2. 

Fio. 2. 




The importance of this fact in relation to the developmental 
morphology of the malformation will be noticed elsewhere. 

(8) Coverings of the aac. 

With regard to the character of the external investment, 
it is very seldom that a normal cutaneous covering exists over 
the whole protrusion. As a rule, the base alone is covered 
with normal skin, while in the rest of its extent the covering 
consists of a thin white glisteuing membrane-like tissue. In 
some specimens the skin ends abruptly, in others it merges gra- 
dually into the membrane noticed. More rarely, however, the 
cutaneous covering is continuous over the whole tumour, even 



848 Report of the Committee on Spina Bifida. 

when large^ as in Specimen No. 14 (St. Mary's Hospital 
Museum, Ghy). We nave seen this condition in a living 
adult, with a tumour measuring 22^ inches (57 cm.) round its 
base, and in which case subsequent post-mortem examination 
showed the spinal cord and nerves to be involved in the sac- 
wall. 

Very little can be judged regarding the presence or 
absence of ulceration, and the vascularity of the sac-wall 
from museum specimek At birth in a considerable proper- 
tion of the cases the summit of the sac is more or less ^^ raw ;"* 
ocoasionaUy it is even gangrenous. Specimen No. 19 (St. 
Bartholomew's Hospital Museum, No. 3480) shows the sepa- 
ration of such a slou&rh and the consequent exposure of the 
cord and nerve-roots which lay within le sac. 

In Specimen No. 15 (St. George's Hospital Museum, 15 a) 
the summit of the sac over an area of about 2*5 cm. presents 
a minutely shreddy surface bounded by a sharply-defined, 
slightly overhanging edge formed by the tissue composing the 
surrounding part of the sac, as though another superimposed 
membrane had been torn off. In support of this view it may 
be noticed that specimens of anencephalus are by no means 
uncommon in museums, in which the head of the foetus is 
adherent to the membranes. Considered in its immediate 
connection with the spinal cord and nerves of the sac, great 
importance attaches to the exact nature of this membrane-like 
area, and this is further increased when the opening of the 
central canal at the hi gest part of the area, as seen in Specimen 
No. 13 (Plate XVI), previously referred to, is recalled to 
mind. It will be remembe red also that in the typical spe- 
cimen first described (Plate XV) the nerves were attached in 
regular series in two longitudinal lines to this membrane, and 
that between the anterior and posterior roots lay a continua- 
tion of the ligamentum denticulatum, unusually exaggerated in 
development. There is strong presumptive evidence, there- 
fore, that the membrane in question contains the attenuated 
neural tissue of the spinal cord from which the nerves lying 
within the sac really take origin. This probability is 
strengthened when it is remembered that the cord, if the pro- 
trusion occurs in the dorsal region, may be found directly 
continuous with the membrane and normally constituted in 

* In the majority of cases, this raw surface, confined to the most prominent 
part of the sac, is sharply limited, and the presence of blood npon or within it 
■nggests the possibility of sadden ruptnre of an adhesion between it and the 
foBtal membranes. 



Retort of the Oommittee on Bpiria Bifida. 349 

the lowest part of the sac, from which it is continued below 
into the intact portion of the vertebral canal. We have 
observed this condition in two specimens. In one, which was 
not preserved, the tamour was situated in the mid-dorsal 
region and presented the typical anatomy already described. 
In the other Specimen, No. 16 {St. Thomas s Hospital Museum, 
LL 12^), the protrnsion involved the spine between the tenth 
dorsal and fourth lumbar vertebrae, and is represented in Fig. 3. 

Fifi. 8. 




Fig. 3 iliowB K normal eonititnUon of tbe cord below the nren of its incorporation 



As strictly analogous examples of this condition of the 
median part of the sac-wall may be mentioned anencephalas 
and ectopia of the abdominal viscera. In both these condi- 
tions the skin is continued into a similar membraniform tissue, 
independent of the amnion, the proper appendages of the skin 
— hairs, glands, &c. — ceasing abruptly at the junction of the 
two. From this consideration it may be assumed that the 
same explanation — ^whatever that may be — is common to all 
the cases. 



850 Report of the Committee on Spina Bifida. 

(4) Disposition of the meninges. 

In all the specimens minutely examined it has been pos- 
sible to trace the arachnoid through the neck of the sac on to 
its interior^ in some cases almost to the summit ; in others it 
has ceased to be separable shortly after entering the sac. 
This last fact should be remembered in determining the nature 
of the sac-wall at some distance from its mouth. The fluids 
therefore^ in these cases is contained in the subarachnoid space. 

The fluid Tvithdrawn from cases of spina bifida hardly 
needs any description in this report. We nevertheless append 
three analyses^ which were kindly undertaken for us by Dr. 
Halliburton^ of fluid from cases referred to in the Report. 



Report on the chemical ifMestigation of Cerebrospinal Fluid from eaeee of 
Spina Bifida, By W. D. Hallibitbton, M.D., B.Sc, Sharpey 
Physiological Scholar, University College, London. 

(From the Physiological Laboratory, University College, London.) 

Case. — Female, sBt. 19 years. 

The liqnid was very faintly opalescent ; this opalescence was not at all 
lessened by filtration. 

Its specific gravity was 1007. 

It was very faintly alkaline. 

Total solids, — The percentage of solids was found to be 1*025. This 
includes organic and inorganic matter. 

The salts consisted of sodium chloride, the most abundant, phosphates, 
and carbonates. No sulphates were present. 

Proteids, — The percentage of proteids was found to be *084i2 : that is 
only a small fraction of the total solids consists of proteids. 

Boiling the liquid increases the amount of opalescence originally 
present. 

Boiling after rendering the liquid faintly acid with weak acetic acid 
produces a small amount of flocculent precipitate. 

On saturating the liquid with powdered magnesium sulphate, a preci- 
pitate of proteid was obtained ; it is the characteristic of proteids of the 
globulin class to be precipitated in this way ; the precipitete was washed, 
collected, re-dissolved; the solution was opalescent^ like solutions of 
globulins generally : on heating it coagulation was found to occur at 75** C. 
Thus this globulin resembles, and probably is identical with the globulin 
of serum, or paraglobulin^ The fact that a globulin is present in such 
relatively large quantities to other proteids explains the fact that the 
original liquid was opalescent. 

Nearly all the proteid present consists of globulin ; on filtering off the 
precipitate produced by the addition of magnesium sulphate, a clear filtrate 
was obtained; on boiling this even after rendering it faintly acid, no 
precipitete took place ; but on the addition of nitric acid, a very faint 
precipitate occurred, which turned yellow on boiling, and orange on the 
addition of ammonia. This proteid, which is present in exceedingly 
minute quantities, is peculiar in not being coagulable by heat. It is, how- 
ever, not a peptone, as it does not g^ve the characteristic colour with copper 
sulphate and potash, and moreover peptones are not predictable by nitric 
aoid. 



Report of the Committee on Spina Bifida. 881 

CarhO'hydrates, — ^A small quantity of a substance which reduces copper 
salts, like dextron, is present. It, however, is present in very small quan- 
tities ; three hundred cubic centimetres were ti&en, the proteids coagulated 
filtered oif, and the liquid concentrated; this was added to two cubic 
centimetres of Fehling^s solution, but were insufficient to produce the 
reduction of all of it. The quantity of cerebrospinal fluid that I had was 
insufficient to enable me to add more. Two cubic centimetres of Fehling's 
solution require for their complete reduction *01 gramme of sugar ; three 
hundred cubic centimetres contain therefore less than *01 gramme of 
sugar ; that is the percentage is less than *008. It may be put approxi- 
mately as '002, as the amount of copper not reduced was very smiJl. 

Fats,^A small amount of fat is present, ether extracting a small 
amount : the quanity was not estimated. 

The composition of the fluid may therefore be thus expressed in a 
tabular way : the numbers are parts per 1000 : 

Water ..... 989*75 



Solid matters 

Proteids (consisting almost exclusively of globulin) 

Sugar (approximately) 

Extractions and soluble salts 

Insoluble salts 

Cerebro-tpinal Fluid. 



10*26 

*842 

•002 

9*406 

*218 



Case. — Emily F — , set. 11 days. Lumbo-sacral spina bifida. Firtt 
tapping. 

The fluid was perfectly dear, with a faint yellow tinge : its reaction 
was slightly alkaline. 

BoUing rendered the liquid slightly cloudy. 

Trommer's test showed that a distinct trace of sugar was present. 

The following is the composition of the fiuid (in parts per 1000) : 

Water . . . 919*877 

Total solids . . 10*128 

Proteids* . . 1*602 

Soluble salts . . 7*544 

Insoluble salts . . *346 

Extractions . *681 

In the above calculation the specific gravity of the fiuid was taken at 
1007, the average specific gravity of cerebro-spinal fiuid. The quantity 
of fiuid obtained in this case was too small to admit of the specific gravity 
being taken in the usual way. 

Ca8B. — ^John S — , 8Bt. 13 weeks. Fourth tapping. 

Iodine had been injected on three previous occasions. 

Fluid. — Perfectly clear, colourless, faintly alkaline. 

The composition of the fluid, in parts per 1000, was as follows : 



Water . 


. 991*658 


Total solids 


8*842 


Proteids 


0*199 


Sugar . 


0*166 


Extractions (minus sugar) 


2*868 


Soluble salts 


. 4*776 


Insoluble salts 


0*889 



* This proteid contains globulin as is seen by the fact that saturating with 
magDedum sulphate produces a precipitate. 



352 Report of the Oommitiee on Spina Bifida. 

The points of interest in the above are as follows : 

1. Proteids, diminished in quantity as compared with other speci- 

mens. They consisted bittibblt op GLOBVLnr, which coagu- 
lated at the same temperature as that at which seram globulin 
or paraglobulin coagulates (75° C.)* 

2. Sugar, very greatly increased in quantity. 

8. Soluble salts, diminished in quantity, as are also the total solids. 
These analyses are very similar to those previously made by Hoppe 
Seyler. Hoppe Seyler's analyses are appended. 

Analynt of the Cer^ro-epinal Liquid, obtained hy puncture in two 
catee of Spina Bifida {Soppe Seyler).* 





I. 


n. 


l8t 

pnnctnro. 


2nd 
puncture. 


8rd 
ponctnie. 


l8t 

puncture. 


3nd 
puncture. 


Water . 
Solid matters 
Proteids 
Extractions and salts 


987*49 

12*51 

1*62 

10-52 


986-88 

18-12 

2-64 

11-30 


986-72 

13-28 

2*46 

11*14 


989*38 

10-67 

•25 

10-42 


989*89 

10*20 

•55 

9*65 



(5) Siee and configuration of the defi^ncy in the neural 
arches, and of the apertwre of communication between the sac 
and the vertebral canal. 

As a general rule^ it may be stated that the size and shape 
of the tumour depend on the extent to which the neural 
arches are deficient. In no specimen have we observed the 
deficiency limited to a single vertebra or even to two vertebrae. 
In the greater number of the dried specimens examined^ the 
cleft is found to involve several vertebrsB ; most usually the 
last lumbar^ and all the sacral. Perhaps the most important 
fact to be noticed is that the actual extent of the protrusion 
forms no certain criterion of the extent of deficiency in the 
neural arches; for in Specimen No. 17 (R. C. S. 271 e) the 
deficiency involves the lowest four dorsal^ and the whole of the 
colunm below, while during life the protrusion, measuring 
5 cm. by 6 cm. in its largest dimensions, was limited to the 
lumbo-sacral region. 

As a rule, in the highest parts of the cleft, the laminae are 
fairly well developed, and may be united by a dense fibrous 
membrane ; lower down they become stunted and ill-formed. 
In extreme cases they are so everted as to lie in a transverse 
vertical plane, and the normal convexity of their inner surface is 
slightly exaggerated. This alteration in direction is associated 

• Hoppe Seyler, Physioloyieche Cfkemiet p. 601. 



Report of the Committee on Spina Bifida. 



353 



with a diminution of the angle of iunctioD between the pedicle 
and the lamina. It may be noted that the actual size of the 
aperture by which the sac communicates with the aound 
portion of the vertebral canal, and thence with the central 
nervous system, however large the cleft in the spinal column . 
may be, can never exceed the size of the neural ring of the 
last entire vertebra, and that it is generally very considerably 
lessened by the deposition of lymph. 

(6) Disposition of the cord and nerves within the sac. 

In the total of 125 specimens examined, leaving out of 
consideration the cases of syringo-myelocele, it has been found 
that the cord enters the sac in 79 cases, i. e. in 63*2 per cent. 
The level at which the cord crosses the sac is variable ; as a 
rule it is somewhat above its centre. Occasionally, however, 
the cord, as it emerges from the vertebral canal, becomes 
immediately connected with the roof of the sac without the 
intervention of any space. 




An aannuilly 1«^ portioD ot the ntc above the cord. 



In other cases, the portion of sac above the cord forms the 
chief part of the whole as in Specimen No. 14 (St. Mary's 
Hospital Moseom, No. G*), represented in Fig. 4. 
VOL. xvm. 23 



854 Report of the Committee on Spina Bifida. 

In many specimens, the cord is attached to thi6 upper 
portion of the sac by a falciform fold of membrane, which 
forms a median septum, imperfect anteriorly. The contained 
cord varies in size, sometimes it seems to have its normal size, 
in other cases it appears attenuated from the traction made on 
it by the distending sac. Beyond its point of attachment, 
though incorporated with the sac-wall, it cannot be further 
traced by dissection. 

In a typical specimen taken from a child twelve days 
old, sections of the spinal cord, including pia mater and 
nerve-roots crossing the sac, are 4 mm. in their longer and 
2 mm. in their shorter diameter at 1 cm. from its attach- 
ment to the sac- wall. Under the microscope they display well- 
marked grey matter of normal structure containing groups of 
normal ganglion cells, the chief of which lie in the anterior 
horns ; other healthy cells occur scantily scattered through the 
rest of the grey matter. The central canal is transversely 
elongated; in places it tends to be T-shaped. The white 
matter contains groups of well-developed medullated fibres, 
but these in the greater part are very small and in many parts 
axis cylinders alone are detectable; the neuroglia corpuscles 
are normally distributed through the grey ajid white matter. 
The sections of the nerves lying upon the cord are quite 
normal. 

In Specimen No. 18 (Charing Cross Hospital Museum, No. 
250 B) the sacral part of the cord impinges on the centre of 
the sac-wall, while the nerve-roots run forward applied to the 
cord ; very few only arise from the sac- wall and these are in 
the immediate neighbourhood of the attached cord. 

The disposition of the nerves varies with that of the cord ; 
sometimes those arising from the cord, as it crosses the sac, 
are directed forwards upon it to reach their proper interver- 
tebral foramina, as in Plate XV, whilst those arising from 
the sac-wall are attached in double series, the anterior and 
posterior roots being often quite distinct and partially separated 
by a well-defined falciform fold, corresponding in position to, 
and continuous with the ligamentum denticulatum. After the 
nerves perforate the dura mater to reach the intervertebral 
foramina, they present the normal anatomy; the ganglia on 
the posterior roots, and the posterior primary divisions of the 
nerves have the usual disposition ; in some cases, however, the 
ganglia are found displaced within the vertebral canal. In the 
Cambridge Museum there are specimens showing approxima- 
tion and fusion of two or more sacral ganglia, a result appa- 



Report of the Oommittee on 8pma Bifida. 355 

rently due to the backward traction made upon the nerves by 
the distendin? force within the Bac.* In one instance, Speci- 
men No. 19 {St. BarthoIomeVa Hospital Museum, No. 3483), 
the lowest nerve-roots are furnished with "ganglia aberrantia " 
within the sac ; the conns medullaris terminates in a filament 
2 mm. in diameter, upon the lower end of which is a well- 
marked gangliform enlargement. 

Considering the close connection between the spinal cord 
(and nerve-roots) and the median portion of the sac-wall, the 
importance of a histological examination of the latter will be 
evident. Transverse sections made through the sac-wall 
1 cm. below the point at which the spinal cord becomes in- 
corporated show an expanded extension of the latter in the 
fibrous tissue forming Qxe test of the sac-wall (Fig. 5). The 




HicTOscop c Beet on of uc wall n the m ddle of wh ch liea > portion of the 
nennl tissus of the flattened cord A complete central canal wiU be seen 
near the left band eztrenutj 

central canal is seen to be continued through the centre of 
the extension , its epithehum presents the normal characters. 
In other sections the canal is much flattened or otherwise 

* Frofeaior Hnmphry hal kindly fovonred na vitb the foltoirinp particnlara 
of these caaeB : 

lOSlA. Acepbalna and Spina bifida in the whole lengQi of the colnion. Cer- 
Tieal ganglia in one maai on etuib aide. Ganglia in other parts separate. 

1(^5. Spina bi&da in sscmra. Three npper laontl gang-lia tm either aide 
united 10 aa to fbrm one trilobed ganglion eneloaed in one aheath of dnra mater. 

1036. Like preceding. 

1037. Spina tuSda in the aacrnm. The two nppei Mcral ganglia on the right 
tide and the three upper on the left are nnited. 

1038. Spina bifida in the upper part of the lacrnm. The loweat Inmbar and 
the flrflt aacral ganglia on the left aide are anited. 



356 Report of the Committee on Spina Bifida. 

altered in form. The flattened tissue of the cord gives origin 
to anterior and posterior nerve-roots, which at their origins 
are contained within the fibrous tissue of the sac-wall, and 
most conspicuous on the posterior aspect of the cord. The 
drawing shows two nerve-bundles in section lying in front of 
the cord. The origin of these from the cord is distinctly 
traceable in other sections. The epidermis is continuous 
over the middle line, but the skin in this situation presents 
no hairs or other appendages. The nervous tissue is of 
uniform structure, presenting no division into white and grey 
parts ; it consists throughout of corpuscles uniformly scattered 
through a finely fibrillar basis, the whole having the general 
appearance of neuroglia. Groups of normal ganglion cells, 
however, occur here and there in the sections; the nerves 
lying in the sac-wall in the same manner present no medul- 
lated fibres, but resemble closely in structure the tissue 
forming the expanded cord. It may be inferred from these 
appearances that the development of medullated fibres has not 
been perfected. 

(7) Unusual variations. 

(a) Subdivision of sac, complete or partial, by partitions. 
Of great importance in relation to treatment by injection is 
the occurrence of partitions within the sac. These partitions 
have various arrangements, and exist in different degrees; at 
times some portions of the sac are completely closed off from 
the rest, but in most cases small f enestrse or apertures of com- 
munication exist in the septa. The presence of these subdivi- 
sions will have the effect of confining fluid to the space into 
which it has been injected. That they do not result from 
operative interference is proved by the fact that in the cases 
in which they have been found most marked, no treatment 
had been at any time adopted. 

The chief partition may be median and include the cord 
lying within the protrusion, together with the nerves passing 
forwards from the median portion of the posterior watt of the 
sac to the intervertebral foramina. In one specimen of this 
kind, which we dissected (Fig. 6) the lateral portions of the sac 
were symmetricaUy subdivided by a horizontal partition which 
crossed them about the junction of their upper and middle 
thirds ; in the centre of each partition there was a smaU 
weU-defined oval aperture. In other cases the partition is 
multiple and consists of two main lateral parts ; the partition of 
each side corresponds in position to the series of nerve-roots ; 



Report of the Committee on 8pma Bifida. 357 

the lateral cavities^ thus more or less closed off from the 
central portion, may be subdivided by cross partitions into 

Fig. 6. 




A mnltilocular spina bifida. 

many secondary spaces. Plate XVII, Specimen No. 20 (Uni- 
versity College Museum, No. 5195). As a rule, all the sub- 
divisions of the sac communicate by small well-defined circular 
openings, but they may however be completely closed. 

(b) Presence of bony outgrowths across the spinal canal in 
the neighbourhood of the tumour. 

The most noteworthy variation in the pathological anatomy 
of spina bifida is one of which we have seen four examples. 
A fifth specimen exists in the Musee Dupuytren in Paris. 

This variation consists in the presence of a distinct 
osseous or osseo-cartilaginous process, crossing the vertebral 
canal in an antero-posterior direction. The specimen in St. 
Thomas's Hospital Museum, No. 21 (Plate XVIII), represents 
very clearly the osteological aspect of the variation, and that 
No. 22 in thelt. C. S. Museum the associated condition of the 
spinal cord (Plate XIX) which presumably existed also in the 
former case. In Sp ecim ens Nos. 20 and 23 in University Col- 
lege Museum (Plate XVII) and in St. Bartholomew's Hospital 
Museum a similar bony process is present, but the spinal cord 



858 Report of the Committee on Spina Bifida. 

is bifid, the bony process lying in its cleft and the halves 
of the cord diverging as they enter the highest part of the 
sac. 

It is interesting to observe, in the St. Thomas's Hospital 
Specimen (Plate VI) that there is a duplication of the centra 
of the bodies of the last two dorsal vertebraa with which the 
intercalated element is connected. This appears to be related 
to the condition in which a portion of the vertebral column is 
completely cleft, of which Specimen No. 24 (R. C. S. Museum, 
No. 277) offers a good example. This is the skeleton of a 
human hydrocephalic foetus with spina bifida involving the 
dorsal, lumbar, and sacral regions. In this specimen the 
bodies of the vertebrae are deficient, so that the spine is com- 
pletely cleft as high as the cervical region. The bodies of 
the lower cervical vertebrae have two centres, these serving 
apparently as points of departure for the bifid column below; 
there is no exostosis crossing the canal at the point of division. 
Below the point of division the vertebral canal on the inner 
side of either half is unclosed by the formation of laminae in 
this situation. It is to be regretted that the soft parts in this 
specimen are wanting. 

There are no specimens in the museums referred to of 
anterior spina bifida, that is, of protrusion through a cleft in 
the bodies of the vertebrae, though such specimens are 
described by a few authors, and it is possible that in the 
case last referred to some allied condition of the soft parts 
existed. 

As another somewhat uncommon condition of the osseous 
system may be noticed that in which there is defective deve- 
lopment of one or more of the vertebral bodies at the seat of 
the cleft. Specimen No. 25 (Plate XX) represents this con- 
dition. The sacrum is twisted to the left owing to a malfor- 
mation of its upper three segments (Fig. 7), consisting in a 
partial absence of the left halves of the first and third segments, 
while the left half of the second segment is produced upwards 
and downwards, as if in some measure to compensate for the 
deficiency. Specimen No. 26 (R. C. S. Museum, No. 278) shows 
a double lateral curvature in the cervical region of a foetus, due 
to a similar cause ; the vertebral canal is throughout unclosed, 
and the cleft extends also between the supra-occipitals. 

In some cases unnatural curvatures in an antero-posterior 
plane exist. Specimen No. 27 (R. 0. S. Museum, No. 274) 
shows the six lower dorsal, the lumbar and sacral vertebrae of 
a newborn child. In the lumbar region the spinal column is 



Report of the Committee on Spina Bifida, 859 

strongly concave anteriorly ; that this is a permanent condition 
of some standing is shown by the fact that the body of the 

Pig. 7. 




Anterior view of the parts represented in Plate XX (reduced). 

vertebra at the summit of the curve is so reduced in thickness 
anteriorly that the contiguous intervertebral discs lie almost 
in contact. 

(8) Ths process of cure. 

a. Meningocele. — There are no specimens of meningocele 
cured by injection in the London museums. Plate XIV, fig. 1 , 
from Specimen No. 4 (Western Infirmary Museum, Glasgow, 
Series 1, No. 2), represents the parts concerned after cure 
by Dr. Morton's method. Specimen No. 22 (E. C. S. Museum, 
Plate XIX) is a meningocele, into the mouth of which the 
posterior part of the cord has prolapsed. The sac, which was 
ligatured during life, is completely fiUed with a homogeneous 
fibroid tissue, a microscopic examination of which shows it to 
be composed of delicate connective tissue containing abundant 
corpuscles. 

6. Meningo-myelocele. The following is a description of 
the appearances seen in the case of an ordinary lumbar spina 
bifida after cure by the injection of Dr. Morton's fluid. Specimen 
No. 28 (R. C. S. Museum, No. 276a) . Externally there is a deep 
puckered depression at the centre of the sac which is every- 



360 Report of the Committee on Spina Bifida, 

where covered with cuticle ; this cuticle is smoother and more 
shining over the centre of lie sac than elsewhere. On section 
(Plate XIV, fig. 2) the sac cavity is seen to be obliterated by a 
mass of fibroid tissue, bounded in front by dura mater: the 
spinal cord crosses the highest part of the sac in the midst of 
this fibroid tissue. In the lower part of the sac anteriorly 
are sections of the nerve-roots passing towards the inter- 
vertebral sacral foramina. The cord above the sac appears 
healthy. 

From this specimen it may be concluded that the oblite- 
ration of the sac is effected by an inflammatory effusion into 
the sac, and its subsequent organisation. The microscopic 
examination of the obliterating material (the child died 11 
weeks after the first injection) shows it to be composed of young 
fibrous tissue, elongated corpuscles lying amongst wavy fibres 
of connective tissue; in places the corpuscles are more 
numerous and spheroidal, the development of the tissue being 
less advanced. 

c. Syringo-myelocele. In another specimen. No. 10, a 
similar process of obliteration had taken place in the greater 
part of the sac after treatment by the same method. In the 
upper and median portions (Fig. 1, page 345) there persisted 
a small unobliterated space, which on section proved to be 
due to a dilatation of the central canal of the corJ within the 
sac (St, Thomases Hospital Museum, LL 13^). 

(9) Theoretical considerations drawn from the anatomical 
facts. 

The points of prime importance disclosed by the micro- 
scopic examination of the sac-wall in a typical case of meningo- 
myelocele are the continuation of the central nervous system 
within the median portion of the sac-wall, the integrity of the 
central canal of the cord within this part, as also the absence 
of true skin over it. Moreover, it displays the absence of any 
meningeal cavities behind the incorporated portion of the 
spinal cord. It is clear, therefore, in the first place, that the 
nerve-roots which traverse the sac arise from this intra- 
mural portion of the central nervous system, and that all ex- 
pressions of descriptive pathological anatomy which imply a 
distribution of the nerves to the sac-wall are a reversal of the 
facts, since the sac-wall is really their source, and the nerves 
within the sac are the proper anterior and posterior roots. But 
more important than this, the histology of the sac-wall in a 
typical case (Fig. 5), by demonstrating the integrity of the 



71 



Report of the Oommittee on 8pma Bifida, 361 

central canal of the included portion of the cord, settles 
beyond doubt what must otherwise be matters of conjecture 
only, that neither does the neural furrow* remain unclosed 
in spina bifida, nor, after having been closed, is it subse- 
quently distended by dropsy and ruptured, this rupture 
being accompanied with the disappearance of that portion of 
cord (with or without the superjacent integuments) which lies 
behind the line of origin of the nerve-roots from it. Lastly, 
this examination serves to complete the refutation of the view 
held by Porster and many subsequent German writers, viz. 
that spina bifida in the great majority of cases is due to a 
dropsy of the central canal of the cord. 

The absence of true skin from the central portion of the 
sac-wall which occurs in almost all cases of meningo-myelo- 
cele, as it does also in anencephalus, is of much interest. The 
surface in question we do not regard as cicatricial, that is, as 
following an ulceration of normally-formed skin, since there 
is no histological evidence of any inflammatory process. It is 
not denied that ulceration may not in some cases be super- 
added. The junction of the skin proper with the membranous 
area may be most aptly likened amongst natural structures to 
that of the skin with the amnion round the attachment of the 
umbilical cord. The membrane implies, in fact, that the 
mesoblastic basis of the true skin and the structures lying in 
subjacent connection with it has not been developed. Among 
pathological conditions, besides anencephalus, related to this 
condition may be cited ectopia of the viscera, the membrane 
which directly encloses them being continuous with the true 
skin in the same manner, and representing the iJl-developed 
substitute of the cutaneous and muscular systems of the ante* 
rior body wall. 

The presence of the spinal cord within the sac-wall in the 
case of spina bifida ofEers no difficulty of explanation when 
the epiblastic origin of the central nervous system is remem- 
bered. The theory therefore which best explains the patho- 
logical anatomy of spina bifida is that which assumes a 
primary defect of development of the mesoblast from which 
the structures closing in the vertebral furrow are developed. 
After the closure of the neural furrow it would appear that 
the processes of mesoblast which subsequently insinuate them- 

* By NEUBAL vimROW IS meant the groove of involuted epiblast from which 
the spinal cord is developed. By yebtebbal pubbow is meant the groove 
resulting from the extension backwards, from the protovertebral mass of the 
processes of blastema from which are developed the neural arches and mem- 
branes of the spinal cord. 



362 "Report of ike Oommittee on Spina Bifida. 

selres between tihe primitiTe Bpinal cord and its overlying epi- 
blast are formed in an insufficient degree to meet and combine, 

or that these processes, shoiild they meet, are not formed in 

Dk^ram* rtprt*«ntimg the/ormaUoit cft^ita ^ida. 
Via. 8. FlO. 9. 




ditatstjon or the central cadkI of 
the cord, the nerve-roota psuing round 
its outer anrface. 



Sbowi diiplBcemeDt backwarda, sod flat- 
tening of the cord with abretchiiig of 
tbe serve-roots from further accnmnk- 
tiOD of fluid. 



sufficient proportion to serve as a basis from which the v 
structures subsequently to be produced over the spinal cord 
can be developed. Hence difEerent degrees o£ deficiency are 



Report of the Committee on Spina Bifida. 868 

met with, from those in which the spinal cord lies within the 
posterior wall of the sac, scantily embedded in fibrous tissue 
(covered with epidermis), to those in which a perfect cuta- 
neous covering exists over the whole sac with, it may be, an 
abundance of fat in the subcutaneous tissue. Muscular tissue, 
however, does not appear to be produced in the median portion 
of the sac-wall, i,e, there is no extension of the muscle plates 
to the mid-line ; whilst the absence of a mesoblastic basis for 
chondrification and osseous formation constitutes, according 
to the definition, a sine qua non of the malformation. Among 
other evidences of arrested development of the neural arches 
may be noticed the association of partial deficiency of the 
vertebral bodies, corresponding with the situation of the pro- 
trusion, Plate XX (R. 0. S. Museum, No. 271a), and also 
Specimen 26 (K. C. S. Museum, No. 278). 

The absence of meningeal spaces behind the cord, to which 
in meningo-myelocele we know of no exception, may be 
explained on the ground that no sufficient mesoblastic basis 
has been produced for the formation of the spinal mem- 
branes, as there appears also to be no proper basis for the 
development of the corium, since although the epidermis is 
continued across the sac, it is not involuted to produce 
the appendages proper to normal skin. It is of import- 
ance to distinguish between the summit of the sac and the 
other parts. The developmental defect is limited to the 
former, the rest of the sac being produced by the displace- 
ment of the healthy parts during the process of protrusion of 
the spinal cord, with which the superjacent tissue is incorpo- 
rated. In the rare cases in which the central canal of the cord 
opens on the summit of the sac. Specimen No. 13 (Middlesex 
Hospital Museum, No. 725), Plate XVI, it may be assumed that 
the neural furrow has never been closed in, and that the median 
portion of the sac below this is represented by the attenuated 
tissue of the spinal cord furnished only perhaps with an 
epithelial investment. In this process of displacement it is 
clear that the nerve-roots connected with the cord will be 
drawn backwards with it, their ultimate position within the 
middle of the protrusion being thus satisfactorily accounted 
for {vide diagrams). There will be no difficulty in explaining 
the presence of cord elements, even, in the lowest part of the 
sac, when the very early age from which the malformation 
must date is considered; for at this time the spinal cord is 
commensurate in length with the vertebral column. The 
great proportional frequency of the protrusion in the lumbo- 



864 Report of the Committee on Spina Bifida. 

sacral region may be associated with the fact that it is in this 
region the normal closure of the neural furrow last occurs. 

Those cases in which the membranes only protrude indicate 
a far less severe defect in the developmental process. The 
cord and its membranes, together with the overlying soft 
parts, are normally formed, and the protrusion appears to be 
like a hernia in other parts, occurring through an unsupported 
spot of the confining cavity ; the cord is retained in position 
by the nerves passing from it, and being quite free of its 
membranes no traction is made upon it by the protrusion, and 
it retains its normal position or is but slightly displaced into 
the neck of the sac. 

In syringo-myelocele, the original deficiency would appear 
to be the same as that described under meningo-myelocele, 
but the accumulation of fluid here occurs within the central 
canal to the exclusion of that within the subarachnoid space. 



Descriptive List of the Specimens Referred to in the Foregoing 

Part of the Report. 

The specimens are placed in the order, in which they ai:e 
referred to in the body of the Report. 

No. 1. — Royal College of Surgeons, No. 271. — ^The lower 
portion of the vertebral column of a child; dry specimen. 
A thin sac, issuing by a narrow neck not wider than a goose- 
quiU in the lower lumbar region. The laminae of the last 
lumbar and of the sacral vertebrae are deficient, the arches 
being completed by membrane. 

No. 2. — St. George's Hospital, No 15 h. — The sac of a 
meningocele removed by excision; it consists internally of two 
divisions, the capacity of one being about two drachms, that 
of the other about four drachms. Each division has a separate 
orifice of communication with the spinal canal, of the size of a 
large goose-quill ; the two apertures in the divided surface of 
the pedicle are about a sixth of an inch apart. Prom a patient, 
aged 5 months, under the care of Mr. Holmes; the tumour, which 
was increasing rapidly, was removed under the carbolic spray. 



Report of the Committee on 8pma Bifida, 365 

No. 3. — Glasgow Royal Infirmary, No. 145. — Dr. Newman 
thus describes it : " Spina bifida and hydrorachis interna 
situated about the middle of the dorsal region.^^ Plate XIII 
shows the preparation in section. The dilated central canal 
(a) is seen to occupy nearly the whole thickness of the cord, 
and is traversed by transverse bands of nerve tissue (6), which 
form incomplete septa. The hydrorachis interna ceased 
abruptly about a quarter of an inch above the sac, with 
which it does not in any way communicate. A small com- 
munication exists between the sac and cavity of the spinal 
membranes. A careful examination showed the complete 
absence of nerve tissue from the wall of the sac. 

No. 4. — Glasgow Western Infi/rmary, Series 1, No. 2. — The 
following account of this specimen was kindly furnished by Dr. 
Coats. A solidified spina bifida in the dorsal region. The tumour 
forms a flat mushroom-like mass with a narrow pedicle, which 
passes between two of the spinous processes (Plate XIV, fig. 1), 
and is continuous with the dura mater spinalis. On palpation 
it does not appear that any of the proper substance of the cord 
passes out, its contour being preserved. The case was success- 
fully treated by the late Dr. J. G, Lyon, 

No. 5. — 8t, Bartholometv's Hospital, No. 3486. — The sac of 
a meningocele successfully removed by operation {vide Dr. 
Wilson^s Report, Path, 8oc. Transactions, vol. xiv). There is 
a longitudinal depression, smooth and unpigmented on the 
summit, with no corresponding eminence on the opposite 
surface. Microscopic sections show this depressed part to be 
composed of fibrous tissue, continuous with the corium, and 
furnished with an epidermal investment. 

No. 6. — St. Ba/rtholomewi's Hospital, No. 3483. — The parts 
concerned in a sacro-coccygeal meningocele, after loss of the 
sac-wall. The extremity of the cord and the cauda equina, 
occupying the lower portion of the neural canal, are completely 
exposed; the cornus medullaris terminates in a filament, which 
presents a gangliform enlargement two mm. in its shorter 
diameter near its lower end. The lowest nerve-roots are fur- 
nished with ^' ganglia aberrantia.'^ The aperture is bounded 
by an irregular ulcerated margin of skin. 

No. 7. — Royal College of Surgeons, No. 273 b. — ^A specimen 
(Plate XV) illustrating the typical anatomy of meningo-myelo- 



366 Report of the Oommittee on Spina Bifida. 

cele, affecting the lumbo-sacral region. For full description 
see text^ pp. 342-3. 

No. 8. — Umveraity College. — A specimen of syringo-myelo- 
cele in the sacral region. The sac measures 1 *5 cm. in diameter. 
Its interior is lined with soft pulpy substance; no spinal nerves 
pass through the sac. The innermost lining of the sac is well 
defined and fibrous^ and on dissecting it off a series of nerves 
is displayed coursing round its outer surface and connected 
with it. A probe passed through the neck of the sac emerges 
from the centre of the spinal cord. The dura mater is distinct 
at the mouth of the sac and lies superficial to the innermost 
membrane referred to. (Mr. Godlee's case.) 

No. 9. — St. Bartholomew's Hospitaly No. 3481. — Syringo- 
myelocele. The sac is about the size of an orange^ and situated 
over the sacrum. At the anterior part are two minute aper- 
tures, through which bristles have been passed into the sub- 
stance of the cord. No nerves traverse the sac cavity. On 
removing the innermost lining of the sac a series of nerves is 
exposed lying in loose, probably the subarachnoid, areolar 
tissue. 

No. 10. — St. Thovia^'s Hospital^ LL 13^. — ^A longitudinal 
section of the parts concerned in lumbo-sacral spina bifida after 
incomplete obliteration by the injection of Dr. Morton's fiuid 
(Pig. 1, p. 345). The lower part of the sac is occluded by 
young fibrous tissue. In the upper part there is a small cavity 
due apparently to a dilatation of the central canal of the portion 
of cord crossing the upper part of the sac. From a child 
eight and a half weeks old. (Mr. Ballance's case.) 

No. 11. — St. Oeorge^s Hospitaly No. 15 g. — Spina bifida 
involving the dorsal, lumbar, and sacral regions. With the 
exception of the three upper, the laminaB of all these vertebras 
are deficient. The tumour consists of two distinct cysts, 
separated by a horizontal septum, the upper about twice as 
large as the lower. The cyst wall is extremely thin. In the 
upper sac, the nerve-roots lie beneath a thin membrane, and 
course round the sides of the sac closely applied to it. This 
inner membrane possibly represents the pia mater ; the sac 
cavity thus corresponding to a dilatation of the central canal of 
the cord. In the lower sac, the nerve-roots are applied to the 
wall, but some are free between their origins on the wall of 



Report of the Committee on Spina Bifida. 367 

the sac and their foramina of exit. The specimen was taken 
from a child aged 6 months ; during life very little, if any, 
movement was observed in the legs ; there was hydrocephalus, 
and the child was very marasmic. 

No. 12. — 8t. Thoma^s Hospital, LL 5^. — Spina bifida of 
unusually large size ; the sac measures transversely 8 cm. j in 
the vertical direction 8*4 cm., and from before backwards 7 
cm. ; situated in the lumbo-sacral region, membraniform over 
its centre; and presenting a longitudinal median furrow; there 
is a considerable extent of skin round the base ; its edges are 
undulating and sharply defined. The cord crosses the upper 
part of the sac, to the upper wall of which it is attached by a 
falsiform membranous fold; the cord subsequently becomes 
incorporated with the sac-wall and gives origin to the nerve- 
roots passing through the cavity. On the exterior, besides the 
median furrow already noticed, there is a median umbilicus 
about 1 cm. ; below the upper edge of the skin which corre- 
sponds to the point at which the cord is attached to the sac. 
Removed from the body of a male foetus at term, with double 
talipes varus and ^^genu recurvatum" on left side. (Pre- 
sented by Dr. Allan McLean, of Portland.) 

No. 13. — Middlesex Hospital, No. 725. — ^Parts concerned in 
a lumbo-sacral spina bifida. The swelling is cordif orm (Plate 
XVI), and presents a well-marked depression in the middle 
line at the seat of attachment of the cord, and corresponding 
with its central canal. There is a bilateral furrow, in the 
situation of partitions, which more or less separate the median 
part of the sac from the lateral. The nerve-roots arise from 
the sac-wall below the seat of depression noticed, and pass 
forwards through the sac to the intervertebral foramina. 
Fig. 2, p. 347, is a reduced profile representation of the con- 
dition. 

No. 14. — St. Mary's Hospital, No. G 3-. — Spina bifida of the 
size of a foetal head, involving lumbo-sacral region. The 
anatomical arrangement is sufficiently like that described at 
page 342 (Plate XV) to need no further description. The con- 
dition chiefiy requiring notice is, that by far the greater part 
of the sac lies above the spinal cord and nerve-roots which 
occupy a comparatively small lower portion (Fig. 4, p. 353). 

No. 15. — St. George's Hospital, No. 15 a. — Spina bifida in 



368 Report of the Committee on Spina Bifida. 

lumbo-sacral region, presenting the typical anatomy. The 
sac is deeply grooved in . the median line ; over a sharply- 
defined area, the size of a shilling, its surface is minutely 
shreddy, as though a superimposed membrane had been 
torn off. 

No. 16. — St. Thomas's Hospitul, No. LL 12^. — Spina 
bifida, involving the spine between the tenth dorsal and fourth 
lumbar vertebras inclusive, the sac measures 6 cm. in diameter^ 
and is membranous over its centre. The spinal cord crosses 
the upper part of the sac, is incorporated in the sac-wall for a 
distance of about 2 cm., after which it again lies free in the 
lower part of the sac, terminating as a cone in the usual 
manner (Fig. 3) . The nerve-roots arise from the cord in a 
continuous series; those arising from the adherent portion 
pass horizontally forwards, those from the lower portion pass 
obliquely downwards to the sacral foramina. Passing from 
before backwards through the sac are broad membranous par- 
titions by which it is partially divided into lesser cavities. 
From a male child, aged 10 weeks. (Presented by Dr. 
Archer.) 

No. 17. — Royal College of Surgeons, No. 271 c. — A portion of 
the vertebral column from a case of spina bifida. There is a 
deficiency in the neural arches, extending from the eighth 
dorsal to the end of the column; the laminaa are widely 
everted, and form an angle of 45° with the antero-posterior 
plane. There was nothing in the size of the tumour to lead, 
during life, to the suspicion of so large a cleft in the vertebral 
I arches. 

No. 18. — Charing Cross Hospital, No. 250 h. — Spina bifida 
in lumbo-sacral region ; sac the size of an orange. The cord 
is attached to its centre ; the nerve-roots run forward applied 
to the cord ; none appear to arise from the sac : a few fine 
nerves arise from the sac in the immediate neighbourhood of 
the attachment of the cord. 

No. 19. — St. Bartholomew's Hospital, No. 3480. — Spina 
bifida in lumbo-sacral region. The centre of the membranous 
portion of the sac-wall has been destroyed by sloughing. The 
lower portion of the spinal cord projects from the vertebral 
canal backwards and presents with some of the nerve-roots 
' within the opened sac. 



Beport of the Committee on Spina Bifida. 369 

No. 20. — University College, No. 5195. — Dorsi - lumbo- 
sacral spina bifida. The nerve-roots arise in double series 
from the posterior and lateral wall, whence they pass straight 
forwards to the intervertebral foramina. The sac is parti- 
tioned into a central and two lateral portions, these latter 
being again divided by transverse septa. On the right side 
the hkteral and central portions communicate by an opening, 
about 6 mm. in diameter, above the spinal cord as it emerges 
from the vertebral canal, and by two or three small openings 
in the lower third of the partition. The right lateral space is 
completely subdivided into an upper and a lower portion, 
the lower portion being again subdivided into non-com- 
municating cavities. In the highest lateral division there 
are two or three nerve-roots forming pairs with which are 
roots lying on the inner aspect of the septum, which there- 
fore corresponds in position with the ligamentum denticu- 
latum. On the left side the disposition of parts is almost 
symmetrical. The spinal cord is traceable into the highest 
part of the sac, and for about 6 mm. is free; beyond this it 
becomes incorporated with the sac- wall. At its entrance into 
the sac the cord is bifid, a process of bone 16 mm. in antero- 
posterior direction, crossing the vertebral canal about 1 cm. 
above the sac and lying between the halves of the cord in this 
situation. The bifurcation of the cor d occ urs below the level 
of the seventh dorsal vertebra (Plate XVII). 

No. 21.— iS^. Thomas's Ho8pital,'So. JjJj 12».— The skeleton 
of a foetus in which there is a spina bifida affecting the last 
two or three dorsal and all the lumbar and sacral vertebrae. 
In connection with the arch of the tenth dorsal vertebra there 
passes directly forwards to the posterior surfaces of the bodies 
a narrow cylindrical process of bone by which the vertebral 
canal is nearly symmetrically bisected. The posterior part of 
the process is expanded laterally and fills the interval between 
the extremities of the laminsB of the tenth dorsal vertebra ; its 
anterior extremity is expanded in the vertical direction. The 
element is structurally discontinuous with the parts to which 
it is apposed (Plate XVIII). The laminae of the vertebrae 
concerned are in the upper part of the cleft slightly deficient 
in length ; those in the lower part are about normal. Viewed 
from the front the bodies of the eleventh and twelfth dorsal 
vertebrae have a marked median depression, as though pos- 
sibly possessed of two ossific centres. The lumbar curve is 
concave forwards; the sacral curve is normal. 

VOL. xviu. 24 



370 Report of the Committee on Spina Bifida. 

No. 22. — Royal OoUege of Surgeons. — The last two dorsal 
and tte two npper lumbar rertebne. The neural arches of 
fihe Tertebrse are deficient, those of the eleventh dorsal and 
second lumbar are closed by fibrous tissue. Through the 
deficiency in the arch of the twelfth dorsal vertebra there pro- 
trudes the sac of a spina bifida. The deficiency in the neural 
arch of the first lumbar vertebra is closed by the expanded 
posterior end of an osseo-cartilaginous element, which crosses 
the vertebral canal from before backwards and perforates the 
spinal cord. This element abuts anteriorly against the poste- 
rior surfaces of the bodies of the twelfth dorsal and first 
lumbar vertebree with the intervening fibro-cartilage. The 
division of the cord occurs unsymmetricaUy ; on the left side 
the anterior column is alone represented in the npper part of 
the division ; the left lateral column ie traceable for a short 
way on the right division. In its lower part the left division 
of the cord becomes nearly equal in size to the right, the 
lateral and posterior columns reappearing. The central canaJ 
is largely dilated above the point of division ; the dilated canal 




traverses the upper part of the right divisiouj the dilatation 
ceasing too in its lower half. Into the mouth of the sac 
(Plate XIX and Fig. 12) there projects a diverticulum of the 
dilated right division of the cord. The roots of the last dorsal 



Report of the Gommittee on Spina Bifida. 371 

nerve arise, the anterior from the left division, the posterior 
from the right division of the cord ; of the nerves below, both 
the roots arise from the reconstituted division of the cord of 
the left side. The cavity of the sac is obliterated by young 
connective tissue. Dr. Batterham kindly furnishes the fol- 
lowing clinical details : — ^A well-nourished female child, three 
years old; she was regarded as " delicate;" there was no para- 
lysis of motor, nor of sensory nerves, nor of sphincters. The 
tumour had not grown since birth. The tumour was sessile, 
and the skin around it presented a few long locks of coarse 
hair ; it was bluish and glossy on the surface, and somewhat 
doughy to the touch. Treatment consisted in the application 
of an india-rubber cord. Death took place on the eighth day 
from convulsions. (Presented by Mr. Vincent Jackson, 
Wolverhampton.) 

No. 23. — 8t. Bartholomew^ 8 Hospital, No. 3485. — A specimen 
of spina bifida in the lumbo-sacral region. A process of bone 
extends from before backwards completely across the vertebral 
canal immediately above the deficiency. This process of bone 
perforates the spinal cord, which appears to reunite below; 
the cord terminates in a flattened expansion which rests upon 
a mass of fat on the inner aspect of the dura mater; the nerves 
come off irregularly from the front of this expansion. Above 
its perforation the cord presents a greatly dilated central 
canal. A thin, smooth membrane lines the dura mater forming 
the sac. 

No. 24. — Boyal College of Surgeons, No. 277. — The skeleton 
of a hydrocephalic foetus with spina^ bifida involving dorsal, 
lumbar, and sacral regions. The bodies of the vertebrae are 
all deficient, the spine being completely cleft, as high as the 
cervical region. The lower bodies of the undivided portion 
of the column have two centres, which serve as points of 
departure for the divided column below. There is no bony 
process crossing the vertebral canal at the point of division ; 
below this point the canal on each side is unclosed on the 
inner aspect, there being apparently no formation of lamina in 
this situation. 

No. 25. — Boyal College of Su/rgeons, No. 271 a. — ^The bones 
from a case of lumbo-sacral spina bifida. The sacrum is 
twisted to the left side owing to a malformation of its upper 
three segments, consisting in a partial absence of the left 



372 Report of the Committee on Spina Bifida. 

halves of tlie first and third segments ; the left half of the 
second segment is produced upwards and downwards so as in 
some measure to compensate for the deficiency (Plate XX, 
and Fig. 7). The specimen was removed from the body of 
a boy 8Bt. 12. The tumour was situated on the right of the 
median line ; it had grown with the child^s growth, but not 
otherwise. He had never walked without crutches, but he 
had complete control over bladder and rectum untU he was 
turned eleven years ; thin dribbling of urine commenced, and 
the bowel lost expulsive power (the rectum was distended with 
hard faeces, which had to be scooped away). An efEort was 
made to remove the fluid as all the symptoms were becoming 
aggravated. He died of meningitis purulenta some weeks 
after the operation. 

No. 26. — Boyal College of Surgeons, No. 278. — The skeleton 
of a foetus, showing deficient closure of the arches in the 
occipito-cervical region. Some of the centres of the cervical 
vertebrae are double. The column presents two lateral curva- 
tures in the upper dorsal, one to the right the other to the left, 
owing to the absence of the opposite halves of the second and 
fourth of the bodies. 

No. 27. — Boyal College of Surgeons, No. 274. — The lower 
dorsal, lumbar, and sacral vertebras of a newborn child. The 
lamina of the four lower dorsal vertebrae below are widely 
separated. The lumbar region is strongly concave anteriorly, 
the other spinal curves as £br as shown being normal. Ante- 
riorly the body of the vertebra at the bottom of the lumbar 
concavity is so reduced in thickness that the contiguous inter- 
vertebral discs lie almost in contact. 

No. 28. — Boyal College of Surgeons, No. 276 a. — ^The parts 
concerned in a lumbo-sacral spina bifida, which was cured by 
the injection of Morton^s fiuid. Externally there is a deep- 
puckered depression at the centre of the sac ; the cuticle here 
is smoother and more shining than that around. On section 
the sac is represented by a mass of connective tissue sharply 
bounded in front by the dura mater ; the spinal cord crosses 
the highest part of the sac through the fibrous tissue noted. 
In the lower part of the sac there are, anteriorly, sections of 
nerve-roots passing towards the intervertebral sacral foramina 
(Plate XIV, Fig. 2), 



Report of the Committee on Spma Bifida, 373 



Pabt II. — Clinical. 

Introductory. — In order to form a correct estimate of tlie 
value of the treatment of spina bifida by the injection of Dr. 
Morton's iodo-glycerine solution,* we have endeavoured to 
ascertain as far as possible what is the natural history of the 
deformity when untreated, and we have also prepared com- 
parative tables of cases treated by injection of Morton's solu- 
tion, by injection of simple solutions of iodine, by ligature, by 
excision, and by puncture and pressure. 

Natural Histoet op Spina Bifida. 

From a study of all the cases tabulated at the end of this 
report, we have been able to gather certain facts in the 
natural history of spina bifida, but to show the natural course 
and termination of the deformity we have collected, in Table 
I, 60 cases, which have not been subjected to any operative 
interference. We have further appealed to the annual reports 
of the Registrar-General for England, and to a valuable report 
on Spina bifida by Professor Demme.t 

Sbx. — Our tables contain 245 cases ; of 156 in whom the sex 
is stated ; 82 were females, 74 were males. Of Demme's 57 
personally observed cases, 31 were females and 26 were males. 
From Table A, page 376, kindly furnished us by the Regis- 
trar-Greneral for England, we find that of 1768 cases of chil- 
dren with spina bifida dying in the first year of life, 989 were 
females and 779 were males. The deformity is therefore 
unquestionably more frequent in females than in males. 

Position op Tumoue. — The position of the tumour is stated 
in 236 of the cases collected by us. In the great majority of 
instances the statement rests upon clinical examination only, 
and as it is often difficult and may be impossible to determine 
with certainty the exact position of the spinal cleft without 
dissection, we would suggest that the subjoined figures should 
be corrected by those given in the first section of this report, 
and which we have added in a second column. Dr. Demme 
also gives the position of the tumour in his cases ; these we 
have added in a third column. 

* The following is Dr. "^oTtou's formula : — Tgt,, lodi. gr. x, Potassii iodidi 
gr. XXX, Glycerini 3j- M. 

t Zwangifftter MecUcimcher Bericht des Jenner'schen KindertpitaU, Bern., 
1882. This report is specially valuable as it contains 57 cases observed by one 
Surgeon, and forming his entire experience. 



874 



Report of the Committee on 8pida Bifida. 



Region. 


Our cases. 


Path, series. 


Demme's cases. 


Cervical 


. 11 


•1 case affecting* • 


5 


Cervico-dorsal 


. 2 


. whole of spine . , 


2 


Dorsal . 


. 14 


9 


13 


Dorsi-lumbar 


. 8 


8 





Lumbar 


. 108 


9 


17 


Dorsi-lumbo-sacral 2 


7 





Lnmbo-sacral 


. 42 


68 


11 


Sacral . 


. 42 


21 


7 


Coccygeal 


. 7 


l(Sacro- 


coeqrg.) 



In two of Demme^s cases there were two tumom's ; in one 
Case over the third and fonrth^ and over the seventh and 
eighth dorsal vertebras ; in the other over the first and second^ 
and over the eighth and ninth dorsal vertebras. The above 
figures show a great preponderance of cases in the lower half 
of the spinal column. 

Complications. — ^In many of the cases in our tables no 
mention is made of the presence or absence of complications^ 
and the records are in several instances so brief that the absence 
of any mention of them cannot be taken as indicating the 
absence of such conditions. The following table is, therefore, 
probably of value as showing the relative, rather than the 
absolute frequency of the complications. Dr. Demme's cases 
having been all recorded by one careful observer are more 
exact in this as in some other particulars. 



ri/v^»i;^<>4^/v«. No. of cases in 
Complications. ^^ ^^^^^ 


No. of cases in 
Demme's table. 


Paralysis 
Talipes . 
Hydrocephalus 
liocy . 
Cretinism 


53 

42 

SO 

2 

1 


Not stated. 

13 

17 
Not stated. 


Curvature of spine. 
Absence of cerebellum 


2 
1 




Harelip 
Cleft palate . 



1 


3 

Not stated. 


Imperforate anus . 
Ectopia vesicae 


1 



1 



General Nuteition. — In only 14 of our cases is there 
mention made of the state of uie general nutrition of the 
patients; 7 are stated to have been marasmic, 7 quite 
healthy. Demme states that of 22 children brought 
to the hospital within the first three or four days of life, 



Report of, the Oommittee on 8pma Bifida. 875 

16 weighed under 2800 grms. (6i lb.); the remaining 6 
were well developed and weighed about 7 lb. He adds that 
all the eases that did not die early from rupture of the sac^ or 
were not cured by an early operation, gradually lost weight 
and showed symptoms of intestinal catarrh. 

Hbebdity. — In one instance recorded in our tables the 
deformity occurred in three successive children in a family, 
and in another in two successive children, the ninth and tenth. 
Demme mentions two cases, in each of which two previous 
children had the same deformity, and three cases in each of 
which one previous child of the same parents had spina bifida. 
In three cases the father had congenital club-foot, and in two 
the mother had harelip ; the brother of one of the cases col- 
lected by us is stated to have had hydrocephalus. 

Twenty-nine of Demme's children were first-born children, 

17 were second-bom, and 11 were later-bom children. 
Pebqubnct. — Dr. Demme found 57 cases of spina bifida in 

36,148 children; Chaussier records 22 cases among 22,298 
children in the Paris Matemite. The report of the Registrar- 
Greneral for the year 1882, states that in England and Wales, 
647 deaths were attributed to this cause alone. 

Natueal Course op the Malady. 

In Table I, we have placed 60 cases that had not been sub- 
jected to any operative treatment ; of this number 25 (41*6 per 
cent.) are stated to have died, and 14 (28*3 per cent.) to have 
undergone spontaneous cure. Of the remaining 21, the 
termination of the case is not stated, although several of 
them were able to follow their ordinary occupations. These 
figures do not, however, represent the real mortality of the 
deformity when allowed to run its natural course, for cases of 
infants dying of this deformity without special treatment are 
not usually recorded in the medical journals, while such as 
recover, with or without treatment, or who live on in spite of 
their deformity, are almost certainly placed on record. A 
more correct estimate of the mortality is afforded by Demme, 
who gives the result in all the 57 cases observed by him. 
He states that of the 82 patients for whom no operation 
was undertaken, not one was alive at the end of two years. 

11 died between the 8th and 14th day. 

9 „ „ 15th and 22nd day. 

5 „ „ 28rd and 80th day. 

8 „ „ 3rd and 4th month. 



376 



Report of the Committee on Spina Bifida. 



1 died at 5 montlis. 

1 ^^ 8 months. 

1 fj 12 months. 

1 ^^ 2 years. 
The Registrar-Greneral of England has courteously favoured 
the Committee with the appended Table A^ from which it is 
seen that the mortality among infants with spina bifida is very 
great in the early months of life. In the Report of the 
Registrar-General for 1882^ 89 deaths are attributed to spina 
bifida in London^ and of this number 86 died under the age 
of one year. 

Tablb a. — Deaths of males and females inEngla/nd and Wales 
under one year of age from spina bifida in each of the three 
years 1881-88. 



Tear and sex. 



1881 



{ 



Males.... 
Females. 



^^^^IFem^ei! 



i««»{p:^^: 



Total deaths in the three f Males 

years 1881-83 t^emales ... 



Age periods. 


0-8 
monUui. 


8-6 
montha. 


6-12 
montha. 


Total under 
1 year. 


188 
286 


29 
43 


26 
22 


243 
350 


216 
255 


89 
64 


22 
26 


277 
335 


202 
229 


32 

44 


25 
31 


259 
304 


606 
769 


100 
141 


73 

79 


779 

989 


1375 


241 


162 


1768 



Cause op Death. — ^In only 17 of our cases in Table I is the 
cause of death sufficiently stated j of these 

8 died from the effects of rupture of the tumour. 
4 ,^ marasmus. 

3 „ convulsions. 

2 „ hydrocephalus. 

Dr. Demme's figures are as follows :— 
15 children £ed from rupture of the sac. 
10 yy „ marasmus. 

7 „ „ intercurrent disease. 



}} 



32 



Report of the Oommittee on Spina Bifida. 



377 



From these facts it is evident that spina bifida is attended 
with great mortality at an early age. We regret that our 
statistics do not enable ns to demonstrate the absolute mortality 
of the deformity when untreated, or the proportion in which 
death depends upon local and upon general conditions. 

In a certain number of the cases recorded death has been 
caused by rupture of the sac, draining away of the cerebro- 
spinal fluid, and subsequent septic meningitis. But we believe 
that in a large proportion of cases death ensues from the 
marasmus and general defective nutrition, so often associated 
with this and other deformities, and which cannot be remedied 
by any local treatment of spina bifida. 

Mods of Spontaneous Cube. — In 18 of our cases in Table I 
the mode of cure of the tumour is stated more or less fully. 
In 8 there was a gradual shrinking of the sac, in 4 the sac 
burst, and in 1 there was ulceration of the sac and general 
oozing. In view of the frequency with which rupture of the 
tumour leads to death, we are justified in speaking of the 
gradual shrinking of the sac of a spina bifida as its natural 
mode of cure. 

Persistence of Tumoub. — In our table are found the cases 
of patients who at the time of record were well and had 
attained the age of 9, 13, 13, 17, 23, 25, 25, 25, 32, 40 and 43. 
Two others were aged respectively 23 and 26 at the time of 
their death. In a certain minority of cases, therefore, the 
presence of spina bifida is not incompatible either with life, 
health, or general activity. 

Treatment by Puncture. 

In Table II, we have placed 46 cases treated by puncture 
or incision of the tumour with or without subsequent com- 
pression. 

Results. — Of these, 30 died, 12 recovered, 2 were un- 
relieved, and in 2 cases the result is not stated. One case was 
submitted to tapping as many as seventy times. 

Region affected. — The mortality in the different regions 
of the spine is shown by the following table : 



Begion of spine. 


Becorered. UnreUered, 


Died. 


Cervical 


. 





... 2 


Dorsal 


. 


,.. 


... 1 


Dorsi-lambar 


. 1 


... 


... 2 


Ltimbar (1 lost sight of) 


. 5 


1 


... 16 


Lombo-sacral 


. 2 


... 1 


... 2 


Sacral 


. 4 


... 


6 



378 



Beport of the Oommiiiee on Spina Bifida. 



In one case (&tal) the poaition of the tnmoar ia not stated. 

Natdki or TuxouB. — 'Hie only means we have of estimating 
the severity of these casee ia to notice the natare of the sac- 
wall, the presence or absence of nerves in the tmnonr, and the 
complicationB mentioned. In a large nmnber of instances no 
reference is made in the scanty record of the cases to any of 
these particulars. 

T^ Sac-Wall. — The sac-wall was membranous in 13 cases, 
in 5 of which it was ulcerated. The sac-wall was covered witli 
healthy skin in 5 cases. The sac-wall is nndeei^bed in 27 
cases. 

CoHTKNTS. — ^Nerves are stated to have been present in the 
sac in 11 cases and absent in 5 cases. No mention is made 
of the contents of the tomonr in 29 cases. 

The tnmoar is said to have been pednncnlated in 2 cases. 

COMPLICATIOHS. — 

Paralysis ..... 10 cases. 
Hydrocephalas 



Talipes . 

Slonghing of sac 

None 

Ko mention of complicatione in 



CAnsE OF DxATH. — In the 30 fotal cases the cause of death 
was as follows :^ 

Meningitis ..... 14 cases. 
" Convulsions " 



Marasmus 
" Uzhaastion " 
Intercurrent disease 
Not specified . 



1 



Many of the cases described nnder the head of " convul- 
eions" were probably really instances of meningitis. Whether 
th i 3 be so or not, it is obvious that meningitis is the great danger 
of this mode of treatment. This method of treatment is an 
imitation of that local change in the tumour (rupture) which 
uiost often ends fatally, and its disastrous results are therefore 
by no means surprising. While in many instances puncture 
of the sac of a spina bifida has proved entirely innocaous, it 
has been so much more often fatal that it should not be under- 
takea even as a palliative measure. 



Report of {he Committee on Spina Bifida. 



379 



Treatment by Lioatuse. 

In Table III, we have placed 16 cases which have been 
treated by ligature of the tumour. 

Results. — Of these 6 died, and 10 recovered. 

Region. — ^The result in the different regions of the spine 
was as follows : 



Begion of spine. 


Becovered. 


Died. 


Cervical 


2 





Cervico-dorsal 


1 





Dorsal .... 





1 


Lumbar 


4 


4 


Lombo-sacral 


1 


1 


Sacral .... 


2 






i> 



y} 



The Sao- wall. — The sac-wall is undescribed in 11 cases. 
The sac-wall is described as healthy skin in . 1 
The sac-wall is described as thin and mem- 
branous in 4 

In 3 cases the tumour was pedunculated; 2 recovered, and 
1 died. 

Contents. — Nerves are stated to have been absent from the 
sac in 3 cases. In no case are nerves stated to have been 
present in the tumour, although in one case two cords which 
resembled nerves passed through the sac. 

This mode of treatment, like excision, permits of a ready 
and certain examination of the contents of the sac. In no case 
did persistent paralysis follow the operation ; this result is in- 
compatible with the presence of nerves in the sacs which were 
removed. 

Complications. — Complications are recorded in 2 cases 
only, both of which recovered ; there was hydrocephalus in 1 
case, and deficient intellect in 1 case. 

Cause of Death. — In the 6 &tal cases the cause of death 
was as follows : 

Meningitis 8 cases. 

Draining of cerebro-spinal fluid . 1 

Intestinal catarrh .... 1 

Not specified .... 1 

Ligature of the tumour is of course inapplicable to cases of 
myelocele, and there is no evidence that any of the 16 cases in 
tins table were of such a nature ; indeed the negative evidence 
is 80 strong as to amount to almost positive proof to the con- 






i} 



880 Bepart of (hs OcmmiUee an Spina Bifida. 



trar^. For cases of meningooele a mortality of 87*5 per cent, 
is luglier tlian that obtained from othor mooes of treatanent. 

Teeatxxnt bt Ezcisiom* 

In Table lY, we have placed 23 cases treated by exdmoa 
of the sac. 

Bismurs. — Of these 16 have recovered^ 7 have died. 

BiaiONS. — ^The mortalily in the different n^ons of tlid 
spine was as follows : 

Beg^ of fpine. BeooTered. IHed* 

Cervical . 2 ••• 

Dorsal . . . . 2 ••• 1 

Lnmbar • .9 ••• 4 

Sacral • • 2 ••• 1 

In two cases^ one of which was &talj the region of the * 
spine is not stated* 

Natitbb ov Tukoub. — ^The sac-wall is nndescribed 

in 12 cases. 

The sac-wall is described as membranoos in 3 ^^ 

(In two of these it was ulcerated.) 

The sac-wall is described as covered with 

healthy skin in .... 8 ^^ 

Contents. — Nerves were certainly absent 

from the sac in .... 16 

Nerves were certainly present in the sac in 1 
(This case was fatal) 

No mention of contents of sac in . . 6 ,, 

Complications. 

None present 5 cases. 

Talipes 8 „ 

Suppuration of tumour . . . 1 ^, 

No mention of complications . . 14 ,, 

Cause of Death. — ^In the 7 fetal cases^ the cause of death 
was — 

Meningitis 5 cases. 

Marasmus 1 ^> 

Not specified 1 ^^ 

Plastic Operation. — ^Appended to Table IV, are two cases 
in which a plastic operation was performed, the inner sac of 






Bspori of the Oommittee on Spina Bifida. 



381 



the tumour being preserved, while flaps of skin reflected from 
its base were united over it ; one of these cases recovered, the 
other died. 

For reasons which are stated lower down we are compelled 
to regard excision of the tumour as an inappropriate treatment 
of spina bifida. 

Teeatmbnt by Injection of Simple Iodine Solution. 

In Table Y, we have placed 26 cases of spina bifida which 
have been treated by injection into the tumour of aqueous or 
spirituous solutions of iodine. 

Ebsult. — Of these cases 20 recovered, 5 died (19*2 per 
cent.), 1 was unrelieved. The results in the different regions 
of the spine were as follows : 



Region of spine. 

Cervical . 
Lumbar 
Lumbo-sacral 
Sacral 
Not stated 



Beoovered. 
1 

7 
3 
6 
3 



Unrelieved. 


1 






• • 



• * 



Died. 


3 
2 





8 cases. 

1 

1 






The Sac— The sac is described as mem- 
branous in (1 ulcerated, 1 nadvoid, 1 
very thin) 

The sac is described as covered by healthy 
skin in 

The sac is not described in the remaining cases. 

Complications. 

Paralysis 5 cases. 

Hydrocephalus .... 3 

l£ocy 1 

None ...... 15 

None specified .... 2 

Cause of Death. — In all the 5 fatal cases convulsions pre- 
ceded death, and in 2 of these 5 cases the sac burst. In 1 
case as many as fourteen injections were made. 



9> 



Tbeatment by Injection op De. Morton's Fluid. 

In Table VI, we have placed 71 cases treated by the injection 
of Dr. Morton's iodo-glycerine solution. Forty-one of these 
cases have been specially reported to the Committee, and have 



382 



Report of the Oommittee on Spina Bifida, 



Begion of spine. 

Cervical 

Dorsal 

Lumbar 

Lmnbo-sacral 

Sacral 

Coccygeal 

Not stated 



UnreHeved. 




1 
1 
1 


2 



Died. 

3 

6 
13 
3 
1 
1 



not been previously published; the remaining 30 cases have 
been collected from various medical journals. 

Result. — Of the 71 cases^ 35 recovered, 27 died, 5 were 
unrelieved, 4 were relieved. 

The 35 cases numbered as recoveries, recovered as regards 
the sac only, the complications associated with the de- 
formity remaining unaltered. The 27 fatal cases died at 
various periods after the operation, and not all as a result of 
the operation. The cases described as ''relieved'^ are those 
in which as a sequel to the injection the tumour became 
smaller or partially solidified. 

BsoiON. — The results in the different regions of the spine 
were as follows : 

Recovered. Relieved. 
2 ... 

4 ... 
15 ... 2 

8 ... 1 

5 ... 

... 1 

1 ... 

The Sac- Wall. — ^The sac-wall is described 
as membranous in (in 14 of these it 
was also ulcerated) .... 

The sac-wall is described as covered with 
normal skin in 

The sac-wall is not described in . 

Complications. 

Paralysis 

Talipes 

Hy^ocephalus 

Rupture of the sac at birth . 
None . . . . . 
None mentioned 

Causes of Death. — In the fatal cases the causes of death 
were as follows : 

Meningitis 

Shock 

Marasmus .... 
Hydrocephalus 

Convulsions .... 
Diarrhooa .... 
Not specified .... 



43 cases. 



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In a letter (dated May 11^ 1885) addressed to the Com- 
mittee Dr. Morton says : — ..." Including those pub- 
lished in my small book in 1877^ I am able to refer to 50 cases 
which have been treated by tapping and injection of the iodo- 
glycerine solution. Of these 41 have been regarded as suc- 
cessful by those who saw them. Thus 9 have been unsuc- 
cessful. This is about the proportion which has been noted 
ever since the adoption of this method of treatment.^^ 

Behabes. 

In the earHer part of this report we have adduced evidence 
which shows conclusively that in a large proportion of specimens 
of spina bifida the spinal cord is in the sac^ and this evidence 
cannot be gainsaid by reference to any cases observed in 
which no nerve-elements have been present in the sac. We 
are not acquainted with any means by which it is possible to 
determine in the living subject that the spinal cord is not in 
the sac of a spina bifida. For this reason we believe that any 
operation involving interference with or removal of the median 
vertical portion of the tumour should be entirely abandoned. 
We are quite conscious of the large measure of success that 
has attended the operations of ligature and excision^ but we 
cannot lose sight of the fact that these operations always 
expose the patient to the grave dangers attending removal of 
the expanded spinal cord and attached nerves. 

The treatment by repeated tapping has proved far too fatal 
to warrant its repetition^ and it does not rest upon any scientific 
basis. 

We believe that success in the treatment of spina bifida is 
to be best obtained by following closely the process of nature 
when spontaneous cure of these tumours occurs. This natural 
process of cure appears to consist in a gradual shrinking of the 
tumour^ and the treatment by injection of iodine commends 
itself to us as the best hitherto introduced^ not only on account 
of its great success^ but also because its mode of action most 
nearly resembles the natural mode of cure. 

A comparison of Tables Y and YI does not show any 
advantage derived from the use of Dr. Morton's iodo-glycerine 
solution. We are of opinion that this comparison is probably 
deceptive, for we believe that Dr. Morton's treatment has been 
adopted more widely than any other plan of treatment and, as 
our table shows, in a number of quite hopeless cases, in which 
other methods of treatment would not have been entertained. 



384 Report of the Committee on 8pma Bifida. 

Althoagh only nine years have elapsed since tlie publication 
of Dr. Morton's first case, the number of cases so treated 
already largely exceeds that treated by any other means, a 
fact largely due to the great success of the earlier cases. 

Dangebs of the Operation. — The first immediate danger 
of the operation is shock, which seems to have been the cause 
of death in five instances. Meningitis, with or without a con- 
tinuous drain of fluid, has been still more fatal. In one case, 
at least, paralysis of limbs supervened and persisted after 
cure of the tumour and appeared to be due to the treatment 
adopted. In four or five other cases paralysis of the lower 
limbs has occurred but has passed off after a variable time ; 
complete paraplegia is reported to have occurred once, and to 
have subsequently disappeared. In three cases hydrocephalus 
set in subsequently to the cure of the spina bifida, and in other 
cases the cure of the latter had no beneficial effect in delaying 
the steady progress of the hydrocephalus. It is not to be 
expected that any treatment of spina bifida will influence this 
cranial condition. In one case the injection of a drachm of 
the iodo-glycerine solution appeared to cause a profuse secre- 
tion of saliva. 

Selection op Cases. — We believe that the best results of 
Dr. Morton's treatment are only to be obtained by a some- 
what careful selection of cases. The circumstances which 
contraindicate it are advanced marasmus, great and increasing 
hydrocephalus, and intercurrent disease. As a rule, it is well 
to wait until the child is at least two months old before sub- 
mitting it to operation, but where the sac-wall is threatening 
to burst treatment may be carried out earlier. Where para- 
lysis or talipes complicate spina bifida the cure of the latter 
must not be regarded as offering any prospect of improving 
the former. 

Method op Opebatino. — Some importance has been 
attached to the position of the child during the injection. 
While we regard the fears that have been expressed on this 
point as exaggerated and due to a misconception of the usual 
anatomy of the tumour, we would recommend that the child 
should be laid upon its side. The puncture into the tumour 
should be made at one side of the base, obliquely through 
healthy skin, and not through membranous sa^wall, the 
objects being to avoid wounding the expanded spinal cord, and 
subsequent leakage of the cerebro-spinal fluid. It is not 
necessary to withdraw any of the fluid contents of the tumour 
before injecting the solution of iodine. From half a drachm to 



Report of the Committee on Spina Bifida. 885 

two drachms of Dr. Morton^s iodo-glycerine solution liave been 
generally injected^ and a drachm of the fluid commends itself 
to us as a suitable quantity in the majority of cases. Should 
the injection fail altogether^ or only a part of the cavity be 
obliterated^ the operation may be repeated at intervals of 
about a fortnight. 

Conclusions. 

1. Notwithstanding many failures^ the plan of treatment 
by injection is the best with which we are acquainted^ and the 
only one which we feel justified in recommending. 

2. A more careful selection of cases than has hitherto been 
made is necessary. 

3. Marasmus^ hydrocephalus^ and intercurrent disease con- 
traindicate the operation. 

4. In cases m which the operation may^ nevertheless^ be 
legitimately performed^ we should consider the following as 
xmfavorable circumstances : — 

a. Distinct evidence of the cord being in the sac^ as 

shown by umbilication or a longitudinal furrow. 
j3. A very thin membranous or ulcerated sac. 
Previous rupture of the sac. 

The occurrence of a distinct impulse between the 
tumour and the anterior f ontanelle ; or a sac^ the 
contents of which are easily returned into the 
spinal canal. 
€. A very early age of the patient. 
6. The best result is to be hoped for in children, who have 
reached the age of two months, in whom there is no paralysis 
or hydrocephalus, and when the sac is covered by healthy 
skin. 

We cannot close this Report without acknowledging the 
indispensable assistance of Mr. S. Or. Shattock, Curator of the 
Museum, St. Thomases Hospital, in analysing the pathological 
specimens, in making dissections, as well as the drawings with 
which the Report is illustrated. 

(Signed) Howabd Mabsh, 

A. Peabce Gould, 

H. H. Clutton, 

Robert Wm. Pabkeb, Hon. See. 

vol. XVIII. 25 



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Clm.Soc Trans Vol. XVlII.Plata XH7. 



I 




^ep/ien MtlUr (GUagow) id 



DESOMPTION OP PLATE XHT, 

Vertical section of the parts concerned in a spina bifida of the mid- 
dorsal region ; the chief part of sac has been removed. 

a, — Dilated central canal in the portion of spinal cord abore 

the protrusion. 
5.— Incomplete septa crossing the dilated canaL 
c. — ^Bemains of sac-wall. 

There is a slight prolapse of the cord into the mouth of the sac. Vide 
p. 365, No. 3. 



i 



din. Soc Trarj .VolOWIE- Hate XT/. 



Stephen f/li!lerfah$si>*}' 



A 



SGSiaftoch dii 




D<michi'--n S £1 /r/^E 



DESCRIPTION OF PLATE XIV. 

Fig. 1. — Portion of spinal column from the dorsal region ; the laminsa 
of the right side have been removed to show the spinal coi*d. 

a. — Outer margin of the aperture in the neural arch through 

which the protrusion has occurred. 
b, — Neck of the consolidated protrusion, 
c, d, — Beflected portions of the dura mater. 

The line of origin of the nerve-roots is quite normal. There is slight 
prolapse of the cord into the mouth of the sac, as in the preceding 
specimen. Vide p. 365, No. 4. 

Fig. 2. — Vertical section of lower part of the spinal column after the 
cure of a spina bifida by the injection of Dr. Morton's iodo-glycerine 
solution. 

a. — Lower portion of the spinal cord above the sac. 

b, — Young connective tissue produced after the injection and 

filling the sac ; into this the spinal cord is traceable for a 

short distance, 
c— Nerve-roots lying in the new connective tissue, and passing 

forwards to the intervertebral foramina. 
d. — ^Anterior divided edge of the dura mater. Vide p. 372, No. 28. 



OlinSoc Trans Vol XVIIl .HaleXV 




DESOBIPTION OP PLATE XV. 

Dissection of the parts concerned in a lumbo-sacral spina bifida, 
showing the typical cmatomical disposition in cases of meningo-myelo- 
cele. A portion of the sac-wall has been cut awaj to show the interior. 

a. — Surface of cord, covered with arachnoid, exposed by the 
removal of portion of dura mater. 

h, — Dura mater entering into the formation of the sac-wall. 

c. — ^Arachnoid lining the sac. 

d, — Lower portion of the spinal cord crossing the interior of 
sac ; some of the nerve-roots pass forwards upon it, towards 
the intervertebral foramina. The other nerve-roots arise 
from the posterior wall of the sac in a vertical series and 
traverse the space horizontallj. 

e. — Falciform process continuous with the pia mater, separating 
the anterior and posterior roots of the nerves of the left 
side; there is a corresponding process on the right side. 
Vide p. 34,2-3. 



CUn So: Trar.s Vol }(Vm.Hate XV'I 




DESCRIPTION OP PLATE XVI. 

Posterior view of the lower part of the trunk of a fcdtus at term 
affected with spina bifida. 

a. — Foramen leading from the outer surface of the