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i
J
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
• -• t * ^
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
•■. : i.r
Veil XVi:: Pla-..e II.
f\. -.v
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-i ..
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.^■■"'lA X
■ ■■■■>
r:,.j
... r>
i
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I.
)
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•':■
•4 -
■* ' - , " J ■',-■'
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.
ITTA 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*" . . .,
, .•^.>!^ ' ■'■
»%
:ir '^'^ - t..
% I
'Tl,-
■'*T;
»» »
^ air ■
^ m ~
Jilt
* *' -♦
H « « ^
•- - •
. , -^'i
■~ -rial »''--
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
9
ngi
yi
Fig.2.
P
Kg .3
.*w
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
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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}£ Jisiicqjrjftc 3i5r,nK liir faulaa ia ciicinn-
sMg^wwcti 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 per 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 higest part of the area, as seen in Specimen
No. 13 (Plate XVI), previously referred to, is recalled to
mind. It will be remembered 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 Specimens 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 cord occurs 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
0
Lumbar
. 108
9
17
Dorsi-lumbo-sacral 2
7
0
Lnmbo-sacral
. 42
68
11
Sacral .
. 42
21
7
Coccygeal
. 7
l(Sacro-
coeqrg.) 0
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 .
0
1
3
Not stated.
Imperforate anus .
Ectopia vesicae
1
0
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
. 0
0
... 2
Dorsal
. 0
,.. 0
... 1
Dorsi-lambar
. 1
... 0
... 2
Ltimbar (1 lost sight of)
. 5
1
... 16
Lombo-sacral
. 2
... 1
... 2
Sacral
. 4
... 0
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
0
Cervico-dorsal
1
0
Dorsal ....
0
1
Lumbar
4
4
Lombo-sacral
1
1
Sacral ....
2
0
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 ••• 0
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.
0
1
0
0
0
• •
• *
Died.
0
3
2
0
0
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.
0
0
1
1
1
0
2
Died.
0
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 ... 0
4 ... 0
15 ... 2
8 ... 1
5 ... 0
0 ... 1
1 ... 0
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.
3
25
22
20
7
2
17
9
f>
a
>y
yj
7 cases.
5
7
2
2
1
3
i>
a
a
>}
Report of the Committee on Spvfia Bifida. 383
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 protrasion
to the cental canal of the cord.
&.— Central or chief part o{ the protrasion ; aronnd this is an
eminence caused by a series of secondary cavities. Vide
p. 367, No. 13.
an SocTrans.VoLMU.PlateXVII
I
DamtlssoniCa Uth.
DESCRIPTION OF PLATE XVII.
Posterior view of a large multilocnlar spina bifida involving the
lowest dorsal and the lumbo-sacral regions. The sac- wall has been cut
away in various situations to show the different divisions of the interior.
a. — The right half of the emerging portion of the spinal cord,
which is divided bj a process of bone, as it enters the sac.
A bristle has been passed from above this into a lateral
sac on the right side.
6. — ^Posterior surface of the bodies of the vertebrsD ; the lower
part of the column generally is convex,
c— The highest of the lateral sacs of the right side.
d, — An opening made into one of the lower sacs.
The nerve-roots arise from the sac-wall and pass forwards to the
intervertebral foramina, which thej enter in a normal manner. Vide
p. 369, No. 20.
* !
Clin. Soc. Trans Voi.XVlU.PlaLe XVIU.
: ' •'■•.:;■ ■^■,
DESCRIPTION OF PLATE XYHI.
Part of a spinal column viewed from behind. There is a long fi8sm*e
in the vertebral canal extending from the tenth dorsal vertebra to the
lower end of the column.
There is a slender process of bone crossing the vertebral canal at the
highest part of the fissure ; anteriorly this abuts against the posterior
surface of the vertebral bodies, posteriorly it is expanded, and completes
the arch of the tenth dorsal vertebra. Vide p. 369, No. 21.
Clin.SoG Itans.VolXVm, Plate XIX.
Dmi^saentCi lith.
DESCRIPTION OF PLATE XIX.
The last two dorsal with the upper two lumbar yertebras. The bodies
of the vertebrsB have been divided vertically, as well as the pedicles of
the arches on its right side; the right halves of the bodies have been
entirely removed, so as to expose the spinal cord ; the cord has been
more fully exposed by turning back the laminaB of the right side. The
cord is perforated by a bony process which crosses the canal.
a. — ^The left division of the cord above the perforation, con-
sisting in its upper part chiefly of the anterior median
column ; in its lower part it is almost of the same size as
the right.
b. — The right division of the cord.
c, — Sheath of dura mater.
d, — The last dorsal nerve.
e. — Divided surface of the osseo-cartilaginous process (by which
the cord is perforated) turned forwards.
/. — Anterior portion of the same process connected with the
bodies of the vertebrae. Vide p. 370, No. 22.
\:\
! Sec Trar.s Vol Xflll.Plare XX.
DESCRIPTION OF PLATE XX.
Lower part of the spinal colamn from a case of spina bifida viewed
from behind. There is a fissure involving the arches of the fourth
lumbar and succeeding vertebrae. The sacrum is sharply inclined to
the left side. Vide pp. 371-2, No. 25.
INDEX.
• 0*
PAGE
Abscesses, peritoneal, in a case of perforation of the vermiform
appendix ; death, after a long interval, from pyasmia (D. W.
Finlay) 16
Addison's disease (P) — pigmentation of the tongue (J. K. Fowler) . 323
Althaus (J.)) case of hemiansssthesia from congenital brain
disease 151
Amputation at the hip in certain desperate cases of disease of the
joint or bone (J. Hutchinson) 240
by Fumeauz Jordan's method (Lewis W. Marshall) , 234
Anderson (James), a case of myzoedema 21
Akdebsok (William), a case of papilloma of the bladder success-
fully removed by operation 313
Aneurism, ingpiinal, ligature of external iliac with two kangaroo-
tail tendon ligatures, and division of the artery between them ;
suppuration of the sac. Recoveiy (W. J. Walsham) . . 254
Arteries, case of obstruction of, extending over many years
(W. B. Hadden) 268
Artery, basilar, thrombosis of, with profound coma, extreme lower-
ing of rectal temperature, and death in five and a half hours
(H. 0. Bastian) 193
external iliac, ligature of, in case of inguinal aneurism
(W. J. Walsham) 254
Bakeb (W. Morrant), three cases of joint disease in connection
with locomotor ataxy
Discussion on above pape
Mr. A. Barker .
68
Dr. Dyce Duckworth .
68
Dr. Hale White .
. 60
Dr. Bazzard
61
Mr. Barwell
63
Sir James Paget .
66,67
Dr. Ord ' . . . .
70
44
Professor Humphry ... 72
Mr. Hutchinson . . . • 74
The President (Sir Andrew Clark) 77,
81, 87, 102, 106, 109, 115, 128
Mr. Hulke 78
Professor Charcot, letters from . 81
Dr. Mozon . . 82, 99
AKER (W. Morrant), Di»eii»tion
Mr. Hcnrj Mnr
Mr. lliTbrn Fa
Dr. Pj-e-Sniith
97, 00
paper (continued).
Dr. Bastinn .
Mr. IIoiTard Marab
Dr. Bnrlovr
Dr. O'Connor .
Dr. Hadden .
Mr. Hopkma .
Mr. M. Baker .
, 103, 105
Dr. BroaaWnt . . .105
Mr. ClemGnt Lueaa . 109
Dr. MuclagRU . . . 113.115
Itej'lij to diacusBion on Chwcofs disease
Ballakce (C. a.) anil W.B.Hadden, 3 cftse of hypertrophy of tb
subcutaneous tissnes of the fac«, hands, and feet [deacribed b;
Babker (A. E.), Remarhs in discusaion on Charcot's disease
Barlow (T.), Semarks in discuseion on Cbarcot's disease
sequel to a paper on three caaee of Kaynand'a diaeaai
(' Clin. Trans..' ivi, 179) ...... ,
Babwell (R.), Bemarke in discussion on Charcot's disease .
unnana! sequela of ovariotomy
three cases of bullet wound
Basilar artery, thrombosis of, with profound coma, extreme lower
ing of rectal temperature, and death in &ve and a half houri
[H. 0. Bastian}
Bastian (E. C). Remarhn in discussion on Charcot's disease 11
a case of thrombosis of the basilar artery, with profount
coma, extreme lowering of rectal temperature, and death ii
five and a half hours
Bennett (A. Hughes), a case of locomotor ataxy, withont diseast
of the posterior cohimna of the spinal cord
Bladder, calculus and tumour of the (carcinoma P); lithotomy
death on the ninth day (J. B. Lunn) ....
papilloma of, case enccessfiilly removed by operatiQji
(W. Anderson)
tumour of; removal; cure JB, Pitts) ,
Brain, lesion of the frontal lobe (W. Hale White) .
disease, congenital, case of heniiancesthesia from i
Althaus) ...........
r (W. H.], Remarjis in discuasion on Charcot's dia-
Bromism, ease of skin eruption due to (B. E. Oarrington)
Bryant (Thomas). Presidential Address delivered February 13,
1S8S
Bullet wound, three cases of (B. Barwell)
D (T.), Semarks in discussion on Charcot's disease
^1
n (T
Index. 421
PAGE
Calculi (prepntial), cases of (J. Oroft) 8
Calculus removed from tke vermiform appendix for the relief of
recurrent typhlitis (0. J. Symonds) 285
see also Bladder, Nephro -lithotomy.
Cabbington (B. E.), a case of skin eruption due to bromism . 28
■ two cases of phlegmonous pharyngitis; notes of post-
mortem by W. Hale White 164
Catheter, cesophageal, new form of (0. J. Symonds) . . . 155
Cayley (W.), a case of haemoptysis treated by the induction of
pneumothorax so as to collapse the lung 278
Chabcot (J. M.)) letters from, read during debate on Charcot's
disease 81
Charcot's disease, Discussion on, see Baker (W. M.).
Choreiform movements, case of, supervening in infancy, and pro-
bably of congenital origin (W. B. Hadden) .... 221
Clabk (Sir Andrew), BemarJes as President in discussion on
Charcot's disease ... 77, 81, 87, 102, 105, 109, 115, 128
Clutton (H. H.), see Beport of Committee on Spina Bifida.
Colotomy, three cases, with delayed opening of the intestine
(N. Davies-Colley) 204
CoBNEY (B.), notes on cases of preputial calculi .... 8
Cretinism, sporndic, a case of (Sidney Phillips) .... 248
Cbockeb (H. Badcliffe), a case of urticaria pigmentosa, or xan-
thelasmoidea 12
Cboft (John), cases of preputial calculi 8
Davies-Collby (N.), on three cases of colotomy, with delayed
opening of the intestine • 204
Dickinson (W. Howship) and J. Rouse, case of nephro- litho-
tomy 189
Dislocation, paralytic, of the patella (C. H. Golding-Bird) . . 25
DucKWOBTH (Dyce), Bemarhs in discussion on Charcot's disease . 58
read letters from Professor Charcot 81
Dysentery, chronic, treatment of, by voluminous enemata of
nitrate of silver (S. Mackenzie) 37
TiNLAY (David W.), a case of perforation of the vermiform ap-
pendix, with peritoneal abscesses ; death, after a long interval,
from pyaemia 16
Foreign bodies, see Com ; Teeth, artificial,
Fowleb (J. K.), pigmentation of the tongue (P Addison's disease)
[described by card] 323
f
Fox (T. Oolcott), on pityriasis oircimS (Horand) and pitjriasis
circinf et marginfi (Tidal) 244
on two cases of Raynaud's dieeaae 300
Fractnra of larynx (W. A. Lane) 335
nnonited, two cases of wiring (CKacnamara) . , 328
of right oleoranon wired antdeeptically; close union
(Rusbton Parker) 3^
Frontal lobe, see Brain.
Gastrostomy for malignant disease of the pharynx, tonsil, &c. (C.
Stonham) 327
GODIBE (Bickman J.), a case of tnmonr of the right kidney in an
infant snccessfdlly removed by an abdominal incision ; recur-
rence; death 31
QoLDiNQ-BiKD (0. H.), a case of paralytic dislocation of the
patella 25
QomJ> (A. Fearce), see B^ort of Oommittee on Spina Bifida
Haddbn (W. B.), on certain nerre symptoms in rhenmatio affec-
' BemarhB in discussion on Charcot's disease . . . 127
a case of choreiform movemaits superrening in in&noy,
and probably of congenital origin 221
a case of obstruction of arteries and Teins extending over
many years 268
see BaHanee and Sadden, hypertrophy of subcntaneous
tisanes.
, Hsmatemesis, recurrent, with urticaria, a case of (J. J. Pringle) . 143
Hcemoptysis, case of, treated by the induction of pnenmothorax
so as to collapse the lung (W. Cayley) 278
Heuiianffisthesia from congenital brain disease, case of (J. Althaus) 151
Hip, amputation at the, in certMU desperate cases of disease of
the joint or bone (J. Hutchinson) ...... 240
^^^ Hip-joint, amputation at the, by Fnmeanx Jordan's method
^B (Lewis W. MarahaU) 234
^^B Hopkins (J.), S^marka in discussion on Oharcot's disease . 127
^^m two cases of mynedema 332
^^K HuiiEE (J. W.). Semarks in discussion on Charcot's disease . .78
^^1 HuUPHBX (Q. IS..), Eemarks in discuBsion on Charcot's disease 72
^^M HuTCHiHSOH (Jonathan), Bemarkt in discussion on Charcot's
^^M disease 74
^^B on amputation at the hip in certain desperate cases of
^^^ diseaseof the joint or hone 240
Index, 423
PAGE
Hjpertropliy of the subcntaneons tissues of the face, hands, and
feet (C. A. Ballance and W. B. Hadden) 325
Inguinal aneurism, see Aneurism,
lodo-gljcerine solution, Morton's, treatment of spina bifida by, see
B&port of Committee on Spina Bifida.
Joint disease in connection with locomotor ataxy, three cases
(W. Morrant Baker) 44
For speakers in discussion on above paper, see Bakbb (W. Morrant).
Jordan (Fumeaux), amputation at the hip-joint by his method
(Lewis W. Marshall) 234
Kidney, right, tumour of, in an infant, successfully removed by an
abdominal incision ; recurrence ; death (R. J. Godlee) . . 31
■ see also N^hro-lUhotomy.
Lane (W. A.), fracture of larynx [described by card] . . . 335
and W. Hale White, cervical rib [described by card] . 334
Larynx, fracture of (W. A. Lane) 335
Lawson (George), OBSophagotomy for the removal of a plate with
three artificial teeth, impacted in the OBsophagus . . . 292
Lediabd (H. W.)} a case of oesophagotomy 297
Lithotomy for calculus and tumour of the bladder ; death on the
ninth day (J. R. Lunn) 225
■ see also ISfephrO'lithotomy,
Locomotor ataxy, three cases of joint-disease in connection with
(W. Morrant Baker) 44
. For speakers in discnssion on above paper, see Baxeb (W. Morrant).
■ a case without disease of the posterior columns of the spinal
cord (A. Hughes Bennett) 168
Lx7CAS (R. Clement), Bema/rka in discussion on Charcot's disease . 109
LuKN (J. R.)} four [five] cases of osteitis deformans . . . 272
calculus and tumour of the bladder (carcinoma ?) ; litho-
tomy ; death on the ninth day 225
Mackenzie (Stephen), on the treatment of chronic dysentery by
voluminous enemata of nitrate of silver 37
■ a case of osteitis deformans [described by card] . . 331
-■ hereditary multiple tumours [described by card] . . 331
Maclagan (T. J.)} BevMvrks in discussion on Charcot's disease 113, 115
424 Index.
PAQK
U^CNUiAS^ (G.)> Semarlu in diBCDBuon on Oharoot's disease 103, 105
■ ■' two caees of wiring ununited firacturea [described by card] 328
Malignant disease of the pharynx, tonsil. Sec. ; ga^troetomj (G.
Stonham) 327
Mabbh (Howard), Semarlu in discussion on Charoot'a disease . 120
aee Jieporl of Committee on Spina Bifida.
Mabshaxl I, Lewis W.), amputations at the hip-joint bj Fameanx
Jordan's method 234
MoBKlS (Henry), Eemarka in discusaion on Charcot's disease . 90
a. oaae of nephro- lithotomy 1B5
Mortou'a iodo- glycerine solntioa, treatment of spina bifida by, see
Report of Committee of Spina, Bifida.
MosoN (W.), Bemarkt in discussion on Charcot's disease . 82, 99
Myeks (A. T.), a case of Raynaud's disease [described by card] . 336
Myia>dema, a case of (James Anderson) 21
' case, with a post-mortem examination {W. Hale White) . 159
two cases (J. Hopkins) 332
Nephro -lithotomy, a case of (Charters J. Symonds) . . . 180
a case of (Henry Morria) 185
. acaaeof (W.HowBhipDickinaonand J.Rouse) . . 189
Nerve symptoms in rheumatic aflectiona (W. B. Uadden) . . 1
left fifth, paralyais of (F. W. Strugnell) . ... 330
Nitrate of ailver, aee SUvsr.
Obstruction of arteries and veins, case eitending ovei- many years
(W. B. Hidden) 268
O'CoNNOB, (B.), Bemarki in discussion on Charcot's disease . 126
(Esophagus, case of malignant stricture of the, illustrating the
use of a new form of cesophageal catheter (C. J. Symonds) . 155
(Esophagotomy for the removal of a plate with three artj^cial
teeth, impacted in the cesophagua (G. Lawson) . . . 292
case of [for plate with artificial tooth] (H. A. Lediard) , 297
Olecranon, right, caae of ununited fracture, wired antiaeptioally ;
close union (Euahton Parker) 329
Obd (W. M.), Remarke in diacussion on Charcot's disease . . 70
Osteitis deformans, four [five] cases (J. B. Lunn) .... 272
case of (Stephen Mackenzie) 331
Ovariotomy, unusual sequeia of (R. Bai'well) 199
Page (Herbert), Bemarlea in discussion on Charcot's disease 97, 99
Faoet (Sir James), Remarla in discussion on Charcot's disease 66, 77
Index, 425
PAGE
Papilloma, successful thyrotomy for, with preservation of voice
(R. W. Parker) 330
of the bladder, case snccesBfully removed by operation (W.
Anderson) 313
Paralysis of the left fifth nerve (F. W. Strugnell) .... 330
Pabeeb (Robert W.), successful thyrotomy for papilloma, with
preservation of voice [described by card] .... 330
' see Be^ort of Committee on Spina Bifida.
Pabkbb (Rushton), a case of ununited fracture of right olecranon
wired antideptically ; close union [described by card] . 329
Patella, case of paralytic dislocation of the (0. H. Golding-Bird) . 25
Perforation, see Vermiform appendix.
Peritoneal abscesses, see Abscesses.
Pharyngitis, phlegmonous, two cases (R. E. Carrington), notes on
post mortem by W. Hale White 164
Phillips (Sidney), a case of sporadic cretinism .... 248
Pigmentation of the tongue (P Addison's disease) (J. E. Fowler) . 323
Pitts (Bernard), case of tumour of the bladder . . . . 320
Pityriasis circind (Horand) and pityriasis circin^ et margine
(Vidal) (T. Oolcott Fox) 244
Plastic operation in cases of spina bifida (A. W. Mayo Robson) . 210
Pneumothorax, case of haemoptysis treated by the induction of, so
as to collapse the lung (W. Oayley) 278
Preputial calculi, cases of (J. Orofb) 8
Presidential address, delivered by Thomas Bryant, F.R.CS.,
President, February 13, 1886 liii
Pbingle (J. J.), on a case of recurrent haematemesis with urticaria 143
Psoriasis, aberrant form of (W. Hale White) 324
Pyaemia, death after a long interval from, in case of perforation of
the vermiform appendix with peritoneal abscesses (D. W.
Finlay) 16
Pye-Smith (P. H.), Bem^jirhs in discussion on Charcot's disease . 99
Raynaud's disease, two cases of (T. Colcott Fox) .... 300
sequel to paper on three cases of (* Clin. Trans.,' xvi, 179)
(T. Barlow) 307
case of (A. T. Myers) 336
Rectal temperature, see Temperatvare.
Report of a committee nominated to investigate Spina Bifida and
its treatment by the injection of Dr. Morton's iodo-glycerine
solution [with table of cases] (Howard Marsh, A. Pearce
Gould, H. H. Glutton, and R. W. Parker) . .339
VOL. xviil. 28
~426 Index.
PAGE
Bhenmatic affectioaa, certain uerve symptoms in (W. B. Harden) 1
Bib, eerrical (W. A. Lane and W. H^le White) . . . .334
Eickets, arrested, a caee of (Seymour Tajlor) .... 177
-BoBSON (A. W. Mayo), a series of cases of spina bifida treated by
plastic operation 210
EODBK (J.), Bee Dickinson and Eottse, case of nepliro- lithotomy.
SOrer, nitrate ot, trmtmeut of cbronio djaeateij lij Tol^aiaoM
eoemattt of (S. Haokaude) .... . . . 87
8Un eruption due to bromiam (B. B. Oorringbm) . . . . -28
Spina bifida, a eeriea of oasea treated by pUatio operation (A. W.
UayoBobeon) . 210
r^ort of a committee appointed to inreatigate, an2 iia
treatment by the i^eotion of Dr. Uorton'e ioOo-gljroeriBe
Spinal oord, oaee of looomotor ataxy, witbout diieaee of the |)oa- .
tarior odiinuu (A. Hngbea Bennett) , , .... %^
'StoiAak (C), malignant disease of the pharynx, toninl, to., fff» ■ ,
troatomy [described by card] , 8S7
Striotnre, malignant, of cesophogna, case illnstrating tiia nae of
a new form of oesophageal catheter (0. J. Symonda] . . USfi
STBUOinsLL (F. W.), pantlysis of tbe left fifth nerve [deacribed 1^
card] 330
Stibcntaneoos tissuea. see Tiseues.
SiMONDS (Ohnrters J.), a case of malignant strictare of the ceso-
phagns, illustrating the use of a new form of cesophi^al
catheter 15S
a case of nephro-lithotoMiy 180
a case in which a calculus was removed from the vermiform
appendix for tbe relief of recurrent typblitiB .... 285
TatIjOB (Seymour), a case of ari'CBted rickete .... 17?
Teeth, artificial, cesophagolomy for the removal of (O. Lawsoh) . 292
(H- A. Lediard) 297
Temperature, rectal, ertreme lowering of, in case of thi^omboeia
of the basilar artery (H. C. Bastian) 193
Thrombosis of the basilar artery, with profoiind coma, extreme
lowering of tbe rectal temperature, and death in five and a
balfhowB(H. C. Baatian) . 193
Thyrotomy, successful, for papilloma, with preservation of voice
(R. TV. Parker) 330
Index. 427
PAo£:
TisBueB, Bnbcataneons, hypertrophy of, in face, hands, and feet
(G. A. Ballance and W. B. Hadden) 325
Tongue, pigmentation of the (P Addison's disease) (J. E. Fowler) . 323
Tamour of right kidney in an infant snccessfolly removed by an
abdominal incision ; reearrence ; death (B. J. Godlee) . . 31
■ of the bladder ; removal ; cure (B. Pitts) .... 320
(carcinoma P) of the bladder (J. R. Lunn) . . . 225
hereditary multiple (S. Mackenzie) 331
Typhlitis, recurrent, calculus removed from the vermiform
appendix for the relief of (G. J. Symonds) .... 285
Urticaria, on a case of recurrent hsematemesis with (J. J. Pidngle) 143
pigmentosa, or xanthelasmoidea (H. R. Grocker) . . 12
Veins, case of obstruction of, extending over many years (W. B.
Hadden) 268
Vermiform appendix, case of perforation of, with peritoneal
abscesses ; death after a long interval from pysBmia (D. W.
Finlay) 16
■ calculus removed from, for the relief of recurrent typhlitis
(G. J. Symonds) 285
Walsham ( W. J.), a case of inguinal aneurism ; ligature of the
external iliac artery with two kangaroo-tail tendon ligatures
and division of the artery between them ; suppuration of the
sac ; recovery [with table of cases] 254
White (W. Hale), Remarks in discussion on Gharcot's disease . 60
on lesions of the frontal lobe 136
a case of myxoedema, with a post-mortem examination . 169
— — aberrant form of psoriasis [described by card] . . . 324
notes of post mortem of case of phlegmonous pharyngitis,
see CarringUm (R. £.)
see Lane and White, cervical rib.
Wiring fractures, see Fra^ctures,
PBIVTED BT J. B. ADLABD, BABIROLOMEW^ CLOSB.
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