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9(arvard Universiti)
XSh^ CDedical School
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MEDICO-CHIRURGICAL
TRANSACTIONS.
PXTBLISHED BY
THE ROYAL
MEDICAL AND CHIRURGIOAL SOCIETY
LONDON.
VOLUME THE SIXTr-EIGHTH.
LONDON :
LONGMANS, GEEEN, AND CO.,
PATERNOSTER ROW.
18S5.
HAPVAPn UNIVERSITY
SCHOGL OF MEC.CiME AND PUBLIC HEAL1M
LIBRARY
29 NOV 1935
MEDICO-CHIRURGICAL
TRANSACTIONS.
PUBLISHED BT
THE ROYAL
MEDICAL AND CHIRTJRGICAL SOCIETY
or
LONDON.
SECOND SERIES.
VOLUME THE FIFTIETH.
LONDON:
LONGMANS, GBEEN, AND CO.,
PATERNOSTER ROW.
1885.
rUIMTBU BY J. E. ADLARD, BARTHOLOMEW CLUBB.
ROYAL
MEDICAL AND CHIEUEGIOAL SOCIETY
OF LONDON.
PATRON.
THE GUEEN.
OFFICERS AND COUNCIL,
ELECTED MARCH 2, 1885.
GEORGE JOHNSON, M.D., P.R.S.
VlCB-rEBSIDBRTS.
TKBA8UKEK8.
8ECKETAK1B8.
L1BEABIAII8.
OTBKE MBMBBB8
OP COUNCIL.
! WILLIAM OVEREND PRIESTLEY, M.D.
HERMANN WEBEll, M.D.
THOMAS BRYANT.
MATTHEW BERKELEY HILL.
r CHARLES BLAND RADCLIFFE, M.D.
I TIMOTHY HOLMES.
C RICHARD DOUGLAS POWELL, M.D.
I HOWARD MARSH.
f WILSON FOX, M.D., F.R.8.
I JOHN WHITAKER HULKE, F.R.S.
HENRY CHARLTON BASTIAN,M.D.,F.R.S.
WILLIAM HENRY BROADBENT, M.D.
THOMAS BUZZARD, M.D.
WILLIAM SELBY CHURCH, M.D.
CHARLES THEODORE WILLIAMS, M.D.
WARRINGTON HAWARD.
SIR WILLIAM MacCORMAC.
THOMAS PICKERING PICK.
WALTER RIVINGTON.
L WILLIAM SEDGWICK.
THB ABOVE FOBM TUB COUNCIL.
RESIDENT LIBBAEIAN.
JAMES BLAKE BAILEY.
A LIST OF THE PRESIDENTS OF THE SOCIETY
FROM ITS FORMATION.
ELBCTBD
1805. WILLIAM SAUNDERS, M.D.
1808. MATTHEW BAILLIE, M.D.
1810. SIB HENRY HALFORD, Bart., M.D., G.C.H.
1813. SIR GILBERT BLANE, Baet., M.D.
1815. HENRY CLINE.
1817. WILLIAM BABmGTON, M.D.
1819. SIR ASTLEY PASTON COOPER, Bart.,K.C.H., D.C.L
1821. JOHN COOKE, M.D.
1823. JOHN ABERNETHY.
1825. GEORGE BIRKBECK, M.D.
1827. BENJAMIN TRAVERS.
1829. PETER MARK ROGET, M.D.
1881. SIR WILLIAM LAWRENCE, Bart.
Uaa. JOHN ELLIOTSON, M.D.
1835. HENRY EARLE.
1837. RICHARD BRIGHT, M.D., D.C.L.
1839. SIR BENJAMIN COLLINS BRODIE, Bart., D.C L.
1841. ROBERT WILLIAMS, M.D.
1848. EDWARD STANLEY.
1845. WILLIAM FREDERICK CHAMBERS, MJ)., K.C.H.
1847. JAMES MONCRIEFF ARNOTT.
1849. THOMAS ADDISON, M.D.
1851. JOSEPH HODGSON.
1853. JAMES COPLAND, M.D.
1855. C3SSAR HENRY HAWKINS.
1857. SIR CHARLES LOCOCK, Bart., M.D.
1859. FREDERIC CARPENTER SKEY.
1861. BENJAMIN GUY BABINGTON, M.D.
1868. RICHARD PARTRIDGE.
1865. SIR JAMES ALDERSON, M.D., D.C.L.
1867. SAMUEL SOLLY.
1869. SIR GEORGE BURROWS, Bart., M.D., D.C.L.
1871. THOMAS BLIZARD CURLING.
1873. CHARLES JAMES BLASIUS WILLIAMS, M.D.
1875. SIR JAMES PAGET, Bart., D.C.L., LL.D.
1877. CHARLES WEST, M D.
1879. JOHN ERIC ERICHSEN.
1881, ANDREW WHYTE BARCLAY, M.D.
1882. JOHN MARSHALL.
1884. GEORGE JOHNSON, M.D.
FELLOWS OP THE SOCIETY APPOINTED BY
THE COUNCIL AS REFEREES OF PAPERS.
FOR THE SESSION OF 1885.86.
BECK, MARCUS.
BELLAMY, EDWARD.
BRUNTON, THOMAS LAUDER, M.D., F.R.S.
CHEADLE, WALTER BUTLER, M.D.
CREIGHTON, CHARLES, M.D.
CROFT, JOHN.
CURNOW, JOHN, M.D.
DICKINSON, WILLIAM HOWSHIP, M.D.
DUCKWORTH, DYCE, M.D.
DUNCAN, JAS. MATTHEWS, M.D., LL.D., F.R.S.
ERICHSEN, JOHN E., LL D., F.R.S.
FAYRER, SIR JOSEPH, K.C.S.I., M.D., F.R.S.
FENWICK, SAMUEL, M.D.
GALABIN, ALFRED LEWIS, M.D.
GEE, SAMUEL JONES, M.D.
GERVIS, HENRY, M.D.
GREEN, T. HENRY, M.D.
HARLEY, JOHN, M.D.
HEWITT, GRAILY, M.D.
HUTCHmSON, JONATHAN, F.R.S.
LANGTON, JOHN
LEGG, JOHN WICKHAM, M.D.
MACNAMARA, CHARLES.
MARCET, WILLIAM, M.D., F.R.S.
MORRIS, HENRY.
MOXON, WALTER, M.D.
ORD, WILLIAM MILLER, M.D.
PAGE. HERBERT WILLIAM, M.A., M.C.
POLLOCK, GEORGE DAVID.
RALFE, CHARLES HENRY, M.D.
SMITH, THOMAS.
STURGES. OCTAVIUS. M.D.
WARING, EDWARD JOHN, M.D.
WILLETT, ALFRED.
WILLIAMS, JOHN, M.D.
WOOD, JOHN, F.R.S.
TBUSTECa or TBI BOCIKTT.
SIE GEOBGE BUEEOWS, Babt., M.D., D.C.L., r.E.S.
THOMAS BLIZAED CUELING, P.E.S.
JOHN BIEKETT, F.L.S.
TBirSTEXS or IHE MABSHALL HALL UKUOBIAL FUITJ).
WALTEE BUTLEE CHEADLE, M.D.
WILLIAM OGLE, M.D.
THOMAS SMITH.
LIBBABT COMHITIEB FOB THB SBSSIOH OF 1885-86.
THOMAS LATJDEE BEUNTON, M.D., F.E.S.
FEANCIS HENEY CHAMPNETS. M.A., M.B.
WILLIAM E. GOWERS, M.D.
JOHN WICKHAM LEGG, M.D.
JOSEPH FEANK PAYNE, M.D.
MARCUS BECK, CM.
FEEDEEICK JAMES GANT.
JEEEMIAH MacCAETHY, M.A.
EGBERT WILLIAM PAEKEE.
WILLIAM JOHNSON WALSHAM, CM.
„ „ f E. DOUGLAS POWELL, M.D.
•^'"•- -^"^-i HOWARD MAESH.
( WILSON FOX, M.D., F.R.S.
i JOHN WHITAKEE HULKE, F.E.S.
FELLOWS
or TBB
ROYAL MEDICAL AND CHIRURGICAL SOCIETY
OF LONDON.
EXPLANATION OF THB ABBREVIATIONS.
P.— President. V.P.— Vice-President.
T. — Treasurer. S.— Secretary.
L, — Librarian. C. — Member of Council.
The figures succeeding the words Trans, and Pro. show the number of Papers
which haTC been contributed to the Transactions or Proceedings by the
Fellow to whose name they are annexed. Referee, Set. Com., and Lib, Com.,
with the dates of office, are attached to the names of those who haTe
served on the Committees of the Society.
OCTOBER, 1885.
Those marked thus (f) have paid the Composition Fee in lieu of further
annual subscriptions.
Amongst the non-residents those marked thus (*) are entitled by
composition to receive the Transactions.
Elected
1846 *Abercbombie, John, M.D.
1877 Abercbombie, John, M.D., Assistant Physician to, and
Lecturer on Forensic Medicine at. Charing Cross Hos-
pital ; 23, Upper Wimpole street, Cavendish square.
1851 •Acland, Sir Henry Wentworth, K.C.B., M.D., LL.D.,
F.R.S., Honorary Physician to H.R.H. the Prince of
Wales ; Regius Professor of Medicine in the University
of Oxford ; Broad Street, Oxford.
] 885 Acland, Tueodore Dyke, M.D., Assistant Physician to the
Hospital for Consumption and Diseases of the Chest,
Brompton -, 70a, Grosveuor street.
X FELLOWS OF THB SOCIBTY^
Elected
1847 AcosTA, Elisha, M.D., 24, Rue de Lazembourg, St.
Honore, Paris.
1852 fADAMs, William, Surgeon to the Great Northern Hospital
and to the National Hospital for the Paralysed and Epi-
leptic ; Consulting Surgeon to the National Orthopaedic
Hospital, Great Portland street; 5, Henrietta street.
Cavendish square. C. 1873-4. Trans. 3.
1867 AiKiN, Charles Arthur, 7, Clifton place, Hyde park.
1837 *AiNswoETH, Ralph Pawsett, M.D., Consulting Physician
to the Manchester Royal Infirmary ; Cliflf Point, Lower
Broughton, Manchester.
1839 Alcock, Sir Rutherford, K.C.B., K.C.T., K.T.S., D.C.L.,
late H.M.'s Envoy Extraordinary at the Court of Pekin.
Trans. I.
1866 Allbutt, Thomas Clifford, A.M., M.D., F.R.S., Physician
to the Leeds General Infirmary; 35, Park square,
Leeds. Trans. 8.
1879 Allchin, William Henry, M.B., F.R.S. Ed., Physician
to, and Lecturer on Medicine at, the Westminster
Hospital; 5, Chandos street. Cavendish square, W.
1863 Alth^us, Julius, M.D., Senior Physician to the Hospital
for Epilepsy and Paralysis, Regent's park ; 48, Harley
street. Cavendish square. Trans. 2.
1884 And£Rson, Alexander Richard, Resident Surgeon,
General Hospital, Nottingham.
1881 Anderson, James, A.M., M.D., 84, Wimpole street. Caven-
dish square.
1862 Andrew, Edwyn, M.D., 12, St. John's Hill, Shrewsbury.
1862 Andrew, James, M.D., Physician to, and Lecturer on Medi-
cine at, St. Bartholomew's Hospital ; 22, Harley street,
Cavendish square. S. 1878-9. C. 1881-2. Trans. \.
1820 Andrews, Thomas, M.D., Norfolk, Virginia.
1880 *Appleton, Henry, M.D., Staines.
1874 AvELiNG, James H., M.D., Physician to the Chelsea Hos-
pital for Women ; 1, Upper Wimpole street, Cavendish
square.
FELLOWS OF THE SOCIETY. XI
BleeUd
1851 *Bakeb, Alfred, Consulting Sargeon to the Birmingham
General Hospital ; 3, Waterloo street, Birmingham.
1873 *Bakeb, J. Wright, Senior Surgeon to the Derbyshire
General Infirmary ; 102, Friargate, Derby.
1865 Baker, William Morbant, Sargeon to, and Lecturer
on Physiology at, St. Bartholomew's Hospital; Con-
sulting Surgeon to the Evelina Hospital for Sick
Children ; Examiner in Surgery at the University of
London ; 26, Wimpole street, Cavendish square. C.
1878-9. Ub, Com, 1876-7. TroM. 6.
1869 Bakewell, Robert Hall, M.D., Ross, Westland, New
Zealand.
1839 fBALFOUR, Thomas Graham, M.D., F.R.S., Surgeon
General; Coombe Lodge, Wimbledon Park. C. 1852-3.
V.P. 1860-1. T. 1872. Lib. Com. 1849. Tran%, 2.
1848 '\l^Ki;LhXDy Edward, M.D., Inspector, Medical Departmeiit,
Local Government Board; 12, Highbury terrace,
Islington. C. 1872. V.P. 1875-6. Referee, 1853-71.
Lib. Com, 1855. Trans. 5.
1866 *Banks, John Thomas, M.D., Physician in Ordinary
to the Queen in Ireland; Physician to Richmond,
Whitworth, and Hardwicke Hospitals ; Regius Pro-
fessor of Physic in the University of Dublin ; Member
of the Senate of the Queen's University in Ireland ;
45, Merrion square, Dublin.
1879 Barker, Arthur Edward James, Surgeon to, and
Assistant Professor of Clinical Surgery at, University
College Hospital ; 87, Harley street, Cavendish square.
Tran$. 3.
1882 Barker, Frederick Charles, M.D., Surgeon-Major,
Bombay Medical Service [care of Arthur E. J.
Barker, 87, Harley street].
1833 t^^RK^^> Thomas Alfred, M.D., Consulting Physician to
St. Thomas's Hospital ; 109, Gloucester place, Port-
man square. C. 1844-5. V.P. 1853-4. T. 1860-2.
Re/eree, 1848-51. Trans. 6.
Xn FELLOWS OF THE SOCIETY.
Elected
1876 Baslow, Thomas, M.D., B.S., PhysiciAii to University
College Hospital; Physician to the Hospital for Sick
Children, Great Ormond street, and Assistant Physician
to the London Fever Hospital; 10, Montague street,
Russell square. Trans, 1.
1881 •Barnes, Henrt, M.D., F.R S. Ed., Physician to the Cum-
berland Infirmary ; 6, Portland square, Carlisle.
1861 Basnes, Robert, M.D.^ 15, Harley street, Cavendish
square. C. 1877-8. Referee, 1867-76. Lib, Com.
1869-73. Trans, 4.
1864 Barratt, Joseph Gillman, M.D.^ 8, Cleyeland gardens,
Bayswater.
1880 Barrow, A. Boyce, Assistant Surgeon to the Westminster
Hospital and to the West London Hospital ; 1 7^ Wel-
beck street, Cayendish square.
1840 Barrow, Benjamin, Surgeon to the Royal Isle of Wight
Infirmary ; Southlands, Ryde, Isle of Wight.
1859 Barwell, Richard, Surgeon to, and Lecturer on Surgery
at, the Charing Cross Hospital; 55, Wimpole street,
C. 1876-77. V.P. 1883-4. IJ^/erw, 1868-75, 1879-82.
Trans. 10.
1868 BastlAlN, Henry Charlton, M.A., M.D., F.R.S., Professor
of Pathological Anatomy in University College, London,
and Physician to University College Hospital ; Physician
for Out-patients to the National Hospital for the
Paralysed and Epileptic; 20, Queen Anne street.
Cavendish square. C. 1885. Trans, 1.
1875 Beach, Fletcher, M.B., Medical Superintendent, Metro-
politan District Asylum, Darenth, near Dartford, Kent.
1883 Beale, Edwin Clifford, M.A., M.B., Assistant Physician
to the City of London Hospital for Diseases of the
Chest ; and Physician to the Great Northern Hospital ;
23, Upper Berkeley street.
1862 Beale, Lionel Smith, M.B., F.R.S., Professor of the
Principles and Practice of Medicine in King's College,
London, and Physician to King's College Hospital ;
61, Grosvenor street. C. 1876-77. Referee, 1873-5.
Trans. 1.
FELLOWS OF THE SOCIETY. Xlll
Elected
I860 *Bejllet, Adam, M.D., M.A., Oak Les, Harrogate.
1856 Beardslet^ Amos^ F.L.S., Bay yilla, Grange-over-SancIs,
Lancashire.
1871 Beck, Marcus, M.S., Professor of Surgery in Uniyersity
College, LondoD, and Surgeon to University College
Hospital; 30, Wimpole street, Gayendish square*
Referee^ 1882-5. Lib. Com, 1881-5.
1880 Beeyor, Charles Edward, M.D., Assistant Physician to
the National Hospital for the Paralysed and Epileptic ;
33, Harley street, Cavendish square. Trane* 1.
1858 Beolet, William Chapman, A.M., M.D., late of the Middle-
sex County Lunatic Asylum, Hanwell ; 26, Saint Peter's
square. Hammersmith. C, 1877-8.
1883 Bell, Hutchinson Royes, Surgeon to, and Demonstrator
of Operatiye Surgery at, King's College Hospital^ 12,
Queen Anne street. Cavendish square.
1871 Bellamy, Edward, Surgeon to, and Lecturer on Anatomy
at, Charing Cross Hospital; Lecturer on Artistic
Anatomy to the Science and Art Department, South
Kensington; 17, Wimpole street,' Cavendish square.
Referee, 1882-5. Lib. Com. 1879-81.
1847 BiNNET, James Henrt, M.D., The Ferns, Weybridge, and
Mentone.
1880 Bennett, Alex. Hughes, M.D., Assistant Physician to the
Westminster Hospital ; 38, Queen Anne street, Cayen-
dish square. Tram.l.
1883 Bennett, Storer, Dental Surgeon to, and Lecturer on
Dental Surgery at, the Middlesex Hospital; Dental
Surgeon to the Dental Hospital of London ; 17, George
street, Hanoyer square.
1877 Bennett, William Henrt, Assistant Surgeon to, and
Lecturer on Anatomy at, St. George's Hospital ; Surgeon
to the Belgraye Hospital for Children ; 1, Chesterfield
street, Mayfair.
1845 fBERRY, Edward Unwin, 17, Sherriff road, West Hamp-
stead.
XIV FELLOWS OF THE SOCIETY.
Elected
1885 Be&rt, James, ABsiBUnt Demonstmtor of AnAtomy, St.
Bartholomew's Hospital ; 27, Upper Bedford place.
1820 Bektin, Stephen, Paris.
1872 Beyerlet, Michael, M.D., Assistant Surgeon to the Nor-
folk and Norwich Hospital ; 63, St. Giles's street, Nor-
wich.
1865 *Bicker8TETH, Edward Robert, Sargeon to the Liverpool
Royal Infirmary, and Lecturer on Clinical Surgery in
the Liverpool Royal Infirmary School of Medicine ; 2,
Rodnev street, Liverpool. Tran9. 1.
1878 BiNDON, William John Verbker, M.D., 48, St. Ann's
street, Manchester.
1854 Bird, Peter Hinckes, F.L.S.
1856 Bird, William, Consulting Surgeon to the West London
Hospital ; Bute House, Hammersmith.
1849 fBiRKETT, Edmund Lloyd, M.D., Consulting Physician to
the City of London Hospital for Diseases of the Chest ;
48, Russell square. C. 1865-6. Referee, 1851-9.
1851 fBiRKSTT, John, F.L.S., Consulting Surgeon to Guy's
Hospital; Corresponding Member of the ''Soci^t^
de Chirurgie " of Paris ; Inspector of Anatomy for the
Provinces in England and Wales; 62, Green street,
Grosvenor square. L. 18.56-7. S. 1863-5. C. 1867-8.
T. 1870-78. V.P. 1879-80. Referee, 1851-5, 1866,
1869, Sei. Com, 1863. Lib, Com. 1852. Tratu.S.
1866 BtsHOP, Edward, M.D.
1881 Btss, Cecil Yates, M.D., Assistant Physician to the
Hospital for Consumption, Brompton, and to the
Middlesex Hospital; 65, Harley street, Cavendish
square. Trans, 1.
1865 Blanchet, Hilarion, Examiner to the College of Physicians
and Surgeons, Lower Canada ; 6, Palace street, Quebec,
Canada east.
1865 Blandpord, George Fielding, M.D., Lecturer on Psycho-
logical Medicine at St. George's Hospital; 71, Gros-
venor street. C. 1883-4.
FELLOWS OF THE SOCIETY. XV
Elecied
1867 Bloxam, Johk Astley, Sargeon to, and Teacher of Opera-
tiye Surgery in, Charing Cross Hospital ; Sargeon for
Oat-Patients to the Lock Hospital ; Junior Sargeon to
the West London Hospital ; 8, George street, Hanover
square.
1823 BojANUS, Louis Hskry, M.D., Wilna.
1846 fBosTOCK, John Ashton, C.B., Hon. Surgeon to H.M. the
Qaeen; Surgeon -Major, Scots Fasilier Guards; 73,
Onslow gardens, Brompton. C.1861-2. V.P. 1870-71.
Set, Com. 1867.
1869 Bourns, Walter, M.D. [care of the National Bank of India,
80, King William street, City] ; Archaco, France.
1882 Bowlby, Anthony Alfred, Surgical Registrar to St. Bar-
tholomew's Hospital ; 75, Warrington crescent, Maida
hill.
1870 *BowLES, Robert Leamon, M.D., 8, West terrace, Folke-
stone.
1841 fBowMAN, Sir William, Bart., LLD., F.R.S., F.L.S.,
Consulting Surgeon to the Royal London Ophthalmic
Hospital, Moorfields ; 5, Clifford street. Bond street.
C. 1862-3. V.P. 1862. Referee, 1845-50, 1854-6.
Lib, dm, 1847. 2Va«#. 3.
1884 Boyd, Stanley, M.B., Assistant Surgeon to the Charing
Cross Hospital ; 27, Gower street.
1862 Brack, Williau Henry, M.D., 7, Queen*s Gate terrace,
Kensington.
1874 Bradshaw, A. P., Surgeon-Major ; Surgeon to the Rt. Hon.
the Commander in Chief in India ; Army Head Quar-
ters, Bengal Presidency. [Agent : Vesey W. Holt, 17,
Whitehall place.]
1883 Bradshaw, James Dixon, M.B., 30, George Street,
Hanover square.
1867 *Brett, Alfred T., M.D., Watford, Herts.
1876 Bridges, Robert, M.B., Manor House, Yattendon, New-
bury, Berks.
XVI FELLOWS OF THB SOCIETY.
Elected
1867 BaiBGSWATER, Thomas^ M.B.^ Harrov-on-the-Hill, Mid-
dlesex.
1868 Bboadbent, William Henrt, M.D., Physician to» and
Lecturer on Medicine at, St. Mary's Hospital ; Consulting
Physician to the London Feyer Hospital ; Examiner in
Medicine at the University of London ; 34, Seymour
street, Portman square. C. 1885. Referee, 1881-4.
Trans. 5.
1851 tBBODHURST, Bebnard Edward, F.L.S., Surgeon to the
Royal Orthopedic Hospital; 20, Grosvenor street.
G. 1868-9. Lib. Com. 1862-3. Trans. 2. Pro. I.
1872 Brodie, George Bernard, M.D., Consulting Physician-
Accoucheur to Queen Charlotte's Hospital ; 3, Chester-
field street, May fair. Trans. I.
1860 BROWN-SfQUABD, Ghables Edouabd, M.D., LL.D., F.B.S.,
Laureate of the Academy of Sciences of Paris ; Professor
of Medicine at the College of France ; Professor of
General Physiology at the Museum of Natural History ;
Paris. Sei. Com. 1862.
1878 Bbownb, Jakes Gbichton, M.D., LL.D., F.R.S., Lord
Chancellor's Visitor in Lunacy; Lecturer on Mental
Diseases, St. Mary's Hospital; 7, Gumherland Ter-
race, Regent's Park.
1880 Browne, James Williav, M.B., 8, Norland place, Uz-
bridge road.
1881 Browne, John Walton, M.D., Sni^on to the Belfast
Ophthalmological Hospital; 10, College square N.,
Belfast.
1881 Browne, Oswald A., M.A., M.B., 25, Bernard street,
Russell square.
1874 Bruce, John Mitchell, M.D., Physician to, and Lecturer
on Materia Medica at, the Charing Cross Hospital;
Assistant Physician to the Hospital for Consumption,
Brompton; 70, Harley street. Trans. 1.
FELLOWS OV THE SOCIETY. XVll
Meeted
1871 Brunton, Thomas LAUDBBy M.D., F.H.S.9 Assistant Physi-
cian tOy and Lecturer on Materia Medica and Thera-
pentics at, St. Bartholomev's Hospital; Examiner in
Materia Mediclt in the Uniyersity of London; 50,
Welbeck street, Cavendish square. Referee^ 1880-85.
Uh. Com, 1882-5.
1860 Bryant, Thomas, Viee-Fruident^ Surgeon to, and Lecturer
on Surgery at, Guy's Hospital ; 53, Upper Brook street,
Orosyenor square. C. 1873-4. V. P. 1885. 8ei. Com.
1863. J2e/eree, 1882-4. Lib. Com. 1868-71. Tram. 9.
Pro. 1.
1855 Bryant, Walter John, Physician to the Home for
Incurable Children, Maida yale ; 23a, Sussex square,
Hyde park gardens.
1823 Buchanan, B. Bartlet, M.D.
1864 Buchanan, George, M.D., F.B.S., Medical Officer of the
Local Goyemment Board ; Member of the Senate of the
Uniyersity of London ; 24, Nottingham place, Maryle-
bone road.
1864 Buckle, Fleetttood, M.D.
1876 BucKNiLL, John Charles, M.D., F.R.S. ; E 2, The Albany,
Piccadilly, and Hill Morton Hall, Rugby.
1881 BuLLER, AuDLEY Cecil, M.D., 10, Clifton hill, St. John's
Wood.
1833 tBuERows, Sir George, Bart., MJ)., D.G.L., LL.D., F.R.S.,
Physician in Ordinary to H.M. the Uueen; Consulting
Physician to St. Bartholomew's Hospital ; Member of
the Senate of the Uniyersity of London ; 18, Cayendish
square. C. 1839-40, 1858-9. T. 1845-7. V. P.
1849-50. P. 1869-70. Referee, 1842-6, 1850-7,
1861-68, 1875-81. Uh. Com. 1836. TroM. 2.
1837 t^usK, George, F.R.S., F.L.S., Consulting Surgeon to the
Seamen's Hospital, Greenwich ; Member of the Senate
of the Uniyersity of London ; 32, Harley street, Cayen-
dish square. C. 1847-8. V.P. 1855. T. 1866.
H^eree, 1846-54, 1857-65. £t5. Com. 1847. Traiu.A.
TOL. Lzvni. h
XVm FELLOWS OP THE SOCIETY.
Elected
1885 Butlee-Sktthe, Albert Chaeles, Senior Surgeon to the
Grosyenor Hospital for Women and Children; 35»
Brook streety Grosyenor sqaare.
1873 BuTLiN, Henrt Tssktham, Assistant Surgeon to, and
Demonstrator of Practical Surgery and of Diseases of
the Larynx at, St. Bartholomew's Hospital ; 47, Queen
Anne street, Cavendish square. Trans. 3.
1871 Butt, William F., 48, Park street, Park lane.
1883 Buxton, Dudley Wilmot, M.D., B.S., 82, Mortimer street,
Cavendish square.
1868 BuzzAED, Thomas, M.D., Physician to the National Hos-
pital for the Paralysed and Epileptic ; 56, Grosvenor
street, Grosvenor square. C. 1885.
1861 *Cadge, William, Surgeon to the Norfolk and Norwich
Hospital; 24, St. Giles's street, Norwich. Trans. 1.
1885 Cahill, John, 26, Albert Gate, Hyde park.
1875 Caetee, Chaeles Henet, H.D., Physician to the Hospital
for Women, Soho square ; 45, Great Cumberland place,
Hyde park.
1853 Caetee, Robeet Beudenell, Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, St. George's
Hospital; 27^ Queen Anne street. Cavendish square.
Trans. 1.
1845 fCAETWEiGHT, Samuel, late Professor of Dental Surgery at
King's College, London, and Surgeon-Dentist to King's
College Hospital ; Consulting Surgeon to the Dental
Hospital; 32, Old Burlington street. C. 1860-1.
Set. C<m. 1863.
1879 Caetweioht, S. Hamilton, Professor of Dental Surgery at
King's College ; 32, Old Burlington street
1868 Cavatt, John, M.D., Physician to St. George's Hospital;
2, Upper Berkeley street, Portman square. Trans, 1.
1871 Catlet, William, M.D., Physician to, and Lecturer on
the Principles and Practice of Medicine at, the Middlesex
Hospital; Physician to the London Fever Hospital
and to the North-Eastem Hospital for Children; 27*
Wimpole street, Cavendish square. Trans. 1.
FELLOWS OP THE SOCIETY. XIX
JSiected
1884 Chaffst, WATLA.ND GHA.RLS8, M.B., Medical Registrar to
the Hospital for Sick Children^ G-reat Ormond street ;
28« Cedars road, Clapham Common.
1845 tCHALK» William Olitsb^ 3« Nottingham terrace, York
gate. Regent's park. C. 1872-3.
1844 fCHAMBEBS, Thomas King, H.D., Hon. Physician to
H.R.H. the Prince of Wales; Consulting Physician
to St. Mary's Hospital and to the Lock Hospital;
8hrabsHillHoase,Sanningdale. C. 1861. T.P. 1867.
L. 1869-72. Referee, 1851-60, 1866. Lib. Com. 1852,
1868. :B^ans. 1.
1879 Champneys, Feakcis Henet, M.A., M.B., Obstetric Phy-
sician to, and Lecturer on Midwifery at, St George's
Hospital; Examiner in Obstetric Medicine in the
University of London ; 60, Great Comberland place.
Idb. Cam. 1885. Trans. 6.
1859 Chance, Feank, M.D., Burleigh House, Sydenham Hill.
1849 Chapmait, Feedeeick, Old Friars, Richmond Green,
Surrey.
1877 Chaeles, T. Ceanstouf, M.D., Lecturer on Practical
Physiology at St. Thomas's Hospital; Crofton Lodge,
Hopton road, Coventry park, Streatham.
1881 *CHAyA88E, Thomas Feederick, M.D., CM., Surgeon
to the Birmingham General Hospit^ 24, Temple Row,
Birmingham. Trans. 1.
1868 Chsadle, Waltee Butlee, M.D., Physician (with charge of
out-patients) to, and Lecturer on Medicine at, St. Mary's
Hospital ; Physician to the Hospital for Sick Children ;
19, Portman street, Portman square. Beferee^ 1885.
1879 Cheyne, William Watson, M.B., Assistant Sui^eon and
Demonstrator of Surgery to King's College Hospital ;
14, Mandeville place, Manchester square, W.
1873 *Chi8Holm, Edwin, M.D., Abergeldie^ Ashfield, near Sydney,
New South Wales.
XX FELLOWS OF THE 80CIBTT.
EUeted
1865 Gholmslet, Williaic, M.D., Physician to the Great
Nortiieni Hospital, and to the Margaret Street Infir-
mary for Consamption ; 63, Grosvenor street, Grosrenor
square. G. 1881-2. Be/ereey 1873-80.
1872 Ghbistis, Thoha.8 Beith, H.D., Medical Superintendent,
Royal India Asylum, Ealing.
1866 Ghuech, William Selby, M.D., Physician to, and Lecturer
on Glinical Medicine at, St. Bartholomew's Hospital ;
130, Harley street, Cavendish square. C. 1885.
J2^«ree, 1874-81.
1860 Claek, Sib Andbew, Bart., M.D., LL.D., F.R.S., Physician
to, and Lecturer on Clinical Medicine at, the London
Hospital; 16, Cavendish square. C. 1875.
1879 Clabk, Andbew, Assistant Surgeon to, and Lecturer on
Practical Surgery at, the Middlesex Hospital; 19,
Cavendish place. Cavendish square, W.
1839 t^LABK, Fbedebick Le Gros, F.R.S., Consulting Suigeon
to St. Thomas's Hospital; The Thorns, Sevenoaks.
S. 1847-9. V.P. 1855-6. Be/eree, 1859-81. Lib. Oom.
1847. Trana. 5.
1882 Clabkb, Ernest, M.B., B.S., 21, Lee terrace, Blackheath.
1848 iOLikBKE, JoHK, M.D., 42, Hertford street, May Fair. C.
1866.
1881 Clarke, W. Bbuce, M.B., Assistant Surgeon to, and
Demonstrator of Anatomy at, St. Bartholomew's
Hospital ; 46, Harley street. Cavendish square.
1842 fCLAYTON, Sir Gsoab Moore Passet, Extra Surgeon-in-
Ordinary to H.R.H. the Prince of Wales, and Surgeon-
in-Ordinary to H.R.H. the Duke of Edinburgh; 5,
Harley street. Cavendish square. C. 1865.
1879 Clutton, Henrt Hugh, M.A., M.B., Assistant Sui^eon to,
and Lecturer on Forensic Medicine at, St. Thomas's
Hospital ; 2, Portland place.
1857 Coates, Charles, M.D., Consulting Physician to the Bath
General and Royal United Hospitals ; 10, Circus, Bath.
FELLOWS OF THE SOCIETT. XXI
BUcted
1868 Cockle, John» M.D., F.L.S., Physician to the Royal Free
Hospital; 8» Suffolk street, Pall Hall. Ttom. 2.
1885 Collins, William Maunssll, M.D., 10, Cadogan place.
1865 CooPBBy Alf&bd, Surgeon for Cut^patients to the Lock
Hospital ; Assbtant Surgeon to St. Mark's Hospital ;
Surgeon to the West London Hospital ; 9, Henrietta
street. Cavendish square.
1843 tCoopsE, William White, Surgeon-Oculist in Ordinary
to H.M. the Queen ; Consulting Ophthalmic Sur-
geon to St. Mary's Hospital; 19, Berkeley square. C.
1858-9. V.P. 1873-4. Uh, Com. 1847, 1856-7.
1 868 CoBKisH, William Bobebt, Surgeon-Major, Madras Army ;
Sanitary Commissioner for Madras; Secretary to the
Inspector-General, Indian Medical Department.
1860 *CoBBY, Thomas Chables Stbuabt, M.D., Ormean Ter-
race, Belfast.
1864 CoiTLSOK, Walteb John, Surgeon to the Lock Hospital,
17, Harley street. Cavendish square.
1860 fCouPEB, John, Surgeon to the London Hospital; Assist-
ant Surgeon to the Royal London Ophthalmic Hospital;
80, GrosTcnor street. C. 1876. Referee 1882-3.
1877 CouFLAND, Sidney, M.D., Physician to, and Lecturer on
Practical Medicine at, the Middlesex Hospital; 14,
Weymouth street, Portland place.
1862 CowBLL, Geobgb, Surgeon to, and Lecturer on Surgery
at, the Westminster Hospital; Surgeon to the Royal
Westminster Ophthalmic Hospital; Surgeon to the
Victoria Hospital for Children; 3, Gayendish place,
Cavendish square. C. 1882-3.
1841 Cbawpobd, Mebytn Abohdall Nott, M.D., Millwood,
Wilbury road, Brighton. C. 1853-4.
1868 Cbawfobd, Sib Thomas, K.C.B., M.D., Director General,
Army Medical Department ; 6, Whitehall yard, and 5,
St. John's park, Biackheath.
1873 Cbeighton, Chables, M.D., 11, New Cayendish street.
Be/ereey 1 882-5. Traru. 1 .
XXU FALLOWS OF THE 80CIETT.
Elected
1869 *Cbe88Wsll, Pxabson B., DowUis, Merthyr Tyd^Q.
1874 Gbipps, William Habbi80N» Assistant Surgeon to St Bar-
tholomew's Hospital ; 2, Stratford place, Oxford street.
Tram. 1.
1882 Gbookbb» Hsnbt Radcliffs, H.D.» Physician to the Skin
Department^ University College Hospital; Assistant
Physician to the East London Hospital for Children i
28, Weiheck street. Cavendish square. Trane. 1.
1868 Cboft, John, Surgeon to, and Lecturer on Clinical Surgery
at, St. Thomas's Hospital ; 48, Brook street, Grosvenor
square. C. 1884. Rtferee, 1885. Lib. Com. 1877-8.
Trans. 1.
1862 Cboicptok, Samuel, M.D., Brookmead, Cranleigh, Surrey.
1837 Cbooeies, John Fabbab, 45, Augusta gardens, Folkestone.
1872 Cbosse, Thomas William, Surgeon to the Norfolk and
Norwich Hospital ; 22, St. Giles's street, Norwich.
1849 *Cbowfoot, William Bdwabd, Beccles, SnflTolk.
1879 CuMBEBBATCH, A. Elein, Aural Surgeon to St. Bartholo-
mew's Hospital ; Aural Surgeon to the Great Northern
Hospital ; 17, Queen Anne street.
1846 CuBLiNG, Henbt, Consulting Surgeon to the Margate Royal
Sea-Bathing Infirmary; Augusta Lodge, Ramsgate,
Kent.
1837 i<!uBLiNO, Thomas Blizabd, F.R.S., Consulting-Sur-
geon to the London Hospital; 27, Brunswick square,
Brighton. S. 1845-6. C. 1850. T. 1854-7. V.P.
1859. P. 1871-2. Referee, 1844-6, 1851-3, 1858,
1865-70, 1875-9. Set. Cam. 1863. Lib. Com. 1839.
Trans. 13. Pro. 1.
1873 Cubnow, John, M.D., Professor of Anatomy at King's
College, London, and Physician to King's College
Hospital ; 3, George street, Hanover square. Referee^
1884-5.
1847 CuBBET, John Edmund, M.D., Lismore, County Waterford.
1822 CusACK, Chbistopheb John, Chateau d'Eu, France.
niXOWB OF THE iOCIBTT. XXUl
Bleeied
1872 Balbt, WiLLiAJf Babtlbtt, H.B., Leeturer on Aural
Sargery at St. Greorge's Hospital; 18, Sayile row.
Tram. 3.
1884 Dallaway, Dennis, Langham Hotel.
1877 Basbishirs, Sakttsl Dukinfiblb, M.D., Physician to
the Badcli£fe Infirmary, dford ; 60, High street
Oxford.
1879 Dabwin, Fbancis, M.B., F.R.S., The Orove, Huntingdon
road, Cambridge.
1848 Daubbnt, Hbnbt, H.D., San Bemo, Italy.
1874 Dayidson, Alexandbb, M.D., Physician to the Liverpool
Northern Hospital; 2, Oambier terrace, Liverpool.
1853 Davizs, Bobebt Gokeb Nash, Rye, Sussex.
1852 Davies, Williah, M.D., 2, Marlborough buildings,
Bath.
1876 Davies-Gollbt, J. Nbvillb C, H.C, Surgeon to, and
Lecturer on Anatomy at, Guy's Hospital ; 36, Harley
street, Cavendish square. Trans. 2.
1878 Datt, Richabd, F.R.S. Ed., Surgeon to, and Lecturer on
Surgery at, the Westminster Hospital; 33, Welbeck
street. Cavendish square. Trans. 1.
1882 Dawson, Telvbbton, M.D., Heathlands, Southboi^m-on-
Sea, Hanto.
1867 Bat, Williak Hbnbt, M.D., Physicisn tq the Si^aiitan
Free Hospital for Women and Children ; 10, Ifanchester
square. ^
1878 Dent, Clinton Thomas, Assistant Surgeon to St.
George's Hospital ; 61, Brook street li'ans. 2.
1859 t^icKiNSON, William Howship, M.D., Physician to, and
Lecturer on Medicine at St. George's Hospital, and
Senior Physician to the Hospital for Sick Children;
9, Chesterfield street, Hayfair. C. 1874-5. Brferee,
1869-73, 1882-6. Sd. Om. 1867-79. Trans. 13.
XXIY FXLLOW8 OP THS BOCIltTT.
Elected
1839 tDixoK, Jambs, Consulting Surgeon to the Royal London
Ophthalmic Hospital, Moortields; Harrow Lands,
Dorking. L. 1849-55. V.P. 1857-8, T. 1863^.
G. 1866-7. Btferee, 1865. Lib. Cbm. 1845-8.
Tram. 4.
1862 DoBBLLy HoBACB B., M.D.» Consulting Physician to the
Royal Hospital for Diseases of the Chest, City road ;
Streate place, Bournemouth. Trans. 2.
1845 DoDD, John.
1879 DoNKiN, Horatio, M.B., Physician to the Westminster
Hospital ; Physician to the East London Hospital for
Children ; 60, Upper Berkeley street, Portman square.
1877 DoBAN, Alban Henry Oriffiths, Assistant Surgeon to the
Samaritan Free Hospital ; 9, G-ranville place, Portman
square. TVafw. 1.
1863 Down, John Lanodon Hatdon, M.D., Physician to, and
Lecturer on Clinical Medicine at, the London Hospital ;
81, Harley street. Cavendish square. C. 1880.
Trans. 2.
1867 Drage, Charlbs, M.D., Hatfield, Herts.
1884 Drage, Lotbll, St. Bartholomew's Hospital.
1879 Drewitt, F. G. Dawtret, M.D., AssisUnt Physician to
the West London Hospital and to the Victoria Hospital
for Children ; 52, Brook street, Ghrosvenor square.
1880 Drurt, Charles Dennis Hill» H.D., Bondgate, Darling.
ton.
1865 Drysdale, Charles Robert, M.D., Physician to the Far-
ringdon Dispensary ; Assistant-Physician to the Metro-
politan Free Ho^ital p 23, Sackyille street, Piccadilly.
1865 tI)u<^K^ORTH, Dtce, M.D., Physician to, and Lecturer on
Clinical Medicine at, St. Bartholomew's Hospital; 11,
Grafton street. Bond street. C. 1883-4. Referee
1885. Trans. 1.
1876 Dudley, William Lewis, M.D., Physician to the City Dis.
pensary ; 149, Cromwell road, South Kensington.
1845 Duff, Oeobgb, M.D., High street, Elgin.
FELLOWS OF THE SOCIBTT. XXY
Bleeted
1874 DuFFiKy Alfbsd B^tnabd, M.D., Professor of Pathological
Anatomy in Bang's College, London, and Physician to
King's College Hospital; 18, DcTonshire street. Port-
land place.
1871 DoKE, Bbn/amin, 2, Windmill road, Clapham common.
1871 *DuKE8, Clement, M.D., B.S., Physician to Bnghy School,
and Senior Physician to the Hospital of St. Cross,
Bnghy ; Snnnyside, Bughy, Warwickshire.
1867 Dukes, H. Chaeles, M.D., Wellesley Villa, Wellesley
road, Croydon.
1880 DuvBAB, James John Macwhieteb, M.D., Hedingham
Honse, Clapham common.
1877 Duncan, James Matthews, H.D., LL.D., F.B.S., Obstetric
Physician to, and Lecturer on Midwifery and Diseases
of Women at, St. Bartholomew's Hospital; 71, Brook
street, Grosvenor square. Referee^ 1881-5. Tram. 1.
1884 Duncan, William A., M.D., Assistant Obstetric Physician
and Teacher of Operative Midwifery, Middlesex Hos-
pital ; 6, Harley street. Cavendish square.
1863 DuEHAM, Aethub Edward, F.L.S., Surgeon to, and Lecturer
on Surgery at, Guy's Hospital^ 82, Brook street,
Orosvenor square. C. 1876-7. Be/eree, 1880-1. Set.
Com. 1867. Lib. Com. 1872-5. Trans. 5.
1874 Durham, Fredbrio, M.B., 82, Brook street, Grosvenor
square.
1843 Durrant, Christopher Merger, M.D., Consulting Physi-
cian to the East Suffolk and Ipswich Hospital ; North-
gate street, Ipswich, Suffolk.
1872 Eager, Beginald, M.D., Northwoods, near Bristol.
1868 Bastes, George, M.B. Lond., Surgeon-Accoucheur to the
Western General Dispensary; 69» Connaught street,
Hyde park square.
1883 Edmunds, Walter, M.C., 79^ Lambeth Palace road, Albert
Embankment Trans. I.
XXTl FELLOWS OF THE SOCIETT.
Elected
1883 Edwabdss^ Edwabd Joshua, MJ)., 17, Orchard street,
Portman Sqaare, W.
1884 Edwabds, F. Swinfobd, Surgeon to the West London
Hospital ; 93, Wimpole street. Cavendish square.
1824 Edwards, Gsosoe.
1869 Elam, Charles, H.D., 75, Barley street. Cavendish square.
1848 Ellis, Geobos Tikeb, late Professor of Anatomy in Uni-
versity College, London; Minsterworth, Gloucester.
C. 1868-4. Trans. 2.
1868 Ellis, James, H.D., the Sanatorium, Anaheim, Los Angeles
County, California.
1854 ^Ellison, James, M.D., Surgeon-in-Ordinary to the Royal
Household, Windsor ; 14, High street, Windsor.
1842 fEsiCHSEN, John Eric, LL.D.,F.R.S., Surgeon Extraordi-
nary to H.H. the Queen ; Emeritus Professor of
Surgery in University College, London, and Consulting
Surgeon to University College Hospital ; 6, Cavendish
pkce, Cavendish sq. C. 1855-6. T.P. 1868. P. 1879-80.
Be/eree, 1866-7, 1884-5. Lib. Cam. 1844-7, 1854.
Trans. 2.
1879 Eve, Frederic S., Pathological Curator of the Museum,
Royal College of Surgeons ; Assistant Surgeon to the
London Hospital ; 15, Finsbury circus. Trans. 2.
1877 EwART, William, H.D., Assistant Physician to, and Lec-
turer on Physiology at, St George's Hospital; 33,
Curzon street, Mayfair.
1875 *Fagan, John, Surgeon to, and Lecturer on Clinical
Surgery at, the Belfast Royal Hospital; 1, Glengall
place, Belfast.
1869 Fairs ANK, Frederick Royston, M.D., 46, Hallgate, Don-
caster.
1862 Farquharson, Robert, M.D., M.P., Higvie Lodge, For-
Chester gardens, Hyde park ; Finzean, Aboyne, Aber-
deenshire, and the Reform Club, Pall Mall. Lib. Cam.
1876-80.
FELLOWS OF THB SOCIBTY. XXTii
Eleeted
1844 fFASBE, Abthus, H.D., F.B.8.^ Physician Bxtraordinary to
H.M. the Queen ; FhyBician-Accoucheur to H.R.H. the
Princess of Wales ; 18, Albert Mansions, Victoria street,
Westminster. C. 1857. V.P. 1864. Referee, 1848-54,
1861-3, 1865-6. Set. Com. 1863. Uh. Com. 1847.
1872 Fatbeb, Sib Joseph, K.G.S.I., M.D., F.R.S., Honorary
Physician to H.M. the Queen, and to H.R.H. the Prince
of Wales, and Physician to H.B.H. the Duke of Edin-
burgh ; Surgeon-Oeneral, late Bengal Medical Sernce ;
Examining Medical Officer to the Secretary of State for
India in Council; President of the Indian Medical
Board ; 53, Wimpole street. Cavendish square. Be/eree,
1881-5.
1872 ^Fenwiok, John C. J., M.D., Physician to the Durham
County Hospital ; 25, North road, Durham.
1863 Fbnt?iok, Samuel, M.D., Physician to the London Hospital ;
29, Harley street, Cayendish square. G. 1880. Be/eree,
1882-5. Trans. 4.
1 880 FERRIB&, Dayid, M.D., LL.D., F.R.S., Professor of Forensic
Medicine at King's College, London, and Physician to
King's CoUege Hospital; Physician for Out-patients
to the National Hospital for the Paralysed and Epilep-
tic ; 34, Cavendish square. Trane. 2.
1852 *Fi£LD, Alfred George.
1849 t^iNCHAM, George Tuphan, M.D., Consulting Physician
to the Westminster Hospital; 13, Belgraye road,
Kmlico. C. 1871.
1879 FiNLAT, Datid White, M.D., Physician to, and Lecturer
on Forensic Medicine at, the Middlesex Hospital;
Physician to the Royal Hospital for Diseases of the
Chest ; 9, Lower Berkeley street, Portman square.
1866 Fish, John Crockett, B.A., M.D., Assistant Physician
to the West London Hospital; 92, Wimpole street.
Cavendish square.
1866 Fitzpatriok, Thomas, M.D., M.A., Physician to the
Western General Dispensary; 30, Sussex gardens,
Hyde park.
XXTIU PILLOWS 07 THB 80CIBTT.
EUeted
1842 Fletcher, Thomas Bell Elcock» M.D., Gonsolting Physi-
cian to the Birmingham General Hospital ; 8« Claren-
don crescent, Leamington. Tratu. 1.
1864 •Folkek, William Henbt, Sorgeon to the North Stafford.
shire Infirmary ; Bedford House, Hanley, Staffordshire.
1877 FoNMAKTiN, Hbkkt db, M.D., Parkhorst, Isle of ^ight.
1848 fFoKBES, John Gbeqobt, Bgerton House, Egerton, Ashford,
Kent. G. 1868-9. Lib. Cam. 1855. Trans. 2.
1852 t^OBSTBB, John Goopbb, Consulting Surgeon to the
Royal Hospital for Children and Women ; 29, Upper
Grosvenor street. C. 1868-9. S. 1873-5. V. P.
1877-8. T. 1879-84. JRe/erw, 1870-2, 1876. Pro. 1.
1865 FosTEB, Balthazab Waltbb, M.D., Professor of Medicine
at the Queen's College, Birmingham, and Physician to
the Birmingham General Hospital; 14, Temple row,
Birmingham.
1883 Fowleb, Jambs Kingston, M.A., M.D., Assistant Phy-
sician to, and Lecturer on Pathological Anatomy at,
the Middlesex Hospital, and Assistant Physician to th
Hospital for Consumption, Brompton; 35, Clarges
street, Piccadilly.
1859 Fox, Edwabd Long, M.D., Consulting Physician to the
Bristol Royal Infirmary ; Church House, Clifton, Glou-
cestershire.
1880 Fox, Thomas Coloott, B.A., M.B., Physician to the Skin
Department of the Paddington Green Hospital for
Children, and Assistant Physician to the Victoria
Hospital for Children; 14, Harley street. Cavendish
square. Trans. 1.
1858 Fox, Wilson, M.D., F.R.S., Librarian, Physician-Extra-
ordinary to H.M. the Queen ; Physician in Ordinary to
H.R.H. the Duke of Edinbui^h ; Holme Professor of
Clinical Medicine in University College, London, and
Physician to University College Hospital; 67 f Gros-
venor street. C. 1875-6. L. 1883-5. Referee, 1869-
74. Lib. dm. 1866-70, 1874. Tram. 3.
FBLLOW8 07 THE 80C1BTT. XXIX
SUeted
1871 FsAifKy Philip, M.D., Cannes^ France.
1884 *F]iANK8, Kbndal, M.D., Surgeon to the Adelaide Hospital
and to the Throat and Ear Hospital, Dablin ; 69, Fits-
wiUiam square, Dablin.
1843 FsASsa, Patbiok, M.D. G. 1866.
1868 Fbesman, William Henby, 21, St. Geoi^'s square, South
Belgrana.
1836 fFBENCH, John Geobgb, 10, Cunningham place, St. John's
Wood road. C. 1852-3.
1884 FvLLEB, Chables Ghinnbb, 10, St. Andrew's place,
Regent's park.
1883 Fulleb, Henbt Boxbubgh, M.B., 45, Carson street, May
Fair.
1876 FuBNEB, WiLLOUOHBT, Assistant Surgeon to the Sussex
County Hospital ; 2, Brunswick place, Brighton.
1864 ^Gaibdneb, William Tennant, M.D., LL.D., Physician in
Ordinary to H.M. the Queen in Scotland ; Professor of
the Practice of Medicine in the University of Glasgow ;
Physician to the Western Infirmary, Glasgow; 225,
St. Vincent street, Glasgow.
1874 Galabin, Alfbed Lewis, MA., M.D., Obstetric Physician
to, and Lecturer on Midwifery and the Diseases of
Women at, Guy's Hospital ; Assistant Physician to the
Hospital for Sick Children ; 49, Wimpole street,
Cavendish square. Referee^ 1882-5. Lib. Com. 1883-
4. Trant. 2.
1883 Galton, John Ghables, M.A., F.L.S., 45, Great Marl-
borough street.
1865 Gant, Fbedebigk James, Senior Surgeon to the Royal Free
Hospital; 16, Connanght square, Hyde park. G. 1880-
81. Lib. Cam. 1882-5. Trant. 3.
1867 Gabland, Edwabd Chables, Yeovil, Somerset.
1867 Gablike, Thomas W., Malyem Cottage, Churchfield road.
Baling.
ZXX VILLOWa OF THB 80CIBTT.
Elected
1854 tC^ASBOB, Alfbsb Baking, M.D., F.R.Sm Consulting Phy-
ridan to Kingfs College Hospital; 10, Harley street,
Cayendish square. C. 1867. V.P. 1880-81. Referee,
1855-65. O^am. 8.
1879 Gakstano, Thomas Waltek SLlrropp, Dobcross, near
Oldham.
1851 fGABKOiN, Geobgs, Sargeon to the British Hospital for
Diseases of the Skin; The Priory, Caerleon, Mon-
mouthshire. C. 1875-6. TrofM. 2.
1819 Oaulteb, Henby.
1866 Gee, Samuel Jones, M.D., Physician to, and Lecturer on
Medicine at, St. Bartholomew's Hospital ; Consulting
Physician to the Hospital for Sick Children ; 54,
Wimpole street, Cavendish square. C. 1883-4. 8ei.
Com. 1879. Ee/eree, 1885. Lib. Com. 1871-6. 2VaiM. 1.
1878 Oebyis, Henbt, H.D., Obstetric Physician to, and Lecturer
on Obstetric Medicine at, St. Thomas's Hospital;
40, Harley street, Cavendish square. Beferee^ 1884-5.
1884 GiBBES, Heneaoe, H.D., Physician to the Metropolitan
Dispensary ; Lecturer on Morbid Histology, Westmin-
ster Hospital ; 44, Charleville road. West Kensington.
1880 Gibbons, Bobsbt Alezandeb, M.D., Physician to the
Grosvenor Hospital for Women and Children; 32,
Cadogan place.
1877 GoDLEE, BiCKMAN JoHN, SuTgcon to University College
Hospital, and Teacher of Operative Surgery in University
College, London ; Surgeon to theNorth-Eastem Hospital
for Children, and to the Hospital for Consumption,
Brompton; 81, Wimpole street. Cavendish square.
Trane. 1.
1870 Godson, Clement, M.D., Assistant^Physidan-Accoucheur
to St. Bartholomew's Hospital ; Consulting Physician
to the City of London Lying-in Hospital ; 9, Grosvenor
street, Grosvenor square.
1851 Goodfellow, Stephen Jennings, M.D., Consulting Phy-
sician to the Middlesex Hospital ; Swinnerton Lodge,
near Dartmouth, Devon. 0. 1864^5. Referee^ 1860-3.
Lib. Com. 1863. Trane. 2.
FELLOWS OF THE SOCIETY. XXXI
Elected
1883 GooDHA&T, Jahes Frsdebio, M.D., Assistant Physician to,
and Curator of the Mosenm at, Guy's Hospital ; Phy-
sician to the Evelina Hospital for Sick Children ; 25^
Weymouth street, Portland place.
1877 Gould, Alfred Peabcs, M.S., Assistant Sui^eon to the
Middlesex Hospital ; Surgeon to the North-west London
Hospital; 16, Queen Anne street, Cayendish square.
Trane. 1.
1873 GowEBs, William Richard, M.D., Assistant Professor of
Clinical Medicine in University College, and Physician
to University College Hospital; Physician for Out-
patients to the National Hospital for the Paralysed and
Epileptic; 50, Queen Anne street, CavendiBh square.
Lib. Cam. 1884-5. Trans. 6.
1851 fGowLLAND, Peter Yeames, Surgeon to St. Mark's Hos-
pital; Surgeon-Major Hon. ArtUlery Company; 34,
Finsbury square.
1846 Gream, George Thompson, M.D., Physician-Accoucheur to
H.R.H. the Princess of Wales ; Mixbury, Eastbourne,
Sussex. C. 1863.
1868 Green, T. Henry, M.D., Physician to, and Lecturer on
Pathology at, Charing Cross Hospital ; Assistant-Phy-
sician to the Hospital for Consumption, Brompton;
74, 'Vnmpole street. Cavendish square. Be/eree, 1882-5.
1875 ^Greenfield, William Smith, M.D., Professor of General
Pathology in the University of Edinburgh ; 7, Heriot
row^ Edinburgh. Sei. Com. 1879. Referee^ 1881.
1843 t^REENHALOH, RoBERT, M.D., Consulting Physician to the
Samaritan Free Hospital for Women and Children,
and to the City of London Lying-in Hospital; 35,
Cavendish square. C. 1871-2. Referee, 1876-7.
Trane. 1.
1860 Greenhow, Edward Headlam, M.D., F.B.S., Consulting
Physician to the Middlesex Hospital ; and Consulting
Physician to the Western General Dispensary ; Castle
Lodge, Reigate. C. 1876-7. J^eree, 1870-5. Trane. Z.
ZXXU FBLL0W8 OP THB SOCIETY.
Elected
1882 Oresswsll, Dan Astlet, M.B., 87, Queen^B cresoent,
Haventock hUl.
1884 Griffiths, Herbert Tyrrell, M.D., 57» Brook street.
1868 Grigg, William Chapman, M.D., Assistant Obstetric Phy-
sician to the Westminster Hospital ; Physician to the
In-Patients, Queen Charlotte's Lying-in-Hospital ;
27 1 Corzon street, Mayfair.
1852 Groye, John, Fyning, Ansten road, Guildford.
1860 GuENEAU de Mussy, Henri, M.D. ; 15, Rue du Cirque,
Paris. Lih, Com, 1863-5.
1849 I^ULL, Sir William Withby, Bart, M.D., D.C.L., LL.D.,
F.R.S., Physician-Extraordinary to the Queen ; Member
of the Senate of the Uniyersity of London ; Consulting
Physician to Guy's Hospital ; 74, Brook street, Gros-
Tenor square. C. 1864. V.P. 1874. JB<;/erM, 1855-63.
Trane. 4.
1885 Gulliver, George, M.B., Assistant Physician to, and Lec-
turer on Comparative Anatomy at, St. Thomas's Hos*
pital; 16, Welbeck street.
1883 GuNN, Robert Marcus, M.B., 54, Queen Anne street,
Cavendish square.
1854 t^^BB^B^o^* Samuel Osborne, M.D., 70, Brook street,
Grosvenor square. S. 1867. C. 1869-70. V.P.
1881-2. Referee, 1862-6, 1868, 1871-80. Trane. 3.
1885 Haig, Alexander, M.B., 30, Welbeck street. Cavendish
square.
1881 Hall, Francis de Hatilland, M.D., Assistant Physician,
and Physician to the Throat Department, and Lecturer
on Forensic Medicine at the Westminster Hospital;
Physician to St. Mark's Hospital; 46, Queen Anne
street. Cavendish square.
1885 Halliburton, William Dobinson, M.D., 135, Gower
street.
1870 Hamilton, Robert, Surgeon to the Royal Southern Hos-
pital, Liverpool ; 1 Prince's road, Liverpool.
FILLOWS OF THE SOCIETY. XXXIU
Elected
1874 Hasbie, Gosbon Kenmuke, M.D., Depaty Inspector
General of HoBpitals ; Florence road, Ealing, and Dnff
House, Banff, N.B.
1856 fHABE, Chaeles John, M.D., late Professor of Clinical
Medicine in Uniyersity CoUege, London, and Itfte Physi-
cian to University College Hospital ; Berkeley House,
15, Manchester square. C. 1873-4.
1857 Haeley, Geoege, M.D., F.B.S. 25, Harley street, Caven-
dish square. C. 1871-2. Beferee, 1865-70, 1873-6.
Sei. Com. 1862-3. Trans. 1.
1864 Habley, John, M.D., F.L.S., Physician to, and Lecturer on
General Anatomy and Physiology at, St. Thomas's
Hospital; 39, Brook street, Grosvenor square. S.
1875-7. C. 1879-80. Referee, 1871-4, 1882-5. Sci.
Com. 1879. Trans, 9.
1880 Haebis, Vincent Doemee, M.D., Assistant Physician to the
Victoria Park Hospital; Demonstrator of Physiology
at St. Bartholomew'8 Hospital; 39, Wimpole street.
Cavendish square.
1872 Haeeis, William H., M.D., Deputy Surgeon-General,
Madras Army (retired) ; late Professor of Midwifery
and Diseases of Women and Children, Madras Medical
College.
1870 Haeeison, Reginald, Surgeon to the Liverpool Royal
Infirmary, and Lecturer on Surgery at the School of
Medicine ; 38, Rodney street, Liverpool. Trans, 1.
1854 Hayiland, Alfeed.
1870 Hawaeb, J. Waeeinoton, Surgeon to St. George's Hospital ;
Surgeon to the Hospital for Sick Children; 16, Savile
row, Burlington gardens. C. 1885. Lib. Com. 1881-4.
Trans. 1.
1838 fHAWKiNs, Chaeles, Inspector of Anatomical Schools in
London; 9, Duke street, Portland place. C. 1846-7.
S. 1850. V.P. 1858. T. 1861-2. Referee, 1859-60.
Lib. Com. 1843. 2¥ans. 2.
VOL. LXYIII. C
XXXiy FELLOWS OF THE SOCIETY.
Eleeted
1885 Hawkins, Fkanois Henbt^ M.B., Physidan to St. George's
and St. James's Dispensary; 47» Upper Berkeley
street
1848 tHAWESLST, Thomas, M.D.y Consultbg Physician to
the Margaret street Dispensary for Consumption and
Diseases of the Chest; 65, Green street, Grosvenor
square, and 20, Lewes crescent, Brighton.
1875 Hates, Thomas Cbawfobb, M.D., Physician-Accoucheur
and Physician for Diseases of Women and Children to
King's College Hospital ; 17^ Claires street, Piccadilly.
1860 Haywabd, Hsnbt Howard, Sui^on Dentbt to, and
Lecturer on Dental Surgery at, St. Mary's Hospital;
38, Harley street, CavendiBh square. C. 1878-9.
1861 Haywabd, William Henby, Corby, Grantham.
1848 *Hsale, James Newton, M.D.
1865 Heath, Chbistopheb, Holme Professor of Clinical Suigery
in University College, London; and Surgeon to Uni-
versity College Hospital; 36, Cavendish square. C.
1880. Lib, dm. 1870-8. Trans. 3.
1850 Heaton, Geobge, M.D., Boston, U.S.
1882 Hensley, Philip J., M.D., Assistant Physician and Lecturer
on Forensic Medicine to St. Bartholomew's Hospital ;
4, Henrietta street, Cavendish square.
1821 Hebbebski, Vincent, M.D., Professor of Medicine in the
University of Wilna.
1877 Hebman, Geobge Ebnest, M.B., Obstetric Physician to,
and Lecturer on Midwifery at, the London Hospital ;
7, West street, Finsbury circus. Tram. 1.
1877 Hebon, Geoboe Allan, M.D., 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 Epileptic; 57, Harley street,
Cavendish square.
1883 Hebbingham, Wilmot Pabkeb, M.B., 22, Bedford square.
FELLOWS OF THE SOCIETY. XXXY
Elected
1843 tHswETT, 8iB Fbescott Oabdneb, Bart., F.R.S., Serjeant-
Sui^eon to H.M. the Queen; Surgeon in Ordinary
to H.B.H. the Prince of Wales; Consulting Surgeon
to St. George's Hospital; Corresponding Member
of the '' Academie de Mddecine/' and of the " Society
de Chirurgie/' Paris; Chesnnt Lodge, Horsham, Sussex.
C. 1859. V.P. 1866-7. Referee, 1850-8, 1860-5,
1868-83. Sei. Com. 1863. Lib, dm. 1846-7. 7}ran8. 7.
1855 Hewitt, W. M. Gbailt, M.D., Professor of Midwifery in
University College, London, and Obstetric Physician to
University CoUege Hospital ; 36, Berkeley square. C.
1876. Referee, 1868-75, 1877-85. Lib. Cam. 1868,
1874.
1880 Hicks, Chables Cybil, M.D., Wokingham, Berks.
1873 HiGOENS, Chables, Assistant Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, Guy's Hospital ; 38,
Brook street, Grosvenor square. Tratu, 2.
1862 Hill, M. Bebkeley, M.B., Tice-President, Professor of
Clinical Surgery in University CoUege, London, and
Surgeon to University College Hospital ; Surgeon to the
Lock Hospital ; 66, Wimpole street. Cavendish square.
C. 1878-9. S. 1881-4. V.P. 1885. Trane. 1.
1867 Hill, Samuel, M.D., 22, Mecklenburgh square.
1861 *Hoffmeistbb, Sib William Cabteb, M.D., Surgeon to
H.M. the Queen in the Isle of Wight; Clifton House,
Cowes, Isle of Wight.
1843 fHoLDEK, LuTHEB, Consulting Surgeon to St. Bartho-
lomew's Hospital, to the Metropolitan Dispensary, and
to the Foundling Hospital; Pinetoft, Ipswich. C.
1859. L. 1865. V.P. 1874. Referee, 1866-7. Lib.
Com. 1858.
1879 Holland, Philip Alexandeb, M.A.
1868 HoLLis, William Ainslie, M.A., M.D., Assistant-Fhy-
sician to the Sussex County Hospital ; 8, Cambridge
road, Brighton,
ZXXTl FELLOWS OF THE SOCIETY.
Elected
1861 HoLHAN, WiLLLiM HsNBT, M.B., 68, Adelaide road, South
Hampatead.
1856 Holmes, Timothy, M.A., Treaeurer, Sorgeon to St George's
Hospital; 18, Great Cumberland place, Hyde park.
C. 1869-70. L. 1873-7. S. 1878-80. V.P. 1881-2.
T. 1885. Referee, 1866-8, 1872, 1883-4. Sei. Com.
1867. Lib. Com, 1863-5. Trans. 8.
1846 fHoLT, Barnabd Wight, Consulting Surgeon to the
Westminster Hospital ; Medical Officer of Health for
Westminster; 14, Savile row, Burlington gardens. C.
1862-3. V.P. 1879-80.
1846 fHoLTHOUSE, Cabsten, 35, Essex street, Strand. C. 1863.
B^eree 1870-6. L^. Com. 1859-60.
1878 Hood, Donald William Cha&les, H.D., Assistant Phy-
sician to the West London Hospital ; 43, Green street.
Park lane.
1883 HoRSLEY, ViOTOB Alexakdeb Hadem, Assistant Surgeon
to University College Hospital, and Assistant Professor
of Pathological Anatomy, University College, London ;
Superintendent of the Brown Institution, Wandsworth
road ; 80, Park street, Grosvenor Square.
1878 Houghton, Walteb B., M.D., Church Villa, Warrior
square, St. Leonards-on-Sea.
1865 HowABD, Benjamin, M.D., New York, U.S.
1881 HowABD, Henby, M.B., abroad [6, The Terrace, Mount
Pleasant, Cambridge].
1874 HowsE, Henby Gbeenway, M.S., Surgeon to, and Lecturer
on Anatomy at, Guy's Hospital ; Surgeon to the Evelina
Hospital for Sick Children ; Examiner in Anatomy in
the University of London ; 10, St. Thomas's street,
Southwark. Set. Com. 1879. Trane. 2.
1884 HuoGABD, William R., M,D., Place de la Synagogue,
2, Geneve.
1857 HuLKE, John Whitakeb, F.R.S., Librarian, Surgeon to
the Middlesex Hospital ; Surgeon to the Royal London
Ophthalmic Hospital, Moorfields ; 10, Old Burlington
street. C. 1871-2. S. 1876-7. L. 1879-85. Sei.
Com. 1867. Lib. Com. 1864-8. Trans. 8.
FSLLOWS OF THJB 80CIBTY. XXXVl
XHeeied
1844 fHuMBT, Edwin, M.D., 83, Hamilton terrace, St. John's
wood. C. 1866-7.
1855 HuMPHBY, GsoBOE MuBBAT, M.D., F.R.S., Sorgeou to
Addenbrooke'a Hospital; Professor of Surgery in the
University of Cambridge. Traru. 6.
1882 HuMPHBT, Laubence, M.B.« 3, Trinity street, Cambridge.
1873 HuNTEB, Sib W. Ouyeb, M.D., Hon. Sargeon to H.M. the
Queen ; late Principal of, and Professor of Medicine in.
Grant Medical College, Bombay; Sargeon-General
Bombay Army; 21, Norfolk crescent, Hyde park.
1849 HussET, Edwabd Law, Consulting Sui^eon to the County
Lunatic Asylum and the Wameford Asylum ; 8, St.
Aldate's, Oxford. Trans, I.
1856 Hutchinson, Jonathan, F.R.S., Consulting Surgeon to,
and Emeritus Professor of Surgery at, the London
Hospital; Consulting Surgeon to the Royal London
Ophthalmic Hospital, Moorfields ; and Surgeon to the
Hospital for Diseases of the Skin; 15, Cavendish
square. C. 1870. V.P. 1882. Referee, 1876-81,
1883-5. Lib, Cam. 1864-5. Trans. 12. Pro. 2.
1820 Hutchinson, Wiluam, M.D.
1840 fHuTTON, Chables, M.D., Consulting Physician to the
General Lying-in Hospital ; 26, Lowndes street, Belgrave
square. C. 1858-9.
1847 Image, William Edmund, Herringswell House, Milden-
hall, Suffolk. Trans. 1.
1856 Inolis, Cobnelius, M.D., Cairo. [Athenaeum Club, Pall
MaU.]
1871 Jaokson, J. HuGHLiNGB, M.D., F.B.S., Physician to the
London Hospital ; Physician to the National Hospital
for the Paralysed and Epileptic ; 3, Manchester square.
1841 tJACKSON, Paul, 51, Wellington road, St. John's Wood.
C. 1862.
1863 Jackson, Thomas Yinoent, Senior Surgeon to the Wolver-
hampton and Staffordshire General Hospital; 47|
Waterloo road, south, Wolverhampton.
XXXYUl FBLL0W8 OF THB SOCIETY.
Elected
1883 Jaoobson, Walteb Hamilton Acland, B.A., M.B., AbsIb-
tant Sargeon to Guy'B Hospital ; Surgeon to the Royal
Hospital for Children and Women; 41, FinBbury
square.
1825 Jakes, John B., M.D.
1883 *JsNKiNS, Edwabd Johnstone, M.D., The AuBtralian
Club, Sydney, New South Wales.
1851 tJENNEB, SiE William, Bart., M.D., K.C.B., D.C.L., LL.D.,
F.R.S., Physician in Ordinary to H.M. the Queen, and
to H.R.H. the Prince of Wales; Emeritus Professor of
Clinical Medicine in University College, London ; and
Consulting Physician to University College Hospital ;
Member of the Senate of the University of London ;
63, Brook street, Orosvenor square. C. 1864. Y.P. 1875.
Referee, 1855, 1859-63. Tram. 3.
1884 Jenninos, Chables Eoebton, M.S., M.B., 75, Park street,
Grosvenor square.
1881 Jennings, William Osgab, M.D., 8, Bue Roy, Paris.
1884 Jessett, Fbedeeig Bowbeman, Surgeon to the Royal
General Dispensary ; 16, Upper Wimpole street.
1883 Jessop, Walteb Henby H., M.B., Demonstrator of Anatomy
at St. Bartholomew's Hospital ; 73, Harley street.
1851 Johnson, Edmund Chables, Corresponding Member of the
Medical and Philosophical Society of Florence, and of
" I'lnstitut G^nevois."
1847 t Johnson, Geobge, M.D., F.R.S., President, Physician to
King's College Hospital ; Member of the Senate of the
University of London ; 1 1, Savile row, Burlington
gardens. C. 1862-3. V.P. 1870. P. 1884-5. L.
1878-80. JRtf/erM, 1853-61, 1864-9. jKi.Owi. 1860-1.
Trana, 10. Pro, I.
1 88 1 Johnson, Geobge Lindsay, M. A., M.D., Cortina, Netherhall
terrace. South Hampstead, and 14, Stratford place,
Oxford street.
1884 Johnston, James, M.D., 7, Hanover square.
FELLOWS OF THE SOCIETY. XXXIX
Meeted
1848 Johnstone, Athol Abchtbald Wood, GoDBulting Surgeon
to the Royal Alexandra Hospital for Sick Children, St.
Moritz House, 61, Dyke road, Brighton. Lib, Com,
1860. Tram. 1.
1876 Jones, Leslie Hudson, M.D., Limefield House, Cheetham
hill, Manchester.
1875 * Jones, Philip Sydney, M.D., Consulting Surgeon to the
Sydney Infirmary; Examiner in Medicine, Sydney
University; 10, College street, Sydney, New South
Wales. [Agents : Messrs. D. Jones & Co., 1, Gresham
buildings, BasinghaU street.]
1859 Jones, Willlajc Pbioe, M.D., Claremont road, Surbiton,
Kingston.
1865 Jordan, Fubneaux, Surgeon to the Queen's Hospital, and
Professor of Surgery at the Queen's College, Birming-
ham ; Gate House, Edmund street, Birmingham.
1881 JuLEB, Henby Bdwabd, Assistant Surgeon Royal West-
minster Ophthalmic Hospital ; Junior Ophthalmic Sur-
geon to St. Mary's Hospital; 77 ^ Wimpole street,
Cayendish square.
1816 *KA.UFFMAirN, Geobge Hebmann, M.D., Hanover.
1882 Keetley, Chablss R. B., Senior Surgeon to the West
London Hospital ; Surgeon to the Surgical Aid Society ;
10, George street, Hanover square.
1872 Kelly, Chables, M.D., Professor of Hygiene at King's
College, London, and Medical Officer cif Health for the
West Sussex Combined Sanitary District; Broadwater
road. Worthing, Sussex.
1848 *K£NDELL, Daniel Bubton, M. D., Heath House, Wakefield,
Yorkshire.
1884 Keseb, Jean Samuel, M.D., 60, Queen Anne street.
1877 *Khoby, Rustonjee Nasebwanjee, M.D., Physician to the
Farell Dispensary, Bomhay ; Girgaum road, Bombay.
1857 KiALLMABK, Henby Walteb, 5, Pembridge gardens, Bays-
water.
Xl FKLLOW8 OF THB SOCIBTY.
Meeied
1881 KiDB, PEBCTy M.A., M.D.y Asnstant FhyBidan to the
Hospital for Consamption, Brompton ; 60, Brook street^
Grosvenor square. I^€MS. 3.
185 1 fKiNGDON, John Abernetht, Sargeon to the City of London
Truss Society, and to the City Dispensary; 2, New
Bank buildings, Lothbnry. C. 1866-7. V.P. 1872-3.
Set. Cam. 1867. Trans. 1.
1885 Klein, Edwabd Emakuel, M.D., F.R.S.» 94, Philbeaeh
gardens, Earl's Court.
1883 Knafton, Geobge, Strathgyle, Portswood, Southampton.
1840 t^^^^i Samuel Abmstrong, Consulting Surgeon to St.
Mary's Hospital and to the Lock Hospital; 49, Norfolk
square, Hyde park. C. 1849-50. V.P. 1865. Referee,
1850.
1884 Lane, William Abbuthnot, M.S., Assistant Surgeon to
the Hospital for Sick Children; 14, St. Thomas's
street, Southwark. Trans. 1.
1882 Lang, William, Ophthalmic Surgeon to the Middlesex
Hospital ; 26, Upper Wimpole street. Cavendish
square.
1865 Langton, John, Surgeon to, and Lecturer on Anatomy
at, St. Bartholomew's Hospital ; Surgeon to the City
of London Truss Society ; 2, Harley street. Cavendish
square. C. 1881-2. Referee, 1885. Lib. Com.
1879-80.
1873 *Labcheb, 0., M.D., Laureate of the Institute of France,
of the Medical Faculty, and Academy of Paris, &c. ;
97, Rue de Passy, Passy, Paris.
1862 Latham, Petbb Wallwobk, M.A., M.D., Downing Pro-
fessor of Medicine, Cambridge University ; Physician
to Addenbrooke's Hospital, Cambridge; 17, Trumping-
ton street, Cambridge.
1816 Lawbenoe, G. E.
1884 Lawson, Geobge, Surgeon to the Royal London Ophthal-
mic Hospital and to the Middlesex Hospitid; 12,
Harley street.
FELLOWS OF THB SOCIETY. xli
JEUcUd
1880 Latcock, Geobgs Lookwood, M.B., Physician to the
Paddington Green Children's Hospital ; 12, Upper
Berkeley street, Portman square.
1882 Ledwich, Edwabd l'Esteakge, Lecturer on Surgical and
Descriptive Anatomy in the Ledwich School of Medi-
cine, Dublin ; 23, Upper Leeson Street, Dublin.
1843 tLEE, HsiTBY, Consulting Surgeon to St. George's Hos-
pital; 9, Savilerow, Burlington gardens. 0. 1856-7.
L. 1863-4. Y.P. 1868-9. Referee, 1855, 1866-8. Sei.
Com, 1867. TrafiB. 13. Pro, 2.
1884 Lee, Bobebt James, M.D., Assistant Physician to the
Hospital for Sick Children ; 6, Savile row.
1883 Leeson, John Rudd, M.D., CM., 6, Clifden road,
Twickenham.
1869 Lego, John Wickham, M.D., Assistant Physician to, and
Lecturer on Pathological Anatomy at, St. Bartholomew's
Hospital; 47, Green street, Park lane. JR^er^e, 1882-5.
Lib, Com. 1878-85. TroM. 2.
1836 Lbiohton, Fbedsbick, M.D.
1872 LiEBBEiCH, Bichaed, Consulting Ophthalmic Surgeon to
St. Thomas's Hospital; Paris.
1878 LisTEBy Sib Joseph, Bart., D.C.L., LL.D., F.B.S., Surgeon
Extraordinary to H.M. the Queen ; Professor of Clinical
Surgery at King's College, London ; and Surgeon to
King's College Hospital; 12, Park crescent, Begent's
park.
1872 *LiTTLE, David, M.D., Senior Surgeon to the Boyal Eye
Hospital, Manchester; 21, St. John street, Manchester.
1871 Little, Louis Stbometeb, Shanghai, China.
1819 Llotd, Bobebt, M.D.
1820 Locheb, J. G., M.C.D., Town Physician of Zurich.
Trans. 2.
1881 LoGKWOOD, Chables Babbett, Surgeon to the Great
Northern Central Hospital, and Demonstrator of
Anatomy at St. Bartholomew's Hospital ; 8, Seijeants'
Inn, Fleet street.
xlii FALLOWS OF TfiS SOCIETY.
Elected
1860 LoNOMOBE, Thomas, C.6., Hon. Sargeon to H.M. the
Qoeen; Sargeon-General, Army Medical Staff, and
Professor of Military Surgery, Army Medical School,
Netley, Southampton; Woolston Lawn, Woolston,
Hants. Tram. 2.
1836 LowENFELD, JosEPH S., M.D., Berbice.
1871 LowNDs, Thomas Mackfoed, M.D., late Professor of
Anatomy and Physiology at Grant Medical College,
Bombay ; Egham Hill, Surrey.
1881 Lucas, Richard Clement, Senior Assistant Surgeon to,
and Demonstrator of Operative and Practical Surgery
at, Guy's Hospital ; Surgeon to the Evelina Hospital
for Sick Children; 18, Finsbnry square.
1883 Lund, Edwabd, Professor of Surgery, Owens College;
Consulting Surgeon to the Manchester Royal In-
firmary ; 22, St. John street, Manchester.
1857 Lyon, Felix William, M.D., 5, North Charlotte street,
Edinburgh.
1882 Lyons, Isidobe.
1867 Mabeely, Geoboe Fbedebick.
1873 MacCabthy, Jebemla.h, M.A., Surgeon to, and Lecturer
on Physiology at, the London Hospital ; 15, Finsbury
square. lAb. Com. 1882-5.
1867 Mac Cobmac, Sib William, M.A., Surgeon to, and Lecturer
on Surgery at, St. Thomas's Hospital; Examiner in
Surgery at the University of London; 13, Harley
street. C. 1884-5. Tram. 1.
1862 *M*DoNNELL, RoBEBT, M.D., F.R.S., Surgeon to Steevens*
Hospital ; 89, Merrion square west, Dublin. Tratu. 2.
1880 *Macfablane, Alexandeb William, M.D., Consulting
Physician to the Kilmarnock Fever Hospital and
Infirmary ; Walmer, Kilmarnock, N.B.
1 866 Macoowan, Alexandeb Thobbubn, Yyvyan House, Clifton,
near Bristol.
FlBLLOWS Ot THE SOCIETY. xUti
JSleeted
1880 McHabdt, Malcolm Macdonald, Ophthalmic Sargeon
to King's College Hospital; Surgeon to the Royal
Soath London Ophthalmic Hospital ; 5, Savile row.
1822 Macintosh, Richabd, M.D.
1859 *M*Intybe, John, M.D., Odiham, Hants.
1873 MacEellab, Alexander Obeelin, M.S.I., Assistant
Surgeon to St. Thomas's Hospital; Surgeon-in-Chief
to the Metropolitan Police Force ; 22, George street,
Hanover square.
1881 Mackenzie, Stephen, M.D., Physician to, and Lecturer on
Medicine at, the London Hospital ; Physician to the
Boyal London Ophthalmic Hospital; 26, Finsbury
square. Trans, 1.
1885 Maokebn, John, M.D., 30, Cambridge street, Hyde park.
1876 Mackey, Edwabd, M.D., I, Brunswick road. Hove, Brighton.
1854 *Maokindeb, Dbafeb, M.D., Consulting Surgeon to the
Dispensary, Gainsborough, Lincolnshire.
1879 Maclaoan, Thomas John, M.D., Physician-in-Ordinary
to their R.H. the Prince and Princess Christian of
Schleswig-Holstein ; 9, Cadogan place, Belgrave square.
1876 Macnahaba, Chableb, Surgeon to, and Lecturer on Sur-
gery at, the Westminster Hospital ; Surgeon to the
Royal Westminster Ophthalmic Hospital; Surgeon-
Major Bengal Medical Service ; Fellow of the Calcutta
University ; 13, Grosvenor street. Referee, 1884-5.
1881 Macbeady, Jonathan F. C. H., Surgeon to the Great
Northern Hospital ; 51, Queen Anne street, Caveiidish
square.
1880 Maddick, Edmund Distin, The Bungalow, Stoke Pogis,
Bucks.
1880 Makins, Geobge Henbt, St Thomas's Hospital, Albert
Embankment.
1876 Mallam, Benjamin, Meadow Side, Leacroft road, Staines.
1855 Mabcet, William, M.D., F.R.S. ; 39, Grosvenor street.
C. 1871. Referee, 1866-70, 1883-5. Set. Com. 1863.
lAh. Cam. 1866-8. Tram. 3.
Xliv FELLOWS OF THB SOCIETY.
Elected
1867 Maesh, F. Howaud, Secretary^ Assistant Sargeon to, and
Lecturer on Anatomy at, St. Bartholomew's Hospital ;
Sargeon to the Hospital for Sick Children, Great
Ormond street ; 36, Bmton street, Berkeley square. C.
1882-3. S. 1885. Uh. Com. 1880-1. Trane.A.
1838 Mabsh, Thomas Parr, M.D.
1851 t^^^SHALii, John, F.R.S., Professor of Anatomy to the
Royal Academy of Arts ; Emeritus Professor of Surgery
in UniYersity College, London, and Consulting Sargeon
to UniYersity College Hospita] ; 10, Savile row, Burling-
ton gardens. C. 1866. V.P. 1875-6. P. 1882-4.
Referee, 1867, 1871-4, 1877-81. Trans. 3.
1884 Maetin, Sidney Harris Cox, M.B., 105, Haverstock hill.
1864 Mason, Francis, Surgeon to, and Lecturer on Operative
Surgery at, St. Thomas's Hospital ; 5, Brook street,
Grosvenor square. C. 1880-81. Trane.l,
1883 Mavdsley, Heney, M.D., Resident Medical Officer, Univer-
sity College Hospital, Gh>wer street.
1839 MsABE, RiCHAED Heney, Consulting Surgeon to the Brad-
ford Infirmary ; Bradford, Yorkshire. Trane, 1.
1870 Meadows, Alfeed, M.D., Physician- Accoucheur to, and
Lecturer on Midwifery at, St. Mary's Hospital; 27,
George street, Hanover square. lAb, Com, 1875-7.
1865 Medwin, Aaeon Georoe, M.D., Dental Surgeon to the
Royal Kent Dispensary, 34, Bruton street, Berkeley
square, and 11, Montpellier row, Blackheath.
1880 Meeedith, William Appleton, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children ; 6,
Queen Anne street, Cavendish square.
1874 Meeeihan, John J., 45, Kensington square.
1815 Meyee, Augustus, M.D., St. Petersburg.
1840 MiDDLEMOEE, RiCHAED, Consulting Surgeon to the Bir*
mingham Eye Hospital; The Limes^ Bristol road|
Edgbaston, Birmingham.
1854 Middleship, Edwaed Aechibald.
FELLOWS OT THE SOCIETY. xlv
Elected
1885 MiLLiCAN, Kexneth Williak, B.A., 27, Doke street,
Manchester sqaare.
1882 Mills, Joseph, 15, Henrietta street, Cavendish sqaare.
1873 MiLNEE, Edwabd, Surgeon for Out-Patients to the Lock
Hospital ; 32, New Cavendish street, Portland place.
1883 Money, Angel, M.D., Assistant Physician to the Hospital
for Sick Children, Great Ormond Street, and to the
City of London Hospital for Diseases of the Chest,
Yictoria park ; 24, Harley street. Trans, 2.
1873 MooEE, NoBHAN, M.D., Assistant Physician and Warden of
the College and Lecturer on Comparative Anatomy,
Demonstrator of Morbid Anatomy, St. Bartholomew's
Hospital ; the College, St Bartholomew's Hospital.
1857 MoEOAN, John, 3, Sussex place, Hyde park gardens.
C. 1880-1. Ub, Com. 1862-3. Trans. 1.
1861 MoEOAN, John Bdwaed, M.D., Physician to the Manchester
Royal Infirmary, and Professor of Medicine in the
Owens College, Manchester; 1, St. Peter's square,
Manchester.
1878 Morgan, John Hammond, M.A., Assistant Surgeon to the
Charing Cross Hospital, and to the Hospital for Sick
Children, Great Ormond street ; 68, Grosvenor street,
TroM. 1.
1874 MoBBis, Henby, M.A., Surgeon to, and Lecturer on Sur-
gery at, the Middlesex Hospital; 2, Mansfield street,
Portland place. Referee, 1882-5. Trans. 9.
1879 Mobbis, Malcolm Alexandeb, Surgeon to the Skin De-
partment of St. Mary's Hospital ; 63, Montagu square.
1885 MoTT» Fbedebick Walkeb, M.B., Lecturer on Physiology,
Charing Cross Hospital ; 55, Torrington square.
1868 MoxoN, Walteb, M.D., F.L.S., Physician to, and Lecturer
on Medicine at, Guy's Hospital ; 6, Finsbury Circus.
Beferee, 1879-85. Trans. 1.
1879 MuNK, William, M.D., Harveian Librarian, Royal College
of Physicians; Consulting Physician to the Royal
Hospital for Incurables ; 40, Finsbury square.
ZIW FELLOWS OP THE SOCIETY.
Uleeted
1873 Murray, Ivor, M.D., F.R.S. Ed. 8, HantriBS Row, Scar-
borough.
1880 MvRRBLL, William, M.D., AmiBtant Physician to the Royal
Hospital for Diseases of the Chest ; Assistant Physician
to, and Lecturer on Materia Medica and Therapeutics at,
the Westminster Hospital ; 38, Weymouth street, Port-
land place. Trans. 1.
1863 Mybrs, Arthur Bowek Richards, Surgeon to the Ist
Battalion, Coldstream Guards ; Hospital, Vincent square,
Westminster. C. 1878-9. Lib. Com. 1877.
1882 Myers, Arthur Thomas, M.D., Medical Registrar, St.
Oeorge's Hospital ; 24, Clarges street, Piccadilly.
1881 Nall, Samuel, M.6., Disley, Cheshire.
1870 NsiLD, Jambs Edward, M.D., Lecturer on Forensic Medi-
cine in the University of Melbourne; 166, Collins
street east, Melbourne, Victoria.
1835 tNsLsoN, Thomas Andrew, M.D., 10, Nottingham terrace,
York gate. Regent's park. Lib. Com. 1841.
1877 . Nettleship, Edward, Ophthalmic Surgeon to, and Lecturer
on Ophthalmology at, St. Thomas's Hospital ; Assistant
Surgeon to the Boyal London Ophthalmic Hospital ;
Ophthalmic Surgeon to the Hospital for Sick Children ;
5, Wimpole street, Cavendish square.
1843 fNEWTON, Edward, 85, Gloucester terrace, Hyde Park.
C. 1863-4.
1 868 Nicholls, James, M.D., 68, Duke street, Chelmsford, Essex.
1849 Norman, Henrt Bureord, Portland Lodge, Southsea,
Hants. Lib. Com. 1857.
1847 *Nour8e, William Edward Charles, Bouverie House,
Mount Radford, Exeter.
1864 NuNK, Thomas William, Consulting Surgeon to the Middle-
sex Hospital ; 8, Stratford place, Oxford street.
1870 NuNNBLSY, Frederick Barham, M.D. Trans. 2.
1884 Oakes, Arthur, M.D., 99, Priory road, West Hampstead,
FBLLOWS OF THE SOCIETY. zlvii
Elected
1880 O'GoNNOE, Beenabd, A.B., M.D., Physician to the North
London Hospital for Consamption, and Physician to
the Westminster General Dispensary ; 17, St. James's
place.
1847 O'CoNKOB, Thomas, March, Cambridgeshire.
1880 OoiLYis, GsoE&s, M.6., Lectorer on Experimental Physics
at the Westminster Hospital; 13, Welbeck street,
Cavendish square.
1880 Ogilvie, Leslie, M.B., Lecturer on Comparative Anatomy
at the Westminster Hospital; 46, Welbeck street,
Cavendish square.
1858 OoLE, JoHK William, M.D., Consulting Physician to St.
George's Hospital; 30, Cavendish square. C. 1873.
Referee, 1864-72. Trans. 4.
1855 *OoLE, William, M.A., M.D., Physician to the Derby In-
firmary ; The Elms, Duffield road, Derby.
1860 OoLE, William, M.D., Superintendent of Statistics in the
Registrar-General's Department, Somerset House ; 10,
Gordon street, Gordon square. S. 1868-70. C. 1876-7.
Lib. Com. 1871-5. Tram. 4.
1870 Oldham, Chaeles Fbedeeic, India [Agents: Messrs.
Grindlay and Co., 55, Parliament street].
1883 ^Gliyeb, Thomas, M.D., Lecturer on Practical Physiology,
University of Durham; and Physician to the New-
castle-upon-Tyne Infirmary; 3, Eldon square, New-
castle-upon-Tyne.
1 871 *0'Neill, William, M.D., Physician to the Lincoln Lunatic
Hospital, Silver street, Lincoln.
1873 Oed, William Millee, M.D., Physician to, and Lecturer
on Medicine at, St. Thomas's Hospital ; Examiner in
Medicine at the University of London ; 7, Brook street,
Hanover square. Be/eree, 1884-5. Trans. 6.
1877 Obmeeod, Joseph Ardeene, M.D., Assistant Physician to
the National Hospital for the Paralysed and Epileptic,
Queen square, and to the City of London Hospital for
Diseases of the Chest, Victoria Park ; 25, Upper Wim«
pole street. Trans, 1,
Xlviii FELLOWS OF THE SOCIETY.
Elected
1885 Obmsby, L. HEPEN8TAL, M.D., Lecturer on Clinical and
Operative Surgery and Surgeon to the Meath Hospital
and County Dublin Infirmary ; Surgeon to the Chil-
dren's Hospital, Dublin ; 92, Merrion square west,
Dublin.
1875 OsBOBN, Samuel, 10, Maddoz street, Regent street, and
Maisonnette, Datchet, Bucks.
1879 Owen, Edmund, Surgeon to St. Mary's Hospital; Surgeon
to the Hospital for Sick Children ; 49, Seymour street,
Portman square. TroM, 1.
1882 Owen, Heebebt Isambaed, M.D., Assistant Physician to,
and Lecturer on Materia Medica at, St. George's
Hospital ; Assistant Physician to the Hospital for Con-
sumption, Brompton ; 5, Hertford street. May Fair.
1874 Paoe, Heebebt William, M.A., M.C., Surgeon (with charge
of out-patients) to, and Joint Lecturer on Surgery at, St.
Mary's Hospital ; 146, Harley street, Cavendish square.
Referee, 1884-5. Trans. 2.
1847 *Pa6e, William Bousfield, Consulting Surgeon to the
Cumberland Infirmary, 78, Carlisle street,. Carlisle.
Trane. 2.
1840 tPAOET, Sib James, Bart., D.C.L., LL.D., F.R.S., Sergeant-
Surgeon to H.M. the Queen ; Surgeon-in-Ordinary to
H.R.H. the Prince of Wales ; Consulting Surgeon to
St. Bartholomew's Hospital; Vice- Chancellor of the
University of London ; 1, Harewood place, Hanover
square. C. 1848-9. V.P. 1861. T. 1867. P. 1875-6.
Referee, 1844-6, 1848, 1851-60, 1862-6, 1868-74. Sci.
Cam, 1863. Lib. Cam. 1846-7. Trane. 12.
1858 *Palet, William, M.D., Physician to the Ripon Dispen-
sary ; Ripon, Yorkshire.
1847 Pabkee, Nicholas, M.D., Paris.
1 873 Pabkee, Robebt William, Surgeon to the East London Hos-
pital for Children ; 8, Old Cavendish street. Lib. Cam,
1885. Trans. 3.
1885 Pabkee, Rushton, M.B., Assistant Surgeon to the Liver-
pool Royal Infirmary ; 59, Rodney street, Liverpool.
FELLOWS OF THE SOCIETY. xlix
- Elected
1841 Paekin, John, H.D., 5, Codrington place, Brighton.
1883 Pasteue, Wiluam, M.D., Medical Registrar to the Middle-
sex Hospital ; Physician to the North-Eastem Hospital
for Children ; 19, Qaeen street. May Fair.
1865 Patt, Feedeeick William, M.D., F.R.S., Physician to
Guy's Hospital; 35, Grosvenor street. G. 1883-4.
Referee, 1871-82. Trane. 1.
1869 Patne, Joseph Feank, M.D., Assistant-Physician to, and
Lecturer on Pathological Anatomy at, St. Thomas's
Hospital ; 78, Wimpole street. Cavendish square. Set.
Com. 1879. Lib. Com. 1878-85.
1879 Peel, Robeet, 120, Collins street east, Melbourne,
Victoria.
1856 Peiece, Richaed Kino, Woodside, Windsor forest, Berks.
1830 Peleghin, Chaeles P., M.D., St. Petersburg.
1855 *Pembeeton, Oliyee, Senior Surgeon to the Birmingham
General Hospital, and Professor of Surgery at the
Queen's College, Birmingham ; 1 2, Temple row, Bir-
mingham. Trane, 1.
1874 Penhall^ John Thomas, 5, Eversfield place, St. Leonard's,
Sussex.
1870 Peeein, John Beswick, Vernon House, Leigh, Lanca-
shire.
1879 *Pe8ikaka, Hoeuasji Dosabuai, Marine Lines, Bombay.
1878 *Philipson, Geoeqe Habe, M.D., M.A., D.C.L., Pro-
fessor of Medicine at Durham University; Senior
Physician to the Newcastle-upon-Tyne Infirmary ; 7»
Bldon square, Newcastle-upon-Tyne.
1883 Phillips, Chaeles Douolas F., M.D., 10, Henrietta street,
Cavendish square, W.
1884 Phillips, Geoeqe Richaed Tuenee, 24, Leinster square,
Bayswater.
1867 Pick, Thomas Pickeeino, Surgeon to, and Lecturer on
Surgery at, St. George's Hospital ; 18, Portman
street, Portman square. C. 1884-5. Referee, 1882-3.
Set. dm. 1870. Uh, Com, 1879-81.
TOL. LXTin. d
1 FELLOWS OV THE 80CIBTY.
Sleeted
1841 ffiTV.ks, Sib Hsnbt Alfred, M.D., Consulting Physieian
to St. George's Hospital, and to the Royal General Dis-
pensary, St. Pancraa ; 28, Gordon square. L. 1851-3.
C. 1861-2. T. 1863-8. V.P. 1870-1. Referee, 1849-
50. Lib. Com, 1847.
1884 Pitt, Gboros Newton, M.D., Assistant Physician to the
East London Hospital for Children ; 34, Ashbam place.
South Kensington.
1885 Poland, John, Demonstrator of Anatomy, Goy^s Hospital ;
16, St. Thomas's street, Southwark.
1884 Pollard, Bilton, M.D., Surgical Registrar, UniYcrsity
College Hospital ; 50, Torrington square.
1871 Pollock, Arthue Julius, M.D., Physician to, and Lecturer
on the Principles and Practice of Medicine at. Charing
Cross Hospital ; Physician to the Foundling Hospital ;
85, Harley street, Cavendish square.
1845 fPoLLOCK, George Dayid, Surgeon-in-Qrdinary to H.B.H.
the Prince of Wales; Consulting Surgeon to St. George's
Hospital; 36, Grosvenor street. C. 1856*7. L. 1859-62.
V.P. 1870-1. Referee, 1858, 1864-9, 1877-85. Trane, 4.
1865 Pollock, James Edward, M.D., Consulting Physician to
the Hospital for Consumption, Brompton ; 52, Upper
Brook street, GrosYenor square. C. 1882-3. Referee,
1872-81.
1871 PooRE, George Vitian, M.D., Professor of Medical Juris-
prudence in University College, London; Assistant-
Physician to University College Hospital; Physician
to the Royal Infirmary for Children and Women,
Waterloo road ; Examiner in Forensic Medicine at the
University of London; 30, Wimpole street. Trane, 1.
1885 Port, Hsineioh, M.D., Physician to the German Hospital ;
48, Finsbury square.
1846 Potter, Jephson, M.D., F.L.S.
1842 Powell, James, M.D.
1867 Powell, Richard Doxjolab, M.D., Secretary, Physician to,
and Lecturer on Practical Medicine at, the Middlesex Hos-
pital; Physician to the Hospital for Consumption and Dis-
eases of the Chest, Brompton ; 62, Wimpole st.. Caven-
dish sq. S. (Oct.) 1883-5. Referee, 1879-83. Tram. 2.
TBLLOWS or THB 80CIBTT. ll
EUeted
1867 PowsB, HxNBY, Ophthalmic Surgeon to, and Lectorer on
Ophthalmic Sargery at, St. Bartholomew's Hospital ;
37a, Great Gamherland place, Hyde park. G. 1882-3.
Referee, 1870-81. Set. dm. 1870. Lib. dm. 1872-8.
1857 Pkibbtlet, Wuliah Oybrend, H.D., LL.D., Ttce-Pren-
deni. Consulting Physician to King's College Hospital,
and to the St. Marylelione Infirmary; 17* Hertford
street, Mayfair. C. 1874-5. V.P. 1884^. Be/eree,
1867-73, 1877-83. Set. Com. 1863.
1883 Pbinole, John James, M.B., CM., Assistant Physician
to the Middlesex Hospital, and to the Royal Hospital
for Diseases of the Chest ; 35, Bruton Street, Berkeley
square.
1874 PvEYES, William Laidlaw, Aural Surgeon to Guy's
Hospital ; 20, Stratford place, Oxford street. Tram. 2.
1875 Pys, Waltee, Surgeon (with charge of out-patients) to
St. Mary's Hospital ; 4, Sacknlle street, Piccadilly.
1877 Pte-Smith, Philip Henry, M.D., Physician to, and
Lecturer on Medicine at, Guy's Hospital ; Examiner in
Physiology at the Uniyersity of London ; 54, Harley
street. Cavendish square.
1 850 tQu AiN, Richard, M.D., F.R.S., Consulting Physician to the
Hospital for Consumption, Brompton ; Member of the
Senate of the University of London ; 67, Harley street.
Cavendish square. G. 1866-7. V.P. 1878-9. Set.
Com. 1863. Tram. 1.
1835 tQuAiN, Richard, F.R.S., Surgeon-Extraordinary to H.M.
the Queen ; Emeritus Professor of Clinical Surgery,
University College, London, and Consulting Surgeon to
University College Hospital; 32, Cavendiih square.
C. 1838-9. L. 1846-8. T. 1851-3. V.P. 1856-7.
Referee, 1845-6, 1848, 1858-9. Lib. Com. 1846.
Tram. 1. Pro. 2.
1852 t^ADOLiFPE, Charles Bland, M.D., Treasurer, Consulting
Physician to the Westminster Hospital ; Physician to
the National Hospital for the Paralysed and Epileptic ;
25, Cavendish square. C. 1867-8. V.P. 1879-80.
T. 1881-5. Referee, 1862-6, 1870-8.
lii PELLOW8 OP THE SOCIETY.
Eleeted
1871 Ralfe, Ghablbs Hbnby, M.D., M.A., AssUtant PhyBicUii
to the London Hospital, and late Physician to the Sea-
men's Hospital, Greenwich ; 26, Qneen Anne street.
Cavendish square. Referee^ 1885.
1857 Ranke, Henbt, M.D., 3, Sophienstrasse, Munich.
1854 Ransom, William Hbnby, M.D., F.B.S., Physician to the
Nottingham General Hospital, Nottingham.
1869 Read, Thomas Laubbnoe, 11, Petersham terrace. Queen's
gate.
1858 Reed, Fbedbbick Geobob, M.D., 46, Hertford street, May-
fur. TVaiw. 1.
1821 Rebdeb, Hbnby, M.D., Yarick, Seneca County, New Tork»
United States.
1857 Rebs, Geobge Owen, M.D., F.RS., Consulting Physician
to Guy's Hospital; 26, Albemarle street, Piccadilly.
C. 1873. Referee, 1860-72, 1875-81. IVon*. 1.
1882 Reid, James, M.D., Resident Physician to H.M. the Queen,
Windsor Castle.
1884 Reid, Thomas Whitehead, Surgeon to the Kent and
Canterbury Hospital ; 34, St. Gorge's place, Canter-
bury.
1855 Reynolds, John Russell, M.D., F.R.S., Vtee-Preeident,
Physician-in-Ordinary to H.M.'s Household; Con-
sulting-Physician to UniTereity College Hospital; 38,
Grosvenor street. C. 1870. V.P. 1883. Referee,
1867-9.
1865 Rhodes, Geobob Winteb, Surgeon to the Huddersfield
Infirmary ; Queen street south, Huddersfield.
1881 Rice, Geobge, M.B.; CM., Sutton, Surrey.
1852 Richabdson, Chbistophbb Thomas, M.B., 13, Nelson
crescent, Ramsgate.
1845 tRi^<^B» Benjamin, M.D.,. 8, Mount street, Grosvenor
square.
1863 Ringeb, Sydney, M.D., F.R.S., Professor of the Principles
and Practice of Medicine in University College, London,
and Physician to University College Hospital ; 15,
Cavendish place. Cavendish square. C. 1881-2.
Rtferee, 1873-80. Traru* 6.
FELLOWS OF THE SOCIETY. liii
Elected
1871 RiTiNOTGN^ Walter, M.S., Sargeon to, and Lecturer on
Surgery at, the London Hospital ; 22, Finsbury
square. G. 1885. Trane, 2.
1871 *RoBEBT8, Dayid Llotd, M.D., Physician to St. Mary's
Hospital, Manchester ; 1 1, St. John street, Deansgate,
Manchester.
1878 RoBSBTS, Fbedebick Thomas, M.D., Professor of Materia
Medica and Therapeutics in University College, London ;
and Physician to University College Hospital; Phy-
sician to the Hospital for Consumption, Brompton;
53, Harley street. Cavendish square.
1857 RoBE&TSON, John Chables Gbobgs, Medical Superinten-
dent of the Cavan District Lunatic Asylum ; Monaghan,
Ireland.
1873 Robebtbon, William H., M.D., Consulting Physician to
the Devonshire Hospital and Buxton Bath Charity;
Buxton, Derbyshire.
1885 RocKWOOD, William Gabbiel, M.D., Colombo, Ceylon.
1 843 RoDEN, William, M.D., Momingside Lodge, Kidderminster.
1850 RoPEB, Geobge, M.D., Consulting Physician to the Eastern
Division of the Royal Maternity Charity ; Physician to
the Royal Infirmary for Children and Women, Waterloo
Bridge road [19, Ovington gardens, S.W.]. C. 1879-80.
1857 Rose, Henby Coopeb, M.D., F.L.S., Surgeon to the
Hampstead Dispensary; Penrose House, Hampstead.
Trans. 1.
1883 Rose, Wiluam, M.B., Assistant Surgeon to tang's College
Hospital ; 50, Harley street. Cavendish square.
1882 Routh, Amand J. McC, M.D., B.S., Physician to the
Samaritan Free Hospital for Women ; Assistant Phy-
sician Accoucheur to the Charing Cross Hospital ;
Obstetric Physician to the St. Marylebone General
Dispensary ; 6, Upper Montagu street, Montagu square.
1849 t^ouTH, Chables Henby Felix, M.D., Physician to the
Samaritan Free Hospital for Women and Children ; 52,
Montagu square. Lib, dm, 1854-5. Trans, 1.
liv VBLLOWS OF THB 80CIBTT.
Elected
1863 Rows, Thomas Smith, M.D., Saigeon to the Boyal Sea-
Bathing Infinnary ; Cecil street, Margate, Kent.
1 882 Rot, Chables Smart, M.D., F.R.S., Professor of Pathology
in the University of Cambridge.
1871 RuTHERFO&D, WiLLiAM, M.D., F.R.S., Professor of Phy.
siology in the University of Edinburgh ; 14, Douglas
crescent, Edinburgh.
1856 Salter, S. James A., M.B., F.R.S., F.L.S., Basingfield, near
Basingstoke, Hants. C. 1871. lAh. Cam. 1878.
Trans. 2.
1849 tSANJDBRsoN, HuGH James, M.D., 26, Upper Berkeley street,
Portnuin square. C. 1872-3. Lib, Com. 1862-3.
1855 Sanderson, John Burdon, M.D., LL.D., F.R.S., Wayn-
flete Professor of Physiology in the University of
Oxford; 50, Banbury road, Oxford. C. 1869-70.
V.P. 1882. Referee, 1867-8, 1876-81. Set. Com.
1862, 1870. LOt, Com. 1876-81. Tran8.2.
1867 Sandford, Folltott James, M.D., Market Drayton,
Shropshire.
1879 Sangstbr, Alfred, B.A., M.B., Physician to the Skin
Department, and Lecturer on Skin Diseases at the
Charing Cross Hospital; 6, SavOe row. Trane. I.
1847 t^ANKEY, William Henrt Octayivb, M.D., Boreatton
park, Bascharch, near Shrewsbury.
1869 Sansom, Arthur Ernest, M.D., Physician (with charge of
out-patients) to the London Hospital ; 84, Harley
street, Cavendish square. Trans. 2.
1 845 t^AUNDERS, Sir Edwin, Surgeon^Dentist to H.M. the Queen,
and to H.RrH. the Prince of Wales ; 13a, George street,
Hanover square. C. 1872-3.
1834 Sauvan, Ludwig V., M.D., Warsaw.
1879 Savage, Oeorgb Hbmry, M.D., Bethlem Boyal Hospitali
St. George's road« Sonthwark.
FELLOWS OF THE SOCIETY. W
Elected
1859 Sayory, Williak Scoyell, F.R.S., Surgeon to, and Lec-
turer on Sargery at, St. Bartholomew's Hospital;
Surgeon to Christ's Hospital; 66, Brook street,
Grosvenor square. C. 1871-2. L. 1878. V.P. 1883-4.
Referee, 1865-70, 1873-77, 1879-82. Set, Cam. 1862,
1867, 1870. Lib. Com. 1866-8. Tram. 6.
1883 SoHAFBE, Edwabd Albert, F.B.S., Jodrell Professor of
Physiology, UniYersity College, London; University
College, Oower street.
1873 ScoTT, John Mooee Johnston, M.D., Lurgan, County
Armagh.
1861 *ScoTT, WILLLA.M, M.D., Senior Physician to the Hudders-
field Infirmary ; Waverley House, Huddersfield.
1882 ScEiYEN, John Barclay, Brigade Surgeon, Bengal (retired),
late Professor of Anatomy, Surgery, and Ophthalmic
Surgery at the Lahore Medical School ; 95, Oxford
gardens. Netting hill.
1863 Sedgwick, William, 12, Park place. Upper Baker street.
C. 1884-5. IVans. 2.
1877 Semon, Felix, M.D., Assistant Physician for Diseases of the
Throat to St. Thomas's Hospital ; 59, Welbeck street,
Cavendish square. Trane. 1.
1 875 Seuple, Robert Hunter, M.D., Physician to the Bloomsbury
Dispensary; 8, Torrington square. Set. Com. 1879.
1873 *Sh AFTER, Lewis, B.A., M.B., Physician to the Devon and
Exeter Hospital ; the Bamfield, Exeter.
1882 Sharkey, Seymour J., M.B., Assistant Physician, Joint
Lecturer on Pathology, and Demonstrator of Morbid
Anatomy, to St. Thomas's Hospital; 2, Portland place.
Trane. 2.
1840 Sharp, William, M.D., F.R.S., Horton House, Rugby.
Trane. 1.
1836 t^H^^y Alexander, Consulting Surgeon to the Middlesex
Hospital; 136, Abbey road> Kilburn. C. 1842. S.
1843-4. V.P. 1851-2. T. 1858-60. JZ^^rw, 1842-3,
1846-50, 1855-7, 1865. Lib. Com. 1843. Trane. 4.
Ivi' rSLLOWS OF THE SOCIETY.
EUeted
1884 Sheild, Arthur Marhaduks, M.6.» B.S., House Saigon,
St. George's Hospital.
1859 SiBLET, Septimus William, 7, Harley street, CsTendish
square. C. 1882-3. 8ci. Com. 1863. Tran».A.
1848 tSiETEKiNG, Edward Hekrt, M.D., Physidan-Extraordi-
uary to H.M. the Queen; Physician-in-Ordinary to
H.R.H. the Prince of Wales ; Physician to St. Mary's
Hospital; 17» Manchester square. G. 1859-60. S.
1861-3. V.P. 1873-4. L. 1881-2. Referee, 1855-8,
1864-72, 1875-80. 8ei. Com. 1862. Tran9. 2.
1842 tSiMON, John, G.B., D.C.L., LL.D., F.B.S., Consulting
Surgeon to St. Thomas's Hospital; 40, Kensington
square. C. 1854-5. V.P. 1865. Referee 1851-3,
1866-81. Trane. 1.
1857 SiORDET, James Lewis, M.6., YiUa Preti, Mentone, Alpes
Maritimes, France.
1882 Smith, Gharles John, 54, Old Steyne, Brighton.
1879 Smith, E. Noble, Senior Surgeon and Surgeon to the
Orthopaedic Department of the Farringdon Dispensary ;
Orthopedic Surgeon to the British Home for Incurables ;
24, Queen Anne street, Gavendish square.
1881 Smith, Eustace, M.D., Physician to H.M. the King of the
Belgians; Physician to the East London Gbildren's
Hospital, and to the Victoria Park Hospital for Dis-
eases of the Ghest ; 5, George street, Hanover square.
1885 Smith, James Greig, M.B., G.M., Surgeon to the Bristol
Royal Infirmary ; 16, Victoria square, Clifton.
1872 Smith, T. Gilbart,.M.A., M.D., Assistant-Physician to the
London Hospital ; Physician to the Royal Hospital for
Diseases of the Ghest, Gity road ; 68, Harley street,
Gavendish square. Trane, 1.
1866 Smith, Hetwood, M.A. M.D., Physician to the Hos-
pital for Women; Physician to the British Lying-in
Hospital ; 18, Harley street, Cayendish square.
FBLLOW8 OF THS SOCIETY. Ivii
Meeted
1838 fSiciTH, Spsnceb, Consalting Sni^eon to St. Mary's Hos.
pital; 92, Oxford terrace, Hyde Park. C. 1854. S.
1855-8. V.P. 1859-60. T. 1865. Be/eree, 1851-3,
1862-4, 1866-78. Lib. Com. 1847.
1863 Smith, Thomas, Surgeon to, and Lecturer on Clinical
Surgery at, St. Bartholomew's Hospital; 5, Stratford
place, Oxford street. S. 1870-2. C. 1875-6. Btferee,
1873-4, 1880-5. 8ci. Cmn. 1867. Tram. 3.
1873 Smith, W. Johnson, Surgeon to the Seamen's Hospital,
Greenwich.
1874 •Smith, William Robert, M.D., F.R.S.£d., Physician to
the Dispensary, Cheltenham ; BayshiU Villa, Chelten-
ham.
1868 Solly, Samuel Edwin, Colorado Springs, Colorado, U.S.
1865 SouTHET, Reginald, M.D., CommlBsioner in Lunacy ; 32,
Groevenor road, Westminster. C. 1881-2. S. 1883.
Referee, 1873-80. Trane. 1.
1844 Spaceman, Feederick R., M.D., Harpenden, St. Alban's.
1875 Spitta, Edmund J., lyy House, Clapham Common, Surrey.
1851 t^PiTTA, Robert John, M.D., East Side, Clapham Com-
mon, Surrey. C. 1878-9. Trane. 1.
1882 Steavenson, William Edward, M.D., 39, Welbeck street,
CaYendish square.
1854 Steyeks, Henry, M.D., Inspector, Medical Department,
Local Government Board.
1884 Stewart, Edward, M.D., 16, Harley street.
1859 Stewart, William Edward, 16, Harley street, Gayendish
square.
1879 ^Stirling, Edward Charles, late Assistant Surgeon and
Lecturer on Physiology at St. George's Hospital;
Adelaide, South Australia [care of T. Gemmell, Esq.,
1 1, Essex street. Strand].
1856 Stogker, Alonzo Henry, M.D., Peckham House, Peckham.
1865 Stokes, William, M.D., Surgeon to the Richmond
Surgical Hospital ; 5, Merrion square north, Dublin.
2Vafi#. 1.
Iviii FELLOWS 07 THE SOCIBTT.
Elected
1884 STONHA.M, Chaelbs, Conitor of the Anatomical Mnsenm,
UniYenity College, London, and AsBistant Surgeon to
the Cancer Hospital, Brompton ; 109» Oower street.
1843 Stoeks, Robeet Rebye, Paris.
1858 fSTEEATFEiLD, JoHN Feexltn, Sargeon to the Royal
London Ophthalmic Hospital, Moorfields ; Professor of
Clinical Ophthalmic Surgery in University College, and
Senior Ophthalmic Sargeon to University College Hos-
pital; 15, Upper Brook street, Orosvenor square. C.
1874-5. Lib. Cam. 1867-8.
1871 Steong, Henet John, M.D., Whitgift House, George street,
Croydon.
1853 fSTUEGBs, OoTAYins, M.D., Physician to, and Lecturer on
Medicine at, the Westminster Hospital; Assistant-
Physician to the Hospital for Sick Children; 85,
Wimpole street, Cavendish square. C. 1878-9. Be-
feree, 1882-5.
1871 fSuTHEELAND, Heket, M.D., Lccturcr on Insanity at the
Westminster Hospital ; 6, Richmond terrace, Whitehall.
1860 SuTBO, SiGiSMUND, M.D., Senior Physician to the German
Hospital ; 37a, Finshury square.
1871 Sutton, Henet Gawen, M.B., Physician to, and Lecturer
on Pathology at, the London Hospital, and Physician
to the City of London Hospital for Diseases of the
Chest; 9, Finshury square. Tran9, 1.
1883 Sutton, John Bland, Lecturer on Comparative Anatomy
and Senior Demonstrator of Anatomy, Middlesex Hos-
pital Medical GoUege; 22, Gordon street, Gordon
square. 2Van#. 2.
1855 Sutton, John Maule, M.D., Medical Officer of Health,
Oldham ; Higher Broughton, Manchester.
1861 *Sw£ETiNO, Gbobgb Bacon, King's Lynn, Norfolk.
1878 ^Sthpson, Thomas, Surgeon to the Lincoln County Hos-
pital ; 3, James street, Lincoln.
1870 Tait, Lawson, Surgeon to the Birmingham and Midland
Hospital for Women; 7, The Crescent, Birmingham.
Tram. 4.
1864 Taussig, Gabeibl, M.D., 70, Piaua Barherini, Rome.
FELLOWS OF THB SOCIBTT. llx
Eleeied
1875 Tat» Wabxk^ Surgeon to the London Hospital and Sargeon
to the North Eastern Hospital for Children and the
Hospital for Skin Diseases, BlackMars; 4> Finsbury
square.
1873 Taylor, Fsbdsiuck, M.D., Physician to, and Lecturer
on Materia Medica at, Guy*s Hospital ; Physician to the
Evelina Hospital for Sick Children ; 11, St Thomas's
street, Southwark. Traiu. 1.
1845 tTATLOB, Thomas, Warwick House, 1, Warwick place, OroTe
End roady St. John's wood.
1859 Teoabt, Edwabd, 49, Jermyn street, St James's.
1874 Thin, Obokge, M.D., 22, Queen Anne street, Carendish
square. TraiM. 9.
1862 Thompson, Edmttnd Stmes, M.D., Physician to the Hos-
pital for Consumption, Brompton ; Gresham Professor
of Medicine; 33, Cavendish square. S. 1871-4.
C. 1878-9. Referee, 1876-7. TraM. 1.
1857 !Fhomp80K, Henbt, M.D., Consulting Physician to the
Middlesex Hospital ; 53, Queen Anne street, Cavendish
square.
1852 fTnoMPsoN, Sib Henbt, Surgeon-Extraordinary to H.M.
the King of the Belgians; Emeritus Professor of
CUnical Surgery in University College, London; and
Consulting Surgeon to University College Hospital;
Corresponding Member of the " Soci6t6 de Chirurgie,"
Paris; 35, Wimpole street. Cavendish square. C.
1869. Tran9. 7.
1862 Thompson, Rboinald Edwabd, M.D., Physician to the
Hospital for Consumption, Brompton ; 47, Park street,
Grosvenor square. C. 1879. S. 1880-82. V. P. 1883-4.
Referee, 1873-8. Set. Com. 1867. Ttom. 2.
1881 Thomson, William Sinclaib, M J)., 40, Ladbroke grove,
Kensington park gardens.
1876 Thobnton, John Knowslet, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children;
22, Portman street, Portnum square. TVoim. 2«
Ix FELLOWS OP TElE SOCIBfY.
Elected
1883 Thvssfield, Thomab William, M.D., 26, The Parade,
Leamington.
1848 fTiLT, Edwahd John, M.D., Gonsalting Physician to the
Farringdon Oeneral Dispensary and Lying-in Charity ;
27, Seymour street. Port man square. Be/eree, 1874-81.
1880 TiYY, William James, 8, Lansdowne place, Clifton, Bristol.
1872 Tomes, Chables S., B.A., F.R.S., Lecturer on Anatomy and
Physiology at the Dental Hospital; 37, Cavendish
square. Lib, Com. 1879.
1867 ToNGE, MoBRis, M.D., Harrow-on -the-Hill, Middlesex.
1882 Tooth, Howabd Henry, M.B., Assistant Demonstrator of
Practical Physiology, St. Bartholomew's Hospital;
34, Harley street. Cavendish square.
1871 *Tbend, Theophilus W., M.D., Raeberry Lodge, South-
ampton.
1879 Tbxves, Fbsdeeick, Surgeon to, and Lecturer on Anatomy
at, the London Hospital ; 18, Gordon square. Trans, 3.
1881 '*'Tr£tes, William Knight, Surgeon to the Royal Sea
Bathing Infirmary for Scrofula; 31, Dalby square,
Ciiftonville, Margate.
1867 Tbotteb, John William, late Surgeon-Major, Coldstream
Guards ; 4, St. Peter's terrace, York.
1859 Tbuman, Edwin Thomas, Surgeon-Dentist in Ordinary to
Her Majesty's Household ; 23, Old Burlington street.
1864 Tufnell, Thomas Jolliffe, Consulting Surgeon to the
City of Dublin Hospital; 58, Lower Mount street,
Merrion square, Dublin. Trans, 1.
1862 TuKE, Thomas Habbington, M.D., Manor House, Chiswick,
and 37) Albemarle street, Piccadilly.
1875 Tubnbb, Fbangis Chablewood, M.A., M.D., Physician
to the North-Eastern Hospital for Children, and to the
London Hospital ; 15, Finsbury square.
1873 Tubneb, Gsobge Bbown, M.D., San Bemo, Italy.
1882 Tubneb, Geoboe Robebtson, Visiting Surgeon to the
Seamen's Hospital, Greenwich ; Joint Lecturer on
Practical Surgery at St. George's Hospital ; 49, Green
street, Park lane.
FBLLOW8 OF THE 80CIETT. Ixi
Elected
1881 Tt80K» William Joseph, M.D., Medical Officer of the
Folkestone Infirmary ; 10, Langhorne gardens, Folke-
stone.
1876 Venn, Albbbt John, M.D., Obstetric Physician to the
Metropolitan Free. Hospital; Physician for the Dis-
eases of Women, West London Hospital ; Physician to
the Victoria Hospital for Children, Chelsea ; 8, Upper
Brook street, Orosvenor square.
1870 Venning, Edgcombe, 30, Gadogan place.
1865 Veen on, Bowateb John, Ophthalmic Surgeon to St. Bar-
tholomew's Hospital and to the West London Hospital ;
14, Clarges street, Piccadilly.
1867 ViNTBAB, Achille, M.D., Physician to the French Embassy
and to the French Hospital, Lisle street, Leicester
square ; 19a, Hanover square.
1828 Vulpes, Benedetto, M.D., Physician to the Hospital of
Aversa, and the Hospital of Incurables, Naples.
1854 Waddington, Edwaed, Hamilton, Auckland, New Zealand.
1870 Wadham, William, M.D., Physician to St. George's Hos-
pital ; 14, Park lane.
1864 Wajtb, Chaeles Deebt, M.B., Senior Physician to the
Westminster General Dispensary ; 3, Old Burlington
street.
1884 Waklet, Thomas, Jun., 96, Redcliffe gardens.
1868 '■'Walkee, Robeet, Surgeon to the Carlisle Dispensary ; 2,
Portland sqoare, Carlisle.
1883 Wallee, Augustus, M.D., 29, Abbey road, St. John's
wood.
1867 '*'Wallis, Geoege, Surgeon to Addenbrooke's Hospital,
Corpus Buildings, Cambridge.
1873 Walsh AM, William Johnson, CM., Assistant Surgeon to,
and Demonstrator of Practical and Orthopaedic Surgery
at, St. Bartholomew's Hospital ; Surgeon to the
Metropolitan Free Hospital; 27, Weymouth street,
Portland place. Ub. Com. 1882-5. Tram. 3.
Ixii 7BLLOW8 07 THE BOCIBTT.
JEUeted
1852 fWALSHE, Walter Hatle, M.D.» Emeritos Professor of the
Principles and Pnustice of Medicine, University College,
London; Consulting Physidan to the Hospital for
Consumption; 41, Hyde park square. C. 1872.
Tram. 1.
1883 *Waltsbs, James Hopkins, 43, Castle street. Beading.
1851 fWALTON, Hatnes, Senior Surgeon to St. Mary's Hospital,
1, Brook street, Orosvenor square. Trans. 1. Pro. 1.
1852 Wake, Daniel» M.D.
1821 Ward, William Tilleaed, Tilleards, Stanhope, Canada.
1846 Ware, James Thomas, Tilford House, near Famham,
Surrey.
1818 Ware, John, Clifton Down, Bristol.
1866 Waring, Edward John, CLE., M.D., 49, Clifton gardens,
Maida vale. Be/eree, 1881-5.
1877 Warner, Francis, M.D., Assistant Physician to the London
Hospital and to the East London Hospital for Children ;
Lecturer on Botany at the London Hospital; 24,
Harley street, Cavendish square. Tram. 1.
1861 Waters, A. T. Houghton, M.D., Physician to the Royal
Infirmary, and Lecturer on the Principles and Practice
of Medicine, in the Liverpool Royal Infirmary School of
Medicine ; 69, Bedford street, Liverpool. Tram. 3.
1879 Waters, John Henry, M.D., CM., 101, Jermyn street.
1878 Watnet, Herbert, M.D., 1, Wilton crescent, Belgrave
square, and Buckhold, Basildon, Reading.
1861 fWATsoN, William Spencer, M.B., Surgeon to the Great
Northern Hospital; Surgeon to the Royal South
London Ophthalmic Hospital; 7, Henrietta street.
Cavendish square. C. 1883-4. Tram. 1.
1879 DE Watteyillb, Armand, M.A., M.D., B.Sc, Medical
Electrician to St. Mary's Hospital ; 30, Welbeck street.
Cavendish square.
1854 Wees, William, M.D., Oilkln View House, Wirksworth,
Derbyshire.
VBLLOWS OF THB SOCIETY. Ixui
Xleeted.
1840 Webb, William Woodham, H.D., 82, Avenae des TermeB,
Paris.
1842 fWiBEB, Fbedibic, M.D., 44, Green street. Park lane.
C. 1857. V.P. 1865.
1857 Webee, Heemann, M.D., Fiee-PresidefU, Physician to
the German Hospital ; 10, GrosYenor street, Grosvenor
square. C. 1874-5. V.P. 1885. Be/eree, 1869-73,
1878-84. Lib. Cam. 1864-73. Trans. 6.
1844 t^EGG, William, M.D., 15, Hertford street, Mayfair.
L. 1854-8. C. 1861-2. T. 1873-80. Lib. Com.
1851-3.
1878 Weiss, Hubeet Foveauz, 11, Hanover square.
1874 Wells, Haeet, M.D., San Tsidro, Buenos Ayres, S.
America.
1854 Wells, Sie Thomas Spencee, Bart., 8urgeon-in-Ordinary
to H.M.'s Household ; Consulting Surg;eon to the
Samaritan Free Hospital for Women and Children ; 3,
Upper Grosrenor street. G. 1870. V.P. 1881.
Trans. 13. Pro. 1.
1842 fWEST, Chaeles, M.D., Corresponding Member of the
Academy of Medicine of Paris; 55, Harley street.
Cavendish square. C. 1855-6. V.P. 1863. P. 1877-8.
Referee, 1848-54, 1857-62, 1864-76, 1880. Sd. Com.
1863. Lib. Cam. 1844-7, 1851. Trans. 2.
1877 West, Samuel, M.D., Physician to the City of London
Hospital for Diseases of the Chest, Victoria Park;
Physician to the Royal Free Hospital ; Medical Begis-
trar and Medical Tutor to St. Bartholomew's Hospital ;
15, Wimpole street. Cavendish square. Trans. 3.
1882 Whaeet, Chaeles John, M.D., Resident Superintendent,
Government Civil Hospital, Hong Kong.
1881 Whabbt, Robeet, M.D., 6, Gordon square.
1878 Whaetom, Hskey Thoenton, M.A., Surgeon to the Kilhum
Dispensary ; 39, St. George's road, Kilhum.
1828 Whatlet, John, M.D.
Ixiy FBLL0W8 OF THK SOCIETY.
JEleeM
1875 Whiphah, Thomas Tilltbb, M.B., Physician to, and Lee
turer on Clinical Medicine at, St. George's Hospital ;
11, Orosvenor street, Grosvenor square.
1849 White, John.
1881 White, William Hale, M.D., Assistant Physician to
Gay's Hospital; 4, St. Thomas's street, Sonthwark.
Trans. 1.
1881 ^Whitehead, Walter, F.R.S.Ed., Sui^eon to the Man-
chester Boyal Infirmary ; Senior Surgeon to the Man-
chester and Salford Lock and Skin Hospital ; 24, St.
Ann's square, Manchester. 2V*an#. 1.
1885 *Whitla, William, M.D., Physician to, and Lecturer in
Medicine at, the Belfast Boyal Hospital ; Consulting
Physician to the Ulster Hospital for Women and Chil-
dren ; 8, College square north, Belfast.
1 877 Whitmoeb, William Tickle, 7, Arlington street, Piccadilly.
1852 WiBLiN, John, M.D., Medical Inspector of Emigrants and
Recruits; Southampton. Trans. I.
1870 *WiLKiN, John F., M.D., M.C., The Warren, Beckenham
park, Kent
1883 * Wilkinson, Thomas Marshall, Surgeon to the Lincoln
County Hospital and to the Lincoln General Dis-
pensary ; 7, Lindum road, Lincoln.
1837 WiLKs, Geokge Augustus Feederick, M.D., Stanhury,
Torquay.
1863 WiLKS, Samuel, M.D., LL.D., F.R.S., Consulting Physician
to, and Lecturer on Medicine at, Guy's Hospital;
Physician in Ordinary to their Royal Highnesses the
Duke and Duchess of Connaught ; 72, Grosvenor street,
GrosYcnor square, i^ere^, 1872-81. Set. Cam. I.
1883 *WiLLANs, William Blundell, Great Hadham, Herts.
1865 t^^^^*^) Alfred, Surgeon to St. Bartholomew's Hospital ;
Surgeon to St. Luke's Hospital ; 36, Wimpole street.
Cavendish square. C. 1880-81. Btferee, 1882-5.
Tram. 2,
FELLOWS OP THE SOCIETY. IxV
Sl&eted
1864 WiLLETT, Edmund Spabshall, M.D., Resident Physician,
Wyke House, Isleworth, Middlesex.
1840 fWiLLiAMS, Chables James Blasius, M.D., F.R.S.,
Physician-Extraordinary to H.M. the Queen; Consulting
Physician to the Hospital for Consumption, Broropton
[47, Upper Brook street, Grosvenor square] ; Villa de
Rocher, Cannes. C. 1849-50. V.P. 1860-1. P.
1873-4. Referee, IS43-4. Set. Com, 1862, Trans, I.
1859 ^Williams, Chables, Surgeon to the Norfolk and Norwich
Hospital ; 48, Prince of Wales road, Norwich.
1866 Williams, Chables Theodobe, M.A., M.D., Physician
to the Hospital for Consumption and Diseases of the
Chest, Brompton ; 47, Upper Brook street, Grosvenor
square. C. 1884-5. Lib, Com, 1880-3. Traru. 3.
1881 Williams, Dawson, M.D., 4, Oxford and Cambridge
Mansions, Marylebone road.
1872 Williams, John, M.D., Obstetric Physician to University
College Hospital; Examiner in Obstetric Medicine
at the University of London ; 11, Queen Anne street,
Cavendish square. Referee, 1878-85. Lib, Com.
1876-82.
1868 Williams, William Rhts, M.D., Commissioner in Lunacy ;
19, Whitehall place.
1863 Wilson, Robebt James, 7, Warrior square, St. Leonard's*
on-Sea, Sussex.
1850 *WiSE, Robebt Stanton, M.D., Consulting Physician to
the Southam Eye and Ear Infirmary; Beech Lawn,
Banbury.
1825 Wise, Thoma.s Alexandeb, M.D.
1879 WoAKES, Edwabd, M.D., Senior Aural Surgeon to the
Loudon Hospital ; 78, Harley street. Cavendish square.
1885 WoLFENDEN, RiCHABD NoBBis, M.D., 19, Upper Wimpole
street.
VOL. LXVIII. e
Ixvi FELLOWS OF THE SOCIETY.
Elected
185 1 fWooD, John, F.R.S., Professor of Clinical Surgery in King's
College, London, and Senior Surgeon to King's College
Hospital; Examiner in Surgery in the University of
London; 61, Wimpole street, Cayendish square. C.
1867-8. V.P. 1877-8. Referee, 1871-6, 1880-85.
Lib. Com, 1866. Trane. 3.
1848 t^ooi>9 WiLLiAH, M.D., Physician to St. Luke's Hospital
for Lunatics; 99, Harley street. Cavendish square.
C. 1867-8. V.P. 1877-8.
1883 Woop, W1LLIA.M Edwabd Ramsden, M.A., M.D., Bock-
hampton, Queensland.
1881 Woodman, Samuel, Consulting Surgeon to the Ramsgate
and St. Lawrence Royal Dispensary; 5, Prospect terrace,
Ramsgate.
1879 WooDV?AED, G. P. M., M.D., Deputy Surgeon-General;
Sydney, New South Wales.
1865 WoTTON, Henby, M.D., 15, Notting Hill terrace, Kensing-
ton.
1878 Teo, Gebald F., M.D., M.C., Professor of Physiology in
King's College, London; Examiner in Physiology,
University of London ; King's College, Strand.
[It is particularly requested that any change of Title, Appcnntment, or
Residence, may be commuuicated to the Secretaries before the Ist of
October in each year, in order that the List may be made as correct as
possible.]
FELLOWS OF THE SOCIETY. IxTii
HONORARY FELLOWS.
(Limited to Tirdre.)
Elected
1883 Carpbntsr, William Benjamin, C.B., M.D., LL.D.»
F.R.S.» CoirespoDding Member of the Institute ; 56,
Regent's park road.
1847 Chad WICK, Edwin, C.B., Corresponding Member of the
Academy of Moral and Political Sciences of the Insti-
tute of France ; Park Cottage, East Sheen.
1883 Fbankland, Edward, M.D., D.C L., Ph.D., P.R.S., Pro-
fessor of Chemistry in the Royal School of Mines ;
Corresponding Member of the French Institute ; Royal
College of Chemistry, South Kensington Museum, and
the Tews, Reigate Hill, Reigate.
1868 HooKEB, Sib Joseph Dalton, C.B., M.D., K.C.S.I.^
D.C.L., LL.D., F.R.S., Member of the Senate of the
University of London, Director of the Royal Botanic
Ghurdens, Kew ; Corresponding Member of the Academy
of Sciences of the Institute of France ; Royal Gardens,
Kew.
1868 HuxLET, Thomas Henbt, LL.D., D.C.L., F.R.S., Professor
of Natural History in the Royal School of Mines;
Secretary to the Royal Society ; Corresponding Member
of the Academies of Sciences of St. Petersburg, Berlin,
Dresden, &c. ; 4, Marlborough place, St. John's wood.
1878 Lotbock, Sib John, Bart., M.P., D.C.L., LL.D., F.R.S.,
High Elms, Bromley, Kent.
Ixviii FELLOWS OF THE SOCIETY.
Elected
1847 Owen, Sib Richa^rd, K.C.B., D.C.L., LL.D., P.R.S., late
Superintendent of the Natural History Departments in
the British Museum ; Foreign Associate of the Academy
of Sciences of the Institute of France ; Sheen Lodge,
Mortlake.
1883 Parker, William Kitchen, F.R.S., Hunterian Professor of
Comparative Anatomy in the Royal College of Sur-
geons ; Crowland, Trinity road, Upper Tooting.
1873 Stokes, George Gabriel, M.A., D.C.L., LL.D., Lucasian
Professor of Mathematics in the University of Cam-
bridge ; Secretary to the Royal Society, &c. ; Lensfield
Cottage, Cambridge.
1 868 Ttndall, John, D.C.L., LL.D., F.R.S., Professor of Natural
Philosophy in the Royal Institution; Corresponding
Member of the Academies and Societies of Sciences of
Gottingen, Haarlem, Geneva, &c. ; Royal Institution,
Albemarle street, Piccadilly.
FELLOWS OF THB SOCIITT. Ixix
FOREIGN HONORARY FELLOWS.
(Limited to Twenty.)
Elected
1878 Baccelli, Guido, M.D., Professor of Medicine at Rome.
1883 Bioelow,Henby J., M.D., Professor of Surgery at Harvard
University, and Surgeon to the Massachusetts General
Hospital.
1876 BiLLKOTH, Theodor, M.D., Professor of Surgery in the
University of Vienna ; Vienna.
1883 Chabcot, J. M., M.D., Physician to the Hdpital de la Salp^-
tri^re» and Professor at the Faculty of Medicine of
Paris ; Member of the Academy of Medicine ; Qnai
Malaquais 1 7, Paris.
1 864 DoNDSKS, Frakz Coknelivs, M.D., LL.D., Professor of Phy-
siology and Ophthalmology at the University of Utrecht.
1883 DuBois Retmond, Emil, M.D., Professor in Berlin ; N. W.
Neue Wilhelmstrasse 15, Berlin.
1866 Hankoyeb, Adolph, M.D., Professor at Copenhagen.
1873 Helmholtz, Hermann Lvdwig Ferdinakd, Professor of
Physics and Physiological Optics ; Berlin.
1873 HoFMANN, A. W., LL.D., Ph.D., Professor of Chemistry,
Berlin.
1868 K5LLIKSR, Albert, Professor of Anatomy in the University
of WUrzbarg.
1856 Langenbeck, Bbrnharp, M.D., late Professor of Surgery
in the University of Berlin.
IXX TELLOWS OF THE SOCIETY*
Elected
1868 Lareet, Hippolytb Babon, Member of the Institate of
France ; Inspector of the " Service de Sant^ Militaire/*
and Member of the '* Conseil de Sant^ des Arm^a ;*'
Commander of the Legion of Honour, &c. ; Rae de
Lille, 91, Paris.
1883 Pasteue, Louis, LL.D., Member of the Institute of France
(Academy of Sciences).
1878 ScANZONi, Friedbeich Wilhelm von, Royal Bavarian Privy
Councillor, and Professor of Medicine in the University
of Wurzburg.
1856 ViRCHOW, Rudolph, M.D., LL.D., Professor of Pathological
Anatomy in the University of Berlin ; Corresponding
Member of the Academy of Sciences of the Institute
of France; Berlin.
LIST OF EESIDENT FELLOWS
ABKANaBD AiCOOBDIira TO
DATE OF ELECTION.
1833 Sir George Burrows, Bt., M.D.,
F.R.S.
Thomas A. Barker, M.D.
1835 Richard Quain, F.R.S.
Thomas A. Nelson, M.D.
1836 Alexander Shaw.
J. George French.
1837 Thomas Biizard Curling, F.R.S.
George Busk, F.R.S.
1838 Charles Hawkins.
Henry Spencer Smith.
1839 T. Graham Balfour, M.D., F.R.8.
Fred. LeGros Clark, F.R.S.
James Dixon.
1840 Chas. J. B. Williams, M.D.,F.R.S.
Charles Hutton, M.D.
Samuel A. Lane.
Sir James Paget, Bt, F.R.S.
1841 Sir Henry A. Pitman, M.D.
Sir William Bowman, Bart.,F.R.S.
John Parkin, M.D.
Paul Jackson.
1842 Charles West, M.D.
Frederic Weber, M.D.
John Simon, C.B., F.R.S.
John Erichsen, F.R.S.
Sir Oscar M. P. Clayton.
1843 Robert Greenhalgh, M.D.
Sir Prescott G. Hewett, Bt., F.R.S.
Henry Lee.
Wm. White Cooper.
Luther Holden.
Edward Newton.
1844 Arthur Farre,M.D., F.R.S.
William Wcgg, M.D.
1844 Thomas King Chambers, M.I).
Edwin Hum by.
1845 Samuel Cartwright.
George D. Pollock.
Thomas Taylor.
Sir Edwin Saunders.
William Oliver Chalk.
Edward U. Berry.
Benjamin Ridge, M.D.
1846 John A. Bostock.
Barnard Wight Holt.
Carsten Holt house.
1847 W. H. 0. Sankey, M.D.
George Johnson," M.D., F.R.S.
1848 Edward H Sieveking, M.D.
Edward Ballard, M.D.
William Wood, M.D.
Thomas Hawksley, M.D.
Edward John Tilt, M.D.
John Clarke, M.D.
John Gregory Forbes.
1849 Hugh J. Sanderson, M.D.
C. H. F. Routh,M.D.
Edmund L. Birkett, M.D.
George T. Fincham, M.D.
Sir William W. Gull, Bt., M.D.,
F.R.S.
1850 Richard Quain, M.D., F.R.S
George Roper, M.D.
1851 Sir Wm Jenner, Bt., M.D., F.R.S.
H. Haynes Walton.
John Birkett.
John A. Kingdon.
Peter Y. GowlUnd.
John Marshall, F.K.S.
Ixxii
CHRONOLOGICAL LIST OF RESIDENT FELLOWS.
1851 John Wood, r.R.S.
Bernard £. Brodhurst.
Robert J. Spitta, M.D.
George Gaskoin.
1852 C. Bland Radcliffe, M.D.
Walter H. Walshe, M.D.
William Adams.
John Cooper Forster.
Sir Henry Thompson.
IS53 Robert Brudenell Carter.
1854 Alfred Baring Garrod, M.D., F.R 8.
Samuel O. Habershon, M.D.
Sir Thomas Spencer Wells, Bt.
1855 W. M. Graily Hewitt, M.D.
J. Burdon Sanderson, M.D., F.R.S.
J. Russell Reyttolds, M.D., F.R.S.
Walter John Bryant, M.D.
1856 Charles J. Hare, M.D.
William Bird.
Jonathan Hutchinson, F.R.S.
Timothy Holmes.
AloDzo H. Slocker, M.D.
1867 William Overend Priestley, M.D.
George Harley, M.D., F.R.S.
Henry Thompson, M D.
Hermann Weber, M.D.
George Owen Rees, M.D., F.R.S.
John Whitaker Hulke, F.R.S.
John Morgan.
Henry Cooper Rose, M.D.
Henry Walter Kiallmark.
1868 Fred. George Reed, M.D.
William Chapman Begley, M.D.
John William Ogle, M.D.
Wilson Fox, M.D., F.R.S.
John Fremlvn Streatfeild.
1859 Wm. Howship Dickinson, M.D.
William Scovell Savory, F.R,S.
Edwin Thomas Truman.
Richard Barwell.
Edward Teeart.
Septimus William Sibley.
William E. Stewart.
1860 Sir Andrew Clark, Bt., M.D.,F.R.S.
Sigismund Sutro, M.D.
William Ogle, M.D.
Thomas Bryant.
John Couper.
Henry Howard Hayward.
1861 Robert Barnes, M.D.
William Spencer Watson.
William Henry Holman.
1862 James Andrew, M.D.
Lionel Smith Beale, M.B., F.R.S.
1862 Thomas H. Tuke, M.D.
Edmund Symes Thompson, M.D.
Reginald Edward Thompson, M.D.
William Henry Brace, M.D.
George Cowelf.
Robert Farquharson, M.D., M.P.
M. Berkeley Hill.
1863 OcUyius Sturges, M.D.
John Langdon H. Down, M.D.
Samuel Wilks, M.D-. F.R.S.
Samuel Fen wick, M.D.
Julius Althaus, M.D.
Sydney Rinper, M.D., F.R.S.
Thomas Smith.
Arthur B. R. Myers.
Arthur £. Durham.
William Sedgwick.
1864 George Buchanan, M.D., F.R.S.
Charles Derby Waite, M.B.
John Harley M.D.
Walter John Coulson.
Thomas William Nunn.
Francis Mason.
Jos. Gillman Barratt, M.D.
1865 Charles Robert Drysdale, M D.
James Edward Pollock, M.D.
William Cholmeley, M.D.
Reginald Southey, M.D.
George Fielding Blandford, M.D.
Dyce Duckworth, M.D.
Frederick W. Payy. M.D., F.R.S.
William Morrant Baker.
John Langton.
Frederick James Gant.
Alfred WUlett.
Bowater John Vernon.
Alfred Cooper.
Christopher Heath.
Henry Wotton.
1866 Thomas Fitzpatrick, M.D.
Samuel Jones Gee, M.D.
Charles Theodore Williams, M.D.
Hey wood Smith, M.D.
John Crockett Fish, M.D.
William Selby Church, M.D.
Edward John Waring, M.D.
1867 William Henry Day. M.D.
Achille Yintras, M.D.
Richard Doudas Powell, M.D.
F. Howard Marsh.
Henry Power.
Sir William MacCormac.
Thomas Pickering Pick.
John Astley Bloxam.
CHRONOLOGICAL LIST OP RESIDENT FELLOWS.
Ixxiii
1867 Charles Arthur Aikin.
Samuel HUl, M.D.
1868 H. Charlton Bastian, M.D., F.R.8.
William Henry Broadbent, M.D.
Thomaa Buzsard, M.D.
John Cavafy, M.D.
Walter Batler Gheadle, M.D.
John Cockle, MJO.
Sir ThoB. Crawford, K.C.B., M.D.
T. Heniy Qreen, M J).
William Rhys Williams, M.D.
Walter Moxon, M.D.
William Chapman Gxigg, ILD.
John Croft.
Geoijge Eastes.
William Heniy Freeman.
1869 Joseph Frank Payne, M.D.
Arthor E. Sansom, M.D.
John Wickham Legg, M.D.
Charles Elam, M.D.
Thomas Laurence Bead.
1870 Alfred Meadows, M.D.
William Wadham, M.D.
J. Wairington Haward.
Edgoombe Venninff.
Clement Godson, M.D.
1871 William Cayley, M.D.
Charles Henry Ralfe, M.D.
Arthur Julius Pollock, M.D.
Thomas L. Bninton, M.D., F.R.8
Henry Gawen Sutton, M.D.
J. Hughlinss Jackson, M.D.,F.R.S.
Henry Sutherland, M.D.
George Vivian Poors, M.D.
Walter Bivington.
Marcus Beck.
Edward Bellamy.
William F. Butt.
Benjamin Duke.
1878 Gilbart Smith, M.D.
Thomas B. Christie, M.D.
George B. Brodie, M.D.
John Williams, M.D.
Sir J. Fajrer, M.D., F.R.S.
Charles 8. Tomes, B.A^ F.R.S.
William Bartlett Dalby.
1873 William Miller Ord, M.D.
Frederick Taylor, M.D.
Korman Moore, M.D.
John Cumow, M.D.
William R. Gowers, M.D.
Sir William Guyer Hunter, M.D.
Charles Creighton, M.D.
Jeremiah McCarthy.
VOL. LXVIII.
1873 Wm. Johnson Smith.
Robert William Parker.
Alex. O. McEellar.
Henry T. Butlin.
Charles Hi^ns.
William J. Walsham.
Edward Miker.
1874 Alfred Lewis Galabin, M.D.
George Thin, M.D.
Alfred B. Duffin, M.D.
James H. AveHng, M.D.
John M. Bruce, M.D.
Henry Morris.
William Laidlaw Purees.
William Harrison Cripps.
Heniy G. Howse.
Herbert William Page.
Frederic Durham.
John J. Merriman.
1875 Thomas T. Whipham, M.B.
Francis Charlewood Turner, M.D
Robert Hunter Semple, M.D.
Thomas Crawford Hayes, M.D.
Charles Henry Carter, M.D
Fletcher Beach, M.B.
Samuel Osbom.
Waren Tay.
Edmund J. Spitta.
1876 Thomas Barlow, M.D.
John C. Bucknill, M.D., F.H.S.
Wm. Lewis Dudley, M.D.
Albert J. Venn, M.D.
John Knowsley Thornton.
Charles Macnamara.
JohnN. C. DaWes-Colley.
1877 Felix Semon, M.D.
Sidney Coupland, M.D.
Francis Warner, M.D.
WiUiam Ewart, M.D.
Alfred Pearoe Gould.
Rickman J. Godlee.
Alban H. G. Doran.
George Ernest Herman, M.B.
Samuel West, M.D.
John Abercrombie, M.D.
J. Matthews Duncan, M.D., F.R.S.
Henry de Fonmartin, M.D.
George Allan Heron, M.D
Joseph A. Ormerod, M.D.
P. Henry Pye-Smith, M.D.
Edward Nettleship.
William Henry Bennett.
William T. Whitmore.
1878 Jas. Crichton Browne, M.D.
/
Ixxiy
CHRONOLOGICAL LIST OF RB8IDBNT FELLOWS.
1878 Fred. T. Roberts, M.D.
Sir Joseph Lister, Bart., F.R.S.
Clinton T. Dent.
John H. Morgan.
Walter Pye.
Gerald F. Tec, M.D.
Donald W. Charles Hood, M.B.
Henry Gerris, M.D.
Herbert Watney, M.D.
Richard Davy.
Hubert Foveaox Weiss.
Henry Thornton Wharton.
1879 Alfred Sangster, M.B.
Edward Woakes, M.D.
Armand de Watteyille, M.D.
Malcolm A. Morris.
A. E. Cumberbatch.
Edmund Owen.
Arthur E. J. Barker.
Frederick Treves.
Horatio Donkin, M.B.
Thomas John Maelagan, M.D.
David White Finlay, M.D.
Andrew Clark.
8. Hamilton Gartwright.
John H. Waters, M.D.
Francb Henry Champneys, M.B.
William Watson Cheyne.
William Monk, M.D.
George Henry Savage, M.D.
H. U. Glutton, M JL.
Frederic S. Eve.
E. Noble Smith.
William Henry AUchin, M.B
F. G. Dawtrey Drewitt, M.D.
1880 Robert Alex. Gibbons, M.D.
David Fenicr, M.D., P.R.S.
Vincent Dormer Harris, M.D.
Jas. John MacWhirterDunbar,M.B.
James William Browne, M.B.
William Appleton Meredith, M.B.
Alexander Hughes Bennett, M.D.
Malcolm Maodonald McHardy.
A. Boyoe Barrow.
William Murrell, M.D.
Bernard O'Connor, A3., M.D.
Leslie Ogiivie, M.B.
George Lockwood Laycock, M.B.
George Ogiivie, M.B.
Charles Inward Beevor, M.D.
Thomas Colcott Fox, M.B.
George Henry Makins.
1881 Francis de Hlavilland Hall, M.D.
Robert Wluurry, M.D.
1881 Cecil Yates Biss, M.D.
Richard Clement Lucas.
Stephen Mackenae, M D.
James Anderson, M.D..
William Hale White, M.D.
Eustace Smith, M.D.
William Sinclair Thomson, M.D.
Percy Kidd, M.D.
Oswald A. Browne, MA..
Audley Cecil Buller.
W. Bruce Clarke, M.B.
Dawson Williams, M.D.
George Lindsay Johnson, M.A.,
M.D.
Henry Edward Juier.
Jonathan F. C. H. Maoready.
C. B. Lockwood.
1882 PhiUp J. Hensley, M.D.
Ernest Clarke.
John Barclay Scriven.
George Robertson Turner.
Howard Henry Tooth, M.B.
Herbert Isambard Owen, M.D.
Charles R. B. KeeUey.
Joseph Mills.
A. T. Myers, M.D.
Anthony A. Bowlby.
Amand J. McC. Routh, M.D.
Seymour J. Sharkey, M.B.
William Lan^.
Henry Radcuffe Oroeker, M.D.
William Edward Steavenson, M.D.
D. Astley Gresswell, M.B.
1883 Edwin Clifford Beale, M.A., M.B.
James Kingston Fowler, M.D.
James Frederic Goodhart, M.D.
John Charles Galton, M.A.
Walter Hamilton Aoland Jaoobson.
Edward Joshua Edwardes, M.D.
Walter H. H. Jessop, M.B.
Walter Edmunds, M.C.
Victor A. Horsley.
Dudley WUmot Buxton, M.D.
Charles Douglas F. Phillips, M.D.
Hutchinson Roves Bell.
Aogel Mone^ M.D.
John James Pringle, M.B.
Henry Roxburgh Fuller, M3.
Wilmot Parker Herringham, M.B.
Augustus Waller,* M.D.
William Pasteur, M.D.
Edward Albert Sohafer, F.R.S.
John Bland Sutton.
William Rose, M.B.
CHRONOLOGICAL LIST OP RESIDENT FELLOWS.
Ixxy
1883 Storer Bennett.
Henry Mandsley, M.B.
Robert Marcos Onnn, M.B.
James Dixon Bradshaw, M.B.
1884 George Newton Pitt, M.D.
Gbarles Stonham.
Stanley Boyd, M.B.
William Arbnthnot Lane, M.S.
Dennis Dallaway.
Thomas Whitehead Reid.
Arthur Marmadnke Sheild, M.B.
Frederic Bowreman Jessett.
Sidney Harris Cox Martin, M.B.
Wayland Charles Chaffey, M.B.
George Lawson.
Heneage Gibbes, M.D.
Thomas Wakley, Jon.
Robert James Lee, M.D.
F. Swinford Edwards.
Herbert Tyrrell Griffiths, M.D.
James Johnston, M.D.
Arthur Oakes, M.D.
Edward Stewart, M.D.
William A. Duncan, M.D.
1884 Charles Chinoer Fuller.
LoTell Draffe.
Jean Samuel Keser, M.D.
Charles E^rton Jenuings, M.S.
George Richard Turner fhiliips.
Bilton Pollard.
1885 Alexander Haig, M.B.
Wm. Dobinson Halliburton, M.D.
Theodore Dyke Adand, M.D^
Kenneth William Millican.
Frederick Walker Mott, M.B.
William Maunsell Collins, M.D.
James Berry.
John CahUl.
Francis Henry Hawkins, M.B.
John Poland.
James Greig Smith.
John Maokem, M.D.
George Gulliver, M.B.
Heinrich Port, M.D.
Edward Emanuel Klein, M.D.,
P.RS.
R. Norris Wolfenden, M.D.
A. C. BuUer-Smythe.
CONTENTS.
PAGB
. List of Officers and Coimcil . . . ▼
List of Presidents of the Society . . . . vi
Referees of Papers . . . yii
Trustees of tlie Society ..... viii
Trustees of the Marshall Hall Memorial Fond . viii
Libraiy Committee ..... viii
List of Fellows . . . . ix
List of Honorary Fellows .... Ixvii
List of Foreign Honorary Fellows . . Iziz
List of Resident Fellows, arranged according to Date of Election bod
List of Plates ..... Ixxxi
Woodcnts . . > . Ixzxii
Adyertisement ..... Izzziii
Regulations relative to Proceedings . Izxziy
I. Address of Geo&ob Johnson, M.D., F.R.S., Presi-
dent, at the Annual Meeting, March 2nd, 1885 1
n. Oase of Cirsoid Aneurism of the Dorsum of the Foot,
with Remarks on the Disease. By Walter
Edmunds, M.C. .31
III. On Expiratory Cervical Emphysema, that is, Emphy-
sema of the Neck occurring during Labour and
during violent Expiratory Efforts. An Experi-
mental Inquiry. By Fbanois Henst OHAJfPNsrB,
MA., M.B. Oxon., F.R.C.P., Assistant Lecturer on
Obstetrics, &c., and Assistant Obstetric Physician
to St. Gorge's Hospital • .37
VOL. LXVIII. g
Ixxviil CONTENTS.
PAOl
IV. A Saccessful Case of Lumbar Nephrectomy for Renal
Calculus. By Hbnrt Mobbis, M.A., RB-CS.,
Surgeon to, and Lecturer on Surgery at, the Mid-
dlesex Hospital . . . 69
y. On the Distribution of the " Tubercle Bacilli " in the
Lesions of Phthisis. By Pbbct Kidd, M.A.,
M.D. Oxon., Assistant Physician to the Hospital
for Consumption and Diseases of the Chest,
Brompton .87
YI. Cases in which Perforation of the Mastoid Cells is
necessary. By W. B. Dalbt, F.B.C.S., M.B. Cantab.,
Aural Surgeon to St. George's Hospital . 115 *
Vn. Case of Double Simultaneous Distal Ligature for
Innominate Aneurysm. By Bichabd Babwell,
F.B.C.S., Senior Surgeon, Charing Cross Hospital . 123
YIII. Case of Displacement and Fracture of the Axis. Life
prolonged for ten years. By D. LowsoN, M.D.
(Communicated by Sir Pbescott Hbwett, Bart.,
P.B.S.) .135
IX. Obseryations on the Badical Cure of Club-Foot, and
Exhibition of Cases which have been Operated on.
By Bichabd Dayt, M.B., F.B.S.E., F.B.C.S.,
Surgeon in Charge of the Orthopedic Department,
Westminster Hospital . 139
X. An Account of Two Families, several Members of
which are Ataxic. By J. A. Obmebod, M.A.,
M.D. Oxon., F.B.C.P., Assistant Physician to the
National Hospital for the Paralysed and Epileptic,
and to the City of London Hospital for Diseases of
the Chest, Victoria Park ; Assistant Medical Tutor
to St. Bartholomew's Hospital . . .147
XI. Fatal HsBmoptysis : the Statistics of the last Fifteen
Years of the Chest Hospital, Victoria Park ; with
Bemarks upon Profuse Non-fatal Haamoptysis. By
Samuel West, M.D., Physician to the Chest Hos-
pital, Victoria Park, and to the Boyal Free Hos-
pital ; Medical Tutor, St. Bai-tholomew's Hospital . 159
CONTJENTS. Ixxix
PAOB
XII. Acute Peritonitis treated by Abdominal Section. By
Fbedbbigk Tbbybs, F.B.O.S., Surgeon to, and
Lecturer on Anatomy at, the London Hospital . 175
XIII. A Case of Abdominal Section for Acute Circumscribed
Peritonitis. Becovery. By Howabd Mabsh,
F.B.O.S., Senior Assistant Surgeon and Lecturer
on Anatomy at St. Bartholomew's Hospital ; Senior
Surgeon to the Hospital for Sick Children . 185
XIY. Aneurism of Abdominal Aorta. Distal Compression
— Cure of the Aneurism — Death from Gangrene of
the Jejunum on Eleventh Day — Necropsy — Be-
marks. By John B. Ltjnn, F.B.C.S. Ed., and
F. L. Bbnham, M.D., St. Marylebone Infirmary,
Netting Hill, W. (Communicated by Mr. B. W.
Pabkbb) .191
XV. On a Case of Aneurism of the Abdominal Aorta,
which caused Gangrene of the Bight Lower
Extremity, partly by Embolism, and partly by
Pressure of the Inferior Yena Cava. By Hbnbt
MoBBis, M.A., M.B., F.B.C.S., Surgeon to, and
Lecturer on Surgery at, the Middlesex Hospital . 199
XYI. Three Cases (Progressive Muscular Atrophy and In-
fantile Paralysis) illustrating the Localisation of
Motor Centres in the Brachial Enlargement of the
Spinal Cord. By C. E. Bbbyob, M.D., Assistant
Physician to the National Hospital for the Paralysed
and Epileptic .... 205
XVII. On the Pathological Histology of the Semilunar and
Superior Cervical Sympathetic Ganglia. By W.
Halb Whitb, M J)., Assistant Physician to Guy's
Hospital . .221
XVIII. Notes on So-called Non-Ovarian Dermoid Abdominal
Tumours. By Alban Dobak, Assistant Surgeon
to the Samaritan Free Hospital . 235
XIX. Case of Cerebral Tumour. By A. Huohbs Bbvnbtt,
M.D. The Surgical Treatment by Bickman J.
GoDLBB, M.S., F.B.C.S. .248
IXXX CONTENTS.
PAGB
XX. The Experimental Production of CHorea and other
Reaaltfl of Capillary EmboliBm of the Brain and
Ooi-d. By Angel Monet, M.D., M.R.O.P. . 277
XXI. Fatty Tomours. By J. Bland Sutton, F.B.O.S.,
Lecturer on Gomparative Anatomy and Senior
Demonstrator of Anatomy, Middlesex Hospital . 293
XXII. On a Case of very .Large Lympho-Sarcomatous
Tumour of the Tongue. By Jonathan Hutchin-
son, F.B.S., Emeritus Professor of Surgery in the
London Hospital College . .311
Index . .323
LIST OP PLATES.
PAGE
1 and II. Tubercle Bacilli in the Leieions of Phthisis. (Pebct
EiDD, M.D.) Pigs. 1 and 2. Acute miliary tu-
berculosis (Case 35). Pig. 3. Phthisis (Case 16).
Fig. 4. Phthisis with intestinal obstruction
(Case 70) .114
III. Pigs. 1—7. On the Pathological Histology of the
Semilunar and Superior Cerrical Sympathetic
Ganglia. (W. Hale White, M.D.) . 234
lY. Fatty Tumours. (J. Bland Sutton.) Pig. 1. Lower
limbs of foBtuB described in the paper, dissected to
show the degeneration of tissues into fat. Pig. 2.
Left oyiduct of a pigeon. Pig. 3. Biceps muscle
from an old woman. Fig. 4. A clavicle with a
fiitty tumour attached . 309
y. On a Case of very Large Lympho-Sarcomatous
Tumour of the Tongue. (Jonathan Hutchinson,
P.E.S.) . . . .322
VI. Ditto. Case of Congenital Unilateral Hypertrophy
of Tongue . . . .322
yn. Ditto. Microscopical Sections from Tongue figured
in Plate y . .322
WOODCTTTS.
PA08
1. Lumbar Nephrectomy for Renal Calculus. (Hsnkt
MoBBis.) Calculus as seen in ntu in the kidney . 73
2. Cases in which Perforation of the Mastoid Cells is neces-
sary. (W. B. Dalby.) Drill for performing the opera-
tion ...... 116
8. Observations on the Radical Cure of Club-Foot.
(RiohabdDayt.) Figure of splint . . 142
4 and 5. Aneurism of Abdominal Aorta. (J. R. Lunn and
F. L. Benham, M.D.) . .194, 195
6. Case of Cerebral Tumour. (A. HvaHBS Bbnnbtt and
B. J. GoDLBE.) External surface of scalp . 248
7. Ditto. Structure of Glioma, from section by Dr. Hebb.
About 400 diam. . . . .251
8. Ditto. Diagram showing position and extent of cerebral
cortex destroyed, as seen from without . . 262
9. Ditto. Diagram of transverse section through ascending
parietal convolution, showing destruction of cerebral
cortex and corona radiata . . 263
10. On Fatty Tumours. (J. Blaitb Suttok.) Organs of
reproduction of Toad and Frog . . . 302
ADVERTISEMENT.
The Council of the Royal Medical and Chirurgical Society
deems it proper to state that the Society does not hold
itself in any way responsible for the statements^ reasonings^
or opinions set forth in the various papers which^ on grounds
of general merits are thought worthy of being published in
its ' Transactions/
Regulations relative to the publication of the ' Proceedings
of the Society/
That, as a general rule, the ' Proceedings ' will be issaed every two
months, subject to variations dependent on the extent of matter
to be printed.
That a Oopy of the ' Proceedings ' will be sent, postage free, to every
Fellow of the Society resident in the United Eangdom.
That the 'Proceedings of the Society' may be obtained by non-
members at the Society's House, 53, Bemers Street, on pre-
payment of an annual subscription of five shillings, which may
be transmitted either by post-office order or in postage-stamps ;
—this will include the expense of conveyance by post to any
part of the United Kingdom ; to other places they will be sent,
carriage free, through a bookseller, or by post, the receiver
paying the foreign charges.
That a notice of every paper will appear in the ' Proceedings.' Authors
will be at liberty, on sending their communications, to intimate
to the Secretary whether they wish them to appear in the ' Pro-
ceedings ' only, or in the ' Proceeding^ ' and ' Transactions ;' and
in all cases they will be expected to furnish an Abstract of the
communication.
The Abstracts of the papers read will be furnished to the Journals
as heretofore.
ADDEESS
07
GEOEGE JOHNSON, M.D., F.R.S.,
PBB8IDBVT,
AT THB
ANNUAL MEETING, MAECH 2m, 1886.
Gnn^LBKiN^ — If I were to estimate the experience of
former Presidents of the Society by a comparison with
my own^ I should conclude that they mast have found the
preparation for the annual meeting the most arduous and
anxious work of the official year. For surely the annual
address^ wbich^ in accordance with custom and precedent^
is mainly composed of obituary notices of recently deceased
Fellows, cannot have been found an easy task by any,
even the ablest and most eloquent, of the many eminent
men who have preceded me in this chair.
One of the most distinguished of our foreign Honorary
Fellows, the late Dr. Samuel D. Gross, of Philadelphia, in
the course of an eloquent and affectionate memoir of his
friend and fellow-countryman. Dr. Valentine Mott, refers
to the difficulties which beset the path of a contemporary
biographer in the following terms : — " It is confessedly
difficult under any circumstances to write the biography
of a contemporary. For, on the one hand, there is great
danger of indulgence in fulsome eulogy, and, on the
VOL. LXTIII. 1
2 PSS8IDBNT^8 ADDBB88.
other, of being blinded by jealousy and prejudice. In
either event injustice is apt to be done alike to the subject
and to the truth of history/' Whether I have succeeded
in my endeavour to avoid these two opposite but equally
faulty extremes I must leave to the judgment of others.
As on previous occasions it has been a source of satis-
faction to me to observe that obituary notices of intimate
friends which I have myself contributed to one or other
of the medical journals have been utilised by former
Presidents of the Society^ so now, in addition to such
personal knowledge as I possess of our deceased Fellows
and their published writings, I have to acknowledge my
indebtedness to the obituaries which have appeared in the
public journals. In some instances, too, I have been much
assisted by information which has been kindly afforded
me by relatives or intimate friends of the deceased.
Since our last annual meeting the names of fourteen
of our Fellows have been erased from our muster-roll by
the hand of death. Of these six were resident Fellows,
namely. Dr. Barclay, Dr. Fairlie Clarke, Mr. C»sar Haw-
kins, Sir Erasmus Wilson, Dr. David Alexander King,
and Dr. Baxter. Six were non-resident Fellows, namely,
Dr. Samuel Best Denton, Dr. Lashmar, Mr. John Arnold,
Mr. James Stock Daniel, Dr. William GiUett Cory, and
Mr. William Collins Worthington. One Honorary Fellow,
Dr. Allen Thomson, and one Foreign Honorary Fellow,
Dr. Samuel D. Gross, complete the list of our losses.
It may be stated in general terms that, while most of
those whose deaths we have to deplore had attained to a
good old age and, having accomplished their life's work,
had retired from the active duties of their profession, in
at least three instances men whose past performances had
led to a well-founded hope of an honorable and brilliant
future, have been cut off in mid-career and at a compa-
ratively early age. I refer particularly to Dr. Fairlie
Clarke, Dr. Baxter, and Dr. King.
I propose now to speak of each of our deceased Fellows
in the order in which their deaths occurred.
i'BBSIDBNT's ADDRESS. 3
JDr. Samuel Best Denton wajs bom on the 3rd May,
1797, and having received his early education at Hull he
entered at the then united Guy's and St. Thomas's Hos-
pitals. He became a Licentiate of the Society of Apothe-
caries in 1820, a Member of the College of Surgeons in
1 843, and M.D. of Aberdeen in 1852. He was elected a Fel-
low of this Society in 1846. After practising at Homsey,
near Hull, for upwards of sixty years, he died March 9th,
1884, having nearly completed his eighty-sixth year.
His partner, Mr. James Thomas Jones, in a private note
with which I have been favoured, states that from his
youth Dr. Denton was an ardent student not only of sub-
jects strictly professional, but also of astronomy, botany,
and other branches of natural history. He had the gift of
forming a rapid and generally a correct diagnosis, and in
his treatment of disease he displayed much care, skill,
and foresight. He was an admirable specimen of the old
English gentleman, never displaying this character to
greater advantage than when in the homes of the poor.
He was a man of the purest truth and integrity, and his
memory is deeply loved and revered. A local paper says
of him : — '^ His old friend. Sir James Alderson, often
advised him to migrate to the metropolis as a more suit-
able field for his talents, but being of a quiet, retiring
nature he preferred to remain in this somewhat secluded
locality. Every respect was shown by the townspeople
during the time of his funeral, all the shops being closed
and business suspended, while the streets and the church
were thronged with sorrowing patients and friends."
Dr. Denton published in the 'Provincial Medical Journal'
a paper on '' Hydrophobia and Chloroform," and in the
' Lancet ' one on '^ Enlargement of the Prostate Gland,"
and another on " Tubercular Disease of the Periosteum."
Dr. Allen Thomson,^ who was elected an Honorary Pel-
low in 1883, was bom in Edinburgh on the 2nd April,
1 For the main facts of Dr. Allen Thomson's career I am indebted to an
interesting memoir by Dr. McEendrick, read before the Philosophical Society of
Glasgow, April 80th, 1884»and to an obituary in the * Lancet,' April 12th, 1884.
4 pbebident'b addbssb.
1809. He was educated at the High School and the
Uniyersity of his native city. As a student his merits
were recognised, as those of his father had been before
him, in his election to the Presidency of the Boyal Medical
Society. In 1830 he took the degree of Doctor of Medi-
cine in the University of Edinburgh, when the bent of
his mind towards embryology was shown by his Gradua-
tion Thesis, " On the Development of the Heart and Blood-
vessels in Vertebrate Animals.^^ After taking his degree
he went for a fifteen months' course of study to Paris,
where he attended the various hospitals, and amongst
other lectures those of Cuvier.
In 1881 he obtained the Fellowship of the Boyal Col-
lege of Surgeons of Edinburgh, and became associated
with the late Dr. William Sharpey in a course of systematic
lectures on Anatomy and Physiology in the Extra- Acade-
mical School. This association continued from 1831 to
1836, when Dr. Sharpey was appointed Professor of Phy-
siology in University College, London. The next three
years, from 1836 to 1839, his health having somewhat
failed from overwork. Dr. Allen Thomson spent on the
Continent with the noble family of Bedford.
In 1839 he was appointed Professor of Anatomy in the
Marischal College and University of Aberdeen, an appoint-
ment which he resigned in 1841 to become again a teacher
of anatomy in the Extramural School in Edinburgh. In
that year Professor Alison resigned the Chair of Institutes
of Medicine (Physiology) in the University of Edinburgh
and in 1842 Dr. Allen Thomson was appointed his suc-
cessor. He held the Edinburgh professorship for six
years, when he was appointed by the Crown in 1848 to
succeed Dr. James JeSray in the Chair of Anatomy in
the University of Glasgow, a professorship which he held
with great distinction for twenty-nine years, resigning it
in 1877, when he was succeeded by its present distin-
guished occupant, Dr Cleland, who in former years had
been one of his demonstrators. During these thirty-five
years he had the unique experience of being a professor
PBBBIDBNT^S ADDBBSS. 5
in three out of the four Scotch nniversities^ and in all of
them he worked with an indefatigable industry^ not merely
in connection with the immediate duties of his chair,
but as a contributor to scientific literature, and at the end
of his days he had become generally known throughout
the scientific world as one of the most careful, judicious,
accurate, and learned investigators and teachers of his
favourite subjects.
It was in the field of embryology that he won his
laurels, and few if any men have done so much to render
this department of biological science familiar to British
naturalists. He wrote largely for the ' Cyclopasdia of
Anatomy and Physiology,' edited by the late Dr. Todd.
The articles on " Circulation," "Generation,'^ and "Ovum,''
are his, and to the past and current editions of the * Ency-
clopsedia Britannica ' he contributed the articles on these
and other kindred subjects. He also wrote on physio-
logical optics, more especially on the mechanism by
which accommodation for vision at different distances is
effected. His name has long been associated with Quain's
' System of Human Anatomy,' as editor especially of the
descriptive parts of the seventh and eighth editions. In
the seventh edition he was associated with Professors
Sharpey and Cleland, in the eighth with Professors
Sharpey and Schafer, and in the ninth and last edition
with Professors Schafer and Thane, of University College.
He brought out a second edition of his father's * Life of
CuUen.' To the Boyal Societies of London and Edin-
burgh, and to British and Foreign journals, he contributed
numerous special papers and articles. To the Boyal
Society alone he contributed about twenty papers.
During his distinguished career he received many scien-
tific honours. He was elected a Fellow of the Royal
Society of Edinburgh in 1838, and of the Royal Society
of London in 1848. For eighteen years, from 1859 to
1877, he was a Member of the Medical Council for the
Universities of Glasgow and St. Andrew's jointly. In
1872 he was President of the Biological Section of the
6 pbebident's address.
British Association at the meeting in Edinburgh^ and
in 1876, he had the honour of being elected President of
the Association. At the meeting at Plymouth, in 1877,
his address on his favourite topic, '^ The Development of
the Forms of Natural Life,*' was a masterly history of the
gradual acceptance of the doctrines connected with the
name of Darwin, whose important generalisations his open
and receptive mind had long before accepted.
In 1871 he received from the University of Edinburgh
the degree of LL.D., and in 1877 the Glasgow University
conferred on him the same degree. In 1882 he received
the degree of D.C.L. from the University of Oxford.
As a citizen of Glasgow Dr. Allen Thomson took a
prominent part in various great public undertakings,
especially as Chairman of the Removal and Buildings
Committee of the University of Glasgow from 1863 to
1874, which led to the erection of the grand university
buildings on Gilmore Hill, and the carrying out of this
great scheme is said to have been largely due to his energy
and tact. He also took an active part in the erection of the
Western Infirmary of Glasgow. This noble institution is
a model hospital, and Dr. Allen Thomson, as a Member of
the Board of the Directors, did much to make it what
it is.
On his retirement from the University of Glasgow in
1877 his portrait, painted by the President of the Scottish
Academy of Arts, the late Sir Daniel Macnee, was
presented by his friends and admirers to the University,
and it now hangs in the Hunterian Museum of that Uni-
versity.
He was appointed a Trustee of the Hunterian Museum
of the Broyal College of Surgeons in succession to the late
Dr. Sharpey.
Dr. Thomson was in his usual good health until within
about four months of his death. About the middle of
December, 1888, he began to complain of his left eye, which
was found to have become glaucomatous, and on December
] 5th Mr. John Couper, with the concurrence of Sir Wm.
pribidbnt's addbbss. 7
Bowman^ performed iridectomy. The operation was suc-
cessfal in relieving pain^ restoring normal tension^ and
maintaining vision. Abont a fortnight later he began to
suffer from lancinating pains^ as he said^ in the course of the
left temporo-anricnlar nerve. Daring the last few weeks
of his life I had the melancholy privilege of attending him
with Mr. Coaper and Mr. Aikin. The next serious sym-
ptom was sudden loss of vision in the right eye. This
was seen to be associated with plugging of the main branch
of the arteria centralis retinas. As there was no evidence
of cardiac valvular disease it is probable that the blood
coagulation had occurred in a vessel altered by senile
degeneration of its walls^ and the neurotic symptoms which
followed were probably due to a similar obstruction in
other vessels. There was a temporary and partial para-
lysis of the left hand ; then the muscles on the right side
of the face were affected ; next the vagus became impli-
cated^ and there followed almost incessant hiccough^ dys*
phagia^ and lastly dyspnoea, which proved fatal on March
22nd, 1884.
The remains, which were taken to Scotland for burial,
were followed by a number of distinguished scientific
friends to Euston Station, where they were met by many
others who had assembled to show their respect and esteem
for the deceased.
Dr. Allen Thomson will long be held in affectionate
remembrance not only for the extent and variety of his
scientific attainments, but for his wisdom in council, the
genuine kindly courtesy which gave an indescribable
charm to his manner, and the enduring warmth of his
friendship.
Dr. Oharles Lashmar, of Croydon, was elected a Fellow
of this Society in 1841, his proposal paper having been
signed by Thomas Addison, Bichard Bright, and Bransby
Cooper. He obtained the license of the Apothecaries^
Company in 1827, and tbe M.D. of Erlangen in 1841.
Having practised at Croydon for more than forty-five
years he retired some years since to Brighton, where he
8 president's addbbss.
died on March 25th^ 1884^ at the age of eighty. I am
not aware that Dr. Lashmar made any contribution to the
literature of the profession.
Dr, Andrew Whyte Barclay ^ was descended from an old
Scotch family^ his father having been a naval officer during
the earlier years of the present century. Bom at Desart
in Fifeshire in 1817, he received his preliminary education
at the Edinburgh High School, commenced the study of
medicine in the University of Edinburgh in 1834, and
graduated M.D. in 1839. He afterwards studied in Berlin,
and subsequently, with two of his brothers, visited Italy
and France. He then went to Cambridge and entered
Cains College, where he obtained several scholarships.
In 1847 he graduated M.B. at Cambridge, and soon
after placed his name on the books of St. George's Hospital,
where he was appointed Medical Begistrar. His reports
of cases during his tenure of that office are said to be of
great value. In 1851 he was elected a Fellow of the
Boyal College of Physicians, and in the following year he
graduated M.D. at Cambridge. In 1857 he was appointed
Assistant Physician to St. Greorge's, and in 1862 he suc-
ceeded Dr. Bence Jones as full physician, which office he
resigned in 1882 in accordance with the laws of the
hospital.
Dr. Barclay held in succession two important lecture-
ships, — that on Materia Medica and that on the Principles
and Practice of Physic. As Physician to the hospital
and as a teacher his work was conscientiously and faith-
fully performed. As Treasurer to the Medical School
during a number of years he was brooght into close contact
with the pupils and was by them much esteemed.
At the College of Physicians, where his business habits
were highly appreciated, he did good work as Councillor,
Examiner, and Censor, and a few months before his death
he was chosen for the important office of Treasurer of the
College. In 1881 he gave the Harveian Oration, and I
1 'LanceV Hay 10th, 1S84, and 'Medical Times and Gaz./ May 17tb,
1884.
PBBSIDBNt's ADDBB88. 9
scarcely need remind yon tliat in the same year he was
elected President of this Society.
Dr. Barclay was the author of several works : ' The
Progress of Sanitary Measures and Preventive Medicine/
' A Manual of Medical Diagnosis^' a third edition of which
was published in 1870 ; ' Grout and Bheumatism in Bela-
tion to Disease of the Heart/ His small volume on
' Medical Errors * involved him in some controversy, since
not all of his contemporaries to whom he imputed error
admitted the justice of the imputation. Our * Transac-
tions ' contain two valuable papers on '' Statistics of
Valvular Disease of the Heart *' (vols, xxxi and xxxv) ;
and the articles on '' Delirium Tremens '^ and on '^ Croup
and Diphtheria " in ' Holmes's System of Surgery/ 1860,
were from Dr. Barclay's pen. For a number of years Dr.
Barclay was Medical Officer of Health for the parish of
Chelsea, and during the latter part of his life his attention
was chiefly given to sanitary subjects. His death occurred
after so short an illness as to give a painful shock to his
numerous friends. I saw him apparently in his usual
good health at a meeting of the College of Physicians on
Thursday the 24th April ; he was taken ill that evening
and died on the morning of the 28th, the immediate cause
of death being cardiac failure consequent on intestinal
irritation.
Dr. Barclay was highly esteemed for his admirable social
qualities^ and it has been said of him that '^ those who
knew him best loved him most.'' He is also deserving
of respect for the courage with which he would contend
for a doctrine which he knew to be unpopular but which
he conscientiously believed to be true. In illustration of
this I may refer to an elaborate paper of his published
thirteen years ago (' Lancet,' March 2nd, 1872), in which
he contends, in opposition to the high authorities whom he
quotes, that the so-called pre-systolic or, as Dr. Qairdner
terms it, the auricular-systolic murmur at the apex of the
heart is not a result of the blood passing into the ventricle
through a constricted or roughened mitral orifice, but that it
10 pbbbidbnt's address.
is a regurgitant murmur the result of mitral incompetence^
and that it is systolic in rhythm. In this contention I
believe that Dr. Barclay was in error, but he nevertheless
deserves credit for having the courage of his opinion.^
In contrast with the courage thus displayed by Dr.
Barclay, I venture to remark in passing that there are
two forms or phases of intellectual cowardice whose ten-
dency is to retard the progress of medical as of other
kinds of knowledge. The one is a dread of, and there-
fore a shrinking from, the advocacy of a doctrine believed
to be true, but which is not in accordance with the
opinion of the majority ; the other is an unwillingness to
investigate facts and to weigh arguments, the tendency of
which might be to prove that doctrines to which we have
publicly professed our assent, may prove to be erroneous,
and therefore demand from us an equally public acknow-
ledgment of our error. As an example of one who to the
very end of his prolonged life displayed in a pre-eminent
degree the moral courage which is the direct opposite
of the cowardice here alluded to, I need only mention the
revered name of the late Sir Thomas Watson.
Mr. John Arnold was elected a Fellow of this Society
in 1878. He was the son of a planter in British Ghiiana.
He was educated at Stonyhurst College, and matriculated
at the University of London in 1868. He was origi-
nally intended for the army, but having failed to pass
the entrance examination at Woolwich, he entered and
went through the usual course at St. Bartholomew's.
^ That a diastolic marmar, accompanied by a thrill leading np to and ter-
minating in the impulse of the yentricle, is a result of mitral constriction or
roughening of the auricular surface of the valyes, was clearly pointed out by
Skoda (' On Auscultation and Percussion/ Dr. Markham's translation, p. 282),
and subsequently by Dr. Markham (' Diseases of the Heart/ Ist ed., p. 206»
2nd ed., p. 122). who quotes in support of the doctrine Hamemjk, Skoda and
Jacksch. Dr. Markham speaks of the murmur as of " comparatively rare
occurrence." Afterwards Dr. Qairdner suggested that since a murmur which
immediately precedes the systole is in fiict synchronous with the systole of the
auricle it might well be designated auricular-systolic. Dr. Gairdner also
showed that the murmur is much more common than prerious writers had
supposed.
pbssidbnt's address. 11
Haying become a Member of the College of Surgeons and
a Licentiate of the Society of Apothecaries^ he was for a
year Obstetric Assistant under Dr. Greenhalgh. He then
returned to Demerara and became Resident Surgeon of
the Colonial Hospital there. During an epidemic of
yellow fever he made some hundreds of post-mortem
examinations^ but I am not aware that the results have
been published. Daring his tenure of office Dr. Craig^
Surgeon-General of Trinidad, visited the Demerara Hos-
pital and was so favorably impressed by Mr. Arnold that
he shortly afterwards offered him the post of Medical
Officer of Health for Trinidad and Surgeon to the Colonial
Hospital there. He discharged the duties of these offices
to the entire satisfaction of the Surgeon- General and other
official superiors, and obtained also a large private practice.
He was more than once compelled to return to Europe
on account of his health, and he died last summer of
tubercular disease while on a visit to Aix-les-Bains. He
is said to have been thoroughly well grounded in his
profession and to have been respected and honoured by all
who knew him.
Dr. Samvsl JD. Orosa, who was elected a Foreign
Honorary Fellow of this Society in 1868, was bom near
Easton in Pennsylvania, July 8th, 1805. After receiving
a classical education he began the study of medicine at
the age of nineteen, and luiving graduated M.D. in the
Jefferson Medical College, Philadelphia, in 1828, he
at once commenced the practice of his profession in that
city. After the lapse of eighteen months, having mean-
while married. Dr. Gross returned to his native place,
Easton, where he soon obtained a good practice, and where,
to increase his knowledge of practical anatomy, he built a
dissecting-room at the end of his garden and dissected
daily for several hours. In October, 1838, he removed to
Cincinnati, having accepted the office of Demonstrator of
Anatomy in the Medical College of Ohio. After teaching
anatomy for two sessions in the Medical College he was
in 1835 unanimously elected to the Chair of Pathological
12 president's address.
Anatomy in the Medical Department of the Cincinnati Col-
lege. Daring the next few years he devoted most of his
time to the stndy of Pathological Anatomy, the collecting
and preservation of specimens, and laying the foandation of
a mnseum of Morbid Anatomy. He thus acquired the
knowledge which enabled him in 1889 to publish his
' Elements of Pathological Anatomy/ of which a second
edition appeared in 1845, and the third and last in 1857.
In 1840 he accepted the Professorship of Surgery in
Louisville Medical Institute, afterwards the University of
Louisville. His class, which during the first session
numbered 204, afterwards increased to 406. In 1843 he
published a monograph ' On the Nature and Treatment of
Wounds of the Intestines,' the result mainly of numerous
experiments which he had performed on dogs. And he
defends himself and others who have practised vivisection
against the unwarrantable charge of cruelty, the result as
he says of " the mawkish sentimentality of the Society for
the Prevention of Cruelty to Animals which have made so
much ado about this matter.'' In 1849 there was a dis-
pute between the University and the City as to the govern-
ment of the University, and at this critical period Dr.
Gross, being in doubt as to the result of the suit, accepted
the offer of the Chair of Surgery in the University of the
city of New York rendered vacant by the resignation of
Dr. Valentine Mott. He passed the winter of 1850-51 in
the city of New York, but before the termination of the
session he was solicited by his former colleagues at Louis-
ville to resume his Chair in that University, the suit in the
meantime having been decided in favour of the University.
For various reasons, amongst others the earnest wish of
his family to return to their former home, he was led to
tender his resignation to the University of New York and
to resume his Chair in that of Louisville.
In 1851 he published 'A Practical Treatise on the
Diseases, Injuries, and Malformations of the Urinary
Bladder, the Prostate Grland, and the Urethra,' and in
1854 his ' Practical Treatise on Foreign Bodies in the Air
PBEaiDENT^S ADDRESS. 13
Passages ' was published. This work is so complete that
if it were now repablished it would require no other
changes or additions than such as would be called for by
the results of laryngoscopic work since the publication of
the original treatise.
In 1856 Dr. Gross accepted the Chair of Surgery in
his alma mater^ the Jefferson Medical College of Phila-
delphia. A strong motive for taking this step was his
desire to be relieved from a large family practice which
left him little time for writing his elaborate ' System of Sur-
gery/ upon which he had been engaged for several years.
In the autumn of 1859 the work was published in two
large octavo volumes, and the sixth and last edition
appeared in 1882.
During the war of the Rebellion, he took great interest
in gunshot wounds, and visited many battle-fields to observe
their peculiar features, of which he made valuable notes.
In March, 1882, he resigned the Chair of Surgery which
he had filled for twenty-six years, and he was thereupon
unanimously elected Emeritus Professor.
In addition to the various works which have here been
mentioned. Dr. Gross published innumerable papers, ad-
dresses, and memoirs in the various medical journals. He
accomplished this vast amount of writing by rising early
and working in an orderly and systematic manner. He
said of himself that '' his genius was the genius of in-
dustry, perseverance, and common sense,'' and the result
has been that no previous medical teacher or author on
the continent of America exercised so widespread and
commanding an influence as Professor Gross. He was a
member of numerous medical and scientific societies both
American and foreign.
In 1872 the University of Oxford conferred on him the
degree of D.C.L., in 1880 the University of Cambridge
that of LL.D., and last year the University of Edinburgh
conferred, in ahsenti&j the degree of LL.D. In 1881 he
was invited by Mr., now Sir William, Maccormac to
deliver the address on behalf of the American delegates
14 PBBSIDBKT^S ADDBB8S.
to the International Medical GongresSj bat to His great
regret he was unable to be present.
With the exception of slight rheumatic pains Dr. Gross
had good health until a few months before his deaths when
he began to sufEer from indigestion^ swollen feet^ and other
symptoms of a weak heart. In January^ 1884^ he had a
bronchial attack which confined him to the house. Being
thus deprived of fresh air and exercise his appetite and
digestive powers failed and he died from exhaustion on
the 6th May last.
In accordance with his expressed wishes, the following
day, after a funeral service in the presence of his family
and attendants, his body was taken to the Crematory at
Washington, Pa., and there reduced to ashes, which on
the following Sunday were deposited in the family vault
beside the coffin of his wife at Woodlands Cemetery.^
JDt. William Fairlie Clarke^ was the son of an officer
in the Civil Service of the Honorable East India Com-
pany, and he was bom at Calcutta in 1838.
He was educated first at the High School of Edin-
burgh, then at Rugby under Dr. Qoulburn, whence he
proceeded to Christ Church, Oxford. After taking his B.A.
degree he returned to Edinburgh with the intention of
studying for the Bar, but finding medicine more to his
taste he gave up the law, and in 1858 entered as a
medical student at King's College. There he soon
attracted the notice and acquired the esteem of his fellow-
students and his teachers, who recognised in him a highly
cultured and refined gentleman with deep and earnest
religious convictions. After graduating M.A. and M.B. at
Oxford in 1862 he returned to Eang's College, and for six
months was House Surgeon of the Hospital, after which,
for one year, he held the office of Assistant Demonstrator
of Anatomy.
^ For further particulars of Dr. Grost'i distingoiahed career see an inte-
resting memoir by Dr. I. Minis Hays, in the ' American Joomal of the Medical
Sciences ' (Jan., 1884), and in the ' Transactions of the College of Physicians
of Philadelphia' (third series, vol. vii).
• ' Lanoet,' and < Brit. Med. Journal/ May 17th, 1884.
PBISIDBNT^S ADDRESS. 15
In 1863 lie obtained the Fellowship of the College of
Surgeons. He then, for a time, travelled on the Continent
with Lord Sliaftesbary, and finally commenced practice as
a pure Surgeon in Carzon Street. He became Clinical
Assistant to Mr. (now Sir William) Bowman at Moorfields,
an office which he held for three years. He also became
in succession Surgeon to the St. George^s and St. James's
Dispensary; Assistant Surgeon to the West London
Hospital, and finally in 1871 Assistant Surgeon to Charing
Cross Hospital. In 1865 he published a 'Manual of the
Practice of Surgery ' which went through three editions.
In 1866 he was elected a Fellow of this Society, and in
our ' Transactions ' for 1872 there is a paper of his on
" A Case of Unilateral Atrophy of the Tongue," and in the
volume for 1874 another paper on " Cases of so-called
Ichthyosis Linguas.'^
I am informed by an eminent Ophthalmic Surgeon that
Fairlie Clarke's account of transverse calcareous opacity
of the cornea ("On Some Eare Forms of Opacity of
the Cornea," 'Brit. Med. Journ.,' Oct. 8th, 1870) is both
original and valuable, and evinces careful and discriminative
clinical observation. He continued to take special interest
in diseases of the tongue, and he published a monograph on
that subject in 1873. He also wrote the article on
" Diseases of the Tongue '^ in Dr. Qaain's * Dictionary of
Medicine.'
He was much interested in various philanthropic sub-
jects. When quite a young man he recognised the great
importance of improving the dwellings of the poor, and in
conjunction with his friend Mr. Bosanquet he established
one of the earliest associations for effecting this upon a
sound financial basis. He also thought much and wrote
well on hospital out-patient reform and provident dispen-
sariesj on poor-law relief, on medical missions, and on the
temperance question. Articles from bis pen on these and
kindred subjects appeared in the ' Edinburgh,' ' Quarterly,'
and 'Fortnightly' Beviews and in ' Macmillan's Magazine.'
In 1870 he married a lady eminently fitted to be his
16 PBSBIDENT^S ADDRESS.
helpmate, and soon afterwards he removed to a larger
house in Mansfield Street, where for some years he lived
very happily. In time, however, he found that his
income from private practice as a pare Surgeon did not
keep pace with the requirements of an increasing family,
and in 1876, having taken his M.D. at Oxford, he deter-
mined to leave London and engage in general practice at
Southborough in Kent. There he spent the last eight
years of his life beloved and respected by all who knew
him, and, in addition to the faithful discharge of his
strictly professional work, taking an active interest in
local and general philanthropic movements, which he was
ever ready to assist by his voice and his pen. In 1881
the village of Southborough, notwithstanding its great
natural advantages, was not free from grave sanitary
defects and Dr. Olarke was long prostrated by a severe
attack of typhoid fever. This serious illness appears to
have left some permanent mischief, and about two months
before his death there arose symptoms of obscure brain
disease which, making rapid progress, proved fatal, to the
grief of his numerous friends, on the 8th May, 1884. His
premature death excited much sympathy for his bereaved
widow and his four sons,
Mr, Oassar Henry Hawkins was born September 19th,
1798, at Bisley, in Grloucestershire. His father the iRev.
Edward Hawkins, was Vicar of Bisley and the youngest
son of Sir GsBsar Hawkins, who was for many years
Surgeon to St. George's Hospital and Sergeant Surgeon
to George II and George III. At the age of nine Mr.
Caasar Hawkins entered Christ's Hospital, where he
remained six years. In 1814, soon after leaving the Blue-
coat School, he was articled for five years to Mr.
Sheppard, a practitioner at Hampton Court. In 1819 he
became a pupil at St. George's Hospital when Sir Everard
Home was the most eminent Surgeon and Mr. Brodie was
acting as his assistant.
He obtained the diploma of the College of Surgeons in
1821, and the same year he was House Surgeon at the
PBBSIDBNT'S ADDRBB8. 17
Lock Hospital. The following year he was House
Surgeon at St. George's. . After this for some years he
taught Anatomy in the Hunterian School in Great Wind-
mill Street. He was appointed Snrgeon to St. George's
in 1829. Prom 1832 to 1834 he lectured with Dr.
Seymour at St. George's on Medical Jurisprudence^ and
after this he lectured on Surgery^ first with Mr. George
Babington and then with Mr. Tatum^ until 1874, after
which he occasionally gave clinical lectures. On resigning
the office of Surgeon to the Hospital in 1861 he was
made Consulting Surgeon, and he was requested by his
old pupils to sit for his bust, which was presented to his
wife.
In 1874 Mr. Hawkins printed for private circulation
two volumes entitled 'Contributions to Pathology and
Surgery.' These consist of a collection of miscellaneous
writings for the most part scattered through the trans-
actions of medical societies and medical periodicals ; they
also contain some admirable clinical lectures. These two
volumes afFord conclusive evidence of his industry and
learning, of his skill and eminence as a Surgeon, and of
his success and influence as a clinical teacher.
Amongst other papers of great interest is a reprint of
a paper in the thirty -fifth volume of our ' Transactions '
"On a Successful Case of Colotomy," to which is
appended a tabular statement of forty-four cases in which
the operation had been performed by other Surgeons.
This publication is believed to have contributed greatly to
encourage resort to the operation, especially in cases of
stricture of the sigmoid flexure of the colon. The paper
affords some striking and instructive illustrations of the
difficulty which attends the diagnosis of the exact seat
and cause of intestinal obstruction.
One of the most interesting clinical lectures is that (in
vol. i, p. 136) "On the Pirst Successful Case of Ovario-
tomy in a London Hospital." This case occurred in the
year 1846, when anaBsthetics were unknown, and when
there was no suspicion that the contact of atmospheric air
VOL. LXVTII. 2
18 pbssidbnt's address.
with the peritoneum could be injurious otherwise than by
being of too low a temperature.
Mr. Hawkins's distinguished career is so well known
that in this room it is scarcely necessary to say that the
former Bluecoat boy and the apothecary's apprentice
lived to obtain all the honours which his professional
brethren could bestow upon a Surgeon of the greatest
eminence. He was twice President of the Boyal College
of Surgeons^ first in 1852 and again in 1861 ; for seven-
teen years be was an Examiner at the College. For some
years he represented the College on the General Medical
Council^ and until his death he was a Trustee of the
Hunterian Museum. In 1849 he delivered the Hunterian
Oration, when H.B.H. the late Prince Consort honoured
the College by his presence. This learned oration
occupies the first place in the volumes of collected
writings before referred to. For the usual period of five
years he was Examiner in Surgery at the University of
London.
On the death of Sir Benjamin Brodie he was appointed
Sergeant Surgeon to the Queen, being the fourth of his
family who had obtained the same distinction. And it is a
noteworthy fact that he was consulted by four generations
of the Boyal Family.
He joined this Society in 1828, and contributed twelve
important papers to the * Transactions.' He served in
succession the offices of Councillor, Eeferee, Vice-Presi-
dent, Treasurer, and in 1855-6 that of President. In
1852 he was President of the Pathological Society, and
he had been a Fellow of the Boyal Society since 1856.
Beferring to some personal characteristics, the writer of
an interesting and appreciative memoir in one of the
journals (^ British Medical Journal,' Aug. 16th, 1884) says
of him, '^ His manners had little enough in common with
the fashionable host, who ' with his arms outstretched as
if he would fly grasps the new comer.' To tell the truth,
many people complained of him as cold and stiff on a slight
acquaintance, but on a closer intimacy all this vanished
pbisidint's address. 19
and his gennine kindness of heart, his sincerity, and his
trostwortliiness endeared him to a large circle of friends/'
Two of Mr. CsBsar Hawkins's elder brothers were the
Bev. Edward E[awkins, D.D., well known as the Provost
of Oriel from 1828 to 1882, and the late Dr. Francis
Hawkins, Physician to the Middlesex Hospital, and Begis-
trar in snccession of the Boyal College of Physicians and
of the General Medical Council. It is not without interest
to observe that of the famous Provost, tod his apparent
coldness and reserve, his biographer, in a recent number
of the ' Quarterly Eeview ' (October, 1883), speaks in
terms almost identical with those which I have just now
quoted as applied to the great Surgeon. The writer says
of the Provost, " A constitutional dread of overstepping by
ahair's-breadth the strict line of truth (so at least it seemed)
not only guarded him effectually from anything approaching
to sentimental outburst, but even kept in check ordinary
expressions of warmth, restrained him — even unpleasantly
if the truth must be told — while in converse with those
whom he did love and trust, as if through fear of possibly
overstating his feelings."
Then follow statements to show that beneath an exterior
apparently cold and reserved " he had the warmest as well
as the most feeling heart.''
It will be evident from these extracts that between the
mental and moral characteristics of the eminent Surgeon
and the famous Oxford Provost there was a close fraternal
resemblance. The brothers, who were deeply attached to
each other, were not long separated by death. The Pro-
vost died on November 18th, 1882, having nearly com-
pleted his ninety-fourth year, and the Surgeon followed on
July 20th, 1884, at the age of eighty-six. His death
appears to have been an indirect result of an accidental
bruise oE his left leg consequent on a stumble in walking
downstairs in December, 1883. This was attended with
much effusion of blood, and subsequently there was evi-
dence of thrombosis in some of the large veins of the same
leg, with constitutional disturbance and loss of strength
20 PBBSIDIBin^B ADDBSS8.
which confined him to his room. After a temporary
improvement there was a relapse with congh and loss of
appetite and at last -rather sudden death from syncope.
One of the most distingoished members of the profes-
sion^ writing to a friend on hearing of the death of Mr.
Cadsar Hawkins, said of him, " We have lost, I think, the
clearest mind in onr profession, in which accuracy was
least swayed by imagination or temper or desire for renown.
I have never known one more discreet or honest in council
or less influenced by self-interest."^
William James Erasmus Wilson^ who was proud of his
Scottish descent, was bom in 1809, his father being then
a medical oflBicer in the navy. He received his earlier
education at Dartford and Swanscombe, in Kent, and in
1825 he commenced his medical studies at St. Bartholo-
mew's, where he is said to have been a favourite pupil
of Abemethy. In 1831 he became a Member of the
Royal College of Surgeons. Soon afterwards Dr. Jones
Quain made him his assistant at University College, and
subsequently he was appointed Demonstrator of Anatomy
under Mrv Richard Quain. While holding this office he
acquired repute as a skilful dissector and a successful
teacher. In conjunction with Dr. Jones Quain he pub-
lished a series of anatomical plates of the human body.
In 1833 he published the ^ Dissector^s Manual,' a second
edition of which appeared in 1853. In 1840 he was
appointed Lecturer on Anatomy and Physiology at the
Middlesex Hospital, and in the same year he published
the 'Anatomist's Vade-Mecum,' illustrated by woodcuts.
This was long a very popular manual and went through
six editions, the last appearing in 1854. He was for some
years a Consulting Surgeon to the Marylebone Infirmary,
where he obtained much experience of general surgical
practice, but ultimately he was led to adopt diseases of
the skin as a special subject of study and practice. In
the department of dermatology he worked with his cha-
» Obitnary in the ' Lancet/ Jnly 26th, 1884.
> ' Lancet/ and < Brit. Med. Journal,' Angnst 16th, 1884.
t'BBSlDSKT^S ADDBEdS. 21
raoterifitic zeal and soon acquired a repntation which by
degrees brought with it a large and very lucrative practice.
In 1842 he published his ' Treatise on Diseases of the
Skin/ a sixth edition of which appeared in 1867. In
addition to this he published numerous other works^
lectures^ and papers on the skin and its diseases^ the titles
of which alone occupy a page and a half of our printed
library catalogue. In 1843 he was elected a Fellow of
the College of Surgeons^ in 1870 a Member of the Council^
and President of the College in 1881. In the same year
he presided over the Dermatological Section of the Inter-
national Medical Congress. In 1844 he was elected a
Fellow of the Boyal Society. He was elected a Fellow of
this Society in 1839^ in 1845 he served on the Library
Committee^ and two of his papers are published in our
' Transactions/ one '' An Account of a Horn Developed
from the Human Skin/' vol. xxvii, the other " On the
Echinococcus Homims^'' vol. zzviii. Erasmus Wilson
by his large professional income^ but chiefly perhaps by
his judicious investments^ became possessed of great
wealthy much of which he distributed during his lifetime
with great but wisely discriminating liberality. The
amount of his private beneficence^ though known to be
very large, cannot be accurately estimated, but he is well
known to have been a most munificent public benefactor.
Amongst other acts of munificence during his lifetime he
expended £5000 in the endowment of a Chair of Derma-
tology in the College of Surgeons, and presented to the
museum an extensive collection of models and drawings
illustrative of diseases of the skin. In the University of
Aberdeen, which had conferred on him the degree of LL.D.,
he founded, in memory of his father, a Chair of Pathology
at a cost of £10,000. He contributed £10,000 towards
the expense of bringing home the Egyptian obelisk
which now adorns the Thames Embankment. In 1873 he
restored the church of Swanscombe, in Kent. Besides
contributing liberally towards the foundation of the Boyal
College of Music he endowed a Wilson scholarship at a
22 FRBSIDBNT^S ADDBBBS.
cost of £2500. In addition to large subscriptions to the
Boyal Medical Benevolent College he erected at his own
sole expense a house for the head-master. He built a new
wing and a chapel to the Sea-Bathing Infirmary at Margate,
at a cost of more than £30^000; and as an eminent
freemason he was a most liberal contributor to the various
charitable institutions connected with the craft. In
recognition of his professional eminence and his munificent
public benefactions Her Majesty the Queen conferred on
him the honour of knighthood in 1881.
Amongst Sir Erasmus Wilson's contributions to general
literature may be mentioned^ ' A Three Weeks' Scramble
Through the Spas of Germany and Belgium/ published in
1858^ and ' Cleopatra's Needle ; with Brief Notes on
Egypt and Egyptian Obelisks/ 1877.
About two years ago he was prostrated by a very serious
illness which left him in delicate health and for more than
a year before his death he had been totally blind. On
July 23rd he was present at the consecration of St.
Saviour's Church at Westgate-on-Sea, of which he laid
the foundation-stone a year previously. A few days
afterwards he was seized with inflammation of the bowels^
which terminated fatally on August 7th. Sir Erasmus
had no family but he leaves a widow and numerous deeply
attached friends. Considering the benefits which by his
great skill he conferred upon the numerous applicants for
his professional aid and his munificent public and private
benefactions he might with truth have appropriated the
words of the patriarch, '^ The blessing of him that was
ready to perish came upon me, and I caused the widow's
heart to sing for joy."
Mr, James Stock Dcmiel, who died last August at the
age of eighty, had been a Fellow of our Society since 1836.
The son of a solicitor at Bamsgate he was educated at the
Rochester Grammar School. He commenced his medical
studies in Edinburgh, where he made the acquaintance of
Thomas Wormald and Eichard Owen, an acquaintance
which was afterwards renewed at St. Bartholomew's.
PBISIDSNT^S ADDRESS. 28
There lie acted as dresser to Wm. Lawrence^ who so
highly appreciated the brilliant social qualities of his
pupil that he often asked him to take the bottom of the
table at his dinner-parties. Amongst other distinguished
men at St. Bartholomew's with whom Mr. Daniel formed
a friendship which was continued through life were Sir
George Burrows, the late Sir Thomas Watson, and Professor
Richard Partridge. After leaving the hospital Mr. Daniel
settled at Bamsgate, where for a number of years he had
a large and lucrative practice. Amongst his intimate
friends and patients there were Sir Moses Montefiore
and the late Augustus Welby Pugin.
Mr. Daniel accompanied Sir Moses on two of his later
journeys, viz. to Wallachia in 1866, and to St. Petersburg
in 1872. The latter journey, on account of Sir Moses
Montefiore's habit of rapid and continuous travelling, Mr.
Daniel, although twenty years younger than his companion,
found very fatiguing. He consequently had to stop on
the way home and he never quite regained his former
strength. He retired from practice as long ago as 1867.
His friends report him to have been a most pleasant and
popular man, well read and a good classic, with an extra-
ordinary memory and brilliant powers of conversation.
He was also a beautiful reader, rendering such pieces as
"Twelfth Night,'' and the farce "A Fish out of Water,''
with wonderful effect.
Dr. David Alexander King having received his earlier
education at the City of London School, was a highly dis-
tinguished student at St. Bartholomew's. In 1882 he
graduated M.B. at the University of London, when he
obtained the Scholarship and Gold Medal for Medicine,
and was second with a Grold Medal in Obstetric Medicine.
He served with distinction in various important offices at
St. Bartholomew's, Casualty Physician, Assistant Demon-
strator of Anatomy, House Physician and Ophthalmic
House Surgeon, and he was appointed Assistant Physician
to the Brompton Hospital for Consumption. He pub-
lished in the 17th vol. of St. Bartholomew's Hospital
24 FBSBIDBNT^S ABDBSSS.
'Reports/ a paper "On Membranous Pharyngitis from
Scarlatinal Infection'' and in the same volume another
paper on " Cases of Intestinal Obstruction/' The 18th
vol. contains an elaborate paper in which the results of
seventy cases of typhoid fever are analysed^ one result of
the analysis being apparently to sh«w that although for
various reasons the early administration of solid food
during the convalescence from typhoid is injurious^ yet
that it is not the cause of the relapse which so often
occurs.
In another paper published in 'Brain' (vol. v, p. 412)
Dr. King has recorded a remarkable case of multiple
cerebral tumours of unusual histological characters. All
the papers afford evidence of accurate and industrious
observation and close reasoning. His brilliant and highly
promising career was cut short by consumption before he
had completed his twenty-eighth year. He died at Tor-
quay on September 4th, 1884.
Dr, William O-illett Cory was elected a Fellow of this
Society in 1853. He obtained the license of the Society
of Apothecaries in 1848, and graduated M.D. Paris in
1865. He commenced practice at Banstead, in Surrey. He
afterwards practised at Brighton, then at Boulogne, and
finally settled at Clifton, where, on the 25th September,
1884, he died in about two hours after an apoplectic
seizure at the age of fifty-eight. In the ^Lancet,' 1848,
he published a " Case of Placenta Previa successfully
Treated by Removing the Placenta before the Child."
In the premature death of Dr. Evan Bucham,an Boater,^
we have to mourn the loss of one who by his great ability,
his varied learning, and yet more by his admirable charac-
ter was known by his many friends, and in the course of
time would have been recognised by the entire profession
and by the public as presenting the very highest type of
an able and accomplished physician.
His father, James Baxter, a personal friend of Chris-
1 See an interesting memoir of Dr. Baxter by one of hia colleaguesi
'Lancet^' January 24tb, 1886.
FAISIDXNT^S ADDRBS8. 25
topher Norths was deecended from an old Scotcli Pres-
byterian family. In early manhood he went to St. Peters-
burg^ where he was Director of the English School in that
city^ and there he married Miss Boss^ the daughter of a
Scotch merchant who had settled in St. Petersburg. Of
this marriage a daughter who died in infancy and the
subject of our notice^ who was bom in 1844^ were the only
children. The mother died of consumption while her son
was still very young. Soon after the death of his wife
Mr. James Baxter was appointed Government Inspector
of Schools in Russian Poland and went to reside at
Kaminetz in the province of Podolsk.
There until the age of sixteen young Baxter was
brought up and educated by his father and an old French
tutor^ and there^ with a great natural aptitude for linguistic
acquirements^ he was placed in favorable circumstances
for obtaining a practical knowledge of the chief European
lai^guages. Bussian and German were the languages of
the people amongst whom he was brought up^ English
was the language of his home^ French he learnt from his
tutor^ and Latin from his father. In October^ 1861^ he
came to England and entered the General Literature and
Science Department of King's College. At that time he
knew nothing of Greeks but in the course of the next
year he had acquired such a knowledge of Greek literature
and history as enabled him to obtain an open scholarship
in classics at Lincoln College^ Oxford^ where he remained
for three terms. His intention then was to become a
classical tutor and Fellow and without doubt he would
have obtained the object of his ambition ; but " there^s
a divinity that shapes our ends^ rough-hew them how we
will.'' Baxter's university career was cut short by a
summons to attend his father, who was dangerously ill in
Bussia and with whom he remained until his deaths which
occurred at the end of a year. On returning to England
he found that he could not resume his place at Oxford^
for his scholarship had lapsed, and for other reasons he
decided to enter the profession of medicine^ which held
26 psbbidbmt'b address.
oat, as he said, '' an opportunity for tlie stady of physical
science and a hope of comparative intellectnal freedom.''
In 1864 he entered the medical department of King's
College, where he obtained the first Wameford entrance
scholarship and in the following spring he was elected a
junior medical scholar in conjunction with the late Prof.
A. H. Garrod and Prof. Gumow. In 1865 he obtained
the Dasent prize open to the whole College and usually
won by students in general literature, the subject for the
essay being " The Minor Poems of Milton."
In 1865 he matriculated in the Honours division of the
University of London, and in 1869, when he graduated
M.B., he obtained the scholarship in medicine and was
second with a Gold Medal in Obstetric Medicine. In
1870 he obtained the degree of M.D. and was marked
with a star as worthy of the Gold Medal.
He held various appointments at Song's College. In
1868-9 he was House Physician. For two years, in 1870-
71, he was Sambrooke Medical Registrar, and he discharged
the duties of this office in so exemplary a manner as to
earn the gratitude alike of students and physicians, of the
former especially, by his admirable bedside teaching. In
1871 he was appointed Medical Tutor and after conscien-
tiously discharging the duties of this laborious office for
three years, he was chosen to succeed Dr. Gttrrod as Pro-
fessor of Materia Medica and Therapeutics and at the
same time he became Assistant Physician to the hospital.
On resigning the office of Medical Tutor he was elected an
Honorary Fellow of King's College. In 1872 he became
a Member of the Boyal College of Physicians and in 1877
he was elected a Fellow. He was subsequently appointed
an examiner in Materia Medica and Therapeutics at the
College, and he held for five years the same office in
the University of London. Whilst still Medical Tutor he
was elected on the medical staff of the recently founded
Evelina Hospital for Sick Children, and he worked dili-
gently at the diseases of children, first in the out-patient
rooms and then in the wards, for the next nine or ten
PBISIDSNT's ADDSB88. 27
years. During -the same period he made his well-known
admirable translation of Bindfleisch's ' Pathological His-
tology ' for the New Sydenham Society, and he revise^ the
fourth edition of Garrod's ' Essentials of Materia Medica/
In the ' Practitioner ^ of 1873 he published a valuable
paper entitled '' The action of Cinchona Alkaloids and their
Congeners on Bacteria and Colourless Blood-corpuscles/'
He was subsequently asked by the medical officer of the
Local Gbyemment Board to investigate the value of dis-
infectants, the result of which inquiry was an admirable
essay, published in a Blue-book in 1875, under the title
''Reports on Experimental Study of Certain Disinfec-
tants."
In 1876 he published in the 'British and Foreign
Medico-Chirurgical Eeview' an able summary of the
physiology of the vaso-motor nervous system, in which he
showed a thorough knowledge of the history and position
of that important subject.
His accurate and extensive knowledge of skin diseases,
derived from many years^ work at the Blackfriars Hospital,
is displayed in a paper on " General Exfoliative Derma-
titis,'' published in the ' British Medical Journal,' vol. ii,
1879.
He had for several years contributed to the 'Academy ' a
series of " Physiological Notes." In March, 1880, he pub-
lished, in conjunction with Dr. Willcocks,a paper on "Clini-
cal Hasmometry," and his latest literary work was a brief
note in ' Brain ' (January, 1884) welcoming the publication
of a Russian review devoted entirely to neurology. In
1881 Dr. Baxter was appointed Physician to the Royal Free
Hospital, with the charge of instructing the lady pupils in
clinical medicine, a work which he performed with cha-
racteristic zeal and efficacy.
Dr. Baxter had always been delicate, and during the
last two years of his life he had a succession of serious
illnesses, which were borne with heroic fortitude and
even cheerfulness. First he had an attack of pleurisy in
the right side^ then a similar attack of the left. With
^8 PBBStDBNT^S ADDBBSS.
this there was some obscare intestinal trouble. Subse-
quently disease, probably tuberculous, attacked the apices
of both lungs, and lastly came albuminuria and dropsy
with exhansting diarrhoea, ending fatally on the 14th of
January. He leaves a widow and a host of devoted
friends to mourn their irrepai*able loss.
Those qualities of Dr. Baxter^s mind and character
which, in addition to his powerful and highly cultured
intellect, excited the love and admiration of his friends,
may briefly be said to have been his conscientious devo-
tion to every work and duty which he undertook, his
scrupulous accuracy of statement, his remarkable power of
clothing his thoughts in clear, vigorous, and appropriate
language, his fine sense of humour, and with all this his
charming modesty of demeanour and his detestation of
unseemly self-assertion and display. He had been a
Fellow of this Society since 1874 and a Referee since
1881.
Mr. William Collins Worthington was bom at the com-
mencement of the century (February 26th, 1800) and at
an early age began the study of medicine and surgery as
a resident pupil at the Norwich County Hospital. There
he had for his teachers the late Drs. Bigby and Philip
Martineau, from whom he imbibed a love of his profes-
sion and a special taste for surgery, together with such
instruction and experience as made him in after-life a
successful lithotomist. On leaving the Norwich Hospital
he entered at the Middlesex Hospital, where he worked
under Sir Charles Bell, and studied anatomy at the school
of Mr. Joshua Brook. He became a Member of the
Boyal College of Surgeons in 1819, and an Honorary
Fellow in 1844. In 1822 he commenced practice at
Lowestoft, and he soon established a cottage hospital, which
under his auspices has grown to its present dimensions, with
accommodation for thirty beds.
He was actively and extensively engaged in practice for
fifty years, during which time he was a frequent contributor
to medical literature. He was a diligent student of
it
FBISIDIBNT'S ADDBS88. 29
pathology and never lost an opportunity of investigating
disease by post-mortem examinations. He thus collected
a considerable number of interesting pathological speci-
mens. Mr. Worthington had been a non-resident Fellow
of the Society since 1842^ and he contributed three papers
to the ' Transactions,' one on '^ Stricture of the Trachea "
(vol. xxv) ; one on " Fistulous Communication between
the Bladder and Ileum simulating Stone '^ (vol. xxvii), and
a third on '' A Case of Sacculated (Esophagus '^ (vol.
:). He also published papers in the 'Lancet' on
Aneurism," '' Paracentesis/' and other subjects. Al- .
though not physically a strong man he had nearly com-
pleted his eighty-fifth year when he died on the 31st January
last. This prolongation of his life with his mental faculties
unimpaired he attributed to his strictly abstemious habits.
He was always opposed to the dietetic use of alcoholic
stimulants, so that both by example and by precept he
was an influential promulgator of temperance doctrines.
Mr. Worthington was highly respected and esteemed by
all classes of the community, amongst whom his long,
useful, and most honorable life had been passed.
It will have been seen from the report of the Council
that our merely financial losses by deaths, resignations,
and non-payment of subscriptions, have been considerably
more than counterbalanced by the unusual number of new
Fellows elected, and the balance-sheet shows a satisfactory
excess of income over our ordinary annual expenditure.
The Council confidently appeal to the Society for their
cordial approval of the extraordinary expenditure which
has been incurred for the removal of the very grave
sanitary defects which were found to exist in the base-
ment of our building, defects of so serious a character as
not only to imperil the health of those who reside on the
premises, but also, though in a less degree, that of the
numerous members of our own and other Societies who
meet within these walls, and who have a right to expect
that all due care shall be taken to guard them against the
dangers resulting from defective drainage.
so pbisidbnt's address.
But in order to render our premises entirely suitable
for the important work of various kinds which is here
carried on^ something is yet required. The lighting aud
ventilation of this meeting-room are not satisfactory ; it
is very difficult to maintain a pleasant uniform tempera-
ture ; and towards the termination of a full meeting the
air becomes not only unpleasant but positively unwhole-
some. There is also abundant evidence that the products
of gas combustion are destroying the bindings of our
extensive and valuable library. The Council whom you
elect to-day will of necessity have their attention directed
to this very important question^ and if their deliberations
should result in making as great an improvement in the
lighting and ventilation as has lately been effected in the
drainage, they will deserve and will doubtless receive the
thanks of the Society.
In conclusion, I think it will be admitted by all who
have attended to the work of the Society, that the papers
and discussions during the past year have been at least
equal to the average of former years in interest and im-
portance, and an inspection of the list of papers to be
read will show that we have an abundance of good mate-
rial to occupy us during the remainder of the session.
The subject of cholera has for some time past excited
much interest, and this interest increases as the time
approaches when a reappearance of the disease in Europe
is not improbable. It has therefore been thought desir-
able that the etiology, pathology, and treatment of cholera
should be discussed at an early meeting of the Society,
and I have undertaken to initiate such a discussion on the
24th inst., when it is hoped that we may have a large
attendance and an instructive debate.
CASE
crason) anetjeism on the doesum
OF THE FOOT,
WITH REMARKS ON THE DISEASE.
BY
WALTER EDMUNDS, M.C.
BaeeiTed April 7th— BMd October 28th, 1884.
John B — , sBt. 29^ was admitted into St. Thomas' Home
for a swelling on the dorsum of the left foot. The tumour
was rounds about one and a half inches in diameter^ pulsated
with the pulse^ and expanded in all directions ; there was
a well-marked thrill with the pulsation. Pressure on the
anterior tibial artery only diminished the pulsation, but
compression of both the anterior and posterior tibials
completely arrested it. This is not a matter of course for
there might have been a communication with the anterior
peroneal artery.
The swelling had been noticed six weeks. There was
no history of injury, or of syphilis. After a few days' rest
in bed an Esmarch's bandage was applied firmly above and
below, but lightly over, the aneurism. This was kept on
for an hour and fifty minutes ; on removing the bandage the
pulsation returned and no improvement had been produced.
It was then decided to excise the aneurism. Accordingly a
32 CIRSOID ANBUBISM ON THl D0B8TTM OF THB TOOT.
week later^ the patient being ansdsthetised^ a longitudinal
incision was made over the tumonr. The sac was exposed^
and on its lower side two arteries proceeding from it were
found : they were each tied by two ligatures and the vessels
divided between them. The artery which supplied the
tumour from above was probably the dorsalis pedis. To
have exposed it for ligaturing at a safe distance above
the aneurism would have necessitated dividing the annular
ligament ; the anterior tibial was therefore exposed above
the ankle^ tied in two places and divided between the
ligatures. This vessel was enlarged. The aneurism still
continued to pulsate, the dorsalis pedis was then tied imme-
diately above the sac and divided, and the sac dissected out,
the vessels being tied as they were exposed: altogether
seven fair-sized arteries were found communicating with the
aneurism. All vessels were tied with catgut. There was
some absorption of the tarsal bones lying immediately under
the aneurism, but fortunately no joint had been opened.
The wound healed slowly but completely, and the patient
went out well.
On examining the tumour it was seen that except for
one bend on its position surface the aneurism was a simple
sac with numerous communicating vessels. The specimen
is in the museum of St. Thomas's Hospital.
Rema/rhs. — The dorsalis pedis artery is peculiarly ex-
posed to injury both directly from blows, and indirectly
from sprains of the foot, traumatic aneurisms of this artery
are consequently not uncommon ; but spontaneous aneurism
is rare, and I have only succeeded in finding records of six
cases in which no cause could be assigned. An abstract
of these cases is added.
With respect to the anastomotic nature of the aneurism
it would seem that Professor Gross's case {vide infra) was
also of this kind, for he remarks that '' from the great
number of ligatures required to arrest the bleeding it would
appear that the tumour was somewhat of the character of an
aneurism by anastomosis.'' Acase is recorded too by Fleury,
in which a punctured wound of one of the smaller arteries
CIB80ID ANBUBISX ON THE DORSUM Of THK FOOT. 83
of the dorsum of the foot was followed by a tamoar which
appeared to consist '' of little vessels anastomosing among
themselves to infinity/'^
Mr. Poland had a case under his care in which there
was a cirsoid aneurism on both the plantar and dorsal
aspect of the foot,' and a somewhat similar case is recorded
by Nicoladoni.*
The treatment of aneurism of the dorsalis pedis or its
branches must depend on the exact nature of the case»
The patient in the Navy (No. 1 in appendix) was cured
by pressure, and if the aneurism can be completely con*
trolled without any great amount of pressure, and if it be
not freely expansile in all directions a trial may be made of
digital compression or, if this cannot be arranged, of instru-
mental compression or of Esmarch's bandage. These
methods having failed or being thought inapplicable we
have to choose between the various operative procedures.
One of M. Panas's cases (No. 6) was cared by the injec-
tion of a solntion of perchloride of iron, and this is the
treatment recommended by M. Henri Toussaint in his able
thesis on this disease.^ There is, however, danger of in-
flammation of the sac in this method, and the proximity
of the tarsal joints is a special reason for avoiding this
complication. Simple ligature of the dorsalis pedis may fail,
though itsacceeded in Mr. Savory's case (No. 5), and the
surest treatment would seem to be excision of the aneurism.
Even a case like Mr. Adams's, in which the aneurism had
in all probability opened into a tarsal joint before the
patient came under observation, would not be an objection
to that treatment, for the opening into the joint would be
exposed in the operation, and the foot could he, if it were
thought necessary, amputated, and this, indeed, is the
treatment which eventually had to be adopted in that
^ 'Archives g^^rales de M^./ 8me s^rie, tome y, 1889.
* ' LanceV vol. i, 1866, p. 636.
■ • Archiy fur klin. Chir./ Band xyUi, 1876.
^ ' CoDsid^ratioDS but I'anatomie de TarUre p^diease et sar sei an^yryimes,
par Henri Toossaint. Paris, 1879.
VOL. LXVIII. 3
84 CIRSOID ANEUBISM ON THB DORSUM OF THE FOOT.
case. In fact, the treatment recommended by Sir Astley
Cooper in his lectures on Surgery is still the best. Speaking
of aneurism of the anterior tibial artery, he says : " Mr.
Henry Cline had a case of this disease upon the upper
part of the foot, and he tied the anterior tibial at the lower
part of the leg, but the pulsation in the aneurism continued
when the boy quitted the hospital. It will be, therefore,
right to tie the artery by opening the sac, so as to secure
it above and below the aperture, if the aneurism be seated
low down in the limb, as the anastomosis with the plantar
arteries is exceedingly free.'^ ^
It would be well, however, to bear in mind the possi-
bility of finding implication of the tarsal joints, and to be
provided in doubtful cases before commencing the opera-
tion with permission to amputate should that be thought
advisable.
Abstract op Six previously recorded Cases op Spontaneous
Aneurism of Dorsalis Pedis Artert.
1. The ease in the Navy (< Report on Health of Navy/ 1872).
Patient was a stoker It.N. He had an anexirism on the dorsalis
pedis artery, which was cured by compression at Haslar Hospital.
2. M. Panas'a first ease ('Bulletin Soc. de Chimrgie,' 3me
s6rie, tome ii, 1873).
Labourer, st. 58, spontaneous dienrism of right dorsalis pedis.
The tumour was partly beneath and partly below the annular liga-
ment; the skin was inflamed. Before admission the aneurism was
mistaken for an abscess, but on commencing to incise it the pulsations
were noticed and the incision was not continued. Three days later
slight oozing, and in three more sharp haomorrhage occurred from
the wound. To an'est this M. Panas tied the anterior tibial, and
this being insufficient also the dorsalis pedis below the aneurism.
This stopped the hsemorrhage and for a time the pulsation, though
it subsequently recurred. The surface of the tumour sloughed,
1 ' Lectaref on the Principles and Practice of Surgery,' vol. ii, p. 63.
CIRSOID ANEUEIBM ON THE DORSUM OP THE FOOT. 85
rigors came on, and the patient died of pysemia with abscesBes in the
lungs.
The treatment M. Fanas would have adopted in this case had not
the haemorrhage rendered ligature necessary was the injection of per-
chloride of iron with temporary pressure round the aneurism.
8. ProfesBor Gross's ease ('Philadelphia Medical Times/ 1874).
Coloured man, sat. 59. There was an aneurism the size of a small
bird's egg on the external aspect of the dorsum of the left foot,
first noticed four months before patient was seen ; no history of
injury. As the aneurism was external to the position of the dorsalis
pedis artery it was thought to be on one of its branches.
Treatment. — Under ether the femoral was controlled and the
aneurismal sac laid open. '*It seems impossible to separate the
sac and trace out the artery by which it b supplied, and hence it
becomes necessary to ligate the anterior tibial which is accomplished
by extending the incision upward and passing a ligature round the
vessel just above the ankle, where it lies between the tendon of the
extensor longus digitorum and the extensor propriuspollicis muscles.
There is still copious hesmorrhage proceeding fi-om the recurrent
circulation, which is dependent on the perforating branches of the
plantar arteries, and from the great number of ligatures required to
arrest the bleeding it would appear that the tumour has somewhat
of the nature of an aneurism by anastomosis."
Secondary hsBmorrhage occurred a week later and was stopped by
acupressure and the ligature of the anterior tibial a second time
(higher up). Hsemorrhage did not recur, but the patient died a
fortnight after from pyssmia with suppuration in the ankle-joint. The
anterior tibial artery was found at the post-mortem to be ossified.
4. Mr, Adams's ease ('British Medical Journal,' yoL ii, 1877, p. 804).
A labourer, set. 29, no known cause, never had syphilis. On dorsum
of foot over outer side of astragalo-scaphoid articulation a tense,
shining pulsating swelling the size of a walnut, diagnosed to be an
aneurism. It was thought better to tie the anterior tibial high up in
the leg rather than near the aneurism for fear of finding the vessel
diseased and creating suppuration among the tendons. Pulsation
ceased. A fortnight later the sac had not consolidated and was
opened. A week later suppuration was found to exist in astragalo-
scaphoid joint and subsequently spread to other joints necessitating
amputation of foot, after which patient recovered.
36 CIRSOID AVEUBISX ON THE DORSUM Of THE FOOT.
5. Mr. Savory's ease (' Britisli Medical Jonmal,* voL i, 1878, p. 75).
A man, st. 49. Aneariam on the donalis pedis beliind the angle
formed by the first and second metatarsal bones. All pulsation
arrested by compression of the artery above the tumour. Oompression
being unsaccesafol the dorsalis pedis was ligatured an inch and a
half above the tamonr, all pulsation ceased, but in three minates
slight pulsation reappeared, and some light pressure waa made on
the sac. The aneurism was cured.
6. If. Panaa's second ease (Thesis by Henri Toossaint, 1879).
Male, SBt. 38, no history of injury, doubtful history of syphilia.
Pulsating tumour the size of a large nut on the dorsum of left foot.
Treated, firstly, by application of Esmarch's bandage but without
result.
Secondly, by electro*puncture but no clot formed and tumour con-
tinued to pulsate.
Thirdly, by mechanical compression ; no benefit.
Fourthly, by ii^'ection of perchloride of iron into sac, the femoral
and the dorsalis pedis (below aneurism) being compressed and an
Esmarch's tube tightly applied round the lower part of the thigh*
This completely cured the aneurism.
(For discussion on this paper see ' Proceedings of Boyal Medical
and Ohirurgical Society,' New Series, vol. i, p. 283.)
ON
EXPIRATORY CERVICAL EMPHYSEMA,
THAT IS,
EMPHYSEMA OF THE NECE OCCUBBINO DUBINO LABOUB
AND DUBINO VIOLENT EIPIBATOBT EFFOBTS.
AN EXPERIMENTAL INQUIBY.
BT
FEANCIS HENET CHAMPNEYS, ILA., M.B. Oxok.,
P.R.C.P.,
ABBUTAHT JM3TWMR OV OBSTSTBIOB, BTa, AlTD A8SI8IAHT OBBTBTBIO
PHT8I0IAH TO 8T. OBOBax'S HOSPITAL.
(BeMhred April 16tb— Bend November 11th, 1884.)
In spite of the fact that emphysema of the neck, face,
and other adjacent parts is an accident of labour which
is not extremely rare, its pathology has hitherto been the
subject of various hypotheses, amounting to little more
than guesses, and even at the present time has never,
hitherto, been the subject of accurate investigation.
The present paper is an effort to place the pathology
of this affection on a firmer basis, and the investigations
here detailed suggested themselves by way of corollary to
experiments concerning the subject of artificial respira-
tion in newborn children and kindred subjects related in
the 'Med.-Chir. Transactions,' vol. bdv, 1881, pp. 41 —
101, and vol. Ixv, 1882, pp. 75—86. But the latter
88 ON EXPIBATORT CERVICAL EMPHTSEMA.
investigation^ concerning mediastinal emphysema and
pneumothorax after tracheotomy (in which the route
followed by the air was proved to be from the tracheo-
tomy wonnd^ beneath the deep cervical fascia and so into
the tissue of the anterior mediastinum beneath the pleura)^
suggested that emphysema of the neck during labour
might follow the same route in an opposite direction.
This it was determined to test by experiment on the
foetus, for the reasons that although it is true that the
affection does not concern foetuses but adult women, yet
(1) fresh foetuses have usually fairly healthy lungs ; (2)
their nearly identical age makes them a nearly uniform
material ; (3) the experiments could in any case only be
illustrative, and therefore could only possess value in pro-
portion to the amount of correspondence which they
showed to the known phenomena. In this way adult
subjects could only serve in the same manner as foetuses.
With these considerations it was determined to choose
foetuses as the subjects of experiment. Two children
only who had breathed for a very short time (Experi-
ments 9 and 10) were also used.
Frequency of occurrence of emphysema, — Johnston and
Sinclair^ (p. 517) had seven cases in the course of seven
years (13,748 labours) in the Dublin Hospital, or less than
1 in 2000 cases.
^Hology.-^It is generally agreed that emphysema of
the neck occurring during labour is due to bearing down.
This will be seen on reference to almost any case on
record (see table of references). Thus in the Dublin
Hospital all the patients affected were primiparse, and in
all the cases severe bearing-down efforts are noted ; it is
obviouR that any cause of obstruction to labour must so
far favour it.
The time of its occurrence tells the same story. It
never occurs before the second stage of labour, though it
may not show itself till the third stage or altogether
after labour (see Dunn's first case) In. any case, how-
^ For the Ust of works quoted in this papier see p. 67.
ON JEXPIBATOBT CBBVICAL BMPHTSBVA. 39
eyer^ it is no doubt produced during the second stage^
even if it does not appear till later.
It need not occur, however, in connection with parturi-
tion at all, but may follow violent coughing (as in Roche's
case, in which there was a foreign body in the trachea),
or perhaps straining at stool (see remarks by Dr. Otis on
McLane's case). Indeed the bearing down in labour
has nothing special about it except that straining is main-
tained for a longer time than under other conditions.
Clinical course, — ^It will perhaps be well to quote one
or two recent cases. Those of Dunn and McLane are
selected as amongst the latest recorded.
Dunn records four cases of emphysema during labour ;
with two of which no details are, however, given. These
are obviously cases of emphysema beginning below, and
probably in connection with rupture of the uterus. Both
ended fatally. This subject is alien to the present
inquiry. The other two cases are more to our purpose.
(1) The first of these occurred in a primipara, who had
an "ordinary labour ^^ (whatever that may mean).
During a violent effort to expel the placenta the right
side of the face became swollen and crepitant. (N.B. — It
pame out in the discussion that the swelling was first
noticed by the patient, and not till half an hour after the
expulsion of the placenta, which throws considerable
doubt on the time of the occurrence.) The swelling
seemed to begin on the lower part of the right sub-
maxillary region, and extended upwards on the nose and
cheek as far as the zygoma ; it gradually extended to the
neckj no other symptoms were noticed. After some
hours, the swelling, which was puffy and moveable,
extended to the upper side of the chest and right arm.
There was no cough, pain, or dyspnoea, and no change in
the respiration. In the next two days the emphysema
extended lower on the chest. The air remained four
days and then gradually disappeared.
(2) The emphysema in the second case began (?) on
the upper part of the right side of the chest under the
40 ON EXPIRATORY CERVICAL EMPHTSEMA.
clavicle^ and extended upwards as far as the zygoma and
down to the middle third of the chest; also to the
shoulder and upper part of the arm.
The details are so meagre that the order of the appear-
ance of the emphysema is open to considerable doubt, but
the localities afEected may be accepted as correct*
McLane's case was that of a primipara, est. 21. The
first stage was very painful, the pains being long and
very severe, lasting two hours, and necessitating the use
of chloroform.
During the second stage there was violent straining;
during one of these efforts the face became congested and
purple, a swelling appeared on the right side near the
trachea, and became much larger during the next three or
four pains, which followed each other rapidly. The
swelling extended to the right cheek. As soon as the
patient recovered from the chloroform she complained of
a constriction in the throat, and had some difficulty in
swallowing. " Her neck, previously slender, was now
thick and cedematous; her face so puffed that on the
right side the eyelids were closed, as if by dropsical
effusion, and the features effaced.^' The swelling crackled
on touch. There was no emphysema below the clavicle.
The whole swelling had disappeared in a week.
We learn from this and other cases that the swelling
appears during the second stage of labour, generally during
some violent straining effort, that it first appears in or
about the suprasternal notch, extends rapidly upwards
along the neck, and may reach the face ; it may also
extend down over the chest and down the arms. Its
course reminds us of that of extravasation of urine affec-*
ting the opposite sex in a different part of the body,
except that in the latter case the urine is unable to travel
down the limbs. To trace the possible course of the air
or the urine would be waste of time, since air easily travels
all over the surface of the body in the subcutaneous cellular
tissue — a fact practically useful in the skinning of animals
—and urine for its part may do the same« All varieties
ON IZPIRATOBT CEBVICAL EMPHT8EMA. 41
of its extension may be found in the appended references.
The other points of interest are that the air is all absorbed
in a week or so, withoat any ill-conseqnences, and never
ends fatally (a fact partly explaining the doubt as to its
pathology).
The last, but perhaps most important, fact is that
there is no disorder of respiration, and never pneumo'^
thorax.
Pathology. — ^We now come to the chief subject of our
investigation.
The theories to account for the phenomena are various.
Oloqnet (p. 88) gives a good account of a case which
of course recovered. He says, " It would be impossible
for me to define here precisely in what spot the bronchi or
their branches were ruptured.^'
MSnisre quoteQ Cloquet.
Blundell (p. 473) attributes it to '' rupture of the trachea
and bronchi.'^ He saw it twice in the same patient, a voci-
ferous Hibernian, and in no other case.
Depaul (p. 689) gives two post-mortem accounts in
which there was interlobular emphysema of the lung, but
not of the neck.
Watson (vol. ii, p. 176) says, ''Air passes into the
mediastinum, and so into the neck/'
Johnston and Sinclair do not explain it.
Bochi (p. 252) in a case in which a foreign body had
got into the trachea, found air in the mediastinum, and
double interlobular emphysema, especially on the left side.
Soyre refers to Cloquet's case, and says, " The rupture
of the trachea was situated a little above the bifurcation of
the bronchi/'
Oppolzer (p. 582) says that the commonest site of inter-
lobular emphysema is the anterior edges of the upper lobes.
" Serious consequences may ensue, if the air advances
towards the hilum of the lung and the mediastinum, and
from thence ascends into the subcutaneous cellular tissue
of the neck and &ce. This is, however, on the whole a
rare event/'
42 ON EXPIBATOBT CERVICAL SMPHT8E1CA.
Trauhe (p. 89) quotes Boch^.
Mackenzie (p. 205) quotes Watson.
Whitney (p. 350) relates a case, but does not speculate
on the pathology.
HaultcoBur (p. 420) refers to Depaul.
Schroeder (p. 455) simply says it is due to ''rupture of the
eir-vesicles.'*
Prince relates a case only.
Worthington does the same.
Atthill refers to Depaul.
Alexeef reters to Depaul and Haaltcoeur.
Nelson relates a case.
Spiegelberg (p. 419) mentions it only as an eyidence of
the force of bearing down.
Dunn (p. 897) remarks that in his second case inter-
lobular emphysema due to laceration of the air-vessels or of
the bronchial tissue was possible. This rapture generally
causes emphysema of the pleura, which may extend to the
subcataneous tissue of the thorax and body generally.
He remarks that Jones and Sieveking say that the same
condition may arise from laceration of the trachea. I
have repeatedly searched for this reference but failed to
find it.
McLane (p. 582) believed the lesion in his case to
have been rupture of the trachea. He had seen but one
other cascj and in that there was rupture of the pulmonary
vesicles.
We have thus a variety of theories :
(1) Rupture of the bronchi.
(2) Bupture of the trachea. .
(8) Rupture of the lung.
The post-mortem records bearing at all on the subject
are meagre in the extreme ; they comprise two autopsies,
showing interlobular emphysema of the lung, but not of
the neck (Depaul), one case of interlobular emphysema,
and air in the mediastinum (Boch6) ; the other theories
are not supported by any actual observations that I have
been able to find.
ON EXPIBATOST CBBVICAL EMPHYSEMA. 43
It became necessary then to pat these theories to the
test.
Mode of experiment. — ^Ifc was obviously impossible to
exactly imitate bearing down, but on considering the con-
jditions it appei^red that they would be best imitated by
patting pressure on the lungs filled with air and within
the thorax. If any encouraging results followed it would
ihen be advisable to stady th^ behaviour of the lungs
removed from the chesty so as to estimate the influence of
the thoracic box.
The desideratum was to produce emphysema of the neck
without pneumothorax. If pneumothorax should occur in
some cases and not in others it would remain to eliminate
its influence by a consideration of the cases.
Apparatus. — The apparatus consisted of a simple mercury
manometer marked in millimetres, attached to a tube ending
in a tracheal cannula. A T-piece answered the purpose of
a mouth-piece for the operator, connected on one side
with the manometer, and on the other with the trachea of
the fcetus throagh the tracheal cannula.
Some experiments were performed with the lungs in
situ, others with the thorax open, others with the lungs
removed from the chest. In one experiment an attempt
was made to trace the course of the air in former experi-
ments by means of a coloured gelatine mass.
ExFEBiMSNT 1. — March 24th, 1882. Male child, bom
March 23rd.
Experiment March 24th, 8 p.nu (about thirty-six hours)*
Tracheotomy was performed, a cannula tied into, the
trachea and connected with a V tube filled with mercury,
to the india-rubber tube of which was connected a T-piece,
through which inflation was practised.
On blowing throagh the T-piece the chest expanded,
then two small projections appeared below the third rib
on each side in the nipple line ; shortly afterwards the
skin along the right stemo-mastoid became swollen ; the
44 ON EZFIBATORT OBRYICAL EMPHYSEMA.
swelling was tympamtio; on pressare air escaped from
the tracheotomy wound.
The extreme height of the manometer = 50 mm., i. e.
height of mercurial column = 100 mm.
Autopsy. — ^Thorax opened under water. Double pneu«
mothoraz. Air bubbles beneath pulmonary pleura at the
reflection of the pleura from the root of the right lung over
the anterior mediastinum. Some diffuse subpleural em-
physema.
On inflating the lungs again after opening the thorax,
air distends the reflection of the pleura over the root of
the right lung still more, and on the left side in the same
manner, raising the pleura from the pericardium, and fol-
lowing the whole course of both phrenic nerves, dissecting
up the pleura.
On plunging the foetus again under water and blowing,
air escapes from two small holes in the anterior inferior
part of each lung, but in larger bubbles from the reflec-
tion of the pleura over the root of the right lung (f were
the small holes in the lungs punctures or ruptures).
The region of the cervical emphysema was next dis-
sected ; the air was found along the course of the right
internal jugular vein :
(a) A bubble could be pressed into this collection from
that in the anterior mediastinum.
(b) A bubble could be pressed the reverse way.
The air seemed to have passed from the anterior
surface of the right lung — near and in front of its
root — ^into the anterior mediastinum, behind the vena
cava superior, and so along the right internal jugular
vein.
BemarJea. — The object of the experiment was to see in
what direction air would escape from the lungs if over-
blown. This succeeded, the air passing from the lung
substance near the root, behind the pleura, and along the
great vessels of the neck.
Pneumothorax was, however, produced on both sides.
ON XXPIRATORT CBBVICAL EMPflTSAMA. 45
ExFSBiMBKT 2. — ^Marcli 31 st^ 1882. Foetas bom March
29tli^ after placenta pnevia (f fall time).
Experiment MarcH Slst^ 8 p.m. Traclieotomy was
performed and a cannula tied into the trachea as before.
Inflation was then practised intermittently^ so as
to imitate^ as far as possible^ bearing down daring
labour.
The maximum height of the mercury column = 60 mm.,
i. e, whole column = 120 mm.
Autopsy. — On opening the thorax, air escaped from
both pleurse. Uniyersal subpleural emphysema. Air
occupies the anterior mediastinum and spreads in front
of the root of each lang into the anterior mediastinum*
No emphysema in right side of neck. Air extends along
the course of the left internal jugular vein and can be
pressed into the collection in front of the root of the right
lung, to and fro ; it passes under the left innominate
vein.
On reinflating the lungs, air is distinctly seen to pass
from beneath the plearae near the root of the right lung,
in front of the right lung into the anterior mediastinum.
Similarly on the left side, where the air chose the same
path upwards along the left phrenic nerve. Air escaped
from several ruptures in the pulmonary pleurse.
Bemarks. — ^The object and results practically the same
as in Exp. 1.
ExPSBiMEUT 3.— April 4th, 1882. Fall-time male child,
bom after turning, April 2nd, 2 a.m.
Experiment April 4th, 8 p.m. An incision was made
from the ensiform cartilage to the pubes. Part of the
right fourth rib was excised, the pleura exposed, and a
cannula tied into the pleural sac, and then connected with
the manometer as before.
Inflation^ was then practised, and the mercorial column
raised to 50 mm., f. a. the column = 100 mm. in height ;
at this height air escaped through a hole made in dissec-
tion at the junction of the diaphragm and right lower
46 ON EXPIRATORY CSRVICAL EMPHT8BMA.
ribs^ wounding the diaphragm but not the plenra^ but
leaving the pleura unsupported and therefore weak at this
point ; from this spot the air travelled behind the peri-
toneum^ stripping it up. The cannula was qaite secure.
On the left side the same condition was found.
RemarJcs. — The object was to compare the strength of
the lung and pleara^ or rather of the lang and pulmonary
pleura^ with that of the parietal plenra. The experiment
failed, but it showed the extreme ease with whicb air
travels beneath the pleura and peritoneum.
ExPERiMBKT 4. — April 5th, 1882. Full-time male child,
born April 2nd, 1882.
Experiment April 5th, at noon. The same apparatus
Was used as before, except that the india-rubber tube,
instead of passing directly to the tracheal cannula, passed
to a Wolffs bottle filled with a warm solution of coloured
gelatine, which was therefore to be driven into the
lungs.
On blowing at the T-piece the gelatine solution passed
into the lungs.
The maximum height of the mercurial column = 30
mm., t. e, the height of the whole column = 60 mm.
Autopsy. — Coloured gelatine in both pleurae. The
pleurae universally oedematous with the same fluid, but
most has collected in front of the root of each lung, in
the anterior mediastinum, but not along the great vessels
of the neck. On blowing air througb the tracheal tube,
air escapes and forms emphysema on the front of the left
lung in one place, and on tbe front of the root of the right
lung, but in no other part. The most cedematous parts
are perfectly air-tight.
RemarTcs, — The object was to produce, if possible,
emphysema of the neck with some coagnlable injection,
to allow of a leisurely dissection. The gelatine, however,
simply transuded almost as if through a filter. I had
observed this in the case of water in an experiment not
here recorded. The most remarkable fact is that the
ON EXPIRATORT CEBVICAL XMPHTSEMA. 47
lungs are simple filters to flaid when they are still abso-
lutely air-tight. The bearing of this is wide, but need not
here be enlarged upon.
Experiment 5. — April 5th, 1882. Female child, born
April 13th, weight 4 lbs., length 17^ in.
N.B. — Manometer was broken at the beginning of the
experiment and could not be used.
Tracheotomy, cannula tied into trachea. Lungs in-
flated intermittently to imitate intermittent bearing down
during laboar.
Autopsy. — Double pneumothorax.
General subpleural emphysema, especially in front of
both roots of the lungs ; no emphysema of the neck.
On inflating the luDgs again, air slightly escaped from
a few places.
BemarJcs. — ^In the absence of the manometer an attempt
was made to repeat the production of emphysema of the
neck, but without success. The foetus was probably
immature.
Experiment 6. — April 17th, 1882. Male child, bom
April 15th, 9 a.m. (hand presented), full time. Length
20^ inches, weight 7 lbs.
Experiment April 17th, 11 a.m., i.e. fifty hoars after
death, continued for an hour and a half. Tracheotomy,
cannula tied into trachea, inflation intermittent.
An escape of air from the incision was noted, 7 froni
trachea. Cannula was tied in again.
Escape of air continued. The skin incision was pro-
longed to the sternum, the trachea was opened as low as
possible and the cannula tied in again.
Escape of air continued, apparently not from trachea
but from right side of it, in the region of the large
vessels.
N.B. The escape of air is only occasional, and does not
prevent the mercurial column from rising to 40 mm. {i.e.
column =80 mm.).
Autopsy. — Double pneumothorax.
48 ON EXPIBAT0B7 CERVICAL BMPHY8EKA.
Both langs show subpleural empbysema^ the right more
than the left.
A large collection of air-bubbles existed on either side in
front of the root of each lung^ the air having got beneath the
reflection of the visceral pleura over the mediastinum nearly
everywhere on the right side. Another collection of
bubbles on each side where the phrenic nerves reach the
diaphragm. A large collection in front of the base of
the right lung. The right half of the anterior medias-
tinum is one huge bubble ; there are no bubbles on the
left half.
The right side of the neck was very carefully dissected.
Air is present beneath right sterno-mastoid muscle, cor«
responding to the place from which it escaped during the
experiment. A continuous chain of air-bubbles extends
from the anterior mediastinum to the collection along the
vessels of the neck on the right side, following the course
of the phrenic nerve. Air can be pressed from collections
on the upper part of the diaphragm, along the course of
each phrenic nerve to the collection in front of the root
of each lung.
On the left side a few small bubbles are found in the
neighbourhood of the incision, and seem to have come
from the incision.
On reinflating the lungs, air can be seen to pass behind
the pleural reflection into the mediastinum as above, and to
escape freely from the surface of both lungs.
Remarks. — The object was still the same, and the ex-
periment succeeded in showing plainly the route taken by
the air from the lung to the neck, but pneumothorax was
also produced
Experiment 7* — June 26th, 1882. Small foetus, ob-
viously premature, bom June 24th.
Experiment June 26th, 5 p.m. Weight of foetus 2|
lbs., length 15^ inches. Tracheotomy, cannula tied into
trachea. Intermittent inflation. Maximum rise of mer-
curial column=40 mm. (t. e. height of whole column = 80
OK BXPIBATOBT CEBVICAL SMPHT8EMA. 49
mm.) Air escaped eventaally from the right side of the
incision.
Autopsy, — On opening the chest one or two doubtful
bubbles escape from the right pleural sac^ none from the
left.
Anterior mediastinum airless in most parts. Along the
great vessels on both sides (especially the right) there is a
continuous chain of air-bubbles^ passing behind the inno-
minate vein towards a collection in front of the root of
each lung.
Subpleural emphysema (slight) in one or two patches
in front of each lung^ but especially on their inner surface
near the root.
Remarlce, — ^The object was the same as that of the
preceding experiments, and the result very instructive.
On the right side the air had taken the usual route, but
there was a little doubtful pneumothorax. On the left
side, however, the air had passed into the neck without
escaping into the pleural sac.
ExPEBiMENT 8. — November 8, 1883. Male, full-time
foetus, quite fresh.
Experiment at 3 p.m. Thoracic viscera with the trachea
were removed en masse. The lungs showed a few super-
ficial lobules expanded, mostly at the apices.
The trachea was attached to the manometer, and a
looking-glass arranged so as to show the side of the lungs
away from the experimenter.
The pressure was begun at a rise of 5 mm. {i. e. the
height of the mercury column = 10 mm.), and the order of
expansion of the different parts observed. It was as
follows :
(1) Left apex.
(2) Bight apex.
(3) Vertical strip along costal angles behind.
(4) Extension downwards over both back and front,
most extensive on the right side, a few isolated patches
refusing to expand.
VOL. LXVIU. 4
50 OH XXPnUTOBT dBVICAL XMPHTBBItA.
(5) Slight bubbling below front of root of left long.
(6) „ aboTO „ „
(7) „ below „ rigbt lung.
(8) „ to ooter side of „ „
One patcb of subpleural emphysema the size of a hemp-
seed on the inner surface of the right upper lobe.
(Up to this time the rise of the mercury column did not
exceed 10 mm [«• a. the height of the whole column =20
mm.]).
Bubbling continued all round the root of the right long,
especially below, the spot of emphysema increased, and
one or two smaller ones formed near it.
Pressure was now increased to a rise of 15 mm. («. e.
height of whole column=30 mm.).
A large patch of emphysema formed at once on the
inner side of each upper lobe, as large as half a marble.
(N.B. — These patches spread when the pressure only
causes a rise of 5 mm., t. e. under a column of 10 mm).
One or two very small patches of emphysema were seen
at the sides of the lungs, but none in front.
A large patch formed on the under surface of the right
upper lobe, also in the fissures of the right lung.
The left lower lobe was then treated separately, the
cannula was thrust into the long substance and secured,
the lung was then inflated. Immediately, a large bubble
rose on the sur&ce, disappearing as soon as pressure was
relaxed, and reappearing instantly when it was resumed.
It was found impossible to burst this even when 100 mm.
pressure (i. e. a rise of 50 mm.) was steadily and repeat-
edly produced.
The bronchi being tied, it was found impossible to burst
them under the greatest expiratory force available (=a rise
of a 50 mm., or a column of a height ^100 mm.).
Bema/rJcs. — The object was to see the behaviour of the
lungs themselves uninfluenced by the thorax, (1) with
regard to the order of expansion of different parts, (2) with
regard to the comparative tenacity of different parts of the
lungs, (8) of the pulmonary pleura, (4) of the bronchi.
0)X SZPIBATOBY CBBVICAL EMPHTBBICA. 51
(1) The order of expansion is given above. It is
curious that the vertical strip along the costal angles^
which is one of the last places to be expanded when the
lungs are within the thorax^ should have been one of the
first to expand here.
(2) The weakest part of the lung was seen to be about
its root^ which gave way (subpleural emphysema) under
the pressure of a column = 20 mm.
(3) The strength of the pulmonary pleura was seen to
vary immensely ; here it could not be ruptured^ in former
experiments the pleura was ruptured by far less pressure.
(4) The bronchi could not be ruptured by the strongest
expiratory effort.
Emphysema^ once formed^ was seen to spread at a com-
paratively small pressure (column = 10 mm.).
ExFESiifENT 9. — November 8th^ 1882. Foetus female^
bom November 6 — 7 (midnight) and lived eight hours.
Artificial respiration had been performed.
Experiment November 8th, 10 p.m. Thorax opened,
but lungs not removed. No pneumothorax ; a few small
subpleural ecchymoses, lungs partly expanded.
Tracheotomy, cannula tied in trachea. Infiation (to a
rises 10 mm., or a colunm=20 mm.) caused no emphy-
sema.
The pressure was increased to a rise of 15 mm. (or a
columns: 30 mm.). Slight scattered interlobular sub-
pleural emphysema followed, most marked in the left lung.
On repeating inflation under the same pressure, emphy-
sema spreads, especially in the fissures.
The pressure was increased to a rise of 20 mm. (or a
column s= 40 mm.), and a bubble of subpleural emphysema
on the inner side of the right middle lobe gave way.
After several repetitions, a large bubble was seen to
occupy the posterior mediastinum, extending below and in
front of the root of the left lung, and gradually extending
upwards thence into the anterior mediastinum between the
thymus and pericardium.
52 ON EXPIRATOBT CERVICAL SMPHT8BMA.
Althoagh pressure was repeatedly increased to a rise of
25 mm. (or a column = 50 mm.) and although the posterior
mediastinum was full of air as far as the diaphragm^ no air
rose into the neck.
Remarks. — The object was to observe the behaviour of
the lungs in situ, bnt with the thorax opened.
(1) No emphysema took place till a rise of 15 mm. (or
a column = 80 mm.)^ t. e. the lung substance gave way at
this pressure.
(2) The first emphysema was between the lobules at the
surface of the lung.
(3) Emphysema appeared very early between the lobes.
(4) The pleura gave way at a rise of 20 mm. (or a
column = 40 mm.)
(5) The air did not rise into the neck.
ExPEBTXEKT 10. — November 9th^ 1882. Male^ seven
months child^ bom midnight November 6th — 7th, died
12.80 p.m. November 8th (thirty-six hours).
Thorax opened. Tracheotomy, cannula in trachea.
On inflating the lungs, a leak is seen in the inner edge
of the left upper lobe (the lung had probably been pricked
in opening the chest). The leak cannot be stopped.
Experiment failed.
Experiment 11.— December 29th, 1882. Pull-time
stillborn male child, of somewhat doubtful freshness (date
of birth unknown) .
Thorax opened, cannula tied into trachea.
Lungs entirely airless, very watery.
Slight expiration inflates patches of the lungs, especi-
ally on the posterior surface.
Additional inflation produces increased expansion of the
same parts, least behind.
Eventually the lungs became almost entirely expanded.
The pressure was increased to a rise of 10 mm. (or a
column = 20 mm.). No emphysema.
The pressure was increased to a rise of 15 mm. (or a
column = 80 mm.). Considerable emphysema of the front
ON SZPIRATOBT OBBYICAL BXPHT8BMA. 53
of the root of the right long occurred^ extending into the
fissure in front between the right upper and middle lobes^
and also (but less) emphysema of the anterior and inner
aspects of the upper and middle lobes. It began most
markedly between the lobules. A bubble burst on the
inner and anterior surface of the right upper and middle
lobes.
Numerous leaks haying occurred through the pleura
the root of the right lung was tied.
Pressure producing a rise of 10 to 15 mm. (or a column
= 20 to 30 mm.) produced well-marked emphysema oi the
front of the root of the left lung^ extending in the anterior
mediastinum and ^ inch along the course of the left
phrenic nerve.
On repeating this^ the inner surface of the upper lobe
became emphysematous^ and a bubble in that situation
burst. Emphysema extended into the fissure between the
upper and middle lobes.
The pressure was increased to a rise of 20 mm. (or a
column = 40 mm.)^ and produced much escape of air from
subpleural bubbles and extension of the emphysema from
the root of the lung downwards into the posterior
mediastinum.
The bronchi were then tied, and the greatest possible
expiratory force exerted^ causing a rise of 75 mm. (or a
column = 150 mm.).
No escape of air took place.
Bemarlci. — (1) Emphysema (= rripture of the lung)
took place at a pressure = a column SO mm. high.
(2) The pleura eventually gave way at this pressure.
(3) The front of the root of each lung was the first
place to give way.
(4) The spaces between the lobules and lobes {i, e. the
interlobular spaces and fissures) were weak places.
(5) The bronchi and trachea could not be ruptured by
the greatest expiratory effort.
ExPEBixxKT 12. — December 30th, 1882. Large full-
54 ON BZPIBATOBT OIBTICAL EMFHTSEXA.
time female child^ stillbom (placenta prssvia)^ about
twenty-four hours.
Thorax opened ; langs unexpanded and very sodden.
Tracheotomy^ cannula tied into trachea. Inflation vras
begun at a rise of 10 mm. (or a column = 20 mm«)^ and
produced scattered inflated patches on the anterior and
internal edges of all the lobes of both lungs^ most marked
inferiorly.
Second inflation at the same pressure produced an
increase of the same^ plus slight subpleural emphysema of
the left base posteriorly.
The third inflation at the same pressure fully inflated
the lungs and slightly increased the emphysema.
The pressure was increased to a rise of 15 mm. (or a
column = 30 mm.)^ and produced a leakage of air from
the left base.
The left base, seeming to be unusually frail, was tied
off, and the experiment resumed.
On repeating the inflation at the same pressure a large
patch of emphysema occupied the tip of the lingnla. A
large bubble formed in front of the root of the left lung,
and smaller ones on the inner surface of the left upper
lobe, mostly interlobular. The emphysema, still mostly
interlobular, extended over the left lung.
The left lung was next tied at the root, and the expe-
riment continued with the right lung.
Inflation was continued with a rise of 15 mm. (or a
column = 30 mm.), which produced interlobular emphy-
sema of the right base. Large bubbles occupied the
fissures between the middle and lower lobes.
The pressure was increased to a rise of^ 20 mm. (or a
column = 40 mm.) ; the emphysema extended over the
front of the middle lobe, and a bubble burst, probably in
one of the fissures.
The root of the right lung was tied and the strongest
expiratory force exerted. No leak was produced at a rise
of 80 mm. (or a column = 160 mm.).
Bemarks. — ^The order of inflation was unlike the
ON BZPIRATOBT dBBTICAL UfPHTSBXA. 55
former experiments^ perhaps in consequence of the sodden
state of the lungs.
(1) The left lung gave way (emphysema) under a column
20 mm. high^ the right under a column 80 mm. high.
(2) The left pleura gave way under a column 80 mm.
high^ the right under a column 40 mm. high.
(8) The spaces between the lobules and lobes (inter-
lobular spaces and fissures) were weak places.
(4) The bronchi and trachea could not be burst by the
greatest expiratory effort.
ExpxBiMBKT 18. — January Ist^ 1883. Full-time stUl-
bom child (craniotomy)^ bom twenty-four hours pre-
viously.
Thorax not opened. Tracheotomy^ cannula tied into
trachea and attached to mercury manometer as before.
The lungs were inflated at a rise not exceeding 10
mm. (or a column 20 mm. high)^ then the thorax was
compressed (the escape of air being prevented)^ causing
an increased rise of 30 mm. (or a column 60 mm. high) .
This was several times repeated^ to imitate as far as
possible the effect of bearing down.
A projection is seen above each clavicle^ apparently
from the apices of the lungs.
After several repetitions the left side of the neck was
seen to be fuU^ and on pouring water on the tracheotomy
incision bubbles were seen to escape from the left side of
the wound.
The initial pressure was now increased^ so as to pro-
duce a rise of 15 mm. (or a column = 30 mm.)^ and then
a rise of 20 mm. (or a column = 40 mm.).
Autopsy, — Considerable emphysema was found round
the root of left lung^ extending into the fissures and
posterior mediastinum. Interlobular emphysema of whole
of left lung, air escaping from several places. Slight
diffused subpleural and interlobular emphysema of right
lung, especially in front of its root.
No emphysema of neck.
56 ON EXFIBATOBT CBBVICAL IMPHT8SMA.
The bronchi being tied^ the greatest possible expiratory
efforts, prodacing a rise of 80 mm. (or a column = 160
mm.)j produced no escape of air.
Remarks. — (1) The dissection threw doubt on the
escape of air from the neck^ at least no air was found
along Jbhe great vessels on dissection.
(2) The emphysema was seen to occupy the inter-
lobular spaces^ fissures^ and the front of the root of the
right lung.
(S) The bronchi and trachea could not be burst by the
greatest expiratory effort.
ExPEJUMENT 14. — February 22nd, 1 883. Full-time still-
bom male child (face presentation), bom Febraary 19th.
Experiment February 22nd, noon. Thorax not opened.
Tracheotomy, cannula tied into trachea.
The lungs were then inflated by intermittent inflations,
the pressure causing a rise not exceeding 15 mm. (or a
column = 30 mm. high), and these inflations were con-
tinued half an hour.
Autopsy. — Lungs completely inflated, no emphysema.
Inflation was then continued at same pressure ; no further
result.
Pressure was then increased so as to produce a rise of
20 mm. (or a column = 40 mm.), producing a small spot
of suhpleural emphysema on the anterior surface of the
internal inferior angle of the right middle lobe, and in
several interlobular spaces on the inner surface of the right
upper and middle lobes.
On repeating the inflation, the emphysema spread and
extended in front of the root of the right lung, from
which air then escaped.
The emphysema extended to the left lung and in front
of its root, markedly between the lobules and in the fissures.
The emphysema then extended slightly into the right
side of the anterior mediastinum, above and in front (from
the front of the root of the right lung), and into the left j
side of the posterior mediastinum behind and below.
ON BTPIBATOBT OBBYICAL IKPHY8VMA. 57
The emphyBema then occupied all the fissnres of both
lungs.
The right side of the posterior mediastinum then became
emphysematous.
Both lungs eventually showed great emphysema behind
all pleural reflections.
Bemarhs. — The lungs were unusually air-tight ; it was
not till a rise of 20 mm, (or a column of 40 mm.) was pro-
^ duced that any emphysema appeared.
(1) The lung tissue gave way at a rise of 20 mm. (or
a column of 40 mm.) .
(2) The pleura gave way at the same pressure when
prolonged.
(8) The pleural reflections and the interlobular spaces
were the weakest. (These include the fissures and the
reflection of the pleura over the root of the lung to the
anterior mediastinum.)
BxPKEiitBNT 15. — February 27th, 1883. Male stillborn
child (premature labour at end of eighth month), bom
February 26th, 2 p.m.
Experiment February 27th, noon.
Tracheotomy, cannula tied into trachea. Lungs were
inflated at a pressure causing a rise not exceeding 15 mm.
(or a column = 30 mm.). This was repeated intermit-
tently for fifteen minutes, when the pressure was increased
to a rise of 20 mm. (or a column = 40 mm.).
No signs of emphysema of the neck.
Autopsy. — ^No emphysema except a small spot on the
inferior edge of the front of the right middle lobe
(? produced in opening thorax), from which air escapes.
On holding this, the emphysema spreads widely over all
surfaces of the right luug. The right lung was then tied
at its root. The left lung sustained a pressure causing a
rise of 20 mm. (or a column = 40 mm.) . On increasing
the pressure to a rise of 40 mm. (or a column = 80 mm.),
diffuse Bubpleural emphysema formed over posterior and
inferior surface of back of left base.
58 ON EXPIBATOBT CBBYICAL SMPHT8EMA.
Bemarhs. — The lung tissue only yielded to a pressure
equal to a column of mercury 80 mm. liigh.
ExpBEiMENT 16.— March 17th, 1883. Stillborn male
child, bom evening of March 15th.
Experiment at 11 a.m., March 17th. Thorax not
opened. Tracheotomy, cannula tied into trachea.
The lungs were inflated intermittently, the pressure
being gradually increased from a rise of 15 mm. (or a
column s 80 mm.) to a rise of 40 mm. (or a column = 80
mm.), at which pressure the column sank as if from a leak.
Autopsy. — ^Air in both pleura, a good deal of fluid ;
lungs very osdematous. One or two very small patches
of subpleural emphysema on both lungs. In front of the
root of the right lung is a large patch extending into the
anterior mediastinum in front, into the posterior medias-
tinum (which is greatly distended) behind, and into the
fissure between the right middle and lower lobes.
On the left side the root of the lung is simply surrounded
with emphysema, raising the reflection of the visceral and
parietal pleura along the inner edge of the lung in its
whole length, thus filling the posterior and left half of
the anterior mediastinum. From the front of the root of
the right lung bubbles extend to the phrenic nerve and
along its course to the diaphragm, where there is a large
collection of bubbles. No collection of bubbles is seen on
dissection on either side of the neck, but they can be
pressed from the anterior mediastinum upwards and escape
alongside of the great vessels on the left side, passing
behind the left innominate vein.
Swmmary. — Bupture of both lungs about their root at
a pressure of 80 mm. of mercury ; escape of air into both
mediastina, on the left side following the phrenic nerve to
the diaphragm. Pneumothorax (double), probably from
escape of air from a rupture of the mediastinum.
Remarks. — The weak parts were the refiections of the
pleura as before, especially the large ones in front of the
root of the luDgs and in the fissures.
OK IZPIBATOBT OIKVIOAL BMPHTSBMA. 59
Althoagli air was not actually found in the neck, a
free communication between the neck and the anterior
mediastinum was demonstrated. The passage of air along
the phrenic nerve to the diaphragm has already been
noted in other cases and also in the experiments on
artificial respiration ('Med-Chir. Trans.,' vol. Ixv, 1882,
pp. 77 and 80).
ExPERDCTNT 1 7.— March 20th, 1883. Pull-time stillborn
male child (second of twins) bom March 19th, 8 a.m.
Experiment March 20th, noon. Thorax not opened.
Tracheotomy, cannula tied into trachea.
Lungs were inflated at a pressure producing a rise not
exceeding 16 mm. (or column = 80 mm.)
Pressure was gradually increased to a rise not exceeding
20 mm. (or column = 40 mm.), giving twenty inflations
at each rise of 5 mm. (or increase of column = 10 mm.).
On reaching this pressure, the left aide of the neck
became distended, and air esca/ped from the left side of the
incisuyn.
Autopsy. — No pneumothorax. The lungs on being
inflated after opening the thorax are found perfectly air-
tight.
Left side. — ^Air extends along the large vessels of the
neck on the left side, and can be traced behind the left
innominate vein to the anterior mediastinum, where a large
collection is continuous with one in front of the root of the
left lung and extending into the fissures of the lung. Air
distends the posterior mediastinum and runs beneath the
whole reflection of the visceral into the parietal pleura,
along the inner edge of the left lung, and from thence
along the diaphragm to the termination of the phrenic
nerve ; a few scattered spots of subpleural emphysema,
especially on the " lingula."
Right side. — No emphysema of neck. Emphysema in
front of root of lung and upwards a little way along
phrenic nerve towards neck (N.B. — The middle lobe was
not separated from the upper) and along the inner side of
60 ON BXPIBATOBT CBBYICAL EMPHYSEMA.
the middle lobe following an intralobar fissure; also
(as on left side) in posterior mediastinum, extending
forwards to the ending of the phrenic nerve in the dia-
phragm, along the reflection of the pleura over the adjacent
sides of the anterior mediastinum, diaphragm, and peri-
cardium ; also upwards along the phrenic nerves.
No other emphysema.
Bemarhs. — Emphysema of the left side of the neck was
produced without pneumothorax. The air as usual had
escaped from the front of the left lung near its root,
into the mediastinum and along the great vessels to the
neck. The fissures were also occupied by emphysema.
The pleura (though not the lung) withstood a pressure
producing a rise = 20 mm. (or a column = 40 mm.).
Consideration of the experiments, — ^The production of em-
physema of the neck was effected in the very first experiment,
but it was not till Exp. 7 that it was produced without
pneumothorax (left side). This result was also achieved
in the last experiment. No. 17 (left side).
The difficulty was to find the necessary pressure.
The question of the significance of the cases in which
pneumothorax was produced will be discussed hereafter.
The route selected by the air was exactly the same as in
emphysema of the mediastinum after tracheotomy (after
entering the mediastinum), but in a contrary direction.
The source of the air was rupture of the lung tissue
producing interlobular emphysema near the anterior aspect
of the root of the lung.
The question why this spot is especially prone to rupture
was capable of two answers : (1) it might be due to inherent
weakness in this part of the luug, (2) it might be due to
the relation between the lung and the thoracic box.
This question was investigated by experiments on the
lungs with the chest open, or after their removal from the
chest. The results obtained showed that in lungs removed
from the pressure of the chest wall, the weakest parts are
the spaces between the lobules and lobes.
ON SXPIBATOBT CERVICAL EMPHTSSMA. 61
This is easily intelligible when it is remembered that
the plenra invests the lung with hardly any adhesion to
its snr&ce^ and that it can be stripped up with almost
inappreciable force by air beneath it. The strength of the
pleura is simply that of an independent investing elastic
bag. If the air escapes from a lobule it finds no resistance
from the pleura except on the surface of the lung^ and may
easily lie between the lobules without any pressure from
the pleura.
With regard to the fissures of the lung^ the same is true ;
the pleura is here^ so to speak^ slack and offers little or no
resistance to air once escaped from the air-cells.
But experiments showed that the root of the lung was
a specially weak spot with the thorax closed^ though not
with the thorax open. In other words^ when the thorax
was open it merely shared the weakness common to all
the pleural reflections.
This point requires some discussion. What is the
physical condition of the lung during inflation within the
closed thoracic walls? The thorax is distended^ the
diaphragm depressed, the sternum, clavicles, and ribs
elevated.
Is the thorax or the lung the more distensible f To
this it must be answered that the lungs can easily be
ruptured within the thorax.
But it nevertheless cannot be doubted that^ up to this
pointy the thorax supports its contents.
Does it do so equally in all directions ? Below,
we have the unbroken plane of the diaphragm ; behind,
in front, and at the outer side we have the ribs and
muscles. But at the inner side we have the compres-
sible mediastinum, whose easy penetrability was proved in
the experiments already alluded to dealing with the sub-
ject of mediastinal emphysema after tracheotomy. This
side then seems to be the direction of least resistance.
When once in the mediastinum, the air is already
within the track of easy penetrability or of slight resis-
tance, leading into the neck, and which probably owes
62 ON ISXPIRATOBt CEBYICAL EMPHT8EHA.
this quality partly to the fact that the upper aperture of
the thorax is the weakest spot in the thoracic box^ not
being directly defended by muscles^ which pass obliquely
from the neck to the upper ribs^ clavicles^ and sternum.
It must also be remembered that this upper aperture of
the thorax is enlarged on inspiration.
The above reasons show that the mediastinum may be
considered to be within the area of diminished resistance.
What happens in a bearing-down effort ? First a deep
inspiration^ which (among other things) raises the upper
ribs and clavicles^ and increases the size of the upper
aperture of the thorax. Next the glottis is closed.
Lastly the whole of the expiratory muscles^ essential and
accessory, put forth their strength.
The least resistance is offered to pressure at the upper
aperture of the thorax.
Thus tlien, on the anterior surface of the root of the lung
is the pleural reflection least supported externally.
We have now to consider the question of the signifi-
cance of the occurrence of pneumothorax in some of the
experiments.
Is the pneumothorax in these cases a link in the chain
ending in emphysema of the neck 7
A very little consideration will suffice to put such an
idea aside.
Let us consider the course of the air on this hypothesis.
It escapes from the air-vesicles beneath the pleura ; bursts
through the pulmonary pleura; must then distend the
pleural cavity ; then bursts through the parietal pleura,
and so gets beneath the deep cervical fascia.
First of all, the autopsies entirely contradict such an
assertion ; they show the course of the air to be different.
Secondly, the air beneath the pulmonary pleura finds
practically no resistance in travelling beneath the pleura,
but the pulmonary pleura is rather tougher than the lung.
The experiments show the tenacity of both lung and
pleura to vary very greatly in the foetus (whatever they
do in the adult), as the following table shows :
6^ XXFIBATOBt CJfistlCAL ]8M?HtSBltA. 63
Lowest force required to hurst the lung : —
Experiment No. 8 . . 20 mm.
„ „ 12 . . 20 „
Lowest force required to burst the plev/ra : —
Experiment No. 11 . . 30 mm.
„ „ 12 . . 30 „
Highest force required to burst the lung : —
Experiment No. 15 . . 80 mm.
Highest force required to bv/rst the plev/ra : —
Experiment No. 8 (N.B., locally) 100 mm.
„ ,,9 . . 40 „
fj >> 1^ • • 4U „
An attempt was made (Exp. 3) to test the tenacity of
the parietal pleura^ but it was unsuccessful. It must^
however, be remembered that the tenacity of a membrane
like the pleura must be very different when raised from
the subjacent structures (pulmonary pleura), and when
subjected to force, which only presses it the more firmly
on its supports. It can easily be imagined that a film of
collodion might add great strength to a membrane if
force was applied in such a direction as to press the film
against the membrane, while its strength would probably
be very small if it had to resist a force from below, that
is, raising it from its supporting membrane.
We therefore conclude that pneumothorax, when it
occurred, had nothing to do with the production of em*
physema of the neck.
We have avoided speaking of the clinical phenomena
which form the actual subject of our consideration, but it
must not be forgotten that pneumothorax never occurs
either with -emphysema of the neck during labour, or as
the result of expiratory efforts.
We have not hitherto spoken of the theories that regard
64 ON KZPIBATORT CBB7ICAL EMPHYSEMA.
emphysema of the neck as due to rapture of the trachea or
of the bronchi.
This may be dismissed in a word : The strongest ezpi^
ratory effort failed to bv/rst the trachea or bronchi ofafoetiis.
The experiment was repeatedly tried^ and amounts to a
" reductio ad absurdum ^' of the hypothesis.
It cannot be alleged that in the cases in which this
accident occurs during labour the patients have had
disease or fistula of their bronchi, or trachea, for the
patients may in all cases be^ and are nearly always,
expressly described as perfectly healthy, and moreover
they suffer no ill-effects.
To the question whether a lung can be ruptured with
impunity we must answer in the affirmative ; if the air
is all absorbed within a week from the subcutaneous
cellular tissue, why not from beneath the pleura ?
Again, the collection beneath the pleura must be small
or it would give physical signs, or at least marked sym-
ptoms, which, however, are always absent.
What actually happens is probably as follows : During
a violent expiratory effort an air-cell near the front of the
root of the lung gives way^ and the air lies beneath the
pulmonary pleura. With the next effort this becomes
larger, and part of it moves in the direction of least
resistance, namely, towards the mediastinum, next time
towards the neck, and so on, until a bubble emerges
beneath the deep cervical fascia. A channel will thus
be formed along which bubbles will pass as quickly almost
as they escape from the lung. They may form a large
collection in the neck, beneath the deep cervical fascia,
where the pressure is small ; eventually they may find their
way into the superficial fascia, and so all over the body.
The gelatine injection (Exp. No. 4) gave us the inte-
resting fact that a lung which is quite air-tight is quite
permeable for fluids. I had previously proved this as
regards water, and it is seen to be true also of a col-
loid mass. This fact has various and important bearings,
which this is not the place to enlarge upon. It may,
ON XXPIRATOBT CXBVICAL XMPHT8SMA. 65
however^ be remarked tliat the air-cells are lined with
an epithelinm not mnch removed from an endothelium,
snch as that which lines serons cavities which are lymph-
sacs and highly permeable to fluids.
The experiments are thns seen to illustrate the clinical
facts of emphysema of the neck during labour, and during
violent expiratory efforts.
The emphysema is essentially expiratory in its nature,
and due to a cause entirely opposite to that which is
answerable for emphysema of the mediastinum after
tracheotomy. In saying this it is conceivably possible
that expiratory emphysema might occur after tracheotomy,
though the conditions under which the operation is per-,
formed are well known to obstruct inspiration rather than
expiration. In this case the operation would have nothing
to do with the emphysema. Emphysema of the lung
may occur from over-distension of a part due to obstruc-
tion in other parts. This is a well-known clinical fact,
and was also illustrated in the experiments quoted above
CMed.-Chir. Trans.,' vol. Ixv, 1882, p. 78, Exp. 19 (L.).
In such a case the air which had escaped beneath the
pulmonary pleura might conceivably be forced into the
mediastinum. But the burden of proof in any case of
tracheotomy rests with the olmerver who asserts that the
emphysema which he finds, is due to expiratory rather
than inspiratory causes. The mediastiual emphysema of
tracheotomy is inspiratory ; the mediastinal emphysema of
violent expiratory efforts is expiratory. Mediastinal em-
physema without subpleural emphysema cannot be expi-
ratory. Subpleural emphysema without mediastinal em-
physema may be inspiratory as well as expiratory. Sub-
pleural, together with mediastinal, emphysema is probably
altogether expiratory, but the former may be due to inspi-
ratory over-distension of part of the lung with obstruction
elsewhere ; the latter may couceivably be due to the
expiratory forcing of the air thus escaped into the medias-
tinum. We are now only speaking of cases of tracheo^
tomy in which the derivation of the air from a cervical
VOL. LXYIII. 5
66 ON IXPIRATOBT CIBYICAL KMPHTSBMA.
woand is a possibility^ and the soarce of the air is there*
fore so far debateable.
Bat while allowing the above possibilities^ we wish to
repeat that the emphysema of tracheotomy occurs under
conditions which obstruct inspiration^ and is therefore
essentially inspiratory, the air being derived from the
cervical wound.
The following conclusions are offered :
1. The cause of emphysema of the neck during labour
is rupture of the lung tissue, the air escaping near the
root of the lung^ passing beneath the pulmonary pleura
into the anterior mediastinum^ and so beneath the deep
cervical fascia into the neck. The route thus marked is
the same by which air sometimes passes into the anterior
mediastinum after tracheotomy (see ' Med.-Chir. Trans./
vol. Ixv, 1882, p. 75,' et seq., and p. 85).
2. The weakest parts of the lung are opposite the
pleural reflections (that is the fissures) and the interlobular
spaces. The anterior surface of the root of the lung is
the weakest spot while the lungs are within the thorax^
being that pleural reflection lying within the comparatively
unsupported area near the upper aperture of the thorax.
3. Pneumothorax, when it occurred during experiment,
had nothing to do with the production of emphysema of
the neck, and in two experiments was not associated with
this emphysema, which thus exactly imitated that occurring
during labour.
4. The healthy bronchi and trachea are able to resist
the greatest possible expiratory efforts.
5. The lungs and pleuraa when quite air-tight are freely
permeable to fluids.
6. The usual rules of practice to restrain bearing down
and accelerate labour after the production of emphysema
of the neck are sound.
7. The accident would seem to be noted in about 1
case in 2000, but it is not improbable that slight cases
are overlooked*
ON EXPISATOBT CIBYICAL IMPHTSIMA. 67
8. The air emerges from the thorax along the great
▼essels^ but may not become superficial till it has travelled
higher up.
9. The emphysema of the lower part of the trunks
usually connected with rupture of the uterus^ belongs to
quite a different category and is generally associated with
a &tal result.
List of worJcs quoted.
Chquet {Jules). De Finfluenoe des Efforts sur les
organes dans la cavity thoracique. Paris^ 1820.
MSniere (P.). Arch. g6n. de M^d., xix, 1829, p. 841.
Blundell {James). Principles and Practice of Obstetricy.
London, 1834.
Depaul. Gaz. m6d. de Paris, Oct. 29, 1842, p. 689.
Watson {Sir Thomas). Principles and Practice of
Physic. London, 1857.
Sinclair {Edward JB.), and Johnston {Oeorge). Practical
Midwifery. London, 1858.
Bochi (Xr.). Bull, de la Soc. Anat. de Paris, 2e s^rie,
iv, 1859, p. 252.
de Soyre {Jules). Gaz. des Hdp., 1864, No. 92, p. 866,
and No. 100, p. 398.
Oppolzer. Yorlesungen uber specielle Pathologic und
Therapie. Brlangen, 1866 — 72.
Traube {Ludwig). Die Symptome der Krankheiten des
Respirations- und Circulations- Apparats. Berlin, 1867.
Ma^ckenstie {Colin). Amer. Jour, of Obst., vol. iv, 1871,
p. 203.
Whitney {James 0.). Best. Med. Surg. Jour., Nov.
30th, 1871, p. 350.
HaultccRur. Gaz. Obst., 1874, p. 420.
Schroeder {Karl). Lehrb. der Geburtshulfe, 4te Aufl.
Bonn, 1874.
Prince {A.). Lancet, Jan. 15th, 1876, p. 117.
Worthington {Francis). Brit. Med. Joar., Jan. 29th,
1876, p. 124.
68 ON IZPIRATOBT CIBYICAL IMPHYSBMA.
Atihill {Blennerha8$ett) . Obst. Jour., vol. iv, 1876,
p. 18.
Alexeef. Arch. f. Gyn. Band ix, 1876, s. 437.
Nelson {H. S.). Edin. Med. Journ., July, 1877, p. 43.
Spiegelberg {Otto). Lehrb. der Geburtshiafe, 1878.
Ohampneys {F, H.). Med.-Chir. Trans., vol. Ixiv, 1881,
pp. 41— 10 J.
Champneya {F. H.). Med.-Cbir. Trans., vol. Ixv, 1882,
pp. 75—86.
Dunn {W. A.). Bost. Med. Surg. Jour., April 26tli,
1883, p. 397.
McLane (/. W.). New York Med. Jour., May 26tli,
1883, p. 582.
[See also Ohahbazian. Arch, de Tocologie, Juillet,
1883.]
[For discuBsion on this ^aper see ' Prooeedinf^ of the Boyal
Medical and Chirurgical Society/ New Series, vol. i, p. 285.J
A SUOCBSSPUL CASE
OF
LUMBAR NEPHBECTOMY EOR RENAL
0ALCULTJ8.
BY
HENET MOEEIS, M.A., F.E.C.S.,
BVBGBOH TO, AVD LXCTVBBB OH BUBOBBT AT, THB MIDDLZBBZ
HOSPITAL.
(R«ceiTed May Sli(p-Read November S5th, 1884.)
RxuBEN W — J »t. 85^ a labourer^ was readmitted into
the Middlesex Hospital on the 18th of October^ 1888, for.
the purpose of undergoing an operation for the relief of
severe suffering due to renal calculus.
He had been a patient in the hospital on three previous
occasions, and an exploratory incision had been made, but
had not led to the detection of the calculus.
In May, 1882, he first came under the notice of Dr.
Douglas Powell, whose notes of the case were kindly
placed at my disposal. The patient at that time was
described as a dark-haired> stoutly-built man, complaining
of pain in his right side ; the pain was not constant, and
varied both in severity and position. It was sometimes
felt in the epigastrium, at others in the right testicle,
thigh, and loin, and shooting down to the bladder. Occa-
sionally it was so severe as to completely " double him
70 LUMBAB NSPHBECTOMT FOB BINAL CALCULUS.
up/' Palpation of the right iliac region gave pain, but
steady pressure often gave relief. The urine was 1035,
acid, and contained a little blood. His symptoms com-
menced at the end of 1881 (five months before admission)
with cutting pains in the pit of the stomach and right
loin, disturbing his rest throughout the night, but more
especially towards the morning. He had gradually become
worse.
Eleven years ago he had scarlet fever ; eight years ago
he was disabled for three months by a blow on his head.
He is prone to catch cold, and attributes the onset of his
illness to lying in a damp barn. He remained under Dr.
Powell's observation for a month, during which time his
urine was frequently examined. On the average he voided
40 ounces a day, of specific gravity 1025 — 1035, acid in
reaction, and containing a trace of albumen.
In November, 1882, he was admitted under me, and it
was at this time that I explored his kidney through an
incision in the loin, both with my fingers and the acu-
puncture needle. This operation seemed to give him
temporary relief, but soon after leaving the hospital in
December, 1882, his pains returned worse than ever, and
he passed a large quantity of blood with his urine. He
also passed two small stones about the size of pins' heads,
but no relief followed.
In May, 1883, he was readmitted, and remained from
the 1st to the 31st of this month. At this time pressure
over the loin caused pain along the course of the right
ureter, and in the right iliac fossa. The urine was 1025,
acid, and contained a little blood and pus, and crystals of
phosphates. There was nearly always a little pus in it,
but blood was less constant and always very limited in
amount. Sometimes the urine was perfectly clear, of
sp. gr. 1005 — 1010; at others thick and high coloured,
but it was always acid. When clear a much larger quan-
tity was voided.
Jolting movements, such as riding in a cab or railway
carriage, and muscular movements, did not increase his
LUMBAR NIPHBXCTOMT TOR RXNAL CALCULUS. 71
pain. Paroxysms of very severe pain came on whilst lie
lay qaite qaiet, and he was frequently awoke out of sleep
by them. It seemed as if any increase of intra-renal
tension, or of pressure of the bowel upon the kidney,
excited these paroxysms. There was a certain periodicity
about their occurrence; 12 midday and 1 a.m. being the
times of most severe suffering.
Another exploratory incisiouj to be followed by nephrec-
tomy if no calculus could be detected, was proposed, but
the patient desired to return home first.
On October 18th, 1883, he came back to me worse than
ever; a thin, haggard, worn-out looking man, with all
the old symptoms aggravated, and having paroxysms of
excruciating pain at all hours and under all circumstances.
The pain was still all on the right side. His urine had
the same characters as before. He had passed another
calculus a little larger than a swan shot; its passage
caused great suffering, but its escape was not followed by
relief. On October 28rd he was in great pain nearly the
whole day, and a small calculus, black and facetted, and
of the size of a pin's head, was found in the urine.
On October 24th the patient was put under an anaes-
thetic, and a transverse incision about three inches in
length was made in the right loin half an inch above
the old cicatrix. Having thoroughly explored the kidney
on both surfaces and compressed it all over between
my fingers and thumb, and having also punctured it, I
idled to detect any stone. The whole kidney was un-
usually hard, but no one part was harder or more resistant
than the rest.
With the assistance of Mr. Gk)uld and the house surgeon,
Mr. Thornton, I removed the kidney through the loin wound
in the following manner : After completing the separation
of the organ from its surroundings I made a vertical
incision downwards from the transverse wound, and one
inch in front of its hinder end. This was done by cutting
from within outwards with a straight prpbe-pointed knife
introduced upon the left index finger. This second incision
72 LUHBAB NBPHBEOTOMY FOB BBNAL CALCULUS.
mach facilitated the application of the ligatares. In an
aneurism needle specially provided with a long handle, a
long loop of twisted silk was passed, as I believe, between
the ureter and blood-vessels. The silk loop was divided and
the vessels tied with one half and the ureter with the other.
With the fingers of the left hand I then forcibly dragged
upwards the lower ribs, whilst with the right hand I drew
the kidney on to the surface of the body. Another liga-
ture was now applied so as to include the whole pedicle.
This was tied firmly. The kidney was next cut away with
a pair of broad-ended scissors. As the renal pelvis was
divided a rounded roagh calculus dropped out of the
kidney into the wound. The ligatures were all cut ofE
short. During the process of dragging the kidney from
its cushion of fat its surface was broken, and for a few
moments there was smart hsBmorrhage from the laceration.
This led me to be as rapid as possible in completing the
removal and applying the ligatures, without waiting to
attempt to stay the bleeding by pressare. After the
kidney was removed a medium-sized vessel in the depth
of the wound gave a little trouble, but was at length
secured by a pair of Wells^ forceps. These forceps were
left in for twenty-four hours, and served as an excellent
means of drainage in addition to the drain-tube. The
edges of the wound were sutured together, a drainage tube
was inserted, and terebene oil on lint, and a pad of absor-
bent cotton wool were retained on the loin by means of a
gauze bandage.
It is needless to report in detail the after-progress of
the case, as nothing occurred to interrupt recovery.
On the fifth day (October 29th) he complained of pain
at the commencement of micturition and continued to do
BO till November 7th. On the sixth day the stitches were
removed. On the seventh day drainage was discontinaed.
On the tenth day sleeping draughts were no longer needed.
On the twelfth day the bowels acted for the first time,
and in response to an enema.
On November 22nd the patient sat up for the first time.
LUMBAR NXPHREGTOMT FOR RIMAL CALCULUS. 73
Calcnlai as seen t'li iii4 m the kidney.
74 LUMBAB NIPHBIOTOMT FOB BINAL CALCULUS.
Noyember 29th. — Two decalcified bone drainage-tabes
were inserted into long narrow fiinuses ; the rest of the
wound had entirely healed.
December 11th. — He left the hospital in good healthy
but with one of the sinuses still unhealed.
The examination of the kidney after its removal dis-
closed a rounded depression in one of the calyces towards
the lower end of the organ. This depression was lined
with a thin cyst-like membrane and was spotted over
with several minute ecchymoses. The calculus exactly
fitted into it^ and had doubtless there lodged till it was
displaced by the manipulations necessary for the excision
of the kidney.
Dr. Ooupland kindly undertook the microscopical exami-
nation and found the kidney structure to be quite healthy.
The kidney was of normal size and of great hardness.
The calculus as it lay in its depression in the kidney was
so thickly surrounded by the renal substance that it could
not be detected by pressing the kidney with the fingers as
it rested on a table.
On July 28th, 1884, 1 heard from Dr. Frederick Pearse,of
Haslemere, to this effect : " W — is hard at work ' charcoal
burning/ the sinus still discharges a watery sero-purulent
fluid enough to soak through four or five pieces of thin
rag in twenty-four hours. He feels as well as ever he did
in his life, and is able to do his work without the slightest
inconvenience. Three or four threads have come away
through the sinus since his return from the hospital, and
he says there is another working out at the present time.''
On November 12th, 1884, Dr. Pearse wrote again:
" I saw W — a week ago. He is in excellent health and at
hard work (charcoal burning). The wound is not quite
closed yet ; there is still a little watery sero-purulent dis-
charge from it.''
Remarks. — ^This case illustrates the great difficulty
which must occasionally be expected in determining the
presence of a stone in the kidney by digital exploration
and acupuncture. The general symptoms pointed con-
LUMBAR NBPHfiBCTOMT VOB BIBNAL CALCTTLUS. 75
dnsivelj to renal calcnlns ; but it was an open qnestion
whether the disease was in the form of nephrolithiasis^
or of one or more distinct calculi of larger size.
The case teaches us not to conclude that a calculas^
even of moderate size^ is not present^ still less that no
calculus at all is there^ because we cannot discover it
either by probing with a needle or by compressing the
kidney between the fingers and thumb. It teaches also
that the abdominal incision^ no more than the lumbar
incision^ can lead to the detection of a stone when it is
thickly surrounded by renal tissue. The position of the
stone could not be made out either by the eye or the
fingers^ when the kidney was out of the body and resting
upon a table. It certainly could not have been detected
whilst the kidney remained in its fatty cushion in the loin.
The prolonged irritation of a calculus in the kidney appears
to have had a hardening effect upon the kidney tissue^
and in this way to have assisted in completely masking
the presence of the calculus.
Two questions arise with respect to the operative treat-
ment of similar cases of calculus in the kidney.
1. Before resorting to nephrectomy can any other step
be taken with the view of ascertaining the whereabouts
of a stone which has escaped detection by digital exami-
nation and needle probing ?
2. Is the lumbar^ or one of the anterior abdominal in-
cisions, the best for nephro- lithotomy, and for nephrectomy
for calculous kidney ?
In answer to the first question I would urge that the
renal substance should be incised from behind, so as to
lay open each of the calyces one after the other until the
stone is found. This of course is advised only for cases
in which the symptoms are severe and point in a marked
manner to calculus in one kidney. Our knowledge of
wounds of the kidney gives us assurance that haemorrhage
from such an incision would be easily controlled, that the
wound though large would readily cicatrize, and a good
working kidney would remain for future service.
76 LUMBAR NXPHBBCTOMT VOB BBNAL CALCULUS.
The risks of such an incision are mach less than those
of nephrectomy, and the patient would have the incalcn-
lable advantage of being left with two kidneys instead
of one.
In answer to the second question I think the lumbar
incision is to be preferred for nephrectomy for calculous
kidneys, and that it is the only incision which ought to be
employed for nephro-lithotomy.
The arguments which have been advanced in favour of
the anterior or abdominal nephrectomy are : (a) when the
peritoneal cavity is opened there is more room for the
necessary manipulations ; (6) that the surgeon can see all
that he is doing, and can secure the renal vessels before
commencing to enucleate the kidney; (c) that the existence
of a second kidney, and its condition, can be ascertained,
and the operation abandoned, if only a solitary kidney or
a diseased second kidney be discovered ; {d) that the end of
the ureter can be brought out of the wound, and that thus
the danger of suppuration along the tube can be avoided ;
(e) that in certain cases, such as hydronephrosis, pyone-
phrosis, and hydatid and simple cystic enlargements, the
peritoneal method, by making evident the nature of the
disease, has enabled the surgeon efPectually to treat the
case by incision and drainage, and thus to do away with
the necessity of nephrectomy.
Of these reasons the first two have only an occasional
importance, and need not be considered in calcalous affec*
tions ; whilst the others are for the most part purely
theoretical, and may sometimes lead to pernicious results.
That an abdominal operation commenced with the in-
tention of nephrectomy, may end advantageously by simply
opening and draining the kidney is no more in favour of
the incision through the peritoneum than of the lumbar
method. In most cases in which such treatment is possible
the cystic character of the disease can be diagnosed with-
out any exploratory incision ; the cyst can as readily be
opened behind the peritoneum as through it; and the
margins of the cyst are as easily stitched to the margins
LUMBAR NXPHBSCTOMT FOB BSNAL CALCULUS. 77
of the wound in the loin as to those of an incision on the
front of the abdomen.
I have thns dealt mosli satisfactorily through a lumbar
incision with the kidney when enormously enlarged by
hydronephrosis. The drainage afforded by the dependent
position of the loin wound leaves nothing to be desired^
and in this respect the lumbar method has a very great
advantage over any anterior abdominal procedure.
For the same reason — the advantageous drainage— the
divided ureter is best dealt with through the loin. In
most cases^ particularly of calculous disease, the ureter may
safely be left to take care of itself. When fixed to an
anterior wound there is an undeniable risk of intestinal
obstruction ; whereas in lumbar nephrectomy^ if suppuration
occur about the end of the ureter, either as the effect of
its own diseased state or of the ligatures on the renal
vessels, the pus can readily escape at the wound, instead
of forming an abscess in the abdominal cavity.
Dr. Williston Wright,^ in a case reported in the ' New
York Medical Journal,' brought the ligatures out at the
lower end of an incision along the outer edge of the rectus
muscle (Langenbuch's incision) ; intestinal obstruction
resulted, and an abscess which formed about the stump
of the renal vessels and ureter failed to empty itself
through the operation wound, but fortunately did so
through the ureter and bladder.
It seems to me to be anatomically wrong to drag the
ureter from the back of the abdomen in order to attach it
to the front, thus stretching it across the peritoneal cavity.
So that even if it should ever be proved the better practice
to open the peritoneum in cases in which an operation
could otherwise effect the same end without injuring that
structure, I do not think that anything could be urged in
favour of this treatment of the ureter.
Bespecting the examination of the opposite kidney the
argument seems plausible, but practically is almost useless.
In the first place there are many cases in which the
» 'New York Med. Journ.,' Feb. 17, 1883.
78 LUXBAB NBFHBECTOXT TOB BBNIL OALOULUS.
nature of the disease^ the character of the nrine^ and the
general condition of the patient make clear the diagnosis
as to the existence and sonndness of the second kidney.
In the second place^ of what value is a digital examination
of a kidney as it lies in the hody 7 Who^ holding the
kidney enveloped in its capsule and fat in his hand in the
post-mortem room, can do more than form an opinion as
to its outline and size 7 Who can thus judge of its
structure 7 Who can say that it is not fatty, granular^
lardaceous, tubercular, cancerous, congested, inflamed,
suppurating, or the subject of thrombosis 7 We know the
kidney may be irreparably diseased without being enlarged
or shrivelled, or without presenting any other character
which is recognisable until it is deprived of its capsule or
split into halves. So that in spite of a digital examina-
tion of the opposite kidney, and even partly because of it,
the fatal mistake may be made of performing nephrectomy
and leaving behind an organ seriously diseased and utterly
insufficient.^
If it be true that there are cases in which the normal
amount of urea is excreted by the hypertrophied areas of
two kidneys, the other areas of which are diseased, the
> instances of this kind in which nephrectomy will be thought
of are infinitely rare ; and the pathological condition is not
likely to be recognised by an intra-abdominal examination.
Where there is a quantity of circumrenal fat it is just
possible that even a shrivelled kidney could not be recog-
nised as such. We know a calculus may be undetected.
When there is a large solid tumour, or a painful
floating tumour (presumably a floating kidney) to be
removed, and owing to some congenital deformity or
deficiency, especially of the genital or urinary apparatus^
a single kidney is suspected, abdominal nephrectomy
should be performed. Therefore, without stating that
^ A case of nephrectomy for flcrofulous kidney which gave support to this
statement was mentioned in my reply to the discnssion on this paper (see
* Proceedings of Boyal Medical and Chirorgical Society/ New Series, vol. i,
p.
LUIfBAB NBPHBICTOXT FOB BVNAL CAL0ULU8. 79
peritoneal neplireotoiny ia never the better operation^
I ventare to assert tliat the lumbar method is the right
one in calcnlons disease. It is so for these reasons : first,
becaose up to the present time the mortality of the lumbar
operation has been only half that of the peritoneal; secondly,
the lumbar operation leaves the peritoneal cavity unopened ;
thirdly, the kidney is of a size to allow its easy removal
through the loin, especially if the ilio-costal space be in-
creased, as it ought to be during the operation, by forcibly
dragging upwards with the left hand the lower ribs;
and fourthly, the loin wound is the most favorable for
drainage.
As to nephrolithotomy, I know of no argument which '
favours the abdominal incision, or the combined abdominal
and lambftr incisions in that operation. All that can be
ascertained by the anterior incisions, about the organ to
be operated upon, can be discovered by the lumbar incision.
The incision of the pelvis renali8,or secreting substance, in
search of or for extracting a calculus, can only be safely
performed behind the uninjured peritoneum ; whereas, the
condition of the opposite kidney would not deter one from
the operation. On the contrary, if the second kidney is
diseased it becomes more urgent not less so to extract the
stone, and thereby to place the kidney operated upon in a
better state for aiding its fellow, or performing the whole
of the excretion.
As all mechanical measures which have been suggested
for ascertaining the character of the urine secreted by the
opposite kidney have proved to be either impracticable or
unreliable, we must depend upon the general symptoms
of each case, and upon the estimation of the daily excretion
of urea.
In connection with this subject two facts are forced
upon the attention by the present case. The first is that
we must not infer that the kidneys are diseased because
they do not excrete the average daily quantity of urea
according to the standard usually given for a healthy
adult.
80 LUMBAR NBPHBBOTOMT fOR RIKAL OALCULUS.
Persons wlio have long been living an invalid tife,
feeding on an invalid diet^ taking no exercise and there-
fore having little or no appetite, and who in consequence
of such a life and of suffering and sleeplessness have lost
flesh, may have very sound kidneys though they do not
excrete more than 250 grains {%. e. not half the standard
quantity) of urea in twenty-four hours. An adult under
these circumstances with two healthy kidneys may not
eliminate more than from *8 to 1*8 per cent, of urea in
from 25 to 35 ounces of urine.
Another remarkable fact is the rapidity with which the
single kidney increased its power of eliminating urea, though
it continued for a long time to discharge a smaller quantity
of water than the two kidneys together had done. This is
partly to be explained perhaps by the diet. The object was
to diminish the nitrogenous matters and fluids as much
as possible for the first week or two after the operation.
Thus though nearly all the food was taken more or less in
a liquid state, there was on the whole less fluid consumed
than there would have been under ordinary circumstances.
In the week immediately preceding the operation, the
daily average quantity of urine passed by this patient was
35 ounces, and the average daily quantity of urea 248
grains.
Five hours after nephrectomy 2^ ounces of urine of
sp. gr. 1022, and containing nearly 11 grains of urea were
passed ; and three hours later 1^ ounces of urine of
sp. gr. 1040 and containing nearly 5^ grains of urea.
During this time a little iced water and a little milk were
the only things swallowed.
In the next five days the average daily quantity of
urine was 28 ounces, and of urea 196^ grains. In the
second twenty four hours after the operation the one
kidney excreted exactly 196 grains, i. e. nearly four fifths
of the daily average of the two kidneys just prior to the
operation. This was a very sudden rise as compared
with the first twenty-four hours after the operation;
during this time 59^ grains of urea were eliminated in:
LUMBAB KlPEBBOTOMT MR BlENAl. CALCULUS. 81
addition to the I69 gprains of the eyening of the day of
operation^ wliich together made a total of 76 grains in the
first twenty-four hours.
The quantity of urine in the first twenty-four hours was
only llj ounces ; in the next twenty-four hours it was 28
ounces.
Between the seventh and twelfth days inclusive the
daily average of urea was 193 grains, and of urine
234 ounces— or 55 grains of urea less^ and 11^ ounces of
urine less than had been excreted by the two kidneys just
previous to the operation.
On and after the third day from the operation the diet
consisted of chicken jelly^ eggj tea^ bread and butter,
coffee^ milk, and custard.
From the fourteenth day the urea increased considerably.
It was very rarely below 200 grains, nearly always above
230 grains, often above 260 grains, occasionally above 320
grains. Even on the fifteenth day 296^ grains, and on
the thirty-sixth day as much as 385 grains were excreted.
On the thirtieth day 45 ounces of urine, containing
nearly 276 grains of urea were discharged, but with this
single exception the daily quantity of urine did not in-
crease until the sixth week. On the thirty-fifth day and
onwards till the patient left the hospital the normal
quantity^ and occasionally even much more than the normal
quantity of urine was passed.
I am indebted to Mr. Paul for the regular and careful
examination of the urine over a very prolonged period.
The results are of the nature of those derived £rom a
physiological experiment, as the kidney removed was
proved to be healthy^ and the kidney remaining has proved
itself so.
[For discubsion on this paper see 'Prooeedings of the Boyal
Medical and Ohirorgioal Society/ New Series, yoL i, p. 291.]
Poiiflmp^.— On Anguat 28th, 1885, Dr. Pearae wrote: "R. W—
told me that a week ago a piece like string came from the wound,
which quickly ceased to discharge, and is now healed up/'
VOIto LaViii*
82
LUMBAB NBPHBBCTOMT FOB BBNAL CALCULUS.
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LUHBAB HIFHBIOTOICT fOB SUTAL OALCdLUS.
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ON THE DISTRIBUTION
0> TBI
** TUBERCLE BACILLI" IN THE LESIONS
OF PHTHISIS.
BT
PEECT KTDD, SLA., M.5).Oxon.,
ABBISTAirT PHTBIOIAir TO THl H06PITA£ VOB OOVBVICPTXOK Ain> DI81A8B8
07 THE 0HS8T, BBOKPTOV.
BMdred April ISth— Bead Decembor 9th. 1884.
Thb publication of Eoch's memorable paper in tbe
' Berliner kliniscbe Wochenschrift,' in 1882, bas led to a
large number of inquiries into tbe relation of the so-called
tubercle bacilli to the process of tuberculosis. It may be
safely said that all attempts to discredit the existence of
these bacilli, or to assign to them inorganic properties,
have entirely failed. Indeed, it would seem rather that
there is a disposition to accept this particular micro-
organism as a full and su£Scient explanation of the whole
question of tuberculosis.
Tubercle bacilli, i. e, bacilli having the special re-action
to certain aniline dyes discovered by Koch, are now
known to be present in the pulmonary cavities of all cases
of true " tubercular phthisis."
It would also be granted that the same organisms can
be detected in the sputum of nearly all cases of this
88 TUBBBOLE BAOILLI IN THE LESIONS OF PHTHISIS.
disease^ at some stage or other of the patient's life. They
have been found in the lesions of artificial tuberculosis of
animals and in acute miliary tuberculosis and phthisis in
the human subject. It seems that whereas the bacilli are
very numerous in artificial tuberculosis, they are less
abundant in what are termed ^^ ti^berculous '^ diseases in
man. Under the last heading it is usual now to include
not only acute miliary tuberculosis and phthisis, but also
scrofulous glandular and joint afEections, and even
lupus.
The experimental side of the question has been ably
investigated in this country by Mr. Watson Cheyne, on
the lines laid down by Koch himself.
Mr. Cheyne*s report published in the ' Practitioner ' of
April, 1883, strongly confirms Koch's conclusions. The
results of the same observer's examination of a certain
number of cases of acute miliary tuberculosis and phthisis
agree with Koch's experience. Hitherto, however, the
number of observations on the distribution of '' tubercle-
bacilli" in the tissues of man has not been large in
England.
It seemed desirable, therefore, in view of the great
importance of the subject, to inquire into the distribution
of these bacilli in a large number of cases of phthisis.
It may be stated at once that this paper will be con-
fined mainly to the consideration of the anatomical relations
of these micro-organisms to the various lesions found in
this disease.
No attempt will be made to discuss the etiology of
phthisis or tuberculosis, except in so far as any informa-
tion concerning the local distribution of the " tubercle
bacilli" may seem to have a distinct bearing on the
question.
The results of the present investigation refer mainly to
the lung and in a less degree to the larynx, intestine, and
lymphatic glands. Other organs and tissues have been
examined in comparatively isolated cases and the results
obtained will be given for what they are worth.
TTTBIBCLB BACILLI IN THX LV8I0K8 OF PHTHISIS. 89
In the case of the long, the object kept in view was
to determine the anatomical distribution of the bacilli in
the various lesions comprised in the phthisical process ; in
other words, to find out whether they were present in all
the lesions of this disease, and if not, to determine their
seat of election.
In describing the anatomical lesions it will be convenient
to avoid the use of the term '^ tubercle '^ as far as possible,
especially in the case of the lung, so as to avoid miscon-
ception.
The following list may be said to comprise the main
pulmonary lesions of phthisis :
(1) Nodules in size from a millet-seed upwards.
(2) Tracts of consolidation, mostly lobular.
(3) Fibroid induration.
(4) Cavities.
The " nodules *' may occur singly or in groups, may be
transparent, opaque, or actually softening.
The '' tracts of consolidation '* may present all stages
from commencing catarrhal pneumonia (pinkish consolida-
tion) to complete caseation (caseous pneumonia) . Fibrin-
ous matter and small cells are found in some cases in
groups of alveoli.
The nodular lesions include bronchioles, alveolar
passages and their corresponding alveoli, together with
the alveolar walls. Such lesions may be regarded as
broncho-pneumonic.
In the case of phthisis and in most instances of acute
miliary tuberculosis, this description applies not only to
the larger nodules, but also to the true miliary granula-
tion.
The histological characters of these several lesions are
too well known to justify a detailed account of them here.
It must be borne in mind, however, that in the case of
phthisis the very earliest miliary nodules are nearly
always associated with a certain amount of fibroid growth.
This is found also in the corresponding lesions of acute
miliary tuberculosis in some cases, but in a very much
90 TUBBBCLE BACILLI IN THB LB8I0NS OF PHTHISIS.
slighter degree. This distinction must not be lost sight
of.
The consolidation which has been incidentally described
as lobular is sometimes apparently "lobar," and has
been so termed by some writers. This, however, is pro-
bably seldom the case. A careful examination rarely
fails to establish the lobular origin and nature of such
consolidation.
The term " cavities " is intended to include true pul-
monary and so-called bronchiectatic cavities.
Pigmentation may be associated with any of the fore-
going changes.
Methodf employed.
Hardening was effected by means of alcohol only,
except in a few cases, where a mixture of alcohol and
chromic acid one sixth per cent, was used.
The sections were stained with the Weigert-Ehrlich
solution of f uchsin, then treated with nitric acid, and sub-
sequently stained with methylene blue.
Oil of cloves was used for clearing the sections at first.
But since Koch's recommendation of oil of cedar in his
complete memoir {" Die Aetiologie der Tuberkulose,"
^Mittheil. aus d. Kais. Gesundheitsamte,' Bd. ii), I have
invariably used this instead, as the aniline colours are
insoluble in it. I have also discarded the ordinary
chloroform solution of Canada balsam, and have used
instead a solution of balsam in benzol for mounting sec-
tions.
In all cases the sections were examined with Abba's
condenser in conjunction with Zeiss's microscope, oculars
ii and iv. The lenses used were Zeiss's F, Hartnack's
Nos. 4 and 7.
Koch seems to suggest that the use of chromic acid as
a hardening agent interferes with the staining of the
bacilli. My experience in the six or seven cases that I
used chromic acid was that the bacilli were quite as well
TUBVBCLE BACILLI IN THE LESIONS OF PHTHISIS. 91
stained as when I used absolute alcohol only. I gave up
chromic acid, however, for the reason that it interferes with
the staining of the tissues with methylene blue. In chromic
acid specimens the tissues acquire a faint greenish stain
with the blue solution.
The blue staining also is far more perfect when the
sections are cleared with oil of cedar instead of oil of
cloves.
Oases,
1. Eliza Q, — Chranie phthiais.—^a.) Emphysematons long studded
with nodnlee of the size of a hemp-seed or rather larger. The
nodules consist of aggregations of caseating areas representing
groups of alveoli, alveolar passages, and bronchioles. The central
parts of the nodnlee are caseous, the peripheral portions consist of
a fibro-ceUular zone divisible into an internal and external territoiy ;
the latter containing more closely crowded ceUs of smaller size.
Numerous pigmented giant-cells are scattered through the fibro-
cellnlar zone. Oonnective-tissue development is proceeding in
this zone. Some of the nodnlee contain thickened and dilated
bronchioles ; in some cases the thickening is mainly of a fibrous
nature, in others it consists of a cellular infiltration. Scattered
small groups of bacilli are seen in comparatively few nodules, and
are situated in caseating alveoli. No bacilli in giant-cells. Some
micrococci in caseous matter in a few spots.
(b.) Scrapings from the wall of a large cavity contained numerous
bacilli.
(e.) Scrapings from a partially softened caseous mass contained
few bacilli.
(d.) Scrapings from a firm caseous part showed no bacilli
I have described the rough anatomy of the nodules in
the present case as being a fairly typical specimen of the
ordinary discrete nodular form of the disease. In the
remaining cases it may be assumed that the nodules con-
form in the main to the above type, unless a statement is
made to the contrary.
2. Edwin B, — Phihisis. — (a.) Lung with commencing catarrhal
92 TUBBBOLB BACILLI IN THE LESIONS OF PHTHISIS.
pneamonia» through which are scattered a few small fibro-caseons
nodnles. No bacilli in any part.
(&.) Emphysematous lung studded with similar nodules. No
bacilli found.
3. John P. — PMhi9%», — (a.) Emphysematous lung studded with
racemose groups of fibro-caseous miliary nodules. No bacilli found
in any part.
(&.) Thickened pleura containing fibro-caseous miliary tubercles,
with giant-cells. No bacilli found.
4. QvmUxo G.^Acute phihUi8,-~-(a.) Fibro-caseous nodules dis-
tributed through emphysematous lung. Bacilli in small groups in
a few caseous spots, large numbers in the walls of microscopical
cavities and in infiltrated brochioles.
(&.) Eibro-caseous miliary nodnles in thickened pleura. No bacilli
found.
5. Jame$ W.-^PMhisis. — (a.) Eibro-caseous nodules in slightly
emphysematous lung. No bacilli found.
(&.) Pleura much thickened, and containing fibro-caseous miliaxy
tubercles. No bacilli found.
6. Wm. F.'-Phthins. — Spongy lung studded with small whitish
nodules consisting mainly of fibrinous matter blocking up the alveoli,
and containing scanty small cells. Some alveoli filled with blood.
No bacilli found.
7. EUen B,—Phth%8i8. — Fibro-caseous racemose nodules in spongy
lung. Bacilli scanty, and only found in caseous alveoli here and
there.
8. Jane S.^Phthisis. — (a.) Opaque miliary nodules in oddematous
lung, consisting mainly of alveoli filled with fibrinous matter and
containing here and there a few large cells with indistinct out-
line. Bacilli extremely few and scattered in the ceUular parts only.
(&.) Larynx. Great thickening of aryteno-epiglottic folds, without
ulceration. Miliary tubercles in different stages and large-celled
infiltration in submucous tissue. Bacilli few and scattered in
epithelioid patches.
9. Henry J, — ChrofUe phthins, eoBiennve emphysema, mtieh pigment
tatum of Iwng and plewra, — (a.) Pleura. Fibro-caseous miliary
tubercles. No bacilli found.
(&.) Lung containing similar but larger nodules, in which caseation
is lees advanced, and traces of cells are visible. Bacilli in some
nodules, but as a rule scanty ; large numbers in a few spots.
10. John W. — Phthisis; disseminated miliary htbercfdosis, — (a.)
Lung containing miliary caseating nodules, yniih. numerous giant-
cells in coarsely reticulated ssone. No bacilli found in giant-cells,
TtTBKBCLB BACILLI IN THB LB8ION8 OT PHTHISIS. dS
or in any part of most of the nodules. In a very few cases^ two
or three bacilli were found in caseating alveoli.
(b.) Liver containing nnmerons fibro-caseous miliary tabercles,
with ntimeroas giant-cells. No bacilli found, but, in a few sections
some granules of the size of micrococci were found stained red.
These grannies were not in the tabercles, but were contained in liver-
cells in the neighbpnrhood of tabercles.
(o.) Miliary taberde of pia mater, with scarcely any caseation, in
connection with the wall, of a small vessel. Bacilli present in
considerable nambers among epithelioid cells.
11. Lowiia J*.— P^tAisM— Emphysematoas lang containing fibro-
4saseoas miliary nodoles. Bacilli in small nambers in a few caseoos
spots, and in larger nambers in microscopical cavities contained in
the nodales. A few bacilli in infiltrated bronchioles in some cases.
12. EUia H. — ^P^m».— Lang examined fresh after freezing. — (a.)
Small fibro-caseoas nodales. Bacilli rather few in caseoas alveoli,
and in sarroanding large-celled areas.
(b.) Firm, caseoas, pneamouic tract. Caseation aniform. No
bacilli foand.
18. Amelia B.^Phihini; pulmonary and laryngeal. — (a.) Taber-
caloas Ijrmphangitis of lang. A string of miliary nodales attached
to either side of the thickened interlobar septum, lang tissae
aroand spongy. Microscopically, the interlobar septam contained
caseoas tracts with giant-cells, the nodales on either side of it
exactly resembling those foand in the lang in ordinary cases of
phthids, and consisting of groaps of caseating alveolL Microscopical
cavities in nodales here and there. The miliary nodales were
evidently secondary to the caseation of the interlobar septam.
Bacilli in moderate nambers in some of the nodales where caseation
is recent, and in the walls of two microscopical cavities. No bacilli
in the old caseoas matter of septam, or in the giant-ceUs of this part.
(b.) Larynx. Deep taberoaloas alceration of the inter-arytenoid
fold. Scanty fibro-caseoas miliary tabercles, and abandant large-
celled infiltration. Bacilli in moderate nambers on the alcerated
sar&ce, and in the more saperfioial tabercles and infiltration.
Bacilli seen in one giant-cell.
14. Alfred F. — PhthiaiB. — Emphysematoas lang containing small
nodales, in which the fibroid tendency is anasaally pronoanced. No
bacilli foand.
15. Henry B. — Phihieie.^a.) Tracts of catarrhal pneamonia, with
scanty caseating foci. No bacilli foand.
(b.) Small fibro-caseoas nodales in spongy lang. No bacilli foand.
16. Eleanor M. — PkthieiB, — ^Taberoaloas lymphangitis. Thickened
d4 TUBBBOLB BACILLI IK THB LESIONS OF FHTHIStS.
pleura, containing miliary tubercles and caseous tracts. Subjacent
lung almost entirely spongy, with exception of its extreme sub-
pleural layer, in which there are numerous fibro-caseous miliary
nodules continuous with the thickened pleura. These nodules re-
semble those commonly found in the lung, consisting of infiltrated
alveoli and alveolar walls with microscopical cavities in the caseating
parts here and there. Bacilli in considerable numbers in the minute
cavities. None elsewhere. (See Plate II, fig. 3.)
17. Oeorge F.— Large caseous mediastinal glands, with subjacent
miliary tuberculosis of lung.
(a.) Caseous matter from gland, consisting simply of fine detritus,
contained no bacilli.
(b.) Fibro-caseous miliary nodules in lung. In most cases con-
tained no bacilli ; but in a few cases one or two bacilli were seen in
alveoli whose cells were beginning to caseate.
18. Eleanor C. — ^P^<^m«.— Fibro-caseous miliaiy nodules in em-
physematous lung. Much pigmentation. BacUli very scanty, in a
few caseous spots.
19. BdchairdH, — P^^m« ; jmeumo^^oroa;.— 'Examined fresh. Lung
containing fibro-caseous nodules of various sizes, with much small-
celled infiltration of alveolar walls. Bacilli very scanty, and only
found in extremely few nodules in caseating alveoli. Micrococci in
places in large numbers.
20. John P. — Phthisis; emphysema. — (a.) Emphysematous lung
studded with fibro-caseous miliaiy nodules. Two different parts
examined, (i) Early stage : nodules veiy scanty, (ii) Later stage :
nodules more numerous, and alveolar walls pigmented and infiltrated
with small cells. In a veiy few sections out of a large number
bacilli were found in the earlier lesions in caseous spots. None in
(ii) later stage.
(&.) Firm, caseous suprarenal capsules. Closely crowded case-
ating areas, with giant-cells and irregular large-celled infiltration.
A few bacilli were found in some few caseous spots and in surround-
ing large-celled zone.
21. JeremiahH, — Fhthisis ; ^^ne/umothoroK, — (a.) Small fibro-caseous
nodules in emphysematous lung. Bacilli in moderate numbers in
microscopical cavities in the nodules; less abundant in walls of
infiltrated bronchioles. Scattered groups in caseous aveoli, enor-
mous numbers in a few spots close to minute cavities.
(&.) Bronchial gland containing caseous areas and miliary tuber-
cles, with giant-cells in their peripheral course of reticulated zone.
A few bacilli in scattered caseous spots and in -tubercles here and
there ; rarely more than two bacilli in the same field.
tUBBBCLS BACItLI tN THllt LBSIOKS OV F£tTHI8IS. 95
(c.) Tnbercnlar ulceration of small mtestine. No bacilli found in
moat sections. One or two bacilli in a few fibro-caseons tubercles
in submucosa.
22. Susan S. — Phthisis. — Tuberculous lymphangitis of lung, start-
ing from thickened caseous interlobar septum. (Lesions exactly like
those in Oase 13.) No bacilli found in nodules or in caseous pleura
23. Thomas C— Phthisis, — (a.) Spongy lung, with scattered small
fibro-caseous nodules. Bacilli scanty, and only in scattered caseous
spots in nodules. «
(b.) Spleen. Amyloid degeneration and irregular caseous patches
containing giant-cells. No bacilli found.
(c.) Mediastinal glands. Fibro-caseous miliary tubercles, with
numerous giant-cells. No bacilli found.
24. John 0,~^Phthisis. — Spongy lung, containing closely set
miliaiy fibro-caseous nodules. Bacilli very numerous in the nodules,
among the caseating epithelioid cells, in caseous tracts, in the
infiltrated waUs of bronchioles, and in small microscopical cavities.
25. BUhmond W. — Acute phthisis, — (a.) Caseous pneumonia.
Caseation almost uniform and very firm. Contents of alveoli fibri-
nous in many parts. Scarcely a trace of cellular structure in most
parts. No bacilli could be found after careful examination of
different parts.
(&.) Tubercular ulceration of small intestine. Miliary tubercles
and large-celled infiltration in submucosa ; tubercles mostly recent.
Bacilli very numerous, and widely distributed in tubercles and epi-
thelioid cells; more abundant in tubercles. Bacilli in a few giant-
cells.
26. Case of phthisis, sent by Dr. Powell.— Extensive catarrhal
pneumonia, with irregular caseating patches. Bacilli few, and only
in scattered points where caseation is incomplete. No bacilli where
caseation is advanced.
27. Emma W.— Phthisis, — ^Early caseous pneumonia of very irre-
gular character. In some parts catarrhal pneumonia; elsewhere
caseous patches, in which are scattered softening foci. Bacilli very
irregularly distributed. The walls of microscopical cavities contain
enormous numbers. In most sections two or three large groups
are seen in caseous alveoli and interalveolar spaces, none in catarrhal
pneumonic parts. The bacilli are not widely disseminated, but
seem to be exclusively collected in large groups. Walls of small
veins in places infiltrated with epithelioid cells, among which bacilli
were seen in a few instances.
28. Bt^hen H.—Phthins; pneumothorax.--(a.) Caseous pneu->
monia like that in last case. Much catarrhal pneumonia. Bacilli
96 TUBBBOiiB BACILtil IN THE LB8I0)f8 Ot PHTtilSld.
in small nnmbera, bat widely diffused throngli parts where caseation
is early.
(b.) Mediastinal gland containing miliary tubercles and epithe-
lioid areas. Caseation commencing at yarious points. Bacilli
numerous both in tubercles and in large-ceUed infiltration, espe-
cially in cortical portion of gland where the disease is most marked.
29. Emihf P.—Phihins. — (a.) Gaseous pneumonia; caseation
irregular; much catarrhal pneumonia. Bacilli scattered in small
numbers where caseation is less advanced, collected in groups in a
few instances in caseous parts.
(h.) Caseous pus from Fallopian tubes, consisting simply of fine
detritus without any cell structure. No bacilli
30. EdUh Q, — PMhisiB. — ^Irregular caseous pneumonia resembling
last case. Bacilli in enormous numbers, collected in groups in
caseous parts. None in catarrhal pneumonic patches.
81. Bm£iy 0,^PMhi8is,—{a.) Gaseous pneumonia. Caseation
firm and uniform. Contents of alyeoli fibrinous in some parts.
Cellular elements in most sections absent or veiy scanty. No
bacilli could be found although numerous sections were taken from
different parts.
(b.) Larynx. Epiglottis enormously thickened and only veiy
slightly ulcerated. Numerous miliary tubercles in various stages in
submucosa, with abundant giant-cells; also extensive large-celled
infiltration. Bacilli veiy few in tubercles and in the base of the
ulcers.
32. £^a<6(7.—P^^m8.— Caseous pneumonia. Caseation very firm,
but less uniform than in last case, with scattered patches of catarrhal
pneumonia. No bacilli found in caseous parts. One group, how-
ever, found at margin of caseation in an alveolus containing an
increased number of epithelial cells.
33. Fred, H.—lAfmpho-M/reoma of MediasHnal Olanda invading the
hmg, which eantained cUso crops of miUary nodtdes, irregularly
pigmented paichee of greyish consolidation resembling caseous pneu-
monia, and soms small cavities, — (a.) Mediastinal glands showed the
usual lympho-sarcomatous structure, and contained no bacilli.
(b.) Pericardium thickened, and containing caseating tracts.
Bacilli in a few large groups among caseous material.
(c.) Lung. 1. The contents of small cavities contained extremely
few bacilli.
2. Large lymphomatous nodules showed same structure as medi-
astinal glands, and were free from anjrthing like caseation. No
bacilli.
3. Qreyish consolidated parts showed the structure of caseous
TUBIBCLK BACILLI IN THB LB8I0NS OV PHTHISIS. 97
pnenmonia combined with much catarrhal pneumonia. Bacilli in
great numbers in Tarious parts when caseation is early among
epithelioid cells, and in microscopical cavities. A few also in
infiltrated walls of bronchioles.
4. Miliary nodules consist of groups of caseating alveoli and
bronchioles exactly like miliary tubercles. No bacilli found in
these nodules.
34. George B, — AevAe miliary tubereuloeis. — (a.) Lung with vary-
ing amount of catarrhal pneumonia stuffed with enormous numbers
of slightly opaque miliary and submiliary nodules, and scattered
fibro-caseous nodules of larger size. In nearly all cases the nodules
obviously consisted of groups of alveoli filled with a finely granular
material, in which were traces of ceUs in some instances. Here and
there an alveolus was filled with large epithelial cells. Frequently
an infiltrated caseating bronchiole was seen in the midst of the
nodule or at one side of it. A large-celled infiltration of the walls
of small veins was seen in some sections. Groups of bacilli were
found in a few of the larger caseous nodules, but none were detected
in the smaller ones except in the caseating walls of some of the
bronchioles. Numerous sections from different parts of the lung
gave the same result
(b.) Spleen. Numerous fibro-caseous miliary tubercles with giant-
cells. No bacilli found.
(e.) Kidney. Cortex contained scanty caseating miliary nodules
and irregular patches of small-celled growth in which were traces
of tubules and glomeruli. Bacilli few, and only in caseous
spots.
35. Jessie H., est. 5^. — Acuie miliary tubercfdosis (specimens sent
by Dr. Angel Money). — (a.) Lung with irregular catarrhal pneu-
monic tracts, studd^ with rather scanty caseating nodules of the
size of hemp-seed. Th^ nodules consist of groups of alveoli filled
with caseating epithelioid cells, infiltrated bronchioles, and an irregu-
lar peripheral small-celled zone; giant-cells scanty. Centres of
nodules completely caseous in places. Bacilli present in enormous
numbers in almost eveiy single nodule, especially among epithelioid
cells, also in giant-cells, bronchioles, and in smaller numbers in
older caseous spots. No bacilli in small-celled zone, or in surround-
ing catarrhal pneumonic parts. Li one place the walls of a minute
arteiy were seen to be infiltrated with epithelioid cells, which gave
rise to a nodular projection from the intima into the lumen of the
vesseL which was patent and filled with blood-corpuscles. Bacilli were
present in great numbers among the epithelioid cells in the vascular
wall. (See Plate I, figs. 1 and 2.)
VOL. LXYIII. 7
98 TUBEBCLB BACILLI IN THB LESIONS OF PHTHISIS.
(h.) Liver. Scanty miliary tubercles. Bacilli in rather small
numbers in giant-cells, and among the epithelioid cells.
(c.) Spleen. Numerous miliary tubercles. Bacilli in large
numbers among epithelioid cells and in giant-cells.
36. Hubert F. L., est. 3. — Acute miliary tubereulons (specimens sent
by Dr. Angel Money). — (a.) Lung. Irregular patches of catarrhal
pneumonia and small caseous nodules and tracts. Bacilli in large
numbers in caseating tracts, comparatively few in nodules, none in
catarrhal pneumonic parts.
(b.) Kidney. Scanty miliary tubercles, in which there are traces
of caseation, and islets of small-celled infiltration in cortex. No
bacilli found.
(c.) Liver. Miliaiy tubercles. Bacilli veiy few in giant-cells,
among epithelioid cells, and in caseating foci.
87. Case of acvJte mUiaa^ tubercidosia in a child (specimens sent
by Dr. Ohaffey). — (a.) Lung containing scattered nodules as large
as hemp-seed. Nodules mainly consist of alveoli filled with fibrinous*
looking material, very few large cells, and scanty giant-cells. Bacilli
in great numbers in alveoli, few in giant-cells.
(b.) Liver. Extreme fotty degeneration and scanty miliary
tubercles, some recent, most of them fibro-caseous. Bacilli few in
giant-cells, among epithelioid cells, and, in a few cases, in more
recent caseous foci.
38. Case of acute miliary tuberculosis in a child (another case sent
by Dr. Ohaffey). — Lung thickly studded with miliary nodules, most
of which are undergoing a fibro-caseous change. Bacilli few and
scattered, among epithelioid cells, in some gpiant-cells, and in caseating
spots.
39. Oeorge H. — Acute miliary tuberculosis, — (a.) Lung oedematous
and studded with miliaiy caseating nodules. Bacilli in small numbers
and scattered in early caseous spots, where traces of epithelioid cells
are to be seen. None in surrounding tracts of catarrhal pneumonia.
(b.) Kidney. Scattered submiliaiy tubercles. Bacilli in rather
small numbers in most of the tubercles, among epithelioid cells, and
in caseating foci, groups in some cases. Some Malpighian capsules
contain a finely granular crescentic zone partially surrounding the
degenerate glomeiTilus, the whole capsule being encircled by an
outer epithelioid zone. Bacilli in varying numbers in the crescentic
internal amorphous (caseating) zone, and in the peripheral epithelioid
ring.
(c.) Liver. Numerous submiliaiy tubercles. Bacilli few and
scattered among epithelioid cells, none in giant-cells, which are
scanty.
TITBBBOLB BACILLI IN THB LB8ION8 OF PHTHISIS. 99
((2.) 3p^6^i^* Sabmiliary tubercles. Bacilli very few and scattered
among epithelioid cells and in a few giant-cells.
40. Amo8 P. — ActUe miliary tuberculoeis.—'Lxmg containing evenly
distributed miliary tubercles, in which caseation is beginning in
nearly all cases. Bacilli few in giant-cells and among epithelioid
cells.
41. Geo. C. — Phihisia. — ^Thick fibroid wall and trabecnla of large
cavity. Bacilli in moderate numbers in superficial caseous layer in
both positions. None in deeper parts.
42. Eli M,^Phthi8i8, — (a.) Fibroid wall of small suppurating
cavity. No bacilli found in sections, in consequence probably of
superficial layer having been detached in preparation, for a scraping
from hardened cavity wall showed abunduit bacilli.
(h.) Tubercular ulceration of small intestine in early stage. No
bacilli found in most sections. One or two bacilli in a few fibio-
caseous tubercles.
(e.) Mediastinal gland containing firm caseating patches with
giant-cells. No bacilli found.
48. James M.^PMhisie, -^Thick fibroid wall of small cavity. No
bacilli seen in cavity wall in sections. A scraping from the cavity
wall after hardening showed a few bacilli.
44. Hugh C. — PMhi8i8.—{a). Pleura thickened, and containing
fibro-caseous miliary tubercles with numerous giant-cells and case-
ating tracts. No bacilli found.
(&.) Trachea. Superficial ulceration with necrotic caseating sur-
face. Small-celled infiltration of mucosa and round about mucous
glands and ducts. No miliaiy tubercles or large-celled growth.
No bacilli in the tissues; one or two are seen on the ulcerated
surface.
45. Edward S.—PhUtisie, — Pleura thickened and containing case-
ous tracts. No bacilli found.
46. James L. — Saeculated hronekieetasis ; abscess of brain, — Exten-
sive excavation of one lung, with foul, inspissated, secretion-like
softening caseous matter. Bronchi generally dilated. No " tuber-
culous " lesion.
(a.) Foetid purulent expectoration during life contained no bacilli,
but numerous micrococci.
(b.) Discharge from cavity after tapping during life contained
micrococci, but no bacilli.
(e.) Contents of cavities after death contained micrococci, but no
bacilli.
(d.) Pus from cerebral abscess contained micrococci, but no
bacilli.
100 TUBBBCLIB BACILLI IK THK LB8ION8 OV PHTHISIS.
47. Charles H. — Sacculated branehiectans ; dbeceee of brain. — Cavi-
tieB in right upper lobe with contents like those in last case. Bronchi
genenJlj dilated. No " tuberculous " lesion.
(a.) Canity contained micrococci, but no bacilli
(b.) Pus from cerebral abscess gave a similar result.
48. Charles L, — Aneurysm of aoria^ compressing ^ft bronchus. —
Ezcayation of left lung (bronchiectatic). Oavity contents contained
some micrococci and a few putrefactive bacilli, but no " tubercle
bacillL"
49. Margaret 8. — Byphilitic stricture of bronc^iw.— Excavation of
corresponding lung (bronchiectatic). Cavity, secretions contained
no " tubercle bacilli." A few micrococci.
50. Archibald M.^Malignant disease qf lung ; tareoma.— Nodules
of all sizes and small cavities containing blood-stained grumous
fluid.
(a.) Cavity secretions contained no " tubercle bacilli."
(b.) Nodulai* growths in lung contained no badllL
51. Walter A. — Laryngeal |>^i^m«.— Tubercular ulceration and
great thickening of aryepiglottic fold. Tubercles scanty. Extensive
large-celled infiltration. Bacilli scattered in small numbers on the
floor of the ulceration and in the submucous tubercles and epithe-
lioid patches.
52. Charles L. — Laryngeal phthisis. — Tuberculous ulceration of
larynx and trachea. Small tumours apparently situated on vocal
cords, but really springing from lateral aspect of interarytenoid
fold. Bacilli in large numbers in the tubercles and epithelioid
areas, in arynx and trachea, and even more abundant in the small
tumours, which consist of collections of miliary tubercles with inter-
vening epithelioid areas.
53. John B. — PWfcm«.— Larynx. Tubercular ulceration of inter-
arjrtenoid fold. Numerous caseating miliary tubercles, and large-
celled growth in mucosa and submucosa. Bacilli present in very
scattered spots and in small numbers at the surface, and in the
more superficial tubercles and epithelioid areas.
54. Wm. J. r.— PWAww.— (a.) Larynx. Deep tubercular ulcera-
tion of the interaiytenoid fold, exposing the muscular layer. Bacilli
in enormous numbers on the floor of the ulceration and in the sub-
jacent tubercles and epithelioid areas.
(6.) Intestine. Deep tubercular ulceration of ileum. Bacilli
numerous at ulcerated surface and in submucous tubercles. Some
bacilli in places in subserous tubercles.
55. Wm.F. — Phthisis, pulmonary and laryngeal.— iMrynx. Miliary
nodules, without ulceration in their immediate vicinity^ in the
TUBEBCLK BACII^I IN THR LB8ION8 OF PHTHISIS. 101
" ainnB pyriformis/' consistizig mainly of small-celled growth, with
scattered, fiEuntlj staining, large-celled areas. A very few bacilli
were found in the latter position in a few sections only.
56. OeorgeO.^PMhisis, pulmonary and laryngeal, — Larynx. Tnber-
eolar ulceration, with great fibroid thickening, both in the base of
the nlcers and in their neighbourhood. Bacilli extremely scanty in
tubercles here and there.
57. Thomas C — P^/tms, pvllmona/ry and laryngeal. — Larynx.
Ghreat swelling of epiglottis, with scarcely any ulceration. Miliary
tubercles and large-celled infiltration. Bacilli widely diffused in
large numbers in tubercles and large-celled patches. Many giant-
ceUs contain bacilli.
58. John P. J. — Laryngeal phthisis, — (a.) Tuberculous ulceration
of larynx and trachea. Tubercles recent in larynx ; fibro-caseous in
trachea ; epithelioid areas. BadUi scattered in very small numbers
through tubercles, and large-celled infiltration in larynx and trachea.
(b.) Tuberculous ulceration of csBCum. Bacilli few and scattered
in caseating tubercles and in tubercles of reticulated tjrpe.
(e.) Mesenteric gland, containing recent miliary tubercles and
larger fibro-caseous nodules. Bacilli scattered in small numbers
through both yarieties of nodule.
59. Frederick J. — LaryngeaX phJthisis. — (a.) Pharynx. Tubercular
ulceration. 1. Small superficial ulcers with suljacent miliary tuber-
cles and epithelioid areas. Bacilli scattered in small numbers in
tubercles and large-celled patches.
2. Large sharply-cut ulcers with much fibroid growth in their
bases. Scanty miliary tubercles of fibro-caseous structure. No
bacilli found.
(&.) Tubercular ulceration of larynx. A small tumour growing
from interarytenoid fold amidst the ulceration, and consisting of
miliary tubercles and epithelioid areas. Bacilli numerous in both
lesions of tumour.
60. Eliaabeth 8. — Phihisis, — Tuberculous ulceration of small in-
testine. Bacilli very few, and found in a comparatively small
number of sections in the floor of the ulceration and in fibro-caseous
submucous tubercles. In a few instances groups of small spherical
granules like micrococci stained red were found in the submucosa.
These bodies appeared to be situated in fat-cells. In the same
sections other fat-cells contained groups of somewhat similar
granules stained blue.
61. WHliam IT.— P^^wm.— Tubercular ulceration of small intes-
tine with numerous fibro-caseous miliaiy tubercles in the subserous
tissue. Great atrophy of intestine. No bacilli found except in one
102 TUBERCLE BACILLI IN THE LESIONS OF PHTHISIS.
section, where a caseating sabmncons tubercle contained one well-
marked badllns.
62. Janet W. — Phthisis. — ^Intestine. Superficial ulceration and
cellular infiltration of mucous coat. No tubercles or " tuberculous "
structure. Lymphatics stuffed with small cells. Fibroid induration
where the disease is most advanced. Great atrophy of intestine.
No bacilli found.
63. Henry B, — ^P^%m«.— Intestine. Tubercular ulceration in
different stages in different parts. No bacilli found in early • or
advanced ulceration.
64. EmU/y C — Phthisis, — Intestine. Deep tubercular ulceration
exposing muscular layer. Submucous tubercles. Bacilli fairly
numerous at the ulcerated surfisu^ and in caseating tubercles.
65. John M. — Phfhisis, — Superficial ulceration of small intestine,
with abundant small-celled infiltration of mucosa and submucosa.
Fibroid thickening of base of ulcers in places. No tubercles or
epithelioid areas. No bacilli.
66. James B, — Phthisis, — (a.) Superficial ulceration of small intes-
tine, with small-celled infiltration of mucosa and submucosa. Nq
tubercles or epithelioid areas. No bacilli found.
(&.) Similar infiltration, but no ulceration. No bacilli found.
Great atrophy of intestine in both cases.
67. John H, — Abscess of liver, — Ulceration of large intestine with
enormous fibroid thickening of gut, probably due to old dysenteiy.
Small-celled infiltration of the whole intestinal wall, witii widely
disseminated micrococci, but no bacilli.
68. John H, — Phthisis, — ^BroncLial gland containing caseating
areas and fibro- caseous miliary tubercles, with giant-cells. No
bacilli found.
69. Annie E, — Phthisis,^BTanchiBl gland. Similar disease to that
in last case. No bacilli found.
70. Daniel E. — Phthisis, — (a.) Mesenteric gland. Caseation com-
mencing in most parts, numerous miliary tubercles and epithelioid
tracts. Bacilli in enormous numbers in all lesions in every single
section examined (see Plate II, fig. 4),
(b.) Liver. Fatty degeneration, early cirrhosis and miliary tuber*
culosis. Badlli in.fieur ntimbers in giant-cells and among epithelioid
cells of tubercles.
71. Samiml L.'—Phthisis, — ^Mesenteric gland in state of uniform
firm caseation. No bacilli found.
72. Hena^ P.— P^^ms.*— Mediastinal gland containing caseating
areas and fibro-caseous miliary tubercles. . Bacilli extremely scanty
in tubercles.
TUBBBCLB BACILLI IN THE LESIONS OF PHTHISIS. 103
73. Arthur T.—PhikUie. — Traolieal gland. Caseating areas aad
miliary tubercles, some recent, others fibro-caseous. Bacilli in very
small numbers in few sections in tubercles and caseous patches.
74. George B, — Aneurysm of ^orfa.— Becent miliary tuberculosis
of pleura, mediastinal glands, and peritoneum.
(a.) Mediastinal gland. Miliaiy tubercles containing giant-cells
and epithelioid areas. No baeilU found.
(b.) Peritoneum. A transparent miliary tubercle crushed out and
examined in fresh state. Bacilli few around epithelioid cells.
75. Henry P.-^Phihieis, — (a.) Tongue. Tubercular ulceration.
Submucous and intermuscular miliary tubercles and epithelioid
areas. Bacilli in considerable numbers in the floor of the ulceration
and in the more superficial tubercles and large-celled infiltration.
In a few spots the bacilli were very numerous.
(h.) Oaseous abscess of sacro-iliac joint. Bacilli rather few in
caseous matter.
76. Tho8, A. — Phthieia, — Tubercular ulceration of tongue. Very
abundant miliary tubercles and large-celled infiltration in sub-
mucous and intermuscular tissue. Caseation beginning in some of
above lesions. Fibroid induration in submucosa. Bacilli in enormous
numbers in both forms of lesion, both in superficial and deeper
parts.
77. John P. — PW^MM.— Tongue. Small tubercular ulcer. Miliary
tubercles with giant-cells, epithelioid areas and caseating patches in
subepithelial layer, and between muscular bundles. Bacilli very
numerous in all the lesions.
78. A ease ofphihisie, — Transparent miliary tubercle of peritoneum
examined fresh. Bacilli few, among epithelioid cells.
79. A ease ofphthina. — Miliary tubercle of peritoneum. Examined
in fresh state. Contained a few bacilli.
80. Andrew M, — Pkthieie, — Thickened pericardium containing
scanty miliary tubercles. Some tubercles fibro-caseous, others of
reticulated type. One well-marked bacillus found in a tubercle of
lattOT class. No bacilli elsewhere in numerous sections.
81. John C — Phthieie, — ^Kidney containilig small, irregular, caseat-
ing patches in cortex, and small-celled foci. Bacilli few and only in
caseous spots.
82. Charles D.— Phthisis, — Caseous masses in kidneys. Smaller
masses shreddy, larger ones putty-like. Bacilli veiy numerous in
shreddy parts ; very scanty in older putty-like material.
83. Phthisis, — ^Tubercular meningitis. Miliary tubercles examined
fresh. Bacilli in fair numbers amid the epithelioid cells of peri-
vascular tubercles.
104 TUBBRCLIB BAOILLI IN THE LESIONS OF PHTHISIS.
84. P^^ms.— Tubercular meningitis. Perivascular miliary tuber-
cles, in which caseation was beginning, contained considerable
numbers of bacilli among epithelioid cells.
85. Oeo, A, — Phthisis, — ^Tubercular meningitis. Sections of hard-
ened "pia mater" showed well-marked perivascular miliaiy tubercles,
with commencing caseation in most cases. Bacilli in fair numbers
both in recent and old tubercles.
86. Charles H. — Abscess of lioer. — Yesicula seminalis on one side
caseous. Bacilli in moderate numbers in soft caseous contents.
87. John F, — Ph^isis. — Bladder. A group of snkU circular super-
ficial ulcers. Oellular infiltration of mucous coap. No tubercles.
Some few bacilli stained blue in base of ulcers. In one section only
a minute caseous nodule was seen embedded in the edge of an ulcer.
This nodule contained two or three well-marked red bacilli
88. Jane M.^Phihisis, — ^Fallopian tube distended with firm caseous
matter. Bacilli extremely scanty in caseous contents.
89. Mary Josephine B. — Phthisis, — Uterus with caseous degenera-
tion of its mucous membrane and irregular ulceration. A few
bacilli found in caseous lining.
90. EUen 8. — Phthisis. — Scrofulous disease of tarsus and of
kidney, (a.) Pui-iform matter from diseased tarsus contained very
numerous baciUi. N.B. — The joint had not been opened, and there
was no communication with the atmosphere.
(b.) Caseous masses in kidney contained numerous bacilli.
The results of the examination of the tnberculons cases
may be thus stated :
Lung . . 31 cases of nodular lesion. Bacilli found in 24
„ . . 10 „ of caseous pneumonia. „ 7
Larynx *) ^3
Tracheal
Intestine . . 12
Lymph, glands 18
Pia mater . 4
Peritoneum . 3
Pericardium . 2
Tongue . . 3
Liver . . 6
Kidney . . 6
Spleen . 4
Scrofulousjoint 2
12
8
6
4
3
2
3
5
5
Bacilli were also foand in single cases in the vesicnla
TUBKRCLK BACILLI IN THE LESIONS OF PHTHISIS. 105
seminalis, Fallopian tube, uterine cavity, bladder, and
suprarenal body.
With reference to the intestine it must be remembered
that in three out of the four cases in which no bacilli
were found, there were no " tuberculous '' lesions in the
base of the ulcers.
In the account of the various cases no detailed record
has been given of the examination of the contents of pul-
monary cavities. I have never yet failed to find bacilli
in the cavity secretions of " tuberculous '* cases in a large
number of observations. They were most plentiful in
vomicae containing thick caseous secretion, and where the
cavity appeared to be of recent formation or was under-
going rapid extension.
Where the secretions were of a thin liquid nature
bacilli were less numerous. It would seem that these
organisms are practically confined to the superficial,
caseous, or suppurating lining of the large cavities. This
layer is never without bacilli, and indeed mostly teems
with them. If, however, this layer be detached, as may
easily occur in making sections, no bacilli may be found ;
in other words, the bacilli do not penetrate far into the
cavity wall. This is what might have been expected, as
the fibroid growth in these parts must oppose a barrier to
the spread of the bacilli.
In microscopical cavities, on the other hand, where we
are able to observe the earliest stages in the process of
excavation, bacilli are often found both at the margin of
the cavity and extending in large tracts into the sur-
rounding caseous tissues. In such oases no demarcating
fibroid zone or capsule has developed round these minute
cavities.
Four cases of extensive excavation, probably of bron-
chiectatio origin, in which one lung was alone affected,
and no tuberculous lesions were present, supplied the
strongest proof of the diagnostic value of the bacilli in
determining whether lung disease is tuberculous or not.
In one of these cases repeated examination of the expec-
106 TUBEBCLB BACILLI IN THK LB8ION8 OF PHTHISIS.
toration and of the cavity contents evacuated by poncture
of the chest during the patient's life strongly pointed to
a disease of a non-tuberculous character.
This conclusion was fully justified at the autopsy by the
general appearance of the lung and by the results of a
microscopical examination of the contents of the pulmo-
nary cavities. In each case tubercle bacilli were absent^
though abundant micrococci were found.
In the other cases similar disease of the lung was found
post mortem^ i, e. cavities with no tuberculous lesion.
The cavity contents contained micrococci^ but no tubercle
bacilli. Here one would think were conditions as
favorable as any likely to arise in the human body for
the cultivation of micro-organisms. Both patients during
their life were placed in wards occupied by phthisical
subjects^ so that every opportunity was afforded to the
tubercle bacilli to take root in the stagnant cavity secre-
tions of these two men. Apparently the soil was not
suited for the nurture and development of these organisms,
and this observation suggests that very special conditions
are required for the entrance and growth of the tubercle
bacillus.
Returning now to the strictly tuberculous cases^ we find
that the bacilli are present in most cases of nodular lesion^
but in the case of phthisis their number is as a rule ex-
tremely small.
The explanation of this fact may be in part derived
from the almost constant association of fibroid growth
even with the earliest nodules. It seems possible that
although the presence of bacilli is connected with the
development of each nodule in the first instance^ yet the
subsequQjit fibrosis and caseation may lead to arrest of de-
velopment or perhaps to destruction of the micro-organisms.
What determines the predominance of fibrosis in one case
and softening in another it is hard to say. It is true^ no
doubt^ as a rule that in children and young persons soften-
ing predominates over fibrosis^ the latter process attaining
its highest development in persons of more advanced age.
TUBERCLE BACILLI IK THE LESIONS OF PHTHISIS. 107
Or to pat it in anotber way, tissues that are undergoing
active growth afford a more loxnriant soil for the develop-
ment of the bacilli than tissues which are mature or de-
generate. Exceptions^ however, are not wanting to such
general statements, and it is only too plain that the idio-
syncracies of tissues in different people are a complete
mystery to us.
Whether the final softening of the nodule is the result
of an awakened activity of the dormant bacilli or their
spores, or whether it is due to a subsequent invasion of
these organisms from the air-passages, is a difficult ques-
tion. It is important to remember the fact, so strongly
insisted upon by Koch, that the spores are extremely
resistant bodies. Koch found that in certain cases caseous
matter apparently containing no bacilli was still infective,
and when inoculated set up tuberculosis with a copious
development of bacilli. He supposes that in such cases
the caseous matter contained the spores, i, e. potential
bacilli, which only required a suitable nidus for their evo-
lution into mature bacilli. These facts may supply the
explanation of the absence of the bacilli in so many of the
nodules. It is, however, difficult to account for the
rapid disappearance of these organisms from the nodules.
I have over and over again examined the earliest
miliary granulations I could find in cases of phthisis and
always with the same result. Bacilli were always few,
and often absent. In the larger nodules, however, where
caseation was advanced, bacilli were collected in large
groups in many instances.
On the other hand, in the seven cases of acute miliary
tuberculosis examined, tubercle bacilli were found in every
instance. This is a striking contrast, but I believe it may
be explained by the acute nature of the process in this
affection as compared with the chronicity of phthisis. It
is an interesting fact that out of these seven cases of acute
miliary tuberculosis bacilli were only found in extremely
large numbers in four, all of which were children. The
other three cases were adults.
108 TUBERCLE BACILLI IN THE LESIONS OF PHTHISIS.
With reference to the localisation of the bacilli in the
stmctures comprising the nodule, I have found them in
most cases only in what seemed to be caseous alveoli or
in alveoli filled with large cells, the so-called epithelioid
cells.
In the latter case, these large cells stain only slightly
and their outlines are very indistinct, an evidence of the
advent of caseation. The bacilli were found in the peri-
pheral fibro-cellular layer in very few instances, and only
then in comparatively small numbers. In several such
instances they were contained in giant-cells.
In a few cases I met with a distinct tuberculosis asso-
ciated with the presence of bacilli in the walls of small
pulmonary veins, and in one instance an arteriole was
similarly affected. Such facts strongly support the views
of Weigert as to the path by which the tubercular virus
commonly enters the circulation.
I have not succeeded in finding the bacilli in the peri-
vascular and peribronchial small-celled growths. They
were present often in large numbers in minute microscopical
cavities in the nodules, and to a less extent in the infil-
trated lining membrane of the corresponding bronchi-
oles.
There can be little doubt that the bacilli are disseminated
in part by the lymphatics of the lung. But the prevailing
nodular character of the more recent pulmonary lesions
suggests that infection of distant parts is the result of
inhalation.
In the first case, infection probably takes place from
atmospheric sources, as Koch believes, whereas in the later
stages this must be largely supplemented by aspiration
into the lung of the contents of the cavities.
It is equally difficult to explain the capricious localisa-
tion of bacilli in the caseous pneumonic tracts. I can
only suggest a similar explanation to that offered in the
case of the nodular form. In some of the most severe
cases of phthisis, caseous pneumonia is the predominant
lesion. It seems doubtful whether any cases of phthisis
TXTBIBOLB BACILLI IN THB LESIONS, OF PHTHISIS. 109
commence as a massive pneumonic consolidation. At
any rate the pre-existence of a nodular stage can hardly
be excluded. If we consider that the primary local
manifestation of the disease is nodular it requires no great
stretch of imagination to regard widespread consolidation,
like caseous pneumonia, as secondary to the presence of
discrete nodules. There is ample evidence that this is
frequently the sequence of events in the later stages of
the disease. Or it may be, as Mr. Watson Cheyne suggests,
that in caseous pneumonia the virus is inhaled into the in-
dividual alveoli. If this were the case we should expect
to find bacilli distributed widely through the consolidation.
This, however, has not been my experience. It may be
that caseous pneumonia is set up in another way. In
certain cases where cavities or rapid softening are present
we are reminded that septic processes are going on, not
only by the character of the attendant pyrexia, but often
also by the odour of the patient's breath. The products
of this process are probably gaseous to some extent, and
can hardly fail to be inhaled into the alveoli. This may
play some part in the production of those large caseous
patches so often found in the sternal region in cases of
advanced destruction of lung.
I have been unable to find any bacilli in those parts of
the lung that have undergone a dense fibroid change.
Neither have I succeeded in detecting their presence in
the pigmented giant-cells often enclosed in the fibroid
tissue, except in the outer fibro-cellular zone of the nodular
growths. Here I have found them in several cases. It
may now be asked whether there is any evidence that the
evolution ot each individual nodular lesion of phthisis is
invariably associated with the presence of the tubercle
bacilli. The answer, I believe, must at present be,
that although this is highly probable direct proof is
wanting.
It is probable that the presence or absence of these
organisms is closely connected with the stage of develop-
ment of the nodules. The presence of comparatively
112 TUBBBCLE BACILLI IN THB LESIONS OT PHTHISIS.
In the thirteen cases of intestinal ulceration ezamined^
bacilli were found in eight cases only.
In four cases bacilli were plentiful.
Three of the cases which gave a negative result as
regards bacilli presented no typical tuberculous changes^
and although the ulceration was slight the mucous coat
was greatly atrophied.
In the foarth case, the ulceration was probably due to
old dysentery and was in no sense tuberculous. No
bacilli were found.
In all the other cases the disease was distinctly tuber-
culous.
Of the thirteen cases in which lymphatic glands were
examined the bacilli were plentiful in three only ; in three
other cases they were very scanty. In seven cases none
could be found.
It seems remarkable at first sight that the mediastinal
glands contained so few bacilli. But it is worthy of note
that all the glands examined were those of adults, most
of whom were dwellers in towns. It is possible that the
pigmentation and induration which is so common in the
mediastinal glands of such persons renders them less suited
for the growth of the bacilli.
The abundant pigment in the glands may possibly
obscure the presence of the bacilli to some extent when
they are very scanty. The namber of bacilli found in
these and other glands depends mainly, however, I believe,
on the stage of the disease. When the tuberculosis is
quite recent they are abundant ; in the later stages it may
be impossible to discover any at all. The observations
referring to other organs than the lung, air-passages,
intestine and lymphatic glands are too scattered and few
to be of much value.
But the detection of the bacilli in such widely different
places as the peritoneum, pia mater, kidney, liver, spleen,
tongue, caseous joint and vesicula seminalis. Fallopian tube,
uterus, and suprarenal capsule is worthy of note.
It is impossible to doubt that the presence of certain
TUBBROLB BACILLI IN THB LESIONS OF PHTHI8IB. 113
bacilli is indissolnbly bound up with the process of " tuber-
culosis^^' although their distribution appears at present to
be somewhat capricious.
In pulmonaiy cavities and in softening caseous matter,
wherever it may occur^ so long as it be associated with
" tuberculous *' or scrofulous affections, there we may be
sure of finding Koch^s bacilli.
It is probable also that in all lesions termed '' tuber-
culous/' the same bacilli can be found at certain stages of
their development by careful search, if a sufficient number
of sections be examined.
But although the extremely small and even insignificant
number of these organisms found in many cases of
advanced and wide-spread '' tuberculous " disease may be
to some extent explained, it will appear to many, perhaps,
improbable that the presence of a few bacilli can be the
sole cause of such extensive structural changes.
I would, however, express the belief that as we know
more of the various conditions incidental to the life-history
of organisms like the tubercle bacillus, we shall be able
to account for much that at present looks like irregularity
and caprice in the behaviour of these parasites.
On the other hand it is much to be hoped that Koch's
brilliant and valuable discovery may not entirely divert
attention from the important influence of constitutional
disposition or diathesis in the production of the various
affections now grouped together as tuberculous.
(For rq^ort of the diBCUsaion on this paper, see ' FrooeedingB of
the Royal Medical and Ohimrgioal Society/ New Series, vol. i,
p.80a)
VOL. LXVIII.
DESCRIPTION OP PLATES I and II.
" Tubercle BaoiUi '* in the Lesions of Phthisis. (Pebci? Kidd,
M.A., M.D. Oxon.)
Pia. l.^Aeide miliary tuberculosis. Case 35.— Lung : two alveoli
which have become fused together. Alveoli filled with large epithe-
lioid cells. Tubercle bacilli in large numbers between the cells, and
in a few instances within the cells (a, a). X 400.
Fia. 2. — Acute miliary iubercrdosis. Same case. — Lung : arteriole
from one of the nodules. Walls of vessel thickened and infiltrated,
with epithelioid cells scattered through a finely granular substance
(commencing caseation). Calibre of vessel encroached upon bj the
growth. Vessel still patent, and occupied bj blood- corpuscles.
a. Thickened wall of vessel.
b. Remains of muscular coat.
c. Cavity of vessel filled with red corpuscles, and containing
a few leucocytes stained blue. X 200.
Fig. 3,^Phihisis. Case 16. — Lung : section from wall of minute
canity. Inner margin of cavity teeming with baoillL No bacilli
elsewhere.
a. Cavity.
' b, Bacillary margin,
c. Surrounding caseous tissue. X 75.-
Fia. 4. — Phthisis, with intestinal vlceration. Case 70. — Mesenteric
gland. Follicle from gland containing numerous bacilli, and sur-
rounded by a broad caseous zone teeming with bacilli. The follicle
has separated from the caseous zone in the process of preparation.
a. Follicle.
b. Caseous zone.
c. Space due to shrinking of follicle from surrounding zone.
X 200.
^-r.c
V^. '
I
j: /,w
* .*^
,» #
'•/,->
\''[.:-
v*^V;«*'/ ^ .
OASES
IN WHICH
PERFORATION OF THE MASTOID CELLS
IS NECESSARY.
W. B. DALBT, P.R.C.S., M.B. Caotab.,
AUBAL BUBGBOir TO BT. OEOBGB'B HOSPITAL.
(Bec«iT6d October 88rd. 1884— Bead Jannary 87th, 1886.)
In the foUowing remarks no reference will be made to
the very common instances in which, after inflammation
of the middle ear, the asnal signs of abscess in the
mastoid process, with softening of the external plate of
bone, are present ; these, especially in the case of children,
are so often met with and treated by a free opening on
the ordinary principles of surgery, that they are perfectly
familiar to everyone. There are, however, a certain
number of cases from which the usual appearances, sym-
ptoms, and local conditions are absent. Among such may
be classed especially those in which the external plate of
bone is healthy, but pus has formed within the cells (with
its attendant dangers to life), and others in which, although
the external plate of bone is the seat of caries, purulent
matter is not within the cells but collects elsewhere.
116 PEBFOBATION OT THB MASTOID CELLS.
In a previous contribution to this Society on * Disease
of the Mastoid Bone ' (vol. Ixii of the ' Transactions/),
the conditions under which a perforation should be
made into the mastoid cells were discussed, especially
in regard to those cases where some of the usual evidences
of pus at no great distance from the surface were absent,
for where these are present the necessity of this proceed-
ing is universally admitted. The indications for operation
in cases of purulent discharge from perforation of the
tympanic membrane included the following symptoms :
continuous pain in the mastoid region, with cedema on
deep and prolonged pressure, pain increased by the recum-
bent position, a high temperature, and a severe rigor.
Further experience since 1878 has not only confirmed
the views which I then expressed, but has forced upon me
the conviction that the conditions under which relief may
be afforded, and a fatal termination avoided, are more
numerous and more various than might be supposed from
the paper referred to. In what follows, when the mastoid
cells are said to have been opened, it will be understood
that the instrument used is a drill (see woodcat) made in
such a manner that the distance to be penetrated is accu-
rately regulated by a stop, so that any risk of boring too
deeply is avoided. The perforation is readily accomplished
in a few seconds when the incision to the bone has been
made. After frequent employment of this plan I can
confidently speak of its superiority both for perfect safety
and for great rapidity.
In many instances, especially in the cases of adults,
when it becomes a matter of immediate urgency to make
an opening into the cells, and when the outer table is
healthy, the advantages will be obvions to those who have
had occasion to resort to this proceeding.
The following cases will illustrate the various and
PSBIOBATION 09 THl MASTOID 0BLL8. 117
serious conditions which may occnr when the mastoid
process becomes inflamed, and which may urgently call
for the letting out of pus, the precise position of which it
is not always easy to point out.
Case 1. — On January Slst, 1884, I saw, with Dr.
Martin, of Somers Place, Hyde Park, a young lady, who,
after an attack of acute inflammation of the left tympanum
followed by a perforation of the membrane, had for some
weeks continuously a most profuse purulent discharge.
Beyond the very copious nature of the discharge there
was no symptom which called for notice. Local treatment
did not materially affect the state of the ear. There was
no redness or swelling over the mastoid, and only slight
tenderness on very firm and continued pressure, which was
relieved by leeches and fomentations. A few weeks later,
after a rise of temperature to 104° F., she had severe
pain in the muscles of the left thigh, and a dragging of
the foot of the same side. She walked as in infimtile
paralysis. The pain passed off. Early in April there
were several sudden rises of temperature up to 104°, only
maintained for a few hours. At no time had there been
rigors. Taking into consideration the long continuance
of the very profuse discharge, the symptoms connected
with the thigh and impaired movements, the rises in
temperature, and the fact that firm and continuous pres-
sure on the mastoid process now for the first time gave
rise to a sharp pain, although there was no oedema or
redness, I advised that an opening should be drilled into
the mastoid cells. Sir James Paget saw this case inde-
pendently of me, and agreed as to the advisability of this
proceeding. When the incision was made the bone was
healthy. In spite of this the bone was drilled, and on
removing the drill foetid matter escaped through the wound.
No further bad symptom impeded recovery.
Cass 2.— On May 80th, 1883, a gentleman, edt. 35,
gave me this history. Since the middle of the previous
January, when he had acute pain in the left ear followed by
118 PIBFORATION OT THB ICABTOID CILfiB.
some pamlent discharge, he had almost constant pain over
the mastoid region. There was a perforation of the tym-
panic membrane, and some, though not profuse, discharge.
There was considerable tenderness and redness, over the
mastoid process. On his return to Lincolnshire, that day
he applied two leeches, and afterwards hot fomentations,
which gave him for a few days great relief. However,
he soon began to suffer as before, and did not come to
town again until October. There was then a good deal
of swelling, the redness was much increased, and there
was considerable oedema.
On cutting down on to the bone there was a large area
quite exposed, but no pus was found in the mastoid cells.
A few days afterwards a long probe was passed from the
wound in a downward direction along the border of the
stemo-mastoid muscle to the lower border of the thyroid
cartilage. Here I made a second opening and passed a
drainage-tube through. At a later date, a third opening
was made down to the bone about two inches behind the
first one, letting out more pus. The pain now shifted
further back, and pressure over the splenius capitis caused
pus to pour out of the external canal of the ear.
Sir James Paget now saw the patient with me, and
decided that another exit must be made for pus in this
part of the occipital region.
After a troublesome dissection in this situation matter
was found in contact with the bone. Thus pus had bur-
rowed under the scalp in the following direction. Prom
the tympanum through the bone to a point outside the
mastoid process, thence to another point under the splenius
and complexus muscles. Between the last opening and
the second a drainage-tube ^as passed. A very large
area of the bone was found exposed. The patient made
a good recovery.
Gasb 8. — A case in some respects like the first narrated
occurred in St. George's Hospital in July, 1884. A middle-
aged woman, after an attack of acute inflammation of the
PBBFOBATION OF THE MASTOID CELLS. 119
r/ght tympannm followed by rise of temperature^ severe
rigors^ and local evidence of matter within the mastoid cells,
came under my care. On making the incision the bone was
perfectly healthy, but on perforating the cells a quantity
of foetid matter escaped. All urgent symptoms passed
away at once. A week afterwards, beyond a slight dis-
charge from the wound, the patient had no inconvenience.
She was, however, seized with a rigor : this was followed by
pus in the knee-joint; the joint was opened, but pus
spreading upwards and the joint becoming disorganised,
it became necessary to amputate the limb above the knee.
This was done by Mr. Haward, and the patient made a
good recovery.
Case 4. — ^A boy whom I saw for the first time on
December 6th, 1883, had a profuse discharge from a
recent perforation in the left tympanum. There was
pain and swelling over the mastoid process extending
above the ear into the temporal region. Free vertical
incisions were made through the scalp over the mastoid,
and on the left temple, letting out pus. The bone was
denuded, and a probe could be passed under the scalp
from one opening to the other. A few days later, further
swelling about three inches behind and above the first
opening made it necessary to make another incision in the
occipital region. The forefinger, passed into all three
incisions, showed that very large areas of the bone had
been exposed. Notwithstanding the free opening, pain
continued with great severity and was accompanied with
great constitutional disturbance.
A general cellulitis of the scalp now set in and a fatal
ending seemed almost certain. Sir James Paget now saw
the case and advised further enlargement of the wounds,
and agreed as to the necessity of further search for matter.
The openings were enlarged. The boy's condition slowly
improved, and when able to travel he was taken abroad.
I saw him in October of this year, and was told that the
opening over the mastoid had only recently completely
healed.
120 FEBTORATION OF THE MASTOID OBLLB.
Cabb 5. — On three or four occasionsj at long intervals
extending over three years^ I had seen a young man in
consequence of occasional head pains and giddiness depend-
ing on a perforation of the left tympanum^ in which
diseased bone was evidently present.
At the beginning of 1884^ whilst he was a few miles
from home^ he was seized with acute pain in the head and
intense giddiness. He was taken home, and in the course
of a few hours became delirious and afterwards partially
unconscious. For two or three days previously he had
complained of a feeling of fulness, and of some pain over
the mastoid bone. On the next day, when I saw him, he
was in the same state. The sderotics were much in-
jected.
Although there was no swelling, but some redness, and
no oedema, I thought that under the circumstances it
would be best to perforate the mastoid cells with a drill.
At the time he was so far unconscious that he recognised
no one, nor subseqaently did he ever remember what had
occurred. The mastoid cells were so gorged with blood
that a large quantity poured out when I removed the drill.
There was no pus in the cells. Within two hours of the
operation he became perfectly conscious. This young man
suffered for many weeks from various symptoms of cerebral
irritation, occasional extreme intolerance of light, severe
headaches being the most prominent. It must be admitted
that had I not formed an opinion (proved to be erroneous)
as to the probable presence of pus within the mastoid
cells I should not have proceeded as I did. The error
in judgment, however, was most likely of material good
as regards the loss of blood.
Case 6. — In referring to one more case, I beg to call
attention to the occasionally slow and insidious course of
the morbid process which may eventuate in pus within the
mastoid cells.
A gentleman between 50 and 60 years of age, first
consulted me on Feb. 11th, 1884, for a catarrh of the
PIRVOBATION or THV KA8T0ID 01LL8. 121
tympanam which had come on after a severe cold on
January 29th, and was accompanied with a feeling of numb-
ness and weight in the mastoid region. I saw him at
intervals of a month, or a fortnight, ap to the end of July,
daring which time he had occasional leeching and coanter-
irritation over the process. At no time was the pain
severe enough to interfere with the daily duties of a very
active political life, and at no time was there more than
slight pain on very firm pressure over the bone. At the
end of July, in anticipation of the probable necessity of
perforating the cells at a later date, he was seen by Sir
James Paget in consultation with myself. There were
then no urgent symptoms beyond very slight cedema on
firm pressure. It was therefore decided to wait for
clearer symptoms of pus within the bone. I did not
again see him till October 1 1th, when he told me that three
days previously there had been very decided pain. On the
next day I let out a quantity of foetid pus from the
cells, the outer table of bone being quite softened by
caries. Throughout the entire illness he had no constitu-
tional disturbance.
I am encouraged to bring these cases before the
Society by the belief that perforation of the mastoid cells
is more frequently and urgently called for than might be
supposed from the literature of the subject.
(For a report of the discuBsion on this paper, see * Proceedings of
the Royal Medical and Ohirorgical Society/ New Series, vol. i,
p. 328.)
CASE
o»
DOUBLE SIMTTLTANEOTJS DISTAL
LIGATURE
FOS
INNOMINATE ANEURYSM.
BT
I
BICHAED BAEWELL, P.R.C.S.,
BSVIOB BUBOBOir, OHAUHO 0B06S HOBVITAL.
BcceiTed July 14th, 1884.— R«ul Juiiuiy 97th, 18*.
Lauba H — , 89t. 48, married, was admitted under my
care into Charing Cross Hospital, Gk)lding Ward, I6th
February, 1884.
Both parents died when patient was too young to know
of their diseases. She has had two sisters ; one died of
" cholera,'' the other is healthy and strong. Her rela-
tives on the mother's side have suffered from heart
affections. Patient's health has until latety been uninter-
ruptedly good. She has had six children born "nYing
and healthy ; two bom dead at full term ; four miscar-
riages.
Eighteen months previous to her admission she fell
forwards upon her chest on the floor of an omnibus. No
124 DOUBUB BIHULTANBOUS DISTAL TilGATUBB
bruising or other immediate ill-effects were noticed. A
month after this she spat up one morning abont a table-
spoonf al of inspissated bloody bat had at that time no
further trouble.
A year ago^ that is six months after the accident, she
noticed an uncomfortable sense of throbbing on the right
side, below the collar-bone ; soon after a pain about the
elbow, which shortly extended up the arm to the shoulder
and became very severe; movement and power of the
arm rapidly diminished. Two months ago she had what
she terms rheumatic fever ; it was confined to the upper
extremity, particularly to the hands, especially of the right
side.
State on (idmission. — Patient looks older than her stated
years ; is pale, thin, and anaemic, has a dry skin and a
temperature of 102*6^. She has some dyspnoea (very
shallow breathing with evident effort), also a dry brassy
cough, considerable loss of vocal power, the voice being
toneless and low.^
The veins of the upper part of the chest are full and
congested, so also are those of the arms, equally so on
both sides. The right half of the sternum, the inner part
of the clavicle, and the two upper costal cartilages of the
same side with their interspaces are involved in a distinct
fulness or protrusion, circular in form, and a little more
than three inches in diameter, and over all this space
pulsation is distinct both to sight and touch, the throb is
most evident in a semicircle below and outside the sterno-
clavicular joint ; the clavicle and the two upper costal
cartilages participate in the pulsation. In the outer half
of the epistemal notch, and also behind the inner part of
the stemo-mastoid muscle, a pulsatile tumour can be felt ;
its outer border reaches as far as, but not beyond, the
interspace between the two heads of the muscle. When
the stemo-mastoid and the fascisB in front of the neck
are relaxed by bending the head forward, deeper palpa-
^ This condition has come on, she mjs, only daring the last week. Some
of her friends notioed it earlier.
FOB INNOMINATE ANEUBTSM. 125
tion shows that the tumonr^ merging out of the chesty does
not merely cover but actually involves the carotid.
All that part of the chest, which I have described as
protruding, is absolutely dull on percussion, and relative
dulness extends beyond the limit of tumefaction and of
pulsation. The dull area is separated from the cardiac
dulness by a line of resonance. Only a small quantity of
air enters the lungs, with r&les and blowing murmurs
throughout ; in places also, markedly at the left base,
there is bronchophony. The left posterior base is more
especially dull, and less air enters that part of the lung
than elsewhere ; here, too, the r&les are most marked.
The apex-beat of the heart is not displaced ; the organ is
healthy, but the second sound is exaggerated ; this exag-
geration is very distinctly marked over the site of the
tumour and to a less degree over a great part of the chest.
Patient has much palpitation and praacordial pain even on
slight exertion. The right radial pulse is very small and
faint, the left one is regular and full, 96. The pulse
of the right tenxporal artery is markedly larger and fuller
than that of the left, also the beat of the right carotid on
a level with the cricoid cartilage is stronger and bigger.
She keeps the right arm very motionless and close to
her side ; the elbow is semiflexed. The limb is markedly
atrophied ; the muscles are flabby and flaccid.
Right. Left.
Middle of upper arm . . 8^ in. 9^ in.
Forearm three inches below elbow 8J in. 9 in.
Extension of the elbow, abduction, and rotation of the
shoulder produce considerable pain, but movement of the
wrist and fingers is painless. The power of the grasp is
diminished ; tested by the dynamometer it stands as 6^
right against 12 left.
There is a good deal of neurotic pain in the arm,
running up in the course of the nerves with formication
and numbness of the hands and fingers.
The patient's appetite is very bad. Tongue rather
126 DOUBLE SIMULTANBOUB DISTAL LIQATUBB
brown bat moist ; some thirst. She complains of a severe
pain on swallowing, which she refers to a spot on a level
with the sixth cervical vertebra, about three inches to the
right of the spine. Although she has pain in various
parts, as in the arm and chest, this appears to be the most
severe and least bearable of her troubles. On applying
the stethoscope to the last cervical vertebras while she
swallows the act is heard to be prolonged, only occa-
sionally reduplicated.
The retina of the right eye presented nothing abnormal.
The vocal cords looked a little relaxed, equally so on both
sides.
During the twelve days ensuing she was carefully
watched and frequently examined. She had during this
time a good deal of pain in the abdomen and some diar-
rhoea. She appeared to be losing strength, while the
lungs were becoming more impervious, less air entering
them, the dulness of the bases extending higher. Her
voice became more and more feeble. Her temperature
was often below the normal, notably on the 19th and 20th
it was 97^ ; on the 21st 97-4°.
The most noteworthy phenomenon, however, was entire
cessation of the right radial pulse — this occurred oil the
20th — four days after her admission. The pulselessness
extended throughout the brachial and all accessible parts
of the axillary, also, I believe, to the subclavian, the third
part of which could not be felt to beat.
The symptonis just described clearly indicated that I
had in this case to do with a high innominate aneurysm,
but certain occurrences are worthy of remark, namely, the
very feeble, Stat© of the. right radial pulse on her first
adimi^sipn Qjid its subsequent total extinction. If together
with these symptoms we collate the fact that almost
sip[i,i^ltaneously with the ^st sense of throbbing, that is
to say, almost simultaneously with the first sign of disease
— severe pain in the arm was felt, we can only qozue .to
one conclusion, namely, that the aneurysm which affected
the upper part of the innominate and its offshoots had at
FOB INNOMINATE ANEURYSM. 127
first inclined chiefly to the right and had more especially
involved the subclavian branch ; and that afterwards this
part was obliterated^ while remaining empty or nearly so^
by compression of the carotid portion of the tamour. It
is of coarse also possible that the obliteration was cansed
by detachment and subsequent impaction of a piece of
clot. On this point I would not dogmatise; but must
point out that spontaneous cure by impaction of clot
leads to solidification with the sac full ; and one should
under such circumstances be able to feel a tumour behind
the clavicular part of the stemo-mastoid muscle. Such
tumour was entirely absent in this case.
Compression of an artery by an aneurysm situated upon
it is by no means an unheard-of occurrence, though by
some authors its possibility has been doubted.^
In this case the mechanism of such compression would
be as follows : — I have elsewhere pointed out ' that the
usual idea of the mode in which the innominate bifurcates
is incorrect ; it is described and depicted as though the
two branches arose side by side and almost at right angles
to each other. In reality the subclavian springs from its
parent trunk almost directly behind the carotid and runs
up some distance close, almost parallel and posterior
to that vessel. If this position of parts be borne in mind,
there will be no difficulty in perceiving how an aneurysm
involving the root of the carotid would very easily com-
press against the vertebrae, the commencement of the sub*
clavian, more especially if that branch were also aneu-
rysmal. It will also be seen how under such circumstances
that artery and its dilatation would be empty or nearly
empty.
The aphonia noted in this case was due to compression
-i>,illrii.'ideft WMB due origiiudly to Sir £. Home; tee Astley Cooper«
'Med.-Chir. Trans./ vol. i, p. 12. I watched a case of aorto-innomiDate
aneurysmi in which the large sac, cnrling over and oompreasing distal i|arts
of the sabdavian, indncea considerable consolidation of the oatei^ part of the
t«Dio«r.
* 'Encyclopedia of Sorgery/ vol. iii» p. 614.
128 DOUBLE SIMULTANEOITS DISTAL LIGATURE
of the trachea as also was the condition of the Inngs.
This latter was a most interesting example of the mode
of disintegration caused by such pressure. It is produced^
as the late Dr. Pearson Irvine^ and I showed^ by obstruc-
tion, not to inspiration, but to expectoration, whence accu-
mulation of secreta, &c., in the larger then in the smaller
bronchi and air-cells, necessarily inducing consolidation,
parenchymatous pneumonia, and breaking down of lung
tissue. The first part of this process I had in this case
the opportunity of watching from day to day.
Having watched the case for ten days, waiting to see if
such process has had occurred in the subclavian would
extend to other parts of the sac, I came to the conclusion
that the advancing morbid condition of the lungs was the
principal cause of the patient's debility and the chief source
of her danger. Indeed, although anaemia is not a condition
favorable to the success of deligation, I foresaw clearly
that postponement would still more jeopardise the lungs
and would render their condition fatal, if even some weeks
hence the aneurysm could be cured. Still, before proposing
any operation it was necessary, since the subclavian artery
was occluded, to ascertain whether the cerebral functions
would be carried on without the supply of blood derived
from the right carotid. I therefore compressed this vessel
with my thumb ; no result followed. Simultaneous com-
pression of both carotids produced, in about five seconds,
pallor of the face, a sense of swimming in the head, and a
distinct depression in the power of the pulse. The two
first symptoms were doubtless due to loss of circulation
through the carotids, the last to interference with the
functions of the vagus nerve.
Having, however, proved that occlusion of the right
carotid produced no cerebral disturbance, I determined
first to tie that vessel and to be guided by the immediate
result as to any further action.
February 28th. — I tied the common carotid artery with
^ < Pathological Tramactions/ vol. xxvui, p. 67, and my book on 'Anenrysm,
especially of the Thorax and Root of the Keck/ p. 101.
FOB INNOXlNATJi ANEURYSM. 129
an ox aorta ligatare abont one inch below its point of
bifarcation. I begged that the right papil might be
watched at the moment of tightening the ligature. One
observer thoaght he perceived a very slight contraction
of the pnpil^ the other believed that no change took place.
After this deligation the clavicle and the protraded
part of the chest pulsated more violently than before. I
tried to make oat if the third part of the subclavian pul-
sated^ but the powerful throb of the clavicle rendered it
impossible to ascertain this point. Fearing^ however^
that occlusion of the strenim in the carotid might divert
blood into the subclavian and thus reopen that part of the
aneurysm^ my colleagues also^ on rapid consultation^
coming to the same conclusionj I laid bare the third part
of the subclavian. It was empty^ and there was not the
slightest pulsation in it^ nevertheless having exposed it,
I^ with a view to future possibilities^ tied it.
In the evening of the same day the pulsation had very
much diminished. On the next day she began to expec-
torate the muco-pus that had for some time past been
accumulating in her lungs. On the fourth day she lost
the pain on swallowing, the voice began to improve and
the protrusion of the upper part of the right chest to
flatten.
March 20th. — ^AU these signs of diminution in the bulk
of the aneurysm continued to increase. On the twenty-first
day she sat up and was pleased to find that she could
painlessly feed herself with the right hand.
28th. — The cervical part of the tumour had apparently
become nearly solid ; the pulsation that remained had in
great degree lost its expansile quality and had assumed
more nearly the character of a communicated heave from
the aorta. But at this date that enlargement appeared
to increase, and although she was kept very still and quiet
the hitherto solidifying tumour became softer, the pulsa-
tion resumed its expansile character, and although the
thoracic protuberance did not at the same time increase,
the clavicle again began to pulsate. The patient averred
VOL. LXVIII. 9
180 DOUBLK SIMULTANBOUS DISTAL LIGATUBB
that she again felt the throbbing^ bat none other of the
subjective symptoms recurred.
April 4th. — ^The cervical portion of the aneurysm had
become almost as large and nearly as pulsatile as it was
before the operation, the thoracic portion continuing
meanwhile to become flatter, and the resonance of this
part to increase. With a bandage of elastic webbing I
bound upon the tumour a pad of cotton-wool, for which
in two days I substituted a round, hollow, elastic ball,
according to a method successfully employed by Mr.
Holmes in a case of subclavian aneurysm.^ This treat-
ment produced a good deal of pain and considerable rest-
lessness, therefore, as at the end of a week no benefit had
resulted, it was discontinued. I was considering the
desirability of employing needles, with or without the
galvanic current, when on the 15th the tumour was found
to be smaller and more solid.
20th. — Solidification and decrease in size of the cervical
portion of the tumour has been progressing regularly
since the last report. To-day she was allowed to get up.
May 6th. — The cervical part of the aneurysm appears
as a small solid tumour behind the inner head of the
stemo-mastoid muscle ; it is lifted by each beat of the
aorta, but has no inherent pulsation. The voice is natural,
she has no cough, suffers, however, a good deal from
muscular rheumatism, and is feeble. She left the hospital
desirous of remaining at home for some time before going
to a convalescent institution.
June 4th. — The patient showed herself at the hospital.
There is no protrusion of the right upper half of the
chest nor any tumour to be felt in the neck. Over the
late site of the aneurysm percussion notes all clear, and
respiratory murmurs are to be heard where previously
only exaggerated heart-sounds were audible. The lungs
are clear down to their lowest bases.
No pulse could be felt in any branch of the right
carotid, nor of the subclavian. The right arm, which has
> 'Lanoet/Feb. 12th, 1876.
FOB IKNOHINATB AKBUBTSH. 131
Hitherto been always rather cooler than the left^ is now
rather warmer, but the temperature of the face is lower
on the right side. It is hoped that the patient will
attend. She was last seen at the end of August, well, as
far as aneurysm is concerned.
Bema/rhs. — ^As I have ahready made some remarks con-
cerning the diagnosis of this case, the few observations I
would offer now shall be very brief.
The disease was distinctly an example of high innomi-
nate aneurysm, eminently fitted as far as situation is con-
cerned for the double distal ligature.
It is possible that some of the Fellows may see a
different mode from that above given of accounting for
the singular occlusion, by the disease itself, of the sub-
clavian artery and its branches. Yet I would point out
that whatever view be taken of the occurrence it cannot
be supposed to have taken place elsewhere, than at or near
the commencement of the vessel, and proximal to the
vertebral artery. With this fact in view, I tested, as
above detailed, the effect of temporarily cutting off the
blood-stream in the carotids. After deligation of the
right common carotid artery no cerebral symptoms what-
ever supervened, although in all probability no blood
found its way directly to the right side of the brain. I
hold this fact to be highly important as aiding to prove a
view, elsewhere expressed,^ that occlusion of a carotid by
ligature or otherwise has no injurious effect upon a sound
and healthy brain.
Whether or not the subclavian artery should also be
tied remained in doubt until after the operation on the
carotid ; I was influenced at that time by the increased
pulsation of the aneurysm, and believe that I may con-
gratulate myself on the course taken.
The lungs were, when I operated, becoming rapidly
filled up with retained secretions. The cessation of pres-
sure on the trachea had almost immediately the effect of
permitting the elimination of large quantities of muco-
1 ' On Aneurysm, espeoially of the Thorax and Boot of the Neck,' p. 81.
132 DOUBLE SIHULTANEOnS DISTAL LIGATUBB
pus^ and Babseqnently of macns, the lungs becoming hj
that process disburdened. To watch the gradual dis-
appearance of the pulmonary symptoms, to hear the dul-
ness clear away and the r&les diminish, was a most
interesting cUnical experience.
One other point I would like to touch upon. The
tumour, or rather that portion of it which was in the neck,
had become by the 20th March (twenty-first day of ope-
ration) nearly solid, was tolerably hard, and had consider-
ably diminished ; about a week later it again began to
soften and to increase until, though the thoracic portion
did not yield in the same way, the cervical purt was
nearly as large as before the operation, the blood in it being
eyidently fluid. As is well Imown, recurrence of pulsation
occasionally occurs after a certain consolidation of the
aneurysm has followed treatment either by the elastic
band, by pressure, or ligature, though I am not aware
that ultimate success has previously been observed to
follow such recurrence in the neck. But the questions
which I would put to the Society are these :
What becomes of the clot (probably soft clot) already
formed in the sac, and which quite disappears when the
recurrent pulsation persists a certain time f
Since no sign of embolism or plugging of vessels
accompanies these phenomena, it would appear that such
clot must again become fluid. If so, what peculiar power
has living and flowing blood that can enable it to dissolve
and liquefy clots formed from its own substance ?
The answers to these questions involve, I believe, some
important points in physiology and in pathology.
It may be well to remind the Fellows of the Society
that since I last had the honour of addressing it on this
subject, two cases of aneurysm about the upper part of
the thorax and the root of the neck have been laid before
it, the one by Mr. Howard Marsh — ^he tied both vessels
simultaneously but without success ; another by Mr.
Morris, who attempted, but failed, in the altered condition
of the parts to tie the carotid — ^this patient also died:
rOB INNOMINATB AKBUBY8H. 183
I have to thank the Hon. James George Beaney^ of
Victoria, for sending me a copy of his ' Clinical Lectares/
One of them gives two cases of innominate aneurysm
treated by consecative ligature of the carotid and sub-
clavian (third part) ; they were both eminently successful.
In neither did the carotid ligature produce any marked
benefit until the subclavian was tied, four and two weeks
afterwards respectively.
I may be permitted also to recall the fact that this is
the sixth case of simultaneous double distal ligature that
I have reported to this Society. Of these, one was for a
very large aorto-innominate aneurysm (a), two for smaller
but still considerable aneurysms of the same description
(6, c), two (including this case) for aneurysms purely in-
nominate (c2, e), one for aneurysm of the first part of the
aorta (/).
The first was one of my earliest cases, such as with my
present increased knowledge I should not subject to any
operation. The other five have been all successful.
a. J. L — , from" Bath ; operated 6th December, 1877.
b. Robert W — ; operated 14th August, 1877.
c. Laura Q — ; operated 6th December, 1877.
d. Catherine H — ; 7th January, 1878.
e. Laura H-^ (this case) ; 28th March, 1884.
/. John S— ; 15th February, 1879.
Note. — It was reported to me in May, 1885, that the
patient was quite well, and going about her household duties
with ease and comfort.
(For a report of the discuBsion on this paper, see 'Proceed-
ings of the Royal Medical and Ohinirgioal Society/ New Series,
vol. i, p. 832.)
CASE
OF
DISPLACEMENT AND ERACTTJRE OF
THE AXIS.
LIFE PROLONGED FOB TEN TEARS.
D. LOWSON, M.D.,
H17LL.
(Ck>]acuinGATSD by Sib FBESCOTT HEWETT, Babt.» F.B.S.)
(BeceiTad Norember 11th, 1884-Bead Febraary lOth, 1886.)
Dislocation, or fracture of the spine, if situated above
the origin of the phrenic, is as a rule immediately fatal.
A few exceptions have occurred. One of these, which I
have kept under observation for ten years, is Unique in
manifesting no paralysis nor other symptoms of nerve
injury. The following is the history of the case : —
On a dark night in the winter of 1 874 W.P — , an old man
of 75, was walking along the highway that runs between
Wakefield and Huddersfield. Coming to a sudden bend in
the road, which in the darkness he did not observe, he
held straight on and fell headlong over a sunk wall six feet
down into the field below, where for some time he lay
stunned and senseless. On recovering consciousness he
experienced excruciating pain in the neck. He made the
136 DI8PLACBMBNT AND rBACTUBB Or THK AXIS.
best of his way home to liis cottage, where he lived
all by himself, undressed and went to bed without any
assistance and slept throughout the whole night. Next
morning the pain had moderated, but he could not raise
his head without a return of the agony. He managed
to get out of bed by pushing his feet out first and lifting
his head with both hands. The same day he consulted a
neighbouring surgeon, who ordered him a liniment, but
apparently did not recognise the nature of the injury. A
fortnight after this he became an out-patient at the
Huddersfield Infirmary, and it was here I first saw him.
At first sight I took it to be a muscular or ligamentous
sprain, but the history and the man's nasal intonation in
articulating led me to examine him more minutely.
He carried his head very carefully and rotation was not
impossible, though limited and painful. The chin was
tilted upwards a little, the occiput depressed as if seeking
for support from the collar of his coat, and the neck was
bent backwards. The mouth was kept open, the respiration
being mainly oral, while the nasal breathing was obstructed.
Deglutition of solids was difficult, but liquids were swallowed
without much trouble. On examining the throat, the
palate and uvula were seen to be pushed forward by a
tumour projecting from the posterior wall of the pharynx.
This tumour was hard and was covered by healthy
mucous membrane, which at the most prominent point
was pale and anaemic from tension. The apex of the
swelling resembled the projecting lip of a cervical
vertebra. There was no paralysis and no anaesthetic or
paraesthetic symptoms. From the position of the promi-
nent part I thought it was the third vertebra, which I
believed had sprung forward from the force of the con-
cussion, there being at the same time probably bilateral
fracture of the neural arch. An attempt was made to
give artificial support to the injured spine, but the patient
preferred to be without it. He left the hospital after
being an in-patient for three weeks.
Three years after the patient returned to have a
DI8PLA0EMENT AND rRACTUBE Or THB AXIS. 137
glaucomatous eye removed. At this tune many of the
symptoms had improved. There was no pain. Rotation
of the head was' much more extensive^ and deglutition was
easy. He died in July of this year^ 1884, from senile
gangrene. A post-mortem examination was obtained with
some difficulty, and the cervical spine was extracted and
carried away. After removal of the soft parts the follow-
ing state of matters was found to exist : —
The axis with odontoid is bent back at an angle, of 60^
with the horizon. There is complete anchylosis between
the bodies of the second and third vertebrae, with the
exception of a small angular interval in front which is
filled with the remnant of the intervertebral cartilage.
The arch of the axis overlaps and encloses that of the
third and is anchylosed to it. The upper articular process
of the third is merged in the pedicle of the axis. The
lower articular process of the axis is widely separated from
the transverse process and is situated on a level with and
behind the same process of the third, from which it is
separated by a narrow groove. The two bones now form
one mass. As regards the atlas there are two anatomical
anomalies viz :— *(1) A foramen behind the articular process
instead of the usual groove for the vertebral artery. (2)
A bony process projecting from the posterior arch to rest
on the root of the spinous process.
In accounting for the mode in which the injuries have
occurred it seems probable that, in falling, the vertex came
first in contact with the ground, and the impetus of the
trunk impacted the upper articular process of the third
cervical vertebra into the pedicle of the axis. (The
probability of a fracture in this locality is increased by the
great separation of the transverse and lower articular
processes.) The trunk then falling backwards over the
head, doubled up the neck, burst or stretched the anterior
common ligament, and drove forward the lower part of
the body of the axis ; the apex of the odontoid, the atlas
and skull were carried back, and the arch of the third was
telescoped into that of the second.
138 DT8PLACSMBNT AHD FBACTUBE Or THS AXIS.
The diagnosis was made by the prominence in the
pharynx. The history of the fall, and the presence of
obstmctiye symptoms to deglutition and respiration, which
did not exist before the injury, exdaded the idea of a
bony outgrowth. The pain and inability to raise the head
were also confirmatory.
Two cases similar to the above were for some time
under the care of Sir Prescott Hewett. The symptoms of
both were nearly identical, but differed from the case
related in having partial paralysis which ultimately passed
away. Tumours in the pharynx existed in these. The
head was bent back and there was great pain. One of
these is still alive, the other has been lost sight of.
An example of a like injury was picked up in a church-
yard and has been described in the ' Medico-Chirurgical
Transactions' by Sir James Paget.^ Professor Flower
describes in the ' Transactions of the Zoological Society '
an injury to the neck of a whale which I believe is not
unlike those already mentioned. The skeleton of the
animal is in the College of Surgeons' Museum.
1 'Med..Chir. Trand./ vol. zxxi, p. 285, and yoI. zxxii, p. 177.
(For report of the discussion on this paper, see ' Proceedings of
the Boyai Medical and Ohirorgical Society,' New Series, vol. i,
p. 336.)
OBSERVATIONS
OV THB
RADICAL CURE OP CLTJB-FOOT,
AND TiXHlHiriQN OF OASES WHIOH HAVE BEEN
OPERATED ON.
BT
EICHAED DAVY. M.B., P.E.S.E., RE.O.S.,
•UBCtBOir IK OHASaa 09 THB OBTHOFJn>I0 DBPIBXMBNT, WBSTKDIBTBB
HOSPITAL.
Beedyed Angut Sdth, 188^-Bead Febmary 10th, 188S.
As mncli thouglit has been bestowed within the last
decade on the radical cure of confirmed club-foot, it may
not be devoid of interest to recapitulate some of the
leading facts gained by experience, and to submit conclu-
sions thereon to the judgment of this Society.
I will divide the consideration of the subject under the
following headings : —
1. Some reasons that have suggested operative pro-
cedures in cases of intractable club-foot.
2. The cases especially suited for operation.
8. The operation itself, the description of its details,
and the necessary instruments.
4. The list of operations (26) performed by myself ; and
notes of other cases operated on by British and foreign
surgeons.
140 RADICAL CURB OF CLUB-FOOT.
5. The exhibition of casts taken before and after opera-
tion^ the osseous wedges removed^ and living specimens
of the results gained.
6. Concluding remarks.
1. Some reasons that have suggested operative pro-
cedures in cases of intractable club-foot.
The obstinate character of severe forms of club-foot,
its general tendency to get worse unless subjected to
continued treatment, and the discouraging relapses occur-
ring even after proper treatment has been employed, may
be mentioned as important grounds for reconsidering the
usual methods of practice in vogue up till 1874. My
experience showing how absolutely useless instrumentation
alone was, I carefully considered the operation of removal
of the cuboid bone, an operation that had been suggested
by Dr. Little in 1854, and practised by Mr. Solly, of St.
Thomas's Hospital, also in 1854.
From an anatomical point of view no structure of
special importance is removed either in excision of the
cuboid bone, or in the excision of a wedge at the transverse
tarsal joint, if the operation described hereafter be
practised.
2. The cases especially suited for operation.
I have never yet operated on any case that had not
been previously subjected to orthopaedic treatment; in
some cases such treatment had been carried out during
the whole of the patient's lifetime ; whilst in others the
condition was so incorrigible as to have necessitated the
abandonment of treatment as hopeless.
3. The operation itself, the description of its details,
and the necessary instruments.
The operation consists of the removal of an osseous
wedge at the transverse tarsal joint ; this operation has
hitherto been confined to cases of talipes varus and
equinuB, with their combination. I will describe the opera-
tion for talipes varus first, then that for equinus.
(1) The operation for iaUpee t*artM.— The patient being
BAOICAL CUBI OF OLUB-rOOT. 141
under the inflnence of an ansBsthetic, and an elastic
bandage being placed on the leg after elevation, an
oblong piece of skin is excised from the enter side of the
foot over the cuboid. This should include the distended
and hypertrophic bursa and should correspond nearly with
the size of the base of the osseous wedge required. On
the inner dide of the foot, at the stereotyped crease of skin,
and in a line over the astragalo-scaphoid joint, a vertical
cut is made of sufficient length to include the thickness
of the scaphoid bone ; these two imaginary lines, drawn
across the dorsum of the tarsal arch, represent roughly the
superficial area of the triangular piece of bone to be
removed. Next, keeping close to the bones, elevate the
tendons, nerves, arteries, and veins with the blunt curved
knife on the dorsum, until the triangular space has been
cleared from the outer to the inner side, for the transit of
the kite-shaped director. Having passed the director
between the tarsal bones and the soft structures above
direct the probe-pointed saw successively along the
grooves on the under surface of the director, and saw
the wedge out with precision. It is usually better to saw
the distal side of the wedge first, and the ankle-joint side
last.
The blunt curved knife is next used on the plantar
aspect of the wedge, the operator again keeping close to
the bones, and lifting out the wedge in one piece by the
aid of strong pointed bone forceps. The wedge usually
embraces the component bones of the transverse tarsal
joint, the cuboid bone invariably predominating ; and
portions of the bones anterior to the transverse tarsal joint,
according to the condition of the deformity. Many of these
osseous wedges are exhibited to the Society. One shows
the component bones of the transverse tarsal joint alone,
viz. astragalus, os calcis, scaphoid, and cuboid. Another
shows portions of every one of the tarsal bones, and the
bases of the four outer metatarsal bones also. (Case 25.)
By this method of operating, simple or compound
wedges of bone may be removed with ease and precision ;
142 BAOIOAL CUBK OF CLUB-VOOT.
their form can also be tested, as they each appear in the
shape of one neat block instead of the debris of a piece-
meal and haphazard dissection.
I prefer, for many reasons, to set np these compound
fractures of the foot immediately that the distortion has
been corrected by rotation and abduction ; the sawn
surfaces of the bones should be co-adapted, and maintained
in situ on the splint, shown in the accompanying woodcut,
prior to the patient's awakening from the anaesthetic.
In applying the splint the patient's thigh, knee, and
upper half of the leg must be first enveloped in a sock of
thick fleecy wool (A) knitted to shape; over this are
applied three or four layers of plaster-of-Paris bandage.
To the surface of the latter the side irons are accurately
adjusted, and are retained in position by additional turns
of the plaster bandage (B). The footpiece slides over
the ends of the side irons, and is regulated by a male
screw, screw washer, and female thumbpiece on each
side iron. Eversion of the anterior half of the foot is
carried out by everting the moveable foot-plate on a pivot
and fixing it by a thumb-screw (0). Any undue pressure
can be at once removed ; wide interruptions at the malleoli
prevent any inconvenience from oodema ; dressings (if
thought to be desirable) may be readily applied, and the
foot leaves the operating table a fixture.
I neither use sutures, nor dressings ; the wounds are
exposed to the air. Cleanliness, however, of a strict
character is maintained, and free drainage provided for.
RADICAL OUBB OF CLUB-TOOT. 148
I have never met with haBmorrliage of a serious natnre ;
this maj be acconnted for bj the plan of keeping close to
the bones^ and bluntly dividing with the curved knife any
articular or osseous branches.
(2) The operation for talipes equinus. — ^A few words will
suffice to indicate the variation necessary in the operation
for cases of talipes eqninus.
Taking again the line of the transverse tarsal joint as a
guide^ on the outer and inner sides of the f oot^ immediately
over this joints two wedge-shaped pieces of skin are
removed equal in extent to the amount of bone demanded.
The soft structures are freed on the dorsum of the foot in
the way previously described; but as the base of the
osseous wedge for equinus cases is at the dorsum^ and its
apex at the sole the parallel wire director^ instead of the
kite-shaped varus one^ is used. The saw is successively
inserted in its grooves^ and by keeping in mind the idea
of a keystone^ a clean wedge of bone is cut out from the
dorsum to the sole of the foot. This wedge is easily
extracted in one piece, and consists of the component
bones of the transverse tarsal joint, and in severe cases of
portions of bone anterior to it. The splint used is the
same as for varus.
4. The list of operations (26) performed by myself, and
reference to those operated on by other surgeons.
The following list embraces a summary of my own
cases : —
144
RADICAL CUBK Of CLUB-IOOT.
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Aug. 31, 1878
Sept. 9, 1879
jQly 22, 1881
Aag. 9, 1881
Aug. 11, 1881
Oct. 21, 1881
Feb. 13, 1881
June 1, 1882
Sept 9. 1882
Aug. 21, 1882
Dec. 19, 1883
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RADICAL OUBE OF CLUB-FOOT. 145
Up to the present 23 individuals have famished 26
distinct operations. Two have submitted to the double
operation at one sittings 19 are boys^ 4 are girls. Four-
teen are cases of talipes equino-varus, ten are cases of
varus^ two cases of talipes equinus. My oldest case is 20,
the youngest 1 year and 4 months. I regret to state that
I have lost one out of the 26 operations, giving a mortality
percentage of 873.
The shortest stay in the hospital occurs in Case 10 (88
days) ; the longest stay is 175 days, in Case 22 ; this
prolonged residence was due to domestic causes. The
average stay in hospital, from the day of operation to the
day of discharge, is 77 days.
All the patients, save the one whose case ended fatally,
have been enabled to walk, and perform the daily routine
of work, subsequent to the operation. In some cases, the
application of a plaster-of -Paris or gum and chalk bandage
has been found necessary for a time, as in the case of
other resections. A high boot must be worn by others.
Patients, after the operation, become absolutely planti-
grade, the scar is small and well out of the line of
pressure; relapses are prevented, and a useful though
shortened foot results.
In recording the work done by British and foreign sur-
geons in similar cases, the list drawn up by Dr. Granville
Faught for Dr. De Forest Willard,^ of the University of
Pennsylvania, is the most complete. Tables are given
of excisions of the cuboid bone, of the astragalus, and of
wedge-shaped excisions at the transverse tarsal joint.
Amongst British surgeons the pioneer was the late Mr.
Solly, who removed the cuboid in 1854;^ Mr. Davies-
CoUey^ also performed a similar operation in 1875.
5. The exhibition of casts taken before and after
operation, the osseous wedges removed, and living speci-
mens of the results gained.
* ' Clnb-foot,' by Dr. De Forest Willard, Philadelphia.
* 'Medico-Chimrgical Transactions,' yoI. xl (1857), p. 118.
» Ibid, voL Ix (1877), p. 11.
VOL. LXVIII, 10
146 BADIOAL OUBB OF OLUB-fOOT.
On the table are thirty casts illustrating especially the
condition of the feet before and after operation^ specimens
are also presented showing how the osseous wedge is
excised in one block ; in all varus cases the cuboid bone
predominates.
Specimen No. 25 includes part of all the bones of the
tarsus, and the bases of the outer four metatarsal bones.
It is seen that the head of the astragalus is dwindled and
misshapen, reminding the observer more of the concavo-
convex aspect of the trapezium. The scapho-cuboid ar-
ticulation is exceedingly pronounced, the bones generally
are not well developed, the ligaments are tough and
hypertrophied, a small bursa is to be seen over the
anterior outer aspect of the os calcis.
Seven living specimens are exhibited. One a young
man who was operated on seven years ago, and who
has never worn any special instrument since. Two of the
cases are wearing a high cork sole.
6. General observations on club-foot, with conclusions.
After an excision at the transverse tarsal joint the ankle-
joint (as a rule) remains unimpaired; but I have seen
stiffening and loss of free motion result.
Excision of an osseous wedge at the transverse tarsal
joint is an operation mainly reserved for inveterate cases,
and for cases where milder measures have failed.
In conclusion, for cases of talipes varus, equino-vams,
(ft equinus, excision of an osseous wedge at the transverse
tarsal joint is, in my opinion, on mechanical grounds a
most valuable operation for restoring symmetry and utility
to a deformed and useless foot, no case is absolutely hope-
less, or to be condemned to amputation before the surgeon
has given this excision fair consideration ; it will, I trust,
after judicial criticism, be yet further adopted, and take
its place amongst the accepted joint excisions in surgery,
(For report of the diBCussion on this paper, see * Proceedings of
the Royal Medical and Chirargical Society/ New Series, vol. i,
p. 339.)
AN ACCOUNT
ov
TWO FAMILrBS, SEYERAL MEMBERS
OE WHICH ARE ATAXIC.
BT
J. A. OBMEBOD, M.A., M.D.Oxoh., F.E.C.P.,
A88ISTAKT FHTBIOIAK TO THI KATIOKAL HOBFITAL TOB THB FABALTgBD ASD
BPIIBFnO, AVD TO THB OITT OV LOBSOIT HOSPITAL BOB DI8BA8B8
OB THB OHBBT, YIOTOBIA FABK ; ABSISTABT IfBDIOAIi
TUTOB TO 8T. BABTHOLOXBW'S HOBFITAL.
(BaoeiTod October ISth. 1884-Sead VthnMrj 94tli, 1886.)
Some years ago the late Professor Friedreich^ described
for the first time a form of ataxia which he believed essen-
tially to resemble the classical type of locomotor ataxy^
bnt which differed from it in several particnlars. The
resemblance consists in the main symptom of incoordina-
tion in movement^ beginning in the legs and spreading at
a variable rate upwards ; the differences are as follows :
(1) Friedreich's disease attacks many members of one
family, usually brothers and sisters, and females no less
than males ; (2) it attacks at a comparatively early period
of life, sometimes quite in childhood ; (8) the disorder of
gait, caused by the ataxy, is uncomplicated and at first
the only symptom, whereas in ordinary tabes the ataxic
stage may be preceded by a large variety of symptoms,
1 * Virchow's Arohiv/ toU. xxtI, zxvii, Ixriii, Ixz.
148 ACCOUNT OF TWO ATAXIC FAMILIES.
motor, sensory or trophic, and above all, by that of pain ;
(4) as the disease progresses, two symptoms may appear
not usually seen in tabes, viz. disorder of articulation and
nystagmus. These also Friedreich regarded as due to
incoordination of movement. Sundry other symptoms,
such as curvature of the spine and contractures of the
feet, have been added. The pathology of the disease
rests as yet on a few cases only ; but it seems to be esta-
blished that there is always systematic sclerosis of the
posterior columns of the cord, and often disease of other
parts of the cord as well.
I will not now go into the literature of the subject,^
but will merely mention that the cases exhibited by Dr.
Carpenter at the Medical Society (1871), Dr. Gowers at
the Clinical Society (' Transactions,' vol. xiv), those pub-
lished by Dr. Dreschfeldin the 'Manchester and Liverpool
Hospital Reports ' (1876), and by Mr. D'Arcy Power in the
'Reports of St. BartholomeVs Hospital^ (1882), comprise,
I believe, all that have been reported in England.
The ccbses which form the subject of this paper are
taken from two different families; three from one, and
two from another. In this second family there is a third
ataxic patient whom I have not seen, and a fourth who
will possibly become ataxic. None of the cases are far
advanced. With respect to the upward spread of the
disease, speech is affected in some only ; well-marked
nystagmus has not yet appeared in any.
Casi 1. — Kate Woodcock, then set. 14, was brought to
me at the National Hospital for the Paralysed and Epi-
leptic, on October 1st, 1880; the account given by her
mother was that she had had measles three years pre-
viously, and soon after it a fever which the mother called
rheumatic fever ; after this she became subject to fits in
the night-time, in which fits she screamed and became
1 See ' Brain,* No. 26, April, 1884 ; and for more recent cases— (a) Scbmidf s
< Jahrbnch/ December, ISSi^^cases by WAUe and others, (fi) ' La Rivista
Clinica,' October, 1884, — cases by Mosso.
ACCOUNT OF TWO ATAXIC FAMILIES. 149
insensible when she was held ; next, she became unable
to walk straight. She was also said to fidget with her
hands and drop things. * The only symptoms I could
notice were that she had a twitching of the mouth and
forehead just like that of chorea; and, as regards the
gait, that after walking several times up and down the
room she became rather unsteady. I took the case to be
probably chorea, and till June, 1881, she continued to
attend, but remained in much the same condition. She
came again during the last three months of 1882, when
she seemed, if anything, more unsteady. In January,
1888, she was laid up with scarlet fever, but came back
to me in the following April. The unsteadiness had then
increased so much that it was evidently due to some-
thing else than chorea. She swayed from side to side
as she walked, and had difficulty in turning; she could
not stand at all with her eyes shut. The patellar tendon
reflex was absent on both sides. Dr. Buzzard, who was
present, kindly verified this for me. The contractility of
the quadriceps muscles (to faradism and to percussion)
and their nutrition, were normal. Till August her condi-
tion remained stationary. It may be summarised as
follows : — Gait unsteady, the left foot turns in as she
walks ; patellar tendon reflexes absent, plantar reflexes
present, tactile sense in feet and toes normal ; muscular
sense normal {%. e. she knows the position of her limbs
when her eyes are shut) ; occasional pain in the head, but
in the limbs no pain, numbness, or paraBsthesia, except a
slight occasional pricking in the feet ; slight awkwardness
in the hands, but nothing really noticeable, speech normal,
no nystagmus, pupils contracting sluggishly to light,
readily for accommodation; fundus of eyes, except for
some tortuosity of the retinal vessels, normal. Still some
twitching of the forehead and of the left upper limb.
Extensor tendons of both great toes prominent ; the
mother thought that the feet had become humped.
In August she became worse. She often went down on
her knees in the streets, the ankles seeming to give ; she
150 ACCOUNT OP TWO ATAXIC FAMILIES.
had another fit^ apparently a kind of fainting fit. On
Angnst 25th I saw her at her mother's cottage^ looking
pale and thin, and only able to get about by holding on
to the banisters and furniture ; she had difficulty in
directing the movements of the legs, e,g, in crossing and
uncrossing them, or in describing a circle in the air with
her foot ; though she still knew how they were placed.
In addition there seemed to be some actual muscular
weakness and the thigh muscles were rather flabby. The
Achilles tendons were becoming tight, and the feet looked
short and stumpy.
She went to the Convalescent Home of the Hospital at
Finchley ; and since then has been at the Holbom Union
Infirmary, where, by the kind permission of Dr. McLeam,
I have twice seen her during the present year (1884) . In
March, she was in bed, unable to get about alone ; there
was slight general stiffness in the legs. In October,
though out of bed, she could not walk ; she had difficulty
in managing the legs even when sitting ; some awkward-
ness of the hands ; handwriting bad, she says her head
shakes when she tries to write ; in reading, she separates
the syllables and sometimes drops one. The legs are cold,
their muscles small, some rigidity at the ankles, though
none at knees ; the feet more deformed than before, being
in a position of equino-varus, the plantar arch high, the
toes, especially the great toes, tending to turn up, and the
toe-balls projecting on the plantar surface. Sensibility in
feet and legs still normal, except that a prick with a needle
hurts her very little.
She is a poorly-developed girl ; though she is now 18,
menstruation has not yet appeared.
Case 2. — John Woodcock, younger brother of the last
patient, came to me first in April, 1883 (age at that time
18). The mother said that during the last two years she
had noticed a " catching '' in his legs, which seemed to
giYQ when he walked and to make him unsteady. This
had come on gradually ; she ascribed it to a fright from
ACCOUNT OP TWO ATAXIC PAMIUB8. 151
an operation for removal of his tonsils. She had noticed
no twitching of his face or limbs^ though she said he was
fidgety in his ways. Two or three months ago he had
compktined of pains in his limbs^ apparently of an aching
character. He had convulsions when a baby^ measles
with his sister Kate^ and also the so-called rheumatic
fever. When seen^ he walked rather unsteadily^ swaying
somewhat from side to side^ though not nearly so badly
as his sister. With eyes shut and feet placed together
he swayed about but did not fall. Patellar tendon reflexes
absent (the quadriceps muscles being normal). Plantar
reflexes slight^ sensibility in feet normal ; speech pladn^ no
nystagmus^ action of the pupils normal.
During the time of his attendance (from April to
October, 1883), he did not improve. Twice he had an
attack of giddiness and fell off a chair ; from time to time
slight irregular movements of the head were noticed ; he
became unable to stand with his eyes shut.
In March, 18 A, I saw him with Dr. McLeam at the
Infirmary ; the walk was more unsteady, he lurched from
side to side and, when he turned, his feet seemed to get
crossed ; Romberg's symptom was well marked. The
nurse said he did not always know where his hands were.
She had also noticed a peculianty in his speech, not
exactly a stammer, but a slowness in bringing out his
words. He paused between words and syllables as he
read aloud to me.
In October there was little change. I noticed that the
toes had a tendency to turn up.
Case 8. — Hannah Woodcock, an elder sister of the last
two patients, present age 20. In 1877, she had the so-
called rheumatic fever with the others. Afterwards she
used to stoop as she walked. She went to service, but
her health failed. She was under Dr. Sturge at the
Royal Free Hospital from October 1880, to June, 1881.
She had been knocked down by a drunken woman in the
street, came home all starting and trembling, and was
152 ACCOUNT OF TWO ATAXIC FAMILIES.
subject afterwards to the same " startings '* and '^ ner-
vonsness/' The mother says that she was told her
daughter had the St. Yitus^s dance (I mention this to show
the probable similarity of onset in her own and her sister's
case) . Carvatnre of the spine was discovered^ and treated
at the Orthopaddic Hospital^ with a spinal support. This
made her much better able to walk.
I have seen her on various occasions from April of last
year till the present time. At first there was nothing
noticeably wrong with her walking, but she has since
acquired an unsteadiness of gait and occasional sideward
lurch. Romberg's symptom, variable at first, is now well
marked; she can neither stand with her eyes shut nor
walk in the dark. Patellar tendon reflexes absent.
During the present year some weakness, or rather awk-
wardness, of the left hand has shown itself. There is
usually a droop of the left eyelid, and sometimes an internal
squint of the left eye ; otherwise nothing abnormal about
the eyes or pupils. There is considerable lateral curvature
of the spine. There is a deformity of the feet, not unlike
that in her sister's case, but no well-marked equino-varus.
An aching and tenderness of the feet, which she some-
times has, may be due to this deformity ; over and above
it I have found no sensory abnormality, nor any true
paralysis of movement, nor loss of electro-contractility in
the muscles. Menstruation has been regular and natural
for the last two or three years.
There are four other members of this family (not
including a child that died of scarlet fever) ; one an elder
brother, age between twenty and thirty, three younger
children, ages from nine to six. All these are in good
health,^ but I may note that in some of them I have been
unable to obtain any patellar tendon reflex, and in others
it seems to be uncertain. In the father and mother it is
normal. The nervous inheritance seems to come from
the mother's side. She had fits till the age of twelve,
another at seventeen, and another when pregnant with
^ Two have since shown symptoms of disease. See note on p. 167.
ACCOUNT OF TWO ATAXIC FAMILIES. 158
the first of these patients (Kate). She has no brothers
and bnt one sister, living at Hailsham. This sister is
insane, but has nevertheless a large family. This family
seemed to me quite healthy, but I had difficulty in obtain-
ing tendon reflexes in the two youngest members.
As to the maternal grandfather of my patients, there
seems good reason for thinking he was ataxic. He was
taken ill at the age of fifty, had severe pains in his legs,
for which he had to take opium ; walked with unsteadi-
ness as if he were drunk ; finally took to crutches, and
died at the age of seventy-five of bronchitis, having had
two or three fits.
In the next family there are three cases of ataxy, and
one girl who will probably become ataxic.
Cass 4. — Ruth Harriet Harmer, »t. 20. I have seen her
at her mother^s cottage on two or three occasions. Her
condition is as follows : — She sits in a humped-up
position, but there is, I am told, no spinal curvature ; her
head sometimes sways a little. When she stands there
are constant balancing movements of the body, and she
becomes more unsteady when she shuts her eyes. She
can only walk by supporting herself against the wall and
furniture, and seems as if she would tumble to one side.
The patellar tendon reflexes are absent. There is, I
think, some actual muscular weakness of the lower limbs,
but they are well nourished and the electro-contractility of
the muscles is normal. When she tries to describe a
circle with her foot she makes a very irregular figure.
The cutaneous sensibility of the feet, in all its modes, and
the muscular sense are normal. The skin of the feet and
legs is cold and mottled. The plantar arch is high and
the foot stumpy looking. Her speech sometimes appears
to be slow and drawling; her mother says it becomes
thick if she reads for long. There is a certain tremulous-
ness of the eyeballs as she follows an object, but no
definite nystagmus. The pupils act normally to light.
The upper limbs are but slightly affected, if at all.
154 AOCOUNT OF TWO ATAXIC FAMILIEB.
The onsteadiness has been noticed ever since she was
thirteen^ bnt she has been bad for two or three years^
since an attack of " low fever.*' (Her mother and another
sister had this same fever ; the symptoms were sorethroat^
bad cold^ and feverishness^ with much debility afterwards.)
In October^ 1882^ she became subject to cramp in the
limbs if they were long in one position. A year later
sharp shooting pains in the legs began^ and tearing pains
in the loins. These improved during the recent hot
summer. Her menses began at seventeen^ and have been
regular and natural since.
Case 5. — Alice Rose Harmer^ ast. 16^ sister of the last
patient. As in her sister's case it was noticed that from
the age of thirteen she was apt to fall and tumble about^
but her walking has been worse the last two or three
years. She now walks unsteadily, and occasionally reels
from side to side ; she is slightly unsteady when she stands
with her eyes shut. Patellar tendon reflexes absent ;
muscular power unimpaired; farado-contractility of muscles
normal. Sensory functions normal in every way. No
pain. There is the same chilliness and mottling of the
legs as in her sister's case^ and the same shape of foot.
She has had during the present year a small but rather
deep ulcer on each middle finger. No marked ataxy of
upper limbs. Speech not noticeably affected. No
nystagmus. She is pallid, and subject to severe head-
aches, which often end with vomiting. Menses regular
since the age of fourteen or fifteen ; twice during the
present year they have been profuse and accompanied with
epistaxis.
There is an elder brother (»t. 21) in New Zealand ;
since he went there he has become hump-backed and
unable to walk about ; he, like his sisters, used to fall
about when he tried to run from the age of thirteen
onwards.
A third sister, est. 11 or 12, has been brought to me
ACCOUNT OF TWO ATAXIC TAMILIE8. 155
because the mother thinks she is beginning to walk like
the other two girls, I cannot corroborate this myself, but
the patellar tendon reflexes are absent, or nearly so.
There are five others, all said to be healthy. Two have
died of convulsions and there have been two stillborn.
The father appears to be not strictly sober ; but neither
in the parents nor grandparents can I make out any definite
history of nervous disease.
The chief interest in this class of cases attaches to the
89tiology. There is a family predisposition, not merely in
the sense of a neurotic diathesis manifesting itself in various
forms, such as epilepsy, insanity, migraine, &c., but pre-
disposition to organic disease of a particular part, viz.
sclerosis of the posterior columns, with possibly other
parts of the cord. The repetition of the disease takes
place usually in the members of one generation. Buti-
meyer observed no less than four collateral branches of
the same stock simultaneously affected. There are several
other nervous diseases which attack brothers and sisters ;
for instance, pseudo-hypertrophic muscular paralysis, pro-
gressive muscular atrophy, Thomsen*s disease, colour-
blindness, and a disease of the yellow spot lately observed
by Mr. Waren Tay. Most of these are also transmissible,
hereditary, that is, in the strict sense, and in some of them
a curious mode of propagation has been traced, viz. that
the disease manifests itself in males but is perpetuated
through their female descendants. Thus, a man is dis-
eased, his sons and their descendants are exempt, his
daughters are themselves exempt, but bear diseased sons.
I would refer in this connection to two interesting family
trees of colour-blindness and of haemophilia, published by
Dr. Wickham Legg in ' St. Bartholomew's Hospital
Reports,' vol. xvii. Dr. Gee, in vol. xiii of the same
^ Reports,' gives an account of a family where diabetes
insipidus was propagated through the daughters. But no
such definite mode of propagation has been shown to exist
in Friedreich's disease. Indeed, with the exception of
Carry's family, Rutimeyer's family, and the first of my
156 ACCOUNT OF TWO ATAXIC FAMILIES.
own^ I do not think that ataxia has been shown to exist
among the ancestry at all. Neither are females exempt
from the disease ; indeed, Friedreich thought they were
particularly prone to it, but this may have been accidental
to his observations, for amongst later cases there is a good
proportion of males.
It is worth noting that these ataxic families are gene-
rally numerically large. One is tempted to think that the
rapid production of children may have caused imperfect
development in some of them.
Lastly, since the disease does not appear at birth, what
other factors besides the family predisposition assist in
its development ? Friedreich held that it was connected
with puberty, and doubtless this is often the case, but
not invariably. I believe that the influence of acute
disease is another possible factor. In two at least of my
three first cases the unsteadiness followed on a feverish
attack. This was described to me as rheumatic fever,
but as there was no redness or swelling of the joints and
no heart affection was left, it can scarcely have been
rheumatic fever. There was sorethroat, feverishness and
aching of the limbs, and several of the family had it at
the same time. Supposing it to have been diphtheria, it
would be likely enoagh that a complaint, which under
ordinary circumstances may be followed by temporary
ataxia, should, in the presence of a family predisposition,
prove the starting-point of permanent spinal disease.
Again, in Case 4, the symptoms were said to have become
much worse after a " low fever*' with sorethroat, &c., from
which the mother and another sister also suffered. In
Case 1, too, it was after an attack of scarlet fever that
the ataxia of gait first became so marked as to be
unmistakable.
ACCOUNT OF TWO ATAXIC PAMILIB8. 157
[A. I — Adams, drowned, nt. 40, a pilot.
Woodcock I
family. I Henry Adams, probably atcuric. Had a brother and sisters
"^ I I healthy (?)
Mrs. Woodcock (has had fits occasion- Mrs. Gravitt, insane.
Has children — Has children —
1. Son, et. 28, healthy. 1. Daoghter, SBt. 29, married,
2. Daughter, sot. 20 (Case 8), healthy.
ataxic, 2. Daughter, SBt. 24, healthy.
8. Daughter (Case 1), ataaie, 8. Daughter, sot. 21, married,
4. Son (Case 2), ataxic, healthy.
5. Daughter, sst. 9, healthy,^ but 4. Son, reported to be healthy.
^ tendon reflex absent 6. Daughter, sot. 16, healthy.
V^ , 6. Son, 8Bt. 7, healthy,* but tendon 6. Daughter, set. 18, healthy, but
reflex abseni or doubtfid, tendon reflex uncertain,
V^tUt 7. Daughter, »t. 6, healthy ; fen- 7. Son, sot. 10, healthy, but te/ndon
"^V/^ don reflex not aUcays obtain* reflex uncertain,
^^ able, (Besides these, three or four either
8. Sod, died young of scarlet fever. dead or stillborn.)
B. Harmer family.
No nervous disease in father or mother, or in their parents, so far as
was known.
Their children are —
1. Daughter, sst. 28, married, healthy.
2. Son, 89t. 24, healthy so far as is known.
8. Son, SBt. 21, ataxic.
4. Daughter, »t. 19 (Case 4), ataxic,
6. Daughter, et. 17 (Case 6), ataxic.
6. Son, et. 14^ reported healthy.
7. Daughter, »t. 11, tendon reflex absent,
8. Son, 8Bt. 9, healthy.
9. Daughter, »t. 7, healthy, but tendon reflex feeble,
(The ftrtt two children that were bom died of convulsions at two months
and two years respectively.)
* Since this paper was written both these children have shown symptoms
similar to those with which the disease began in their elder relatives (July,
1885).
(For report of the discoBEdon on thia paper see ' Proceedings of
the Boyal Medical and Ghimrgical Society,' New Series, vol. i,
p. 346.)
t^^n ZdL^ H^. (ici. - fr^^-s^tiu.
FATAL HEMOPTYSIS:
THE STATISTICS OP THE LAST FIFTEEN YEAES OF
THE CHEST HOSPITAL, VICTOEU PARK,-
WITH
KEMAEKS UPON FBOFUSE NON-FATAL H^IMOFTYSIS.
BY
SAMUEL WEST, M.D.,
PHTBIOIAK TO THE CHS8T HOSPITAL, TIGTOBIA PABZ, AKD TO THE BOTAL
PBBB HOSPITAL; KBDIOAL TTTOB, ST. BABTHOLOMBW'S HOSPITAL.
(Aeedred November llih, 1884-Kead February 84th, 188S.)
It is an opinion now generally expressed that fatal
pulmonary hsemorrliage has for its cause^ with bat few
exceptions^ some gross lesion of the pulmonary vessels^
viz. either ruptured aneurysm or erosion.
It is remarkable, however, how little there is in
literature beyond the record of isolated cases to support
this, as I believe, quite correct conclusion. The present
paper is a contribution to the subject based upon the
post-mortem evidence of the past fifteen years at the City
of London Chest Hospital. Dr. Douglas Powell^ has
published similar observations extending over some years
at the Brompton Hospital. The only other original paper
of importance I am acquainted with is that by Dr. Yald
Basmussen.'
^ < Tranflaotions of the Pathotogioal Society,' vol. zzii.
* Translated by Dr. Moore, in * Edinb. Med. Jonm.,' vol. xiv.
160 FATAL HJEMOPTTSIS.
Although I have not introduced into the present
statistics cases which I have met with in other places^
the general conclusions I draw^ other than statistical^ are
so framed as to include the experience gained from these
other sources.
The statistics deal entirely with fatal cases of pul-
monary hasmoptysis. After discussing these I shall con-
sider what light is thrown by them upon cases of profuse
pulmonary hasmoptysis which have not proved fatal.
By the term pulmonary haBmorrhage I wish to exclude
all cases of heamoptysis due to the rupture of a large
vessel into the trachea or larger bronchi, as in the course
of thoracic aneurism or new growth, and to speak only of
those cases in which the hasmorrhage has its source in
some portion of the lung tissue, i.e. of hasmoptysis in its
usual limited sense.
The cases number 26, 20 males and 6 females.
1&-20 20-25 25-30 80-86 85-40 40-50 60-60
Males .
2
2
4
2
2
8
4 ..
. 19
Femalea
8
1
1
1
.
6
Totals .5 8 5 2 2 4 4 ... 25
In one of the 26 the age is not given, and although the
numbers are too small to justify any absolute conclusion,
this table seems to show that there is no special liability
at any particular age.
The earliest case was in a lad of 16, and the latest in
a man of 53.
Sex. — It is noteworthy how much more frequent these
cases seem to be in men than in women, in the propor-
tion of 20 to 6 or 8^ to 1.
This may be associated with the fact that the male
has a greater power of resistance to phthisis than the
female, or, in other words, that the disease more often
becomes chronic in the male. To this point attention will
be drawn again later.
FATAL HJCH0PTT8IS. 161
The condition of the hmga. — Phthisis was in all cases
present^ and was clearly the primary cause. Cavities
were always foond and cavities not of recent date^ bat
with thick fibroid walls^ and ribbed or crossed by coarse
trabecnlae, such as are found usually in the most chronic
forms of phthisis.
Both sides were similarly affected^ though not to equal
degree^ in 16 cases^ while in 9 one side only was exca-
vated^ the opposite lung being in the condition of comple-
mentary emphysema^ or, as it is often called, of compen-
satory hypertrophy.
These very chronic cavities seem to constitute a group
of phthisis quite apart from the other and more ordinary
form. In these the disease develops very slowly, often
insidiously, so that there may be perhaps no history of
any previous illness, and death sometimes occurs quite
unexpectedly from haemoptysis in patients who have been
thought, and have appeared, in good health. Indeed, in
this class of cases profuse haemoptysis seems to be the
risk most to be dreaded.
In other words, profuse haemoptysis generally occurs
in chronic phthisis, or from chronic cavities, very rarely
in the subacute, and possibly never in the acute form of
the disease.
Ciiuse of hemorrhage, — The source of the haemorrhage
was found in 16 cases out of 25, and proved to be aneu-
rysm in 11, and ulcerated vessel in 6.
In the cases in which I have myself made the exami-
nation I have only twice failed to find the source, and one
of these cases of faiilure is not included in the present
number.
Too much stress must not be laid upon the term used,
for ruptured aneurysms sometimes look like ulcerated
vessels, especially when, by the force of the blood-stream,
the whole or nearly the whole of the sac has been torn
away, and I further observe in the post-mortem notes of
recent years that aneurysm is a term more commonly
found than ulcerated vessel, while in some of the earlier
VOL. Lxviii. n
162 TATAL HJ1X0PTTBI8.
notes the diagnosis of ulcerated vessel has the explanation
added^ '' No saccular dilatation fonnd^'' but for the reasons
given the explanation is hardly adequate.
In my own oases I have only once or twice seen
ulcerated vessels among many cases of aneurysm^ and
BasmuBsen says that he has himseU never met with an
ulcerated vessel as distinguished from aneurysm. The
difference is therefore probably in most cases rather one
of terms than of reality.
The side. — The hsBmorrhage came from the left side for
certain in 11 cases^ and with probability in 5 more ; and
from the right side for certain in 6^ and with probability
in 3 more. So that the left side is more often the source
of the haamorrhage than the right in the proportion of 16
to 9^ or nearly 2 to 1.
When the chronic excavation before referred to is
limited to one side it appears to be also most fre-
quently on the left side^ in the proportion in the present
cases of 6 to 2. I know of no other statistics on this
point; but this conclusion quite agrees with other observa-
tions of my own.
It does not; however^ necessarily follow that the source
of the hesmorrhage is found upon the side most affected^
or if so in the most diseased part of it.
The seat. — ^Any chronic cavity, whatever its size, may
be the source of the hsBmorrhage, from a small single
cavity — the only spot of disease, it may be, in the lung —
not larger than a filbert, to an enormous cavity, produced
by the complete excavation of the whole lung.
The cavity from which the haemorrhage came was in
the upper lobe 9 or probably 10 times, in the middle lobe
twice, and in the lower 7 times, and of these last it was
found 6 times in the apex of the lower lobe. In two
cases the whole lung was excavated.
In the majority of cases, therefore, the haamorrhage
came from the upper lobe. The next commonest source
was the apex of the lower lobe, or in the middle lobe.
The lower part of the lower lobe is an unusual position.
FATAL HJIlffOPTTSIS. 168
The favoarite seat^ therefore^ is the middle of the long
laterally^ and near the periphery^ whether in the lower
part of the upper lobe^ or the upper part of the lower.
This is also the spot at which perforation most frequently
occurs in pneumothorazj and it is interesting to associate
these two facts together.
Anev/ryam of the pulmonary artery. — Basmussen^ in his
paper^ draws a distinction between aneurysms^ i.e. definite
sacs or pouches, and ectasias or dilatations. I do not
think it desirable or necessary to make this distinction^ for
the two classes are differentiated by no fixed characteristicsj
and there is every transitional stage between the one and
the other^ so that it is simpler to regard them as different
degrees of the same affectiouj and to speak of them all as
aneurysms.
These aneurysms spring always from a branch of the
pulmonary artery^ sometimes from one of the main divi-
sions; but more often from a medium-sized branchy though
frequently at only a very short distance from the origin
of the smaller branch from the main trunks so that a
bristle may pass quite easily at once into the main vessel.
These facts are of importance^ I thinks as bearing upon
the origin of these aneurysms. They develop^ as a rule,
in the longitudinal axis of the vessel, away from the main
trunk and into the lung-cavity.
They are usually found upon a trabecula which forms a
more or less prominent ridge in the walls of the cavity ;
sometimes, though rarely, upon a trabecula which crosses
the cavity, though Basmussen says that he has never seen
this latter position, and it is certainly rare. Occasionally
there is no indication of the trabecula, but the aneurysm
projects at once from what appears to be the smooth wall
of tiie cavity.
The trabecule are the remains of the indurated vessels
and bronchi of the lung, and are largest towards the root
of the lung. Hence the aneurysms also are found in the
part of the cavity nearest to the root. Cavities, there-
fore, in which aneurysms are being searched for, may be
164 FATAL HA1C0PTT8I8.
opened through the pleura^ i.e. from the periphery, with-
out risk of destroying the aneurysm.
Their shape is^ as a rule^ more or less globular, extend-
ing from one side of the vessel. Those of large size have
frequently secondary pouches or sacculations upon them,
and sometimes look almost like a mulberry. At other
times they form more irregularly oval swellings, also with
secondary sacculations. This is the condition to which
Basmussen gives the name of ectasias. True fusiform
aneurysms are, I think, from the nature of things almost
impossible.
They are usually small, sometimes not larger than a
pea, only very rarely larger than a Morella cherry, i.e. ^
to i""^ in diameter. Aneurysms as big as a walnut are very
unusual. I have exhibited two of this size ; one of them,
oval in shape, measured one inch and three quarters long
and one inch wide. I have never met with a description
of a larger aneurysm than this. There is no relation
between the size of the cavity in the lung and the occur-
rence or size of an aneurysm. The cavity may be so
small as to be completely filled by the aneurysm, and that
too when other much larger cavities are present. In two of
the cases recorded here, the cavity was formed by excavation
of the whole lung, while the aneurysm was of small size.
Aneurysms are in most cases single. This is remarkable,
but instances of multiple aneurysm are recorded by many
observers. One of the cases in these tables had several.
With regard to clotting, Basmussen states that pul-
monary aneurysms are never found to contain laminated
clot. Further observation proves the statement to be
incorrect. It is, however, true that they frequently do
not. The larger aneurysms generally do according to my
experience, and many of the smaller ones may. Dr.
Percy Kidd's case is a notable instance of this, for nearly
every one of the numerous aneurysms there found was
occupied by laminated clot, which in some nearly filled
the cavity completely.
Many of the solid lumps found projecting from the
FATAL HJBM0PTT8IS. 165
walls of chronic cavities are^ I believe^ anenrysmsj which
have become obliterated or cured by clottings in the
same way that anenrysms cnre elsewhere^ but clotting
does not necessarily prevent rnptare in pnlmonary any
more than in other aneurysms.
Clotting often occurs not only in the sac^ but also after
rupture outside it in the cavity^ and this clot^ too^ is some-
times laminated. The size of the aneurysm thus becomes
sometimes deceptive, and it appears much larger than it
really is.
This clotting may explain the cases of remittent hasmo-
ptysis, but though essentially a conservative process,
whether within or without the sac, it does not necessarily
prevent a fatal result.
The seat of rupture is generally at the periphery, i.e.
at a point distant from the vessel from which it springs,
but occasionally it is found at the base of the sac, as it
were between the sac and the vessel.
The aperture is sometimes small, and may then be
easily closed by clotting ; at other times it is irregular
and large, and in some cases the whole sac or the greater
part of it is torn bodily off, and the rent into the vessel
is represented by the origin of the sac. Some of these
cases would look very like simple erosion of the vessel.
In some of my own cases, I have only been able, on care-
ful examination, to satisfy myself that I had an aneurysm,
and not an erosion to deaJ with.
As in aneurysms elsewhere, the final rupture rarely
comes without warning. In most cases there is, or has
been within recent periods, some premonitory h»morrhage.
This clinical fact, associated with the known pathology,
shows the importance of early and strict treatment of
even slight haBmorrhage in chronic phthisis.
Basmussen draws a distinction as to the access and the
amount of haBmorrhage between the two classes which he
makes of aneurysm and ectasia, but I do not think so
sharp a distinction is warranted either by clinical experi-
ence or by pathological observation.
166 FATAL HJ!MOPTTSIS.
The pathogenesis of pulmonary aneurysm is^ I tliink^
simple. There is no case recorded^ so far as I am aware^
of an aneurysm of the pulmonary artery developing in an
otherwise healthy lung. It is conceivable that atheroma
or syphilitic disease^ or some other primary affection of
the pulmonary artery might lead to aneurysms^ but such
conditions are, to say the least, very rare. Hence we
are justified in connecting the development of the aneurysm
with a pre-existing cavity in the lung as abeady shown.
The formation of the aneurysm may be attributed :
I. To changes set up in the walls of the vessel, of an
inflammatory or degenerative nature, by direct extension
from the walls of the cavity.
In nearly all acute inflammatory or rapid cases clotting
occurs in the vessels of the neighbourhood, and they are
early obliterated. When the process becomes circum-
scribed, and a chronic cavity is formed, it frequently
happens that a vessel of larger size remains unobliterated,
and that its coats become subsequently involved in the
same fibroid change which had occurred in the walls of
the cavity. If the vessel remain patent the blood pres-
sure within slowly distends the fibroid part to form a
pouch.
The growth of the aneurysm is still further aided by :
n. The want of support upon the side towards the
cavity, so that this side of the vessel is not only the
weakest in itself, but also the direction of least external
resistance.
It is, moreover, not utiusual to find the vessel from
which the aneurysm springs constricted or even perhaps
completely obliterated peripherally, a condition which
tends still further to promote the formation of aneurysm,
by making the same spot also the point of maximum
pressure from within.
These facts explain the association of aneurysm with
chronic cavities only.
Ulceration of vessels. — Where a cavity is of more recent
formation and has not passed into the chronic stage, or
lATAL aSMOPTTSIS. 167
where in a chronic cavity ulceration has set in^ the change
in the walls of the vessel are of a more acute character.
They too may become involved in the ulceration^ and after
considerable thinning may rupture. But in most cases
this is prevented by clotting within^ and the vessel is
quickly obliterated. This is so common in phthisis that
occlusion of vessels has been regarded as one of the most
characteristic features of the disease. If this were not
so, hsBmorrhage ought to be even more frequent than it is^
and fatal hsBmoptysis one of the commonest causes of
death. The contrary is, however, the case. The per-
centage of deaths from hsemoptysis in phthisis is small,
probably not more than 1 or 2 per cent, of all the fatal
cases. My own statistics give about 1'5 per year, or
about 2 to 2*5 per cent, of deaths from all causes in
phthisis.
Although the pulmonary artery is the vessel usually
affected in both aneurysm and ulceration, still the pul-
monary vein may be attacked. I have met with one case
of this kind in which the death was due to ulceration of
a branch of the pulmonary vein, but it is the only case I
know of.
In conclusion, aneurysm being a thing of slow growth,
can arise only in chronic cases. In early phthisis haemor-
rhage is probably due to ulceration or erosion of vessels,
but this is rarely copious and very seldom fatal, for
phthisis as a rule seals the vessels as it invades them.
When hsBmoptysis leads to death, it does so in one of
two ways, either by frequent recurrence of haemorrhage
and gradually increasing exhaustion, as occurs in similar
recurrent haemorrhage from other parts, or suddenly in a
few moments. To this latter group the name of suffo-
cative haemoptysis is given. Occasionally, however, the
sudden result is due to cardiac syncope, though as a fact
this more frequently occurs as the final cause of death in
the cases belonging to the first group, i.e. where death is
the result of exhaustion.
16^ VATAL HAflMOPTTSlS.
The qaestion now arises : '' Are the causes of profuse
pulmonary hsemoptysis the same in the non-fatal as in the
fatal cases ? *'
To this question an affirmative answer must^ I think^
be given without hesitation^ and for the following
reasons :
1. Cases recover which can in no way be distinguished
clinically from those which die.
2. In cases which have lingered and finally died from
exhaustion (remittent or intermittent haemoptysis) the two
lesions described^ viz. aneurysm or ulceration, have been
found.
8. We have sufficient pathological evidence that pul-
monary aneurysms may, like aneurysms elsewhere, spon-
taneously cure, and though it may be urged as an objec-
tion that if this were true, cured aneurysms should be
frequently found in cases of phthisis, I do not think the
objection of much weight, for they are often not looked
for, and even when looked for carefully are not easy to
find, while it is possible that many of the firm fibrous masses
frequently found and described in chronic cavities, and of
which no very satisfactory pathological explanation is
usually forthcoming, may be really aneurysms oblite-
rated and cured. Several such cases have been recently
described.
4. The evidence is still stronger in favour of the cure
of ulcerated vessels. In acute phthisis the vessels are at
once considerably involved, and the wonder is not that
profuse haemoptysis occasionally occurs, but that it is not
much more frequent. It is prevented, we know, by the
thrombosis and obliteration of vessels which advance pari
passu with the disease, and the same process continues
also in chronic phthisis, in which, as is abundantly proved,
ulceration of vessels is very rarely the cause of fatal
haemoptysis.
Nor are the cases of phthisis ab haemoptoe, i. e. those
cases in which profuse haemoptysis is the first or earliest
recognisable symptom of the disease, necessarily opposed
FATAL HJBMOPTT8I8. 169
to the present views of haBmoptysis, for it is well known
that disease may exist in the lung which no physical
examination can detect^ and that it is often of a latent^
insidious or chronic kind, and that aneurysms have been
found in such cases.
The doctrine of phthisis ab hsdmoptoe can hardly I think
be accepted except in the sense of post and not propter
hsemoptoem ; and though it is true that after hsBmoptysis
destructive lesions may advance with great rapidity in the
lang ; it is, however, equally true that the hsdmorrhage
sometimes not only does no harm but may even seem to
do good.
It would carry me beyond the scope of this paper were
I to bring forward evidence from the clinical records of
cases to establish each of these assertions, but upon the
answer given to these questions will depend largely the
methods of treatment we pursue, and as rational thera-
peutics must rest upon the basis of correct pathology their
importance is self-evident.
170
lATAL HAMOPTT8I8.
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ACUTE PEBITONITIS TREATED BY
ABDOMINAL SECTION.
BT
FBEDEBIOK TBEVES, F.B.O.S.,
gVBeiOV TQ» AHD LIOTUSBB OK AVATOICY AT, THB lOVDOK HOBPITAL.
B«06iT«d October lit, ISM-Katd March 10th, 1886.
Among the great ohanges that have of late years taken
place in the practice of surgery there are probably none
more remarkable or more revolutionary than those that
concern the serous membranes. Within quite recent times
serous cavities were held by surgeons in a kind of respectful
dread — they were sacred enclosures^ into which the knife
of the boldest seldom ventured ; they held an immunity
from all forms of active interference and were accounted
exempt from the rudimentary principles of surgical treat-
ment. With regard to the larger cavities — ^those of the
chest and abdomen — ^it is interesting to note how abruptly
operative procedures ceased at the confines of the pleura
and peritoneum. Disease was pursued by the knife up to
the very walls of these cavities, but when it had found a
place within the enclosure itself it had found a sanctuary
into which the surgeon did not trespass.
The most remarkable advances of modem surgery are
176 ACUTS PSBIT0NITI8 TRBATSD
based upon a disregard of the supposed peouliarities of
the serous membranes and — following after this — upon the
application to serous cavities^ and the viscera they contain^
of the common general principles of surgical practice.
Ovariotomy is founded upon the same principle that
advises the removal of a tumour of the surface ; extirpa-
tion of a disorganised kidney upon the same principle
that urges the excision of a disorganised eyeball; and
excision of an epithelioma of the colon^ or pylorus^ upon
the same principle that sanctions the removal of an epithe-
lioma of the lip. It cannot, indeed, be said that the
surgery of the chest and abdomen, as it now appears,
involves any new element in the treatment of disease.
The most striking of the operations that have of late
years been directed against the serous cavities and their
viscera, consist at the best merely of the application to
those parts of common principles of treatment that have
long been applied to other portions of the body.
It is to the treatment of inflammatory affections of
serous membranes that I would venture to especially
draw attention.
In the management of inflammatory conditions of
superficial parts or — it may even be said^-of parts beyond
the confines of the serous membranes, it is the common
and most ancient practice (when milder means have
failed) to freely incise the involved part, for the purpose
of relieving congestion and tension, and more especially
for the purpose of giving a free escape to all inflammatory
products. It is only within comparatively recent times,
and only in a progressive and cautious manner, that
surgeons have applied this common principle to the treat-
ment of inflammations of serous cavities. They began in
the first place with small serous cavities — ^with the joints.
The disordered joint was cut into, the inflammatory
matters that it contained were evacuated, it was washed
out and drained, and the result was satisfactory. One has
not to go far back in the history of surgery to find a
time when the treatment of a synovitis of the knee by
BT ABDOMINAL SECTION. 177
incision and drainage^ and a washing out of the joints
woald be considered a violent and reprehensible measure.
Next in turn came a much larger serous membrane— the
pleura. The inflammatory products of pleuritis were at
first cautiously removed by tapping; gradually the common
principle of treatment was extended^ and the pleural
cavity was cut into ; it was washed out and drained. The
results were good^ although the means employed would
have struck terror to the heart of the ancient surgeon.
Quite recently, even the pericardium has been attacked
and suppurative pericarditis has been treated upon the
same principles that direct the treatment of suppurative
affections elsewhere.
Finally, this common therapeutic measure has been
applied to the greatest of the serous membranes — the
peritoneum. Cases of chronic localised peritonitis, and
especially of pelvic peritonitis, have been treated with
considerable success by means of abdominal section, with
subsequent irrigation, and drainage of the suppurating
cavity.
Considering the very high death-rate of acute diffused
peritonitis, and, indeed, the almost invariable fatality of
that disease, it appeared to me that the common surgical
measure above alluded to might well be applied to this
affection.
Its success in chronic localised peritonitis appeared to
encourage its application to the more violent and rapid
form of inflammation.
Apart from some such active treatment it must be
confessed that the treatment of acute peritonitis, and
particularly of that form depending upon perforation,
remains in about the same condition at the present time
that it held a hundred years ago. Thus Heister, writing
in 1739 on perforation of the bowel, could only advise
that the patient be kept quiet, that he be urged to eat
abstemiously, and to lie upon his belly. "The rest,'* says
this ingenious author, '' is to be left to Divine Providence
and the strength of the constitution.'^
VOL. LXVIII. 12
178 ACUTE PABITONITIS TREATED
I might now give details of a case of acute diffused
peritonitis that was treated with success by abdominal
section. It is the only case upon which I have performed
the operation^ and I am not aware that this form of peri-
tonitis has hitherto been deliberately subjected to this
particular proceeding.
A single woman^ 8Bt. 20^ was admitted into the London
Hospital^ under the care of my colleague^ Dr. Herman, on
January 21st, 1884. For twelve months she had led an
immoral life, and had acquired gonorrhoea. On admission
she was found to be suffering from chronic pelvic peri-
tonitis, which appears to have commenced two months
previously and to have been due to the extension of the
gonorrhoeal inflammation to the uterus and Fallopian
tubes. She was weak, wasted, and ansBmic, and had a
purulent vaginal discharge. She had much pain and
tenderness in the left iliac region, and in that position a
slight swelling could be detected, which appeared to
extend down into the anterior cul-de-aac. Tbere was no
general abdominal tenderness; her bowels acted regu-
larly without medicine ; she took her food fairly, and was
not sick. Her temperature ranged between 99° and 101°
or 102°. She remained in this condition, getting neither
better nor worse, for about a month, and on February
25th she suddenly developed the evidences of acute peri-
tonitis. When I saw her on the following day, at Dr.
Herman's request, I found her greatly prostrated. Her
abdomen, which had hitherto been flaccid, was now very
tense, evenly distended and tympanitic, and exceedingly
tender. Her bowels had ceased to act. She was troubled
with almost constant vomiting, and could retain nothing
on her stomach. The ejected matters had an unpleasant
intestinal odour. Her pulse was very small, weak, and
frequent, and her tongue dry. She had had morphia.
Her condition being very critical, I arranged at once to
open the abdomen, whicb I did on the afternoon of Feb-
ruary 26th. I made an incision in the linea alba below
the umbilicus large enough to admit my hand. On open-
BT ABDOXIKAt 8SCTI0K. 179
ing the serons cavity a quantity of semi-opaque fluid
gushed out; wliicli was mixed with flakes of lymph and
pus. It was very offensive and had a decided feculent
odour. It ran out on to the floor^ and the amount there-
fore could not be measured. I then gently introduced a
sponge^ and cleared out a sufficient amount of the remain-
ing fluid to enable me to see the condition of the parts.
Examination showed localised pelvic peritonitis on the left
side ; this had led to a large abscess^ the walls of which
were formed partly by the left pelvic peritoneum and
partly by many coils of small intestine which were matted
together in the utmost confusion. The slight swelling
previously felt in the left iliac region had been apparently
caused by this mass of intestines^ while that detected in
the anterior euUde-acLC had been due to the purulent
collection. The abscess that had been so long hemmed
in by a barrier of adherent intestines had bursty at last^
into the general peritoneal cavity^ and had so set up acute
and general peritonitis. I enlarged, with my finger, the
opening into the abscess, and sponged out a large quantity
of thin stinking pus, which welled up on pressure from
the depths of the pelvis. Such adhesions between the
matted bowels as could be broken down I tore through.
The majority were too tough. The general surface of the
peritoneum exhibited the ordinary appearances of acute
peritonitis. The intestines were lightly glued together
where they were in contact with one another. I now
proceeded to thoroughly wash out the whole peritoneal
cavity. I poured in many quarts of warm water mixed
with a little carbolic solution. The pelvis was well sponged
out. I continued the cleansing process until the water
returned quite clear and free from smell. A large drainage-
tube, six inches in length, was passed down to the bottom
of the pelvis, and the abdominal wound — save the part
occupied by the tube — ^was carefully closed. The opera-
tion was conducted under strict Listerian precautions, and
the usual gauze dressings applied. The patient only
vomited twice after the operation, probably from the
180 ACUTE PERITONITIS TREATED
effects of the ether. No food of any kind was admin-
istered by the mouth for four days^ during which time
morphia was freely given and the strength supported by
enemata of peptonized beef-tea and brandy. These
enemata were administered every two or three hours and
were readily absorbed. The bowels acted spontaneously
on the fifth day after the operation. For four days the
patient suffered from carboluria. There was a very copious
purulent discharge from the wound, which for nearly a
fortnight was dressed twice a day. The antiseptic dress-
ings were discontinued on the fifth day. The carbolic
acid produced severe irritation of the skin^ and apparently
caused the edges of the wound to slough. After the fifth
day iodoform gauze was used ; and the wound was well
irrigated with very weak carbolic lotion twice or three
times every day. The tube of the irrigator was passed
deep down into the pelvis. The wound healed all but the
part occupied by the drain ; the discharge gradually
diminished, and the patient underwent a very rapid and
remarkable improvement. In time a very small drainage-
tube took the place of the larger one, and the discharge
diminished to about two drachms in the twenty -four hours.
By April 5th the patient was allowed to walk in the garden.
On May 3rd the tube was removed and the wound allowed
to close. She was kept under observation until June 6th,
when she was finally discharged. In August last she again
came to the hospital. She had just menstruated for the
first time since her illness ; the process had been attended
with severe pain and vomiting. A few days afterwards the
thin scar over the site of the old drainage-hole gave way
and some pus again escaped. The urgent trouble, how-
ever, soon subsided, and she went out with a minute tube
in the wound to prevent its healing, although the amount
of discharge barely soiled a piece of lint in the course of
twenty-four hours.
With the effect of the operation upon the original
pelvic trouble the present inquiry is not directly concerned ;
nor has sufficient time elapsed for that question to be de-
BY ABDOMINAL SECTION. 181
cided. I think that it may^ however^ be claimed that the
treatment of the acnte affection was snccessfal^ and that
the abdominal section in every probability saved the
patient's life.
In many instances the abdomen has been opened in
cases of acnte perforative peritonitis where an error in
diagnosis had been made and the affection mistaken for
intestinal obstmction. Daplay has coUected several of
such cases.^
In many reported instances^ moreover^ laparotomy^
undertaken for some independent disease^ has been per-
formed^ during the progress of an acute peritoneal inflam-
mation. I am not aware^ however^ that abdominal section
has been deliberately adopted as a means of treatment in
this acute affection.
So long ago as 1848 Mr. Hancock^ in a paper read
before the Medical Society, threw out a proposal for this
method of treating peritonitis, and presumably he included
the acute as well as the chronic form. Mr. Hancock has des-
cribed a case of localised chronic peritonitis, following dis-
ease in the appendix, in which he had evacuated a quantity
of inflammatory matter through an abdominal incision. He
concludes his comments with this remark, '' I trust the
time will come when this plan will be successfully employed
in other cases of peritonitis.''
Of the instances above alluded to, of laparotomy per-
formed during acute peritoneal inflammation, owing to an
error in diagnosis, death appears — ^with one exception — ^to
have been the result in all. They were principally cases
of acute perforative peritonitis, and as soon as the nature
of the case was rendered evident by the laparotomy, all
further treatment was abandoned, and the case left, as
Heister would say, " to Divine Providence and the strength
of the constitution." The exception alluded to was
afforded by a most interesting case recorded by Dr.
Buchanan, of Glasgow.' The symptoms were believed to
> < Arcliivet g^n. de MM./ 1879, p. 207.
• « Unoet,' vol. i, 1871, p. 776.
182 AOUn PBBIT0NITI8 TBKATBD
be dne to intestinal obstruction. The abdomen was
opened ; no canse of obstruotion was founds but^ on the
other hand, an extensive acate peritonitis. The abdominal
cavity was sponged oat, and the patient recovered. The
cause of the serous inflammation was not evident, and the
precise nature of the case is a little obscure.
With regard to the instances where laparotomy has
been performed during the height of acute peritonitis, for
some intercurrent disease, it must be confessed also that
death has followed in the majority of the cases. In many
of these examples, however, operative interference was
undertaken when the patient was in extremis, and no es-
pecial treatment was directed against the peritoneal
inflammation.
There are at the same time some notable instances of
recovery under this circumstance. As examples I might
cite two cases, one by M, Terrier,^ the other by Professor
Juillard.' In the former a laparotomy was performed to
relieve a strangulation of the gut, by a band ; in the latter
an ovariotomy was undertaken in a case where symptoms
of acute intestinal obstruction had suddenly set in. In
both there was acute general peritonitis, in both strict
Listerian precautions were adopted, in both a perfect
recovery followed.
Another most successful case is reported by Mr. Thomas
Keith, of Edinburgh,' Here an ovariotomy was performed
when the cyst was gangrenous, and when distinct evi-
dences of acute peritonitis existed. This bold operation
of Mr. Keith^s is, so far as I know, the first of its kind
in this country.
I have selected these three cases because they present
another common feature of considerable interest. The three
patients had suffered from previous attacks of peritonitis
of a localised or chronic form. I believe that this latter
circamstance contributed in no small degree to the final
^ < Ball, et Mem. de la Soc. de Chir. de Paria,' 1879, p. 664.
• Ibid., p. 627.
s < Lancet,' vol. ii, 1865, p. 86.
BT ABDOMINAL BBOTION. 183
success of the operations. The peritoneum would appear
to become in time almost acclimatised to inflammatory
attacks^ and there is certain evidence to show that a
peritoneum that has once been inflamed will bear opera-
tive interference with greater indifference than will a
membrane upon which no such morbid process has en-
croached.
It is to be noted that^ in my own case, the patient had
had somewhat extensive chronic peritonitis before the
acute attack, for which the abdominal cavity was opened,
set in.
In conclusion, I would venture to suggest the use of
abdominal section in the treatment of acute general peri-
tonitis ; the incision to be followed by irrigation of the
serous cavity, and subsequent drainage.
The cases for which this measure would appear to be
best adapted are those of acute peritoneal inflammation,
depending upon sudden perforation by ulcer, or by gun-
shot or other wound, cases due to injuries other than
those producing perforation, and examples of acute peri-
tonitis due to the bursting of an abscess into the serous
cavity.
In all such instances the incision, if it be made at all,
should be made without delay, and, indeed, as soon as
possible after the diagnosis has been distinctly established.
It would be difficult to name a condition in disease where
temporising would be more utterly futile, or more reckless,
or more entirely purposeless. The grave character of the
affection would render almost any measure justifiable.
Indeed, the lover of the curious will have to search far
into the records of medicine before he will find an instance
of recovery from acute perforative peritonitis ; and in a
case so urgent and so desperate it can hardly be a violent
or unreasonable act to apply to the relief of peritoneal in-
flammation the same measures that have been so success-
ful in the cure of inflammations of other parts.
Dr. Parkes, of Chicago, has shown by a series of valu-
able experiments how much can be done to save life in
184 ACUTE PERITONITIS TREATED BT ABDOMIMAI. SECTION.
cases of perforation of the intestine by gunshot wounds.
This surgeon shot a number of dogs through the abdomen.
He allowed an interval to elapse during which extravasation
of intestinal contents could take place. He then opened
the abdomen^ closed the perforations in the bowel by
suture or resection^ cleaned the peritoneal cavity and united
the parietal incision. By this means he saved the lives
of many dogs who would otherwise have died without
doubt of acute perforative peritonitis.^
Professor Kocher, of Berne, has performed laparotomy
in a pistol-shot wound of the stomach with success. The
operation was performed three hours after the injury, and
the wound in the stomach was closed by sutures. Dr.
William Bull has also published' a most successful case of
laparotomy for gunshot wound of the intestine. The holes
in the intestine were closed by sutures and the peritoneal
cavity washed out. The operation was performed seven-
teen hours after the accident, and there were already evi-
dences of extensive peritoneal inflammation.
There are, of course, cases of acute inflammation of the
peritoneum, to which this mode of treatment, or any other
measure of like purport, would not be applicable. Among
such may be named peritonitis in connection with carci-
noma, or tuberculosis of the serous membrane, the peri-
tonitis that is the outcome of general septicaemia, and that
attended with extensive rupture of certain of the viscera.
*■ * Qunshot Wounds of the SmuU Intestine/ Chicago, 1884.
> * New York Medical Journal,' Feh. 14th, 1885.
(For report of the discussion on this paper see 'Proceedings
of the Royal Medical and Chii-urgical Society/ New Series, vol. i,
p. 362.)
A CAS E
OF
ABDOMINAL SECTION
FOB
ACUTE CIRCUMSCRIBED PERITONITIS.
RECOVERY.
BT
HOWARD MARSH, P.R.C.S.,
BBNIOB ABBIBTAKT BTTB&BOK AND LIOTUBBB ON ANATOICY AT BT.
BABTHOLOMBW'a HOSPITAL; 8BNI0B SUBOBON TO THE
HOSPITAL FOB 8I0K CHILDBBN.
Received March 8nl— Read March lOtli. 1885.
J. R — y a medical student^ aet. 19^ was admitted iuto
St. Bartholomew's Hospital, on December 18th, 1884,
under the care of Dr. Andrew. He stated that, thoagh
subject to occasional constipation, he had been in good
health till December 8th, when, having taken some aperient
medicine, he was attacked with severe griping pain, and
with sickness which had continued till his admission.
The bowels acted several times after the medicine, but for
the last three days nothing had been passed. When first
seen he lay with his legs extended. The abdomen was
tympanitic and distended, and slightly tender. A little
below and to the left of the umbilicus there was an area
about eight inches squure, which was firm and resistant,
186 ABDOMINAL SECTION FOB
dull on percassion^ painful on pressure, and yielding an
obscure sense of deep-seated fluctuation. This area was
slightly raised above the surrounding surface, and the skin
was oedematous and presented a slight flush. As it was
believed that the case was one of circumscribed peritonitis,
it was on the following day determined to perform an
exploratory operation. Just before the patient was
removed to the operating theatre he was violently sick
several times, and it was obvious that his condition was
rapidly becoming very critical. When he was under
chloroform, I made an incision about two inches long just
outside the linea semi-lunaris, and opened the cavity of the
peritoneum. As soon as this was done, from two and a
half to three pints of extremely foetid pus, evidently under
considerable tension, streamed out. A careful digital
examination was now made, but nothing beyond distended
coils of small intestine could be felt. The abscess-cavity
was washed out with a solution of carbolic acid lotion (1
in 60) introduced by means of a soft india-rubber
catheter, and a piece of drainage-tube eight inches
long and about the size of a little finger, was inserted
through the wound, the upper and the lower ends of which
were brought together to avoid the danger of intestinal
protrusion. Carbolic dressings were applied, and kept in
place with a lightly adjusted bandage. Two hours after
the operation he was cold and collapsed, and his pulse was
very quick and small ; two hours later, however, he had
rallied considerably, and his pulse was 96, regular, and
fairly strong, and his temperature was normal. He had
been sick several times, but the material vomited had
quite changed its character, and now consisted merely of
clear, bilious liquid, derived from the upper part of the
small intestine.
December 20th. — He was decidedly better. Pulse 96,
temperature normal, and he had passed a good night,
sleeping quietly, with a few intervals of wakefulness.
He was sick occasionally till 8 a.m., bringing up about
14 oz. of bilious fluid. In the night, at 10 p.m. and at
ACUTB CISCUMBOSIBID PEBIT0NITI8. 187
2 a.m. a third of a grain of morphia had been injected
under the skin. Discharge was profnse^ and the dressings
were found to be soaked through. During the day the
bowels acted three times^ the motions being light coloured
and fluid. He was fed with small nutritive enemata^ and
only allowed to take^ by the mouthy a teaspoonful of iced
water occasionally. He complained of intense thirst
during the day. An enema of starch and opium was given
to check the action of the bowels. At 6 p.m. the area of
dulness could be felt to extend across the middle line
towards the right iliac fossa, and in this situation he
complained of tenderness on pressure. The nurse was
directed to keep him as &r as possible on his left side.
21st. — ^Night rather restless. Morning temperature
was 99*6^. There had been no more sickness. The
abdomen was less tympanitic ; the area of dulness was
diminished ; the bowels had acted four times within the
last twenty-four hours, the motions consisting of light
yellow liquid, mixed with small, solid, well-formed faeces.
He was taking milk and beef tea in small quantities.
22nd. — ^Was improving. Temperature last night was
99*6^, this morning normal. Pulse 96. As the drainage-
tube was found to have slipped out it was discontinued.
Still a large quantity of purulent discharge. A piece of
distended intestine protruded slightly at the bottom of
the wound.
23rd. — Steadily improving. Wound looked well.
Temperature ranging from 100® in the morning to 101*8®
in the evening. Pulse 108, small. Was still fed with
enemata. He had taken about a pint of warm milk and
water, and two small cups of tea, and a little bread and
milk.
26th. — Decidedly better. Abdominal distension had
subsided. Discharge copious, but healthy. Free from
f oetor. Bowels were acting twice a day, and the motions,
though in great part fluid, contained well-formed fadces.
Still on liquid diet. Was occasionally taking ten minims
of tincture of opium to quiet the bowels.
188 ABDOMINAL SECTION FOR
January 4th — Doing well. Had minced chop for
dinner. For the last four days the cavity had been
washed out with a solution of 1 in 1000 of tincture of
iodine introduced by means of a soft india-rubber catheter.
This passed easily for eight inches or more in several
directions among the coils of the small intestine.
12th. — There had been a threatening of a protrusion of
the intestine through the wound^ but this had been
prevented by the application of a compress of cotton wool
over a piece of oiled lint and a lightly applied bandage.
He now spent the greater part of the day on a couch.
20th. — Doing well, but his bowels now seldom acted
without an enema. The protrusion of the intestine was
less marked.
February 20th. — Since the last note there had been
little requiring detailed description. He had gradually
improved and gained flesh and strength. His temperature
had been as a rule normal, and his pulse between 80 and
90. But both on Feb. 8th and on Feb. 19th he had
attacks of sickness, lasting for some hours ; his temperature
rose to 101°, and his pulse to 96, while at the same time
there was marked increase in the amount of discharge.
During the past week he had improved quickly in strength
and colour. The bowels now never acted without injection.
The wound was slowly closing by granulation, and was
only about half an inch in length.
March 7th. — Wound now closed. Bowels still never
acted without an injection. He seemed quite well.
Remarks. — Neither Dr. Andrew nor myself could form
any definite opinion as to the origin of this attack ; but it
seemed not unlikely that inoculation of the peritoneum
had occurred from the escape of pus from an abscess
formed in the mesentery round old suppurated glands.
Although the case was one of circumscribed peritonitis,
that it yet involved fully a third of the whole abdominal
cavity was shown by the fact that the swelling and dulness
not only occupied the greater part of the left lumbar
aud iliac regions, but was found, ac^ distension subsided,
ACUTB CIRCUMSCBIBED PBRIT0NITI8. 189
to extend for several inches across the middle line in the
direction of the right iliac fossa. The extent of the
mischief was also disclosed by the direction and distance
from which pus was washed out when the catheter was
introduced. It was therefore an instance of much more
extensive disease than would generally pass by the name
of circumscribed, and approached the characters of an
example of general peritonitis. It thus has at least some
bearing on the treatment of the latter affection.
At the time the operation was performed the patient
was so constantly sick, and so rapidly passing into a
condition of collapse, that it was the opinion of all who
saw him that unless relieved he would live but a very few
hours. The operation calls for no especial comment.
It consisted merely in the opening and washing out of a
large intra-peritoneal abscess. It may, however, be
remarked that it seemed better to rest content with the
evacuation of the matter which had collected than to
enter into any investigation into the origin and nature of
the case. To have taken the latter course would not only
have involved the danger of disturbing the adhesions which
were acting as a barrier to circumscribe the mischief, but
also the risk of rupturing the softened intestinal coils and
producing fsBcal extravasation. Besides, any investigation
of this kind could scarcely have led to any useful result,
while it would certainly have necessitated a considerable
enlargement of the wound, and increased the possibility of
an escape of some portion of distended intestine.
(For report of the discassion on this paper, see ' Proceedings of
the Royal Medical and Ghirurfidcal Society,' New Series, vol. i,
p. 362.)
ANEURISM OF ABDOMINAL AORTA.
DISTAL COMPRESSION-CURE OF THE ANEURISM— DEATH
FROM GANGRENE OF THE JEJUNUM ON ELEVENTH
DAY— NECROPSY— REMARKS.
BY
JOHN R. LUNN, F.R.C.S.Ed.,
▲in>
P. L. BENHAM, M.D.,
ST. MARTLEBOKB IVTIBMABT, VOTTIKe HILL, W.
(CovmnacATBD bt Mb. R. W. PARKER.)
AeceiYed Jauiury Snd— B«ad April 14th, 1885.
E. B — J 89t. 32^ a shoemaker by trade^ was admitted
into the Infirmary in October^ 1883. He had been in the
army nine years, and had syphilis five years ago. No
history of strain or injury.
Two weeks before admittance he was suddenly seized
with severe pains in his back and epigastric region ; these
became much worse daring the night, and at the same
time he noticed a pulsating swelling in the abdomen, which
had not been previously observed. He continued in the
same condition up to the time of admission.
On admission the patient's general appearance was
healthy ; there was slight hypertrophy of the heart and a
192 ANBUBISM OF ABDOMINAL AOBTA.
•
trace of albamen in the urine. He lay chiefly on his right
side ; there was no marked tension or tenderness of the
abdomen ; strong pulsation could be seen and felt between
the costal cartilages of the eighth and ninth ribs in the
middle line. A large tumour could be felt deep down in the
epigastric region^ shading off into the right and left hypo-
chondriac and umbiL'cal regions ; moveable by the hand but
not with respiration. Pulsation was distinctly expansible^
and movement was greatest on the right side. There was
a slight systolic murmur over the swelling. Compression
of the aorta below the tumour caused pain and uneasiness
in the region of the tumour^ but the size and pulsation
were lessened. The dimensions of the tumour were about
six to seven inches from side to side, five to six inches
from above downwards, and reached apparently from the
vertebral column to the anterior abdominal wall. No
diminution or inequality of pulsation in the femoral arteries.
Bowels confined ; no vomiting.
As the usual remedies, including rest, low diet, nar-
cotics, &c., gave no relief, and the patient was evidently
getting worse, he was extremely anxious that some
operation should be performed.
On October 31st the patient was placed under the influ-
ence of chloroform, and compression of the abdominal
aorta just above and to the left of the umbilicus was
commenced. Carte's tourniquet was used, and the usual
precautions taken in the application and continuation of
the pressure. Chloroform and ether were used alternately,
and compression was applied for four and three-quarter
hours. During the latter half of this period the pulse
became very rapid, feeble, and irregular, and the breathing
embarrassed. A small quantity of urine was drawn off
by catheter, and showed a marked increase of albumen.
After the completion of the operation an ice-bag was
applied to the abdomen, and the patient passed a good
night. On the following morning all the physical signs of
the aneurism were less marked. The ice-bag was discon-
tinued on the second day. There was slight vomiting on
ANKUBISM OV ABDOMINAL AOBTA. 198
the first and third day after the operation (which appa-
rently was dae to the chloroform and morphia) ^ bat
otherwise the patient expressed himself as mach better,
and the tnmonr was smaller, harder, and pulsation less
marked.
He continued to do well for several days, but on Nov.
8th persistent vomiting, chiefly of dark grumous material,
set in. Pulse 192, and feeble ; thirst was intense, there
was congestion of the face, and some dulness over the right
lung was detected. From this time the patient gradually
became worse, and died November 11th, or the twelfth
day after the operation.
Post-mortem examination (forty-eight hours after death) .
— Body fairly well nourished. Head ^lormal. The heart
was found hypertrophied, and the cavities dilated. The
aorta was free from atheroma. Lungs emphysematous.
Serous effusion in right pleural cavity (1^ pts.). Sh'ght
consolidation of middle third of right lung ; congestion of
base of left lung.
Abdomen. — ^No evidence of peritonitis. Intestines
normal, with the exception of about two feet of lower
portion of jejunum, which was very dark in colour in its
entire thickness, had a peculiar earthy smell, and co^itained
black grumous fluid, similar to the vomit during life.
Immediately below the coeliac axis was a large sacculated
aneurism, which sprang from the front of the aorta ; the
orifice being oval (1x2 inches). This was filled with a
spongy red clot protruding slightly into the lumen of the
vessel (see woodcut, p. 195.) The vertical diameter was
about four inches, the horizontal five inches, and the antero-
posterior four inches. The clot covered the front and
partly the sides of the aorta ; there was no erosion of the
vertebr89. The duodenum curved over its anterior surface
from the right upper corner to the lower margin of the
sac, and was closely attached. The pancreas lay loosely on
the upper surface. The left renal vein was firmly adherent,
and crossed over the anterior surface about the centre of
the sac. The aneurism in shape resembled a retort with
VOL. LXVIII. 13
194
ANIUBISM OV ABDOMINAL AOBTA.
ANIDBISM or ABDOHINAL AOBTA.
195
196 ANBUBIBM OV ABDOMINAL AORTA.
the body to the left^ and the beak (origin of the saperior
mesenteric artery) to the front and right; the left side
was fixed, and the right more moveable (see woodcnt^
p. 194) . The branches of the ccBliac axis ran along the top
of the sac and were adherent to it. The phrenic and right
renal arteries were given off from the sac ; the left renal
from the aorta just behind it. The saperior mesenteric
seemed to be the branch chiefly involved ; it was dilated
and formed a secondary aneurism. The main branch was
almost, and the lesser branches completely, occluded.
There was a recent loose black clot in the right iliac
artery, and the deep-seated abdominal veins were much
distended with blood.
Bemarks. — The only reported cases we have been able to
find in which operative treatment has been attempted,
are the following : —
1. A cured case is reported by Dr. Moxon and Mr.
Durham in the 'Med.-Chir. Trans.,^ of 1872, vol. Iv, when
proximal compression by Liston's tourniquet was applied
for ten hours under chloroform.
2. Mr. Bryant relates a case in the same volume which
was treated by distal pressure with Liston^s tourniquet for
twelve hours, and after an interval of twelve hours the
tourniquet was reapplied for a further period of three
hours. The patient died thirty-nine hours after its first
application,
8. Dr. Greenhow reports a cured case of abdominal
aneurism in the ' Med.-Chir. Trans./ vol. Ivi, for 1878.
4. Dr. Murray, of Newcastle, has also reported a case
cured by proximal pressure upon the abdominal aorta.
From the above list it will be seen that, with one
exception, surgeons have previously chosen proximal rather
than distal compression in cases of abdominal aneurism.
It may therefore be of interest to draw attention to the
main points in the present example. Firstly, as to the
symptoms during the operation, and the result thereof,
aud secondly as to the conclusions that may be drawn from
the case.
ANBUBISM OF ABDOMINAL AORTA. 197
Firstly^ there was marked alteration in the circnlation^
shown by a great temporary increase of albumen in the
urine^ presumably from the higher blood-pressure in the
renal arteries^ great acceleration and smallness of the
radial pulse with rapidity and oppression of breathing
from diminution of blood in the lower extremities^ and
corresponding increase in the lungs. This interference
did not subside when pressure was discontinued, but
persisted and gave rise to partial consolidation of the
lung. This raises the question whether venesection per-
formed shortly after the operation would have been of
service in restoring the equilibrium of the blood-pressure.
The next point is the obstinate vomiting and hiccough
which began on the sixth day (distinct in time and
character from the early vomiting due to the anassthetic
and morphia). This persisted more or less until death,
and strongly resembled the vomiting of intestinal obstruc-
tion. The most probable causes of the vomiting appeared
to be —
1. Nervous from pressure on the aortic plexus of the
sympathetic.
2. Congested state of the stomach.
3. Intestinal obstruction arising either from peritonitis,
laceration of the smaU intestine by the pad of the tourniquet,
or, lastly, gangrene of the intestine from occlusion of the
superior mesenteric artery.
On careful consideration of the whole case, and remem-
bering the character of the vomit, gangrene of the intestine
appeared to be the real cause. This seems to be proved
by the autopsy, for gangrene of a considerable length of
the gut was obviously the cause of death, and this condi-
tion was clearly due to the arterial thrombosis. This
complete blocking of the superior mesenteric artery was
an unfortunate but unpreventable result of its arising from
the distal part of the aneurism where the clot was firmest,
as other vessels arising nearer to the upper portion of the
sac remained patent.
The conclusions we draw, then, from the experience of
198 ANIURISM OF ABDOMINAL AORTA.
this case^ are, that the operation was justifiable and even
hopef al ; that it accomplished the purpose intended ; and
that recovery would probably have taken place had not
the process of cure been (unavoidably) too thorough ; and
that further, although fatal consequences must almost in-
evitably follow from these conditions, they cannot be recog-
nised so precisely in cases similar to ours as to prohibit
the use of the means of cure we adopted.
The specimen is presented to the museum of the Boyal
College of Surgeons.
(For report of the discuBsion on this paper see ' Proceedings of
the Boyal Medical and Chirurgical Society/ New Series^ voL i,
p. 426.)
ON A CASE
ANEURISM OF THE ABDOMINAL AORTA,
WHICH OAUSBD
GANGRENE OP THE EIGHT LOWER EXTREMITY, PARTLY
BY EMBOLISM, AND PARTLY BY PRESSURE
ON THE INFERIOR VENA CAVA.
BT
HENET MORRIS, M.A., M.B., RE.C.S.,
SUBOBOV TO, AHD LBOTUBBB OV SUBOXBT AT, THB lODDLBSXZ HOSPITAL.
Beceived April 9th— Bead April 14th, 1885.
Thx following case is an instance of what is probably a
very rare cause of gangrene of the lower limb ; and an
example of death from an anearism full, or nearly fall, of
laminated clot. It is also another illustration of th^ fact
that advanced caries of the vertebral column may exist
without any obvious clinical signs of the disease.^
ThoB. S— j est. 38, a carver and gilder, was admitted on
January Ist, 1885, with gangrene of the right lower limb.
On the 27th of December, 1884, at 6 a.m., the morning
being bitterly cold, he started to go to work as usaal, but
> Since writing the above another caie of advanced ipinal caries withont
symptoma, and the result of aneurism of the arch of the aorta has passed
under my notice. The patient died suddenly whilst turning in bed fitmi the
breaking of the spine at the diseased point.
200 AMBUKI8M OF THE ABDOMlNAt AOBTA.
on crossing the road jast ontside his hoose^ he was seized
with pains, numbness, and a pricking sensation in the soles
of his feet and the calves of his legs, accompanied by
profuse sweating. He recrossed the road and reached his
own door, grasping the railings to save himself from fall-
ing. He was, however, obliged to let himself down for
rest, but after a time with much difficulty he raised him-
self with his hands, unlatched the door, entered the housOj
and again lowered himself to the ground, almost entirely by
the aid of his hands. For some time he remained at the
foot of the staircase, but at length he was discovered
and carried up to bed by the other inmates, who applied
hot water bottles to his feet and legs. During all this
time both legs had seemed to him to be similarly and
equally affected, but in the course of the same day he
regained the mobility and sensibility of the left lower
limb. On the following day (December 28th), the right
leg and foot began to turn black ; apd continuing to get
worse, he was brought to the Middlesex Hospital on New
Year's Day.
On admission, he told us that sixteen years ago he had
syphilis, that he had never suffered from rheumatism, nor
from any lung or heart disease, though for some time past
he had been subject to shortness of breath ; that six
months ago an attack of ^' lumbago '^ kept him in bed for
about a week ; and that three months ago he was taken
with drowsiness and throbbing pain in the right temple
and right eyeball, and could not raise his right upper
eyelid. He had, in fact, temporary complete ptosis.
His father died aged forty, cause unknown ; his mother
aged sixty -three, from cancer of the breast ; and one sister
died, aged fifty-five, of heart disease.
The patient was a large-framed stout man. The whole
of his right lower limb up to Poupart's ligament was
greatly swollen and oedematous, and large hard swollen
areas of a faintly bluish-red colour were observed on the
front and inner aspects of the enlarged thigh. The femoral
artery in the right groin could not be felt, that in the left
AKXUBI8M OV THB ABDOMINAL AORTA. 201
was beating feebly. Tbe whole of tlie foot and tlie lower
third of the leg were quite gangrenoas^ being blackish grey,
swollen, and oedematons ; there was a parplish red discolo-
ration over the calf, and mottling of the skin nearly up to
the knee. He still complained of slight weakness and cold-
ness in the left foot, but there were no signs of gangrene
there. The veins of the abdominal parietes, especially of
the right side, were particularly distended. Skin of trunk
moist. Pupils equal. His pulse 88, soft and weak ; heart's
impulse feeble and ill-defined, no valvular* disease, but
mitral sounds thought to be not quite clear. Urine clear,
acid, 1025. Abdomen and rectum were carefully exam-
ined, as it was supposed, from the condition of the limb
and the character of the gangrene, that a tumour of some
sort must be obstructing both artery and vein as they
passed along the pelvis to the groin. This examination
afforded no information.
The question of amputation was anxiously discussed, and
it was resolved to amputate as soon as time had been
allowed for collateral circulation to be established and the
gangrene gave any appearance of not further spreading.
In the meanwhile the danger of septicffimic infection in
such a form of gangrene was considered to be unusually
great.
On January 11th the gangrene seemed to have stayed
its progress just below the knee. The temperature began
to run high, being 102*8°, and on the three following days
it sometimes reached 104°.
On the 14th the thigh was amputated in its lower
third, the circular method being preferred as it was
thought to cause the least division and disturbance of the
arteries. A feeble and tiny stream of blood coursed out
of the superficial femoral trunk ; the main vessel was
torsioned. At the time of the operation it was feared
that the stump would slough because the muscles were so
pale and bloodless, and there was gaseous crepitation felt
in the deep tissues of the thigh.
The patient lived eight days after the amputation, the
202 ANKUBISM 01 THE ABDOMINAL AOBTA.
stump showed saperficially no signs of sloughing^ bnt
neither did it show any signs of healing; no pulsation
returned in the right femoral artery. Slight delirium
and diarrhoea set in on the day of the operation^ the
temperature kept high^ subsultus tendinum was marked,
the delirium and restlessness increased, the urine became
albuminous, the excreta at last were passed unconsciously,
vomiting became incessant, the face cyanosed, and death
occurred on the afternoon of January 22nd.
The autopsy was made twenty-three hours after death
by Dr. Fowler, and the following is the summary of the
post-mortem report : —
Oeneral appearance, — Well nourished. The right thigh
had been amputated a little below the junction of the
middle and lower third of the femur. There was oedema
of the left leg. The veins of the abdomen and lower part
of thorax were prominent, and more than the usual num-
ber of venous radicles were visible.
Stump : The edges of the flaps were united by sutures ;
but little reparative action had occurred ; there was no
actual union at the outer margin of the wound, but the
opposed edges here were covered with granulations.
On laying open the wound the muscular and intermus-
cular structures presented a horrible sloughy appearance ;
the sloughs emitted a most foetid odour. The hip-joint
was intact. There was no infiltration or other change in
the integument of the stump.
Heart 12, oz. There were a few small soft clots,
mostly of post-mortem formation, in the right cavities of
the heart with some fluid blood. The (right) valves were
normal, the muscular tissue pale and rather soft. The
left cavities contained some small post-mortem clots and
fluid blood. The valves were competent ; there were a few
spots of atheroma in the anterior curtain of the mitral valve
and also in the first part of the aorta. The muscular tissue
was pale and soft, but not obviously fatty.
The left lung showed some emphysema along the
anterior edges, and was oedematous in both upper and
ANEUBISM OF THS ABDOMINAL AOBTA. • 203
lower lobes. The posterior portions of the right lung were
completely collapsed and non-crepitant.
Abdomen.'^Tbe peritoneal cavity contained aboat two
ounces of clear serous fluid. There was a considerable
deposit of fat upon the abdominal walls. In the inner
margin of the right lobe of the liver close to the round
ligament there was a small pale wedge-shaped area^ pro-
bably an infarction. The liver tissue was pale, soft, and
swollen. The liver weighed 71 ounces.
The spleen was large, weighing 9^ ounces, soft and
congested. The kidneys were swollen, each weighing 7j
ounces, the capsule thin and slightly adherent. In the
upper margin of the left kidney there was a small, pale,
wedge-shaped area much resembling that in the liver.
The renal tissue was firm, the cortex showed a slightly
granular sur&ce.
Vessels : The aorta, and arteries of the extremities, with
the vena cava and corresponding veins, were removed entire
and afterwards dissected. They presented the following
appearances. The arch of the aorta and the thoracic aorta
showed numerous patches of atheroma. Immediately
below the point where the aorta passes beneath the dia-
phritgm, and pushing forward the crura of the latter
muscle, there was an oval aneurism projecting from the
right side of the vessel. It measured externally 2^ inches
in its long diameter and was about equal in size to a
Tangerine orange. The mouth of the sac, 1| inches long
and oval in shape, was situated so that its central point
nearly coincided with the origin of the superior mesenteric
artery. This latter was not, however, involved in the
aneurism. From the mouth of the sac some laminated
clot was protruding ; the sac itself was nearly filled with
similar clot. The posterior wall of the sac bad been quite
destroyed and the aneurism was here limited by the first
and second lumbar vertebres, the bodies of which were
deeply eroded — to the extent of half an inch in depth.
The intervertebral disc and edges of the bodies were
scarcely at all affected. The aorta was blocked at its
204 ANlUftlSM OV THB ABDOMINAL AORTA.
bifurcation^ the clot eztendixig for nearly an equal distance
(about I inch) into each common iUac vessel. The cen-
tral portion of this clot was paler than the upper and
lower portions^ and appeared slightly laminated. Just
above the origin of the right profunda artery a lami-
nated clot (a portion of the clot from the aneurismal sac)
was found blocking the vessel ; above and below it were
some non-laminated coagula. The divided femoral artery
of the stump had been twisted, the end was plugged
with firm coagula for a distance of two inches. The vena
cava was completely blocked by a tapering thrombus from
one inch and a half below the margin of the sac of the
aneurism. The common iliac veins were both completely
blocked ; the external iliac and femoral veins were also
blocked, the right femoral down to the point of amputa-
tion, the left just above the point corresponding to the
origin of the profunda artery. A minute branch of the
femoral artery was included in a fine ligature which sur-
rounded the cut end of the vein.
(For report of the discussion on this paper see ' Pirooeedings of
the Boyal Medical and Ohirorgical Society/ New Series, voL i,
p. 426.)
THREE OASES
(PBOGRE88IVE MUSCULAR ATROPHY
AND INFAimLE PABALTSIS)
XILUBTKATIKG- THB
IiOOALISATION OF MOTOR CBNTBES IN THE BBAOHIAL
BNLABOEMBNT OF THB SPINAL OOBD.
C. E. BEEVOB, M.D.,
ASBIfTAKT FHTSIOIAV TO THM VATIOVAL HOSPITAL VOB THB FABALTBBD AVD
BPILBFTIO.
BeedTed December 9th, 1884-B«ed April 14th, 188ft.
Thx two cases which I have shown this evening are
chiefly important with regard to the localisation of the
centres for different groups of mnscles of the upper limbs,
in the different segments of the brachial enlargement of
the spinal cord.
The first case is one of progressive mascnlar atrophy.
The patient is 88 years old, and has been a goldbeater
for eighteen years; he attributes his illness to violent
muscular exertion, but he has been a larapUghter for the
last six years and much exposed to wet and cold. There
is no family or previous history of importance. Three
years ago he began to have difficulty in extending the
206 PBOORIBHIYB MUSCULAR ATROPHY
third and foarth fingers of the right hand ; he then thinks
that the mnscles of the right arm began to waste^ and he
gradually lost power in them.
A year after the onsets the left arm became affected^
and he had trouble in supinating the forearm, then in
flexing the elbow, and in abdacting the arm away from the
trunk.
For the last six months the legs have felt weak.
Preaefiii conMtion. — In the right arm the muscles most
affected are, the extensors of the wrist and fingers and
thumb, the small muscles of the hand, the interossei, the
flexors of the fingers, the biceps, supinator longus,
deltoid, rhomboid, serratus magnus, teres major and
minor.
The interossei, especially the first, and the muscles of
the hand are very much wasted and the extensors of the
fingers are more atrophied than the flexors. The fingers
are rigidly flexed; he cannot extend or separate, but
can just flex them. In the right forearm supination is
more difficult than pronation.
The biceps, brachialis anticus and supinator longus are
much wasted, and though he has no power to flex the
elbow-joint he can just make the two first muscles contract.
On the other hand, the triceps is so strong and well
developed that he can prevent the elbow- joint being
forcibly fiexed. The deltoid is very much wasted, specially
the middle part, and he is unable to abduct the humerus
away from the trunk, although the supraspinatus seems to
contract. The pectoralis major acts fairly well, but the
sternal better than the clavicular half, and he can with
much difficulty fiex the shoulder-joint, bringing the arms
forwards, though not to the horizontal line. In so doing
the scapula projects backwards and away from the trunk,
owing to the serratus magnus being much wasted and
incapable of advancing the inferior angle of the scapula.
The absence of action of the serratus magnus is well seen
when the arm is forcibly raised above the horizontal line,
and allowed to drop, when it falls at once on removing the
AMD IKFANTILB PARALYSIS. 207
support. In addnoting the humerns to the tnmk the
latissimuB dorsi acts fairly well^ bat not the teres major
and minor. He cannot draw the scapula towards the
spine by the rhomboid muscle. The upper end of the
trapesius acts normally, the rest of the muscle not so well
as in healthy and in shrugging the shoulders the scapulaa
appear to be elevated by the trapezii and not by the leva-
tores anguli Bcapul».
In the left arm the changes have not proceeded so far,
and there are some important differences. Here the
muscles most affected are, biceps, brachialis anticus, supi-
nator longus, deltoid, rhomboid, supra- and infra-spinati,
teres major and minor, serratus magnus, extensors of
thumb, and to a less degree, the extensors of the fingers.
There is not so much wasting of the hand and forearm as
on the right. He can flex the fingers and thumb well,
and use the small muscles of the ball of the thumb, being
able to touch all the tips of his fingers with the thumbs.
He can extend the first finger well, but the wrist and other
fingers he can only just extend, and the thumb not at all.
When the hand is supported the interossei can separate the
fingers. The biceps and supinator longus are much
wasted and absolutely no voluntary movement can be pro-
duced ; the inaction of the supinator longus is strikingly
seen, in comparison with the extensors of the fingers
which he can still throw into action. I may remark that
this is just the opposite to lead paralysis, where the
extensors are paralysed and the supinator longus, which is
really a flexor of the elbow-joint, escapes; this is im-
portant, as lead paralysis is considered by some writers to
be due to disease of the cells of the anterior cornua of the
cord. On the other hand, the triceps is strong, normal,
and well formed. The deltoid, the supra- and infra-
spinati are much atrophied and their movements nil. The
pectoralis major is rather weak in its action and the
clavicular more affected than the sternal part, so that he is
unable to bring the humerus forward so well as on the
right side. In adducting the humerus to the trunk, the
208 PBOOBBSSIYI MUSOULAB ATROPHY
latissunns dorsi acts well and better than on the rights
but no action can be seen in the teres minor and major.
The serratns magnns does not act at all^ bat there is not
that protmsion of the posterior border of the scapolaa
which is so marked on the other side. This is probably
due to the npper fibres of the pectoralis major not being
strong enoagh to advance the arm^ so that no strain is pat
upon the upper part of the scapula. The rhomboid is
quite powerless to draw the scapula to the spine.
The patient carries his head bent forwards and there is
much prominence of the upper dorsal and last cervical
spines. He has some difficulty in extending the neck and
throwing the head backwards^ and then when it is allowed
to come forwards again it falls suddenly after it has passed
the vertical position ; this is due to the weak action of the
muscles keeping the head erect — the splenii^ complexi^
and trachelo-mastoid muscles.
The sterno-mastoids^ however^ act normally and can
turn the head to the right or left.
The pupils are equals but the right does not act to light,
though it does to accommodation.
The left pupil reacts to light and to accommodation.
With regard to the electric reactions of the affected
muscles I may state that there is no reaction to the
induced faradic current on the right side in the interossei,
extensors and flexors of fingers and thumbs the deltoid,
the rhomboid, the serratus magnus, the spinator longus,
and the teres major ; of these, the extensors of the fingers,
their flexors and the rhomboid only react to a strong
constant current and to the positive better than the
negative pole ; the biceps does react to the faradic current,
but in this muscle slight power still exists.
The lower and middle parts of the trapezius react to
a rather strong faradic current. In the left side the
biceps, supinator longus, deltoid, rhomboid, supra-spinatus,
inf ra-spinatus, teres major and minor, and serratus magnus
do not react to strong faradic currents ; the biceps and
supinator longus react to the positive pole of a strong
AND INVANTILB PABALTSiS. 209
constant cnrrent^ as do also the teres major and minor.
The peotoralis major reacts to a moderately strong faradic
carrenti which is also required to produce contraction in
the middle and lower parts of the trapezius.
The legSj though weak^ do not present any marked
wasting or loss of power. The patellar tendon reflexes
are increased^ a condition which I have seen in other cases
of muscular atrophy^ and especially in one which I
published in ^ Brain/ (Part ziz) where ankle clonus was
also produced. This is probably due to sclerosis of the
lateral columns secondary to the primary lesion.
The second case which I have brought forward is that
of a young man^ aged 18^ who had infantile paralysis
when one year old^ following scarlet f erer ; that is^ in less
time than two or three months after the fever. He was
paralysed in all the limbs, but he recovered more or less
with the exception of the left arm^ which remained most
affected. He states that, as long as he can rememberi
his right arm has been strong but the left arm weak ; he
was able to walk from two years old, but the feet have
always been more or less contracted.
Present condition. — ^The patient is affected more or less
in all his limbs, the left arm being the most disabled.
The right upper limh below the elbow is normal and quite
strong, the muscles of the hand and forearm being very
well developed and possessing considerable power.
The triceps, including the long head, is very much
wasted and he has not the least power to contract it ; he
cannot keep the elbow extended nor can he extend the
elbow-joint when the forearm is allowed to hang at right
angles to the upper arm. The triceps gives no reaction
to electric current, either faradic or constant.
The biceps and brachialis anticus and the deltoid are
normally developed and act very vigorously. The pecto-
ralis major is very well represented in its upper clavi-
cular part, whilst the lower or sternal part is absolutely
gone, not a trace of it being seen, so that the anterior
fold of the axilla passes in a line towards the upper end
VOL. LXVIII. 14
210 PROOBlBSiyB MU8GUI.AB ATSOPHY
of the stemnin^ instead of to the lower. The pectoralis
minor cannot be made out. He has very little power
in pressing with the right hand on a table when the
arms are extended^ a movement which is specially dne to
the action of the lower part of the pectoralis major.
The serratas magnas is not affected, and he can raise
the arm high up in the air with considerable strength.
The remaining muscles of the scapula are normal^
including the infra- and supra- spinati, the teres minor^
the subscapularis and teres major, the rhomboid, and the
trapezius. The latissimus dorsi is absent and cannot
be made to act; when the patient tries to adduct the
humerus to the trunk against resistance, the work is done
by the muscles of the scapula, which is thereby drawn
forwards away from the trunk.
These muscles take the place of the latissimus dorsi in
placing the arm behind the back. There is no reaction in
the latissimus to faradic or constant electric currents.
In rotating outwards the humerus by the teres minor
and infra-spinatus, the scapula is drawn forwards, the
rhomboid not having sufficient power to keep it fixed.
The left a/rm is more affected than the right, and is
generally wasted, the circumference of the right forearm
being eight and a half inches, whilst the left is only seven
and a quarter.
The muscles of the ball of the. thumb and the interossei
are not wasted, and he has good movement in them.
The extensor aspect of the forearm is wasted, and he can
only just extend the fingers and wrist to the horizontal
line; in so doing the wrist becomes flexed, while the
fingers are hyper-extended. He has no power to extend
the thumb. These extensors require strong faradic
current for their contraction. In the upper arm, which is
considerably wasted, the biceps and supinator longus act
fairly well, but not so strongly as on the right side. The
triceps is very much wasted and no contraction can be
produced either by the will or by strong faradic or con-
stant currents, with the exception of its long head, which
▲ND INfANTILB PASALTSIS. 211
reacts to a strong faradio and to the positive pole of a
strong constant current. The deltoid is also a good deal
wasted^ bnt the patient is just able to abduct the arm to
the horizontal position.
The serratus magnus is somewhat affected, so that he
cannot raise the arm further than the horizontal \me,
unless the elbow be flexed^ thereby reducing the weight
of the arm^ but this inability may be also due to the
weak action of the deltoid. Li adducting the humerus to
the trunks no action is seen of the latissimus dorsi or the
teres major or minor. What action there is appears to
be done by the posterior part of the deltoid^ which also
has slight power in rotating the hanging humerus out-
wards. The patient cannot effect any rotation inwards^
the special rotators^ both in and out^ being very much
wasted and quite powerless.
The pectoralis major is much wasted^ especially the
sternal part, of which a thin band only is visible, so that
he is unable to keep the left hand touching the right
shoulder. The supra- and infra-spinati are very much
wasted and powerless. The rhomboid is incapable of
drawing back the scapula to the spine, and although the
upper fibres of the trapezius act normally the rest of the
muscle acts feebly.
In the lower limbs the feet are much altered in shape,
the toes being hyper-extended whilst the arch of the foot
is very much increased, the length of the feet being thus
much shortened. This alteration seems to be due chiefly
to the non-action of the interossei, and is similar to the
claw shape assumed by the hand when the interossei
are affected. The tendo Achillis does not appear to be
contracted.
The patient can flex the toes of both feet, and slightly
flex upwards the right ankle, but not the left. He
cannot evert either foot by means of the peronei^ and
can only just invert both ankles by the tibialis anticus,
the right better than the left. The electric examination
shows no reaction in the peronei of the left leg to strong
212 PB00BIB8IVI XUSOULAB ATBOPHY
faradisation and only slight contraction to a strong con-
stant current. The tibialis anticas of the right leg reacts
very slightly to a strong faradic cnrrent, whilst that in the
left reacts only to a strong constant current.
There is no patellar tendon reflex in either leg^ which
is in marked contrast to the condition in the other case.
With regard to the electric reactions in this case^ there
is no reaction to a strong faradic or constant current in
the right arm, of the triceps^ pectoralis minor^ or latissimus
dorsi ; the clavicular part of the pectoralis major reacts
normally to faradisation, while the sternal half, being
absent, cannot of course be tested ; the serratus magnus
requires a faradic current rather stronger than normal to
make it contract.
In the left arm there is no reaction to strong currents
in the triceps (with the exception of the long head which
contracts to a strong faradic, and to the positive pole of
a strong constant current), the latissimus dorsi, the
supra- and the infra-spinatus, the teres major and minor,
or the rhomboid. The clavicular part of the pectoralis
major reacts normally, but the sternal part only to a
strong faradic current. The extensors of the fingers,
the supinator longus, biceps and serratus magnus react to
strong faradic currents, as does the deltoid, but the ante-
rior and posterior parts of this muscle react rather better
than the middle part ; this is of some importance as the
deltoid may be looked upon as composed of three muscles,
the anterior part of which acts in conjunction with the
clavicular part of the pectoralis major, which in this case
acts fairly well.
The two cases which have been brought forward may
be both considered together, for although one is a case of
progressive muscular atrophy and the other is one of
infantile paralysis, they are both due to a similar cause,
viz. a lesion affecting the cells of the anterior comua of
the spinal cord, and especially of the brachial enlargement.
With regard to progressive muscular atrophy it has been
considered by Friedreich that the disease lies primarily
AND INVANTILB PABALT8I8. 218
in the masoles themselyes^ but at present most writers
consider that the cells of the anterior comna are the seat
of disease.
My object in bringing forward these cases is to prove
clinically the correctness of the experiments of Professors
Ferrier and Yeo on monkeys. These obserrers divided the
several motor roots of the brachial and lumbar plexuses
and on stimulating the peripheral ends various groups and
combinations of muscles were put into action. I have
drawn up a list of these muscles taken from Ferrier's
paper in the ' Proceedings of the Royal Society^' 1881^
and also from a paper of his in ' Brain^' Parts 14 and 15 ;
and parallel with this list I have given lists of the muscles
affected in my two cases. The condition of the two arms
is given separately in each case^ so that it can be seen
at a glance how each is affected.
There has always been a difficulty in explaining why
in diseases like progressive muscular atrophy and infantile
paralysis certain muscles should be picked out and others
left. The groups of muscles affected do not correspond
to the nerve supply of any one peripheral nerve ; and the
extensors as a whole do not suffer more than the flexors^
although they are generally the weaker muscles ; for while
the extensors of the wrist and fingers are usually the first
to suffer^ the triceps has always been remarkable for its
immunity from attack^ and has frequently been noticed as
the last to be affected.
On looking at these two cases^I think it will be observed
that broadly the one is the counterpart of the other ; I do
not mean absolutely so^ for it is not easy to find hard-
and-&st stereotyped limits to clinical cases. Comparing
the muscles affected in each case^ it will be seen that in
that of progressive muscular atrophy they correspond to
the muscles assigned by Ferrier and Yeo to the upper and
lower ends of the brachial enlargement^ whilst the case of
infantile paralysis corresponds to the muscles governed by
the middle of that enlargement. Although the experi-
ments of Ferrier and Yeo were made on the motor nerves,
214 PB00BI88I7I XUBOULiLB ATROPHY
the gproaps of masoles assigned to the different roots
correspond also to the anterior comnal cells supplying
them.
On looking at the list of muscles affected in the case of
progressive muscular atrophy it will be seen that there are
some differences between the two arms.
In the right arm the muscles innervated by the fourth
and fifth cervical^ according to Ferrier and Yeo^ are all
affected^ with the exception in the fourth cervical of the
(lupra-and infra-spinati muscles which have escaped^ sothat^
excluding these two muscles and the diaphragm — ^which
has the nuclear origin of the phrenic in the medulla and
not in the cervical cord — ^not a single muscle has escaped.
On looking at the sixth cervical group^ the pronators of
the wrist are slightly affected^ but the serratus magnus is
the only muscle seriously damaged, and this is also
supplied by the affected zone of the fifth cervical. In
the seventh cervical, all the muscles have escaped except
the flexors of the wrist and fingers and the teres major;
and it is interesting to note that the muscles which are
supplied by, and only by, the sixth and seventh cervical
have escaped ; this is in striking contrast to the case of
infantile paralysis, where the same muscles are the only
ones which are paralysed. The eighth cervical zone has
all its muscles affected excepting the long head of the
triceps and the pectoralis major, about which Ferrier has
some doubt as to its proper position here. The first
dorsal, representing the hand muscles, is entirely damaged.
When we examine the left arm we find that the disease,
while following the general course of the other arm, has
shifted its position a little higher up, so that we see, con-
trary to what is usual, that the small muscles of the hand
supplied by the first dorsal have escaped, and the disease
does not seriously begin till we reach the fifth cervical
zone.
The pectoralis major is affected^ but in the upper or
clavicular part more than the lower or sternal half —in
contradistinction to what is found in the other patient-—
AND IMVANTILB PABALTBIB. 215
and I certainly think that the pectoraUs major may have
its two halves assigned to different parts of the cord> the
clavicular half going along with the anterior fibres of the
deltoid^ of which it is a continnation^ whilst the sternal half
is more associated with the triceps gronp. This grouping is
also illustrated by physiological action^ for in pressing the
two hands togetJier the clavicular part of the pectoralis
major^ the anterior fibres of the deltoid and the biceps are
associated^ whilst in pressing the hands downwards^ against
a table^ the sternal part of the pectoralis major and the
triceps act together^ the biceps not being used in this
movement^ which may be illustrated by pressing on the
table to assist in rising from a chair. In the fourth and fifth
cervical groups all the muscles are involved^ as on the
opposite side^ but with the exception that the supra- and
infra-spinati are also affected^ whilst the extensors of the
fingers have more power than on the right side.
In the list of the muscles affected in the infantile para-
lysis case^ it will be seen that only the triceps^ pectoralis
major (sternal half)^ and latissimus dorsi are absolutely
powerless and give no reaction to electric stimulation.
Now these muscles^ according to Ferrier's list^ are inner-
vated only by the sixth and seventh cervical roots^ and if
these are seriously damaged^ or rather if the anterior comua^
the segments of the cord containing their nerve-cells^ are
diseased they become powerless. It is interesting to note
that these three muscles are the only ones in the sixth and
seventh cervical zones which are supplied by both these
nerves ; the teres major and subscapularis^ both internal
rotators^ are supplied by the seventh cervical alone^ and
the pronators by the sixth alone^ and these have escaped.
I can only suggest that these may perhaps have another
nerve supply from a different zone which has not yet been
discovered. I think some light may be thrown on this
apparent anomaly when we examine the left arm.
In the left arm precisely the same muscles are affected
as in the rights but the disease has gone further and
involved other zones of the cord. And here we see that
216 PBOORBSSIVB MUSCULAR ATROPHY
the subsoapnlaris and the teres major, the clavicnlar por-
tion of the pectoralis major, the rhomboid, the snpra- and
infra-spinati must be added to the list of muscles severely
affected. I think it is interesting to note that the
remaining muscles supplied by the sixth and seventh cer-
vical are here invaded, as the disease is more extensive.
The pectoralis major is here more affected in the sternal than
its clavicular part, following a course similar to the muscle
of the right side. The fact of the deltoid being somewhat
affected would lead us to place the clavicular part of the
pectoralis major along with the deltoid, whilst the sternal
part would be assigned to the sixth and seventh dorsal
zones.
I confess it is difficult to make the spinati harmonise
with the fourth cervical zone.
Besides the above muscles the serratus magnus, deltoid,
and extensors of the wrist are somewhat affected, though
they possess voluntary movement, and all respond to strong
faradisation. They would show a moderate extension of
the disease to the fourth and fifth cervical.
It will be seen that the eighth cervical and first dorsal
are almost intact, the small muscles of the hand and
flexors of the fingers thereby escaping.
It seems probable that in the case of progressive
muscular atrophy the disease began with atrophy of the
right hand muscles, and so corresponded to the first
dorsal segment of the spinal cord; the disease subse-
quently attacked the upper end of the cord, the fourth and
fifth cervical, the middle part of the brachial enlargement
not being affected or only very slightly.
It is very extraordinary why the extremities of this
enlargement should be most attacked, and why the disease
should, BO to say, leap over the middle part ; perhaps
some difference in the blood-supply of the middle and ends
of this part of the cord may in future time be discovered.
It is of course possible that the disease may begin in the
two extremities at the same time, and I think that in the
left arm the disease seems to have commenced at the
AND IMFANTILS PA&ALYSIB. 217
upper part of the brachial enlargement as shown by
the biceps and deltoid being first affected.
In the case of in&ntile paralysis^ the whole of the
brachial enlargement was probably entirely affected at
firsts the ends recovered completely in the right arm^ bat
to a less degree in the left^ while the middle has been left
permanently paralysed^ but why we do not at present
know.
A third case which was under the care of Dr. Ferrier
at the Queen Square Hospital — whom I have to thank for
allowing me to publish it here — ^is a boy^ aged 13^ who had
infantile paralysis when two and a half years old^ affecting
the right arm and the legs.
At present the right arm is affected in the triceps group
of muscles corresponding to those supplied by the sixth
and seventh cervical roots^ and therefore corresponds to
the second of the cases already described^ viz. that of
infantile paralysis.
In the right arm he has all the movements of the small
muscles of the hand and interossei, and can extend and
flex the wrist and fingers^ and these muscles react nor-
mally to the faradic current. The biceps^ brachialis
anticus and supinator longus act well but the triceps is
very much weaker than in the left arm^ and it is impor-
tant to note that whereas the long head of the triceps
(which is placed in the eighth cervical group) reacts to
nearly a normal faradic current^ the short head reacts very
slightly to a strong &radic current and to the positive pole
of a rather strong constant current^ whereas all parts of
the left triceps react to the normal faradic and constant
currents. The right deltoid abducts the humerus well^
but the sternal half of the pectoralis major is decidedly
weaker than the clavicular part^ and while this clavicular
part acts normally to &radisation, the sternal part requires
a much stronger current than does the same part of the
muscle on the left side.
The serratus magnus is very weak^ and in carrying the
right arm forwards to the horizontal line, the posterior
2J8 PBOORIBBIVB MUSCULAR ATBOPHY
border is seen to protmde very much owing to the weak
action of the serratus magnns ; the protmsion is most
marked jnst before the horizontal line is reached^ bnt after
this is passed and the arm is raised nearly vertical^ the
protrasion disappears ; this may possibly be dne to the
lower fibres of the serratas being less affected than the
upper fibres (?) ; this muscle reacts very b'ttle, if at all^
to a strong faradio current. The infra-spinatus and teres
minor^ the external rotators of the shoulder^ act better
than the internal rotators^ the subscapularis and teres
major.
In adducting the right humerus to the trunk against
resistance, the latissimus dorsi hardly appears to contract
at all, and the scapula is drawn away from the trunk by
the teres muscles ; the right latissimus acts very slightly
to a strong faradic current. The patient has apparently
some difficulty in drawing the right scapula towards the
spine, but the rhomboids act to nearly a normal &radic
current.
In this case it will be seen that the muscles affected
belong to the groups innervated by the sixth and seventh
cervical roots, the fourth, fifth, and eighth cervical and
the first dorsal escaping. In the seventh cervical we have
the teres major, latissimus dorsi, subscapularis, peotoralis
major (sternal half), and triceps, in fact all the muscles,
except the flexor of wrist and fingers, which being also
supplied by the eighth cervical escapes. In the sixth
cervical, the latissimus dorsi, the pectoralis major, serratus
magnus and triceps are affected. It may be said that the
serratus magnus ought to have escaped as it is also in-
nervated by the fifth cervical^ but it seems probable that
this muscle is twofold in its action, and the upper fibres
are supplied by the sixth cervical, while the lower fibres
inserted into the lower end of the scapula are supplied by
the fifth cervical, and this grouping is borne out by the
movements produced by Ferrier and Yeo in monkeys.
AKD IKVANTILI PABALTSIS.
219
RRRIER iLND TEO^ LIST.
^ atrophy.
Infimtae iMnlyiii.
Bight
Left.
JUght
Left.
UtDanal.
Smftll mnsolei of hand and inter-
onei
X
mCmricoL
Long flezon . . . .
X
Ulnar flexors of wrist
X
Small muscles o£ hand
X
Extensors of wrists and fingers .
X
—
Triceps, long bead
1
X
—
(Peotoralis major P).
—
Sternal part
7ihCenrieal.
1
Teres major . . . .
X 1 X
X
Latissimos dorsi
1
X
X
Sabseapnlaris ....
X
. Peotoralis rn^or
—
Sternal part
X
Flexors of wrist and fingers
(median) . . . .
X
Triceps
X
X
eaCuvieal.
Latissimns dorst
X
X
Peotoralis major
—
Sternal part
X
Serratos magnns
X
X
^^
Pronators (fiexor of wrist ?)
— .
Triceps
X
X
6ihCenneal.
Deltoid (oUvicnlar part) .
X
X
—
Biceps
Biaehialis anticns
X
X
X
X
Serratns magnns
X
X
_
Supinator longns
X 1 X
Extensors of wrist and fingers .
X 1 -
4ikOervieal.
Deltoid
X
X
__
Rhomboid
X
X
X
Snpra-spinatns . . . .
In£ra*simiatns . . . .
X
X
X
X
^eres minor) ....
Brachialis anticns
X
X
X
X
X
X
X
Supinator long^
X
X
Extensors of wrist and fingers .
X
^
Diaphragm . . . .
1
f
X Seyerely aflSected.
- SUgbtly aifec
ted.
Ferrier has since found that the above list is one root too high (* Proc Boy.
Soc./ ToL 86, 1888, p. 229), and the groups of muscles should refer from the
220 PBOOBSBSIYl MUBCULA.B ATBOPHT.
ilfth eerrieal to the teoond donal, to that the group atsigned to the foarth
oeirioal really helongt to the fifth, and the fifth to the nzth, Ac.
(For a report of the discnseion od this paper, see 'Proceed-
ings of the Royal Medical and Chirurgical Society/ New Seriea,
vol. i, p. 480.)
ON THE PATHOLOGICAL HISTOLOGY
OVTBI
SEMTLUNAR AND SUPERIOR CERVICAL
SYMPATHETIC GANGLIA.
BY
W. HALE WHITE, M.D.,
A88IBTAST PHT8I0IAK TO QTTX'a HOSPITAL.
ReceiTwi Febnuury 10th— Scad April 88th, 1866.
WiSHiNa to discover whether or not the sympathetic
ganglia were affected in certain diseases^ I have been
occupying my spare time during the last two years in
preparing a number of sections^ in all over a hundred and
fifty^ of the semilunar and superior cervical ganglia^ with
a view to discovering how far the structure of these bodies
might vary within normal limits. Inasmuch as this sub-
ject is very cursorily referred to in any text-books^ with
the exception of one or two Italian ones^ I thought the
results of my investigations might be of use to some
members of our profession.
In order to avoid any bias I adopted the following
method of procedure. As soon as the post-mortem
examination was made the specimen was put into a bottle
which was numbered^ whilst the description of the post-
mortem was entered in a book against this number. The
222 PATHOLOGICAL fllSTOLOOT OV THl BIXILUKAR
sections were in dne time oat and a description of the
appearances presented was written oat ; after this was
done^ by reference to the nnmber of the post-mortem, the
disease of which the patient died coold be discovered.
It will thas be seen that in no case was I aware of the
canse of death when I described the microscopical
appearances.
Before going any farther I woald point oat that the
size of the ganglion, whether saperior cervical or semilanar^
is of no pathological significance whatever. Thas I have
seen the saperior cervical vary from a quarter of an inch
to more than an inch in length, and in the latter case the
width was increased in proportion ; again I have noted that
the middle cervical, which is usaally so small, may be
actually larger than the saperior. In the case of the
semilunar I have always cut the sections so as to get the
largest area, and whilst the largest measures an inch and
a half by rather over half an inch, the smallest is no
larger than the section of a split pea. The size bears no
relationship to the cause of death, for in some instances in
which I have cut sections of the same ganglion from
different cases of the same disease, the size has varied
considerably.
As a rule the shape of the superior cervical is that of a
spindle, and that of the semilunar, like the thumbnail ;
but I do not think that any importance should be
attributed to differences in shape, for very often the semi-
lunar is of such a shape that it cannot be likened to any
object whatever, and I have seen the middle cervical so
irregular that it might have been mistaken for a small
semilunar. Giovanni^ practically agrees with what I have
said, for although he says that alterations in the quantity of
the constituent elements of the ganglia alter their size, he
points out, what his tables show, that the variations in
volume are too great to be of any service to pathology.
The naked-eye vascularity of the sympathetic system is
of no pathological significance, for the vessels are so small
> < Pfttalogia del Simpatioo.' di A. De Giovanni.
AMD SUPIRlOfi CIRVICAL 8TMPATHITIC QANGLIA. 228
that no constant arrangement can be described; tbns,
sometimes the artery before entering the ganglion will run
on it for some little distance^ whilst in others it will enter
it directly. What I have here pointed out is markedly
shown in my preparations ; thns^ in making the post-mortem
on a case of myxoedema^ the middle cervical ganglion
appeared so vascular that all who were present thought it
abnormal. Microscopic examination showed no increased
vascularity ; it was merely an anatomical accident that the
vessels were running some way over the surface before
entering the ganglion. The greatest vascular engorge-
ment I have ever seen occurred in a case of diabetes^ but
this was only to be noted after microscopical examination,
not being visible to the naked eye. That apparent
hyperaemia is valueless is also seen from the fact that
Gtiovanni records that it existed in pleuro-pneumonia,
tubercle, cardiac disease, atheroma, chronic nephritis,
typhoid fever, cancer, puerperal peritonitis, hydrophobia,
and diphtheria. A condition present in such a variety
of diseases cannot have much significance.
I do not think it is possible to say much about oedema
of the ganglia, at least as being visible to the naked eye.
This is not surprising when we remember their small size,
the densenesB of their capsule and of the interstitiid
connective tissue ; as in the case of hypersomia, Giovanni's
enormous number of ganglia which he says were oedema-
tous show that either it can be of no importance, or, what
I suspect is probably correct, that he has recorded many
which were really quite normal as oedematous.
With regard to surrounding fat, the superior cervical
ganglion has none, and that around the semilunar varies
very much in quantity, but without affecting the internal
structure of the organ any more than does that around
the kidney or heart. The ganglia are generally of a solid
firm consistency. I have not noticed any variations in this
respect in the various specimens I have examined.
I have met with no case of adhesion of the ganglia to
the surrounding parts.
224 PATHOLOaiCAL HI8TOLOOT OP THl BIXILUVAB
It will thuB be seen that I have come across no example
of any external appearance of the ganglia being of any
significance whatever either as an indication of obvions
disease or of what we may expect to find internally ; in
factj I shonld be inclined to say that the only possible
cases in which the external appearance of the ganglia
could be of any importance are> firstly^ those in which one
or more of them were implicated in, or affected secondarily
by^ some morbid growth snch as carcinoma or sarcoma ;
secondly^ those in which an aneurysm, abscess^ tumour, or
other new formation pressed on them ; thirdly, those in
which a mechanical injuiy has affected them ; fourthly,
those in which some chronic inflammatory or malignant
process either spread into them from surrounding parts,
or by contraction of the newly -formed fibrous tissue pressed
upon them ; fifthly, those in which an enlargement was
caused by something internal, such as an abscess or a
tumour. It will be seen that all the above are theoretical
affections of which we have very little knowledge ; they are
introduced chiefly to show how rare any morbid affections
of the ganglia visible to the naked eye must be. The trunk
of the sympathetic is more often implicated as is seen in
some cases of aneurysm. It is of course conceivable that
sometimes the sympathetic should be affected by general
conditions such as tubercle and lardaceous disease^ but of
this I have no experience.
We now come to the microscopic appearances of the
ganglia, and the nerve-cells, as they are of so much
importance, will first of all occupy our attention.
The typical ganglionic nerve-cell from the sympathetic
ganglia is like a nerve-cell from elsewhere. It is large,
takes the logwood stain well, is rounded, has one or more
processes, and a distinct nucleus and nucleolus. I find that
among the cases which I have examined the following are
marked as presenting cells which exactly correspond to
the above description : — Cancer of bladder, aortic disease,
sarcoma of breast, double phthisis, bronchopneumonia,
chronic Bright's disease (two cases), cancer of oesophagus.
AMD BUPIBIOB CIBYICAL STMPATHETIC QANQLIA. 225
rnptnre of intestine^ stricture of urethra^ diphtheria^ and
scald. It is especially to be noted that in the two cases
of chronic Bright's disease, the description of the cells
states that they are exceptionally typical^ for Dr. Sanndby^
has written a paper in which he says that in chronic
Bright's disease the ganglion cells are abnormal, being
pigmented and degenerate. He also refers to a paper by
Drs. Da Costa and Longstreth, in the 'American Journal
of Medical Science ' for July, 1880, and states that these
authors go so far as to attempt to explain the phenomena
of Bright's disease by these changes in the cells. My
experience is that patients dying of this malady are not
more liable than any others to have abnormal cells in their
sympathetic ganglia. The two cases of diphtheria and
scald were children, the cells were exactly similar to those
from adults.
I do not think any importance can be attached to the
number of the cells found; for, in the .first place they
are so irregularly scattered about in the ganglia that we
can never be sure that one section shows them in their
maximum number, sometimes the section happens to be
taken through a part which consists of little else than nerve-
fibres and some fibrous tissue ; in the second place, ganglion
cells may so often be found in what is to the naked eye
sympathetic nerve trunk, that even if we were inclined to
think the ganglion contained but few cells, it is quite
possible that this deficiency would be compensated for by a
large number of cells being present in the nerve trunk. It
is far more common to see sympathetic ganglion cells
without processes than with them, the absence does not
appear to be connected with any particular disease and is
I think of no pathological value.
Often no nucleus or nucleolus can be seen in an other-
wise healthy cell ; there is no present evidence to show
that the presence or absence of the nucleus is of any more
importance than the presence or absence of processes.
The typical nerve-cell from either of the sympathetic
> • Brit. Med. Journal/ Jan. 18tb, 1888.
VOL. LXVIII. 15
226 PATHOLOGICAL HI8T0L00T OF THK 8»1LUNAR
ganglia now nnder consideration is larger and more
ronnded than an anterior coma cell from the cervical
spinal cord« Its difference in shape is clearly due to its
not sending off so many processes. Sometimes the cells
may be smaller, eyen half the size, and still, as far as one
can judge, they are capable of functional activity. In
specimens from the following cases the cells appes^ned to
be of a normal size : anthrax, cancer of bladder, aortic
disease, sarcoma of breast, double phthisis, broncho-
pneumonia, cirrhosis of the liver complicated with granular
kidney, another case of granular kidney (concerning these
specimens I have made the note that I have seldom seen
better examples of normal cells), rupture of the intestine
with peritonitis, stricture of urethra, phthisis, tumour of
brain, another case of granular kidney where it is likewise
remarked that the cells are remarkably good, diphtheria,
scald.
In all the above the size of the cells is normal over all
or nearly all the specimens. In some other cases they
are small in one part and large in another. It must also
be borne in mind that the size of a cell will depend some-
what on the direction of the section. When a cell is
small, that diminution in size is nearly always due to pig-
mentary degeneration, which we will consider presently ;
some cells are, however, pigmented without any alteration
in size. In cases dying of the following diseases the cells
were diminished sufficiently in size for the diminution to
be noteworthy : diabetes (four cases), idiopathic anaemia
(two cases), abdominal aneurism (superior cervical gan-
glion, the cells are reduced to a minute mass with no
resemblance to the original), broncho-pneumonia, sarcoma
of pelvis, gangrene of foot from atheroma, malignant
disease of the bladder, aneurism of abdominal aorta (semi-
lunar ganglion), aortic disease, myx oedema, general malig-
nant disease.
On contrasting this list with that in which the cells are
not diminished in size, it will be seen that the second
enumeration contains many more wasting diseases than
AND SUPIRIOB CBBVICAL BTMPATHKTIC OANOLIA. 227
did the first : thus there are four cases of diabetes and
three of malignant disease. So we may say that as a
general role wasting of cells is most marked in wasting
diseases^ but that this is subject to many variations.
We now come to the degenerations of the cells, of
these the only one of any importance is the pigmentary.
This may or may not be accompanied by diminution in size.
In all the specimens above mentioned, as showing a
decrease in size, some or other of the cells were pigmented ;
in slides taken from the following diseases the cells were
pigmented although not diminished in size : anthrax,
cancer of the bladder (two cases), aortic disease, sarcoma
of breast, phthisis (two cases), chronic Bright's disease
(three cases), purpura, broncho-pneumonia, cancer of
oesophagus, abdominal aneurism, rupture of the intestine,
tumour of the brain.
Pigmentation occurs in specimens taken from people
dying of almost any disease, and in consequence of its
almost universal presence, in greater or less quantity, in
the cells of almost all specimens of sympathetic ganglia
one is compelled to look upon it as of no pathological
importance. The only thing to be noted is that it is
entirely absent in the two cases in which the ganglia of
children were subject to examination. It is just possible
that the interpretation of this almost universal pigmenta-
tion is that it is connected with the smaller ailments from
which none of us are free. This might perhaps apply to
the semilunar ganglia with more force than the cervical,
but both seem to be with equal frequency pigmented.
Bef erence to Giovanni's work will show that age has very
little to do with the quantity of pigmentation, so that
perhaps it is no more than an accident that the two cases
of children which I examined show no pigment.
This pigmentary degeneration usually occurs as small,
roundish, bright yellow masses in the nerve-cell;
frequently it may be observed that whilst part of the cell
has undergone pigmentary degeneration part is quite free
and well stained with logwood, which agent has no effect
228 PATHOLOGICAL HI8T0LOOT OF THK BKMILUNAR
on the degenerate part. The intensity of the yellow colour
is liable to fade if the specimen has been kept long. If
the change be extreme the cells are represented by little
masses of yellow pigment shrunk away from the capsole^
bearing but little resemblance to the original cell, which
thus sometimes looks like the section of a vein with a
little blood-pigment in it. I do not think that this con-
dition can be shown to be associated with any particular
condition of the blood-vessels or surrounding tissues.
Sometimes the cell has a fine granular appearance. I
am unable to connect this with any particular disease.
Considering that the pigment tends to disappear the
longer the specimen is kept, I am inclined to think that
these granules may be pigmentary ones from which the
colouring matter has become dissolved out.
Often the cell presents a vague, ill-defined outline, so
that it is almost impossible to define its margin. It is
more common for this condition of border to exist at one
part of the cell only, it may, however, exist all over. It
is frequently coexistent with absence of the nucleus ; in
such cases the contrast between a healthy cell with a
well-defined nucleus and the vague non-nucleated mis-
shapen one is very striking. Like the other variations of
the cell this vague condition cannot, as far as I know, be
connected with any particular disease. Although I have
occasionally seen what I have taken to be fat granules
present in a cell, I certainly should not think fatty
degeneration to be so common as one would infer from
Giovanni's statements. Of other degenerations of nerve-
cells in sympathetic ganglia I have no experience. In
some of the best specimens the nucleus does not stain at
all, but stands out as a bright colourless spot with a dark
nucleolus in the centre, in others the nucleus stains dark.
From a study of the cells one is driven to the conclusion
that in the present state of our knowledge their varying
appearance cannot be said to be of any significance ;
either the variations may be very great and the cell be
still normal, or, in at least four fifths of the cases examined.
AND SUPIBIOB 0SS71CAL BTMPATHjmO QANQLIA. 22d
the cells were abnormal ; and if the latter hypothesis be
true we are still unable to connect the abnormal condition
of cell with any particular disease or symptoms.
Taking next the nerve-fibres they are quickly disposed
of. It is often difficult to distinguish them from the
connective-tissue fibres, but it is to be remembered that
they usually run in much more regular parallel bundles than
the latter, these parallel bundles when cut contract up and
g^ve an appearance very like that of geological strata that
have undergone a little upheaval. Although the majority
of the fibres are grey, a few white ones may be occasionally
seen. I have never seen pigmentary degeneration of
nerve-fibres, nor indeed have I seen any changes in them
of which I could speak with much confidence. When it
is remembered that they are irregularly mixed up with the
connective tissue of the ganglion the difficulty of distin-
guishing any sclerosis of the nerve-fibres in the ganglion
will at once be apparent.
With regard to the fibrous stroma of sympathetic gan-
glia one can never give an opinion as to whether the
quantity is abnormal or not, for not only does it vary
very much in different parts of the same ganglion, but
the amount present varies much in different ganglia, a
fact which is not surprising when we remember how they
themselves vary in size. Then, again, the fibrous tissue
may appear to be more than it really is from the section
having been so cut as to include a great deal of connective-
tissue fibre, for that is more abundant at the surfaces
than elsewhere owing to its forming a fibrous sheath for
the ganglion. In some sections which I have examined
the space which generally exists between the nerve-cell
and its capsule has disappeared, and this would seem to
be due to the connective-tissue stroma pressing down the
capsule tightly on the cell. This state of things was
observable in sections taken from cases of cancer of the
bladder, glioma of the brain, myxoedema, and chronic
Bright's disease. Whether or not this is to be regarded
as abnormal and can be looked upon as evidence of in-
230 PATHOLOGICAL HI8T0L00T OF THX SBMILUNAB
oreased interstitial tissue, is, I think, very doubtful, seeing
that it occurs in such widely different diseases in which
there is no reason to suspect any sympathetic change.
It is, however, the only evidence, slight though it
be, of increased connective tissue, that I have found.
Then, again, as we have been unable to decide whether the
specimen shall be considered abnormal when the cells have
undergone pigmentary degeneration, we ought to hesitate
before we say too much about slight pressure on them.
Perhaps of all the specimens I have examined one of the
semilunar ganglion from a case of abdominal aneurism
shows most fibrous tissue, and in this one the nerve-cells
are much atrophied, although the capsule is not pressed
in. This is mentioned because of the possibility that it
may be connected with pressure on nerves by the aneu-
rism. Sometimes the capsule around the cell stains well
and shows numerous nuclei, at other times but little of it
is to be seen.
Next comes the consideration of the vessels. In the
first place let it be borne in mind that vessels are much
more numerous in the superior cervical than in the semi-
lunar ganglion. As might be expected, considering their
varying shape, I have not been able to discover any
constant arrangement of the vessels in the semilunar,
whilst in the superior cervical the normal arrangement is
for a good-sized vessel to enter at the side, as the
central artery of the retina enters the optic nerve, and
then to run vertically down the centre of the ganglion
in its long axis ; this artery gives off several branches
and is accompanied by a vein and a good quantity of
connective tissue in the form of a sheath. If the small
vessels be very evident it may be taken as evidence of con-
gestion. In one diabetic specimen they were so numerous
and seemed so dilated that although there was no blood in
them, one was forced to the conclusion that there was
congestion, and that the blood had dropped out in the
preparation of the specimen. The most extreme conges-
tion I have seen was from other cases of diabetes ; here
AND 8UPIRI0B OIBVIOAL BTMPATHXTIC OANOLIA. 231
the yessels were yerj numerous and all crammed with
blood-corpuscles. Diabetes is the only disease in which
the congestion has been sufficient to be noteworthy. I
haye not been so fortunate in finding hasmorrhage as
Gioyanni^ for I haye neyer seen it in the substance of the
ganglion and only once in its sheath ; this occurred in
sections of the superior ceryical ganglion in a case of
abdominal aneurism^ but not the same one as I haye just
mentioned as haying the increased fibrous tissue in the
semilunar ganglion. In some examples of chronic Bright's
disease the minute arteries haye their walls thickenedj but^
in this disease^ I haye generally found that^ with this
exception, the ganglion is healthy.
We haye now to treat of inflammation of the ganglion.
Only acute inflammation calls for consideration, for we haye
seen how difficult it is to pronounce on chronic hyperplasia
of the fibrous tissue. The characteristic of acute inflam-
mation is the presence of innumerable small cells quite
obscuring the section, so that the component nerye-cells
can with difficulty be distinguished ; this may be accom-
panied by congestion. Very many of these cells are
undoubtedly white blood-corpuscles, for in some sections
they may be seen in the act of passing out of the yessels ;
but it is yery probable that some are dne to a proliferation of
the cells of the connectiye tissue, for there is an undonbted
increase of the elongated nuclei of the connectiye tissue
which forms a sheath for the bundles of nerye-fibres. I haye
recorded elsewhere ^ that I haye found this condition of in-
flammation in diabetes ; I haye also seen it to a slight degree
in one case of each of aortic disease, tumour of the brain, and
in a child who died from the effects of a scald, but excepting
in diabetes it has not been present in an extreme degree
saye in a case of purpura haBmorrhagica. Considering the
lessons we haye learnt as to the great yariations which
may be present, yet the ganglion must not be set aside
as abnormal, I should not be disposed to make much of
the three cases in which the inflammation was slight,
> ' P«th. Trans./ vol. xxxvi.
282 PATHOliOGIOAIi HISTOLOGY OP THK SBMlLUHAfi
perhaps it was connected with some trivial ailment.
Before discussing the case of purpura hsemorrhagica it
would be better to haye more examples, this one shows^
however, undonbted extreme inflammation. Cases of idio-
pathic ansBmia which I have examined do not show any
inflammation. The last condition I have to mention is
that in two cases of sections of the semilunar ganglion from
children I have found little masses of lymphoid tissue in
the ganglion. These masses are not diffuse but each has
a distinct capsule. It would seem as though one of the
very numerous small lymphatic glands near to the semi-
lunar ganglia has got inside instead of outside of it. As a
result of the examination of many sections of semilunar and
superior cervical ganglia I may, I think, say that the only
lesion which can be positively said to be abnormal is the acute
inflammatory condition just described, in which the section
is crowded with small cells : therefore the only diseases
in which I have found the ganglia undoubtedly deviating
from the normal are diabetes and purpura h»morrhagica«
In chronic Bright's disease the vessels in the ganglia are
thickened, otherwise the ganglion is healthy.
This is I feel a poor result for so much work as I have
gone through, but that is one reason why I have brought
this paper before the Society, so that others may be saved
the trouble of going over the same ground that I have.
The fullest descriptions of the pathological histology of
the sympathetic with which I am acquainted are given by
A. De Giovanni, ' Patologia del Simpatico,* and by Foa
in the ' Rivista Olinica di Bologna,' 1874, p. 206.
Polaillon^ in an article which is not of much interest
from a pathological point of view, gives a very good
historical summary of the knowledge of the normal struc-
ture of sympathetic ganglia up to 1866. He says that
the granules so frequently seen in the nerve-cells are
due to post-mortem affection of the proper substance of
the cell. There is, I think, however, no doubt that this is
not so, for if it were it should be present in all the ganglia
^ ' Journal de I'Axuttomie et de la Physiologies' 1866.
AND SUPKBIOB CISTICAL 8TMPATH1TIC GANGLIA. 283
that I haye> for they were all prepared the same way, and
also it should be present in other nerve-cells sach as those
of the spinal cord. Yirchow also thinks that these changes
in the nerve-cells are ante mortem ; he describes them in
fevers and old age.
Dickson suggests that in locomotor ataxy the gastric
cases may be due to the affection of the semilunar ganglia.
This may or may not be so, but the evidence he adduces is
not proof, for he says Dr. Clarke has found in some cases
great pigmentation and that these observations have been
fully confirmed by those of MM. Poincar^ and Henry
Bonnet.^ I have already shown that pigmentation is of
too universal an occurrence to be of any importance in
explaining any rare malady such as the gastric crises of
locomotor ataxy. The French authors just mentioned
found changes in general paralysis o^ the insane. Dr.
Savage' who has had a large experience, has discovered no
changes in the sympathetic which can be constantly
associated with insanity.*
^ < Annales MWoo-Pftyohologiqnei,' 4me i^rie, Tome ISme, 1868.
* ' Insanity, and allied neuroses,' Lond.^ 1884.
* Whilst this paper was passing through the press. Dr. Long Fox pnhUshed
a book on ' The Inflnenoe of the Sympathetic on Disease.'
(For report of the diBOussion on this paper, see ' Plroceedings of
the Eoyal Medical and Ohirorgical Society,' New Series, vol. i,
p. 436.)
DESCRIPTION OP PLATE III.
(On the Pathological Histology of the Semilunar and Superior
Cervical Sympathetic Qanglia, by W. Halb White, M.D.)
Fio. 1. — Section of a semilunar ganglion from a case of anthrax.
Normal, x 250 diameters.
Fig. 2.— Section of a semilunar ganglion from a case of carcinoma
of the breast. Normal. Shows processes well. X 250 diameters.
Fia. 8. — Section of a superior ceryical ganglion from a case of
abdominal aneurism. Shows the extreme atrophy of the cells,
which are reduced to mere masses of pigment in the centre of their
capsules, x 250 diameters.
Fig. 4. — Section of a superior cervical ganglion from a case of
atheroma of the arteries and gangrene of the 1^. Shows extreme
granular pigmentation of cells, x 300 diameters.
Fig. 5. — Section of a semilunar ganglion from a case of purpura
hsemorrhagica, showing the abundance of leucocytes and prolifera-
tion of nuclei. X 800 diameters.
Fig. 6. — Shows the contrast in size between the largest and
smallest semilunar ganglia met with.
Fig. 7.— Shows the contrast in size between the largest and
smallest superior cervical ganglia met with.
Pi'^t-e III
M.'dCh-ir TrHius.YcJ LXVILI
.(•^^^^^
Fi^
r^r X^:
1 .;5
Fi ,\ 4
O
NOTES
OV 8O-0AIiUa>
NON-OVAEIAN DERMOID ABDOMINAL
TUM0UE8.
ALBAN DORAN,
AflSIBTAST BI7BOS0N TO THB 8AHABITAK VBBB HOSPITAL.
Aecdred Norember S9ih, 1884-Bead April SSth, 1886.
Thi object of this contribation is to show tbat many
dermoid cysts of the abdomen that have been described
as non-oyarian^ are really ovarian cysts that have become
separated from their pedicles. This is especially the case
with regard to cysts of the great omentum. Not that it
can be denied that dermoid abdominal cysts may originate
independently of the ovary^ or that cysts of the great
omentum may be non-oyarian^ but growths of the former
class are yery rarCj whilst evidence is wanting that
primary cysts of the great omentum are ever dermoid.
In October, 1884^ a married woman, aged 33, was ad-
mitted into the Samaritan Hospital. She had always
enjoyed good health. Six years before her admission she
noticed something moving about in her abdomen — a lump
lying rather to the left of the umbilicus. Since that date
she had been pregnant, and the lump had shifted to the
right side. The lower part of the abdomen was occupied.
286 NOTBB ON 80-CALLBD NON-OYARtAN
on the right side, by an obscurely flnctuating tumour that
extended towards, bat not deeply into, the right flank ; it
passed only an inch or two beyond the middle line to the
left, and did not stretch the abdominal walls between the
umbilicus and pnbes after the manner of ovarian tumours.
There was tympanitic resonance over the tumour, espe-
cially towards the right side. The pelvic viscera were
quite free from any sign of disease or implication with the
tumour.
On October 27th Dr. Bantock operated upon the patient.
An incision was made along the outer border of the right
rectus abdominis muscle. The surface of the tnmour
was exposed ; it appeared to be smooth, pale, and slightly
shiny. On tapping with a Dieulafoy's aspirator, a pint of
flnid resembling pus was drawn off. The tumour was
then found to be intimately connected with the great
omentum and strongly adherent to the ascending meso-
colon. It was not deemed judicious to lay it open before
removal, lest the contents, which appeared to be purulent,
should escape into the peritoneal cavity. After the
tumour had been cut away, the right ovary was drawn up
out of the pelvis and found to be quite healthy. The
left was not searched for, as there were no direct grounds
for suspicion at the time that the tumour might be
ovarian. On examining the tumour after the operation it
was found to be stuffed with hair, lubricated with seba-
ceous material. There was no trace of either tube or
pedicle. On the inner wall were some plates of bone and a
tooth of very anomalous form, somewhat resembling a
bicuspid, but tapering almost to a point at its edge.
Both the operator and myself more than suspected after
examination of this tumour that it was a cyst of the left
ovary. Complete separation of the pedicle of a dermoid
cyst is not unknown, and in such cases it is generally to
the omentum that the cyst adheres. I have described and
figured elsewhere^ a case under the care of Mr. Thornton
^ * Clinical and Pathological Obeervations on Tamoun of the Ovary, Fal»
lopian Tabe and Broad Ligament' Figs. 87, 28.
DERMOID ABDOMINAL TUMOURS. 287
where an abdominal tamour had existed for seven years^
during which period the patient gaye birth to four chil-
dren. At the operation a dermoid cyst was founds closely
adherent to the omentum. The left oyary was absent, a
short, firm tag of tissue hanging from the omentum dose
to the Fallopian tube. It is very probable that the former
case was of the same kind as the latter, and that many
other instances of alleged non-ovarian dermoid-cysts should
properly be placed under the same category. In the first
of the above cases, had the operation been performed
many years ago, the ovarian nature of the cyst might
never have been suspected, and had the patient recovered,
no record of the state of the pelvic organs would have
been obtainable. It would probably have been described
as a dermoid cyst of the omentum.
A week after the operation in this case, I assisted Dr.
Bantock at an ovariotomy where a curious condition of the
ovary was detected, which may throw light on an unex-
pected manner in which dermoid and other ovarian cysts
become adherent to the omentum. The patient, who had
been under the care of Dr, Amand Bouth, was a woman
aged 42, the mother of several children. On opening the
abdominal cavity, a small, almost unilocular papillomatous
cystic tumour of the right ovary was discovered and re-
moved. On examining the great omentum, which was
thin and healthy, a soft white body was found adherent
to its posterior aspect towards its right free border, almost
at the level of the umbilicus. A pedicle about four inches
in length was traced to the left angle of the uterus and
consisted of a dark red, cylindrical body, which proved to
be the Fallopian tube ; of a long fibrous cord, the utero-
ovarian ligament much hypertrophied ; and of some long
vessels of small calibre, the ovarian artery and veins. The
soft, white body proved to be the left ovary. It con-
tained one dilated follicle, about half an inch in diameter,
and was removed, together with the portion of omentum
to which it adhered.
It is not easy to understand how this ovary reached
288 KOTIS ON 80-CALL1D NON-OVABIAK
its position behind the omentum, which did not descend
unusually low. I know of no previously recorded case
where an ovary, not enlarg'ed, had become displaced in
this manner. The tumour of the opposite ovary could
hardly have dragged it out of the pelvis, for it was not
adherent to that tumour. It is also difficult to believe
that the tumour could have pushed the ovary up as it en-
large ; if a cystic ovary can push up the opposite
unenlarged ovary it is singular that this condition is not
more frequently seen. This latter argument applies with
yet greater force to the theory that pregnancy might have
drawn up the left ovary. We do not find ovaries drawn
up in this manner in women who have borne children.
It is probable that in the case under consideration the
ovarian ligament and tube were congenitally of abnormal
length, and that the ovary had become displaced from
some peculiar habitual position of the patient.
In some previously recorded examples of cysts adherent
to the omentum, it is possible that the ovary had become
adherent before developing cystic disease. The stretched
tube and ovarian ligament would in such a case be very
prone to atrophy, and the tumour would then of necessity
receive its vascular supply from the omentum. I do not,
however, believe that a tumour can increase after torsion of
its pedicle. Freund has rightly questioned the possibility
of adhesions supplying sufficient blood to a non-malignant
tumour, so as to enable it to continue to enlarge when
separated from its original channels of supply.^ In these
adhesions, except when the tumour is malignant, the veins
greatly exceed the arteries in size and number. Occasional
increase in the bulk of the tumour is due to congestion or
intracystic haBmorrhage.
I now come to the main argument suggested by the
above cases, which is, that many cases of dermoid cyst of
the abdomen recorded as non-ovarian were probably
ovarian dermoid cysts that had become adherent to the
^ *' Extra-uterine Gestation/' 'Edinburgh Medical Journal/ September
November, Hud December, 1883.
DERMOID ABDOMINAL TUMOURS. 289
omentam or to other stractareBj and separated from their
pedicles. This oannot always be the case, for dermoid
abdominal tnmonrs have been met with in males, and none
of the foetal relics of the female type persistent in the male
could possibly adhere to the omentum and break off their
pedicles, even if they did become subject to dermoid
cystic disease. Thus in Dr. Ord's case^ the dermoid cyst
found between the bladder and rectum of a man, might
and probably did arise from a foetal relic, but it had no
pedicle and could not have become detached from its
pelvic connections. Turning to Lebert's original article
on dermoid cysts,' where clinical details are more complete
than in his later observations on the subject in the ' Traits
d' Anatomic Pathologique,' I find that there is strong
reason to doubt that all of the cases he describes as non-
ovarian had no connection with the ovary.
The cases of dermoid cysts in the testis, brain, facial
structures and thorax, as well as of similar cysts in the
liver, stomach, diaphragm, &c., in males may be set aside
at present. One case of dermoid cyst in the liver of a
woman might have been an instance of adhesion of a
dermoid ovarian cyst to that organ ; still the hepatic origin
of the cyst is more probable. Several cases of dermoid
cyst of the uterus are described by Lebert. The first was
originally noted by Fabricius Hildanus, but Lebert states
that there was some doubt as to the precise seat of the
tumour, anatomical details being very incompletely
recorded. The same authority mentions cases of dermoid
tumour of the uterus described by Samson, Birch, Tyson,
and Osiander, but they all appear to be based on the evi-
dence of hair and teeth passed during or after labour, and
it is most probable that all, including Hildanus's, were
instances of ovarian growths acquiring connections with
the uterus and upper part of the vagina, with subsequent
communication between their cavities.
* ** An Aoooimt of a large Dermoid Cyst found in the Abdomen of a Man,"
< Med.-Cbir. Trans./ yol. IxUi, 1880.
* "Dee Kystes Dermoidet et de rH^t^rotopie Plastiqae en 0^n6«l,"
< Gazette M^icale de Paris,' 1862.
240 N0TI8 OH BO-CALLBD NOM-OTABIAN
Taming to three cases qaoted by Lebert as examples of
non-OTarian dermoid cysts of the abdomen in women^ where
the tamonr was attached to the peritoneum, the evidence
that they were truly non-ovarian is generally defective. I
pnt aside several other cases where the dermoid cyst was
developed between the atems and rectum, not only because
the origin of the tumour in such cases is obscure, but
chiefly because these cases do not bear directly on the
subject of the present communication. I find that Buysch
has recorded a case of dermoid cyst of the great omentum,
but there is no evidence that the cyst was non-ovarian.
AndnJ describes a case of dermoid cyst growing between
the layers of the mesentery of a negress, but makes no
mention of the state of the ovaries. Peritoneal relations
become so confused, in many cases of abdominal tumour,
as to deceive experienced anatomists. 8chutzer has
described a case of dermoid cyst of the mesentery in a
girl aged 15, but this appeared to be an instance of
included foetation, as parts of a skeleton were found.
8cortinagna notes a case of dermoid cyst of the peritoneum
discharging for five years through an abdominal fistula,
but there is no mention of the ovaries. Besides, before
the possibility of separation of a pedicle was recognised,
the stump of the pedicle might have been taken for an
atrophied ovary. A case of dentigerous cyst of the
omentum in a young girl, described by Laflise and Bucher,
occurred in 1763, and here again the state of the pelvic
viscera is unnoticed.
The last case of this kind in Lebert^s series is remarkable.
A woman over forty years of age had been for several
years under the treatment of Dr. Boux, in the South of
France. A large abdominal tumour extended from the
stomach to the bladder. The patient died suddenly.
Beneath the great curvature of the stomach a large cyst
was found. On each side a '' broad peritoneal fold ''
fixed it to the small intestines. It was separated from the
bladder by a smaller cyst, the size and shape of a pear.
The tumours were dermoid. No mention is made of the
DBRMOID ABDOMINAL TUMOURS. 241
ovarieSj nor of the great omentum ; indeed, it seems
probable tbat the large cyst lay in the omentum. The
necropsy was made '' by a doctor from St. Mazimin/^ and
the account of the examination was written and sent to
Dr. Bouz by a veterinary surgeon who was present on the
occasion.
Such are the cases recorded by Lebert, whom I find
constantly quoted as an authority in contemporary literature
on the subject of dermoid cysts. It is to be remembered
that of late years, since ovarian pathology has been more
extensively studied, and since surgeons have made a rule
of carefully searching the pelvic viscera when performing
abdominal section, we have not heard of non-ovarian abdo-
minal dermoid cysts in women. From the evidence of
cases collected by Lebert, as compared with the specimens^
upon which this paper is based, I am inclined to think, as
I have already declared, firstly, that non-ovarian dermoid
tumours within the abdominal cavity are extremely rare,
but do occur, the chief proof being their occasional
presence in male patients ; and secondly, that the grea,t
majority of dermoid cysts described as non-ovarian are
examples of tumours that were of ovarian origin, but had
become adherent to other structures and then had separated
from their pedicles. Dermoid cysts of the great omentum
are especially doubtful in this respect, and no museum
specimen of such a disease can be safely held up as an
example of a dermoid tumour springing primarily from the
omentum, unless there be very dear evidence that the
pelvic viscera have been carefully searched, and both
ovaries accounted for.
^ Thete spedmens are preserved in the Miueiim of the Bojal College of
SnrgeoDi of Enghmd, Pathological Seriee, Sabseries Diaeaies of the Ovariei.
(For report of the disonsaion on this paper, see ' Proceedings of
the Boyal Medical and Ohimrgical Sodety/ New Series, yol. i,
p. 433.)
VOL. IiXVIII. 16
CASE OF CEREBBAL TUMOUB.
BT
A. HUGHES BENNETT, M.D., P.E.C.P.,
FHTBIOIAV TO THS HOaPITAL 10& BPILWBT AND PA&ALTBI8, AVD
ABSIBTAin PHTSICIAV TO TBI WBBTIOKSTKB HOSPITAL.
THE SUBQIOAL TBEATMENT
BT
RICKMAN J. QODLEE, M.S., P.R.C.S.,
BVBeSOK TO nraYBBBITT COLLBOl HOSPITAL.
Aoeeifed Jtaantj ISth-Bcad May Itth, 1885.
The cliief features of interest in tlie oase^ to whicli the
attention of the Society is directed, are, that during life
the existence of a tumour was diagnosed in the brain, and
its situation localised, entirely by the signs and symptoms
exhibited, without any external manifestations on the
surface of the skull. This growth was removed without
any immediate injurious effects on the intelligence and
general condition of the patient. Although he died four
weeks after the operation, the fatal termination was due,
not to any special effects on the nervous centres, but to a
secondary surgical complication. The case, moreover,
teaches some important physiological, pathological, and
clinical lessons, and suggests practical reflections which
may prove useful to future medicine and surgery.
244 CASE or cerebral tumour.
History. ''^The patient was a farmer^ est. 25, wlio applied
for advice to the Hospital for Epilepsy and Paralysis,
Regent's Park, on November 3rd, 1884. His chief com-
plaint was paralysis of the left hand and arm, which incapa-
citated him from work. He stated that his family history
was nnimportant, that he had always been temperate and in
robast health, and that he never had safEered from syphilis
or a day's illness of any kind in his life. About four years
ago, while in Canada, a piece of timber fell from a hoase,
struck him on the left side of the head and knocked him
down. He thinks he lost consciousness for a few moments,
after which he so far recovered as to be able to resume his
work. On the following day he was quite well. With the
exception of occasional slight headaches he afterwards re-
mained in good health for a year, at the end of which time
he first began to experience a feeling of twitching in the left
side of his mouth and tongue. This soon developed into
attacks of a paroxysmal character, which gradually became
more pronounced and frequent, and continued to occur at
irregular intervals. Some months afterwards he had a " fit ''
which began with a peculiar feeling in the left side of the
face and tongue, and turning of the head to the left side.
The sensation ran down the left side of the neck to the
arm and leg, and culminated in loss of consciousness and
general convulsions. For a few days subsequent to this
the patient suffered from headache, and felt generally
unwell, but ultimately regained his former condition. For
two and a half years, although maintaining his robust
health, he was subject to daily recurrences of the
paroxysmal twitchings of the left side of the face without
loss of consciousness, and also to the more severe general
convulsive seizures with loss of consciousness, which
occurred on an average about once a month. Six months
before admission spasmodic twitchings of the left hand
and arm, without loss of consciousness, were observed and
these have continued daily, alternating with the already
mentioned twitchings of the face, the two, however, rarely
occurring at the same time. Shortly afterwards weakness
CABB OF CKBEBBAL TUMOUR. 245
of the left fingers, hand and forearm was experienced,
which gradually increased to complete paralysis. Since
the apper extremity began to be i^ected, there had been
no recarrence of the general convulsive attacks with loss
of consciousness. The patient was able to continue at
work till August, 1884, when the weakness of the arm
prevented him using his tools. Since then twitching of
a like nature has taken place in the left leg, which usually
supervenes upon, and is accompanied by, similar attacks
in the arm on the same side. Quite recently the left
lower extremity has been weak and the patient has walked
a little lame.
Present condition. — On examination the patient was found
in robust general health. His intelligence was unimpaired.
All his organs and functions were normal except those
about to be described. He suffered from frequent violent
paroxysmal attacks of lancinating pain in the head, not
localised but diffused over the vertex. There was nothing
abnormal to be detected on the scalp or skull, and there was
no special tenderness. On deep and hard pressure there
was an area, not strictly defined, which seemed to be more
sensitive than the neighbourhood. This was situated in
the parietal region, close to the right of the sagittal
suture, on a level with a line drawn vertically from the
anterior portion of the external meatus of the ear. The
movements of the eyeballs and pupils were normal ; vision
was normal, the patient being able to read No. 3 of
Jaeger's types at twelve inches with the left, and No. 5
with the right eye. Examination of the fundi showed all
the usual appearances of optic neuritis on both sides,
most marked on the right, in the retina of which a
number of small heemorrhages were discernible. There
was slight comparative immobility of the left side of the
f^ce, chiefly elicited by attempts at forced movements.
The tongue when protruded pointed slightly to the left.
Articulation was normal. The hearing was asserted by
the patient to be normal, but was less acute in the right
ear. A watch which on the left side was heard at three
246 CASE OV CEBBBSAL TUMOUR.
feet^ was only detected on the right at eight inches. The
common sensibility of the head^ and the other special senses
were normal. There was complete paralysis of the left
fingers^ thumb and hand. The movements of the elbow-
joint were very limited^ and those of the shoulder impaired.
There was no attempt at supination or pronation of the
forearm. There was no trace of rigidity or wasting of the
muscles. The irritability to mechanical stimulus of those
of the forearm was markedly increased^ and the tem-
perature of the skin was lower on the left as compared
with the right side. The left lower extremity was
stated to be weaker than the rights but^ when the
patient lay in bed^ its movements seemed much the same
as those of the other^ but were performed with more
hesitation and less alacrity. When walking there was
slight lameness^ the toes were not completely cleared
from the ground^ so as to necessitate slight swinging of
the leg in progression. The limbs were of equal size
and the muscles of normal appearance. Their mechanical
irritability and the knee-jerk phenomenon were greater
on the left side, though somewhat excessive in both. The
temperature of both legs was equal. The sensibility of the
skin was everywhere normal, and the appearance of both
sides of the body was the same.
Progress of the case. — ^While under observation in the
hospital the condition described continued. The patient
suffered frequently from paroxysmal attacks of lancinating
pains in the head. These lasted sometimes for twelve or
more hours at a time, and they were so violent that the
patient was occasionally delirious and kept the whole ward
disturbed with his cries. There were intervals during
which he was entirely free from pain. He also suffered
from seizures of very severe sickness not specially asso-
ciated with the headaches. During these he vomited all
food, and when the stomach was empty continued to retch
with great violence. This would sometimes last for several
days^ causing great distress, and much reducing the
strength of the patient. During residence in the hospital
CASIB OV CBBSBBAL TUHOUB. 247
the attacks of paroxysmal twitohings of the muscles were
frequently observed. These occurred many times every
day. The most common form was a rhythmical tremor
which began in the first, second^ and third fingers of the
left hand^ which afterwards spread to the thumb and wrist
as &r as the elbow. This continued for perhaps a minute^
and then ceased, generally by the limb being held or
rubbed. Another form began in the left angle of the
mouth and side of the face, and a feeling as if the tongue
was being contracted. These parts also continued to
twitch for a minute or two. These two kinds of attacks
rarely occurred at the same time, but took place inde-
pendently of one another. Sometimes, but not commonly,
the movements began in the face or arm, extended from
the one to the other, and from thence down the side of the
neck and body to the leg, so that the whole left side was
convulsed without any loss of consciousness. The leg
was never observed to be affected by itself.
Diagnosis. — The sequence of events described, with all
the circumstances of the case, led to the diagnosis that
there was an encephalic growth, probably of limited size,
involving the cortex of the brain, and situated at the
middle part of the fissure of Rolando.
Treatment. — The patient was ordered the bromide and
iodide of potassium, twenty grains of each, thrice daily,
which he took for a month. Ice to the head gave no
relief, and the vomiting was unrelieved by any treatment.
The severe pain was ameliorated by hypodermic injections
of morphia.
The terrible sufferings of the patient rendered life
intolerable to him. All remedial measures having failed,
and as it was obvious *that his symptoms were extending,
and that a fatal termination was not far distant, it -v^as
determined that an attempt be made to remove the morbid
lesion. It was hoped that even if such a proceeding was
not permanently successful it might alleviate some of the
more pressing symptoms. The novelty and risks of the
proposed treatment having been fully placed before the
248
CABB OF CSBBBAAL TUMOUR.
patient and his friends^ they readily consented to the
adoption of any measures which offered any prospects of
mitigating the argent distress or of averting a certain
death.
Operation. — In order to expose the cortex of the brain
at the middle third of the fissure of Rolando the following
procedures were adopted. A longitudinal line was drawn
between the frontal and occipital protuberances, down the
middle line of the scalp (Fig. 1, i). A second line was
drawn at right angles to this at the level of the anterior
border of the external meatus of the ear (Fig. 1,£). Parallel
to this a third line was drawn at the level of the posterior
FlQ. 1.
External larfaoe of icalp. 1, 2, 8, 4. Linei to determine position
of ftasnre of Rolando. + Theoretical and actaal position of tamonr.
^ Tender spot on scalp, a, b, o. Position and order of trephine
openings.
border of the mastoid process, which reached the longitu-
dinal line about two inches behind the second (Fig. 1, S),
From the junction of the first and third lines, a fourth was
CA8B OV CEBSBRAL TUMOUR. 249
drawn diagonally downwards^ reaching the second at a point
two inches above the external meatus (Fig. 1, 4). This
diagonal line was believed to represent the direction of the
fissure of Rolando. The spot where theoretically the centre
of the trephine should have been placed was about half an
inch behind the diagonal^ and about one and a half inches
from the longitudinal line (Fig. 1^ + ). As there was a tender
point on the scalp about two inches anterior and to the
inside of this (Fig. 1^ ^), it was determined to make the first
opening in the skull between the two. (The order and
position of the trephine openings are seen in Fig. l,abc.)
On November 25th^ a trephine one inch in diameter
was applied to this region (Fig. 1^ a) and a circle of bone
removed. The centre of the aperture was one and a quarter
inches from the middle line and half an inch behind a line
drawn vertically from the meatus of the ear. The dura
mater was found normal in appearance. In this a crucial
incision was made^ through which the brain substance
bulged^ as was thought^ abnormally. The surface appeared
somewhat more yellow in colour than natural^ but was
otherwise apparently as in health. A second trephine
opening was made^ slightly overlapping the first (Fig. 1^ b),
external and slightly in front of it, and the angles thus left
were rounded off with a chisel and hammer, the brain being
protected by a copper spatula. The incision in the dura
mater was prolonged, exposing an increased sur&ce of brain
but without further revelations. The trephine was applied
a third time so as to join the two former openings poste-
riorly (Fig. 1, c), and when the edges were chipped off a
triangular aperture with rounded angles was left, measur-
ing two, by one and three quarter inches. The inci-
sion in the dura was then prolonged, exposing a surface
of brain nearly the siae of the opening in the skull, which
presented the same appearance as that already described.
Occupying most of this space and crossing it obliquely
from above and behind, forwards and downwards, was a
convolution, down the posterior aspect of which ran a
large blood-vessel. Into the centre of, and parallel with
250 CASl OV CBBBBBAL T0MO0B.
this convolation^ an incision about three quarters of an inch
in length was made with a scalpel. From an eighth to a
quarter of an inch below the surface^ a transparent
lobulated solid tumour was seen^ thinly incapsulated, but
perfectly isolated from the snrrounding brain substance.
After prolonging the incision in the cortex^ the surface and
sides of the growth were easily separated by means of a
narrow spatula of steel so tempered that it coald be bent into
any shape required. The mass was conical in shape the base
being upwards. After its superficial portion was isolated^
the finger was, as far as possible, inserted behind the tumour,
and attempts made to enucleate it. In doing so the upper
half broke across. A large Yolkmann's sharp spoon was
then employed to scrape out the deeper parts of the growth ;
and this was continued till all the morbid material
was removed and apparently healthy brain matter only
remained. This part of the operation was rendered
difficult by the rapid welling of blood into the wound. No
artery of any size spouted but there was a general oozing,
which accumulated rapidly as soon as the sponge was
removed. The cavity thus left was about one and a half
inches in depth and of a size into which a pigeon's egg
would fit. The haemorrhage was arrested by applying over
the cut surface a suitable electrode from an electro-cautery.
The dura mater was then drawn together at its anterior
part by a few carbolised silk sutures, and a drainage-tube
of moderate calibre, made of india rubber, was inserted into
the wound beneath the dura at its posterior border. The skin
was brought accurately together, except where the tube lay,
by silver wire and silk sutures. During the entire opera-
tion the carbolic spray was used, and both before and
after, all the ordinary antiseptic precautions were taken.^
^ The antiseptic precantions were as follows : — ^The patient's head haying
been previously shaved, except the very lowest part of the scalp quite below
the ocdpnti the whole was thoroughly soaked with carbolic acid lotion
(1 — 20), but particular attention was not directed to the sores left from some
blisters at the upper part of the neck, which were not noticed till afberwards.
After the patient was placed on the table the parts were again washed with
1—20 lotion, and the upper portion of the body was surrounded by carbolised
CASS OP CSBEBBAL TUMOUR. 251
The wound was dressed with carbolic acid gaoze^ completely
covering the scalp, and firmly fixed in position with
bandages. Daring the entire operation, which lasted two
hoars, the patient took chloroform without a bad symptom,
and no nervous phenomena were developed. Sabsequent
examination proved the tamour to be a glioma about the
size of a walnut, presenting the usual microscopical appear-
ances of that disease (Fig. 2).
Fie. 2.
Stmctare of glioma, from section by Dr. Hebb, about 400 diam.
Progress of the ease after operation. — Half an hour after
the operation the patient was in the usual drowsy condi-
tion which follows the administration of chloroform. He
answered questions rationally and comprehended what was
said to him. There was no increase of paralysis of the face
or tongue, and articulation was as before. There was no
trace of movement in any part of the left upper extremity,
but the left leg could be moved at will, but to what extent
it was not judged advisable to determine. Six hours after-
towels, one being also placed beneath the head. Instroments and hands
were soaked in the same lotion and the spray was nsed throughout the
operation.
252 CASE OF CBBEBRAL TUMOUR.
wards the patient was quiet and comfortable. He had taken
small quantities of milk and soda water^ and had not been
sick. Pulse 80, full and regular ; temp. 98°. There was no
pain in the head and only slight soreness of the wound was
complained of. There was slight paresis of the left side
of the face and occasional twitchings of both angles of the
month, the cheeks, and the alae of the nose. There had
been no movements elsewhere.
November 26th (the day after the operation). — Pulse 56,
of good strength and regular, morning temp. 98*4°.
The patient had recovered from the effects of the ansBS-
thetic, and was now quite sensible and intelligent. There
had been occasional vomiting, shooting pains in the head,
and twitchings on the left side of the &ce. During the
night a fair amount of nourishment had been taken. The
wound was dressed. A small amount of serum had
soaked down to the edge of the dressing behind. The
edges of the incision were in perfect apposition, and the
scalp was quite flat.
27th. — The patient had passed a good night, and slept
well. Had no return of vomiting ; had occasional twitch-
ing of the left arm and side of the face, as well as occa-
sional shooting pains in the head. The morning pulse 54,
temp. 97*6°. Passed water, and the bowels acted freely
after an enema. Took plenty of fluid nourishment.
The patient was quiet, and at time of visit without pain.
He was somewhat drowsy and apathetic, but perfectly
intelligent, and answered questions with promptitude and
accuracy. Articulation was normal. The movements of
the eyeballs were natural. The pupils were somewhat
dilated, equal, and contracted to light. There was
distinct but slight paresis of the left side of the face.
The tongue, when protruded, inclined somewhat to the left.
The left upper extremity was throughout immovable.
The left leg could be raised and pulled up when desired,
but for fear of disturbing the patient, the amount of this
was not fully tested. The left knee-jerk was markedly
increased. The sensibility of the skin was everywhere
CA81 OF CBBBBRAL TUMOUB. 253
normal. There liad been nowhere any twitchings for the
last twenty-four hours. During the day there were occa-
sional shooting pains in the head. The wound was left
untouched as there was no appearance of discharge.
28tli. — During last night the patient slept fairly well,
bat was occasionally disturbed by sharp pains in the head.
Morning pulse 60, temp. 98*6^. The patient was brigbt
and cheerful. He has had no twitchings of the face or
limbs, but had suffered from occasional pains in the head.
The paresis of the face was very slight, the articulation
natural, and the condition of the limbs as before. He
had taken plenty of nourishment. When the wound was
dressed the discharge was found to consist of a small
amount of thickish pink serum, with an obvious though
faint smell. There was a distinct bulging of the scalp at
the seat of operation, where it was slightly tender.
29th. — The patient had passed a good night. Morning
temp. 98*6°, pulse 76. During the day there was no
return of the pains in the head, or twitchings of the limbs.
The general condition was as before. The patient was in
good spirits, intelligent, and took food well. The left leg
could be moved at will. During the evening there
was some swelling of the eyelids and face, accom-
panied with smarting pain. On changing the dressings
the lips of the wound was found swollen, and the discharge
had a decidedly putrefactive smell. The lower lateral
incision was opened up, and the drainage-tube removed
and washed. From the openings some thick brown pus
was squeezed. The scalp in the neighbourhood of the
wound was somewhat cedematous. Dressings were re-
applied as before.
30th. — ^The general condition was as before, except
that to-day there were no movements of the left lower
extremity. Morning temp. 99*4^, pulse 88. The swelling
of the face and scalp was very considerable. In the
morning the drainage-tube and several stitches were
removed, and a dressing of wet boracic lint substituted for
the gauze. The wound was freely syringed with carbolic
254 0A8X or CBBBBBAL TUMOUB.
lotion (1 — ^20) in which iodoform was suspended. The
dressings were changed twice dnring the daj^ and on the
last occasion all the stitches were removed. By this time
there was hardly any trace of putrefactive smell. A hernia
cerebri as large as half an orange^ consisting of granular
looking matter mixed with blood-clot^ had protruded
through the lips of the wound. Towards evening the
swelling of the face and scalp had considerably diminished.
At midnight the patient felt quite comfortable.
December 1st. — ^To-day an extended examination was
made. Morning temp. 98*4^^ pulse 88. The patient
felt well in every respect. He was cheerful^ perfectly
intelligent^ conversed freely^ and took an interest in the
details of his case. For some time there had been no
trace of twitchings of the limbs or pains in the head.
The swelling of the face and scalp had almost disappeared.
The pupils were equal and normal. Vision was normal.
The movement of the eyeballs was natural. The skin
was cool and moist. The mouth and face were drawn
slightly to the right on forced movement, and the tongue
was protruded slightly to the left ; articulation and hearing
were as before. There was no movement whatever of any
part of the left upper or lower extremities. The sensi-
bility of the skin of the left limbs was considerably
diminished to touch, but not lost. The left knee-jerk
was still considerably exaggerated as compared to the
right. The plantar reflex was the same on both sides.
The general condition of the patient was excellent, and
his appetite good. The urine was loaded with urates, but
otherwise normal. The wound was dressed morning and
evening. The hernia, which had somewhat increased in
size, was freely treated with carbolic acid, iodoform, and
a solution of chloride of zinc (gr. xl — 5j)* The discharge
had almost lost its offensive smell.
2nd. — The general condition as before. Now there was
no trace of oedema of the face or scalp. Morning temp.
98'6^, pulse 88. The hernia cerebri appeared to be some-
what larger.
0A8E 07 OBBSBBAL TUMOUB. 255
3rd. — The general condition as before. Morning
temp. 97'6^, pulse 64. The greater portion of the
hernia^ which had now reached the size of half a cricket-
ball^ was clipped awaj with scissors. The parts removed
consisted chiefly of granular matter and blood-clot^ and
apparently contained little true cerebral matter. They had
a faint offensive smell. This removal was continued till
a surface was reached where the tissues bled freely^ which
was only very slightly above the level of the scalp. This
was freely treated with a strong solution of chloride of
zinc and iodoform. The stump was dressed with boracic
lint soaked in carbolic lotion, which was tucked under the
edges of the flaps. The whole as at former dressings
was enveloped in a mass of salicylic wool and firmly
bandaged. Immediately after the dressing the temperature
was 100^ In the evening when the wound was dressed
again the discharge was found copious and watery.
4th. — The general condition as before. Morning
temp: 98*4^, pulse 88. A cap of block tin was fitted over
the hernia which bled slightly from small points all over
its surface. The discharge was diminished and now quite
odourless.
13th. — ^During the last ten days the general condition
of the patient had continued to improve. On ezaimina-
tion to-day he felt well in every respect. There had
been no pain in the head or twitchings in the &ce or
limbs. The appetite was excellent and all the organic
functions were normally performed. The disposition was
cheerful and the intelligence perfect. The patient con-
versed all day with the nurse, who could detect no signs
of mental failure. There was still slight paresis of the
left side of the &oe and tongue. The movements of the
eyeballs were normal. The pupils were equal, and con-
tracted normally to light and accommodation. Vision was
apparently normal, and No. 7 of Jaeger's types could be
read with the right and No. 4 with the left eye at twelve
inches in rather a bad light. The optic neuritis still
existed in both eyes, but was distinctly improved, the
256 cyisB or cbribral tumour.
hsdmorrliages in the right having almost completely dis-
appeared^ and the swelling of the left disc being almost
gone. The sensibility of the &ce was normal and all the
special senses were as before the operation. The entire left
upper extremity still remained completely paralysedj the
muscles being limp and flaccid and without trace of
rigidity. The left lower limb was also without voluntary
movement. The sensibility of the skin of the entire left
side, below the neck, was diminished to touch, but not
altogether lost. The temperatnre of both sides was nearly
the same. The mechanical irritability of the muscles and
the tendon-reflexes on the left side were increased as
compared to those on the right, and on the left there was
well-marked ankle clonus. There was nowhere any
rigidity or wasting of the muscles.
During the last ten days there was no essential change
in the wound, except from day to day a gradual in-
crease in size of the hernia. This now projected about
an inch above the scalp. Its surface was smooth and
clean, and the discharge was copious, colourless, and
odourless. The margins of the mass were clipped away
so that no mechanical obstruction might be offered to the
contraction of the flaps, which process seemed to be in
progress. In doing so a vascular part was soon reached,
and a clear fluid in considerable quantity exuded. The
deep surface of the flaps was covered with healthy granu-
lations.
16th.— The patient continued well till last night,
when he was restless, and felt his left arm and leg very
cold. About six this morning he was seized with a
rigor which lasted five minutes. Soon afterwards he
suffered from shooting pains in the head and was very
sick. Five hours after, the temperature was 100-2^, the
pulse 100. The patient complained of severe pain in the
frontal region. He was dull, apathetic, and nauseated.
There were twitchings in the right arm and leg, and occa-
sionally slight ones on both sides of the face. Until
to-day there had been little change in the wound, except
CASK OF GBBSBBAL TUHOUB. 257
thAt the flapB were gradnallj drawing together and
tending to out off the superficial part of the hernia. This
morning it was fonnd that the hernial mass had greatly
increased in size. It was now ragged and of a dark
colour. Attempts to remoye portions of it were prevented
by the profuse haemorrhage. There was no putrefactive
smell. . In the evening it was found that the patient
during the day had suffered much from pain in the head
and vomiting. A hypodermic injection of morphia had
beeja given in the afternoon^ wMch had produced sleep
for several hours. The temp, was 102'2^^ the pulse 100.
Later the temp, was 104*6°, the pulse 140.
17th. — Morning temp. 102*6°, pulse 140. Passed a
very restless night, suffering much pain 'in the. head,
and in the right arm and leg. Was found pale and
dull and very feverish. The patient understood what
was said to him, but was slow to answer, and his replies
were not easily understood. Another injection of morphia
was given witJiout inducing sleep or relieving pain. The
hernia was found to have greatly increased in size, and
was again about the siise o£ half a cricket ball.
18th. — ^The patient passed a fairly quiet night. Morn-
ing temp. 101*2°, pulse 140» Has had little or no pain
in the head, was quite intelligent and answered ques-
tions sensibly. There were no twitchings or increase of
paralysis. He was feverish and very thirsty, but con-
tinued to take a good amount of fluid nourishment. The
hernia was breaking down by a sloughing process, and a
considerable quantity of semi-fluid detritus flowed from
the cavities forming in the mass. This had again a slight
putre&ctive smell.
19th. — The general condition was the same as yester-
day. The hernia was clipped off almost to a level
with the bone, and a flat plate was placed and secured
over the stump. In the evening the patient was very
feverish and very talkative. He volubly related inci-
dents in his past life, and carried on conversations
quite sensibly with imaginary persons. He was very
VOL. LXVIII. 17
258 CA8B or CBRXBRAL TUMOUR.
restless and had no sleep. He was intelligent and
answered questions correctly. Articulation was somewhat
thick and indistinct. There was no apparent increase of
paralysis^ and the right limbs moved freely as before.
He still continued to take plenty of nourishment. Evening
temp. 108-6°, pulse 150.
20th. — Has had no sleep for twenty-four hours. Was
still very restless and feverish, but had no pain. Was
evidently weaker, but there were no new symptoms.
Temp. 104"', pulse 150. When the eyelids were opened
both eyes were seen deviating to the left, but coidd be
voluntarily fixed in a straight line. No change in the
wound.
21st. — The patient was evidently sinking. He was
emaciated and a bedsore had developed on the right
gluteal region. Still feverish, restless, and sleepless.
He continued to talk volubly with a thick indistinct
utterance. Temp. 104*4°, pulse 144, very weak. Was
perfectly sensible. Bowels relaxed and motions passed
involuntarily in bed. There was a general tremor of all
the limbs, and the right side occasionally twitched.
22nd. — Had gradually become weaker. The breath
had a sweatish smell and the skin a yellowish waxy
appearance. The articulation was so indistinct as to be
unintelligible. Had no pain, no sleep, was very feverish,
and now refused food. Was still perfectly sensible.
23rd. — Since last report gradually sank, and died at 8
a.m. this morning. No new symptoms occurred and the
patient was sensible to the end. The condition of the
wound continued as last described.
The posUmortem examination (December 24th, thirty
hours after death). — The body throughout was thin but
not greatly emaciated. There was no special muscular
wasting, the rigor mortis was well marked, and the skin was
everywhere of a pale yellow colour and of waxy appearance.
On the most prominent part of the left gluteal region was
a circular patch three inches in diameter, of black dis-
colouration. On cutting across and into this, it was
f
CASH 07 CEBSBBAL TUUOUB. 259
found to extend an inch in depth into the tissnes^ indad-
ing a portion of muscle. On the right parietal region
was an open wound of the scalp. This was of an irregular
quadrilateral shape and measured three by two and a half
inches. It reached to within half an inch of the middle
line of the skull and its direction in its longest axis lay
between this and the posterior margin of the ear. The
edges were somewhat raised^ everted^ covered with healthy
granulations, and for a quarter of an inch free, beyond
which the skin was adherent to the bone. Elsewhere the
scalp was healthy, and there were no signs of pus or putre-
factive smell. The space between the edges of the wound
was filled up by the base of the hernia which had been shaved
off. This spread over the surfB.ce of the bone to which
it was adherent, and had to be cut away with the knife.
The removal of this exposed the aperture in the skull
made by the trephine. This was of triangular shape with
blunt rounded angles and measured two, by one and three
quarter inches. Its longer axis lay almost exactly between
the parietal protuberance and the central line of the skull,
reaching to within about half an inch of both. The edge
of the bone was perfectly healthy and presented the appear*
ance of a clean cut. The skull cap was removed in the
usual manner and the brain and cord were taken out,
when it was seen that the inner aspect of the arachnoid
at the base of the cranium was lined by a layer of pale
yellow, coagulated, recent lymph. This was most abundant
in the right middle fossa and over the base of the
sphenoid bone. It also extended for a short way down
the spinal canal. The dura mater of the base was some-
what thickened but otherwise normal.
The brain. — On inspecting the base of the brain a thin
layer of lymph was found spread over the surface of
the arachnoid. This was most abundant over the base
of the right temporo-sphenoidal lobe, over the pons and
medulla, and down the upper part of the spinal cord for
about an inch. It reached forwards, but less in amount,
to the bases of the frontal lobes, sideways to the inner
260 GABi: or gbrbbbal tuhoub,
edge of the left temporo-aphenoidal lobe, and backwards
as far as the anterior border of the cerebellam. The
outer edges of the cerebellam, most of the left temporo-
sphenoidal lobe, and the onder sarf ace of the frontal lobes
were entirely free from the effusion. This deposit of
lymph extended from the base of the brain over the right
temporo-sphenoidal lobe, and could then be followed by
a tract about an inch wide to the under surface of the
wound, from which it evidently emanated. The mem-
branes covering the under surface of the right temporo-
sphenoidal lobe were markedly congested and their vessels
dilated. There was also slight injection of those at the
under surface of the cerebellum. Elsewhere the mem-
branes of the base were healthy. The convolutions of the
base of the brain were everywhere normal in appearance,
except that those of the right temporo-sphenoidal lobe
were somewhat more flat and the sulci less deep than those
of the opposite side. The consistency of the cortex was
here everywhere intact, except a patch of slight softening
about the size of a sixpenny piece at the most anterior
extremity of the temporo-sphenoidal lobe. The external
surface of the dura mater covering the hemispheres was
on both sides normal in appearance, except over the right
parietal region, where the wound had been made, through
which protruded the base of the hernia cerebri. This corre-
sponded almost exactly in size, shape, and position with the
aperture in the skull and measured two and a half by two
inches. The free edge of the dura was adherent all
round to the cut surface of the bone. On reflecting this
from the brain it was found normal in every respect on
the left side. On the right it was somewhat thickened
throughout, and very considerably so immediately round
the wound, especially behind and below. Here also in
several places there were recent adhesions of the two
layers of the arachnoid which were readily torn across
without force. Traces of lymph were found scattered
over the whole hemisphere, but chiefly over the occipital
and temporo-sphenoidal lobes. It was most abundant in
CASE OF CEREBRAL TUMOUR. 261
a narrow tract stretcbing from the lower border of the
wound^ proceeding downwards to the base of the brain as
already described. Above and in front of the wound
there was no appearance of inflammatory exudation.
Throughont the left side there was slight snbarachnoid
effusion. The anterior lobes were pale and normal in
colour. Behind a vertical line drawn through the bases
of the frontal convolutions the membranes at the upper
pari of the cerebrum were of a pinker colour^ and their
vessels more injected with bloody than in front and
below ; otherwise their appearance was normal. The
convolutions on this side appeared to be slightly flattened
and the sulci somewhat shallow^ otherwise they were
normal. On the right side the membranes above and in
front of the wound were precisely the same as on the left.
Behind and beloWj and especially over the superior part of
the temporo-sphenoidal convolutions, they were intensely
congested. The convolutions of the frontal and parietal
regions on this side, both in appearance and consistency,
were in all respects the same as those on the other, and
they were equally voluminous on both sides, but the parietal
area had a shrunken appearance as if it had &llen inwards.
In the centre of this, and occupying the position of the
fissure of Bolando, was the wound in the brain. It
corresponded in position to the hole in the skull, but was
a trifle larger, measuring two and a half by two inches, the
longest axis being directed somewhat obliquely from above
downwards.
The destruction of the cerebral cortex is illustrated in
the accompanying diagrams (Figs. 3 and 4), and will be
seen to involve, first, the entire length and thickness of
the ascending parietal convolution with the exception of a
small portion of its superior and inferior extremities, both
of which remained intact ] secondly, almost the entire
upper ibhird of the ascending frontal convolution, and the
posterior portion of its upper half ; and thirdly, the anterior
third of the gyrus supramarginalis. This deficiency in
the grey matter was occupied by the rough material
262
CABE or CBBEBRAL TUXOUB.
constituting tbe stamp of tbe hernia cerebri which projected
about half an inch beyond the surface of the brain.
Surrounding and closely adjacent to this on its anterior,
saperior, and posterior aspects, the cerebral cortex was
normal in appearance and firm in consistency. Th.e
margin of the aperture in the grey matter was sharply
cut, slightly folded inwards, and its inner edges were
adherent to the hernia. At the inferior border of the wound
the convolutions, although normal in appearance, were
Fig. 8.
Diagram showing poiition and extent of cerebral cortex destroyed
as seen from without. The white space occupied by stamp of hernia
cerebri.
slightly softened to the touch, and this softening extended
so as to include the superior temporo-sphenoidal convolu-
tion, below which the cortex was of firm and normal con-
sistence. On the inner aspect of the right hemisphere
there was a circular depression, about the size of a six-
penny piece, without softening, and which appeared
as if the part had fallen inwards. This involved fche
terminal portion of the fissure of Bolando, and a part
of the sulcus caloso-marginalis, a small portion of the
CkBW^OV CIBBBRAL TITlCOnB. 263
gyruB fomicatuB^ the posterior part of the marginal
convolution, and the anterior border of the quadrilateral
lobule. A transverse section was made across the brain
through the ascending parietal convolution in the direction
of the fissure of Eolando. The deficiency in the cortex is
seen in Fig. 4 to consist of complete absence of that part
which corresponds to the middle parietal fasciculus with the
inferior portion of the superior, and the superior portion
Fig. 4.
Diagram of tnngvene section through ascending parietal conro-
Intion showing destmction of cerehral cortex and corona radiata.
The white space occupied hy granular matter of hernia cerehrL
of the inferior parietal fasciculi. The spaces thus left
had partially collapsed, and were filled with new formation
from which the hernia cerebri sprang. This morbid
condition had in an irregular and unequal manner spread
inwards, reaching as far as the upper margins of the
corpus callosum and internal capsule. The brain having
undergone the process of hardening it was not easy to
exactly limit the softening, which seemed to be confined
entirely to the centrum ovale. The lower portion of the
264 GAtS OP GSmSfiAL TiriCOUB.
inferior^ and the inner portion of the superior parietal fasci-
culi were uninjared. So also were the insnlar lobe^ the
internal and external oapsolea^ the corpus calloaum, the
optio thalamus^ and the lenticular and caudate nuclei.
Whether the lateral ventricle had been opened into it is
difficult to saj. There was no collection of foreign matter
in its interior ; at the same time the morbid process had
extended in close proximity to it.
A histological examination of the different tissues was
made by Dr. Hebb^ who reported their condition to be as
follows :
" The appearance of a section of the glioma has
already been referred to (Fig. 2). The hernia cerebri
and subjacent tissues consisted of blood-dot^ granular
matter^ and disorganised nervous tissue. The cortex in
the neighbourhood of the wound presented the appearance
of inflammatory change in its pia mater and superficial
layer^ but was otherwise normcJ. Elsewhere the structure
of the brain was healthy, and nowhere was there any
evidence of gliomatous disease. The retinad and optic
nerves presented all the usual appearances of nenro-
retinitis in a well marked but not advanced stage. The
membranes of the cord had undergone marked change.
The inter-meningeal space at the upper cervical region
was filled with pus. In the cervical and dorsal regions
the membrane was considerably thickened, which condition
gradually diminished from above downwards. In the grey
matter of the cord there was evidence of nuclear activity,
apparently of quite recent origin, otherwise it was healthy.
There was no trace of descending sclerosis."
Oommentary. — In commenting on the preceding series
of facts it will be convenient to discuss the points of
interest under the following heads : (1) Diagnosis, (2) the
surgical treatment, (3) the clinical phenomena tifter the
Operation, (4) revelations of the autopsy, physiologically
and pathologically considered.
1 . Diagnosis. — All the circumstances of this case pointed
to an encephalic growth on the right side. This was
OAdB Of OBBUBRAL TUXODB. 265
more especially evidenced bj the slow and insidious in-
vasion of the symptoms^ the gradual progress and special
distribution of the paralysis^ the violent intracranial pain,
the uncontrollable attacks of vomiting, and the double
optic neuritis. Whether a tumour on the right side of
the brain was caused by the blow on the left side of the
head a year previous to the development of the first signs
of ill-health, must remain uncertain.
It was also concluded that the morbid lesion involved the
cortical substance, because certain motor phenomena were
developed, and certain motor districts implicated after a
definite method and in definite order ; the paralysis was
unaccompanied by any alterations in sensibility ; and above
all, because of the existence of certain paroi^smal seizures
of local convulsion, without loss of consciousness, which
were eminently suggestive of irritation of cerebral grey
matter.
The special seat of the lesion was further believed to
be the middle part of the right fissure of Rolando. This
conclusion was arrived at by the consideration of the com-
bined revelations of physiological es^periment and clinical
observation. After centuries of doubt and confusion on
the subject of cerebral localisation, quite recent investi-
gations have at last rendered it certain that around this
sulcus are grouped those nervous areas which preside over
I^B movements of the other side of the body. Adopting
the topography of the brain constructed by Professor
Ferrier as the result of his well-known researches, it may
be said in general terms, that the motor centres which
govern the voluntary movements of the lips and tongue
are situated in the lower portions of the ascending parietal
and frontal convolutions. Higher up in the same gyri are
the areas for the muscles of the face. Occupying the middle
portion and nearly the whole extent of the ascending
parietal convolution are the centres of the fingers and
hand. In the middle of the ascending frontal convolution
are those elements which originate movements of the arm
and upper arm, including flexion, pronation, and supina-
266 CASS or ckbxbral TcrKOUB.
tion of tbe forearm. At the superior and posterior aspect
of the ascending parietal convolation is the centre for the
lower extremity^ and at the upper and anterior portion of
the ascending frontal convolation are centres for complex
movements of both the upper and lower limbs. Now^ in
the case before us there was complete paralysis of the
fingers and hand^ with inability to pronate and snpinate
the forearm, there was partial paresis of the movements
of the elbow, and weakness of those of the shoulder-joint.
There was also slight paresis of the leg and one side of
the face. Accompanying all these there were paroxysmal
convulsions in all these regions, occurring either singly or
in definite order one after the other. These phenomena
were to be accounted for by an extensive but not abso-
lutely complete destruction of the motor centres of the
fingers, hand, and forearm, with slight encroachment on,
and irritation of, those of the face, upper arm, and leg. A
very definite localisation of the disease was thus permitted,
and the tumour was pronounced to have occupied the
whole thickness of the middle two fourths of the ascending
parietal convolution, and a portion of the adjoining upper
half of the ascending frontal convolution. The morbid
lesion, whilst almost completely destroying these areas, in
addition modified the functions and caused irritation of
those in their neighbourhood, without seriously involving
their structure, namely, the superior and inferior ex-
tremities of the ascending parietal and frontal convolutions,
and the postero-parietal lobule.
Having thus accurately localised the position of the
tumour its size could as a consequence be approximated.
Assuming the disease to be limited to the cortex at the point
already indicated, the fact that the centres of the leg above,
of the face and tongue below, of the sense of sight behind,
and of the movements of the eyeballs in front, were not
seriously involved, proved that the growth was of limited
size. A glance at the relative position and size of the con-
volutions of the human cerebrum indicate that a foreign
body occupying such a position could not, roughly speaking.
0A8X OF CEREBRAL TUVOVE. 267
exceed some two inches in diameter. It was probable that
the growth took its origin in the lower third of the ascend-
ing parietal convolntion^ and as it increased in size spread
upwards «nd backwards, further involving its substance
and part of the ascending frontal convolution, finally
reaching the lower edge of the postero-parietal lobule.
Such disease might therefore be represented by an ovoid
mass the size and shape of a pigeon's egg, lying obliquely
in the fissure of Rolando. This theoretical reasoning
arrived at before the operation, subsequently proved to
have been substantially correct.
The question finally arose whether the tumour was
confined to the cortex or whether it was situated in the
centrum ovale below, and from thence invaded the grey
matter. It was not forgotten that a slowly-growing mass,
reaching considerable dimensions, might develop in the
conducting elements of the brain, without causing sym-
ptoms capable of exact definition. It was also fully
recognised that a small tumour immediately under the
cortex and involving its under sur&ce might cause pre-
cisely the same symptoms as one limited to the grey
matter. From an operative point of view the existence
of even a large growth, which in this case was improbable,
would not necessarily interfere with the procedure, because
in that case little harm could be done to the life of the
patient, and his urgent symptoms, on the other hand,
might be relieved by the simple process of trephining.
If the tumour was small the grey matter could be incised
and the mass removed. As a matter of fact this last is
what actually was done in the case under consideration,
the growth being found in the centrum ovale, under the
cortex, involving the convolutions before determined.
As to the probable nature of the tumour, the age of
the patient, the absence of syphilis, and the slow growth
of the disease suggested glioma, but on this point no
definite conclusions were hazarded.
2. The surgical treatment, — For the purpose of
removing the tumour from the brain, three trephine holes
\
268 CA8B OF CEBBBRA.L TTJUOUB.
were made in the sknll^ becaase after tlie first piece of
bone was taken away and no superficial disease discovered^
it was tbougbt advisable to enlarge the openings to further
expose tbe brain and to make room for completing^
tbe operation. The aperture made by the three
removals^ even when the angles were chipped oS, only
measured 2x1} inches. The tumour was found exactly
in the centre of the openings and in the position corre-
sponding with theoretical calculation and measurement.
It had no relation whatever to the tender spot on the skuU^
and, had attention been confined exclusively to that^ the
result would have been entirely misleading. The process
of trephining involved no difficulties, but it exemplified the
advantages of the chisel and hammer over Hay's saw for
rounding off comers of bone. In similar operations it
might be advisable in the future to employ a larger
trephine. One convolution only being exposed during
the operation, there was at the time some question as to
whether it was the ascending frontal or parietal. This
doubt arose from the circumstance that in the attempt to
approach the tender spot^ the theoretical position had
been slightly departed from, and the trephine advanced
and raised, so as to come between the two. Accordingly
for the moment this convolution was thought to be the
ascending frontal, the aperture in the bone being so small
that its relations could not be seen. After death, however,
it was apparent that the convolution which had been incised
was that in which from the first the disease had been
diagnosed to exist, namely, the ascending parietal. There
was no external appearance of disease about this part of
the bbrtex except that it seemed swollen, less glossy, and
less vascular than natural. An incision into this showed
the morbid growth to be immediately under the surface,
and almost completely involving the entire thickness of
the cortex. On clearing the superficial parts of the
growth, a small spatula, neither sharp nor blunt, and so
tempered that it would keep any shape given it, was found
a most serviceable instrument. Such is preferable to the
CAfiE or ClfiEBBAL TUMOUB. 269
use of the cautery^ as the latter so chars the parts as to
modify their natural appearance^ and thus prevent a
differentiation between healthy and diseased tissues. It
may be questioned whether it was advisable to arrest the
hadmorrhage from the interior of the wound by means of
the g^vano-cautery. Such a proceeding leads of
necessity to the formation of a considerable amount of
detritus which may afterwards prove detrimental. The
bleeding moreover was not severe and would no doubt
have become arrested by natural means. The advisability
of introducing a drainage-tube may also be questioned.
It was not judged safe to completely close so large a
wound^ distended as it must have been with accumulated
serum and blood. Moreover^ had putrefaction not occurred
it is not likely that the soft india-rubber tube would have
caused any serious irritation. The argument in favour of
complete closure of the wound^ so strongly advocated by
those whose experience is confined to operations on the
brains of monkeys^ is^ it is maintained^ not convincing
when applied to a large injury in the human subject^ the
more rapid healing of the tissues of the lower animals
being a matter of common knowledge. Another point
of doubt is the propriety of introducing sutures into
the dura mater. The most important matter for discus-
sion^ however^ is the occurrence of putrefaction^ which
undoubtedly appeared in the wound some days after the
operation. This^ it may be maintained^ was the cause of
the inflammation and consequent hernia cerebri. All
the usual antiseptic precautions were taken during the
operation^ and the only flaws in its strict application
which suggest themselves are^ firstj that the scalp was not
sufficiently purified prior to the operation, and second, that
no special measures were taken to carbolise the galvano-
cautery apparatus. In future operations of this nature it
is strongly urged that surgeons should not only employ
carbolic acid, but also a solution of corrosive sublimate as
antisepticSj and that the scalp should not only be rubbed
with these, but soaked with them for some hours previously.
270 CASK or CBRSBSAL TUMOUB.
There may have been other sources of septic contagion in
the washing of the sponges^ or from the blisters on the neck
which escaped observation. It may be doubted whether the
putrefaction was ever completely subdued ; the fact of the
meningitis occurring at last^and that of a smell having again
become apparent after the attempt at removal of the second
protrusion^ point probably to a continued septic infection.
As to the hernia two observations only have to be made.
Firstj it was remarkable that the discharge continued for
such a long time to be so copious and so watery^ which
suggested the idea of its being cerebro-spinal fluid.
Secondly^ there was a difficulty in shaving it off owing to
the enormous size of its base^ and to the danger of serious
haemorrhage.
3. Clinical phenomena following the operation. — The
patient^ on recovery from the effects of chloroform after
the operation, was found perfectly intelligent, the former
pain in the head, and violent twitchings in the limbs, had
disappeared and never returned, there was no increase of
the paralysis of the face or leg, and all the organic func-
tions remained normal. The only change which had
taken place was completion of the paresis of the upper
extremity, which was now paralysed throughout. This was
evidently due to the unavoidable destruction of the
remaining arm centres in the removal of the tumour.
Otherwise the neighbouring brain matter had not been
injured, as was evidenced by all other functions remaining
intact. The surgical operation itself in no way injured
the nervous centres with the exceptions mentioned, while
it immediately relieved all the distressing symptoms.
This satisfactory condition remained unchanged for four
days, when the discharge from the wound was found to
have a putrid smell. Coincident with this began the
hernia cerebri, and following its development, arose fresh
symptoms in the shape of paresis of the left leg and
partial ansBsthesia of one half of the body. These were
probably due to the effects of simple pressure, and possibly
to the subsequent secondary softening of the conducting
CA8B OF CEREBRAL TUMOUR. 271
fibres cansed bj it. That the inflammatory oondition which
led to this was parely local was shown by the fact that^
with the above exception^ the condition of the patient
remained in all respects as before the operation. The
temperature never reached 100° or the pulse 100 beats
per minnte. The intelligence was absolutely intact and
the appetite and general condition in every respect
satisfactory. The patient had lost all pains in his head^
all traces of twitchings of the limbs^ and all his severe
attacks of vomiting. Even the doable optic neuritis had
markedly diminished. This state continued daily to
improve till the twenty-first day^ when suddenly the
patient was seized with a rigor followed by fever and all
the symptoms of meningitis from which he died a week
afterwards. This inflammation was afterwards seen to be
local and due to septic matter from the wound causing
irritation of certain areas of the cerebral membranes. If
putrefaction was the sole cause of this condition^ hope may
be entertained that by its prevention in other cases a more
satisfactory termination may be looked for. Although
meningitis continued to a fatal end^ no new nervous sym-
ptoms supervened^ the absence of which was probably due
to the presence of a hole in the skuU^ through which excess
of pressure was relieved.
4. Revelations of the autopsy, — ^After deaths inspection of
the parts showed that the brain was practically everywhere
healthy except the area injured by the operation and
the membranes in its immediate neighbourhood. From its
lower border a narrow tract of recently effused lymph ex-
tended downwards by the temporo-sphenoidal lobe towards
the base of the skuU^ over a large portion of which it
spread^ leaving the adjacent parts healthy. It was there-
fore obvious that this condition was produced by irritating
matter from the interior of the wound^ flowing downwards
between the layers of the arachnoid^ accumulating at the
base^ and by its presence causing meningitis in its track.
The local inflammation of the wound had so opened out
the parts and separated the adhesions as to permit the
272 CASE OF CEBBBRAL TtJMOtB.
discharge to percolate into tlie craniaj cavity^ but not
till three weeks after the operation. Had this not
occurred there is no reason why the healing process should
not have been maintained^ and the entire wound become
ultimately cicatrised. The patient would then have con-
tinued permanently in a satisfactory condition, and escaped
the secondary and fatal complication. The recovery from
serious surgical injuries to the brain-substance of man, as
well as experimental researches on that of animals^ show
that such a termination is perfectly possible.
The cortical substance at the edges of the wound in the
brain was firm and healthy, except at the inferior border,
which was slightly softened, probably from infiltration of
the meningeal effusion. The deficiency in the grey matter
was clearly defined and the portions of absent convo-
lutions could be accurately limited. On the subject of
central localisation only general conclusions can be drawn,
as the destruction was not limited to the cortex, but in
great part was situated in the centrum ovale below. The
fibres, however, thus injured were those corresponding to
the grey matter above, and may therefore be said to
represent the conducting media of the higher centres.
The symptoms immediately before the death of the patient,
as far as they go, entirely harmonise with those which
have already been determined by experimental inquiry to
arise from corresponding lesions of cortical matter, with
others superadded, which can be easily explained by the
processes of pressure and softening in the neighbourhood.
The inferior extremities of the ascending frontal and
parietal convolutions being found only very slightly
involved, accounts for the almost total absence of oro-
lingual symptoms during life. The almost total destruc-
tion of the remainder of the ascending parietal convolution
explains the complete paralysis of the fingers and hand,
and the partial paresis of the face. The lesion of the
middle third of the ascending frontal convolution produced
the immobility of the elbow- and shoulder-joints, and the
loss of pronation and supination in the forearm. The
0A8E or OSBBBRAL TUMOUB. 278
almost complete immmiity from disease of tlie lower part
of this gyrus permitted the nearly natural movements of
the facej lips^ and tongue during life. The bases of the
three frontal couYolutions were perfectly healthy^ but a
day or two before death temporary conjugate deviation of
the eyeballs was observed^ both being turned towards
the leftj which was probably due to irritation of these
regions by the neighbouring disease. At no time was there
any paralysis of the muscles of the eyeballs. The postero-
parietal lobule was found almost intact^ its anterior margin
only being involyed in the wound. For some days after
the Operation the patient moved his left leg freely^ and it
was only after the appearance of the hernia that the limb
became paralysed. This was therefore due not to destruc-
tion of the cortical centre of the lower extremity^ but to
pressure and softening within the wound. This was evi-
denced by the sinking in of the healthy convolutions on
the inner aspect of the hemisphere at a point exactly
corresponding with the situation of the conducting fibres
of this region. The anterior portion of the supra-mar-
ginal gyrus was absent. This convolution Professor Fer-
rier associates with the sense of sight. In this case there
was no evidence of any serious impairment of vision or
hemiopia^ although the patient saw better with the left
than with the right eye. There was^ however^ double optic
neuritis^ most marked on the right side. The deficiency
in sight was evidently due to this and not to a central
lesion^ in which case the weakness of vision would have been
chiefly in the opposite or left eye. It is therefore probable
that no appreciable loss of function could be attributed
to the disorganisation of a portion of the right supra-mar-
ginal gyrus. It iS; however^ to be observed that the con-
volution was only partially destroyed, and Professor Ter-
rier has shown that even when it is completely oblite-
rated on one side the consequent blindness on the other
is only temporary, the opiposite centre appai*ently rapidly
compensating for the loss. Shortly before death the
patient, though sensible, talked very volubly, oarried on
VOL. Lxvin. 18
274 CASB or cerebral tumour.
conversation with imaginary persons^ and recited the most
elaborate and yet perfectly coherent adventures. May
these not have been the result of visual hallucinations,
and due to irritation of this centre 7^
Although the right superior temporo-sphenoidal convo-
lution was somewhat softened it was not so to any great
extent^ and it was probably recent and due to mechanical
infiltration. During life the hearing of the left ear was
perfect. The comparative deafness on the right side
was due to deficiency in the auditory apparatus and not
to a central lesion.
The destruction of the centrum ovale for the main -part
corresponded with that of the cortical substance above.
Its exact limits were difficult to define owing to the
gradual softening in the neighbourhood. The internal
capsule, corpus callosum and basal ganglia were, how-
ever, intact. So also was the remainder of the brain.
The intellect, other senses, with all the organs and func-
tions of the body except those already detailed, remained
normal till the last.
Such are the main points of interest and reflections
concerning a case which throughout has been a source of
great anxiety and responsibility. This has chiefly been
due to the fact that we have not had the advantage of
any precedent of a like nature to guide us in our methods
of procedure. Operations on the brain-substance have
not been uncommon in the history of medicine, but these
have hitherto been performed either for the relief of
surgical injuries, or for disease indicated by local mani-
festations. We have nowhere been able to discover the
recorded example of a case where a cerebral tumour was
diagnosed by the symptoms observed, without visible or
tangible external signs, and was in consequence operated
on and successfully removed. Since this has been accom*
plished in the present instance, the public papers have
asserted that the same has already been carried out on
^ In connection with the sense of sight, the fact may be noted that the
optic nenritis was most severe on the side of the cerebral lesion.
CASE OF CIBBBRAL TUMOUB. 275
several occasions in the Boyal Infirmary of Glasgow. To
this it can only be said that up to the present date no
report of snch proceedings is to be foand in medical or
scientific literature.
In conclusion^ we would observe thatj although unfortu-
nately in this instance life was not permanently preserved,
the experience we have gained by this case leads us to the
belief that there is an encouraging prospect for the future
of cerebral medicine and surgery, and that as a tumour of
the brain can be diagnosed with precision and successfully
removed without immediate danger to life, we confidently
anticipate that under more favorable circumstances the
operation will be performed with lasting benefit to the
patient.
(For report of the discussion on this paper, see ' Proceedings of
the Boyal Medical and Ohimrgioal Society,' New Series, vol. i,
p. 438.)
THE
EXPERIMENTAL PRODUCTION OF CHOREA
AND OTHBS BB8ULTS OF
CAPILLARY EMBOLISM OF THE BRAIN
AND CORD.^
BY
ANGEL MONEY, M.D., M.B.C.P.,
ABSISTAITT PHYBICIAK, HOSPITAL FOB 8I0K OHUDBBV, OBBAT OBMOVD
BTBBXT, AlTD YIOTOBIA PABK CHXST HOSPITAL.
Received Mareh lOtli-Bedl May Seth, 188S.
In December, 1883, at the completion of my Medical
Registrarsliip at the Hospital for Sick Children I resolved
to undertake the investigation of whioh the present
communication is the first record. It seemed to me
that the possible effects of genuine capillary embolism in
cerebro-spinal pathology had been far from adequately
considered. I commenced my experimental investigation
on the Ist of October, 1884, at the Brown Institution, to
which my friend Mr. Victor Horsley had just been
appointed Professor Superintendent*
The material with which I began to work was guinea*
pigs and rabbits as subjects and bismuth and starch as
1 Towards the expenses of this research a grant was made by the British
Medical Association on the recommendation of the Scientific Grants Com*
mittee of the Association.
278 EXPEBIMSNTAL PRODUCTION OF CHOREA.
artificial emboli. My object in choosing bismnth and
starch was the circumstance that each conld be recognised
in the nervous tissues by means of a simple chemical
reaction. Ammonium sulphide would turn the crystals of
subnitrate of bismuth blacky whilst iodine would impart
a blue-black colour to the granules of which starch is
composed.
I found it necessary to make a microscopical examina-
tion of many particulate substances having the following
qualities. First of all the powder must not be too heavy
or the temporary suspension in a " neutral '^ salt solution
would be impossible. Secondly, the particles must be
capable of easy recognition, or hours of unnecessary labour
would be required to discover their locality after injection ;
and lastly, the size of the particles must not be too great, or
vessels larger than capillaries would be blocked. Another
consideration was that particles must be chosen which
had no great tendency to agglomerate when the powder
was distributed through a *75 per cent, salt solution. I
may say at once that the particles with which I have
obtained the best results have been the granules of
potato starch, those of arrowroot, and those of carmine.
The individual granules of the last-named powder are very
much smaller than a red blood-corpuscle, but a suspension
of the powder in salt solution always contained many
granular masses larger than the average red blood-
corpuscle.
The next difficulty which had to be overcome was the
method of production of embolism. It was obvious that
direct entry of the arterial cerebral and spinal circulation
was most necessary, or at all events most advisable.
After many dissections and much deliberation I came to
the conclusion that in rabbits and guinea-pigs the only
way of obtaining results without having recourse to too
large an operation was to inject into the aorta by way of
the common carotid arteries. I found that by slowly
injecting the particulate liquid into one or other common
carotid the aortic flood nearly always carried the minute
SZPIBIMBNTAL PRODUCTION OF CHOREA. 279
particles up one or both vertebral arteries^ which are given
off in rabbits and guinea-pigs much in the same way as
they are in the human subject. The internal carotid is a
very slender branch of the common carotid^ and injection
upwards from the common carotid always failed, in the
animals mentioned^ to get into the brain or circle of Willis.
The operation which I performed on rabbits and
guinea-pigs^ cats^ and dogs was as follows : The animal
having been first ansBsthetised by means of ether or
chloroform^ it was fixed upon the operation table and an
incision made a little to one side of the median line of the
neck^ say the right. The skin and fascia were then
divided with the knife and scissors and the muscles
separated by blind hooks. The carotid artery was then
explored and cleaned and laid upon a platform of white
paper. A ligature was next put on the vessel at the upper
end of the wound^ and a clip served to close the lumen of
the artery at the lower end of the wound. By means of
a pair of scissors a snip was then made in the wall of the
artery nearer the upper than the lower end of the exposed
vessel. The next point was the introduction and tying in
of a fine steel blunt-pointed cannula adapted from an
ordinary hypodermic syringe. The cannula having been
introduced the body of the syringe was filled with the
particulate liquid^ then the clip was released from the
artery and a drop of blood was allowed to flow out at the
free end of the cannula j the syringe was then promptly
fitted on to the cannula and the injection slowly made.
The blood pressure is so low that it can easily be overcome
without using any force to the piston of the syringe.
The injection completed^ a moment or two is spent in
waiting till the flush of blood had washed all the injected
fluid out of the proximal end of the carotid artery^ when
the clip is reapplied^ the cannula removed^ the vessel
ligatured^ and the wound closed and sutured. The surface
of the wound was washed with a solution of carbolic acid^
and every care was taken to prevent septic inoculation^
though the spray was not generally used.
280 EXPIBIMBNTAL FBOD0OTIOII OF OHOEEA.
I shall divide the information which I have to com-
municate into three parts. The first division will treat of
the clinical phenomena which are apparently dependent on
capillary embolism of the brain and spinal cord. The second
part will deal with the anatomical changes caused by this
process. The third section will be concerned with remarks
bearing on the pathology of the clinical and anatomical
factS; and more especially of those facts as they relate to
chorea. This division of matter will not, however, be
strictly adhered to.
Olinical phenomena.
1. The most important observation which has come out
as the result of these experiments is the production of
involuntary movements indistinguishable from those of
human chorea, allowance being made for differences of
anatomy. The choreic movements observed in the animals
experimented on by me were, I believe, not due to capillary
embolism of the brain proper. Whenever they were present
emboli were always found in the capiUaries of the spinal
cord.
2. Some form of " uncontrollable *' movement was
observed in almost every experiment in which the capillary
emboli lodged in the brain. Sometimes the animal rolled
round the longitudinal axis of the body. In other animals
the movement was round an imaginary circle with the
centre to one side of the animal ; the movement in these
cases was always in one and the same direction. Other
animals made somersaults, revolving round a transverse
axis of their trunks. Other animals, again, had a kind of
" rocket " movement in which they darted forwards, gene-
rally in a direction obliquely with the long axis of their
bodies. These '' forced '' movements were exactly like
those due to section of various parts of the brain and
which have long been known to physiologists. That
capillary embolism can give rise to such movements of
SXPSRIHENTAL PBODUCTIOK OF OHORSA. 281
rotation is^ so far aa I haTe been able to ascertain^ a new
fact, thoagh tbere appears to me to be nothing strange in
the occnrrence of such movements as the resnlt of
capillary embolism. I have observed these ''forced"
movements in the gainea-pig, cat, and dog. These
movements were unattended by any appreciable paralysis
or tonic spasm. Not infrequently there was an abnormal
carriage of the head and it seemed as though the cephalic
posture afforded some kind of comfort to the animal,
which appeared to be very giddy when the head was placed
in its normal position, which could easily be done. As a
rule this abnormal carriage was due to a rotation of the
head round the long axis of the neck, so that one side
of the face was directed towards the floor whilst the nose
was projected forwards and upwards.
3. In the majority of cases the animals experimented on
by me have had marked nystagmus, either horizontal or
oblique ; .this has been observed in the four kinds of
animals used. The rhythmical movements of the eyes
were not absolutely constant, and generally tended to
disappear when the animals lived more than a day.^ The
rate varied somewhat ; a common rate was about eight
to-and-fro small vibrations in five seconds. So far as my
notes go the affection was always bilateral. (Well-marked
conjugate deviation of the eyes was observed in a dog.)
4. Twitchings of irregularly distributed groups of
muscles were observed in most of the animals experimented
on. These twitches were observed in the face, neck, head,
upper part of trunk and forelegs. A few of the artificial
emboli were found in sections of the upper part of the
spinal cord in these cases.
AmpKfication of 1 and 4a. — ^As these twitches in my first
experiments were not a marked feature I did not attach
much importance to them as throwing light od the patho-
logy of chorea. The main point to prove in connection
with chorea as due to embolism is the fact that a succes-
sion of clonic spasms can be caused by the embolism
' V%d$ AdamkiewicS) Zor Lehre Gehimdnick.
282 BXP8RIMEKTAL PRODUCTION OV CHOREA.
becaase a series of moyements of different groups of
mnscles is the most essential feature of chorea.
I shall now describe more in detail the case of a cat
which^ I believe^ settles the point in qnestion — ^that chorea
may be due to capillary embolism.
A black female cat was submitted to experiment at 11.30
a.m. on February 18th^ 1885. The operation was finished
and the animal came to at 12 noon. As soon as con-
sciousness was fully restored the choreoid movements were
observed. The right foreleg was chiefly affected, but the
movements were present in the face, head, and neck, upper
half of trunk, shoulders, and forelegs. There was also
horizontal nystagmus. The muscular contractions were
thus arranged : the face would twitch into a grimace in
which the angle of the mouth would be drawn outwards
and upwards ; the head would be jerked in one direction
and then the shoulders would be shrugged and the arm
drawn inwards and paw contract and the trunk jerked all
in saccession. The movements were disorderly. The
movements of this cat were such that to my observation
and many others who observed them they could not be
distinguished from a typical case of chorea in the human
being. Naturally the characteristic pronations and supina-
tions of the forearm were not present for the very obvious
reason that cats do not possess such movements. But
there were other symptoms present. The reflex action
in the upper limbs was greatly exaggerated, whilst the
reflex action of the lower limbs was simply normal. A
tap on the lower limb caused strong movement of the
upper whilst giving rise to a normal reflex movement
in its own muscles.
The animal seemed to be in a drowsy, giddy state, and
preferred to lie on its left side. When disturbed it always
sprang round in a circle to the left with the base of the
tail as a fixed centre. Moreover, when sat upon its
haunches it moved with good force and apparently viciously
all its limbs. Careful observation during the whole eight
hours it lived failed to detect any sign of actual paralysis
BXPEBIMEKTAL PBOD0CTIOK 0I> CHOBEA. 283
or tonic spasm. No loss of sensation coald be made ont
in any part. The pnpils were natural and acted appa-
rently naturally. The temperature was 96° in the vagina,
and observations in the axillsB did not detect any appre-
ciable difference on the two sides of the body. The
respirations were 30, the pulse 120. The movements
continued, increasing in frequency, till death, which was
no doubt due to collapse. At the autopsy no naked-
eye lesion could be detected ; the right common carotid
was the artery used, and the injection was made down-
wards towards the heart, and the emboli (arrowroot
granules) must have gone chiefly up the vertebral arteries.
Emboli were found in all parts of the brain. There
were emboli in the upper half of the spinal cord ; they
were not numerous, generally speaking two or three
granules were found in almost every section of the cervical
enlargement of the cord. None were detected in the lumbar
region. (Specimens shown of the emboli in this case.)
It is important, I think, to associate the presence of emboli
in the cervical part of the spinal cord with the greater
affection of the muscles supplied from this part and with
the increased reflex excitability. There were no choreoid
movements in the lower limbs, no exaggeration of reflexes,
and no emboli in the spinal cord of this region. Can we
resist the conclusion that the clinical symptoms are related
etiologioally to the presence of the emboli in the spinal
cord ? I think not.^
5. In several of the animals experimented on the head
and neck was the seat of almost rhythmical to-and-fro
movements which lasted till death or until the animal was
killed. The longest duration was five days in a guinea-
pig. In one guinea-pig where carmine was injected the
1 I have notes of at least two cases of typical severe chorea in girls in which
a tap on the upper part of the hack of the forearm produced movement of the
indez-flnger, or middle, or ring- and little fingers, according to the site per-
cussed ; in these two cases the knee-jerks were exaggerated so that their equi-
valents could he ohtained hy drawing down the patella with the forefinger
and percussing the straining forefinger.
284 IXPEKIKIKTAL PBOD0CTION OV CHOREA.
rotation movements persisted for thirty-six hours^ and
then completely passed away. The animal was allowed to
live for ten days ; it was then killed. Carmine was fonnd
blocking many of the capillaries of the pons and cerebral
hemispheres {vide microscopical specimens). Rhythmiccul
repetitions of one movement and an irregular auceeasion of
different movements have thus been observed. So that the
experimental " chorea " differs from and resembles both,
the " chorea ^^ of animals and that of man. Some more
clinical symptoms due to capillary embolism remain to be
recorded.
6. Absolnte paralysis of 'the right foreleg was observed
in one guinea-pig^ and there was also absolnte paralysis of
the whole of the right side of the face. No reflex action
could be got in any part of these paralysed areas, though
sensation appeared to be intact. In this case starch
granules were found blocking an arteriole in the cervical
cord, and I believe this embolism was the cause of the
fiaccidity and palsy of the foreleg. The emboli were
freely scattered over the brain, and I regard the facial
palsy as being due to total anaemia of the facial nucleus as
the result of embolism ; the facial nuclei are homologous
with the nuclei in the spinal cord. These observations
show that paralysis of spinal order may be due to embolism
of the vessels of the spinal cord. Some cases of myelitis
and infantile paralysis may have such a mode of origin.
7. Perfect left hemiplegia of cerebral type was observed
in a cat after the injection upwards into the right internal
carotid. Death followed in two days, and the autopsy
showed that the larger vessels were perfectly free from
emboli, which were limited to the smallest arterioles, if not
to the capillaries alone {vide sections). (In this cat there
was, in addition, absolute paralysis of the right pupil.)
8. The respiration was variously affected ; in some
experiments the animals clearly died from paralysis of
respiration whilst under the influence of the anaesthetic,
but no doubt as the result of embolism of the medulla
oblongata.
BXPBBIMENTAL PBODUCTION OF CHOREA. 285
9. The pulse varied much; the hearths action was
sometimes markedly slowed ; at others greatly qiiickened.
10. The temperature in every case was greatly lowered.
In the cat and dog it fell from the normal 99^ to 94^ ; in
guinea-pigs from 101® (which is about the normal) to 92® —
95®. In the hemiplegic cat the temperature of the paralysed
side was *4® colder than the right side. Temperature in
rectum 98®, left axilla 95*8®, right axilla 96-2®.
Ghneralisation. — Any symptom or group of symptoms of
disease of the nervous system may be caused by capillary
embolism. The experimental results above recorded are
alone sufficient to defend this position. My investigation
also shows that a certain amount of capillary embolism
may be present in the convolutions and other parts of the
brain without inducing any obvious symptoms during life.
Anatomy. — ^With regard to anatomical appearances
there is not much to be said. For the most part the
capillary emboli give rise to no changes (in the time
during which the animals have lived), the longest duration
being ten days. Excepting blocking of the capillaries,
nothing abnormal has been seen in the nervous tissues.
In a monkey with perfect cerebral hemiplegia the
result of capillwry embolism, there were areas of capillary
congestion of a bluish-red colour, of which Mr. Victor
Horsley was kind enough to make a water-colour drawing
immediately after removal of the brain. The whole of
the right hemisphere was greatly swollen as the specimen
still shows, and as is well seen in the water-colour sketch.
In a dog there were minute areas of anaemia surrounded
by congestion of capillary vessels in the pia mater of the
convex surface. I have to thank Mr. J. J. Lister for a
pencil drawing of this dog's brain.
Pathology. — ^I may now pass on to the last division of
my paper. In chorea three factors are present, viz.
spontaneous movements, inco-ordination of volitional move-
ments and paresis. According to Dr. Oowers ('' Paralytic
Ohorto,'^ ' British Medical Jdumd,' vol. i, 1881, p. 69)
these three phenomena are present in every caisi^, thbugh
286 SXPIBIXBNTAL PBODUOTION OF OHOBXA.
one may be present almost to tlie ezclnsion of the others.
In my experimental observations I Have not noticed any
appreciable inco-ordination or paresis. I offer the sugges-
tion that the varieties of chorea as observed in ordinary
practice are dependent upon the seat of the lesion giving
rise to the chorea. It may be that where the inco-ordina-
tion is the most marked feature that the seat of the lesion
is in another part of the motor tract to that which gives
rise to spontaneous movements. The seat of the lesion
may possibly be the same whether paresis or clonic spasm
is the most marked feature. At least paresis and clonic
spasm appear to be closely related to each other. I am
not prepared to go so far as to say positively that the
more involuntary movement the leas paresis^ and con-
versely. It is possible that what holds good in this
respect of the grey matter of the spinal cord does not hold
good of the grey matter of the brain.
There is a marked contrast between the '' chorea '^ of
animals and that of man. Hughlings Jackson, Broadbent.
Bastian^ Tuckwell^ and Todd^ with others^ have strongly
advocated the cerebral origin of the disease in man for
reasons which appear to me to be unanswerable.^
I look on the occurrence of nystagmus^ twitchings in
the face and muscles of the jaw which were present in my
experimental observations as due to disturbance of the
functions of the nerve nuclei in the pons which are
strictly analogous to the nerve nuclei in the spinal cord.
The '^ uncontrollable '' movements or movements of
rotation I regard as due to lesion of parts above the
spinal cord^ and which may be spoken of as the brain
proper.
In none of my observations have I seen clonic spasms
which could be set down to lesion of the brain proper ; this
statement applies to guinea-'pigs^ rabbitSj cats, and dogs.
1 Broadbenffl ar^nment that the reflex addons are never exaggerated in
human chorea and therefore the lesion is not spinal is not ahsolately true. In
some cases of human chorea the reflex actions are exaggerated, and in many
cases they are perverted.
V^VNLIHSRTAL PBODUCTION OF CHOBKA. 287
Why did not capillary embolism of tlie motor parts of
the brain proper in these animals produce choreoid move-
ments or even clonic spasms? I do not pretend to
answer this question^ but merely offer some remarks which
may possibly throw some light thereon.
The pyramidal tracts in the animals in question are but
ill developed. Pitres has shown that in the guinea-pig
and rabbit the cortico-medullary fibres stop short at the
medulla oblongata; in the cat and dog but a slender
strand passes down the opposite lateral column of the
spinal cord. Nervous discharges originating in the
highest motor centres cannot act on the nuclei in the spinal
cord of the animals in question without first passing
through other ganglionic centres, whereas in man nervous
discharges originating in the highest motor centres can by
passing down the well-developed pyramidal tracts act
directly on the nerve nuclei in the spinal cord.
The '' forced '' movements observed in my experiments
must obviously have been due to nervous discharges
originating simultaneously in a large mass of ganglionic
tissue situate in one side of the brain ; these nervous dis-
charges were doubtless due to the presence of emboli in
the vessels of the brain. Trousseau has spoken of
''forced'^ movements under the name of chorea saltatoria.
As to what part of the brain was concerned in the produc-
tion of these " forced " movements I am unable to say,
for the emboli were widely distributed.
I suggest that all involuntary movements are dependent
— physiologically— on an essential similar nervous dis-
charge ; the variety of the involuntary movement must be
explained on such grounds as difference in the site of the
lesion, and possibly to combinations of lesions and the
like.
Capillary emboli may cause clonic spasm either after
the manner of an irritant or as the result of a defective
nutrition of the grey matter supplied by the obstructed
capillaries. I submit that the latter view is the more
plausible one. According to my observation the movements
288 EXPERIMKNTAL PBODUCTION OF CHOBSA.
tended to increase in frequency. The first indication o£
loss of nutrition would^ no doubt^ be a loss of control. A
negative condition — loss of nutrition — ^would thus be
capable of causing a positive condition— clonic spasm or
tonic spasm. The difference between clonic and tonic
spasm is probably one of degree.
The state of innutrition of the motor centres on which
I believe chorea depends may be brought about by many
causes. Bastian's theory of thrombosis of minute vessels
and Dickinson's theory of hyperaemia and exudation
receive support from the results of my experiments.
My observations clearly show that the effects of capil--
lary embolism may be entirely recovered from ; and this
is an argument in favour of the theory that chorea can be
caused by capillary embolism.
From my experience at the Hospital for Sick Children
and elsewhere I have been brought much into contact with
cases of chorea. I have been struck with the remarkable
association of paralysis with involuntary movement.
The facts of ''paralytic chorea*' as observed by
Hughlings Jackson^ Broadbent^ Gowers, and as I can
myself bear witness to, are very suggestive of the patho-
logy of chorea.
A good interpretation, and probably a coiTect one, is to
regard the paralysis as tbe expression of a profounder
damage of nutrition of motor centres than gives rise to
chorea. Chauveau has recorded a case of paralysis of the
extensors with chorea of the flexors of a leg in a puppy.
Ferrier has made a generalisation to the effect that the
extensors and abductors generally are weaker than the
flexors and adductors. Apply this to Chauveau's puppy,
and we may suppose that there was the same degree of
innutrition in the nerve nuclei energising the puppy's
diseased leg, but that degree of innutrition caused para-
lysis of the weaker extensors and chorea of the stronger
flexors.
" Chorea '' in anvntah as described by awf Aor^.^^Hugh-
llngs Jadkfloii, Goffers, Oniltitifl, aiid others hkve feh6%a
IXPIBIMXNTAL PftODUOTION Of CHOREA. 289
that chorea in the dog continues after section immediately
below the medalla oblongata. This circumstance^ together
with the fact of the discovery of anatomical alterations
only in the spinal cord, points to the conclusion that the
chorea is dependent on disturbance of the functions of the
spinal cord. My experiments support these conclusions.
Anacker has described *' chorea " in the cat and cow.
In the cat the movements were limited to the head and
neck and eyes (horizontal nystagmus) ; the affection
came on whilst the cat was suckling and ceased after the
completion of suckling. In the cow the affection super-
vened on calving ; the movements were limited to rhyth-
mical jerkings of the head from side to side.
Chauveau has observed '' chorea '' in the female pnppy ;
in one case there was paralysis and atrophy of the right
foreleg, which was followed by chorea; another case I
have mentioned above. Hughlings Jackson states very
dearly that in the dog "chorea" consists in a rapid
repetition of one movement rather than in a succession of
different movements.
I introduce the above facts in order to show that the
term chorea is a very elastic one. I think it important
that we should have a class, called by no matter what
name, which shall include every species of involuntary
movement. Clonic spasm is easily separated off from
tonic spasm, at all events theoretically, and for the most
part practically. The large subclass of involuntary move-
ments— clonic spasm — contains many varieties such as
simple twitch, rhythmical twitchings, the slow succession
of movements of what may be termed typical chorea, the
movements of disseminated sclerosis, and so forth.
Literature of experimental ca^llary emhoUem. — The
literature of the subject of artificial capillary embolism is
meagre. Panum, Frevost, and Cotard and others have
published works on the subject of experimental embolism,
but they admittedly occluded much larger vessels than
capillaries.
VOL. Lxvin. 19
290 BZPSBnCBNTAL PBODUOTIOH Of OHOBIA.
Feltz ('Embolies Oapillaires/ 1870) used emboli fine
enough to penetrate to the capilTaries, but he used very
large quantities of such materials as pus and canoerons
particles which could hardly be regarded as innocuous sub-
stances. Moreover, he was chiefly at pains to prove that
capillary embolism of the brain could cause sudden death.
My experiments leave no doubt on that point.
Concluding remarks on chorea. — Kirkes, Tuckwell,
Hughlings Jackson, Broadbent, and Bastian have sup-
ported the doctrine of blockage of minute vessels as the
cause of some cases of chorea, and although some post-
mortem evidence has been forthcoming tending to support
this view, yet such evidence must always be open to
objections. The vascular obstruction may not have
resulted from embolism, or it may have been the conse-
quence of the pathological condition on which the chorea
depended, and other possibilities suggest themselves.
Experimental evidence appears to me to be free from
objections of the kind just mentioned.
It may be argued that though I have succeeded in
proving that movements indistinguishable from those of
chorea can be caused by capillary embolism, yet I have
not yet shown that actual chorea can be so caused. It
may be urged that it is necessary that the animal shall
live, and that the movements shall pass away. The last
argument is futile, for I have shown that animals affected
with rhythmical movements, with movements of rotation
and with simple twitchings do live and recover, and there
is no doubt that the movements are in some way depen-
dent on the artificial embolism. I may add that I have
monkeys in my possession at the present time which are
alive and in good general health three weeks after the
induction of capillary embolism of one side of their brains.
The collapse which results from embolism of the pons and
medulla is the difficulty which cannot be overcome when
we wish to cause embolism of the upper part of the spinal
cord. I have made an attempt to cause embolism of the
XZPBBIMINTAL PBODUOTION Of OHOBSA. 291
Inmbar part of the spinal oord and have sacceededj bat
then the emboli also get into the arteries of the viscera
and canse death in a day. (In this attempt the starchy
fluid was injected by means of a catheter from the f emorsJ
artery. Complete palsy resulted^ but at the upper boun-
dary of the palsy twitchings were present during the time
the animal lived. In a second attempt where less starch
was injected no nervous symptoms followed and none of
the starch could be found in the spinal cord.)
That the twitchings and movements are not dependent
on the presence of emboli in the capillaries of the muscles
and nerves is apparently proved by the fact that an injection
of a large or small quantity of starch into the femoral artery
distally may be made without any phenomena at all being
observed.
My future efforts will be directed to the investigation
of the question whether chorea can be caused by capillary
embolism of the cerebral hemispheres of monkeys as being
animals the nervous system of which is the nearest
approach to that of man.
(For report of the discnamon on this paper see 'Proceedings
of the Boyal Medical and Ohimrgical Society/ New Series, toL i,
p. 449.)
FATTY TUMOURS.
BT
J. BLAND SUTTON, P.E.C.S.,
LBOTITBIB OH OOMPABATITS AVATOMT IVD 8BVI0B DBMOVSXBllOm
OF AVATOmr, ICZDDXiBBBX HOSPITAL.
R0CdT0d Oetober Ifith. IMi-Baid Jnu Mh, 188S.
LiFOMATA are morbid growths whioh oocnr so fre-
qaently^ are so well knowiij and apparently poBsefls so
little scientific interest^ that it may with reason be asked^
What can there be that is novel to write concerning
themT
For the most part these tnmonrs are to be regarded as
overgrowths of ihe snbcntaneons tissne^ and as snch are
exceedingly prone to occnr on the tmnk and proximal
segment of the limbs. These examples are not objects
for consideration in this paper, bnt the rarer kinds — ^those
which occnr in unnsoal situations — ^will afford much scope
for speculation.
The first case which excited my interest in the ques-
tion was that of an old man who, some years previously^
had a ventral hernia, through which a small piece of
omentum protruded. This had never caused the patient
any inconvenience until a few months before he applied
to the surgeon, when he observed that the tumour had
commenced to grow and had at that time attained the
294 fATTT TUMOimS.
size of an orange. Later on the man died from inter-
current disease, and an opportnnity was afforded for
examining the tumour. It was found to communicate
with the interior of the abdomen hj an exceedingly narrow
pedicle^ but was uniformly adherent to the subcutaneous
tissue of the abdominal wall, from which adhesions it
derived its nutrition ; the vessels in the pedicle were very
few and small. In this case it was obvious that the small
piece of omentum originally protruded had engrafted
itself on to the subcutaneous tissue of the abdomen, and
acquiring new growth had become in fact a " tumour " in
the true sense of the word, viz. it had ctcquvred {nde-
Examples of fatty tumours growing in rare situations
will now be described.
In the Winter Session of 1883 I removed the biceps
cubiti muscle of an old woman, a dissecting-room subject^
the upper part of which had become metamorphosed into
a fatty tumour, lobulated as these growths usually are
when they occur in subcutaneous tissue. It was not an
example of fatty degeneration of muscular tissue such as
one sees in cases where muscles are put out of use by in-
fantile paralysis, or injury to the dominant nerve, but a
genuine lobulated lipoma. It seems to me that possibly
this muscle had been injured, the damaged part had
retrograded into fat, assumed an autonomy and grown
into a tumour. (Plate FV, fig. 8.)
Professor Turner has recorded a similar growth between
the greater and lesser pectorals. Sir James Paget refers
to one in the museum of the College of Surgeons con-
nected with the heart of a sheep, and M. Gauchois
reported in the ' Gazette des Hdpitaux,' July 5th, 1888,
the removal of a large fatty tumour from beneath the
tongue.
The information afforded by the examination of the
tumour occupying the biceps muscle enables me to decide
accurately with regard to a fatty tumour removed by Mr.
Pearce Gtovld from the clavicle of a child. The growth
JfATTY TDMO0H8. 295
was sitaated beneath the stemo-mastoid muscle^ and was
BO firmly attached to the periosteum of the clavicle that
a portion of the membrane was removed in extirpating the
growth. After removal^ that portion of the tumour which
rested on the clavicle was found to contain a very thin
sheet of striated muscle-fibre^ and the inference to be
gathered from this fact is — ^that we have in this case
to do with one of those abnormal muscles for which the
clavicle is famous; the muscular tissue had undergone
degeneration and formed a fatty mass^ which as the child
grew acquired sufficient size to attract attention^ and thus
came into the domain of tumours and the hands of the
surgeon. It is represented in Plate lY^ fig. 4.
As a case supporting the view here advocated, I will
refer to an admirably reported case in ' Path. Soc. Trans.j'
vol. zxviii^ p. 221^ by Mr. Butlin. A fatty tumour was
removed from the leg of a girl, aged 7 years, by Mr.
Thomas Smith. It was first noticed when the child was a
year old, the time at which she began to walk. The tumour
occupied the upper and back part of the leg, a little below
the knee. When removed it was found that the growth
lay among the deep muscles of the leg, and passed between
the tibia and fibula, thrusting the interosseous membrane
in front of it.
The tumour, which was of the size of a festal head, was
composed of fibrous and adipose tissue in equal propor-
tions. It was enclosed in a capsule, and the various
fatty lobules were surrounded by broad trabeculas of
fibrous tissue. In the middle of many of these fibrous
trabecules thin reddish bands or fibres could be seen
which afterwards turned out to be striated muscle-fibre.
The fibres ran in various directions throughout all parts
of the tumour, but were most abundant in a longitudinal
direction and towards the anterior part of the mass.
Mr. Butlin concludes that most of the muscular fibre
was enclosed within the tumour during its growth and
was not of new formation.
Here, as in the instance of the biceps, and Mr. Gk)uld*B
296 FATTT TUMOURS.
case previoasly described, it may reasonably be supposed
that we have to do with an aberrant muscular slip which
has undergone fatty degeneration, and the retrograded
elements of which have assumed an independence and
grown into a tumour. The curious bands, capsule, and
trabeculsB recall strongly the arrangement of connectiye
tissue between the fasciculi of an ordinary limb muscle.
In the ' Path. Soc. Trans,' vol. xii, p. 148, Mr. Thomas
Smith records a case of especial interest on account of its
bearing on this question of muscular tissue degenerating
into fat. Sir James Paget had removed a pedunculated
fibro-muscular tumour of the uterus. On laying open the
growth it was found to contain a cyst and a fatty tumour
the size of a pigeon's egg, and to be surrounded by a
fibro-oellular capsule.
There can be little doubt that this mass of fat, occur-
ring in a situation usually devoid of fat, is a good
example of the doctrine here advanced concerning these
fatty tumours in " atypical " situations.
By way of broadly illustrating the question, a few
examples from some of the domestic animals are given.
If the scrotum of a bull or ram be examined, it will be
found to contain scarcely any fat, practically none.
Examine now an ox or a wether sheep, say a year after
they have been castrated. The scrotum is composed of
an exceedingly thin layer of skin enclosing a large amount
of fat, indeed, in the case of the ox it may weigh several
pounds. Why is this f The testicle having been
removed, the dartoid tissue and the proper coverings of
the testis have degenerated into fat which, having no func-
tion to fulfil, has grown into the condition of a '^ tumour.''
''Hen birds" offer themselves as additional examples.
In the early chick, two ovaries and two oviducts may be
seen, but in the adult bird the right ovary has disap-
peared ; often the oviduct shares the same fate, but fre-
quently it is represented by a small duct about half an
inch in length connected with the cloaca. This remnant
may exhibit two forms of degeneration : (a) The rarer is a
FATTT TUMOUSS. 297
cystic condition; bat more commonly one finds (6) a
small fatty tnmonr developed on its npper extremity.
This occars most constantly in tame birds as fowls and
pigeons. (Plate IV, fig. 2.)
It is well known that lipomata occasionally develop in
connection with the alimentary canal, particularly in horses
and oxen. Two remarkable tomoors of this sort have
come under my notice. They were found loose in the
peritoneal cavity of a mare which was killed at the Zoo-
logical Gardens for the purpose of feeding the animals.
The larger of the two measures four inches by three, the
smaller three inches by two and a half, both are covered
with a layer of serous membrane, and after careful exami-
nation no trace of a pedicle could be discovered.
On section they present the granular appearance so
characteristic of omental fat.
The only opinion to offer concerning these masses is
that they represent overgrown ''appendices epiploic©''
which hung suspended to the gut by an extremely narrow
pedicle, and that during the struggles of the animal in the
process of killing they became detached, for it is impro-
bable and inconsistent to suppose that they lived and
grew loose in the peritoneal cavity.
Inflarnmatory new'formations may degenerate into fat
and become veritable fatty tu^mours.
In the museum of the Boyal College of Surgeons is a
specimen in the general pathology series. No. 196^ the gift
of Dr. Norman Moore. ''It consists of a section of a
mass of fat which surrounded a portion of the ureter, in
which a calculus was impacted. Near the centre of the
section a small portion of the wall of the ureter is seen,
upon which the calculus rested ; bands of fibrous tissue
pass from it into the fatty tissue. The mass formed a
distinct tumour. It was probably produced by fatty de-
generation of newly-formed fibrous tissue (inflammatory
new-formation) occasioned by the irritation of the cal-
culus.'' The above account is taken from the catalogue.
The museum of the Middlesex Hospital contains a
2d8 I^ATTY TtMO0£0.
specimen showing a rectum and anns^ the seat of a stric-
tare the result of syphilis. The lower portion of the
bowel^ uterus^ and vagina are embedded in a mass of fat
measuring three inches from before backward. This mass
of fat is divided and subdivided by bands of fibrous tissue^
which in places give it a reticulated appearance. Sinuses
lead from the gnt to open around the margin of the anus.
This seems to be a specimen of the same nature as the
preceding one^ and may be explained in this way. In the
early stage of the stricture a certain amount of inflamma-
tion was present^ which led to exudation of inflammatory
products ; these in their turn retrograded into fat^ which
later on^ irritated by the stricture and the sinuses leading
from the bowel^ grew into a tumour. It must be remem-
bered^ however^ that this retrogression of inflammatory
new-formations completely disgfuises all traces of the
original inflammation.
Dr. J. K. Fowler first drew my attention to the very
frequent presence of a large collection of fat around the
bowel in cases of long standing stricture^ having himself
observed it in very many instances.
Mr. T. W. Nunn reported to the Pathological Society, for
Mr. Worthington (vide vol. xv, p. 100), an example of a
fatty tumour surrounding the rectum, and on carefully
going into the details of the case there can be little
doubt that it was of precisely the same nature as the two
cases just recounted. It was associated with old standing
disease of the uterus, and thus serves as a striking confir-
mation of Dr. Fowler^s observations. As a curious and
valuable case in support of the view here advanced as to
the probable origin of these collections of fat, the follow-
ing may be used as an illustration.
M. Paul Berger relates, in the ' Gazette des Hdpitaux '
of November 15th, 1883, that a man was admitted into
La Charity with a salivary calculus impacted in Steno's
duct. The irritation had caused hypertrophy of the pad
of fat lying between the masseter and buccinator muscles,
known as Bichat's boule graissevse.
JATtT TtJlfOUBS. 299
In these cases of fatty degeneration of inflammatory
new-formations a large quantity of fibrous tissue is present
wluch forms alveoli containing the adipose matter.
Attention must now be invited to another mode by which
fatty tumours may arise^ i. e., by the degeneration of the
soft parts of parasitic foetuses.
The museum of the Middlesex Hospital possesses a
fatty tumour^ containing a shapeless mass of bone^ which
was removed from the buttock of a man by Mr. Henry
Morris^ November^ 1876. Bone in a fatty tumour is by
no means unknown^ indeed^ several cases have been
recorded^ but it is of rare occurrence.
The question which now suggests itself is this : — ^Are
these tumours containing bone to be regarded as
" lipomata '^ in the ordinary sense of the term f Certainly
not. They are examples of immature foetuses attached to
the trunk of a perfect individual^ or, as they are often
called, ''parasitic foetuses/' in contradistinction to the
autosite or mature being who is the unfortunate bearer of
one.
The explanation would be that the soft parts of the
attached foetus undergo fatty metamorphosis, but the bone
remains unchanged. These may continue quiescent
throughout a long life, but from some cause or other, we
know not what, may suddenly take on active growth, in
the same way as the piece of omentum in the first case
considered.
As an undoubted example of fatty tumours arising in
attached foetuses, reference should be made to the Terato-
logical Catalogue of the College of Surgeons Museum,
No. 182.
This specimen consists of the head of a human foetus
with a large lobulated vascular tumour, the remains of a
second foetus, growing from the median fissure of the
palate. The bulk of the tumour is made up of fat. (Full
details will be found in the catalogue.)
Mr. Butlin refers to a case described by Arnold. A
child survived its birth six days with a large tumour filling
800 FATTT TOMOUBS.
its pharynx and moath. It was a lipoma^ inasmnoh as it
oonsisted chiefly of fat^ but it contained also fibrons tiasne^
cartilage^ cysts^ and even striated mascle-fibres (' St.
Barth. Hosp. Bep./ vol. xiii). A very remarkable case is
recorded in 'Path. Soc. Trans./ vol. zzziii^ p. 287, by Mr.
Frederick Treves. An instance of fatty degeneration of
an attached foetus similar to Arnold's case came under my
notice this year, but the parents refused to give me tlie
g^wth.
It will now be important to ascertain, if possible, on
what this fatty metamorphosis depends.
An interesting fact is pointed oat by Otto in his
' ' Compendium of Human and Comparative Pathological
Anatomy' (South's Translation, 1881) to the effect that
parts devoid of nerves are exceedingly prone to undergo
fatty change, and by way of example he cites cases of
parasitic foetuses which as a rule are without nerves, and
contain a considerable quantity of fat in lieu of more
important tissue, such as muscle. By way of illustrating
the relation between absence of nerves and presence of fat
I will detail a remarkable case which came under my own
observation. m
Early in 1888 Mr. Edgar Nicholson obtained for me a
foetus with the following history : — ^The mother, a healthy
woman who had passed successfully through several
pregnancies, and was again in the fifth month of gesta*
tion, fell down six stairs on to her stomach, with her
legs doubled beneath her. Stunned by the fall she lay
in that position until help arrived. After remaining in
bed for a few days she felt well again, but never felt the
child move about as in previous pregnancies, and she
feared it was dead. At the eighth month the child
was born, lived for four or five hours, and then died.
On examining the body it was found that whereas all
parts above the umbilicus presented the appearance and
size of a child of eight months of intra-uterine life, the
parts below were those of a foetus about the fifth or sixth
month of gestation.
fATTT TUM0ITB8. 801
Looking to the spinal column it was found to present
the sac of a spina bifida at the first lumbar yertebra^ and
at this point the canal and column suddenly ended ; no
trace of the remaining lumbar^ sacral^ or coccygeal
yertebrao could be found. The ossa innominata were
fused along their yertebral borders^ the ureters were
dilated and the kidneys cystic. No trace of the lumbar^
sacralj coccygeal^ or sympathetic neryes could be detected.
On reflecting the ^in of the legs^ which was yery thin^
I was surprised to find that they consisted of bones corre-
sponding in their degree of deyelopment to about the fifth
month of gestation^ bone and cartilage being present in
due proportion^ but all other tissues^ except a few blood-
yesselsj being represented by fat ; indeed^ these legs would
be best described as fatty tumowrs in the shape of lower
limbs, contaimng bone and cartilage.
The explanation seems to be that when the woman fell^
she fractured the child's spine^ destroyed the continuity of
the spinal cord^ and depriyed the limbs of their nerye
supply^ whichj in consequence^ degenerated into adipose
tissue. (Plate IV, fig. 1.)
In spite of this eyidence it may be still fairly argued
that we haye no satisfactory eyidence that these attached
foetuses oyer had any important tissues to suffer degprada-
tion, and as one cannot say positiyely that they had, the
eyidence on that point remains more or less circumstantial.
But I shall now proceed to detail a case where the process
has been traced from the perfect tissue to the fatty condi-
tion, and, what is still more important, the tissue in
question occasionally persists in its perfect form.
Such eyidence is afforded by :
The Fat Body of Frogs and Toads.
If the abdomen of a frog, Rana temporaria, be opened
and the alimentary canal with the liyer be remoyed, the
reproductiye organs will then come into yiew. If the frog
802
VATTT TtnCOUBB.
be a male the following disposition of parts will be
observed :
Toa<L
Frog.
T. The testes. A pair of yellow oval bodies^ dotted
with black specks^ usually one fourth of an inch long,
lying on the ventral surface of the kidneys. From theae
issue the vasa efferentia, about ten or twelve in number,
which pass into the median border of the corresponding
kidney. The spermatozoa pass from these into the tubules
of the kidney to escape by the ureter, u, which in the
frog serves not only as the main duct of the kidney but
also as a vas deferens. Just before the ureters enter the
cloaca, c, they form pouch-Uke dilatations known as the
vesiculsa seminales. Passing from the summit of these
receptacles in the male frog is a thin streak representing
the Miillerian duct, which reaches as far forward as the
root of the lung, m.d. Lying on the anterior extremity of
the testis and sometimes connected with it is a mass of fat
with three or four finger-like processes. This collection of
fat is known as the " fat body '^ or corpus adiposum, ca.
Turning now to the female frog the following arrange-
ment is seen :
0. The ovaries. A pair of black masses lying in the
folds of the peritoneum in front of the kidbeys^ their
surface dotted with ova, and varying in size^ shape^ and
colour according to the time of year.
fATTT TtTMOITRS. 803
M.D. The ovidncts. A pair of oonyolated tubes com-
mencing at the root of the long with funnel-shaped orifices
and ending posteriorly in the cloaca, the genital ducts
in the female being quite distinct from the ureters.
Lying on the anterior end of the ovary and connected
with it is a corpus adiposum exactly corresponding to
that on the testis of the male.
It is to this fat body that attention is now invited, for
its history affords us a clear and instructive example of the
process by which the rarer kinds of lipomata we have been
considering indubitably arise.
The origin of the body in question has attracted the
•attention of some careful observers. Von Wittich's
researches clearly show that the fat body and testis are
developed from the genital ridge in the embryo, but the
anterior part undergoes fatty degeneration, whereas the
posterior part develops into a testis. This means that
that portion of the genital ridge which under certain con-
ditions becomes part of the ovary is represented in adult
frogs by fat. There can be very little doubt on this score,
for if anyone has the patience to examine say fifty frogs,
he will be pretty certain to find one or more frogs in
which the fat body is replaced by an ovary in addition
to the testis, so that the frog possesses in fact an ovo-
testis.
The common toad, Bufo vulgaris^ affords excellent and
important evidence on this head.
In the male toad, wedged in between the testis and
the fat body, is a third structure, usually referred to as
''Bidder's organ'' (see woodcut on page 802). Careful
inquiry by numerous competent observers has settled, on
microscopical and embryological grounds, that '' Bidder's
organ '' is really a persistent portion of the ovary which
has not been involved in the general fatty metamorphosis
of the anterior end of the genital ridge.
There is another fact which serves to demonstrate the
ovarian nature of " Bidder's organ," and to which due
consideration has not been given. In the toad the Mulle-
804 lATTT TUMOUBS.
rian dncts^ ICD.^ are always more obyioas than in the f rog>
and the careful examination of several scores of toads has
convinced me that the amount of development of the ducts in
question corresponds to the size of Bidder's organ. That
isj as a rulcj if these ducts are large Bidder's organs are
well developed and vice versa. Also in those specimens
of Bona temporaria possessing an ovo-testis which I have
examined — and at least five examples have come under my
notice in examining 250 frogs kindly collected for me by
my brother— the Miillerian ducts (oviducts) have been
developed in corresponding proportion. Hence it would
seem that as the abnormal ovary approaches more and
more to a mature condition so do the accessory ducts
assume a functional size.
Now and then a frog may be found in whom the meta-
morphosis has exceeded its normal limits so as to convert
a part or even the whole of the testis into fat.
A similar condition may affect the female^ whereby a
portion of the entire ovary of one side (according to my
observations usually the right one) may degenerate into
adipose tissue.
These facts go to show that in Amphibians (but not
confined to this group) there is a tendency on the part of
the anterior extremity of the genital ridge, instead of
developing into an important tissue^ to undergo conversion
or degeneration into fat which now and then exceeds its
general limits. Hence, nearly every frog possesses as pari
of its internal anatony '* a fatty tumour.'*
It is important also to notice that this metamorphosed
tissue behaves itself exactly like a tumour: ''it has a
growth independent of the rest of the body."
For if the anterior end of the genital ridge develops
into ovarian tissue it remains of a proper size, and I have
never seen it exceed normal limits, but when represented
by fat it grows a/nd increases in size, for it has no function
to keep it in check.
Lastly, it is important to note that, in common with
fatty tumours affecting man, general emaciation has no
fATTt tUMOUES. 305
effect upon these fat bodies of frogs ; indeed^ so far as my
dissections go, the thinnest frogs and toads have the largest
and best developed fat bodies. In this respect they differ
from camels, in whose humps these collections of fat dimi-
nish towards the end of a long and toilsome journey.
Another class now awaits consideration, viz. " Dermoid
Cysts.''
It is a well-established fact that these cysts may be
made up of the most complex structures, including in one
tumour skin with its glands, hair, teeth, bone, muscular,
and in rare cases nervous tissue. Fat also enters largely
into the composition of these growths. If the facts
recorded in the first part of this paper be correctly inter-
preted, then there can be little reasonable doubt that in
the early stage of these dermoid cysts, most of the com-
plex tissues of the body may enter into their composition,
but lacking function, may later undergo fatty degenera-
tion, as in the examples of parasitic foBtuses previously
considered. The explanation is a simple one and suggests
a probable mode of accounting for the origin of fat in
these very remarkable formations.
Lastly, a few words must be written about the "Lipoma
arborescens '' occasionally found in the neighbourhood of
joints affected with chronic disease. The only example I
have seen is the very beautiful specimen (No. 327 in the
Catalogue of the Museum of the College of Surgeons)
from whence the following account is extracted :
^* A section of the condyle of a femur, around the arti-
cular margin of which there is a crowd of small oval and
branched growths, of fibrous and fatty stracture, each
covered by a shining membrane, like a reflection of syno-
vial membrane, and all attached by loDg and slender
pedicles. Their shapes and sizes are various ; some are
like branching threads; others are nearly cylindrical;
others flattened and lanceolate. They are examples of
the " Lipoma arborescens '^ of Miiller. The articular car-
tilage has been removed from the front of the condyle,
and the exposed bone is hard and polished, with an
VOL. LZVIII. 20
306 FATTY TUMOaBS.
appearance of goaty deposit on it ; elsewhere the carti-
lage is thin/'
It seems to me that in this specimen we have to deal
with a case in which viUons growths sprouted from an
inflamed synovial membrane^ but their nutrition was
interfered with^ on account of their long and slender
pedicles ; hence diminished nutrition of the little growths
led to their fatty degeneration.
It is a fact well recognised in pathology^ that^ as a rule,
growths with long and slender stalks rarely attain any
important size and often suffer necrosis or detachment in
consequence ; hence it is not propounding anything far-
fetched or fanciful to suggest that these minute fatty
tumours arise by degeneration of the villous processes which
frequently infest the syn>ovial membranes of joints in certain
chronic diseases.
Mr. Butlin in his paper on '' Fatty Tumours in In&mcy
and Childhood '^ ('Barth. Hosp. Rep./ vol. xiii) has pat
forward an opinion^ that the occurrence of fat in many of
these tumours is the result of secondary changes^ and
refers to a case reported by Weber, in which a tumour
consisted of telangiectasis, fat, and fibrous tissue ; it was
supposed that the fat and fibrous tissue resulted from
secondary changes occurring in a nsevus.
In writing on the subject of fatty tumours in his
' Surgical Pathology' Sir James Paget says : " Respect-
ing the causes of these tumours few things can
be more obscure, nearly all knowledge on this point is
negative.''
May one venture to hope that the few facts related in
this paper will go a little way towards dispersing some of
this darkness.
The substance of the paper amounts to this :
Any of th^ soft tissues of the body, normal or patho*
logical, may degenerate into fat, and this retrograded tissue
does, in some instances, assume an autonomy a/nd grow into
a fatty tumour.
A list of references to interesting examples of fatty
FATTT TUM0UE8. 80?
tnmonrs^ whose details Iiare a bearing on the views
advocated in this paper^ is appended.
Fatty Tumours in Unusual Situations, ^c.
Bone. — Attached to ischium. Mr. T. Smith, 'Path.
Soc. Trans./ vol. zvii, p. 286. To the neck of the radins.
Mr. T. Smith, 'Path. Soc. Trans.,' vol. xix, p. 844.
Attached to the clavicle. Mr. Pearce Gould, p. 294 of
this paper. To coccyx. Mr. T. Smith, ' Path. Soc.
Trans.,' vol. xxi, p. 884.
Nervous System. — A fatty tumour growing from the
superior peduncles of the cerebellum. ' Catalogue of
Museum,' Middlesex Hospital, No. 884. From the
cranial dura mater. Mr. Sibley, 'Path. Soc. Trans.,'
vol. vii, p. 1. In the interior of the spinal canal
near the seventh cervical and first dorsal vertebrsB.
' Path. Soc. Trans.,' vol. iii, p. 248, by Mr. Obr6. Median
nerve in the palm of the hand. Mr. Pearce Gk>uld,
'Catalogue of Museum,' Middlesex Hospital, No. 2191.
Patty tumours on nerves. VirchoVs ' Archiv,' Bd. xv,
s. 61. Lipoma of sacrum connected with the spinal mem-
branes. Mr. Athol Johnson, ' Path. Soc. Trans.' vol. viii,
p. 16.
In Muscles. — In the heart of a sheep. Museum,
College of Surgeons. Between the greater and lesser
pectorals. Prof. Turner, quoted in Paget's ' Surgical
Pathology.' In the tongue simulating ranula. Dr. F.
Churchill, 'Path 3oc. Trans.,' vol. xxiii, p. 234. In-
volving the biceps (Author). Beneath the tongue.
M. Cauchois, ' Gaz. des H6p.,' July 7th, 1888. Involving
the muscles of the calf. Mr. T. Smith's case, reported in
' Path. Soc. Trans.,' vol. xxviii, p. 221. In a fibro-myoma
of the uterus. Mr. T. Smith, ' Path. Soc. Trans.,' vol.
xii, p. 148. Beneath ocoipito-frontalis ; also one attached
to the complexus. Mid. Hosp. Museum.
Intestines. — Of an ox. ' Catalogue of the Museum,'
308 fATTT TUXOUBS.
College of Surgeons^ No. 824. A fatty tamonr project-
ing into the cavity of tlie gat at the angle of junction of
the two segments of the ileo-cscal valve. Prof. Turner^
Paget's ' Surgical Pathology.' Attached to the mesen-
tery. Sir Spencer Wells, ' Path. Soc. Trans./ vol. rix,
p. 248. In the abdomen. Weighing 29| lbs. Mr. Pick,
'Path. Soc. Trans./ vol. xx, p. 887. In abdomen; con-
taining osseous tissue. Dr. Dreschfeld, ' Path. Soc. Trans./
vol. zxxi^ p. 287.
Throat — In pharynx and larynx. Mr. Holt, ' Path. Soc.
Trans./ vol. v, p. 128. In pharynx. Dr. Frederick
Taylor, ' Path. Soc. Trans.,' vol. xxviii, p. 216. The right
arytseno-epiglottidean fold. Mr. Sydney Jones, ' Path. Soc.
Trans.,' vol. xxxii, p. 248.
External Orga/ns of Chneration. — To the scrotum. Mr.
Henry Gray, ' Path. Soc. Trans.,' vol. vi, p. 280. To the
labium. Unreported. A case of the author of this paper.
Lower Limb. — Sole of foot. Mr. Gray, 'Path. Soc. Trans/
vol. xiv, p. 248.
Fatty Tunoura in Paraaitie Fostiises. — Attached to the
head of the autosite. Museum, College of Surgeons.
' Teratological Catalogue,' No. 181. Attached to coccyx.
Mr. Frederick Treves, 'Path. Soc. Trans./ vol. xxxiii,
p. 287. Attached to sacrum, lipome calcific congenital.
Dr. L. Briolle, ' Gaz. des Hdpitaux,' Jan. 28rd, 1883.
Attached to median line of palate and filling the pharynx
and mouth. Arnold's case referred to by Mr. Butlin in
' Barth. Hosp. Bep.,' vol. xiii. Many examples are given
by Braune, G^schwiilste der Kreuzbeingegend.
(For a report of the discossion on this paper, see * Proceed-
ings of the Boyal MedLoal and Chimrgioal Society/ New Series,
vol. U P« ^^0
DESCRIPTION OP PLATE IV.
(Patty Tumours, by J. Blaitd Suttok, P.R.O.S.)
Pio. 1. — ^The lower limbs of the fostus described in the paper,
dissected to show the degeneration of the tissues into fat. F. Pemur.
A. T. Adipose tissue. T. Tibia.
Pia. 2. — The left OTiduct of a pigeon. The rudimentary right
oviduct is shown with a fatty tumour dereloped on its summit.
Pia. 3. — Biceps muscle from an old woman. The upper part is
occupied by a fatty tumour.
Pio. 4.— A davicle with a fatty tumour attached. Mr. Pearoe
(xould*s case.
Plate IV
Med . Chir.Tra-ns .Vol . LXVill.
Msnt-am Bros* . litK.
ON A CASE
O* TBBT I.&B8B
LYMPHO-8ARCOMATOU8 TUMOUE OF
THE TONGUE.
JONATHAN HUTCHINSON, F.R,S.,
BUEBITTB PB0FB880K OP 8UBGBBT IN THB LONDON HOSPITAL COLLIOB.
BeceiTed AprU 14th— Read Jane 9th, 1885.
Thi case whicli forms the basis of my present communi-
cation was nnder my care abont fonr years ago. The
entire tongue of a young man^ only twenty -twoj was then
removed on account of a tumour which had been slowly
growing for more than half his life^ and which had at
length attained such a size that it impeded swallowing and
even threatened suffocation. I have purposely allowed a
considerable period to elapse before submitting the case
to the consideration of the Society^ because I wished to
have the evidence afforded by time as to the true character
of the growth. Two years had passed by^ and as the patient
remained quite well^ I had begun to hope that we might
assume it as probable that the tumour was of an innocent
character. I am sorry to say^ however, that after this
long interval these hopes have been disappointed.
312 LYMPHO-SABCOMATOnS TTTHOUB OF THB TONGUE.
The whole mass weighed after removal seven ounces.
It was by far the largest tamonr of the tongue that I have
ever seen removed^ and I believe the largest on record.
The subject of the case was a medical student^ a^god^ at
the time of the operation^ twenty-two years. His father
was a medical man^ and the conditions had, consequently^
been carefully watched from the first. No growth had been
observed^ and no morbid condition of the organ noticed^
during the first few years of life^ and bis father having
had occasion to make applications to the tonsils in child-
hood^ felt sure that he should have seen it^ had anything
been present.
The first symptom that was observed was at about the
age of ten^ and consisted of a swelling in the left side of
the organ^ with a rough papillary growth on its posterior
surface. Without causing any inconvenience except from
its sizcj the tumour continued to increase^ and when^ in
the latter part of 1880, I first saw the patient^ the organ
was fixed in the mouth by its mere bulk, and speech was
difficult. At this time the tumour consisted of a large
rounded mass, deeply embedded in the tongue, and
wedging itself against the sides of the lower jaw. The
tip of the tongue was free, and could be moved on the
surface of the tumour, but with this exception the whole
of the organ was involved. The tumour could easily be
felt externally as a hard mass bulging downwards behind
the chin. The mucous membrane of the tongue over the
tumour was quite healthy, with the exception of the
posterior two thirds on the left side, which presented a
coarse papillary growth, not in the least painful, nor
ulcerated, but which was continuous with the substance of
the tumour beneath. The surface at this part was
nodular, like the outside of a mulberry. Had it not been
for this growth, which implicated the overlying parts, so
moveable was the mucous membrane and the superficial
layer of muscular structure on the tumour, that one might
have been tempted to hope that it was encapsuled, and
might possibly be shelled out.
LT1CPHO-8AB0O1CATOU8 TTTKOUB Of THB TONGUE. 318
I had had the advantage of the opinion of Sir James
Paget^ to whose kindness indeed I had been indebted for
haying the patient placed under my charge^ and I subse-
quently obtained that of Mr. Savory and several other
professional friends.
It was felt by all that the time must come when it
would be absolutely necessary to operate^ and^ encouraged
by the long duration of the case^ we were all hopeful that
the disease was not in any sense malignant. As to its
precise character^ however^ no one ventured a confident
opinion. The operation was not performed until nearly a
year after I had first seen the patient^ and in the interval
the growth had increased considerably^ and the incon-
venience had finally become unbearable.
The operation was done on November 20th, 1881, and
1 had in it the able assistance of Mr. Waren Tay and
Mr. E. W. Parker.
The patient having been put under ether a preliminary
tracheotomy was performed. It would have been better
to have done this without the anaesthetic, for as soon as
insensibility commenced the mass fell back upon the glottis
and the patient was in the utmost danger from asphyxia.
It was impracticable to draw it forward sufficiently to
effect relief, and, after a hurried completion of the tracheo-
tomy, we were obliged to do artificial respiration for some
time to restore animation. The patient having well
rallied the pharynx was next plugged with sponge, and an
exploratory incision was made into the substance of the
tumour in order to ascertain whether or not it was en-
capsuled. Finding that it was not so, that it was very
firmly fixed on all sides, and that it was quite impossible
to get the finger either beneath or beyond it from the
mouth, I at once made an incision through the lip and
chin and cut the symphysis of the jaw. Having freed
the muscular attachments and widely separated the two
halves of the jaw, access was gained to the base of
the organ. Having well isolated the mass, partly by
scissors and partly by tearing, the wire ecraseur was
814 LTKPHO-BABOOlCATOnB TUKOUB Of THS TONGUB.
applied over its base just in front of the epiglottis, and
the removal completed. There was no trouble from
haemorrhage.
No difficulty occurred in the after treatment. The
jaw united well and a rapid recovery followed.
The drawings (Plate Y) give a good idea of the ap-
pearance of the growth^ both on its surface and in section.
It will be seen that the mammillated pafcch occupies an area
larger than a crown-piece^ and that its growths are at
least a quarter of an inch in height. The tumour itself,
as seen in section, was almost globular, and measured two
and a half inches across. It completely replaced the
substance of the tongue^ with the exception of a portion
about three fourths of an inch in length at its tip. The
posterior two thirds of the growth showed a greyish fibrous
structure, which was divided into loculi by white bands.
The anterior part was red, not so hard, and much more
vascular ; but obscurely divided in like manner into lobes.
On its surface the growth was everywhere bounded by a
tolerably well-marked layer of fibrous tissue. On its
surface in many parts, especially in front, were seen what
looked like the cut ends of small muscular bundles. There
were no cysts, and nothing that was conclusively erectile.
The muscular bundles of the front part were inseparably
attached to the growth. j
One half of the tumour was sent to the College of Sur-
geons, where it was examined by Mr. Eve, the pathological
curator, who also obtained the assistance of Dr. Klein.
The other half was examined independently by my eldest
son, who had the valuable assistance of Mr. Bickman Grodlee
in inspecting the microscopic sections. These observers all
agreed in reporting that the growth was of the connective-
tissue type, and probably a round-celled or lympho-sar-
coma. Here and there in its substance muscular fibres,
atrophied by pressure, coald be demonstrated. A tendency
to the development of well-formed fibrous tissue was a
strongly characterised feature. The enclosed loculi were
of very various sizes and contained cells, which had rela-
LT1CPH0-8ABC01CAT0UB TUICOUB Of THB TONOUB. 815
tiyely large nuclei and an ill-defined cell substance.
Between the cells a fine reticular tissue was seen in
parts.
The much enlarged papillee were infiltrated with cells,
not apparently differing from those in the alveoli
beneath.
Between the papillad in some of the fissures the
deep epithelial cells had much enlarged and under-
gone granular degeneration. Eyerywhere there was a
sharp line of separation between epithelium and corium.
(PI. VII.)
It will be well before attempting to discuss the clinical
relationships of this case to give its termination, and also
to cite any evidence which can be obtained from the
records of other cases more or less resembling it.
After his recovery my patient, who was a gentleman of
great pluck, at once returned to his medical studies at
Belfast. From time to time I heard of his being quite
well, and two years after the operation I heard that he
was intending to present himself for examination at our
London College, and that I should then have an oppor-
tunity of seeing him and hearing how well he could make
himself understood. About six months later, however, I
had the disappointment of being informed of his death. A
growth had very rapidly sprouted up in the floor of his
mouth and had in a short time brought about the fatal
event, partly by pressure and partly by haemorrhage. I
did not hear of the recurrence until after his death, and
there was no post-mortem. I believe that there was no
evidence of gland disease.
I am not able to produce either from the records of
other surgeons or from my own experience, any case
which is an exact parallel to the one which has been de-
scribed. The following cases, however, in a fragmentary
way, some from one aspect, and some from another, seem
to throw light upon its probable nature. We may note
that we have to deal with a tumour which invaded the
substance of the organ in which it was placed ; which
816 LTMFHO-8AB001CATOUB TUHOUB OT THB TOHOUS.
began in very early life ; which was attended by coarse
mammiUation of the surface ; which continued to grow
painlessly and very slowly through a long series of years ;
which never produced gland disease ; which recurred
locally after removal^ and which under the microscope pre-
sented the characters of an infiltrating lympho-sarcoma^
with dilatation of blood-vessels.
The first case to which I shall refer is that of a child^
aged three^ in whom a mammillated growth on the pos-
terior part of the tongue had been present from birth.
It had caused no inconvenience but was slowly increasing.
I excised it by means of the cautery^ and the child^ I
believe, remains well. It did not go deeply into the
substance of the tongue.^ The method of removal de-
stroyed the specimen for microscopic purposes.
Specimen 1067a in the Museum of the College of Sur-
geons is the tongue of an infant in whom similar conditions,
but on a much larger scale, were present. It was shown
by Dr. Hickman, in 1869, at the Pathological Society, and
is described in vol. xx of the ' Transactions.' The infant
was bom with a mammillated tumour on the left side of
the dorsum of its tongue as big as a plum stone. It was
sessile and extended from the line of the circumvallate
papillsd back to the epiglottis. Owing to its peculiar
position, rather than its size, it caused death by suffocation
within sixteen hours of birth. A committee appointed by
the Society reported that it consisted of hypertrophied
gland follicles and ducts with an intervening matrix
of nucleated connective tissue. Its blood-vessels were
large and numerous, but there was no definite erectile
tissue.
Mr. Listen has recorded a case in which he operated on
a lad, aged nineteen, for a tumour of the tongue which
had been present from birth. In some respects this case
resembles the ordinary macroglossia of young children,
but in others it differs from it, and is suggestive rather of
^ I poaseee a oolonred sketch illnstratiiig this case. It was produced at
the Society's meetiiig.
LTKPHO-SA&COICATOITB TUKOUfi OF THB TONQUB. 817
a naovoid mole. The tongae filled the month and pro-
jected over the lips. It was elastic and compressible and
its surface was crossed by large venous trunks. The
papillad over it were much enlarged^ and granular points
were numerous. There was an ulcerated fissure near its
centre which frequently bled. Mr. Liston tied the lingual
arteries and then ligatured the whole tongue. Unfortu-
nately the patient died of pyasmia.
My next case (Plate VI) is clearly very like Mr.
Listen's excepting as to size. Its subject was^ when I first
saw him in 1872^ a lad of twelve. He is now a porter at
Woking Junction aged twenty-four^ and in good health.
The state of his tongue has not materially changed. The
portrait shows considerable hypertrophic enlargement of
the organ chiefly of its left half^ and the surface is covered
with mammillated and granular points^ just such as Mr.
Liston described, and such as were present in the case
which is the chief subject of this paper. Some of them
were vascular, Uke parts of a venous n»vus. The condi-
tion had been noticed soon after birth • and it increased
somewhat in growth. He was sent to the London Hos-
pital from Famham when he was twelve, because it had
increased somewhat, and with a view to operation. I kept
him under observation a few weeks and finding that the
condition caused the boy no inconvenience whatever I
deferred any interference. My decision has been justified
by the fact that he has got no worse. This case seems
to differ from that which my paper chiefly concerns in
that there is no tendency to continued growth in the sub-
stance of the organ. It is very possible, however, that
this tendency may yet declare itself.^
The next case was a child under the care of Mr. Waren
Tay in the London Hospital. The tumour was congenital
and deeply placed in the substance of the left half of the
^ The man who is the snhject of this case attended the meeting for
inspection. Further examination made it certain that although, as may he
seen in Plate VI, the growth appears to inyolve hoth halves, it is really limited
to the lsft» and onJjy encroaches on the right hy hnlging over.
318 LTXPHO-8AEC01CATOU8 TUKOtJR OF THS TONQtB.
tongne^ bulging both below and on the dorsum. The tip
of the tongue was free^ there was no papillary hypertrophy,
and the tumour, although partly soUd, consisted chiefly of
cysts. I beUeve the child died after an operation for its
removal.
Closely parallel to this, and presenting also features of
similarity to my own, is a case which I find narrated by
my friend Dr. George Brady, of Sunderland, in the
' Medical Times and Gazette' for 1867. An infant had,
at birth^ a bluish looking tumour under and in its tongue,
which was taken for a cyst. It was punctured freely, and
almost fatal bleeding followed. At the age of fourteen
Dr. Brady attempted the removal of the tumour, which was
then a softish solid. It was sought to excise the growth
from under the tongue without removal of the latter, but
the tumour was so ill-defined and the bleeding was such
that the operation was not perfectly completed. The boy,
however, recovered and at the end of several years was
still well and without any new growth.
A case which has been recorded, in excellent detail, by
Mr. Henry Amott, in the ' Pathological Transactions '
(vol. xxiii), well illustrates the combination of congenital
hypertrophy of various different structures in the same
organ. The infant was fourteen months old when he was
operated on by Mr. Simon in St. Thomas's Hospital. The
tongue was of very great size and lolled out between the
stretched lips. It had been large from birth and had
hindered sucking. The child died of pneumonia three
weeks after removal^ by the 6craseur, of the greater part of
the tongue. Mr. Amott records that *^ there were present,
first, a nsBvoid affection of the blood-vessels; secondly, a
thickening and induration caused by a long-continued
sub-inflammatory state ; and thirdly, a general enlargement
of the lymphatics. Bather large irregular spaces, with
very thin walls, and mostly with no visible contents, were
met with in every section. Some of these spaces were
filled with blood, but for the most part they contained
only clear fluid with a few vesicular bodies — swollen
LYMPH0-BAKC0MAT0U8 TUMOUR OP THE TONOUB. Sl9
epithelial cells — ^in oontact witli their walls^ possibly
dilated lympliatics/'
In none of the cases which I have quoted, excepting
mj own, was there any proof of the presence of any solid
growth which might deserve the name of lympho-sarcoma.
In Mr. Brady's case the growth was solid and very
possibly of this natnre; but it was not so diagnosed, and in
Mr. Listen's we have no microscopic examination at all.
In several of the others we must remember that the child
died after operation in early life and thus no opportunity
was afforded for the further developments which took
place in mine. The only recorded example of sarcoma, so
diagnosed, which I have been able to find, is one published
by Professor Jacobi, of New York, and quoted, with
valuable criticism and additional facts, by Mr. Butlin in
his ' College Lectures.' In this instance the tumour
was the size of a hazel-nut at birth, and as big as a
walnut when, at three months old, it was removed. It
was a firm, rounded, elastic mass, deeply furrowed on its
surface. Its section was uniform, excepting that in its
centre was a small cyst. Its external portions contained
muscular tissue, but its chief structure was that of a
spindle-celled sarcoma. There were some round-cells, but
not much intercellular substance. The child in this
instance was well five months after the operation but
nothing more is known of it.
The last case which I shall quote is one published
by Mr. Folker, of Hanley. In it a large solid tumour
which had been growing for twenty years was success-
fully removed from the tongue of an adult man. It was
diagnosed as '' fibrous.''
The cases which I have adduced justify, I think, the
conclusion that my case ought to rank as one of a group
in which hypertrophic structures, present in the tongue at
the time of birth, subsequently take on a more or less erratic
development. These congenital excesses are probably
analogous to moles and nadvi of the skin ; and in the
tongue, as proved in several cases, dilatation of blood-
320 LTMP»0-8ABCOMATOt78 TtJMOUE OF THB TONGtTB.
vessels and of lymphatics is a conspicaoas element in tlie
growth. We know that moles of the skin often show
▼ascolar as well as papillary and fibrons hypertrophy.
All the stmctures^ in irregular proportions in different
cases^ are involved much as we have noted in the series
which I have this evening produced. Moles and neevoid
moles of the skin sometimes take on growth tendency^ and
this may happen at any period of life^ and sometimes^ as is
well known^ melanotic sarcoma may occur in them. In
some rare instances fibroid hypertrophy in moles shows a
definite tendency to recur. I once removed for % young
lady a huge pigmented and papillary mole which grew on
the pubes and involved the labium. It was impossible to
remove the whole. A tendency to subsequent growth
was most definite^ and second and third operations were
required. The subcutaneous fibroid hypertrophy produced
a dense hard mass an inch and a half in thickness. The
pathological processes displayed in this case were probably
very similar to those which occurred in the tongue in the
case which I have had the honour to bring before the
Society.
In conclusion a few words may be said as to the sur-
gical aspects of the case. It mighty perhaps^ have been
better^ as regards the prospects of immunity^ if I had
operated when the patient first came under my notice. My
reasons for delay were^ that the growth had already
attained such a size that the operation must of necessity
be a very formidable one^ and that as it seemed highly
probable that the tumour was innocent so it was wise to
put off the danger as long as possible. Guided by our
experience in this instance^ I should certainly in any similar
case — in which a tumour in the tongue, however appa-
rently innocent, was steadily growing, however slowly —
be inclined to advise an early removal. It may be
doubted, however, whether a patient in whom such a
growth caused neither pain nor inconvenience and had
been present for years, would be inclined to submit early to
an operation involving the loss of the entire tongue. Such
LTKPHO-8AB0O1CATO17S TUKOUB OF THE TONGUE. 321
would have been the conditions nnder which any snrgeon
who saw this case before I did woold ha^e had to
advise.
(For report of the discnssion on this paper, see ' Proceedings of
the Boyal Medical and Chimrgical Society/ New Series, vol. i,
p. 458.
VOL. LXVIII, 21
DESCRIPTION OP PLATES V, VI, ahd VH.
(On a Case of very large Lympho-Barcomaioiis Tamour of the
Tongue, by Jonathan Hutchinson, F.R.S.)
Plate V.
Case of Lympho-sarcomatons Tumour (see p. 311).
Fia. 1.— The tongue, after removal, seen from before.
Fio. 2. — The same seen from the side.
Fio. 3.— A longitudinal section of the tongue from tip to base.
Plate VL
Case of Congenital Unilateral Hypertrophy of Tongue (see p. 317).
(A papillaiy, lymphatic, and nsevoid mole.)
Plate VII.
Microscopical Sections from Tongue, figured in Plate V.
(Drawn by Mr. J. Hutchinson, jun.)
Fig. 1. — Section of the surface of the tongue made through part
of two of the large "papillsB" which covered it. The epithelial
layer was everywhere well defined, and here presents nothing
abnormal; the subjacent layer is very vascular and somewhat
infiltrated with lymphoid cells, whilst towards the lower part these
show a tendency to be arranged in irregular alveoli.
a. Homy layer.
h. Bete mucosum.
c. Vessels.
d. Deep part beginning to show an alveolar arrangement.
Fig. 2. — ^A section characteristic of the great mass of the tumour,
showing large rounded alveoli filled with lymphoid cells of uniform
size, enclosed by bands of fibrous tissue and intersected by finer
strands of the latter.
Plate V.
Med CKir . Trans . Vol . LXVIll .
Plat.e VI
Med . ChiT- Trajis Vol . LXVIII
Congenital unilateral Hypertrophy of tongue.
1 K H.ifAmuM i4«l
M..t-. Vd.
': LXVLi.
v'.-V-VI'i'r/Vf >•;...•,>• ,f. A /vTl,.? ■^Jtf ■■.-''.' -■ .''•■.■'
FU
V>: :-
t^' ':-; :/r
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t. IX
INDEX.
The$e Indices to the annual volumes are made on the same principle as,
and are in eontinuation of, the General Index to the first fifty -three volumes
of the * Transactions/ They are inserted, as soon as printed, in the Library
copy, where the entire Indes to the current date may always be consulted.
ABDOMINAL SECTION, acute peritonitis treated bj (F.
Treves) .176
case of, for acute circumscribed peritonitis : recoyerj
(Howard Marsh) .185
— TUMOURS, see Tumours.
ANEUEISM of ABBOHiNAL AORTA ; distal compression ; cure of
the aneurism; death from gangrene of the jejunum on
eleventh day ; necropsy ; remarks (J. E. Luun and E. L.
Benham) . . . . 19L
State of patient before operation, 191-2; compreBsion of abdominal
aorta by Carte's tourniquet, 192-3; post-mortem appearances, 198-6 ;
note ox four recorded cases in which operative treatment has been
attempted, 196 ; remarks on symptoms daring operation in the pre-
sent case and conclusions drawn, 197-8.
which caused gangrene of the right lower extremity,
partly by embolism, and partly by pressure on the inferior
vena cava (H. Morris) . 199
State of patient on admission, 199-201 ; amputation of thigh, 201 ;
post-mortem report» 202-4.
— oiESOiD, on the dorsum of the foot, with remarks on the
disease (Walter Edmunds) .31
State of patient on admission, 81; description of operation, 82;
remarks, 32; abstract of six preWously recorded cases, 34.
— iimoMiHATE, case of double simultaneous distal ligature
for (E. Barwell; . . .123
History of patient, and state on admission, 123-8 description of
operation and subsequent account of patient, 128-30; remarks,
131-82 ; note of five other cases of double nmultaneous distal lin-
tnre, 133.
324 INDEX.
AOfiTA, ABDOMINAL, aneunBin of; dirital compression ; cure of
the aDeurism; death from gaogrene oi the jejunum on
eleventh day ; necropsy ; remarks (J. B. Lunn and F. L.
Benham) . . . ,191
which caused gangrene of the right lower extremity,
partly by embolism, and partly by pressure on the inferior
yena cava (Henry Morns) . . . 198
Arnold, John, of Demerara^ obituary notice . . 10
ATAXIA, an account of two families, several members of which
are ataxic (J. A. Ormerod) . 147
Description of Friedreich's disease, 147-8 ; account of five casea^
148-64; fstiology, 155-6; trees of the two families described, 157.
ATBOPHY, FB0QBES8ITE MUBCULAB, caso illustrating the
localisation of motor centres in the brachial enlargement
of the spinal cord (C. £. Beevor) . . 205
AXIS, case of displacement and fracture of the ; life prolonged
for ten years (D. Lowson) . . . 135
History of the case, 135-6 ; acconnt of post-mortem examination,
137 ; probable manner in which the ii^aries occurred, 137; reference
to similar cases, 138.
BACILLI, see Tubercle Bacilli.
Barclay, Andrew Whyte, M.D., obituary notice . 8
BAMWELLy Bichard,
Case of double simultaneous distal ligature for innominate
aneurysm ..... 123
Baxter, Evan Buchanan, M.D., obituary notice . . 24
BEEVOB, C. E., M.D.
Three cases (progressive muscular atrophy and infantile
paralysis) illustrating the localisation of motor centres in
the brachial enlargement of the spinal cord 205
BENHAM^ F. Z., M.D.9 see Lunn and Benham, aneurism of
abdominal aorta.
BENNETT, A, Ruahea, M.D.
Case of cerebral tumour ; the surgical treatment by B. J.
Godlee . . .243
BEACHIAL ENLAEGEMENT, see Spinal Cord.
BEAIN, TUMOiTB of, see Tumour.
CALCULUS, BEKAL, successful case of lumbar nephrectomy for
(H. Morris) . .69
INDEX. 825
CEEEBEAL TUMOUB, Bee Tumour.
CEEVICAL, STTPBBioa, GANGLION, see Sympathetic Ganglia.
CJSJMFNSYS, Francis Henry, M.B.
Od expiratory cervical emphyBema, that is emphysema of
the neck occurring during labour, and during violent
expiratory efforts \ an experimental inquiry . 37
CHOBEA, the experimental production of, and other results of
capillary embolism of the brain and cord (Angel Money)
277
Subjects and materials used, 277-8 ; account of the operation per-
formed, 279; clinical phenomena observed, 260-5; generalisation,
anatomy, pathology, 285-8 ; literature of the subject, 288-9; con-
cluding remarks, 289-91.
Clarke, William Fairlie, M.D., obituary notice . . 14
CLTJB-EOOT, observations on the badica.l cube of, and exhibi-
tion of cases which have been operated on (E. Davy) 139
Reasons that have suggested operatire procedures, and cases
especially snited, 140 ; operation for talipes varus, 140-2 ; for talipes
equinus, 143; table of cases and remarks, 144-5; description of
specimens, &c., 146.
Cory, William Gillett, M.D., ofOroydon^ obituary notice . 24
DAZBT, W,B,
Cases in which perforation of the mastoid cells is necessary
115
Daniel, James Stock, obituary notice . . .22
BAVT, Biehard.
Observations on the radical cure of club-foot, and exhibition
of cases which have been operated on • . 139
Denton, Samuel Best, M.D., obituary notice . . 3
DEEMOID ABDOMINAL TUMOUES, see Tumours.
BORAN, Alban.
Notes on so-called non-ovarian dermoid abdominal tumours
235
EBMUNBS, Walter,
Case of cirsoid aneurism on the dorsum of the foot, with
remarks on the disease • . .31
EMBOLISM, CAFiLLABT, of the braiit and cobd, experimental
production of (A. Money) . . . 277
826 nrDKx.
EMPHYSEMA, expiba.toby osbtical, that is emphysema of
the neck occurring during labour, and during yiolent
expiratory efforts (F. H. Champneys) • 36
Objects of paper, 37 ; frequency of occurrence* etiology, clinical
coorte and post- mortem records of emphysema, 38-42; mode of
experiment and apparatas used, 43; account of seventeen experi-
ments, 43-60 ; consideration of the experiments, 60-6 ; conclusions,
66 ; list of works quoted, 67.
EXTEEMITY, bioht loweb, see Leg.
FEAGTUEE and BiBPLA^CEMSirr of the axis ; life prolonged
for ten years (D. Lowson) , . 135
GANGLIA, see Sympathetic Ganglia,
GANGEENE of the biqht loweb extbemity in case of
aneurism of the abdominal aorta, caused partly by em-
bolism and partly by pressure on the inferior vena cava
(H. Morris) . . . .199
— of JEJUB^iTM in case of aneurism of abdominal aorta cured by
distal compression (J. E. Lunn and F. L. Benham) 191
QOBLEE, B, J,, see Bennett, case of cerebral tumour.
Gross, Samuel D., M.D., of Philadelphia, Hon, Fellow, obituary
notice . . . . .11
HiBMOPTYSIS, TATAL ; the statistics of the last fifteen years
of the Chest Hospital, Victoria Park ; with remarks upon
profiise non-fatal hemoptysis (S. West) . . 159
Scope of paper, 159-60; age and sex of cases described, 160;
condition of the lungs ; cause of hssmorrhage, 161 ; side and seat of
hsemorrhage, 162 ; aneurysm of pulmonary artery, 163 ; ulceration
of vessels, 166; conclusions, 167-9; table of cases, 170-3.
Hawkins, C»sar Henry, obituary notice . . 16
Hebb, E. G.
Histological examination of the tissues in Dr. Hughes
Bennett and Mr. Godlee's case of cerebral tumour . 264
HUTGHINSON, Jonathan, on a case of very large lympho-
sarcomatous tumour of the tongue . 311
INNOMINATE ANEUEISM, see Aneurism.
JEJUNUM, OAKQBEXE of, in case of aneurism of abdominal aorta
cured by distal compression (J. E. Lunn and F. L.
Benham) ... 191
JOHNSON, George, M.D., F.E S.
Annual Address as President, March 2, 1885 . 1
INDEX. 327
JODD, Percv, M.D.
On the distribution of the '^ tubercle bacilli " in the lesions
of phthisis . . .87
KIDNEY, see Nephrectomy.
£ing, David Alexander, M.B., obituary notice . . 23
LABOITE, emphysema occurring during, see Emphysema,
Lashmar, Charles, M.D., ofOroydon, obituary notice . 7
LEG, BIGHT, gangrene of, in case of aneurism of the abdominal
aorta, caused partly by embolism, and partly by pressure
on the inferior vena cava (H. Morris) . 199
LIGATXJBE, noiTBLE siMirLTAirEOUs distal, for innominate
aneurysm (B. Barwell) • 123
LOCALISATION of motob centbes, see Spinal Cbr J, brachial
enlargement of the.
ZOWSON, D., M.D.
Case of displacement and fracture of the axis ; life prolonged
for ten years .... 135
LUNir, John, and F. L. Benham, M.D.
Aneurism of abdominal aorta ; distal compression ; cure of
the aneurism ; death from gangrene of the jejunum on
eleventh day ; necropsy ; remarks. 191
LYMPHO-SAECOMATOUS TUMOUE, see Tumour.
MABSH, Howard^ a case of abdominal section for acute cir-
cumscribed peritonitis ; recovery . . 185
MASTOID CELLS, cases in which perforation is necessary
(W.B. Dalby) . . .116
Cases in which the operation should hg performed, 115; descrip-
tion of the drill med, 116 ; account of six cases, 117-21.
MONEY, Angel.
The experimental production of chorea, and other results of
capillary embolism of the brain and cord . 277
M0BBI8, ffenrv.
A successful case of lumbar nephrectomy for renal cal-
culus . . . .69
— On a case of aneurism of the abdominal aorta, which
caused gangrene of the right lower extremity, partly by
embolism, and partly by pressure on the inferior vena
cava ..... 199
MOTOB CENTBES, localisatiok of, see Spinal Cord.
MXJSCTJLAB ATBOPHT, see Atrophy.
NECK, EMPHYSEMA of, See Umphyeema.
Gro88,Samuel D,,U.D,,ofPhiladel'
phia. Foreign Honorarif Fellow 11
Hawkins, Cesar Hen'ry . . 16
King, David Alexander, M.B. .23
La8hmar,Charle8,]tf.D.,q^Ooyc{o» 7
Thomson, Allen, M.D., of JSdim-
hurghf Honorarjf Fellow . . 3
Wilson, Sir Wm. James Erasmus 20
Worthington^ William Collins . 28
328 INDEX.
NEPHBECTOMY, luhbas, for renal calculus, a BuccesBful
case (H. Morris) • . . .69
History of patient, 69-71 ; description of operation, 71-2 ; aocoant
of patient after operation, 72-4; steps to be taken before resorting*
to nephrectomy, 75; reasons for preferring lumbar to abdominal
incision, 76-9 ; amount of urea excreted, 79-81 ; condition of urine
before and after operation, 82-6.
Obituary notices of deceased Fellows of the Society, 1884-85.
Arnold, Jobn, ofDemerara . 10
Barclay, Andrew Whyte,
M.D 8
Baxter^ Evan Buchanan, M.D. 24
Clarke, William Fairlie, M.D. 14
Cory, William Gillett, M.D.,
of Clifton . . .24
Daniel, James Stock . . 22
Denton, Samuel Best, M.D. . 3
OBMEEOD, J. A., M.D.
An account of two families, several members of which are
ataxic ..... 147
PARALYSIS, htfaktile, two cases illustrating the localisation
of motor centres in the brachial enlargement of the spinal
cord (C. E. Beevor) . . . .205
PERITONITIS, ACUTE, treated by abdominal section (F.
Treves) . . . . .175
Modem surgical treatment of serous membranes, 175-7 ; bistory
of case and description of operation, 178-80; cases in wbich lapa-
rotomy bas been performed during acate peritoneal inflammation,
181 ; experiments by Dr. Parkes on dogs, 183-4; cases of laparotomy
for sbot-wounds, 184.
circumscribed, case of abdominal section for ; recovery
(Howard Marsh) . .185
Description of operation and subsequent bistory of patient^ 185-8 ;
remarks, 188-9.
PHTHISIS, distribution of the '•tubercle bacilli" in the lesions
of (Percy Kidd) . .87
Presidents Address, see Johnson {George).
SEMILUNAE (GANGLION, see Sympathetic Ganglia.
SPINAL COED ; three cases (progressive muscular atrophy
and infantile paralysis) illustrating the localisation of
motor centres in the brachial enlargement of the (C. E.
Beevor) . . . . .206
Condition of muscles, &c, in patient 1 (progressire muscular
atropby), 206-9; in patient 2 (infantile paralysis), 209-12; compa*
rison of muscles affected witb tbose assigned by Professors Ferrier and
Teo to tbe bracbial enlargement, 218-16 ; condition of patient 8 (in-
fantile paralysis), 217-18 ; table of muscles in Ferrier and Teo's
list sbowing tbose affected in these cases, 219.
INDEX. 329
SUTTON, J. Bland.
Fatty tumours .... 293
SYMPATHETIC GANGLIA, bemiluwab and supbhiob oeb-
viOAL, on the pathological histology of the (W. Hale
White) . .221
Procedure adopted in the inYettigation, 221-2 ; size, shape, naked-
eye Yaecnlarityi oedema, Ac* of the ganglia, 222-8; microaoopic
appearances — serve-cells, 224-8, nerve-fibres, 229-30, yesaels,
230-1 ; inflammation of the ganglion, 281-2; reference to Qiovanni,
Foa, Polaillon, &c., 282-8.
Thomson, Allen, M.D., of Edinburgh, Hon, Fellow^ obituary
notice . . .3
TONGUE, case of very large lymfho-sabcohatous ttjmovb
of (J. Hutchinson) . .811
Description of case, 811-12 ; account of operation, 818 ; description
of growth removed, 814-16 ; subsequent history of patient, 815 ;
relation of cases somewhat similar to preceding, 816-19; pathology
and surgical aspect of the present case, 819-21.
TREVES, Erederiek.
Acute peritonitis treated by abdominal section 175
TUBERCLE BACILLI, distribution of, in the lesions of
phthisis (Percy Kidd) . . .87
Reference to papers by Koch and Watson Gheyne, 87-8; pul-
monary lesions of phthisis, 89-90; methods employed, 90; descrip-
tion of ninety cases and summary, 91-104; distribation of bacilli
in the foregoing cases, 105-18.
TUMOUfi, CSBEBBAL, casc of (A. Hughes Bennett), the surgical
treatment by E. J. Godlee . . 243
History, &c., of patient, progress, diagnosis, and treatment of
the case, 248-7 ; account of the operation, 248-51 ; progress after
operation, 251-8; post-mortem examination, 258-68; histological
examination of the tissues by Dr. Hebb, 264; commentary on the
case, 264-75.
— very large lympho-sabcomatous, of the tongue (J.
Hutchinson) . . . • 311
TUMOUES, FATTY (J. Bland Sutton) . 293
Cases of fatty tumours in rare situations, 294-^; examples of
tissue degenerating into fat in domestic animals, &c., 296-8; tumours
from degeneration of soft parts of parasitic fostuses, 299-801 ; fat
body of firogs and toads, 801-4; dermoid cysts, 805-6; literature,
307-8.
— NOK-OYABIAN DEBMOII) ABDOMINAL, n^otoS On SO-Called
(A. Doran) .... 235
Gases of Dr. Bantock, Mr. Thornton, &c., quoted in illustration of
the paper, 285-8; reference to cases collected by Lebert, with reasons
for doubting the non-ovarian character of many of them, 239-40 ;
conclusions, 241.
VOL. LXVIII. 22
330 IHDEX.
WJEST, Samuel, M.D.
Fatal bemoptysis ; the statistics of the last fifteen years of
the Chest Hospital, Victoria Park ; with remarks upon
profuse non-fatal hiemoptysis . 159
WHITE, W. Rale, M.D.
On the pathological histology of the semilunar and superior
cervical sympathetic ganglia . . 220
Wilson, Sir William James ErasmuSp obituary notice 20
Wortbington, William Collins^ obituary notice . . 28
FHINTKD BY J. £ AD1.ABJ>, BARTHOLOMEW CLOSE.
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