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THE GIFT OF
it:
o
MEDICO-CHIEURGICAL
TEANSACTIONS
THE ROYAL
MEDICAL AND OHIBURGICAL SOCIETY
LONDON ■
VOLUME THE EIGHTY-FIFTH
{SECOND SERIES, VOLUME THE SIXTY-SEVENTH)
LONDON
LONGMANS, OBEEN AND CO.
(FOB THE KOfAL MEDICAI, AND CHIIIUUGICAL SOCIETY OF LONDON)
PATERNOSTElt ROW
Issued from the Society's House at 20, Eanaver
Square, W,
December, 1902.
PRINTED BY ADLABD AND SON, BARTHOLOMEW CLOSE, E.G.
CONTENTS
List of Officers and Council . . .
Referees of Papers ....
Trustees of the Society ....
Trustees of the Marshall Hall Memorial Fund
Committee on Suspended Animation in the DroWned
Library Committee ....
House Committee ....
List of Presidents of the Society from its Formation
List of Honorary Fellows
List of Foreign Honorary Fellows
List of Resident Fellows
List of Resident Fellows arranged according to Date of Elec tion Ix
List of Non-resident Fellows .... Ixvii
Proceedings at the Annual General Meeting (including Report
of Council) ..... Ixxxvii
List of Papers . . . ... . xcvii
Address of Frederick William Pavy, M.D , LL.D., F.R.S.,
F.R.C.P., President, at the Annual Meetings March Ist, 1902 xcix
Papers . . .1
Index . .... 361
PA61
iri
vi
vi
• •
Vll
• •
Vll
• •
Vll
• • •
Vlll
ix
X
xi
141665
ROYAL
MEDICAL AND CHIEURGICAL SOCIETY
OP LONDON.
PATBON
THE KING
OFFICERS AND COUNCIL
ELECTED MARCH 1, 1902.
ALFRED WILLETT
VICE-PEES1DENT8
fSiE R. Douglas Powell, Baet., M.D., K.C.V.O.
SiE Dyce Duckwoeth, M.D., LL.D.
N. Chables Macnamaba
Edgcombe Venijing
(Sib William Selby Chubch, Baet., M.D.
HON. TEEA8UEEB8 ■! j WaKEINGTON HaWAED
(Geobge Newton Pitt, M.D.
HON. SECEETAElESJc^j^j^j^ ^HOMAS DenT.
fNoEMAN MOOEE, M.D.
HON. LIBBAEIAN8 ^gjcKMAN J. GoDLEB, M.S.
'James Bjngston Powleb, M.D.
Aechibald Edwabd Gaeeod, M.D.
Fbancis de Havilland Hall, M.D.
Sib Isambabd Owen, M.D.
Amand Jules McConnell Rooth, M.D.
Walteb Hamilton Acland Jacobson
Henbt Edwabd Juleb
Chables R. B. Kektley
Chaeles Baeeett Lockwood
^Thomas Laubence Read
THE ABOVE FORM THE COUNCIL.
SKCUETARY AND CONSULTING LlBltAKlAN
J. Y. W. Mac Altstek, F.S.A.
OtHEB MEMBEE8
OF COUNCIL
FELLOWS OF THE SOCIETY APPOINTED BY THE
COUNCIL AS REFEREES OF PAPERS
FOR THE SESSION OF 1902-8
John Abbbcbombie, M.D.
Abthub E. J. Babeeb
Sib William H. Bennett,K.C.V.O.
Stanley Boyd, B.S.
J. Rose Bbadfobd, M.D., F.R.S.
Henby Tbentham Butlin
Thomas Buzzabd, M.D.
William Cayley, M.D.
Chables J. Cullingwobth, M.D.
Alban Doban
Pbbdebic S. Eve
Alfbed Lewis Galabin, M.D.
S. J. Gee, M.D.
J. F. GOODHABT, M.D.
W. S. A. Gbiffith, M.D.
Vincent D. Habbis, M.D.
Philip John Hensley, M.D.
SiB ViCTOB A. Haden Hobsley,
£ .Iv.b.
Walteb H. H. Jbssof, M.B.
Jebemiah McCabthy
G. H. Makins, C.B.
John Hammond Moboan, C.V.O.
F. W. Mott, M.D., F.R.S.
Joseph Fbank Payne, M.D.
Bebnabd Pitts, M.C.
Gbobge Vivian Poobb, M.D.
Philip H. Pye-Smith, M.D., F.U.IS.
Fbedebice T. Robebts, M.D.
Abthub Ebnest Sansom, M.D.
^eymoub J. Shabeey, M.D.
A. Mabmaduke Sheild, B.C.
•
Hebbebt R. Sfenceb, M.D.
Fbedebice Taylob, M.D.
HowABD H. Tooth, C.M.G., M.D.
Augustus Walleb, M.D., F.K.IS.
William Johnson Walsham, CM.
TRUSTEES
TRUSTEES OP THE SOCIETY'S INVESTMENTS
Walteb Butleb Cheadle, M.D.
Fbedebice Taylob, M.D.
Alfbed Willett
T&USTEES fob the DEBENTUBE-HOLDEKb
Samuel Jones Gee, M.D., Chairman
Sib Thomas Bablow, Babt., K.C.V.O., M.D.
C. Theodobe Williams, M.D.
TRUSTEES OF THE MARSHALL HALL MEMORIAL FUND
Walteb Butlek Cheadle, M.D.
WiLLiiM Ogle, M.D,
Sib Thomas Smith, Babt.
COMMITTEES
COMMITTEE APPOINTED TO INVESTIGATE THE SUBJECT OF
SUSPENDED ANIMATION IN THE DROWNED
Edwakd Albert Schafeb, F.R.S., Chairman
The Pbbbident
The Hon. Secbetabies
Fbedebick W. Mott, M.D., F.R
Henby Poweb
Thomas Pickebing Pice, Hon, Sec.
LIBRARY COMMITTEE FOR 1902-3
The President
The Hon. Libbabians
The Hon. Secbetabies
W. R. Dakin, M.D.
Alban Doban
William Ewabt, M.D.
W. P. Hebbingham, M.D.
Stephen Paget
Joseph Fbank Payne, M.D.
Geobge Vivian Poobe, M.D.
D'Abcy Poweb, M.B.
P. H. Pye-Smith, M.D., F.R.S.
A. QUABBY SiLCOCK, B.S.
house committee FOR 1902-3
The Pbesident
The Hon. Tbeasubebs
The Hon. Libbabians
The Hon. Secbetabies
H. E. JULEB
T. Laubence Read
PRESIDKNTS Of THE SOCIETY PBOM ITS POBMATION
AS THE "MEUICO-CHIBURGIOAL SOCIETY/' 18«J
ELBCTBD
moa WlLLUil SAUNUEKS, M.D.
1808 MATTHEW BAII.LIE, M.D.
1810 sui ilENRY ilALFOKD, Babt., M.D., G.C.Ii.
18J8 SIK GILBERT BLANE, Ba»t., M.D,
18ia IIENKY CLINE
1817 WILLIAM BABINUTON, M.D.
1819 SIR AS'l'LKY I'ASTiJN COOPER, Bart,, K.C.H,
1821 JOHN COOKE, ML
1H23 JOHN ABERNETHY
1825 (JEOHGE BIHKBECK, M.D.
1827 BENJAMIN TKAVERb
1829 PETER MARK KOUET, M.D
1831 SIR WILLIAM LAWRENCE, Ba»t.
1833 JOHN KI.I.|ill.OX.M.D.(Fir.lFr«.id«nlurtb>ti<H:ict)'.IU-r
u 1 . ;,■> .,. llo)-al.M.-.li.:»lumlClilrurxi.'Hl8o.-i.rlyo(
183S UENiii 'l,',w;l,i.
1837 KICHARD BRIGHT, M.D.
1839 SIR BENJAMIN Col,lJNS BRODIE, Bami.
1841 ROBERT WILLIAMS. M.D.
1843 EDWARD STANLKV
I84S WILLIAM I'UliDLlllCk CHAMBERS, M.D.. K.C.H.
1847 JAMES MOKCUIEFI ARNOTT
1849 THOMAS ADDISON, M.D.
1851 JOSEPH HODGSON
1853 JAMBS COJ'LAND, M.D.
1855 C-ESAR HENRY HAWKINS
1357 SIR CHARLES J.OCOCK, Bakt., M.D,
1839 FREDERIC CARPENTER SKEY
1861 liENJAMlN GUY BASINGTON, M.D
1863 RICHARD PARTRIDGE
1865 SIR JAMBS ALDERSON. M.D.
1867 SAMUEL SOLLY
186S SIR GEORGE BURROWS, Baet., M.D,
1871 THOMAS BLIZARD CURLING
1873 CHARLES JAMES BLA8IUS WILLIAMS, AID.
1875 SIR JAMES PAGET. B*rt,
1877 CHARLES WEST, M.D,
1879 JOHN ERIC ERICHSEN
1881 .4.NDREW WUYTB BARCLAY, M.D
1882 JOHN MARSHALL
1884 SIR GEORGE JOHNSON, M.D,
1886 GEORGE DAVID POLLOCK
1888 ;iIR EDWARD HENRY SIEVEKINU, M.D.
1890 TIMOTHY HOLMES
1892 SIR A^JDREW CLARK, Babt., M.D.
(Died; titk Nov.. 1893. (Ill <i Sir. W. S.Chiirch, Senior [JI/-W,V„/
Vice-PresideHt.ucleil ns PreaidciU until 1st March. I.";i4,
1894 JONATHAN HUTCHINSON
1896 WILLIAM HOWSHIP DICKINSON M D.
1898 THOMAS BRYANT
1900 FREDERICK WILLIAM PAVY. M.D., LLI),, t'li.K
1902 ALFRED WILLETT
HONORARY FELLOWS
(Limited to Twelve.)
Elected
1887 Foster, Sir Michael, K.C.B., M.D., LL.D., F.R.S., M.P.,
Professor of Physiology in the University of Cam-
bridge, Nine Wells, Great Shelford, Cambridge.
1868 Hooker, Sir Joseph Dalton, M.D., C.B., G.C.S.I., D.C.L.,
LL.D., F.R.S., Corresponding Member of the Academy
of Sciences of France; The Camp, Sunniiigdale.
1896 Kelvin, The Right Hon. Lord, P.C, G.C.V.O., F.R.S ,
Pres. R.S.E., D.C.L., LL.D., &c., Glasgow.
1878 AvEBURY, The Right Hon. Lord, D.C.L., LL.D., F.R.S.,
High Elms, Farnborough, Kent, R.S.O.
1873 Stokes, Sir George Gabriel, Bart., M.A., D.C.L., LL.D.,
Sc.D., F.R.S. , Lucasiau Professor of Mathematics in the
University of Cambridge i Lensfield Cottage, Cam-
bridge.
1887 Turner, Sir William, M.B., D.C.L., LL.D., F.R.S., Pro-
fessor of Anatomy in the University of Edinburu;h ;
6, Eton Terrace, Edinburgli.
FOREIGN HONORARY FELLOWS
(Liaited to Tveaty.)
Elected
1878 Baccslli, Guido, M.D., Rome.
1896 VON Bergmann, Ernst, Berlin.
1887 Billings, John S.,M.D., D.C.L.Ozou., New York.
1896 CzERNT, Vincent, M.D., Heidelberg.
1896 Erb, Wiluelm, M.D., Professor of Clinical Medicine,
Heidelberg.
1887 VON EsMARCU, His Excellency Friedricu, M.D., Kiel.
1896 FouRNiER, Alfred, M.D., Paris.
1896 Koch, Robert, M.D., Berlin.
1896 KocHER, Theodore, M.D., Berne.
1868 KoLLiKER, Albert, Wiinburg.
1896 Layeran, a., M.D., Paris.
1896 Marie, Pierre, M.D., Paris.
1896 Mirza-Ali, M.D., Teheran.
1896 Mitchell, Samuel Wbiu, M.D., PhiUdelplna.
FELLOWS
OF THB
KOYAL MEDICAL AND CHIRURGICAL SOCIETY
OF LONDON
EXPLANATION OF THE ABBREVIATIONS
P. — President. C. — Member of Council.
V.P. — Vice-President. Sci, Com. — Member of a Scientific Committee.
T. — Treasurer. So, Com. — Member of House Committee.
L. — Hon. Librarian. Lib, Com. — Member of Library Committee.
S. — Hon. Secretary. Bldff, Com. — Member of Building Committee.
Dis. Com. — Member of Discussions Committee.
The abbreviations Trans, and Pro., followed by figures, show the number of
Papers which have been contributed to the Transactions or FrO'
ceedings by the Fellow whose name they follow. Referee, Sci, Com., Lib.
Com., Bldg. Com.y Ho. Com., and Dis. Com., witli the dates of office, are
attached to the names of those who have served as Referees of papers
and on the Committees of the Society.
Names printed in this type ^I'e of those Fellows who have paid the Com-
position Fee in lieu of further annual subscriptions.
Names printed in this ti/pe are of those Fellows who have paid the Com-
position Fee entitling them to receive the Transactions.
RESIDENT FELLOWS
[N.B. — Fellows are reminded that they are, themselves, responsible for the
correctness of the descriptions in the following lists, and it is
particularly requested that any change of Title, Appointment, or
Residence may be t;ommunicated to the Hon. Secretaries before the
1st of July in each year.]
Elected
IS98 Aarons, S. Jervois, M.D., 14, Stratford place, Oxford
street.
1877 Abercrombie, John, M.D., Phypician to, and Lecturer on
Forensic Medicine at, Charing Cross Hospital; 23,
Upper Wimpole street, Cavendish square. C. 1896-8.
Referee, 1898 — . Trans, 2.
XII RESIDENT VKLLOW8
Elected
1885 A.BBAHAM, Phinkas S., M.A., M.l)., Dermatologist to
the West London Hospital, Assistant Surgeon to
Hospital for Diseases of the Skin, Blackfriars; 2,
Henrietta street, Cavendish square.
1885 AcLAND, TuEODOBE Dyke, M.D., Physician to St. Thomas's
Hospital, and Physician to the Hospital for Consump-
tion and Diseases of the Chest, Brompton ; 19,Bryan-
ston square.
1897 Addison, Christopher, M.D., Charing Cross Hospital
Medical School, Chandos street.
1879 Allchin, William Henry, M.D., F.R.S. Ed., Senior
Physician to the Westminster Hospital; 5, Chandos
street, Cavendish square. C. 1898-9. Referee^ 1897.
1890 Allingham, Herbert William, Surgeon to His Majesty's
Household, Surgeon to the Great Northern Hospital ;
Assistant Surgeon to St. George's Hospital; 25, Gros-
venor street, Grosvenor square.
18S8 Anderson, John, M.D., C.I.E., Physician to the Seamen's
Hospital, Greenwich ; Lecturer on Tropical Medicine
at St. Mary's Hospital Medical School ; 9, Harley
street, Cavendish square.
1891 Andbewes, Frederick William, M.D., Highwood,
Hampstead lane, Highgate.
1902 Armour, Donald John, M.B., Bentinck street.
1893 Bailey, Robert Cozens, M.S., 21, Welbeck street,
Cavendish square.
1891 Baker, Charles Ernest, M.B., 5, Gledhow gardens,
South Kensington.
1900 Baldwin, Aslett, 6, Manchester square.
1887 Ball, James Barry, M.D., Physician to the West
London Hos[)ital ; 12, Upper Wimpole street. Caven-
dish square.
IIUSIDBNT FELLOWS Xlll
Elected
i88o Ballancb, Charles Alfred, M.S., Assistant Surgeon to
St. Thomas's Hospital and to the Hospital for Sick
Children, Great Ormond street ; Surgeon to the
National Hospital for the Paralysed and Epileptic,
Queen square; 106, Harley street, Cavendish square.
Trans. 6.
1879 Barker, Arthur Edward James, Professor of the Prin-
ciples and Practice of Surgery and Professor of Clinical
Surgery at University College, and Surgeon to Uni-
versity College Hospital, London ; 87, Harley street.
Cavendish square. C. 1895-7. Referee, 1897 — .
Tr^ns. 7.
1876 Barlow, Sir Thomas, Bart., K.C.V.O., M.D., B.S.,
Trustee for Debenture- holders ; Physician to His
Majesty's Household ; Physician to University College
Hospital; 10, Wimpole street. Cavendish square. C.
1892. S. 1899-1902. Referee, 1896-9. Trans. 2.
1893 Barrett, Howard, 49, Gordon square.
1880 Barrow, A. Boyce, Surgeon to King's College Hospital;
8, Upper Wimpole street, Cavendish square.
1896 Barton, James Kingston, 14, Ashburn place, Courtfield
road, South Kensington.
1859 Harwell, Richard, Consrulting Surgeon to the Charing
Cross Hospital ; o.5,Wimpole street. C. 1876-77. V.P.
1883-4. Referee, 1868-75, 1879-82. Trans. 12.
Pro. 1.
1868 Bastian, Henry Charlton, M.A., M.D., F.R.S., Emeritus
Professor of the Principles and Practice of Medicine
and of Clinical Medicine in University College,
London ; Consulting Physician to University College
Hospital and Physician to the National Hospital for
the Paralysed and Epileptic ; 8a, Manchester square.
C. 1885. Referee, 1886-96. Trans. 3.
1890 Bateman, William A. F., Bridge House, Eichmond,
Surrey.
1891 Batten, Frederick E., M.D., B.C., 33, Harley street.
XIV RESIDENT FELLOWS
Elected
1875 Beach, Fletcher, M.B., Physician to the West End
Hospital for Nervous Diseases, Winchester HoiiRe,
Kingston Hill [79, Wimpole street].
1883 Bbale, Edwin Clifford, M.A., M.B., Physician to the
City of London Hospital for Diseases of the Chest,
and Physician to the Great Northern Central 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. 1876-7. Referee, l873-r*.
Trans, 1.
1897 Beddabd, a. P., M.B., Assistant Physician to Guy's
Hospital ; 44, Seymour street.
1880 Beevor, Charles Edward, M.D., Physician for Out-
patients to the National Hospital for the Paralysed and
Epileptic, and to the Great Northern Hospital; 135,
Harley street. Cavendish square. C. 1900-2. Referee^
1896-1900. Trans, 1.
1901 Beevor, Sir Hugh Reeve, Bart., M.D., 17, Wimpole
street. Cavendish square.
1877 Bennett, Sir William Henry, K.C.V.O., Surgeon to
St. George's Hospital ; 1, Chesterfield street, Mayfair.
C. 1893-4. Referee, 1892-93, 1899—. Trans. 4.
1897 Berkeley, Comyns, M.B., B.C., Physician to Out-
Patients, Chelsea Hospital for Women ; .53, Wimpole
street.
1885 Berry, James, B.S., Surgeon to the Royal Free Hospital,
and Lecturer on Surgery at the London School of
Medicine for Women ; Demonstrator of Practical Sur-
gery, St. Bartholomew's Hospital ; 21, Wimpole street,
Cavendish square.
#
1893 BiDWELL, Leonard A., Senior Assistant Surgeon to the
West London Hospital; 15, Upper Wimpole street,
Cavendish square.
RESIDENT FELLOWS XV
Elected
1851 Birkett, John, F.L.S., Consulting Surgeon to Guy'8
Hospital ; Corresponding Member of the Soci6t^
de Chirurgie of Paris ; 1, Sussex gardens. L. 1856-7.
S. 1863-5. C. 1867-8. T. 1870-78. V.P. 1879-80.
Referee, 1851-5, 1866, 1869. Set. Com. 1863. Lib.
Com. 1852. Trans. 8.
1897 Blacker, G. F., M.D., Obstetric Physician to University
College Hospital and to the Great Northern Central
Hospital ; 11, Wimpole street, Cavendish square.
1901 Blaikie, J. Brunton, M.D., CM., 22, Grosvenor street
Grosvenor square.
1883 Bland-Sutton, John, Assistant Surgeon to the Middle-
sex Hospital; Surgeon to the Chelsea Hospital for
Women ; 47, Brook street, Grosvenor square. Trans.
6.
1865 Blandford, George Fielding, M.D., Lecturer on Psycho-
logical Medicine at St. George's Hospital ; 48, Wimpole
street, Cavendish square. C. 1883-4. V.P. 1898-
1900.
1891 BoKENHAM, Thomas Jessopp, 10, Devonshire street,
Portland place.
1882 BowLBY, Anthony Alfred, C.M.G., Assistant Surgeon to
St. Bartholomew's Hospital; 24, Manchester square.
Trans. 8.
18/0 Bowles, Robert Leamon, M.D.^ 16, Upper Brook street,
Grosvenor square. C. 1897-9. Sci. Com. 1896-
1902. Trans. 3.
1886 BoxALL, Robert, M.D., Obstetric Physician to Out-
patients, and Lecturer on Midwifery and Diseases of
Women, at the Middlesex Hospital; 40, Portland place.
1884 BoYD> Stanley, B.S., Surgeon to, and Lecturer on
Surgery at, the Charing Cross Hospital; Surgeon
to the Paddington Green Children's Hospital; Con-
sulting Surgeon to the New Hospital for Women ; 134,
Harley street, Cavendish square. Referee, 1895 — .
Trans. 1.
XVI RKAinKNT KKLLOWK
Electeti
1890 Bradford, John Rose, M.I)., I). So., F.IIS., PlivRician
to University College Hospital ; S, Manchester square.
Referee, 1899—. Tram. 1.
1897 Bbailey, William Arthur, M.D., 11, Old Burlington
street.
1899 Bbemridge, Richard Habding, 72, Great Russell street.
1901 Beewerton, Elmore Weight, 45, Weymouth street,
Portland place.
1898 Broadbent, J. F. H., M.D., 35, Seymour street.
1868 Broadbent, Sir William Henry, Bart., K.C.V.O., M.D.,
E.R.S., LL.D., Physician in Ordinary to II. M. the
King ; Consulting Physician to St. Mary's Hospital ;
Consulting Physician to the London Fever Hospital ;
84, Brook street, G-rosvenor square. C. 1885.
Referee, 1881-4, 1891-7. Trans. 5.
1872 Brodie, Geoege Beenaed, M.D., Consulting Physician-
Accoucheur to Queen Charlotte's Hospital ; 3, Carlos
place, Grosvenor square. Trans. \.
1880 Browne, James William, M.B., 37, Holland Park
avenue. C. 1900-1.
1881 Browne, Oswald Auchinleck, M.A., M.D., Physician to
the Royal Hospital for Diseases of the Chest and to
the Metropolitan Hospital ; 7, Upper Wimpole street.
1874 Bruce, John Mitchell, M.D., Physician to, and Lecturer
on Medicine at, the Charing Cross Hospital; Con-
sulting Physician to the Hospital for Consumption,
Brompton; 23, Harley street. C. 1892, 1S97-9. S.
1893-6. ScL Com. 1889-1902. Ho. Com. 1898-9.
Referee, 1886-91. Lib. Com. 1888-91. Trans. ^.
1898 Bruce, Samuel Noble, 15, Queensborough terrace, Ilvde
Park.
1871 Brunton, Sir Thomas Lauder, M.D., D.Sc, LL.D.,
F.R.S., Physician to, and Lecturer on Pharmacology
and Therapeutics at, St. Bartholomew's Hospital; 10,
Stratford place, Oxford street. C. 1888-9. Referee,
1880-87. Lib. Com. 1882-7. Trans. 2.
RESIDENT FELLOWS XVll
Elected
1898 Bryant, J. H., M.D., Assistant Physician to Guy's
Hospital; 4, St. Thomas's street, London bridge.
I860 Bryant, Thomas, M.Ch., Honorary Surgeon-in-Ordinary
to H.M. the King, Consulting Surgeon to Guy*s
Hospital; Member of the Society de Chirurgie, Paris;
27, Grosvenor street, Grosvenor square. P. 1898-1900.
C. 1873-4. V.P. 1885-6. Sci. Com. 1863. Beferee,
1882-4. Lib. Com, 1868-71. Trans, 17. Pro, 1.
1901 BucKNALL, Thomas Rupert Hampden, M.S., M.D. ; 35,
Harley street, Cavendish square.
1889 Bull, William Charles, M.B., Aural Surgeon to, and
Lecturer on Aural Surgery at, St. George's Hospital ;
5, Clarges street, Piccadilly.
1893 BuRGHARD, Fr^d^ric Francois, M.D., M.S., Surgeon
to King's College Hospital and Paddington Green
Children's Hospital; 86, Harley street. Cavendish
square.
1885 Butler-Smythe, Albert Charles, Senior Out-Patient
Surgeon, Samaritan Free Hospital for Women and
Children, Soho ; Senior Surgeon to the Grosvenor
Hospital for Women and Children ; 76, Brook street,
Grosvenor square.
1873 BntHn, Henry Trentham, D.C.L., Surgeon to St.
Bartholomew's Hospital ; 82, Harley street. Cavendish
square. C. 1887-8. 22c/pre^, 1893— . Trans, A. Pro, I,
1896 BuTTAR, Charles, M.D., 10, Kensington gardens square.
Bays water. Pro, 1.
1883 Buxton, Dudley Wilmot, M.D., B.S., Administrator, and
Teacher of the Use, of Anaesthetics, in University College
Hospital ; Consulting Anaesthetist to the National Hos-
pital for the Paralysed and Epileptic, Queen square,
and Anaesthetist to the London Dental Hospital ; 82,
Mortimer street, Cavendish square.
1899 Buzzard, Edward Farquhar, M.B., 33, Harley street.
Cavendish square.
VOL. LXYXV. 1)
• • •
XVIU RESIDENT FELLOWS
Elected
1868 Buzzard, Thomas, M.D., Physician to the National Hos-
pital for the Paralysed and Epileptic ; 74, Grosvenor
street, Grosvenor square. C. 1 880-6. Referee, \SS7 — .
1885 Cahill, John^ M.D., Sargeon to the Hospital of St.
John and St. Elizabeth; 12, Seville street, Lowndes
square.
1893 Caley, Henry Albert, M.D., Physician in charge of
Out-patients, Lecturer on Materia Medica and Thera-
peutics, and Dean of the Medical School, St. Mary's
Hospital ; 24, Upper Berkeley street, Portman square.
1887 Calvert, James, M.D., 113, Harley street. Trans. 1.
1897 Cantlie, James, M.B., 46, Devonshire street.
1901 Cargill, Lionel Vernon, 31, Harley street, Cavendish
square.
1888 Carless, Albert, M.S., Professor of Surgery in King's
College, London ; Surgeon to King's College Hospital ;
10, Wei heck street.
1896 Carr, J. Walter, M.D., Physician to the Boyal Free
Hospital ; Physician to the Victoria Hospital for
Children; 19, Cavendish place. Trans. 1.
1898 Carter, H. Ronald, 11, Leonard place, Kensington.
1853 Carter, Robert Brudenell, Consulting Ophthalmic
Surgeon to St. George's Hospital; 31, Harley street,
Cavendish square, and Kenilworth, Clapham common.
Trans. 1.
1888 Cautley, Edmund, M.D., B.C., 15, Upper Brook street.
Trans. 1.
1871 Cayley, William, M.D., Consulting Physician to the
Middlesex Hospital, Consulting Physician to the London
Fever Hospital, and to the North-Eastern Hospital for
Children; 27, Wimpole street. Cavendish square. C.
1888. Referee, 1886-7, 1899—. Lib. Com. \SS6 -7.
Trans. 2.
1879 Champneys, Francis Henry, M.D., Physician-Accoucheur
and Lecturer on Obstetric Medicine at St. Bartholo-
mew's Hospital; 42, Upper Brook street, Grosvenor
square. C. 1898-1900. Referee, 1891-8. Lib.
Com. 1885-98. Trans. S.
RESIDENT FELLOWS XiX
Elected
1868 Cheadle, Walter Butler, M.D., Trustee ; Physician to,
and Lecturer on Clinical Medicine at, St. Mary's Hos-
pital; Consulting Physician to the Hospital for Sick
Children; 19, Portman street, Portman square. S.
1886-8. C. 1890-91. 5ci. Cbw. 1889-95. Bldg. Com.
1889-92. Referee, 1885. Trans, I.
1879 Cheyne, William "Watson, M.B., F.R.S., Surgeon to
King's College Hospital, and Professor of Clinical
Surgery in King's College, London; 75, Harley street.
Cavendish square. C. 1897-9. Referee, 1894-7. Lib.
Com. 1886-8, 1891-6. Trans. 1.
1890 Childs, Christopher, M.D., 10, Manchester square.
1866 Chnrch, Sir William Selby, Bart., K.C.B., M.D., Hon.
m
Treasurer, President of the Royal College of Physicians
of London, Physician to, and Lecturer on Clinical
Medicine at, St. Bartholomew's Hospital ; 130, Harley
street, Cavendish square. C. 1885-6. V.P. 1892-4.
T. 1894—. Referee, 1874-81. Ho. Com. 1898—.
1879 Clark, Andrew, Surgeon to, and Lecturer on Surgery
at, the Middlesex Hospital; 71, Harley street, Caven-
dish square.
1882 Clarke, Ernest, M.D., B.S., Surgeon to the Central
London Ophthalmic Hospital ; Ophthalmic Surgeon to
the Miller Hospital; 3, Chandos street. Cavendish
square.
1890 Clarke, James Jackson, M.B., Assistant Surgeon to the
North- West London and City Orthopaedic Hospitals ;
18, Portland Place.
1848 Clarke, John, M.D., 48, Carlisle place, Victoria street.
C. 1866.
1888 Clarke, Robert Henry, M.B., 80, Hamlet Gardens,
Ravenscourt Park.
XX RKSIDKNT KKLLOW8
Elected
1881 Clarke, W. Bbuce, M.B., Assistant Surgeon to, and
Lecturer on Anatomy at, St. Bartholomew *» Hospital ;
Surgeon to the West London Hospital, 51, Harley
street. Cavendish square. C. 1899-1901. Tram. 1.
1879 Clutton, Henry Hugh, M.B., M.C., Surgeon to St.
Thomas's Hospital; 2, Portland place. C. 1897-9.
1)18, Com. 1897-8. Referee^ 1896-7. TranM. 3.
1888 Cock, Frederick William, M.D., 1, Porchester Houses.
Porchester square.
1902 Collier, James Stansfield, M.D., B.Sc, 57a, Wimpole
street.
1897 CoLMAN, W. S., M.D., Assistant Physician to St. Thomas's
Hospital ; 9, Wimpole street.
1865 Cooper, Sir Alfred, Surgeon in Ordinary to H.R.H. the
Duke of Saxe-Coburg-Gotha ; Consulting Surgeon
to the West London Hospital and to St. Mark's Hos-
pital : 9, Henrietta street, Cavendish square.
1898 CoRFiELD, W. H., M.D., Professor of Hygiene and Public
Health at University College, London ; Medical
Officer of Health for St. George's, Hanover square ;
19, Sa?ile row, and Whindown, Bexhill, Sussex.
1889 CosENs, Charles Henry, 49, Oxford terrace, Hyde Park.
1902 Cotton, Holland John, M.D., CM., 33, Lowndes
street.
1860 Conper, John, Consulting Surgeon to the Royal London
Ophthalmic Hospital and to the London Hospital;
80, Grosvenor street. C. 1876. Referee, 1882-3.
1877 CouPLAND, Sidney, M.D., Commissioner in Lunacy;
late Physician to, and Lecturer on Medicine at, the
Middlesex Hospital ; 16, Queen Anne street. Cavendish
square. C. 1893-4. Referee, 1892-3. Ho. Com.
1895-8.
1862 Cowell, Georoe, Consulting Surgeon to the Westminster
Hospital and to the Royal Westminster Ophthalmic
Hospital; 24, Harrington gardens. South Kensington.
C. 1882-3.
RESIDENT FELLOWS XXI
Elected
1897 Ceawfued, Raymond H. Payne, M.D., 71, Harley
street.
1878 Chichton-Browne, Sir James, M.D., LL.D., F.R.S.,
Lord Chancellor's Visitor in Lunacy; 61, Carlisle
place Mansions, Victoria street.
1874 Cripps, William Harrison, Surgeon to St. Bartholomew's
Hospital ; 2, Stratford place, Oxford street. C.
1890-91. Trans. 1.
1882 Crocker, Henry Radcliffe, M.D., Physician to the Skin
Department, University College Hospital; 121, Harley
street, Cavendish square. Trans, 3.
1898 Cromeie, Alexander, M.D., 3, Bickenhall Mansions,
Gloucester place.
1899 Crosse, W. H., M.D., 37, Albemarle street, Piccadilly.
1890 Crowle, Thomas Henry Rickard, 35, St. James's
place.
1888 CuLLiNGWORTH, Charles James, M.D., D.C.L., Obstetric
Physician and Lecturer on Diseases of Women to St.
Thomas's Hospital; 14, Manchester square. Referee^
1896—.
1879 CuMBERBATCH, A. Elkin, M.B., Aural Surgeon to St.
Bartholomew's Hospital, and to the National Hos-
pital for the Paralysed and Epileptic; 80, Portland
place. Trans, 1.
1898 CuRRiE, A. Stark, M.D., 81, Queen's road, Finsbury
park.
1886 Dakin, William Radford, M.D., Obstetric Physician to,
and Lecturer in Midwifery at, St. George's Hospital,
and Physician to the General Lying-in Hospital ;
8, Grosvenor street, Grosvenor square. Lib. Com,
1902—.
7872 Dalby, Sir William Bartlett, M.B., Consulting Aural
Surgeon to St. George's Hospital; 18, Savile row.
C. 1896-7. V.P. 1901-2. Trans. 4.
XXll RESIDENT FELLOWS
Elected
1891 Dalton, Noeman, M.D., Physician to King's College
Hospital ; Professor of Pathological Anatomy in
King's College, London; 4, Mansfield street, Caven-
dish square.
1896 Dauber, John Henry, M.B., B.Ch., Assistant Physician
to the Hospital for Women, Soho square ; 29, Charles
street, Berkeley square.
1889 Dean, Henry Percy, M.S., Surgeon to the London
Hospital ; 69> Harley street. Cavendish square.
1878 Dent, Clinton Thomas, Hon. Secretary, Surgeon to,
and Lecturer on Surgery at, St. George's Hospital ;
61, Brook street. C. 1890. S. 1901— . Bldg. Com.
1890-2. Beferee, 1892—1901. Trans. 6.
1891 De Santi, Philip Robert William, Assistant Surgeon
and Aural Surgeon to the Westminster Hospital ;
15, Stratford place.
1894 Dickinson, Thomas Vincent, M.D., Physician to
the Italian Hospital, Queen square ; 33, Sloaue
street.
1859 Dickinson, William Howshif, M.D., Consulting P)iy-
sician to St. George* s Hospital, and Consulting Phy-
sician to the Hospital for Sick Children ; Honorary
Fellow of Caius College, Cambridge ; 9, Chesterfield
street, Mayfair. P. 1896-8. C. 1874-5. V. P. 1887.
Referee, 1869-73. 1882-6. Sci. Com. 1867, 1879,
1889-96. Trans. 16.
1891 Dickinson, William Lee, M.D., Assistant Physician to
St. George's Hospital and to the Hospital for Sick
Children ; 9, Chesterfield street, Mayfair.
1889 DoDD, Henry Work, Surgeon to the Royal Westminster
Ophthalmic Hospital; Ophthalmic Surgeon to the
Royal Free Hospital and to the West-End Hospital
for Nervous Diseases ; 136, Harley street. Cavendish
square.
c
RESIDENT FELLOWS Xxiii
Elected
1888 DoNELAN, James, M.B., M.C., Physician to the Italian
Hospital^ Queen square ; 6, Manchester square.
1877 DoRAN, Alban Henry Griffiths, Surgeon to the Samn-
ritan Free Hospital ; 9, Granville place, Portman square.
C. 1893-4. Lib. Com. 1891-3, 1899—. Referee,
1898—. Trans. 3.
1891 Dove, Percy W., M.B., 80, Crouch hill.
1896 DowNES, Joseph Lockhart, M.B., CM., 269, Romford
road.
1893 Drysdalb, John H., M.B., 11, Devonshire place.
1865 Duckworth, Sir Dtce, M.D., LL.D., Physician to, and
Lecturer on Clinical Medicine at, St. Bartholomew's
Hospital; 11, G-rafton street. Bond street. C. 1883-4.
V.P. 1902— Refereey 1885-97. Trans. 2.
1880 Dunbar, James John Magwhirter, M.D., Hedingham
House, Clapham Common.
1884 Duncan, William, M.D., Obstetric Physician to, and
Lecturer on Midwifery at, the Middlesex Hospital; 6,
Harley street, Cavendish square.
1887 Dunn, Hugh Pergy, Ophthalmic Surgeon to the West
London Hospital ; 54, Wimpole street. Cavendish
square.
1898 Dunn, L. A., M.S., 51, Devonshire street, Portland
place.
1874 Durham, Frederic, M.B., Senior Surgeon to the North-
West London Hospital; 52, Brook street, Grosvenor
square.
1894 Durham, Herbert Edward, M.B., 52, Brook street,
Grosvenor square. Trans. 2.
1868 Eastes, George, M.B.Lond.,35, Gloucester terrace, Hyde
Park. C. 1892-3.
XXIV RESIDENT FELLOWS
Elected
1893 EccLEs, William McAdam, M.S., A8i«i8tant Surgeon to
the West London Hospital and to the City of Loudon
Truss Society; 124, Harley street.
1891 Eddowes, Alfred, M.D., 28, Wimpole street.
1898 Edkins, J. S., Brambles, Watford road, Nortliwood.
1898 Edmunds, P. J., M.B., 5, Great Marlborough street,
Regent street.
1883 Edmunds, Walter, M.C, 2, Devonshire place, Portland
place. Trans. 3.
1884 Edwards, Frederick Swinford, Surgeon to the West
London Hospital, and to St. Peter^s Hospital ; Senior
Assistant Surgeon to St. Mark's Hospital ; 55,
Harley street. Cavendish square.
1 902 Evans, Arthur, M.S., 53, Queen Anne street. Cavendish
square.
1898 Evans, Willmott H., M.D., B.S., B.Sc, Assistant Sur-
geon and Surgeon in charge of Skin Department,
Royal Free Hospital; 2, Upper Wimpole street.
1879 Eve, Frederic S., Surgeon to the London Hospital;
Surgeon to the Evelina Hospital for Sick Children ;
125, Harley street, Cavendish square. C. 1897-9.
Referee, 1902—. Trms, 4.
1877 EwART, William, M.D., Physician to St. George's Hospital
and to the Belgrave Hospital for Children ; 33,Curzon
street, Mayfair. C. 1895-7. Lib, Com. 1897—.
Sci, Com, 1889-1902. Trans. 2. Pro. I.
1900 Fairbairn, John Shields, M.B., 60, Wimpole street.
1872 Fayrer, Sir Joseph, Bart., K.C.S.L, LL.D., M.D., F.R.S.,
Surgeon-General; Physician Extraordinary to H.M.
the King ; late Physician to the Secretary of State
for India in Council, and President of the Medical
Board at the India Office; 16, Dewonshire street, Port-
land place. C. 1888. Referee, 1881-7.
RESIDENT FELLOWS XXV
Elected
1898 Fenwick, E. Hubrt, Surgeon to the London Hospital
and to St. Peter's Hospital; 14, Savile row.
1 880 Pehrier, David, M.D., LL.D., F.R.S., Professor of Neuro-
pathology in King*s College, London, and Physician to
King's College Hospital; Physician to the National
Hospital for the Paralysed and Epileptic; 34, Caven-
dish square. Referee, 1891-6. C. 1896-8. Dw. Com,
1896—. Trans. 2.
1889 Field, George P., Aural Surgeon to, and Lecturer on
Aural Surgery at, St. Mary's Hospital ; 34, Wimpole
street, Cavendish square.
«
1900 Flemming, Percy, M,D., B.S., Assistant Ophthalmic
Surgeon to University College Hospital ; Assistant
Surgeon to the Royal London Ophthalmic Hospital,
City road ; 31 , Wimpole street.
1891 Fletcher, Herbert Morley, M.D., Assistant Physician,
East London Hospital for Children ; 98, Harley street,
Cavendish square.
1892 Forsbrook, William Henry Russell, M.D., 40, Lower
Belgrave street, Eaton square.
1896 FouLBRTON, Alexander Grant Russell, Middlesex
Hospital. Trans, 1.
1883 Fowler, James Kingston, M.D., Physician to, and
Lecturer on Medicine at, the Middlesex Hospital ;
Physician to the Hospital for Consumption, Brompton,
35, Clarges street, Piccadilly. C. 1902— . Trans, \,
1880 Fox, Thomas Colcott, B.A., M.B., Physician for Diseases
of the Skin to the Westminster Hospital, and Physician
to the Skin Department of the Paddington Green Hos-
pital for Children ; 14, Harley street. Cavendish square.
Trans, 1 .
XXVI RESIDENT PELLOW8
Elected
1871 Frank, Philip, M.D.,3, Elvaston place, South Kensing-
ton.
1902 French, Herbert, M.6., 26, St. Thomas'n street.
1896 Freyer, p. J., M.D., M.Ch., Surgeon to St. Peter's
Hospital ; 46, Harley street, Cayendish square. Trant. I .
1898 Fripp, a. Downing, C.B., M.V.O., M.S., Honorary Sur-
geon in Ordinary to H.M. the King ; Assistant Surgeon
to Guy's Hospital; 19, Portland place.
1898 Frost, William Adams, Ophthalmic Surgeon to St.
George's Hospital, and Surgeon to Royal Westminster
Ophthalmic Hospital ; 30, Cavendish square.
1884 Fuller, Charles Chinner, 10, St. Andrew's place,
Regent's Park.
1883 Fuller, Henry Roxburgh, M.D., 45, Curzon street,
Mayfair.
1894 FuRNiVALL, Percy, Assistant Surgeon, London Hospital ;
Assistant Surgeon, St. Mark's Hospital ; 28, Wey-
mouth street, Portland place.
1899 Furth, Karl, M.D., 94, Harley Street.
1874 Galabin, Alfred Lewis, M.D., Obstetric Physician
to, and Lecturer on Midwifery and the Diseases of
Women at, Guy's Hospital ; 49, Wimpolest., Cavendish
square. C. 1892. Referee, 1882-91, 1896—. Lib.
Com. 1883-4. Trans. 2.
1895 Galloway, James, M.D., Physician, Skin Department,
and Joint Lecturer on Practical Medicine, Charing
Cross Hospital; 54, Harley street. Cavendish square.
1883 Galton, John Charles, M.A., F.L.S., 10, Upper Cheyne
row, Chelsea.
1865 Gant, Frederick James, Consulting Surgeon to the Royal
Free Hospital; 16, Connaught square, Hyde Park.
C. 1880-81. V.P. 1897-9. Referee, 1886-97. Lib,
Com. 1882-5. Tram. 3. •
i.
RESIDENT FELLOWS XXVU
Elected
1854 Oarrod, Sir Alfred Baring, M.D., F.R.S., Physician
Extraordinary to Her late Majesty Queen Victoria ;
Consulting Physician to King's College Hospital; 10,
Harley street, Cavendish square. C. 1867. V.P.
1880-81. Referee, 1855-65. Trans. 9.
1886 Gakrod, Archibald Edward, M.D., Medical Registrar
and Demonstrator of Morbid Anatomy, St. Bartholo-
mew's Hospital ; Physician to the Hospital for Sick
Children, Great Ormond street ; 9, Chandos street,
Cavendish square. C. 1902—. Sci. Com, 1889-
1902. Ub, Com. 1896-1902. Trans. 7.
1887 Gay, John, 119, Upper Richmond road, Putney. .
1866 Gee, Samuel Jones, M.D., Chairman of Trustees for
Debenture-holders; Honorary Physician to H.R.H.
the' Prince of Wales ; Physician to St. Bartholomew's
Hospital; 31, Upper Brook street, Grosvenor square.
C. 1883-4. L. (June) 1887-99. V.P. 1899-1900. Sci.
Com.\S79. Bldg.Com. 1889-92. Referee, \mb -7 y
1900—. Lib. Com. 1871-6. Ho. Com. 1898-1900.
Trans. 1.
1898 GiBBEs, CuTHBEET Chafman, M.D., 89, Harley street.
1880 Gibbons, Robert Alexander, M.D., Physician to the
Grosvenor Hospital for Women and Children ; 29,
Cadogan place. C. 1896-7. Trans. 1.
1893 Giles, Arthur Edward, M.D., B.Sc, Assistant Surgeon,
Chelsea Hospital for Women ; 10, Upper Wimpole
street.
1894 Gill, Richard, 72, Wimpole street.
1877 GoDLEE, RiCKMAN JoHN,M.S., JSTow. Librarian; Honorary
Surgeon-in-Ordinary to H.M. the King; Surgeon
to University College Hospital, and Professor of Clinical
Surgery in University College, London ; Surgeon to
the Hospital for Consumption, Brompton ; 19, Wim-
pole street. Cavendish square. S. 1892-4. L.
1895—. 12tf/eree, 1886-91. Ho. Com. 1898—.
Trans. 11.
XXVll] RESIDENT VELLOWti
Elected
1870 Godson, Clement, M.D., Consultiog Physiciau to tbe
City of London Lying-in Hospital ; 82, Brook street,
Grosvenor square.
1886 GoLDiNG-BiRD, CuTUBEUT HiLTox, M.B., Surgeon to, and
Lecturer on Clinical Surgery at, Guy*s Hospital ;
12, Queen Anne street, Cavendish square. Ttokm. 1.
1897 GooDBODY, F. W., M.D., 6, Chandos street, Cavendish
square.
1896 GooDALL, Edward Wilbekfokce, M.D., B.S., Eastern
Hospital, Homerton.
1883 GooDHART, James Frederic, M.D., Physician tu Guy*s
Hospital ; Consulting Pliysician to the Evelina iios-
pital for Sick Children ; 25, Portland place. Referee^
1900—. Lib. Com. 1893-6.
18H9 Goods ALL, David Henry, Surgeon to the Metropolitan
Hospital ; Surgeon to St. Mark's Hospital ; 1 7, Devon-
shire place, Upper Wimpole street.
1895 GossAGE, Alfred Milne, M.B., 54, Upper Berkeley
street.
1877 Gould, Alfred Pearce, M.S., Surgeon to, and Lecturer
on Surgical Pathology at, the Middlesex Hospital ;
10, Queen Anne street, Cavendish square. C. 1892-3.
S. 1898—1901. Referee, 1895-8. Ho. Com, 1892-8.
Lib. Com. 1891. Trans. 3.
1891 Gow, William J., M.D., Assistant Obstetric Physician
to St. Mary's Hospital ; Obstetric Physician to the
Royal Hospital for Women and Children ; Physician
to Out-Patients, Queen Charlotte's Lying-in Hospital ;
27, Weymouth street, Portland place.
1 873 Oowers, Sir William Richard, M.D., F.R.S., Consulting
Physician to University College Hospital ; Physician
to the National Hospital for the Paralysed and Epi-
leptic ; 50, Queen Anne street, Cavendish square.
C. 1891. Referee, 1888-90. Lib. Com. 1884-6. Trans. 7.
1892 Grant, J. Dundas, M.A., M.D., 18, Cavendish square.
RESIDENT FELLOWS XXIX
Elected
IS68 Green, T. Heney, M.D., Physician to the Charing Cross
Hospital, and to the Hospital for Consumption,
Brompton ; 74, Wimpole street, Cavendish square.
C. 1886. Referee, 1882-5.
188.0 Griffith, Walter Spencee Anderson, M.D., Assistant
Physician-Accoucheur, St. Bartholomew's Hospital ;
Physician to Queen Charlotte's Lying-in Hospital ;
96, Harley street, Cavendish square. Referee, 1902 — .
1889 GuBB, Alfred S., M.D., 29, Gower street.
1883 GuNN, Robert Marcus, M.B., Surgeon to the Royal
London Ophthalmic Hospital, Moorfields ,- Ophthalmic
Surgeon to the National Hospital for the Paralysed
and Epileptic; .54, Queen Anne street. Cavendish
square.
1890 Guthrie, Leonard George, M.D., B.Ch., Physician to
the Eegent's Park Hospital for Epilepsy and Paralysis ;
Assistant Physician to the North-West London Hos-
pital; Assistant Physician to the Children's Hospital,
Paddington Green; 1.5, Upper Berkeley street. Port-
man square.
1 886 H ABERSHON, Samuel Hebbebt, M.D., Assistant Physician
to the Hospital for Consumption, Brompton; 88,
Harley street, Cavendish square.
188.5 Haig, Alexander, M.D., Physician to the Metropolitan
Hospital, and to the Royal Hospital for Children
and Women ; 7, Brook street, Grosvenor square.
Trans, 6.
1890 Hale, Charles Douglas Bowdich, M.D., 3, Sussex
place, Hyde Park.
1881 Hall, Francis de Havilland, M.D., Physician to,
and Joint Lecturer on Medicine at, the Westminster
Hospital; 47, Wimpole street, Cavendish square.
C. 1901. Referee, 1893-7.
XXX RESIDENT FELLOWS
Elected
1891 Hamer, William Heaton, M.D., I a, Bramnhill gardenSy
Dartmouth park hill, Highgate.
1889 Handfield-Jones, Montagu, M.D., Obstetric Physician
to, and Lecturer on Midwifery and Diseases of Women
at, St. Mary's Hospital ; Physician to the British
Lying-in Hospital ; 35, CaTendish square.
1893 Habley, Yauguan, M.D., 25, Harley street. Cavendish
square.
1901 Harmer, William Douglas, M.B., 45, Weymouth
street.
1892 Harold, John, M.B., 91, Harley street. Cavendish square.
1880 Harris, Vincent Dormer, M.D., Physician to the City
of London Hospital for Diseases of the Chest, Victoria
Park; 22, Queen Anne street, Cavendish square.
Referee, 1899—.
1870 Harrison, Reginald, Surgeon to St. Peter's Hospital ;
6, Lower Berkeley street, Portman square. C. 1894-5.
V.-P. 1898-1900. Trans, 4.
1870 Haward, J. Warrington, Hon. Treasurer; Consulting
Surgeon to, and Lecturer on Clinical Surgery at, St.
George's Hospital ; 57, Green street, Grosvenor Square.
C.1885. S. 1888-91. V.P. 1894-5. T. (June) 1895—.
Lib, Com, 1881-4. Sci, Com, 1889-91. Bldg, Com.
{Sec.) 1889-92. Ro. Com, 1892—. Trans. 3.
1891 Hawkins, Herbert Pennell, M.D., B.Ch., Physician to
St. Thomas's Hospital ; 56, Portland place.
1875 Hayes, Thomas Crawford, M.D., Physician-Accoucheur
and Physician for Diseases of Women and Children to
King's College Hospital, and Professor of Midwifery
in King's College ; Physician for Diseases of Women
to the Royal Free Hospital ; 1 7, Clarges street,
Piccadilly.
1891 Hayward, John Arthur, M.D., 17, Lingfield road,
Wimbledon. Pro. 1.
RESIDENT FELLOWS XXXI
Elected
1865 Heath, Cheistopher, Emeritus Professor of Clinical
Surgery in University College, London ; and Consulting
Surgeon to University College Hospital ; 36, Cavendish
square. C. 1880. V.P. 1889. Lib. Com. 1870-3.
Trans, 4.
1895 Henderson,EdwardErskin£,B.A.,M.B., B.C., 20, Queen
Anne street, Cavendish square.
1 901 Henry, John Patrick, M.D., B.Ch., Ophthalmic Surgeon
to the Italian Hospital, Queen square ; Oculist to
the London School Board ; 41,Welbeck street, Caven-
dish square.
1882 Hensley, Philip John, M.D., Physician to, and Lecturer
on Forensic Medicine at, St. Bartholomew's Hospital ;
4, Henrietta street, Cavendish square. Referee,
1897—.
1877 Herman, George Ernest, M.B., Obstetric Physician to,
and Lecturer on Midwifery at, the London Hospital ;
20, Harley street, Cavendish square. C. 1900-2.
Referee, 1892-1900. Lib. Com. 1898-1900. OUrans. I.
1900 Hern, William, 7, Stratford place.
1877 Heron, George Allan, M.D., Physician to the City of
London Hospital for Diseases of the Chest, Victoria
Park; 57, Harley street. Cavendish square.
1891 Herring, Herbert T., M.B., B.S., 50, Harley street,
Cavendish square.
1883 Herringham,Wilmot Parker, M.D., Assistant Physician,
St. Bartholomew's Hospital; 40, Wimpole street.
Cavendish square. Lib. Com. 1902 — . Trans. 2.
1893 Herschell, George, M.D., 36, Harley street, Caven^
dish square.
1887 Hewitt, Frederic William, M.V.O., M.D., Honorary
Anaesthetist to H.M. the King ; Anaesthetist to, and
Instructor in Ansesthetics at, the London Hospital;
Anaesthetist at the Dental Hospital of London ; 14,
Queen Anne street. Cavendish square. Trans. 3.
XXXn RE81DKNT FELLOWS
Electetl
1873 HiGGENS^ Chables, Ophthalmic Surj^eon to, and Lecturer
on Ophthalmic Surgery at, Gny'it Honpital ; 52, Brook
street, Grosvenor square. C. .l8!)4-r>. TVant. 2.
1890 Hill, G. William, M.D., B.Sc, 26, Weymouth street,
Portland place.
1899 HiLLTRR, Alfred P., M.D,, 30, Wimpole street.
1856 Holmes, Timothy, M.A., Consulting Surgeon to St.
George's Hospital; Corresponding Member of the
Societe de Chirurgie, Paris ; fi, Sussex place, Hyde
Park. C. 1869-70. L. 1873-7. S. 1878-80. V.P.
1881-2. T. 1885-7. P. 1890-92. Bldtj.Com. (Chair-
man) 1889-92. Referee, 1866-8, 1872, 1883-4.
Sci. Com. 1867. TM. Com. 1863-5, 1892-5. Ho. Com.
1892-8. Trans. S.
1878 Hood, Donald William Charles, C.V.O., M.D., Senior
Physician to the West London Hospital ; Examining^
Physician for King's Messengers, Foreijjn Office ;
43, Green street, Park lane.
1898 HoRDER, Thomas J., M.D., 141, Harley street.
1883 HoRSLEY, Sir Victor Alexander Haden, F.R.S.,
Surgeon to University College Hospital, Surgeon to
the National Hospital for the Paralysed and Epileptic ;
25, Cavendish square. Referee, 1897 — . Trans. 1.
1896 Horton-Smitii, Percival, M.D., 19, Devonshire street,
Portland place. Sci. Com. 1897- 1902. Trans. 1.
1892 Howard, R. J. Bliss, M.D., 31, Queen Anne street.
Cavendish square.
1874 HowsE, Sir Henry Greenway, M.S., Surgeon to, and
Lecturer on Surgery at, Guy's Hospital ; Consulting
Surgeon to the Evelina Hospital for Sick Children ;
59, Brook street, Grosvenor square. C. 1890. V.P.
1899-1901. Sci. Com. 1879. Referee, 1887-9.
Trans, 3.
BESIDSNT FELLOWS XXXlll
Elected
1889 Hunter, William, M.D., Senior Assistant Physician to
the London Fever Hospital ; Curator and Pathologist,
Charing Cross Hospital; 103, Harley street.
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 Senior
Surgeon to the Hospital for Diseases of the Skin; 15,
Cavendish square. C. 1870. V.P. 1882. P. 1894-5.
Referee, 1876-81, 1883-94. Ub. Com. 1864-5
Trans. 15^ Pro. 2.
1888 Hutchinson, Jonathan, Juu., Surgeon to the London
Hospital; 1, Park crescent. Trans. 3.
1897 Hutchison, Robebt, M.D., 22, Queen Anne street,
Cavendish square.
1871 Jackson, J. Hughlings, M.D., LL.D., F.E.S., Consulting
Physician to the London Hospital ; Physician to the
National Hospital for the Paralysed and Epileptic ; 3,
Manchester square. C. 1889.
1883 Jacobson, Waltek Hamilton Acland, M.Ch.Oxon.,
Assistant Surgeon to Guy's Hospital; Surgeon to the
Royal Hospital for Children and Women ; 66, Great
Cumberland place, Hyde Park. C. 1902 — . Referee,
1895-1902. Ub, Com. 1896-1902. Trans. 2.
1897 Jenner, Louis, M.B., 4a, Bloomsbury square.
1883 Jessof, Walter H. H., M.B., Ophthalmic Surgeon to
St. Bartholomew's Hospital; 73, Harley street. Referee,
1901.
1881 Johnson, George Lindsay, M.D., Cortina, Netherhall
gardens. South Hampstead, and 36, Finsbury pave-
ment.
1889 Johnson, Raymond, M.B., B.S., Assistant Surgeon to
University College Hospital ; Surgeon to the Victoria
Hospital for Children; 11, Wimpole street. Caven-
dish square. Trans. 1 .
VOL. LXXXV. t
XXXIV RESIDIi:NT KKLLOWs
Hlleeted
188-4 Johnston, James, M.D., 53, Prince's square, Bayswater.
1899 Jones, George. M.B., 8, Church terrace, Lee.
1887 Jones, Henby Lewis, M.D., Medical Officer in charge of
Electrical Departmeut at St. Bartholomew's Hospital ;
61, Wimpole street. Cavendish square.
1896 Jones, L. Vernon, B.A., M.D., B.Ch., 7, Arlington
street, St. James's.
1881 JuLER, Henry Edward, Ophthalmic Surgeon to St.
Mary's Hospital; Surgeon to the Royal Westminster
Ophthalmic Hospital ; Consulting Ophthalmic Surgeon
to the London Lock Hospital ; 23, Cavendish square.
C. 1901—. Ro. Com. 1902—.
1898 Keep, A. Corrie, M.D., CM., Surgeon to out-patient«
Samaritan Free Hospital for Women and Children ;
14, Gloucester place, Portman square.
1882 Keetley, Charles R. B., Senior Surgeon to the West
Loudon Hospital ; 56, Grosvenor street, Grosvenor
square. C. 1901 — . Tram, 1.
1898 Kellock, Thomas Herbert, M.D., B.C., Assistant Sur-
geon to Middlesex Hospital and to the Hospital for
Sick Children ; 8, Queen Anne street, Cavendish
square.
1901 Keltnack, T. N., M.D., 53, Harley street.
1902 Kerr, James, W.D., D.P.H., School Board for London,
Victoria Embankment.
1857 Kiallmark, Henry Walter, 5, Pembridge gardens. C.
1890-91.
1881 KiDD, Percy, M.D., Physician to the Hospital for Con-
sumption, Brompton ; Physician to the London
Hospital; 60, Brook street, Grosvenor square.
C. 1900-2. Trans, 4.
RESIDENT FALLOWS XXXV
Elected
1851 Kingdon, John Abernethy, Consulting Surgeon to the
Bank of England, Threadneedle street. C, 1866-7.
V.P. 1872-3. Sci. Com. 1867. Trans. 1.
1900 Lake^ Richard, 19, Harley street. Trans. \.
1896 Lane, James Ernest, Surgeon to Out«patients, St.
Mary's Hospital ; 46, Queen Anne .Street, Cavendish
square.
1884 Lane, William Arbuthnot, M.S., Surgeon to Guy*s
Hospital and to the Hospital for Sick Children, 21,
Cavendish square. Trans, 4.
1882 Lang, William, Ophthalmic Surgeon to, and Lecturer
on Ophthalmic Surgery at, the Middlesex Hospital;
Surgeon to the Royal London Ophthalmic Hospital,
Moorfields; 22, Cavendish square.
1894 Langdon-Down, Reginald Langdon, M.B., B.C., 47,
Welbeck street.
1865 Langton, John, Surgeon to, and Lecturer on CHnical
Surgery at, St. Bartholomew's Hospital ; Surgeon to
the City of London Truss Society ; 62, Harley street.
Cavendish square. C. 1881-2. V.P. 1895-7,
Referee, 1885-95. Lib. Com. 1879-80, 1888-95,
Trans. 2.
1898 Latham, A. C, M.D., 44, Brook street, Grosvenpr
square.
1890 Law, Edward, M.D., CM., 8, Wimpole street, Cavendish
square.
1898 Lawford, J. B., Ophthalmic Surgeon and Lecturer on
Ophthalmology, St. Thomas's Hospital; Surgeon to
Royal London Ophthalmic Hospital ; 99, Harley street.
1888 Lawrence, Laurie Asher, 9, Upper Wimpole street.
1890 Lawrie, Edward, M.B., Surgeon Lieutenant-Colonel,
Indian Medical Department ; late Residency Surgeon,
Hyderabad, Deccan ; Harley Lodge, 115a, Harley
street.
XXXVl RKdlOENT KKLLOWb
Elected
1893 Lawson, Arnold^ Ophthalmic Surgeon to the Childreu's
Hospital, Paddington Green ; 12, Harley street, Caven-
dish square.
1884 Lawson, George, Consulting Surgeon to the Royal
London Ophthalmic Hospital ; Consulting Surgeon to
the Middlesex Hospital ; 1 2, Harley street, Cavendish
square.
1900 Leaf, Cecil Huntington, M.A., M.B. ; 75, Wimpole
street. Cavendish square.
1896 Lee, William Edward, M.D., 36, Finsbury pavement.
1895 Lees, David Bridge, M.D., Physician to, and Lecturer
on Medicine at, St. Mary's Hospital, and Physician to
the Hospital for Sick Children ; 22, Weymouth street,
Portland place. Trans. 2.
1899 Legge, Thomas Mobison, M.D., 2, Mitre court buildings.
Temple.
1900 Lendon, Edwin Haeding, M.D., 162, Holland park
avenue.
1895 Leslie, BoBERT Murray, M.B., Assistant Physician to
Royal Hospital for Diseases of the Chest ; 26, Harley
street, Cavendish square.
1897 Levy, Alfred 6., M.D., 41, Devonshire street, Portland
place.
1886 Lewers, Arthur Hamilton Nicholson, M.D., Obstetric
Physician to the London Hospital ; 72, Harley street.
Cavendish square. Trans. 1.
1878 Lister, Right Hon. Lord, P.C, CM., D.C.L., LL.D.,
F.R.S., Sergeant-Surgeon in Ordinary to H.M. the
King; Emeritus Professor of Clinical Surgery in
King's College, London ; and Consulting Surgeon to
King's College Hospital ; 12, Park crescent, Itegent's
Park. C. 1892.
1891 Little, Ernest Muirhead, Surgeon to the National
Orthopaedic Hospital; 40, Seymour street, Portman
square.
RESIDENT FELLOWS XXXVll
Elected
1889 Little, John Fletchek, M.B., 32, Harley street, Caven-
dish square.
1881 LocKWooD, Charles Barrett, Surgeon to the Great
Northern Central Hospital; Assistant Surgeon to, and
Lecturer on Surgical and Descriptive Anatomy at, St.
Bartholomew's Hospital ; 1 9, Upper Berkeley street,
Portman square. C. 1901 — . Trans, 4.
1897 Low, Harold, 10, Evelyn gardens.
1881 Lucas, Richard Clement, B.S., M.B., Surgeon to, and
Lecturer on Surgery, late Lecturer on Anatomy at,
Guy's Hospital ; Consulting Surgeon to the Evelina
Hospital for Sick Children; 50, Wimpole street,
Cavendish square. C. 1900-2. Uo. Com. 1901-2.
Trans, 3.
1888 LuFP, Arthur Pearson, M.D., B.Sc, Physician to Out-
patients and Lecturer on Medical Jurisprudence at
St. Mary's Hospital ; 9, Queen Anne street. Caven-
dish square. Trans, 1 .
1887 Lush, Percy J. F., M.B., 4, Maresfield gardens, Hamp-
stead.
1898 Lyster, C. R. C, Bolingbroke Hospital, Wandsworth
common.
1873 MacCarthy, Jeremiah, M.A., Consulting Surgeon to the
London Hospital, late Lecturer on Surgery at the
London Hospital Medical College ; 1 , Cambridge place,
Victoria road, Kensington. C. 1886-7. Lib, Com.
1882-5. Referee, 1890—.
1899 Macdonald, Greville, M.D., 85, Harley street.
1898 McFadyean, John, The Eoyal Veterinary College,
Camden Town.
1894 Macfadyen, Allan, M.D., CM., Jenner Institute of
Preventive Medicine, Chelsea bridge.
XXXVlll KE8IDENT FELLOWS
Elected
1880 Mc Hardy, Malcolm Macdonald, Ophthalmic Surgeuii
to King's College Hospital, and Professor of Ophthalmic
Surgery in King's College, London ; Senior Surgeon to
the Royal £ye Hospital, Southwark ; 5, Savile row.
1873 MacKellar, Alexander Obrrlin, M.Ch., Surgeon to
St. Thomas's Hospital ; Surgeon-in-Chief to the Metro-
politan Police Force ; 79, Wimpole street, Cavendish
square.
1881 Mackenzie, Stephen, M.D., Physician to the London Hos-
pital; Physician to the Royal London Ophthalmic
Hospital; 18, Cavendish square. C. 1899-1900.
Referee, 1890-9. Trans. 1.
1879 Maclagan, Thomas John, M.D., Physician-in-Ordinary
to their R.H. the Prince and Princess Christian of
Schleswig-Holstein ; 9, Cadogan place, Belgrave square.
1881 Macready, Jonathan Forster Christian Horace, Sur-
geon to the Great Northern Hospital ; 42, Devonshire
street.
1880 Maddick, Edmund Distin, 31, Cavendish square.
1886 Maguire, Robert, M.D., Physician to Out-patients and
Joint Lecturer on Pathology at St. Mary's Hospital ;
Physician to the Hospital for Consumption, Brompton ;
4, Seymour street, Portman square. Sci. Com,
1889-1902.
1880 Makins, George Henry, C.B., Surgeon to St. Thomas's
Hospital ; Consulting Surgeon to the Evelina Hos-
pital for Children ; 47, Charles street, Berkeley
square. C. 1899-1900. Referee, 1898-9, 1902—.
Trans, 2.
1885 Malcolm, John David, M.B., CM., Surgeon to the
Samaritan Free Hospital ; 1 .3, Portman street, Portman
square. Trans. 2.
RESIDENT FELLOWS XXXIX
tJlected
1890 Manson, Patrick, C.M.G., M.D., CM., LL.D., F.R.S.,
Physician to the Seamen's Hospital, Albert Docks ;
Lecturer on Tropical Medicine at St. George's Hos-
pital; 21, Queen Anne street, Cavendish square.
1867 Marsh, F. Howard, Surgeon to, and Lecturer on Surgery
at, St. Bartholomew's Hospital ; 30, Bruton street,
Berkeley square. C. 1882-3, 1889. S. 1885-7. V.P.
1891-3.' Lib. Com. l8S0-\. Trans, 4.
1891 Martin, Henry Charkington, M.D., 27, Oxford
square.
1884 Martin, Sidney Harris Cox, M.D., F.R.S., Assistant
Physician to University College Hospital, and to the
Hospital for Consumption, Brompton ; Professor of
Pathology, University College, London; 10, Mans-
field street, Portland place.
1892 Masters, John Alfred, M.D., 31, Albert gate, Hyde
Park.
1891 May, William Page, M.D., B.Sc, 9, Manchester square.
1880 Meredith, William Appleton, M.B., CM., Surgeon to
the Samaritan Free Hospital for Women and Children ;
21, Manchester square. C. 1897-9. Ho. Com.
1898-9. Trans. 1.
1894 MiCHELS, Ernst, M.D., Surgeon to the German Hos-
pital ; 48, Finsbury square. Trans. 2.
1893 MiLEY, Miles, M.B., 21, Belsize avenue, Hampstead.
1887 MiVAET, Frederick St. George, M.D., Local Govern-
ment Board Inspector ; 13, Stafford terrace, Kensing-
ton.
1891 MoLiNE, Paul, M.B., 42, Walton street, Chelsea.
1873 Moore, Norman, M.D., Hon. Librarian, Assistant
Physician and Lecturer on Medicine to St. Bartholo-
mew's Hospital; 94, Gloucester place, Portman square.
C. 1891-2. L. 1899—. S. 1896-9. Referee, 1886-90.
Ho, Com. 1898—. Sci. Com. 1889-1902-
tI resident PELLOW8
Elected
1878 Morgan, John Hammond, C.Y.O., M.A., Surgeon to the
Charing Cross Hospital, and to the Hospital for Sick
Children, Great Ormond street ; 68, Orosvenor street.
C. 1895-7. Bi9. Com. 1896-7. Referee, 1901—.
TraM. 2.
1894 MoRisoN, Alexander, M.D., 14, Upper Berkeley
street.
1874 Morris, Henry, M.A., Surgeon to the Middlesex Hos-
pital ; 8, Cavendish square. C. 1888-9. Y.P. 1900-2.
Referee, 1882-7. Lib, Com. 1895-6. Trant. 10.
1879 Morris, Malcolm Alexander, Surgeon to the Skin
Department of, and Lecturer on Dermatology at, St.
Mary's Hospital ; 8, Harley street. Cavendish square.
Sci. Com. 1889-1902. Traru. 1.
1898 Morrison, James, M.D., 11, Brook street, Orosvenor
square.
1885 MoTT, Frederick Walker, M.D., F.R.S., Assistant
Physician, Charing Cross Hospital ; Pathologist to
the London County Council ; 25, Nottingham place.
Referee, 1900—. Set. Com. 1899—. TraM. 1.
1902 Mummery, John Percy Lockhart, B.A., 10, Cavendish
place.
1899 Mundy, Herbert, St. Bartholomew's Hospital.
1900 MuKPHY, William Reid, D.S.O., Lieutenant-Colonel
I.M.S. ; East India and Colonial Club, 16, St. James's
street.
1896 Murphy, James Keggh, M.B., St. Bartholomew's
Hospital.
1888 Murray, Hubert Montague, M.D., Physician to Out-
patients, and Joint Lecturer on Medicine at, the
Charing Cross Hospital; Physician to the Victoria
Hospital for Children ; 25, Manchester square.
RESIDENT FELLOWS xli
Elected
1898 Murray, John, Assistant Surgeon to the Middlesex
Hospital and to the Faddington Green Children's
Hospital ; 110, Harley street.
1880 MuRRELL, William, M.D., Physician to, and Lecturer on
Materia Medica^ Pharmacology, and Therapeutics at,
the Westminster Hospital ; 1 7, Welbeck street. Caven-
dish square. Sci. Com, 1889-1902. Trans, 1.
1863 Myers, Arthur Bowen Richards, late Brigade-Surgeon,
Brigade of G-uards; 43, Gloucester street, Warwick
square. C. 1878-9. Lib, Com. 1877.
1864 Nunn, Thomas William, Consulting Surgeon to the
Middlesex Hospital ; 27, York terrace, York gate.
1880 Ogilvie, George, M.B., B.Sc, Physician to the Hos-
pital for Epilepsy and Paralysis, Regent's Park ; 22,
Welbeck street. Cavendish square. Trans, I.
1891 Ogle, Cyril, M.A., M.B., Assistant Physician to St.
George's Hospital ; 96, Gloucester place, Portman
square.
1858 Ogle, John Willi am» M.D., Consulting Physician
to St. George's Hospital ; 96, Gloucester place,
Portman square. C. 1873. V.P. 1886. Referee,
1864-72. Trans. 4.
1860 Ogle, William, M.D., late Superintendent of Statistics in
the Registrar-General's Department, Somerset House ;
10, Gordon street, Gordon square. S. 1868-70.
C. 1876-7. V.P. 1887. Lib.Com. 1871-5. Trans, 5.
1892 Openshaw, T. Horrocks, M.B., M.S., Surgeon to, and
Lecturer on Anatomy at, the London Hospital ; 1 6,
Wimpole street, Cavendish square.
1877 Obmerod, Joseph Arderne, M.D., Assistant Physician
to St. Bartholomew's Hospital ; Physician to the
National Hospital for the Paralysed and Epileptic,
Queen square; 25, Upper Wimpole street. C. 1897.
Lib. Com, 1896-7. Trans. 1.
xlii RESIDENT FELLOWS
Elected
1875 OsBORN, Samuel, 1a, Devonshire street, Portland place,
and Maisonnette, Datchet, Bucks.
1879 Owen, Edmund, M.B., Senior Surgeon to, and Lecturer
on ClinicAl Surgery at, St. Mary's Hospital; Senior
Surgeon to the Hospital for Sick Children, Great
Ormond street ; 64, Great Cumberland place, Hyde
park. C. 1896-7. Trans. 4.
1882 OwBN, Sir Isambard, M.D., Deputy.Chancellor of the
University of Wales ; Physician to, and Lecturer on
Forensic Medicine at, St. George*K Hospital : 40,
CuTZOU street, Mayfair. C. 1902 — . Bldg, Com.
1889-92. Referee, 1893, 1895-1902.
1892 Page, H. Marmaduke, 14. Greuville place, South Ken-
sington.
1874 Page, Herbert William, M.A., M.C., Surgeon to, and
Joint Lecturer on Surgery at, St. Mary's Hospital ;
146, Harley street. Cavendish square. C. 1890-
91. Referee, 1884-9. Lib. Com. 1886.S. Trans.
4,
1886 Paget, Stephen, Surgeon to the West London Hospital ;
Surgeon to the Throat and Ear Department of the
Middlesex Hospital ; 70, Harley street. Lib. Com.
1902—.
1895 Parker, Charles Arthur, 141, Harley street, Cavendish
square.
1889 Parsons, J. Inglis, M.D., Physician to the Chelsea
Hospital for Women ; 3, Queen street, Mayfair.
1883 Pasteur, William, M.D., Physician to the Middlesex
Hospital ; Consulting Physician to the North-Eastern
Hospital for Children ; 4, Chandos street, Cavendish
square.
1901 Paterson, Herbert John, 9, Upper Winipole street.
1891 Paterson, William Bromfield, 7a, Manchester square.
RESIDENT FELLOWS xHii
Elected
1891 Paton, Edward Percy, M.D., M.S., 84, Park street,
Grosvenor square.
1865 Pavy, Frederick William, M.D., LL.D., F.R.S., Con-
sulting Physician to Guy's Hospital ; 35, Grosvenor
street. P. 1900-2. C. 1883-4. V.P. 1893-4. Referee,
1871-82. Trans. 1.
1869 Payne, Joseph Frank, M.D., Physician to, and Lecturer
on Medicine at, St. Thomas's Hospital ; 78, Wimpole
street, Cavendish square. C. 1887. Referee, 1890 — .
Sci, Com, 1879. Lib. Com. 1878-85, 1889—.
1894 Pegler, L. Remington, M.D., 2, Henrietta street,
Cavendish square.
1898 Pendlebury, Herbert Stringpellow, M.B., B.C., 44,
Brook street, Grosvenor square.
1887 Penrose, Francis George, M.D., Physician to St.
George's Hospital and to the Hospital for Sick
Children, Great Ormond street; 84, Wimpole street.
Cavendish square. Sci, Cam. 1889-1902.
1890 Perry, Edwin Cooper, M.D., Physician to, and Demon-
strator of Pathology at, Guy's Hospital; The Super-
intendent's House, Guy's Hospital.
1895 Phbar, Arthur G., M.D., Assistant Physician and Patho-
logist to the Metropolitan Hospital; 47, Weymouth
street, Portland place. Trans. 1.
1883 Phillips, Charles Douglas F., M.D., LL.D., 10, Hen-
rietta street. Cavendish square.
1884 Phillips, George Richard Turner, J. P., 28, Palace
Court, Bayswater hill.
xliv RESIDENT FELLOWS
Elected
1889 Phillips, Sidney, M.D., Phyitician and Lecturer on
Medicine at St. Mary's Hospital ; Senior Physician to
the London Fever Hospital, and to the Lock Hospital ;
62, Upper Berkeley street, Portman square. Trana, \ .
1867 Pick, Thomas Pickering, Consulting Surgeon to St.
George's Hospital ; 1 8, Portman street, Portman
square. C. 1884-5. V.P. 1893-4. Referee, 1882-3,
1891-93. Sex, Com. 1870, 1889—. Lib. Com.
1879-81.
1884 Pitt, George Newton, M.D., Hon. Secretary, Physician
to, and Pathologist at, Guy's Hospital; 15, Portland
place. S. 1902—. Referee, 1897-1902. TVaiu. 1.
1889 Pitts, Bernard, M.A., M.C., Surgeon to St. Thomas's
Hospital and Lecturer on Surgery; Surgeon to the
Hospital for Sick Children, Great Ormond street ;
109, Harley street, Cavendish square. Referee,
1897—.
1899 Playfaib, Ernest, M.B., 57, Gloucester terrace, Hyde
Park.
1901 Plimmer, Harry George, 28, St. John's Wood road.
1885 Poland, John, Surgeon to the City Orthopaedic Hospital
and Miller Hospital, Greenwich ; 2, Mansfield street.
Cavendish square.
1884 Pollard, Bilton, B.S., Surgeon to University College
Hospital; Consulting Surgeon to the North-Eastem
Hospital for Children ; 24, Harley street. Cavendish
square. Trans. 1.
1865 Pollock, James Edward, M.D., Consulting Physician to
the Hospital for Consumption, Brompton ; 37, Colling-
haim place. C. 1882-3. V.P. 1896-7. Referee,
1872-81.
1894 Pollock, William Rivers, M.B., B.C., Assistant Obs-
tetric Physician to the Westminster Hospital ; 56,
Park street, Grosvenor square.
RESIDENT FELLOWS xlv
Elected
1871 PooRE, George Vivian, M.D., Professor of Medical Juris-
prudence and Clinical Medicine in University College,
London ; Physician to University College Hospital ;
24a, Portland place. C. 1890-91. Referee, 1887-9,
1892—. Lib, Com. 1895—. Trans. 2.
1867 Powell, Sir Richard Douglas, Bart., K.C.V.O.^ M.D.,
Physician Extraordinary to H.M. the King ; Physician
to, and Lecturer on Medicine at, the Middlesex
Hospital ; Consulting Physician to the Hospital for
Consumption, Brompton ; 62, Wimpole street, Caven-
dish square. S. (Oct.) 1883-5. C. 1887-8. V.P.
1902—. Referee, 1879-83, 1886. Trans. 3.
1887 Power, D'Abcy, M.A., M.B., Assistant Surgeon at St.
Bartholomew's Hospital; Surgeon to the Victoria
Hospital for Children, Chelsea; 10a, Chandos street,
Cavendish Square. Lib. Com, 1896 — . Trans, 2.
1867 Power, Henry, Consulting Ophthalmic Surgeon to St.
Bartholomew's Hospital ; 10a, Chandos street. Caven-
dish square, and Bagdale Hall, Whitby. C. 1882-3.
V.P. 1892-3. Referee, 1870-81, 1891-2. Sci. Com.
1870, 1889—. Lib. Com. 1872-8.
1883 Pbingle, John James, M.B., CM., Physician in Charge
of Skin Department at the Middlesex Hospital; 23,
Lower Seymour street, Portman square. Trans, 2.
1874 Purves, William Laidlaw, Aural Surgeon to Guy's Hos-
pital ; 20, Stratford place, Oxford street. Titans, 2.
1877 Pye-Smith, Philip Henry, M.D., F.R.S., Physician to
and Lecturer on Medicine at, Guy's Hospital; 48, Brook
street, Grosvenor square. C. 1893-4. Lib, Com,
1887-93, 1899—. Referee, 1897—. Trans, 1.
1898 Ramsay, Herbert Murray, 35a, Hertford street.
1893 Rankin, Guthrie, 4, Chesham street, Belgrave square.
1 899 Bawling, Louis Bathe, M.B., B.C., 16, Montagu street,
Portman square.
xlvi RESIDENT KELLOWS
Elected
1892 11ayn£B» Henry, M.D., Lecturer on PsychologicAl Medi-
cine to St. Thomas's Hospital ; IG, Queen Anne street,
Cavendish square.
1869 Head, Thomas Laurence, 1 1, Petersham terrace. Queen's
gate. C. 1901-—. Ho. Com. 1902—.
1891 Reece, Richard James, 62, Addison gardens.
1882 Reid, Sir James, Bart., G.C.V.O., K.C.B., M.I)., Physi-
cian-in-Ordinary to H.M. the King ; 72, Grosvenor
street, Grosvenor square.
1891 Rendel, Arthur BowEN, M.A., M.B., B.C., 43, Albion
street, Hyde Park.
1887 Richardson, Gilbert, M.A., M.D., Hillside, Putney
hill.
1863 Ringer, Sydney, M.D., F.R.S., Holme Professor of
Clinical Medicine in University College, London,
and Physician to University College Hospital ; 15,
Cavendish place, Cavendish square. C. 1881-2.
V.P. 1900-2. Referee, 1873-80, 1889-97. Trant. 6.
1900 Riviere, Clive, M.D., 19, Devonshire street.
1896 Roberts, Charles Hubert, M.D., Physician to Oiit-
Patients, Samaritan Hospital for Women ; Physician
to Out-patients, Queen Charlotte's Lying-in Hospital,
London ; 21, Welbeck street.
1893 Roberts, D. Watkin, M.D., bii, Manchester street,
Manchester square.
1878 Roberts, Frederick Thomas, M.D., Professor of Medi-
cine, and of Clinical Medicine, in University College,
London ; Physician to University College Hospital ;
Consulting Physician to the Hospital for Consumption,
Brompton ; 102, Harley street, Cavendish square.
C. 1894-5. Referee, 1899—. Sci, Com, 1889-1902.
1898 Robertson, F. W., M.D., ** Ravenstone," Lingfield road,
Wimbledon, Surrey.
1901 Robinson, George Henkell Drummond, M.D.,S4, Park
street, Grosvenor square.
RESIDENT FELLOWS xlvii
Elected
1896 Robinson, Henry Betham, M.S.. Assistant Surgeon to,
and Surgeon in Charge of the Throat Department,
St. Thomas's Hospital; Assistant Surgeon to the East
London Hospital for Children, Shadwell ; 1, Upper
Wimpole street.
1889 RoBSON, Arthub William Mayo, Professor of Surgery,
Yorkshire College, Leeds; Senior Surgeon, Leeds
General Infirmary; 8, Park crescent, London, and
7, Park square, Leeds. Trans. 5. Pro, 1.
1890 RoLLESTON, Humphry Davy, M.D., Physician to, and
Lecturer on Pathology at, St. George's Hospital;
Senior Physician to Out-patients, Victoria Hospital
for Children ; 55, Upper Brook street, Grosvenor
square.
1857 Hose, Henry Cooper, M.D., 16, Warwick road, Maida
Vale. C. 1886-7. Trans, 1.
1888 RouGHTON, Edmund Wilkinson, B.S., M.D., Surgeon
and Surgical Tutor to the Royal Free Hospital ; 38,
Queen Anne street. Trans. 1.
1882 RouTH, Amand Jules McConnel, M.D., B.S., Obstetric
Physician to, and Lecturer on Midwifery at, the
Charing Cross Hospital ; Physician to the Samaritan
Free Hospital for Women and Children ; 14a,
Manchester square. C. 1902—. Lib, Com, 1900-2.
Referee, 1900-2.
1849 Routh, Charles Henry Felix, M.D., Consulting Phy-
sician to the Samaritan Free Hospital for Women and
Children ; 52, Montagu square. Lib, Com. 1854-5.
Trans. 1.
1891 Russell, J. S. Risien, M.D., Assistant Physician to
University College Hospital, and Pathologist to the
National Hospital for the Paralysed and Epileptic,
Queen square; 44, Wimpole street, Cavendish square.
Trans, 1.
Xlviii RESIDENT FELLOWS
Elected
1900 Ryall, Charles, 51, Queen Anne street.
1886 Sainsbury, Harrington, M.D., Physician to the Royal
Free Hospital ; Physician to the City of London Hos-
pital for Diseases of the Chest ; 52, Wimpole street.
Cavendish square. Trans. 1.
1899 Sandtland, John Edward, M.B., 1, Montague square.
1869 Sansom, Arthur Ernest, M.D., Physician to the London
Hospital ; Consulting Physician, North - Eastern
Hospital for Children ; 84, Harley street. Cavendish
square. C. 1887-8. Referee, 1889—, Trans. 3.
1902 Saunders, Edward Arthur, M.B., B.Ch., 49, Harley
street, Cavendish square.
1879 Savage, George Henry, M.D., Lecturer on Mental Dis-
eases at Guy's Hospital ; 3, Henrietta street. Caven-
dish square. C. 1898-9.
1892 Sghorstein,Gu8Tave M.A.,M.B.,6.Ch.,D.P.H., Assistant
Physician to the London Hospital, and to the Hospital
for Consumption, Brompton ; 11, Portland place.
1899 Scott, Lindley Marcroft, M.D., 98, Sloane street.
1863 Sedgwick, William, 101, Gloucester place, Portman
square. C. 1884-5. Trans, 3.
1892 Segundo, Charles Sempill de, M.B., B.S., 6, Brook
street, Hanover square.
1892 Selwyn-Harvey, John Stephenson, M.D., 1, Astwood
road, Cromwell road.
1877 Semon, Sir Felix, M.D., Physician Extraordinary to
H.M. the King ; Physician for Diseases of the
Throat to the National Hospital for Epilepsy and
Paralysis, Queen square ; 39, Wimpole street.
Cavendish square. C. 1895-7. Lib, Com. 1894-5.
Trans, 3.
RESIDENT FELLOWS xlix'
Elected
1900 Sequeira, James Harry^ M.D., 13, Welbeck street.
1894 Sewill, Joseph Septon, 9a, Cavendish square.
1882 Sharkey, Seymour John, M.D., Physician to, and Joint
Lecturer on Medicine at, St. Thomas's Hospital;
22, Harley street. Cavendish square. C. 1899-
1900. i^<?/eree, 1897-9, 1902— . Trans. 2.
1900 Shaw, Harold Batty, M.D., 7, Devonshire street, Port-
land place.
1886 Shaw, Lauriston Elgie, M.D., Physician to Guy's Hos-
pital ; 64, Harley street. Cavendish square.
1884 Sheild, Arthur Marmaduke, M.B., B.C., Assistant Sur-
geon to St. George's Hospital ; 4, Cavendish place.
Referee, 1897 — . Trans. 6.
1896 Shore, Thomas William, M.D., Heathfield, AUeyn park,
Dulwich.
848 Sieveking, Sir Edward Henry, M.D.,LL.D., F.S.A.,
Physician Extraordinary to H.M. the King; Consulting
Physician to St. Mary's and the Lock Hospitals; 17,
Manchester square. C. 1859-60. S. 1861-3. V.P.
1873-4. L. 1881-2. P. 1888-9. Referee, 1855-8,
1864-72, 1875-80. Sci. Com. 1862. Trans, 2.
t886 SiLCOCK, Arthur Quakry, B.S., Surgeon in charge of Out-
patients, and Teacher of Operative Surgery, St. Mary's
Hospital; Surgeon to the Royal London Ophthalmic
Hospital ; 52, Harley street, Cavendish square. Lib,
Com, 1895—.
1842 Simon, Sir John, K.C.B., F.E.S., Hon. M.D.Dublin,
1887, Consulting Surgeon to St. Thomas's Hospital;
40, Kensington square. C. 1854-5. V.P. 1865.
Referee, 1851-3, 1866-81. Trans. I.-
1899 Simpson, William John Ritchie, M.D., 12, Gloucester
place, Portman square.
d
1 KESIDKNT KKLLOWS
Eleeied
1894 Slater, Charles, M.6., 81, St. Ermiirs niausions, West*
minster.
1890 Smale, Morton, Surgeon Dentist to St. Mary's Hos-
pital ; 22a, Cavendish square.
1879 Smith, E. Noble, Surgeon to tlie City Orthopsedic
Hospital ; Surgeon to All Saints' Children's Hospital ;
Orthopaedic Surgeon to the British Home for Incur-
ables ; 24, Queen Anne street, Cavendish square.
1881 Smith, Eustace, M.D., Physician to H.M. the King of tbe
Belgians; Physician to the East London Children**
Hospital, and to the Victoria Park Hospital for
Diseases of the Chest; 15, Queen Anne street. Caven-
dish square. C. 1899-1900.
1866 Smith, Heywood, M.A.,M.D., 18, Harley street, Cavendish
square.
1889 Smith, Egbert Percy, M.D., B.S., Lecturer on Psycho-
logical Medicine, Charing Cross Hospital ; 36, Queen
Anne street.
1863 Smith, Sir Thomas, Bart., Honorary Sergeant- Surgeon to
H.M. the King ; Consulting Surgeon to St. Bartholo-
mew's Hospital ; 5, Stratford place, Oxford street.
S. 1870-2. C. 1875-6. V.P. 1887-8. Referee, 1873-4.
1880-6. ScL Com. 1867. Trans. 4.
1872 Smith, Thomas Gilbart, M.D., Physician to the London
Hospital ; Physician to the Royal Hospital for Diseaaes
of the Chest, City road ; 68, Harley street, Cavendish
square. C. 1890. Trans. I.
1873 Smith, W. Johnson, Surgeon to the Seamen's Hospital
Society, Greenwich.
1874 Smith, William Robert, M.D., D.Sc, F.R.S.Edin., Bar-
rister-at-Law, Professor of Forensic Medicine, and
Director of the Laboratories of State Medicine in
King's College, London ; 74, Great Russell street.
Trans, 1.
RESIDENT FELLOWS li
Elected
1889 Spencer, Herbert R., M.D., B.S., Professor of Mid-
wifery in University College ; Obstetric Physician to
University College Hospital; 104, Harley street.
Referee, 1894—.
1887 Spencer, Walter George, M.B., M.S., Surgeon to, and
Lecturer on Physiology at, the Westminster Hospital ;
35, Brook street, Grosvenor square. Trans, 2.
1888 Spicer, Robert Henry Scanes, M.D., Surgeon to the
Department for Diseases of the Throat, St. Mary's
Hospital ; 28, Welbeck street, Cavendish square.
1890 Spicer, William Thomas Holmes, M.B., 5, Wimpole
street, Cavendish square.
1875 Spitta, Edmund Johnson, Ivy House, 31, South Side,
Clapham Common, Surrey.
1885 Squire, John Edward, M.D., Physician to the North
London Hospital for Consumption ; 2, Harley street.
Cavendish square. Trans, 2.
1897 Stainer, Edward, M.A., M.B., 60, Wimpole street.
1896 Stephens, John William Watson, M.B., B.C., 8,
Fopstone road, Earl's Court.
1899 Stewart, Purves, M.D., 7, Harley street. Trans. 1.
1856 Stocker, Alonzo Henry, M.D., Peckham House,
Peckham.
1884 Stonham, Charles, Surgeon to, and Lecturer on Surgery
and Teacher of Operative Surgery at, the Westminster
Hospital ; Surgeon to the Poplar Hospital for Acci-
dents ; 4, Harley street. Cavendish square.
1896 Sutherland, George Alexander, M.D., Physician
to Paddington Green Children's Hospital; Assistant
Physician to the North-West London Hospital ; 73,
Wimpole street, Cavendish square.
Hi KESIDfcINT PKLLOW«
Elected
1896 Swan, Charles Robert John Atkin, M.B., B.Cli., 4
DevoDport street, Hyde Park.
1890 Syebs, Henry Waltee, M.D., 75, Wiropole street.
1886 Symonds, Chartrrs James, M.S., M.D., Surgeon to,Aiicl
Surgeon in cliarge of the Throat Department at,
Guy's Hospital; 58, Portland place.
1875 Tay, Waben, Senior Surgeon to the London Hospital,
to the Royal London Ophthalmic Hospital, and to
the Hospital for Diseases of the Skin, Blackfriars ;
Consulting Surgeon to the North-Eastern Hospital
for Children ; 4, Finsbtiry square.
1873 Taylor, Frederick, M.D., Trustee ; Physician lo, and
Lecturer on Medicine at, Guy's Hospital ; Consulting
Physician to the Mvelinn Hospital for Sick Children ;
20, Wimpole street, Cavendish square. S. 1889-93.
C. 1894-6. Sci, Com. 1889-1902. Referee, 1887-8,
1899—. Trans, 3.
1893 Taylor, James, M.D., Assistant Physician to the National
Hospital for the Paralysed and Epileptic ; Physician
to the North-Eastern Hospital for Children, and to
the National Orthopaedic Ilof^pital ; 49, Welbeck
street. Cavendish square. Trans. 1 .
1890 Taylor, Seymour, M.D., Assistant Physician, West London
Hospital; 16, Seymour street, Portman square.
1859 Tegart, Edward, 60, Scassdale Villa?, Kensington.
C. 1888-9.
1874 Thin, George, M.D., 63, Harley street, Cavendish square.
C. 1893-4. Trans, 14.
1900 Thompson, Charles Herbert, M.D., 133, Harley street.
Cavendish square.
1862 Thompson, Edmund Symes, M.D., Consulting Physician
to the Hospital for Consumption, Brompton ; Gresham
Professor of Medicine ; 33, Cavendish square. S.
1871-4. C. 1878-9. ScL Com. 1889-1902. Referee,
IS 76- 7. Trans. I .
KBSIDENT FELLOWS iiii
Elected
1852. Tkompson, Sir Henry, Bart., Surgeon-Extraordinary to
H.M. the King of the Belgians ; Emeritus Professor of
Clinical Surgery in University College, London , and
Consulting Surgeon to University College Hospital ;
35, Wimpole street. Cavendish square. V.P. 1888.
C. 1869. Trans. 8,
18G2 Thompson, Reginald Edward, M.D., Consulting Physi-
cian to the Hospital for Consumption, Brompton;
13, Cheyne gardens, Chelsea. C. 1879. S. 1880-82.
V.P. 1883-4. Referee, 1873-8. Scu Com, 1867.
Trans. 2.
1899 Thomson, Hebdekt Campbell, M.D., 34, Queen Anne
street. Trans, 2.
1892 Thomson, StClair, M.D., Physician to the Throat
Hospital, Golden Square ; Surgeon to the Itoyal Ear
Hbspital, London ; 28, Queen Anne street, Cavendish
square. Trans, I.
1900 Thomson-Walker, John William, M.B., 8, Cavendish
^ place.
1892 Thorne, William Bezlt, M.D., 53, Upper Brook street.
1899 Thursfield, James Hugh, M.D., 10, Bentinck street,
Manchester square. Trans, 1.
1889 TiRARD, Nestor Isidore Charles, M.D., Professor of the
Principles and Practice of Medicine, King's College ;
Physician to King's College Hospital, and Physician to
the Evelina Hospital for Sick Children ; 74, Harley
street. Cavendish square.
1872 Tomes, Charles Sissmore, M.A., F.R.S., 9, Park
crescent, Portland place. C. 1887. V.P. 1897-99.
Lib. Com. 1879.
IM82 Tooth, Howard Henry, C.M.G., M.D., Physician to the
National Hospital for the Paralysed and Epileptic,
Queen square ; Assistant Physician to St. Bartholo-
mew's Hospital ; 34, Harley street, Cavendish square.
Referee, 1902—. Sci, Com, 1H96-1902.
liv RESIDENT FELLOWS
Elected
1879 Treves, Sib Frederick, Bart., C.B., K.C.V.O.,Hononiry
Sergeant-Surgeon to II. M. the King; Snrgeon-in-
Ordinary to H.E.H. the Prince of Wales ; Consulting
Surgeon to the London Hospital ; 6, Wimpole street.
Cavendish square. C. 1895-6. Referee, 1890-95.
Set, Com. 1889-95. Trant, 0.
1902 Trevor, Robert Salusbuby, M.B., B.C., 21, FitzGeorge
avenue. West Kensington.
1859 Truman, Edwin Tho3Ias, Surgeon - Dentist to His
Majesty's Household ; 23, Old Burlington street.
1897 TuNNiCLiFPE, Fbancis Wiiittaker, M.I)., (), Devonshire
street, Portland place.
1889 TuBNBULL, Geobge Lindsay, M.D., 47, Ladbroke square.
1882 Tubneb, Geobge Robebtson, Surgeon to, and Joint
Lecturer on Surgery at, St. George's Hospital ; Visit-
ing Surgeon to the Seamen's Hospital, Greenwich ; 41,
Half Moon street, Piccadilly. Tram, 1.
1898 Tubneb, William, M.B., B.S., Assistant Surgeon, Weat-
minster Hospital ; 53, Queen Anne street, Cavendish
square.
1896 Tubneb, William Aldben, M.D., Assistant Physician
to King's College Hospital and to the National
Hospital for the Paralysed and Epileptic, Queen
Square ; 13, Queen Anne street, Cavendish square.
1896 Tubney, Horace Geobge, M.D., Joint Lecturer on
Pathology and Assistant Physician to St. Thomas's
Hospital; 68, Portland place. Trans, 1.
1892 Tweedy, John, Professor of Ophthalmic Medicine and
Surgery in University College, Ophthalmic Surgeon to
University College Hospital, and Surgeon to the Royal
London Ophthalmic Hospital ; 100, Harley street.
Cavendish square.
KISSIDBNT FELLOWS Iv
Elected
1876 Venn, Albert John, M.D., 63, Q-rosvenor street.
1870 Venning, Edgcombe, 30, Cadogan place. C. 1898-1900.
V.P. 1902—.
1902 Vincent, Ralph, M.D., B.S., 1, Harley street.
1891 Voelckee, Arthur Francis, M.D., B.S., Assistant
Physician to, and Lecturer on Pathology at, the Mid-
dlesex Hospital ; Assistant Physician, Hospital for
Sick Children, Great Ormond street; 101, Harley
street.
1896 Waqgett, Ernest, M.B., B.C., Surgeon, London Throat
Hospital ; Surgeon to Out Patient Throat and Ear
Department, Great Northern Central Hospital ; 46,
Upper Brook street.
1884 Waklet, Thomas, jun., 5, Queen's Gate, South Ken-
sington.
1896 Waldo, Frederick Joseph, M.D., City Coroner, 40,
Lansdowne road, Holland park.
1900 Walker, H. Roe, 8, Harley street, Cavendish square.
1887 Wallace, Edward James, M.D., 22, Hans crescent,
Chelsea.
1883 Waller, Augustus, M.D., F.E.S., Lecturer on Physiology,
St. Mary's Hospital; Weston Lodge, 16, Grove End
road, St. John's Wood. Referee, 1895 — .
1888 Wallis, Frederick Charles, M.B., B.C., Assistant
Surgeon to the Charing Cross Hospital ; 107, Harley
street, Cavendish square.
1896 Walsham, Hugh, M.A., M.D., Assistant Physician to the
City of London Hospital for Diseases of the Chest;
Assistant Medical Officer in Electrical Department,
St. Bartholomew's Hospital ; 114, Harley street,
Cavendish square.
1873 Walsham, William Johnson, CM., Surgeon to, and
Lecturer on Surgery at, St. Bartholomew's Hospital ;
Consulting Surgeon to the Metropolitan Hospital ;
77, Harley Street, Cavendish square. C. 1888-9.
Referee, 1895—. Lib. Com. 1882-5. Trans, 8.
Ivi RESIDENT KELU>W8
Elected
1880 Wa.bd, Allan Ogier, M.D., 73, Gheapside.
1890 Ward, Arthur Henry, Surgeon to Out-patients, Lock
Hospital; 31, Qrosvenor street.
1894 Ward-Humphreys, George Herbert, 7, Cavendish
place. Cavendish square.
1891 Waring, H. J., M.B., M.S., B.Sc, Assistant Surgeon
and Demonstrator of Operative Surgery, St. Bar-
tholomew's Hospital ; Surgeon, Metropolitan Hos-
pital; 37, Wimpole street.
1877 Warner, Francis, M.D., Physician to, and Lecturer on
Materia Medica and Therapeutics at, the London Hos-
pital ; 5, Prince of Wales terrace, Kensington Palace.
C. 1899-1901. Trans. 3.
1894 Waterhouse, Herbert Furnivall, CM., Senior Assist-
ant Surgeon and Lecturer on Anatomy, Charing
Cross Hospital; Surgeon, Victoria Hospital for Chil-
dren ; 81, Wimpole street,
1861 Watson, William Spencer, M.B., Gl, Bedford gardens,
Campden hill, Kensington. C. 1883-4. TrariM. 1.
1891 Weber, Frederic Parkes, M.I)., Physician to the
German Hospital, Dalston ; 19, Harley street. Trans,
1. Pro. 1.
18.57 Weber, Sir Hermann, M.D., Consulting Physician to
the German Hospital ; 10, Grosvenor street, Grosvenor
square. C. 1874-5. V.P. 1885-6. Sci. Com. 1880-
1902. Beferee, 1869-73, 1878-84. Lib. Com. 1864-73.
Trans. 6.
1895 Wells, Sydney Russell, M.D,, 24, Somerset street,
Portman square.
1877 West, Samuel, M.D., Assistant Physician to St. Bartholo-
mew's Hospital; Senior Physician to the Royal Free
Hospital; 15, Wimpole street, Cavendish square.
C. 1894-5. Lib. Com. 1892-4. Trans. 7-
RESIDENT FELLOW8 Ivii
Elected
1888 Wetheued, Frank Joseph, M.D., Assistant Physician
to the Hospital for Consumption, Brompton ; 83, Harley
street. Cavendish square. Trans, 1.
1881 Wha-RRY, Robert, M.D., 7, Cambridge gate, Eegent's
park.
187.^ Whipham, Thomas Tillyer, M.D., Consulting Physician
to St. George's Hospital; ll,Gro8venor street, Gros-
venor square. C. 1892-3.
1891 White, Charles Percival, M.B., B.C., 22, Cadogan
gardens.
1881 White, William Hale, M.D., Physician to, and Lecturer
on Materia Medica at, Guy's Hospital ; 65, Harley
street, Cavendish square. C. 1900-2. Referee, 1888-
97, 1899-1900. Trans. 4.
1890 White-Cooper, W. G. 0., M.B., 5, Courtfield road,
Gloucester road.
1897 Whitfield, Arthur, M.D., 12, Upper Berkeley street.
1899 Whiting, Arthur J., M.D., 142, Harley street.
1863 Wilks, Sir Samuel, Bart.,M.D.,LL.D.,F.R.S., Physician
Extraordinary to Her late Majesty Queen Victoria,
Physician in Ordinary to their Royal Highnesses the
Duke and Duchess of Connaught; Consulting Physi-
cian to Guy's Hospital ; 8, Prince Arthur road,
Hampstead. Referee, 1872-81.
1890 WiLLCocKS, Frederick, M.D., Physician to Out-Patients,
and Lecturer on Materia Medica and Therapeutics, at
the Charing Cross Hospital ; Physician to the Evelina
Hospital for Sick Children; 14, Mandeville place,
Manchester square.
1865 Willett, Alfred, President; Trustee; Surgeon to St.
Bartholomew's Hospital; Surgeon to St. Luke's
Hospital ; 36, Wimpole street. Cavendish square.
C. 1880-1. V.P. 1890-1. P. 1902—. Referee,
1882-9, 1892-1902. Bldg. Com. 1889-92. Ho. Com.
1 892-8. Trans. 2.
Iviii RESIDENT FELLOWS
Elected
1887 WiLLETT, Edgab, M.B., 22, Qneen Anne street, Caven-
dish square.
1888 Williams, Campbell, 18, Qaeen Anne street.
1866 Williams, Charles Theodore, M.A., M.D., Trustee for
DebenturC'holders ; Consulting Physician to the Hos-
pital for Consumption and Diseases of the Chest,
Brompton ; 2, Upper Brook street, Grosvenor square.
C. 1884-5. V.P. 1900.2. Referee, 1888-1900. Lib.
Com, 1880-3. So. Com. 1900-2. Set. Com. 1889-
1902. Trans. 6.
1881 Williams, Dawson, M.D., Physician to the East London
Hospital for Children ; 2, Wyndham place, Bryanston
square. Trans, 1.
1900 Williams, Hugh Lloyd, 2, Upper Wimpole street.
1872 Williams, Sir John, Bart., M.D., Physician-Accoucheur
to H.R.H. the Princess of Wales, Physician to
H.R.H. the Princess Beatrice; Emeritus Professor
of Obstetric Medicine, University College, London ;
Consulting Obstetric Physician to University College
Hospital; 63, Brook street, Grosvenor square. C.
1891. Referee, 1878-90. Lib. Com. 1876-82.
1901 Williams, Leonard, M.D., 8, York street, Portman
square.
1890 Wills, William Alfred, M.D., Assistant Physician to
the Westminster Hospital ; Senior Physician to the
North-Eastern Hospital for Children ; 29, Lower
Seymour street, Portman square.
1879 WoAKES, Edward, M.D., Senior Aural Surgeon to the
London Hospital ; 78, Harley street. Cavendish square.
1887 Wood, Thomas Outterson, M.D., Senior Physician to
the West End Hospital for Nervous Diseases; 40,
Margaret street, Cavendish square.
RESIDENT FELLOWS Hx
Elected
1891 WooDFORDE, Alfred Pownall, 160, Ooldhawk road.
Shepherd's Bush.
1890 Wtnter, Walter Essex, M.D., Physician to the
Middlesex Hospital; 30, Upper Berkeley street,
Portman square.
LIST OF RESIDENT FELLOWS
ABBANOBD ACCOBDINO TO
DATE OE ELECTION
1842
1848
1849
1851
1852
1853
1854
1856
1857
1858
1859
1860
1861
1862
Sir John Simon, .K.C.B., F.R.S.
Sir Edward H, Sieveking, M.D.
John Clarke, M.D.
C. H. F. Routh, M.D.
John Birkett.
John A. Kingdon.
Sir Henry Thompson, Bart.
Robert Brudenell Carter.
Sir Alfred B. Garrod, M.D., F.R.S.
Jonathan Hutchinson, F.R.S.
Timothy Holmes.
AloDzo H. Stocker, M.D.
Sir Hermann Weber, M.D.
Henry Cooper B-ose, M.D.
Henry Walter Kiallmark.
John William Ogle, M.D.
Wm. Howship Dickinson, M.D.
Edwin Thomas Truman.
Richard Bar well.
Edward Tegart.
William Ogle, M.D.
Thomas Bryant.
John Couper.
Henry Howard Hay ward.
William Spencer Watson.
Lionel Smith Beale, M.B., F.R.S.
Edmund Symes Thompson, M.D.
Reginald Edward Thompson, M.D.
George Co well.
1863 Sir SamuelWilk8,Bt.,M.D.,F.R.S.
Samuel Fenwick, M.D.
Sydney Ringer, M.D., F.R.S.
Sir Thomas Smith, Bart.
Arthur B. R. Myers.
William Sedgwick.
1864 Thomas William Nunn.
1865 James Edward Pollock, M.D.
George Fielding Blandford, M.D.
Sir Dyce Duckworth, M.D.
Frederick W. Pavy, M.D., F.R.S.
John Langton.
Frederick James Gant.
Alfred Willett.
Sir Alfred Cooper.
Christopher Heath.
1866 Samuel Jones Gee, M.D.
Charles Theodore Williams, M.D.
Heywood Smith, M.D.
Sir William Selby Church, Bart.,
K.C.B., M.D.
1867 Sir R. Douglas Powell, Bart., M.D.
F. Howard Marsh.
Henry Power.
Tiiomas Pickering Pick.
1868 H. Charlton Bastian, M.D., F.R.S.
Sir W. H. Broadbent, Bart., M.D.
Thomas Buzzard, M.D.
Walter Butler Cheadle, M.D.
CUHUNOLOGICAL LIST OF lifclSIDENT F£LLOWS
Ixi
1868 T. Henry Green, M.D.
George Eastes.
1869 Joseph Frank Payne, M.D.
Arthur E. Sansom, M.D. |
Thomas Laurence Read.
1870 J. Warrington Haward. '
Edgcombe Venning.
Clement Godson, M.D.
Reginald Harrison.
Robert Leamon Bowles, M.D.
1871 William Cayley, M.D.
Sir T. Lauder Bruntou, M.D., '
F.R.S.
J,Hughlinj»sJackson,M.D.,F.ll.S.
George Vivian Poore, M.D.
Philip Frank, M.D.
1872 T. Gilbart-Smith, M.D.
George B. Brodie, M.D.
Sir John Williams, Bart., M.D.
Sir J. Fayrer, M.D., F.R.S.
Charles S. Tomes, M.A., F.K.S.
Sir William BartlettDalbv.
1873 Frederick Taylor, M.D.
Norman Moore, M.D.
Sir William R.Gowers,M.D.,F.I{.S.
Jeremiah McCarthy.
Wm. Johnson Smith.
Alex. 0. MacKellar.
Henry T. Butlin.
Charles Higgens.
William J. Walsham.
1874 Alfred Lewis Galabin, M.D.
George Thin, M.D.
John Mitchell Bruce, M.D.
Henry Morris.
\Villiam Laidlaw Piirves.
William Harrison Cripps.
Sir Henry G. Howse, M.S.
Herbert William Paiye.
Frederic Durham.
William Robert Smith, xM.D.
1875 Thomas T. Whipham, M.D.
Thomas Crawford Hayes, M.D.
Waren Tay.
Edmund J. Spitta.
Samuel C. Osborn.
Fletcher Beach, M.B.
1876 SirThomasBarlow,Bart.,K.C.V.O.,
M.D.
Albert J. Venn, M.D.
1877 Sir Felix Semon, M.D.
Sidney Coupland, M.D.
Francis Warner, M.D.
William Ewart, M.D.
1877 Alfred Pearce Gould, M.S.
Rickman J. Godlee, M.S.
Alban H. G. Doran.
George Ernest Herman, M.B.
Samuel West, M.D.
John Abercrombie, M.D.
George Allan Heron, M.D.
J[oseph A. Ormerod, M.D.
P. Henry Pye-Smith, M.D., F.R.S.
*Sir William Henry Bennett.
1878 Sir Jas. Crichton-Browne, M.D.
Fred. T. Roberts, M.D.
Lord Lister, P.C, O.M., F.U.S.
Clinton T. Dent.
John H. Morgan, C.V.O.
Donald W.Charles Hood, M.D.
1 879 Edward Woakes, M.D.
Malcolm A. Morris.
A. E. Cumberbatch.
Edmund Owen.
Arthur E. J. Barker.
Sir FredJc. Treves, Bart., C.B..
K.C.V.O.
Thomas John Maclagan, M.D.
Andrew Clark.
Francis Henry Champneys, .M.D.
William Watson Cheyne, F.R.S.
George Henry Savage, M.D.
H. H. Glutton, M.A.
Frederic S. Eve.
E. Noble Smith.
William Henry AUchin, M.I).
1880 Robert Alex. Gibbons, M.D.
David Ferrier, M.D., F.R.S.
Vincent Dormer Harris, M.D.
Edmund Distin Maddick.
Jas. John MacWhirterDunl)ar,M.D.
James William Browne, M.B.
William Appleton Meredith, M.B.
Malcolm Macdonald McHardv.
A. Boyce Barrow.
William Murrell, M.D.
George Ogilvie, M.B.
Charles Edward Beevor, M.D.
Thomas Colcott Fox, M.B
George Henry Makins, C.B.
1881 Francis de Havilland Hall, M.D.
Robert Wharry, M.D.
Richard Clement Lucas, B.S.
Stephen Mackenzie, M.I).
William Hale White, M.D.
Eustace Smith, M.D.
Percy Kidd, M.D.
Oswald A. Browne, M.D.
Ixii
UHKOiVOLOOICAL LIST OK KBSIDENT FELLOWS
1881 W, Brace Clarke, M.B.
Dawson Williams, M.D.
George Lindsay Johnson, M.D.
Henry Edward Juler.
Jonathan F. C. H. Macready.
C. B. Lock wood.
1882 Philip J. Hensley, M.D.
Ernest Clarke, M.D., B.S.
George Bx)bertson Turner.
Howard Henry Tooth, C.M.G.,
M.D.
Sir Herbert Isambard Owen,
M.D.
Charles R. B. Keetley.
Anthony A. Bowl by, C.M.G.
Amand J. McC. Routh, M.D.
Seymour J. Sharkey, M.D.
William Lang.
Henry Radcliffe Crocker, M.D.
Sir James Reid, Bart., G.C.V.O.
1883 Edwin Clifford Beale, M.A., M.B.
James Kingston Fowler, M.D.
James Frederic Goodhart, M.D.
John Charles Galton, M.A.
W. Hamilton A. Jacobson, M.Ch.
Walter H. Jessop, M.B.
Walter Edmunds, M.C.
Sir Victor A. Horsley, F.R.S.
Dudley Wilmot Buxton, M.D.
Charles Douglas F. Phillips, M.D.
John James Pringle, M.B.
Henry Roxburgh Fuller, M.D.
Wilmot Parker Herringham, M.D.
Augustus Waller, M.D.
William Pasteur, M.D.
John Bland-Sutton.
Robert Marcus Gunn, M.B.
1884 George Newton Pitt, M.D.
Charles Stonham.
Stanley Boyd, B.S.
William Arbuthnot Lane, M.S.
Arthur Marmaduke Sheild, M.B.
Sidney Harris Cox Martin, M.D.,
F.R.S.
George Lawson.
Thomas Wakley, jun.
F. Swinford Edwards.
James Johnston, M.D.
William Duncan, M.D.
Charles Chinner Fuller.
George Richard Turner Pjjillips.
Bilton Pollard.
1885 Alexander Haig, M.D.
Theodore Dyke Acland, M.D.
1885 FrederickWalkerMott,M.D.,F.R.S
James Berry.
John Cahill, M.D.
John Poland.
A. C. Butlcr-Smythe.
Charles Alfred Ballance, M.S.
Walters. A. Griffith, M.D.
John Edward Squire, M.D.
John D. Malcolm, M.B., CM.
Phineas S. Abraham, M.D.
1886 Robert Maguire, M.D.
Harrington Sainsbury, M.D.
Cuthbert Hilton Golding.Bird,M.B.
Lauriston Elgie Shaw, M.D.
Charters James Symonds, M.S.
Robert Boxall, M.D.
Allan Ogier Ward, M.D.
Archibald Edward Garrod, M.D.
Stephen Paget.
William Radford Dakin, M.D.
Samuel Herbert Habershon, M.D.
Arthur Quarry Silcock.
Arthur H. N. Lewers. M.D.
1887 Walter George Spencer.
Thomas Outterson Wood, M.D.
E'lgar William Willett, M.B.
Henry Lewis Jones, M.D.
Francis Georjre Penrose, M.D.
Hugh Percy Dunn.
Frederic William Hewitt, M.D.
James Barry Ball, M.D.
Gilbert Richardson, M.D.
D*Arcy Power, M.B.
John Gay.
James Calvert, M.D.
Percy J. F. Lush, M.B.
Edward James Wallace, M.D.
! 1888 Robert Henry Scanes Spicer, M.D.
' Jonathan Hutchinson, jun.
j Campbell Williams.
! James Donelan, M.B., CM.
John Anderson, M.D., CLE.
I Laurie Asher Lawrence.
Arthur Pearson Luff, M.D., B.Sc.
Albert Carless, M.S.
Frederick C Wallis, M.B., B.C.
Charles James CuUingworth, M.D.
Edmund CauMey, M.D., B.C.
H. Montague Murray, M.D.
Frank Joseph Wethered, M.D.
j Edmund Wilkinson Roughton, B.S.
' Frederick William Cock, M.D.
Robert Henry Clarke, M.B.
1880 Montagu Handfield-Jones, M.D.
CHRONOLOGICAL LIST OF RESIDENT FELLOWS
X111
1889 David Henry Goodsall. 1891
Raymoml Johnson, M.B.
John Fletcher Little, M.B.
Henry Work Dodd.
George Lindsay Turnbull, M.D.
Sidney Phillips, M.D.
William Charles Bull, M.B.
George P. Field.
Charles Henry Cosens.
Henry Percy Dean, M.B., M.S.
Alfred Samuel Gubb, M.D.
William Hunter, M.D.
J. Inglis Parsons, M.D.
Bernard Pitts, M.B., M.C. I
Robert Percy Smith, M.D., B.S. I
Herbert R. Spencer, M.D., B.S.
Nestor Isidore Chas. Tirard, M.D.
Arthur William Mayo Robson.
1890 John Rose Bradford, M.D., F.R.S. 1892
Roland Danvers Brinton, M.D.
Charles D. B. Hale, M.D. |
Edwin Cooper Perry, M.D.
Morton Smale. !
Frederick Willcocks, M.D.
William T. Holmes Spicer, M.B.
Thomas Henry Crowle.
Henry Walter Syers, M.D.
Seymour Taylor, M.D.
William Alfred Wills, M.D.
G. 0. White-Cooper, M.B.
Herbert William Allingham.
William A. F. Bateman.
James Jackson Clarke, M.B. 1893
Leonard G. Guthrie, M.D., B.CIi.
G. William Hill, M.D., B.Sc.
Edward Law, M.D., CM.
Patrick Manson, C.M.G., M.D.
CM., F.R.S.
Humphry D. Rolleston, M.D.
Arthur Henry Ward.
Walter Essex Wynter, M.D., B.S
Edward Lawrie, M.B.
Christopher Childs, M.D.
1891 William Lee Dickinson, M.D.
Herbert P. Hawkins, M.D., B.Ch.
CyrilOgle, M.A., M.B.
Arthur F. Voelcker, M.D., B.S.
Alfred Pownall Woodforde. 1894
Herbert T. Herring, M.B., B.S.
Ernest Muirhead Little.
Henry Charrington Martin, M.D.
Frederick William Andrewes, M.D.
Alfred Eddowes, M.D.
Herbert Morley Fletcher, M.D.
William Heaton Hamer, M.D.
William Bromfield Paferson.
Holburt Jacob Waring.
Frederic Parkes Weber, M.D.
F. E. Batten, M.D.
Thomas Jessopp Bokenham.
Norman Dalton, M.D.
P. R. W. De Santi.
P. W. Dove.
William J. Gow, M.D.
Paul Frank Moline, M.B.
Edward Percy Paton, M.D.
Arthur Bowen Rendel, M.B., B.C.
James Samuel Risien Russell,
M.D.
Charles Percival White, M.B.,B.C.
W. Page May, M.D.
Richard J. Reece.
J. Dundas Grant, M.D.
R. J. Bliss Howard, M.D.
Thomas Horrocks Openshaw, M.B.
William Bezly Thome, M.D.
W. H. Russell Forsbrook, M.D.
John Harold, M.B.
John Alfred Masters, M.D.
Gustave Schorstein, M.B.
Charles Sempill de Segundo, M.B.
John Tweedy.
J. S.Selwyn- Harvey, M.D.
StClair Thomson, M.D.
Henry Rayner, M.D.
H. Marmaduke Page.
James Taylor, M.D.
Howard Barrett.
Robert Cozens Bailey, M.B.
Henry Albert Caley, M.D.
Arthur Edward Giles, M.D.
Miles Miley, M.B.
D. Watkin Roberts, M.D.
Leonard A. Bidwell.
Frederic F. Burghard, M.D., M.S.
J. H. Drysdale, M.B.
William McAdam Ecoles, M.S.
Vaughan Harley, M.D.
George Herschell, M.D.
Arnold Lawson.
Guthrie Rankin.
Richard Gill.
Joseph Sefton Sewill.
Thomas Vincent Dickinson, M.D.
Herhert Edward Durham, M.B.
Alexander Morison, M.D.
L. Hemington Pejjler, M.D.
Herbt. Furnivall Waterhouse, CM .
Ixiv
CHRONOLOGICAL LIST OF KKSIDENT FELLOWS
1894 Percy Furnivall.
R. L. Langdon-Down, M.B.,6.C.
Allan Macfadjen, M.D., B.S.
Ernst Micliels, M.D.
Wm. Rivers Pollock, M.B., B.C.
Charles Slater, M.B.
G. H. Ward-Humphrejs.
1S95 Charles Arthur Parker.
Sydney Russell Wells, M.D.
Alfred Milne Gossage, M.B.
Robert Murray Leslie, M.B.
James Galloway, M.D.
David Bridge Lees, M.D.
Arthur G. Phear, M.D.
1896 Joseph Lockhart Downes, M.B.
Edward Wilberforce Good all, M.D.
James Ernest Lane.
Georsje Alex. Sutherland, M.D.
Charles Buttar, M.D.
P. J. Ereyer, M.D., I. M.S., M.A.
Percival Horton-Smith, M.D.
Thomas William Shore, M.D.
William Aldren Turner, M.D.
Charles Hubert Roberts, M.D.
Charles R. J. Atkin Swan, M.B.
James Kingston Barton.
J. Walter Carr, M.D.
John H. Dauber, M.A., M.B., B.Ch.
Alexander Grant Russell Eoulerton.
L. Vernon Jones,B- A., M.D., B.Ch.
Henry Betham Robinson. M.S.
Horace George Turney, M.D.
Ernest Waggett, M.B., B.C.
Frederick Joseph Waldo, M.D.
Huirh Walsham, M.D.
J. W. W. Stephens, M.D.
1897 Comjns Berkeley, M.B., B.C.
William Arthur Brailey, M.D.
James Cantlie, M.B.
Raymond H.Payne Crawfurd, Mi.D.
Louis Jenner, M.B.
Francis Whittaker Tunnicliffe, M.D.
Arthur Wiiitfield, M.D.
Edward Stainer, M.A., M.B.
Alfred G. Levy, M.D.
A. P. Beddard, M.B.
G. F. Blacker, M.D.
W. S. Colman, M.D.
F. W. Goodbody, M.D.
R. Hutchison, M.D.
Harold Low.
Christopher Addison, M.D.
1808 J. 11. Bryant,. M.D.
W. H. Corfield, M.D.
1898 L. A. Dunn, M.S.
E. Hurry Fenwick.
A. Downing Fripp, C.B., M.V.O.,
M.S.
A. Corrie Keep, M.D.
A. C. Latham, M.D.
J. B. Lawford.
John McFadyean.
11. Murray Ramsay.
J. F. H. Broadbent, M.D.
H. Ronald Carter.
A. Stark Currie, M.D.
P. J. Edmunds, M.B.
James Morrison, M.D.
J. S. Edkins.
Thomas J. Horder, M.D.
F. W. Robertson.
S. Jervois Aarons, M.D.
Willmott Evans, M.D., B.S., B.Sc.
John Murray.
W. Adams Frost.
C. R. C. Lyster.
Samuel Noble Bruce.
Cuthhert Chapman Gibhes, M.D.
H. Stringfellow Pendlei)urv,
M.B.
William Turner, M.B.
Alexander Crombie, M.D.
Thomas Herbert Kellock, M.D.
1 1S09 James Hugii Thursfield. M.D.
Lindlev Marcroft Scott, M.D.
Alfred'P. Hillier, M.D.
; Louis Bathe Rawling, M.B.
John Edward Sandiland, M.B.
j Herbert Mundy.
Arthur J. Whiiiner, M.D.
W. H. Crosse, M.D.
Edward Farquhar Buzzard, M.B.
Grevilie Macdonald, M.D.
George Jones, M.B.
Riehard Harding Bremridge.
Herbert Campbell Thomson, M.D.
Thomas Morison Legge, M.D
William John Ritchie Simpson
M.D.
Ernest Playfair, M.B.
Karl FiJrth, M.D.
Purves Stewart, M.D.
1900 Clive Riviere, M.B.
H. Roe Walker.
Richard Lake.
Percy Flemming, M.D., B.S.
John Shields Fairbairn, M.B.,
B.Ch.
CHKONOLOOTCAL LIST OP KES1DI2NT FELLOWS
Ixv
1900 Hu-li Lloyd Williams.
Aslett Baldwiu.
Charles Ryall.
William Hern.
Cecil Huntington Leaf, M.B.
Edwin Harding Lendon, M.D.
Lieut.-Col. William Reid Murphy,
D.S.O., I.M.S.
James Harry Sequeira, M.D.
Harold Batty Shaw, M.D.
Charles Herbert Thompson, M.D.
John William Thomson- Walker.
1901 Sir Hugh Reeve Beevor, Bart.,
M.D.
J. Brunton Blaikie, M.D.
John Patrick Henry, M.D.
Herbert Johii Paterson.
George Henkell Drummond Robin-
son, M.D.
Elmore Wright Brewerton.
1901 Thomas Rupert Hampden Bucknall.
M.S., M.D.
William Douglas Harmer.
Harry Georjje Plimmer.
Lionel Vernon Carsfill.
T. N. Kelynack, M.D.
Leonard Williams/ M.D.
1902 J. P. L. Mummery, B.A.
James Stansfield Collier, M.D.,
B.Sc.
RobertSalusburyTrevor,M.B.,B.C.
Edward Arthur Saunders, M.B.,
B.Ch.
Ralph Vincent, M.D., B.C.
Herbert French, M.B.
Holland John Cotton, M.D., CM.
Arthur Evans, M.S.
James Kerr, M.D., D.P.H.
Donald John Armour, M.B,
VOL. LXXXV.
The following ITon-resident Fellows pay an annual subscription
of £3 38., and are thereby entitled to all the privileges
of Resident Fellows.
Elected
1900 Blake, William Henky, M.D.Brux., Bedford Lodge,
West Wickham, Kent.
1884 Dkage, Lovell, M.D., B.Ch.Oxon., Burleigh Mead,
Hatfield, Herts.
1897 Gilford, Hastings, Norwood House, King's road,
Reading. Trans. 1.
1873 Parker, Robert William, Senior Surgeon to the East
London Hospital for Children ; Senior Surgeon to
the German Hospital ; Caryll Hurst, West Grinstead,
Sussex. C. 1888-9, 1899 — 1901. S. 1895-8. Bldg.
Com. 1889-92. Referee, 1891-5. Lib. Com, 1885-87.
1892-5, 1898-9. Ho, Com. 1892-5, 1899—1901.
Trans, 4,
1900 Price-Jones, Cecil, M.B., 7, Claremont road, Surbiton,
Surrey.
1882 Reid, Thomas Whitehead, M.D., Surgeon to the Kent
and Canterbury Hospital ; St. George's House, Canter,
bury.
1891 RuFFER, Marc Armand, M.D., The Quarantine Board,
Alexandria.
1898 Thomas, J. Lynn, C.B., Surgeon to the Cardiff Infirmary ;
Consulting Surgeon to the Hamadryad Hospital,
Green-lawn, Pen-y-Lan, Cardifi*.
NON-RESIDENT FELLOWS
Elected
1866 Allbutt, Thomas Clifford, M.D., LL.D.Olasgow, F.R.S.,
Regius Professor of Physic, University of Cambridge ;
Consulting Physician to the Leeds General Infirmary ;
St. Rhadegund's, Cambridge. Trans, 8.
1884 Anderson, Alexander Richard, Surgeon to the General
Hospital, 5, East Circus Street, Nottingham. Trans, i.
1880 Appleton, Henry, M.D. (Address uncommunicated.)
1896 Bagshawe, Frederic, M.D., J.P., 35, Warrior Square, St
Leonard's-on-Sea.
1902 Bailey, William Henry, M.B., Featherstone Hall,
Southall, Middlesex.
1895 Baldwin, Gerald R., 166, Victoria street, Melbourne,
Australia.
1891 Balgarnie, TP'ilfred, M.B., The Dutch House, Hartley
Wintney, Winchfield.
1896 Ball, Charles Bent, M.D., Ch.M., 24, Merrion square
North, Dublin.
1866 Banks, Sir John, K.C.B., M.D., LL.D., D.Sc, Physician
in Ordinary to H.M. the King in Ireland; Physician
to Richmond, Whitworth, and Hardwicke Hospitals;
Regius Professor of Physic in the University of Dublin ;
45, Merrion square, Dublin.
1886 Banks, Sir William Mitchell, M.D., Surgeon to the
Liverpool Royal Infirmary ; 28, Rodney street, Liver-
pool.
Ixviii yoy-RKSIDEXr FELLOWS
Elected
1900 Bjrdsitell, Noel Deas, M.D., The Sanatorium, Mun-
desley, Norfolk.
1882 Barker, Frederick Charles, M.D., Surgeon-Major,
Bombay Medical Ser?ice.
1881 Barnes, Hbnrt, M.D., LL.D., F.R.S. Ed., Physician to the
Cumberland Infirmary ; 6, Portland square, Carlisle.
1861 Barnes, Robert, M.D., Bernersmede, Eastbourne. C.
1877-8. V.P. 1889-90. Referee, 1867-76, 1891—.
Zi5. Com. 1869-73. iSci. Com. 1889— 1902. Tratu.A.
1860 Bealey, Adam, M.D., M.A., Felsham Lodge, Felsham road,
St. Leoiiard*s-ou-Sea, Sussex.
1896 Belben, Frank, M.B., Endsleigh, Suffolk road, Bourne-
mouth.
1880 Bennett, Alexander Hughes, M.D. (Travelling.)
1889 Bentley, Arthur J, M,, M.D., Mena House, Pyramids,
Cairo, Egypt.
1872 Beverley, Michael, M.D.. Consulting Surgeon to the
Norfolk and Norwich Hospital; 54, Prince of Walea
road, Norwich.
1865 Bickersteih, Edward Bobert, Consulting Surgeon to
the Liverpool Royal Infirmary ; 2, Rodney street,
Liverpool. Trans, 1.
1892 Bickersteth, Bobert ALlexandeRjM, A., M.B., Assistant
Surgeon to the Liverpool Royal Infirmary : 2, Rodney
street, Liverpool.
1849 Birkett, Edmund Lloyd, M.D., Consulting Physician to
the City of Loudon Hospital for Diseases of the
Chest; Westbourne Rectory, Emsworth, Hampshire.
C. 1865-6. Referee, 1851-9.
1901 Bissuopp, Francis R. B., M.D., Belle Vue, Mount Plea-
sant, Tunbridge Wells.
1900 Blake, William Henry, M.D.Brux., Bedford Lodge,
West Wickham, Kent.
1865 Blanchet, Hilarion, 35, Coniilard street, Quebec,
Canada.
NON-RESIDENT FELLOfFS Ixix
Elected
1890 BosTOCK, B. AsHTON, Surgeon, Scots Guards, Cefn Mor,
Penmaen, Glamorganshire.
1869 Bourne, Walter, M.D. (Travelling.)
1874 Bralshaw, A, F., C.B., Surgeon Major-General,
III, Banbury road, Oxford.
1899 Bradshaw, Thomas Robert, M.D., 51, Rodney street,
Liverpool. Trans. 2.
1900 BrainE'Hartnell, James Christopher Eeginald, Cots-
wold Sanatorium, Stroud, Glos.
1876 Bridges, Robert, M.B., Manor House, Yattendon, New-
bury, Berks.
1867 Bridgewater, Thomas, M.B., LL.D., Harrow-on-the-Hill,
Middlesex.
1891 Brodie, Charles Gordon, Fernhill, Wootton Bridge, Isle
of Wight.
1892 Bronner, Adolph, M.D., Senior Surgeon to Bradford
Eye and Ear Hospital ; Laryngologist to Bradford
Royal Infirmary ; 33, Manor row, Bradford.
1894 Brook, William Henry Breffit, M.D., B.S., 8, East-
gate, Lincoln.
1899 Brooksbank, Hugh Lamplugh, M.B., B.C., 5, College
road, Windermere.
1888 Browne, Henry Langley, Moor House, West Bromwicb.
1881 Browne, John Walton, M.D., Surgeon to the Belfast
Royal Hospital; Surgeon to the Belfast Ophthalmic
Hospital ; 10, College square N., Belfast.
1864 Buckle, Fleetwood, M.D., Merton Lodge, Mertori road,
Souihsea.
1901 Byrne, William Samuel, M.D., Anne street, Brisbane,
Queensland.
1851 Cadge, William, Consulting Surgeon to the Norfolk and
Norwich Hospital ; 49, St. Giles's street, Norwich.
Trans. 1.
1891 Campbell, Henri Johnstone, M.D., 36, Manningliam
lane, Bradford.
Ixx NON-RESIDENT FELLOWS
Elected
1900 Carlfon, Thomas Baxter.
1875 Carter, Charles Henrt, M.D., Consulting Physician to
the Hospital for Women, Soho Square ; 5, Homefield
road, Bromley, Kent.
1888 Garter, William Jeffreys Becher, Aliwal North, Cape
Colony.
1898 Cave, Edward John, M.D., Bath.
1884 Ohaffef, Wafland Charles, M.D., Physician to the
Royal Alexandra Hospital for Children; 13, Montpellier
road, Brighton.
1885 Chapman, Paul Morgan^ M.D., Physician to the Here-
ford General Infirmary, 1, St. John street, Hereford.
Trans, 1.
1881 Chavasse, Thomas Frederick, M.D., CM., Senior Surgeon
to the Birmingham General Hospital ; 22, Temple row,
Birmingham. Trans, 3.
1873 Chisholm, Edwin, M.D., 44, Rossi yn gardens. Darling-
hurst, Sydney, New South Wales.
1896 Christopherson, John Brian, M.D., B.C., Assist-
ant Demonstrator of Anatomy at St. Bartholomew's
Hospital ; Surgeon to Seamen's Hospital, Albert Dock ;
c/o P.M.O., Egyptian Army, Cairo.
1892 Clark, James Charles, 35, Castle road, Bedford.
1897 Clark, W, Gladstone, Civil Service Club, Capetown.
1857 CoATES, Charles, M.D., Consulting Physician to the
Bath Royal United Hospital ; 10, Circus, Bath.
1893 Cole, Robert Henry, M.D., Moorcroft, Hillingdon,
Uxbridge.
1891 Cook, Herbert George, M.D., B.S., 22, Newport road,
Cardifi".
1899 CoRRiGAN, William Jenkinson, Cloughmore, Splott
avenue, Cardiff.
1891 CouMBE, John Batten, M.D., 64, Caeran road, Newport,
Mon.
1869 Cresswell, Pearson B., C.B., Senior Surgeon to the
Merthyr General Hospital ; Dowlais, Merthyr Tydfil.
NON-RESIDENT FELLOWS Ixxi
Elected
1892 Cross, Francis Bichjrdson, M.B., Ophthalmic Surgeon
to the Bristol Royal Infirmary, and Sargeon to the
Bristol Eye Hospital; Worcester House, Clifton,
Bristol.
1895 Bjrdel, Jbjn, M.D., Aix-les-Bains, Savoy.
1879 Darwin Francis, M.B., F.R.S., Wychfield, Huntingdon
road, Cambridge.
1574 Davidson, Alexander, M.D., Consulting Physician to
the Liverpool Royal Infirmary; Emeritus Professor,
University College, Liverpool; 2, Gambier terrace,
Liverpool.
1&78 Davy, Richard, Consulting Surgeon to the Westminster
Hospital; Burstone House, Bow, North Devon.
Trans, 1.
1882 Dawson, Tblvbrton, M.D., Heathlands, Southbourne-
on-Sea, Hants.
1889 Dblepinb, Sheridan, B.Sc, M.B., CM., Professor of
Pathology, Owens College, Manchester. Trans. I.
1899 Douglas, Archibald Egbert John, M.B., B.S.,
c/o Watson & Co., 7, Waterloo place, S.W.
1867 Draoe, Charles, M.D., Hatfield, Herts.
1884 Draoe, Lovell, M.D.Oxon., Burleigh Mead, Hatfield,
Herts.
1898 Dreschfeld, Julius, Farndon House, Eusholme, Man-
chester.
1885 Drummond, David, M.D., 7, Saville place, Newcastle-
on-Tyne.
1880 Drurf, Charles Dennis Hill, M.D., Bondgate, Dar-
lington.
1899 Drury, Edward Out Dru, M.B., B.S., Grahamstown,
South Africa.
1&71 Dukes, Clement, M.D., B.S., Physician to Rugby School,
and Senior Physician to the Hospital of St. Cross,
Rugby ; Sunny side, Rugby, Warwickshire.
1867 Dukes, Major Charles, M.D., Clarence Villa, Torrs
park, Ilfracombe, North Devon.
Ixxii NON'RESIDENT FELLOWS
Elected
1889 Duncan, John, M.D., St. Petersburg, Russia.
1872 Ejgbb, Bbginjld, M.D., Northwoods, near Bristol.
1887 Easmon, John Fabbbll, M.D., Assistant Colonial Sur-
geon, Gold Coast Colony, and Acting Chief Medical
OflBcer of the Colony ; Accra, Gold Coast, West Africa.
1887 Elliott, John, 24, Nicholas street, Chester.
1868 Ellis, Jambs, M.D., The Sanatorium, Anaheim, Los
Angeles County, California.
1889 Elliston, William Alfbbd, M.D., Stoke Hall, Ipswich.
1875 Fagan, John, Consulting Surgeon to the Belfast Royal
Hospital ; 20, Fitzwilliam place, Dublin.
1897 Faqqe, Thomas Hbnbt, M.I)., Villa de la Porte Rouge,
Monte Carlo.
1869 Fairbank, Frbdbrick Botston, M.D., Westcott, Dorking.
1902 Fennell, Charlbs Hbnrt, M.A., M.D., Darenth Asylum,
Dartford, Kent.
1872 Fenwick, John C, J,, M.D., Physician to the Durham
County Hospital ; Long Framlington, Morpeth.
1879 Finlaf, David Whitb, M.D., Professor of the Practice
of Medicine in the University of Aberdeen ; Physi-
cian and Lecturer on Clinical Medicine to the Aber-
deen Royal Infirmary ; Consulting Physician to the
Royal Hospital for Diseases of the Chest, London ;
2, Queen's terrace, Aberdeen. Referee^ 1891-3.
Trans. 2.
1864 Folker, William Hbnrt, Consulting and late Hon.
Surgeon to the North Staffordshire Infirmary ; Bedford
House, Hanley, Staffordshire.
1896 FoRESTiER, Henri, M.D., Aix-les-Bains, Savoie, France.
1892 Foster, Michael George, M.A., M.B., Villa Camilla,
San Remo.
1884 Franks, Kendal, M.D., c/o J. H. Franks, Esq., C.B.,
Dalriada, Elackrock, co. Dublin. Trans, 2.
1876 FuRNER, Willoughbt, M.D., Surgeon to the Sussex
County Hospital ; Brunswick square, Brighton.
NON-RESIDENT FELLOIVS Ixxiii
Eleeteti
1864 Oairdner, 8tb William Tbnnjnt, M.D., K.C.B., LL.B.,
F.R.S., Honorary Physician in Ordinary to H.M. the
King in Scotland ; formerly Professor of the Practice
of Medicine in the University of Glasgow ; Honorary
Consulting Physician to the Western Infirmary,
Glasgow ; 32, Q-eorge square, Edinburgh. Trans. 1.
1885 Gjmgbb, Arthur, M.D., F.R.S., Emeritus Professor of
Physiology in the Owens College, Victoria University,
Manchester; Montreux, Switzerland.
1867 Garland, Edward Charles, Yeovil, Somerset.
1879 Garstang, Thomas Walter Rarropp, Englefield,
Delamer road, Bowdon, Cheshire.
1889 Gaskell, Walter Holbrook, M.D., F.E.S., Lecturer on
Physiology, University of Cambridge ; The Uplands,
Great Shelford, Cambs.
1884 GiBBES, Heneagb, M.D., Health Officer, Detroit,
Michigan, U.S.A.
1897 Gibson, George Alexander, M.D., D.Sc, 3, Drumsheugh
Gardens, Edinburgh.
1897 Gilford, Hastings, Norwood House, King's road,
Reading. Trans, 2.
1893 Gordon, William, M.B., M.C., The Old Rectory, Goring.
on-Thames, Oxon.
1890 Gordon, William, M.D., Barnfield Lodge, Exeter.
1898 Granville, Alexander, Turf Club, Cairo.
1898 Graf, J, A,, M.B., Wadham Lodge, Uxbridge road,
Ealing.
1889 Greene, George Edward Joseph, M.A., D.Sc, F.L.S.,
Monte Vista, Ferns, County Wexford.
1875 Greenfield, William Smith, M.D., Professor of Pathology
and Clinical Medicine in the University of Edinburgh ;
7, Heriot row, Edinburgh. Set, Com, 1879. Referee,
1881.
1900 Greer, William Jones, 2, Chepstow road, Newport,
Mon.
1882 Gresswell, Dan Astlet, M.A., M.D., D.P.H., Chairman,
Board of Public Health, Melbourne, Victoria.
Ixxiv NON-RESIDENT FELLOWS
Efected
1889 Obiffiths, Josbph, M.A., M.D., CM., Reader in Surgery
in the University of Cambridge ; Surgeon to Adden-
brooke's Hospital ; 63, Trumpington street, Cam-
bridge. Pro. 1.
1870 Hamilton, Bobbbt, Consulting Surgeon to the Royal
Southern Hospital, Liverpool ; Magherabuoy, Port-
rush, CO. Antrim, Ireland.
1864 Harley, John, M.D., F.L.S., Hon. Physician to St.
Thomas's Hospital; Consulting Physician to the
London Fever Hospital; Beeding, Piilborough, Sussex.
S. 1875-7. C. 1879-80. V.P. 1895-7. Referee,
1871-4, 1882-95. Sci, Com. 1879. Trans. 10.
1901 HdBTiQAN, T. J. P., *' Heathcote," East Grinstead,
Sussex.
1854 Hafiljnd, Alfbsd, Ridgemouut, Frimley Green, Surrey..
1890 Haviland, Fbank Papillon, M.D., B.C., 57, Warrior
square, St. Leonard's-on-Sea.
1885 Hawkins, Fbancis Hbnby, M.D., Physician to the Royal
Berkshire Hospital; 73, London street^ Reading.
TraiM. 1.
1900 Hatfobl, Ebnest James, M.D., c/o The Agent, Claude's
Ashanti Goldfields, Limited, Cape Coast Castle, Gold
Coast.
1860 Hajrward, Henbt Howabl, Consulting Surgeon Dentist
to St. Mary's Hospital; Harbledown, 120, Queen's
road, Richmond. C. 1878-9.
1861 Hatwabd, William Hbnbf, Oxford road, Burnley,
Lancashire.
1899 Hind, Henbt, Harrogate.
1900 Hobhouse, Edmund, M.D., 36, Brunswick place, Brighton.
1843 Holden, Lvtheb, Consulting Surgeon to St. Bartholo-
mew's Hospital, Pinetoft, Ipswich. C. 1859. L.
1865. V.P. 1874. JK(?/tfrtftf, 1866-7. Xi6. Com. 1858.
NON-RESIDENT FELLOW b Ixxv
Elected
1894 Holland^ Jambs Frank, M.D., St. Moritz, Engadine,
Switzerland.
1868 HoLLis, William Ajnslib, M.D., Fliysician to the Sussex
County Hospital ; 1 , Palmeira avenue. Hove. Trans. \,
1881 Howard, Henrt, M.B., Medical Officer ol Health,
Williamstown, Melbourne, Victoria.
1898 HuLKE, 8. Backhouse, Ivy House, Walmer, Kent.
1882 Humphry, Laurence, M.D., 3, Trinity street, Cambridge.
1847 Image, William Edmund, Herringswell House, Milden-
hall, Suffolk. Trans, 1.
1883 Jenkins, Edward Johnstone, M.D., The Australian
Club, Sydney, New South Wales.
1881 Jennings, William Oscar, M.D., 74, Avenue Marceau,
Paris.
1901 Johnson, Edward Angas, M.B., St. Catharine's, Pros-
pect, South Australia.
1889 Johnson, Harold J., Senior Assistant, Gloucester County
Asylum, Gloucester.
1876 Jones, Leslie Hudson, M.D., Limefield House, Cheetham
hill, Manchester.
1875 Jones, Philip Sydney, M.D., Consulting Surgeon to the
Sydney Infirmary ; 10, College street, Sydney, New
South Wales. [Agents: Messrs. D. Jones & Co.,
Wool Exchange, Coleman Street, E.C.]
1865 Jordan, Furneaux, Consulting Surgeon to the Queen's
Hospital, Birmingham ; Harborne, near Birmingham.
1872 Kelly, Charles, M.D., Ellesmere, Gratwicke road.
Worthing, Sussex.
1890 Kerr, J, G, Douglas, M.B., CM., 6, The Circus, Bath.
1884 Keser, Jean Samuel, M.D., Villa St. Martin, Vevey,
Switzerland,
Ixxvi N0N-RB81DENT FELLOWS
Elected
1877 Khory, Bustomjbb Nasebwanjee, M.D.Briix., Hormazd
Villa, Khumballa hill, Bombay.
1898 KLEFSTAD'SiLLONViLLBy O., M.D., Aix-les-Bains, Savoie.
1888 KrNSEF, Sir William Bafmond, C.M.G., Westfield,
Catherine road, Sarbiton. (Travelling.)
1889 Lancaster, Ernest le Cronier, M.B., B.Ch., Assistant
Physician ^o the Swansea Hospital ; Hon. Physician to
the Swansea and South Wales Institution for the
Blind ; Winchester House, Swansea, S. Wales.
1873 Larcher, O., 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, Peter Wallwork, M.D., Downing Professor of
Medicine, Cambridge University, 1874-94 ; Senior
Physician to Addenbrooke's Hospital, Cambridge;
17, Trumpington street, Cambridge.
1880 Latcock, George Lockwood, M.B., CM., Melbourne,
Victoria, Australia.
1892 Lazarus-Barlow, Walter Stdnet, M.D., Cecil House,
Cavendish road, Sutton, Surrey. Set. Com, 1892 —
1902.
1886 Lediard, Henri Ambrose, M.D., Surgeon to the Cum-
berland Infirmary ; 35, Lowther street, Carlisle.
Trans, 1.
1882 LsDWiCH, Edward l*Estrangb, Anatomist to the Royal
College of Surgeons, Ireland ; 30, Upper Fitz-
william street, Dublin.
1883 LsBsoN, John Budd, M.D., CM., Clifden House,
Twickenham.
1869 Lego, John Wickham, M.D. C. 1886. Referee, 1882-5.
Uh, Com. 1878-85. Trans. 2.
1898 Lindsay, Jambs, M.A., M.D., 13, College square East,
Belfast.
NON-RESIIJENT FELLOWS Ixxvii
Elected
1889 Little, James, M.D., Physician to the Adelaide Hos-
pital; 14, Stephen's Green North, Dublin.
1894 Loirs, Thomas Faoan, 16, The Circus, Bath.
1889 MacAlistsr, Donald, M.A., B.Sc, M.D., Physician to
Addenbrooke's Hospital ; Liinacre Lecturer and Tutor,
St. John's College; University Lecturer in Medicine;
St. John's College, Cambridge.
1887 Macdonald, Oeobos Childs, M.D. (Address uncom-
municated.)
1866 Macgowan, Alexandbr Thobburn, M.D., Vyvian House,
Clifton park, Bristol.
1869 M'Intyre, John, M.D., LL.D., Odiham, Hants.
1876 Mackbt, JEdwabd, M.D., Physician to the Sussex County
Hospital ; Senior Physician to the Royal Alexandra
Hospital for Sick Children ; 56, Lansdowne place,
Brighton.
1864 Mackinder, Dbapeb, M.D., 1 2, Park View Villas, Hove,
Sussex.
1893 MacLeod, Surgeon-Colonel Kenneth, M.D., The
Towers, Woolston, S. Hants.
1876 Macnamara, N, Charles, Consulting Surgeon to the
Westminster Hospital, and to the Royal Westminster
Ophthalmic Hospital ; The Lodge, Chorley Wood.
C. 1891-2. V.P. 1902—. Referee, 1884-90, 1895-7.
Lib. Com. 1886-90.
1891 Manbt, Alan Beeve, M.V.O., M.D., Surgeon Apothecary
to His Majesty's Household at Sandringham and to
T.E.H, the Prince and Princess of Wales at Sand-
ringham; East Rudham, Norfolk.
1894 Marriott, Charles William, M.D., Aubrey House, Bath
road, Reading.
1892 Martin, Christopher, M.B., CM., Surgeon to the Bir-
mingham and Midland Hospital for Women ; 35.
George road, Edgbaston, Birmingham.
.xxviii NON'RESIDENT FELLOH'S
Elected
1899 Mjbtfn, Gilbert John Kinq^ M.D., 8, Gay street, Bath.
1883 MiUDSLET, Renrt OjrRj M.D., 22, Collins street, Mel-
bourne, Victoria.
1839 Meade, Bichjrd Renrt, Consulting Surgeon to the
Bradford Infirmary; Bradford, Yorkshire. Tran9, 1.
1897 Merry, William Joseph Oollinqs, M.D., B.Ch., 2,
Chiswick place, Eastbourne.
1898 Millard, William Joseph Kelson, M.D., 7, Bayshill
▼illas, Cheltenham.
1895 MillS'Boberts, Bobebt Rebbebt, Hafod-ty, Llanberis,
North Wales.
1896 MooBE, i9/£ Jbfi^,M.D., 40, Fitzwilliam square west,DiA)lin.
1891 MoBBis, Gbaham, Wallington, Surrey.
1894 MoBSEy Thomas Rebbebt, All Saints' Green, Norwich.
Trans. 1.
1902 MoTNiHAN, Bebkeley Geobge Andbew, M.S., 33, Park
square, Leeds.
1892 Myddelton-Gavey, E. Hebbebt, 16, Broadwater Down,
Tunbridge Wells.
1881 Nall, Samuel, M.B., Dryburst Lodge, Disley, Stockport.
1889 Napieb, Fbancis Robatio, M.B., Cape Town.
1870 Neild, James Edwabd, M.D., Lecturer on Forensic
Medicine and Psychological Medicine in the University
of Melbourne ; 21, Spring street, Melbourne, Victoria.
1895 Newsholme, Abthub, M.D., 1 1, Gloucester place,
Brighton.
1868 NiCHOLLS, James, M.D., Trekenning House, St. Columb,
Cornwall.
1847 Nourae, William Edwabd Ghables, Norfolk Lodge,
Thurloe road, Torquay.
1884 Cakes, Abthub, M.D., Narrabri, Cole Park road,
Twickenham.
1880 O'Connob, Bebnard, A.B., M.D.. Senior Physician to
the North London Hospital for Consumption ; 25
Hamilton road . Ealing.
NON-RESIDENT FELLOWS Ixxix
Elected
1856 Ogle, William^ M.A., M.D., Consulting Physician to the
Royal Derbyshire Infirmary ; The Elms, Duffield road,
Derby.
1&70 Oldham, Charles Frederic^ India [Agents: Messrs.
Grindlay and Co., 55, Parliament street].
1896 Oliver, Oeorqe, M.D., Siversleigh, Earnham, Surrey,
and Harrogate.
1883 Oliver, Thomas, M.A., M.D., Professor of Physiology,
University of Durham ; and Physician to the New-
castle-on-Tyne Infirmary ; 7, Ellison place, Newcastle-
on-Tyne. Tran9, 1.
1871 O'Neill, William, M.D.. CM., late Physician to the Lin-
coln Lunatic Hospital, and Physician, Lincoln General
Dispensary, &c. ; 2, Lindum road, Lincoln.
1890 Ord, William Wallis, M.D., The Hall, Salisbury.
1886 Ormsby, L. Hepenstal, M.D., Lecturer on Clinical
and Operative Surgery and Surgeon to the Meath
Hospital and County Dublin Infirmary ; Surgeon to the
Children's Hospital, Dublin ; 92, Merrion square West,
Dublin.
1887 Paget, Charles Edward, Medical Officer of Health to
the County Council of Northamptonshire ; County
Hall, Northampton.
1868 Paley, William, M.D., Physician to the Ripon Dis-
pensary ; Yore Bank, Ripon, Yorkshire. •
1887 Fardington, George Lucas, M.I)., 47, Mount Pleasant
road, Tunbridge Wells.
1873 Parker, Robert William, Senior Surgeon to the East
London Hospital for Children ; Senior Surgeon to
the German Hospital ; Caryll Hurst, West Grinstead,
Sussex. C. 1888-9, 1899— 1901. S. 1895-8. Bldg.
Com. 1889-92. Bejeree, 1891-5. Lib. Com, 1885-87,
1892-5, 1898-9. Ro. Com. 1892-5, 1899—1901.
IVans. 4.
1885 Parker, Eushton, M.B., B.S., Professor of Surgery,
University College, Liverpool (Victoria University) ;
Surgeon to the Liverpool Royal Infirmary ; 59.
Rodney street, Liverpool.
Ixxx NON-MESIVENT FELLOWS
Elected
1891 Farkin, Alfred, M.S., M.D., 24, Albion street, Hull.
Trans. 1.
1879 Fbbl, Bobbrt, 120, Collins street East, Melbourne,
Victoria.
1874 Fbnhall, John Thomas, The Cedars, Broadwas-on-Teme,
Worcester.
1897 Pbrbam, Chablbs Hbbbbut, M.D., 55, Bromham Road,
Bedford.
1879 Pesikaka, Hobmasji Dosabhai, 43, Hornby road,
Bombay.
1878 Philipson, Sir Gbobgb Habs, M.D., D.C.L., Professor
of Medicine in Durham University ; Consulting Physi-
cian to the Newcastle-upon-Tyne Royal Infirmary ; 7,
Eldon square, Newcastle-upon-Tyne.
1898 Phillips, L. O. Fowbll, Kasr-el-Aini Hospital, Cairo.
1891 FiBRCS, Bbdfobd, M.D., The Retreat, York.
1897 FiQG, T. Strangbwats, St. John's College, Cambridge.
1841 Pitman, Sir Rrnry Alfrbd, M.D., Consulting Physician
to St. George's Hospital ; Cranbrook, Bycullah park,
Enfield. L. 1851-3. C. 1861-2. T. 1863-8. V.P.
1870-1. Referee, 1849-50. Lib. Com, 1847.
1692 Fowbll, Hbrbbrt Andrbws, M.A., M.D., M.Ch., Piccards
Rough, Guildford.
1900 PbicE'Jonbs, Cecil, M.B., 7, Claremont road, Surbiton,
Surrey.
1897 QuA^TBr-PAPAFio, Benjamin William, M.D., Accra,
6old Coast, West Africa.
1857 VON Ban KB, Henbt, M.D., 3, Sophienstrasse, Munich.
1890 Bansom, William Bramwell, M.D., Physician to the
Nottingham General Hospital; The Pavement, Not-
tingham. Trans, 1.
1854 Bansom, William Henbt, M.D., F.R.S., Consulting
Physician to tlie Nottingham General Hospital; 17;
Park Valley, Nottingham. Trans, 1.
1902 Bajf, Nathan, M.D., B.S., 66, Rodney street, Liverpool.
NON-RESIDENT FELLOWS Ixxxi
Elected
1884 Eeid, Thomas Whitehead, M.D., Surgeon to the Kent
and Canterbury Hospital ; St. George's House, Canter-
bury, Kent.
1901 Betssmann, Charles Henrf, M.D., B.C., B.Sc, St.
Peter's, College Green, Adelaide, South Australia.
1881 Bice, Oeorge, M.B., CM., Sutton, Surrey.
1889 BiVERs, W, R. Btvers, M.D., St. John's College. Cam-
bridge.
1871 Boberts, David Lloyd, M.D., F.R.S.E., Consulting Obstet-
ric Physician to the Manchester Royal Infirmary ; Phy-
sician to St. Mary's Hospital, and Lecturer on ClinicaJ
Obstetrics and Gynaecology at the Owens College,
Manchester; 11, St. John street, Manchester.
1889 BoBERTS, Leslie, M.D., 46, Rodney street, Liverpool.
1873 BoBERTSON, William Henry, M.D., Consulting Physician
to the Buxton Bath Charity and Devonshire Hospital ;
Buxton, Derbyshire.
1888 BobinsoHy Frederick William, M.D., CM., Huddersfield.
1885 BocKWOOD, William Gabriel, M.D., Colombo, Ceylon.
1898 Bogers, Leonard, I. M.S. [care of Messrs. Watson & Co.,
Calcutta.] Trans, 2.
1868 BowEy Thomas Smith, M.D., Consulting Surgeon to the
Koyal Sea-Bathing Infirmary ; Union crescent, Mar-
gate, Kent.
1891 Buffer, Marc Jrmand, M.D., The Quarantine Board,
Alexandria.
1898 Salter, A., M.D.
1855 Sanderson, Sir John Burdon, Bart., M.D., LL.D.,
D.CL.Durham, D.Sc, F.R.S., Regius Professor of
Medicine in the University of Oxford; 64, Banbury
road, Oxford. C 1869-70. V.P. 1882. Referee,
1867-8, 1876-81. Sci. Com, 1862, 1870. Lib. Com.
1876-81. Trans. 2.
VOL. LXXXV. /
Ixxxii NON-RESIDENT FELLOWS
Elected
1867 Sandford, Folliott Jjmes^ M.D., V.D., late Surgeon-
Major, 2nd Batt. S.Y.L.Infy., now Hon. Sargeon-
Major; Surgeon to the Market Drayton Dispensary,
and Consulting Physician to the Market Drayton
Cottage Hospital ; Market Drayton, Shropshire.
1886 Saundbt, Robert^ M.D., LL.D., Physician to the General
Hospital, and Consulting Physician to the Hospital for
Women, and to the Eye Hospital, Birmingham ; Pro-
fessor of Medicine, Mason University College; MOb,
Great Charles street, Birmingham.
1891 Saunders, Frederick William, M.B., B.C., Chieveley
House, near Newbury, Berks.
1883 ScHlFER, Edward Albert, LL.D., F.E.S., Professor of
Physiology in the University of Edinburgh. C. 1899-
1900. Referee, 1888-99. Sci. Com. 1889—.
1861 Scott, William, M.D., Senior Physician to the H udders-
field Infirmary ; Waverley House, Huddersfield.
1897 Semple, Edward^ M.D., Grove house, Fenstanton, Hunts.
1897 Setmovr, 8urg,'Major Charles, Bareilly, North-West
Provinces, India.
1899 Shuttle WORTH, George Edward, M.D., Ancaster House,
Biichmond Hill.
1887 SiDEBOTHAM, Edward John, M.B., Erlesdene, Bowdon,
Cheshire.
1857 SiORDET, James Lewis, M.B., Villa Cabrolles, Men tone,
Alpes Maritimes, France.
1896 Sloane, John Stretton, M.B., B.S., B.Sc, 7, Highfield
street, Leicester.
1891 Smith, O, Cockburn, M.D., 29, Lansdown crescent,
Cheltenham.
1886 Smith, Howard Lyon, Buckland House, Buckland
Newton, Dorchester.
1894 Smith, Robert Shingleton, M.D., B.Sc, Deepholm,
Clifton Park, Clifton, Bristol.
1894 Smith, Thomas Rudolph, M.B., B.C., Blytheholm,
Stockton-on-Tees.
NON- RESIDENT FELLOfTS fxxxiii
Elected
1868 SoLLTy Samuel Edwin, Colorado Springs, Colorado, U.S.A.
1899 Stephen, Gut NevillEj Foreign Office Medical Staflf.
1891 Stevens, Surg.-Capt. Cecil Bobert, M.B., B.S., I.M.S.,
Eden Hospital, Calcutta.
1854 Stevens, Henry, M.D., late Inspector, Medical Depart-
ment, Local Government Board, Whitehall; Durham
Lodge, St. Margaret's road, Twickenham.
1884 Stewart, Edward, M.D., Brook House, East Grinstead.
1879 Stirling, Edward Charles, M.D., Senior Surgeon to
the Adelaide Hospital ; Lecturer on Physiology in the
University of Adelaide, South Australia [care of
Messrs. Elder and Co., 7, St. Helen's place].
1871 Strong, Henry John, M.D., J.P., Consulting Surgeon
to the Croydon General Hospital ; Colonnade House,
The Steyne, Worthing.
1890 Sympson, E. Mansel, M.D., B.C., Surgeon to the
Lincoln County Hospital; Deloraine Court, Lincoln.
1886 Teale, Thomas Fridgin, M.B., F.R.S., Consulting Sur-
geon to the Leeds General Infirmary ; 38, Cookridge
street^ Leeds.
1898 Thomas, J, Lynn, C.B., Surgeon to the Cardiff Infirmary ;
Consulting Surgeon to the Hamadryad Hospital;
Green Lawn, Pen-y-lan, Cardiff.
1890 Thomas, William Robert, M.D., Little Forest, Bath road,
Bournemouth.
1891 Thomson, John Roberts, M.D., Monkchester, Bourne
mouth.
1876 Thornton, J. Knowsley, M.B., CM., Consulting Sur-
geon to the Samaritan Free Hospital for Women and
Children; Hildersham Hall, Cambridge. C. 1891
Lib. Com. 1886-90, 1893-95. Trans. 5.
1883 Thursfield, Thomas William, M.D., Physician to the
Warneford and South Warwickshire General Hospital ;
Selwootl, Beauchamp square, Leamington.
Ixxxiv NON'RESIDENT FELL0W8
Elected
1880 TiVTy William James, 8, Lansdowne place, Clifton,
Bristol.
1&71 Trend, Thbophilus W,, M.D., I , Grosvenor square, South-
ampton.
1881 Treves, William Knight, Surgeou to the National
Hospital for Scrofula; 31, Dalby square, Clifton?ille,
Margate.
1867 Trotter, John William, formerly Surgeon-Major,
Coldstream Guards ; 4, St. Peter's terrace, York.
1873 Turner, George Broifn, M.D., Camden House, Hem^l
Ilempsted, Herts.
1894 Turner, Philip Dymock, M.D., Sudbury, Isle of Wight.
1891 TiFEED, Reginald, M.D., Hembury Fort Cross, Honiton,
Devon.
1881 Tyson, William Joseph, M.D., Senior Medical OflBcer of
the Victoria Hospital, Folkestone ; 10, Langhorne
Garden*, Folkestone.
1900 Uhthoff, John Caldwell, M.D.,Wavertree House, Hove,
Brighton.
1867 Vintras, Achille, M.D., late Physician to the French
Embassy and Senior Physician to the French Hospital
and Dispensary, Shaftesbury avenue ; De Courcel
road, Brighton.
1854 Waddington, Edward, Hamilton, Auckland, New Zea-
land.
1868 Walker, Robert, Clovelly, Bideford.
1867 Wallis, George, Consulting Surgeon to Addenbrooke*s
Hospital ; 6, Hills road, Cambridge.
1899 Walters, Frederick Rufenacht, M.D., Crooksbury
Sanatorium, Farnham, Surrey.
1883 Walters, James Hopkins, Surgeon to the Royal Berk-
shire Hospital; 15, Friar street, Reading.
1899 Wardb, Wilfred Brougham, M.D., 13, Lonsdale
Gardens, Tunbridge Wells.
1846 Ware,' James Thomas, Til ford House, near Farnham,
Surrey.
NONliMSIlJENT FELLOWS IXXXV
Elected
1861 Waters, A, T, Houghton, M.D., Consulting Physi-
cian to the Royal Infirmary ; 69, Bedford street, Liver-
pool. Trans, 3.
1874 Wells, Hjrrt, M.D., San Ysidro, Buenos Ayres,
S. America.
1882 Whjrrt, Charles John, M.D., 14, Ewell road, Surbiton,
Surrey.
1897 White, Charles Powell ^ 2, Bland ford Gardens, Wood-
house lane, Leeds.
1881 Whitehead, Walter, F.R.S. Ed., Senior Surgeon to the
Manchester Royal Infirmary, Manchester and Salford
Lock Hospital, and Manchester and Salford Skin
Hospital ; Professor of Clinical Surgery, Owens College,
Victoria University; 499, Oxford road, Manchester.
Trans. 1.
1885 Whitla, Sir William, M.A., M.D., Professor of Materia
Medica and Therapeutics, Queen's College, Belfast ;
Physician to, and Lecturer in Medicine at, the Belfast
Royal Hospital ; Consulting Physician to the Ulster
Hospital for Women and Children ; Consulting Phy-
sician to the Belfast Ophthalmic Hospital; 8, College
square north, Belfast.
1870 Wilkin, John F., M.D., Rose Ash Court, South Molton,
Devon.
1883 Willans, William Blundell, Much Hadham, Herts.
1896 Williams, Alfred Henry, M.D., Rotorna, Harrow.
1859 Williams, Charles, Senior Surgeon to the Norfolk and
Norwich Hospital ; 48, Prince of Wales road, Norwich.
1887 Wilson, Arthur Rervey, M.D., .504, Broadway,
Boston, U.S.A.
1889 Wise, A. Tucker, M.D., Montreux, Switzerland.
1850 Wise, Robert Stanton, M.D., Consulting Physician to
the Southam Eye and Ear Infirmary ; Beech Lawn,
Banburv.
1885 WoLFENDENjEiCHARD NoRRis, M.D.,Rangemont, Seaford.
Sussex.
Ixxxvi N0N-RE8JI)ENT FELLOWS
Elected
1892 WooDHBAD, Obrmjn SrMSf M.D., Professor of Patlio-
logy in the University of Cambridge ; 6, Scrope ter-
race, Cambridge.
1879 Woodward, O. P. 3f., M.D., Deputy Surgeon- General ;
157, Liverpool street, Hyde Park, Sydney, New Soiitli
Wales.
1892 Wright, Almroth Edward, M.D., Ch.B., Oakhurst,
Netley, Hants.
1899 Winter, Andrew Ellis, M .D., Corner House, Beckenham,
Kent.
ANNUAL MEETING.
March Ist, 1902, at 5 p.m.
Present— F. W. Pavy, M.D., LL.D., F.R.S., President;
Sir Thomas
Clinton
[AS Barlow, Bart., M.D., ^ ,^ ^i
^ -r, r Hon. Sees.;
T. Dent, )
and 32 Fellows.
The President nominated Drs. Horton-Smith and
Goodall as Scrutineers, and declared the Ballot open until
six o'clock.
The Report of the Council, including the Treasurers'
Report, was read by the Senior Honorary Secretary.
Report op the Council.
The Council has pleasure in reporting that the position
of the Society, both as regards its financial stability and
the promotion of its principal objects, is entirely satis-
factory.
The number of new Fellows added during the past year
is not so large as usual, but this is probably the result of
the exceptionally large increase which has taken place
during the four or five preceding years.
During the past year there have been elected 12
Resident Fellows and 5 Non-resident Fellows, while 9
IxXXviii ANNUAL MEETING.
Fellows have been lost by death and 6 by resignation.
The Roll of Fellows now stands as follows :
Honorary Fellows — English
Foreign
Fellows — Resident ....
Non-resident
. 6
. 16
•
22
. 526
. 289
815
Total . . . .837
In view of the termination in 1904 of the Berners
Street lease, which produces a profit rental of about £435,
and of the fact that the income of the Society would then
be insufficient, without interference with the vigorous
working of the Society, to meet the annually increasing
expenditure and the repayment of the debentures, the
Council felt compelled to take into serious consideration
the utilisation of other resources. They came to the con-
clusion that the best and, as it appeared, the only adequate
means of increasing the income of the Society, to meet
the prospective loss of rent, was to let off the rooms
hitherto occupied by the Resident Librarian. These
rooms were estimated to be of the value of from £400 to
£500 per annum. On receiving an offer, which had to be
dealt with immediately, of £270 per annum for the use of
the meeting room, and of three of the ten rooms occupied
by their resident officer, they decided to accept it, and to
make a suitable arrangement with the resident officer to
meet the altered circumstances. There are still seven
rooms to be let, and the offers now before the House
Committee justify the belief that the income of the Society
will be substantially and permanently increased by the
change.
The arrangement made led the Council to consider the
whole question of the service of the Society.
For some years it has been apparent that the business
operations of the Society could not be carried on satisfac-
ANNUAL MEETING. Ixxxix
torily by the officer, who was responsible also for the daily
work of the Library, and that a division of duties had
become absolutely necessary. After earnest consideration
the Council decided that the work of the Society would be
better done — and responsibility more fairly apportioned —
by a Secretary and a Librarian. They therefore appointed
Mr. MacAlister to be Secretary and Mr. Clarke to be
Librarian, with a clear definition of their respective duties.
Mr. MacAlister^ s long experience as Resident Librarian
will still be at the service of the Fellows who may desire
to consult him on matters connected with the Library.
The changes in the Bye-laws rendered necessary by
these decisions are submitted for confirmation, and the
Council have confidence in looking to the Fellows to
indemnify them for the action that was taken under the
exigency of the circumstances that existed.
The new arrangement as to papers works extremely
well, and most authors have availed themselves of the
privilege of printing their papers in the journals immedi-
ately after being read.
The following Reports have been received :
Report of the Honorary Librarian ft,
^^ The Honoraiy Librarians have pleasure in report-
ing on the steady growth and increased useful-
ness of the Library.
^' There have been added to the Library during 1901
a total of 686 volumes, 355 of which have been
received as gifts from Fellows and others. In
addition to these the use of 258 volumes of
new books, much in demand, has been obtained
from Lewis's Library.
" The total number of books issued to Fellows was
3683 : in addition to these a very large number
of books has been used by Fellows in the
Library.
"The question of increased accommodation for
books has become rather pressing, and is now
XC ANNUAL MEETING
under the serious coDsideration of the Library
Committee. Along with this question will be
considered the advisability of new shelf nota-
tion to make the reference from the catalogue
to books more direct than is possible under the
present arrangement."
Norman Moore.
r. j. godlee.
Report of Committee on GUmates and Baths,
" I beg to state that during the past year the publi-
cation of the concluding volume of ' The
Climates and Baths of Great Britain and
Ireland * has been taken in hand by the Com-
mittee with the sanction of the Council.
'^ This is now being vigorously pushed forwards, and
Messrs. Macmillan have promised that an
advanced copy shall be in the hands of the
President at the Annual General Meeting on
March 1st.
'^The publication of the volume will complete the
work of the Committee."
P. Horton-Smith.
Report of the Honorary Treasurers.
'^ The Honorary Treasurers report that the financial
position of the Society is in a satisfactory con-
dition. The surplus of assets over liabilities
amounts to £27,919 S^. 4d., showing an increase
in the assets during the year of £769 135.
The income has been well maintained, the total
for the year amounting to £4319 ]0«. 9d.,
showing £8 As, 2d. less than in 1900; this
difference is more than accounted for by the
diminution in the number of entrance fees paid
during the year.^^
W. S. Church,
Warrinqton Haward.
ANNUAL MEETING XCl
The Council has passed the following resolution :
^^ The Council desires to express its warm apprecia-
tion of the valuable work performed by the
members of the Committee appointed to investi-
gate the Medical Climatology and Balneology
of Great Britain and Ireland, and to tender its
best thanks to those who have aided the Society
in this work/'
The President moved —
^' That the Report of the Council, together with the
Treasurers' audited Statement of Accounts, be
adopted/'
After some discussion this was carried.
The President moved —
"That the following alterations in the Bye-laws,
which have been made by the Council under
the powers conferred on them by the Charter,
be and are hereby confirmed, — that is to say :
Bye-laws — Chap. XI, including Sections I, II,
III, and IV, are rescinded, and the following
substituted therefor :
I. The Secretary shall either not be a Fellow of the
Society ; or, if a Fellow, shall cease to be so on his
election to and acceptance of that office.
II. The Secretary shall give such security as may be re-
quired by the Council.
III. The Secretary shall transact the general business of
the Society and conduct its correspondence under
the direction of the Council and of the House Com-
mittee; he shall receive all papers submitted for
reading, send them to the appointed referees, enter
the referees' reports in the proper book, and pass
the Society's publications through the press ; he shall
supervise the servants of the Society in their work,
and be responsible for their orderly conduct; he
shall supervise and take care of the Society's pre-
mises and other property, report on defects, and deal
with emergencies ; he shall be in attendance during
XCll ANNUAL MEETING
all meetings of the Society, of the Council, and of
the House Committee, and shall attend daily at the
Society's House for such time as shall be fixed by the
Council in the " Standing Orders." He shall further
generally assist the Hon. Secretaries in the non-
scientific part of their work.
IV. The Librarian shall be responsible for the arranging
and cataloguing of the books, and generally for the
proper conduct of the Library; he shall attend
daily between the hours of 10 a.m. and 6.30 p.m. ;
he shall be in attendance at the meetings of the
Library Committee, and shall submit to the Hon.
Librarians and the Library Committee all books
recommended to be added to the Library or offered
for purchase, and be responsible for the keeping in
proper order of the books and other contents of the
Library.
Chaf. XII, Sect. I, line 2. — The word ^resident' is
deleted.
Chap. XV, Sect. Ill, lines 3 and 4. — The word
^ Secretary ^ is substituted for the words ^Resi-
dent Librarian.^ "
Carried nem. con.
The President read the Annual Address {see p. xcix) .
The usual votes of thanks to the retiring President and
other officers, and members of Council, were carried unani-
mously.
At six o^clock the President called upon the Scruti-
neers to close the ballot, and to report the result.
The Scrutineers announced the result of the ballot to
be as follows :
Presiden t . — Alfred Willett .
Vice-Presidents, — Sir Richard Douglas -Powell,
Bart., M.D., K.C.V.O. ; Sir Dyce Duckworth, M.D.,
LL.D. ; N. Charles Macnamara ; Bdgcombe Venning.
Honorary Treasurers, — Sir William Selby Church,
Bart., M.D. ; J. Warrington Haward.
ANNUAL MEETING XOIU
Honorary Secretaries. — George Newton Pitt, M.D. ;
Clinton Thomas Dent.
Honora/ry Librarians, — Norman Moore, M.D. ;
Rickman J. Godlee, M.S.
Members of Council. — James Kingston Fowler,
M.D. ; Archibald Edward Garrod, M.D. ; Francis
de Havilland Hall, M.D. ; Isambard Owen, M.D. ;
Amand Jules McConnell Routh, M.D. ; Walter
Hamilton Acland Jacobson ; Henry Edward Juler ;
Charles R. B. Keetley ; Charles Barrett Lockwood ;
Thomas Laurence Read.
The President then installed the President elect, Mr.
Alfred Willett, in the chair, and invested him with the
President's badge and master-key.
The President elect briefly thanked the Fellows for
electing him, and declared the meeting closed.
XCIV
INCOME AND EXFKNDITUUK ACCOUNT
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LIST OP PAPERS.
N.B. — The Council of the Royal Medical and Chirurgical Society deem 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 merit, are thought worthy of being published
in the Transactions,
PAGB
I. Acute Dilatation of the Stomacb, with Illustrative
Cases ; by H. Campbell Thomson, M.D., P.R.C.P.,
Assistant Physician; Pathologist and Curator of
the Museum to the Middlesex Hospital; Medical
Tutor to the Medical School . .1
II. Ulceration of the (Esophagus and Stomach due to
swallowing Strong Hydrochloric Acid ; Lessons of
Treatment deduced from Three Cases ; by C. B.
Keetley, F.R.C.S., Surgeon to the West London
Hospital . . .23
III. Case of Intestinal Obstruction due to the Pressure of
a Vesical Sacculus upon a Coil of Small Intestine ;
by Thomas Bryant, F.R.C.S. . .37
IV. An Analysis of Forty-six Cases of Cancer of the
Breast which have been operated upon and sur-
vived the Operation from Five to Thirty-five
Years; with Remai'ks upon the Treatment of
Recurrent Growths, including the Disease of the
Second Breast, Operative and otherwise; by
Thomas Bryant, M.Ch., F.R.C.S., Consulting
Surgeon to Guy's Hospital . . .43
V. About Alkaptonuria; by Archibald E. Garrod,
M.A., M.D. . . .69
VOL. LXXX7. y
XCVm LIST OF PAPERS
PA6B
YI. Two Cases of Ligature of the Left Carotid for Aneu-
rysm of the Arch of the Aorta, with the Post-
mortem Specimens of Four Cases; by Cheisto-
PHEK Heath, F.R.C.S., Consulting Surgeon to
University College Hospital .79
TIL The Surgical Treatment of Obstruction in the
Common Bile-duct by Concretions, with especial
reference to the Operation of Choledochotomy as
modified by the Author, illustrated by Sixty Casea;
by A. W. Mayo Robson, P.R.C.S., Senior Surgeon
to the General Infirmary at Leeds ; Emeritus Pro-
fessor of Surgery in the Yorkshire College of the
Victoria University . .93
YIII. A Contribution to the Study of Tropical Abscess of
the Liver; by Rickman J. Godlee, M.S. . 119
IX. Some General and Etiological Details concerning
Leprosy in the Sudan; by T. J. Tonkin, late
Medical Officer to the Hausa Association's Central
Sudan Expedition, 1893-4-5 . . .145
X. Leprosy in Natal and Cape Colony ; by Jonathan
Hutchinson .... 161
XL The Possibility of Recovery from the Active Stage
of Malignant Endocarditis, illustrated by Cases
and Specimens; by Wili*iam Ewart, M.D.,
F.R.C.P., and A. S. Morley, L.R.C.P., M.R.C.S. . 189
XII. A Contribution to the Study of Malignant Endocar-
ditis; by F. J. PoYNTON, M.D., M.R.C.P., and
Alexander Paine, M.D. . . . 211
XIII. Modern Methods of Vaccination and their Scien-
tific Basis ; an Address by S. Monckton Copem an,
M. A., M.D.Cantab., F.R.C.P.Lond. . . 243
XIY. Clinical and Experimental Observations introducing
a Discussion on the Regeneration of Peripheral
Nerves ; an Address by Charles Ballance and
PuRVES Stewart; with Lantern and Micro-
scopical Demonstration . . . 283
XV. Ateleiosis, a Disease characterised by Conspicuous
Delay of Growth and Development ; by Hastings
Gilford, F.R.C.S.Eng. . . .305
Index ...... 361
ADDRESS
OF
FREDERICK WILLIAM PAVY, M.D.,
LiL.D., P. U.S., F.R.C.P.,
PRESIDENT,
AT THE
ANNUAL MEETINa, MAECH 1st, 1902.
Gentlemen, — By the onward march of time, which stops
for no one, we are brought to another Annual Meeting.
Last year we met under mournful circumstances, arising
from the death, but a short time previously, of the good
Queen Victoria, who had passed through a record reign —
regarded alike from its duration, the happy social condi-
tions that existed, and the great strides of advance that
took place in knowledge. A tie of many years as our
Patron was severed. All have to bow to the inexorable
laws of nature ; and fortunate are we now in finding that
our tie with royalty has been renewed by the gracious
assent of His Majesty King Edward VII to become our
Patron, thus creating a line of succession of patronage
through three Sovereigns.
Satisfaction will, I am sure, be felt at the honour that
VOL. LXXXV, : t .h... >!'
president's address
was conferred upon our Society by the King in receiving
our address of condolence on the death of Her Majesty the
late Queen at an audience granted to a deputation from
the Society for the purpose.
I referred last year to the altered procedure that has
been adopted with regard to the publication of papers.
With the surrounding changes effected by the advance of
time, the restrictive character of the traditions of the
Society stood as a bar to communications being presented
for reading. There seemed to be a growing prospect of
the usefulness of the Society being checked by dearth of
material. To meet these circumstances it was decreed in
the Standing Orders that ** after a paper has been read
before the Society, the author, or authors, shall be entitled
to publish it in one or more medical or scientific periodi-
cals— provided that in the heading of sucli paper it shall
be stated that it belongs to and was read before this
Society."
As the result of the year's working under the new
regulation, it is noticeable that authors have extensively
availed themselves of the opportunity afforded them of
promptly placing their communications before the profes-
sion; and if speedy diffusion of knowledge is to be con-
sidered advantageous, benefit has been conferred upon both
profession and author. Quality has always been looked
upon as a primary consideration in the acceptance of
papers ; and, with the alteration that has been made, there
can be no doubt that the Society has greatly improved its
position for attaining the object desired.
Our death roll at the last Annual Meeting was a heavy
one, comprising as it did twenty-one Fellows, and includ-
ing an exceptional number of men of mark in the profes-
sion. This year death has dealt more lightly with us, ten
being the number of obituary records to place before the
meeting. Of the ten deaths one occurred at 90, one at
89, two at 87, one at 85, two at G5, one at G3, one at 59,
and one at 32. I will take the records in the order in
which the deaths occurred.
PRESIDENT'S ADDRESS ci
Benjamin Barrow, F.R.C.S., J.P., who died at Ryde,
Isle of Wight, on March 7th, 1901, was born at Bath in
1814. Two of his brothers became Generals in the British
Army, a'hd each gained the distinction of K.C.B.
Mr. Barrow was articled to Mr. Stanley, Surgeon to St.
Bartholomew's Hospital, and resided in his house, where
Mr. Luther Holden was one of Mr. Barrow's fellow-pupils.
He became M.E.C.S. in 1836, and F.R.C.S. in 1862, and
served as Surgeon in the Army until he settled in practice
in Ryde in 1848.
At St. Bartholomew's, we have it on Mr. Holden's autho-
rity, Mr. Barrow was " quite an example to the other stu-
dents in the way in which he did his work. He was an
excellent talker, but not a good listener. At the Aber-
nethian Debating Society he always commanded attention.
He was the original Founder and Secretary of the Con-
temporary Club, which consisted of St. Bartholomew's men
during the period between 1830 and 1840," and numbered
among its members Sir Richard Owen, Sir Charles Locock,
Sir James Paget, Dr. Jeaffreson, Dr. Bostock, and other
notabilities.
He was a good man of business, and played a foremost
part in the public affairs of Ryde, especially in the crusade
against the polluted surface wells from which the inhabit-
ants drank. In connection with this matter he allowed
himself no rest until the water from the neighbouring
chalk downs was brought to supply the town. Similarly he
fought for the proper sewerage of the place and the drain-
age of the marshes, and succeeded in caj'rying his point in
face of strenuous opposition. He was Chairman of the
Water Committee and of other sanitary committees, and
was nine times Mayor of Ryde. The Esplanade and other
public works of the town were largely due to his advocacy.
He was one of the founders of the Infirmary, and was one
of its honorary surgeons, and subsequently its consulting
surgeon. Some six other local institutions were also
founded during his residence in Ryde, and obtained his
powerful support. In 1881 he was President of the British
cii presidext's address
Medical Association when the annual meeting was held at
Ryde.
Mr. Barrow was twice married; firstly to Miss Stanley,
and secondly to Miss Arnold, who has suryiyed him. He
had no child.
In the autumn of 1900, whilst staying in London, he
fell in the street, and sustained a comminuted fracture of
the left wrist, of which he characteristically made light.
Sinuses formed, however, and the arm was amputated
above the elbow in January, 1901, by his friend Mr. Alfred
Willett, who attended him in conjunction with Mr. Ingleby
Mackenzie. Notwithstanding Mr. Barrow's great age —
over 86 — the stump was entirely healed at the end of three
weeks ; but a little later he became restless, and gradually
sank. He was followed to the grave by a large concourse
of all ranks of people, amidst every manifestation of
sorrow, as was only, it may be said, his due, for he had
unceasingly worked with enthusiasm for the public good.
Sir Edwin Saunders, F.R.C.S.Eng., whose death took
place after a short illness at his residence, Fairlawn, Wim-
bledon Common, on March 15th, 1901, at the patriarchal
age of 87, was born in 1814 in London, where his father
was a book publisher. Early in life he showed great apti-
tude in connection with mechanical appliances and inven-
tions. He became articled as a dental pupil to Mr.
Lemaile, and gave some lectures on elementary mechanics
and anatomy before a mechanics' institute. At one of
these Mr. Tyrrell, Surgeon to St. Thomas's Hospital, was
present, and was so " favourably impressed by the young
lecturer that, after a consultation with his colleagues, he
invited him to give a course of lectures at the hospital. ^^
After his admission to the Membership of the Royal Col-
lege of Surgeons, in 1839, Sir Edwin became Dental Sur-
geon and Lecturer on Dental Surgery to St. Thomas's
Hospital. He became a Fellow of his College in 1855.
In 1840 he investigated the date of eruption of the various
teeth, and published the results under the title of *'The
Teeth a Test of Age." In 1846, at the earnest desire of
1»RESIDENT*S ADDEESS Clil
Mr. Nasmyth, when attacked with illness, Sir Edwin took
his large dental practice, succeeding also to the appoint-
ment of Dental Surgeon to Ciueen Victoria, the Prince
Consort, and other members of the Royal Family. In
1883 he received the honour of knighthood.
He was amongst the earliest to seek to obtain from the
Royal College of Surgeons an examination and diploma
for dental practitioners, and Parliament was eventually
induced to give authority to the College thus to extend
its powers. In 1859 he and others established the Dental
Hospital and School in Soho Square. The institution pros-
pered, and became so successful that in 1874 a larger
establishment became necessary ; and chiefly through Sir
Edwin Saunders' energy and liberality, and his influence
over others, the hospital in Leicester Square was equipped
and handed over free of debt. In commemoration of these
services his colleagues and friends established the Saun-
ders Scholarship at the School. He subsequently remained
on the management committee until it was decided to
build the new hospital recently inaugurated; when, as
he did not agree with the majority of his colleagues, he
resigned.
At Sir Edwin Saunders' house the Odontological Society
was started in 1857 : lie was its first Treasurer, and twice,
viz. in 1804 and 1879, he held office as its President. In
1881 he occupied the chair of the dental section at the
meeting of the International Medical Congress in London.
He was also President of the Metropolitan Counties Branch
of the Ihitish Medical Association in the same vear, and
was a constant attendant at the meetings of the British
Dental Association, over which he presided in London in
188G. He was alwavs anxious to associate the dental with
the medical profession ; and recognised the necessity of a
special training in dentistry, which he regarded as a
branch of medicine. It is also largely due to his efforts
and example that the dental ])rofession owes its present
high position in this country.
He married Maria, daugliier of ilr. E. Burgess ; and at
civ PRESIDENT'S ADDRESS
their golden wedding his friends presented him with an
illuminated address, bound in vellum, and to Lady Saun-
ders a diamond brooch. He relinquished practice several
years before his death, and enjoyed the ensuing leisure.
In his beautiful garden at Wimbledon he attained great
success in the cultivation of chiysanthemums and other
flowers. Altogether he possessed keen and wide sym-
pathies, was hospitable to a degree, and a good conversa-
tionalist. He also possessed an inexhaustible fund of
knowledge of art and travel. It is easy, therefore, to per-
ceive how such a man became the head of his branch of
the profession, and how wide a gap was created by his
retirement from practice. His funeral at Putney was
attended by very many medical and dental practitioners.
Christopher Mercer Durrant, M.D.Edin., F.R.C.P.Lond.,
who was Consulting Physician to the East Suffolk and
Ipswich Hospital, died on April 6th, 1901, in his eighty-
eighth year. He was born in Lewes in 1814, and was
apprenticed for many years to a medical practitioner at
Maidstone. He next spent six months in Berlin, that he
might study German; and then proceeded to Edinburgh,
where he took the M.l). degree in 1839. In the same year
he commenced practice as a physician in Ipswich. Soon
afterwards he was appointed Physician to the East Suffolk
Hospital, in which institution- he henceforward took a very
warm interest, and to which he attracted many patients
anxious to obtain his advice. He further assisted the
Ipswich Nurses^ Home and the Convalescent Home at
Felixstowe, and was a member of the Acting Committee
of both institutions. He was a J.P. for East Suffolk.
Dr. Durrant became M.H.C.P. in 1859, and was elected
F.B/.C.P. in 1873. He was also one of the oldest Fellows
of our Society, having joined in 1843.
In 1879 a serious illness compelled him to discontinue
his work on the acting staff of the East Suffolk Hospital,
and on his resignation he was appointed Consulting Phy-
sician, which post he retained until his death.
He married, in 1839, the daughter of William Rawes,
president's address cv
il.l). The marriage was a happy one, and they lived to
celebrate their golden wedding surrounded by a numerous
family.
He was the first President of the East Anglian Branch
of the British Medical Association after its foundation in
1843, and again occupied the chair when it celebrated its
jubilee in 1893. He contributed several papers to the
* British Medical Journal.' He was a kind-hearted phy-
sician, greatly esteemed in East Anglia, both socially and
professionally ; and in middle life he had a large practice
as a consulting physician.
John Cavafy, M.D., F.R.C.P., Consulting Physician to
St. George's Hospital, died suddenly on April 28th, 1901.
He was of Greek descent, and was born at Tulse Hill in
June, 1838. He was educated at Brighton and University
College, and then worked for foui* years in the office of his
father, a well-known merchant in the City of London.
Young Cavafy's desires were, however, towards medicine ;
and eventually he ** entered " at St. George's Hospital, in
October, 1861, when he was twenty-three years of age.
He graduated M.B.Lond. in 1807, and M.D. two years
later. In 18G8 he became M.R.C.P., and was elected a
Fellow in 187(). He was subsequently a Councillor of the
College, and Examiner in Medicine both for the College
and for the University of London.
At St. George's Hospital Medical School he held the
several offices of Demonstrator of Histology, Lecturer on
Comparative Anatomy, Medical Registrar, Lecturer on
Physiology, and, finally. Lecturer on Medicine. He was
appointed Assistant Physician to the Hospital in 1875,
and Physician in 1882, when lie also took charge of the
skin department. During the International Medical Con-
gress held in London in 1881, he was Honorary Secretary
to the Section of Dermatology. Early in 1890 he suffered
severely fi'om enteric fever, had a protracted convalescence,
and never regained his previous strength. He subse-
quently gave an admirable lecture on his own case, which
was published in ^The Clinical Journal.' In 1898, feeling
cvi president's address
that his strength was failing, he resigned his Physieiancy
to St. George's Hospital, and was elected Consulting Phy-
sician. He was also at one time Physician to the Victoria
Hospital for Children.
Ur. Cavafy was always a lucid lecturer and teacher, and
possessed a very wide acquaintance with medical literature.
He contributed many papers to Heath's * Dictionary of
Surgery,' to the ' St. George's Hospital Eeports,' the medi-
cal journals, and the Transactions of various societies,
amongst the latter being a paper on *' Amoeboid Move-
ments of the Colourless Blood-corpuscles in Leucha^mia,"
read before this Society in 1880. His papers chiefly re-
lated to diseases of the skin, though he also wrote on the
** Education of the General Practitioner," ** Diabetes,''
** Myxoedema," " Yellow Atrophy of the Liver," " Eheu-
matism treated by Salicylate of Soda," and " Rheumatic
Nodules."
From his retirement in 1898, Dr. Cavafy lived at Hove,
Sussex, and after an attack of influenza had a remarkably
slow pulse. Whilst visiting London in April last he died
suddenly and painlessly from cardiac syncope. His wife,
by whom he has left one daughter, was the youngest
daughter of Mr. Antonio Ralli.
Dr. Cavafy was a born artist with the brush, a good
musician, and excelled as a linguist ; had a ready wit, and
was fluent in conversation; was a genial companion, a
keen humorist, and had a true love of nature, especially
of botany and ornithology. In his school and college he
was courteous and loyal to those with whom he came in
contact. He possessed great ability as a teacher, was
highly sensitive and sympathetic with the patients, and
conscientiously devoted to his duties, both to them and to
the students. Altogether, as an intimate acquaintance of
more than forty years' standing wrote in the * Lancet,' " he
was a learned physician, he was a just and honourable
man. No man ever made firmer friends or fewer foes."
Carstoii Holthouse, E.ll.C.S., who died on July 18th,
1901, was within three months of completing his ninety-
president's address cvii
first year, and was probably the senior member of this
Society. He was bom at Edmonton in October, 1810;
and at the age of fourteen was apprenticed to his uncle,
Mr. Le Gay Brewerton, at Bawtiy, Yorks. He studied
medicine at St. Bartholomew's Hospital, was dresser under
Sir William Lawrence, and clinical clerk under Dr.
Latham. He became L.S.A. in 1832, and M.R.C.S. in
1833, and studied for a time in Paris. Returning to
London, he worked in the out-patient department of St.
Bartholomew's Hospital, and published three papers on
Acarus scabiei, which attracted considerable attention.
In 1843 he was appointed Lecturer on Anatomy and
Physiology at the Aldersgate School of Medicine upon Mr.
Skey's promotion to the Lectureship on Anatomy at St.
Bartholomew's. He worked strenuously at the subject of
his lectures, and soon established for himself a reputation
as an anatomist; and in the same year, 1843, he was
elected one of the 150 original Fellows of the Royal Col-
lege of Surgeons.
Westminster Hospital started a medical school in 1841,
but it cume to an end in 184(). In 1849, however, a new
staff of lecturers was appointed, and to Mr. Holthouse was
assigned the Chair of Anatomy. But the school was not
at first successful ; and, after lecturing for five years with-
out any pecuniary reward, Mr. Holthouse resigned. H(»
was then appointed sole manager of the school, and even-
tually placed it on a substantial foundation, so that he was
virtually the founder of the Westminster Hospital Medical
School of to-day. In 1853 he was appointed Assistant
Surgeon to the Hospital, and in 1857 became Surgeon,
having meanwhile served on the staff of the British Hos-
pital at Smyrna during the Crimean war. Before this
(jpisode in his career he had studied ophthalmology ; and
in 1854 he published six lectures on the " Pathology of
Strabismus and its Treatment by Operation.' In 1857
he assisted to found the vSurrey Ophthalmic Dispensary,
now well known as the Royal Eye Hospital, Southwark.
In the following year he j)ublished a work '^ On Squinting,
cviii president's address
Paralytic Affections of the Eye, and Certain Forms of
Impaired Vision.' He wrote a book * On Hernial and
other Tumours of the Groin,' and an article for Holmes'
^ System of Surgery ^ on " The Lower Extremity."
On his retirement from the Surgeoncy to the West-
minster Hospital, in 1875, Mr. Holthouse was appointed
its Consulting Smgeon. He subsequently stai-ted an in-
stitution for the reception and treatment of inebriates.
The venture, however, brought him anxiety and loss,
though, as an object lesson, it probably assisted in the
passage of the Inebriates Act, which soon ensued.
As a surgeon he excelled in diagnosis. In operative
surgery he was not so brilliant. As a writer in the
' British Medical Journal ' truly remarks, " in spite of
real ability and devotion to his profession, Mr. Holthouse
never reaped the reward that he might have looked for.
Whilst his work in each branch of surgery that he took
up was thorough so far as it went, he allowed his energies
to range over too many subjects, and when success in one
seemed close at hand he had already turned his attention
to another. Confident also, and justly so, in his own
powers of diagnosis and his judgment as to treatment, he
was scarcely ready enough to make allowance for the views
which others might take of a case. These characteristics
were naturally a serious bar to success in practice."
After a long and vigorous life, he was seized about two
years before his death with right-sided hemiplegia and
aphasia, from which he quickly recovered. But other
attacks followed, rendering him quite helpless during
several of the closing weeks of life.
Mr. Holthouse was twice married, and has left three
sons by his first wife. His second wife, who also died
before him, was Martha, the daughter of Dr. John Nicol,
of Inverness. By her he had no children.
Thomas Vincent Jackson, F.R.C.S.Edin., M.R.C.S.Eng.,
J. P., Surgeon to the Wolverhampton and Staffordshire
General Hospital, died at his house in Wolverhampton
on October 12th, 1901, at the age of G5. He was born in
president's address cix
London, and educated at Brighton and King's College
School. He studied medicine at University College,
London ; and, after a distinguished career, became Pre-
sident of the College Medical Society. He obtained the
diploma of M.E.C.S. in 1857, and that of L.S.A. in 1858.
He was elected Demonstrator of Anatomy in University
College School, and House Suigeon in the hospital; and
acted as private assistant to Mr. Richard Quain. For
reasons of health he quitted London ; first assisted Ur.
Quinton, of Willenhall, and was appointed in 1861 House
Surgeon to the Wolverhampton and Staffordshire General
Hospital. Subsequently, joining Dr. Gatis in practice, he
was appointed Honorary Suigeon to the hospital. He
became E.R.C.S.Edin. in 1883, and was for many years
Consulting Surgeon to the Hospital for Women and Sur-
geon to the Orphan Asylum at Wolverhampton. He was
also Life Governor of Birmingham L^niversity, and a
member of several medical societies.
Besides holding these several hospital appointments, he
was for nearly forty years engaged in general practice.
This did not, however, prevent him from achieving a high
repute as a suigeon and successful operator in South
Staffordshire. He contributed ai-ticles to the medical
press on perinseal operations, lithotomy, and colotomy ;
published, in 1889, an ' Essay on the Medical Profession
and Public Life ; ' and in 1898 an ' Address on the Medical
Craft in Britain, from the Earliest Period to the Victorian
Era.' He was a Justice of the Peace for the town of Wol-
verhampton and for the county of Stafford.
Early in his career he joined the British Medical Asso-
ciation ; was one of the founders of the Staffordshire
branch, served as its Secretary from 1874 to 1888, and
filled the Presidential Chair in 1889. He also represented
his branch on the Central Council of the Association for
the last twenty years of his life, and was a most constant
attendant at the Council meetings.
He gave a large amount of time to -the municipal work
of Wolverhampton ; was elected Town Councillor in 1876,
ex t»RESlDENT*S ADDRESS
served on several standing committees of the Council, and
was for many years Chairman of the Public Works Com-
mittee. He became Mayor of the borough in 1887, the
year of Queen Victoria's Jubilee ; and largely through his
exertions the Queen Victoria Nursing Home for Wolver-
hampton, which cost £5000, was erected as a memorial of
the Jubilee. He was an Alderman of the borough from
1887 onwards. He discharged the duties of all these posts
with zeal and ability, and always evinced a keen desire to
promote the welfare of the people among whom he lived.
In 1896 he assisted largely in remodelling the operating
theatre of the Wolverhampton and StafEordshire General
Hospital in accordance with modern requirements.
He was twice married : first to the daughter of his
early partner. Dr. Gatis ; secondly to the daughter of Dr.
Symonds, of Southampton. This lady survived him.
Mr. Jackson's health had lately failed, but his final
illness was of brief duiation. On October 6th he felt
unwell, but gave evidence in a police case next day. On
October 9th pneumonia was detected, and he died on the
12th. The first part of the funeral service was conducted
at Wolverhampton on October 17th, and was attended by
the Mayor and Corporation, by a large body of Mr. Jack-
son's medical colleagues, and by the officials of the many
institutions with which he was connected. The interment
took place on the same day at Highgate Cemetery, London.
Throughout life Mr. Jackson won the sincere respect
and regard of his colleagues, his patients, and his fellow-
citizens of all shades of political opinion. One of his
friends in the Midlands wrote thus of him: — ** As a sur-
geon Vincent Jackson was a bold and enterprising opera-
tor, a keen observer, quiet in his work, but considerate and
careful. To those who knew little of him his manners
often seemed nervously excitable, not to say fussy, but this
was all upon the surface. His old friends and patients
found beneath the superficial mannerism sound judgment,
wide knowledge, and generous self-sacrifice, and so learned
to prize him as a faithful friend and a devoted doctor."
president's address cxi
Henry Spencer Smith, F.R.C.S.Eng., who was the doyen
of this Society, to which he was elected as long ago as
1838, died on October 29th, 1901, aged 89, at his residence
in Oxford Terrace, Paddington. He received his profes-
sional education chiefly at St. Bartholomew's Hospital,
where he was a pupil of Mr. (afterwards Sir William)
Lawrence. He also studied at Berlin and Paris, and
became M.B/.C.S.Eng. in 18'i7. Subsequently he was
House Surgeon to St. Bartholomew's Hospital and Surgeon
to the Royal General Dispensary, Aldersgate Street. He
was appointed one of the three Assistant Surgeons to St.
Mary's Hospital upon its foundation in 1851. When a
medical school in connection with that hospital was origi-
nated, in 1854, he was appointed its Dean, and for six
years laboured unremittingly at the work. When h(»
resigned the post in 18()() he was presented by the stu-
dents with a piece of plate, and by the lecturers with
a silver-gilt inkstand. He lectured for many years in St.
Maiy's Medical School on Surgery; and upon his retire-
ment from the Surgeoncy to the Hospital was elected Con-
sulting Surgeon. He was also a member, and the Hono-
rary Secretary, of the Government Commission of Inquiry
into the question of Venereal Disease as occurring in the
Navy and Army. He was one of the original Fellows of
the Royal College of Surgeons of England who were chosen
in 1843, and, after the death of Mr. Carston Holthouse in
July last, became the sole sui'vivor of those original Fel-
lows. He held office as a member of the Council of the
College from 1807 to 1875, and had been a member of the
Court of Examiners. He had at various times held ofiice
in this Society, as Councillor, Secretary, Vice-President,
and Treasurer, and served as Referee and member of tlie
Librarv Committee, but never contributed to the Societv's
* Transactions.'
He translated into English Schwann's ' Microscopic
Researches into the Accordance in the Structure and
Growth of Animals and Plants,' which was published
by the Sydenham Society. He also translated Bischoft's
cxii president's address
memoir ' On the Periodical Maturation and Extrusion of
Ova, independently of Coitus, in Mammalia and Man ; '
and he contributed various clinical lectures to the medical
journals.
Mr. Smith retired from practice about fifteen years ago.
He was twice married, and has left a widow, with a son
and daughter from his first marriage.
Henry Sutherland, M.D., M.A.Oxon., M.R.C.P.Lond.,
died on November 19th, 1901, aged 59. He was the
second of the six sons of Dr. Alexander John Sutherland,
F.R.C.P., F.R.S. Both father and son were Physicians
to St. Luke's Hospital for the Insane.
Henry Sutherland was educated at Westminster and
Radley Schools, and at both Oxford and Cambridge Uni-
versities. He took the B.A.Cantab, in 1867, the M.A.
and M.B.Oxon. in 1869, and the M.D.Oxon. in 1872. His
medical studies were pursued at St. George's Hospital,
London, and Addenbrooke's Hospital, Cambridge ; and he
became M.R.C.P.Lond. in 1870. He studied insanity at
Bethlem Royal Hospital and at the West Riding Asylum,
Wakefield, under Dr. (now Sir James) Crichton-Browne.
Rettiming to London to practise, he was, in 1872, ap-
pointed Lecturer on Psychological Medicine to the West-
minster Hospital, a post which he retained for about fifteen
years. His work lay henceforth in this special branch of
practice, though he was also for some thirty years Phy-
sician to the St. George's, Hanover Square, Dispensary.
That post he highly valued, as it kept him in touch with
general medicine.
Dr. Sutherland was a Fellow or Member of eight of the
chief medical societies of London, and the author of several
articles on subjects connected with his own speciality, very
many of which appeared in the columns of the * Lancet.'
In early manhood he excelled as a fencer, gaining the
" prize foils " both at Oxford and at Cambridge ; he also
excelled in running. He was an enthusiastic Freemason,
and had held the Mastership of several Lodges, besides
being a Past Grand Deacon. He was industrious and
president'vS address cxiii
painstaking, a generous and genial host, and alwaj's widely
considerate for others ; so that he naturally made and re-
tained a large circle of friends. He married somewhat
late in life, and has left a widow to mourn his death.
Sir William MacCormaCy Bart., K.C.B., K.C.Y.O.,
F.E.C.S.Eng. and Ireland, D.Sc, M.Ch., E.TT.I., Honorary
Sergeant-Surgeon to H.M. the King; Consulting Surgeon
to, and Emeritus Lectm^er in Surgery at, St. Thomas's
Hospital ; ex-President of the Royal College of Surgeons
of England.
The death of Sir William MacCormac, on December 3rd,
1901, deprived surgery of one of its foremost exponents.
He had been a prominent figure in every professional event
for thirty years, so that his life-work covered a peculiarly
wide field.
William MacCormac was the eldest son of Dr. Henry
MacCormac of Belfast, and was bom there in 1830. Dr.
MacCormac was a cultured physician, an expert in tropical
diseases, and a strenuous advocate of the value of fresh air
in the treatment of phthisis. Young MacCormac received
his early education at the Royal Belfast Institution, and
studied medicine at Dublin and at Paris. He became
successively B.A. in 185G, M.A. in 1858, M.Ch. in 1879,
and D.Sc. (honoris causa) in 1882 in the Queen's Univer-
sity in Ireland, and in 1882 he also received its gold medal.
After graduation he studied surgery for a considerable
time at Berlin, where he made the firm and lasting friend-
ship of von Langenbeck, Billroth, and von Esmarch. He
subsequently became a member of the Senate, and Exa-
miner in Surgery, of the Queen's University ; Honorary
M.D. and M.Ch. of the University of Dublin ; and Fellow
of the Royal College of Surgeons of Ireland. He early
commenced practice in Belfast, where he was for six years
Surgeon, and subsequently Consulting Surgeon, to the
Royal Hospital.
Not being entirely satisfied with the prospects open to
him in his native city, he decided to seek his fortune in
London; and had just established himself here in 1870
cxiv president's address
when the Franco-German war began. Hastening to Paris,
he joined Sir John Farley, the representative of the British
Red Cross Society, Dr. Franks (of Cannes), who had been
an English Army Surgeon, and Dr. Marion Sims, all de-
sirous to succour the wounded. They decided to establish
an Anglo-American Ambulance, which proceeded first to
Mezieres and Sedan with Mr. MacCormac as its chief sur-
geon. Sedan was reached on August 30th, just in time for
the fighting. This foreign ambulance was so placed and
so well equipped in the matter of surgical appliances and
comforts as to be able to render services such as no other
ambulance in either army was in a position to do during
the war. For a hospital they were assigned an infantry
barracks on the ramparts of Sedan, overlooking the
Meuse, in which 384 beds were set up. On August »31st
MacCormac, with several colleagues, went on to Balan,
where no fewer than 260 wounded were attended to the
same evening. On the next morning, September 1st, he was
back in Sedan. The French wounded were about 12,000 ;
and of these 274 were received in the course of that day
into the beds of the Anglo-American Ambulance, while
many more were treated there and sent away. Each day
considerably more than a hundred major operations were
performed, and MacCormac's share of these was a large
one. A day of his work at the Caserne d'Asfeld is well
described in his own words : " I did not succeed in keeping
a record of all the work that was done that day. Indeed,
I only wonder I kept any record at all. I find, however,
that I performed several amputations of the leg, the thigh,
the forearm, and the arm ; that I excised the shoulder
and the elbow joints, and also performed partial resections
of the upper and lower maxillae, and of nearly the whole
ulna. The number of bullets and pieces of shell that were
extracted from various parts of the body are too numerous
to reckon.'' His energy, decision of character, and robust
constitution enabled him to withstand enormous vicissi-
tudes and fatigue, including a febrile attack, the result of
inoculation with infective discharge. In spite of his mul-
president's address cxv
tifarious duties, however, he kept a diary of his experi-
ences in the field, the publication of which in weekly
instalments brought his name prominently before the pro-
fession and the public, not only of his own country, but all
over the civilised world. He remained at Sedan until the
wounded had been dealt with, discharging all the duties of
his post with zeal and ability.
Returning to London just when the staff was being
appointed to the new St. Thomas's Hospital, he obtained
the post of Assistant Sui'geon against strong competition,
being greatly assisted in his election by the London Com-
mittee of the Red Cross Society, who entertained a high
opinion of the work which he had accomplished under
their direction.
At St. Thomas's he became full Surgeon in 1873 and
Lecturer on Surgery, and after several years of service
retired as Consulting Surgeon and Emeritus Lecturer on
Clinical Surgeiy. He was earnest and zealous in his
work at both hospital and school. He educated his pupils
thoroughly in the art and science of surgery, brought the
work of the hospital under the eyes of the profession at
home and abroad, and materially advanced his own profes-
sional reputation.
In 187 G he acted as Chief Surgeon to the National Aid
Society for the Sick and Wounded in War during the
Tui'co- Servian campaign, and was present at the Battle of
Alexinatz; but he did not remain long away from Eng-
land. As one result of his experience on several battle-
fields he became deeply impressed with the value of female
nurses in the stationary hospitals at the seat of war, though
not within the zone of fire. He also made the well-known
collection of gunshot fractures now to be found in St.
Thomas's Museum.
Besides his appointment at St. Thomas's he was Con-
sulting Surgeon to the French, the Italian, and Queen
Charlotte's Hospitals ; and examined in surgery at the
University of London, and for Her Majesty's Naval, Army,
and Indian Medical Services.
VOL. LXXXV. *
cxvi president's address
In 1881 lie was Honoraiy General Secretary to the Inter-
national Medical Congress held that year in London, and
fulfilled the duties so efficiently that the late Queen
Victoria subsequently conferred upon him the honour of
knighthood. This Congress was, in fact, one of the great
events of his life. Its success depended very largely upon
the broad lines on which it was organised, and the energy
with which it was administered by its Secretary-General.
Henceforth private professional work came to him in
abundance. He was elected President of the Medical
Society of London in 1888, and held the similar post in
the Metropolitan Counties Branch of the British Medical
Association in 1890.
Sir William MacCormac became a Member of the Royal
College of Surgeons of England in 1857, and was admitted
a Fellow (ad eundem) in 1871. In 1883 he was elected a
member of the Council, and in 1887 became a member of
the Court of Examiners. In 1893 he delivered the Brad-
shaw Lecture, choosing as his subject " Sir Astley Cooper
and his Surgical Work." In 1897 Sir William MacCor-
mac was elected President of the College, and in the four
succeeding years he was re-elected to the same high office.
The last of these occasions was memorable, inasmuch as
it conferred upon him the distinguished honour of occupy-
ing the Presidential Chair during the celebration of the
centenary of the College, when again his great organising
powers were brought into play with marked success.
In 1897 Sir William MacCormac was created a baronet
on the occasion of Queen Victoria's Diamond Jubilee ; and
was appointed Surgeon-in-Ordinary to the Prince of Wales,
whom he attended in the following year after the accident
to the Prince's patella. In recognition of his services in
connection with the repair of the fracture, the Queen made
him a Knight of the Royal Victorian Order; and soon
after his present Majesty's accession he was appointed
honorary Sergeant- Surgeon to the King. On February
14th, 1899, Sir William delivered the Hunterian Oration
in the presence of the Prince of Wales.
peesident's address cxvii
Honours from foreign countries, too, fell thick upon Sir
William MacCormac. He was appointed in 1898 an Hono-
rary Member of the Imperial Military Academy of Medi-
cine of St. Petersburg, a^d was Honorary Fellow or
Member of various other Foreign Medical and Surgical
Societies ; Officer of the Legion of Honour, Commander
of the Order of Dannebrog of Denmark, of the Crown of
Italy, and of the Tahovo of Sei'via. He held also Orders
given by the riders of Prussia, Portugal, Sweden, Bavaria,
Spain, and Turkey; and in this country was a Knight of
Grace of the Order of the Hospital of St. John of Jeru-
salem in England, and was Chief Surgeon to the ambu-
lance department of the Order.
He published several papers on surgical subjects in the
medical journals, and read others before the different medi-
cal societies with which he was connected. He read two
such papers before this Society, viz. one on " A Case of
Resection of the Shoidder and Elbow Joints in the same
Arm for Gunshot Injury," read March 12th, 1872; and
the other on *' The Wounded in the Transvaal War," read
on May 22nd, 1900. He also wrote in 1871 a graphic
account of his experiences in war, under the title of
*Work under the Red Cross,' which was translated into
German, French, Spanish, Dutch, Italian, Russian, and
Japanese. He published in 1880 ' Antiseptic Surgery,'
which gave rise to one of the most interesting debates of
modern times. It was introduced by him, and in the sub-
sequent spirited discussion most of the chief surgeons of
the day took part. Listerism, it may be noted, was not at
that time accepted by all. The first part of his work on
' Surgical Operations ' appeared in 1885 ; but although
he worked constantly upon it he did not live to complete
it. He also wrote on " Abdominal Surgery."
At the beginning of the present war in South Africa he
volunteered for service, and was appointed by the Govern-
ment Consulting Surgeon to the Field Force. On Novem-
ber 3rd, 1899, at a week's notice, he and his old pupil, Mr.
Makins, sailed for Capetown. He had a gi^and '' send-off "
cxviii peesident's address
at Waterloo Station, Sir John Furley, Dr. P. Frank, and
Dr. Blewitt, three of the colleagues with whom he had
worked in the Franco-German campaign, being present
to wish him '* God-speed and a safe return/ ' He soon
found himself amongst the wounded of Sir Red vers Bul-
ler's army, after the unsuccessful attempt to cross the
Tugela ; and then returned to Cape Colony and the Orange
River to take charge of the arrangements for the wounded
from Lord Methuen's force advancing to the relief of Kim-
berley. He was at the seat of war for some four and a
half months. Whilst in South Africa he visited all the
hospitals in Natal iand in Cape Colony, and was at the
front four times. He was also in hospital himself for a
short interval, suffering from dysentery. Upon his return
home the Knighthood of the Order of the Bath was con-
ferred upon him, and he was honoured with an invitation
to dine with the Queen at Osborne.
He was not particularly strong, and in the course of life
suffered from several illnesses. After an attack of erysi-
pelas, in 1879, his hair rapidly turned grey ; and in 189G
pneumonia and empyema brought him nearly to death's
door. But he recovered, and it was only a few months
before his death that he was known to be indisposed. Since
his return from South Africa he had suffered from dvs-
enteric symptoms, lumbar pain, and abdominal tenderness.
His appetite had failed, and he had lost flesh and suffered
from sleeplessness. The fogs of October and November
last in London tried him severely ; and a trip to Bath in
conjunction with Lady MacCormac was undertaken, in
the hope that it would expedite his recovery. He had
slept only at fitful intervals^ and chiefly in his chair ; but
after a deep hot mineral bath, on the morning of his
arrival, he slept well in bed the greater part of the day
and following night. Xext morning, however, whilst he
was arranging for a second bath he died suddenly in his
bed.
Sir William MacCormac married, in 1861, Miss Charters,
of Belfast, who survives him, and of whom it may be said
peesident's address cxix
that she charmed and cheered his life, and was to him
throughout his career a devoted helpmate. Sir William
left no family.
The first part of the funeral service took place at St.
Peter's, Yere Street, where the body of the church was
filled to its utmost capacity by friends and confreres of the
deceased, and by representatives of the many public bodies
to which he was affiliated. The King was represented,
as also were the French and German Ambassadors, the
Army Medical Department, the Xaval Medical Service, the
British Medical Association, the two Royal Colleges, and
the hospitals to which he was attached. The interment
took place at Kensal Green, and was also very largely
attended.
Such are the chief facts in the professional career of Sir
William MacCormac ; it still remains to notice some of the
characteristics of his manv-sided nature.
He was so well known to the Fellows of this Society
that it is not necessary- to do more than just allude to his
massive frame, fine open countenance, genial smile, and
charm of manner that endeared him to all. His hospi-
tality, kindliness, and generosity were unbounded ; and his
professional success enabled him to exercise these facidties
without stint of any kind. This open-handed hospitality
was exercised towards pupils, colleagues, and members of
the profession from all parts of the world, and with a
cordiality not easily forgotten. Beneath his roof, indeed,
the most distinguished members of the profession from
Europe and America were constantly assembled.
He was an early riser, and ofttimes an inordinate worker.
A proof of his capacity for work was furnished by the fact
that immediately after the meeting of the International
Medical Congress of 1881 he started to edit the 2370
pages of the ' Transactions,' which, in their three lan-
guages, appeared complete within a period of six months
from the termination of the meeting.
He was a most popular teacher, and in 1899 a dinner
was given in his honour by the practitioners scattered over
CXX PEESIDEXT's ADllRKSS
England who had held office as House Surgeons at St.
Thomas's Hospital during his tenure of office as Surgeon,
from which only five were absent, and they unavoidably
so. Until the last he kept himself thoroughly abreast of
English, American, and Continental literature. In his
lectures he furnished his class with the most recent and
approved views on the subject under discussion, and a
printed summary of the same was given to each of the
class. He was also an efficient, considerate, and fair
examiner.
As a surgeon he disliked over-specialisation. He adopted
with avidity each advance in operative surgery and sur-
gical technique, and was ready to make trial of any appli-
ance or new instrument that promised well.
Sir William MacCormac had travelled in most countries
of Europe and twice in America, and was a charming
travelling companion ; but he was usually impatient of
holidays and anxious to return to his work. He was a
good draughtsman. In his youth he had loved athletics ;
later in life was fond of walking; and, finally, becoming
an enthusiastic golfer, he and his dog were familiar figures
on the links at Mitcham and Deal. A dog, indeed, was
his constant companion through life. Fishing was appa-
rently the only form of sport in which he indulged.
He had innumerable friends, amongst whom were some
of the highest in the land ; but to others who were less
successful his kindness and generosity were no less marked.
He deserved good fortune, and when it came he was not
spoilt by it. He was ambitious, and rigidly determined
to see his own schemes succeed. He was especially proud
of his profession, his school, and his college. In 1898,
when the Lord Mayor of London received the Presidents
of the two (Colleges and the other heads of the profession,
the occasion gave our deceased confrere great satisfaction,
especially as Lord Lansdowne announced on the occasion
tliat **all the reforms asked for by the Army Medical
Department and the profession had been granted, and that
president's address cxxi
the Queen herself had graciously consented to the new
corps being styled the Royal Army Medical Corps."
Arthur Nesham Weir, M.l)., B.Sc.Lond., F.R.C.S.Eng.,
died on January 24th of the present year from a railway
accident, at the early age of 32. After an extended train-
ing at Merchant Taylors' School he entered, in 1887, at
St. Baitholomew's Hospital, where he had a distinguished
career. On entrance he gained an open scholarship in
Science, in the following year a junior scholarship, and in
1892 the Brackenbury Scholarship in Siugery. He took
the degree of B.Sc.Lond. in 1888, that of M.B. in 1894,
and M.l). (in State Medicine) in 1899 ; became a Member
of the Royal College of Surgeons in 1892, and Fellow of
that College in 1894.
At St. Bartholomew's he acted as Sir Thomas Smith's
House Surgeon, and afterwards l)r. Champneys appointed
him his midwifery assistant, which post he held for three
months. He was also senior Assistant Demonstrator of
Anatomy.
On leaving the hospital he worked for nine months as
Medical Inspector for the Home Office (Burial Acts De-
partment), and then went to South Africa as senior Civil
Surgeon to Princess Charlotte's Hospital in Natal. When
that hospital was disbanded he went to No. 19 Stationary
Hospital at Harrissmith, Orange River Colony, where the
work was very heavy, and his professional skill obtained
for him a considerable reputation. He came home in July
of last year.
For three months before his death Dr. Weir acted tem-
porarily as Medical Officer of Health at Tottenham, but
had decided not to remain on. He became a Fellow of
this Society in 1896, and was also a member of the Anato-
mical Society. Altogether he was a man of considerable
ability and of sterling qualities, and a highly promising
member of our profession. Moreover, not only did he
excel in medical science and art, he was also an enthu-
siastic athlete. In his student days he was captain of the
St. Bartholomew's Hospital football team ; more than held
cxxii peesident's address
kis own at boxing, fives, and water-polo ; and was captain
of the Stanmore Golf Club in 1899-1900. For ten yeai-s,
too, he was a member of the Old Merchant Taylors' Foot-
ball Club.
The funeral took place at Kensal Green Cemetery, and
was attended by many medical men, and by representa-
tives of the many clubs of which Dr. Weir was a member.
ACUTE DILATATION OF THE STOMACH
WITH ILLUSTRATIVE CASES
BY
H. CAMPBELL THOMSON, M.D., F.E.C.P.
ASSISTANT PHYSICIAN; PATHOLOGIST AND CTTEATOB OF THE MUSEUM TO
THE MIDDLESEX HOSPITAL; MEDICAL TUTOR IN THE MEDICAL SCHOOL.
Received 5th July— Read October 22na, 1901.
AcDTE dilatation of the stomach is characterised by its
sudden onset, by the vomiting of enormous quantities of
fluid, and by very severe general symptoms, which, in the
recorded cases, have generally ended fatally within a few
days after the first onset of the disease.
The condition was first fully described by Dr. Hilton
Fagge,^ who recorded four cases, two of which had come
under his own personal observation. Since then, although
a number of cases have been recorded, the subject does
not appear to have attracted much attention. 1 have
during the past three years made post-mortem examina-
tions upon four cases in which death was immediately due
to this condition, and I believe that the disease, though
of course very uncommon, is not so rare as has generally
been supposed, and that probably the difference between
the very serious cases and the less severe forms of dilata-
1 'Guy's Hosp. Reports/ 1872-3.
VOL. LXXXV. . 1
2 ACUTE DILATATION OP THE STOMACH
tion, also acute, which not infrequently accompany severe
illnesses, is one of degree rather than of kind.
Before referring to the cases recorded by others I will
give a brief account of those which have come under my
own notice, and 1 must here acknowledge my indebted-
ness to Mr. Henry Morris and Dr. Kingston Fowler, who
have kindly allowed me to make use of the clinical notes
of cases which have been under their care. The first
case is one in which acute dilatation suddenly supervened
upon chronic dilatation, the latter being due to a growth
of the pylorus.
The patient was a man aged 48, and was admitted
into the Middlesex Hospital on October 31st, 1899, under
the care of Dr. Kingston Fowler. Symptoms had
■existed for three months before admission, the chief
being discomfort after food and frequent vomiting.
On admission the patient was found to be considerably
emaciated ; the stomach was dilated, and extended down-
wards to about an inch above the umbilicus ; no splash
was obtained. " An indefinite tumour could be felt in
the epigastrium. The pulse was 84, regular, and the
patient, considering the disease he was suffering from,
did not appear to be unduly ill, and certainly presented
no immediate symptoms of an alarming character. On
November 3rd, i, e, three days after admission, the
stomach was washed out in order to relieve the vomiting,
which occurred at intervals, and which in no way differed
from that which usually takes place in cases of pyloric
cancer. On this occasion 38 oz. were drawn off with a
soft syphon tube. The patient expressed himself as
feeling relieved by the washing, and the process was
repeated on the following morning (November 4th), no
vomiting having occurred in the interval. Eelief was
«/gain obtained, and the patient was able to take about
Tialf a pint of beef tea and a very little pudding at
mid-day.
Suddenly, during the afternoon, a change for the worse
took place, which was ushered in by slight hiccough,
ACUTE DILATATION OP THE STOMACH d
accompanied by abdominal pain and uneasiness^ whicli
the patient attributed to flatulence; at 6 p.m. the pain
was considerable, at 8 p.m. he vomited about 8 oz. of
thick, dark brown fluid, and an hour later (9.15 p.m.) he
was very collapsed, with a feeble pulse of 120, a sub-
normal temperature, and cold extremities.
'J'here was now severe abdominal pain, the outline of
the stomach was easily seen, and appeared to cover a
greater area than formerly; there was no * muscular
rigidity, but the abdominal walls did not appear to move
with respiration. In the face of these acute symptoms
it was thought possible that a perforation of the stomach
might have taken place ; a i gr. of morphia was given
hypodermically, and hot bottles were put to the feet ; no
food was given by the mouth. About midnight the
patient was very wakeful, but slept after a second injec-
tion of morphia. The next day (November 5th) the
patient was drowsy, but said he had no pain, the pulse
was 120, and the abdomen moved slightly with respira-
tion ; the lower border of the stomach now reached the
umbilicus, and a tympanitic percussion note could be
obtained in the left axilla as high as the fourth rib.
Nourishment was given by nutrient enemata and supposi-
tories, which were retained.
The general condition remained about the same all
day, but towards evening the patient became more
collapsed, and at 6 p.m. a hypodermic injection of
strychnine was given. The abdomen, however, became
more distended. Death took place at 2.55 a.m. on the
morning of November 7th.
During the acute illness the urine became very scanty,
none at all was passed from 1 a.m. till midnight on
November 5th, when a catheter was passed, but only one
ounce was drawn off.
At the post-mortem examination the contents of the
abdomen were almost entirely obscured by the dilated
stomach, which was tightly distended with gas, and also
contained a considerable quantity of dark brown fluid.
4 ACUTE DILATATION OF THE STOMACH
In shape the stomach was cylindrical, the lesser curva-
ture making a sharp curve, while the greater curvature
was rounded and reached a point just below the level of
the iliac crest. There was a growth of the pylorus which
considerably narrowed the orifice.
This case, th^n, is an example of acute dilatation sud-
denly superveping upon a chronic one ; owing to the
stricture the stomach had, no doubt, for some time had
a considerable strain put upon it, and then suddenly acute
dilatation set in. Possibly the slight irritation produced
by washing out the stomach may have upset the balance ;
or, and what I think is more likely, the growth may have
implicated some of the nervous structures in the neigh-
bourhood.
The second case occurred after an exploration of the
kidney.
The patient, a man aged 26, was admitted under the
care of Mr. Henry Morris with symptoms pointing to
the presence of renal calculus, and on these grounds the
right kidney was explored by a lumbar incision on July
30th, 1900 ; there was nothing of special note connected
with the operation. Vomiting commenced a few hours
after the operation was performed, and persisted almost
incessantly up to the time of death, which took place on
the evening of August 4th. The temperature fluctuated
a little but kept low, and reached 98° before death ; the
pulse was very rapid, varying from 120 to 140 per minute.
There was no suppression of urine, on the day of death
33 oz. were passed.
At the post-mortem examination, made on August 5th,
I found the stomach to be enormously distended and of
cylindrical shape, the lower end being on a level with
the iliac crest ; the first part of the duodenum was also
distended. The contents of the stomach consisted of gas
and a considerable quantity of thick green fluid. The
intestines — with the exception of the first part of the
duodenum — were all somewhat collapsed. There was no
obstruction of the pylorus, and no definite change of any
ACUTE DILATATION OF THE STOMACH O
kind to be observed in the stomach walls. The recent
incision into the right kidney was in process of healing,
and all the structures around it appeared healthy; there
was some chronic nephritis of both kidneys.
The third case was that of a female aged 40, who
was admitted into the hospital under my care (in the
absence of Dr. Fowler), suffering with deep jaundice,
which had come on suddenly with severe pain a few
weeks previously.
As the diagnosis between gall-stones and malignant
disease was somewhat uncertain, it was thought advisable
to explore the abdomen ; this was accordingly done by
Mr, Murray on April 30th, 1901, the condition proving to
be a growth of the head of the pancreas, and a distended
gall-bladder ; the gall-bladder was drained and the wound
sutured.
All went perfectly well till May 4th, when the patient
passed a restless night, and vomited early in the moroing
of May 5th. 8he also became very collapsed, but this
may have been partially due to some haemorrhage which
occurred in the wound. The vomiting, however, per-
sisted, and large quantities of brownish fluid were thrown
up ; the urine became scanty, and the temperature was
subnormal before death, which took place on May 9th.
The post-mortem examination showed the stomach to
be greatly distended, but chiefly with gas, there being
only a small quantity of greenish fluid present. The
stomach had the same cylindrical appearances as in the
other cases, but was not quite so large as any of the
other three which I have met with.
There was a hard tumour of the head of the pancreas,
but it was not very prominent, and as far as could be
seen it had not caused any definite obstruction to the
pylorus, nor was any obvious dilatation of the stomach
noted when the abdomen was explored.
The next case is one in which acute dilatation occurred
as a complication of pleurisy and pneumonia.
The patient, a female aged 24, was admitted into the
0 ACUTE DILATATION OF THE STOMACH
hospital tinder the care of Dr. Fowler on Jnne 26th, 1901.
She wag first taken ill on Jnne 24th, and prerions to that
she had been in good health.
On admission there were signs of consolidation over
the lower lobe of the right Inng, and also well-marked
signs of pleurisy on the same side. The next morning
(June 27th) there was some improvement, and no signs of
any extension of the disease ; later on in the day,
however, there was pain and friction in the left side, and
at 1 p.m. the patient suddenly vomited. The vomiting
continued incessantly from 1 p.m., June 27th, till 6.30 a.m.,
June 28th, and then ceased till 1.5 p.m. the same day,
when it recommenced and continued till death, which
took place at 2 a.m., June 29th, i. e. about thirty-six
hours after the vomiting first began. The vomit was of
a dark greenish colour, and large quantities were brought
up without any violent effort. The abdomen was very
carefully examined on the 28th, but no distension was
obHerved until the afternoon of that day (3 p.m.).
The urine was passed in usual quantities throughout
the illness, but it may here be mentioned that at the
post-mortem examination the bladder was perfectly empty.
At the post-mortem examination the stomach was
enormously distended, and reached down to the pubes.
Its appearance is well shown by the accompanying photo-
graphs, which were taken at the time.
I^ho stomach contained about 85 oz. of dark greenish
fluid, and the mortuary attendant informed me that a
large quantity had escaped by the mouth when the body
was being moved. On relieving the stomach of its
contents it rapidly shrank, and in a few minutes it had
the appearance of being but little larger than normal,
and no one seeing it would have thought it could have
been so cMiormously dilated only a few minutes before ;
the stomach walls appeared perfectly healthy, and micro-
scopically there were no changes to be detected.
Hie intestines were collapsed, apparently from com-
pression ; there were no other abnormalities in any of the
S ACUTE DUATATION OP THE STOMACH
other abdominal organs, except that the liver was rather
larger than normal.
In the thorax the lower lobe of the right lung was
consolidated and in a condition of red hepatisation ; there
was no pneumonia elsewhere. Both pleurae were exten-
sively covered with a thick yellow exudation, which on
the left side was particularly marked over the base of
the lung, where it rested on the diaphragm.
Acute dilatation of the stomach may arise without any
apparent cause whatever, the patient being, as far as one
can tell, in ordinary health up to the time of the onset of
; acute symptoms. This was so in Fagge^s second case, in
which the patient died after three days' acute illness, and
after death no other morbid condition was found except
that of the stomach. Fagge considered that the actual
process of enlargement of the stomach is more gradual,
and is in the end succeeded by sudden symptoms of great
severity; but although this is sometimes so — as, for
instance, in the case I have recorded, where there was
obstruction to the pylorus, and possibly also in the case
in which there was a tumour of the pancreas, — there is
no reason to believe that there was any slow dilatation
previous to the acute symptoms in the other two cases.
In many cases {v. Table) some other morbid condition
is found in addition to the dilated stomach, and in other
instances the dilatation appears to follow immediately
upon some surgical operation, which may or may not be
connected with the abdomen.
In the case recorded by Mr. Morris the operation con-
sisted in the removal of some necrosed bone from the
foot ; the patient began to vomit about an hour after the
conclusion of the operation, and brought up quantities of
thin, greenish fluid almost continuously until death took
place, two days afterwards.
The accompanying table of 10 cases; shows some of
the associations which have been observed between acute
dilatation of the stomach and other lesions, and surgical
operations.
ACUTE DILATATION OF THE STOMACH
9
Table of Ten Gases of Acute Dilatation of Stomach}
So.
Author.
!
Reference.
1
Sex.
1
Age.
1
Morbid conditions
found in addition to
dilated stomach.
1
Operation (if any)
prior to the onaet
of symptoms.
1
Hilton
Fagge
* Guy's Hosp.
Reports/
1872-3
M.
1
18 Retro-peritoneal
, abscess communi-
cating with
; duodenum
— i
2
t»
! M.
30 Nil
1
3
Miller
and
Humby
* Trans. Path.
Soc./ vol. iv ;
also quoted by
Fugge
F.
4S Nil
1
1
4
Hughes-
Bennett
* Principles and
Practice of
Med.;' also
quoted by Fagge
M.
26 ' Empyema
!
1
6
Henry
Morris
•Trans. Path. M.
Soc./ vol. xxxiv
1
37 \ Nil
1
Operation upon
foot.
6
Goodhart
,M.
29 Nil, except some
1 oedema of lungs
Excision of
knee.
7
Campbell
Thomson
— M.
1
1
1
48 Carcinoma of
! pylorus
i
Passage of soft
tube into
stomach.
8
9
— M.
1
1
1
I
140
Nil
Carcinoma of
Exploration of
right kidney
(extra-perito-
neal method).
Abdominal
1 1 pancreas
exploration.
10
1
1
it
F.
1
1
24
1
i
Pneumonia and ex-
tensive diaphrag-
matic pleurisy,
the latter chiefly
on the left side
From this table the cases may be conveniently arranged
in the following groups :
^ For a fuller collection of published cases see the author's book on
'Acute Dilatation of the Stomach.'
10 ACUTE DILATATION OP THE STOMACH
A. Those in which the dilatation occurred without any
apparent cause, and in which, after death, no
other lesion was found. (Nos. 2 and 3.)
E. Those in which after death some other lesion has
been found. (Nos. 1,4, 7, 9, and 10.)
c. Those in which the dilatation has followed some
surgical operation, and in which after death no
other lesion has been found. (Nos. 5, 6, and 8.)
In two cases. there was ^some surgical interference as
well as another lesion found after death, viz. in No. 7, in
which a tube was passed into the stomach, and in No. 9,
in which the abdomen was explored; and although these
operations may have had a certain amount of influence in
determining the onset of the condition, there can, I
think, be little doubt that the predominant factor in each
was the growth, which, as will be seen later on, probably
produced the effects by implicating surrounding nerve
structures.
I may here mention another case where the dilatation
followed an operation, of which Mr. Henry Morris has
kindly given me the notes. The patient, a thin weakly
man, underwent nephrectomy for polycystic disease of the
kidney, after which all the symptoms of acute dilatation
set in : the abdomen became unsymmetrically distended,
and great quantities of fluid were vomited until the time
of death. Although there can be no doubt as to the
nature of the disease, as no post-mortem examination was
obtained, I have not included it in the table on the pre-
ceding page.
There is yet another group of cases, in which in
debilitated subjects the ingestion of a large quantity
of badly masticated food appears to have been the excit-
ing cause. In a case mentioned by Dr. Walter Broad-
bent,^ a man after tramping about the country for two
days without food, and who was therefore very exhausted,
partook of a large meal of roast pork, after which he was
seized with abdominal pain and vomiting, which in spite
1 'Medical Magazine,' July, 1901.
ACUTE DILATATION OF THE STOMACH 11
of treatment terminated fatally in two days. After death
the stomach was found to be enormously dilated, the
lower border reaching nearly to the pubes.
In a case recorded by Dr. W. H. Dickinson/ dilatation
occurred in a child suffering from fatty degeneration of
the heart, and after death the stomach, which was greatly
distended, was inflated with gas and contained a large
quantity of meat and potatoes, which were in lumps with
sharp angles and edges, just as they had been cut by the
nurse.
A case has also been recorded by Box and Wallace
which followed an injury to the abdomen.^
Stcmmary of symptoms and post-mortem appearances.
Distension of abdomen, — As might be expected, the
distended stomach gives rise to a swelling of the
abdomen ; the swelling is not uniform, but fills chiefly the
left half and lower part of the abdomen, the right hypo-
chondrium sometimes appearing to be flattened. This
swelling, which is of diagnostic value, is not, however,
quite constant, for in the case recorded by Mr. Af orris
it is stated that the abdomen was retracted, and after
death, although the stomach was enormously dilated and
occupied almost the whole of the abdomen, its anterior
surface was said to be flattened. No doubt the abdominal
swelling varies with the vomiting, especially in those
cases where there is a large quantity of fluid in the
stomach, as in one of Fagge^s cases, where the swelling
disappeared after a quantity of fluid had been removed
by the stomach-pump.
Peristaltic waves of contraction, with one exception, do
not seem to have ever been observed in these cases, which,
I think, lather opposes the theory suggested by Popper
and Stengel, that spasmodic contraction of the pyloius is
the cause of the dilatation.
^ * Trans. Path. Soc. Lond.,* vol. xiii.
« 'Trans. Clin. Soc.,' 1898.
12 ACDTE DILiTATIOH OF THE 8T0HACH
Vomiting, — Vomiting appears to be a constant symptom,
and naually large quantities of browniah or greenish fluid
are brought up. The fluid is usually thin and watery,
and is generally vomited without causing the patient any
great effort or distress .
Urine. — As a, rule the urine becomes very scanty, and
almost entirely suppressed for the last twenty-fimr hours
before death. In seven cases in which the condition of
the urine is mentioned, there was more or less suppression
in five, and in three of these it was almost absolute during
the last twenty-four hours of lif6 ; in two it is mentioned
that a catheter was passed under the idea that there
might be retention, but only a few drops of water were
drawn off.
General symptoms. — The general symptoms are those of
collapse : the pulse is small and very rapid, the respira-
tions are frequent, and the temperature low, usually sub-
normal. There is also great thirst, which is probably
accounted for by the excessive vomiting of fluid.
Diagram of shape of stoiuncli
Condition of the stomach. — The appearance of the
stomach as seen after death is very characteristic ; it is
ACUTE DILATATION OF THE STOMACH 13
like a tightly distended cylinder, shaped like a V with
one limb shorter than the other. The angle between the
two limbs formed by the lesser curvature is a very sharp
one.
The walls of the stomach, though so much distended, do
not after the stomach has collapsed usually appear to be
much thinned, and moreover they retain their elasticity, as
shown by the contraction which occurs after death as soon
as the contents are let out. There are, in fact, no definite
abnormalities to be observed in connection with the stomach
walls.
The intestines. — The condition of the intestines varies :
usually they are collapsed and have the appearance of
having been compressed by the distended stomach ; some-
times parts of them may be distended, especially the
duodenum, and in Fagge^s first case there was some dis-
tension of the caecum and ascending colon.
The immediate cause of acute dilatation of the stomach
probably depends upon some disturbance of the nervous
system, which gives rise to paralysis of the muscular
walls, and which also frequently causes excessive secretion
into the stomach cavity. Another explanation which
seems within the bounds of possibility is that the dis-
tension might be caused by a rapid production of gas
within the stomach. This mode of origin was actually
suggested in one case, in which the patient was known to
have drunk two bottles of effervescing lemonade not very
long before the acute symptoms began ; but Hughes-
Bennett, under whose care the case was, rejected the idea,
and preferred to leave the cause unexplained rather than
suppose that gas sufficient to distend the stomach so
enormously could have been generated by two bottles of
lemonade. Neither is there, as far as I can find, any
evidence whatever that there has been any undue putre-
faction taking place in the stomach in any of these cases ;
and, moreover, this view of the causation would not
explain the occurrence of excessive secretion.
In considering the part which the nervous system may
14 ACUTE DILATATION OP THE STOMACH
take in the production of acute dilatation there are two
processes to be taken into account, viz. (1) the dilatation
and (2) the increased secretion ; and the question at once
arises concerning the relationship of these two processes
to each other: do they take place independently, or is
one dependent in some way upon the other ?
The inclination hitherto seems to have been to look
upon the increase of secretion as the primary condition,
and to regard the dilatation as secondary and immediately
dependent upon it. This appears to have been the view
taken by Fagge, when, in speaking of his first case, he
says that the stomach was paralysed from over- distension
and unable to rid itself of its burden.
Mr. Henry Morris also took this view; he considered
that both dilatation and vomiting were due to excessive
secretion, and on these grounds proposed that the disease
should be called "acute gastrorrhoea.^^
In support of this view Mr. Morris quoted Moreau's
experiments, which showed that after a loop of intestine
had been isolated by ligatures, and all the nerves passing
to it along the mesentery cut, a paralytic secretion took
place, and the intestine was found to contain a quantity
of fluid which on chemical examination proved to be a
very dilute intestinal secretion. Dr. Pye-Smith and Sii-
T. Lauder Brunton ^ have shown that the regulating in-
fluences conveyed by the nerves divided in Moreau^s
experiments arise from some of the ganglia in the solar
plexus.
As a result of Mr. Henry Morrises paper, Dr. J. F.
Goodhart ^ brought forward notes of all the cases of
dilated stomach not due to pyloric obstruction observed
in the post-mortem room of Guy^s Hospital from 1875 to
1882, and in the light of general information obtained
from these Dr. Goodhart concluded that "paralysis of
the viscus is, if not the determining cause, at any rate an
accompanying condition.^^
^ * Report of Brit. Assoc, for Advancement of Science/ 1874 and 1875.
* 'Trans. Patb. Soc. Load./ vol. xxxiv.
ACUTE DILATATION OP THE STOMACH 15
It is, of course, naturally very difficult to establish the
exact relationship between the two conditions, but although
they are so often present together, and produced by the
same underlying cause, I think the available evidence
shows that they are at any rate distinctly separate pro-
cesses, and that the dilatation is not the mere mechanical
result of excessive secretion. In some cases, for instance,
there is very little fluid present, the stomach being in
such cases almost entirely blown out by gas.
I have recently had an opportunity of observing an
interesting case in which the stomach appeared to be in
an early stage of acute dilatation, and in this instance
there was no fluid at all, and only a very slight trace
of semi- solid, almost completely digested food. The
patient was an old woman who died almost immediately
after the conclusion of a severe operation upon the lower
jaw, and at the post-mortem examination the stomach was
distended with gas, and had the cylindrical sausage-
shaped appearance which is so typical in the more
advanced cases.
The appearance of the stomach in this case is seen in the
accompanying figure, which is taken Irom a sketch made at
the time, for which I am indebted to Mr. W. T. Hillier.
The stomach, though much distended (it measured about
nine inches in length in the longer limb, and about seven
inches at its greatest circumference), was nothing like the
size which the others I have met with reached ; but natu-
rally there must be an early stage of the condition, and this
case, I believe, is. an example of such.
This case, then, as far as it goes, tends to show that the
distension may take place independently of the secretion,
and some information regarding the relationship between
the two processes may, I think, be obtained from the con-
sideration of cases of chronic dilatation which depend
upon pyloric obstruction. In many of these there is a
very great secretion, just as there is in the acute cases.
Osier and Macrae,^ for instance, mention a case of dilatation
* * Cancer of the Stomach/ p. 81.
Ifi ACUTE DILATATION OP THB STOMACH
of the stomach due to malignant growth of the pylorus, in
which on two occasions the stomach was washed and
emptied as thoroughly as possible, and for forty-eight
hours afterwards the patient was fed by the rectum, and
Apiw&rance ol
tage of commencingf ai
all nourishment by the mouth stopped. At the expiration
of this time, on the first occasion 545 c.c. of fluid were
drawn off, and on the second occasion 600 c.c. In such
cases as this the increased secretion is obviously secondary
to the dilatation, as it also frequently is in cases of chronic
ACUTE DILATATION OF THE STOMACH 17
dilatation which are not due to obstruction ; and it seems,
therefore, that the increased secretion is an accompaniment
of, or a result of, the dilatation rather than a cause of it.
The two conditions, there is little doubt, are independent
processes which come into action separately or in com-
bination, and it is most likely that their relative import-
ance varies. There can be no doubt that excessive
secretion, when present, adds greatly to the gravity of the
situation, but there does not seem to be any clear proof
that excessive secretion can act as the dilating force,
unless there is at the same time some paralysis of the
stomach walls.
The stomach derives its nerve supply from the vagi and
the splanchnic nerves ; stimulation of the vagi gives rise to
peristaltic movements, while stimulation of the splanchnic
nerves brings the movements to a standstill. Sir Michael
Foster,^ in speaking of the nervous mechanism of the
alimentary canal, says, " We may, therefore, speak of
fibres inhibitory of peristaltic movements of the stomach
and intestines as passing from the spinal cord through the
splanchnic nerves, and reaching those organs through
the abdominal plexuses.^^ With regard to the nervous
mechanism of secretion Sir Michael Foster says, "It has
been suggested that while impulses reaching the stomach
along the vagi excite secretion, those reaching the stomach
along the sympathetic nerves inhibit it; but this has not
been satisfactorily proved.^^
Dilatation of the stomach can probably be produced by
the local interference of nerves of the stomach,^ or it may
arise after a shock affecting the general nervous system.
Examples of the latter are seen in cases such as that
1 * Text-book of Phys / part ii, p. 491.
' Paralysis of the musculjir coat of the stomach limited to the pyloric
portion, and preventing the propulsion of food into the duodenum, has been
stated to be a cause of dilatation, and Wilson Fox (* Diseases of the Stomach,'
p. 215) quotes a case recorded by Andial, where there was extensive
ulceration of the pyloric region witliout obstruction, and yet extreme
dilatation of the stomach. Trauhe attributes such dilatation to destruction
of the branches of the pnenmogastric nerve.
VOL. LXXXV. 2
18 ACUTE DILATATION OP THE STOMACH
recorded by Mr. Henry Morris, where the dilatation
followed an operation upon the foot; while examples of
local interference are shown where the disease has fol-
lowed some lesion in the neighbourhood of the stomach,
and it is interesting to note how, in No. 10 of the preceding
table, the onset of the condition appeared to coincide with
the spreading of an acute pleurisy to the base of the left
lung, which must be in close relationship to the nervous
system of the stomach.
As cases of acute dilatation have followed closely upon
operations, it is necessary to inquire into the possibility of
the anaesthetic having some influence in their causation.
Mr. Morris considered this question fully with regard to
his case, and came to the conclusion that the anaesthetic
was not to blame, and examination of the other cases does
not show any direct evidence that the condition can be
traced to this cause ; but it would seem quite possible that
under certain conditions an anaesthetic might influence the
dilatation through its wide-spread effects upon the nervous
system.
The theory that there may be an obstruction of the
pylorus must be given up, at any rate in many cases,
since there is so frequently dilatation of the duodenum,
and also since biliary contents have been noted in the
vomit.
The idea that there is some obstruction lower down has
received a considerable amount of support, and the fact
that the distended bowel often terminates in collapsed
bowel, at about the point where the superior mesenteric
artery is situated, has suggested the theory that, under
certain conditions, a traction of the mesentery takes place
which pulls upon the artery and converts it into a
constricting cord. The conditions which are thought to
be necessary to bring this about are collapse of the
intestines and their prolapse into the pelvis. While con-
striction by the mesenteric artery is probably mechanically
possible, it is very doubtful whether the conditions neces-
sary to produce it are often present during life, and
ACUTE DILATATION OP THE STOMACH 19
certainly in many autopsies the intestines, although col-
lapsed, have not been 'found prolapsed into the pelvis.^
On the other hand, it seems very likely that after the
stomach has become paralysed, and distension taken place,
some secondary obstruction may take place, either through
kinks in the pyloric region, or, as Box and Wallace - suggest,
through pressure of the distended organ upon the duodenum.
As above stated, the theory of obstruction seems to have
largely arisen in order to account for the sudden termina-
tion of distended intestine in collapse, as is found in other
forms of obstruction ; but it must be remembered that if it
be allowed that there is a primary paresis of the stomach
wall, there is no reason why that paresis should not extend
along the first few inches of the intestine as well. Against
any constant cause of obstruction, such as the mesenteric
artery, is the fact that the point where the distension ends
varies ; in some cases only the first part of the duodenum
is involved, while in others the distension has extended
some way along the jejunum. Also the fact that in many
cases the bowels have acted freely (in some cases there has
been severe diarrhoea) is against any marked obstruction
by an external cause.
Acute dilatation of the stomach, though of course very
much more rare, is probably closely allied in its causation
and nature to the paralytic distension of intestines which
frequently occurs after severe abdominal operations, and
also in inflammatory conditions of the peritoneum. At
present there seems no adequate explanation as to why
the intestines should be distended in some cases and the
stomach in others, though most likely this difference
depends upon differences in reaction to stimulation of
different nerve ganglia.
I think that acute dilatation of the stomach, to some
1 The paragraph dealing with pressure of the mesenteric artery as a
possible cause has been inserted since the paper was read. Further infor-
mation on this subject, and also on the whole question of duodenal obstruc-
tion, will be found by Dr. William Ewart in the ' Lancet/ October 28th,
1899, and November 2nd, 1901.
2 * Lancet/ November 6th, 1901.
20 ACUTE DILATATION OP THE STOMACH
extent, is not so rare as supposed, and that if looked for
all degrees of severity may be found between the slighter
forms of dilatation — such as, for instance, are not in-
frequently noted in acute specific fevers — and the most
severe and rapidly fatal cases, such as I have described
to-night. Treatment of the recorded cases seldom seems
to have been of any avail in checking the disease, but a few
cases have been recorded as ending in recovery. Box and
Wallace quote five, and Mayo Robson and Moynihan, in
their recent work on ^ Diseases of the Stomach,' ^ give an
account of two cases which came under their care, and
recovered after exhibiting all the typical symptoms of the
disease. The most obvious indication in these very severe
cases is to relieve the distension of the stomach by means
of a tube, and this seems to have been an important factor,
if not the chief one, in some of the cases which have
recovered.
All nutrition should be administered by the rectum, and
the tendency to collapse met by hypodermic injections of
strychnine. Some of the more serious symptoms are pro-
bably produced by the loss of the large quantities of fluid
which are secreted, and this loss should be counteracted
by injection of saline solution into the rectum or by trans-
fusion.
Lastly, it must be remembered that possibly on some
occasions the condition may be a more general one than
seems at first sight, and that the dilatation of the stomach
may be one of the local manifestations of general collapse.
^ ' Diseases of the Stomach and their Surgical Treatment.'
ACUTE DILATATION OF THE STOMACH 21
DISCUSSION.
Dr. T. R. BsADSHAW (Liverpool) thought the most obvious
explanation of this condition was pyloric obstruction. If nerve
disturbance leading i o paralysis were the cause, how could the
excessive vomiting bu explained? For the stomach contents
to be expelled active contraction of the stomach wall was
necessary. If there were no obstruction at the pyloric orifice,
it would have been expected that a portion of the gastric
contents would have passed into the duodenum. The post-
mortem examination, moreover, showed the intestines contracted,
which also supported the theory of obstruction. A case was
referred to of old gastric ulcer in which enormous dilatation of
the stomach was present ; on three occasions there was sudden
dilatation with vomiting, and later sudden relief by the bowel.
At one time an attack came on after eating carrot, and within
the last year, when only liquid food had been taken, no attack
had occurred, suggesting narrowing and obstruction at the
pylorus. He suggested that the exciting cause of the dilatation
was some kink of the pyloric region of the stomach.
Dr. W. P. Herringham could not understand how the
excessive secretion could follow the acute active dilatation, as
was apparently maintained in the paper, seeing that the organ
was under constant outside pressure in the abdominal cavity.
It seemed to be a necessary supposition that there must be a
distending force. The gas described in the paper as being
present in the stomach could not have been aspirated into the
viscus from the outside ; it must have been formed within the
stomach, and this associated with the paralysis of its muscular
wall was, he suggested, the cause of its dilatation.
Dr. Arthur Voelcker referred to the case described in the
paper in which the dilatation occurred in association with right-
sided pleurisy. This, he thought, threw some light on the
physical sign seen in left-sided pleurisy of a high stomach
resonance. The vomiting of bile-stained fluid seemed to
negative the obstruction theory and to favour the paralytic
theory. In regard to treatment, he would hesitate to recommend
lavage of the stomach, ospocially in such cases as were critical.
The President (Dr. F. W. Pavy) considered that this acute
dilatation was comparable to the dilatation that might occur in
the case of the bladder. Under atony or paralysis of the mus-
cidar wall the stomach would yield to a distending influence
from within, but an active dilatation of the stomach was incon-
ceivable. Either the secretion of fluid or the formation of gas
or the presence of food was necessary for the dilatation. He
had in former times seen the experimental division of the vagi
22 ACUTE DILATATION OF THE STOMACH
in a dog lead to paralysis of the muscular walls of the oesophagus
and an enormous dilatation of it from the accumulation of the
food that the animal had afterwards swallowed.
Dr. Campbell Thomson, in reply, said that peristaltic con-
traction had never been observed in these cases, and there was
no post-mortem evidence in the cases he had described of any
mechanical displacement of the stomach such as might lead to
kinking. He did not mean that there was any active dilatation,
but that paralysis was the primary factor, and the distending
force of air or secretion the secondary factor.
ULCERATION OP THE (ESOPHAGUS
AND STOMACH
DUB TO SWALLOWING STRONG HYDRO-
CHLORIC ACID
LESSONS OF TREATMENT DEDUCED FROM
THREE CASES
BY
C. B. KEETLEY, F.R.C.S.
SURGEON TO THE WEST LONDON HOSPITAL
Received September 26th— Read November 12th, 1901
The main conclusion I draw from a study of these three
cases is that, in cases of poisoning by the more powerful
corrosive acids, surgical intervention should be almost
immediate, and that it is a mistake to postpone resort to
surgery until there is no other alternative except that of
letting the patient die of inanition. I will give the
histories briefly, and then discuss the question of treat-
ment.
Case 1. — Enormous dilatation of stomach developed
after accidental poisoning by strong hydrochloric acid.
Loreta's operation. Complete relief, apparently lasting.
Rapid recovery of flesh and strength.
In the middle of October, 1897, I was asked by my
colleague. Dr. J. B. Ball, to see a patient of his, Alice M — ,
24 ULCERATION OF THE (ESOPHAGUS AND STOMACH
aged 32, who had eight months previously swallowed pure
hydrochloric acid by mistake. This was the most striking
case of chronic dilatation of the stomach I have seen, and
it is much to be regretted that no photograph was taken.
When she stood up, whether she was viewed from the front
or from the side, the whole anterior abdominal wall, except
in the left iliac region and the extreme right of the right
lumbar region, could be seen pushed forward by the
stomach. The patient was very emaciated, and the shape
and movements of the organ could be seen with ease.
There was a difficulty of swallowing, and immediate
vomiting, which, together with the history of corrosive
acid poisoning, suggested either stricture or spasm of the
oesophagus as well as of the pylorus. In fact, at this time
it seemed almost equally difficult to get food into and out
of the stomach.
October 18th, 1897, operation. Incision in middle line
above umbilicus. Stomach presented. Pylorus could be felt
some inches away in the right iliac or lower part of the right
lumbar region. No adhesions or signs of thickening of
the stomach wall were found. The pyloric portion of the
stomach was now "hauled" outside. The word "haul"
gives a better idea of the length and size of the organ
than would the usual word "pull." Protective gauze
packing. One and a half inch incision into stomach.
Pylorus thickened and so contracted that it would only
just admit the closed blades of a pair of polypus forceps.
Gradual dilatation was made, first with the forceps, next
with the little finger, lastly with a three-bladed rectal
dilator. With the latter the pyloric opening was stretched
to a circumference of four and a half inches, and a slight
sensation of tearing was felt. Closure and removal of
dilator. Stomach washed out with hot water through
wound. Suture of opening in stomach and of wound in
abdominal wall.
Improvement began at once and progressed rapidly.
Indeed, as soon as the patient had fully recovered
consciousness after the anaesthetic she felt well, and com-
tJLCERATION OF THE (ESOPHAGUS AND STOMACH 25
plained of nothing afterwards but an inordinate appetite.
Vomiting ceased. The patient rapidly put on flesh. A
year afterwards she was in good health and strength. The
stomach never quite returned to its normal size. Last
year I heard she had not been so well recently, but did not
learn what was the matter. She has left her former
address, and I cannot find her, so I cannot report on her
present state. The patient was shown at the 1897
December meeting of the West London Medico-Chirur-
gical Society. I cannot remember who was the medical
friend who saw her last year ; but, if he sees this, I hope
he will communicate with me.
Case 2. — Suicidal poisoning by strong hydrochloric
acid. Rapid development of bronchitis and obstruction to
breathing. Extreme weakness. Abdominal incision, but
stomach not opened on account of sudden collapse. Great
temporary improvement for ten days. Death three days
later. Contraction of pylorus and pneumonia.
October 19th, 1897. — The day after the operation on
Case 1, Case 2 was readmitted into hospital. Thomas P — ,
aged 25, had been first admitted under Dr. Hood.
History. — Thirty-two days before, he had swallowed
strong hydrochloric acid with suicidal intent. After
eighteen days in hospital he was discharged. He had
then no pains and no physical signs of illness, and he
" could swallow thin foods and milk.^^ Very shortly after
]eaving he began to lose flesh, found difficulty in swal-
lowing even liquids, and at last " what food he did swallow
was vomited. Now there is a constant feeling of sickness.^'
0?^ admisftioiL — Emaciation. No ulceration or cicatrisa-
tion of mouth or fauces. Cannot swallow saliva. " At-
tempts to pass oesophageal bougies cause much distress
and induce vomiting.^^ Signs of pyloric obstruction.
Greater curvature of stomach descends an inch below
umbilicus. Palpation causes slight pain and excites spas-
modic contraction. No thickening can be felt. Vomit
for the most part liquid and very dark brown. Constipa-
26 CJLCERATION OF THE (ESOPHAGUS AND STOMACH
tion. October 2 1st, rectal feeding commenced. October
28tli, patient has been getting more and more emaciated.
Mr. Keetley saw him and recommended operation. I
noticed that he was then suffering from some bronchial or
pneumonic affection with expectoration of copious blackish
phlegm.
October 29th, operation. Made an incision to the right
of the middle line. The pylorus was exposed, but before
further steps could be taken, patient became collapsed
and blue. It was considered necessary to postpone open-
ing stomach. Iodoform gauze (wrung out in 1 — 2000
sublimate lotion) was placed in wound so as to prepare for
a future second stage of operation, without anaesthetic, in a
day or two. A few ounces of neutral saline were injected
subcutaneously into the axilla, and fourteen ounces of
warm milk into the rectum. A urethral bougie was
passed down oesophagus.
My intention, as may have been inferred, was to enlarge
the pylorus without a general anaesthetic about forty-eight
hours after the unfinished operation ; but a curious change
in the patient prevented me. ^' He was much better in the
night, and for the first time for eight days was able to take
fluid by mouth." For the next ten days he took milk
freely and easily, and improved in strength and spirits
every day. But, unfortunately, on the eleventh day a good
deal of pain was complained of in the right side. On the
thirteenth day the note is : ^^ Better night. Kept expecto-
rating dark-coloured phlegm. Very collapsed in morning.
Very little pulse. Gradually sank and died."
The temperature had ranged from 97° to 98*4°, rising
only one degree the day before death.
Post-mortem, — The only observations noted are pneu-
monia of the base of the lung, congestion, and possibly a
stricture of the upper part of the cesophagus, thickening
and a very tight stricture of the pylorus, enormous disten-
sion of stomach.
It is difficult to be sure of what occurred in this case
after the incomplete operation. Possibly the passage of the
ULCERATION OF THE (ESOPHAGUS AND STOMACH 27
urethral bougie down the oesophagus restored the power of
swallowing, but as the pyloric stricture remained unrelieved,
less fluid passed out of than into the stomach, and so the
gastric dilatation increased and the general condition
became more dangerous. I was lulled into a false sense of
security by the improvement in the patient^s spirits and
appearance.
Notes by Mr. Flavelle and Mr. Granville.
Case 3. — Suicidal poisoning by strong hydrochloric acid.
Stricture and progressive ulceration of oesophagus and of
pyloric part of stomach as well as of pylorus. Great emacia-
tion and depression. Gastro-enterostomy with Murphy^s
button. Immediate relief and continued improvement for
nearly six weeks, then death from bronchitis and pneu-
monia. Murphy^s button found in stomach, and ulceration
of oesophagus unhealed.
Emily B — , aged 46, admitted under Dr. Hood, Septem-
ber 13th, 1900. Patient got drunk and attempted suicide
with strong HCl. " Spat out most of it." Mouth and
fauces burnt by acid. Pain all down throat and in stomach.
Great thirst. An emetic and then Pot. Bicarb, and calcined
magnesia. Pulse 104, good volume and tension.
For ten days she had pain, and the vomit occasionally
contained blood. Garg. Pot. Chlor. and Mist. Bismuthi Co.
+ glyc. acid, carbol. t)\x. The mixture seemed to remove
both pain and vomiting. Nutrient enemata. September
30th (eighteenth day). — Mouth and lips healed. October
1st. — Milk by mouth. October 9th. — Nutrient enemata
stopped. Takes more by mouth ; great hunger.
Swallowing, unfortunately, became more and more difii-
cult. Before October 27th (forty-third day) scarcely even
the smallest quantity of liquid could be swallowed. Emacia-
tion and weakness were extreme. Nutrient enemata had
been renewed on the 23rd. October 27th, operation.
Median incision. Pylorus presented at once in middle line,
but could not be turned out, owing to extensive and tough
adhesions. Incision prolonged up to xiphoid. Left rectus
28 ULCERATION OF THE a:SOPHAGUS AND STOMACH
and superjacent skin cut through transversely. Extensive
strong adhesions of stomach to omentum, abdominal wall,
and transverse colon, partly clamped and all divided or
separated. Stomach could then be moved. The pyloric
portion was contracted to the shape of a small sausage ;
the cardiac end was smaller than natural, and almost en-
tirely under the left costal margin. An anterior gastro-
jejunostomy with a Murphy^s button was performed. The
bowel and stomach apertures were tightened round the
halves of the buttons by two or three interrupted fine silk
sero-muscular sutures.
The contracted pyloric part of the stomach was three or
four inches long. Its lumen would not admit the tip of the
little finger, — in fact, seemed almost impervious. Parietal
wound closed in layers. No drain.
Patient very collapsed after operation. Pulse in evening
176. Nutrient enemata not retained.
Milk and hot water (in equal parts) were therefore given
by the mouth at once, ^v (^j every quarter of an hour) .
This was repeated in the evening ; no vomiting. Patient^s
condition improved.
October 28th (day after operation). — Pulse 112. Liquid
food retained both by stomach and rectum. October 30th.
— Better still ; pulse 90. Patient vomited altogether three
times in the course of the first ten days. On the tenth
night she retched a great deal. There was no abdominal
tenderness. Did the Murphy^s button fall back into the
stomach at this time and cause the retching ? Feeding by
the mouth was stopped for twenty-four hours and then
resumed cautiously with milk and " valentin.'^ No more
vomiting.
The wound healed. The patient increased in strength
and cheerfulness. The temperature was normal till Novem-
ber 20th (twenty- fifth day after operation), when it began
to rise gradually, and on the twenty-ninth day reached
101*6°; it only once reached 102° (four-hourly chart).
With the rising temperature we noticed a slight cough
with mucous expectoration. No pain or tenderness in epi-
ULCERATION OF THE (ESOPHAGUS AND STOMACH 29
gastrium. Some pain over base of right lung, and occasional
paroxysms of pain in " left iliac region." Was this caused
by the button, which X rays had, a week before, shown to
have probably fallen back into the stomach ? Rales on
coughing, but no dulness at right base. November 24th. —
Mucus slightly rusty. Chest tender when percussed.
November 29th. — Sputum offensive, muco-purulent, more
copious. December 2nd (thirty-ninth day after operation) ,
— Cannot swallow solid food. December 4th. — Diarrhoea
for last three days. December 5th. — Died collapsed.
Post-mortem (cesophagus) . — At upper extremity a stric-
ture two inches long, scarcely admitting a lead pencil. At
cardiac end a second stricture, less tight, but with ulcera-
tion still active. Stomach : — Murphy^s button free in the
cavity. Ulceration quite healed. The cicatrised and con-
tracted pyloric end has further contracted longitudinally
to about half its length at the date of the gastro-enteros-
tomy (six weeks before) . A narrow curved or sinuous pas-
sage leads through it into the duodenum.
The gastro-enterostomy was perfect, with a free passage
. into distal loop of jejunum, and a narrower one into
proximal.
The extensive adhesions observed at the operation had
nearly all disappeared, and nothing remained to interfere
with free movements of the stomach.
Lungs. — Large bronchi ulcerated and containing foul
purulent secretion. Grey hepatisation of left lung through-
out. Some pneumonia at base of right lung.
Notes by Mr. Bennett and Mr. 0. Inchley.
Remarks on the three cases, — ^That which was least
injured and non-suicidal recovered, but passed through a
period of illness, which if left unrelieved must have had
serious consequences.
Both suicidal cases were much worse than Case 1 at the
time of operation. Besides, in both cases the bronchial
trouble began before operation. In Case 2 the following
note was recorded the day after the acid was swallowed : —
30 ULCERATION OP THE (ESOPHAGUS AND STOMACH
" Large mucous rslles all over chest, back and front. '^ Two
days later there is the note, "Respiration, especially at
night, is very noisy, and sounds as if it was obstructed/^
The note on the day of his discharge is, " Lungs practically
clear ; ^^ it continues, " no sickness, no dysphagia, no ^^
etc., etc. Nevertheless this patient had to be readmitted
in fourteen davs worse than ever. There is no note about
his respiratory organs on readmission, probably because
attention was concentrated on his serious oesophageal and
gastric trouble. Cases 2 and 3 did not suffer to anything
like the same extent as Case 1 from gastric dilatation ;
indeed, Case 3 had a stomach much smaller than normal.
But they were more seriously injured in the oesophagus.
A careful post-mortem examination of that organ from
Case 3 persuades me that its ulceration was still progres-
sive rather than healing, although her death occurred forty
days after operation and eighty-three days after swallow-
ing the corrosive acid. Both fatal cases died of septic
broncho-pneumonia ; I see no reason for attributing this to
the operations. In Case 2 nothing was done but the
making a small incision in the abdominal wall. In Case 3
healing was rapid. A post-mortem examination showed the
gastro-enterostomy to be perfect, and not only was there
no peritonitis, but most of the adhesions seen at the opera-
tion, forty days before, had been absorbed.
I believe the ulceration of the oesophagus or of the
pharynx leads to the infection of the air-passages. This
may occur directly through the lymphatics, or indirectly
through the passage of muco-purulent discharge down-
wards through a glottis, perhaps itself oedematous or
thickened, or otherwise impaired by the action of the acid,
not necessarily on the glottis itself, but on parts closely
adjacent to it.
At the same time the physical strength, and mental and
moral state of such patients, are lowered extremely, by
both the causes and the results of the accident. The
utmost conceivable depth of " lowness " is reached by a
patient who, as a consequence of swallowing a corrosive
ULCERATION OF THE (ESOPHAGUS AND STOMACH 31
acid suicidally, is for a long period neither able to pass
food through the oesophagus nor chyme through the
pylorus.
The question of treatment, — These cases seem to me to
teach certain lessons. Conclusions should be drawn cau-
tiously from a short series of only three cases ; but the
rules I am going to lay down are indicated by these cases,
not only collectively, but individually. It is not, therefore,
a mere matter of statistics.
1. The patient should receive no food (either liquid or
solid) by the mouth for several weeks, i. e. he should not
be fed by the mouth as soon as he can swallow with little
or no pain ; but oral feeding should be postponed until there
is good reason to believe that the injuries have completely
healed,
2. When the injuries are serious {and they generally are
so) , an operation should be performed within a few days of
the date of the poisoning, the sooner the better.
It must always be a matter of conjecture to determine
whether the injuries have healed or not. The only parts
of the injured tract visible are the mouth and pharynx.
But the pylorus, or even the middle of the stomach may
be much wors;^, as, e, g,, in Case 3, not to mention the
oesophagus. In this Case 3, the mouth and lips are noted
as healed on the 18th day ; but active ulceration of the
gullet was found after death, on the eighty-fourth day
(three months after the accident).
I am afraid that it is rarely safe to assume that a case
of this kind is not serious, unless it is positively known
that only a minute quantity of acid has been swallowed.
Case 3 was scarcely a truly suicidal one. The patient got
drunk on the ^^ rent money,^^ was scolded by her husband,
drank the acid, but spat most of it out again, was brought
to the hospital and made to swallow calcined lime and an
emetic, and yet her injuries were terrible.
Even when swallowed by pure accident, an ounce or
more is easily taken into the gullet before the mistake is
discovered, and most of it passes into the stomach, run-
32 ULCERATION OF THE (ESOPHAGUS AND STOMACH
ning along the lesser curvature till it is stopped by tlie
pylorus or by food already in the stomach.
All the three cases were treated according to what seems
to be the usual practice, that is they were allowed to
swallow food when they could do it without much difficulty
or pain. Case 2 was fed by the mouth from the very first
day. Case 3 began with milk on the 6th day, and took
puddings on the 15th. She never got as far as fish or
meat.
Granting that the patient should not be fed at all by
the mouth for several weeks, and that we should only
be satisfied with rectal feeding in trivial cases, the severe
cases remain to raise the question of Operative Treatment,
The region most seriously injured is usually the pyloric
part of the stomach. The problem for the surgeon^s solu-
tion is not simple.
The choice of operations apparently lies between gas-
trostomy, duodenostomy, jejunostomy, gastro-enteroatomy,
and a combination of gastrostomy with gastro-enteros-
tomy.
Gastrostomy does not give rest to the most injured part,
namely the pylorus. Gastro-enterostomy does not rest the
oesophagus. Jejunostomy, when properly done, is prac-
tically a double operation. Duodenostomy would seem to
be the simplest and most straightforward procedure,
although it is liable to permit bile to leak out and irritate
the skin.
All these methods are open to the objection that, in
the by no means unlikely event of an oesophageal or a
pyloric contraction taking place after all, a secondary
operation may have to be done, in addition to one for un-
doing the first operation.
Therefore the indications would most likely be best met
by combining a gastrostomy with a gastro-enterostomy, and
carrying the gastrostomy tube through the gastro-entero-
stomy wound for some distance down the efferent loop of
the jejunum. This is, practically, the method recommended
by Witzel for an ordinary gastro-enterostomy, except that
ULCERATION OP THE (ESOPHAGUS AND STOMACH 38
in the cases I am writing about something more is desir-
able, viz, an arrangement for washing out and draining the
stomach through the gastrostomy wound. This could be
obtained either by using a double tube, specially con-
structed so that the shorter channel opened into the stomach;
or, more readily, by passing the long, narrow gastro-jejunal
tube through a short, wide gastric tube.
If in spite of treatment pyloric contraction should take
place, this plan provides a gastro-enterostomy ready made.
The gastrostomy wound could be closed or kept open,
according to the final condition of the oesophagus.
In the hands of careful and experienced operators the
method would probably be found very safe, as the patient
would be operated on while in fair physical condition, and
the gastro-jejunal tube should resist the dangers of the
'^ vicious circle. ^^ These dangers could be further mini-
mised by using Murphy's button, and, should that contriv-
ance fall into the stomach, the gastrostomy wound itself
could be enlarged to permit its extraction.
Further, the treatment above recommended would reduce
to a minimum the danger of infection of the air-passages
through the swallowing or the regurgitation of septic dis-
charge, or of food, either of which might easily find its way
through a glottis cedematous and stiffened either by direct
injury or by injury to neighbouring parts.
In a long series of cases of poisoning by corrosives, now
and then the glottis, etc., is likely to be so severely
injured as to demand prompt tracheotomy. This would
make it more than ever desirable not to feed by the mouth.
At the post-mortem examination of Case 3 I was struck
by the resemblance of the ulcerated bronchi to those of a
case in which bronchial infection and gangrene had been
caused by a tracheo-cesophageal fistula.
After 'treatment. — Feeding by the gastro-jejunal tube
would be commenced at once, in spite even of moderate
ether or chloroform vomiting, should those anaesthetics be
used. But gas alone, or with oxygen, would suffice for
the operation described, or even local anaesthesia.
VOL. LXXXV. 3
34 ULCERATION OF THE (I':SOPHAGUS AND STOMACH
Local treatment should be given to (1) the mouth and
nose, (2) the pharynx and oesophagus, and (3) the stomach.
1. The mouth, — ^This should be frequently washed out
with warm solution of chlorate of potash or warm boracic
lotion, or both. Dirty teeth should be cleaned, diseased
teeth treated with pure carbolic acid or by extraction,
and suppurating alveoli attended to. If the process is very
painful owing to the burning, then gas, cocaine, or eucaine
should be used.
The nasal passages should be attended to if unhealthy^
If healthy they should be left untouched.
2. The pharynx is said not to be reached by gargles.
It should be sprayed frequently with hot boracic lotion,
and twice a day dusted with a little, not much, iodoform
powder through a puff.
As soon as the patient can swallow without pain, he
should be allowed hot water or hot neutral saline ad lib.,
and be encouraged to take it.
The stomach. — The hot water swallowed should be
allowed to escape by the short gastrostomy tube, so that
it would tend to wash out the stomach also. In addition,
after each meal given by the gastro-jejunal tube, the
stomach should be ^yashed out with hot water by the
gastric tube.
The application, in some such way as that above
sketched, of the principles of surgery to this distressing
class of cases would, I believe, greatly reduce their mor-
tality, and lessen the permanent injury done to those who
more or less recover.
ULCERATION OF THE (ESOPHAGUS AND STOMACH 35
DISCUSSION
r-
Mr. E. Percy Paton referred to a case which came under
his care four weeks after swallowing hydrochloric acid with
suicidal intention, a woman aged SO, in whom the chief injury
seemed to be to the oesophagus ; but an oesophageal tube was
fairly easily passed, and she improved for a time under washing
out of the stomach. A few days later, however, great disten-
sion of the stomach supervened; it was not dilated but very
tense, and felt about the size of a foetal head. He ascribed this
distension to obstruction both at the oesophageal and pyloric
openings of the stomach. An incision was then made into the
stomach, and the first part of the duodenum was so ulcerated
that gentle pressure with the finger through the pylorus caused
rupture of its wall. The rupture was closed by suturing trans-
versely and by an omental graft ; this held well, but the patient
died in forty-eight hours. At the necropsy it was found that
there was only a small portion of the gastric mucous membrane
unaffected by the acid. A gastro-enterosfcomy might have given
more chance of recovery, and he regretted that he had not per-
formed that operation.
Mr. Clinton Dent believed that any operation performed
in the dark, such as Loreta's operation, was unsatisfactory. A
pyloroplasty was, in his opinion, much more satisfactory, as in
that operation a good view was obtained of the mucous mem-
brane of the stomach and duodenum, and the extent of the
injury done by the acid could be estimated. Where there
was dilatation of the stomach a gastro-enterostoniy was not
a good method, and with a Murphy button still more unsuit-
able. Senn*s plates or stitching were methods to be preferred.
The avoiding of feeding by the mouth for a long time was
questionable. A broad rule after gastric operations was to feed
by the stomach as soon as possible, providing the food were
hot. Suicidal cases, it had seemed to him, did just as well as
non-suicidal cases, the depressed psychical condition, as far as he
had been able to observe, in no way retarding healing and
recovery.
The Chairman (Mr. J. Warrington Haward) thought it was
rare for the oesophagus to be so injured in these cases that a
tube could not be passed ; the difficulty in swallowing arose
largely from spasm and painfulness. For stricture of the
pylorus pyloroplasty seemed to be the best method, but if that
were contra-indicated by any condition such as duodenal ulcera-
tion, a gastro-enterostomy could be performed. For this he
preferred Senn's plates to Murphy's button on account of the
36 ULCERATION OF THE (ESOPHAGUS AND STOMACH
probability of the latter falling back into the stomach. He did
not think it probable that any contraction would occur around
the gastro-enterostomy opening if the edge were sewn round
with a fine continuous suture. The healing of any part of the
body depended on the general nutrition, and feeding by the
mouth helped this much more than feeding by otber channels.
He had never regretted feeding a patient by tbe mouth too soon
after the operation, but he had had cause to regret not having
done so earlier.
Mr. Keetley, in reply, said that the case described by Mr.
Percy Paton was another instance of the need for early operation.
When the pylorus was not seriously injured, e, g, as in Case 1,
Loreta's operation might suffice, and it was safer than either
pyloroplasty or gastro-enterostomy. Comparative statistics of
the operation were at present misleading, because those of
Loreta's operation were collected from an early period in which
all these operations were more dangerous than now. In recent
years the mortality of gastric operations in general had dimin-
ished, but Loreta's operation had gone out of fashion. He also
favoured the use of a Murphy button ; as Miculicz had pointed
out, it prevented the development of a vicious circle, in the way
of the contents of the stomach passing through the gastro-
enterostomy opening back into the duodenum and into the
stomach again. Supposing that the Murphy button did fall
back into the cavity of the stomach, it could easily be removed.
CASE 01 INTESTINAL OBSTEUCTION
DUE TO THE
PEESSUEE OF A VESICAL SACCULUS UPON A.
COIL OF SMALL INTESTINE
BY
THOMAS BEYANT, F.E.C.S.
lleceived August 6tli— Read November 26tli, 1901
On April 8th, 1901, I was asked by Dr. M. Biggs, of
New Wandsworth, to see Mr. F — , aged 67, who had
been suffering for five days from intestinal obstruction,
and had been vomiting brown foetid fluid for twelve
hours.
Dr. Biggs had been attending Mr. F — for four days
previously for what he regarded as angina pectoris ; but
at my visit the symptoms of this affection had been much
relieved, and the attacks had become less frequent and
severe.
It was during these early days that the bowel complica-
tion had appeared, and persisted in spite of the use of such
medicines as had previously given relief; and it was owing
to the investigation by Dr. Biggs into the cause of the
obstruction that he found in his patient's abdomen the
enlargement of a tumour the existence of which he had
38 CASE OF INTESTINAL OBSTRUCTION
recognised in the autumn of 1899, Dr. Biggs having at
that time been called in for some passing bladder trouble
associated with a diflSculty of micturition, which was
successfully treated by the passage of a catheter on a single
occasion.
At that time Dr. Biggs had, however, made out that
there was some enlargement of the prostate gland, and
had discovered the presence of a small firm tumour on the
right side of the median line of the abdomen over the
region of the bladder. There were then no special sym-
ptoms, and up to the time of my being called into con-
sultation, the patient had been practically free from all
bladder complications — indeed. Dr. Biggs had not been
consulted by his patient from June, 1900, until April,
1901, the date of his present illness.
When I saw the patient on April 8th, he was evidently
very ill and feeble. His angina symptoms were not in
evidence, but those of obstruction were well marked ; he
had not passed a motion for five days, and had but re-
cently brought up some foetid brown fluid. His abdomen
was somewhat swollen but not tense, and. the swelling
occupied the left central abdominal region below the um-
bilicus, which suggested small intestine obstruction, and
over this region the percussion note was mostly resonant.
On the right of the median line of the abdomen a tense
sausage-like swelling was however made out, which ex-
tended upwards as high as, if not above, the umbilicus
and to the right beyond the semilunar line, and over this
area there was distinct dulness and much re^stance.
The prostate gland was examined and found to be
somewhat enlarged, and with the finger in the rectum it
was thought that some resisting growth at the brim of the
pelvis could be felt. There was no diflSculty in micturi-
tion, and the urine passed was clear and sweet. In my
presence the patient passed several ounces, and he wjis
sure that he could quite empty his bladder. No change
in the size or tension of the tumour followed micturition.
The tumour when the bladder was emptied seemed to be
CASE OF INTE8TIMAL OBSTEDCTIOS dtf
slightly niovdble from side to side, its manipulation was
not painful, nor did external pressure appear to make anj
ciiange in its condition.
On this visit I advised the use of full enemata, and on
these failing, aod the symptoms of obstruction persisting,
an abdominal exploration.
The means suggested, although well applied, were not
successful; the fluid thrown into the bowel returned
hardly more than discoloured, and the vomiting not only
persisted, but by the 10th had become ffecal. Under
these circumstances an exploratory operation was decided
upon.
This was carried out on the early morning of April
11th, with the patient under the influence of ether, which
he took well.
I made an incision over the abdominal tumour in the
right semilunar line, and came down upon an empty
-caecum and some pale empty coils of small intestines [vide
diagram), situated on the right of a tense elastic sausage-
40 CASE OF INTESTINAL OBSTRUCTION
like tumour, one coil of empty bowel being found emerg-
ing from between the tumour and the bodies of the lumbar
vertebrae {vide diagram). There were no signs of local
inflammation. I passed my finger in front of the
tumour, which was in contact with the abdominal pari-
etes, and also behind the tumour, which pressed back-
wards upon the spine, and in so doing found that the
tumour had so pressed upon the small intestine as to
occlude it, for, as already described, the small intestine to
the right of the tumour was flaccid and empty, whereas
that on the left was much distended, congested, and full.
The upper end of the tumour was rounded and un-
attached, the lower end seemed to be attached to the
bladder. A catheter was then passed and a quantity of
clear limpid urine drawn off, but this action had no in-
fluence upon the shape of the tumour. I then, with th&
catheter in the bladder, pressed with my fingers — which
were grasping the tumour — upon its body, when slowly
and surely the tumour was emptied, and the conclusion
was forced upon us that we were dealing with a vesical
sacculus which had a very small orifice of communication
with the bladder. The contents of the sacculus were like
clear urine. The parts were then readjusted and sutured,
and the patient put to bed. For some hours after the
operation Dr. Biggs reported the patient seemed to be
under the anaesthetic and slept peacefully. His pulse was
good; some flatus had passed downwards, but no motion.
At 8 p.m. he had hiccough, which was so sudden and
severe as to jerk the whole body, and seemed momentarily
to lift the body from the bed ; at 9.30 p.m. some ounces of
urine were drawn off. During the night he was restless,
and at 2 a.m. his breathing became bad ; three or four
breaths were taken and then a long pause. Shortly after
dawn he had a rigor, and the temperature ran up to 104°.
From this time he gradually sank, and died about 8 a.m.
on April 12th, or about twenty-two hours after the opera-
tion. No change in the abdomen was observed.
Jfo post-mortem examination could be obtained.
CASE OP INTESTINAL OBSTRUCTION 41
Eemarhs. — This case is published as an unusual one —
for it seems certain that the cause of the patient's intes-
tinal obstruction was due to the pressure of the sausage-
shaped vesical sacculus upon a coil of small intestine
which passed behind it, and between it and the spinal
column; and this view is supported by the fact that on
opening the abdomen in our operation the colon and small
intestine on the right of the tumour were found pale and
empty, whereas the small intestine on the left side was
found full and congested, the seat of pressure upon the
bowel by the tumour being very evident.
It is likewise clear that the opening of communication
between the sacculus and the bladder must have been
very minute, for the bladder seemed to have performed its
functions during the formation of the sacculus in apparently
a satisfactory way, and even at the time of operation, when
the bladder was emptied by means of a catheter, the tension
in the sacculus was not materially affected, for it was only
upon my manually compressing the sacculus that it was
emptied, and then but slowly. ,
When I first felt the sacculus during the operation, I
thought of the possibility of its being a urachal cyst; but
when I found its upper end was free, unattached, and
rounded, I dismissed the thought, and from the position
of its base upon the upper right half of the bladder the
question of its having any connection with the ureter was
not entertained. The conclusion therefore remains : That
as a cause of intestinal obstruction, a vesical sacculus
must not be forgotten as a possible one.
42 CASE OF INTESTINAL OBSTRUCTION
DISCUSSION
Mr. Eeginald Harrison referred to two cases in some
respects similar. In one, occurring in connection with a large
posterior vesical sacculus, there were long bouts of obstinate
constipation, for wbicb no explanation could be given. An
operation was performed, and the sacculus was found to be in
contact with the rectum, and pressing upon it so that it was
evident the constipation was due to this cause. After it was
drained the constipation, which bad been serious, disappeared.
In the other there was a large suppurating vesical sacculus, the
apex of which at the necropsy was found adherent to and con-
strictiog a coil of small intestine. The lumen of the gut was at
the point of adhesion constricted to about half its normal
diameter.
Mr. Clinton Dent asked as to the actual condition of the
gut, whether diseased or otherwise, particularly if there were
any stenosis. In the absence of inflammatory adhesion, the
obstruction of the bowel from mere pressure was extraordinary.
Mr. Bryant, in reply, remarked that Mr. Eeginald Harrison's
first case was comparable with that which he had described, but
the second differed, inasmuch as the sacculu's was adherent to
the intestine and had caused actual narrowing. In his own cases
it was quite obvious that the pressure of the sacculus was the
cause of the obstruction, for there was no organic stricture, and
as soon as the sacculus was raised the contents of the distended
intestine passed into the empty intestine below. The intestine
above the sacculus was congested, while that below it was
absolutely white and empty. There was no evidence whatever
of adhesion or organic disease.
AN ANALYSIS OF FORTY-SIX CASES
OF
CANCER OF THE BREAST
WHICH HAVE BEEN OPERATED UPON AND SURVIVED THE
OPERATION FROM FIVE TO THIRTY-FIVE YEARS
With Remarks upon the Treatment of Recurrent Growths,
including the Disease of the Second Breast,
Operative and otherwise
BY
THOMAS BRYANT, M.Ch., F.E.C.S.
CONSULTING SURGEON TO GUy's HOSPITAL.
Received March 10th— Read May 13th, 1002
The paper I ask your attention to this evening should be
regarded as a sequel to a communication made by Mr.
Marmaduke Sheild^ on January 25th, 1898, to this Society,
when I had the honour to occupy the presidential chair ; as
it was from the interesting collection of facts which he had
gathered from varied sources, and analysed, that I was led
to search my own note-books, and to extract from them
such material as might throw some light upon — (1) the
prospects of life after primary operations for cancer of the
breast ; (2) the question of recurrence of the disease at the
seat of the primary operation and second breast ; and (8)
44 CANCER OF THE BREAST
the nature and effects of operation upon the progress of
the disease.
It must, however, be steadily borne in mind by the
readers of this paper, that the cases tabulated include only
such examples of cancer of the breast as have been under
my care, and have been operated upon, and have survived
the primary operation five years and upwards ; for I have
always felt that the three years' freedom from recurrent
disease after a primary operation, which has been so dog-
matically laid down as a significant indication of a cure of
cancerous disease, was not only unreliable but misleading.
In my book on ^Diseases of the Breast,' published in
1887, I satisfactorily showed (page 152) the inaccuracy of
such a view, and pointed out that if, after the primary
operation for cancer of the breast, forty patients out of
sixty there tabulated died within this three years limit,
there were at least twenty patients who had survived the
primary operation from five to ten years, for four of these
twenty instances lived for eight or nine years, and six for
ten years.
In the tables I now bring before you, many instances of
much longer survival after the primary operation will be
found recorded, and likewise many instances of recurrence
of disease after prolonged periods of immunity which are
very striking.
Group I
includes seventeen cases of cancer of the breast relieved by
operation which are now alive, or have died without evidence
of recurrent disease, five or more years after operation.
Of this group four have died, and thirteen are living and
in good health.
Of the four which died —
Case 15 died from an accident, aged 62, five years after
the primary operation.
Case 16 from old age, aged 80, twenty years after
operation.
CANCER OF THE BREAST 45
Case 14 from acute jaundice, aged 63, fourteen years
after operation, and
Case 13 from intestinal obstruction due to gall-stones,
aged 79, thirteen years after operation. In both of these
cases a necropsy was performed, and no evidence of recur-
rent disease was found.
Of the thirteen cases which are now alive and well, one
has remained free from recurrence for five years, one for
six years, three for eight years, three for nine years, two
for ten years, two for fourteen years, and one for sixteen
years.
Taking the whole group of seventeen cases together,
there was an absence of anv evidence of 'recurrent disease
from five to ten years after the primary operation in nine
cases or in more than half, and from ten to twenty years in
eight cases, thirteen of these patients being now alive and
apparently well.
I should like here to say that the operation I now do,
and have done for many years, is neither the one I was
originally taught and had seen practised by my senioi*
colleagues — which was certainly inadequate — where lym-
phatic glands were rarely removed, or anything more than
the diseased breast itself, with the skin covering it when
involved; nor is it the more modern operation known as
"Halsted's," and made public in 1894, but which should
be known as " Moore^s," or Baiiks^s, who advocated the
principle of free removal in 1882, not only of the diseased
breast with the fat and skin over it in every case, but also
of the pectoral muscle, fascia and lymphoid tissue from the
axillary vessels, and which is now known as the complete
or adequate operation.
The Operation adopted.
My operation is something between the two, but nearer
the latter than the former, and I hold with the results
before me that it is a complete and adequate measure
under the most favourable conditions.
My routine operation is to remove the whole gland that
46 CANCER OF THE BREAST
is diseased with the skin and fat over the diseased area ;
when the axillary glands are enlarged to dissect out the
axilla and subpectoral spaces, and in every case, for
examination purposes, to cut into the axilla, and to take
away glands or lymphoid tissue which appear to be
suspicious, but otherwise not to dissect it out, my incision
into the axilla skirting the axillary border of the pectoral
muscle. I invariably drain the wound through the axilla
for the first two or three days.
The pectoral muscle I dissect clean, but do not remove
it, although, should disease be found to have invaded the
muscle, the diseased muscle must be freely taken away. I
regard the removal of the muscle as a routine measure to
be unnecessary, and the facts I now bring before you tend
to support this view, — for I am more impressed by accu-
mulating experience that successful results in operations
for cancer are more certainly to be secured by an early
operation than by " performing tremendous operations
upon practically hopeless cases. ^' ^
I may say at once that it was from the careful study of
Moore^s memorable paper on "Inadequate Operations on
Cancer,^^ published in 1867 in the fiftieth volume of the
^Transactions^ of this Society, that I was led to deviate
from the practice I had been taught, and to follow, as far
as I thought right, in the lines of Moore^s suggestions,
which have been, without question, the basis of all recent
operative procedures.
In more recent times the principle of free removal of
cancerous disease has been well brought before the pro-
fession by Sir W. Mitchell Banks in papers of great
importance published in 1877, 1882, and 1900 in the
' British Medical Journal,^ and it is through him more than
any other writer that Moore^s views have become estab-
lished.
What I regard as a point of more importance than so-
called complete or adequate operations is early interference,
and in my sanguine hours I have imagined with Sir
1 E. Banks, 'Brit. Med. Journ./ Jan. 4th, 1902, p. 5.
CANCER OF THE BREAST 47
Mitchell Banks what the results would be if all cancers
were thoroughly excised when they were no bigger than
peas, or, as I would prefer to say, when the disease is in
its very early stage.
Indeed, I am fairly sure that it has been from my acting,
upon this principle that I am enabled to bring before you
to-day the satisfactory results of treatment which my tables
indicate, for in Group I, in which there are seventeen cases
tabulated, the disease was in most of them in an early stage
of development when submitted to operation. The disease
appeared, when I first saw the cases, as a lump in the
breast without skin implication or lymphatic glandular
enlargement, and in which the question arose as to the^
lump being due either to the presence of a cyst or early
cancerous infiltration, for at this stage of the tumour^s
growth the question could only be settled by an exploratory
incision.
Under such circumstances an exploratory incision was
made into the lump, and when cancer was recognised the
gland was removed. Under these circumstances the good
results which have been recorded are to be explained, and
they are certainly satisfactory. They are, moreover, what
I expected they would be when I operated, for in 1900 I
wrote a paper for a sister society ^ on ^ Cysts of the Breast :
their Relation, Frequency, Diagnosiii, and Treatment,' and
in composing it I analysed 242 consecutive cases of breast
disease, as they had recently appeared before me in private
practice ; 168 of these cases were registered as solid
tumours or examples of cancer or sarcoma, and 67 as cases
of cystic disease.
Of these 163 diagnosed as solid tumours, 126 were^
operated upon, and out of the 67 examples of cyst disease
44 were operated upon, the percentage of cyst disease to
cancerous disease being 25 to 74 ; the conclusion becoming
clear that out of every four cases of breast disease, more or
less simulating cancer, one will prove to be an example of
cyst disease.
^ Medioal Society of London, vol. xxiii ; * Lancet/ April 28th, 1900.
48 CANCER OP THE BREAST
I went, however, much further, and was able to show
that if we eliminate from our consideration all such
examples of cancerous tumours of the breast as are so well
marked as to forbid an error in diagnosis being made, and
apply our argument to those alone in which there is only a
lump in the breast gland without any collateral symptoms
to support a diagnosis of cancer, it would not be wrong to
conclude that in every two cases of this kind one will be
cystic and the other cancerous.
In these cases of early cancer an exploratory operation
was undertaken, and when the tumour was found to be
cancerous the gland was removed by the mode of operation
I have described, the operation having been undertaken at
the period of the tumour^s growth after which the most
favourable result might be expected. In all of these the
axilla was explored, but not dissected, the incision I adopt
allowing the finger to explore the subpectoral spaces.
In all of these cases the whole gland was removed with
the fat over it and integument. In all of these the
pectoral muscle was well cleaned, but not removed. In a
few of these only were enlarged lymphatic glands found.
In all of those early cases microscopic evidence was
sought, and found to correspond with that which the
naked-eye appearances had suggested. In fact, in the
majority of the cases of this group, as well as in many in
Group II, the same remarks are applicable. The disease
in all was palpably cancer, and the success recorded is due
to its complete and early removal.
Group II.
This group includes nineteen cases of cancer of the
breast relieved by operation and followed by recurrence
in the seat of the primary operation.
In three of the cases (Nos. 12, 17, 18) recurrence took
place in the scar of the primary operation, and a second
CANCER OF THE BREAST 49
operation was performed one year after the primary ; two
of these three cases were well and in good health four years
later, and in the third case ten years later.
In nine cases recurrence occurred from three to seven
years after the primary operation. In three of these no
second operation was called for.
In one of the three cases in which no operation was
performed (Case 4) the recurrent disease appeared as
tubercles in the flaps three years after the primary opera-
tion and spread slowly for nine years, when bladder disease
appeared. In another (Case 1) the recurrence showed
itself as a sternal growth six years after operation. In
the third case (No. 2) chest symptoms appeared seven
years after operation.
In the six other cases second operations were undertaken
three, three, four, five, five, and seven years respectively
after the primary. In one (19), three years after the first
operation a tumour was removed from the axilla, and the
patient died six years later from lung disease, aged sixty-
five, having survived the first operation nine years. In
Case 14, where a second operation was called for three
years after the first, the patient was well six years later.
In Case 15, where an interval of four years had passed
between the first and second operation, the patient was well
six years later. In a fourth case (6), where a second opera-
tion was called for five years after the first, a recurrence
took place after a second five years, when chest symptoms
appeared. In the fifth case (13), where a second operation
was performed five years after the first, and a third small
one two years after the second, the patient was active and
in good health twelve years after the first operation and
five after the last. In the sixth case (16), where a second
operation in the scar was performed seven years after the
first operation, the patient was well in all ways five years
later, or twelve years after the breast was removed.
Of the seven other cases of this section of the group the
intervals between the first operation and a recurrence were
from ten to thirty years.
VOL. LXXXV. 4
50 CANCER OF THE BREAST
In Case 10 of the tables a woman aged fifty-two was
operated upon, and had no recurrence for ten years, when
it appeared in the scar, and as the local disease gave her
no pain and was of slow growth it was left alone.
In Case 8, where a woman of fifty was operated upon, a
recurrence took place eleven years afterwards, when a
second operation was performed upon the scar, and she was
well two years later.
In Case 3 a woman aged sixty had been operated upon,
and a recurrence was suggested twelve years later by abdo-
minal symptoms.
In Case 7, a woman aged thirty, a recurrence of disease in
the flaps took place thirteen years after the primary opera-
tion. A second operation and a small third were performed^
and one year after the last she was well.
In Case 5 the woman, when thirty-eight, had her breast
removed for cancer; twenty-five years later she had a
recurrence in the skin over the seat of operation, which
spread, but she was alive five years later.
In Case 9, where a woman aged forty-six was operated
upon, no return took placed for thirty-one years, when it
appeared as a sternal growth, and five years later this
patient was eighty-two, and in good health.
In Case 11 the patient had been operated upon when
forty-six years of age, and thirty-two years later, when
seventy-eight years of age, she had a recurrence upon the
sternum, but was otherwise well.
Group III.
This group includes ten cases of recurrent disease after
operation in which the second breast was involved; and
four cases in which the breast disease was associated with
cancer of other parts of the body.
In four of the ten cases (Nos. 22, 24, 26, 29) the second
breast was attacked about two years after the first had
been removed. In one (No. 27) of the six other cases the
CANCER OP THE BREAST 5]
second breast became diseased three years after the
primary operation. In two others (25 and 28) ten years
elapsed before the recurrence appeared; and in the two
other cases (Nos. 21 and 23) the interval between the
primary operation and the appearance of the disease in
the second breast was respectively twenty-three and
twenty-four years, the recurrent disease having in both
these cases involved at the same time the scar of the first
operation — this fact suggesting to the sceptical mind the
truth of the view that the primary disease had been
cancerous.
In four of these ten cases the second breast was not
removed, the local disease having been extensive and
inoperable. In Case 21 the patient was sixty-seven years
of age, in Case 23 eighty years of age, in Case 29 forty-
eight years of age, and in Case 27 only thirty-eight years
of age.
In the remaining six cases the second breast was
removed. In one (20) no signs of return were to be
traced six years later ; in Case 24 no signs of return
existed five years later ; in Case 26 the patient was well
two years later, and in Case 28 three years later. In Case
25 there was no recent history.
The four remaining cases in Group III have been added
as cases of interest, but tliey do not form any part of my
tables.
In Case 30 a woman aged sixty had her breast removed
for cancer, and came under care fourteen years later,
when seventy-four years of age, for cancer of her hand,
which was treated by amputation.
In Case 31 a patient who was treated for epithelioma of
the nose at the age of sixty-eight with success returned
for treatment five years later, when seventy-three years of
age, with an acute cancerous affection of her breast,
lymphatics, and skin, which was inoperable.
In Case 32 a woman, who came under treatment when
seventy-two years of age with atrophic breast cancer of
52
CANCER OF THE BREAST
twenty years^ standing, reappeared six years later with an
epithelial cancer of her nose.
The last case (33) is one in which an annular cancerous
stricture of the rectum co-existed with an extensive
cancerous affection of the left breast of four years' growth.
I regard these cases as illustrative of coincidences in
the history of cancer, and record them as such.
I propose now, in order to make the questions respecting
these Groups II and III of recurrent cases clearer, to
analyse them further, and to subdivide them into tables, in
order to show —
First, the length of the interval that existed between
the first operation and the recurrence of the disease.
Second, as to the seat of the recurrence.
And thirdly, as to the duration of life after operative
interference.
Table I op Group II.
Including eight cases of recurrence not requiring
operation.
Number of
'Length of
Age of 1
C^ A e
case in
Group II.
interval between
first operation
patieui at
time of
Seat of
recurrence.
Subsequent history.
J
and recurrence.
3 years
recurrence.
55
About scar
Spread slowly for nine
4
years^ when bladder sym-
ptoms appeared.
1
6 years
56
Sternum
In good health.
2
7 years
61
About scar ;
chest
symptoms
—
10
0
10 years
62
1 About scar
Very slow growth.
3
12 years
72
Abdomiual
1 symptoms
5
25 years
63
Id scar
!
Atrophic cancer, alive five
years later.
9
i 31 years
77
Sternum
1
Alive five years later, aged
82.
11
32 vears
•
78
! Sternum
In good health.
CANCER OP THE BREAST
53
In this group of eight cases five had survived the
primary operation from 6 to 36 years, one had died from
lung disease 9 years after operation, one was evidently
suffering from bladder disease 12 years after operation,
and a third sinking with chest disease 10 years after
operation, — all, it may be assumed, of a cancerous nature,
the eight cases having respectively survived the first
operation 6, 9, 10, 10, 12, 30, 32, and 36 years, and five of
these having apparently some years of life before them.
Table II, Group II.
Including eleven cases of recurrence ivlth second and third
operation.
No.
12
17
18
19
14
15
1r»
O
16
8
7
Interval between
Seat of
I'ptiirii
first and second
Age.
History,
operation.
1 year
51
In scar
10 years later well.
1 year
42
In scar
4 years later well.
1 year
48
In scar
4 years later well.
3 years
60
In axilla and
6 years later died of lung
scar
disease 9 years after first
operation.
3 years
55
In scar
6 years later well, or 9
years after first opera-
tion.
, 4 years
56
In scar
3rd operation 2 years later ;
6 years later was well, or
12 years after first opera-
tion.
6 years
52
In scar
5 years later another recur-
rence with chest sym-
ptoms, 10 years after first
operation.
5 years
42
1
In scar
Also 3rd operation, after
which was well 5 years
later, or 12 years after
first operation.
7 years
57
In scar
5 years later well.
10 years
61
In scar
2 years later well.
13 years
43
Also 3rd
operation in
scar
1 year later well.
54 CANCER OF THE BREAST
In this group of eleven cases —
Two had lived five years after the primary operation,
and were^ in good health four years after a second opera-
tion.
One had lived eleven years after the primary operation,
and was well ten years after the second.
One had lived nine years after the first operation, and
was well six years after the second.
One had lived twelve years after the first operation, and
was in good health five years after the second.
A second had survived the first operation twelve years,
and was well two years after a second.
A third had survived the first operation twelve years, a
second and a third operation, and six years later had no
signs of return.
One survived the first operation fourteen years, and was
well one year after the third.
One case had survived the first operation seven years,
had endured a second three years after the first, and four
years later died from chest symptoms.
One case had no signs of recurrence for twelve years,
when, at the age of seventy-two, symptoms appeared
suggestive of abdominal disease.
One case had lived twelve years after the first operation,
and, five years after the second, had some suspicious chest
symptoms.
In three of the eleven cases death had taken place or
was near at hand seven, twelve, and twelve years respec-
tively after the primary operation.
And in eight others there was every prospect of con-
tinuous health, five, five, nine, eleven, twelve, twelve,
twelve, and fourteen years respectively after the breast
had been originally removed.
CANCER OF THE BREAST
55
Group III.
Including ten cases in which the second breast became
involved in the disease.
Interval between
Case.
fint operation
and recurrence.
Operation.
History.
22
2 years
Yes,
1 year later recurrence in scar of last
aged 55
operation.
24
2 years
Yes,
6 years after second operation in good
aged 57
health.
26
2 years
Yes.
5 years after second operation in good
aged 52
health.
29
2 years
No,
Open cancer of scar of first operation.
aged 50
with disease of second breast.
27
3 years
No,
Open cancer of scar of first operation,
aged 37
with disease of second breast.
20
4 years
Yes,
aged 54
6 years luter no signs of recurrence.
28
10 years
Yes,
Breast nnd glands removed ; 3 years later
aged 48
well.
25
10 years
Yes,
Did well after operation, but no recent
aged 50
report.
21
24 years
No,
nged 66
Open cancer of second breast.
23
23 years
No,
Open cancer of original scnr and second
aged 80
breast.
In five of these cases no second operation was performed,
as in all of them an open cancerous ulcer existed, and it
was evident that the sands of lifers hourglass had nearly-
run out. In these cases two, two, three, twenty-three, and
twenty-four years respectively had passed before a recur-
rence of the disease had appeared, and the patients were,
when seen with the disease of the second breast, thirty-
seven, fifty, fifty-five, sixty-six, and eighty years of age.
In the second five cases the second breast was removed.
In two of these the interval between the removal of the
first breast and the recurrence of the disease in the second
breast was two years, and both patients, who were at the
second operation fifty-two and fifty-seven years of age,
were well and free from disease five years later.
In Case No. 20, where the interval between the first
56 CANCER OF THE BREAST
operation and the recurrence in the second breast was four
years, and the patient was aged fifty-four, there were no
signs of recurrence six years later.
In Case 28, where the interval of recurrence was ten
years, and the second operation was performed when the
patient was forty-eight, the breast and enlarged axillary
glands being cleared away, there were no signs of a return
of the disease three years later ; and
In Case 25, where the same period of ten years had
passed before the second breast was removed, when the
patient was fifty, a good recovery followed the operation,
but there is no later history.
Taking the ten cases, however, as a wh6le, it appears
that in three instances where recurrence took place in the
second breast within three years of the operation upon
the first, surgical interference could do but little, as also
in two other cases where the subjects were sixty-six and
eighty years of age.
It must be recorded that in two others where recurrence
took place in less than three years, the patients respectively
being fifty-two and fifty-seven years of age, there were
no indications of recurrence when last seen five years
subsequently, or eight years after the primary operation.
In Case 20, where the second breast was removed four
years after the first, the patient was well six years later,
or ten years after the primary operation; and in Case
28, where the interval between the removal of the first
breast and the second was ten years, the patient was
known to be well three years later, or thirteen years after
the first operation.
Conclusions.
If we look at these tables as a whole it will be evident
that the interval which may take place between the primary
amputation of a breast for cancer and its recurrence in the
scar or second breast, when such occurs, is most uncertain.
That whilst in half the cases tabulated recurrence took
place in five years or less, in the second half the interval
CANCER OP THE BREAST 57
before recurrence appeared varied from six to thirty-two
years; and that in at least two thirds of these cases it
occurred after ten years ; and also that when second or third
operations were undertaken the prospects of life were not
bad (Table II, Group II and Group III).
With respect to the seat of the recurrence, it seems that
such appeared in or about the scar of the original operation
in fourteen cases ; in the scar and axilla in only one case ;
in the sternum in three cases ; in the second breast in ten
cases, and in five of this ten the scar of the first operation
was likewise involved.
I would here ask the surgeons who advocate the clearing
out of the axilla of all lymphoid tissue as a rule of practice
in every case to consider the fact given above ; in only one
case was the axilla cleared out in an operation for a recur-
rent affection, and as already described, it is not my custom
to clear it out in all ; and yet these results do not suggest
an inadequate operation.
I bring this paper before the profession with no little
pleasure, for it shows that operations for cancer of the
breast, when undertake )l at an early period of the disease,
are not so unsatisfactory in their ultimate results as we
have been led to believe. To have been able to tabulate,
in Group I, seventeen cases of operation without evidence
of recurrence in nine cases from five to ten years, and in
eight cases from ten to twenty years after the primary
operation, and to add that thirteen out of these seventeen
cases are now alive and well, with probably some years of
enjoyable life before them, is somewhat startling.
Added to these conclusions is the assurance that should
recurrence of disease appear after the primary operation,
the prospects of prolonged life without second or third
operations, as shown in Table I, Group II, are neither
unreasonable nor unsatisfactory; for only two of the eight
cases so tabulated had survived the first operation less than
ten years, and six had survived from ten to thirty-six years,
and five of these had apparently some years of life before
them.
58 CANCER OF THE BREAST
To show, moreover, as in Table II, Group II, when
recurrence of disease takes place and has been treated by
second or third operations much benefit may be conferred,
is likewise encouraging, for the study of this table which I
ask you to make will suggest that second, and even third
operations undertaken as soon as recurrences appear are
often followed by fairly long periods of enjoyable life, for
in five or six of the cases tabulated the patients were well
and in good health five or six years after these operations.
Where the second breast has become involved, a like
principle of practice is likewise suggested. In four out of
the ten cases tabulated no operation was justifiable, but in
six cases the second breast was removed, and in four of
these cases there were no indications of recurrent disease
five years, six years, two years, and three years respectively ;
so that it may fairly be said that operations on the second
breast are not only justifiable, but conducive to prolonged
life. For my own part, I am so much more satisfied with
the results of my own practice since I have put together
the materials embodied in the paper I have just read, and
brought out the results of its analysis, that I do not feel
disposed to deviate from it in any great degree unless the
advocates of what I must describe as an over-zealous practice
can prove to me that I am wrong and that they are right
by the publication of material facts better than those I
have now recorded.
By way of summary I should like to express my con-
viction that the results of operations for cancer, whether
of the breast or elsewhere, would be i^uch better than
they now are if they could always be undertaken during
the early development of the disease, as illustrated by the
majority of the cases in my tables — Groups I and II ;
that every breast tumour, neither clearly inflammatory nor
encapsuled, which seems to involve gland tissue, and may
therefore be cancerous, should be at once explored and
removed, if found to be cancerous, with the whole gland ;
and that recurrent growths when localised should be
similarly treated.
CANCEE OP THE BREAST 59
In advanced and neglected cases, where the lymphatic
glands and covering integument are involved, Moore^s,
Banks^s, Halsted^s, or Gould^s so-called complete operation
may be called for, but its results are not by any means so
likely to be as favourable as those I have reported.
Lastly, in cases of recurrence not favourable for operation,
unless the removal of the ovaries can be shown in the
future to be successful, the X rays should be employed,
for the benefit which has been derived by this treatment
when judiciously applied by men of understanding has in
my own experience been so successful as to raise hopes
which I hardly like fully to express, and at the same time
seems to be free from danger or serious consequences
when utilised by those who know the dangers of pene-
trating rays carelessly employed, and the difficulties with
which the practice bristles. I must, however, add that
the influence of the rays, to make them effective, must be
maintained for several months after it has seemed to be
beneficial ; a three months^ course, with about three appli-
cations a week, appears to be the shortest from which any
permanent good is to be expected, and this treatment is
full of hope.
60
CANCEK OF THE BKEART
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VOL. LXXXV.
66
CANCEK OF THK BREAST
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CANCER OF THE BKEAST 67
DISCUSSION.
Sir William Banes desired in the first place to thank Mr.
Bryant for the courteous and generous way in which he had
referred to such work as he had done in the matter of the
operative treatment of cancer of the breast. His first paper on
that subject was read to the Lancashire and Cheshire Branch
of the British Medical Association in 1877; the next to the
Worcester meeting of the Association in 1882, when he narrated
the results of forty- two cases ; and the next to the Harveian
Society in 1887, when he presented eighty-two cases. He
finally gave the Lettsomiau Lectures at the Medical Society of
London in 1900 on the subject of " Cancer of the Breast." He
had not overhauled his statistics quite recently, but he felt
sure that those whicii he presented that night were very near
the mark.
Table of fifty-eight cases in which patients lived for, or were alive
at, periods varying from five to twenty-three years.
(1) Six cases where death resulted from local retiirn.
4 patients lived from 5 to 10 years.
2 „ „ to 12 and 14 years respectively.
(2) Twelve cases where there was no local return of the
disease, but where it recurred in other parts of the body.
9 patients lived from 5 to 10 years.
3 „ „ to 10, 10, and 14 years respectively.
(3) Twelve cases where there was no return of cancer
anywhere, and where the patients died from other diseases.
9 patients lived from 5 to 9 years.
3 „ „ to 11, 16, and 18 years respectively.
(4) Twenty-eight cases now living,
14 alive from 5 to 10 years.
12 „ „ 10 „ 20 „
2 „ at 20 and 23 „ respectively.
He thought the result of the operations whicli had been
done by himself and Mr. Bryant were very satisfactory, as
showing that they had evidently prolonged life in many cases,
and completely extirpated the disease in not a few. But the
great thing now was to encourage the medical profession and
the public to look with grave suspicion upon the smallest and
most innocent-looking breast tumour, and to have early recourse
to operation. The operation he had long ago suggested and
for many years carried out reached, he believed, the limits of
reasonable surgery. It had been stated by certain surgeons
68 CANCER OP THE BREAST
that the entire credit of the introduction of free operations for
breast cancer was due to the researches of Stiles and Heidenhain
and the operation of Halsted based thereon. He had the most
sincere respect for the works of the two first-named gentlemen,
but they were investigations in microscopic anatomy, while all
that the surgeon needed to know about the lymphatics of the
breast had been common property for long enough. As for
Halsted's operation, cancer did not recur in the great pectoral
muscle except as progressive from the skin and subcutaneous.
The removal of that muscle he considered both unnecessary
and unscientific, and he entertained the same view of the
removal of the cervical glands as a routine part of the opera-
tion. If extra access to the top of the axilla were required, that
could be obtained by dividing the great pectoral at its upper
end and uniting it again by buried sutures. As for the removal
of affected cervical glands, he had tried it many times, and he
never knew a case which survived. Finallv, it had been main-
tained that if a patient were alive and well three years after
being operated upon she might be put down in a table of
statistics as "cured." He agreed with Mr. Bryant that this
was a dangerous fallacy, and he trusted that it would in future
be banished from the category of reliable statistics.
Mr. Bryant, in reply, said that Sir William Banks's results
were entirely confirmatory of his own. From his own expe-
perience the drastic surgery for cancer of the breast was
unnecessary, and the larger operation involved an avoidable
risk ; the chief point was early operation, when a safer minor
operation was sufficient.
ABOUT ALKAPTONURIA
BY
AECHIBALD E. GTAEEOD, M.A., M.D.
Received October 2l8t— Rend November ?6tb, 1901
In a paper read before this Society in 1899, the present
writer gave the results of the examination of the urine in
five cases of alkaptonuria not previously recorded, and a
summary of the then state of our knowledge of this rare
and interesting urinary abnormality.
The object of the present communication is to call atten-
tion to certain facts, and to record some observations, which
tend to throw fresh light upon its nature and causation.
1. The Relation of Alkaptonuria to Consanguinity
of Parents.
That alkaptonuria may be met with in several members
of a family was first pointed out by Kirk in 1886, and of
the cases since recorded a considerable number have served
to emphasise this fact. However, although brothers and
sisters share this peculiarity, there is, as yet, no known
instance of its transmission from one generation to another,
nor is anything known as to the urine of children of alkap-
tonuric individuals.
70 ABOUT ALKAPTONURIA
On t)he other hand I am able to bring forward evidence
which seems to point, in no uncertain manner, to a very
special liability of alkaptonuria to occur in the children of
first cousins. The information available relates to four
families, including no less than eleven alkaptonuric mem-
bers, or more than a quarter of the recorded examples of
the condition.
I have recently learnt that the parents of my own
patient, Thomas P — , and of an infant brother, born in
the present year, who also is alkaptonuric, are first
cousins, their mothers being sisters.
Again, in the notes which were kindly furnished to me
by Dr. Pavy of a family of fourteen, referred to in my
previous paper, of whom four were alkaptonuric, it is
mentioned that in this instance also the parents were first
cousins.
I am also greatly indebted to Dr. Eobert Kirk for kindly
making inquiries from the father of the three children
whose cases were so thoroughly investigated by him some
years ago, inquiries which brought to light the fact
that their parents also were first cousins, the children of
sisters. Dr. Kirk adds that the mother is dead, that the
father has married again, and that his only child by his
second wife, who is not a blood relation, is not alkap-
tonuric.
Against this may be set the fact that the parents of the
patient studied by Dr. Walter Smith in 1882, and of a
younger brother whose urine I examined, were not blood
relations.
The children of first cousins form so small a section of
the community, and the number of alkaptonuric persons is
so very small, that the association in no less than three
out of four families can hardly be ascribed to chance, and
further evidence bearing upon this point would be of
great interest.
In a recent paper by Erich Meyer it is mentioned that
the parents of his patient were related, but the exact
degree of relationship is not stated. Elsewhere the litera-
ABOUT ALKAPTONURIA 71
ture is silent upon this matter, a silence which counts for
little, seeing that the information is not usually forthcoming
unless asked for, as Dr. Kirk's experience and my own
show.
There are some indications that the younger members
of a family are more liable than the elder ones. Thus
the alkaptonuric members of the family observed by Dr.
Pavy, were the ninth, eleventh, thirteenth, and fourteenth.
Thomas P — and his alkaptonuric brother are the fourth
and fifth children, and in the family observed by Dr. Kirk,
the second, third, and fourth children showed the pecu-
liarity.
The facts here brought forward lend support to the
view that alkaptonuria is what may be described as a
" freak '^ of metabolism, a chemical abnormality more or
less analogous to structural malformations. They can
hardly be reconciled with the theory that it results from
a special form of infection of the alimentary canal.
There is here no question of the intensification of family
tendencies by intermarriage, for in no instance were the
parents themselves alkaptonuric, and, as has been already
mentioned, there is, up to now, no recorded instance of
alkaptotturia in two generations of a family.
2. The Onset of Alkaptonuria in a New-horn Infant.
That alkaptonuria may persist through life without aliy
apparent detriment to health, and may date from earliest
infancy, has long been known, but there have hitherto been
wanting observations bearing upon the exact period of its
onset in congenital cases. This deficiency I am now able
to supply to some extent.
The fifth child (a male) of the parents of Thomas P —
and the second alkaptonuric member of the family, was
born at 6 a.m. on March 1st, 1901. The mother was
tended after her confinement by a district nurse, and both
she and the nurse were fully alive to the possibility that
the child might show the same peculiarity as its elder
brother, and were on the look-out for any indication that
72 ABOUT ALKAPTONURIA
this was the case. The information which follows was
given to me by the nurse within a few days of the infantas
birth.
During the first day of life the child was put to the
breast, and was given a teaspoonful of butter and sugar,
according to a practice common among the poorer classes.
The napkins were first changed at 9 p.m. on March 1st
(when the child was fifteen hours old), and it was specially
noted that, although urine had been passed freely, there
was no indication whatever of the staining which was so
familiar in the case of the elder child.
When the napkins were next changed, at 11 a.m. on
March 2nd, the nurse noticed a slight staining, and at 10.30
a.m. on March 3rd (fifty-two hours after birth), and on all
subsequent occasions, the napkins were deeply stained in
the characteristic manner.
The child had been put to the breast during the previous
night, and on the morning of March 3rd the nurse found
that the mother's breasts contained milk, but were not full.
The mother was not conscious of the " draught " until a
later hour on March 3rd.
Some urine collected during the eighth to eleventh days
of life reduced Fehling's solution, and had all the ordinary
properties of alkapton urine.
The above facts, carefullv recorded bv one who was
wholly without bias in favour of any theory of the nature
of alkaptonuria, or knowledge of the questions at issue,
nevertheless agree completely with what was to be expected
on theoretical grounds.
The evidence available points to tyrosin, formed as a
product of pancreatic digestion, as the parent substance of
the homogentisic acid which imparts to alkapton urine its
peculiar properties, and we should anticipate that the
peculiarity of metabolism would first manifest itself after
the entry of proteid food into the alimentary canal. As,
moreover, the human tissues appear to be able to destroy a
certain amount of homogentisic acid, this substance would
not be excreted until this destructive power was overtaxed.
ABOUT ALKAPTONURIA 73
The observations on the new-born infant appear to be
most readily explained on the assumption that the develop-
ment of alkaptonuria resulted from feeding, but as the
child was suckled, the exact time when food began to
enter the alimentary canal cannot be fixed with any degree
of certainty.
When the elder child was first seen by me the mother
stated that in his case her attention had been first called to
the staining of the napkins on the day after his birth, thus
in both instances the condition may be fairly described as
congenital. In this connection a most interesting case re-
cently recorded by Winternitz may be referred to. He had
under observation a family of three alkaptonuric children,
a boy aged twelve, a girl aged ten, and another girl aged
six. The mother, who stated that the urine of the two
elder children had stained the napkins from the first days
after their birth, added that this had only been the case
with the youngest child during the last year. This recalls
Maguire's case in which the condition was said to have
dated from the age of twenty-seven, the intermittent case
recorded by Stange, and the still more puzzling cases of
temporary alkaptonuria.
3. The lieldtion in Time of the Output of Homogentisic Acid
to a Proteid Meal.
In a quite recent paper, which embodies many other
observations of much interest, Mittelbach gives the results
of the estimation of the reducing power of the samples of
urine passed by his patient at different periods of a twelve-
hour day, which show the maximum excretion of homogen-
tisic acid following within the first two or three hours after
the chief meal, and not, as is the case with the ordinary
products of metabolism, appearing in the urine in the
largest quantities from five to seven hours after a meal.
This result was so unexpected, and seemed so difficult
to reconcile with the view that tyrosin is the parent sub-
stance of homogentisic acid in these cases, that further
observations upon the point appeared desirable. I accord-
74
ABOUT ALKAPTONURIA
ingly estimated the reducing power of the several speci-
mens of urine passed by Thomas P — (aged four) during
three periods of twenty-four hours each, and the results are
embodied in the following tables. The estimations were
made by Baumann's silver method, but, owing to the small
bulk of many of the specimens, 5 instead of 10 c.c. of
urine were used for each testing, and it was not attempted
to secure estimations withiin 0*5 c.c. of ~^ silver nitrate
solution.
The urine of the child is always rich in homogentisic
acid, and the daily output approaches that of some of the
adult patients. At the age of three the average daily ex-
cretion during seven days was 2*6 grms. of homogentisic
acid, and that of Meyer s patient of about the same age was
3*24. The figures for adults vary between 3 and 6 grms.
per twenty-four hours.
Day 1 . — On this day the patient was taking the ordinary
hospital diet for children of his age. The first meal was at
5 a.m : dinner consisting of minced meat and rice pudding
at 12 noon; tea including an egg at 3.45; supper consist-
ing of milk and bread and butter at 6 p.m.
Hour of da>.
1
Qaantity of
ui'ine passed
in c.c.
No. of c.c. Y^ silver
nitrate solution re-
duced by & c.c. urine.
No. of c.c. xo silver
solution reduciiile by
total urine.
1
Correspondino; to
a reducing power
per hour of—
A.M. 9.30
60
10
120
f
i
i
P.M. 12.30
53
10-5
111-3
37 c.c.
4
46
13
119-6
34-2
5.55
27
16
86-4
45
9.80
55
11
121
33-7
i A.M. 12.45
35
9
63
19-3
; 3.45
28
5-5
30-8
10-2
J ^
25
5-5
27-5
12-2
Totals .
329 c.c.
679-6 c.c.
(corresponding to
2*79 grammes of
homogentisic acid)
Here the maximum excretion per hour was between 4
and 5.55 p.m., {. e. four to six hours after the chief meal,
ABOUT ALKAPTONURIA
75
but the results are somewhat obscured by the overlapping
of the effects of several meals rich in proteid.
Day 2. — On this day the diet was so arranged that the
articles richest in proteids .were given at the chief meal,
which, as before, was at 12 noon, and hourly specimens of
urine were fortunately obtained from 4 to 9 p.m. inclusive.
It is clearly seen that although there is a conspicuous rise
in the specimen passed at 1 '30 pan., the maximum excre-
tion was between 3 and 7 p.m.
Hour of day.
1
Quantity of
urine pussed
ill c.c.
No. of c.c. f^ silver
nitrate solution re-
duced by 5 c.c. urine.
No. of c.c. ^5 silver
solution reducible by
total urine.
Correspondinji; to
H reducing; power
per hour of —
A.M. i^.55
26
6
31-2
11.40
43
5-5
47-3
27 c.c.
! P.M. 1.30
25
16
80
43-6
1 2.50
30
10
HO
45
1 4
30
11-5
87
8V5
5
32
15
96
96
«
20
15
60
60
7
31
14
86-8
86-8
1 8
25
10
50
50
9
24
8-5
40-8
40-8
10.55
65
3
39
20-3
A.M. 12.55
27
6
32-4
16-2
1 2
5
6 or 7
S-4?
7-7
4.40
16
7
22-4
8-4
i 8
i
41
8
65-6
19-6
Totak- .
[ 440 c.c.
806-9 c.c.
(corre8polH^nl^ to
3*327 grammes of
•
i
hoiiiogentisic ncid)
The total excretion of homogeiitisic acid was increased,
owing to some increase of the proteid food, partly in the
form of Plasmon. The effect of the early breakfast at 5
a.m. is still clearly marked.
Day 3. — On this day the meal richest in proteid was
given at 9 a.m. instead of at noon, and the maximum
output of reducing substance per hour was also three hours
earlier, viz. between 12.15 and 4.25 p.m. The rise during
the hours immediately following the meal is again very
76
ABOUT ALKAPTONURIA
noticeable. The total reducing power of the twenty-four
hours^ urine was on this day somewhat larger still.
Hour of day.
Quantity of
uriite passed
in c.c.
No. of c.c. y" silver
nitrate solution re-
duced by 5 c.c. urine.
No. of c.c. Y^y silver
solution reducible by
total urine.
Corresponding to
a reducing power
per hour of—
A.M. 6
32
6
38-4
_
8
30
9
•
•
9.25
26
5
26
18-3 c.c.
11.15
46
8
73-6
40-1
'■ P.M. 12.15
29
9
52-2
52-2
4.25
99
14
277-2
66-5
6
46
8-5
78-2
49-3
9.30
95
6-5
123-5
35-3
11.45
31
7-5
46-5
20-6
A.M. 2.50
35
6
42
13-6
4.45
41
4-5
36-9
19-2
Totals .
510 c.c. 1
1
It will be at once apparent that these results do not
bear out Dr. Mittelbach^s observation that the reducing
power of the urine reaches its maximum within two or
three hours of a proteid meal, but show, on the other hand,
that in the case of my patient, although such a meal is
quickly followed by a much increased excretion of homo-
gentisic acid, a still larger amount is excreted during the
second period of four hours than during the four hours
immediately following the meal. In a word, they tend to
support the view that the change from ty rosin to homo-
gentisic acid takes place in the tissues after the absorption
of the former, rather than the alternative view that the
change in question is brought about in the alimentary
canal.
Since the publication of the previous paper in 1899,
cases of alkaptonuria have been recorded by Winternitz
(three children in one family), E. Meyer (one child), and
Mittelbach (an adult male) ; and these with the infant
above described raise the total of recorded examples to
thirty-seven.
ABOUT ALKAPTONURIA 77
The following additions may also be made to the biblio-
graphy there given :
HuPPERT, H. — Ueberdie Homogentisinsaure. Deutsches
Archiv f. klin. Medicin, 1899, Ixiv (Festschrift), p. 129.
WiNTERNiTZ. — Miinchener med. Wochenschr., 1899, xlvi,
p. 749.
Orton, K. J. P., and Garrod, A. E. — The Benzoylation
of Alkapton Urine. Journal of Physiology, 1901, xxvii^
p. 89.
Meyer, Erich. — Ueber Alkaptonurie. Deutsches Archiv
f. klin. Med., 1901, Ixx, p. 443.
Mittelbach, F. — Ein Beitrag zur Kenntniss der Alkap-
tonurie. Deutsches Archiv f. klin. Med., 1901, Ixxi,
p. 50.
78 ABOUT ALKOPTONURIA
DISCUSSION.
The Chairman (Dr. C. Theodore Williams) expressed regret
that more papers on chemical pathology were not communicated
to the Society. It was along these lines that the greatest
advance in medicine had been made. After alluding to the
importance of being able to recognise the presence of alkapton
in the urine in examination for life insurance, he asked by
what test it could be distinguished from sugar in the urine.
Dr. W. A. Osborne mentioned the case of a man who was
rejected for life assurance because his urine reduced Fehling's
solution, which he had found to be due to alkapton. A second
and a third brother were similarly affected, and their parents
were first cousins. These were the three cases that had been
described by Dr. Pavy. Homogentisic acid was present in the
urine as a salt. If homogentisic acid was derived, as was sug-
gested, from ty rosin, then a person the subject of alkaptonuria
if fed on a ty rosin-free diet should cease to pass alkapton in
the urine. Such a diet might consist of sugar, fat, and gelatine.
It was very difficult to understand on chemical grounds how
ty rosin could become changed into homogentisic acid. He
suggested that it might be a good plan to give an alkaptonuric
patient some of the intermediate substances between ty rosin and
homogentisic acid, and observe the effect on the excretion of
alkapton in the urine.
Dr. Garrod, in reply, said that it would be difficult to ^ive a
tyrosin-free diet in his case, as the patient was a child of four
years. The experiment had been tried abroad by Mittelbach,
whose adult patient had consented to take only tea and brandy
for three days. Mittelbach found that after such fasting the
homogentisic acid excretion fell to about one third of the usual
amount, but that the acid did not completely disappear from
the urine.
TWO CASES
OF
LIGATURE OF THE LEFT CAEOTID
FOR
ANEURYSM OF THE ARCH OF THE
AORTA
WITH THE POST-MORTEM SPECIMENS OF FOUR CASES
BY
CHRISTOPHER HEATH, F.R.C.S.
CONSULTING SURGEON TO UNIVERSITY COLLEGE HOSPITAL
Received October 29tli, 1901— Read February lUb, 1903
The foUowiug are the notes of tlie sixth and seventh
cases in which I have tied the left carotid for aneurysm
of the arch of the aortji. I briefly referred to the sixth
case in some " Remarks on the Distal Ligature in the
Treatment of Aneurism/^ published in the ^British Medical
Journal ^ of February 19th, 1898, but the seventh case
occurred after that date.
Case 6. — Martha Fogarty, aged 61, following the occu-
pation of a monthly nurse, came under the observation of
Dr. Robinson at the Mile Eud Infirmary in July, 1890.
80 LIGATURE OP THE LEFT CAROTID
Since her husband's death she had supported herself by-
monthly nursing and the letting of lodgings, and never
undertook anything like hard work. Three years before
she experienced pain in her right shoulder, which was
shortly afterwards followed by the discovery of a pulsating
swelling above the right clavicle. She thereupon went to
the London Hospital and remained there three weeks. It
was then proposed to perform some operation for her
relief, but this she declined, and took her discharge.
In December, 1889, when nursing a lying-in case, she
noticed that the act of coughing caused her great pain in
the supra-clavicular region, and about the same period
her voice became cracked. Soon after Christmas of 1889
she could not lie comfortably on her back, and when she
did so experienced a feeling of impending suffocation.
In July, 1890, she was admitted to the Mile End
Infirmary, when Dr. Robinson noted a marked pulsa-
tion in the supra-sternal notch. She was kept closely
in bed, and iodide of potassium was administered in full
doses for many weeks, but no alteration in the pulsation
resulted. She suffered a good deal from cough, and corn-
plained of constant pain in the neighbourhood of the
pulsation, and this was much intensified during the act of
coughing. Over the pulsation a marked bruit was audible,
a similarly well-marked systolic bruit being heard at the
apex-beat. The pulses in the wrist were equal in volume
and regular, 92. There were no signs of arterial degenera-
tion in the superficial vessels anywhere. Her invariable
position in bed was a sitting one, with the knees drawn
up and her head resting upon them. On the slightest
inclination backwards there was an increase of the
dyspnoea, and inspiration was accompanied by stridor.
The patient was small and of spare build. Her
hair was turning grey, and the arcus senilis was well
marked. Her complexion was sallow. There was no local
oedema. After the treatment by rest and the iodide had
been pursued for some weeks without any improvement
in the patient^s condition, the advisability of submitting
LIGATURE OP THE LEFT CAROTID 81
to an operation was placed before her by Dr. Robinson,
and she consented to it. Accordingly, Mr. Heath applied
a carbolised silk ligature to the left carotid, above the
omo-hyoid, on November 16th, 1890, no anassthetic being
employed. On the evening of the operation the tempera-
ture of the left side of the face was 82°, that of the right
side being 94°. The pulse in the left radial was noticed
to have diminished in volume considerably. The patient
at this time complained of a throbbing pain in the
neighbourhood of the incision, and also of dysphagia.
The pain in her right shoulder she declared to be gone.
On November 19th (third day) it was noted that
respiration, which had been distinctly noisy, particularly
inspiration, was now unaccompanied by the least -noise.
The patient was much better, able to recline against her
pillows and indulge in sleep, and declared herself quite
comfortable. The pupils were noted to be equal and
active.
On November 22nd she was able to sleep for seven
hours, a thing she had long been a stranger to. The
wound healed by first intention, and her progress was
uneventful until January 3rd, 1891, when she complained
of some return of the pain in the right shoulder and in
the interscapular region. She had occasional attacks of
epistaxis about this time without obvious cause, and some
cough of a laryngeal character persisted. In February,
1891, the pulsating tumour above the sternum, though
still visible, was thought to have contracted, and the
patient was able to lie and sleep in any position without
discomfort. On April 3rd (five months after the opera-
tion) she complained of some return of dysphagia. In
June, as she complained of some recurrence of pain in
the right shoulder, and the pulse was full and hard. Dr.
Robinson ordered her tablets of nitro-glycerine, under
which the pain subsided. She continued to improve, and
was discharged from the infirmary at her own request on
August 8th, 1891.
This patient was admitted to the London Hospital
VOL. LXXXV. 6
82 LIGATURE OF THE LEFT CAROTID
under Dr. Gilbart -Smith on September 3rd, 1891, when
a pulsating tumour existed at the inner end of the right
clavicle, and could be just felt about it. About the
middle of November she began to complain of great
pain shooting through the sternum and between the
shoulders, and died suddenly on November 29th, 1891,
more than a year after the operation.
For the following abstract of a case of aneurysm
under the care of Dr. Roberts, I am indebted to Mr.
Bucknall, late Surgical Registrar of University College
Hospital.
Case 7. — James Smith, aged 36, a labourer, waS
admitted November 4tb, 1898, complaining of " pain in
the chest. '^ From boyhood till the age of twenty-six he
served as a hand on a fishing smack. Since then he has
worked as a rough labourer, doing heavy lifting. For
seventeen years he has served his time in the Militia
Artillery, '^ lifting guns.^' Was in bed with rheumatism
for seventeen weeks at the age of twenty-two. Had some
swellings in the groins once, but no syphilis. Often
drunk, and smoked half an ounce of shag daily.
Family history. — Father died of consumption aged
twenty-eight.
Present illness, — Began in April, 1898, with pain
behind the sternum, which came on when he ceased
working, and lasted till he settled to work again, and
^' warmed to his work.^^
In September the pain became worse, and spread over
the right upper chest to the scapula, and ran down the
right arm as far as the internal condyle. He had to
give up work and go to bed for four days.
The pain continued to get worse, and was least felt
whilst doing manual labour.
During October, 1898, he had a cough.
State on admission (November 5tli). — Patient pre-
LIGATURE OP THE LEFT CAROTID 83
sented all the signs of an aneurysm projecting forwards
in the first and second right intercostal spaces. The
first and second right spaces were bulged, and dull on
percussion for a distance of one inch from the sternal
margin, and pulsation of an expansile character could be
seen and felt here, and in the episternal notch and right
supra-clavicular fossa.
The inner ends of both clavicles were projected for-
wards by the swelling, especially the rights and each
beat of the pulse threw them further forward, and
caused a heaving of the upper part of the chest.
Some dilated veins lay over the front of the chest, and
the jugulars were also distended.
Patient had a frequent brassy cough, and the voice was
harsh ; but the laryngoscope showed that both cords
moved equally. There was marked " tracheal tugging/'
the right pupil was larger than the left (slightly), arid
the right radial pulse might have been a shade earlier
than the left ; it was certainly much larger in volume.
The pulse was regular, 68 to the minute, high tension,
large, collapsing rapidly during diastole in a manner
typical of aortic regurgitation. Heart apex-beat heaving
in fifth space, in the nipple line.
On auscultation a blowing systolic murmur could be
heard over the aneurysm ; the second sound could be
clearly heard in the second right interspace, and along
the left border of the sternum a murmur could be heard
following the second sound, and running through the
whole period of diastole. A blowing systolic murmur
could be heard at the apex. The lungs were examined
and found healthy.
Notes before operation, — During November and De-
cember, 1898, and the first half of January, 1899, patient
had severe attacks of pain in the shoulders, back, and
side of the neck and face. The aneurysm at first
became smaller, but during January it increased in size,
and definite swelling and pulsation appeared beneath the
pectoral just below the right clavicle. During this
84 LIGATURE OP THE LEFT CAEOTID
period patient^s temperature remained normal. On
January 18th patient was transferred for operation.
Operation (January 18th, 1899, by Mr. Heath). — The
left common carotid was ligatured with carbolised silk
opposite the cricoid, eucaine j3 being used as a local
anaBsthetic. There were no succeeding nervous sym-
ptoms.
On January 19th and 20th the patient slept badly,
owing to pain in the region of the aneurysm. On the
20th the pulsation in the aneurysm was distinctly less
marked, and daily improvement was noted until February
1st, when he returned to the Medical ward with the
operation wound healed. The pulsation was now much
less distinct and forcible, and patient was free from pain
and had slept well since January 20th. His cough" was
less frequent, and less brassy in character.
On February 16th patient complained of pain in the
chest and cough, and, on listeiiing to the chest, rS,les and
rhonchi could be heard scattered over both lungs.
On February 17th his temperature shot up to 103°,
and from this date till the day of his death (March 21st)
he had constant remittent fever varying between 100°
and 104°, usually about 102°, with daily remissions of
two to three degrees. The lungs showed all the signs
of rapid and wide-spread tubercular infiltration and con-
solidation, and later cavity formation at the apices was
evident.
The patient grew thinner and weaker daily, and ex-
pectorated copious purulent sputa containing tubercle
bacilli. He sank and died on March 21st, having been
ill a little over a month. The aneurysm gave rise to no
symptoms during this time, and was daily less evident.
The post-mortem specimens from patients on whom I
have tied the left carotid for aortic aneurysm are four in
number.
1. The patient was a labourer who had had a pulsating
swelling in the neck for nearly a year, and was under the
LIGATURE OP THE LEFT CAROTID 85
late Dr. Cockle when I tied his left carotid with catgut
in February, 1872. ^^ The symptoms due to the pressure
of the aneurysm at once abated." When seen in March,
1873^ he was in a very satisfactory condition, but in
June, 1875, after resuming his laborious occupation of
hedging and ditching, a pulsating tumour much larger
than before the operation projected above the sternum.
The aneurysm burst externally in September, 1876.
(See ^ Clin, Soc. Trans,,' vol. v, p, 183, and vol. x,
p, 96.)
^^ The arch of the aorta is generally dilated ; upon the
anterior surface of its ascending portion is an oval
opening, about an inch and a half in diameter, which
communicates with a large sacculated aneurysm. The
aneurysm projects forwards, and ascends in the neck
beneath the sterno-hyoid and thyroid muscles as high as
the cricoid cartilage, where there is a large opening, at
which it had burst through the skin. The transverse
portion of the arch is compressed by the sac, and the
left brachio-cephalic vein is obliterated. The posterior
surface of the sternum is eroded and forms part of the
wall of the aneurysm, which had also compressed the
left lung. The left carotid artery is obliterated and
contracted at a point half an inch below the cricoid
cartilage, where a ligature has been applied ; it contains
a fibrinous coagulum only adherent at the seat of
ligature. There is no evidence that the internal coats
of the artery were divided by the ligature '' (College of
Surgeons Museum, 3167),
With regard to this last statement, I may mention that
the catgut broke in tying, and that I then doubled it
and tied the artery as firmly as I dared. The drawing
given by Messrs. Ballance and Edmunds (^ Ligation in
Continuity,' p. 193) of this preparation is in my opinion
incorrect. ' It will be noticed that the sac contains no
clot, for the reason that the examination took place three
days after death in very hot weather, and in the country,
and the decomposed condition of the clot necessitated
86 LIOA.TUBS OF THE LEFT CABOTID
the washing of it away. This was most anfortanate^ as
it has led to the idea that no coagolam had formed as a
result of the operation^ whereas a large amount of clot
had formed^ and had led to the apparent cure of the
aneurysm until the patient resumed his labour^ when it
again grew and burst externally^ four and a half years
after the ligature was applied.
Specimen 2^ from a man aged 38^ whose case is re-
ported in the Clinical Society's ' Transactions ' for 1891,
by Dr. H. E. Harris, under whose care the patient wiis
in tlie St. George's-in-the-East Infirmary. I tied the
left carotid on March 8th, 1890. For a fortnight the
aneurysm appeared to decrease in size, but the patient
was more distressed with dyspnoea and cough. After
that date it again increased in every direction and be-
came more prominent, and the patient died suddenly on
May 12th, two months after the operation.
The aneurysm springs from the upper and anterior
part of the transverse portion of the arch, with which
the sac communicated by a rounded opening of 1^ inches
diameter. The opening is entirely to the proximal side
of the great vessels, and the sac projects upwards and to
the left, its summit being If inches above the sternal
notch.
The sac is entirely filled with clot, of which the outer
layer, from | to 1 inch in thickness, is composed of
decolourised fibrin, while the central portion is made up
of ordinary red coagulum.
From the orifice of the aneurysm ante-mortem clots
extend in a radiate fashion into the aorta, and into the
innominate and left subclavian arteries, in which they
tail off to threads. This clot, after being subjected to
the action of weak spirit, was smooth, well defined, of
considerable consistence, and separated like a membrane
from the body of the clot. A section of the main clot
showed it to be fleshy, and slight pressure caused it to
split up into laminae. Just above the aortic opening
LIGATURE OP THE LEFT CAROTID 87
the clot was distinctly adherent over a surface nearly an
inch in length to the concavity of the arch, which was
extensively calcareous.
A ligature had been applied to the left carotid five
eighths of an inch below the bifurcation of the artery, at
which point the vessel is interrupted for about half an
inch by a mass of fibrous tissue. Above, the artery is
completely filled by an organised but still coloured clot.
Below, a completely decolourised clot extends along and is
firmly adherent to the posterior wall of the vessel ; this
clot ceases one and a quarter inches above the commence-
ment of the artery, with the exception of an exceedingly
fine filament, which is continuous with the clot in the
aneurysm. The remains of a ligature may be observed
embedded in the fibrous tissue, which has also entangled
the pneumogastrio nerve (College of Surgeons Museum,
3167a) (Plate I).
Specimen 3 was from Dr. Robinson^s patient (Case 6).
The first part of the arch of the aorta is uniformly
dilated. From the right superior aspect of the trans-
verse arch, in front of the innominate artery, which is
dilated and involved, springs an aneurysmal sac of the
size of a small orange, with an opening into the aorta of
the size of half a crown. The sac was adherent to the
trachea, and is almost completely filled with laminated
clot. The left carotid is filled with firm adherent clot,
and higher up is obliterated by a ligature, which has
disappeared. The clot in the left carotid does not extend
into the aorta. The aorta was extensively diseased
(University College Museum, 1233) (Plate II).
Specimen 4 was from Dr. Roberts's patient (Case 7).
There are two aneurysmal sacs, a large one springing
from the ascending aorta, and a smaller one arising from
the back of the innominate artery,- Both contained
laminated clot.
The aortic aneurysm forms a tumour as large as a
88 LIGATURE OF THE LEFT CAROTID
clenched male fist, lying to the right of the extra-peri-
cardial ascending aorta, and communicating with its
lumen by an orifice the size of a florin. This pierced
the antero-external wall of the vessel about midway
between the pericardium and the origin of the innominate.
The fibrous tissue forming the wall of the aneurysm
extended around the vena cava and the origin of the
innominate, and to the jugular vein. The manubrium
sterni and ribs are adherent to the sac.
On opening the aneurysmal sac it was found to be
filled with clot, the central part soft and rather fluid,
the main mass distinctly laminated. The most peripheral
portion was decolourised.
The innominate aneurysm forms a tumour as large as
a hen^s egg arising from the artery a quarter of an inch
from its bifurcation. It lay behind and to the left of the
larger aneurysm, to which it adhered, being in close
contact with, and adherent to, the trachea on the inner
side. It contained laminated clot, and communicated
with the larger sac by its lower end.
The left carotid is obliterated an inch below the bifur-
cation and converted into a fibrous cord half an inch
long. Below that there is solid clot filling the vessel to
within half an inch of the aorta close to the larger sac.
The aorta is extensiyely diseased. The lungs were
universally adherent and solid with tubercles, which had
broken down beneath the apex of both upper lobes,
leaving a ragged cavity the size of a small hen^s egg in
each (University College Museum, 1234) (Plate III).
That the application of a ligature to the left carotid has
an effect upon an aneurysm of the transverse portion of
the arch of the aorta is, I think, sufficiently shown by the
cases just read. In the woman it is noted that on the
third day after the operation the respiration, which had
been distinctly noisy, had become quiet, and the patient
was able to recline against her pillows. On the sixth
day/she was able to sleep for seven hours consecutively.
LIGATURE OP THE LEFT CAROTID 89
In the man, on the third day the pulsation of the aneurysm
was distinctly less marked. But the relief in my first
case (Dr. Cockle^s patient) was even more marked, for I
brought him before the Clinical Society more than a year
after the operation, when it was recorded that ^^ the
patient is in perfect health, and feels no inconvenience
from his chest. He sleeps well and can lie on either side
equally well. The right chest wall in front is quite
restored to its natural shape, or if anything is a little
flatter now than its fellow. On palpation, the heaving
impulse formerly existing over the right anterior chest
wall is almost entirely gone. On percussion, the right
anterior chest wall, formerly so dull, has, to a consider-
able extent, recovered its normal condition ^^ (^ Clin. Soc.
Trans.,' vol. vi, 1873).
The preparation from this patient shows no clot, for
the reason I have already given, but the other three
preparations show thick laminated clot in each sac, and
in the last case (Dr. Roberts^) the second or innominate
aneurysm was also full of clot.
Various theories have been advanced to account for
the formation of laminated clot in these cases. The
simplest was that it depended upon the enforced rest in
bed following the operation ; but the fact is that in every
case the effect of prolonged rest in bed had been tried
for many weeks without the slightest benefit. Next it
was suggested that the clot, beginning at the point of
ligature, spread down into the aneurysm, and thus led to
the formation of a coagulum in the sac. This is contrary
to fact, as shown in the preparations before you, for in
no single case was the left carotid involved in the sac,
and it is noted that the small thread-like clot, which, in
some instances, spread down the carotid, in one case
only extended into the aorta, and joined that in the
aneurysm. I maintain the view which I have always
held about these cases, viz. that the distal ligature
affects the current of blood in the aneurysm, probably by
90 LIGATURE OP THE LEFT CAROTID
retarding it^ and thus, causes it to flow around the sac
instead of directly through or past it, and in this way
leads to the deposit of laminated fibrin on the probably
roughened wall of the sac.
When this normal cure of the aneurysm has gone on
for some time, there is no doubt a tendency for the small
remaining cavity to become blocked with soft coagulum,
and this is probably a critical moment for the patient, and
may account for the sudden deaths which have occurred
at considerable periods after the operation. An aneurysm
which is semi- or completely solid must necessarily exercise
much greater pressure on its surroundings than one which
only contains fluid blood, whilst the sudden arrest of a
stream of blood through a sac so near the heart would be
likely to interfere witli its action and lead to syncope.
For the drawings of three of the preparations illus-
trating this paper I have to thank Mr. T. W. P.
Lawrence^ F.R.C.S., Curator of the University College
Museum.
Med. Chir. Trans., Vol. 85.
Heath: Ligature of Left Carotid. Plate L
A Left carotid at ligfttnre. C Loose olot in Aorta.
B Bigbt cArotid. DD Aortic Aneniyam.
id. Chir. Trana., Vol. 85.
Heath : Ligature of Left Carotid. Plate II.
"A
A Left carotid at ligatui'e. C Arch of Aorta.
B Inuominata artery. D Ulot filling Aneuryam.
Bale d /^aaKfwon, LliL, LM
Med. Chit. Trans., Vol. 85.
llealh: Lignliire of L,ft Carolid. PM.II! '"V/l
Casb T.
A Lett carotid at ligature, C Arch of Aorta.
B Right carotid. D Clot fUliag Aneur^Rin.
Bolt £ DaKithau, Lid., Lilk
LIGATURE OP THE LEFT CAROTID 91
DISCUSSION
Mr. A. Carless referred to the case of a woman aged 40,
with aneurysm of the aorta, the specimen from which was shown,
which was published in the * British Medical Journal' for
December 3rd, 1898, p. 1685, in whom the left carotid had
been ligatured by Mr. Carless, and the left subclavian by Mr.
Eose, with improvement in the signs and symptoms in the case.
During the five months before coming under observation she
had suffered from pain in the right arm, shoulder, and neck,
with dysphonia and dysphagia. She had a dry ringing cough.
There was no specific history, and she had had two healthy
children. On admission to hospital there was bulging of the
chest wall at the level of the first and second ribs on each side,
with marked pulsation in the intercostal spaces. In addition
there was a pulsating swelling below the insertion of the left
sterno-mastoid muscle. The left temporal and radial pulses
were less than the right. While in hospital several attacks of
syncope occurred, and as the tension of the projecting saccule
beneath the sterno-mastoid appeared to be increasing, the left
carotid was tied. For a few days afterwards there was a slight
increase of tension in the sac, with some paresis of the left side
of the face and tongue ; but these symptoms soon disappeared,
the dyspnoea became less, and the pulsation diminished. Twenty-
four days after the ligature of the carotid the subclavian was
tied. Six months later there was very little pulsation above the
clavicles, and she was able to do her work for three years, with
some short intervals of rest, when she suddenly died from
rupture into the left pleural cavity. The aneurysm was found
at the necropsy to be non- sacculated. The left subclavian and
carotid were contracted, and the innominate had been absorbed
into the general aneurysmal mass.
Dr. Frederick T. Egberts remarked that the chief point
for discussion was under what conditions distal ligature of
arteries should be performed for thoracic aneurysm. In his
case upon which Mr. Heath operated the two main causes of
the aneurysm were heavy work and alcoholism ; he thought that
excessive smoking might also have had some influence. There
was no history of syphilis. The indication for the operation
was the extreme suffering which the patient endured, and it
was performed in spite of the fact that there was free aortic
regurgitation and marked arterial degeneration. Much benefit
was derived from the operation, both as regards the physical
conditions of the aneurysm and the sensations of the patient.
Dr. Eoberts alluded to another case of aortic aneurysm recently
92 LIGATURE OP THE LEFT CAROTID
under his care, in which first the left carotid and afterwards
the subclavian artery were ligatured by Mr. Bucknall, with
decided benefit.
Mr. R. Babwell said, in reference to the suitability of cases
for operation, that clot was not likely to form in symmetrical
dilatations of the aorta, even if the vessels were tied ; but if the
aneurysm were sacculated clot was much more likely to form
after distal ligature. He agreed with Mr. Heath that the clot-
ting probably originated in the sac itself, close to the exit of
the ligatured vessel from the sac, and not at the seat of ligature.
In his opinion there were cases in which it was preferable to tie
the carotid and subclavian on the right side rather than the left,
the indications as to which side should be tied being derived
from the state of the vocal cords and pupils. Among such
cases he would have been inclined to have placed those described
in the paper.
Mr. T. R. H. Bucknall referred to the case of a man aged
47, who had had syphilis, in whom a swelling below the left
stern o-mastoid was present. There were indications of pressure
on the trachea and left bronchus, but none of pressure on the
recurrent laryngeal nerve. The left carotid and the third part
of the subclavian were tied, with the result that the patient was
free from symptoms for two months, the pulsation becoming
less. Mr. Bucknall then discussed the question of danger from
ligature of the carotid, particularly the cerebral symptoms which
formerly preceded death not infrequently.
Mr. Heath, in reply, said that his rule had been to tie the
artery which came off next beyond the aneurysm, and he quite
agreed that in some cases it might be better to tie the right
than the left carotid.
THE SURGICAL TREATMENT
OF
OBSTRUCTION IN THE COMMON BILE
DUCT BY CONCRETIONS
WITH ESPECIAL REFERENCE TO THE OPERATION OF
CHOLEDOCHOTOMY AS MODIFIED BY THE
AUTHOR, ILLUSTRATED BY SIXTY
CASES
BY •
A. W. MAYO EOBSON, F.E.C.S.,
SENIOB SUBGEON TO THE GENEBAL INFIBMABY AT LEEDS ; EMEBITUS
FBOFESSOB OF SUBGEBY IN THE YOBKSHIBE COLLEGE
OF THE VICTOEIA UNIVERSITY
Received December 16th, 1901— Read March 25th, 1902.
Whbn once gall-stones have reached the common duct,
their attempted dislodgment by purely medical means is
with few exceptions disappointing in the extreme, and
the unfortunate patients are condemned to a lingering
and painful illness usually ending in death, unless the
obstruction can be removed by surgical intervention.
Seeing that it is only twelve years ^ince Courvoisier
first removed a gall-stone from the common duct by direct
incision, the progress in this branch of surgery must be
very pronounced when we can safely affirm that there is
no portion of the gall-bladder, cystic, common, or primary
94 THE SURGICAL TREATMENT OF OBSTRUCTION
division of the hepatic ducts which cannot under ordinary
circumstances be reached for the removal of concretions,
and that with great probability of success.
No surgeon should attempt the removal of gall-stones
unless he is prepared for any of the various operations on
the biliary passages, as it is almost impossible to say
beforehand what may be required until the ducts have
been explored by the fingers and the condition of the
parts ascertained, and no operation should as a rule be
concluded until it is clearly made out that the ducts,
including the hepatic and common, are quite free from
concretions, otherwise disappointment and dissatisfaction
are certain to follow.
Arguing from some hundreds of cases of cholelithiasis
on which I have operated, I find that the common bile-
duct has to be attacked in one out of every five or six
cases.
In a few cases, concretions may be manipulated back-
wards into the gall-bladder, and thence extracted by
scoop or forceps, but this can only be done when the
cystic duct is dilated. I have been able to clear the
ducts in this way on ten occasions. Occasionally a small
stone may be pressed into the duodenum, but this is
exceptional and inadvisable, as it may be pushed into the
diverticulum of Vater and so be missed, and the whole
operation rendered futile. In patients too old or too ill
to bear choledochotomy, a rapid cholecystotomy may be
performed, so as to relieve the jaundice and allow solvent
injections to be employed ; but my experience of this
treatment has not been so favourable as to make me very
hopeful of accomplishing the solution or the diminution
to the passing point of the concretion deliberately left
behind, and a subsequent operation is usually necessary.
Crushing concretions by means of pressure by the
finger and thumb through the duct walls is a method I
formerly employed in over thirty cases with considerable
success and without fatality, but it is only available for
soft concretions, and fragments are apt to be left and then
IN THE COMMON BILE-DUCT BY CONCRETIONS 95
to produce further trouble. I have not once adopted this
method during the past two years unless I could at the
same time remove the fragments.
Cholecystenterostomy or short-circuiting the obstruc-
tion should never be performed for gall-stones, as it leaves
the cause untouched, and the small opening is apt to con-
tract and lead to speedy recurrence of the symptoms.
This has actually occurred in my own practice, and in that
of other surgeons. Out of nearly thirty cholecysten-
terostomies that I have performed, I have only done it on
ten occasions for gall-stones, and not once during the past
two years.
If the patient be too ill for choledochotomy, the gall-
bladder can be very rapidly united to the colon with very
little disturbance of adhesions, and this as a means of
giving relief answers quite as well as the more difficult
operation of uniting the gall-bladder and duodenum : this
operation is, however, only applicable when the gall-
bladder is dilated, which is unusual in cholelithiasis.
The operation of uniting a dilated duct to the intestine
or draining a dilated duct on to the surface may be
occasionally called for, and I have twice done the former
and once the latter operation, in all the cases followed by
recovery.
Reaching the common duct through the opened duo-
denum, a modification of choledochotomy seemed to me,
when it was first suggested by Dr. McBurney, an easy and
ideal operation, and at that time it was easier than
ordinary choledochotomy ; but I feel sure that there is a
greater danger of sepsis by this method owing to the
necessary enterotomy, and since I have adopted my
modification of choledochotomy I have not repeated the
operation through the duodenum, since I am quite clear
that it is not only more difficult and more dangerous, but
that it does not afford so great a facility in clearing the
whole of the ducts of concretions. I have performed it
eleven times with three fatalities, which compares unfa-
vourably with the ordinary operation of choledochotomy.
96 THE SURGICAL TREATMENT OF OBSTRUCTION
Lastly, and most important, we come to the ideal
operation for the removal of stones from the common
duct, choledochotomy, which, after experience of all
other methods in vogue for the removal of gall-stones
from the common duct, I have come to the conclusion is
the only one to be relied on, and as an operation is there-
fore worthy of special study.
Moreover, as the result of my experience in sixty
cases, I have been able to modify the operation in such
a way, that what was formerly a most difficult procedure,
involving prolonged manipulation, special appliances, and
at least two assistants, and only to be undertaken after
all other means had failed, is now a comparatively simple
operation in the greater number of cases, only requiring
the help of one assistant and not requiring the use of
any special apparatus.
By this method the time involved in the operation is
reduced considerably, and where adhesions do not give
unusual trouble it is easy to complete the work in from
thirty to forty minutes, which not only means a saving
of time and fatigue to the operator, but a considerable
saving of shock to the patient.
I always employ a firm sand-bag under the back oppo-
site the liver, which not only pushes the spine and with
it the common duct forward, so that it is several inches
nearer the surface, but acts like the Trendelenberg posi-
tion in pelvic surgery by letting the viscera fall away
from the field of operation. I then make a vertical
incision over the middle of the right rectus, the fibres
of which are separated by the finger, which I find to be
the most expeditious and the most effective method of
exposing the gall-bladder and bile-ducts ; but when it is
necessary to open either the common duct or the deeper
part of the cystic duct, instead of prolonging the in-
cision downwards as was formerly done, I now carry it
upwards in the interval between the ensiform cartilage
and the right costal margin as high as possible, thus ex-
posing the upper surface of the liver very freely. It
IN THE COMMON BILE-DUCT BY CONCRETIONS ' 97
will now be found that by lifting the lower border of
the liver in bulk (if needful, first drawing the organ
downwards from under cover of the ribs), the whole
of the gall-bladder and the cystic and common ducts
are brought quite close to the surface, and as the gall-
bladder IS usually strong enough to bear traction, the
assistant can take hold of it by fingers or forceps, and
by gentle traction can keep the parts well exposed, at
the same time that, by means of his left hand with a flat
sponge under it, he retracts the left side of the wound
;ind the viscera, which would otherwise fall over the
common duct and impede the view.
It will now be observed that instead of the gall-
bladder and cystic duct making a considerable angle
with the common duct, an almost straight passage is
found from the opening in the gall-bladder to the entrance
of the bile-duct into the duodenum, and if adhesions
have been thoroughly separated as they should always
be, the surgeon has immediately under his eye the whole
length of the ducts with the head of the pancreas and
the duodenum. So complete is the exposure, that if
needful the peritoneum can be incised and the common
duct separated from the structures in the free border of
the lesser omentum ; but this is not necessary except
where a growth has to be excised.
The surgeon, whose hands are both free, can now
with his left finger and thumb so manipulate the common
duct as to render prominent any concretions, which can
be directly cut down on, the edges of the opening in the
duct being caught by pressure forceps.
The assistant can now take hold of the forceps with
his left hand, as they with the sponge will form suffi-
cient retractor, since the duct is so near the surface.
When the duct is incised there is usually a free flow
of bile, which it must be remembered is probably infec-
tive; but a sponge in the kidney pouch, and rapidly mop-
ping up the bile as it flows, by means of sterilised gauze
pads, avoids any soiling of the surrounding parts, and if
VOL. LXXXV. 7
98 THE SURGICAL TREATMENT OP OBSTRUCTION
thought necessary the bulk of the infected bile can be
drawn ofE by the aspirator, either from the gall-bladder
or from tlie common duct above the obstruction, before
the incision into the duct is made.
After removing all obvious concretions, the fingers
are passed behind the duodenum and along the course
of the hepatic ducts, to feel if other gall-stones are
hidden there, and a gall-stone scoop, the only special
instrument I use, is passed quite up into the primary
division of the hepatic duct in the liver, and quite dovsrn
to the duodenal orifice of the common bile-duct ; and if
thought necessary to insure the opening into the duo-
denum being patent, a long probe is passed into the bowel.
The incision into the bile-duct is now closed by an
ordinary curved round needle held in the fingers with-
out any needle-holder, a continuous catgut suture being
used for the margins of the duct proper, and a con-
tinuous fine chromic catgut or spun celluloid thread being
employed to close the peritoneal edges of the duct.
In some cases, v\^here the pancreas is indurated and
swollen from chronic pancreatitis, and likely to exert
pressure on the common duct for a time, I insert a
drainage-tube directly into the duct and close the open-
ing around it by a purse-string suture, the tube being
fixed into the opening by a catgut stitch which will
hold for about a week ; but where this is not done I
usually fix a drainage-tube into the fundus of the gall-
bladder in the same way, as this drains away all infected
bile and avoids pressure on the newly sutured opening in
the duct.
So easy is it to remove impacted stones after this
method of exposure that I now never spend much time in
manipulating stones impacted even in the cystic duct,
but at once incise the duct, remove the concretions, and
close the opening, without damaging the duct by much
pressure and prolonged manipulation.
Although there is seldom any fear of leakage or of
infection, yet, owing to the separation of extensive adhe-
IN THE COMMON BILE-DUCT BY CONCRETIONS 99
sions, there is usually some tendency to pouring out of
fluid in the first twenty- four hours. I therefore gene-
rally insert a gauze drain through a split drainage-tube,
bringing it out either through a stab wound in the loin
or forwards by the side of the gall-bladder drain.
The wound is closed in the usual way by continuous
catgut sutures, first to peritoneum and deep rectus
sheath, next to the anterior rectus sheath, and lastly
to skin.
To those having little experience in this operation,
the modifications I have employed may seem trivial, but
to those who have experienced the difficulties of the
ordinary operation I feel sure the method I have de-
scribed, which enables the whole of the bile passages to
be dealt with as a straight tube close to the surface, will
be sufficiently appreciated.
But the technique of the operation is not the only
important part of the treatment of these serious cases,
which require thought and care not only before and at
the time of, but subsequent to operation.
A careful study of the causes of mortality in opera-
tions on the common duct shows that haBmorrhage, either
immediate, consecutive, or secondary, cannot be ignored
as a danger, and that shock, apart from hasmorrhage,
has next to claim our attention.
Sepsis is no longer the bugbear that it used to be,
thanks to a rigid all-round asepsis, the employment of
gauze drainage, and the careful avoidance of soiling the
wound by infected bile.
Although there is a greater tendency to bleeding in
chronic jaundice from pancreatic disease than when
jaundice is due to gall-stone obstruction, I think there
can be no doubt that in all cholaemic conditions the
blood becomes so altered that the coagulability becomes
seriously diminished, and that these factors demand
fierious attention before any operation is undertaken in
cases of common duct cholelithiasis. After reading
Professor Wright's researches on the coagulability of
100 THE SURGICAL TREATMENT OF OBSTRUCTION
tlie blood, published in the ' Brit. Med. Journ.^ for
December 19tli, 1891, my mind was prepared to grasp
the possibility of turning the experience gained on dogs
to practical uses in the human subject, as I had lost two
jaundiced patients, one in 1888 and one in 1890, from
persistent oozing of blood subsequent to operation. I
therefore at once began to employ it in these cases, and
with benefit ; but it has been only within the last two
years, since using chloride of calcium in apparently
heroic doses, that I have been able to get at the real
value of the drug, which I now always employ in
jaundiced patients, both before operation in thirty -grain
doses by the mouth, and afterwards in i'ixty-grain doses
by the rectum thrice daily for several days.
The following case, reported by Dr. W. Gough,
affords a good example of its utility.
Mrs. M. E. G — , aged 88, was admitted to the Leeds
General Infirmary on January 23rd, 1901.
History, — She had had typhoid fever in September,
1899, and had never been quite well since. Shortly after-
wards she began to suffer from biliary colic, though she
had never been jaundiced till six months before admis-
sion, from which time jaundice had never left her. On
December 24th, 1900, she became much worse, and had
very severe paroxysmal pain, accompanied by shivering
and profuse sweats. From that time she lost weight
very rapidly and the jaundice deepened. On admission
the liver could be felt below the ribs, and there was a
distinct fulness on deep palpation in the region of the
pancreas. From January 21st to 31st she took calcium
chloride in twenty-grain doses thrice daily.
Duodeno-choledochotomy was performed on January
31st. There was very little bleeding. A stone nearly
as large as a pigeon^s egg was removed from the ampulla
of Vater, which was laid open over a director, introduced
through the papilla at its opening into the duodenum.
The head of the pancreas was felt to be much enlarged
and hard. The incision into the ampulla was not
IN THE COMMON BILE-DUCT BY CONGESTIONS 101
sutured, but through it the common bile-duct, very much
dilated, was explored by the finger. The anterior wound
in the duodenum was then sutured and the abdominal
wound closed. A drainage-tube was inserted through a
stab wound in the right loin. The patient, inadvertently,
did not have calcium chloride given in the nutrient
enernata, as is usual in these cases.
After history. — She did well till the morning of
February 2nd, when the nurse noticed at 3 a.m. that
the dressings were soaked with bright blood. The
drainage wound was exposed, but no haemorrhage was
occurrfng there. On examining the abdominal incision
blood was seen to be slowly oozing from it and the stitch
punctures. One drachm of calcium chloride was at once
administered by the mouth, and three stitches were
removed ; the surface of the wound was then seen to be
oozing all over. It was packed with gauze soaked in
tincture of hamamelis, and a firm dressing applied.
One drachm of calcium chloride was given again in two
hours, and afterwards repeated in thirty-grain doses
every two hours for six times, it being then given thrice
daily. There was no recurrence of haemorrhage, and the
patient made an uninterrupted recovery. The drainage-
tube was removed on February 4th, and she returned
home within the month. An examination of the blood
showed a very marked diminution in the blood-plates.
I think it is important to ligature all bleeding points,
and not to trust simply to forcipressure i and while in
non-jaundiced patients adhesions may be simpljj- sepa-
rated, in these cases I prefer to divide adhesions between
ligatures where practicable.
Where there is persistent oozing of blood from
innumerable points, a tampon of sterilised gauze forms a
useful means of haemostasis, and this may be made more
efficient by employing at the same time a solution of
supra-renal extract to the bleeding surfaces.
The best treatment- of shock is preventive, and to that
end it is desirable to lose as little blood as possible,
102 THE SURGICAL TREATMENT OF OBSTRUCTION
though I do not agree with those who assert that shock
in operation is always dependent on loss of blood. The
patient is enveloped in a roughly made suit of gamgee
tissue, and where he is very feeble, or the operation is
likely to be prolonged, it is performed on a heated
table. A large enema of normal saline solution,
with or without stimulant, given fifteen to twenty
minutes before, and the administration of ten minims
of Liq. Strychniae subcutaneously just before com-
mencing anaesthesia, are useful. Expedition in operat-
ing is an important factor in lessening shock, espe-
cially in abdominal surgery, for it stands to reason
that prolonged manipulation and exposure of the viscera
in patients so ill as the class of cases we are now con-
sidering must generally be, will be badly borne ; for it is
not only the work of the surgeon but the deep anaesthesia
that adds to the shock, since, for choledochotomy to be
well and expeditiously performed, the muscles must be
well relaxed. Choledochotomy should occupy from half
an hour to an hour, and in case of unusual complications
a little longer ; but it seems to me that the surgeon who
spends two, three, or four hours over one operation is
either lacking in skill or judgment.
After operation, a pint of saline fluid, with one ounce
of brandy, is given by enema, and five minims of Liq.
Strychniae are given subcutaneously every two hours for
several hours if called for. Subcutaneous injections
of saline fluid or intra-venous infusion are only rarely
required.
As I have performed the operation of choledochotomy
for the removal of gall-stones from the common duct on
sixty occasions, it would be too tedious to read even a
short abstract of them all; I shall therefore refer those
who wish for more detail to the second edition of mv
book on ^ Diseases of the Gall-bladder and Bile-ducts/
where an account is given of all my cases, twenty-eight
in number, operated on up to December 31st, 1899, and to
IN THE COMMON BILE-DUCT BY CONCRETIONS 103
the list of cases, thirty-two in number, operated on since
January 1st, 1900, copies of which I hand round.
It is interesting to note that the mortality of the whole
series of sixty choledochotomies is 16*6 per cent., or,
excluding the duodeno-choledochotomies, 14*2 per cent. ;
but, while those operated on before 1900 give a rate of
23*8 per cent., those since January 1st, 1900, show only
7-1 per cent, of deaths, and of the two fatal cases, one
was from heart disease and the other from . pulmonary
congestion and shock, both deaths, I believe, being
essentially due to ether anaesthesia, the ether having
been given by means of the old apparatus with an
india-rubber bag, a method which I have discarded on
account of its asphyxial tendency and its want of
cleanliness.
I think, therefore, it is quite reasonable to assume
that, with due precautions, the mortality of the opera-
tion of choledochotomy should be reduced to 5 per cent,
or under.
P.S., March 21st, 1902. — Since handing my paper to the
Secretary I have had eight additional cases of choledocho-
tomy, all of which have recovered. It may interest the
Fellows of the Society to note that the final paragraph of
the paper was a forecast. Fortunately the unavoidable
postponement of the communication has enabled me to
prove that a 5 per cent, mortality was a reasonable esti-
mate, for it will be seen that of the cases — twenty-one in
number — operated on since July of last year all have
recovered ; and that including all my cases of choledocho-
tomy since January, 1900, there has only been a mortality
of 5'5 per cent.
104
THE SURGICAL TREATMENT OP OBSTRUCTION
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110 THE SURGICAL TREATMENT OF OBSTRUCTION
DISCUSSION
Sir Dycb Duckworth. — Although Mr. Robson's communica-
tion was mainly of surgical interest, there were some points in
it of interest to physicians. He would first remark that
physicians gladly recognised the importance of surgical treat-
ment for biliary calculi, and especially because no method of
medication was really known to be efficient in causing the
expulsion of these concretions. The important matter for the
physician here was an accurate diagnosis. It was found that
many cases of biliary colic occurred where the physical signs
were of little aid to the diagnosis. Symptoms of pains, rigors,
and vomiting were met with in the absence of signs of obstruc-
tion, and such were apt to recur from time to time, all indicating
the presence of calculi or grit in the gall-bladder, hepatic or
cystic ducts. The liver might, or might not be palpable, and
the fundus of the gall-bladder was seldom detectable. Such
cases commonly demanded operative interference, and evacuation
of the gall-bladder generally proved lastingly curative of all the
untoward symptoms. The diagnosis between impacted calculus
in the common bile-duct and obstruction by new growth in^the
duct on the head of the pancreas was often of extreme difficulty,
wasting being common to both conditions with chronic jaundice.
Simple biliary colic was generally unattended by pyrexia, and so
was occlusion of the cystic or common duct for the first few
days. Subsequently, febrile symptoms were apt to supervene,
and some inflammatory change in the gall-bladder or ducts was
then to be suspected. Operation was called for in such cases,
and not seldom pus was met with in the gall-bladder or ducts,
together with calculi. It would be wrong nowadays to delay
interference in such cases. No doubt many persons lived for
years with many calculi lodged in the gall-bladder, but there
was always a risk of biliary colic, or of the onset of malignant
disease in the coats of the gall-bladder, or the ducts, as
advancing years progressed, from their prolonged irritation. It
was commoner to meet with gall-stones in persons of the
arthritic habit with gouty inheritance, and by diet and other
measures their formation might be prevented. Physicians now
gladly sought the assistance of surgeons in most of these cases,
and fully appreciated the skill brought to bear with so much
success in the removal of biliary calculi. Each case, however,
demanded special attention, and not every case was suitable for,
or required, surgical interference.
Mr. GoDLEE, after congratulating Mr. Mayo Eobson on the
large number of successes, and remarking on the very large
IN THE COMMON BILE-DUCT BY CONCRETIONS 111
number of cases that came under his care, expressed his regret
that the author of the paper was unable to be present, as he
would have liked to put some questions to him. In the first
place he would have been glad to know what length of incision
was found necessary in order to pull down and forward the liver
to such an extent as to bring the cystic duct and the common
bile-duct into one straight line. He showed that the incision
proposed was a combination of that which was common in the
early days of this department of surgery, and that which had
been more frequently used of recent years. The plan of putting
a large sand- bag under the spine was one the advantages of which
he could bear witness to. He desired in the next place to inquire
whether Mr. Mayo Eobson considered that it was equally good
in all cases requiring anastomosis to join the gall-bladder to
the colon or to join it to the duodenum ; it was difficult to accept
this position, as the uses of the bile in intestinal digestion would
then be only to a small extent available. He also would have
liked to know in what proportion of the cases which were
jaundiced at the time of the operation the characteristic
haemorrhage occurred, and also what proportion of them were
receiving the heroic doses of chloride of calcium. He had met
with four cases of this bleeding, one a case of gall-stones
complicated with carcinoma of the hepatic ducts in which
bleeding occurred several days after the operation, and continued
for the several weeks which intervened before the patient's
death. In this case no chloride of calcium had been given. In
another case of carcinoma, chloride of calcium had been given
before the operation, which consisted only in an exploratory
incision, but bleeding began as soon as the patient was put to
bed after the operation. A third case will be reported shortly
to the Society in which jaundice was due to an obstruction to
the common duct, and in which cholecyst-duodenostomy was
performed after giving large doses of the drug. Bleeding
occurred a few days after the operation, but ceased as the
jaundice subsided. A fourth case was one of very chronic
jaundice due to a large stone impacted in the ampulla of Vater.
Chloride of calcium had been given freely, but the bleeding
occurred within a few days of the operation. The drug had
not, however, been given by enema after the operation, as Mr.
Eobson recommends. Finally he would have liked to hear
what Mr. Eobson would do in a case where numerous small
stones occupied the hepatic ducts. In such a case it would be
impossible to be certain that all had been extracted by the
scoop, and it would, no doubt, be safer to drain the duct for some
time. Mr. Godlee emphasised the importance of the assertion
that the contents of the common bile-duct in which stones have
been long impacted are usually septic, and pointed out that the
introduction of the scoop into the duodenum would necessarily
112 THE SURGICAL TKEATMENT OF OBSTRUCTION
introduce some of the intestinal contents into the wound. He
also ix)inted out how readilv the duodenal contents made their
way back into the common duct after it was opened, and illus-
trated this hy a case in which a large gall-stone had made its
way by ulceration into the duodenum and become impacted in
the ileum; about twenty grape-sldns occupied the indurated
and shrivelled gall-bladder.
Mr. G-odlee replied that he had given 40-grain doses four
times a day, but he had l>een rather disappointed with the
results. He pointed out that one cause for the subsidence of
the bleeding might be the disappearance of the jaundice due to
the operation. This occurs in all cases except those of cancer,
in which, moreover, another cause of the tendency to bleed
might be the presence of the cancer itself.
Dr. J. H. Keat said that, while highly appreciating the im-
proved methods of surgery by which the mortality from operation
for the removal of stones from the common bile-duct had been
so greatly lessened, he could not agree with Mayo Robson in
almost entirely ignoring the effect of medical treatment. There
could be no doubt that, whether owing to medical treatment or
the vis medicatrix natuvie, there were manv who suffered from
impacted stones who made an excellent recovery without opera-
tion. He spoke from personal experience. After many attacks
of severe biliary colic he at length became jaundiced through
occlusion of the common duct, and was just about to undergo
operation when he passed several stones, and now, for years
past, he had not suffered from gall-stones in any form. He
referred to those cases, well known to medical men, where the
symptoms were obscure, and were often regarded as pointing to
malignant disease, and yet the patients, either through the
direct passage of the stones through the duct or their indirect
passage into the intestines, got rid of mU pain and jaundice, and
continued to live in robust health. It was quite true that little
could be expected from remedies given for the solution of stones
unless in those cases where the stone was protruding into the
duodenum, but there was no reason to doubt that by medical
and hygienic treatment the quality of the bile could be so
altered as to relieve spasm of the duct. He would have liked
to ask Mayo Robson how long one might suffer from jaundice
before resorting to operation. The answer to this question
must of course depend on whether there was greater risk in
submitting to operation or in waiting for a possibly favourable
issue. He noted in the appendix to Mayo Robson's paper that
the condition of the patieot was given a year or a year and a
half after operation. This was not sufficient. He had recently
under his care a patient on whom cliolecystotomy had been
performed in 1895, and cholecystectomy in 1897, and on both
occasions she was discharged from the hospital as cured. She
IN THE COMMON BILE-DUCT BY CONCRETIONS 113
has since suffered almost as much as before operation, and on
one or two occasions been almost in articulo mortis. Medical
men in general practice had greater opportunities of following
the life-history of a patient than those attached to hospitals or
in consulting practice, and could not help observing how often
the power of resisting and overcoming disease was lowered in
those who had undergone major operations. In some cases of
obstruction of the common duct operation was certainly advis-
able. It could not, however, be regarded as a radical cure. If
there was a tendency to gall-stones, their removal bv the knife
did not preclude others being formed.
Dr. H. A. Caley remarked, with reference to the use of
calcium chloride as a haemostatic, that, had Mr. Mayo Eobson
been present, he would have inquired as to the reasons which
had led him to prescribe it in such much larger doses than
formerly. The author of the paper had referred to Prof.
Wright's experiments on the effect of calcium chloride in
increasing the coagulability of the blood, but the amount of the
salt given by him was considerably larger than that originally
suggested by Prof. Wright, who had indicated that to overstep
a certain limit of dosage might have the opposite effect of again
reducing coagulability. This question as to the amount requisite
to produce the maximum degree of coagulability in conditions
such as those referred to in the paper had an important bearing
on its employment in heemorrhagic conditions generally.
Mr. Butler-Smythi5 thought it was a matter for regret that
so valuable a contribution to the surgery of gall-stones should
have been brought before the Society at a time when so many
surgeolis who were interested in this subject were absent from
town. He, too, wished Mr. Mayo Eobson had been present, for
there were some questions he would have wished to ask him.
He could not imagine anything more difficult or disagreeable
than to criticise a paper or to enter into a discussion in the
absence of the author. However, there were one or two matters
relating to the technique of the operation which seemed to him
to call for remarks. As regards the incisions, no mention was
made as to the extent of the vertical one, and to his mind an
author, bringing before a society a modification of any surgical
procedure, could not be too exact in explaining the details. He
agreed that the oblique incision, when carried out, would find
more room, but he would like to say that he had frequently seen
the cx)mmon duct well exposed by a 5-inch vertical incision
outside the rectus muscle. Then with regard to the amount of
Liq. Strychninse administered, he would like to know if Mr. Mayo
Eobson carried out this method as a general routine, or only in
exceptional cases. Knowing how different individuals were
more or less susceptible to that drug, and also that it was
a cumulative poison, he thought the doses given were, to say the
VOL. LXXXV. 8
114 THE 8UKGICAL TREATMENT OF OBSTRUCTION
■
least, heroic. In his practice he had lately seen a fatal issue,
with all the symptoms of strychnia poisoning, following the
subcutaneous injection of that drug in ten-minim doses, thrice
repeated within three hours. He would like to have the
opinion of some of the physicians present as to the quantity
of Liq. Strychninse that might safely be injected in repeated
doses.
Mr. Herbert Paterson thought that the most remarkable
feature in Mr. Mayo Bobson's brilliant series of cases was the
striking freedom from sepsis and consequent low mortality.
From what he had seen, sepsis was by far the commonest cause
of death in these operations. With regard to cholecystenteros-
tomy, it was interesting to recollect that the first case in this
country was brought before this Society by Mr. Mayo Eobson,
and he believed that he was right in saying that it was our
present President who was the first to suggest the performance
of this operation in cases of gall-stones, as an alternative to
leaving the patient with the discomfort and inconvenience of a
permanent biliary fistula. He was of the opinion that further
evidence was required as to the value of calcium chloride in
diminishing or arresting haemorrhage, and it did not seem clear
that the case quoted by Mr. Robson was evidence of the value
of this treatment. For notwithstanding that the patient had had
calcium chloride before operation, there was bleeding from the
wound. The wound was packed with gauze soaked in Tr.
Hamamelis, and the bleeding ceased. Surely the stoppage of
the bleeding was due to the haemostatic action of the hama-
melis, rather than to the subsequent administration of calcium
chloride. He thought it was scarcely fair to attribute the* vague
symptoms comprised in the term general debility to an operation
performed many years before, as had been suggested by one of
the speakers. It was within the experience of all how ready
patients were to find some cause, often clearly an erroneous one,
for all their ailments, and their morbid minds eagerly grasped
at a previous operation, however long ago performed, as furnish-
ing uiefons et origo of any real or imaginary indisposition. As
to the administration of large doses of strychnine, he had given
as much as forty minims subcutaneously within four hours with
a successful result. .
He ventured to disagree with the opinion expressed by Mr.
Robson that deep anaesthesia added to the shock of the operation,
for ho was convinced that the shock produced by the operation
was inversely proportional to the depth of the anaesthesia ; the
lighter the anaesthesia the greater the shock ; the more profound
the narcosis, the less was the patient affected by the manipula-
tions of the operator. He was very glad that Mr. Eobson had
spoken unfavourably of ether as an anaesthetic in these cases.
Personally, he was most strongly against the use of ether in any
IN THE COMMON BILE-DUCT BY CONCRETIONS 115
abdominal operation, and it was his firm belief that in these severe
and prolonged operations the use of ether greatly militated
against a favourable result ; indeed, from his own experience he
believed that in such cases it increased the mortality as much as
5 per cent.
The President desired to associate Limself with the ex-
pressions of deep regret at Mr. Mayo Eobson's absence;
obviously it rendered the discussion much less thorough and
complete. He would have liked to ask Mr. Mayo Robson one
or two questions. It would be instructive to learn in what
number or proportion of cases of obstruction in the common
duct had the diagnosis of concretions in that duct, previously
made, proved to be well founded. Again, was jaundice due to
this cause as frequent as jaundice due to new growth or other
external cause ? Did Mr. Mayo Robson's experience lead him
to attach importance to any one or more symptoms as indicative
of obstruction by concretions ? From his own experience he*
could confirm the author's observation of tbe alteration in
direction and relation to each other of the cystic and common
ducts in these cases of concretion in the common duct producing
obstruction.
Author's remarks on paper read in his a^hsence, from abstracts of
the discussion kindly furnished by the Secretary of the
Society.
Mr. Mato Robson wished first to apologise for his unavoidable
absence from the meeting when his paper was read, the reason
being that he was detained in the south of Europe by an opera-
tion that could not be deferred.
Sir Dyce Duckworth's remarks on diagnosis and treatment
entirely coincided with the author's views, and although the
paper was essentially surgical, he fully grasped the fact that all
these cases were to begin with purely medical, and only surgical
after the diagnosis had been reasonably established and general
treatment had failed to bring about reUef .
Mr. Rickman J. Godlee had asked as to the length of
incision ; it was a modification of the vertical incision that the
author had been employing for several years, the incision being
extended upwards over the liver, if necessary, quite up to the
angle between the right costal margin and the ensif orm cartilage,
the length of this extension depending mainly on the size of the
liver, the incision being also a little nearer the mid-line, so as to
obtain the extension by splitting rather than dividing the fibres
of the rectus, except a little obliquely towards the upper end.
The average length of the incision would be about five inches
116 THE SURaiCAL TREATMENT OP OBSTRUCTION
but this might be exceeded, if necessary, without any weakening
of the abdominal wall if the anterior and posterior sheath of the
rectus were sutured separately. The author had done it through
a four-inch incision, but did not hesitate to extend the incision
to whatever extent necessary to draw forward the anterior
border of the liver.
As to the question of draining the gall-bladder into the bowel,
if the patient be in a condition to bear exposure of the duodenum
to the extent necessarv to effect the anastomosis, the common duct
will be efficiently exposed by the operation now described, and
can be readily cleared ; but if the patient be in a very poor con-
dition the author finds by experience that an anastomosis
between the gall-bladder and colon, which can be effected in a
few minutes with very little exposure of viscera, is quite efficient
in giving relief, and in fact his first case of cholecystenteros-
tomy, in 1888, was a gall-bladder-colic anastomosis, and the
patient is now in good health ; so much, therefore, for the diges-
tive use of the bile. For the control of haemorrhage in deeply
jaundiced cases by chloride of calcium it must be given by
enema in 60- gr. doses subsequent to operation until the blood
has clotted in the divided vessels. As to the question of clearing
the hepatic duct, by the method he had described the hepatic duct
quite up to the liver was fully exposed, and could be freely
manipulated. Through the opening in the common duct the
author had passed his finger up to the division of the hepatic
duct, and had been able to discover and remove concretions from
it by means of his gall-stone scoop. The passage of a probe
(not the scoop) into the duodenum, in order to prove the duct
clear, had not in the author's experience led to any untoward
result, though it must be accepted as a fact that the bile in any
case requiring choledochotomy is always infective.
Dr. J. H. Keay's views as to the utility of olive oil were so
fully answered by Sir Dyce Duckworth's very extensive experi-
ence of its uselessness, that it seems needless to further discuss
the question.
As to the subsequent history of cases operated on, if Dr.
Keay will refer to the second edition of the author's book on
* Diseases of the Gall-bladder and Bile-ducts ' he will see that
many of the cases are referred to years after as quite well ; but
the cases here brought forward to illustrate the operation
described are of course only comparatively recent, as the com-
plete operation, which is the " raison d'etre " of the paper, is of
quite recent date. A great number of the patients operated on
are private cases, and can easily be ref eiTed to, and many of them
are well known to the author to be now in excellent health, as one
would expect when the only cause of their illness has been
removed.
Mr. Mayo Robson wished to emphasise the fact that recurrence
IN THE COMMON BILE-DUCT BY CONCRETIONS 117
of gall-stones after operation in his experience is extremely un-
common, and almost unknown if the ducts have been thoroughly
cleared at the time of operation, though subsequent operations
may be necessary if the operation be incomplete, as it necessarily
was in some of the early cases. It is with this view of
making the operation absolutely complete and efficient that the
author has devised this radical operation.
Dr. H. A. Caley had asked as to the reason of giving large
doses of calcium chloride ; that had arisen as the result of
experience. In order to get the maximum effect the drug should
be given not longer than two or three days before operation, and
it was not necessary beyond two or three days subsequently, but
during that time it was desirable to have a sufficient amount of
the lime salt in the circulation, in order to increase the coagulat-
ing power of the blood.
In answer to Mr. A. C. Butler- Smy the, strychnia given sub-
cutaneously is, in the author's- experience, much less toxic than
when given by the mouth, and the speaker's remarks as to the
danger would not lead him to alter his practice in employing
it, as he had found the drug undoubtedly very useful.
In answer to Mr. Herbert Paterson, the author thought that
ether, if carefully administered, was a safer anaesthetic than
chloroform at the time of operating, but he entirely agreed with
the speaker that chloroform was a very comfortable anaesthetic
both for the patient and operator in abdominal operations if
skilfully given, and probably, looking to the after progress, in
many long and serious cases a safer all-round anaesthetic. He
felt the difficulty of proving the value of calcium chloride, and
its use in the case quoted is open to objection in that hamamelis
was used as well. Nevertheless the author's experience in a
large number of cases left no doubt on his mind that the drug
was of great value. He was glad that Mr. Paterson agreed
that it was scarcely fair to attribute the vagus symptoms com-
prised in the term general debility to an operation performed
many years before, as had been suggested by one of the
speakers.
In answer to the remarks of the President, Mr. Mayo Eobson
had seldom operated expressly for gall-stones and found malig-
nant disease to be the sole cause of the [jaundice; but in a
number of cases where the operation had been undertaken as
an exploratory procedure, and where cancer was suspected, gall-
stones or chronic pancreatitis had been discovered, and the
patient had been cured by the operation.
In a paper recently given before the Medical Society of
London, ** Observations on the Surgical Treatment of Obstruc-
tive Jaundice from an Experience of over 200 Cases," and
published in the 'British Medical Journal' for January 18th,
1902, the author had dealt at length on the diagnosis of the
118 TREATMENT OP OBSTRUCTION IN BILE-DUCT
causes of obstructive jaundice, and bad given his experience of
operations on 212 cases, out of which 60 were the subjects of
malignant disease, and 152 had suffered from gall-stones or
other non-malignant causes of obstruction.
A CONTRIBUTION
TO THE
STUDY OF TROPICAL ABSCESS OF
THE LIVEE
BY
KICKMAN J. aODLEE, M.S.
Received March 0th— Read May 13th, 1902
In the course of an experience of tropical abscess of
the liver, somewhat large for an English surgeon, though
ridiculously small as compared with that of those prac-
tising in the tropics, 1 have been led to think about the
disease and its complications, and trust that the follow-
ing contribution to its study may be, if disjointed, not
therefore without interest. Possibly it may elicit some
useful comment and criticism, and it is on this account
that the statements contained in it are somewhat dog-
matic. I will first deal with some of the complications.
Perihepatitis, usually perihepatic peritonitis, is an
almost invariable accompaniment of tropical abscess, and
must always exist to a greater or less extent when the
120 STUDY OF TROPICAL ABSCESS OP THE LIVER
abscess reaches the surface of the liver; but it is
astonishing how little there is in some cases even when
the matter has approached within perhaps half an inch
of the surface. If there be no adhesions the introduction
of an exploring trocar or an aspirator needle into the
liver will probably be immediately followed by the
escape of pus into the peritoneal cavity. Supposing the
needle has been introduced for the sake of discovering
the existence of an abscess, and the operation for its
evacuation be immediately proceeded with, there may yet
have been time for a quite considerable quantity of pus
to have escaped in the few minutes which have elapsed
before the peritoneum is reached. It is even possible to
mistake this free pus for the abscess itself. The further
exploration of the liver under these circumstances is
essential. But first the peritoneal cavity in the neigh-
bourhood of the puncture should be carefully sponged,
for although the pus may contain no other organism
than the Amoeba coli, and need not necessarily give rise
to septic peritonitis, there is no security that streptococci
or staphylococci or Bacterium coli commune may not be
present. It is scarcely possible under these circum-
stances to sew the liver up to the abdominal wall, as each
stitch will most likely enter the abscess cavity, and the
stitch holes will leak. It is safer, therefore, to pack
round the part where the incision is to be made before
the abscess is actually opened, and after the opening
has been made to manipulate the parts as gently as
possible.
Perihepatic peritonitis is the cause of the acute pain
that is often met with as distinguished from the typical
liver pains. This pain is of course superficial, and is accom-
panied by acute tenderness easily elicited by even light per-
cussion. Peritonitis occurs often in definite attacks, accom-
panied by fever and vomiting, and often yields a useful
physical sign, i, e, friction, which may be felt with the
hand and heard with the stethoscope over the liver.
It exercises a protective effect by shutting off the part
STUDY OF TROPICAL ABSCESS OP THE LIVER 121
into which an abscess is pointing, so that when rupture
occurs a subdiaphragmatic abscess results, and not a
general peritonitis.
As might be expected, peritonitis most commonly
affects the convex surface of the liver, which thus often
leads to the adhesion in whole or in part of this surface
of the liver to the diaphragm. When this has occurred
an enormous amount of pus may accumulate in the liver
without giving rise to any enlargement downwards, and
the enlargement upwards may only be indicated by partial
dulness in the lower part of the chest ; the dulness is least
marked when the lung is adherent to the pleura, because
the lung cannot then be displaced upwards by the
approximation of the diaphragm to the chest wall.
Perihepatic peritonitis may also occur on the under
surface of the liver, and may then give rise to very
serious results. The stomach, duodenum, and colon may
become firmly adherent to the liver, and after the abscess
has been evacuated the consequent contraction may lead
to considerable displacement of these viscera, giving rise
to such troubles as dilated stomach from kinking of the
duodenum. But it is a much more serious thing if the
transverse fissure and the small omentum have been the
seat of the peritonitis, for any one or all of the hepatic
ducts may be partially or completely obstructed.
I have recently seen with Dr. Manson a case which
bears out this statement.
A man aged 35, in the Civil Service, who had been in
India almost continuously since 1887, and had had some
pretty severe attacks of fever, began to have hepatic
troubles following dysentery in May, 1900. The special
points in his illness were that he had had several
attacks of acute pain and indigestion, accompanied with
high fever ; and that an unsuccessful attempt to open the
abscess through the chest wall in the lower axilla had
been made in Madras in May, 1901. It will be observed
that the history suggests a good deal of peritonitis. I
opened the abscess without difficulty through the old scar
122 STUDY OP TROPICAL ABSCESS OF THE LIVER
in July, 1901, and during convalescence, which was rather
tedious, there was from the first a ratlier large quantity
of bile in the discharge. This escape of bile is not
uncommon ; it indicates that a bile-duct of some size com-
municates with the abscess, and though it delays healing
seldom gives; rise to trouble. In this case, however, after
the abscess had contracted and pus had ceased to flow,
bile still came from a small opening in the scar. After
a while it nearly stopped ; but at the end of September,
after some abdominal pain, all the bile came through the
wound, and the stools became white. On November 7th
the flow of bile ceased, and the patient became intensely
jaundiced.
Knowing the danger from haemorrhage of operating on
a jaundiced patient, I passed probes into the wound and
fortunately re-established the flow of bile by this channel ;
and when the jaundice had diminished, and after the
administration of large doses of chloride of calcium, I
opened the abdomen on November 28th, and found the
matting together of the viscera I have described above.
It was quite hopeless to free the common bile-duct from
the dense surrounding adhesions, as I had hoped to do,
and so, as the gall-bladder, though not distended (because
the bile was escaping through the wound), contained bile,
I anastomosed it with the first part of the duodenum,
using a Robson^s bobbin. It was a diflBcult task. I
ought to have waited still longer, i, e. until the jaundice
had completely disappeared, for after a few days haemor-
rhage occurred in the wound, and to the consequent
stretching of the parts I attribute the partial giving way
of the junction, and the escape of bile and duodennl con-
tents through the abdominal wound for awhile. At last,
however, the leak stopped and the wounds healed, the
stools becoming of normal colour, and the patient^s health
soon re-establishing itself. I must add, however, that he
had an attack apparently of indigestion in January, 1902,
followed by the escape of bile for a few days from the
abdominal wound. But this has again closed, and at
STUDY OP TROPICAL ABSCESS OF THE LIVEK 123
present he is quite well. His condition for the next six
months will be watched with interest.
The escape of the tchole of the hlle through the loound
is fortunately not of common occurrence. I have never
before met with it in cases of tropical abscess, though I
have seen it in hydatid of the liver. It does not neces-
sarily lead to loss of appetite or difficulties in digestion,
but it sooner or later causes emaciation, which may become
extreme. I have seen bedsores form over the projecting
angles of the ribs and angles of the scapulae.
I am permitted by the kindness of my friends Dr.
Manson and Sir W. H. Bennett to mention the only other
two instances 1 have heard of in connection with tropical
abscess, and I would suggest that in fatal cases the same
condition as that which occurred in the one I have just
described will be met with. In Dr. Manson ^s case (Case 1)
the patient died after four months in a state of extreme
emaciation, though the fistula was apparently beginning
to close ; and in Sir William Bennett^s case the sinus
gradually closed after seven months, and the patient
made a complete recovery (Case 2).
In connection with this subject reference may be made
to cases, with which all will be familiar, where there is
complete obstruction to the common bile-duct, either
from calculus, tumour, or inflammatory adhesions. These
patients do not, as far as I have seen, emaciate ; on the
contrary, their nutrition may remain fair for years, and it
is quite remarkable how long the fatal event may be
delayed.
It has been shown by the beautiful observations of
Klein that the direction of the flow in the lymphatics of
the diaphragm is upwards. As might, therefore, have
been expected, pleurisy is a very common accompaniment
of tropical abscess. It is a useful diagnostic sign. It is
also a note of warning. Rupture into the pleura is in
my experience one of the most dangerous outcomes of
this disease. I could, if it were advisable, give more
124 STUDY OF TROPICAL ABSCESS OF THE LIVER
than one example of this catastrophe being followed by
the most extraordinarily rapid pleural effusion. In one,
indeed (Case 3), though I saw the patient within twenty-
four hours of the rupture of an abscess which had for so
many months remained dormant that its very existence
had been doubted, the patient appeared to be moribund,
and the pleura contained an enormous amount of fluid.
But even when the pleura is opened at once, if the
lung have not previously contracted adhesions to the
chest wall, it is not unlikely that it may collapse against
the spine and never expand again, and the most extensive
Estlander^s operations may fail to effect a cure.
The patient, therefore^ who has extensive 'pleural adhe-
sions is saved from very grave dangers.
It would often save trouble and anxiety if the presence
or absence of such adhesions could be determined. This
is, however, notoriously difficult and often impossible,
which is my excuse for mentioning two aids to diagnosis
which have not, I think, received sufficient attention.
1. The upper level of the dulness caused by a liver
which is enlarged upwards is, speaking generally, con-
siderably lowered when the patient is placed on his left
side. If, however, the lower part of the pleural sac is
obliterated by adhesions this does not occur, because the
lung cannot be sucked down into the pleural sinus by the
falling away of the liver — that falling away which so
frequently causes pain when the patient attempts to lie on
the left side.
2. In very thin people, even when the parts are
normal, I have pointed out (^ British Medical Journal,'
October 6th, 1900, p. 997) that it is often possible on
careful inspection to see the lower margin of the lung on
the right side move upward and downward on respiration.
It may sometimes be observed on the left side, especially
if the spleen be enlarged, or there be a great enlargement
of the left lobe of the liver, or, indeed, any tumour in this
situation ; and on the right side it is more obvious when
STUDY OF TROPICAL ABSCESS OF THE LIVER 125
the liver is enlarged than when it is of normal size.
This sign requires somewhat careful inspection for its
discovery, and is only of use in emaciated or very thin
subjects. If it be present it is a certain proof that there
are no adhesions in this situation, and that there is little
or no pleural effusion.
Whilst writing this paper I had under my care a
young woman in the last stage of emaciation from
advanced actinomycosis, in whom I was able to demon-
strate this phenomenon to spectators standing at some
little distance from the bed. It was in her visible on
both sides. It has been doubted by physiologists whether
on deep inspiration the lung ever reaches the bottom of
the pleural sinus. Careful observation of this patient
showed that on very deep inspiration the lower border
moved quite as far as the anatomical limit of the pleural
cavity.
Though not quite germane to the subject, it may not
be out of place to throw out the suggestion that when
the liver is much displaced downwards by a pleural effu-
sion, and there is no corresponding displacement of the
heart outwards, it is almost certain that the base of the
lung is not adherent to the diaphragm. Under these
circumstances it may be almost impossible to say whether
the fluid is above or below the diaphragm.
In connection with the question of adhesions I desire
to make a practical suggestion. If the incision for opening
the abscess has necessarily to pass through the pleura
below the lower border of the lung, it is often difficult or
impossible to tell whether the cavity is obliterated by
lymph or not. I have more than once cut down through
both layers of the pleura, and as no air entered, have gone
on to incise the diaphragm and liver. On withdrawing
the finger, however, the ominous sound made by air
rushing into the chest has shown that the two layers of
the pleura were at first only held together by the
attraction of cohesion or by very feeble adhesions, and a
laborious process of stitching up the hole had to be
126 STUDY OF TROPICAL ABSCESS OF THE LIVEK
undertaken. The right way to proceed, if there be any
doubt, is to cut through the diaphragm across its fibres at
the part nearest its costal attachment, and to sew up a
flap of the muscle to the intercostal muscles at the opposite
end of the wound. The incision into the abscess can then
be undertaken without fear of producing pneumothorax.
By adopting this precaution I do not expect to meet with
the above-mentioned accident again.
Pleurisy may lead to serous efEusion, or to empyema,
without any rupture of the liver abscess through the
diaphragm, and such an efEusion may keep up the tem-
perature after the successful evacuation of the hepatic
abscess.
I once opened a large tropical abscess on an Indian
army surgeon who was in an extremely exhausted condi-
tion. There remained some dulness in the back, and the
temperature did not fall to normal. The removal by
aspiration, several days later, of a few ounces of clear
fluid was immediately followed by disappearance of the
pyrexia, and from this time the patient made an uninter-
rupted recovery.
On another occasion, when the physical signs and
symptoms were almost the same, the fluid was pus, and an
equally good result followed the insertion of a drainage-
tube into the pleura.
A less successful result followed in the case of a young
officer whom I saw with Dr. Ringer, and whose abscess I
had opened in the lower axilla. Repeated attempts at
aspiration of the chest were unsuccessful, because there
was much recent lymph as well as fluid in the pleura.
In the hope of securing better drainage, I made a
second incision into the abscess behind, and in doing so
found that I had opened the pleura, and a considerable
quantity of clear fluid and large masses of lymph escaped.
Thinking that some of the pus from the abscess had pro-
bably entered the pleura, 1 therefore placed through this
second opening one tube into the abscess and one into the
STUDY OF TROPICAL ABSCESS OF THE LIVER 127
pleura, but I am sure it would have been better to have
sewn up the opening in the pleura, and to have left this
cavity for treatment later on ; for the recent pleural
adhesions gave way owing to the violent coughing of the
patient, the lung collapsed, and a general pneumothorax
was produced. The case was a very septic one, and a
fatal result was probably inevitable ; but I think it was
hastened by the pleural complication.
I said that the existence of friction was an ominous
sign, for although rupture into the lung, as every one
knows, often leads to a rapid cure of the disease, no one
who has seen the disastrous results that may ensue would
dream of waiting for it to occur. Wlifn there in marked
pleural friction, therefore, exploration of the liver should he
made withotU delay.
I am thus led to the next part of my subject.
Changes that take jdace in the lungs, — It is obvious that
in every case in which an abscess bursts into the lung a
certain amount of lung tissue must be destroyed, and an
abscess of greater or smaller extent must be formed. In
those which recover in a short time this is a negligible
quantity. But it is often far otherwise. The next most
favourable cases are those in which a small abscess forms
in the lower part of the lung either in front or behind.
Most commonly the signs of cavity will be met with below
and to the inner side of the right nipple ; but the cavity
not infrequently occurs behind, and in rarer cases a liver
abscess bursts into the left lung and forms a cavity there.
At the end of the paper will be found an account of cases
illustrating each of these conditions (Cases 4, 5, and 6).
If such abscesses are opened as soon as they are dis-
covered it is probable that they will heal readily. But, if
operation is delayed, a series of phenomena may occur that
are not unlikely to give rise to a very chronic condition
which may end fatally. These abscesses do not behave
like those resulting from pneumonia, injury, or tubercle,
but have a peculiar tendency to burrow by means of long
128 STUDY OP TROPICAL ABSCESS OP THE LIVER
and intricate tubular processes which are very difficult to
follow up and drain, and may lead to the gradual destruc-
tion of large areas of lung tissue. I have seen one lobe
almost completely disorganised in the course of an illness
extending over many months (Case 7). The suppurat-
ing tracks are sometimes in the lung itself, sometimes
partly in the lung and partly in the pleura. The pus
discharged from them has the characters which we are
accustomed to associate with liver pus, — that is, it is
inodorous, thick, slimy, and chocolate- coloured, and may
contain the Amoeha coli, so that I am inclined to believe
that the peculiarity of the process depends upon the
presence of this parasite. In these cases haemorrhage is a
common symptom ; it is often frequent and severe, and
occasionally fatal (Case 8). The continued discharge of
what has been recognised as liver pus has led to the as-
sumption that the abscess of the liver is still unhealed ; but
this is certainly not always the case, for I have met with
an instance in which the patient, a young man from an un-
healthy Indian tea-garden, died of haemorrhage, and at the
post-mortem examination so little trace of the liver abscess
remained that the medical man who made the necropsy
stated that there never had been an abscess of the liver at
all. This, however, I knew to be incorrect, for I had had
my finger in the patient^ s liver, and the observation did
not surprise me, for I have been struck with the complete
way in which all traces of a liver abscess even of large size
may disappear (Case 8). This is surely a not unimportant
fact in making a prognosis, and accounts for the com-
pleteness of the cure if recovery takes place. It is also
interesting to note that if a secondary abscess forms in
the left lung, as a result of the inspiration of matter
from the opposite side, the pus formed in it may be
slimy and chocolate-coloured like that which came from
the original abscess (Case 9). I do not mean to say
that chocolate-coloured pus may not come from a primary
abscess of the lung ; it may do so, but physicians will agree
that this is a most exceptional occurrence. It may he
STUDY OP TROPICAL ABSCESS OP THE LIVER 129
Safely stated that the persistent discharge of chocolate-
coloured pus does not prove that the liver abscess is not
healed.
Another danger to which a patient with an imperfectly
drained abscess of the lung is exposed is abscess of the
brain. I have met with two such cases following tropical
abscess (Cases 9 and 10). In one I opened the abscess
myself, and in the other I directed the operation; both
ended fatally.
The practical deduction from what has been stated
is that pulmonary abscess consequent on hepatic abscess
should be opened without delay, and that a careful search
should be made for outlying suppurating tracks; that
these should be drained by the insertion of full-sized
tubes, and, as far as possible, laid freely open, even if
this should necessitate extensive removal of ribs; and,
finally, that the tubes should not be removed or shortened
until the surgeon is satisfied that closure of the abscess is
almost complete.
Dr. Manson, with whom I have been associated in
several of the cases that have come under my care during
recent years, has shown that, in the majority, the Amoeba
coli is present in the pus. In some its presence is more
easily demonstrated a few days after the abscess is
opened than on the day of operation. In some it is
found in abundance many weeks later, when the case is,
perhaps, pursuing a normal course towards recovery.
There is, therefore, strong suspicion that the amoeba has
something to do with the causation of tropical abscess.
This persistence of the organism, and the very slight
effect it may, under some circumstances, produce, possibly
account for one of the most striking features of this
disease — its occasional extreme chronicity. One cannot
fail to be struck with the long periods of time during
which an abscess may be latent, with the way in which
symptoms that point strongly to the existence of an
VOL. LXXXV. 9
130 HTIJDY OF TROPICAL ABSCESS OF THE LIVER
abscess may disappear, and with the comparatively shght
disturbance of health tliat is not inconsistent Avith the
presence of an abscess. I have known a young oflScer,
who was suspected of having an abscess, go through a
winter's hunting and return to show himself, as he
thought, well, though the abscess was almost pointing at
the epigastrium ; and it is well knovm that an abscess
may show itself years after a patient has returned from
the tropics.
Some abscesses, on the other hand, after a long period
of latency suddenly become acutely septic. These cases
most likely become infected from some part of the intes-
tinal tract with the Bacterium coli commune or some
other septic organisms.
I had under my care last year a young officer invalided
home from India on account of liver abscess. But his
symptoms so completely disappeared that he was supposed
to be well, and was sent abroad to recruit. He had,
however, occasional attacks of acute epigastric pain, in
one of which a swelling formed at the epigastrium, which
was caused by the rupture of the abscess in this situation.
This was accompanied by great collapse, and was quickly
followed by double parotid bubo. The abscess and the
two parotid buboes were opened, but the patient died in
a few days with all the symptoms of acute septicaemia.
Some liver abscesses contracted in the tropics are, on
the other hand, acute and septic from the first. These
should, I think, be placed in a class by themselves, and
are not, properly speaking, examples of tropical abscess,
but are part of a general pyaemic process. They may
arise in this country. They are often multiple, and, as
far as my experience goes, are quite hopeless cases to
treat.
But some genuine tropical abscesses are very acute.
I saw lately a young man from Central Africa who had
had many attacks of fever, but no hepatic s}Tnptoms till
he reached Europe on leave. In the course of a few
weeks he developed a small abscess in the right lobe. It
STUDY OF TROPICAL ABSCESS OF THE LIVER 131
was easily reached, and healed in a shorter space of time
than any other case I have had to treat, a very few
weeks sufficing for the cure.
The majority of tropical abscesses that I have seen
have been single, and I believe that many of the cases
which have been reported of a second abscess following
the first are those in which the drainage-tube has been
removed too soon, or in which a diverticulum of the
original abscess has never been properly drained, and has
been shut ofE from the main cavity. I think it is of
great importance at the time of the operation to explore
the cavity very carefully with the finger, and to open up
all branches of it, as far as possible, before the drainage-
tube is inserted.
I am, of course, not likely to forget that the cases we
see in England have been sent home from distant parts
of the world, and am prepared to hear that others of a
totally different type may be met with by surgeons who
are on the spot where the disease originates. I have,
indeed, been frequently told that we in England do not
see the really bad cases, which may be true, though it
must be owned that some of them are bad enough in all
conscience.
The last point I would deal with is the question of the
he fit place to make the incision, and will begin by stating
that I consider, if possible, the seat of election for the
operation is in the lower axilla. If two lines be drawn
vertically downwards, prolonging the anterior and posterior
folds of the axilla as far as the margin of the ribs, they
will, at the lower part, enclose the space where the widest
interval intervenes between the lowest part of the pleura
and the costal margin, an interval generally of two
inches, and often even greater. The incision may con-
veniently be made transversely, — that is, parallel with the
lower margin of the pleura ; and the portion of one rib
132 STUDY OP TROPICAL ABSCESS OF THE LIVER
and cartilage that crosses the wound obliquely should be
removed, great care being taken to separate the structures
on the deep surface of it without injuring the pleura, in
case, by chance, it should extend lower than usual.
Generally the structure thus exposed consists only of the
origin of the diaphragm, but if the pleura should be low,
it is easily recognised, and may, without any difficulty, be
dissected up without injuring it, and fastened, out of the
way, to the upper part of the wound. If it should acci-
dentally have been opened, the suture of the opening is a
simple matter, and it is essential to make it perfectly air-
tight before proceeding. The rest of the operation con-
sists in incising the diaphragm, either in the direction of
its fibres or across them (I prefer the former method),
and then cutting through the diaphragmatic peritoneum.
If there be no adhesions the liver may either be sutured
to the diaphragm and chest walls, or the parts around the
opening may be carefully plugged with some antiseptic
material. If the latter course be adopted, it must not be
forgotten that if the abscess be large the liver will at
once shift its position, and that this shifting will take
place in the upward direction.
It may be asked, " Why lay down this dogmatic rule
when it is well known that the abscess may occur in any
part of the liver ? '^ But to this it may be answered
that, in my experience at all events, by far the majority
of abscesses occur in the right lobe ; and that, if they be
of large size, they can generally be opened in this
situation, even if they form a projection in the epigastrium
or most nearly approach the surface behind. I have
already referred to the difficulties and dangers of incising
the liver behind, depending upon the fact that it is
necessarily a transpleural operation. The epigastric
incision does not drain well, and I am therefore in the
habit, even if the abscess appears to be pointing in this
situation, of ascertaining to begin with whether or no the
matter can be reached at a moderate distance from the
side. It is a question whether, if this be found to be the
STUDY OP TROPICAL ABSCESS OP THE LIVER 133
case, and after making the lateral incision the epigastric
tumour disappears, the surgeon should be content, or
whether he should make an epigastric incision as well.
A case recently under my care, and referred to in an
earlier part of this paper (page 130), supplies an argument
in favour of the latter course. I had been content with
the single incision in the side, but it turned out that the
epigastric swelling had been caused by a localised peri-
toneal collection of matter due to the bursting of the
abscess in front. The communication was not, however,
sufficiently free to allow of satisfactory drainage, and it
was necessary to make the anterior opening in the course
of a few days.
I do not deny that the epigastric incision is the only
possible one in certain abscesses in the right lobe, and in
all of those that occur in the left lobe.
I would strongly deprecate a lateral incision below the
costal margin, because the opening is certain to become
troublesomely oblique in the course of a few days as the
liver shrinks up under the ribs.
The opening into the liver itself may conveniently be
made with a long pair of dressing forceps followed by
the finger. In this way abscesses at a great distance
from the surface may be safely reached and effectually
drained.
Haemorrhage is often free, but it usually stops spon-
taneously if the finger be retained for a minute or two in
the wound. Should it not do so, careful plugging round
the tube must be practised. Some cases bleed extensively
after the operation, and the bleeding occurs on subse-
quent occasions. I am not referring to the slight
haemorrhages which often occur for many days in cases
which are pursuing a normal course, but to those in
which the loss is considerable. I look upon this as a
grave sign, and think it occurs most in the septic as
opposed to what I have called the amoebic abscesses.
A certain amount of blood often escapes into the
peritoneum as the result of the preliminary puncture. It
184 STUDY OF TROPICAL ABSCESS OP THE LfVER
seldom is of any moment, but dangerous and even fatal
cases of exploratory puncture have been recorded. It is
not unlikely that these patients were either jaundiced or
suffering from leucocythaemia.
I cannot conclude without referring to Dr. Manson^s
ingenious device of introducing a drainage-tube through
a large trocar plunged boldly through all the superficial
tissues into the abscess. It has yielded excellent results
in the hands of many, and I would not say a word
against it. But for my own part I prefer to know in
what condition I have left the pleura and peritoneum,
and to have ascertained what the size and shape and
possible ramifications of the abscess may be ; to have
opened these up if it appears to be necessary to do so,
and to have placed the tube or tubes in what seems
to be the best position for the future draining of the
cavity.
Illnstrative Cases,
Case 1 (escape of all the hile through the incision made
into the abscess; death). — This case was under the care
of Dr. Manson, and has been published by him in
^ Medical Reports,' Imperial Chinese Maritime Customs,
circa 1884.
The patient was a man aged about 34, a tea-taster,
resident fifteen years in China, chiefly at Amoy. Ten
years previously he had had pleurisy, and suffered from
stricture and chronic sores on the legs. For the previous
four or five years he had suffered from chronic dysentery,
and had been of habitually intemperate habits.
Liver symptoms began in February, 1 883 ; there were
pain, fever, and other symptoms of hepatitis. By August
the liver had considerably enlarged and some friction was
heard.
On September 14tli he reluctantly consented to an
exploration, and pus, which was found at a depth of two
or three inches in large quantity of dark chocolate-brown
STUDY OF TROPICAL ABSCESS OP THE LIVER 135
colour, escaped freely through the cannula which had been
introduced. A drainage-tube was passed through the
cannula, eight inches long, and through this the residual
pus was from time to time removed by aspiration. Bile
in small quantities appeared in the pus, and by the
beginning of October it was large in amount.
On October 13th there was an extensive haemorrhage.
On October 16th the abscess was irrigated with a solu-
tion of salicylic acid, and some sloughy material escaped.
On October 19th the bile was discharged in very great
quantity, and on the 30th it all came through the wound,
and the stools became white. About the same time some
thick sloughs came away. After this the bile was
collected in a bottle, and the daily amount varied from
28 oz. to 35 oz. His weight diminished, but the appetite
remained good.
On December 22nd the tube was plugged, but this was
followed by a rise of temperature, so the plug was
removed.
On December 24th, 25th, and 26th there was bile in
the motions.
He was then sent on a voyage to America, but on the
way he died, on January 29th, 1884, apparently from
exhaustion, owing to the very rough weather ; but it was
noted that the amount of bile discharged was reduced to
14 oz. jper diem, and that the stools were coloured, so it is
probable that he would, like the following case, have
recovered if he had not experienced such a tossing upon
his voyage.
Case 2 {escape of all the bile through the incision
wade into the abscess; recovery). — The patient was a man
aged 46, a railway engineer, under the care of Sir W. H.
Bennett, who has kindly furnished these notes. He had
lived in India since the age of three years. He was well
until October, 1898, when he began to have occasional
attacks of acute diarrhoea and severe malarial fever.
In May, 1899, he came under observation suffering
136 STUDY OP TEOPICAL ABSCESS OF THE LIVER
from an abscess in the right lobe of the liver, which was
opened below the end of the eleventh rib, at which spot
the abscess was bulging, on May 22nd.
Nothing peculiar was noticed at the operation, but
seven hours afterwards the dressings were thoroughly
soaked through with pure bile, which continued to flow
intermittently.
The stools were generally white but sometimes piebald,
and partially regained normal colour during the occa-
sional stoppage of the leakage. Dyspepsia was trouble-
some. There was often great constipation, sometimes
diarrhoea. Emaciation was extreme.
The wound was open from May 22nd to December 26th,
when permanent closure occurred.
Leakage stopped suddenly twice after gradually dimin-
ishing to a certain point. The first stoppage of leakage
occurred on September 28th, and no bile was seen for a
week. Then a profuse flow began suddenly. . During the
cessation of leakage the stools became more normal in
colour, but whitened again with the recurrence of the flow
of bile.
The patient was more or less jaundiced until about a
fortnight before the final healing of the wound.
Case 3 (ricpture into pleura; very rapid effusion), —
The patient was a man aged about 25, a Ceylon tea
planter, under the care of Dr. Bramwell of Cheltenham.
He had had hepatic symptoms dating from August, 1895.
They subsided, and it was thought that the abscess had
disappeared.
Symptoms reappeared in the spring of 1896. The only
physical sign observed was a slight elevation of dulness
in front. It was intended that I should see him on
April 26th, but on April 23rd the abscess burst into the
pleura during the night.
On the morning of the 24tli the right side was dull all
over, and the patient was very ill indeed.
In the afternoon I saw him and first aspirated two
STUDY OF TROPICAL ABSCESS OF THE LIVER 137
pints of sticky material resembling pea soup, and then,
without removing any rib, let out a further large quantity
by an incision on the seventh interspace in the axilla. I
did not think he could stand a more severe operation.
He died in a day or two, and a second abscess was
found which was apparently about to burst into the peri-
toneum. The position of it was not stated.
Case 4 {pulmonary abscess in anterior part of lung), —
The patient was a lady aged about 30, who had been in
India, and who was seen with Sir Richard Douglas Powell.
This is one of the very few cases of tropical abscess I have
met with in women. The patient developed an abscess in
the right lobe of the liver, which burst into the lung, and
which I opened by means of a lateral incision in July, 1896.
The fever did not completely subside, and there were
signs of right pleurisy, but exploration with the aspirator
revealed nothing. The expectoration continued.
She left for the country with the wound unhealed, and
by November, 1896, it was obvious that there was an
abscess in the lung to the right of the sternum, about
opposite the fifth rib. This was opened and drained.
The expectoration stopped, and both wounds finally healed
soundly.
The patient has remained well since.
Case 5 [pulmonary abscess in base of lung behind), —
Dr. S — , aged 35, I.M.S., China and India. He had had
dysentery and hepatitis in 1894, and was invalided home
September, 1894. He had one rigor in October, 1894, and
right pleurisy, lasting one month, followed by normal
temperature for a fortnight. The abscess burst into the
lung in December, 1894.
I saw him in January, 1895. The physical signs
indicated a liver of normal size and a pulmonary abscess
behind. The expectoration was about six ounces of blood-
stained muco-pus per dient. The pulmonary abscess was
opened January 31st, 1895. The expectoration stopped
138 STUDY OF TROPICAL ABSCESS OF THE LIVER
thirty-six hours after operation. The abscess was com-
pletely healed in three weeks.
Cask 6 {abscess in left lung), — Lieut. , aged 28.
Sent to me by Dr. John Anderson. He had been in India
from 1892 to 1899. He had had no fever or dysentery.
Hepatic symptoms began in May, 1899. An operation
was performed, but no pus was found. Expectoration of
blood and pus began July, 1899, after a fall. He was
invalided home in November, 1899.
Left empyema was diagnosed. An operation was per-
formed, resulting in the discovery of some clear fluid in
the left pleura and the absence of an abscess beneath the
left side of diaphragm.
On a subsequent occasion the right pleura and subdia-
phragmatic region were explored and found to be healthy.
I first saw the patient March 17th, 1900. The physical
signs pointed to an abscess in the base of the left lung,
behind and inside, and below the angle of the scapula.
There was no marked enlargement of the liver. There
was copious expectoration of reddish-brown pus. The
expectoration occasionally stopped, which always caused a
rise of temperature.
I opened the abscess in the situation indicated by
the physical signs, namely, higher up than the previous
incision into the left pleura, removing a piece of the eighth
rib. The abscess was in the lung ; it had thick walls and
many prolongations. No communication was found with
the liver.
His general health at once became quite good, but
healing was, as might have been expected, slow, the
wound not being completely closed till November, 1900.
Cask 7 {extensive and fatal destruction of lung), — The
patient was a man aged 46. When first seen in June,
1897, by Dr. Hector Mackenzie he had been twenty-two
years in India.
In 1890 he had malarial fever.
STUDY OF TROPICAL ABSCESS OF THE LIVEE 139
In 1892 he had typhoid fever and was afterwards
invalided home. There was no history of dysentery.
In February, 1897, he was quite suddenly attacked
with diarrhoea, and temporarily lost power over the
sphincter ani. He had pain over the "ribs on the right
side at the same time. He went up to the hills for a
time, and while there was very ill with fever every night
and rigors. Then a purulent discharge from the rectum
came on. He returned to Calcutta, and an abscess of the
rectum was diagnosed; he was relieved by hot hip-baths,
but was very ill, and lost flesh and strength.
The pain in the side continued, and in March, 1897, a
severe dry cough came on. In April he began to ex-
pectorate pus stained with blood, and continued to do so
more or less till the end of the case. He was sent to
England. Cough, sweating, pyrexia, and depression of
spirits continued on his voyage home.
When examined by us there were signs of enlargement
of the liver upwards in front (level of third rib), but no
increase of liver dulness downwards. The rectum ap-
peared to be healthy.
On July 8th, 1897, a large abscess was opened anteriorly
and laterally, and this was followed by a gradual improve-
ment in health ; but drainage was never satisfactory, and
there were occasional attacks of increased cough and
expectoration owing to retention of discharge.
On December 6th, 1897, the ramifications of the abscess,
which were now found distinctly to involve the pleura, were
very thoroughly opened up.
During the year 1898 there were periods of improve-
ment and relapse. At one time it looked as if he would
make a good recovery; but at the end of the year the
tendency was gradually downhill, and his condition be-
came more obviously septic.
On March 27th, 1899, though he was then very ill
indeed, a further attempt at opening up the suppurating
tracks was made. They were found to be very extensive,
reaching up almost to the apex of the lung. The cavities
140 STUDY OP TROPICAL ABSCESS OF THE LIVER
were bounded in part by the chest walls, in part by
broken-down lung tissue. A great portion of the anterior
aspect of the right lung had been destroyed by the suppu-
rating process. He only survived this operation a few
days. There was no post-mortem examination.
Case 8 {destruction of lung ; fatal hsemoptysis) . — The
patient was a man aged 26, a tea planter, bom in India,
educated in England, and who returned to India in 1886
and stayed there till 1893, and had had some attacks of
fever.
He had dysentery in March, 1893, and was in hospital
in Calcutta. The dysentery was not quite cured, and he
was invalided home in November, 1898, in a very bad
state. The dysentery stopped on the voyage, and on
arrival home he was well except for a dry cough.
On December 13th he began to spit blood and matter.
On February 20th, 1894, he came under my care. He
had lost three stones in weight, and had constant cough ;
copious chocolate-coloured expectoration ; hectic tempera-
ture ; diarrhoea with blood and mucus ; pain in defaeca-
tion and difficulty in micturition. His appetite was good;
he was given a milk diet. The physical signs indicated
great enlargement of the liver and an abscess at base of
right lung.
An operation was performed on February 21st. An
abscess in the lung was opened behind and a finger passed
through the diaphragm into the liver. Considerable im-
provement followed, but there were frequent haemoptyses.
Fatal haemoptysis occurred on April 24th, 1894.
Post-moriem, — The liver was found to be firmly ad-
herent to diaphragm at the upper part, but there was no
sign of an abscess. The right lung was firmly adherent
to the diaphragm and to the chest wall up to the level of
the eighth rib. A large irregular cavitj' occupied the
lower and middle lobes, and there was a cavity as large
as a Tangerine orange at the right apex. The liver and
kidneys were amyloid.
STUDY OP TROPICAL ABSCESS OP THE LIVEE 141
Case 9 {abscetfses in both lungs and in brain). — The
patient, a man aged 43, had lived in India for ten years.
He had dysentery soon_ after his arrival, from which he
completely recovered. Sixteen months before his admis-
sion to hospital he had had symptoms of liver abscess.
Five months later the abscess burst into the lung, and
Ifour months after that he was operated upon, portions of
the seventh rib in the axilla and of the eighth and ninth
ribs behind having been excised. This had not relieved
the patient ; it is uncertain if pus was found.
On admission there were no signs of enlargement of
liver. The physical signs pointed to the existence of an
abscess at the base of the right lung. Exploration,
however, failed to detect the presence of pus.
Three days after operation symptoms of cerebral
abscess commenced. Eight days later an abscess was
opened in the right occipital lobe, the only localising sign
being tenderness on percussion. On the same occasion
an abscess in the base of the right lung was opened
through the old scar in the axilla, more space being
gained by removal of more portions of ribs.
No improvement followed, and another trephine opening
was made in the hope of finding a second abscess in the
brain, but none was discovered, and the patient died twenty
days after the first operation.
At the post-mortem examination the lower lobe of the
right lung was fibrotic and riddled with cavities. The
right pleural cavity was obliterated at the base. The left
lung contained a cavity as large as an orange opposite
the fifth, sixth, and seventh ribs, and the pleura in this
situation was obliterated. The brain contained a large
abscess in the right occipital lobe, but there were no other
collections of pus. There was little or nothing to indicate
the old abscess in the liver.
Case 10 {abscesses in the lung and the brain), — The
patient was a man aged 33, a merchant, and was seen with
Dr. Crombie January 9th, 1901. He had been in Calcutta
seven years. He had had very little fever.
142 STUDY OF TROPICAL ABSCE8S OF THE LIVEK
In May, 1 897, he had dysentery and congestion of liver,
which lasted till end of 1897. He was invalided home
on account of sprue in January, 1898, and remained till
September, 1898. Liver symptoms began in September,
1899. Pus was removed by aspiration in October, 1899.
Aspiration was again performed in November, 1899, but
nothing was found.
In January, 1900, cough began, and had continued ever
since. He had had intervals from fever and cough lasting a
week, but not longer. These were followed by a rise of
temperature and expectoration. He had lost some flesh,
but not much.
In June, 1901, he had signs of a pulmonary abscess at
the right base, which was opened by a posterior incision
opposite the eighth rib. There was a gradual improve-
ment, though drainage was never perfect, because the
cavity had many branches, and a considerable amount of
bright blood and pus was discharged from the wound and
expectorated as well. He improved so much, however,
that he was sent to Christchurch, Hants, under the care
of Dr. Leslie Burnett.
In September symptoms of cerebral abscess manifested
themselves, and before long symptoms pointing to affec-
tion of the left motor area appeared.
Dr. Burnett explored this region, but found no pus.
A few days later, at my suggestion, he explored further
back and found a considerable abscess in the left occipital
lobe. There was some improvement, but the patient died
on August 3rd.
Post-mortem, — The right lobe of the liver was found to
be adherent to the diaphragm, but contained no pus (cf.
Case 8) ; the abscess in the lung was extensive, and
branched out into numerous pockets ; part of its wall was
formed by the ribs (cf. Case 7). A considerable cavity
existed just beyond the end of the drainage-tube. The
abscess in the occipital lobe was not empty, an accumula-
tion existing beyond the end of the drainage-tube.
STUDY OF TROPICAL ABSCESS OF THE LIVER 143
DISCUSSION.
Dr. Patrick Manson, referring to the operation he had
devised, said it was meant for an ordiuary surgeon away from
all assistance, as in tropical countries. He asked why it was
that abscess of the liver extended upwards and did not lead to
depression of the liver, as a pleural effusion did. Had Mr.
G-odlee ever seen the escape of hepatic pus into the peritoneal
cavity produce serious consequences ? for he himself had not.
Dr. A. Crombie alluded to the time when it was the invariable
custom to empty liver abscesses by the aspirator, and said that
small and recent abscesses were still successfully treated by
this method. Even in the case of larger abscesses, if acute and
recent, recovery had followed repeated aspiration, in one case
after so often as fourteen times. The operation itself produced
no constitutional disturbance, and Dr. Lawrie had described
cases in which a single aspiration had effected a cure, and other
similar cases he had himself met with. During a thirty years*
experience of the treatment of liver abscess, in only one case
had the liver been stitched to the parietes, and never once had
he seen any ill result from the escape of pus into the abdo-
minal cavity after direct incision. In the tropics, at any rate,
such pus was aseptic, and it often probably escaped into the
peritoneal cavity. Reference was made to the occurrence of
severe hcemorrhage during operation, which, however, was
always controlled easily by pressure.
Mr. Cantlie was a thorough upholder of Dr. Manson's
method of aspiration for the treatment of liver abscess. It was
a very appropriate operation for surgeons undertaking the
operation single-banded, and. had the advantage in being, as it
were, a natural sequence of the exploratory puncture. In the
absence of suitable nursing and- other assistance it was a great
boon. Haemorrhage with Dr. Manson's operation could hardly
occur; cutting the liver with the knife was the chief cause of
haemorrhage. A metal drainage-tube was not advisable in liver
absces»; an india-rubber tube which would be compressed by
inspiration and expand again during expiration was good in
preventing escape of pus by the side of the tube. He had only
had two fatal cases among the many in which he had employed
this method, and these were the first he had operated on.
Dr. William Gabriel Rockwood, during twenty-five years,
had had over a hundred cases of operation for abscess of the
liver. In the earlier he had aspirated; subsequently he had
only operated by incisions between ribs. The latter method in
acute cases proved of no avail; now he was accustomed to
144 STUDY OF TROPICAL ABSCESS OP THE LIVER
excise a portion of the rib. In chronic afebrile cases aspira-
tion might suffice ; in acute cases, with thick pus and much
debris, nothing short of excision of a portion of rib would do
good. Lateral incision even might not be sufficient, and
incision in the middle line might be required.
Mr. G-ODLEE, in reply, thought that the liver sometimes
enlarged upwards because adhesions had been formed between
the lower part of it arid the abdominal wall. He could not say
that he had ever seen any serious harm from the escape of pus
into the peritoneal cavity, but he referred to one case which
was followed by severe pain apparently indicating general
peritonitis, from which, however, the patient recovered. Burst-
ing of the abscess into the peritoneum was, of course, disastrous.
Aspiration in liver abscess was much on a level with that for
empyema; a certain number recovered, but probably the
majority came to operation sooner or later, and aspiration
merely meant delay. At the time of operation bleeding was
seldom serious, and was almost certainly stopped by pressure,
but the later haemorrhage could not thus be arrested.
SOME GENERAL AND ETIOLOGICAL DETAILS
CONCERNING
LEPROSY IN THE SUDA.N
BY
T. J. TONKIN
LATE MEDICAL OPFICBB TO THE HAI78A ASSOCIATION'S CENTRAL SUDAN
EXPEDITION, 1893-4-5.
Received October 29th, 1901— Read May 27th, 1902.
The object of the paper which I have the honour to
read to you this evening is* to bring before y.our notice
an account of some of the aetiological factors probably
concerned in ihe maintenance of leprosy in the Sudan.
When the opportunity, which I am now enjoying, first
presented itself to me, my idea was to make the scope of
the paper wider, but considerations of time rendered
that impossible. Before I enter on the subject proper,
however, it is perhaps desirable that I should tell you
something about the leper field from which I have drawn
my results. I will begin by defining the term Sudan.
Our Imperial losses and gains in the country immediately
around Khartoum have tended to concentrate our national
attention on that particular scrap of country to such an
extent, that it is probable that many people are ignorant
that any other Sudan than that to the south of Egypt
exists. The Egyptian Sudan, however, is only a small
part of a great whole. The Sudan proper is an immense
reach of country stretching across the continent of Africa
VOL. LXXXV. 10
\
146 LEPROSY IN THE SUDAN
at its widest part. The seaboard of the Atlantic from
Cape Yerd to the mouth of the River Roquelle is its
western boundary ; its boundary on the east is the valley
of the Nile. Its northern edge from Egypt to the
mountains of Senegambia coincides with the southern
fringe of the Sahara, while to the south its limit may be
placed at a line drawn from the mouth of the Roquelle, —
that is of course Freetown, Sierra Leone, — to the outfall
into the Nile of the Bahar Eg-Gazal.
The Sudanese leper field is on a scale proportionate to
the region that contains it. It lies in the centre and to
the west of the centre of the Sudan. I would describe it
as a belt, say five hundred miles wide, coming out of the
eastward probably from beyond Darfur, embracing Lake
Chad, stretching across our Northern Nigeria, holding its
own over and beyond the waters of the Middle Niger, and
finally losing itself as it approaches the upper waters of
that river away to the south-west of Timbuctoo. The
whole of this area is very strongly affected by the disease.
The Northern Nigerian regions in which I travelled are
especially unfortunate in this particular. They are
occupied by the sufferers from leprosy as by a vast standing
army. Everywhere and on all sides the familiar uniform
is met. Large towns are heavily garrisoneci ; the smaller
have detachments and companies proportionate to their
size. During parts of my journey I do not remember
touching at any village so small that it had not some
lepers. In places I found settlements of considerable
size, apparently specially designed for them, at any rate
almost entirely populated by them. In the large towns
lepers may be seen in almost every street and square. In
some of the streets they sit in rows and companies, in
others, and near the borders of the market places and on
the open spaces by the gates they collect in gangs and
troops.
Kano, the principal commercial city of Northern
Nigeria, is a veritable hive of lepers. In that city (of the
size and importance of which something may be inferred
\ LEPROSY IN THE SUDAN 147
from the fact that it is protected by fifteen miles of earth-
works, has fifteen gates, and a daily market on which from
twenty to thirty thousand people may often be seen at
once) hundreds of lepers live together in various houses or
collections of houses. There are many such colonies in
Kano. In them young and old, male and female, the
well-nigh healthy and the fearfully diseased, the vigorous
and the dying, promiscuously herd. With regard to the
surroundings of these communities, insanitary as a des-
criptive term would be feebleness itself. The apathy that
gradually creeps over the leper as the disease closes its
grip upon him, makes the inhabitants of such places less
careful about personal cleanliiless and the cleanliness
of their dwellings than the average native is. The
result is easily evident. In the dark tomb-like huts
which the heat and glare of the sun, and the persistent
attentions of the fly tribe, render necessary in these parts
of the Sudan, the smell emanating from the neglected
ulcers of scores of leprous occupants hangs like an oily
foetid fog upon the air. Inside and outside, foodstuffs and
other matters in decaying conditions are allowed to
accumulate. The usual etiquette of the Hausa household
is suspended, and it is among such surroundings as these
that the lepers, representing among themselves every age
and every degree and variety of their disorder, live and
die.
In Northern Nigeria familiarity with leprosy is a social
characteristic. The disease is so common that in spite of
the repulsive appearance of the sufferers, the general
public have, as far as I could make out, no active objection
to it. They are accustomed to it, and regard it as one of
the stable things of the world, and the chance of catching
it as one of the ills to which human flesh is inevitably
heir. They do nothing so far as I know to limit the
chance of contagion. Lepers are permitted to mingle
freely with the healthy population, engage in business,
and marry whom they will. When they live in com-
munities it is not because thev are forced to do so, but
148 LEPROSY IN THE SUDAN '
rather because community of interest acting through long
years has drawn them together. Lepers are not subject
to any municipal or social disabilities on account of their
disease. I have frequently seen them tailoring, selling
second-hand clothes, and presiding at provision stalls.
Nor did I notice any repugnance on the part of the
people to the idea of having their national food (which is
thick and porridge-likej served out by a pair of scaly,
mutilated, and often ulcerated hands ; time and old custom
have hardened them to it. The native of Northern
Nigeria regards a man whose limbs have been reduced to
a mere fraction of their normal proportions, and whose
skin is broken, seamed, and puckered by leprosy, in
much the same light as we should regard a person with a
club foot or a wooden leg, and the idea of walking twenty
yards further for the privilege of buying a meal from a
healthy salesman or woman, would, if it were ever
suggested to the native mind, be derided as unnecessary
and foolish. This is the state of things in Northern
Nigeria, a region extending over some five hundred
thousand square miles, and I have every reason to believe
that it is only a slightly accentuated example of the
similar conditions obtaining elsewhere in the Sudan.
Having, then, given you some sort of impressionist idea
of the locality and extent of the Sudanese leper field, I
will pass on to the aetiological portion of my paper.
There is, I take it, at this time of day, little need to
insist on the improbability of the transmission from parent
to offspring of a disease which depends for its causation
upon the action of a specific poison. In a paper of this
kind it is quite unnecessary for me to bring forward
evidence either from the Sudan or elsewhere bearing on
this point. It is generally admitted that in no sense of
the term can leprosy be regarded as a heritable disease,
and I am not taking any liberty, therefore, in starting
with the assumption that in every case the disorder is the
result of a fresh individual infection by the specific
bacillus.
LEPROSY IN THE SUDAN 149
The first question that naturally arises in connection
with the spread of leprosy relates to the working sources
of the bacillus. There is a peculiar appropriateness in
dealing with this question in relation to West Africa.
Evidence that bears strongly on this point is closely
interwoven with West African history, and with the
great enforced migration of West African natives that
was determined by the now extinct trans- Atlantic slave
trade from the Guinea Coast to certain parts of America.
At the time of the discovery of America that continent
was free from leprosy, and it continued to be so until the
middle of the sixteenth century. Then, with the ever-
increasing demand for. labour set up by the cotton and
sugar plantations, came the slave traffic, and, by means of
that traffic, wide areas of the Western World were flooded
with Africaus, drawn from the very infected region that I
have just been describing to you.
From the Sudanese leper field these people took the
disease with them across the ocean, with the result that
America was infected, an infection that is responsible for
the existence of the disease in that continent to-day.
The American leper field is the daughter of the Sudanese,
and the link between them was evidently individual, man-
to-man infection. Such facts as these', even if they were
unsupported, which they are not, would appear to be
inconsistent with the supposition of any other regular
source of the bacillus than the diseased tissues of
previously infected individuals.
If it be, then, granted that in every case leprosy is the
result of a fresh infection of the individual by the bacillus,
and admitted that the immediate source of fche bacillus is
usually the damaged tissues of previously affected indi-
viduals, the next problem that presents itself for solution
is the determination of the general mode by which trans-
ference of the bacillus from previously affected to fresh
subjects is accomplished. I do not use the word infection
in this instance, because, in the case of leprosy, it is
probable that more than mere transference of the bacillus
150 LEPROSY IN THE SUDAN
is necessary to the initiation of the disease. As far as
the actual first transference, however, is concerned, it
seems likely that it is achieved by a process of mediate
contagion. The bacilli are transferred from their source,
disintegrating leprous surfaces, to surfaces previously
healthy by the agency of various things, among which
personal clothing and bedding occupy the chief place.
Penetration of these fresh surfaces is, however, still
necessary even to the possibility of infection, and this is
probably effected by the help of other influences, which
act as introducing media by making breaches in the pro-
tecting epidermal layers and allowing the bacillus to
reach the deeper and more readily- damageable structures
of the skin. These introducing agencies are of various
natures, atmospherical, frictional, due to the attacks of
insects, and variation in the particular influence at work,
and, more or less, the particular surface affected, occur
with fair constancy among the various leper fields of the
world.
It can hardly liave* escaped the notice of people
interested in leprosy that the feature known as leontiasis
is more marked and much more common in extreme
northern and southern leper fields than in those situated in
warmer regions. The feature referred to is of frequent
occurrence among the Icelandic and Norse lepers. In
the Barbary States I can say from personal experience
that it is very much rarer, while in the Sudanese area,
which I have had particular opportunities for observing,
it is most infrequent. The explanation of this relative
variation in the occurrence of what has come to be
regarded as a classical feature of the disease is probably
to be found in a sort of general rule, in response to which
the first advance of certain microbic skin affections, and
among them the initial lesions of leprosy, tend to fall with
major severity upon surfaces ot* the body most exi)osed to
wear and tear. The frequent appearance of the common
boil at the collar line on the neck, of erysipelatous
inflammation at the junction of mucous and cutaneous^
»• r* •••••• • •
»•« • •• • • • •
» • • • • • • •
LEPROSY IN THE SUDAN 151
ulcerated and sound surfaces, of seborrhoea under the
irritative pressure of the hat-band, and of a whole
collection of parasitic disorders in the much-scratched
region of the hairy scalp, are instances of this. The
leontiasis of leprosy is a further case in point. The face
of the Scandinavian, exposed as it often is to violent
alternations of temperature, from the warmth of the
house to the biting frost and scathing wind of the outer
air, is prone to chap and crack, and to have thereby its
more sensitive layers exposed by the damage to the
epidermis, and their resistance to morbid influences
lowered by the consequent congestion of the blood-
vessels. The habits of the people in Norway with regard
to bedding are, I understand, gregarious, and have
not, I believe, until recently been affected by the con-
dition of any member of the family that may have
happened to be suffering from the endemic disease.
Bacilli, freed from the surfaces of a suppurating leper
and lying ready for mischief in the bed, would, at any
rate, find some difficulty in making an impression on the
smooth oily surfaces of the parts of the body that are, in
those countries, constantly protected from the air. With
the skin of the face, however, matters would be different.
'J'here would be little hindrance to their effecting an
entrance through its cracked weather-damaged surface,
and, other things being favourable, little difficulty in
increasing the already irritated and thickened condition
of the cutis and of the subjacent structures up to the
intense visible specific disturbance referred to.
The native of warmer climates is not exposed to this par-
ticular localising influence, hence the rarity of the resulting
feature among them. But they are subject to others from
which the Northerner is exempt. One of these, quite as
characteristic in its way as leontiasis, though not so readily
apparent, is the thickening of the outer borders of the
feet in barefooted races. The feet of the tropical native
who pads unprotected over sand and rock, through mud
and water, are especially prone to fall early under the
I
152 LEPROSY IN THE SUDAN
influence of the bacillus. The inner borders of the feet
are held safe by the protecting influence of the plantar
arch, but the outer are in contact with the ground, and
the skin over them is thickened and cracked by constant
exposure to alternating conditions of wet and dryness, and
by frequent small violences, and becomes thereby reduced
to a condition parallel to that described as affecting the
face of the Norseman. Long nights, during which the
injured outer surfaces are scuffled up and down over harsh
sleeping mats, supply, should the mats have been previously
infected by the discharges of a suppurating lepBr, an
opportunity by which the bacilli may gain access not only
to the most intimate structures of the skin itself, but also
to the areolar tissue that lies below, l^he dense infiltra-
tion of these outer borders of the feet, the consequent
interference with adjacent plantar nerve supplies, and the
resulting injury to or loss of the lesser toes which so
frequently follows among barefooted races, at least in
Africa, I regard as the analogue of the leontiasis of the
boot- wearing Northerner ; and both 1 look upon as instances
in which free germs from infected garments or bedding
obtain direct entrance into and through a damaged and
chronically irritated skin surface, the pre-existent damage
and irritation being answerable for the marked neoplastic
changes that equally in both places ensue. That in the
Sudan these and similar processes are the ordinary modes of
leprous infection is highly probable. The situations in which
the other early lesions of the disease first show themselves
lend colour to this view. The early lesions first show them-
selves on the prominences of the body, on the cheek-bones,
the temporal ridges, the outer surfaces of the extremities,
the scapular region, the buttocks. In all the situations
mentioned the skin is at a disadvantage with regard to
wear and tear. Lying about, as the average ISudaiiese
native does, on the hard ground, or on a mat almost as
hard, these parts are in constant, and to a certain extent
violent contact with his garments. To those who know
the Sudanese native well this is a circumstance full of
LEPROSY IN THE SUDAN 153
significance, and one which it is difficult not to associate
with the preference evinced by early leprous lesions for
these localities. The average Sudani is not a cleanly
person. The clothes he wears, the mats, whether of skin
or grass, on which he lies, the loose covering with which
he keeps off the chill of the early hours of the morning,
are never washed, and are used indiscriminately by him-
self and friends. It is uncustomary for a Hausa to wash
anything that belongs to him, or to have it washed.
Wealthy men buy their robes, which are made of cotton
textiles, new, and when they are dirty they sell them to
less fortunate people than themselves, people who cannot
afford to be so nice in these particulars ; or they give them
away. It is considered an honour to be the recipient of a
king's raiment. But, however they may obtain them, the
people who get these second-hand garments wear them as
long as they think proper ; and then, when they feel they
can afford it, or when the clothes become too dirty for a
person in their particular class of life to wear any longer,
they pass them on to some one lower in the social scale.
In this way a regular circulation in clothes is established,
the rich selling or giving to the middle classes, the middle
classes to the poorer, and the poor borrowing, begging, steal-
ing, selling, or lending among themselves. A single robe,
during its life as a robe, may have in this way from five
to fifty different owners. As long as half a dozen shreds
of it continue to cling to the neck-band, so long does it
contiime to do its duty. It responds during the course of
its existence to the influence of a kind of gravitation, fall-
ing layer by layer through the various strata of society,
till, from gracing, it may be, in its crisp new early days,
the shoulders of a prince, it may come at last in its thread-
bareness to be the only covering of the poor man's slave,
or later still its tattered remnants may be found to be con-
veniently lending themselves to the exhibition of the alms-
earning ulcers of the wayside beggar. But with all its
varying fortunes it will probably never — and this is where
the peculiar danger comes in — have been washed.
154 LEPROSY IN THE SUDAN
In accordance with this unfortunate custom, robes
stiff with leprous exudation often pass warm from the
bodies of lepers to those of previously unaffected persons.
Let us take an example. A really well-to-do man buys
his robes new. If he wears white he will on an average
become the possessor of two or three new garments every
month. When he buys a robe it is fresh from the hands
of the maker. He puts it on, wears it till it is dirty, then
sells it. He thus puts into circulation from twenty to
forty robes a year. Putting aside all other sources of
contamination, just imagine the possibilities of the case if
that man happens to be a suppurating leper. Another
man buys one of those robes, wears it by day and rolls
about by night with nothing between him and the hardness
of the ground but that leprous garment. The patches of
skin covering the prominences of his body bear the brunt
of contact with the garment. Their superficial irregu-
larities, the follicles and the like, become stocked with
bacilli which are rubbed into them from the surfaces of
the infected garment. Then an abrasion of the epidermis,
which may be due to accidental violence, to coincident
disease, or, as is probably more often the case, to the attacks
of mosquitoes, fleas, or body lice, and consequent scratching,
occurs, and the horny protecting layers of the skin are
injured. Through the trifling wounds of the nature
suggested, the bacilli make their way from the outer works
of the skin to the innermost recesses of its structure, and
an invasion is complete. Whether the invaders will make
good their local foothold or be destroyed, or whether,
should they succeed in making their local footing good,
they will then be held powerless for evil or succeed in
making further advances against the defences of the system
they are invading, will depend upon the powers of resist-
ance to which they find themselves opposed, and probably
to some extent upon the numbers and virulence of the
invading bands of bacilli. If the system be vigorous it is
probable that no evil result will accrue ; but if the reverse
be the case, if the system attacked be under the ban of
LEPROSY IN THE SUDAN 155
I
thq influences that determine the occurrence of the pre-
disposition to the disease, if its powers be, moreover,
depressed by ill-health, privation, over-strain, or general
reverses, the bacilli may make good their foothold, and an
attack of the disease, more or less severe according to
individual circumstances, may result.
But it is with the predisposition to the disease that we
get into the actual working habits of the leprosy bacillus.
It is well known that individuals of every race may remain
exposed during long periods of time to all the possibilities
just sketched, and may even certainly incur the risk of
constant and close association with lepers without affording
any evidence of having contracted the disease. This state
of affairs is explained on the supposition that a certain
condition of contributory lowering of vitality is necessary
on the part of tissues attacked before the bacillus can
effect its characteristic results. This condition of lowered
vitality is called a state of predisposition, but what that
condition may actually be, and how exactly it is acquired,
are still questions that are being debated.
It has been suggested that the tendency to leprosy is
natural to certain races. This can hardly be the case, for
if it were so each member of such races would possess the
innate characteristic in common with the rest. It does
not appear, however, to be of such general occurrence.
Healthy persons not only may, but often do live for
indefinite periods of time on terms of the closest intimacy
with lepers of their own race, tribe, and even family, with-
out developing the disorder. This state of things would
appear to be incompatible with the existence of a natural
susceptibility, and we are probably justified, when con-
sidering the factors that have to do with the causation of
leprosy in leaving it out of the question. As susceptibili-
ties must be either natural or acquired, this leaves us with
the acquired group on our hands. Now, it being admitted
that a parent is capable of transmitting to his offspring a
disposition obtained by himself, it follows that susceptibili-
ties falling within this class must be either acquired by an
156 LEPROSY~IN THE SUDAN
individual personally, or received by him as an inheritance
from the parent or more remote ancestor with whom they
originated. In other words, they may be either acquired
personally or inherited. But this classification is not the
one best suited to present requirements, the question, of
first importance with regard to leprosy being not when,
but how the predisposition is acquired. It will be, there-
fore, more to the point to take acquired susceptibilities in
bulk, and divide them with reference to their probable
causes into two classes : (l) those that can reasonably be
ascribed to the leprosy of a parent or more remote ancestor,
namely, specific tendencies; and (2) those that cannot.
When this is done we shall find that we have to some
extent affected the question of time also, for it is evident
that all susceptibilities due to leprosy must be inherited,
while those due to other causes may be either inherited or
personally acquired, or both. This classification is also
one that lends itself readily to further simplification, for
the first class may be shown to be of doubtful occurrence.
The same evidence that is advanced against the theory of
heredity as applied to the disease itself may with equal
relevance be urged against the theory of a speciHc origin
of the tendency. Of my own results, I found among the
lepers I examined in the Sudan that only about one out of
every ten was born of tainted ancestry, — that is, in only
about one case out of every ten did leprosy occur among
the more immediate forebears of the patient. Moreover, of
the children of lepers it appeared that less than ten per
cent, ultimately developed the disorder. It is manifestly
impossible that the condition that predisposed the leper to
his disease should have had its source in ancestral leprosy
when the individuals progenitors as far back as could be
ascertained have been free from the disease ; so as only
one leper in every ten is born of tainted parentage, such a
source of the tendency could only be possible in a similar
proportion of cases. Moreover, if the leprosy of a parent
or ancestor were a regular source of the tendency in a
descendant, the resulting tendency should be at its strong-
LEPROSY IN THE SUDAN 157
est in the immediate descendants^ namely, the children of
lepers ; yet even of such children as are born after the
inception of the disease in their parents, and exposed to
contagion during their infancy, childhood, and often
adolescent and adult years as well, less than 10 per cent,
ultimately develop the disorder. If these data are correct,
a specific source of the tendency is only possible in one
•case out of every ten ; and out of every ten cases in which
it might occur, and if it did occur might reasonably be
expected to be at its strongest, in less than one is there
evidence of the existence of any predisposition at all.
Out of 220 of my own cases in which I went closely into
family history, in only eighteen could the tendency which
we suppose to be necessary to the development of the
disorder have possibly had its source in the disease of a
forebear, since the immediate ancestors of the rest for two
generations at least had been free from taint. If the
diffusion of leprosy depended to any extent upon the
transmission of a tendency of specific origin it would not
be unreasonable to expect a larger proportion than 18
possibilities out of 220.
It is fairly clear that the bulk of the persons who
suffer from leprosy do not owe their liability to the pre-
existent disease of an ancestor. What, then, is the
source of the tendency ? In reply to this question, I
should say that it is probable it may be more accurately
traced to adverse circumstances of a general nature ; but,
among these, I think a leading place should be accorded
to defective diet. I do not refer to any particular
improper foodstuff, but to a definite dietetic defect.
It appears to me that there is one great common factor
pervading the leper fields of the world. That common
factor is a diet which, when considered chemically, will
be found deficient in one specific direction. In all the
countries of the world without exception, in which
leprosy has acquired anything like a footing, the national
diet is wanting in nitrogenous elements. In India and
China rice is the staple foodstuff of the masses. In
158 LEPROSY IN THE SUDAN
Scandinavia and in Iceland the exigencies of climate call
for the consumption of large quantities of fat, to the
displacement of other necessary aliments. In the West
Indian and Pacific islands the bulk of the population live
largely on vegetable food, and in the Sudan the existence
of millions rests on a porridge-like preparation of dhurra
or a solid substratum of yam.
It is probably not too much to say that eighty per
cent, of the inhabitants of the endemic area of the
Western Sudan subsist on a vegetable diet of the straitest
sort, and I believe that this circumstance definitely affects
their resistance to leprosy.
It is a matter of common knowledge how excessively
prone to ulcerative changes are the peripheral tissues of
the tropical native of the poorer classes. That the rest
of his tissues are in the same tumble-down condition is
doubtless the case, but we can see his skin, and the
readiness with which ulcers follow the slightest scratch,
or appear on the cornea without any apparent encourage-
ment at all, is so well marked as to be immediately
evident even to the most casual observer.
This state of things is probably due to the specific
defect in his diet. It is not always that the native does not
get enough food, but that he does not get the right kind
of food. He needs a certain definite amount of nitrogenous
nourishment for the effective discharge of the functions
of his body, and for the maintenance, at a normal
standard, of the vitality of that body^s tissues, and the
getting of that certain definite amount he fails to achieve.
In the effort to get it, moreover, out of a national array
of foodstuffs that contain an overwhelming percentage of
carbohydrate or hydrocarbon material, as the case may
be, and very little more than a mere trace of the desired
element, he still further adds to his embarrassments. In
the vain attempt to get enough nitrogen for his needs
he charges himself with very bulky meals, taxing his
digestive organs to their utmost limit. And, in the end, he
probably does not succeed in getting the necessary amount,
LEPROSY IN THE SUDAN 159
because the percentage of nitrogenous material in his
foodstuffs is so low that he has eaten all he can hold
long before he has got the quantity commensurate to his
needs. All he does by his efforts is to further increase
his difficulties by encumbering his economy with a large
amount of superfluous, and therefore deleterious carbon.
Enfeebled as the resistive powers of the tissues are
already by lack of nitrogen, it is not difficult to imagine
that this overburden of carbon, littering up blood, lymph,
and tissue elements, may have the effect of still further
reducing their power of resisting morbid changes, and,
as a consequence, rendering the individual yet more liable
to the endemic disease.
But I do not claim that this dietetic factor is by itself
sufficiently potent to lay a man of ordinary powers open
to the attack of the leprosy bacillus. I only suggest that
it is a factor common to all the leper fields of the world,
and that it diminishes to such an extent the resistance
naturally offered by the tissues of the normal body to
disease, that that resistance is, on the supervention of (in
some cases even slight) further adversity, readily disposed
of altogether. The additional adverse influence often
shows up very clearly. In the Sudan, among the bulk of
the people time is measured and dates are defined by events,
and 1 have been struck by the frequency with which the
year or so immediately succeeding some untoward event —
a war, a famine, or a pestilence — have been named by
patients as the time of the onset of their disease. In
many cases business reverses or domestic losses involving
sudden poverty or grief have appeared to pave the way
for the malady. In women the first signs of its invasion
not infrequently appear during lactation. The bodily
prostration consequent upon the dangers and privations
attending pilgrimages, and other long journeys over wild
and savage countries, is frequently taken advantage of by
the disease, and prisoners of war often develop it within
a reasonably short space of time from their introduction
to a life of slavery.
160 LEPROSY IN THE SUDAN
I look upon these last-named adverse circumstances,
however, only in the light of last straws, and they may take
a hundred different forms according to the nationality,
habits, age, or sex of the persons affected; they are, in
fact, mere accidents. The rank of common and constant
factor predisposing to the disease can in my opinion only
be accorded to one thing, and that is an absence from the
dietaries of the affected races of the amount of nitrogen
necessary for their needs.
In the near future I hope to have the opportunity of
working up this defective diet idea on fuller lines, and in
the light of more exact information. For the moment I
must content myself by hoping that the a-nitrogenous theory
which I have ndvanced this evening may prove a possible
basis on which to accpunt for the occurrence of what is
emphatically the most important factor that has to do with
the causation of leprosy.
Foi" disciission see end of Mr, Hutchinson's ijaper.
LEPROSY IN NATAL AND CAPE COLONY
BY
JONATHAN HUTCHINSON
Received 4th April, 1902— Read 27th May, 1902
Having recently returned from a short tour in South
Africa, undertaken with the object of inquiring as to the
causes of the prevalence of leprosy there, I am desirous
to submit to the criticism of the Royal Medical and
Chirurgical Society the conclusions which have been
arrived at. At the outset I may admit that although I
went, I trust, with an open mind as regards the reception
of evidence, it was not without strong prepossessions.
For now nearly half a century I have felt convinced that
the origin of leprosy must be in some way connected with
the use of fish as food. To this conclusion the general facts
as regards the distribution and prevalence of the disease,
its decline in some re^ons and its persistence or even
increase in others, seemed conclusively to point. As years
have gone on and evidence has accumulated, this convic-
tion gained strength, and also assumed better definition.
At the same time I have, in common with many other
observers, been inclined to discredit the opinions of those
who hold that contagion is the principal, if not the sole
cause of the spread of the malady.
Such being my convictions, a study of the facts offered
by South African observers as to the conditions under
which the disease had developed and was spreading in
their regions, led me to believe that a quite exceptional
VOL. LXXXV. 11
162 LEPROSY IN NATAL AND CAPE COLONY
opportunity was afforded for an attempt to solve problems
of great importance. The disease in Cape Colony had
been only recently introduced, and was as yet only very
sparingly prevalent ; whilst in Natal and some other parts
its first occurrence was of yet more recent date/ and its
dissemination yet more scanty. In countries where it
has long been endemic and prevails extensively, the
possibilities as regards hereditary transmission and con-
tagion become so inextricably mixed up with those as to
fish-food, that it is almost impossible to feel confidence in
any conclusions which may be suggested. It occurred to
me that in South Africa, with a quite recent development
of the disease in virgin populations, representing very
different races, and scattered sparingly over immense
tracts of country, the facts might be more easy to deal
with. I was further encouraged by the knowledge that
these facts had already received the attention of the
Colonial Governments, at whose request the district
medical officers — a body of men second to none in
intelligence and capacity for such observation — had made
local inquiries, the results of which would be available.
A further stimulus was added by statements which came
from the Natal colony, to the effect that there the disease
occurred to those who never, under any circumstances,
eat any kind of fish. In addition to examining the facts
as to leprosy itself, it seemed desirable to obtain detailed
knowledge as to the extent to which fish is employed as
food in the different regions of South Africa, and the
conditions under which it is supplied. On these and
other subjects I had previously sought information by
correspondence, and with only very partial results.
It may be convenient at the outset to say a few words
as to whether or not leprosy is a new disease in the
districts in question. In the more northerly parts of Africa ;
^ In Captain Lucas's report of evidence before the Commission in
Natal, 1886, he states that he made inquiries of Mr. Osborne (residing
in the Zululand Eeserve), who made investigations and could not find
that leprosy was known or had ever been heard of in the Zulu country.
LEPROSY IN NATAJ. AND CAPE COLONY 163
about the Zambesi, the great Lakes, Lake Chad, and on
both the west and east coasts there is no doubt that it
has long prevailed as an indigenous disease. As regards
South Africa the facts are, however, in dispute. The dis-
pute concerns the Hottentot (or Gariepine) races only ; for
all admit that in the eastern districts amongst the Bantu
tribes (Kaffirs and allied races) it was unknown. The
evidence as to the Hottentots is almost none, and it is
quite certain that if they knew the disease before the
Dutch occupation ifc was to an exceedingly small extent.
No Dutch record of such disease occurs, and the Dutch
settlers were well familiar with it in other colonies. The
first record of leprosy in South Africa was in 1756, when
three Dutch persons living on a farm at Stellenbosch, near
to Cape Town, were found to be its subjects. A Govern-
ment inquiry was made, the records of which are extant,
and not a hint is given that the disease was known
amongst the Hottentots, who at that date were engaged
in large numbers as slaves on the farms. During the
next fifty years the Government records are silent as to
the disease, but at the end of that time disquietude was
manifested in the Cape Town district on account of its
gradual increase. Two or more different contentions
may be sustained as to the mode of its introduction
into, or of its origin in, the Colony. It is undoubted
that the Dutch had brought over detachments of Malays
who were to catch and cure fish in Table Bay and
at other places on the coast, and it is certain that the
farmers were at that period feeding their slave-labourers
on rice and salt fish. The Dutch are, as a race, fond
of salt fish, and it may be plausibly suggested that the
first victims had developed their malady de novo from
using this food, and that they were but the first drops of
a shower which was about to fall over the whole district.
On the other hand, it may be suggested that they obtained
the disease by direct personal contagion either from their
slaves or from some Malay or other immigrant, who
brought it from the East. It may be remarked in passing
164 LEPROSY IN NATAL AND CAPE COLONY
that not the slightest suggestion of either of these modes
of introduction occurs in the Government records. If it
were granted that the Hottentots had the disease^ the
question — unanswerable, I submit, by any contagionist —
remains, " Why had it not spread among them ? ^' Their
conditions of life were such as to pre-eminently favour
the spreading of a contagious malady, yet it is admitted
on all hands that it did not become common among them
until they came under the influence of Dutch masters.
Excepting in the introduction of some new article of food,
no change in their habits can be mentioned which was
likely to conduce to the spread of any specific disease. It
appears to my mind, therefore, that the contagionist would
be wise to abandon the suggestion that the Hottentots
had the disease at all, for it would prove too much. There
is no doubt, however, that eventually the Hottentots and
their bastard descendants were the chief sufferers from
it. They are so to the present day. Nor is there any
doubt that a certain number of Kaffirs who have ac-
quired leprosy attribute their disease to association with
Hottentots. This suggestion is, however, as we shall see
presently, capable of a quite different explanation, and may
be held to prove nothing more than that the person making
it has been into Cape Colony, where Hottentots abound.
It may perhaps not be considered inappropriate to
interpolate here a few words as to the use of the words
Hottentot and Kaffir, and as to the present distribution
of races in South Africa. It was of course with Hotten-
tots only that the early settlers came into contact. They
inhabited all the western and south-western part of South
Africa, and it was only at a later period that white men
came into collision and intercourse with a totally different
race consisting of many various tribes now known to be of
Bantu stock. It may be convenient in this paper to speak
of these Bantu tribes as " Kaffirs/^ As regards the distribu-
tion of the two races, it may be understood that Hotten-
tot tribes occupied the western half of South Africa, and
Bantus or Kaffirs the eastern. Both were pastoral and
LEPKOSY IN NATAL AND CAPE COLONY 165
relied chiefly upon their flocks and herds for food^ but the
Kaffirs were also to some extent cultivators of the soil.
Neither the one nor the other were fishermen, nor did
they specially frequent the sea-coast, but it is possible
that, on occasion, those who did so ate molluscs and other
easily obtainable products of the water. It is certain,
however, that they were not addicted to fishing, and that
they did not attempt to salt or cure fish. The Hottentots
had no prejudice against fish, and appear to have taken to
it freely when their Dutch masters placed it within their
reach. The Kaffirs, on the other hand, had, almost univer-
sally, a strong prejudice against fish, so strong that many
authorities state that they would on no account touch it.
I shall have to deal with the Kaffirs when I come to con-
sider the introduction of leprosy into Natal, and its pre-
valence there and in the districts which used to be known
as Caffraria. For the present we are concerned only with
the Hottentots, for it was amongst them that leprosy first
spread, and to whom for nearly a century it was probably
almost wholly confined. In former times there was con-
stant feud between Hottentot and Kaffir. The races did
not mix nor come into any sort of social contact. The
advent of Europeans has largely modified the state of
society as we find it at present. The pure Hottentot has
been supplanted by a hybrid race of mixed Dutch extrac-
tion now known as " Cape boys," and race-antipathies have
to a considerable extent disappeared. It is even said that
in some parts Hottentots and Kaffirs have intermarried
and become the parents of a mixed race. As a natural
result of this, aided by the introduction of Christian
teaching, the Kaffir prejudice to fish as food has become
modified, and many Kaffirs will now catch and eat fresh
fish, and a still larger number will eat it freely in the
altered condition in which it is presented after being salted
or dried. A general observation of much importance to
our present inquiry is that both Hottentots and Kaffirs
are very prone to wander about the country. The labour
market over the whole of Cape Colony is to a large extent
166 LEPROSY IN NATAL AND CAPE COLONY
supplied by Kaffirs who have left their native hills in the
hope of earning money to buy wives and cattle. They do
not migrate with intent to settle, but purpose to return to
their kraals as soon as their object is attained. In Tem-
buland I was assured that there was scarcely an adult
native who had not done his wanderjahre, visiting Cape
Town, Grahamstown, Kimberley, or Johannesburg. Nor
was this willingness to wander confined, my informants
stated, to men. Many young women had, I was assured,
lived for a time as servants in the large towns, and after-
wards returned to their homes to marry and settle.^
The first cases of leprosy observed in Cape Colony
were, as already stated, in Dutch farmers. This was in
1756. The place was Stellenbosch, a small town not
twenty miles from Cape Town itself, now the Nuremberg
of South Africa, as containing the oldest and best pre-
served relics of the original settlers. No further reference
to leprosy occurs until 1817, when the disease had so
much increased that a leper home, under the care of
Moravian missionaries, was established. Its site was a
valley in the mountains near to the now fashionable
watering-place of Caledon, and not far from Stellenbosch.
Hemel en Aarde received lepers for twenty-eight years, and
during that period had a total of 400 inmates. It was
visited by a very intelligent traveller, Mr. James Back-
house, of York, in 1835, who records that he found it with
1 A source of many errors in our inferences as to the incidence of
leprosy in different places, is forgetfulness of the fact that the lep«r
may have acquired the disease in some place at a distance from where
he is found. The incubation period may be long, as long as a dozen
years in some instances, and thus there is opportunity for repeated
changes of domicile. In every instance in which leprosy occurs in a
region supposed to be exempt, the leper should be asked as to where ho
has lived in bygone years.
In England, at the i^resent time, there are probably not fewer than
from 50 to 100 lepers, but they are all imported cases.
It may be the fact that in Persia, Palestine, and many inland places
where only a few lepers are found, and but little fish is eaten, some
of the cases are imported ones. The Arabs in the north of Africa and
the Kiiilirs in the south ai'e notably migratory.
LEPROSY IN NATAL AND €APE COLONY 167
eighty inmates, chiefly Hottentots, and that the pastor who
superintended it told him that they did not consider the
disease contagious. After this, smaller leper homes were
formed in different parts, Graaf Reinet, Lovedale, etc.,
affording evidence that the disease was making its way
from west to east. In 1845 the Hemel en Aarde leper
home was transferred to Robben Island, and in 1894 the
Cape Government, in view of the difficulty of transporting
patients, and the expense of their maintenance on the
island, formed an eastern establishment in Tembuland,
which is now known as Em j any ana. At this latter, natives
only are received (with the fewest exceptions).
During quite recent years a leper home was constituted
at Pretoria, and just before the outbreak of the war the
Transvaal Government had built a larger establishment a
few miles from the town. With the exception of a little
home with six patients at the foot of the Bluff at Dui'ban,
Robben Island, Emjanyana, and Pretoria are, I believe, at
the present time the only places in South Africa where
lepers are received with the object of segregation.
Robben Island has 560 ; Emjanyana, 400 ; and there
are at large, i, e, not in confinement, in Cape Colony,
an uncertain number ; in the native territories of Caffraria,
500 ; in Natal, 200 ; and in Zululand, 8.^
Having thus briefly referred to the chief facts as to
races of South Africa and the early history of the spread
of leprosy amongst them, it is now needful to give some
facts as to the fish industry.
Although the bays and mouths of rivers on the coast
everywhere abound in excellent fish, nothing worthy of
the name of a fishing industry has ever existed on the
eastern or south-eastern shores, and until a very recent
period the adjacent districts were quite free from
^ Dr. Impey, in 1896, estimated the number of lepers in South Africa
as being (500 in Cape Colony itself, 250 in Griqualand East, the same
number in Basutolaud, nearly as many in Natal, whilst the Orange Free
State had only 150, and the Transvaal only 30. The location of these
numbers confirms the conclusion that the disease had spread from the
Cape Town district east and north.
168 LEPROSY IN NATAL AND CAPE COLONY
leprosy. On the western and soutli-western, on the con-
trary, at numerous places there have been colonies of
fishermen who, after primitive fashions, prepared fish, by
drying and salting, for use inland.^ Until recently these
have been chiefiy in the hands of Malays. The first was
in Cape Town itself ; but Kalk Bay, Mossel Bay, Saldanha
Bay, and other places soon followed. The fish was sent
inland in carts, and as roads were bad, it is probable that
it did not at first go very far. It is on record that it was
in great demand, and Bamberger, who in 1797 travelled
on foot through the Colony, and was repeatedly beholden
to Hottentot slaves for a meal, states that they shared
with him their rations, consisting of ^^ salt-Jish and rice.''
As roads were made, and more especially when railways
were constructed, we may assume that the salt -fish was
carried further and further inland. At the present day
large quantities are consumed in Johannesburg and the
other mining centres.
It may not be without its object to state that the first
South African leper who came under my own notice was
a Welshman who had been engaged in laying down the
railway to Kimberley. He told me that Cape salt-fish,
brought on by the rails, had been the principal article of
food for himself and his men. Our best means of
estimating the dietetic habits of the Dutch farmers of
that day is probably afforded by ascertaining those of
the present, and for this a single instance will serve.
Malmesbury is an old Dutch town in an agricultural
district about forty miles from Cape Town in the direction
of Saldanha Bay. Here I visited a fish-warehouse, and
saw the salted fish. I was told that the farmers bought
it regularly for their labourers, and that, often tempted
by the wholesale price, they bought much more at a time
^ Thus it will be seen that a fisher community may be exempt from
leprosy if the art of curing be not practised, and all the fish caught be
eaten fresh. A community which has long been accustomed to live on
fresh fish with impimity, or with but little leprosy, may experience an
outbreak of it if the art of curing be introduced. This occurred in the
case of the Sandwich Islands, and possibly in New Caledonia.
LEPROSY IN NATAL AND CAPE COLONY 169
than they could consume whilst in good condition. It
was not of a quality which would keep good more than a
fortnight.
Several Dutch farmers, now themselves inmates of
Robben Island, and from various districts, confirmed what
I had learned at Malmesbury, and said that it was usual
for the labourers to eat salt-fish for breakfast and supper.
The kind of fish here referred to is what is known as " sack-
fish/^ because it is sold in sacks, and is an article of
which our English market knows nothing. It is usually
prepared by steeping large fragments of coarse fish in a
very strong brine for about a fortnight, after which it is
allowed to dry, is packed in sacks, and will keep without
obvious decomposition for about three weeks. There are
several better kinds of dried and salted fish in the market,
but these fall to the share of the more wealthy. It is the
^^ sack-fish ^^ which is supplied to labourers, and which is
almost exclusively under suspicion as the cause of leprosy.
Enough has perhaps been said to prove that this kind
of fish has been in the past, and still is, accessible to
very large sections of the inhabitants of Cape Colony.
It would be by no means difficult to show that, in the
main, the districts to which it is chiefly supplied are
precisely those in which leprosy is most common. It
would, however, be tedious to attempt to do this on
the present occasion, and I may freely admit that the
data do not at present exist which would justify more
than general statements. A leprosy map for Cape Colony
has been constructed by Dr. Impey, and statistical tables
showing local prevalence have been compiled by Dr.
Gregory, the zealous and able Medical Officer of Health
for Cape Colony. Both these observers have, however, in
discrediting the fish-hypothesis, contented themselves by
observing that there is no proof of excessive prevalence
on the sea-coast. To this objection the reply is obvious,
that it is not where salt-fish is prepared but where it is
eaten that we must expect its ill results, and that the
chief object of salting is to allow of its being sent inland.
170 LEPROSY IN NATAL AND CAPE COLONY
Under certain special local conditions, absence of roads,
or periodically recurring inclemency of climate, the in-
habitants of fishing villages may be induced to eat the fish
which they have salted, but under other conditions they
may find it to their interest to send almost the whole of it
away. In the early days of Cape history we may believe
that the fish caught was eaten chiefly near to the places
where it was taken, and in those times, as I have already
said, the centres for leprosy were in the neighbourhood of
the bays on the coast. The conditions have, however,
changed, roads and railways have been made, and the
factors which now appear to influence the distribution of
leprosy appear to be : — agricultural as opposed to pastoral
pursuits, — a fairly dense population, in which the native
element (bastard Hottentot) largely predominates : — and
Dutch proprietorship. Exceptions to these statements
occur in the case of the great mining centres, but in them
the population is a migratory one, and, although many
may receive the germs of the disease, but few remain
there to develop it. As a rule leprosy is not encountered
in the large towns of Cape Colony, but in the agricultural
districts adjacent to them. In the latter it is scattered
sparingly, largo districts arc free, but here and there a
farm has its one, two, or three, and it may be known to
have existed for several generations. Nowhere are there
many cases, and rarely indeed does it affect more than a
few members of the same family. Many examples occur
of quite isolated lepers, — that is, of those who have lived
at their homes through the whole course of their disease
without communicating it. When it shows itself in
early life, very usually more than one member of the
family is its subject. Instances of the disease in two
brothers are far more common than those in which
husband and wife suffer together. My inference from
this is that children not infrequently acquire the disease
from contaminated food which an adult would avoid.
I may perhaps be permitted here to advert briefly to
the facts which, in other regions than South Africa, and
LEPROSY IN NATAL AND CAPE COLONY 171
not only in our own time but in ages long past, appear
to connect leprosy with the use of fish as food.
The disease is one which has prevailed in all ages, and
which, whilst by no means ubiquitous, has occurred to
almost all races and in the most varied climates. Its
sameness under all conditions wholly precludes the idea
that it can be produced by any accidental combination
of conditions, or that it has anything to do with mere
poverty. It has appeared to be incident to a certain
stage of civilisation, not the highest and not the lowest,
and it has prevailed in some populations coincidently
with religious maxims which necessitated a large con-
sumption of salt fish. It has wholly disappeared from
certain large territories where those maxims have lost
their force, and it still persists in others where they
still obtain (Spain and Italy). Roughly speaking, it
is now prevalent all over the world in ratio with the
salt-fish-consuming habits of the population. In almost
all places where it has prevailed a popular suspicion
has been entertained, and sometimes a strong one, that
it was caused by fish. Now there is no other article of
food which can be named, the use of which is common to
all leprosy districts.
It is the chief object of the present paper to maintain
two principal propositions, and to these I may now address
myself.
The first is that leprosy is undoubtedly communicable
from person to person, but that the mode of its communi-
cation is peculiar and does not come under the head of
contagion properly so called.
The second is that, whilst personal communication ob-
viously cannot explain the origin of any disease, the facts
as regards the origin and distribution of leprosy in South
Africa strongly favour the belief that it can arise de
novo as a specialised form of disease — possibly of tubercu-
losis— from the use of imperfectly cured fish.
As regards the first half of my first proposition, I well
know that my contagionist friends will tell me that I
172 LEPROSY IN NATAL AND CAPE COLONY
need not have gone to South Africa to learn that ; they
had long known that leprosy was communicable. But I
may perhaps be allowed to suggest that their belief was
in the main an inference from bacteriological theory, and
that it was supported by exceedingly little of clinical
evidence. The cases with which their writings teem as
instances of contagion are all of them open to the
objection that the disease might have originated de novo
from food, since they all occurred in communities where
the disease was prevalent and where fish was eaten.
The constantly-quoted case recorded by Dr. Hawtrey
Benson in Ireland was the only one in which this
explanation could not be given. In all the others the
supposed exposure to contagion might have been the
merest coincidence. I do not think, therefore, that the
evidence which I am now about to offer, and which will,
I trust, set at rest for ever the discussion as to communi-
cability, ought to be received by the contagionist school
with feelings other than those of simple gratitude.
The facts which convinced me on this point were the
following : — First, near to the village of Howick, in
Natal, on the open veldt, I saw young lads unquestionably
the subjects of leprosy, who had never left their native
kraals, and concerning whom it was morally certain that
they had never eaten salt-fish. They were living in the
same kraal with adults who were the subjects of leprosy
and who had probably obtained it in Cape Colony.
Subsequently in other parts of Natal 1 met with precisely
similar facts. Now leprosy is not endemic in Natal ; it
cannot be suggested that there are any conditions as
regards food or mode of life which can conduce to it.
The kraals are widely separated from each other on the
open hillside, and their inhabitants have usually enjoyed
good health. Leprosy is of recent introduction, and is
met with only very sparingly. In all instances in which
young persons were its subjects there was the history of
its introduction into the affected kraal by an adult who
had previously sojourned in a fish-eating district. That
LEPROSY IN NATAL AND CAPE COLONY 173
in these instances the young persons derived their disease
either by inheritance or personal communication seemed
indisputable, and the idea of inheritance appeared to be
negatived by the fact that often the young sufferers were
the nephews or nieces and not the children of the indi-
vidual who had originated the disease. Thus, then, the
inference seemed inevitable that the disease had been
communicated from one person to another. Nowhere,
however, had it spread to many. Its incidence appeared
to have been most erratic. A few had been taken and a
great many, who had apparently been equally exposed,
had been spared. Amongst the district medical officers
with whom I conversed exactly the same difficulties had
been recognised. With very few exceptions all thought
that the disease was in some way communicable, but all
admitted that it was most difficult to conjecture by what
means the communication took place. 1 am speaking now
of observations made in Natal, where little or no fish is
eaten, for over the whole of Cape Colony proper the use of
salted fish is such that no cases which may appear to imply
personal communication can be accepted as conclusive.
Reflecting upon the difficulties which the proved in-
stances of personal communication presented, it occurred
to me that it might possibly be by the discharges from
sores on the hands of lepers finding access to the stomach
on articles of food. The more I thought over this hypo-
thesis the better it seemed to fit with the ascertained
facts. Suppurating sores on the hands of lepers are in
certain stages very common, and they remain for a long
time. The Hottentots and Kaffirs are exceedingly careless
feeders, and there is nothing in the least difficult of belief
that food, fruit, or other dainties might be taken directly
from a hand so affected. This would be especially likely
to occur in the case of children. Inasmuch as it would
make communication a sort of accident, it would well
explain both the rarity and the irregularity of its occur-
rence. The subject is, however, of such importance that
I will venture in some detail to state the principal reasons
174 LEPROSY IN NATAL AND CAPE COLONY
which induce me to believe that this is the true
explanation.
The facts which seem to support the hypothesis that
in all cases in which the disease spreads from person to
person the bacillus is received by the stomach are the
following.
The first symptoms of leprosy are almost always those
of a blood disease. There is never any primary sore or
other indication of local infection. The earliest phenomena,
whether affecting the skin or the nervous system, are as
a rule bilateral, and imply blood contamination.
There is not the slightest reason for believing that any
recognisable peculiarity in individuals, either as regards
temperament or health, in any way predisposes to
leprosy.
It is impossible to believe in communication by the
breath, for attendants in leper houses, and others who
may be in constant and close communication with lepers,
never take it. It is also for the same reason impossible
to believe in contagion through the skin. To these argu-
ments may be added that it is very rare for both husband
and wife to suffer, and that many experiments in inocu-
latioii have been tried without result.
The arguments just advanced have been felt to be so
strong, by a large majority of medical observers, that prior
to the discovery of the bacillus there was a very general
disbelief in the contagiousness of leprosy. This was the
verdict given by the College of Physicians after a detailed
inquiry, and it was that of the best Indian authorities.
We are now confronted with the proved existence of a
parasite, and with evidence beyond dispute that in some
way the disease can be communicated. We are driven,
therefore, to seek the explanation of its communication in
some direction which has hitherto either wholly or in part
escaped notice, and which can be made to fit with the
very erratic incidence with which such communication is
observed to occur. Now the suggestion that the bacillus
is receiv,ed into the stomach by the direct contamination
LEPROSY IN NATAL AND CAPE COLONY 175
of food by leprous discharges does meet these conditions ;
such contamination of food is not likely to occur, except-
ing under conditions of extreme carelessness as to feeding,
and it is only amongst those who feed very carelessly that
proofs of the communication of leprosy are met with.
Amongst the cleanly communities of Europe and America,
although there are plenty of leper-patients who might
serve as sources of infection, no such communication
appears to occur.^
The question of de novo origin is so important that a
little further detail respecting it may be allowed.
In South Africa leprosy is rare, and is sparingly scat-
tered over very wide and thinly populated districts. The
disease has now been present for several generations, and
hereditary transmission is therefore possible. There is no
sort of doubt that family as well as regional prevalence is
not very infrequently noted. Yet it remains the fact that
as far as the evidence can be obtained, a great majority of
the cases which occur in adults are de novo cases.
One after another, both whites and coloured persons tell
us that no relative has suffered, and that they themselves
never saw leprosy until it occurred in their own persons.
This latter statement is the more credible because the dis-
ease is rare, and it would have been difficult for them to
find its subjects. In many instances it might have been
well-nigh impossible. I will quote directly some facts
1 The following is a most instructive statement of fact. 1 quote it from
Dr. Thin's pages^ where it is cited as if proving the value of isolation :
Dr. T. H. Hall has recorded a case in which " leprous families of negro
slaves in Bahia were exiled deep into the fertile woods of Northern
Brazil. In their exile they were furnished with means of rearing
poultry, pigs, goats, of fishing and trapping game, of cultivating
cassava, yams, plantain, maize, etc., and then they were left entirely to
themselves. Among these exiles, when visited after the lapse of many
years, leprosy was found extinguished ; a sound negro colony occupied
the place of the old leprous one." It would appear clear from this
narrative that in the migration inland the community left behind it the
real cause of the malady. It is clear also that personal communication,
imaided, was unable to maintain the disease. It died out.
176 LEPROSY IN NATAL AND CAPE COLONY
collected by myself, but before doing so I may adduce
some, offered without any preconceived object by an ob-
server who, if he had prejudged the question at all, had
done so in a direction opposite to my conclusions. Dr.
Impey, in his little manual on lepra, has published the
portraits of many who were under his care on Robben
Island, and he has given with each a brief account of the
patient^s case. In all he mentions particularly the family
history ; and presumably when he omits to specify supposed
exposure to contagion no facts on this head were to be
obtained.
He states, respecting one case, that the man had
cohabited with a leper ; and in another, that its subject
had worn a leper^s clothes, and had he been aware of any
similar risks run in any other cases, no doubt he would
have named them. He does not do so, and the omission
extends to thirty out of his thirty- two cases.
As regards family history, it is specially stated to be
absent in twenty-three out of the thirty-two cases. Thus
we find that a proportion of seventy-two per cent, of the
adults in the Robben Island establishment were, — so far as
Dr. Impey, who as resident medical officer had every
opportunity for investigating the facts, could sift them — de
novo cases. Most of the patients were men, and of the
dark races. Is it unreasonable to believe that such a
preponderance of negative evidence does really imply that
the disease was, in many instances at least, the result
neither of inheritance nor of personal contagion ?^
Statements precisely similar to those made to Dr. Impey,
were made to myself over and over again during my
investigations in Natal and Tembuland.
In entering upon my second proposition, that a diet
of salt fish is capable of originating leprosy de novo, and
that it has in South Africa been the one sole cause of its
origin, and by far the principal influence in its diffusion,
1 In the course of a Report on Leprosy in Kashmir, Dr. Neve tells us
that out of 143 patients 6 only had leprous relations, 47 knew of other
lepers in their villages, and 96 knew of no others in their vicinity.
LEPROSY IN NATAL AND CAPE COLONY 177
r am aware that many will think that I have a very
difficult task. To some it may appear almost absurd to
suggest that a malady, the phenomena of which are
certainly in connection with the presence of a specific
bacillus, can ever be of de novo origin. To such let me
explain that by de novo origin is meant origin independ-
ently either of contagion or inheritance, that is, with-
out personal transference of germ-material. It is not
meant that the bacillus can arise de novo, but that the
disease leprosy can do so. If leprosy can begin in a
community in which no lepers have previously existed,
then it is convenient to speak of such beginning as de
novo without for one moment suggesting that it comes
without the precedent occurrence of very definite causative
influences. It may be that, after all, leprosy is only a
modified form of tuberculosis, and that the same bacillus
has undergone modification in connection with peculiarities
in food supply. Without, however, allowing too much
weight to this or any other hypothesis, it behoves us to
look the facts fairly in the face. The discovery of the
bacillus and the admission which must now be fully and
freely made that it maybe transferred from person to person,
and that when so transferred it produces the full phenomena
of the disease, although invaluable evidence of the qnasi-^
specificity of the malady, are not facts which . cover the
whole ground. It still remains for us to examine whether
there are other modes apart from personal communication
by which the bacillus may gain access to the human
body, or by which it may, so to speak, be bred up into
specificity from a closely related organism.^
1 An exceedingly important question in connection with fish food and
leprosy is whether the fish simply serves as a vehicle for the introduction
of the bacillus into the system, or whether it only stimulates the bacillus
to activity. On the one hypothesis the continued use of salt-fish diet
might be of no moment when once the disease was contracted ; on the
other it may be very prejudicial. It is possible that the reason why
leprosy was regarded as incurable in the past was because fish food was
still supplied, and much of the credit which is from time to time accorded
to various modes of treatment in asylums and elsewhere may be simply
VOL. LXXXV. 12
178 LEPROSY IN NATAL AND CAPE COLONY
Taking syphilis as our best example of a somewhat
chronic disease of specific character which spreads by
contagion, and by contagion only, an instructive contrast
may be drawn between it and leprosy. Neither of them
show any regard to the race, the age, or the state of
health of those whom they affect. Syphilis is, however,
met with chiefly in towns, leprosy in country districts.
If either one of a married couple contracts syphilis and
cohabitation be continued, the other is certain to become
infected ; this is very exceptional in leprosy. In syphilis
there is a primary sore denoting the site of inoculation ;
none such is ever observed in leprosy. Experimental
inoculation always succeeds in syphilis ; never in leprosy.
Syphilis may be communicated freely in vaccination; it
is very improbable that leprosy can be so conveyed. If
syphilis has once got foothold in any town or community
it will maintain itself from generation to generation ;
leprosy, on the other hand, although well established,
often shows a most definite tendency to die out, without
any other assignable cause than gradual changes in the
social habits of the community.
The consumption, on a large scale, of the kind of fish
under suspicion, has been proved as regards many of the
districts in Cape Colony most affected with leprosy, and
shown to be at least possible in all.
We are now in a position to state definitely the
questions which are at issue in reference to the spread of
leprosy in South Africa. Eespecting the principal facts
there will, I think, be no dispute. It has advanced
steadily from west to east during the last century and a
half, and is now invading regions to the east of the
Drakensberg range, which were until recently free.
Not for a moment can it be contended that there has
been any change in the general well-being of the com-
munities involved, which would explain it. The malady
has proved no respecter of race, and those who have
due to the change in food and the abstinence from fish. No fish is now
supplied as a rule either on Robben Island or at Emjanyana.
LEPROSY IN NATAL AND CAPE COLONY 179
become its victims were still living under a sunny sky on
the slopes of breezy hills^ and exempt from hardship.
Two conjectures only seem possible. Either the disease
has spread by contagion or through the influence of some
article of diet which has been introduced during the
period under consideration. Now there is no doubt that
salted fish has been so introduced^ and there is no other
article of diet which can be suspected. The issue, there-
fore, lies between salt fish as a cause of the de novo
origin of the malady, aided occasionally by personal
communication as a cause of increased local prevalence,
and contagion pure and simple. There will probably be
no dispute as to the mode by which the disease has been
recently introduced into Caffraria and Natal. Contagion-
ists, as well as others, will accept the suggestion that it
has beexi carried there by men who have been into Cape
Colony. No one will wish to suggest that in these
regions it has originated in any sense spontaneously.
The question is, then, under what special influences were
these wanderers brought in the Cape district which
occasioned them to become lepers ? Were they the
victims of unsuspected contagion, or did they acquire it
by eating salt-fish ? In slightly varied terms the same
question is to be asked respecting all instances of the
advance of the disease in Cape Colony itself. I have
instanced Natal and Caffraria simply because in them
the problem is offered in its simplest and most definite
form.
I have made throughout this paper no concealment of
my own opinion that the chief cause of the spread of
leprosy in South Africa has been the use of salt fish and
not contagion, and it is not without some risk of repetition
that I now recapitulate the principal grounds for that
belief.
Putting aside the cases in which the disease has begun
in childhood, and in which personal communication may
be suspected, a large proportion of the adult lepers in
South Africa assert strongly that they have not had
180 LEPROSY IN NATAL AND CAPE COLONY
leprous parents, nor been in any way exposed to risk of
contagion. Many assert that they had never in their
lives seen a leper until the disease was disclosed in their
own persons. These assertions are made not only by
coloured persons but by intelligent Dutch farmers and
others. Of the latter class several were in confinement
on Robben Island when I visited it, and they all made
this statement, whilst they all admitted that they had
habitually eaten salt-fish. Negative statements of this
kind must always be received with caution, but when they
are repeated by one person after another it is impossible
to put them wholly aside. It must also be remembered
that leprosy is a very chronic and very conspicuous
disease. It cannot be concealed from relatives and
neighbours, and it often leaves indelible and well-recog-
nised traces behind it. If a man has leprous relatives,
his neighbours will know of it, and the dread of contagion
is such in the minds of most that any association with
strangers suffering from the disease would be most care-
fully shunned. When we remember also that the com-
munication of leprosy would appear to be possible only
under conditions of exceptional and most intimate inter-
course, I feel convinced that we may accept the statements
of patients when they say that they have never been ex-
posed to such risk. A large majority of the South African
cases are then, as regards both contagion and inheritance,
of de novo origin.
Another argument against the suggestion of contagion
is the scattered distribution of the disease and the absence
of any foci of great prevalence. Unlike syphilis, it is not
met with in large towns, but dotted, as it were, very
sparingly over very large agricultural districts. Many
cases are solitary ones, and although undoubtedly it some-
times affects several members of a family, there is no
record of its having spread as an epidemic in any village
or district.
Although scattered over the whole of British South
Africa, from the north of the Transvaal to the southern
LEPROSY IN NATAL AND CAPE COLONY 181
coast, it is by no means evenly distributed, and there are
large districts which are yet wholly free. On the theory
of contagion no explanation could be offered of its local
distribution, whilst the varying facilities in obtaining salt-
fish do to a large extent fit with the observed facts.
Excepting in cases of family prevalence, where personal
communication may be suspected, there is in South Africa,
as in all other regions where leprosy prevails, a marked
disproportion in the sexes. Three men to two women is
the usual result of statistical calculations, and were the
communication cases omitted it would probably make the
disproportion two to one. On the theory of contagion I
can suggest no explanation of this world-wide fact, whilst
in support of that of fish causation it may be plausibly
suggested that men engaged in labour eat more than
women, that men secure for themselves the larger share
of animal food, and that men are less prone than women
to object to articles that have been over-kept.
Thus then, in conclusion, I venture to say that the
hypothesis of bad-fish causation, taken together with the
admitted possibility of food-communication under certain
conditions, is one which satisfactorily meets the facts as
to leprosy not only in South Africa, but over the whole
world. To those who discredit it I throw the challenge
to produce any other which makes any approach to
doing so.
It is impossible to maintain that personal communica-
tion will explain it when in South Africa we find that of
those who, as physicians, nurses, etc., associate daily
with lepers no one over takes it, whilst of those who
become its victims four out of five believe that they have
never even seen a leper.
182 mscussiON on leprosy
DISCUSSION.
Dr. Gr. A. Hansen (Bergen), in opening the discussion on the
two papers read at the last meeting of the Society, expressed the
opinion that leprosy was solely contagious. From his first
pathological researches he had come to the conclusion that
leprosy was a specific disease, which should have a specific course.
Illustrations were given of foci of the disease, some of which, at
first sight, seemed to favour the old theory of inheritance ; but
it was pointed out that although the disease occurred in families
living together, yet it occurred as frequently in others living
together but not related. As to the supposed aetiology of leprosy
from fish eating, he thought that leprosy did not occur in many
conmiunities where ciu-ed fish was an ordinary article of diet. If
it were so the leprosy bacillus should have been found in the fish,
but that had not been done. The leprosy bacillus was very
difl&cult to cultivate, therefore it was difficult to believe that it
could survive for any length of time in salt fish. In regard to
the supposed de novo origin of the disease, its incubation period
was not so long as had been supposed ; it was probable that the
disease might be existent for several years in a patient but
concealed, and hence wide-spread infection might arise. The
disease always spreads along the channels of communication
between peoples, even among people who ate but little fish ; such
a channel of communication, for example, as that over the Alps.
Although as much fish as ever was being eaten in Norway, yet
leprosy was disappearing. From the time that isolation of lepers
was enforced — in 1856 — the diminution might be traced; this
diminution in Norway had been from 2870 cases to, approxi-
mately, 1500 cases. Their way of living was just as it was some
fifty years ago. The cause of the spread of the cases there had
been uncleanliness, leading by a certain prevalent intimacy of
intercourse — as that which required hospitality to share the
same bed with a guest — to contagion. Many lepers from Norway
emigrated to America, but there had been no spread of the
disease to the children or grandchildren of these, negativing the
hereditary theory. In Bergen very much fish was eaten, both
fresh and cured, almost at every meal, yet there was no leprosy.
Dr. GrEORGE Thin referred to the admission of Mr. Hutchinson
of the contagiousness of leprosy. The case shown by Dr. J.
Ha^^rbrey Benson was, in his opinion, a crucial case proving its
contagiousness. This observer showed to the Medical Society of
Dublin a case of developed leprosy that had come from the West
Indies. Several years after this patient's death his brother was
aifected ; the two brothers having occupied the same bed, worn
DISCUSSION ON LEPROSY 183
the same clothes, and used the same eating utensils. But this
case was not an isolated one: several others were alluded to
proving its contagiousness on intimate association. In relation
to the food theory, he had many years ago in China fed a leper
on a diet rich in animal food without any amelioration of the
disease. In one of the papers the predisposing cause was held
to be lack of animal food, in the other it was considered to be
due to eating a nitrogenous food. He remarked on the occur-
rence of leprosy without any obvious primary lesion. The leprosy
bacillus produced so little local irritation that it was possible
the actual entry of the bacillus might not attract attention;
microscopically, too, there were very few inflammatory signs.
It was possible that the entry of the bacilli might be by inhala-
tion, which was supported by the S3anmetrical distribution of
the lesions in some cases. The bacillus was shown by Campana
at a congress in Rome as growing in sugar agar, but it was
said that the bacilli, to give cultivations, must be taken during
the so-called leprosy fever. As to the de 7wvo theory, there were
no recorded facts to show that leprosy had developed anywhere
without the possibility of contagion. Lepers had been known
longer in Egypt than anywhere else, therefore Africa was the last
place to go to for de novo cases at the present time. The move-
ments of African tribes being so wide, it was quite likely that
cases might have reached South Africa from the northern or
interior parts. The fact that leprosy was not recorded among
the natives did not negative its possible existence. How could
the disease develop de novo without the bacilli developing de
novo ? The fish theory had been investigated by a commission
in India, who concluded that fish was not the cause of leprosy,
and that no form of diet had any specific influence. It was to
be hoped that even now some measures might be commenced to
mitigate the dissemination of leprosy in India — in the way of
segregation especially. Leprosy was introduced from China into
AustraHa, but by careful isolation its spread was prevented.
Wherever lepers went leprosy was apt to crop up.
Dr. Hansen considered that the disease was probably intro-
duced through the skin. There was slow development, but little
irritation, and often neglect of his condition on the part of the
patient. The antiseptic action of the gastric juice would pro-
bably prevent infection through the stomach.
Dr. Patrick Manson acknowledged himself a contagionist.
The spread of the disease was comparable to that of tuberculosis,
only it was a more difficult process. The staining characters of
the bacilli in each disease were similar ; the difficulty in cultiva-
tion was great in the case of tubercle, and almost insurmountable
in the case of leprosy ; the channel of introduction of either was
obscure. The difficulty of accepting the fish theory was very
great. It was not definitely stated, however, whether the fish
184 DISCUSSION ON LEPEOSY
eaten contained the bacilli, or that it merely lowered the bodily
resistance. It was allowed that much fish eating might not be
associated with leprosy. It was an acute observation of Mr.
Hutchinson that leprosy was a disease of an intermediate stage
of civiUsation, between the savage and the fully civilised man ;
the same applied to tuberculosis. No reference was made in the
first paper as to whether the Soudanese ate fish, fresh or dried ;
the negroes probably did not use salt fish. The dietetic theories
were neither of them conclusive. Beri-beri had itself been
attributed to a defect in the nitrogeneous element of food.
Defective diet was a favourite cloak for ignorance of aetiology.
Two concurrences were not necessarily related as cause and
effect. The occijrrence of ainhum had been held to be a mani-
festation of leprosy, but in his experience this was not so.
Was the elimination of a fish diet in Eobin Island followed by a
greater curability of the disease? In many cases of leprosy
which he had seen the first lesion was asjrmmetrical, and there
was no evidence of a constitutional disease. The principal
medical officer of Ceylon had recently told him that the Dutch
prisoners in Ceylon had succeeded in cultivating the leprosy
bacillus in a fish- broth ; if this were true it was a strong argument
in favour of the fish theory. The origin of the germs of disease
was probably in the remote geological past, and had been evolved
from those times in remote ancestors. The obstacles in the
way of ameliorating leprosy in India were almost insuperable
from the ignorance of a lay public. The mode of entrance of
the leprosy germ, as was suggested in Dr. Tonkin's paper, was
very Hkely by the use of infected clothing and bed linen. But
the spread of leprosy probably depended on a multipHcation of
opportunities, during some of which, by the fortuitous concur-
rence of certain necessary but rarely recurring conditions, the
disease became implanted ; hence the difficulty of the propaga-
tion of the disease. It was well known that malarial infection
was through the skin ; it was probable that the relatively large
parasite of ankylostomiasis similarly entered through the skin ;
and it could easily be understood how that the minute bacillus of
leprosy might likewise gain entry through the skin.
Sir William E. Kynsey said the use of dried fish in Ceylon
was almost universal, both as a staple food and as a condiment.
The importation of dried fish into Ceylon was enormous, the
greater part going up country. Leprosy was almost unknown
inland, but was prevalent in certain foci along the coast where
fresh fish was obtainable. In several instances of single cases of
leprosy in a family the patients had been wet-nui'sed, but he had
not lieen able to ascertain whether the nurses were leprous or not.
It was suggested that the bacilli might be in the milk. In
several instances it seemed that leprosy was associated with
vaccination.
DISCUSSION ON LEPROSY 185
Dr. Hansen said that in Norway there was no evidence either
of the .association of leprosy with vaccination or of the occur-
rence of the leprosy bacilH in human milk.
Sir Lauder Brunton had seen many cases of leprosy at
Jerusalem which resembled very much syphiHtic cases, and
especially were certain late cases of syphilis of the larynx similar
in their appearances to the lesions of leprosy. It might be
possible that in cases of leprosy there might be a mixed infection.
It was probable, indeed, that infection depended both on the
bacillus and on a special susceptibility. Such susceptibility
might depe?id on many factors, of which one was not unlikely
imperfect feeding, as in the case of tuberculosis. Professor
Unna had found that if any oxidising substance such as pyro-
gallic acid were appHed to a leprous sore it was made much worse,
and he also found that this could be counteracted by making the
blood less alkaline, as by the administration of hydrochloric acid ;
it therefore might be that by emdeavouring to render the blood
acid, not necessarily by giving hydrochloric acid, but by giving
nitrogenous food even, if it were only leguminous, the disease
might be stayed. The ground-nut in the Soudan, one of the
LeguminossB, might supply the necessary nitrogenous element for
the Soudanese. If people ate a great amount of fish they would
probably eat less of other food ; thus fish might act either by
replacing flesh food or by itself adding a substance to the blood
such as trimethylamine, present in herring brine, which would
favour the growth of the organism.
Dr. T. M. Young had seen much leprosy in Siberia, China,
India, and the west coast of Africa, and had been struck by the
active motility of the leprosy bacillus, suggesting a life history
outside the himian body, possibly in salted fish. He had not
found the leprosy bacillus so numerous in the leprous sores of
fishermen as in the deeper connective tissues. It was probable
that the bacillus Hved in the living tissues, and not in the tissues
being cast off, and that the disease was not spread by discharges
from sores. The eating of the different forms of fish did not, in
his experience, correspond with the distribution of leprosy.
Dr. Heron had served on a committee ten years ago with
Mr. Hutchinson to consider the findings of the Leprosy Commis-
sion. As Mr. Hutchinson had adopted the theory that leprosy
was a communicable disease it was surely not necessary for him
to adhere to the fish-eating theory, every part of which was
indeed pure theory. A valuable test would be the finding of
leprosy bacilli in dried fish in the laboratory. Alluding to the
report of the committee on the Leprosy Commission, out of 464
lepers 99 had never tasted fish ; 162 lepers in asylums scattered
all over India had not eaten fish; some of these came from
high up in the Himalayas, and several had never seen fish. Of
200 lepers examined by the Commission, 39 habitually, 57 occa-
186 DISCUSSION ON LEPROSY
sionally, 68 seldom, and 46 never ate fish. All the arguments
in the paper more strongly supported the contagion theory than
the salt-fish theory.
Dr. Alfred Hillier had seen cases of leprosy in Africa, both
in the south and north. The exclusion of fresh fish seemed in
his opinion rather against the fish theory. The fact that a leprous
patient had never, as he believed, seen a case of the disease before
had not much significance, as the malady was easily overlooked
and often disregarded. The communicability of leprosy by con-
taminated food was quite understandable. Eating of salt fish
was prevalent in certain parts of the home country, and yet there
was no leprosy. Leprosy had all over the world vanished with
the spread of sanitary conditions.
Mr. Tonkin, in reply, said that with regard to Mr. Hutch-
inson's paper, he was in agreement with the opinions expressed
in it so far as this — ^that a dietetic factor determined the occur-
rence of leprosy. That the dietetic factor at fault, however, was
an article of diet, and that article fish, he thought hardly so pro-
bable. The fish hypothesis did not appear to him to be capable
of sufficiently wide application to account for all the facts con-
nected with the spread of the disease. Among the circumstances
surrounding leprosy in the Sudan, fish played but an insig-
nificant part. Fish was rarely used by the people as an article
of diet. It was certainly consumed in the parts of the country
affected by leprosy, but to a small extent. In Upper Hausaland
fish-containing water was scarce. The river element was mainly
represented by beds that contained torrents during the rains,
and were waterless, or only occupied by chains of more or
less widely separated pools, during the dry season. Owing to
the difficiilt and dangerous nature of the country, transport
from more freely watered districts was expensive, and was
therefore generally occupied with more valuable freight. He
would grant that what fish did come into this part of the country
was of an extremely doubtful nature, but, owing to the circum-
stances lie had stated, its amount was small — so small indeed as
to be negligible.
During the whole course of the stay of the Hausa Association's
Expedition in Kano town and province, the district generally
looked upon in the Sudan as the most leper- stricken, fish was
only offered them for sale on one occasion. In the country shops
and markets one rarely saw it; even in the biggest towns it
could only be procured after a more or less prolonged search
for it. Kano market was the greatest market in all central
Negroland. During the dry season from twenty to thirty
thousand people might often be seen on it at one time ; a thing
that could be bought anywhere in this part of the Sudan could
l)e bought there. Yet, to illustrate the inconspicuousness of the
fish element, he would call attention to the significant facts that
DISCUSSION ON LEPROSY 187
Dr. Henry Earth's minute description of this market, written in
the early fifties, contained no mention of fish ; that neither of the
descriptions that had appeared in his late companion Canon
Robinson's two books, * Hausaland * and * Nigeria,' contained any
mention of it ; and that his own Hsts, carefully compiled from
daily notes, and reaching a total of nearly ninety articles and
classes of articles, did not include it among the number. Fish
in any form was rare in the central parts of Northern Nigeria,
and it was in those parts that leprosy was most prevalent. The
conditions obtaining in the neighbourhood of Lake Chad were
roughly parallel. There was, he beheved, when and where the
water was accessible, a certain amount of fish caught in the lake
on aU its sides, but it was only at the north-western angle that
the business was sufficiently highly organised to be called an
industry. Without arrangements for catching on a large scale,
and for transport of the catches that were made, the influence of
a sheet of fish-bearing water, no matter how large it might be,
could extend Httle further than the immediate dwellers on its
shores. So far as he knew, no such arrangements existed on
Lake Chad except at its north-western end. In that locality
there was a town that might be called the Grimsby of the Chad.
By the inhabitants of that town fish in considerable quantities
was caught, prepared, and exported, but the stream of exportation
was not into the leper- stricken Sudan, but entirely northward
into the Tebu country, a country in which no leprosy was reported
to exist. He said that this state of things pointed to a small
consumption of fish in the leper area in the Sudan, and he did
not think, therefore, that the supposition that fish was intimately
connected with the dissemination of leprosy would, even on
further examination, be found to receive much support from the
facts pertaining to the spread of the disease iu that region.
Mr. Hutchinson, in reply, stated that he regretted the short-
ness of time which was at his disposal. He did so the less,
however, because, for the most part, those who had spoken had
not dealt with the facts stated in his paper, but had been content
to enunciate their own opinions. Dr. Manson was the only one
who had brought any new facts into the discussion, and his
statements as to the hope of cultivation of the bacillus on fish
were of great interest. He (Mr. Hutchinson) lived in the daily
hope that some one would announce the discovery of the bacillus
in decomposing fish. It was, however, an inquiry needing great
patience, for if present it is in aU probability rare. If it were
common, leprosy would be much more general than it is. All
who had spoken had slurred over the difficulties which surround
the theory of contagion in the ordinary sense. The failure of
attempts to inoculate leprosy ; the facts that husband and wife
very rarely suffer together and that the healthy inmates of leper
asylums never contract the disease, were, to his mind, conclusive
188 DISCUSSION ON LEPROSY
against it. It was supported in South Africa by the almost
universal assertion of those who suffered that they had never
consorted with lepers or even seen them. In reply to Dr. Thin
he said that he held it to be a pure delusion that in the Middle
Ages segregation measures were the cause of the disappearance
of leprosy. There never was any real or efficient segregation,
and the leper homes were for the most merely retreats for those
who wished to resort to them. The same statement applied, he
felt sure, to what was now taking place in Norway. There also
there was no segregation which would be efficient on the theory
that the disease spread easily by contagion. One third of the
Norwegian lepers were still at home with their friends. The
disease was, moreover, disappearing just as rapidly in Madeira,
where no attempts whatever were made at compulsory segrega-
tion. As regards practical measures, he added that he would be
quite prepared in South Africa to do away with all compulsory
segregation, and to allow the lepers to return to their homes.
They should be under supervision, and should be well warned as
to the risk of commensal communication. It was probably an
exceedingly small one. Above all, the fish-curing trade should
be controlled. If no badly cured fish were allowed to get into
the market, it was his opinion that leprosy would soon cease to
exist.
THE POSSIBILITY OF RECOVERY
FROM THE
ACTIVE STAGE OF MALIGNANT
ENDOCARDITIS
ILLUSTRATED BY OASES AND SPECIMENS
BY
WILLIAM EWAET, M.D., F.E.C.P.
AND
A. S. MOELEY, L.E.C.P., M.E.C S.
Received February 11th— Read April 22nd, 1902
Clinical and post-mortem observations in the cases to
be narrated seem to warrant the conclusion that in its
infective stage malignant endocarditis may be amenable
to treatment, and the purpose of this paper is to urge the
necessity for early diagnosis and for adequate treatment
before irremediable structural damage has bccurred. Its
fatality is great because those who do not succumb early
to the infection almost inevitably die of some of its late
results. Instances of both these modes of termination are
190 THE POSSIBILITY OF RECOVERY PROM THE
afforded by the following three fatal cases which were
simultaneously under observation.
Cases of recovery from ulcerative endocarditis are not
unknown in the modern annals of medicine. As in most
of the published cases ocular evidence of the cardiac
lesions was not obtained, there must remain some doubt
as to the severity of the attack and as to the existence of
the disease in its worst form. Fatal cases afford evidence
as to the nature and extent of the lesions, and as to their
progressive or regressive character ; and cases such as
two of the present ones, where death interrupted the be-
ginnings of reparative changes whilst revealing the pre-
sence of the destructive lesions of malignant endocarditis^
are capable of supplying collateral evidence on the question
of the curability of the disease, particularly when, as in
them, some clinical improvement had occurred in association
with the arrest of the local morbid process.
A simultaneous study of the clinical aspects of the
three cases which ran a protracted course illustrates
various points in the natural history, in the pathology, in
the diagnosis, and in the prognosis and treatment of the
disease. But the chief conclusions to be drawn from
them are based upon the contrast in their pathological
appearances. A careful inspection of the three hearts
shows that the primary endocardial lesions may, as in one
of them, continue to the end to be progressively destruc-
tive ; or that, as in the other two, they may make room
for changes of repair.
This pathological contrast agrees with the clinical
differences. In one of our cases death resulted from
the local disease, in the other two from its more remote
consequences, whilst in the latter the slight improvement
noted towards the end suggested the view that the infec-
tive virulence of the disease was on the decrease.
Case 1. — C. B — , aged 17, a pale, emaciated, nervous
girl, was admitted on April 1st, 1901 (Med. Eeg., No. 565),
complaining of severe cough, great debility, faintness,
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 191
and palpitation. The mother had formerly suffered from
rheumatic fever. The patient had enjoyed previously
good health, spending most of her time out of doors. In
December, 1900, she was laid up in bed for eight days
with severe pains in the left leg and hip, and soon after
she was laid up with pain in the left foot for three
weeks. For the last two months she has had dyspnoea
and palpitation, and progressive wasting. On admission
she was so pale and thin that the diagnosis of severe
phthisis was that which occurred at first sight, and this
seemed to be borne out by the aspect and complexion, the
wasting of the muscles of the thorax, and the complaint
of cough. The pulse was compressible and 140 per minute;
the respirations 48 ; and the temperature 102*2° F. The
breath was extremely foul owing to the neglected state of
the mouth. The throat was dry and injected. The tongue
was dry, cracked, and furred.
On examination the thorax does not move freely, and
the left ribs are more prominent than the right, though
there is no scoliosis. The pulmonary resonance is
defective at the left base.
Heart, — The apex beats in the nipple line in the fifth
space. There is a loud systolic murmur and a doubtful
presystolic murmur and thrill, with an accentuated second
sound at the apex. The pulmonary second sound is
accentuated with a loud pulmonary systolic murmur.
On April 3rd she complained of pain in the feet, which
were a little red and swollen.
On April 15th a cough, accompanied by some blood-
streaked expectoration, appeared, and a few crackles with
diminished resonance were detected at the right supra-
scapular fossa. The temperature was very irregular
throughout this period, ranging from 103° to 99° F.
There were occasional night sweats. These symptoms
and signs, together with the aspect of the patient, led to
the adoption of the original diagnosis of tubercular
phthisis with rheumatism and mitral stenosis. She had
been treated throughout this time with salicylates and
192 THE P088IBILITT OP RECOVERY PROM THE
potassium iodide and quinine pills. Her mouth had been
carefully disinfected and her bowels regulated. From
April loth to April 23rd she was taking gr. j of protargol
in ^ss of distilled water three times a day, and gias of
Easton's Syrup. The diet had been restricted for a few
days to milk, and was then gradually increased till a
very Kberal diet with minced meat and vegetables was
allowed.
On April 18th she had somewhat improved in colour,
and the night sweats had been controlled' by atropine.
On the 2Ist she became drowsy and complained of
intense headache. The murmurs varied from day to day,
and on the 24th the condition of the heart was reported
as follows : — " Apex -beat in fifth space jnat outside the
nipple line. The beat is diffuse. The right ventricle is
not much dilated. At the apex there are a systolic and
a diastolic murmur ; the first sound is loud and flapping.
Both sounds at the base are suggestive of murmurs. The
action is somewhat cantering and irregular."
On the 26th the headache and drowsiness persisted,
and tuberculous meningitis was suspected.
On the 28th she was somewhat better and the drowsi-
ness and headache had quite disappeared, but in the
early morning of the 29th she suddenly died of syncope.
Teupeuatube Chabt of Case 1,
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The post-mortem examination revealed a large patch of
heavy, grey, necrotic vegetations at the mitral valve, ex-
tending into the left auricle. Some of the chordte ten-
dineae of the mitral valve had ulcerated and ruptured.
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 193
The heart was slightly dilated and hypertrophied. Peri-
cardial adhesions of some standing occurred over the left
ventricle and over the anterior surface of the right
ventricle.
The lungs showed no signs of phthisis. There were no
pulmonary infarcts ; but the spleen, which weighed 19 oz._,
presented small white infarcts and a rather larger haemor-
rhagic infarct. The kidneys also contained three or four
white infarcts and several recent ones. The brain weighed
3 lbs., and was apparently normal.
Case 2. — E. I — , aged 14, a dark intelligent girl with
sharp features, was admitted on April 9th, 1901 (Med.
Reg., No. 614), complaining of palpitation, dyspnoea,
and cough. There was a family history of rheumatism.
She herself had had measles as an infant, and rheumatic
fever two years previously, for which she was treated in
a children's hospital.
On admission she was remarkably pale and emaciated.
^^ Her teeth and gums in a very had state. Tongue clean.
Fingers clubbed and bluish. Thoracic movement defi-
cient, and myoidema very marked. Lungs : tympanitic
all over, except at the apex of the right lower lobe,
which is dull. Heart : apex in fifth space, almost in the
left mid-axillary line. At the apex there is a marked
thrill with a presystolic and diastolic murmur; and at
the aortic site a diastolic thrill, with a systolic and diastolic
harsh murmur conducted down the sternum. The
diastolic murmur is occasionally distinctly musical. The
liver is enlarged to two inches below the right costal
margin. The urine contains much albumen and a deposit
of phosphates. Blood examination : the red cells number
3,000,000, and the white 15,000 per c.mm.''
A provisional diagnosis of aortic and mitral disease and
of phthisis was made at first, but in a few days the
remittent temperature and the changeable murmurs, to-
gether with the leucocytosis, led to the diagnosis of
malignant endocarditis, which was subsequently verified.
VOL. LXXXV. 13
194 THE POSSIBILITY OF RECOVERY FROM THE
On April 10th some pus appeared in the urine. The
physical signs remained unaltered. The sputum was
examined, and no tubercle bacilli were discovered.
On April 20th the presystolic murmur was much less
marked, but the aortic diastolic was intensely loud and
musical, with a very distinct shock perceptible on palpa-
tion. The lungs were drier, and no adventitious sounds
were audible. The temperature was still markedly hectic,
and the pallor was increasing. The pyrexia persisted.
The treatment had consisted of tonics, uro tropin, cod-
liver oil and malt, and ichthyol administered internally,
and of disinfecting lotions for the mouth.
On May 2nd a course of daily injections of anti-
streptococcus serum (5 c.c.) was commenced. The effect
of these was to produce great mental depression, the
patient becoming lachrymose. The following day some
red blotches were observed scattered over the face and
arms ; these, however, rapidly disappeared. There were
no rigors.
On May 18th the musical aortic murmur was replaced
by a soft blowing murmur. The emaciation had in-
creased although the face appeared full in the parotid
region. There w.us slight bronchitis at the time.
At the end of May she was occasionally delirious at
night. She ate her food greedily, and, except for fits of
depression after the injections of the serum, was fairly
cheerful. The pyrexia persisted, and there were a few
attacks of pain over the liver and spleen. On one
occasion distinct friction was felt and heard over the
liver, and suggested the possibility of hepatic infarct with
perihepatitis. On another occasion after an attack of
pain a little blood was found in the urine, possibly due to
a renal infarct.
On May 24th a 20 per cent, ointment of protargol
was ordered to be rubbed into the skin twice daily as in
the third case, and this was continued throughout.
On May 27th a tonic containing T. Digitalis v\iv, Liq.
Strych. Dj^iij, Liq. Hydr. Perchl. i^lviij, and T. Ferri Perchl.
ACTIVE STAGE OP MAlIGJJAJiT ESDOCARDITIS
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196 THE POSSIBILITY OF RECOVERY FROM THE
v\Yu] was prescribed on account of the " canter rhythm ^'
observed. This had the effect of quieting the heart and
of improving its force. On June 10th a pill of nitrate
of silver, gr. -^-^^ was ordered to be taken three times a
day.
Since that date the case pursued much the same
course.
The hectic temperature with high evening rises con-
tinued to the end, and she never left her bed. During
the last three weeks, however, there was decided im-
provement in the appetite, in the aspect and manner, and
in the strength, and she sat up in bed unsupported at
frequent intervals during the day. A definite hope was,
therefore, entertained of her ultimate recovery. Death
occurred rather unexpectedly on July 8th, after a short
period of dyspnoea.
Post-mortem. — Both pleural cavities contained moderate
effusions. The pericardium contained about 4 oz. of fluid.
The spleen was firm, and weighed 11 oz. The liver
presented a nutmegged appearance. The left kidney was
the seat of a congenital hydronephrosis. There were no
infarcts in these organs. The presence of malignant
endocarditis was verified. The affection was limited to
the base of the aorta and the semilunar valves, which
were thickened by granular and beady deposits. To one
of them, that nearest the mitral orifice, a delicate flat
ribbon-like pedunculated vegetation, about half an inch
long, was attached. This was slightly rough and yellow-
ish, as if atheromatous, with some pink staining. Where
this appendage came into contact with the arterial surface
above, an uneven but perfectly clean ulceration was
found, nearly one third inch in diameter, which perforated
the vessel wall as far as the adventitia.
Search was made for necrotic grey vegetations, but
none were found, either at the surface of the ulcer, which
was perfectly clear of loose deposits and apparently in
process of healing, or at the damaged valve, the beady-
deposit of which was mostly of glistenicg aspect, not
ACTIVE STAGE OP MALIGNANT ENDOCAEDITIS 197
rough or granular. There was no parietal endocarditis.
The tricuspid and the mitral membranes were also
perfect, and the auriculo-ventricular orifices and the
auricles normal.
The right bronchial artery, which was of large size in
connection with the cardiac malformation, was thickened
and roughened by yellow atheroma, almost from the point
of its origin. A loose atheromatous yellowish plug, about
half an inch in length, was removed from the vessel.
The cardiac conditions described were such as would
produce very free aortic reflux as well as a systolic bruit,
and the regurgitation was probably sufficient to have
interfered with the diastolic rise of the anterior mitral
flap ; but the mitral valve presented no structural change
whatever in the direction of stenosis. The heart was
large, and the two ventricles presented almost equal thick-
ness of wall and equal dilatation. This was connected
with a remarkable anomaly, viz. complete absence of the
pulmonary artery with considerable deficiency of the
septum, which need not be insisted upon, as the specimen
will be exhibited and the condition fully described before
another Society.
Remarks, — As regards the cardiac anomaly, there was
nothing in the history prior to the rheumatic fever to
lead to congenital disease being suspected. Although
rather small for her age the child was not cyanotic, and
her breathlessness on exertion had been chiefly noticed
since the rheumatic fever. The diagnosis was correct as
regards the causation of the double aortic murmur, and as
regards the presence of malignant endocarditis. But mitral
stenosis was, as so often happens, diagnosed where it did
not exist. At most there may have been pressure upon
the anterior mitral flap from aortic regurgitation.
It is noteworthy that in this case few traces of
embolism were found except a yellow deposit in the right
lung, which proved, on examination, to be beset with
tubercle bacilli. At the necropsy there was no evidence
of any recrudescence of the virulent a^ection. The heart
198 THE POSSIBILITY OF RECOVERY FROM THE
lesions, with the exception of the brittle appendage, were
apparently in process of healing.
In this case, as in Case 8, the rheumatic diathesis
and the oral sepsis were prominent aetiological factors.
This leaves us in doubt as to which of these infecting
agents may bear the responsibility for the cardiac changes.
The diagnosis of ulcerative endocarditis had been
obvious a few days after her adnlission, owing to the
hectic temperature, the pallor, the night sweats, the
emaciation, and the changing cardiac murmurs. But the
measures of treatment did not prove adequate. In par-
ticular, the injections of antistreptococcus serum were
disappointing both in their failure to benefit the condition,
and in the depression which they undoubtedly occasioned.
Some improvement was apparent after the inunctions of
protargol were commenced, and after silver nitrate was
administered. Meanwhile the internal treatment by heart
tonics and perchloride of mercury was continued, and to
the action of these remedies some share in the slight im-
provement may be ascribed.
Cask 3. — H. B — , traveller, aged 32, married, was
admitted into St. George's Hospital on April 28th, 1901
(Med. Reg., No. 741), and died on June 9th, greatly
emaciated and exhausted, after a long illness, beginning
in November, 1900. For the early notes of the case our
thanks are due to Dr. A. H, Newth, of Hay wards Heath.
The patient's previous health had been good, excepting
gonorrhoea at the age of sixteen, scarlet fever at the
age of nineteen, rheumatic fever at the age of twenty —
from which he made a good recovery, — and two or three
years ago some acute gastritis with anaemia ^ His habits
formerly had been rather alcoholic. The family history
mentions the death of a sister of " phthisis,^' and tempo-
rary hysterical insanity in anotJier sister. The present
illness began in November, 1900, with severe rigors, but
he went on with his duties for a month afterwards. He
was then seen by X)r. George L. Johnson, of Woolwich,
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 199
who reports he was suffering from acute gastric catarrh,
with congestion and evidence of early cirrliosis of the
liver, and from head and back pain, probably due to
influenza with abdominal complications. No albumen or
sugar had been found in the urine.
On January 26th, 1901, he came under Dr. Newth^s care,
whose report is as follows : — "Patient very much emaciated;
no cough, nor dulness in lungs ; liver somewhat contracted ;
spleen enlarged. No rigors, but night sweats, saturating
clothes and blankets. Obstinate constipation. No albumen
nor sugar. The blood did not show any remarkable excess
of leucocytes, but the globules were crenulated, and there
seemed to be a large quantity of free nuclei, and also
some blood plaques. The night sweats improved under
quinine, nux vomica, nitro-hydrochloric acid, purgatives,
etc. ; the urine became normal and the sweating lessened
considerably, so as to be almost insignificant. He gained
strength and was able to walk out. Subsequently he had
some rheumatic inflammation in the right foot, which
yielded to salicylate ; and after this he gradually got
weaker.^^
A consultation was held on March 15th with Dr.
John J. Uhthoff, who thought it probable that deep-seated
suppuration, perhaps in the liver, existed ; but no definite
conclusion was arrived at except the desirability of his
removal to the hospital.
Dr. Newth's last note (April 21st) is to the following
effect : — " There have been no rigors ; the night sweating
has subsided, but the pain and tenderness in the left side
continue. The temperature oscillates between 100^ and
102° ; pulse about 100. There has been practically no
cough, no expectoration, no irritation of the fauces, and
vomiting only once or twice ; but the emaciation is ex-
treme in spite of plenty of nourishment and of fairly good
appetite and digestion. For weeks he has been too weak
to get out of bed, except for short periods. The treat-
ment has consisted in quinine and arsenic, and latterly a
simple effervescing mixture. ^^
200 THE POSSIBILITY OF RECOVERY PROM THE
His appearance when admitted on April 28th was, but
for the remaining energy in the gaze, that of a man at
the extremity of chronic phthisis; he was pale and
emaciated, with extreme muscular wasting; his weight
reduced to 7 st. 2 lbs. There was no anasarca. On
examination a few rhonchi only were found in the lungs,
which were clearly not seriously affected ; but a double
murmur was heard at the aortic area. A murmur was
also attached to the first sound at the apex of the heart.
The diagnosis of malignant vegetative endocarditis was
arrived at on this evidence.
The liver and spleen were apparently normal. An
examination of the blood showed a diminution of the red
cells to 1,500,000, and an increase of the white to 25,000
per c.mm. The blood proved to be sterile.
The pulse (100) was of the '^ water-hammer type,^^ and
there was marked pulsation of the carotids and other
arteries. The temperature oscillated from 99° to 101*5°.
The night sweats were profuse. The urine was high-
coloured (sp. gr. 1019), and presented only a cloud of
albumen.
The mouth was in a very bad condition, with decaying
stumps and fetid stomatitis. This was at once treated.
On May 10th a course of daily injections into the
abdominal walls of 10 c.c. of antistreptococcus serum
from the Jenner Institute was commenced. They re-
mained without any marked result. Meanwhile the
general condition had improved slightly under the influence
of food and nursing, but the emaciation continued to
increase. A few lardaceous casts were reported to be
present in the urine on May 10th.
On May 21st an ointment consisting of 20 per cent,
protargol in lanoline and lard was ordered to be rubbed
into the skin daily, about 53 being used at each inunction,
and the injections of antistreptococcus serum were con-
tinued for a few days longer. From this date a slight
improvement was noted. The patient had better nights,
and seemed to gain a little strength, although the tempo-
ACTIVE BTAGE OP MALIGNANT ENDOCARDITIS 201
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202 THE POSSIBILITY OF RECOVERY FROM THE
rature remained irregular. There were occasional attacks
of severe pain in the hepatic and splenic regions, which
suggested infarction; but at no time was there any sub-
cutaneous haemorrhage or haematuria.
Oq June 8th he appeared so much better that his earnest
appeal to be allowed to be carried into the quadrangle
was granted. Unfortunately even this seems to have
been too great an exertion, for an attack of acute
cardiac dilatation supervened, from which he died on the
following day.
The post-mortem revealed considerable cardiac disease,
but no tubercular affection of the lungs or other organs.
There was a slight excess of fluid in the pericardium.
The vegetations of malignant ulcerative endocarditis
occupied the aortic and the mitral valves and part of
the adjoining ventricular surfaces. We shall presently
revert to the cardiac changes. There were old and
recent infarctions of the spleen and kidneys, but no
lardaceous disease was present. In the kidneys there
was a slight diffuse overgrowth of fibrous tissue. The
spleen was firm, and weighed II oz. The liver was
fatty.
The Appearances presented hy the Heart in the three
cases, and the Conclusions suggested.
On closer inspection the individual specimens present
the following appearances : — The heart in the first case
shows malignant endocarditis of the mitral valve in its
worst form and stage ; the vegetative and the ulcerative
processes are alike unchecked. Heavy vegetations, of
greyish necrotic aspect, cover the mitral flap, inducing
slight infection of the infra- aortic surface opposite, but
not of the aortic orifice ; and several of the chordae are
ulcerated through. No healthy fibrin is anywhere to be
seen, and there are no changes of repair perceptible to
the naked eye. These lesions are entirely adequate to
explain the symptoms and the fatal termination. The
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 203
patient died of the direct effects of the disease, partly
destructive and partly toxic.
In the second case, in which it was difficult to determine
the precise duration of the acute affection, the changes
were limited to the aortic orifice. The vegetative process
is here identified by the presence of a long narrow strip
of altered fibrin growing from one of the valves, and also
inferentially by the embolic mass of similar material
occupying the first portion of one of the large bronchial
arteries. The malignancy of the ulcerative process is
likewise attested by the ulceration through the coats of
the aorta near the orifice of one of the coronaries. On
the other hand, there is no evidence of recent disease —
no grey necrotic aspect of the vegetations. The long
pedunculated vegetation was brittle, and presented the
same yellowish atheromatous mottling as the embolic
plug, apparently indicative of staleness of the fibrin
rather than of its recent deposition. The ulceration of
the aorta, which had probably been set up by the
Avhipping action of the long vegetation, did not seem to
have been progressing, but rather healing, as some of its
edges were smooth and its surface not unhealthy ; and,
with the exception of the long pedunculated appendage,
the aortic vegetations were reduced to clear glistening
warty deposits. In this case the cardiac lesions found at
the necropsy were hardly adequate to explain death ; they
rather suggested the inference that the endocarditis had
been worse at some previous time than at the final stage.
But the state of the lung and the plugged bronchial artery
established a complication which the patient, in her ex-
hausted state, had been unable to survive.
In the third case it is possible to fix a date for the
beginning of the disease, and the continued and pro-
gressive symptoms warrant us in regardinjr it as having
been from the first infective. After a duration of six
months the disease, if it had remained unchecked, should
have culminated in its worst developments. Asa fact, the
heart suggests an opposite conclusion. In this respect
204 THE POSSIBILITY OP KECOVERY FROM THE
there is a striking contrast between the heart in Case 1
and this heart, where a deep ulceration of the aorta and
a slight ulceration of the aortic cusps are associated with
a vegetative affection of the mitral flap and of the infra-
aortic surface opposed to it. The lesions are of greater
superficial extent, but they present the aspect of healing
rather than of degeneration. Though none of the chorda©
are ruptured several of them present nodes, which, how-
ever, are not granular, but smooth, as though there had
been for some time no further deposit of fibrin or micro-
organisms upon them. By the side of the few vegeta-
tions which remain on the mitral flap there are many
smooth knobs of the same character, free from granular
fibrin, and glistening as though clothed with endocardium.
The fibrin of the vegetations is nowhere grey, but of
pink or opaque white aspect. In short, most of the
appearances suggest that the destructive stage of the dis-
ease had been got over and the necrotic surfaces cleared
away, although the healthier fibrin had not been removed
nor converted into fibrous tissue. The aortic valves
present no rough fibrin, but nodules only. The aortic
ulceration is situated just in front of the mouth of the
coronary orifice, and the fine nodular deposits close to
the ulceration suggest that fibrin might have grown there
which had since disappeared. Some fibrin remained,
and this helped to plug the channel of the coronary
artery. The fatty degeneration visible in the left ventricle
was apparently the secondary result which brought about
death, and was probably due to coronary obstruction.
An inspection of the three hearts side by side shows
beyond any doubt — (1) that in all three the disease Avas
malignant endocarditis; (2) that in Case 1 the lesions
were considerably more severe and more active. In this
heart are seen — (a) several ruptured chordaG ; (h) abundant
shaggy vegetations of greyish, granular, necrotic fibrin.
But in the other two hearts, although the vegetations are
numerous, none of them present the same grey necrotic
aspect or the same granular crumbling surface. None
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 205
m
of them are broken at their extremity, but rounded, as
though any ulceration or rupture had been smoothed over.
Many of them, too, are beady or knobby, as though they
had cast off their appendages. The general impression
is conveyed, by the firm look, the clear pinkish colour,
and the glistening surface of these vegetations, that they
are in a stage of regression of the fibrinous or bacterial
deposit.
These differences might be regarded as due to an
original difference in the virulence of the affection. It
is impossible to form any definite opinion as to what
appearances might have been presented by these hearts
at their worst stage. The partial destruction of the aorta
in both of them is unmistakable evidence of the extreme
activity of the disease at some previous time, but it does
not appear from the specimens that the worst stage was
the final one. On the other hand, the clinical records of
the cases enable us to follow the history of the lesions.
In one of them. Case 3, the onset of the acute stage
had occuiTed six months previously, and acute symptoms
lasted throughout almost to the end. Yet the terminal
condition of the endocardium was not of the worst type.
And the progress noticed in the symptoms bears out the
view that the endocarditis itself was not in the stage of
progression. The same remarks apply in a modified degree
to Case 2.
The pathological conclusion which we feel justified in
drawing is that the changes in both these cases had
previously been of a more active type than they were
shortly before death, whereas in the first case the endo-
carditis was at its acme.
Remarks on the Casks.
In addition to a few remarks as to the source of
infection, special attention will be given to the following
points : — (1) The insidious onset, and (2) the often pro-
206 THE POSSIBILITY OF RECOVERY PROM THE
longed duration of the disease ; (3) the extreme emacia-
tion and other symptoms simulating phthisis ; (4) the
difficulty of a correct diagnosis even at a late date. But
the chief object of this communication is to illustrate
further points of practical importance : — (5) The fatal
tendency of the disease if not treated ; (6) the possibility
of arrest, and of partial recovery even at an advanced
stage ; and lastly, (7) the share taken by treatment in
aiding recovery, and suggestions as to the probable
mode of action of the remedies.
In two of the cases an arthritic and probably rheu-
matic element was present. Although we are scarcely
warranted in regarding common rheumatic infection as cap-
able of development into the malignant forms of endocar-
ditis, it is possible that the micro-organisms of rheumatism
may have acquired a higher degree of virulence, either
alone or in association with other septic organisms, and
, may have led to the ulceration. Perhaps, however, the cases
were due to simple septic infection, and if so, a sufficient
supply may have existed in the oral sepsis at least in two
of the cases. The blood was found free in one case from
staphylococci and streptococci, and in two of the cases
the injection of antistreptococcus serum failed to check the
disease. In Case 2 there was no recent rheumatic element,
nor any other known source of infection beyond that
which, from its extent and degree, may be provisionally
regarded as an adequate cause, viz. the oral sepsis from
decaying teeth.
(1) On the subject of the insidious mode of onset the
clinical histories supply their own comment. None of
the cases presented initial symptoms identifying the acute
attack as one of cardiac disease, nor any subsequent
clinical events identifying a late onset, whilst the post-
mortem appearances were those of lesions of old standing.
Sometimes cerebral embolism occurs whilst the patient is
engaged in laborious work, and death follows in a few
days. Instances of this kind, such as that diagnosed and
treated by one of us as malignant endocarditis probably
ACTIVE STAGE OF MALIGNANT ENDOCARDITIS 207
originating in dental caries/ supply a complete proof that
the lesion need not at first give rise to any marked
symptoms. The fact that a period of latency may exist
in some cases is of clinical importance.
(2) Where an abrupt termination is not occasioned by
any major complication the disease under ordinary treat-
ment and nursing may run a protracted course, which in
our cases, without allowing for any preliminary period of
latency, reached a duration of probably not less than 13,
14, and 26 weeks respectively.
(3) Most striking is the intense emaciation often
observed. In our three cases it was the more remarkable
owing to its contrast with the liberal amount of food
taken, and to the absence of any wearing influence except
that of the fever. It was considerable in all three cases,
but in Case 3 it was extreme, and such as is seen only in
starvation or in the ultimate stage of phthisis. The
general aspect of the patients was also that of advanced
pulmonary tuberculosis. The hectic temperature without
rigors was a point of resemblance between the cases.
(4) Diagnosis is probably impossible at the earliest
stage of most cases. Even should a murmur be detected
it seems doubtful, having regard to the latency of
symptoms referred to above, whether its due significance
would be put upon it. increasing responsibility attaches
to diagnosis in the later stages, and the history of each
case shows that even then the symptoms may not reveal
their real cause.
In all three cases the provisional diagnosis of pul-
monary tuberculosis was made at first sight prior to
searching examination, and in one of them phthisis or
latent suppuration had also been diagnosed, prior to the
patient^ s admission, at a consultation held among phy-
sicians in the country.
^ "A Case of Fiital Malignsmt Kmlociirditis npparently <Uie to Infection
from Dental Caries and Stoniutitis treated by Antistreptoroccus Sernm and by
Saline Injections," read before the Ipswicli Meeting of the lJriti.sli Medical
Association, 1900, by Win. Ewart, M.D.j cf*. ' IJrit. Med. .lourn.,' 1900,
vol. ii, pp. 906 and 1057.
208 THE POSSIBILITY OF RECOVERY FROM THE
(5) The cases illustrate the slowly destructive tendency
of the disease apart from the fatal complications which
so often shorten its course.
(6) The most important teaching conveyed by the
cases is that the cardiac lesions of malignant endocarditis
are not incompatible with recovery under treatment.
Whilst in the case which was under treatment for rheu-
matism there was no sign of improvement, nor any
evidence of repair in the lesions traceable after death, in
the other cases in which systematic antiseptic treatment
was applied perceptible progress was made clinically,
and the improvement was such as to warrant a hope of
ultimate recovery, death supervening, particularly in the
male case, almost as an accident. The reality of the
improvement observed in the patients was borne out by
the post-mortem appearances in the heart, where some of
the destructive changes had made way for the changes
of repair.
(7) Therapeutical conclusions are always difficult, but
in this set of cases they are facilitated by the clinical
record. In the first case a purely antirheumatic and
restorative treatment failed to stay the downward pro-
gress. In the other two, antistreptococcus serum from
the Jenner Institute was obtained and given a fair trial.
But here an important question must remain unanswered.
The serum may have made some impression upon the
vegetations, but during its administration it had no influence
upon the clinical progress of the patients. In one of the
latter definite depression was induced by the injections,
and the amount had to be reduced. It may be said, then,
that the curative value of antistreptococcus serum injec-
tions has received better support' from some other published
cases than from these.
In both cases improvement occurred very soon after
protargol inunctions were adopted as an adjunct to
previous treatment, and as the improvement continued
when the serum injections were left off, it seems warrant-
able to think that the inunctions had a definite share in
ACTIVE STAGE OP MALIGNANT ENDOCARDITIS 209
the result. If correct, this view would corroborate similar
observations which have been reported by others, and it
would warrant our recommending for further trial a
method which is entirely free from inconvenience or com-
plications. Questions as to the selection of the ointment,
whether unguentum Crede, or protargol ointment, or any
other, as to its strength, and as to the frequency of its
use, may be left for further trial.
Addendum by Dr. Ewart.
The treatment which I had intended to apply in these
cases, but which was postponed in view of the partial
improvement otherwise obtained, does not hitherto rest
upon any direct observations made in this disease, but
upon the good results, hitherto unpublished, which I have
obtained in acute pneumonia from intra- venous injections.
I believe that the rational, and it is to be hoped the
successful treatment of endocarditis will be found in the
intra- venous injection method.
Intra-venous injections of perchloride of mercury have
been used with marked success in the human subject for
the cure of Werlhof s disease by A. Lusignoli.^ Fischer "
reports the cure of a malignant carbuncle due to anthrax
infection, without any incision, by intra-venous injections
of colloidal silver. These facts add some support to the
view which I have ventured to formulate ; and being
satisfied from a personal acquaintance with the method
that intra-venous injections may be administered by the
expert without too serious a risk, I should be disposed to
adopt them in any obvious instance of a disease which,
as these cases show, almost inevitably tends to a fatal
termination.
^ Cf. 'Brazil-Medico/ Oct. 15th, 1901, and 'Journal of the American
Medicul Association/ Dec. 21st, 1901, p. 1713.
a Cf. 'Miinch. med. Wochenschrift,' Nov. 19th, 1901.
For DisciLssion see page 239.
VOL. LXXXV. 14
A CONTRIBUTION
TO THE
STUDY OF MALIGNANT ENDOC AEDITIS
BY
F. J. POYNTON, M.D., M.E.C.P.
AND
ALEXANDER PAINE, M.D.
Received December 4th, 1901— Read April 8th, 1002
I. Introductory Outline.
(a) a Group of Cases of Malignant Endocarditis closehj
associated with Rheumatic Fever,
While investigating the pathogenesis of rheumatic
fever, our attention has been directed to certain cases of
progressive heart disease which run a more or less pro-
longed course, and terminate almost invariably in death.
After death it is found that the valves of the heart are
very extensively diseased, and that the morbid process is
often extremely active. Among such cases there is one
group in which we Avere particularly interested, for previous
to the fatal illness there had been a history of rheumatic
fever ; sometimes there had been repeated attacks, and
212 STUDY OP MALIGNANT ENDOCARDITIS
during the last illness symptoms had arisen which sug-
gested that rheumatism of some unusual type was in
reality the true excitant. The symptoms in these cases
arose insidiously, and there was no local focus of suppura-
tion, no wound or other demonstrable cause which may be
considered to have been the starting-point of this progres-
sive form of heart disease. This class of case is well
recognised, for it is a comparatively common one in the
large hospitals. It is possible in some instances to detect
the nature of the disease even early in the illness, because
of the persistently excited action of the heart and loud-
ness of a systolic murmur ; but on the other hand, even
when death has occurred, several observers of equal
acumen, and with the same advantages in the study of
the case, may differ in their opinion as to whether the
condition is one of I'heumatic morbus cordis or so-called
*^ infective endocarditis.^^ No doubt the great majority
of these cases as they progress diverge more and more
from the appearance of rheumatic fever, and the force of
the disease falls so exclusively upon the cardiac valves
that it may be difficult in the end to detect any clinical
resemblance ; but it is equally certain that the more these
cases are carefully studied, the more difficult it is to say
where a distinctive line can be drawn between them and
acute rheumatism. Anaemia, prostration, wasting, pyrexia,
and infarction are very frequent and important symptoms
in this disease, but there is not one of these which may
not occur, to a lesser degree, in severe rheumatic fever.
In these cases, again, suppuration does not occur even in
the blood-clot of the aneurysms that may result, but
numerous white infarcts are often found in the kidneys,
lungs, or spleen after death.
(b) ^^ Malignant '' Preferable to ^* Infective '' as a Title for
this Form of Endocarditis,
The usual procedure in this country is to describe such
cases as examples of ^^ infective endocarditis," and if by
STUDY OF MALIGNANT ENDOCARDITIS 218
this terra no suggestion were implied that rheumatic valvu-
litis was non-infective, the description would be an ex-
cellent one. It is unfortunate that such is not the case,
but that through no fault in the term itself the name in
question has been widely used in contradistinction to
rheumatic valvulitis ; and this is the more strange because
for several years rheumatic fever has, in spite of the
absence of actual proof, been looked upon as due to an
infection.
For this condition the name malignant endocarditis
seems to us preferable, for whether it proves fatal or not,
the type is malignant.
(c) Researches of other Investigators iipon Malignant
Endocarditis,
An immense amount of research has been devoted to
the study of malignant endocarditis, and it would be im-
possible in such a paper as this to mention the names of
the many investigators. Their results have been of far-
reaching importance. They have definitely settled the
microbic origin of the condition. They have also shown
that various micro-organisms may give rise to malignant
endocarditis, but that the most usual cause is a strepto-
coccus. Experiments upon animals have resulted in the
reproduction of the disease, though not with constancy,
and in some cases the cardiac valves have been damaged
mechanically before valvulitis has resulted. It may be
justly asserted that these investigators have elucidated
the broad outlines of the pathology of malignant endo-
carditis, though there are several difficult problems yet
to be solved, among Avhich is the relation of such cases
to rheumatic fever.
(d) Renewed Investigation of Malignant Endocarditis
Desirable,
Heretofore it has not been possible to solve this
problem, for there has been no agreement upon the cause
214 STUDY OF MALIGNANT ENDOCARDITIS
of rheumatic fever. The outcome of this limitation of
knowledge has been the wide-spread belief that malignant
endocarditis in a rheumatic patient is invariably a result
of some secondary infection of the tissues injured by
previous rheumatism. Nevertheless there have been
some clinicians and pathologists who have felt this atti-
tude to be too rigid, and have, without the means of
bringing forward complete proof, believed that some
cases are truly rheumatic in origin. At the present time
so much evidence has been obtained in favour of
rheumatic fever being the result of a diplococcus infection,
that it seems a proper occasion to once more investigate
this question of the relation of the two diseases
(e) The Result of the Authors^ Investigations,
It is this investigation with which our paper is con-
cerned, and our conclusion can be shortly stated thus : —
That there is a group of cases of malignant endocarditis
which is rheumatic in nature. How comprehensive this
group will prove to be further investigations alone can
decide.
Before we summarise the reasons for this conclusion
we are anxious to make clear the scope of our paper.
We do not claim that the view that rheumatic fever is a
cause of malignant endocarditis is an original one ; we are
well aware that others — as, for example. Ogle, Osier,
Peter, Burkart, and Fernet — have entertained this opinion ;
that others before us have demonstrated that organisms
similar in their morphology may occur in the two diseases,
and have felt that in some instances no clinical distinc-
tions can be drawn between simple and malignant valvu-
litis. Our paper, as its title claims, is but a contribution
to the study of malignant endocarditis, and affords, we
believe, a strong support of the view that malignant endo-
carditis may be of rheumatic origin.
STUDY OF MALIGNANT ENDOCARDITIS 215
(f) Reasons for the Assertion that there is a Malignant
Rheumatic Endocarditis,
The chief reasons upon which we rely for support of
our assertion can be summarised thus :
Firstly. The probability that some of these cases are
rheumatic is in accord with clinical experience.
The clinical cases we record will bear out this state-
ment.
Secondly. The probability that some of these are
rheumatic is in accord with pathological experience.
The minute investigation of the morbid anatomy of the
clinical cases we record supports this conclusion.
Thirdly. The probability that some of these cases are
rheumatic is in our opinion in accord with bacteriological
experience, for —
1. A diplococcus is a cause of rheumatic fever. The
evidence in favour of this we have already dealt with in
a series of papers published during the last two years.
2. A diplococcus can be isolated in pure culture from
these cases of malignant endocarditis, which will reproduce
the*disease in rabbits.
3. The cultural and morphological characteristics of
these two diplococci resemble one another so closely as to
lead to the conclusion they are identical organisms.
4. The Diplococcus rheum aticus will produce malignant
endocarditis, indistinguishable from that produced by the
diplococcus isolated from certain cases of malignant endo-
carditis in man.
5. The Diplococcus rheumaticus may produce in a
rabbit first a recoverable illness with the manifestations of
rheumatic fever, and then on a second inoculation malig-
nant endocarditis.
6. A diplococcus isolated from certain cases of malig-
nant endocarditis in man will produce not only malignant
endocarditis in rabbits, but a condition indistinguishable
from the disease we believe to be rheumatic fever.
216 STUDY OF MALIGNANT ENDOCAEDITIS
7. By these diplococci, every grade of valvulitis from
simple to malignant, and from malignant to simple, can be
produced, as our macroscopic specimens bear witness.
II. The Invest[gation.
(a) Clinicalj Experimental, and Pathological Observa-
tions.
The first case will make clear the type we are engaged
in studying.
Case 1. — A child, aged 11, was admitted to St. Mary^s
Hospital, under the care of Dr. W. B. Cheadle, upon
October 22nd, 1897, and died November 12th. When
three and a half years of age he had suffered from
rheumatic fever, and when five and a half from scarlet
fever. His mother had suffered from rheumatic fever.
Five weeks before admission there had been swelling of
the knees and ankles, and for five months there had been
complaints of obscure pains in the chest and abdomen.
There was no history of an injury, no suppurating focus,
«nd no obvious cause which could be looked upon as an
explanation of some secondary infection. Upon admis-
sion the boy was very anaemic, the temperature was
100'8°, pulse 100, respirations 28. The heart was much
enlarged, there was a loud systolic mitral murmur, and
also an aortic systolic murmur. The liver and spleen
were enlarged, the urine was natural. Soon after admis-
sion crepitations were heard at the base of the left
lung posteriorly, and there was pain in the left side.
Upon October 28th blood and albumen were found in
the urine, and until death, upon the 12th of November,
there was irregular pyrexia. Ha^maturia became per-
sistent, and casts were found in the urine. There was
pain over the spleen, and progressive enlargement of that
organ. Purpura, vomiting, progressive anaemia, emacia-
STUDY OF MALIGNANT ENDOCARDITIS 217
tion, and sweating were prominent symptoms, and finally
the pulse became irregular and intermittent, and death
resulted from cardiac failure.
The necropsy showed recent pericarditis, with two
ounces of fluid in the pericardium, which contained a few
flakes. There was extensive ulceration of both flaps of
the mitral valve, and exuberant granulations spread over
the surface of the auricle. The valves upon the right
side of the heart were not affected ; the heart itself was
hypertrophied and dilated. There were numerous white
infarcts in the spleen, with perisplenitis ; it was soft, and
weighed five ounces. There were numerous white
infarcts in the kidneys, but none found in the lungs.
Numerous subserous haBmorrhages were visible along the
intestines. There were no abscesses, but many white
infarcts, as already stated. Numerous micrococci were
found in the granulations.
We admit that secondary infections can occur during
life without any demonstrable cause, but it seems to us
legitimate to argue upon such a case as this in the
following way : — Rheumatic fever is a bacterial disease,
and one which apparently does not confer immunity.
Evidence at present points to it as the result of a diplo-
coccus infection, and it would appear that the diplococcus
may exist for long periods in the body.
In such a case as the above there was a family and
personal history of rheumatism, and such a child, as all
clinical experience has shown, may be justly termed
rheumatic. If, then, from such a case a diplococcus be
isolated, it is as legitimate to assume that it may be the
Diplococcus rheumaticus, under some unusual conditions,
as to assume a secondary infection. The proof must rest
upon an accurate study of the micro-organism which is
isolated, by various methods, including among these the
method of experiment.
Case 2. — The next case was that of a woman aged 50,
who was admitted to St. Mary^s Hospital, under Dr.
218 STUDY OP MALIGNANT ENDOCARDITIS
W. B. Cheadle, in June, 1898, for dyspnoea of some
months^ duration. The only cause that was given for
this dyspnoea was an attack of rheumatic fever eight
years previously. Upon admission she was cyanosed and
short of breath, and complained of pain in the left side.
There was orthopnoea. The temperature was 102*8°,
pulse 103, respiration 40. The heart was much enlarged,
and there was a mitral systolic murmur. The hands
were deformed by previous attacks of rheumatism. The
nature of the case remained quite in doubt, though
towards the end irregular pyrexia, infarctions in the
lungs and spleen, and purpura suggested the diagnosis
of malignant endocarditis.
The necropsy showed recent pericarditis, adhesive in
type, and also old adhesions, the result of a previous
at;t)acK.
The mitral, tricuspid, and aortic valves showed exten-
sive vegetative endocarditis, and there were vegetations
over the surface of the left auricle. There were white
infarcts in the lungs and spleen, but none in the kidneys.
There was no suppuration. Numerous micrococci were
visible in the granulations.
The necropsy disclosed malignant endocarditis of the
characteristic type, yet clinically this case was most
obscure, and resembled at first a severe rheumatic
morbus cordis. It was not until the end of the illness
that the malignant character of the disease became
apparent.
Case 3. — A patient aged 16 was admitted into St.
Mary^s Hospital in Januaiy, 1900, under Dr. Lees, suffer-
ing from morbus cordis. When six years of age he had
an attack of rheumatic fever, and since that time had
suffered from three more definite attacks. His mother
had suffered from rheumatic fever. The final illness had
commenced insidiously, with pain round the heart, and
three weeks before admission there had been pains in the
ankles and knees. No cause was assigned for this illness.
STUDY OF MALIGNANT ENDOCARDITIS 219
and on special inquiry of the mother she volunteered that
she had thought this was another attack of rheumatism,
because it commenced just as the previous attacks had
done.
On admission the patient was very anaemic and wasted,
and there was irregular pyrexia, with well-marked mitral
and probably aortic disease.
The course of the illness was progressive and malig-
nant in type. Irregular fever, enlargement of the spleen,
and haematuria, with progressive anaemia and emaciation,
were the prominent symptoms, and throughout the time
that the patient was in the hospital no doubt was enter-
tained as to the nature of the illness.
The necropsy showed a few ounces of clear fluid in the
pericardium ; the mitral valve was fringed with numerous
minute vegetations, varying in size from a pin^s head to
a pea. There were recent vegetations upon the aortic
valve, but the right side of the heart was unaffected. In
the spleen there were three white infarcts, and in the left
kidney" one.
There was no suppuration.
This case was, in one respect, the converse of the pre-
ceding. The clinical diagnosis was quite definite, but the
post-mortem showed a condition which, without the clini-
cal history for a guide, could have been explained as
active rheumatic morbus cordis, and not as malignant
endocarditis.
We investigated the bacteriology of this case, and at
first included it (the resemblance was so striking) among
our first series of cases of rheumatic fever published in
the ^ Lancet^ in September, 1900; but we finally con-
cluded, before publication, that it was better to rigidly
exclude a border-line case of this kind, and have not
made allusion to it until the present paper.
The bacteriological investigations resulted as follows :
Numerous diplococci growing in chains were demon-
strated in films made from the granulations of the mitral
220 STUDY OF MALIGNANT ENDOCARDITIS
valve, and cultures were made with the following media :
— agar, ascitic fluid, acid and alkaline bouillon, an
alkaline pork medium, and in milk and bouillon slightly
acidified with lactic acid. The liquid media were incu-
bated both aerobically and anaerobically.
Twenty-four hours afterwards the results were as
follows ;
Upon agar, a poor growth of minute discrete colonies
consisting of extremely minute diplococci. The pork
medium and ascitic fluid were sterile. The alkaline
bouillon showed a very poor growth of minute diplococci.
The acid milk, both aerobically and anaerobically,
showed a vigorous growth of diplococci in chains. This
diplococcus was grown in the milk medium by means of
subcultures for two months. From the original tubes a
subculture was made upon blood-agar, and upon two
occasions Mr. Plimmer injected into the auricular vein of
a rabbit the contents of one blood-agar tube. The result
in each case was negative.
The isolation of a minute diplococcus from a case such
as this is in accord with the experience of Professor Litten,*
who also isolated a minute diplococcus from a condition
which he termed the malignant non-septic form of
rheumatic endocarditis. Such cases as these he considered
to be characterised by pyrexia, infarction, pallor, and
sweating, with haematuria and enlargement of the spleen,
but no suppuration.
Professor Litten was inclined to the view that this
diplococcus was probably not identical with the diplococcus
described by Professor Wassermann^ as the cause of
rheumatic fever. We believe that the diplococcus we
isolated in this case is identical with the diplococcus
^ ** Ueber dio maligne (nichtseptische) Form der Endocarditis rheuma-
tica," ' Berliner klinische Wocheiischrif t/ 1899, No. 29, p. 644.
2 " Ueber den Infectioseu-Charakter und den Zusammenhang von acuten
Gelenkrheumatismus und Chorea,*' 'Berliner klinische Wochenschrift,*
1899, No. 29, p. 638.
STUDY OP MALIGNANT ENDOCARDITIS 221
which we have now isolated from twenty cases of rheu-
matic fever.
Case 4. — This fourth case, although a case of rheu-
matic fever, we mention here because it resembled malig-
nant endocarditis in this respect, that during life upon
two occasions diplococci growing in chains were isolated
from the blood. The patient was under the care of
Dr. D. B. Lees, and the case was published in full in
the 'Mirror of the Lancet,^ October 28th, 1899, and
was the first from which we isolated the diplococcus
of rheumatic fever from the blood. We naturally-
thought at that time that the case was one of malig-
nant septic endocarditis, because we isolated streptococci
from the blood during life, though previous investigations
had made us somewhat doubtful of the validity of this
conclusion. The clinical history, the course and character
of the disease, and the result of the necropsy proved conclu-
sively that it was a case of severe rheumatic fever. Though
a most severe case of rheumatic fever with numerous and
severe local lesions there was no suppuration, and yet
during life there was a streptococcus, or, to be more exact,
a diplococcus which grew in chains, circulating in the
blood-stream.
Case 5. — A boy aged 10 was admitted to St. Mary^s
Hospital in April, 1900, for heart disease, under the care of
Dr. W. B. Cheadle. Six weeks before admission he had
suffered from pain over the heart, sweating, and attacks
of diarrhoea. A year previous to this he had been in the
hospital for an attack of rheumatic fever, and one brother
had also suffered from rheumatic fever. On admission
aortic and mitral valvulitis were discovered, and a very
noticeable feature was extensive muscular wasting.
Upon April 30th he developed pericarditis.
In May there was arthritis, the ankles and knees being
affected. There were also diarrhoea and vomiting. In
June crepitations were detected in the lungs. In July
222 STUDY OF MALIGNANT ENDOCARDITIS
infarction, sweating, and wasting were prominent, and
death occurred in July, after eighty-eight days of irregu-
lar pyrexia.
This appeared to us during life to be a classical case of
rheumatic malignant endocarditis.
There was unfortunately no opportunity of obtaining a
complete necropsy, but the heart was removed, and the
pericardium was found generally adherent. The heart
itself was very little enlarged, but upon the mitral and
aortic valves and on the wall of the left auricle there were
extensive and exuberant granulations. The right side
was not affected. Films showed minute diplococci in
chains. Aerobic cultures in the milk medium were ob-
tained and transferred to blood-agar. A series of impor-
tant experimental results followed.
The growth from six tubes was intra- venously injected
into a rabbit on July 28th, and upon the 31st and 1st of
August the left knee-joint and left shoulder- joint were
swollen. The animal died suddenly upon the fifth day.
The necropsy showed exuberant granulations upon identi-
cal valves, namely, the aortic and mitral. The micro-
organisms were demonstrated in great numbers in the
damaged valves.
In thus reproducing malignant endocarditis without
any previous injury to the cardiac valves, we confirmed
the classical investigations of Dreschfeld, Eibbert, Bonome,
Eoux, Mannaberg, and others. It will also be apparent
that in the course of this investigation we have con-
firmed the results of other observers by the experimental
production of infarction and haemorrhages.
Upon August 8th a second inoculation, from a culture
obtained from this rabbit, was made into a smaller animal.
Death occurred upon the fifth day from vegetative aortic
valvulitis. No other valve was affected.
The cultures from this rabbit were contaminated with
the Bacillus coli, so recourse was had to the original
culture, and a third inoculation made with a smaller quan-
tity of the organism.
STUDY OF MALIGNANT ENDOCARDITIS 223
Death occurred on the nineteenth day. There was
arthritis of the right knee and diarrhoea, but no clinical
evidence of valvulitis or pericarditis. Death occurred
from gradual cardiac failure due to dilatation and fatty
degeneration of the heart muscle with ante-mortem throm-
bosis. In this case it will be observed there was no
manifestation of malignant endocarditis, but the necropsy
showed a simple endocarditis.
A larger quantity of the original culture was used for
a fourth injection.
Death occurred on the tenth day. During life there
were noted diarrhoea, heart disease, and arthritis of the
right shoulder- joint. The necropsy showed well-marked
malignant mitral valvulitis, white infarcts in both kidneys
and in the spleen, but no pericarditis (Plate 6, figs. 1 and 2) .
A smaller quantity of the original culture was injected
into a fifth rabbit, which was killed — for it was moribund
— upon the tenth day. During life diarrhoea, pericarditis^
and arthritis were noted.
The po&t-mortem confirmed that this condition was one
of rheumatic fever.
The culture from this case was injected into a sixth
rabbit, and death occurred upon the tenth day. There
was arthritis, but no valvulitis. The hearths action was,
however, extremely rapid, and for some days there was a
mitral systolic murmur.
It is evident from this series of inoculations that in three
nstances definite malignant endocarditis resulted, in two
death occurred from cardiac failure — without malignant
endocarditis, — and in one case death occurred from peri-
carditis.
Arthritis was frequent. One symptom occurred whicli
we have not noticed in rabbits inoculated with the Diplo-
coccus rheumaticns from rheumatic fever, namely, diar-
rhoea ; and this we know occurs not infrequently in man
during the course of malignant endocarditis, and was a
prominent symptom in the case from which this organism
was isolated.
224 STUDY OF MALIGNANT ENDOCARDITIS
Case 6. — A boy aged 13 was admitted into St. Mary^s
Hospital, November, 1900, for morbus cordis, under the
care of Dr. Lees. Six years before he had suffered from
enteric fever, and three years before from pneumonia
and rheumatic fever. He had been ailing for two months
previous to admission, and had suffered from pains in the
chest and abdomen. The boy was pale and sallow, but
well nourished ; there were mitral and aortic disease, and
an enlarged spleen. He remained in the hospital until
his death in January, and during that time there was
usually irregular pyrexia, though sometimes for days the
temperature remained normal. Death was sudden.
The necropsy showed general pericardial adhesion, and
f ungating masses of vegetation upon the mitral and aortic
valves. There were petechiae under the capsule of the
liver. The spleen weighed fifteen ounces, was tough in
consistence, and contained one recent infarct. There
were numerous small haemorrhages- in the cortices of both
kidneys. There was no suppuration. Two hours after
death the mitral valve was exposed, and four tubes of
the acid milk medium inoculated with fragments of the
granulations. In two out of four there was a pure
growth of very small diplococci growing in chains. Two
were sterile.
Upon January 24th the growth from six small tubes
was injected into a strong rabbit at 1 noon.
At 3 o^ clock the temperature had risen to 105*2^, and
a blowing systolic murmur was audible.
During the rest of January the temperature was raised,
there was some diarrhoea, and the heart was rapid.
During February there was improvement, but occa-
sional fever.
During March improvement continued.
Upon April 8th the hind limbs were found completely
paralysed, and there were complete incontinence and loss
of tone of the anal sphincter. The diplococci were
isolated from the urine and the animal was killed. There
was no definite valvulitis or pericarditis, and nothing to be
STUDY OF MALIGNANT ENDOCARDITIS 225
found in the other viscera of importance except a haenior-
i-hage into the pia mater some quarter of an inch in
vertical extent immediately above the lumbar enlargement.
It will be noticed that whether because the resistance
of the animal was unusually great, or the initial inocula-
tion not sufficient, the disease was not reproduced ; but
the length of time (ten weeks) that the diplococci
remained active in th^ body is a point of much interest.
Another inoculation from the original culture was made
upon January 25th, a day after the former inoculation,
into a rabbit of smaller size. The animal was killed upon
the tenth day ; during life there were pyrexia and morbus
cordis.
The post-mortem showed well-marked vegetative mitral
valvulitis (Plate I, fig. 1), petechiae in the heart wall, a
white infarct which was softening in the left kidney, also
white infarcts in the right kidney and spleen.
A pure growth of the diplococcus was obtained from
the blood in the heart.
The third rabbit was inoculated from a culture from
the preceding, and died in the night of the third day.
The heart throughout the illness was extremely excited.
The necropsy showed the nearest approach to septicaemia
we have seen with this diplococcus. Except for a minute
granulation upon the aortic flap of the mitral and early
peritonitis, there was no local lesion to be seen. Numer-
ous diplococci were present in the granulation. There
was excess of fluid in the pericardium, and numerous
diplococci were present in the pericardial tissues.
The liver was pale ; the kidneys pale ; the spleen
large, soft, and dark. The lungs showed no definite
changes.
A fourth rabbit was inoculated from a culture from the
preceding, and death ensued upon the sixth day. The
necropsy showed pericarditis, with a fibrino-cellular exuda-
tion ; slight mitral valvulitis, a small white infarct in the
left kidney, and some perisplenitis — a condition of rheu-
matic fever.
VOL. LXXXV. 15
226 STUDY OF MALIGNANT ENDOCARDITIS
A fifth rabbit was inoculated with a culture from the
fourth, and died on the fourteenth day of severe pericarditis.
The necropsy showed general recent pericardial adhesion,
and a condition which resembled the severe general
plastic pericarditis in the rheumatic fever of childhood.
There was no valvulitis.
Thus again it will be seen that both malignant endo-
carditis and a condition we believe indistinguishable from
rheumatic fever had been produced by inoculations of
this diplococcus.
This concludes our clinical investigations, though we
would emphasise the fact that in some of these cases of
malignant endocarditis in rheumatic subjects rigors may
occur for many weeks, yet after death not a trace of sup-
puration be found, and infarcts be discovered to be
cicatrising. We have also obtained from post-mortem
records thirty cases of malignant endocarditis without
the mention of an abscess in any one, and all of them
giving a previous history of rheumatic fever.
nie next experiment illustrates that a culture origi-
nally obtained from a case of rheumatic fever may produce
the malignant type of endocarditis after it has been passed
through several rabbits (13).
In June, 1901, an intra-venous injection was made into
a rabbit from a culture which was the direct descendant
of the original one obtained from the pericardial fluid of a
fatal case of rheumatic fever in March, 1900.
A very loud mitral murmur developed upon the seventh
day, and the animal died upon the eighth. The necropsy
showed that there was a large fungating vegetation upon
the mitral valve, with white infarcts in the kidneys and
spleen and one small one in liver. The condition was
one of characteristic malignant endocarditis (Plate I,
fig. 2).
The next experiment proves that a rabbit may survive
a first inoculation with the diplococcus of rheumatic fever,
recover completely, except for a slight thickening of the
STUDY OF MALIGNANT ENDOCARDITIS 227
mitral valve, and then may die from malignant endocar-
ditis, the result of a second inoculation.
The first injection was made from a culture of the
diplococcus obtained from a boy suffering from acute
rheumatic pericarditis. Treatment had necessitated a
venesection, and the organism was isolated from the blood
of the living patient.
The injection was made upon March 27th, 1900, and
four days afterwards there was arthritis of the right knee-
joint. Later the animal became thinner and irritable,
both knee-joints were affected, and the heart sounds were
very rapid and weak. In May recovery commenced, and
eventually the animal regained health.
Six months after recovery from the previous illness the
second inoculation was made, upon January SOth, 1901.
The culture used was from the pericardial exudation of a
fatal case of rheumatic pericarditis. The original growth
had been obtained in the pericardial fluid itself in March,
1900. This organism had repeatedly caused rheumatic
fever in rabbits, and two specimens of simple valvulitis
caused by it are shown among the macroscopic specimens.
For some months the organism had been kept growing
in the acid milk medium, but it had not of late been
passed through an animal, and we were doubtful whether
it had not completely lost all virulence.
The organism was transferred to blood-agar tubes in
the usual manner, and an exceptionally large amount used
for inoculation.
The temperature upon the next day was 103°, but until
the fourteenth day we noticed no change at all, and then
we found the heart very excited. This in a rabbit is not
a reliable sign of cardiac disease, and as there was no
murmur we somewhat hastily concluded that there was no
result to be expected. The animal was found dead on the
nineteenth day.
The necropsy made the cause of death quite clear.
The heart was large and the cavity of the left ventricle
dilated. Vegetative endocarditis of the aortic valve had
228 STUDY OP MALIGNANT ENDOCARDITIS
practically closed the lumen of the aorta, and the aortic
ring was thickened. Minute beads were found fringing
the mitral valve, and its aortic cusp was thickened by
previous endocarditis.
From the aortic vegetations the diplococcus was isolated,
and was demonstrated in the sections of the valve. There
were no infarcts. It must, we think, be allowed that this
was a very remarkable and suggestive result.
Two macroscopic specimens of rabbits^ hearts are also
shown, one resulting from an injection with the Di'plococcxbs
rhettmatictts, and one from the diplococcus obtained from
a case of malignant endocarditis, which illustrate the
transitional phases of the valvulitis (Plate I, fig. 3), and
also a third specimen showing primary malignant tricuspid
endocarditis produced by the diplococcus of rheumatic
fever.
The remainder of the series of experimental investiga-
tions we must record very briefly. These investigations
were made with the Streptococcus pyogeneSy and empha-
sise, we believe, the salient points of our previous
results.
Upon two occasions virulent cultures of the Strepto-
coccus pyogenes obtained from a case of puerperal fever
were supplied to us from the Jenner Institute. The
virulence had been increased by passing the organism
through a series of rabbits, and the cultures that we
received may be looked upon as characteristic of the
virulent Streptococcus pyogenes.
We treated this micro-organism in the same way that
we did the Diplococcus rheumatictcs, that is, transferred it
first to the acid medium, and thence to blood-agar. The
only difference in detail was the use for inoculation of a
small part of the growth from one tube instead of the
growth from some four or six tubes. With such a small
quantity as this, in our experience, no result is obtained
with the diplococcus of rheumatic fever.
The rabbits died in every instance within twenty-four
hours of inoculation. The post-mortem appearances
STUDY OP MALIGNANT ENDOCARDITIS 229
differed widely from those which we have previously de-
scribed. There were haemorrhages from the mucous sur-
faces. The blood was fluid, the spleen large, dark and
soft, the kidneys pale and extremely friable. There were
no local lesions, such as arthritis or valvulitis. Micro-
scopic examination of the organs showed great numbers
of streptococci in the blood capillaries and tissues.
On each occasion this condition of septicaemia resulted,
and although we cultivated the streptococcus for a week
in the acid medium (a medium which is not considered to
be a favourable one), the result on inoculation was the
same.
It may be objected to these results that the virulence
of the streptococcus had been artificially raised, and that
they are not therefore comparable to our previous investi-
gations, but this objection cannot be raised against the
next case. A woman was admitted to St. Mary^s Hos-
pital, suffering from septic absorption from a suppurative
phlebitis. An operation cured her, and from the pus the
iStreptococcus pyogenes was isolated and cultivated -in the
acid medium, and then transferred to blood agar. Intra-
venous inoculation of a rabbit resulted in death within
twenty-four hours from a condition of septicaemia of
the same nature as that which resulted from the strepto-
coccus sent to us from the Jenner Institute.
The last experiment was made with a streptococcus
isolated from the pus of a suppurative pericarditis. The
patient, a boy, had died from a streptococcus pyaemia, the
result of a punctured wound of the right knee-joint.
The same procedure was adopted as before, and on
this occasion the rabbit lived for five days, during which
time arthritis of the right carpal joint developed.
The post-mortem showed purulent arthritis, small
abscesses in the liver and both lungs, a clear exudation in
the pericardium, and a fibrino-cellular exudation in the
pleurae. There was no valvulitis.
These investigations with the Slreptococctis pyogenes
serve to show more distinctly the definite character of
230. STUDY OF MALIGNANT ENDOCARDITIS
the results we have obtained with the diplococcus of
rheumatic fever and the diplococcus isolated from cer-
tain cases of malignant endocarditis. We do not pretend
for a moment that they settle the question of the relation
of these various processes to one another^ but they demon-
strate that, as in man, characteristic rheumatic fever and
this type of malignant endocarditis, and pyaemia and septi-
caemia from the Streptococcus pyogenes, are different con-
ditions, and suggest that there must be some very definite
reason for such differences.
These clinical cases, the experimental investigations,
and our specimens show, we believe —
Firstly, that the probability that some of these cases of
malignant endocarditis are rheumatic is not contrary to
clinical experience.
Secondly, that a diplococcus is the cause of some of
these cases of malignant endocarditis.
Thirdly, that this diplococcus will reproduce in rabbits
malignant endocarditis, and also a condition we consider
to be rheumatic fever.
Fourthly, that the Diplococcus rheumatic us will produce
malignant endocarditis.
(b) Histology,
The minute anatomy of the two conditions is the next
consideration.
If a necropsy is made upon a characteristic case of
rheumatic fever and upon a case of malignant endo-
carditis of the type under consideration, the most striking
feature in which they differ is found to be the condition
of the damaged cardiac valves.
In acute rheumatism there are minute vegetations, in
malignant endocarditis there are as a rule large exuberant
masses, with possibly also ulceration of the valve substance
and rupture of chordae tendinea?. Yet these large vegeta-
tions, save in one respect, do not differ in their microscopic
structure from the minute ones. There is the same
STUDY OF MALIGNANT ENDOCARDITIS 231
necrosis, the same cell infiltration, the same swelling of
the connective tissue.
If a careful search is made in the damaged valve of
rheumatic fever, the diplococci may be found in regions
where the process has not reached the limit of necrosis
(Plate III, fig. 2), though the search is not easy because
the fibrous framework of the valve is not an easy struc-
ture to examine minutely. If search is made in the
necrotic part of the vegetation, all attempt to demonstrate
the micro-organisms may and probably will be met with
failure ; they have been for the most part destroyed.
But in malignant endocarditis they are found in masses,
sometimes fringing the free edge of the vegetation, some-
times buried in the necrotic tissue (Plate IV, figs. 1 and 2) .
This then, we believe, is the essential difference in the
morbid anatomy of the two conditions. Hence it is that
in rheumatic fever, death does not occur from acute valvu-
litis but from peri- and myocarditis, whilst in malignant
endocarditis death occurs almost invariably from valvulitis
and its secondary results ; though occasionally during the
illness, sometimes within the last few days of life, peri-
carditis may develop. Hence it is that numerous white
infarcts occur in the malignant form, and are exceptional
in the simple. The white infarcts need no detached clot
or fragment of vegetation for their formation, it is suffi-
cient that a considerable mass of the micro-organisms be
carried to the spot, and there set up by their poisonous
action the phenomenon of coagulation necrosis and those
other changes which make these lesions, as it were, visceral
nodules. Upon innumerable occasions these organisms,
which grow so vigorously in the vegetation, are scattered
in every direction by the blood-stream, and give rise to
the irregular fever, the sweating, the prostration and
wasting. In the heart the process steadily advances, but
it by no means follows, and indeed does not follow, that
the secondary foci in the various viscera will also of
necessity steadily progress. The place of election in this
disease is the heart, and no one can seriously doubt that
232 STUDY OF MALIGNANT ENDOCARDITIS
the chemistry of each particular organ of the body must
b^e in some measure peculiar, and it is not strange that
while the process is spreading in the heart an infarct in
the kidney, for example, may be healing.
The clinical distinction between a characteristic rheu-
matic fever and malignant endocarditis is wide, and the
difference in the vegetations in the two conditions is
equally wide, but just as the two clinical conditions merge
the one into the other, so too do these vegetations. In
some cases of rheumatic fever there may be many diplo-
cocci in the valves (Plate III, fig. 2). In some cases of
malignant endocarditis the vast majority of the micro-
organisms are destroyed. The first represent cases of
rheumatic feVer, which toward the end approach the type
of malignant endocarditis ; the second represent those
cases of subacute malignant endocarditis of long duration
in which the virulence appears to be low in intensity, but
persistent in character.
There does not appear to us to be any essential differ-
ence in the morbid anatomy of the two conditions other
than this, that for some occult reason the micro-organism
in the malignant type, instead of being destroyed in the
vegetation, survives and multiplies. It also seems un-
likely to us that the organisms select a previously damaged
valve, — the results of experiment, indeed, decided against
this ; it is more probable that there is in this type, as in
rheumatic fever, that same tendency for the diplococci to
attack the cardiac valves, and that damaged valves from
lack of a full power of resistance permit the rapid and con-
tinual growth of the micro-organisms, and in this wny
predispose to the malignant type of the disease.
(c) Bacteriological Details,
To turn now to some of the bacteriological details.
We have no knowledge of the occurrence of the diplo-
coccus we have isolated from these cases of malignant
endocarditis outside the body, except in so far as we
STUDY OF MALIGNANT ENDOCARDITIS 233
have studied it in culture. In the body it is present in
the local lesions which characterise the disease, and in
these situations it may be discovered by staining sections
of those morbid structures with appropriate dyes, though
more readily still by treating films made from scrapings
of these tissues.
The organism is stained best by the aniline dyes, but in
our experience, though it stains by Gramas method, it
does not retain the stain with tenacity. It may be
present in the vegetations upon the cardiac valves in
enormous numbers where it can be seen in the sub-
stance of the vegetation, and also in large masses in
direct contact with the blood-stream.
In this situation it is present as a minute diplococcus,
measuring 0*5 or even less in diameter. We have isolated
it in pure culture by the incubation of scrapings of the
vegetation in a mixture of bouillon and milk slightly
acidified with lactic acid, a medium such as we used for
isolating the diplococcus from cases of rheumatic fever.
When cultivated in this manner it resembled very closely
the latter organism, though it is slightly smaller, and may
grow in longer chains in fluid media, and form more
definite masses upon the solid ones. Such differences as
these, we believe, can be explained by its more rapid growth.
In sub-cultures made upon blood agar, which is very
suitable for maintaining its virulence, the difference
between these two organisms is hardly discernible.
Both form upon this medium discrete colonies of minute
size, the smaller and younger of which are translucent,
the older and larger opaque, and of a yellowish colour.
On ordinarj^ media the growths of the two organisms are
strikingly similar. Thus in bouillon they form a slightly
granular deposit on the sides and bottom of the tube,
while the supernatant fluid remains clear. On gelatine
both form discrete non-liquefying colonies, but these
media are not suitable for its growth.
Both these organisms coagulate the milk medium,
forming a firm coagulum, but the diplococcus from the
23't STUDY OP MALIGNANT ENDOCARDITIS
malignant type the more rapidly. By both, alkaline
media are rendered very distinctly acid.
This acid-producing property is a well-known feature
in the growth of many bacteria. Dr. Sidney Martin, in
his important researches upon the poisons of infective
endocarditis, attributed this to a non-proteid body.
When we recall how much attention has been directed to
the possibility of some acid-producing process in the
metabolism of rheumatic affections, and when we bear in
mind the wide-spread belief in the value of treatment by
alkalies, we are led to wonder whether sufficient atten-
tion has been given by clinicians to this result of bacterial
growth in rheumatic and gouty affections. Is it not
possible that in a gouty subject an attack of gout may result
from an infection with these acid-producing bacteria ?
The pathological action of the organism was studied
by isolating it in the milk and bouillon medium and then
transferring it to blood agar. Injections were made
directly into the circulation of rabbits through the auri-
cular vein.
III. Concluding Observations,
(a) Upon the Specific Nature of Rheumatic Fever, '
Finally, it remains for us to touch very briefly upon
some of the considerations that arise if it be true that some
cases of malignant endocarditis are rheumatic in origin.
In these considerations, much must turn upon the question
whether rheumatic fever is a specific disease. If it be a
specific disease the processes involved must be specific,
and the problem arises to what extent this specific
character is due to the poisons which are formed by the
micro-organism, and to what extent to the peculiar tissue
reactions. As knowledge upon this problem is gained,
the mode of origin of the malignant type may become
apparent. Again, whatever the nature of the poisons
that are formed in rheumatic fever, those of this type of
STUDY OP MALIGNANT ENDOCARDITIS 235
malignant endocarditis would be allied to them, a conclu-
sion which, in the future, may have a close bearing upon
the treatment of the disease.
(b) Upon the Relation of Septic to Rheumatic Processes.
An interesting point which arises from this question of
the specific nature of rheumatic fever is the relation of
rheumatic to septic processes. Are these disthict in their
essence, or is rheumatic fevei^ an infection with attenuated
pyogenic cocci, as Singer maintains ? ^
We have been compelled to differ from Singer because
we have isolated only one organism from rheumatic fever ;
nevertheless, this question must still arise in a slightly
modified form thus : — Is this diplococcus we have isolated
the attenuated Streptococctis pyogenes, and rheumatism a
result of this attenuation ? In reply to this we would ask,
can the term " attenuation '^ be applied in this sense ? ^
Chemical pathology will, we suppose, solve this ques-
tion, and meantime we are driven back to clinical expe-
rience, and ask of it once more, is rheumatic fever a
specific disease ? If it is, the diplococcus, call it what
yoa will, must be to this extent specific, that it has
produced a constant disease. It is to be hoped that this
problem of the relation of rheumatic to septic processes
will be solved before very long, and if the diplococcus
described by ourselves and others prove to be the only
cause of rheumatic fever, this solution will mark another
step in the progress of our knowledge.
(c) The Position that this Type of Malignant Endocarditis
occupies.
Again, if the two processes, rheumatic and septic, are
essentially different, then, we suppose, mild acute rheuma-
^ "Weitere Erfahrungen iiber die Aetiologie des acuten Gelenkrheuma-
tismus," ' Wiener klinischen Wochenschrift/ Jahrgang 1901, No. 20.
* Bheumatic fever may prove fatal with the evidences of great
virulence.
286 STUDY OF MALIGNANT ENDOCARDITIS
tism corresponds to the milder forms of pyaemia, virulent
rheumatism to severe pyaemia ; this form of endocarditis to
malignant endocarditis with suppuration, while septicaemia
perhaps finds a parallel in some cases of rheumatism
with profound toxaemia.
We have undertaken some investigations into this
subject — starting from the assumption that the micro-
organisms isolated from distinct types of rheumatic and
septic diseases should, if placed under the same conditions
out of the body, produce also distinct types of disease in
susceptible animals.
Thus from rheumatic fever, puerperal fever, suppura-
tive phlebitis, pyaemia, and cellulitis, we have isolated the
organisms, and have endeavoured, as far as possible, to
maintain their virulence by transferring them at once to
blood agar. Eabbits have been injected with these
cultures, but as yet pygemia has not resulted from the
Diplococcus rheumaticuSy or rheumatic fever from the
pyogenic organisms. Triboulet records the same ex-
perience.^ We do not pretend these investigations
are by any means sufficient to settle this question ;
but we make allusion to them because it does seem an
important point in the study of the large group of patho-
genic cocci to choose typical examples of the disease of
which they are thought to be the cause, and then to put
these organisms to the test of experiment under similar
conditions, rather than to deal with cultures, the virulence
of which has been artificially raised, or with organisms
that have been placed upon various media far removed
from their natural soil.
(d) Local Malignancy in other Rheumatic ilaniftstatiovs.
To the assertion that these cases of malignant endocar-
ditis are rheumatic the fair criticism may be raised that
such persistent local processes should be met with also in
other of the rheumatic manifestations. It cannot be supposed
1 'Le Rhumatisme Articulaire Aigu/ 1901.
STUDY OF MALIGNANT KNDOCARDITIS 237
that any lesion, except of the heart or great blood-vessels,
would produce the same condition of blood infection as
does the malignant endocarditis, for there will not be that
same relation of the local lesions to the general blood-r
stream.
1 . Malignant pericarditis. — Yet it is well recognised that
there is in childhood a persistent intractable malignart
form of pericarditis. This may smoulder on for months,
the process throughout being a repeated local pericarditis,
never an acute general inflammation. In such a con-
dition as this, if the organisms in the pericardium had the
§ame easy access to the general circulation that they have
in the vegetation of a valve, we should suspect the similar
character of the two conditions would be at once apparent.
2. Malignant arthritis and rheiunatoid arthritis. — It is
probable, too, that the same process occurs sometimes in
the joints, and gives rise to chronic destructive lesions of
one or more, a condition included in the disease of joints
known as rheumatoid arthritis. Such a condition of the
joints need not react to treatment by salicylate of soda
any more than do the conditions of endocarditis or
pericarditis.
We have isolated, cultivated, and demonstrated in the
synovial membrane from a knee-joint which contained
two drachms of clear fluid, in which the cartilage had
been eroded and the synovial membrane had been much
thickened by prolonged and chronic disease, a diplococcus
which reproduced severe arthritis in a rabbit, and in one
instance a monarticular osteo-arthritis. The patient, an
old man, had died from an acute poison (carbolic acid),
and no history had been obtained of the origin of this
condition of rheumatoid arthritis. Nevertheless this
demonstrated the fact that destructive non-suppurative
lesions of the joints may exist in the human being as a
result of the presence of a diplococcus indistinguishable
in morphology from the Diplococcus rheumaticus, and this
has a very important bearing upon the pathology of
rheumatoid affections of the joints.
288 STUDY OF MALIGNANT ENDOCAKDITIS
(e) The Insidious Onset of Rheumatic Fever.
Another criticism of the investigation that may be
raised from the clinical side is, that though malignant
endocarditis and rheumatic fever may in their course
sometimes resemble one another, their modes of onset are
widely different. The onset of rheumatic fever, it may-
be said, is comparatively acute ; of this type of malignant
endocarditis almost invariably very gradual.
Rheumatic fever, no doubt, does very often commence
somewhat acutely, but in childhood we are repeatedly met
with the history that before the definite rheumatic sym-
ptoms were noticed the child had been out of health, was
becoming anjemic and irritable, and was losing flesh. If
the temperature is taken it may be found to be raised
during this period. The onset of rheumatic fever is then
often insidious, as Sir William Church emphasised in his
article upon acute rheumatism in Professor Clifford
Allbutt^s ^ System of Medicine.^ It appears to us that
observations in every direction tend to strengthen the
view that this diplococcus may live for long periods in the
body, as it certainly does in culture outside of the body.
Possibly it may remain latent ; often it produces indeter-
minate symptoms, and finally it may produce character-
istic symptoms. The repeated relapses of the chronic
types of rheumatic fever are most probably to be explained
in this resistance of the micro-organism to complete
destruction.
We must once more thank Dr. W. B. Cheadle and Dr.
D. B. Lees for leave to make use of their clinical cases.
It would be impossible, if it were not for this assistance,
to collect sufficient data for the generalisations which are
essential in investigations of this nature. To Mr. H. G.
Plimmer, Pathologist to St. Mary^s Hospital, we must
also again express our indebtedness.
Med. Chir. Trans., Vol. 85
Poynten ana Paine: Malignant Endecardilis, Plate I.
The Heart of a Rabbit. Exp. Xo. (3). Case No. \'I.
The milcal valve is exposed, and upon il is seen a large vegetati
Tim-, llKA
The m lira I vnl
ha-l Wen' '.l.t'niii''/ Ir'.m
Vic. i.
The Hrakt ok a Kahbii'.
The tticiupid valve is i.'x|h>si.iI. and
shows soteral sitinll vq^tations.
The innculalion was made wirh a
dijilococcus isolated from malignant
ilieu malic end ocani ills. (Case
N... V.I
Fin. 3. Fia. 4.
Photograph of agar pkles ptepaced wilh vaccine material /aur weeij afterl
Gl.YCKRi NATION i showing inhibitory ellecl nf different percentages of glycetina. ¥
Fir.. I. — 10 per cent, glycerine. Fm. 3. — 40 pel cent, glyccitne.
Fig. z.— 30 per cent, glycerine. KiG. 4.— 50 per cent, glycerine.
Med. Chir. Trans., Vol. 86.
■ faednalioii. Plate 111.
Photograph of calf, showiog result, on the siitth day, of inoculation wilh
vatiolo- vaccine lymph. Series I.
(Third remove from the monkey shown on Fig. i, )
Med, Chir. Tr.ns., Vol. S5.
Med. Chir. Trans., Vol.
Cofeman: Va^iittalicil. Piale V.
\
Photograph of calf, .showing result, on the sixth day, of inoculation with
variolo- vaccine lymph. Series III.
(Fourth remove from monkey shown above.)
Med. Chir. Tra
CoftmaH: y<icdnalKa. Plate VJ.
MODERN METHODS OP VACCINATION 271
DISCUSSION.
Dr. Leonard Dobson referred to t\xe difficulties met with in
the production of calf lymph. In his experience the best lymph
was obtained from calves with light hair. The results, however,
as tested by vaccination, varied greatly with the condition of
the animal. In some instances, for example, good vesicles that
had developed on the fourth day, on the lifth day dried up,
leaving scabs alone. Lymph would become inert from many
causes ; if the glycerine were acid, sooner or later it would become
inert ; similarly it would do so if it were exposed to light or
heat. It was unfortunate that there was no test for the
activity of lymph except the result on the calf and on the child ;
and, moreover, lymph which produced a good result in the calf
might be ineffective for the child. There was no test known at
present by which the activity of lymph could be standardised.
Recent complaints as to the efficiency of lymph were mostly in
regard to the secondary vaccination of adults; the present
epidemic gave the first general experience of this. In some
cases it was possible to produce good vesiculation in the same
person again and again within a short time from the use of
different lymphs. He knew of the case of a child who in the
space of four months had been vaccinated successfully no less
than three times. In his own case, after having been success-
fully vaccinated with lymph from the Government laboratories,
he shortly afterwards accidentally inoculated his finger with
lymph from another source, with the result that a typical vesicle
developed. What efficient re- vaccination really was was not yet
established.
Professor Sims Woodhead, in resuming the discussion in-
troduced by Dr. Copeman, on December 10th, 1901,^ said that he
had done many experiments with the object of observing the
effect of adding glycerine to calf lymph, and that he could
corroborate Dr. Copeman' s observations on the action of gly-
cerine on vaccine lymph, and on micro-organisms. The non-
sporing organisms, with a few exceptions, were almost entirely
eliminated by a 50 per cent, solution of glycerine ; even in such
a resistent form as the Streptococcus pyogenes aureus a large
number were eliminated, sometimes only about 5 per 1000 being
left. The spore-bearing organisms were almost unaffected. Thus
some indication as to the nature of the vaccine organisms, which
might be so small as to be invisible with the highest powers of
the microscope now available, was given. The organisms
1 'British Medical Journal,' December 14th, 1901, p. 1736.
272 MODERN METHODS OF VACCINATION
present in lymph were chiefly skin organisms and non-sporing,
and hence were amenable to glycerinisation. It had been
pointed out by the Special Commission on Glycerinated Calf
Vaccine Lymphs that when non- spore bearing organisms were
present in large numbers this was due to imperfect glyceri-
nation, but that when spore- bearing organisms were in excess
in any lymph it was an index that that lymph had not been
sufficiently carefully collected. He alluded to the effect of
glycerinisation on the activity of the lymph, and expressed the
opinion that little or no weakening occurred within three or four
weeks. After a longer time weakening probably did, to a slight
extent, occur, but the deterioration was more likely to be due to
under- glycerinisation than to over-glycerinisation. When organ-
isms that grow best at the body temperature were in excess
glycerinisation had a more active influence. The local inflam-
matory effect of vaccine had been considered of late by many to
be greater than formerly, but this was probably due to imperfect
glycerinisation, the great-er part of the local effect being always
due to extraneous organisms. He suggested that the Local
Government Board might be able to prepare statistics from
their returns to decide that point.
Dr. T. D. Ac LAND said that whilst acting as medical officer to
the Royal Commission on Vaccination he had had an unusual
opportunity of seeing the methods of vaccination practised
throughout the country, and of forming an opinion as to the
manner in which the operation was carried out, and the cause
and extent of vaccinal injuries. In the course of the same
inquiry he had been brought intimately into relation with the
Medical Department of the Local Government Board, and was
able to appreciate the manner in which its offic*^rs carried out
the difficult and often thankless task of maintaining efficient
vaccination. Theie could be no question that the country owed
much to Dr. Copeman for his researches into the origin and
purity of vaccine lymph, and for his share in the establishment
of an institute able to supply calf lymph on a scale quite im-
possible a few years ago. Dr. Acland hoped that the Govern-
ment would take steps to establish a laboratory on a far larger
scale than at present, so that all prartitioners in the kingdom
might be able to obtain lymph from a laboratory fitted with
every requisite for perfect work, unfettered by economies neces-
sary in an establishment run solely tor trade purposes. He
thought that it would be well also if all supplies of vaccine lymph
were placed under Government control, and expressed regret
that there should be two " Jenner Institutes '* in this country —
the one formerly known as the " British Institute of Preventive
Medicine " in Chelsea, where the National Vaccine Establish-
ment was temporarily situated, the other the Jenner Institute
for calf lymph in Battersea, to which the name by priori tv
MODERN METHODS OF VACCINATION 273
belonged. It was inevitable that confusion should arise be-
tween the two establishments, and it had arisen.
The Nature and Origin of Vaccine Lymjph,
Vaccination, although it was the first protective inoculation
practised on a large scale throughout the whole civilised world,
had, in all things except the extent of its use, been outstripped
in the scientific details of its technique by many of its successors
in the department of protective inoculations as now carried out.
The practical question now was whether a protective virus
could be obtained from b(jvine animals by the inoculation of
existing lymph, or of the virus of inoculated smallpox (which
differs in many important particulars from the natural or
exantheuiatous form). It would seem that Dr. Copeman, by
transmitting smallpox through the monkey, and by inoculating
bo vines with the virus so obtained, had produced a lymph which
was of a similar, and possibly of the same nature as that which
would be obtained from cows who had accidentally contracted
local pocks from a milker suffering from inoculated smallpox.
Lymph derived from such a source, and definitely derived from
smallpox, seemed to be capable of producing " vaccinia ** in man,
whilst it had lost its power of transmitting smallpox. Whether
this lymph was identical with what was called vaccine lymph
could only be decided by further experiment. The lymph now
in use in this country, whatever its origin, was not merely an
attenuated smallpox virus, since, if this were the case, some
amongst the many millions of vaccinated children would be
likely to develop smallpox instead of vaccinia. Dr. Acland was
not aware that any such case had been recorded. The general-
ised eruption, which in rare instances followed vaccination, was
generalised vaccinia, not variola.
The Preparation of Lymph.
Glycerine had long been used to dilute the lymph, and to
serve as a medium for triturating the lymph products obtained
from the calf, but no experiments were made previous to Dr.
Copeman' s to show that the treatment by glycerine was capable
of producing a sterile lymph, that was a lymph freed from all
extraneous organisms. Dr. Copeman's researches had at any
rate shown that lymph freed from all organisms capable of
cultivation on ordinary media did not lose its specific property.
This answered the question which had been raised whether
erysipelas was a stage in the evolution of inoculated cow-pox.
Standardising Lymph.
The standardisation of vaccine lymph had hitherto presented
practically insuperable difficulties. It was possible that the
VOL. LXXXV. 18
274 MODERN METHODS OF VACCINATIOK
facts demonstrated by Drs. Calmette and Gucrin ^ might enable
this difficulty to be overcome. They had shown that the rabbit
was susceptible to the vaccine virus, and consequently the
potency of any particular batch of lymph might readily be tried
before it was sent out. The method had been tested successfully
for two years at Lille, with the great advantage that it was
found possible to eliminate inert batches of lymph prepared for
vaccination.
The Actual Methods of Vaccination,
Vaccination as practised was open to two main objections :
(1) that the necessity for causing a local sore created a definite
point of vulnerability in the individual vaccinated, and formed a
possible starting-point for various inflammatory complications ;
(2) that it created a certain amount of opposition, since in the
homes of the poor a vaccinated child imposed a burden on the
often overworked mother which was hardly realised by those
who had no practical acquaintance with the facts ; the gain to
the community was impersonal and remote, while the sick child
was a present and very real source of anxiety and difficulty.
The necessity for producing a local pock seemed to depend
upon the fact that so far all efforts to isolate and cultivate a
" vaccinia '* organism in vitro had failed, so that the only prac-
ticable method of administering vaccine lymph medicinally was
to create a local pock of a certain an a, arrived at by experience,
and to leave the production of the immunising bodies to take
place in the i>erson of the individual vaccinated.
The Production of an Antitoxin in the Body hy Local Inoculation
(Vaccination).
Dr. Acland recognised two views as to the means wherebv
protection was attained by vaccination, (a) " That by the local
inoculation a body, presumably an organism, is introduced into
the tissues, which by its multiplication, after absorption, produces
the desired antitoxins." According to this hypothesis, the
number or extent of superficial vesiculations is immaterial, if
only sufficient of the original virus was introduced at the point
of inoculation to overcome the resistance of the individual. Dr.
Acland knew of no evidence corroborative of this hypothesis ;
on the contrary, such evidence as there was went to show that
(ft) under ordinary circumstances a given area of vesiculation
was necessary, and that the immunising effect of vaccination
Ix^re a more or less definite relation to the area of the vesicles.
This would follow if it were a fact, as now generally supposed,
1 * Annalos do Tlnstitut Pasteur,* 1901, vol. xv, p. 161.
MODERN METHODS OF VACCINATION 275
that the area of vesiculation bore a direct relation to the amount
of antitoxin produced. From these considerations several
important questions — practical, therapeutical, and political —
arose. 1. Why was it necessary to produce on the arm of a
' newly bom infant the same number of vesicles as on a fully
grown man ? It might be urged as a matter of clinical experi-
ence that infants required a larger dose of vaccine lymph as of
other remedial substances, such as arsenic and belladonna,
because their tissues were more active, they were more sus-
ceptible to the infection of smallpox, and the changes (increase)
in their body- weights had no parallel in the adult, all of which
circumstances necessitated a proportionately larger reserve of
the immunising material if the dose was to be effective. 2. How
was it that different standards of efficient vaccination were per-
mitted ? Ought there not to be an irreducible minimum below
which no certificate of successful vaccination should be given ?
If satisfactory immunity — a variable quantity for every indivi-
dual— could only be procured by a certain standard of vaccina-
tion, it was surely desirable that there should be a uniform
certificate of successful or efficient vaccination. At present it
was mainly those vaccinated by the public vaccinator who were
efficiently protected according to the official standard. Those
vaccinated in private might have one, two, three, or four vesicles,
according to the conscience of the operator or the insistence of
the mother. The medical profession ought to endeavour to
create a public opinion in favour of a really efficient standard of
vaccination, and not give its tacit approval to its performance
as a piece of therapeutic ritual which had to be got over as
cheaply as possible. 3. Did the number or area of scars really
give any indication as to the efficiency of protection ? This was
a most difficult question, but fortunately one to which a great
deal of attention has been directed, notably by Dr. Coupland,
whose work was a model of thoroughness, and by Dr. Barry,
whose report on the smallpox epidemic at Sheffield was well
knovni. It would appear from the figures given in the report of
the Royal Commission on Vaccination, 1896, that in nearly 7000
cases the mortality was 62 amongst those with one mark, and
32 amongst those with four. These figures emphasised the
fact that a minimal standard of efficient vaccination was much
required if the community was to take full advantage of
the protection of vaccination against smallpox. Vaccinia or
immunity to subsequent vaccination had been produced by
many experimenters without the formation of superficial vesicles
both in man and animals. Burckhart vaccinated six children
whose mothers had been successfully vaccinated whilst pregnant.
The operation was unsuccessful in all of them. Kellock vacci-
nated 38 women in various stages of pregnancy, and found that
the infants resisted vaccination directly as the stage of preg-
276 MODERN METHODS OP VACCINATION
nancy at which the mother was vaccinated. In 21 cases the
children of women who were vaccinated during the latter half
of pregnancy proved insusceptible of vaccination ; whilst in 14,
whose mothers were vaccinated before the seventh month, vacci-
nation was successfully performed. Smallpox contracted by a
mother before her confinement might be transmitted to the
foetus, and a child whose mother had contracted smallpox during
the third week before delivery might prove insusceptible to
vaccination. Straus and Beclard, Chauveau and Menard, had
also made experiments which confirmed these clinical observations,
since they had found that the serum of calves taken during the
height of vaccinia produced a measure of immunity in other
animals of the same species ; when injected intra- venously the
serum injections acted at once, whilst immunity was not secured
in the calf by vaccination before the eleventh or twelfth day, or in
the pig two days earlier. This date, according to Cory; was
approximately the period after vaccination at which immunity
began to be secured in man. The time varied very much in
different individuals of the same species ; in man probably the
receptivity to successful vaccination diminished gradually during
the second week, and became extinct before the fourth. Dr.
Acland had recorded a case of vaccinia generalised by auto-
inoculation, in which the pocks continued to develop for four
weeks certainly. Such evidence tended to show (1) that the
serum of a vaccinated animal was capable of modifying and
possibly destroying the susceptibility of another animal of the
same species to vaccination ; (2) that it was not essential for
the immune animal to have been actually vaccinated in order
that it might be rendered refractive against further inoculations
of the same virus ; and (3) that whereas serum injections had a
rapidly immunising power, vaccination was a comparatively slow
process, a fact which had an important bearing on the question
as to whether it served any useful purpose to vaccinate an
individual who had already been exposod to the infection of
smallpox. Dr. Acland then referred to ine attempts which had
been made to treat variola by the antitoxin of vaccinia.
Kinyoun ^ had recorded two cases of variola treated with serum
taken from a calf vaccinated four weeks previously. The
observations were inconclusive. Each case received 15 c.c. of
serum followed later by 20 c.c. more. One case died in seventy-
two hours. In 1896 MM. Beclard, Chauveau, and Menard had
recorded - observations made on seventeen cases of variola of all
ages treated by subcutaneous injections of serum taken from a
vaccinated calf. In one case no less than a litre and a half was
injected without causing any local or general disturbance, and
^ * Philadelphia Med. News/ February 2nd, 1895.
2 * Ann. de Tlnstitut Pasteur,* vol. x, 1896, p. 1,
MODERN METHODS OF VACCINATION 277
the patient recovered. These cases had been alluded to by Dr.
Copeman in his Milroy Lectures, but in a later communication
the same observers had given an account of further experiments
on the immunising power of the blood of man and animals, after
vaccination, against the vaccinal or variolous infections, and they
came to the definite conclusion that not only did the serum of a
vaccinated calf taken on the fourteenth day after inoculation
possess certain powers both in the direction of conferring
immunity and assisting the cure in the body, but that it also
acted on vaccine lymph in the test-tube, rendering it inert.
They also concluded that the serum of convalescents from variola
had the same destructive power over the vaccinal virus. All
these experiments seemed to indicate the general truth of
Jenner's hypothesis, and to supply the scientific basis which was
lacking from his empirical practice — a practice which, although
empirical, had stood the test of time and of rigid experimental
test. They also served to indicate the direction in which the
advance might be made. Dr. Copeman had made it possible to
obtain from the calf a supply of antitoxin directly derived from
variola ; might it not be that this would afford a means of com-
bating variola itself ? It might well be asked that Dr. Cope-
man, should he be willing, should be granted the opportunity
of testing the accuracy of the scientific facts by utilising them
for the treatment of variola.
Dr. Acland then gave notice of the following resolution :
" That, in the opinion of this meeting of the Fellows of
the Eoyal Medical and Chirurgical Society, it is desirable
that the Government should without delay make such addi-
tions to the National Vaccine Establishment as shall enable
it to supply glycerinated calf lymph to all medical practi-
tioners who may desire to use it ; and that, in view of the
national importance of the subject, steps should be taken to
test and regulate the sale of all imported lymph, and to
inspect the manufacture of all that is made in this
country.**
Professor Haccius (Geneva) acknowledged the debt conferred
on universal medical science by Jenner, and also later by Dr.
Copeman. In 1892, when in Switzerland there was difficulty
in procuring good calf lymph, he transmitted variola to a calf,
from this to six other calves, and eventually with success to chil-
dren, typical vaccine vesicles being formed. Professor Chauveau
attacked these experiments on the ground of accidental inocula-
tion with vaccinia in the laboratory, saying that the disease was
vaccinia and not modified variola ; but this source of fallacy was
eliminated by transmitting the inoculated smallpox from calf to
calf before inoculating it on children. Professor Chauveau had
inoculated a cow with variola, and from the vesicle produced had
inoculated a child who developed typical variola. This, however,
278 MODERN METHODS OF VACCINATION
V
was to be explained by the direct transference of variola virus to
the child, the cow being merely a stage in its transference. In
Munich and Stettin smallpox had been transmitted to calves,
the inoculations being performed apart from vaccine establish-
ments. It was recognised that in many instances variola could
not be thus transmitted to the calf, but he believed that the iden-
tity of variola and vaccinia would be established. His results on
children were quite good, there being no generalised eruption.
Allusion was made to glycerinated lymph and to powdered dry
lymph — the one being successful, the other not. The collection of
calf lymph was now conducted under better conditions than
formerly, thus diminishing from the first the number of ex-
traneous organisms. It was hoped that in a short time vacci-
nation would become compulsory in Switzerland.
The discussion was adjourned.
Adjourned Discussion, January 28th, 1902.
Dr. Sidney Coupland, in resuming this discussion, referred
to the great improvement that had supervened in modern vac-
cination methods, mainly as a result of the introduction of
glycerinated lymph, the use of which had been made obligatory
by the Act of 1898. The objects of recent improvements had
been to obviate the risks of the process, and there had been the
even greater advance in having vaccination performed at home,
and in raising the age of the children required to be vaccinated.
The vaccinal injuries had been in the past, perhaps, too lightly
considered by the profession. In the majority of cases with
ill-effects it had not been the lymph which had been at fault,
but some accidental complication. He quite agreed with Dr.
Aclaud that full control of all the vaccine lymph used in this
country should be iu the hands of the Government. Large
unsightly scars were unnecessary, and were often associated
with inefficient vraccination. The scars from purified lymph
were often small, and did not even present the size which was
formerly supposed to be an essential index of good vaccination.
Indeed, probably now the number of the scars was the best
evidence of efficient protection. The question was probably
one of dose, as in the use of antitoxin in cases of an infectious
disease. The scars were numerically a permanent record of the
dose, whilst the statistics of Marson, Gay ton, Barry, and others
prove that the efficiency of vaccination in mitigating an attack
of smallpox is in direct relation to the number of insertions.
Thus Barry found, at Sheffield, the proportion of mild attacks
to be 20 per cent, in persons who had been vaccinated in one
place only, and 52 per cent, iu those who had four marks. It
was admitted that vaccination was a good prophylactic against
smallpox, but it had its limitations. When smallpox invaded
MODEKN METHODS OF VACCINATION 279
a house or other small community where all were equally ex-
posed to iufection, some escaped and others were attacked.
Among those who had had smallpox previously, personally
collected statistics showed that 1 in 20 were attacked a second
time, and in the epidemic at Warrington, investigated by Dr.
J. D. Savill, an even larger proportion, namely, 9 out of 41,
had second attacks. But a single vaccination did not afford
this degree of protection. Of those who had been only vaccinated
once in childhood, about 25 per cent, were liable to contract
the disease when living in a smallpox atmosphere. Recently
vaccinated persons were much more powerfully protected than
the more remote ; about 1 in 7 of those who were vaccinated
for the first time on their being exposed to smallpox infection
contracted the disease. Revaccin^tion properly performed con-
ferred practically absolute immunity ; even in a person who had
had smallpox the immunity could be prolonged by revaccination.
In children under ten vaccinated in infancy, liability to attack
was about 1 in 11 or 12 ; but 2 out of 3 of un vaccinated children
were likely to take the disease on being exposed to infection for
the first time. These results, it was pointed out, were based on
a relatively few cases — some three epidemics. It was probable
that even recently vaccinated persons were not all absolutely
immune, owing to their vaccination with various strains of
lymph, some of which had become inert.
Dr. Albert E. Cope stated that he represented the body of
public vaccinators, and that he wished to describe his own
practice as an illustration of the way in which the actual work
of vaccination was carried out. The arm in the case of infants,
which had been washed by the mother, was first rubbed with
a pledget of boric wool saturated in rectified spirit, and then
dried with a pledget of dry wool. For revaccination a 20 per
cent, carbolic soap was used with which to wash the arm.
The water was boiled, a pledget of wood-wool was used to
apply the soap, the excess was rapidly washed off with water
or rectified spirit, and the arm was dried with a similar
pledget. The instrument he had found most useful was a
lancet made of platinum, hardened with iridium, so that it
might be flame- sterilised. The best ejector of the lymph from
the tube was a solid rubber bulb with a funnel-shaped perfora-
tion through which the tube was passed, and the outer aperture
closed by the thumb before compression. Lymph was placed
on the arm and the skin was lightly scratched through it, the
faintest trace of blood being drawn. An interval was allowed
until an erythematous reaction was visible, when a boric pad
was applied and strapped on. This was allowed to remain for
a week, then a powder of boric acid, zinc, and starch was applied
under another boric pad. The most troublesome complication he
had had was an eczema occurring under the strapping, which
280 MODERN METHODS OF VACCINATION
subsided readily under the application of calamine lotion.
Complications of any kind were very rare. Revacci nation was
obtainable at about fourteen after good vaccination in infancy ;
it would be well to arrange for it to be done on children before
leaving school, so that later it should not interfere with the
daily work of adult life. This might well be made a Govern-
ment regulation.
Mr. William F. Blake asked ^hat constituted a successful
revaccination. If two persons were vaccinated from the same
tube, and one took but the other did not, could it be asserted
that the person who did not take was protected against small-
pox ? He also asked what was meant by the statement that
had been made earlier in the discussion that successful vacci-
nation might occur several times within a few months in the
same person.
Dr. F. Churchill asked if there was any age beyond which
vaccination might safely be discarded. It was probable that
persons of all ages were liable to contract the disease. It was
a question whether the present epidemics of smallpox were
really so effectively controlled by improved methods of vaccina-
tion and isolation as in the earlier epidemics by rougher
measures. It was possible that the more elaborate procedures
acted as a deterrent against vaccination being universally had
recourse to, because the poor have their infected children so
amply provided for at the expense of the State.
Dr. Bernard O'Connor asked whether a second or third
revaccination was necessary ; theoretically he had thought re-
vaccination should be continued until it failed to produce any
result.
Dr. CopEMAN, in reply, stated that dilute glycerine had a
gradual inhibitory effect on micro-organisms that were non-
spore-bearing'; most of the pathogenic organisms were non-
spore-bearing, and the spore-bearing organisms at all likely to
be present were of no pathogenic importance. Even if such
organisms as those of erysipelas and tubercle were intentionally
added to the lymph in considerable quantity, the subsequent
addition of glycerine gradually eliminated them, so that -after
an interval of about a month the lymph became entirely freed
from infective qualities. The same dose or amount of vacci-
nation was probably desirable in the child as in the adult.
Probably a greater effect, however, relatively to the size of the
individual was obtained in the adult. There was at present
no efficient method of standardisation of lymph ; the only
useful test was the clinical result. It was not possible as yet
to afford the same degree of protection by injecting an
antitoxic serum into the system. With the use of glyceri-
nated lymph there was not the same destruction of skin tissue
as even in what was considered perfect vaccination of years
MODERN METHODS OP VACCINATION 281
ago. It was essential that all persons should be revaecinated
at least once in later life. There was no doubt that a person
might contract smallpox twice or even three times. In
referring to the high degree of immunity that vaccination gave,
he said that he had on two occasions accidentally inoculated
himself with smallpox, with the residt that no infection took
place. If no effect was observed to follow the use of lymph
which subsequently was suspected of being inert, an interval
of at least a month should be allowed to elapse before revacci-
nation, because a slight local immunity might be produced even
by inadequate vaccination. In recent methods there was pro-
bably no weakening of the lymph by mixing with glycerine as
compared with the old arm-to-arm method, for it was believed
that the microbes of vaccinia were contained in the epithelial
cells which were removed in the pulp from the calf, while in
vaccination from the human arm only the fluid from the loculi
was taken. Dr. Copeman, in conclusion, referred to the possi-
bility of protection against smallpox by internal administration.
CLINICAL AND EXPERIMENTAL OBSERVATIONS
INTRODUCING A DISCUSSION
ON THE
REGENERATION OP PERIPHERAL
NERVES
AN ADDRESS
BY
CHAELES BALLANCE and PUEVES STEWAET
With Lantern and Microscopical Demonstration
Read I'ebruary 25th, 1902
SYLLABUS.
1. Preliminary Remarks — The " central " school — The " peripheral " doc-
trine.
2. Changes following the division of a peripheral nerve.
A. Degeneration.
(1) Changes in the axis-cylinders and medullary sheaths.
(2) Cellular proliferation.
{a) Of leucocytes.
(5) Of connective-tissue cells.
(c) Of neurilemma cells.
B. Eegeneration.
(1) In the proximal segment of a divided nerve which has
not been reunited.
(2) In the distal segment of a divided nerve reunited to the
proximal segment by sutures.
(3) In the distal segment of a divided nerve whose cut ends
have been left widely separated.
3. Nerve grafts.
256 MODERN METHODS OF VACCINATION
demanded up to some 8000 tubes per diem can be at once
despatched to the National Vaccine Establishment at
Whitehall, from whence the lymph is distributed to public
vaccinators.
7. Recording the results of vaccinations hy 2)w6Zzc
vaccinators, — Each public vaccinator receives, in response
to application made to the National Vaccine Establish-
ment, a consignment of lymph, together with a scTiedule
in which to record the ;results of its use, and these
schedules, after having been examined at the National
Vaccine Establishment, are sent to the laboratories. The
schedules indicate the series number of the lymph, the
date of its despatch from the National Vaccine Establish-
ment, the name of the public vaccinator to whom it was
supplied, the number of tubes sent, the dates when the
several tubes were used, the number of persons vaccinated,
the number of scarifications made, and the number of
vesicles obtained. All these details are recorded at the
laboratories, and from the last two items information as to
the success which has resulted, both as regards individuals
vaccinated and insertions of lymph made, is obtained and
set forth, both in full and in the form of a percentage. In
addition to these records a register is kept stating the
particulars of the calves employed, the details of the
lymph obtained from each calf, including the results of
the bacteriological examinations, the lesults of the use of
the lymph at the Animal Vaccine Establishment, and also
the number of tubes of each series despatched to the
National Vaccine Establishment.
During the first year of operations nearly 500,000 tubes
of glycerinated lymph were sent out from the Government
Laboratories. Notwithstanding the difficulties that had
naturally to be overcome in the inauguration of work of a
character entirely new to practically all those engaged
upon it, the success attending the use of the lymph at the
hands of public vaccinators throughout the country was
distinctly gratifying, the returns made by them to the
National Vaccine Establishment showing that a case
1
Mi-d. Ohiv. TniDs,, Vol. HO.
U-ncf <C SIni'tirl ■ ltcqi-:oaHon of Wen
"■■ /• .-r ft
.V^i*'>,.t,.
SciBti<i Dcn-e o( oal. Two days aftsr dtvisioi., Lin.giUutinal sectii.u
of lowur Olid of ph'oximiil sogiUHiil, sluni'ing iiillll.valii.ii of tliu norve-
fibi-es by prolifoniletl luiu'ocytus. Tlio lowor part of tlie liguro ropiiiaeiibs
REGENERATION OF PERIPHERAL NERVES 285
A. Degeiieratiou.
B. Regeneration.
The two processes overlap in point of time, regenera-
tive changes commencing before degeneration is complete.
Degeneration.
Degenerative changes affect the lower end of the
proximal segment and the whole extent of the distal
segment. They occur simultaneously in these parts, and
do not spread from the centre to the periphery, nor vice
versd}
1, Changes in the axis-cylinders and medullary sheaths,
— Fragmentation commences on the fourth day after the
traumatism. The smallest axis-cylinders and medullary
sheaths are more resistent than the larger ones, and
remain unbroken until the fifth day (see ' Healing of
Nerves,^ plate 1, fig. 2). After that date, however, all
the axis-cylinders and medullary sheaths, small as well
as large, become completely fragmented.
The broken-down axis-cylinders aud medullary sheaths
form globular or ovoid masses, which gradually become
absorbed. The process of absorption is practically
complete by the end of five weeks, though a few scanty
remains of fatty debris can often be detected for a long
period afterwards.
2, Cellular changes: — (a) Leucocytes. — Diapedesis begins
immediately after the injury, and is well marked for the
first three days (see plate). It remains evident for two
weeks, after which it gradually subsides.
(b) Connective-tissue cells. — These commence to pro-
liferate on the second day. They have an absorbent
action on the fragmented myelin and axis- cylinders (see
'Healing of Nerves,^ plate 15, fig. 3). This process of
absorption having been completed, they then proceed to
the formation of fibrous tissue. Thus the degenerated
^ The illustrative plates to which reference is made in the subsequent
part of this paper are to be found in *The Healing of Nerves/ by-
Charles Ballance and Purves Stewart (Macmillan^ 1901).
286 EEGRNERATION OP PERIPHERAL NERVES
Tierve-trnnk becomes denser in consistence than in the
normal condition.
(c) Neurilemma cells, — These cells proliferate at a
somewhat earlier time than the connective-tissue cells,
and in a patchy fashion (see ^ Healing of Nerves/ plate
15, fig. 2). A possible explanation of the earlier pro-
liferation of the neurilemma cells as compared with that
of the connective-tissue cells may be found in the fact
that the neurilemma cells are nearer to the degenerating
elements, and therefore receive the chemical stimalns
first. After a short period, during which they have an
absorbent action on the medullary sheaths, they relinquish
this function to the connective-tissue cells, and commence
the regenerative process by arranging themselves in
closely packed longitudinal columns.
Regeneration.
(1) In the proximal segment of a divided nerve which
has not been reunited, — Changes occur which result ulti-
mately in the formation of the well-known so-called
" end-bulb'^ — a dense, club-shaped swelling in which
are numerous young nerve-fibres, coiled and intertwisted
in all directions, embedded in fibrous tissue. According
to the " central '' theory of nerve regeneration, these
new fibres were regarded as outgrowths from the central
end, which, unable to find their way into the distal
segment, had turned back on themselves in a futile
manner like the apex of a fountain. This, however,
is not so. Every new fibre of the permanent end-bulb is
laid down in separate short links, each in apposition to a
neurilemma cell, thickest near the nucleus of the cell and
tailing off at each extremity. Those short lengths of
young nerve-fibres are, at first, separated by some dis-
tance from the ends of the central axis-cylinders. The
end-bnlb is not formed by a downgrowth and recurving
of axis-cylinders, but by the development of new fibres
in a structure which we have named the '' j)rimitive end-
0
REGENERATION OP PERIPHERAL NERVES 287
hiM} '' — a mop-like protuberance which is formed imme-
diately the nerve-trunk is divided, the result of the
curling back upon themselves by the divided nerve-fibres
(see ' Healing of Nerves/ plate 1, fig. 1). In this '^ primi-
tive end-bulb '' degeneration occurs as above described,
and is followed by regeneration, a process carried out by the
proliferated neurilemma cells, which secrete small islands
of axis-cylinders and medullary sheaths. These islands
later overlap in an imbricating fashion and ultimately
fuse together to form a long nerve-fibre continuous with
one of the nerve-fibres of the proximal segment above.
(2) In the distal segment of a divided nerve, reunited to
the ^proximal segment by sutures, — The proliferated neuri-
lemma cells arrange themselves in longitudinal columns,
separated by strata of proliferated connective-tissue
cells. The neurilemma cells have a nenroblastic function
and proceed to form new axis- cylinders and medullary
sheaths.
At the end of three weeks (with the Golgi method)
neuroblastic action is first detected (see 'Healing of
Nerves,^ plates 8, 9, and 10). All through the distal seg-
ment scattered neuroblasts are seen, from whose opposite
poles young axis-cylinders grow out longitudinally,
stretching out towards similar processes of adjacent
neuroblasts in the same longitudinal column, but not yet
reaching them. By the end of four weeks these young
processes have grown in length so as to overlap and fuse
into long axis-cylinders (see ' Healing of Nerves,^ plates
10, 11, and 12). In sections stained by the Weigert and
Stroebe methods respectively the same process can also
be studied, and the new axis-cylinders and medullary
sheaths are seen to be secreted by the cells of the neuri-
lemma. In the earliest stage of this process the young
fibre is deposited along one side of the body of the cell
in the vicinity of the nucleus. It grows in length and
assumes a spindle form, thickest in the neighbourhood of
the nucleus and tapering off at each pole (see ' Healing
of Nerves,' plate 2, fig. 5, and plate 14, fig. 6). These
262 MODERN METHODS OP VACCINATION
all vaccinators, public and private alike, shall conform to a
definite standard. The further suggestion has been made
that every medical man should become a public vaccinator,
to the extent that he should have the right of claiming a
fee from public funds for every vaccination performed by
him, provided that he was willing that his work should be
subject to inspection on behalf of the Oovernment. But
the originators of this idea can hardly have realised the
magnitude of the inspectorial staff that would be required
if such an arrangement were to be put in force.
The treatment of the arm, at the time of vaccination
and subsequently during the progress of the case, is
another subject which has aroused jconsiderable contro-
versy, and concerning which much divergence of opinion
would appear to exist. Thus, in some quarters, the initial
cleansing of the arm is said to be objected to by the
parents as a reflection on the care, or want of care, on
their part, as regards the condition of their children ; but
in general it is found that a little tactfulness in explain-
ing the difference between ordinary and surgical cleanli-
ness has sufficed to overcome the difiiculty. In addition
to this aspect of the case the friction employed in the
process is of value in causing a slight capillary dilatation
which undoubtedly contributes to the success of the
operation. Water, soap -and water, spirits of wine, or
antiseptic solutions, of greater or less potency, containing
boric or carbolic acid, lysol or perchloride of mercury,
for instance, are employed by different operators for the
purpose, of which, in all probability, a warm solution of
boric acid is the most generally useful, — a stronger
antiseptic, such as corrosive sublimate, unless removed by
the subsequent use of sterilised water or alcohol, being
liable to exert a somewhat deleterious effect upon the
lymph.
The method to be employed at the operation and
during the maturation of the vesicles for the protection
of the vaccinated area from extraneous infection has not
been defined by the regulations, for the reason that it
MODEKN METHODS OP VACCINATION 263
appeared probable that each man would best attain the
desired end by the same methods that he would ordinarily
employ in the treatment of any other case of minor
surgical injury. As was to be expected, therefore, the
means adopted for the protection of the vaccination
wounds have been very various, and different trade firms
have undoubtedly reaped an extensive harvest by the
introduction and energetic advertisement of special
dressings of one and another kind. In Paris, at the time
of my official visit, a semi-transparent material, known as
'HafFetas Marinier,^' not unlike thin isinglass plaster, and
which adheres to the skin when moistened ^vith water,
was, I found, invariably employed to protect the vacci-
nated area during the first few days following the operation ;
and a somewhat similar substance, advertised by an
English firm, is, I believe, at present utilised to a con-
siderable extent in this country. But during the second
week of the process it is essential that some dressing of
an absorbent nature should be employed, as it is during
this period that oozing from the vesicles occasionally
supervenes.
The means employed for retaining the dressings in
position are almost as numerous as the latter themselves.
At the Government Station in LamVs Conduit Street a
dressing composed of a couple of layers of boric lint,
kept in place by means of pieces of rubber strapping
which do not entirely encircle the arm, is applied at
the time of vaccination, and this is replaced by another
exactly similar dressing when, a week later, the case
returns for inspection of the result. But, whatever be
the nature of the dressing, the free use beneath it of a
dusting powder of boric acid has a most beneficial effect
in preventing any undue amount of inflammatory reac-
tion.
Concerning the nature of the instrument best adapted
for the purpose of vaccination I desire to offer a few
remarks. Here, again, each operator will probably attain
the greatest measure of success with that instrument to
CLINICAL AND EXPERIMENTAL OBSERVATIONS
INTRODUCING A DISCUSSION
ON THE
REGENERATION OP PERIPHERAL
NERVES
AN ADDRESS
BY
CHARLES BALLANCE and PURVES STEWART
With Lantern and Microscopical Demonstration
Read I'ebruary 25th, 1902
SYLLABUS.
1. Preliminary Eemarks — The " central " scliool — The " peripheral " doc-
trine.
2. Changes following the division of a peripheral nerve.
A. Degeneration.
(1) Changes in the axis-cylinders and medullary sheaths.
(2) Cellular proliferation.
(a) Of leucocytes.
(5) Of connective-tissue cells.
(c) Of neurilemma cells.
B. Regeneration.
(1) In the proximal segment of a divided nerve which has
not been reunited.
(2) In the distal segment of a divided nerve reunited to the
proximal segment by sutures.
(3) In the distal segment of a divided nerve whose cut ends
have been left widely separated.
3. Nerve grafts.
284 REGENERATION OV PERIPHERAL NERVES
4. Clinical observations : (1) Primary suture ; (2) Secondary suture ; (3)
NcTve grafts.
5. Topics suggested for discussion : (1) The mode of regeneration of peri-
pheral nerve tissue ; (2) The absence of regeneration in the spinal cord and
brain; (3) The bearing of this on the neuron theory ; (4) Indications and
contra-indications for operative interference ; (5) Comparative advantages of
various operations.
The fact lias long been admitted that regeneration
can occur in peripheral nerves if their opposing ends^
previously divided, are brought into apposition.
As to the process whereby this regeneration is accom-
plislied, however, there have been two schools of opinion,
which may be termed the " central ^' and ^* peripheral "
respectively.
According to the ^^ central '^ school (supported by
Ranvier, Waller, His, Vanlair, Stroebe, Howell and
Huber, and others), the new nerve-fibres which occur in
the distal segment of a reunited nerve-trunk are formed
by a process of downgrowth from the proximal segment,
and thread their way gradually along the neurilemm|i
sheaths of the distal segment, already rendered empty by
the degeneration of the old axis-cylinders and medullary
sheaths. The new fibres are thereby guided ultimately
to the periphery.
The ^' peripheral '^ doctrine, hitherto a less popular
one (amongst whose chief supporters may bo mentioned
Tizzoni, Cattani, Bethe, Kennedy, and Galeotti and
Levi), teaches that the new nerve-fibres are formed
locally in the distal segment from pre-existing elements
there. This, in our opinion, is the correct view, and its
accuracy is demonstrable by the lantern slides and
microscopic sections illustrating this paper, the results of
our experimental observations in the lower animals and
clinical observations in man.
If a peripheral nerve be cut across, certain changes
(^ccur in the lower part of the proximal segment and
throughout the entire extent of the distal segment.
These changes consist of —
Mi-d, Cliir. Tmn>,, Vol. SO.
Ballnnce ,t Slnmrl
.-- "'■■■■ '-^"S f*'' -....-"•-.-'J,"^ ^ J
Sciatic iiorve of cat. Two days aftflr divisioi
of lower end -A proximii.1 Hegiuuiil, «Vi"iviiie ii
fibres by piolifrr.ited loiii-i>pyt"^s. Tim
the site of ijperntidiy.
REGENERATION OF PERIPHERAL NERVES 285
A. Degeneratiou.
B. Begeneration.
The two processes overlap in point of time, regenera-
tive changes commencing before degeneration is complete.
Degeneration.
Degenerative changes affect the lower end of the
proximal segment and the whole extent of the distal
segment. They occur simultaneously in these parts, and
do not spread from the centre to the periphery, nor vice
versd}
1, Changes in the axis-cylinders and medullary sheaths,
— Fragmentation commences on the fourth day after the
traumatism. The smallest axis-cylinders and medullary
sheaths are more resistent than the larger ones, and
remain unbroken until the fifth day (see ' Healing of
Nerves,^ plate 1, fig. 2). After that date, however, all
the axis-cylinders and medullary sheaths, small as well
as large, become completely fragmented.
The broken-down axis-cylinders aud medullary sheaths
form globular or ovoid masses, which gradually become
absorbed. The process of absorption is practically
complete by the end of five weeks, though a few scanty
remains of fatty debris can often be detected for a long
period afterwards.
2. Cellular changes : — (a) Leucocytes. — Diapedesis begins
immediately after the injury, and is well marked for the
first three days (see plate). It remains evident for two
weeks, after which it gradually subsides.
(b) Connective-tissue cells, — These commence to pro-
liferate on the second day. They have an absorbent
action on the fragmented myelin and axis- cylinders (see
'Healing of Nerves,^ plate 15, fig. 3). This process of
absorption having been completed, they then proceed to
the formation of fibrous tissue. Thus the degenerated
1 The illustrative plates to which reference is made in the subsequent
part of this paper are to be found in *The Healing of Nerves/ by-
Charles Ballance and Purves Stewart (Macmillan^ 1901).
286 EEGRNERATION OF PERIPHERAL NERVES
nevve-trnnk becomes denser in consistence than in the
normal condition.
(c) NpMrilenima cells, — These cells proliferate at a
somewhat earlier time than the connective-tissue cells,
and in a patchy fashion (see ^ Healing of Nerves/ plate
15, fig. 2). A possible explanation of the earlier pro-
liferation of the neurilemma cells as compared with that
of the connective-tissue cells may be found in the fact
that the neurilemma cells are nearer to the degenerating
elements, and therefore receive the chemical stimulus
first. After a short period, during which they have an
absorbent action on the medullary sheaths, they relinquish
this function to the connective-tissue cells, and commence
the regenerative process by arranging themselves in
closely packed longitudinal columns.
Begeneration.
(1) In the proximal segment of a divided nerve which
has not been reunited. — Changes occur which result ulti-
mately in the formation of the well-known so-called
^^ end-biilb '^ — a dense, club-shaped swelling in which
are numerous young nerve-fibres, coiled and intertwisted
in all directions, embedded in fibrous tissue. According
to the '' central '' theory of nerve regeneration, these
new fibres were regarded as outgrowths from the central
end, which, unable to find their way into the distal
segment, had turned back on themselves in a futile
manner like the apex of a fountain. This, however,
is not so. Every new fibre of the permanent end-bulb is
laid down in separate short links, each in apposition to a
neurilemma cell, thickest near the nucleus of the cell and
tailing off at each extremity. These short lengths of
young nerve-fibres are, at first, separated by some dis-
tance from the ends of the central axis-cylinders. The
end-bulb is not formed by a downgrowth and recurving
of axis-cylinders, but by the development of new fibres
in a structure which we have named the ^^ primitive end-
REGENERATION OF PERIPHERAL NERVES 287
hull) '^ — a mop-like protuberance which is formed imme-
diately the nerve-trunk is divided, the result of the
curling back upon themselves by the divided nerve-fibres
(see ^ Healing of Nerves/ plate 1, fig. 1). In this '^ primi-
tive end-bulb '' degeneration occurs as above described,
and is followed by regeneration, a process carried out by the
proliferated neurilemma cells, which secrete small islands
of axis-cylinders and medullary sheaths. These islands
later overlap in an imbricating fashion and ultimately
fuse together to form a long nerve-fibre continuous with
one of the nerve-fibres of the proximal segment above.
(2) In the distal segment of a divided verve, reunited to
the proximal segment by sutures, — The proliferated neuri-
lemma cells arrange themselves in longitudinal columns,
separated by strata of proliferated connective-tissue
cells. The neurilemma cells have a nenroblastic function
and proceed to form new axis- cylinders and medullary
sheaths.
At the end of three weeks (with the Golgi method)
nenroblastic action is first detected (see ^Healing of
Nerves,' plates 8, 9, and 10). All through the distal seg-
ment scattered neuroblasts are seen, from whose opposite
poles young axis- cylinders grow out longitudinally,
stretching out towards similar processes of adjacent
neuroblasts in the same longitudinal column, but not yet
reaching them. By the end of four weeks these young
processes have grown in length so as to overlap and fuse
into long axis-cylinders (see ^ Healing of Nerves,' plates
10, 11, and 12). In sections stained by the Weigert and
Stroebe methods respectively the same process can also
be studied, and the new axis-cylinders and medullary
sheaths are seen to be secreted by the cells of the neuri-
lemma. In the earliest stage of this process the young
fibre is deposited along one side of the body of the cell
in the vicinity of the nucleus. It grows in length and
assumes a spindle form, thickest in the neighbourhood of
the nucleus and tapering off at each pole (see ' Healing
of Nerves,' plate 2, fig. 5, and plate 14, fig. 6). These
288 REGENERATION OF PERIPHERAL NERVES
short lengths of new nerve-iibre grow in length until the
processes of adjacent cells overlap in an imbricating
fashion. They then fuse together to form a continuous
undulating fibre in whose course are numerous bead-like
swellings, corresponding to the neurilemma cells from
which it has been secreted (see ^ Healing of Nerves/
plate 3, fig. 12), As time goes on, the new axis-
cylinders and medullary sheaths (both secreted by the
neurilemma cells) gradually increase in diameter, the
bead-like swellings disappear, and ultimately the adult
form of fibre is attained.
The new fibres in the distal segment have a longi-
tudinal direction from the outset, whilst in the inter-
mediate scar-tissue between the proximal and distal
segments their direction is wildly irregular (see ^ Healing
of Nerves,^ plates 7 and 8). But the mode of formation
is the same in every case.
(3) In the distal ^ segment of a divided nerve whose
cut ends have been left widely separated, — According
to the " central ^' theory, it being impossible for new
fibres to reach the distal segment from the proximal,
regeneration cannot occur. But such is not the case.
Regeneration can occur in the distal segment of a nerve
even although widely separated from the proximal segment,
and the process is exactly the same as that which occurs
in a reunited distal segment. It commences, however,
at a later date (four or five weeks after division, instead
of three weeks, as in a reunited nerve), and progresses
more slowly. Moreover the new fibres do not attain
beyond the sinuous, beaded stage characteristic of incom-
plete maturity (see ^Healing of Nerves,^ plate 4, fig. 13
and plate 14, fig. 9). If, however, such a distal segment,
already partially regenerated, be sutured to the proximal
segment, the new fibres quickly attain to adult propor-
tions, thus illustrating the common truth that physio-
logical activity is necessary for anatomical perfection.
Cases where the distal segment is in a condition of
inflammatory sclerosis — such neuritis being usually of
KEGENEKATION OF PERIPHERAL NERVES ^89
microbic origin — may exhibit great delay or even total
inhibition of the regenerative process.
Nerve Grafts. — In a number of cases, both in animals
and in man, we have inserted a graft of fresh nerve tissue
to join the proximal and distal segments of a divided
nerve when separated too widely for suture. The longest
graft that we have successfully employed in man has been
two inches in length.
In such cases the transplanted portion of nerve serves
to restore conductivity in the divided nerve-trunk. But
it does so by acting simply as a scafEold into which there
migrate successively leucocytes, connective-tissue cells,
and neurilemma cells. Alongside the ingrowing blood-
vessels of the new living tissue replacing the graft, the
neurilemma cells (derived both from the proximal and
from the distal segments) advance into the substance of
the graft. There they proceed to arrange themselves
into columns and secrete new axis-cylinders and medullary
sheaths in the usual manner, whereby the proximal and
distal segments become functionally reunited. In a
microscopic section of a graft in the sixth week after
operation, the neurilemma cells are found in greatest
abundance by the side of newly formed blood-vessels of
the young connective tissue replacing the graft. They
appear around the vessels, under a low power, like a
dense shoal of minnows (see ' Healing of Nerves,'
plate 3, fig. 11). None of the original cells of the graft
take part in this process of regeneration.
Clinical Remarks. — From what has been already stated
it follows that in every case of accidental division of a
nerve-trunk its reunion ought to be attempted either
(1) Primary suture at the time of injury ;
(2) Secondary suture at a later date ; or
(3) Transplantation of a portion of nerve from another
animal.
VOL. LXXXV. 19
290 REGENEKATION OF rEKirilElJAL NEKVE8
In such operations tlie most satisfactory suture is
one of the finest silk. It should be inserted in the
fibrous sheath of the nerve, three or four sutures at least
being used.
(1) Primary suture. — In this the surfaces, being already
newly rawed, do not require to be ^' refreshed *' unless
they are ragged. Thus little or no shortening of the
nerve- trunk results.
It should be remembered, however, that immediate
return of function is not to be expected after primary
suture, since before regeneration can occur degeneration
must first take place. Return of function therefore
occurs only after jsome weeks, the earliest date (in the
lower animals) being the end of the fourth week.
(2) Secondary aiiture. — The immediate results of this
procedure depend largely upon the length of time which
has elapsed since the primary injury. If the period has
been long enough (four weeks at least) to permit of
regeneration in the distal segment to be fairly advanced,
an immediate return of sensation in the previously ansBs-
thetic area is often observed. There is no reason to
suppose that any interval is too long to attempt secondary
suture. In cases, however, where suppuration or microbic
infection has occurred in the distal segment as a result of
the injury, an interstitial neuritis may be set up suflBcient
to entirely prevent regeneration. This consideration
would explain the striking success of certain cases of
secondary suture and tlie equally conspicuous failure of
others.
The inspection of the portion of the distal segment
exposed at the operation gives no clue to the surgeon as
to whether or not regeneration has occurred, but a
microscopical examination of the small portion of tissue
removed from the distal segment (in order to raw it
previous to suture) may demonstrate that regeneration
has taken place. The surgeon then may confidently
predict the success of his operation. Thus, though
operation may be advised in all cases, a successful result
i
REGENERATION OP PERIPHERAL NERVES 291
cannot be predetermined^ p.nd is not assured (if the
primary wound healed after suppuration) until sensation
returns after the operation, or until a microscopical
examination proves that regeneration has taken place in
the distal segment.
In successful cases sensation always returns before
motor power. Thus, for example, in one of our cases of
complete division of the external popliteal nerve foui*
months before by a bullet (of which a portion was found
at the time of operation, between the proximal and distal
segments), sensation had returned by the time the patient
recovered consciousness after the anaesthetic, whereas
motor recovery had not commenced five weeks later,
though the muscular atrophy was distinctly less.
(3) Nerve grafts, — These are to be recommended only
in cases where apposition of the proximal and distal seg-
ments is surgically unattainable. In our opinion nerve
grafting is a preferable operation to that of turning a
flap from one segment into the other, inasmuch as the
making of such a flap diminishes the size of the nerve-
trunk from which it is derived, whereas a graft unites
undiminished ends.
The following subjects are suggested as a possible
basis for discussion :
(1) The mode of regeneration of peripheral nerve
tissue.
(2) The absence of regeneration in the spinal cord
and brain after injuries, and its association with the
absence of neurilemma cells in the central nervous
system.
(3) The bearing of this on the neuron theory.
(4) Indications and contra-indications for operative
interference.
(5) Comparative advantages of various operations.
[Dr. PuiiVES Stewart, after demonstrating by means of the
epidiascope a number of drawings and photographs illustrating
the processes of degeneration and of regeneration, added :]
202 KKGEXEkATIOK OF I'EKH'UEKAL NKKVES
If the views which we have maintained are correct, they
entail a reconstruction of our conceptions as to the architec-
ture of the nervous system. According to Waldeyer^s
neuron theory, wliich has for the last eleven years practi-
cally held the field, every nerve-fibre is a mere outgrowth
from a nerve-cell, which outgrowth degenerates if cut ofE
from its parent cell, and can only regenerate again by a
process of downgrowth from that cell. According to the
neuron theory, regeneration ought to be impossible in the
distal segment of a divided nerve whose ends have re-
mained mdely separated. But our observations show that
such is not the case. The neuron theory therefore, so far,
at any rate, as the peripheral nervous system is concerned,
must be discarded.
With regard to the clinical side of the question, if our
views are correct, operative reunion of . peripheral nerves
ought to be attempted in almost every case. But are
there any contra-indications for such operation ? Firstly,
there may be anatomical difficulties. Thus, for example, if
the whole of the roots of the brachial plexus have been
ruptured close to tlioir exit from the intervertebral fora-
mina, the surgeon might perhaps hesitate before diving
down into a deep and dangerous dissection at the root of
the neck. Another contra-indication might be the total
loss of galvanic excitability in the atrophied muscles.
Obviously it is not worth while reuniting a motor nerve
if there are no muscle-fibres left for it to innervate. But
such total disappearance of muscle-fibres is certainly less
frequent than is commonly supposed. Thus I have exa-
mined the electrical reactions of muscles in a case sixteen
years after division of their motor nerve, and still obtained
some reaction to galvanism.
REGENERATION OP PERIPHERAL NERVES 293
DISCUSSION
Professor C. S. SHERRiNaTON thought the paper proposed a
revolution in the teaching as to structure of nerves which was
opposed to the neuron theory. It had been suggested that a
nerve-fibre was not a single nerve-cell process, but a series of
nerve-cells. The paper reminded him of experience as to the
absence of regeneration after experimental lesions of the central
nervous system, even after section of the posterior columns of
the cord, which were hardly spinal fibres, but rather the direct
continuation of peripheral nerves. After removal of the pos-
terior ganglia he had, however, on one occasion found apparently
new-formed nerve-fibres in the spinal part of the tract fifty-five
days after the operation. Physiological difficulties in regard to
the nature of nerve action — on an electrical type — were perhaps
more easily explained by the new linked chain theory giving
retardation of the impulses at the intervals between the quasi-
electrical conductors. Similarly, the difference in resistance
between the longitudinal and transverse axes of the nerve was
accounted for to some extent, as were also the facts of polarisa-
tion, by the idea that the axis-cylinders were not continuous
fibres, but apposed short lengths. However, this theory was
perhaps somewhat difficult to accept in view of the degeneration
in the peripheral nerves after removal of the trophic centres in
the spinal cord. The regeneration of centripetally conducting
fibres was even more difficult to get over.
Dr. R. Kennedy (Glasgow) considered that these researches
fully corroborated the results of his own investigations, published
by the Royal Society some five years ago, by which the theory of
the regeneration of nerves by a downgrowth f rom the peripheral
end was combated. He referred to the view that the higher up
a nerve was divided the longer was the time taken for the
restoration of sensation. In his experience this had not been
the case, and restoration of sensation had occurred as rapidly
when the nerve was divided at one point as at another. This
theory could not explain the rapid return of sensation after
apposition of the divided nerves, occurring as it might even on
the day following operation. The demonstration of newly
formed fibres in the peripheral segment which had been for
some time totally separated from the central segment was first
made by Philipeaux and Vulpian in 1859, and had been confirmed
by Bowlby and himself, and by other observers. These young
fibres, however, never attained maturity while unconnected with
the central end, for the reason that they had remained without
an opportunity of performing their function of the normal trans-
294 REGENERATION OF PERIPHERAL NERVES
mission of impulses from the nerve- cell. Dr. Kennedy then
referred to the healing of divided nerves, and the restoration of
the normal paths for the transmission of impulses. If the non-
corresponding ends of nerve-fibres were brought into apposition
and united, the consequence was that the peripheral terminations
became in connection with centres in the central nervous system,
to whose innervation they did not by nature belong. To deter-
mine this question he divided the sciatic nerve in dogs, and
reunited it so that the fibres on the external aspect of the cen-
tral end were in contact with those on the internal aspect of
the peripheral end, and vice versu. The result was that function
was completely restored, and that as rapidly as in control animals
in which the nerve had been divided and united as accurately as
possible. A second series of experiments were then undertaken.
The median, ulnar, and musculo-cutaneous nerves were divided
above the elbow in dogs, and the musculo-spiral was divided at
the same point; the central end of the musculo-spiral was then
attached by suture to the peripheral ends of the three nerves which
supplied the flexor muscles, and vice versa. The result was that
the animals in which these cross-sutures were made regained co-
ordination of movement perfectly. In these animals, after co-
ordinated function had been restored, the condition of the
cerebral cortical areas associated respectively with flexion and
extension of the paw were examined by cortical stimulation, and
it was found that the relative positions of the two areas had
become reversed. He also referred to a case in which he had
for facial spasm divided the facial nerve and united the
l)eripheral end to the spinal accessory, with the result that the
face recovered its power of movement to a great extent, but
that whenever the ])atient suddenly lifted the right arm a
spasm of the face was produced.
Dr. R. A. Fleming (Edinburgh) said that he was still, to
some extent, an upliolder of the '* C(»niral '* view of regeneration,
and he did not see why it should not l)o compatible with the
finding of new-formed fibres in the distal segment of a divided
nerve. He refornul to some experiments which he had per-
formed on rabbits in which he had ligatured the sciatic nerve
in two places, and he had been able to demonstrate young axis-
cylinders both in the part between the two ligatures and also
in the ])eri])beral ])art ei<rliteen weeks after the operation. He
asked Mr. Ballance and Dr. Stewart what method of fixing they
had adopted, and in what medium the sections had been cut.
Stroebe's method was parlicularly apt to give fallacious results
when a[>plied to celloidin specimens. H(.' did not agree with
their observations that the fin(? nervofibres degenerated more
slowly than the larger fibres, but he thought, on the ccmtrary,
that they degenerated more ra])idly. He had for long held
that the neurilemma nuclei acted as trophic agents to the
REGENERATION OP PERIPHERAL NERVES 295
axis-cylinder which they protected. It was therefore, from his
standpoint, not improbable that regeneration should take place
from these cells. When old neurilemma sheaths were found to
contain small new fibres, it was always in the central end of a
divided nerve ; this ^he held to be in favour of the central
theory, and he considered that the sketches in Mr. Ballance's
and Dr. Purves Stewart's book bore out this contention. To
hold the peripheral theory it was not necessary to absolutely
reject the central. It was a matter for future experiment
whether union of nerve by first intention without previous
degeneration of the peripheral segment was possible, but present
researches seemed almost uniformly to point to such primary
union being very problematical.
Dr. Fleming stated that his specimens above referred to were
cut in paraffin and stained by a modification of Stroebe's
method.
Mr. W. Thorburn (Manchester) referred to the extraordinary
way in which the central nervous system adapted itself to the
new conditions after reunion of divided nerves. In a case in
which a portion of practically the whole of the brachial plexus
was excised, so that it was impossible to unite each nerve to its
corresponding trunk, a more or less indiscriminate union was
performed, and there was as a result but little confusion in the
weak movements that returned.
Adjourned Discussion, March 11th, 1902.
Prof. J. N. Langley (Cambridge), in resuming the adjourned
discussion on this subject, remarked that the primary question
was whether a nerve separated from its central connections
could regenerate of itself ; from his own experiments and obser-
vations he had come to the conclusion that a peripheral nerve
might regenerate of itself. His own observations had had to
do with the sympathetic system ; after a sympathetic ganglion
had been removed in the cat, two years later there was appa-
rently regeneration of medullated and non-medullated fibres.
It was very difficult to distinguish with certainty between non-
medullated nerve-fibres and strands of connective tissue, and
therefore non-medullated fibres might possibly exist between
the peripheral ends and their centres, which were undiscover-
able by the microscope; and thus it was possible that the
severed nerves might receive a stimulus from the central
ganglia by fibres that could not be traced. After extirpation
of the superior cervical ganglion at the end of a year the
])eripheral end was stimulated without effect, then another
portion of the central end was excised, but after an interval of
days there was no degeneration in the peripheral end, thus
apparently excluding the possibility of nerve stimuli reaching
296 REGENEKATION OF PERIPHERAL NERVES
the peripheral end from its own central end. It was possible
that the sympathetic system recovered more easily than the
ordinary peripheral nerves; but eveu in them, although there was
return of histological structure, there was no return of function.
This was possibly due to the greater vulnerability of the
terminations of the sympathetic nerve as compared with the
' fibres themselves. The variation in recovery would probably
differ in different nerves and in different animals. As to the
manner in which the actual regeneration occurred, the neuro-
blast view of the authors of the paper was not convincing ; the
observations made were on sections, and it was not possible to
follow a nerve-fibre by this method ; the method of teasing was
necessary. The Golgi stain was erratic, and osmic acid stains
were certainly preferable both to it and the Weigert stain.
His observations had rather revealed the idea of a long multi-
nucleated cell than a series of short cells as the authors had
maintained. The difficulty of admitting the phagocytic action
of the connective-tissue cells for the medulla was obvious in
view of the fact that they were separated by a membrane — the
neurilemma. The earlier disappearance of the medullary sub-
stance of the large fibres was probably due to the staining
agent. In his experience this change was earlier in the small
than in the larger fibres. The rapid return of sensation
(from an hour to a day) in cases of secondary suture was not
cleared up by the paper. If recovery of function did not
correspond with regeneration of structure how could it be
explained ? The nerve could not be cut without the stump of
the central end degenerating, and this in itself negatived the
rapid recovery on the basis suggested in the paper, as seven to
ten days at least were required for their recovery. He would
suggest as a theory that the division of one or more nerve-
fibrils might happen just between two nerve segments, and thus
the two in contact end to end might escape injury, and being in
anatomical continuity might transmit sensory impulses. In
the surgical operations for the repair of a divided facial nerve
it was usual partially to divide the spinal accessory nerve and
to graft the facial on the central end of the spinal accessory.
He would suggest that it might be better to cut the spinal
accessory nerve right across, to split it, and to unite one
portion thus divided to the facial and the other to the peri-
phora,l trunk of the spinal accessory.
Dr. F. W. MoTT congratulated the authors of the paper on
affording still further proof that regeneration of a divided
nerve took place from the periphery. For some time past he
had been engaged with Professor Halliburton in making a series
of observations upon the chemical changes occurring in nerves
undergoing degeneration and regeneration after their division.
The inquiry was not conducted for the purpose of ascertaining
REGENERATION OP PERIPHERAL NERVES 297
how regeneration took place ; therefore a positive opinion in the
paper which was published in the * Philosophical Transactions *
was not expressed, but Dr. Mott, from the histological examina-
tion of the nerves, came to the conclusion that new axis-
cjlinders were formed by the proliferation of the cells of the
neurilemmal sheath. Subsequent observations which he had
made confirmed this opinion. He stated that he relied upon
teased preparations rather than sections, as a most valuable
method of studying both degeneration and regeneration, because
individual fibres could thus be seen in their entirety. He used
the direct Marchi method for fixing and hardening the tissues,
which stained the myelin a greenish grey and the degenerated
myelin black. He considered that this was a more valuable
method than the Weigert, which stained both myelin and
degenerated myelin blue. The protoplasmic substance of the
new axis- cylinders and the nuclei of the neurilemmal cells were
subsequently stained by the Strobe method and logwood. In
this way he was enabled to see the proliferation of the neuri-
lemmal cells, their phagocytic action upon the degenerated
products, and formation of the axis-cylinder process and new
sheaths by a process of differentiation of their protoplasm.
He purposely did not use the term " secretion of axis-
cylinders " which the authors of the paper had employed. He
was of the opinion that the axis-cylinders were formed more
especially by the nuclear protoplasm of the cells. Frequently
in the neighbouihood of the nuclei of these teased preparations
he had seen the products of degeneration of the my-elin stained
black, mingled with highly refractive, much lighter stained
globules which appeared like the new myelin. He stated that
he was at present engaged with Professor Halliburton in making
further inquiries regarding the process of degeneration and
regeneration under the following conditions : — (1) the process
of regeneration of the divided ulnar nerve after section of a
sufficient number of posterior roots on one side to produce
paralysis ; (2) the conditions of the nerve terminations in the
skin and muscles. So far the observations were not sufficiently
numerous to make any definite statement, but they tended to
show that stimulus played an important part in regeneration.
He asked the authors of the paper whether they had in their
numerous experiments tested the conductivity of the nerve
above and below the seat of division and union with the faradie
current. Dr. Mott considered the Golgi method, which the
authors of the paper had used, unreliable for pathological
purposes. The experiments of Dr. Kennedy, of Glasgow, had
practically established the fact that regeneration of nerves took
place from the periphery, and this had now been confirmed by
the researches of Mr. Ballance and Dr. Purves Stewart.
Mr. Mato Bobson was sorry that he had been unable to be
298 REGENERATION OP PERIPHERAL NERVES
^present to hear the opening paper, but he had had the oppor-
tunity of becoming acquainted with what had passed at the lajat
meeting of the Society. The experiments proved conclusively all
that has been advanced by the authors, but he thought that the
clinical observations he had reported some years ago, and whicli
bore very pertinently on some of the questions, had not quite
received the notice they merited. The questions he bad
advanced could only be partly settled experimentally, and he
hoped, now that he had a ** pied a terre " in London, to find
time to work at the subject from this point of view. Some
of the points could, however, be better settled by clinical re-
search. He believed that he had been the first to perforin
nerve grafting, and, so far as he knew, the idea had not been
previously conceived. His first example had been fully reported
in the 'Transactions of the Clinical Society of London' for
January, 1889.
The case was that of a young girl from whom he removed a
tumour of the forearm the size of a small orange, which
involved the median nerve, after which sensation and movement
in the parts supplied by the nerve were found to be absent. It
had occurred to him that if he could substitute a fresh portion
of nerve for the part removed he might be able to restore the lost
function ; and the day after the first operation he reopened the
wound and transferred a portion of posterior tibial nerve
directly from a young man's leg amputated in an adjoining
theatre by a colleague, the interval between the amputation and
the grafting being merely momentary, the graft being trans-
ferred in normal saline solution. The interesting point now
came in, for, much to his astonishment, sensation in all the
parts supplied by the median nerve had been good when tested
the following day, and remained so throughout the convalescence,
though the motor functions were only restored later.
Now, according to the authors of the paper, degeneration in
the distal segment of a divided nerve did not begin until four
days subsequent to the accident, and what he wanted to know
was — in case of an aseptic division of nerve and an immediate
restoration of continuity either by immediate union or by union
of an aseptic graft — whether or not degeneration of the divided
segment was a necessity, — whether, in fact, the restoration of
physiological activity by the re-establishment of nervous im-
pulses along it might not prevent degeneration and so lead to
anatomical perfection ; or, to put it in another way, whether
the immediate establishment of anatomical continuity might
not keep up physiological activity, and so prevent degeneration
of the distal segment.
Facts were stubborn things, and those that he had given
required an explanation. Some physiologists had chosen to
ignore his observations, doubtless because tliey could not
REGENRRATION OP PKRIPHERAL NERVES 299
explain them, and possibly thinking them due to inaccurate
observation ; but he was positive of his facts, and if his explana-
tions were not correct they would have to be proved inaccurate
by further experiments and clinical observations before he
could be satisfied.
Now, as to the time when regeneration of the distal segment
was possible, he could give an example, also published (* British
Medical Journal,' October 31st, 1896). In this case, seen in
January, 1890, seven months after a scythe accident, a man
aged 29 had been sent to him with a useless arm. There was a
large scar over the inner and lower end of the arm just above
the elbow, and the parts supplied by the median and ulnar
nerves were absolutely paralysed, so that the forearm was a
useless flail. He determined to try to save the limb, and to
this end he exposed the nerves and excised the bulbous ends ;
with slight tension he secured end-to-end union of the ulnar
nerve, but the extremities of the median were separated by a
space of fully three inches, into which he inserted the spinal cord
of a rabbit, thus securing continuity. In ten days sensation
began to return in the median which had been united by a
graft, but in the ulnar which had been directly united, a
return of sensation was much longer delayed, as was return of
muscular power. Ultimately complete recovery ensued. So
complete was the recovery that the man returned to his work
as a platelayer on the Midland Eailway.
This case was interesting as showing that so long after division
as seven months was not too late to hope for restoration of
function in the distal segment of a divided nerve. As to the
material for suture, to his mind fine xylolised catgut was better
than silk or any non-absorbent material. The authors of
the paper put the limit of a successful graft as two inches ; in
the cases he had related the graft was fully three inches long.
In venturing on these criticisms he would at the same time
congratulate the authors on the excellent work they had done.
Dr. W. Aldren Turner discussed the attack made in the
paper on the neuron theory in relation to the peripheral nerves.
He did not think it would lead to the neuron theory being
discarded, as there were too many facts in its favour. There
were not only the facts of Wallerian degeneration, but there
was an important change affecting the central end of the divided
nerve extending up to the nerve-cell which had not been dealt
with. It was, indeed, a defect of the paper that the condition of
the whole of the peripheral nerve (including its cell) after
section was not described. The fact that new fibres did not
reach maturity until the divided ends were sutured rather
supported than negatived the neuron theory. He asked what
occurred in the peripheral nerves in acute anterior polio-
myelitis ; if regeneration did not occur the neuron theory was
272 MODERN METHODS OF VACCINATION
present in lymph were chiefly skin organisms and non-sporing,
and hence were amenable to glycerinisation. It had been
pointed out by the Special Commission on Glycerinated Calf
Vaccine Lymphs that when non-spore bearing organisms were
present in large numbers this was due to imperfect glyceri-
nation, but that when spore-bearing organisms were in excess
in any lymph it was an index that that lymph had not been
sufficiently carefully collected. He alluded to the effect of
glycerinisation on the activity of the lymph, and expressed the
opinion that little or no weakening occurred within three or four
weeks. After a longer time weakening probably did, to a slight
extent, occur, but the deterioration was more likely to be.du^ to
under-glycerinisation than to over-glycerinisation. When organ-
isms that grow best at the body temperature were in excess
glycerinisation had a more active influence. The local inflam-
matory effect of vaccine had been considered of late by many to
be greater than formerly, but this was probably due to imperfect
glycerinisation, the greater part of the local effect being always
due to extraneous organisms. He suggested that the Local
Q-overnment Board might be able to prepare statistics from
their returns to decide that point.
Dr. T. D. AcLAND said that whilst acting as medical officer to
the Royal Commission on Vaccination he had had an unusual
opportunity of seeing the methods of vaccination practised
throusfhout the country, and of forming an opinion as to the
manner in which the operation was carried out, and the cause
and extent of vaccinal injuries. In the course of the same
inquiry he had been brought intimately into relation with the
Medical Department of the Local G-overnment Board, and was
able to appreciate the manner in which its officers carried out
the difficult and often thankless task of maintaining efficient
VEiccinatiou. There could be no question that the country owed
much to Dr. Cope man for his researches into the origin and
purity of vaccine lymph, and for his share in the establishment
of an institute able to supply calf lymph on a scale quite im-
possible a few years ago. Dr. Acland hoped that the Govern-
ment would take steps to establish a laboratory on a far larger
scale thaD at present, so that all practitioners in the kingdom
might be able to obtain lymph from a laboratory fitted with
every requisite for perfect work, unfettered by economies neces-
sary in an establishment run solely for trade purposes. He
thought that it would be well also if all supplies of vaccine lymph
were placed under Government control, and expressed regret
that there should be two " Jenner Institutes " in this country —
the one formerly known as the " British Institute of Preventive
Medicine " in Chelsea, where the National Vaccine Establish-
ment was temporarily situated, the other the Jenner Institute
for calf lymph in Battersea, to which the name by priority
BEGENERATION OF PERIPHERAL NERVES 301
ration of their results in his description of the nerve-fibre as a
series of linked cells, each of them containing in solution
electrolytes, thereby explaining the retardation of electrical
stimuli in their passage along a peripheral nerve. In the
course of his remarks he had also referred to the occurrence of
regeneration in the posterior roots five weeks after the excision
of the root-ganglion, and he now showed them, for him, a
photograph of such regeneration taken by him in 1894. They
had examined nerves from several cases of anterior polio-
myelitis in which Dr. Batten had cut sections, but had failed
in these particular instances to find evidences either of degene-
ration or of regeneration ; but in this connection there was an
interesting point figured by Ziegler in his * Pathology ' (Bd. ii,
fig. 194, 6th German edition, 1890). This picture was de-
scribed as showing advanced degeneration in a peripheral
nerve after atrophy of the anterior horns, but in their opinion
it might equally well be described as showing the beaded stage
of regeneration so frequently illustrated in their series of draw-
ings. With regard to Dr. Fleming's question as to whether
primary reunion ever occurred after division and immediate
suture, they would unhesitatingly answer in the negative.
Professor Langley's experiments on regeneration in the cervical
sympathetic were of great interest, and afforded another corro-
boration of the results obtained by themselves. He seemed
inclined to doubt the phagocytic action of the proliferated
connective-tissue cells on the theoretic ground of the supposed
continued integrity of the neurilemma sheath. They had,
however, satisfied themselves that the proliferated connective-
tissue cells did contain myelin, and that process of phagocytosis
was identical with that observed in all other injured tissues.
As to the immediate return of sensation in certain cases of
secondary suture, the clinical fact was beyond question, not
only from their own observations but from those of many
observers. The most ingenious explanation of those cases in
which sensation was alleged to return immediately after primary
suture appeared to be that offered by Professor Langley
himself, namely, that there were probably a number of fibres
in which the severance happened to occur exactly at a node of
Ranvier, and in which no degeneration needed necessarily to
occur proximal to the site of injury. He was not inclined to
accept Professor Langley's suggestion that in facio-accessory
anastomosis for the treatment of facial palsy the accessorius
should be partly divided (rather than merely incising its
sheath) in order to obtain end-to-end anastomosis with the
stump of the facial. Such a procedure would be based upon
the old theory of the outgrowth of new fibres from the proximal
end, which was no longer tenable. The chemistry of nerve
regeneration, to which Dr. Mott, in conjunction with Professor
302 REGENERATION OF PERIPHERAL NERVES
Halliburton, had made such valuable contributions, was a point
which thev did not venture to discuss. The conclusions,
however, at which those authors had arrived were in many
respects strikingly similar to their own histological work. The
discussion of the neuron theorv he would leave to Dr. Stewart.
Dr. Ptjrves Stewart, in reply, said that Mr. Ballance had
already dealt with a number of points raised by the various
speakers, and that he would only allude to those not already
referred to by him. A very interesting question was raised by
Professor Sherrington when he asked why, if the nerve-fibre
was a linked chain of cells, did the whole chain degenerate and
not merely the injured links ? To this he would venture to
suggest that the explanation was to be found in the loss of im-
pulses from the rest of the nervous system which necessarily
occurred when a nerve -fibre was divided. Dr. Fleming had
inquired as to the fixing methods employed by them in the course
of their research. In most cases the nerves had been fixed in
Miiller's fluid ; they had found that formalin-hardened speci-
mens did not^take the aniline blue stain properly. Stroebe's stain
was uncertain in its results, but when it was successful the
pictures yielded by it were of great value. But the bulk of their
results did not depend upon the observations made with the
Stroebe stain ; they were based chiefly on the Weigei-t- stained
series. Dr. Fleming still held that in the process of degeneration
the finest fibres broke down earlier than the larger ones. They
could not agree with that statement, and in some sections of
degenerating nerve stained by Dr. Batten, to which he had
recently had access, a similar survival of the finest fibres was also
quite clear, as described by them in their research. The G-olgi
method, as Professor Langley pointed out, was rather an un-
certain one, but in their cases it had been most successfully
carried out for them by Dr. David Orr, of Prestwich. He did
not think that the cells described by them as neuroblasts
could be connective-tissue or glia cells, for they had been
totally absent in the distal segment at the end of one and two
weeks respectively, and abundantly j) resent at the third and
fourth weeks, and their axis-cylinder ^^rocesses had been many
times longer at the fourth week than at the third. Both Dr.
Batten and Dr. Turner had properly pointed out that to gain a
proper conception of the processes of degeneration and of
regeneration, it was not sufficient to confine one's examination
to the immediate neighbourhood of the injury, but that one
should examine the whole extent of the nerve. In many cases
this had been done by them, and in every instance the changes
had been identical throughout the entire peripheral extent of
the nerve. The well-known delay in the return of motor
functions as compared Avith the early recovery of sensation
was probably referable to the muscular atrophy which had
KEGENERATION OF PERIPHEKAL NERVES 303
to be recovered from, in addition to the recovery of the nerve-
trunk.
But the various views which had been expressed in the
course of this discussion had not shaken the essential fact
from which they had started, viz. that regeneration occurred in
a nerve-fibre even wlien it was permanently cut off from its cor-
responding nerve- cell. The question then arose, " On what
theory could these facts be explained ? " The neuron theory
did not explain them. According to the neuron theory the
nervous system was made up of innumerable units called
** neurons." Each neuron is supposed to consist of a nerve-cell,
with its various processes, the nerve-fibres, all of them being
mere outgrowths from the cell. But this theory did not fit all
the facts. Thus, for example, it did not explain the absence of
regeneration in the central nervous system after injury, nor did
it account for the occurrence of regeneration in the peiipheral
nerves when cut off from the central nervous system. The
logical procedure was not to shut their eyes to the facts and
cling to the moribund neuron theory, but to stick to the facts
and throw the inadequate theory overboard.
And if so, wliat hypotheses were they to substitute which
would harmonise with the facts? It was perfectly obvious
that the central nervous system exerts a profound influence
upon all nerve-fibres, including those of the peripheral nerves.
Degeneration undoubtedly did occur in a nerve-fibre if sepa-
rated from its corresponding nerve-cell ; but the probable
reason for this degeneration was that the function of the nerve-
cell was to divert impulses from other parts of the nervous
system into the nerve-fibre; and the nerve-fibre degenerated,
not because it was cut off from the nerve-cell as a cell, but
because it was cut off from the impulses reaching it from the
rest of the nervous system.
The most reasonable explanation appeared to be that offered
by Apathy, and supported by Bethe, Nissl, and others, accord-
ing to which the essential elements of the nervous system were
the nerve-fibrils. Each nerve-fibre was made up of a bundle of
these nerve-fibrils. The fibrils of different parts of the body
were connected one with another through the central nervous
system, which was a huge ** exchange " in which the nerve-cells
acted as convenient shunts or depots, transmitting impulses
from one set of fibrils to another. When an outlying nerve-
fibre was cut ofi* from the central exchange it was no longer
functionally active, and therefore degeneration set in. But the
central segment, which remained connected with its correspond-
ing nerve-cell or nerve-shunt, still received impulses from other
fibrils (through the cell), and did not degenerate. Later on,
the detached distal segment was regenerated by the activity of
304 REGENERATION OF PERIPHERAL NERVES
the neurilemma cells, and was ready to resume its function if
linked on to the central nervous system. The essential elements
of the nervous system, therefore, were the nerve-fibrils; the
nerve-cells were accessories. Their conception of the nervous
system should be that of a vast and delicate interlacement of
nerve-fibrils, with nerve-cells interspersed at convenient in-
tervals to act as depots or shunts for nerve impulses.
ATELEIOSIS
A DIBBASE CHARACTERISED BY
CONSPICUOUS DELAY OF GROWH AND DEVELOPMENT
BY
HASTINGS GILFORD, F.E.C.S.Eng.
Received April 5th, 1902— Read June 11th, 1902
Introduction.
In 1868 Professor Schaaffliausen, of Bonn, wrote an
account of a dwarf who died at the age of 61, and whose
appearance and proportions were those of a child. This
dwarf showed no signs of cretinism, rickets, or any other
of the known causes of stunted growth. Fourteen years later
Schaaffhausenwas able to obtain the skeleton, when he found
that the development of the bones corresponded with the
development of the soft parts, for most of the epiphyses
were still ununited. No other contribution of any import-
ance to this particular type of dwarfism appeared until
1891, when Dr. Arnold Paltauf described another case in
his monograph on ^^ Zwergwuchs." A third instance was
recorded in the same year by Dr. Schmidt, of Munich.
Dr. Manouvrier, of Paris (1896), and Dr. Joachimsthal, of
Berlin (1899), then followed with other cases. It is also
probable that the dwarf briefly described by Professors
VOL. LXXXV. 20
306 ATELEIOSIS
Ranke and von Voit (1885), and another by Dr. A. A.
Bouchard (1884), were of the same type. Further exam-
ples of the disease have been incidentally referred to by
Professor Quetelet, Dr. N. W. Kingsley, Drs. Gould and
Pyle, Geoffrey St. Hilaire, and others. We also find
instances in the writings of certain semi-scientific and
popular authors, such as E. J. Wood, E. Gamier, P. O.
Barnum, and " Count " Boruwlaski.
By far the most important of these contributions is that
by Dr. Paltauf, who gives the results of a post-morteTn
examination of his case, and compares it with other forms
of dwarfism. I myself have been able to examine two
skeletons, and four living cases, and to make one post-
mortem examination.
Though the details given of many of the cases whicli
have been recorded are somewhat meagre, yet there
appears to be sufficient material to enable us to form a
fairly complete picture of the disease. This disease can-
not be accounted for by any of the known causes of
dwarfism. Cretinism, syphilis, microcephaly, achondro-
plasia, rickets, and congenital heart disease, can be
excluded. In short, the morbid condition has a definite
individuality. Its most striking feature appears to be the
delay in growth and development. Though other diseases
may have a retarding effect upon these processes, yet in
none of them does this one feature stand out so promi-
nently. In cretinism, for example, though the delay of
development may be of equal degree, yet it differs in that
there are certain other morbid conditions of mind and body
which are quite as conspicuous. This delay of growth
and development is so evidently the main feature, that I
have suggested that the disease should receive a name
which emphasises this fact. I have proposed that it
should receive the name of Ateleiosis (aTcXftoifrt^*, not
arriving at perfection). It should be noticed that usually
neither growth nor development is arrested, though both
are indefinitely retarded. Those who are affected may,
in fact, grow slowly up to the age of 30 years, or even later.
ATELEIOSIS 307
Tlie examples recorded seem to be capable of division into
groups or classes, according to the age at which the dis-
ease first declares itself. Like cretinism, it may appear
either before birth (Group I), during infancy (Group II),
or not until the later stages of development (Group III).
The subjects of the disease are, therefore, not neces-
sarily dwarfs. Most of the cases began during infancy
or early childhood, and consequently belong to the
second class, when the disorder apparently exhibits its
most characteristic features. We may find eventually that
there is a fourth class, for it is not improbable that it may
also begin after puberty.^ In all likelihood the disease,
as a rule, becomes so ill-defined when it appears in these
later years that it can only be recognised as a mere
eccentricity of normal development, or is lost altogether in
those variations to which all life is subject.
I now propose to divide my subject into two parts, first
giving a short account of the cases which have been
reported up to this time, with fuller details of those
which have come under my own observation. There will
then be a description (in Part II) of the chief features
of the malady, followed by remarks on its diagnosis and
pathology. The description of a disease which has no
name is so inconvenient that I have ventured to use the
name I have suggested throughout the rest of this article.
Part I.
Group I. — Ateleiosis beginning during Fetal lAfe,
Case 1. — In the Museum of the Royal College of
Surgeons of England is the " skeleton of a female child of
unusually stunted growth and arrested osseous develop-
ment." It is the skeleton of Caroline Crachami, who was
exhibited in London in 1824, under the name of " the
Sicilian dwarf," and at the time of her death was said to
be of the age of 9 years. A portrait of her in oils is also
^ A possible example may be found in Konig's case on p. 343.
304 REGENERATION OF PERIPHERAL NERVES
the neurilemma cells, and was ready to resume its function if
linked on to the central nervous system. The essential elements
of the nervous system, therefore, were the nerve-fibrils ; the
nerve- cells were accessories. Their conception of the nervous
system should be that of a vast and delicate interlacement of
nerve-fibrils, with nerve-cells interspersed at convenient in-
tervals to act as depots or shunts for nerve impulses.
ATELEIOSIS
A DIBBASE CHARACTERISED BY
CONSPICUOUS DELAY OF GROWH AND DEVELOPMENT
BY
HASTINGS GILFORD, F.R.C.S.Eng.
Received April 5th, 1902— Read June 11th, 1902
Introduction.
In 1868 Professor Schaaffliausen, of Bonn, wrote an
account of a dwarf who died at the age of 61, and whose
appearance and proportions were those of a child. This
dwarf showed no signs of cretinism, rickets, or any other
of the known causes of stunted growth. Fourteen years later
Schaaffhausenwas able to obtain the skeleton, when he found
that the development of the bones corresponded with the
development of the soft parts, for most of the epiphyses
were still ununited. No other contribution of any import-
ance to this particular type of dwarfism appeared until
1891, when Dr. Arnold Paltauf described another case in
his monograph on ^^ Zwergwuchs.^^ A third instance was
recorded in the same year by Dr. Schmidt, of Munich.
Dr. Manouvrier, of Paris (1896), and Dr. Joachimsthal, of
Berlin (1899), then followed with other cases. It is also
probable that the dwarf briefly described by Professors
VOL. LXXXV. 20
306 ATELEIOSIS
Ranke and von Voit (1885), and another by Dr. A. A.
Bouchard (1884), were of the same type. Further exam-
ples of the disease have been incidentally referred to by
Professor Quetelet, Dr. X. W. Kingsley, Drs. Gould and
Pyle, Geoffrey St. Hilaire, and others. We also find
instances in the writings of certain semi-scientific and
popular authors, such as E. J. Wood, E. Gamier, P. O.
Bamum, and " Count '' Boruwlaski.
By far the most important of these contributions is that
by Dr. Paltauf, who gives the results of a post-mortem
examination of his case, and compares it with other forms
of dwarfism. I myself have been able to examine two
skeletons, and four li\'ing cases, and to make one post-
mortem examination.
Though the details given of many of the cases which
have been recorded are somewhat meagre, yet there
appears to be sufficient material to enable us to form a
fairly complete picture of the disease. This disease can-
not be accounted for by any of the known causes of
dwarfism. Cretinism, syphilis, microcephaly, achondro-
plasia, rickets, and congenital heart disease, can be
excluded. In short, tlie morbid condition has a definite
individuality. Its most striking feature appears to be the
delay in growth and development. Though other diseases
may have a retarding effect upon these processes, yet in
none of them does this one feature stand out so promi-
nently. In cretinism, for example, though the delay of
development may be of equal degree, yet it differs in that
there are certain other morbid conditions of mind and body
which are quite as conspicuous. This delay of growth
and development is so evidently the main feature, that I
have suggested that the disease should receive a name
which emphasises this fact. I have proposed that it
should receive the name of Ateleiosis (arcXftaifrtg, not
arriving at perfection). It should be noticed that usually
neither growth nor development is arrested, though both
are indefinitely retarded. Those who are affected may,
in fact, grow slowly up to the age of 30 years, or even later.
ATELEIOSIS 307
The examples recorded seem to be capable of division into
groups or classes, according to the age at which the dis-
ease first declares itself. Like cretinism, it may appear
either before birth (Group I), during infancy (Group II),
or not until the later stages of development (Group III).
The subjects of the disease are, therefore, not neces-
sarily dwarfs. Most of the cases began during infancy
or early childhood, and consequently belong to the
second class, when the disorder apparently exhibits its
most characteristic features. We may find eventually that
there is a fourth class, for it is not improbable that it may
also begin after puberty.^ In all likelihood the disease,
as a rule, becomes so ill-defined when it appears in these
later years that it can only be recognised as a mere
eccentricity of normal development, or is lost altogether in
those variations to which all life is subject.
I now propose to divide my subject into two parts, first
giving a short account of the cases which have been
reported up to this time, with fuller details of those
which have come under my own observation. There will
then be a description (in Part II) of the chief features
of the malady, followed by remarks on its diagnosis and
pathology. The description of a disease which has no
name is so inconvenient that I have ventured to use the
name I have suggested throughout the rest of this article.
Part I.
Group I. — AteUiosis beginning during Fetal Life,
Case 1. — In the Museum of the Royal College of
Surgeons of England is the " skeleton of a female child of
unusually stunted growth and arrested osseous develop-
ment." It is the skeleton of Caroline Crachami, who was
exhibited in London in 1824, under the name of " the
Sicilian dwarf," and at the time of her death was said to
be of the age of 9 years. A portrait of her in oils is also
^ A possible example may be found in Konig's case on p. 343.
308 ATKLKIOSIS
preserved on the walls of one of the staircases in the
Museum. Through the kindness of the Council of the
Royal College of Surgeons I have been able to obtain a
photograph of both the skeleton and the picture. Her
portrait shows that she was of a thin and delicate figure,
and that her hands and feet were in proportion to the rest
of her body. A cast of her face, left ankle and foot, and
a portion of one upper extremity, which are included in
the case with the skeleton, exhibit the same features.
Her attitude is indicative of weakness or fatigue, and the
expression on her face is dull and heavy. She looks much
older than her years, but this is partly due to the promin-
ence of her nose, which would have been remarkable
even in an adult. Her hair is plentiful, and the nails are
well formed.
After her death an examination of her body was made
by Sir Everard Home,^ who has written the following
account of her :
" An Italian woman, aged 20 years, when, by her
reckoning, three months gone with her child, was trayell-
ing in a caravan with the baggage of the Duke of
Wellington's army. In the middle of the night, in a
violent storm, when she was fast asleep, a monkey that had
been chained on the top of the caravan, in its fright found
its way into it, and, as the warmest berth it could find, got
under her clothes. Half asleep, she put her hand down to
scratch herself, but on scratching the monkey it bit her
fino-ers and threw her into fits. She did not miscarry, but
went her full time. The child, when born, weighed one
])ound, and measured seven inches in length. It ^vas
reared with difficulty, and was carried by its parents to
Ireland, where it became consum])tive.
" It was brought to London and sliown as a curiosity.
It died just after it completed its ninth year. I saw it
several times while alive, and it came into my possession
after death.
" On examination of the body after death the fontanelle
^ * Lectures on Comparative Anatomy/ 1828, vol. v, p. 191.
Med. Chir. Tmns.,Yo!. 85:
.Kefciusii Gtoiipi. Cusr. 1. SkdtLon of Caroliue Cmcbami (a)
atftnding by tho aide of uurmal skeletoii uf a child a! 15 mouths (h).
The oaaification uF Cbe former is lass advanced tbaa it is in Che latter.
The akuleton. which is iu tho Royal College of Surgeous' Museum in
London, is distorted bj the pftsaaga of an iron rod through its oerebro-
apiiial axis. [For pcrrirait see end of paper.
ATELEIOSIS 309
was closed.^ There was no fat in any part but in the
sockets of the eyes, behind the balls. The uterus had not
been developed beyond that contained in a foetus of four
months. The bladder was distended with urine to the size
of a hen^s egg. As the child had never made water freely
from its birth, the bladder probably had been injured at
the time the monkey alarmed the mother. On comparing
the ovaria with those of an abortion of three months, they
were nearly of the same size.
" The child, when I saw it, could walk alone, but with no
confidence. Its sight was very quick, much attracted by
bright objects, delighted with everything that glitters,
mightily pleased with fine clothes; had a shrill voice and
spoke in a low tone ; had some taste for music. Was very
sensible of kindness, and quickly recognised any person
who had treated it kindly. The mother has had a fifth
child in Ireland, which, like her first three children, is
naturally formed."
In the accounts of her death in the newspapers ^ of the
day, it is stated that she had been " for some time afflicted
with a cough," and that " on Thursday last she was
exhibited as usual, and received upwards of 200 visitors ;
towards the evening a languor appeared to come over
her, and on her way from the exhibition room she
expired."
I^he skeleton has been but indifferently mounted, for a
rod has been so run through the cerebro-spinal cavity as to
obliterate all the natural curves, dislocate the atlas and
skull off the axis, and project through the anterior
fontanelle.
From this cause it is impossible to obtain accurate
measurements of some parts, and the whole aspect of
the skeleton is distorted. The clavicles are horizontal, the
scapulae are dragged away from the thorax, and the
shoulders are raised so as to appear stiff and square, and
very different from their rounded appearance in the paint-
* This is incorrect.
'^ ' The Newspaper/ June, 1824.
310 ATELEIOSIS
ing. Owing to this elevation of the shoulders one does
not notice at first the disproportionate length of the upper
extremities, inasmuch as they do not reach down too low
on the thigh. The pelvis, also, is made to project forward
so that its brim is almost horizontal, while the lower limbs
are dragged up to such an extent as to diminish the
height appreciably.
Another source of inaccuracy of measurement is due to
shrivelling of the epiphysial cartilages.
Height, 49 cm. = 19^ inches.
Middle point of total height, 1*8 cm. = 4 inch, above the
symphysis pubis.
Length of spine, 5*8 cm. = 2^ inches.
Clavicle, 4*8 cm. = 1^ inches.
Acromion to elbow, 8*9 cm. = 3^ inches.
External condyle to lower end of radius, 7 cm. = 2f
inches.
Fenmr, 12 cm. = 4J inches.
Tibia, 9 cm. = 3^ inches.
Total length of lower extremity, 23 cm. = 9 j^^r inches.
Foot, 6'S cm. = 2J inches.
Hand, 6 cm. = 2| inches.
Skull : greatest length, 12*6 cm. = o inclios ; greatest
breadth, 9*4 cm. = 3f inches ; vertex to base, 8*o5 cm. =
3| inches ; circumference, 35 cm. = 13J inches.
The skull is verv thin and delicatelv formed. The
anterior fontanelle is open for a length of 1*6 cm. (4 inch)
and a width of 1*2 cm. (fV inch), but the posterior
fontanelle is closed. The lower half of the frontal suture
is closed, but there is a small unossified oval area 6 nun.
(^ inch) long, near the superior angle of the occipital bone
close to the left lambdoid suture. Another is present at
the bottom of each occipital groove. The basi-sphenoid
and basi-occipital bones are not united. There is no
thickening of the sutures. The skull is unopened, but on
placing a lighted match in the occipital foramen the bones
of the calvarium are seen to be of fairly even thickness,
and on looking through the open fontanelle the sella
ATELEIOSIS 311
turcica and the other parts of the base are also found to
be normal. The ear bones are of adult size, but the
auditory process is a mere ring, like that which is met
with in infants. The palate is of normal shape, but the
alveolar border of the upper jaw is very irregular, and,
owing to absorption of the outer part of the alveolus from
the canine teeth backwards, descends lower in front than
behind. The mandible is ill-formed. Its angle and ramus
are like those of an infant, and while the alveolar portion
is unduly thick, the chin is ill-developed, and therefore
recedent. The dental formula is as follows, viz. :
Upper jaw, 2 m. x 1 c, 1 — 2 in., 1 c. x 2 m.
Lower jaw, 2 m. x 1 c, 1 — 2 in., 1 c. x 2 m.
The teeth are all of the temporary set, and are of
natural size as a rule, but very irregularly placed. All
four of the second molars can be seen, though they do not
project to the level of the gums. The two upper first
molars, as well as the right upper second molar, are carious,
but the others are sound.
Ossification throughout is greatly delayed. This is shown
both in the backward condition of the epiphyses, and in the
smallness and delicacy of the shafts. There is but a trace
of roughness to show where muscles were attached, and the
position of several of the muscular prominences is not visible.
The long bones possess hardly any curve, and are narrowest
at the middle of their shafts, and from thence increase in
width towards their ends. The ribs have very abrupt
curves at their angles, but are almost straight from thence
forwards, and those on the right project more and are
more horizontal than those on the left. This last peculi-
arity of position is possibly due to the way in which the
specimen is mounted. There are no centres visible for the
spinous and transverse processes of the vertebrae, and the
atlas is not united behind. The sacral vertebrae are not
joined together. There are no laminae for the lateral
surfaces, and the anterior parts of the uppermost sacral
vertebrae are not united to the posterior. There are no
coccygeal centres. There are no centres for the crests of
312 ATELEIOSIS
the ilia, and the three parts of the ossa innominata are
widely separated by cartilage, while there is a very distinct
interval between the ramus of each pubis and ischium.
There are no centres for the tuberosities of the ischia, for
the symphysis pubis, or for the anterior inferior spines.
The centres for the heads of the femora are small, and
there is none for the trochanters. There is also none for
the patellaB. There is a small area of bone in the cartilage
cap over the lower end of each femur, but it seems to be
present in the outer condyle only. Both the upper and
lower ends of the tibiae also contain centres, which have
apparently grown to about a third of their proper size.
The ends of the fibulae have no ossification centres. These
bones are bent in towards the tibiae so as almost to touch
them at their lower ends. Each os calcis and astragalus
is of fair size, but of the four other internal bones the
external cuneiform alone contains a centre. Traces of
centres are present in the heads of the metatarsals.
The sternum has four distinct centres, though the lower
of these seems to be partially joined. The uppermost is
much the largest. There is no trace of a fifth centre for
the gladiolus. The scapulae have no centres for the
acromion processes ; that for each coracoid is present, but
not united. Small centres are present in the heads and
tuberosities of the humeri, and there is a small one also
for each radial head. There is no epiphysis for the radius
or ulna of either side. Of the carpal bones, that for the
OS magnum and cuneiform are alone present. There are
no centres for the heads of the metacarpals. Ossification
is almost equal on the two sides.
It will be seen that, judging from these centres which
are present, the ossification is about equal to that of a
child during its second year. The centres for the lower
ends of the radii, of the fibulae and of the gladiolus, which
ordinarily appear in the second year, are not present,
whereas those of the lower end of tibiae which appear in
the second year are well represented. There are also
traces of the heads of metatarsal bones which do not
ATELEIOSIS 313
usually appear until the third year. Ossification is there-
fore somewhat irregular, but, on the whole, is not more
advanced than that of most children between one and two
years of age. The dentition is that of a child who has
attained the age of two years. But on comparing the
proportions of Caroline Crachami with those of a normal
child, we find that the height of her skeleton (49 cm. =
19^ inches) is a little less than the measurement which
Spiegelberg^ gives of the height (51 cm. = 20y^ inches)
of an average mature foetus ; while the length of the head
of Caroline Crachami is 12*6 cm. (5*4 inches), as compared
with 11*75 cm. (4^ inches) of the normal newborn infant.
The breadth of the skull in Caroline Crachami is 9*4 cm.
(3| inches), as compared with 9*25 cm. (3^ inches) of the
newborn child. In other words, if we add on a little to
the measurements of Caroline Crachami in consideration
for the loss in height which is produced by the method of
mounting, and for the measurements having been taken
from a skeleton, we may say that while Caroline Crachami
was of the height of a newborn baby of average size, her
skull was a little larger, especially in the longitudinal
diameter.
Remarks, — Caroline Crachami is an example of one of
two possible diseases. We must either regard her as what
the French term a sub- or demi-microcephalic imbecile, or as
an instance of ateleiosis occurring in foetal life. There
seems to be no question that she was an imbecile. Her
inability to walk with confidence, her quickness of sight,
attraction to bright objects, and pleasure in music and fine
clothes are all points which would claim attention in an
imbecile. The fact that they are recorded implies that
they were the most conspicuous features of her mental con-
dition, and that indications of a higher intelligence were
absent. This view is corroborated by the facial appearance
of the child, which is eminently characteristic of microcephal-
ism. The nose is much too large in proportion to the face,
and the mandible is too small, giving a ferretty or rat-like
^ * Text-book of Midwifery/ (N.S.S. translation), vol. ii, p. 121.
314 ATELEIOSIS
appearance to the countenance, such as is commonly seen
among small-headed idiots.
On the other hand, the head is distinctly npt micro-
cephalic. Its size is, on the contrary, rather over than
under that which is natural to infants whose development
corresponds with that of Caroline Crachami. Moreover,
observations which have been made on the bones of idiots
show that there is no delay of development in their case.^
There is more to be said in favour of the case being one
of ateleiosis. Not only is there marked delay of develop-
ment of the skeleton and a comparatively large skull, but
we have the very important fact that the internal sexual
organs were still more backward in their development than
were the bones. This, we shall presently see, is a feature
of most cases of ateleiosis. There is, therefore, good
reason to believe that Caroline Crachami's condition was
not due to primary hypoplasia of the brain, but was the
result of a more wide-spread developmental error. In
other words, the hypoplasia of the brain was only part of
a general hypoplasia. At the same time we must recognise
that it was probably this defective development of the brain
which gave the case its peculiar features. Though the
virtual arrest of development of the brain of an infant may
not interfere with the intellectual faculties beyond keeping
them more or less childish ; yet, if the arrest takes place at
an earlier age, there must be a period at which development
cannot be virtually stopped without imbecility resulting.
In that case, what is more likely than that the condition
will present the facial as well as the mental characters of
primary microcephaly ? It should be noted that according*
to Boyd's tables^ the weight of the brain at the age of
nine years (lir)4 grammes = 40^ oz.) is not far from its
highest (1244 grammes = 48 oz.), whereas in the case of
Caroline Crachami, we must regard the brain as but slightly
heavier than that of a newborn child (283 grammes =
10 oz.).
' Dr. Placzch, * Zeitschrift f . Etlinol./ 1901, p. 335.
' * Quain's Anatomy/ vol. iii, part 1, p. 178.
ATELEIOSIS 315
Doubtful Cases.
There is a very pronounced form of infantilism which
cannot be accounted for by any of the recognised causes of
delayed development. The stature is so diminutive, and the
proportions so good, that these dwarfs are in great demand
for the purposes of exhibition in shows. It is probable
that they are examples of ateleiosis beginning in fcetal
life.
Among the best known of these was Frank Flynn,
or " General Mite/^ who was examined by Virchow/
who found that he was 80*7 cm. (31 1 inches) in height,
while the head was 41 '5 cm. (16^ inches) in circumference.
His head, therefore, as Virchow pointed out, was a little
too large for his body, though he was in other respects
of excellent proportions. Professors Ranke and von Voit,^
who examined him one vear later, found that he then
weighed 6570 grammes (14 lbs. 7i oz.), and was 824 mm.
(32 .J in.) in height. He was of quick apprehension-
and good memory, while his intelligence, in spite of the
extreme smallness of his head, was excellent. Ranke
considered him to have the proportions of an adult, though
the head and feet were a little too large, and his arms a
little too short.
Nothing is said of the sexual organs, except that they
were undeveloped.
Another example of the same condition was also
examined by Ranke and von Voit.^ This was that of
Millie Edwards, who was of the age of 12 years. She was
described as being of a very quick and lively disposition,
and of excellent intelligence and memory. She was 72
cm. {2^ feet) high, and weighed 6601 grms (27 lbs.), but
no other measurements were given, though it was stated
that her proportions were correct.
A still more striking case was that of Pauline
J ' Zeitschrif t f . Ethnologie/ 1883-4, Bd. xv.
« '-Arch, f . Anthrop. Braunschweig/ 1885-6, Bd. xvi, s. 228.
^ Loc. cit.
316 ATELEIOSIS
Muster, a Belgian dwarf, who was no more than 30 cm.
(llf inches) in length at birth. She was examined by
Virchow ^ at the age of 3 years, when she weighed 3*63
kilos. (8 lbs.), was 538 mm. (21|- inches) high, and measured
363 mm. (14^ inches) round the head. At the age of five
she was examined by Dr. A. A. Bouchard,^ who found that
she was then 550 mm. (21|^ inches high, and that the
circumference of her head had increased to 390 mm.
(15| inches). She had twenty-two teeth, but no particulars
are given of the state of dentition. Virchow said of her,
that she talked with quickness and volubility, and was
exceedingly bright and lively. She was described by others
as being in perpetual movement and of good intelligence.
No examination of the bones was made in any of
these cases; we cannot therefore say definitely to what
class of dwarfism they belong, though they are evidently
examples of the same morbid condition, and that condi-
tion is one of infantilism. It will be noticed that the
intelligence was good in all three, though the heads were
very small. The size of the head and length of the body
of Pauline Muster were very near to those of Caroline
Crachami, but it should be observed that there was in
reality a difference between them, for Caroline Crachami,
at the reputed age of 9 years, was of about the same size
as Pauline Muster at three. Their photographs show
them to be of the same facial type, and in some respects
they resembled microcephalic dwarfs, for different obser-
vers seem to have been much struck with their quick
movements and extreme restlessness.
(tROUp II. — Atelpto.sis hegtnnmg during Ivfancy or early
Childhood,
Case 2. — According to his birth certificate, T. L. Spooner
was born in Layer Breton, Essex, on February 23rd, 1874,
and is therefore now twenty-eight years of age. The
^ * Zeitschrift f . Ethnologie/ Bd. iv, s. 215.
■2 * Journ. d. Med. de Bordeaux/ 1884-5, vol. xiv, pp. 276—279.
Med, Chir. Trfl.DS., Vol. 85.
flilid u. tioriiii^l buy □£ (I yetLia, lite phytlu^iiuniv And pto
portions ure childiiili aud tliu sexual otgau>i iufuutila, wtif
the attitude, cxprcsaioii and the maittings oi the face a
ATELEIOSIS 317
photographs of his father and mother and of some of his
brothers and sisters show that they are all of ordinary size
and development. Of five brothers and two sisters one only
is dead (from pneumonia). He was of average size when
born, and cut his teeth at the usual age. He had measles
in childhood, and during the last three years has had
influenza twice. Nothing is known of the closure of the
fontanelles. It was first noticed that he was not growling
when he was between one and two years old, though there
was no illness nor any other circumstance to account for
it. He went to school at ten, and left at sixteen, after
passing the sixth standard. I first saw him when he was
just over twenty-three years of age. He was then
1*078 m. (3 feet 6 inches) in height. One year after-
wards, when I measured him again, he was 1*086 m.
(3 feet Of inches) high, and three years later he had still
further increased to 1*096 m. (3 feet 7 J- inches). On
February 21st of this year, or one year after he was last
measured, he was still of the same height. Other
measurements on the last occasion were as follows, viz. :
Head, 49*5 cm. = 19^ inches in circumference; 17
cm. = Gf inches in greatest length ; 13*9 cm. = 5^ inches
in greatest breadth.
Round chest in nipple line, 62*6 cm. = 24g inches inspira-
tion ; 61 cm. = 24 inches expiration.
Round abdomen, 56 cm. = 22^ inches ; middle point of
total length, 1 cm. above the pubes.
Cpper extremity, — Arm from acromion to elbow, 20*75
cm. = 8^ inches ; forearm, external condyle to styloid
process, 17*3 cm. = 6f inches ; length of hand, 11*75 cni.
= 4yV inches.
Lower extremity. — Great trochanter to external condyle,
28*5 cm. = 12 inches ; lower end of femur to internal
malleolus, 24 cm. = 9 -j^ inches ; length of foot, 17 cm. =
6 1 inches.
Weight, 25 kilos. = 4 st. 1 lb.
These measurements vary very little from those which I
made four years before.
296 BEGENEKATION OF PERIPHERAL NERVES
the peripheral end from its own central end. It was possible
that the sympathetic system recovered more easily than the
ordinary peripheral nerves; but even in them, although there was
return of histological structure, there was no return of function.
This was possibly due to the greater vulnerability of the
terminations of the sympathetic nerve as compared with the
^ fibres themselves. The variation in recovery would probably
differ in different nerves and in different animals. As to the
manner in which the actual regeneration occurred, the neuro-
blast view of the authors of the paper was not convincing ; the
observations made were on sections, and it was not possible to
follow a nerve-fibre by this method ; the method of teasing was
necessary. The Golgi stain was erratic, and osmic acid stains
were certainly preferable both to it and the Weigert stain.
His observations had rather revealed the idea of a long multi-
nucleated cell than a scries of short cells as the authors had
maintained. The difficulty of admitting the phagocytic action
of the connective-tissue cells for the medulla was obvious in
view of the fact that tlioy were separated by a membrane — the
neurilemma. The earlier disappearance of the medullary sub-
stance of the large fibres was probably due to the staining
agent. In his experience this change was earlier in the small
than in the larger fibres. The rapid return of sensation
(from an hour to a day) in cases of secondary suture was not
cleared up by the paper. If recovery of function did not
correspond with regeneration of structure how could it be
explained ? The nerve could not be cut without the stump of
the central end degenerating, and this in itself negatived the
rapid recovery on the basis suggested in the j^aper, as seven to
ten days at least were required for their recovery. He would
suggest as a theory that the division of one or more nerve-
fibrils might happen just between two nerve segments, and thus
the two in contact end to end might escape injury, and being in
anatomical continuity might transmit sensory impulses. In
the surgical operations for the repair of a divided facial nerve
it was usual partially to divide the spinal accessory nerve and
to graft the facial on the central end of the spinal accessory.
He would suggest that it might be better to cut the spinal
accessory nerve right across, to split it, and to unite one
portion thus divided to the facial and the other to the peri-
ph<^ral trunk of the spinal accessory.
Dr. F. W. MoTT congratulated the authors of the paper on
affording still further proof that regeneration of a divided
nerve took i)lace from the periphery. For some time past he
had been engaged with Professor Halliburton in making a spries
of observations upon the chemical changes occurring in nerves
undergoing degeneration and regeneration after their division.
The inquiry was not conducted for the purpose of ascertaining
^^^^^ Med. Chir. Trans., Vol
H Gilford: Aleleiosis. Plate !U.
1
\
f
1
1
1
L
Aldciosis. Oroup ii. Case 2. Radiogram of hand of Pinto 11., age
years. Note tbe size of the haiid.
Ball d- IMnifA™!., Lid., torn
J
ATELEIOSIS 319
immaturity, there are marks of age upon liis face, and a
certain air of assurance in liis manner which prevent his
being mistaken for a child. His mental development and
tastes are somewhat childish, for though he does not care
to associate with children, he is inclined to indulge in
childish games. He is fond of reading, and is capable of
steady application to his daily work. He earns 36*. a week
as an under-gardener. His muscles seem to be of the size
and strength of those of a child of his height. The pulse
averages about one hundred beats to the minute. The heart
is of normal size, but a faint soft murmur can be heard
after the second aortic sound with an interval between them.
The arteries are in good condition, and there is no arcus
senilis. The organs of special sense appear to be
normal. He sweats freely when he exerts himself to any
unusual extent.
Genital and urinary organs, — The breasts look prominent,
but no gland tissue can be felt. The external organs of
generation are in size and appearance like those of a child
of about three years of age. The testicles are undescended,
though each forms a projection and can be felt in its canal.
Th6y are of infantile development, but testicular sensation
is well marked. From what I can gather there has been
none of the emotional evidences of puberty. The breasts
are not developed. The urine is normal in quality, but I
cannot speak as to its quantity.
Osseoiis system, — The fontanelles are closed. There
appears to be no irregularity of ossification anywhere. All
the bones are slightly formed. A radiogram of one hand
taken four years ago showed that ossification corresponded
with that of a boy of about the age of ten years, though
the bones themselves are smaller than usual, and the
muscular prominences are not easily detected. A radiogram
which I had taken a year ago shows that ossification had
made but little advance during the previous three years.
The bones are, as a rule, perhaps a little thicker or a little
longer, but there appears to be no more progress in the
fusion of the epiphyses. The hand is apparently just
Med. Chir. Trans., Vol. 85."
Gil/ord: Alslfiosis. Plate IIT.
ATELEIOSIS 319
immaturity, there are marks of age upon liis face, and a
certain air of assurance in liis manner which prevent his
being mistaken for a child. His mental development and
tastes are somewhat childish, for though he does not care
to associate with children, he is inclined to indulge in
childish games. He is fond of reading, and is capable of
steady application to his daily work. He earns Ss, a week
as an under-gardener. His muscles seem to be of the size
and strength of those of a child of his height. The pulse
averages about one hundred beats to the minute. The heart
is of normal size, but a faint soft murmur can be heard
after the second aortic sound with an interval between them.
The arteries are in good condition, and there is no arcus
senilis. The organs of special sense appear to be
normal. He sweats freely when he exerts himself to any
unusual extent.
Genital and urinary organs. — The breasts look prominent,
but no gland tissue can be felt. The external organs of
generation are in size and appearance like those of a child
of about three years of age. The testicles are undescended,
though each forms a projection and can be felt in its canal.
Th^y are of infantile development, but testicular sensation
is well marked. From what I can gather there has been
none of the emotional evidences of puberty. The breasts
are not developed. The urine is normal in quality, but I
cannot speak as to its quantity.
Osseous system, — The fontanelles are closed. There
appears to be no irregularity of ossification anywhere. All
the bones are slightly formed. A radiogram of one hand
taken four years ago showed that ossification corresponded
with that of a boy of about the age of ten years, though
the bones themselves are smaller than usual, and the
muscular prominences are not easily detected. A radiogram
which I had taken a year ago shows that ossification had
made but little advance during the previous three years.
The bones are, as a rule, perhaps a little thicker or a little
longer, but there appears to be no more progress in the
fusion of the epiphyses. The hand is apparently just
Mea. Chir. Traits., Vol. 861'
Giljord: Ateleiosis. I'lalc lU.
AMpMiit, Grijiiji a. Cn.'-i: 2. Radiogram o£ Laiid o! Plate 13., age
28. TIjk Oiaification rOHtiuLles iliat whieb is uaua,! at from 10 to 12
yearn. Note tbe size of tlie imiid,
ATELEIOSIS 319
immaturity, there are marks of age upon liis face, and a
certain air of assurance in liis manner which prevent his
being mistaken for a child. His mental development and
tastes are somewhat childish, for though he does not care
to associate with children, he is inclined to indulge in
childish games. He is fond of reading, and is capable of
steady application to his daily work. He earns Ss, a week
as an under-gardener. His muscles seem to be of the size
and strength of those of a child of his height. The pulse
averages about one hundred beats to the minute. The heart
is of normal size, but a faint soft murmur can be heard
after the second aortic sound with an interval between them.
The arteries are in good condition, and there is no arcus
senilis. The organs of special sense appear to be
normal. He sweats freely when he exerts himself to any
unusual extent.
Genital and urinary organs. — The breasts look prominent,
but no gland tissue can be felt. The external organs of
generation are in size and appearance like those of a child
of about three years of age. The testicles are undescended,
though each forms a projection and can be felt in its canal.
They are of infantile development, but testicular sensation
is well marked. From what I can gather there has been
none of the emotional evidences of puberty. The breasts
are not developed. The urine is normal in quality, but I
cannot speak as to its quantity.
Osseous system, — The fontanelles are closed. There
appears to be no irregularity of ossification anywhere. All
the bones are slightly formed. A radiogram of one hand
taken four years ago showed that ossification corresponded
with that of a boy of about the age of ten years, though
the bones themselves are smaller than usual, and the
muscular prominences are not easily detected. A radiogram
which I had taken a year ago shows that ossification had
made but little advance during the previous three years.
The bones are, as a rule, perhaps a little thicker or a little
longer, but there appears to be no more progress in the
fusion of the epiphyses. The hand is apparently just
320 ATELEIOSIS
8 mm. (^ in.) longer. The long bones of the arm and
hand are perhaps more lightly and delicately formed than
are those of most children of ten years.
Case 3. — The following is a female case in which I
was able to make a complete examination of the whole
body, and to obtain a radiogram of the forearm and hand.
This dwarf was born in Paris eighteen years ago. Her
mother, who is of ordinary stature, sought my advice for
obesity. She told me that there were two other children
beside this dwarf, but that they and the father are of
ordinary stature, and she does not know that any other
member of the family has ever had any abnormality of
growth. This dwarf child was small at first, but grew at
an ordinary rate until she was a little over two years of
age. After this period she still continued to grow at a
fairly uniform, but much diminished, rate. She has had
attacks of bronchitis in childhood, but with that exception
has been healthy. She presents no sign of approaching
puberty, but, on the contrary, in almost every respect
resembles a child. She differs in that her intelligence is
certainly more mature than is usual in a child of her
height. She is of a lively disposition, but is not restless.
She sweats on taking any unusual exertion. Her hair
is fine, eyes full, nose depressed at the bridge, lips
thin, and chin small. The appearance of her face is
spoiled when she smiles by the projection of her teeth,
which are also very irregular. Teething began, it
is said, at the eighth month, but nothing is known of the
time of onset of the second dentition. The teeth form two
irregular rows and are much crowded and displaced.
Some belong to the permanent, and some to the temporary
set. In the upper jaw are four permanent incisors, of
which the two lateral are only just through the gums,
while two of the tem]iovarv set still remain. There are
also two temporary canines, two premolars, and four per-
manent and decayed molars, while one decayed temporary
molar has been crowded out. In the lower jaw are only
Med, Chir. Trans., Vol. 8^
(lillonl: AkleiosLi. PlaklV.
AleMonU. Group U. Case 3. Age 18 yearsi, height 2tl.
Djia. (-SSOm.). Anormftl adult band ia iatrodueed fortbe aake
of compariaon. Note the charttcterialip physiognomy, anil
thocro*ded teeth. A radiogram showed tlmtossiiioation was
equal to that which is usual at six years.
ATELEIOSIS 321
two small and imperfect incisors, two temporary canines,
four crowded premolars, and two molars, one of which is
decayed to the roots. The appetite is said to be excellent,
she has six meals a day, and altogether her food is thought
to be equal in quantity to that taken by an average child
of the age of from twelve to fourteen years. The mother
states that the anterior fontanelle did not close until she
was seven or eight years of age. Measurements of her
head and body are as follows, viz. :
Total height, 850 mm. = 33J inches.
Head circumference, 445 mm. = 17^ inches.
Round the chest in the nipple-line between inspiration
and expiration, 475 mm. = 18| inches.
Round abdomen at umbilicus, 460 mm. = ISJ inches.
Arm, 153 mm. = 6 inches.
Forearm, 140 mm. = 5^ inches.
Hand to extremity of middle finger, 107*5 mm. = 44^
inches.
Thigh, 230 mm. = 9 inches.
Leg, 250 mm. = 9J inches.
Foot, 125 mm. = 5 inches.
A radiogram of the hands shows that the ossification is
a little more advanced than that of a child of six years,
as shown in Mr. Poland^s atlas. Ossification is more
forward in the right hand than in the left. Her manner
is childish; she has not the slightest objection to being
stripped of her clothes and examined. She possesses no
hair on her body, and her breasts and sexual organs are
undeveloped. The pelvis is that of a child, and there has
never been any sign of the onset of menstruation. A faint
systolic murmur can be heard over the upper part of the
sternum. The heart appears to be normal in other respects.
She possesses little muscular strength, but is certainly
able to endure far more fatigue than a child of her height.
Her mother declares that she can walk 3 kilometres (2
miles), and has once walked 6 kilometres (3f miles)
without undue fatigue. She gains her living on the stage
and is an expert dancer.
VOL. LXXXV. 21
ATELEIOSIS 321
two small and imperfect incisors, two temporary canines,
four crowded premolars, and two molars, one of which is
decayed to the roots. The appetite is said to be excellent,
she has six meals a day, and altogether her food is thought
to be equal in quantity to that taken by an average child
of the age of from twelve to fourteen years. The mother
states that the anterior fontanelle did not close until she
was seven or eight years of age. Measurements of her
head and body are as follows, viz. :
Total height, 850 mm. = 33J inches.
Head circumference, 445 mm. = 17^ inches.
Round the chest in the nipple-line between inspiration
and expiration, 475 mm. = 18| inches.
Round abdomen at umbilicus, 460 mm. = ISJ inches.
Arm, 153 mm. = 6 inches.
Forearm, 140 mm. = 5^ inches.
Hand to extremity of middle finger, 107*5 mm. = 44^
inches.
Thigh, 230 mm. = 9 inches.
Leg, 250 mm. = 9J inches.
Foot, 125 mm. = 5 inches.
A radiogram of the hands shows that the ossification is
a little more advanced than that of a child of six years,
as shown in Mr. Poland^s atlas. Ossification is more
forward in the right hand than in the left. Her manner
is childish ; she has not the slightest objection to being
stripped of her clothes and examined. She possesses no
hair on her body, and her breasts and sexual organs are
undeveloped. The pelvis is that of a child, and there has
never been any sign of the onset of menstruation. A faint
systolic murmur can be heard over the upper part of the
sternum. The heart appears to be normal in other respects.
She possesses little muscular strength, but is certainly
able to endure far more fatigue than a child of her height.
Her mother declares that she can walk 3 kilometres (2
miles), and has once walked 6 kilometres (3f miles)
without undue fatigue. She gains her living on the stage
and is an expert dancer.
VOL. LXXXV. 21
322 ATELEI08IS
Case 4. — There is a skeleton in the Barclay collection
of the Royal College of Surgeons of Edinburgh which
shows^ the changes which characterise the bones of these
ateleiotic dwarfs, and I have to thank the Museum
Committee for permission to describe and photograph
this specimen. I could find no description beyond that
which is given on the label. This sets forth that it is
"the skeleton of the dwarf Bobbie Fenwick, who died in
1815, upwards of fifty. The bones of the ossa innominata
remain disunited, as do all the epiphyses, except the right
upper end of ulnar. Lines of junction can be seen in
most vertebrae, ribs, sacrum, fingers, and toes. Several of
the second set of teeth have never protruded.^^
The measurements of the skeleton are as follows, viz. :
Height, 3 feet 10 inches == 1188 min^
Length of spine, 35 inches = 890 mm.
Skull : greatest length, 7^ inches = 185 mm. ; greatest
width, 5f inches = 145 mm. ; circumference, 19|^ inches =
505 mm.
Biacromial, 11^ inches = 285 mm.
Humerus, 13J inches = 350 mm.
Radius, 9^ inches = 250 mm.
Hand, 5 J inches =130 mm.
Femur, 18^ inches = 470 mm.
Tibia, 13 inches = 330 mm.
Foot, 6 inches = 153 mm.
Pelvis, antero-posterior, 2i inches = 65 mm. ; transverse,
3-| inches = 85 mm.
Between anterior superior spines, 6-^ inches = 160 mm.
Crest to crest, 6-| inches =173 mm.
The bones are small and slightly formed, and the mus-
cular prominences are not well marked, though they can
be readily recognised. The proportions are, apparently,
faulty, but allowance must be made for the very liberal
supply of inter-vertebral substance^ which has been put in
1 According to Mr. Morris (' Anatomy of the Joints/ p. 69) the inter-
vertebral substance does not normally exceed one quarter of the total
length of the spine, but in this skeleton it must be nearly half that length.
Skalotou of Bobbie i:\
Muaeom, of Edinburgb
pbyses about the knee j
are not united. The spine
of intervertebral oemeut.
tins.. 1.18SJII.
u ihu l^■yl^l Ciillcgi.' of Surguons'
loa B,re d-:l\cate\y formed, tha epi-
larged and many of the epipbyaea
loDgo^---^- ^'-- " '
g to the
ATELEI08IS 323
by the articulator. In some parts, indeed, its depth
equals or even exceeds that of the vertebrae between
which it is placed. This accounts for much of the dis-
proportionate shortness of the limbs, and also for the fact
that the middle point of total length is at the sacral
eminence, whereas it was probably during life a little
above the pubes. Something should also, for the same
reason, be discounted from the height, which probably did
not amount to more than 1*100 mm. during life.
The skull, it will be noticed, is a little below the average
size for an adult. It is, apparently, of normal thickness,
and shows no irregularities of ossification. The sella
turcica is neither too small nor too large. The basi-
sphenoid and basi-occipital are not yet united. The angle
of the lower jaw is somewhat open, and the body is
shallow, behind the canine teeth. The palate is flat, and
the dentition is very irregular.
Its formula is —
Upper 4.24 6
Lower 3 '• 2 ^- 4 P^* 4 "^-
In the upper jaws the right canine has evidently
erupted at a much later date than its neighbours, and has
been crowded out by them. One of the premolars, though
visible, has not descended. Of the three right molars,
two have their crowns flush with the alveolus, as if they
also had not erupted, and the same is the case with the
last of the corresponding teeth on the left side. Another
is decayed to the roots, and the third has been broken off.
In the lower jaw the left lateral incisor has not yet been
^^cut,^^ and the same is the case with the two canines.
Two of the premolars are very little above the level of
the alveolus. There is a cavity left by an absent first
right molar, and the second has just erupted. All the
teeth are of average size, but are very irregularly placed,
some projecting unduly, while others are below their proper
level. Another noticeable peculiarity in the lower jaw is
the presence of two fissures, one running downwards just
324 ATELEIOSIS
outside the right central incisor, and the other from the
root of the right canine, so as, apparently, to separate the
bone between them from the rest of the jaw. The spinal .
and sacral epiphyses are all united. The sternum is short,
and the upper pieces are still separate, while the third and
fourth show an evident groove in their line of fusion. The
coracoid and acromial processes are still separate. The
rib epiphyses are all united. Ossification is, as a rule,
more advanced on one side than on the other; thus the
line of union of the right upper epiphysis of the humerus
can be seen only on close examination, while, on the left
side, it is evident at once. The stage of ossification is not
symmetrical. This is especially true of the radii, for the
head is still separate on the right side, whfle it has, ap-
parently, been recently united on the left. The line of
junction at the lower ends of each humerus can be seen
only on near inspection. The lower ends of the radii are
still separate, and so apparently are those of the ulnee.
The pelvis is flat and shallow, and the ossa innominata are
still divided into their three constituent bones by well-
marked cartilaginous divisions. The crest of the ilium is
rough, and the edges are sharp, showing that its epiphysis
had not united and has been detached. The cotyloid
cavity is shallow and its lip irregular. The natural curve
of the femur is not exaggerated. The head of the bone is
flattened and roughened at its upper part, as if the cartilage
there had been unusually thick. It is either ununited,
or is quite recently united, to the neck on the right side,
but it is difficult to see the line of junction on the left.
There is no adventitious deposit about this or any other
joint. The neck is unusually short and runs into the shaft
at an angle of about 120 degrees. The lesser trochanter
is very prominent. A noteworthy point about the femur
is the relative enlargement of each lower epiphysis, which
is rather conspicuous. The lower epiphysis on the left
side is detached, but on the right it is joined, and the
epiphysial line can be seen with difiiculty. In no case
does there appear to be any cartilage in the epiphysial
ATELEIOSIS 325
lines, and it is possible that the epiphyses are not always
separate when they appear to be so.
Case 5. — Another example of the same disease has been
described by Professor SchaafEhausen^.
This was a male dwarf who died at the age of 61. His
height was 94 cm. {S^-^ f^et) ; weight 45 Pfund (2250 grms.).
His parents and one sister were tall, and two brothers were
about 5 feet (152 '5 cm.) high. There were three other
dwarfs in the family, twQ of whom were alive, one being of
his own height, and the other 5 inches (12*7 cm.) taller.
One brother, who was dead, had presented the same
characters as himself in regard to voice and beard. " He
had an old head on a childish body." The head was of
circumference of 520 mm. (20 ^ inches), or about that of a
boy of five years of age. " It seemed as if the growth of
the head had remained childish, whilst at the same time
most of the characters of the body were also childish."
His intelligence was good, but not exceptional. The head
was 170 mm. (6| inches) long, as in the first year of life,
whilst its greatest breadth was 150 mm. (5^ inches) . The
internal surface of the skull showed the impression of
many deep convolutions. He had a squeaky voice, he was
neither bald nor grey, though hair was absent from all
parts except the head. Although he looked old, his face
retained the characters of childhood, as was shown by the
bulging forehead, the undeveloped nose, thick upper lip,
and weak chin. The skull had a very childish form,
which was especially shown in the lack of prominence of
the parietal eminences, in the open condition of all the
sutures, and in the serration of the bones, which re-
sembled that of a child in the first year of life. The
internal organs were not larger than those of a child of six
years. He appeared not to be virile, and there was
cryptorchism on both sides. In other respects he showed
marks of age. He had lost most of his front teeth, and
1 ' Verhand. d. Naturhist. Verein. d. preuss. Rhein. u. Westphal./ 38
Jahr. Erstes Heft., Bonn, 1868, S. 26.
314 ATELEIOSIS
appearance to the countenance, such as is commonly seen
among small-headed idiots.
On the other hand, the head is distinctly npt micro-
cephalic. Its size is, on the contrary, rather over than
under that which is natural to infants whose development
corresponds with that of Caroline Crachami. Moreover,
observations which have been made on the bones of idiots
show that there is no delay of development in their case.^
j There is more to be said in favour of the case being one
'j of ateleiosis. Not only is there marked delay of develop-
ment of the skeleton and a comparatively large skull, but
we have the very important fact that the internal sexual
organs were still more backward in their development than
were the bones. This, we shall presently see, is a feature
of most cases of ateleiosis. There is, therefore, good
reason to believe that Caroline Cracliami's condition was
not due to primary hypoplasia of the brain, but was the
result of a more wide-spread developmental error. In
other words, the hypoplasia of the brain was only part of
a general hypoplasia. At the same time we must recognise
that it was probably this defective development of the brain
which gave the case its peculiar features. Though the
virtual arrest of development of the brain of an infant may
not interfere with the intellectual faculties beyond keeping
them more or less childish ; yety if the arrest takes place at
an earlier age, there must be a period at which development
cannot be virtually stopped without imbecility resulting.
In that case, what is more likelv than that the condition
will present the facial as well as the mental characters of
primary microcephaly ? It should be noted that according
to Boyd\s tables^ the weight of the brain at the age of
nine years (1154 grammes = 40^ oz.) is not far from its
highest (1244 grammes = 43 oz.), whereas in the case of
Caroline Crachami, we must regard the brain as but slightly
heavier than that of a newborn child (283 grammes =
10 oz.).
' Dr. Placzch, ' Zeitschrift f . Ethnol./ 1901, p. 335.
' ' Quain's Anatomy/ vol. iii, part 1, p. 178.
ATELEJOSIS 327
described by His and Schauta. The former of these two
was a cretin. Schauta^s case may also have been one of
cretinism ; it will be referred to among the doubtful cases.
Another case of operation cretinism by G-rundler is then
quoted, and some cases are referred to which occur in
Otto^s ^ Lehrbuch ' and are described by Naegele. The
latter alludes to the Edinburgh skeleton (Case 2). Paltauf
believes that the infantile peh4s of obstetricians is not a
local phenomenon only, but is part of a wide-spread con-
dition of infantilism, such as is found in ateleiosis and
cretinism. He quotes details of the descriptions of some
of these pelves, in each of which there was some noticeable
delay in the process of ossification. Three were apparently
of cretinous or myxcedematous persons; in another the
bones were thick, light, and spongj". One belonged to a
dwarf woman of the age of 31 years, who was of childish
intellect, and may possibly have been a cretin. She gave
birth to a child of 5 lbs. 6 oz. (2*4 kilos.) in weight.
Paltauf then describes the microscopical appearances of
the ossification zones, and compares the disease with natural
dwarfism, rickets, so-called f cetal rickets, congenital osteo-
porosis and cretinism, and with normal childish growth. He
then alludes to some well-known dwarfs, such as ^^ General
Mite,^^ Jeffrey Hudson, Boruwlaski, and " Admiral Piccolo-
mini,^^ and finally goes into the question of the influence of
the genital organs on growth. Paltauf, in his paper, does
not clearly distinguish between ateleiosis and cretinism
and other causes of defective development, though he
fully recognises that his case (Mikolajek) stands apart
from these secondary forms of dwarfism.
Case 6. — ^PaltauFs own case of ateleiosis, was a male
named Mikolajek, of the age of 49, who died from acute
disseminated tuberculosis in Professor Kahler^s clinik in
the Vienna hospital. He was born in Galicia. His
parents and brothers and sisters were of medium size.
At one time he suffered from a rheumatic affection of the
right knee-joint, but subsequently recovered. Later,
328 ATELEIOSIS
while occupied as a gardener, he developed the same com-
plaint in the left knee. At this time, and again four
years before his death, he became affected with general
oedema, but was at each time well in a few weeks. Three
weeks before his entrance into the hospital he again
became dropsical, and at the same time suffered from
breathlessness and cough. He had had no other diseases.
The bones were small, though he was of comparatively
great muscular development. The genital organs resembled
those of a child. The prepuce was phimotic, and though
the left testicle was in the scrotum, the right was still in
the inguinal canal. The chief measurements were as
follows :
Height, 112*5 cm. = 44^ inches.
Head: circumference, 54 cm. = 21J inches; mento-occi-
pital, 22*5 cm. = 8| inches; bi-parietal, 15 cm. = 5|^
inches.
Chest at nipple line, 67 cm. = 26-g inches.
Abdomen midway between xiphoid process and sym-
physis, 79 cm. = 31^ inches.
Extremities from acromion to end of middle finger^,
52 cm. = 20^ inches.
Olecranon to styloid process of ulna, 18*5 cm. = 7^
inches.
Great trochanter to external malleolus, 56 cm. = 22
inches.
Great trochanter to external condyle of femur, 26 cm.
= lOJ inches.
Internal condyle to internal malleolus, 28 cm. = 11
inches.
Nothing is said of his intelligence, but inasmuch as he
was for twenty-one years valet to a colonel in the army, it
is not likely that it was defective. The sella turcica was
'^ peculiarly large and deep.^^ It measured 17 mm. (3- inch)
in length and 16 nun. (-| inch) in breadth, or 6 mm. and
3 mm. (^ and y^y inch) respectively more than that which
is usual in the adult. The thyroid gland was found at
the po.st-mortem examination to be very small and pale
ATELEIOSIS 329
red in colour. Some of the glands of the left side of the
neck were of the size of hazel-nuts, and were hard and
yellowish and dry on section. The left lung was free
and the right adherent. The left lung had three lobes.
Both lungs contained disseminated tubercles. The heart
was enlarged on the right side, but the valves were
normal. The spleen was slightly enlarged, but the liver,
kidneys, adrenal capsules, and stomach were normal. The
teeth were well developed, not carious, and without sign
of rickets or other disease. All were of the permanent
set ; and except that there were only eight fully cut molars,
their number, size, and arrangement were as in the adult.
The third upper molar on either side was only just appear-
ing through the gums. The spinal column was 425 mm.
(16-| inches) long, and showed slight scoliosis, with the upper
convexity to the left. There was also lumbar lordosis.
The ends of the spinous and transverse processes were
still cartilaginous, and there were no signs of bone centres.
The ribs showed no evidence of rickets. The sternum
was in four pieces, and the ensiform process consisted of
pure cartilage. There was slight bending of the clavicles,
but it was not of the same character as that which is seen
in rickets. The epiphyses of the sternal ends contained no
traces of bone. They were 90 mm. long, that of a seven-year-
old child being 94 mm. (3f inches). The shoulder blades
were like those of a child, and the epiphyses were cartila-
ginous and not joined. The condyles of the humerus were
somewhat enlarged, especially the internal, though the
whole of the lower end was bigger than usual. In the
trochlea the beginning of bone formation could be seen.
The top of the radius and the end of the olecranon were
not united to their respective diaphyses. The carpal
bones were of the usual number, but were smaller than in
the normal adult, and their shape was sharply defined.
The epiphyses of the long bones of the hands were either
quite free, or were united by cartilage or by slight bony
union only. The three bones of the pelvic girdle were
separate ; the sutures between the pubes and ischia were
ATELEIOSIS 331
shaped, or irregular, and hardly looking like cartilage-cells.
Their groups lay free in the ground substance. The next
stratum was that of the calcified cartilage of the diaphysis.
This, too, was very abruptly defined, of smooth outline
towards the cartilage, but very irregularly toothed towards
the shaft of the bone. The cells were arranged in more
or less regular vertical lines as in normal ossification.
These lines were continued into the cartilage zone, where
they soon spread out, and their cells became more
scattered. Finally, in the cancellous bone of the shaft,
thin, delicate septa divided off large spaces filled with
secondary marrow. The cartilage was not only present on
the ends of the bone, but followed the diaphysis for a
short distance under the periosteum.
Paltauf insists that the calcification of cartilage in the
two strata above mentioned must not be confounded with
true ossification. It is rather to be compared with the
deposit of mineral salts in the cartilage of the aged, such
as occurs in the rib and laryngeal cartilages of old people.
Next to these, in the child, is a layer of developing bone,
but in the dwarf, though there is a formation of bone, it
is thin, fibrous, and broken.
Case 7. — Dr. Manou^-rier^ has also given an account
of a case of this disease. His patient, Auguste Tuaillon,
was normal at birth, and walked at the age of 13 months.
He fell downstairs at the age of 3 years, but impairment
of growth was not noticed until he was 4^ years old. At
this same age he had a very hard, prominent abdomen,
and was always very constipated.
Dr. Manouvrier believes that the anomaly of growth
really took place earlier, and was due to some injury of
the brain produced by the fall. He points out that
growth was delayed, and not brought to a sudden stop,
for there was satisfactory evidence that growth to the
extent of 4 cm. had taken place between the ages of 17
and 21. At the age of 20 he was '95 m. (3|- feet)
i * Bull. Soc. Anthrop./ 4th series, tome vii,1896, April 2nd, pp. 264—290.
332 ATBLEI08IS
high, and 17 kilos. (374 l^s.) in weight. At the age of
23, when the account was written, he still weighed only
17 kilos. (37 i lbs.), but had increased in height to "99 m.
(3^ feet). Nothing is said of the state of his ossifi-
cation. Tlie wisdom teeth had not been cut, and
some of the milk teeth were still persisting. There
was no appearance of rickets. His muscular strength
was about equal to that of a child of six. His appear-
ance, proportions, and gait were childish, and he was
often mistaken for a child, but his manner and con-
versation were not childish. He appeared to be of
average intelligence. The condition of the genital organs
was infantile. At the age of 14 or 15, according to his
own account, he showed some of the psychical phenomena
of puberty, but there appears to have been no real
evidence on this point. The skull measured : — Greatest
length, 178 mm. = 6| inches ; transverse diameter,
148 mm. = o^ inches; vertical, 127 mm. = 5 inches;
horizontal circumference, 530 mm. = 20|^ inches.
Casks 8 to 11. — A short account of some instances of
dwarfism are given by Dr. Joachimsthal,^ of Berlin, four of
which appear to be ateleiotic. He examined a troupe of
German dwarfs, and selected some of them for detailed
description. He also refers to other cases, and compares
tlio disease with achondroplasia and cretinism. Of his six
cases of dwarfism one commenced at the third year, and
will therefore come under my second group In his second
case, the abnormality was first noticed in the seventh year,
in the third at the tenth year, in the fourth at the eighth
year, but he says nothing of the time of commencement in
the last two. The ages varied from 30 to 36 years, and
lialf of thoiii were male and half female. Measurements
of lieight appear to have been made by the director of the
troupe as each dwarf came under his care. These are
coiripared by Dr. Joachimstlial with those which he him-
selt' niado when he first saw them. In one of these the
1 • Deiitsch. med. Woch./ No. 17, 1899, s. 269.
ATELEIOSIS 333
first measurement was made in the fifteenth and another
in the seventeenth years. It is therefore possible that the
respective increase of 10 cm. (3| inches) in fifteen years,
and 29 cm. (11^ inches) in fourteen years, was in part
due to natural growth at the time of puberty. But the
same can hardly be said of two other cases in which the
first measurement was taken in the twenty-first and
twenty-second year, respectively. In the first of these
two, the rate of growth was 25 cm. (9| in.) in thirteen years,
and in the other 22 cm. (8| in.) in fourteen years. It
cannot be said whether growth in these cases was con-
tinuous or regular, though Joachimsthal mentions that in
his second case, where the age was 36, there had been a
noticeable increase in height during the last three years.
If we compare the heights of these dwarfs with the
heights of normal children, we find that, according to
Quetelet^s tables, the first case grew from the height of a
child of 3|- years, until within sixteen years he had reached
the height of a child of 6 years. His second case grew in
fourteen years from the height of a child of 6 to that of
one of 10 years. His third in thirteen years from that of
a child 8 J, to that of one of 11 years ; and his fourth from
that of a child of 6 to that of one of 11 years.
Radiograms are given of the hands of four cases, and
the first also includes the greater part of the upper extre-
mity. It is noteworthy that the radiograms of the first
case show that, while the height was equal to that of a
child of 6 years, the ossification was equal to that of a
child between the eleventh and twelfth years. Similar
delay in ossification is shown in the next three cases. But
in the fifth and sixth there was complete epiphysial
growth. These were two females of the age of 26 years,
who had not been measured during the last ten years.
They differ from the other female, who was of the age of
30, not only in ossification, but also in regard to menstrua-
tion. In both o:^ them menstruation had been regular
since their twentieth year. It is unfortunate that no
photographs are given, other than radiograms, and very
332 ATELEIOSIS
high, and 17 kilos. (37^ lbs.) in weight. At the age of
23, when the account was written, he still weighed only
17 kilos. (37 i lbs.), but had increased in height to '99 m.
(3^ feet). Nothing is said of the state of his ossifi-
cation. The wisdom teeth had not been cut, and
some of the milk teeth were still persisting. There
was no appearance of rickets. His muscular strength
was about equal to that of a child of six. His appear-
ance, proportions, and gait were childish, and he was
often mistaken for a child, but his manner and con-
versation were not childish. He appeared to be of
average intelligence. The condition of the genital organs^
was infantile. At the age of 14 or 15, according to his
own account, he showed some of the psychical phenomena
of puberty, but there appears to have been no real
evidence on this point. The skull measured : — Greatest
length, 178 mm. = 6| inches ; transverse diameter,
148 mm. = 5^ inches ; vertical, 127 mm. = 5 inches ;
horizontal circumference, 530 mm. = 20|^ inches.
Cases 8 to 11. — A short account of some instances of
dwarfism are given by Dr. Joachimsthal,^ of Berlin, four of
which appear to be ateleiotic. He examined a troupe of
German dwarfs, and selected some of them for detailed
description. He also refers to other cases, and compares
the disease with achondroplasia and cretinism. Of his six
cases of dwarfism one commenced at the third year, and
will therefore come under my second group In his second
case, the abnormality was first noticed in the seventh year,
in the third at the tenth year, in the fourth at the eighth
year, but he says nothing of the time of commencement in
the last two. The ages varied from 30 to 36 years, and
half of them were male and half female. Measurements
of height appear to have been made by the director of the
troupe as each dwarf came under his care. These are
compared by Dr. Joachimsthal with those which he him-
self made when he first saw them. In one of these the
1 * Deutsch. med. Woch./ No. 17, 1899, s. 269.
ATELEIOSIS 333
first measurement was made in the fifteenth and another
in the seventeenth years. It is therefore possible that the
respective increase of 10 cm. (3| inches) in fifteen years,
and 29 cm. (11^ inches) in fourteen years, was in part
due to natural growth at the time of puberty. But the
same can hardly be said of two other cases in which the
first measurement was taken in the twenty-first and
twenty-second year, respectively. In the first of these
two, the rate of growth was 25 cm. (9| in.) in thirteen years,
and in the other 22 cm. (8| in.) in fourteen years. It
cannot be said whether growth in these cases was con-
tinuous or regular, though Joachimsthal mentions that in
his second case, where the age was 36, there had been a
noticeable increase in height during the last three years.
If we compare the heights of these dwarfs with the
heights of normal children, we find that, according to
Quetelet^s tables, the first case grew from the height of a
child of 3f years, until within sixteen years he had reached
the height of a child of 6 years. His second case grew in
fourteen years from the height of a child of 6 to that of
one of 10 years. His third in thirteen years from that of
a child 8 J, to that of one of 11 years ; and his fourth from
that of a child of 6 to that of one of 11 years.
Radiograms are given of the hands of four cases, and
the first also includes the greater part of the upper extre-
mity. It is noteworthy that the radiograms of the first
case show that, while the height was equal to that of a
child of 6 years, the ossification was equal to that of a
child between the eleventh and twelfth years. Similar
delay in ossification is shown in the next three cases. But
in the fifth and sixth there was complete epiphysial
growth. These were two females of the age of 26 years,
who had not been measured during the last ten years.
They differ from the other female, who was of the age of
30, not only in ossification, but also in regard to menstrua-
tion. In both o:^ them menstruation had been regular
since their twentieth year. It is unfortunate that no
photographs are given, other than radiograms, and very
334 ATELEIOSIS
little is said of the general appearance and of the condi-
tion of the sexual and other organs. In the first case,
that of a male, the voice was high pitched, and there
was no hair, except on the head. They are said to have
been well proportioned, but there are no measurements
other than those of height. The first case was said to
have been of good mental development. It is almost
certain that the first four were instances of ateleiosis, while
the last two were probably of the same nature.
At the end of his paper Joachimsthal alludes to Schaaff-
hausen^s case, and also mentions the cases of Schauta and
Paltauf. He refers also to a skeleton shown him by
Waldeyer, of a female dwarf of the age of 65 years, and
119 cm. high (3 feet 10^ inches), in whom the dwarfism
was perhaps of the same nature.
Doubtful Case.
A doubtful case is described by Dr. Thomson.^ The
patient was a girl who was of the age of four years
and eight months when Dr. Thomson first saw her, and
she died nearly ten months afterwards. The parents
were healthy, but of ten children one was said never to
have grown properly, and to have been always dull, while
another was a well-marked sporadic cretin. At three and
a half years the patient was 27 inches (68*5 cm.) high;
one year and two months later she was 28 4 inches (72*5
cm.) high, weighed 20 lbs. 7 oz. (9*34 kilos.), and
measured 18^ inches (47 cm.) round the head. Nearly
eleven months afterwards she was 30 J inches (76*4* cm.)
high and weighed 21 lbs. 4 oz. (9*5 kilos.) First dentition
began at the age of four months. At the age of four years
and eight months the ossification of the carpus and hand
resembled that of a child of two or three years. The
anterior fontanelle was still open^ but ten months after-
^ " A Case of a Peculiar Form of Dwarf Growth," by John Thomson,
M.D., with notice of post-mortem examination by Jessie Macgregor,
M.D., * Scot. Med. and Surg. Journ.,' March, 1900.
Med. Ohir. TraiiB., Vol. 85.
Atele oiU ( uvji Co. 12 Mart u Laus, aged
28 years he ght 4It 9i n (146m a staod ng on the right,
next to 1 m IS h 3 brot! er of 13 and ou II e left ie a. nor-
mal adult The atifle os s began at tlio age nf 11. Note
the al«eiice of sgtubI lia t the cli Id h eexaal orgaua,
and the jouthf 1 aspect acd propoct ons comh ned with the
weathen g of age
ATELEIOSIS 335
wards it was nearly closed. The mental condition was
normal. Improvement occurred during the use of
thyrocol. Death took place as the result of syncopal
attacks, which resembled those which accompany lymphatic
hypertrophy. At the post-mortem examination the
thymus gland was found to be hypertrophied, though it
did not flatten the trachea. The thyroid gland and heart
were normal. The surface of the brain was much con-
gested. This case was probably one of infantilism due to
lymphatic hypertrophy.
Group III. — Ateleiosis beginning hetuceen the Ages of
Infancy or early Childhood and Puberty,
Cases' which belong to the previous class evidently
belong definitely to one group, for they are all stamped
with the facial and other characters which belong to infancy
and early childhood. But after this age we can no longer
say that we have to deal with one distinct facial type,
for as infancy is left behind so the face changes, and the
proportions approach to those of the adult. The subjects
of ateleiosis commencing during these later years, will
therefore exhibit different features from those which are
shown during infancy. They will not be so dwarfed ; the
delay of osseous development will not be so conspicuous;
the physiognomy will not be so infantile ; the proportions
of the body and limbs will approach nearer to those of the
adult, and they will be more likely to attain puberty.
The following cases are given in illustration of this third
class.
Case 12. — Martin Lane, aged 28 years, was of the fol-
lowing measurements :
Weight, 35-6 kilos. = 79 lbs.
Height, 1*46 m. (4 feet 9^ inches).
Head : circumference, 52 cm. (20^ inches) ; length, 17*4
cm. (6|- inches)-; breadth, 14'2 cm. (5-j^ inches).
Chest round nipple-line, 73 cm. (28| inches) to 75 cm.
(29^ inches).
336 ATELEIOSIS
Abdomen at umbilicus, 69 cm. (27^ inches) .
Upper extremity ; acromia to elbow, 24*5 cm. (9|-
inches) ; external condyle to styloid process of radius, 22
cm. (8|- inches) ; hand, 17*5 cm. (6|^ inches).
Middle point of total height, 2 cm. above pubes.
Lower extremity : great trochanter to external condyle,
39 cm. (15|^ inches) ; external condyle to external mal-
leolus, 36*3 cm. (14|- inches) ; hand, 25*3 cm. (10 inches).
History . — The father is a "small-made man,^^ and
rather below the medium height. The mother and six
brothers and sisters are of average growth. There is a
brother of the age of thirteen who is 1*34 m. (4 feet
2|- inches) high. The mother believes that Martin was of
about the same height when he was of the same age. It
was noticed that Martin seemed to have stopped growing
at about that time. He was then just leaving school.
His mother cannot account for the circumstance, for he
was quite healthy at the time and has had no illness either
before or since.
General appearaoice, — The proportions and appearance
are those of a lad of fourteen years. He was at one time
shown at a meeting of the Eeading Pathological Society,
when nearly all those who were present judged him to be
of that age. His occupation was that of a farm boy. It
was not possible for him to get work as a man, and his
mother said that she always kept his certificate of birth in
hand, because no one would believe that he was other than
a boy until she had shown it. I myself first saw him
among the crowd at a village jumble sale, and at once
recognised that he was an instance of delayed develop-
ment. The skin of his face was more rough and weather-
worn than one ever sees in a youth, though his manner
and voice were in keeping with his size.
His intelligence was not good, though he answered
questions intelligently and seemed to have a fair memory.
He had passed the fourth standard at school, and could
read and write as well as most boys of his walk of life.
His mother told me that he was too stupid to do better
ATELEIOSIS 337
work than minding sheep, and that he was not worth the
3^. 6cZ. a week which was paid him. He was not quite so
strong as his brother of thirteen, and on having him
stripped it was evident that the muscles were not of good
size. He was, however, capable of working all day and
then taking a walk of four miles without feeling tired.
His hands and feet were rather large, and there was
slight kyphosis and lordosis of the spine. He was also
knock-kneed and flat-footed to the same degree, so that his
gait was somewhat awkward and shambling.
Though the skin of the body felt harsh and dry he said
that he sweated when he became over-heated. The hair
of his head was fine and thin. There was plenty of
lanugo over the body and limbs. His teeth were sound
and the dentition was regular. There was no sign of
syphilis either in the teeth or in any other part. His
appetite and digestion were good. He ate about as much
as is customary for a youth of his age. The bowels were
regular, the urine was of sp. gr. 1018 and was otherwise
normal. The special senses were of ordinary acuteness.
A radiogram of the right hand and wrist showed that the
ossification was equal to that of a youth of fourteen or
fifteen. The distal epiphyses of the radius and ulna which
usually unite at from eighteen to twenty years were still
separated by a narrow line of cartilage.
Auscultation of the heart revealed a slight basal systolic
murmur, but no other abnormality. The blood-corpuscles
counted by means of a Thoma-Zeiss haemocytometer showed
4,800,000 red discs to the c. mm., while the leucocytes were-
in the proportion of 1 to 450 red. These white cell&
appeared to be normal, but no stained specimen was.
examined.
The external genital organs were of the size and appear-
ance of those of a child of eight or nine years. There was
no pubic hair. The right testicle was descended, and the
left could be felt about half-way down the inguinal canal.
Testicular sensation was present, but there was no sign of
virility. He was of an unusually timid disposition and would
VOL. LXXXV. 22
338 ATELEIOSIS
never come to see me without his thirteen-year-old brother.
He was also very modest and greatly objected to exposure
of his body.
Less than three months after these observations were
made, Martin Lane was ailected with an illness which was
probably influenza. Pneumonia then set in and he was
seized with a series of eclampsic attacks, in one of which he
died. He was attended by Dr. Robinson, of Sonning, who
most kindly informed me of his death and assisted me to
make a post-mortem examination.
Result of post-mortem examination,— ^at was present in
ordinary proportions. The lymphatic glands of the an-
terior mediastinum were enlarged to the size of peas or
small beans. In other parts they could be detected with
difficulty. The lower lobes of both lungs and middle lobe
of the right were of a dark homogeneous plum colour, and
broke down easily on pressure with the thumb, exuding
quantities of frothy serum. There were no signs of
[ tubercles.
! The heart weighed 8^ oz. = 241*5 grms.
The mitral valves were crumpled and thickened with
atheroma, but seemed to be fairly efficient. An old
organised clot was present in the right ventricle and ex-
tended for some distance up the pulmonary artery. The
wall of the ventricle round the coronary artery of the
aorta was slightly atheromatous. A ductus arteriosus was
present but was not open. The thyroid gland weighed
179 grains = 11*5 grms. Its two lobes were separate, no
isthmus being present. Its structure was homogeneous,
and on microscopic examination nothing abnormal was
detected save a slight excess of interacinal fibrous tissue.
The brain weighed 2 lbs. 13 oz. = 1275 grms. No
abnormalitv could be detected.
The hypophysis cerebri was examined and appeared to
be in every way normal, but unfortunately through an
oversight it was not weighed or taken away for micro-
i scopical examination.
The stomach and intestines were normal.
338 ATELEIOSIS
never come to see me without his thirteen-year-old brother.
He was also very modest and greatly objected to exposure
of his body.
Less than three months after these observations were
made, Martin Lane was affected with an illness which was
probably influenza. Pneumonia then set in and he was
seized with a series of eclampsic attacks, in one of which he
died. He was attended by Dr. Robinson, of Sonning, who
most kindly informed me of his death and assisted me to
make a post-mortem examination.
Result of post-mortem examination.— ^Fsit was present in
ordinary proportions. The lymphatic glands of the an-
terior mediastinum were enlarged to the size of peas or
small beans. In other parts they could be detected with,
difficulty. The lower lobes of both lungs and middle lobe
of the right were of a dark homogeneous plum colour, and
broke down easily on pressure with the thumb, exuding
quantities of frothy serum. There were no signs of
tubercles.
The heart weighed 8^ oz. = 241*5 grms.
The mitral valves were crumpled and thickened with
atheroma, but seemed to be fairly efficient. An old
organised clot was present in the right ventricle and ex-
tended for some distance up .the pulmonary artery. The
wall of the ventricle round the coronary artery of the
aorta was slightly atheromatous. A ductus arteriosus was
present but was not open. The thyroid gland weighed
179 grains = 11*5 grms. Its two lobes were separate, no
isthmus being present. Its structure was homogeneous,
and on microscopic examination nothing abnormal was
detected save a slight excess of interacinal fibrous tissue.
The brain weighed 2 lbs. 13 oz. = 1275 grms. No
abnormalitv could be detected.
The hypophysis cerebri was examined and appeared to
be in every way normal, but unfortunately through an
oversight it was not weighed or taken away for micro-
scopical examination.
The stomach and intestines were normal.
Med. Chir. Trans., Vol. 85.
Gilfiyrd : Aleleiosis. PUile VII.
A
Case 12 — Sectiou through ossifjloR 1 t t
BBBii under \ objective
At the lower part of the drawing is ti >. pi-u l i u iiuil riiiiiiiii(,
at right anglea to it i3 the epiphysial (.actilagr dmd f ^ the epipbisia
(qq the left) from the diaphjsia (on the right)
Med. Chir. Trans., Vol. 1
Gilford : Atelei^»dH. Plate VIII.
ATELEIOSIS 339
The liver was not weighed.
The kidneys weighed 7|- oz. = 220'4 grms.
Supra-renal capsules weighed : spleen, 3^ oz. = 92*25
grms. ; pancreas, 2^ oz. = 63 grms.
All the abdominal organs were examined microscopically
and were found to be quite healthy, with the exception of
some recent small cell infiltration in the kidneys, and liver,
which was evidently the result of the illness from which
death resulted.
The testicles together weighed 15 grains (1 grm.) ; that
on the right side was still in the inguinal canal, and was
a little smaller than the left, which was descended.
A section of the left testicle was kindly examined for
me by Mr. McAdam Eccles, who reported that there was
no evidence of abnormality beyond the extreme delay of
development ; the organs resembled those met with in
^arly infancy.
The several parts of the sternum were still separated by
-cartilage, and there was a small ossification centre in the
ensiform cartilage ; the ribs showed no beading.
The clavicles were fully ossified, and their muscular
prominences were fairly well marked.
In the skull the frontal suture was obliterated, and the
different pieces of the temporal and occipital bones were
fused together, but the basi-sphenoid and basi-occipital
were ununited. The os innominatum was still divided into
its three constituent bones by thin lines of cartilage. The
lower epiphysis of the tibia was separated from the
diaphysis by a thin line of cartilage. A piece of this was
afterwards examined under the microscope.
Microscopical characters of zone of ossification, — ^A
section through the epiphysial cartilage of the lower end
of the left tibia when compared with PaltauFs description
of the epiphysial cartilage in his case shows the following
characters : — The cartilage extends under the periosteum
on the epiphysial side to such a distance that it probably
embraces the whole of the ossified part of the epiphysis.
The periosteum is, perhaps, a little thicker than normal.
340 ATELEIOSIS
The cancellous tissue of both the epiphysis and the
diaphysis has a very open meshwork, causing the section
to be extremely fragile and difficult to cut. The peripheral
layer of calcified cartilage is of very unequal thickness; it
consists of an irregular, shallow, abrupt, disconnected line,
lying between a thin layer of imperfectly ossified bone on
the one sjde, and the cartilage of the epiphysis on the other;
its stain (logwood) is intermediate in tint between that of
the bone and the cartilage ; its margin is very uneven
towards the bone and more even on the side of the cartilage.
The cartilage cells are small and scattered, and of irregu-
lar shape, becoming first slowly, and then rapidly larger and
rounder as they approach the diaphysis. Close to the
diaphysial border they are collected together into large,,
round, or oval encapsuled masses, which take the logwood
much better than any other part. A few of these masses
are piled into somewhat oblique, irregular columns.
Most of the columns are entirely surrounded by cartilage,
but here and there are spaces containing marrow-cells,
which are open towards the bone. Paltauf s stratum of
calcified cartilat>*o is so l)roken and indistinct that it is not
easy to define.
Case 13. — Di*. vSchniidt,^ of Munich, describes an instance
in Theresa Fend, a g'irl of the age of sixteen years, who
was of norniiil size for the first half of her life, and in her
ninth year was in bed for a fortni^-ht with a severe illness,
of which no details were obtainable.
From this time uTowth almost ceased, and at most did
not amount to more than 1 or 2 inches (2*5 or 5 cm.),
When Dr. Schmidt saw her at the aire of sixteen years she
hail the a]>]>oaranoe of a child of eiirht : this being the
tinu^ at which she first ii*aye eyidence of delayed irl^^^^th.
'I'ho crand]>aronts and two sisters were of normal size. She
was not miorooephalic, but. on the contrary, was of good
iutelliirenoe, well-proportioned, and of good muscular and
' * Zur Kouutuiss dos Zworvfwuohsos. Aivh. f. Anthix^p..' Bd. xx, 1S91,
8. o\>.
ATELEIOSIS 341
-fatty development. She had broad shoulders, a well-
formed thorax, and healthy lungs. There were no signs
of the approach of puberty, and no hair on the pubes or
armpits, though there waa plenty on the head. The
abdomen appeared to be inflated with gas, though there
was no sign of abdominal tumour or of ascites. The teeth
were of the permanent set, though the canines of the right
side were only just appearing through the gum. They
first appeared in the sixteenth year. The other teeth
appeared to be normal. Five molars were erupted, and
three others seemed to be about to break through. Her
height was 1160 mm. (3 feet 9|- inches), the height of an
average girl of her age in Bavaria being 1520 mm. (5 feet) .
A photograph of the girl is given with the article.
Doubtful Cases.
Mr. Hutchinson^ has described a case of apparent
ateleiotic dwarfdom in a young man. The condition was
associated with marked overgi*owth of the gums. He
was of the age of twenty- five, though he looked like a boy
of twelve. The testes and penis were like those of a
young child, while the voice was cracked and feeble, and
there was no sexual hair. He was of good intelligence.
A photograph which was taken of his face and head
showed no peculiarity of physiognomy, except that he
looked strongly prognathous, this appearance being due to
the overgrowth of the gums. There was no indication of
syphilis.
Dr. Kirk, of Glasgow,^ has described a case of imper-
fect development in a male aet. 22 years. He was 4 feet
•J- inch (123 cm.) high, and a radiogram showed that the
ossification was equal to that of a child of half his
age. Nothing is said of the state of the sexual organs.
^ "A Case of Hypertrophy of the Gums with General Dwarfdom."
Jonathan Hutchinson, F.R.S., 'Edin. Med. Journ./ n. s., vol. i. No. 2, p.
117.
- 'Lancet/ May 4th, 1901, vol. i, p. 1267.
330 ATELEIOSIS
also present, and the epiphyses of the crests of the ilia
and of the other parts of the ossa innominata were not
united. The cartilaginous lining of the acetabulum was
thicker than usual. The femora were slightly formed ;
their lower epiphyses being of about the same thicknees
as those of a child seven years old. The head of each femur
was small and shallow, and, with the neck, took a
direction from the shaft which made a smaller angle than
is usual with the child, but was more open than in the
adult. The epiphyses of the tibiae and fibulae were not
yet united. The patellae were of ordinary form and size,
and the bones of the feet, like those of the hand, corre-
sponded in ossification with those of a seven-year-old child.
Dr. Paltauf made a microscopical examination of the
epiphyses of several bones, and gives two illustrations of
sections through the ossifying zone of the lower end of a
femur. He found the periosteum thick and fibrillar. The
most conspicuous features of these sections were two strata
of calcified cartilage, one enveloping the diaphysial end,
and another (the thinner) the epiphysial end of the bone.
In cutting from below upwards through the epiphysial line,
the following parts were cut through. First, the cancellous
bone of the epiphysis with somewhat large marrow spaces
and thin ))()ny septa. Then a stratum of calcified cartilage,
abrupt, of a bluish colour, shallow, and of irregular depth, so
that in parts it was quite absent, the bone of the epiphysis
coming in contact with the cartilage. It contained large,
scattered, hyaline, and glistening cells, with oval or irregular
nuclei. Next came the cartilage of the epiphysial line
proper, which was hyaline, and, at this point, contained
scattered cells in small irregular groups separated from
each other bv fine striie of delicate fibrils. Some were
long spindle-cells with nuclei and nucleoli ; ))ut the deeper
cells showed much variation in size, form, and dis-
tribution. In the centre thev resembled those which are
found in the covering cartilage of joints. Those nearest
the epiphysis were larger, plainer, more numerous, and in
bigger groups. Some of them were long and spindle-
ATELEIOSIS 343
The transverse and other processes contained cartilaginous
patches, and isolated bone centres occurred in the epi-
physes of the yertebrae. The three bone centres of the
great trochanter were surrounded by cartilage. This
may have been an instance of ateleiosis combined with
osteomalacia, but it seems more probable that the condi-
tion was a form of infantilism, the direct result of osteo-
malacia beginning in a young subject.
Konig^s * case, which is quoted by Paltauf, was
that of a girl who died at the age of 18 years, from
" Cysticercus cerebri.^^ She was above the average height
of women and had a well-developed head. The bones of
the pelvis were very thick and spongy, and light in weight.
A Y-shaped cartilage separated each innominate bone
into its three constituent bones. The iliac bones were
greatly deformed. There was hypoplasia of the genital
organs, the breasts being as small as those of a child, the
mons veneris undeveloped and without hair, and the vagina
narrow. The uterus resembled that of a new-born child,
and the ovaries those of a girl of from 12 to 14 years.
Some osteo-chondromata were found growing fi#m the
pelvis. The bones of the pelvis seem to have been the
only bones examined.
This case may have been one of infantilism due to
osteomalacia, as in the previous case, but the extreme
hypoplasia of the sexual organs is suggestive of ateleiosis.
It is interesting that osteomalacia should have occurred
under such circumstances, seeing that removal of the
ovaries is of so great effect in curing osteomalacia. It is
also of interest in showing that it is possible for delay of
bone development to be associated with normal stature.
Paltauf also gives a few details of another case of
dwarfism, which seems to belong to this third class.
On referring to the original account, it is evident that
insufficient particulars were given to warrant its inclusion
in my list. This case is one which is described by Dr. F.
* ' Beschreibung eines kindlichen Beckens und kindlicher Gteschlechts-
theile von einem 18 Jahre alten Madchen/ Inaug-Diss.^ Marburg, 1855.
344 ATELEIOSIS
Rohrer,! of Zurich. The father was syphilitic, and the
mother was a tall woman who had died of phthisis.
The patient was a man of the age of twenty, well pro-
portioned, but thin, and looking old for his age. His
facial appearance was not very intelligent. He was
120 cm. (3 feet llj inches) high, and was normal at birth.
In the second, and again in the eleventh year, he fell on
his head, and in the twelfth year cut his head with a
hatchet. Since this last accident there was incontinence
of urine and " cessation ^^ of growth and development.
The voice remained a childish soprano. The sexual organs
were undeveloped, like those of a child from five to seven
years. There was no sign of sexual hair. The prepuce
covered the penis, and the testicles were quite rudimentary
on both sides.
In addition to these cases there are others which have
been referred to by Professor Quetelet,^ Sir G. M. Hum-
phry,* Dr. N. W. Kingsley,* Messrs. Gould and Pyle,^ and
some information may also be gathered from the Natural
Histor^ of Geoffrey St. Hilaire,^ and from certain semi-
scientific authors, such as E. Garnier,^ Le Roux and J.
Garnier,® and E. J. Wood.^ We have also the autobiography
of " Boruwlaski," ^° who was himself one of these dwarfs,
and a very candid account by Barnum.^^ Much that is
" popular " in these writings must be regarded with sus-
picion, but in some respects they may certainly be relied
upon. This is especially the case when no object is to be
gained by deceit, and when the tale told in one case tallies
with that told in another, or where it corresponds with
facts which are already known. I have also myself seen
many instances which have been exhibited at variety and
^ ' Virch. Arch/ Bd. ci, s. 197. ^ *Les Nains et les Geants/
2 ' Anthropometrie.* ^ * Acrobats and Mountebanks/
3 ' On the Skeleton/ » ' Giants and Dwarfs/
* 'Oral Deformities/ ^^ ' Memoirs of Count Boruwlaski/
^ 'Anomalies and Curiosities of Medicine/
« ' Histoire Naturelle/ i^ ' Life of P. O. Barnum/
DESCEIPTION OF PLATE IX.
Ateleiosis : a Disease characterised by Conspicuous Delay of Growth
and Development (Hastings Gilvobd, F.KG.S.Eno.).
Group of dwarfs showing features of ateleiosis of the second group.
1
o
3
5
X a
4
1
20
6
7
8
19
9, 10, 11
18
17
16
12,13
14 15
The features are those of stereotyped childhood. Hence the stature
is small, the limbs short, the head large, and the face broad and flat ;
the bridge of the nose is undeveloped, and the distance from the ear to
the vertex is unusually great. The facial type is so well defined in
some cases (Nos. 5, 9, 10, 11, 14, 15, 16) as to obliterate the natural
expression of character and produce a strong resemblance between
dwarfs of different families But added to these childish features are
the lines and superficial markings of age. In the case of No. 9 there is
facial hair, and in at least four others (Nos. 6, 11, 14, 15) there was
evidence of sexual maturity. All these dwarfs have been exhibited in
variety shows, and are or were of good intelligence.
The most noteworthy of the group are Charles Stratton (No. 14), who
was known as Tom Thumb, and his wife (No. 15) Lavinia Warren.
They are said to have had one child. Charles Stratton died in 1883 at
the age of 41. Minnie Warren (No. 11), sister of Lavinia, married
George Washington Nutt (No. 10), who died in 1881 at the age of
33 years. No. 9 is known as Baron Magri. Boruwlaski (No. 6) was
bom in Poland in 1739, and died at Durham in 1837, aged 98. He
married a lady of ordinary stature and had two children. He published
a " memoir " of his life. The photograph is from a portrait in oils in
the Hunterian Museum of London. No. 4 is the French dwarf described
on p. 320 ; and No. 17 is described on p. 316. Nos. 12, 13, 19, and 20 are
the German brothers Franz and Carl Bossow ; No. 4 is Annie Nelson,
and No. 16 the mulatto known as Chiquita.
Med. Chir. Trans., Vol, 1
II..M..I-. ,-i -y) .tiviiiU ,b..\viijy kn,!.ui-^, of atelGiosis oE tha second
^'raup, Tlieir pruportioiiH and facial cliacacters ara childish, ttongh
they nhnvi the superliciEil markings of age. The two htada at the
right hand lowtr corner ari! those of " Tom Tliumb " and his wife, and
the bust ill uniforin below the figure at the opposite corner is that of
Boruwlaaki.
DESCEIPTION OF PLATE IX.
Ateleiosis : a Disease characterised by Conspicuous Delay of Growth
and Development (Hastings Gilvosd, F.E.G.S.Eno.).
6boup of dwarfs showing features of ateleiosis of the second group.
1
o
3
5
X *
'
4
1
1
20
6
7
8
19
9, 10, 11
18
17
16
12,13
14 15
The features are those of stereotyped childhood. Hence the stature
is small, the limbs short, the head large, and the face broad and flat ;
the bridge of the nose is undeveloped, and the distance from the ear to
the vertex is unusually great. The facial type is so well defined in
some cases (Nos. 5, 9, 10, 11, 14, 15, 16) as to obliterate the natural
expression of character and produce a strong resemblance between
dwarfs of different families But added to these childish features are
the lines and superficial markings of age. In the case of No. 9 there is
facial hair, and in at least four others (Nos. 6, 11, 14, 15) there was
evidence of sexual maturity. All these dwarfs have been exhibited in
variety shows, and are or were of good intelligence.
The most noteworthy of the group are Charles Stratton (No. 14), who
was known as Tom Thumb, and his wife (No. 15) Lavinia Warren.
They are said to have had one child. Charles Stratton died in 1883 at
the age of 41. Minnie Warren (No. 11), sister of Lavinia, married
George Washington Nutt (No. 10), who died in 1881 at the age of
33 years. No. 9 is known as Baron Magri. Boruwlaski (No. 6) was
bom in Poland in 1739, and died at Durham in 1837, aged 98. He
married a lady of ordinary stature and had two children. He published
a "memoir" of his life. The photograph is from a portrait in oils in
the Hunterian Museum of London. No. 4 is the French dwarf described
on p. 320 ; and No. 17 is described on p. 316. Nos. 12, 13, 19, and 20 are
the German brothers Franz and Carl Eossow ; No. 4 is Annie Nelson,
and No. 16 the mulatto known as Chiquita.
I
ATELEI0SI8 345
other shows, some oi which I hare been able to examine.
From all these different sources it is possible to piece
together a fairly connected account of the disease. Its
main clinical and anatomical features may be summed up
BjS follows :
Part II.
» General Description of Ateleiosis.
Etiology, — In Dr. Schmidt's case (No. 13), in which
dwarfism began at the age of eight years, there appears to
have been some indication of a definite disturbance of health
at the onset, but no details of the illness were obtainable. In
one other instance arrest of growth seems to have dated from
injury. This instance is reported by Rohrer : there had
been three accidents to the head, but the case is not one of
unquestionable Ateleiosis. There is no satisfactory evidence
of the taint of syphilis in any of the cases. I can find no
instance of its direct transmission from parent to offspring,
though it undoubtedly occurs as a family disease among
brothers and sisters. Boruwlaski was one of a family of
dwarfs, and the wife of Charles Stratton, who was un-
doubtedly ateleiotic, had a sister who was a "midget."
The conclusion that we arrive at is that the actual cause
of the disease is unknown.
Facial and general appearance. — These vary with the
age of onset of the disease. In its most characteristic
form, i. e, when it begins during infancy or early child-
hood, ateleiosis may probably be invariably recognised by its
remarkable perpetuation of childish characters. The head is
large in comparison with the rest of the body, and is broad
and high. The extremities are, as a rule, short, and the
middle point of the body is therefore, as in childhood,
above the pubic symphysis. The relative length of the
segments of the limbs is also like those which are notice-
able in childhood. The facial type is so distinctly childish
that it is probable that ateleiotic dwarfs of the second class
may be distinguished from all other dwarfs by their
346 ATELEIOSIS
pKysiognomy alone. The face is broad and flat. The
nose is undeveloped, especially at the bridge, iand is, as a
rule, retrousse. The voice is usually thin or piping, and
may be so high pitched as to be squeaky. It has appeared
to me to be more treble among females than among males.
In no case does there seem to have been any growth of
hair on the face, and in none has there been any baldness.
From these general features it will be understood that
these dwarfs are very like one another in appearance.
They resemble each other in the same way that one baby
resembles another baby. Their features lack that variety
which is ordinarily produced by age, and which is, ta
a large extent, due to one part of the face growing more
rapidly than another part. But, while the grosser features
change very little, those finer changes, which mark the
progress of age, appear to continue as in ordinary indi-
viduals. The face of a middle-aged ateleiotic dwarf of
well-marked type is such as we may imagine would result
if the features of an infant remained stereotyped through
the succeeding periods of life. It retains its childish form
while it undergoes the wrinkling and weathering of age.
Indications of age are also present in the internal organs,,
as in Schaaffhausen^s case (No. 5), in which death occurred
at sixty-one.
0-sseous' and mu.sridar S'l/stems. — The most conspicuous^
feature of the bones is the marked delay in the process of
ossification. This is shown in three ways — by the late
api)earance of the centres of ossification, by their delayed
fusion, and by lack of vigour of bone growth generally.
The last is manifested in the smallness and delicacy of the
bones, especially of the long bones, and in the ill-develop-
inent of the muscular prominences.
On the other hand, Paltauf, in his account of his case,
draws special attention to the prominence of the lines and
ridges of bone produced by the attachment of muscles
But these do not show very conspicuously in his portrait
of the skeleton, and it is perhaps right to infer that he is
comparing the skeleton, not with a man of the same age,.
ATELEIOSIS 347
but with a child of the same size. These bony prominences
probably vary greatly in accordance with the variation in
the size of the muscles, but, as a rule, are more marked
than is usual in children, and less marked than in adults.
They are very different from the exaggerated lines and
eminences which are seen in rickets. The different mani-
festations of osseous feebleness do not keep pace with one
another, for it will invariably be found that the age, as
determined by the ossification of the epiphyses, is in
advance of that which is indicated by the height and pro-
portions of the skeleton. The discrepancy is not, as a
rule, great, but is noticeable in every case in which the
state of epiphysial ossification is mentioned.
Muscular development is usually proportionate to the size.
Martin Lane (Case 12) at twenty-eight was not so strong as
his brother of fourteen. On the other hand, in one case that
I have seen, the strength was undoubtedly excessive, but
this was probably accounted for by the fact that the dwarf
in question had been trained to perform as a " strong
man.^^ His shoulders and upper extremities were dispro-
portionately big. It is also possible that the prominence
of the bony eminences upon which Paltauf lays stress in
his description of the skeleton of Mikolajek were to be
explained by some exceptional growth of the muscles.
But, as a rule, dwarfs of this type seem to be little, if at
all, stronger than the children of their own size, though
they are possessed of much greater powers of endurance.
Many of them are skirt-dancers or actors, and all of those
which I have seen have been able to carry on their work
without undue effort and without detriment to health.
Dentition, — The teeth are, as a rule, decidedly backward
in development, though they are of ordinary size. In some
cases they are well preserved, and are regular in form and
situation. In these it will, I think, be noticed that they
have undergone but little wear, indicating that they have
not long erupted, as was noticed in Paltauf s case. Room
is then found for them in the diminutive jaw by the non-
appearance of the back molars. In other instances they are.
ATELEI0SI8 345
other shows, some oi which I have been able to examine.
From all these different sources it is possible to piece
together a fairly connected account of the disease. Its
main clinical and anatomical features may be summed up
AS follows :
Part II.
• General Descrijption of Ateleiosis,
Etiology, — In Dr. Schmidt^s case (No. 13), in which
dwarfism began at the age of eight years, there appears to
have been some indication of a definite disturbance of health
at the onset, but no details of the illness were obtainable. In
one other instance arrest of growth seems to have dated from
injury. This instance is reported by Rohrer : there had
been three accidents to the head, but the case is not one of
unquestionable Ateleiosis. There is no satisfactory evidence
of the taint of syphilis in any of the cases. I can find no
instance of its direct transmission from parent to offspring,
though it undoubtedly occurs as a family disease among
brothers and sisters. Boruwlaski was one of a family of
dwarfs, and the wife of Charles Stratton, who was un-
doubtedly ateleiotic, had a sister who was a "midget."
The conclusion that we arrive at is that the actual cause
of the disease is unknown.
Facial and general appearance, — These vary with the
age of onset of the disease. In its most characteristic
form, i, e, when it begins during infancy or early child-
hood, ateleiosis may probably be invariably recognised by its
remarkable perpetuation of childish characters. The head is
large in comparison with the rest of the body, and is broad
and high. The extremities are, as a rule, short, and the
middle point of the body is therefore, as in childhood,
above the pubic symphysis. The relative length of the
segments of the limbs is also like those which are notice-
able in childhood. The facial type is so distinctly childish
that it is probable that ateleiotic dwarfs of the second class
may be distinguished from all other dwarfs by their
346 ATELEIOSIS
physiognomy alone. The face is broad and flat. The
nose is undeveloped, especially at the bridge, and is, as a
rule, retrousse. The voice is usually thin or piping, and
may be so high pitched as to be squeaky. It has appeared
to me to be more treble among females than among males.
In no case does there seem to have been any growth of
hair on the face, and in none has there been anv baldness.
From these general features it will be understood that
these dwarfs are very like one another in appearance-
Thev resemble each other in the same wav that one babv
resembles another babv. Their features lack that varietv
which is ordinarily produced by age, and which is, to
a large extent, due to one part of the face growing more
rapidly than another part. But, while the grosser features
change very little, those finer changes, which mark the
progress of age, appear to continue as in ordinary indi-
viduals. The face of a middle-aged ateleiotic dwarf of
well-marked type is such as we may imagine would result
if the features of an infant remained stereotj-ped through
the succeeding periods of life. It retains its childish form
while it undergoes the wrinkling and weathering of age.
Indications of age are also present in the internal organs,
as in Schaaffhausen^s case (Xo. o), in which death occurred
at sixtv-one.
0'S.s-eou.s' and miiscidar s-t/stems. — The most conspicuous
feature of the bones is the marked delay in the process of
ossification. This is shown in three wavs — bv the late
appearance of the centres of ossification, by their delayed
fusion, and by lack of vigour of bone growth generally.
The last is manifested in the smallness and delicacv of the
bones, especially of the long bones, and in the ill-develop-
ment of the muscular prominences.
On the other hand, Paltauf, in his account of his case,
draws special attention to the prominence of the lines and
ridges of bone produced by the attachment of muscles
But these do not show very conspicuously in his portrait
of the skeleton, and it is perhaps right to infer that he is
comparing the skeleton, not with a man of the same age,,
ATELEIOSIS 347
but with a child of the same size. These bony prominences
probably vary greatly in accordance with the variation in
the size of the muscles, but, as a rule, are more marked
than is usual in children, and less marked than in adults.
They are very different from the exaggerated lines and
eminences which are seen in rickets. The different mani-
festations of osseous feebleness do not keep pace with one
another, for it will invariably be found that the age, as
determined by the ossification of the epiphyses, is in
advance of that which is indicated by the height and pro-
portions of the skeleton. The discrepancy is not, as a
rule, great, but is noticeable in every case in which the
state of epiphysial ossification is mentioned.
Muscular development is usually proportionate to the size,
Martin Lane (Case 12) at twenty-eight was not so strong as
his brother of fourteen. On the other hand, in one case that
I have seen, the strength was undoubtedly excessive, but
this was probably accounted for by the fact that the dwarf
in question had been trained to perform as a " strong
man.^^ His shoulders and upper extremities were dispro-
portionately big. It is also possible that the prominence
of the bony eminences upon which Paltauf lays stress in
his description of the skeleton of Mikolajek were to be
explained by some exceptional growth of the muscles.
But, as a rule, dwarfs of this type seem to be little, if at
all, stronger than the children of their own size, though
they are possessed of much greater powers of endurance.
Many of them are skirt-dancers or actors, and all of those
which I have seen have been able to carry on their work
without undue effort and without detriment to health.
Dentition, — The teeth are, as a rule, decidedly backward
in development, though they are of ordinary size. In some
cases they are well preserved, and are regular in form and
situation. In these it will, I think, be noticed that they
have undergone but little wear, indicating that they have
not long erupted, as was noticed in Paltauf s case. Room
is then found for them in the diminutive jaw by the non-
appearance of the back molars. In other instances they are.
•'348 ATELEIOSIS
more or less, irregularly disposed, as was the case in " Tom
Thmnb/^ whose jaw was examined by Dr. N. W. Kingsley,^
who fomid " a most marked mal-position of the teeth, so
much so, that he had a double row of teeth all round/^
In the case of Bobbie Fenwick, who died after the age of
fifty, dentition was very irregular, owing to the late
eruption of several of the teeth. A third variety is found
in some of the younger ateleiotic dwarfs, where the milk
teeth persist side by side with the permanent ones, as was
seen in my third case.
Nervous system, — The size of the head varies greatly,
though, as a rule, it does not come far short of that of the
average adult.
According to Quetelet, the circumference of the head of
a,n adult male measures 564 mm. (22^ inches). Martin Lane
(No. 12) was 520 mm. (20^ inches), in SchaafEhausen^s
case (No. 5) the bare skull was of this same measurement,
and in Manouvrier^s (7) it reached to 530 mm. (20|- inches),
but in my second case (female) it was so low as 445 mm.
{VI i^ inches). Sir G. M. Humphry says that the circum-
ference of the cranium of an adult male is 525 mm. (20|-
inches), and this is not much more than the 505 mm. (19|-
inches) of the skull of Bobbie Fen^vick. The variation in
these measurements must largely depend upon the age at
which the disease begins. Thus, in my third case, in which
the disease seems to have commenced during the first year,
the skull was smaller than it was in my second case, where
it began in the second year. In the case of Caroline
Crachami, in which the disease began during foetal life, we
have the smallest measurement of all (349 mm.). On the
other hand, we notice that in Dr. Schmidt's case (No. 13),
the skull of Theresa Fend had a circumference of only 505
mm. (19-J inches), which was the same as that of the bare
skull of Bobbie Fenwick, though ateleiosis did not begin
until the age of eight years. These variations are probably
• such as occur under normal circumstances in the sizes of
different skulls.
1 ' A Treatise on Oral Deformities/ p. 8.
ATELEIOSIS 349'
It is not easy to say whether the intelligence of these-
dwarfs is greater than usual, but there can be no doubt
whatever that it is, as a rule, in no way defective. They
are very quick in comprehension, have good memories, and
usually appear to have but little difficulty in learning-
foreign languages. Some have, undoubtedly, possessed
mental abilities above the average.
Thus, Boruwlaski ^vrote an autobiography which was^
excellent, both in composition and style. Jacob Lehman
was regarded in his time as a great artist, and Geoffrey
Hudson was thought to be possessed of sufficient ability
to be employed as a confidential messenger to the French
Court by Charles I. The intelligence, however, is not
always good, for Martin Lane (No. 12) was certainly some-
what deficient in this respect.
Sexual system, — The sexual organs are markedly un-
developed. This is true of every case in which these
organs are mentioned. Indeed, the genitals are decidedly
more backward than the rest of the body. This I have
noted in my second case, and in Schaaffhausen^s case (No. 4)
there was cryptorchism of both sides. On the other hand,,
we have it on excellent authority that Boruwlaski married
and became the father of three children. He writes with
so much candour and simplicity that in reading his auto-
biography it is not easy to doubt his statements on this
subject. In one of his portraits he is represented with
his wife and one child. Yet this, and other portraits
of him, one of which is in the Hunterian Museum,
corroborate the impression which is conveyed by his
memoir that he was undoubtedly an ateleiotic dwarf.
" Tom Thumb,^^ again, married a dwarf of the same
kind as himself, who is said to have given birth to a
child of average size who died in infancy. It is quite
possible that there was some deception in this case.
It may be observed, moreover, that the appearance and
proportions of " Tom Thumb '' and his wife, as shown in
their photographs, are conspicuously infantile. We cannot,
therefore, believe that it is possible for dwarfs of this
350 ATELEIOSIS
type to be virile until the evidence is stronger than it
now is.
Condition of other organs, — There was some indication
of disturbance of the heart in my third case. In the
absence of other causes I attributed it to some congenital
anomaly. Such an anomaly existed in Case No. 12, when
a permanent but not patent ductus arteriosus was found
^fter death. The mitral valves were crumpled and
thickened.
The thyroid gland in Paltauf s case (No. 6) was small
and pale red in colour. In my second case it seemed to
be small, and at one time there appeared to be evidences
of its defective action. In my third case, and again in
Case No. 12, the gland was undoubtedly of good develop-
ment.
The pituitary body was enlarged in Paltauf s case
(No. 6), the sella turcica of Mikolajek being bigger even
than that of the normal adult. Unfortunately Paltauf
says nothing of the condition of the pituitary body itself.
Still more unfortunately I myself failed to obtain this organ
for microscopical examination at the necropsy (Case 12),
though I noticed it appeared to be quite natural. In both
of the skeletons I have examined (Cases No. 1 and 5)
there was no disproportion in the size of the sella turcica.
Schaaffhausen does not mention the subject. It is there-
fore probable that there was no conspicuous abnormality
of the pituitary body in his case (No. 6). Dr. Byrom
Bramwell found evidences of defective action of the
pancreas in the case of infantilism which he examined.
There is no evidence of disorder of the thymus, spleen,
lymphatic glands, bone marrow, or of the suprarenal bodies.
Bate of growth. — Strictly speaking, it is not true that
ateleiotic dwarfs are stereotyped children, even if we regard
them from the physicial aspect alone, for gro^vtli changes
take place which are of the same nature as those which
occur in ordinary individuals, though they are much less
in degree, and extend over a much longer period. Never-
theless, it seems certain that a time arrives after which
ATELEIOSIS 351
they grow no further, though this may vary in dif-
ferent cases. Thus it is explicitly stated of Boruwlaski
that he ceased to grow at the age of thirty ; while Geoffrey
Hudson is said to have remained of the height of
18 inches (45*8 cm.) from the age of eight until the age of
thirty, after which period he increased to 3 feet 9 inches
(114*5 cm.), and then grew no further. No reliance can
be placed upon the accuracy of these figures, but of the
general circumstance of the cessation of growth before the
attainment of average stature there seems to be no question.
It is true that Joachimsthal shows that in one of his cases
(No. 8), in which the age was thirty-six years, there had
been noticeable increase in height since the age of thirty-
three, yet no one has reported any case in which growth
has continued after the age of forty ; and the skeleton of
Bobbie Fenwick shows that growth of the skeleton had
practically ceased at about the age of fifty.
Duration of life, — " Tom Thumb " was said to be fifty-
three when he died, and his companion, ^^ Commodore '^
Nutt, forty-one ; Paltauf's case lived to forty-nine years.
There seems to be good evidence that ateleiotic dwarfs
may live to a ripe old age. Thus Geoffrey Hudson is
said to have lived to the age of sixty-two, while it is stated
that Boruwlaski did not die until he had reached the age
of ninety-eight. He was born in 1739, and was buried
near to Stephen Kemble, in Durham Cathedral, in 1837.
Diagnosis.
The only diseases with which ateleiosis is likely to be
confounded are those which retard growth and develop-
ment. The chief of these are cretinism and myxcedema,
syphilis, mongolianism, mitral disease, achondroplasia,
rickets, microcephaly, and normal infantilism.
Cretinism, myxoedema, mongolianism, and microcephaly
are distinguished by the fact that they affect the intelli-
gence. It is, of course, quite possible for an ateleiotic
dwarf to be an imbecile, but in that event the lack of in-
!
352 ATELEIOSIS
telligence is not part of the disease, but is one of those-
accidental accompaniments which may be met with in
association with any disease. The only exception to this-
is to be found in those instances of ateleiosis which com-
mence during intra-uterine life, and of which one example
has been given (Case No. 1). But in that case the imbecility
was the natural outcome of the very early period at which
the disease began'. The head was not disproportionately
small, but was, on the contrary, a little too large for the-
body.
Cretinism and myxcedema, when well marked in tha
living subject, show characters which are quite unmistak-
able, but it is possible that the skeleton of a cretin may be-
very difficult to distinguish from the skeleton of an
ateleiotic dwarf. There may be delay of development in
both cases, and it seems that in cretinism this delay may
be quite as conspicuous as it is in ateleiosis ; but, as a*
rule, the skeleton of the cretin is not only immature, but
is deformed, especially in the bones of the lower ex-
tremities. The long bones are thick, " the pelvis may be-
narrow as in rickets.^^ Microscopically " Grawitz found
in a typical case that all signs of columnar formation of
the cartilage cells were absent.^^ ^ Difficulties would arise
of a still more puzzling nature should cretinism or
myxcedema be associated with ateleiosis. This is by no
means unlikely, for in one of my cases there were-
myxoedematous symptoms, and cases are sometimes re-
ported as cretinism in which the intelligence is good. In
these mixed cases it is possible that nothing but the
history would be of any avail in coming to a decision as
to the diagnosis, and it is also possible that the twcr
diseases may be so intermingled that no one could say
which has the priority.
Ricliets and achondrojdasia produce so much deformity
that it is not likely that either of them can be mistaken
for ateleiosis. • The proportionate development of ateleiotia
dwarfs, their well-formed figures, good intelligence, and
1 * Diseases of the Thyroid Gland/ Dr. Murray, p. 99.
ATELEIOSIS 353
conspicuous immaturity, cause them to stand apart from all
diseases, which by affecting one part of the skeleton more
than another part produce manifest disproportion in size.
Syphilis. — Mr. Hutchinson ^ says that " in certain
cases arrest of growth occurs as a consequence of the in-
herited taint, and the patient remains a dwarf .^^ " In
most of these cases it would appear that there is arrest of
sexual development also, but this is not invariable."
Professor Fournier has paid a good deal of attention to
this manifestation of congenital syphilis. On turning to
the account of his observations^ it is evident that the
infantilism which is produced by syphilis is not so con-
spicuous as that which we meet with in ateleiosis. Pro-
fessor Fournier gives measurements of six cases, and the
shortest of them (1*33 m.) was, at the age of eighteen,
much taller than the tallest of those who are in my second
class. Moreover, development continues in these syphilitic
cases until in course of time it is completed. They are
not ateleiotic, because they do ultimately reach maturity.
Menstruation or virility may be delayed " until the seven-
teenth, eighteenth, or nineteenth years, or even later."
There appears to be some growth of sexual hair on the face
or body. Lastly, the infantilism of syphilis seems to
produce no special type of face, unless it be the type which
is produced by the syphilis itself. Not one of the cases
of ateleiosis I have seen has shown the usual evidences of
the syphilitic taint.
Infantilism, — The word infantilism has been much used
by French writers to signify arrested or retarded develop-
ment. Though it is not a happy designation when applied
to development which has become arrested during late
childhood or youth, yet it is very convenient. Some such
word is as much needed to express defective development,
as the word dwarfism is needed to express defective growth.
But it is unfortunate that some writers use the word as if
it denoted a disease. Infantilism is not a disease, but a con-
* * Twentieth Century System of Medicine/ vol. xviii, p. 390.
« ' Le Syph. Hered. Tardus/ 1886, p. 26.
VOL. LXXXV. 23
354 ATELEIOSIS
dition or symptom. Thus Brissaud,^ who says the word was
introduced by Lasegue and Brouardel, applies it to a con-
dition which resulted from myxoedema. Lacomme ^ uses it
for that form of immaturity which sometimes accompanies
congenital heart disease, and is generally believed to be
produced by defective nutrition. Lacomme is, however,
of the opinion that the relation is not causal, and Giraudeau ^
and Ferrannini,'* in describing other cases, express the
same opinion. It has also been shown that infantilism
may be an occasional feature of achondroplasia, and
hydrocephalus. It may sometimes result from imperfect
development of the sexual organs. It is possible that some
of these cases are cases of ateleiosis combined with con-
genital heart disease, cretinism, or other disorder. But
unless the facial, sexual, and osseous features of ateleiosis
are well marked, such cases must at present be put on one
side and not included among those of ateleiosis.
There is one other condition to which the word infantil-
ism is appropriate, and that is a condition which may be
termed normal infantilism. We recognise that growth
varies greatly, and that it sometimes becomes excessive
without being morbid. Just in the same way as there are
normal giants, so there may be normal dwarfs, and in
some of these dwarfs there is not only delay or arrest of
growth but also of development. These constitute instances
of normal infantilism. I am indebted to Mrs. Keith and
Miss Keith for permission to examine one of the most
striking cases of this condition which I have yet seen.
This case was that of a girl of the age of fifteen years and
a half, whose stature was no greater than that of a girl of six,
whose ossification and dentition corresponded to that of a girl
of eleven, and whose sexual development was not more ad-
vanced than that which is usual at twelve. Though there
appeared to be no cause for this condition it could be
* ' Le9ons sur des Mai. Nerv./ p. 606, Paris, 1895.
-2 ' Loire Med.,* March 15th, 1899, p. 63.
3 * Arch. General de Med.,' tome viii, p. 547.
4 ' Kiforma Medica,' December 7th, 1800, pp. 162, 375, 687,
Med. Chir. Trnns , Vo
Nnriu^t hifniililhiii. (iirl of 15J (mi tbe ri^lit) compared
with Qoraial girl at b\. In ordinary luEantilism there is no
peculiar type of faca, while tho delay o! development is nut
so abrupt or i;QaKpicuous as it is in that special form of
loIaiitiliEm. which is termed AteleJosis. Note that in thin
case though the stature ia about ten years behindhand, the
carriage, facial expression, proportions of the hady, aad
development of the pelvis and sexual organs are not far
short of those which are uaual in girU of her a^e. See page
li
■I
I
I
t
,
i
i
I
ATELEIOSIS 355
distinguished from the cases of ateleiosis which have been
recorded in the following particulars : — There was no
special type of face ; the girl resembled her mother in
appearance. * The proportions . of the body were adult
rather than childish, the middle point being at the pubic
symphysis, while the extremities were comparatively long.
The intelligence was fully equal to that of most girls of her
age. Lastly, though the condition had been first noticed
when she was between two and three years old, the delay
of development was not very conspicuous, and, above all,
the pelvis and sexual organs were by no means infantile.
Pathology.
There can be no doubt that the most conspicuous feature
of the condition, of which these cases are examples, is the
delay of growth and development.
Now, the question we have to ask ourselves is, does
this delay affect the whole body simultaneously, or
does it, like cretinism, originate in one organ, and from
thence produce a secondary effect upon the rest of the
bodv ?
At first it seems much more natural to look upon it as a
primary affection of the body as a whole. In fact, this
view seems to be taken by most of those who write upon
the subject of these dwarfs, though it is true that
Schaaffhausen is the only author who expressly states this
opinion. But on examining the cases a little closer it soon
becomes evident that we have to deal not with a physio-
logical variation, but with, a disorder. The process is not
altogether uniform, for some parts are more affected than
others ; there is far greater variation than ever exists in
health. Moreover, the hindrance to development is, as has
already been shown, far too abrupt and pronounced to
constitute a normal infantilism.
Having settled that ateleiosis is a disease, we have next
to find out which organ or part is responsible for its
appearance. The organs which we regard with most
suspicion are the sexual organs, the thyroid gland, the
356 ATELEIOSIS
pituitary body, and the skeleton. It is also possible that
the pancreas, the heart, or some other organ may play a
part in the production of the malady, but inasmuch as their
disorder is only occasional,. and is certainly not a common
feature, we can dismiss them. They may be causes of
infantilism, but cannot be causes of ateleiosis.
Now, of all the organs which have been mentioned, the
sexual organs seem to be most worthy of our attention.
They were markedly backward in development in all the
cases which have been reported. Moreover, we know that
arrest of development of these organs does have an effect
on growth. Those who are so circumstanced are some-
times of small stature, and of poor development generally.
Indeed, some authorities ^ recognise an infantile type as the
result of sexual ill-development. Further, those who are
sexually precocious are nearly always also of premature
development in other respects. Thus, I have now under
observation a girl who began to menstruate when two and
a half years old. At four her height and weight were
equal to those of a girl of double her age, and on taking a
radiogram of her hand it was found that ossification was
also equal to that of a girl of eight. The sexual develop-
ment was like that of a girl who was commencing
puberty. If premature sexual development can give rise
to so groat acceleration of growth, it seems not improbable
that tlic opposite condition of sexual immaturity may be
capable of producing as striking an effect in hindering
growth.
On the otlier hand, we know that the infantilism
which sonictinics results from sexual ill-development is but
slight in degree, and that such a condition as ateleiosis has
never been known to result from removal of the sexual
organs of children. The fact that ateleiosis may occur in
two or throe menil)ers of the same family makes it exceed-
ingly iniproba1;le that the disease may be a very rare and
exce])tional result of this malformation. Such a coinci-
^ Dr. ¥. J. McCann, * Amor. Juvirn. Mod. Sci./ vol. cxii. No. 4, October,
181)0, p. ai)L\
ATBLEIOSIS 357
dence would be almost too extraordinary to be possible.
Moreover instances have been given of the procreation of
children by these dwarfs. I myself have seen two of
these sexually mature cases.
Mr. Hutchinson is of the opinion that the cause of this
form of dwarfism will probably be found in some disorder
of the pituitary body. We know that gigantism sometimes
results from disease of this organ, and it is not improbable
that some other affection of the same part, or a similar
affection occurring in early life, might give rise to a dis-
order of an opposite nature. In support of this view is the
fact that both acromegaly and ateleiosis are associated with
imperfections of the sexual apparatus. Moreover, in Pal-
tauf s case (No. 6), disease of the pituitary body was actually
present,* though we know nothing of its nature. The only
indication of its presence was the very large size of the
sella turcica. On the other hand, in the four other cases
of ateleiosis, Nos. 1, 5, 6, and 12, which have been
examined after death, no enlargement of the sella turcica
or of the pituitary body was noticed. The sella turcica
was certainly not abnormal in the three post-mortem cases
which I have described.
Paltauf does not so much as mention the possibility of
ateleiosis being due to some general anomaly of growth,
but apparently takes it for granted that it must necessarily
be, in the first place, a disease of the bones only. It is
his opinion that the disease is confined to those bones
which are of cartilaginous origin, and that it does not affect
the membrane bones. In support of this view, he alludes
to a case of Professor His', in which the bqnes of the skull
continued to grow while the brain did not. This case,
however, was one of cretinism, not of ateleiosis. But in
infantile life ossification is naturally much more advanced
in membrane than in cartilage bones, and the apparent
difference to which Paltauf alludes must surely be due to
this cause, and not to the exercise of any selection by the
disease. In the same way we can explain the " cretinoid "
type of face, which is also referred to by Paltauf.
358 ATELEIOSIS
The following considerations are in favour of Paltauf s
view that the afEection is primarily one of the skeleton.
When the growth of the skeleton is prematurely stopped,
as in rickets and achondroplasia, the muscles and other
soft parts do not continue to grow as if the skeleton were
normal, but, on the contrary, the growth of the soft tissues
becomes adapted to that of the underlying bones. May not
the disease with which we are now dealing be due to delay
not of growth only, but of development as well, followed by
a similar adaptation of the development of the soft parts ?
In other words, is ateleiosis a primary hypoplasia of the
skeleton ? And does the general immaturity merely indi-
cate a physiological effort on the part of the soft structures
to keep pace with this disorder of the skeleton ? A great
objection to this view is the fact that, if we may judge
from the state of the epiphyses, the development of the
bones is not less than, but is in advance of that of the
soft parts; whereas were the disease primarily of the
bones, to which the soft parts have accommodated them-
selves, we should expect the reverse. Moreover, there is
evidence that the anomaly of the sexual organs may
precede that of the skeleton by some years.
It is not yet possible to come to any conclusion as to
the causation and nature of ateleiosis. The disease must,
at present, be regarded as a form of infantilism. Yet it
cannot be considered a sexual infantilism, that is, an
infantilism produced by imperfect development of the
sexual organs; for it seems clear that the sexual defect
when it exists is not the cause of the general delay of
development, but is merely its precursor. Moreover that
form of infantilism which is known to be produced by
maldevelopment of the sexual organs is quite distinct from
ateleiosis.
Now infantilism is a condition which is associated with
many abnormalities. Thus, in Mr. Hutchinson^s doubtful
case of ateleiosis, the infantilism was combined with hyper-
plasia of the gums. Similarly, in Dr. Thomson^s case, thymic
hypertrophy was present ; while, in Paltauf 's doubtful case.
ATE1.EI08IS :359
there was ORtcomalacia. Dr. Byrom Bramwell has ex-
hibited a patient in whom the infantilism wan attributed tu
defective action of the pancreas, and Dr. Bryant has shown
me the records of ci case in which infantilism coexisted with
pscu do-hyp ertrophic palsy In Bobbie Fenwick's skeleton
there was some curious anomaly of the mandible, and in
Martin Lane the same tendency to anomalous manifestations
of development showtd itself in the presence of a persistent
though not p^tent ductus arteriosus. Lastly, in the case of
Mikalojek theiewasen]arg;ement of the pituitary body. It
seems not unlikely that in some instances in which infantilism
is attributed to congenital heart disease or imperfect action
of the thyroid gland, the relation between those conditions
is not in reality one of cause and effect, but is due to
some such similar association. There is, apparently, some
common factor, with the nature of which we are as yet
unacquainted. All that can be said is that in ateleiosis
there ia defective development of the body as a whole, that
this is often preceded by hypoplasia of the sexual organs,
and is prone to be associated with some growth anomaly of
other parts.
I
INDEX
I%e Indices to the annual volumes are made on the same principle as,
and are in continuation of, the General Index to the first ffty-three volumes
of the ' Transactions.* They are inserted in the Library copy^ where the
entire Index to the current date may altoays he consulted.
ABSCESS of liver: Contribution to study of tropical abscess
of liver (R. J. Godlee) . . .119
Acland, T. D., M.D. : Discussion on modern methods of vaccina-
tion . . . .272
ALKAPTONURIA (A. E. Garrod, M.D.) . . 69
ANEURYSM of arch of aorta: Two cases of ligature of left
carotid for aneurysm of arch of aorta ; post-mortem
specimens of four cases (C. Heath) . . 79
Annual Meeting : Proceedings at Annual Meeting, March 1st,
1902 .... Ixxxvii
AORTA (aneurysm of) : Two cases of ligature of left carotid
for aneurysm of arch of aorta ; post-mortem specimens
of four cases (C. Heath) . . .79
ARTERY (left carotid) : Two cases of ligature i'or aneurysm
of arch of aorta (C. Heath) . . .79
ATELEIOSIS : Disease characterised by conspicuous delay
in growth and development (H. Gilford) . 305
BALLANCE, Charles, and 8TUABT, Pttrves, M.D,
Clinical and experimental observations, introducing a dis-
cussion on the regeneration of peripheral nerves : an
address, with lantern and microscopical demonstra-
tions ..... 283
Discussion (p. 293) : Professor C. S. Sherrington, Dr. R.
Kennedy, Dr. R. A. Fleming, Mr. W. Thorburn.
Adjourned Discussion (p. 295) : Professor J. N. Langley,
Dr. F. W. Mott, Mr. Mayo Robson, Dr. W. Aldren
Turner, Mr. Rickman J. Godlee, Dr. F. E. Batten, Mr.
Ballance (reply), Dr. Purves Stuart (reply).
VOL. LXXXV. 24
354 ATELEI08IS
dition or symptom. Thus Brissaud,^ who says the word was
introduced by Lasegue and Brouardel, applies it to a con-
dition which resulted from myxcEdema. Lacomme* uses it
for that form of immaturity which sometimes accompanies
congenital heart disease, and is generally believed to be
produced by defective nutrition. Lacomme is, however,
of the opinion that the relation is not causal, and Giraudeau ^
and Ferrannini,* in describing other cases, express the
same opinion. It has also been shown that infantilism
may be an occasional feature of achondroplasia, and
hydrocephalus. It may sometimes result from imperfect
development of the sexual organs. It is possible that some
of these cases are cases of ateleiosis combined with con-
genital heart disease, cretinism, or other disorder. But
unless the facial, sexual, and osseous features of ateleiosis
are well marked, such cases must at present be put on one
side and not included among those of ateleiosis.
There is one other condition to which the word infantil-
ism is appropriate, and that is a condition which may be
termed normal infantilism. We recognise that growth
varies greatly, and that it sometimes becomes excessive
without l)eiiig morbid. Just in the same way as there are
normal giants, so tliere may be normal dwarfs, and in
some of these dwarfs there is not only delay or arrest of
growth l)ut also of doyelo])nient. These ccmstitute instances
of normal infantilism. I am indel)ted to Mrs. Keith and
Miss Keith for ])onnission to examine one of the most
strikin<2r cases of this condition which I have yet seen.
This case was that of a girl of the age of fifteen years and
a half, whose stature was no greater than that of a girl of six, li
whose ossification and dentition corresponded to that of a girl
of eleven, and whoso sexual development was not more ad-
vanced than that which is usual at twelve. Though there
appeared to be no cause for this condition it could be
* ' Lemons sur dcs Mai. Nerv./ p. 006, Paris, 1895.
'^ ' Loire Med.,' March 15th, 1899, p. 63.
3 * Arch. General de Med.,' tome viii, p. 547.
4 ' Riforma Medica,' December 7th, 1800, pp. 162, 375, 687.
INDEX 363
CANCER (of breast) : Analysis of forty-six cases operated on
and surviving operation from five to. thirty-five years ;
treatment of recurrent growths, including disease of
second breast (T. Bryant) . . .43
Cantlie, James : Discussion on tropical abscess of the liver 143
CAPE COLONY : Leprosy in (J. Hutchinson, F.R.S.) . 161
Carless, A. : Discussion on ligature of left carotid for aneurysm
of arch of aorta . . . .91
CAROTID (left) : see Artery.
Cavafy, John, M.D. : obituary notice . . . cv
CHOLEDOCHOTOMY in treatment of obstruction in common
bile-duct by concretions (A. W. Mayo Robson) . 93
Churchill, F., M.D. : Discussion on modern methods of vaccina-
tion . . . .280
CLIMATOLOGY (medical) and Balneology of Great Britain :
Report of Committee . . . xc
Cope, Albert E. : Discussion on modern methods of vaccina-
tion . . . . .279
OOPEMAN, 8. MoncMon, M.D.
Modern methods of vaccination, and their scientific basis :
an address .... 243
Discussion (p. 271) : Dr. Leonard Dobson, Professor Sims
Woodhead, Dr. T. D. Acland, Professor Haccius.
Adjouraed discussion (p. 278) : Dr. Sidney Coupland,
Dr. Albert E. Cope, Mr. William F. Blake, Dr. F.
Churchill, Dr. Bernard O'Connor, Dr. Copeman (reply).
Council : Report of Council . . Ixxxvii
Coupland, Sidney : Discussion on modern methods of vaccina-
tion . . . . .278
Crombie, Alexander, M.D. : Discussion on tropical abscess of
the liver ..... 143
Dent, Clinton T. : Discussion on ulceration of stomach and
oesophagus . . . .35
— Discussion on case of intestinal obstruction due to
pressure of vesical calculus upon coil of small intestine
42
DEVELOPMENT AND GROWTH, conspicuous delay in
(ateleiosis) (H. Gilford) . . .305
DILATATION, acute, of stomach (H. Campbell Thomson,
M.D.) . . . 1
364 INDEX
Dobsou, Leonard : Discussion ou modern methods of vaccina-
tion ..... 271
Drysdale, J. H., M.D. : Discussion on malignant endocarditis
242
Duckworth, Sir Dvce : Discussion on surgical treatment of
obstruction in common bile-duct by concretions . llO
Durrant, Christopher Mercer, M.D. : obituary notice . civ
ENDOCARDITIS, malignant: possibility of recovery from
active stage of (W. Ewart, M.D., and A. S. Morley)
189
EWART, William, M.D., and MOELEY, A. 8.
The j)Ossibility of recovery from the active stage of malig-
nant endocarditis, illustrated by cases and specimens
189
For discussion see end of Dr. Poynton and Dr. Paine's
paper (pp. 239 et seq.).
Fleming, R. A. : Discussion on regeneration of peripheral
nerves ..... 294
Gr ALL-STONES : surgical treatment of obstruction in common
bile-duct by concretions, with especial reference to
choledochotomy (A. W. Mayo Robsoii) . . 93
GABBOD, ArcJiihald E.
About alkaptonuria . . . .69
Discussion (p. 78) : Dr. C. Theodore Williams, Dr. W. A.
Osborne, Dr. G-arrod (reply).
GILFOBD, Hastings.
Ateleiosis : a disease characterised by consj^icuous delay in
growth and development . . . 305
GOD LEE, Eichman J.
A contribution to the study of tro2)ical abscess of the liver
119
Discussion (p. 143) : Dr. Patrick Hanson, Dr. A. Crombie,
Mr. Cantlie, Dr. W. Gr. Rockwood, Mr. Godlee (reply).
— Discussion ou surgical treatment of obstruction in
common bile-duct by concretions . .111
— Discussion on regeneration of peripheral nerves . 300
GROWTH AND DEVELOPMENT, conspicuous delay in
(ateleiosis) (H. Gilford) . . .305
Haccius, Professor : Discussion on modern methods of vaccina-
tion . . . . .277
Hansen, G. A. : Dijieussion on leprosy . 182, 183, 185
INDEX 365
Harrison, Reginald ; Discussion on case of intestinal obstruction
due to pressure of vesical calculus upon coil of small in-
testine . . . . .37
Haward, J. Warrington : Discussion on ulceration of stomach
and oesophagus . . . .35
HEATH, Christopher.
Two cases of ligature of the left carotid for aneurysm of
the arch of the aorta, with the ppst-morteiii specimens of
four cases . . . . .79
Discussion (p. 91) : Mr. A. Carless, Dr. Frederick T.
Eoberts, Mr. R. Barwell, Mr. T. R. H. Bucknall, Mr.
Heath (replj).
Heron, George Allan, M.D. : Discussion on leprosy . 185
Herringham, W. P., M.D. : Discussion on acute dilatation of
stomach . . . . . . 21
Hi llier, Alfred, M.D. : Discussion on leprosy . . 186
Holthouse, Carsten: obituary notice . . . cvi
HUTCHINSON. Jonathan, F.B.S,
Leprosy in Natal and Cape Colony . . 161
Discussion (p. 182) : Dr. G. A. Hansen, Dr. George Thin,
Dr. Patrick Man son, Sir William R. Kynsey, Sir Lauder
Brunton, Dr. T. M. Young, Dr. Heron, Dr. Alfred
Hillier, Mr. Tonkin (reply), Mr. Hutchinson (reply).
HYDROCHLORIC ACID (strong) : swallowing causing ulcera-
tion of oesophagus and stomach (C. B. Keetley) . 23
INTESTINE (obstruction) due to pressure of vesical sacculus
upon coil of small intestine (T. Bryant) . . 37
Jackson, Thomas Vincent, F.R.C.S.Edin. : obituary notice eviii
Keay, J. H. : Discussion on surgical treatment of obstmction
in the common bile-duct by concretions . 112
KEETLEY, C. B.
Ulceration of the oesophagus and stomach due to swallow-
ing strong hydrochloric acid : lessons of treatment
deduced from three cases . . . 123
Discussion (p. 35) : Mr. E. Percy Paton, Mr. Clinton Dent,
Mr. J. Warrington Haward, Mr. Keetley (reply).
Kennedy, R. : Discussion on regeneration of peripheral nerves
293
Kynsey, Sir William R., C.M.G. : Discussion on leprosy . 184
Langley, Professor J. N. : Discussion on regeneration of
peripheral nerves . . . .295
366 INDEX
Lees, D. B., M.D. : Discussion on inalignaut endocarditis 239
LEPEOSY in Natal and Cape Colony (J. Hutchinson, F.E.S.)
161
— in the Sudan (T. J. Tonkin) . . .145
LIGrATURE of left carotid for aneurysm of arch of aorta (C.
Heath) . .- . . .79
Liver, abscess (tropical) : contribution to study of tropical
abscess of liver (E,. J. Godlee) . .119
MiicCormac, Sir William, Bart., K.C.B., K.C.V.O., F.E.C.S.
cxiii
Manson, Patrick, C.M.Gr., M.D. : Discussion on tropical abscess
of liver ..... 143
— Discussion on leprosy . . . 183
MOBLEY, A. S., and EWABT, William, M.D.
The possibility of recovery from the active stage of malig-
nant endocarditis, illustrated by cases and specimens
189
For Discussion see end of Drs. Poynton and Paine's paper
(pp. 239 et seq.).
Mott, F. W., M.D., F.E.S. : Discussion on regeneration of peri-
pheral nerves .... 296
NATAL, Leprosy in (J. Hutcbinson, F.E.S.) . . 161
NEEVES (Peripheral) : Clinical and experimental observations
on regeneration of (C. Ballance and Purves Stewart,
M.D.y . . .283
Obituary Notice.^ af deceased Fellow.^ of the Society, 1901-2:
Barrow, Benjamin, MacCormac, Sir William,
F.K.C.S. . . . ci Hart., K.C.B., K.C.V.O.,
Cavafy, John, M.D. . cv F.K.C.S cxiii
Durrant, Christopher Saunders, Sir Edwin,
Mercer, M.D. . . civ F.K.C.S cii
Holthouse, Carsten. Smith, Henry Spencer,
F.K.C.S. . . . cvi F.K.C.S cxi
Jackson, Thomas Vin- Sutherland, Henry, M.D. . cxii
cent, F.K.C.S.Edin. . cviii Weir, Arthur Nesham, MD. cxxi
OBSTEUCTION in ooninion bile-duct by concretions; surgical
treatment- with especial reference to choledocliotomy
(A. W. Mayo Eobson) . . .93
— (intestinal) due to pressure of vesical sacculus upon
coil of small intestine (T. Bryant) . . 37
INDEX 367
O'Connor, Bernard, M.D. : Discussion on modern methods of
vaccination .... 280
(ESOPHAGUS : Ulceration of oesophagus and stomach due to
swallowing strong hydrochloric acid : treatment (C. B.
Keetley)' . ' . . . .23
Osborne, W. A. : Discussion on alkaptonuria . . 78
PAINE, Alexander, M.B., and POYNTON, F. /., M.D.
A contribution to the study of malignant endocarditis
211
Discussion (p. 239) : Dr. A. E. Sansom, Dr. D. B. Lees,
Dr. G. Newton Pitt, Dr. F. Parkes Weber, Dr. E. W. A
Walker, Dr. J. H. Drysdale, Dr. William Blake, Dr.
Poynton (reply). Dr. Paine (reply). v^
Paterson, Herbert : Discussion on surgical treatment of obstruc-
tion of common bile-duct by concretions . .114
Paton, E. Percy : Discussion on ulceration of stomach and oeso-
phagus . . . . .36
Pavy, Frederick William, M.D., F.E.S. : Address as President
at the Annual Meeting, March 1st, 1902 . . xcix
— Discussion on acute dilatation of the stomach . 21
PEEIPHEEAL NEEVES: see J^erves (peripheral).
Pitt, G. Newton, M.D. : Discussion on malignant endocarditis
240
POYNTON, F. J., M.D., and PAINE, Alexander, M.D.
A contribution to the study of malignant endocarditis
211
Discussion (p. 239) : Dr. A. E. Sansom, Dr. D. B. Lees,
Dr. G. Newton Pitt, Dr. F. Parkes Weber, Dr. E. W. A.
Walker, Dr. J. H. Drysdale, Dr. William Blake, Dr.
Poynton (reply). Dr. Paine (reply).
EECUEEENT GEOWTHS after operation for cancer of
breast : treatment, operative and otherwise (T. Bryant)
43
EEGENEEATION of peripheral nerves : Clinical and experi-
mental observations on (C.Ballance and Purves Stewart,
M.D.) . . . . .283
Eoberts, Frederick T., M.D. : Discussion on ligature of left
carotid iox aneurysm of arch of aorta . . 91
368 INDEX
B0B80N, A. W. Mayo.
The surgical treatment of obstruction in the comiiion bile-
duet bj concretions, with especial reference to the opera-
tion of choledochotomy as modified by the author, illus-
trated by sixty cases . . . .93
Discussion (p. 110) : Sir Dyce Duckworth, Mr. Godlee,
Dr. J. H. Keay, Dr. H. A. Caley, Mr. Butler-Smythe,
Mr. Herbert Paterson, The President (Mr. Alfred
Willett).
(p. 115) Author's remarks on paper read in his absence.
— Discussion on regeneration of peripheral nerves . 297
Rockwood, William Grabriel : Discussion on tropical abscess of
the liver ..... 143
SACCULUS, vesical, causing intestinal obstruction by pressure
on small intestine (T. Bryant) . . 37
Sansora, A. E., M.D. : Discussion on malignant endocarditis
239
Saunders, Sir Edwin, F.E.C.S. : obituary notice . cii
SCIENTIFIC BASIS of modern methods of vaccination (S.
Monckton Copeman, M.D.) . . . 243
Sherrington, Professor C. S., F.R.S. : Discussion on regenera-
tion of peripheral nerves . . . 293
Smith, Henry Spencer, F.E.C.S. : obituary notice . cxi
STEWART, Purves, M,D., and BALLANCE, Charles.
Clinical and experimental observations introducing a dis-
cussion on the regeneration of peripheral nerves : an
address, with lantern and microscopical demonstration
283
Discussion (p. 293) : Professor C. S. Sherrington, Dr. E.
Kennedy, Dr. E. A. Fleming, Mr. W. Thorburn.
Adjourned discussion (p. 295) : Professor J. N. Langley,
Dr. F. W. Mott, Mr. Mayo Eobson, Dr. W. Aldren
Turner, Mr. Eickman J. Grodlee, Dr. F. E. Batten, Mr.
Ballance (reply), Dr. Purves Stewart (reply).
STOMACH: dilatation, acute (H. Campbell Thomson, M.D.) 1
— ulceration of oesophagus and stomach due to swallow-
ing strong hydrochloric acid; treatment (C. B. Keetlev)
23
SUDAN (The) : leprosy in (T. J. Tonkin) . . 145
Sutherland, Henry, M.D. : obituary notice . . cxii
INDEX 369
Thin, Greorge, M.D. : Discussion on leprosy . . 182
THOMSON, H. Campbell M,T),
Acute dilatation of the stomach, witji illustrative
cases . . . . .1
Discussion (p. 21) : Dr. T. E. Bradshaw, Dr. W. P. Her-
rin^ham, Dr. Arthur Voelcker, The President (Dr. F. W.
Pavy), Dr. Campbell Thomson (reply).
Thorbum, W : Discussion on regeneration of peripheral
nerves ..... 295
TONKIN, T.J.
Some general and etiological details concerning leprosy in
the Sudan .... 145
For Discussion see end of Mr. Jonathan Hutchinson's
paper (pp. 182 et seq.)
Treasurers' Eeport :
Statement of Cash Eeceipts and Payments . xc
— of Liabilities and Assets . . . xcv
Income and Expenditure account . . xciv
Turner, W. Aldren, M.D. : Discussion on regeneration of peri-
pheral nerves .... 299
ULCEEATION of oesophagus and stomach due to swallowing
strong hydrochloric acid ; treatment (C. B. Keetley) 23
VACCINATION : modern methods of vaccination and their
scientific basis (S. Monckton Copeman, M.D.) . 243
Voelcker, Arthur, M.D. : Discussion on acute dilatation of the
stomach . . . . .21
Walker, E. W. Ainley, M.D. : Discussion on malignant endo-
carditis ..... 241
Weber, F. Parkes, M.D. : Discussion on malignant endocarditis
241
Weir, Arthur Nesham, M.D. : Obituary notice . . cxxi
Willett, Alfred: Discussion on surgical treatment of obstruc-
tion of common bile-duct by concretions . 115
Williams, C. Theodore, M.D. : Discussion on alkaptonuria 78
Woodhead, Professor G. Sims, M.D. : Discussion on modern
methods of vaccination . . .271
Young, T. M. : Discussion on leprosy . . 185
PBINTBD BY ADLAKD AND SON, BARTHOLOMBW CLOSE.
VOL. LXXXV. 25
INDEX
The Indices to the annual volumes are made on the same principle as,
and are in continuation of, the General Index to the first fifty-three volumes
of the * Transactions.* They are inserted in the Library copyy where the
entire Index to the current date may always be consulted.
ABSCESS of liver: Contribution to study of tropical abscess
of liver (R. J. Godlee) . . .119
Acland, T. D., M.D. : Discussion on modern methods of vaccina-
tion ..... 272
ALKAPTONURIA (A. E. Garrod, M.D.) . . 69
ANEURYSM of arch of aorta: Two cases of ligature of left
carotid for aneurysm of arch of aorta ; post-mortem
specimens of four cases (C. Heath) . . 79
Annual Meeting : Proceedings at Annual Meeting, March 1st,
1902 .... Ixxxvii
AORTA (aneurysm of) : Two cases of ligature of left carotid
for aneurysm of arch of aorta; post-mortem specimens
of four cases (C. Heath) . . .79
ARTERY (left carotid) : Two cases of ligature tor aneurysm
of arch of aorta (C. Heath) . . .79
ATELEIOSIS : Disease characterised by conspicuous delay
in growth and development (H. Gilford) . 305
BALLANCE, Charles, and 8TUABT, Ptirves, M.D.
Clinical and experimental observations, introducing a dis-
cussion on the regeneration of peripheral nerves : an
address, with lantern and microscopical demonstra-
tions ..... 283
Discussion (p. 293) : Professor C. S. Sherrington, Dr. R.
Kennedy, Dr. R. A. Fleming, Mr. W. Thorburn.
Adjourned Discussion (p. 295) : Professor J. N. Langley,
Dr. F. W. Mott, Mr. Mayo Robson, Dr. W. Aldren
Turner, Mr. Rickman J. Godlee, Dr. F. E. Batten, Mr.
Ballance (reply), Dr. Purves Stuart (reply).
VOL. LXXXV. 24
362 INDEX
Banks, Sir William Mitchell : Discussion on results of opera-
tion for cancer of the breast . . . &7
Barrow, Benjamin, F.R.C.S. : obituary notice . ci
Barwell, E. : Discussion on ligature of left carotid for aneurysm
of arch of aorta . . . .92
Batten, Frederick E., M.D. : Discussion on regeneration of
peripheral nerves .... 300
BILE-DUCT: Surgical treatment of obstruction in common
bile-duct by concretions, with especial reference to chole-
dochotomy (A. W. Mayo Eobson) . . 93
BLADDER : Vesical sacculus causing intestinal obstruction by
pressure on small intestine (T. Bryant) . . 37
Blake, William, M.D. : Discussion on malignant endocarditis
242
— Discussion on modern methods of vaccination , 280
Bradshaw, T. R., M.D. : Discussion on acute dilatation of the
stomach . . . . .21
BREAST (cancer) : Analysis of forty-six cases operated on and
surviving operation from five to thirty-five years ; treat-
ment of recurrent growths including disease of second
breast (T. Bryant) . . . .43
Brunton, Sir Lauder, M.D., F.R.S. : Discussion on leprosy
185
BEY ANT, Thomas,
Case of intestinal obstruction due to the pressure of a
vesical sacculus upon a coil of small intestine . 37
Discussion (p. 42) : Mr. Reginald Harrison, Mr. Clinton
Dent.
— An analysis of forty-six cases of cancer of the breast
which have been operated on and survived the operation
from five to thirty-five years ; with remarks upon the
treatment of recurrent growths, including the disease of
the second breast, operative and otherwise . 43
Discussion (p. Q*7) : Sir William Banks.
Mr. Bryant (reply) . . . .67
Bucknall, T. R. H. ; Discussion on ligature of left carotid for
aneurvsm of arch of aorta . . .92
Butler- Smy the, A. C. : Discussion on surgical treatment of
common bile-duct by concretions . .113
Caley, H. A., M.D. : Discussion on surgical treatment of
obstruction of common bile«duct by concretions . 113
INDEX 363
CANCER (of breast) : Analysis of forty-six cases operated on
and surviving operation from five to. thirty-five years;
treatment of recurrent growths, including disease of
second breast (T. Bryant) . . . .48
Cantlie, James i Discussion on tropical abscess of the liver 143
CAPE COLONY : Leprosy in (J. Hutchinson, F.R.S.) . 161
Ccirless, A. : Discussion on ligature of left carotid for aneurysm
of arch of aorta . . . .91
CAROTID (left) : see Artery.
Cavafy, John, M.D. : obituary notice . . . cv
CHOLEDOCHOTOMY in treatment of obstruction in common
bile-duct by concretions (A. W. Mayo Robsou) . 93
Churchill, F., M.D. : Discussion on modern methods of vaccina-
tion . . . . .280
CLIMATOLOGY (medical) and Balneology of Great Britain :
Report of Committee . . . xc
Cope, Albert E. : Discussion on modern methods of vaccina-
tion ..... 279
GOPEMAN, 8. MoncUon, M.D.
Modern methods of vaccination, and their scientific basis :
an address .... 243
Discussion (p. 271) : Dr. Leonard Dobson, Professor Sims
Woodhead, Dr. T. D. Acland, Professor Haccius.
Adjouraed discussion (p. 278) : Dr. Sidney Coupland,
Dr. Albert E. Cope, Mr. William F. Blake, Dr. F.
Churchill, Dr. Bernard O'Connor, Dr. Copeman (reply).
Council : Report of Council . . Ixxxvii
Coupland, Sidney : Discussion on modern methods of vaccina-
tion ..... 278
Crombie, Alexander, M.D. : Discussion on tropical abscess of
the liver ..... 143
Dent, Clinton T. : Discussion on ulceration of stomach and
oesophagus . . . .35
— Discussion on case of intestinal obstruction due to
pressure of vesical calculus upon coil of small intestine
42
DEVELOPMENT AND GROWTH, conspicuous delay in
(ateleiosis) (H. Gilford) . . .305
DILATATION, acute, of stomach (H. Campbell Thomson,
M.D.) . . . 1
364 INDEX
Dobsou, Leonard: Discussion ou modern methods of vaccina-
tion ..... 271
Drysdale, J. H., M.D. : Discussion on malignant endocarditis
242
Duckworth, Sir Dyce : Discussion on surgical treatment of
obstruction in common bile-duct by concretions . 110
Durrant, Christopher Mercer, M.D. : obituary notice . civ
ENDOCAEDITIS, malignant : possibility of recovery from
active stage of (W. Ewart, M.D., and A. S. Morley)
189
EWABT, William, M.D., and MOELEY, A. S,
The ])Ossibility of recovery from the active stage of malig-
nant endocarditis, illustrated by cases and specimens
189
For discussion see end of Dr. Poynton and Dr. Paine's
paper (pp. 239 et seq.).
Fleming, R. A. : Discussion on regeneration of peripheral
nerves ..... 294
GALL-STONES: surgical treatment of obstruction in common
bile-duct by concretions, with especial reference to
cboledochotomy (A. W. Mayo Eobson) . . 93
GABBOD, Archihald E.
About alkaptonuria . . . .69
Discussion (p. 78) : Dr. C. Theodore Williams, Dr. W. A.
Osborne, Dr. Oarrod (reply).
GILFOBD, Hastings.
Ateleiosis : a disease characterised by consj^icuous delay in
growth and development . . . 305
GOD LEE, Bichman J.
A contribution to the study of tropical abscess of the liver
119
Discussion (p. 143) : Dr. Patrick Hanson, Dr. A. Crombie,
Mr. Cantlie, Dr. W. Gr. Eockwood, Mr. Grodlee (reply).
— Discussion ou surgical treatment of obstruction in
common bile-duct by concretions . . Ill
— Discussion on regeneration of peri})heral nerves . 300
GEOWTH AND DEVELOPMENT, conspicuous delay in
(ateleiosis) (H. Gilford) . . .305
Haccius, Professor : Discussion on modern methods of vaccina-
tion ..... 277
Hansen, G. A. : DJjscussion on leprosy . 182, 183, 185
INDEX 365
Harrison, Keginald : Discussion on case of intestinal obstruction
due to pressure of vesical calculus upon coil of small in-
testine . . . . .37
Haward, J. Warrington : Discussion on ulceration of stomach
and oesopliagus . . . .35
HEATH, Christopher.
Two cases of ligature of the left carotid for aneurysm of
the arch of the aorta, with the ppst-mortein specimens of
four cases . . . . .79
Discussion (p. 91) : Mr. A. Carless, Dr. Frederick T.
Roberts, Mr. E. Barwell, Mr. T. E. H. Bucknall, Mr.
Heath (reply).
Heron, George Allan, M.D. : Discussion on leprosy . 185
Herringham, W. P., M.D. : Discussion on acute dilatation of
stomach ... . . .21
Hillier, Alfred, M.D. : Discussion on leprosy . . 186
Holthouse, Carsten: obituary notice . . . cvi
HUTCHINSON, Jonathan, F.B.8,
Leprosy in Natal and Cape Colony . . 161
Discussion (p. 182) : Dr. G. A. Hansen, Dr. George Thin,
Dr. Patrick Man son. Sir William E. Kynsey, Sir Lauder
Brunton, Dr. T. M. Young, Dr. Heron, Dr. Alfred
Hillier, Mr. Tonkin (reply), Mr. Hutchinson (reply).
HYDEOCHLOEIC ACID (strong) : swallowing causing ulcera-
tion of oesophagus and stomach (C. B. Keetley) . 23
INTESTINE (obstruction) due to pressure of vesical sacculus
upon coil of small intestine (T. Bryant) . .37
Jackson, Thomas Vincent, F.E.C.S.Edin. : obituary notice eviii
Keay, J. H. : Discussion on surgical treatment of obstruction
in the common bile-duct by concretions . 112
KEETLEY, C. B.
Ulceration of the oesophagus and stomach due to swallow-
ing strong hydrochloric acid : lessons of treatment
deduced from three cases . . . 123
Discussion (p. 35) : Mr. E. Percy Paton, Mr. Clinton Dent,
Mr. J. Warrington Haward, Mr. Keetley (reply).
Kennedy, E. : Discussion on regeneration of peripheral nerves
293
Kynsey, Sir William E., C.M.G. : Discussion on leprosy . 184
Langley, Professor J. N. : Discussion on regeneration of
peripheral nerves .... 295
366 INDEX
Lees, D. B., M.D. : Discussion on malignaut endocarditis 239
LEPROSY in Natal and Cape Colony (J. Hutchinson, F.E.S.)
161
— in the Sudan (T. J. Tonkin) . . .145
LIGATURE of left carotid for aneurysm of arch of aorta (C.
Heath) .- . . .79
Liver, abscess (tropical) : contribution to study of tropical
abscess of liver (R. J. Godlee) . . 119
MjicCormac, Sir William, Bart., K.C.B., K.C.V.O., F.R.C.S.
cxiii
Manson, Patrick, C.M.G., M.D. : Discussion on tropical abscess
of liver ..... 143
— Discussion on leprosy . . . 183
MOBLEY, A, 8., and EWABT, William, M.D.
The possibility of recovery from the active stage of malig-
nant endocarditis, illustrated by cases and specimens
189
For Discussion see end of Drs. Poyuton and Paine's paper
(pp. 239 et seq.).
Mott, F. W., M.D., F.R.S. : Discussion on regeneration of peri-
pheral nerves .... 296
NATAL, Lei)rosy in (J. Hutchinson, F.R.S.) . . 161
NERVES (Peripheral) : Clinical and experimental observations
on regeneration of (C. Ballance and Purves Stewart,
M.D.)^ . . . .283
Obituary Noticeff of deceased Fellows (tf the Society, 1901-2:
BarroAv, Benjamin, MacCi)rmac, Sir William,
F.K.C.S. . . . ci Bart., K.C.B., K.C.V.O.,
Cavafy, John, M.D. . cv F.K.C.IS cxiii
Durrant, Christopher Saunders, Sir Edwin,
Mercer, M.D. . . civ F.K.C.S cii
Ilolthouse, Carsten, Smith, Henry Spencer,
F.K.C.S. . . . cvi F.R.C.S cxi
Jackson, Thomas Vin- Sutherland, Henry, M.D. . cxii
cent, F.K.C.S. Edin. . cviii Weir, Arthur Nesham, M.D. cxxi
OBSTRUCTION in common bile-duct bv concretions ; surgical
treatment witli especial reference to clioledocliotomy
(A. W. Mayo Robsou) . . .93
— (intestinal) due to pressure of vesical sacculus upon
coil of small intestine (T. Bryant) . . 37
INDEX 367
O'Connor, Bernard, M.D. : Discussion on modern methods of
vaccination .... 280
(ESOPHAGUS : Ulceration of oesophagus and stomach due to
swallowing strong hydrochloric acid : treatment (C. B.
Keetley)' . ' . . . .23
Osborne, W. A. : Discussion on alkaptonuria . . 78
PAINE, Alexander, M.B., and FO YNTON, F. /., M.D.
A contribution to the study of malignant endocarditis
211
Discussion (p. 239) : Dr. A. E. Sansom, Dr. D. B. Lees,
Dr. a. Newton Pitt, Dr. F. Parkes Weber, Dr. E. W. A
Walker, Dr. J. H. Drysdale, Dr. William Blake, Dr.
Poynton (reply), Dr. Paine (reply). \^
Paterson, Herbert : Discussion on surgical treatment of obstruc-
tion of common bile-duct by concretions . .114
Paton, E. Percy : Discussion on ulceration of stomach and oeso-
phagus . . ... .35
Pavy, Frederick William, M.D., F.R.S. : Address as President
at the Annual Meeting, March 1st, 1902 . . xcix
— Discussion on acute dilatation of the stomach . 21
PERIPHERAL NERVES: see J^erves (peripheral).
Pitt, G. Newton, M.D. : Discussion on malignant endocarditis
240
POYNTON, F. J., M.B., and PAINE, Alexander, M.D.
A contribution to the study of malignant endocarditis
211
Discussion (p. 239) : Dr. A. E. Sansom, Dr. D. B. Lees,
Dr. G. Newton Pitt, Dr. F. Parkes Weber, Dr. E. W. A.
Walker, Dr. J. H. Drysdale, Dr. William Blake, Dr.
Poynton (reply). Dr. Paine (reply).
RECURRENT GROWTHS after operation for cancer of
breast : treatment, operative and otherwise (T. Bryant)
43
REGENERATION of peripheral nerves : Clinical and experi-
mental observations on (C. Ballance and Purves Stewart,
M.D.) . . . . .283
Roberts, Frederick T., M.D. : Discussion on ligature of left
carotid for aneurysm of arch of aorta . . 91
368 INDEX
B0B80N, A, W. Mayo,
The surgical treatment of obstruction in the comiiion bile-
duct by concretions, with esjDecial reference to the opera-
tion of choledochotomy as modified by the author, illus-
trated by sixty cases . . . .93
Discussion (p. 110) : Sir Dyce Duckworth, Mr. Godlee,
Dr. J. H. Keay, Dr. H. A. Caley, Mr. Butler-Smythe,
Mr. Herbert Paterson, The President (Mr. Alfred
Willett).
(p. 115) Author's remarks on paper read in his absence.
— Discussion on regeneration of peripheral nerves . 297
Eiockwood, William Q-abriel : Discussion ou tropical abscess of
the liver ..... 143
SACCTJLUS, vesical, causing intestinal obstruction by pressure
on small intestine (T. Bryant) . .37
Sansora, A. E., M.D. : Discussion on malignant endocarditis
239
Saunders, Sir Edwin, P.R.C.S. : obituary notice . cii
SCIENTIFIC BASIS of modern methods of vaccination (S.
Monckton Copeman, M.D.) . . . 243
Sherrington, Professor C. S., F.E..S. : Discussion on regenera-
tion of peripheral nerves . . . 293
Smith, Henry Spencer, F.E..C.S. : obituary notice . cxi
STEWART, Purves, M,D., and BALLANCE, Charles.
Clinical and experimental observations introducing a dis-
cussion on the regeneration of peripheral nerves : an
address, with lantern and microscopical demonstration
283
Discussion (p. 293) : Professor C. S. Sherrington, Dr. E.
Kennedy, Dr. R. A. Fleming, Mr. W. Thorburn,
Adjourned discussion (p. 295) : Professor J. N. Langley,
Dr. F. W. Mott, Mr. Mayo Robson, Dr. W. Aldren
Turner, Mr. Rickman J. G-odlee, Dr. F. E. Batten, Mr.
Ballance (reply), Dr. Purves Stewart (reply).
STOMACH: dilatation, acute (H. Campbell Thomson, M.D.) 1
— ulceration of oesophagus and stomach due to swallow-
ing strong hydrochloric acid; treatment (C. B. Keetlev)
23
SUDAN (The) : leprosy in (T. J. Tonkin) . . 145
Sutherland, Henry, M.D. : obituary notice . . cxii
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