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MEDICOCHIRTJRGICAL
TRANSACTIONS.
ITRUSIIET) BV
THE EOYAL
MEDICAL AND CHIRURGICAL SOCIETY
OF
LONDON.
VOLUME THE THIRTY-FOURTH.
LONDON :
LONGMAN, BROWN, GREEN, AND LONGMANS,
PATERNOSTER-ROW.
1851.
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MEDIC0-CH1RURGICAL
TRANSACTIONS.
rrr.usHED by
THE EOYAL
MEDICAL AND CHIRURGICAL SOCIETY
OF
LONDON.
SECOND SERIES.
VOLUME THE SIXTEENTH.
LONDON :
LONGMAN, BROWN, GREEN, AND LONGMANS,
PATERNOSTER-ROW.
1851.
EOYAL
MEDICAL AND CHIKURGICAL SOCIETY
OF LONDON.
PATRON.
THE QUEEN.
OFFICERS AND COUNCIL,
ELECTED MARCH 1, 1851.
VICE-PRESIDENTS.
TREASURERS.
SECRETARIES.
LIBRARIANS
OTHER MEMBERS
OF THE COUNCIL.
PRESIDENT.
JOSEPH HODGSON F.R.S.
f THOMAS MAYO, M.D. F.R.S.
I JOHN THOMSON, M.D.
I WILLIAM COULSON.
L ALEXANDER SHAW.
r ROBERT BENTLEY TODD, M.D. F.R.S.
I RICHARD QUAD*, F.R.S.
rSETH THOMPSON, M.D.
I CAMPBELL DE MORGAN.
r HENRY PITMAN, M.D.
1 JAMES DIXON.
GEORGE CURSHAM, M.D.
SIR JAMES EYRE, M.D.
WILLIAM MACLNTYRE, M.D.
WILLIAM MERRIMAN, M.D.
ALEX. SUTHERLAND, M.D. F.R.S.
JAMES CLAYTON.
IIEXRY HANCOCK.
JOHN HILTON. F.R.S.
HENRY CHARLES JOHNSON.
.ANDREW M. MACWHINNIE.
TRUSTEES OF THE SOCIETY.
JAMES M. ARXOTT, F.R.S.
JAMES COPLAND, M.D. F.R.S.
EDWARD STANLEY, F.R.S.
REM DENT ASSIST ANT-I.IBR ARIAN .
THOMAS WILLIAMS
FELLOWS OF THE SOCIETY APPOINTED BY
THE COUNCIL AS REFEREES OF PAPERS,
FOR THE SESSION OF 1849-50.
ADDISON, THOMAS, M.D.
ARNOTT, JAMES MONCRD2FF, F.R.S.
BALY, WILLIAM, M.D. F.R.S.
BARKER, THOMAS ALFRED. M.D.
BELL, THOMAS, F.R.S.
BIRD, GOLDING, M.D. F.R.S.
BOWMAN, WILLIAM, F.R.S.
BRODIE, BENJAMIN COLLINS, BART. F.R.S.
BURROWS, GEORGE, M.D. F.R.S.
BUSK, GEORGE, F.R.S.
COPLAND, JAMES, M.D. F.R.S.
DALRYMPLE, JOHN, F.R.S.
DICKSON, ROBERT, M.D.
FARRE, ARTHUR, M.D. F.R.S.
FERGUSON, ROBERT, M.D.
HALL, MARSHALL, M.D. F.R.S.
HAWKINS, CESAR HENRY.
HEWETT, PRESCOTT GARDNER,
HILTON, JOHN, F.R.S.
HODGKIN, THOMAS, M.D.
JONES, HENRY BENCE, M.D. F.R.S.
LANE, SAMUEL ARMSTRONG.
LAWRENCE, WILLIAM, F.R.S.
LEE, ROBERT, M.D. F.R.S.
LOCOCK, CHARLES, M.D.
MACILWAIN, GEORGE.
MAYO, THOMAS, M.D. F.R.S.
PEREIRA, JONATHAN, M.D. F.R.S. F.L.S.
PHILLIPS, BENJAMIN, F.R.S.
PITMAN, HENRY ALFRED, M.D.
SHAW, ALEXANDER.
STANLEY, EDWARD, F.R.S.
STROUD, WILLIAM, M.D.
TRAVERS, BENJAMIN, F.R.S
WATSON, THOMAS, M.D.
WEST. CHARLES. M.D.
A LIST OF THE PRESIDENTS OF THE SOCIETY,
FROM ITS FORMATION.
ELECTED
1805. WILLIAM SAUNDERS, M.D.
1808. MATTHEW BAILLIE, M.D.
1810. SIR HENRY HALFORD, Bart., M.D. G.C.II.
1813. SIR GILBERT BLANE, Bart., M.D.
1815. HENRY CLINE.
1817. WILLIAM BABINGTON, M.D.
1819. SIR ASTLEY PASTON COOPER, Bart., K.C.H. D.C.L.
1821. JOHN COOKE, M.D.
1823. JOHN ABERNETHY.
1825. GEORGE BIRKBECK, M.D.
1827. BENJAMIN TRAVERS.
1829. PETER MARK ROGET, M.D.
1831. WILLIAM LAWRENCE.
1833. JOHN ELLIOTSON, M.D.
1835. HENRY EARLE.
1837. RICHARD BRIGHT, M.D.
1839. SIR BENJAMIN COLLINS BRODIE, Bart.
1841. ROBERT WILLIAMS. M.I).
1848. EDWARD STANLEY.
1846. WILLIAM FREDERICK CHAMBERS, M.D. KA II
IK47. JAMES MoNl'EIEEE AEXOTT.
1849. THOMAS M'lHSOX, M.D.
1851. JOSEPH HODGSON
FELLOWS
ROYAL MEDICAL AND CHIRURGICAL SOCIETY
OF LONDON.
EXPLANATION OF THE ABBREVIATIONS.
P. — President. V.P. — Vice-President.
T. — Treasurer. S. — Secretary.
L. — Librarian. C. — Member of Council.
AUGUST 1851.
Amongst the non-residents, those marked thus (*) are entitled by
composition to receive the Transactions.
Elected
1841 *James Abercrombie, M.D., Cape of Good Hope.
1846 *John Abercrombie, M.D., Physician to the General
Dispensary, Cheltenham; Cheltenham.
1851 * Henry Wentworth Acland, M.D. F.R.S., Physician to
the Radcliffe Infirmary, Oxford.
1847 Elias Acosta, Caraccas ; Venezuela.
1842 William Acton, Queen Anne-street, Cavendish-square.
1818 Walter Adam, M.D., Physician to the Royal Public Dis-
pensary, Edinburgh.
1851 John Adams, Surgeon to the London Hospital; St. Helen's-
place, Bishopsgate-street.
1818 Thomas Addison, M.D., Physician to, and Lecturer on
Medicine at, Guy's Hospital; New-street, Spring-gardens.
C. 1826. V.P. 1837. P. 1849.
1814 Joseph Ager, M.D., Great Portland-street, Portland-place.
C. 1836.
1837 *Ralph Fawsett Ainsworth, M.D., Manchester.
1819 George Frederick Albert.
X FELLOWS OF THE SOCIETY.
Elected
1839 Rutherford Alcock, K.C.T. K.T.S., China.
1826 James Alderson, M.D. F.R.S., Physician to St. Mary's
Hospital; Berkeley-square. S. 1829. C. 1848. T.
L849.
1843 Charles James Berridge Aldis, M.D., Physician to the
London and Surrey Dispensaries, and Lecturer on
Medicine at the Hunterian School of Medicine ; Chester-
terrace, Chester-square.
1850 Charles Revans Alexander, Assistant-Surgeon to the
Royal Infirmary for Diseases of the Eye ; Cork-street,
Bond-street.
1813 Henry Alexander, F.R.S., Surgeon-Oculist in Ordinary to
the Queen, and Surgeon to the Royal Infirmary for
Diseasesof the Eye ; Cork-street, Bond-street. C. 1840.
V.P. 1850.
1836 Henry Ancell, Norfolk-crescent, Oxford-square. C. 184".
1817 Alexander Anderson.
1820 Thomas Andrews, M.D., Norfolk, Virginia.
1813 William Ankers, Knutsford.
1S19 Professor Antommarcht, Florence.
1825 Thomas Graham Arnold, M.D., Stamford.
1818 William WITHERING Arnold, M.D., Physician to the
Infirmary and Lunatic Asylum, Leicester.
1819 James Mon(-rieff Arnott, F.R.S., New Burlington-street.
L. 1826. V.P. 1832. T. 1835. C. 1846. P. 1847.
1817 John Asiiiurner, M.D. M.R.I. A.; Grosvenor-street.
C. 1821.
IMS James Ramsey Atkins, M.I). F.L.S., Grove House Lunatic
Asylum; Stoke Newingtou-green.
1841 John Avery, Surgeon to the Charing-orosa Hospital ; Queen-
street, May-fair.
1825 Benjamin Guy Barington, M.D. P.R.S., Physician to
Guy's IIos|iit:il. lad Physician to the l>eaf and Dumb
Institution; George-street, Hanover-square. ('. 1829.
V.P. 18i:.. T. IMS.
1846 CoRNiMUB Mi ii m. ii Siimii Babington, M.D. , Physician
to Queen Charlotte's Lying-in Hospital; .9, Hertford*
street, Maj -fair
FELLOWS OF THE SOCIETY. XI
Elected
1820 *John H. Badley, Dudley.
1838 Francis Badgley, M.D., Toronto, Upper Canada.
1840 William Bainbridge, Kingston, Surrey.
1836 Andrew Wood Baird, M.D., Ipswich.
1839 Thomas Graham Balfour, M.D., Royal Military Asylum;
Chelsea.
1848 Edward Ballard, M.D., Myddleton-square.
1849 Thomas Ballard, Southwick-place, Hyde-park.
1837 William Baly, M.D. F.R.S., Physician to the Milbank
Prison, and Lecturer on Forensic Medicine at St. Bar-
tholomew's Hospital ; Queen Anne-street, Cavendish-
square. C. 1845. L. 1847. S. 1848.
1847 Andrew Whyte Barclay, M.D., Physician to the Chelsea
Dispensary ; Curzon-street, May-fair.
1848 Edgar Barker, Edgeware-road, Hyde-park.
1833 Thomas Alfred Barker, M.D., Physician to, and Lecturer
on Medicine at, St. Thomas's Hospital ; Grosvenor-
street, Grosvenor-square. C. 1844.
1843 Thomas Herbert Barker, Priory-terrace, Bedford.
1847 George Hilaro Barlow, M.D., Physician to Guy's Hos-
pital ; Union-street, Southwark.
1849 William Frederick Barlow, Resident Medical Officer,
Westminster Hospital.
1840 Benjamin Barrow, Ryde, Isle of Wight.
1844 William Richard Basham, M.D., Physician to, and Lec-
turer on Materia Medica at, the Westminster Hospital;
Chester-street, Grosvenor-place.
1841 George Beaman, King-street, Co vent-garden.
1 83G William Beaumont, Professor of Surgery in the University
of King's College ; Toronto, Upper Canada.
1840 Charles Beevor, Surgeon to the St. Marylebone Dispensary;
Berners-street, Oxford-street.
1819 Thomas Bell, F.R.S. L.S. and G.S., Professor of Zoology
in King's College, London, and Lecturer on Diseases of
the Teeth at Guy's Hospital; New Broad-street, City.
C. 1832.
IS47 James Henry Bennet, M.D., Cambridge - square, Hyde-
park.
Ml FELLOWS OF THE SOCIETY.
Elected
18-15 Edwin I/nwin Berry, James-street, Co vent-garden.
1820 Stephen Bertin, Paris.
1827 William Birch, Barton, Lichfield.
1845 Golding Bird, M.D. F.R.S., Assistant-Physician to, and
Lecturer on Materia Medica at, Guy's Hospital; Russell-
square.
1850 James Bird, M.D., Hyde-park-square, Hyde-park.
1849 Edmund Lloyd Birkett, M.D., 4, Montague-street, Russell-
square.
1851 George Birkett, M.D., 9, DuncaD-terrace, Islington.
1851 John Birkett, Assistant Surgeon to, and Lecturer on
Anatomy at, Guy's Hospital, 6, Wellington-street,
Southwark.
1 M4 ti Hugh Birt, Morro Velhio, Minas Geraes, Rio Janeiro, Brazil;
Surgeon to the Morro Velhio Hospital.
1843 Patrick Black, M.D., Assistant-Physician to St. Bartholo-
mew's Hospital, and Physician to the Seamen's Hospital
Ship "Dreadnought;" Bedford-square.
1844 Thomas Blackall, M.D., Physician to the Seamen's
Hospital Ship "Dreadnought;" Queen-street, May-
fair.
1S47 George C. Blackman, M.D., New York, U.S.
1839 Richard Blaoden, Surgeon-Accoucheur, and Surgeon Ex-
traordinary to the Queen ; Surgeon in Ordinary to Her
Royal Highness the Duchess of Kent ; Albemarlc-street,
Piccadilly. C.ls 17.
1814 Thou as I'.imii, M.D., Physician to the Sussex County Hos-
pital ; Brighton, Sussex.
1840 Peyton Blakimon, M.I). F.R.S., St. Leonard's-ou-Sea.
1845 Hi. Mii Blsnkinsop, Warwick.
isi i -'Henry C. Boisraoom, M.D., Cheltenham.
1823 I - lli.Ma Bojantjs, M.D., Wilna.
1816 Hues Bomb, M.D., Inspector-Genera] of Hospitals;
Edinburgh.
1810 John Booth, M.D., Physician to the General Hospital at
Birmingham.
1846 Pi hi; Bossbt, Thomas-street, Woolwich.
184o John Ash ins Bostoi k, 34, Clarges-street, Piccadilly.
FELLOWS OF THE SOCIETY. XU1
Elected
1 849 Edward Barons Bowman, M.D., Oxford-terrace, Middleton-
road, Dalston.
IS-11 William Bowman, F.R.S., Professor of Physiology and
General Anatomy at King's College, London, and
Assistant- Surgeon to King's College Hospital, and to
the Royal Ophthalmic Hospital, Moorfields ; Clifford-
street, Bond-street.
1844 Robert Brandon.
1814 Richard Bright, M.D. F.R.S., Physician Extraordinary to
the Queen, and Consulting Physician to Guy's Hos-
pital ; Savile-row, Regent-street. C. 1821. V. P. 1827.
P. 1837.
1851 Bernard Edward Brodhurst, Assistant-Surgeon to the
Royal Orthopaedic Hospital, Brook-street, Grosvenor-
square.
1813 Sir Benjamin Collins Brodie, Bart., D.C.L. F.R.S.,
Serjeant-Surgeon to the Queen, Surgeon in Ordinary to
His Royal Highness Prince Albert, Foreign Cor-
respondent of the Institute of France, and Foreign
Associate of the Royal Academy of Medicine of Paris ;
Savile-row, Regent-street. C. 1814. V.P. 1816. P.1839.
1844 Charles Brooke, B.A. (Cantab.) F.R.S., Keppel-street,
Russell-square.
1848 William Philpot Brookes, M.D., Surgeon to the Chel-
tenham General Hospital and Dispensary, and Visiting
Medical Officer to the Cheltenham District of Lunatic
Asylums; Albion House, Cheltenham.
1842 Charles Blakely Brown, M.B., Physician to Queen
Charlotte's Lying-in Hospital, and St. George's and
St. James's Dispensary ; Hill-street, Berkeley-square.
1847 George Brown, Grenadier Guards' Hospital, Rochester-row,
Westminster.
1847 *Robert Brown, Wiuckley-square, Preston, Lancashire.
1851 Alexander Browne, M.D., Army and Navy Club, St.
James's-square.
1818 *Samuel Barwick Bruce, Surgeon to the Forces; Ripon.
1827 M. Pierre Brclatour, Surgeon to the Hospital; Bordeaux.
1823 B. Bartlet Buchanan, M.D.
XIV FELLOWS OF THE SOCIETY.
Elected
1843 John Charles Buck.mll, M.B., Axminster, Devonshire.
1839 George Budd, M.D. F.R.S., Fellow of Caius College,
Cambridge ; Professor of Medicine in King's College,
London ; Physician to King's College Hospital ; Dover-
street, Piccadilly. C. 1846.
1839 Thomas Henry Burgess, M.D., Half-moon-street, Piccadilly.
1833 George Burrows, M.D. F.R.S., Physician to, and Lecturer
on Medicine at, St. Bartholomew's Hospital; Cavendish-
square. C. 1839. T. 1845. V.P. 1849.
1820 Samuel Burrows.
1837 George Busk, F.R.S., Surgeon to the Seamen's Hospital-ship
"Dreadnought;" Croom's-hill, Greenwich. C. 1847.
1850 John Stevenson Busiinan, M.D., Nottingham-place, New
Road.
1818 John Butter, M.D. F.R.S. F.L.S., Physician to the Plymouth
Eye Infirmary ; Plymouth.
1851 William Cadge, Assistant-Surgeon to University College
Hospital; !), Huntley-street, Bedford-square.
IS.">1 Thomas Callaway, Demonstrator of Anatomy at Guy's
Hospital ; Wellington-street, Southwark.
1842 HeNRK Cantis, Maddox-street, Hanover-square.
1847 John Bi •rfohd Caklill, M.D., Berners-strcet, Oxford-street.
1839 Sir Robert Carswell, M.D., Physician to his Majesty the
King of the Belgians ; Brussels.
1825 Harry Carter, M.D., Physician to the Kent and Canterbury
Hospital; Canterbury.
1818 Richard ('aut\\ right, Bloomsbury-squarc.
1820 Samuel Cartwright, F.U.S., Savile-row, Regent-street,
and Xizi'U's Howe, near Tollbridge.
1845 SaHUII Cvu i wiur.iiT, Jan., Savile-row, Regent-street.
1839 William CaTHBOW, Weymouth-street, Portland-place.
1845 William Oliver Chalk, Nottingham-terraoe, New-road.
1818 BlOHABD OHAMBJ 1.1 VIM., Kingston, Jamaica.
IS I I THOMA8 Kim. ChAKBIBB, M.D., Physician to St. Mary's
Hospital; Hill-strict, Berkeley-square.
1816 William Pmdikioi Chaxbibs, M.D. K.C.H. F.R.S.,
l'h\sician to the Queen ; Hurdle House, near Lymington,
Bants. ('. ims. V.P. 1821. P. 1846
FELLOWS OF THE SOCIETY. XV
Elected
18-49 Frederick Chapman, Richmond-green, Richmond, Surrey.
183" Henry Thomas Chapman, Lower Seymour-street, Portman-
square.
1838 George Chaplin Child, M.D., Consulting Physician to the
Westminster General Dispensary ; Queen Anne-street,
Cavendish-square.
1849 William Francis Chorley, M.D., Physician to the St.
Marylebone Dispensary; 3, South Molton-street, Oxford-
street.
1842 William Dingle Chowne, M D., Physician to the
Charing-cross Hospital; Connaught-place West, Hyde-
park.
1847 Benjamin Clark, Brook-street, Grosvenor-square.
1839 Frederick Le Gros Clark, Assistant-Surgeon to, and
Lecturer on Descriptive and Surgical Auatomy at, St.
Thomas's Hospital ; Consulting Surgeon to the Western
General Dispensary ; Spring-gardens. S. 1847.
1827 Sir James Clark, Bart., M.D. F.R.S., Physician to the
Queen, Physician in Ordinary to His Royal Highness
Prince Albert, and Consulting Physician to his Majesty
the King of the Belgians; Brook -street, Grosvenor-
square. C. 1830. V.P. 1832.
1845 John Clark, M.D., Staff Surgeon, 2d class ; West Indies.
1848 John Clarke, M.D., Physician to the British Lying-in
Hospital ; Clifford-street, Bond-street.
1850 Josiaii Clarkson, New Hall-street, Birmingham.
1835 James Clayton, Percy-street, Bedford-square. C. 1850.
1842 Oscar Moore Passey Clayton, Percy - street, Bedford-
square.
1851 Edward Cock, Surgeon to Guy's Hospital; St. Thomas's-
street, Southwark.
1850 Daniel Whitaker Cohen, M.D., Assistant Physician to St.
Thomas's Hospital ; Cleveland-row, St. James's.
1835 *William Colborne, Chippenham, Wiltshire.
1818 Robert Cole, F.L.S., Holybourne, Hampshire.
1828 John Conolly, M.D., Hanwell, Middlesex.
1840 * William Robert Cooke, Burford, Oxfordshire.
1820 Benjamin Cooper, Stamford.
XVI FELLOWS OF THE SOCIF.TY.
Elected
1S-10 Bransby Blake Cooper, F.R.S., Surgeon to, and Lecturer
on Surgery at, Guy's Hospital; New- street, Spring-
gardens. C. 1830. V.P. 1842.
1819 George Cooper, Brentford, Middlesex.
1841 George Lewis Cooper, Surgeon to the Bloomsbury Dis-
pensary; Woburn-place, Russell-square.
1843 William White Cooper, Senior Surgeon to the North London
Eye Infirmary, to the Honorable Artillery Company, and
Ophthalmic Surgeon to St. Mary's Hospital ; Berkcley-sq.
1841 Holmes Coote, Demonstrator of Anatomy at St. Bartholo-
mew's Hospital ; Robert-street, Adelphi.
1835 George Ford Copeland, Cheltenham.
1822 James Copland, M.D. F.R.S., Consulting Physician to
Queen Charlotte's Lying-in Hospital ; Old Burlington-
street. C. 1830. V.P. 1838.
1847 John Rose Cormack, M.D., Putney, Surrey.
1839 *Charles Cesar Corsellis, M.D., Resident Physician to
the Lunatic Asylum, Wakefield, Yorkshire.
1814 *William Cother, Surgeon to the Infirmary, Gloucester.
1847 Richard Payne Cotton, M.D., Assistant-Physician to the
Hospital for Consumption and Diseases of the Chest ;
Bolton-strcet, Piccadilly.
1828 William Coulson, Vice-President, Surgeon to the Magdalen
Hospital, Consulting Surgeon to the City Lying-in
Hospital, ami Senior-Surgeon to St. Mary's Hospital ;
Frederick's-place, Old Jewry. C. 1831. L. 1832.
1817 *SirPiimii' Crampton, Bart., F.R.S., Surgeon-General to
the Forces in Ireland, Dublin.
1841 MEBTTH Abohdaxi Nott Crawford, M.D., Physician to,
and Lecturer on Medicine at, the Middlesex Hospital;
Upper Berkeley-street, l'ortman-square.
1822 Sib Albxandbb Crichton, M.D. F.K.S. and F.L.S., Phy-
ii in Ordinary to their Imperial Majesties the l',m-
peror and Dowager Empress of all the Hussias ; the
Grove, Sevenoaks, Kent. C. 1823
isir Ci. mil. i < u i ri ii ii i , Assistant • Surgeon to the London
Hospital, and the Royal London Ophthalmic Hospital;
Finsbnry-eqnare.
FELLOWS OF THE SOCIETY. XVU
Elected
1837 John Farrar Crookes, Russell-square.
1849 *William Edward Crowfoot, Beccles, Suffolk.
1851 James Cameron Gumming, M.D., 1, Cadogan-place, Sloane-
street.
1818 William Cuming, M.D., Professor of Botany at the Glasgow
Institution and Surgeon to the Royal Infirmary at
18-16 Henry Curltng, Ramsgate, Kent.
1837 Thomas Blizard Curling, F.R.S., Surgeon to, and
Lecturer on Surgery at, the London Hospital ; New
Broad-street, City. S. 1845. C. 1850.
1847 John Edmund Currey, M.D., Lismore, Ireland.
1836 George Cursham, M.D., Physician to the Hospital for
Consumption and Diseases of the Chest, and to the
Female Orphan Asylum ; Savile-row, Regent-street.
S. 1842. C. 1850.
1822 Christopher John Cusack, Chateau d'Eu, France.
1828 Adolphe Dalmas, M.D., Paris.
1840 John Dalrymple, F.R.S., Consulting Surgeon to the
London Ophthalmic Hospital ; Grosvenor-street, Gros-
venor-square. C. 1848.
1851 Nathaniel John Dampier, Wobum-place, Russell-square.
1836 *James Stock Daniel, Ramsgate.
1850 John Bampfylde Daniell, M.D., Physician to the Royal
Pimlico Dispensary; Grosvenor-street, Grosvenor-
square.
1820 George Darling, M.D., Russell-square C. 1841.
1818 *Sir Francis Sacheverel Darwin, Knt., M.D., BreadsaU
Priory, near Derby.
1848 Henry Daubeny, Manchester-square.
1846 Frederick Davies, Upper Gower-street, Bedford-square.
1818 *Henry Davies, M.D., 6, Duchess-street, Portland-place.
C. 1827. V.P. 1848.
1847 John Davies, M.D., Physician to the Hertford Infirmary,
and Visiting Physician to the County Gaol and Lunatic
Asylum,"Hertford.
1820 Thomas Davis, Brook-street, Hanover-square. C. 1843.
1818 James Dawson, Liverpool.
XV111 FELLOWS OK THE SOCIETY.
Elected
1847 George Edward Day, M.D. F.R.S., Chandos Professor of
Medicine, St. Andrew's.
1841 Campbell De Morgan, Secretary, Surgeon to, and Lecturer
on Physiology at, the Middlesex Hospital; Upper
Seymour-street, Portman-square.
1846 *Samuel Best Denton, Ivy-lodge, Hornsea, East Riding,
Yorkshire.
1844 Robert Dickson, M.D., Hertford-street, May-fair.
1839 James Dixon, Librarian, Assistant-Surgeon to St. Thomas's
Hospital, and Surgeon to the Royal London Ophthalmic
Hospital, Green-street, Park-Jane.
1845 John Dodd, Bryanston-street, Portman-square.
1839 Henry Pye Lewis Drew, Gower-street, Portman-square.
1846 John Drummond, Deputy Inspector of Fleets and Hospitals;
Royal Naval Hospital, Chatham.
1843 Thomas Jones Drury, M.D., Physician to the Salop In-
firmary; Shrewsbury, Shropshire.
1845 George Duff, M.D., Genoa.
1845 Edward Willson Duffin, Laugham-place, Portland-place.
1833 Robert Dunn, Norfolk-street, Strand. C. 1845.
1843 Christopher Mercer Dubbant, M.D., Physician to
the East Suffolk and Ipswich Hospital; Ipswich,
Suffolk.
1839 Henry Sumner Dyer, M.D., Bryanstou-square.
1836 James William Earle, Norwich.
1824 George Edwards.
1823 Charles Chandler Egerton, Kendal Lodge, Epping.
1848 George Vineh Ellis, Professor of Anatomy in University
College, London ; Albert-street, liegout's-Park.
is.'!.". William England, M.D., Wisbeach, Cambridgeshire.
1842 John Eric Ericusen, Professor of Surgery in University
College, London, and Surgeou to University College
Hospital ; Welbeck-street, Cavendish-square.
1815 Griffith Francis Doksi.ii Evans, M.D., High-street,
Bedford. C. 1838.
1836 George Fahian Evans, M.B., Physician to the Birmingham
Hospital, Waterloo-street, Birmingham.
is is William h man Evans, M.D.
FELLOWS OF THE SOCIETY. XIX
Elected
1841 Sir James Eyre, M.D., Physician-Accoucheur to St. George's
and St. James's Dispensary ; Brook-street, Grosvenor-
square. C. 1851.
1844 Arthur Farhe, M.D. F.R.S., Professor of Midwifery in
King's College, London ; Hertford-street, Blay-fair.
1831 Robert Ferguson, M.D., Physician-Accoucheur to the
Queen, Physician to the Westminster Lying-in Hospital;
Park-street, Grosvenor-square. C. 1839. V.P. 1847.
1841 William Fergusson, F.R.S., Professor of Surgery in King's
College, London ; Surgeon to King's College Hospital,
and to II.R.H. Prince Albert ; George-street, Havover-
square. C. 1849.
1850 *Frederick Field, Birmingham.
1849 George Tupman Fincham, M.D., Physician to the Western
Dispensary ; Chapel-street, Grosvenor-place.
1836 John William Fisher, Surgeon-in-Chief to the Metropolitan
Police Force ; Grosvenor-gate. C. 1843.
1838 George Lionel Fitzmaurice, Gloucester-place, Portman-
square.
1842 Thomas Bell Elcock Fletcher, M.D., Physician to the
General Dispensary, Birmingham.
1841 John Forbes, M.D. F.R.S., Physician to her Majesty's
Household ; Old Burlington-street.
1848 John Gregory Forbes, Devonport-street, Hyde-park.
1817 *Robert Thomas Forster, Southwell, Notts.
1820 Thomas Forster, M.D., Hartfield-lodge, East Grinstead.
1846 Algernon Frampton, M.D., Physician to the London Hos-
pital ; New Broad-street, City.
1816 John W. Francis, M.D., Professor of Materia Mcdica in the
University of New York, U.S.
1841 John Christopher August. Franz, M.D., Royal German
Spa, Brighton.
1843 Patrick Fraser, M.D., Assistant-Physician to the London
Hospital ; Guilford-street, Russell-square.
1836 John George French, Surgeon to St. James's Infirmary;
Great Marlborough-street, Regent-street.
1849 Robert Temple Frere, M.D., Physician-Accoucheur to,
and Lecturer on Midwifery at, the Middlesex Hospital ;
Queen-street, May-fair.
XX FELLOWS OF THE SOCIETY.
Elected
1846 Henry William Fuller, M.B., Assistant-Physician to, and
Lecturer on Medical Jurisprudence at, St. George's
Hospital, Manchester-square.
1815 *Georoe Frederick Furnival, Egham, Surrey.
1851 George Gaskoin, Cambridge-terrace, Hyde-park.
1819 John Samuel Gaskoin, Clarges-street, Piccadilly. C. 1836.
1819 Henry Gaulter.
1848 John Gay, Surgeon to the Royal Free Hospital ; Finsbury-
place, Fiusbury-square.
1821 *Richard Francis George, Surgeon to the Bath Hospital.
1841 John Durance George, F.G.S., Lecturer on Dental Surgery
at University College, London, and Dental Surgeon to
University College Hospital ; Old Burlington-street.
1812 George Goldie, M.D., York.
1851 Stephen Jennings Goodfellow, M.D., Physician to the
Royal General Dispensary, and Lecturer on Forensic
Medicine at the Middlesex Hospital ; Russell-square.
1818 James Alexander Gordon, M.D. F.R.S., Burford-lodge,
Box-hill. C. 1828. V.P. 1829.
1851 Peter Yeames Gowlland, Finsbury-square.
1844 John Grantham, Cray ford, Kent.
1850 Henry Gray, Wilton-street, Grosvenor-place.
1846 George Thompson Gream, M.D., Hertford-street, May-
fair.
1816 Joseph Henry Green, F.R.S., Surgeon to, and Lecturer on
Surgery at, St. Thomas's Hospital ; Hadley, Middlesex.
C. 1820. V.P. 1830.
1841 George Gregory, M.D., Physician to the Smallpox Hospital;
Camden-squarc, Camden New-town. S. 1825. C. 1849.
1843 Robert Greenhalgh, Surgeon-Accoucheur to the Royal
General Dispensary, St. Pancras ; 1 1, Upper Woburn-
place, Russell-square.
1814 John Gkove, M.D., Salisbury.
1849 William Wiumv (ii u, M.D., Assistant-Physician to Guy's
Hospital ; St. Tliomas's-street, Southwark.
1837 James Manry Gully, M.D., Holyrood-house, Great Malvern.
1819 Sir John Gunning, Knight, C.B., Inspector of Hospitals;
Paris.
FELLOWS OF THE SOCIETY. XXI
Elected
1842 Charles William Gardiner Guthrie, Assistant-Surgeon
to the Westminster Hospital, and to the Westminster
Ophthalmic Hospital, Pall-Mali, St. James's.
1849 Hammett Hailey, Newport Pagnell, Bucks.
1842 *Georgb Hall, M.D.
1845 John Hall, M.D., Deputy Inspector-General of Hospitals;
Cape of Good Hope.
1848 Alexander Halley, M.D., Queen Anne-street, Cavendish-
square.
1819 Thomas Hammerton, Piccadilly. C. 1829.
1838 Henry Hancock, Surgeon to the Charing-cross Hospital;
Harley-street, Cavendish-square. C. 1851.
1849 *Richard James Hansard, Broad-street, Oxford.
1848 *Geouge Harcourt, M.D., Chertsey, Surrey.
1836 John Fosse Harding, Mylne-street, Myddleton-square.
1843 Thomas Sunderland Harrison, M.D. F.L.S., Garston-
lodge, Somersetshire.
1846 John Harrison, the Court-yard, Albany.
1841 William Harvey, Surgeon to the Royal Dispensary for
Diseases of the Ear, and to the Freemasons' Female
Charity; Soho-square.
1828 C^sar Henry Hawkins, Vice-President of the Royal
College of Surgeons of England, Surgeon to St. George's
Hospital; Grosvenor-street, Grosvenor-square. C. 1830.
V.P. 1838. T. 1841.
1838 Charles Hawkins, Savile-row, Regent-street. C. 1846.
S. 1850.
1848 Thomas Hawksley, M.D., George- street, Hanover-square.
1820 Thomas Emerson Headlam, M.D., Newcastle-upon-
Tyne.
1848 James Newton Heale, M.D., Physician to the Royal Free
Hospital ; Westbourne-crescent, Hyde-park.
1850 George Heaton, M.D., Boston, U.S
1829 Thomas Heberden, M.D., Park-street, Grosvenor-square.
1844 John Hennen, M.D., Physician to the Western General
Dispensary ; Upper Southwick-street, Hyde-Park. L.
1848.
XX11 FELLOWS OK THE SOCIETY.
Elected
18-18 Mitchell Henry, Assistant-Surgeon to the Middlesex Hos-
pital; Harley-street, Cavendish-square.
1849 Amos Henriques, Upper Berkeley-street, Portman-square.
1821 Vincent Herberski, M.D., Professor of Medicine in the
University of Wilna.
1843 Prescott Gardner Hewett, Assistant-Surgeon to St.
George's Hospital, Lecturer on Anatomy at St. George's
Hospital Medical School ; Hertford-street, May-fair.
1841 *Nathaniel Highmore, Consulting-Surgeon to the Wey-
mouth and Dorsetshire Eye Infirmary ; Sherborne,
Dorsetshire.
1814 *William Hill, Wootou-under-Edge, Gloucestershire.
1842 William Augustus Hillman, Lecturer on Anatomy and
Physiology at the Westminster Hospital, Surgeon to
the Farringdon General Dispensary ; Argyll-street,
Regent-street.
1841 John Hilton, F.R.S., Surgeon to, and Lecturer on Anatomy
at, Guy's Hospital; New Broad-street, City. C. 1851.
1848 Martin Thomas IIiscox, M.D., Bath, Somersetshire.
1840 Thomas Hodgkin, M.D., Bedford-square. C. 1842.
1813 Joseph Hodgson, F.R.S., President; Westbourne-terrace,
Hyde-park. C. 1817.
1835 Thomas Henry Holberton, Hampton, Middlesex.
1843 Luther IIolden, Ely-place, Holborn.
1814 Henry Holland, M.D. F.R.S., Physician Extraordinary to
the Queen, and Physiciau in Ordinary to H.R.H.
Prince Albert; Brook-street, Grosvenor-square. C. 1817.
V.P. 1826.
184(i Barnard Wight Holt, Surgeou to the Westminster Hospital;
Parliament-street, Westminster.
1846 Carsten H. HOLTHOUSE, Surgeon to the Public Dispensary,
Lincoln's Inn ; Lecturer on Anatomy and Physiology ;
Scrle-street, Lincoln's-inn-fields.
1819 *John Howell, M.D. P.E.S. E. ; Clifton, Gloucestershire.
1828 *Ed\yakd Howill, M.D., Swansea, Glamorganshire.
is II Edwin Huuby, Windsor-terrace, Maida-hill.
1822 &OBEBT Hi'mk, M.D. C.B., Inspector of Hospitals; Commis-
sioner iu Lunacy ; Canon-street, May-fair. V.P. 1836.
FELLOWS OP THE SOCIETY. XX111
Elected
1840 Henry Hunt, M.D., Brook-street, Hanover-square.
1842 Christopher Thomas Agrippa Hunter, Downham,
Norfolk.
1849 Edward Law Hussey, Surgeon to the Radcliffe Infirmary,
Oxford.
1820 William Hutchinson, M.D.
1840 Charles Hutton, M.D., Physician to the Royal Infirmary
for Children ; Lowndes-street, Belgrave-square.
1848 George Cockburn Hyde, Montpelier-square, Brompton.
1838 William Ifil, M.D.
1847 William Edmund Image, Surgeon to the Suffolk General
Hospital ; Bury St. Edmund's, Suffolk.
1826 William Ingram, Midhurst, Sussex.
1839 Alexander Russell Jackson, M.D., Warley Barracks,
Essex.
1845 *Henry Jackson, Surgeon to the Sheffield General In-
firmary ; St. James's-row, Sheffield.
1841 Paul Jackson, Thayer-street, Manchester-square.
1847 Thomas Reynolds Jackson, Charles-street, St. James's.
1841 Maximilian Mority Jacobovicz, M.D., Pesth.
1825 John B. James, M.D.
1847 * William Withall James, Exeter, Devonshire.
1844 Samuel John Jeaffreson, M.D., Leamington, Warwick-
shire.
1839 Julius Jeffreys, F.R.S., Bath, Somersetshire.
1840 *George Samuel Jenks, M.D., Brighton.
1851 William Jenner, M.D., Professor of Pathological Anatomy
in University College, and Assistant-Physician to Univer-
sity College Hospital, Albany-street, Regent's-park.
1848 Athol Archibald Wood Johnson, Lecturer on Physiology
at St. George's Hospital Medical School ; and Surgeon
to St. George's and St. James's Dispensary ; Half Moon-
street, Piccadilly.
1851 Edmund Charles Johnson, M.D., Savile-row ; and
Arlington-street, Piccadilly.
1821 Sir Edward Johnson, M.D., Weymouth, Dorsetshire.
1847 George Johnson, M.D., Assistant-Physician to King's
College Hospital ; Woburn-square.
XXIV FELLOWS OK THE SOCIETY.
Elected
1837 Henry Charles Johnson, Assistant-Surgeon to, and Lec-
turer on Medical Jurisprudence at, St. George's Hospital;
Savile-row, Regent-street. C. 1850.
1844 John Johnston, Old Burlington-street.
1 844 Henry Bence Jones, M.D. F.R.S., Physician to St. George's
Hospital ; Grosvenor-street, Grosvenor-square.
1835 Henry Derviche Jones, Soho-square.
1837 Thomas William Jones, M.D., Physician to the City Dis-
pensary ; Finshury-pavement, Finsbury-square.
1829 *George Charles Julius, Richmond, Surrey.
1816 *George Hermann Kauffmann, M.D., Hanover.
1815 Robert Keate, Serjeant-Surgeon to the Queen, Surgeon to
H.R.H. the Duchess of Gloucester, and to St. George's
Hospital; Hertford-street, May-fair. C. 1818. V.P. 1826.
1848 * Daniel Burton Ken dell, M.D., St. John's, Wakefield,
Yorkshire.
1847 Alfred Keyser, Norfolk-crescent, Oxford-square.
1839 *David King, M.D., Eltham, Keut.
1851 John Abernethy Kingdon, New Bank-buildings, City.
1836 Peter Nugent Kingston, M.D., Physician to the West-
minster Hospital ; Curzon-street, May-fair. C. 1846.
1806 James Laird, M.D.
1840 Samuel Armstrong Lane, Lecturer on Anatomy; Surgeon
to the Lock Hospiial, and to St. Mary's Hospital ;
Grosvcnor-place, Hyde-park. C. 1849.
1841 *Ciiarles Lasiimar, M.D., Croydon, Surrey.
1810 G. E. Lawiu \< IE.
1809 William Lawrence, F.R.S., Surgeon Extraordinary to
the Queen ; Surgeon to St. Bartholomew's Hospital,
ami to Bridewell and Bethlem Hospitals; Lecturer on
Surgery at St. Bartholomew's Hospital ; Whitehall-
place, Whitehall. S. 1813. V.P. 1818. C. 1820.
T. 1821. P. 1831.
1840 Thomas Laycock, M.D., York.
1848 "JxBBl l,i \< ii, lleywood, near Bury, Lancashire.
1823 John <;. Uatii, M.D.
1822 Johh Joseph Ledsajc, Surgeon u> the Birmingham Eye
Infirmary , Birmingham.
FELLOWS OF THE SOCIETY. XXV
Elected
1822 Robert Lee, M.D. F.R.S., Physician to the British
Lying-in Hospital ; Physician-Accoucheur to the St.
Marylebone Infirmary ; and Lecturer on Midwifery at
St. George's Hospital ; Savile-row, Regent-street.
C. 1829. S. 1830. V.P. 1835.
1823 Henry Lee, M.D., Keppel-street, Russell-square. C. 1837.
S. 1839.
1843 Henry Lee, Assistant-Surgeon to King's College Hospital,
and Surgeon to the Lock Hospital ; Dover-street,
Piccadilly.
1851 George Macartney Leese, Gloucester-place, Portman-
square.
1836 Frederick Leighton, M.D., Franckfort-on-the-Maine.
1847 John Charles Weaver Lever, M.D., Physician-Accoucheur
to Guy's Hospital ; Wellington-street, Southwark.
1847 Sir John Liddell, M.D. F.R.S. C.B., Inspector of Hos-
pitals ; Royal Hospital, Greenwich.
1806 John Link, M.D.
1845 William John Little, M.D., Physician to, and Lecturer
on Medicine at, the London Hospital ; Finsbury-square.
1819 Robert Lloyd, M.D.
1824 Eusebius Arthur Lloyd, Surgeon to St. Bartholomew's
and Christ's Hospitals; Bedford-row. S. 1827.
V.P. 1838. C. 1843.
1820 J. G. Locher, M.C.D., Town Physician of Zurich.
1844 Edward Francis Lonsdale, Assistant-Surgeon to the Royal
Orthopaedic Hospital ; Montague-street, Russell-square.
1824 Charles Locock, M.D., First Physician-Accoucheur to
the Queen, and Consulting Physician to the General
Lying-in Hospital ; Hertford-street, May-fair. C. 1826.
V.P. 1841.
1846 Henry Thomas Lomax, Stafford.
1836 Joseph S. Lowenfeld, M.D., Berbice.
1815 *Peter Luard, M.D.
1847 Henry John M'Dotjgall.
1846 William M'Ewen, M.D., Surgeon to the Cheshire County
Gaol, and House-Surgeon to the Chester General In-
firmary ; Newgate-street, Chester.
XXVI FELLOWS OF THE SOCIETY.
Elected
1814 Sir James Macgrigor, Bart., M.D. K.C.B. K.T.S. LL.D.
F.R.S. L. and E., Director-General of the Medical
Department of the Army; Harley-street, Cavendish-
square. C. 1820. V.P. 1815.
1823 George Macilwain, Consulting Surgeon to the Finsbury
Dispensary; The Court-Yard, Albany. C. 1829.
V.P. 1848.
1839 William Macintyre, M.D., Harley-street, Cavendish-
square. C. 1850.
1848 Frederick William Mackenzie, M.D., Chester-place,
Hyde-park-square.
1818 William Mackenzie, Surgeon to the Eye Infirmary,
Glasgow.
1822 Richard Mackintosh, M.D.
1844 Daniel Maclachlan, M.D., Physician to the Royal
Hospital, Chelsea, and Deputy Inspector-General of
Hospitals ; Royal Hospital, Chelsea.
1851 Samuel Maclean, Brook-street, Grosveuor-square.
1849 David Macloughlin, M.D., Chapel-place, Cavendish-
square.
1819 Duncan Maclachlan Maclure, Harley-street, Cavendish-
square.
1842 John Macnaught, M.D., Bedford-street, Liverpool.
1835 Daniel Chambers Macreight, M.D., St. Hillier's, Jersey.
1837 Andrew Melville M'Whinnie, Lecturer on Comparative
Anatomy at St. Bartholomew's Hospital; Assistant-
Surgeon to the London Hospital for Diseases of the
Skin; Bridge-street, Black friars. C. 1851.
1848 William Orlando Markham, M.D., Assistant-Physician
to St. Mary's Hospital; Clarges- street, Piccadilly.
1824 Sir Henry Maush, Bart., M.D., Dublin.
1838 Thomas Parr Marsh, M.D., Physician to the Salop In-
firmary, Shrewsbury.
1851 John Marshall, Assistant-Surgeon to University College
Hospital ; Mornington-cresccnt-place, Hampstead-road.
isili John MAR8TON, Gloucester-gardens, Hyde-park.
1841 James RaNALO .Mvrtin, F.R.S., Lower Grosvenor-street,
Grosvenor-square.
FELLOWS OF THE SOCIETY. XXV11
Elected
1819 *John Masfen, Surgeon to the County General Infirmary,
and Fever Hospital, Stafford.
1849 George Bellasis Masfen, Stafford.
1818 J. P. Maunoik, Professor of Surgery at Geneva.
1820 Herbekt Mayo, F.R.S., Boppart-on-the-Rhine. S. 1825.
V.P. 1834.
1837 Thomas Mayo, M.D. F.R.S., Vice-President, Physician
to the St. Marylebone Infirmary ; Wimpole-street,
Cavendish-square. S. 1841. C. 1847.
1839 Richard Henry Meade, Bradford, Yorkshire.
1819 *Thomas Medhurst, Hurstbourne Tarrant, Hampshire.
1837 Samuel William John Merriman, M.D., Physician to the
Royal Infirmary for Children, Consulting Physician to
the Westminster General Dispensary, and Assistant-
Physician to the West London Lying-in Institution ;
Brook-street, Grosvenor-square. C. 1851.
1847 Edward Meryon, M.D. (Loud.), Clarges-street, Piccadilly.
1815 Augustus Meyer, M.D., St. Petersburgh.
1840 Richard Middlemore, Surgeon to the Eye Infirmary,
Birmingham.
1847 James Miller, M.D., Welbeck-street, Cavendish-square.
1818 *Patrick Miller, M.D. F.R.S. E., Physician to the
Devon and Exeter Hospitals, and to the Lunatic Asylum ;
Exeter, Devonshire.
1848 Gavin Milroy, M.D.
1844 Nathaniel Montefiore, Hyde-park-square, Hyde-park.
1828 Joseph Moore, M.D., Physician to the Royal Freemasons'
Female Charity ; Consulting Physician to Queen
Charlotte's Lying-in Hospital ; Savile-row, Regent-
street. C. 1837.
1836 George Moore, M.D., Hastings.
1848 Charles Hewitt Moore, Surgeon to, and Lecturer on
Anatomy at, the Middlesex Hospital ; Mortimer-street,
Cavendish-square.
1851 Frederick John Mouat, M.D., Professor of Medicine in
the Medical College of Calcutta, and Secretary of the
Council of Education in India ; Calcutta.
1814 *George Frederick Muhry, M.D., Hanover.
XXV111 FELLOWS OF THE SOCIETY.
Elected
1847 Simon Murchison, Lower Heyford, Oxon.
1841 Edward William Murphy, M.D., Professor of Midwifery
in University College, London ; Henrietta-street,
Cavendish-square.
1845 Thomas D. Mutter, M.D., Professor of Surgery in Jefferson
Medical College ; Philadelphia.
1840 Robert Nairne, M.D., Physician to, and Lecturer on
Medicine at, St. George's Hospital ; Charles-street,
Berkeley-square. C. 1848.
1835 Thomas Andrew Nelson, M.D., George-street, Portman-
square.
1843 Edward Newton, Howland-street, Fitzroy-square.
1851 James Nichols, Savile-row, Regent-street.
1816 Thomas Nixon (Army).
1819 *George Norman, Surgeon to the United Hospital and
Puerperal Charity ; Bath, Somersetshire.
1849 Henry Burford Norman, Surgeon to the St. Marylebone
Dispensary, and to the Western Ophthalmic Institution ;
Duchess-street, Portland-place.
1845 Henry Norris, South Petherton, Somerset.
1849 *ArthurNoverre, Great Stanmore, Middlesex.
1847 *William Edward Cuarles Nourse, Claphani, near
Worthing, Sussex.
1843 William O'Connor, George-street, Portman-square.
1847 Thomas O'Connor, March, Cambridgeshire.
1846 Francis Odling, Devonshire-street, Portland-place.
1822 James Adey Ogle, M.D. F.R.S., Clinical and Aldrichiau
Professor of Medicine, Oxford ; and Senior Physician
to the Kadcliffe Infirmary ; Oxford.
1850 Henry Oldham, M.D., Obstetric Physician to Guy's
Hospital ; Devonshire-square, Bishopsgate street.
1842 William Piers Obkskos.
1846 *Edward Latham Ohmkhod, M.D., Old Steyne, Brighton.
1847 William Km.wiei, I'ai.i:, M.D. Physician to, and Lecturer
on Medicine at, St. George's Hospital ; Curzon-street,
May-fair.
1847 *\Vii,i.i\\i BoCBFTJUiS Page, Surgeon to the Cumberland
Infirmary ; Carlisle.
FELLOWS OF THE SOCIETY. XXIX
Elected
1840 James Paget, F.R.S., Assistant-Surgeon to, and Lecturer
on General and Morbid Anatomy and Physiology, and
Warden of the Collegiate Establishment at, St.
Bartholomew's Hospital. C. 1848.
1806 *Robert Paley, M.D., Bishopston-grange, near Ripon,
Yorkshire.
1836 S. W. Langston Parker, Colmore-row, Birmingham.
1847 Nicholas Parker, M.B., Microscopical Demonstrator of
Morbid Anatomy at the London Hospital School of
Medicine ; Finsbury-square.
1841 John Parkin, M.D., Thurloe-place, West Brompton.
1851 James Part, 7, Camden-road Villas, Camden-town.
1828 Richard Partridge, F.R.S., Surgeon to King's College
Hospital, and Professor of Anatomy in King's College,
London; New-street, Spring-gardens. S. 1832. C. 1837.
V.P. 1847.
1819 Granville Sharp Pattison, New York, U.S.
1845 Thomas Bevill Peacock, M.D., Assistant-Physician to
St. Thomas's Hospital ; Finsbury-circus, Finsbury-
square.
1830 Charles P. Pelechin, M.D., St. Petersburgh.
1819 John Pryor Peregrine, M.D., Jersey.
1839 Thomas Peregrine, M.D., Half-moon-street, Piccadilly.
1831 Jonathan Pereira, M.D. F.R.S. F.L.S., Assistant-Physician
to, and Lecturer on Materia Medica at, the London
Hospital; Finsbury-square. C. 1844. V.P. 1847.
1844 William Vesalius Pettigrew, M.D., Chester-street,
Grosvenor-place.
1837 Benjamin Phillips, F.R.S., Surgeon to, and Lecturer on
Surgery at, the Westminster Hospital ; Wimpole-street,
Cavendish-square. L. 1841. T. 1847.
1814 *Edward Phillips, M.D., Physician to the County Hospital;
Winchester, Hampshire.
1848 Edward Phillips, M.D., Coventry, Warwickshire.
1846 Francis Richard Philp, M.D., Physician to St. Luke's
Hospital ; Kensington-house, Kensington.
1851 *James Hollins Pickford, M.D., M.R.I. A., Brighton.
1851 John Picton, M.D., Wyndham Club, St. James's-square.
XXX FELLOWS OF THE SOCIETY.
Elected
1836 Isaac Pidduck, M.D., Physician to the Bloorasbury Dis-
pensary ; Montague-street, Russell-square.
184 1 HenryAlfred Pitman, M..D., Librarian; Assistant-Physician
to, and Lecturer on Materia Medica at, St. George's
Hospital ; Montague-place, Russell-square.
1850 Alfred Poland, Assistant-Surgeon to Guy's Hospital, and
to the Royal Ophthalmic Hospital ; St. Thomas' s-street,
Southwark.
1845 George David Pollock, Surgeon to the North London
Eye-Infirmary, and Lecturer on Anatomy at St. George's
Hospital Medical School ; Grosvenor-street, Grosvenor-
square.
1843 Charles Pope, M.D. M.A. F.L.S., Temple Cloud, near
Bristol.
1846 Jepiison Potter, M.D. F.L.S., Oxford-road, Manchester.
1840 Lewis POWELL, John-street, Berkeley-square.
1842 James Powell, M.B. (Loud.), Guilford-street, Russell-
square.
1851 Robert Francis Power, M.D., Bolton-street, Piccadilly.
1839 John Propert, New Cavendish-street, Portland-place.
1845 John Pyle, Surgeon to the North London Eye-Intirmary ;
Oxford-terrace, Hyde-park.
1816 Sir William Pym, M.D., Inspector of Hospitals.
1830 Jones Quain, M.D., Paris.
1850 Richard Quain, M.D., Assistant-Physician to the Hospital
for Consumption ; Harley-street, Cavendish-square.
1835 Richard Quain, F.R.S., Treasurers Surgeon to University
College Hospital, ami Professor of Clinical Surgery and
of Anatomy in University College, London ; Cavendish-
square. C. 1838. L. 1846.
180" John Ramsey, M.D., Physician to the Infirmary at New-
castle.
1821 Henry Reedeh, M.D., Ridge House, Chipping, Sndbury.
1835 G. Reonoli, Professor of Surgery iii the Universitj of Pita.
1846 James lii.m, M.D., Physician to the Infirmary of St. QQn
ami Bloonubary; General Lying-in Hospital, &c.j
Brook-street, Grosvcnoi square.
1847 Samuel Richards, M.D., Bedford-square.
FELLOWS OF THE SOCIETY. XXXI
Elected
1829 Siu John Richardson, Knt. F.R.S. C.B., Surgeon to the
Naval Hospital ; Haslar Hospital, Gosport.
1849 William Richardson, M.D., Radnor-place, Hyde-park.
1843 Joseph Ridge, M.D., Dorset-square.
1845 Benjamin Ridge, M.D., Putney, Surrey.
1829 * Archibald Robertson, M.D. F.R.S. L. and E., Physician
to the General Infirmary, Northampton.
1843 George Robinson, M.D., Newcastle-on-Tyne.
1851 Richard Radford Robinson, Camberwell, Surrey.
1843 William Roden, M.D. F.L.S., Kidderminster, Worcester-
shire.
1835 George Hamilton Roe, M.D., Physician to, and Lecturer
on Medicine at, the Westminster Hospital ; Upper
Brook-street, Grosvenor-square. C. 1841.
1836 Arnold Rogers, Hanover-square.
1846 William Richard Rogers, M.D., Berners-street, Oxford-
street.
1819 Henry Shuckburgh Roots, M.D., Consulting-Physician to
St. Thomas's Hospital; Russell-square. C. 1833.
V.P. 1834.
1829 William Sudlow Roots, Kingston, Surrey.
1850 George Rofer, Guy's Hospital; St. Thomas's-street, South-
ward
1836 Richard Roscoe, M.D., Twickenham, Middlesex.
1835 *Caleb Bcrrell Rose, Swaffham, Norfolk.
1850 Archibald Colo.uhoun Ross, M.D., Madeira.
1849 Charles Henry Felix Routh, M.D., Dorset-square.
1845 Henry Mortimer Rowdon, Baker-street, Portman-square.
1841 Richard Rowland, M.D., Assistant-Physician to the
Charing-cross Hospital ; Woburn-pjace, Russell-square.
1836 James Russell, Birmingham.
1845 James Russell, jun., Birmingham.
1851 Henry Hyde Salter, M.B., King's College, Strand.
1827 *Thomas Salter, F.L.S., Poole, Dorsetshire.
1844 *Tiiomas Bell Salter, M.D. F.L.S., Ryde, Isle of Wight.
1842 George Sampson, Chester-street, Belgrave-square.
1849 Hugh James Sanderson, Upper Berkeley-street, Portman-
square.
XXX11 FELLOWS OF THE SOCIETY.
Elected
1847 William Henry Octavius Sankey, M.B. (Lond.), London
Fever Hospital, Liverpool-road, Islington.
1845 Edwin Saunders, Surgeon-Dentist to the Queen, and
Lecturer on Diseases of the Teeth at St. Thomas's
Hospital ; George-street, Hanover-square.
1834 Ludwig V. Sauvan, M.D., Warsaw.
1840 Augustin Sayer, M.D., Upper Seymour-street, Portman-
square.
1824 Edward James Seymour, M.D. F.R.S., Charles-street,
Berkeley-square. C. 1826. S. 1827. V.P. 1830.
1840 William Sharp, F.R.S. F.G.S. F.R.A.S., Rugby, Warwick-
shire.
1837 William Siiarpey, M.D. F.R.S. L. and E., Professor of
Anatomy and Physiology in University College, London ;
Gloucester-crescent, Regent's-park. C. 1848.
1836 Alexander Shaw, Vice-President ; Surgeon to, and Lecturer
on Surgery at, the Middlesex Hospital ; Henrietta-street,
Cavendish- square. C. 1842. S. 1843.
1848 *Edward James Shearman, M.D., Rotherham, Yorkshire.
1849 Francis Sibson, M.D. F.R.S., Physician to St. Mary's
Hospital ; Brook-street, Grosvenor-square.
1848 Edward Henry Sieveking, M.D., Assistant-Physician
to St. Mary's Hospital ; Beutinek-street, Manchester-
square.
1839 Thomas Hookham Silvester, M.D. , High-street, Clapham.
1842 John Simon, F.R.S., Lecturer on Pathology at St. Thomas's
Hospital ; Lancaster-place, Strand.
1821 Charles Skene, M.D., Professor of Anatomy and Surgery;
Marischal College, Aberdeen.
1827 George Robert Skene, Bedford.
1824 Frederic Carpenter Skey, F.R.S., Assistant-Surgeon to,
and Lecturer on Anatomy at, St. Batholornew's Hospital;
Surgeon to the Northern Dispensary ; Grosvenor-street,
Grosvenor-square. C. 1828. L. 1829. V.P. L841.
1838 HbKBI SMITH, Nrnior Assistant-Surgeon to St. Mary's
Hospital; and Lecturer on Surgery in the Medical
School adjoining St. George's Hospital ; Upper Seymour-
street, Portman-square.
FELLOWS OF THE SOCIETY. XXX111
Elected
1835 John Gregory Smith, Hare wood, Yorkshire.
1810 Noel Thomas Smith, M.D., Newcastle-on-Tyne.
1S43 Robert William Smith, M.D. M.R.I.A., Professor of
Surgery in the University of Dublin ; Surgeon to the
Richmond Hospital ; Dublin.
1845 William Smith, Park-street, Bristol.
18-47 William Smith, M.D., Weymouth, Dorsetshire.
1850 William Tyler Smith, M.D., Physician -Accoucheur to
St. Mary's Hospital; Upper Grosvenor-street, Grosvenor-
square.
1843 John Snow, M.D., Frith-street, Soho-sqnare.
1819 *George Snowden, Ramsgate, Kent.
1851 John Soden, Surgeon to the Bath Hospital ; Bath, Somerset.
1816 *John Smith Soden, New Sidney-place, Bath.
1830 Samuel Solly, F.R.S., Senior Assistant-Surgeon to
St. Thomas's Hospital ; St. Helen' s-place, Bishopsgatc-
street. L. 1838. C. 1845. V.P. 1849.
1844 FREDERiCKRoBERTSPACKMAN,M.B.,Harpenden, St.Alban's.
1834 James Spark, Newcastle, Staffordshire.
1851 Robert JonN Spitta, M.B., Clapham, Surrey.
1843 *Stephen Spranger, Grantham, Lincolnshire.
1838 George James Squibb, Orchard street, Portman-square.
1815 Edward Stanley, F.R.S., Surgeon to St. Bartholomew's
Hospital; Brook-street, Grosvenor-square. C. 1821.
S. 1824. V.P. 1827. T. 1832. P. 1843.
1851 James Startin, Savile-row, Regent-street.
1842 Alexander Patrick Stewart, M.D., Assistant-Physician
to, and Lecturer on Materia Medica at, the Middlesex
Hospital; Grosvenor-street, Grosvenor-square.
1839 Thomas Stone, M.D., Haydock Lodge Retreat, near
Warrington, Lancashire.
1843 Robert Reeve Storks.
1844 John Sopek Streeter, Harpur-street, Red Lion-square.
1847 William Allen Sumner, Surgeon to the Portland Town
Free Dispensary ; Abbey-road, St. John's Wood.
1839 Alexander John Sutherland, M.D. F.R.S., Physician to
St. Luke's Hospital ; Parliament-street, Westminster.
C. 1850.
XXXIV FELLOWS OF THE SOCIETY.
Elected
1842 James Stub, Professor of Clinical Surgery in the University
of Edinburgh ; Charlotte -square, Edinburgh.
1844 Richard William Tamplin, Surgeon to the Royal Ortho-
paedic Hospital ; Old Burlington-street.
1848 Thomas Hawkes Tanner, M.D., Physician to the Hospital
for Women, Red Lion-square ; Charlotte-street, Bedford-
square.
1840 Thomas Tatum, Surgeon to, and Lecturer on Surgery at,
St. George's Hospital ; George-street, Hanover-square.
1835 John Colley Taunton, Surgeon to the City of London
Truss Society, and to the City Dispensary ; Hatton-
garden, Holborn. C. 1840.
1845 *John Taylor, M.D., Physician to the Infirmary; Hudders-
field.
1845 Thomas Taylor, Vere-street, Cavendish-square.
1817 Frederick Thackeray, M.D., Physician to Addenbrooke's
Hospital, Cambridge.
1845 Evan Thomas, Pwllheli, North Wales.
1839 Seth Thompson, M.D., Secretary; Physician to, and Lec-
turer on Medicine at, the Middlesex Hospital ; Lower
Seymour-street, Portman-square. C. 1849. S. 1850.
1842 Theofhilus Thompson, M.D. F.R.S., Physician to the
Hospital for Consumption and Diseases of the Chest ;
Bedford-square.
IS.'i.'i Fkederick Hale Thomson, Berners-street, Oxford -street.
1819 John Thomson, M.D. F.L.S., Vice- President ; Physician to
the Finsbury Dispensary ; Dalby-terrace, Islington.
C. 1833. L. 1834. V.P. 1850.
1850 Robert Dundas Thomson, M.D., Professor of Chemistry,
liiiviisity of Glasgow.
1836 John Tin i:\am, M.D., Devizes, Wiltshire.
is |,s Edward John Tilt, M.D., Physician to the Farringdon
Dispensary ; York-street, Portman-square.
183 I BoSlIH 15i-.nti.ky TODD, M.D. F.R.S., Treasurer; Physician
to King 'a College Hospital, Professor of Physiology and
of General ami Morbid Anatomy in King's College,
London; New-street, Spring-gardens. L. 1842, T.
1850.
FELLOWS OF THE SOC1ISTY. XXXV
Elected
1828 James Torrie, M.D., Aberdeen.
1843 Joseph Toynbee, F.R.S., Surgeon to the St. George's and
St. James's Dispensary, and Aural Surgeon to St. Mary's
Hospital ; Savile-row, Regent-street.
1850 Samuel JonN Tracy, Surgeon-Dentist to St. Bartholomew's
and Christ's Hospitals; Finsbury-plaee, Finsbury-square.
1808 Benjamin Travers, F.R.S., Surgeon Extraordinary to the
Queen, Surgeon in Ordinary to His Royal Highness
Prince Albert; Bruton-street, Bond-street. C. 1810.
V. P. 1817. P. 1827.
1841 Matthew Truman, M.D., Norland-square, Notting-hill.
1835 John Cusson Turner, M.D., Brighton.
1845 Thomas Turner, Surgeon to the Royal Manchester Infirmary,
and Lecturer on Anatomy ; Mosley-street, Manchester.
1846 Alexander Ure, Surgeon to the Westminster General Dis-
pensary, and to St. Mary's Hospital ; Grosvenor-street,
Grosvenor-square.
1819 Barnard Van Oven, M.D., Consulting Surgeon to the
Charity for Delivering Jewish Lying-in Women; Gower-
street, Bedford-square.
1806 Bowyer Vaux.
1839 William Randall Vickers, Baker-street, Portman-square.
1814 *John Painter Vincent, Woodland's Kemsing, near Seven-
oaks, Kent.
1810 James Vose, M.D.
1828 Benedetto Vulpes, M.D., Physician to the Hospital of
Aversa, and to the Hospital of Incurables, Naples.
1841 Robert Wade, Surgeon to the Westminster General Dis-
pensary ; Dean-street, Soho.
1823 William Wagner, M.D., Berlin.
1820 Thomas Walker, M.D., Physician to the Forces; Lower
Seymour-street, Portman-square.
1851 Henry Haynes Walton, Assistant-Surgeon to St. Mary'8
Hospital ; Grosvenor-street, Grosvenor-square.
1846 Nathaniel Ward, Assistant-Surgeon to, and Demonstrator
of Anatomy at, the London Hospital ; Broad-street-
buildings, City.
1845 Thomas Ogier Ward, M.D., Leonard-place, Kensington.
XXXVI FELLOWS OF THE SOCIETY.
Elected
1821 William Tilleard Ward, York -place, Portman-square.
1846 James Thomas Ware, Surgeon to the Finsbury Dispensary;
and to the Convalescent Institution, Russell-square.
1811 John Ware, Clifton, near Bristol.
1814 Martin Ware, Russell-square. C. 1844. T. 1846.
1816 *Charles Bruce Warner, Cirencester, Gloucestershire.
1829 Elias Taylor Warky, Wimborne, Dorsetshire.
1837 Thomas Watson, M.D., Henrietta-street, Cavendish-square.
C. 1840. V.P. 1845.
1S47 *Thomas Watson, Holbeach, Lincolnshire.
1840 William Woodham Webb, Gislingham, near Thwaite,
Suffolk.
1842 Frederic Weber, M.D., Physician to the St. George's and
St. James's Dispensary ; Norfolk-street, Park-lane.
1835 John Webster, M.D. F.R.S., Consulting Physiciau to the
St. George's and St. James's Dispensary; Brook-street,
Grosvenor-squnre. C. 1843.
1844 William Wegg, M.D., Physician to the St. George's and
St. James's Dispensary; Maddox - street, Hanover-
square.
1816 Sir Augustus West, Knt., Deputy-Inspector of Hospitals
to the Portuguese Forces ; Paris.
1842 Charles West, M.D., Lecturer on Midwifery at St. Bar-
tholomew's Hospital; Wimpole-street, Cavendish-square.
1811 Thomas West, M.D. F.L.S., Daventry.
1828 John Whatley, M.D.
1849 John White, The Albany, Piccadilly.
1840 Joseph Wk ken of. n, Birmingham.
1824 *Wili,iam John Wickiiam, Surgeon to the Winchester
Hospital ; Winchester.
1844 Fbkdzbiok Wh.dhore, High-street, Shoreditch.
1837 George Augustus Frederick Wn KB, M.D., Temple-walk,
Matlock, Derbyshire.
1840 Charles JaHXS Blasttjs Williams, M.D. F.R.S., Holles-
Btreet, Cavendish-square, C 1849.
isjii limpid Win. is, M.D., Barnes, Surrey. L. 1838.
1839 Erasmus Wilson, F.R.S., Consulting Surgeon to the St.
Pancras Infirmary ; Henrietta-street, Cavendish-square.
FELLOWS OF THE SOCIETY. XXXV11
Elected
1839 James Arthur Wilson, M.D., Physician to St. George's
Hospital; Dover-street, Piccadilly. C. 1846.
1831 William James Wilson, Surgeon to the Manchester
Infirmary ; Manchester.
1850 *Robert Stanton Wise, M.D., Banbury, Oxon.
1825 Thomas Alexander Wise, India.
1851 John Wood, Haymarket.
1841 George Leighton Wood, Surgeon to the Bath Hospital;
Queen-square, Bath.
1848 William Wood, M.D., Resident Medical Officer, Bethlem
Hospital.
1843 John Ward Woodfall, M.D., Assistant-Physician to the
Westminster Hospital ; Davies-street, Berkeley-square.
1847 Robert Woollaston, Conduit-street, Westboume-terrace.
1833 Thomas Wormald, Assistant-Surgeon to St. Bartholomew's
Hospital ; Bedford-row. C. 1839.
1842 William Collins Worthington, Surgeon to the Infirmary,
Lowestoft, Suffolk.
1848 Edward John Wright, Kennington-row, Kennington.
[It is particularly requested, that any change of Title or Residence may be
communicated to the Secretaries before the 1st of August in each year, in
order that the List may be made as correct as possible.]
FELLOWS Or THE SOCIETY,
HONORARY FELLOWS.
{Limited to Twelve.)
Elected
1841 William Thomas Brande, F.R.S. L. and Ed., Professor of
Chemistry at the Royal Institution of Great Britain ;
Royal Mint, Tower-hill.
1835 Sm David Brewster, K.H. LL.D. F.R.S. L. and E., &c,
Cor. Mem. Institute of France, &c. ; Kingussie.
1841 Robert Brown, D.C.L. F.R.S. , Vice-President of the Lin-
nean Society ; British Museum.
1835 The Very Rev. William Buckland, D.D. F.R.S., Dean of
Westminster.
1847 Edwin Chadwick, Commissioner of the Board of Health.
1835 Michael Faraday, D.C.L. F.R.S., Cor. Memb. Institute
of France ; Royal Institution.
1841 Sir JonN Frederick William Herschel, Bart., D.C.L.
F.R.S., President of the Royal Astronomical Society ;
Somerset-House.
1835 Sir William Jackson Hooker, LL.D. F.R.S. L. and E.,
Royal Botanic Garden, Kew.
1847 Richard Owen, F.R.S., Cor. Memb. Institute of France ;
Huntcrian Professor to, and Curator of the Museum of,
the Royal College of Surgeons of England.
1835 The Rev. Adam Sedgwick, A.M. F.R.S. &c, Woodwardian
Lecturer, Cambridge.
1841 The Rev. William Wiiewell, D.D. F.R.S., Master of
Trinity College, Cambridge.
FELLOWS OF THE SOCIETY.
FOREIGN HONORARY FELLOWS.
(Limited to Twenty-four.)
Elected
1841 G. Andral, M.D., Professor in the Faculty of Medicine,
Paris.
1815 Paolo Assalini, M.D., Professor of Surgery, and Chief
Surgeon to the Military Hospital at Milan, &c.
1835 Carl Johan Eckstrom, K.P.S. and W., Physician to the
King of Sweden, First Surgeon to the Seraphim Hospital,
Stockholm.
1835 W. J. Edwards, M.D. F.R.S., Member of the Institute of
France, Paris.
1841 Christian Gottfried Ehrenberg, Berlin.
1835 Baron A. de Humboldt, Member of the Institute of France,
&c. ; Berlin.
1841 James Jackson, M.D., Professor of Medicine in the Uni-
versity of Cambridge, Boston, U.S.
1843 Baron Justus Liebig, M.D. F.R.S., Professor of Chemistry
in the University of Giessen, &c.
1841 P. C. A. Louis, M.D., Physician to the Hotel- Dieu,
Member of the Royal Academy of Medicine, &c,
Paris.
1841 F. Magendie, M.D., Member of the Institute; Physician to
the Hospital of the Salpetriere ; Paris.
1847 Professor Carlo Matteucci, University of Pisa.
1841 Johann Muller, M.D., Professor of Anatomy and Phy-
siology, and Director of the Royal Anatomical Museum,
Berlin.
1835 J. C. Oersted, M.D., Professor of Physics in the University
of Copenhagen, &c. &c.
1835 Professor Orfila, Dean of the Faculty, &c. &c, Paris.
1841 Bartolomeo Panizza, M.D., Pavia.
1850 Carl Rokitansky, M.D., Curator of the Imperial Patho-
logical Museum at the University of Vienna, &c. &c.
Xl FELLOWS OF THE SOCIETY.
Elected
1843 Philibert Joseph Roux, Member of the French Institute;
Surgeon in Chief of the Hotel-Dieu ; Professor in the
Faculty of Medicine, Paris.
1835 C. J. Timminck, Director of the Museum of Natural History
of the King of Holland, Amsterdam.
1835 Frederick Tiedemann, M.D., Professor of Anatomy and
Physiology, Heidelberg.
1841 John C. Warren, M.D., Professor of Anatomy and Surgery
in the University of Cambridge, Boston, U.S.
CONTENTS.
List of Officers and Council
List of Referees
List of Presidents of the Society
List of Fellows of the Society -
I. History of a successful case of Ovariotomy. By E. W. Duffin,
Surgeon. With a Description of the Morbid Anatomy of the
Sac. By Robert Lee, M.D. F.R.S., Fellow of the Royal Col-
lege of Physicians, Physician to the British Lying-in Hospital,
Physician-Accoucheur to the St. Mary- le- Bone Infirmary,
Lecturer on Midwifery and the Diseases of Women and Chil-
dren at St. George's Hospital - - 1
II. An Analysis of 10S Cases of Ovariotomy, which have occurred in
Great Britain, with Appendix. By Robert Lee, M.D. F.R.S.,
Fellow of the Royal College of Physicians, Physician to the
British Lying-in Hospital, Physician -Accoucheur to the St.
Mary - le - Bone Infirmary, Lecturer on Midwifery and the
Diseases of Women and Children at St. George's Hospital - 10
III. A Case of Softening of the Spinal Marrow in a boy affected with
Chorea. By Robert Nairne, M.D., Physician to, and Lecturer
on Medicine at, St. George's Hospital - - -37
IV. Case illustrating the difficulties of Diagnosis of Morbid Growths
from the Upper Jaw : with Remarks. By Preseott Hewett,
Assistant Surgeon to St. George's Hospital, and Lecturer on
Anatomy - - - - - 43
V. Cases of Rupture of the Liver or Spleen : with Remarks. By
Athol Johnson, Fellow of the Royal College of Surgeons,
Surgeon to the St. George's and St. James's Dispensary, and
Lecturer on Physiology and General Anatomy at St. George's
Hospital - - 53
VI. Account of a case in which the Cesarean Section was performed ;
with Remarks on the peculiar sources of Danger attendant on
the Operation. By Charles West, M.D., Physician-Accoucheur
to St. Bartholomew's Hospital, and Lecturer on Midwifery in
the Medical College - - - - 61
d
xlii
PAGE
VII. A Case of Caesarean Section. By Dr. Oldham, Obstetric Phy-
sician and Lecturer on Midwifery, &c, at Guy's Hospital - 89
VLTI. Case of Extensive Necrosis of the Boues of the Cranium and
removal of large portions thereof. By John Druminond,
F.R.M.C.S., Deputy Inspector of Hospitals, Melville Naval
Hospital, Chatham ----- 103
IX. An account of a Case of Fracture and Distortion of the Pelvis,
combined with an unusual form of Dislocation of the Femur.
By Charles Hewitt Moore, Surgeon to the Middlesex Hospital.
(With Two Woodcuts) - - 107
X. Experiments on Chylous or Chylo - Serous Urine. By Johu
Mayer, Esq., Assistant Surgeon to the Second Native Veteran
Battalion. With a History of the Patient. By George Pearse,
M.D., Garrison - Surgeon of Bangalore. Communicated by
H. Bcnce Jones, M.D. F.R.S. - '- 1 L8
XI. Cases illustrating some Difficulties in the Diagnosis of Pleuritic
Effusion. By T. A. Barker, M.D., Physician to, and Lecturer
ou the Practice of Medicine at, St. Thomas's Hospital - 131
XII. Case of Popliteal Aneurism treated by Compression, with some
Remarks upon this method of treating Aneurism, and a List
of the Cases in which it has been employed in Dublin. By
O'Bryen Bellingham, M.U., Fellow of, and Member of the
Court of Examiners of, the Royal College of Sturgeons in
Ireland, Surgeon to St. Vincent's Eospital, &c., ire. Com-
municated by Sir Benjamin Brodie, Bart., F.U.S. - - 1 13
XIII. Account of the Dissection of a case in which Two Popliteal
Aneurisms had been treated bj Compression of the Femoral
Arteries. Bj Prescotl Hewett, Assistant Surgeon to St.
George's Hospital, and Lecturer ou Anatomy, &c. - - 1G1
XIV. Ou the Relation of Sleep to Convulsive Vll'eetious. I'.\ William
Frederick Barlow, M.R.C.S., Resilient Medical Officer to the
Westminster Hospital - - - 107
XV. On Fitly Degeneration of the Placenta, and the Influence of
this Disease in producing Abortion, Death of the I
I hemorrhage, and Premature Labour. Bj Roller! Barnes,
-Ml > . (LoncL), Obstetric Surgeon to the Western Gh
Dispensary, and Lecturer on Midwifery, Communicated by
Professor Murphy. (With Two I'latcs) - - - 183
\\ I On some Secondary PI ■ I bj Atmo-
spheric Electricity, B\ C, F. Schonbein, Professor ol Chemistry
at Basle, &c . Stc. 1 Id Faraday, D.I I.
F.R.8., Professor ol Chemi trj al the Royal Institution,
IIouorai\ I'Vilou ol the Mi. heal and Chimi 205
CONTENTS. xliii
PAGE
XVII. On the Employment of the Heat of Electricity in Practical
Surgery. By John Marshall, F.R.C.S.. Assistant -Surgeon to
the University College Hospital. Communicated by Richard
Quain, Esq., F.R.S. - - - - 221
XVIII. A Case of Strangulated Obturator or Thyroideal Hernia,
successfully relieved by Operation. By Henry Obre, formerly
Assistant-Surgeon to the St. Mary-le-Bone Infirmary. Com-
municated by Professor Erichsen - - - 233
XIX. Some Observations on the Pathology of those Affections of the
Ear which produce Disease in the Brain. By Joseph Toynbee,
E.R.S., Fellow of the Royal College of Surgeons in England,
Aural Surgeon to St. Mary's Hospital, and Consulting Surgeon
to the St. George's and St. James's General Dispensary. (With
Four Woodcuts) - - - - - 239
XX. A Case of Obstruction of the Colon, relieved by an Operation
performed at the Groin. By James Luke, Senior Surgeon to
the London and St. Luke's Hospitals, Lecturer on Surgery,
and Member of the Council of the Royal College of Surgeons
of England, &c, &c. Communicated by James Moncrieff
Arnott, F.R.S. - - - - - 263
XXI. On the Variations of the Sulphates and Phosphates excreted in
Acute Chorea, Delirium Tremens, and Inflammation of the
Brain. By H. Benee Jones, M.D. A.M. (Cantab.), F.R.S.
F.C.S., Physician to St. George's Hospital - - 277
XXII. Account of a case in which a Large Cyst containing Hydatids
was developed at the Root of the Neck, death ensuing from
Rupture of the Left Subclavian Artery. By James Dixon,
Surgeon to the Royal London Ophthalmic Hospital, and
• Assistant-Surgeon to St. Thomas's Hospital - - 315
XXIII. A Case of Aneurismal Dilatation of the Posterior Tibial Vein,
communicating indirectly with the Upper Part of the Popliteal
Artery. By Edward Cock, Surgeon to Guy's Hospital. (With
One Woodcut) - - - - - 327
XXIV. On a New Method of Treatment applicable to certain Cases
of Epiphora. By William Bowman, F.R.S., Professor of Phy-
siology and of General and Morbid Anatomy in King's College,
Assistant-Surgeon to the King's College Hospital, and to the
Royal London Ophthalmic Hospital - - - 337
Donations to the Library ----- 347
Index - - - - - - 355
ADVERTISEMENT.
The Council of the Royal Medical and Chirurgical Society
deems it proper to state, that the Society does not hold
itself in any way responsible for the statements, reasonings,
or opinions set forth in the various papers, which, on grounds
of general merit, are thought worthy of being published in
its Transactions.
HISTORY OF A
SUCCESSFUL CASE OF OVARIOTOMY.
BY
E. \V. DUFFIN, Surgeon.
WITH A DESCRIPTION OF
THE MORBID ANATOMY OF THE SAC.
BY
ROBERT LEE, M.D. F.R.S.
fellow of the royal college of physicians,
physician to the british lying-in hospital,
physician-accoucheur to the st. mary-le-bone infirmary,
lecturer on midwifery and the diseases of women and children
at st. George's hospital.
Received September 19th. — Head November 12tb, 18">0
On the 23d of August last, a woman, 38 years of age,
and whose general health was in every respect unimpaired,
applied to me for the purpose of having an Ovarian Cyst
extirpated. The tumour completely filled the abdomen, and
in so uniform a manner, that it was impossible to determine
in which ovary it was seated; though, from the imperfect
history the patient gave of the commencement of her disease,
there was reason to believe that the left ovarium was the
organ affected. The patient presented the appearance of a
woman who had completed her eighth month of pregnancy,
and stated that the abdomen had attained this size in the
course of seven or eight months ; as previous to the early
part of the year no visible enlargement of the region existed;
nor was she in any way aware that she was the subject of
1
2 me. duffin's case or OVARIOTOMY.
the tumour in question. The progress of the disease, there-
fore, seemed to be more than usually rapid, and was, moreover,
complicated with frequent and severe attacks of neuralgia in
the outer and lower third of the right thigh ; caused, as was
afterwards proved, by the pressure of the cyst on the cor-
responding sciatic nerve. The tumour could easily be moved
by manipulation of the abdominal parietes j and, so far as
could be ascertained by such means, was free from adhesions
likely to interfere with its extirpation. The woman was
herself very urgent, and impatient to get rid of the disease,
though made fully aware by myself and others of the extreme
danger that would attend the operation. She was, however,
a person of strong nerve, and very determined character ;
fully impressed, moreover, in her own mind, that the operation
would not prove fatal; a circumstance which had great weight
in determining me to yield to her solicitations.
On the 27th of the month, the patient took a dose of
active purgative medicine, in order to evacuate her bowels
very completely, and render it unnecessary to administer
any further aperient for several days. On the following
afternoon, assisted by Messrs. Fergusson, Ire, and Henry
Smith, and in the presence of Dr. Barker, of St. Thomas's
Hospital, I proceeded to remove the sac, Dr. Snow having
kindly undertaken to administer chloroform beforehand ; the
temperature of the apartment was raised to about 80° of
Fahrenheit.
The patient being placed in a reclining position at the
edge of her bed, was supported behind by Mr. I re, who,
by passing bis arms round her body, kept up the necessary
amount of support by compressing the abdomen on each side
with both hands, so as to compensate for the loss of support
to t lie \ iscera, in proportion as the sac discharged its contents.
An incision "as made into the abdomen in the course of the
linea alba, midway between the umbilicus and pubes, but
only of siillieient size to admit the forefinger, that the
surface of the tumour might be firsl carefully examined by
this means, and its freedom from adhesions likely to frustrate
the future steps of the operation ascertained. The tumour
MR. DUFMN S CASE OF OVARIOTOMY. IS
was found to be unattached at all points except its base :
here the attachment was extensive, involving the whole
length of the broad ligament, which in the course of the
disease, as afterwards appeared, had become considerably
elongated. The opening in the abdominal parietes was then
enlarged by means of a director and bistoury, till the length
was nearly three inches. The contents of the sac, amounting
to 130 fluid ounces, were then evacuated by means of a
trocar introduced at the commencement of the lower third
of the tumour. As the thick, viscid, ropy, light brown-
coloured fluid escaped, the parietes of the cyst were care-
fully drawn by a rotary movement through the opening in
the abdomen. At this part of the operation some difficulty
was experienced in consequence of the sac containing within
its parietes a secondary cyst about the size of an ordinary
orange, and which was found afterwards to contain rather
more than two ounces of the same kind of viscid fluid. This
sac, had it been a trifle larger, must of necessity have been
perforated by slitting open, to a certain extent, the primary
cyst, and again using the trocar. The tumour being now
entirely out of the abdomen, was found to be attached at its
base, by a neck of an inch and a half, or thereabouts, in
length. On examining this carefully, three large arteries
and one considerable vein were discovered. Between the
roots of these a needle was passed armed with a double
ligature, formed of three threads of strong silk, and
tied on each side. A general ligature was then passed
round the whole neck externally, for greater safety, and
the tumour was separated by means of a pair of knife-edged
scissors.
Reflecting on the two great causes of death, in unsuccessful
cases of Ovariotomy, and the three several periods at which
a fatal termination may occur, — viz. either within forty-eight
hours, owing to the direct shock of the operation; a day or
two later, from inflammation of the peritoneum arising from
wounding this membrane ; or at a still later period, caused,
as it appears, on the separation of the slough by putrefactive
I MR. DUFFIN's CASE 01'' OVARIOTOMY.
decomposition within the peritoneal cavity; — it suggested
itself to me, that this latter consequence, as well as the
irritation created by the ligature remaining in the abdomen,
might be obviated by keeping the tied portion completely
out of this cavity. I determined, therefore, to do so, by
stitching the cut extremity and ligature in the wound, so as
to prevent their receding into the pelvis, and to retain them
in that situation till the ligature should come away, and
the wound, if it previously closed, reopen to let the slough
escape. Had the neck of the cyst been longer, it was my
intention to have kept the whole portion included in the
ligature entirely outside the abdominal parieteg, by passing a
long needle through it, exterior to the surface ; but not being
of a length sufficient to admit of this, the above plan was
substituted, and I have great satisfaction in saying that it
answered every expectation; the wound healing up entirely
by the first intention, and afterwards, on the ninth day,
opening, for the purpose of allowing the ligature and slough
to escape on the fifteenth ; then continuing to suppurate for
a few days, till the reopened part finally closed on the twenty-
second day. The only objection to this plan was the dis-
agreeable dragging, of which the patient afterwards com-
plained, occasioned by the abdominal parietcs being, as it
were, tied down to the spine. On the separation of the
ligature the abdomen resumed its naturally round contour,
and the dragging sensation gradually ceased, disappearing
altogether in about a fortnight. Could it have been ascer-
tained with sufficient certainty beforehand, that (he seat of
disease was the left ovarium, the opening through the
abdominal parietcs might have been made through the
fascia transversalis, at a point more directly over the base of
the tumour; the distance between the ligature and external
Opening would then have been considerably less, and the
disagreeable dragging, in all probability, would have been
obviated. In the present instance it appears, that the
separated end of the neck of the cyst formed no adhesion to
tlie peritoneum, though kept in contact with that membrane
during fourteen daw or at least none of sufficient strength
Ma. duffin's case of ovariotomy. 5
to resist the subsequent elevation of the abdomen, as nothing
of the kind could, after that time, be detected ; the intestines
having to all appearance resumed their proper situation, and
the form of the body its natural roundness. Had the
attachment continued, a permanent band crossing the pelvis
in an oblique direction would have existed, around which
the intestines might have coiled, and become the seat of
internal hernia.
Treatment. — Shortly after the patient was put to bed, she
took two grains of opium, and passed a good night. The
next morning (29th) I found her with a tranquil, soft, re-
gular pulse (7G) ; moist, though somewhat white, tongue,
the effect of the opium ; perspiring skin, and cheerful coun-
tenance; there was no tenderness of abdomen, and the wound
was uniting. To prevent the necessity of her stirring from
the position in which she had been placed, the bladder was
emptied by means of the catheter, and two grains of opium
were again administered, her diet being restricted to tea,
bread and butter, and water gruel. She passed the day
tranquilly ; sleeping soundly, or dosing the greater part of
the time. At night, the urine was again drawn off, and two
grains more of opium were given. The same phenomena
presented themselves daily, and the same treatment was
pursued, till the fifth morning, when she complained a good
deal of the dragging uneasiness already alluded to ; the
abdomen was somewhat tumid from flatulence, and tender
to the touch ; pulse 86, but soft. A copious enema of salt
and water was carefully injected, and the bowels by this
means being speedily emptied on a sheet doubled and passed
under her as she lay, that the position she had preserved
since the operation might not in any way be disturbed, the
tenderness soon subsided, and in the afternoon I found her
as well as on the preceding days. The opium was repeated ;
she slept well, and in the morning had not an untoward
symptom. The enema was again administered with ad-
vantage, and at night the opium. She was now allowed
I) MR. Ul'FFlN 'B CASE OF OVAKIOTOMT.
sonic chicken broth. Every morning an injection was given,
the opiate, however, was discontinued on the seventh night.
The wound healed by the first intention ; but on the ninth
day its lower fourth began to reopen, and discharged fetid
matter. On the fifteenth day the ligature and a part of the
slough came away. In the course of the following week the
remainder of the slough was discharged along with the
matter secreted by the edges of the wound ; and on the
twenty-second clay the whole was healed. The enemata were
discontinued after the fifteenth day ; the patient then rose to
the night-chair. On the eighteenth she was able to get up
and move about her room, but complained of faintness, which
gradually went off as she became accustomed to the change
of position. Since the above date she has daily gained
strength, and been for some weeks past engaged in her usual
occupation, that of a ladies' dressmaker.
DISSECTION OF THE CYST.
ROBERT LEE, M.D. F.R.S.
An Ovarian Cyst, which contained two gallons of thick,
\isrid, brownish fluid, was removed by Mr. Duflin through
an opening in the abdominal parietes, on the 27th of August
last. The following is an anatomical description of the walls
of this cyst. They are composed of three distinct coats ox
layers. First, a peritoneal covering; secondly, a middle
fibrous coat; and thirdly, a dense membranous sac, in which
t he fluid had been contained.
At the pedicle or root of the cyst, the peritoneal coat has
been divided by an incision an inch and a half iu length.
The flit cuds of three considerable arteries and one large
DR. LEE's DISSECTION OF AN OVARIAN CYST. 7
vein arc seen in this opening, and likewise the divided
extremity of the fallopian tube. The peritoneum is here
thin, and adheres loosely by cellular membrane to the middle
coat; but over the whole of the remaining portion of the
cyst, the peritoneum is thick, opaque, and adheres firmly to
the tissue below. The peritoneal covering of the cyst does
not essentially differ from the peritoneum, which invests the
pelvic and abdominal viscera, with which it had evidently
been continuous. The fallopian tube, about a foot in length,
extends from the pedicle or root to the opposite extremity
of the cyst, where it is seen terminating in the corpus
fimbriatum.
The middle coat of the cyst is thick at the pedicle, and
has been separated into several distinct strata or layers, to
which numerous branches of arteries are distributed. With
these arteries are observed, proceeding to the middle coat,
numerous trunks and branches of nerves with ganglionic
enlargements. The middle coat becomes thinner as it ex-
tends outward from the root to the apex of the cyst, where
it presents the appearance of a very dense fibrous mem-
brane, which closely adheres both to the peritoneum and
the internal coat of the cyst. In the preparation, these
three layers at this extremity are seen entirely separated
from one another, and constituting three perfectly distinct
structures.
The internal coat of the cyst is firm and thick, and
presents on its inner surface a rough, irregular, puckered
appearance, which, in some spots, has a brown or yellowish
colour. Little difficulty was experienced in detaching the
internal from the middle coat at the root, but at the apex
they adhered very firmly to one another, as did the middle
to the peritoneal coat. The first attempt to divide the in-
ternal coat of the cyst into two distinct membranes was
not successful ; but at the suggestion of Mr. Henry Charles
Johnson, on the 8th inst., who then expressed his conviction,
that it would be found to consist of two perfectly distinct
membranous layers, like the wall of the Graafian vesicle,
8 DR. LEE S DISSECTION OF AN OVARIAN CYST.
I renewed the attempt with the forceps and point of the
scissors, while the parts were immersed in rectified alcohol,
and succeeded in clearly demonstrating that the inner coat
of the cyst is not a simple membrane, but consists of two
distinct membranous layers, like the wall of the Graafian
vesicle.
Imbedded in the middle coat, near the root, is another
and much smaller cyst with a lining membrane, which pre-
sents, on the inner surface, precisely the same appearances as
those seen on the inner surface of the larger cyst. The
lining membrane of this smaller cyst is likewise composed of
two distinct layers, like that of the larger cyst and the
Graafian vesicle, both before and after the escape of the
ovum. From the preparation, it is seen that a thin stratum of
the middle coat is interposed between these two cysts, and
that they are independent of each other. But the smaller
cyst, though not adherent to the outer surface of the larger,
has grown so as to encroach on the cavity of the latter, the
lining membrane of which smaller cyst has protruded before
it. From this dissection it is obvious, that the smaller
cyst did not grow from the inner surface of the larger, nor
from its outer surface ; but that in the progress of develop-
ment of the smaller cyst, it pushed before it a portion of the
lining membrane of the larger, and thus acquired the layer
of reflected membrane from the inner coat of the larger cyst
by which it is invested.
At the base or root of the great cyst in the middle fibrous
coat, between the outer surface of the smaller cyst and
peritoneum, there is a group of small multiloculai cysts,
which contained similar fluid, have all the same structure,
and bear the same relation to one another, as the two cysts
above described. These multilocuhv cysts have evidently
been formed independently of each other; hut in the pro-
gress of their growth and enlargement, some of them have
encroached upon the cavities of those cysts with which they
were contiguous, and in the same mechanical manner hn\e
acquired reflected portions of their membranes.
DE. LEE'S DISSECTION OF AN OVARIAN CYST. \)
The walls of this Ovarian Cyst, which I have now described,
contain all the elementary structures 'which enter into the
composition of the human ovarium in the healthy condition,
peritoneum, stroma and Graafian vesicles, with blood-vessels
and ganglionic nerves ; — whether all multilocular cysts are
formed in the same manner, future observation must de-
termine.
AN ANALYSIS OF
108 CASES OF OVARIOTOMY,
WHICH HAVE OCCI'RRF.D l>
GREAT BRITAIN.
ROBERT LEE, M.D. F.R.S.
FELLOW OF THE ROYAL COLLEGE OF PHYSICIAN-,
PHYSICIAN TO THE BRITISH LYING-IN HOSPITAL,
PHYSICIAN-ACCOUCHEUR TO THE ST. MARY-LE-BONE INFIRMARY.
LECTURER ON MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN,
at ST. George's hospital.
Received October 80th.— Read November ISth, 1*50.
Dr. Nathan Smith, Professor of Physic and Surgery in
Yale College, Connecticut, published, in the ' Edinburgh
Medical and Surgical Journal' for 18:22, the history of a
" Case of Ovarian Dropsy, successfully removed by a Surgical
Operation." There was a large tumour in the right side of
the abdomen, which was moveable to a considerable extent,
and in which a distinct fluctuation could be perceived.
" The patient being placed on a bed," observes Dr. Smith,
"with her head and shoulders somewhat raised, an assistant
pushed up the tumour to the middle of the abdomen, and
held it there. I then commenced an incision about an
null below the umbilicus, directly in the lima alba, and
extended it downwards three inches. I carried it down to
the peritoneum, and there stopped till the blood had ceased
to Bow, which it soon did. The peritoneum was then
divided the whole extent of the external incision. The
tumour, now exposed to \ iew , was punctured; a eanula was
introduced, ami seven pints of a dark-coloured ropy Said
were discharged into a vessel. About one pint was lost, so
Dll. lee's analysis of CASES OF OVARIOTOMY. 1 1
that the whole was about eight pounds. Previous to punc-
turing the tumour, by introducing the finger by the side of
itj I ascertained that it adhered for some extent to the
parietes of the abdomen, on the right side, between the
spine of the ilium, and the false ribs. After evacuating the
fluid, I drew out the sac, which brought out with it, and
adhering to it, a considerable portion of omentum. This
was separated from the sac by the knife; and two arteries,
which we feared might bleed, were tied with leather liga-
tures, and the omentum was returned. By continuing to
pull out the sac, the ovarian ligament was brought out ; it
was cut off; two small arteries were secured as before, and
the ligament returned. I then endeavoured to separate the
sac from its adhesions to the parietes of the abdomen, which
occupied a space about two inches square. This was effected
by a slight touch of the knife, at the anterior part of the
adhesion, and by the use of the fingers. The sac then came
out whole, excepting where the puncture had been made,
and I should think it might weigh between two and four
ounces. The incision was then closed with adhesive plaster,
and a bandage applied round the abdomen. No unfavor-
able symptoms occurred after the operation. In three weeks
the patient was able to sit up and walk, and since has per-
fectly recovered ."
This operation, similar in the first stage to the Csesarean
section, but much less formidable, was undertaken by Pro-
fessor Smith, from the following considerations : — " The
patient, although her health was not greatly injured, was
sensibly affected by the disease. She was quite certain that
the increase of the tumour in a given time was augmented,
and probably, at no distant time, would destroy her. — I had
also an opportunity to dissect the body of a patient who had
died of ovarian dropsy, after having been tapped seven times.
In this case, the sac was found to be the right ovarium,
which filled the whole abdomen, but adhered to no part,
except the proper ligament, which was not larger than the
finger. — I have seen two other ovarian sacs which were
taken from patients after death ; they had been tapped
12 DR. LEE'S ANALYSIS OF CASES OF OVAIUOTOMT-.
several times, and the sacs were equally unattached, except
to their own ligaments. Thence I inferred, that in a case
of ovarian dropsy, while the tumour remained moveahle, it
might be removed with a prospect of success ; and the event
has justified my expectations. The mode of operating in
the above case has been described in several of my last
courses of 'Lectures on Surgery.' "
In the following year, 1823, Mr. John Lizars, of Edin-
burgh, made a long incision through the abdominal parietes
of a woman, aged 27, who, in the opinion of some of the most
experienced physicians in that city, was afflicted with ovarian
disease; but the symptoms were produced by obesity and
distension of the intestines, and there was no ovarian cyst or
tumour found present to remove, on laying open the abdo-
men. This patient did not die from the operation. In
1825 Mr. Lizars removed an enlarged ovarium by a long
incision from another patient. Some haemorrhage followed
the operation. The other ovarium was diseased, and was
not removed. In 1825 Mr. Lizars operated in another case,
and the results were fatal. In 182G Mr. Lizars repeated
the operation, but he encountered a vascular tumour which
could not be removed. In 1820 Dr. Granville made an
incision of nine inches and a half through the abdominal
parietes of a woman who had an ovarian cyst ; but the
adhesions were so strong, that the operation was abandoned.
In 1827 Dr. Granville repeated the operation, but there was
no ovarian tumour to remove. Some time after this, it was
proposed again to perform the operation; but the consent of
the patient could not be obtained, and she died some years
after under the care of Dr. Scott, of Stratton Street. ISoth
ovaria were sound; and the enlargement arose from a great
vascular tumour imbedded in the walls of the uterus. The
preparation of the uterus and tumour is in the Museum of
St. George's Hospital.
The difficulty, or rather the impossibility, of determining
whether ovarian cysta and tumours were present in these
eases, and whether, ulien they actually existed, their extir-
pation was practicable] were Btrikinglj illustrated by these
DR. LEE'S ANALYSIS OF CASES OF OVARIOTOMY. 13
operations ; and during six years after their performance
ovariotomy was almost wholly abandoned in this country.
In 1833 the operation, as performed by Dr. N. Smith, was
revived by Mr. Jeaffreson, of Framlingham, who made an in-
cision one inch and a half to two inches between the umbilicus
and pubes, through the abdominal parietes of a patient,
exposed an ovarian cyst, which had no adhesions, and after
emptying the cyst by tapping, drew it out, tied and excised
the root. During the last twenty-seven years the operation
of ovariotomy has been attempted or performed more than
one hundred and thirty times in Great Britain. Of 108
cases I have obtained authentic reports ; and now beg
leave to present an Analysis of these to the Royal Medical
and Chirurgical Society. In about one third of these cases
there was either no ovarian cyst or tumour to remove, or
there were present ovarian cysts and tumours the removal
of which was found to be impracticable. It is demonstrated
by the following Analysis of 108 Cases of Ovariotomy, that in
about one third of the whole number, before an opening had
been made into the sac of the peritoneum, it was impossible
to determine whether any ovarian disease actually existed ;
or whether, when ovarian cysts and tumours were present, it
was possible to extirpate them by a surgical operation.
Postscript.
Since the preceding paper was presented to the Society,
details more or less complete have been obtained, of 54
additional cases of Ovariotomy which have occurred in Great
Britain. An analysis of these has been aj>pended to the
table, making, in all, 162 cases in which the operation has
been undertaken. In GO the ovarian disease could not be
removed ; 19 of these proved fatal. Of the remaining 102
cases in which the operation was completed, 42 terminated
fatally. The present condition of the 60 patients who re-
covered is very imperfectly known.
14 dr. lee's ANALYSIS OF 1(32 CASES of ovariotomy.
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DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 21
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DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 23
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24 DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY.
1
-3
ed.
ed.
dof
onitis.
a
P
a °
g a
o a
■a
o
ot
oved.
ovaria
oved.
ovaria
oved.
a
(2
rem
Both
rem
Both
rem
a"
m,
ide.
ide.
"5 cr
5W a a
o
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o
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_, - .» 1 0 .
Feb. 1846,
; repeated
adopted to
r the liga-
." " The
consisting
municated
psical an
pain ; a
1 escaped
cision ex
ook plac
and Surf
lr. Southan
, or adoptin
rpool, havin
[ thought,
te the othe
ory incisio
Bainbrigge
ent irritativ
ery favorabl
Bd.)
tapping si
tal peritonit
p. 278— 308
de, Oct. 184J
; a moveab
In
lui
ii
a t
ed.
.s « «s s .- a
. 3. c ^ s S o
|
1
; after her last confinement became
he tumour had increased rapidly w
inches long ; six pounds of ascetic
jssful attempt to tap the tumour;
mour removed ; faintness ; dyspnce
died on the 26th. (Provincial M
new series, 1847.)
I made an exploratory incision," says 5
determining on the propriety of extirpatior
ecommended by Mr. Bainbrigge of Live
fied myself that adhesions existed, which
o extensive in extirpation, might facility
e patient recovered from the explora
>ymptom, but died from the effect of Mr.
uration of the cyst having produced vio
mour was multilocular, consequently a v
nbrigge's plan." (This case is not publish
ur first perceived eighteen months before
sion ; both ovaria diseased and removed ; fa
owed. (Ed. Med. & Surg. Journ., vol. Ixv, p
and five children. Seen first by Dr. Handys
subsequent to the birth of her last child
ry, with a large dropsical swelling
welling increased; tapping; the tap
sion four inches ; a similar procedi
ith the exception of the line of exi
recto-vaginal cul-de-sac of periton
ried out per vaginam." The tumo
1 ten i mis. (Dr. Ilandyside has c
the following case.)
3
children
ecentl; t
ade thret
unsucc
ions ; tu
nd she
tumour of the left ova
tumour and dropsical s
thrice. Sept. 3, " Inc
that in the last case, w
ture being through the
two ligatures were car
chiefly of cysts, weighe
the history of this and
Journal, vol. iii
' In another case
" with a view of
the operation r
previously satis
they proved to
operation. Th
without a bad
operation, supp
fever. The tu
one for Mr. Bai
Unmarried ; tumo
times, large inc
and phlebitis fol
Mrs. 1' — , married
eleven months
Mary H — . Five
was tapped ; r
incision first m
no adhesions ;
tended ; adhes
on the 23d, a
DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 25
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26 dr. lee's analysis of 162 CASES of ovariotomy.
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ul. XXX,
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s. Mar-
d 1850;
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r>
:n ; enlargement first observed se'
ade ; no adhesions ; the incision
lialf of the ensiform cartilage an
pped and drawn out ; uterus six
er removed ; afterwards became
edico-Chirurgical Transactions, V
C 3->
O 3.
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atment by pressure twelve month
ithin a year. Tapped 1846 an
; a slight recent adhesion. Inc
n enormous triple headed cyst
peritonitis. (History communi
to Dr. Lee, and not previously pu
i
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sion first m
uch and a ]
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lanied six year:
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gravid; cysts
and had a heal
p. 95.)
3 <S
M
i-s
culty overcom
pp. 1-3.)
ept. 1848, a tu
gastrium first
1850, the ab<
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ried, and safe
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Died on the 1
Dr. Ely and M
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DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 27
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DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 29
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30 DR. lee's? analysis of 162 CASES of ovariotomy.
1
Recovered.
Died.
Died.
Recovered.
Recovered.
Died.
la
o g
Removed.
Removed.
Removed.
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1
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Mrs. II — . Two large compound tumours, involving both ovaries._(Ibid.)
Mrs. G — . Small tumour, non-adherent. (Ibid.)
Large compound tumour. (Ibid.)
Miss K — . Large, and slightly adherent tumour. (Ibid.)
Large tumour, with very short pedicle. (Ibid.)
Mrs. P — . Very large malignant mass; inseparably adherent posteriorly;
extreme suffering from distension by solid matter, and rapidly approaching
death, rendered the attempted operation justifiable. (Ibid.) The fol-
lowing details of this case have been communicated to Dr. Lee by
Dr. Hogg: —
Mrs. P— . Married in 1841 ; never pregnant. January 1844, first per-
ceived enlargement of the abdomen. In 1846 had strong pressure
applied to the abdomen, after being tapped by Mr. J. Brown. A second
tapping ; the operation of ovariotomy undertaken by Dr. F. Bird, 6th
January, 1848, present Dr. Rigby, Mr. Holt, two assistants, and Dr.
Hogg, who has communicated these details to Dr. Lee. " An incision
of two inches was made in the linea alba, midway between the umbilicus
and pubes, and twenty pints of liquid were drawn off by a large canula ;
the opening was then fairly made into the cavity of the abdomen, and
the solid tumour seized by forceps ; the size, however, of the tumour
was such that the opening was of necessity extended to ten inches before
it could be drawn forth ; tumour then found adhering strongly behind
the small intestines, and, in fact, to all the abdominal viscera. Dr. F.
Bird attempted to separate it from them, by conveying his hand behind
it, and, to a certain extent, succeeded in so doing; but on the tumour
advancing through the opening, it brought the colon with it, rather
before it, which was so firmly adhering that it defied all attempts at
separation, even with the handle of the scalpel; the removal being im-
possible, it was replaced in the abdomen, and the external opening sewed
up. The operation occupied an hour and ten minutes, during the whole
™
i
' 1848,
Jan. 6th.
(B
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DR. LEE'S ANALYSIS OF 162 CASES OF OVARIOTOMY. 31
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32 dr. lee's analysis of 1G2 CASES of ovariotomy.
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DR. LEF.'s ANALYSIS OF 162 CASES OF OVARIOTOMY. 33
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3! DR. lee's analysis of 162 CASES of ovariotomy.
DR. LEE's ANALYSIS OF 1G2 CASES OF OVARIOTOMY. 35
X 53 _;
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. The patient pal
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ector, to within a short dista
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btful ; diarrhoea ; sickness ; aj
V
nlargement of abdomen at thi
slowly increased ; abdomen me
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c swelling between uterus and
omen." Insensible from chloro
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walls ; punctured, and seven ga
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g thought that the attachmen
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the abdominal walls, lumbar re
pedicle tied and divided; haei
; four or five other vessels tied
of blood, feeble efforts to set
ito a state of collapse, and died
ommunicated by Mr. Baker
rough him to Dr. Lee.)
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"
A CASE OF
SOFTENING OF THE SPINAL MARROW
IN A BOY AFFECTED WITH CHOREA.
ROBERT NAIRNE, M.D.
PHYSICIAN TO, AND LECTURER ON MEDICINE AT, ST. GEORGE'S HOSPITAL.
Received November Uth— Read November OCth, l*5n
As all facts which relate to disease in the Spinal Marrow
may prove important in the elucidation of its physiology, I
have thought that the history of the following case, aud an
account of the appearances found after death, might interest
this Society.
George Strange, aet. 1 7, a greengrocer's hoy, was admitted
into St. George's Hospital on the 27th of June last. When
I approached the sofa, on which he lay in the waiting room,
and asked him to put out his tongue, I observed that he
thrust it out in the same manner as a person with chorea.
He had also the convulsive movements and distortion of
features of chorea. His articulation was imperfect, but he
had sufficient command over it to speak to me. He told
me that he had pain in his back and knees and feet. He
was unable to walk or even to stand. When he had been
placed in bed I found that there was redness on his knees
and ankles, as in rheumatism. His tongue was loaded, his
skin was hot, and his pulse 108. On listening over the
region of the heart I ascertained that there was a mitral
systolic murmur.
His relations informed mc that he had suffered from
38 dr. nairne's case of
rheumatism several times since the age of twelve, and that the
last attack was about Christmas; but that this was the first time
they had seen him "in this way." From Mr. James George of
Kensington, under whose care he had been previous to his
admission into the hospital, I afterwards learnt, that, " for
the last five weeks the friends had observed an unsteady,
jerking action in his hands, which prevented him from placing
things quietly in their places. The last two weeks he
stuttered much, and frequently contorted his mouth. On
the 18th he complained of rheumatism ; but felt better on the
22d, and went to market in a cart. On his return he
complained of having had an unusii.il jolting. Up to this
time he had been able to walk ; but on the next day he kept
his bed, and did not attempt to walk afterwards. The
rheumatism, and chorea more especially, increased from this
day. He was said to have had a fit on the morning of
the 24th."
I treated him under the impression that he was suffering
from an acute attack of rheumatism, which had brought on
chorea. The following day he seemed better, his articulation
was more perfect, and the convulsive movements less frequent.
On the 29th, however, he was worse, redness appeared on
his knuckles, and was no longer to be seen on his knees and
feet. He had not slept since he had been in the house.
On the 30th he became more restless, was delirious during
the night, and on the 1st of July was evidently much worse.
His features were more distorted, the pulse was weaker. The
convulsive movements were more frequent, and so violent that
the sides of his legs and body had become excoriated. During
the last two days of his life he passed his motions under him.
He died a little after midnight of the 3d, the convulsive
movements having ceased some hours before his death, and
as a state of coma came on.
The body was examined twelve hours after death. The
contents of the spinal canal were first looked at. The spinal
veins were distended with blood. A portion of the spinal
marrow, an inch at least in length, and situated opposite t In-
third and fourth dorsal vertebra, was white, and so soft thai
SOFTENING OF THE SPINAL MARROW. 39
the slightest pressure of the finger broke it up. It was almost
in a fluid state.1 The whole thickness of this portion was in
this state. In consistence, firmness, and colour, all the rest
of the cord was strongly in contrast with this part. Within
the cranium the sinuses of the dura mater and meningeal
vessels were gorged with blood, and so also were the large
veins distributed over the surface of the brain. The sub-
stance of the brain was firm throughout. Its cortical struc-
ture was darker than usual, and bloody puncta were very
numerous in the medullary substance.
The pericardium was found adhering entirely to the heart.
The left ventricle of the heart was firmly contracted ; the
other cavities contained very small coagula. On the auricular
surface of the mitral valve, numerous minute small rounded
excrescences presented themselves, giving a fringed appearance
to the valve ; the other valves were healthy. Both lungs
were loaded with blood, and there were patches of extravasated
blood in their most depending parts. There was nothing
unusual observed in the cavity of the abdomen.
This case is an additional instance of the frequent occur-
rence of chorea in rheumatism or in those of a rheumatic
diathesis, to which attention has been of late years directed.
But in Strange there was also palsy of the lower limbs.
When he was admitted into the hospital, the inability to walk
and the pain in the back I considered to be owing to
rheumatism ; but no doubt these symptoms were connected
with the disease of the spinal marrow, the existence of which
was revealed after death.
There are four instances recorded of softening of the spinal
marrow in persons previously affected with chorea. Ollivier
d' Angers quotes one as related by Brera, and two as having
occurred to Guersent ; but, he adds, " j'ai eu l'occasion d'ouvrir
sous ses yeux le rachis d'un enfant qui etait egalement affecte
1 In the central part of this softened portion of the spinal marrow there
was fluid, and the remainder was so thoroughly disorganised that it was
thought unnecessary to put any of it under the microscope.
40 dr. nairne's case of
de choree, chez lcquel la moclle epiniere n'offrit aucune altera-
tion sensible : sa consistance, sa couleur, et celle de ses mem-
branes etaieut dans l'etat natui'el ; c'est ce qu'on observe le
■plus souvent."1 The fourth case is recorded by Dr. Keir, of
Moscow." The history of the boy's symptoms, who had had
chorea for three years, and the report of his state seven clays
only previous to his death, " walks about daily for some time
without assistance," is a proof that the softening could not
have been in the relation to this disease of cause and effect.
I would observe, moreover, that the result generally noticed
of organic alteration of nervous structure is palsy, and not
spasm.
When we examine the facts which morbid anatomy has
accumulated, we find that there is no condition of diseased
structure which has been constantly discovered in chorea.
Nor do I think that what has been observed in the brain
and spinal cord, in such cases, affords any proof that chorea
originates in either one or the other. In support of this
conclusion I will add the result of what I have observed in
the practice of St. George's Hospital. Besides Strange, I
have seen three other patients with chorea who have died
there. In all, a careful examination was made of the con-
tents within the cranium and spinal canal. One was under
my own care, and two were patients of Dr. Macleod. In
all, there was congestion of the vessels of the brain. In my
own patient there was congestion of the vertebral veins and
of the substance of the spinal cord. In the first one, which
occurred in the practice of Dr. Macleod, the posterior veins
of the spinal cord were rather more than usually distended
with blood, but there was no alteration in tin' appearance of
the spinal marrow itself. It was also found perfectly healthy
in the second case, though the veins of the cord were much
congested. But the state of congestion in the vessels of the
brain and spinal marrow, which was observed in these time
eases, is of very frequent occurrence where the convulsions
I Trail <■ ilc la Mucllr F.|>iiin ir, ;i"" nl.. loin, li, |> B17.
' Eilin. Aleilical and Surgical Journal, vol. iliii, p, 98.
SOFTENING OF THE SPINAL MARROW. 41
of chorea have not been exhibited. They are seen, for
example, very generally in the bodies of persons who have
died in various forms of fevers. Enough, I think, has been
adduced to show that the pathology of chorea is not to be
explained by the morbid anatomy of the brain or spinal
marrow. Clinical observations of the disease and study of
its symptoms, of the various causes in which it originates,
and of its wonderful mental phases, will give us a truer insight
into its nature. Contemplating it under all the circumstances
with which it is connected, I am inclined to agree with my
colleague, Dr. Wilson, that " chorea is more than merely
nervous," that it is a disorder of the entire system, and does
not proceed specially from the nerve, though expressed
principally by the muscle."1
The softening of the spiual marrow, in this case, cannot,
I conceive, be considered otherwise than as an accidental
occurrence viewed in relation to chorea. Here arises, how-
ever, an interesting inquiry. It will be remembered that
palsy ensued in the lower limbs of George Strange, but that
he felt pain in them. Moreover, as often as any one
approached Strange's bed, and still more manifestly when a
question was put to him, the convulsive movements of the
voluntary muscles were increased, not only in the face and
upper part of the body, but even more violently in the lower
limbs, and below that portion of the spiual marrow in which
disease was going on to complete disintegration. The
structure of a considerable portion of the spinal cord appeared
to be altogether destroyed through its entire thickness, and,
according to the usual teachiug in physiology, incapable of
the office of conducting nervous impressions. Yet the
voluntary muscles of the palsied half of the body were excited
to increased convulsive action by the influence of emotion.
We are taught that there should be a perfect state of the
spinal cord, in order that an impression may be conveyed
from the brain to the spinal nerves. We are also told that
' On Spasm, Languor, and Talsy, p. 101.
12 DR. NAIRNE ON SOFTENING OF THE SPINAL MARROW.
the seat of emotion is in the mesocephale. If these be true
propositions, I would ask through what channel were the
impressions conveyed to the voluntary muscles in Strange's
palsied lower limbs, when they were thrown into convulsive
movements under emotional excitement ? I confess that I find
no satisfactory answer to this question ; and this case seems to
me to prove that there is yet much for us to learn respecting
the functions of the spinal marrow.
CASE
ILLUSTRATING THE DIFFICULTIES OF DIAGNOSIS
OF
MORBID GROWTHS FROM THE UPPER JAW.
WITH REMARKS.
PRESCOTT HEWETT,
ASSISTANT SURGEON TO ST. GEORGE'S HOSPITAL, AND LECTURER ON ANATOMY.
Received November 12th. — Read December 10th, ISom.
Thinking that in the details of the following Case will be
found some points of great practical interest, I venture to lay
this communication before the Royal Medical and Chirur-
gical Society.
A man, Eet. 25, was admitted into St. George's Hospital,
under my care, in the month of May, 1848, with a large
tumour, of an irregular shape, occupying various regions of
the left side of the face. In the cheek, it formed a swelling,
of the size of a turkey's egg, filling up the greater part of
the superior maxillary regiou, the outline of the bone being
perceptible to the touch in a few places only; the zygomatic
arch, however, was much more prominent and more curved
than natural, having been pushed forward by the growth of
the tumour, portions of which could even be felt under the
temporal muscle. The diseased structure was also found, in
the shape of small flattened bodies, at the lower part of the
orbit, lying immediately underneath the conjunctiva, and
apparently quite moveable; the bones of the inner and outer
walls of this cavity, as well as those forming its circum-
1 1 MR. HEWETT ON THE DIAGNOSIS OF
ference, were not in the least degree affected or displaced,
but it was impossible exactly to make out the state of the
bones at the lower wall, owing to the tumours which were
here ; the eye-ball was not more prominent than natural.
Portions of the morbid growth were also detected in the
left nasal fossa, from whence a small, round mass projected
slightly, at times, into the pharynx; a probe was easily passed
from the nostril into the pharynx, both above and below
the tumour, and the finger, curved roimd the posterior border
of the palate, there recognised a firm body which could easily
be pushed from side to side ; the shape of the nose was
altogether unaltered. The roof of the mouth was free from
disease, neither the teeth nor the bones in this region being
in the least displaced; but the tumour was found extensively
overlapping the front part of the alveolar process, and pro-
jecting beneath the lip. The diseased structure, wherever
it could be fairly examined, appeared to be of a round shape,
but lobulated ; it was firm and clastic to the touch, and, at
the back part of the pharynx, it was of a dead white colour
and glistening appearance ; in all the various regions which
it occupied, it appeared to be moveable. The skin, con-
junctiva, and mucous membrane of the nose, were quite
healthy, and no enlarged glands could be detected in any
part.
The patient stated that six years previous to his admission
into the hospital, he was troubled with a disease, supposed
to be a polypus of the nose, which was easily removed with
the forceps ; some little time afterwards, the cheek was, for
the first time, observed to swell, and gradually increased in
size; the tumour subsequently made its appearance in the
orbit and other regions: but all this was unattended by pain,
neither was there much inconvenience, except about the
nostril, and even this was not very great. Finding that
the tumour was steadily increasing in size, the patient, a
year ago, consulted a person who attempted to destroy it
uitli caustic, which had apparently been applied extensively
in two different places, two large cicatrices being still visible
in these parts; one of them, situated over the loner margin
MORBID GROWTHS FROM THE UPPER JAW. 45
of the orbit, had, by its contraction, caused eversion of the
eyebd, the other was on the inside of the cheek. Little or
no effect was produced on the disease by this treatment; the
sores caused by the caustic healed kindly, and no fungating
growths ever made their appearance at these spots. At
various times, during the course of the disease, there had
been extensive bleeding from the nose; these bleedings had
somewhat reduced the patient, who was of a spare habit and
pale; this paleness was accounted for by a loss of blood,
which had occurred shortly before his admission into the
hospital.
At a consultation of the surgeons, it having been decided
that the removal of the upper jaw was justifiable in this
case, I undertook the operation, the patient himself, before
whom were laid all the dangers incident to it, being most
urgent that something should be done for him.
Dr. Snow, to whom the surgeons of St. George's are so
much indebted for the able manner in which he, for a long
time, administered chloroform at the hospital, gave it on
this occasion.
The patient being seated in a chair, the usual incisions
were made, and the bones having been divided with a strong
pair of cutting forceps, the superior maxillary and the malar
were easily tilted out of their place; but it was then dis-
covered that the disease was not connected with the upper
jaw, — it was lying behind it. Hoping that I should, never-
theless, still be able to get away the whole of the tumour, I
first removed the greater portion which was in view, dissect-
ing it from off the pterygoid process to which it was attached.
I then, by gently pulling, got out that part which was lying
under the temporal muscle, where it was imbedded in loose
cellular tissue ; that portion which was in the orbit required
some careful dissection, as it was partly attached to the
conjunctiva. At this stage of the operation, as the patient
became faint, he was placed in the horizontal posture, and a
small quantity of stimulant was administered, by which
means he soon rallied. I then proceeded to remove, with a
pair of strong curved scissors, that portion of the tumour
46 MR. HEWETT ON THE DIAGNOSIS OF
which I found projecting into the nasal cavity. The pulse
having again failed, the patient was at once laid on a bed,
and carried into an adjoining room; different restorative
means were made use of, and he appeared to rally somewhat :
but shortly afterwards, observing that the breathing became
difficult, Mr. Charles Johnson and myself thought it ad-
visable, as a last resource, to make an opening into the
crico-thyroid membrane, and, by means of a tube, to try and
keep up artificial respiration. When the opening was made
into the larynx, I observed that some frothy blood imme-
diately made its escape; the tube was readily passed, but all
our efforts were ineffectual, the patient continued to sink,
and soon died.
Throughout the operation I met with but few vessels, and
one only of any size ; this, most probably the termination of
the internal maxillary, was secured by a ligature ; to the
other vessels blue lint was applied : on the whole, no great
amount of blood was lost, and there was no bleeding from
the incision in the neck.1
On examining the bones which had been removed during
the operation, it was found that they had both undergone
very great alteration in their shape, which had been produced
by the pressure of the tumour lying behind them. In the
superior maxillary, the antrum was all but obliterated ; the
posterior wall of this sinus having been forced against the
anterior one, there was merely a chink left, the cavity of
which was quite free, and lined by healthy mucous membrane;
and, instead of a maxillary tuberosity, there was here a
depression which had served partly to lodge the tumour
during life. The malar process of this bone and the malar
itself, very much expanded) were much thinner, and formed
a much greater curve than natural : the osseous structure
itself was perfectly healthy.
Sections of the various tumours presented, both to the
' I have avoided entering into any details about the chloroform, as I
prefer sending, with this OOimminication, a letter which 1 received from
Dr. Snow mi tht Subject
MORBID GROWTHS FROM THE UPPER JAW. 47
naked eye and under the microscope, a well-marked and
purely fibrous appearance.
The body was examined twenty-three hours after death,
and a careful dissection of the parts concerned in the disease,
for which the operation had been performed, showed that the
morbid growth had originated in the roof of the left nostril,
and especially on the inner side of the pterygoid process and
under surface of the body of the sphenoid, to which parts
small portions of the tumour were still found firmly attached.
The sphenoidal sinuses were filled with diseased structure
and very much dilated, so much so that, at one point, the
bone had altogether disappeared, and left a small hole, where
the tumour was lying in contact with the dura-mater. A
small portion of the growth was also found at the upper and
back part of the septum nasi, which was forced over to the
right side, and partially destroyed by absorption ; here the
mucous membrane was somewhat thickened, and there was
a small pendulous body, loosely connected with the velum
palati, which was hanging by the side of the uvula. Small
flattened growths, of a similar nature and a bulbous shape,
were found deeply imbedded in the spheno- maxillary and
temporal fossae, as well as at the back part of the orbit ; they
were all connected to each other; none of them had any attach-
ments to the bones, but they were connected with the growths
in the nostril by a slender pedicle passing in the direction of
the spheno-palatine foramen ; the growth in the orbit had
reached this situation by creeping through the spheno-
maxillary fissure ; the bones of the orbit were quite healthy.
The structure of these growths resembled that of the tumours
removed at the operation, — it was purely fibrous.
The trachea and the bronchial tubes, even to their minute
ramifications, contained a quantity of frothy blood. The
structure of the lungs was crepitant throughout, but each
section presented numerous small, dark spots of ecchymosis,
produced by some of the air-cells having been also filled with
blood ; these organs were otherwise free from disease. The
heart was healthy; its cavities contained some small black
clots, but the greater part of the blood was thin and fluid,
48 MR. HEWETT ON TIIE DIAGNOSIS OF
and did not coagulate on exposure to air. — The other viscera
were quite healthy.
In considering the practicability of an operation in the
preceding case, the first important point to be decided was
as to the nature of the tumours, for, had the disease been
carcinomatous, an operation would have been, in my opiuion,
altogether unjustifiable ; but the details of the case, and
especially the length of time during which the disease had
existed, led to the conclusion that, in all probability, it was
not of an encephaloid nature ; the general opinion was, that
it was of a fibrous character. The subsequent dissection and
the microscopic examinations proved this opinion to have
been perfectly correct.
The next question to be examined was the point of origin
of the disease ; and herein lay the great difficulty of the case.
After a due consideration of all the circumstances, — the
appearance of the tumour in the face, the various situations
it occupied, and the history, it appeared most probable that
the disease, having originated in the antrum, had burst
through some of the walls of this cavity and made its way
into the regious in which it was found ; the palate, it is true,
was not depressed, neither were the teeth affected, but this
did not seem sufficient to me to invalidate such an opinion ;
for, although a tumour originating in the antrum will
generally expand the walls of this cavity, it sometimes happens
that the disease makes its way in some directions much
more readily than it docs in others. In the museum of
St. George's Hospital, there is a preparation, which I put
up some years back, in which a tumour starting from the
antrum had made its way upwards, outwards, and inwards,
bursting the various walls, but had left the palate unaffected.
A portion of the disease had, Recording to the patient's
account, been extracted, some years previously, from tin
nostril; but the gradual swelling of the face, the tumour
having subsequently made its appearance in the cheek, and
the nose being altogether unaltered in shape, led to the
MORBID GROWTHS FROM THE UPPER JAW. I.)
supposition that this was one of those cases in which a
tumour had made its way from the antrum into the nose,
from whence it had been removed as a polypus.
The possibility of the disease having arisen in the pterygo-
maxillary fossa was discussed ; but the probability of such
being the case in the present instance was thought to be very
slight.1
The appearances noticed during the operation and the
subsequent dissection revealed the true nature of the case.
The growth, I have little doubt, began in the upper part
of the nasal cavity, and from thence spread in the various
directions already noticed. It had reached the pterygo-
maxillary fossa, either by destroying a portion of the palate
bone, or by originally passing through the spheno-palatine
foramen ; once in the fossa its subsequent progress may easily
be traced ; it passed into the orbit through the spheno-
maxillary fissure ; and, in the face, it had, in some parts,
made the bones yield, and, in others, it had so completely
moulded itself to their shape, creeping over their cutaneous
surfaces, that the outlines of the bone were scarcely dis-
cernible.
That a polypus of the nose, of a purely fibrous character,
should take the course which I have just described, is, I
believe, of very rare occurrence ; some cases have, however,
been recorded, which show that these growths do sometimes
make their appearance in regions where one would little
expect to find them. Such was the case in a patient lately
operated upon in St. George's Hospital by Mr. H. Charles
Johnson, where a fibrous tumour, lying in the orbit, was
ultimately traced, by its pedicle, into the nose, through a
hole in the inner wall of the orbit ; and yet there was nothing
about this patient to lead to the supposition that the disease
had originated in the nostril.
1 A case of this nature is quoted in the twenty-third volume of the
Archives Generates de Medeciue,' in which a lobulated fibrous tumour,
originating, according to the Docteur Del Greco's report, in the ptorygo-
maxillary fossa, had made its way into the various regious which were
occupied by the tumour in the patient at present under consideration.
xxxiv. 4
50 ME. IIEWETT ON DIAGNOSIS OF MORBID GROWTHS.
I purposely avoid alluding to the growths of an encephaloid
nature, so frequently found in this locality, as their mode of
progress usually differs widely from that of the purely fibrous
tumour ; readily insinuating themselves through the fissures,
they not unfrequently make their appearance in regions far
from that in which they originally began.
Some of the appearances observed in the post-mortem
examination naturally lead to a question of great practical
importance in the present day. I refer to the blood which
was found in the air-cells and bronchial tubes. In my mind
there is no doubt that that blood found its way into these
parts by passing through the glottis ; and if this was the case,
it may fairly be asked, whether such an occurrence would
have taken place had no chloroform been used, — the proba-
bilities are that it would not. It is, I believe, now generally
admitted that one of the effects, both of chloroform and ether,
is to suspend the irritability of the glottis, whereby in those
operations about the mouth, in which there must be a certain
amount of hicmorrhage, there is a risk that some of the blood
may find its way into the windpipe, without there being any
cough excited to expel it ; and several eminent surgeons, both
abroad and in this country, have not failed, of late, to con-
demn the administration of these agents in operations of this
nature. Some surgeons being unwilling to submit their
patients to all the pain incident to such serious operations
have, however, adopted a middle course, administering the
chloroform in the first steps of the operation only, hoping
thus to avoid all risk; but it remains still to be proi ed « h< -ther,
even with this precaution, there may not be danger in using
anaesthetics in some operations about the mouth.
dr. snow's letter. 51
Letter from Dr. Snoio referred to in Mr. Hewett's Paper.
On May 18th, 1848, I administered chloroform, at St.
George's Hospital, to a young man with a tumour of the
superior maxillary bone. The vapour was given to him
rather slowly with the apparatus which I generally employ;
and he became gradually insensible, without previous excite-
ment or struggling. In about three minutes, the inhalation
was suspended, and some teeth were extracted without causing
any sign of pain. A little more chloroform was given, that
the operation of removing the tumour might commence,
whilst the patient was under its full effect. When the
inhalation was discontinued, he was in the condition that has
been named the third degree of narcotism. He was passive,
but the muscles were not relaxed, and the breathing was not
stertorous. He remained quite silent and motionless during
the early part of the operation, whilst the flaps were made,
but afterwards he began to groan and move his limbs, and
was not again rendered altogether insensible ; for, although
a few minims of chloroform were sprinkled, from time to
time, on a sponge, and held near to his face, he got very
little of the vapour, as the hands of Mr. Hewett and the
surgeons assisting him were constantly in the way, and the
cavity of the mouth and nostrils was laid widely open. The
only effect, indeed, that I could produce, was partially to
lull the patient, on one or two occasions. During this
time, the effect of the chloroform never exceeded the second
degree, or that state in which the mental functions are con-
fused, but not suspended. He executed voluntary movements
of his arms and legs. Sometimes it was necessary to hold
his hands, and, at one time, he appeared conscious, for he
folded his arms, as if making an effort not to raise his hands
to the seat of pain. He seemed a good deal embarrassed
during the operation with the blood which flowed into his
throat. He leaned forward once or twice to get rid of it,
and I thought that he vomited some blood on one of these
occasions.
52 dr. snow's letter.
In the course of the operation, and at a time when he
was but little under the influence of chloroform, the patient
became faint, he was laid down, and brandy was given to
him. No more chloroform was administered after this time.
When I left the Hospital, a little while after the removal of
the patient from the operating theatre, he was much exhausted,
but seemed cruite conscious, and did as he was told. There
was then no difficulty of breathing, and, in my opinion, the
influence of the chloroform had altogether left him.
CASES OF
RUPTURE OF THE LIVER OR SPLEEN.
WITH REMARKS.
BY
ATHOL JOHNSON,
FELLOW OF THE ROYAL COLLEGE OF SURGEONS,
SURGEON TO THE ST. GEORGE'S AND ST. JAMES'S DISPENSARY, AND
LECTURER ON PHYSIOLOGY AND GENERAL ANATOMY AT ST. GEORGE'S HOSPITAL.
Received IVrcmber 31th, 1850.— Read January 14th, 1851.
The following Cases came under my notice whilst House-
Surgeon to St. George's Hospital in the year 1845.
Case I. — Rupture of the Liver and Right Lung. Death
almost immediate. — John Pratt, set. 25, was brought to St.
George's Hospital on the 4th of April, 1845, having fallen
from a scaffold about thirty feet high, a short time pre-
viously. He was perfectly sensible when admitted; but was
in a state of extreme collapse, with very exsanguine features,
and complained of intense pain in the abdomen, which was
swollen and tense : there was also much difficulty of breath-
ing, with dulness over the right lung. He never rallied ;
but died in about an hour.
On examination of the body after death, a large quantity
of blood, not coagulated, was found in the cavity of the
peritoneum ; it had proceeded from an extensive laceration of
the liver, penetrating deep into the structure of this organ,
and principally situated at the upper surface of the right
lobe ; the structure of the liver was healthy.
The cavity of the right pleura also contained a large
quantity of blood, and the right lung presented two very
54 mr. Johnson's cases of
extensive lacerations penetrating deep into its structure.
None of the ribs were fractured ; but the costal cartilages,
from the fourth downwards, were separated from their con-
nections with the sternum, and in one or two places the
parietal pleura was torn through.
The left arm and leg were also fractured.
Case II. — Extensive Rupture of the Liver, ivith Effusion
of Blood and Bile into the Peritoneum. Death on the third
day. — James Lucas, set. 40, admitted into St. George's
Hospital under the care of Mr. Cutler, May 20, 18-15. This
patient, shortly before his admission, was knocked down by
a horse, and the wheel of a carriage passed over bis belly.
He was in a state of extreme collapse, with bloodless features,
and complained of intense pain over his abdomen, which
was considerably distended ; some of the ribs on the right
side were felt to be fractured. He was placed nearly in a
sitting posture, by means of a bed-chair; — a roller applied
round the ribs, and a draught containing morphia ordered
every four hours.
The pain gradually subsided, though he remained very
exsanguine, and he appeared to be gaining some strength,
when he died suddenly, three clays after the accident, on
attempting to raise himself up, to get upon a bed-pan.
The post-mortem examination disclosed the following
appearances : — There was a bruise over tlic anterior wall of
the abdomen. The cavity of the peritoneum was filled with
a large quantity of blood, the greater part of which was
Quid. The convolutions of the intestines were glued to-
gether by the fibrin of the cxtravasatcd blood, which had
partially lost its colour, and formed slender adhesions, which
were easily destroyed by separating the parts. After the
removal of the blood and fibrin, the parts underneath were
found to be discoloured, but presented no increase of vas-
cularity. There was an extensive rupture of the liver, ex-
tending through the whole thickness of the right lobe, as
well as through tin- lobulus Spigelii. The ruptured parts
weir will adapted to each other, and pretty firmly united
RUPTURE OF THE LJVER OR SPLEEN. 55
by the fibrin of the extravasated blood. The whole of the
blood contained in the peritoneum was deeply bile-tinged.
The other abdominal viscera were healthy.
The fourth, fifth, and sixth ribs on the right side were
fractured near their posterior extremities.
Case III. — Extensive Laceration of the Spleen, with slight
Laceration of the Liver. Death on the third day. — John Jolbff,
set. 32, admitted into St. George's Hospital, August 14th,
1845, under the care of Mr. Tatuni. This patient was
reported to have Mien from a height of thirty feet, striking
his side against a pole. When brought in, he was in a
state of complete collapse, with blanched skin, and com-
plaining of excruciating pain in the abdomen, which was
hard and swollen; one of the lower ribs on the left side
was found to be fractured. He was placed in bed, with his
shoulders raised on a bed-chair, and doses of morphia in
camphor mixture given occasionally. He still continued
very pale, and in the evening was slightly sick.
The pain gradually subsided, and with the exception of
being troubled occasionally with flatulence, he appeared to
be going on well till the night of the third day after the
accident, when, contrary to the directions which had been
given, he got out of bed for the purpose of having it made.
He was almost immediately seized with faiutuess, and died
in half an hour.
Examination after Death. — The cavity of the abdomen
contained a large quantity of bloody fluid, mixed with dark
coagula of blood ; these had proceeded from an extensive
laceration of the posterior margin of the spleen, which was
of a pale colour, soft and grumous, and in several places
mixed with circumscribed extravasations of blood. A small
laceration also existed at the upper surface of the left side
of the liver near the spleen. The other viscera were healthy.
The tenth rib on the left side was fractured in two
places.
Case IV. — Extensive Ruptures, perfectly united, about the
56 bib. Johnson's cases of
Liver and right Kidney. Death from Fracture of the Spine,
three weeks after the accident. — .Tames Doyle, ret. 38, ad-
mitted into St. George's Hospital under the care of Mr.
Hawkins, having fallen from a hay-rick about thirty-five feet
high, striking his back against a log of wood. There was
complete loss of voluntary motion and sensation in the parts
below the nipples of the breast, respiration being carried on
by means of the diaphragm.
The right arm was completely paralysed, and the left
partially so : he complained of much pain in the arms, and
also in the abdomen (which was a little distended), although
the parietes were quite iusensible. He was also in a state
of considerable collapse, which continued for several hours.
The urine, which was regularly drawn off, contained con-
siderable quantities of blood. Sloughs gradually formed
upon the back and other parts subjected to pressure ; the
respiration became impeded, and he died exactly three weeks
after the accident.
Sectio Cadaveris. — The bod}' of the seventh cervical ver-
tebra was found broken up into several fragments, blood
was effused upon the external surface of the spinal dura
mater, and the spinal cord in this situation was softened
and diffluent to the extent of about an inch and a half.
The lungs were gorged with red frothy serum, and their
tissue a little softened.
The cavity of the peritoneum contained a little bloody
serum, and some blood was found extravasated in the sub-
peritoneal areolar tissue of the right loin, extending from
the right hypochondriuin into the pelvis; this extravasation
had evidently existed for some little time, as the blood had
lost a large portion of its colouring matter. An extensive
rapture was found cm the upper surface of the right lobe of
the liver; this rapture, which measured five inches in length,
wa3 perfectly united, witli the exception of some few points
(There the peritoneal coat still remained broken ; but no
lymph was found on the serous membrane, which retained
its polished appearance. The rupture did not extend very
deeply into the organ. Another smaller rupture, also per-
RUPTURE OF THE LIVER OR SPLEEN. 57
fectly united, was found in the neighbourhood of the large
one.
Several ruptures, beautifully united, but not extending
more than two lines in depth, were found on the anterior
surface of the right kidney; no inflammation existed about
this organ, or in the surrounding areolar tissue.
Case V. — (Supposed) Rupture of the Liver. Recovery. —
Emma Mason, set. 6, was admitted into St. George's Hos-
pital under the care of Mr. Keate, on the 5th February,
1845. She was in a state of complete collapse, but sensible,
and complaining excessively of extreme pain in the abdomen,
which seemed full and tense: — there were some slight graizes
of the shin over the situation of the liver, produced by the
passage of the wheel of a cart over the belly shortly before
admission.
The patient gradually recovered from the collapse, but
remained very pale and exsanguine, and continued to complain
for some clays of pain in the abdomen, especially about the
right hypochoudrium ; no febrile symptoms, however, super-
vened, and the pain gradually subsided. She was removed
home by the mother about the ninth day after the accident.
I continued to see the child, who remained weak and pale
for some time after the accident, but gradually regained her
health and strength.
Remarks. — I have ventured to bring these cases before
the Society with the view of illustrating a kind of accident
of not very infrequent occurrence, as is shown by the fact that
these five, together with four other cases, came under my
oare as House-Surgeon in St. George's Hospital during a
single year.
The general character of the symptoms in all the cases
which I saw, was very similar : — Extreme collapse, combined
with the very exsanguine appearance of the patient ; intense
pain in the abdomen, especially in the region of the liver or
spleen, coming on immediately after a severe blow in that
situation : together with the more or less distended state of
58 mr. Johnson's cases of
the belly, the distension not being entirely tympanitic ; — were
usually sufficient to induce me to suspect that such an injury
had occurred. That the pain which is usually so much
complained of in the first instance is not inflammatory, is, I
think, shown by the first four of these cases ; for in these
instances, though some days had elapsed from the time of
the injury, no appearance of inflammation was found; the
pain being due, I believe, at first, rather to the laceration
and sudden stretching of the peritoneum, largely supplied as
it is with nerves from the sympathetic system.
The principal point of interest, however, about these cases,
is, I think, as respects the prognosis. This, of course, is
very unfavorable, but still I believe that the injury, if of
moderate extent, is not necessarily fatal ; this, I conceive,
being satisfactorily shown by the fourth case, which appears
to me to be a very interesting one, as, in this instance, an
opportunity was afforded, by the patient dying from the effects
of a totally distinct injury (fracture of the spine), of demon-
strating, by a post-mortem examination, that the liver, as
well indeed as the kidney, had been lacerated, and that
union had taken place, without, apparently, any amount of
inflammation having been set up.
I believe fully myself that the liver had also been ruptured
in the fifth case ; and such was the opinion expressed at a
time when there appeared every probability of the child
dying. As, however, the patient recovered, and no oppor-
tunity, consequently, was afforded of demonstrating that
such an injury had actually taken place, this case is not of
so much value as the previous one, as many might fairly
doubt, whether some error had not been committed in the
diagnosis.1
1 Since tliis paper was read at the Booiety, Mr. Madlwain has directed
up, attention to two cases of incised wounds of the liver, which, although
m,i i , n • 1 1 _v iii point, are interesting.
One (recorded I", Fab. Sildanns) of a Swiss, who received a wound with
a broadsword; I hligmum followed, and the surgeon, finding
a piece of the liver protruding ai Hie wound, removed it. The man seems
in have had a difficult, but still a perfect, recovery, lie died three yean
RUPTURE OF THE LIVEH OR SPLEEN". 59
With regard to the treatment, it was directed to the
following points : —
1st. Instead of hastily administering brandy and other
stimulants, rather to favour the state of collapse, guarding, of
course, against its going too far, in the hopes of checking
the liEeruorrhage at the time, and allowing coagulation to
take place so as to arrest it in a more permanent manner.
2d. To keep the patient in a state of the most perfect
rest, not allowing him to make any exertion himself, and to
place him in such a position that breathing might be car-
ried on with the least possible disturbance of the abdominal
viscera. The bowels also ought not to be disturbed for
some days.
In the Second and Third cases related, it was owing to
some imprudence on the part of the nurse or the patient, that
fresh and fatal haemorrhage appeared to have occurred.
And 3dly. To prevent the patient from tossing about, as
he is inclined to do from the violence of the pain, and so
tending to produce fresh bleeding, opiates were freely admi-
nistered. Of these morphia, given in full doses, with a little
afterwards of fever, when the remaining portion of the liver was found to be
healthy.
The other case was related by Mr. Scrivens at the London Medical
Society in 1S2S. A man stabbed himself with a carving knife : he bled ad
: but rallying, went on very well for eleven days, when he went
out and drank freely of spirits. Peritonitis supervened, which proved fatal.
On examination there was found a "considerable" wound of the liver per-
fectly healed.
1 might also refer to some experiments on rabbits performed by Dr.
Monro, as quoted in Hennen's 'Military Surgery,' in which it appeared that
considerable portions of the liver might be removed without injuring the
health of the animal, the wounds cicatrizing as in other parts.
Mr. Macilwain observes very justly, that so many of these cases prove
fatal from adventitious causes, that it is extremely desirable to adopt every
means of improving our diagnosis ; this, he considers, would be materially
assisted if those varieties which are observed in the nature, duration, and
other details of that stage, which wc now designate by the general term
" collapse," were more particularly recorded.
60 mr. Johnson's cases of rupture of the liver.
ether and camphor mixture, if the collapse were excessive,
seemed to agree the best.
I may mention, in conclusion, that I have looked over
several books upon the subject, but am not aware that any
case has been published to prove that union has actually
taken place after rupture of the liver or spleen, without any
external wound.
ACCOUNT OF A CASE
CESAREAN SECTION WAS PERFORMED
REMARKS ON THE PECULIAR SOURCES OF DANGER ATTENDANT
ON THE OPERATION.
CHARLES WEST, M.D.
PHYSICIAN-ACCOUCHEUR TO ST. BARTHOLOMEW'S HOSPITAL, AI*
LECTURER ON MIDWIFERY IN THE MEDICAL COLLEGE.
Received December 20th, 1850.— Read January 28th, 1851.
There are some subjects connected with the exercise of
our profession, concerning which scarcely any one can be
said to have experience, but each has to fall back upon the
accumulated observation and experience of many others.
This circumstance attaches a veal value to the publication of
isolated cases, and must serve as my apology for bringing
the following history before the notice of the Fellows of
the Medical and Chirurgical Society.
Elizabeth Williams was one of eight children, of whom
seven reached adult age. Her father, who had been insane
for some years previously, died at the age of 73, her
mother at that of 68. Two of her brothers and one sister
died of phthisis, and this sister was insane for some years
before her death. Two brothers and a sister survive in
good bodily health, but the sister is of weak intellect ; and
Elizabeth herself had, on more than one occasion, shown
indications of insanity.
62 dr. west's case of
As a child, E. Williams's health had been good, but it be-
came much impaired about the age of 15, when she began to
menstruate ; and ever since then she had frequently, indeed
almost constantly, suffered from pain in the back, referred
especially to the pelvis. About the age of 23 the pain
became much severer than it had ever been before ; but, in
spite of this, and of the advice which she received from
some medical man not to many, she married, at the age of
25, the husband of her deceased sister. She did not become
pregnant until fifteen months after marriage ; but conception
was followed by a very considerable increase of pain, asso-
ciated, during the latter half of her pregnancy, with a great
and rapidly increasing difficulty in walking. For some
weeks before her confinement she did not move further than
from her bedroom on the second floor to her sitting-room
on the first floor, where she generally spent the whole day
lying or sitting upon her sofa. Sometimes, however, she
moved about her room, and, on the day before her confine-
ment, was occupied in putting lip curtains to the windows ;
her disinclination to walk seeming to be due, at least, as
much to her nervous temperament and wayward disposition,
as to any physical incapacity for exertion.
She was in the fifth month of her pregnancy when she
placed herself under the care of Mr. Wren, of Brownlow-
street, to whose kindness I am indebted for many facts in
her history, as well as for the permission to lay her case
before this Society. There was nothing in her appearance,
either when she first came under Mr. Wren's care or sub-
sequently, to suggest the idea of her being deformed ; the
ouly peculiarity which she presented being that she always
stooped very much forwards. During her pregnancy her
bowels required the constant use of purgatives ; her appetite
was bad, she was much annoyed by heart-burn, had occa-
sional faintings, and suffered much from palpitation; her pulse
beating habitually L30 in the minute, (a rate of frequency
which she said it had manifested for years), but varying
under every source of excitement. She was nervous and
excitable in the highest degree, looking forward with much
CESAREAN SECTION. 63
apprehension to her labour, and especially to the pain
attending it ; and was urgent in extorting a promise that
she should be permitted to inhale chloroform when labour
came on.
It was in this unfavorable state, both of body and mind,
though much benefited by Mr. Wren's treatment, that
Mrs. Williams reached the end of her pregnancy, and labour-
pains came on at 1 a.m. on the 7th of May, 1850; she
having been married just two years, and being in the 27th
year of her age.
Mr. Wren was summoned at 3 a.m., and discovering, on
his first examination, the existence of extreme pelvic de-
formity, despatched a messenger for me ; and I arrived at a
quarter to 5 a.m. I learned that the pains which the
patient had had were very feeble, and returned only about
every quarter of an hour. She bore them, however, veiy
ill, tossing about the bed, crying out for chloroform, and
becoming almost unmanageable on any attempt to make a
vaginal examination.
She was a small, slim person ; and as she lay in bed
presented no sign of deformity, and her extremities were
straight and well formed. Her face was pale, and her pulse
frequent and feeble. On examining her spine it was found
to be perfectly straight, but the sacrum was bent into an
almost semicircular form, with a great convexity projecting
backwards ; the pubic arch was a little wider than would
suffice to allow of laying one finger between the rami of the
pubes ; the tuberosities of the ischia did not seem to be
much above an inch apart, and the rami of the pubes ran
out into a sort of beak ; the bones being bent at the junction
of the pubis and ischium, and being at this point not more
than an inch apart.
The os uteri could be reached with difficulty ; it was open
to about the size of half a crown ; its lips were still thick,
but soft.
At a quarter to 10 a.m., Dr. Ramsbotham and Dr. Murphy
saw the patient with Mr. Wren and myself; her case appear-
ing to us to be one in which, even irrespective of the interests
G4 dr. west's case of
of the child, the Cesarean section was called for. Auscul-
tation, moreover, had ascertained the child to be living.
Pains had occurred, though feebly, since 5 a.m., and the
os uteri was now found by Dr. Ramsbotham to be fully
dilated. During his examination the membranes broke,
and liquor amnii escaped, though not in any large quantity.
The head was found to be presenting.
The circumstances which seemed to point out the
Csesarean section as the only admissible proceeding, were not
merely the probability of the existence of a very considerable
degree of contraction of the pelvic brim, but also the
extreme narrowness of the outlet, which would render the
introduction of the hand to guard the embryotomy instru-
ment impossible ; while even supposing the head of the child
to have been so mutilated, as to admit of its extraction, it was
yet doubtful whether the body could be extracted, and tbc
rather, since the narrowness of the outlet would quite prevent
any attempt at evisceration from succeeding.
On the other hand it might be alleged, that though any
attempt at extracting the child would be both dangerous,
difficult, and tedious, and would most likely occupy some two
or three hours, yet it could probably be effected. Although
it was quite true that, should serious difficulty occur in ex-
tracting the body, it would not be possible to eviscerate the
child, yet the chances were against the existence of any such
difficulty as to be absolutely insurmountable ; while, though
injury might be inflicted on the mother, yet injuries to parts
within the pelvis being so much less formidable than injuries
to the uterus itself; the endeavours to deliver by the Datura]
passages would, on the whole, be preferable, as far as the
mother was concerned, to the more hazardous experiment of
the Caesarcan section.
Dr. Uamshot ham's opinion inclined to the latter \ it \\ ;
but although he thought the foetus might, by great exertion,
be draggerl through the pelvis after craniotomy had been
effected, he nevertheless acquiesced in the view that Dr.
Murphy ami myself took, of the great danger necessarily
attending such forcible efforts ; and this, in addition to the
CESAREAN SECTION. 65
possible chance of ultimate failure, induced him to agree
with us, and to sanction the performance of the Cassarean
section. It was determined to request Mr. Skey, who was
the only surgeon in the metropolis who had ever performed
the operation on the living subject, to undertake it. To this
request Mr. Skey kindly acceded, after he had been made
acquainted with the particulars of the case ; and it was in
conjunction with him that the subsequent treatment of the
patient was carried out.
As no circumstance seemed to indicate the necessity for
earlier interference, 4 o'clock p.m. was the hour fixed for
the operation. For permission to lay before the Society the
details of its performance, I have to acknowledge my obli-
gation to the kindness of Mr. Skey.
On assembling at 4 o'clock, we found that the patient
had had but very little uterine action ; her bowels had been
relieved by an enema, and she had taken a little beef-tea
occasionally. The necessity for the performance of the
Csesarean section being explained to her, she readily con-
sented to undergo it, but on condition that she should be
previously rendered insensible to pain by the use of chloro-
form ; and no representation of the comparatively slight
suffering which the operation would occasion, or of the
possible increase of danger to which the employment of
chloroform might expose her, could at all shake this reso-
lution.
On receiving the assurauce that her desire, in this respect,
should be complied with, she at once became contented,
went quietly through all the preliminaries of the operation,
and, during her subsequent illness, showed a remarkable
degree of equanimity and patience, which were interrupted
only when the wound was dressed, and the apprehension of
pain then rendered her immediately excited, and difficult to
manage.
The patient was now placed on a table, with her feet
resting on two chairs, and her shoulders somewhat raised;
the catheter was passed, and a small quantity of urine drawn
off; the fetal heart was distinctly heard, beating in the
xxxvi. 3
66 dr. west's case of
right half of the abdomen, but the uterine souffle was not
clearly perceived anywhere ; facts, the inferences from which
were confirmed during the operation.
An assistant being stationed on each side of the patient,
to prevent the escape of the intestines, and the inhalation of
chloroform having begun, Mr. Skey now marked the line
of the incision with ink ; and so completely was the contour
of the abdomen altered by the contraction of the pelvis, that
the incision, seven inches in length, was carried two inches
above the umbilicus, and down to the commencement of the
pubic hair, and it was afterwards found necessary to carry it
an inch higher.
Inhalation of chloroform began at 18 minutes past 5; at
25,J minutes past 5 the first incision was made, and at 31s
minutes past 5 the child was extracted, the operation having
been somewhat delayed by the circumstance that the patient
began to struggle after the first incision, so that it became
necessary to pause, in order to give her more chloroform.
The abdominal integuments were extremely thin ; no
bleeding took place from them. On opening the peritoneum,
about a drachm of transparent serum escaped ; and on
dividing it to the whole extent of the external wound, the
uterus presented itself, occupying it so completely that no
intestines were to be seen. The uterus was turned obliquely
on its long axis, the right fallopian tube and ovary being
distinctly in new, the front of the uterus looking towards
the left side, and the organ corresponding in its direction
very nearly to that of the left oblique diameter of the pelvis.
Care was taken, however, to make the incision in the mesial
line of the uterus. The walls of the outer half of the uterus
bled comparatively little; but the bleeding from the vessels
of the inner half was tire, though not alarming. The total
thickness of the uterine wall was about three quarters of an
inch. The cavity of the uterus was opened at the lower part
of the wound, and a director of peculiar construction, in-
vented by Mr. Skey for the purpose, and used by him in his
former operation, was then introduced, and the incision
carried upon it quite Dp to the fundus of the womb. The
CESAREAN SECTION. G7
child was now seen lying in the third position of Nacgele
(the second of most authors), namely, with its back to the
right, and forwards. The membranes were at once torn
through, and the child, a fine girl, was taken out. Its
surface looked slightly livid, and for a few seconds it did not
cry. It then, however, began to breathe, and in two or three
minutes cried loudly, without any measures having been
needed to resuscitate it. It may, perhaps, be as well to add,
that the child still survives, and is in good health.
The uterus did not contract much ; it diminished, indeed,
in length, but the wound remained widely open, and the
placenta was seen attached to the posterior part of the organ.
The uterine cavity was now filled with blood, and the placenta
looking as if it were entirely detached, it was removed by
Mr. Skey ; who found, however, that its complete separation
required rather firm traction.
No sooner was the placenta removed from the uterus, than
the blood welled up from it, partly from its interior, partly
from its cut edges, just like water gushing from a spring ;
a profuse, steady, uniform stream running down upon the
floor, and which seemed, for a few seconds, as though it
would not cease so long as there was any blood to flow.
From a pint and a half to a quart of blood was thus lost;
and, diu'iug the continuance of this very profuse bleeding,
the patient's pulse became very feeble, though it never
altogether ceased; while, owing to the insensibility pre-
viously produced by the chloroform, it was some minutes
before she could attempt to swallow. The first indication
of returning consciousness was furnished by several violent
attempts to vomit, during which the intestines (especially on
the left side of the uterus), which had come into view imme-
diately on the removal of the child, prolapsed, and could
with difficulty be retained in the abdomen, even by closing
the integuments over it.
By degrees the haemorrhage abated ; no other means
having been resorted to, to excite uterine action, than
moderate pressure with the hand on the abdomen. At G
p.m., the hemorrhage had quite ceased, though the uterus
68 dr. west's c.vse of
was not firmly contracted, nor the wound closed tight. Five
sutures were now placed in the abdominal integuments, the
last, one inch and a half above the lower edge of the wound ;
a space being left here at my request, in compliance with the
suggestion of some continental surgeons, who attach import-
ance to an aperture being left for the escape of the discharges
from the uterine wound. Broad strips of plaster were next
applied ; and an eighteen-tailed bandage, which had been
placed under the patient before the operation was begun,
was now brought together over some large sheets of cotton
wool, which served to protect the abdomen from pressure.
The patient was now carefully lifted into bed ; and imme-
diately on being placed there, efforts at vomiting came on,
during which firm pressure was made on her abdomen, to
prevent, if possible, protrusion of the intestines. As soon
as they had a little subsided, sixty drops of Tincture of Opium,
were given in a little brandy, but were almost immediately
rejected, and she refused to take any more laudanum, saying
it would make her vomit.
At this time, though her pulse was extremely feeble and
her extremities were cold, yet her mind was calm and col-
lected, nor did her intellect become at all disturbed, until
within an hour or two of her death.
Two doses of morphia were given her between 7 and 10
p.m., but both were rejected soon afterwards, and the patient
made frequent efforts to vomit during the first two hours
after the operation. At 10 p.m., however, she expressed
herself as feeling comfortable, and lier pulse, though ex-
tremely feeble, did not exceed 108 beats in the minute. On
examining the wound, a portion of omentum was seen to
have escaped beneath the lowest suture, and having been
returned with some difficulty, an additional suture was put
in to close the lower edge of the wound, and the renewal of
the accident was thus prevented.
In consequence of the irritability of her stomach, it was
determined to endeavour to keep the patient under the in-
fluence of opium, and to supply her with nourishment mainly
b\ mi ana ofenemata; ami accordingly a drachm and a half
CESAREAN SECTION. 69
of laudanum was thrown into the rectum at midnight ; and
was followed in about an hour by an enema of four ounces
of strong beef-tea, thickened with isinglass. The laudanum
in smaller doses and the beef-tea were given in enemata at
intervals of about every four hours ; so that during the first
sixty-two hours after the operation, $v mxiv, of the former,
and j.xlviii of the lattei', were thrown into the rectum ; the
beef-tea being thickened with isinglass, and occasionally
mixed with brandy.
From the time of the operation to her death, the
patient was watched incessantly by Mr. Cupiss, Mr. W. H.
Strettou, Mr. Arthur Stretton, or Mr. Hillier, four very
intelligent students at St. Bartholomew's, who not only did
everything which the most unwearied care could do to save
her, but also recorded, with the minutest accuracy, every
change in her condition.
For the first twenty hours she dozed at intervals, though
she continued in a state of great depression and vomited
occasionally ; but the irritability of the stomach gradually
diminished ; the lochial discharge appeared, and continued
to flow scantily, but without any unnatural character during
the remainder of the patient's life. She passed water,
throughout the whole of her illness, without any difficulty,
and suffered scarcely any pain ; while the distressing efforts
to vomit were always relieved, sometimes entirely arrested,
by firm pressure upon the abdomen. Her condition during
the 8th of May continued one of great depression; and though
her sickness was less, yet she took nothing more than a little
ice, and a spoonful of milk occasionally. Her pulse was 148
at 10 p.m. ; having been 160 at the same time on the previous
day. Moreover, she bore the cutting off some of her soiled
linen very well, and expressed a wish for some wine.
She passed the night of the 8th of May on the whole
comfortably, dozed a good deal, and took wine-and-water
frequently; but was slightly sick at 5 a.m., on the 9th ;
when she threw up a little clear fluid, being the first time
of her vomiting for more than twenty hours.
During the day she took sago and milk readily, hut refused
70 dr. west's case of
wine; and continued apparcntlybetter till half past3p.ni., when
she vomited a dark brown, offensive fluid ; and this vomiting
recurring thrice before 10 p.m., left her evidently deterio-
rated, aud she passed a more restless night than the pre-
ceding one had been.
At a quarter to 7 a.m., on the 10th, vomiting of green matter
had returned; aud the patient seemed more feeble. She had
taken very little by the mouth, aud the disposition to sick-
ness and distaste for almost everything, with the inability to
bear more than a teaspoouful or two of any nourishment at
a time, interfered greatly with all endeavours to support her
powers. She had complained sometimes of headache, es-
pecially when sickness was felt ; aud it became a question
with Mr. Skey and myself whether any advantage likely to
accrue from the continuance of the laudanum in the encmata
was such as to counterbalance the possible evil of maintaining
a constipated condition of the bowels, and of keeping up or
aggravating the patient's sickness. The character of the
matters vomited seemed, indeed, to point to a more serious
and less remediable cause ; but still it was determined to
try the effect of omittiug the laudanum.
Various stimulants and various articles of food were tried
during the course of the day, but she took very little of any ;
champagne and ice being the two things that seemed most
grateful to her. She had one or two returns of green
vomiting during the day, but did not appear, at 11 p.m., to
have at all retrograded since the morning.
She became very restless, however, and was sick twice
after 11 p.m. ; the opium was accordingly resumed in the enc-
mata, and early on the morning of May the 1 1th, small doses
of the black drop were given every two hours at Or. Murphy's
suggestion. By 3 p.m., under the continuance of the opium
and the encmata of beef-tea, with such small amounts of
food and stimulants as she could be induced to take, she
rallied surprisingly; the lochial discharge, which had alum I
ceased for the previous twelve hours, reappeared; ami her
pulse, which had ranged at about 1 10 to 150, though still
l Hi, was somen hat less feeble.
CESAREAN SECTION. 71
At 3 p.m., Dr. Ramsbotham, Dr. Murphy, Mr. Skey,
Mr. Wren, and I, saw her together, and felt more hopeful
about her than at any time for the previous twenty-four
hours. There was, however, one bad symptom about her
even then, which was that her temperature, which during the
night had sunk very low, continued so, and that there was a
cold perspiration upon her sui'face. Almost immediately
after this visit, too, the other favorable symptoms began to
disappear; her skin became quite cold, her pulse thready,
and she sank into a state of collapse like that of a cholera
patient, her intellect continuing clear, and considerable
muscular power remaining, until within a couple of hours of
her death, which took place at half-past 6 a. m, on May 12th;
108£ hours after the operation.
At the examination of the body 33 j hours after death,
the abdominal cavity and the pelvis were alone examiued.
Decomposition had already advanced ; the body gave out
a very offensive odour; there were livid spots on the surface
of the abdomen, which was tympanitic.
The external wound was now six inches long; union had
taken place for about two inches at its lower edge, and about
the situation of the fourth suture, but elsewhere its edges
were gaping.
A portion of healthy omentum, about two inches loug, was
found lying free at the lower edge of the wound beneath the
integuments, but external to the peritoneal cavity.
There was no effusion of fluid into the abdominal cavity ;
the viscera were all exceedingly bloodless, but a thin layer
of dirty yellow lymph connected the opposite surfaces of the
pale, large intestines to each other, and also at some points
united the intestines to the uterus.
A thick layer of yellow lymph lined the abdominal walls
from the umbilicus downwards. On stripping it off, the
peritoneum appeared thickened, and destitute of its natural
polish, but scarcely, if at all, increased in vascularity. The
intestines contained very little fluid, no solid faeces, some
flatus.
OK. WEST 8 CASE OF
The bladder was empty and flattened, and appeared to
have adapted itself to the altered shape and relations of the
parts, being almost completely out of the pelvis. It was
(mite pale and healthy.
The uterus was moderately contracted, but not the slightest
effort had been made to close the wound, the external edges
of which were retracted, and lay at least an inch apart, while
the internal edges were but just in apposition.
At the wound, the substance of the uterus looked swollen
and infiltrated, the wall there measuring 1*2 inch in thick-
ness, while at the fundus of the organ it was only "7 thick.
The length of the external uterine wound was 3-65 inches ;
of the inner 2-5. The edges of the wound were covered by
a thin layer of a dirty brownish matter, in all probability
altered blood ; beneath which they were of a pale dirty,
straw colour. Elsewhere the substance of the organ was
pale and bloodless, looking as white as veal; presenting no
sign of inflammation, no thickening of its veins, neither
eoagula nor blood in their channels.
The placenta had been attached posteriorly near the
fundus of the uterus, but rather to its left side. The surface
to which it had been attached looked quite healthy, as did
the whole interior of the uterus, and also the vagina, in
neither of which was there any blood nor any sort of morbid
secretion.
The pelvis was a very well-marked specimen of the de-
formity produced by mollitics ossium.
The lumbar vertebrae had been driven down into the pelvic
cavity, so that, as the body lay upon its back, a line drawn
from the symphysis pubis directly backwards, touched the
upper part of the fourth lumbar vertebra.
The length of such a line was 4*2 inches.
Transverse diameter of the brim I' „
The rami of the pubes were projected forwards into a beak,
the width of which was -75 of an inch, while its length,
measured from the inner surface of the symphysis, was 1*2
inch ; by which the anteroposterior diameter was reduced
t'> ■'■ inches
CESAREAN SECTION. 73
The bodies of the fourth and fifth lumbar vertebrae were
much flattened, so that from the upper part of the fourth to
the upper part of the sacrum they measured only 1*5 inch.
The sacrum was so greatly curved that from about its
third vertebra it ran horizontally forwards. The depth of
the bone to the point where it bent forwards, was rather less
than one inch and a half; while from the point of the coccyx
along the horizontal part of the sacrum it was 2*75.
Distance between the two anterior superior spines of ilia . . . S inches.
„ „ tuberosities of ischia 1'2 „
„ „ point of coccyx,and summit of the pubic arch 2"8 „
„ „ rami of the pubes at the lower edge of the beak 1'05 „
Width at the upper part of the pubic arch -G „
Agreeing, as I do, most cordially with the rule laid down
in British Midwifery, which gives the mother's life a claim
paramount to every other consideration, it cannot but be
with a feeling of deep regret that I am compelled to add
another to the already long list of failures of this operation.
Happily, however, in this instance, the painful question which
sometimes besets us after an unfortunate operation, as to
1 I am acquainted with 409 authentic cases of the Cesarean section, 341
of which are collected in Kayser's very valuable essay ' De Eventu Sectionis
Csesarca?.' In 251 of these cases the mother died; in 158 she survived.
The fate of the children is mentioned in 347 instances : in 110 of which
they were still-born, in 237 they were born living. There can, however, be no
doubt but that these figures convey a very exaggerated impression as to the
proportion of recoveries, and that the unfavorable estimate of English
authors is nearer the truth. Both Kayser and Naegele regard the results
given by the published cases as unfair ; and the former mentions the fact,
which of itself affords strong evidence on this point, that while the total
maternal mortality among the cases which he had collected was 03 per cent.,
the mortality of cases occurring in lying-in hospitals, in which institutions
failures must, of necessity, be reported as well as successes, amounted to
79 per cent. This last figure does not differ very materially from that-
afforded by the cases occurring in this country ; 49 of which yield 7 re-
coveries, (or 8, if Mr. Whitehead's case, where the patient survived till the
thirty-second day, and died then chiefly from the advance of disease in her
hip, be classed among the number;) (he rate of maternal mortality being in
the former case 857, in the latter 83'0 per cent.
74 dr. west's case of
whether some different course might not have been adopted with
better prospects of success, does not arise ; since the extreme
degree of pelvic deformity must have rendered any attempt
at extracting a mutilated child almost certainly unsuccessful;
while the absence during pregnancy of evidence of the con-
tracted state of the pelvis, sufficiently accounts for no
measures having been adopted for the induction of premature
labour.
But though there was here no alternative left, and though
if a similar case presented itself to me to-morrow, I should
again advise the same course, yet it cannot be denied that
the Cesarean section is attended by perils peculiar to itself,
such as beset no other operation either in surgery or ob-
stetric practice, and which, I confess, would make me shrink
from recommending its performance in every instance where
the way seemed open for any other proceeding.
The clangers peculiar to this operation, and inseparable
from it even when most carefully performed, may be referred
to the following four heads: —
1. The danger arising from haemorrhage, which proceeds
from a source different from that whence bleeding takes
place in any other operation, and which is not capable of
being arrested by the same means as suppress it under
ordinary circumstances.
2. That dependent on the shock inflicted on the nervous
system, as well by the violent interference with the most
important process that ever goes on in the organism within
the same limited time, as by the injury to a part so im-
portant and so richly supplied with nerves as the uterus of a
parturient woman.
3. The hazard inseparable from extensive injury to the
peritoneum, when unbluntcd in its sympathies and unaltered
in its texture, as in cases of ovarian or other tumours, for the
removal of which a similar exposure of the abdominal cavity
is sometimes practised.
I. That which results from the infliction of a wound on
the uterus, at a time when, in the ordinary course of things.
the processes which nature is prepared to carry on in it,
CESAREAN SECTION. 75
consist iu the desintegration and removal of its tissue ; the
very opposite, indeed, to those essential for the repair of injury.
To all, except the last of these sources of dangei', attention
has been more or less directed ; but still the amount of peril to
which the patient is exposed from each, has, perhaps, been
scarcely sufficiently investigated.
Kayser, in his valuable essay on the Caesarean Section,
states the cause of death in 1 23 cases ; in 77 of which the
patient died of inflammation, in 30 from the shock to the
nervous system, in 12 from haemorrhage, and in 4 from some
accidental occurrence not of necessity associated with the
operation. In some of these cases, however, no post-mortem
examination was made ; in others the date of the patient's
death is not stated ; while in several, more than one of the
above-mentioned causes had contributed to occasion the
patient's death. Selecting, therefore, such of Kayser's cases
as were complete in all respects, and adding to them such
others as have since come to my knowledge with the requisite
details, I have drawn up the accompanying table, as affording
some approximation to a correct view of the causes of death
after the Cfesarean section.
From this table1 it appears that, in 41 out of 147 cases,
a notable amount of haemorrhage occurred either during the
operation or subsequent to it; and in a third of this number
haemorrhage was the sole cause of the patient's death. In
seven instances the haemorrhage arose, in great measure,
from the placenta being wounded in the course of the
operation ; an accident which probably might be avoided in
the majority of instances, by careful prelimiuai'y auscultation.
In twenty instances it occurred at the time of the operation,
and proceeded in part from the edges of the wound, in pari,
and usually in greater measure, from the seat of the
placenta, and followed its detachment or spontaneous sepa-
ration. In the remaining fourteen cases the more important
bleeding was secondary, taking place after the completion of
the operation and closure of the wound, escaping externally
1 Vide p. 80.
7C> dr. west's case OF
in one or two instances, but in the other cases being poured
out into the abdominal cavity, and being discovered in the
form of coagula of greater or less magnitude, on examination
of the patient's body after death.
Against this hemorrhage the resources of art can effect
but little. The injury of the uterine substance can hardly
fail to impair the contractile power of the organ, while that
arrangement of the uterine sinuses which tends to prevent
the occurrence of hemorrhage after the separation of the
placenta, even where the womb remains uncontracted, can be
of no service in checking the bleeding from the wound.
It does not seem easy to say why profuse bleeding has
occurred in some cases and not in others, and the impossi-
bility of estimating the dangers of the operation before-hand
with any near approach to correctness, is to my mind by no
means the least of the difficulties that attend upon it. It
may, perhaps, be thought that, in the case related above,
the administration of chloroform had something to do with
the very tardy contractions of the uterus ; and my own
experience of this agent, which I frequently employ in
obstetric operations, inclines me to believe that this may have
been the case, though it must not be forgotten that the
uterine action was very feeble even from the commencement
of labour. Serious hemorrhage attended on four1 out of seven
cases of the Caesareau section in which anaesthetic agents were
employed ; but in two" the action of the uterus continued
vigorous, although the patient was in a state of complete
unconsciousness; while Mr. Skey's patient, on whom lie
operated at St. Bartholomew's, ";i* never thoroughly under
the influence of the ether; and the hemorrhage in Dr.
Ninimo's recent case depended, in great measure, upon the
placenta having been wounded. The risk of serious hemor-
rhage is doubtless diminished by not operating till after the
1 Namely, the present case, and those of Mr. Bkey, Dr. Nimmo, and
Professor Huter; numbers 100, ill, L09, and B in the Table of reference.
5 The cases of Mr. Campbell, No. •'><>, ami Dr. Oldham, No. l:il ; besides
rhich ii was employed with advantage in Dr. Oldham's late successful ease,
reported in Hie ' Medical Times' of angusf 16, 1851,
CESAREAN SECTION. / /
liquor amnii has escaped or been evacuated ; but the danger
of exciting violent peritoneal inflammation, is probably a
sufficient reason against following the practice of Professor
von Ritgen of Giessen,1 who advises that the uterus be drawn
forwards, and surrounded with sponges dipped in cold water,
till vigorous and permanent contraction has been induced ;
though in one or two cases which terminated successfully
this proceeding has been adopted.
The shock to the nervous system is a very serious cause
of the mortality of patients who undergo the Cajsarean
section. In thirty-three of 147 fatal cases, the patient sank
under the shock ; no haemorrhage having either attended
the operation or followed it, and no morbid appearances
having been discovered after death. In eleven cases more,
though the more prominent symptoms during life were those
of shock, yet examination after death discovered the effects
of previous inflammation ; and reference has already been
made to nine other cases where the symptoms of shock might
be, in measure, due to the loss of blood.
Two causes, both alike beyond the control of the prac-
titioner, expose the patient to this shock : one, the sudden
interruption of the labour; the other, the injury to the
womb ; and the feeble person, exhausted by previous disease
and suffering, and therefore least able to bear up against
their influence, is she whose case, in general, most urgently
calls for the performance of this operation. The employment
of opium in large and frequently repeated doses, as originally
suggested by Dr. Stokes, in cases of peritonitis from perfo-
ration of the intestines, and of the successful adoption of
which, in a case of rupture of the uterus, Dr. Mitchell has
related2 a very interesting example, would probably do some-
thing towards warding off the symptoms of collapse. The
discontinuance of the opium, in the case just recorded, was
probably injudicious; and the patient's brief rallying after-
wards was, perhaps, due to its readmiuistration. At the
1 Neue Zeitsclirift fiir Geburtskunde, Bd. ix, s. 212.
3 Dublin Journal of Medical Science, Jau. 1843.
78 dr. west's case of
same time, the recovery of those patients who have survived
the operation, does not seem to be attributable to the adop-
tion of any one appropriate and well-considered plan of
treatment ; but their history is characterised by the very
slight degree in which the shock was experienced, or the
rapidity with which it spontaneously passed away; so that
the fortunate issue of the operation appears to have been
clue to the vigour of the patient, rather than to the skill of
the doctor.
In fifty-sis out of the 147 cases, or in 37 per cent.,
the symptoms during life, and the appearances discovered
after death, were those of inflammation of the peritoneum,
or, in some cases, of the uterus, and, in not a few instances,
the morbid processes are said to have issued in gangrene. In
twenty-nine cases more, the consequences of inflammation
were found after death, though its symptoms were more or
less masked by those dependent on previous haemorrhage,
or on the shock of the operation. It certainly can be no
cause of surprise, that in eighty-five out of 147 cases, or in
57 per cent., the evidences of peritoneal inflammation
should have been present ; for, in addition to all those
influences peculiar to child-birth, which lender peritoneal in-
flammation more frequent then than at any other time, there
is superadded the extensive injury inflicted by the operation,
the long exposure of the abdominal cavity, and the subse-
quent escape, in many instances, of blood, or of the uterine
discharges into it. Moreover, in addition to all of these
causes tending to produce serious inflammation of the peri-
toneum, there is the absolute necessity of the occurrence of
some degree of inflammation for the closure of the wound,
and the repair, in as far as nature can effect it, of the
grievous injury which has been inflicted by the operation.
How narrow most be the limits which, in a patient who has
undergone the Cesarean section, separate the healthy action
essential to repair, from the morbid action that tends to
destruction !
The state of the wound has, unfortunately, engaged less
attention than the interest and importance of the inquiries
CESAREAN SECTION. 7'J
on which it bears, might well demand. Still, even from the
imperfect data with which we are furnished, it seems clear
that one of the first steps which nature takes towards the
repair of the injury in these cases, consists almost invariably
in the setting up of inflammation of the peritoneal surface
of the uterus, and of the corresponding portion of the abdo-
minal peritoneum, or, less often, of the peritoneal surface of
the intestines; with the view of forming adhesions all roimd the
wound of the uterus, and thus isolating it from the cavity of the
abdomen. This being effected, adhesion takes place between
the cut edges of the peritoneum ; which, lymph effused upon
its surface, strengthens, though this often takes place but
slowly, and, for a long time, imperfectly ; as, for instance, in
a case related by Professor von Ritgen,1 in which a fistulous
communication between the surface of the body and the
interior of the womb did not close till the sixty-fifth day.
Afterwards the divided tissue of the uterus itself, in some
instances, becomes united, though this last step always takes
place most imperfectly, and sometimes not at all.
In many of the fatal cases it has been found that no step
whatever has been taken towards repair ; in more the process
set up has been a perverted one, and there is no attempt at
adhesion, but a dirty exudation covers the pale and bloodless
peritoneum extensively, or is poured out in a fluid form into
the abdominal cavity ; while in others, as already mentioned,
parts are found with their vitality destroyed, and this not
by the excessive activity of powers which, moderated, might
have conduced to repair, but by their deficiency.
And this brings me to the last cause of the high mortality
which follows this operation, and a cause against which skill
can avail absolutely nothing, since it is inseparable from
those processes which nature sets on foot after the uterus is
emptied of its contents, be the period of pregnancy, at which
that takes place, what it may. In a large proportion of
cases, the record of the examination after death states, that
the wound of the uterus was found gaping widely, even many
1 Neue Zeitsohrift fur Geburtskunde. Bd. is, Hefi 8.
80 dr. west's case of
days after the operation was performed. In other instances
it is stated that the inner edges of the uterine wound were
in contact, but the outer were far apart ; and that, along
the whole wounded surface, no indication was to be found
of any attempt at its closure ; while I know of but two
instances in which the edges of the uterine wound are said
to have presented a granulating surface.1
Tardy, however, though the union of the wound of the
uterus is, it yet takes place eventually, if the patient survives;
and the history of the subsequent pregnancies and labours
of women who have undergone the Csesareau section, proves
that this union must, in some cases, have acquired a con-
siderable degree of strength. The great majority of in-
stances, however, in which women have survived the operation,
illustrate, in spite of the incompleteness of their record, the
serious difficulties in the way of a cure, and the imperfect
manner in which it is almost invariably accomplished. The
giving way of the uterus at the cicatrix of the operation in
a subsequent pregnancy, and the escape of the ovum into
the abdominal cavity, are occurrences with which all who
are conversant with the history of the Csesareau section are
familiar.2 Imperfect, too, as the accounts of the cicatrix
are, in those cases in which death has occurred after the lapse
of some months from the performance of the operation, they
yet suffice to show the frail nature of this bond of union. The
womb, indeed, is generally adherent to the abdominal walls,
but its divided substance is almost always found ununited ;
tbc edges of the wound being closed merely by the union of
the peritoneum. Even where the union has gone deeper, it
has yet been effected only by means of a dense, quite
unyielding, or but slightly elastic, cellular tissue ; in some
instances, of such low organisation as to have been found
converted into a hard, almost bony, substance. How slow,
1 Whitehead, 'Medical Gazette,' Sept. 1841; and in'Rusfa
Magazin,1 &c, Bd. ilv, p. 857, as quoted bj Kayser, p. 87.
M .mi s of the b cases are detailed bj Professor Michaelisof Kiel, in his
..■in ible essay oi
Qebiete dei Getrartahulfe ;' Kiel, L833.
CESAREAN SECTION. 81
too, the processes are by which, even under favorable cir-
cumstances, this cicatrix tissue becomes assimilated to the
structure of the organ in which it is developed, can hardly
be better shown than by the following account by Dr.
Lange,1 of the examination of the uterus of a woman who
died of some chest affection nearly two years after the per-
formance of the Csesarean section.
" Just over the symphysis pubis there was a deep depressed
cicatrix several lines in depth, and of the size of a sixpence.
From the inner surface of the abdominal walls there was
seen, continued from this cicatrix, a wedge-shaped prolon-
gation, half an inch in length, as thick as the finger, of
a round, but slightly flattened, shape, extending to the
anterior wall of the uterus, and being closely united to it.
In the interior of this band there was a cavity which com-
municated with that of the uterus, by an opening two lines
in diameter. The iuterior of this conical cavity was lined
by a prolongation into it of the uterine mucous membrane,
and there seemed, moreover, to be a process of reproduction
of uterine tissue in course of progress from the basis towards
the apex of the cavity. Several bands of a callous substance,
resembling that just described, ran from the sides of the
larger cicatrix to the anterior wall of the uterus."
Dr. Lange remarks, concerning these appearances of
which I have given an abridged description, that this sort of
diverticulum proceeding from the uterus, indicates sufficiently
clearly that the healing of the wound was not effected by
union of its edges, but by the effusion of plastic lymph from
the inflamed uterine peritoneum, and its cohesion with the
inflamed abdominal peritoneum.
The surgeon who removes a limb in which gangrene has
commenced, knows that, unless his incisions are made sonic
distauce above the decaying tissue, he can have no hope of
the healing of the wound. The uterus, after delivery, is in
1 In a paper at p. 126, vol. iv, of the ' Vierteljahrschrift fib- die gesammte
Hcilkunde,' for 18-16, which contains by far the best account of the struc-
ture of the cicatrix, in these cases ever yet published.
xxxiv. G
82 dr. west's case of
a condition, not certainly of decay, but, at least, of desinte-
gration. Instead of there being any natural tendency to
an increased afflux of blood towards it, that first step towards
the repair of injur}', the very dischfirge of its contents cuts
off half the supplies of blood previouslj7 directed to it. From
the weight of 3sxiv> which the organ has been ascertained
to have just after delivery, it is reduced, in the course of six
weeks, to a weight not exceeding an ounce and a half. This
change, too, is effected, not by simple absorption, but is
attended also by a general degradation of its tissue, of which
the abundant presence of fat globules in the lochial discharge,
and in the debris which cover the interior of the organ, is
ample evidence.1 It is true, indeed, that, simultaneously
with the removal of the old tissue, there goes on a formation
of new ; but of a tissue much more lowly organised, pos-
sessed of but small power to repair injury, and which
commonly requires, for its higher development, the appro-
priate stimulus furnished to the uterus by pregnancy, and
the sojourn of an ovum in its cavity.
The condition of the uterus in the patient whose history
I have related, gave an apt illustration of the correctness of
these views. The organ was generally pale and bloodless,
the edges of the incision through it were swollen, infiltrated,
cedematous, and discoloured by altered blood, so as to look,
at first, almost as if gangrenous ; and I have little doubt but
that, in many of the cases in which the organ was alleged
' Sec Virchow's account of the microscopic examination of the uterus of
a woman who died fourteen days after delivery, in the 'Verhandhmgen der
Gesellschaft fiir (iebnrtshiilfc,' in Revlin, vol. iii, p. xvii; with whieh the
brief aceou ill by Kollikcr, in the ' Zeit sell rift fur Wissenschaftlichc Zoologie,'
vol. i, p. 7.'<, perfectly harmonises. He elaborate essaj of IYofessor Franz
Kilian, in 'Ilenle and Pfeuffer's Zeitschrift,' vol. ix, p. 1, tarnishes :i mora
complete account than is elsewhere in be found, both of the development of
the I' He of the Utems, and of the changes which take place in it after
delivery ; ami demonstrates the fad of the removal of the old uterine tissue.
ami the production, ill its place, of a new and more lowly Organised tissne.
to which reference is incidentally made by Mr. Elainej in his paper in the
'Philosophical Transactions' for I860, pari ii. pp. 519-20.
cesarean section. 83
to have been in a state of gangrene,1 that condition was, as
in the above instance, apparent rather than real.
If, then, such and so many dangers beset this operation,
if the recoveries from it be so few, and the mortality so great,
while the causes of that mortality are, for the most part,
beyond the power either of surgical dexterity or medical
skill to obviate, and some of them inseparable from those
processes which needs must follow delivery, we may, I think,
feel satisfied that the general rule in British Midwifery,
which prohibits the performance of the Cesarean Section,
except where delivery would otherwise be altogether im-
possible, rests on a far sounder foundation than that of mere
prejudice, or blind obedience to the dicta of men eminent
in their profession.
At the same time, these facts can yield no apology for
those who, in cases calling for this operation, allow, from
any cause whatever, the right moment to pass by unused.
They rather leave such conduct altogether without excuse,
since, by it, dangers always great are rendered insur-
mountable, and hopes, small at the best, are utterly destroyed.
1 Many cases of an analogous condition of the uterus, in women who have
undergone the Csesarean section, might be adduced. The following may
suffice from the history of a woman who died thirty days after the perform-
ance of the Cajsarean section. " The wound of the uterus was slightly closed
at its lower part ; but at its upper end, where it had been carried quite up
to the fundus uteri, it not merely gaped widely, but the absorption of its
edges had gone on with such activity, that nearly the whole of the fundus
uteri was consumed." — Busch, ' Geburtshulniche Abhandlungen,' 8vo,
Marburg, 1S2G, p. 243. He attributes this condition of the uterus to the
effects of the osteomalacia, which was still advancing at the time of the
patient's death; but it may, I think, with more propriety, be referred to
those causes mentioned in the text as acting on the uterus after delivery.
8i
I)K. WESTS CASE OF
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CESAREAN SECTION.
85
References to the Cases enumerated in the foregoing Table.
1. Bell, Medico-Chirurgical Transactions, vol. iv
2. Thompson, Medical Records, &c.
3. Wraith, Provincial Med. Journ., Jan. 21, 1843.
4. Engeltrum, Gemeinsame Deutsche. Zeitschr. f.
Geburtsk., iv ...... .
5. Ansiaux, Clinique Chirurg., p. 63
6. Baudelocque, Transact. Medicales ; Septr. 1833.
7. Anonymous, at Vienna, Balfour, Northern Journ. ;
May 1846.
8. Hiiter, Neue Zeitschr. f. Geburtsk; xxvii, p. 358.
9. Steiu, Siebold's Journal ; vol. xiii
10. Lyon, Monthly Journ. of Med. Science, Dec. 1845.
11. Etlinger, Observationes Obstetrics?; 4to, Bonnae,
1844.
12. Merrem, Gemeins, Deutsche Zeitschr. f. Geburtsk. ;
iii, p. 341
13. Johannknecht, Abhandl. d. arztl. Gesellsch. z.
Miinster; 1829, p. 366
14. Kirchoffer, Neue Zeits. f. Geburtsk. ; xix, p. 305
15. Hull, Defence of the Cesarean Operation
15*. Shipman, American Journal of Medical Science ;
July, 1849.
16. Hull, Defence of the Ca:sarean Operation
17. Hunold, Stein, Geburtshiilfl. Abhandl.
18. Henderson, Ediub. Med. Surg. Journ. ; xvii, p. 105
19. Armbruster, Stein, Lehranstalt der Geburtsk., p. 184
20. M'Kibbin, Edinb. Med. Surg. Journ. ; xxxv, p. 352
21. Thibault.Arch. Gen. de Medeciue; June 1844
22. Montgomery, Dublin Journal ; Jan. 1835
23. Chalmers, Hamilton's Outlines of Midwifery
Edinb. 1806, p. 293 ....
24. Cooper, Med. Observ. and Enquiries ; v
25. Juppin, Journ. de Med. Chirurgie, &c. ; liv, p. 65
26. Baudelocque, Recueil Periodique ; v, p. 435 .
27. Kottmann, Rheinische Jahrb. f. Med. u. Chir,
vi, pt. 2
28. Legroux, Revue Med. ; iii, p. 353
29. Textor, Neue Zeits. f. Geburtsk. ; v, p. 161 .
30. Dolilhoff, Rust's Magaziu, vol. Iii
Kayser,
No. 71.
No. 37.
No. 145.
No. 100.
No. 181.
p. 82. No. 162.
p-
77.
No.
147
p-
79.
No.
155
p-
54.
No.
67.
p-
w,
No
61.
p-
56.
No.
72.
p-
67.
No.
113
p-
73.
No.
182
p-
80.
No.
158
p. 87. No. 186.
p-
46.
No.
40.
p-
46.
No.
41.
p-
49.
No.
49.
p-
55.
No.
69.
p-
69.
No.
119
p-
78.
No.
150.
p
88.
No
190
p-
91.
No.
199
! 6
DR. WEST S CASE OF
Wolff, Neue Zeitschr. f. Geburtsk
D*Outrepont, ibid. ; xiii, p. 431.
Etlinger, Observationes Obstetrics ; p. 49.
Klein, Loiler's Journal ; vol. ii
Assalini, Michaelis, Abhandlungen ; p. 87, obs. Ii
Buscli, ibid.; p. 91, obs. 37
Cams, Gem. Dents. Zeits. f. Geburtsk.; ii, p. 406
Griife, Berlin. Med. Zeitung; 1832, No. 16 .
Moreau, Arch. Gun. de Med.; Fevr., 1838 .
Cox, Provincial Med. Journ.; Sept. 18, 1844.
Deleurye, Obs. stir la Section Cesarienne
Kluge, Siebold's Journal ; viii, p. 72
Emraert, Scbmidt's Jabrb. ; 1847, No. 8.
Grenser, Neue Zeits. f. Geburtsk. ; xxv, p. 242.
Wiedemann, Siebold's Lucina; vol. i, pt. 3 .
Serres, Baudelocque, Recueil, &c. ; v, p. 428
Oesterlen, Michaelis, op. cit. ; p. 90, obs. 27
Wood, Med. -Chir.-Trans. ; vol. vii
Kellie, Ed. Med. Surg. Journ.; vol. viii, p. 11
Stein, Annalen d. Geburtsk.; pt. 3
Wood, Memoirs of Med. Soc. of London ; vol. v .
Hamilton, Outlines, &c. .....
Osiander, Coram. Soc. Reg. Med. Gott. ; 1813 .
Decke, Rust's Magazin; vol. wii
Bongiovanni, Omodei Annali; April, 1825 .
Michaelis, l'faff's Mitthcilungcn ; p. Ill
Jungmann, Oest. Med. Jabrb.; vol. xxv
Radford, Ed. Med. Surg. Journ.; vol. lv, p. 67.
K6mm, Oest. Med. Jabrb. ; xviii ....
Campbell, Med. Gazette ; May, 1849.
Roederer, Siebold's Lucina ; vol. iv, pt. 1 .
Baudelocque, Lachapellc, Accouehetneus ; vol. iii,
p. 506
Bongiovanni, Omodei Annali ; vol. xxix
Ulsamer, Siebold's Journal ; vol. x . . .
Gueury, Gaz. des Hdpitaux ; 1840, No. 79 .
Putcgnat, Monthl] Retrospect; Oct. 1848.
Balfour, Monthly Journal ; Aug. 1847.
Seidler, Rust's Magazin ; vol. xx
Oc Beauclair, Gi-ineinsamc Dcuts. Zeits.; i, p. 115
Anonymous, Kleincrt's Repertorinm : vol. iv
Miinrini, Osscrvationi Mediche ; 1827, No. 10
\\ enilel.stadt, Siebold's Lucina; iii, p. 315 .
Plamio, Neue /cits, f, Geburtsk. ; \i, p. 400
Brooke, Am. Journal >>i" Med, Science; May, ls3G
Roederer, Siebold's lucina ; iv, pt. i .
viii, p. 354 . Kayser, p. 92. No. 203.
p. 55.
No. 68.
p. 66.
No. 108.
p. 73.
No. 131.
p. 76.
No. 1 13.
p. 82.
No. 163.
p. 90.
No. 197.
p. 48.
No. 48.
p. 78.
No. 149.
p. 59.
No. 82.
p. 57.
No. 78.
p. 67.
No. 111.
p. 65.
No. 107.
p. 64.
No. 102.
p. 46.
No. 42.
p. 55.
No. 70.
p. 53.
No. 62.
p. 60.
No. 87.
p. 71.
No. 126.
p. 71.
No. 12 7.
p. 85.
NO. 170.
p. 90.
No. 198.
p. 93. No. 209.
p. 63.
N...
98.
p. 71.
No.
185,
p. 75.
No
111.
p. 87.
No.
185.
p. 72.
No
128.
p. 71.
No.
134.
p. 77.
No.
IIS.
p. 78.
No.
151
p. 83.
No.
16 «•
P. BB.
No.
193..
p. 9.1.
No
206.
1'. H
\,,
36.
(J/ESAKI'lAN SECTION.
76. Kenckel, Michaelis Abhandl.; p. 76, obs. 19 . Kayser,
77. Stein, Geschichte d. Kaisergeb. .
78. Osiander, Comm. Soc. Reg. Gott. ; 1813
79. Berger, Siebold's Journal; vol. v, p. 142
80. Comelis, Annales d. Med. Beige; July, 1836
80.* Martini, Canstatt's Jahrb. f. Geb.; 1847, p. 327.
81. Dormann, ibid.; xx, p. 324.
81.* Hiiter, Neue Zeitschr. f. Geb. ; xxvii, p. 366.
82. Genth, ibid. ; xxvii, p. 200.
83. Ohle, Salzb. Med. Chir. Zeitung, vol. 110 .
84. Leydig, Gem. d. Zeitschr. f. Geburtsk. ; vi, p. 328
85. Rust, Siebold's Journal f. Geburtsk., vol. xiii
86. Siebold, Neue Zeitschr. f. Geburtsk. ; xviii, p. 45.
87. Busch, ibid. ; xxviii, p. 207.
88. Bongiovanni, Omodei Annali, vol. xxix
89. Ward, Med. Gazette ; vol. xxi .
90. Neuber, Hufeland's Journal ; lxxxiii, p. 52
91. Dubois, Lachapelle, op. cit. ; iii, p. 504
92. Reuter, Heidelb., Clin. Annalen ; x, p. 431
93. Coley, Case of Caesarean Section.
94. Busch, Neue Zeits. f. Geburtsk. ; xxviii, p. 207.
95. Schiitzer, Michaelis, op. cit., p. 76, obs. 14
96. Hoebeken, Bull. Med. Beige ; Fevr, 1838
97. Kranefuss, Rust's Magazin; xlv, p. 257
98. Hoebeken, Bull. Med. Beige; Jan. 1840
99. Eck, Thorn's Erfahrungen, &c. .
100. Ficker, Salzb. Med. Chir. Zeit. ; 1806
101. Lovati, Gem. d. Zeitschr.; v. p. 137 .
102. Nimmo, Monthly Journal; Sept. 1850.
103. Kunsemiiller, Neue Zeitschr., &c. ; xii, p. 375.
104. Sannemann, Lancet ; July 13, 1850.
105. Ritgen, Heidelb. Clin. Annalen; i, p. 263 . .
106. Martin, Duo Sectioni C<esarea2 Exempla; 4to, Jenae, 1850.
107. Barlow, London Med. Surg. Journal ; iv, No. 96 .
108. Busch, Neue Zeitschr., &c. ; v, p. 170 . .
109. The Author.
110. Ritgen, Gem. d. Zeitschr. f. Geburtsk. ; v. p. 577 .
111. Skey, Lancet; Feb. 6, 1847.
112. Schlegel, Michaelis ; op. cit., p. 89, obs. 24 . .
113. Fritz, Oest. Med. Jahrb., vol. xix ...
114. Dubois, Archives Gen. de Mud. ; May, 1839 .
115. Servaes, Siebold's Journal ; vol. ii . . .
116. Baudelocque, Lachapelle ; op. cit., vol. iii . .
117. Hemic, Siebold's Journal, vol. vii . . .
118. Busch, Gem. d. Zeitschr. f. Geburtsk. ; iii, p. 292
p. 45.
No.
38.
p. 50.
No
54.
p. 61.
No
90.
p. 68.
No.
116
p. 89.
No.
101
p-
59.
No.
83.
p
65.
No
105
p
70.
No.
123
p
70.
No
124
p
93.
No
208
p-
81.
No.
159
p
72.
No
129
p-
81.
No.
1G0
p
43.
No.
84.
p-
82.
No.
169
1'
87.
No.
187
p-
92.
No.
204
p-
54.
No.
65.
p-
59.
No.
85.
p-
79.
No.
154.
p. 70. No. 122.
p. 77.
p. 81.
No. 146.
No. 161.
p. 80. No. 156.
p-
65.
No.
106
p
91.
No
201
p-
92.
No
205
p-
60.
No.
88.
p-
62.
No
95.
p-
73.
No
133
p
78.
No.
1 52
88
DR. WEST s CASE (if CESAREAN SECTION'.
02 1
119. Ferrario, ibid.; v, p. 140 .
120. llaase.Neue Zeitschr., &c, iii, p. 407
121. Weissenhorn, De Partu Cesareo .
122. Coutouly, Reeueil Period, de la Soc. do Med
xxxiv, p. 277 ....
123. Kill, in. Gem. d. Zeitschr. f. Gcburtsk. ; vi, p
124. Busch, Med. Zeitung, 1840, No. 1
125. Micbaelis, Siebold's Lucina, vol. v
126. Siebold, Weidmann.Compar. inter Sectionem, &c
127. Siebold, Siebold's Journal, vol. i, p. 279
128. Meyer, ibid.; v, p. 105 .. .
129. Mursinna, Journal f. die Chinirgie, &c. ; ii, p. 247
130. Hooper, Lancet ; Feb. 4, 1843.
131. Oldham, Med. Gazette; Feb. 21, 1851.
132. Stein, Praktische Abbandl. ii. d. Kaiserg.
133. Atkinson, On Division of the Symphysis
134. Haas, Gescbichte eines Kaiserschnittes
135. Lauverjat, Neue Methode, &c.
130. Hasner, Siebold's Lucina; vol. vi
137. Beclard, Lachapelle j op. cit., iii
138. Dormann, Neue Zeitschr., &c. ; xx, p. 324.
139. Dubois, Lachapelle; op. cit., iii, p. 495
140. D'Outrepont, Salzb. Med. Chir. Zcit. ; 1822, v. iv
141. Anonymous, Osiander, Entliinclungsk.; vol. ii, pt. 2
142. Schmidt, Siebold's Journal, viii, p. 257
143. Busch, Micbaelis; op. cit., p. 95, obs. 38 .
144. Stoltz, Mcdicinische Aunalcn, vol. v .
p. 79. No. 153.
p. 85. No. 180.
p. 52. No. 60.
p. 53. No. 63.
p. 80. No. 157.
p. 91. No. 202.
p. 60. No. 89.
p. 47. No. 47.
p. 63. No. 101.
p. 75. No. 140.
p. 58. No. 81.
p. 47. No. 43.
p. 47. No. 46.
p. 51. No. 58.
p. 49. No. 51.
p. 61. No. 92.
p. 69. No. 118.
p. 83. No. 168.
p. 68. No. 117.
p. 62. No. J6.
p. 75. No. 139.
p. 72. No. 130.
p. 91. No. 200.
A
CASE OF CiESAREAN SECTION.
BY
DR. OLDHAM,
OBSTETRIC PHYSICIAN AND LECTURER ON MIDWIFERY, ETC.,
AT GUY'S HOSPITAL.
Received January 14th. — Head February 11th, 1851.
Sarah — , set. 23, engaged at waistcoat-making in Bethnal
Green, was born a feeble child, and during childhood was
weak and rickety. The mother states that she was 7 years
old before she could put her feet to the ground, and 13 years
of age before she could walk securely. At 16 she first began
to menstruate, and has continued to do so with tolerable
regularity ever since, and her general health has been fairly
good. She is now four feet eight inches in height, walks
lame, and her legs are curved, so that she retains a de-
formed and dwarfish appearance. Her face and features are
small, and her countenance is that of a girl of 14 or 15
years of age, and her circulation habitually rapid.
She applied to me for advice in the middle of September,
1850, complaining of amenorrhoea, of seven months' standing,
the result, as she declared, of cold, for which she had in-
effectually taken various medicines. At this time the
abdomen was prominently large, and by auscultation the
beats of the foetal heart and uterine murmur were readily
detected. She denied, at this time, the possibility of preg-
nancy, but subsequently she admitted that she had had sexual
intercourse on two occasions, but she was in so much alarm
at the time that she thought it impossible that she could
have become pregnant. The lower lumbar vertebrae and
the sacrum were observed to be deeply curved, and the
90 dr. oldham's case of
uterus was anteverted in a marked degree. On examination,
the orifice of the vagina was found to retain much of the
virgin contraction, from an imperfect laceration of the hymen;
the canal itself was narrow and very tender, so that she
shrunk from the necessary exploration. The projection of
the promontory of the sacrum was so great as to shorten the
conjugate diameter to about two inches ; but the pelvic
cavity and outlet were comparatively roomy. She was
advised without loss of time to obtain a room near Guy's
Hospital, and to be entered as a patient of the Lying-in
Charity.
Sept. 23, 1850. This morning I determined to induce
labour by puncturing the membranes, the bowels having
previously been relieved by castor-oil. For this purpose a
long slightly-curved canula, with a sharp-pointed stilette,
which could be withdrawn at will from the canula, was
employed. Some difficulty was experienced in reaching the
os-utcri, as the patient lay on her side, on account of the
height at which it was placed, the extreme tenderness of her
soft structures, and her inability to flex her thighs well,
which was caused by the prominence of the anteverted uterus.
She was therefore placed on her back, and the canula having
entered the amnial sac, about eight ounces of clear liquor
amnii were drawn off. At this time the foetal head could
be felt, distinctly marked out on the abdomen above the
pubes.
21th. This morning the bowels had been again relieved
by aperient medicine, and some uneasiness about the uterus
had been felt. Mr. Davies, who had charge of the case,
examined and found the left arm in the vagina. On visiting
her, I found that the child was still alive, and that touching
the palm of the hand in the vagina, excited reflex muscular
movement. The os uteri surrounded the arm, and the
uterus was quiescent. The patient was ordered to keep
quiet, and it was requested that no further vaginal exami-
nation should he made.
25th. She had not slept well on account of some irregular
diffused uterine pain. The arm and os uteri were in the same
CESAREAN SECTION. 91
condition. She had passed urine freely, and during the day
was tolerably free from pain. Her pulse is rapid, 93 in the
minute, which is natural to her ; but there are no febrile
symptoms, and she is in good spirits.
26th. Early this morning 3yj of castor-oil were given,
which acted freely on the bowels in the course of the morning.
At 9 a.m., some regular uterine pains commenced ; and
when I saw her the os uteri was found to be dilating well,
and the vagina softer and less tender. The skin of the
foetal arm was peeling off.
Vaginal examination was forbidden.
At half-past 9 p.m., the os uteri was fully dilated, but
the loose soft margin of it could still be felt, on account of
the foetal head being so held above the brim as not to have
any bearing upon it. Some efforts at delivery were now
made, the rectum and bladder being both empty.
A full exploration of the pelvic brim and the presenting
part was made by the cautious introduction of the fingers of
the left hand, with a view, if practicable, of running them
beyond the brim, and catching and bringing down a foot ;
the right hand at the same time pressing the uterus from
the abdomen, and doubling down towards the pelvic inlet
the lower limbs of the foetus, in a direction to meet the hand
in the vagina. The patient was at this time on her back,
but the pelvic brim was so contracted that it was soon
obvious that any hope of delivery in this way must be aban-
doned. Traction was then made on the protruding arm,
which shortly gave way at the elbow-joint ; but the efforts of
traction were found to have some effect upon the head, in
moving it from above the pubes to the brim, which was aided
by external pressure, directing it from the one part to the
other. After the arm had separated, the head was so far
within reach that the perforator could be made to touch it,
and it was opened without difficulty. After the brain had
been emptied, and,under the influence of regular and powerful
uterine action, the bones of the head had shrunk together ,
repeated efforts were made with the crotchet, applied within
the skull and outside of it, to draw the head through the
92 dr. oldham's case of
brim. In doing this the cranial bones and a part of the
base of the skull were torn up, but without making any
material way through the contracted brim. In the course
of this operation, which was occasionally suspended for ten
minutes to rest and refresh the patient, the right side of the
pelvis was found to have squeezed into it the right hand and
foot, both of which could be distinctly felt in this situation.
A hope was now entertained that one or other of these limbs
would double deeper into the pelvis, so as to be caught and
drawn down, and attempts were made to accomplish this, but
ineffectually. No hold could be got of either the foot or
hand beyond the slippery tips of each, and labour-pains did
not press them lower. A polypus canula and ligature were
sent for, but the noose could not be passed over the ankle or
wrist, and consequently there was no purchase for it. "With
the narrow brim of the pelvis thus packed by this complex
presentation, the different parts of which mutually obstructed
the process of each other's descent, and judging from the
difficulties already experienced on attempting delivery — of
the far greater ones which must be encountered in order to
complete it — it became a question whether delivery should
not be effected by the Cesarean section. After a conside-
ration of the case, I determined in favour of it, but before
undertaking it, a consultation was held with my colleague,
Dr. Lever, who having examined the patient, acquiesced in
this decision, and without further delay preparations were
made for performing it.
The room was heated by a good fire until the temperature
was sensibly warm, some candles were obtained from the
Hospital, and the Assistant-surgeon of the Hospital, Mr.
Poland wlio operated, with the Resident Obstetric Clerks,
soon arrived. The bladder was emptied by a catheter. The
patient was placed completely under the influence of chloro-
form, and one gentleman had charge of the chloroform, and
kept her during the operation under its power. The patient
was drawn to the right side of the bed, the shoulders mm
slightly raised, and the besl arrangements were made to let
her maintain, without moving, the same position after the
CESAREAN SECTION. 93
operation. One assistant was directed to close the abdomen
as the uterus contracted on being emptied, and the act of
delivery was undertaken by myself. An incision beginning
about two inches above the umbilicus, and carried down to
five inches below it, so as nearly to reach the pubes, was made
in the course of the linca alba, just missing the umbilicus
itself. No bleeding of consequence followed this incision,
and the uterus was soon exposed. On opening the abdominal
cavity, some three or four ounces of transparent straw-coloured
fluid ran out, and were caught by a sponge. The body of
the uterus was seen to contract in a perfectly even way, on
thus being laid bare, and to form a hardened compact body,
its surface having its natural polish, and neither the large
veins nor smaller capillaries beiug strikingly injected. The
omentum glided easily between the fundus uteri and the
abdominal wall, with a descent of about two inches. The
uterine wall was then cut through, and the direction of the
incision was slightly curved, the convexity looking to the
right side. The length of the opening was about five inches,
and the incision was made to reach the lowest part of the
uterus near the cervix, so as to open the womb from below.
Bat little blood wras lost. I then passed my right hand into
the cavity, and withdrew a full sized seven mouths' foetus,
by laying hold of its thigh. The uterus immediately con-
tracted, and the intestines appeared at the upper part of the
abdominal opening, which was promptly closed. The hand
was again introduced between the membranes and the surface
of the uterus, and with but little delay the placenta and
membranes were removed, the former being attached to the
upper part of the posterior wall. The uterus then contracted,
and in doing so the convex border of the incised wall was
seen to wrinkle, and not to adapt itself to the corresponding
surface. Some venous bleeding took place, but to no great
amount. A sponge wrung out of warm water was now gently
drawn over that portion of the convex border of the intestines
and omentum which had protruded and been smeared with
blood, and the upper part of the external opening was at
once closed by the application of sutures. Whilst this was
94 dr. oldham's case of
being done by Mr. Poland, I held a sponge over the edges
of the uterine opening, gently pressing them together, and
by the time that the wound was closed above, all bleeding
had ceased, and the two surfaces were evenly adapted, and
were seen to be quite free from any interposed structure.
Other sutures, eleven in all, were then applied ; some broad
strips of plaster were drawn across the abdomen, and two
cushions of Hnt were placed vertically on the sides of the
central incision, and a binder cut out into tails was adjusted
over the whole. During the operation the patient was quiet,
excepting when the uterus was at its height of contraction,
when she wriggled about slightly, but hardly enough to in-
commode Mr. Poland. The pulse was of good strength, and
she was left reclining on her back, and sleeping in a tranquil
manner under the influence of chloroform.
At a quarter to four, a.m., three quarters of an hour after
the operation, she opened her eyes as though waking from
a natural sleep, and she then told me that she had known
nothing of the operation, and felt quite comfortable. Just
before this her pulse was IIS in the minute, and the respi-
ration 32.
During the remainder of the night she took 31J of lauda-
num ; at first, 3J was given her soon after she awoke, half an
hour after which she began to shiver; the pulse became
rapid and weak ; the respiration quickened and catching ;
the extremities cold; and she complained urgently of an
oppressive tightness over the upper part of the abdomen. A
small quantity of hot brandy-and-watcr was given her, and
5ss of laudanum, and some warm clothes wore tacked around
her. The bandage was loosened at its upper part, which
gave her some relief. In an hour's time she was in a
profuse sweat, and felt easy, but was indisposed to sleeps
The remaining 38a of laudanum was then given, and towards
morning she had some sleep.
First (lay. — In the morning she expressed herself as
foiling comfortable, and free from pain. She breathes easily,
and the skin is freely perspiring. Pulse I80j tongue moist,
slightly furred. The upper part of the abdomen, above tin
CESAREAN SECTION. 95
bandage, is distended with flatus, so as to bulge up above
the edge of the bandage. ^vj of dark-coloured urine were
drawn off by the catheter. The pupils are contracted,
evidently from the effects of opium, and she is in a quiet
dozy state, readily, however, answeriug questions, and quite
free from restlessness.
Great care was taken to keep her undisturbed, and she
was ordered cold drinks of spring- or toast-water, or tea.
In the course of the day she was ordered — Julepi Ammon.
Acet. c. Mist. Camph. et Tinct. Hyoscyam. 3SS, 4,1S horis,
but of this she took only two doses.
In the evening. — She had passed the day in a perfectly
tranquil manner, sleeping a good deal. She had taken freely
of the cold liquids from time to time, and there was but
little alteration in her general state, which was as favorable
as could be expected. Between six and seven ounces of
clear urine were drawn off. She had sweated profusely at
intervals during the day, requiring the clothes to be lightened,
and now the skin is warm and moist. There is no abdo-
minal tenderness.
The vulva was sponged with warm water ; warm napkins
were applied, and the sheets were shifted from under her
with as little movement as possible. There was a moderate
dark-coloured lochia! discharge. — Calomel, gr. j, Pulv. opii,
gr. ij, in forma Pilul. Statim sumenda.
Another pill was ordered to be given, at the discretion of
the resident obstetric clerk who sat up with her, if the first
should fail to procure rest.
Second day. — The second pill was given at 2 a.m., and
she passed a tolerably quiet night. Towards morning she
complained of a sharp shooting pain below the edge of the
false ribs on the right side, with short, free intermissions.
Pain also was felt in the uterine region, and the abdomen
was more tympanitic. She had passed urine of her own
accord during the night. Pulse 150, small ; respiration
more rapid; mind clear. The pain in the side increased
towards noon, and the breathing was more embarrassed.
Some cloths wrung out of hot water were applied to the
96 dr. oldham's case of
side. Another two grains of opium were given, and the
vulva again sponged ; she had partaken freely of barley- and
toast-water, and tea; on one occasion she had vomited, hut
without effort. In the afternoon her breathing became
catching, and more frequent ; her pulse more rapid and
feeble, and evidence of vital exhaustion was apparent. She
died in the evening.
From the time of her delivery to her death, this patient
was watched, without intermission, by Mr. Davies and the
resident obstetric clerks.
Post-mortem examination. — Thirty-six hours after death
an inspection of the abdomen was made by myself with
Messrs. Stacker and Morgan, the obstetric assistants. The
upper region of the abdomen, above the bandages, was
distended by flatus ; but the middle and lower parts, which
had been covered by plaster, were comparatively flat. On
removing the bandage and plaster, the edges of the external
wound were seen closely approximated ; and on cutting
through the sutures, the process of adhesion was found to have
made some advance, so that it needed some little traction,
beyond the weight of the neighbouring tissues, to reopen the
incision. On exposing the abdominal cavity, a few coils of the
small intestines, near the uterus, were seen not much injected,
but with some films of recent lymph between them, and some
serous fluid tinged with blood, and intermixed with flakes of
lymph. But the degree of peritonitis was not great, and it
did not extend to the upper part of the abdomen. The
bowels were distended with gas, but their solid contents
were trifling. The omentum was much thickened and
indurated, and its blood-vessels were filled with blood. It
sunk upon the fundus uteri, and there, being comparatively
fixed, it formed a barrier, which prevented the blood from
the open uterus running into the peritoneal cavity. The
uterus occupied its normal position after delivery ; rather in-
clined to the left, and well-reduced in size. The length of
the incision was reduced to three inches, and its eorved
outline more distinct than when made during the operation.
CESAREAN SECTION. 97
The edges, for almost the entire length, were separated,
leaving a gap of a half to three fourths of an inch in width,
when measured from the outer surface. The edges, towards
the inner surface of the uterus, were nearer together, but
still apart, and some lochial discharge ran out through the
opening, which, during life, had apparently been retained
within the limits of the uterus by the close fitting in of the
abdominal walls with the pressure of lint and strapping, and
the upper wall of indurated omentum. The length of the
uterus was nine inches and a quarter, and if a line were
drawn half an inch transversely above the centre, the
incision would be contained in the lower part. The peri-
toneal surface of the uterus was more opaque than natural,
with here and there some shreds of recent lymph ; but there
was but little vascular injection. The muscular structure of
the uterus, and the veins were not inflamed or thickened, ex-
cepting at the margin of the opening, where the tissue felt
moi-e dense and crisper than usual. The os uteri was un-
injured. A corpus luteum was in the right ovary. The
pelvis, which I was fortunate enough to procure, is altogether
small, all its diameters being below the standard measure-
ment, excepting at the outlet, which is sufficiently spacious.
The principal deformity is in the conjugate diameter of the
brim, on account of the promontory of the sacrum jutting
forward with an inclination to the right side. It measures
two inches. From the promontory to the right pectineal
eminence there is a space of two inches, but to the left
pectineal eminence, there is two inches and an eighth. The
transverse measurement is four inches and three fourths, and
the oblique, four inches. The diameters of the cavity, al-
though contracted, are not so reduced as to cause any serious
obstacle, in a practical point of view, to the removal of a child.
Remarks. — There were two practical questions suggested
by this case : — 1 . What was the best plan to attempt to
follow out in the delivery at first ? 2. Were the complica-
tions such as, under the circumstances, to justify the
Caesarean section?
xxxiv. 7
98 dr. oldham's case of
1. When first I saw tins young woman, she was already
seven months advanced in pregnancy, and my conviction,
after a vaginal examination, was that there were, as nearly
as possible, two inches in the conjugate diameter, which was
the particular solid obstruction to be considered in the
delivery.
The two methods of treatment which might be adopted,
were — (1) to induce premature labour, and deliver by
craniotomy, and (2) to allow her to go to term, and then
perform the Cesarean section. By inducing premature
labour, although at the age of viability, there was no expec-
tation of saving the child, but only that, by removing a body
of relatively small dimensions, the operation by the crotchet
would be facilitated. The important favorable circumstance
in this mode of delivery was, that it afforded, in my judg-
ment, a reasonable expectation of being completed through
the birth-passages by an operation, from which the mother
might escape with impunity, although at the sacrifice of the
child. In favour of the Cesarean section, there was the
probable preservation of the child, and the somewhat dimi-
nished risk from so formidable an operation, by a careful
preparation of the patient for it — undertaking it at a selected
moment, and such attention to points of practice, during and
after it, as have lately been found of service in abdominal
surgery. This mode of delivery would, I believe, have found
favour in the eyes of some obstetric practitioners, with whom
the expectation of saving the child's life would have out-
weighed the degree of operative danger to which the mother
would be exposed. My own judgment was clearly in con-
currence with the practice which was adopted. Had the
pelvic deformity been greater, and pregnancy, aa in this case.
been concealed until the seventh month, preventing, there-
fore, an early induction of labour, there could have been no
hesitation in having recourse to the Cesarean section. But
with a conjugate diameter of two inches, and a sullieiently
spacious cavity and outlet, there was m> fair a likelihood of
delivering by the crotchet, that I should have felt culpable in
not undertaking it. In the election between the safety of
CESAREAN section. 99
the child, and an augmented danger to the mother from a
serious surgical operation, I was not disposed, in this case,
to tamper with the maxim which happily prevails with
obstetric practitioners in England in favour of the mother.
And although the results of this case, when separated from
these and after-considerations, and appearing nakedly as in
a statistical table, are most gloomy and disappointing, and
delivery by the Cesarean section, at first, might have rescued
the child, and offered a better chance for the mother, yet I
should not, in a similar case, feel justified in deviating from
the same practice. My conviction is, that the mal-position
of the child, which was, of course, unexpected, and beyond
control, so augmented the difficulties of the first hinderance,
as to thwart my purpose.
With reference to the second question, it will be noticed,
that, twelve hours were suffered to elapse to allow the first
stage of labour to be well completed, and to favour the
physiological softening of the vagina and external organs.
In introducing my hand, with the view of learning more
accurately the degree of deformity of the pelvis, I had the
remote expectation that I might probably seize, with the
fingers, a lower extremity, by the same kind of manipulation
which Dr. Lee has practised successfully in some cases of
unavoidable haemorrhage, with a rigid undilated os uteri.
Failing in this, the prolapsed arm was, with the aid of
external pressure, made the means, by traction on it, of
bringing the head over the brim, which allowed of its being
opened, reduced, and drawn upon, until I hoped to get it
through the brim. It was in a pause of this operation that,
on sweeping the inlet of the pelvis with the finger, I found
that a foot had descended by the side of the hand, and had
been squeezed into the right side of the pelvis by the action
of the uterus. On watching the effect of some labour-pains,
I found that the force of the contractions was spent, not in
pressing one part below the other, but in wedging them
altogether in the narrow brim. It was obvious that, if
either extremity could be dislodged from the brim and
brought down, it might be made of great service in helping
100 dr. oldham's case of
delivery; but all attempts to accomplish this manoeuvre failed,
as no sufficient hold coidd be got of them. With this new
source of difficulty, what was best to be done ? It appeared
tome that one of two courses might be followed. The first
was to persevere in removing the mutilated foetus through
the vagina ; and the second, to deliver by the Caesarian
section. I felt, too, that it was imperative to decide between
them at once, as the effect of every half-hour's delay, espe-
cially if employed in further efforts at extraction, would
increase the danger of the Cesarean section, and, indeed, if
long persevered in, would compromise all chance of its success.
The patient at this time manifested no signs of exhaustion,
the pulse, though rapid, was of good volume ; her spirits
were fairly good ; the abdomen was free from tenderness,
and the sexual passages were not inflamed. The principal
reason which induced me to prefer the Cesarean section
was, that I feared the patient would not sustain such pro-
longed efforts at delivery as would have been necessary,
and that she might die exhausted before or soon after
delivery. The girl had but a feeble constitution, although
her health had not, of late years, been bad ; and I had no
confidence in its enduring against this hard trial of its
powers. From the efforts I had already made, and from
some experience in severe cases of craniotomy, I was quite
sure that it would be a tedious and most difficult task,
although aided by a fast advancing putrefaction of the foetus,
to effect delivery; and that even the life of a strong woman
would have been placed in peril by it. I could not but call
to mind a case which occurred iu the Lying-in Charity of
(itiy's, in October, 1835, at which 1 was present. The
patient, aged 32, was in labour with her sixth child, and the
right hand and arm descended at the commencement of
labour. An effort was made to turn by the student in
attendance, but ineffectually, She was bled to jwj, :u'd
took 100 drops of laudanum, when another attempt at version
was made by the assistant-accoucheur, which also faded.
The pelvis was found to be contracted in all its diameter-,
and the conjugate diameter measured two inches ten lines.
CESAREAN SECTION. 101
Eight hours from the first attempt at delivery, she was
removed from her lodgings to a ward prepared for her in the
hospital, and Dr. Ashwell then took charge of the case. She
had already had a rigor ; the pulse was rapid, and the
abdomen tender. Without trying again to turn, Dr. Ashwell
made attempts to remove the child by the cutting hook ; but
it could not be fixed upon the neck to sever the head from
the trunk. The thorax was perforated ; but after the most
strenuous efforts, perseveringly followed out for many hours,
it was obliged to be abandoned as hopeless, and the woman
died undelivered. The pelvis is now upon the table. " If
this case could again occur," says Dr. Ashwell, (vide 'Guy's
Hospital Reports/ Vol. I,) " at the full period, and the
knowledge now attained were possessed, there would, I think,
be little hesitation as to the propriety of the Cesarean
section."
Another unfavorable circumstance in this case, in reference
to persisting with the crotchet, Mas the state of the vagina.
This canal has been noticed as retaining the structure of
early age. It was closely ribbed throughout, very vascular,
with a thin epithelial covering, and a feeling imparted to the
finger of its being structurally weak and easily lacerahle.
This was remarked to those around me at the beginning,
as a source of danger in a prolonged craniotomy case; and,
excepting when the hand was introduced which lacerated
the fourchette, this canal was very carefully guarded when
the crotchet was being used. Should the patient survive
the immediate dangers of delivery, I could not help feeling
that there was a great risk of vaginal sloughing, with its
revolting consequences.
On the other hand, the Cesarean section offered a speedy
and sure, instead of a prolonged and doubtful delivery, it
was not yet forbidden from exhaustion or any signs of in-
ilammation ; on the score of suffering, it contrasted most
favorably with the other practice, and I thought, upon the
whole, that the chance of ultimate success from it was
greater.
There is but little need of comment on the operation
102 dr. oldha.m's cask or c.esakkan section.
itself, beyond the detail which has been given of it. It
was performed much in the usual way without difficulty,
and with nothing untoward. The incision was made as low
down in the front wall as possible, and the slight curve in
its direction was suggested by me, with the hope of catching
the outline of the muscular fibres of the inner surface of
the uterus, and so far favouring the closure of the wound
within. It certainly failed to do so, and I do not know
that there was any advantage over the straight incision.
The little hfemorrhagc which attended the operation, and
which did not delay the closure of the external wound, was,
in great measure, due, I conclude, to the uterus being at
the seventh month of gestation instead of the ninth, to the
placenta being attached to the posterior wall, and to the
incision being low down in the uterus, where the veins would
be less developed.
The influence of the chloroform appeared to me to be a
gain in every way.
It will be seen that the after-treatment by opium was
steadily followed out, and the repetition of the doses was
only suspended when the patient appeared at the time to be
under its influence. The extent of reparation of the external
wound, and the admirable manner in which the structures
were laid out, to limit the mischief from the open wound in
the uterus, and prevent its extravasated contents being
diffused in the abdominal cavity, arc worthy of attention,
and must have been greatly favoured by the perfect tran-
quillity of the patient under the influence of opium.
CASE OF
EXTENSIVE NECROSIS
THE BONES OF THE CRANIUM
REMOVAL OF LARGE PORTIONS THEREOF.
JOHN DRUMMOND, F.R.M.C.S.
DEPUTY INSPECTOR OF HOSPITALS,
MELVILLE NAVAL HOSPITAL, CHATHAM.
lteceived January 14th. — Read March 25th, 1851.
The subject of the following narrative exhibits a greater
extent of disease, affecting the Bones of the Cranium, (without
in any way producing injury to the general health or cerebral
functions of the patient,) perhaps, than any case on record,
and as such may be deemed worthy of notice.
Thomas Blackmail, in 1845, was a sailor, serving on board
H.M.S. "Mutine," at Sierra Leone, when, from falbng
down a flight of stone steps, he received a contused wound
of the scalp, covering the left side of the occipital bone.
The bone was not supposed to have been injured at the
time.
In October, 1845, we find him a patient in the Royal
Naval Hospital, Plymouth ; when the bone was, for the first
time, found denuded of its pericranium to a considerable
extent. Shortly after this he suffered from an attack of
erysipelatous inflammation, involving the whole of the head
104 mr. duummond's case of extensive
and face, leaving numerous purulent deposits under various
parts of the scalp. The process of necrosis became more
evident, and at different points matter was observed oozing
from beneath the diseased bones ; and when they had sepa-
rated from each other at the coronal and sagittal sutures,
the pulsations of the brain were distinctly risible.
In July, 1846, he was removed to Melville Hospital,
Chatham.
It is scarcely necessary to trace the progress of the disease
during a period of six years ; further than to remark that
his chief suffering arose from repeated attacks of erysipelas ;
often accompanied by much febrile excitement. His general
health, however, at no time appeared much impaired, but, as
a prophylactic against the effects of long protracted irritation
and profuse suppuration, it was deemed expedient to afford
a generous diet, with a moderate allowance of wine or malt
liquor.
It was observed, that as the process either of Caries or
Necrosis (for they were coexistent) advanced, the disease at-
tacked, at some points, both tables of the bone simultaneously,
while at others the external alone suffered. In the former
case, the bones separated from the dura mater in large
portions, while, on the other hand, when the external table
alone suffered, it separated more slowly in smaller portions,
and came more distinctly under the term Caries.
The disease still continues in the remaining portions of
the cranium, and I may here observe, that at no point does
there appear the slightest tendency to ossific reproduction.
Ou taking a general view of the head, the integuments
are observed to have receded from their natural position, and
to form several irregular masses, and Nature has provided the
demiieijibrou8 membrane (by the deposition of lymph and by
cicatrisation) with a delicate ami highly vascular integument,
through which the pulsations of the cerebrum are distinctly
visible. On minute examination of the head, the following
portions of hone are found to have been removed: — Of
NECROSIS OF THE BONES OF THE CRANIUM. 105
the right side of the frontal, parietal, aud squamous part of the
temporal bones, about five square inches j the whole of the
occipital, to within a short space of the foramen magnum, is
deficient, save a portion of the centre, of about two square
inches, which is detached, and moveable ; this is in process
of being thrown off. A large portion of the left side of the
frontal, parietal, and temporal bones, remains at present firm,
but in a diseased state, as is evident from numerous openings,
discharging pus of a fetid nature, through which the bones
can be felt, in a state of caries. A portion of the posterior
part of each parietal bone exists, as a slender arch over the
vertex.
It is scarcely to be expected that this patient will be
so fortunate as to resist the effects of complete destruction
of the whole of the bones of the skull, which, if he
live, must sooner or later take place. At present he is
in robust health, suffering but little inconvenience from
the extent of the disease. He continues a patient in this
Hospital.
Two very accurate casts of the case, in wax, have been
taken, one of which has been deposited in Haslar Hospital,
and the other in Fort Pitt, Chatham, and which are well
worthy the notice of any pathologist visiting these esta-
blishments.
AN ACCOUNT OF A CASE OF
FRACTURE AND DISTORTION
OF
THE PELVIS,
\.N UNUSUAL FORM OF DISLOCATION OF THE FEMUR.
CHARLES HEWITT MOORE,
SURGEON TO THE MIDDLESEX HOSPIT VI..
Received January 34th. — Read March 2fithj 1851.
The subject of Deformities of the Pelvis is oue which has
met with very full and satisfactory investigation. The causes
from which they arise, and the mode in which each cause
produces its proper consequent deformity, have been so well
ascertained, that it can be at once determined by some salient
characters whether any particular specimen be an instance
of congenital malformation, or of deformity from disease, or
from injury. When, for instance, one of the lateral masses
of the sacrum is wanting, and its central portion is articulated,
or rather anchyloscd, with the adjoining ilium, we can clearly
trace in that congenital fault in the formation of the sacrum,
the cause of the approximation of one acetabulum to the pro-
montory, aud of the whole os innominatum to the mesial line,
as well as of the straightening of the ilio-pectineal line, the
altered axis, the diminished capacity, and all the other one-
sided distortions of Niigele's oblinue pelvis. The deformity
in cases of fracture of the pelvic bones, is usually limited
to that occasioned by the displacement of the fragments
and the presence of the reparative callus. That remarkable
compression of the pelvis, which is sometimes so extreme that
the promontory of the sacrum and the base of the acetabulum
coalesce, points clearly, through the softening of the bones,
108 MR. MOORli's CASE OF
to Rickets or Mollities ossium as its cause. Particular de-
formities, again, can be traced to causes extraneous to the
pelvis itself; sometimes to the extremities below the pelvis,
sometimes to the spine above it ; and in the latter instance
it is interesting to observe the constancy of the relation
between particular deformities of the pelvis and particular
curvatures of the spine, — a relation that is maintained whether
the cause be a curvature of the spine which leads to the dis-
tortion of the pelvis, or the deformity commence with the
pelvis and extend subsequently to the spine.1
Examples are exceedingly rare, however, in which more
than one cause of deformity exists in the same pelvis : and
there is, I believe, no instance in which so many of the
principles of deformity are illustrated as in the accompanying
specimen. By these reasons, as well as by the extensive
nature of the injuries it has sustained, I am induced to lay
an account of it before the Society. For the opportunity of
doing so I have the pleasure of expressing my obligation to
Dr. Seth Thompson.
James Thomas Ilorsfield, a stone-sawyer, was crushed
beneath a heavy piece of timber several years before death.
At the age of GO he died in the Middlesex Hospital, under
the care of Dr. Seth Thompson, of advanced disease of his
heart and kidneys ; and the following circumstances were
noticed at the post-mortem examination, which add to the
interest of the disease in his pelvis. For some of these par-
ticulars I am indebted to the careful and accurate observation
of Mr. Sibley, a pupil of the Hospital, who was prevent at
the examination.
The skull was in few parts less than half an meh in thick-
ness. The processes at its base were blunted, and the crista
galli projected upward as a great knob of bone. In the
section presented to the Society, the enlargement is seen to
be due to the expansion of the whole bone, which, notwith-
standing irregular increase in the bulk of the separated fibres
' Etakitanskj
FRACTURE AND DISTORTION OF THE PELVIS. 100
and laminae, remains altogether porous, and presents no dis-
tinction of compact and diploetic structure. The outer surface
is comparatively smooth, though it is unusually porous ; the
inner is roughened by the deposition of uneven masses of
bone upon it, and by the consequent increase in the depth
of the grooves for vessels.
The vertebrae were rough and porous ; and a few exostoses
projected from the margins of their bodies. On making a
horizontal section of the intervertebral substances, the con-
centric circles were seen to be composed of calcareous matter
and soft cartilage alternating.
The pelvis and adjoining bones exceed their natural weight
by about one half. Like the skull, they are thick and coarse;
their processes are bulky, and their crests blunted. The
upper part of the left femur is thickened by the deposition
of new bone upon its exterior. The right femur was com-
paratively healthy.
Moreover, extensive disease was discovered in the arterial
system. The aortic and other cardiac valves were calcified;
and the aorta, from the heart to its bifurcation, was covered
with patches of calcareous deposit. The interual carotid
and the basilar arteries were the most diseased ; they were so
brittle as to break down under the finger.
The pelvis is brokeu into several fragments ; and in such
a manner that its anterior portion is completely separated
from the posterior. The fracture on the left side passes
through the acetabulum, that on the right side just in front
of it ; and the ischio-pubal ramus is broken on both sides.
On the left side the innominatum is broken into three
fragments, which correspond almost precisely with the seg-
ments of which the bone is composed in early life. For the
lines of fracture, as they traverse the acetabulum, divide it
in the proportions of rather more than two fifths, which are
severed with the ischium, and rather less than two fifths with
the ilium, whilst the other fifth remains with the puhes.
The head of the femur has been driven between the
fragments of the innominatum, and lies entirely within the
pelvis. It is driven so far inward that the great trochanter
110 MR. MOORE'S CASK OF
no longer projects beyond the crest, but touches the outer
surface, of the ilium; it has even worn away, by its friction,
the prominent upper margin of the acetabulum, and formed
a shallow excavation on the outer surface of the ilium, into
which it fits. The attenuated articular edge of the ilium
rests upon the top of the neck of the femur close to the
trochanter. The body of the ischium is displaced inwards,
and encroaches on the cavity of the pelvis.
Although the fragments of the innominatum arc enlarged
by considerable quantities of callus, yet no osseous union of
the fractures has been accomplished. An incomplete new
socket has been formed by the articular portions of the
ischium and pubes, which expand into broad cup-shaped
plates around the displaced head of the bone. A large gap,
however, exists at the upper and inner part of the new socket,
in which the head appeal's and partly projects; and the
ischium and pubes do not meet below the neck at all. So
firmly, nevertheless, was the femur bound in its new position,
that it could not have been dislodged without the division of
the thick fibro-cartilaginous substance which united the
fragments together.
The proper structures of the joint were nearly destroyed.
The whole of the cartilage had disappeared ; and the articular
surfaces of the macerated fragments are everywhere rough
and porous and present only on the ischium any of the cha-
racters of an articulating bony surface.
The right os innominatum is broken into two fragments
by two fractures, which extend into the thyroid foramen. The
upper fracture is situated just in front of the acetabulum:
its extremities are much enlarged by a deposition of callus,
but have not united, and they meet by a ball-and-soeket
shaped surface, — the broad and hollowed pubic fragment
embracing the convex and enlarged portion next the ace-
tabulum. The surfaces being very rough, and having heen
held together by frbfo-cartilage, were capable of very little
motion nver one another.
The fracture of the ramus of this (the right) bone severs
the ischium from the pubes precisely at the line of their
FRACTURE AND DISTORTION OF THE PELVIS. Ill
original junction ; that of the left innominatum was broken
nearer the ischium. Though their broken surfaces are
rounded off and covered with compact bone, yet neither on
the right nor on the left side has the fracture of the ramus
been effectually repaired.
Thus, on the right side the innominatum is broken in
front of the acetabulum, and has not reunited, but the hip-
joint is uninjured : on the left side the fracture breaks
through the acetabulum, and has also not been repaired ;
while the articulation is constituted by the ilium and the top
of the shaft of the femur, that is, by the highest and inner-
most part of the old acetabulum, and the lowest and outer-
most part of the upper end of the femur. These injuries
have, of course, given rise to considerable changes of shape
and relative position, which differ on the two sides; and they
have been increased in degree by the softness, which has been
brought on by disease, of the bones.
On the left side no material change has taken place in the
ilium, which was the only part concerned in locomotion on
that side. For, though the weight of the body was conveyed
to the left lower extremity through the shaft, instead of the
head and neck of the femur, yet it was convej'ed, as it
naturally is, by the posterior thickened portion of the ilium.
The left ischium is merely displaced, and not altered in
shape.
On the right side, however, other changes have taken
place subsequently to the occurrence of the fractures. Two
of these changes are principal or fundamental ones, upon
which the production of the rest has depended.
The os innominatum having been fractured just in front
of the acetabulum, and across its ischio-pubal ramus, and
neither of its fractures having reunited, it has missed the
support which it usually obtains from the inflexibility of the
osseous pelvic circle, and has gradually been bent by the
weight it had to transmit from the spine to the hip-joint ; it
has yielded just external to the sacro-iliac synchondrosis.
The acetabulum, therefore, is elevated towards the promontory
of the sacrum ; and the ischial ramus (the other anterior
112 MR. moore's case of
extremity of the fragment) is raised an inch above the corres-
ponding ramus of the pubes. Hence the autero-posterior
dimensions of the whole right side of the pelvis, of the inlet,
the outlet, and the right sacro-sciatic notch, are diminished
to the extent to which the acetabulum and ischium are
raised ; and the ilio-pectineal line being unnaturally bent at
its posterior part, is straighter than natural in front, and
thrusts the symphysis pubis to the left of the mesial line.
This last deviation is less than it would be, were not the line
bent again at an angle in the contrary direction to its
posterior curvature. For, from the part where the body of
the pubes is broken, the linea ileo-pectinea runs forward
nearly parallel to the opposite pubes, instead of forward and
inward, to the crest. And yet, as both pubes form nearly a
right angle at their spines, the crest is, as usual, a continuous
transverse line. But all these distortions are exaggerated by
a second fundamental change, which affects the sacrum. The
right limb, having a souud hip-joint, must necessarily have
been more used than the left ; while, at the same time, it was
removed further off from the centre of gravity than the left
limb, by the whole length of the neck and head of the femur.
The spinal column, therefore, in transmitting more weight
to a greater distance, has acquired a curvature forward and
to the right in the lower lumbar and upper sacral regions.
But the inordinate pressure on the right side has been felt in
the pelvis as well as in the spine, and has not only increased
the bending of the ilium and ilio-pectineal line, but so com-
pressed the right lateral mass of the sacrum, as to deprive it
of three-quarters of an inch of its natural breadth. The whole
righl innominatum is, therefore, brought by so much nearer
the mesial line, and the deformities of the right side of the
pelvis are accordingly increased.
The vertebrae arc depressed, as well as displaced laterally,
and the third instead of the fifth lumbar is on the level of
the nearest part of the crest of the ilium. The lower half
of the sacrum and the coccyx, sweeping forward into the
perineum, compensate for the excessive inclination of the
sacrum backward below the lumbar curve.
FRACTURE AND DISTORTION OF THE PELVIS. ] 13
The case thus detailed presents points of much interest
both to the obstetric and to the surgical practitioner.
I. The pelvis, in its form, resembles that which is known
as the triangular pelvis. The inlet is shaped like a triangle
with its sides pressed in. From the promontory of the
sacrum to the right acetabulum, there is a distance of only
an inch and a quarter, while on the left side the ischium is
no further than half an inch from the promontory; and the
pubic fragment rises over the head of the femur to within an
inch and a quarter of the top of the last lumbar vertebra.
I presume there will be no difficulty in admitting that such
an inlet, in a female, would be impassable. So little, indeed,
is it capable of giving passage to the head of a child, that
it will not admit the head of its own femur. The capacity
of the pelvis itself is, proportionally, even more diminished
by the approximation of the innominatum and sacrum on the
right side, and by the intrusion of the head of the femur and
the body of the ischium on the left. The projection of the
coccyx forward, and the elevation of the right tuber ischii,
considerably narrow the outlet, and would contract it to an
extreme degree, were it not that the tuberosity of the left, or
displaced ischium, is everted.
It is of further importance with reference to Midwifery, as
it adds, I believe, a new cause to the list of those from which
deformity of the pelvis may be expected. The causes in this
pelvis are different on the two sides. Of that which occurred
on the left side, viz., a dislocation of the femur through a
broken acetabulum, I am aware of two instances j1 of that to
which the very serious contraction of the right side is due,
viz., the gradual elevation of an acetabulum unsupported by
the pubes in front, I am unacquainted with any previous
example. It is interesting, however, to observe that the
pelvis partakes of the deformities which are produced by a
' Surgical Essays, by Sir Astlcy Cooper and Benjamin Travers, vol. i,
p. 51; Moreau's 'Icones Obstetricae,' by J. S. Streeter, Plate XIT. The,
original of this plate is in the Musee Dupuytren, in Paris.
xxxiv. 8
114 mr. moore's case of
congenital absence of the lateral mass of the sacrum on the
one hand, and on the other by the weakness of the bones
which is consequent on rickets and mollities ossium.
II. In a surgical poiut of view the case is interesting, as
being one of recovery from, perhaps, as severe an injury of
the pelvis as any on record. None of the fractures have
united indeed, but the man's life was not destroyed; and
though he continued lame through life, yet he walked
without marked difficulty. I am told that he had only a
moderate limp, which is surprising when we consider that
one hip-joint was so seriously damaged, and that, as the
continuity of the pelvic circle of bones was destroyed, only
its posterior part was concerned in locomotion. This, how-
ever, is not the only case in which very serious injury of the
pelvis has not prevented its use as an organ of locomotion.
On opening the body of a boy who had been crushed between
the wheel of a dray and a wall, and who afterwards walked
into the Hospital Surgery, not appearing seriously in-
jured, and sat up in bed without discomfort, I found the
pubes much comminuted on both sides above the obturator
foramen, and fragments of bone lying between the bladder
and the body of the pubes, simple fractures, through the
rami of the pubes just below the symphysis, as well as through
the tuberosities of the ischium, and both sacro-iliac synchon-
droses lacerated anteriorly — a small piece of the anterior
edge of the sacrum on the right side being detached with
the fibro-cartilage.
Another point of great interest to the practical Burgeon,
is the relation of the lower extremities to a pelvis so injured.
And in this respect, again, the condition differs on the two
sides, and is, I apprehend, in part unprecedented.
An os innominatum is fractured just in front of the hip-
joint; no displacement is perceptible at the time, and
perhaps the only proof of the nature of the accident is
afforded by a large mass of callus, which is felt behind the
psoas muscle when the patient leaves the care of the surgeon.
After a time, however, when the patient has regained freedom
FRACTURE AND DISTORTION OF THE PELVIS. 115
in walking, and is thought to be well, the limb of the same
side becomes much shortened and somewhat inverted ; and
at the same time some inconvenience gradually comes on in
the perineum, and increases equally with the shortening of
the limb. All these symptoms would be explained by such
a condition as that on the right side of the pelvis under
consideration. The fracture not having united, and the
bones being, perhaps, somewhat soft, the acetabulum has been
elevated more than an inch, and as its aspect became more
anterior the more it was raised, the limb must have been
turned inward. The other anterior extremity of the fragment
being raised too, necessarily encroached upon the lower part
of the pelvis, and could easily have been felt pressing upon
the rectum by the finger introduced within the anus.
On the left side the injury is such as must have produced
very marked symptoms at the time of the accident. Some
of these symptoms remain permanently, and have even been
exaggerated by the subsequent changes in the pelvis. There
may have been others at the time of the accident, but I do
not venture to speculate upon them with insufficient data :
I will mention merely those which do exist, and shall be
happy if, in the interest that is so extensively felt in the
Society's proceedings, the attention of the surgeon under
whose care this terrible accident recovered, should be attracted
to the account of its termination, and he should be induced
to supply the particulars which at present are necessarily
wanting.
1 . The left limb is shortened more than two inches. This
is due to the elevation of the femur, the head of which lies
so high within the pelvis as almost to touch the promontory
of the sacrum.
2. The trochanter major is sunken deeply in the hip.
It could not be more depressed beneath the surface than it
is, without a still greater destruction of the os innominatum.
It is, in fact, in contact with the ilium ; and the gradual
wearing away of that bone has increased not only the loss of
the natural prominence of the trochanter, but also the
shortening of the limb.
llfi MR. MOORE'S CASE OF
3. The position of the limb is that of partial flexion and
adduction. It is neither inverted nor everted.
4. The chief movement of which the joint is capable, is
abduction. The facility of this movement is due to the large
size and incompleteness of the new socket, in which the head
of the bone is but loosely lodged. Flexion, too, is mode-
rately free, and the psoas and iliacus muscles Lave left two
deep grooves in the situation of the ilio-pectineal eminence
which give proof of their vigorous action. Extension of the
limb is quite precluded by the position of the everted tuber
ischii close behind the shaft of the femur below, and of a
small projecting piece of bone in front of the shallow exca-
vation on the ilium, which meets the front of the trochanter
in extension of the limb. The movement of circumduction,
not being performed on the radius of the neck of the bone,
is reduced to a mere rotation of its shaft, and even that
movement could have been but slightly effected in conse-
quence of the close manner in which the neck is impacted
between the fragments of the innominatum, as well as of the
disadvantageous position of the rotatory muscles attached to
the depressed trochanter.
The records of surgery contain accounts of other cases of
fracture traversing the acetabulum, and attended with dis-
placement of the fragments. Sir Astlcy Cooper mentioned
some in which the symptoms had resembled those of dislo-
cation of the dorsum ilii. Mr. Earlc, in Vol, XIX of the
Society's Transactions, brought forward others, which he
distinguished from fracture of the neck of the femur. It is
plain that with a careful examination (and if the effusion of
blood were not inordinate) the injury on the left ride of this
pelvis would not have been confounded with any of the
ordinary fractures and luxations of the hip. lor, although
with considerable shortening, and some flexion and adduction,
it may have resembled a dislocation upon the dorsum of the
ilium, it must have been distinguished from that accident by
the disappearance of the head and trochanter of the femur,
by the facility of abduction of the joint, and probably by the
absence of tin- symptom of inversion of the foot, as well as
FRACTURE AND DISTORTION OF THE PELVIS. 117
by the severe general symptoms which such vast injuries
must have occasioned. It could not have been confounded
with a fracture of the neck of the femur, when the loss of
the prominence of the trochanter was observed, and the joint
was found freely capable of abduction.
One other subject remains to be noticed, viz., the disease
of the bones. It appears to have been general throughout
the osseous system, and (judging by the appearances of the
left ilium and femur, and of the interior of the skull,) to
have been in great part inflammatory. The irregular manner
in which the bony matter is seen, under the microscope, to
be accumulated, corresponds with this opinion ; and the
disease agrees generally with that described by Rokitansky
under the name of Osteoporosis, — a rarefaction or attenuation
of the osseous texture originating in inflammation and
succeeded by a more or less excessive deposition of new bony
matter, which gives hardness and increased weight to the
bone. It is stated by him to occur in some elderly persons
who bear marks of having suffered from rickets in early life.
No such marks, however, were found in this individual ; and
the influence of the disease on the pelvis, which was limited
to the narrowing of the lateral mass of the sacrum under
the compression to which that part was subjected, is too
slight to have been produced by a disease which softens and
leads to distortion of bones so much as rickets.
I have examined numerous examples of fracture of the
os innominatum traversing the acetabulum, but have found
none in which the course of the fractures seemed at all
determined by that of the original sutures. Nor, indeed,
have I found any in which fracture was combined with
disease of the bone. In healthy bones the fractures pass in
any direction, quite irrespectively of former suture. But in
this pelvis the line of fracture through the left acetabulum,
and the right ischio-pubal ramus, corresponds precisely with
that of the original suture. The instance is a solitary one ;
yet I may venture to suggest the question, which future
observation may solve, whether this disease in producing
118 MR. MOORE's CASE OF FRACTURE OF THE PELVIS.
expansion and softening of the bones does not sometimes
chiefly affect and reopen the sutures, reducing the bones to
the condition which is natural to them in early life.
Lastly, I regret that the want of the history of the case
should prevent a certain conclusion being drawn as to whether
the failure in tlic process for repairing these fractures,
although so much callus has been thrown out upon the
bones, is to be attributed to the disease or to any accidental
cause.
EXPLANATION OF TILE PLATES.
Plate I. — Front view of the Pelvis anil left Femur, described in Mr. Moore's
paper.
„ II. — View of Hie same Pelvis from (lie left side. The left Femur has
been removed; and portions of the right [senium and Pubos
are seen through the Left Thyroid foramen and the broken
Acetabulum.
The Pelvis is in the Museum of the Middlesex Hospital.
118*
119
EXPERIMENTS
ON
CHYLOUS Oil CHYLO- SEROUS URINE.
JOHN MAYER, ESQ.
ASSISTANT SURGEON TO THE SECOND NATIVE VETERAN BATTALION.
A HISTORY OF THE PATIENT.
GEORGE PEARSE, M.D.
GARRISON-SURGEON OF BANGALORE.
COMMUNII
II. BENCE JONES, M.D. F.R.S.
Received January 80th.— Read March 11th, 1861.
The experiments to be detailed were made at the request
of Dr. Pearse, Garrison- Surgeon of Bangalore, who was
desirous of ascertaining the real nature of the matters that
imparted to the urine, passed by one of his female patients,
the peculiar characters which have received the titles given
in the heading.
For the attainment of the object in view, it will at once
be seen, that no extended analysis of the whole constituents
of the urine was required, nor were any quantitative deter-
minations needed.
The absence or presence of caseine, in any recognisable
form, was the first point to be ascertained. The secondary
points to be attended to were the absence or presence of
pus and phosphates, these being the only known bodies
which, when diffused through healthy urine, were likely to
120
MR. MAYER S EXPERIMENTS ON
cause it to be mistaken for urine, such as that about to be
described.
The specimen of urine, brought for examination, appeared
of a dirty milk colour, resembling gum ammoniac mixture ;
its consistence somewhat thicker than milk, and its smell
very faint; indeed the urinous odour was scarcely perceptible:
the sp. gr. was about r013.
Experiments.
No. 1. Portion of the
urine placed on a filter of
common bibulous paper.
No. 2. Litmus paper
immersed in the urine.
Turmeric paper im-
mersed.
No. 3. Boiled, per se,
in a flask, the contents
then placed on a filter.
No. 4. Filtrate from
No. 3, which now appeared
perfectly clear, like ordi-
nary urine, having been
collected in another flask,
treated with strong acetic
acid guttatim.
No. 5. Flask containing
the filtrate from No. .'),
plus acetic acid, exposed
again to boiling tempera-
ture for some minutes.
No. 6. Two parts of the
urine and one of Bethel
were placed u\ 1 stoppered
phial, whub, after being
closed, was briskly agi-
tated two oi three times
for about half a minute.
Passed through, milky
and unaltered, nothing
perceptible being retained
on the filter.
Became faintly red-
dened.
Remained unaltered.
Remained on the filter
a copious white precipi-
tate, on the surface of
which there was some
matter resembling fat.
No clouding, no pre-
cipitate, nor perceptible
change of any kind.
No opacity, nor appear-
ance of anything like curd.
The contents of the
phial now becami
dividing into three por-
tions ; two Of which were
fluid, the third semi-solid,
ibis portion occupied s
space in the phial between
the two fluid portions; the
upper fluid was distin-
guished, not only by its
position but by the sniell,
;is aether ; its colour, how-
ever, was somewhat al-
tered, it had now a faint
yellon tint. The semi-solid
portion was i tremulous
Absent, pus and mucus.
Absent, any strong al-
kali. The fear that albu-
men, if present, might,
when the urinewas heated,
he held in solution by al-
kalies, was thus removed.
Present, albumen, with
some other matter, to be
further investigated.
Absent, probably ca-
serne.
Absent, caseinc.
i. some fatty
matter, previously com-
bined with the semi-solid
portion, but winch was
separated from it by the
superior affinity of Bther
for such suiist.ii:
Present, in the form of
the semi-solid, jelly-like
COagulum, either albumen
or tibrine. Tins substance,
when combined with the
matter held in solution by
the .ether, forms the Inilk-
like matter, that so dis
guises the urine.
CHYLOUS OR CHYLO-SEROVS URINE.
12]
After standing three
weeks, t lie phial and con-
tents were again examined.
No. 7. A small slip of
blotting-paper was rubbed
against the internal surface
of the phial, so as to be-
come smeared w ith someof
the matter deposited there.
No. 8. Portion of the
urine treated with nitric
acid in a test-tube.
No. 9. Portion of the
urine placed in a stoppered
phial, with some strips of
lead, and well agitated.
jelly-like coagulum. The
third portion, which occu-
pied the low est part of the
phial, was urine as it usu-
ally appears.
No perceptible change
had taken place, except
that the upper or the
Betherial portion of the
contents of the phial bad
deposited a semi-crystal-
line matter, much resem-
bling stearine, on that
part of the internal surface
of the phial with which it
was in contact.
The smeared paper,
when rubbed between the
fingers, became partly
transparent, as happens
with paper substances.
Copious deposition of a
white floceulent precipi-
tate.
No deposition of coagu-
lum or filaments on the
lead.
The deposition of the
fatty matter arose from
the partial evaporation of
the aether, the phial being
but very loosely stoppered.
Deductions from No. 6
confirmed.
Absent, phosphates.
Presence of albumen con-
firmed.
Absent, fibrine.
After an interval of three weeks, a second specimen of
chylous urine, from the same individual, of precisely similar
appearance, was obtained ; the experiments made with the
first were repeated, with the same results. The details are,
therefore, not given : they are mentioned merely as offering
confirmation of those recorded.
The general deductions from all the experiments made,
are : — first, the absence of caseine ; second, the absence of
pus and phosphates ; third, the presence of albumen ; fourth,
the presence of animal fat, which confers on the urine its
milky appearance.
To test to the utmost (as far as the time and means at
my disposal would permit) not only the truth of the above
general deductions, but the delicacy of the direct method, an
indirect mode of proof was employed ; it consisted in treating
122
MR. MAYERS EXPERIMENTS OX
artificial mixtures of milk and urine by the method used in
the examination of the chylous urine. In this case, if the
previous deductions be correct, the results will he reversed.
The first series of experiments was made with cow's milk
and health}- human urine. The second series with human
milk and healthy human urine. These artificial mixtures
were made to resemble, as much as possible, in appearance
the chylous urine. The difference of the sp. gr. betweeu
the chylous urine and such mixtures was not determined.
Experiments.
U.MllH
No. 1. Two parts of
milk and one of aether
were agitated in a phial.
No. 2. A mixture of
row's milk and healthy'
human urine, made as de-
scribed, agitated with a
little aether in a phial.
No. 3. A fresli portion
of healthy human urine
and cow's milk, mixed
as before, amounting to
about Jiv, boiled for some
time, probably ten mi-
nutes, after cooling fil-
tered.
No 4. Filtrate from No.
3, treated with acetic acid,
.1 lew drops.
No. 5. A mixture, as
before, of cow's milk and
healthy human urine, test-
ed by litmus paper.
No clearing, as in the
case of the chylous urine ;
no effect, hut that of being
somewhat less white, look-
ingas if diluted with water.
No clearing whatever;
escape of some gas, with
effervescence, the nature
of which I had not time to
examine.
No precipitate nor de-
posit of any kind in the
flask. Slight pellicle on
the surface formed while
boiling.
Copious and immediate
precipitate of white curdy
matter.
Scarcely any percepti-
ble action; if any, slightly
acid.
Absent, the matter that
the aether takes up from
the chylous uriue.
Absent, the matter which
ether takes up from chy-
lous urine.
Absent, any matter co-
agulable by heat, i icept
the pellicle, which is a
well - known form of
caseine.
Present, eascine.
Absent, any free alkali
that could hold albumen
in solution, had it been
preseut.
From these experiments it follows : —
1st. That tether, by simple agitation, docs not take up
those parts of milk which give it the well-known white
appearance.
2d. That when urine and milk are mixed and agitator]
with tether, although a well-marked action takes place, no
clearing whatever ensues, the tether being in these eireinu-
stattees equally incapable of taking up the particles that
give to the mixture its peculiar appearance.
CHYLOUS OR CHYLO-SEROUS URINE. 123
3d. That an artificial mixture of cow's milk and healthy
human urine will afford, hy boiling, no trace of albumen,
contrasting with the behaviour of chylous urine, under
similar treatment, in a most striking manner.
4th. That although no trace of albumen could be detected
by continued boiling (no uncombined alkali being present in
the mixture), an immediate precipitate of caseine follows on
adding acetic acid to the boiled artificial mixture, and again
boiling, — this being exactly the reverse of what takes place
when chylous urine is similarly treated, showing in the one
case the total absence of caseine, and in the other the sim-
plicity of its detection when present.
Previous to following out the plan of proof which I had
laid down for myself, I was desirous (never having previously
experimented with human milk) of gaining such information
as I could, relative to this kind of milk, and its behaviour
with reagents : with this object, I consulted all the chemical
works in my possession. In by far the greater number,
nothing is said of peculiar kinds of milk — cow's milk being
taken as the type of all ; however, in Professor Branded
'Manual of Chemistry,' these passages occur : — "Its albumen
or caseine (meaning that of human milk) is said to furnish
soluble compounds with acids, so that it is not coagulated by
them. Of fifteen samples, only three were coagulated by
acetic and hydrochloric acids," &c. (see p. 1361, vol.
ii, of the fifth edition) ; and in Dr. Thomson's ' System
of Chemistry,' (p. 502, vol. iv, sixth edition,) are the
following words : — "None of the methods by which cow's
milk is coagulated succeed in producing the coagulation of
woman's milk," &c. Dr. Thomson quotes from Clarke, 'Irish
Transactions,' vol. ii, p, 175. Dr. Gregory says: — "If care-
fully neutralised by an acid, milk is not coagulated, but
it is then coagulated by boiling." ('Outlines of Chemistry,'
p. 535.) Dr. Turner, in the eighth edition of his 'Elements
of Chemistry,' though published two years later than Dr.
Gregory's 'Outlines,' says not a word regarding the behaviour
of milk in the circumstances under consideration.
After perusing these conflicting passages, I little doubted
121 MR. MAYER-'s EXPERIMENTS ON
that it would be necessary to seek for some new mode of
proof; but being unwilling at once to abandon the method
I had first proposed, and so far pursued with the most
satisfactory results, I obtained specimens of milk from three
women, which I numbered 1, 2, and 3. A small portion
from each of these was treated with acetic acid, only the
portion from No. 2 gave a precipitate ; the quantity of acid
was increased gradually with the two other portions, but
without effect.
Another portion from each specimen was treated with
half its bulk of strong acetic acid, still only No. 2 gave a
precipitate. Fresh portions of each were boiled, and then
small quantities of acetic acid were added to each, the effect
being as before. Again, fresh portions from each were taken ;
acetic acid in small quantities added; all three were boiled; all
three gave a precipitate, which remained in each ease at the
surface of the fluid. This slight difference in the mode of pro-
ceeding appeared to promise all that I wished; but before
proceeding further, I obtained two new specimens of human
milk, neither of which gave a precipitate by the simple addition
of acetic acid, but both readily did so after boiling. Not to
take up more time by further details, it will suffice to state,
that I treated eleven specimens of human milk, obtained
from different females, in the manner above stated ; of these,
four gave a precipitate by the simple addition of acetic
acid — seven refused to do so, — all readily afforded a copious
precipitate by boiling, the acid having been first added.
Sixteen specimens of human milk, obtained from different
females, having now shown the same behaviour, 1 had
sufficient confidence in the method; but before trying its
efficacy in the presence of urine, 1 was anxious to ascertain
its delicacy; half a drachm of human milk was therefore
diluted with S ounces of water, and 20 drops of dilute acetic
acid added ; the whole boiled. The reaction not being sntli-
eiently distinct, 1 addeil 2 I or 26 minims of the same milk, and
half a drachm of dilute acid, and boiled again ; a copious
precipitate, white and lloceulent as usual, occurred. In an
imperial pint of water at 62 there are S?.'i(l grains; and in
CHYLOUS OR CHYLO-SEROrs UR1XE.
125
half a pint (the quantity of water used to dilute the milk)
4375 grams ; and in 1 drachm of human milk, the sp. gr.
of which does not vary much from that of water, there will
be about 55 grains. Now the mean of three analyses quoted
by Professor Brande, gives in 100 parts of human milk, two
of caseine (or 225) : from these data, it is evident that 55
parts will contain 1*23 grains of caseine, — and if, as the
experiment proves, we find 1'23 grains of caseine in 4375
water + 55 milk + 55 acid = 4485 grains of fluid, the reaction
is sufficiently delicate for all practical purposes, being in
whole numbers 1 grain discernible in 3646. Having thus
removed an apparent obstacle to the intended method of in-
vestigation, I proceeded to make the following experiments: —
No. 1. Two parts of
human milk, with one of
aether, agitated in a phial.
No. 2. An artificial mix-
ture of human milk and
human urine, made as be-
fore, agitated with ."ether.
No. 3. An artificial mix-
ture of human milk and
human urine, made as lie-
fore, boiled and filtered.
No. 4. The filtrate from
No. 3, treated with acetic
acid, and again boiled.
No. 5. A mixture, as
before, of human milk and
human urine, treated by
litmus paper.
No. 6. A mixture of
healthy human urine jj.
white of egg ?j, mixed
with ;fss of water and ?ij
of human milk, boiled,
and then filtered.
No. 7. To the filtrate
from No. 6 added 3ss of
dilute acetic acid, the
whole boiled and after-
wards filtered.
Results.
No clearing whatever,
the action being precisely
similar to that with cow's
milk.
The action, in this case,
is exactly similar to that
with cow's milk.
No precipitate ; slight
pellicle ou the surface of
the fluid, separated by the
filter, the fluid passing
through unchanged.
A copious white, curdy,
flocculeut precipitate.
No perceptible action.
Opaque white precipi-
tate, which, after the fil-
trate bad passed through
nearly clear, was kept on
the filter.
White candy precipitate
after boiling some time ;
precipitate left upon the
filter.
Absent, that matter
which the aether takes up
from chylous urine.
Absent, that matter
which aether takes up
from chylous urine.
Abseut, all traces of al-
bumen ; the pellicle being,
as before observed, a form
of caseine.
Present, caseine.
Absent, any uncombined
alkalies that could hold
albumen in solution, had
it been present.
Present, albumen.
Present, caseine.
Experiments 6 and 7 were repeated, with the serum
126 MR, mayer's experiments on chylous urine.
of blood, instead of white of egg, with precisely similar
results. Before their bearing on this subject is noticed, the
results of this series, as far as No. 5, when compared with
those of the second series, show7 that they are identical ;
comfirmation stronger could not be desired. Both series
show, that caseine, in either of the forms taken, is, in the
presence of urine, easily detectable ; consequently it would
have been discerned had it been present in any of the spe-
cimens of chylous urine examined. Experiments G and
7 show, that although there may be present also albumen
in quantity, the caseine is still to be detected, while its
presence in no way interferes with the detection of albumen ;
hence, it is evident we can always be sure of detecting either
of these bodies, or all, when present in urine. The detection
of fibrine is less insisted on than that of the other two bodies,
as the spontaneous coagulability of the fibrine at once an-
nounces the presence of this substance; but the facility of
detecting fibrine, albumen, and caseine, all or singly, is not
the only result of these experiments ; henceforward, no
fraudulent mixture of milk with urine can pass without being
detected. The negative action of Pether on such mixtures,
the absence of a precipitate by boiling, and a precipitate ob-
tained by boiling after adding acetic acid, will immediately
point out the deception.
STATEMENT OE A CASE OE CHYLOUS OR
CHYLO-SEROUS URINE.
BY
GEORGE TEARSE, M.D.
About the end of March, 1850, I was requested to visit
Mrs. Catherine R — , an Indo - Briton, setat. 22 years,
married, and the mother of three healthy children, the
youngest of whom, ten months old, is a particularly strong
and healthy infant. She lias been nursing up to the present
time, although, of late, with a very scanty supply of milk.
She is a tall young woman, very thin, but of a healthy
appearance, and, according to her own account, her general
health is very good. When nursing her two eldest children,
which she continued to do until they were fourteen or
fifteen months old, she states, that she observed, for some
time previous to weaning them, that her urine had become
white like milk, which peculiar appearance it lost soon after
she discontinued nursing.
Towards the end of November last, her infant being then
about five months old, her attention was again attracted to the
peculiar white appearance the urine had assumed, when she
applied for medical advice, and the following is the account
of her condition, given by the medical officer by whom she
was then attended.
" Appeared pale and weak, and complained of general
debility and loss of tone in the system. She had been con-
fined some months before, and was then nursing a very large
vigorous infant. The urine, for some time previous to her
application for treatment, had particularly attracted her at-
tention ; when seen then by me, it was of a pale milky
appearance, and, on cooling, became gelatinous, and fre-
quently was of more than usual quantity. This appearance
128 dr. pearse's statement of a case of
of the urine had been noticed after former confinements
while nursing, and had disappeared shortly after her children
were weaned. I was of opinion that a nurse should be
procured for the child, when, as on former occasions, it was
to be hoped, the drain on the system being removed, the
kidneys and other organs of the system generally would take
on a more vigorous action : the patient being unwilling how-
ever, for many rcasous, to give up nursing, with the view of
giving tone to the system, and, if possible, putting a stop to
this unhealthy secretion from the kidneys, various tonics were
used, as Columba and Quinine. An occasional laxative of
Rhubarb and Magnesia being, at the same time, used when
necessary.
" During this course of tonics, the patient had an attack of
simple continued fever, which was treated in the usual way.
Quinine and the Muriated Tincture of Iron were again
used ; the Infusion of Gentian with Quinine, the Decoction
of Cinchona, and the Mineral Acids, with a few alterative
doses of blue pill occasionally, and a warm plaster to the
loins, were also latterly ordered. Port-wine and a generous
diet being, at the same time, the regimen adopted.
" As no effect, however, was produced on the appearance
and character of the urine by the above treatment up to
the end of January, 1850, although the general health did
not seem more impaired than at first, a change of air to
Bangalore was advised."
Mis. H — having resolved to come to this place, a distance
of about sixty miles, for further advice, states that, on the
journey, which occupied nine days, she suffered from a
slight attack of fever, lasting one or two days, but Bays she
is now in her usual good health. The bowels are said to be
regular, and appetite pretty good, but it is always very mode-
rate and small; tongue clean; pulse 90j no unusual thirst;
has no feeling of uneasiness in the region of the kidneys
or epigastrium; HO ni^lit sweats, and Bleeps "ell. The first
specimen of the urine seen by me, was passed early in the
morning, and was nearly as white as pure milk, and in
moderate quantity. This was accidentally spilled. The
CHYLOUS OR CHYLO-SEROUS URINE. 129
next specimen obtained, passed also before breakfast, formed
a thick, but not firm jelly, in the glass in which it was con-
tained, and was of the same whitish appearance as the first;
the only test applied to it was a few drops of diluted nitric
acid, which caused it to separate into a serum, having
a firm coagulum in its centre. The patient was at once
made to wean her child, and a course of tonic treatment
recommended, the following mixture being given : —
R Ferri sulphatis, grs. xij ;
Aqua, Jviij ;
Quhia; sulphatis, grs. xviij ;
Acid, sulph. dilut., rn.xx;
Mft. mist. ;
the bowels being kept regular by occasional small doses of
her usual aperient (Castor Oil), and she was advised to be as
much in the open air as possible, morning and evening.
About the middle of April an opportunity offered of having
the urine carefully analysed; but the specimen then obtained,
though still retaining the milky appearance, had a reddish-
brown tinge, evidently from containing a large admixture
of healthy urine ; it did not coagulate as before, though
the patient herself declares that it always does form a jelly
when allowed to stand for some time without being agitated.
Her answers to questions regarding her health are still the
same, viz., that it is very good, and that there is nothing
particular the matter with her beyond the condition of the
urine. She, however, appears to me to have lost flesh, but
neither she nor her friends, her father being an intelligent
European sergeant, perceive any change in that respect,
and she is anxious to be allowed to rejoin her family at
Hoonsoor.
OASES ILLUSTRATING SOME DIFFICULTIES
DIAGNOSIS OF PLEURITIC EFFUSION.
T. A. BARKER, M.D.
physician to, and lecturer on the practice of medicine at,
st. thomas's hospital.
Received January Slst. — Read May 27th, 1851.
Case I. — John Isaacs, set. 26, a labourer, of moderate
stature and size, was admitted into St. Thomas's Hospital
on Jan. 1, 1850. He had been subject to severe dyspnoea
for three years, and an attack of more than ordinary
severity commenced two months before his admission into
the hospital.
When first seen by me, the countenance was expressive
of great distress, the face and lips were dusky, the veins of
the neck much distended, and the respiration frequent,
laboured, and not quite regular.
The pulse was rapid, but too feeble to be counted. The
sounds of the heart could be heard, but they were very
faint, and not regular, some beats apparently being too feeble
to be audible. The cardiac region was as resonant as any
part of the left side of the chest. The impulse of the heart
could not be felt. There was great dullness ou percussion
over the whole of the right side of the chest ; and no res-
piratory sounds could be heard in the right lung, except at
the upper and lower parts anteriorly, where very faint
breath-sounds could be distinguished occasionally.
The left side of the chest was very resonant in every part,
including the cardiac region; and throughout the whole of
the left lung the natural breath -sounds were replaced by
132 DR. BARKER ON THE DIFFICULTIES IN THE .
rhonchus, sibilus, and large crepitation. The ribs on the
left side were elevated as much as possible at each inspira-
tion; the right ribs were nearly fixed. There was not much
cough ; the expectoration was of moderate amount, mucous
and tenacious.
The man lay constantly on the right side, the body
being bent a little forwards ; and lying on the left side, or
even on the back, immediately brought on most distressing
anxiety, and a sense of impending suffocation. He never
assumed any other position, when recumbent, up to the time
of his death.
Eighteen leeches applied to the sternum, and full doses
of Tartar Emetic, gave a little relief; but the next day all the
symptoms above enumerated were increased. From the
first I had entertained a suspicion that this might be a case
of severe bronchitis in the left luug, with extensive effusion
into the right pleura, and that the usual symptoms of effu-
sion were somewhat modified by old adhesions.
The following points appeared to favour this view : —
1. The patient's position in bed. As already stated, be
constantly lay on the right side ; and a change from that to
any other position, except the erect posture, seemed to
threaten immediate suffocation.
2. The great and universal dullness on percussion of the
right side.
3. The absence of respiratory sounds on the right side,
with the exception of the very feeble murmurs heard at the
apex and base of the lung anteriorly.
4. The almost fixed condition of the ribs on the right
side.
On the other hand, it might he urged that nothing in
the history of the case indicated a recent attack of pleuritis,
and the symptoms had come on more gradually and had
existed longer than seemed consistent with the supposition
that they were caused by a great and rapid effusion into the
pleura. Moreover, there had been Bevera] similar attacks,
though not so severe, from which he had recovered more or
less completely. Measurement of the chest did not lead to
DIAGNOSIS OF PLEURITIC EFFUSION. 133
any satisfactory conclusion. The extreme restlessness of
the patient, when disturbed, together with the rapid and
laboured breathing, rendered careful measurement impossible,
and, after many attempts, I felt a doubt which side was
the larger; but the difference, if any, was very slight. I
did not, however, attach much importance to this equality
in the circumference of the two sides of the chest. Two
years ago I had a patient from whose chest 160 oz. of
serum were withdrawn by a trocar, and yet, repeated
measurements by three persons had not shown any enlarge-
ment of the affected side.
The evidence from the voice was negative; no vocal thrill
could be felt on either side.
The faint breath-sounds heard in two places on the right
side might depend on old pleuritic adhesions.
Taking all these cireumstances into consideration, I
thought extensive effusion probable, but not certain. But
it was manifest that the right lung was useless; — no res-
piration was going on in that organ; — the patient's danger
was great; — if there was fluid in the pleura an operation
might relieve him ; — if there was no fluid, a puncture,
under tbc existing circumstances, could not do harm.
My colleague, Mr. Le Gros Clark, at my request, intro-
duced a very fine trocar between the fifth and sixth ribs,
about half-way between the sternum and the spine. No
fluid escaped through the canula, but the cellular membrane
immediately became slightly emphysematous. A piece of
lint and adhesive plaster were placed over the wound ; and
except the slight pain of the puncture, the operation did
not cause the least inconvenience.1
No change took place in the character of the symptoms.
1 I have great doubt whether the introduction of an ordinary grooved
needle is, in all cases, sufficient to test the preseuce of fluid. My colleague,
Mr. James Dixon, once used such a needle, and no fluid passed along the
groove ; but so confident did I feel of the presence of fluid in the chest, that
I requested him to use a very fine trocar. He introduced this very carefully;
and on withdrawing the trocar, thin serum flowed out freely. About two
quarts were withdrawn.
134 DR. DARKER ON THE DIFFICULTIES IN THE
On the sixth, four days after the operation, the man said lie
felt more comfortahlc ; he sat up in a chair before the fire,
and, without having made any complaint, expired rather
suddenly.
Sectio Cadaveris. — The right side of the chest was very
dull and the left very resonant after death. The cellular
tissue around the wound which had been made by the trocar
was slightly emphysematous.
The left lung was emphysematous ; the disease was not
very much advanced in any one part, but the whole lung
appeared to be more or less affected. The left bronchial
tubes were red and injected, and contained a little mucus.
The heart was completely overlapped by the edge of the
lung, and was pushed under and partly to the right of the
sternum ; indeed the emphysema of the left lung had acted
on the heart and mediastinum exactly in the same way as
very extensive pleuritic effusion would have done; — the
heart being displaced in the manner just stated, and the
mediastinum being pressed laterally so as to encroach very
greatly on the right side of the chest. To such an extent
had this gone, that the central part of the mediastinum was
not more than two inches from the right ribs.
On the right side the pulmonary and costal pleurae were
universally adherent by delicate but perfectly-formed cellular
tissue, which could be separated by the fingers without
lacerating the lung. The lung itself contained scarcely
any air; it was pale and bloodless, and very closely resembled
healthy lung which has long been compressed by effusion
into the pleura. It was described by Mr. William Adams,
who made the post-mortem examination, as "diminished to
less titan one fourth of its natural size, and disposed in the
form of a thin layer adherent to the thoracic parictcs." It
was just possible to trace the line of the puncture which
had been made by the trocar. Besides the diminution in
the capacity of the right side of the chest, caused by the
encroachment of the left lung, it was still farther lessened
by the liver, which, though not enlarged or otherwise diseased,
DIAGNOSIS OF PLEURITIC EFFUSION. 135
extended so high into the chest, that the diaphragm had
narrowly escaped being wounded by the trocar, though the
instrument, introduced above the sixth rib, had been carefully
passed upwards.
The condition of the lung in this case was such as I
never saw before, and have not known to be described by
others. It appears to me that the only explanation which
can be given of the alterations which had taken place in
the chest, is the following : — That there had, at some former
period, been pleurisy with effusion on the right side ; that
the fluid had subsequently been absorbed, but that the
compressed lung had not again expanded, and had become
adherent to the ribs. Under ordinary circumstances, these
changes would have caused great and evident contraction of
the right side of the chest; but in the case now under con-
sideration, this contraction had been prevented, partly by
the opposite emphysematous lung and the heart, and partly
by the liver occupying the space which had previously been
filled by the right lung.
In addition to the unusual morbid changes detailed giving
rise to insuperable difficulties in arriving at a correct
diagnosis, this case is interesting as an example of the
impunity attending a trial operation, by means of a grooved
needle or fine trocar, in doubtful cases of hydrothorax or
empyema. Having ascertained in this case, that if there
was not fluid in the chest, — the presence of which I certainly
thought highly probable, — there was at all events some
very great impediment to the entrance of air into the lung,
and, being assured of this, I entertained no fear of serious
mischief arising from a puncture of that organ.
Case II. — William W — , set. 45, a flute-player, ad-
mitted Jan. 14, 1851. He stated that he had enjoyed good
health until four months prior to his admission, when he
was attacked with very severe pain, first in the left, and
subsequently in the right iliac and lumbar regions. He
was bled and salivated ; and, in a fortnight, though not quite
well, returned to his work. He soon became ill again, and
136 Dll. BARKER ON THE DIFFICULTIES IN THE
after attending as an out-patient at St. Bartholomew's Hos-
pital, and elsewhere, he was admitted as my patient, bringing
a note from his last medical attendant, stating that he had
had rheumatism and pericarditis, and was then labouring
under valvular disease of the heart.
When first seen by me, his countenance was expressive
of much suffering. He had no headache, but said he had
lately been much troubled by muscae volitantes. His
speech had become thick and indistinct within the last few
weeks ; and within the same time, he had almost lost all
power in his lower extremities, having a little power only in
the right leg, but none in the left ; sensation, however, was
not impaired. Respiration was short, hurried, and chiefly
abdominal ; the lower ribs on the left side did not move at
all. The resonance of the anterior and lateral parts of the
chest, on both sides, was natural, and the respiratory sounds
were healthy, with the exception of slight rhonchus. When
he lay on the back, with the shoulders a little elevated, he
suffered little pain so long as he remained perfectly still;
but, turning to either side, rising up, coughing, drawing a
deep inspiration, or making any other movement of the
trunk, caused most excruciating pain. The seat of pain
was stated to be limited to the left side of the body, occu-
pying the lowest part of the chest and the abdomeu on that
side; and this, he said, had for some time past been the sole
scat of his sufferings. So great was the agony caused by
turning to cither side, or sitting up, that it was with groat
difficulty he could be placed in such a position as to enable
me to examine the back of the chest. Nevertheless I satis-
fied myself that the chest was everywhere sufficiently re-
sonant, and that healthy respiration was going on in the
posterior parts of both lungs. Percussion of the two lowest
dorsal and upper Lumbar rertebrse caused pain of the same
kind, and limited to the same parts, as any movement of the
trunk had done. Although he was said to have had rheu-
matism and pericarditis, and to be then suffering from -val-
vular disease, the account he gave of his case would not
have led mc to suppose that he had had the two former, and
DIAGNOSIS OF PLEURITIC EFFUSION. 137
1 could not detect any evidence of the latter disease. He
had been repeatedly blistered over the left side of the abdo-
men ; but n0 blisters or leeches had been applied to the
cardiac region. The pulse was about 100, small, and soft.
My examination of this case not having led to the detect-
tion of any symptom of disease in the viscera of the chest
or abdomen, 1 could not account for the excruciating pain
in the left side, unless the spinal cord was diseased at the
lower part of the dorsal division ; the seat of the pain, the
fixed state of the lower left ribs, the feeble condition of the
lower extremities, and the complete paralysis of the left leg,
could all be accounted for on the supposition that this dis-
ease of the cord existed ; and the severe pain caused by
percussing the lower dorsal and upper lumbar vertebra?,
strengthened this view. Except in two respects, the sym-
ptoms did not change their character, and no others super-
vened up to the time of his death. After he had been
slightly affected by mercury, he became quite free from p:iin,
so long as he remained completely at rest ; but any move-
ment of the trunk continued to cause as much agony as
when he was first admitted, and consequently he always lay
on his back, with the shoulders a little raised. The res-
piration gradually became more hurried, and a very slight
cough became more troublesome. Four days before his
death no change had taken place in the respiratory sounds,
except that the rhouchus was rather louder and more general
than when he was admitted, and the posterior part of the
chest had become a little more dull on percussion on the
left than on the right side, with a corresponding feebleness
of the respiratory sounds, these changes being more remark-
able in the lower than in the upper portion of the back.
Two days before his death, although he made no complaint,
observing that the respiration had become much more rapid,
I again examined the chest completely. On the right side
there were the ordinary sounds caused by slight and partial
bronchitis ; on the left, over the anterior and lateral parts,
that is, over the whole portion which could be examined
138 DR. BARKER ON THE DIFFICULTIES IN THE
whilst he was recumbent, there was tolerably good resonance,
though not quite so clear as on the right side, and slight
sibilus and rhonchus could be heard everywhere. On
placing him in the erect position, I found the whole of the
back of the chest gave a very much duller sound, when per-
cussed, on the left than on the right side ; and over the
same parts, the respiratory sounds were feeble and distant.
I could not hear cegophany; and the change in the patient's
position did not cause the least alteration in the sounds
heard, either on percussion or auscultation, in the anterior
parts of the chest.
The patient had gradually been becoming feebler, and
the tongue dry and brown, but the mind was not affected ;
and there was no other change in the symptoms except those
already mentioned. He took a good deal of nourishment
and stimulus, but died two days after the last examination of
the chest, and seven days after his admission into the hospital.
The post-mortem examination was made on Jan. 22,
twenty-four hours after death. The arachnoid, covering the
upper part of the anterior and middle lobes of the brain,
was white and opaque; and, when cut through, it was found
that this membrane, together with the pia mater and inter-
vening areolar tissue, formed a dense layer, a line in thick-
ness, extending over and dipping between the convolutions.
The brain was healthy. The spinal cord and its canal wen
most carefully examined, but exhibited no mark of disease
in any part, excepting on the arachnoid of the cervical por-
tion, where there were a few small white patches. The
viscera of the abdomen were quite healthy. The heart was
of natural size and structure. On the mitral valves were a
few patches of atheromatous deposit ; and, at the base of
each aortic valve, was a minute quantity of earthy matter.
The pericardium contained ^ss of scrum, and there was an
old, firm adhesion, of small size, at the back of the left
ventricle. The right lung collapsed, and was quite healthy.
The left lung collapsed, but did not fall to the bach of tin-
chest; it was found to be floating on fluid. This fluid was
confined to the back part of the chest by a narrow line of
DIAGNOSIS Or PLEURITIC EFFUSION. 139
pleuritic adhesion, extending from the upper part of the root
of the lung to the top of the chest, behind the apex, and con-
tinued along the ribs to the diaphragm, which it joined about
half-way between the ensiform cartilage and the vertebra?.
A portion of the base of the lung being adherent to the
diaphragm, completed the separation of the left side into
two cavities. The pleura of the anterior and larger cavity,
was perfectly healthy; that lining the posterior part was
completely coated by a thin layer of loosely adherent gra-
nular lymph. This cavity contained about three pints of
dirty serum, mixed with granular matter, offensively fetid ;
and there was also a considerable quantity of air. The lung
was quite healthy, with the exception of one spot, the size of
a filbert, at the lower and posterior part of the upper lobe,
from which it was evident that a gangrenous slough had
recently separated. The cavity resulting from this com-
municated with a small bronchial tube. The line of adhesion _
between the pleurae was in no place more than half an inch
broad. In some parts of this line, the adhesion, though
evidently recent, was firm; but in others it was so slight, as
to cause surprise that the weight of the fluid, when the body
was moved, had not separated it. I think it very probable
that the completion of the communication between the sac
of the pleura and the bronchial tube, had only taken place
very shortly before death. When the chest was last ex-
amined by me, the man being erect, there was no resonance
at the upper part, which must have been the case, if air
had then been present ; and after the examination had been
made, I ascertained, from the sister of the ward, that, although
the man had died " very easily," as she expressed it, his
respiration had, rather suddenly, become much accelerated
about two hours before death.
The post-mortem appearances in this case fully account
for the symptoms referable to the chest, which were observed
two days before death ; but they do not, in my opinion,
explain the long-continued and severe pain in the left side
of the abdomen and left lumbar region. It is true, that
both in pneumonia and pleurisy, some other part than the
chest is often stated to be the seat of pain ; but, in this case,
140 DR. BARKER ON THE DIFFICULTIES IN THE
though there may be a doubt as to the exact time when the
pleurisy commenced, it is quite certain that the pain in the
abdomen preceded it by many weeks. The only other morbid
change observed was the disease in the arachnoid and pia
mater, and between this and the pain seated in the abdomen
there was no apparent connection.
It is difficult to assign any date for the slough in the left
lung, and the commencement of the pleuritic effusion. It
is certain that these did not exist when he was first seen by
me. At no time was there any sudden increase of, or
alteration in the symptoms, such as would, in ordinary cases,
arise from commencing pleuritis. Four days before death I
am satisfied that the effusion, if it existed, was not extensive ;
and I entertain no doubt that a considerable amouut of the
effusion must have occurred within two days of death.
In the 'Medical Gazette' for Nov. 10, 1843, I published
a case in which a very small slough, at the posterior part of
the left lung, had given rise to pleurisy with extensive
effusion and pneumothorax. Three days before that on
which the presence of air and serum in the pleura was
detected, there had been no more marked symptoms of dis-
ease in the lungs than those which were observed in the
case just related ; i. e. slight sibilus and rhonchus ; and yet,
iu those three days, air had been admitted into the cavity
of the chest, through the gangrenous perforation in the lung ;
and pleuritis, with extensive effusion, had occurred without
any symptoms arising which had attracted the attention of
the patient or his attendants. There had been no pain, no
uneasiness, no acceleration of the circulation or respiration,
no fever, no unusual position in bed, — in short none of the
prominent symptoms which usually attend such eases. We
cannot, therefore, doubt the possibility of the changes in the
chest which were observed in the case of W. W — , just
related, having all occurred within a few days of death; and
that such change may take place in very debilitated Bubjects,
without giving rise to constitutional disturbance, local pain,
or any great disorder of the respiration, must be well known
to every careful observer of disease.
In the case last mentioned there were adhesions so
DIAGNOSIS OF PLEURITIC EFFUSION. 141
situated, that healthy respiration could be heard in the upper
and anterior part of the chest as low as the seventh rib,
whilst the unequivocal sounds of pneumothorax were confined
to the anterior parts below that rib, in whatever situation
the patient might be placed ; recumbent, upright, on either
side, or bending forwards.
There was a peculiarity in the hue of adhesion between
the costal and pulmonary pleura;, in the case of W. W — ,
which I have seen in three other cases. It commenced
behind the apex of the lung, and extended obliquely forwards,
until, at the diaphragm, it was about half-way between the
ensiform cartilage and the spine. All the pleura, posterior
to this line of adhesion, which may be roughly estimated at
one third of the entire membrane, was thickly coated with
granular lymph ; all the membrane anterior to this line was
perfectly healthy. Looking to the position which the patient
constantly maintained in bed, this line of adhesion must
have been nearly horizontal ; and it appears probable, that
the effusion into the pleura was not, in the first instance,
limited by previously existing disease, but that the fluid had
gravitated to the posterior part of the chest, and that ad-
hesions of the pleune, at the margins of the fluid, had sub-
sequently taken place.
Only one of the three cases in which I have observed
similar morbid changes was seen by me during life. The
man was under the care of a surgeon for a tumour in the
neck, and confined to his bed, where he lay almost constantly
on his back. I was asked to see him, on account of his
respiration having been observed to have become short and
rapid, but the man made no complaint ; and it was only
after he had beeu closely questioned, that he made mention
of pain on the lower part of the right lumbar region, which
he thought was rheumatism, as it did not distress him when
he kept quiet. Ou examining the chest, the symptoms were
almost the same as those observed in W. W — , two days
before death. Puerile respiration on one side; on the other
side, rather feeble respiratory sounds, and diminished re-
sonance over the anterior half of the chest ; dullness on
142 DR. BARKER ON THE DIAGNOSIS OF FLI'.URITIC EFFUSION.
percussion and very feeble respiratory sounds over the pos-
terior half. The man died the next day. In this case
there was no disease of the lung; but the morbid appearances
in all other respects, so far as the chest was concerned, were
so similar to those observed in the case of W. W — , that I
do not think it necessary to describe them.
Before concluding this paper, I will briefly notice two
other cases in which there were all the symptoms which are
usually enumerated as indicative of pleuritic effusion, ex-
cepting the absence of respiratory sounds ; in both, feeble
sounds could be heard on almost every part of the right (the
suspected) side. In the first of these cases, there was reason
to suspect tubercles in an early stage ; but there had been
symptoms of pleurisy five weeks before I saw him. He
lived nine weeks afterwards. After death, the costal and
pulmonary pleura? were found adherent in all directions, so
as to divide the cavity into about twenty compartments,
many of which commuuicated freely with each other. The
symptoms of effusion, minus the loss of respiratory sounds,
were in this case easily explained.
In the other case, the patient passed from under my care
before he died, and no post-mortem was made; but, whilst he
was under me, the pleura was punctured three times, in
three different situations, in consequence of bulging and
fluctuation in the intercostal spaces.
At the first operation 1G oz. of pus escaped; at the second
about 5 oz. ; at the third a still smaller quantity. In this
case there can be little doubt there were adhesions dividing
the sac of the pleura into distinct cavities, and keeping
portions of the lung in contact with the parictcs of the chest.
Notwithstanding the number of cases which liavc been
related of unusual and complicated morbid changes in the
viscera of the chest, necessarily causing doubts, difficulties,
and errors iu forming a diagnosis, I believe there are some
novel features iu those which I have related ; and in that
belief 1 have offered them to the consideration of the
Society.
CASE OF
POPLITEAL ANEURISM
TREATED BY COMPRESSION,
WITH SOME REMARKS UPON THIS METHOD 01' TREATING ANEURISM,
AND A LIST OF THE CASES IN WHICH IT HAS BEEN
EMPLOYED IN DUBLIN.
BY
O'BRYEN BELLINGHAM, M.D.
FELLOW OF, AND MEMBER OF THE COURT OF EXAMINERS OF,
THE ROYAL COLLEGE OF SURGEONS IN IRELAND,
SURGEON TO ST. VINCENT'S HOSPITAL, ETC., ETC.
COMMUNICATED BY
SIR BENJAMIN BRODIE, Bart., F.R.S.
Received February 7tli— Read June 10th, 1851.
Charles Maher, set. 42, a labourer from the county of
Carlow, was admitted into St. Vincent's Hospital, under the
care of Mr. Belliugham, Nov. 26th, 1850, labouring under
popliteal aneurism on the right side. He states that he
was formerly in the army, and served eight years in the
19th Regiment of Infantry, three of which were spent in
the "West Indies. He enjoyed very good health, with the
exception of an attack of dysentery, under which he suffered
there ; he was discharged ten years ago, owing to defective
vision, caused by some opacity of the cornea of the right
eye. He has been engaged since then in agricultural
labour; latterly, his employment has consisted in spade labour,
in deepening the bed of a river, in a hard soil, where he
was sometimes up to his knees in water. He attributes the
disease to this work, the right lower extremity being prin-
144 DR. BELLINGHAM ON THE TREATMENT OF
cipally employed in it ; he says he never received a strain, or
other injury.
He states that, in June last, he first began to feel pain,
which was referred to the centre of the sole of the right
foot; that about a month afterwards, the limb swelled
from the ankle to the knee, and became nearly double the
size of the other, accompanied by cramp in the leg and
pain in the ham, which he observed to be fuller than the
other. About three weeks ago, he noticed the pulsation for
the first time ; he continued to work up to a week ago ; and
has made several applications to the part, among the rest a
blister, with the hope of relief. He then applied to a
medical man, who recommended him to come up to Dublin
to be treated, as he could not afford to lie up in the
country.
The popliteal region of the right limb is occupied by a
tumour, which has a very strong and heaving impulse, both
posteriorly and laterally, elevating the head when the ste-
thoscope is laid on it ; on pressing upon the artery in the
groin, the pulsation ceases, and the tumour collapses in a
certain degree; and, on auscultation over it, a short, harsh,
bruit de sovfflet is heard. The tumour completely fills the
popliteal space, is about the size of an orange, measuring
three inches from above downwards, and three inches and
a half transversely ; the ham-string tendons are much
stretched, and the integuments covering it are discoloured
from the effects of a blister which had been applied in the
country. The limb, at this part, measures fifteen inches
and a half in circumference, the opposite limb, at the same
point, fourteen inches. The limb, from the ham downwards,
looks to be somewhat larger than the other; and, on measure-
ment at the calf, is found to be fourteen inches and a half,
while on the other side it is only thirteen inches and a halt".
He is a stout and muscular man ; his general health very
good; the action of the heart regular; no increased im-
pulse ; pulse 6 I , strong.
November 80th. — The patient was directed to remain
constantly in bed, to take half a drachm of the Pulv. Jalap.
rOPLITEAL ANEURISM BY COMPRESSION. 145
Comp. every night, and to be restricted to the following
diet: —
Two ounces of bread and two ounces of milk for breakfast.
The same for supper.
Two ounces of bread, two ounces of milk, and two ounces
of meat for dinner.
December 3d. — The patient has not exceeded, so far as I
can learn, the dietary prescribed ; he makes no complaint,
except of thirst, and of it only when questioned. The pulse
is smaller and softer, and the limb at the site of the
aneurism has diminished half an inch in circumference.
4th. — Compression commenced to-day, at 11 o'clock, a.m.,
by means of two instruments, one upon the artery as it crosses
the horizontal ramus of the pubes, the other at the lower
third of the thigh ; the pulse at this time being soft, small,
and compressible, and beating only 56 in the minute.
Little congestion of the limb was caused by the pressure ;
and the sac became, in a great measure, flaccid. The com-
pression was maintained during the day, so as to check
pulsation in the tumour ; at each visit to the patient, how-
ever, a considerable impulse was felt in it, as he could not
tell when the pulsation was checked; and in the slight move-
ments in bed, the artery slipped from under the pad.
Half- past eight o'clock, p.m. — The aneurism does not
collapse now when the pressure is maintained, but its out-
lines can be distinctly felt ; the patient's skin is cool ; he
makes no complaint of pain, but says he is very thirsty; and
he was allowed a little whey. The patient by this time
appeared to understand the object of the compression, and
could tell when the pulsation in the tumour was checked ;
the management of the compressing instruments was, there-
fore, left to him during the night, and he was directed to
alternate the points of pressure whenever pain was experi-
enced, and not to allow any impulse in the aneurism. I
had, I should have observed, marked with ink, upon the
patient's thigh, the points upon which he was to keep the
pad of the compressing instruments, and this part of the
limb was directed to be dusted occasionally with flour.
xxxi v. 10
146 DR. BELLINGHAM ON THE TREATMENT OF
5th. — The patient remained awake during the night, and
says that he continued the pressure so as not to allow any
pulsation in the aneurism during the night. At the hour
of visit this morning (between nine and ten o'clock), on
unscrewing the instrument, the pulsation of the aneurism
was found to have ceased, and the tumour was hard, solid,
and circumscribed. An enlarged collateral vessel, running
down the centre of the popliteal space, was felt faintly beating
low down in this part ; the enlarged articular arteries about
the knee were not felt, and the patient had experienced no
pain about the joint or in the leg. He was directed to
remain in bed, and to continue moderate pressure.
10th. — The compressing instruments have not been applied
for some days ; the patient is quite free from pain ; and the
swelling of the limb perceptible on his admission has dimi-
nished. He has been kept in bed, and the diet has been
gradually improved, so that he is now nearly upon full diet.
The aneurismal tumour is solid and firm, the integuments
covering it are loose now, and the ham-string tendons are
not stretched as they were. Neither the anterior tibial
artery upon the dorsum of the foot, nor the posterior tibial
can be felt, nor is the pulsation of the articular arteries
about the knee perceptible; the only vessel felt bring a
branch which runs over the centre of the popliteal space.
17th. — The patient has remained in bed since the date of
tlic last report; he docs not suffer the slightest inconvenience,
and the tumour has diminished a little in size.
22d. — The patient was permitted to get up to-day ; the
limb, he says, feels somewhat stiff, and the ankle is slightly
oedematous ; in other respects he is perfectly will.
January 2d. — The patient feels no inconvenience now of
any kind; the aneurismal tumour is hard, solid, and smaller.
In order to promote absorption, he was directed to rub t lie
ham with the ointment of hydriodatc of potass, to which a
little mercurial ointment was added.
28th. — The patient returned to the country to-day; the
limb is as strong as the other; and his gcueral health i> very
good.
POPLITEAL ANEURISM BY COMPRESSION. 147
This makes the thirty-sixth case of external aneurism,
treated by compression, in Dublin, between the years 184-3
and 1850 inclusive, as will appear from the following table,
containing a list of these cases; in which, under separate
heads, I have given the situation of the aneurism, the hos-
pital or other locality where the patient was treated, the
name of the surgeon who had the management of the case,
the result, and the name of the journal in which the case
was published, with some observations in reference to the
subsequent history of these patients.
148
DR. BELLINGHAM OX THE TREATMENT OF
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POPLITEAL ANEURISM BY COMPRESSION. 151
The foregoing table contains a list of all the cases of
popliteal or femoral aneurism, treated by compression, in
Dublin, during the last seven years. It includes, also, I
believe, every case of aneurism in these vessels, admitted
into the Dublin Hospitals, or treated in Dublin within that
period, with the exception of four; viz., a case of femoral
aneurism where compression was not employed at all, and
the artery was tied with success ; a case of large popliteal
aneurism, where the sac had formed a communication with
the knee-joint, and the limb was amputated ; a case of
traumatic aneurism high up in the femoral artery, where the
vessel was tied with success ; and a case of varicose aneurism
in the thigh, to which neither compression nor the ligature
was adopted.
The table has been limited to the cases treated in Dublin,
partly because the practice may be said to have originated
there, and, without intending anything disparaging to other
places, or other surgeons, is perhaps best understood there;
and the most improved instruments for making compression
liave been employed there. It appeared to me, likewise,
that the value of this method of treating aneurism would be
best illustrated by a table of the Dublin cases, because these
were not selected cases, but almost every patient labouring
under popliteal or femoral aneurism, admitted into the hos-
pitals in Dublin, since the year 1843, has been treated by
compression. Besides, it was from Dublin alone that I
could give a list of all the cases which came under treat-
ment during the period in question ; or, that I could vouch
for the accuracy of the details, or for the permanence of the
cures, which I am enabled to do, as I had the opportunity
of seeing the majority of the cases given in the table, while
under treatment ; of assisting in the treatment of some of
them ; and of examining the diseased parts, either when the
patient died subsequently, or when amputation of the limb
was had recourse to.
This list, it will be observed, includes 32 cases of popliteal
and femoral aneurism, viz., 6 of femoral and 26 of popliteal
aneurism, 3 cases of brachial, and 1 of radial aneurism.
152 DR. BELLINUIIAM ON THE TREATMENT OF
Of the 3 cases of brachial aneurism, 2 were cured by com-
pression ; in the third a high bifurcation of the brachial artery
existed, and when the operation came to be performed
two vessels required to be tied : all three were examples of
traumatic aneurism. The radial aneurism was also an
example of traumatic aneurism, and was cured by com-
pression. Of the G cases of femoral aneurism, 5 were cured
by compression ; the sixth was a case of diffuse aneurism,
in which the ligature would equally have failed, and in
which amputation of the limb was the ouly resource.
Of the 26 cases of popliteal aneurism, 21 were perfectly
cured; one of them, however, (No. 9,) died, as I have observed,
suddenly, owing to organic disease of the heart, forty-eight
hours after the cessation of pulsation in the aneurism. Of
the remaining five cases, one (No. 20) was unable to continue
the compression, being obliged to return to his employment ;
and now, after an interval of three years, during which the
patient has been constantly occupied in a laborious employ-
ment, he has never suffered any inconvenience from it ; the
tumour is sjB&HeF, and its" pulsation nun- feeble. In another
(No. i 1), compression was discontinued, and the artery tied,
the patient recovering. In a third (No. 17) galvano-puneture
was combined with compression; the patient soon afterwards
was attacked with erysipelas in a very scire form and died.
In a fourth (No. 33) the aneurism enlarged considerably,
pressure having been discontinued, and the limb was ampu-
tated. And n the tilth (No. 35) the patient died of pul-
monary disease, and the aneurism, on examination after death,
was found to be in a great measure filled up by fibrin. I
may add, that the only two eases m the list in which
amputation was pe formed, occurred in a military, not a civil
hospital, where the treatment was of course conducted by
the military medical officer, temporarily in charge.
In three of the casesin this list. (Nos. 8 and ."">, l'Jand 80,
and 22, 25, and 31,) the patients underwent the treatment
DJ compression lor aneurism in opposite limbs, one of them
was tieated three times, u/.., twice for popliteal aneurism in
POPLITEAL ANEURISM BY COMPRESSION. 153
opposite limbs, and once for femoral, each time with success.
One of the patients (No. 13) had undergone the operation
by ligature for popliteal aneurism in the opposite limb, some
years previously. Four of the patients in this list (Nos. 3
and 5, 7, 10, and 32) have since died, two of aortal aneurism,
one probably also of internal aneurism, and one of cerebral
disease ; another1 (No. 19 and 20) is at present labouring
under aneurism of the aorta. Only two of the patients in
the foregoing list (Nos. 14 and 31) were females.
When compression first came to be employed in Dublin
as a mode of treating aneurism, it was objected that the
disease would be liable to return : in no case, however, marked
cured in the forgoing list has any thing of the kind occurred;
the cure in all has been permanent, and the patients have
gained the perfect use of the limb. Indeed, from the
manner in which compression brings about the cure of aueu-
rism, it is clear that the disease cannot return in the same
part of the vessel, and, in the opportunities which I have had
of examining the parts some time subsequently, owing to
the patient's death from other causes, the artery has in-
variably been found to be obliterated at the seat of the
aneurism, and converted into an impervious, ligamentous
band at the part ; while the portion of the artery upon
which pressure had been made, preserved its normal condition,
and neither it nor the vein (which, from its proximity to, and
close connection with the artery, must always, in cases of
femoral or popliteal aneurism, be compressed with the
artery,) presented, in a single instance, any deviation from
the normal and healthy state.
'When we contrast the results of the treatment of aneurism
by compression, with the results of the ligature in aneurism
of the same arteries, as furnished by the most recent statistical
tables, the comparison appears very favorable to compression:
thus, the table which I have given contains 36 cases ; in 29
1 This patient has since died, and I had the opportunity of making an
examination of the limbs.
154 DE. BELLINGHAM ON THE TREATMENT OF
a cure was effected by compression ; of the remaining 7 cases
the artery was tied in 2, the patients recovering. In 1,
pressure was discontinued, the aneurism subsequently dimi-
nished in size, and the patient had the perfect use of the
limb for three years, when symptoms of aneurism of the
aorta supervened, and compelled him to give up his employ-
ment. In 2, the limb was amputated, the patients recovering;
and in the remaining two, death occurred, in one from
pulmonary disease, in the other from a severe attack of
erysipelas ; but in both, the local disease was very nearly
cured, the aneurismal sacs being almost completely filled by
fibrine deposited in concentric layers.
If we now turn to the statistics of the ligature, furnished
by the most recent statistical tables, the results appear much
less satisfactory. Thus, in a table given by Dr. Norris in
the 'American Journal of Medical Science,' 188 cases where
the femoral artery was tied for aneurism are reported, (in
155 for popliteal aneurism,) and the following are the
results : —
No. of cases. Cured. Died.
188 142 Hi
The majority of the deaths was owing to gangrene,
secondary lnemorrhage, phlebitis, tetanus, &c. ; while six of
the patients who recovered underwent amputation of the
limb.
Another table is contained in Mr. Crisp's ' Treatise on
the Diseases of the Blood-vessels.' This includes 11!) cases
of popliteal aneurism treated by the ligature, with the
following results : —
No. of cases. Cored. Died.
119 103 16
The deaths were the result of secondary hamiorrhage,
gangrene, phlebitis, tetanus, delirium tremens, the shock of
the operation, and suppuration in the sac. Six of the pa-
tients under the head "cured," underwent amputation of
POPLITEAL ANEURISM BY COMPRESSION. 155
the limb after the ligature ; and six others recovered, not-
withstanding the occurrence of gangrene, secondary haemor-
rhage, or suppuration in the sac.
The summary of the results of the ligature, in the cases
of popliteal and femoral aneurism, contained in these tables,
would appear to be even too favorable to the ligature.
The same cases are included in both ; and it is evident that
they can form only a moiety of the cases of aneurism of
these vessels, in which the ligature has been used, during
the period in question, (fully half a century.) When we
consider, in addition, with what unwillingness cases which
turn out unfavorably are published, it seems highly pro-
bable, that, if we were in possession of full statistics of all
the operations for aneurism performed upon these vessels,
the per centage of deaths would be found to be much
greater. Even taking the statistics of the ligature as we
find them, if we contrast its results with that of compression
in the same forms of aneurism, we perceive a remarkable
immunity from risk, in the one method of treatment, and a
considerable amount of risk attending the operation in the
other. Thus, the great majority of the deaths after the liga-
ture were owing to secondary haemorrhage, gangrene, phle-
bitis, tetanus, and delirium tremens, in other words, directly
to the result of the operation ; while in the treatment by
compression, all those accidents were avoided, not one of
them having occurred in the thirty-six cases contained in
my table. The two deaths in it were, I may say, from
causes independent of the treatment ; the one having been
from erysipelas, which was prevalent in the hospital at the
time ; the other from pulmonary disease. Both were like-
wise men of broken-down constitutions, with diseased heart
and arteries; very unfavorable subjects, consequently, for
operation, and in whom, if the ligature had been used, it
would most probably have proved a failure.
Although compression has proved eminently successful in
Dublin, as a mode of treating certain forms of aneurism,
and has so completely superseded the ligature there, that
156 DR. BEI.LINGHAM ON TIIE TREATMENT OF
the latter has not been had recourse to for several years past
in a single case of popliteal aneurism, either in hospital or
in private practice, it must be confessed that the reports
from most other places are less favorable ; it is therefore
scarcely unreasonable to conclude that compression cannot
have been employed in the same way, that equally effective
instruments cannot have been used, or that the same pre-
cautions cannot have been taken to ensure success. Indeed,
a perusal of the cases which have been published of the
failure of compression in the hands of surgeons out of Dublin,
(which have beeu put so prominently forward in some places)
has satisfied me, that the failure in the majority resulted
either from the imperfection of the instruments employed,
from an unnecessary degree of pressure having been used,
or from its having been made in an imperfect manner, from
tight bandages having been applied to the limb while pres-
sure was maintained upon the main artery, from the treat-
ment having been commenced without due attention to
constitutional measures, or finally from compression haying
been used in cases where the ligature would eqn illy have
failed.
It is unnecessary to say that compression is not employed
at the present day with the object of endeavouring to ob-
literate the artery at the point compressed, if it were, few
patients would have beeu found possessed of the fortitude to
submit to the pain such an amount of pressure would occa-
sion. I do not, however, mean to assert, that compression
is a painless process; but I do Bay that the pain may lie
much increased, and that the patient may be, and often has
been, put to a great deal of unnecessary pain, and may
refuse to continue its use from this cause alone.
I do not wish it, either, to be supposed that compression
is advocated in every form of aneurism, or that it is supposed
to be capable of effecting a cure in every variety of the
disease, as, for instance, in diffused aneurism, or where the
aneurismal sac' had been allowed to attain an extremcl,
lar^o size, or where tin- sac of a popliteal aneurism had
formed a communication with the Unci' joint, or had caused
POPLITEAL ANEURISM B\ COMPRESSION. 157
erosion of the bone ; in fact in cases where amputation is
perhaps our only resource.
Compression, as a mode of treatment in aneurism, is advo-
cated mainly as a substitute for the ligature, and for cases
to which the ligature is applicable, provided the sac is so
situated that compression can be made upon the artery at
its cardiac side, as well as for cases where the arterial tunics
are diseased, and the ligature would be consequently very
likely to fail. It is advocated because pathology has shown
that it brings about the cure of aneurism by the very mode
in which nature, under the most favorable circumstances,
effects this object, and because experience has proved it to
be a safe and certain method of treatment, while all experi-
ence has shown the ligature to be directly the reverse.
If we expect, however, to be successful, and if we hope to
effect a cure speedily, our efforts must be mainly directed to
the means whereby pressure may be maintained with as
little inconvenieuce as possible to the patient, which will
depend in a great measure upon the kind of apparatus used,
and its completeness ; upon the manner in which the pressure
is maintained ; and, upon the constitutional measures adopted
previous to the treatment being commenced, and while it is
in progress.
A good deal will also depend upon the intelligence and
tractability of the patient. In a mode of treatment which
usually occupies several days, and sometimes more, it is not
easy to have a constant surveillance ; and if the patient
unscrews the instrument the moment the surgeon's back is
turned, the cure must of course be retarded ; or, if he is too
stupid to understand the manner of using the compressing
force, or the object with which it is applied, the pressure will
be imperfectly maintained, and at each visit the surgeon will
probably find the pad of the instrument resting upon any
other part than the artery.
With respect to the instruments, I need only observe that
those which are available now, are in many respects superior
to those we were in possession of a fun years ago, the un-
158 DR. BELLIN0HA1I ON THE TREATMENT OF
yielding force of the screw has been superseded by the
elastic force of the vulcanized India-rubber bnads, an
improvement for which we are indebted to Dr. Carte ; the
treatment, consequently, has been much simplified, and the
pressure can be borne with less inconvenience by the patient.
While upon this point, I may observe that it is scarcely
doing justice to this method of treating aneurism, to under-
take it without being provided with a proper apparatus for
carrying it out ; yet this would appear not unfrequentlv to
have occurred in the trials of compression made in other
places, aud these very cases have been afterwards published
as examples of the failure of compression, and have been
made a ground for decrying this method of treatment, while
the fault lay, in a great measure, with the surgeon who com-
menced the treatment without having proper instruments at
hand for carrying it out.
In the list which I have given, of the cases of aneurism
treated by compression in Dublin, there were few in which
the treatment was so quickly successful, and in which the
pulsation of the aneurism ceased within so short a period, as
in that just detailed. This fortunate result may be attri-
buted, in part, to the constitutional treatment to which the
patient was subjected, previous to the application of the
compressing instruments, and as this was the first case in
which constitutional measures of the kind were combined
with the local measures, and as it promises to be an im-
portant agent in the treatment, in future, I may be permitted
to make a few remarks upon it.
When the patient was admitted into the hospital, his
pulse, as I have said, was strong and incompressible. In
such a state of the circulation, a much greater amount of
pressure would have been found necessary in order to stop
the pulsation of tin- aneurism than was required in his case;
greater pain would unavoidably have been inflicted on him,
and greater difficulty would have been experienced in main-
taining the pressure from this very cause.
With the view of diminishing the hardness and incom-
TOPLITEAIi ANEURISM BY COMPRESSION. 159
pressibility of the pulse, bleeding has been sometimes ad-
vantageously premised, particularly when the patient was
young and plethoric. I was unwilling, however, to bleed
this patient, as although muscular and stout, he did not
appear to be a favorable subject for the abstraction of blood.
I preferred, therefore, adopting a plan of treatment, which I
have employed with advantage in some cases of aneurism of
the aorta, under the use of which I have found the pulse to
become soft, small, and compressible, and its frequency to
be diminished. This consists in an extremely restricted
diet, especially as respects fluids, the utmost amount allowed
being but six ounces in the twenty-four hours, with eight
ounces of solid food in the same period, combined with the
daily or frequent use of some hydragogue cathartic, the
patient being at the same time strictly confined to the
horizontal posture.
Under the use of this regimen, continued for some days,
the hardness and incompressibility of this patient's pulse
diminished and it became slower; the compressing instru-
ments were consequently borne with little inconvenience.
At the same time, the watery constituents of the blood being
diminished, this fluid became more dense, by which the
deposition of its fibrin, in its passage through the aneurismal
sac, was favoured; this began early to be deposited, and before
twenty-four hours had so much increased that the pulsation
of the aneurism ceased. Had compression, on the other
hand, been at once commenced without any preparatory
treatment, much stronger pressure would have been required;
and as the pain is, in some measure, in the ratio to the degree
of pressure, this patient would have been subjected to much
unnecessary pain while the treatment would unavoidably
have been more prolonged.
Although in many of the cases in the list which I have
given, compression proved effectual without almost any pre-
paratory treatment, and in none was any, like that adopted
here, employed, I am of opinion that it ought to constitute
a prominent item in the treatment, tending, as it most
certainly does, to diminish the pain which the compressing
160 DR. BELLINT.IIAM ON POPLITEAL ANEURISM.
instruments occasion, as well as to shorten the period required
for their employment. And I am convinced that if in
future, constitutional measures analogous to those employed
in this case, are made to precede the local treatment, and
that the latter is fully and fairly carried out, no case to
which compression is applicable will be found to resist, and
those who ai'e most sceptical will be obliged to acknowledge
its superiority over the ligature.
ACCOUNT OF
THE DISSECTION OF A CASE
IN WHICH
TWO POPLITEAL ANEURISMS
HAD BEEN TKEATED BY
COMPRESSION OF THE FEMORAL ARTERIES.
PRESCOTT HEWETT,
ASSISTANT SURGEON TO ST. GEORGE'S HOSPITAL,
AND LECTURER ON ANATOMY, ETC.
Received June litli.— Read June loth, 1851.
F. V — , aet. 38, was admitted into St. George's Hos-
pital, under the care of Mr. Cutler, on the 7th of June,
1848, with a tumour in each popliteal space : that on the
right side was very large, and completely filled this region ;
it presented pulsation, expansion, and the bruit usually ob-
served about aneurisms ; but the sac, although compressible,
could not be emptied. Below the tumour, the limb was
slightlyoedematous; but the skin, somewhat tense and shining,
was natural in colour; handling gave little or no pain. The
disease had, it appeared, existed about three months, and
when first observed, the swelling was not larger thau a
plum. No treatment whatsoever had been adopted for it.
The tumour in the left ham was very much smaller, not
exceeding the size of a small egg; it was hard, and to a great
degree, apparently solid, but pulsation was evident in it,
although much less marked than on the right side. The
following was the only history which could be obtained from
the patient, a foreigner, as to the disease on the left side.
xxxiv. 11
162 MR. hewett's case of
The tumour had first been noticed about eighteen months
back, its appearance being speedily followed by great swell-
ing of the limb, which increased to about twice its natural
size. Shortly afterwards he went into the Wexford In-
firmary, where, by means of an instrument, compression was
established on the femoral artery, and kept up, more or less,
for seventeen weeks; under this treatment, the limb gradually
regained its natural dimensions, and the tumour was reduced
to its present size. He then left the infirmary ; but the
state of his general health was such that he had not been
able to undertake any work in his trade, which was that of
a musical instrument maker. The tumour in the left ham
had presented little or no variation, and had caused him but
slight inconvenience. His health had begun to give way
about two years and a half ago; he was pallid, and his whole
aspect was that of a man suffering from great debility.
At a consultation of the surgeons, it was determined,
under existiug circumstances, that compression should be
applied first upon the right femoral artery, by means of a
ring tourniquet, which was so adapted as only to lessen the
circulation. In some little time, all oedema of the limb
disappeared, and the tumour itself became loss in size and
firmer, but pulsation still remained evident in it. Some six
weeks after the patient's admission into the hospital, and
whilst under treatment, he began to complain of cough and
expectoration, with some difficulty of breathing. Nothing
abnormal was detected about the heart by auscultation, but
the lungs were found to be engorged at the back part. lie
at first appeared to derive some little benefit from the treat-
ment which was adopted, but subsequently the difficulty of
breathing and the cough increased much in severity ; these
symptoms went on without mitigation for about a fortnight,
when he one day suddenly brought up a large quantity of
arterial looking blood, and died soon afterwards.
At an examination of the tumour made some short time
before the patient's death, it was found that there was still
some pulsation left, but that the mass had become inueli
firmer and more solid; the ring tourniquet had, it appeared,
TWO POPLITEAL ANEURISMS. 163
for the greater part of the time, only been worn during a
few hours daily. No change whatsoever had occurred on the
left side.
For the notes of the history of this case, I am indebted
to Mr. Richard Blagden, Surgical Registrar to the Hospital.
The body was examined thirty-one hours after death.
On the left side, the aneurismal tumour, deeply imbedded
in the popliteal space, was lying between the joint and the
artery. Pyriform in shape, with the base downwards, it
was about the size of an egg, and appeared to be perfectly
solid, but on cutting into it, the lower half only of the sac
was found filled with closely packed laminated coagula, very
firm, and of a fawn colour ; the remaining part of the sac
containing only a small quantity of recently coagulated blood,
was lined by a perfectly smooth membrane continuous with
the internal coat of the artery and of the same colour,
except in that part which was stained by the contact of the
recent clots. The opening from the sac into the upper part
of the artery was a free one, nearly as large as the vessel
itself; that leading into the lower part of the artery was a
small one, only admitting a common-sized probe ; this part
of the artery which had been carried backwards and pressed
upon by the development of the sac, was itself much reduced
in size, but still pervious ; its coats were for the greater part
healthy, and so were those of the anterior and posterior
tibial arteries, which were of their normal size. Immediately
above the aneurism, the coats of the artery were extensively
thickened by atheromatous deposits, and this diseased ap-
pearance, more or less marked, existed also in the lower part
of the femoral. In this diseased part of the artery, there
were three distinct aneurismal dilatations, about the size of
filberts, two in the femoral vessel, and one in the popliteal,
half an inch above the larger aneurism. The femoral artery
was pervious in its whole length, and at its upper part quite
healthy in structure; the femoral vein was also pervious and
healthy, and presented no morbid adhesions to the artery ;
the sheath of the vessels and the surrounding cellular tissue
164 mil hew bit's case of
in the thigh were not thickened. The popliteal vein and
nerve were firmly adherent to the aneurism al sac, and so too
were some fibres of the gastrocnemius muscle; the nerve was
flattened with its fibrils spread over the outer and back part
of the tumour. On the right side, the aneurism, somewhat
larger than a cricket-ball, was also lying between the artery
and the kuee, the vessel running down the centre of the
posterior surface of the tumour, which was closely united to
the joint. The whole of the sac was completely filled with
laminated coagula, except at the back part, where there was
a small channel, by which the blood might pass from the
upper to the lower part of the vessel ; the surface of this
channel was rough, and recently coagulated fibrin was
deposited in it ; the opening of this channel into the upper
part of the artery was a free one, and lined by a smooth
membrane ; at the lower part the communication of the
channel and the artery was much contracted, this part of
the vessel itself being much diminished in size, in fact not
larger than the posteiior tibial. Above the aneurism, the
coats of the vessel were thickened by atheromatous deposits,
and here, too, about an inch and a half higher up, there was
another ancurismal dilatation as large as a nut. Patches of
atheroma existed also in different parts of the femoral, but
tins vessel was otherwise healthy and pervious in its whole
length. The femoral vein was also healthy and pervious,
and not more adherent, in any part of its course to the
artery, than natural ; the surrounding cellular tissue was
healthy. The popliteal vein and nerve here presented the
same appearances as those observed on the left side, being
displaced and adherent to the back part of the sac, which,
towards its outer side, was covered with the expanded fibrils
of the nerve. Some of the muscular fibres of the gas-
trocnemius were so adherent to the sac, that they could not
be removed without destroying its walls.
In the chest, some old adhesions were found in the
pericardium, but the heart and its vessels presented
nothing remarkable. The aorta was extensively affected
with atheroma throughout a great part ol' its couim'; and 80,
TWO POPLITEAL ANEURISMS. 1C5
too, were the three large vessels arising from its arch, which
generally was somewhat dilated. Three distinct aneurisms
existed in this part of the vessel; the smallest, of the size of
a cob-nut, was situated at the point of origin, of the brachio-
cephalic artery, involving a part of this vessel; no coagula
were found in it. The second, as large as a walnut, and
situated on the concave portion of the arch, nearly corres-
ponding to the first one, passed forwards, partly overlapping
the pulmonary artery and adhering to it; its opening, of the
size of the little finger, was perfectly smooth, as if lined by
the internal coat of the artery, and its cavity was partially
filled with coagula. The third, and largest of the three,
which was situated at the back part of the artery, imme-
diately behind the origin of the large vessels, had made its
way upwards between them and the windpipe, to which it
was firmly and extensively adherent ; its opening was a free
one, and its cavity partially filled up by coagula of some
standing ; at the back part of the sac there was a small
ulcerated opening leading into the windpipe, about an inch
above its bifurcation, through which the fatal haemorrhage
had taken place. In the air-tubes were found clots of
recently coagulated blood ; in addition to which the lungs
themselves presented several well-marked patches of pul-
monary apoplexy; both these organs were extensively affected
with emphysema.
In the abdomen all the organs were healthy, excepting
the kidneys, which were somewhat smaller than natural,
and rough on their surfaces, with several small cysts in their
structure.
ON
THE RELATION OF SLEEP
TO
CONVULSIVE AFFECTIONS.
WILLIAM FREDERICK BARLOW, M.R.C.S.
RESIDENT MEDICAL OFFICER TO THE WESTMINSTER HOSPITAL.
Received February 5th. — Read April 8th, 1851.
The relation of Sleep to Diseases in general is a subject
still needng full investigation ; and that which it holds to
Convulsive Affections would he found especially worthy of
research. The history even of the spasmodic disorders which
occur in sleep is so meager and unsatisfactory, that one
more accurate and ample is required ; but as the facts which
illustrate it are for the most part common, I will confine
my observations to some points respecting the causes of the
convulsions which happen either in light or profound repose.
Sleep produces certain peculiar states, both of body and
mind, which must have a most considerable connection with
convulsive maladies ; and I would beg the particular atten-
tion of the Society to —
i. The condition of the Circulation and Respiration.
ii. To that of the Motor Force and Muscular Irritability.
in. To the Emotions of Dreaming,
iv. To the withdrawal of the Will.
i. Of the state of the Circulation and Respiration. — I will
not here consider whether sleep itself may not be a conse-
quence of cerebral congestion falling short of that which
168 MR. BARLOW ON THE RELATION OF
would give rise to coma; but there is every reason to believe
that the vessels of the brain are fuller at that period than
in wakefulness. It may even be concluded that they are
necessarily so from the position of the patient, and the state
of the respiration. There is sometimes during sleep plain
evidence of congestion ; the face is flushed, the conjunctivae
are reddened, the veins of the neck and temple are turgid,
the countenance looks occasionally swollen, the lip is some-
what livid, the pulse labours, the breathing is heavy, or even
stertorous. We may be certain that the state of the
vessels external to the brain is, more or less, a guide to that
of those within. Through the cerebral circulation being
impeded, the brain may so mechanically irritate the spinal
cord as to lead directly to convulsive actions. That circu-
lation is apt to be unusually disturbed, if sleep be preceded
by unusual bodily or mental excitement, by a luxurious or
immoderate meal, and by the emotions of dreaming, whencc-
soever arising; and whatever its difficulties, the helpless
condition of volition is such that it cannot be assisted
through the respiration, as in wakefulness.
ii. Of the Increase of the Motor Force and Muscular
Irritability . — It may be assumed that, in many who arc pre-
disposed to convulsions, spasmodic affections partly happen
from the renewal and increase of the motor force which take
place in sleep. Some phenomena of hybernation, and some,
too, observable in paralytic limbs cut off from cerebral but
not spinal influence, show well how irritability is fed by
stillness; and it would be futile to deny, that liability to
spasm, of every kind, is, catena paribus, in direct ratio of the
measure of the motor force. During wakefulness this force
must be continually lessened, and kept in check bj expen-
diture carried on in some form or other ; but in repose
its augmentation may become dangerous in subjects liable
to convulsion. Whatever be the cause which imme-
diately excites it to unruly action, its own quantity or in-
tensity must be well considered. We cannot too clearly
regard this force as dependent on and modified by the
SLEEP TO CONVULSIVE AFFECTIONS. 169
blood's condition, as all secretions are ; and it is not more
the office of the glands, each after its kind, to separate their
fluids, than it is the vital function of the spinal cord,
through the replenished vessels it abounds with, to supply
unfailingly the motor power, whereof there is not only a
different measure in sleep and wakefulness, but a superfluity
in childhood, and a deficiency in age, whilst in some dis-
eases it is as much below, as in others it is above, the de-
mands of the system. I say nothing of idiosyncrasies, which
would reward inquiry. Sleep may most manifestly be so
indulged as to confirm or cause spasmodic aflections. The
vast amount of time consumed in it by infancy and child-
hood, wherein prevails frequently a most perilous excitability,
calls for attention. Coma is fairly, in some of its conse-
quences, comparable to an extraordinarily protracted repose,
and may bring on, as I have frequently noticed in young chil-
dren, so morbid a susceptibility of spasmodic action, that
the slightest touch or a drop of water will reflexly excite
general convulsions.
in. The Emotions of Dreaming. — These are, very pro-
bably, amongst the most common immediate causes of the
convulsions of sleep ; and this we should be justified in
suspecting from the marked effect of emotion in epilepsy,
laryngismus stridulus, and other forms of spasmodic malady
during the waking state.
It is needless to enter at any length into the intense
horror which dreams may occasion ; all must have felt it ;
but in childhood they are singularly pertinacious and terrible,
and may partly explain the frequency of convulsions at that
time of life. Nor does the danger cease at the moment of
awaking, for spectra are prone to linger and agitate.
I have frequently watched the quiverings of the muscles
and the starting of the limbs in dreams, which T regard
amongst the most frequent of all the causes of convulsive
action. The dreams of epileptics have been pointedly re-
ferred to by Aretreus ; and they have often a most unhappy
influence on their dreadful disorder, breaking the sleep with
170 MR. BARLOW ON THE RELATION OF
frightful paroxysms, and in some instances deferring by
terror the time of its approach.
Emotion, speaking generally, has never so much dominion
as in sleep, wherein the restraining power of volition is with-
drawn, and there is a kind of general paralysis, attended
commonly with high irritability, which extremely favours its
inordinate play. Even the healthiest and strongest men are
appalled by, and tremble from, the frightful and fantastic
visions of their sleep ; but to judge rightly of the effect of
emotions in dreams, we must place fully before us the
various conditions in which they have to act. The epileptic
is oftentimes so excessively excitable that there is a risk of
the slightest impressions. The young subject of laryngismus
stridulus is as irritable occasionally as a sensitive plant ; not
a change of mind or body but acts with unusual and morbid
violence. In tetanus or hydrophobia no impression is trifling.
The limbs of the paralysed are now and then noted to be
convulsed by a touch.
Dreams are, for the most part, referable to excitement
of mind previous to sleep, to immediate impressions on the
nervous system, to changes of the blood, and to various
impeded or embarrassed conditions of the respiration and
circulation. It would be well to subdivide this outline
minutely, and to treat at length of their origin, which,
well considered, would be found to illustrate much that is
obscure in nervous pathology. The resemblance which
exists between dreaming and delirium, extends somewhat
to their causes. Both are oftentimes referable to impressions
on the sentient nerves. A sensation too obscure to awaken
is very likely to produce dreaming; violent or long-continued
pain, especially if it happen in exhausted subjects who have
been long sleepless, is very apt to be the origin of delirium.
The state of volition is intimately connected with both in-
stances, and throws equal light upon each ; if it be suspended,
or almost so, in the one, it may become so weakened and
languid in the other, as to lose all effectual control over
the operations of the mind. Delirium must be regarded :is
a source of convulsion ; therein, as in dreaming, the emo-
tions rise sometimes to their highest pitch.
SLEEP TO CONVULSIVE AFFECTIONS. 171
It is occasionally not a little hard to say if a person be
delirious or dreaming; the best test will be found in the
endeavour to rouse him completely, and noting the effect of
wakefulness on his delusion. During typhus there is often a
prolonged dream, the will of the patient being as much with-
drawn from directing his mind as from governing his muscles ;
and be it remarked that this condition may be commonly
enough quite dispelled by fully rousing him. I watched but
lately a young man dangerously stricken with typhus fever
whilst he lay in unsound sleep. There was a lively quiver-
ing of the muscles of the face, particularly of the orbicularis
oris. At one time it affected half, at another both sides of
the countenance ; the hands were in frequent tremor, and
now and then the forearm was jerked abruptly. I imagine
a dream was disturbing him. On my perfectly awaking him,
and his will becoming active, all these movements ceased ;
but they returned the moment he relapsed into slumber.
In considering the relation of sleep to spasmodic move-
ments, it must always be inquired, as a matter of course,
whether it be sound or not. In truly sound sleep, chorea
no longer waywardly agitates, and paralysis agitans ceases to
shake, and many forms of local affections of the motor force
find temporary quiet ; but uot so if the slumber be ruffled by
emotions. I observed of a patient with mercurial erethism,
that whatever agitated his mind disturbed also his body;
the mere question of a stranger would make his muscles
quiver. I watched his sleep; then he was often in perfect
rest ; but at other times he startled occasionally, and seemed
to be dreaming when he did so.
The opposite influence of calm and disturbed sleep is
clearly instanced by the following observation. A woman
was affected with an almost perpetual tremor of the right
arm and hand, which was extremely aggravated by emotion.
I carefully noted that the arm and hand were completely
still during perfectly sound sleep ; but in imperfect or light
repose there was a varying amount of tremor. The hand,
no less in sleep than in wakefulness, became a delicate index
of the condition of the mind. One night, when the patient
172 MR. BARLOW ON THE RELATION OF
was resting profoundly, I examined the hand as it lay by
her side; not a muscle quivered; but shortly afterwards the
slumber became manifestly imperfect, and then the hand
and arm, influenced as it seemed by the emotion of dream-
ing, shook very forcibly. On a subsequent night I watched
more minutely, and for a longer time. In calm sleep the
hand lay in perfect rest, but anything which disturbed the
repose served also to renew the tremblings. When it be-
came very violent, she occasionally seemed about to awake,
and even performed a voluntary act or two, and made a kind
of complaining noise, as though annoyed by something; but
instead of arousing completely, she relapsed gradually into
her former complete unconsciousness, the slow subsiding of
the tremors well marking its return. And so she would lie,
without any movement of the voluntary muscles, the arm
participating in the perfect quiet, until a noise partly dis-
composed her and renewed the tremors, which it was in-
teresting to note, were frequently the only sign whatever of
some degree of mental activity.
There are some cases of hemiplegia wherein, though the
will be powerless, intense passion violently convulses the
affected parts; it may be well supposed that these are not
a whit less amenable to the excitement of a dream than to
the agitation of the waking state.
It is very probable that chorea, epilepsy, and other forms
of convulsive action, arc at times first excited by the emotion
of dreaming; and that this is one reason why their immediate
origin is not seldom involved in so much obscurity.
iv. Of the withdrawal of Volition. — There arc a variety
of considerations all tending to show that the withdrawal of
the will in time of sleep must predispose greatly to con-
vulsive actions.
Almost all the experiments which demonstrate and illustrate
the reflex function arc of necessity performed after the removal
of the scat of volition; and it now seems strange that those
movements should ever have been called voluntary which
cannot be excited until volition is withdrawn.
SLEEP TO CONVULSIVE AFFECTIONS. 173
The reflex movements of paralytic limbs are, ceteris pa-
ribus, always excited with a facility inverse to the power of
the will ; on the partial return of that power they become
more difficult to occasion, aud they fail to be provoked on its
complete restoration.
But all states which abolish the command of, or enfeeble
the 'will, predispose to involuntary action. Putting pa-
thology out of question, we may note the fact commonly in
the course of life. In infancy the emotions are written on
the expression and gestures with a freedom denotive of an
uneducated, and almost powerless will ; in age the hand
often trembles, partly because of the declining energy of the
voluntary fuuction.
Disease shows the same truth daily. In the coma both
of adults and children, I have repeatedly excited reflex
movements, and have observed the experiments foiled by
the return of the mind's activity. Chorea is an affection
wherein the balance between the voluntary or emotional
powers is temporarily broken ; the tongue cannot utter and
the hand is made useless from the perpetual interference of
restless emotion with the yielding will.
But experiments upon sleep itself are, after all, the
best exemplifiers of the condition of the will in that wonder-
ful state, and of the readiness wherewith reflex or convulsive
movements may be excited in consequence.
I passed my finger gently over the palm of the hand of a
child who lay fast asleep. The fingers closed and grasped
so firmly that I could draw away the arm from the side,
drag it in different directions, or lift it upwards. At length
the child awoke ; the same kind and degree of irritation
was applied, but the fingers would not close thereupon, for the
will obviously counteracted the impression produced by the
recently effectual stimulus.
I have times and often occasioned other reflex movements
in children during sleep. I have noted the arm to be
suddenly withdrawn on tickling the hand, — the orbicularis
palpebral to contract and corrugate on the eyelash being
touched, whilst a frown was produced simultaneously ; yet
174 MR. BARLOW ON THE RELATION OF
was the child not startled, no change affected the breathing,
and sleep went soundly on.
Once upon my irritating the hand of au infant in fast
repose, there was a general convulsive start, and a laryngeal
noise at the same moment. This fact may be compared to
another ; in a nearly asphyxiated newborn infant I pro-
duced several times a most distinct inspiration by tickling
the palm of the hand.
These, and other similar movements, were occasioned at
different periods of sleep. Increase of irritability favours
them undoubtedly, but it is far from being indispensable to
their causation. All that is essential is a quiescent will.
According to Dr. Baly, they may be excited in their full
intensity immediately after the beginning of sleep.
There are states of extreme excitability of the nervous
system, such as those instanced by tetanus and hydrophobia,
in which they could, no doubt, be most readily produced ;
but sleep, so difficult to obtain in such cases, must be guarded
from irritation with most scrupulous care.
We must be prepared for failure when attempting to
cause motions of this kind. Sometimes the sleeper is half
aroused by the touch, and a movement follows which is
emotional or voluntary. As yet, I have experimented
almost exclusively on young children, preferring them
because their surface is so excitable, their irritability pro-
verbial, their motor force excessive, their sleep profound.
But the most favorable condition, not even excepting
early infancy, for the production of reflex movements during
sleep, is that of cerebral paralysis, attended by aruesthesia.
A young man, made paraplegic by this form of disorder, lay
sleeping profoundly ; I turned up the bedclothes gently,
and, having exposed the legs, pricked the soles of the feet
with a piu, and provoked the quickest and strongest con-
tractions, and renewed them again and again at pleasure,
the man still reposing as fastly as though nothing had
touched him. The reason was clear ; he was so truly anes-
thetic, that neither the raising of the bedclothes, nor the
exposure of the legs to the cold air, nor even the sharp and
SLEEP TO CONVULSIVE AFFECTIONS. 175
rude punctures were at all felt by him, though the last were
very effectual iu exciting a reflex action of his muscles.
Extreme insensibility and extreme excitability prevailed
together.1
In two other cases of paraplegia attended also by loss of
sensation, I excited similar movements during sleep, and
with equal facility, without awaking the patient.
Experiments of this kind are a simple and admirable test
of the real state of sensation in some cases of loss of volun-
tary power. A patient may assert that he does not feel at
all, because his sensation is obscure or abnormal; a better
proof of anaesthesia lies in the fact that keen impressions
on the nerves of sense break not his rest.
In cases of anaesthesia from cerebral disease, in which there
is no loss or impairment of voluntary power, it would be
highly interesting to try the effect of stimulating the affected
surface during deep repose, with the view of provoking the
muscles to contraction.
In those instances of paralysis in which the will is but
partially deprived of control, and somewhat resists the in-
fluence of the means whereby we endeavour to occasion
reflex movements, sleep offers a propitious time for trial.
Hybernation is a more favorable state for the production
of reflex movements than that of sleep, because it more
fully suspends sensation, augments irritability, and withholds
the will. Dr. Marshall Hall long ago observed how very
readily the hybernant animal might be excited to motion,
how the "slightest" touch of the hedgehog, and the merest
shake of the bat, would produce acts of inspiration. I have
since noted similar phenomena. A dormouse lay in the
hybernant state, not a respiratory movement was perceptible ;
on my lightly touching the tips of the hair, there followed
quick, deep inspirations, which became gradually slower and
invisible. I also excited a distinct contraction of the
sphincter of the eyelid by irritating its lash, and retraction
of the extremities by stimulating the feet. These obser-
1 "La scnsibilitt' est done Jisliuctc de l'cxcitabilite." — M. Flourcns.
176 MR. BARLOW ON THE RELATION OF
vations were repeated. No movements of this kind can be
thus excited in the same creature when fairly awake.
In the deep, long, peculiar sleep of the unborn child,
motions of its limbs may be readily occasioned by to and fro
moving the hand, with a light pressure, on the abdomen of
its mother. I believe them to be reflex, as Dr. Simpson
insists, and they occur, according to him, in the anencephalous
as well as the perfect infant. This fact is incompatible with the
idea which some have entertained of their being voluntary.
Reflex actions would more frequently be observed as the
effects of incision during the profound sleep or coma of
chloroform, but for the extraordinary influence of that potent
agent on the motor force and muscular irritability. But
respiration continues as a reflex act during the extreme un-
consciousness, and when it fails as such, may be excited,
though not invariably, by the sudden impression of cold.
I happened to see Mr. Paget, when observing the effects of
inflammation in the wing of a bat, which he had placed
under the power of chloroform, revive the respiratory move-
ments from time to time by simply blowing upon the skin.
But let it be again remarked in connection with what
occurs in sleep, hybernation and coma, that whatever with-
draws the will in the leaking state, predisposes most obviously
to the effectual excitement of reflex actions. In this way
attention may predispose to them. One clay when travelling
by railway with a strong, keen wind blowing in my face, I
found myself breathing in a deep sighing manner. My at-
tention happened to be fully fixed, and had withheld the will
from its due action on the respiratory muscles. The moment
I breathed voluntarily again the impression of the cold lost
its effect. Reverie, in like manner, by abstracting volition,
lends power to the influence of emotion, which will act upon
the person absorbed in thought much as it docs upon those
who lie asleep.
1 have performed a variety of experiments, which all tend
to show the will as an antagonist of various causes of spas-
modic action. I have acted with galvanism on the hyhernant
dormouse, and stirred its muscles with a force which would
SLEEP TO CONVULSIVE AFFECTIONS. 177
not have operated, at least not visibly, in the waking
state. In the same way I have affected the decapitated as
I could not have influenced the perfect, frog. I have
remarked the limb of the human subject to be so contracted
by volition as to resist galvanism. In the headless dragon-
fly I have produced respiratory movements with a galvanic
force which the entire insect could have readily overcome.
1 have made similar observations with respect to temperature.
The impression of cold on the conscious and unconscious is
altogether different ; I have seen the eft run rapidly along a
surface so heated that it would have been convulsed instantly,
but for its striving will.
Illustrations of this kind would have been classed, by
Lord Bacon, under the expressive and convenient head of
" wrestling instances," which, in his own language, " we are
also wont to call instances of predominance. They are such
as point out the predominance of powers compared with each
other, and which of them is the more energetic, and superior,
or more weak and inferior."1 Now, in sleep, the mind cannot
wrestle with, and oppose any cause of convulsion, as it can
in wakefulness ; the body is left altogether unaided, and
impressions play on it as though there were no will ; and we
cannot but conclude, that all kinds of physical irritation, and
all forms of emotional disturbance, must have more power
then. Our safety lies often in the facility with which
we are awakened ; by this, affrighting dreams are shortened ;
by this, the power is brought abruptly into play, whereby
we can control or modify many forms of spasms. But
here let me note a good effect of distressful dreaming in
many sorts of difficult respiration. The patient complains
of the repeated disturbance, and begs an anodyne, little
thinking that he requires the influence of volition, from time
to time, to aid his breathing, and that profound, uninterrupted
sleep would soon merge into dissolution. The dreams which
awaken, indirectly, preserve him.
I have already alluded to the reflex actions which may
1 Novum Organnm.
xxxiv. 12
178 MR. BARLOW ON THE RELATION OF
be occasioned during sleep in paralytic limbs. Paralysis
should certainly be more studied both in light and deep sleep.
Many instructive observations might, I suppose, be made in
that extremely interesting class of cases wherein emotion
acts freely on parts lost almost, or absolutely, to the
influence of the will. "What would be the effect of the
agitation of a dream in that kind of facial paralysis in which
the features are still subservient to expression, though
volition cannot reach them ? In such a case the symmetry
of expression is destroyed in wakefulness ; but in a
dream it might, perchance, be restored from the will
being withdrawn, by the influence of sleep, from con-
trolling the unparalysed half of the countenance. Or,
on the contrary, it might happen that the paralytic parts
would be still the more influenced from being more
irritable, and by consequence more easily acted on than the
opposite.
But we must note the twofold influence of sleep in regard
to the movement of paralysed parts. Whilst dreamful slumber
may unusually distm-b them, placid sleep may have such an
effect in calming the emotions as to relax muscles, which seem
to be invariably contracted in the waking state. A little
girl, five years of age, had partial hemiplegia of the right
side, the face being affected as well as the limbs. The
fingers were invariably flexed in wakefulness, and very
strongly under the influence of emotion, but in sleep they
were perfectly relaxed, and 1 could straighten them with the
greatest readiness. The face, too, looked quite unparalysed
in sleep, though, on awaking, emotion so unequally influenced
the two halves of the countenance, as to make obvious the
paralysis of the right one.
In a hemiplcgic woman whose arm had been long and
severely contracted, the efl'ect of sleep was remarkable. At
a time when, in wakefulness, there v>as such obstinate con-
traction of the forearm and lingers, that the patient could
not straighten them, nor could they be extended for her,
sleep quite dispelled this involuntary motion. \Yakefulness
renewed it directly. Once, whilst examining the limb in
SLEEP TO CONVULSIVE AFFECTION'S. 179
sleep, I partly disturbed the patient, and forthwith there was a
convulsive starting of it.
Since making the former of these observations, I have
learnt that Professor Romberg has remarked contraction of
the flexor muscles of paralysed parts to cease during sleep.
Sometimes it is an object to straighten a rigid or contracted
limb, and to keep it extended; sleep may offer an opportunity
for doing so where we should be foiled in wakefulness.
There is nothing to wonder at in this occasional relaxing
influence of sleep in instances of paralysis ; the like effect of
it has long since been noted by Sir Charles Bell, Sir
Benjamin Brodie, and others in cases of local affections of
the motor nerves.
In instances of a different description, and in which the mind
takes no part in producing the rigidity or convulsive action,
the muscles still act during perfect rest. Dr. Marshall Hall
has mentioned a case in which the paralytic limb was con-
tracted and drawn to the side in time of sleep. Sir Charles
Bell has narrated an example of disease of the brain which oc-
curred to a boy of eleven years of age. There was general
paralysis, yet when he slept the left arm was always raised.
I observed a case of hemiplegia in a girl five years of age.
She was convulsed in her sleep, but the unparalysed parts
were exclusively affected. The disorder could not have
sprung from emotion, for, in the waking state, the paralytic
limbs were contracted with violence by the operation of
the passions, whilst the opposite were under most absolute
control. The effect of sleep, then, varies greatly in cases
of paralysis, and this is one reason for new observation. Well
investigated, it would throw considerable light not only on
paralytic, but convulsive disorders ; these, though seeming
so opposite at first sight, are mutually illustrative to the
highest degree.
A few remarks in reference to treatment arise most
obviously from the preceding outline. Sleep should un-
questionably be watched much oftener than it is, in order
to detect, prevent, give aid in, and combat the effects of,
convulsion. Symptoms which long baffle inquiry, and which
180 MR. BARLOW ON THE RELATION OF
are really imputable to " hidden seizures," as Dr. Marshall
Hall has termed them, can only be accouuted for, in many
instances, by watching sleep. It is an eventful period,
speaking pathologically ; apoplexy, epilepsy, paralysis, and
attacks which lead either to mania or enfeeblement of mind,
all, as we know, may happen then. I observed in one case
that a peculiar, transient, recurrent kind of partial anaesthesia
was produced by sleep.
The patient should always be awakened if convulsions
threaten, or if the sleep be unusually heavy and profound,
or disturbed by harassing and tumultuous dreams. A fit
may be indicated by turgidity of the veins of the head and
neck, by a quivering of the muscles of the face, startings of
the limbs, contraction of the fingers, crowing inspiration, and
a dilated pupil ; but persistent expiratory efforts are espe-
cially alarming, and frequently begin the attack.
Sometimes it will be enough simply to partially arouse the
patient ; but frequently it will be necessary to completely
awaken him, and keep him awake. Assuredly there are
some cases in which sleep and epilepsy are not merely coin-
cident, but absolutely related as cause and effect. Esquirol
narrates an instance of the disorder in which the attack was
uniformly preceded by sleep, to prevent which was to postpone
it always. Heberdcn speaks of another, in which the patient
entreated the bystanders to restrain him from sleeping.
Dr. Hugh Ley mentions a case of laryngismus stridulus, in
which the coming paroxysm was delayed most evidently by
keeping the child awake and amused. Mr. Solly mentions
an epileptic who believed that he could prevent his paroxysms
by inspiring deeply. I well remember watching a patient in
partial epilepsy ; for awhile he strove successfully with the
incipient attack, commanding his breathing, and opposing,
by his volition, the contraction of his hands ; but, at length,
he fell into complete unconsciousness and pitiable contortions.
I have seen many cases in which spasmodic action has been
entirely mastered by efforts of the will.1 In limbs partially
1 I may refer I" a coinimm ic.-il inn made Itv me to I lie ' Lancet' for 1MO,
SLEEP TO CONVULSIVE AFFECTIONS. 181
paralysed, but prone to spasm, I have remarked emotion
and volition to contend together, and now one prevail, and
now the other. A good example of a wrestling instance is
given by Cruveilhier, who speaks of a case of flexion and
rigidity of the lower extremities, which was permanent unless
a great effort at extension was made. But I doubt not that
even epilepsy is far oftener prevented in wakefulness than
we think, by those efforts of the mind which should, by all
means, be encouraged. This is partly to be explained by our
rule over emotion; partly, perhaps, by the effect of attention;
but, most of all, by the command of volition over the respi-
ratory movements. In sleep this is lost to us ; and in that
state we find the truth negatively exemplified, that volition is
not only a directing, but very often a conservative, power.
It is stated amongst the aphorisms of Hippocrates that the
arrest of respiration indicates convulsions. And certainly
the excitement of inspiration hinders them, as Dr. Denman
showed when he suddenly applied cold to the face in cases
of puerperal paroxysm.
In the deep sleep which not uncommonly succeeds to
epilepsy, inspiration may, occasionally, be most advan-
tageously produced by means of sudden and transient cold,
the return of blood from the congested brain being, by this
means, greatly promoted ; and where there is dangerously
and to au essay on "Some of the Relations of Volition to the Physiology
and Pathology of the Spinal Cord" in the 'Medical Gazette' for ISIS,
in which I have more fully entered into the question of the antagonism
between the power of the will and various causes of spasmodic action.
See Professor Volkmann's remarks in 'Midler's Archives' for 1S38, and
a note of Dr. Baly in his translation of Midler's ' Elements of Physiology,'
2d edition, p. 800 ; and Dr. Marshall Hall's second and third memoirs on
the " Nervous System," in the Transactions of the Society. Dr. Holland's
reflections on Sleep, Dreaming, and others, also, in which he refers directly
to Volition, may be consulted with great advantage in respect to several points
on which this paper touches. I would also make reference to some obser-
vations of Mr. Hunter, Mr. Grainger, Dr. William Budd, Dr. Watson,
Dr. West, Dr. Carpenter, Dr. Kirkes, and Mr. Paget, and those which
Dr. Sibsou has published, since the reading of this paper, in the last volume
of the ' Provincial Medical Transactions.'
182 THE RELATION OK SLEET TO CONVULSIVE AFFECTI0N8.
profound coma, it may be necessary to irritate, and even
to rapidly and severely inflame, the skin, so as to preserve
consciousness by pain. The successful treatment of nar-
cotic poisoning suggests much here.
There are some further points respecting the management
of convulsive diseases in time of sleep, to which allusion will
be excused on account of their importance. The sleep of
the epileptic does harm often, both from deficiency and
excess; and there are many cases in which it should, if
possible, be as regularly recurrent as that of plants. The
mind should be calm previous to repose, lest it be hard
to obtain or dreamful ; but its approach is often deferred
by intense anxiety.
The head should be elevated, — but after sleep has come on,
if the patient, from fear of obstinate wakefulness, object to
raise it previous to repose ; states of ana;miamake exceptions
to the rule. Indigestible or immoderate suppers and drastic
purgatives, and anything whatever which may irritate the
sleeper, or produce dreaming, or embarrass his respiration,
should be shunned, of course. Opiates are generally to be
avoided in epilepsy, for they make sleep too profound, or
occasion excitement ; but delirium tremens no more coutra-
indicatcs their use than the incessant motions of the obstinate
chorea which endangers life by exhaustion ; and chloroform
may be found of essential value, when other narcotics have
been tried and have failed.
More indications in reference to treatment might here be
touched upon, but I fear to trespass longeron the indulgent
attention of the Society ; and would only add an expression
of the hope that this small contribution, although very im-
perfect, may be of some service to future inquirers.
ON
FATTY DEGENERATION of the PLACENTA,
AND
THE INFLUENCE OF THIS DISEASE
IN PRODUCING ABORTION, DEATH OF THE FCETUS, II.EM0RRHA0E,
AND PREMATURE LABOUR.
BY
ROBERT BARNES, M.D. (Lond.)
OBSTETRIC SURGEON TO THE WESTERN GENERAL DISPENSARY,
AND LECTURER ON MIDWIFERY.
COMMUNICATKD BY
PROFESSOR MURPHY.
deceived February 19tli. — Head May 13tli, 1851.
Case I. — In October, 1850, Mr. Hum by sent me a
placenta taken from a lady who had been prematurely
delivered. In the sixth mouth of pregnancy, this lady was
seized suddenly, and without pain, with flooding, while walking
in the garden, but not having used any extraordinary
exertion. The flooding stopped on this occasion, and re-
turned without pain or any obvious cause in about three
weeks. This time premature labour followed. The child
presented every sign of having been dead some time before
delivery.
Appearance of the Placenta. — The uterine surface was
studded with fatty masses, varying in size from that of a
bean, to one mass which was as large as a pigeon's egg.
These masses extended inwards into the substance of the
placenta, and the largest occupied the whole thickness, and
was visible on the foetal surface.
184 DK. BARNES ON
Although the difference of structure and consistence
between these masses and the normal placental tissue was
striking, it was difficult to isolate them by dissection. The
placental tissue appeared to have undergone a fatty trans-
formation in the seat of these masses, and not that fatty
tumours had become developed independently. The fatty
masses were traversed like the rest of the placenta, by
branches of the umbilical vessels. Indeed it was obvious
from the dissection, as was subsequently demonstrated by
microscopical analysis, that the fatty masses were consti-
tuted of placental structure variously altered, either by the
simple deposition of fat, or by actual degeneration. They
were of dense structure and firm consistence, of a pale
yellowish colour; the knife used in incising them was
rendered greasy; and portions laid upon paper caused a
greasy stain. No vestige of blood could be seen in them.
They appeared as hard foreign bodies, interspersed in the
softer spongy structure of the healthy placenta.
It was manifest that this diseased condition of the placenta
was the cause of the haemorrhage, of the death of the foetus,
and of the premature labour ; and I shall presently en-
deavour to explain in what manner I conceive these events
were brought about. I deferred publishing any account of
the case until I should receive a report from my friend Dr.
Hassall, upon the minute anatomical structure of these fatty
masses, having forwarded to him specimens for examination.
Dr. Hassall did examine them; but being too much engaged
at the time to make drawings and commit to writing an
account of his observations, preserved specimens until his
leisure should permit him to complete what I required.
Case II. — In December, 1850, Mr. Ilumby sent me
another placenta for inspection, which had been taken from
a patient who had also been delivered prematurely. In this
instance there was no haemorrhage, but labour had come on
suddenly at the seventh month. As in the former case,
the child appeared to have been dead some time before
delivery.
FATTY DEGENERATION OF THE PLACENTA. 185
Appearance of the Placenta. — Nearly one-half of the
uterine surface was thickly studded with fatty masses,
varying in size from that of a pea to that of a walnut.
Adipose matter appeared to be aggregated into firm defined
masses, isolated from the surrounding placental tissue. No
large umbilical vessels could be traced in their substance.
In this respect they differed from the tumours in the first
placenta : possibly the vessels had been obliterated or replaced
by cellular tissue, in consequence of pressure and cessation
of function. The minute structure of the masses in this
case differed, however, in no particular from that of the first:
like them, they were composed of umbilical capillaries and
villi, with the investing chorion in various stages of fatty
deposition and degeneration. In the grosser physical cha-
racters also, the masses found in both placentas entirely
corresponded. In this case, as in the former, the masses
were chiefly seen on the maternal surface of the placenta,
the larger ones penetrating more or less deeply into its
substance ; some even occupying its entire thickness. There
were only two or three small spots in which it could be
perceived that fatty masses were being developed on the
foetal surface. The masses were of solid consistence, and
appeared as hard bodies imbedded in the softer spongy
structure of the healthy placenta.
This second case confirmed me in my opinion as to the
importance of this alteration in the structure of the placenta.
It showed that not only haemorrhage might be occasioned
by it, and hence premature labour ; but also that premature
labour might be excited in consequence of the death of the
foetus, which had, in all probability, been brought about by
the necessarily imperfect performance of the functions of the
placenta. I forwarded portions of this placenta also to
Dr. Hassall, and procured from time to time healthy recent
placentas, that we might be enabled to compare the healthy
and diseased structures.
"While waiting for the drawings of the intimate structure
of these fatty placentas, which Dr. Hassall had undertaken
186 DR. BARNES ON
to prepare for me, I observed in the ' Brit, and For. Med.-
Chir. Rev./ for January, 1851, an account of a case of fatty
degeneration of the placenta by Professor Kiliau. The case,
in its pathological history, nearly resembles the second case
related in this paper ; death of the foetus and premature
labour are correctly ascribed to the placental disease. But
I cannot think it necessary, with reference to the cases I
have observed, to discuss and to refute, as Professor Kilian
does, the possibility of these fatty masses being of post-
mortem production, or the supposition that they are the
result of the conversion of blood-globules into fat. In the
perspicuous statement of the microscopical examination
which follows, Dr. Hassall has, I think, clearly established
the true character and origin of tliis important affection in
the cases which form the subject of this communication.
I have here to mention that I am not acquainted with
any description of fatty degeneration of the placenta, or even
with any account of a case of the disease, excepting Professor
Kiliau's and those recorded in this paper, sufficiently precise
and minute to establish its exact nature and importance.
In the numerous obstetric works I have consulted, 1 find
only the most casual and general allusion to the disease.
The minute pathological changes observed in the placentas,
are accurately described in the following report of Dr. Hassall,
and faithfully delineated in the accompanying drawings.
I transcribe the report :
" I am sorry to perceive that the delay which has occurred
in the preparation of the drawings, illustrative of the general
anatomy of the normal and abnormal placenta, has been the
cause of your being anticipated, although to a slight extent
only, in the publication of your important observations on
that organ; and 1 regret the circumstance the more when
I consider that I am mainly responsible for that delay.
"The pathological changes which occur in the placenta
from fatty deposition ami degeneration, will be more clearly
comprehended if we take, in the firs) place, a brief survey of
the normal structure of thai organ.
"The disease in question, so far as my observations have
FATTY DEGENERATION 01' THE PLACENTA. 187
yet extended, oi-iginates in, and is mainly limited to, the
foetal portion of the placenta; it is this, therefore, that we
shall have to describe more particularly, which, it is to be
remembered, however, constitutes almost the entire sub-
stance and bulk of the organ.
" The placenta is divisible into numerous lobes and lobules
of variable size, and consists of two portions, a maternal and
a foetal.
" The maternal portion is made up of blood-vessels, arteries,
and veins, dilating into sinuses, derived from the mother,
and which are covered externally with a layer of cellular
decidua (see fig. 1). The cellular decidua is usually de-
scribed as enveloping each villus, of which it is enumerated
as forming one of the coats. This description I have not
been able to verify ; it is extremely rare to observe this
membrane in connection with the villi j and I believe that
the tufts of villi are not in union, but merely in apposition
with this layer, which covers and dips down between and
into the lobes and lobules of the placenta.
" The fatal portion consists of the ramifications of the
umbilical vein and arteries enclosed in a layer of chorion.
Each umbilical artery, after numerous divisions, and when
reduced to a certain diameter, gives off consecutively a series
of loops, the last of which terminates in a radicle of the
umbilical vein. The placental villi are either simple or
compound, according as they consist of a single loop, or are
made up of an arterial and venous trunk, with numerous
intervening loops. The plan of development of the
terminal divisions of the blood-vessels constituting the
foetal placenta, is very peculiar, and is not, I believe, gene-
rally recognised. Each vessel is double, that is to say, the
same vascular sheath is divided by a septum into two
channels. This formation is best seen in fragments of
recent placentas which contain blood, and which have been
immersed in a weak solution of common salt, or in injected
preparations.
" A second very great peculiarity is the unusually large
diameter of the capillaries forming the loops of the villi, and
188 DIt. BARNES ON
which is such as to admit two or three rows of Mood-cor-
puscles at a time.
" The walls of the placental blood-vessels, like those of
other vessels of the same diameter occurring elsewhere, are
thickly studded with elongated nuclei, which, in fresh
healthy placentas, are obscured, though not concealed, by
the chorion (fig. 3 a). It is best seen in fragments of
placenta which have been immersed, for a few minutes, in
water, or extremely dilute acetic acid. Such fragments,
viewed with an object-glass magnifying 350 diam. lin.,
present to observation innumerable nuclei ; some of these
belong to the chorion, but others to the vessels beneath.
Skirting the margins of the vessels will be noticed, in par-
ticular, a series of cells of a slightly oval form ; these belong
exclusively to the chorion (fig. 3 a). Iu perfectly fresh
placentas the chorion adheres so firmly to the vessels that it
is difficult to detach it ; when, however, the placenta has
been kept a day or two, it separates readily enough, and in
fragments torn up with needles, the membrane will be found,
in some cases, to be attached to the vessels, and in others to
have become removed (fig. 3 b).
" Such is a very brief outline of the structure of the normal
placenta. In the placenta affected with fatty degeneration,
certain of the lobes, in place of presenting the red spongy
texture of healthy tissue, exhibit a fatty appearance, and are
of a yellow colour, glistening, firm, and exsanguine, while
the remaining lobes present their ordinary characters, at
least to the unaided eye.
" I will now endeavour to determine the nature of the
changes which have ensued in these altered lobes, and
examine both the maternal and foetal portions of the placenta
as contained in them.
"The maternal portion, as already described, consists of
the fibrous walls of the internal blood-vessels, covered on the
outside by cellular decidua. Both these structures presented,
to a great extent, their normal characters; the walls of the
vessels were nucleated, and the cells of the decidua were of
the usual size. The important difference, however, was
FATTY DEGENERATION OF THE PLACENTA. 189
noticed that both vessels and cells were studded over with
numerous minute spherules, some of which appeared to be
upon the surface, but others evidently were contained within
the coats of the vessels, and in the cavities of the cells (fig. 2) .
The maternal portion of the placenta was therefore not free
from disease.
" The fcetal portion of the placenta, as already noticed,
consists of the umbilical vessels and chorion. On placing a
small portion of one of the diseased lobes in water, the first
thing which strikes the observer, is that the tufts of villi
do not expand or float out in the same way as in the healthy
placenta, and on endeavouring to separate the fragments
into its component villi with needles, the extreme brittleness
of the whole structure becomes apparent. Examined with
the half-inch object-glass, the villi are observed to be much
broken up, and darker than usual, especially near their ter-
minations, which reflect a yellowish colour. Viewed with a
glass of 420 diam. lin., a variety of structural changes are
detected.
" 1st. We observe that the villi are thickly studded with
innumerable minute spherules of oil (figs. 4, 5).
"2d. The chorion is much altered; it is thickened, and
destitute of nuclei.
" 3d. The walls of the vessels no longer contain nuclei ;
these having, in all probability, become degenerated into
spherules of oil (fig. 5).
"4th. The spherules of oil are contained, some in the
chorion, some in the walls of the blood-vessels, and many in
the intervals or spaces between these (fig. 5).
" 5th. The cavities of the vessels are almost invariably
free from fatty deposition.
"6th. The vessels are destitute of blood (figs. 4, 5).
" Such was the usual condition of the several component
structures ; sometimes, however, in places, the disease ap-
peared to have progressed still further, and to have produced
almost complete disorganisation and disintegration of tissue.
"Turning our attention to those lobes of the placenta
which, to the eye, present a normal appearance, we detect
190 DR. 1SAR.NES ON
in them manifest evidences of the same destructive changes
in progress; considerable fatty deposition is visible, and the
nuclear structure of the parietes of the blood-vessels and of
the chorion is, to some extent, implicated (fig. 4). In these
portions, the distribution of the oil-molecules coincides
exactly with the course of the blood in the vessels. This
observation shows that the condition of the blood itself is
intimately connected with the origin of the deposit.
" It must not be forgotten, however, that a very small
quantity of fat, in the form of minute spherules, is almost
constantly present in the placenta.
" In order to judge how far the pathological changes in
the placenta resulting from fatty degeneration above given,
accord with those observed by Professor Kilian, I will quote
his description.
" ' Examined with the microscope, the extreme ends of the
vessels of this portion were found to form little knobbed
swellings composed a£ fat-globules, stronglyreflecting the light.
From these ends of the vessels filled with fat droplets closely
packed together, the blood-corpuscles of the placental vessels
were quite absent ; but in proportion as the vessels were
traced back from their terminations, the fat-globules were
progressively replaced by blood- globules, the walls of their
vessels which, at their terminations, were also loaded with
fat, recovering their natural appearance. The remotest
ramifications of the healthy portions of the placenta con-
tinued entirely normal ; and where the yellow portion joined
the coloured, many of the terminating vessels were destitute
of fat ; others contained droplets, but none showed the
dense masses observed at the uterine surface.'
" I will quote another passage conveying Professor Kilian's
remarks on the origin of this disease. 'But it may be
inquired whether this fatty formation occurs during the
healthy conditions of life, and becomes the MUM mortis j
whether it results from decomposition after death, OT whether,
originating during life, it maybe but the expression of other
causes, inducing the degeneration of the ovum, and a
symptom of retrogressive metamorphosis of the placenta.
FATTY DEGENERATION OF THE PLACENTA. 191
On examining the fetus, all parts were found apparently
normal, except a contused state of its head and face, and a
large effusion of blood between the scalp and the cranium ;
so that it might be inferred that the child died from some
cause of pressure on the brain, and the described changes in
the placenta were only the product of decomposition con-
sequent on its death. Against this view, however, many
objections may be urged. There is no fact known of the con-
version of stagnant blood into fat. Virchow and Reinhardt
have only seen the formation of fatty corpuscles within the
colourless blood-corpuscles. The changes which occur in
the terminations of the blood-vessels, or other metamorphosis
after death, authorise no such view. The author, too,
(Professor Kilian) after macerating healthy placentas in
water until approaching putrefaction, never found this obtu-
ration produced, a few droplets here and there being formed
only on the walls of the vessels.' "
Connected with the anatomical facts thus related by Dr.
Hassall, are various physiological, medical, and obstetric con-
siderations of great interest and importance. Some of
these I will endeavour to point out as comprehensively as
possible.
The researches of Rokitansky, Bowman, Handfield Jones,
George Johnson, R. Quain, Paget and others, taken collec-
tively, fully assert the prominent position which fatty degene-
ration is destined to occupy in general pathology. To demon-
strate the existence of a disease in the placenta, an organ
intermediate between the mother and her offspring, similar
in its nature, development, progress, and termination to that
which the observers I have referred to, have shown to be of such
importance, when affecting the liver, kidneys, heart, mus-
cles, vessels, and other structures of the body, cannot be un-
interesting. The demonstration of fatty degeneration in the
placenta, not only supplies a new chapter in the history of
the disease, aiding in the acquisition of a more comprehensive
knowledge of its nature, but it also throws a new light upon
a question of the deepest interest in the study of this and
many other of the most formidable diseases. Long-con-
192 DR. BARNES ON
tinued observation and accurate analysis have established
the hereditary nature of insanity and phthisis ; our acquaint-
ance with fatty degeneration is too recent and too little
advanced to have admitted of any extended investigations
into the transmission of this disease to successive genera-
tions. There exist, therefore, at present few facts from
which any trustworthy conclusion can be drawn. The
occurrence, therefore, of fatty degeneration in the placenta, •
the organ by means of which the embryo derives the ma-
terials for its growth from the mother, and in which the
elements of mother and child are being constantly inter-
changed, affords the strongest presumptive evidence, that
the germs of that disease which pervade the system and
circulate in the blood of the mother, may be directly
transmitted to her offspring.
In support of this view, that the placenta may be the
medium through which the various morbid diatheses may be
propagated from the mother to the embryo, and also as
affording further proof that the placenta is in nowise exempt
from those diseases which affect the permanent organs of the
female, it deserves to be remembered, that the placenta may
be attacked by inflammation and congestion ; that it may be
the seat of the deposition of fibrin, cartilage, bone, and even
cancerous matter ; and the case of a phthisical patient is
related1 in which small crude tubercles were formed on the
external surface of the uterus, under the peritoneum, and
eight or ten on the uterine surface of the placenta.
With regard to the frequency of fatty disease in the
placenta, it is at present difficult to form an accurate opinion.
I am in the habit of minutely examining the placenta on
every opportunity ; and I have not unfrequentl v secu fatty
masses in various stages of growth in placentas expelled at
the full period of gestation. In these cases it is to be pre-
sumed, that the balance of healthy placenta preserved was
sufficient for the development of the foetus. There are cer-
tain physiological considerations which render it probable,
1 M. Hardy, 'Arch. Q&l >le MM,' .hiin 1834,
FATTY DEGENERATION OF THE PLACENTA. 193
that the placenta is especially prone to become the seat of
fatty deposition. The decarbonising function of that
organ is one ; but there are several others which deserve
attention. Pregnancy itself appears to predispose to the
formation of fat. The increased proportion of fibrin in
the blood ; the tendency to albuminous urine ; the con-
stant presence of fat in that secretion ; the secretion of fat
in the breasts; and the observation that a certain amount
of free fat is always present in the healthy placenta,
constitute a series of facts, which, viewed in their relation to
each other, may elucidate those morbid processes which lead
to the production of an excess of fat in the circulating system.
Certainly, the elimination of this material from the economy,
is obstructed by the encroachment on the cavity of the chest,
the pressure upon the liver, kidneys, and other abdominal
organs, and the growing disinclination to exercise, which
attend the progress of gestation.
The observation of fatty degeneration in the placenta pre-
sents another point of interest with reference to the study
of the general pathology of that disease. It furnishes an
example of the rapidity with which it may proceed, which is
capable of close limitation. The placenta being a caducous
organ lasting but a few months, all the pathological changes
observed in it, we know, must have been wrought within a
certain brief period of time. When we find, therefore, that
the disease has proceeded from simple deposition to dege-
neration, and even disintegration of the original tissues in a
placenta expelled at the seventh month of pregnancy, we are
in possession of accurate data by which to form an estimate
of the rapidity with which these changes may occur. No
similar data can be obtained with reference to the like
changes in other organs.
I will not, however, dwell longer upon the general relations
of fatty degeneration of the placenta, as T am anxious to advert
to the practical bearings of the disease on obstetric practice.
The effects that must result, sooner or later, according to
the rate of increase of the morbid alteration of an organ so
essential to the foetus as the placenta, are not difficult to
xxxiv. 13
194 DR. BARNES ON"
understand. In exact proportion as the growth of the
embryo requires a larger and more unimpeded extent of
placental structure, in which its blood may be brought into
multiplied points of contact with the blood of the mother,
large portions of placenta are being gradually rendered use-
less for this purpose ; and the coats of the villi throughout the
remainder are probably undergoing a disorganisation which
must materially impede the performance of their function, of
permitting the interchange of elements between the maternal
and foetal blood. If this conversion of healthy placental
structure proceed at such a ratio as to exceed the normal
increase of healthy placental tissue, a period must arrive
when the healthy portion of placenta will be insufficient
for the production of those changes in the blood of the
foetus which are essential to its growth and life. When
this period arrives, then, the foetus will perish, and prema-
ture labour will follow, — unless, indeed, premature labour
be induced during the life of the foetus by a process to which
I will next advert.
One of the conditions essential to the perfect cohesion of
the placenta to the uterus, is the preservation of the uniform
spongy structure of the placenta. The whole uterine surface
of the placenta must present an equal consistence, so that
every part may permit of equable distension, whether from the
maternal or the foetal circulating system, and be equally
adapted to the opposing surface of the uterus. This condition
is necessary to enable it to preserve this adaptation throughout
the peristaltic movements to which the walls of the uterus
become more and more liable as gestation advances. But
when, as is the case in these examples of fatty tumours in
the placenta, certain parts of the uterine surface are hard
and unyielding, while intervening portions are of a soft and
yielding character, the entire placenta is no longer in a con-
dition to follow the movements of the uterus and preserve
its connections. The hard portions, moreover, in which fat
has occupied the walls of the foetal vessels, and by pressure
obliterated the cavernous structure, no longer maintain any
vascular communication with the uterus. The maternal
FATTY DEGENERATION OF THE PLACENTA. 195
or cavernous portion of the placenta being cither closed up,
or otherwise rendered useless, the channels of communication
with the uterus necessarily disappear. Accordingly, in these
portions no oblique valvular openings, no remains of arteries,
could be discerned, such as usually exist, and such as were
observed on the maternal surface of the more healthy por-
tions of the diseased placentas. The consequence of this
loss of homogeneity of tissue, and cessation of vascular con-
nection with the uterus, is, that when the peristaltic move-
ments of the uterus assume an active character, as they
often do towards the seventh month of pregnancy, or even
earlier, the cohesion between the placenta and the uterus is
soon destroyed at those points where the fatty masses are
largest and hardest. This partial disruption can hardly
occur without involving some separation of the placenta not
diseased, in the immediate proximity of these masses. Haemor-
rhage results ; the effusion of blood and the formation of
coagula excite increased action of the uterus ; further de-
tachment follows ; premature labour is imminent ; and if it
ensue immediately, the child may be born alive. But this
event may not occur on the first appearance of flooding, as
the first case I have related will show. Should it not so
happen, the favorable opportunity for the child will be lost.
That amount of disease which is sufficient to cause partial
detachment of the placenta is scarcely compatible with pro-
longed life of the foetus ; and in all probability, the foetus will
have been cut off from defective nutrition, before a further
detachment and haemorrhage could bring about the expulsion
of the contents of the uterus.
I think the two cases I have related are interesting and
valuable as illustrations of the two processes just described.
In one case, premature labour was induced by partial de-
tachment of the placenta and haemorrhage ; in the other, the
premature labour was the result of the death of the foetus.
Certainly in one, probably in both, the death of the foetus
was occasioned by the gradually increasing obstruction of
the placental circulation.
I have thus referred to the different states of fattv
196 DR. BARNES ON
degeneration in the placenta, entailing different consequences
to mother and embryo, according to the ratio of increase
the disease may have followed. In the first kind, the disease
has made so little advance, that the child may be carried in
safety to the end of the natural term of gestation. In the
second kind, of which I have given two examples, the disease
has proceeded at such a rate as not necessarily to involve
the destruction of the child. At the seventh month the
child is viable, and if, as I have shown, premature labour
should, by any means, be induced before the child has
perished, a living child may be born. I have now to indi-
cate a third kind or degree, which not only places the
mother in danger, but necessarily destroys the embryo. If
the disease proceed so rapidly as to have invaded a large
portion of the placenta in the early months of pregnancy,
it may be the immediate cause of abortion.
The various causes of abortion usually enumerated by
systematic authors, are mostly insufficient to account for the
event. I believe there is a growing disposition to attribute
to diseases of the ovum the first place; and those who are
in the habit of examining the ova of women said to have
aborted in consequence of injuries, mental emotions, habit
or other causes assigned to the mother, will, perhaps, be
disposed to admit, that such ova exliibit, for the most part,
appearances of disease which deserve a large share of atten-
tion in determining the cause of the abortion. Observation
inclines me to conclude that disease of the ovum mostly
precedes its detachment from the uterus; and perhaps future
experience will show that fatty deposition is a disease to
which the ovum is particularly obnoxious.
As a cause of haemorrhage before delivery, this disease of
the placenta is especially deserving of consideration, When
this even! occurs in the course of pregnancy, it is usual to
infer that the placenta has been in part, or wholly, detached.
When the placenta has been attached to the cervix uteri,
the hemorrhage is easily explained ; but when this is not
the ease, then I would hazard the opinion that the detach-
ment was preceded by disease of the placenta.
FATTY DEGENERATION OF THE PLACENTA. 197
With regard to the treatment or obstetric management
of these cases, I wish to offer a few observations. There
arc few conclusions which have acquired a more settled
possession of the minds of obstetric practitioners than this ;
namely, that patients are liable to a recurrence of affections
in future labours similar in character to those which had
occurred in former labours. Consequently when a par-
ticular anomaly or disease has occurred before, and especially
more than once, to place the mother or her offspring in
peril, it is an established rule to endeavour, in subsequent
pregnancies, to anticipate the expected unfavorable result
by timely interference. As a striking illustration of this
recurrent tendency of some disease of the placenta, I am
tempted to quote the following case : —
In 1817, I saw a placenta exhibited to the Pathological
Society, by Dr. Ramsbotham.1 It was enormously hyper-
trophied, but did not appear to consist of more than ordinary
placental tissue. The patient from whom it was taken had
lost six children successively, which had all been expelled
putrid. In each instance the placenta had been hyper-
trophied, adherent, and generally contained indurated masses
of lymph. On her being a seventh time pregnant, it was
deemed expedient to induce premature labour with the view
of saving the child. The attempt was not successful : the
child gasped heavily two or three times, and died. I
entertain little doubt that the fatty degeneration of the
placenta is a disease peculiarly apt to recur in successive
pregnancies, and to blight the fruit of successive conceptions.
I believe, therefore, that the rule I have referred to finds
an appropriate application in this case. When it has been
observed that the embryo has been lost in one or more
pregnancies, in consequence of this disease, it must be a
matter for serious consideration whether the induction of
premature labour should not be recommended in a future
pregnancy.
Many other points having more or less bearing upon this
' Transactions of the Pathological Society, 1847-8.
l'J8 DR. BARNES ON
subject present themselves ; but I am anxious that this paper
should not be extended to an improper length ; and that its
more practical features should not be overlaid by speculations.
In concluding, I cannot but express my sense of the many
imperfections of this paper. But however imperfect, I am
not without hope, that this account will be accepted as a
useful contribution in extending the knowledge of an im-
portant subject in general pathology; and in directing atten-
tion to a source of danger to mother and child, comparatively
unnoticed in obstetric practice.
APPENDIX.
Since the foregoing paper was submitted to the Society, I
have, through the kindness of Mr. Bartlett, of Notting-hill,
been put in possession of the following case, illustrative of a
new feature in the history of granular deposit and degene-
ration of the placenta.
A lady, about three months and a half pregnant, was
riding over a very rough road in a dog - cart j she was
much shaken ; and making a false step in getting out, she
Buffered further succussion. Symptoms indicating the death
of the foetus followed, but miscarriage did not ensue. She
went on to what she calculated to be the full term of ges-
tation before labour took place. The ovum was expelled
entire; it was found that the embryo had attained the
development only of the fourth month; there was no sign
of putrefaction. The placenta was an inch in thickness,
nodulated in parts, universally film in texture, and of a
yellow ish-white colour. It had undergone general granular
metamorphosis. The entire ovum has been preserved in
spirit for some months; but the adipose character of the
placenta was remarked by Mr. Bartlett in the recent state.
Portions of it have been submitted to microscopical exami-
nation by l>r. Ilassall and myself, and appearances identical
in character with those described in the placentas of the two
cases related in my former communication have been ob-
FATTY DEFENERATION OK THE PLACENTA.
1<J9
served; the main difference being, that in this instance every
part of the organ is affected.
There can be little doubt that the foetus really perished
in consequence of the succussiou the lady experienced in
the early period of pregnancy. Whether the ovum had been
previously affected with a disposition to granular degenera-
tion, or any other disease, must be a matter of conjecture
only. In all probability the granular metamorphosis of the
placenta, if it did not take its rise at that date, was, at all
events, completed subsequently to the death of the foetus.
During this process of conversion, the placenta probably
preserved its connection with the uterus. One singular pur-
pose it evidently fulfilled, was the preservation of the ovum
from putrefaction, and its retention in the womb for some
months after the death of the foetus.
Authors have recorded cases in which the placenta has
been retained for a lengthened period after delivery, without
giving rise to those symptoms which usually attend putre-
faction or the presence of a foreign body in the uterus.
Saxtorph even says, "I have reason to believe that a placenta,
which is entire and uninjured, enclosed in the uterus, ad-
herent to it, and shut out from access of air, never becomes
putrid."
In many of these cases it is highly probable that granular
metamorphosis is the conservative process.
In connection with the present case, I am desirous of
defining the meaning I wish to attach to the terms " fatty
deposition" and "fatty degeneration," more especially as they
are apt to convey different ideas to different pathologists.
Fat, properly so called, is a normal organised structure,
consisting of blood-vessels and cells, the cavities of which
contain oily matter. This, like other organised structures, is
subject to various lesions, such as hypertrophy and atrophy,
or degeneration. It is to this latter condition, as affecting
the organised adipose tissues, that the term " fatty degene-
ration" ought in strictness to be confined. This, the true
fatty degeneration, differs entirely from that affection of the
200 DR. BARNES ON FATTY DEGENERATION.
placenta which I have, ill my first communication, brought
under the notice of the Society. In this affection of the
placenta there is no formation of fat, but deposit of oil in
the form of minute granules or spherules, and consecutive
degeneration of the structures in which the oil is deposited.
" Granular oily deposit in, and consecutive degeneration of,
the proper tissues of the placenta," -would be a more correct
and precise expression to indicate the nature of the changes
which that organ undergoes in consequence of the affection
which, for the sake of brevity, and uniformity with others,
I have denominated " fatty degeneration of the placenta."
In its anatomical characters it corresponds with that affec-
tion of the liver and kidney to which the term " fatty dege-
neration" has been generally applied.
This distinction between true fatty degeneration and
granular deposit, with accompanying degeneration, is im-
portant to bear in mind ; it has been pointed out by several
recent pathologists. By many the term "fatty deposit" is
applied to the abnormal development of true fat; and "fatty
degeneration" to the deposit of oil and degeneration of
structure which occur in the liver, kidney, &c. Employed
in the above sense, it is obvious that these terms arc in-
accurate.
The granular oily and disorganising affection of the pla-
centa may manifest itself under very different conditions : —
1st. It may, no doubt, occur during life as the result of
the transformation of fibrin or albumen effused through in-
flammation. We have analogous examples in the change
which clots of blood, fibrin, 8ec, undergo in other organs of
the economy. I have examined a placenta in which osseous
matter, fibrin, and granular degeneration were all observed ;
but I was unable, in this instance, to determine whether ox
not the granular degeneration was the result of changes
effected in the bony matter, and fibrin previously effused;
The converse sequence of events may hereafter be observed.
It is possible that the coats of the umbilical vessels may be
so weakened by granular degeneration, at a period when
blood is stdl circulating in them, thai rupture and hiemor-
FATTY DEGENERATION OF THE PLACENTA. 201
rhage nlay ensue. This may be one cause of placental
apoplexy, resembling that form of cerebral apoplexy de-
scribed by Mr. Paget as occurring as a consequence of gra-
nular degeneration of the capillaries of the brain.
2dly. It may originate in functional derangement either
in the placenta or in remote organs, and apart from organic
lesion. I believe the two cases which form the subject of
the first communication must be referred to this head. It
would appear that organs having a decarbonising function to
perform, — as the Uver, kidney, and placenta, — are especially
prone to suffer granular oily degeneration.1
3dly. It may occur as a post-mortem change, and re-
semble the metamorphosis of muscular tissue into oil, and
the formation of adipocire. Of this form, the case recorded
in this Appendix offers a striking example. Although of less
importance iu relation to obstetric practice, it is still not
without pathological interest to establish the fact, that gra-
nular metamorphosis may take place in the placenta while
retained in the living womb. — May 24, 1851.
1 Dr. Mackenzie brought me (May 29th) a placenta quite fresh, healthy-
looking, of average size. It had been expelled at full period ; the child was
living; the mother had enjoyed good health throughout gestation. Ex-
tending over about half the fcetal surface, under the membranes, there is a
layer of a glistening yellowish-white substance, exactly resembling true fat.
On making a section, this layer was found to be in parts nearly half an inch
thick. In colour and firmness it offers a remarkable contrast with the
healthy placental tissue. It may be separated into two or three lamina?
but is intimately adherent to the proper placental structure. This fatty-
looking substance was examined while quite recent with Dr. Hassall. The
basis of it was found to be fibrin ; it showed obscure fibrillation, but no
organic structure. From whatever part a section is taken, innumerable
spherules of oil are observed in it. This specimen offers a clear example of
an effusion of fibrin in the placenta uudergoing granular degeneration.
13*
202 EXPLANATION OF PLATE.
PLATE I.
Fig. 1. — Normal Placenta.
Portion of the maternal placenta.
a. Wall of cell.
b. Cells of decidua.
Magnified 420 times.
Fig. 2. — Abnormal Placenta.
Portion of maternal placenta affected with fatty degeneration.
a. Wall of blood-vessel.
b. Cells of decidua.
Magnified 420 times.
204 EXPLANATION OF PLATE.
PLATE II.
Fig. 3. — Normal Placenta.
Portions of a villus.
a. Vessel with its investing chorion.
b. The same deprived of its chorion.
c. Chorion detached, showing its cellular formation.
Magnified 420 times.
Fig. 4. — Abnormal Placenta.
Villi affected with fatty degeneration in an early stage.
A. Vessels invested with chorion.
b. Vessels denuded of chorion.
Magnified 220 diameters.
FlG. 5. — Abnormal Placenta.
Portions of a villus affected with fatty degeneration.
a and b. Branches partially denuded of their investing chorion, and
showing much fatty deposition in (he form of minute
spherules.
c. A blood-vessel entirely deprived of its chorion,
Magnified 420 diameters.
'
ON SOME
SECONDARY PHYSIOLOGICAL EFFECTS
PRODUCED BY
ATMOSPHERIC ELECTRICITY.
C. F. SCIIONBEIN,
PROFESSOR OF CHEMISTRY AT B.iSLK, ETC., ETC.
COMMUNICATED BY
M. FARADAY, D.C.L., F.R.S.,
PROFESSOR OF CHEMISTRY AT THE ROYAL INSTITUTION,
HONORARY FELLOW OF THE MEDICAL AND CHI KURGICAI. SOCIETY.
Received March ?I]i.— Read June S4th, 1851.
As artificially excited Electricity produces some very
striking effects upon the animal system, so it has heen very
often supposed that Atmospheric Electricity also exerts a
powerful influence on living beings in general, and on the
human body in particular.
Although much has been said and written on this supposed
influence, yet I am afraid that the best of it will not reach
beyond the limits of conjecture; and most of it will fall,
not only within the circle of "doubtful truths," but within
the larger compass of evident errors.
If a chemist may be allowed to give his opinion on a
physiological subject, I should venture to say, that the phy-
siological importance of electricity has, upon the whole,
been much exaggerated, that agent, in comparison to heat
and light, acting but an inferior part in the economy of
organised beings.
For more than one reason, it is not, however, my inten-
tion to enter here into the entire details of so difficult a
206 M. SCHONBEIN ON SOME EFFECTS OF
subject; and I therefore shall confine myself to pointing out
some indirect effects of electricity, which, in my opinion,
are of peculiar interest both to the physician and to the
physiologist.
Philosophers endeavour to distinguish between the im-
mediate and the indirect effects of any cause, and they are
assuredly very right in doing so; but, in many cases, it is
very difficult, or quite impossible, to make the distinction.
As to electricity, it seems as if it were capable of acting
directly upon all the organs of sensation, upon that of
smell, &c.
Concerning the cause of the peculiar sensation apparently
excited by electricity in the olfactory nerves, it may now be
considered as a settled point, that it is not electricity itself
that produces, what has often been called, the electrical
smell, but that it is the peculiar gaseous matter, which I have
named ozone, and shown to be formed out of oxygen, wheu
subjected to electrical influences.
The most striking proof of the correctness of my state-
ment, is the fact, that chemically pure oxygen, or atmo-
spheric ail-, when enclosed within a tube or small bottle, and
exposed to the action of electrical sparks, becomes ozonifcrous,
i. e., permanently assumes the odour perceived near electrical
points, or in the neighbourhood of electrical batteries at the
time of their discharge, or at places which happen to be struck
by lightning, or near dry glass plates when rubbed iu
atmospheric air, or at the positive electrodes, when water is
electrolysing, or, also, when moist ratified oxygen, or atmo-
spheric air, at the common temperature, is kept in contael
with phosphorus. There cannot, therefore, any longer In- a
question regarding a truly electrical smell, /'. <•., whether
electricity immediately affects the olfactory nerves.
As to the sour taste which is perceived when elec-
trical sparks arc caused to pass, cither from negatively- or
positively-charged conductors, to the tongue, it may also be
considered as a matter of certainty, that it is not an imme-
diate effect of electricity, but is due to some nitric acid;
which, under electrical influence, is formed out of the eon-
ATMOSPHERIC ELECTRICITY. 207
stitueut parts of the atmospheric air, through which the
electrical sparks happen to pass.
The correctness of this statement is proved, in the first
place, by Cavendish's experiment, or, what comes to the
same, by the fact that litmus paper becomes red, or a band
of filtering paper, when impregnated with a solution of
potash, becomes nitriferous, if they be for a certain time
exposed to the action of electrical sparks passing through
atmospheric air.
For these reasons, we may safely assert that electricity
would affect neither the nose nor the tongue, if atmospheric
air did not happen to contain oxygen and nitrogen ; though,
to my knowledge, this has not yet been experimentally
demonstrated.
As to the phenomena of sound and light, so frequently
perceived by our ear and eye during electrical discharges,
there can be hardly any doubt that electricity lias nothing
to do with them directly, and that they are due to the
vibrations into which the particles of air, &c, happen to be
thrown by the electrical discharges.
Whether the best known and most peculiar sensations
called forth in the nerves of touch (the electrical shock in
all its various degrees), are to be considered as a primitive
effect of electicity, I am not prepared to say ; it is, however,
very possible that the proximate cause even of that physio-
logical phenomenon, may be something different from elec-
tricity, and that this agent, as such, may have no power of
acting directly upon any organ of sensation.
Before proceeding farther, I may, perhaps, be allowed to
draw the attention of my medical hearers to a fact, which,
in relation to the question before us, is worthy of their most
attentive consideration.
All the effects called electrical, such as the chemical com-
bination, or the separation of elementary bodies, the gene-
ration of heat, light, and magnetism, the contraction of
muscles, &c, are not produced by what is called statical
electricity. These phenomena are only called forth when
the state of electrical antagonism, excited in some way or
208 M. SCHONBETN ON SOME EFFECTS OF
other, in ponderable matters, is in the act of disappearing,
or, as it is usually expressed, when both the electricities are
uniting.
Of the effects produced, either by positive or negative
electricity, when in their tensional condition, we know
nothing, if we except their inductive actions.
After having made these introductory remarks, I think
we are fully prepared to enter into the details of our prin-
cipal subject. My own experiments, and those of De la
Rive, Marignac, Berzclius, Erdmann, and Marchand, have,
I think, satisfactorily demonstrated, that pure or atmospheric
oxygen, on being exposed to the action of electrical sparks,
is transformed into that odoriferous matter which the eminent
philosophers mentioned, have declared to be nothing but an
allotropic modification of common oxygen ; whilst I have
hitherto been inclined to consider it as a peculiar peroxide
of hydrogen, being, in many respects, similar to Thenard's
oxygenated water. But I will not conceal from my hearers,
that the results of the researches I have of late instituted,
with a view of settling the question of the chemical nature
of ozone, are rather in favour of De la Rive's and Berzelius'
views than of my own opinion ; but, notwithstanding, I do
not yet venture to pronounce my final judgment upon the
subject. As to the point, however, with which we arc now
occupied, it luckily matters very little winch of those
divergent opinions may be correct, for we have, at present,
to deal with the effects only, and not with the nature of
ozone.
As for the chemical character of this enigmatical body,
we may say that it is the most powerful oxidising agent ue
as yet know of, transforming, in the cold, even silver into
the peroxide of that metal, iodine into iodic acid, nitrogen
(a strong base being present) into nitric acid, the ''-oils" acids
into " -ic" acids, the " -itcs" salts into " -ates" salts, the
metallic Bulphurets into sulphates. Ozone destroys, instan-
taneously, sulphuretted, aeleniuretted, phosphoretted, iodu<
retted, arseniurctted, and stibiurcttcd hydrogen, oxidising
their con -til unit parts; it eliminates iodine from a number
ATMOSPHERIC ELECTRICITY. 209
of iodides ; it changes the yellow prussiate of potash into
the red cyanide, precipitates from the salts of the protoxide
of manganese their base, in the shape of wad or hydrate of
peroxide of manganese, &c.
Ozone also acts powerfully upon most organic matters, in
consequence of which, like chlorine, it discharges the colour
of the organic pigments, and is rapidly taken up by a variety
of vegetable and animal substances, such as albumen, casein,
fibrin, glue, blood, starch, vegetable fibrous matters, &c.
Ozone possesses an eminent electro-motive power, being
similar to that enjoyed by chlorine, bromine, iodine, and a
number of metallic peroxides. But what must make ozone
most interesting both to the physician and physiologist, are
the physiological effects produced by this subtle agent upon
the animal system. These effects are, as we shall presently
see, very similar to those of chlorine and bromine.
When I began my researches on the chemical generation
of ozone about ten years ago, I frequently inhaled strongly
ozonised air, and the consequence was a really painful
affection of the chest, a sort of asthma, connected with a
violent cough, which forced me to discontinue, for a time,
my investigations.
I do not doubt, therefore, for an instant, but that pure
ozone, in spite of its being (according to De la Rive and
Berzelius) nothing but allotropised oxygen, would act as a
most powerful poison, and would quickly destroy the strongest
animal life, if exposed to its action. At least, I saw that
mice, when placed in strongly ozonised air, died in a very
short time.
The facts just mentioned render it, I think, quite certain
that ozone (perhaps on account of its exalted oxidising
powers) is a poisonous substance capable of producing, even
in minute doses, deleterious effects upon the system when
introduced into the lungs, — effects very like those caused by
chlorine or bromine.
If by some natural cause, chlorine, for instance, should
happen to be thrown into, or be formed within, the atmo-
sphere, at different times in different quantities, what chemist
210 M. SCHONBEIN ON SOME EFFECTS OF
or physiologist could, for a moment, doubt that such atmo-
spheric chlorine would produce chemical aud physiological
effects proportional, as to their amount, to the quantity of
the chlorine happening to exist in the atmospheric air at
those times?
As a fact, certainly, no such chlorification of the atmo-
sphere takes place ; but, in consequence of electrical dis-
charges continually going on in the atmosphere, ozone, a
chlorine-like substance, is incessantly formed there out of
atmospheric oxygen. My ozonometric observations show-
that the quantity of ozone present in the atmosphere at the
same place, varies at different times, bearing, very likely,
some ratio to the amount of the electrical discharges taking
place at a given time, and also depending, in some measure,
upon the direction of the currents of air.
If, at given periods and places, comparatively large quan-
tities of ozone happen to be formed, and, for some time, in-
haled, I think we have as little reason to wonder at the
sensitive mucous membranes becoming then irritated or
inflamed, as we have to be surprised at seeing paste of starch
containing some iodide of potassium turned blue, after
having been exposed, for some time, to the action of that
ozoniferous air. After ascertaining the identity of the ozone
produced, by means of phosphorus, out of common or atmo-
spheric oxygen, with that produced by electrical sparks
passing through the same sort of oxygen ; and, farther, after
finding out that the ozone, which was chemically produced,
acted powerfully and injuriously upon the system, and after
convincing myself, at last, t lint there arc always appreciable,
though varying, quantities of ozone to be met with in the
atmosphere, I could not help conjecturing that that ozoni-
ferous atmosphere would produce, upon tin' animal consti-
tution, effects, lesser or greater, according to the quantity of
ozone existing in the air for the time being. 1 hardly need
say that I suspected certain catarrhal affections to be the
principal physiological effects brought about by atmospheric
ozone. To test, as far as my limited means enabled DM,
the correctness of this view, I induced, some years ago,
ATMOSPHERIC ELECTRICITY. 211
several physicians of Basle to compare with me the lists of
their catarrhal patients with the tables of my atmosphero-
ozonometric observations, and we could not help being struck
at the coincidence of what I called my blue days, with an
unusual number of catarrhal cases. I am, of course, very
far from thinking that the matter is decided by those in-
sulated observations, for we cannot arrive at certainty, unless
we multiply these comparative observations. It seems,
therefore, to me to be highly desirable that physicians and
physiologists should, in many different places, and under
a variety of circumstances, make comparable atmosphero-
ozonometric observations,1 making them simultaneously, with
the observations on the frequency of catarrhal affections, &c.
I hardly need remark, that the temperature and moisture
of the atmosphere, the winds and their directions, &c,
should not be left unnoticed.
That very minute quantities of certain substances have
the power of acting most energetically upon the system, is a
well-known fact, and we have good reason to suspect that,
now and then, poisonous matters are spread through our
atmosphere ; but, to my knowledge, no such matter has as
yet been found there with satisfactory certainty. Now, as
I cannot entertain any doubt that ozone is a regular con-
stituent part of free atmospheric air, it seems to me that
this substance yields, as it were, a handle, which ought to
be laid hold of for instituting researches on the terra incog-
nita of miasmatic bodies. I therefore recommend the
subject to the attention of physicians and physiologists.
I shall proceed in my attempt to show that the electrical
condition of the atmosphere is most likely intimately con-
1 Mr. Biirgy, bookbinder, of Basle, makes ozonometers according to my
directions, for a few shillings a piece. Such an ozonometer consists of
a box holding bands of ozone test-paper, bound up into thirteen packets;
twelve of these packets contain sixty bauds each, and one thirty only; these
are calculated for making two observations a day, during twelve months.
A chromatic scale and instructions for using the ozonometer are added.
Mr. Newman, the instrument maker in Regent-street, will prepare the same
test-paper.
212 M. SCHONBE1N ON SOME EFFECTS OF
nccted with another subject, also highly important in a
physiological point of view.
ON MIASMATIC SUBSTANCES.
By miasmatic substances I understand gaseous or vapour-
ous matters which prove deleterious to the system, if inhaled
even with large volumes of air ; such poisons are produced
and thrown into the atmosphere either by purely chemical,
or physical, or physiologically chemical actions, taking place
within the earth, or upon its surface, in stagnant or moving
waters, or in the atmosphere itself.
It is well known that we may artificially produce a
number of gaseous inorganic substances, minute quantities of
which have the power of poisoning atmospheric air and of
making it entirely unfit to sustain animal life. Sulphuretted,
selcniuretted, phosphorctted, arseniuretted, and stibiuretted
hydrogen are examples. Those gases, being distinguished
by a high degree of oxidability, owe, perhaps, their poisonous
character to that chemical property. There is another set
of gaseous or vaporous bodies, minute quantities of which
also act energetically upon the auimal system, and which
may, in some respects, be considered as the chemical antipodes
and antidotes to the gases before mentioned, instantaneously
destroying the latter and being highly oxidising agents.
Such substances are — ozone, chlorine, bromine, and iodine,
the chemical, voltaic, and physiological properties of which,
in many respects, closely resemble each other.
As to the first set of the gaseous matters named, none of
them, sulphuretted ami perhaps phosphorctted hydrogen
excepted, arc produced by a natural cause and thrown into
the atmosphere. And even those two gases arc engendered
in sueli very iiiiuufe quantities, that with the exception of a
few localities, they cannot exert any general influence upon
animal life.
Of the second set there is certainly one, which inappreci-
able quantities is met witli in the atmosphere, namely, ozone.
Hut there exists an inexhaustible source from which mias-
ATMOSPHERIC ELECTRICITY. 213
matic substances arc abundantly and unremittingly flowing
into tbe atmospberc, and that source is the infinite number
of plants and animals daily and hourly dying away within
and upon the earth, in the seas and other waters, and even
in the atmosphere. An immense quantity of organic matter
constituting those vegetable and animal substances, so
soon as life has departed from them, undergoes a variety of
chemical changes, in consequence of which carbonic acid,
ammonia, in many instances carburetted, sulphuretted, and
phosphoretted hydrogen, are produced. But besides these
compounds which are sent into the atmosphere, a number
of gaseous substances are formed whose chemical nature is,
as yet, entirely unknown. Of these matters we have, however,
some reason to admit that if mixed up even with large
quantities of atmospheric air and introduced into the lungs,
they produce very deleterious effects upon the system.
If we are allowed to admit that such deleterious gases
are disengaged from putrefying organic matters, we shall also,
I think, be permitted to consider putrefaction as one of the
principal causes of the pollution of the atmosphere by mias-
matic substances.
If we consider that the putrefaction of organic matters is
constantly going on, on almost every point of our globe, it
can hardly fail that in the process of time, the miasmatic
gases, small as their absolute quantity may be with reference
to the immense bulk of the atmosphere, would accumulate
so much, as to render the latter poisonous and unfit for
sustaining animal life, if nature had not contrived some
general arrangement for destroying those miasmatic sub-
stances again.
The question now arises, what means nature employs
for arriving at that end.
I am inclined to believe that the ozone, which is formed
under the influence of atmospheric electricity, amongst other
functions, performs that work of destruction, so important to
animal life : and the reasons that make me entertain sucb a
notion are the following: —
Ozone, as already mentioned, is an agent of high oxidising
xxxiv. 14
214 M. BCBONBEIH ON SOME EFFECTS OF
power, acting even in the cold not only upon most of the
inorganic oxidable matters, but also upon almost all organic
substances, and changing their chemical constitution, con-
jointly with their physiological properties.
With the view of testing the destructive power of arti-
ficially prepared ozone upon the miasmatic gases, disengaged
from putrefying animal matters, I suspended, within a
bottle holding about sixty litres, a piece of flesh, which was
in a high state of putrefaction, and weighing about four
ounces. After the flesh had remained for one minute only
in the vessel, its atmospheric air was so strongly charged
with the flesh miasma as to exhibit a most fetid and nau-
seous odour.
_ To produce ozone, I put into the bottom of the miasmatiscd
bottle a piece of phosphorus, about one inch long, covering
half its bulk with water, and exposing the whole to a tem-
perature of 18 — 20° C. For comparison's sake, another
bottle holding pure atmospheric air was provided with
phosphorus and water to generate ozone. After a few
minutes, I could detect, by means of my test-paper, the
presence of ozone in the last vessel, whilst in the miasmatic
bottle, no ozone could be observed, but still the fetid odour
was perceived. After the lapse of about twelve minutes,
however, the fetid smell had entirely been destroyed ; free
ozone then made its appearance.
From these facts I draw the conclusion, that the first
portions of the ozone which was produced in the miasmatic
bottle, were employed for destroying the miasma, /. e. oxidi-
sing its constituent parts, free ozone only making its
appearance when the last particle of the miasmatic gas had
been destroyed.
The power of ozone to destroy the miasma disengaged
from putrid flesh, was exhibited in a still more striking
manner by the following means : — The air of a bottle
holding sixty litres was so strongly ozonised, as almost
instantaneously to colour dark blue the moist teat-papeTj on
its being introduced into the vessel. The phoaphonu «;>s
then removed, and the bottle cleaned with water ; a piece of
ATMOSPHERIC ELECTRICITY. 215
strongly putrid flesh, weighing about four ounces, was intro-
duced into the ozoniferous vessel, and it could remain
therein for fully nine hours before the ambient air assumed
the slightest fetid odour. During that space of time, from
half-hour to half-hour, I tested the air of the bottle, and
found, indeed, its ozone continually diminishing ; but as long
as the test paper indicated the presence of free ozone, the
most delicate nose could not perceive the slightest fetid smell
within the bottle. So soon, however, as the test-paper was
no longer acted upon, the nauseous odour began to make its
appearance.
From these experiments we learn that all the miasmatic
substances which were produced by the putrid flesh, in the
course of nine hours, were completely destroyed by the
ozone contained in the bottle of sixty litres' capacity.
Now, if we admit that the disengagement of the miasmatic
matters were uniform during the course of the nine hours,
we are allowed to conclude that those four ounces of putrid
flesh would have miasmatised 9 + 60=540 bottles, or 32,400
litres of air just as strongly as 60 litres of air were impreg-
nated with miasma, within a minute, by the same four ounces
of flesh.
But what was the weight of the ozone that disinfected
32,400 litres of such fetid air, or destroyed the miasma, which
was emitted during nine hours by the four ounces of the
putrid flesh ? According to my former experiments, 60 litres
of air being as strongly as possible ozonised, are capable of
transforming about 87 milligrammes of silver into the pci'-
oxide of that metal, which requires 13 milligrammes of
oxygen. Whether ozone be an allotropic modification of
common oxygen, or whether it be a peroxide of hydrogen,
it is certain that the 13 milligrammes of chemically-excited
oxygen which was contained in the ozonised air of the bottle,
and was capable of transforming 87 milligrammes of silver
into the peroxide, destroyed by oxydation the miasma, which
in nine hours was disengaged from the putrid flesh.
Whatever the chemical nature of that miasma may have
216 M. SCHONBEIN ON SOME EFFECTS OK
been, we are, at any rate, allowed to assume that its weight
must have been proportional to the quantity of ozone by
which it was destroyed. Now, the quantity of ozone which
did that work having been so very minute, the weight of the
miasmatic substance destroyed by it cannot have been much
larger.
To convey to my hearers a still more distinct idea of the
extreme minuteness of the quantities which are concerned
in the miasmatic experiments mentioned, I will give some
further data.
Sixty litres of atmospheric air weigh about 78,000 milli-
grammes, and contain, if strongly ozonised, (by means of
phosphorus) about 13 milligrammes of active oxygen, i. e.,
5555 of ozone ; from whence, and from the experiments
before mentioned, it follows that atmospheric air, containing
but ^ of ozone, has the power of disinfecting 510 times its
own volume of air, which is as strongly loaded with miasma
as GO litres of air become by four ounces of highly putrid
flesh within a minute : or what comes to the same, atmos-
pheric air, containing but 55,5555 of ozone, is able to disinfect
its own volume of such miasmatic air.
From these statements it appears, that in miasmatic
substances, though still affecting very strongly the sense of
smell, we have to deal with infinitesimal quantities of matter;
and it follows farther, that extremely minute quantities of
ozone are required to be formed in the atmosphere, in order
to destroy the oxidable miasmatic bodies thrown into it by
putrefying organic matters, those miasmata making up (as
to quantity) but a very small portion of the rest of the pro-
duct of spontaneous putrefaction.
That ozone occurs in atmospheric air, is a natural conse-
quence of the formation of that principle by electrical
discharges, acting on atmospheric oxygen; and that ozone is
present in the atmosphere, can directly be proved by means
of my test-paper.
We may therefore conclude, that the electrical discharges,
constantly taking place iii different parts of the atmosphere,
and eng; adoring ozone, indirectly purify it from the oxidable
ATMOSPHERIC ELECTRICITY. 217
miasmatic gaseous matters with which it happens to be
continually contaminated, and maintain it in that condition
which is compatible with the sustenance of animal life.
By means of atmospheric electricity, nature has, as I think,
established a process, through which she arrives on a large
scale at the same end, which we try to get at in a small
way by chlorine fumigations ; or to express myself more
distinctly, atmospheric ozone is continually produced for the
purification of the atmospheric ocean, which is incessantly
infected by miasmatic gases, just as chlorine may be pro-
duced for the disinfection of small volumes of air contaiuing
miasmata.
And as nature so well knows how to arrive by simple
means at a variety of ends, so in this instance. For if the
oxidable miasmata be destroyed by atmospheric ozone, which
itself is a miasmatic principle, that ozone, vice versa, also
suffers destruction by those miasmatic matters ; this is one
of the reasons why atmospheric ozone, although it is con-
tinually engendered, cannot, in general at least, accumulate
in the atmosphere to an extent which is dangerous to animal
life.
It is a very old popular opinion, that thunderstorms are
capable of purifying the atmosphere ; and I think there are
some grounds for entertaining that notion.
As we now know, that during a thunderstorm compara-
tively large quantities of ozone are formed, we can easily
conceive in what manner such a purification may be brought
about. The deterioration of atmospheric air which is sup-
posed to take place in the hot season, may possibly consist
only in an accumulation of miasmatic gases (principally
resulting from the putrefaction of organic matters) in the
lower regions of the atmosphere; and the purification of
the air can be effected only by the destruction of those
miasmatic gases. Now, as ozone is abundantly produced by
thunderstorms' that principle will act like chlorine, and will
1 I must not omit to mcutiou here au interesting observation made by
the excellent Swiss engineer, Mr. Bncbwalder, who communicated it to me.
This gentleman, having for years been engaged in surveying our Alps, had
218 M, B0BONBE1N OH SOME EPFECTS OF
purify tlie air in which those electrical phenomena take
place.
It is possible and even probable, that sometimes (under
given circumstances and in certain localities) a disproportion
will occur as to the quantities of ozone and oxidahle mias-
matic gases which are engendered at the same time, so that
the quantity of atmospheric ozone may not be sufficient to
destroy all the miasmatic matter arriving in the atmosphere.
Now, according to the chemical quality (physiological pro-
perties) aud the quantity of that surplus of miasmatic matters,
more or less perceptible effects will be produced upon animal
life, that is, some kind of epidemic will, to a greater or lesser
degree, prevail.
As indicated by my test-paper, the atmosphere is usually
more or less ozoniferous; hence it follows that oxidable
miasmatic matters, such as sulphuretted hydrogen, the fetid
gases emitted by putrefying flesh, &c, can no more exist in
that ozoniferous air, than they could exist in air containing
the slightest traces of free chlorine.
I do not know whether the assertion be true, that during
the prevalence of certain diseases, such as cholera, the atmo-
sphere is deficient of ozone ; but nothing can be easier than
testing that assertion.
I have still to speak of some facts which, in my opinion,
arc worthy of the attention of physicians aud physiologists.
ii mil v opportunities of observing, in the immediate neighbourhood, ami even
iu the very midst of thunderstorms, the grand and awful effects produced
by the electricity of the clouds.
One day, when Mr. Buchwaldei wax on the summit of the Scnlis (near
Appcnzell), aud was couched with his servant under a little tint, which Mas
pitched upon a field of snow, on a Budden he was enveloped by a thick
electrical cloud, from which lightning proceeded in all directions. One Bash
struck the master and ihe servant | it instantaneous]; killed I he latter, and
immediately afterwards the tenl was filled with a very strong and peculiar
odour. When \lr. Buchwalder visited me in mj laboratory, he happened to
"H II strongl] ozonised air, with which 1 was just then experimenting; and
without any hesitation the engineer declared that the odour of that air was
identical with the smell perceived by him in his tent upon the heights
ni the Scnlis
ATMOSPHERIC ELECTRICITY. 219
As far as my own observations go, above all other seasons
winter is most distinguished by the abundance of atmospheric
ozone; from which fact we may conclude, that in winter time
the atmosphere must be freest from oxidable miasmatic
matters.
I have also ascertained the remarkable fact, that the higher
strata of the atmosphere arc more ozoniferous than the lower
ones. Having made experiments on different heights of the
Jura mountains, 12 — 1800 feet above the level of Basle, I
invariably found that my ozonometer exhibited there higher
ozonometric degrees than it did at the same time in Basle.
Hence we may infer, that the higher regions of the atmo-
sphere contain less oxidable miasmatic matter than those
which are nearer the surface of the earth. Now, as the
generation of some diseases, such as the yellow fever, &c,
seems to be connected with certain seasons and geographical
positions, it would, I think, be worth while to ascertain, by
comparative ozonometric observations, whether certain dis-
eases bear any relation to the ozoniferous state of that
portion of the atmosphere within which they happen to
occur.
Considering the great obscurity in which the causes of
most diseases are as yet enveloped, and as it is, nevertheless,
highly probable that some at least, if not many of them, are
the effects of chemical agents which exist in the atmosphere,
and have a great physiological effect, i. e., act in most minute
quantities with great energy upon the animal constitution,
scientific physicians and physiologists should earnestly follow
out any train of research which promises to increase our
insight into the connection between abnormal physiological
phenomena, and physical or chemical agents.
One remark more and I have done.
By a series of experiments, I think, I have satisfactorily
proved that the ozone, which is produced out of pure or
atmospheric oxygen by electrical sparks, is, in every respect,
identical with that ozone which is engendered out of pure or
atmospheric oxygen by the means of phosphorus, or with
220 M. SCHONBEIN ON ATMOSPHERIC ELECTRIC ITT.
the ozone which is disengaged at the positive electrode dining
the electrolysis of water. On this account, we cannot
entertain the slightest doubt, that electric and voltaic, as well
as chemical ozone, has the power of destroying oxidable
miasmatic gases ; but to remove even the shghtest shade of
doubt on the subject, I have experimentally convinced my-
self that they have the same action.
If a small inclosed volume of pure oxygen or atmospheric
air, which has previously been strongly charged with mias-
mata by putrid meat, be subject to the action of electrical
sparks, it will soon become disinfected ; and on mixing up
miasmatised oxygen or atmospheric air with a sufficient
quantity of ozoniferous oxygen, obtained from water which
has been electrolysed, the same effects will be produced.
ON THE EMPLOYMENT
OF
THE HEAT OF ELECTRICITY
IN PRACTICAL SURGERY.
JOHN MARSHALL, F.R.C.S.
SsSlSTANT-SURGEON TO THE UNIVERSITY COLLEGE HOSPITAL,
COMMUNICATED BY
RICHARD QUAIN, ESQ., F.R.S.
Received April 7th.— Read April 22(1, 1851.
Thk object of the present paper being to direct the
attention of the Profession to the employment of the Heat
of Electricity in Practical Surgery, I wi 1, in the first place,
describe the case, by the peculiarities of which its applica-
tion was originally suggested.
Early in September last, (1850,) Richard W. H — , a
native of London, aged 25, of delicate constitution and
strumous habit, who had chiefly resided in the metropolis,
and had been for some years engaged therein as a linen-
draper's shopman, came under my care, as an out-patient, at
the University College Hospital, with an obstinate fistula
in the right cheek, resulting from a succession of abscesses.
According to the statement which he made, it appears that in
November, 1849, (being then out of health,) he was first
troubled with a swelling of the cheek, the cause of which he
does not know. For a period of nine or ten weeks, the
swelling became alternately better and worse — being some-
222 >IH. MARSHALL ON THE APPLICATION OF
times, after the use of fomentations and purgatives, reduced
to a small lump the size of a bean, — and at other times,
enlarging even in the course of a couple of hours, so that
the mouth could hardly be opened. Up to the beginning of
February, this swelling had caused more inconvenience than
pain ; but the cheek then became so swollen, stiff, and
painful, that he applied to Mr. Ancell, who discovered a
small deep-seated abscess, which after three or four days,
was opened by an incision inside the cheek. During
the next four weeks, the discharge continued, and it became
necessary, owing to farther suppuration in the neighbourhood,
to make other incisions, and ultimately to unite them on the
inner surface of the cheek. About the middle of March, the
cheek again swelled, so as nearly to close the right eye, and
a fresh formation of pus, accompanied by constitutional dis-
turbance, took place, — on this occasion tending towards the
skin, which became much inflamed. Two separate punctures
through the integument, made at different times, were found
necessary to evacuate the accumulated pus, and soon after a
large probe could be passed quite through the cheek, the
passage having two small external orifices and one long
internal opening. Finally it became necessary to lay open
the two outer orifices into one.
By the use of poultices, lotions for the mouth, occasional
purgatives, and a course of tonic medicine, the suppurating
cavities in the cheek gradually diminished, and, together
with the external and internal wounds, became so contracted,
that there remained merely a narrow fistulous passage leading
into the mouth. Two or three times, in the early part of
May, the external orifice of the fistula temporarily healed,
but the cicatrix always became again inflamed, and was burst
through by matter accumulating behind it ; while the dis-
charge from the inner opening never entirely ceased. About
the beginning of June, as the fistulous passage did not
heal, it was thought advisable to try the etl'eet of improving
the geucral health, and Mr. II — was sent to Margate,
where he attended, as an out-patient, at "The Royal 8ea-
bathing Infirmary," under tin care of Mr. Field. Here,
THE HEAT OF UJ.ECT1UCITY IN PRACTICAL SUKGEB.Y. 223
besides proper medical treatment, he took sea-baths, an
Iodine oiutment was applied to the face, and an Iodine
injection made use of to stimulate the walls of the fistula.
Once or twice, the outer wound again closed up, but only
for two or three clays. At the end of six weeks he left
Margate, very much more vigorous in health, but (under-
standing from Mr. Field that probably even a six months'
residence there would not suffice to cure the fistula) he
returned to London, and very soon after, an increased dis-
charge escaped from both ends of the fistulous passage,
which was pronounced by Mr. Ancell to be as intractable
as ever. It continued in the same state until the 3d of
September, when I first saw the patient at the Hospital.
At that date, I found on the right cheek, behind the
angle of the mouth, a puckered depression, at the bottom of
which was an elevated and inflamed cicatrix, about an inch
long and a quarter of an inch wide ; on the fore-part of the
cicatrix a small fungous granulation marked the principal
orifice of the fistula. About half an inch behind this was a
smaller orifice, apparently quite recently ulcerated, which led
into the side of the fistulous track. On the inside of the
cheek, a long cleft extended backwards on a level with the
lower molar teeth. At the further part of this cleft, opposite
the second molar tooth, a fleshy projection indicated the
internal fistulous orifice. The direction of the fistula was at
first obliquely inwards through the skin, then backwards,
and then inwards again into the mouth; its length was If
inches ; it would only just admit a fine probe, and was
somewhat narrowed at either orifice. The tissues around
it were hard, but not tender on pressure. A small quantity
of a very thick whitish, almost curdy pus, escaped from both
ends of it. Its position was altogether below the Stenonian
duct, and no saliva ever flowed through it. The patient
was at this time rather thinner than usual, and appeared
anxious and miserable. The constant discharge and un-
sightly dressings annoyed himself and others, and rendered
him objectionable, and even unfit for his situation as a
shopman,
224 MR. MARSHALL ON THE APPLICATION OF
Finding that tlic pus was somewhat pent up in the fistula,
I enlarged the principal external orifice by about a quarter
of an inch, and then, with a view of stimulating the
lining membrane and maintaining a free exit for the matter,
it was injected with a solution of Sulphate of Copper,
and some threads of lint, moistened with the solution, were
introduced into it. Under this treatment, in about three
weeks, the hinder of the two external openings completely
closed up, but the main fistulous track showed no disposition
to heal. Other injections containing Sulphate of Zinc,
Nitrate of Silver, or Iodine, and ultimately the solid caustic,
were successively tried, being frequently used by myself, so
as to ensure their efficient application. In the mean time,
he took wine aud porter, Quinine and Sulphuric Acid, and
afterwards Quinine and Iron. His strength improved, the
local stimulants employed produced iucrcased action along
the fistula; but even after six or seven weeks there was no
disposition to adhesion of its sides.
After such persevering trials on the part of others as well
as myself, it appeared probable that the treatment hitherto
adopted would not succeed in closing a fistulous passage, the
condition of which had undergone no material improvement
for more than six months. The patient, moreover, becoming
dispirited, it became necessary to try some other method,
and I proposed to revive the inner surface of the fistula
cither by the actual cautery, or by dissecting out the callous
tissue along it, and bringing the cut surface together by
hare-lip pins and sutures. The former of these two methods
seemed in everyway preferable, but it was obviously difficult,
or I might say impossible, effectually to cauterize, by the
ordinary hot wire, the whole length of an extremely narrow
and winding passage, marly two inches long, through which
a fine probe could only be insinuated by tedious manipula-
tion; and cauterization of the accessible part only oft In- fistula,
would probably have ended in no permanent advantage.
It then occurred tome that a piece of platinum wire, which
might be easily passed through the narrowest and most
tortuous passage, might, by being made to form part of the
THE HEAT OF ELECTRICITY IN PRACTICAL SURGERY. 225
circuit of a powerful galvanic battery, be so intensely heated
throughout its whole lengtb, while still lying in the fistula,
as most effectually to cauterize every portion of its inner
surface.
No rational objection appearing to this plan, I commenced
by making some preliminary experiments on both dead and
living animal tissues. In these trials, the objects held in
view were : —
1st. To ascertain the possibility of obtaining a sufficiently
equable cauteriziug heat along the whole length of a wire
in contact with a moist conducting substance, like animal
tissue.
2dly. To determine the nature and extent of the effect,
produced on the tissue itself, and its consequences, both
immediate and remote, in the living animal.
3dly. To learn by actual trial, before operating on the
human subject, the size of wire best suited to accomplish
the desired purpose, the battery power requisite to heat the
wire under the peculiar circumstances, and the length of
time during which the electric current should be allowed to
traverse it.
4thly. To familiarise one's self with the practice of cau-
terization by this mode, so as to be able to adopt such con-
trivances and precautions as experience might suggest.
The experiments were made with a Grove's batterv of
four cells, each having a platina surface of thirty-two, and a
zinc surface of thirty-eight square inches. Fine platina
wire was the agent employed to localise the electric heat.
On dead animal matter, it was found that a tubular
portion of the tissue was destroyed immediately around the
whole length of the imbedded portion of the wire, the thick-
ness of tissue cauterized being somewhat greater at either
end than towards the middle of the imbedded wire; the
depth to which the cautery reached, depending on the power
of the battery, the size of the wire, and the duration of the
current, was, therefore, entirely under control. A few seconds
only were required to destroy, effectually, the surfaces in
actual contact with the heated wire. In the living animal,
2'26 MR. MARSHALL ON TIIE APPLICATION OF
a rather longer time was needed to produce corresponding
effects, but no mischief from laceration or bursting of the
tissues, or from shock to the general system, arose. The opera
tions were performed on a rabbit and dog, placed under
the influence of chloroform, and consisted chiefly in the
perforation of considerable thicknesses of the soft parts.
Inflammation along the course of the cauterized track,
separation of tubular sloughs thrown out at either orifice of
the wound, and active granulation and suppuration, occurred
in rapid succession, and finally the wounds, in all cases,
quickly healed.
The practicability and safety of cauterization by the heat
of electricity being thus established, I proceeded, on the
5th of November, in the presence of Professor Sharpcy
and Dr. Ditchfield, to submit my patient to the following
operation. The same battery was employed as before. One
of the poles was interrupted, the broken end terminating at
a mercury cup; a fine platinum wire, ^.th of an inch thick,
was passed leisurely, and without producing pain, through
the fistula, until it appeared in the mouth of the patient.
The part of the wire outside the check was then twisted
on to one of the stout copper poles of the battery, whilst the
other end, visible at the inner orifice of the fistula, was
brought into contact with the other pole, which, for that
purpose, was passed into the mouth. During these arrange-
ments, the circuit of the battery remained open. The
patient, who had not taken chloroform, was now desired to
keep quiet and allow his head to be firmly held. The
galvanic circuit was then closed by dipping the interrupted
pole into the mercury ; when the platinum wire instantly
became heated; and, at the expiration of nine seconds, the
circuit was broken, the cauterization being supposed, from
previous experience, to be, by that time, sufficiently com-
plete. The poles of the battery being then removed, the
platinum wire was found to cling slightly to the cau-
terized sides of the fistula, so that two fingers wore held
on the check whilst it was carefully withdrawn. Both
Orifices of the fistula would now have admitted a crow-quill,
THE HEAT OF ELECTRICITY IN PRACTICAL SURGERY. 227
and were surrounded by a well-defined, opaque, whitish
eschar. The patient expressed himself surprised at the small
amount of pain produced by the operation ; he had felt a
seuse of burning upon his cheek, and of pricking within the
mouth ; but no pain along the fistulous track. About five
or ten minutes afterwards he went away, feeling nothing
beyond a sense of stiffness in the cheek.
On the next two days, a little swelling and redness
appeared along the course of the fistula, accompanied by
the escape of a thin, brownish fluid. On the fourth day
the sloughs visible at either opening were loosening; that at
the inner orifice came away on the fifth clay, that at the
outer on the sixth day. The swelling of the surrounding
parts aided in extruding the sloughs, and also in bringing
together the sides of the fistula, the inner surface of which
was now secreting healthy pus. The quantity of this secre-
tion gradually diminished ; on the eighth day the inner
opening was no longer distinguishable; and on the 16th
November, the eleventh clay after the operation, the ex-
ternal opening was also soundly and permanently cicatrized.
About a week after this, a slight stiffness and swelling
came on in the back part of the cheek ; and a small quantity
of thick curdy pus, was again found escaping into the
mouth from the deep cleft previously described on the inner
side of the cheek. I thought the fistula had reopened ; but
it was not so. On examination I found a small opening, at
the back part of this cleft, from which a single drop of pus
could be squeezed by pressure over the middle of the
masseter muscle; this opening led into a narrow blind pouch,
or sinus, which had hitherto escaped my observation, and
which extended backwards for nearly an inch by the outer
side of the lower jaw-bone. As this sinus was probably
lined by the same indolent substance as the fistula which
had already been obliterated, I proposed to cauterize its
interior, and on the 14th of December, au attempt was
made to accomplish this, by introducing into it a piece of
platinum wire doubled back upon itself so as to form a
close bend, along which the electric current was made to
228 MR. MARSHALL ON THE APPLICATION OF
pass, its two ends being previously connected with the two
poles of the battery, which were carried into the mouth.
The operation was continued for ten seconds only, but it
did not prove successful; and accordingly, on the 18th of
December, I repeated it in the same manner, the electric
current being allowed to flow for fifteen seconds. The
wisdom tooth, which rather crowded the jaw, was also ex-
tracted by my friend Mr. Samuel Morris, who assisted me at
the time. The cautery produced rather more pain than in
the first operation, a very thick slough was thrown out, and
the sinus finally closed in somewhat less than a fortnight.
During the progress of the cure, and for some weeks sub-
sequently, good diet, wine, and tonics were prescribed. Up
to the present date, March 22d, 1851, the cheek has
continued quite sound, and the deep puckering of its outer
surface is fast disappearing.
The case just related satisfactorily illustrates the peculiar
advantages of the method of cauterization by means of the
heat of electricity. The electric cautery, as it may con-
veniently be called, has the recommendation of being under
proper care, intense, rapid, certain and uniform. It is
simple and easy of application ; for the wire, or other sub-
stance to be heated, may be duly and deliberately adjusted,
whilst yet unconnected with the source of heat : its employ-
ment is unaccompanied by the terrors of a formidable appa-
ratus, as the batteiy may be placed in an adjoining room :
it may be used in deep-seated parts, and under many con-
ditions in which no other cautery could be applied: its effects
may be carefully measured, and are completely under control,
being immediately arrested by breaking the galvanic current:
it is so limited in its action as to cause no unnecessary
destruction, or injury to adjacent parts ; and lastly, its use
appears to be safe, and its consequences favorable.
It may here be mentioned, that subsequently to the cure
of the above-mentioned fistula, my attention was called to
the fact that M. Kabre Palaprat had already used a platinum
wire heated by galvanism for producing deep-seated moxas.
THE HEAT OF ELECTRICITY IN PRACTICAL SURGERY. 229
His method is described, though not very intelligibly, in
Becquerel's * Traite de l'Electricite,' 1836, vol. iv, p. 306,
but it is not stated that M. Palaprat employed it, or even
recommended it, as a curative agent in the treatment of
surgical disease.
For all such cases, however, in which potential cauterization
may be advisable, and in which neither the common heated
wire nor button is available, the electric cautery will, I feel
assured, be employed with advantage, as, for instance, in
obstinate fistulas, leading into the mouth, or communicating
with the trachea ; in intractable perineo-urethral or recto-
urethral fistulas ; for cauterizing the edges of vesico-vaginal
fistulas, or the internal surfaces of long sinuses, resulting
from abscesses, or from incompletely obliterated cysts; for
arresting haemorrhage in certain parts, otherwise difficult of
access ; for uniformly cauterizing deep poisoned wounds, and
in other conceivable instances.
But during the progress of my experiments, another and
very different application of the electric cautery suggested
itself, viz., that of employing the incandescent wire in
the section of soft parts in the living body. In the ex-
periments on dead animal tissues, I had found that a con-
siderable thickness of muscular substance could be cut
through by the heated wire in a few seconds ; and I had
further ascertained, in the living animal, that no haemorrhage
occurred, from the division, by the hot wire, of veins as large
as a crow-quill, or of arteries a very little smaller.
It seemed probable, therefore, that it would be simple
and safe to apply this method for the removal of redundant
vascular parts, instead of the knife, scissors, or ligature ; as,
for example, in haemorrhoids, both external and internal ;
polypi of the uterus ; and certain forms of erectile tumours,
or any other soft pedunculated growths. For extirpation of
diseased portions of the tongue or of the os uteri, it also
appeared likely to be useful. Moreover, in certain peculiar
cases, where simple division of the tissues alone was required,
it seemed worthy of trial, as in the various kinds of rectal
fistulas, or in fissure of the anus. As a means of obliterating
xxxiv. 15
230 MR. MARSHALL ON THE APPLICATION OF
varicose veins, it might also prove safe and efficacious. Lastly,
in the case of persons having a strong hemorrhagic ten-
dency, this mode of dividing the soft parts appeared to
offer great advantages.
It was evident that the application of the actual cautery
to such purposes, would be open to the objection of returning
to a mean3 of cure already abandoned as barbarous ; but
the peculiai'ities of this method of cauterization appeared
to give such a command over the agent to be employed,
as had been hitherto impracticable. I have accordingly
used it in four cases of rectal fistula?; in five cases of in-
ternal haemorrhoids ; in two cases of external haemorrhoids,
and in one of fissure of the anus. As some of these cases
are still under treatment, and as their number is yet too
inconsiderable for the purpose of fully testing a method so
entirely new and open to improvement, I propose to defer,
till another occasion, a statement of the results of these and
of such other operations as I may hereafter have the op-
portunity of performing. In the meantime, I may state,
that no bad consequences have followed in any case, and
that, at present, all have been attended with success.
Description of the apparatus employed, and of the mode of
operating.
The apparatus necessary for operations by the Electric
Cautery consists of a moderately powerful galvanic battery,
fitted up with flexible poles, one of which is interrupted at a
mercury cup ; of terminal copper holders for the cauterizing
wire ; and of platina wires of various thickness, fitted up with
plates or balls of the same metal, if required.
The kind of battery is quite indifferent ; but I have used,
on the ground of economy and simplicity of arrangement,
one composed of iron and zinc on Sturgeon's principle, \\ liicli,
as a long-continued current is never needed, answers per-
fectly. Each cast-iron cell has about 120 square inches of
surface, whilst each zinc clement has 90. Four, six, eight,
or nine such cells are used, according to the length of
wire required to be heated. The nine cells will heat 1 inches
THE HEAT OF ELECTRICITY IN PRACTICAL SURGERY. 231
of platina wire ith of an inch thick in two seconds, and 6
inches in four seconds. The acid employed is one part of
sulphuric acid to ten of water. This battery being, however,
objectionable, from its size and weight, from the necessity of
fixing the elements every time it is used, and from the large
quantity of fluid employed, I am now having constructed
one of a different form, which will be more compact and
lighter, having the elements permanently fitted, and re-
quiring, moreover, very little acid to work it.
The poles, which are necessarily stout, and which, there-
fore, if composed entirely of copper, would be very stubborn,
may be made flexible by having a part of each composed of
a column of mercury enclosed hermetically in a vulcanised
indian-rubber tube, into each end of which the copper part
of the pole is to be fitted. Moreover, one pole should be
interrupted at a mercury cup, so as to render it easy to close
and open the circuit instantaneously.
To the ends of the poles, stout copper holders, which may
be plated, are fitted or unfitted at pleasure ; these are con-
structed with a slit, to receive the cauterizing wire, which is
fixed during the operation, and held tight by a sliding
ferrule or screw.
Method. — In operating on a fistula, open at each end,
the platina wire is first passed through the fistulous passage ;
its ends are then fitted on to the holders and these on to the
two poles. The soft parts around being held aside, and the
wire carefully disposed, the circuit is closed at the mercury
cup, for a period calculated beforehand, as necessary to
complete the cauterization.
If the passage be a cul-de-sac, the wire may, if practicable,
be carried through it on a nffivus-needle, and then be used
as just now described; or, being first fixed to the holders,
it may be bent into a loop, (having its two sides kept apart,)
which is then inserted into the sinus, and the electric current
made to pass along it.
The length of wire between the poles should just correspond
with that of the fistula or sinus to be cauterized ; and the
time necessary for the operation may be best determined by
232 MR. MARSHALL ON THE HEAT OF ELECTRICITY.
allowing about twice the period taken by the same wire and
battery to cauterize a track of the same length through a
piece of dead muscular tissue.
When soft parts are to be quickly divided by the electric
cautery, as in the case of fistula in ano, the wire should be
at least twice as long as the thickness of the part to be cut
through, so that it may be drawn, during the operation, to
and fro with a sawing movement.
For the removal of soft parts, the wire (being fixed to the
holders in the form of a loop, twice as long as the thickness
of the part to be cut away,) is placed against the base of that
part, and being heated, is used with or without a slight
sawing movement.
If the part to be removed be large, it may be first trans-
fixed by the wire, which being then properly fitted to the
poles of the battery and heated, is made to divide one half
of the mass, and then, without being unfitted, is carried to
the bottom of the cut already made and drawn through the
remaining half.
In proportion to the vascularity of the part to be divided
or removed, the wire must be thicker, the heat less intense,
and the sawing more gently performed, so that the section
may be gradual and the cautery be allowed a longer time to
penetrate and close the larger vessels.
Lastly, other modes of application, by varying the forms
of the platina employed, will be suggested according to
circumstances.
A CASE OF
STRANGULATED OBTURATOR
OR
THYROIDEAL HERNIA,
SUCCESSFULLY RELIEVED BY OPERATION.
HENRY OBHE,
FORMERLY ASSISTANT-SURGEON TO THE ST. MARY-LE-BONE INFIRMARY.
COilMUNlCATED BY
PROFESSOR ERICHSEN.
Received April 12th.— Read June 2-ith, 1851.
Protrusion of a portion of intestine through the opening
which transmits the vessels in the Obturator Ligament, is a
displacement of very rare occurrence. The authors of our
own country, who have devoted their attention to the sub-
ject of Hernia, and collected a vast amount of scattered
information, have been unable to find a single case of this
accident, which had been detected during life; instances are
not so rare of the patient suffering from all the usual sym-
ptoms of strangulated intestine, and after death, a portion of
intestine having been found protruding below the obturator
ligament. Continental writers have described the disease
more frequently, recorded a number of cases, and have pre-
served the parts, showing death to have been caused by
undetected strangulation through this opening. I have been
equally unsuccessful in finding in their writings instances in
which this hernia has been relieved by operation. Sir A.
234 mr. obex's successful case or
Cooper gives the account of a case by M. Malaval, published
in the Memoirs of the Royal Academy of Surgery of Paris,
in which he attempted to reduce a hernia of this description,
and succeeded in returning the intestine, but not the omen-
tum. M. Arnaud made an incision down to the swelling,
and found a piece of omentum protruding, which he cut
away, as well as a portion of the sac, and the patient
recovered. The simplicity of the operation as described,
must throw some doubt on the correctness of the descrip-
tion, of omentum having passed through the obturator
opening. We cannot reconcile so deep a part being exposed
by a simple incision. When we reflect on the depth of the
obturator foramen, and its protection by muscular structures,
which both cover and surround the opening, we can readily
conceive not only with what difficulty the intestine can be
displaced in this direction, but also when it occurs, how
numerous are the impediments to its presenting the usual
form and character of a hernial protrusion in other parts.
The faithful narration of the symptoms and appearances
which presented themselves in a case of this description,
which lately came under my observation, will best enable
others to recognise this accident, and prepare them for the
difficulties which must present themselves, in an operation
for the release of a portion of strangulated intestine so
deeply situated.
Mrs. W — , a tall person, moderately stout, set. 55, the
mother of a large family, applied to Mr. Gardener, of Lisson
Grove, on the evening of Tuesday, February 18th, 1851. She
was suffering from abdominal pain and nausea : aperient
medicines were prescribed. On the following morning, Mr.
Gardener, finding her symptoms not relieved, inquired if
she were the subject of rupture, and was answered in the
negative. At the next visit, on the 20th, his patient hail
not received the slightest relief; on the contrary, the abdo-
minal pain had increased, and was accompanied by vomiting.
Mr. Gardener, feeling confident that these symptoms u ere the
STRANGULATED OBTURATOR OR THYROIDEAL HERNIA. 235
result of some mechanical obstruction, examined the regions
in which hernia is usually found, and satisfied himself that
there was no hernial tumour, but a little below the femoral
region on the right side, he detected a degree of hardness
resembling a small gland, of the size of a bean, and deeply
seated. During the day, Mr. Robinson accompanied him,
to make a more careful examination of the thigh, but was
unable to discover more than a general fulness of its upper
and anterior part, in addition to the deeply-seated hardness
before mentioned. These gentlemen were inclined to think
a portion of intestine had become strangulated. Early on
Friday the 21st inst., I visited the patient with Mr.
Gardener. She was in bed, suffering extreme abdominal pain
in the umbilical region, and during the previous 12 hours,
her vomiting had become stercoraceous and incessant. The
countenance was pale and contracted, the voice faltering, the
pulse weak, small, and intermitting at every third or fourth
pulsation; in short, all the symptoms of impending dissolu-
tion from strangulated intestine were present. Whilst sitting
by her side, and examining her under the bed-clothes, I
was unable to detect any tumour or swelling, aud was inclined
to consider the impediment as existing within the abdominal
cavity, when Mr. Gardener directed my attention to the
previously described hardness. Ou uncovering the upper
part of both thighs at the same time, the eye detected a
slight degree of fulness in Scarpa's triangle on the right
side; this triangle of the opposite limb was well marked
with a hollow or depression passing down its centre, but
this was lost on the affected side, and the whole contour of
this part of the limb was visibly fuller than that of the cor-
responding; there was no tumour or circumscribed swelling,
but on standing over the patient, and using firm pressure
with the ends of the fingers over the neighbourhood of the
femoral artery, and a little below the saphenous opening, a
distinct hardness could be felt (slight in its extent), giving
an impression as if the sheath of the vessels were being
pressed on. The patient still persisted in her statement,
236 MR. OlSRi's SUCCESSFUL CASE OF
that she never had been the subject of rupture. Ou further
inquiry, however, Mrs. W — stated that she had felt some
slight inconvenience and pain in the right limb, for the
previous fortnight, which she attributed to the enlargement
of two little glands, about the junction of the upper and
middle thirds of the thigh, accompanied with pain in the
part, so as to oblige her to rest the extremity. The action
of the bowels had been irregular during the same period.
Her dangerous state having been duly considered, it was
thought prudent to make an incision down to the hard
structure, in the hope that it might be caused by constriction
of the intestine deeply situated in the femoral canal. The
uncertainty of the result having been named to the sufferer
and her husband, they consented to the operation as a
probable means of saving her life. I made a straight incision
into Scarpa's triangle, as in the customary operation for
tying the femoral artery, beginning about three inches below
Poupart's ligament ; the dissection was continued in the
direction of the enlarged and hardened structure, until the
cribriform fascia was opened, and the saphenous opening ex-
posed, when some little disappointment was felt in not
finding a portion of intestine confined there. The extremity
of the index finger could now distinctly feel the hardened
structure, deeply situated at the inner border of this opening ;
the dissection was resumed and continued with difficulty
in so deep a part, and some embarrassment was caused by
the saphenic vein, which passed through part of the wound,
as did also branches of the anterior crural nerve. The fascia
lata was divided, and the pectincus muscle exposed at the
inner side of the wound, which it was found necessary to elon-
gate, as it was impossible to continue the dissection at such B
depth, unless the original incision were extended. The ex-
ternal fibres of this flat muscle were cleared from the sur-
rounding structure, and divided transversely for about an inch
and a half or two inches. I had only to separate with my
finger some cellular tissue, when a portion of intestine,
covered with its sac, and thinly held down by the other inns-
STRANGULATED OBTURATOR OR THYROIDEAL HERNIA. 237
color structures that surrounded it, came into view. On
beiug liberated, it suddenly ascended into the wound, being
distended by flatus to the size of a pigeon's egg. Its true
character was now discovered, and the finger with some
difficulty, from the depth at which it was situated, passed
along the protruding intestine to the obturator opening,
through which it had escaped. The narrow circumference
of the foramen and the surrounding bones were examined
both by Mr. Gardener and myself. The symptoms of
strangulation having existed three days, it was considered
prudent to open the sac, which contained a portion of the
small intestine, blue and congested; and though the opening
through which it had passed did not tightly inclose its neck,
it was deemed prudent to divide its edge slightly, as some
difficulty would have been found in returning the intestine
without using pressure to empty it of its flatus. The extreme
depth of the wound, added to the upward turn which the
index finger was obliged to take in being used as a director
to a blunt-pointed bistoury for the division of the stricture,
was found the most difficult part of the operation, as well as
to avoid various important vessels and nerves that surrounded
the knife. Unfortunately the saphenic vein not having been
sufficiently held out of the way, was divided at the same
time as the stricture ; and from the extreme depth of the
wound it was a matter of congratulation that no other serious
mischief had taken place. The intestine having been returned
as well as the sac, some little difficulty was found in securing
the upper division of the vein, which was the only bleeding
part. This being the only ligature requisite, the wound
was closed by the necessary bandages, and the patient placed
in bed. No medicines were administered. As the bowels
had acted three times in the course of the day, after the
operation, an opiate was prescribed at bedtime.
22d. Has passed a good night. No abdominal pain ;
pulse intermitting ; a rough sound to be heard accom-
panying the second sound of the heart.
23d. The patient is going on favorably.
238 mr. obrk's case of strangulated obturator.
March 1st. The ligature came away to day. From this
time she made a rapid improvement ; the pulse lost its in-
termission ; the sounds of the heart became regular and
natural ; and when she was examined a month after the
operation, no hernial protrusion was to be felt, and she bad
no inconvenience whatever in walking.
SOME
OBSERVATIONS ON THE PATHOLOGY
OF THOSE
AFFECTIONS OF THE EAlt
WHICH PRODUCE
DISEASE IN THE BRAIN.
JOSEPH TOYNBEE, F.R.S.
FELLOW OF THE ROYAL COLLEGE OF SURGEONS IN ENGLAND,
AURAL SURGEON TO ST. MARy's HOSPITAL, AND
CONSULTING SURGEON TO THE ST. GEORGF.'s AND ST. JAMES's
GENERAL DISPENSARY.
Received April 22d. — Read June 24th, 1851.
It was my intention to lay before the Medical and Chirur-
gical Society some extended researches into the Pathology and
Treatment of the Affections of the Ear, which give rise to
Disease in the Brain. The reason that has induced me to
abandon this intention, and to limit myself to some observa-
tions in pathology, is the great extent to which the inquiry
has conducted me, and the consequent impossibility to do
justice to so important a subject in the limits of a Paper.
Being anxious, nevertheless, to submit to the Fellows of
this Society some of the results at which I have arrived, in
order that those results may be duly considered, I have
brought before them certain leading points, which, I trust,
will not be deemed unworthy of their attention.
The great frequency of cases in which disease advances
from the Ear to the Brain is, unfortunately, too well known
to the medical profession, by the almost constant occurrence
of fatal instances in which disorganisation of the brain, and
its membranes have supervened upon long-standing affections
240 MR. TOYNBEE ON THE PATHOLOGY OF
of the ear. In our own country this subject has occupied
the especial attention of some of its most celebrated members,
among whom may be named Abercoinbie, Bright, Watson,
and Burne, while, on the continent, it has been investigated
by Morgagni, Itard and Lallemand. The results of the
researches of these writers, among whom the name of
Lallemand may be especially referred to, are of considerable
interest ; but the want felt by every inquirer into this branch
of surgery, is a proper classification of those cases which
have thus far been included under the comprehensive term,
" caries of the petrous bone ending in disease of the brain."
It has been my object to supply this want; and, in the following
brief communication, I shall attempt — 1st, to point out the
nature of the several affections of the ear which produce
disease in the brain ; and 2d, to show that each of the cavities
of the ear has its particular division of the encephalon to
which it communicates disease, thus :
1. Affections of the external meatus and mastoid cells
produce disease in the lateral sinus and cerebellum.
2. Affections of the tympanic cavity produce disease in
the cerebrum.
3. Affections of the vestibule and cochlea produce disease
in the medulla oblongata.
In the consideration of this subject I shall examine,
seriatim : —
1. The affections of the external meatus.
2. Those of the mastoid cells.
3. Those of the tympanic cavity.
4. Those of the vestibule and cochlea.
1. AFFECTIONS OF THE EXTKIINAL MEATt 3,
Anatomical Observations,
The osseous external meatus is lined by epidermis, the
dermis, and the periosteum. In a paper lately published
by the Royal Society,1 I have shewn that these three
structures are continuous with the membrana tympani,
' 'Phflosophiool Transaotioos,1 I'.ui 1, L861, page 159.
CERTAIN AFFECTIONS (VF THE EAK. 241
of which, indeed, they form the three outermost lamina?.
The knowledge of the fact, that the dermis of the external
meatus is continuous with, and forms one of the layers of
the membrana tympani, is of considerable importance to the
surgeon; for it will be seen that disease originating in this
lamina is frequently prolonged to the meatus ; whence it is
liable to progress to the bone and the brain.1 The dermoid
layer of the membrana tympani is well supplied by blood-
vessels and nerves, and it adheres by fine cellular tissue to
the outer surface of the radiate fibrous lamina. In the
meatus, the dermis and periosteum are so intimately con-
nected, that it is almost impossible to separate them, and
the blood-vessels which ramify through them have a com-
munication with those in the substance of the osseous
meatus. The intimate connection between the dermis of
the external meatus and the substance of the bone is
therefore very obvious.
The relations of the osseous walls of the external meatus
to the cavity of the cranium are of much interest. In the
adult, it will be found that the upper wall of the meatus
consists of a solid lamina of bone, varying from a line to two
lines in thickness, which separates the cavity of the meatus
from that occupied by the middle lobe of the cerebrum. In
some instances, a prolongation of the tympanic cavity is
found to extend into the substance of this upper wall of the
meatus. The posterior wall of the meatus has intimate re-
lations with the sulcus lateralis and the fossa cerebelli,
especially at the period of youth, and previous to the age of
twenty-five or thirty.2 At these periods of life it will be
' The circumstance that iiiflammatiou, originating in the external meatus
from cold or the use of an ear-pick or pin, often rapidly extends to the
membrana tympani, causing its partial or complete destruction, may be ac-
counted for by the free communication that exists between the blood-vessels
of the dermis and those of the dermoid layer of the membrana tympani.
1 In later periods of life, the mastoid cells arc developed to so great an
extent, as to separate the posterior wall of the meatus from the sulcus
lateralis ; and disease then occurring in the meatus, unless it is very exten-
sive, is generally confined to the mastoid cells, and does not involve the
cavity of the cerebellum.
242 MR. TOYNBEE ON THE PATHOLOGY OF
found that the layer of bone forming the outer third of the
posterior wall of the meatus, and which separates the cavity
of the meatus from that of the sulcus of the lateral sinus, is
frequently not more than half a line in thickness ; indeed, it
is often so thin as to be translucent; this layer of bone is
penetrated by numerous orifices for blood-vessels, which
extend into its substance, and they communicate with those
derived from the dura mater. In instances where the pos-
terior wall of the meatus is thicker than stated above, the
blood-vessels ramifying through its substance, and which
arise from the membranous meatus, seem, nevertheless, to
have a communication with those which enter the bone at
its inner surface. The inner two thirds of the external
meatus has intimate relations with the sulcus lateralis
through the medium of the mastoid cells, a very narrow
portion of which cells is all that exists between them ; not
unfrequently, this portion of the osseous wall of the meatus
is so thin, as to be translucent, and sometimes portions of
it are absent, and a direct communication exists between the
meatus and the mastoid cells.
From the above anatomical observations, it will, I think,
be apparent, that disease originating in the external meatus
during the first half of the period of life, is liable to extend
to the fossa cerebelli, and especially to that portion of it
which contains the lateral sinus. The result of careful
observation has been to show, that as a general rule,1 when-
ever disease in the cerebellar canty supervenes upon an
affection of the ear, the external meatus has been the portion
of the ear affected.
I shall now proceed to point out the nature of the disease
in the meatus which is found most commonly to extend to
the bone, and thence to the cavity of the cerebellum. Pre-
vious to doing so, however, I may perhaps be allowed the
opportunity of stating, that in this paper, and indeed in all
my researches into diseases of the ear, I have thought it
1 To this general rule there arc two exceptions, wliicli will be totted
CERTAIN AFFECTIONS OF THE EAE. 243
desirable to abolish the use of the term otorrhoea ; when it
is known that discharge from the external meatus may arise
from as many as seven different sources, it must appear evi-
dent to every scientific medical practitioner, that the disease
causing the discharge should be specified, instead of using a
word which can only be considered as a mask under which
is concealed our ignorance of the real nature of the affection.
One of the most common affections of the external
meatus is, chronic catarrhal inflammation of its dermoid
layer ; this name I have given to the affection in which the
surface of the dermis becomes red, and instead of secreting
the epidermis in a continuous layer, the cells composing
this structure are thrown off in an early stage of their
development and form a mucous discharge. Tins affection,
innocent as it appears, without proceeding to ulceration, is
the most frequent cause of disease to the bone and cere-
bellum. It often persists during many years, all which
time the discharge never ceases, or only for short intervals ;
the surface of the dermis often loses its unnatural redness,
but its substance becomes tumefied, and often to so great an
extent, as nearly to close the cavity of the meatus. Co-
existent with this condition of the dermis, the periosteum
becomes soft and detached from the bone, the blood-vessels
having become much enlarged, the bone inflames, and caries
or necrosis follows; the dura mater is detached from its
inner surface, the lateral sinus inflames, purulent matter is
deposited on its external as well as on its internal surface,
and death occurs as the result of purulent infection. In
cases where the lateral sinus is not so deeply involved, the
cerebellum in the vicinity of the diseased bone is found to
be much softened, in a state of purulent degeneration, or an
abscess occupies one of its hemispheres.1 During the progress
1 Dr. Watson, in his published Lectures, 3d edition, vol. i, p. 370, makes
some very interesting observations on those cases of disease in the car which
terminate in purulent infection. In the subjoined Table I have made a
careful analysis of these and of all other fully-recorded cases I have been
able to meet with, in winch disease has been prolonged from the ear to the
brain and has produced death.
244 MR. TOYNBEE ON THE PATHOLOGY or
of the morbid changes which have been enumerated, there
are frequently no symptoms calculated to indicate to the
medical man the presence of so formidable a disease, and
which may terminate in the death of the patient after an
acute attack of a few days' duration.
The patient suffers little, or perhaps no pain in the ear or
head ; the surface of the meatus presents no appearance of
ulceration, even although extensive caries of the bone may
be present ; the only prominent symptom is the presence of
discharge, which, as a general rule, does not disappear, or
only during short periods. An examination of the accom-
panying table is sufficient to show, that the chronic disease
of the ear may endure so long as twenty years, or even
during the whole of a long life, without the occurrence of
any formidable symptoms ; and cases of this nature have
induced the profession to look upon the symptom of long-
persistent discharge, as one of but trifling importance ; but
the result of my own observations is to show, that as a
general rule, if the progress of this affection be unchecked,
the bone and cavity of the cranium become slowly diseased,
and death is liable to ensue upon the occurrence of any
trifling exciting cause, as an attack of influenza, cold, or a
blow on the head. In the foregoing observations I have
alluded to only one form of disease in the external meatus
which is productive of fatal mischief to the cerebellum, viz.,
chronic catarrhal inflammation of the dermoid layer; in the
majority of cases which I have examined, death has taken
place without the occurrence of ulceration in this membrane;
but in those instances where a large portion of bone is
necrosed, the membranous meatus ulcerates, and through
the aperture the necrosed bone is distinctly felt.
I shall now proceed to notice those exceptional eases, to
which allusion has already been made, where disease i> pro-
pagated from the external meatus to the cerebral cavity, and
where the cavity of the cerebellum is not affected. Previous
to doing so, it will be requisite for me to make sonic obser-
vations on the structure and relations of the osseous external
meatus during the early periods of life.
*24.-j
/
"W
I
Sf!s-
CERTAIN AFFECTIONS OF THE EAK. 245
At the time of birth, and for the first year subsequent to
it, the only rudiment of the osseous external meatus, is the
superficial depression, situated in the middle of the outer
and lower part of the pars squamosa, immediately posterior
to the root of the zygomatic process. This depression, to
which the name fossa auditoria may, with propriety, be ap-
plied, has the rudiments of the mastoid process posterior to
it ; the surface of tbis "fossa auditoria" is more smooth and
its substance is more dense, and it contains fewer foramina
than the surrounding bone. At the period of birth, the
portion of bone forming this fossa is not more than half a
line or three quarters of a line thick, and the membranous
meatus is attached to its outer, and the dura mater to its
inner surface. Its structure is far from being compact and
dense ; and in its substance the blood-vessels from the meatus
communicate with those of the dura mater. The relations
of the fossa auditoria at the period of birth, and during the
first year of life, are shown in the figure, which represents a
vertical section of the temporal bone from without inwards
in a line through the fenestra ovalis, (fig. I.)1 Subse-
quently to the first year of life, and during the period of
youth, the substance of the bone situated between the fossa
auditoria and the middle cerebral fossa, so increases in thick-
ness, that the outer and inner surfaces of the cranium are
separated by a space varying from a line to a line and a half
thick, (fig. 2.) As the bone approaches maturity, the fossa
auditoria assumes an oblique position, and forms the upper
wall of the external auditory meatus, and it is separated from
the cavity of the middle cerebral fossa by a dense layer of
bone, into which the tympanic cavity is not unfrequently pro-
longed, (fig. 3.) In the adult, the fossa auditoria has lost its
oblique direction, and forms a horizontal lamina of bone.
This position of the fossa auditoria is seen in fig. 4.
A consideration of the above description of the relations of
the fossa auditoria will render it evident, that at an early
1 In this as well as in the two following figures, a indicates the fossa
auditoria ; b the inner surface of the fossa auditoria forming part of the outer
wall of the middle cerebral fossa; c the cavity of the tympanum.
xxxiv. 16
246 MR. TOYNBEE ON THE PATHOLOGY OF
period of life, viz., during the first year, there exists between
the membranous meatus and the dura mater of the middle
cerebral cavity, only a very delicate layer of bone, through
which disease is liable to extend from the meatus to the
brain. As the bone is developed, the external meatus is
separated from the cerebral cavity by a more considerable
space, and the meatus is brought into intimate relations
with the lateral sinus j it will, accordingly, be found, tbat
disease which is prolonged from the external meatus to the
cerebral cavity, originates and affects the bone within the
first year of life. As a general rule, this disease, if un-
checked, destroys life within a few months of its origin ; but
cases are met with, and of which I have recorded two in the
subjoined Table, where death did not occur in childhood, but
where nature made vigorous efforts to repair the injury to
the bone ; but in which the disease had so injured the cere-
brum and its membranes, that, although one patient lived
eleven, and the other between fifty and sixty years, death
ultimately occurred in each from the effects produced during
the first year of life. It may at first appear difficult to dis-
tinguish between these cases and those of disease occurring
in the upper wall of the tympanum, which produce death
by exactly the same changes in the brain and its mem-
branes. The distinguishing difference will, however, be
found in the fact, that where the disease has originated during
early life in the external meatus, the portion of bone which
then formed the fossa auditoria, (and which in later life
becomes the upper wall of the meatus-,) is the seat of the
disease. Where the disease begins in early life, certain re-
sults of the process of reparation arc apparent in the form of
new hone, which is deposited, not only on the inner, but on
the outer surface of the squamous hone and auditory meatus,
which results are not met with, in ordinary eases of caries,
in the upper wall of the tympanum.
A seronit exception to the rule above laid down, that
disease in the cerebellum and lateral sinus originates in
affections of the meatus exteruus, is found in those cases
where disease extends backwards from the tympanic cavity,
CERTAIN AFFECTIONS OF THE EAR. 247
involves the mastoid cells, and produces caries of their inner
wall. These cases appear to be rare; and, as a general rule,
the mastoid cells become affected as the result of disease
originating in the external meatus.
The pathological conditions produced by the diseases of
the external meatus may be summed up as follows : —
1. Coagula in lateral sinus.
2. Pus in lateral sinus.
3. Pus in lateral sinus, and secondary deposits.
4. Pus on the surface of the cerebellum.
5. Abscess in the substance of the cerebellum.
2. AFFECTIONS OF THE MASTOID CELLS.
It will be sufficient for me to indicate here, that in the
adult, the posterior surface of the mastoid cells is covered by
the dura mater of the cerebellar cavity, and that the lateral
sinus is lodged in a sulcus of this wall, in order to render it
evident that disease is liable to be propagated from the
mastoid cells to the lateral sinus and cerebellum. The source
of the diseases of the mastoid cells is generally the external
meatus, and they have, therefore, been alluded to in the
preceding section; but cases of disease originating in the
mastoid cells, and which proceed to the destruction of its
posterior wall, the lateral sinus and cerebellum, are sometimes
met with, and of one of these I give the particulars.
T. D — , ret. 29, four months previously to his death,
complained of great pain in the situation of the right mastoid
process ; this pain was attended by earache, drowsiness,
giddiness, and a discharge from the meatus. Upon examina-
tion, the membrana tympani was observed to be entire, but
its surface was dull, and it had a milky colour. The surface of
the meatus was tumefied, and the discharge originated from
it. In spite of all treatment, the head symptoms greatly
increased, and stupor supervened. An abscess which formed
behind the ear was opened, and a large quantity of purulent
matter was discharged without affording any relief.
218 MR. TOYNBEE ON THE PATHOLOGY OF
Post-mortem Inspection. — The external meatus contained a
considerable quantity of muco-serous discharge; the surface of
its dermoid layer was denuded of epidermis; its substance was
much tumefied. The membrana tympani was entire, but of
a dull leaden hue, and much softer than natural. The cavity
of the tympanum contained a considerable quantity of purulent
matter, and its lining membrane was vascular, thick, and
flocculent. The incus had disappeared, the stapes retained
its position, but was surrounded by bands of adhesion. The
bony walls of the tympanum were healthy. The mastoid
cells were full of purulent matter ; upon its removal, the bony
laminae dividing the cells were found to be extensively carious,
large portions of them having been removed. The whole of
the inner wall of the mastoid cells, usually formed by the
floor of the lateral sinus, was completely destroyed, and in
the macerated bone the mastoid cells communicated with
the cavity of the cranium by an elongated orifice, measuring
one inch and a quarter from above downwards, and more than
half an inch from before backwards. A circular orifice about
the size of a pea existed at the posterior and upper part of
the mastoid process, which allowed of the passage of pus into
the abscess behind the ear, which was opened during life,
and through which, there is no doubt, the incus had been
discharged. I had not an opportunity of examining the
state of the cerebellum ; the membranous lateral sinus
was much attenuated. Tt is interesting to observe that,
although the disease in this case was very extensive, it was
almost wholly confined to the mastoid cells, in which, no
doubt, it had originated. The condition of the mucous
membrane of the tympanic cavity, and of the dermoid layer
of the external meatus, may be looked upon as the result
of sympathetic action.
3. AFFECTIONS OF THE TYMTANIC CAVITY.
Cases of disease originating in the tympanic cavity and
extending through its upper wall to the dura mater and
iiK In urn, arc of more frequent occurrence than those which
CERTAIN AFFECTIONS OF THE EAR. 249
formed the subject of the last section. The frequency of
cases of disease of the cerebrum and its membranes which
originate in the tympanic cavity, may be accounted for,
firstly, by the great liability of the mucous membrane of
the tympanum to undergo pathological changes ; and secondly,
by the existence of very intimate relations between this
membrane and the dura mater.
Anatomical Observations.
The intimate relations between the mucous membrane of
the tympanum and the dura mater, to which allusion has
just been made, occurs at the upper wall of the tympanum,
which will be found to consist of a lamina of bone extending
from the angle of union between the squamous and petrous
bones to the vestibule and semicircular canals, and from the
mastoid cells posteriorly to the eustachian tube anteriorly.
This lamina is about an inch in length, and at its middle
part, which is widest, about a third or half an inch in breadth.
The structure of the upper wall of the tympanum varies very
much in different persons. It may be described as being
generally from a quarter to half a line thick, but it is very
often so thin as to be translucent ; and it is far from being
an uncommon occurrence, that this lamina is deficient in
parts so as to admit of the mucous membrane of the tympanum
being in contact with the dura mater. It will readily be
conceived, that disease attacking the mucous membrane of
the tympanum is liable to implicate the upper osseous wall,
and dissection shows that this wall is the one usually affected
whenever the bone has become diseased.
The affections of the mucous membrane of the tympanum
which usually give rise to disease in the brain, are acute
inflammation, chronic catarrhal inflammation, and ulceration,
but of these the one most frequently occurring is chronic
inflammation. Chronic catarrhal inflammation of the mucous
membrane of the tympanum, one of the affections which has
been comprised under the term otorrhoea, most frequently
originates at the period of childhood, and an attack of cold,
scarlet fever, scarlatina, measles, or low fever, is generally the
250 MR. TOYNBKE ON THE PATHOLOGY OF
exciting cause. The predisposing cause may almost always
be traced to a tendency to glandular enlargement ; and
although this affection of the mucous membrane of the
tympanum occurs sometimes where the tendency above
alluded to does not exist, still I think it will be found that
in these cases, it does not remain longer than a few weeks,
and that it never terminates in disease of the bone. This
affection, at its origin, consists in a hypertrophy of the
mucous membrane lining the tympanum ; this thickening is
accompanied by an increased secretion of mucus with which
the tympanic cavity becomes completely distended. The
inner surface of the membrana tympani is thus pressed upon,
and it becomes slowly atrophied, and a portion of it is
removed by absorption ; an orifice in the membrana tympani
is thus produced through which the mucus, secreted in the
tympanum, is discharged into the meatus externus. Upon
removing the discharge from the meatus and tympanum, the
tympanic mucous membrane can be distinctly observed
through the aperture in the membrana tympani ; it is
generally found to be so thick as to fill up a considerable
portion of the tympanic cavity, of a bright red colour, and
its surface shining. The discharge differs from that secreted
in chronic catarrhal inflammation of the dermoid meatus in
consisting of portions of viscid mucus, which float in water
without mingling with it ; sometimes these portions are so
small as to appear like pieces of fine string or thread.
Chronic catarrhal inflammation of the mucous membrane of
the tympanum may continue during many years without the
occurrence of any ulcerative process, but its presence is very
commonly the cause of disease in the petrous bone and in
the cerebrum. In some cases the irritation of the mucous
membrane of the tympanum appears to be sufficient to
originate disease in the cerebrum, and an abscess is developed
in its substance, without the occurrence of any morbid con-
dition in the bone or dura mater. The usual result of a
prolonged continuance of this affection is, that the mucous
membrane lining the upper wall of the tympanum becomes
detached from the hone, while the dura mater, at the same
CURTAIN AFFECTIONS 01' THE EAR. 251
time, loses its adhesion to its upper surface ; the substance
of the bone having thus lost its supply of nutrient fluid,
becomes carious, purulent matter is secreted around it, and
the two investing membranes ulcerate, the disease spreading
from the dura mater to the substance of the brain. The
pathological changes produced in the brain and its mem-
branes by the affection of the ear, now under consideration,
may be thus enumerated :
1. Inflammation of the dura mater, and its separation from
the surface of the petrous bone by serum.
2. Ulceration of the dura mater, and its complete detach-
ment from the petrous bone.
3. An abscess in the substance of the cerebrum.
4. Undefined suppuration of the substance of the cerebrum.
From an examination of cases, it appears that chronic
catarrhal inflammation of the mucous membrane of the
tympanic cavity, may exist as many as twenty or more years
without the production of any disease beyond it, or, at least
without the existence of any symptoms by which the presence
of such disease can be diagnosed ; nevertheless, in the great
majority of cases, vital structures become sensibly affected
in a much shorter period. It is not in my power to enter
here into the details of cases belonging to this class ; but
those desirous of obtaining further information will refer to
the accompanying Tables, which contain the leading facts of
importance pertaining to many well-authenticated cases.
4. THE LABYRINTH.
Cases in which disease is propagated from the cavities of
the vestibule and cochlea to that of the cranium, are of much
more unfrequent occurrence, than those which have been
previously referred to. To those who are aware how directly
the auditory nerve establishes a communication between the
two cavities above named and the medulla oblongata, it
may be well conceived, that disease occurriug in them, is
liable to be prolonged to the medulla, and to the membranes
investing it. This communication may take place without
the presence of any disease of the bone, the small orifices at
252
MR. TOY.N'BEE ON THE PATHOLOGY OF
the floor of the internal auditory meatus, through which the
flne filaments of the nerve take their course, being quite
sufficient to allow of the transmission of the disease from within
outwards. The affection which is the source of the disease
in the medulla oblongata, so far as my experience has gone,
appears to originate in ulceration of the mucous membrane of
the tympanum; this affection having proceeded to the destruc-
tion of the fibrous investment of the tympanum, the stapes
is detached from the circumference of the fenestra ovalis, and
is discharged from the external meatus, or the membrane
covering the fenestra rotunda is destroyed. Sometimes both
of these changes take place ; sometimes only one : under
either circumstance, the lining membrane of the labyrinth
partakes of the diseased action which originated in the tym-
panum, the labyrinth becomes filled with purulent matter,
the expansion of the auditory nerve is destroyed by ulcera-
tion, and its trunk becomes inflamed; the inflammation
extends through its substance as far as the medulla oblongata,
the membranes of which are implicated in the disease, and
death ensues from an effusion of pus or serum.
I shall not lengthen this paper by entering into a more
minute consideration of this branch of the subject, but will
refer to the following analysis of three cases of —
Disease in the Cerebral Cavity, extending from the Labyrinth.
Duration of
Acute symptoms
Ry whom the
case was reported
age.
chronic
symptoms.
causing death — their
duration.
rost-mortem appearances.
J?
Not stated.
Toothache; fever;
Auditory nerve in a state of
Hard. 'Trait, ;
cerebral irritation.
suppuration ; pus in lahv-
lies Mai
Five weeks.
rintli ; pus on the surface
nf eercbrnm and cere-
bellum.
d'OreUle,'
torn. i,p. 254.
42
Thirty-five
Pain in head; coma.
Pus in tympanum and laby-
Mr. Streeter,
years.
Five days.
rinth, and around the me-
dulla oblongata.
Med. Gazette,
1834, p. 553.
17
For twelve
Pain in head anil
I'us in tympanals and laby-
Mr. Am ry,
years,
ear. Twenty-two
rinth ; auditor] nerve of
MS. notes and
diseliarge
daye.
I dlft colour; purulent
preparation,
from left ear.
matter deposited cm the
itirface of the medulla
oblongata, crura cerebri,
to Author.
an i i i varolii.
CERTAIN AFFECTIONS OK TI1E EAR. 253
Conclusion.
The preceding observations, together with the report of
cases, as detailed in the Tables, appear to show that chronic
catarrhal inflammation affecting the dermoid layer of the
membrana tympani, the dermoid meatus, or the mucous
membrane lining the cavity of the tympanum, if allowed to
proceed unchecked or uninfluenced by the aid of remedial
measures, is liable to produce results fatal to life. These
fatal results may occur within the first few months of the
existence of the disease, or they may be deferred so long as
ten, twenty, or even fifty years ; in some cases patients die
at an advanced period of life from disease quite independent
of that in the ear. The result of my investigations, never-
theless, tends to show, that the affections above named cannot
exist during many years, without causing a greater or less
amount of disease in the bone, dura mater, or brain ; and it
is evident from the inspection of cases, in which some disease
irrespective of the ear has caused death, that a very trifling
exciting cause would have been sufficient to give origin to
fatal disease in the brain. It is important, therefore, to bear
in mind, that the bone, dura mater, and substance of the brain,
may be slowly undergoing disorganisation without the pre-
sence of any other symptoms, calculated to reveal to the
medical man the existence of formidable disease, than the
presence of a discharge from the external auditory meatus.
From the facts cited above and in the following Tables, I
think it may be laid down as a rule, that no person suffering
from chronic catarrhal inflammation of the dermoid layer of
the meatus, the membrana tympani, or of the mucous membrane
of the tympanum* can be assured that disease is not being
prolonged to the temporal bone, the brain, and its membranes ;
and that any ordinary exciting cause, as an attack of fever
or influenza, a bloiv on the head, fyc, may not induce the
appearance of acute symptoms, which, as a general rule, are
speedily fatal.
1 In these three affections are included the great majority of cases hitherto
styled — otorrhea.
254
MR. TOYNBEE ON THE PATHOLOGY OF
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260
MR. TOYNBEE ON THE PATHOLOGY OF
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CERTAIN AFFECTIONS OF THE EAR. 261
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17
202
MR. TOYNREE ON AFFECTIONS OF THE EAR.
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i).
A CASE OF
OBSTRUCTION OF THE COLON,
RELIEVED BY AN OPERATION PERFORMED AT THE GROIN.
BY
JAMES LUKE,
SENIOR SURGEON TO THE LONDON AND ST. LUKE'S HOSPITALS,
LECTURER ON SURGERY, AND
MEMBER OF THE COUNCIL OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND,
ETC., ETC.
COMMUNICATED BY
JAMES MONCRIEFF ARNOTT, F.R.S.
Received April 25th. — Read June 2-lth, 1851.
The interest attached usually to cases of Intestinal Ob-
struction arising out of the obscurities by which they are
attended, and the treatment of them by operation, induces
me to believe, that the following may not be unacceptable
to the Society. Under that impression, and with the inten-
tion of placing it in connection with those other cases of
intestinal obstruction, of which its members are already
cognisant, I have prepared a report for the Society's consi-
deration.
The subject of my report is a man 60 years of age, by
profession a wine cooper ; thin, and of temperate habits.
He applied at my residence Dec. 16th, 1850, complaining of
being generally unwell. He attributed his ailment to a cold,
which he thought he had taken about five weeks previously,
by remaining for a considerable time in a damp cellar. He
did not complain of any pain, but his countenance was
264 mr. luke's case of
depressed ; his eyes sallow, and his tongue coated. There
was not any increased frequency of pulse, nor increased heat
of skin. Upon inquiry, he stated that his bowels were con-
fined, and that lately he had some difficulty in getting
medicine to act upon them. His complaints were considered
to be the result of ordinary constipation, and two pills con-
taining grs. x of Pil. Rhei Comp. were ordered to be taken
immediately.
17th. After the pills were taken, there was one small
evacuation of lumpy freces, but from this he did not ex-
perience any feeling of relief. He was ordered to take 5j of
Castor Oil, which he was to repeat provided the bowels
should not be opened before the evening.
18th. By the continued mastication of bread (as in-
structed), the Castor Oil remained on the stomach four hours,
and was then rejected. In the evening he took = ss of
Castor Oil, which was also rejected. This morning he feels
worse, his bowels have not been relieved, and he vomits
everything taken into the stomach. He complains of pain
at the pnecordia, and also in the neighbourhood of the
caecum, in which latter situation the abdomen is somewhat
tumid, but in neither situation is the pain increased by the
pressure of the hand. The skin is hot, the pulse quick, and
the tongue thickly coated. The urine is scanty, and on
cooling is very turbid from the deposit of lithates. He
feels so unwell that he is not enabled to go to business,
which he has done up to yesterday.
Ordered a blister, to be applied to the pit of the stomach,
the surface of which is to be dressed with lint dipped in
It. Opii. He is to take one grain of Calomel with a quarter
of a grain of the Extract of Opium, every four hours ; and in
the evening ;jss of Infusion of Senna, with .^ss of Epsom
Salts, and ,;j of Tincture of Ginger.
19th. The sickness has ceased, and he feels better to-day.
There has not been any evacuation from the bowels, and the
abdomen has become more tumid, yet the pain which he
spoke of yesterday, is less. The transverse colon can be
OBSTRUCTION OF THIS COLON. 265
traced across the abdomen, distended and tympanitic. The
blister has produced vesication.
Ordered to take two drops of Croton Oil on bread, made
into pills.
20th. There has not been any action on the bowels, and
the abdomen is still more distended. There is some pain
over the crecum, but not in any other part, even when pressed
with the hand. The skin is cool and moist. He feels
weak, and a troublesome hiccough has supervened, which
occasionally distresses him much. He abstains almost
entirely from food, from a fear that the taking it will cause
vomiting.
Ordered a large injection of salt and water, to be thrown
up the rectum ; and to take fifteen grains of compound
extract of Colocynth with two grains of Calomel.
21st. I requested Dr. Munk to meet me in consultation.
The injection had brought away a small quantity of hardened
feces, but the medicine had not produced any evacuation
from the bowels. The abdomen has become more tumid
and tympanitic, and the sensation of air passing from one
part of the abdomen to another, has frequently been ex-
perienced by the patient. There is little or no pain, but
there is a feeling of distension. He feels weaker, and is
evidently more prostrate, and the hiccough is occasionally,
but not constantly, very troublesome. Both Dr. Munk and
myself think there are strong grounds for supposing that
obstruction exists in the bowels, but that at present it is
premature to adopt that opinion definitively until further
trial has been given to medicine. By way of exploration,
the oesophagus tube was passed into the rectum. When
introduced to the extent of twelve inches, its further pro-
gress was obstructed, and it could not be passed beyond
that limit. "Warm water, injected through the tube, re-
turned immediately without bringing away any feces.
Ordered one grain of Aloes, and half a grain of Calomel,
every hour. Two drops of Croton Oil on bread to be used
as a suppository.
266 mr. luke's case of
22d. There has not been any relief from the bowels, and
the patient is evidently worse. The abdomen is more dis-
tended, and the pulse has become irregular and weak.
Ordered to continue the pills.
23d. Symptoms are still worse than yesterday, and the
patient has passed a very bad night. There have not been
any evacuations from the bowels, and the disteusiou of the
abdomen has much increased. The hiccough continues,
but the sickness has been stayed ; the pulse is very irregular
and weak ; the countenance is pinched. With symptoms
progressively becoming more severe, without reasonable
grounds for hope of relief from the further administration
of medicine, Dr. Munk and myself thought that the time
had arrived when it was our duty to propose operative
interference, under the idea that the obstruction of the
bowel which, on the 21st, we strongly suspected, did really
exist, and was irremediable by other means.
Before adopting that conclusion, we were fully aware of
the uncertainties generally attendant upon abdominal section
in such cases, and of the undesirableness of such a proceed-
ing, except with the presence of some pretty clear indication
of the seat of obstruction, by which our endeavours might
be directed. Before proposing an operation, we had, there-
fore, to determine whether the indications in the present
case, of the probable scat of obstruction, tended to remove the
objections usually opposed to an operation, such as that the
performance of which we now meditated on. In reviewing
the previous progress of the case, it was recollected, that in
its development the colon had been prominently distended,
and nearly its whole course well defined through the
abdominal parietcs. The inference from this fact was
of great importance, for it clearly indicated that the whole
of the distended intestine must be above the point of ob-
struction, and it followed as a consequence, that the obstruc-
tion occupied a position near to its lower extremity. A
confirmation of this view was derived from the introduction
of the (£S0phagn8 tube which had been used, per anuni, on
OBSTRUCTION OF THE COLON.
267
the 21st, when it met with obstruction to its passage about
twelve inches distant from the orifice. The water injected
tlirough the tube had also immediately returned. Con-
sidering the whole of these facts in connection, we thought
we were justified in concluding, that the obstruction was
situated about the sigmoid flexure of the colon, a position
in which such obstructions are not infrequently found. We
accordingly determined to act upon that conclusion, not, how-
ever, forgetting that the conclusion was liable to be erroneous.
I had nest to determine the particular kind of operation
which I would select for performance. Assuming the
correctness of our conclusion, that operation which passes
under the name of Amussat, appeared to recommend itself
by the circumstance of its avoiding the necessity of peri-
toneal section ; and was suggested to me on that account.
Yet, as I thought it not prudent to assume that our con-
clusion respecting the seat of obstruction was certainly
correct, I determined to adopt that operation which would
at least give me some opportunity of extending my search,
provided I did not find the obstruction at the point vhere
it was supposed to be, thinking that the increased proba-
bility thus afforded, of finding the obstruction, would be
more than an adequate compensation for the little increased
danger from peritoneal section. I therefore opened the ab-
dominal parietes near the groin. Assisted by my colleague
Mr. Wordsworth, Mr. Tomkins, and Dr. Munk, I made a
nearly perpendicular incision, about four inches in length, a
little to the outside of the course of the epigastric artery,
the lower extremity of which incision terminated a little
above Poupart's ligament. This part was rendered pro-
minent by the distended intestine bulging forward, and was
selected for the above reasons, as well as for the purpose of
avoiding the epigastric artery. The abdominal muscles and
fascias were divided in succession, and the peritoneum
opened to the extent of about two inches. The colon,
greatly distended, presented itself at the opening, with a
considerable tendency to protrude ; this, however, was ob-
268 Mil. LUKli's CASK 01
viated by the hand. When a finger was introduced, serous
fluid, to the extent of several ounces, made its escape, and
when the finger was passed along the surface of the intestine
in a downward direction, it came in contact with a hard
diseased mass, which appeared to encircle the intestine, and
limit the extent of its distension. This was recognised to
be a stricture. Having thus clearly ascertained the precise
seat of obstruction, and its cause, I proceeded to open the
intestine above the part obstructed. This was accomplished
at the part which presented itself at the opening in the
parietes, by means of a longitudinal incision through the
tunics to the extent of about one inch. Through the
aperture thus made, half a chamber-utensil full of fluid
fseculent matter made its escape, after which the patient
expressed himself much relieved. The finger was next in-
troduced, through the intestinal aperture, towards the rectum,
when it was ascertained that the colon had been rendered
impervious by the stricture, about two inches from the
aperture. Having thus satisfactorily accomplished the object
of the operation, the wound was partially closed by two
sutures, the lowest of which was passed through one of the
appendices epiploic^ which lay conveniently for. the purpose ;
this being done with the intention of securing a correspon-
dence between the intestinal and parietal apertures, for the
more ready discharge of fieculcnt matter through the wound.
The surface was loosely covered with lint, and the patient
replaced in bed. He was but little exhausted by the opera-
tion, and did not sustain a greater exposure of the peritoneal
surface than is common in the ordinary operation for stran-
gulated hernia. Twenty drops of Tr. Opii were ordered to
be taken immediately, and brandy-and-watcr and beef-tea
occasionally.
Dec. 21th. The patient has passed a good night, and is
much better this morning. He is cheerful, and talks of
his recovery, and of his return to business. The pulse has
recovered its regularity, and has more si length. The at-
tendants state that more than half a pailful of f;eees lias
OBSTRUCTION OF THE COLOX. 269
passed from the wound during the night, and the abdomen
has become flat and free from tympanitis.
Ordered nourishment and brandy-and-water, and the
parts to be kept very clean by the frequent removal of the
discharges which take place from the wound.
25th. He has passed an indifferent night, and is not so
well as yesterday. He is more exhausted, and the tongue
and mouth are dry. The instructions respecting cleanliness
have not been attended to, and the thigh and lower part of
the abdomen have, in consequence, remained covered with
faeces. He complains of this neglect, and is much irritated.
To obviate this, in future, a constant nurse is to be provided.
Ordered 20 drops of Tr. Opii at bedtime, and an addi-
tion to the nourishment and stimulus.
2Gth. He has slept well during the night, and is recovered
from the depression of yesterday. His tongue is moist, and
his pulse good. He is free from pain, and can bear the
pressure of the hand on the abdomen without inconvenience.
The surface which was yesterday covered with fasces, is now
affected by erysipelas.
Ordered to continue the use of nourishment, and to take
half a bottle of wine daily. Collodion to be applied to the
erysipelatous surface and surrounding part.
27th. In all respects better. Erysipelas has disappeared.
The nurse reports that two stools have been passed per
anum, but fasces continue to be passed through the wound.
He says he is weak, yet his pulse is good, and his tongue
clean.
Ordered, Collodion to be again applied to the surface
near the wound, for its protection from faecal discharges.
Jan. 1st. He has continued to improve since the last
report, and several evacuations have been passed per anum.
His appetite is as good, or nearly so, as in health. I found
him raised in bed eating his dinner. The position has
caused a tendency to protrusion of the intestine at the
wound. The sutures have ulcerated and were removed, their
place being supplied by pieces of adhesive plaister drawn
270 mr. luke's case or
across the upper part of the wound. To prevent the ten-
dency to protrusion, the patient was ordered to keep in the
recumbent position, and a cushion was bound over the part
for its support.
20th. The improvement has been uniform since the last
report. For some days the wound has been healed, with
the exception of that part corresponding to the aperture in
the intestine. The mucous membrane of the intestine
projects slightly through the aperture of the parietes, which
is of sufficient size to admit the point of the finger, nor
does it appear to have any disposition to contract. There
is but little faeculent discharge at this aperture, and that
little is restrained by the use of a pad and circular belt.
The faces are almost wholly passed per anum. The strength
has very much increased, and his appetite is excellent.
During the last few days he has walked out, and to-day has
walked a distance of two miles. It was intended to attempt
the dilatation of the stricture by the introduction of bougies
through the wound; the passage of faces by their natural
course has been so free, and apparently unobstructed, that
this intention has been considered unnecessary to be acted
on. The only direction given, is to support the part, and
close the aperture by the continual use of the pad and belt.
30th. The passage of faeces, per anum, has again ceased.
A bougie having been introduced through the groin, they
again partially returned to their natural channel ; the greater
part, however, pass by the opening at the groin, and some
inconvenience has been experienced from their constant
tendency to escape. A well-fitted truss has been used with
success to obviate this tendency, since the use of which lie
has suffered but little inconvenience, and has been enabled
to pursue his ordinary occupation to the present time almost
without interruption.1
1 August 20th. To this date the patient has continued at his employment
without interruption, nor has he found i1 ae& w] I a single
day. The wound at the groin remains nearly as at the last report in
January, and the truss effeotualrj prevents the est tp md, from
OBSTRUCTION OF THE COLON. 271
The foregoing case furnishes a good illustration of a class
of obstructions probably of more frequent occurrence than
any other aft'ecting the intestinal canal. In connection with
it arise some interesting and important practical considera-
tions. In the first place, it may be worthy of remark, that
difficulties and dangers which always attend obstructions,
occupying the upper part of the intestinal tube, are, in some
degree, mitigated in those forms which occupy its lower
extremity; and symptoms, which in the former run their
course to a fatal termination, with a rapidity which leaves
little time for deliberation, in the latter, are often gradual and
insidious iu their access, and slow in their progress, so that
many weeks may elapse, even when unrelieved, before they
become fatal. Exceptional cases, however, not infrequently
occur, which demand a promptitude of relief equal to that
demanded by any other class. There can be little doubt,
that in every case of ascertained mechanical obstruction,
protracted delay militates greatly against the success of
operative proceedings when ultimately adopted, and on that
account should be avoided as far as the circumstances of the
case will admit. In this respect the above case contrasts
favorably with one of a similar nature, which occurred to
me some time since at the London Hospital, and reported
in Mr. Phillips's excellent paper on Intestinal Obstructions,
published in the Thirty-first Volume of the Transactions of
this Society. Iu that case the thirteenth day of total ob-
struction had elapsed when I first saw the patient. On the
fourteenth day an operation similar to that in the prescut
case was performed. On the following day the patient
died. Examination revealed a rupture, to the extent of
six inches of the peritoneal tunic, at the transverse colon,
which had doubtless taken place through over-distension.
On the other hand, it is difficult, if not impossible, to
this circumstance, lie suffers very little inconvenience. A part ouly of the
faeces is discharged at the groin ; the remainder passes naturally, per anum.
The patient reports himself well in general heafth, and nearly as strong as
before the operation.
27.2 mr. luke's case of
determine with certainty the dependence of symptoms
upon mechanical obstruction, at an early period of their
development ; or to distinguish them from symptoms aris-
ing from constipations, the result of arrested function.
Time alone, in many, makes manifest the true state of
the case, and although this involves a necessity of delay,
there appears to be no other advisable alternative. The
difficulties of diagnosis are, therefore, the principal obstacles
to a prudent, yet decided and effective, course of treatment
in many of these forms of disease, and it consequently
becomes a matter of more than usual importance, and
requires the most careful study in each case. The attention
which this subject has already received from Mr. Phillips,
in the valuable paper referred to, renders it unnecessary
that I should enter upon it at large. But I might ob-
serve, that symptoms of mechanical obstruction should be
admitted with extreme caution, for the reason, that they arc
more or less common to these aud to other affections. Thus
pain, constipation, sickness, and distended abdomen, may
depend upon mere functional disturbance, and cither sepa-
rately or in combination, while some of them may be absent,
or exist in a very slight degree under the actual presence of
mechanical obstruction. With respect to pain, little in-
formation is generally to be derived from this symptom,
which will serve the purposes of diagnosis. In some cases,
it is a severe attendant upon obstruction, in others, it is
absent, or exists in a slight degree only. It is important
to mention, that, when present, it is not generally referred to
the scat of obstruction, but to some other and distant part .
If relied on by the surgeon as a guide to the obstruction, it
may therefore mislead, when the question of the position of
an operation becomes a matter to lie determined on. Thus,
in five cases of obstruction at the sigmoid flexure of the
colon, the pain was referred by the patients to the region of
the umbilicus, a circumstance illustrative of the little depen-
dence which should be placed upon the symptom of pain in
directing the course of surgical proceedings in such cases.
OBSTRUCTION OF THE COLON. 273
Witli respect to constipation, although this symptom is
present in all forms of mechanical obstruction, it is equally
so in some forms of mere functional derangement. In the
case of a female, I was witness to the persistence of consti-
pation for a period of thirteen weeks ; in that instance it
was the result of functional disturbance, and was relieved by
the administi'ation of purgatives.
Distended and tumid abdomen is also a symptom common
to mechanical obstruction and to functional inactivity, and
in both may be attended by uneasy feelings to the patient.
Although distension of abdomen may not generally be
deemed characteristic of mechanical obstruction, yet when
the many other circumstances, which are usually to be con-
sidered, lead to the supposition of its existence, it becomes
a very important evidence as bearing upon the demonstra-
tion of its seat ; and, in combination with the information
derived from the introduction of the oesophagus tube per
anum, will frequently determine the diagnosis with sufficient
accuracy for all practical purposes. In availing ourselves
of these means, due caution is requisite, for unless this be
observed, erroneous conclusions may be the result. The
affirmative evidence which a generally distended colon affords,
I have hitherto considered sufficiently conclusive that the
seat of obstruction occupies its lower part, for the reason,
that distension of intestine is limited to that part which lies
above the part obstructed. The interference, however, of
much fat on the abdominal parietes, or a general distension
of all parts of the intestinal canal, may obscure the defined
contour of this viscus, which is present in most cases, and
render any conclusion from this source uncertain or
difficult.
In like manner, the oesophagus tube, when introduced
per rectum, will be adequate to detect any obstruction
within its reach. But in using it, it is necessary to recollect
that the tube may be entangled in the folds and fleTxures of
the intestine, or in coming in contact with an obstruction,
may be bent, and return towards the rectum. In the first
274 mr. lure's case of
case the error may arise of supposing that an abnormal ob-
struction exists, when there is no such obstruction ; in the
last that there is not any obstruction when obstruction is
present. The latter source of error is detected by the in-
troduction of the finger into the anus. With due care in
the combined use of these two means of diagnosis, I believe
reliance may be generally placed in them for the purpose of
determining the seat of obstruction when it is situated in
the lower part of the colon.
When the diagnosis has been thus determined, the con-
sideration arises, what kind of operation is best to be
performed in these cases. Two have been proposed and
performed, the one by Amussat, and performed in the loins,
the other by Littre, and performed in the groin.
In the present instance the operation preferred was that
of opening the abdominal parietes at the left groin. Having
witnessed its results, and duly considered its details, I am
disposed not to regret the preference which I adopted. The
operation of Amussat, performed as it is at the loins, has the
appreciable advantage of not requiring an opening to be
made into the cavity of the peritoneum, by which circum-
stance the important object is obtained of diminishing, in
some degree, but not entirely removing, the probability of
the occurrence of peritoneal inflammation. The demerits of
the operation, however, are several, and possibly, upon review ,
will be considered to outweigh the foregoing advantage, even
in reference to the question of danger.
Foremost amongst tbese, may be stated the impossibility
of doing more for the patient's relief than opening the colon
at the scat of operation ; indeed this seems to be the only
object for which it can be undertaken. It is, however,
important to recollect, in reference to this matter, that
obstructions, even at the lower extremity of the colon, may
not always be of a character to require BUch opening, and in
some of them the opening of the intestine may lie im-
proper. Thus there are obstructions occasionally occurring,
produced by fibrous bands overlying the intestine, or by stiiin-
OBSTRUCTION OF THE COLON. 275
gulations, in either case the result of causes acting exteriorly
to its tunics. The proper treatment in such cases is to
divide the bands, or relieve the cause of strangulation. The
mere opening of the intestine above the seat of obstruction,
would probably be insufficient for effectual relief, since un-
removed constriction or strangulation would be likely to
continue their ordinary injurious effects upon the tunics of
the intestine, and to lead to the most serious of its usually
attendant consequences. This demerit derives additional
weight from the circumstance of the surgeon's inability to
predicate the cause of obstruction, and his consequent
liability, on the one hand, to make an opening, and inflict
an injury, which the circumstances of the case may not have
demanded, and on the other, to leave that unrelieved which
the emergency really required.
"When the diagnosis is correct, and the opening neces-
sary from causes existing within the tunics of the intes-
tine, experience has amply shown that the lumbar opening
is sufficient for the purpose in view of relieving the dis-
tended colon ; yet, in the event of an error in diagnosis,
it does not provide any facilities for its correction, and the
surgeon is dependent upon one venture for success. The
danger of total failure of affording relief consequent upon
this state of things, must therefore be attributable as a
demerit to the operation in the loins. It is scarcely neces-
sary to mention, that lesser, but still important, evils result
from position of the operation. Thus, in this position,
the feculent discharges which necessarily continue to pass
from the intestine through the opening, cannot be con-
veniently attended to by the patient himself; while experience
has shown that the disposition to contraction in the wound
arising from its great depth, may occasionally produce in-
terruption to their escape, and require renewed surgical
interfei-ence.
In all these particulars, with the exception of the* neces-
sary attendant of peritoneal section, the operation of opening
the abdominal parietes at the groin, as in the above-related
276 mr. luke's case of obstruction of the colon.
case, in all cases of obstruction or suspected obstruction in
tbe lower part of tbe colon, appears to me to be the opera-
tion which should be preferred.
It affords facilities for modifying the treatment, as may be
advisable after immediate examination of the cause of obstruc-
tion, either by opening the intestine when incapable of relief
by other means, or by dividing or removing any existing cause
of constriction or strangulation. It enables the surgeon to
extend his search within a limited range, when his diagnosis
of the seat of obstruction has been proved to be incorrect.
When requisite and proper, it enables him to open the colon
close to, or nearly close to, the seat of obstruction, and thus
preserve to the patient, for the performance of its proper func-
tion, the utmost extent of intestinal canal of which the case
is susceptible ; and it eventually secures to him those facilities
for attending to his own comfort, which appear almost a
necessary condition to make life endurable under such
circumstances.
ON THE VARIATIONS OF THE
SULPHATES AND PHOSPHATES
EXCRETED I>
ACUTE CHOREA, DELIRIUM TREMENS,
AND
INFLAMMATION OF THE BRAIN.
H. BENCE JONES, M.D., A.M. (Cantab.), F.R.S., F.C.S.,
PHYSICIAN TO ST. GEORGE'S HOSPITAL.
Received May 1st.— Read June 24th, 1851.
In the Medico-Chirurgical Transactions for 1817, some
cases are recorded of the variations of the quantity of phos-
phates excreted by the kidneys in delirium tremens, and in
inflammation of the brain. I stated in conclusion, "that the
excess of action, or the want of action of oxygen, may
possibly ultimately be proved by the balance, not only to be
traceable by its effect on the nervous tissue, but that other
tissues may give a corresponding result ; with this view, the
variations of the sulphates in disease deserve the most careful
investigation."
In the present communication, I purpose to relate the
most remarkable cases I have met with of the variation of
the sulphates in disease.
Generally, the variation of the sulphates and phosphates
in the healthy urine of a person on mixed diet, taking
moderate exercise, may be stated thus : —
The sulphates vary— SpMifi0
gravity
After food, from 11-S5 grs. of sulphate of baryta per 1000 grs. urine, 1033'9.
Before food, to 793 grs 10265.
xxxiv. 18
278 DR. BENCE JONES ON THE VARIATIONS OF
The phosphates vary — BpwBta
gravity.
After food, from 7'22 grs. of phosphate of lime, per 1000 grs. urine, 1030'0.
Before food, to 7'96 grs 1027-9.
(See 'Philosophical Transactions/ 1845 and 1849.)
Having determined the variations of the sulphates in
the state of health, when different diets, and different
amounts of exercise, and different medicines were taken, I
proceeded to examine the variations of the sulphates in
disease. At the same time, the total amount of alkaline and
earthy phosphates was determined, partly in order to see
whether the amount of sulphates and of phosphates bore any
relation to one another, and partly to test the conclusions
which were drawn in my previous paper, on the variations
of the phosphates in disease.
The detail of 58 cases, in which 148 determinations of the
amount of sulphates and phosphates were made, would be too
long for this Society. But a few of the most interesting
examples out of the most important classes into which the
cases were divided, may possess some interest, and not be too
tedious.
The cases were thus classified • —
1. Acute and chronic diseases, in which the muscular
structures were chiefly affected.
2. Functional diseases of the brain, as delirium tremens
and some other forms of delirium.
3. Acute inflammatory diseases of the nervous structures.
4. Chronic diseases of the nervous structures.
5. Acute diseases, in which neither the nervous nor the
muscular structures were chiefly affected.
6. Chronic diseases, in which neither the muscular nor
the nervous structures were chiefly affected.
The last three classes I shall not dwell on here, a* they
gave only negative results. The numbers obtained in the
analyses will he found in the 'Philosophical Transactions' for
18.">0. In the first three classes respectively, cases of chorea,
of delirium tremens, and of inflammation of the brain are
included; and it is the variation of the sulphates and phos-
SULPHATES AND PHOSPHATES. 279
phates in these diseases, which I purpose to illustrate by the
most marked cases which came under my notice.
First, then, on the amount of Sulphates and Phosphates
in that disease in which the muscular structure is chiefly
affected, namely, chorea. Chronic chorea gave me no
marked results; but the following cases of acute chorea, that
is, in which the muscular motions were so intense and so
continuous that life was endangered, gave a most decided
increase of the sulphates, without any increase in the phos-
phates of the urine.
Class I.
Case 1. — Mary B — , set. 19, Holland Ward; admitted
March 8, 1848, having for the first time had rheumatic pains
in the lower extremities for three days. The skin was hot ;
pulse 120, full and hard ; tongue white; great thirst and loss of
appetite ; bowels confined. The right knee was swollen and
very painful on pressure, but not red. The ankles were hot,
red, and swollen, and very tender. There was a soft mur-
mur heard with the first sound of the heart, and some pain
in the epigastrium. Venesectio ad 3x'j> Cal., gr. x; Opii,
gr. J j hac nocte; lit. Semite eras; ht. Ammonite Citr., 4t,a horis.
9th. Passed a restless night. The pains becoming worse
when she perspired in bed ; ankles less swollen, but the
elbows and wrists are now affected ; pulse quiet ; blood
buffed and cupped ; heart's action is increased, but no
murmur is heard to-day.
10th. Had slight wandering and could not sleep at all.
She lies very low in bed ; has a slight cough ; perspires very
much; countenance is uneasy; so much pain in the joints
that she cannot have the bed-clothes on her; bowels open;
pulse quiet. Cal., gr. iij ; Opii, gr. \, ter die.
11 th. Catamenia appeared this morning.
13th. There was pain in the region of the heart, and she
was cupped to Jx ; the mouth was sore.
16th. There was pain in the left side; frequent cough;
and pulse 120. She was bled to 5xiv, and put again on
fever diet ; she had had beef-tea, a pint for two days.
280 DR. BENCE JONES ON THE VARIATIONS OF
17th. Blood buffed and cupped. The pains were relieved.
21st. Broth diet. — 22d. Fish diet. — 27th. Swellings,
pain, and redness are gone. She sleeps well; tongue clean;
bowels open ; appetite good. Ordinary diet.
April 3d. Improving ; slight pains occasionally.
8th. Was attacked with chorea this morning. Broth
diet was ordered.
10th. Hydrarg. Chlor., gr. iij ; statim et ter die; Ht.
Senna? eras mane. Heart's action very rapid.
1 1 tli. Ulcers on the side of the tongue, which have the
appearance of aphtha; ; valvular murmur very distinct
towards the apex; motions very dark. Rep. Calomel,
ht. Sennae eras; ht. Nitri c. Vini Ant. Tart., 5J, 6"s horis.
12th. Has been very violent during the whole of the
night. Hirudincs viij ; reg. pub. statim.
13th. More quiet this morning, but very violent during
the night. Gums red ; pulse 120. Valvular murmur
towards the apex ; has had no sleep ; water caught this
morning scanty, thick, gives a deposit of much reddish
brown urate of ammonia, contained a minute quantity of
albumen, and about four ounces in quantity, became very
pink on the addition of ammonia. Specific gravity = 1032-3.
516'15 grs. boiled with Chlor. of Barium
and Nitric Acid, Sulphate of
Baryta =1205=2500 grs. per 1000 urine.
After being re-treated with acid, and re-washed.
516*15 grs. precipitated by Chlor. of Calcium
and Ammonia. Total phospbatcs=0'35 = O'fiS grs. per 1000 urine.
Some hours afterwards the same day about an ounce and
half of water was again caught. It was thick, as before,
from urate of ammonia. Specific gravity = 1035-2.
517'G0grs. boiled with Chloride of Barium
and Nitric Acid, Sulphate of
Baryta =ll-26 =21-73 gre.per 10'
After being re-burnt and re-treated.
Ht. Scnnae statim. Adde sing, haust. Viui Colcb., »lx ;
Liq. Potassic, i)|,xx.
SULPHATES AND PHOSPHATES. 281
14th. Has been very violent the whole of the night; had no
sleep ; ulceration on the tongue much increased ; has been
inclined to sleep during the morning ; bowels well open. Bal.
Calidum. Liq. Amm. Acet., 5vj; Ainrn. Sesqui-carb., gr. ij; Sp.
seth.Nitr., 3j; ht.Pin1ent.5vj; 6"shoris; ht. Morphise hac nocte.
15th. Has slept a good portion of the night, and seems
disposed to continue to do so ; is very quiet this morning.
Did not have the bath, because she was so very violent.
Skin very hot; bowels not open since yesterday; passes her
water in bed ; sweats very much ; tongue very much loaded.
Irregular spasmodic movements of the hands very much
less. Rep. Mist, et ht. Sennse si opus est.
16th. Was very restless and disturbed during the night;
bowels not open ; water passed this morning thick, chiefly
from urate of ammonia, and contains a trace of albumen ;
she is much quieter than she was. Specific gravity =1030-0.
515'00 grs. boiled with Chloride of Barium
and Nitric Acid, Sulphate of
Baryta ....... . =375 = 7'28 grs. per 1000 urine.
515"00 grs. precipitated by Chloride of
Calcium and Ammonia. Total
Phosphates (not pink) . . . = 3-80= 7'38
17th. Had morphia last night; had a very quiet night;
bowels opened without the aperient ; water passed this
morning, paler colour, slight cloud of urate of ammonia,
acid. Specific gravity = 1013-1.
506-55 grs. boiled with Chloride of Barium
and Nitric Acid, Sulphate of
Baryta = P30 = 2'56grs. per 1000 urine.
50G-55 grs. precipitated by Chloride of
Calcium and Ammonia. Total
Phosphates = 2-20 = 4-34
18th. Has passed a most excellent night ; there was no
necessity for a night draught ; herpes about the lips. Perst.
Hydr. c. Creta, gr. iij ; Doveri pulv., gr. ij, bis in die.
19th. Passed a very quiet night. Perstet.
20th. Slept well during the night, and is much better
282 DR. BENCE JONES ON THE VARIATIONS Oh
this morning. Gums red and sore ; systolic sound is much
softer ; pulse 84. Rep. pulv. et mist.
22d. Gums affected with mercury; systolic murmur much
softer ; pulse 8-k Fish diet.
24th. Ordinary diet. Ht. Sennre alt. mane. Perst.
25th. Does not seem able to collect her thoughts ; twitch
ing of the hands and legs rather leas.
26th. Ht. Ammoniae Citr., 6"s horis.
May 2d. Vini albi, 51J quotidie. Rep. ht., ter die.
4th. Right knee and ankle very red, and swelled, and
painful. Cal., gr. iv; Opii, gr. J, hac uocte ; lit. Semite eras
mane. Broth diet. Vini Ant., »lxx ; Vini Colch., mx ;
mist. Camph., jxj, ter die.
5th. Ankle and knee rather better.
6th. Left ankle and knee rather swelled and paiuful. lit.
Colchici c. Opio, nocte maneque. Ht. Semis: eras mane ct pro
re nata.
7th. Much better this moruing. The irregular spasmodic
actions still continue, and she does not appear to have it in
her power to express what she means.
8th. lit. Colch. c. Opio, hac uocte. Ht. Salin. ex Am-
monia, ter die.
9th. Continues to improve. Ordinary diet.
12th. Bowels not open ; pains in the knees and ankles
quite gone ; the spasmodic movements of the hands and feet
still continue without much change ; she seems better able
to collect her thoughts.
16th. Going into the country. Relieved.
The variations of the sulphates and phosphates may be
tabulated thus : —
Bnlphata of Baryta Specific
per 1000
On'the 5th day, afterSulphate of Magnesia. 8B-09gra. , L032-8 , 0-68 btb.
„ 5th da; later „ . 21-73 „ . 1035-2
„ 8th day, quieter, „ . 7-88 „ . 1080O . C'84 ,.
„ 9th day „ . 2-56 „ . 10131 . W0 ..
In this case the Sulphate of Magnesia which was given
interferes with the result. and renders it less conclusive than
SULPHATES AND PHOSPHATES. 283
it would otherwise have been. The diminution of the phos-
phates is very remarkable, and probably arose from the
small quantity of food which could be taken.
Case 2. — Charles G — , ait. 8, Hope Ward; admitted
Nov. 16, 1849. Had scarlet fever three weeks previous to his
admission. Was attacked by chorea three days ago ; it is
supposed, in consequence of cold, as he got out of bed in his
night shirt without his shoes, and crept through a hedge into a
field, where he was found in consequence of his cries. When
brought home he had a rigor, and two days afterwards the
chorea began. On admission he was not able to stand or
to feed himself. He slept well; but the fits of motion came
on always stronger at night than during the day. His face
was flushed. He took two minims of Liq. Potassse Arsenitis
thrice daily, with aperients, and afterwards he took bark.
In a week he improved; and about Christmas he was able to
feed himself and to walk across the ward without help.
December 31st. This day very excited and very weak.
He was ordered to omit the bark, and to take two tea-
spoonfuls of wine every four hours. From this day violent
spasmodic action commenced, which hindered him from
obtaining any sleep, and prevented him from taking but
very little food.
January 2d. Can get very little sleep, is " continuously
on the work in every muscle." Able to swallow only a
little arrowroot and wine.
3d. The bark was continued. His motions were very
violent, altogether preventing all sleep. The face was very
flushed.
4th. Strong muscular action continues. Obtains no sleep.
Has been unable to speak for the last four days, from the
involuntary motions of the tongue. He was this day ordered
the sixth of a grain of tartarised antimony every six hours.
5th. Rather more quiet and has had a little sleep.
Urine passed this morning at half-past ten, a.m., the first
that could be obtained throughout this period of excitement,
was of a light yellow colour. Gave a very large deposit
284 DR. BENCE JONES ON THE VARIATIONS OF
of urate of ammonia. Was acid to test-paper ; gave with
nitric acid immediate crystallisation of nitrate of urea.
Specific gravity, 1030-6.
515-3 grs. precipitated bj Chloride of
Barium and dilute Nitric Acid,
Sulphate of Baryta . . = 5-80 = 1125 grs. pcrlOOO uriue.
5153 grs. precipitated by Chloride of
Calcium and Ammonia, Phos-
phate of Lime . . .=1-70= 3-29
6th. Has had a good night, and is much quieter. Tongue
furred ; pulse 84, weak ; asked for his dinner. The urine
passed at ten, a.m., was obtained; gave a large deposit
of urate of ammonia. Specific gravity = 103T8.
515-9 grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 5-50 = 1066 grs. pcrlOOO urine.
515-9 grs. precipitated by Chloride of
Calcium and Ammonia, Phos-
phate of Lime . . .= 1-30=2-52
7th. Urine passed early this morning. Had the same
appearance as yesterday. Specific gravity = 1031-2. gave
crystals of nitrate of urea immediately on the addition of
nitric acid.
515-6 grs. boiled with Chloride of Ba-
rium and dilate Nitric Acid,
Sulphate of Baryta . . = 575 = 1P15 grs. pcrlOOO urine.
515'Ggrs. precipitated by Chloride of
Calcium and Ammonia, Phos-
phate of Lime . . . = 1,81=8,B4 ,,
9th. Urine passed this morning early, the involuntary
motions being much less. Specific gravity = 1028-1; urine
acid to test-paper; still gave a large precipitate of urate of
ammonia.
514,-9 grs. boiled -with Chloride of Ba-
rium and dilate Nitric Acid,
Balphate of Baryta . . =3-80= 7*39 grs. per 1000 urine.
514'3grs. precipitated bj Chloride of
Ciii'iiiiu and \nihimii.i, l'hos-
of Lime . . . - l*80> 3-60
SULPHATES AND PHOSPHATES. 285
10th. Pulse 84 ; much quieter ; has taken his dinner of
arrowroot; is still hardly able to protrude his tongue, incon-
sequence of the involuntary motions ; urine passed early this
morning. Specific gravity = 10186 ; much clearer, more
plentiful, and rather paler.
509-3 grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 2'00 = 392 grs. per 1000 urine.
509-3 grs. precipitated by Chloride of
Calcium and Ammonia, Phos-
phate of Lime . . .=0-80 = 157
14th. Has continued improving, becoming quieter each
day ; pulse 84 ; tongue slightly furred, and protruded more
slowly and steadily. Has taken no solid animal food what-
ever; since the 6th of January, his food has been arrowroot,
milk, and beef-tea. Has continued two ounces of wine daily.
Urine passed this morning quite clear. Specific gravity =
10160.
50S-0grs. boiled with Chloride of Ba-
rium and Nitric Acid, Sul-
phate of Baryta . . . = 2"20 = 4-32 grs. per 1000 urine.
508'0 grs. precipitated by Chloride of
Calcium and Ammonia, Phos-
phate of Lime . . . = 070 = 1-37
April 11th. Has been gradually improving up to this
time. Urine passed this morning, acid; not of a deep colour.
Specific gravity = 1030-6.
515-8 grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 4'20 = 8'01 grs. per 1000 urine.
He has for some time had full diet, and been able to take
some exercise. His weight, about this time, was only 3 libs.,
and his height 4 feet 1 inch. He remained in the house
until the end of May, when he went home; he became much
more unsteady almost immediately after his return, and he was
readmitted under my care on June 12th. He remained suffer-
ing from chronic chorea for some months ; he went out, but
Sulphate of
linn la.
Urine.
Specific Total
Gravity. Phosphates.
l nm
11-25 grs.
per
1000
1030-6 329 grs.
10-66
,,
1031-8 2-52
„
11-15
H
1031-2 2-54
„
r 7-39
,,
L0284 3-50
„
3-92
„
101S-6 1 57
„
8-01
M
1030-6
286 DR. BENCE JONES ON THE VARIATIONS Of
very slightly improved; all medicine was omitted; no further
treatment was adopted, and he came to his Ward on January
21st, 1851, perfectly steady, and much stouter than when he
left the house. He says that within a month after leaving
the hospital, he got quite well, without taking any medicine;
and since then he has grown stout. Can walk about quite
steadily, face full and fat, and complexion ruddy.
The variations of the sulphates and phosphates may be
arranged thus : —
6th day, very violent
7th day
8th day
10th day, much quieter
11th day
102dday
When it is remembered that this patient was only eight
years old, weighing, at this time, less than 34 lbs., and taking
scarcely any food, the increase of sulphates is most remark-
able. When the sulphates were most, then an excess of
urea was always detectable. The phosphates were not in-
creased, nor indeed (though the abstinence from food was
excessive) are they remarkably diminished.
The comparison of the amount of sulphates on the 6th,
7th, and 8th days, when the disease was at its height, and
on the 102d when the patient was convalescent and eating
full diet, is worthy of remark.
Case 3. — Elizabeth C — , set. 23, servant, Queen's Ward ;
admitted March 27, 1850. Had slight chorea lor a fortnight
previous to her admission, and had been out of health during
the winter. Particularly observed to be more irritable in
her temper, and to have lost her sleep. No appearance of
worms had been noticed in the motions. She was given
ordinary diet, with an aperient of Calomel and Seaminony,
five drops of Liq. Potass. Arscnitis three times daily. She
was not obliged to keep her bed.
31st. The nurse observed that she w&a strange in her
SULPHATES AND PHOSPHATES. 287
manner, and she went to bed in the afternoon because she
felt ill. She vomited ; and was much more unsteady than
she had previously been.
April 1st. The catamenia appeared. She became very
restless, and the face was much Hushed ; at night she was
delirious. The bowels not having acted, she was ordered
Pul. Cal. c. Jalap., 9j, statim ; lit. Sennse, post horas tres.
2d. The symptoms remain the same. The urine passed
late in the evening was of a reddish colour, contained a
thick deposit of urate of ammonia ; on the addition of
caustic ammonia, the red colour of senna and alkali appeared.
On the addition of nitric acid, an immediate crystallisation
of nitrate of urea formed. There was also a trace of
albumen. The urine was acid to test-paper; and very de-
cidedly acid on the 6th. Specific gravity = 10360.
518-0 grs. boiled with Chloride of Ba-
rium and Nitric Acid, Sul-
phate of Baryta . . . = 10-30=19-88 grs. per 1000 urine.
Ice was applied to the head. Two pints of strong beef-
tea, and a pint of milk, for her food. Liq. Opii Sedativi, ni,xv;
Sp, iEth. Sulph., 5ss; ht. Piment., 5x3, 6"3 horis; Ferri Sesqui-
oxyd., 55s, e. faece sacchari 6tla horis alternis; Enema Vesp. c.
P. Jalapae, ;;iij.
3d. 01. Ricini, gss, statim. Enema commune eras cum
ht. Sennae, Jj. Chorea very violent.
4th. Remains in the same state ; catamenia still slightly
present. Vini Rubri, Jij, ter die; urine passed this morning
very deep coloured ; contained scarcely a trace of albumen ;
gave a very large precipitate of urate of ammonia ; and on
the addition of nitric acid, it gave an immediate crystallisa-
tion of nitrate of urea. Acid to test-paper. Specific gra-
vity = 1033-8.
5169 grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 8-20 = 15-86 grs. per 1000 urine.
5th. Still continues delirious, and in violent motion,
though the spasmodic action is less violent to-day. No
288 DR. BENCE JONES ON THE VARIATIONS OF
water had been passed from twelve o'clock midday yesterday,
excepting a small quantity, which was passed involuntary
under her. At twelve o'clock this day the water was drawn
off, in quantity 32 ounces ; deep coloured, gave a plentiful
deposit of urate of ammonia. No trace of albumen. Acid.
Specific gravity = 1028-4.
5142 grs. boiled with Chloride of Ba-
rium and Nitric Acid, Sul-
phate of Baryta . . . =7-10 = 1380 grs. perlOOOuriue.
514'2grs. precipitated by Chloride of
Calcium and Ammonia, Total
Phosphates. . . . = 335 = 651
6th. Urine drawn off to-day at twelve o'clock. Not so
deep coloured. No deposit of urate of ammonia. Did not
give with nitric acid an immediate precipitate of nitrate of
urea. Contained no albumen. Specific gravity = 10268.
513'4grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 4S0= 936 grs. per 1000 urine.
7th. The last twenty-four hours she has become much
quieter; but she bursts into fits of crying without any
reason. Urine drawn off at twelve o'clock, about 19 ounces,
not so deep coloured. Gave no deposit of urate of ammonia.
Contained no albumen. Specific gravity = 1025"4.
5127 grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 310 = 6'08 grs. per 1000 urine.
8th. Urine passed by herself without the catheter, much
paler colour. Tongue coated at the back. Skin perspiring
much. Is lying nearly quiet; much exhausted, but free from
spasmodic motions.
l:-'th. Is gaining strength. Urine made last night, and
early this morning. Acid; clear. Specific gravity = 1016' 4.
50S2grs. boiled with Chloride of Ba-
rium and dilute Nitric Acid,
Sulphate of Baryta . . = 9'40= 472 grs. per 1000 urine,
Specific
Gravity.
1036-0
Total
Phosphates.
10338
1028-4
6-51 grs. per
1026-8
1000 urine.
1025-4
1016-4
SULPHATES AND PHOSPHATES. 289
17th. There is the slightest spasmodic action of the
muscles.
21st. She went out steady. Able to walk well.
The variation of the salts may be seen in the following
table : —
Sulphate of
Baryta.
3d day, very violent 19-8S grs. per 1000 urine.
5th day „ 15-86
6th day „ 13-80
7th day „ 9'36
Sth day, much quieter 6-08 „
13th day „ 472
On the 3d day the amount of sulphates depended on
the sulphate of magnesia, as well as on the violent action of
the muscles. Nitrate of urea crystals formed immediately
on the addition of nitric acid to the urine.
The 5th and fith days, no salts were taken, and the in-
crease of the sulphates was very decided. The urea was
also in excess. The phosphates were not diminished. As
the muscular action became quieter, the sulphates in the
urine diminished.
Cases of acute chorea as severe as these are very un-
common. From the commencement of this investigation I
have, as yet, seen but one other case ; and in that, also, the
urine immediately gave evidence of an excess of urea. To
the eye the amount of Sulphates precipitated by chloride of
barium, after boiling with hydrochloric acid, appeared to be
in excess. But this mode of estimating the amount of
Sulphates without the balance, is too uncertain to be trusted.
It is worthy of notice, how high the specific gravity of the
urine is in the three cases related ; this was not only owing
to the amount of urea in solution, but still more to the
amount of Sulphates. These salts increasing the specific
gravity three times as much as an equal quantity of urea
would do.
I pass on, secondly, to the amount of Sulphates and Phos-
phates in some functional diseases of the brain. The fol-
lowing four cases of delirium tremens I place in this class.
290 DR. UENCE JONES ON THE VARIATIONS OF
Class II.
Case 1. — Jessie P — , set. 39, Fuller Ward ; a carpenter,
and keeper of a beer-shop. Admitted March 29th, 184-7.
Said to have had a fit three years ago; and last Christmas is
said to have had another fit, which was thought to be apoplec-
tic. On the 20th of this month he again felt the warning of a
fit. For this he was bled to syncope, and the bleeding was
repeated, but this treatment did not avert the fit ; after the
fit he was blistered and mercuralised. He then became
delirious, but got some sleep at intervals, and remained in
this state until Saturday the 27th. The delirium then
became very violent indeed, and he has not slept since.
When brought to the hospital, he struggled violently and
talked incessantly, and there was constant and general tremor
of the lips and hands. Though he was reported to be a
sober man, yet, on inquiry, it turned out that he was much
the contrary. 6 p.m., skin pale and clammy ; pulse scarcely
perceptible ; right pupil very much dilated ; left, very much
contracted and not acting. Passed some urine in bed at
10 o'clock in the evening. Bowels not open. Emp. Cauth.
Nucha;; Tr. Opii, 5ss ; Sp. Ammonia Axomat., .sss; Sp.
.Ethcris C, 5j ; Armae Pimentse, jjss ; statim. Rep. at.
sine Tr. Opii, 2'1'" horis.
10th day, 30th. Has been very violent all night; has
had no sleep; took four ounces of brandy during the night.
Bowels not open at half-past 10, a.m. Enema statim.
2 p.m. Four ounces of water drawn off; acid, contained
oxalate of lime, slightly albuminous, with some fibrinous
ea>ls. Specific gravity = 102 I? 1.
Rc-trcnt. .1
512-37 graius of iirinr, inii'ipil.-ilrd bj Chloride I'nnr.
of Barium, and \<-iil : Bulpliatcol Karyta = ss?=17 31 grs.pcrlOOO
512'5<i ipitated by Chi. Cal. anil
Ammonia, Pho phateol Liime. . = <rt."j = s; >(
The tongue was dry, and the teeth covered with black
Bordesi
Enema. Terebinth., statim. ELep, Vespere.
SULPHATES AND PHOSPHATES. 291
Sp. Ammonias Arom., jss; ht. Nitri, Jjss, 3tis horis. Hyd.
Chlor., gr. iij, tertiis horis.
The pupil of the right eye has been much larger than
the left for nearly twenty years. It is stated that he could
see best with the left eye.
Died at half-past 9, p.m.
Examined at home by rue, April 1st, half-past 4, p.m.
No signs of decomposition. Skull thick ; brain not wet,
firm ; slight opacity under the arachnoid ; ventricles of the
brain not distended, contained a small quantity of clear fluid ;
choroid plexus of a purple colour ; puncta of blood in the
substance of the brain more than usual ; base of the brain
healthy; no clot or softening in any part could be found.
Right kidney healthy, with a speck of white deposit in
the cortical structure ; capsule readily removed.
Left kidney, capsule could, with great difficulty, be torn
off in many places; the capsule split, so as to leave a layer
adhering to the surface of the kidney. The surface was
covered with cysts, some larger than a split pea, full of
gummy, soft, solid matter ; these extended in places deep
into the cortical structure of the kidney, and in some places
encroached on the pyramids. Some white spots were seen
similar to that in the right kidney. There was but a small
portion of this left kidney that was not studded with these
cysts ; but where they were absent, the kidney appeared
healthy. The pelvis of neither kidney was injected. There
was much fat around the pelvis of the left kidney.
The heart was large and flabby ; the auricles dilated and
containing coagula ; the valves were all healthy, but there
was much atheromatous and osseous deposit at the com-
mencement of the aorta. There were no tubercles in the
lungs. The other organs were not examined.
In the single analysis given in this case, the Sulphates are
much increased, and the Phosphates are diminished.
Case 2. — Richard W — , pet. 40, King's Ward ; brewer.
Admitted April 24th, 1849, half-past 4, p.m.
He works in a brewery; and has had two, if not three,
292 1)11. BENCB JONES ON THE VARIATIONS OF
attacks of delirium tremens. The last attack was four
months ago. The last but one, six months before that.
States that he drinks about two pints and a half of ale per
day, but no spirits. The present attack began three days
ago, with loss of sleep, excessive talking, and delirium. He
has had no sleep since the attack began. On admission he
was in a state of delirium, busy and incessantly chattering ;
his whole body was in a constant tremor; he would not be
still for an instant, but was otherwise perfectly obedient
when spoken to. The face was rather pale, and he had no
headache.
He was ordei'ed Senna immediately. Tr. Opii, t>lxx ;
Mist. Camphorse, Sjss, 4lls horis. Porter, one pint.
25th. Has had a sleepless night, talking so constantly
that he kept the other patients awake. He has been ex-
hausting himself all the morning, in efforts to disengage
his feet from the straps in which they are fastened. Pulse
108, soft and compressible, occasionally intermitting. Tongue
moist, covered with a yellowish creamy fnr, very tremulous.
He is bathed in a profuse perspiration ; says he has no
headache and no appetite. Since his admission to the
present time, he has taken only a few monthfids of meat
and a pint of porter. In his medicine he has taken about
two drachms of laudanum. Urine passed early this morning,
not very scanty. Specific gravity = 10378. Gave with heat
and acid a slight coagulum of albumen ; with cold nitric
acid an immediate crystallisation of nitrate of urea. Quickly
deposited crystals of triple phosphate in small quantity.
518'9 grains boiled with Chloride of
Barium, and dilute Nitric Acid,
Sulphate of Baryta . . . . = 10'S0 = 20-77 grs. per 1000 urine.
5189 grains, with Hydrochloric Arid,
and then Chloride of Calcium
and Ammonia, Phosphate of
Lime = 116= 2'14
Urine passed in the afternoon, 5 p.m., the same day.
Acid to test-paper; gave a very large deposit of urate of am-
monia ; also a considerable deposit of albumen by heal and
SULPHATES AND PHOSPHATES. 293
acid ; and an immediate precipitate of nitrate of urea.
Specific gravity = 1041-2.
520-6 grains boiled with Chloride of
Barium, and dilute Nitric Acid,
Sulphate of Baryta . . . . = 19-10 = 36-69 grs. per 1000 urine.
520-6 grains, precipitated by Chloride
of Calcium and Ammonia,
Phosphate of Lime . . . . = 310 = 595
19364 grains, precipitated by strong
Acetic Acid after Urate of Am-
monia was dissolved, Uric Acid = 2'35 = 1-21 „
10 p.m. He became much more delirious, noisy, and
intractable. The perspiration pouring in large quantity
from all parts of his body. Sp. Genevaj, fij.
26th, 1 p.m. No improvement. Pulse became weaker
and more fluttering ; brandy was given. At 5 p.m. he was
sick ; and soon after he died.
Examination April 27th, 1 p.m. There was a large
number of vascular ramifications on the interior of the
cranium. The arachnoid was rather opaque from subarach-
noidean fluid in the meshes of the pia mater. The superficial
veins of the hemispheres of the brain were much congested ;
the substance of the brain was more watery than natural,
but firm, and the puncta vasculosa numerous. The ventricles
were not dilated ; the choroid plexuses were dark, and had
two or three small cysts. There was a small spot of ex-
travasated blood along the posterior margin of the cerebellum
under the arachnoid, dipping down into the sulci, but not
into the substance of the cerebellum. In the posterior fossa
of the cranium, at the point corresponding to the extravasated
blood, was a fossa large enough to admit the extremity of the
finger, but not extending through the whole thickness of the
bone.
The posterior part of the left lung was congested ; there
were adhesions of old standing at the lower part of the
right lung, and near its apex a small cretaceous tubercle ;
both lungs were crepitant throughout. The heart was
covered with fat ; the cavities were rather large, and the
xxxiv. 19
294 DR. BENCE JONES ON THE VARIATIONS OF
valves perfectly healthy. There was no fluid in the peri-
cardium ; there were a few spots of atheroma at the com-
mencement of the aorta.
The right lohe of the liver was adherent to the diaphragm;
the whole substance of the liver was greenish, and of a pasty
consistence; the gall-bladder was much distended with bile;
the spleen was exceedingly small and healthy ; the kidneys
were congested ; the Malpighian tufts being full of blood ;
on the surface of both kidneys were several small cysts, but
the structure was otherwise healthy.
The bladder had exceedingly thin walls. Throughout the
body the blood was perfectly fluid.
Sulphate of Specific Total
Baryta. gravity. Phosphates.
In this case on the 5th day 2077 grs. per 1000 urine 1037'8 2'14.
5th night 3707 „ 1011-2 505.
„ „ 6th, died.
Some sulphate of magnesia had been taken on the day
previous to that on which the water was examined, and,
doubtless, this partly increased the sulphates to the enormous
amount here stated. The urea was also in great excess
whilst the phosphates were below the amount of health,
though the specific gravity was unusually high.
Case 3. — Robert B — , set. 26, waiter, Fuller Ward.
Admitted January 3d, 1850, at half-past 7 p.m. Always pale
and sickly.1 Was taken ill on the 23d of December, with
sickness and loss of sleep. lie had been poorly for a fortnight,
so much so that soon after Christmas he gave up work : with
rest and opiates he improved, and returned to his work for two
or three days previous to his admission. In consequence of
his excited state and his loss of sleep he came to the hospital.
He was very violent until 11 p.m., when the strait-waistcoat
1 This patient said that lui was in the habit of drinking .-I quarter of a pint
of gin, and three pints of beer daily. He had been in Ms situation for two
years, and had taken more than his usual quantity at Christmas; thai lie
never had any illuess Uke this before. Had had rheumatic fever four years
ago.
SULPHATES AND PHOSPHATES. 295
was put on. Sp. iEther Sulph. Comp., Sp. Ammoniae Arom.,
aa 3j, Mist. Camph., giss ; sextis horis. Opii, gr. ij ; Ext.
Gentianse, gr. xv, ft. suppositorium, statim. At 12 p.ni.,Tr.
Opii, jj statim. ; 2 pints of porter and a mutton chop were
ordered, after this he slept well until 4 a.m. Perspiring
excessively on waking, he still talked much, but was not
violent.
4th January, water passed at half-past 7 a.m. Thick from
urate of ammonia. Deposit very pink coloured, filtered.
Specific gravity = 1037-4. Acid.
5187 grains boiled with Chloride of
Barium, and dilute Nitric Acid,
Sulphate of Baryta . . . . = 9'8 = 13'10 grs. per 1000 urine.
5187 grains precipitated by Chloride
of Calcium and Ammonia. Total
phosphates = 5-10 = 9-83 „ „
Was much less excited during the day.
5th January, no more perspiration. Urine made before
breakfast had the same appearance as yesterday; filtered.
Specific gravity =1034-6.
5173 grains boiled with Chloride of
Barium, and Nitric Acid, Sul-
phate of Baryta .... =670=12-95 grs. per 1000 urine.
517'3 grains precipitated by Chloride
of Calcium and Ammonia. Total
= 4-60=8-89
He got up to dinner, having no symptoms.
11th January. He went out without any return of the
delirium.
Sulphate of Specific Total
Baryta. gravity. Phosphates .
In this case on the 13th day 1310 grs. per 1000 urine 1037-4 9-83.
14th day 12-95 „ 1034-6 8'89.
„ „ 20th, went out.
Here also the sulphates are increased. The phosphates
are also not diminished, probably, in consequence of the
patient being able to eat. The amount of urea was not
tested, but from the high specific gravity it is very probable
that an excess of urea was present.
296 DR. BENCE JONES ON THE VARIATIONS OF
Case 4. — Thomas J — , get. 34, broker. Admitted
April 23d, 1850, York Ward. His wife states, that for eight
years he has been in the habit of living chiefly on drink,
taking but one meal daily. For some weeks past he has at
times been slightly delirious ; on the evening of the 21st, he
was first seen, when he was very delirious, and had had no
sleep for the previous forty-eight hours. Tr. Opii was given,
first in drachm, and afterwards in two drachm doses, and by
the following morning he had taken ten drachms of laudanum,
and two grains of acetate of morphia. He was, at this time,
very violent, having spectral illusions, a very rapid and
feeble pulse, and tremors of the tongue and limbs.
He was induced to inhale chloroform. He became very
rigid and somewhat convulsed before he was insensible ; but
he was quite insensible by the time forty minims had been
inhaled ; a little more chloroform was given occasionally to
keep him asleep, two drachms being inhaled in all. He
slept for about three quarters of an hour, and was quiet when
he awoke, but not free from delusion. He took two drachms
of tincture of opium in the course of the night of the 22d,
and was a little better on the morning of the 23d. Pulse
stronger and less frequent, but still he was sleepless, and six
doses of opium in pills of three grains each were given in
the course of the day, without any apparent effect. He
inhaled a drachm of chloroform at seven p.m., and slept for
about an hour ; but, on being left by his medical man, his
attendants let him get up and go out into the street, when
he became unmanageable and was brought to the hospital.
For this account I am indebted to Dr. Snow. On admission
he was given Sp. iEtheris, c. 3j, Liq. Antiin. Tart., -ij, Mist.
Camph., 3ix, 4"s horis.
24th April, 10 a.m. He has not slept more than twenty
minutes during the night, and only five minutes at a time.
He is very quiet. The pulse is rapid anil feeble. Twelve
ounces of urine were passed last night. — 2 p.m. lie has been
sleeping for about an hour and a half, and is again disposed
to sleep. Twenty-two ounces of urine were passed this
morning; deep coloured, clear, acid. Specific gravity = 1027-5.
SULPHATES AND PHOSPHATES. 297
513-75 grains boiled with Chloride of
Barium, and dilute Nitric Acid,
Sulphate of Baryta . . . . =9-10 = 1771 grs. per 1000 urine.
On the addition of nitric acid to this urine, an immediate
crystallisation of nitrate of urea occurred.
The Antimony was omitted, and he was ordered ht.
Morphia;, ^ij, hac nocte.
25th. He slept nearly all yesterday afternoon, until about
9 o'clock p.m., waking at intervals of about an hour and a
half. He slept very little during the night, and not above
five minutes at a time.
2 p.m. He has taken a mutton chop and a pint of porter.
Pulse 80, very full. He starts often in his sleep.
He passed about twelve ounces of urine, deep coloured,
acid, contained an excess of urea, but did not give immediate
crystallisation. Specific gravity = 1025-4.
512-7 grains boiled with Chloride of
Barium, and dilute Nitric Acid,
Sulphate of Baryta . . . . = 6-40 = 12-48 grs. per 1000 uriue.
Continue the medicine thrice daily, ht. Morphise, ^iij, hac
nocte.
April 26th. He slept four or five hours yesterday afternoon,
but had no sleep during the night. He occasionally fancies
he sees objects before him, otherwise he is very quiet. Ht.
Morphise, ^iij, hac nocte et rep. post boras tres.
27th. Slept four or five hours yesterday afternoon, but
not more than two hours during the night. He has taken
his chop and pint of porter each day. He is very quiet, but
fancies he sees objects about him. Tr. Opii, 5ss, Mist.
Camph. Jiss, vesp. et post boras tres rep.
28th. Slept from 8 p.m. to 2 a.m. From this time he
slept well, but for three weeks he required some opiate each
night. He went out on the 21st of May, cured.
Sulphate of Specific
Baryta. gravity.
In this case 6th day 17-71 grs. per 1000 urine . 10275
7th day 12-48 „ 10254
" 33d day, went out.
298 DR. BENCE JONES ON THE VARIATIONS OF
The urea was in great excess when the sulphates were
most in this urine also, and as the sulphates diminished less
urea was found.
The amount of sulphates and of phosphates obtained in
other cases of delirium tremens is stated in the table in the
' Philosophical Transactions ;' but to give all the details of the
cases would extend this paper without adding to its value.
The four cases which I have selected are sufficient to show
the striking increase of the sulphates in delirium tremens.
I pass on, then, thirdly, to the amount of sulphates and
phosphates in acute inflammatory affections of the nervous
structures.
The four following cases of acute or subacute inflammation
of the brain will give the variations of the sulphates and
phosphates in this class of cases.
Class III.
Case 1. — Philip B — , set. 25, admitted November 24th,
1847.
On the 3d of November he was seen by the house surgeon,
with a scalp wound, which had been made with a shovel on
the left side of the head, near the vertex. There was great
haemorrhage, which was restrained by pressure, but he would
not stay in the house.
On the 5th, he came with some fever, but without head
symptoms, except pain, and from that time he followed his
employment (he was a gentleman's servant) till the 21st of
November, when he was attacked with severe headache and
felt very ill. On the evening of the 23d, a severe rigor
occurred, followed by much heat and sweating.
On admission on the 24th, his countenance was heavy;
his articulation thick, and performed with some slight diffi-
culty, and he could not walk unsupported. The right portio
dura acted imperfectly; the tongue was somewhat drawn to
the left side ; the right arm numbed and almost powerless ; he
complained of slighl headache. The pulse was si, quick and
regular, The tongue moist, and the skin cool. A scab about
SULPHATES AND PHOSPHATES. 299
two inches long remained from the wound, which appeared
to have healed soundly, except in the centre, where a sinuous
opening led down to exposed bone. A brisk purgative was
immediately given, and repeated the 26th and 29th.
The day after his admission he was much better, and on
the 29th all the symptoms had disappeared, excepting slight
numbness of the arm. In the evening, however, he insisted
on getting up, and it was some considerable time before he
could be induced to go to bed ; and the following morning
there was a recurrence of all the symptoms of the 24th, with
the superaddition of slight numbness of the right lower
extremity, and pain in the left side of the head. But the
pulse was still only 80, and the skin was cool.
December 1st. There was almost total paralysis of the
right side.
2d. The paralysis is complete j the headache more severe ;
the countenance more dull and heavy; the articulation veiy
thick and indistinct; and at half-past 1 p.m. he was
trephined. The wound being enlarged crucially the peri-
cranium was found to be readily separable from the bone,
which, however, was only exposed in one spot. On the
removal of a crown of bone by the trephine, some very fetid
pus mixed with brain-like matter escaped, and two pieces
more were therefore taken away by the instrument. The
dura mater was then found to be separated for some distance,
but healthy in appearance, except in one part, where there
was a perforation, the size of the top of the thumb, round
which it was sloughy. Out of this opening pus escaped from
beneath the membrane. Perhaps, altogether, three ounces
of matter were let out.
Water passed, before the operation, rather deep coloured.
Gave a slight deposit of urate of ammonia and oxalate of
lime. Specific gravity = 1018-7, acid reaction.
509-35 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta = 2-02 = 3-96 grs. per 1000 urine.
509-35 grains precipitated by Chloride
of Calcium and Ammonia, Phos-
phate of Lime .... = 262 = 5-14- „ „
300 DR. BENCE JONES ON THE VARIATIONS OF
10 p.m. The headache had left him. He felt inclined to
sleep, and the pulse was 108 and soft.
3d. He had a quiet night. The pulse fell to 88. The
tongue was rather cleaner. The countenance perhaps im-
proved. The other symptoms the same as before the opera-
tion. Water passed about 2 p.m., all that he had passed
since half-past 1 the day before. Deeper colour, much more
loaded with urate of ammonia. Specific gravity = 102726.
51303 grains boiled with Chloride of
Barium, and Nitric Acid, Sul-
phate of Baryta = 5-77 = ll'23grs. per 1000 urine.
51363 grains precipitated by Cldoride
of Calcium and Ammonia. Total
Phosphates = 572 = 11*13
4th. Water passed about 11 a.m., of much lighter colour.
Gave no precipitate on standing. Acid to test-paper.
Specific gravity = 1013' 1.
506'55 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta = V47 = 2 91 grs. per 1000 uriuc.
50655 grains precipitated by Chloride
of Calcium and Ammonia. Total
Phosphates : = 307 = 606
5th. He was lying in a state bordering on insensibility,
and could scarcely speak. The eyes were half shut. The
paralysed arm was contracted and stiff, and the thumb was
drawn into the palm of the hand.
Cth. Early this morning a rigor occurred. His motions
were passed under him. The skin was warm and moist.
The pulse 110, jerking. Tongue was furred. Pus was
escaping freely from the wound. The dura mater was more
sloughy, and the brain more prominent. It was Btated that,
during the afternoon, he became much Less sensible] ami that
the jaws were so firmly fixed as to require some force to be
used when it was necessary to open them,
Water passed at 1 1 a.m., gave a deposit of urate of ammonia
and crystallised phosphate of lime, acid to test-paper.
Specific gravity = 10270.
SULPHATES AND PHOSPHATES. 301
513'50 grains boiled with Chloride of
Barium aud Nitric Acid, Sul-
phate of Baryta = 3-77 = 7'34 grs. per 1000 urine.
256'02 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta = 1*97 = 7"69 „ „
513'50 grains precipitated by Chloride
of Calcium and Ammonia. Total
Phosphates = 5"52 = 1075
51330 grains precipitated by Chloride
of Calcium and Ammonia. Total
Phosphates = 5-67 = 1P04 „ „
11 p.m. The face was noticed to be much swollen and
red j and in this state he remained until between 3 and 4 a.m.
on the 7th, when he died.
Post mortem examination 33^ hours after death. On
removing the skull cap, no mischief was detected between the
bone and the dura mater, but the exposed portion of dura
mater presented a large opening through which the brain
protruded ; all the exposed portion was sloughy, and covered
with lymph and most offensive discharge. On removing
the dura mater, the convolutions of the brain appeared
much flattened. On the right side, with this exception, there
was nothing of auy importance. On the left side there was a
small, nearly circular, piece of the surface of the brain, which
was prominent and sloughy, and which corresponded to the
opening in the dura mater ; through this latter projecting
portion there was an opening leading into the substance of the
brain, and communicating with a large foul abscess, which
occupied a large space towards the posterior portion of the
hemisphere, and extended to the upper wall of the left ven-
tricle, into the cavity of which it had very nearly perforated.
The walls of the abscess were perfectly distinct aud firm.
The substance of the brain surrounding the abscess was of
a light lemon colour, aud soft and pulpy in consistence. The
greater portion of the left hemisphere not implicated in the
abscess, was in this inflamed aud altered condition, and on
the outer side, where the mischief extended to the grey
substance, the latter was entirely changed in character,
302 DR. BENCE JONES ON THE VARIATIONS OF
and had the same appearance as the other inflamed parts.
The lateral ventricles were distended with thin serum. The
septum lucidum was much softened and very readily lacerated.
The base of the skull was natural.
There was some partial and firm adhesions of the pleura on
both sides, chiefly at the upper part. Both cavities contained
a quantity of blood mixed with serum. The upper portion
of the lungs was crepitant, but the lower parts were highly
congested and much compressed. The right lung was much
collapsed when the chest was opened. There did not appear
any injury of either lung. The other viscera were healthy.
The variations of the sulphates and phosphates may be thus
given.
Total
Phosphates. Vrinc.
514 grs. per 1000
1113
606
C 1075
(. 1104
The inflammation was not of the most intense character; but
the increase of the sulphates and phosphates is apparent, and
the corresponding variations of the two salts is very distinct.
Case 2. — Emma F — , set. 11, Crayle Ward. The mother
says the child was strong, healthy, and very quick ; has two
more children quite healthy. Admitted March 22d, 1818.
Has had pain at the top of the head for fourteen days, for
which the head has been shaved ; had some disease of the scalp ;
the mother states that she fell down stairs yesterday, since
which she has boon much worse. The tongue is furred; the
pulse 130, sharp; the bowels open ; the pupils large, but acting;
she answers questions very readily ; is unable to stand ; the
head is thrown hack; there is no strabismus: fever diet.
Hirudincs xij teniporibus, Cal., gr. iij, statim, ht. sennne,
5jss, post horas trcs. Ilydr. Chlor., gr. ij, pulv. Opii, gr. \,
ter die. lit. Nitri ; ,^jss, <>'M horis. Glacics capiti.
23d. Skin hot and dry ; pulse 108, small and rather sharp;
Sulphate of
Specific
Baryta.
gravity.
12th day, 3 96 grs.
per
1000 urine.
. 1018-7
13th day, 11-23
„
10273
14th day, 2-91
„
10131
16th day, ™]
»
1027-0
16th night, died
SULPHATES AND PHOSPHATES. 303
face swollen, looks heavy, and is very drowsy; motions green-
ish and lumpy; distinct pulsation in the carotids; has uot
been sick; water thick, scanty, and contains no albumen;
that passed last night alkaline when I got it ; a drop
or two of hydrochloric acid was added, filtered. Specific
gravity = 1030-0.
5150 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta = 4'55 = 8-83 grs. per 1000 urine.
515'0 grains precipitated by Chloride
of Calcium and Ammonia. Total
phosphates = 4'S5 = 9'41 „
Rep. Calomel, 6ta horis. Rep. ht. Sennae. Tint of milk.
24th. Water scanty ; mouth rather sore ; pupils dilated ;
still very drowsy and heavy ; tongue rather brown. Rep. Pil.
c. Opii, gr. i, vice \. Enema commune statim. P. c. glacie.
In the afternoon the opium was omitted. P. c. Hydr.
Chlor., gr. ij, 6tl3 horis. Emp. Lyttae Nuchse ; Ung. Hydr.
Ulceri. All the water that was passed from the previous
night to 1 p.m. was about a pint, secreted after senna and salts
had been taken ; on long standing, it gave an excessive de-
posit of urate of ammonia. Acid. Specific gravity = 10290.
514'50 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta =5-50 = 10'69 grs. per 1000 urine.
514'50 grains precipitated pink by
Chloride of Calcium and Ammo-
nia. Total Phosphates . . .= 4-35=8-45
25th. Pulse 1 15, sharp and hard; pupils large and sluggish;
breathing hurried; complains of pain in the chest. P. c. Pil.
ter die.
26th. Mouth sore; takes more notice; bowels not open. P.
27th. The nurse says that she was delirious last night ;
complains of a good deal of pain in the head ; pulse quick,
skin hot. 01. Ricini, Jss, statim ; Pc. Pil. bis in die.
28th. Skin dry ; pupils rather smaller ; sees double ;
head not so much thrown back ; bowels well open by the
oil, and motions very copious ; urine scanty. Rep. Oleum.
P. c. ht.; Rep. Emp. Lyttaj, and Ung. Hydrarg.
29th. Pulse only 84 ; bowels freely open ; sees double.
304 DR. BENCE JONES ON THE VARIATIONS OF
30th. Face more flushed; head more thrown back; pupils
more dilated; pulse 81; seems to suffer most acute pain; com-
plains chiefly of her back; bowels have not acted; water scanty,
contains no albumen ; acid. Specific gravity = 10298.
514'90 grains boiled with Chloride of
Barium and Nitric Aeid, Sul-
phate of Baryta = 4'55 = 8S3 grs. per 1000 urine.
514'90 grains, precipitated by Chlo-
ride of Calcium and Ammonia.
Total phosphates . . . . = 525 = 1019
Infri. Ung. Hydrarg. omni nocte. P. c. ht. 4^ horis.
Enema commune hac vespere.
31st. Head still thrown back; is quite insensible; does
not appear to see at all. Water passed under her. Insen-
sibility came on last evening. Face flushed ; pulse 60.
Pul. Jalap, c. 3j, statim. P. c. unguento. Adde haustui
Tr. Lyttse nix. Water to be drawn off.
1st. Much better ; sees pei'fectly; bowels were open four or
five times, but the motions were passed under her; water much
more plentiful, 18 ounces drawn off this morning ; is quite sen-
sible, and complains of a great deal of pain in the head ; pupils
not nearly so dilated, but frequently changing; pulse 80; head
still thrown back ; passed a very restless night. Rep. omnia.
2d. Quite insensible ; takes no notice of anything ; face
flushed ; squints very much, and the face is at times con-
vulsed ; is very restless, and calls out occasionally ; pulse 86,
very small ; bowels have operated once, and a good deal of
water has been passed under her ; the skin is hot and dry;
pupils arc dilated, and she is evidently much lower.
3d. Still insensible ; perspiring very freely ; pupils very
dilated, and squinting ; not so much urine passed as yester-
day j bowels not open; pulse 100; there is some difficulty
in swallowing ; water drawn oft' to-day, acid ; contained some
albumen, blood and pus globules. Specific gravity = 1031*4.
515'70 grains boiled with Chloride of
Barium and Nitric Acid, Sul-
phate of Baryta = 4'85 = 940 grs. per 1000 urine.
515 70 grains precipitated by Cliloi
ide of Calcium nd ammonia,
total phosphates . . . . = 4-65 = 9-01
SULPHATES AND PHOSPHATES. 305
*>
4th. Rather more sensible; pulse 150 running; lies per-
fectly quiet ; skin perspiring ; makes hut little water ; bowels
not open; is sinking. Emp. Lyttse amplum nuchae. Pul.
Jalap, c. statim. Vini Rubri, 3VJ-
5th. Died at 5 o'clock this morning. Examined thirty-
two hours after.
The body was well formed and rather thin. The vessels
of the dura mater were gorged with blood. The convolu-
tions of the brain were much flattened. The superficial
vessels were much distended, and the subarachnoid cellular
tissue on the superior surface of the brain contained a small
quantity of very slightly opaque serum. The substance of
the brain presented very many puncta of blood, and the
cortical structure was dark in appearance. The lateral ven-
tricles were distended with serum, which contained some
flocculi of lymph, making it slightly turbid. The septum
was softer than natural, and jelly like, but not tattered. In
the subarachnoid cellular tissue at the base of the brain,
there was a much larger quantity of semi-transparent lymph
effused. The structure of the cerebellum was somewhat softer
than the cerebrum, but this might have resulted since death.
In the upper part of the right lung, there was a small
patch of scrofulous matter, with the deposit of several small
miliary tubercles in its neighbourhood; other small semi-
transparent tubercles were found thinly scattered over the
other portions of the lung. In the left lung there were also
a few miliary tubercles ; the lower lobe was inflamed and
hepatised at its lower part, and greatly congested. The
heart was healthy. The kidneys were healthy in structure,
but the mucous membrane of the pelvis was slightly congested
in both. The mucous membrane of the bladder was con-
gested, perhaps slightly inflamed.
In this case.
15 tli day
16th „
Sulphate of Baryta.
8-83 grs. per 1000 urine
10-69
Specific Gravity.
10300
10290
Total Phosphates.
9-41
S-45
22d „
26th „
8-83
9-46
10298
1031-4
1019
9-01
28th, died.
306 DR. BENCE JONES ON THE VARIATIONS OF
In this case also, the corresponding increase of the sul-
phates and phosphates is remarkable, considering the age of
the patient. The post-mortem examination leaves no doubt
whatever as to the nature of the disease.
Case 3. — Henry P — , set. 23, York Ward, accustomed to
drink freely. Admitted May 16, 1849 ; having been an out-
patient for ha;moptysis. Complains of pains all over the
body and limbs, with constant tremor, which he has had for
ten days ; sleeps badly ; no appetite ; feels very weak ; is
covered with profuse perspiration ; tongue rough, has been
much furred ; pulse feeble; has occasional attacks of dyspnoea ;
bowels rather confined ; has much headache ; petechia?
over the body. Milk diet and beef tea. Salines, blue pill,
and castor oil.
17th. He says he has attacks of shivering four or five times
a day, afterwards he perspires ; bowels have been open this
morning ; pulse 72, soft ; slept well last night.
18th. He is in a constant perspiration ; skin hot ; hands
trembling ; slept well last night ; tongue coated and moist ;
no headache ; starts up from his sleep frequently in the
night ; he is occasionally slightly delirious, and says that he
sometimes fancies two persons are walking along the ward
when there is only one.
19th. Feels extremely weak ; tongue tremulous, moist,
and creamy, furred at the base ; he perspires less than he
did ; pulse 72, soft, intermitting ; he sleeps in short, light
dosings, very frequently both day and night ; still occasionally
he is slightly delirious ; bowels not open ; no appetite ; urine
very dark.
20th. Has been very delirious and noisy all night, having
no sleep. To-day he has a dull, heavy, vacant look ; he answers
questions, but not readily ; he does what he is told to do ;
left eyelid closed ; pupils neither dilated nor contracted ; no
strabismus; face not flushed ; complains of great pain across
the forehead ; tongue is protruded towards the left side ; the
left arm is paralysed, lying by his side ; so also appears to
be the left leg ; the right arm is in constant tremor, and
SULPHATES AND PHOSPHATES. 307
moved about unsteadily without any apparent object ; urine
passed early this morning, deep coloured, alkaline. Specific
gravity=1031-6.
5158 grs. boiled with Chloride of Barium
and dilute Nitric acid, Sulphate
of Baryta = 5-10 = 9-88 grs. per 1000 urine.
515'8 grs. precipitated by Chloride of
Calcium and Ammonia. Total
phosphates = 4-40 = 8-72 „ „
Late at night about 32 ounces were drawn off; acid; con-
tained phosphate of lime crystals. Very deep coloured, con-
tained some few blood globules, probably from the catheter.
Specific gravity 1032-2. On the 22d, torulse were very
evident, but no trace of sugar could be found.
516-1 grs. boiled with Chloride of Barium
and dilute Nitric aeid, Sulphate
of Baryta = 5-20 = 10-07grs. per 1000 urine.
516'1 grs. precipitated by Chloride of
Calcium and Ammonia. Total
phosphates = 4-60 = 8-91 „ „
Enema commune statim ; Emp. Lytt. nuchre, Radatur
caput ; Glacies capiti. Calomel gr. ij ; Opii gr. i 6tl8 horis ;
ht. Nitri, ^iss, 6t,s horis.
21st. Rather less pain across the forehead. He was very
noisy and delirious all yesterday and last night ; he is now
quiet, speaking only occasionally ; still answers questions,
but with less readiness ; still does some things which he is told
to do ; paralysis of the left side of the body the same as yes-
terday; he speaks with the right side of the mouth (as also
he did yesterday) ; the right hand still moves about and is in
constant tremor ; the eyes are both turned towards the right
side ; tongue rather red at the tip, furred at the base ; skin
hot and dry; no contraction or dilatation of the pupils ; eyes
bloodshot and suffused ; pulse variable, 11 a.m., 84; 1 p.m.,
144, soft ; bowels were open yesterday after the injection,
not to-day. On examination of the chest, want of breathing
was found at the apex of the right lung. Twenty -four
ounces of urine were drawn off early this morning, acid,
specific gravity = 1016-4, contained more blood-globules.
308 DR. BENCE JONES ON THE VARIATIONS OF
508-2 grs. boiled with Chloride of Barium
and dilute Nitric acid, Sulphate
of Baryta = 3'40 = 6'69 grs. per 1000 urine.
508'2 grs. precipitated by Chloride
of Calcium and Ammonia. Total
phosphates = 2-40 = 474 „ „
Later in the evening about 18 ounces of urine were drawn
off, acid. Specific gravity= 1018-2.
509-1 grs. boiled with Chloride of Barium
and dilute Nitric acid, Sulphate
of Baryta =4-20 = 8-25 grs. per 1000 urine.
509-1 grs. precipitated by Chloride of
Calcium and Ammonia. Total
phosphates = 2-90 = 5-69
Enema commune statim P. c. Pil., 4tl3 horis, c. Pulv. Opii,
gr. 5. At 9, when the urine was drawn off, he became coma-
tose ; pupils dilated.
22d. He continued comatose throughout the night, and
died at j before 11 a.m.
Examined May 23d, 1 p.m.
The dura mater was very vascular, and the Pacchionian
glands larger than natural. The arachnoid was slightly opaque,
and the superficial veins enormously distended. The substance
of the brain was tolerably firm; not wet; very vascular. The
lateral ventricles were dilated with clear fluid. At the base
of the brain in the posterior subarachnoidean space there were
slight traces of opacity, apparently from lymph. Two or
three small tubercles were found in the cineritious substance
of the posterior part of the right lobe of the cerebellum.
Both lungs were adherent to the parietes of the thorax.
There was cretaceous deposit in the bronchial glands. The
lungs were crepitant, but congested; at tho posterior part of
the left, was a large patch of pulmonary apoplexy ; in both
there were a few tubercles, particularly in the apex of the
left. Heart quite healthy, containing no coagulum.
Liver healthy for the greater part. At the upper part of
the right lobe was a large cyst, with a dense wall, containing
tbick, whitish, chccsy-lookiiig matter, also some gelatinous
substance.
We
have, then,
Specific
Gravity.
1031-6
Total
Phosphates.
. 8-72
1032-2
. 8-91
1016-4
. 4-72
101S-2
. 5-69
SULPHATES AND PHOSPHATES. 309
Both kidneys were congested, smooth on the surface; a
few tubercles were found in each.
Bladder was much distended with urine,
on the —
Sulphate of Baryta.
loth day . 9-S8 grs. per 1000 urine
„ night . 10-07
16th day . 6-69
„ night . 8-25
17th day, died. The increase of the sulphates and phos-
phates is not so marked as in the previous case; but the
specific gravity being considered, it is evidently present.
Case IV. — George M — , set. 22, uuder-butler, York
Ward. Admitted October 16, 1848. The man who came
with him said that he was taken ill on the 13th with pain
in the head. On the 14th he was worse, and had leeches
applied to the head ; on the loth he became delirious, and
the next day was sent to the hospital. Mr. Keate made
inquiry for me, and the history of this man's illness appeared
to be true. He had had no cough previous to the headache,
and had been out with the carriage one day before it began.
Water passed on the evening of the 16th ; scarcely acid to
test-paper. On standing twenty-four hours, contained some
granules and tufts of phosphate of lime, and some phosphate
of ammonia and magnesia. It was clear when passed.
Specific gravity = 1027-85, neutral.
514-20 grains, boiled with Chloride of
Barium and Nitric Acid, Sulphate
of Baryta . . . = 4-30 = 8-55 grs. per 1000 urine.
514-20 grains, precipitated by Chloride
of Calcium and Ammonia. Total
phosphates . . . = 3-70 = 7-19 „
2000 grains of urine with Hydrochloric
Acid, Uric Acid . . = 295 = T47 „
Ht. Potasse Citr. 6tls horis j ht. Rhei mane.
Oct. 17. Is very delirious; face flushed; tongue moist
and furred; conjunctiva? suffused; head hot; pulse 100;
skin hot and dry. Hirudines viij, temporibus.
xxxiv. 20
310 DR. BENCE JONES ON THE VARIATIONS OF
P. c. lit. c. Vini Ant. Pot. Tart., tilxl ; Cal., gr. iv, hac
nocte. Emp. Canth. ampl.
18th. Has been very delirious all night ; constantly talk-
ing ; lies on his back ; passes his stools and his water in bed ;
pulse 90 ; face still much flushed, and head hot. Urine
drawn off this evening. Specific gravity = 1020" 1 ; gave a
deposit of phosphate of ammonia and magnesia in twenty-
four hours ; about half a pint, neutral.
513-20 grains, boiled with Chloride of
Barium and Nitric Acid, Sulphate
of Baryta . . . .= 4'01 = 7'81grs. per 1000 urine.
513'20 grains, precipitated by Chloride of
Calcium aud Ammonia. Total
phosphates . . . . = 3-30 = 6'43
205 1'2 grains, with Hydrochloric Acid;
Uric Acid . . . .= 1-55=075
C. Cruent. temporibus ad. ^viij ; Perst. Vespere Calomel
gr. iij, hac nocte, et post horas iv.
19th. Faceless flushed, and skin less hot; low muttering,
with convulsive movements of the hands ; eyelids nearly
closed ; pupils insensible, not dilated, or but slightly so ;
bowels open ; pulse 96. The catheter could not be intro-
duced, but the water was passed freely under him.
Enema commune statim. Calomel, gr. viij vespere.
20th. Lies quite still, and moans sometimes ; face pale,
cooler, with a slight perspiration ; eyelids more open ; eyes
fixed ; pupils insensible ; slight strabismus ; skin hot ; pulse
] 10, sharp; tongue cooled; and much occasional hiccough.
"Water drawn off at 2 p.m., 16 3, quickly gave a deposit
of urate of ammonia, highly acid, and remained so on the
25th. Specific gravity = 1031-4..
51570 grains, boiled with Chloride of
Barium anil Nitric Acid, Sulphate
of Baryta . . . . = G00=--llf.3grs. per loon urine.
515-70 grains, precipitated by Chloride < if
Calcium ami Ammonia. Total
phosphates . . . =4-80=9-30
20G24O grains, with Hydrochloric Acid.
\eid .... =1-65=0-80
SULPHATES AND PHOSPHATES. 311
Rep. Enema vespere Glacies Capiti subinde. Hyd. c.
creta, grs. v, 6tl3 horis.
21st. Gradually sinking; urine drawn off late ; veiy thick
from urate of ammonia, filtered. Specific gravity = 1026-2.
Twenty-six ounces of urine.
513'10 graius, boiled with Chloride of
Barium and Nitric Acid, Sulphate
of Baryta .... = 5-20=1013 grs. per 1000 uriue.
513'10 grains, precipitated by Chloride
of Calcium and Ammonia. Total
phosphates . . . =4-10= 7-09
He died in the night.
Examined 27 hours after. Body in good condition.
The vessels of the dura mater were congested, and the
large veins of the pia mater ; there were about the usual
number of puncta vasculosa ; no increased depth in the
colour of the grey matter ; there was a slight amount of sub-
arachnoid fluid on the convex surface of the hemispheres ; no
effusion of lymph or pus anywhere ; the lateral ventricles
contained a small quantity of serous fluid, which was
perhaps a little turbid; the septum lucidum and fornix were
but little, if at all, softened ; the blood-vessels ramifying in
the superficial structure of one of the thalami optici had un-
dergone a peculiar alteration, which appeared to consist in
the deposit of an opaque white matter in their coats ; the
matter consisted of oily molecules, sometimes very distinct,
and resembled, on the whole, some varieties of scrofulous
deposit ; the large vessels at the base were not observed to
have undergone any morbid change ; the substance of the
brain was everywhere healthy, so far as the eye could judge,
but very wet.
The left pleura was healthy ; there were some old adhesions
on the right side ; both lungs contained numerous miliary
tubercles, which were most advanced towards the apex of the
left lung ; there was no vomica ; the left lung, at its posterior
part, was excessively congested, so much so that a piece of it
sank in water ; it did not, however, seem to be truly hepa-
tised ; the right lung was similarly affected to a much less
Specific Gravity.
Phosphat
1027-8 ...
710
10261 ...
6-43
1031-4 ...
9-30
1026-2 ...
799
313 DR. BENCE JONES ON THE VARIATIONS OF
degree ; the pericardium contained an ounce of serous fluid ;
the heart was healthy ; the aorta healthy, and its coats not
stained j liver healthy ; kidneys contained numerous small
tubercles, but were otherwise healthy ; spleen rather en-
larged.
The deposit in the blood-vessels of the brain appears to
have been similar to that found by Dr. Hughes Bennett in
cases of inflammation of the brain.
We have, then, in this case : —
Total
Sulphate of Baryta.
4th day ... S-55 grs. per 1000 urine
6th „ ... 7-81
8th „ ... 1163
9th „ ... 10-13
9th night, died.
There is, therefore, a very decided increase in the sul-
phates and phosphates, and the corresponding increase and
diminution of the two salts is again apparent.
The four cases, though not so marked as those which I
have recorded in my previous paper in the ' Medico-Chirur-
gical Transactions' for 1847, are confirmatory of the state-
ments made, that in inflammation of the brain the phos-
phates are increased. From these cases it is probable that
the sulphates arc also increased in the same disease.
Conclusion.
These, then, are the most remarkable examples which have
occurred to me, of the increase of the sulphates in disease.
The phenomenon common to acute chorea and to intense
delirium tremens, is increased and unceasing DQUSCUlai
action ; the result of which is, an increase of the sulphates
and of the urea in the urine ; just as in health they would
be increased if continued exercise was taken.
In my former paper I stated, that in delirium tremens,
when no food was taken, the phosphates were diminished;
and I attributed this to the diminished action of oxygen on
the nervous structure. How far I was correct in my con-
clusion, further experiments must determine; but as in tins
SULPHATES AND PHOSPHATES. 313
paper I have shown that the phosphates were diminished in
acute chorea, when no food could be taken, it must be ad-
mitted, that abstinence from food in itself lessens the phos-
phates, more than from my former experiments appeared to
be the case. Still, however great the abstinence from food
in chorea may be, the amount of phosphates in that disease,
or in any other, was never found to be so low as in the
cases of delirium tremens, recorded in my previous paper.
Cases of excess of urea in the urine possess some interest,
in consequence of the opinion of Dr. Prout, that the excre-
tion of an excess of urea, constituted a disease analogous to
diabetes. The cases I have now detailed, of excess of urea
in chorea and delirium tremens, point to the fact, that the
increase is a consequence of the changes taking place in the
muscles, and that the amount of urea does not constitute
the disease, but is a result of the changes which are taking
place within. The muscles are highly complex organic
compounds, in which sulphur exists in an unoxidised state ;
and the muscular action is accompanied, if not caused, by
an action of oxygen, which, among other results, gives rise
to the formation of urea and sulphuric acid, the amount of
oxidation being proportioned to the intensity of the mus-
cular action.
In my former paper, I also stated, that in cases of
increased action of the brain, an increased formation of
phosphoric acid results from an increased oxidising action
taking place in the nervous structures. The cases which I
have now related, of the variation of the sulphates and phos-
phates confirm the fact, that in inflammation of the brain,
the phosphates are considerably increased, and they lead to
the belief that in the same cases, the sulphates also are
above the average amount. When it is remembered that
the amount of sulphur in the albumen of the brain, is pro-
bably not very different from the amount of phosphorus in
the cerebral fatty matter, the simultaneous and correspond-
ing increase of the phosphates and sulphates in inflammation
of the brain, is seen to depend on the same oxidising .action
which takes place at one time, on all the elements of the
314 DR. BENCE JONES ON SULPHATES AND PHOSPHATES.
nervous structure, at another time, on all the elements of
the muscular structure, according as an increased action of
the brain or of the muscles takes place.
I cannot quit this subject without again repeating, that
these experiments are preliminary; they show the action of
the inspired oxygen within the human body, in a few
striking cases. They are slight demonstrations of the far
more extensive results which may be obtained, by taking
into the account the quantity of phosphates and sulphates
which are thrown out of the kidneys in twenty-four hours.
But in such experiments, unless the greatest care is taken
in determining the exact quantity of urine secreted in
twenty-four hours precisely, the results will lead to error,
and not to truth.
ACCOUNT OF A CASE IN WHICH
A LARGE CYST CONTAINING HYDATIDS
WAS DEVELOPED AT
THE ROOT OF THE NECK,
DEATH ENSUING FROM RUPTURE OF THE LEFT SUBCLAVIAN AKTERY.
BY
JAMES DIXON,
SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL,
AND ASSISTANT-SURGEON TO ST. THOMAS'S HOSPITAL.
Received May 6th.— Read June 34th, 1851.
The following case presents so many points for consider-
ation, in respect of the origin of the disease, its course, and
unexpected result, as to render it, I believe, worthy of being
brought under the notice of practical surgeons.
Henry Moore, a waterman, set. 24, of healthy appear-
ance, and free from any signs of scrofula, was admitted into
St. Thomas's Hospital, January 14, 1851.
Nine years ago he first noticed a small, fixed lump, about
the size of a pigeon's egg, rising just above the level of the
left clavicle, at the outer side of the sterno-mastoid muscle.
It felt firm to the touch, was painless when pressed upon,
and the skin covering it was of natural appearance. It grew
very slowly; and the only inconvenience the patieut felt was
an occasional numbness and tingling in the left arm and hand.
About a year ago he noticed that his left hand, which, in
consequence of his employment, was often in the water, be-
came more readily chilled than the right, and then remained
numb for a considerable time. This led him frequently to
examine the hand ; and in doing so, he discovered that there
was sometimes no pulse to be felt at the left wrist ; and
316 Mil. dixon's case of
about six mouths since pulsation ceased there entirely.
About this period he gave up his employment as bargeman,
as the exertion of using the pole brought on pain and numb-
ness throughout the left arm.
When he came to the hospital, the tumour presented the
following appearances : — Its bulk, as far as it could be de-
fined, was about that of a hen's egg ; it seemed to rise up
from about the situation of the first rib, behind the left
stemo- mastoid muscle and carotid sheath, having pushed
the^e parts forwards and towards the right side, aud the ex-
ternal jugular vein slightly backwards. Above the middle
part of the clavicle the swelling was but slightly prominent,
being bound down by the cervical fascia : the omo-hyoidcus
muscle could here be felt running obliquely across it. The
most prominent part was on the median plane, about an inch
above the top of the sternum : at this spot the displaced left
common carotid artery could be seen pulsating, and it com-
municated a harsh thrilling impulse to the finger. Parallel
to the artery, and between it and the inner edge of the
sterno-mastoid muscle, lay a large vein, which might be
made to swell up considerably by pressing just above the
top of the sternum. The pomum Adami lay rather higher
than natural, and the notch in the thyroid cartilage was
more than half an inch to the right of the median plane.
In no part of the tumour itself was any ancurismal pulsa-
tion, or bellows-sound, discoverable ; the thrill felt above the
sternum being due to the carotid artery, thrust forwards by
the growth behind it ; and the impulse communicated to the
mass became more and more feeble as the linger was re-
moved from the neighbourhood of this vessel. The only
spot where anything like the elasticity of fluid could be
detected was an inch above the left stcrno-clavicular arti-
culation, where the sterno-mastoid muscle and large anterior
jugular vein, diverging from each other, seemed to leave the
tumour covered only by skin and fascia.
The patient's voice was hoane and weak, and had been
so for about three months before his admission. He had no
difficulty in swallowing, and the effort caused no movement
A LARUE CYST CONTAINING HYDATIDS. 317
in the tumour. Not the slightest pulsation could be traced
iu the left arm, not even in the axillary artery ; but the re-
turn of blood through the vein seemed free, as there was no
oedema of the limb.
The position of the tumour, then, as far as it could be
explored, was evidently behind the left carotid sheath ; and
it seemed probable that it had closed the subclavian artery
by compressing that vessel against the first rib. With re-
spect to the nature of the tumour, the diagnosis appeared to
lie between encephaloid deposit, and a cyst containing fluid ;
its slow progress making the latter supposition the more
probable one.
After much careful examination, it was decided that an
exploratory opening should be made, and on the 25th of
January a fine trochar was passed directly backwards, an
inch above the left sterno-clavicular articulation, between
the inner edge of the sterno-mastoid muscle and the large
vein running beside it. About one drachm of clear, colourless
fluid escaped, and pressure over the swelling failed to bring
out any larger quantity. For several days after this punc-
ture had been made, the harsh thrill in the left common
carotid artery almost ceased ; and it was thought by some
who carefully examined the patient, that a very feeble pulsa-
tion could be detected in the left radial artery.
In consequence of the prevalence of erysipelas in the ward,
no further operation was attempted until the 8th of March.
The patient's general health meantime continued good, and
he felt no inconvenience, except occasionally some obscure pain
in the neck, and slight numbness in the left upper extre-
mity. The operation was necessarily slow, in consequence of
the important parts in the immediate neighbourhood of the
incision, and the uncertainty existing as to the position in
which some of them might be found. The incision was
commenced about an inch above the left sterno-clavicular
articulation, and carried upwards along the inner edge of the
sterno-mastoid muscle to the extent of an inch and a half.
The large vein, which afterwards proved to be an unusually
developed anterior jugular, bulged into the wound so much
318 mr. dixon's case of
that, to avoid it, it was thought best to shift the position of
the wound by drawing the skin a little outwards, so as to
bring the incision nearly over the interval between the
sternal and the clavicular portion of the sterno- mastoid
muscle. The fibres of the latter having been carefully di-
vided, part of the stcrno-thyroid muscle was seen, having
been brought a little out of its natural position by the pres-
sure of the tumour. As soon as the fibres of this muscle
had been separated to the same extent as those of the pre-
ceding one, a fascia-like structure was exposed, which felt
elastic to the finger, as if containing fluid. A fine trochar
was passed in, and a few drops of clear, colourless fluid
escaped, similar in character to that which had been pre-
viously found. The knife was carried along the cauula, and
the fascia-like structure divided to the extent of more than
half an inch. Immediately a thin membrane presented,
which, on being drawn out, proved to be an empty hydatid,
about the size of a marble. Another hydatid bulged into
the opening, and (the nature of the swelling being thus as-
certained) I passed in my finger, and found a large sac so
filled with hydatids of various sizes that I could not ascer-
tain its precise extent. I brought several of the Urgent
cysts, some of them as large as a hen's egg, against the edge
of the first rib, and broke them one after another ; after-
wards withdrawing the empty skins as they presented them-
selves at the wound. Carrying the knife upon my finger
into the opening I had made into the sac, I enlarged it,
directly upwards, to the extent of two or three lines, and
was then able to pass my forefinger behind the sternum and
along the edge of the first rib, but could not reach the
bottom of the sac, where several hydatids could be felt
crowded together.
In making this last incision some slight arterial bleeding
occurred, apparently from some muscular branch of the
stemo-niastoid in the upper angle of the wound. Pressure
with the finger and thumb arrested this, and a compress
and bandage were applied over the spot, to prevent its
recurrence.
A LARGE CYST CONTAINING HYDATIDS. 319
The patient complained much of pain during the opera-
tion, and became faint and exhausted ; but as his circulation
resumed its activity, the pulsation of his left radial artery
became almost as distinct as that of the right.
He passed a pretty good night, and felt easy the next
morning.
March 9th. — The sac still containing a large quantity of
broken and entire hydatids, and blood having also escaped
into its cavity, presented almost as large a swelling as before
the operation. The pulse at the left wrist was rather less
than it had been overnight.
On the 10th the compress was removed from the wound,
and, as no farther bleeding had occurred, a poultice was
applied.
11th. — Two whole hydatids, the size of pigeons' eggs, and
several smaller ones, passed out of the wound to-day, together
with many fragments of larger ones which had been broken
at the time of the operation. An offensive sanies begins to
drain away from the wound.
13th. — Two more entire hydatids, similar to those passed
on the 11th, several others the size of peas, and fragments
of broken ones, came away. The patient feels easy. The
discharge from the wound is more copious, and, although
very fetid, has more of the appearance of healthy pus.
15th. — I passed my finger this morning through the wound,
so as just to enter the opening in the sac. The patient was
directed to lie as much as possible in such a position as to
favour the escape of the discharge.
17th. — The pus from the wound is very fetid. My little
finger, passed into the sac, does not come in contact with
any hydatid, but enters an empty space. No hydatids have
passed out for the last four days. The patient's appetite
begins to flag, and he feels low, but does not complain of
much pain. He was ordered to take Liq. Cinchouje, nixx,
twice a day, and a pint of porter with his dinner.
19th. — One entire hydatid, as large as a hen's egg, passed
this morning, and three burst ones about half that size.
The patient feels better again, and his appetite has improved.
320 MR. DIXON's CASE OF
20th. — Two large hydatids passed to-day. Tlie opening
in the sac begins to contract, so that it only admits the tip
of the little finger. Fetid sanies continues to drain away.
Nothing worthy of note in the patient's condition occurred
till the —
27th (the nineteenth day after the operation), when I was
sent for, at 10 a.m., in consequence of bleeding having oc-
curred from the wound. One of the dressers happened to
be near at hand when word was brought him that the patient
was bleeding. A large clot had slowly forced its way out of
the wound, followed by a jet of blood. Pressure was applied
over the wound, and when I arrived all haemorrhage had
ceased, and only a little colourless fluid, like that from a
hydatid, welled up now and then from the opening. The
patient was much blanched ; the sac was distended, evidently
with clot; pulsation could be felt at the left wrist, but feebler
than at the right. A little strip of whitish tissue, like dead
cellular membrane, hung in the wound. I ordered the
patient to be constantly watched, and a bladder of ice to be
laid on the part.
1 p.m. — An empty hydatid (when full, the size of a hen's
egg,) came awny an hour ago, and no blood passed then or
since; the patient described a peculiar sense of oppression - -
" a burden" he termed it — about the left side of the sternum,
as having preceded this morning's burst of haemorrhage. He
was ordered to omit the porter, and to allay his thirst by
sucking, now and then, a bit of ice.
28th. — I was sent for again at 4 a.m. A fresh burst of
bleeding had taken place, and had been checked by pressure,
as before. At the same time a strip of fibrous tissue, about
five inches long by two in width, like Bloughy fascia, passed
out of the wound. This made it appear probable that the
whole sac was in a state of slough, and was loosening from
the surrounding textures, and that the bleeding was taking
place from the various \essils destroyed in the process.
When J arrived at the bedside all bleeding had ceased.
The patient "as bo faint thai 1 gave him two ounces of wine.
The dresser continued to watch beside him, ready to apply
pressure on the first sign of clot in the wound.
A LARGE CYST CONTAINING HYDATIDS.
321
9 a,m, — No more haemorrhage. At 5 p.m. I was again
summoned. A fresh jet had occurred, instantly stopped by
the dresser in attendance. With but slender prospect of
success, I now determined to explore just so far as to ascer-
tain whether the blood came from any partially divided
vessel at the mouth of the sac, and consequently within
reach. I extended the skin-wound two inches upwards,
along the sterno-mastoid muscle, and made a cut an inch
long outwards from the lower end of the wound, and then
cut carefully through all the clavicular portion of the sterno-
mastoid muscle. The central tendon of the omo-hyoideus
was thus exposed and divided, and a clear view obtained of
the mouth of the wound in the sac; and along its outer edge
lay a very large vein (the internal jugular). It was quite
collapsed, and it was only by running the finger over it that
a little blood could be made to pass along it, and its being
a vein demonstrated. No aperture could be found in its
wall, nor could any cut vessel be discovered.
From time to time, during this exploration, masses of
broken-down and putrid clot were jerked out from the sac
with great force, together with much bloody sanies, but no
fresh blood flowed. Any attempt to enlarge the opening
in the sac seemed out of the question ; a compress was
therefore laid over the wound, and a bladder of ice applied.
The patient died the following day, at 10 a.m.
29th. — Body examined four hours after death. The chest
alone could be inspected. The first bone of the sternum,
the left clavicle, together with the five lower cervical and
three upper dorsal vertebra;, and the first two ribs on both
sides, the larynx, oesophagus, aorta, and upper half of the
left lung, were removed for subsequent examination. A few
ounces of serum were in the cavity of the left pleura, stained
by the transudation of colouring matter from the clot in the
sac. There was a patch of quite recent fibrin on the outer
side of the middle lobe of the left lung, and three or four
slender bands of this deposit, were attached to the costal
pleura adjoining. There were no signs of old pleuritis any-
where, and the lung was crepitant throughout.
322 MR. dixon's case of
The larynx, trachea, and bronchi having been removed
from the preparation, it required great care to dissect away
the oesophagus without opening the inner wall of the hydatid
sac, so closely were the two structures united. The portion
of the vertebral column removed from the body, consisting
of the five lower cervical and three upper dorsal vertebrae,
presented a considerable curvature, the concavity being to-
ward the left side. The sac, formed of condensed cellular
tissue, was attached above to the left side of the third cer-
vical vertebra, and thence along the median plane of the
vertebral column, as far down as the lower part of the body
of the second dorsal vertebra; from the latter point it passed
on to the convexity of the aortic arch.
On dividing the vertebral attachment of the sac, so as to
obtain a view of its interior, the fifth, sixth, and seventh cer-
vical vertebras were found to have undergone absorption to
the extent of almost the left half of their bodies ; and the
corresponding portions of the second dorsal vertebra had
suffered in nearly the same degree. The head and neck of
the first and second ribs had likewise disappeared. The
vertebral vessels were exposed at one or two points of their
course through the foramina in the trausverse cervical pro-
cesses, and the cancellated texture of these processes laid
bare, like that of the bodies of the vertebrre.
From the left side of the second dorsal vertebra the sac
was traced, as above noticed, on to the convexity of the arch
of the aorta ; but, by careful dissection, it might be separated
from the coat of this vessel as far as the outer side of the
origin of the left subclavian artery. At this point, however,
the sac and aorta became united by delicate vessels, and this
union extended for a distance of nearly two inches (inward
along the arch.
The sac next came in contact with the apex of the left
lung, to which it was intimately united, by fibrinous adhe-
sion, to the extent of the palm of one's hand ; no intervening
layer of pleura being distinguishable. Loosely attached to
the inner surface of 1 1n- second rib and border of the first,
the sac passed on to the internal surface of the sealeni
A LARGE CYST CONTAINING HYDATIDS. 323
muscles, and so back to the transverse processes of the four
lowermost cervical vertebra?, from which situation we began
to trace it.
Superficial to the anterior surface of the sac ran the left
common carotid artery, accompanied, when above the level
of the sternum, by a very large anterior jugular vein, which,
from its great size and relative position to the artery, had,
during the patient's lifetime, been supposed to be the in-
ternal jugular. The last-mentioned vein, however, had been
widely separated from the carotid artery by the pressure of
the swelling, and lay to the outer side of the incision made
into the sac; the carotid artery and vagus nerve skirting
the inner edge of the same opening.
The scaleni muscles were found in their natural position,
and the subclavian artery emerged from between them in
the usual way ; it seemed, however, rather smaller than
natural, and, on drawing it out a little from between the
muscles, it had evidently undergone constriction in that
situation.
The dissection having been pursued to the extent above
described, without interfering with the wound, to prevent
the possibility of injuring any vessel in the neighbourhood,
the interior of the sac was examined from behind, by draw-
ing forward that portion which had been detached from the
vertebra?. "When cleared of the broken-down and putrid
clots which filled it,1 it presented a surface of sloughy shreds
of membrane, except at the back part, where the bony
structure of the vertebra? was laid bare. It was probably
from this situation that the long strip of fibrous tissue had
been detached, which passed out of the wound on the occa-
sion of the burst of ha?morrhage.
The source of this haemorrhage was now discovered. At
the bottom of the sac the left subclavian artery lay exposed
to the extent of nearly an inch, and exhibited a slit, about
half an inch long, through which a probe passed directly
into the aorta. The latter having been laid open along the
concavity of its arch, the probe was seen lying in the
entrance of the subclavian artery. This vessel was next
A solitary, collapsed, hydatid was found within the sac.
3i4 mr. dlxon's case of
slit up along its outer side, from its origin almost to tlie
point where it passed between the scaleni. Its cellular coat
was so thickened, and so identified with the condensed
pleura, that it was impossible to trace the bounds of each.
The inner coat of the artery was everywhere entire, except
at one spot, distant about three quarters of an inch from its
aortic origin, where its inner wall presented a shallow oval
depression, half an inch in width, the long axis parallel to
the course of the artery. Along half of the circumference
of this oval depression the coats of the artery had given way,
so as to establish the communication above described be-
tween its cavity and that of the sac.
Although externally to the scaleni the calibre of the
artery was free, and its size scarcely, if at all, less than
natural, a probe could not be passed downwards to the seat
of rupture ; and the cause of this was now apparent. The
long-continued compression of the artery between the sac of
hydatids and the edge of the first rib had terminated in total
obliteration of the vessel at the latter point, so that for a
distance of more than half an inch it was merely a rounded
cord. The vertebral and internal mammary arteries took
their usual course (the latter being, perhaps, larger than
natural); the thyroid axis was given off in the usual way;
and about three-quarters of an inch farther on, the sub-
clavian, having narrowed to a tube less than half a line in
diameter, became entirely closed. As this closure must have
been of old standing, the circulation in the left arm had
probably been carried on by the anastomosis existing be-
tween the supra-scapular and subscapular arteries ; but, con-
sidering the total absence of pulsation at the wrist for so
long a time previous to the sac being opened, it is difficult
to account for so distinct a pulsation having been restored
immediately after the operation.
With regard to the manner in which the rupture of the
subclavian artery occurred, one would rather have expected
to find evidence of ulceration of its outer coat, at the point
where it was laid bare by the separation of the sloughy por-
tion of the sac, than at the corresponding spot within the
A LAROE CYST CONTAINING HYDATIDS. 325
cavity of the vessel. Indeed, my first impression, on viewing
the rent in its wall, was, that it had been wounded during
the operation, more especially as some arterial bleeding had
taken place towards its conclusion. A little examination,
however, proved that this accident could not have happened.
When my finger was first introduced into the opening I had
made in the sac, its cavity was entirely choked up with
hydatids ; and it was not until several of these had been
broken, in the manner above described, that the point of
my finger could be brought fairly in contact with the edge
of the first rib. The only enlargement of the original wound
in the sac was made, as I have stated, directly upwards, in
a line with the angle of the jaw, and by means of a small
scalpel introduced on my finger. If we notice, on the pre-
paration,1 the distance between the opening in the sac and the
rent in the subclavian artery, the possibility of a wound of the
latter appears altogether out of the question; nor should I have
alluded to it at all, but for the circumstance of arterial bleed-
ing taking place when the opening in the sac was enlarged.
That the artery was not injured subsequently to the
operation is certain ; for no probe or similar instrument was
ever passed into the wound, its patency being, as I thought,
best ensured by passing the point of my finger into it from
time to time.
The bleeding, too, which followed the last small incision
was arrested by pressure, maintained for about an hour with
the finger and thumb, at the mouth of the wound, and for
some hours afterwards with a pad of lint. During eighteen
days, broken or entire hydatids were passing out; and it was
not until the nineteenth day after the operation that the
fatal haemorrhage commenced.
With the knowledge we now possess of the extent to
which the disease had proceeded, there can, I think, be no
doubt that the operation hastened the patient's death, by
the free admission of air into the sac, and the consequent
1 The preparation was exhibited to the Society; it is preserved in the
Museum of St. Thomas's Hospital.
xxxiv. 21
326 LARGE CYST CONTAINING HYDATIDS.
sloughing of its walls; but with the uncertainty which
necessarily existed as to the real nature of the case, it would
have been wrong to have abandoned it without an operation
of some kind being attempted. Here was a cyst, containing
fluid, steadily increasing iu bulk, which had entirely stopped
the current of blood through the subclavian artery, and was
gradually impeding that through the common carotid, as
well as the return of blood through the veins of the neck.
The pressure on the nerves supplying the left arm had
already obliged the patient to abandon his employment, and
the alteration in his voice seemed to indicate an amount of
pressure on the trachea, which might ultimately end in
suffocation.
It seems impossible to determine with certainty the struc-
ture in which the hydatids were first developed ; but if we
regard the rounded pits seen here and there on the eroded
surface of the vertebrae, it seems not unlikely that they may
have been the original seat of the parasites, which, as they
grew, would of course press on the nerves passing down to
form the brachial plexus, and thus cause the tingling and
numbness of the left arm and baud, which were the earliest
symptoms noticed by the patient. The sheath of the left
longus colli muscle, and the anterior ligaments of the cer-
vical vertebrse, probably formed the sac at an earlier stage
of the disease ; condensed cellular tissue, and, ultimately,
the pleura covering the apex of the left lung, together with
fibrinous deposit, completed it at a later period. The pres-
sure which had latterly been exercised upon the superior
and inferior laryngeal nerves on the affected side, had,
doubtless, caused the pecidiar weak and hoarse tone of the
patient's voice.
Microscopical examination of most of the hydatids was
made as soon as they were voided. In several, of the size
of pigeons' eggs, clusters of cchinococcus were found, in
various stages of development ; but neither in the largest
cyst, which «as equal in bulk to a hen's egg, nor in those
about the size of a pea, could any of these bodies be detected.
A CASE OF
ANEURISMAL DILATATION
OF
THE POSTERIOR TIBIAL VEIN,
COMMUNICATING INDIRECTLY WITH
THE UPPER PART OF THE POPLITEAL ARTERY.
EDWARD COCK,
SURGEON TO GUT'S HOSPITAL.
Received May 7th.— Head May 27tli, 1851.
The obscurity which involved this case during its pro-
gress, the remarkable and, I believe, unique character of
disease which it exhibited, when at length its true character
became developed, and the difficulty of explaining some of the
circumstances connected with it, have induced me to lay it
before the Fellows of the Medical and Chirurgical Society.
George Mortimer, set. 28, a tide-waiter, was admitted into
Guy's Hospital under my care on the 30th of October, 1850,
for a painful and swollen state of the left leg.
He was married, had always enjoyed good health, and
had led a steady, temperate, and active life. His statement
was as follows : between three and four months ago, while
stationed at Gravesend, he was attacked by fever, which
confined him to his bed for a considerable period and left
him in a very debilitated state. He was then removed to
Carshalton for the benefit of his health ; and about five weeks
ago, when endeavouring for the first time to walk about, he
discovered that his leg was stiff, painful, and swollen. These
symptoms gradually increased until he was admitted into
the Hospital.
328 MR. cock's case of aneuiusmal dilatation
On examining the limb (October 30) as he lay in bed, I
found general enlargement and oedema from the knee down
to the toes. The cellular effusion was greatest about the
ankle and instep. The principal enlargement was at the
back of the leg, where the calf was bulged out into a promi-
nence, extending from the knee to rather more than half-
way down, tense and tender. Deep-seated fluctuation was
very distinct, and it was evident that a large collection of
fluid existed under the gastrocnemii muscles. He had been
the subject, during the last few weeks, of occasional rigors
with exacerbations of pain and fever ; and there was every
reason to suppose that a large collection of pus had formed
between the superficial and deep-seated muscles. While
engaged in making the examination, my attention was
accidently directed to a large cicatrix on his thigh ; and I
then learnt that his femoral artery had been tied eleven
years previously by Mr. Tracey of Dartmouth, for a sup-
posed wound of the popliteal artery inflicted by a stab with
a knife. The operation had been performed two weeks after
the injury, on the occurrence of secondary hemorrhage, and
had been perfectly successful. He speedily recovered the
full use of his leg, and never experienced the slightest incon-
venience ; neither has he ever been aware of the existence
at any time of any tumour or swelling. He however has
subsequently informed mc, that two years after the artery
had been tied he became the subject of varicose veins on the
same leg; that he had recourse to bandages, which he iron
between three and four years and then left them off. The
veins had by that time somewhat diminished in size, but
had acquired a permanent enlargement and thickening of
their coats, which has since continued.
The history which I have just related induced me to
make a second careful examination of the limb.
The femoral artery could be felt pulsating along the upper
part of the thigh. The anterior and posterior tibial arteries
could be felt to beat vigorously, after displacing the super-
jacent oedema by pressure; not the slightest sense of pul-
sation, not the faintest sound or murmur could be detected
OP THE POSTERIOR TIBIAL VEIN. 329
in the tumour at the calf; it was totally uninfluenced by
arresting the flow of blood through the artery at the groin;
and I still considered it to be a large abscess.
The suffering condition of the patient required that some
relief should be afforded ; and accordingly, on October 30th,
an incision was made into the cavity near the upper and
inner part of the leg, where the walls appeared to be thinnest.
A flow of blood followed the withdrawal of the lancet, until
between two and three ounces had been spontaneously dis-
charged through the opening. The blood was dark, grumous,
and pitchy in its character, did not coagulate, and had
evidently been extravasated for a considerable period. Its
evacuation sensibly diminished the tension of the swelling,
and the pain was relieved. A piece of lint was laid over the
part ; the limb was placed on a pillow, and strict quietude
enjoined.
On November 1st he was again complaining of a good
deal of pain in the leg, accompanied by fever and restlessness.
A small quantity of pus had oozed through the wound, which
was nearly blocked up by a clot of blood. On removing this
with a pair of forceps a copious discharge of pus took place,
and in a few minutes nearly a pint had flowed away. The
fluid was offensive in its character, and contained numerous
half-decomposed softened-down coagula of blood. Fomenta-
tions were applied over the leg and a generous diet ordered.
It was now quite evident, that at any rate the larger part
of the swelling had consisted of an extensive accumulation of
matter beneath the gastrocnemii muscles ; and the free dis-
charge which now took place was accompanied by a marked
improvement in the symptoms, both locally and generally.
I need not trouble the Society with the details of the
case during the next ten days, as they are those incident to
a large deep-seated abscess ; a large quantity of pus, partially
mixed with blood, bad been evacuated, and the patient had
began to rally in health and strength.
Nearly a fortnight had now elapsed since the leg was
first punctured. The extravasated and decomposed blood
had been entirely got rid of. The discharge of pus from
330 mr. cock's case of aneurysmal dilatation
the now contracted and diminished cavity, was small in
quantity and healthy in character. The leg had returned
to nearly its natural size and shape ; the man's health was
daily improving.
During this period I had frequently turned the case over
in my mind, endeavouring to account for the effusion of so
considerable a quantity of blood and the formation of so
large an abscess ; canvassing the possibility of a connection
between the recent circumstances and the former wound of
the popliteal artery. My speculations on the subject could
now be but of little importance. The solution of the mystery
was nearer than I anticipated.
On November the 14th, just fifteen days after the puncture
had been made, when the state of the patient promised a
speedy convalescence, arterial haemorrhage suddenly took
place from the wound, and before competent assistance could
he afforded he had lost nearly three pints of blood. The
flow was arrested by a firm compress placed over the wound,
and by pressure on the artery at the groin, which, however,
he could only bear in a modified degree. On my arrival I
found the entire cavity of the original abscess tense and
distended to more than its original size, whilst its walls had
evidently given way, and blood was gradually effusing itself
upwards through the popliteal space iuto the thigh. The
entire leg had a swollen, shiny, and livid appearance. There
could be no doubt that arterial haemorrhage was going on,
and that the remedial means must be prompt and decisive.
Three methods of treatment suggested themselves, which
I respectively considered and discussed with Mr. Poland, the
only one of my colleagues whose assistance was available at
the time. The first was to place a ligature on the upper
femoral or external iliac artery; the second was to lay open
the cavity of the leg, evacuate its contents, search for the
vessel which afforded the haemorrhage and if possible secure
it; the third was to amputate above the knee.
'We came to the conclusion that a ligature on the upper
femora] or Qiao artery would probably throw us on to the
horns of a dilemma; that, from the free collateral circulation
OF THE POSTERIOR TIBIAL VEIN. 331
resulting from the former operation, it might at best afford
but a temporary check to the bleeding ; whilst on the other
hand, if the supply of blood to the leg became materially
diminished in its then present state, gangrene would follow
as an almost inevitable result. This proposition was there-
fore abandoned. The second shared the same fate, as we
considered that the operation of laying open the cavity and
searching for the vessel was, as regarded the collapsed state
of the patient, too severe in its character; and, considering
our ignorance of the source of haemorrhage, too uncertain in
its results to be attempted. Our last resource was amputa-
tion ; and I removed the leg a short distance above the knee.
The remaining history of the patient may be dismissed in
a few words. He rallied slowly from the prostration
produced by the loss of blood and from the shock of the
operation ; but in a month's time the stump was nearly
healed and I considered him as convalescent. He then
became the subject of low fever accompanied by bronchial
irritation and general constitutional irritability. His
appetite failed, and he began to exhibit all the symptoms
which had preceded several cases of fatal phlebitis, a disease
which was at that time epidemic in our hospital. I deter-
mined to remove him before it was too late ; and finding that
he had a comfortable home at Carshalton despatched him
thither without delay. The change acted most beneficially.
In a week's time his unfavorable symptoms had all dis-
appeared, he rapidly recovered, and is now filling the situa-
tion of gate keeper at the Custom House.
The amputated leg was most carefully dissected by Mr.
Poland who has kindly furnished me with the following
account of his examination : —
The limb cedematous and much increased in size, A
small lancet wound on the inner side of the calf, giving exit
to puriform fluid and decomposed blood with clots. Close
by, thinning of the integuments, which appeared just on the
point of giving way by ulceration. On removing the in-
teguments, all the superficial veins were found much enlarged,
332 mr. cock's case OF ANEURISMAL DILATATION
and their coats exceedingly thickened, hut the vessels them-
selves were quite pervious. A track of subcutaneous suppu-
ration extended from near the knee to the ankle, the pus of
pinkish colour mixed with some clots of blood. The gas-
trocnemius muscle expanded and very thin, as was also the
soleus, which was exceedingly stretched and distended. Ou
rcflexing these muscles, a large diffused collection of blood
in part coagulated was found beneath, extending from the
knee to half-way down the leg. On washing away this
blood, an aneurismal sac about the size of a cluck's egg was
brought into view. It was situated beneath the upper part
of the soleus muscle, and had displaced the posterior tibial
nerve, which curved round and was stretched over its outer
border. The sac had given way by an ulcerated opening
at the upper part near the entrance of a vessel. The vessels,
both arteries and veins, were carefully dissected out and pre-
sented the following appearances : —
lu the centre of the popliteal space, lying on the posterior
ligament of the knee, was a small and firm sac about the
size of a pigeon's egg: its walls, in part, cartilaginous with
ossific deposit; within a cavity lined by fibrin, and empty.
Leading to the sac from above were two vessels, viz. the
popliteal artery and vein. The artery was somewhat smaller
than normal but otherwise healthy and pervious, and freely
entered the sac. The vein tapered dowu and was lost ou
the walls of the sac as a fibrous cord ; above, its coats were
much thickened and filled with firm old coagulated blood.
From the lower part of the sac issued two vessels, both freely
communicating with its interior. The smaller one \\:is the
efferent continuation of the popliteal artery much diminished
in size, which, after passing down as usual to the leg, divided
into the anterior and posterior tibial and peroneal branches.
These vessels were quite pervious and natural, and, although
small in size, evidently constituted the normal arterial dis-
tribution to the leg. The larger Vessel descending from the
sac, proved to be the continuation of the popliteal vein ; it
was greatly thickened, pouched, and puckered, but quite
pervious, and passed down to the lower bonier of the pup-
OF THE POSTERIOR TIBIAL VEIN. 333
liteus muscle where it divided into two trunks. The one
of these, which was completely filled and obliterated by old
firmly coagulated fibrin, accompanied the anterior tibial
artery. The other, which formed the continuation of the ori-
ginal trunk, was pervious, and led directly into the interior
of the aneurismal sac, with the walls of which its coats became
identified. Again, from the lower part of the sac there
emerged three or four large branches which were impervious,
with thickened walls and solid fibrinous contents. These
accompanied the posterior tibial and peroneal arteries. That
all these vessels were veins notwithstanding the arterial
character and thickness of their coats, and that they con-
stituted, in fact, the venae comites to the arteries of the leg,
was distinctly made out by the dissection, and furthermore
by washing out their contents and discovering their valves.
They were all completely obliterated along the whole of
their course ; and the blood must have been returned from
the leg entirely through the agency of the superficial veins.
The several facts connected with this case which were
brought to light by the dissection, may be shortly enumerated
as follows : —
1st. That the popliteal vein and artery had both been
wounded by the original injury eleven years ago, and that a
permanent communication had become established between
the two vessels, maintained through the intervention of a
small sac common to both.
2dly. That the popliteal vein above the seat of injury had
become obliterated and was obstructed up to the line of
amputation. That it probably regained its permeability at its
junction with the saplucna minor vein, which vessel appeared
to have returned the greater part of the blood from the leg.
3dly. That the popliteal vein below the seat of injury had
become dilated and thickened, apparently from the impulse
of the blood received into it from the artery, and that it
terminated below in an aueurismal dilatation of the posterior
tibial vein, while all the vence comites of the leg had
become completely obstructed and obliterated.
334 MR. cock's case of aneurismal dilatation
4thly. That at some subsequent period the walls of the
venous aneurismal dilatation must have given away, allowing
the extravasation of a certain amount of blood beneath the
gastrocnemii muscles.
5thly. That in consequence of or at any rate connected
with this extravasation of blood, was the occurrence of an
abscess, which finally, after the lapse of eleven years, again
brought the patient under surgical treatment.
Thus it will appear that the history of this case extended
over a period of eleven years ; the original wound and the
final abcess constituting the commencement and termination.
The chronological order in which the other intermediate
changes and events occurred, necessarily becomes a subject
for conjecture and discussion. We possess no precise clue
to guide us as to the succession observed by the obliteration
of the popliteal vein above the original wound; the dilatation
and formation of the venous aneurismal sac below, the
obliteration of the venae comites of the leg, and lastly the
escape of blood from the sac beneath the muscles. Con-
sequently it is by no means clear how far these events were
dependent on each other.
It will, however, be remembered that the superficial veins
of the leg became dilated and thickened about two years
after the femoral artery had been tied ; and this may, in
some measure, serve to fix the period when the obstruction
of the venae comites took place.
The subject presents a wide field for inductive reasoning
and ingenious speculation, but I have forborne to add to
the length of my communication by stating more than was
necessary to lay before the Society a simple recital of Gaels,
I subjoin a communication which Mr. Traccy has been
kind enough to send mc, relative to the details of the origi-
nal injury.
"I saw Mortimer within an hour of the event, October
30, 1839, and found a small wound in the popliteal apace
from which blood was oozing slowly ; a small thread of
arterial blood being distinctly visible over the darker mums
blood, which constituted by far the jrreater part of the
hemorrhage.
OF THE POSTERIOR TIBIAL VEIN. 335
As the blood did not issue per saltum, my impression was
that only a small artery had been wounded, and that the
popliteal had escaped, more especially as I found that
moderate pressure of the thumb over the wound commanded
all bleeding.
The lad was sent to bed, strict rest was enjoined, and a
firm compress was placed over the wound secured by a
bandage.
Before leaving the house, I was shown a dinner knife,
old and well worn at the back towards the end, so that,
although originally round, it had become tapering at the
extremity. On comparing the length of the wound with
the breadth of the blade, I found that the knife must have
penetrated deeply, but still could not reconcile such slight
haemorrhage with the wound of an important artery.
Every thing went on well for the first day or two, the bleed-
ing was completely restrained, and there was no complaint but
from the tightness of the bandage. About the third day a
spot of dark coloured blood appeared through the compress.
This was removed and more carefully applied, and the band-
age carried higher up the thigh so as to make firm pressure
on the femoral artery below the groin. Things again went
on well up to the eighth or ninth day, so that I began to
entertain hopes that nothing more would be necessary, when
the spot again made its appearance. On examining the
wound, no union had taken place, but, with the exception of
a little puffiness, it looked healthy. The same treatment
was continued till the 12th of November (twelve days after
the accident), and I doubt whether during that time a table-
spoonful of blood had been lost. On that day (viz. the
1 2th) I found the edges of the wound everted and the colour
of the surrounding skin slightly livid. On making mode-
rate pressure with my finger, a small sized coagulum slipt
out, and a moderate flow of clear blood followed. I deter-
mined to take the bull by the horns, and accordingly tied
the femoral artery, the ligature around which instantly
stopped the haemorrhage.
From this period everything went on most satisfactorily.
On the fifth day union throughout the line of operation had
336 mr. cock's case of aneurismal dilatation.
taken place, except immediately about the ligature, which
came away on the twelfth clay, by which time also the wound
iu the popliteal space had firmly united. The lad perfectly
recovered and returned to his work, and for some two or
three years afterwards felt no inconvenience, as I used to
see him constantly. He then left the town, and I heard
no more of him until you again brought him to my re-
collection."
DESCRIPTION OF THE PLATE.
A. Small Aneurismal Sac resulting from the original wound of tlic popliteal
artery and vein, communicating with the artery above and below, and
with the vein below.
B. Foplitcal Artery entering the sac from above.
c. Popliteal Artery leaving the sac below, and proceeding to its normal
distribution iu the leg.
d. Upper portion of the Popliteal Vein obliterated and attached as a cord
to the sac.
E. Lower portion of the Foplitcal Vein dilated and thickened, leaving the
sac and carrying arterial blood, and terminating below iu an aneurismal
dilatation of the posterior tibial vein.
F. Aneurismal dilatation of the posterior tibial vein.
G. Vena; Comitcs of the leg, anterior and posterior tibial, and peroneal,
obliterated.
336*
ON A
NEW METHOD OF TREATMENT
APPLICABLE TO
CERTAIN CASES OF EPIPHORA.
WILLIAM BOWMAN, F.R.S.
PROFESSOR OF PHYSIOLOGY AND OF GENERAL AND MORBID ANATOMY IN
KING'S COLLEGE, ASSISTANT-SURGEON TO THE KING'S COLLEGE HOSPITAL,
AND TO THE ROYAL LONDON OPHTHALMIC HOSPITAL,
Received May 13th. — Read Ju
The most common cause of obstruction to the flow of the
tears into the nose, is inflammatory thickening of the
mucous lining of the excretory channels, with accumulation
of morbid secretions in the sac. But there are other causes,
affecting only the puncta or canaliculi, yet equally prevent-
ing the escape of the tears, and therefore quite as annoying
and as detrimental to sight. It is to certain examples of
this latter kind, that the present brief communication refers.
Among these may be mentioned, displacements outwards
of the puncta, generally the lower one, so that the tears no
longer reach the orifice, and of course cannot enter the
canal; and closure of the puncta or canaliculi, following
mechanical injury or ulceration.
Of the displacements of the puncta, a common one is that
which attends ectropion, in which the mucous membrane of
the lid is thickened and often cuticular, and the tarsal mar-
gin, including that part surmounted by the punctum,
becomes rounded and flattened, and the punctum thrown
out of the course of the tears. The mucous lining of the
338 MR. bowman's new method of treatment
canal and sac here often participates in the inflammatory
thickening.
The treatment of this displacement may sometimes resolve
itself wholly into that of the ectropion, and the punctum,
when restored, as far as possible, to its proper direction, may,
in a great measure, resume its function. And I have re-
marked, that in some instances of old standing ectropion,
although the punctum continues displaced, yet the stil-
licidium lacrymarum gradually subsides, apparently in con-
sequence of the diminishing sensibility of the mucous
membrane as an excitant of the lacrymal secretion, under
its long exposure to the air, and slow approach towards the
characters of skin. Indeed, it is singular how little these
patients sometimes suffer from the obstruction, except when
the secretion is augmented by a cold wind, or other acci-
dental cause.
In other cases it will happen, that after the ectropion is
cured by one of the various operations in common use, the
epiphora remains, — the punctum either continuing a little
displaced, or at least surrounded by tumid tissue, and irre-
parably altered in structure. If it should appear that the
sac is itself healthy, the mode of treatment presently to be
described will then be applicable.
But there is another and a much simpler displacement of
the punctum than that which accompanies ectropion, and
which, as far as regards the arrest of the tears on the front
of the eye, is even more incommodious to vision, inasmuch
as the lid itself, retaining nearly its natural positiou, holds
up the tears upon the front of the cornea, where they occa-
sion false refractions of the light, which are not common in
the epiphora of ectropion. Moreover, the secretion of tears
seems to be maintained at its usual rate, and is not di-
minished as it often is in chronic ectropion.
A close examination is necessary to detect the cause of
the epiphora in these instances. The lid is cither in natural
contact with the globe, or only slightly recedes from it in
certain positions, as when the eye is turned upwards. The
natural prominence on which the punctum is placed, is
IN CERTAIN CASES OF EPIPHORA. 339
however, wanting, and, instead of it, there is a flattened or
rounded cutaneous surface, on which the orifice may be dis-
cerned (though with difficulty) at a little distance from the
mucous surface of the lid, and much reduced in size, being
in fact never wetted by the tears, but dry and contracted.
When the situation of the orifice is discovered, a probe
may be easily introduced into the sac, which is itself empty,
proving the integrity of the apparatus, except as regards the
position of the punctum.
There appear to be at least two causes of this displace-
ment of the punctum : one, a slight chronic inflammation of
that part of the conjunctiva lying near the punctum, pro-
ducing thickening and consequent eversion — (this may exist
alone or in connection with any of the chronic ophthalmia?,
especially those of the lid), — the other, a chronic affection
of the skin of the lower lid, somewhat resembling eczema,
by which a general but moderate contraction of it is pro-
duced, and the puncturn is drawn outwards.
It is a remarkable fact, that an extremely slight dis-
placement outwards, will destroy the function of the lower
punctum, and the following considerations are offered in
explanation of it. The puncta are naturally so placed, as
to be either altogether on the conjunctival aspect of the
lid (as in some of the lower animals), or else (as in man) at
the very margin at which the skin and conjunctiva blend.
Now skin differs from mucous membrane, in the superficial
layers of the cuticle being rendered greasy by the sebaceous
secretion, so that they throw off water as greased paper
does; whereas, the corresponding part of mucous membrane
is moist, and water adheres to it. To apply this to the eye-
lids, and their relation to the passage of the lacrymal fluid :
— the tears have to be directed towards the puncta, and to
enter these orifices ; and if the skin were not greasy up to
the margin of the lids, the tears would be very apt, indeed
would be certain, to ooze over the tarsal margin on to the
cheek. The skin of the lids is, however, exceedingly deli-
cate and thin, and deficient in sebaceous follicles. But to
supply this want, there is a great development of sebaceous
310 mr. bowman's new method of treatment
glands, placed so as to pour their secretion on the margin of
the lid, close upon the line of junction of the skin with the
mucous memhrane — on that part where there must be a
constant tendency for the moisture of the mucous membrane
to soak through and wet the surface of the cuticle, and yet
where it is so essential to the retention of the tears, that
the skin should be greasy. So that I regard the meibomian
glands as existing, not for the purpose, as stated in anato-
mical works, of preventing the agglutination of the lids when
closed, (which would be no more likely to happen here, without
sebaceous matter, than it is to occur between the lips of the
orifice of the urethra,) but for the purpose of maintaining
that greasy state of the surface of the cuticle at the margin
of the lid, which prevents the tears from escaping over the
cheek. And I may add, that the probable use of that
sebaceous gland, called the caruncle, is to throw the tears
into a little pool above it, where they may be taken up by
the puncta ; for even the lower punctum glides above the
caruncle in the winking movements of the lids. Now it
appears, that the punctum, though situated on the confines
of skin and mucous membrane, partakes only of the character
of the latter. Its margin is always naturally moistened by
the tears, and is not greasy. The mucous surface on its
inner side, over which the tears approach it, is also moist
and conjunctival. Now in the cases to which attention has
been called, the punctum has its margin greasy and cutieular,
as a consequence of its displacement and exposure, and the
membrane on its inner side is similarly changed, so that the
tens arc prevented from coming up to it, and do not wel it,
but collect in a drop at the caruncle. And if the punctual
is pushed back into contact with the tears, its margin
instantly throws off the moisture, and cannot lie wetted by
it. In some cases, a margin of ggth of an inch of greasy
membrane on the conjunctival side of the punctum, is suffi-
cient to destroy its function.
I had seen instances of epiphora depending im the •-triic-
tural changes now adverted to, which resisted all treat incut
short of operation, and in which DO Operative procedure like
IN CERTAIN CASES OF EPIPHORA. 341
those in common use — such as removal of a portion of
mucous membrane — seemed to promise a good result, when
the following case presented itself: —
A woman, ret. 43, came to he relieved of chronic ophthal-
mia in the left eye. The upper lid was a little deformed
between the punctum and sac, owing to its having, as she
said, been injured when she was eight years old. On exa-
mination, the caual was found to have been torn completely
across, yet the orifices to have remained open, so that a probe
introduced through the punctum, emerged near the caruncle,
and could be reintroduced at the lower orifice (which was of
ample size), and carried forwards into the sac. No epiphora
existed.
A second case, much resembling this, occurring some
time afterwards, led me to reflect whether a somewhat simi-
lar division of the lacrymal canal might not be artificially
made with advantage in some inveterate examples of epiphora,
so as to remedy all the inconveniences of the affection, by
giving the tears a new way into the sac; for these instances
seemed to show, that such an orifice in the canaliculus would
not be disposed to contract, as it might have been expected
to do from the analogy of other mucous ducts, while it
would probably serve as well as the original punctum to con-
vey the tears. This idea was tested in the following manner :
A young man, engaged in a warehouse in the city, had
suffered for two years, from constant watering of the eyes.
The skin of the lower lids seemed to have been affected with
chronic eczema — it was red, shining, and contracted. The
lower lids at the inner can thus were a little separated from
the globe, so that the puncta had not their proper backward
direction, but appeared flattened and slightly everted. The
tears, collecting at the inner canthus, did not touch the
puncta. The upper puncta were similarly flattened, and
were small and indistinct. A probe passed readily through
all the puncta into the sacs.
14th Feb., 1850. Introducing a probe into the left lower
punctum, I cut transversely upon it, midway between the
punctum and caruncle, on the conjunctival aspect, and
342 MR. bowman's new method of treatment
brought out the probe at the wound. I then slit up the canal
a little way towards, but not quite up to, the punctum. This
wound of course did not completely cut across the canal. It
was made where the tears collected, and I hoped that it would
remain open and allow them to enter the canal. But though
I kept it open by separating the edges daily, and afterwards
by passing a thread through the punctum into the canal,
and bringing it out at the new opening, the tendency to
close was so great, that on removing the thread ten days
after, the wound immediately healed, and the operation
proved unavailing. While the thread had remained, how-
ever, he had experienced great relief, and the tears had
hardly accumulated.
On March 9th, the canal was pervious to a probe from
the punctum to the sac, without obstruction. Despairing of
keeping open an orifice thus made in the side of the duct, I
determined to attempt the same object in another way, viz.,
by slitting up the canal from the punctum, for a length suf-
ficient to carry backwards the orifice on to that part of the
mucous surface, where the tears collected. This I did with
a scalpel, by the aid of a punctum probe introduced as a
guide. On the following day, the section being adherent in
its whole extent, I broke through the adhesions with a probe,
and repeated the same process a few times, so as to prevent
union of the margins, while the wound was healing. On the
20th, the canal was converted into a groove, and the edges
showed no further disposition to adhere. The tears found
their way from this groove along the remaining part of the
canal into the sac, and the epiphora was almost entirely re-
lieved. I was therefore encouraged to perform the same
operation on the opposite lower lid, and was pleased to see
it followed by the same satisfactory result. In July, the
parts remained in exactly the same state. The epiphora was
quite removed. He could pursue his employment with com-
fort. I have recently seen him, and found the cure
satisfactory.
The experience afforded by this case, led me to reject the
plan of dividing the canal transversely, as first suggested by
IN CERTAIN CASES OP EPIPHOKA. 343
the cases of accidental injury, and to adopt the more simple
expedient of slitting it up for a short distance from the
punctum, on the conjunctival aspect.
In thus destroying the punctum, I was not without some
misgivings whether the tears would be taken up by the new
orifice thus artificially made, at a part of the canal unpro-
vided with the same structural arrangements which it is
usual to attribute to the puncta. These fears were unfounded,
for the tears entered the canal perfectly at the intermediate
point. This result renders it probable, that too much im-
portance has been given to the punctum by writers on the
lacrymal apparatus, and perhaps also to that three-sided
channel which is said to be formed between the margins of
the lids and the globe of the eye, when the lids are closed,
and which is supposed to be useful in directing the tears
towards the puncta. In the sheep, the orifices of the puncta
are obliquely placed on the flat, or slightly rounded, margin
of the lids, and the shape of the meibomian margin does not
admit of the formation of any such triangular groove as that
now alluded to. In the human subject, also, I believe it
will be found, on close examination, that the edges of the
lids are not so bevilled as to form a triangular groove by
their apposition in front of the globe. When the lids are
closed, they touch each other by the posterior or meibomian,
and not by the ciliary, lip of their margin. Indeed, the posi-
tion occupied by the meibomian orifices would prevent this
supposed channel from playing the part usually assigned to it.
It is interesting to notice the difference in the tendency
to contract manifested by the new orifice, according as it is
made by a total transverse, or by a partial longitudinal
division. In both cases, the divided tissues of the wall pro-
bably undergo the same kind, and most likely the same
degree of contraction ; but when the division is transverse,
a slight contraction in the circular direction will close the
canal ; whereas, when it is longitudinal or oblique, a corre-
sponding amount of contraction of the divided margin of
the wall cannot close, or even much constrict, the entrance
to the canal, because the wall is only divided along one side
of its circumference, and the rest is left uninjured.
344 MR. bowman's new method of treatment
In fact, the analogy of the urethra guided me in this
respect, where, in the able hands of my friend Mr. Fergusson,
I had seen a longitudinal division of the canal from the
orifice which remains after amputation of the penis, obviate
that most troublesome of the results of this operation, the
tendency to a stricture at the point cut across. Both canals
are allied in structure and function, as ducts of glands, and
both possess in their walls that muscular element which
seems the seat of the slow contraction, following division, to
which allusion is now made.
Of course I should not advise this operation to be per-
formed in recent cases of displaced puncta, nor in any in
which other and milder treatment seemed available. It is
well to remark, however, that no visible deformity results
from it, and that no one would be aware it had been per-
formed without an accurate examination of the part.
The following is another instance in which it has been at
once successful in relieving a long-standing case of most
annoying epiphora.
A clerk to a shipping-agent, set. 57, caught slight cold in
the right eye two years and a half ago, and since then the
tears have always ran over the check, especially when ex-
posed to the cold air ; at times the eye has been inflamed in
a trifling degree. He has been annoyed with having to use
the handkerchief constantly through the day, and his sight
has been much troubled by the continual suffusion of the
eye with tears.
I found the sac and lacrymal apparatus quite healthy,
except that the border of the lower lid, in its inner half, was
rounded and slightly flattened, so as not to fit accurately to
the globe. The punrtimi, instead of being at the Summit
of the usual angular projection, lay forward on a flat surface,
and was hardly visible. Tin- skin around it was dry and
cuticular, and the tears never reached it, but accumulated
about the caruncle and along the margin of the lid. I
passed a probe with ease through the punetum into the rac ;
there was no obstruction.
I slit up the canal for one eighth of an inch, on a probe,
and along the mucous aspect. Two days after he came to
IN CERTAIN CASES OF EPIPHORA. 345
have the margins of the slit separated. They were adherent
and filled up by lymph, which I broke through. He had
experienced no relief as yet. Two days afterwards I found
the slit permanently established, its margins healed, and the
orifice carried backwards on the conjunctival surface for one
eighth of an inch to near the caruncle. He was greatly
relieved. He had been out much in the air iu the prevail-
ing east wind the previous day, and the eye had scarcely
watered at all. In the last two clays the eye had been better
than for two years and a half. Since this I have frequently
seen him, but no further interference has been required. He
seems entirely cured.
At the commencement of this communication I alluded to
cases of epiphora, depending not on displaced but on ob-
structed puncta or canals. Such cases do occur every now
and then, either by simple contraction or stricture of the
canal, or from ulceration or accidental injury. It is remark-
able that the tears do not always accumulate in these cases,
either from the remaining punctum doing double duty, or
from the ordinary secretion of tears being scanty. My friend
Dr. Budd sent me a patient suffering from the secondary
effects of concussion of the eyeball. I found, besides, that
the lower canal had been divided about the middle, and that
it was completely obstructed at the seat of the cicatrix.
There was no stillicidium. But, in general, such a condition
is attended with weeping; and in some of these cases, a
modification of the operation I have described may be appli-
cable. The proposals of Monro and Petit, to make new
conduits, by carrying a thread, or making an incision, into
the sac, have long since been forgotten. Such artificial
passages close as soon as the seton or the bougie ceases to be
inserted. It seems essential to the object of restoring the
course 'of the tears, that the canaliculus should itself furnish
the channel ; and this can be accomplished only in those
instances in which the point of obstruction is sufficiently far
from the sac to allow of the canal being slit up iu the interval,
and through the conjunctiva. Two methods of operating
offer themselves : the first, by cutting transversely across
346 NEW METHOD OF TREATMENT OF EPIPHORA.
the direction of the canal, close to the obstruction, on the
side towards the sac, and then slitting up the canal on a
probe introduced at the wound made ; the second, supposing
no orifice can be found after this transverse section, by
opening the sac below the tendo oculi, and then slitting up
the canal, near the obstruction, on a probe run into it from
the sac. The orifice of the canaliculi within the sac is so
large, that I have no doubt a skilful surgeon could readily
do this, if he had previously taken pains to acquaint himself
with the anatomy of the parts. I have found it easy in the
dead subject, but have not yet had a case in which to test its
feasibility in the living. Of course the canal in these cases
must be slit up through the conjunctiva, near the caruncle,
or the tears could not find their way into it.
In conclusion, I would observe that there are cases of
epiphora depending on obstruction of the canaliculi close to
the sac, in which this operation would be out of place. The
sac itself is empty; a probe passes easily along the canal
from the dilated punctum, and is arrested at the entrance to
the sac. If forced against the obstruction, the outer wall of
the sac, with the skin over it, is moved towards the nose,
and the surgeon experiences an elastic resistance; ■whereas,
if there is no such stoppage, and the probe enters the sac,
it comes into contact with the inner or osseous wall, and the
skin over it is not moved. As the distance between the
punctum and the inner wall of the sac is just half an inch
when the canal is stretched by drawing the lid outwards, a
probe covered with gold for that length will prove a useful
help for determining whether the probe has actually pene-
trated the sac. In these cases, it will be remarked that the
punctum is wetted by the tears; and it seems to nic that
that not uncommon dilatation of the orifice and of the
canal, usually attributed to paralysis or relaxation, is, in
fact, the consequence of the stricture — the tears constantly
filling those parts on their way to the sac, but being unable
t<> pass onwards.
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INDEX.
Amussat and Littre, relative merits of their operations in cases of
obstruction of the colon
Aneurism, treated by compression
list of cases treated in Dublin by compression .
statistics of cases treated by ligature
causes of failure in treatment of, by compression
constitutional treatment in
Aneurismal dilatation of the posterior tibial vein, communicating
with the popliteal artery
Aneurisms, dissection of a case of two popliteal, treated by com
pression ....
Atmospheric electricity, secondary physiological effects produced by
its effect in purifying the atmosphere
PAGE
274
143
148
154
156
158
327
161
205
217
Barker, T. Alfred, M.D., cases illustrating some difficulties in the
diagnosis of pleuritic effusion . . .131
Barlow, William Frederick, on the relation of sleep to convulsive
affections ..... 167
Barnes, Robert, M.D., on fatty degeneration of the placenta . 183
Bellingiiam, O'Bryen, M.D., case of popliteal aneurism treated by
compression, with remarks by . . 1 43
Bowman, William, on a new method of treatment applicable to
certain cases of epiphora .... 337
Brain, disease in the, produced by affections of the ear . . 239
cases of, originating in affections of the tym-
panic cavity . . - 254
inflammation of the, variations of the sulphates and phos-
phates in . . . . . 277
Bronchial tubes, containing blood in case of removal of upper jaw - 47
356
Csesarean section, case of, by Dr. "West .
description of the operation
rate of mortality after
dimensions of pelvis in case of
sources of danger in . . .
frequency of haemorrhage in
use of chloroform in cases of
condition of wound in uterus after
causes of death in 117 fatal cases of
references to cases of .
case of, by Dr. Oldham
description of the operation in
Caruncle, use of ... .
Cerebellum, disease in, originating in affections of the external
meatus .....
Chloroform, on use of, in operations about the mouth
Letter from Dr. Snow on effects of, in a case of removal
of tumour from upper jaw
haemorrhage perhaps increased by its use in Cesarean
section'
in a case of delirium tremens
Chorea, softening of spinal marrow in a boy affected with
association of, with rheumatism
acute, variations of the sulphates and phosphates in
Chylo-scrous urine, experiments on
case of
Cock, Edward, a case of aneurismal dilatation of the posterior tibial
vein communicating indirectly with the upper part of the
popliteal artery, by
Colon, obstruction of the, relieved by operation in the groin .
diagnosis of
Compression, treatment of aneurism by .
list of cases of aneurism treated in Dublin by
causes of failure in treatment of aneurism by
dissection of two popliteal aneurisms treated by
Convulsive affections, relations of sleep to
Cyst, ovarian, dissection of
containing hydatids developed at the root of the neck
Degeneration, fatty, of the placenta
Delirium tremens, variations of the sulphates ami phosphates in
Diagnosis of morbid growths from the upper jaw
of pleuritic effusion, difficult tea of
INDEX. 357
PAGE
Dislocation of the femur, unusual form of . 107
Distortion of the pelvis . . . . . ib.
Dixon, James, account of a case in which a large cyst containing
hydatids was developed at the root of the neck, death ensuing
from rupture of the left subclavian artery . 315
Dreaming, emotions of . . . . . 169
Dkujijiond, John, case of extensive necrosis of the bones of the
cranium, and removal of large portions thereof . . 103
Duffin, E. W., successful case of ovariotomy . . . 1
Dura mater, cases of disease of, from affections of the tympanic
Cavity .....
Ear, affections of the, which produce disease in the brain
external meatus of, anatomical observations on
disease of external meatus of, propagated to fossa cerebelli
mastoid cells of, affections of the
tympanic cavity of, affections of
labyrinth, affections of
table of disease of dura mater and brain origiuating in
Electricity, cause of sensations produced by " .
atmospheric, secondary physiological effects produced by
its effect in purifying the atmosphere
used in practical surgery
Epiphora, new method of treatment of
Fatty degeneration of the placenta
microscopical examination in
frequency of
management of .
Femur, unusual form of dislocation of
Fistula in cheek, cured by heat of galvanic electricity
Fracture and distortion of the pelvis
Galvanism, experiments with heat produced by
section of soft parts effected by heat of .
mode of operating with .
Granville, Dr., vascular tumour of uterus mistaken for ovarian tumour
254
239
240
242
247
219
251
254
20G
205
217
221
337
183
186
192
197
109
226
107
225
229
231
12
Groin, operation performed at the, for the relief of obstructed colon 263
Haemorrhage in Ca:sarean section . . . .75
Hassall, Dr., structure of placenta, normal, and in fatty degene-
ration, by . . . . .186
Heat of electricity, employment of, in practical surgery . . 221
Hernia, strangulated obturator, relieved by operation . 233
xxxiv. 23
358
Hewett, Prescott, case illustrating difficulties of diagnosis of morbid
growths from the upper jaw, with remarks, by 43
account of the dissection of a case in which
two popliteal aneurisms had been treated by
compression, by . . .161
Hydatid cyst developed at the root of the neck, with death from
haemorrhage . . . . .315
Jaw, upper, difficulties of diagnosis of morbid growths from . 43
effusion of blood into bronchial tubes in a case of re-
moval of . . . 47
use of chloroform in operations on . .50
Johnson, Athol, cases of rupture of the liver or spleen, by . 53
Jones, H. Bence, M.D., on the variations of the sulphates and
phosphates excreted in acute chorea, delirium tremens, and
inflammation of the brain, by ... 277
Kidney, rupture of, with union . . . . ">7
Kilian, Professor, his views on fatty degeneration of the placenta 190
Labyrinth, affections of . . . . 251
Lacrymal canals, diagnosis of stricture of . . 347
Lange, Dr., account of state of uterus two years after Cesarean
section . . . .81
Lateral siuus, disease in, originating in affections of the external
meatus ...... 259
Lee, Dr. Robert, dissection of an ovarian cyst by . . . 6
analysis of 108 cases of ovariotomy by 10
Littre and Amussat, relative merits of their operations in cases of
obstruction of the colon .... 274
Liver, cases of rupture of . . 53
union of rupture of . . . .56
supposed rupture of, with recovery . 57
union of wounds of . . . . 5S
Lizars, Mr., ovariotomy performed by . 12
Luke, James, a case of obstruction of the colon relieved by an ope-
ration performed at the groin . . 263
Lung, slough in, obscure symptoms in cases of . 137-40
Macilwain, Mr., remark on diagnosis in internal injuries . 52
AIaokiiai.i,, .loir v, mi the employment of the heat of electricity in
practical surgery . ■ . . .221
Mastoid cells, affections of the . . . , . Mf
M \ykii, Josi -I'll, experiments on chylous or objlo-aerous mine 119
359
PAGE
Meatus, external, of ear, anatomical observations on . . 240
disease of, propagated to fossa of cerebellum . 240
Meibomian glands, use of . . . . . 342
Miasmatic substances, origin of . . . . 212
influence of ozone in removing . .214
Milk, human, effect of reagents upon . . . . 123
Moore, Charles Hewitt, case of fracture and dislocation of the
pelvis, combined with an unusual form of dislocation of the
femur ...... 107
Morbid growths from the upper jaw, difficulties of diagnosis of . 43
Mortality, rate of, after Cesarean section . . .73
Nairne, Robert, m.d., case of softening of the spinal marrow . 37
Necrosis of the bones of the cranium . . 103
Needle, grooved, insufficient in some cases to detect fluid . 133
Obre Henry, a case of strangulated obturator or thyroideal hernia
relieved by operation .... 223
Obstruction of the colon relieved by operation performed at the groin 263
Obturator hernia relieved by operation . . . 233
Oldham, Henry, m.d., cases of Cesarean section by 89
Ovarian cyst, dissection of an . . . .6
identity of structure with ovarium . . . 9
vascular tumour of uterus mistaken for . .12
Ovariotomy, successful ease of . . . . 1
prevention of the return of the neck of cyst in . 4
analysis of 162 cases of, with postscript by Dr. R. Lee 10
first performed by Dr. Nathan Smith . . . ib.
Ozone, chemical characters of ... . 208
effects of excess of, in atmosphere . . . 210
most abundant in winter, and at high levels . . 219
Ozonometer . ... . . . 211
Pearse, George, m.d., history of a patient affected with chylo-serous
urine ..... 127
Pelvis, dimensions of, in a case in which Cesarean section had been
performed . . . 72
fracture and distortion of . . 107
dimensions of, in case of fracture with distortion . 113
Phosphates, their variations in certain diseases . 277
Placenta, normal structure of . . 186
fatty degeneration of . . . 183
microscopical examination of . 186
frequency of . . . 192
360
Pleurisy, absence of symptoms in case of
Pleuritic effusion, diagnosis of .
Poland, Mr., Csesareau section performed by
Polypus of the nose, unusual course of
Popliteal aneurism, treated by compression
dissection of a case of, treated by compression
artery, communicating indirectly with aneurismal dilatation
of the posterior tibial vein .
Pterygo-maxiHary fossa, growths originating in
Puncta lacrymalia, displacement of, a cause of epiphora
causes of .
Rupture of the liver or spleen, cases of
and kidney, united
supposed, with recovery
or spleen, not necessarily fatal
Rupture of internal organs, treatment in cases of
Schonbein, C. F., on some secondary physiological effects pro
duced by atmospheric electricity
Secondary physiological effects produced by atmospheric electricity
Skey, Mr., Csesarean section performed by .
Sleep, relation of, to convulsive affections
state of circulation and respiration in
increase of motor force and muscular irritability in
withdrawal of volition in
reflex actions in ... .
Smith, Dr. Nathan, ovariotomy first performed by
Snow, Dr., on the effect of chloroform in an operation on a morbid
growth from upper jaw
Spinal marrow, case of softening of, in a boy affected with chorea
convnlsions in paralysed parts in softening of
Spleen, case of rupture of .
Subclavian artery, rupture of the, in a case of hydatid cyst developed
at the root of the neck
Sulphates and phosphates, their variations in certain diseases
Thunderstorms, how purifiers of the atmosphere
odour developed during, similar to that of ozone
Thyroideal hernia relieved by operation .
Tibial vein, posterior, aneurismal dilatation of
Tovndbe, JosErn, observations on the pathology of those affections
of the car which produce disease in the brain
INDEX. 361
PAGE
Tympanic cavity, anatomical observations on . . 249
affections of . . . 249
table of cases of disease of the dura mater and
brain originating in affections of . . 254
Uterus, vascular tumour of, mistaken for ovarian tumour . . 12
slow union of wounds of . . .80
examination of state of, two years after Csesarean section . 81
Vessels, congestion of, in chorea . . 40
West, Cn.uii.Es, M.D., account of a case in which Ca>sarean section
was performed . . . . .61
END OF VOL. XXXIV.
IDLAKI), PBINT1:K3, BAKTHOLOMEW CLOSE.
R Royal Medical and Chirurgical
35 Society of London
R67 Medico-chirurgical trans-
v.3A actions
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